The COVID Positive Pathway: a collaboration between public health agencies, primary care, and metropolitan hospitals in Melbourne.

OBJECTIVES: To assess the capacity of the COVID Positive Pathway, a collaborative model of care involving the Victorian public health unit, hospital services, primary care, community organisations, and the North Western Melbourne Primary Health Network, to support people with coronavirus disease 2019 (COVID-19) isolating at home. DESIGN, SETTING, PARTICIPANTS: Cohort study of adults in northwest Melbourne with COVID-19, 3 August - 31 December 2020. MAIN OUTCOME MEASURES: Demographic and clinical characteristics, and social and welfare needs of people cared for in the Pathway, by care tier level. RESULTS: Of 1392 people referred to the Pathway by the public health unit, 858 were eligible for enrolment, and 711 consented to participation; 647 (91%) remained in the Pathway until they had recovered and isolation was no longer required. A total of 575 participants (81%) received care in primary care, mostly from their usual general practitioners; 155 people (22%) received care from hospital outreach services, and 64 (9%) needed high tier care (hospitalisation). Assistance with food and other basic supplies was required by 239 people in the Pathway (34%). CONCLUSIONS: The COVID Positive Pathway is a feasible multidisciplinary, tiered model of care for people with COVID-19. About 80% of participants could be adequately supported by primary care and community organisations, allowing hospital services to be reserved for people with more severe illness or with risk factors for disease progression. The principles of this model could be applied to other health conditions if regulatory and funding barriers to information-sharing and care delivery by health care providers can be overcome.

Socioeconomic gradients in admission to coronary or intensive care units among Australians presenting with non-traumatic chest pain in emergency departments.

BACKGROUND: Socioeconomic inequalities in cardiovascular morbidity have been previously reported showing direct associations between socioeconomic disadvantage and worse health outcomes. However, disagreement remains regarding the strength of the direct associations. The main objective of this panel design was to inspect socioeconomic gradients in admission to a coronary care unit (CCU) or an intensive care unit (ICU) among adult patients presenting with non-traumatic chest pain in three acute-care public hospitals in Victoria, Australia, during 2009-2013. METHODS: Consecutive adults aged 18 or over presenting with chest pain in three emergency departments (ED) in Victoria, Australia during the five-year study period were eligible to participate. A relative index of inequality of socioeconomic status (SES) was estimated based on residential postcode socioeconomic index for areas (SEIFA) disadvantage scores. Admission to specialised care units over repeated presentations was modelled using a multivariable Generalized Estimating Equations approach that accounted for various socio-demographic and clinical variables. RESULTS: Non-traumatic chest pain accounted for 10% of all presentations in the emergency departments (ED). A total of 53,177 individuals presented during the study period, with 22.5% presenting more than once. Of all patients, 17,579 (33.1%) were hospitalised over time, of whom 8584 (48.8%) were treated in a specialised care unit. Female sex was independently associated with fewer admissions to CCU / ICU, whereas, a dose-response effect of socioeconomic disadvantage and admission to CCU / ICU was found, with risk of admission increasing incrementally as SES declined. Patients coming from the lowest SES locations were 27% more likely to be admitted to these units compared with those coming from the least disadvantaged locations, p <  0.001. Men were significantly more likely to be admitted to such units than similarly affected and aged women among those diagnosed with angina pectoris, arrhythmia, myocardial infarction, heart failure, chest pain, and general signs and symptoms. CONCLUSIONS: This study is the first to report socioeconomic gradients in admission to CCU / ICU in patients presenting with chest pain showing a dose-response effect. Our findings suggest increased cardiovascular morbidity as socioeconomic disadvantage increases.

Why do children present to emergency departments? Exploring motivators and measures of presentation appropriateness for children presenting to a paediatric emergency department.

AIM: To compare the parental motivators and referring general practitioner's (GP's) reasons for advising emergency department (ED) attendance with the assessment of ED medical staff. To compare ED clinician opinion with other published methods that have attempted to define 'primary care suitable' presentations to the ED. METHODS: A prospective observational study and series of surveys regarding the attendance of children presenting to a single tertiary paediatric ED. Surveys were distributed to the treating ED clinician, the child's parent/guardian, and the referring GP. Results between the three groups were analysed and compared. RESULTS: There were a total of 1069 presentations during the study period. Six hundred (58.4%, 95% CI 55.3-61.4%) presentations were judged as 'ED appropriate' by the treating ED clinician. When compared with methods used to retrospectively judge whether ED patients are considered 'primary care suitable', ED clinicians disagree between 22.4 and 38.8% of the time. For patients who presented directly to ED, 85.6% did so for a medical reason, whilst 32.1% did so for a GP access reason. Being referred by a GP improved the ED clinicians' opinion of the appropriateness of the presentation (49.2 vs. 73.9%, P < 0.05). CONCLUSIONS: We caution that many strategies attempting to 'solve' the issue of increasing ED attendances by paediatric patients have been driven by opinion, and a better understanding of the motivators that drive this behaviour is needed. We believe the solution to increasing utilisation of EDs by children must be a balanced approach that addresses community expectations and appropriately resources EDs.

Sex differences in in-hospital mortality following a first acute myocardial infarction: symptomatology, delayed presentation, and hospital setting.

BACKGROUND: Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated. METHODS: Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated. RESULTS: Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %. CONCLUSIONS: Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI.

Emergency department mental health presentations by people born in refugee source countries: an epidemiological logistic regression study in a Medicare Local region in Australia.

This study investigated if people born in refugee source countries are disproportionately represented among those receiving a diagnosis of mental illness within emergency departments (EDs). The setting was the Cities of Greater Dandenong and Casey, the resettlement region for one-twelfth of Australia's refugees. An epidemiological, secondary data analysis compared mental illness diagnoses received in EDs by refugee and non-refugee populations. Data was the Victorian Emergency Minimum Dataset in the 2008-09 financial year. Univariate and multivariate logistic regression created predictive models for mental illness using five variables: age, sex, refugee background, interpreter use and preferred language. Collinearity, model fit and model stability were examined. Multivariate analysis showed age and sex to be the only significant risk factors for mental illness diagnosis in EDs. 'Refugee status', 'interpreter use' and 'preferred language' were not associatedwith a mental health diagnosis following risk adjustment forthe effects ofage and sex. The disappearance ofthe univariate association after adjustment for age and sex is a salutary lesson for Medicare Locals and other health planners regarding the importance of adjusting analyses of health service data for demographic characteristics.

Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo.

STUDY OBJECTIVE: We compare efficacy of ondansetron and metoclopramide with placebo for adults with undifferentiated emergency department (ED) nausea and vomiting. METHODS: A prospective, randomized, double-blind, placebo-controlled trial was conducted in 2 metropolitan EDs in Melbourne, Australia. Eligible patients with ED nausea and vomiting were randomized to receive 4 mg intravenous ondansetron, 20 mg intravenous metoclopramide, or saline solution placebo. Primary outcome was mean change in visual analog scale (VAS) rating of nausea severity from enrollment to 30 minutes after study drug administration. Secondary outcomes included patient satisfaction, need for rescue antiemetic treatment, and adverse events. RESULTS: Of 270 recruited patients, 258 (95.6%) were available for analysis. Of these patients, 87 (33.7%) received ondansetron; 88 (34.1%), metoclopramide; and 83 (32.2%), placebo. Baseline characteristics between treatment groups and recruitment site were similar. Mean decrease in VAS score was 27 mm (95% confidence interval [CI] 22 to 33 mm) for ondansetron, 28 mm (95% CI 22 to 34 mm) for metoclopramide, and 23 mm (95% CI 16 to 30 mm) for placebo. Satisfaction with treatment was reported by 54.1% (95% CI 43.5% to 64.5%), 61.6% (95% CI 51.0% to 71.4%), and 59.5% (95% CI 48.4% to 69.9%) for ondansetron, metoclopramide, and placebo, respectively; rescue medication was required by 34.5% (95% CI 25.0% to 45.1%), 17.9% (95% CI 10.8% to 27.2%), and 36.3% (95% CI 26.3% to 47.2%), respectively. Nine minor adverse events were reported. CONCLUSION: Reductions in nausea severity for this adult ED nausea and vomiting population were similar for 4 mg intravenous ondansetron, 20 mg intravenous metoclopramide, and placebo. There was a trend toward greater reductions in VAS ratings and a lesser requirement for rescue medication in the antiemetic drug groups, but differences from the placebo group did not reach significance. The majority of patients in all groups were satisfied with treatment.

Integrating the six C's of disaster response: Lessons from the mega terrorist attack on October 7, 2023.

On October 7, 2023, over 2,500 Hamas terrorists infiltrated Israel from Gaza and killed over 1,400 people and injured 2,800, resulting in the largest terrorist attack in Israel's history. Several models describe the principles of managing a mass casualty event. One of them is an Australian construct known as the six C's. While command, control, and coordination are familiar concepts, the six C's emphasize the importance of communication and community (consequences and community connection). We describe how two emergency departments in Israel-Assuta Ashdod and the Hadassah Medical Center-Ein Kerem-responded to this disaster in the context of the six C's.

Examining emergency departments practices on advance care directives and medical treatment decision making using the victorian emergency minimum dataset.

INTRODUCTION: Existence of Advance Care Planning (ACP) documents including contact details of Medical Treatment Decision Makers (MTDM), are essential patient care records that support Emergency Department (ED) clinicians in implementing treatment concordant with patients' expressed wishes. Based upon previous findings, we conducted a statewide study to evaluate the performance of Victorian public hospital emergency departments on reporting of availability of records for ACP. METHOD: The study is a quantitative retrospective observational comparative design based upon ED tier levels as defined by the Australasian College for Emergency Medicine (ACEM) for the calendar year 2021. RESULTS: Of 1.8 million total Victorian ED attendances, 15,222 patients had an ACP alert status recorded. Of these, 7296 were aged ≥ 65 years (study group). Of the thirty-one public EDs that submitted data, 65 % were accredited and assigned a level of service tier. The presence of ACP alerts positively correlated to location, tier level, age and gender (MANOVA wilk's; p < 0.001, value=.981, F = (12, 15,300), partial ƞ2 = .006, observed power = 1.0 = 95.919). CONCLUSION: The identified rate of ACP reporting is low. Strategies to improve the result include synchronising ACP (generated at different points) electronically, staff education, training and further validation of the data at the sending and receiving agencies.

Machine learning in clinical practice: Evaluation of an artificial intelligence tool after implementation.

OBJECTIVE: Artificial intelligence (AI) has gradually found its way into healthcare, and its future integration into clinical practice is inevitable. In the present study, we evaluate the accuracy of a novel AI algorithm designed to predict admission based on a triage note after clinical implementation. This is the first of such studies to investigate real-time AI performance in the emergency setting. METHODS: The novel AI algorithm that predicts admission using a triage note was translated into clinical practice and integrated within St Vincent's Hospital Melbourne's electronic emergency patient management system. The data were collected from 1 January 2021 to 17 August 2022 to evaluate the diagnostic accuracy of the AI system after implementation. RESULTS: A total of 77 125 ED presentations were included. The live AI algorithm has a sensitivity of 73.1% (95% confidence interval 72.5-73.8), specificity of 74.3% (73.9-74.7), positive predictive value of 50% (49.6-50.4) and negative predictive value of 88.7% (88.5-89) with a total accuracy of 74% (73.7-74.3). The accuracy of the system was at the lowest for admission to psychiatric units (34%) and at the highest for gastroenterology and medical admission (84% and 80%, respectively). CONCLUSION: Our study showed the diagnostic evaluation of a real-time AI clinical decision-support tool became less accurate than the original. Although real-time sensitivity and specificity of the AI tool was still acceptable as a decision-support tool in the ED, we propose that continuous training and evaluation of AI-enabled clinical support tools in healthcare are conducted to ensure consistent accuracy and performance to prevent inadvertent consequences.

Evaluating the impact of junior doctors in quality improvement - a 10-year review.

Objectives The importance of engaging junior doctors in quality improvement (QI) initiatives is well recognised. Junior doctors bring fresh perspectives and engage closely with patients, consumers, families and the healthcare team. They are well positioned to recognise inefficiencies in the system that may compromise safe, timely and effective care. To promote QI participation by our junior doctors our organisation created a specific role; the Improvement House Medical Officer (IHMO). The objective of this study is to describe and evaluate the IHMO rotation at the Royal Melbourne Hospital, a large tertiary hospital in Australia. Methods A mixed-methods study was performed that involved a survey of previous IHMOs since 2011, including a review of the major QI projects undertaken by IHMOs. Results Twenty-seven out of 40 IHMOs completed the survey. Doctors were attracted to the rotation to make an impact on the working conditions of junior doctors (selected by 20 respondents, 74%) and improve the quality of health care experienced by patients (18, 67%). Most respondents strongly agreed or agreed (22, 82%) that they used the skills gained in the rotation in their ongoing work. More than 40 QI projects have been led or co-led by IHMOs since 2011. Challenges of the role included the short timeframe of the rotation and the perceived slow pace of institutional change. Respondents found engaging other junior doctors with QI and understanding the hospital's organisational structure to be barriers. Conclusions The full engagement of junior doctors in QI upholds a healthcare culture that celebrates innovation and promotes patient safety. The IHMO rotation offers an immersive, experiential and impactful way to do so.

Early prediction of hospital admission of emergency department patients.

OBJECTIVE: The early prediction of hospital admission is important to ED patient management. Using available electronic data, we aimed to develop a predictive model for hospital admission. METHODS: We analysed all presentations to the ED of a tertiary referral centre over 7 years. To our knowledge, our data set of nearly 600 000 presentations is the largest reported. Using demographic, clinical, socioeconomic, triage, vital signs, pathology data and keywords in electronic notes, we trained a machine learning (ML) model with presentations from 2015 to 2020 and evaluated it on a held-out data set from 2021 to mid-2022. We assessed electronic medical records (EMRs) data at patient arrival (baseline), 30, 60, 120 and 240 min after ED presentation. RESULTS: The training data set included 424 354 data points and the validation data set 53 403. We developed and trained a binary classifier to predict inpatient admission. On a held-out test data set of 121 258 data points, we predicted admission with 86% accuracy within 30 min of ED presentation with 94% discrimination. All models for different time points from ED presentation produced an area under the receiver operating characteristic curve (AUC) ≥0.93 for admission overall, with sensitivity/specificity/F1-scores of 0.83/0.90/0.84 for any inpatient admission at 30 min after presentation and 0.81/0.92/0.84 at baseline. The models retained lower but still high AUC levels when separated for short stay units or inpatient admissions. CONCLUSION: We combined available electronic data and ML technology to achieve excellent predictive performance for subsequent hospital admission. Such prediction may assist with patient flow.

A Descriptive Analysis of the Use of Chemical, Biological, Radiological, and Nuclear Weapons by Violent Non-State Actors and the Modern-Day Environment of Threat.

INTRODUCTION: The use of chemical, biological, radiation, and nuclear (CBRN) weapons is not new, and though rare, it is an issue of concern around the world due to their ability to cause large-scale mass-casualty events and their potential threat to global stability. The purpose of this study is to explore the use of CBRN weapons by non-state actors through analysis of the Violent Non-State Actor (VNSA) CBRN Event database, and aims to better inform health care systems of the potential risks and consequences of such events. METHODS: Data collection was performed using a retrospective database search through the VNSA CBRN Event database. RESULTS: A total of 565 events were recorded. Five hundred and five (505) events (89.4%) involved single agents while 60 events (10.6%) involved multiple agents. Fatalities numbered 965 for chemical agents, 19 for biological agents, and none for radiological and nuclear events. Injuries numbered 7,540 for chemical agents, 59 for biological agents, 50 for radiological events, and none for nuclear attacks. Fatality and injury per attack was 2.22 and 17.37, respectively, for chemical event agents and 0.15 and 0.48, respectively, for biological event agents. CONCLUSION: Violent Non-State Actors were responsible for 565 unique events around the world involving the use of CBRN weapons from 1990-2020. The United States (118), Russia (49), and Iraq (43) accounted for the top three countries where these events occurred. While CBRN events remain relatively rare, technological advances have the potential to facilitate the use of such weapons as part of a hybrid warfare strategy with significant repercussions for civilian health and health care systems.

Screening major trauma patients for prevalence of illicit drugs.

INTRODUCTION: Australasian emergency departments (ED) routinely test patient alcohol levels following major trauma, but assessment for illicit drugs is uncommon. METHODS: A prospective cross-sectional study of major motor-vehicle-related trauma patients attending both adult major trauma centres in Victoria, Australia. All eligible patients had point-of-care saliva testing to determine the prevalence of common illicit drugs. RESULTS: Over 12 months, 1411 patients were screened, 36 refused (2.6%) and 63 were excluded. Of the final 1312 cases included, 173 (13.2%; 95% confidence interval 11.5, 15.1) tested positive to at least one illicit substance, with 133 (76.9%; 69.7, 82.8) positive for meth/amphetamines. One in five had more than one illicit substance detected. Patients testing positive were most frequently in motor vehicles (91.9% vs. 85.6%) and least frequently cyclists (2.3% vs. 4.2%) or pedestrians (5.2% vs. 10.3%), compared to those testing negative. They were younger (mean age 35.4 vs. 43.1 years), more likely to arrive overnight (27.2% vs. 12.1%) or after single vehicle crashes (54.3% vs. 42.3%). Although the initial disposition from ED did not differ, those testing positive were more likely to re-present within 28 days (13.9% vs. 5.4%). DISCUSSION AND CONCLUSIONS: A high prevalence of potentially illicit substances among patients presenting with suspected major trauma supports the need for urgent preventive strategies. The low rate of patient refusal and large numbers screened by ED staff suggests that point-of care testing for illicit substances in major trauma is acceptable and feasible. This study and ongoing surveillance may be used to inform driver education strategies.

Acute chest pain investigation: utility of cardiac CT angiography in guiding troponin measurement.

PURPOSE: To assess the impact on length of stay and rate of major adverse cardiovascular events of a cardiac computed tomographic (CT) angiography-guided algorithm to examine patients who present to the emergency department (ED) with low- to intermediate-risk chest pain. MATERIALS AND METHODS: The study was approved by the institutional review board, and all patients gave written informed consent. Two hundred three consecutive patients (mean age, 55 years ± 11 [standard deviation]; 123 men) with low- to intermediate-risk ischemic-type chest pain were prospectively enrolled. Patients underwent initial cardiac CT angiography with subsequent treatment determined by reference to findings at cardiac CT angiography; patients without overt plaque were immediately discharged from the hospital, patients with nonobstructive plaque and mild-to-moderate stenoses were discharged after a negative 6-hour troponin level, and patients with severe stenoses were admitted to the hospital. Discharged patients were followed up for a mean of 14.2 months. Additionally, length of stay and safety outcomes among these patients were compared with those in 102 consecutive patients with low- to intermediate-risk chest pain who presented to the ED and underwent a standard of care (SOC) work-up without cardiac CT angiography. One-way analysis of variance with Bonferroni correction was used to compare length of stay between groups. RESULTS: Cardiac CT angiography findings in the 203 patients who underwent cardiac CT angiography were as follows: Sixty-five (32%) patients had no plaque, 107 (53%) had nonobstructive plaque, and 31 (15%) had severe stenoses. At follow-up, there were no deaths or cases of acute coronary syndrome (cardiac CT angiography, 0%, 95% confidence interval [CI]: 0%, 1.85%; SOC, 0%, 95% CI: 0%, 3.63%), and the rate of readmission to the hospital because of chest pain was higher with the SOC approach (9% vs 1%, P = .01). Mean ED length of stay was lower with cardiac CT angiography (6.62 hours ± 0.38 after a single troponin level and 9.15 hours ± 0.30 after serial troponin levels) than with the SOC approach (11.62 hours ± 0.47, P < .001). CONCLUSION: Tailoring troponin measurement to cardiac CT angiography findings is safe and allows early discharge of patients with low- to intermediate-risk chest pain, resulting in reduced length of stay.

Child and adolescent mental health problems and substance use presentations to an emergency department.

OBJECTIVE: The aim of this study was to determine the characteristics and referral pattern of children and adolescents with mental health problems, substance misuse and comorbidity presenting to the emergency department (ED) of a large public hospital. METHOD: A file audit of the ED information system was conducted over a 12 month period. Outcome measures included age, gender, diagnostic presentation, assessment, referral and disposal. RESULTS: Forty-four substance misuse, 128 mental health and 82 comorbidity presentations were identified; 80% required treatment within 30 minutes. Few substance misuse cases were seen by mental health services and no substance misuse cases were referred for mental health service assessment. All mental health and comorbidity cases were seen by mental health services; 41% were referred to outpatient and 18% to inpatient services. Those with mental health problems displayed high levels of self-mutilation, and those with comorbidity displayed high levels of self-mutilation and substance misuse. Alcohol use was common in the substance misuse group, and over the counter or prescription medications were abused by the mental health and comorbidity groups. CONCLUSIONS: This age group places a high demand on the ED. All children and adolescents with recognized mental health symptoms were seen by mental health services, but those with substance misuse were not. Given the long-term problems associated with substance misuse, this is a missed opportunity for intervention.

Characteristics and clinical outcomes for mental health patients admitted to a behavioural assessment unit: Implications for model of care and practice.

Behavioural assessment units (BAU) have been established in emergency departments (EDs) to provide short-term observation, treatment, and care to people experiencing acute behavioural disturbance. A prospective observational study was conducted in a cohort of adult patients admitted to one BAU located within an ED (July-December 2017) to compare clinical characteristics, treatment outcomes, and use of restrictive interventions for those who received a specialist mental health (MH) assessment with those who did not. Of the 457 patients, 61.5% received a specialist MH assessment. This group had a lower acuity (Australasian Triage Score 10.4%; CI 0.2-2.0% vs 13.6%; CI 9.3-19.5%); more arrived with police (28.8%; CI 23.8-34.3 vs 5.1%; CI 2.7-9.4%); and were subjected to restrictive interventions while in the BAU. Security responses for unarmed threat (code grey) were higher (10.9%; CI 7.8-15.0% vs 4.4%; CI 2.3-8.5%), as was the use of chemical restraint (4.2%; CI 2.4-7.2 vs 0.0% CI 0.0 - 2.1%). Those requiring specialist MH assessment had a longer length of stay (12.7 vs 5.2 hours). Further development of the BAU model of care must include targeted, evidence-based strategies to minimize the use of restrictive interventions and ensure timely access to acute mental health services.

The Snake Study: Survey of National Attitudes and Knowledge in Envenomation.

Despite recent reviews of best practice for the treatment of Australian venomous bites and stings, there is controversy about some aspects of care, particularly the use of antivenom. Our aim was to understand current attitudes and practice in the management of suspected snake envenoming. A single-stage, cross-sectional survey of Australian emergency care physicians who had treated snake envenomation in the previous 36 months was conducted. Hospital pharmacists were also invited to complete a survey about antivenom availability, usage, and wastage in Australian hospitals. The survey was available between 5 March and 16 June 2019. A total of 121 snake envenoming cases were reported, and more than a third (44.6%) of patients were not treated with antivenom. For those treated with antivenom (n = 67), 29 patients (43%) received more than one ampoule. Nearly a quarter of respondents (21%) identified that antivenom availability was, or could be, a barrier to manage snake envenoming, while cost was identified as the least important factor. Adverse reactions following antivenom use were described in 11.9% of cases (n = 8). The majority of patients with suspected envenoming did not receive antivenom. We noted variation in dosage, sources of information, beliefs, and approaches to the care of the envenomed patient.

Small dose... big poison.

BACKGROUND: It is not possible to identify all toxic substances in a single journal article. However, there are some exposures that in small doses are potentially fatal. Many of these exposures are particularly toxic to children. Using data from poison control centres, it is possible to recognise this group of exposures. OBJECTIVE: This article provides information to assist the general practitioner to identify potential toxic substance exposures in children. DISCUSSION: In this article the authors report the signs and symptoms of toxic exposures and identify the time of onset. Where clear recommendations on the period of observation and known fatal dose are available, these are provided. We do not discuss management or disposition, and advise readers to contact the Poison Information Service or a toxicologist for this advice.

Ambulance management of patients with penetrating truncal trauma and hypotension in Melbourne, Australia.

OBJECTIVE: Penetrating truncal trauma with hypotension is uncommon in Australia. Current pre-hospital clinical practice guidelines based on overseas studies recommend expedited transport to definitive trauma care and that i.v. fluid should only be administered to maintain palpable blood pressure. METHODS: A retrospective review included all adult patients with penetrating truncal trauma and hypotension (systolic blood pressure <90 mmHg) attended by emergency medical services in Victoria between January 2006 and December 2018. Patient pre-hospital characteristics and hospital outcomes are described using descriptive statistics. Predictors of fluid resuscitation and mortality were examined using logistic regression analyses. RESULTS: Between 2006 and 2018 there were 101 hypotensive, penetrating truncal injury major trauma patients in Melbourne, Victoria transported by road ambulance to a major trauma service. The median age of these patients was 38 years (interquartile range [IQR] 27-50) and 85% were male. Median scene time was 16.6 min (IQR 12-26) and median pre-hospital time was 53.0 min (IQR 38-66). Intravenous fluid resuscitation was given in 54.5% of cases. The mechanism of injury was stabbing in 91.1% and gunshot wound in 8.9%. Urgent surgery was required in 72.3% of cases, 32.7% of patients were admitted to the intensive care unit and there were eight deaths (8.3%). CONCLUSION: Penetrating truncal trauma with hypotension is rare in Melbourne, Australia with most patients having the injury caused by stabbing rather than shooting. Compared with outcomes reported in the USA and Europe, the mortality rate is low.