Suspected Pulmonary Embolism Exclusion with D-dimers in Emergency Departments (SPEED-ED)

Pulmonary embolism (PE) refers to blood clots in the lung. They can cause sudden death, collapse, chest pain, shortness of breath yet sometimes they cause no symptoms at all and are discovered incidentally. As they can be severe, they have become regarded as a not-to-miss diagnosis. As they can present with a variety of symptoms, emergency clinicians consider the possibility of PE on a frequent basis.

When considering whether a patient has a PE, the clinician may confirm or exclude the diagnosis directly with definitive chest scans. However, these scans are time consuming, costly and have other side effects including exposure to radiation and to chemical contrast agents. When patients are assessed to be less likely of having a PE, it is often possible to safely exclude PE by applying a set of clinical decision rules or doing a blood test called a D-dimer. If the level of D-dimer is below a certain threshold, then PE can be excluded.

We aim to safely exclude PE without scans where possible. Evidence has been building that employing a higher D-dimer threshold is reasonable, yet uptake of this newer approach is limited. We hope to demonstrate that a higher threshold can work in Australia without compromising safety. This will be a large study that answers this question and if shown to be the case, then patient care can be improved while using less resources in busy emergency departments.

Validation of a Modified Fibrinogen on Admission with Trauma (FibAT) Score in the Australian Setting

Soon after injury, some individuals develop a condition where their body doesn't clot properly, leading to increased blood transfusions and increased mortality. An important aspect of clotting is a protein called fibrinogen which forms the scaffolding on which clots are formed. Fibrinogen is the first aspect of clotting that is impaired, but it is easily replaced if it is recognised with a specific blood test. Unfortunately this blood test may not be available rapidly in rural hospitals, which may lead to a delay in recognition. A scoring system called the Fibrinogen on Admission for Trauma (FibAT) has been developed in France, but includes criteria/interventions which we don't routinely do in Australia. In this study we will evaluate the FibAT's accuracy in detecting low levels of fibrinogen using data from 3 Queensland trauma centres. We will only use criteria that is available in rural settings.
This study is expected to show that even a modified FibAT is quite good at ruling in low fibrinogen so that it can be replaced early when a patient arrives in a rural hospital.

SPASMS: Study of Paediatric Appendicitis Scores and Management Strategies

Abdominal pain is one of the commonest reasons for children to attend the emergency department (ED), and acute appendicitis is the most common cause of abdominal pain requiring surgery. There are various clinical prediction scores that have been developed to help doctors diagnose appendicitis; however, most scores were developed overseas and are not routinely used in Australian EDs. The aim of this project is to review different published scores and compare them with overall clinician impression in diagnosing acute appendicitis in children presenting to ED.

The project will include all patients presenting to the ED with abdominal pain that are having investigations for possible appendicitis. The treating doctor will be asked to complete a case report form detailing patient history, examination findings, investigation results, as well as their overall clinical impression of the patient’s likelihood of having the diagnosis of appendicitis. Data collected will be analysed by project researchers to determine which scores are the most helpful for clinicians in diagnosing acute appendicitis in children presenting to Australian EDs, with the expectation that this will improve future care provided to children with abdominal pain.

Ultrasound-guided supraclavicular block versus Bier block for closed reduction of upper extremity injuries in the emergency department: an open-label, non-inferiority, randomised control trial

Upper limb injuries including bony fractures/dislocations, are sometimes deformed and require realignment in the emergency department (ED). Numerous techniques are available to allow this procedure to be painless. Bier block (BB) involves placing a band on the upper part of the affected arm to constrict blood flow, with injection of numbing agent into a hand vein on the same side to make the entire arm numb. An alternative technique is ultrasound guided supraclavicular blocks (UGSCB), which involves introducing a needle under ultrasound guidance to nerves situated just above the collar bone and injecting numbing agent around these nerves to make the arm go numb. However, the effectiveness of UGSCB when performed by ED doctors is unknown and patients might recover more quickly. We aim to conduct a randomised trial to compare UGSCB versus BB for re-aligning fractures/dislocations of the upper limb in the ED.

Pharmacological Emergency management of Agitation in Children and Young People – randomised controlled trials of Oral and intraMuscular medication: PEAChY-O and PEAChY-M

Acute severe behavioural disturbance (ASBD) is an emergency situation where a patient experiences severe agitation or aggression. These individuals commonly present to the emergency department (ED) for treatment. Medications are often provided to assist the person to feel calmer. In most instances, oral medications are used. When the patient is extremely agitated, an intramuscular (IM) injection will be given.

In individuals less than 18 years, there is minimal available evidence to guide doctors about which medications work best. It is also not known how well these medications are tolerated by these young people. Therefore, the PREDICT (Paediatric Research in Emergency Departments International Collaborative) network is running two trials across a number of Australian EDs to create evidence to be used to guide the treatment for these young people.

The first study (PEAChY-O) compares two oral medications - olanzapine and diazepam - to determine which medication works better. The second study (PEAChY-M) compares two IM medications – olanzapine and droperidol. These medications were chosen because they are used as standard of care in Australian EDs and are recommended on current Clinical Practice Guidelines (CPGs). These are important studies because they will be the first trials to compare any medications head-to-head in a randomised trial across either the oral or IM routes.
Once the results are available, they will be used to guide future clinical practice including influencing the recommendations made in Australian guidelines, ensuring that these young people receive evidence-based treatments.

Prothrombinex-VF® for coagulopathy of liver disease in acutely bleeding patients; Too much of a good thing?

Chronic liver disease (CLD) is prevalent in Australian society and is the 11th leading cause of premature death (1). Thirty eight percent of patients experience gastrointestinal bleeding (GI) as a complication(2). The underlying balance between bleeding and clotting tendency is altered in chronic liver disease, making management of acute bleeding challenging in the emergency setting(3). There is a lack of high-quality evidence to guide the best combination of blood products and other medications to stop bleeding(4).

Prothrombinex®-VF is a blood product which can help to improve the level of clotting factors in the body thereby reducing bleeding tendency. It is indicated for anticoagulant reversal in acute bleeding(5). In practice many emergency physicians have used the product for patients with chronic liver disease who present with acute bleeding, although it is not licensed for this indication(6).

A retrospective Queensland study performed by this author showed that half of Prothrombinex®-VF usage for liver disease was in the emergency department by emergency physicians. It suggested that the product makes little impact on reversal of laboratory blood clotting tests and it raised important safety concerns regarding the develop of a syndrome of accelerated bleeding and clotting concurrently(6).

This expanded statewide audit of Prothrombinex®-VF in chronic liver disease in Queensland seeks to define efficacy and safety of the product. There is no statewide guideline for Prothrombinex®-VF and this data will contribute valuable information to developing future guidance for clinicians.

Vasopressor Infusion via Peripheral vs Central Access in emergency department patients with shock – The VIPCA RCT

Shock is an umbrella description for poor blood supply to vital organs, and can lead to multi-organ failure and death. Emergency department (ED) patients with shock are amongst the sickest, with 1/3 being admitted to an intensive care unit (ICU). Low blood pressure, a key feature of shock which causes the poor blood supply to vital organs, can be treated with medications called vasopressors. Vasopressors traditionally have been given through a so-called 'central line'. Central lines are invasive to insert and require skill, and the actual insertion can lead to complications. More evidence has emerged that so-called peripheral lines (aka 'drip') are safe for vasopressor infusion. Randomised controlled trials (RCT) to compare the two strategies will provide high quality data to inform clinicians as to which approach is best for patients, staff and the healthcare budget. We propose a feasibility RCT to test processes and inform a large phase-III RCT to definitively answer this question.

Watch-house detainee emergency healthcare

In the acute phase of police detention, health concerns can emerge for detainees, especially around drug dependence, mental health conditions, and physical injury. In addition are system complexities including crowding.

In the event of an infectious disease outbreak (such as COVID-19), crowded conditions amongst a population with greater underlying burden of disease than the general population creates significant public health and economic concern. Furthermore, access to resources and expertise to manage health concerns in this environment can be challenging, especially in rural areas.

Researchers will interview key stakeholders involved with the care delivery and decision making of detainees, to identify innovative strategies to delivering healthcare in watch-house settings. This research will consider the decision making processes and costs associated with the delivery of healthcare in police watch-houses that may reduce the need for transfer to hospital emergency departments or reduce the potential for deaths in custody.

This research addresses the World Health Organisation’s (WHO) recommendation to understand how evidence-based health services can be provided for those requiring treatment, care and illness prevention whilst in police custody. It also identifies ways in which the need for expensive hospital stays can be minimised.

The expected impact of this research is the capability to identify and inform joined-up approaches so that cost-effective, safe, quality emergency care can be provided to detainees in police watch-house settings.

SONIC: Study of Neck Injuries in Children. A PREDICT study

Currently in Australia, children with suspected neck injuries undergo neck scans such as x-rays, computed tomography (CT) or magnetic resonance imaging (MRI). However these scans may carry risks from radiation exposure, and are often associated with discomfort and distress for young patients and the need for sedation.

Considerable emergency department time and costs are also associated with these scans and it is unclear when it can be safely avoided. Rules and tools can help doctors decide when scans are necessary. The SONIC study aims to look at whether existing rules for adults are also appropriate for use in children, and to develop and test a specific tool to help doctors decide which children need a neck x-ray or scan. The study will involve a large number of children across multiple hospitals in Australia and New Zealand. The research is expected to help researchers learn more about looking after children with neck injuries and hopefully allow us to safely limit the number of scans that need to be done.

The SONIC study is also supported by the Commonwealth of Australia through a MRFF Grant ID1199748 administered by the Murdoch Children’s Research Institute.

Prospective Observational study of cannulation of Kids in the Emergency (POKIE)

Paediatric peripheral intravenous cannula (PIVC) insertion is a frequently performed procedure in the emergency department (ED), which can result in significant distress for both the child and caregiver, particularly when there are multiple attempts. Children with difficult intravenous access (DIVA) are generally poorly recognised but several studies have developed prediction tools. Furthermore, the use of ultrasound (US) has been demonstrated to improve the success rate of paediatric DIVA patients when used as an adjunct.

This research will shine a spotlight on current practice in the largest mixed ED in Queensland, which aims to determine factors contributing to paediatric DIVA patients and attitudes towards the use of US to assist first pass success. Furthermore, this background data will lay the foundation to inform an interventional trial using US to improve PIVC practices for children in the ED. Novice researchers in this project will be well supported by a research team with a strong track record of completing projects that can impact patient care