Better ways of pain management in adults with hip fractures

Hip fractures are extremely painful yet medications which are usually used to manage the pain can have significant complications, particularly in frail individuals. Numbing medications injected into the groin on the side of the hip fracture have been shown to decrease pain, confusion and chest infections in patients with hip fracture awaiting an operation.

It is usual for most patients presenting to emergency departments with a hip fracture to get a single injection of numbing medication. What isn’t known is whether multiple regular doses of numbing medications injected regularly via a plastic tube in the groin are more effective than a single injection in managing the pain of hip fractures.
The purpose of this study is to show multiple regular doses of numbing medications are better than a single injection. This will be achieved by examining the difference in the amount of pain, the quantity of pain medications, and the degree of confusion between the patients getting multiple doses and those getting a single injection.

This study will be the first of its kind to be done in an emergency department and is also unique in that it will involve patients with dementia who make up more than a third of patients with hip fracture and are usually excluded from studies. The study is expected to help manage the pain of the 1.6 million hip fracture patients worldwide and give emergency doctors an additional option of managing hip fracture pain.

First aid oxygen treatment of divers with decompression sickness

Decompression sickness (DCS), commonly called the bends, involves formation of gas bubbles in the body following scuba diving. These bubbles can cause a variety of problems, ranging from minor aches and pain, to severe stroke-like symptoms. Providing pre-hospital oxygen therapy at the highest concentration possible provides needed oxygen to body tissues, reduces bubbles and can often relieve symptoms. Oxygen has been shown to reduce the number of hyperbaric treatments a diver with DCS will require so improving pre-hospital oxygen delivery will lead to decreased hospital costs. However, the ideal oxygen delivery system has not been determined.

Using new techniques and equipment, this research will identify the optimal device for delivering oxygen to divers with DCS leading to recommendations which will improve the health outcomes of injured divers. We will measure how effectively varied breathing devices deliver oxygen to the body tissues and remove bubbles from the diver’s blood while assessing innovative equipment. This study will assess a new commercially available oral mask to improve oxygen delivery with a demand system. A medical oxygen re-breather, which like an anaesthetic machine absorbs carbon dioxide and adds small amounts of oxygen to the breathing circuit, will be also assessed.

Assessing the use of these devices will not only determine their efficacy to deliver oxygen to injured divers but also provide guidance on appropriate systems to use for dive operators with limited medical oxygen. Assessing the change in bubble grade with oxygen delivery will add evidence for its use. This research will provide information that can guide pre-hospital and emergency clinicians when choosing the type of oxygen delivery devices used for injured divers improving patient outcomes and decreasing costs.

Ketamine versus propofol in sedation of psychiatric patients requiring retrieval

In this study, we will compare the safety and effectiveness of ketamine and propofol in sedating acute psychiatric patients needing aeromedical retrieval. We believe that this is the first trial of its kind which will elucidate the complications, the safety profile and effectiveness of the two drugs in sedating acute psychiatric patients. The study will be a prospective, open-labelled, randomised controlled trial. Patients will be drawn the Northern Territory and Queensland. Through this study, we will better inform clinicians in their choice of a suitable sedation agent and potential provide an additional sedation choice in aeromedical and other critical care environments. Furthermore, this research has the potential to establish sedation guidelines in the aeromedical retrieval of acute psychiatric patients for Australia and internationally.

Research Scholarship Grant Dr Jeremy Furyk

Status epilepticus (SE) occurs when seizures do not stop spontaneously and can result in long-term disabilities and occasionally death. There is a paucity of high quality evidence on SE, particularly in children and causes and outcomes are different from adults. This program of research on SE uses mixed methods to address this gap in knowledge. The research includes identifying consensus research priorities among experts and a qualitative evaluation of alternatives to informed consent (which is a potential barrier to prospective emergency research).

Research Scholarship Grant: Dr Jeremy Furyk

The importance of good quality clinical trials in health care is being increasingly recognized worldwide. The London School of Hygiene & Tropical Medicine (LSHTM) is the leading postgraduate medical institution in Europe in the subjects of public health and tropical medicine.
The Master of Science in Clinical Trials, conducted online, aims to provide those with some experience in the area of clinical trials to broaden their role in design, management, analysis and reporting of clinical trials.

The first year of the course covers the core topics of; fundamentals of clinical trials, basic statistics for clinical trials, clinical trials in practice and reporting and reviewing clinical trials. Techniques, and methods learnt from the course will directly benefit the Emergency Department at Townsville and with emergency medicine research activities at the hospital and within the region.

Capacity Building Grant: The Townsville Hospital

The Townsville Hospital Emergency Department (ED) aimed to increase research capacity in the ED . The vision was to create a sustainable research culture within the ED, with a positive research profile and a clear point of contact making Townsville attractive for collaborative research and to establish a track record of research success and outputs ensuring the long-term future of ED research.

Noel Stevenson Research Scholarship: A/Prof Peter Aitken

Disasters have caused the loss of more than 12 million lives and affected more than 50 million people in the past 50 years alone. Disasters involve not just more patients, but a different type of patient in a system under extreme stress. Emergency Departments (ED), as the ‘front door’ to the health system are a key part of the disaster response and a well prepared ED is essential to save lives. Being prepared involves education and training however disaster health education is not well developed in Australia. The research program aim is the development of a disaster education framework for the health workforce in Australia. This framework will incorporate learning needs and identify strategies to meet them in a manner which is both cost and outcome effective. A key outcome will be development and evaluation of a post graduate qualification in disaster health consistent with this framework. The current state of education in disaster health in Australia will be reviewed including a comparison of strategies used, relative effectiveness and barriers to success. Common problems will be identified from literature and Australian experience to help target educational priorities. This will include ED and Australian teams deployed overseas, many of whom were ED staff. A secondary aim is development of a network to strengthen both emergency medicine response to disasters and disaster health research.

Drugs for the treatment of nausea and vomiting in adult patients in the emergency department setting

Nausea and vomiting is a common and distressing presenting complaint in emergency departments. Nausea describes the unpleasant sensation of the imminent need to vomit, whereas vomiting refers to the forceful oral expulsion of gastric contents associated with contraction of the abdominal and chest wall musculature. The complications from nausea and vomiting can range from trivial to serious, such as dehydration and oesophageal rupture.

High level evidence supports the use of antiemetics in the management of nausea and vomiting in many settings and populations, however there is little guidance or consensus in recommendations for the management of nausea and vomiting in the adult emergency department setting. Recommendations are inconsistent and rarely evidence based. It is not possible to extrapolate this evidence from other treatment settings to the emergency department population because of differences in aetiologies, patient populations and other factors.

Using the strict methodology outlined by the Cochrane collaboration, we will conduct a systematic review of randomized controlled trials (RCTs) of antiemetic agents in the management of nausea and vomiting in the emergency department setting.

Ketamine IntraNasally Delivered in the Emergency Room: KINDER

Sick and injured children in the Emergency Department (ED) often require procedures which can cause severe pain (like fracture reduction, stitching wounds, abscess drainage) or otherwise require the child to be still and cooperative (CT scans, lumbar punctures, removal of foreign bodies). Sedative drugs are given to these patients both to relieve pain/distress and to keep them still for the procedure.

ED sedation of children now has a well established body of evidence. Most of the literature relates to when the drug is given intravenously or intramuscularly. Drug delivery by these routes leads to reliable effects as the drug bypasses the liver without being broken down before it reaches the brain. However, both these routes require a needle which requires staff to hold down a young child against their will, frequently causing great distress along with the pain of the needle. Great efforts have gone into making EDs "Ouchless" where unnecessary pain for children is reduced or eliminated. Sedation is itself part of this effort. The intranasal route (injecting the medicine up the nose with a plastic syringe) could represent a needle-free alternative.

Ketamine is the most common drug used for paediatric sedation in Australian EDs and can be given intranasally. No studies have examined its use for ED sedation but many studies support its use in anaesthetics and dental clinics where it has been shown to be safe and effective.

A Prospective Observational Cohort Study of Paediatric Status Epilepticus in Emergency Departments of Australia and New Zealand. The Status Epilepticus Australasian Registry for Children (SEARCh)

Convulsive status epilepticus (CSE) occurs when seizures do not stop spontaneously. It is the most severe form of epilepsy, and can result in long-term disabilities and rarely death. It can affect both adults and children, although the causes and outcomes are different in these groups of patients. Treatments of patients with CSE are largely based on expert opinion rather than strong evidence, due to the difficult nature of conducting quality trials in patients with this relatively infrequent condition in the emergency setting. We will determine the incidence and causes of CSE in children in Australia and New Zealand and collect information on the type of seizure, duration, treatment and outcome to determine ways to improve the management of children with CSE.