Noel Stevenson Research Scholarship: Dr Colin Page

Dr Colin Page was awarded the Noel Stevenson Fellowship (in honour of eminent Queensland emergency medicine physician, Dr Noel Stevenson) to undertake a Doctorate of Philosophy (PHD). Dr Page is studying the antidotes and treatments that are commonly used by medical staff when looking after patients who are affected by drug toxicity. The PhD will be based at Princess Alexandra Hospital within the clinical toxicology unit with extension to other toxicology units/hospitals within Australia. It will be undertaken through the University of Newcastle (NSW) under the supervision of A/Prof Geoff Isbister and Prof Nicholas Buckley, who are both leaders in clinical toxicology research publications.

Dr Page has developed a clinical toxicology service at Princess Alexandra Hospital and Queensland through a locally run clinical toxicology unit and is the honorary medical director of the Queensland Poisons Information Centre. Clinical toxicology is the speciality that manages patients who are affected by drug toxicity either accidentally or in overdose. The project will primarily research antidotes and other treatments that are used in the management of toxicology patients. This will allow the introduction of safer treatments, new treatments and progressing the scientific basis behind treatments used in clinical toxicology.

Australia, Asia and New Zealand Dyspnoea in Emergency Departments Study

Shortness of breath (dyspnoea) is a terrifying symptom experienced by patients and is a common reason for presentation to Emergency Departments. There are a wide range of causes including flair up due to chronic conditions such as asthma, heart failure, chronic lung disease or liver or kidney failure. Acute conditions such as a collapsed lung, chest infection (including pneumonia), trauma (including fractured ribs), airway blockage or an allergic reaction can also be the cause.

There is significant knowledge about patients who are admitted to hospital with common causes, however there is little conclusive information about Dyspnoea as a symptom, the distribution of causes, the proportion of patients requiring admission and whether treatment complies with evidence-based guidelines.

A recent pilot study in Europe found that 53 per cent of patients had a respiratory cause for symptoms, 22 per cent had a cardiac cause, and 15 per cent had both cardiac and respiratory components. Almost two-thirds were admitted to hospital with over one-third discharged from ED. However, in many ways, the study raised more questions than it answered. The study was also too small to comment on adherence to evidence-based guidelines.

For that reason, a larger EuroDEM (digital elevation model) study is planned for 2014. The study will be complemented by the Australia, Asia and New Zealand Dyspnoea Departments of Emergency Medicine (AANZDEM) which will collect data from a different region with different systems of care. It will focus on the range of causes, variation over seasons and geographical areas, and compliance with recommended treatments.

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.

Morale, stress and coping strategies of staff working in the emergency department: a national and international comparison.

Workplace stress in the emergency department (ED) is an internationally recognised issue. It is important to understand how ED staff cope with the stressors within their working environment. The overall aim of this study was to describe and compare the impact of the working environment and varied coping strategies amongst medical and nursing staff working in Emergency Departments (ED) in Australia and Sweden.

The HALT-IT trial: Tranexamic Acid for the Treatment of Gastrointestinal Bleeding, an International Trial

Gastrointestinal (GI) bleeding is a common emergency with a substantial mortality rate. Bleeding from the upper gastrointestinal system is caused by ulcers, stomach inflammation and oesophageal varices and carries a fatality rate of up to 10%. Lower GI bleeding has a variety of causes and a case fatality of about 15%. Between 10% and 25% of patients will have a repeat bleed after their first episode, and these people are four times more likely to die than people without repeated bleeding.

The clotting of blood helps to stem bleeding and blood clot break down may play an important role in GI bleeding and re-bleeding. Tranexamic acid (TXA) is a drug used to reduce clot breakdown. It has been shown to reduce the probability of requiring a blood transfusion by about a third in surgical patients, without causing serious side effects from promoting clotting. This high quality randomised controlled trial will investigate the effectiveness and safety of TXA in GI bleeding.

Supplementing Pain Management in the ED – Conventional Treatment versus Intravenous Adjunctive Low Dose Ketamine (SPECIAL-K).

Pain is a common feature of major traumatic injuries. Little research has been done into the utilisation of low dose Ketamine for analgesia in the ED. Ketamine has the potential to be a highly effective method of analgesic management in haemodynamically unstable trauma patients who are unsuitable for large doses of opioid drugs but it is not utilised for this purpose due to a lack of supporting evidence and clinical concern about potential side effects. The clinical impact of this trial is in the development of an evidence base to support the use of Ketamine for analgesic purposes in the ED. Our hypothesis is that low-dose Ketamine provides effective (statistically significant reduction in pain score), safe (low rates of emergence and adverse events) and tolerable (patient reported effects/willingness to use again) analgesia when used in sub-anaesthetic doses in patients with traumatic injuries. If proven this will have significant implications for the clinical care of patients and in pain management guidelines with traumatic injuries in the ED.

Magnesium in Irukandji Syndrome Trial (MIST).

This research project did not commence.

Serum catecholamine levels in Irukandji Syndrome (IS)

Irukandji Syndrome (IS) is a condition caused by the venom of jellyfish found in the tropical waters of Australia and has received significant media attention over the past decade. The syndrome most commonly presents with a variable combination of severe generalised pain, involving the torso and limbs, nausea and vomiting, sweating, headache and severely elevated blood pressure and pulse. Documented complications of IS include myocardial (heart) damage and failure, intracerebral haemorrhage (bleeding on the brain) and death.

The signs and symptoms of IS are believed to be due to excessive release of endogenous catecholamines (stress hormones). A number of in-vitro and animal studies have documented elevated adrenaline and noradrenaline levels after exposure to venom from Carukia barnesi and related jellyfish. To date, no human trials have measured serum catecholamines in patients with suspected IS.

This elevation in serum catecholamines may account for the profoundly elevated blood pressure and heart rate seen with IS. However, it is unclear what association the severe generalised pain of IS has with elevation of the endogenous catecholamines, i.e. cause or effect. The research team will conduct a prospective, observational, case-control study on patients with IS at The Townsville Hospital to measure serum levels of noradrenaline and adrenaline.

Validating the Manchester Acute Coronary Syndromes (MACS) Clinical Decision Rule

Diagnosis of heart attack (acute myocardial infarction) relies on troponin testing along with additional inpatient investigations. Researchers in the United Kingdom have developed a clinical decision rule (the MACS rule) for avoiding unnecessary hospitalisation for patients with chest pain. The MACS rule places individuals into four risk groups with suggested dispositions for each group, with the very low risk eligible for immediate discharge. Initial validation of the rule revealed that 31.5% of patients met the low risk criteria and so could be discharged from hospital with no further investigation. Of these patients, none had a heart attack within 30 days.
This study will conduct an external validation of the MACS rule using a sample of 1000 patients who presented to the Royal Brisbane and Women’s Hospital emergency department with chest pain. If the MACS rule accuracy identifies a group of patients who do not have a heart attack, it could be used in clinical care to rapidly rule out heart attack, decrease resource utilisation and ensure that patients are not subjected to unnecessary testing in hospital.

A randomised controlled trial of intravenous paracetamol and oral paracetamol to control acute pain

Pain is a common reason for presentation to the emergency department. In 78–86% of Australian emergency department presentations pain is a primary component and therefore represents a major clinical care issue. However, numerous studies have shown that pain is poorly managed in the emergency department.

This project aims to provide evidence that intravenous (IV) paracetamol produces superior analgesia than oral paracetamol in the emergency department setting and that IV paracetamol produces good patient satisfaction, few side-effects and reduced length of hospital stay. To date the majority of trials into the effectiveness of IV paracetamol have focused on specific disease states and, to the research teams’ knowledge, no trials have been conducted to assess the efficacy of IV paracetamol in the Australian emergency department setting.