In this April issue.

Abstract

Between 2004 and 2017, ED presentation rates increased across most mental health (MH) diagnostic groups, most notably for psychoactive substance use-related disorders. To reduce MH crisis care in Australian EDs, a key strategy must be the reduction of psychoactive substance use in the community. Policies are also needed to strengthen the capability of community MH services and primary care professionals to recognise, diagnose and treat MH patients in the community. This is the second of three papers reporting data for MH ED presentations in Australia. The first was published last year, and the third will be published soon. We publish two papers that look at the safety of vasopressors when given peripherally. One paper is a systematic review, and the other reports data from the ARISE trial. The former concludes that extravasation is uncommon and is unlikely to lead to major complications when administration is for a limited time and the patient is under close observation. The latter paper reports that starting a vasopressor infusion peripherally was common in the ARISE trial, was more frequent in trial participants with higher severity of illness and was associated with some improvements in processes of care. After adjustment, it was not associated with an increased risk of death. Variation in the management of paediatric head injury occurs worldwide. A large prospective study of 20 137 children (under 18 years) describes imaging and admission practices of children presenting with head injury across 10 hospital EDs in Australia and New Zealand. All presentations with head injury without prior imaging were eligible for inclusion. The authors conclude that, across the 10 largely tertiary EDs included in the study, the overall rate of computerised tomography of the brain was low, with no significant variation between sites. Although Emergency Medicine is a profession with complex clinical and leadership demands, studies of leadership in it are in their infancy. An online Delphi study of 87 Australasian Directors of Emergency Medicine explores this in detail. Participants were sorted into four panels reflecting their leadership experience and geographical location. The authors recommend that Directors of Emergency Medicine must engage in programmes to support the development of leadership and non-clinical skills to enable them to cope with the responsibilities of the hybrid role of physician-leader. The development and delivery of specialised leadership programmes attuned to the hybridity of the Director role and the complexity of hospitals is vital for ensuring high-quality patient care and successful running of departments. A group from Monash explored women's expectations and experiences when presenting to the ED with early pregnancy bleeding. Using a qualitative methodology and two semi-structured interviews (before and after), 22 women completed the follow-up interview. Four themes relating to the patient experience were identified. Pregnancy bleeding is a distressing and anxiety-provoking experience for women attending the ED. Appropriate emotional support is critical for good holistic care. A group from Geelong examined the characteristics, outcomes and flow of patients over the age of 45 years with a life-limiting illness (LLI) presenting to a regional ED. Of patients, 12% had an LLI. This group was older, had a significantly longer median length of stay in ED and was less likely to leave the ED within 4 h. Of patients with an LLI, 46% had some form of advanced care documentation. Patients with an LLI were more likely to require hospital admission. Haemorrhage in paediatric trauma is a significant cause of morbidity and mortality. There is an increasing focus on the role of fibrinogen in traumatic haemorrhage and the association of low fibrinogen levels with poor patient outcomes. There is also a move towards using viscoelastic haemostatic assays to rapidly assess coagulation status and guide clinicians in the replacement of coagulation factors. In children, there is limited uptake of these principles and a paucity of data to support a change in practice. The early identification of hypofibrinogenaemia and acute traumatic haemorrhage in paediatric trauma using viscoelastic haemostatic assay testing and subsequent early fibrinogen replacement with a concentrated off-the-shelf product is an attractive treatment option. There is currently insufficient good evidence to support the use of fibrinogen concentrate over cryoprecipitate in paediatric trauma. Time-based targets have been part of the EM culture for nearly 20 years after their introduction in the United Kingdom. One area of concern has been the impact these targets have on the training of trainees.