Nitrous Sedation procedure
Troubleshooting the ventilator
Choosing Wisely campaign
Review the 6 radiology related pathways from the Choosing Wisely campaign, which will be implemented soon.
Most of these are well known to ED clinicians and should already form the backbone of your clinical practice.
If you are unaware of these feel free to review them and discuss with a senior member of staff.
The PE flowchart is complex although can be distilled down – you should first start with a good grasp of the Well’s score and the PERC rule.
Acute Ankle trauma and the Ottawa Ankle RuleRANZCR-Clinical-Decision-Rules-pages-8-11
Suspected lower limb DVTRANZCR-Clinical-Decision-Rules-pages-12-13
Suspected Pulmonary EmbolismRANZCR-Clinical-Decision-Rules-pages-15-23
Acute low back painRANZCR-Clinical-Decision-Rules-pages-25-29
Cervical spine traumaRANZCR-Clinical-Decision-Rules-pages-30-39
NEW TROPONIN – OLD TIMI
Thanks to Prof Anne-Maree Kelly for her update on the new troponin assay.
She has provided a flowchart and FAQ below for you to review.
Please also see the TIMI scoring worksheet, for those unfamiliar with the TIMI score.Hs Trop flow diagram.7 Nov 18 (1)
Troponin change FAQ_corrected (1)
walking through the central line
we discovered at registrar training last week that many of our team had not placed a central line so here is a walk through the process….
Why does the patient need CVC – access, multiple lumens, centrally active medications, monitoring
Where should the CVC go – IJ, subclavian, femoral
Position – complications to lying flat, Trendelenburg, sedation/intubated
Potential complications – bleeding, pneumothorax, failure
Consent the patient – procedure, options, complications (pain, allergic reaction, bleeding, pneumothorax, infection, failure, neuropraxia)
Set it up yourself
US – cover, sterile gel, positioning
Procedure tray – large area
Dishes – antiseptic wash, saline, disposing sharps
CVC kit – introducer/seeker, guidewire (check glides, some unwrap but care doesn’t become unsterile), dilator, CVC – check each lumen/leave brown uncapped, caps, adjustable hubs)
Syringes – 5ml for local, 20ml for saline + needles
Gown, gloves, mask, goggles, drapes
Suture material and instruments
Antiseptic skin wash
Clear dressing to fix line
Team – performing clinician, assistant, supervising doctor, backup
Monitoring of patient – ECG (BP + Sats if sedated)
Nurse in charge aware
Check vein with US first – position, anatomy, thrombus
Position patient/US/procedure tray/staff to monitor
Scrub hands, glove + gown
Wash patient + drape – large sterile area
Draw up LA
Position equipment in order of use so easy to reach
Check CVC lumens with saline flush + leave brown lumen uncapped
US to identify vein
50mg lignocaine with adrenaline into skin
Seeker needle with saline in syringe, using US in longitudinal to guide and cannulate vein
Hold with other hand to fix position on skin
Feed guidewire, remove needle
Confirm position of wire with US before dilating
Feed CVC with one hand always holding guidewire (care that wire does not become unsterile), depth determined by line markings 10-15cm – confirm ECG trace
Remove wire – announce to staff to document
Aspirate and flush each lumen before capping
Fix to skin with hub (clamp and fastener)
Suture 4 points (hub and distal) position
Cover with clear dressing
Confirm position with CXR
Dispose of sharps/wire and biohazard material
Vein cannulated – number of attempts
Guide wire inserted, vein dilated, CVC inserted, GUIDE WIRE REMOVED, fixed at “x”cm
Confirmed with CXR – position in SVC at junction with RA (level of right main bronchus), no pneumothorax
For more information about MENTAL REHEARSAL and how this can help in critical situations and performing procedures, read this link:
/ EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria
There is a new sepsis pathway which will rollout 5th November at Western Health. The pathway contains two important and useful components:
- a bundle of actions to execute within the first 60 minutes of suspicion of sepsis
- empiric antibiotics, grouped by suspected source
There is an opt-out box to tick, should you, as the treating clinician, feel that sepsis is NOT likely – in ED these patients may include presentations such as likely viral illness, simple pharyngitis/tonsillitis or simple gastroenteritis.
There are new MANDATORY anaphylaxis notifications that have been issued by the Department of Health that are IN EFFECT as of 1st November 2018.
You can read the entire document below but the most important parts have been extracted below:
What to notify?
ALL cases of anaphylaxis that present to our emergency department – regardless of whether symptoms have improved or not, and regardless of whether the trigger is known or not.
Urticaria or angioedema, if occurring in isolation, do not need to be reported.
Cases of anaphylaxis that occur whilst in hospital, curiously, do not need to be reported.
How to notify?
Where the suspected cause is the consumption of a packaged food:
Notifications are required to be made:
immediately (within 24 hours of diagnosis),
by telephone (1300 651 160, which is staffed 24 hours a day, seven days a week),
• with the details listed in the ‘notification details’, below, to the departmental staff member.
If in doubt about whether the suspected cause was a packaged food, hospitals are advised to
use this notification route.
Where the suspected cause is anything other than packaged food
Notifications are required to be made:
• within five days of initial diagnosis of anaphylaxis,
• electronically via the online form through the department’s website at
and click on the link in the notification table for anaphylaxis,
• with the details listed in ‘notification details’, below.
Anaphylaxis notifications guidance Oct 18
This poster was created by Simon Green, a nurse practitioner, and modified for use at Western Health by Ian Law and Neil Long
SMS: Thinking about paediatrics
Thanks to A/Prof Dr David Krieser for his presentation at Senior Medical Staff teaching in October 2018.
His talk has been broken into 3 parts:
- Don’t Forget the Bubbles recap
2. Paediatric cases and paediatric deaths in ED
3. ED redevelopment and other shortcuts in paeds ED