Category: modules

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 Rule



Suspected lower limb DVT



Suspected Pulmonary Embolism



Acute low back pain



Cervical spine trauma



Head trauma


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

Local anaesthetic

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

Remove syringe

Feed guidewire, remove needle

Confirm position of wire with US before dilating

Dilate vein

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


Aseptic technique


Local anaesthetic

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:

EMCrit-RACC / EHPR Part 5: Using Mental Practice and Visualization Exercises by Mike Lauria


Sepsis pathway

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
Sepsis Pathway Emergency Final 17.10.18


  • empiric antibiotics, grouped by suspected source
Sepsis empiric therapy_V11_9.10.18


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.

Anaphylaxis notifications

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