Emergency medicine

Objectives: To assess the capacity of intensive care units (ICUs) in Australia to respond to the expected increase in demand associated with COVID‐19. Design: Analysis of Australian and New Zealand Intensive Care Society (ANZICS) registry data, supplemented by an ICU surge capability survey and veterinary facilities survey (both March 2020). Settings: All Australian ICUs and veterinary facilities. Main outcome measures: Baseline numbers of ICU beds, ventilators, dialysis machines, extracorporeal membrane oxygenation machines, intravenous infusion pumps, and staff (senior medical staff, registered nurses); incremental capability to increase capacity (surge) by increasing ICU bed numbers; ventilator‐to‐bed ratios; number of ventilators in veterinary facilities. Results: The 191 ICUs in Australia provide 2378 intensive care beds during baseline activity (9.3 ICU beds per 100 000 population). Of the 175 ICUs that responded to the surge survey (with 2228 intensive care beds), a maximal surge would add an additional 4258 intensive care beds (191% increase) and 2631 invasive ventilators (120% increase). This surge would require additional staffing of as many as 4092 senior doctors (245% increase over baseline) and 42 720 registered ICU nurses (269% increase over baseline). An additional 188 ventilators are available in veterinary facilities, including 179 human model ventilators. Conclusions: The directors of Australian ICUs report that intensive care bed capacity could be near tripled in response to the expected increase in demand caused by COVID‐19. But maximal surge in bed numbers could be hampered by a shortfall in invasive ventilators and would also require a large increase in clinician and nursing staff numbers.

Edward Litton · Tamara Bucci · Shaila Chavan · Yvonne Y Ho · Anthony Holley · Gretta Howard · Sue Huckson · Philomena Kwong · Johnny Millar · Nhi Nguyen · Paul Secombe · Marc Ziegenfuss · David Pilcher

Herpes zoster ophthalmicus (HZO), a condition that affects the ophthalmic division of the trigeminal nerve, is caused by reactivation of latent varicella zoster virus;1,2 about 10% of people with varicella zoster infections experience HZO.1 Over the past decade, the number of emergency department presentations by people with herpes zoster in Australia has increased by 2–6% per year, and the number of people with herpes zoster managed in general practice has almost doubled.3 The purpose of our study was to develop a contemporary perspective of the clinical presentation, incidence of complications, and treatment practice for patients with HZO referred to an Australian tertiary eye hospital. We performed a retrospective audit of digital health records of the first 100 consecutive patients who presented to the Royal Victorian Eye and Ear Hospital (RVEEH) emergency department with HZO during July 2017 – July 2018. The investigation was approved by the Human Research Ethics Committee of the Hospital as a quality control project (reference, 18/1416HL). The clinical features at the time of presentation of the 100 patients are summarised in the Box. Sixty‐five patients initially presented to their general practitioner, 20 to a hospital emergency department, and 15 directly to the RVEEH. The mean time between rash onset and presentation to a GP or emergency department was 3.3 days (range, 0–14 days). For 51 patients, treatment commenced before presentation to the RVEEH (famciclovir, 27; valaciclovir, 16; acyclovir, 6; two patients had received no topical treatment); treatment had commenced within 72 hours of the rash developing for 36 of these patients (71%). The recommended dose and frequency were prescribed for 16 of the 51 patients: famciclovir (500 mg three times a day), two patients; valaciclovir (1 g three times a day), 12 patients; acyclovir (800 mg five times a day), two patients. For 29 patients, antiviral therapy was prescribed at lower than the recommended dose (famciclovir, 21 patients; valaciclovir, two patients; acyclovir, two patients) or prescribed as a topical treatment (acyclovir, two patients); the prescribing information was not documented for five patients. Nineteen of the 68 patients who attended follow‐up 7–14 days after their initial presentation to the RVEEH presented with ocular symptoms regarded as late complications, including four with more than one complication. Eight of 29 patients (29%) who had not commenced systemic antiviral therapy within 72 hours of rash onset developed late complications, as did 13 of 71 patients (18%) who were treated within 72 hours (Fisher exact test: P = 0.78). We found concerning variations in timing and practice of treating HZO, despite recognised clinical guidelines.4,5 This may be partly explained by diagnostic uncertainty caused by the variability of clinical signs during the early stages of HZO,6 and by an earlier discrepancy between the famciclovir dosing recommended by therapeutic guidelines (250 mg three times a day) and recommendations based upon the results of a clinical trial4 (500 mg three times a day). This discrepancy has since been resolved in the therapeutic guidelines.4 Our findings suggest that education of all health care professionals involved in the care of patients with HZO needs to be improved. Clinical practice guidelines must provide clear and consistent information about managing HZO. Box – Demographic characteristics and clinical features of 100 consecutive people presenting with herpes zoster ophthalmicus to the Royal Victorian Eye and Ear Hospital, July 2017 – July 2018 Characteristic Sex (men) 52 Age at presentation (years), median (IQR) 59 (39–76) Age at presentation (years), range 16–93 Clinical features at presentation Best‐corrected visual acuity ≥ 6/12 62 Intra‐ocular pressure (mmHg), mean (SD) 15.4 (5.9) Rash 92 Pain 63 Conjunctivitis 62 Lid swelling 53 Skin erythema 41 Anterior uveitis 26 Keratitis 20 Other* 6 Late complications 19 Uveitis 11 Keratitis 5 Other† 3 IQR = interquartile range; SD = standard deviation. * Raised intra‐ocular pressure, retinitis/choroiditis, optic neuritis, cranial nerve palsy. † Neuralgia, elevated intra‐ocular pressure.

Rahul Chakrabarti · Grace George · Kristen Wells · Carmel Crock

Objectives: To evaluate the impact of the Victorian Stroke Telemedicine (VST) program during its first 12 months on the quality of care provided to patients presenting with suspected stroke to hospitals in regional Victoria. Design: Historical controlled cohort study comparing outcomes during a 12‐month control period with those for the initial 12 months of full implementation of the VST program at each hospital. Setting: 16 hospitals in regional Victoria that participated in the VST program between 1 January 2010 and 30 January 2016. Participants: Adult patients with suspected stroke presenting to the emergency departments of the participating hospitals. Main outcome measures: Indicators for key processes of care, including symptom onset‐to‐arrival, door‐to‐first medical review, and door‐to‐CT times; provision and timeliness of provision of thrombolysis to patients with ischaemic stroke. Results: 2887 patients with suspected stroke presented to participating emergency departments during the control period, 3178 during the intervention period; the patient characteristics were similar for both periods. A slightly larger proportion of patients with ischaemic stroke who arrived within 4.5 hours of symptom onset received thrombolysis during the intervention than during the control period (37% v 30%). Door‐to‐CT scan time (median, 25 min [IQR, 13–49 min] v 34 min [IQR, 18–76 min]) and door‐to‐needle time for stroke thrombolysis (73 min [IQR, 56–96 min] v 102 min [IQR, 77–128 min]) were shorter during the intervention. The proportions of patients who received thrombolysis and had a symptomatic intracerebral haemorrhage (4% v 16%) or died in hospital (6% v 20%) were smaller during the intervention period. Conclusions: Telemedicine has provided Victorian regional hospitals access to expert care for emergency department patients with suspected acute stroke. Eligible patients with ischaemic stroke are now receiving stroke thrombolysis more quickly and safely.

Chris F Bladin · Joosup Kim · Kathleen L Bagot · Michelle Vu · Natasha Moloczij · Sonia Denisenko · Chris Price · Nancy Pompeani · Lauren Arthurson · Casey Hair · Justin Rabl · Mick O'Shea · Patrick Groot · Leslie Bolitho · Bruce CV Campbell · Helen M Dewey · Geoffrey A Donnan · Dominique A Cadilhac

The impact of discharge destination on outcomes after treatment for orthopaedic trauma requires further investigation

Lara A Kimmel · Pamela M Simpson · Anne E Holland · Elton R Edwards · Peter A Cameron · Richard S Steiger · Richard S Page · Raphael Hau · Andrew Bucknill · Jessica Kasza · Belinda J Gabbe

To the Editor: Currie and colleagues highlight the important topic of animal vaccines as occupational hazards and the need for improved clinician advice to manage patients safely.1 The article title describes “high pressure” injections, yet the oil emulsion vaccine of most concern, against ovine Johne's disease, is delivered via a standard needle injection. All accidental mineral oil injections are of concern (as are all high pressure injections). Appropriate identification and advice can be obtained by contacting a Poisons Information Centre (PIC). This was not discussed by Currie and colleagues, although it was recommended in a reference they cited.2 Unlike some vaccine manufacturers, the publicly funded PIC service provides 24‐hour emergency medical advice (131 126) for the public and health professionals. PICs access the Australian National Poisons Register, which allows rapid identification of the dozens of oil‐containing vaccines. Currently in Australia, oil adjuvant vaccines lack clear labelling to identify the presence of oil on the front packaging. Increased prominence would aid recognition, similar to initiatives for active ingredients within human therapeutic products. Indeed, review of the unscheduled status of most animal vaccines is required as they possess a risk assessment profile at odds with the Scheduling Policy Framework.3 Improved pharmacovigilance of veterinary products (and agrochemicals) is urgently required, particularly regarding the risks posed to human health. Unpublished analysis of data from Australian PIC annual reports identified about 2000 cases annually of human exposures to veterinary pharmaceuticals. We recently reported on human exposures to veterinary pharmaceuticals from New South Wales PIC calls from 2014 to 2016, with 30 exposures to Johne's disease vaccine alone.4 Collectively, PICs have over 20 times the number of reports to the designated authority for post‐market surveillance; the Australian Adverse Experience Reporting Program run by the Australian Pesticides and Veterinary Medicines Authority received 91 reports for human effects from registered veterinary medicines and agricultural chemical products combined in 2015.5 There is an opportunity for PICs to be engaged more efficiently in surveillance, which would allow the collection of additional information through follow‐up calls to understand risk factors, evaluate outcomes and recommend interventions to prevent future injuries. This would facilitate improvements in management of human exposures to veterinary pharmaceuticals to protect occupational health.

Jared A Brown · Nicholas A Buckley · Rose Cairns · Claire E Wylie

Christmas is known for festive decorations

Paul Heyworth · Ryan Shulman

Essential oil exposures are frequent in Australia, and more than half involve children

Kristenbella AYR Lee · Joanna E Harnett · Rose Cairns

An 88-year-old woman presented with 2 months of right upper quadrant pain, weight loss, and 3 days of fevers

Sudharsan Venkatesan · Henrik Falhammar

Greater coordination is needed to shift from a “mantle of safety” to providing adequate health care for rural and remote Australians

Peter Aitken

Achieving gender equity in intensive care medicine requires specific interventions to attract and retain female trainees and support their progress to leadership roles

Lucy J Modra · Sarah A Yong

… but how are we deciding which patients are selected for ICU referral and admission?

Alison M Mudge

To the Editor: A 40‐year‐old man with no past medical history presented to the emergency department complaining of a painful red rash across his back, which he noticed when he undressed at home after work. On examination, the patient was systemically well with normal vital signs. He had a non‐blanching, band‐shaped erythematous rash across his upper back, with no associated vesicles, consistent with a first degree burn. The patient worked as a field environmental engineer and was required to wear high visibility shirts throughout his working day. It was noticed that the band‐shaped rash coincided with the upper high visibility band on his work shirt (Box). The patient also reported that the high visibility tape on his shirt often becomes extremely hot when he works out in the sun, and he occasionally has to change position so the shirt does not touch his skin in that area. The rash was managed as a first degree burn, with emollient aloe vera cream and simple analgesia. Retroreflective tape is used on work clothing to increase the wearer's visibility to others, especially in the dark. It usually consists of minute glass beads or prismatic elements encapsulated in a transparent film, which reflect light back towards its source. Safety warnings mention cases of increased heat build‐up around shoulders, neck and ears, but no cases have been published in the medical literature. Skin abrasions have also been described when aged tape cracked and frayed was brushed against the forehead.1 The manufacturers also warn about the tape risk to smoulder or melt when subjected to heat. To the authors' knowledge, this is the first reported case of skin burns occurring secondary to overheating of retroreflective tape. Even though not life‐threatening, it caused discomfort to the patient for a few days. Workplaces mandating clothes with retroreflective tape should ensure that garments with the tape in areas touching the skin are not worn in very hot and sunny conditions and consider using removable vests instead. Manufacturers should consider designing shirts that decrease direct contact between retroreflective tape and skin, potentially by increasing the number or thickness of cloth layers under it. Box – Band‐shaped erythematous rash across the patient's upper back coinciding with the upper retroreflective band on the work shirt

Ioana Vlad

The most frequent reason for retrieval, myocardial infarction, requires early treatment and extensive long term management

Fergus W Gardiner · Alice M Richardson · Lara Bishop · Abby Harwood · Elli Gardiner · Lauren Gale · Narcissus Teoh · Robyn M Lucas · Martin Laverty

The proportion of head injuries that is acutely clinically significant is greater for recreational sports than for contact sports associated with risk of concussion

Nitaa Eapen · Gavin A Davis · Meredith L Borland · Natalie Phillips · Ed Oakley · Stephen Hearps · Amit Kochar · Sarah Dalton · John Cheek · Jeremy Furyk · Mark D Lyttle · Silvia Bressan · Louise Crowe · Stuart Dalziel · Emma Tavender · Franz E Babl

Antivenom dosage for Australian elapid envenoming should be decided by clinical evaluation of individual patients

Scott A Weinstein · Peter J Mirtschin · Julian White

The availability of paracetamol needs to be restricted to stem the increasing number of overdoses

Rose Cairns · Jared A Brown · Claire E Wylie · Andrew H Dawson · Geoffrey K Isbister · Nicholas A Buckley

Mental and behavioural disorders in rural and remote communities trigger a considerable number of RFDS retrievals

Fergus W Gardiner · Mathew Coleman · Narcissus Teoh · Abby Harwood · Neil T Coffee · Lauren Gale · Lara Bishop · Martin Laverty

N arrowly targeting single risk factors will not reduce gaps in injury burden and other health outcomes

Geoffrey J Dobb · Kwok M Ho

Objectives: To investigate the admission characteristics and hospital outcomes for Indigenous and non‐Indigenous patients admitted to intensive units (ICUs) after major trauma. Design, setting: Retrospective analysis of Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database data from 92 Australian ICUs for the 6‐year period, 2010–2015. Participants: Patients older than 17 years of age admitted to public hospital ICUs with a primary diagnosis of trauma. Main outcome measures: ICU and overall hospital lengths of stay, hospital discharge destination, and ICU and overall hospital mortality rates for Indigenous and non‐Indigenous patients. Results: 23 804 people were admitted to Australian public hospital ICUs after major trauma; 1754 (7.4%) were Indigenous Australians. The population‐standardised incidence of admissions was consistently higher for Indigenous Australians than for non‐Indigenous Australians (847 per million v 251 per million population; incidence ratio, 3.37; 95% CI, 3.19–3.57). Overall hospital mortality rates were similar for Indigenous and non‐Indigenous patients (adjusted odds ratio [aOR], 1.04; 95% CI, 0.82–1.31). Indigenous patients were more likely than non‐Indigenous patients to be discharged to another hospital (non‐Indigenous v Indigenous: aOR, 0.84; 95% CI, 0.72–0.96) less likely to be discharged home (non‐Indigenous v Indigenous: aOR, 1.17; 95% CI, 1.04–1.31). Conclusion: The population rate of trauma‐related ICU admissions was substantially higher for Indigenous than non‐Indigenous patients, but hospital mortality rates after ICU admission were similar. Indigenous patients were more likely to be discharged to a another hospital and less likely to be discharged home than non‐Indigenous patients.

Fraser Magee · Anthony Wilson · Michael J Bailey · David Pilcher · Paul J Secombe · Paul Young · Rinaldo Bellomo

Early risk stratification is central to determining the need for further investigations

Jason Chan · Jonathan Hunter · Douglas Morel · Emma Ballard · David Brain · Alan Yan · Julia Hocking

Given the devastating consequences of TSCI, improved primary prevention strategies are needed

Ben Beck · Peter A Cameron · Sandra Braaf · Andrew Nunn · Mark C Fitzgerald · Rodney T Judson · Warwick J Teague · Alyse Lennox · James W Middleton · James E Harrison · Belinda J Gabbe

General practitioners provide a flexible response to the changed needs of the disasteraffected population

Penelope L Burns · Kirsty A Douglas · Wendy Hu

A system that integrates all aspects of health care is essential for facing future challenges

Gerard J FitzGerald · Anthony Capon · Peter Aitken