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There is a paucity of literature pertaining to the role and techniques of moulage for creating high-fidelity medical simulations. As part of an Intensive Care Crisis Event Management Course, simulation of an extensive torso burn was desired. The aim of the moulage was to enhance the realism of the scenario but additionally to enable a chest wall escharotomy to be performed.A simple step-wise technique for preparing a chest wall burn moulage that may be fitted to mannequins of all sizes and shapes is described.Utilization of the chest wall moulage as part of an overall strategy to prepare mannequins' for a severe burns scenario is detailed.In the case of the chest wall burn model, moulage was used as more than a visual realism enhancing strategy-it served as an educational tool in its own right, permitting demonstration of a procedure performed infrequently outside the walls of major burns centers.

Many individuals suffering from acute or progressive neurologic problems are managed in intensive care units. The capacity for these patients to exert autonomy regarding their own treatment is frequently compromised. Disease processes may impair consciousness and lucidity. Similarly, this may result from drugs, most frequently sedatives and analgesics that are necessitated by the treatments they are receiving, such as mechanical ventilation. This article will address the ethical and legal issues surrounding withdrawal of therapy, as they pertain to patients managed in intensive care units. Contemporary principles guiding clinicians’ decision making will be reviewed, followed by concerns and issues regarding common sources of conflict and misconception between patients, their families and healthcare professionals.

Summary Non-invasive positive pressure ventilation (NIV) is now widely used for a variety of chronic neuromuscular diseases, and available evidence demonstrates improved quality and quantity of life. Clinicians should be aware of the natural history of each neuromuscular disorder in order to make informed decisions about life-prolonging therapies in the intensive care setting. Attention to co-morbidities and reversible causes of exacerbations of respiratory failure are important given that these are often treatable. Nutritional factors play an important role in patients receiving NIV. End of life planning should be discussed with all patients requiring non-invasive ventilation.

Summary Parkinson's disease (PD) is a common neurodegenerative disorder, occurring in at least 1% of patients older than 65 years of age and characterized by bradykinesia, rigidity, and tremor. Parkinsonism is a broad term for patients with PD and Parkinson's like disorders. Due to the aging population, the number of patients admitted to the intensive care unit (ICU) with PD or disorders with Parkinsonism is expected to rise in the future. For optimal ICU care, PD co-morbidities of memory impairment, aspiration, and dysautonomia require special attention. Withdrawal of dopaminergic medications in the perioperative state or ICU can lead to worsened PD symptoms, chest wall rigidity complicating ventilator management, and a severe hyperpyrexia, rigid, encephalopathic state termed neuroleptic malignant syndrome (NMS). PD patients are also sensitive to antipsychotic and antiemetic medications, which can exacerbate rigidity and aspiration. Elderly patients with PD are more sensitive to sedative medications and more susceptible to develop post-operative or ICU delirium, which has increased morbidity and mortality. PD patients are at increased risk of increased perioperative aspiration pneumonia and its associated morbidity and mortality. Specialized ICU management strategies for patients with PD are described.

Brain death commonly occurs after a devastating central nervous system (CNS) injury from head trauma or stroke. Severe brain injury and brain death create a variety of extra-cerebral organ manifestations including neuroendocrine hormone deficiencies, systemic inflammatory response syndrome (SIRS), neurogenic pulmonary oedema (NPE), myocardial stunning, as well as electrolyte and immunologic derangements. Spinal-mediated reflexes after brain death may be alarming to medical staff and families alike, and proper recognition and counselling to the family is necessary to prevent further emotional turmoil and doubt against the diagnosis of brain death. The challenge for the intensive care unit (ICU) physician is maintaining adequate organ perfusion and metabolism in brain-dead patients who eventually become organ donors. Due to the potential benefit from organ donation, maximal ICU management strategies should be employed to maintain viable organs until brain death is confirmed and the patient's wishes for organ donation can be expressed through family or documentation. Optimal ICU management of brain-dead patents who become organ donors increases the opportunity for organ transplantation and provides donation of organs previously not spared.

Summary Weakness is a common problem in patients requiring intensive care unit management. Critical illness polyneuromyopathy is a useful term to describe the acquired neuropathy and/or myopathy that develops in the setting of critical illness. There is a broad differential diagnosis and although most cases can be diagnosed clinically, a range of investigations may be required. The principal risk factors are systemic inflammatory response syndrome (particularly due to severe sepsis), corticosteroid and neuromuscular blocking drug administration and hyperglycaemia. Treatment remains largely supportive, emphasizing the importance of preventative strategies. This article will answer common questions pertaining to critical illness weakness.

Objectives: (i) To profile ED consultations where drug seeking is considered; (ii) to clarify if an Australian patient cohort shares the characteristics identified in the literature, that is, high rate of psychiatric, chronic pain and drug dependency problems; (iii) to quantify the extent of missed organic disease in suspected drug-seeking presentations. Methods: Prospective descriptive study with an initial enrolment period of 3 months, follow up at 3 and 5 years. Tertiary hospital ED doctors voluntarily identified suspected drug-seeking behaviour. Patients' demographic information, past history, presenting features, investigations, management and missed diagnoses of organic pathology were collected. Recurrent presentations of drug seeking, self-harming, psychiatric, chronic pain and drug dependency complaints were documented. Results: Thirty-seven presentations (31 patients) of 10 958 total attendances were analysed. All patients were less than 65 years. Twenty-one patients (68%, 95% confidence interval [CI 49.7-85.8]) were on unemployment or disability pension. Twenty-six presentations (70%[95% CI 54.2-86.3]) described psychiatric problems, whereas three presentations (8%[95% CI 0.0-18.3]) had chronic pain and 10 presentations (27%[95% CI 11.4-42.7]) had drug dependency problems. Twenty-six patients (84%[95% CI 69.3-98.4]) recurrently presented with self-harming and drug-seeking behaviour at 3 years. The risk of missing organic pathology was 8/37 (22%[95% CI 7.0-36.2]). Conclusions: Further characterization of this population would help accurate diagnosis of this aberrant behaviour and decrease the risk of missing organic pathology. The management of frequently presenting patients should prompt formulation of departmental plans to effectively assess and manage these people.

Objective: The objective of the present study were to determine factors used by ED doctors to diagnose drug seeking and their attitude towards management of this patient group. Methods: Prospective, descriptive study, of doctors working in a tertiary hospital ED. Doctors voluntarily identified patients they suspected were drug seeking and completed a written survey. Results: Thirty-seven surveys were completed for presentations involving 31 patients. A patient's specific request for narcotics, previous documented episodes of suspected drug seeking, an unwillingness to try simple analgesia and demanding or aggressive behaviour were the most frequently used factors for diagnosing drug seeking. These factors are similar to, but not the same, as the criteria in the literature. Doctors commonly found consultations involving drug seeking to be unsatisfying. Conclusions: Factors, such as those used by doctors in the present study, should not be used as diagnostic markers. Further study is warranted in order to improve the effectiveness of consultations involving drug seeking.

Objective: The aim of the study was to determine the range of cerebrospinal fluid findings associated with emergency department disposition and treatment of patients with headache suspicious of subarachnoid haemorrhage but a negative or equivocal computed tomoraphy head scan, in particular the role of xanthochromic index. Methods: A retrospective review of medical records of 196 adult patients who underwent cerebrospinal fluid examination for red cell count and xanthochromia for suspected subarachnoid haemorrhage but had a normal or equivocal computed tomography scan. Results: Included in the study were 196 patients. Only one patient out of 189 with a negative computed tomography scan was found to have a subarachnoid haemorrhage caused by a ruptured aneurysm (0.5%; 95% confidence intervals 0–2.9%). Three other patients were diagnosed with benign subarachnoid haemorrhage. Ninety-one patients were stratified into the lowest possible risk group for subarachnoid haemorrhage and discharged home from the emergency department. All patients with equivocal computed tomography head scans and a positive xanthochromic index were admitted for cerebral angiography. In many cases, cerebrospinal fluid findings did not appear to influence clinical decision-making. Conclusions: In the study institution, cerebrospinal fluid results appeared to have a variable influence on clinical decision-making for patients with suspected subarachnoid haemorrhage and a non-diagnostic computed tomography head scan. Of particular concern is the lack of validation of the tests used in this investigative approach, the frequency of patients having a lumbar puncture where the results did not influence their management, the inconsistency in the laboratory’s technique for performing tests on cerebrospinal fluid and the very low yield of detecting patients with subarachnoid haemorrhage and a potentially treatable causative lesion.

The current recommended ‘next investigation’ for patients with a suspected subarachnoid haemorrhage and a negative non-contrast computed tomography head scan, is a lumbar puncture. The cerebrospinal fluid obtained at lumbar puncture may be examined for the presence of blood and xanthochromia. Xanthochromia may be assessed by macroscopic examination or by spectrophotometry. Total red cell count and the three-tube test have poor sensitivity and specificity as investigations for diagnosing subarachnoid haemorrhage. Macroscopic examination for xanthochromia is unreliable, with a risk of false-negative results. Spectrophotometric examination for xanthochromia is associated with false positive results. The use of cerebrospinal fluid derivative spectroscopy and D-Dimer testing using an enzyme-linked immunosorbent assay need further evaluation. In the future, computed tomography angiography or magnetic resonance angiography may change current practice. Until then, all patients should be advised to have a lumbar puncture. A cerebrospinal fluid specimen obtained at least 8 h after the onset of headache and analysed for xanthochromia via spectrophotometry has the best chance of placing the patient in the lowest possible risk category. The emergency physician must be aware of the methods of cerebrospinal fluid analysis used locally.

Aim: In the current climate of medical education, there is an ever-increasing demand for and emphasis on simulation as both a teaching and training tool. The objective of our study was to compare the realism and practicality of a number of artificial blood products that could be used for high-fidelity simulation. Method: A literature and internet search was performed and 15 artificial blood products were identified from a variety of sources. One product was excluded due to its potential toxicity risks. Five observers, blinded to the products, performed two assessments on each product using an evaluation tool with 14 predefined criteria including color, consistency, clotting, and staining potential to manikin skin and clothing. Each criterion was rated using a five-point Likert scale. The products were left for 24 hours, both refrigerated and at room temperature, and then reassessed. Statistical analysis was performed to identify the most suitable products, and both inter- and intra-rater variability were examined. Results: Three products scored consistently well with all five assessors, with one product in particular scoring well in almost every criterion. This highest-rated product had a mean rating of 3.6 of 5.0 (95% posterior Interval 3.4-3.7). Inter-rater variability was minor with average ratings varying from 3.0 to 3.4 between the highest and lowest scorer. Intrarater variability was negligible with good agreement between first and second rating as per weighted kappa scores (K = 0.67). Conclusion: The most realistic and practical form of artificial blood identified was a commercial product called KD151 Flowing Blood Syrup. It was found to be not only realistic in appearance but practical in terms of storage and stain removal.

Visual inspection of a patient's urine has long been used by physicians, with colour recognised as having important clinical implications. In this review the authors will revisit this ancient pastime with relevance to contemporary medical practice.

A 51-year-old Burmese woman with no family orpersonal history of psychiatric disorders was ad-mittedtotheCriticalCareUnit(CCU)followingananteriorresectionformetastatic(lungandhepatic)adenocarcinoma of the sigmoid colon. Postopera-tivelythereweretwoinitialcomplications:first,anepisode of rectal bleeding from the anastomosissite, necessitating a return to theatre for explora-tion only; second, an episode of pulmonaryoedema, during which there were no prolongedperiods of hypoxaemia, and which resolved fol-lowing non-invasive continuous positive airwaypressureventilation.OnreturntoCCU,thepatientshowed no signs of delirium, was oriented intime, place and person, and was communicatingappropriately.Subsequently, eight hours after returning fromtheatre her Glasgow Coma Scale fell from 15 to 6(E1M4V1), with no obvious focal neurologicalabnormality. Blood tests (i.e. full blood profile,liver function tests, urea and electrolytes) andarterial blood gases revealed no cause for thisdeterioration.Accordingly, she was intubated andventilated, and a head CT scan was performedwhich revealed no apparent abnormalities toexplain her deterioration. She regained a full levelof consciousness the next day. Then, however, herlevel of consciousness progressively dropped overseveral hours. On examination, she kept her eye-lids clenched, and it was impossible to assess herpupils, which rolled backwards on manual eyelidretraction. Otherwise, cranial nerve examinationwas entirely normal, including a good gag reflex.Assessment of upper and lower limb neurologywas equally unremarkable with down-goingplantar responses.A Bi-Spectral (BIS) monitor (routinely used tomonitor intra-operative conscious levels) wasemployed to assess EEG activity and level of con-sciousness, as no electroencephalogram could beimmediately arranged. This demonstrated a bi-spectral index of 85–90, which is associated withwakefulness, and not any major intra-cerebralevent or convulsive activity.

Death from mushroom poisoning in Australia is rare and usually due to liver failure produced by Amanita phalloides. We report a 53-year-old woman in Queensland who died from an acute muscarinic syndrome 10 hours after eating mushrooms belonging to the genus Rubinoboletus. To our knowledge, this is the first death in Australia caused by non-amatoxin-producing mushrooms. It highlights the need for awareness of non-amatoxin-producing mushrooms as potentially lethal.

Cardiac surgery is a relatively new speciality which has burgeoned from its nascent state in the 1960s to a mammoth industry, such that over 1,000,000 cardiac procedures are conducted in the US on an annual basis.1 The development of safe cardiopulmonary bypass and the surgical techniques which it facilitated saw a huge rise in coronary and valve surgery over the subsequent 30 years. However, the “bread and butter” of cardiac surgery remained relatively unchanged despite the advent of off-pump bypass and use of arterial grafts until the last 10–15 years. Interventional cardiology, changing social views on what constitutes “too old” or “too sick”, improved intensive care and an increased use of mechanical assist devices such as intra-aortic balloon pump devices has changed the face of cardiac surgery. The increased uptake of percutaneous coronary interventions (PCI) since the advent of devices such as drug-eluting stents has all but removed the simple single vessel coronary graft for the cardiac operating list. As PCI devices improve, more and more studies comparing CABGs to PCI with stents are being reported, showing similar results in terms of death, MI and stroke, and whilst stents are associated in these studies with an increased need for re-vascularization, this gap is narrowing.2 The cardiac surgeon and cardiac anaesthetist are therefore being presented with octogenarians with poor left ventricular function and the associated organ dysfunction commonly seen in this age group. Paediatric patients, many of whom would not have previously survived birth, are now being presented for consideration of surgery in the first weeks post birth. Children and adults are supported on ventricular assist devices for many months or years, either as bridging or destination therapy. These patient groups are the sickest, frequently with the most to gain from a successful outcome, but occupy more ICU bed days, and many more health care pounds and dollars. The care pathway of the un-complicated post cardiac surgery patient is clear and generally straight, with a supervisory eye being the main function of the intensivist in the post operative period. However, as the patients become sicker and older (or younger in the paediatric population), and pre-operative organ dysfunction becomes the rule rather than the exception, the close collaboration of surgeon, intensivist, anaesthetist and perfusionist becomes key in the final discharge of these patients from hospital. A clear understanding of pre-operative risks, intraoperative procedures and post operative organ support are essential for the optimal result for the patient. This issue has chosen a number of fields associated with “high-end” cardiac surgery. It is by no means exhaustive, but reflects the major changes as they have impacted the critical care environment over the past decade. We have included a review on ventricular assist devices as recent data confirms their efficacy and improvement in survival in patients with severe heart failure, a condition whose incidence increases with each passing year. Some of the articles are reviews of a specific field, and some “tricks” or “pearls” that we wished we had learned many years ago. The articles are the combined work of intensivists, anaesthetists and cardiac surgeons, and the issue aims to be a practical guide augmented with recent data and evidence, rather than an isolated academic precis.