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Purpose To determine if a regimen of restricted fluids and early vasopressor compared to usual care is feasible for initial resuscitation of hypotension due to suspected sepsis. Methods A prospective, randomised, open-label, clinical trial of a restricted fluid resuscitation regimen in the first 6 h among patients in the emergency department (ED) with suspected sepsis and a systolic blood pressure under 100 mmHg, after minimum 1000 ml of IV fluid. Primary outcome was total fluid administered within 6 h post randomisation. Results There were 99 participants (50 restricted volume and 49 usual care) in the intention-to-treat analysis. Median volume from presentation to 6 h in the restricted volume group was 2387 ml [first to third quartile (Q1-Q3) 1750-2750 ml]; 30 ml/kg (Q1-Q3 32-39 ml/kg) vs. 3000 ml (Q1-Q3 2250-3900 ml); 43 ml/kg (Q1-Q3 35-50 ml/kg) in the usual care group (p < 0.001). Median duration of vasopressor support was 21 h (Q1-Q3 9-42 h) vs. 33 h (Q1-Q3 15-50 h), (p = 0.13) in the restricted volume and usual care groups, respectively. At 90-days, 4 of 48 (8%) in the restricted volume group and 3 of 47 (6%) in the usual care group had died. Protocol deviations occurred in 6/50 (12%) in restricted group and 11/49 (22%) in the usual care group, and serious adverse events in four cases (8%) in each group. Conclusions A regimen of restricted fluids and early vasopressor in ED patients with suspected sepsis and hypotension appears feasible. Illness severity was moderate and mortality rates low. A future trial is necessary with recruitment of high-risk patients to determine effects on clinical outcomes in this setting., Author(s): Stephen P. J. Macdonald [sup.1] [sup.2] [sup.3], Gerben Keijzers [sup.4] [sup.5] [sup.6], David McD Taylor [sup.7] [sup.8], Frances Kinnear [sup.9], Glenn Arendts [sup.1] [sup.2] [sup.10], Daniel M. Fatovich [sup.1] [...]

Objectives: Demand for ED care is increasing at a rate higher than population growth. Strategies to attenuate ED demands include diverting low‐acuity general practice‐type ED attendees to alternate primary healthcare settings. The present study assessed the ED attendees' receptiveness to accept triage nurse's face‐to‐face advice to explore alternate options for medical care and what factors influence the level of acceptance. Methods: The ED attendees of four major public hospital EDs in Brisbane were surveyed between August and October 2018, using a questionnaire informed by Health Belief Model's cues to action. Results: Of the 514 valid responses, 81% of respondents were very likely/likely to accept the triage nurse's advice to see a general practitioner. Self‐perceived urgency of presenting condition/s (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.78–0.97), not having confidence in general practitioner (OR 0.37, 95% CI 0.21–0.66) and having a medical record at the hospital (OR 0.60, 95% CI 0.36–0.99) were negatively associated with the likelihood of accepting the advice. For every point increase in perceived seriousness, the odds of accepting the advice decreased by 16% (95% CI 6–25%). Conclusion: Most of the participants believed that EDs were for emergent care and they attended the ED because they perceived their presenting condition/s to be serious and/or urgent. The acceptability of face‐to‐face advice by triage nurse to seek help in general practice was influenced by perceived threats of the illness, and the underlying beliefs about availability, accessibility, suitability and affordability of the service. [ABSTRACT FROM AUTHOR]

Objective: To describe the characteristics, assessment and management of older emergency department (ED) patients with non‐traumatic headache. Methods: Planned sub‐study of a prospective, multicentre, international, observational study, which included adult patients presenting to ED with non‐traumatic headache. Patients aged ≥75 years were compared to those aged <75 years. Outcomes of interest were epidemiology, investigations, serious headache diagnosis and outcome. Results: A total of 298 patients (7%) in the parent study were aged ≥75 years. Older patients were less likely to report severe headache pain or subjective fever (both P < 0.001). On examination, older patients were more likely to be confused, have lower Glasgow Coma Scores and to have new neurological deficits (all P < 0.001). Serious secondary headache disorder (composite of headache due to subarachnoid haemorrhage (SAH), intracranial haemorrhage, meningitis, encephalitis, cerebral abscess, neoplasm, hydrocephalus, vascular dissection, stroke, hypertensive crisis, temporal arteritis, idiopathic intracranial hypertension or ventriculoperitoneal shunt complications) was diagnosed in 18% of older patients compared to 6% of younger patients (P < 0.001). Computed tomography brain imaging was performed in 66% of patients ≥75 years compared to 35% of younger patients (P < 0.001). Older patients were less likely to be discharged (43% vs 63%, P < 0.001). Conclusions: Older patients with headache had different clinical features to the younger cohort and were more likely to have a serious secondary cause of headache than younger adults. There should be a low threshold for investigation in older patients attending ED with non‐traumatic headache. [ABSTRACT FROM AUTHOR]

Background and Aim: Migraine headache is commonly diagnosed in emergency departments (ED). There is relatively little real-world information about the epidemiology, investigation, management, adherence to therapeutic guidelines and disposition of patients treated in ED with a final diagnosis of migraine. The primary aim of the current study is to get a snapshot of assessment and management patterns of acute migraine presentations to the different settings of EDs with a view to raise awareness. Methods: This is a planned sub-study of a prospective study conducted in 67 health services in 10 countries including Australia, New Zealand, Southeast Asia, Europe, and the UK investigating the epidemiology and outcome of adult patients presenting to ED with nontraumatic headache. Outcomes of interest for this study are demographics, clinical features (including severity), patterns of investigation, treatment, disposition, and outcome of patients diagnosed as having migraine as their final ED diagnosis. Results: The cohort comprises 1,101 patients with a mean age of 39 years (SD ± 13.5; 73.7% [811]) were female. Most patients had had migraine diagnosed previously (77.7%). Neuroimaging was performed in 25.9% with a very low diagnostic yield or significant findings (0.07%). Treatment of mild migraine was in accordance with current guidelines, but few patients with moderate or severe symptoms received recommended treatment. Paracetamol (46.3%) and nonsteroidal anti-inflammatory drugs (42.7%) were the most commonly prescribed agents. Metoclopramide (22.8%), ondansetron (19.2%), chlorpromazine (12.8%), and prochlorperazine (12.8%) were also used. Conclusions: This study suggests that therapeutic practices are not congruent with current guidelines, especially for patients with severe symptoms. Efforts to improve and sustain compliance with existing management best practices are required. [ABSTRACT FROM AUTHOR]

Objective: To describe the epidemiology of nontraumatic headache in adults presenting to emergency departments (EDs). Background: Headache is a common reason for presentation to EDs. Little is known about the epidemiology, investigation, and treatment of nontraumatic headache in patients attending EDs internationally. Methods: An international, multicenter, observational, cross‐sectional study was conducted over one calendar month in 2019. Participants were adults (≥18 years) with nontraumatic headache as the main presenting complaint. Exclusion criteria were recent head trauma, missing records, interhospital transfers, re‐presentation with same headache as a recent visit, and headache as an associated symptom. Data collected included demographics, clinical assessment, investigation, treatment, and outcome. Results: We enrolled 4536 patients (67 hospitals, 10 countries). "Thunderclap" onset was noted in 14.2% of cases (644/4536). Headache was rated as severe in 27.2% (1235/4536). New neurological examination findings were uncommon (3.2%; 147/4536). Head computed tomography (CT) was performed in 36.6% of patients (1661/4536), of which 9.9% showed clinically important pathology (165/1661). There was substantial variation in CT scan utilization between countries (15.9%–75.0%). More than 30 different diagnoses were made. Presumed nonmigraine benign headache accounted for 45.4% of cases (2058/4536) with another 24.3% classified as migraine (1101/4536). A small subgroup of patients have a serious secondary cause for their headache (7.1%; 323/4536) with subarachnoid hemorrhage (SAH), stroke, neoplasm, non‐SAH intracranial hemorrhage/hematoma, and meningitis accounting for about 1% each. Most patients were treated with simple analgesics (paracetamol, aspirin, or nonsteroidal anti‐inflammatory agents). Most patients were discharged home (83.8%; 3792/4526). In‐hospital mortality was 0.3% (11/4526). Conclusion: Diagnosis and management of headache in the ED is challenging. A small group of patients have a serious secondary cause for their symptoms. There is wide variation in the use of neuroimaging and treatments. Further work is needed to understand the variation in practice and to better inform international guidelines regarding emergent neuroimaging and treatment. [ABSTRACT FROM AUTHOR]

Objectives: Pregnancy is defined as a 'red flag' in headache assessment. We aimed to describe the prevalence and causes of serious secondary headache in pregnant ED patients. Methods: Unplanned secondary analysis of HEAD Study/HEAD Colombia data. Results: 3.2% (117/3643) of ED headache patients aged 18–50 years were pregnant, of whom six (5.1%) had a serious secondary cause identified. The proportion of patients with serious headache causes was not significantly different between pregnant female, non‐pregnant female and male patient subgroups (P = 0.89). Conclusion: Inclusion of pregnancy as a 'red flag' in ED headache assessment is not supported by these data. [ABSTRACT FROM AUTHOR]

Objectives: To investigate patient‐level factors predictive for computed tomography of the brain (CTB) use and abnormality in head injured children in Australia and New Zealand. Methods: Retrospective data from tertiary, urban/suburban and regional/rural EDs including factors predictive for CTB use and abnormality. Results: Of 3072 children at 31 EDs, 212 (6.9%) had a CTB scan, of which 66 (31%) were abnormal. Increasing age, serious mechanisms of injury and decreasing Glasgow Coma Score were predictive for ordering CTB. Decreasing age was predictive for CTB abnormalities. Other factors were not. Conclusion: Patient‐level drivers of CTB use in children in Australia and New Zealand are consistent with international data. [ABSTRACT FROM AUTHOR]

Objective: To explore trends in presentation and key performance indicators with respect to children seeking mental health services at The Prince Charles Hospital Children's Emergency Department (TPCH‐CED), Brisbane. Methods: A retrospective audit was performed utilising data obtained from the local Emergency Department Information System for all mental health presentations between 1 January 2013 and 1 January 2018 to TPCH‐CED. Results: A total of 1078 children presented to TPCH‐CED requiring mental health review between 2013 and 2018. Mental health presentations almost doubled over the 5 years (185 attendances in 2013; 342 in 2017); however, as a proportion of overall presentations, there was no significant increase. The percentage of mental health presentations meeting the National Emergency Access Target criteria dropped from 63% in 2013 to 39% in 2017 (P < 0.0001). Those requiring a mental health inpatient stay were more likely to have very extended length of stay within the CED. Suicidal ideation was the most common presenting complaint (72% of mental health presentations). Violence and aggression were noted in a consistent proportion of mental health presentations (4.4–12%). Conclusions: Despite failing to demonstrate an interval increase in the proportion of children presenting to TPCH‐CED requiring mental health services, it is clear that children with mental health needs, like their adult counterparts, disproportionately experience delays to appropriate care when compared with children presenting with other emergency conditions. Ongoing research is warranted to assess standards of care and the impact of mental health presentations on CEDs. [ABSTRACT FROM AUTHOR]