Dr David McCreary Emergency Physician The Case It’s a beautiful Sunday morning outside your ED and that can mean only one thing – the cyclists are out. Where there are cyclists, there are cyclists falling over. And where there are cyclists falling over, there are limb injuries. Today we bring you a case from just such a Lycra-clad gentleman presenting with a painful and deformed right wrist. Let’s get straight to it with a look at the X-ray, shall we? What does the X-ray show? There is fracture through the scaphoid waist with lateral dislocation of the scaphoid. A fleck of bone is noted posterior to the capitate. There is a volar tilt of the lunate with dorsal dislocation of the carpus relative to the lunate. Impression: Findings are in keeping with a complex trans-scaphoid perilunate fracture-dislocation injury Tell me more about perilunate dislocation, why does it matter? Well my geeky education excitement for this case is that it is a great exam question, but also an injury that is commonly missed (though I admit that one is pretty obvious) on initial presentation so it’s important that we understand the injury pattern and mechanism. Common, you say? How common? Around 25% are reportedly missed on initial presentation - a stat I always find surprising but that’s what is frequently reported. I wonder whether this is due to more subtle presentations than that above, or due to “distal radius looks normal, must be a sprain” assessments, not remembering to look at the radius’ upstairs neighbours. Around 10% of all wrist injuries - not my personal practice as I’m sure I’m not seeing 1 of these for every 10 wrists. Maybe I’m adding to the 25% - there’s a thought that will fester. Mechanism A fall onto a hyperextended wrist ± forearm supination Classification The Mayfield classification . Mayfield and pals did a cadaveric study where they loaded 32 wrists to failure in wrist extension, ulnar deviation and intercarpal supination and described the 4 distinct patterns that emerged from x-ray and dissection findings. 4 stages : progressing from I → IV in a clockwise fashion Radioscaphocapitate ligament and scapholunate ligaments (a fracture through the scaphoid will do it) – that’s where you’ll get your Terry-Thomas sign Disruption of the lunocapitate joint (a fracture through the capitate) Lunotriquetral ligament (or fracture through triquetrum) – true perilunate dissociation Radiolunate ligament (That’ll give you a lunate dislocation as all tethers are gone) I find it easier to conceptualise and remember visually using this: Adapted from (1) Complications Median nerve injury / acute carpal tunnel syndrome Avascular necrosis of scaphoid and lunate (in treatment delay) Post traumatic osteoarthritis What are we looking for on X-ray? On the AP it can be easily missed Look for disruption of Gilula’s lines: Wouldn’t be an orthopaedic case if I didn’t use a picture courtesy of OrthoFlow - go get OrthoFlow … Piece of pie sign - the abnormal triangular appearance of the lunate on a PA image of the wrist (can be a sign of either perilunate or lunate dislocation. Case courtesy of Dr Andrew Dixon, Radiopaedia.org , rID: 9906 Spilt teacup sign - for lunate dislocation: abnormal volar displacement and tilt of the dislocated lunate on a lateral film. Case courtesy of Dr Andrew Dixon, Radiopaedia.org , rID: 9906 Management Well clearly with all that hard to pronounce, deformed anatomy, these injuries are going to require operative fixation by our friendly neighbourhood bone doc In the meantime, however, they need urgent reduction to prevent median nerve injury, particularly if signs of acute carpal tunnel syndrome already present This is a video showing how to reduce - I really like their bedside finger traps for some pre-procedure traction. It also demonstrates how difficult it can be sometimes to agree on whether it’s peri or proper lunate Some practical advice for Lunate dislocations, however – unless there is acute carpal tunnel or you can’t get the patient rapidly to theatre for reduction under GA by orthopaedics, try to resist the temptation to reduce these in the ED. Lunate dislocations are are notoriously difficult to reduce non-operatively and have been known to cause injury to practitioners who have tried in the past – but ulnar collateral ligament injuries are a discussion for another blog. 👍 References Kennedy SA, Allan CH. In Brief: Mayfield et al. Classification: Carpal Dislocations and Progressive Perilunar Instability. Clin Orthop Relat Res. 2012 Apr;470(4):1243–5. Goodman AD, Harris AP, Gil JA, Park J, Raducha J, Got CJ. Evaluation, Management, and Outcomes of Lunate and Perilunate Dislocations. Orthopedics. 2019 Jan 1;42(1):e1–6. OrthoFlow App – iOS & Android Declarations/Shameless Plug: Dave wrote the OrthoFlow App when he was a registrar along with a couple of Orthopaedic registrars (now consultants) and a GP (who drew the medical illustrations above). He has just finished writing the latest version for iOS which is available right now. DAVE MCCREARY Emergency Physician Dave McCreary, MBChB MSc FRCEM Dave is an Emergency Physician who completed training between the UK and Australia and completed an MSc in Trauma Science with QMUL. His clinical interests include trauma, critical care, evidence based medicine and human factors. Dave is a regular contributor the RCEMLearning podcast and is a FOAMed editor for RCEMLearning. He dislikes coriander, decaff coffee and dermatology.

Dr David McCreary Emergency Physician Peer review: Dr Mike Khoury THE CASE A 60-year-old female presents to the Emergency Department with progressive shortness of breath over several months. On assessment in the emergency department, she had marked shortness of breath at rest and oxygen saturation of 90% on room air. A portable erect chest X-ray was performed: Given that this patient was symptomatic, the team decided to pop in a pigtail catheter to drain the large right-sided effusion. Following this, the patient’s respiratory effort improved and all seemed well! High-fives and congratulatory statements all around… …that is until the wee-small hours of the morning when the patient became acutely short of breath, with respiratory failure and the following repeat X-ray: HOW WOULD YOU DESCRIBE THIS X-RAY? Chest X-ray showing an appropriately positioned right intercostal pigtail drain in situ with associated interval change demonstrating drainage of the large right-sided pleural effusion seen in the original image. There is some alveolar airspace opacity within the right-mid and lower zones. WHAT HAS CAUSED THESE CHANGES? Re-expansion Pulmonary Oedema (RPO) An uncommon complication following draining of a pneumothorax or pleural effusion Incidence is reported between 0.2-14% (according to the British Thoracic Society), though most reports seem to be <1% LET’S LEVEL-UP ON RE-EXPANSION PULMONARY OEDEMA (RPO)… PATHOPHYSIOLOGY The pathophysiology of RPO is multifactorial and poorly understood (a great caveat when writing about any condition). The primary (or at least the easiest) theory is: Ventilation and perfusion of collapsed lung Leads to a dramatic inflammatory response Causes increased permeability of pulmonary capillaries One can think of this as a type of reperfusion lung injury. RISK FACTORS Age 20-40 years Duration of lung collapse >72 hours Application of negative pressures (>20cmH2O) during drainage Rapid, large-volume drainage (>1.5L fluid) You can’t do much about their age, but you can take the other factors into consideration when draining. CLINICAL FEATURES Pretty much all the symptoms of severe/flash pulmonary oedema, but <24 hours post pleural drainage Chest discomfort Cough Frothy sputum Dyspnoea Hypoxia Marked work of breathing OK, PULMONARY OEDEMA MANAGEMENT – THAT’S NITRATES AND DIURETICS, RIGHT? Well, no, not in this case. I’ll spare you my rant (for now) about diuretics in flash pulmonary oedema – in the meantime, Swami over at EMDocs.net has a pretty concise explanation here . Generally speaking, flash APO patients haven’t been sat at home being given litres of fluid by medical staff so are unlikely to be truly fluid overloaded – their fluid is just in the wrong place. Their problem is with afterload . Oh there I go, and I said I was going to spare the rant… Nitrates then? Well, as per the above partial-rant ordinarily they are the mainstay of APO treatment. But with RPO there is no evidence for them and they are unlikely to work as we aren’t dealing with afterload physiology here. SO, WHAT DOES THAT LEAVE US? SUPPORTIVE CARE: The severe cases are likely to need NIV or invasive ventilation (as did the patient from this case) Lie the patient with the unaffected side down – this will encourage dependent blood flow to the good lung Fluids – rather than diuresis, if anything these patients may need some filling PREVENTION IS, AS THEY SAY, BETTER THAN CURE: Suction: if you are using negative pressure, keep it below 20cmH2O Avoid that completionist temptation and limit draining to 1-1.5L If patient reports vague chest pressure this may a sign of precipitous drop in intrapleural pressure so thoracocentesis should be stopped ANY GUIDELINES ON THIS? Why yes, the BTS 2010 guideline says thoracocentesis should be stopped when: No more fluid or air can be aspirated (that’s a given, no?) The patient develops cough or chest discomfort 5L has been withdrawn There are descriptions of 3-6.5L being drained without issue, but the guidelines are more conservative due to the reportedly terrible mortality of RPO (up to 20%). This best-evidence review does suggest that patients with no respiratory symptoms could drain larger volumes to dryness, with caution to avoid negative intrathoracic pressures. I’d say that’s something for a risk/benefit, case-by-case decision. But wait, my patient clearly has a lot more than 1.5L fluid - what do I do with the rest? The BTS guideline briefly comments that in the case of pleural effusions, the amount drained in the first hour should be a maximum of 1.5L. After an hour the remaining fluid can be drained off slowly. If in doubt, contact your friendly neighbourhood respiratory team for advice. AND WHILE WE’RE TALKING PLEURAL FLUID – PARTICULARLY FOR THE EXAM-SITTERS OUT THERE… HOW DO YOU CATEGORISE THE CAUSES OF PLEURAL EFFUSION? Transudate: an imbalance between hydrostatic and oncotic pressure Think: heart failure / atelectasis / hepatic hydrothorax / hypoalbuminaemia / nephrotic syndrome Exudate: an alteration of local factors precipitating fluid collection Think: malignancy / ARDS / Pancreatitis / Empyema / Sarcoidosis Ex udate = Ex cess Protein WHAT CRITERIA DO WE USE TO DETERMINE IF FLUID IS EXUDATE? Light’s criteria (98% Sn | 83% Sp). Pleural fluid is exudative if it meets at least one of: Pleural fluid protein / Serum protein >0.5 Pleural fluid LDH / Serum LDH >0.6 Pleural fluid LDH > 2/3 of the upper limit of normal for serum LDH Yes, it’s worth memorising those if you are sitting exams. For everyone else, there’s always MDCalc . Remember, this post isn’t to discourage you from draining symptomatic effusions – but let it give you pause for thought and hopefully have you prepared in case RPO happens on your watch. That’s all for now. - Dave REFERENCES / FURTHER READING The 2010 BTS Thoracocentesis Guideline This best evidence topic: Does re-expansion pulmonary oedema exist? (Spoiler: they conclude yes, but rarely). This case report with brief review of RPO MDCalc’s Light’s Criteria calculator Anand Swaminathan’s discussion of furosemide for APO on emDocs.net – read this and save yourself my rants DAVID MCCREARY Emergency Physician, Alfred Health Dave is an Emergency Physician who completed training between the UK and Australia and completed an MSc in Trauma Science with QMUL. His clinical interests include trauma, critical care, evidence based medicine and human factors. Dave is a regular contributor the RCEMLearning podcast and is a FOAMed editor for RCEMLearning. He dislikes coriander, decaff coffee and dermatology.

Dr Stephen Gilmartin Emergency Physician Editors: Dr Hector Thomson | Dr David McCreary The Case A 27-year-old male attends the emergency department with facial injuries following an alleged assault with a blunt instrument.  He has swelling to his right periorbital area with difficulty opening his eyelids and his eye feels tense.  You manage to just about open his eye and he can only appreciate light but is unable to count fingers, his pupil is sluggish and his Intra-ocular Pressure (IOP) is 52mmhg. What is the diagnosis and which procedure can you perform to save this patient's vision? Orbital compartment syndrome, secondary to retrobulbar haemorrhage. The eye socket is a fixed space and retrobulbar blood can cause increased pressure resulting in ischaemia of the optic nerve and retina causing potentially irreversible visual loss. Orbital decompression via a lateral canthotomy and cantholysis should be performed as soon as possible once the diagnosis is made. The procedure is most successful when performed in under 60-90 minutes. This means that in clinical scenarios where the diagnosis is clear cut as above, lateral canthotomy should be performed before  radiological confirmation of the diagnosis. What are the indications for orbital decompression? In a patient with blunt trauma to the eye in whom you have diagnosed or strongly suspect a retrobulbar haematoma any of the associated features suggest an orbital compartment syndrome and should prompt immediate lateral canthotomy: Relative Afferent Pupillary Defect Decreased Visual Acuity (<6/18) Increased Intra-ocular Pressure: 40 mmHg and above of pressure requires decompression Proptosis Ophthalmoplegia The only contraindication is suspicion of globe rupture (diagnosis can be difficult but IOP may be <5mmHg). Should I get a CT first? Good question. The answer really depends on how readily available your CT scanner is, your index of suspicion for the diagnosis, and how assessable your patient is (the intubated patient can be a challenge). Orbital compartment syndrome is a clinical and time-critical diagnosis however and decompression is a relatively low-morbidity procedure and as such shouldn't be delayed for CT unless there is a question of the diagnosis. What if I can't get the eye open? The eye is often extremely swollen and difficult to examine. Still, it  is important to make a good attempt to examine the globe, and pupil and to determine gross visual acuity. Some techniques which can be effective are: Getting an assistant to help with eyelid retraction using folded pieces of dry gauze on the upper and lower lids then slowly drawing the skin apart with your fingertips Examining for proptosis and feeling the firmness of the eye compared to the contralateral side Using paper clips (appropriately shaped and cleaned with an alcohol wipe) to retract the eyelids, as below: Images courtesy of tamingthesru.com 's: " The Mighty Paperclip " 🤓 Editor's note: Don't have paperclips to hand? Officeworks closed? I've previously used the end of the plunger from a 10ml syringe to lift the upper eyelid, particularly for giving you some space to perform the decompression. What if I still can't get the eye open? POCUS to the rescue! Ultrasound can be used here to examine for: Afferent pupillary defects Ophthalmoplegia Globe rupture Retinal detachment   The videos below talk you through how you may go about performing an ultrasound examination of the eye: Do I really have to do it? Can't I just send the patient to my friendly neighbourhood trauma centre to sort it out? Afraid not! Time is optic nerve. Optic nerve is sight. This is a low-morbidity procedure, often not even requiring repair afterwards and has potential to save the patient's sight. Performing an Orbital Decompression (Lateral Canthotomy & Cantholysis) Equipment needed: Sterile gloves Sterile saline Lignocaine with adrenaline Syringe 25G needle Straight kelly clamp / Haemostat Iris or suture scissors Toothed forceps Technique Clean : Clean the area with sterile saline (Pro tip: do not use chlorhex or alcohol containing solutions) Local : Infiltrate local anaesthetic into the skin at the lateral margin of the eye extending out to the orbital rim Crush : Approaching from the nasal size, clamp the lateral canthus for 1 minute to reduce bleeding Canthotomy : Raise the skin of the lateral canthus away from the eye and cut with the scissors, making a 1-2cm incision.   This is in order to expose the underlying lateral canthal tendon.  Cantholysis : Using toothed forceps grasp the lower eyelid laterally at the ‘last lash” and pull upwards towards the ceiling. This will place the inferior canthal tendon under tension. With the closed iris scissor gently sweep the tissue between the orbital rim and the toothed forceps holding the eyelid. The tip of the scissors will ‘twang’ this structure like a guitar string. Cut the tendon. (Don’t expect to be able to see the tendon – there is likely to be bleeding). Check : If successful the lower eyelid should be loose and free to move, there should be substantial release of blood and the globe should now feel softer. Retest IOP, pupillary response and visual acuity. (Images courtesy of The Procedures Course ) What about the other tendons? Only cut the inferior lateral tendon. This will allow the eye to move forwards which relieves the compartment syndrome. Cutting the superior tendon is unlikely to allow much more movement, and is more likely to need formal repair in theatre. Procedure Tips Don’t pad the eye – you want to keep checking the pupils Apply chloramphenicol ointment to the skin incision and the conjunctiva post procedure There is often significant swelling around the eye.   This may make identification, clamping and cutting of the lateral canthus difficult.  This may mean this part of the process has to be done in stages. Twang! Rely on the feel of 'twanging' the tendon - this will no longer be felt following successful cantholysis and the lid will become mobile. Ask an assistant to retract eyelids using methods discussed above Anaesthetise the eye with local anaesthetic drops and have a low threshold for procedural sedation if safe to do so. Case Conclusion You immediately perform a lateral canthotomy.   There is a satisfying release of blood and the eye becomes less firm immediately. His IOP is now improving to within normal limits and he can count your fingers, though his vision is still slightly blurred. You organise a CT of his brain and facial bones and ophthalmology is rushing in to perform a detailed assessment of his eye. Want your first time performing this procedure to be less high-stakes? Book your spot on The Procedures Course . Our two-day cadaveric course teaching life, limb and sight-saving procedures. Additional Resources Have a listen to the Procedures Course Podcast where Dr Mike Noonan (Emergency and Trauma Physician) dives into the nuances of the procedure with ophthalmologist A/Prof Anthony Hall References Groombridge C, Maini A, Mathew J, O'Keeffe F, Noonan M, Smit V, Fitzgerald M, Hall A. Orbital decompression. Emerg Med Australas. 2021 Jun;33(3):552-554. doi: 10.1111/1742-6723.13768. Epub 2021 Mar 11. PMID: 33709505. Available at: https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.13768 Dr Stephen Gilmartin Emergency Physician Stephen is an emergency medicine doctor from Ireland (who has since returned to the Motherland). He has interests in trauma, ultrasound and medical education. He’s amazed that your brain is active 24/7, 365 days of the year until your death, the only two times it stops is during an exam and when you’re trying to write a funny bio!

JOURNAL CLUB PODCAST DECEMBER 2022 DR DANNY MARHABA DR JIUN KAE PUI PROFESSOR PETER CAMERON Welcome to the December Journal Club Podcast. We are again joined by Professor Peter Cameron, Academic Director for the Alfred Emergency and Trauma Centre and Dr Jiun Kae Pui, Emergency Consultant at Alfred Emergency and Trauma Centre. This month we discuss the benefit of reduced FiO2 for patients following cardiac arrest and the use of double-sequetial-external-defibrillation vs vector change in VF. EFFECT OF LOWER VS HIGHER OXYGEN SATURATION TARGETS ON SURVIVAL TO HOSPITAL DISCHARGE AMONG PATIENTS RESUSCITATED AFTER OUT-OF-HOSPITAL CARDIAC ARREST. THE EXACT RANDOMIZED CLINICAL TRIAL READ IT HERE CLINCIAL QUESTION: Does reducing FiO2 after cardiac arrest to target SpO2 90-94% in the out of hospital setting improve survival at hospital discharge? BACKGROUND Hyperoxia after OOHCA has been implicated in worse outcomes, leading to advocacy against hyperoxia (1). Does this evidence extend to the early post-arrest environment, or should early hyperoxia be tolerated for the initial resuscitation, transport and investigations? STUDY DESIGN & PICO DESIGN Open Label Randomized Controlled Trial. POPULATION Unconscious adults ≥ 18 years of age, with ROSC following OOHCA with SpO2 ≥95% while receiving oxygen of 10L/min or 100% FiO2 if intubated. INTERVENTION Oxygen reduced initially to 4LPM to achieve peripheral SpO2 of 90-94%. COMPARISON Higher flow oxygen to achieve peripheral SpO2 of 98-100%. OUTCOME Primary: Survival to hospital discharge Secondary Outcomes A collection of findings including rearrest, hypoxia out-of-ICU, survival to ICU discharge, and hospital LOS. FINDINGS Survival to discharge was not improved in the arm with reduced oxygen targets (90-94%). AUTHORS' CONCLUSIONS Among patients achieving ROSC after out-of-hospital cardiac arrest, targeting an oxygen saturation of 90% to 94%, compared with 98% to 100%, until admission to the ICU did not significantly improve survival to hospital discharge. JOURNAL CLUB THOUGHTS The lower target of SpO2 90-94% did not improve survival. In fact, there was a signal to harm with an absolute survival difference of 9.6%, and an odds ratio of 0.68 reaching P = 0.05 in favour of the early hyperoxia arm (the actual number was 0.0496 however JAMA requires this be rounded up to 0.05. When looking at the secondary outcome of hypoxia, there was a clear increased likelihood of hypoxia when targeting the lower SpO2. Intuitively this makes sense, hypoxia is more likely with lower initial oxygen targets, and early hypoxia after OOHCA can cause worse outcomes. Though we know that hyperoxia is harmful, hypoxia is probably worse. In the undifferentiated patient after OOHCA, who is undergoing transport and initial investigations – it is prudent to provide a higher oxygenation target in the early 1-2 until transport, resuscitation and initial investigations are attained. Typically, researchers will exert a great degree of effort to avoid stopping a trial early. One reason is because the results often vary in both directions as the trial progresses, this is why a pre-determined stop point is optimal – so that the trial is not stopped as soon as a 0.05 limit is reached (in either direction). Recruitment in this trial was challenged by varying ethics requirements across states, which changed during the course of recruitment – as well as the COVID pandemic due to changes of protocols in oxygen provision. SHOULD PREHOSPITAL CLINICIANS INCORPORATE DOUBLE-SEQUENTIAL-EXTERNAL-DEFIBRILLATION OR A VECTOR CHANGE IN REFRACTORY VFIB ARREST? READ IT HERE CLINCIAL QUESTION: Should prehospital clinicians incorporate double-sequential-external-defibrillation or a vector change in refractory VFib arrest? BACKGROUND Double-Sequential-External-Defibrillation (DSED) has been proposed as an intervention to improve the likelihood of achieving return of spontaneous circulation (ROSC) from refractory ventricular fibrillation (VF) (2), without damaging the involved defibrillators (3). Reducing time to ROSC, is one component of the pursuit to increase neurologically intact survival in patients with out-of-hospital-cardiac-arrest (OOHCA). STUDY DESIGN & PICO DESIGN Open-label cluster randomised controlled trial. POPULATION (TARGET) Patients ≥18 years of age who suffered an OOHCA in VF or VT, which persisted despite 3 standard anterolateral defibrillations with 2-minute intervals. INTERVENTION 6 prehospital cohorts, crossing over to vector change antero-posterior defibrillation, or to one-person DSED. COMPARISON Standard ALS including standard anterolateral defibrillation. OUTCOME Primary outcome Survival to Hospital Discharge Secondary outcomes Termination of VF ROSC Modified Rankin Scale Score ≤2 WHAT WERE THE FINDINGS? Primary Outcome 38/125 (30.4% of) patients in the DSED arm survived, compared with 31/143 (21.7%) in the Vector Change arm, and 18/135 (13.3%) in the standard treatment arm. The adjusted relative risk (aRR) of both DSED and Vector Change arms demonstrated a statistically significant increase in survival when compared to standard treatment. Secondary Outcomes All secondary outcomes in the DSED arm reached statistically significance, from termination of VF (aRR 1.25, CI 1.09 – 1.44) to likelihood of ROSC (aRR 1.72, CI 1.22 – 2.42), to proportion of MRS ≤ 2 at discharge (aRR 2.21, CI 1.26 – 3.88). Only likelihood of termination of VF in the vector change arm reached statistical significance (aRR 1.18, CI 1.03 – 1.36). AUTHORS' CONCLLUSIONS Among patients with refractory ventricular fibrillation, survival to hospital discharge occurred more frequently among those who received DSED or VC defibrillation than among those who received standard defibrillation. JOURNAL CLUB THOUGHTS A 30% survival under any intervention for patients with a refractory VF arrest is a high survival percentage. CLINICAL BOTTOM LINE This is a practice-changing trial - in patients with a refractory VF or VT arrest, who fail to respond to standard defibrillation where other interventions (such as E-CPR) are unavailable, it would be prudent to make use of a vector change or DSED to improve patient outcomes. DR DANNNY MARHABA Emergency Registrar Danny is an Emergency Medicine Registrar at the Emergency and Trauma Centre and the current Senior Registrar for research. He trained in regional NSW before moving back to Melbourne to complete his training at the Alfred.

Josh Monester & Hector Thomson Welcome to our Acing the ACEM Exams series where we unlock the key study habits, resources and top tips from recent successful exam candidates. Recent exam successfuls, Josh Monester and Hector Thomson have crafted their tips into this epic post. Disclaimer: There is no right way to study for this exam, there are as many approaches as people who have sat. Every person will tell you their way was the “best” way. Our way worked for us; it definitely won’t be everyone’s cup of tea: take it with a pinch of salt. What are your top tips for the exam? Pick a date to sit and commit to it. Most people suggest at least 12 months of study. It’s a long slog. Keep a focus on stuff that recharges your batteries. Read the f***ing question. (RTFQ became a mantra and served us well) Read all the documents on the ACEM website. Understand what specific terms mean (eg management ≠ assessment/investigations). The best piece of advice given to me: Josh: From my friend and boss Claire Gorham in Darwin: “Show them how much you know!” It shifted my focus from panic to acknowledgement that actually I do know lots and have put in the work. Hector: Read The Resilience Shield. An evidence-based look at resilience written by three SAS veterans, one of whom was a military doctor. It introduced me to Pomodoro timing (25-minute chunks followed by a 5-minute break) and a whole host of other techniques to make sure I stayed sane. So how does the actual process work? Time commitment: A rough ballpark is that you should put in at least 1000 hours of high-quality study to pass the exam. This means approximately 20 hours a week for 50 weeks. Plan far ahead how you’re practically going to do this: strategically consider rotations, life events, leave, and working part-time. Many people (including us) chose to work part-time in the lead-up to the exam. In the three months before sitting, Josh worked 0.75, Hector worked 0.5. We both worked full-time before this. The key point here is the ability to put in the hours. Family and friends: Get your friends, family, significant other etc on board about the time commitment you’ll need to put in, and make plans early to remain human. Holidays, date nights, sleep-ins etc are extremely important, so don’t neglect these. Content: You need consultant-level knowledge. Use the Study Guide for Medical Expertise (page 39 of the curriculum), print this off and cross it off as you go. You need to be able to talk like an expert in all of the “expert” level domains. This is an exit exam. ☝️ Read that again: no really, read the Study Guide ☝️ Style: Develop this early by doing past questions. Learn how to be concise and precise in your answers. No wasted words. You are the consultant. Timing: The 3-hour SAQ is very time-pressured. It will go down to the wire. However, don’t worry about this at the start. As you get more confident and do more papers you’ll pick up the pace and learn the time a 12 or 18-mark question will take you. We aimed to finish with 15 minutes to review questions. Toxicology: There is a HUGE amount of content to cover here. Don’t defer it. We suggest doing a little every week alongside other content. Tracking your study time Josh: The giant nerd in me wanted to track my study, so I used toggl. It helped me reflect on weeks where I did more or less study and why. Below is a screenshot of my study hours over 12 months: the most important point here is that there are times you’ll do more or less due to life continuing to happen. This is okay! Hector: I put a massive whiteboard above my desk and wrote out all the topics I wanted to cover. Then I would tick them off as I went. It seems daunting at first but it is motivating to see the progress. I also ticked off the topics in the Medical Expertise Guide to make sure I was covering everything. What was your rough timeline for study? 14-16 months out: The contemplation phase: pick a date and commit, buy/find the books (hard copy or PDFs), talk to your DEMT and friends who have recently sat the exam. Plan your rotations. Read all the documents on the ACEM website, plan a study timetable and when you’ll sit AFEM. 12 months out: Start studying according to your timetable. Build your knowledge base and get used to the type of questions. You should aim to cover all the content in the first six months. Review a few past questions on EDvivas Read the relevant chapters in Dunn (or you can use Cameron or Tintinalli) Make ankis or study notes (depending on your style) Do some MCQs Re-do the SAQ questions (and see how much you've learned!) A little tox per week: aim for 2-3 topics alongside your other content study. Own the ABG: 2-3 cases per week (if you've not done so already) 6-4 months out: Form your study group if you haven’t got one already. Do lots of questions and mark each other’s papers. Get used to giving and receiving feedback. We did the Geelong papers as one-hour papers to start with. Do these to time. Aim to cover all 30 over about 10 weeks (equivalent to a full paper per week). These are tried and tested. 4 months out: Start doing fully-timed 3-hour SAQ papers. Get these marked by FACEMs, if you can, or someone who has recently passed. Using the list on DoctorsWriting, we met at the library, did a paper in the morning, treated ourselves to lunch and then marked it in the afternoon. 3 months out: Sit your hospital’s practice exam. Use this as a go/no-go point to make sure your medical expertise is up to scratch. After this point, technique and timing can be improved, but if you’ve got massive knowledge gaps in medical expertise it’s hard to compensate. 2 months out: At least weekly 3-hour papers. We started doing the formatted papers on the ACEM Website to exam conditions (old Monash and NSW Practice papers). 1 month out: Aim for 2-3 papers per week to time. Last week: Almost there… You’ve done the work. Taper your study and rest up! Pitfalls Not giving yourself enough time to study. “I’ll see how I go”. Inevitably people who said this deferred their attempt. Not reading the f***ing question. (RTFQ) Anki There is a huge amount of content to learn for this exam. We committed to using Anki (but any flashcard program will do). Spaced repetition is damn effective. There are some days you’ll hate your Anki deck, but we promise it’s worth it. What textbooks/resources would you recommend? There is so much out there. Be careful using non-college recommended texts or resources. You might disagree with an answer but the college will mark from the texts. Textbooks Dunn - this is the mainstay of your study. Bullet points and searchable. Digestible. Many questions are based on Dunn. Cameron - good for an overview early, the tables get used for questions. Excellent legal/admin chapters. Perhaps not detailed enough for full SAQs. Tintinalli - excellent for deep dive, but presents bricks of text which are impenetrable. Good for details in tables. Rosen - we didn’t use at all. Own the ABG - MUST read in full early in your study. Tox Handbook - MUST have a copy. Gold dust. Use the latest edition (4e). Online ACEM Policies and modules: there are several policies and guidelines (eg access block, mentoring, cultural competency) - read at least once. They will come up! Doctors Writing - central location for all practice exams, has an excellent summary “EMIndex” for revision to check you haven’t missed anything big. Geelong papers: excellent one-hour papers. We loved these. EDVivas: You’ll love-hate this website from your Primary. Can search the FEx questions by topic. Use this in your first six months of content study. ECG Weekly: Weekly 10-15 minute videos on core ECG topics by dreamboat and ECG guru Amal Mattu. $26 USD per year subscription. Highly recommend it. LITFL Top 150 ECGs LITFL Top Tox cases EM:RAP: Pricey but good for the commute to work EMCQPractice: Full MCQ papers and a useful “study series” with MCQs by topic. Costs $$ and difficult exams, but worthwhile overall. Courses AFEM: See below Many other courses which we can’t speak to as we didn’t do. How did you study for MCQs? Nobody really talks about these, because the pass mark is higher. It’s very difficult to study for as you’ll often be tested on minutiae. The MCQ book by de Alwys gives a good guide to the style of questions, however is now a little dated in its content. DoctorsWriting has some widely published recalled questions from previous years which you must do. Read: must do. We found the MCQ exam more difficult/challenging to prepare for, but the pressure here is on the specific medical knowledge and reading the question. Much of the content here comes from Dunn: so make this the mainstay of your MCQ study. When to sit AFEM? (Disclaimer: We’re not affiliated with AFEM in any way, but have done the course.) The AFEM Course is run in Brisbane with a virtual option twice a year (Feb and Aug). It’s an excellent review of high-yield topics and gives you the opportunity to do a full SAQ and MCQ exam in a single day. The first 50 applicants get their SAQ paper marked, so sign up early. There are two approaches to when to do the course: 9 months out from your exam: This gives you the perspective of the breadth and depth of what you need to know. People say it can be overwhelming this far out. Do it this way if you want more structure early in your study. 3 months out from your exam: This is the way we did it, more as a check to make sure we hadn’t missed any core content, and to benchmark ourselves against a high-quality SAQ exam. The three normal points of panic: It seems to be a universal experience: everyone experiences these panic moments, and then wonders if anyone has ever felt like this before. 1 month into study: “OMG there is so much content to cover I will never be able to study this.” (You will.) 6 months into study: “OMG these papers are so difficult, how am I ever going to be slick enough to pass?” (You need more practice but will get there.) 1 month out: “OMG am I going to fail? Have I just wasted a year of my life on study?” (You've never had better medical knowledge in your life and will smash it.) You’re allowed to freak out. Take a (guilt-free) day off. Talk to your study group or mentor. Let your support people know. Do something for yourself. Final Thoughts Enjoy becoming a better doctor. (Why did no one teach me about ARVD earlier?) This is the best your knowledge of emergency medicine will ever be. Josh & Hector

Hector Thomson, Nathan Hunter and Josh Monester There are a number of excellent guides to the OSCE floating around from different health services. These are our thoughts on having sat the 2023.2 Fellowship OSCE. My written knowledge was excellent, surely translating this into the OSCE will be easy? We were shocked at how wrong this is. Yes, having good medical expertise is crucial to passing this exam, but the OSCE is about so much more, all packaged into a “thinking on your feet” format, mixed in with your analytical and communication skills. It requires a huge amount of OSCE-specific study and preparation, and lots and lots of practice. Performing for the OSCE did not come naturally to us, but at some stage you’ll find that it “clicks” and it even becomes enjoyable. What is the OSCE all about? The OSCE is about showing the examiners you are a safe, capable colleague who they would happily let manage their resus area. In the beginning we were desperate for people to give us templates. To go into each station and give a prepared TED talk on hyponatraemia but sadly this is not how you score points. Whenever anyone asked if specific words meant we had to do something in a particular way (screen for domestic violence/check for drug use/safety net) we inevitably realised that “It depends.” Rather than developing templates, be present, actively listen and just perform the tasks the stem asks of you. Should I power through after the written exam? If you sit the OSCE immediately after the written there is approximately four months between exams, so some people choose to sit at the next sitting and some the subsequent one (10 months between exams). Some arguments for power through to the next sitting: You’ll remember your fine-grained written knowledge more easily This minimises the total time you are studying You can continue on as a study group You can get the whole exam process over Some arguments to defer to a subsequent sitting: If you feel you need more time to understand the OSCE format and exam to adequately prepare If you are burnt out Major life events We chose to continue straight through. We started our OSCE campaign two weeks after we sat the written. Keep in mind you will not have your results yet! While it can be hard to motivate yourself, you need to start. If you wait 6 weeks for your written result there is not enough time. What was your timeline to prepare? 0-2 weeks post written: Rest and Recovery We took time off and took a deep breath. Booked Airbnbs in various parts of the state and enjoyed a drink. 2 weeks post written: Planning We sat down and marked out dates along with an overall approach to preparation. 3 months out: Exposure Tried to do as many OSCEs as we could. We filmed our stations and reviewed them. Initially we stayed within our group then gradually started doing more with FACEMs. 2 months out: Style We did private coaching sessions to work on our weak points. We developed the phrases that worked for us that we could use in different stations. 1-2 months out: Stamina We sat mock OSCEs and started to do 6 OSCE in a row. 1 month out: Polish Went to an OSCE preparation course in Sydney which included a full 2 day OSCE 1-2 week out: Confidence We only did stations with people who would give us good feedback. We did stations we liked and felt good about. Do I keep doing my ankis/flashcards? You still need to keep up your “medical expertise” to do well at the OSCE. Thankfully the focus shifts from small facts to approaches and key treatments. We developed a list of core topics and thought about what would be important from an assessment (history/exam/investigations) and management (resus/specific/supportive/disposition) perspective. That being said there are some facts that are useful to have to hand to explain things to patients and to sound clever in an SCBD, (e.g. 25% of women have bleeding in early pregnancy and 50% will go on to have a normal pregnancy. These can be useful additions to your anki deck should you continue using it, or form a separate deck of ‘OSCE nuggets’ What do the domains mean? You need to read everything in the “Fellowship Examination Resources” page. Similarly to the written you need to figure out what you are being examined on and ANSWER THE F***ING QUESTION. Read the Glossary of Terms a few times. You need to know how assessment and management questions differ. The focus of the written exam is almost entirely on Medical Expertise, as this is far easier to mark in written format. However, the OSCE focuses not only on Medical Expertise, but multiple other domains. The key document here is the OSCE Domain Criteria on the ACEM exam resources page. The bottom of each OSCE stem lists the domains and relative percentages upon which the station is marked. This is so important because it tells you where to focus your time. For example, if there is a station where you are advising a Junior Registrar, if there is 40% Scholarship and Teaching, you will need to spend significant time ticking off the relevant points under this domain. If the domains are 100% Medical Expertise, do not waste any time with teaching points including checking level and understanding, feel free to steamroll the roleplayer with your amazing knowledge. How should I practise? Unlike the written where you can do practice papers on your own, the OSCE is a team sport. You need a study group to meet with regularly. We aimed for at least one station a day. There’s real benefit from repetition and a quick Zoom call after or before a shift to go through one station each still felt very worthwhile. We had a study group of three and tried to organise longer sessions when we were all off. We did a mix of online and in-person (thanks Erin for letting us use your living room.) The in-person sessions are so much more useful however with ED shift work sometimes you can’t find time. Obviously examination stations are much more useful when done in person! (The authors, elated at discovering the “Under the sea” filter on zoom!) It’s important to recognise that OSCE study is a different beast to written study. Being on the spot, practising stations, receiving critical feedback, and rehearsing stations over and over will tire you out mentally much quicker. We found that even our in-person longer study sessions rarely lasted more than a few hours before we had to stop doing stations for the day, or at least take a very extended lunch break. We would then generally use the rest of the day to do things such as read through and brainstorm past exam reports, filter through our anki decks (suspending any no-longer useful cards), or identify and prepare summaries for key OSCE topics or station styles. As much as it is painful to hear your own voice, filming these sessions is useful. We spent more time debriefing and going over the station than actually performing then for the first month. We would do a station with one person being the candidate, one asking the question and one marking. We would listen to the recording and then talk about the station. Sometimes we would get the candidate to repeat a section if we had collectively come up with a better approach. This was really helpful if you felt you bombed a section (or whole station), allowing you to get it clear in your head, practice hearing the right words come out of your mouth, and importantly, keep your confidence up. Make sure you are practising to time. Set up a timer on your phone with reading time and then a 6 minute and 7 minute buzzer. We used a shorter reading time to allow for moving between rooms. Outside of your study group you need to hassle all the FACEMs you can (even ones you are scared of) to do stations with. If you have examiners in your ED get in contact with them early. They know how the whole process works and will point out your bad habits early. Everyone has a different approach to this exam so try to get a variety of opinions. Examination reports - Hidden gold One resource that a lot of people only skim is the examination reports. (Thanks Gavin for suggesting this!) There is a surprisingly large amount of information released in these reports that can allow you to extrapolate a station. It also gives a good idea of what mistakes people consistently make. Once you start trying to write some OSCE stations you will realise what a difficult task it is to write one. As such there are common stations that will come up time and time again. If a station works well as a discriminator it may be simply reworked. We read through the reports and then generated possible questions and answers. Where do I get OSCEs? There are generally shared folders of hospital’s practice OSCEs floating around. Ask the group who just sat. Generally the further back you go towards 2015 the worse the quality. The Monash OSCE website is excellent. We formed an excel spreadsheet to keep track of which stations we each had done. For each we tried to take away key learning points and traps. This was useful when we were still figuring out what the stations meant but dropped off towards the end, however did come in useful when trying to find a particular station that we’d practised and wanted to re-visit. How do I read a stem? This is a crucial skill that must be developed. There are many ways to read a stem. We recommend top down then back up taking it all in. Then being deliberate. Label the station to give yourself a framework -  “Life-threatening paediatric asthma” Analyse every word - It is all there for a reason. (Rural ED for example means you will need to think about retrieval). These stations are picked apart during their creation process and they do not add in red herrings. Figure out the domains and their weighting - This will guide how much time you need to spend on each part to maximise your marks Read the tasks - You must perform these to score points. For every patient outside the room consider: This patient This place This time A 25-year-old in a major trauma centre at 10 am is a very different patient to a 90-year-old in a rural urgent care centre at 2 am. You must frame your answers in this response. You also have a copy of the stem in the room. Placing the stem in the same place in every station can be useful. If it’s under your right hand every time if you get lost or forget what you need to do you can look down. Is there a framework for answering SCBD questions? We were taught the LISA system (Thanks Chris Roubal) and while we could talk about different structures for different stations this is the most useful. This is a handy way to frame your clinical answers and provides a nice structure to answering questions in a SCBD. Label: This patient has a life-threatening anaphylaxis with upper airway obstruction Issues: The key issues will be treating anaphylaxis and securing a definitive airway. There is a high risk of this patient needing a surgical airway given their significant angioedema. Show the examiner you know what is going on and what is going to harm the patient This is where you show your prioritisation and decision making! Send for help: “I would urgently call for assistance from anaesthetics/ENT/ICU…” This was put in as a reminder to always use key available resources. Remember to always REFER FOR A REASON. Do not simply push the clinical problem onto another specialty. Take ownership as the FACEM but recognise when you need help from other teams. Actions: Clearly list out your steps in ORDER OF CLINICAL PRIORITY Adrenaline: 0.5mg IM into anterolateral thigh with 2nd dose at 5 minutes while starting and adrenaline infusion at…. Oxygen: 15L via hudson mask while….. As with the written, be very clear in your treatments giving a dose, route and a clinical endpoint you are aiming for. What about areas of clinical controversy? This is where you get to show off you’re ready to be a consultant! Avoid sitting on the fence and saying “Well I could do this and I could do this…” Just as at work, there will be areas of grey. Make a decision and explain your thinking e.g. “I recognise the competing priorities however I would use… and then change my plan if….” How do I deal with all the feedback? This is the most concentrated period of negative feedback you will have received in your life. You will get feedback from your bosses and peers and it is hard to not take it to heart. Especially people who you work with daily and respect. Remember that the OSCE is an intensely personal exercise and everyone has a different approach, so there will always be something you could have done better. Take on board the feedback but be careful not to let it hurt your confidence. You need both cheerleaders and critics. As you learn the process, harsh critics are useful to point out mistakes. As the date approaches you need to shift to cheerleaders who will make you feel good about yourself. Do not underestimate how much confidence plays a part in performing on the day. Do I do the courses? We chose to do the Teemwork course. It was useful to do a full exam run-through over two days. While your hospital will hopefully run a mock this is usually 6 stations. The full two-day experience is invaluable. How do I handle the stress? The mindset we tried to cultivate was that we had done the hard work preparing for the written and this was our chance to show off everything we had learned. It may sound absurd but if you can try and enjoy the day it will set everyone in the exam room at ease. One of us used a lot of self-talk. The mantra of “Calm Clear Confident: I am the consultant” repeated over and over proved useful. EMCRIT and First10em have done some great ED-specific summaries. What do I do on the day? Do what you can to minimise any possible additional stressors. Some things that we’ve found helpful or seen help other candidates are: Planning or even pre-preparing your meals before and in between the exams. Booking into a hotel near the examination centre. This was even helpful for some candidates living in the same city as their examination centre, if there was a reason their sleep may be significantly disrupted at home, or if transport was particularly unreliable. Make a plan A, B, and C for how you will get there should you miss your bus/train or your Uber cancels 4 times in a row. If you are a caffeine drinker, consider planning the timing of your pre-exam beverage to optimise mental clarity and minimise palpitations. The exam cannot pause to allow you a toilet break. Lastly, pay attention to how your performance changes throughout the day in your practice sessions. Especially later on when you may be practising 3-6 stations in a row. If, like most of us, it sometimes takes you a station or two to warm up and get into the right mindset, it might be worth calling in a favour from a study buddy or willing FACEM. Ask them to run one or two stations (at most, don’t exhaust yourself) for you an hour or so before you attend the exam. It is critical that you pick stations you are very comfortable with, and know you will completely walk through to help keep your confidence at peak level! What do I do once I’m in the room? When the sound goes you need to hit the ground running. Walk straight in confidently and introduce yourself. Actively engage with the station. It can help to have your first sentence or two prepared and briefly rehearsed, to avoid it coming out in a jumble as you close the door and try to sit on a chair with your adrenaline through the roof. If you feel yourself losing direction, always remember to return to the tasks. Keep the provided copy of the stem in front of you, and don’t be afraid to pause for a second to re-read the list of tasks during the station and make sure you’re not going off-piste. On this note, the examiners and confederates really want you to pass. They will help guide you as much as they are allowed to within the strict limits of the station and general OSCE protocol. If they interrupt you or repeat a question, you can safely take it as a clear sign that you need to immediately wrap up what you’re currently talking about. Even if what you are saying is 100% factually correct and clinically genius, if you’ve strayed away from the tasks, or have already ticked everything on their mark sheet for that section then you are gaining no points and only wasting precious time. What do I do if the station is going to shit? It’s ok to ask for a second to gather your thoughts. Take a couple of slow breaths and re-check the stem provided in the room to make sure you haven’t missed something. If you don’t want to leave too big of a silent space, you can ask the examiner or confederate to please repeat their question, to give you a few extra seconds. Examiners are limited in the questions they can ask, which are mostly scripted, and they can’t prompt you to talk about a specific topic you’ve missed. They can however circle back to something you’ve already mentioned and ask you to expand on this. For this reason, briefly and clearly listing/signposting the topics or areas you’re about to talk about in your answer permits them to give you a nudge to go back and expand on that area and squeeze out a few more points. If you keep your planned answer structure secret in your head and then forget one section, they can’t help. Despite all the practice in the world, it’s still really common to have “bombed” a station, or at least feel like you’ve done so. Practise during your mock OSCE to have a technique that works for you. We were taught to physically close the door to the station room with purpose, allowing a clear break mentally. Take a deep breath or have a sip of water and move straight on to the next station. What do I do after day 1? Debrief if you have to. Beware those who sat on the same day. Just because they said something doesn’t mean that was the right answer! Writing down the stations and then putting it away worked to let it go. Exercise heavily so you will go to sleep then eat something comforting. Lean on your support people and get into a good headspace. You are so close! Conclusion/Top tips You will trauma bond with your study group - lean into these. Baked goods and cocktails certainly made our experience a lot less painful! This will be the most concentrated period of negative/constructive feedback you’ve likely ever received. Feedback tends to focus on ways to improve, not pats on the back for your good work. Keep your performance in perspective, use the feedback to improve but try not to get bogged down in it. Be kind to yourself. Preparing for this exam will take its toll, so make sure you’re prioritising keeping your body well-fed, exercised, and rested. Accept support from those close to you. Whether this is in the form of meals, transport, entertainment, or anything else. You will have plenty of opportunity to return the favours once you are on the other side! On this note, as much as some friends or relatives may offer their assistance, try and keep your practice of OSCE content limited to those in your study group or FACEMs/registrars on the other side of the exam. A well-meaning model may offer a limb for you to practise a neuro exam on, but they won’t help you iron out bad habits or offer you what may be useful but potentially uncomfortable critique. HECTOR THOMSON Emergency Registrar Hector is a post-fellowship exams ED trainee currently working at Adult Retrieval Victoria. He enjoys shoulder dislocations, trauma, rugby union, fresh pasta and good gin. He doesn’t like vague allergies or cats. NATHAN HUNTER Emergency Registrar Nathan is an advanced trainee at The Alfred. At work (and increasingly on his days off) he can generally be found running a sim of some variety, which he has been heard to describe as ‘basically Dungeons and Dragons but with a defibrillator’. He enjoys getting his ultrasound images to balance by the rule of thirds, and sculpting aesthetically satisfying POP casts. He misses drawing little doodles of patient’s ailing body parts in paper-based notes and is still to this day searching for a clinical use for glitter. JOSH MONESTER Emergency Registrar Josh is a senior emergency medicine registrar with Alfred Health, having crash-landed back in Victoria after a protracted “working lap” of the country, dodging sharks in WA and chasing waterholes in the NT. He works to fuel his ice cream habit, but is driven by his love of trauma, ultrasound and medical education.

Author: Dr Hector Thomson Editor: Dr Dave McCreary None of us got into emergency medicine because we love rashes. A wise FACEM once told me, “I only care if it doesn’t blanch, involves their mucous membranes, has massive vesicles or their skin is falling off.” I actually find this quite a nice list of red flags. Another way to think about this is a rash in a patient with: Systemic symptoms Fever or abnormal vital signs Intra-oral or mucous membrane lesions Blistering Bruising New medications There are just some rashes that you come across and go… what the $&@% is that? The Case At a recent MET call on the ward, I stumbled across a bloke in absolute misery. Having started Alopurinol for his gout a month prior he had come out in a rash a few days earlier. At his first ED visit, he was diagnosed with "urticaria, possibly allergic", and started on antihistamines and prednisolone. He had a slight cough so maybe a viral trigger. He had represented a few days later with it worsening. Now day 5, his whole body was covered. It looked like this with almost 90% erythroderma. Source: Thompson & Thompson Genetics in Medicine, 8th Edition https://doctorlib.info/medical/thompson-genetics-medicine/20.html He could barely swallow, his eyes were red and weeping and he was starting to having trouble passing urine. He was absolutely miserable and the MET call had been called for pain, despite enough opioids to put down an elephant in the last 4 hours. So, what is this? This is Toxic Epidermal Necrolysis (TEN). Wait, isn’t it called Steven Johnson Syndrome? Well, no… they are the same disease, on a spectrum. TENS is when the total body surface area is >30%. Source: Adapted from Fig 21.9 Bolognia and Bastuji-Garin S. et al. Arch Derm 129: 92, 1993 Pathophysiology The mechanism still isn’t fully understood but the result is a Type IV hypersensitivity reaction where cytotoxic lymphocytes apoptose kerinaocytes causing blistering, bullae formation and sloughing of detached skin. This results in full-thickness epidermal necrosis which can be confirmed on skin biopsy. Source: Wikipedia 🚨Primary Flashback: Type IV is the cytotoxic, cell mediated delayed hypersensitivity reaction 🚨 SJS/TENS is extremely rare (1-2 per million/year with a slight female predominance). This disease has a high mortality. The majority of SJS/TENS is medication-related.  More than 200 medications have been reported as a trigger. The most common can be remembered by "SATAN": Sulphonamides Allopurinol Tetracyclines Anticonvulsants (Phenytoin/Carbamazepine/Phenobarb) NSAID. Often this is within 1 week of antibiotics and 1 month of anticonvulsants. In a paediatric population think of Mycoplasma pneumoniae and Herpes simplex. In adults think of HIV, Leukaemia and lymphoma. Presentation SJS/TENS usually develops within the first week of antibiotic therapy but up to 2 months after starting an anticonvulsant. There is often a prodromal illness resembling an URTI with fever, sore throat, runny nose, conjunctivitis, malaise, arthralgia and dysuria. Diagnostic hint: Dysuria is present in the majority of cases. Rash with dysuria should raise concern for SJS with associated urethritis. Then a tender/painful red rash develops on the trunk and extending over hours to days onto the face and limbs usually reaching its maximum by four days. The blisters merge to form sheets of skin detachment, exposing red, oozing dermis. Nikolsky sign is positive –blisters and erosions form when the skin is rubbed gently. Source: Dermnet Source: https://www.grepmed.com/images/4305/sign-video-clinical-nikolskys-ten Mucosal involvement is prominent and severe including: Eyes: conjunctivitis Lips/mouth: painful ulcers/red crusted hips Pharynx/oesophagus: restricted oral intake Genital area and urinary tract: erosions, ulcers, urinary retention Upper respiratory tract: cough and respiratory distress Gastrointesinal tract: diarrhoea Complications SJS/TEN can be fatal with a mortality rate of 10% for SJS and 30% for TEN  from: Dehydration Infection and sepsis ARDS GI perforation Acute renal failure DIC Thromboembolism Scoring SJS/TENS can be scored on the SCORTEN or ABCD-10 score – look this one up when you need to use it. Treatment Stop the offending agent! Then our job is supportive care. Think of this as a severe burn. Give them multimodal analgesia, fluids aiming for 1ml/kg/hr of urine output, dressings, keep them warm and isolate them to prevent secondary infection. These patients should all be transferred to a burns unit as they will need plastics, ophthalmology, intensive care and pain input. Avoid silver sulphadiazine as this can exacerbate things. Steroids, Monoclonal antibodies, IVIG, plasmapheresis are all options but controversial. ☝️Pro tip: Early IDC – the mucosal irritation can make later attempts painful! Case Conclusion After sending some photos off to our local friendly plastics surgeons and dermatologists I received some very excited return calls. The patient was whisked across to the tertiary burns centre where he stayed for over a week where he needed to get extensive input from the pain team as his rash slowly resolved. Key Points SJS/TENS are different ends of the same spectrum of your skin falling off usually after a new medication Rash + Dysuria – think TENS/SJS Nikolsky sign = epidermis detaches from dermis with rubbing Medication triggers are numerous but for exams remember: SATAN Treat as a severe burn References Dermnet: https://dermnetnz.org/topics/stevens-johnson-syndrome-toxic-epidermal-necrolysis FOAM: http://www.emdocs.net/stevens-johnson-syndrome-and-toxic-epidermal-necrolysis-mimics-differential-diagnosis-and-initial-management/ https://coreem.net/podcast/episode-162-0-stevens-johnson-syndrome-toxic-epidermal-necrolysis/ Gerull R, Nelle M, Schaible T.  Toxic epidermal necrolysis and Stevens-Johnson syndrome: A review.  Crit Care Med.  2011; 39:1521-1532. Dodiuk-Gad RP, Chung WH, Valeyrie-Allanore L, Shear NH. Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: An Update. Am J Clin Dermatol. 2015;16(6):475-493. doi:10.1007/s40257-015-0158-0 More Info Lerch M, Mainetti C, Terziroli Beretta-Piccoli B, Harr T. Current Perspectives on Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Clin Rev Allergy Immunol. 2018;54(1):147-76. Han F, Zhang J, Guo Q, et al. Successful treatment of toxic epidermal necrolysis using plasmapheresis: A prospective observational study. J Crit Care. 2017;42:65-68. doi:10.1016/j.jcrc.2017.07.002 More Info HECTOR THOMSON Emergency Registrar Hector (the one on the left) is an Emergency Medicine Advanced Trainee at The Alfred. He’s still clinging to the basic science knowledge he gained during primary exam prep and enjoys shoulder dislocations, trauma, rugby union, fresh pasta and good gin. He doesn’t like vague allergies or cats.

Dr Gavin Ng Emergency Physician Editor: Dr Hector Thomson THE CASE You receive an ambulance notification on Saturday morning. “We are coming to you in 10 minutes. We attended a 70-year-old gentleman with positional vertigo symptoms and gave him 12.5mg IM procholorperazine (Stemetil). His initial GCS was 14 – it is now 3. He has also desaturated to 76% on room air.” The patient arrives shortly thereafter. There are two striking features on the clinical examination – he has widespread generalised erythema over his entire body, and he is noted to have significant rigidity in his lower limbs bilaterally. His other vital signs are as follows: HR 100 BP 160/110   RR 24 SpO2 100% 15L non-rebreather   T 35.7   GCS 3 He is noted to have trismus, and bilateral peri-orbital oedema as well. A wheeze is noted on auscultation. References Caplan, L.R. (2022). Posterior Circulation Cerebrovascular Syndromes. In J. F. Dashe (Ed.), UpToDate. Retrieved March 5, 2023 from https://www.uptodate.com/contents/posterior-circulation-cerebrovascular-syndromes Din, L., & Preuss, C. V. (2022). Prochlorperazine - StatPearls - NCBI Bookshelf. Retrieved March 4, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK537083/ Lavonas, E.J. (2021). First-generation (typical) antipsychotic medication poisoning. In M.Ganetsky (Ed.), UpToDate. Retrieved March 5, 2023 from https://www.uptodate.com/contents/first-generation-typical-antipsychotic-medication-poisoning Campbell D. The management of acute dystonic reactions [Internet]. NPS MedicineWise. 2001 Retrieved march 5, 2023 from https://www.nps.org.au/australian-prescriber/articles/the-management-of-acute-dystonic-reactions Eskow Jaunarajs KL, Bonsi P, Chesselet MF, Standaert DG, Pisani A. Striatal cholinergic dysfunction as a unifying theme in the pathophysiology of dystonia [Internet]. Progress in neurobiology. U.S. National Library of Medicine; 2015. Retried march 5, 2023 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4420693/ Gavin Ng Emergency Physician Gavin Ng is an Emergency Physician and Co-Director of Emergency Medicine training at The Alfred. Gavin has worked in a variety of clinical settings, ranging from metropolitan EDs to regional areas in Victoria. His clinical interests are Critical Care Medicine and Trauma medicine, and he has previous experience working as a Trauma Fellow at Alfred Health. He is also a current ALS2 (Advanced Life Support Level 2) instructor. He also has a passion for education – he has previously been involved in teaching junior medical staff through the Northern Clinical School.

Dr Luke Phillips Emergency Physician Peer review: Dr Rob Buttner A 65-year-old female undergoing chemotherapy for breast cancer presents to your ED with septic shock and likely febrile neutropenia. She does not have any central access device and tells you that the nurses and doctors always struggle finding her veins. You put the tourniquet on and cannot palpate a vein or visualise one on the back of her hands. Do you try to find a vein blindly, potentially wasting precious minutes and increasing time to antibiotics and fluids/inotropes with multiple attempts, or do you reach for the ultrasound probe? Ultrasound-guided vascular access has been shown to decrease the number of needle puncture attempts, complications, and decrease the requirement for central lines (Blanco, 2019). In the right hands, it can also save time. It is important for clinicians to have adequate cognitive knowledge, workflow understanding, and visuospatial skills to safely execute this procedure. The operator should also be familiar with the anatomical variations, equipment operations, and potential complications and their prevention. The following video outlines the key steps for ultrasound-guided IV Cannulation (USGIVC): LIKE WHAT YOU SEE AND WANT TO LEARN MORE POINT-OF-CARE ULTRASOUND SKILLS? Then join us for our upcoming Ultrasound Courses at Alfred Health. Learn from our expert emergency physicians how to perform lifesaving ultrasound at the bedside. Our core course covers procedural guidance, AAA scanning and eFAST; and our advanced course covers basic Echo and Lung Ultrasound. More information can be found here. LET’S LOOK AT SOME PRO-TIPS TO HELP ENSURE CORRECT PATIENT SELECTION AND SUCCESS IN YOUR IV CANNULATION. WHICH PATIENTS REQUIRE ULTRASOUND-GUIDED IV CANNULATION? The Adult Difficult IV Access (A-DIVA) Scale is a clinical tool that can be used to assess patients at risk of difficult IV access (DIVA) and potentially escalate to early USGIVC. The study identified key variables that were associated with DIVA. These included previous history of difficulty with IV access, failed first attempt, difficulty visualising or palpating a vein or if the patient has spindly, small veins. The more of these variables a patient has, the less likely you are to be successful without ultrasound. THE A-DIVA SCALE The scale consists of 5 questions, with one point for each yes: Low risk (score 0-1) = 4% failed attempt, Moderate (2-3) = 37% chance of failed first attempt, High risk (4-5) = 94% chance of failed first attempt. A score of three was associated with 55% first-attempt success. WHAT SIZE AND LENGTH OF CANNULA SHOULD I USE? Use a long IV cannula even when a vessel is at 1cm depth, as you may still run out of length with the standard IV cannulas. This also ensures a significant proportion of the cannula is in the vessel and won’t dislodge with arm movements. At The Alfred, we use Braun Introcan Safety Deep Access IV catheters. WHAT VEINS SHOULD I SELECT TO CANNULATE? The following considerations should be considered when selecting a vein for a USGIVC: TOP TIPS FOR NEEDLE GUIDANCE Most USGIVCs are inserted using the out-of-plane technique. This involves identifying the desired vein in the transverse plane and using a needle approach over the centre of the vein. The vessel should appear in the short axis as a hypoechoic circle on the screen, with the needle visualised as a hyperechoic point in cross-section. Before needle or catheter insertion, the depth of the centre of the intended vessel should be estimated from the ultrasound image. Choose an angle of insertion that triangulates the path of the needle toward the vessel lumen, ensuring that you don’t run out of cannula length (Think Pythagoras’ Theorem from high school maths). Note that a steeper angle of insertion may make it more difficult to visualise the needle tip. Figure: Explaining the distance from skin to vessel in ultrasound-guided cannulation. While this distance (d) is estimated in the short axis, the real distance to reach the vein depends on the insertion angle. Assuming a 45° insertion angle, this real distance is equal to d multiplied by 1.4. Of note, the real distance decreases with sloped insertions and increases using shallower insertions Figure: Real distance from skin to vein measured directly in the long axis. As shown, the shallowest insertions determine the longest pathway to reach the vein, resulting in a large proportion of the catheter dwelling outside the vein and ultimately leading to catheter failure. In contrast, sloped insertions lead to shortening the distance to reach the vein, and aid in increasing the proportion of the catheter dwelling in the vein lumen (Image from Blanco 2019). Care must be taken to follow the needle tip as it advances to avoid underestimating the depth of the tip. This can be achieved by using the leapfrog method (nicely visualised in the video below by our very own Rob Buttner) where once you have identified the needle tip, the probe is advanced just ahead of the tip before advancing the needle again until it just comes into view. This will limit the likelihood of advancing the cannula through the posterior venous wall of the vein and causing extravasation. LOST YOUR NEEDLE TIP? DO NOT ADVANCE THE NEEDLE OR JIGGLE IT UP AND DOWN AND FOLLOW THESE STEPS: Stop and look at your cannula position in relation to the probe. Is it on an angle? Is the probe too far away? If so, then sweep the probe back and adjust your probe angle to better align with the needle. If everything seems to be good, then fan the probe back towards the needle tip. Once you have found what you think to be the tip wiggle it from side to side to confirm and then carry on using the leap-frog technique until you have successfully cannulated the vessel. A lot of these skills are transferrable to other ultrasound-guided procedures. Becoming skilled at ultrasound-guided cannulation and visualising the needle tip will lead to medical mastery in other ultrasound-guided procedures such as nerve blocks, central lines, pleural taps and many more. PREPARATION IS KEY Treat USGIV like any other ultrasound-guided procedure (arterial line insertion, nerve blocks), taking adequate time to set up your environment and positioning. You may need an assistant to position the patient’s arm. Your comfort increases your chances of success. The ultrasound machine should always be directly in your line of sight – this will almost always be on the opposite side of the patient. Even when time-pressured, taking a few moments to optimise these things will increase chances of first-pass success and likely reduce overall time to access. Consider using local anaesthetic – this is not just for the patient; it is for you. Increased patient comfort will result in less movement and distraction from visualising your needle position. FURTHER RESOURCES This video from Kylie Baker a FACEM and ultrasound guru in Ipswich QLD outlines some of the pitfalls encountered when performing ultrasound needle guidance and is a must-watch for anyone doing US-guided procedures. REFERENCES AIUM (2019). AIUM Practice Parameter for the Use of Ultrasound to Guide Vascular Access Journal of Ultrasound in Medicine, 38(3), E4–E18. https://doi.org/10.1002/jum.14954 Blanco, P. (2019). Ultrasound-guided peripheral venous cannulation in critically ill patients: a practical guideline. Ultrasound J11,  https://doi.org/10.1186/s13089-019-0144-5 Fields, J. M., Dean, A. J., Todman, R. W., Au, A. K., Anderson, K. L., Ku, B. S., Panebianco, N. (2012). The effect of vessel depth, diameter, and location on ultrasound-guided peripheral intravenous catheter longevity. The American Journal of Emergency Medicine, 30(7), 1134–1140. https://doi.org/10.1016/j.ajem.2011.07.027 Shokoohi, H., Boniface, K., McCarthy, M., Khedir Al-tiae, T., Sattarian, M., & Ding, R. et al. (2013). Ultrasound-Guided Peripheral Intravenous Access Program Is Associated With a Marked Reduction in Central Venous Catheter Use in Noncritically Ill Emergency Department Patients. Annals Of Emergency Medicine, 61(2), 198-203. doi: 1016/j.annemergmed.2012.09.016 Van Loon, F., Puijn, L., Houterman, S. and Bouwman, A. (2016). Development of the A-DIVA Scale. Medicine, 95(16), p.e3428. van Loon FHJ, van Hooff LWE, de Boer HD, Koopman SSHA, Buise MP, Korsten HHM, Dierick-van Daele ATM, Bouwman ARA (2019). The Modified A-DIVA Scale as a Predictive Tool for Prospective Identification of Adult Patients at Risk of a Difficult Intravenous Access: A Multicenter Validation Study. J Clin Med. 8(2):144. doi: 10.3390/jcm8020144. LUKE PHILLIPS Emergency Physician Dr Luke Phillips is an Emergency Physician at Alfred Health who has moved to the greener climes of Ireland. He is a passionate educator and has been fortunate enough to be able to combine this with his love of emergency ultrasound. Luke has a special interest in the use of focused ultrasound for critically unwell patients, in trauma management and in the use of ultrasound to guide procedures and improve patient safety in the ED. He is currently the Co-Chair of the Emergency Medicine Ultrasound Group (EMUGS.org) Board of Directors and holds a number of CCPU units through ASUM. Luke is also involved in the department’s international education program and has developed a Certificate of Emergency Medicine which is currently being run in both Germany and India. He also has interests in human factors, debriefing (particularly after clinical events), and simulation. His Twitter handle is @lukemphillips.

Dr Binula Wickramarachchi Emergency Physician Peer Review: Dr David McCreary THE CASE A 72-year-old man presents to the emergency department with persistent hiccups for 4 days. As you walk over to his cubicle, you think back to all the different ways you’ve tried to cure your own hiccups. What does holding your breath, drinking water upside down and getting frightened have in common anyway? AREN'T HICCUPS NORMAL? Hiccups are a normal everyday experience, usually attributed to a trigger such as a carbonated drink or spicy food. The vast majority of hiccups will last minutes to hours, and almost all benign cases of hiccups will last less than 48 hours. There are a number of theories as to the specific function of hiccups, with the most interesting being that it is a vestigial reflex, primarily involved in the maturation of the respiratory tract in utero. This is thought to be the reason that frequent hiccups in a foetus are a hallmark of the third trimester of pregnancy, as well as in the early neonatal weeks. WHAT ARE HICCUPS? Hiccups (AKA ‘singultus’ for those of you who are Latin-inclined) are spontaneous, involuntary and spasmodic contractions of the diaphragm and intercostal muscles, predominantly affecting the left hemidiaphragm. These spasms result in a sudden inspiration, which is immediately followed by the abrupt closure of the glottis, creating the onomatopoeic ‘hiccup’ sound. This process occurs in a reflex arc involving: An afferent limb: phrenic & vagus nerves and the sympathetic chain. A central mediator: thought to be within the medulla, near the respiratory centre. An efferent limb: the phrenic nerve, as well as neural connections to the glottis and inspiratory intercostal muscles. Anatomy of the hiccups reflux arc. M. Steger et al. 🤓 PHYSIOLOGY PEARL The sudden closure of the glottis is thought to be a protective reflex to prevent the hyperventilation that would result from hiccups. Patients with tracheostomies have been shown to develop hypocapnoea secondary to hiccups, as their airway bypasses the glottis. WHAT CAUSES HICCUPS? There are a multitude of causes of hiccups, but the underlying principle is that one or more parts of the above reflex arc are activated. This most commonly includes vagus or phrenic nerve activation due to gastro-oesophageal causes (gastric distension, GORD, gastritis, peptic ulcer disease or gastric cancer), but can also be due to inflammation or mass effect on these nerves anywhere in their course within the neck and thorax. Central nervous system aetiologies are also important to consider. Structural lesions such as tumour, aneurysm and vascular malformations in the medulla are of particular concern, and hiccups are specifically implicated in lateral medullary infarction. Hiccups in this category will however very rarely be an isolated symptom. The most significant consideration is that of malignancy. This can range from locally invasive gastro-oesophageal, pancreatic and lung cancers, to more advanced metastatic malignancies with significant thoraco-abdominal lymphadenopathy. The prevalence of hiccups in this population has been reported as high as 1 – 9%1. Other less frequent causes include: Medication-related Dexamethasone Diazepam, midazolam Tramadol Metabolic Hyponatraemia, hypokalaemia, hypocalcaemia & renal impairment Psychogenic These hiccups typically disappear during sleep Post-operative Related to irritation of the phrenic nerve ASSESSMENT Features on assessment that are important to elicit are: Characterise the hiccups and their effects – time course, relieving factors, effects on quality of life (eating, drinking and sleeping) Explore possible aetiologies – to exclude any treatable causes, as well as identify any features of malignancy Examination – seeking features of infection or inflammation in the head, neck, chest or abdomen. Paying particular attention to potential mass lesions or lymphadenopathy. Investigation with pathology and imaging can then be guided by the findings above. If the initial assessment is unremarkable, consideration should be given to initiating empirical treatment while further investigations are undertaken. If a patient is known to have advanced malignancy, the aetiology of intractable hiccups is likely multifactorial. It is generally recommended that the focus should be on symptomatic treatment of these patients, rather than exhaustive ongoing evaluation. MANAGEMENT The mainstay of treatment for hiccups of less than 48 hours is physical manoeuvres. Many of these will be familiar to us as home-cures for hiccups! These can be divided into: Inducing hypercapnia via breath-holding or breathing into a paper bag. This is thought to interrupt the hiccup reflex arc due to its effect on the medulla and the respiratory centre Stimulating the nasopharynx via drinking cold water, pulling on the tongue or performing a Valsalva. This increases vagal stimulation to interrupt the reflex arc. 🤓 FUN FACT The mechanism of frightening someone out of their hiccups is believed to occur due to the interruption of the reflex arc at the sympathetic chain, which forms part of the afferent limb of the arc. For those patients with hiccups for more than 48 hours, empirical pharmacological treatment can be initiated. The evidence base for the use of many of these are not well established. Both single-drug therapy as well as multi-modal therapies may also be trialled. The main options here are: Proton-pump inhibitors (PPI) Baclofen Gabapentin Metoclopramide Chlorpromazine Various other medications have also been trialled, with very variable reports of efficacy in the literature. Some of these options are: haloperidol, amitriptyline, pregabalin, phenytoin, sodium valproate and carbamazepine. THERE'S AN ALGORITHM FOR THAT... BACK TO THE CASE The patient tells you of their unfortunate recent diagnosis of advanced pancreatic cancer, and that they’re awaiting their initial oncology appointment in 2 days. The patient was started on regular pantoprazole and metoclopramide, with a plan for the oncology team to initiate baclofen if the hiccups had not resolved by the time of his oncology appointment. SIMPSONS CONSULT And finally, further proof that the Simpsons have always been ahead of their time and have an answer for everything... REFERENCES Calsina-Berna, A., García-Gómez, G., González-Barboteo, J., & Porta-Sales, J. (2012). Treatment of chronic hiccups in cancer patients: a systematic review. Journal of palliative medicine, 15(10), 1142-1150 Steger, M., Schneemann, M., & Fox, M. (2015). Systemic review: the pathogenesis and pharmacological treatment of hiccups. Alimentary pharmacology & therapeutics, 42(9), 1037-1050. Kahrilas, P. J., & Shi, G. (1997). Why do we hiccup?. Gut, 41(5), 712-713. Polito, N. B., & Fellows, S. E. (2017). Pharmacologic interventions for intractable and persistent hiccups: a systematic review. The Journal of Emergency Medicine, 53(4), 540-549. BINULA WICKRAMARACHCHI Emergency Physician Binula is an Emergency Physician at the Alfred Hospital. He grew up among the verdant hills of Auckland, New Zealand, obtaining his medical degree and Postgraduate Diploma in Clinical Education at the University of Auckland. He also has a passion for point of care ultrasound, particularly echo and lung ultrasound. At home, Binula is a devoted parent to his two feline daughters, and is the household co-lead for the acclimatisation to a new human child.

Dr David McCreary Emergency Physician Pelvic fractures are pretty common, particularly if you work in a trauma centre. From a trauma resuscitation perspective, we're usually most concerned with whether a pelvic injury is unstable with disruption of the pelvic ring, and if there is active arterial bleeding. When our patients are haemodynamically behaving themselves, and don't have active bleeding we can take a breath and relax and think about, amongst other things, getting a urinary catheter in the patient...and that's when we should be thinking about a retrograde urethrogram (RUG). This came up in a few discussions in our Grand Rounds sessions last year, so I thought it would be useful to do a quick refresher on the technique. 🤨 Just here to refresh on the technique? Click here, I've got you covered. 😉 WHY IS IT IMPORTANT? Urethral injury is a common complication, up to 24%, of pelvic fractures Bad if missed (just ask a urologist - they hate managing urethral strictures) Can be made worse with insertion of a urinary catheter (partial tear = bad. Poking at it can cause it to become a complete transection = very bad) WHO SHOULD GET IT? Firstly, men. 97% of urethral injuries occur in male patients(1); the shorter female urethra is less prone to shearing stresses. If you think there are signs of urethral injury in a female patient (approx. 80% are associated with vaginal laceration or blood at the introitus(2)) – skip the RUG and get the urologists involved. Back to the blokes, if you remember back to your ATLS/EMST course they quote: Gross haematuria Inability to void Unstable pelvic fractures (particularly with symphysis diastasis(1), straddle fractures and Malgaigne fractures) Blood at the urethral meatus Scrotal haematoma Perineal ecchymoses High-riding prostate Any of the above and you should be checking out that urethra. Now, I remember quoting the above list in my first ATLS course (In 2009? Oh my.), but as a fresh-faced PGY-2 I’ll admit thinking of it as some difficult, fancy imaging technique that I would need to beg some clever radiologist to perform, I had no idea that it was actually pretty easy and could be done in a trauma bay using the overhead X-Ray. ANATOMY Before looking at the technique, it’s worth having a refresh on the anatomy, just so we know what we’re looking for. The male urethra has 4 Parts: Anteriorly: Penile Bulbous Posteriorly: (Most common injury - up to 25% of pelvic fractures) Membranous Prostatic OK, SO HOW DO I DO IT? Technique: Get some (water soluble) contrast media from radiology Place the patient in 25–30-degree oblique position Having a pelvic fracture patient in an oblique position is a challenge – the fluoroscopy / X-Ray can be aimed from an oblique position, with the penis positioned appropriately to allow visualisation of the entire urethra Insert Foley catheter 2-3cm into meatus and inflate the balloon with 2-3ml of water, stretch the penis to straighten the urethra, hold catheter in place. Inject 20-30ml of undiluted, sterile, water soluble contrast Take X-ray image every 10 mls Be careful not to spill – it’ll mess up your images and give false positives or unequivocal tests If images show intact urethra: Deflate balloon Advance Foley into bladder and inflate balloon with 10ml water If images show injury, or equivocal or if advancement of foley causes pain or resistance is met – stop advancing and chat to your friendly neighbourhood pee-pee surgeon WHAT WOULD ABNORMAL FINDINGS LOOK LIKE? Intravasation of contrast Urethral occlusion (failure of dye to enter the bladder) But what does that actually look like? FIRST, A NORMAL TEST TO GET YOUR SIGHTS IN (Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 61843) NOW, AN ABNORMAL TEST Note the venous intravasation of contrast that has escaped through a urethral defect. (Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 61843) INJURY CLASSIFICATION Now for sprinkles on top of our required knowledge, urethral injuries can be classified by a couple of systems: the AAST and the Goldman Classification. For our purposes the AAST is more straightforward, but Goldman as apparently more widely accepted, so I’ll include them both. AAST System THE GOLDMAN SYSTEM (My super-mature way to remember the name is that urine is, or at least should be, golden and we’re doing this test in men): WHY DOES CLASSIFICATION MATTER? Grade I: May be conservatively managed. Grades II-V: usually result in severe stricture and so urology may take for immediate surgery TAKE HOMES? Consider urethral injury with pelvic fracture, particularly if you have symphysis diastasis Have a really low threshold to do RUG It's really a lot easier than you think If in doubt on results, or if your patient is female, get a urology opinion REFERENCES / FURTHER READING Lückhoff C, Mitra B, Cameron PA, Fitzgerald M, Royce P. The diagnosis of acute urethral trauma. Injury. 2011 Sep;42(9):913–6. DOI: 10.1016/j.injury.2010.08.007 PMID:  20739022 The Royal Melbourne Hospital guideline is great, with some useful flow charts. This review is where I got a lot of this from and has some great learning points (Ingram MD, Watson SG, Skippage PL, Patel U. Urethral Injuries after Pelvic Trauma: Evaluation with Urethrography. RadioGraphics. 2008 Oct;28(6):1631–43.) Radiopaedia, as always have a nice summary with some more pictures A comprehensive, if a little dull, video summary on youtube DAVID MCCREARY Emergency Physician Dave is an Emergency Physician, one of the Alfred's Directors of EM training, and the creator of this education blog. He trained between the UK and Australia and completed an MSc in Trauma Science with QMUL. His clinical interests include trauma, critical care, evidence based medicine and human factors. Dave is a regular contributor the RCEMLearning podcast and is a FOAMed editor for RCEMLearning. He dislikes coriander, decaff coffee and dermatology.

Dr Hector Thomson Emergency Registrar Peer review: Dr Binula Wickramarachchi Babies do lots of funny movements. As an ACEM trainee working in a paediatric ED one of my greatest joys is learning all the cool baby reflexes from my RACP colleagues - fencing posture is my favourite so far! THE CASE In a recent shift as the waiting room doctor, I saw a 7-month-old who had been doing some “funny movements” over the past few weeks. They were happening more frequently and now interrupting feeds. She looked like a happy and well baby in the waiting room. Then the mum pulled up the videos she had taken. The little baby would suddenly throw its arms out and cry every few seconds. SO, WHAT IS GOING ON? Infantile spasms. These are a rare, but serious type of seizure, occurring in 1 in 2,000 children. The onset of IS peaks between 4 and 6 months, although these seizures can begin anytime in the first two years. 🤓 SIDE NOTE: HISTORY LESSON 🤓 English physician Dr W. J. West first described infantile spasms in 1840 with a letter to the Lancet outlining what he had observed in his own son. “The child is now near a year old; was a remarkably fine, healthy child when born, and continued to thrive till he was four months old. It was at this time that I first observed slight bobbing of the head forward, which I then regarded as a trick, but were, in fact, the first indications of disease; for these bobbings increased in frequency, and at length became so frequent and powerful, as to cause a complete heaving of the head forward toward his knees, and then immediately relaxing into the upright position, these bowings and relaxings would be repeated alternately at intervals of a few seconds, and repeated from ten to twenty or more times at each attack, which attack would not continue more than two or three minutes; he sometimes has two, three, or more attacks in the day; they come on whether sitting or lying; just before they come on he is all alive and in motion, making a strange noise, and then all of a sudden down goes his head and upwards his knees; he then appears frightened and screams out; at one time, he lost flesh, looked pale and exhausted, but latterly he has regained his good looks, and, independent of this affection, is a fine grown child.” WHAT DO THE MOVEMENTS LOOK LIKE? The seizures include repetitive, but often subtle movements. Typically sudden flexor or extensor spasms of the head, neck, trunk or extremities May include head nodding or facial or eye movements Commonly symmetrical, but may be asymmetric Often cries before or after Each event lasts 1-2 seconds, but these can cluster together, occurring every few seconds for periods of several minutes. Most commonly shortly after waking from sleep You can watch the YouTube clip of this gif here, or some further examples (including some that are pretty subtle) can be seen in videos here and here. DIFFERENTIAL DIAGNOSIS Non-epileptic episodes such as shuddering and benign myoclonus of infancy Benign myoclonic epilepsy of infancy Other infantile epilepsies POSSIBLE CAUSES Tuberous sclerosis complex -> Look for skin lesions Trisomy 21 -> Examine for dysmorphic features and ask about perinatal screening Genetic causes -> Ask about family history of seizures/Development delay Focal structural abnormalities -> Ask about early handedness Perinatal hypoxic-ischaemic encephalopathy -> Ask about perinatal complications Ask about milestones and chart the patient's head circumference. Source: https://dermnetnz.org/topics/tuberous-sclerosis COMPLICATIONS Associated with developmental delay in 80% of infants High rates of ongoing epilepsy SIDE NOTE: WHAT IS WEST SYNDROME? Described by our friend, Dr William James West (from your history lesson, above). West Syndrome is a triad (all good eponyms are) of: Infantile spasm Hypsarrhythmia on EEG Developmental arrest/regression Not all children with infantile spasm will have all features of West Syndrome. DIAGNOSIS 🚨 Suspicion needs an urgent neurology review - this is a neurological emergency - wake up on-call people for this 🚨 Urgent EEG Prompt MRI brain Other investigations for the underlying aetiology (if unknown), including: Chromosomal microarray Urine metabolic screen Consideration of other genetic testing TREATMENT This will be guided by the neurologists but first-line is high dose prednisolone Prompt treatment is required to minimise the adverse developmental impact Vigrabatrin is first-line in infants with Tuberous Sclerosis Complex ☝️ Practice Point: High dose prednisolone treatment is associated with increased risk of serious and/or opportunistic infections - if these kids present febrile or unwell, manage as sepsis. CASE CONCLUSION The baby got an urgent EEG in the ED which showed the classic hypsarrhythmia. They were admitted under the neurology team and high dose steroids commenced. Over the coming weeks the spasms decreased in frequency. TAKE HOME POINTS: If a picture is worth a thousand words, then a video is worth a million. Look for typically sudden, brief, bilateral and symmetric contraction of the muscles of the neck, trunk and extremities, occurring in clusters Infantile spasm requires an urgent neurology review and EEG Treatment is high dose steroids Early recognition and treatment can minimise developmental impact INFANTILE SPASMS AWARENESS WEEK Infantile Spasms Awareness Week (ISAW) is held annually on December 1-7. During ISAW 2017, the ISAN introduced the "STOP Infantile Spasms" mnemonic, an easily remembered acronym, to raise awareness about this rare, yet serious seizure disorder. Source: https://www.epilepsy.com/learn/types-epilepsy-syndromes/infantile-spasms-west-syndrome#West-Story USEFUL RESOURCES RCH CPG: https://www.rch.org.au/clinicalguide/guideline_index/Infantile_Spasms/ Epilepsy Foundation: https://www.epilepsy.com/article/2020/11/infantile-spasms-awareness-week Dermnet: Tubular sclerosis: https://dermnetnz.org/topics/tuberous-sclerosis OTHER FOAMED CONTENT EMC Cases: https://emergencymedicinecases.com/em-quick-hits-april-2022/ REFERENCES Hancock EC, Osborne JP, Edwards SW. Treatment of infantile spasms. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD001770. doi: 10.1002/14651858.cd001770.pub3 Wilmhurs JM, Ibekwe RC, O’Callaghan FJK, Epileptic spasms – 175 years on: Trying to teach an old dog new tricks. Seizure 44(2017) 81-86. doi: 10.1016/j.seizure.2016.11.021 West WJ. On a peculiar form of infantile convulsions. Lancet. 1841;1:724–725 doi: 10.1016/S0140-6736(00)40184-4 (that's right, a doi for an 1841 article) HECTOR THOMSON Emergency Registrar Hector (the one on the left) is an Emergency Medicine Advanced Trainee at The Alfred. He’s still clinging to the basic science knowledge he gained during primary exam prep and enjoys shoulder dislocations, trauma, rugby union, fresh pasta and good gin. He doesn’t like vague allergies or cats.