Bedside lung ultrasound in critically ill patients can serve as a tool to diagnose common lung pathologies, monitor its course and guide clinical management.

IntroductionOveruse of CT Pulmonary Angiograms (CTPA) for diagnosing pulmonary embolism (PE), particularly in Emergency Departments (ED), is considered problematic. Marked variations in positive CTPA rates are reported, with American 4–10% yields driving most concerns. Higher resolution CTPA may increase sub-segmental PE (SSPE) diagnoses, which may be up to 40% false positive. Excessive use and false positives could increase harm vs. benefit. These issues have not been systematically examined outside America.AimsTo describe current yield variation and CTPA utilisation in Australasian ED, exploring potential factors correlated with variation.MethodsA retrospective multi-centre review of consecutive ED-ordered CTPA using standard radiology reports. ED CTPA report data were inputted onto preformatted data-sheets. The primary outcome was site level yield, analysed both intra-site and against a nominated 15.3% yield. Factors potentially associated with yield were assessed for correlation.ResultsFourteen radiology departments (15 ED) provided 7077 CTPA data (94% ≥64-slice CT); PE were reported in 1028 (yield 14.6% (95%CI 13.8–15.4%; range 9.3–25.3%; site variation p <0.0001) with four sites significantly below and one above the 15.3% target. Admissions, CTPA usage, PE diagnosis rates and size of PE were uncorrelated with yield. Large PE (≥lobar) were 55% (CI: 52.1–58.2%) and SSPE 8.8% (CI: 7.1–10.5%) of positive scans. CTPA usage (0.2–1.5% adult attendances) was correlated (p<0.006) with PE diagnosis but not SSPE: large PE proportions.Discussion/ ConclusionsWe found significant intra-site CTPA yield variation within Australasia. Yield was not clearly correlated with CTPA usage or increased small PE rates. Both SSPE and large PE rates were similar to higher yield historical cohorts. CTPA use was considerably below USA 2.5–3% rates. Higher CTPA utilisation was positively correlated with PE diagnoses, but without evidence of increased proportions of small PE. This suggests that increased diagnoses seem to be of clinically relevant sized PE.

The present study suggests that NEDOCS method of processing the objective overcrowding data does not accurately reflect the subjective assessment of the senior staff working at that time in the ED. This might be because the assumptions of the original NEDOCS study are flawed.

Objectives:To explore current literature on chronic pain syndromes and develop ED recommendations for the management and minimalization of chronic non-cancer pain. Methods:A focused literature review. Results:Chronic pain is a common presentation to the ED but is poorly understood and managed.Research into the psychophysiology of chronic pain shows that there are definite changes in the receptive and processing pathways in patients suffering chronic pain syndromes. Evidence shows the effectiveness of early recognition with multimodal treatment, however high level evidence is lacking. All experts recommend balanced drug therapy, cognitive and behavioural interventions. Certain interventions are appropriate to the ED setting. Conclusions:Emergency Medicine lacks a cohesive, informed strategy for management of chronic pain. The proposed guidelines represent the first step toward establishing consistency in the management of patients with chronic pain syndromes. Further work needs to be undertaken at a national level in developing evidence based guidelines.

Drug manipulation causes complex action and reaction in chronic pain. Emergency physicians must also optimize cognitive and behavioural aspects of treatment to successfully manage this systemic disease.