ORCID Profile
0000-0003-2093-855X
Current Organisations
University of Southampton
,
Royal North Shore Hospital
,
CareFlight
Does something not look right? The information on this page has been harvested from data sources that may not be up to date. We continue to work with information providers to improve coverage and quality. To report an issue, use the Feedback Form.
Publisher: Wiley
Date: 16-08-2017
Abstract: To review incident reports relating to problems encountered during the ED management of patients with 'airway or breathing' problems, with the aim of finding and highlighting common themes within these rare events, and making recommendations to further improve patient safety in the areas in which deficiencies have been identified. Thematic analysis of 36 incidents reported from Australasian EDs, which were related to problems with airway and breathing. In all, 51 problems were identified among the 36 incidents related to airway and/or breathing. Fourteen involved clinical decision-making, 11 equipment, nine communication, seven intubation, five surgical access and five pneumothorax. Eight incidents involved children and there were nine deaths within hours or days. Recommendations for improving preparedness of ED staff and facilities have been made for each of the problem areas identified with respect to clinical practice, equipment, communication and clinical process. Analysis of incidents from the Australasian Emergency Medicine Events Register allows clusters of like-events to be identified and characterised, providing the possibility of getting a better idea of how problems present and progress, with some information about contributing factors, characteristics and context. This will pave the way for earlier and better detection of life-threatening problems and the development and reinforcement of preventive and corrective strategies.
Publisher: Wiley
Date: 05-02-2021
Abstract: The aims of the present study were to describe current airway management practices after a failed intubation attempt in Australian and New Zealand EDs and to explore factors associated with second attempt success. Data were collected from a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry). All intubation episodes that required a second attempt between March 2010 and November 2015 were analysed. Analysis for association with success at the second attempt was undertaken for patient factors including predicted difficulty of laryngoscopy, as well as for changes in laryngoscope type, adjunct devices, intubator and intubating manoeuvres. Of the 762 patients with a failed first intubation attempt, 603 (79.1%) were intubated successfully at the second attempt. The majority of second attempts were undertaken by emergency consultants (36.8%) and emergency registrars (34.2%). A change in intubator occurred in 56.5% of intubation episodes and was associated with higher second attempt success (unadjusted odds ratio [OR] 1.85 95% confidence interval [CI] 1.29–2.65). In 69.7% of second attempts at intubation, there was no change in laryngoscope type. Changes in laryngoscope type, adjunct devices and intubation manoeuvres were not significantly associated with success at the second attempt. In adjusted analyses, second attempt success was higher for a change from a non‐consultant intubator to a consultant intubator from any specialty (adjusted OR 2.31 95% CI 1.35–3.95) and where laryngoscopy was not predicted to be difficult (adjusted OR 2.58 95% CI 1.58–4.21). The majority of second intubation attempts were undertaken by emergency consultants and registrars. A change from a non‐consultant intubator to a consultant intubator of any specialty for the second attempt and intubation episodes where laryngoscopy was predicted to be non‐difficult were associated with a higher success rate at intubation. Participation in routine collection and monitoring of airway management practices via a Registry may enable the introduction of appropriate improvements in airway procedures and reduce complication rates.
Publisher: BMJ
Date: 11-03-2021
Publisher: Wiley
Date: 29-01-2015
Abstract: To investigate the first pass success rate, airway grade and complications in two tertiary EDs with the C-MAC video laryngoscope (VL), when compared with standard direct laryngoscopy (DL). This was a retrospective analysis of prospectively collected data entered into an airway registry database in the EDs of Royal North Shore and St George Hospitals (SGH) over a 30 month period. Doctors had the choice of using either DL using a Macintosh or Miller blade or a C-MAC VL for the intubation. Six hundred and nineteen consecutive patients were recruited. There was no statistical difference between VL and DL in grade of view obtained, P = 0.526. Chance of intubation success increased by more than threefold by using a C-MAC VL in the setting of a grade III/IV (total of 109) on DL (OR = 3.06 95% CI: 1.52-6.17 P = 0.002). This is the first observational study of airway management comparing the C-MAC VL with DL blades in an Australian ED population. Our findings revealed that although the C-MAC VL overall did not provide an enhanced view of the larynx over the Macintosh DL, it was superior to DL when the grade was at least grade III. Currently we are unable to reliably predict the grade by any algorithm prior to intubation. Findings from this study suggest that the C-MAC VL should be considered as the first line laryngoscope in all ED intubations not just the ones predicted to be difficult.
Publisher: Wiley
Date: 12-2012
Abstract: To describe the practice of endotracheal intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the indication, staff seniority, technique, number of attempts required and the rate of complications. A prospective observational study. Two hundred and ninety-five intubations occurred in 18 months. Trauma was the indication for intubation in 30.5% (95% CI 25.3-36.0) and medical conditions in 69.5% (95% CI 64.0-74.5). Emergency physicians were team leaders in 69.5% (95% CI 64.0-74.5), whereas ED registrars or senior Resident Medical Officers made the first attempt at intubation in 88.1% (95% CI 83.9-91.3). Difficult laryngoscopy occurred in 24.0% (95% CI 19.5-29.3) of first attempts, whereas first pass success occurred in 83.4% (95% CI 78.7-87.2). A difficult intubation occurred in 3.4% (95% CI 1.9-6.1) and all patients were intubated orally in five or less attempts. A bougie was used in 30.9% (95% CI 25.8-36.5) of first attempts, whereas a stylet in 37.5% (95% CI 32.1-43.3). Complications occurred in 29.0% (95% CI 23.5-34.1) of the patients, with desaturation the commonest in 15.7% (95% CI 11.9-20.5). Cardiac arrest occurred in 2.2% (95% CI 0.9-4.4) after intubation. No surgical airways were undertaken. Although the majority of results are comparable with overseas data, the rates of difficult laryngoscopy and desaturation are higher than previously reported. We feel that this data has highlighted the need for practice improvement within our department and we would encourage all those who undertake emergent airway management to audit their own practice of this high-risk procedure.
Publisher: The Korean Society of Emergency Medicine
Date: 30-09-2018
DOI: 10.15441/CEEM.17.243
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2013
Publisher: Wiley
Date: 09-10-2021
Publisher: Wiley
Date: 11-11-2020
Publisher: Wiley
Date: 22-09-2021
Abstract: Patients intubated in the ED are at an increased risk of post‐intubation hypotension. However, evidence regarding the most appropriate induction agent is lacking. The present study aims to describe and compare the haemodynamic effect of propofol, ketamine and thiopentone during rapid sequence induction. This is an observational study using data prospectively collected from the Australian and New Zealand Emergency Department Airway Registry between June 2012 and March 2019. The distribution of induction agents across medical and trauma patients were obtained with descriptive statistics. The relationship between induction agent, dose and change in pre‐ and post‐intubation systolic blood pressure (SBP) was described using multivariable logistic regression. The SBP pre‐ and post‐intubation was the primary measure of haemodynamic stability. From the 5063 intubation episodes, 2229 met the inclusion criteria. Of those, 785 (35.2%) patients were induced with thiopentone, 773 (34.7%) with propofol and 671 (30.1%) with ketamine. Of the included population, 396 (17.8%) patients experienced a reduction in pre‐intubation SBP exceeding 20%. Both propofol ( P = 0.01) and ketamine ( P = 0.01) had an independent and dose‐dependent association with hypotension, noting that a higher proportion of patients induced with ketamine had a shock index exceeding 0.9. Propofol was associated with post‐intubation hypotension and it is recommended clinicians consider using the lowest effective dose to reduce this risk. Reflecting its perceived haemodynamic stability, patients who received ketamine were more likely to have a higher shock index however, there was also an association with post‐intubation hypotension.
Publisher: Wiley
Date: 03-12-2019
Abstract: To describe the epidemiology, clinical practice and outcomes of paediatric ED intubation in Australia and New Zealand. Prospectively collected airway management audit data from 43 EDs in Australia and New Zealand that was submitted to the Australia and New Zealand Emergency Department Airway Registry between 2010 and 2015. Paediatric cases accounted for 4.94% (270/5463) of cases (median age = 3, interquartile range [IQR] = 2-9). A median of 5 (IQR = 2-9) intubations were reported per department per year. Most intubations were performed for medical indications (72.2%), including seizure (25.2%) and respiratory failure (15.2%). Patients were physiologically compromised prior to intubation with 69.5% comatose, 50.9% outside of the normal age-adjusted range for respiratory rate, 15.9% hypoxic and 12.6% hypotensive. Complication rate was 33.3% and desaturation was the most common (18.5%). The ED mortality rate was 3.8%. First pass success (FPS) was 80% (95% CI 75.2-84.8). Infants less than 1 year of age had lower FPS, higher rates of difficult laryngoscopy and higher rates of desaturation than other age groups. Paediatric intubation in Australasian EDs is rare from a departmental and in idual provider viewpoint. Success rates are similar to contemporary international registries. Complications are common and ongoing collaborative multicentre audit with resultant quality improvement is desirable to facilitate improved success and reduced complications.
Publisher: Wiley
Date: 05-06-2017
Abstract: The aim of this study was to describe the practice of endotracheal intubation across a range of Australasian EDs. We established a multicentre airway registry (The Australian and New Zealand Emergency Department Airway Registry [ANZEDAR]) prospectively capturing intubations from 43 Australian and New Zealand EDs over 24 months using the ANZEDAR form. Information recorded included patient demographics, intubation indications, predicted difficulty, rapid sequence induction and endotracheal intubation preparation technique, induction drugs, airway adjuncts and complications. Factors associated with first attempt success were explored. Of the 3710 intubations captured, 3533 were in adults (95.2%), 2835 (76.4%) for medical and 810 (21.8%) for trauma indications. Overall, 3127 (84.3%) patients were successfully intubated at the first attempt the majority by ED doctors (2654 [72.1%]). A total of 10 surgical airways were performed, all of which were successful cricothyroidotomies. Propofol, thiopentone or ketamine were used with similar frequency for induction, and suxamethonium was the most often used muscle relaxant. Adverse events were reported in 964 (26%), the majority involving desaturation or hypotension. Australasian ED doctors, predominantly specialist emergency physicians or trainees, perform the majority of ED intubations using rapid sequence induction as their preferred technique mainly for medical indications. First attempt success rate was not different between different types of EDs, and is comparable published international data. Complications are not infrequent, and are comparable to other published series. Monitoring and reporting of ED intubation practice will enable continued improvements in the safety of this high-risk procedure.
Publisher: Elsevier BV
Date: 10-2017
DOI: 10.1016/J.ANNEMERGMED.2017.04.007
Abstract: The influence of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) on the conduct of future sepsis research is unknown. We seek to examine the potential effect of the new definitions on the identification and outcomes of patients enrolled in a sepsis trial. This was a post hoc analysis of the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial of early goal-directed therapy that recruited 1,591 adult patients presenting to the emergency department (ED) with early septic shock diagnosed by greater than or equal to 2 systemic inflammatory response syndrome criteria and either refractory hypotension or hyperlactatemia. The proportion of participants who would have met the Sepsis-3 criteria for quick Sequential Organ Failure Assessment (qSOFA) score, sepsis (an increased Sequential Organ Failure Assessment score ≥2 because of infection) and septic shock before randomization, their baseline characteristics, interventions delivered, and mortality were determined. There were 1,139 participants who had a qSOFA score of greater than or equal to 2 at baseline (71.6% [95% confidence interval {CI} 69.4% to 73.8%]). In contrast, 1,347 participants (84.7% [95% CI 82.9% to 86.4%]) met the Sepsis-3 criteria for sepsis. Only 1,010 participants were both qSOFA positive and met the Sepsis-3 criteria for sepsis (63.5% [95% CI 61.1% to 65.8%]). The Sepsis-3 definition for septic shock was met at baseline by 203 participants (12.8% [95% CI 11.2% to 14.5%]), of whom 175 (86.2% [95% CI 81.5% to 91.0%]) were also qSOFA positive. Ninety-day mortality for participants fulfilling the Sepsis-3 criteria for sepsis and septic shock was 20.4% (95% CI 18.2% to 22.5%) (274/1,344) and 29.6% (95% CI 23.3% to 35.8% [60/203]) versus 9.4% (95% CI 5.8% to 13.1%) (23/244) and 17.1% (95% CI 15.1% to 19.1% [237/1,388]), respectively, for participants not meeting the criteria (risk differences 11.0% [95% CI 6.2% to 14.8%] and 12.5% [95% CI 6.3% to 19.4%], respectively). Most ARISE participants did not meet the Sepsis-3 definition for septic shock at baseline. However, the majority fulfilled the new sepsis definition and mortality was higher than for participants not fulfilling the criteria. A quarter of participants meeting the new sepsis definition did not fulfill the qSOFA screening criteria, potentially limiting its utility as a screening tool for sepsis trials with patients with suspected infection in the ED. The implications of the new definitions for patients not eligible for recruitment into the ARISE trial are unknown.
Publisher: Wiley
Date: 22-08-2022
Publisher: Wiley
Date: 02-2009
DOI: 10.1111/J.1742-6723.2009.01156.X
Abstract: Although human interaction with leeches is common in Australia, there is little documented literature on ocular injuries as a result of contact with a leech. We report a case of ocular leech attachment and a previously undocumented method of removal with hypertonic saline solution.
Publisher: Wiley
Date: 11-06-2018
Abstract: This study aimed to quantify the proportion of patients undergoing rapid sequence intubation using ketamine in Australian and New Zealand EDs between 2010 and 2015. The Australian and New Zealand Emergency Department Airway Registry is a multicentre airway registry prospectively capturing data from 43 sites. Data on demographics and physiology, the attending staff and indication for intubation were recorded. The primary outcome was the annual percentage of patients intubated with ketamine. A logistic regression analysis was conducted to evaluate the factors associated with ketamine use. A total of 4658 patients met inclusion criteria. The annual incidence of ketamine use increased from 5% to 28% over the study period (P < 0.0001). In the logistic regression analysis, the presence of an emergency physician as a team leader was the strongest predictor of ketamine use (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.44-2.34). The OR for an increase in one point on the Glasgow Coma Scale was 1.10 (95% CI 1.07-1.12), whereas an increase of 1 mmHg of systolic blood pressure had an OR of 0.98 (95% CI 0.98-0.99). Intubation occurring in a major referral hospital had an OR of 0.68 (95% CI 0.56-0.82), while trauma conferred an OR of 1.38 (95% CI 1.25-1.53). Ketamine use increased between 2010 and 2015. Lower systolic blood pressure, the presence of an emergency medicine team leader, trauma and a higher Glasgow Coma Scale were associated with increased odds of ketamine use. Intubation occurring in a major referral centre was associated with lower odds of ketamine use.
Publisher: Wiley
Date: 11-11-2015
Abstract: We aim to investigate whether a bundle of changes made to the practice of endotracheal intubation in our ED was associated with an improvement in first pass success rate and a reduction in the incidence of complications. We used a prospective observational study. The data on 360 patients who were intubated during an 18-month period following the introduction of these changes were compared with our previously published observational data. Success on first attempt at intubation improved 83.4% to 93.9% (P < 0.0001). The proportion of patients with one or more complication fell from 29.0% to 19.4% (P < 0.042). Oesophageal intubation fell from 4.0% to 0.3% (P < 0.001), and there was a non-significant reduction in the rate of desaturation, from 15.6% to 10.9% (P < 0.07). We have shown that, through the introduction of a bundle of changes that spans the domains of staff training, equipment and practice standardisation, we have made significant improvements in the safety of patients undergoing endotracheal intubation in our ED.
Publisher: Wiley
Date: 21-07-2013
Abstract: The objective of the present study was to describe the factors associated with delays in the delivery of appropriate antibiotics to patients admitted to the intensive care unit (ICU) from the ED or wards with septic shock. All adult patients admitted to the ICU, at a single centre who had presented via the ED within the previous 48 h and who had septic shock were included. Data regarding the cause of sepsis, timing of administration of antibiotics, the appropriateness of antibiotics, results of cultures and features potentially related to delay in the administration of appropriate antibiotics were collected by a single investigator, onto specifically designed data forms. Descriptive statistics and univariate analysis were undertaken to determine the timing of appropriate antibiotics administration. Eighty-nine patients who developed septic shock within 48 h of hospital presentation were admitted to the ICU at Royal North Shore between 2005 and 2008. The median time to administration of antibiotics was 120 min (interquartile range [IQR], 40-225) and the median time to administration of appropriate antibiotics was 188 min (IQR, 65-440 min). Patients who did not have sepsis as their initial diagnosis (90 vs 268 min P < 0.002), those who waited until investigations were performed (88 vs 320 min P < 0.001) and younger patients (β = -5.6 P = 0.04) had longer time delays to receive antibiotic therapy. Patients who were assessed by an emergency physician after developing septic shock were given antibiotics that were appropriate in a median of 20 min (IQR, 10-160 min), those assessed initially by a resident medical officer after developing septic shock in a median of 180 min (IQR, 78-563 min). This retrospective cohort study found that there were significant delays associated with the administration of appropriate antibiotics in patients admitted to the ICU from the ED or the wards with septic shock. Delays were greater in patients who were not seen by an emergency physician, those in whom the diagnosis of sepsis was not considered initially and in those whose therapy was delayed while awaiting the performance of investigations.
Publisher: BMJ
Date: 09-12-2020
DOI: 10.1136/EMERMED-2019-208424
Abstract: Apnoeic oxygenation (ApOx) has been demonstrated to reduce the incidence of desaturation, although evidence of benefit has been conflicting depending on the technique used. The aim of this study was to compare the incidence of desaturation between patients who received ApOx via conventional nasal cannula (NC) and those who did not, using a large, multicentre airway registry. This study is an analysis of 24 months of prospectively collected data in the Australia and New Zealand Emergency Department Airway Registry (June 2013–June 2015). The registry includes information on all intubated adults from 43 emergency departments. Patients intubated during cardiac arrest (n=393), those who received active ventilation prior to the first intubation attempt (n=486), and where the use of ApOx was not recorded either way (n=312) were excluded. The proportion of patients who desaturated (Sa0 2 ) in the group that received ApOx and those that did not were compared. To evaluate the association of ApOx with patient desaturation, a logistic regression model based on factors expected to influence desaturation was performed. Of 2519 patients analysed, 1669 (66.3%) received ApOx via NC while 850 (33.7%) did not. Desaturation in the cohort receiving ApOx was 10.4% compared with standard care (no ApOx) 13.7%. ApOx had a protective effect for desaturation (OR 0.71 95% CI 0.53 to 0.95). Single intubation attempt was associated with reduced risk of desaturation of (OR 0.10, 95% CI 0.06 to 0.17) this was increased on second attempt (OR 0.37, 95% CI 0.21 to 0.68). Desaturation was also associated with the physician recording that they had anticipated a difficult airway (OR 1.83, 95% CI 1.34 to 2.48). This large multicentre registry study provides evidence that ApOx delivered through a conventional NC is associated with a lower incidence of desaturation in patients undergoing rapid sequence intubation. ACTRN12613001052729.
Publisher: Wiley
Date: 10-08-2017
DOI: 10.1111/AJR.12366
Abstract: To describe the practice and procedure of emergency intubation in Whanganui Emergency Department, New Zealand and determine whether intubation can be carried out effectively in the rural setting. A prospective observational study using the Australia and New Zealand Airway Registry proforma to collect data on the indication, lead intubator, first-pass success rate and peri-procedural complications. Data were also collected on whether a formal airway assessment was carried out and whether a checklist was used. Twenty-three patients were intubated in the emergency department over a 12-month period. Sixty-two percent (14/23 cases) were medical encounters and the remaining 38% of indications due to a trauma. Head injury was the most common indication (23%). Ninety-two percent of primary intubators were emergency department-based Fellowship of the Australasian College for Emergency Medicine or resident medical officers, while anaesthetic-trained operators accounted for just 8%. Our first-pass intubation success rate was 87% and 16% of cases had procedural complications. Sixty-five percent (15/23) carried out a formal airway assessment and a checklist was only used in 23% of cases. This sequential case series is the first study looking at airway management in rural New Zealand emergency department airway practice. Overall intubation success rates were comparable to larger tertiary centres across Australasia. We have demonstrated that with adequate resources and adherence to interventions, a rural emergency department can provide effective airway management.
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Toby Fogg.