Emergency Care

Last updated 1 Jun 2026 · Emergency Medicine

📋 Key Information Summary

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Anaphylaxis is a clinical diagnosis — administer IM adrenaline 500 µg (adult) into the anterolateral thigh immediately if suspected; delay increases mortality.
Adrenaline is the only first-line drug for anaphylaxis — antihistamines and corticosteroids are adjuncts only and must never delay adrenaline.
Acute cardiogenic pulmonary oedema (ACPO) requires IV frusemide 40–80 mg, GTN spray/patch, and sitting position; non-invasive ventilation (BiPAP/CPAP) reduces intubation rates.
Severe/life-threatening asthma is a medical emergency — continuous nebulised salbutamol 5 mg + ipratropium bromide 500 µg, IV magnesium sulphate 2 g over 20 min, and early senior/ICU involvement.
Status epilepticus (≥5 min continuous seizure or ≥2 discrete seizures without recovery): first-line IV lorazepam 4 mg; if no IV access, IM midazolam 10 mg or PR diazepam 20 mg.
Severe hypoglycaemia (BGL <3.0 mmol/L with altered consciousness): IV glucose 50 mL of 50% dextrose (or 100 mL of 25% in paediatrics); IM glucagon 1 mg if no IV access.
The Twelve Golden Rules — including calling for help early, doing one thing at a time, and staying with the patient — underpin safe emergency management.
Structured approach (ABCDE assessment, systematic secondary survey) is essential for every acute presentation; reassess frequently.
All patients with anaphylaxis must be observed for a biphasic reaction for ≥4 hours (≥6 hours if severe or slow-onset); prescribe an adrenaline autoinjector on discharge.
Aboriginal and Torres Strait Islander peoples experience higher rates of anaphylaxis, cardiovascular disease, and hypoglycaemia, with barriers including remote access and health literacy — early retrieval and culturally safe care are essential.
Airway adjuncts (oropharyngeal airway, nasopharyngeal airway, bag-valve-mask) are fundamental skills; every clinician managing emergencies must be proficient.
Always document drug doses, routes, times, and clinical response; emergency presentations are high-risk for communication errors during handover.

Introduction & Australian Epidemiology

Medical emergencies in primary care, rural and remote settings, and hospital emergency departments are a leading cause of morbidity and mortality in Australia. Rapid recognition and systematic management of acute presentations — including anaphylaxis, acute cardiogenic pulmonary oedema, severe asthma, status epilepticus, and severe hypoglycaemia — are core competencies for all clinicians. This article provides an Australian-focused, evidence-based guide to managing these critical conditions.

Each year in Australia, approximately 80,000 people present to emergency departments with acute anaphylaxis, with food allergy the most common trigger in children and drug/insect venom allergy predominant in adults (Mullins et al., 2021). Asthma accounts for over 38,000 hospital admissions annually, with an age-standardised mortality rate of approximately 4.1 per 100,000 (AIHW, 2023). Acute heart failure and cardiogenic pulmonary oedema are responsible for over 60,000 hospitalisations per year, particularly in older Australians and those with established ischaemic heart disease. Status epilepticus has an incidence of approximately 15–20 per 100,000 per year and carries a mortality of 10–20% if treatment is delayed beyond 30 minutes. Severe hypoglycaemia is a frequent emergency in people with diabetes, with an estimated annual incidence of 1–2 episodes per 100 patient-years in insulin-treated type 1 diabetes, and is associated with increased cardiovascular events and mortality.

Aboriginal and Torres Strait Islander peoples are disproportionately affected by all of these conditions, with rates of cardiovascular hospitalisation approximately 1.7 times higher, asthma prevalence approximately 1.4 times higher, and diabetes-related hypoglycaemia significantly elevated compared with non-Indigenous Australians (AIHW, 2023). Remote communities face additional barriers including limited access to emergency medications, delayed retrieval times, and workforce shortages.

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Time-critical interventions save lives. In every emergency scenario below, the first 5–10 minutes of management are the most consequential. Delays in adrenaline for anaphylaxis, bronchodilators for severe asthma, benzodiazepines for status epilepticus, or glucose for hypoglycaemia directly increase mortality.

Twelve Golden Rules & Vital Basic Skills

Every emergency presentation, regardless of the underlying condition, should be managed according to the following foundational principles. These rules apply universally to acute anaphylaxis, pulmonary oedema, severe asthma, status epilepticus, hypoglycaemia, and all other time-critical conditions.

The Twelve Golden Rules

Call for Help Early

Activate 000 (Ambulance) or your hospital emergency response system as soon as a serious emergency is suspected. Do not wait for full assessment.

Assess the Danger — To Yourself, Staff, and Patient

Ensure scene safety. Check for sharps, needles, violent or agitated patients. Don PPE as appropriate (gloves for body fluids, EpiPen® risk).

Use an ABCDE Approach

Airway → Breathing → Circulation → Disability → Exposure. Assess and treat each domain sequentially before moving on. Reassess after every intervention.

Do One Thing at a Time

Avoid multiple simultaneous interventions unless staffed to do so. Multitasking causes errors in high-stress situations.

Stay With the Patient

Never leave an acutely unwell patient alone. Delegate tasks (medications, monitoring, documentation) to others if possible.

Know Your Emergency Drugs and Equipment

Familiarise yourself with the location and contents of your emergency trolley/crash cart before an event occurs. Check expiry dates regularly.

Give Oxygen When in Doubt

Apply high-flow oxygen (15 L/min via non-rebreather mask) to any acutely unwell patient, unless contraindicated (e.g., chronic CO₂ retainers — titrate to SpO₂ 88–92%).

Get IV/IO Access and Take Bloods

Establish IV access (two large-bore cannulae, 16–18G) as soon as possible. Send bloods (FBC, UEC, glucose, LFTs, troponin, lactate, VBG/ABG, blood cultures if febrile).

Monitor Continuously

Continuous pulse oximetry, ECG monitoring, regular NIBP (every 5 min in the critically unwell). Use a cardiac monitor or defibrillator as soon as available.

Reassess After Every Intervention

After every drug, fluid bolus, or manoeuvre, reassess ABCDE. Document the response. Escalate if no improvement.

Communicate Clearly — Use ISBAR

Use the ISBAR framework (Introduction, Situation, Background, Assessment, Recommendation) for all clinical handovers, especially phone calls to retrieval services or specialists.

Document Everything

Record drug doses, routes, times, and patient responses in real time (or have a scribe). Use a structured emergency flow chart if available.

Vital Basic Skills

All clinicians managing emergency presentations must be proficient in the following core skills:

Skill	Key Points
Airway manoeuvres	Head-tilt/chin-lift (or jaw thrust if cervical spine concern). Insert oropharyngeal airway (OPA) in unconscious patients; nasopharyngeal airway (NPA) if semi-conscious or trismus present.
Bag-valve-mask (BVM) ventilation	Two-person technique preferred (one to hold mask, one to squeeze bag). Connect to high-flow O₂ (15 L/min). Each breath over 1 second, visible chest rise.
CPR (adult)	30:2 ratio (compressions:breaths). Rate 100–120/min, depth 5–6 cm. Minimise interruptions. Apply defibrillator as soon as available.
Adrenaline IM injection	Anaphylaxis: 500 µg (0.5 mL of 1:1000) IM anterolateral thigh. May repeat every 5 min. Paediatric: 10 µg/kg (0.01 mL/kg of 1:1000), max 500 µg.
IV/IO access	Two large-bore (16–18G) peripheral IV cannulae. If IV access fails within 2 attempts or 90 seconds, proceed to intraosseous (IO) access (proximal tibia or proximal humerus).
Glucose administration	IV: 50 mL of 50% dextrose (25 g glucose) in adults. IM glucagon 1 mg if no IV access. Buccal glucose gel (15–20 g) if conscious and able to swallow.
12-lead ECG acquisition	Should be obtained within 10 minutes of any chest pain, breathlessness, or cardiac symptom. Recognise STEMI, arrhythmias, and hyperkalaemia patterns.
Use of AED (defibrillator)	Apply pads, follow voice prompts. VF/pVT: shock immediately. Ensure no one is touching the patient during analysis and shock delivery.

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Never delay adrenaline in anaphylaxis or glucose in severe hypoglycaemia to obtain IV access. Use IM adrenaline and IM glucagon respectively. These are life-saving, time-critical interventions.

Acute Anaphylaxis & Angioedema

Definition & Clinical Recognition

Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction characterised by a rapid onset of airway, breathing, and/or circulatory compromise, usually associated with skin and mucosal changes. The Australasian Society of Clinical Immunology and Allergy (ASCIA) defines anaphylaxis as likely when any one of the following criteria is met:

Criterion 1: Acute onset of skin/mucosal involvement (urticaria, flushing, angioedema) PLUS respiratory compromise (dyspnoea, wheeze, stridor, hypoxia) OR cardiovascular compromise (hypotension, syncope, incontinence).
Criterion 2: Two or more of the following occurring rapidly after exposure to a likely allergen: skin/mucosal changes, respiratory compromise, cardiovascular compromise, persistent gastrointestinal symptoms (crampy abdominal pain, vomiting).
Criterion 3: Hypotension after exposure to a known allergen for that patient (age-specific systolic BP drop >30% from baseline or SBP <90 mmHg in adults, or age-appropriate hypotension in children).

Common Triggers in Australia

Trigger	Details
Food	Peanut, tree nut, cow's milk, egg, shellfish, wheat, sesame — most common trigger in children. Australia has one of the highest food allergy rates globally.
Insect venoms	Jack jumper ant (Myrmecia pilosula), honey bee, European wasp. Jack jumper ant anaphylaxis is particularly prevalent in Tasmania and southern mainland states.
Medications	Beta-lactam antibiotics (penicillins, cephalosporins), NSAIDs, neuromuscular blocking agents, chemotherapy agents, monoclonal antibodies.
Contrast media	Iodinated contrast (CT scans) and gadolinium (MRI). Non-ionic iodinated contrast has lower risk.
Idiopathic	No identifiable trigger in 10–20% of cases — consider mast cell disorders referral.

Severity Grading

Mild (Not Anaphylaxis)

Localised Reaction

Localised urticaria, localised angioedema, itch at injection site. No systemic involvement. No airway, breathing, or circulation compromise.

Setting: Observation in primary care / ED — monitor for progression

Moderate — Anaphylaxis

Systemic Reaction

Generalised urticaria/erythema, angioedema, throat tightness, mild bronchospasm, nausea/vomiting, tachycardia, feeling of impending doom. Responsive to treatment.

Setting: ED — IM adrenaline, IV fluids, continuous monitoring

Severe — Life-Threatening

Cardiovascular Collapse / Respiratory Failure

Hypotension (SBP <90 mmHg or >30% decrease), severe bronchospasm, stridor, loss of consciousness, cardiac arrest, cyanosis. May be biphasic.

Setting: Resuscitation bay / ICU — repeated adrenaline, IV fluids 1–2 L, consider IV adrenaline infusion

Angioedema Without Anaphylaxis

Angioedema (localised swelling of deeper dermis/subcutaneous tissue, commonly affecting lips, tongue, eyelids, and larynx) may occur without urticaria and without meeting anaphylaxis criteria. Consider:

ACE inhibitor–associated angioedema: Onset may be delayed (months to years after starting an ACE inhibitor). No urticaria. Manage with airway protection, IV icatibant (bradykinin B2 receptor antagonist, PBS authority required) or C1-esterase inhibitor concentrate if bradykinin-mediated.
Hereditary angioedema (HAE): C1-esterase inhibitor deficiency. Recurrent episodes of non-pruritic, non-pitting angioedema without urticaria. Manage acutely with C1-INH concentrate (Berinert®) or icatibant. Refer to immunology for long-term management.
Allergic angioedema: May be the first sign of anaphylaxis — monitor closely and treat if progression occurs.

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Laryngeal angioedema with stridor is a medical emergency. Prepare for advanced airway management (call anaesthetics/ENT immediately). Do not delay adrenaline — even if the mechanism is not clearly IgE-mediated, give IM adrenaline 500 µg while definitive management is arranged.

Acute Management — Stepwise Approach

Step 1: Immediate Actions

Remove trigger if identifiable (stop IV infusion, remove stinger by scraping — do not squeeze).
Call 000 (if pre-hospital) or activate emergency team (if in-hospital).
Position patient supine with legs elevated (if tolerated). If vomiting or respiratory distress, allow to sit upright. Do not stand the patient up — sudden empty ventricle syndrome can cause cardiac arrest.
High-flow oxygen (15 L/min via non-rebreather mask).

Step 2: Adrenaline (First-Line, Life-Saving)

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Adrenaline (Epinephrine)

EpiPen® / Anapen® · Syringe · Catecholamine

Adult dose 500 µg (0.5 mL of 1:1000) IM anterolateral thigh. Repeat every 5 min as needed.

Paediatric dose 10 µg/kg (0.01 mL/kg of 1:1000) IM anterolateral thigh. Max 500 µg. Repeat every 5 min.

Route IM (preferred) → IV infusion if refractory (5–20 µg/min, titrate) — ICU only

Duration As needed until response. Typically 1–3 doses sufficient.

Renal/Hepatic No dose adjustment required.

PBS status ✔ PBS General Benefit (ampoules and autoinjectors)

Step 3: Second-Line Therapies (Adjuncts — Never Delay Adrenaline)

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Chlorphenamine (Chlorpheniramine)

Polaramine® · Antihistamine (H1 antagonist)

Adult dose 10 mg IV/IM slowly (over 1 min). May repeat 6-hourly PO.

Paediatric dose 250 µg/kg IV/IM (max 10 mg).

PBS status ✔ PBS General Benefit

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Hydrocortisone

Solu-Cortef® · Corticosteroid

Adult dose 200 mg IV/IM. May reduce biphasic reaction risk.

Paediatric dose 4 mg/kg IV/IM (max 200 mg).

PBS status ✔ PBS General Benefit

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Salbutamol (nebulised)

Ventolin® · β2-agonist bronchodilator

Adult dose 5 mg nebulised, repeat as needed for bronchospasm.

Paediatric dose 2.5–5 mg nebulised.

PBS status ✔ PBS General Benefit

Step 4: Fluid Resuscitation

Adults: Rapid IV bolus 0.9% sodium chloride 500–1000 mL. Repeat as needed (may require 1–2 L or more in severe anaphylaxis with distributive shock).
Children: 20 mL/kg bolus of 0.9% NaCl, repeat as needed (max 40–60 mL/kg in first hour).
If refractory hypotension despite ≥2 L crystalloid + repeated IM adrenaline, commence IV adrenaline infusion (5–20 µg/min) in a monitored setting (ICU/anaesthesia).

Step 5: Disposition & Observation

All patients treated for anaphylaxis should be observed in an acute care setting for minimum 4 hours from the last dose of adrenaline (ASCIA: ≥6 hours for severe/protracted reactions, biphasic reactions, or those with a history of biphasic anaphylaxis).
Admit to hospital if: refractory or biphasic reaction, severe airway involvement, biphasic risk factors (late adrenaline, history of severe allergy, mast cell disorder), or no reliable carer at home.
Prescribe two adrenaline autoinjectors on discharge (EpiPen® Jr 150 µg for children 15–30 kg; EpiPen® 300 µg for >30 kg; Anapen® 300 µg or 500 µg as alternative). Demonstrate use and provide ASCIA Action Plan.
Referral to clinical immunology/allergy specialist within 4–6 weeks for identification of trigger and long-term management plan.

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Biphasic anaphylaxis: Occurs in up to 20% of cases, typically 1–72 hours after initial reaction (usually 4–12 hours). Prolonged observation is mandatory. Patients discharged with a self-injectable adrenaline device must be instructed to call 000 and use the device if symptoms recur.

Acute Cardiogenic Pulmonary Oedema & Severe Asthma

Acute Cardiogenic Pulmonary Oedema (ACPO)

Clinical Presentation

ACPO presents with acute dyspnoea, orthopnoea, pink frothy sputum, bilateral crackles on auscultation, tachycardia, hypertension (or hypotension in cardiogenic shock), raised JVP, and peripheral oedema. Common precipitants in Australia include acute coronary syndrome (ACS), hypertensive emergency, acute valvular dysfunction (particularly mitral regurgitation), arrhythmia (especially rapid atrial fibrillation), and fluid overload in chronic heart failure.

Severity Assessment

Mild

Mild Pulmonary Congestion

Dyspnoea on exertion, bibasal crackles, SpO₂ >92% on room air, no hypotension. BNP often mildly elevated.

Setting: ED / cardiology ward — oral diuretics, monitoring

Moderate

Established Pulmonary Oedema

Dyspnoea at rest, widespread crackles, SpO₂ 88–92%, mild hypertension. Responds to IV diuretics and GTN.

Setting: ED / CCU — IV frusemide, GTN, non-invasive ventilation

Severe

Cardiogenic Shock / Flash Pulmonary Oedema

Severe respiratory distress, pink frothy sputum, SpO₂ <88%, SBP <90 mmHg (cardiogenic shock) or >180 mmHg (hypertensive emergency), cyanosis, altered consciousness.

Setting: Resuscitation bay / ICU — invasive monitoring, consider intubation, vasopressors if shock

Immediate Management

Sit Upright (if tolerated)

Reduces preload and improves respiratory mechanics. High-flow oxygen (15 L/min) aiming for SpO₂ 94–98%.

IV Frusemide

40–80 mg IV bolus (double the patient's usual oral dose if on chronic diuretics). Onset within 15 min. May repeat at 1–2 hours.

GTN (Glyceryl Trinitrate)

Sublingual spray 400 µg, repeat every 5 min (up to 3 doses). If SBP >100 mmHg, apply GTN patch (5–10 mg/24h) or commence IV GTN infusion (10–200 µg/min, titrate).

Non-Invasive Ventilation (NIV)

CPAP (5–10 cmH₂O) or BiPAP (IPAP 10–15, EPAP 5–8 cmH₂O) reduces work of breathing and improves oxygenation. Reduces intubation rate and mortality. Initiate early.

Identify & Treat Precipitant

12-lead ECG (STEMI? arrhythmia?), troponin, BNP, chest X-ray. Treat ACS (dual antiplatelet, anticoagulation, emergent PCI if STEMI). Control AF rate/rhythm. Correct valvular pathology.

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Frusemide

Lasix® · Loop diuretic

Adult dose 40–80 mg IV bolus. Double chronic oral dose. Repeat 1–2 hourly as needed.

Renal adjustment Higher doses required in CKD (eGFR <30: start at 80–120 mg). May need continuous infusion (5–20 mg/hr) in refractory cases.

PBS status ✔ PBS General Benefit

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GTN (Glyceryl Trinitrate)

Anginine® / Rectogesic® · Nitrate vasodilator

Adult dose Sublingual 400 µg (1 spray) every 5 min, up to 3 doses. IV infusion 10–200 µg/min, titrate to SBP.

Contraindication SBP <90 mmHg, recent PDE5 inhibitor use (sildenafil within 24 h, tadalafil within 48 h), severe aortic stenosis, hypertrophic cardiomyopathy.

PBS status ✔ PBS General Benefit

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Do NOT give GTN to patients with SBP <90 mmHg or suspected right ventricular infarction. In cardiogenic shock (hypotension + pulmonary oedema), volume resuscitation and vasopressors (noradrenaline) are required — transfer to ICU with inotropic support.

Severe & Life-Threatening Asthma

Severity Assessment

Moderate Exacerbation

Worsening Symptoms

Dyspnoea limits speech, RR 20–25/min, HR 100–120/min, SpO₂ ≥92%, PEF 50–75% predicted. Can speak in sentences.

Setting: ED observation — salbutamol nebulisers, oral prednisolone

Severe

Significant Respiratory Distress

Cannot complete sentences, RR >25/min, HR >120/min, SpO₂ <92%, PEF 33–50% predicted. Use of accessory muscles. Silent chest is an ominous sign.

Setting: Resuscitation bay — continuous nebulised salbutamol, IV magnesium, senior review

Life-Threatening

Imminent Respiratory Arrest

Drowsiness, confusion, silent chest, bradycardia, SpO₂ <92%, PEF <33% predicted, cyanosis, exhaustion. PaCO₂ normal or rising (≥45 mmHg) indicates fatigue.

Setting: Resuscitation bay / ICU — IV ketamine, IV aminophylline, consider intubation + mechanical ventilation

Management of Severe/Life-Threatening Asthma

Oxygen

High-flow O₂ via mask. Target SpO₂ 94–98%. Avoid hyperoxia causing atelectasis.

Continuous Nebulised Salbutamol + Ipratropium

Salbutamol 5 mg + ipratropium bromide 500 µg nebulised, driven by O₂ at 6–8 L/min. Repeat every 20 min for 3 doses, then hourly.

IV Magnesium Sulphate

2 g (8 mmol) IV over 20 min. May repeat once in 1–2 hours if insufficient response. Monitor for hypotension and flushing.

Systemic Corticosteroids

Prednisolone 50 mg PO (or hydrocortisone 200 mg IV if unable to swallow). Continue for 5–7 days.

Escalation if No Response

IV aminophylline (250 mg over 20 min, then 0.5–0.7 mg/kg/hr), IV ketamine (0.1–0.2 mg/kg — dissociative dose for agitated patient with refractory bronchospasm), senior/ICU/anaesthetic review for intubation.

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Salbutamol (nebulised)

Ventolin® Nebules® · β2-agonist

Adult dose 5 mg nebulised, repeat every 20 min × 3, then hourly. May use continuous nebulisation (10–15 mg/hr) in severe cases.

Paediatric dose 2.5–5 mg nebulised every 20 min. Alternatively, 4–8 puffs MDI + spacer every 20 min.

PBS status ✔ PBS General Benefit

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Magnesium Sulphate

Generic · Electrolyte / Bronchodilator

Adult dose 2 g (8 mmol) IV in 100 mL 0.9% NaCl over 20 min. May repeat once.

Paediatric dose 40 mg/kg IV over 20 min (max 2 g).

Monitoring Blood pressure every 5 min during infusion. Watch for hypotension, flushing, areflexia.

PBS status ✔ PBS General Benefit

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Prednisolone

Panafcortelone® / Solone® · Corticosteroid

Adult dose 50 mg PO once daily for 5–7 days. (Hydrocortisone 200 mg IV if unable to swallow.)

Paediatric dose 1–2 mg/kg PO once daily (max 50 mg) for 3–5 days.

PBS status ✔ PBS General Benefit

⚠️

Silent chest in asthma is an ominous sign — it indicates minimal air movement and impending respiratory arrest. Prepare immediately for advanced airway management. Do not delay intubation if the patient is becoming drowsy, exhausted, or has a rising PaCO₂.

Status Epilepticus & Severe Hypoglycaemia

Status Epilepticus

Definition

Status epilepticus is defined as:

Convulsive status epilepticus (CSE): Continuous generalised tonic-clonic seizure activity lasting ≥5 minutes, OR ≥2 discrete seizures without full recovery of consciousness between seizures. This is the most common and dangerous form.
Non-convulsive status epilepticus (NCSE): Altered consciousness with or without subtle motor features, confirmed by EEG. Consider in patients with prolonged post-ictal confusion or unexplained altered mental state.

Aetiology

Common causes include known epilepsy with medication non-adherence (most common), acute structural brain lesion (stroke, tumour, trauma), CNS infection (meningitis, encephalitis), metabolic derangement (hypoglycaemia, hyponatraemia, hypocalcaemia, uraemia, hepatic encephalopathy), drug/alcohol withdrawal (benzodiazepines, alcohol), and drug toxicity (tricyclic antidepressants, theophylline, isoniazid).

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Status epilepticus becomes progressively more resistant to treatment over time. Mortality rises significantly after 30 minutes of continuous seizure activity. Treat aggressively and early. Always check BGL — hypoglycaemia is a reversible cause.

Stepwise Management (Time-Zero = Seizure Onset)

0–5 min

Initial Assessment & Stabilisation

ABC approach. Position laterally. Suction airway. Apply O₂. Establish IV access. Check BGL immediately — treat hypoglycaemia if present. Send bloods: glucose, UEC, FBC, calcium, magnesium, LFTs, anticonvulsant levels, VBG/ABG, blood cultures. 12-lead ECG. Consider benzodiazepine if seizure continues.

5–20 min

First-Line: Benzodiazepines

IV lorazepam 4 mg over 1–2 min (preferred). If no IV access: IM midazolam 10 mg (for adults >40 kg) or PR diazepam 20 mg. May repeat once after 5–10 min if seizure continues.

20–40 min

Second-Line: Anticonvulsant Therapy

If seizure continues despite two doses of benzodiazepines: IV levetiracetam 60 mg/kg over 15 min (max 4.5 g), OR IV phenytoin 20 mg/kg at max 50 mg/min (with cardiac monitoring — risk of arrhythmia/hypotension), OR IV sodium valproate 40 mg/kg over 10 min (max 3 g). Simultaneously arrange ICU/anaesthetic review.

>40 min

Refractory Status Epilepticus — ICU

General anaesthesia with continuous EEG monitoring. IV midazolam infusion (0.2 mg/kg bolus, then 0.1–2 mg/kg/hr), OR IV propofol (1–2 mg/kg bolus, then 1–10 mg/kg/hr), OR IV thiopentone (3–5 mg/kg bolus, then 3–5 mg/kg/hr). Intubation and mechanical ventilation required. Target: burst suppression on EEG.

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Lorazepam

Ativan® · Benzodiazepine

Adult dose 4 mg IV over 1–2 min. May repeat once after 5–10 min. (Max 8 mg.)

Paediatric dose 0.1 mg/kg IV (max 4 mg). May repeat once.

Caution Risk of respiratory depression — have flumazenil available. Avoid in pre-existing significant respiratory disease without airway support.

PBS status ✔ PBS General Benefit

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Midazolam (IM)

Hypnovel® · Benzodiazepine

Adult dose 10 mg IM (for adults >40 kg). Rapid onset (3–5 min IM). May repeat once.

Paediatric dose 0.2 mg/kg IM (max 10 mg).

PBS status ✔ PBS General Benefit

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Levetiracetam

Keppra® · Anticonvulsant (SV2A ligand)

Adult dose 60 mg/kg IV over 15 min (max 4.5 g).

Renal adjustment eGFR 30–50: max 3 g; eGFR <30: max 1.5 g. Haemodialysis: supplemental dose 250–500 mg post-dialysis.

Advantages No cardiac monitoring required. No significant drug interactions. Well tolerated.

PBS status 🔶 PBS Authority Required

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Phenytoin (IV)

Dilantin® · Hydantoin anticonvulsant

Adult dose 20 mg/kg IV at max 50 mg/min (use NS flush — precipitates in dextrose). Loading dose, then 100 mg PO/IV TDS or BD.

Monitoring Continuous ECG and BP monitoring during infusion. Risk of hypotension and arrhythmia (especially in elderly and those with cardiac disease).

Renal/Hepatic Reduce dose in hepatic impairment. Adjust based on therapeutic drug monitoring (target 40–80 µmol/L or 10–20 mg/L).

PBS status ✔ PBS General Benefit

Severe Hypoglycaemia

Definition

Severe hypoglycaemia is defined as a blood glucose level (BGL) <3.0 mmol/L with severe neuroglycopenic symptoms requiring external assistance for recovery. This may manifest as altered consciousness, seizures, inability to self-treat, or loss of consciousness. In clinical practice, any BGL <4.0 mmol/L with symptoms should be treated urgently.

Common Causes in Australia

Insulin therapy (type 1 and type 2 diabetes) — most common cause. Missed meals, excess dose, intercurrent illness.
Sulfonylureas (glibenclamide, glipizide, gliclazide, glimepiride) — prolonged hypoglycaemia risk (especially glibenclamide, up to 24–48 hours). Particularly dangerous in the elderly and in renal impairment.
Alcohol excess — impaired hepatic gluconeogenesis. Often presents overnight or early morning.
Critical illness — sepsis, hepatic failure, adrenal insufficiency, starvation.
Insulinoma — rare pancreatic tumour. Consider in recurrent unexplained hypoglycaemia.

Immediate Management

Confirm BGL

Point-of-care glucometer (capillary). If BGL <3.0 mmol/L or patient is unconscious/seizing, treat immediately.

IV Glucose (First-Line if IV Access)

Adults: 50 mL of 50% dextrose (25 g glucose) IV bolus. May repeat. Children: 2–5 mL/kg of 10% dextrose (0.2–0.5 g/kg) IV bolus. (Or 100 mL of 25% dextrose in paediatrics.)

IM Glucagon (If No IV Access)

Adults: Glucagon 1 mg IM (or SC). Onset 10–15 min. Children <25 kg: 500 µg IM. Note: Glucagon is ineffective in sulfonylurea-induced and alcohol-induced hypoglycaemia (requires hepatic glycogen stores).

Recheck BGL

Recheck BGL at 15 min. Repeat glucose administration if BGL remains <4.0 mmol/L. Continue until BGL >5.0 mmol/L and patient is asymptomatic.

Maintain Glucose Infusion

Commence 10% dextrose infusion at 100 mL/hr (adults) after initial correction. Monitor BGL every 30–60 min. Essential in sulfonylurea-induced hypoglycaemia (prolonged risk) and in patients receiving insulin infusions.

Identify & Treat Cause

Review insulin/diabetes medications. Stop offending agent. Consider octreotide for sulfonylurea-induced hypoglycaemia (50–100 µg SC/IV TDS). Check UEC, LFTs, cortisol, alcohol level.

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Glucose 50% (Dextrose)

Generic · IV Glucose

Adult dose 50 mL of 50% dextrose (25 g glucose) IV push. Repeat if BGL remains <4.0 mmol/L.

Paediatric dose 2–5 mL/kg of 10% dextrose (0.2–0.5 g/kg) IV. Never use 50% dextrose in children (hyperosmolar risk).

Caution Highly hyperosmolar (2500 mOsm/L). Extravasation causes tissue necrosis. Ensure IV line is patent.

PBS status ✔ PBS General Benefit

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Glucagon

GlucaGen® HypoKit® · Hormone

Adult dose 1 mg IM/SC. Onset 10–15 min. May cause nausea/vomiting — position recovery.

Paediatric dose <25 kg: 500 µg IM/SC. ≥25 kg: 1 mg IM/SC.

Limitation Ineffective in sulfonylurea-induced, alcohol-induced, and hepatic failure–related hypoglycaemia (requires glycogen stores).

PBS status 🔶 PBS Authority Required

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Octreotide

Sandostatin® · Somatostatin analogue

Adult dose 50–100 µg SC/IV TDS for sulfonylurea-induced hypoglycaemia. Inhibits insulin secretion.

Duration Continue until BGL stable >5 mmol/L off dextrose infusion (may be 24–72 hours for long-acting sulfonylureas).

PBS status 🔶 PBS Authority Required

⚠️

Sulfonylurea-induced hypoglycaemia is frequently prolonged and recurrent. Patients (especially the elderly on glibenclamide) require dextrose infusion and prolonged observation (≥24 hours). Consider octreotide to suppress insulin secretion. Advise cessation of the offending sulfonylurea and switch to a safer agent.

Disposition

Discharge criteria (insulin-related): BGL >5.0 mmol/L for ≥1 hour, eating and drinking, identified and corrected precipitant, reliable carer, diabetes team review arranged.
Admit: All sulfonylurea-induced hypoglycaemia (prolonged risk), recurrent episodes, unexplained cause, no reliable carer, elderly, hepatic/renal impairment.
Review medications: Reduce insulin doses, cease or reduce sulfonylurea, consider safer alternatives (e.g., gliclazide MR over glibenclamide), and provide education on hypoglycaemia recognition and treatment.

Special Populations

🤰

Pregnancy

Anaphylaxis: Adrenaline is safe and essential — IM doses unchanged. Hypotension is more harmful to the fetus than adrenaline. Left lateral tilt (15–30°) to avoid aortocaval compression.

Status epilepticus: Benzodiazepines are first-line even in pregnancy. Levetiracetam is preferred second-line (better safety data in pregnancy than phenytoin or valproate). Avoid valproate in first trimester (teratogenic — neural tube defects).

Hypoglycaemia: IV glucose as per standard adult dosing. Gestational diabetes treated with insulin has hypoglycaemia risk — educate on recognition. Glucagon is safe.

Pulmonary oedema: Exclude peripartum cardiomyopathy (especially in third trimester or within 5 months postpartum). GTN is relatively safe. Avoid ACE inhibitors (teratogenic). Frusemide is generally safe short-term.

👶

Paediatrics

Anaphylaxis: Adrenaline 10 µg/kg IM (0.01 mL/kg of 1:1000), max 500 µg. EpiPen® Jr (150 µg) for 15–30 kg. Anapen® Jr (150 µg) as alternative.

Status epilepticus: Lorazepam 0.1 mg/kg IV (max 4 mg) or midazolam 0.2 mg/kg IM (max 10 mg). Levetiracetam 40–60 mg/kg IV (max 3 g). Phenytoin 20 mg/kg IV.

Hypoglycaemia: 2–5 mL/kg of 10% dextrose IV (0.2–0.5 g/kg). Never use 50% dextrose in children — risk of extravasation injury and hyperosmolarity. Neonatal hypoglycaemia: 2.5 mL/kg of 10% dextrose IV bolus.

Asthma: Salbutamol 2.5–5 mg nebulised every 20 min. IV salbutamol infusion 1–5 µg/kg/min for refractory cases. Weight-based IV magnesium sulphate (40 mg/kg, max 2 g).

👴

Elderly

Anaphylaxis: Higher cardiovascular risk — may present with atypical features (isolated hypotension without urticaria). Adrenaline doses unchanged but use with caution in patients on beta-blockers (may be refractory — consider IV adrenaline and glucagon 1–2 mg IV for beta-blocker–associated refractory anaphylaxis).

Hypoglycaemia: Polypharmacy is a major risk factor. Long-acting sulfonylureas (glibenclamide) should be avoided. Falls and fractures are common complications of hypoglycaemia in the elderly.

Pulmonary oedema: Start lower IV GTN doses (avoid excessive hypotension). Caution with IV frusemide — risk of acute renal impairment and electrolyte derangement.

Status epilepticus: Increased sensitivity to benzodiazepines — respiratory depression risk. Lower initial lorazepam dose (2 mg) may be considered. Phenytoin infusion increases risk of arrhythmia — mandatory cardiac monitoring.

🫘

Renal Impairment

Frusemide: Higher doses required (eGFR <30: start 80–120 mg IV). May need continuous infusion. Monitor UEC after each dose.

Levetiracetam: eGFR 30–50: max 3 g; eGFR <30: max 1.5 g.

Hypoglycaemia: Increased risk in CKD (reduced insulin clearance, reduced gluconeogenesis, reduced appetite). Sulfonylureas (especially glibenclamide) accumulate and should be avoided.

Magnesium sulphate: Use with caution — hypermagnesaemia risk. Monitor serum magnesium if repeated doses required.

🫁

Hepatic Impairment

Hypoglycaemia: Hepatic failure reduces glycogen stores and gluconeogenesis — glucagon may be ineffective. Requires continuous IV dextrose infusion and close monitoring. Check LFTs, ammonia, and coagulation.

Phenytoin: Reduced protein binding in liver disease — lower total drug levels may still be therapeutic. Consider free phenytoin levels.

Prednisolone: Prednisolone is preferred over prednisone (does not require hepatic conversion). Hydrocortisone IV for acute situations.

🛡️

Immunocompromised

General: Broaden differential diagnosis — seizures may indicate CNS infection (opportunistic pathogens including Toxoplasma, Cryptococcus, CMV, JC virus), CNS lymphoma, or metabolic encephalopathy.

Anaphylaxis: Higher risk of drug-induced anaphylaxis (chemotherapy agents, monoclonal antibodies such as rituximab and infliximab). Pre-medication with corticosteroids and antihistamines may reduce but does not eliminate risk.

Asthma: Inhaled corticosteroids may need review in patients on systemic immunosuppression. Consider atypical infections (aspergillus, PCP) as triggers for wheeze.

Investigations

The following investigations should be considered in the emergency management of the conditions discussed. Availability and MBS item numbers are noted for the Australian context.

Essential Blood glucose level (BGL) — point-of-care glucometer Available in all settings including primary care and pre-hospital. No MBS item for POCT. Available within seconds. Essential in every altered conscious state and every emergency presentation.

Essential 12-lead ECG MBS Item 11707. Available in most primary care practices and all emergency departments. Obtain within 10 minutes of chest pain or cardiac symptoms. Identify STEMI, arrhythmias, hyperkalaemia.

Essential Venous blood gas (VBG) or arterial blood gas (ABG) MBS Item 66696 (VBG). Provides pH, pCO₂, pO₂, lactate, glucose, electrolytes, haemoglobin. ABG (MBS Item 66695) required if accurate SpO₂ correlation needed or in respiratory failure. VBG adequate for most emergency assessments.

Essential Full blood count (FBC), urea/electrolytes/creatinine (UEC), liver function tests (LFTs) MBS Items 65060 (FBC), 66515 (UEC), 66512 (LFTs). Available in all hospital laboratories. Results within 1 hour in most emergency departments.

Available Serum tryptase MBS Item 65137 (tryptase level, immunological). Measure within 1–2 hours of anaphylaxis onset and again at 24 hours (baseline). Elevated acute tryptase confirms mast cell degranulation. Not all rural labs offer this — send to reference lab if needed.

Available Troponin (high-sensitivity) MBS Item 66597. Available in most hospital labs. Essential in ACPO to exclude ACS. Serial measurements (0 and 2 hours with hs-troponin assay). Point-of-care troponin increasingly available in rural settings.

Available BNP / NT-proBNP MBS Item 66605 (BNP). Differentiates cardiac vs respiratory dyspnoea. BNP >100 pg/mL or NT-proBNP >300 pg/mL suggests heart failure. Available in most hospital labs.

Available Chest X-ray MBS Item 58101. Available in most GP practices with imaging and all emergency departments. Bilateral pulmonary infiltrates in ACPO. Hyperinflation in asthma. Rule out pneumothorax, pneumonia.

Available CT brain (non-contrast) MBS Item 56001. Indicated in first seizure, status epilepticus of unknown cause, focal neurological signs, or suspected intracranial pathology. May require transfer to regional centre in rural areas.

Referral EEG (electroencephalography) MBS Item 11014. Referral to neurology service. Essential for suspected non-convulsive status epilepticus and for monitoring burst suppression during treatment of refractory status. Limited availability in rural/regional areas — telehealth EEG interpretation expanding.

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples experience significantly higher rates of the emergency conditions discussed in this article. Cardiovascular disease hospitalisation rates are approximately 1.7 times higher than in non-Indigenous Australians. Type 2 diabetes prevalence is approximately 3–4 times higher, with substantially increased rates of hypoglycaemia requiring emergency presentation. Asthma prevalence and severity are elevated, particularly in children. Anaphylaxis from jack jumper ant stings disproportionately affects Indigenous communities in regional and remote areas of southern and central Australia.

Remote access to care

Many Aboriginal and Torres Strait Islander communities are in remote or very remote areas with limited access to emergency services, medical retrieval, and hospital care. Retrieval times may exceed 1–2 hours. Community health centres must be equipped with emergency drugs and basic equipment, and health workers must be trained in anaphylaxis management, glucose administration, and basic life support.

Diabetes-related hypoglycaemia

Aboriginal and Torres Strait Islander peoples have significantly higher rates of insulin-treated diabetes and sulfonylurea use, with increased hypoglycaemia risk. Access to diabetes educators and endocrinology services is limited in remote areas. Ensure communities have glucagon kits and trained personnel. Telephone support through specialist diabetes services should be available 24/7.

Medication access and storage

Adrenaline autoinjectors require storage below 25°C — this is challenging in remote communities during hot seasons. Ampoules and syringes are an alternative. PBS access is essential; ensure remote area pharmacies (Section 100/RPBS) are stocked with emergency medications. MBS telehealth items (e.g., 91790, 91803) enable specialist consultation.

Cultural safety and communication

Use culturally safe communication. Engage Aboriginal Health Workers and Practitioners (AHW/Ps) in emergency management and follow-up. Avoid language barriers by using interpreters where needed. Acknowledge the role of family and community in healthcare decisions. Understand that shame, fear of hospital, and past negative experiences may delay presentation.

Cardiovascular emergencies

Aboriginal and Torres Strait Islander peoples have higher rates of acute coronary syndrome, rheumatic heart disease, and cardiomyopathy as causes of acute pulmonary oedema. Ensure ECG acquisition is available in all remote health clinics. Awareness of acute rheumatic fever presentations is critical — new murmurs in young people require urgent investigation.

📚 References

1. Australasian Society of Clinical Immunology and Allergy (ASCIA). ASCIA Guidelines – Acute Management of Anaphylaxis. ASCIA; 2024. Available at: allergy.org.au
2. Mullins RJ, Wainstein BK, Barnes EH, Liew WK, Campbell DE. Increases in anaphylaxis fatalities in Australia from 1997 to 2013. Clin Exp Allergy. 2016;46(8):1099–1110.
3. Australian Institute of Health and Welfare (AIHW). Chronic Respiratory Conditions: Asthma. AIHW; 2023. Cat. no. ACM 40.
4. National Asthma Council Australia. Australian Asthma Handbook, Version 2.2. National Asthma Council Australia; 2024. Available at: asthmahandbook.org.au
5. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart Lung Circ. 2016;25(9):895–951.
6. Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012;17(1):3–23.
7. Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61.
8. Royal Australian College of General Practitioners (RACGP). Management of Type 2 Diabetes: A Handbook for General Practice. RACGP; 2020.
9. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary Report. AIHW; 2023. Cat. no. IHW 222.
10. NHMRC Centre of Research Excellence in Severe Asthma. Australian Severe Asthma Handbook. Version 2.0. NHMRC CRE; 2023.
11. Resuscitation Council UK. Emergency Treatment of Anaphylactic Reactions: Guidelines for Healthcare Providers. Resuscitation Council UK; 2021.
12. Kidney Health Australia. Chronic Kidney Disease Management in Primary Care. 4th ed. Kidney Health Australia; 2020.
13. The Royal Australian College of General Practishers (RACGP). Emergency Response Planning in General Practice. RACGP; 2022.
14. Australasian College for Emergency Medicine (ACEM). Guidelines on the Management of Acute Cardiogenic Pulmonary Oedema in the Emergency Department. ACEM; 2019.
15. Australian Government Department of Health. Pharmaceutical Benefits Scheme (PBS) Schedule. Commonwealth of Australia; 2024. Available at: pbs.gov.au

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).