We propose to conduct a multi-centre blinded cluster cross over randomised clinical trial (RCT) of plasmalyte (PL), a balanced salt solution versus normal saline (NS) in patients admitted to an Intensive Care Unit (ICU) with diabetic ketoacidosis (DKA), a life-threatening complication of diabetes mellitus. DKA results in elevated acid levels in the blood leading to severe dehydration and electrolyte imbalance.

ICU admission rates for patients with DKA in Australia has risen annually. In 2019 and 2020, there were 2751 and 2812 admissions to ICUs respectively. Almost all patients present through the Emergency Departments and in regional hospitals, they are often admitted to the ICU.

NS is often used as the first line fluid for dehydration, but NS use frequently results in persistent acidosis. We have shown in a pilot trial, conducted in 7 Queensland regional Emergency departments and ICUs, that the use of a balanced salt solution such as PL resulted in a more rapid resolution of acidosis with trends to shorter length of ICU and hospital stay as compared to NS. The efficacy of PL in DKA needs evaluation in a large clinical trial.

We plan to study 480 patients from Australia of whom a third will be expected to be enrolled in Queensland. Patients will be randomised to receive either NS or PL and the primary end point is hospital length of stay. This proposed trial will answer a fundamental clinical question and will inform policy and practice in Australia and New Zealand and around the world.

Syndesmosis injuries, also known as a high ankle sprain, due to ligamentous injury are relatively uncommon but can have devastating outcomes when missed. This includes chronic pain, instability and osteoarthritis. Early surgical fixation of these injuries is recommended in some cases. Magnetic Resonance Imaging (MRI) is the most accurate way to diagnose these, but not ordered in the emergency department (ED) due to its cost and poor availability. Although clinical tests can help to narrow down who needs an MRI, they are often inaccurate in the acute phase. Ultrasound performed by sonographers can visualise ligament to components of the syndesmosis complex to streamline MRI referrals but is under demand during the day and not available afterhours. Point of Care Ultrasound (POCUS) performed by clinicians is an alternative option for imaging.

Emergency physiotherapy practitioners (EPP) typically manage patients with musculoskeletal injuries in the ED and are well placed to perform musculoskeletal POCUS. This study will evaluate the feasibility and accuracy of ED physiotherapist-performed POCUS for the diagnosis of ligament injury in the ED, indicative of a syndesmosis injury, against radiology-performed ultrasound. This could guide MRI patient selection to allow for earlier detection of unstable ankle injuries and expedite outpatient orthopaedic expert review and management. If POCUS by ED physiotherapists is demonstrated to be feasible and accurate for these syndesmosis injuries, the results of this study could inform the development of a diagnostic pathway that could be implemented in EDs locally and throughout Australia.

The next phase of studies, titled "Paris on Country," represents a continuation of efforts in Australia and New Zealand to enhance care for infants and children presenting with acute respiratory issues in emergency departments. Through these studies, we have successfully implemented changes in treatment protocols, aimed at alleviating respiratory distress and reducing anxiety for both patients and their parents.

In rural and remote areas of Queensland, approximately 38 percent of the state's total population resides. However, access to healthcare and emergency services in these areas can significantly differ from urban regions. The primary goal of this project is to elevate the standard of care for children experiencing acute respiratory distress in remote and regional settings to match the level of care available in larger cities.