a swollen face…

The Case.

A 36 year old male presents through your sub-acute area with increasing facial pain & swelling. He reports a simple trip and fall 18 hours earlier (no alcohol on board, recalls all events), where his right cheek struck a concrete step. He had no LOC at the time, and has no historical features concerning for intracranial injury.

He is worried today as the swelling ‘just keeps getting worse’.

On examination he has obvious marked right zygomatic/maxillary swelling and ecchymoses. His cranial nerves are ok (particularly extra-occular movements and facial sensation). When you palpate his facial bones, for find something unexpected which leads you to expediting his CT scan….

What has happened here ?
What other injuries may have been sustained ??
What do you do next ???

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a difficult airway…

The Case.

The ‘Batphone’ alerted us of a 68 year old female who is postictal following two seizures in rapid succession. She has a history of ‘a brain tumour’.

P 120. BP 176 systolic !! GCS 8/15. Afebrile. Sats 98% (15L NRB + guedel airway).

She arrives direct to your resus bay 4-5 minutes later and she is actively seizing.

A) Obstructed (Guedel on floor). Trismus ++.

  • Bilateral nasopharyngeal airways inserted
  • Two-handed jaw thrust
  • Ventilating well on 100% BVM.

 B) Bilateral air entry. Sats 99% on O2. No added sounds.

 C) P 130 (sinus) BP 185 systolic. Diaphoretic. Warm peripheries.

  • 2x IVC inserted
  • 500mL N.Saline bolus

D) Actively seizing (GTCS with movement in all 4 limbs). Pupils 4mm (L+R).

  • 2x 5mg IV Midazolam (seizure resolved)
  • 1gram IV Phenytoin (loading commenced at cessation of seizure)

E) Temp 37*C. BSL 13. No rashes, contusions etc.

Impression:

Status Epilepticus (3x seizures with no return to normal mental state)

  • ? secondary to ‘brain tumour’ or associated haemorrhage
  • No other medical history available
  • “Family are bringing in her medications”

Following resolution of her seizure she remains obtunded, GCS (E1V1M4) 6/15 and still obstructing her airway. A decision is made to RSI for airway control and prevention of secondary brain injury, followed by urgent CT. Continue reading

just a tablespoon…

This is the story of a 59 year old man who presented to our ED with a complaint of haemoptysis. He is otherwise well, takes no regular medications and besides his ’50 per day’ smoking history (over 40-odd years) he has no health concerns or past medical problems.

On the morning of presentation he had his usual morning ‘cough and splutter’ and was surprised to find blood in his tissue. He then proceeding to expectorate a small blood clot. “Its not that big, just a tablespoon”. He may have had some right sided pleuritic chest pain with it.

He looks well, with no increased work of breathing. Room air saturations of 94%.  Good air entry with mild end expiratory wheeze. Normal cardiac examination.

This is his CXR…..

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