no place like home….

I am now 6 weeks into my 6 month anaesthetic secondment. There have been some interesting challenges settling into the new job but I am largely enjoying my time perfecting basic airway manoeuvers, laryngoscopy and playing with some brilliant airway toys (McGrath video laryngoscopes, the AirTraq, intubating LMAs etc). I thought I’d share with you a case (from Anaesthetic week 2) that presenting some multifaceted challenges & several points of reflection …

The Case.

A 59 year old male undergoes an elective radical prostatectomy. He is previously well, however takes some ‘herbal Chinese medicines’ that he stopped 2 weeks prior to surgery. His surgery appears to go without a hitch, except for the 1200mL of blood in the surgical suction container at the end of the case. He has received 2 liters of Hartmann’s & 500mL Volvuven during his OT time. He is extubated and taken to recovery at the end of the case where he reports feeling quite comfortable.

I am called back to recovery about 20-25 minutes later to address his hypotension. Continue reading

a world of trouble…

The case.

A 3 week old infant is bought into your ED late at night. She is febrile and looks incredibly unwell. Her parents report a 36 hour history of increasing vomiting and poor oral intake. She has not had a wet nappy for 12 hours or so and the parents now report a fever of 39.5*C.

She was born at 39 weeks gestation following an unremarkable pregnancy and delivery. They were only in hospital for 2 days as everything was going so well…..

When you approach this child in resus, you immediately identify that she is in a whole world of trouble. She is flat and listless, tachypnoeic at 70/min (with moderate work of breathing) and tachycardic at 204 bpm. Her capillary return is 5-6 seconds and her skin is mottled. Her abdomen is quite obviously distended.

Amongst the flurry of activity at the bedside the following x-ray is taken….

SickSickInfant

What’s going on here ?
What are your differentials ??
What are you going to do next ???

Continue reading

a poison puzzler…

23 year old female is bought to ED by her family after an intentional overdose of ~ 100 ‘diet tablets’ which she ingested 1.5-2 hours earlier.

She is agitated, anxious, tremulous and profoundly diaphoretic.
P 170. BP 123/70. Sats 100%. RR 32. Temp 36.8*C.
Patent airway. Chest clear. Soft, non-tender abdomen.
Pupils 4mm (equal & reactive).
Normal tone & power in all 4 limbs.
5-6 beats of inducible clonus at the ankles.

BSL 13.1
ECG. Sinus tachycardia @ 170/min (confirmed by increasing paper-speed to 50mm/sec).
VBG.

 

What do you think she took ?

Continue reading

shades of grey…

A few days ago I was looking after a 31/40 gestation restrained passenger from low-speed MVA with a slight seatbelt abrasion in her RIF & mild suprapubic pain. She looked well, HR 70 with BP 108 systolic and no features of peritonism.

As I placed the US-probe on for her FAST, this was the first image I acquired…..

   

Continue reading

more than man-flu…

The case:

19 year old male who presented as ‘lethargic & generally unwell’ is wheeled into resus. He is so weak it takes 2 staff and his father to lift him from the wheelchair to our stretcher.

He looks horrible. A mixture of white & grey. Clammy & diaphoretic. Pulse 130/min (sinus). BP 92systolic. He looks dry. Chest clear with sats of 95% on room air. No murmurs. JVP not seen.

The nurses have quite rightly initiated our ‘Septic-Pathway’ designed to rapidly initiate IV access, cultures, lactate, fluids & early antibiotics.

As your first saline bolus is rushing in, he reports having generalised lethargy & malaise for 4-5 days during which time he has not gotten out of bed… He has had fevers, drenching night sweats and rigors. Minimal cough but no dyspnoea.

Systems review & closer examination brings you no closer to finding the source of sepsis.

It does cross my mind that he has a horrible case of ‘man-flu’ …

Bloods are unhelpful. WCC normal. CRP 33. EUCs normal.

For me, his CXR changed my mind & subsequent course of action….

What are your thoughts ? DDx ?

What would you do next ??

The conclusion can be found here…. more than man-flu (part2)…

observing the occult…

The case:

A motorcyclist is minding his own business, stationary at a set of lights and is rear-ended by a car at ~60-70km/h. He is thrown 10 meters or so from his bike and lands on his left side. Remarkably he is systemically well, except for significant left lateral chest wall pain !!

You think he has reduced air-entry on the left side, but is he’s not dyspnoeic, nor hypoxic. The remainder of his primary survey is unremarkable.

This is his supine CXR…

EFAST showed no evidence of free intraperitoneal fluid, but this is what I saw on the chest….

Continue reading

supply & demand…

Case:

74 year old female is placed in the acute-area of our ED with a complaint of retrosternal chest tightness at approximately 9am. Her symptoms sound very typical for ACS. She looks clammy and pale.

My colleague has placed her on telemetry, high flow oxygen and has prescribed 300mg aspirin &  600mcg sublingual anginine.

I am handed her ECG, which shows a sinus tachycardia and evidence of left ventricular hypertrophy with a repolarisation pattern. Of concern is the associated anterior ST depression, so I make my way to the bedside….

…as I approach her bed I witness her telemetry deteriorate from a sinus tachycardia to ventricular fibrillation !!

There is a defibrillator 15 metres away, across the department. The following takes place…

  • Precordial thump (by me. did nothing except hurt my hand).
  • Immediate CPR until defib pads placed.
  • 200J shock
  • 2 further minutes of CPR with 1mg IV adrenaline.
  • 3 minutes post arrest she has return of spontaneous circulation.

Cardiology are notified of this and want her in their Cath-lab immediately….

Continue reading

a tonne of bricks…

… well it wasn’t really a tonne; more like a dozen or so individual bricks falling from a height of 3-4 metres that peppered and glanced a patient I saw 48 hours ago.

Whilst he presented as a ‘trauma’ and was cleared of any significant injury, his greatest concern was his left ankle which was swollen and tender diffusely. He felt that as he was attempting to dodge the falling bricks, his ankle buckled and went under him (demonstrating an extreme plantar flexion mechanism with his good ankle).

These are two of his original xrays.

   

I thought this case gave me the perfect excuse to share one of my favourite orthopaedic papers that I discovered earlier in the year.

by Yu JS, Cody ME in Emerg Radiol. 2009 Jul;16(4):309-18.

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…..

Continue reading