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