Comments for Broome Docs

Comment on Paracentesis: are you stabbing in the dark? by evangeline

evangeline — Mon, 17 Dec 2012 08:29:07 +0000

Great post. Tks for sharing!

Comment on Ectopic pregnancy – HCG hiccups, some older evidence by Jenna Linehan

Jenna Linehan — Sat, 01 Dec 2012 10:25:34 +0000

Hi All,
Just wanted to share some information from the ISUOG conference this year.
The stuff on HCG (that the levels have been seen to rise but only 55% over 2 days in viable pregnancy) was what was also being talked about at the ISUOG conference this year. I wanted to also mention that they also discussed cases showing that the BHCG cutoffs where you should expect to see a gestational sac are much too low in most guidelines. One case (the most extreme example) was presented with a BHCG of 22 000, no gestational sac seen. A few days later (could have been 1 or 2 days- can’t remember) two gestational sacs were seen- i.e twins. Final outcome was singleton baby (although can’t remember if this was @ 12 weeks with a heartbeat, or a live birth). In the discussion was many cases where people in the states were given methotrexate after a certain HCG was reached and the uterus was empty (think cut off in many guidelines is generally around 4000-5000) on the grounds that an ectopic was assumed. The conclusion was that it is much safer to follow stable patients with positive HCG and no gestational sac identified and re ultrasound than to intervene with either D&C assuming miscarriage or methotrexate. Similar discussion revolved around fetuses without heartbeat that had failed to grow.. cases were presented where 10 days of no growth was recorded but resulted in a viable pregnancy at 12 weeks. (once again the extreme case, but highlighting that its better to follow stable patients than intervene with D&C as missed miscarriage is not sure).
Adrian- research around your sac diameter and embryo length cut-off was also discussed, – also from London (probably similar research/authors to what is influencing ASUM guideline changes.)

Comment on Course Review: Advanced Paediatric Life Support (APLS) by sinead ahern

sinead ahern — Tue, 11 Sep 2012 01:47:28 +0000

Tim!!!! Where did you get the ” most anaesthetists only deal with elective , fasted ….” !!!! What lies, what rot!!!! We tube patients in the OR, in Emerg, in ICU all with blood, food, sputum, vomit and other delights…… The pristine airway is a treat – not an expectation.
Hope you are well. It has been a long time since Flinders physician training !!!!

Comment on Paracentesis: are you stabbing in the dark? by graeme pickford

graeme pickford — Tue, 28 Aug 2012 03:52:35 +0000

Great site–The rural generalist’s emcrit. Great summary of this topic.
re albumin. I am stuck on this issue. In large volume paracentesis (say 5-6L +) I tend to give colloid in palliative patients due to it being easy to find, but in patients with a better prognosis I still reach for albumin.
Do you have a preference/opinion, given that the guidelines/evidence could go either way?

Comment on Case 044: the answer by Christine Oha

Christine Oha — Thu, 19 Jul 2012 17:07:19 +0000

I am a CRNA and we use nitrous quite a bit in the US.

Comment on Clinical Case 020: the ABC of APO by Denis

Denis — Sat, 07 Jul 2012 11:01:54 +0000

Hi, just wondering what your opinion is on the use of GTN (SL) in a hypertensive patient with APO who is also in rapid AF at a rate over 180bpm. I’ve heard conflicting views on whether the GTN can be harmful. Thanks, great site by the way!

Comment on Broome Docs is Moving address by Tim Leeuwenburg

Tim Leeuwenburg — Mon, 04 Jun 2012 10:57:08 +0000

Casey, can you leave a ‘re direct’ link at the old domain to the new one?

I’ve been proletscising your site to all and sundry….keen to make sure people can still access the links..

Good luck with the move.

Comment on Clinical Case 054: Just a sip by Leon Gussow

Leon Gussow — Fri, 01 Jun 2012 01:47:43 +0000

Although we can estimate the volume of liniment this child might have swallowed, it is important to keep in mind that this is only an estimate, and it’s always possible that the child ingested more than we thought.

The average volume of a swallow in a young child is about 0.2 ml/kg of liquid, or about 2.2 ml in this patient. Since the child seems to have found the taste of this product rather unpleasant, it is likely (but not certain) that he actually ingested less than a swallow.

My primary concern in this product would be with methyl salicylate and camphor.
Methyl salicylate is concentrated, readily absorbed through the gastrointestinal tract, and can cause severe early-onset salicylate toxicity. Since there is 15 g methyl salicylate per 50 ml liniment, a 2.2 ml ingestion would involve 660 mg or 60 mg/kg. In general, ingestions of less than 150 mg/kg of salicylate are considered nontoxic, ingestions of 150-300 mg/kg are considered moderately toxic, and greater than 500 mg/kg potentially lethal. Although I would not expect the amount ingested by this child to produce significant toxicity, it is always possible that the ingested more than 1 swallow, and I observe him for at least 6 hours.

Camphor is a rapidly acting neurotoxin, producing both excitation and depression. As little as 1 g has produced fatality in an 18-month-old child. Major toxicity has not been associated with ingestions less than 30 mg/kg.

Since there is 4.5 g camphor per 50 ml liniment, 2.2 ml would contain approximately 200 mg camphor, or 18 mg/kg. Again, since he patient may have ingested more than one swallow, I would observe him for a least 6 hours for onset of seizure activity.

Oil of turpentine is a low-viscosity hydrocarbon that can cause significant aspiration or inhalational injury. It can also cause CNS depression. It is reassuring that the child seems to have no respiratory symptoms on presentation, but again careful observation is essential.

Menthol rarely causes significant toxicity, but can cause neurological and gastrointestinal effects.

I would expect this child to do well and be discharged home after 6 hours in the ED, but pediatric toxicology is full of unpleasant surprises. During observation, I would look for any signs of respiratory distress, coughing, wheezing, tachypnea, mental status changes, ataxia, or seizure activity.

In the States, the best resource would be the local poison control center, 1-800-222-1222.

Comment on Clinical Case 048: We Ask an Epidural Expert by martin ibach

martin ibach — Thu, 31 May 2012 03:53:56 +0000

Just got back in touch with your website – had forgotten how good it is-well done..
As I’ve been upskilling my anaesthetics in recent times I have found myself in Karratha and will be in Broome Sept/Oct.. and all tips much appreciated!
Good to hear Ketamine mentioned.. once again a potential saviour..

Comment on Clinical Case 054: Just a sip by Tim Leeuwenburg

Tim Leeuwenburg — Tue, 29 May 2012 22:20:59 +0000

OK, two days and noone has bitten

Love the classic ‘smells like a gymnasium’ comment

Camphor is hepatotoxic..but its the salicylate that worries me most.

How much has he ingested? Dunno, one hopes that evolution has equipped kids with enough nous not to gobble down nasties, but who knows for sure?

Other that WikiPedia, I’d be speakingto Poisons Info of dialling a friend. Poisons Info in my part of the world is interestin, as the freecall 1300 number is just one digit different from Pizza Express…so occcasionally urgent calls late at night for tox advice lead to rather bizarre convsations with the spotty-faced teenager answering the pizza store phone if I have mis-dialled.

Anyhow…it’s been a couple pf days? Is the kid still alive?