small things, BIG

differenceDr Peter ChengRegional Forum

June 2013

Problem : A 4yo presents with bilateral swollen eyelids with normal eye, not itchy, afebrile.

What could this be and what test should I perform ?

Usually idiopathic98% minimal change diseaseEdema often starts periorbitallyNORMAL renal f(x)Highly treatable – corticosteroid 3mth / salt and fluid R /20% alb (occ.)Cx - thrombosis / sepsis

To my surprise, I find: 3+ proteinuria

Dependent edemaHypoalbuminemia < 25

Answer:NEPHROTIC SYNDROME

Problem : It’s a busy Saturday night and a 70yo man is bleeding profusely from his nose despite pinching his nose for 20mins. I return to find him in a panic and vomiting everywhere with nobody to clean up the mess.

What could I have done to avoid this scenario?

Epistaxis nose cliphttp://www.ennovations.co.uk

£ 4.13ebay

AUD 2cents !!

Tricks of the Trade - The Wooden TongueDepressor: A Multiuse Tool for the EPhttp://www.acep.org

Problem : I examine a 40yo who was assaulted and has significant periorbital bruising. I am concerned about eye trauma but am unable to open his eyes with my fingers.

What do I reach for?

The earlier the easierTake 2 dry cotton

buds Apply tip as close as

possible to eyelashes

Roll tip along contour of globe

Tip should finish up semi-buried in socket above and below eye

Maintain gentle downward pressure

Problem : I have just intubated a sick asthmatic and she’s getting hard to ventilate from all the air in her stomach blowing up right in front of me. My best NG insertion skills have failed me, what do I do ??

Split open 8.0 ETT with scalpelApply lube Put down split ETT behind the existing

ETT (intubate esophagus) Insert NGT through 2nd ETTPeel ETT away from NGT

Problem : A 6yo girl has a pebble in her L ear. During the procedure, she wriggles about and the pebble is pushed further in. Her mother asks if it is easier that I put her to sleep.

What are my chances of success ?

Removal of ear canal foreign bodies in children: What can go wrong and when to referBCMJ, Vol. 51, No. 1, January, February 2009, page(s) 20-24 Articles

Ask :1. Do I have a cooperative patient?2. Is medial or lateral?3. Can I grab it? 4. Can I get behind it?

Complications (15-70%)Trauma eg. TM perforation, canal lac, ossicle

fracture

Major Cx : hearing loss, vertigo, meningitis, facial n paralysis

If it’s a pebble, DON’T DO IT!

Problem : A febrile 4 week old presents with fever and lethargy. You drip the child but there’s still no sign of wee. You dread the thought of an in-out catheter. How do I make the child wee ?

a) Bribe him with candy (sucrose)

b) Threaten him with a catheter

c) Tickle his genitals

d) Give him a Balinese massage

PreparationGentle tapping of suprapubic area 100/min for 30

secs

Light circular massage of

lumbar paravertebral

area for 30 secs

Wee in a jiffy!

Feed beforehandSucroseUndress and wash area

Give him a massage!

Noninvasive bladder stimulationHerreros Fernandez ML et al. A new

technique for fast and safe collection of urine in newborns.

Single centre, neonatal unit, n=80, 30 days old 86.3% of infants wee < 5mins Median time to wee = 45s Safe Controlled crying Choose the right patient (not shocked or toxic,

not delay treatment)

Arch Dis Child 2013 Jan; 98(1): 27-9

Problem: It’s my 14th patient on the short stay round who is 80yo man with pleuritic CP, mild hemoptysis, ex-smoker but currently asymptomatic. His CXR is normal but his D-dimer is elevated at 700 (N=500ηg/L) without an obvious cause.

What is his risk of PE ?

Age-adjusted D-dimerDiagnostic accuracy of conventional or

age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis13 cohorts, 12497 patients, non-high PTPAge-adjusted cutoff = Age x 10Increases specificity by 10-20% (increasing

with age)Acceptable reduction of sensitivity to 97%PPV 21% (1 in 5)Reduction in up to 30-50% imaging!BMJ 2013;346:f2492

No standard reference 2 types of units

DDU = D-dimer unitsFEU = Fibrinogen Equivalent units

Local lab variation in conversion factorsMicrog/ml, nanog/ml, mg/L, etc.Will need system wide change

Problem : A 22yo woman presents with dizziness, vomiting and fatigue. You find nystagmus where the fast beating component is to the left on leftward gaze and to the right on rightward gaze.

Is this peripheral vertigo?

Nystagmus redflagsHx prolonged persistent dizzinessMulti-directionalNon-fatigueing

Brainstem ADEM on spinal cord MRI (normal CTB/MRI brain)

US tips1. No gel ?

Chlorhexidine H20

2. Superficial FB ?Increased distance Pt comfort

Lots of lube

No pressure

Adjust gainAngle

probe

Images from : academiclifeinem.blogspot.com.au

3. LOV ?

RETINAL DETACHMENT( GAIN DOWN )

VITREOUS HAEMORRHAGE( GAIN UP )

US websiteshttp://www.ultrasoundpodcast.com

Mike Malin & Matt Dawson et al1-minute Ultrasound Iphone app

Procedural videos : http://www.sonospot.com

Free echo videos :

Problem : A man presents to ED in agony from a painful tooth and seeks your expert treatment. You are reminded again why you changed from dentistry to medicine, which isn’t helping. What do you do?

Mucosal block :2ml – volume is key2% lignocaineDeepest part of sulcus just above toothFrom canine to canine Upper and lower

Dental trauma

Trauma

Deciduous

Interfering bite Extract

Non interfering

biteLeave

Permanent

Fractured Seal

AvulsedRe-implant

or store and refer

Inwards

>18yo >3mm

Reposition and splint

<18yo <7mm Leave

Outwards or sideways

Reposition if mobile or interfering

Simulation Monitor

http://www.youtube.com/watch feature=player_embedded&v=rrcYjyM2gvA

Docscan

“ what you do matters ”- Mel Herbert