1. TCS POTPOURRI CASES, PEARLS AND ONE VERY LONELY CAT 2. PEEP VALVES STILL AWESOME BUT ONE PITFALL 3. Case 83yo male from home Brought in by daughter apparently delirious Past few days 4. PMHx Osteoarthritis HTN Hypercholesterolaemia Glaucoma Prostate ca - radical prostatectomy years ago Recurrent lower limb cellulitis presumed secondary to poor venous return Mild heart failure 5. O/E Delirious HR 123 regular, BP 110/75, sats 96% RA, RR 28 Chest - very minor creeps both bases HSDNA Minor pitting oedema to both lower limbs Some cellulitis to both lower limbs but minor 6. Workup? Who did a gas? VBG pH 7.12 pCO2 35 O2 67 HCO3- 14 Na+ 141 K+ 4.2 Cl- 105 Ca2+ 1.15 BSL 8.3 Lactate 1.5 Cr 153 Hb 143 7. Go! Metabolic Acidosis Anion Gap = 22 HAGMA Compensated (it is a VBG after all) acute comp expected pCO2 is 29 Delta ratio = 1 Therefore VBG pH 7.12 pCO2 35 O2 67 HCO3- 14 Na+ 141 K+ 4.2 Cl- 105 Ca2+ 1.15 BSL 8.3 Lactate 1.5 Cr 153 Hb 143 8. Uncomplicated HAGMA LTKR, CATMUDPILES You can ask more history if you want 9. Pyroglutamic acidosis Concurrent paracetamol and flucloxacillin Accumulation of pyroglutamic acid in glutathione depleted states HAGMA of exclusion 10. ABG pH 7.4 pCO2 40 pO2 95 HCO3- 22 Na+ 135 K+ 5.0 Cl- 100 lactate 1.0 11. real name is Hakan Lonecat Yaman 12. Closed Loop Communication Were gonna make it work this time people 13. Vertigo 14. Vertigo Great Article CMAJ 2011 on Acute Vestibular Syndrome Most elements of the Hx and exam are crap in determining whether peripheral or central AVS = symptoms for 24/24 and no focal neuro Frighteningly, the authors report many of the signs and symptoms (type of dizziness, hearing loss, patterns of nystagmus, Hallpike-Dix) are not as predictive as we classically are taught 15. Better than a diffusion weighted MRI at diagnosing posterior stroke Do the horizontal head impulse test. (Normal = central cause) Check for directionally-alternating nystagmus movement on left and right gaze. Do the alternate cover test. 16. HiNTs 4 step procedural teaching watch me watch me while i explain tell me what to do you do it and tell me what you're doing 17. MCA CVA either tPA or tPA + retrieval mRS 0-2 (functional dependence) at 90 days was 60% vs 35% No sig difference in 90 day mortality or intracranial bleed Why bother with tPA at all? 18. However REVASCAT demonstrated an impressive 4.8% absolute increase in the rate of death within the first 7 days after randomization Did not use perfusion imaging like other trials but relied on non-con CTs and CTA Is it ethical for tPA to be given after hours; given that none of the imaging modalities used in these studies are available? 19. Schatzker Schatzker I: fracture of the lateral tibial plateau Schatzker II: split and depression of the lateral tibial plateau, type I fracture with a depressed component Schatzker III: pure depression of the lateral tibial plateau Schatzker IV: medial tibial plateau Schatzker V: involving both tibial plateau Schatzker VI: fracture through the metadiaphysis of the tibia and both medial and lateral plateau 20. 4 21. 1 22. 5 23. 6 24. 3 25. 2 26. Gustillo Anderson Type 1 - wound 10cm 3A - adequate tissue for coverage 3B - requires free soft tissue transfer 3C - vascular injury 27. 2 28. 3B 29. 1 30. 3C 31. 3A 32. Eligible had SBP 70 or a palpable radial pulse Protocols were continued until haemorrhage control or 2 hours post arrival to hospital Study group received 1L less on average Significant reduction in blunt trauma mortality at 24 hours 3% vs 18% 33. ARVD 34. To determine the incidence of clinically relevant adverse cardiac events in patients hospitalised for chest pain with 2 troponin-negative findings, non- concerning initial ED vital signs, and non- ischaemic, interpretable electrocardiographic findings. 11,230 met inclusion criteria 35. After excluding patients with abnormal vital signs, electrocardiographic ischaemia, left bundle branch block, or a pacemaker rhythm, a primary end point event was identified in 4 of 7266 patients (0.06% [95% CI, 0.02%-0.14%]). Of these events, 2 were non-cardiac and 2 were possibly iatrogenic. 36. HHS vs DKA its a spectrum often mixed