Dr Peter Cheng Regional 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 idiopathic 98% minimal change disease Edema often starts periorbitally NORMAL 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 edema Hypoalbuminemia < 25 Answer:NEPHROTICSYNDROME

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 clip £ 4.13 ebay AUD 2cents !!

Tricks of the Trade - The Wooden Tongue Depressor: A Multiuse Tool for the EP

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?

Take 2 dry cotton buds Take 2 dry cotton buds Apply tip as close as possible to eyelashes Apply tip as close as possible to eyelashes Roll tip along contour of globe Roll tip along contour of globe Tip should finish up semi-buried in socket above and below eye Tip should finish up semi-buried in socket above and below eye Maintain gentle downward pressure 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 scalpel Split open 8.0 ETT with scalpel Apply lube Apply lube Put down split ETT behind the existing ETT (intubate esophagus) Put down split ETT behind the existing ETT (intubate esophagus) Insert NGT through 2 nd ETT Insert NGT through 2 nd ETT Peel ETT away from NGT Peel 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 refer BCMJ, Vol. 51, No. 1, January, February 2009, page(s) Articles

Ask : 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%) Complications (15-70%) Trauma eg. TM perforation, canal lac, ossicle fracture Trauma eg. TM perforation, canal lac, ossicle fracture Major Cx : hearing loss, vertigo, meningitis, facial n paralysis 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 ?  Bribe him with candy (sucrose)  Threaten him with a catheter  Tickle his genitals  Give him a Balinese massage

Preparation Gentle tapping of suprapubic area 100/min for 30 secs Light circular massage of lumbar paravertebral area for 30 secs Wee in a jiffy! Feed beforehand Sucrose Undress and wash area Give him a massage!

Herreros 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 Single centre, neonatal unit, n=80, 30 days old 86.3% of infants wee < 5mins 86.3% of infants wee < 5mins Median time to wee = 45s Median time to wee = 45s Safe Safe Controlled crying Controlled crying Choose the right patient (not shocked or toxic, not delay treatment) Choose the right patient (not shocked or toxic, not delay treatment) Arch Dis Child 2013 Jan; 98(1): 27-9

Problem: It’s my 14 th 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 ?

Diagnostic accuracy of conventional or age adjusted D-dimer cut-off values in older patients with suspected venous thromboembolism: systematic review and meta-analysis 13 cohorts, patients, non-high PTP 13 cohorts, patients, non-high PTP Age-adjusted cutoff = Age x 10 Age-adjusted cutoff = Age x 10 Increases specificity by 10-20% (increasing with age) Increases specificity by 10-20% (increasing with age) Acceptable reduction of sensitivity to 97% Acceptable reduction of sensitivity to 97% PPV 21% (1 in 5) PPV 21% (1 in 5) Reduction in up to 30-50% imaging! Reduction in up to 30-50% imaging! BMJ 2013;346:f2492

No standard reference No standard reference 2 types of units 2 types of units DDU = D-dimer units DDU = D-dimer units FEU = Fibrinogen Equivalent units FEU = Fibrinogen Equivalent units Local lab variation in conversion factors Local lab variation in conversion factors Microg/ml, nanog/ml, mg/L, etc. Microg/ml, nanog/ml, mg/L, etc. Will need system wide change 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?

Hx prolonged persistent dizziness Hx prolonged persistent dizziness Multi-directional Multi-directional Non-fatigueing Non-fatigueing Brainstem ADEM on spinal cord MRI (normal CTB/MRI brain)

1.No gel ? Chlorhexidine Chlorhexidine H20 H20 2.Superficial FB ? Increased distance Increased distance Pt comfort Pt comfort Lots of lube No pressure Adjust gain Angle probe Images from : academiclifeinem.blogspot.com.au 3. LOV ?

RETINAL DETACHMENT ( GAIN DOWN ) VITREOUS HAEMORRHAGE ( GAIN UP )

Mike Malin & Matt Dawson et al 1-minute Ultrasound Iphone app Procedural videos : 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 key 2% lignocaine Deepest part of sulcus just above tooth From canine to canine Upper and lower Mucosal block : 2ml – volume is key 2% lignocaine Deepest part of sulcus just above tooth From canine to canine Upper and lower

TraumaDeciduousInterfering biteExtract Non interfering bite LeavePermanentFracturedSealAvulsed Re-implant or store and refer Inwards>18yo >3mm Reposition and splint <18yo <7mmLeave Outwards or sideways Reposition if mobile or interfering

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- Mel Herbert