TC ’ S P O T P O U R R ITHE M E ME ED I T I ON

W H AT I S A M E M E ?

F E A ST ST U DY

• I’ve mentioned it before• Essentially found shocked

septic kids in Africa did worse with fluid boluses over maintenance fluid

• Comment from the floor was “yeah but they’ll all have malaria and the fluid will make their cerebral oedema worse”

• Fair enough

SH UT U P F E R G I E

• The non-anaemic and non-malaria patients were analysed

• Found to have the same poor outcomes with fluid boluses over maintenance fluids as the anaemia and malaria kids

• Regardless of whether albumin or crystalloids given

SG A R BO S S A C R I T E R I A

• Smith modified Sgarbossa rule:

• At least one lead with concordant STE (Sgarbossa criterion 1) or

• At least one lead of V1-V3 with concordant ST depression (Sgarbossa criterion 2) or

• Proportionally excessively discordant ST elevation in V1-V4, as defined by an ST/S ratio of equal to or more than 0.20 and at least 2 mm of STE. (this replaces Sgarbossa criterion 3 which uses an absolute of 5mm)

SE V E R E C U TA N E O U S A DV E R SE R E AC T I O N S• Drug hypersensitivity syndrome is the same as DRESS

• SJS/TEN

• Acute generalised exanthematous pustulosis (AGEP)

• drug induced erythroderma

• Severe, unexpected reaction to a medicine(s)

• high fever, a morbilliform skin rash

• inflammation of one or more internal organs including the liver, kidneys, lungs and/or heart

• It generally starts two to eight weeks after taking the responsible medicine.

C U L PR I T S

• Allopurinol

• AEDs esp. carbamazepine, phenobarbitol, phenytoin

• Sulfonamides

• But really anything

M E A C U L PA

wire left in

Individual Factors

Patient Factors

Task Factors

Education and

Training

Team and

Social Factors

Working Condition

s

Equipment and

resourcesCommunication

Organisational and

strategic Factors

CH O I CE S RANK RATE18 G I VC 8 . 5F R R I C 00 : 46

6F R SH EATH 7F R R I C 1 : 008 . 5F R R I C 8 . 5F R S HE ATH 1 : 05

14G LU MEN CVC 14G I VC 1 : 307F R R I C 6F R S HE ATH 2 : 1016 G I VC 14G 13 .3 CM I VC 2 : 1020 G I VC 16G I VC 2 : 2014 G I VC 18G I VC 4 : 23

8 . 5F R SH EATH 14 G LU MEN CVC 5 : 2014G 13 .3 CM I VC 20G I VC 6 : 47

C O U N T RY W E E K

• 13yo playing football, someone stepped on his foot while trying to spin round

• pain

T I LL A U X F RAC T U R E

• Salter Harris III distal tibia epiphysis

• Caused by an avulsion of the anterior inferior tibiofibular ligament

• Mechanism of injury is thought to be due to an external rotation force

• 12-14yo

• A period of time exists when the lateral physis is the only portion not fused

• An additional fracture in the posterior distal tibial metaphysis in the coronal plane would result in a…?

BA R BA RA

• 70yo lady

• sore right knee

• normal XR with GP

• moderate effusion, ROM ~70º

• No PMHx

P L A N ?

WH AT A RE YOU LOO K I NG FOR I N T HE SYN OV I AL FLU I D?

C O U R S E

• D/C with NSAIDS and Dx with pseudogout

• Recalled 2 days later after bacteria grown

• Sent home by ED as patient feeling ok

• No bloods done

• Back 5 days after initial presentation with obvious septic joint

• Unwitnessed arrest

• Initial non-VF Rhythm

• Lack of bystander CPR

• >30 min to ROSC

• >30 min of CPR

• Evidence of unresponsive hypoperfusion and microcirculatory failure:

• pH <7.2 and Lactate >7

• Age >85

• End-Stage Renal Disease (ESRD

• Non-Cardiac Causes: Cardiac arrest due to drugs, drowning, acute stroke, terminal cancer and trauma, just to name a few non-cardiac causes, are likely to result in poor outcomes post-resuscitation.

Unfavourable for Cath

AVO I D

• All STEMI criteria patients

• excluded if sats <94%

• There was an increase in the rate of recurrent myocardial infarction in the oxygen group compared with the no oxygen group (5.5% versus 0.9%; P=0.006)

• An increase in frequency of cardiac arrhythmia (40.4% versus 31.4%; P=0.05).

• At 6 months, the oxygen group had an increase in myocardial infarct size on cardiac magnetic resonance (n=139; 20.3 versus 13.1 g; P=0.04).

PLU G F O R A C H A R I TY

• I’ve belonged for ~5years

• “Medics Beyond Medicine”

• For doctors who want to connect with people with mental and physical disabilities rather than just see them in a clinical setting

• Generally revolves around outings

• Recently featured on channel 9 news

• Emma and Dave volunteered their time

• “Daniel” here has myotonic dystrophy as seen by the tell tale baldness pattern

• “Chris” has a rare chromosomal abnormality that means he has a compulsion to wear a cap in an inappropriate setting

AG E A D J US T E D D - D I M E R

• Wells score ≤4

• Age ✷ D-dimer (0.01mg/L)

• ie a 70yo will have an acceptable D-dimer <0.7mg/L

• Validated in multiple studies

• I think we should use it

C E N TO R• History of fever• Tonsillar exudates• Tender anterior cervical adenopathy• Absence of cough• The Modified Centor Criteria add the patient's age to

the criteria• Age <15 add 1 point• Age >44 subtract 1 point• -1, 0 or 1 points - No antibiotic or throat culture

necessary (Risk of strep. infection <10%)• 2 or 3 points - Should receive a throat culture and treat

with an antibiotic if culture is positive (Risk of strep. infection 32% if 3 criteria, 15% if 2)

• 4 or 5 points - Treat empirically with an antibiotic (Risk of strep. infection 56%)

• The presence of all four variables indicates a 40 - 60% positive predictive value for a culture of the throat to test positive for Group A Streptococcus bacteria. The absence of all four variables indicates a negative predictive value of greater than 80%

W H AT A N T I B I O T I C

• Phenoxymethylpenicllin

• Cheap, proven

• Never been a resistant GABHS to penicillin

• Good anaerobic cover just in case the patient has…

F U S O B AC T E R I U M N E C R O P H O NU M

• lemierre’s syndrome

• Thrombus of the internal jugular

• Sepsis

• Mortality of ~5%

• Not sensitive to macrolides