small things, BIG difference

1. small things, BIG difference Dr Peter Cheng Regional Forum June 2013

2. Problem : A 4yo presents with bilateral swollen eyelids with normal eye, not itchy, afebrile. What could this be and what test should I perform ?

3. To my surprise, I find: 3+ proteinuria Answer: NEPHROTIC SYNDROME Dependent edema Hypoalbuminemia < 25 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

4. 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?

6. Epistaxis nose clip http://www.ennovations.co.uk £ 4.13 ebay AUD 2cents !!

7. Tricks of the Trade - The Wooden Tongue Depressor: A Multiuse Tool for the EP http://www.acep.org

8. 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?

9. The earlier the easier Take 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

11. 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 ??

12. Split open 8.0 ETT with scalpel Apply lube Put down split ETT behind the existing ETT (intubate esophagus) Insert NGT through 2nd ETT Peel ETT away from NGT

13. 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 ?

14. 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) 20-24 Articles

15. If it’s a pebble, DON’T DO IT! • Ask : • Do I have a cooperative patient? • Is medial or lateral? • Can I grab it? • 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

16. 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

17. Feed beforehand Sucrose Undress and wash area Give him a massage!

18. Noninvasive bladder stimulation 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 • 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

19. 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 ?

20. Age-adjusted D-dimer 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, 12497 patients, non-high PTP • Age-adjusted cutoff = Age x 10 • Increases 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

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

22. 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?

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

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

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

27. US websites http://www.ultrasoundpodcast.com Mike Malin & Matt Dawson et al 1-minute Ultrasound Iphone app Procedural videos : http://www.sonospot.com Free echo videos :

28. Mucosal block : 2ml – volume is key 2% lignocaine Deepest part of sulcus just above tooth From canine to canine Upper and lower 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?

29. Dental trauma

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

31. Docscan

32. “ what you do matters ” - Mel Herbert