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 ?
To my surprise, I find:
Answer:
NEPHROTIC
SYNDROME
3+ proteinuria
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
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
http://www.ennovations.co.uk
ebay
£ 4.13
AUD 2cents !!
Tricks of the Trade - The Wooden
Tongue
Depressor: A Multiuse Tool for the EP
http://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?
 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
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
 Apply lube
 Put down split ETT behind the existing ETT
(intubate esophagus)
 Insert NGT through 2nd ETT
 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) 20-24 Articles
 Ask :
1.
2.
3.
4.
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
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
Preparation
Feed beforehand
Sucrose
Undress and wash area
Give him
a
massage!
Gentle tapping of
suprapubic area
100/min for 30 secs
Light circular
massage of lumbar
paravertebral area
for 30 secs
Wee in a jiffy!
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
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 ?
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
 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
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
 Multi-directional
 Non-fatigueing
Brainstem ADEM on spinal cord MRI
(normal CTB/MRI brain)
1. No gel ?


Chlorhexidine
H20
2. Superficial FB ?
 Increased distance
 Pt comfort
3. LOV ?
Lots of lube
No pressure
Adjust gain
Angle probe
Images from : academiclifeinem.blogspot.com.au
RETINAL DETACHMENTVITREOUS HAEMORRHAGE
( GAIN DOWN )
( GAIN UP )
http://www.ultrasoundpodcast.com
Mike Malin & Matt Dawson et al
1-minute Ultrasound Iphone app
Procedural videos :
Free echo videos :
http://www.sonospot.com
Problem : A man presents to ED in agony from
a painful tooth and seeks your expert
treatment. You are reminded again why you
Mucosal block :
changed from dentistry to medicine, which
2ml – volume is key
isn’t helping. What do you do?
2% lignocaine
Deepest part of
sulcus just above
tooth
From canine to
canine
Upper and lower
Interfering bite
Extract
Non interfering
bite
Leave
Fractured
Seal
Avulsed
Re-implant or
store and refer
Deciduous
Trauma
Permanent
>18yo >3mm
Reposition
and splint
<18yo <7mm
Leave
Inwards
Outwards or
sideways
Reposition if
mobile or
interfering
http://www.youtube.com/watch
feature=player_embedded&v=rrcYjyM2gvA
- Mel Herbert