Archives for September 2012

Conservatism Fails.

Had this patient through our department recently. Nice old bloke who fell at home onto a concrete step. Impact to left chest wall, mid axillary line.

He was sore but otherwise well, P 60 stats 98% RR 14 no other concerns, abdo SNT

Played with USS got my stratosphere on.

CXR for “size” which showed small pneumothorax, rib fractures. 

No Signifigant past medical history, never smoked or any occupation exposures.

Plan was conservative management, analgesia and to return if any concerns.

 Patient returned 2 days later with exertional dyspnoea, everything a bit harder to do around home.

Obs wise had RR 18 Sats were around 94% P 66

Examining him showed impressive subcutaneous emphysema, best I have ever seen outside of post op patients.

Repeat CXR showed the s/c emphysema and increase in size of pneumo. It is a bit harder to see as s/c emphysema on anterior chest gives an impression of lung markings.

CT scan was done after discussion with surgical colleagues. Wanted to better assess the size of the pneumothorax and rule out any other pathology.

I was impressed at how extensive the pneumothorax and s/c emphysema was. 

 So patient got his chest drain and was parked on the ward for a day. Then on his way.

Reflective stuff below:

So I was looking around at information on conservative management of traumatic pneumothorax and there is not really much evidence. (someone prove me wrong)

I’m just new at this game but it seems most opt for conservative management with majority of pneumothorasces. Provided they do not cause compromise and are “small” but it seems a little hazy. Some folks I have worked with like to do a needle drainage, feeling that it will reduce the morbidity.

So would you have imaged further earlier? would you have drained/needled him earlier?

Best reference I could find: http://www.bestbets.org/bets/bet.php?id=104

Where is that needle? Are you sure?

Saw this bloke about a month ago now.

Patient was brought into ED by a radiologist and nurse.

He was having an ultrasound guided hydrodilitation of his Left shoulder for adhesive capsulitis.

Radologist injected 20ml of ropivicaine within 30 seconds the patient complained of his tongue feeling numb. He then had difficulty speaking, by this time he was on a wheelchair and on his way to ED. Reports from both his wife and himself after was that he had dysarthria and no receptive or expressive dysphasia. He proceeded to have shaking and jerking of his arms and legs and decreased level of conciousness. no tongue biting or incontinence. no chest pain or palpitations (pt thinks)

So he was improved slightly by the time he got to ED GCS 14-15. speaking clearly but feeling “off” no focal deficits to be found.

Airway was good, Breathing fine, IV access gained whilst ECG taken which showed a sinus bradycardia without any specific conduction blocks. Had intralipid ready but didnt give as sx improving.
Within futher 5 minutes patient was completely normal again, he made his way home. but didnt feel that the procedure helped his shoulder pain except for the time he was “thinking he might die” when his shoulder wasnt such a worry.

So patient likely had LAST,
I had not seen it before and thought might share this.
Some changes from the case and discussion after, the MSK rad guys do their injections in clinic rooms by ED not at other end of hosp.

Ropivicaine. Intra-articular inj: 150 mg (7.5 mg/ml soln)

So a bit about Local Anestetic Systemic Toxicity:

The classic description of LAST includes subjective symptoms of CNS excitement such as auditory changes, circumoral numbness, metallic taste, and agitation that then progress to seizures and/or CNS depression (coma, respiratory arrest). In classic descriptions of LAST, cardiac toxicity does not occur without preceding CNS toxicity.

Futher Reading, its a good overview ect.

http://journals.lww.com/rapm/Fulltext/2010/03000/ASRA_Practice_Advisory_on_Local_Anesthetic.7.aspx

Bad things come in Plain packages?

I don’t know how much its been in the media outside of our little corner of the world but New Zealand and Australia are currently in a humdinger of a fight with the global tobacco giants. what about I hear you say?

Plain packaging like these below.

I’m not talking about the warning labels, we have had those for years. I mean the fact the only way to known brand and type/variant is that little one line of text. This was first suggested in NZ by the Department of Health’s Toxic Substances Board (great name) in 1989 but the real push has been a government goal to have NZ smoke free by 2025! We have no displays in shops, No Advertising, No sponsorship, No smoking in bars and restaurants. These all happened with minimal fight from the tobacco companies but they are getting riled up with this one.

The discussion is this. Is New Zealand by pushing for plain packaging impinging on the intellectual rights of tobacco companies? If so it is warranted in the public interest?

British and American Tobacco and others are pushing their message with a campaign see below.

http://www.batnz.com/group/sites/BAT_5LPJ9K.nsf/vwPagesWebLive/DO8TX6FE?opendocument&SKN=1

BAT are pushing a campaign that the changes will make no difference to smoking rates quoting their own studies and ignoring others.

The crux is that it has not been trialed anywhere in the world. Anyways its an interesting public health stoush and ill keep you posted =)