A 47-year-old male was admitted to the intensive care unit (ICU) following a high-speed motorcycle accident. He had a number of injuries including bilateral pneumothoraces, multiple spinal fractures, an open-book pelvis fracture, and a brachial plexus injury. Bilateral chest drains were inserted and external fixation of the pelvis was performed. The patient was extubated eventually at day 15 but required reintubation within 12 hours because of a poor cough and sputum retention
What are the indications for a tracheostomy and when shout it be considered?
A 62 year old lady with a metallic aortic valve was admitted to the cardiac unit for urgent surgical repair of a severely regurgitant mitral valve. He was normally on warfarin for his metal valve. This was stopped and unfractionated heparin commenced on day 4 once his INR level had dropped below the therapeutic range. The patient’s platelet count was 147*10^9/L on admission. By day 4 it had dropped to 85*10^9/L. After heparin was started it dropped further to a nadir of 55*10^9/L on day 8.
Could this be due to heparin induced thrombocytopenia? What investigations are required and how should we treat it? Read More »
A 54 year old man with a history of alcohol excess was admitted under the medical team with an upper gastro-intestinal bleed. He had a background of pulmonary fibrosis that limited his exercise tolerance to 30 yards. Antibiotics, terlipressin and fluid resuscitation, including blood, were given. An oesophago-gastro-duodenoscopy demonstrated severe portal gastropathy but no active bleeding or varices. An abdominal ultrasound demonstrated cirrhosis and some moderate ascites. On day two of the patient’s hospital admission he was admitted to the intensive care unit (ICU) with respiratory failure and non-invasive ventilation was started. Over the next few days his condition deteriorated and he required vasopressor support. By day 6 the patient was oliguric, and his creatinine had risen from 102 to 155 µmoles/l.
What is the cause for his acute kidney injury? Could it be hepatorenal syndrome? Read More »
A 40 year old lady was admitted under the medical team with pneumonia. She was normally well with no history of respiratory illnesses. On day two of her hospital admission she became more hypoxic necessitating continuous-positive-airway-pressure. Her condition rapidly worsened and her chest x-ray showed diffuse bilateral infiltrates. An echocardiogram demonstrated normal systolic function. She was intubated and ventilated. Despite sedation, ARDSnet ventilation, paralysis and then proning her, she remained severely hypoxaemic. A therapeutic bronchoscopy was performed prior to proning but did not improve her condition.
Should she be referred for consideration of ECMO and was is this evidence to support it’s use?
A young man is admitted to the surgical unit with several months of worsening abdominal pain. It has become much more severe over the last 24 hours. A CT scan shows evidence of acute pancreatitis with no gallstones or biliary duct dilatation.. He is normally well with no history of alcohol excess. His triglyceride level is elevated at 83.7mmol/L and a diagnosis of hypertriglyceridaemia induced acute pancreatitis is made.
What is hypertriglyceridaemia induced acute pancreatitis and how is it treated?
A patient underwent a laparotomy due to bowel perforation with peritonitis and septic shock and required ventilation for several days. He was sedated with midazolam and fentanyl. After extubation he became agitated overnight, pulled out his invasive monitoring lines and was attempting to climb out of bed.
How should his acute confusional state be managed?Read More »