Category: Basic Sciences

Hypertriglyceridaemia Induced Acute Pancreatitis

Hypertriglyceridaemia Induced Acute Pancreatitis

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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?

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Mannitol and Sodium Bicarbonate in Rhabdomyolysis

Mannitol and Sodium Bicarbonate in Rhabdomyolysis

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A patient with polytrauma develops compartment syndrome with an ischaemic leg 24hrs into his admission. He undergoes revascularisation and fasciotomies, but develops rhabdomyolysis and acute kidney injury with a CK that peaks at over 100,000.

Is there a role for mannitol and bicarbonate in the management of his rhabdomyolysis and AKI?Read More »

Pentoxifylline in Alcoholic Hepatitis

Pentoxifylline in Alcoholic Hepatitis

ICM Case Summaries1 Comment

A 28 year old male presented to the Emergency Department with an upper gastrointestinal bleed. This was managed  with resuscitation and endoscopic diathermy and adrenaline injection This was his first presentation to secondary care with complications from his significant alcohol intake. He reported drinking at least 50 units of alcohol per week. Ultrasound examination demonstrated an enlarged liver with changes consistent with steatosis. On day 3 of his admission, he became tachycardic, tachypnoeic and increasingly lethargic. Examination revealed jaundice, bi-basal lung crepitations and mild confusion. Investigation confirmed an acute hepatitis by blood chemistry and repeat ultrasound. In the absence of any other cause, a diagnosis of acute alcoholic hepatitis was considered.

In patients with acute alcoholic hepatitis, does pentoxifylline reduce mortality?Read More »

Decompressive Laparotomy in Abdominal Compartment Syndrome

Decompressive Laparotomy in Abdominal Compartment Syndrome

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A 55 yr old man developed severe necrotizing pancreatitis with multiorgan failure. One week into his illness he had developed multiple intra-abdominal collections and had high intra-abdominal pressures. Initial conservative management failed, percutaneous drainage of his collections failed to reduce the abdominal pressures, and he underwent decompressive laparotomy.

What is the evidence behind the current guidelines for the measurement of intra-abdominal hypertension and the use of decompressive laparotomy in the management of Abdominal Compartment Syndrome?Read More »

Statins for Subarachnoid Haemorrhage

Statins for Subarachnoid Haemorrhage

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A 63 yr old woman collapsed at home and was brought into ED with a GCS of 3/15. She was a known hypertensive and hypercholesterolaemic. CT scan revealed a Fisher grade 3 subarachnoid haemorrhage. A ruptured middle cerebral artery was secured 24 hours later. She extubated on day 3 with a GCS of 13, but dropped her GCS to 10 on day 5 and was treated for vasospasm, which included continuing the nimodipine and simvastatin from her admission.

What is the evidence for ‘statins’ for the prevention of Vasospasm in Aneurysmal Subarachnoid Haemorrhage?Read More »

Sodium Bicarbonate in Amitriptyline Overdose

Sodium Bicarbonate in Amitriptyline Overdose

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A 40 year old man with pre-existing mental health problems presented after an overdose of 6g of amitriptyline. He was deeply unconscious and required invasive ventilation. He was commenced on bicarbonate therapy and hyperventilated to pH 7.5. Around 12 hours after admission he developed tonic-clonic seizures, a broad complex tachycardia and subsequently suffered a cardiac arrest that was refractory to defibrillation, adrenaline and amiodarone. He was given additional 8.4% bicarbonate and further defibrillation attempts and was successfully resuscitated after 90 minutes.

What is the rationale for the use of sodium bicarbonate in the management of amitriptyline overdose?Read More »

Tranexamic Acid in Trauma

Tranexamic Acid in Trauma

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A 19 year old man experienced a head on collision as the driver of a car. He suffered significant lower limb open fractures, pelvic fractures, lung injuries and a small subarachnoid bleed. Initial management was performed in ED and included oxygen, IV access and fluid, lower limb and spine immobilisation, and analgesia. He underwent a trauma series CT scan, which identified the various injuries given above. At no point was his level of consciousness a concern, and he maintained his own patent airway throughout. He did not show signs of haemodynamic instability or evidence of life threatening haemorrhage. Tranexamic acid (TXA) was not given.

What is the evidence for using tranexamic acid in trauma?

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Botulism

Botulism

ICM Case Summaries1 Comment

A young female IV drug abuser presented with dysarthria, diplopia and weakness with loss of her gag reflex. She had recently had an abscess wound on her arm debrided. She was intubated for airway protection, and underwent early tracheostomy. She was treated with intravenous antibiotics and botulism antitoxin after electromyography and nerve conduction studies were consistent with a diagnosis of botulism. She was weaned from the ventilator within 2 weeks and the Health Protection Agency later confirmed the presence of botulism neurotoxin A from wound swabs.

What are the clinical features of Botulism and how is it managed?Read More »

Loop Diuretics in Acute Kidney Injury

Loop Diuretics in Acute Kidney Injury

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A 65 year old woman underwent an elective mitral valve repair (MVR) and four vessel coronary artery bypass graft (CABG) procedure. Pre-operatively she was diagnosed with chronic kidney disease (CKD) secondary to hypertensive nephropathy, and chronic airway disease secondary to smoking. Her baseline creatinine was 275. Surgery was uneventful but in the post-operatively period she developed pulmonary oedema and worsening acute kidney injury (AKI). On day 2 her creatinine reached 420 and oliguria occurred (urine output < 0.5 ml kg-1 hr-1). Non-invasive respiratory ventilation provided adequate support and maintained a normal blood PaCO2 and pH, although her base excess drifted to -7 mmol l-1.Dopamine was administered at 2–10 μg kg-1 min-1, titrated to MAP ≧ 75 mmHg; pericardial pacing continued to maintain sinus rhythm at 60 bpm; her CVP was 14 mmHg and stable. Furosemide was started and given by a continuous infusion of 10 mg hr-1 after an initial bolus of 100 mg to try and help with diuresis.

Is there any evidence to support the use of loop diuretics in acute kidney injury?

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Tranexamic acid and rFVIIa in Major Obstetric Haemorrhage

Tranexamic acid and rFVIIa in Major Obstetric Haemorrhage

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A 40yr old multiparous woman required an emergency Caesarean section, during which she had a 3.5L blood loss requiring a B-Lynch suture, a Rusch balloon and 4 units of packed red cells. She suffered a further 1.5L postpartum vaginal bleed, returned to theatre and underwent a subtotal hysterectomy during which she received a massive transfusion. Postoperatively, she had a further 1.5L bleed and had a Rusch balloon reinserted. She was given recombinant Factor VIIa and regular tranexamic acid. Haemostasis was achieved and she left hospital with her healthy baby boy 8 days later.

What is the evidence for using recombinant FVIIa and antifibrinolytics in major obstetric haemorrhage?Read More »