Tag: toxicology

Sep 4 2019: St Vincent’s regional teaching

Regional teaching -ST vincents Hospital 4/9/19 with thanks to Dr Rasanga Peiris

It was interactive scenarios with small group discussions. These were the answers we came up with & there may be more correct answers

  1. Disaster management

There was a rail track accident at Parliament station and AV calls on a Wednesday Morning. ED is full.

Preparation broadly categorise to :          Stuff                     Space                    Staff


Vacate resuscitation for critical pts – send people to ward, discharge lounge, home.

Expect minor traumas and walk-ins – designated fast track area


Inform relevant disciplines, Director. Activate code brown.

Theatre – cancel the electives                    Inform blood blank and Radiology

Delegate staff –set teams in each bay. One Ed consultant/ reg to the triage.


Source Ventilators, plasters, IV poles, Dressing/trauma packs.

Need extra drugs ( Iv morphine, fentanyl, cefazolin , fluids, inotropes)



50 Y M vomiting, SOB, Blurring of vision and chest pain. Etoh ++ last night

Obs -PR 110 RR 28   BP  130-90   spo2 97%   GCs 14 drowsy with slurred speech

pH7.21                  HC03  10               pCO2    18            glucose  7            urea 15

sodium 145         K   4.5                   Cl 105                    Lactate 5              OSm 335

Breath alcohol 0.01%

Agent – likely a toxic alchol – HAGMA + increase OSmolar gap + low alcohol levels

*oral & IV alcohol             * Iv sodium bicarbonate                               *formipazole                     * Iv fluids


Young girl ingested Amyl nitrate a night club instead of sniffing it. She presented with SOB + hypoxia.

Her blood gas was given & had a methaemoglobin level of 38%

* O2 via venture               *Methelene blue


A young male has tachycardia with hyperthermia with exaggerated reflexes and a clonus : Serotonin syndrome

*cooling active (cold fluids & bladder irrigation ) & passive (Ice packs around the body with a body bag )

*benzodiazepines                           *cyproheptadine


Echo: Fluid responsiveness during shock

LVOT VTI (Velocity time integral) normal 15-20cm  – better determinant of fluid responsiveness rather than EF

*VTI is based on LVOT stroke volume                    * gives a quantitative measure

  • Apical 5 chamber view
  • Get a doppler graph (PW) of the LVOT -draw and get the height of the blood column
  • Get someone to raise leg to increase the venous return & repeat VTI – if VTI increases : fluid responsive


Shoulder reduction techniques:

Explain the pt the option of using each technique and it’s ok to expect to transition to using sedation if the shoulder is still not in. You need compliant pts. Fractured NOH cannot be reduced without surgery.

Cunningham https://litfl.com/cunningham-shoulder-technique/

  • Best for when humeral head is up under acromium and biceps is causing tension aim to massage biceps. Relax pt and bring shoulder blades back to open joint
  • Pt is usually holding arm flexed to body.

Kocker’s method https://www.youtube.com/watch?v=2wiIlT6_YLM

  • Best when humeral head is under glenoid and there is a step in deltoid muscle area.
  • Pt is usually holding arm down by side

Spaso https://litfl.com/spaso-technique/

  • One of the ‘zero position’ techniques aim to align muscles and bring the shoulder back.
  • Pt lays back, gentle straight traction on wrist, supinate arm once brought forward.

Winter’s Wrap: Registrar Training 19.04.2017 – Organ donation, contrast nephropathy and paracetamol overdose

Organ Donation – Dr Forbes McGain (Intensivist)


Brain Death vs Circulatory Death

Clinical Testing – normothermic

– Sedating drugs excluded – *Baclofen mimics brain death

– cranial nerve testing

– Apnoea test

Imaging – if inappropriate for clinical test, unstable, spinal reflexes present


ED responsibility:

Contact Donor Coordinator – ICU registrar or Consultant, or Donate Life via switchboard

Initiate conversation but ensure family aware ICU attendance is NOT too prolong life but for consideration of organ donation


consider for donation if:  Brain death or imminently dying and withdrawal of cardiorespiratory support planned

Intubated and Ventilated

BP adequate for organ perfusion

No Malignancy or HIV

Age 1-80 years



Contrast Nephropathy – Dr Jamie MacGilivray

Limited evidence

Variable definition of nephropathy

Jamie’s audit showed 16 patients actually had improvement in renal function!!


In summary – understand the clinical indication for the scan requested and the timeframe within which results are needed. Renal function should not delay an appropriate CT.

Paracetamol Overdose – Dr Deb Maher




Guidelines for writing SAQs…for registrars presenting at Footscray to incorporate into their presentation:

Guidelines for Writing the Fellowship SAQ Examination Paper


Toxicology with Zeff

Thanks to local legend Dr Zeff Koutsogiannis who gave two presentations related to toxicology.

UPDATE 26/9/17: Thanks to Dr Neil Long FACEM for providing audio for these talks

Murder she wrote (or toxicology and the blood gas)




Masterchef (or cardiovascular toxicity in the poisoned patient)



Slides only versions:

Murder,she wrote (Western teaching)


Cardiovascular Toxicity in thepoisoned patient (Western teaching)

Winter’s Wrap 15/2/17 – Toxicology with Zeff

A great turnout for the first Footscray session!

A massive thanks to Dr Zeff Koutsogiannis for enlightening us on the usefulness of ABGs and cardiotoxic drug ingestions.



6 easy steps

1-2-3-4 rule

causes of metabolic acidosis – CAT MUDPILES (you fill it in!)

osmolar gap – make sure osmolality and UEC are requested at the same time

lactate gap  – compare the lab lactate measurement with blood gas machine measurement, consider “glycolate” a metabolite of ethylene glycol



SALT              NaBicarb – give as a bolus in TCA OD (not an infusion)

SUGAR          High dose insulin-dextrose to improve pump function in BB and CCB OD

COLOUR       Methylene blue for profound hypotension despite fluid, available from theatre 1-2ml/kg/hr

FAT                Intralipid only for LA injection with CVS toxicity


QT measurement – 3 limb leads, 3 V leads, take the MEDIAN measurement then plot on QT nomogram to determine likelihood of developing torsades


TAPNA  Australasia Toxicology Network Scientific Meeting April 27-29, 2017




Ethylene Glycol toxicity

Thanks Dr An Le for his presentation on ethylene glycol toxicity.




Key points:

  1. key ingredient in antifreeze and other industrial products
  2. any deliberate or significant ingestions are potentially lethal (>0.5ml/kg)
  3. produces characteristic toxidrome with CNS depression, metabolic raised anion gap raised osmolar gap acidosis and potentially renal failure
  4. antidote is ethanol
  5. disposition is usually to HDU