Sep 18 2019: VFRAC, toxicology and Kreb’s cycle crap, funny brain mass

Teaching session Wednesday 18th September 2019 (Sunshine) with thanks to Dr Hazizi Othman


VFRAC clinic (by Physiotherapy practitioner Laura McCalman)

  1. Inclusion criteria
  • Adults only (>17 yrs old)
  • Simple, stable fracture
  • Joint dislocations
  1. Exclusion criteria
  • Paeds (<16)
  • Finger bones distal to and including carpal row (scaphoid and query scaphoid is managed at VFRAC / fracture clinic)
  • Open fracture
  • High velocity trauma
  • NV compromise / compartment syndrome
  • Multiple injury site
  • NESB
  • Incomplete clinical information
  • Undiagnosed knee injury (suggested that referral back to GP to get MRI as outpatient would be quicker, and there is clear guideline on MRI rebates)
  1. Key points
  • Documentation
  • Correct letter to pt (no date – advising that pt will be called in 3 days time)
  • Correct contact details (get clerk to check)
  • Consider VTE prophylaxis

>2000 cases triaged in 1 yr and 0 adverse effect, and reduced operation cost

GPs have direct phone line to ortho reg, and can refer to clinic directly


Case presentation (Dr Lucy Selleck)


36 y.o M brought in by partner to ED – ingested 250mls of Yates Buffalo Pro deliberately, 30 mins prior.


200g/L Bromoxynil

200g/L MCPA

Previous ECATT involvement, lives at home with children

GCS 15, HR 110/min on presentation


Initial management

  • Advised by Poisons to intubate
  • ETT (within 40mins of arrival)à NGT, aspirated 30 mls of cream coloured liquid
  • Charcoal
  • ECG – normal / Paracetamol & ETOH levels were negative
  • Initial VBG was normal apart from lactate 3.0, within 1.5hrs à pH 7.18, pCO2 60, pO2 131 on FiO2 100%


Effects of Bromoxynil /MCPA

  • General cellular dysfunction
  • Uncoupling of oxidative phosphorylation
  • Increased CO2 production, hyperthermia
  • GI upset, hepatotoxicity
  • Rhabdomyolisis, acute renal failure
  • Myocardial toxicity, shock
  • Coma and death


Methods of cooling (to combat hyperthermia)

  • IV cold fluid
  • Ice pack – neck/groin/axilla
  • Fan
  • Cooling blanket/jacket – available at The Alfred
  • IDC and bladder washout
  • Sedation & paralysis
  • Ventilator set to cool
  • Haemofiltration
  • ECMO



  • Multi organ failure
    • Raised TropI to 10
    • CK to 285 000 at Day 2
    • ALT 470, AST 2001, INR 1.9
    • BP 85/51 unsupported (MAP 60) – needing vasopressors
    • K 7.1
    • PO4 4.13
  • Not for ECMO – given overload hyperdynamic state
  • Decision for fasciotomy by plastics for rhabdo – arrested in OT, cardiac standstill & died.


Radiology case (Dr Dan Axelsson)



47 y.o Vietnamese man with history of 2-3 days of confusion, 10 days of fevers/vomiting

  • No significant PMHx
  • No ETOH/substance use (confirmed by mother)
  • Social – born in Vietnam, works as a labourer
  • Decision to organize CTB to exclude ICH
  • CTB revealed large 3x6cm left frontal rim enhancing lesion, with surrounding vasogenic oedema and midline shift. Abscess stemming from olfactory groove where the is bony thinning, and surrounding paranasal sinus disease.
  • History revisited – pt was at RVE&E hospital 2/52 prior to presentation, had FESS & instrumentation.
  • Outcome: Craniotomy, drainage of abscess, organism: Strep pneumoniae, Strep lugdunensis, Finegoldia magna