Case presentation for regional Paediatric meeting - presents a case of critically ill 16 month old boy with sepsis. Case and case discussion presents the successful resuscitation of critically ill Paediatric patient, highlighting the associated challenges with being in a peripheral hospital setting.
Lecture 14 & 15 truth telling & breaking bad news (BBN)Dr Ghaiath Hussein
Truth telling & breaking bad news (BBN) in the practice of medicine. The ethical principles and the practical skills needed for breaking unfavourable news, with emphsis on the Islamic aspects and the practice in Saudi Arabia
Lecture 14 & 15 truth telling & breaking bad news (BBN)Dr Ghaiath Hussein
Truth telling & breaking bad news (BBN) in the practice of medicine. The ethical principles and the practical skills needed for breaking unfavourable news, with emphsis on the Islamic aspects and the practice in Saudi Arabia
Presented by Scrub Ninjas® NCLEX-RN Review Game
www.scrubninjas.com
10 NCLEX Practice Questions on Management of Care for your NCLEX-RN/PN Review.
Scrub Ninjas® NCLEX-RN/PN Review APP
NCLEX RN Exam Review, the first ever NCLEX video game! Conquer your nursing boards by playing an action-packed ninja video game designed to make learning fun. Our content tailor-made for the NCLEX (A full range of high yield questions like the actual exam) based on the content guidelines from the NCSBN.
Awaken the mind with the Scrub Ninjas® and arm yourself with epic surgical infused ninja weapons, and traditional Japanese masks. Created for the visual learner, this stimulating game will help you retain high yield content and facts while as you strengthen your nursing skills. A perfect NCLEX study tool for all of you students on the go! Maximize and master your exams with friends and classmates. We wish you success future nurses of America, game on!
AVAILABLE ON
iTunes: http://bit.ly/NCLEXRNitunesFULL
Google Play: http://bit.ly/NCLEXANDROID
Frank Lockie, paediatric intensivist, discusses how kids are just little adults at Bedside Critical Care Conference 4 (Cairns, 2013)
The podcasts accompanying these slides will be uploaded onto www.intensivecarenetwork.com and libsyn.
Presented by Scrub Ninjas® NCLEX-RN Review Game
www.scrubninjas.com
10 NCLEX Practice Questions on Management of Care for your NCLEX-RN/PN Review.
Scrub Ninjas® NCLEX-RN/PN Review APP
NCLEX RN Exam Review, the first ever NCLEX video game! Conquer your nursing boards by playing an action-packed ninja video game designed to make learning fun. Our content tailor-made for the NCLEX (A full range of high yield questions like the actual exam) based on the content guidelines from the NCSBN.
Awaken the mind with the Scrub Ninjas® and arm yourself with epic surgical infused ninja weapons, and traditional Japanese masks. Created for the visual learner, this stimulating game will help you retain high yield content and facts while as you strengthen your nursing skills. A perfect NCLEX study tool for all of you students on the go! Maximize and master your exams with friends and classmates. We wish you success future nurses of America, game on!
AVAILABLE ON
iTunes: http://bit.ly/NCLEXRNitunesFULL
Google Play: http://bit.ly/NCLEXANDROID
Frank Lockie, paediatric intensivist, discusses how kids are just little adults at Bedside Critical Care Conference 4 (Cairns, 2013)
The podcasts accompanying these slides will be uploaded onto www.intensivecarenetwork.com and libsyn.
Dr Derek Thompson: Building a caring futureNuffield Trust
In this slideshow, Dr Derek Thompson, GP and Medical Director at Northumbria Healthcare Foundation Trust, on reducing the length of hospital stay and building a caring future.
Dr Thompson spoke at the Nuffield Trust ‘Reducing the length of stay’ event in September2014.
Palliative Care and Acute Oncology IntegrationRecoveryPackage
Dr Catherine O'Doherty, Consultant in Palliative Medicine, Trust Acute Oncology Lead and Lead Cancer Clinician, Basildon and Thurrock University Hospitals NHS Foundation Trust
Karen Andrews, Head of Nursing for Macmillan/Acute Oncology and EOL services, Basildon and Thurrock University Hospitals NHS Foundation Trust
Phase 3 Med Student Orientation SHH ED - 22-07-22.pptxBishan Rajapakse
This is the orientation lecture given to the Phase 3 medical students rotating through the Shellharbour ED. These slides are to be for easy access for students and staff alike.
What nelson forgot 4 - Super CME for Common Pediatric OPD questionsGaurav Gupta
What nelson forgot 4 - Super CME for Common Pediatric OPD questions, 12th July 2019
Common Office practice questions, answered in just 5-10 minutes per topic ...
Wellbeing talk for intern orientation week. ISLHD (Illawarra Shoalhaven Local Health District) presented by Dr Bishan Rajapakse (Emergency Physician, FACEM, PhD) and Dr Skye Macleod (Emergency Fellow /UOW lecturer) - an informal and exploratory talk about strategies for maintaining and promoting wellbeing in the challenging healthcare area of modern medicine
Presentation at the SRMO weekly teaching for Shellharbour Hospital ED - by Dr Mahsa Fateminayyeri, MD - trainee, who covers an approach to sepsis in the ED setting, and highlights the value of a sepsis pathway to expedite antibiotic treatment and provide early resuscitation in order to promote good outcomes
Re-framing Failure into success - EM Fellowship OSCEBishan Rajapakse
This is an old talk given in 2018 about transforming exam failure into success, at the "ACE the OSCE" held at Westmead Sydney. It was a course for Emergency Physicians in training sitting the ACEM fellowship exam
This is a power point presentation describing the Shellharbour ED Mentorship program, describing the benefits, goals and expectations of mentorship in the department.
Shellharbour ED Orientation July 2022- expectations and aspirations overview Bishan Rajapakse
This was an Orientation talk for new doctors doctors working in Shellharbour ED - expectations and a framework for practice. Shellharbour is a lovely peripheral hospital ED situated in the coastal region of Illawarra NSW. We see >30,000 patients per year, with a broad and interesting range of acuity. Our staff is made up of an interesting mix of local and international doctors who embrace a small hospital team spirit, tackling large hospital problems. Our ED is a mixed adult and paediatric ED that is located 30 mins away from a fully serviced Tertiary hospital. We support ACEM Advanced training with a FACEM led department, supported by ACRRM and Senior CMOs in the medical leadership. The department is host to UOW Clinical Medical students, and subspecialty training term or ED Ultrasound. Our hospital is in the process of an upgrade to include short stay an ICU. The work is challenging but rewarding , and embraces the full mix of what a coast peripheral ED can hope to offer.
Em consultants wellbeing talk Dr Bishan Rajapakse & Dr Hughes MakoniBishan Rajapakse
This is a talk given for the ISLHD Wellbeing week for JMOs on 16th September 2019 - Two emergency Physicians sharing their experiences and tips with maintaining wellbeing whilst working in medicine.
Wellbeing and mentorship - SRMO Orientation Feb 2020Bishan Rajapakse
This talk was part of the orientation for Senior Resident medical officers (SRMOs) working in at Shellharbour ED. The idea behind the talk was to convey the importance of wellbeing for quality patient care, workforce sustainability, and creating a workplace culture that we want to nurture and be proud of!
A talk given to at the ACEM (Australasian College of Emergency Medicine) pre-congress workshop for the Annual Scientific Sessions in Hobart, Tasmania 2019.
These are reflections and tips shared by Dr Bishan Rajapakse, an Integrative, Academic, Emergency Physician, along his towards "prioritizing wellbeing" in the first 12 months of working as an Emergency Medicine Specialist in NSW, Australia.
Bishan is an EM Fellow with ACEM and a committee member of the Global Emergency Care committee (GECCo), as well an advocate fo Mental Health and researcher in doctor wellbeing.
1. the road less travelled prioritising wellbeing3Bishan Rajapakse
This is a talk that given at the NSW Emergency Medicine Wellbeing day. I talked about the "importance of prioritising wellbeing" illustrated through the trials and tribulations of my lengthy, yet fruitful training journey - which included basic surgical training, international research, and emergency medicine specialist training.. plus a whole lot of adventure, fun and despair! The aim was to provide some hope, inspiration, and tips for those who are inclined to take the path less travelled!
A great tutorial from Dr Alistair Jones NHS medical educator (http://www.yorkshiremedicaleducation.co.uk/about-us) on ECG syndromes. Beyond the basics (but essential knowledge for training emergency physicians)
Presentation by Dr Jason Wu - resident in Critical Care at TWH, for the critical care journal club report findings of a paper by Kaukonen KM, et al. N Engl J Med. 2015 & update from the recent SMACC conference in Chicago #FOAMed #SMACC (http://www.ncbi.nlm.nih.gov/m/pubmed/25776936/)
The emergency and intensive care management of OP poisoning Bishan Rajapakse
This talk was given at the Wollongong Hospital Intensive Care departments registrar teaching session. The surprise ending video can be found on the following web page whilst scrolling to the bottom ... http://lifeinthefastlane.com/education/international-em/ I hope you enjoy. Comments on the presentation are welcome.
Thank you
This talk on "Fevers in Travellers" focusses history taking skills, diagnosis and treatment of Malaria and some other tropical disease that we may on rare occasions encounter in the urban ED environment of New South Wales. I would like to thank Dr Julian Chow, and his sources, for sharing this comprehensive talk on the topic, which was presented as part of the Wollongong Emergency Medicine registrar teaching program. We would welcome comments and further contributions on this topic.
Airway management in the Emergency Department for TraineesBishan Rajapakse
This is a power point presentation on Airway Management given by our deputy director in Emergency Medicine Training at the Wollongong Hospital, Paul Labana (consultant Emergency Physician) that presents a case illustrating difficulties in airway management and gives an overview of airway management in the emergency department. (Nb another video to do with airway management, and "airway exchange" can be found on this link http://youtu.be/6vaWNknIDQg) - thanks to Paul for sharing his educational material in the name of free open access meducation (#FOAMed)
Opthalmology in the ED - Dr Andrew White (June 2013)Bishan Rajapakse
This comprehensive overview of common ophthalmological presentations that ED registrars may encounter has been kindly shared by Dr Andrew White BMedSci(hons) MBBS PhD FRANZCO, Consultant Ophthalmologist, Westmead Hospital & Sydney Medical School (USyd)
An overview of the management of Rhabdomyolysis, put together for the weekly Emergency Medicine registrar teaching session at Wollongong Hospital ED. Information in the presentation is from both the journals and medicine 2.0 (and in particular "FOAMed" -the free open access medical education network that aims to improve sharing of medical education resources through the web). Enjoy. @trainthetrainer
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
The POPPY STUDY (Preconception to post-partum cardiovascular function in prim...
Paediatric Resuscitation in a Peripheral Hospital ED (6-12-2020)
1. Paediatric Resuscitation –
the Peripheral hospital ED
perspective:
Dr Bishan Rajapakse, FACEM, PhD, MBChB
Emergency Physician, Shellharbour Hospital
Honorary Clinical Lecturer, UOW
Thinking on your feet, and living by
the skin of your teeth
Pop in Paediatrics
The Wollongong Hospital
Monday 7th Dec 2020
2. Overview
• Shellharbour ED context
• Case presentation and discussion of 16 month old patient
• Paeds resus in peripheral hospital
• Challenges / Practical realities / Interim and future
solutions
• Regional Paediatric Education Strategies with impact
3. My Background /
Perspective
• Emergency Physician Shellharbour
• Portfolio
• Medical Education / UOW Medical
students
• Research / Educational Research &
Simulation
• Wellbeing & Culture Change
• Keen on Kindness
• Wellbeing Research
4. Shellharbour Hospital:
Peripheral Hospital ED
Emergency Department
- 2 resus beds
- 12 Acute Adults+ 2 Acute Paeds
- 5 Subacute treatment spaces
Inpatient Service
- 87 Medical, Surgical and specialty beds
- Close observation Unit (9 beds)
- General Medicine
- Geriatric Medicine
- Surgical (8 Bed day care)
- 69 Mental Health beds
- NO Paeds /OBGYN
Presentations
30,000 presentations/year
6000 Paediatric presentations
5. Medical Staffing Shellharbour Hospital (for
Paeds presentation)
ED (AM/PM/Night)
• FACEM Cover 0800 – 2400 (Day/Evening)
• 2-3 ED doctors per shift (non consultant)
Paediatrics
• ED Paeds treatment (2 beds )
• Wollongong Hospital admission via paediatric
registrar
• Paediatrician on call can review patient at
SHH (30mins away)
• Vision for Life -> NETS
Anaesthetics (M-F elective lists only)
• No anaesthetics on call
• Will help out if needed between cases
6. Paeds Presentations to SHH (20% of total)
• SHH ED -30,000 total annual
presentations
• 20% (5100/25,000) of Pts are
paediatric (<16years)
• 44% (2400/25,000) are acute
patients (rest Fast Track)
• 30 patients patients are
transferred to other hospitals per
month (12% of acute patients)
Based on analysis in 2019 over 10 months (Courtesy of K Ruperto & T Couttie)
7. Medical Transfer (>30% of in-patient admissions; all
paeds admissions)
ED
Psych
Gen
Med
SSH
Gen
Surg O&G Paeds
ICU
SHH
TWH (30 mins
ambulance)
Retrieval
PICU
Paeds/
Paed
Trauma
SCH (1.5 hours
ambulance)
R
e
t
r
i
e
v
a
l
Med
subspecs
8. Paeds Medical
Transfers &
Retrieval
• Patient Transport Service
• Ambulance NSW
• Medical Retrieval (NETS)
• Transfer Times
• Wollongong Hospital
• 20-30 mins; ambulance
• Sydney Children's Hospital
• 1.5 hrs via ambulance
• 30 mins via helicopter)
10. Our patient; Mast JS, 16 months old male
PMHx -Nil
Medications - Nil Regular
Allergies – NKDA
Social Hx
- Lives with single mother and 2
older sisters
- Attends day care
11. Triage Note – Category 3 (0224)
Woke from sleep tonight vomiting. ate the same
dinner as family, well today. fever. Foot and mouth
disease last week, went back to day care yesterday.
Examination
Temp 39, No rashes no lymphadenopathy
A - Asleep but rousable
B - Chest clear, O2 sats 99% on RA
C – HR 132
D – Asleep but rousable, No neck stiffness
Abdomen soft
Anogenital area NAD
ENT - Mild pharyngitis
Initial Visit
08/10/20
Presented
0224
History
16/12 old – fevers, rhinitis, cough
1/7
Quiet during evening
Woke up with fever 2am
• Normal oral fluid intake and
fluid output
• Nil medications given at home
• Attended daycare during the
day
• No known sick contacts
• Nil PMHx, IUTD
14. Observations on Representation
Temp 36
A – patent
B – RR 45, O2 sats 97% RA
C - HR 176, central cap refil – 5 seconds seconds, BP 80/40
D – Responding to voice
Representation
08/10/20 1539
Triage Note (Cat 2)
unwell since last night presented in this ED
and d/c this morning O/A alert, crying, irritable
mottled skin, non blanching
haemorrhagic area to right arm unable to fully
get Obs as pt. agitated, taken straight to acute
area/resus
15. Initial Assessment at Triage
Child in his mother’s arms, lethargic
Mottled
Capillary refill 5 seconds
Non-blanching lesion on right upper arm
Nb – Parental consent has been obtained for this photo to be used for educational purposes
16. Logistics and our ED Context at
time of presentation
• Space = Bad
• Our ED was bed blocked
• 2 Resus beds full
• All acute & 2 paediatric beds full
• Staffing = Good
• Cross over tome between morning and evening shifts
The 2 resus beds were full
• Other Factors
• Infection control (febrile child in covid times)
• Mother also had a 5 year old child with her and
another child in the waiting room. Single mother
17. Representation Hx 08/10/20 1540
History
16/12 old , last well 10/7 prior
Unwell with hand, foot & mouth disease for 7 days
Cleared GP to return to daycare 2/7 prior to ED presentations
First day back at daycare yesterday 1/7 prior
• Ate dinner and slept
• Awoke 2330, unusual cry, fever at 0200hrs
• Presented to ED 2:30am, fever settled, tolerating fluids,
• d/c home with representation advice
18. Representation Hx 08/10/20 1540
After getting home from ED patient
- off his food,
- dozing on and off for the whole day,
- mother again noted a weaker than usual cry
• RASH noted rash on his upper arm and his abdomen this
afternoon
• Decided to represent as patient was having difficulty walking
Last paracetamol 2 hours prior to presentation
19. Representation Ex - 08/10/20
1540
Examination
General - looks unwell, lethargic, mottled, whinging, lying on mum
A – Patent
B – Good air entry , Chest clear, nil creps or wheeze
C - Cap refill 5 seconds centrally, tongue moist
D – Lethargic, responding to verbal stimulation
Rash: Purple non-blanching rash approx. 4cSparse non blanching
purple lesions 1-2mm in diameter on the lower abdomen and
noted on scrotum and buttock cleft
x 2cm in the right upper medial arm
Abdomen soft non tender, nil palpable masses
ENT - Crusty rhinorhea on nares bilaterally, Ears & Throat NAD
Chest good air entry bilaterally, nil creps, nil wheeze
21. Our Working Diagnosis
Meningococcal Septicaemia with associated
septic shock
Invasive Meningococcal Disease (IMD)
- 30-50% of patients present with meningitis without
bacteraemia
- 40% with combination of bacteraemia and meningitis
- 7-10% with bacteraemia only
22. Initial Treatment
Patient moved to resus
2 x 22G IVC inserted into cubital
fossae
2 x sets of blood cultures taken
Ceftriaxone 50mg/kg
administered
Dexamethasone 0.15mg/kg
given
10mls/kg saline bolus x 2 given
25. Progress and
involvement of
NETS
• Patient look sick from outset; RED FLAGs
• Suspicion of invasive meningococcal disease
(IMD)
• Duration of symptoms]
• In Septic shock; Hypotensive, tachycardic,
and biochemical marker of severe sepsis
(with lactic acidosis)
• Called Paediatrician (TWH)
• In alignment with plan already instituted -
IV Ceftriaxone 50mg/kg, and 10+10mls/kg
NS fluid bolus
• Suggested broadening the antibiotic
spectrum to include IV Vancomycin
• Activated NETS as no response to initial fluids
and Red flags
• After describing the case – sent NETS team
via helicopter
26. Vision for Life
• Collaborative discussion with NETS – agreed with
recognition likely meningococcal sepsis with potential for
cardiovascular collapse, and multi-organ failure
• Confirmed immediate dispatch of retrieval team via
helicopter (ETA 30 mins)
• NETS advised early intubation in anticipation of imminent
cardiovascular collapse due to severe septic shock
• Decision to proceed with ED staff +/- Anaesthetics if contactable
• Advised also initiate adrenaline infusion prior to this as BP
could easily drop
27. Re-Cap
Patient: 16 month old male
Working Diagnosis: Meningococcal
Septicaemia with severe septic shock
Treatment: Crystalloid boluses x 2,
ceftriaxone, dexamethasone, vancomycin,
gentamicin
Current Plan: Early ionotropic support and
intubation
Disposition: PICU Sydney children's
hospital, NETS team via helicopter
activated (will arrive in 30mins)
28. In the resus
room…
• Patient + Mother/Grandmother
• Existing Resus TEAM
• Evening FACEM (Team Leader)
• Registrar ED Advanced Trainee (primary survey
• Resus nurse and Paeds nurse
• Medical student
In rest of Emergency Department
• Acute area – Day FACEM, senior and junior
doctors (cross over time)
• FAST track –Doctors x1, Nurse practitioner ,
Nursing staff
29. Assembling
our
Intubation
Team
• 2 FACEMs
• One Team Leader
• One Airway
• ACEM AT – Drugs
• Airway Nurse, Drugs, Scribe
• Social Worker – notified to be present
• Medical student supporting the
patient psychosocially in interim
31. Intubation 1722 (presented 1.5 hours prior)
FACEM2 Airway/FACEM1 Team leader/ED Reg- Drugs
DSI with ketamine 12 + 8mg and rocuronium 16mg
• Direct laryngoscopy with bougie, 3.5mm cuffed tube ETT
• Good vision of ETT going through the cords
• 13cm at teeth
• CO2 trace obtained post intubation
O2 sats initially 99% however within 30 seconds started dropping
32. Initial Intubation - 1722
Tube was suctioned , nil improvement in sats
• ETT removed
• Rescue LMA size 2 inserted , O2 sats improved back to 90- 100%
Discussion:
- advice from video-link team was that the patient wasn’t being
ventilated fast enough once intubated
- Possible blocked ETT from vomitus/secretions
33. Re-intubations, and tube adjustment
1. Anaesthetist arrived in the department
(1741)
• First attempt with Size 4 Cuffed ETT
• CO2 trace obtained however, perceived air
leak around tube
• Dropping O2 saturations
• ETT removed, LMA size 2 reinserted
Re intubation by Anaesthetist
• Second attempt with Size 4.5 cuffed ETT
• O2 sats 100%
• Tube secured by NETS, 15cm at the teeth
3. O2 sats dropping -
Endobronchial Intubation
suspected
Confirmed Endobronchial
intubation with CXR
Tube pulled back with cuff up,
ventilation nil problems – O2 sats
99%
34.
35.
36. Further progress in SHH prior to transfer
• Femoral central line – inserted by FACEM
• Social worker input for with Mother; prepared to go to SCH in helicopter
• Updated diagnosis and uncertain prognosis at this stage
• Patient continued to have borderline BP , improving pH and lactate and
transferred
• Left SHH ED at 23:05pm
38. Progress in Sydney
Children’s Hospital
(Total 8 days in ICU
and Ward)
• PICU SCH (arrived 9/10/2020)
• LP not performed due to clinical instability and
lack of meningeal symptoms
• 8/10/2020 BC Growth of Neisseria Meningitidis,
PCR positive 9/10
• Public Health notified
• ID recommended 7 days IV ceftriaxone
• TTE normal on 9/10/2020
• Improving Petichiae and R axillary skin leasion -
USS no collection
• General Ward
• Progress with Nutrition and Physio
• Nil neurological deficit detected in walking
and feeding
• D/c 17/10/2020
• Script for Cephalexin 5/7 for erythematous lesion
R axilla
39. A Good Outcome
• Note from physiotherapist after discharge
20/10/20
(Mum) reports she feels (patient) has
returned to his pre-illness GM skill level .
He is running climbing stairs and his balance
appears fine and that their GP saw (patient)
yesterday and was of the opinion he did not
need physio F/U .
Emergency Physician SHH – contacted
mother for telephone follow up (1 month
later)
• Master JS was doing well – very grateful
for care by all staff in SHH and NETS
• Told in SCH hospital that good care may
have saved her son’s life
41. Points for
Discussion
• Meningococcal sepsis ; Rare but important
condition to treat expediently
• Desaturation post intubation
• Ventilation in Paediatric patients - Ambu
bag
• Cuff Leak
• Complexity of high level paediatric
resuscitation in peripheral ED
• Organizing a resus team
• Challenges of paediatric intubation
• Availability of anaesthetist
• Necessity for time critical helicopter
transfer to PICU
44. Thompson et al (2006)– “Clinical recognition of meningococcal disease in
children and adolescents” - Lancet
“Few infections can cause the
tremendous stress that occurs
when meningococcal disease
enters a community.”
“The rapid onset of disease, the
fulminant course of some infected
patients, and the mortality and
morbidity are all reasons why this
infection is so dreaded.”
• Importance of early recognition
48. ANZCOR : Introduction to
Paediatric Advanced Life
Support Techniques
in Paediatric Advanced
Life Support
With cuffed tubes, a size 3.5 mm for children
1-2 years of age and for older children
according to the formula age (years)/4 + 3.5
mm.
Irrespective of formulae, the correct size
should enable adequate lung inflation with
escape of a small volume of gas around the
tube on application of moderate pressure.
However, cuffed tubes or closer fitting
uncuffed tubes may be preferable when lung
compliance is poor. Initial insertion of a cuffed
tube obviates the need to change a tube
when oxygenation is compromised by a leak
around a tube which is too small.
49. Paediatric patient who needs intubation
/ionotropes in Peripheral hospital setting
Challenges to patient
• Low frequency presentation
• Onsite critical care FACEMs;
• Backup via NETS
• Variable availability of Acute
Anaesthetic back up
• No onsite ICU or Paeds ICU
• Retrieval at best 30 mins away
(usually 1-2 hours or more)’
Challenges to Department (Emergency)
• FACEM resources tied up for
several hours to one patient (in
this case 3 hours continuously)
• Impact on other Acute patients
in ED
50. Potential solutions to Resource limitations
For the Patient
Early involvement of Pediatrician
• In person, over phone advice
Early Involvement of NETS
Phone a FACEM friend (Paeds dual trained)
Involve social worker to address psychosocial
needs of parents
For Department
• Involve on call FACEM staff
• Involve ED Director
• Involve DMS
Extra staffing / RE-allocate staff
51. Gratitude for
Regional
Paeds
Education
strategies!
• Strategic Education
• Insitu Simulation of Paeds
cases
• Regional Sim training
• Regional Case discussion
education sessions (Pop in
Paeds – montly meeting)
• APLS courses
• Support Champion educators
• Liason specialist paediatric
staff
• Paediatric CNC
• Dual Trained FACEMs (Paeds
/ED)
• Scope for More?
• Closing the feedback
loops for good
care/areas to improve
(to all staff)
• Other knowledge
translation strategies
• Regular Paeds
contact
• Online Education
• Clinical decision
aids / Web/ smart
phone based
52. Paediatric
Education across
the region has
many faces, and
always creates a
smile
Shellharbour ED FACEMs and ED Nursing staff post Resus for Kids training update
53. Summary
of Key
Points
• Meningococcal sepsis is rare but important
condition to recognize early and treat
• Paediatric Resus is challenging in the context of
the peripheral hospital ED setting (lack of
onsite critical care & Paeds inpatient services)
• Strategic regional Paediatric education
including SIM/case discussion/championship is
an investment that is worth the effort!
55. Acknowledgements
Support with presentation & clinical care
• Dr Michael Culshaw - FACEM ISLHD & Tracie Couttie - Paediatric Nurse
Consultant
• Dr Shalini Cleophas – FACEM ISLHD
• Dr Jane Friedrich (ACEM advanced Trainee Registrar)
• Entir Shellharbour ED staff (Nurse in Charge , Resus Staff, also UOW Med
student Eyra Muzner)
• Wollongong Paediatrics Department
• Wollongong Anaesthetics Department
• NETS & Sydney Children’s Hospital ICU