Joseph Ting

Ciguatera poisoning: a global issue with common management problems.

Ciguatera poisoning, a toxinological syndrome comprising an enigmatic mixture of gastrointestinal, neurocutaneous and constitutional symptoms, is a common food-borne illness related to contaminated fish consumption. As many as 50 000 cases worldwide are reported annually, and the condition is endemic in tropical and subtropical regions of the Pacific Basin, Indian Ocean and Caribbean. Isolated outbreaks occur sporadically but with increasing frequency in temperate areas such as Europe and North America. Increase in travel between temperate countries and endemic areas and importation of susceptible fish has led to its encroachment into regions of the world where ciguatera has previously been rarely encountered. In the developed world, ciguatera poses a public health threat due to delayed or missed diagnosis. Ciguatera is frequently encountered in Australia. Sporadic cases are often misdiagnosed or not medically attended to, leading to persistent or recurrent debilitating symptoms lasting months to years. Without treatment, distinctive neurologic symptoms persist, occasionally being mistaken for multiple sclerosis. Constitutional symptoms may be misdiagnosed as chronic fatigue syndrome. A common source outbreak is easier to recognize and therefore notify to public health organizations. We present a case series of four adult tourists who developed ciguatera poisoning after consuming contaminated fish in Vanuatu. All responded well to intravenous mannitol. This is in contrast to a fifth patient who developed symptoms suggestive of ciguatoxicity in the same week as the index cases but actually had staphylococcal endocarditis with bacteraemia. In addition to a lack of response to mannitol, clinical and laboratory indices of sepsis were present in this patient. Apart from ciguatera, acute gastroenteritis followed by neurological symptoms may be due to paralytic or neurotoxic shellfish poisoning, scombroid and pufferfish toxicity, botulism, enterovirus 71, toxidromes and bacteraemia. Clinical aspects of ciguatera toxicity, its pathophysiology, diagnostic difficulties and epidemiology are discussed.

Comparison between single-dose oral prednisolone and oral dexamethasone in the treatment of croup: A randomized, double-blinded clinical trial

Objective:u2002 To compare the effectiveness of three corticosteroid regimens in children with mild to moderate croup.

Ciguatera Poisoning: An Example of a Public Health Challenge

Abstract: Ciguatera is a common form of fish poisoning, endemic in all nations of the Pacific region Several thousand cases have been notified tc Queensland authorities over a 10‐year period However, many cases remain undiagnosed and mos go unreported. The public health implications include raising awareness of the condition, ensuring that ciguatera is considered in differential diagnosi; and promoting better documentation and reporting.

Profiling patients suspected of drug seeking in an adult emergency department

Objectives:u2002 (i) To profile ED consultations where drug seeking is considered; (ii) to clarify if an Australian patient cohort shares the characteristics identified in the literature, that is, high rate of psychiatric, chronic pain and drug dependency problems; and (iii) to quantify the extent of missed organic disease in suspected drug‐seeking presentations.

Hyperosmolar Diabetic Non-Ketotic Coma, Hyperkalaemia and an Unusual Near Death Experience

Generally, cardiac arrest due to pulseless electrical activity has a poor outcome, except when reversible factors such as acute hyperkalaemia are identified and managed early. Hyperosmolar diabetic non-ketotic coma may lead to acute hyperkalaemia. Hyperosmolar diabetic non-ketotic coma is a metabolic emergency usually seen in elderly non-insulin dependent diabetics, characterized by severe hyperglycaemia, volume depletion, altered consciousness, confusion and less frequently neurological deficit. Cerebrovascular accident or transient ischaemic attack may be mistakenly diagnosed, particularly if the patient has no history of diabetes mellitus. Delays in diagnosis and management of glycaemic emergencies presenting as a constellation of neurological abnormalities can be avoided by routine early measurement of blood glucose. Hyperosmolar diabetic non-ketotic coma should be considered in any patient with altered consciousness or neurologic deficit in conjunction with hyperglycaemia. As hyperosmolar diabetic non-ketotic coma results in severe fluid depletion, electrolyte disturbance, profound hyperglycaemia and an altered mental state, the guiding principles of therapy include aggressive rehydration, insulin therapy, correction of electrolyte abnormalities and treatment of any underlying illnesses. Treatment of acute hyperkalaemia includes calcium ions, insulin with dextrose, salbutamol and haemodialysis.

Diagnosing drug-seeking behaviour in an adult emergency department

Objective:u2002 The objective of the present study were to determine factors used by ED doctors to diagnose drug seeking and their attitude towards management of this patient group.

Using propofol as salvage therapy to contain severe drug-induced agitation in the Emergency Department: a case report.

Propofol is an effective and safe procedural anaesthetic agent when used in the Emergency Department (ED) [1,2]. Illicit drug-induced agitation is a frequent presentation to the ED [3], comprising 27% of ED attendances for psychiatric conditions in the United States between 1992 and 2000 [4]. We report a case where propofol was used for a novel indication, that is, to attain rapid sedation of a wellknown patient presenting to the ED with severe recurrent drug-induced agitation after failure of standard pharmacological interventions [5,6].

Applying the Ottawa subarachnoid haemorrhage rule on a cohort of emergency department patients with headache

Objective The Ottawa subarachnoid haemorrhage (SAH) rule suggests that alert patients older than 15 years with a severe nontraumatic headache reaching maximum intensity within 1u2009h and absence of high-risk variables effectively have a SAH ruled out. We aimed to determine the proportion of emergency department (ED) patients with any headache fulfilling the entry criteria for the Ottawa SAH rule. Patients and methods The Ottawa SAH rule was applied retrospectively in a substudy of a prospective snapshot of 34 EDs in Queensland, Australia, carried out over 4 weeks in September 2014. Patient aged 18 years and older with a nontraumatic headache of any potential cause were included. Clinical data and results of investigations were collected. Results Data were available for 644 (76%) patients. A total of 149 (23.1%, 95% confidence interval: 20.0–26.5%) fulfilled and 495 (76.9%, 95% confidence interval: 73.5–80.0%) did not fulfil the entry criteria. In patients who fulfilled the entry criteria, 30 (<5% overall) did not have any high-risk variables for SAH. In patients who fulfilled the entry criteria and had at least 1 high-risk feature, almost half (46%) received a computed tomographic brain. No SAH were missed. Conclusion In this descriptive observational study, the majority of ED patients presenting with a headache did not fulfil the entry criteria for the Ottawa SAH rule. Less than 5% of the patients in this cohort could have SAH excluded on the basis of the rule. More definitive studies are needed to determine an accepted benchmark for the proportion of patients receiving further work-up (computed tomographic brain) after fulfilling the entry criteria for the Ottawa SAH rule.

Abdominal surface i.v. access as a temporising measure in resuscitation: CASE LETTERS

Dear Editor, A 79-year-old man was brought into the ED after feeling dizzy at a betting agency. Ambulance reported the patient having diarrhoea and was concerned about his clamminess and a systolic blood pressure of 80 mmHg. He was thought to be severely dehydrated from gastroenteritis. Field i.v. cannulation was unsuccessful. Past medical history included non-insulin-dependent diabetes mellitus, chronic obstructive pulmonary disease with good exercise tolerance and Stage III diabetic nephropathy with a premorbid estimated glomerular filtration rate of 43 mL/min. The patient was a retired cafe owner who lived alone and was independent. Six months earlier he had recovered well from surgery for localised bladder cancer. His medications included metoprolol, insulin gargline, aspirin and simvastatin. The patient’s arrival observations were blood pressure 96/50, pulse 85/min in sinus rhythm (on metoprolol), reference range 12/min and SaO2 97% on room air. He was pale but undistressed, with a soft protuberant abdomen that was not tender and without a palpable aneurysmal mass. In addition to a normal ECG, there had been no symptoms of acute coronary syndrome or pulmonary embolus. The patient was transferred into the resuscitation bay after passing gross malaena. He had no upper gastrointestinal disease, did not use anticoagulants and denied acute or chronic alcohol intake. Peripheral i.v. access was difficult to achieve. A 22-G cannula was inserted into his right lower anterior abdominal wall for 2 L of normal saline fluid bolus resuscitation and 1 g of tranexamic acid (Fig. 1). A second 18-G i.v. line was inserted into the antecubital fossa for administration of bolus and i.v. infusion of pantoprazole. The patient’s preresuscitation Hb was 110 g/dL, lactate 3.4 mmol/L and his serum glucose 11.4 mmol/L. An urgent endoscopy demonstrated 800 mL of arterial bleeding from a gastric fundus ulcer. Haemostasis was achieved with a single 1:10 000 adrenaline injection into the vessel. There was no rebleeding on follow-up Figure 1. Anterior abdominal wall peripheral i.v. cannula.

Topical chloramphenicol prophylaxis is of dubious benefit in corneal abrasion

Dear Editor, I read with interest the clinical trial comparing 5% homatropine with placebo eye drops in patients with corneal abrasion, which found no significant difference in pain reduction at up to 24 h after enrolment. Meek et al. used chloramphenicol ointment in all study participants presumably to reduce the risk of abrasion-related corneal infection. However, there is no proven benefit of topical antimicrobial chemoprophylaxis in reducing secondary infection in patients with corneal abrasions, and topical fluoroquinolones could delay corneal epithelial healing after keratectomy. Furthermore, the MOTE Trial, an ED-based clinical trial of topical anaesthesia to treat corneal injury found no secondary infection at 48 h and 2 weeks in adults who were neither prescribed nor used topical antimicrobial chemoprophylaxis during the study period. Chemoprophylaxis has only been reported to be effective for ocular trauma in high-risk rural settings in less developed countries. In view of the sparse evidence of benefit, as well as the inconvenience and additional cost of antimicrobial eye ointment or drops administration in minor corneal abrasion, I seek clarification for the use of topical chloramphenicol prophylaxis in Meek’s study. As all participants are to receive that chloramphenicol ointment, the study protocol implies prophylaxis to be the standard of care for the ED management for uncomplicated corneal abrasion. The possibility remains that chloramphenicol ointment used in Meek’s study could interfere with ciliary absorption of homatropine, reducing the latter’s intended therapeutic effect and minimizing analgesic difference discerned between the homatropine and placebo arms.emm_1406 231