An 82 year old man underwent elective removal of a common bile duct stent by endoscopic retrograde cholangiopancreatography (ERCP). He had been fit and well before the procedure. His medical history was unremarkable apart from longstanding intermittent right upper quadrant pain. He took omeprazole tablets 20 mg once daily. The procedure was successful and lasted about 20 minutes, during which time he was given no intravenous fluid. At the end of the procedure he was turned from the prone to the supine position in the ERCP suite. At once his oxygen saturation, as measured by pulse oxymetry, dropped to 70% and he became profoundly hypotensive, with a pulse of 50 beats/min. He was unresponsive, with a Glasgow coma scale of 3/15. Immediate resuscitation with oxygen and fluid restored his oxygen saturation and blood pressure, but he remained unresponsive. A 12 lead electrocardiogram showed massive anterior ST segment elevation with reciprocal changes. He was urgently moved to the cardiology catheterisation laboratory for primary percutaneous coronary intervention because myocardial infarction was suspected, but on arrival his electrocardiogram was normal. Generalised hypertonicity with brisk reflexes and upgoing planters were noted at this stage. Because he was haemodynamically stable, computed tomography of the head was performed without delay to rule out an acute intracranial bleed (figs 1⇓ and 2⇓). Fig 1 Axial computed tomogram of the head Fig 2 Sagittal computed tomogram of the head ### 1 What do the computed tomograms show? #### Short answer The computed tomograms of the head show large quantities of air in the cerebral vasculature. #### Long answer Figures 3⇓ and 4 ⇓ show axial …

An 82-year-old man underwent the routine removal of a common bile duct (CBD) stent by endoscopic retrograde cholangiopancreatography (ERCP). He had been fit and well prior to the procedure, and his past medical history was unremarkable. He had presented 18 months previously with acute cholangitis caused by gallstones.

BACKGROUNDEchocardiography has been shown to positively impact on the management of the critically ill patient. However, many published studies have a significant bias towards inclusion of cardiothoracic patients. We present an audit of the impact of echocardiography on the management of patients in a district general hospital intensive care unit (ICU).METHODSWe conducted a prospective audit of all echocardiograms, both transthoracic (TTE) and transoesophageal (TOE), performed on our ICU between October 1, 2005, and December 31, 2007. In addition to patient characteristics, we recorded the indication for the echocardiogram, and any change in management that occurred as a result of the study.RESULTSTwo hundred and fifty-eight echocardiograms were performed in 217 patients, of which 224 (86.8%) were performed by intensive care consultants. One hundred and eighty-seven studies (72.4%) were TTEs and 71 (27.8%) were TOEs. TTE provided diagnostic images in 91.3% of spontaneously breathing and 84.2% of mechanically ventilated patients. Management was changed directly as a result of information provided in 51.2% of studies. Changes included fluid administration, inotrope or drug therapy, and treatment limitation.CONCLUSIONSEchocardiography may have a significant impact on the management of patients in the general ICU. We recommend that appropriate training in echocardiography should be incorporated into the intensive care curriculum in the UK.

We present a case of fatal cardiac tamponade that occurred in association with a peripherally inserted central catheter (PICC) inserted from the right antecubital fossa. Migration of the catheter from the right atrium within 24 h of insertion lead to the administration of a potassium-enriched sodium chloride solution into the pericardial space with the development of ST-segment elevation and progression to pulseless electrical activity and, subsequently, ventricular fibrillation. Although signs of tamponade were seen on echocardiography, we propose that myocardial hyperkalaemia from the diffusion of potassium through the epicardium accounted for some of the clinical picture. PICC lines carry a greater risk of migration because of the tip movement associated with arm abduction and, therefore, care must be taken to ensure that the catheter tip is correctly positioned to reduce this risk. When such catheters are used for intra-operative central venous access, we believe chest radiography is mandatory before fluid administration through the catheter, but that this is unnecessary when the catheter is being used solely for central venous pressure monitoring. The use of softer catheters may reduce the risk of vessel perforation. Once tamponade is suspected, all drugs and infusions administered via the catheter should be reviewed, the catheter aspirated and echocardiography performed urgently. This may be facilitated by the greater availability of limited bedside echocardiography within critical care units and theatre complexes.

Although heart disease is now the joint leading cause of maternal mortality in the UK, critical aortic stenosis is rarely encountered in parturients. Caesarean section is advisable in these patients to minimise the haemodynamic stress of labour and delivery. The use of an opioid-based general anaesthetic technique also helps to maintain cardiovascular stability. During a two-year period, four women with critical aortic stenosis requiring caesarean section presented to our institution. In all women, a rapid sequence induction of anaesthesia was performed using etomidate 0.1 to 0.2 mg·kg−1, suxamethonium 1.5 mg·kg−1 and remifentanil 2 to 4 μg·kg−1. Anaesthesia was then maintained with isoflurane, nitrous oxide and a remifentanil infusion at 0.05 to 0.15 μg·kg−1min−1. There was good haemodynamic stability throughout, except for a short period in one patient who became hypotensive after a significant post-partum haemorrhage secondary to uterine atony. All parturients were successfully extubated at the end of surgery and made excellent postoperative recoveries. Neonates were born in good condition with Apgar scores of 10, 9, 6 and 5 at 1 min and 10, 10, 10 and 10 at 5 min. We suggest that remifentanil is an ideal agent for parturients with severe aortic stenosis requiring general anaesthesia for caesarean section. Remifentanil provides cardiovascular stability in conjunction with rapid emergence from anaesthesia in the parturient and minimal side effects in the neonate.

Serological responses to vaccination with typhoid or meningococcal vaccine separately or in combination *Antigen Typhoid Vi Meningococcal A Meningococcal CPrevaccination antibody titres (geometric mean (range) (mg/l))0 3 (0-1-2-7) 5 4 (2-1-16-0) 3 0 (0-8-21-0) Difference (95% confidence intervalt; P value): AvC 80to 130;0-9 81 to 116;0-7 83to 146;0-5 BvC 75 to 132; 1 0 87 to 126; 0-6 76to 132; 0 9Antibody timres at 3-6 weeks (mg/i) Group A (n=54) 2 1 (0 3-26 0) 5-3 (2 3-22-0) 2-8 (0 9-22 0) Group B (n=50) 0-2 (0-1-1-8) 23-3 (5 8-93 0) 34 0 (4 0-420 0)Group C (n=53) 3-7 (0-3-45-0) 22-2 (5-5-174-0) 31 9 (6 0-520 0)1 Office of Population Censuses and Surveys.County monitors.London:

MRICAL 847patients with glandular fever almost invariably develop a rash if given ampicillin,25 and the same is true to a lesser extent for some other antibiotics.A survey of the literature shows that there has been a particularly high incidence of rashes in patients treated with ampicillin for Sabnonella infections.It has been postulated that some of the rashes may be produced by endotoxin released by rapid lysis of bacteria, though there is little evidence to support this.Many of these patients received high dosage, but we have been unable to show a significant relationship between dosage and incidence.An intensive investigation is being undertaken in an attempt to provide information on many of the unexplained features of the rash associated with ampicillin therapy.-I am, etc.,

Spontaneous perforation of the bowel without evidence of intestinal obstruction is reported in six infants who had exchange transfusions for rhesus incompatibility, and in a seventh who had prolonged intravenous fluids via the umbilical vein. The pathological findings resemble those found in acute necrotizing enterocolitis in adults, which is known to be associated with arterial hypotension. The cause in these infants may also be due to a period of hypotension during the transfusion, and hypoxia and superimposed infection may also play an important part.