Archive for December 2009

DundeeNotChest – Star Wars Facebooking

December 27, 2009

Not very medical, or chest-y, but it’s Christmas.

Star Wars Facebook Updates


Empyema and Pleural Drainage

December 23, 2009

Empyema: This is defined as collection of pus in a naturally occurring cavity and is a complication of pneumonia. Nb Empyemas do occur in the gall bladder and rarely an intracranial subdural empyema.

What is the difference between and abscess and empyema:

Empyemas are accumulations of pus from a pre-existing anatomical cavity


Abscess: accumulations of pus in a newly formed structure, formed by adjacent healthy cells in an attempt to keep the pus from infecting neighbouring cells

The four steps to Empyema:

  1. 1. Pneumonia
  2. 2. Simple parapnuemonice effusion
  3. 3. Complex parapneumonic effusion
  4. 4. empyema
  1. Pneumonia
  1. Simple parapneumonic effusion (a pleural effusion being excess fluid that accumulates in the pleural cavity results from inflammation of the pleura by the adjacent pneumonia infection. This infection causes increased capillary permeability and exudation of fluid into the pleural space. Initially the pleural fluid is sterile, so will appear clear with:
  • low white cell count
  • lactate dehydrongenase, LDH (low levels in a transudate – passive secretion and high levels in exudate as a result of inflammation)
  • normal glucose and pH.

This simple parapneumonic effusion appears on a CXR or USS as a free flowing effusion.

  1. This develops into a complicated paraneumonic effusion as the fluid is invaded by the bacteria from the adjacent pneumonia. This leads to:
  • Increased numbers of neutrophils
  • Decreased glucose levels
  • Pleural fluid acidosis
  • Elevated LDH

It is classified as complicated because it requires drainage for resolution

  1. Empyema Thoracis: This develops as the complicated parapneumonic effusion fails to resolve and there is frank pus accumulation in the pleural space. The patient will appear:
  • acutely unwell with a high fever
  • elevated neutrophils =  granulocytois
  • marked elevation in LDH > 1000U/l
  • Marked pleural fluid acidosis
  • Marked decreased glucose level

Laboratory studies indicate that preexisting pleural fluid is required for the development of empyema because it is not seen after direct inoculation into a dry pleural space. The pus is seen after is has been removed by drainage of which there are various options which will be discussed bellow.

Treatment: IV augmentin TDS for 5 day + drainage

Nb Hippocrates in 500BC recognised the serious problem of empyema and recommended treating it with an open drainage

Risk factors for developing and empyema from pneumonia:

  • Low albumin <30 g/l
  • Low sodium <130 mmol/l
  • Platlet count >400
  • IV drug use
  • Hx of alcohol abuse
  • Hx of COPD

Pleural drainage:

  • Thoracocentesis: a procedure to remove fluid from the pleural space and then used diagnostical to establish the cause of the pleural effusion.
  • Chest drain (tube thoracostomy): position tube under USS guidance in a dependent part of the empyema. The key to this procedure is  prompt drainage. There are two techniques:

Recent studies have shown that thrombolytic therapy (streptokinase) for complicated parapneumonic effusions have been effective if administered early and at this stage show a 70-90% success rate in halting the progression to empyema

  • VATS – videa assisted throrascopy, with the patient under local or general anesthesia to allow direct visiulisation, via an endoscope so minimally invasive, of the empyema so it can be drained completely or decortication = removal of inflamed pleural layer. Most often used in patients with multi-located empyema

Universal Serial Bus, Obviously

December 18, 2009

Convergence, what a wonderful thing.  We need glucometers in iPhones, surely?  Or perhaps one of those machines to analyse urine dipsticks on a Nintendo DSi?

I want a Firewire 800 drive with a CT scanner attached to it – like the Star Trek Widdly-wip machine.


Xmas Parties

December 18, 2009

Xmas Party number 1 tonight – tonight DundeeChest was the “Plus 1”.  An opportunity to talk to some GP trainees, and also a St Andrews and Edinburgh medical student.  She was intrigued by the DundeeChest idea, I think.  Enough to google us?  I suspect so.  I’d like to think the word might spread across to Lothian, we might get a few more hits, and perhaps a few more regular readers, or, perhaps, some contributions?

So, Kerry, if you’re reading this; welcome to DundeeChest!  Register, and get posting.

And Merry Christmas.

Radiation Doses

December 16, 2009

To follow on from the radiation dosage questionnaire data I presented at grand round the other week, here’s something from today’s e-news suggesting how many extra cancers are caused each year due to excessive CT scanning.

As always, there’s a question on the actual equivalence of dose for a CXR, and a CT.  Our data here has a CXR as 0.02 mSv, about 3 days background radiation in the UK.  To give an idea of lethality, Dr Slotin (The original Mr Manhattan) received a dose of 21 Sv, and died 9 days later.  That’s a million CXRs in a single dose.

Still, I think we massively underestimate the impact of ionising radiation on our young (and old) patients.

Learning Opportunities

December 13, 2009

Hello DundeeChesters.

This week there’s plenty to do in East Block, with so many SpRs floating around you’re bound to get some quality teaching.

Monday AM – Ward Round, Dr Winter’s Clinic, Cancer Clinic with Dr Brown.

Monday PM – EBUS and Bronch list, Dr France’s Clinic, Dr Fardon’s Clinic (Without Dr Fardon)

Tuesday AM – X-Ray Meeting at 08:30, Ward Round. Dr Winter’s Clinic, Dr Smith’s Clinic

Tuesday PM – Sleep Clinic

Wednesday AM – ILD Clinic, Asthma Clinic, Ward Round, Bronch list, with an EBUS on it

Wednesday PM – DundeeApples teaching

Thursday AM – CF Clinic, Ward Round

Thursday Lunch – Medical Grand Round

Thursday PM – Lung Cancer MDT

Friday AM – Cough Clinic, Bronch list with EBUS

Friday Lunch – Respiratory Department Xmas Quiz!

Friday PM – DundeePears teaching

Friday Night – Respiratory Department Xmas Night Out!

I’m on the ward all week, so there’ll be HDU patients to review, referrals to see in far flung areas of the hospital, bits of ad-hoc teaching on whatever comes into my head, you know the sort of thing.

Plus blogging on the site, with any tid-bits I find lying around this interweb, thingy.

The future of education, or do you fancy a free iPhone…

December 10, 2009

Give away 1000 free iPhones, ask the students to use them for learning, and then be shocked when the feedback is awesome!

Seriously, I think the iPhone/iPod Touch platform is the way forward for medical education and support – it’s such a versatile little thing, powerful, and now almost ubiquitous.  You can even get free tickets to the cinema with an Orange iPhone now.