RA for HFs is not widely used in UK EDs, proving that there is room for improvement .The finding that RA blocks are performed by the ED medical staff in 84% of the responding EDs practising RA was reassuring for developing the service in our hospital. FICB should be considered as an alternative to parenteral analgesia in adult patients with HF.

A 29-year-old man was admitted following the deliberate (witnessed) ingestion of approximately 300 mL of 'Roundup Ace,' a herbicide containing glyphosate as its active ingredient. On presentation he was agitated and sweating, with partial airway obstruction and trismus. He required intubation and mechanical ventilation for airway control.Initial blood gases were normal but within a few hours of admission he had developed a severe and persistent lactic acidosis. A continuous sodium bicarbonate infusion was commenced in an attempt to reverse this. Hyperkalaemia developed rapidly, and was associated with cardiac arrhythmias including ventricular tachycardia. Hyperkalaemia was initially managed with intravenous calcium gluconate and insulin and dextrose, while a haemofiltration catheter was inserted. Seven hours after admission, the patient was started on continuous veno-venous haemofiltration (CVVHF), which two hours later was changed to haemodiafiltration (CVVHDF) following telephone advice from the National Poisons Information Service. CVVHDF was maintained almost continuously, at a dose of 35 mL/kg/h, for around 40 hours of his 59-hour admission to the critical care unit. Accusol 35 (Baxter International Inc.) was used as the buffer solution.Hypotension became a persistent problem, and by hour 10 of his admission, a noradrenaline infusion was commenced at a rate of 0.543 µg/kg/min. Despite the patient receiving approximately 10 litres of intravenous fluid on the first day of admission alone, and maintaining a mean central venous pressure of around 12.5 cm H 2 O, he was requiring up to 1.43 µg/kg/min of noradrenaline by day 2. Although oesophageal Doppler haemodynamic monitoring was available on the unit it was not used. This was due to fears that the patient was at increased risk of oesophageal perforation, secondary to the corrosive effects of GlySH.Approximately 12 hours after admission, the patient developed torrential watery diarrhoea and a distended abdomen. Serum pH was maintained within a relatively normal range but lactataemia persisted despite CVVHDF (Figure 1). Therefore, when more stable on day 2, CVVHDF was interrupted and the patient had a CT scan of his abdomen to rule out an intra-abdominal cause for the high lactate. The CT revealed an ileus and otherwise apparently normal internal organs. The patient also had an upper GI endoscopy due to concerns that the GlySH ingestion may have caused a stenosed or perforated oesophagus. His oesophagus was ulcerated, though patent, and he had extensive oesophago-gastritis.After returning from the CT scanner and before restarting haemofiltration, the patient suffered a cardiac arrest. Return of spontaneous circulation occurred with cardiopulmonary resuscitation (CPR) and a single synchronised DC shock for ventricular tachycardia. He was placed back on CVVHDF and a transthoracic echocardiogram revealed no structural cardiac Fatal poisoning with glyphosatesurfactant herbicide E Beswick, J MilloA 29-year-old man was admitted following deliberate ingestion of appro...

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