Background: Royal Darwin Hospital (RDH) is the only major hospital for the 'Top End' of Northern Territory and Western Australia. As retrieval distances exceed 2600 km, resident generalist surgeons undertake all emergency neurosurgery. Methods: Retrospective clinical study from RDH records and review of prospectively collected datasets from RDH Intensive Care Unit and National Critical Care Trauma Response Centre for all emergency neurosurgery patients between 2008 and 2013. Results: Data were obtained from 161 patients with 167 admissions (73% male, 39% indigenous) who underwent 195 procedures (33 per year), including burr hole, craniotomy, cerebral and posterior fossa craniectomy, elevation fracture and ventricular drain. Trauma accounted for 68%, with alcohol as a known factor in 57%. Subdural haematoma (SDH) accounted for 53%. Severity of head injury at presentation correlated with outcome (R 2 = 0.12, P < 0.001). Factors associated with death included injury at remote location (P = 0.022), time injury to operation >24 h (P = 0.023) and specific diagnoses of acute SDH (P = 0.006), acute-on-chronic SDH (P = 0.053) and infection (P = 0.052). Indigenous patients were younger (40 versus 55 years, P < 0.001) and more likely to have alcohol as a factor in trauma cases (71% versus 49%, P = 0.027). Time from injury to hospital was high for accidents at a remote location (12.9 versus 1.3 h, P < 0.001); however, Glasgow Outcome Scales (P = 0.13) were no different to accident at metropolitan Darwin. Conclusion: General surgeons at RDH perform a wide range of emergency neurosurgical procedures primarily for trauma. Factors contributing to poor outcomes included remote location of trauma and delay in reaching the hospital. Outcomes at 3 months appear acceptable.

A prospective randomized controlled trial was conducted in patients undergoing elective cholecystectomy to assess the value of routine chest physiotherapy. One hundred and two patients entered the study: 47 patients developed no pulmonary complications, 29 had pulmonary atelectasis and a further 26 developed chest infection. The pattern of changes in anerial oxygen tension in the period after operation supponed the Hiniral allocation of the patients. Of 51 patients not receiving physiotherapy, 11 developed atelectasis and 19 chest infection. Of 51 treated patients, 18 developed atelectasis and seven chest infection. Routine prophylactic postoperative chest physiotherapy decreased significantly the frequency of chest infection (P< 0.02). PATIENTS AND METHODS Consecutive patients undergoing elective cholecystectomy were included in the study. Respiratory status was established before operation using a ques

SUMMARYAmniotic fluid embolism (AFE) is a rare and potentially fatal complication of pregnancy. In this case report, we highlight the successful use of sodium bicarbonate in a patient with an AFE. We present a case of a 38-year-old mother admitted for an elective caesarean section. Following the delivery of her baby, the mother suffered a cardiac arrest. Following a protracted resuscitation, transoesophageal echocardiography demonstrated evidence of acute pulmonary hypertension, with an empty left ventricle and an over-distended right ventricle. In view of these findings and no improvement noted from on-going resuscitation, sodium bicarbonate was infused as a pulmonary vasodilator. Almost instantaneous return of spontaneous circulation was noted, with normalisation of cardiac parameters. We propose that in patients suspected with AFE and who have been unresponsive to advance cardiac life support measures, and where right ventricular failure is present with acidosis and/or hypercarbia, the use of sodium bicarbonate should be considered. BACKGROUND

A prospective randomized controlled trial was conducted in patients undergoing elective cholecystectomy to assess the value of routine chest physiotherapy. One hundred and two patients entered the study: 47 patients developed no pulmonary complications, 29 had pulmonary atelectasis and a further 26 developed chest infection. The pattern of changes in arterial oxygen tension in the period after operation supported the clinical allocation of the patients. Of 51 patients not receiving physiotherapy, 11 developed atelectasis and 19 chest infection. Of 51 treated patients, 18 developed atelectasis and seven chest infection. Routine prophylactic postoperative chest physiotherapy decreased significantly the frequency of chest infection (P less than 0.02).

BACKGROUND AND PURPOSE: To test the design and feasibility of a very large randomised controlled trial assessing the efficacy and safety of antithrombotic therapy started within 48 hours of symptom onset in patients with suspected acute ischaemic stroke. DESIGN: Randomised controlled multicentre open study, with a 3 x 2 factorial design, allocating patients to: medium dose subcutaneous heparin (12,500 units twice per day), versus low dose subcutaneous heparin (5000 units twice per day) versus no heparin; and aspirin (300 mg daily) versus no aspirin. Treatment was given for two weeks or until discharge from hospital if sooner. RESULTS: 984 patients were randomised. CT was performed in 924 (94%) (before randomisation in 622/984 (63%). Within 14 days: 97 patients had died (10%), 30 (3.0%) had a fatal or non-fatal recurrent ischaemic stroke, nine (0.9%) had fatal or non-fatal recurrent stroke due to intracranial haemorrhage, and eight (0.8%) had a fatal or non-fatal pulmonary embolus. At six months, vital status was known for 975 patients (99%), of whom 210 (22%) were dead, 373 (38%) were alive but dependent, and 225 (23%) were independent but not fully recovered. CONCLUSIONS: The trial procedures proved practicable and a wide variety of patients were recruited. Sample size calculation based on the event rates confirmed that reliable evidence on the balance of risk and benefit of early antithrombotic therapy might require a study with more than 20,000 patients. Recruitment rates in the pilot study indicated that if about 200 hospitals participated, recruitment could be completed by 1997.