A 15-year-old girl presented after intentional ingestion of dapsone (7.2 g) and small quantities of azathioprine, methotrexate and prednisolone. The resulting methaemoglobinaemia and lactic acidosis persisted despite treatment with methylene blue, multiple-dose activated charcoal and ascorbic acid. Continuous veno-venous haemofiltration for 75 hours was used to treat the dapsone overdose. The patient's serum dapsone concentrations were measured during and after continuous veno-venous haemofiltration. The rate of elimination of dapsone was over three times higher during, compared to after, continuous veno-venous haemofiltration. Continuous renal replacement therapy successfully reduced toxic dapsone concentrations in this patient with a good outcome.

Phosphine poisoning is responsible for hundreds of thousands of deaths per year in countries where access to this pesticide is unrestricted. Metal phosphides release phosphine gas on contact with moisture, and ingestion of these tablets most often results in death despite intensive support. A 36-year-old woman presented to a regional hospital after ingesting multiple aluminium phosphide pesticide tablets and rapidly developed severe cardiogenic shock. In this case, serendipitous access to an untested Extracorporeal Membrane Oxygenation (ECMO) service of a regional hospital effected a successful rescue and prevented the predicted death. We discuss the toxicology, management and the evidence for and against using ECMO in this acute poisoning.

Background: Fibrinolytic therapy has reduced mortality following acute myocardial infarction (AMI) with the major effect coming from early achievement of infarct-related artery patency. Aim: To evaluate the door-to-needle time for fibrinolytic administration for AMI and to identify factors associated with a prolonged door-to-needle time. Materials and Methods: Our study was a prospective audit of patients who were thrombolyzed for AMI at our hospital from July 1, 2004 to March 15, 2005. All patients admitted with AMI, who were candidates for fibrinolysis, were included. We recorded the door-to-needle time. Whenever pos sible, we tried to find out the reason for prolonged door-to-needle time. Results: A door-to-needle time of <30 min could be achieved in 19 of our 35 patients (54.28%). Mean door-to-needle time was 45.25 min.Discussion: Although most guidelines recommend a door-to-needle time of less than 30 min, most hospi tals fail to achieve this in most patients. A study conducted by Zed et al. at the Vancouver General Hospital showed that a door-to-needle time of less than 30 min was achieved in only 24.3%. The door-to-needle time achieved at our center was shorter. In most of our patients who were thrombolyzed late, a delay in taking or interpreting an electrocardiogram was responsible. Transfer to the intensive care unit for throm bolysis also resulted in considerable delay. Conclusions: A door-to-needle time of less than 30 mins could be achieved in 19 of our 35 patients (54.28%). A significant number of AMI patients thrombolyzed did not meet the guideline for door-to-needle time of less than 30 min.

Background: The management of acute intracranial hypertension refractory, to the medical management, remains a challenging endeavour. Mortality and morbidity rates remain high despite optimal medical management. Decompressive craniectomy has been proposed as an effective treatment for patients who have raised intracranial pressure (ICP) refractory, to the medical management. This study examined the outcome of patients who underwent this procedure. Aim: To assess the outcome of patients who underwent decompressive craniectomy. Materials and Methods: We conducted a prospective audit of consecutive patients of one neurosurgical unit, who underwent decompressive craniectomy at a tertiary care centre between 01/01/2004 to 31/03/2005. A complete neurological assessment, including Glasgow coma scale (GCS) and pupils was done and recorded at the time of admission, deterioration, post-op one wk and post op three wks. End points were Glasgow outcome score (GOS) and Karnofsky score at 30 days, at discharge and at 6 months. Results: We studied 12 patients who were aged 30 to 69 yrs (Mean = 47 yrs). Unlike most interventions in critical care, survival is not an acceptable single end point. Good recovery (Karnofsky score ≥80 / GOS≥4) was seen in five patients. Three patients were alive with severe disability (Karnofsky score 1 70 / GOS 2-3), at follow up. Four patients died (Karnofsky score 0 / GOS 1). Conclusion: Eight patients who underwent decompressive craniectomy survived. Five of these patients had a good recovery. The other three survived with severe disability.