Journal of Emergencies, Trauma, and Shock
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REVIEW ARTICLE
Emergency management of fat embolism syndrome
Nissar Shaikh
January-April 2009, 2(1):29-33
DOI:10.4103/0974-2700.44680  PMID:19561953
Fat emboli occur in all patients with long-bone fractures, but only few patients develop systemic dysfunction, particularly the triad of skin, brain, and lung dysfunction known as the fat embolism syndrome (FES). Here we review the FES literature under different subheadings. The incidence of FES varies from 1-29%. The etiology may be traumatic or, rarely, nontraumatic. Various factors increase the incidence of FES. Mechanical and biochemical theories have been proposed for the pathophysiology of FES. The clinical manifestations include respiratory and cerebral dysfunction and a petechial rash. Diagnosis of FES is difficult. The other causes for the above-mentioned organ dysfunction have to be excluded. The clinical criteria along with imaging studies help in diagnosis. FES can be detected early by continuous pulse oximetry in high-risk patients. Treatment of FES is essentially supportive. Medications, including steroids, heparin, alcohol, and dextran, have been found to be ineffective.
  44,156 1,053 13
EVIDENCE BASED REVIEW
Use of antiemetics in children with acute gastroenteritis: Are they safe and effective?
Jacob Manteuffel
January-April 2009, 2(1):3-5
DOI:10.4103/0974-2700.44674  PMID:19561947
The use of antiemetics is a controversial topic in treatment of pediatric gastroenteritis. Although not recommended by the American Academy of Pediatrics, antiemetics are commonly prescribed by physicians. A review of the literature shows side effects of promethazine, prochlorperazine, and metoclopramide are common and potentially dangerous. Ondansetron has recently been studied as an adjunct to oral rehydration therapy in treatment of acute gastroenteritis with mild to moderate dehydration. Although studies are limited, early research suggests the medication is safe when used in a single dose and can be effective to prevent vomiting, the need for intravenous fluids, and hospital admission.
  24,419 589 3
ORIGINAL ARTICLES
Injuries, negative consequences, and risk behaviors among both injured and uninjured emergency department patients who report using alcohol and marijuana
Robert Woolard, Janette Baird, Michael J Mello, Christina Lee, Magda Harington, Ted Nirenberg, Bruce Becker, Lynn Stein, Richard Longabaugh
January-April 2009, 2(1):23-28
DOI:10.4103/0974-2700.44679  PMID:19561952
Background: Brief intervention (BI) to reduce hazardous drinking and negative consequences such as injury has been effective when given in the emergency department (ED). The effectiveness and effect of BI has varied between injured and uninjured ED patients. This study compares injured and uninjured ED patients who admit to alcohol and marijuana use to determine their need and their readiness for BI. Patients and Methods: Participants volunteered to enter a randomized controlled trial of BI to reduce hazardous alcohol and marijuana use. Adult ED patients who had had alcohol in the last month and smoked marijuana in the last year were recruited. Those patients who were admitted to hospital, were under police custody, or were seeking treatment for substance use or psychiatric disorder were excluded. Research assistants interviewed participants using a validated questionnaire. Data were analyzed using SAS (version 9.1). Binominal tests of proportions, t-test analyses, and transformations were conducted as appropriate. Results: Injured (n = 249) and uninjured (n = 266) study participants reported very high, statistically equivalent (P > 0.05), rates of binge drinking (4-5 days/month), marijuana use (13 days/month), driving under the influence of marijuana or alcohol (>49% in the last 3 months), injury (>83% in the last year), and other negative consequences (>64% in the last 3 months) prior to their ED visit. These behaviors and the consequences demonstrate a need for change. Both injured and uninjured subjects were ready to change (>56%) and confident they could change (>91%) alcohol and marijuana use. Discussion: ED patients who admit to alcohol and marijuana use also use other hazardous substances and participate in high-risk behaviors. In both injured and uninjured patients who admit using alcohol and marijuana, the ED visit is an opportunity to deliver BI to reduce alcohol and marijuana use and associated risk behaviors and the subsequent injury and negative consequences. Given their risk behaviors and experience of negative consequences, members of both injured and uninjured groups have an equal need for BI. Fortunately, in both groups, a high number of members express motivation to change.
  20,752 148 6
SYMPOSIUM
Leptospirosis: The "mysterious" mimic
Ricardo Izurieta, Sagar Galwankar, Angela Clem
January-June 2008, 1(1):21-33
DOI:10.4103/0974-2700.40573  PMID:19561939
Leptospirosis is a potentially fatal bacterial disease that can display a wide array of clinical presentations thus mimicking better-known illnesses. Although, leptospirosis is primarily a zoonotic disease, it frequently inflicts severe illness and death on communities around the globe. A comprehensive overview of the disease in wake of the 2006 outbreaks in India is hereby presented and discussed.
  16,423 440 2
SYMPOSIUM ON SONOGRAPHY AND SURVIVAL
The role of bedside ultrasound in the diagnosis of pericardial effusion and cardiac tamponade
Adam Goodman, Phillips Perera, Thomas Mailhot, Diku Mandavia
January-March 2012, 5(1):72-75
DOI:10.4103/0974-2700.93118  PMID:22416160
This review article discusses two clinical cases of patients presenting to the emergency department with pericardial effusions. The role of bedside ultrasound in the detection of pericardial effusions is investigated, with special attention to the specific ultrasound features of cardiac tamponade. Through this review, clinicians caring for patients with pericardial effusions will learn to rapidly diagnose this condition directly at the bedside. Clinicians will also learn to differentiate between simple pericardial effusions in contrast to more complicated effusions causing cardiac tamponade. Indications for emergency pericardiocentesis are covered, so that clinicians can rapidly determine which group of patients will benefit from an emergency procedure to drain the effusion.
  15,606 29 10
CASE REPORTS
A 19-year-old male with palpitations
Shailendra Upadhyay, Shweta Upadhyay
January-June 2008, 1(1):55-57
DOI:10.4103/0974-2700.41792  PMID:19561944
A 19-year-old male presented to the emergency department (ED) following intermittent episodes of palpitations. Classical "epsilon waves" noted on his initial electrocardiogram prompted an evaluation for arrhythmogenic right ventricular dysplasia (ARVD). The diagnosis was confirmed with magnetic resonance imaging of the heart and stress test. A prompt recognition and management of this condition in the ED helped prevent significant mortality that may be associated with ARVD.
  14,521 265 -
PRACTITIONER SECTION
Emergency treatment of a snake bite: Pearls from literature
Syed Moied Ahmed, Mohib Ahmed, Abu Nadeem, Jyotsna Mahajan, Adarash Choudhary, Jyotishka Pal
July-December 2008, 1(2):97-105
DOI:10.4103/0974-2700.43190  PMID:19561988
Snake bite is a well-known occupational hazard amongst farmers, plantation workers, and other outdoor workers and results in much morbidity and mortality throughout the world. This occupational hazard is no more an issue restricted to a particular part of the world; it has become a global issue. Accurate statistics of the incidence of snakebite and its morbidity and mortality throughout the world does not exist; however, it is certain to be higher than what is reported. This is because even today most of the victims initially approach traditional healers for treatment and many are not even registered in the hospital. Hence, registering such patients is an important goal if we are to have accurate statistics and reduce the morbidity and mortality due to snakebite. World Health Organization/South East Asian Region Organisation (WHO/SEARO) has published guidelines, specific for the South East Asian region, for the clinical management of snakebites. The same guidelines may be applied for managing snakebite patients in other parts of the world also, since no other professional body has come up with any other evidence-based guidelines. In this article we highlight the incidence and clinical features of different types of snakebite and the management guidelines as per the WHO/SEARO recommendation.
  13,951 572 7
SYMPOSIUM ON CURRENT TRENDS IN CRITICAL ILLNESS AND INJURY SCIENCE
The advent of ECMO and pumpless extracorporeal lung assist in ARDS
IA Hamid, AS Hariharan, NR Ravi Shankar
April-June 2011, 4(2):244-250
DOI:10.4103/0974-2700.82212  PMID:21769212
Despite advances in critical care facilities and ventilation therapies acute respiratory distress syndrome (ARDS) is associated with high mortality rates. The condition can stem from a multitude of causes including pneumonia, septicemia and trauma ultimately resulting in ARDS. ARDS is characterized by respiratory insufficiency with severe hypoxemia or hypercapnia. The treatment strategy depends on the knowledge of the underlying disease. But lung-protective ventilation with adjusted positive end-expiratory pressure remains the most effective therapeutic tool despite advances in prone positioning, inhalation of nitric oxide and the use of steroids. Newer modalities including extracorporeal membrane oxygenation (ECMO) and pumpless extracorporeal lung assist (PECLA) are being increasingly introduced in critical care settings as rescue therapies in patients who fail to respond to conservative measures. We describe here the introduction and advances of both ECMO and PECLA in the management of ARDS.
  14,064 22 5
PICTORIAL EDUCATION
Acute scrotal bleeding
Sudip Kumar Ghosh, Debabrata Bandyopadhyay
October-December 2010, 3(4):416-417
DOI:10.4103/0974-2700.70778  PMID:21063571
We report a case of acute scrotal hemorrhage from multiple angiokeratomas on scrotum, because of the rarity of the condition and to emphasize the importance of considering this condition in the evaluation of acute scrotal bleeding.
  13,811 23 -
PRACTITIONER SECTION
Principles of diagnosis and management of traumatic pneumothorax
Anita Sharma, Parul Jindal
January-June 2008, 1(1):34-41
DOI:10.4103/0974-2700.41789  PMID:19561940
Presence of air and fluid with in the chest might have been documented as early as Fifth Century B.C. by a physician in ancient Greece, who practiced the so-called Hippocratic succession of the chest. This is due to a development of communication between intrapulmonary air space and pleural space, or through the chest wall between the atmosphere and pleural space. Air enters the pleural space until the pressure gradient is eliminated or the communication is closed. Increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (noniatrogenic and iatrogenic) pneumothorax. Clinical spectrum of pneumothorax varies from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination. Simple erect chest radiograph is sufficient though; many investigations are useful in accessing the future line of action. However, in certain life-threatening conditions obtaining imaging studies can causes an unnecessary and potential lethal delay in treatment.
  12,702 574 8
SYMPOSIUM ON CURRENT TRENDS IN ACUTE CARE
Pediatric cardiac emergencies: Children are not small adults
Aisha Frazier, Elizabeth A Hunt, Kathryn Holmes
January-March 2011, 4(1):89-96
DOI:10.4103/0974-2700.76842  PMID:21633575
Compared with adults, cardiac emergencies are infrequent in children and clinical presentation is often quite variable. In adults, cardiac emergencies are most commonly related to complications of coronary artery disease; however, in pediatric cases, the coronaries are only rarely the underlying problem. Pediatric cardiac emergencies comprise a range of pathology including but not limited to undiagnosed congenital heart disease in the infant; complications of palliated congenital heart disease in children; arrhythmias related to underlying cardiac pathology in the teenager and acquired heart disease. The emergency room physician and pediatric intensivist will usually be the first and second lines of care for pediatric cardiac emergencies and thus it is imperative that they have knowledge of the diverse presentations of cardiac disease in order to increase the likelihood of delivering early appropriate therapy and referral. The objective of this review is to outline cardiac emergencies in the pediatric population and contrast the presentation with adults.
  12,323 40 2
A primer on burn resuscitation
Ferdinand K Bacomo, Kevin K Chung
January-March 2011, 4(1):109-113
DOI:10.4103/0974-2700.76845  PMID:21633578
Since the early 1900s, the scope of burn resuscitation has evolved dramatically. Due to various advances in pre-hospital care and training, under-resuscitation of patients with severe burns is now relatively uncommon. Over-resuscitation, otherwise known as "fluid creep", has emerged as one of the most important problems during the initial phases of burn care over the past decade. To avoid the complications of over-resuscitation, careful hourly titration of fluid rates based on compilation of various clinical end points by a bedside provider is vital. The aim of this review is to provide a practical approach to the resuscitation of severely burned patients.
  10,373 35 5
SYMPOSIUM ON EMERGENCY NEUROSCIENCES
Management of penetrating brain injury
Syed Faraz Kazim, Muhammad Shahzad Shamim, Muhammad Zubair Tahir, Syed Ather Enam, Shahan Waheed
July-September 2011, 4(3):395-402
DOI:10.4103/0974-2700.83871  PMID:21887033
Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of Guidelines for the Management of Penetrating Brain Injuryin 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on Guidelines for the Management of Penetrating Brain Injury and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI patients. Cerebral angiography is recommended in patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI patients.
  10,145 27 12
LETTERS TO EDITOR
Isolated transverse process fracture of the lumbar vertebrae
Amit Agrawal, Sandeep Srivastava, Anand Kakani
September-December 2009, 2(3):217-218
DOI:10.4103/0974-2700.55350  PMID:20009319
  9,503 364 -
SYMPOSIUM ON COMMON PRACTICES FOR UNCOMMON PROBLEMS IN ACUTE MEDICINE
Acute management of vascular air embolism
Nissar Shaikh, Firdous Ummunisa
September-December 2009, 2(3):180-185
DOI:10.4103/0974-2700.55330  PMID:20009308
Vascular air embolism (VAE) is known since early nineteenth century. It is the entrainment of air or gas from operative field or other communications into the venous or arterial vasculature. Exact incidence of VAE is difficult to estimate. High risk surgeries for VAE are sitting position and posterior fossa neurosurgeries, cesarean section, laparoscopic, orthopedic, surgeries invasive procedures, pulmonary overpressure syndrome, and decompression syndrome. Risk factors for VAE are operative site 5 cm  above the heart, creation of pressure gradient which will facilitate entry of air into the circulation, orogenital sex during pregnancy, rapid ascent in scuba (self contained underwater breathing apparatus) divers and barotrauma or chest trauma. Large bolus of air can lead to right ventricular air lock and immediate fatality. In up to 35% patient, the foramen ovale is patent which can cause paradoxical arterial air embolism. VAE affects cardiovascular, pulmonary and central nervous system. High index of clinical suspicion is must to diagnose VAE. The transesophgeal echocardiography is the most sensitive device which will detect smallest amount of air in the circulation. Treatment of VAE is to prevent further entrainment of air, reduce the volume of air entrained and haemodynamic support. Mortality of VAE ranges from 48 to 80%. VAE can be prevented significantly by proper positioning during surgery, optimal hydration, avoiding use of nitrous oxide, meticulous care during insertion, removal of central venous catheter, proper guidance, and training of scuba divers.
  9,075 358 12
EKG PEARL
Wellen's syndrome: An ominous EKG pattern
Nicole E Mead, Kelly P O'Keefe
September-December 2009, 2(3):206-208
DOI:10.4103/0974-2700.55347  PMID:20009314
Wellen's syndrome is a characteristic T-wave on an electrocardiogram during a pain-free period in a patient with intermittent chest pain. This finding suggests a high-degree stenosis of the proximal left anterior descending (LAD) coronary artery that will soon result in an acute anterior wall myocardial infarction (MI) if the patient is not urgently catheterized and the occlusion opened. This case report discusses a young male patient with no known cardiac disease with an EKG that demonstrates the classic Wellen's T-waves. He was urgently taken to cardiac catheterization and his 95% proximal LAD stenosis was reduced via drug-eluding stent. Through knowledge of Wellen's T-waves, more anterior wall MIs can be prevented.
  8,095 529 7
EXPERT COMMENTARY
Interval appendectomy in adults: A necessary evil?
Benjamin Quartey
July-September 2012, 5(3):213-216
DOI:10.4103/0974-2700.99683  PMID:22988397
The management of appendiceal mass remains a matter of major controversy in the current literature. Currently, initial nonoperative management followed by interval appendectomy is favored over immediate appendicectomy. However, the necessity of doing an interval appendectomy has been questioned - is it a necessary evil? The present review revisits the above controversy, evaluates the current literature, assesses the need for interval appendectomy in adults, and provides recommendations.
  8,566 29 -
CASE REPORTS
Epstein-Barr virus-associated hemophagocytic syndrome mimicking severe sepsis
Talya Spivack, Rashmi Chawla, Paul E Marik
July-December 2008, 1(2):119-122
DOI:10.4103/0974-2700.43198  PMID:19561991
Severe sepsis is amongst the most common reasons for admission to the intensive care unit (ICU) throughout the world and is a common cause of death. The diagnosis of sepsis is usually straightforward, being based on a constellation of clinical and laboratory features. Noninfectious disorders, including pancreatitis, drug reactions, and autoimmune disorders, may cause a systemic inflammatory response that mimics sepsis. We present the case of a 32-year-old male with Epstein-Barr virus-associated hemophagocytic syndrome who presented to the ICU with features of severe sepsis which progressed to multisystem organ failure and death despite aggressive supportive measures.
  8,136 271 -
PRACTITIONER SECTION
Cardiac arrest and pregnancy
Tabitha A Campbell, Tracy G Sanson
January-April 2009, 2(1):34-42
DOI:10.4103/0974-2700.43586  PMID:19561954
Cardiopulmonary arrest in pregnancy is rare occurring in 1 in 30,000 pregnancies. When it does occur, it is important for a clinician to be familiar with the features peculiar to the pregnant state. Knowledge of the anatomic and physiologic changes of pregnancy is helpful in the treatment and diagnosis. Although the main focus should be on the mother, it should not be forgotten that there is another potential life at stake. Resuscitation of the mother is performed in the same manner as in any other patient, except for a few minor adjustments because of the changes of pregnancy. The specialties of obstetrics and neonatology should be involved early in the process to ensure appropriate treatment of both mother and the newborn. This article will explore the changes that occur in pregnancy and their impact on treatment. The common causes of maternal cardiac arrest will be discussed briefly.
  7,902 444 7
CASE SERIES
Adult necrotizing enterocolitis and non occlusive mesenteric ischemia
Sanoop Koshy Zachariah
July-September 2011, 4(3):430-432
DOI:10.4103/0974-2700.83881  PMID:21887043
Adult necrotizing enterocolitis and non occlusive mesenteric ischemia are rare causes of acute abdomen in adults. Accurate preoperative diagnosis is often difficult in these cases. Here, four cases of massive bowel necrosis with varying segments of small and large bowel involvement are described, all of whom underwent surgery. These cases give an opportunity to review the literature on such lethal diseases including non occlusive intestinal necrosis, neonatal necrotizing enterocolitis and adult necrotizing enterocolitis. The similarities and differences in etiology, pathophysiology, clinical and radiological findings are discussed.
  8,223 12 5
SYMPOSIUM ON CURRENT TRENDS IN CRITICAL ILLNESS AND INJURY SCIENCE
Abdominal compartment syndrome - Intra-abdominal hypertension: Defining, diagnosing, and managing
Theodossis S Papavramidis, Athanasios D Marinis, Ioannis Pliakos, Isaak Kesisoglou, Nicki Papavramidou
April-June 2011, 4(2):279-291
DOI:10.4103/0974-2700.82224  PMID:21769216
Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) are increasingly recognized as potential complications in intensive care unit (ICU) patients. ACS and IAH affect all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. ACS/IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of ACS/IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. We start this article with a brief historic review on ACS/IAH. Then, we present the definitions concerning parameters necessary in understanding ACS/IAH. Finally, pathophysiology aspects of both phenomena are presented, prior to exploring the various facets of ACS/IAH management.
  7,970 32 16
CASE REPORTS
An unusual presentation of Bell's palsy: A case report and review of literature
Anna McFarlin, Bradley Peckler
January-June 2008, 1(1):50-52
DOI:10.4103/0974-2700.40574  PMID:19561942
In clinical medicine there may be times when clinical conditions manifest differently both when they present individually or concomitantly. Such scenarios warrant a broader differential diagnosis with thorough investigations. We present one such case of a patient of Bell's palsy with unexplained eye pain on the ipsilateral side. The patient had a chronic retinal detachment which became worse due to the concomitant Bell's palsy.
  7,560 273 -
ORIGINAL ARTICLES
Using continuous renal replacement therapy to manage patients of shock and acute renal failure
Sachin S Soni, Amit P Nagarik, Gopal Kishan Adikey, Anuradha Raman
January-April 2009, 2(1):19-22
DOI:10.4103/0974-2700.44678  PMID:19561951
Background: The incidence of acute renal failure (ARF) in the hospital setting is increasing. It portends excessive morbidity and mortality and a considerable burden on hospital resources. Extracorporeal therapies show promise in the management of patients with shock and ARF. It is said that the potential of such therapy goes beyond just providing renal support. The aim of our study was to analyze the clinical setting and outcomes of critically ill ARF patients managed with continuous renal replacement therapy (CRRT). Patients and Methods: Ours was a retrospective study of 50 patients treated between January 2004 and November 2005. These 50 patients were in clinical shock and had concomitant ARF. All of these patients underwent CVVHDF (continuous veno-venous hemodiafiltration) in the intensive care unit. For the purpose of this study, shock was defined as systolic BP < 100 mm Hg in spite of administration of one or more inotropic agents. SOFA (Sequential Organ Failure Assessment) score before initiation of dialysis support was recorded in all cases. CVVHDF was performed using the Diapact (Braun) CRRT machine. The vascular access used was as follows: femoral in 32, internal jugular in 8, arteriovenous fistula (AVF) in 4, and subclavian in 6 patients. We used 0.9% or 0.45% (half-normal) saline as a prefilter replacement, with addition of 10% calcium gluconate, magnesium sulphate, sodium bicarbonate, and potassium chloride in separate units, while maintaining careful monitoring of electrolytes. Anticoagulation of the extracorporeal circuit was achieved with systemic heparin in 26 patients; frequent saline flushes were used in the other 24 patients. Results: Of the 50 patients studied, 29 were males and 21 females (1.4:1). The average age was 52.88 years (range: 20-75 years). Causes of ARF included sepsis in 24 (48%), hemodynamically mediated renal failure (HMRF) in 18 (36%), and acute over chronic kidney disease in 8 (16%) patients. The overall mortality was 74%. The average SOFA score was 14.31. The variables influencing mortality on multivariate analysis were: age [odds ratio (OR):1.65; 95% CI: 1.35 to 1.92; P = 0.04], serum creatinine (OR:1.68; 95% CI: 1.44 to 1.86; P = 0.03), and serum bicarbonate (OR: 0.76; 95% CI: 0.55 to 0.94; P = 0.01). On univariate analysis the SOFA score was found to be a useful predictor of mortality. Conclusions: Despite advances in treating critically ill patients with newer extracorporeal therapies, mortality is dismally high. Multiorgan dysfunction adversely affects outcome of CRRT. Older age, level of azotemia, and severity of metabolic acidosis are important predictors of adverse outcome.
  7,332 422 1
SYMPOSIUM ON COMMON PRACTICES FOR UNCOMMON PROBLEMS IN ACUTE MEDICINE
Managing human bites
Pradnya D Patil, Tanmay S Panchabhai, Sagar C Galwankar
September-December 2009, 2(3):186-190
DOI:10.4103/0974-2700.55331  PMID:20009309
Human bites are frequently overlooked in making a diagnosis in the emergency room. They are particularly notorious due to the polymicrobial nature of human saliva inoculated in the wound and the risk they pose for transmission of infectious diseases. Early treatment, appropriate prophylaxis and surgical evaluation are the key to achieving desired treatment outcomes. Through this article, we have tried to summarize the diagnostic features, complications as well as the recommended treatment alternatives for human bites based on the current available evidence.
  7,517 181 4
SYMPOSIUM ON CURRENT TRENDS IN ACUTE CARE
Heparin-induced thrombocytopenia
Nissar Shaikh
January-March 2011, 4(1):97-102
DOI:10.4103/0974-2700.76843  PMID:21633576
In the last 7 decades heparin has remained the most commonly used anticoagulant. Its use is increasing, mainly due to the increase in the number of vascular interventions and aging population. The most feared complication of heparin use is heparin-induced thrombocytopenia (HIT). HIT is a clinicopathologic hypercoagulable, procoagulant prothrombotic condition in patients on heparin therapy, and decrease in platelet count by 50% or to less than 100,000, from 5 to 14 days of therapy. This prothrombotic hypercoagulable state in HIT patient is due to the combined effect of various factors, such as platelet activation, mainly the formation of PF4/heparin/IgG complex, stimulation of the intrinsic factor, and loss of anticoagulant effect of heparin. Diagnosis of HIT is done by clinical condition, heparin use, and timing of thrombocytopenia, and it is confirmed by either serotonin release assay or ELISA assay. Complications of HIT are venous/arterial thrombosis, skin gangrene, and acute platelet activation syndrome. Stopping heparin is the basic initial treatment, and Direct Thrombin Inhibitors (DTI) are medication of choice in these patients. A few routine but essential procedures performed by using heparin are hemodialysis, Percutaneous Coronary Intervention, and Cardiopulmonary Bypass; but it cannot be used if a patient develops HIT. HIT patients with unstable angina, thromboembolism, or indwelling devices, such as valve replacement or intraaortic balloon pump, will require alternative anticoagulation therapy. HIT can be prevented significantly by keeping heparin therapy shorter, avoiding bovine heparin, using low-molecular weight heparin, and stopping heparin use for flush and heparin lock.
  7,669 21 2
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