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2010| July-September | Volume 3 | Issue 3
Online since
July 19, 2010
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SYMPOSIUM ON CRITICAL CARDIAC CARE IN CHILDREN
Cardiac arrest in children
Erika E Tress, Patrick M Kochanek, Richard A Saladino, Mioara D Manole
July-September 2010, 3(3):267-272
DOI
:10.4103/0974-2700.66528
PMID
:20930971
Major advances in the field of pediatric cardiac arrest (CA) were made during the last decade, starting with the publication of pediatric Utstein guidelines, the 2005 recommendations by the International Liaison Committee on Resuscitation, and culminating in multicenter collaborations. The epidemiology and pathophysiology of in-hospital and out-of-hospital CA are now well described. Four phases of CA are described and the term "post-cardiac arrest syndrome" has been proposed, along with treatment goals for each of its four phases: immediate post-arrest, early post-arrest, intermediate and recovery phase. Hypothermia is recommended to be considered as a therapy for post-CA syndrome in comatose patients after CA, and large multicenter prospective studies are underway. We reviewed landmark articles related to pediatric CA published during the last decade. We present the current knowledge of epidemiology, pathophysiology and treatment of CA relevant to pre-hospital and acute care health practitioners.
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211
CASE SNIPPETS
Heterotopic pregnancy: A diagnosis we should suspect more often
Karim Ibn Majdoub Hassani, Abderrahim El Bouazzaoui, Mohammed Khatouf, Khalid Mazaz
July-September 2010, 3(3):304-304
DOI
:10.4103/0974-2700.66563
PMID
:20930992
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SYMPOSIUM ON CRITICAL CARDIAC CARE IN CHILDREN
Emergency diagnosis and management of pediatric arrhythmias
Carla R Hanash, Jane E Crosson
July-September 2010, 3(3):251-260
DOI
:10.4103/0974-2700.66525
PMID
:20930969
True emergencies due to unstable arrhythmias in children are rare, as most rhythm disturbances in this age group are well-tolerated. However, presentation to an emergency department with symptoms of palpitations, fatigue and/or syncope is much more common. Sinus tachycardia is by far the most commonly reported arrhythmia, followed by supraventricular tachycardia. Emergency physicians should be prepared for diagnosis and to acutely manage various types of arrhythmias seen in children, to assess the need for further diagnostic testing, and to determine whether cardiology evaluation and follow-up are needed. This article is intended to provide diagnostic and management guidelines of the most common types of arrhythmias seen in children with structurally normal hearts as well as those associated with congenital heart disease and cardiomyopathies.
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ORIGINAL ARTICLES
Developing a clinically relevant classification to predict mortality in severe leptospirosis
Senaka Rajapakse, Chaturaka Rodrigo, Rashan Haniffa
July-September 2010, 3(3):213-219
DOI
:10.4103/0974-2700.66519
PMID
:20930963
Background
: Severe leptospirosis requires critical care and has a high mortality. We reviewed the literature to identify factors predicting mortality, and such predictors were classified according to the predisposition, infection, response, organ dysfunction (PIRO) concept, which is a risk stratification model used in severe sepsis.
Material and Methods
: PUBMED was searched for all articles (English), with the key word "leptospirosis" in any field, within the last 20 years. Data were collected from 45 relevant papers and grouped into each component of the PIRO model.
Results
: The following correlated with increased mortality: predisposition - increasing age and chronic alcoholism; infection - leptospiraemic burden; response - hemodynamic disturbances, leukocytosis; organ dysfunction - multiple organ dysfunction syndrome, pulmonary involvement and acute renal failure.
Conclusions
: Further research is needed to identify the role of infecting serovars, clinical signs, inflammatory markers, cytokines and evidence of hepatic dysfunction as prognostic indicators. It is hoped that this paper will be an initiative to create a staging system for severity of leptospirosis based on the PIRO model with an added component for treatment-related predictors.
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Reviewing the blood ordering schedule for elective orthopedic surgeries at a level one trauma care center
Arulselvi Subramanian, Kanchana Rangarajan, Sudeep Kumar, Kamran Farooque, Vijay Sharma, Mahesh Chandra Misra
July-September 2010, 3(3):225-230
DOI
:10.4103/0974-2700.66521
PMID
:20930965
Background
: Patients undergoing elective orthopedic surgeries often incur excess blood loss necessitating transfusion. The preoperative placement of blood requests frequently overshoots the actual need resulting in unnecessary crossmatching.
Aims
: Our primary goal was to audit the blood utilization in elective orthopedic surgeries in our hospital over a 1-year period and recommend a blood ordering schedule.
Materials and Methods
: A retrospective analysis of patients who underwent elective orthopedic surgeries over a period of 1 year was done. The data collected include patients' age, sex, type of surgical procedure, pre- and postoperative hemoglobin (Hb) levels, number of units crossmatched, returned, transfused, crossmatch to transfusion ratio (C:T), transfusion indices, estimated blood loss for each surgical procedure, and the actual and predicted fall in Hb. We propose a blood ordering schedule based on surgical blood ordering equation.
Results and Conclusions
: A total of 487 patients with a median age of 37±17 years (mean ± standard deviation) were evaluated. One thousand three hundred and seventy-seven units of blood were crossmatched and only 564 units were transfused to 260 patients. Fifty-nine percent of the units crossmatched were not transfused. Six of the 12 elective procedures had a C:T ratio higher than 2.5. Ten of the 12 procedures (83.3%) had a low transfusion index (TI < 0.5). The calculated red blood cell units were less than 0.5 in 5 of the 12 elective procedures, and hence we recommend a group and save policy for these procedures. Blood ordering schedule based on patient and surgical variables would provide an efficient way of blood utilization and management of resources.
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CASE REPORTS
A case of renal artery thrombosis with renal infarction
Valerie M Lopez, Jonathan Glauser
July-September 2010, 3(3):302-302
DOI
:10.4103/0974-2700.66569
PMID
:20930986
Renal artery thrombosis is a rare, but serious and often misdiagnosed, condition. Emergency physicians and other physicians need to consider this diagnosis in unexplained flank pain, especially in patients with risk factors for this disease. In this case report, the authors review a case of renal infarction caused by renal artery thrombosis in a patient with risk factors for thrombosis but no previous history of thromboembolism. A review of scholarly articles was performed and the case is discussed in the context of the current knowledge of this condition. Common presenting symptoms, features of the history and risk factors will all be discussed herein. Diagnostic evaluation of flank pain in the setting of the suspicion of renal infarction will be discussed, including the modalities of high-resolution computed tomography, renal angiography, scintography and ultrasound. Acute management and prognosis will also be discussed.
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LETTERS TO EDITOR
Surgical field fire and skin burns caused by alcohol-based skin preparation
Rajan Patel, KD Chavda, Santosh Hukkeri
July-September 2010, 3(3):305-305
DOI
:10.4103/0974-2700.66530
PMID
:20930995
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CASE SNIPPETS
Acute idiopathic gastric necrosis, perforation and shock
Nereo Vettoretto, Fabio Viotti, Lucio Taglietti, Maurizio Giovanetti
July-September 2010, 3(3):304-304
DOI
:10.4103/0974-2700.66564
PMID
:20930990
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EMERGENCY TOXICOLOGY
Anticholinergic delirium following
Datura stramonium
ingestion: Implications for the Internet age
David Vearrier, Michael I Greenberg
July-September 2010, 3(3):303-303
DOI
:10.4103/0974-2700.66565
PMID
:20930988
Recreational use of Datura to deliberately induce an anticholinergic delirium is not uncommon. We present a case of Datura intoxication in a young adult who learned about the recreational use of Datura on the Internet and subsequently purchased
Datura stramonium
seeds from an online vendor. Using the Google search engine, we conducted searches for "Datura," "jimson weed" and "Datura seeds" and reviewed the first 200 search results for each search term. We found 16 websites recommending the recreational use of Datura, 12 vendors selling seeds of genus Datura and one website that both promoted the recreational use of Datura and also sold
Datura stramonium
leaves. The promotion of recreational use of Datura on the Internet represents a danger to public health and the ability to purchase Datura seeds from Internet vendors may increase the prevalence of Datura abuse.
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SYMPOSIUM ON CRITICAL CARDIAC CARE IN CHILDREN
Defibrillation in children
Sarah E Haskell, Dianne L Atkins
July-September 2010, 3(3):261-266
DOI
:10.4103/0974-2700.66526
PMID
:20930970
Defibrillation is the only effective treatment for ventricular fibrillation (VF). Optimal methods for defibrillation in children are derived and extrapolated from adult data. VF occurs as the initial rhythm in 8-20% of pediatric cardiac arrests. This has fostered a new interest in determining the optimal technique for pediatric defibrillation. This review will provide a brief background of the history of defibrillation and a review of the current literature on pediatric defibrillation. The literature search was performed through PubMed, using the MeSH headings of cardiopulmonary resuscitation, defibrillation and electric countershock. The authors' personal bibliographic files were also searched. Only published articles were chosen. The recommended energy dose has been 2 J/kg for 30 years, but recent reports may indicate that higher dosages may be more effective and safe. In 2005, the European Resuscitation Council recommended 4 J/kg as the initial dose, without escalation for subsequent shocks. Automated external defibrillators are increasingly used for pediatric cardiac arrest, and available reports indicate high success rates. Additional research on pediatric defibrillation is critical in order to be able to provide an equivalent standard of care for children in cardiac arrest and improve outcomes.
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Out-of-hospital cardiac arrests in children
Antti Kamarainen
July-September 2010, 3(3):273-276
DOI
:10.4103/0974-2700.66531
PMID
:20930972
Prehospital pediatric cardiac arrest is a rare event compared with adult cardiac arrest. Despite the recent advancements in postresuscitation care improving the outcome of adult patients, similar evidence is lacking in pediatric victims of cardiac arrest. In this brief article, the current data on pediatric cardiac arrest occurring in the prehospital setting are reviewed. The annual incidence of pediatric out-of-hospital cardiac arrest is approximately 8-10 cases per 100,000 persons. The outcome is generally poor, as only 2-9.6% of patients survive to hospital discharge. The neurologic outcome of survivors is good in 24-31% of patients. Current evidence is insufficient to strongly support or refute the use of mild therapeutic hypothermia during the postresuscitation phase in pediatric patients. The application of a goal-directed treatment protocol for pediatric cardiac arrest and postresuscitation syndrome needs to be evaluated.
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Bedside emergency cardiac ultrasound in children
Stephanie J Doniger
July-September 2010, 3(3):282-291
DOI
:10.4103/0974-2700.66535
PMID
:20930974
Bedside emergency ultrasound has rapidly developed over the past several years and has now become part of the standard of care for several applications. While it has only recently been applied to critically ill pediatric patients, several of the well-established adult indications may be applied to pediatric patients. One of the most important and life-saving applications is bedside echocardiography. While bedside emergency ultrasonography does not serve to replace formal comprehensive studies, it serves as an extension of the physical examination. It is especially useful as a rapid and effective tool in the diagnosis of pericardial effusions, tamponade and in distinguishing potentially reversible causes of pulseless electrical activity from asystole. Most recently, left ventricular function and inferior vena cava measurements have proven helpful in the assessment of undifferentiated hypotension and shock in adults and children. Future research remains to be carried out in determining the efficacy of bedside ultrasonography in pediatric-specific pathology such as congenital heart disease. This article serves as a comprehensive review of the adult literature and a review of the recent applications in the pediatric emergency department. It also highlights the techniques of bedside ultrasonography with examples of normal and pathologic images.
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Better outcome after pediatric resuscitation is still a dilemma
Sandeep Sahu, Kamal Kishore, Indu Lata
July-September 2010, 3(3):243-250
DOI
:10.4103/0974-2700.66524
PMID
:20930968
Pediatric cardiac arrest is not a single problem. Although most episodes of pediatric cardiac arrest occur as complications and progression of respiratory failure and shock. Sudden cardiac arrest may result from abrupt and unexpected arrhythmias. With a better-tailored therapy, we can optimize the outcome. In the hospital, cardiac arrest often develops as a progression of respiratory failure and shock. Typically half or more of pediatric victims of in-hospital arrest have pre-existing respiratory failure and one-third or more have shock, although these figures vary somewhat among reporting hospitals. When in-hospital respiratory arrest or failure is treated before the development of cardiac arrest, survival ranges from 60% to 97%. Bradyarrthmia, asystole or pulseless electric activity (PEA) were recorded as an initial rhythm in half or more of the recent reports of in-hospital cardiac arrest, with survival to hospital discharge ranging from 22% to 40%. Data allowing characterization of out of hospital pediatric arrest are limited, although existing data support the long-held belief that as with hospitalized children, cardiac arrest most often occurs as a progression of respiratory failure or shock to cardiac arrest with bradyasystole rhythm. Although VF (Ventricular fibrillation, is a very rapid, uncoordinated, ineffective series of contractions throughout the lower chambers of the heart. Unless stopped, these chaotic impulses are fatal) and VT (Ventricular tachycardia is a rapid heartbeat that originates in one of the ventricles of the heart. To be classified as tachycardia, the heart rate is usually at least 100 beats per minute) are not common out-of-cardiac arrest in children, they are more likely to be present with sudden, witnessed collapse, particularly among adolescents. Pre-hospital care till the late 1980s was mainly concerned with adult care, and the initial focus for pediatric resuscitation was provision of oxygen and ventilation, with initial rhythm at the time of emergency medical services arrival being infrequently recorded. In the 1987 series, pre-hospital pediatric cardiac arrest demonstrated asystole in 80%, PEA in 10.5% and VF or VT in 9.6%. Only 29% arrests were witnessed, however, and death in many victims was caused by sudden infant death syndrome.
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MATERNOFETAL EMERGENCIES
Strangulation injury from indigenous rocking cradle
Abhijeet Saha, Prerna Batra, Anuradha Bansal
July-September 2010, 3(3):298-298
DOI
:10.4103/0974-2700.66543
PMID
:20930979
Indigenously made rocking cradle is frequently used in rural India. We report strangulation from an indigenously made rocking cradle in an 11-month-old female child. The unique mode of injury and its mechanism have been discussed. Strangulation is an important cause of homicidal and suicidal injury in adults but in children it is usually accidental leading to death due to asphyxia as a result of partial hanging. In western countries, it is the third most common cause of accidental childhood deaths, 17% of them being due to ropes and cords. It ranks fourth amongst the causes of unintentional injury in children less than 1 year of age following roadside accidents, drowning and burns. However, in India, strangulation injury is under reported although indigenous rocking cradles are very commonly used in rural India, and they are even more dangerous than the cribs and adult beds as there are no safety mechanisms therein. We report a case of accidental strangulation following suspension from an indigenously made rocking cradle. The unique mode of injury has prompted us to report this case.
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Hyperreactio luteinalis with preeclampsia
Alev Atis, Filiz Cifci, Yavuz Aydin, Gulseli Ozdemir, Nimet Goker
July-September 2010, 3(3):298-299
DOI
:10.4103/0974-2700.66545
PMID
:20930978
Hyperreactio luteinalis (HL) is a condition associated with bilateral and, in rare cases, unilateral ovarian enlargement due to theca lutein cysts. HL is a benign condition, usually found incidentally at cesarean section, which can appear anaplastic and lead to unnecessary ovarian resection. A 24-year-old woman with 35 weeks of gestation attended with bilaterally enlarged ovaries. She had preeclampsia and preterm contractions. Due to breech presentation of baby and nulliparity and possible severe preeclampsia, she delivered by cesarean section. The ovaries had an anaplastic appearance and a biopsy was taken during cesarean section. Pathology revealed multiple benign theca lutein cysts. There are 51 reported cases of HL associated with a normal pregnancy in the literature. It is estimated that approximately 60% of the cases of HL is not associated with trophoblastic disease and occurs with normal singleton pregnancy. Only three of them were found to be associated with preeclampsia and this is the fourth case. HL may help explain the underlying cause of preeclampsia in these cases. There are multiple benign ovarian lesions in HL, which can mimic ovarian neoplasms. Accordingly, it is important to exclude these from the differential diagnosis via a wedge biopsy and frozen section to avoid unnecessary surgical excision.
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LETTERS TO EDITOR
Double-lumen endobronchial tube in the emergency management of massive hemoptysis
Luciano Santana-Cabrera, Manuela Fernandez Arroyo, Alina Uriarte Rodriguez, Manuel Sanchez-Palacios
July-September 2010, 3(3):305-305
DOI
:10.4103/0974-2700.66527
PMID
:20930994
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CASE REPORTS
Fatal dialysis disequilibrium syndrome: A tale of two patients
Nissar Shaikh, Andr'e Louon, Yolande Hanssens
July-September 2010, 3(3):300-300
DOI
:10.4103/0974-2700.66555
PMID
:20930984
Dialysis disequilibrium syndrome (DDS) is a central nervous system disorder, which occurs during hemodialysis (HD) or within 24 h following the first HD. DDS commonly occurs in patients suffering from end-stage renal failure undergoing HD for the first time. In a critically ill patient suffering from severe sepsis or septic shock, the combined effects of post-HD brain edema and changes in the brain due to septic encephalopathy, may become amplified leading to DDS. Here we report 2 cases with acute renal failure (ARF), undergoing HD for more than a week and being ventilated and who developed DDS. DDS might have contributed to the sudden deterioration and death in these septic patients. The first case was a 31-year-old male, involved in a motor vehicle accident and had a severe abdominal injury. Underwent laparotomy and hemostasis was achieved. On day 4, the patient developed hemorrhagic shock associated with ARF, which prompted daily HD. On day 8, he went into septic shock. On day 16, 1 h after his daily HD, he became unresponsive and his pupils became dilated and fixed and he expired 2 days later. The second case was a young male who suffered severe abdominal and chest injury after a fall from a height. He developed ARF on day 3 and required HD. On day 9, he had septic shock. Three days later, during his daily HD, he became unconscious and his pupils were not reacting to light and the patient died on day 12. Conclusion: In patients with severe sepsis/septic shock, DDS may occur even after repeated sessions of HD. The acute care physicians, intensivists, and nephrologists should be aware of the risks of DDS.
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TALES OF PENETRATING TRAUMA
Successful removal of an impacted metallic arrowhead penetrating up to the brainstem
Dharmdas Paramhans, Sapna Shukla, Ankur Batra, Raj K Mathur
July-September 2010, 3(3):303-303
DOI
:10.4103/0974-2700.66566
PMID
:20930989
A case of impacted metallic arrowhead in the brain through an unusual route of the neck and behind the external carotid artery to the base of the skull up to the brainstem is reported. Review of the literature reveals no previous reports of this type of injury. A 35-year-old man was admitted to the hospital after 36 h of injury, being fully conscious and with partial facial palsy. The arrowhead was successfully removed by exploration of the entry wound, without any neurovascular complications. The patient not only survived the operation but was also discharged in an improved neurological condition.
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CASE REPORTS
Traumatic haemorrhage of occult phaeochromocytoma in a patient with septic shock
Mohammad Shahnawaz Moazzam, Syed Moied Ahmed, Shahjahan Bano
July-September 2010, 3(3):300-300
DOI
:10.4103/0974-2700.66549
PMID
:20930983
Phaeochromocytoma can have a variety of presentations; however, traumatic haemorrhage into a phaeochromocytoma is a very rare presentation. Diagnosing and managing a critically ill, septic patient with a Phaeochromocytoma can be very challenging. We report a case of 53 years old man with a previously undiagnosed Phaeochromocytoma, who presented initially with bowel perforation following an assault. Following a laparotomy for bowel resection and anastomosis, whilst on the intensive care unit, he developed paroxysmal severe hypertension overlying septic shock. Phaeochromocytoma was confirmed using a computed tomography scan and urinary assay of metanephrine and catecholamines. We managed the haemodynamic instability using labetalol and noradrenaline infusions. As his septic state improved he was convention therapy and following control of his symptoms over the next few weeks, he underwent an uncomplicated right sided adrenalectomy. He made a full recovery.
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Fatal spontaneous rectus sheath hematoma in a patient with cirrhosis
Danielle M McCarthy, Shashi Bellam
July-September 2010, 3(3):300-300
DOI
:10.4103/0974-2700.66550
PMID
:20930982
Rectus sheath hematoma (RSH) is an uncommon and often misdiagnosed condition. This well-described entity is typically self-limited. In rare cases, the condition may be fatal. We report a case of a patient with cirrhosis who died of progressive RSH and its subsequent complications.
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Post exercise ice water immersion: Is it a form of active recovery?
Fatimah Lateef
July-September 2010, 3(3):302-303
DOI
:10.4103/0974-2700.66570
PMID
:20930987
Ice water immersion and contrast temperature water immersion therapy post exercise is fast becoming a common practice among athletes involved in a variety of sports. Several mechanisms have been put forth to explain the rationale for its use. However, there is still a lack of evidence from a sufficiently large-scale trial to support the routine practice and formal incorporation into certain sporting guidelines. We describe here two athletes who applied the therapy post exercise and presented to the Emergency Department with delayed onset muscle pain.
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CASE SNIPPETS
Maxillomandibular impalement due to a gardening hoe strike to the face
Elio Hitoshi Shinohara, Shajadi Carlos Pardo-Kaba, Marcelo Zillo Martini, Carlos Henrique Hueb
July-September 2010, 3(3):304-304
DOI
:10.4103/0974-2700.66561
PMID
:20930991
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LETTERS TO EDITOR
Traumatic diaphragmatic rupture with delayed gastric incarceration
Nisar Ahmad Wani, Tasleem Lone Kosar, Asrar Ahmad, Mohammad Yusuf
July-September 2010, 3(3):306-306
DOI
:10.4103/0974-2700.66539
PMID
:20930998
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ORIGINAL ARTICLES
Acute febrile encephalopathy in adults from Northwest India
Ashish Bhalla, Vika Suri, Subhash Varma, Navneet Sharma, Sushil Mahi, Paramjeet Singh, Niranjan K Khandelwal
July-September 2010, 3(3):220-224
DOI
:10.4103/0974-2700.66520
PMID
:20930964
Background
: Acute onset fever with altered mentation is a common problem encountered by the physician practicing in tropical countries. Central nervous system (CNS) infections are the most common cause resulting in fever with altered mentation in children.
Aim
: In this study, we have tried to analyze the cause of encephalopathy following short febrile illness in adults presenting to a tertiary care center in Northwestern part of India.
Setting and Design
: A prospective observational study carried out in a tertiary care center in the Northwestern India over a period of 1 year.
Material and Methods
: A total of 127 patients with fever of less than 2 weeks duration along with alteration in mentation were studied prospectively over a period of 12 months. The demographic variables were recorded in detail. In addition to routine investigations, cerebrospinal fluid analysis, noncontrast- and contrast-enhanced computed tomography, along with magnetic resonance imaging were performed in all the subjects.
Statistical
Analysis
: The results were analyzed using SPSS statistical software. The values were expressed as mean with standard deviation for contiguous variable as percentage for the others.
Results and Conclusion
: Out of these, 70% had primary CNS infection as the etiology. A total of 33% patients had meningitis, 29.9% had evidence of meningoencephalitis, and 12.7% were diagnosed as sepsis-associated encephalopathy. These were followed by cerebral malaria, leptospirosis, and brain abscess as the cause of febrile encephalopathy in adults. Among the noninfectious causes, acute disseminated encephalomyelitis, cortical venous thrombosis, and neuroleptic malignant syndrome were documented in 2.36% each. In 11% of the patients, the final diagnosis could not be made in spite of the extensive investigations. Our study demonstrates that acute febrile encephalopathy in adults is a heterogeneous syndrome with primary CNS infections being the commonest etiology.
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SYMPOSIUM ON CRITICAL CARDIAC CARE IN CHILDREN
Hypothermia and pediatric cardiac arrest
Michelle L Schlunt, Lynn Wang
July-September 2010, 3(3):277-281
DOI
:10.4103/0974-2700.66533
PMID
:20930973
The survival outcome following pediatric cardiac arrest still remains poor. Survival to hospital discharge ranges anywhere from 0 to 38% when considering both out-of-hospital and in-hospital arrests, with up to 50% of the survivors having neurologic injury. The use of mild induced hypothermia has not been definitively proven to improve outcomes following pediatric cardiac arrest. This may be due to the lack of consensus regarding target temperature, best method of cooling, optimal duration of cooling and identifying the patient population who will receive the greatest benefit. We review the current applications of induced hypothermia in pediatric patients following cardiac arrest after searching the current literature through Pubmed and Ovid journal databases. We put forth compiled recommendations/guidelines for initiating hypothermia therapy, its maintenance, associated monitoring and suggested adjunctive therapies to produce favorable neurologic and survival outcomes.
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CASE REPORTS
Asymptomatic diaphragmatic rupture with retroperitoneal opening as a result of blunt trauma
Adnan Narci, Tolga Altug Sen, Resit Koken
July-September 2010, 3(3):301-302
DOI
:10.4103/0974-2700.66556
PMID
:20930985
Blunt traumas of the abdomen and thorax are important clinical problems in pediatric ages. Severity of trauma may not always be compatible with the patients' clinical situation. A 2-year-old male child was admitted to our emergency clinic as a result of tractor crash accident. Physical examination of the child was normal. The abdominal and thoracic ultrasonography (USG) examination performed in the emergency clinic was normal. In thoracic computed tomography (CT) scan of the patient, there was irregularity of the right diaphragmatic contour that was described as micro perforation-rupture (the free air was just in the perihepatic and retroperitoneal area, which was not passing through the abdomen). The patient was followed-up for 1 week in the hospital with a diagnosis of retroperitoneal diaphragmatic rupture. It is not appropriate to decide the severity of trauma in childhood on the basis of clinical findings. Although severe trauma and sustaining radiological examinations, the patients' clinical pictures may be surprisingly normal, as in our patient. In such cases, there may not be any clinical symptom. CT scan examination must be preferred to USG for both primary diagnosis and follow-up of these patients. According to the current literature, there is no reported case with retroperitoneal rupture of the diaphragm.
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CASE SNIPPETS
A case of quadriplegia with gastric perforation
Sankalp Dwivedi, Amit Agrawal, Manisha Bhatt, Surya Pratap Singh
July-September 2010, 3(3):304-304
DOI
:10.4103/0974-2700.66562
PMID
:20930993
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2
2,947
40
LETTERS TO EDITOR
Paradoxical reaction to midazolam reversed with flumazenil
Luciano Santana Cabrera, Ana Sanchez Santana, Pilar Eugenio Robaina, Manuel Sanchez Palacios
July-September 2010, 3(3):307-307
DOI
:10.4103/0974-2700.66551
PMID
:20931003
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2
4,992
55
Management of acute ischemic stroke
Vishal Sharma, Alka Sharma
July-September 2010, 3(3):307-307
DOI
:10.4103/0974-2700.66552
PMID
:20931004
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2
2,689
79
Chest pain in young people: Is cannabis a risk factor?
Pascal Bilbault, Corina M Duja, Jean Y Bornemann, Claire Kam, Gerald Roul, Jacques Kopferschmitt
July-September 2010, 3(3):307-307
DOI
:10.4103/0974-2700.66546
PMID
:20931005
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2
4,331
81
MATERNOFETAL EMERGENCIES
A newborn with cardiomegaly
Shailendra Upadhyay, Sabrina Law, Dipak Kholwadwala
July-September 2010, 3(3):298-298
DOI
:10.4103/0974-2700.66541
PMID
:20930980
An infant with Down's syndrome was noted to have hypoxemia and tachypnea at birth. The clinical examination, electrocardiogram (ECG) and the chest X-ray findings suggested a specific diagnosis that is not usually associated with Down's syndrome. Despite the extremely rare association of Ebstein's anomaly with Down's syndrome, this diagnosis was highly suspected from the initial evaluation. An echocardiogram confirmed the diagnosis of Ebstein's anomaly in this neonate. So far, only about seven cases of Ebstein's anomaly associated with Down's syndrome have been reported in the literature. This case is discussed for its rarity; it also highlights the importance of clinical examination and initial investigations that had suggested the diagnosis well prior to that of the echocardiogram.
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4,129
75
Postcoital vaginoperitoneal fistula after hysterectomy for gynecological malignancy
Shilpa Singla, Sunesh Kumar Jain
July-September 2010, 3(3):299-299
DOI
:10.4103/0974-2700.66547
PMID
:20930981
A true incidence of postcoital fistula is not known as it is seldom suspected. It presents as acute pneumoperitoneum with signs and symptoms same as that of perforation of a hollow viscus. A 38-year-old parous woman presented with postcoital fistula 10 weeks after panhysterectomy for carcinoma ovary stage IIIc. Pneumoperitoneum was detected, with large amount of gas under the diaphragm on radiograph of the abdomen. A breach was found in the vaginal vault. All other causes of fistula were excluded. Fistula healed spontaneously on follow-up.
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ORIGINAL ARTICLES
Comparing the efficacy and safety of two regimens of sequential systemic corticosteroids in the treatment of acute exacerbation of bronchial asthma
Praveen Aggarwal, Sanjeev Bhoi
July-September 2010, 3(3):231-237
DOI
:10.4103/0974-2700.66522
PMID
:20930966
Background
: Corticosteroids are commonly used in the management of acute asthma. However, studies comparing various steroids in the management of acute asthma are lacking.
Objective
: To compare the efficacy and safety of two treatment regimens - intravenous (IV) methylprednisolone (MP) followed by oral MP and IV hydrocortisone (HC) followed by oral prednisolone in acute bronchial asthma patients.
Materials and Methods
: This was a randomized, prospective study performed in the emergency department (ED) of a tertiary care hospital in North India. A total of 94 patients with acute asthma were randomly allocated to either of the two treatment groups: Group A (n = 49) or Group B (n = 45). Patients in Group A were administered HC 200 mg IV 6-hourly until discharge from the ED, followed by oral prednisolone 0.75 mg/kg daily for 2 weeks. Patients in Group B were administered MP 125 mg IV bolus, followed by 40 mg MP IV 6-hourly until discharge, and then oral MP 0.6 mg/kg daily for 2 weeks. All clinical variables, peak expiratory flow (PEF) and forced expiratory volume in one second (FEV
1
) were assessed at baseline, at 1, 3 and 6 h and at every 6 h thereafter until discharge from the ED. The patients were followed-up after 2 weeks of discharge. The response to treatment was assessed by clinical and spirometric evaluation. Independent t-tests and chi-square tests were used to compare the two treatment regimens.
Results
: The baseline characteristics were comparable in the two groups. There was a significant improvement in PEF and FEV
1
within the groups at 2 weeks of treatment when compared to the baseline. At 2 weeks of follow-up, Group B showed significant improvement over Group A in PEF (P < 0.0001), FEV
1
(P < 0.0001) and asthma score (P = 0.034). There was a significant increase in the blood sugar value at 2 weeks in both the groups. However, the increase was greater in Group A as compared to Group B (P < 0.0001).
Conclusion
: This study suggests that in acute asthma patients, IV MP followed by oral MP is a more efficacious and safer treatment regimen than IV HC followed by oral prednisolone.
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155
LETTERS TO EDITOR
Bedside sonography to diagnose bladder trauma in the emergency department
Tanweer Karim, Margaret Topno
July-September 2010, 3(3):305-305
DOI
:10.4103/0974-2700.66529
PMID
:20930997
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2,765
60
An in-flight respiratory emergency and survival in the sky
S SenthilKumaran, P Thirumalaikolundusubramanian
July-September 2010, 3(3):308-308
DOI
:10.4103/0974-2700.66559
PMID
:20931009
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2,583
61
Foreign body of the rectum: An unusual case
Y Narjis, K Rabbani, K Hakkou, T Aboulhassan, A Louzi, R Benelkhayat, B Finech, A EL Idrissi Dafali
July-September 2010, 3(3):306-306
DOI
:10.4103/0974-2700.66542
PMID
:20931001
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3,092
59
Unusual malignant cause of adult intussusception: Stromal tumor of the small bowel
Khalid Rabbani, Youssef Narjis, Benacer Finech, Abdelhamid Elidrissi
July-September 2010, 3(3):306-306
DOI
:10.4103/0974-2700.66544
PMID
:20931002
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2,537
53
ANIMAL EXPERIMENTATION
Using inverted autogenous veins to substitute arteries in a canine model
Saman Nikeghbalian, Seyed Mohammad Vahid Hosseini, Ali Mohammad Bananzadeh, Ahmad Monabati, Mohammad Hadi Bagheri, Tannaz Razmi, Seyed Ali Malek-Hosseini
July-September 2010, 3(3):238-242
DOI
:10.4103/0974-2700.66523
PMID
:20930967
Aims
: Rapid harvesting of autogenous graft over a wire is an optional way in trauma surgery and it places the inverted conduit so that its adventitial layer is within the lumen of the graft. Our aim of this study was to compare the patency of inverted autogenous graft vs noninverted graft in dogs.
Settings and Design
: Experimental animal models.
Materials and Methods
: In this experimental study, 12 dogs were anesthetized and 10 cm of the external jugular vein was excised. The vein was equally divided into two 5-cm sections. One section was inverted and the other was left intact. Afterward, 5 cm of both the femoral arteries were removed and the right (inverted) and the left (not inverted) arteries were grafted, respectively. The patency of the arteries was evaluated by Color Doppler ultrasonography immediately postoperation and up to 6 months thereafter.
Statistical Analysis
: Data were analyzed with Fisher's exact test using SPSS version 15. P value below 0.05 was significant.
Results
: None of the 12 inverted vein grafts were patent at 3
rd
to 14
th
days follow-up with Doppler ultrasonography. All of them were completely obstructed by thrombosis. However, 11 (92%) of the noninverted vein grafts were patent both at 3 and 6 months follow-up. One of the noninverted grafts was almost completely obstructed with thrombosis (90%) and the other 2 were incompletely obstructed with intimal thickening.
Conclusions
: Despite many favorable results in the previous studies with regard to excellent patency of inverted vein graft, our results were disappointing and we recommend using the graft in the right direction and taking care to preserve the intima intact.
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EDITORIAL
What's new in Emergencies, Trauma, and Shock? Developing predictor models for infectious diseases
Takashi Kokudo, Fukumi Nakamura-Uchiyama, Kenji Ohnishi
July-September 2010, 3(3):211-212
DOI
:10.4103/0974-2700.66518
PMID
:20930962
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3,357
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LETTERS TO EDITOR
Collapse of left lung after endotracheal intubation: Is it always due to misplacement of tube?
Mohan Gurjar, Sanjay Singhal, Banani Poddar, RK Singh
July-September 2010, 3(3):305-305
DOI
:10.4103/0974-2700.66532
PMID
:20930996
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3,371
60
Cardiac tamponade mimicking septic shock diagnosed by early echocardiography
Afzal Azim, PB Rao, Piyush Srivastav, Parikshit Singh
July-September 2010, 3(3):306-306
DOI
:10.4103/0974-2700.66534
PMID
:20930999
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2,805
67
Shock: A presentation of enteric fever
Bilal Mirza, Lubna Ijaz, Muhammad Saleem, Muhammad Sharif, Afzal Sheikh
July-September 2010, 3(3):306-306
DOI
:10.4103/0974-2700.66536
PMID
:20931000
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Author's Reply
Dale Birenbaum
July-September 2010, 3(3):307-307
PMID
:20931007
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Commenting on biomarkers for differentiating between SIRS and sepsis
Viroj Wiwanitkit
July-September 2010, 3(3):308-308
DOI
:10.4103/0974-2700.66554
PMID
:20931011
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Authors' reply
Chamindie Punyadeera, Marion E Schneider, Dave Schaffer, Hsin-Yun Hsu, Thomas O Joos, Fabian Kriebel, Manfred Weiss, Wim F.J. Verhaegh
July-September 2010, 3(3):308-308
PMID
:20931008
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43
Posterior dislocation of elbow with brachial artery injury
Karun Jain, Shashi Y Kumar, Mruthyunjaya , R Ravishankar, Ayyappan V Nair
July-September 2010, 3(3):308-308
DOI
:10.4103/0974-2700.66560
PMID
:20931010
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49
Role of clinical parameters and early noncontrast magnetic resonance imaging scan of brain in prediction of final neurologic outcome of hanging victims
Srijan Mazumdar, Priyam Mukherjee, Soumik Goswami, Jotideb Mukhopadhyay
July-September 2010, 3(3):307-307
DOI
:10.4103/0974-2700.66548
PMID
:20931006
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PICTORIAL EDUCATION
An unusual presentation of an atypical hangman's fracture
Fevzi Yilmaz, Sami Akbulut, Ozkan Kose
July-September 2010, 3(3):292-293
DOI
:10.4103/0974-2700.66537
PMID
:20930975
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3,751
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A nosy fish
J Madana, Deeke Yolmo, S Gopalakrishnan, Sunil Kumar Saxena
July-September 2010, 3(3):293-295
DOI
:10.4103/0974-2700.66538
PMID
:20930976
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3,136
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Near-fatal subdural empyema complicating a rapidly progressive orbital cellulites
Nicholas Robert Johnston, John Joseph Ah-Chan, Hans Robert Stegehuis
July-September 2010, 3(3):295-297
DOI
:10.4103/0974-2700.66540
PMID
:20930977
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© 2008 Journal of Emergencies, Trauma, and Shock | Published by Wolters Kluwer -
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Online since 15
th
April, 2008