Indian Journal of Emergency Medicine

 We describe the characteristic MRI findings of a child who presented in the emergency with breathing difficulty.

Keywords: Joubert’s Syndrome; Molar Tooth Sign; Batwing Sign; Buttock Sign; Pontomesencephalic Cleft.

 Colonic baro trauma resulting from an increase in intra-luminal pressure and may lead to perforation. In most cases such an injury is iatrogenic following air insufflation during colonoscopy and rarely due to industrial accidents. Most reported cases and existing literature advocates early radio imaging to diagnosed barotrauma to colon. We present a case report of a 36 years old male worker of a biscuit factory presented in our emergency department following exposure to high pressure air. However, in our case the perforation presented lately and repeated radio-imaging was unable to detect any signs of an impending perforation.

Keywords: Colonic Barotrauma; Barotrauma; Perforation; Compressed Air; Industrial Baro Trauma.

 We report a case of a young female who ingested large dose of combinations of amlodipine and atenolol. She has taken 90 tabs of Amlodipin-Atenalol combination. she was treated succsesfully. This case highlights how the early and aggressive management in emergency department and intensive care management can result in a favourable clinical outcome.

Keywords: Amlodipine overdose; Atenolol overdose; beta blocker overdose; CCB overdose; combination drug overdose.

 Avascular necrosis is clinically characterized by gradual onset of pain in motion and relieved by rest in affected joint. The pathophysiology of avascular necrosis has not been completely elucidated; whereas some cases of disease clearly have direct cause, the pathophysiology is uncertain for most cases. Avascular necrosis in Sheehan’s syndrome has not been described in published literature so for and may be due to disease state itself or to chronic corticosteroid therapy. We report a case of Sheehan’s syndrome developing avascular necrosis of femoral head. A 42 year women had lactational failure in last pregnancy followed by secondary amenorrhea and other features of hypopituitarism. On clinical and biochemical evaluation she was diagnosed as a case of Sheehan’s syndrome and was put on replacement therapy. After 15 years on replacement therapy she started getting pain on left hip with limp on same side and she was diagnosed having avascular necrosis of left femoral head and she was subjected to decompression and now following orthopedician.

Keywords: Sheehan’s Syndrome; Avascular Necrosis.

 Acute flaccid paralysis is one of the common presentation in Emergency and Gullian-Barre Syndrome and Periodic Hypokalemic Paralysis being important differriantial diagnosis with separate management. But the combination of both these conditions can be a diagnostic challenge for Emergency Physician. We report a case of 20 year old male who presented with such an association of Hypokalemia along with Guillian Barre Syndrome highliting the importance of the need to rule out various differential diagnosis during management of acute flaccid paralysis.

Keywords: Guillian Barre Syndrome; Hypokalemia; Hypokalemic Periodic Palsy; Nerve Conduction Studies.

 Bochdalek hernia is the commonest type of diaphgramatic hernia. It was first described in 1754 by Mc Culley. In 1848 Bochdalek described that diaphragmatic hernia occurs due to improper fusion of posterolateral foramina of diaphragm. We present a case of 48 year old female who first presented with chief complaints of epistaxis with cervical and lumbar back pain. She was diagnosed as a case of multiple myeloma and started on drug thalidomide. On follow ups the patient started having respiratory complaints for which she underwent X-ray chest and CT thorax which further revealed that patient had developed a new onset bochdaleks hernia as X-ray chest on her previous visits was normal. With no other preceding risk factors or previous respiratory complaints, we came to a conclusion that this could be a case where thalidomide, which till now has only experimentally proven to cause hernia, may be a cause of this new onset bochdaleks hernia.

Keywords: Bochdalek hernia; Thalidomide.

 Spontaneous cerebellar hematomas occupy a special place among all intracranial hemorrhages because of the risk of sudden deterioration due to either acute hydrocephalus or brain stem compression. These hematomas also have a significant incidence of delayed worsening, necessitating careful observation in conservatively treated patients. Unlike supratentorial hemorrhages, there is not much controversy that timely surgical evacuation improves survival and hence it is mandatory for the physician manning the Emergency to know the guidelines for conservative and surgical management.

Keywords: Cerebellum; External Ventricular Drain; Hydrocephalus, Hypertension; Vermis; Suboccipital Craniotomy.

 Introduction: Typhoid fever is a very common disease of the developing world, being a major public health concern in countries like India. The antibiotic susceptibility scenario varies significantly across regions. In India the pictures are conflicting. Objective: The objective of the study was to identify the antibiotic susceptibility pattern of S. typhi among registered patients in a tertiary care hospital in India. Materials and Methods: The study was done at Peerless Hospital and B. K. Roy Research Center which is a tertiary care Hospital in Kolkata. This was a record-based retrospective cross-sectional and descriptive analysis using SAS software version 9.3.2 during 2012 to 2013. The patients included in the study were admitted in the hospital with accessible medical records. Results: Among 86 recruited patients, the average age was 43.14 years and 59.30%, subjects were male. Overall, fever (91.86%) was the most common symptom followed by nausea (84.88%), diarrhea (83.72%), vomiting (63.95%) and body ache (51.16%). Of total 86 blood samples, 23 (26.74%) samples were blood culture positive. Of these 23 blood culture positive samples, 20 (23.26%) samples were positive for Salmonella Ser.typhi and 3 (3.49%) samples were positive for Salmonella Ser. paratyphi. Overall, among the 23 blood culture positive subjects, isolated bacterial strains were 100% sensitive to ampicillin, amoxicillin/clavulanic acid, piperacillin/tazobactum, cefoperazone/sulbactam, ceftriaxone, cefepime, ertapenem, imipenem, meropenem, tigecycline and colistin and 100% resistant to cefuroxime axetil, cefuroxime, amikacin and gentamycin. Conclusion: blood culture positivity and resistant pattern to commonly used antibiotics for S. typhi was substantially high among the patients admitted in a tertiary care hospital in eastern part of India and a standardized protocol for proper antibiotic treatment and management of the patients infected with S. typhi is warranted.

Keywords: Typhoid; Antibiotic; Salmonella Ser. typhi.

  Clinical care of patients with end-stage renal disease (ESRD) is complex and often involves management of conditions outside of dialysis provision. Hypoglycemia is a well recognized complication of chronic kidney disease and hemodialysis, yet its prevalence among patients who are undergoing hemodialysis is subject of much debate as many of these hypoglycemic episodes may be asymptomatic. However, health effects associated with these episodes; both symptomatic and asymptomatic, can be severe, even causing sudden death of the patients. The evaluation of uremic hypoglycemia in patients of diabetes involves exclusion of obvious causes such as insulin and oral hypoglycemic therapy. Spontaneous uremic hypoglycemia in patients who do not have diabetes has been attributed to various factors like, diminished renal gluconeogenesis, poor nutrition resulting in deficiency of precursors of gluconeogenesis, impaired glycogenolysis, impaired renal insulin degradation and clearance and in a few cases, inadequate response from immediate counter-regulatory hormones such as catecholamine and glucagon. However, the mechanism(s) seems to differ from one patient to the other. And when the patients of end stage renal disease are initiated on renal replacement therapy in the form of hemodialysis , many factors related to hemodialysis itself such as of glucose-free dialysis fluid, glucose loss into the dialysate and diffusion of glucose from plasma to erythrocytes may predispose these patients to hypoglycemia. This observational prospective study was carried in the hemodialysis unit of the department of medicine, Acharya Shri Chander college of Medical Sciences and Hospital, Sidhra, Jammu. The 40 patients above 18 years of age, who were receiving maintenance hemodialysis were included in this study. The results showed progressively decreased blood glucose values in majority (80%) of the patients after the start of hemodialysis and out of 11 patients who actually developed hypoglycemia, only four patients exhibited symptoms of hypoglycemia. The aim of the study was to characterize the episodes of hypoglycemia, so that proper care is taken in anticipating, preventing and managing these episodes in future sessions of hemodialysis in this highly vulnerable group of patients .

Keywords: Hypoglycemia; Chroni

 Context: Tube blockage is a common airway accident in intensive care unit (ICU) and can even be fatal. Nursing staff are the first line care giver in ICU. Aims: The present study was designed to assess the knowledge of tube blockage and ascertain nursing professionals’ knowledge of life-saving management strategies in such patients. Settings and Design: After approval from the institute, this crosssectional study was conducted in a tertiary care hospital in December 2014. Methods and Material: A questionnaire was handed over to the staff nurses for data collection and scoring was done. The staff was divided into two groups based on their ICU experience duration. Knowledge score was expressed in percentage and percentile scale. Statistical Analysis used: Unpaired t test was used for measuring central tendencies, dispersion and comparisons. Fisher’s exact was used for comparison and a p value < 0.05 was considered significant. Results: 17 staff members (77.27%) finished and submitted the questionnaire. The mean + standard deviation (SD) percentile score of knowledge was 50.0 + 28.42. 10 (58.82%) staff were having ICU experience of more than 2 years at the time of assessment. 52.94% of the responders had poor knowledge. The mean percentile knowledge score of the experienced group was significantly higher than the relatively inexperienced group (63.53 + 26.93 versus 30.67 + 17.96; p 0.013). Conclusions: Knowledge related to tube blockage and management is relatively lower in ICU staff. Targeted education and training should be given to the newly recruited and rotational staff to ensure patient safety.

Keywords: Tracheostomy/Endotracheal Tube; Tube Blockage; Tube Blockage/ Management; Intensive Care Unit.

 Introduction: ABG is a painful procedure and it requires lot of skills to master the art of obtaining ABG from sick patients specially who are in shock,thus even the most skilful of person requires quite a few attempts,so main idea of this study is to come up with something which can be an alternative to ABG.Various studies have been done where comparisons have been drawn between ABG VS VBG VS CBG but since VBG is also an invasive procedure, so less invasive procedure was obtaining a CBG and the whole idea of the study is that can CBG replace ABG? CBG only requires a finger prick or heel stick, and is much less painful than an ABG. The results, however, are not as reliable as an ABG. Aims and Objectives: To investigate the degree of corroboration between capillary blood gas (CBG) and ABG values using correlation analysis and to evaluate whether capillary blood gas can be equally reliable as arterial blood gas (ABG) to be used in clinical practice. Reliability of CBG over ABG is aimed to make blood gas analysis easier, less painful, faster and equally reliable. Also, it will be easier to assess blood gases in patients with generalized oedema, feeble pulses and in anxious and psychiatric / psychotic patients where ABG can be difficult. Materials and Methods: Blood samples were drawn simultaneously from the radial artery via an arterial puncture into a heparinised syringe and the fingertip via finger prick into a capillary tube of every patient participating in the study. Two sets of capillary samples was taken in order to assess the repeatability of capillary sampling. Immediately afterwards an arterial sample was taken from the radial artery in order to assess the agreement between the capillary and arterial samples. These samples so obtained was analyzed immediately by the blood gas analyzer (AVL Compact 3, Roche Diagnostics GmbH, Mannheim, Germany) of the Emergency Department for values of acid-base and oxygenation: pH, PO2 , PCO2 , HCO3 values will be recorded. Blood gases was obtained if the patients need blood gases analysis for clinical decisions. In addition, the measurement of oxygen saturation (SpO2) was obtained from a finger pulse oximeter (Non-invasive pulse oximeter). Results and Conclusion:Although CBG is far less invasive than ABG, but the values obtained by the T-TEST method of analysis shows disparity between the two. There is some level of similarity in the values of HCO3 and PCO2 but the values of PO2 and PH did not have any correlation. Hence, the study concludes that CBG cannot replace ABG until more studies are done with greater sample size.

Keywords: Capillary blood gas; PCO2 ; pH; Blood gas analysis.

 Background: Surgical reconstruction of segmental skeletal defects represents a true challenge for the orthopaedic surgeons. Masquelet et al described a two stage technique for reconstruction of bone defects known as induced membrane technique in the management of segmental skeletal defects resulting from traumatic bone loss, osteomyelitis. Materials and Methods: Eight patients with segmental bone defects were treated in our hospital by induced membrane technique. The mean age of patients was 36 years (age range18 – 55 years). The causes of the defects were traumatic bone loss in 4 patients and chronic osteomyelitis in 4 patients. The defects were located in femur (n=3), tibia (n=3), humerus (n=1), radius shaft (n=1). The defect ranges were from 3 – 9 cms. All cases were treated by induced membrane technique in two stages. Results: Bone union happened in all patients. Duration of keeping cement spacer was 6 – 8 weeks. Five out of 8 cases required second episode of bone grafting. Conclusion: The induced membrane technique is a valid option for the management of segmental defects if done judiciously but the time required for growth and maturation of graft is relatively long.

Keywords: Induced Membrane; Osteomyelitis; Bone Defects; Cement Spacer; Post Traumatic.

 Objectives: Increasing number of patients present now a days with pancytopeniadue to B12 and folic acid deficiencies, bone marrow failures and hypersplenism. The changing diet, lifestyle, and environment could be the cause for the increased incidence. It is important to have a clinical diagnosis at presentation itself, to identify and treat the potentially correctable causes of pancytopenia like vitamin B12 deficiency. The present study was to look into the correlation between clinical diagnosis and final diagnosis; and also to study the clinical profile, etiological factors,and treatment response in the subgroup of patients diagnosed to have B12/folate deficiency. Methods: It was a cross-sectional study involving 65patients in one year. Their clinical diagnosis (made after history, physical examination and hemogram) was compared with the final diagnosis. The subgroup of patients diagnosed to have B12/folate deficiency was studied in detail for their clinical profile & etiological factors. Results: There was a statistically significant correlation between clinical & final diagnosis. Sensitivity of clinical diagnosis was highest (93%) for B12/folate deficiency. Diet history, knuckle pigmentation, glossitis and MCV>100fl had a statistically significant association with B12/folate deficiency. Conclusions: B12/folate deficiency and acute leukemia were the commonest causes for pancytopenia. Sensitivity of clinical and pathological diagnoses of B12 deficiency was 93% and 73% respectively. Hence high clinical suspicion is mandatory for diagnosis of vitamin B12 deficiency. The diagnosis of vitamin B12/folate deficiency can be predicted using the dietary history, knuckle pigmentation, glossitis and MCV>100fl.

Keywords: Pancytopenia; B12 Deficiency; Folic Acid Deficiency; ClinicoPathological Correlation.

 First aid is most urgent need to stabilize patient condition before any kind of intervention is sought. Scientists estimate the volume of blood in a human body to be approximately 7 percent of body weight. An observational study of 61 patients with bleeding wound chosen by random assortment was carried out. All patients were divided in two groups: Group - I, Axiostat® (Chitosan Haemostatic Dressing) and Group - II, Conventional Cotton dressing. The patients were divided in both groups by 1:1 randomization. A total of thirty patients in group – I and thirty one patients in group –II were subjected to the study. A standard pattern was followed for application of dressing to bleeding wound in both groups and different parameters were recorded. Results showed that haemostatic time in group-I (Axiostat®) was 2.125±1.35 minutes where in group-II (cotton gauze) it was 13.08±6.40 minutes. Only 61% of patients who were applied with cotton gauze showed no rebleeding after removal whereas 83% patients showed no rebleeding after removal of Axiostat® in 30 minutes. Axiostat® could be easily applied and removal was also effective by application of saline where about 63% of patients showed an excellent ease of removal when only 10% of patients applied with cotton gauze showed excellent removal. The aim of this study was to evaluate the efficacy and safety of use of external haemostat Axiostat® to control the flow of blood and attain haemostasis in comparison with conventional cotton gauze dressing.

Keywords: Axiostat®; Bleeding; Chitosan; Cotton; Dressing; Trauma.