Indian Journal of Emergency Medicine

Fat embolism (FE) is defined as a blockage of vasculature by fat globules that originate either from bone marrow or adipose tissue. It mainly affects the lungs, but can also affect the skin, retina, and central nervous system. FE is very common after long bone fractures, but this may lead to a rare clinical entity called fat embolism syndrome (FES), a systemic inflammatory cascade affecting multiple organ systems which has a high mortality and morbidity. We report a case of a 22 year old male presented with left femur fracture after a mechanical fall. Orthopedic repair was done, but he developed FES and ARDS on 2nd day of the injury following which he was aggressively anaged for these complications of his long bone fracture and was discharged in a stable condition after 16 days.

Keywords: Trauma; Femur Fracture; Fat Embolism Syndrome; Acute Respiratory Syndrome.

Pulmonary embolism is a life-threatening condition and in most cases the presentation is typical with h/o pleuritic chest pain, breathlessness and h/o prolonged immobilization. However unusual presentations are not very rare and its awareness can avoid delay in its diagnosis and prevent mortality. A 23 years old male presented to ER with non-specific complaints of right upper quadrant pain and fever for 2 days. His vital signs were within normal limits apart from tachycardia and all initial investigations were normal. Due to his increased breathlessness, Well’s score was checked but it was zero. However D-dimer was done which showed high values 1000ng/ml following which CTPA was performed that showed multiple right sided pulmonary emboli. He was then started on LMWH and Direct thrombin inhibitor and was discharged after 4 days. The purpose of publishing this case is to make physicians aware of the unusual presentations of pulmonary embolism and that too in a patient who did not have any known risk factors.

Keywords: Pulmonary Embolism; Unusual Presentation; Abdominal Pain; S1Q3T3; CTPA; Well’s Score; LMWH; UFH.

A 59 years old male was presented to our Emergency Department with complaints of multiple episode of vomiting and fresh blood in vomitus, loose stools and reddish coloured urine after consuming some home made bottle gourd juice. Later he was diagnosed as bottle gourd toxicity with a shock which led to MODS. He was aggressively managed with IV fluids, pantoprazole infusion, antibiotics and other supportive medications. He improved and was discharged in a stable condition after 7 days of hospitalization.
Keywords: Bottle Gourd; Bitter Juice; Toxicity; Shock; Multi Organ Dysfunction Syndrome (MODS).

Pitutary macroadenoma and microadenoma has their own clinical presentations. These conditions are not very common and they may present with varied symptoms to the ED. There are instances when these conditions are incidentally detected by emergency radiological investigations. However in most of the instances the patient may present with vague complaints like dizziness and headache and in some rare instances the patient may resent with poor GCS. The cause may be attributed to the raised ICP due to growing adenoma or sometimes due to other effects.

Keywords: Macroadenoma; Headache; Altered Sensorium; Disorientation.

Concomitant acute myocardial infarction and ischemic cerebrovascular accidents has been rarely reported in the literature. In this report, we are describing a 74 year old male patient previous diabetic and hypertensive who presented to ER with a H/O sudden fall at home after which he had weakness of left leg, slurring of speech and left sided hemianopia after which a screening MRI revealed a Rt sided thalamic lacunar infarct. On further probing he revealed a vague epigastric pain and ECG revealed ST elevation in Lead II,III and AVF with atrial fibrillation & CVR. After that pt was urgently shifted to cath lab for percutaneous coronary intervention. This association can best be described as “cardio-cerebral infarction”. Early recognition of such cases is important and determines the patient’s further management and prognosis.

Keywords: Hemianopia; Myocardial Infarction; Lacunar Infarct; Cardio Cerebral Infarct; Diabetes Mellitus.

Central nervous system involvement in rheumatoid arthritis is infrequent. The most frequent neurological manifestations of rheumatoid arthritis are peripheral neuropathy and cervical spinal cord compression due to subluxation of the cervical vertebrae. Cerebral rheumatoid vasculitis is an uncommon and serious complication which can be life-threatening Neurological involvement in RA is rare, present in only 1% of patients. Disorders of the central nervous system (CNS) include cervical myelopathy, vasculitis, RNs located within the CNS, or meningitis. Stroke also occurs with increased frequency. CNS vasculitis is extremely rare. The diagnosis is supported by magnetic resonance imaging (MRI), alone or with magnetic resonance angiography (MRA), showing the segmental vascular stenosis characteristic of vasculitis. Peripheral neuropathy is usually manifested as sensorimotor neuropathy or mononeuritis multiplex. The underlying mechanism is small vessel vasculitis of the vasa vasorum of the nerves with ischaemic neuropathy and demyelinisation as part of the rheumatoid vasculitis (RV) syndrome. Rheumatoid vasculitis typically affects small and medium-size blood vessels. It is associated with high rates of premature mortality with up to 40% of patients dying by 5 years as well as significant morbidity due to both organ damage from vasculitis and consequences of the treatment. High levels of circulating immune complexes have been observed in atients with rheumatoid vasculitis, and in particular high serum levels of rheumatoid factor are often detected at the time of onset of vasculitis.Deposition of immune complexes most likely contributes to small vessel inflammation and organ damage. Anti CCP levels also tend to be higher in patients with RA who have systemic vasculitis than in those who do not. Histologically, rheumatoid vasculitis involves blood vessels of the small arteries, and all layers of the vessel wall are infiltrated by neutrophils, lymphocytes, and plasma cells.

Keywords: Cerebral Vasculitis; Rheumatoid Arthritis; Cerebral Magnetic Resonance Imaging; Central Nervous System.

Transient cortical blindness is a rare complication of mild head trauma, but it always creates fear in the patient and their family. However, it usually has a benign outcome. Post traumatic Transient Cortical Blindness is defined as temporary and complete visual loss associated with normal pupillary reflexes and fundoscopic examination with return of visual function without any long term neurological complications following minor head trauma. Since the number of reported cases are very less, transient blindness after head injury has been mostly attributed to hysteria if brain imaging and fundoscopy examination is normal. Post traumatic Transient Cortical Blindness was first reported by Lemiere [in 1918]but its pathophysiology is still unknown. We report one such case of transient blindness.

Keywords: Head Injury; Transient Blindness; Cortical Blindness; Brain Cortex; Post Traumatic Blindness.

Introduction: Naphthalene is bicyclic aromatic hydrocarbon most commonly used as insect and moth repellent household product for storing clothes. The toxic manifestations have been proposedly due to increased free radical formation leading to lipid peroxidation and formation of epoxide and further ultimate DNA damage. Naphthalene toxicity manifests at doses ranging 5 to 15 gms to incidences as low as 2 gm have been reported in children.

Keywords: Toxicity; Non Bilious Vomiting; Headache; Cyanosis.

Aortic dissection is a life threatening condition of the aorta. Early diagnosis and management can reduce the patient’s morbidity and mortality; hence one should have a high index of suspicion for this condition. This case reports a 53 yrs old male presenting with headache, slurring of speech, Rt leg weakness with dyspnoea and sweating. A patient of aortic dissection can present in many ways depending on the site involved and may mimic other disorders like ACS, PE or CVA. Therefore, clinicians must always be aware of aortic dissection and its different clinical manifestations.

Keywords: Aortic dissection; Pulmonary Embolism.

Introduction: In 1916, Hans Reiter described the classic triad of arthritis, nongonococcal urethritis, and conjunctivitis (Reiters syndrome) in a Prussian soldier with diarrhea, during the first world war. Reiter’s syndrome is defined as a complication of non gonococcal urethritis in which there is arthritis (mainly knees, ankles and feet), conjunctivitis, rashes, cardiac and neurological problems. Other features include; iritis, keratoderma blenorrhagicum, circinate balanitis, plantar fasciitis, Achilles tendonitis, aortic incompetence. RS is triggered by bacterial infection that enters via mucosal surfaces usually, (but not always) associated with human leukocyte antigen (HLA)- B27. Nongonococcal venereal disease (most often Chlamydia) and infectious diarrhea usually precede reiter’s syndrome. These include infections with: Shigella flexneri, Shigella dysenteriae, Salmonella typhimurium, Salmonella enteritidis, Streptococcus viridans, Mycoplasma pneumonia, Cyclospora, Chlamydia trachomatis, Yersinia enterocolitica, and Yersinia pseudotuberculosis. Campylobacter jejuni . Others include Chlamydia pneumoniæ and Ureaplasma urealiticum. 

Keywords: Urethritis; Tendonitis; Conjunctivitis; Morning Stiffness.

Acute MI would rarely be a first differential diagnosis in a young boy of 19 years old withintellectual disabilitywith non-specific complaints. We present a case of a 19-year old boywithhistory of seizure disorder, who presented to the Emergency Department with complaint ofnon-specific chest discomfort since1 day.While being examined, he had one episode of seizure after which he suddenly developed cardiac arrest;he was immediately given high quality CPR along with DC shock (initial rhythm = VF) as per ACLS protocol. Post ROSC2D Echo revealed LV dysfunction with LVEF~ 40%. Post ROSC ECG revealed AWMI. Patient was loaded with antiplatelets, statins and anticoagulants. Patient underwent CAG which revealed single vessel disease. Subsequently, he underwent primary PTCA+ Stent (DES) to LAD with good end result. He was discharged in a stable condition after 6 days.

Keywords: ST Elevation Myocardial Infarction (STEMI); Anterior Wall Myocardial Infarction (AWMI); Acute Myocardial Infarction (AMI); Left Anterior Descending Artery (LAD); Coronary Angiography (CAG); Primary PTCA + Stent to LAD; Intellectual Disability; Ventricular Fibrillation (VF); Cardiopulmonary Resuscitation (CPR); DC Shock; Seizure Disorder; Generalized Tonic-Clonic Seizure (GTCS).

Aims of the Study: Profound hyponatraemia (<125 mmol/l) is frequent in the emergency department. Its incidence appears to increase with age and in patient’s on antihypertensive medication particularly diuretics.Our objectives
were to investigate impact of diuretics on the incidence of profound hyponatraemia and identify its risk factors.

Methods: The incidence of profound hyponatraemia among patients admitted to the emergency department of our hospital was observed over one year. Risk factors for profound hyponatraemia were analysed in a observational study. Each adult patient admitted during the study periods with a blood sodium level <135mmol/l was taken into study.

Results: A total of 50 patients of hyponatraemia were analysed, of which 11 patients were in sepsis,10 had renal failure and 8 patients had heart failure as risk factor.Patients on diuretics were 19, of which 9 patients were on combination of thiazide with angiotensin receptor blockers. 

Conclusions: Out of patients analysed in our ED, the most common risk factor was found to be sepsis followed by renal failure, heart failure and diuretics mainly comprising the thiazide group. Female patients were more commonly and were affected at an early age compared to male patients.

Keywords: Diuretics; Hyponatraemia; Risk Factors.

Background: Organophosphorus poisoning has a high mortality rate. Various factors decide prognosis of organophosphate poisoning. This study is carried out to analyze the significance of estimation of serum pseudo cholinesterase in assessment of severity as well as prognosis in OP poisoning. 

Materials and Methods: This prospective study was conducted at department of Medicine in McGann teaching hospital attached to Shimoga institute of medical sciences from June 2017 to December 2017. Total of 123 documented OP patients were analyzed. Noting of symptoms, signs, need of oxygen, ventilator support and their assessment with PChE levels carried out. Informed consent was taken from each study participant. Ethical committee approval was obtained to carry out the study. Suitable statistical methods applied to assess correlation and variables.

Results: Among 123 patients, majority were male (64.2%), belonged to 21-30 age group (34.1%), were from rural areas (91%) and commonest compound ingested is chlorpyrifos (60.9%).Patients needing ventilator support were 3, 13 and 43 in patients of moderate poisoning, severe poisoning and very severe poisoning respectively, where as it was none in patients with mild poisoning and normal PChE levels. There were 21 deaths in very severe poisoning patients where as it was 4 and 1 in severe and moderate poisoning patients respectively and none in mild poisoning patients and in patients with normal PChE levels.

Conclusions: Significant correlation (p value <0.001) was observed between PChE levels with clinical manifestations, need of mechanical ventilation and in hospital outcome. These findings can enforce the evaluation of patient’s prognosis, complications and treatment plan.

Keywords: Organophosphorus Poisoning; Pseudo Cholinesterase; Ventilator Support.

The spectrum of clinical disease in fatty liver with steatohepatitis varies from the asymptomatic elevation of liver enzymes to severe liver disease with fibrosis and nodular regeneration. Patients with nonalcoholic steatohepatitis can develop progressive liver disease and complications to the point that they may need liver transplantation.Nonalcoholic steatohepatitis should be considered as a cause for chronically elevated liver enzymes in asymptomatic diabetic patients particularly if they are obese and have hyperlipidemia.This study was carried out among 100 diabetic patients diagnosed to be with hepatic dysfunction attending tertiary care hospital during the study period. Maximum number of patients had diabetic nephropathy (17%), followed by diabetic retinopathy (15%), peripheral neuropathy (11%) and peripheral vascular disease (4%). Neuropathy, Nephropathy, PVD and Retinopathy were present in patients
who had diabetes for more than 10 years.

Keywords: Diabetes; LFT; NAFLD.

Introduction: Blood Stream Infections increase the mortality rate, prolonging hospital stay in ICU, posing a challenge to the skill of not only the clinician but also to the microbiologist. Easy availability and indiscriminate use of antibiotics is leading to antimicrobial resistance.

Objective: To review the spectrum of organisms isolated and their antibiotic sensitivity pattern in the Intensive Care Unit to minimize the risk of morbidity and mortality.

Method: 235 suspected cases of septicemia from ICU were taken; co morbid illness and outcome were noted. Blood culture and their antibiotic susceptibility profile were done.

Results: Of the 235 suspected cases, 47 (20%) were culture positive with Gram Negative Organisms predominant (70.21%) over Gram Positive Organism (27.65%). Klebsiella species was the most common organism isolated (38.29%). Of the 13 GPC, 38.46% cases showed Vancomycin resistance.

Conclusion: Gram Negative Organisms were most common etiological agents with Klebsiella being most predominant. The rate of Vancomycin resistance from isolated organisms was high. Mortality rate was high (17.02%). 

Keywords: Septicemia; Intensive Care Unit; Mortality; Vancomycin; Klebsiella.

Introduction: The Revised National Tuberculosis Control Programme (RNTCP) uses sputum negativity as prognostic indicator but does not consider any other dimension of health. Apart from physical symptoms, TB patients face social and economic problems. Therefore, the overall impact of TB on health and patients’ perception of well being should be considered. This can be performed by measuring the Quality of Life (QoL).

Methodology: A cross sectional study was undertaken in the Chalalkere Tuberculosis Unit of Chitradurga district for a period of two months between February and March, 2017. About 60 patients who are treatment for tuberculosis attending the tuberculosis unit were included as the study samples. The patients thus selected were obtained an informed, bilingual and written consent.

Results: The mean score of the physical component summary (PCS) was 54.1, mental component summary (MCS) was 48.6, physical functioning (PH) was 62.1, role limitation due to physical health (RP) was 52.2, body pain was 60.2, general health was 41.7, role limitation due to emotional problem was 54, energy/fatigue was 44.4, mental health was 46.7 and social functioning was 49.2.

Conclusion: The mean value of physical component summary, mental component summary, physical health and mental health were higher for class III of SES, RP, MH and VT were higher for Class V of SES and BP was higher for class I of SES.

Keywords: Quality of Life; Tuberculosis; SES.

Background: Dengue infection can occur as epidemics in India. If early treatment is not instituted it has high mortality. Currently there is no specific antiviral drug or vaccine available for treatment of dengue, preventive measures play a crucial role in controlling the infection and reducing mortality. Sex and gender are major factors which impact incidence, severity and response to vaccination and therapy in dengue, so that preventive measures may be targeted to the at risk population.

Aims: The aim of the study is to analyse gender patterns in dengue and its impact on the severity of dengue.

Materials and Methods: A total of 132 seropositive cases of dengue were analysed for the haematological parameters (haematocrit, blood counts) and serology in association with gender and age of the patients over one month period in November 2016 at KIMS hospital Bengaluru.The relevant data obtained from the microbiology register and haematology report forms was tabulated for analysis.

Results: Our patients were aged 5months-65years with an average of 32years. 30% constituted paediatric group with 70% in non paediatric (>12years) group. There was a male predominance with 55% males, 45% females and male to female ratio of 1.2:1. In the paediatric group we had 45% males (18/40) and 55% females (22/40). The lab parameters showed a rise in haematocrit in 54% of females as against 49% of males and was more marked in paediatric group. Leucopenia was significantly seen in higher proportion of males (44%) as against females (34%). The differential counts showed marginally higher proportion of lymphocytes especially atypical lymphocytes in females compared to males (56%vs 49%). Neutropenia and thrombocytopenia were seen in marginally higher proportion of males than females were 29% vs 24% and severe thrombocytopenia was 59% and 54% respectively. NS1 antigen positivity was noted in higher proportion of males compared to females (33% vs 22%) whereas association with antibody was seen in higher proportion of females compared to males 44% vs 35%). 

Conclusion: Gender differences play an important role in prevalence and severity of dengue. Awareness of this factor and implementing preventive measures targeted at the risk population helps to reduce mortality and morbidity of disease.

Keywords: Dengue; Gender; Hematocrit; Leucopenia; Thrombocytopenia; Serology.

Background: Fever with thrombocytopenia is one of the commonest medical problem encountered in India. Management of complications associated with it is the most challenging task for emergency physician which includes bleeding manifestations, ARDS, hepatitis, acute kidney injury, shock syndrome.

Aims and Objective: This study was conducted to analyse the cause and outcome of fever associated with thrombocytopenia.

Materials and Methods: 100 patients of fever associated with thrombocytopenia who were admitted in the department of emergency medicine, JJM Medical College, Davangere were included in prospective clinical study.

Results: 100 patients of fever with thrombocytopenia were analysed out of which male patients were 56 (56%) and female patients were 44 (44%). Among them those who were dengue positive were 64 (64%), Malaria cases were 12 (12%), typhus were 4 (4%), Negative fever profile were 20 (20%). Out of these 100 patients who developed ARDS were 25 (25%), Acute kidney injury were 8 (8%), hepatitis were 7 (7%), patients who developed rash/ petechiae and platelet count less than 20,000 were 60 (60%). Discussion: Infections particularly dengue was the commonest cause of fever with thrombocytopenia, with majority of patients developing bleeding manifestations and ARDS as a complication. The commonest bleeding manifestation were petechiae and purpura. In some patients diagnosed with malaria also developed complication like ARDS, while patients diagnosed with typhus fever had no complications like ARDS. In majority of patients thrombocytopenia was transient and by treating the specific cause improvement in platelet count was noticed during the course of illness.

Keywords: Fever; Thrombocytopenia; Bleeding Manifestation; Petechiae; Purpura.

Introduction: All over the world, with the increasing risk factors like obesity and sedentary lifestyle, it is expected that incidence of Metabolic syndrome (MetS) will be increasing dramatically. It is well established that the five components of MetS also individually increase the risk of cardiovascular disease.

Aims and Objectives: The aim of our study was to determine the incidence of MetS in the cases of acute myocardial ischemia; and to study the detrimental impact of syndrome and its components over the in-hospital outcome in these patients.

Methods: A total of one hundred and fifty patients of acute myocardial infarction (AMI) were included in this study.

Results: Among these 150 AMI patients (113 males, 37 females) one hundred and two (68%) met with ATP III criteria of MetS. The mean age for the entire cohort was 54.99±13.18 years. In our study high prevalence of MetS (68%) was observed in the patients of AMI and at least one risk factor of Mets was present in 98.67% of patients. Most common combination of MetS observed was a four combination of obesity+ hyperglycemia+elevated triglycerides+ low-HDl (OB+DM+HTG+low-HDL) in 16.67%. most common three components combination observed was OB+DM+HDL (8.82%). HT, DM and HDL showed significant correlation with adverse in-hospital outcome among AMI patients (p<0.05).

Conclusion: The present study concludes that there is noticeable high occurrence of metabolic syndrome and its components in the cases of AMI. In our findings hypertension showed strong association with adverse outcome in these patients.

Background: Chronic obstructive pulmonary disease is the fourth leading cause of mortality worldwide. It is defined as a disease formal categorized by airflow limitation that is not fully reversible. Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of cardiovascular disease. Electrocardiography (ECG) carries information about cardiac disease and prognosis in COPD patients. However, Echocardiography provides a rapid,
noninvasive, portable, and accurate method to evaluate cardiac functions. 

Methods: 125 patients of COPD fulfilling the inclusion criteria coming to OPD/ wards of Medicine, Civil Hospital, Ahmedabad were recruited. They were staged by pulmonary function test (PFT) and evaluated by electrocardiography and echocardiography. Statistical analysis of correlation was done with chi square test and statistical significance was taken p<0.05. 

Results: Mean age was 56.24±9.41years, with male preponderance, male to female ratio 4.43:1. Mean duration of disease was 6.22±4.28years. The common symptoms were Breathlessness (100%). Most common ECG and ECHO
finding was RAD (51.2%) and PAH (54.4%) respectively. Statistically Right axis deviation and Poor ‘r’ wave progression were significantly correlated with disease severity by ECG findings while R.A. dilatation, R.V.dilatation and Pulmonary hypertensionwere significantly correlated with disease severity by ECHO findings (p<0.05). Conclusions: COPD is more common in males and in the 5th and 6th decadeof life. Most of the patients have fairly advanced disease at presentation. The incidence of abnormalities of ECG and echocardiography increases with COPD severity. ECG and echocardiography are better tools than clinical methods in detecting R.V. dysfunction in COPD.

Keywords: COPD; Electrocardiography; Echocardiography; Pulmonary Arterial Hypertension.

Background and Aim: Ventilator associated pneumonia (VAP) is a common complication in critically ill patient affecting 9 to 27% of all critically ill patients. We have done the study of ventilator associated pneumonia (VAP) with various risk factors like age, sex, duration of ventilation, airway access, various organisms and their culture and sensitivity to various antibiotics and comorbid conditions associated with ventilator associated pneumonia. 

Material and Methods: The present study was conducted in our Medical ICU of Civil Hospital during period from November 2009 to November 2011. It includes 100 cases of mechanically ventilated patients of age more than 15 years. VAP was defined as the occurrence of a new and persistent radiographic infiltrate in conjunction with positive endotracheal aspirate culture. A cut off of 7 days of mechanical ventilator was used to distinguish patient with early nset VAP from those with late onset VAP. Risk factors like age, sex, duration of mechanical ventilation and comorbid conditions like COPD, stroke, ischemic heart disease were studied.

Results: Most common comorbid state associated with mechanical ventilatory support was COPD and 72.72% patients with COPD developed VAP. incidence of VAP was highest with reintubation (70%) followed by tracheostomy (30%) and non-invasive ventilation (20%). most common organism for VAP was Pseudomonas with 37.5% incidence, followed by Staphylococcus Aureus (16.66%), Klebslia (16.66%),

Conclusion: Ventilator associated pneumonia is an important cause of mortality in ICU patients. Most important risk factors for development of VAP include age >60 years, presence of co-morbid illnesses, re intubations, duration of ICU stay.
Keywords: COPD; Ischemic Heart Disease; Stroke; Ventilator Associated Pneumonia.

Organophosphorus poisoning (OP poisoning) is common poisoning specially in developing countries like India. This compound is easily available, cheap and is used in agricultural field as pesticides. Both accidental and suicidal poisoning has been reported. Laboratory parameters like erythrocyte cholinesterase activity has been used to support clinical diagnosis and to predict prognosis and it is costly. Pseudocholinesterase is cheaper alternative but it is less reliable. There are few other biochemical markers including CPK which is usually raised in cases of acute OP poisoning and it is a cheaper investigation and is easily performed in all laboratories. Hence this study was done to evaluate role of creatine phosphokinase levels to support clinical diagnosis as well as predicting prognosis in acute OP compound poisoning.

Materials and Methods: It was a prospective observational study which included 50 patients who presented within 6 hours of consumption of OP compound afterconsidering inclusion and exclusion criteria. Patients were categorized into mild, moderate and severe poisoning according to POP score and initial CPK levels were noted. Data expressed in percentages and chi-square test was used to know statistical significance.

Results: Out of 50 patients, 28 (56%)had mild, 16 (32%) had moderate and 6 (12%) had severe poisoning. Initial CPK levels were positively correlated with POP score. Four deaths occurred in our studyout of which one had moderate poisoning and threehad severe poisoning.

Conclusion: Initial CPK levels correlated with severity of OP compound poisoning and mortality.

Keywords: Creatine Phospokinase (CPK); Organophosphorus Poisoning.

Introduction: Dog bites are common in India accounting to 1-2% of patients presenting to Emergency department. There is long drawn controversy regarding the treatment protocol for dog bites. Several studies have shown comparable amount of wound infection in both these techniques with better aesthetic appearance following Primary closure. We conducted a study to compare the rate of infection, aesthetic outcome & the wound healing time between Primary closure and Non-closure technique.

Materials & Methods: After Ethical committee clearance,120 consecutive patients with Dog bite wounds were included in this Experimental control trial. The patients were divided into two groups based on computer-based randomization.All dog bite wounds received initial wound care. One group underwent Primary suturing of wound and in other group wounds were dressed without suturing. Prophylactic antibiotics were given to all patients. Human immunoglobulin was administered according to WHO guidelines. Infection rates, cosmetic appearance and healing time were compared.

Results: The infection rate in primary closure was 8.3% as compared to 11.7% in Non-closure. However, it was not statistically significant (P=0.543). Primarily closed wounds had 86.7% good scars as compared to 11.7% in Non-closure which was statistically significant (p=0.001). We also found that the Mean healing time was 23.65 days in Primary closure and 49.05 in Non-closure.

Conclusion: Primary suturing of dog bite wounds leads to faster healing rate with no significant change in the infection rate & yields a good cosmetic scar. Local infiltration of wound with immunoglobulin showed no change in the rate of infection.

Keywords: Dog Bite; Healing Time; Infection; Non-Closure; Primary Suturing.

Sepsis is a major cause of death in ALF accounting for 24- 49% of death in Indian patients which is in fact more common than renal failure or GI bleed. We aimed to study the prevalence of sepsis in ALF and the role of prophylactic antibiotics in limiting the incidence of infections in ALF and improving related mortality. 46 patients of ALF were stratified into 2 main groups with SIRS>=2 and SIRS<2 on admission based on the number of SIRS components. Patients with SIRS>=2 were studied for the prevalence of sepsis in ALF. Patients with SIRS<2 were studied for the incidence of sepsis and the role of prophylactic antibiotics in ALF dividing them further into control group who received prophylactic antibiotics and the Test group who were given antibiotics only on worsening due to sepsis or there were evidence of infection. SIRS was documented regularly and on every episode of worsening. Prevalence of sepsis was studied by observing day1 infections. Role of prophylactic antibiotics was studied by documenting subsequent infections and related mortality in control group and comparing with the test group without prophylactic antibiotics. 70% of infected patients expressed more than 2 SIRS components whereas 27.3% infected patients never expressed more than 1 SIRS component. 50% infection rate was noted with expression of more than 2 SIRS components as compared to 14.3% who remained SIRS<2 without deterioration. Prevalence of sepsis was 64%. Mortality in the infected was 69% compared to 30% in the non infected. 71.4% infections with 40% related mortality was observed in the control group on prophylactic antibiotics whereas in the test group without antibiotic prophylaxis 75% infection were observed with 66.7% related mortality. This prospective evaluation points to SIRS being closely associated with infections. Use of prophylactic antibiotics may limit the incidence of infection and reduce sepsis related mortality in ALF.

Keywords: Sepsis; Prophylactic Antibiotics.