[ ISSN : 2576-0173 ]
Transcranial doppler; Vasospasm; Subarachnoid hemorrhage; Basilar artery; Vertebro-basilar
Transcranial Doppler (TCD) is commonly used in the monitoring of neuro-critical patient. In the subarachnoid hemorrhage is used in the early diagnosis of cerebral vasospasm. We studied a 30 years old male patient, with severe traumatic brain injury, and right epidural parietal hematoma, right cerebellum hematoma and posttraumatic subarachnoid hemorrhage in posterior territory. The initial Glasgow Coma Score (GCS) was in 4 points. TCD was done one day 2, 3, 6, 14 y 21. We used as vasospasm diagnosis in basilar artery, the criteria of VmBA >95 cm/sec and VmBA /VmECVA > 2 referred to Soustiel Ratio (SI). The patient was diagnosed with early vasospasm of the basilar artery on day 3, based on a VmBA = 121 cm/ sec and SI = 3.36. The patient was treated with nimodipine immediately of vasospasm diagnosis. It also had neurosurgical treatment with evacuation of the epidural and cerebellum hematoma. Repeat TCD measurement was not done until day 6, the VmBA was 79 cm/sec and the IS was 2.29. It was transferred to another floor after 25 days in the ICU, with a GCS of 12. The TCD was used as a diagnosis kit in the vasospasm and show his usefulness in the develop tracing of traumatic subarachnoid hemorrhage in posterior territory. It showed the TCD value in the monitoring of neurocritical patient with severe brain injury and high suspicion of vasospasm develop.
Transcranial Doppler (TCD) is commonly used in the monitoring of neuro-critical patient. In the subarachnoid hemorrhage is used in the early diagnosis of cerebral vasospasm.
We studied a 30 years old male patient, with severe traumatic brain injury, and right epidural parietal hematoma, right cerebellum hematoma and posttraumatic subarachnoid hemorrhage in posterior territory. The initial Glasgow Coma Score (GCS) was in 4 points.
TCD was done one day 2, 3, 6, 14 y 21. We used as vasospasm diagnosis in basilar artery, the criteria of VmBA >95 cm/sec and VmBA /VmECVA > 2 referred to Soustiel Ratio (SI).
The patient was diagnosed with early vasospasm of the basilar artery on day 3, based on a VmBA = 121 cm/ sec and SI = 3.36. The patient was treated with nimodipine immediately of vasospasm diagnosis. It also had neurosurgical treatment with evacuation of the epidural and cerebellum hematoma.
Repeat TCD measurement was not done until day 6, the VmBA was 79 cm/sec and the IS was 2.29.
It was transferred to another floor after 25 days in the ICU, with a GCS of 12.
The TCD was used as a diagnosis kit in the vasospasm and show his usefulness in the develop tracing of traumatic subarachnoid hemorrhage in posterior territory. It showed the TCD value in the monitoring of neurocritical patient with severe brain injury and high suspicion of vasospasm develop.
Transcranial doppler; Vasospasm; Subarachnoid hemorrhage; Basilar artery; Vertebro-basilar
Alexeis PO, Calixto MC, Elías GRA and Mario SMJ. Transcranial Doppler in Posttraumatic Vasospasm Diagnosis of Basilar Artery: Case Report. SM Emerg Med Crit Care. 2017; 1(1): 1001
The Transcranial Doppler is commonly used in the monitoring of neuro-critical patient [1]. In the Subarachnoid Hemorrhage (SAH) is frequently used in the diagnosis of early cerebral vasospasm [2].
The TCD vasospasm diagnosis in SAH patients is validated in the Cerebral Middle Arteries (MCA’s) [3,5], but it’s poorly defined in the posterior territory [2,6].
Many years ago in SAH, the vasospasm diagnosis was only explored in the anterior circulation. In the posterior territory it was evaluated in some cases with traumatic subarachnoid hemorrhage [7].
During the last years, TCD was used to measure the cerebral flow arteries velocities as vasospasm rates suspected in the posterior territory [6].
Recently, the posterior rate or Soustiel Index (SI) is used in the vasospasm diagnosis of basilar artery [5,8,9].
We find the Soustiel Index to calculate the ratio between the Basilar Artery (BA) and Vertebral Artery (VA). We divided the last intensity value in the mean velocity of BA and the average of the Mean Velocity (Vm) in vertebral’s arteries. The normal value is 2 [5,8,9].
We studied a 30 years old male patient, with severe brain injury by a sort of blunt trauma. T he initial GCS was in 4 points, with oro-tracheal intubation and artificial mechanic ventilation necessity. The cranial CT scan showed a patient with right parietal epidural hematoma, right cerebellum hematoma and posttraumatic subarachnoid hemorrhage in posterior territory, with no other significant lesions. The patient was evaluated by neurosurgery, with non-surgical yardstick.
It was admitted to Intensive Critical Care Unit (ICU) and we star with neuro-intensive treatment.
We performed TCD with a Doppler EZ - DOP equipment and 2 MHz transductor. All exams were realized by the same explorer. The TCD was done one day 2, 3, 6, 14 y 21.
On day 2, the test showed high velocities pattern in CMA’s and Cerebral Anterior Arteries (CAA’s) in both hemispheres, associated to high resistance pattern, in right Cerebral Posterior Artery (CPA) (Table 1)
The Vm in both CMA’s were over 120 cm/sec, but the Lindergard Rate (LI) in both cases were<3 (Generally in vasospasm cases the LI≥3) [7]. This vasospasm is associated to low values of IP and IR.
In this patient the anterior vasospasm criteria’s were absent. We consider as cerebral hyperemia pattern and it were present in the 4 arteries of the anterior territory.
We used as vasospasm diagnosis in basilar artery, the criteria of VmBA>95 cm/sec and VmBA/VmECVA>2 referred to Soustiel ratio.
We explored the vertebro-basilar system, and we found BA with Vm: 99 cm/sec and the Soustiel Rate (SI): 1.82 with a high suspicion of BA vasospasm because the patient had a high Vm value in AB, but the Soustiel rate was normal.
The patient was diagnosed with an early vasospasm of the basilar artery on hospital day 3, based on a Vm BA = 121 cm/sec and a (SI) VmBA/VmECVA = 3.36 (Table 2).
The patient had a neurologic deterioration with GCS in 3 points. We began the treatment with calcio-antagonistic (nimodipine 60 mg/4 hrs).
The neuro-surgical physicians return to evaluate the patient and recognized a neurosurgical intervention necessity. The epidural hematoma and cerebellum hematoma were evacuated. The patient remained with similar neurologic state during 72 hrs with GCS in 3 points.
The TCD measurement was not done until day 6. The VmBA was 79 cm/sec and the SI = 2.29. We find a normal pattern bilateral in CMA’s and CAA’s, with Vm decrease in vertebro-basilar territory. The patient moves the GCS to 6 points.
In the next day’s the TCD showed slow and progressive decrease of the VM BA velocities with a clinical and neurologic patient recovery (Table 2).
The patient was transferred to another floor after 25 days in the ICU, with a neurologic state and GCS 12 points
According to studies performed in patients with cerebral vasospasm after a traumatic brain injury, using criteria of a VmBA >90 cm/sec, the basilar artery vasospasm was in 19%; it was recorded from post-injury between days 2nd and 12th.
The literature describe in these case as values of Vm>90 cm/sec in BA, showing a vasospasm diagnosis in posterior territory arteries with angiographic correlation performed [2,10].
The traumatic vasospasm AB was present in younger patients with a low score in GCS at the hospital admission [10]. These results are according with our findings.
Orthel et al. used Vm>90 cm/sec and the Soustiel rate (SI>2.5) in BA as vasospasm criteria. In 102 patient was performed the SI and it was positive in 23 patient (22.5%), this criteria represented a significant risk of vasospasm development [10].
When the Soustiel rate is about >2, the diagnosis of vasospasm is about 95% of specificity [6,7,9].
The SI>2.5 is associated to moderate vasospasm and when the SI > 3 and with Vm in BA > 95 cm/sec, the diagnosis of severe vasospasm have a specificity and sensibility near to 100% [7-9].
In our case since the first TCD with Vm in BA of 99 cm/sec, we had a high suspicion of vasospasm. The second TCD showed a severe vasospasm in BA based on a VmBA of 121 cm/sec and a SI of 3.36 (Figures 1 and 2 and Table 2).
The beneficial effect showed by nimodipine in some studies, in a subgroup of brain injury patients with subarachnoid hemorrhage make suggest this drug use in the treatment of the patient. The nimodipine was included in our institutional guide by treat the ASH, although we should be very careful, because it can increase the risk of adverse reactions in someone patient.
Next to 6th day, the patient began with progressive decrease in BA velocities associated to a better clinical condition. These findings showed a close relationship between vasospasm resolution and the neurologic recovery.
Alexeis PO, Calixto MC, Elías GRA and Mario SMJ. Transcranial Doppler in Posttraumatic Vasospasm Diagnosis of Basilar Artery: Case Report. SM Emerg Med Crit Care. 2017; 1(1): 1001.
A 7-month-old female presented to the emergency department after several hours of listlessness and occasional vomiting. Her last bowel movement was two hours earlier, and was noted to be non bloody by the mother.
Shant Broukian¹* and Ryan Don Aycock²
A 61-year-old previously healthy male presented to an emergency department with a pruritic rash on his left first toe after returning from a vacation that included a visit to Miami, Florida. He recalled walking barefoot during his time there.
Kevin Tavangarian¹* and Ryan Don Aycock²
Globally, the elderly are succumbing to anger. This anger has multiple etiologies but a common cause. It starts with a fundamental frustration in their living condition. How we manage their anger in the clinic, Emergency Department, or hospital will determine the success of our intervention.
Keith A. Raymond¹*
A 26 year old Indian man presented with recurrent left-sided abdominal pain and nausea to the emergency department. He had just returned from India few days ago and had just recovered from an upper respiratory tract infection.
Ee Ling GOH¹*
Pregabalin is a drug widely used in patients with neuropathic pain. While it may cause common adverse events such as dizziness, somnolence and peripheral edema, there are a few reports addressing a possible relationship between pregabalin and heart failure. Here we report an elderly woman with a history of heart failure New York Heart Association (NYHA) class I who was taking pregabalin presented with acute decompensated heart failure and acute kidney injury. With discontinuation of pregabalin and supportive treatment, patient’s symptoms improved rapidly and she was discharged well. Though exact mechanism is still unclear, it is believed that antagonism of the L-type calcium channels in vasculature plays a role in pregabalin induced heart failure. Current American Heart Association (AHA) guideline recommends prescribing pregabalin with caution in patients with NYHA class III to IV heart failure. From this case report, we would suggest to use pregabalin cautiously in all patients with history of heart failure (NYHA class I to IV) especially when there is co-existing renal impairment.
Ting LYU, Hongen Wu, and Eeling GOH¹*
Recently, health accidents relief and medical dispute adjustment act (called Shin Hae-Cheol law) went into effect. Although the medical profession expressed its concern about passive treatment, the many civic groups welcome the SHC law. Of note, cases of some outcome are automatically entered into mediation process without consent of doctors or hospitals. However, this is a violation to the principal of the law. Because the law should be criteria-driven (or process-driven), not out driven. It needed that medical process should have its own predefined indication and contraindication or predefined criteria in detail if the society decided to give any legal obligation to doctors.
Sion Jo, Jae Baek Lee¹*, Youngho Jin, Taeoh Jeong, and Jaechol Yoon
Introduction: Anaphylaxis occurs worldwide and recent data from developed countries indicate a continued increase, not only in children but also in adults. In children, food allergens are the most frequent elicitors. In adults, besides food, hymenoptera venoms and drugs are frequent causes of anaphylaxis. Milk and egg are the most frequent foods involved in small children and adolescents. In the last decades, fish parasite Anisakis simplex is considered to be an important cause of food allergy among adults in Spain and Japan. At present, Anisakis simplex is one of the most important hidden food allergens in adults who suffer from anaphylaxis in these geographical areas.
Methods: This retrospective, case-based and time series study was conducted over a sixteen years period, from January 2000 to December 2016, in patients studied in our Department and diagnosed of anaphylaxis induced by Anisakis simplex. The diagnosis was confirmed with a combination of clinical data, skin tests and specific IgE determinations.
Results: A mean population prevalence of 3 cases per 100.000 inhabitants and year was recorded. The ratio of females to males was 2.5:1 and the median age was 59 years (range 18 - 88 years). Most anaphylaxis cases (65%) were treated in Emergency rooms, 12.5% of them were hospitalized and 1% admitted in Intensive Care Unit. Most patients were undertreated with H1-receptor antagonists (antihistamines) and steroids, and only 34% received injected adrenaline.
Conclusion: This study shown that Anisakis simplex induces most allergic reactions in non-atopic middle aged adults in northern Spain. Drug cofactors (NSAIDs, ACE-inhibitors and beta-blockers) are involved in most of the patients studied. In emergency departments, digestive signs were not taken into account as an additional organ affected, and subsequently most patients were not treated with adrenaline. It is expected that more cases of allergy to Anisakis simplex in sea-fish consumption areas could appear
Audicana Berasategui Maria Teresa¹*, Girao Popolizio Italo and Longo Areso Natividad
Ipsilateral fracture of the femur and tibia, denominated as floating knee, are results of high-energy trauma related to high rates of associated injuries and complications. This case reports a type IIIA exposed floating knee, with loss of joint bone fragments of the tibia and femur during an accident. Guided by the MESS score, limb saving was performed, fragments were reinserted and joint reconstruction was performed. The patient had bone consolidation in four months, infection with fistula in the knee at six months with some improvement when treated and osteonecrosis of the reinserted fragments was observed at sixteen months (lateral femoral condyle and lateral tibial plateau). The patient maintains the arc of motion in the knee of 10-90 degrees of flexion extension, walks without crutches, but with a limp, valgus and pain. The use of scores like MESS helps in the decision to rescue or amputate severe cases, but it does not predict the functional outcome, and the floating knee is commonly associated with complications and worse case functional results, especially when it involves intra articular fractures, comminuted fractures and infection, factors that are present in this reported case.
Bruno Gonçalves Pereira Paschoa¹*, Gustavo Tadeu Sanchez, Carlos Eduardo da Silveira Franciozi, Daniel Balbachevsky, Fernando Baldy dos Reis, and Marcos Vinicius Malheiros Luzo
Introduction: Hemorrhages are one of the main causes of maternal mortality, as much in developing countries as in developed countries.
Objective: To expose our experiences with the techniques of surgical interventions applied in the emergency treatment of the obstetric hemorrhages.
Materials and Methods: The study applied is descriptive, retrospective, from transversal court in 51 patients. Those whom it was necessary to apply surgical emergency interventions to control the obstetric hemorrhages; from January 1988 to February 2017 at the General hospital “Ciro Redondo Garcia”, in Artemisa, Cuba.
Results: The average ages of operated patients are 27 years (95% CI for the 25.0000 to mediates 28.8057) years. The childbirth type that preceded with the most frequent event of hemorrhage is the Caesarean operation (27/49=55.1%). The main causes of hemorrhages are the uterine atony (22/51=43.1%), vaginal and cervix lacerations (10/51=19.6%). The most used surgical intervention is the total hysterectomy associated with the ligature of the hypogastric arteries (25/51=49.0%). Surgical conservative techniques were applied to patients with uterine atony, achieving in all of them total control of the hemorrhage (6/51=11.7%). There was one maternal death (1/51=2.0%).
Conclusions: The surgical technique used for the treatment of the obstetric hemorrhages was the total hysterectomy associated to the ligature of the hypogastric arteries, in young patients, with uterine atony, vaginal and cervical lacerations. There was one maternal death. It was possible to conserve the uterus in patients with uterine atony, applying surgical conservative techniques that’s why we consider, that these techniques should be applied with more frequency, whenever the patient’s clinical circumstances allow it.
Ibáñez Cayon Fernando¹*, García García Avelino, Díaz Suárez Yeney, Sánchez González Pablo, Suarez Barreto Osbel Bárbaro, and Chan Jon Chu Richan
Background: Acute poisonings commonly present to the Accident and Emergency (A&E) department, but specific epidemiologic data regarding poisonings in Botswana is limited in the current medical literature. This study was performed to generate patterns on which future studies and preventative programs can be based.
Methods: This is a retrospective chart review conducted on poisoning cases which presented to the A&E in Princess Marina Hospital (PMH) in Gaborone, Botswana from January 2016 to June 2016.
Results: 289 patients were seen in the A&E at PMH for acute poisonings. Of these, 57% were female. Of all the toxic exposures, 58% were intentional. Patients who were age 16-35 were more commonly affected than younger and older patients. While most patients were admitted, only 3 required ICU and the case fatality rate among all patients was 0.7%.
Conclusion: The rate of toxic exposure cases in Botswana appears to be increasing. Paraffin, paracetamol, snake bites, traditional medicines and unknown ingestions are the most commonly encountered poisonings presenting to the A&E in the first half of the year. Many of these are mild and can be discharged home without hospital admission; however, some are deadly and require close monitoring and aggressive care. Paraffin ingestion is quite common among children, at times fatal and almost always accidental making it an ideal target for public health initiatives. Women are more likely than men to ingest toxic substances and more commonly do so intentionally. This investigation was limited by its retrospective design, but shows basic patterns on which larger and prospective studies can be based.
Aurelio Rodriguez¹*, Jackie Shibata², Pon-Pon², Erick Ciroe², and Megan Cox³