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.

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.

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.

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.

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.

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.

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.

 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

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.

Objective: To evaluate the effects of an Alveolar Recruitment Maneuver on the reduction of complications, days of ventilation, ICU stay and mortality in ventilated patients.

Design: Trial with controlled background.

Scope: 500-bed University Hospital, 10-bed multipurpose ICU.

Patients: Patients ventilated from January 2010 to December 2012 with protective ventilation without MRA and patients ventilated using the same strategy and MRA from January 2013 to December 2015.

Interventions: Alveolar recruitment maneuver variant characterized by gradual increase of PEEP till doubling the previous value, with duration of two minutes and a frequency of three times a day.

Variables: Complications, days of ventilation, ICU stay and mortality.

Results: We included 97 patients in the control group and 101 in the trial´s group. The average days of ventilation were 6.81 in the control group and 6.79 in the study; the average ICU stay was 8.93 in the control group and 9.44 in the trial´s group. Patients in the trial´s group had fewer complications and mortality was 38.6%, lower than control (52.6%).

Conclusions: The two groups were homogeneous in terms of age, causes of ventilation, APACHE II, LIS index and Berlin classification. Mortality was lower than what predicted by the scales used in the trial´s group. Complications and mortality were significantly lower in the experimental group and there was no difference in relation to days of ventilation and ICU stay

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.

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.

Septic shock is an inflammatory response to an infection leading to cardiovascular dysfunction. Today, only few studies have evaluated whether cardiac dysfunction in septic shock is due to load modifications, neuroendocrine influence or intrinsic cardiac alterations. The isolated working heart approach allows measurement of cardiac function under controlled conditions. Our study demonstrated for the first time that in septic shock rat, alteration of cardiac function is characterized by both systolic and diastolic dysfunctions beside load conditions. This observation might help to apprehend the particular dysfunction associated with sepsis.

In Sepsis-3, sepsis and septic shock are defined as below. “Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Organ dysfunction can be identified as an acute change in total SOFA score ≥2 points consequent to the infection.” “Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.

Objectives: Horse riding as a recreational or professional activity can be more hazardous than motor cycle riding or motor vehicle driving. Pelvic and acetabular fractures following equestrian related accidents form only a small subset of commonly sustained injuries, and as a result there is a dearth of literature on this topic. This paper reviews a large group of injuries sustained in relation to equine activities, describes the common mechanisms and aims to highlight the severity of injuries in this patient group.

Methods and Results: Data from the registry of 3 databases (2 tertiary care hospitals in U.K and Australia, and the German National database) were collated. A total of 62 patients with an average age of 40.5 were obtained with the majority being female (14 males, 48 female). The mechanisms of injury were seen to fall in 4 main groups.
Group 1 included patients who had saddle injuries, Group 2 who were kicked by horse, Group 3 who were ejected by the horse and Group 4 who were ejected and either rolled on or trodden on by the horse. The severity of the injuries corresponded with the increasing energy or impact of the injuries.

Conclusion: Equine related injuries are often severe, and can include injuries similar to those more commonly seen following motorcycle accidents. An awareness of the mechanism of injury should draw attention to the possible diagnoses, and result in appropriate imaging and subsequent management. Trauma and emergency room staff should be aware of the range of injuries associated with this type of accident.

Background: The American Heart Association (AHA) put forth a set of guidelines for universal standard of care for patients who experience an in-hospital resuscitation event or receive post-cardiac arrest care following an in-hospital or out-of-hospital event. While some studies have suggested that Medical Emergency Response Teams (MERTs) help reduce mortality from unexpected cardiac arrest [1] and reduce the number of unexpected ICU admissions [2], there remains a paucity of data on the impact of formalized training of MERTs on adherence to the recommended AHA guidelines, as well as the impact of quality simulation training in implementing effective MERT training.

Methods: We performed a retrospective cohort analysis of cardiopulmonary and cardiac arrest codes called at ORMC before and after the implementation of the MERT program. We looked at code metrics according to the AHA guidelines one year before the implementation of High Fidelity Mannequin training and one year after its implementation. This data was separated into Group A, pre-MERT training, and Group B, post-MERT training. We analyzed time to chest compressions, time to first dose of epinephrine, and type of rhythm during the actual code, as well as adherence to post resuscitation guideline metrics such as oxygen titration, maintaining normothermia and normal blood pressure.

Results: Statistically significant differences between groups were found in comparing time to delivery of first shock for Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (pVT). No statistical significance was discovered in time to epinephrine, time to first compressions, or post-resuscitation guidelines.

Conclusions: MERT training can assist in better meeting AHA metrics. Use of HFM is a valuable investment for that training in that it can mitigate gaps in assessment, improve clinical outcomes and decreases patient mortality.

Aortic dissection haunts every emergency physician as it is a life-threatening and time critical condition where patients may not present with the typical stabbing chest pain that radiates to the back. Discussed here are three cases of aortic dissection that manifested in three different presenting symptoms and how focused bedside ultrasound played a pivotal role in the management.

To determine the relationship of hyperchloremia on development of Acute Kidney Injury (AKI), hyperchloremic metabolic acidosis, PICU length of stay and mortality in critically ill children. We did retrospective review of medical records of all children (aged 1 month to 16 years) admitted in our PICU from January to December 2015. Study population was divided into groups based on Chloride (Cl) level. Children with Cl level >110 meq/L were labelled as hyperchloremic groups and those with 0.05).