Extensive subcutaneous emphysema from scalp to lower limbs in a 44-year old

A 44-year-old man was admitted after being found suspended by his ankles from a bridge for 5 days. The events leading to it was not clearly known initially. On examination, the patient was hypotensive and hypothermic, airway was oedematous and both lower limbs were mottled with dusky feet. Both foot pulses were impalpable, with prolonged capillary refill time and sensation barely present. Doppler signals were not heard in the feet, but groin pulses and popliteal signals were present. On CT, the patient had bilateral pneumothoraxes, extensive subcutaneous emphysema throughout the body from the subcutaneous tissue of the scalp to both lower limbs and pneumomediastinum and pneumoperitoneum. CT angiogram showed opacification up to proximal crural vessels and absence beyond. After multispeciality input and optimisation of his physiology, he underwent bilateral below knee amputations as they were non-salvageable.

Optical Fibre Sensor for Capillary Refill Time and Contact Pressure Measurements under the Foot

Capillary refill time (CRT) refers to the time taken for body tissue to regain its colour after an applied blanching pressure is released. Usually, pressure is manually applied and not measured. Upon release of pressure, simple mental counting is typically used to estimate how long it takes for the skin to regain its colour. However, this method is subjective and can provide inaccurate readings due to human error. CRT is often used to assess shock and hydration but also has the potential to assess peripheral arterial disease which can result in tissue breakdown, foot ulcers and ultimately amputation, especially in people with diabetes. The aim of this study was to design an optical fibre sensor to simultaneously detect blood volume changes and the contact pressure applied to the foot. The CRT probe combines two sensors: a plastic optical fibre (POF) based on photoplethysmography (PPG) to measure blood volume changes and a fibre Bragg grating to measure skin contact pressure. The results from 10 healthy volunteers demonstrate that the blanching pressure on the subject’s first metatarsal head of the foot was 100.8 ± 4.8 kPa (mean and standard deviation), the average CRT was 1.37 ± 0.46 s and the time to achieve a stable blood volume was 4.77 ± 1.57 s. For individual volunteers, the fastest CRT measured was 0.82 ± 0.11 and the slowest 1.94 ± 0.49 s. The combined sensor and curve fitting process has the potential to provide increased reliability and accuracy for CRT measurement of the foot in diabetic foot ulcer clinics and in the community.

Laporan Kasus: Babesiosis pada Anjing Pomeranian

Babesiosis atau piroplasmosis merupakan penyakit parasit didalam sel darah merah akibat infeksi protozoa dari genus Babesia. Kejadian babesiosis pada anjing umumnya disebabkan oleh Babesia canis dan B. gibsoni. Caplak merupakan vektor penting dalam penyebaran penyakit protozoa darah. Jenis caplak daerah tropis dan subtropis yang mejadi vektor penyakit adalah Rhipicephalus sanguineus. Hasil pegamatan ditemukan kasus babesiosis pada anjing pomeranian, berjenis kelamin jantan, usia satu tahun dengan gejala klinis penurunan nafsu makan dan ditemukan infeksi caplak di seluruh tubuhnya. Hasil pemeriksaan fisik menunjukkan Capillary Refill Time >2 detik, mukosa mulut pucat, peningkatan suhu tubuh dan dehidrasi. Hasil pemeriksaan Complete Blood Count (CBC) diinterpretasikan bahwa anjing mengalami anemia mikrositik hiperkromik, leukositosis, eritrositopenia dan trombositopenia. Hasil pemeriksaan mikroskopik ulas darah menunjukkan adanya infeksi protozoa Babesia sp. yang ditandai dengan stadium merozoit dengan bentuk piriform secara khas berpasangan membentuk buah pir (the pear shaped form) dan tropozoit berbentuk lingkaran pada eritrosit. Terapi yang diberikan yaitu ivermectin (0,2-0,5 mg/kg BB, q: 7-14 hari, SC) setiap seminggu selama empat kali, diphenhydramine (1 mg/kg BB, q: 8-12 jam, SC), Clindamycin (25 mg/kg BB, q: 12 jam, PO) diberikan selama 14 hari dan hematopoetik sekali sehari 1 tablet yang diberikan selama 7 hari. Kondisi anjing membaik setelah 14 hari.

Clinical Phenotypes of Hypoxia in Patients with COVID-19

The aim of the study was to examine the clinical phenotypes of hypoxia in patients with COVID-19 in relation to the severity of acute respiratory failure (ARF).Material and methods. Sixty patients with severe COVID-19 and manifestations of acute respiratory failure admitted to the infectious disease hospitals of Nizhny Novgorod were enrolled in the study.The study included patients with transcutaneous saturation (SpO2) below 93% on spontaneous breathing, who required correction of respiratory alterations according to the Interim Clinical Guidelines for the Treatment of Patients with COVID-19. All patients were divided into 2 groups of 30 patients each according to the nature of respiratory impairment. Group 1 included patients without breathing difficulties who had respiratory rate up to 25 per minute. Group 2 patients had breathing difficulties and respiratory rate over 25 per minute.In addition to SpO2, severity of respiratory difficulties, respiratory rate (RR), forced breathing (FB), heart rate (HR), acid-base balance (ABB) and arterial and venous blood gases, capillary refill time, blood lactate level were assessed. The severity of lung involvement was determined using chest computed tomography, and severity of disease was assessed using the NEWS score. Respiratory treatment required for ARF correction and the outcome of hospitalization were also considered.Results. In group 1, the mean age was 66 (56; 67) years and the disease severity was 8 (7; 10) points. Group 1 patients had minor tachycardia and tachypnoea, there were no lactate elevation or prolonged capillary refill time. Mean SpO2 was as low as 86 (83; 89)%. Venous blood pH and pCO2 values were within normal reference intervals, mean BE was 6 (4; 9) mmol/l, pO2 was 42 (41; 44) mm Hg, and SO2 was 67 (65; 70)%. Mean arterial blood pO2 was 73 (69; 75) mm Hg, SO2 was 86 (83; 90)%, and O2 was 37 (35; 39) mm Hg. Oxygen therapy with the flow rate of 5-15 l/min in prone position helped correct ARF. All patients of this group were discharged from hospital.In group 2, the mean age was 76 (70;79) years and the disease severity was 14 (12; 18) points. Anxiety was observed in 15 patients, prolonged capillary refill time was seen in 13 patients, and increased lactate level in 18 patients. Mean RR was 34 (30; 37) per minute, HR was 110 (103; 121) per minute, and SpO2 was 76 (69; 83)%. Mean venous blood pH was 7.21 (7.18; 7.27), pCO2 was 69 (61; 77) mm Hg, BE was -5 (-7; 2) mmol/l, pO2 was 25 (22; 28) mm Hg, SO2 was 47 (43; 55)%. Mean arterial blood pO2 was 57 (50; 65) mm Hg, SO2 was 74 (69; 80)%, and pCO2 was 67 (58; 74) mm Hg. In the group 2 patients, the standard oxygen therapy in prone position failed to correct ARF, and high flow oxygen therapy, noninvasive CPAP with FiO2 of 50-90% or noninvasive CPAP+PS were administered. Fourteen patients were started on invasive lung ventilation. There were 10 fatal outcomes (33%) in this group.Conclusion. Two clinical phenotypes of hypoxia in patients with COVID-19 can be distinguished. The first pattern is characterized by reduced SpO2 (80-93%), no tachypnoea (RR >25 per minute) and moderate arterial hypoxemia without tissue hypoxia and acidosis («silent hypoxia»). It is typical for younger patients and associates with less lung damage and disease severity than in patients with severe ARF. Hypoxemia can be corrected by prone position and oxygen therapy and does not require switching to mechanical ventilation. The second pattern of hypoxia is characterized by significant arterial hypoxemia and hypercapnia with tissue hypoxia and acidosis. Its correction requires the use of noninvasive or invasive mechanical ventilation.

Evaluation of CABS score based on vitals in children at admission for prediction of severity of illness and outcome

Background: Triage in an emergency is sorting out the patients based on the severity of illness and prioritizing care accordingly. Kumar et al devised a score taking temperature, heart rate, respiratory rate, blood pressure, capillary refill time, oxygen saturation, and sensorium. We propose to evaluate a sickness scoring system based on capillary refill time, sensorium using AVPU score, blood pressure, and oxygen saturation by pulse oximetry (CABS) which are least affected by stress, anxiety, temperature, acidosis, etc.Methods: Prospective study in children admitted consecutively in the age group one month to 12 years from 1st January 2019 to 31st December 2019, to paediatric intensive care unit. Triage score applied at the time of the first contact. Each variable in the study was scored as 0 for being normal and a score of 1 for being abnormal. The total score for each child is obtained. The outcome at discharge was correlated with the study variables and total score. ROC curve analysis was done for the overall predictive ability of the score.Results: Of 346 children admitted, 27 expired, and 319 children were discharged. The risk of mortality increased with the increasing score. CFT, sensorium, blood pressure, and oxygen saturation are all significantly associated with mortality. A cut-off score of 2 has the highest sensitivity and specificity of 96.3% and 70.2%. The total score has 90% predictive accuracy as AUC is 0.913.Conclusions: As no special training is required for its implementation, the score is promising as a triage tool in resource-poor settings.