Case Report: Safe Tourniquet Removal in Black Mamba (Dendroaspis polylepis) Bites

The black mamba is known for its notorious potent neurotoxic venom. For this reason, their bites are often erroneously treated in the field with the application of a tourniquet in the hope of delaying systemic spread of the venom. Observational studies have shown that inappropriate tourniquet application is a common, harmful practice. An arterial tourniquet is not a recommended first aid measure because of the risk of limb ischemia and gangrene. When inappropriately applied, the rapid removal of the tourniquet in the emergency department may precipitate a life-threatening venom and metabolic toxin rush, leading to respiratory arrest. We present two cases of black mamba bites in Gauteng, South Africa, where gradual tourniquet removal was used to avoid a venom rush and rapid respiratory paralysis. Venom and metabolic toxin rush with potentially fatal respiratory muscle paralysis may be averted by gradual, cautious removal of field-applied tourniquets with concomitant antivenom administration.

Analysis of Facial Muscle Depths to Guide Botulinum Toxin Therapy of the Periocular Region

Purpose: Botulinum toxin (BTX) injections are used in cosmetic surgery to efface facial wrinkles. Botulinum toxin relaxes the muscle by preventing the release of the neurotransmitter acetylcholine at the neuromuscular junction located at the posterior muscle surface causing local muscle paralysis. The purpose of this study is to provide anatomic knowledge of muscle belly depths of the frontalis, corrugator supercilii, procerus, and orbicularis oculi muscles in an attempt to improve the efficacy of BTX treatment of glabellar, forehead, and lateral eyelid rhytides. Methods: Six-millimeter punch biopsies were obtained from 7 fresh cadavers. Biopsies were taken from the corrugator supercilii, frontalis, procerus, and orbicularis oculi muscles at the sites of routine BTX injection. Specimens were fixed in formalin, and representative H&E-stained sections were used to measure muscle surface depths by light microscopy equipped with digital camera that includes a digital micrometer. One-way analysis of variance test analyses were used to identify statistical differences between measured muscle depths. Results: The measured anterior muscle depth of the corrugator supercilii, frontalis, procerus, and orbicularis oculi was found to be 4.2 ± 0.6, 3.9 ± 0.6, 2.9 ± 0.4, and 2.3 ± 0.7 mm, respectively. The anterior muscle surface of the corrugator supercilii and frontalis was found to be deeper than that of the procerus and orbicularis oculi ( P < .001). The posterior surface depth of the corrugator supercilii, frontalis, procerus, and orbicularis oculi was found to be 6.6 ± 0.8, 5.1 ± 0.7, 4.9 ± 0.7, and 3.8 ± 1.0 mm, respectively. The posterior surface depth of the corrugator supercilii was found to be significantly deeper than that of the frontalis, procerus, and orbicularis oculi ( P < .001); the posterior surface depth of the frontalis and procerus was deeper than that of the orbicularis oculi ( P < .001). The muscle belly width of the corrugator supercilii, frontalis, procerus, and orbicularis oculi measured 2.5 ± 0.9, 1.1 ± 0.4, 2.0 ± 0.6, and 1.5 ± 0.5 mm, respectively. The corrugator supercilii was found to be thicker than the frontalis and orbicularis oculi, while the procerus was found to be thicker than the frontalis ( P < .001). Conclusion: The findings above demonstrate statistical differences in the posterior muscle surface depth of the corrugator supercilii, frontalis, procerus, and orbicularis oculi which can be used clinically to improve BTX injection efficacy when used to efface facial rhytides.

Perawatan Luka Penderita Kusta Dengan Daun Tetanus (Leea Aequata L) Pengobatan Tradisonal Suku Karo

ABSTRAK Kusta merupakan penyakit yang disebabkan oleh mycobacterium leprae. Penyakit kusta pada stadium lanjut sering disertai luka akibat terjadinya kerusakan saraf pada daerah kaki yang menimbulkan gangguan sensibilitas kelumpuhan otot dan luka penderita kusta sering infeksi dan sulit untuk disembuhkan karena pasien sering terlambat datang untuk berobat. Perawatan luka kusta dengan menggunakan agen topikal yang tepat merupakan faktor terpenting dalam penyembuhan Luka penderita Kusta . Tujuan dilakukannya penelitian ini diharapkan dapat meningkatkan pengetahuan masyarakat terhadap pentingnya perawatan luka pada penderita kusta di pusat Rehabilitasi kusta Desa Galang. Adapun kegiatan yang dilakukan yaitu berupa pemeriksaan kesehatan dan juga perawatan luka penderita kusta dengan menggunakan obat tradisional tambar tetanus (LEEA AEQUATA L). Penderita kusta yang mengikuti perawatan luka sebanyak 34 orang. Masyarakat sangat antusias dalam mengikuti perawatan luka yang dilaksanakan serta akan berupaya melaksanakannya secara mandiri dirumah untuk meningkatkan status kesehatan penderita kusta. Kata Kunci : Penderita Kusta, Luka , LEEA AEQUATA L. ABSTRACT Leprosy is a disease caused by mycobacterium leprae. Leprosy at an advanced stage is often accompanied by injuries due to nerve damage in the leg area which causes impaired sensibility, muscle paralysis, and leprosy wounds are often infected and difficult to heal because patients often come late for treatment. The treatment of leprosy wounds by using the right topical agent is the most important factor in the healing of leprosy wounds. The purpose of this research is expected to increase public knowledge of the importance of wound care for people with leprosy at the Leprosy Rehabilitation Center in Galang Village. The activities carried out are in the form of health checks and also the treatment of leprosy wounds using the traditional tambar tetanus medicine(LEEA AEQUATA L). The community is very enthusiastic about participating in the counseling that is carried out and will try to implement it independently which can improve the health status of leprosy sufferers. Keywords: Leprosy Patients, Wounds, LEEA AEQUATA L.

“I Can’t breathe”: Two Case Reports of Inadequate Reversal of Residual Muscle Paralysis

Reversal of residual muscle paralysis is usually done at the end of a General Anaesthesia with Relaxant Technique (GART) before extubation. However, some patients may have inadequate reversal of their residual muscle paralysis. This may lead to persistent muscle paralysis despite the patient being awake from anaesthesia. A scenario of “I can’t breathe” therefore comes to play which is scary and discomforting to the affected patients. We hereby present two cases of inadequate reversal of residual muscle paralysis in our patients who underwent different procedures under general anaesthesia. The aim of this presentation is to highlight the need for adequate reversal of residual muscle paralysis, the need to routinely monitor neuromuscular function during general anaesthesia and to review the existing literature.

RESPIRATORY ARREST DURING MONITORED ANAESTHESIA CARE

We report a 72 year-old, American Society of Anaesthesiologist Class II(ASA II), male patient scheduled for burr hole and evacuation for Chronic Sub Dural Haematoma. He went into a 70 minute apnea and complete muscle paralysis after receiving midazolam(1.0 mg) and fentanyl (50 μg) intravenously for sedation and analgaesia necessitating respiratory support until recovery . Conclusion : Midazolam and fentanyl should be used with utmost caution in elderly as combination of both can lead to respiratory arrest necessitating respiratory support until full recovery

Mind the Gap: Acetazolamide Prolonged Periods without Paralysis in a Girl with Andersen-Tawil Syndrome

We present a case report of a 13-year-old girl with Andersen-Tawil Syndrome (ATS), a rare genetic disorder which is characterized by dysmorphic features, ventricular arrhythmias, and frequent episodes of muscle paralysis that interfere with daily activities and social engagement. After the introduction of off-label treatment with acetazolamide periods without paralysis lengthened, our patient became more independent of the help of her parents and required a wheelchair less frequently, thus improving her social life. Based on our experience, we recommend a trial of acetazolamide in patients with ATS.

Thyrotoxic periodic paralysis with normokalemia: a rare case report

Thyrotoxic periodic paralysis (TPP) is a rare etiology for muscle paralysis. It is frequently seen in Asian men. Apart from paralysis, most of them are asymptomatic and are devoid of other clinical features of hyperthyroidism. Due to the rarity of this condition, it is often missed and hence fatal. The metabolic derangement seen in TPP is hypokalemia and is thought to be the pathogenesis of the muscle paralysis. Although in rare clinical encounters, patients with TPP may present with normokalemia. The disorder usually presents in the 3rd decade. The cause for mortality in patients with TPP may be due to respiratory muscle paralysis leading to compromise of the respiratory function or refractory arrhythmias due to hypokalemia. Here we report a rare case of TPP with normokalemia.

Hypokalaemic quadriparesis with respiratory failure due to latent Sjogren syndrome

Sjogren’s syndrome (SS) is an autoimmune disease with involvement of multiple organs, including both glandular and extraglandular organs. Usually involvement of glandular organs manifests before the extraglandular ones, but when the sequence is reversed, diagnosis may be missed. Hypokalaemic quadriparesis in SS is not uncommon. Respiratory failure in hypokalaemia is not usually seen, but in SS, it has been reported. We report a case of a 55-year-old woman who presented with sudden onset flaccid quadriparesis and respiratory muscle paralysis secondary to severe hypokalaemia. On detailed investigation, she was detected to have distal renal tubular acidosis secondary to clinically inapparent and asymptomatic SS.