Autonomic instability in severe tetanus: a case report

Tetanus is an infectious disease of the nervous system caused by Clostridium tetani, and is characterized by tonic muscle contractions, painful spasms, and autonomic dysfunction. Severe autonomic dysfunction associated with tetanus can be life-threatening. We present a 62-year-old female who experienced lockjaw after an ankle fracture. The patient was diagnosed with tetanus and received tetanus immunoglobulin and a vaccination. The patient subsequently experienced labile hypertension. This case highlights the challenge and importance of managing cardiovascular instability.

Metformin-associated lactic acidosis

A 58-year-old female with known type 2 diabetes mellitus continued to take her usual medications, including metformin, an ACE inhibitor and a non-steroidal anti-inflammatory drug, while suffering from diarrhoea and vomiting. On presentation to the emergency department, she was found to have a profound lactic acidosis, cardiovascular instability and acute kidney injury. Despite a pH of 6.6, lactate of 14 mmol/L and a brief asystolic cardiac arrest, supportive treatment and the use of renal replacement therapy resulted in rapid improvement in her acid–base abnormalities and haemodynamic parameters. Metformin-associated lactic acidosis is a rare but life-threatening complication of diabetes management. Patient education and awareness amongst clinicians are paramount in the prevention and treatment of this condition.

The correlation between the cardiovascular instability and the size of the developed ischaemic lesions in patients who underwent carotid stenting

Aims In this study we investigated the relationship between cardiovascular instability and the size of the developed ischaemic lesions during carotid stent implantation by diffusion-weighted (DWI) magnetic resonance (MR) examination. Material and methods We retrospectively analyzed anaesthesia reports and follow-up MR examinations after stent implantation of 192 patients in a 3-year period. Nineteen aspects of cardiovascular status were analyzed. We registered the duration of the intervention, low and high blood pressure (BP) values during anaesthesia and heart rates. The fluctuations of BP and heart rate and the time of their compensations after the stent expansion were also recorded. Values were compared with the number and the size of ischaemic lesions on DWI scans. We used Spearman and Kendall rank correlations and Welch’s tests for statistical analysis. Values of p ≤ 0.05 were considered as statistically significant. Results Decreased heart rate significantly correlated with the number ( p = 0.0123) and size ( p = 0.00323) of ischaemic lesions during stent expansion. Other cardiovascular parameters did not show any significant correlations. Conclusions Our results indicate that only heart rate attenuation affects the size of ischaemic lesions; thus the prevention of bradycardia is highly important.

Efficacy and safety of levetiracetam versus phenytoin as second line antiepileptic agent in Pediatric convulsive status epilepticus: A systematic review and meta-analysis of randomized controlled trials

ObjectiveTo evaluate the efficacy and safety of Levetiracetam (LEV) in comparison to phenytoin (PHT) as second line antiseizure medication (ASM) for Pediatric convulsive status epilepticus (SE).Data sourcePubMed, Embase, Google scholar, Scopus, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database of Systematic Reviews and Cochrane Central Register of Controlled Trials.Study selectionRandomized controlled trials (RCTs) assessing LEV and PHT as second line agent for convulsive SE in children <18 years published between 1st January 2000 to 30th September 2020.Data extractionThe data was pooled regarding the proportion of children achieving seizure cessation within 5-60 minutes of completion of study drug infusion (primary outcome); and seizure cessation within 5 minutes, time to achieve seizure cessation, seizure recurrence between 1-24 hours, intubation, and cardiovascular instability (secondary outcomes). Data was analysed using RevMan version 5.4 and quality analysis was done using Cochrane risk-of-bias tool. The study protocol was submitted to PROSPERO for registration.Data synthesisEleven RCTs with 2177 children (1024 received LEV and 988 received PHT) were enrolled. Seizure cessation within 5-60 minutes was similar with both the drugs [81% in LEV vs. 76% in PHT, risk ratio (RR)=1.04, 95% CI 0.9-1.13, p=0.29]. Seizure recurrences within 1-24 hours was higher with PHT as comparison to LEV (15% vs 9%, RR=0.64, 95% CI 0.42-0.99, p=0.04). Seizure cessation within 5 minutes, time to achieve seizure cessation, requirement of intubation/mechanical ventilation, and cardiovascular instability were similar with both the drugs. Three studies had low risk of bias and eight studies had high risk of bias.ConclusionThe efficacy and safety of LEV is not superior to PHT as second line ASM medication for Pediatric convulsive SE. However, the seizure recurrences between 1-24 hours were significantly higher with PHT in comparison to LEV.

Allogenic blood patch pleurodesis for continuous pneumothorax in three cats

Case series summary Following diaphragmatic herniorrhaphy, three cats developed a continuous pneumothorax. All three cats required continuous suction to evacuate air from the thoracic cavity. Despite continuous suction, the pneumothorax persisted for all cats and blood patch pleurodesis (BPP) was performed using blood donor cats. All three cats had resolution of their pneumothorax within 24 h of BPP. Relevance and novel information This is the first report of BPP used in feline patients. More recently autologous BPP has been reported for use in dogs and humans, with a reportedly high success rate. BPP may allow timely resolution of continuous pneumothorax in cats and provide an alternative treatment option to prolonged medical management or surgical intervention. Allogenic blood from a donor cat may be necessitated in feline BPP when cardiovascular instability is appreciated in these small patients.

An Intentional Aconite Overdose: A Case Report

BackgroundAconite is one of the most toxic known herbs, widely used for centuries as an essential Chinese medicine, but also for deliberate poisoning throughout history. Clinically indicated in herbal medicine for a range of ailments from headaches to muscle spasm, unfortunately the narrow therapeutic window may lead to a range of toxic presentations. The mechanism of action of the pharmacologically active compounds in Aconite relate to the activation of voltage gated sodium channels within a range of tissue including myocardial, neuronal and smooth muscle leading to persistent cellular activity.Case presentationWe report on a rare case of a fifty year old male with intentional aconite overdose presenting with refractory cardiovascular instability from persistent life threatening arrhythmias, respiratory failure and seizure activity.ConclusionAn overview of Aconite, its history, pharmacological effects, treatment of overdose and outcomes is presented.

Flecainide toxicity: a presentation to the emergency department with literature review

Flecainide toxicity can result in increased cardiovascular instability which can significantly alter patient outcome if not recognised early. In this case report, the management of a 68-year-old woman who took an unintentional overdose of flecainide is detailed. We look at the management she received in the emergency department and her successful recovery and follow-up since the admission. In addition, the case report outlines the ECG changes that are most commonly documented in flecainide overdose and reviews the frequently used treatment methods for the overdose as summarised in current literature.

Estudio APRICOT sobre la seguridad de los más pequeños

El manejo anestésico del paciente pediátrico requiere de una formación y unas estructuras específicas, debido a las situaciones adversas que se pueden producir. El estudio APRICOT (Anaesthesia PRactice In Children Obervational Trial) con una muestra de más de 30.000 pacientes de 33 países europeos y a través de un minucioso análisis observacional de cohortes prospectivo, recoge la naturaleza, la incidencia y los factores de riesgo de los evento críticos más comprometedores; desde los más comunes como el laringoespasmo o el broncoespasmo, la bradicardia hasta la parada cardiaca, pasando por fenómenos neurológicos, anafilaxia o errores de medicación. Obtiene unos resultados que distan en algunos aspectos de lo estudiado hasta ahora. La diversidad de los datos analizados permite identificar aquellos factores de riesgo relacionados con los eventos críticos, entre ellos el anestesista y el centro hospitalario. Pero sobre todo da pie a la necesidad de crear guías de manejo anestésico pediátrico encaminadas hacia una Anestesia más segura. ABSTRACT APRICOT report about our yougest´s safety The perioperative care of infants and children demands special training and facilities due to possible critical events. The APRICOT study (Anaesthesia PRactice In Children Obervational Trial) analyses more than 30.000 anaesthetic procedures from 33 different European countries. Through a detailed prospective observational cohort study, this trial identifies the incidence, the nature and the outcomes of severe critical events in children, including laryngospasm, bronchospasm, cardiovascular instability and cardiac arrest, neurological damage, anaphylaxis or drug errors. Some reported results differ from what was previously published in the literature. Large variation of the collected data allows to identify those risk factors contributing to the severe critical events, among them, the anaesthetist and the centre. This study especially motivates to create clinical practice guidelines of paediatric anaesthesia management for a safer Anaesthesia.

GUILLAIN-BARRE SYNDROME: A CASE REPORT

Guillain-Barre syndrome (GBS) is a complicated degenerative neurological disorder which can be acute or chronic in nature. It is an acquired condition which is characterized by progressive, symmetrical, proximal and distal tingling and weakness. Muscle stretch reflexes are decreased to absent and loss of sensation is common. Etiology remains unclear but pathophysiology includes demyelination of spinal nerve roots. Death is rare. Early diagnosis and prompt referral should occur in severe cases due to the incidence of potential ventilation failure and cardiovascular instability in some patients. The case of a 26-year-old male presenting to a physician is described. The importance of a correct diagnosis by the physician and the subsequent management is reviewed. Key words: Guillain-Barre syndrome, extremity weakness, peripheral nerves, trauma