Feroza Motara

A review of hemodynamic monitoring techniques, methods and devices for the emergency physician

ABSTRACT The emergency department (ED) is frequently the doorway to the intensive care unit (ICU) for a significant number of critically ill patients presenting to the hospital. Hemodynamic monitoring (HDM) which is a key component in the effective management of the critically ill patient presenting to the ED, is primarily concerned with assessing the performance of the cardiovascular system and determining the correct therapeutic intervention to optimise end‐organ oxygen delivery. The spectrum of hemodynamic monitoring ranges from simple clinical assessment and routine bedside monitoring to point of care ultrasonography and various invasive monitoring devices. The clinician must be aware of the range of available techniques, methods, interventions and technological advances as well as possess a sound approach to basic hemodynamic monitoring prior to selecting the optimal modality. This article comprises an in depth discussion of an approach to hemodynamic monitoring techniques and principles as well as methods of predicting fluid responsiveness as it applies to the ED clinician. We review the role, applicability and validity of various methods and techniques that include; clinical assessment, passive leg raising, blood pressure, finger based monitoring devices, the mini‐fluid challenge, the end‐expiratory occlusion test, central venous pressure monitoring, the pulmonary artery catheter, ultrasonography, bioreactance and other modern invasive hemodynamic monitoring devices.

Finding the mental foramen

The mental foramen and mental nerve are clinically important landmarks for clinicians across various disciplines including dentists, oral maxillofacial surgeons, emergency physicians and plastic and reconstructive surgeons. To minimize complications related to procedures in the vicinity of the mental foramen and nerve, knowledge of its anatomy and anatomical variations is cardinal to concerned clinicians. In this review, basic anatomy, procedural complications, hard and soft tissue relations, variations between population groups, asymmetry, accessory mental foramina and the use of various radiological modalities to determine the position of the mental foramen are reviewed to provide a more thorough understanding of this important landmark.

Humanitarian medical response to the Syrian Arab Republic (April 7, 2013 to April 23, 2013)

The Syrian Arab Republic is entrenched in a deadly civil war, plunging the country into a state of chaos. With 3.2 million refugees abroad, 7.6 million internally displaced persons, and more than 200,000 killed, humanitarian assistance and international intervention are in dire need. This report outlines the response to the Syrian humanitarian crisis by a South African-based nongovernmental organization (NGO). It describes the experiences of a health care worker, the patient profiles, and the lessons learned in a war zone. Responding to a nation in need is of paramount importance. In order to maximize the benefit conferred, the team should always attempt to implement measures that leave a lasting legacy.

The Ultrasonographic Determination of the Position of the Mental Foramen and its Relation to the Mandibular Premolar Teeth

INTRODUCTION The position of the mental foramen has been well researched in cadaver specimens, radiographically as well as intraoperatively. To our knowledge, this landmark study is the first to make use of ultrasonography in a study population to determine the position of the mental foramen in relation to the mandibular premolar teeth. Ultrasonography has great potential to further revolutionize the practice of medicine and dento-maxillofacial surgery. AIM To make use of ultrasound to determine the position of the mental foramen and its relation to the mandibular premolar teeth. MATERIALS AND METHODS One hundred Black and Caucasian subjects were enrolled. A high frequency (8MHz) transducer (PLF.805ST) of a diagnostic ultrasound system (model SSA-510A) was applied above the inferior border of the mandible, just lateral to the mentum. With the marker of the transducer pointing cranially, the position of the mental foramen in relation to the closest mandibular premolar tooth was determined. The position was compared across race, sex and age groups. RESULTS All mental foramina (100%) were visualised. Overall the most frequent position of the mental foramen was in line with the long axis of the second premolar on the right (44%) and between the first and second premolars on the left (44%). There were no statistical differences (p >0.05) between race groups, sex and age groups with regard to the position of the mental foramen in relation to the mandibular premolars. However, in Blacks, the most frequent position of the mental foramen was in line with the long axis of the second premolar and in Caucasians the most common position was between the first and second premolars. The most frequent position of the mental foramen in females was in line with the long axis of the second premolar on the right and between the first and second premolars on the left. In males, the most frequent position of the mental foramen was in line with the long axis of the second premolar bilaterally. The most common position of the mental foramen in the age group category 18-30 years was between the first and second premolars. In patients aged 31-60 years the most frequent position was in line with the long axis of the second premolar. CONCLUSION Ultrasound is a sensitive modality to locate the mental foramen. There are differences in the most common position of the mental foramen with regard to the long axis of the premolar teeth. Ultrasonography has the potential to revolutionize the practice of dento-maxillofacial surgery.

A Somalia mission experience

Reports about The Horn of Africa Famine Crisis in 2011 flooded our news bulletins and newspapers. Yet the nations of the world failed to respond and alleviate the unfolding disaster. In August 2011, the Gift of the Givers Foundation mobilised what was to become the largest humanitarian mission ever conducted by an African organisation. Almost a year later, the effort continues, changing the face of disaster medicine as we know it.

HTLV-1, ATLL, refractory hypercalcaemia and HIV-1 co-infection

Abstract Adult T-cell lymphoma/leukemia (ATLL) is a rare tumour of T-lymphocytes that is associated with human T-lymphotrophic virus type 1 (HTLV-1) infection as well as severe/refractory hypercalcaemia. Human immunodefficiency virus type 1 (HIV-1) infected individuals are at increased risk of acquiring co-infection with HTLV-1. We present the case of a 37 -year -old HIV-1 positive and antiretroviral therapy naive woman who was admitted to the ICU with delirium, a generalised maculopapular rash, severe hypercalcaemia of 4.48 mmol/L (normal < 2.7 mmol/L) and a positive HTLV-1 serology. The diagnosis of ATLL was confirmed on biopsy. Her hypercalcaemic state proved refractory to conventional therapy, but was rapidly corrected with a modified haemodialysis technique using a dialysate with a low low-calcium concentration.

Audit of defibrillators at an urban public sector hospital

Introduction Life-threatening emergencies are not limited to the emergency department. Any delay in intervention during an emergency often culminates into a poor outcome. Early electrical defibrillation is one of the most important interventions in patients with cardiac arrest. This study aimed to conduct a clinical audit of defibrillator devices at an urban public sector hospital in Johannesburg. Methods All defibrillator devices within various areas of the hospital were assessed. Device characteristics were recorded into a data collection sheet and subjected to further analysis. Results This study assessed 112 out of 123 areas in the hospital with a total of 143 defibrillators comprising 139(97.2%) manual external defibrillators (MED) and four(2.8%) automated external defibrillators (AED). MEDs were located in the general wards (n=52, 37.4%), theatre complex (n=25, 17.9%), high dependency areas (n=27, 19.4%) and non-sleepover areas (n=35, 25.2%). Daily checklist books were available for 101 (72.7%) MEDs, 26 (18.7%) had at least once daily documented checks over a 5-day period while 57 (41.0%) had been serviced in the last 12 months. Seven MEDs (4.9%) and one AED (0.7%) had critical problems. Conclusion Compliance with regard to the availability of defibrillator checklist books, conducting and recording of daily defibrillator checks, timely service maintenance of defibrillators and identification of critical device problems was suboptimal in this study. There is a need for ongoing training of hospital staff as well as the establishment of systems to prevent potential adverse consequences due to device failure.

Survival after Cardiac Arrest Secondary to Massive Pulmonary Embolism

Introduction It is estimated that the diagnosis of pulmonary embolism (PE) is missed in as many as 84% of all cases of PE. Cardiac arrest following PE is generally associated with poor outcomes. Case Report A 43-year-old man presented to the Emergency Department (ED) in cardiac arrest. Swelling of his right lower limb was noted on arrival. Point of care ultrasound was performed during ongoing cardiopulmonary resuscitation (CPR) and showed a thrombus in the right iliofemoral vein as well as dilatation of the right ventricle. Fibrinolytic therapy was initiated immediately and a return of spontaneous circulation (ROSC) was achieved 30 minutes later. The diagnosis of PE was finally confirmed on computed tomography pulmonary angiography once haemodynamic stability was achieved. The patient was thereafter transferred to the intensive care unit for postresuscitation care and further management. Several days later, he was discharged home neurologically intact and fully recovered. Discussion Since outcomes after cardiac arrest following PE are generally dismal, available and potentially life-saving interventions to restore pulmonary circulation should be rapidly implemented when PE is the likely cause of cardiac arrest.

First-presentation with psychotic behavior to the Emergency Department: Meningitis or not, that is the question

Introduction: Meningitis is a potentially life threatening medical emergency. Psychotic behavior may be a presenting feature in patients with meningitis. We aimed to determine the value of various clinical and laboratory features at ruling‐out meningitis in the patient presenting with a first‐episode of psychotic behavior. Methods: Medical records of 159 subjects presenting to a tertiary academic hospital over a 6‐month period with one or more psychotic features for the first time were prospectively gathered. Pathological cerebrospinal fluid findings as well as clinical and other laboratory findings were tabulated and discussed retrospectively. Results: Cerebrospinal fluid was obtained in 153/159 (96.2%) subjects. Meningitis was confirmed in twenty‐eight (18.3%) subjects. Of these, a) one or more clinical feature of meningitis (headache, neck stiffness, photophobia or focal neuropathy) was present in 21 subjects (75.0%), b) visual hallucinations in 15 subjects (53.6%), c) pyrexia >37.5 °C in 7 subjects (25.0%), d) CRP >10 mg/L in 21 subjects (75.0%), e) HIV seropositive status in 19 subjects (67.9%) and f) an absence of illicit substances on urinalysis in 23 subjects (82.1%). Various combinations of these variables, where the presence of ≥1 variable was regarded as positive, were unable to rule‐out meningitis in all study subjects. Conclusion: The absence of these six parameters; alone or in various combinations, was unable to rule‐out meningitis in all patients presenting to our ED with a first‐episode of psychotic behavior. When the underlying etiology of psychotic behavior is not obvious, the clinician should adopt a low threshold to perform a lumbar puncture.

A Case of Female Acute Urinary Retention Presenting to the ED

Introduction Acute urinary retention is a rare occurrence in women necessitating further investigation. Potential underlying causes may be broadly classified into obstructive, neurological, pharmacological, and psychogenic categories. Case A 36-year-old nulliparous female presented to the Emergency Department with a two-day history of acute urinary retention. Point-of-care ultrasonography and CT scan imaging confirmed the presence of a large uterine mass causing compression of the bladder. The acute retention was relieved with urethral catheterization. A Uterine leiomyoma was confirmed on histology after hysterectomy. Discussion Once the acute urinary retention has been relieved by insertion of a urethral catheter, the underlying cause of the obstruction must be determined. Although uterine leiomyoma is a fairly common finding in the general population, it is an extremely rare cause of acute urinary retention in women with just a handful of reported cases in the literature.