Madhuri Gore

Utility of optic nerve ultrasonography in head injury

BACKGROUND CT has evolved as the gold standard for evaluation of head injury, but early CT is not always possible. Bedside ultrasonography is available in most trauma units and optic nerve ultrasound (ONUS) examination should be feasible. OBJECTIVE To evaluate the role of ONUS for people with head injury. SETTING Tertiary care trauma service in a teaching hospital in a large metropolitan city in India. DESIGN Prospective, blinded, observational study. METHODS From April 2006 to January 2007, all adult patients with head injury but without obvious ocular trauma, for whom it was possible to perform CT, were enrolled. Using a 7.5-MHz ultrasonographic probe on the closed eyelids, optic nerve sheath diameter (ONSD) was measured on either side. A mean binocular ONSD less than 5.00 mm was considered normal. Cranial CT findings were used as a reference standard to evaluate ONUS. RESULTS The study included 100 participants (72 men, 28 women, median age 28 years, median Glasgow Coma Scale score 11). Clinical features did not correlate with CT for signs of raised intracranial pressure (ICP). The mean binocular ONSD (5.8+/-0.57 mm) was significantly increased among individuals with signs of raised ICP on CT compared with the mean ONSD (3.5+/-0.75 mm) among those without such signs. ONUS revealed evidence of raised ICP in 74 cases (confirmed by CT in 72 cases), 59 of whom had significant intracranial haematoma needing surgical evacuation. Of the 26 cases with negative ONUS, confirmed by CT in 25 cases, only 1 needed surgical intervention for drainage of intracranial haematoma. ONUS was false positive for two and false negative for one person. The sensitivity of ONUS in detecting elevated ICP was 98.6%, specificity 92.8%, positive predictive value 97.26% and negative predictive value 96.3%. CONCLUSION ONUS has potential as a sensitive bedside screening test for detecting raised ICP and the presence of intracranial haematoma needing surgical intervention in adult head injury. This can be of immense help for unstable patients, in mass casualty situations and in remote locations.

Prevalence and risk factors of Metallo β-lactamase producing Pseudomonas aeruginosa and Acinetobacter species in burns and surgical wards in a tertiary care hospital.

Introduction: The production of Metallo-β-lactamases (MBLs) is one of the resistance mechanisms of Pseudomonas aeruginosa and Acinetobacter species. There is not much Indian data on the prevalence of MBLs in burns and surgical wards. Materials and Methods: A total of 145 non-duplicate isolates of carbapenem-resistant Pseudomonas aeruginosa and Acinetobacter species, isolated from pus/wound swabs and endotracheal secretions from burns and surgical wards, were tested for MBL production by modified ethylene diamine tetra acetic acid (EDTA) disc synergy and double disc synergy tests. Results: Prevalence of MBLs was 26.9% by both the above tests. All MBL-positive isolates were multidrug resistant. Only 6.06% (2/33) P.aeruginosa and 16.67% (1/06) Acinetobacter species were susceptible to piperacillin-tazobactam and netilmycin, respectively. These patients had multiple risk factors like >8 days hospital stay, catheterization, IV lines, previous antibiotic use, mechanical ventilation, etc. Graft application and surgical intervention were significant risk factors in MBL-positive patients. Overall mortality in MBL-positive patients was 34.21%. Conclusion: Emergence of MBL-producing Pseudomonas aeruginosa and Acinetobacter species in this hospital is alarming, which reflect excessive use of carbapenems and at the same time, pose a therapeutic challenge to clinicians as well as to microbiologists. Therefore, a strict antibiotic policy and implementation of proper infection control practices will go a long way to prevent further spread of MBLs. Detection of MBLs should also become mandatory in all hospitals.

Microbiological assessment of cadaver skin grafts received in a Skin Bank

PURPOSE Study on the microbiological assessment of cadaver skin grafts was undertaken in the Skin Bank at the Department of Surgery in L.T.M. Medical College and Hospital, Mumbai, India. PROCEDURE Microbiology of the skin grafts was studied immediately on receipt and after antibiotic treatment. The antimicrobial and antifungal agents used were crystalline penicillin, gentamicin, amikacin, ceftazidime and amphotericin B. FINDINGS Escherichia coli, Staphylococcus aureus and Candida species were the predominant microorganisms isolated on pre-processing cultures from cadaver skin grafts. Seventy percent of pre-processing cultures showed growth. After first cycle antibiotic treatment, 52.4% of grafts showing growth became sterile. Growth of Klebsiella pneumoniae persisted in two cases, even after 2nd cycle of antibiotic treatment. After the use of antifungal, 57.1% of those showing fungal growth became sterile. CONCLUSION Various antibiotics and antifungals can be used in order to minimize the discard rate of skin grafts.

Impact of enteral nutrition on nitrogen balance in patients of trauma

Background: A prospective study of 50 patients of trauma was carried out at a tertiary level trauma center in Mumbai. The aim was to study the hypermetabolic response to trauma and the effect of early enteral feeding and nutritional supplementation in blunting this response in these patients. Methods: Early enteral feeding was started within 72 h in most patients. The caloric requirement was calculated as per the body weight and a 150: 1 ratio of nonprotein calories to protein was maintained. A 24-h urinary nitrogen loss was estimated and nitrogen balance was calculated on days 1, 3 and 7. Results: The correlation between the injury severity and the severity of catabolism was also analysed. Urinary nitrogen loss and nitrogen balance were used as parameters to evaluate the hypermetabolic response. Conclusions: Early (within 72 h) enteral nutritional support blunts this hypermetabolic response to some extent in these trauma patients.

Deceased donor skin allograft banking: Response and utilization

Background: In the absence of xenograft and biosynthetic skin substitutes, deceased donor skin allografts is a feasible option for saving life of patient with extensive burn injury in our country. Aims: The first deceased donor skin allograft bank in India became functional at Lokmanya Tilak Municipal (LTM) medical college and hospital on 24th April 2000. The response of Indian society to this new concept of skin donation after death and the pattern of utilization of banked allografts from 2000 to 2010 has been presented in this study. Settings and Design: This allograft skin bank was established by the department of surgery. The departments of surgery and microbiology share the responsibility of smooth functioning of the bank. Materials and Methods: The response in terms of number of donations and the profile of donors was analyzed from records. Pattern and outcome of allograft utilization was studied from specially designed forms. Results: During these ten years, 262 deceased donor skin allograft donations were received. The response showed significant improvement after counselling was extended to the community. Majority of the donors were above 70 years of age and procurement was done at home for most. Skin allografts from 249 donors were used for 165 patients in ten years. The outcome was encouraging with seven deaths in 151 recipients with burn injuries. Conclusions: Our experience shows that the Indian society is ready to accept the concept of skin donation after death. Use of skin allografts is life saving for large burns. We need to prepare guidelines for the establishment of more skin banks in the country.

Galactorrhea and amenorrhea in burn patients.

INTRODUCTION Galactorrhea and/or amenorrhea, although uncommonly reported in post-burn patients, is a complex problem to treat. Patient is reluctant to volunteer history of these symptoms, unless asked specifically. AIM To study profile of adult female patients with galactorrhea and/or amenorrhea in post burn period. MATERIALS AND METHOD A prospective study of all adult female patients presenting with or detected to have galactorrhea and/or amenorrhea in post burn period was conducted over 6 months period. Detailed clinical examination, estimation of LH, FSH, Prolactin levels and X-ray of skull was done in all patients. The data collected was analyzed. Patients with hyperprolactinemia and galactorrhea were treated with Bromocriptine for 3 weeks to 3 months. In all patients with amenorrhea, pregnancy was ruled out by gynecological examination and urine pregnancy test. RESULTS During this period, 30 patients (15.15%) were detected to have galactorrhea and/or amenorrhoea. The extent of burn in these patients was 20-65%of body surface area. Out of 30 patients, 5 had galactorrhea and amenorrhea, 1 galactorrhea alone and 24 had amenorrhea alone. Analysis of voluntary disclosures and detection on interrogation was done. Till the end of study, 4 patients with galactorrhea had complete relief, 2 patients reported reduction in discharge. DISCUSSION Galactorrhea was distressing for all and was always associated with high prolactine levels .The reverse was not true. All the patients had chest burns besides other body areas. Association was noted between menstrual aberration and ovulatory phase at the time of burn. CONCLUSION Galactorrhea and menstrual disturbances do exist in female patients in reproductive age group in post burn period and patients should be especially interrogated for these symptoms by the burn care providers.

Excision of carbuncle with primary split-thickness skin grafting as a new treatment modality

Carbuncles are debilitating skin infections commonly seen in diabetic patients. Excision of these infective lesions leads to large defects that require prolonged hospital stay and repeated dressings with ensuing pain and bleeding. This study is an attempt to cover the wounds resulting from excision of carbuncle with primary skin grafting so as to decrease the hospital stay and frequency of dressings.

Training in trauma care.

In a dubious distinction for the country, the World Health Organization has revealed in its first ever Global Status Report on Road Safety that more people die in road accidents in India than anywhere else in the world, including the more populous China. (Dipak Kumar Dash, TNN, Aug 17, 2009, 04.10 am IST. New Delhi) About 250 people die in road accidents in India everyday (‘Strategy on road safety must’ TOI on 7th March, 2009) and the total number of deaths every year due to road accidents has now passed the 135,000 mark, according to the latest report of National Crime Records Bureau or NCRB. Besides road traffic accidents we have our share of victims of terrorist activities, accidents at work places, natural and man-made disasters, etc. Out of these about 78% are men in age group of 20–44 years, causing significant impact on productivity. (Joshipura MK, Shah HS, Patel PR, Divatia PA. Trauma care systems in India—An overview. Indian J Crit Care Med 2004;8:93-7) No credible data is available to ascertain the outcome of trauma victims; it is generally perceived that outcomes in patients with single system injury (e.g. musculoskeletal trauma) have improved. Unfortunately, the same cannot be said for polytrauma. There is a high mortality rate amongst those with multisystem injuries, which can be attributed to the primitive state of trauma-care systems, lack of prehospital care and inadequate critical care. It is established that the mortality in serious (ISS > 16) injuries is six times worse in a developing country such as India compared to a developed country. (Mock CN, Jurkovich GJ, nii-Amon-Kotei D, Arreola-Risa C, Maier RV. Trauma mortality patterns in three nations at different economic levels: Implications for global trauma system development. J Trauma 1998;44:804-14.) For any improvement in this area, it is essential to establish trauma system in the country and have health care professionals trained to provide efficient care to trauma victims at every step—pre-hospital, in-hospital and rehabilitation. Establishment of trauma system would fall within the purview of central and state government authorities. But professional bodies such as The Association of Surgeons of India can play pivotal role in training of health care professionals. Unfortunately such efforts have remained restricted to a few pockets in our country.

Polyethylene Surgical Drape Dressing for Split Thickness Skin Graft Donor Areas

A variety of dressings has been used for covering the split thickness skin graft donor areas. Some of these are alginates, collagen sheets, films and the most commonly used impregnat‐ ed tulle gras dressing. The chief goal of management of donor area is to achieve early epi‐ thelisation without infection. Minimum pain, easy availability and low cost of dressing are other desirable criteria. A controlled clinical trial was conducted to compare Vaseline im‐ pregnated gauze and Banana leaf dressing (BLD) (Fig 1) developed at the burn unit at LTM medical college and hospital in 1997. [1] The results showed BLD to be effective with signifi‐ cantly less pain and at much lower cost.

Nothing glamorous about it

This article is based on the Mumbai NABICON Research Award 2012 oration which I delivered an oration at Vadodara in January 2013 during NABICON 2013. It traces my journey over about 25 years in the field of burn care. I have tried to share the thought process and the efforts involved in contributing meaningfully to some areas in this field. There is a lot more to be done to improve the quality of acute care of burnt patients in our country. With the large number of burnt patients that we still continue to face, it is a major challenge and I strongly feel that all the research and new developments in this field should henceforth be coming from us - Indians. I fervently hope that this article stimulates at least a few to think, innovate and apply and contribute to clinical research addressing our problems.