Nissar Shaikh

Emergency management of fat embolism syndrome.

Fat emboli occur in all patients with long-bone fractures, but only few patients develop systemic dysfunction, particularly the triad of skin, brain, and lung dysfunction known as the fat embolism syndrome (FES). Here we review the FES literature under different subheadings. The incidence of FES varies from 1–29%. The etiology may be traumatic or, rarely, nontraumatic. Various factors increase the incidence of FES. Mechanical and biochemical theories have been proposed for the pathophysiology of FES. The clinical manifestations include respiratory and cerebral dysfunction and a petechial rash. Diagnosis of FES is difficult. The other causes for the above-mentioned organ dysfunction have to be excluded. The clinical criteria along with imaging studies help in diagnosis. FES can be detected early by continuous pulse oximetry in high-risk patients. Treatment of FES is essentially supportive. Medications, including steroids, heparin, alcohol, and dextran, have been found to be ineffective.

Acute management of vascular air embolism

Vascular air embolism (VAE) is known since early nineteenth century. It is the entrainment of air or gas from operative field or other communications into the venous or arterial vasculature. Exact incidence of VAE is difficult to estimate. High risk surgeries for VAE are sitting position and posterior fossa neurosurgeries, cesarean section, laparoscopic, orthopedic, surgeries invasive procedures, pulmonary overpressure syndrome, and decompression syndrome. Risk factors for VAE are operative site 5 cm above the heart, creation of pressure gradient which will facilitate entry of air into the circulation, orogenital sex during pregnancy, rapid ascent in scuba (self contained underwater breathing apparatus) divers and barotrauma or chest trauma. Large bolus of air can lead to right ventricular air lock and immediate fatality. In up to 35% patient, the foramen ovale is patent which can cause paradoxical arterial air embolism. VAE affects cardiovascular, pulmonary and central nervous system. High index of clinical suspicion is must to diagnose VAE. The transesophgeal echocardiography is the most sensitive device which will detect smallest amount of air in the circulation. Treatment of VAE is to prevent further entrainment of air, reduce the volume of air entrained and haemodynamic support. Mortality of VAE ranges from 48 to 80%. VAE can be prevented significantly by proper positioning during surgery, optimal hydration, avoiding use of nitrous oxide, meticulous care during insertion, removal of central venous catheter, proper guidance, and training of scuba divers.

World Society of Emergency Surgery (WSES) guidelines for management of skin and soft tissue infections

Skin and soft tissue infections (SSTIs) encompass a variety of pathological conditions ranging from simple superficial infections to severe necrotizing soft tissue infections. Necrotizing soft tissue infections (NSTIs) are potentially life-threatening infections of any layer of the soft tissue compartment associated with widespread necrosis and systemic toxicity. Successful management of NSTIs involves prompt recognition, timely surgical debridement or drainage, resuscitation and appropriate antibiotic therapy. A worldwide international panel of experts developed evidence-based guidelines for management of soft tissue infections. The multifaceted nature of these infections has led to a collaboration among surgeons, intensive care and infectious diseases specialists, who have shared these guidelines, implementing clinical practice recommendations.

Fat embolism syndrome: clinical and imaging considerations: case report and review of literature.

Fat embolism syndrome (FES) is a serious clinical disorder occurring after trauma, orthopedic procedures and rarely in non-traumatic patients. Fat emboli develop in nearly all patients with bone fractures, but they are usually asymptomatic. Small number of patients develop signs and symptoms of various organ system dysfunction due to either mechanical obstruction of capillaries by fat emboli or due to hydrolysis of fat to fatty acids. A triad of lung, brain and skin involvement develop after an asymptomatic period of 24 to 72 hours. This symptom complex is called FES. The incidence reported is up to 30%, but many mild cases may recover unnoticed. Diagnosis of fat embolism is clinical with nonspecific, insensitive diagnostic test results. Treatment of fat embolism syndrome remains supportive and in most cases can be prevented by early fixation of large bone factures. Here we report two cases of traumatic fat embolism, which were diagnosed initially by Gurds criteria and subsequently confirmed by typical appearance on magnetic resonance imaging (MRI) of the brain in these patients. These patients were successfully treated with supportive management. In conclusion, diagnosis of FES needs high index of suspicion, exclusion of other conditions and use of clinical criteria in combination with imaging. Magnetic resonance imaging of the brain is of great importance in diagnosis and management of these patients.

Tension pneumocephalus as complication of burr-hole drainage of chronic subdural hematoma: A case report.

Background: Pneumocephalus is the presence of air in the cranial cavity. When this intracranial air causes increased intracranial pressure and leads to neurological deterioration, it is known as tension pneumocephalus (TP). TP can be a major life-threatening postoperative complication, especially after evacuation of chronic subdural hematoma. We report a case of TP after evacuation of chronic subdural hematoma and review the literature. Case Description: A 70-year-old man developed right-sided weakness after being admitted with minor head trauma a few weeks earlier. He was found to have a chronic subdural hematoma and underwent burr-hole evacuation. On day 3, he suddenly deteriorated and needed intubation and ventilation. Computerized tomography (CT) of the brain showed typical Mount Fuji’s sign due to TP. Immediately, 20-30 mL of air was aspirated from the intracranial fossa, and a catheter drain was inserted. The patient became fully awake after few hours and was extubated successfully. The drain was removed on day 5, and he was transferred to the ward before being discharged home. Conclusion: TP after evacuation of a chronic subdural hematoma is a neurosurgical emergency and needs immediate resuscitation and therapy; hence it is of vital importance that all acute-care physicians, intensivists and neurosurgeons be aware of this clinical emergency.

Hospital epidemiology of emergent cervical necrotizing fasciitis.

Background: Necrotizing fasciitis (NF) is a surgical emergency. It is a rapidly progressing infection of the fascia and subcutaneous tissue and could be fatal if not diagnosed early and treated properly. NF is common in the groin, abdomen, and extremities but rare in the neck and the head. Cervical necrotizing fasciitis (CNF) is an aggressive infection of the neck and the head, with devastating complications such as airway obstruction, pneumonia, pulmonary abscess, jugular venous thrombophlebitis, mediastinitis, and septic shock associated with high mortality. Aim: To assess the presentation, comorbidities, type of infection, severity of disease, and intensive care outcome of CNF. Methods: Medical records of the patients treated for NF in the surgical intensive care unit (SICU) from January 1995 to February 2005 were reviewed retrospectively. Results: Out of 94 patients with NF, 5 (5.3%) had CNF. Four patients were male. The mean age of our patients was 41.2 ± 14.8 years. Sixty percent of patients had an operative procedure as the predisposing factor and 80% of patients received nonsteroidal anti-inflammatory drugs (NSAIDs). The only comorbidity associated was diabetes mellitus (DM) in 3 patients (60%). Sixty percent of the cases had type1 NF. Mean sequential organ failure assessment (SOFA) score on admission to the ICU was 8.8 ± 3.6. All patients had undergone debridement at least two times. During the initial 24 h our patients received 5.8 ± 3.0 l of fluid, 2.0 ± 1.4 units of packed red blood cells (PRBC), 4.8 ± 3.6 units of fresh frozen plasma (FFP), and 3.0 ± 4.5 units of platelet concentrate. The mean number of days patients were intubated was 5.2 ± 5.1 days and the mean ICU stay was 6.4 ± 5.2 days. Sixty percent of cases had multiorgan dysfunction (MODS) and one patient died, resulting in a mortality rate of 20%. Conclusion: According to our study, CNF represents around 5% of NF patients. CNF was higher among male patients and in patients with history NSAIDs and dental surgeries. Type 1 NF was more common and DM was the only comorbid condition seen in this limited number of patients. The low mortality may be due to the early diagnosis and aggressive surgical treatment combined with optimal supportive intensive care management.

Necrotizing fasciitis: A decade of surgical intensive care experience

Necrotizing fasciitis is a rare disease, potentially limb and life-threatening infection of fascia, subcutaneous tissue with occasionally muscular involvement. Necrotizing faciitis is a surgical emergency with high morbidity and mortality. Aim: Aim of this study was to analyze presentation, microbiology, surgical, resuscitative management and outcome of this devastating soft tissue infection. Materials and Methods: The medical records of necrotizing fasciitis patients treated in surgical intensive care unit (SICU) of our hospital from Jan 1995 to Feb 2005 were reviewed retrospectively. Results: Ninety-four patients with necrotizing fasciitis were treated in the surgical intensive care unit during the review period. Necrotizing fasciitis accounted for 1.15% of total admissions to our SICU. The mean age of our patients was 48.6 years, 75.5% of the cases were male. Diabetes mellitus was the most common comorbid disease (56.4%), 24.5% patients had hypertension, 14.9% patients had coronary artery disease, 9.6% had renal disease and 6.4% cases were obese. History of operation (11.7%) was most common predisposing factor in our patients. All patients had leucocytosis at admission to the hospital. Mean duration of symptoms was 3.4 days. Mean number of surgical debridement was 2.1, mean sequential organ failure assessment (SOFA) score at admission to SICU was 8.6, 56.38% cases were type 1 necrotizing fasciitis and 43.61% had type 2 infection. Streptococci were most common bacteria isolated (52.1%), commonest regions of the body affected by necrotizing fasciitis were the leg and the foot. Mean intubated days and intensive care unit (ICU) stay were 4.8 and 7.6 days respectively. Mean fluid, blood, fresh frozen plasma and platelets concentrate received in first 24 hours were 4.8 liters, 2.0 units, 3.9 units and 1.6 units respectively. Most commonly used antibiotics were piperacillin with tazobactum and clindamycin. Common complication was ventricular tachycardia (6.4). 46.8% patients had multi organ dysfunction, 15 of them died giving a mortality of 16% in this study. Conclusion: Necrotizing fasciitis is more common in males, diabetes mellitus was the most common comorbid disease, type 1-necrotizing fasciitis was more common and the most common regions of the body affected by necrotizing fasciitis were the leg and the foot.

Heparin-induced thrombocytopenia

In the last 7 decades heparin has remained the most commonly used anticoagulant. Its use is increasing, mainly due to the increase in the number of vascular interventions and aging population. The most feared complication of heparin use is heparin-induced thrombocytopenia (HIT). HIT is a clinicopathologic hypercoagulable, procoagulant prothrombotic condition in patients on heparin therapy, and decrease in platelet count by 50% or to less than 100,000, from 5 to 14 days of therapy. This prothrombotic hypercoagulable state in HIT patient is due to the combined effect of various factors, such as platelet activation, mainly the formation of PF4/heparin/IgG complex, stimulation of the intrinsic factor, and loss of anticoagulant effect of heparin. Diagnosis of HIT is done by clinical condition, heparin use, and timing of thrombocytopenia, and it is confirmed by either serotonin release assay or ELISA assay. Complications of HIT are venous/arterial thrombosis, skin gangrene, and acute platelet activation syndrome. Stopping heparin is the basic initial treatment, and Direct Thrombin Inhibitors (DTI) are medication of choice in these patients. A few routine but essential procedures performed by using heparin are hemodialysis, Percutaneous Coronary Intervention, and Cardiopulmonary Bypass; but it cannot be used if a patient develops HIT. HIT patients with unstable angina, thromboembolism, or indwelling devices, such as valve replacement or intraaortic balloon pump, will require alternative anticoagulation therapy. HIT can be prevented significantly by keeping heparin therapy shorter, avoiding bovine heparin, using low-molecular weight heparin, and stopping heparin use for flush and heparin lock.

Fatal dialysis disequilibrium syndrome: A tale of two patients

Dialysis disequilibrium syndrome (DDS) is a central nervous system disorder, which occurs during hemodialysis (HD) or within 24 h following the first HD. DDS commonly occurs in patients suffering from end-stage renal failure undergoing HD for the first time. In a critically ill patient suffering from severe sepsis or septic shock, the combined effects of post-HD brain edema and changes in the brain due to septic encephalopathy, may become amplified leading to DDS. Here we report 2 cases with acute renal failure (ARF), undergoing HD for more than a week and being ventilated and who developed DDS. DDS might have contributed to the sudden deterioration and death in these septic patients. The first case was a 31-year-old male, involved in a motor vehicle accident and had a severe abdominal injury. Underwent laparotomy and hemostasis was achieved. On day 4, the patient developed hemorrhagic shock associated with ARF, which prompted daily HD. On day 8, he went into septic shock. On day 16, 1 h after his daily HD, he became unresponsive and his pupils became dilated and fixed and he expired 2 days later. The second case was a young male who suffered severe abdominal and chest injury after a fall from a height. He developed ARF on day 3 and required HD. On day 9, he had septic shock. Three days later, during his daily HD, he became unconscious and his pupils were not reacting to light and the patient died on day 12. Conclusion: In patients with severe sepsis/septic shock, DDS may occur even after repeated sessions of HD. The acute care physicians, intensivists, and nephrologists should be aware of the risks of DDS.

Neuroleptic malignant syndrome and closed head injury: A case report and review.

Neuroleptic malignant syndrome (NMS) is a rare, but potentially lethal neurological emergency. Fifty percent of traumatic brain injury (TBI) patients will have emotional disorders and post-traumatic agitations. Haloperidol is a neuroleptic antipsychotic medication commonly used in the traumatic brain injury patients due to its advantage of no effect on respiration and conscious level. But it is one of the common medications causing NMS. A 19-year-old male driver involved in the road traffic accident had an acute subdural hematoma, which was immediately evacuated. Postoperatively, he was awake. He was weaned from ventilator and extubated. He received 20 mg of intravenous haloperidol in divided doses with in 24 hours to control his agitation. Next day, he became drowsy, spastic, febrile, and tachycardic with labile blood pressure. He was diagnosed to have NMS, needed intubation, aggressive hydration and pharmacological treatment with dentrolene sodium and bromocriptin. He was weaned from ventilator and extubated on day 17. He was transferred to the ward and then discharged to be followed in out-patient clinic. NMS in head injury patient is rare and difficult to diagnose. Diagnosis of NMS should be suspected if two of the four cardinal signs and symptoms are developed following the use of neuroleptic or dopamine agonist medication withdrawal.