Sankalp Dwivedi

Epidemiology and clinical characteristics of traumatic brain injuries in a rural setting in Maharashtra, India. 2007-2009

Context: Though some studies have described traumatic brain injuries in tertiary care, urban hospitals in India, very limited information is available from rural settings. Aims: To evaluate and describe the epidemiological and clinical characteristics of patients with traumatic brain injury and their clinical outcomes following admission to a rural, tertiary care teaching hospital in India. Settings and Design: Retrospective, cross-sectional, hospital-based study from January 2007 to December 2009. Materials and Methods: Epidemiological and clinical data from all patients with traumatic brain injury (TBI) admitted to the neurosurgery service of a rural hospital in district Wardha, Maharashtra, India, from 2007 to 2009 were analyzed. The medical records of all eligible patients were reviewed and data collected on age, sex, place of residence, Glasgow Coma Scale (GCS) score, mechanism of injury, severity of injury, concurrent injuries, length of hospital stay, computed tomography (CT) scan results, type of management, indication and type of surgical intervention, and outcome. Statistical Analysis: Data analysis was performed using STATA version 11.0. Results: The medical records of 1,926 eligible patients with TBI were analyzed. The median age of the study population was 31 years (range <1 year to 98 years). The majority of TBI cases occurred in persons aged 21 - 30 years (535 or 27.7%), and in males (1,363 or 70.76%). Most patients resided in nearby rural areas and the most frequent external cause of injury was motor vehicle crash (56.3%). The overall TBI-related mortality during the study period was 6.4%. From 2007 to 2009, TBI-related mortality significantly decreased (P < 0.01) during each year (2007: 8.9%, 2008: 8.5%, and 2009: 4.9%). This decrease in mortality could be due to access and availability of better health care facilities. Conclusions: Road traffic crashes are the leading cause of TBI in rural Maharashtra ffecting mainly young adult males. At least 10% of survivors had moderate or more severe TBI-related disabilities. Future research should include prospective, population based studies to better elucidate the incidence, prevalence, and economic impact of TBI in rural India.

The 2014 Academic College of Emergency Experts in India's INDO‑US Joint Working Group (JWG) White Paper on "Developing Trauma Sciences and Injury Care in India"

It is encouraging to see the much needed shift in the understanding and recognition of the concept of “burden of disease” in the context of traumatic injury. Equally important is understanding that the impact of trauma burden rivals that of nontraumatic morbidities. Subsequently, this paradigm shift reinstates the appeal for timely interventions as the standard for management of traumatic emergencies. Emergency trauma care in India has been disorganized due to inadequate sensitivity toward patients affected by trauma as well as the haphazard, nonuniform acceptance of standardization as the norm. Some of the major hospitals across various regions in the country do have trauma care units, but even those lack protocols to ensure that all trauma cases are handled by those units, largely owing to lack of structured referral system. As a first step to reform the state of trauma care in the country, a detailed overview is needed to gain insight into the prevailing reality. The objectives of this paper are to thus weave a foundation based on the statistical and qualitative burden of trauma in the country; the available infrastructure of trauma care centers equipped to deal with trauma; the need and scope of standardized protocols for intervention; and most importantly, the application of these in shaping educational initiatives in advancing emergency trauma care in the country.

Characteristics of patients who died from traumatic brain injury in two rural hospital emergency departments in Maharashtra, India, 2007-2009.

Introduction: Trauma is one of the leading causes of morbidity and mortality in the world and in India. Objective: To describe 1) selected epidemiological and clinical characteristics of persons with traumatic brain injury (TBI) who died within 24 h after admission to the emergency departments (EDs) of two medical facilities in rural India and 2) the methods used to transport these patients from the locale of the injury incident to the study sites. Materials and Methods: Medical records of all injured patients regardless of age or sex who died within 24 h after admission to both EDs during January 31, 2007 through December 31, 2009 were reviewed and abstracted. Demographic variables and information on prehospital care, time and mechanism of injury, mode of transport to EDs, and primary hospital resuscitation were abstracted and analyzed. Results: Of the 113 injured patients in this study, 42 had TBI and died within 24 h of ED admission. All of these TBI patients were transported to the ED by relatives or bystanders in non-ambulance vehicles. Most of the patients with TBI (78.5%) were 21-50-years-old; and overall 90.0% were males. Persons working near or along busy roads struck by vehicles accounted for 80.9% of all TBI cases. Severe TBIs were present in 97.6% of the patients; of these, 92.8% had a Glasgow Coma Scale (GCS) score of 3 on arrival. Other concurrent injuries included superficial lacerations (85.7%), facial injuries (57.1%), and upper (35.7%) and lower (30.9%) extremity fractures. Common lesions recognized on computed tomography (CT) scan were acute subdural hematoma (21.4%), subarachnoid hemorrhage with diffuse cerebral edema (16.6%), and skull base fracture with diffuse cerebral edema (14.2%); in 21.4% of cases, the CT scan were reported normal. Conclusion: Most of the TBI patients who died within 24 h after admission to EDs in this study were not transported to EDs in emergency medical vehicles; most were of working age (ages 20-50 years); were male; and were day laborers working on busy interstate roads where they were hit by vehicles.

Simultaneous hemorrhage in intracranial aneurysms and in renal cyst in a case of polycystic kidney disease

We report an unusual case of simultaneous hemorrhage in intracranial aneurysms and in renal cyst in a case of polycystic kidney disease. A 27-year-old gentleman presented with progressive headache and intermittent vomiting of one month duration. Initial computerized tomography (CT) scan and magnetic resonance imaging/angiography revealed a large mass lesion in the right temporal fossa. Over the previous 15 days, he developed progressive weakness in his left upper and lower limbs, and the headache worsened in severity. A repeat of CT scan showed an evidence of aneurysmal bleed and a large temporal lobe hematoma. The patient underwent urgent evacuation of the intracerebral of hematoma and excision of the redundant aneurysmal sac. The patient made excellent recovery in the post-operative period; however, for him, the pain abdomen was persisting. Detailed work-up with contrast-enhanced abdominal CT scan revealed bilateral multiple cysts in the kidneys with evidence of intracystic hemorrhage on the left side. An extensive search of the literature revealed that this kind of presentation has not been reported previously.

Giant solitary neurofibroma presenting as a neck mass in an infant.

Solitary neurofibroma is a rare tumor of the head and neck region. It is more common in viscera, where it is associated with features of NF1. It occurs most often between the third and fourth decade. These lesions are extremely rare in infants. We report a case of giant, solitary neurofibroma presenting as a progressive mass in parotid region in an infant. This case is unique in its age of presentation (11 months), site, size (about 8 × 15 cm) without any symptoms or neurological deficit.

A case of quadriplegia with gastric perforation.

Patients with cervical cord lesions have an increased susceptibility of developing life-threatening gastrointestinal complications.[1-5] The reported incidence of gastrointestinal tract complications in spinal cord injury patients ranges from 4.7%[3] to 6.2%.[1] A 45-year-old gentleman was admitted in the critical care unit with the complaints of progressive quadriparesis of 2 weeks duration. He was bedridden and was on an indwelling urinary catheter for the last 7 days. His general and systemic examination was unremarkable. Neurologically, higher mental functions and cranial nerve examination were normal. He had hypotonia in all four limbs, sensory loss to all modalities below C5 and grade 1-2/5 power in the upper and lower limbs. Deep tendon reflexes were sluggish in both upper and lower limbs. Bilateral planters were extensor. X-ray of the cervical spine was normal. Magnetic resonance imaging of the cervical spine showed diffuse cord compression (C3-5 level) with signal intensity changes [Figure 1]. A case of quadriplegia with gastric perforation

Blunt trauma to the parotid gland in child

Blunt trauma to the parotid gland is extremely rare and requires considerable force. We present a unique case in which a child sustained parotid injury without any associated injury to the facial skeleton, parotid gland and ductal structures and managed successfully. A literature search revealed that this type of injury has not been reported previously.

Role of opioids as coinduction agent with propofol and their effect on apnea time, recovery time, and sedation score

Background: Laryngeal mask airway (LMA) is a supraglottic device which requires lesser depth of anaesthesia, evokes lesser hemodynamic response and causes lesser stimulation of airway as compared to traditional definitive airway device endotracheal tube. Its placement is possible without muscle relaxants thereby allowing maintenance of anaesthesia on spontaneous respiration thus preventing apnoea or minimizing apnoea time. Propofol, the commonly used induction agent, causes cardiorespiratory depression at higher induction doses. To attenuate this, co-induction agents combined with propofol has been a regular I/V anaesthetic technique these days. Aim: Comparing apnoea time, recovery time and sedation scores using propofol-fentanyl and propofol-butorphanol combination. Methodology: Hundred patients scheduled for various elective surgical procedures were randomly selected and divided into two groups of 50 each. As coinduction drug Group F received fentanyl and Group B received butorphanol. In both the groups induction was achieved with I/V propofol and LMA was placed. Apnoea time was noted after induction. Recovery time and sedation scores were recorded after anaesthetic agents were turned off. Results: As compared to group F apnoea time was significantly less and recovery time was significantly more in group B (P < 0.05). Statistically postoperative sedation was significantly higher in group B than in group F at 1/2 hr but clinically, majority were responding to verbal commands. At 1 hour no significant difference in sedation was noted between the groups. Conclusion: Considering respiratory and recovery profile propofol -butorphanol combination is a safer alternative to propofol-fentanyl combination for LMA insertion.

What happens to the hemodynamic responses for laryngeal mask airway insertion when we supplement propofol with butorphanol or fentanyl for induction of anesthesia: A comparative assessment and critical review

Background: There is a delicate balance between respiratory tract anatomy, its physiology, physiological response to anesthetic agents, and airway management. The traditional gadgets to secure airway are face masks or endotracheal tubes. Recently, laryngeal mask airway (LMA) is gaining popularity. It does not require laryngoscopy thereby minimizing hemodynamic responses. For LMA placement, propofol is the induction agent of choice. Propofol, when used alone, requires large doses and leads to undesirable cardiorespiratory depression. To culminate its dose, various adjuncts are combined with it. Aim: Comparison of hemodynamic response of LMA using either butorphanol or fentanyl (according to group allocated) in combination with propofol. Methodology: Hundred patients scheduled for various surgical procedures were randomly selected and divided into two groups of 50 patients each, Group F (propofol and fentanyl) and Group B (propofol and butorphanol). One minute after giving intravenous (IV) opioids, induction was achieved with IV propofol 2.5 mg/kg. Depth of anesthesia was assessed, and LMA was inserted. Hemodynamic variables were measured before premedication, after premedication; 1, 3, and 5 min after insertion and after extubation of LMA. Results: After insertion of LMA, statistically significant drop in mean heart rate, systolic blood pressure (BP), diastolic BP, and mean BP was noted in Group F as compared to Group B (P < 0.05). Conclusion: The use of propofol-butorphanol combination produces stable hemodynamics as compared to propofol-fentanyl combination.