Shahan Waheed

Management of penetrating brain injury.

Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of Guidelines for the Management of Penetrating Brain Injury in 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on Guidelines for the Management of Penetrating Brain Injury and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI patients. Cerebral angiography is recommended in patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI patients.

The Karachi intracranial stenosis study (KISS) Protocol: An urban multicenter case-control investigation reporting the clinical, radiologic and biochemical associations of intracranial stenosis in Pakistan

BackgroundIntracranial stenosis is the most common cause of stroke among Asians. It has a poor prognosis with a high rate of recurrence. No effective medical or surgical treatment modality has been developed for the treatment of stroke due to intracranial stenosis. We aim to identify risk factors and biomarkers for intracranial stenosis and to develop techniques such as use of transcranial doppler to help diagnose intracranial stenosis in a cost-effective manner.Methods/DesignThe Karachi Intracranial Stenosis Study (KISS) is a prospective, observational, case-control study to describe the clinical features and determine the risk factors of patients with stroke due to intracranial stenosis and compare them to those with stroke due to other etiologies as well as to unaffected individuals. We plan to recruit 200 patients with stroke due to intracranial stenosis and two control groups each of 150 matched individuals. The first set of controls will include patients with ischemic stroke that is due to other atherosclerotic mechanisms specifically lacunar and cardioembolic strokes. The second group will consist of stroke free individuals. Standardized interviews will be conducted to determine demographic, medical, social, and behavioral variables along with baseline medications. Mandatory procedures for inclusion in the study are clinical confirmation of stroke by a healthcare professional within 72 hours of onset, 12 lead electrocardiogram, and neuroimaging. In addition, lipid profile, serum glucose, creatinine and HbA1C will be measured in all participants. Ancillary tests will include carotid ultrasound, transcranial doppler and magnetic resonance or computed tomography angiogram to rule out concurrent carotid disease. Echocardiogram and other additional investigations will be performed at these centers at the discretion of the regional physicians.DiscussionThe results of this study will help inform locally relevant clinical guidelines and effective public health and individual interventions.

New onset refractory status epilepticus as an unusual presentation of a suspected organophosphate poisoning.

New onset refractory status epilepticus (NORSE) is a new entity in medical literature. It has different infectious and noninfectious etiologies showing a devastating impact onto the clinical outcome of patients. Therapy with anaesthetic and antiepileptic agents often fails to improve the condition, unless the primary cause is rectified. Here is presented the case of a young female with a history of depression who after a recent bereavement came to the Emergency Department of Aga Khan University Hospital with complaints of drowsiness that lasted for few hours. Though she had no history of organophosphate poisoning, her physical examination and further investigations were suggestive of the diagnosis. During her hospital stay, she developed refractory status epilepticus. Her seizures did not respond to standard antiepileptic and intravenous anesthetic agents and subsided only after intravenous infusion of atropine for a few days. Organophosphate poisoning is a very common presentation in the developing world and the associated status epilepticus poses a devastating problem for emergency physicians. In patients with suspected organophosphate poisoning with favoring clinical exam findings, the continuation of atropine intravenous infusion can be a safe option to abate seizures.

Biventricular thrombus in hypereosinophilic syndrome presenting with shortness of breath.

A 48 years old male presented to clinic with 12 months of low grade fever with shortness of breath which has progressively worsened with no associated weight loss, night sweats or loss of appetite. There was no prior history of chronic illness before the current illness. Laboratory workup revealed a high white blood cell count with predominant eosinophils. Chest X-ray was normal. Transthoracic echocardiography and Cardiac Magnetic Resonance showed biventricular thrombi. On further extensive workup the findings were consistent with hypereosinophilic syndrome. The patient was started on oral steroids, hydroxyurea, imatanib mesylate and oral anticoagulation. The patient responded to the treatment with complete resolution of his symptoms over the course of few months. The repeat Echocardiogram after a year showed normal left ventricular systolic and diastolic function with complete resolution of biventricular thrombi.

Terrorist attacks in the largest metropolitan city of Pakistan: profile of soft tissue and skeletal injuries from a single trauma center

BACKGROUND Pakistan has been hugely struck with massive bomb explosions (car and suicide bombs) resulting in multiple casualties in the past few years. The aim of this study is to present the patterns of skeletal and soft tissue injuries and to review the outcome of the victims who presented to our hospital. METHODS This is a retrospective chart review from January 2008 to December 2012. The medical record numbers of patients were obtained from the hospital Health Information and Management Sciences (HIMS) as per the ICD-9 coding. RESULTS During the study period, more than 100 suicide and implanted bomb blast attacks took place in the public proceedings, government offices, residential areas and other places of the city. Altogether 262 patients were enrolled in the study. The mean age of the patients was 31±14 years. The shrapnel inflicted wounds were present on to the upper limb in 24 patients and the lower limb in 50. CONCLUSION Long bone fractures were the most common skeletal injuries. The fractures were complicated by penetrating fragments and nails which result in post operative infections and prolonged hospital stay.

Comparison of qSOFA and SOFA score for predicting mortality in severe sepsis and septic shock patients in the emergency department of a low middle income country

Objective We aimed to determine a comparison between the Quick Sequential Organ Failure Assessment (qSOFA) score and existing Sequential Organ Failure Assessment (SOFA) score when applied to severe sepsis & septic shock patients in the Emergency Department (ED) for prediction of in-hospital mortality in the setting of a tertiary care hospital ED in a low-middle income country. Method We conducted a prospective observational cohort study on 760 subjects. The qSOFA, SOFA score and in-hospital mortality were assessed by area under the receiver operating curve (AUROC). We calculated sensitivity and specificity for each score for outcomes at cut-offs of 0.92 and 0.63 for qSOFA and SOFA in Severe Sepsis respectively and 0.89 and 0.63 for qSOFA and SOFA in Septic shock respectively. Results In patients with severe sepsis, the AUROC of qSOFA for predicting mortality in subjects was 0.92 (95% CI; 0.89–0.94) with 96% sensitivity and 87% specificity in comparison to the AUROC of SOFA score which was 0.63 (95% CI; 0.55–0.70 with 71% sensitivity and 57% specificity. In patients with septic shock, the AUROC of qSOFA for predicting mortality in subjects was 0.89 (95% CI; 0.85–0.92) with 92% sensitivity and 85% specificity in comparison to the AUROC of SOFA score which was 0.63 (95% CI; 0.55–0.70 with 70% sensitivity and 59% specificity. Conclusion Our study concludes that qSOFA score is an effective tool at predicting in hospital mortality in comparison to SOFA score when applied to severe sepsis and septic shock patients in the setting of a tertiary care hospital ED of a low-middle income country however, further studies are needed before application for this purpose.

Fungal endocarditis presenting with right lumbar pain and femoral artery ischemia – An unusual case report

Fungal endocarditis is a rare entity which has a poor outcome. Our case reports an atypical presentation of similar pathology now presenting with femoral artery ischemia in an immune competent individual. A 62-year Asian male presented with sudden onset of right sided lumbar pain. Initial clinical exam was consistent with right sided renal colic. Intravenous analgesia did not relieve the pain. Repeat clinical examination revealed absent right femoral artery pulsation. The patient underwent a Computerized tomography angiography of right lower extremity. Echocardiogram revealed valvular vegetations that were later revealed to be because of Aspergillus Terreus. This case highlights the atypical presentation of a rare fungal endocarditis in an immune competent individual presenting with right sided lumbar pain. This case is of particular interest for emergency physicians who are at the forefront and may require to deal with such presentations.

Cerebral Venous Sinus Thrombosis with Tentorial Haemorrhagic Infarctions in Combined Proteins Deficiency and Hyperhomocysteinemia Treated with Anticoagulation- Limited Evidence with Good Results: A Case Report

We are presenting a case of a 40-year-old lady who presented with sudden loss of consciousness. Computed Tomography scan of her brain revealed the presence of blood in her sub-arachnoid space on her right hemisphere, cerebral oedema, and cerebral venous sinus thrombosis later magnetic Resonance Imaging revealed extensive cerebral venous sinuses thrombosis formation associated with supra and infra-tentorial haemorrhages. Elevated levels of plasma homocysteine and deficient levels of protein S. Patient was anticoagulated with warfarin and INR was monitored. She recovered successfully with no complication of anticoagulation observed. The use of anticoagulation had a favourable outcome in our patient but the evidence of its use lacking to date.

Community emergency medicine: Benefits and challenges of screening for elder abuse in the emergency department of a developing country.

As people live longer and fewer babies are born, the elderly became the fastest and largest growing population of the world, expected to increase further from 86 million in 2005 to 394 million in 2050 worldwide. Older patients represent a large bulk of the population arriving in emergency departments (EDs) all over the world.[1] They use hospitals more frequently than younger patients, have more hospital admissions from the ED and more prolonged hospital stays.[2] Elder abuse is defined as a single, or repeated, act which causes harm or distress to an older person and it can occur within any relationship where there is an expectation of trust from the elder person’s perspective.[3,4] The ED setting is a particularly important environment being the first point of contact with formal services for the abused elderly population.[5] Careful consideration is demanded when older people attend the ED, with particular attention paid to assessment of subjective and objective data in terms of manifestations and potential indicators of abuse. There are no reliable elder abuse and neglect prevalence and incidence figures from Pakistan. There is also a lack of specific healthcare institutions and reporting systems for dealing with elder abuse in the country. In the present article we will be discussing the factors responsible for the ED presentation of elder abuse, reasons why such abuse is not reported and communication strategies that could be applied in screening for elder abuse.

Confusing presentation of chaetomium brain abscess.

Abstract We put forth the case of a young immunocompetent female who presented with fever and left basal ganglia bleed secondary to vasculitis. After 2 weeks of prednisolone therapy, she continued to deteriorate. MRI scan revealed enhancement of previous hematoma, pus was aspirated surgically and fungal culture grew Chaetomium.