Shruti Jain

A multi factorial analysis of the epidemiology of injuries from falls from heights

Background: Fall from height is a common cause of morbidity and mortality in suburban population in India. These cases are either domestic or workplace injuries with different causative factors. We analyzed different aspects of these falls to identify their risk factors. Materials and Methods: We conducted prospective and retrospective epidemiological study to identify various causative, contributory factors, and resultant injuries in cases of fall from height. The study group comprised of semiurban population and involved both domestic and workplace injuries presenting to a tertiary care hospital. Results: There were 208 cases of workplace (112) and domestic (96) fall from height. In domestic cases absence of parapet on roof was the commonest cause, most of falls occurred during summer and rainy season. Alcohol consumption prior to fall was commonest associated factor in adult males. Children mostly fell while playing on roof and climbing trees. Among workplace cases, civil construction site injuries were commonest and absence of any protective gear and long working and evening hours were commonest associated factors. Mean injury severity score was 10.86 in domestic cases and 14.87 in workplace cases. There were 17 mortalities with head injury being commonest associated cause. Only difference in incidence of alcohol consumption and permanent disability was statistically significant between workplace and domestic falls. Conclusion: Different factors are responsible for domestic and workplace cases of fall from height. Most of these cases are potentially preventable.

Lightwand: a useful aid in faciomaxillary trauma

Airway management in patients of faciomaxillary injury is of great concern to the anesthesiologist. Bag and mask ventilation and orotracheal intubation may be difficult with these patients. Recently, a middle aged, obese female presented in the emergency department after sustaining a blast injury, with laceration of the upper chest and left submandibular region. Laceration of the submandibular region was communicating with the intraoral space and the airway was filled with blood. The airway was secured with nasotracheal intubation aided by a lightwand, after failure with the Macintosh laryngoscope. This case report highlights the importance of the lightwand in intubating a patient with a bleeding airway and when the bright light glow of the lightwand gives sufficient direction toward the glottis for successful tracheal intubation.

Effect of peri-operative intravenous infusion of lignocaine on haemodynamic responses to intubation, extubation and post-operative analgesia

Background and Aims: Lignocaine in intravenous (IV) bolus dose has been used for minimising haemodynamic changes associated with intubation and extubation. Furthermore, IV infusion has been used for post-operative analgesia. We investigated whether IV peri-operative lignocaine (bolus and infusion) would be able to produce both the effects simultaneously in elective laparoscopic cholecystectomies. Methods: In this randomised prospective study, 60 patients undergoing elective laparoscopic cholecystectomy were randomly divided into two groups of 30 each. In Group A, patients received 6 ml normal saline as bolus over 10 min followed by 6 ml/h infusion whereas in Group B, patients received preservative free 2% lignocaine 1.5 mg/kg IV bolus (made to a volume of 6 ml with normal saline) administered over a period of 10 min and thereafter an infusion at a rate of 1.5 mg/kg/h (pre-diluted in normal saline made to a volume of 6 ml/h. P < 0.05 was considered as significant. Results: The rise in pulse rate (PR) and mean arterial pressure (MAP) were less in Group B as compared to the Group A (P < 0.05) during intubation as well as during extubation. Furthermore, the Group B had significant longer mean pain-free post-operative period of 5½ h as compared to 54.43 min in the Group A (P < 0.05). Conclusion: Administration of lignocaine infusion attenuates the rise in PR as well as MAP during the peri-intubation and peri-extubation period. Furthermore, infusion of lignocaine significantly increases the mean pain-free period post-operatively.

Anesthetic management of a pediatric patient with rare bilateral macrostomia

respiratory pattern then became irregular. Finally, the lungs could not be ventilated even with high-pressure manual ventilation because of board-like rigidity. SpO2 fell to 45%, and did not recover until spontaneous respiration restarted in a couple of minutes. Although the breath-hold seemed different from emergence agitation, the trachea was extubated because the respiratory pattern became stable. However, immediately after extubation, ventilation again became difficult because of board-like rigidity. SpO2 and heart rate fell to 30% and 40 bÆmin, respectively. Spontaneous respiration reappeared before a muscle relaxant could be given. SpO2 and heart rate recovered quickly. Rigidity of both upper limbs, however, was not relieved. Both hands protruded with flexed elbows. Diazepam i.v. did not relieve the rigidity. The eyes were fixed centrally and the pupils were equal and reactive. He was transferred to the ICU. EEG was normal. The rigidity of the upper and lower limbs, although less marked, persisted and was diagnosed as a dystonic reaction by a pediatric neurologist. The rigidity of the limbs gradually subsided and disappeared completely by 8 h. The patient was discharged 2 days later without complications. In this case, the anesthesia consisted simply of sevoflurane, nitrous oxide and a muscle relaxant. Although dystonic reactions have been reported in cases using halogenated-volatile anesthetics, drugs potentially provoking dystonic reactions were used in all cases (1). Neither the patient nor his mother took any medicines in this case. There is no direct evidence that sevoflurane elicits dystonic reactions, although nitrous oxide induced rigidity and catatonic jerking of the extremities in volunteers at 1.55 atm (2). This report may suggest that nitrous oxide can potentially induce dystonic reactions. Neostigmine i.v. is unlikely to cause dystonic reactions, as it does not pass through the blood-brain barrier because of its low lipid solubility. There are no reports that atropine and vecronium provoke extrapyramidal signs. Agitation is frequently observed at emergence from sevoflurane anesthesia. Desaturation after extubation may be explained by agitation or laryngospasm. However, difficult ventilation before extubation could not be explained, because it is unlikely that manual ventilation was completely prevented by emergence agitation in a 2-month-old infant, as long as a tracheal tube was placed correctly. Seizure activity on EEG is often induced by sevoflurane. Zachirias (3) reported transient generalized convulsive movement and board-like rigidity in children during induction with sevoflurane. Sevoflurane concentration in the central nervous system is rapidly changing at both induction and emergence. Thus, a possibility that the rigidity was induced by a seizure was not excluded. On the other hand, EEG showed normal pattern in the ICU, while the rigidity of the limbs remained. Thus, the rigidity would be different from a sevoflurane-induced seizure, at least, after emergence. Transient movement disorders are not uncommon in pediatric practice (4). Most of these disorders are idiopathic and unassociated with other neurological diseases. Environment insults such as perinatal anoxia, head trauma and stroke may trigger dystonic reactions. This abnormal movement appears in the first month of life, and gradually disappears over a few months. Although none has been reported in association with anesthesia, the stress of general anesthesia, emergence agitation or surgery could provoke a transient movement disorder. Diazepam was ineffective to relieve the rigidity in this case. Diphenhydramine is reported to be effective for dystonia with minimal side effects (5). We should have considered its use after the rigidity had been diagnosed as a dystonic reaction. We could not identify a cause for dystonic reactions. However, we believe it worthwhile to report that dystonicreactions in infants, though rare could be a cause of difficult ventilation. Shin Kawana md, Yuki Toyoshima PhD, Fuminori Tobise md and Toshiyuki Takahashi MD Hokkaido Children’s Hospital and Medical Center, 1-10-1 Zenibako, Otaru 047-0261, Japan (email: skawana@tree.odn.ne.jp)

Randomized controlled trial for evaluating the analgesic effect of nalbuphine as an adjuvant to bupivacaine in supraclavicular block under ultrasound guidance

Introduction: Benefits of regional anesthesia can be prolonged by adding adjuvants to local anesthetics. This study was designed to test the efficacy of adding nalbuphine to bupivacaine in supraclavicular brachial plexus blockade using ultrasound (US) guidance. Methodology: This was a prospective, randomized, double-blind study involving sixty patients of either sex undergoing elective orthopedic procedures of upper limb. In control Group C (n = 30), 30 mL of 0.375% bupivacaine + 1 mL normal saline and in study Group N (n = 30), 30 mL of 0.375% bupivacaine + 1 mL (10 mg) nalbuphine were used for giving supraclavicular block under US guidance. Parameters assessed were onset and duration of sensory and motor block, duration of analgesia (DOA), and any adverse events. Data between the groups were analyzed using independent t-test with SPSS 16.0 software. Results: In Group N, there was a statistically significant shorter time to onset of sensory blockade (4.89 ± 1.5 vs. 14.62 ± 1.73 min, P = 0.000), longer duration of sensory block (373.17 ± 15.56 min vs. 157.82 ± 11.02 min, P = 0.000), shorter onset time to achieve motor block (8.83 ± 1.9 min vs. 18.76 ± 1.75 min, P = 0.000), longer duration of motor block (313.92 ± 16.22 min vs. 121.87 ± 16.62 min, P = 0.000), and prolonged analgesia (389.33 ± 14.52 min vs. 171.65 ± 19.79 min, P = 0.000). Conclusion: Nalbuphine when added to bupivacaine as an adjuvant in supraclavicular block significantly shortened the onset of sensory and motor block and enhanced the duration of sensory and motor block and DOA.

Myocardial ischaemia secondary to intramyometrial injection of methylergonovine maleate.

Sir, Ergonovine is used in obstetric practice and as a diagnostic agent in cardiac catheterisation laboratories. This drug may precipitate acute myocardial infarction due to prolonged coronary spasm.[1] We report a case of acute myocardial ischaemia caused by intramyometrial administration of methylergonovine maleate during caesarean section. A healthy, 28-year-old woman (height 155 cm, weight 76 kg, gravida 2, para 2) at 38 weeks gestation underwent an emergency lower section caesarean section (LSCS) due to scar tenderness of previous LSCS. She had no history of preeclampsia, migraine and risk factors for coronary heart disease such as smoking, diabetes mellitus, hypertension, hyperlipidaemia and obesity. Spinal anaesthesia was administered with a 25-gauge needle at L3-L4 interspace with 12 mg of 0.5% of hyperbaric bupivacaine. After the delivery of the foetus, despite uterine massage, continuous intravenous oxytocin infusion and intramuscular carboprost (15-methyl-PGF2α) 250 μg, the uterus remained atonic. In a desperate attempt to achieve uterine contraction, the obstetrician gave a single intramyometrial injection of 0.2 mg methylergonovine maleate. Immediately, patients blood pressure (BP) increased from 126/84 mm Hg to 164/104 mm Hg. Heart rate (HR) increased from 86/min to 104/min. Electrocardiogram (ECG) revealed sinus rhythm and oxygen saturation remained 100%. In next 5 min, patients BP increased to 190/116 mm Hg and HR to 120/min. She started complaining of headache, substernal chest pain and developed laboured breathing. Chest auscultation revealed bilateral crepitations and ECG now showed non-specific T-wave abnormalities with ST-segment elevation. Patient was immediately intubated, and mechanical ventilation with positive end-expiratory pressure was started. Injection furosemide 20 mg was given, and nitroglycerine infusion at 5 μg/min was started. Uterus, by now, had contracted and wound closure was done. The patient was transferred to Intensive Care Unit for mechanical ventilation and monitoring of her vitals. Immediate post-operative X-ray chest showed pulmonary oedema. Subsequently, BP started stabilizing towards normal values and ECG changes reverted to normal rhythm. Chest became clear by the end of 3 h. Creatine phosphokinase and troponin levels were within normal limits. The patient was extubated after 8 h and shifted to post-operative room. Despite the frequent usage of methyl ergonovine maleate for routine management of the third stage of labour and post-partum atony, cardiac complications of this drug have rarely been reported. The risk factors for coronary artery spasm by ergot derivatives are Asian origin, age >30, smoking, family history of ischaemic heart disease and history of migraine.[2] Although other conditions such as oesophageal spasm are known to mimic angina and are accompanied by non-specific ECG changes, the onset of clinical symptoms and ECG changes immediately after intramyometrial administration of methyl ergonovine suggest cardiac aetiology (coronary vasospasm).[3] The recommended mode of administration of methylergonovine maleate in the post-partum period is intramuscular. Intravascular (IV) or intramyometrial route is not recommended. Intramyometrial injection leading to myocardial ischaemia has been reported rarely.[3] Because the myometrium is a highly vascular tissue, the intramyometrial injection of methylergonovine maleate might behave as an IV administration of drug.[3] IV injection can cause hypertension, myocardial infarction, acute heart failure, pulmonary oedema, cerebral haemorrhage and retinal detachment.[4] If IV administration is considered essential as a life-saving measure, injection should be given in incremental doses with careful monitoring of BP and ECG.[5] Nitroglycerine was successfully used to reverse ergonovine-induced coronary spasm. It also prevents subsequent development of myocardial ischaemia and infarction.[3] Thus, intramyometrial injection of ergonovine is not to be encouraged as it can cause coronary artery spasm in obstetric patients. Prompt evaluation and management may prevent or reduce the morbidity or mortality caused by this drug. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

A prospective randomized control study comparing classic laryngeal mask airway with Guedel's airway for tracheal tube exchange and smooth extubation

Introduction: Extubation in deep plane of anesthesia followed by Guedels oropharyngeal airway (OPATM) insertion is a routine method to avoid hemodynamic changes associated with tracheal extubation. Exchange of endotracheal tube (ETT) with Classic laryngeal mask airway (LMATM) prior to emergence from anesthesia also serves similar purpose. We had compared the hemodynamic changes involved during this ETT/LMATM and ETT/OPATM exchange technique. Material and Methods: This was a randomized prospective study on ASA I and 2 patients undergoing elective surgery under general anesthesia. These patients were randomly divided into two groups i.e. OPA group and LMA group of 50 patients each. Hemodynamic parameters i.e. systolic blood pressure (SBP) and heart rate (HR) were recorded during exchange of ETT with OPATM or LMATM. Coughing / bucking during removal of OPATM and LMATM, and presence of post operative sore throat for both the groups were also graded and recorded. Data within the groups have been analyzed using paired “t” test while those between the groups were analyzed using unpaired “t” test. Chi square test was used to analyze grades of coughing and post operative sore throat. Results: In both groups, hemodynamic parameters rose significantly as OPATM/LMATM was placed (P < 0.05) and then started declining. Hemodynamic parameters continued to fall in LMA group after extubation. However in OPA group, hemodynamic parameters continued to rise even after extubation and declined only when OPATM was removed. There was no statistical significant difference between the LMA and OPA group in respect to coughing and post operative sore throat. Conclusion: LMATM is superior to OPATM for exchange of ETT as it provides greater hemodynamic stability.

Comparison of classic laryngeal mask airway with Ambu laryngeal mask for tracheal tube exchange: A prospective randomized controlled study

Background and Aim: Exchanging endotracheal tube (ETT) with classic laryngeal mask airway™ (CLMA™) prior to emergence from anaesthesia is a safe technique to prevent the coughing and haemodynamic changes during extubation. We had compared CLMA™ and AMBU laryngeal mask™ (ALM™) during ETT/laryngeal mask (LM) for haemodynamic changes and other parameters. Methods: A total of 100 American Society of Anesthesiologist Grade I and II adult female patients undergoing elective laparoscopic cholecystectomy under general anaesthesia were selected and randomly divided into two groups of 50 patients each. In Group I, CLMA™ and in Group II, ALM™ was placed prior to tracheal extubation. Haemodynamic parameters were recorded during ETT/LM exchange. Glottic view was seen through the LM using flexible fibrescope. Coughing/bucking during removal of LM, ease of placement and post-operative sore throat for both groups were graded and recorded. Statistical Analysis: Data within the groups was analysed using paired t-test while between the groups was analysed using unpaired t-test. Chi-square test was used to analyse grades of glottic view, coughing, and post-operative sore throat. Results: In Group I, there was a significant rise in systolic blood pressure and heart rate in contrast to insignificant rise in Group II. Glottis view was significantly better in Group II. Incidence of coughing, ease of placement and post-operative sore throat was identical between both groups. Conclusion: ALM™ is superior to CLMA™ for exchange of ETT before extubation due to greater haemodynamic stability during exchange phase and is better positioned.