Background : Stroke, characterized by sudden loss of cerebral function, is among one of the leading cause of death and disability world over. The newer treatment modalities have changed the landscape of stroke treatment but are very much time bound. Aim: To characterize pre-hospital and in-hospital factors affecting acute stroke management thus defining lacunae in stroke management. Subjects and Methods: A prospective observational study, conducted at the emergency department of a tertiary care center in southern India from August 2015 to July 2016. All stroke patients presenting within first 24 hours of onset were included. A pre -defined Knowledge-Attitude-Practice (KAP) questionnaire was used. Results: Total of 133 patients were eligible out of which 28 were excluded for various reasons. Majority were >60 years age and male (61%). About 60% arrived within window. Distance from the hospital was one of the major factors for arrival within the window period. When compared by KAP questionnaire, bystanders of those arriving within window period had better awareness of stroke symptoms. Conclusions: Improving awareness of stroke symptoms and increasing availability of EMS is likely increase chances of stroke patients receiving appropriate acute management.

Background: The incidence and risk factors for delirium vary among studies. Objective: We aimed to determine the incidence, risk factors, and impact on outcome of delirium in a medical Intensive Care Unit (ICU) in Tunisia using a prospective observational study. Patients: All consecutive patients admitted to the ICU between May 2012 and April 2013 were included if they were aged more than 18 years and had an ICU stay of more than 24 h. Patients who had a cardiac arrest or have a history of dementia or psychosis were excluded. Patients eligible for the study were evaluated by the medical staff to detect delirium using the CAM-ICU. Results: A total of 206 patients were included, 167 did not present delirium and 39 (19%) were analyzed for delirium. Delirious patients had a significantly longer duration of mechanical ventilation (10 days[6–20] vs. 2 days[0–7]) respectively and length of stay in ICU (21.5 days [10.5–32.5] vs. 8 days [5–13]), with no impact on mortality. Delirium was associated with high incidence of unintentional removal of catheters (39% vs. 9%; P < 0.0001), endotracheal tubes (18% vs. 1%; P < 0.0001), and urinary catheters (28% vs. 2%, P < 0.0001). In multivariable risk regression analysis, age (odds ratio [OR] = 4.1, 95% confidence interval [CI]: 1.39–12.21; P = 0.01), hypertension (OR = 3.3, 95% CI: 1.31–8.13; P = 0.011), COPD (OR = 3.5, 95% CI: 1.47–8.59; P = 0.005), steroids (OR = 2.8, 95% CI: 1.05–7.28; P = 0.038), and sedation (OR = 5.4, 95% CI: 2.08–13.9; P < 0.0001) were independent risk factors for delirium. We did not find a relationship between delirium and mortality. Conclusion: Delirium is frequent in the ICU and is associated with poor outcome. Several risk factors for delirium are linked to intensive care environment.

Context: Optic nerve sheath diameter (ONSD) has long been accepted as a reliable proxy of intracranial pressure especially in critical care and bedside settings. The present consensus is to measure ONSD in both eyes and take average value, which is cumbersome and a potential cause of discomfort to the patient. Aim: We aim to compare the values of ONSD of the right and left eye in a random sample as measured by bedside ocular ultrasonography (USG) in Indian adults. Settings and Design: This was a prospective study conducted from September 2012 to March 2013 in the Department of Internal Medicine of a tertiary care hospital situated at moderate high altitude (11,500 ft) in India. Materials and Methods: Patients admitted with high altitude pulmonary edema (HAPE) were recruited by convenience sampling. The ONSD of both eyes were measured 3 mm behind the globe using a 7.5 MHz linear probe on the closed eyelids of supine subjects. Statistical Analysis: Analysis was done using SPSS 17.0. Results: A total of 47 patients of HAPE were recruited to the study with daily ONSD recording of both eyes during the admission period. The mean ONSD of the left eye was 4.60 (standard deviation [SD] = 0.71) whereas the mean ONSD of right eye 4.59 (SD = 0.72). The ONSD of the right eye and left eye was strongly correlated (correlation coefficient = 0.98 with P < 0.0001). The mean difference in the ONSD of both eyes (right–left) was −0.0044 (SD = 0.11) which was not statistically significant (P = 0.533). Conclusion: Our results suggest that the difference in ONSD of both eyes is not statistically significant in disease or health. This study also suggests that the ONSD of either eye can be predicted by the other eye recordings. Based on these findings, it can be suggested that during ocular USG for routine bedside/research purposes it is sufficient to measure ONSD of any of the one eye to save time and avoid discomfort to the patient.

Background: The World Health Organization guidelines provide suggestions on early recognition and treatment of severe dengue (SD); however, mortality in this group can be high and is related both to disease severity and the treatment complications. Subjects and Methods: In this prospective observational study, we report our results where standard therapy (ST) was enhanced by Intensive Care Unit (ICU) supportive measures that have proven beneficial in other conditions that share similar pathophysiology of capillary leak and fluid overload. These include early albumin for crystalloid-refractory shock, proactive monitoring for symptomatic abdominal compartment syndrome (ACS), application of a high-risk intubation management protocol, and other therapies. We compared outcomes in a matched retrospective cohort who received ST. Results: We found improved outcomes using these interventions in patients with the most devastating forms of dengue (ST+ group). We could demonstrate decreased positive fluid balance on days 1–3 and less symptomatic ACS that necessitated invasive percutaneous drainage (7.7% in ST+ group vs. 30% in ST group, P = 0.025). Other benefits in ST+ group included lower intubation and positive pressure ventilation requirements (18.4% in ST+ vs. 53.3% in ST, P = 0.003), lower incidence of major hemorrhage and acute kidney injury, and reduced pediatric ICU stays and mortality (2.6% in ST+ group vs. 26% in ST group, P = 0.004). Conclusion: Children with SD with refractory shock are at extremely high mortality risk. We describe the proactive application of several targeted ICU supportive interventions in addition to ST and could show that these interventions resulted in decreased resuscitation morbidity and improved outcomes in SD.

Context: Varicella pneumonia is a rare but a serious complication of chickenpox in adults. There is paucity of data on varicella pneumonia from India. Aims: The aim of this study is to describe the clinical manifestations, hospital course, treatment, and outcome of adult patients with severe varicella pneumonia. Settings and Design: This was a retrospective, observational study of patients with severe varicella pneumonia attending a tertiary care teaching hospital. Subjects and Methods: The cases of varicella were identified by a computerized search of the medical record for the period between January 2010 and December 2016. During this period, 137 patients got admitted with varicella of which 22 had severe varicella pneumonia. Statistical Analysis: Mean and standard deviation were computed. Fisher's Z-test of proportions and analysis of variance were applied. Results: There were 17 (77.3%) men and 5 (22.7%) women. The mean age of the patients was 33.4 ± 10.8 years. History of contact with an infected person followed by high-grade fever and typical rash was present in all patients. Forty-five percent (10/22) of patients were immunosuppressed. All the patients received intravenous acyclovir. Forty-five percent (10/22) of patients received invasive mechanical ventilation. The various factors associated with the need for mechanical ventilation were partial pressure of oxygen:fraction of inspired oxygen ratio <150, quick sequential (sepsis-related) organ failure assessment (qSOFA) >2, and early bacterial coinfection. The mean Intensive Care Unit and hospital stay were 7 days (range; 1–16) and 9 days (range; 4–21), respectively. The overall mortality was 22.7% and reached 50% in those requiring invasive ventilation. The mortality was higher among patients with qSOFA >3, mean arterial blood pressure <60 mmHg, and severe acute respiratory distress syndrome at presentation. Conclusions: Patients with severe varicella pneumonia are at an increased risk of respiratory failure and death.

Objectives: cardiopulmonary bypass (CPB) can be complicated by vasoplegia that is refractory to vasopressors. Methylene blue (MB) represents an alternative in such cases. Patients and Methods: Retrospective observational historical control-matched study. From 2010 to 2015, all patients who received MB for vasoplegia post-CPB were included in this study. Historical controls from the period of 2004 to 2009 were matched. End-points were the time till improvement of vasoplegia (Ti), 30-day mortality, cardiac surgical Intensive Care Unit (CSICU) morbidity, and length of stay (LOS). Results: Twenty-eight patients were matched in both groups. There were no statistically significant differences between the two groups in demographic, laboratory data on admission, or hemodynamic profile before use of MB. Ti and time to complete discontinuation of vasopressors were statistically significant less in MB group (8.2 ± 2.6 vs. 29.7 ± 6.4, P = 0.00 and 22.6 ± 5.2 vs. 55.3 ± 9.4, P = 0.00) respectively. Mortality at day 30 was significantly higher in controls compared to MB (1 patient [3.6%] vs. 6 patients [21.4%], long rank P = 0.04). CSICU, hospital LOS, and incidence of renal failure was significantly higher in control group (12.4 ± 3.7 vs. 7 ± 1.4, P = 0.03), (19.5 ± 2.4 vs. 10.9 ± 3.2, P = 0.05) and (9 patients [32.1%] vs. 2 patients [7.1%], P = 0.04), respectively. Duration of mechanical ventilation was less in MB patients; however, did not reach statistical significance. Conclusions: the use of MB for vasoplegia postcardiac surgery was associated with rapid recovery of hemodynamics, shorter need for vasopressors, less ICU mortality, less incidence of renal failure, and shorter LOS.

Background and Aims: This study aimed to compare glycemic control between continuous intravenous regular insulin infusion and single-dose subcutaneous insulin glargine injection in medical critically ill patients. Subjects and Methods: A prospective noninferiority study was conducted in medical critically ill patients who developed hyperglycemia and required regular insulin infusion by the Intensive Care Unit glycemic control protocol. The eligible patients were switched from the daily regular insulin requirement to single-dose subcutaneous insulin glargine injection by a 100% conversion dose. Arterial blood glucose was checked every 2 h for 24 h. Success cases were blood glucose levels of 80–200 mg/dL during the study period. The mean time-averaged area under the curves (AUCs) of blood glucose levels between the two types of insulin were compared by t-test. Results: Of 20 cases, 14 cases (70%) were successful. The mean time-averaged AUCs of blood glucose levels between the two types of insulin were not significantly different (155.91 ± 27.54 mg/dL vs. 151.70 ± 17.07 mg/dL, P = 0.56) and less than the predefined noninferior margin. No severe hypoglycemic cases were detected during the study period. Conclusions: Single-dose subcutaneous insulin glargine injection was feasibly applied for glycemic control in medical critically ill patients. The glycemic control in the critically ill patients by a single dose of subcutaneous insulin glargine was comparable to standard intravenous regular insulin infusion. A conversion dose of 100% of the daily requirement of regular insulin is suggested.

Smoke inhalation injury is a major determinant of morbidity and mortality in fire victims. It is a complex multifaceted injury affecting initially the airway; however, in short time, it can become a complex life-threatening systemic disease affecting every organ in the body. In this review, we provide a summary of the underlying pathophysiology of organ dysfunction and provide an up-to-date survey of the various critical care modalities that have been found beneficial in caring for these patients. Major pathophysiological change is development of edema in the respiratory tract. The tracheobronchial tree is injured by steam and toxic chemicals, leading to bronchoconstriction. Lung parenchyma is damaged by the release of proteolytic elastases, leading to release of inflammatory mediators, increase in transvascular flux of fluids, and development of pulmonary edema and atelectasis. Decreased levels of surfactant and immunomodulators such as interleukins and tumor-necrosis-factor-α accentuate the injury. A primary survey is conducted at the site of fire, to ensure adequate airway, breathing, and circulation. A good intravenous access is obtained for the administration of resuscitation fluids. Early intubation, preferably with fiberoptic bronchoscope, is prudent before development of airway edema. Bronchial hygiene is maintained, which involves therapeutic coughing, chest physiotherapy, deep breathing exercises, and early ambulation. Pharmacological agents such as beta-2 agonists, racemic epinephrine, N-acetyl cysteine, and aerosolized heparin are used for improving oxygenation of lungs. Newer agents being tested are perfluorohexane, porcine pulmonary surfactant, and ClearMate. Early diagnosis and treatment of smoke inhalation injury are the keys for better outcome.

A 48–year-old male was bitten by a dog on the forehead and on the RIGHT side of left eyebrow on November 26, 2017, at 2 pm. The patient was immediately rushed to a nearby private hospital where an MBBS doctor gave him immediate wound wash with soap and water and prescribed five doses of rabies vaccine intramuscularly (IM). Since the patient weight was 60 kg, he was also prescribed 2400 IU of equine rabies immunoglobulin (ERIG), but as eRIG was not available, it was not administered. All the four doses of rabies vaccine were given IM in gluteus muscle. On December 17, 2017, the patient was brought to the Government Regional Hospital Hamirpur with the symptoms of difficulty in swallowing water (Hydrophobia) for 2 days. He was given injection diazepam and referred to Rajinder Prasad Government Medical College Tanda, Kangra, Himachal Pradesh, India, where he died of suspected rabies on December 19, 2017. The explicit consent to publish this report and picture was taken from the relatives of the patient, so that others have a lesson from this case report.

We present two cases of respiratory insufficiency due to left lung collapse secondary to massive pericardial effusion. Both patients had pericardial effusion due to their underlying disease. Radioimaging showed compression of the left bronchus. Patients got symptomatic relief after pericardiocentesis. Follow-up imaging showed expansion of the lung.

Amitraz is a nonsystemic insecticide and acaricide which is sometimes also used as scabicide. Due to its widespread use, amitraz poisoning has emerged during the past decade and a half although the literatures on human intoxication cases are scarce. Amitraz poisoning can present with numerous symptoms involving central nervous, cardiovascular, and respiratory systems. The mainstay of treatment is supportive and symptomatic. We present the case of a 60-year-old gentleman who was shifted from another hospital in unconscious state with an alleged history of consumption of an unknown substance which later was known to be amitraz.