Anticholinergic drug-induced benign unilateral anisocoria: common, but frequently overlooked side effect


Sudden anisocoria have always been ominous signs among critically ill patients, which requires prompt attention. There are various causes of anisocoria, which call for comprehensive evaluation to rule out neurologic causes such as Adie’s pupil, uncal herniation, compression of third cranial nerve, meningeal irritation, and seizures as opposed to the pharmacological causes such as anticholinergic drugs, anesthesia, and recreational drugs versus causes such as migraine and trauma to the eye. We hereby report a case of a patient with unilateral anisocoria from dilated left pupil due to the nebulized ipratropium bromide, a cholinergic antagonist that resolved with discontinuation of the medication. The purpose of this case report is to emphasize the importance of thorough physical assessment, an early review of the medications, and the use of inexpensive diagnostic test to save time and avoid the expensive diagnostic study.

Authors: Gaurav Gheewala, Salim Surani, Rizwan Ishtiaq, Sneha Reddy, Iqbal Ratnani

Case series: two cases of life threatening dynamic airway obstruction from thyroid mass


We present 2 cases of dynamic airway obstruction with respiratory failure leading to cardiac arrest. Both have significant aetiology of cystic thyroid mass with sudden haemorrhagic changes leading to airway obstruction. We discuss the plausible pathophysiology leading to cardiopulmonary compromise where tracheobronchomalacia (TBM) and excessive dynamic airway collapse (EDAC) play a significant role. We note that this is under recognised and can be present as a life-threatening event. Recognition of these pathophysiology process facilitate surgical management of thyroid obstructive airway disease.

Authors: Yeeshay Lee, Haozheng Wong, Sing Chee Tan, Rana Muhammad Habibullah, Yoke Yeow Yap, Faheem Khan, Chee Keat Tan

Respiratory arrest following CT guided selective cervical nerve root injection

CT guided cervical nerve root injection is performed for diagnostic purposes or to reduce inflammation and pain in cervical radiculopathy. Steroid and local anaesthetic are injected under CT guidance around the nerve root. This is performed as an outpatient procedure with most patients being able to be discharged 15-30 mins after the procedure. CT guidance allows the operator to see the best pathway for the needle whilst visualising structures such as the carotid and vertebral artery.

It is generally a safe procedure, with one recent study by RS Pobiel et al showing out of 802 fluoroscopy guided cervical nerve root blockades there were no major complications.

Authors: Arran Keir, Umesh C. Pandey, Thomas Cheri, Ross Freebairn

Use of levocarnitine as an alternative treatment for non-anticoagulant rodenticide poisoning


The objective of this text is to inform and motivate further investigation about the use of levocarnitine as an alternative antidote in patients poisoned by non-anticoagulant rodenticides in a kind of retrospective study through the report of 3 serial cases presented in the Intensive Care Unit (ICU) of the General Hospital Zacatecas 'Luz González Cosío', in Zacatecas, Mexico. Two of them were intoxicated with zinc phosphide and one with sodium fluoracetate, all with similar signs and symptoms. In addition to having received vital support measures in the ICU, levocarnitine was administered intravenously, with remission of symptoms in the short term and hospital discharge without apparent sequelae. Therefore, it is appropriate to consider future research on the use of levocarnitine in this kind of patients, in addition to vital support measures.

Authors: Omar Alberto Venegas Gurrola, Mónica Rodríguez Borroel, Omar Uriel Sánchez Alba, César Fabián Díaz García

Methaemoglobinaemia-induced oxygen desaturation complicating chest trauma

Case presentation

A 72-year-old man presented to the Emergency Department by ambulance following a rollover motor vehicle crash preceded by black-out symptoms. He had been suffering from dermatitis herpetiformis for the last six years and was being treated with dapsone 100 mg and a partially gluten-free diet. On admission he had a respiratory rate of 22, pulse oximetry saturations of 89% improving to 93% with 3 l/min via nasal prongs, a heart rate of 75 bpm, and a non-invasive blood pressure of 111/52. No life-threatening injuries were identified on primary or secondary survey. A trauma CT-series noted left sided rib fractures.

Authors: Ravi Mistry, Ross Freebairn

Propofol-induced macroglossia: a case report


A 78-year-old lady, without prior exposure to propofol, was admitted to the hospital due to recurrent seizures, and respiratory arrest, which required intubation in order to secure her airway. Propofol was used as the initial sedative agent. Two weeks later she required again administration of propofol, time at which she developed acute macroglossia. This subsided after weaning off the propofol. When she was cared by another team and received for the third time propofol, she developed macroglossia again, and similarly subsided when propofol was weaned off. Allergic reactions to propofol are well documented. We believe that an allergic reaction occurred upon the second and third administration of propofol in our patient.

Authors: Abbas Alshami, Johanan Luna, Joseph Varon

Malignant pericardial effusion presenting as a wheeze- case report


Slow growing pericardial effusion is detected less commonly than acute pericardial tamponade. However, it is equally life threatening if it is more than 250 to 300 ml and can contribute to a similar picture of a fix cardiac output obstructive shock. We would like to report a case of malignant pericardial effusion that was detected in the ICU when the patient presented to the hospital with shortness of breath and generalized wheezes suggestive of respiratory failure from chronic obstructive lung disease (COPD).

Authors: Eng Kiang Lee

Case report: central venous pressure-guided de-resuscitation in sepsis patients with fluid overload induced acute kidney injury


Background: Aggressive fluid resuscitation is commonly administered in septic patients as recommended by Surviving Sepsis Campaign. However, positive fluid cumulative balance resulting in fluid overload is correlated with various complications such as acute kidney injury, acute respiratory distress and delayed wound healing.

Case report: This report presents four septic patients with fluid overload and acute kidney injury who underwent active de-resuscitation aiming central venous pressure between zero and two mmHg.

Discussion: In all patients, central venous pressure guided de-resuscitation was associated with systemic oxygenation improvement (arterial lactate dropped from 8.3 to 0.8 mmol/l, from 5.3 to 0.3 mmol/l, from 3.5 to 0.5 mmol/l, and from 3.3 to 0.7 mmol/l) and acute kidney injury resolution without hemodynamic instability and elevated lactate level. Negative cumulative balance is associated with a significant reduction of norepinephrine dose.

Conclusion: A de-resuscitation strategy based on the target of central venous pressure 0-2 mmHg is a safe and effective procedure that resulted in improvement in hemodynamics, serum lactate, renal function and also systemic oxygenation.

Authors: Ni Luh Kusuma Dewi, Yohanes WH George

Status epilepticus caused by cerebral venous thrombosis in the puerperal period: case report and literature review


Status epilepticus (SE) caused by cerebral venous thrombosis (CVT) is rare in pregnancy and puerperium, with few cases described in literature. Seizures in pregnancy are usually due to previous epilepsy or pregnancy related disease, such as eclampsia, posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome (RCVS), eclampsia and thrombotic thrombocytopenic purpura (TTP). Due to its high mortality, the SE and the underlying disease must be promptly managed. In this article, we present a case of SE in postpartum due to cerebral venous thrombosis and we reviewed the cases described on the topic.

Authors: Orivaldo Alves Barbosa, João Filho Araujo Ribeiro, Paola Lima Lemos

Role of hemofilter with endotoxin adsorption capacity in management of septic shock


We reported an adolescent male with acute lymphoblastic leukemia who developed septic shock due to Klebsiella pneumoniae. Continuous renal replacement therapy using a hemofilter with endotoxin adsorption capacity was used to remove endotoxin and cytokines. The promising result suggested that this technique may be applied as an adjuvant therapy for treatment of septic shock.

Authors: Wun Fung Hui, Winnie Kwai Yu Chan

A 20-year-old woman with spinal cord injury without radiological abnormalities (SCIWORA)


Spinal cord injury without radiological abnormalities (SCIWORA) has been defined as a direct trauma to the spinal cord, with no radiological or tomographic abnormalities, although there is a deficit, whether motor, sensory or both. To establish the final diagnosis, shock, obstetrical complications, penetrating trauma to the spine and congenital malformations should be excluded.

Authors: Omar Alberto Venegas Gurrola, Omar Uriel Sánchez Alba, María Isabel Solís Gamboa, Goretti Monserrat Rodríguez Delgado

Factors contributing to the accuracy of initial screening values measured by noninvasive spectrophotometric hemoglobin monitoring in an Emergency Department


Objective: Spectrophotometric hemoglobin (SpHb) monitoring is a new noninvasive technology for measuring hemoglobin (Hb). However, few studies have assessed the usefulness of the initial screening SpHb values, especially when measured in an Emergency Department. In this study, we examined the correlation between the initial screening SpHb values and laboratory-measured hemoglobin (Hb) concentrations.

Design: This was a retrospective, single center study.

Setting: Emergency Department in a University hospital.

Patients: 105 cases between February and July 2016.

Interventions: The correlation between SpHb and Hb was determined in univariate analysis. Multiple regression analysis was then performed with ΔHb (defined as the absolute difference between SpHb and Hb [|SpHb-Hb|]) as the dependent variable to identify factors associated with reduced accuracy of SpHb.

Results: The initial screening SpHb value was only moderately correlated with Hb in univariate analysis (r=0.736, p<0.001). In multiple regression analysis, male sex and diastolic blood pressure were significantly associated with ΔHb (p=0.003 and p=0.022, respectively).

Conclusions: The initial screening SpHb value was only moderately correlated with Hb. SpHb might affected by patient factors, including male sex and diastolic blood pressure.


Portal venous gas entrapment secondary to mesenteric ischemia after withdrawal of intra-aortic balloon pump: A case report with a rare ultrasound image


After coronary artery bypass graft (CABG), mesenteric ischemia is a rare but dreadful complication with high mortality rates. Prophylactic use of intra-aortic balloon pump (IABP) is a common practice in patients with severe coronary artery disease awaiting CABG. During withdrawal of the IABP, there is a risk of dislodging atheromatous debris, thus causing peripheral and mesenteric emboli, which can cause mesenteric ischemia. Here we are reporting on a case where a patient had an IABP installed after a ST-elevation myocardial infarction (STEMI) while awaiting CABG surgery. After surgery, the IABP was eventually removed, but rising lactates led to further investigation. The abdominal computerized tomography (CT) scan showed extensive bowel pneumatosis and portal venous gas entrapment. The patient died despite aggressive non-surgical management. This case shows a fatal complication of IABP use in a high-risk patient undergoing CABG surgery and highlights the need for careful aorta and peripheral vascular assessment prior to IABP device insertion to avoid intestinal compromise.


A fatal case of cerebral oedema and myocarditis associated with secondary dengue infection


Background: Secondary dengue infection (SDI), in the form of two sequential infections by different serotypes, will lead to severe dengue. Concomitant organ failure in particular cardiovascular (CVS) and central nervous system (CNS) carries further rise in the mortality rate.

Case report: We report a confirmed SDI in a 27-year-old man who presented with hypovolemic shock due to persistent vomiting and diarrhoea. He was stabilized after fluid resuscitation. However, he developed sudden onset of seizure and myocarditis with unstable haemodynamic thereafter. After stabilization, his gag and cough reflexes were absent with dilated pupils. Imaging of the brain showed extensive cerebral oedema with poor flow beyond the internal carotid arteries and its branches above circle of Willis. He remained comatose with subsequent complications of diabetes insipidus, secondary bacterial infection, and acute kidney injury. He passed away after 19 days of admission.

Discussion: There is a higher risk of severe dengue with SDI as it is associated with antibodydependent enhancement (ADE) mechanism. The pre-existing dengue antibodies enhance virus replication by activating memory T-cells causing surges in inflammatory cytokines. The increased capillary permeability with massive vascular leak most likely led to the extensive cerebral oedema in this patient. The concomitant cardiovascular failure also led to his irreversible outcome.

Conclusion: Severe cardiovascular and neurological manifestations can occur in SDI with resultant in the fatality. Therefore, early recognition of risk factors in the early phase of severe dengue is important to prevent the irreversible outcome.


“Complete” loss of brain stem reflexes - not always brain death! Beware of amitriptyline overdose


We present a case of “complete” loss of brain stem reflexes following amitriptyline overdose, which mimicked brain death. This case highlights the complexities associated with clinical brain death determination and calls for close attention to details.

Based on previously published case reports, we analyse the relationship with the amitriptyline dose, blood level and timing of neurological recovery. Ours is the fourth case report in literature demonstrating “complete” loss of brain stem reflexes following amitriptyline overdose.

The amount of amitriptyline ingested in these cases (including our case report) ranged from 500 mg to 9 g; the blood concentrations ranged from 1.35 microgram/ml to 3.43 microgram/ml. The neurological recovery seems to start by day two to four with complete neurological recovery by day five to seven.