Clinical Pearls - Eye Signs

I just came across some eye signs and the conditions in which they were present and its really fascinating to know their significance.

1. Bilateral Ptosis in a middle aged lady with a recent Right MCA infarct and old Left MCA infarct.

It occurs frequently in patients with hemispheric strokes, especially in association with right hemispheric lesions. Complete bilateral ptosis is usually caused by large infarctions and may be a premonitory sign of an impending herniation.Isolated b/l ptosis has been previously reported in association with midbrain lesions due to subacute encephalitis and midbrain hemorrhage.
Complete ophthalmoplegia, the combination of bilateral ptosis with loss of all extraocular movements, is rarely a consequence of ischemic stroke can be manifestation of bilateral paramedian midbrain-thalamic infarction.

2. Upward Gaze Deviation in a 26 year old man with hypoxic ischaemic brain damage secondary to cardiomyopathy and cardiac arrest.
This deviation is seen in hypoxic brain damage as their is loss of cerebellar Purkinje cells that normally balance vestibular and gaze - holding mechanisms.
In contrast tonic downward gaze deviation with small unreactive pupls is seen in camatose patients due to bilateral thalamic infarction or haemorrhage.

Intracerebral Haemorrhage

Hello friends, there are two articles on this issue, one in CCM Dec2008 and 2nd in Current opinion of Jan 09(published ahead).
Both articles talk about medical management and emphasis on BP control as obvious to limit size of haematoma. Role of Factor VII is still controversial, associtaed with thromboembolic phenomenon with no survival benefit. Role and protocol of Prothrombinex is well given in both articles for warfarin induced ICH. Various antihypertensives and their doses are given in table form for ready reckoner in CCM article.

Simple way to reduce morbidity and mortality in surgical patients all over the world

WHO has provided a simple checklist which we can apply to our hospitals wherever we work.This is from the current edition of NEJM.

www.nejm.org January 14, 2009 (10.1056/NEJMsa0810119)

A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population
Implementation of the checklist was associated with concomitant reductions in the rates of death and complications among patients at least 16 years of age who were undergoing noncardiac surgery in a diverse group of hospitals.

I suggest that this list should be posted in the surgeons clinic,pre-anaesthetic clinics and most importantly in pre-operative and operating theatres.

It is the simple things in life which when followed religiously lead to amazing results.

M

Keeping ourselves on track!!

I fully agree with my friend, Anuj, regarding scanning the journals and I can see Harjit already has done some work by scanning Intensive care medicine. I take responsibility of clinics. Let others also come up with ideas. Anuj, you can take care of CCM by SCCM.
Cheers!!

Intensive care medicine recent articles, Dec'08

I have read these two articles and feel that they carry reasonable daily practice importance.

Review - a must read article: Renal replacement therapies: physiological review

Intensive Care Med (2008) 34:2139–2146

Maximizing rates of empiric appropriate

antibiotic therapy with minimized use

of broad-spectrum agents: are surveillance

cultures the key? Intensive Care Med (2008) 34:2130–2133

DOI 10.1007/s00134-008-1249-7

(This is just a summary of the article)E

EDITORIAL

Of the many therapeutic decisions, physicians have to face

in daily ICU practice choosing initial antibiotic therapy in

the patient with suspected severe nosocomial sepsis is one

of the more challenging.

In patients at risk for infection with multidrug

resistant (MDR) pathogens, the clinician has to resort to

broad-spectrum antimicrobials, which are themselves

linked with the emergence of multidrug resistance.

In this respect,appropriate empirical antibiotic therapy should

have a balanced antimicrobial spectrum that includes the

susceptibility of the infectious pathogen, but does not add

unnecessary selection pressure.

As an alternative to empirical combination antibiotic

therapy, a more focused initial antibiotic selection guided

by surveillance cultures (SC) has been reported.

As more reports solidify the clinical usefulness

of SC, cost remains probably the most important factor

prohibiting a general use of systematic SC.

ICUs with a high prevalence of MDR will

benefit the most, as will be patient populations with a high

risk for MDR infection, such as patients with a complex

history, a prolonged hospital stay and numerous previous

antibiotics. To reduce the cost one can consider restricting

surveillance to this ‘difficult’ patient category.

How to keep oneself updated in critcal care?

15th January 2009.
Beginning is Half done.
Lets congratulate Amit for his innovative idea of ongoing virtual meeting of like minded people.
It allows us to solve each other's clinical queries.
Let us set the ball rolling.
How one can keep oneself updated in the rapidly evolving field of critical care.
Yesterday's evidence is disproved today,for example hype of Glycemic control.
We have thought of following system.
I consider following journals have maximum impact on critical care practice all over the world.
1.NEJM
2.Intensive care medicine from ESICM
3.Critical care medicine from SCCM.
4.Critical care clinics.
5.Current opinion on critical care.
6.Critical care [Forum]
To some extant JAMA,LANCET,BMJ,CHEST,AJRCCM.
If we designate one journal each to one or two individual ,whose responsibility is to keep track of what is published in each issue and post summary of suggestions .
The suggestions include...worth reading article,breakthrough article,new idea but poor study etc etc.
This will enable all of us to keep updated but saves time of scanning each journal each month.
I will we very happy to know other ideas to get the same level of updates.

Anuj M. Clerk
M.D, F.N.B., E.D.I.C.
PDCC ISCCM,
Intensive care ,
Westmead ,NSW
Australia.

HFOV

Dr Vishal Gupta has asked about High Frequency Oscillatory Ventilation, there are some articles available to understand principles. The links are -

1.http://www.med.umich.edu/ccmu/docs/HFOV.pdf
2.http://scalpel.stanford.edu/ICU/HFOV%20Guidelines.pdf
3.High-Frequency Oscillatory Ventilation for Adult Patients With ARDS
Kenneth P. W. Chan, Thomas E. Stewart and Sangeeta Mehta
Chest 2007;131;1907-1916