Download Bed-side ultrasound of the optic nerve

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Indian Journal of Critical Care Medicine January-February 2013 Vol 17 Issue 1
References
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Narendra H, Baghavan KR. Guide-wire embolism during subclavian
vein catheterization by Seldinger technique. Indian J Crit Care Med
2006;10:257-9.
Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide
wire: Mishap or blunder? Br J Anaesth 2002;88:144-6.
Guo H, Peng F, Ueda T. Retracted: Loss of the guide wire. Circ J
2006;70:1520-2.
Wadehra A, Ganjoo P, Tandon MS. Guide wire loss during central venous
cannulation. Indian J Anaesth 2010;54:587-8.
Batra RK, Guleria S, Mandal S. Unusual complication of internal
jugular vein cannultion. Indian J Chest Dis Allied Sci 2002;44:137-9.
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Figure 2: Chest X‑ray of patient showing CVC (1), guide wire (2), non‑‘J’
end of guide wire (3). (arrowed)
DOI: 10.4103/0972-5229.112148
Bed-side ultrasound of
the optic nerve sheath
in a patient with bilateral
acutely dilated pupils
Figure 3: Ghatak’s technique to prevent guide‑wire retention in central
vein by fixing their non‑‘J’ end with mosquito forceps or small artery
forceps. (arrowed)
wire and forceps assembly can easily be pulled out of
CVC. A good backflow of blood and no resistance to
saline flush confirms central lumen free of guide wire
and proper placement. Postprocedure, operator and the
nurse assistant should confirm the guide wire retrieval
in the procedure tray as part of a check-list. Last but not
the least, check X-ray is confirmatory for early detection
of complications.
Tanmoy Ghatak, Afzal Azim,
Arvind K. Baronia, Neelima K. Ghatak1
Department of Critical Care Medicine, SGPGIMS, 1Gynecology and
Obstetrics, CSSMU, Lucknow, Uttar Pradesh, India
Correspondence to:
Dr. Tanmoy Ghatak,
Department of Critical Care Medicine, SGPGIMS, Lucknow,
Uttar Pradesh, India.
E-mail: [email protected]
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Sir,
Now-a-days, point of care ultrasound (USG) has
become an integral part of management of critically ill
patients. From routine invasive procedural guidance to
lung and cardiac USG has changed our routine practice.
Here, we highlight one more possible role of USG in
managing these sick patients.
A 52-year-old male, who met with road traffic accident
while driving his car 2 weeks ago, referred to our
hospital with diagnosis of fracture right femur shaft,
fracture left sided ribs (2nd-4th), severe acute respiratory
distress syndrome on mechanical ventilation, acute
kidney injury, and requiring vasoactive agents. 2 days
later in the morning round, during the examination he
was found to have bilateral dilated pupils (5 mm in
size) and light reflex was absent. At that time, he was
deeply sedated with continuous infusion of midazolam
(5 mg/h) and fentanyl (150 μg/h) and there was no
new insult that could lead to intra cranial event.
Computed tomography (CT) of the head was planned,
but it was hold due to the presence of high ventilatory
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Indian Journal of Critical Care Medicine January-February 2013 Vol 17 Issue 1
support (Positive end-expiratory pressure, PEEP 14)
and vasoactive (Nor-adrenaline at 0.3 μg/kg/min)
requirement. Bed-side USG of the optic nerve sheath
(ONS) showed diameter of 0.3 cm. Meanwhile, during
further evaluation we realized that the pupillary
dialatation could be attributed to the accidental use
of tropicamide eye drops (instead of methylcellulose)
by morning nursing staff. Both types of eye drops were
kept by the bedside as tropicamide was used to aid
fundus examination the day before. The pupillary size
had returned to normal a few hours later.
ONS comprises of the optic nerve enclosed within
cerebrospinal fluid and dura mater. The diameter of ONS
is thus influenced by CSF pressure variation making it a
useful tool to predict raised intracranial pressure (ICP). In
recent years, the role of ultrasonography of ONS has been
evaluated mainly in trauma patients in the emergency
department.[1-3] A cut-off for ONS diameter of 5 mm
was considered positive for elevated ICP in most of the
studies. In a study by Rajajee et al., the authors found
that ONS diameter ≥0.48 cm has a sensitivity of 96%
(95% CI 91-99%) and a specificity of 94% (92-96%) for
raised intracranial pressure >20 mmHg in neurological
patient.[4]
Presently there is little evidence that optic nerve USG
could replace the need for CT scan to assess raised
intracranial pressure among critically ill patients.
However, this can be a useful tool for rapid and safe
assessment of unstable patients.
Mohan Gurjar, Nabeel Muzaffar, Afzal Azim,
Arvind K. Baronia
Department of Critical Care Medicine, Sanjay Gandhi Postgraduate
Institute of Medical Sciences, Lucknow,
Uttar Pradesh, India
Correspondence to:
Dr. Mohan Gurjar,
Department of Critical Care Medicine, Sanjay Gandhi Postgraduate
Institute of Medical Sciences (SGPGIMS), Lucknow,
Uttar Pradesh, India.
E-mail: [email protected]
References
1.
2.
3.
4.
Tayal VS, Neulander M, Norton HJ, Foster T, Saunders T, Blaivas M.
Emergency department sonographic measurement of optic nerve sheath
diameter to detect findings of increased intracranial pressure in adult
head injury patients. Ann Emerg Med 2007;49:508-14.
Qayyum H, Ramlakhan S. Can ocular ultrasound predict intracranial
hypertension? A pilot diagnostic accuracy evaluation in a UK emergency
department. Eur J Emerg Med 2013;20:91-7.
Blaivas M, Theodoro D, Sierzenski PR. Elevated intracranial pressure
detected by bedside emergency ultrasonography of the optic nerve
sheath. Acad Emerg Med 2003;10:376-81.
Rajajee V, Vanaman M, Fletcher JJ, Jacobs TL. Optic nerve ultrasound
for the detection of raised intracranial pressure. Neurocrit Care
2011;15:506-15.
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DOI: 10.4103/0972-5229.112150
Red man syndrome due
to accidental overdose of
rifampicin
Sir,
A 4-year-old boy presented with alleged history of
accidental consumption of the entire bottle of rifampicin
syrup (30 ml bottle, 5 ml/100 mg) i.e. 600 mg. The syrup
rifampicin was prescribed for his elder sister who had
pulmonary tuberculosis. Immediately after consuming
the syrup, he developed nausea and abdominal pain.
After half an hour, fever, facial flushing, and pruritus
appeared, and in the next two hours, rapidly increasing
periorbital edema was noticed. There was also history of
orange red discoloration of tears and urine. There was
no history of convulsions, lethargy, altered sensorium,
diarrhea, or bleeding manifestations. On admission,
he was alert with a heart rate 110/min. respiratory
rate 26/min and blood pressure 96/60 mm Hg. Facial
flushing, periorbital edema, and urticarial rash were
present [Figure 1]. Rest of the general and systemic
examination was normal. His complete blood count,
serum electrolytes, electrocardiograph, and renal
function tests were normal. Liver function tests
revealed mild elevation in the transaminase levels. After
admission, he continued to pass red urine for one day.
His facial flushing, periorbital edema, and urticaria
disappeared in one day. He was discharged after 2 days
of hospital stay. This can be considered as a probable
adverse drug reaction as per causality assessment on
Naranjo’s scale.[1] On follow-up after one month, he had
no complaints, and liver function tests were normal.
Rifampicin is an antibacterial agent, used mainly in the
treatment of tuberculosis and is generally well-tolerated.[2]
When given in usual doses, fewer than 4% of patients
with tuberculosis have significant adverse reactions.
Common side effects include abdominal discomfort,
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