ABSTRACT
PURPOSE@#Impending compartment syndrome is a common event following closed tibia fractures, which can progress to sinister compartment syndrome. Fasciotomy is the only definitive treatment available, though it has its own drawbacks and complications. Medical management at present consists of limb elevation and adequate hydration. This study aims at determining whether intravenous administration of Mannitol reduced the intracompartmental pressure in patients with closed tibial fractures.@*METHODS@#This is a double blinded, randomized control trial done in a single tertiary care center in India. Forty-five patients were recruited between February 2012 and October 2012. Forty patients who presented to the emergency department with isolated, closed, high velocity, and proximal 2/3 tibia fractures were included in this study. Patients with contraindication to Mannitol were excluded. They were allocated into 2 groups by the investigator using computer generated randomization. The pressure in the anterior compartment of the leg was measured with a handheld Stryker pressure monitor. Then either 20% Mannitol or 0.9% normal saline as given intravenously in a blinded manner, based on the randomization. The intracompartmental pressure was measured at 0, 1 and 3 h after the infusion. The participant, investigator and statistician were masked to the group assessment.@*RESULTS@#There was no difference in intracompartmental pressures at 1 or 3 h, between the groups. However, in patients with the baseline of compartmental pressures ≥30 mmHg, Mannitol showed a marked reduction in pressure of 8.5 mmHg at 1 h compared to almost no change in pressure in the saline group. There were no adverse events with the use of Mannitol.@*CONCLUSIONS@#This preliminary study appears to show that Mannitol is useful in the management of the increased compartment pressure. The limitations of this study were that it only involved a small group of patients and the baseline pressures in both the groups were not comparable. More studies are required before the use of Mannitol as a standard of care in the management of compartment syndrome can be established.
ABSTRACT
Tuberculous meningitis [TBM] is a major clinical and public health problem, both for diagnosis and management. We compare two established scoring systems, Thwaites and the Lancet consensus scoring system for the diagnosis of TB and compare the clinical outcome in a tertiary care setting. We analyzed 306 patients with central nervous system [CNS] infection over a 5-year period and classified them based on the unit's diagnosis, the Thwaites classification as well as the newer Lancet consensus scoring system. Patients with discordant results-reasons for discordance as well as differences in outcome were also analyzed. Among the 306 patients, the final diagnosis of the treating physician was TBM in 84.6% [260/306], acute CNS infections in 9.5% [29/306], pyogenic meningitis in 4.2% [13/306] and aseptic meningitis in 1.3% [4/306]. Among these 306 patients, 284 [92.8%] were classified as "TBM" by the Thwaites" score and the rest as "Pyogenic". The Lancet score on these patients classified 29 cases [9.5%] as 'Definite-TBM', 43 cases [14.1%] as "Probable-TBM", 186 cases [60.8%] as "Possible-TBM" and the rest as "Non TBM". There was moderate agreement between the unit diagnosis and Thwaites classification [Kappa statistic = 0.53], as well as the Lancet scoring systems. There is only moderate agreement between the Thwaites classification as well as the Lancet scoring systems. It was noted that 32/ 284 [11%] of patients who were classified as TBM by the Thwaites system were classified as "Non TBM" by the Lancet score and 6/258 [2%] of those who were diagnosed as possible, probable or definite TB were classified as Non TB by the Thwaites score. However, patients who had discordant results between these scores were not different from those who had concordant results when treatment was initiated based on expert clinical evaluation in the tertiary care setting. There was only moderate agreement between the Thwaites' score and the Lancet consensus scoring systems. There is need to prospectively evaluate the cost effectiveness of simple but more effective rapid diagnostic alogrithm in the diagnosis of TB, particularly in a setting without CT and MRI facilities