Hypertensive encephalopathy following snake bite in a child: A diagnostic dilemma.

Children in rural India are a vulnerable group for snake bites. Improper elicitation of history and atypical presentations could lead to misdiagnosis and delay in treatment. We are reporting the case of an 8-year-old male child who presented with convulsions, unconsciousness and hypertension who was initially managed as a case of hypertensive encephalopathy showing no sign of improvement even after 20 hs. The history when reviewed suggested neurotoxic snake bite although the patient did not have any classical local findings. Anti-snake venom administration was followed by prompt recovery. We therefore suggest that snake bite should be considered in patients from rural background presenting with hypertension, convulsion and unconsciousness, even in the absence of classical features of snake bite.

Efficacy of intrathecal midazolam with or without epidural methylprednisolone for management of post-herpetic neuralgia involving lumbosacral dermatomes.

BACKGROUND: Post herpetic neuralgia is a chronic neuropathic pain syndrome which remains one of the most difficult pain disorders to treat. Epidural injection of methylprednisolone with or without local anesthetic provides relief for neuralgia for a short duration only. Recent studies have shown a promising anti nociceptive effect for intrathecal midazolam, a water soluble benzodiazepine, due to its interaction with benzodiazepine-GABA-A receptor complex within the spinal cord. STUDY DESIGN: A randomized, double blind study was conducted at 2 different centers in India. SETTING: Two different interventional pain practice centers in India. OBJECTIVES: To quantify the effectiveness of a single intrathecal injection of midazolam 2 mg with and without epidural methylprednisolone 60 mg for management of pain and allodynia in 150 adult patients with postherpetic neuralgia of 3-6 months duration involving lumbosacral dermatomes. METHODS: Patients in Group M-0 (n=50) received epidural methylprednisolone (60 mg), patients in group M-1 (n=50) received midazolam 2 mg in the intrathecal space while patients in Group M-2 (n=50) received methylprednisolone (60 mg) in the epidural space plus midazolam 2 mg in the intrathecal space. RESULTS: The administration of intrathecal midazolam (2 mg) provided short term improvement in post herpetic neuralgia similar to epidural methylprednisolone. However, the combination of intrathecal midazolam with epidural methylprednisolone resulted in prolonged duration of analgesia in patients with post herpetic neuralgia. The need for analgesics was also significantly less in patients who received the combination compared to those who received either intrathecal midazolam or epidural methylprednisolone. No serious adverse effect was reported with the use of intrathecal midazolam except a mild degree of sedation. CONCLUSION: The combination of intrathecal midazolam with epidural methylprednisolone resulted in prolonged duration of analgesia in patients with post herpetic neuralgia of lumbosacral dermatomes due to the complementary anti nociceptive action of intrathecal midazolam with epidural methylprednisolone on spinal nerve roots. LIMITATIONS: The dose-response relationship of intrathecal midazolam was not evaluated in our study, so further study should be conducted with different doses of intrathecal midazolam for management of PHN.

Complication following primary repair of a penetrating bull horn injury to the trachea.

A 22-year-old male patient was admitted to the casualty with a bull horn injury in the lower zone of the neck in the midline. The patient was conscious and distressed but hemodynamically stable. Local examination revealed a lacerated wound. He underwent emergency primary repair of the wound under halothane anesthesia; intubation was done keeping in readiness all preparations for difficult airway management. Postoperatively, elective controlled ventilation was performed with continuous infusion of muscle relaxant. After approximately 8 hours of controlled ventilation, the syringe pump failed; this initially went unnoticed and made the patient cough and buck on the tube. Infusion was restarted after a bolus dose of vecuronium bromide intravenously but, meanwhile, the patient developed subcutaneous emphysema in the neck. He was immediately transferred to the operating room, where exploration of the surgical site revealed dehiscence of the tracheal wound; this had led to the subcutaneous emphysema. Repair of the tracheal wound dehiscence was not possible due to both lack of space and lack of tissue for apposition. Hence, a tracheostomy tube was inserted through the tracheal wound and the patient was transferred to the intensive care unit for elective controlled ventilation. The patient was weaned off the ventilator within 24 h and transferred to the surgical ward on spontaneous ventilation with the tracheostomy tube in situ. The size of the patient's tracheostomy tube was reduced gradually by the serial exchange method. The wound ultimately healed with minimal scarring.