Humour Jan 16

PDF Version

LAUGHTER – THE BEST MEDICINE

A cheerful heart is good medicine

WHOLE BODY MASTER CHECK-UP (Simian outpatient dept., Vellore)

Lower limb Then Upper limb examination

Examination Of the head

 

And finally… Per rectal Examination

Even they know that a full physical examination is incomplete without a PR…

Contents Jan 16

CONTENTS

CURRENT MEDICAL ISSUES Volume 14 Issue 1 January 2016

Issue focus – CHILDHOOD ASTHMA

Editorial

Cover page

CMI journal in 5 minutes

TOPIC IN FOCUS

Childhood asthma – A practical approach to management  Sneha Varkki            

Acute episode of asthma in children Jacob E, Manivachagan M.N., Balachandran A

ARTICLES

Lung Cancer Prince James
Case report – Organophospate poisoning     Rajan A, Jesudoss I, Premkumar J        
Bedside ultrasound Kishore Kumar Pichamuthu                        

EVIDENCE BASED MEDICINE

Intensive blood pressure control – SPRINT trial                     

Pre-term premature rupture of membranes – PPROMT trial

Appendicitis – Surgical vs. Conservative management

Grave’s disease – Cochrane Evidence Update

Corticosteroids in sepsis – Cochrane Evidence Update

MEDICINE AND THE LAW

Legal aspects of medicine – Questions, What is a medico-legal case D. Samuel Abraham

MEDICAL IMAGES

CME in Images

HUMAN INTEREST STORY

Prem Jyoti – A pioneering medical work among Malto tribals Interview with Dr. Isac David    

REGULARS

Letters from Readers

Clinical Questions from readers

CME Quiz

Drug Dialogues

Medical news from around the world

Laughter the best medicine

DEVOTIONAL


Devotional Jan 16

PDF Version

Dead branches

But one thing I do: Forgetting what is behind and straining toward what is ahead, I press on toward the goal to win the prize for which God has called me heavenward in Christ Jesus. Philippians 3:13,14

The chief worries of life arise from the foolish habit of looking before or after. As a patient with double vision from some transient unequal action of the muscles of the eye finds magical relief from well-adjusted glasses, so, returning to the clear bin ocular vision of to-day, the over anxious student finds peace when he looks neither back ward to the past nor forward to the future. William Osler – A way of Life

Just outside my office, there is a lovely climber that produces tufts of pink blossoms. During the season of flowers, the plant is a favourite haunt for scores of honey bees, butterflies and other insects of various shapes and sizes looking for nectar. Watching the flowers and the bees was a favourite pastime of mine – a pretty scene of beauty and harmony.

The rains were pretty heavy this year, and one day, I was dismayed when I looked outside the balcony only to see that the climber had fallen down. This had never happened before. The reason was not hard to fathom. There was a huge mass of dead leaves and branches that had soaked in the rain and had become heavy. Finally, the burden became too much to bear and the whole mass just collapsed from its support. The dead leaves and branches had been hidden from view by the fresh leaves until now – I had never noticed them before.

What an apt metaphor for our lives. Beware of holding on to the dead things of our life. Hurtful experiences, unforgiven people, regrets, bitterness and painful memories in the past – these are things we hold on to and brood over from time to time. The past is dead and gone, but if we hold on to it, things accumulate slowly. Similarly the future does not exist except in our minds and anxiety concerning the future is also a dead accumulation. Everything will appear to be fine in fair weather, when things are going well, when the sun is shining. But when the season turns gloomy and difficult, the dead things of our life can become burdensome and can be so overwhelming that they pull you down from what supports you. It is high time we did a good spring-cleaning of our lives and do it regularly, daily even. Get rid of the past – the hurts and regrets, forgive and let go, do not hold on to bitterness and vengeance. The only things from the past that we need to hold on to are good memories and what we have learnt from unpleasant and difficult circumstances – these are the only life-giving things worth keeping. The rest simply need to go.

Give all your worries and cares to God, for he cares about you1. Do not worry about tomorrow for tomorrow will worry about itself 2.
11 Peter 5:7, 2Mathew 6:34

By Yeshv Kumhar

CME IN IMAGES

PDF Version

CME IN IMAGES
(Test your knowledge – Answers are given below)


Case 1
This middle aged patient presented with several months of generalized fatigue and darkening of her skin including the palms and soles. She was not on any chronic medications. Examination showed pallor but was otherwise unremarkable.

Questions:

  1. What are some metabolic conditions that can cause hyperpigmentation of the skin?
  2. What are some basic tests that can be done to determine a diagnosis for hyperpigmentation?
  3. Patient’s CBC showed hemoglobin of 6.1 and an MCV of 102.6. Sodium and potassium were normal and there was no evidence of cirrhosis or thyromegaly on exam. What is the most likely diagnosis and what would you prescribe for treatment?
  4. What are some common drugs that can also cause skin hyperpigmentation?

 

Case 2



A 24 year old lady presented with low back pain radiating to left leg for 3 years. The pain increased with walking and bending. She did not give any history to suggest neurological deficits.

Her physical examination was unremarkable. MRI and X-ray images of the lumbosacral spine are shown above.

Questions:
1. What do the images show? (Clue: Look at L5 vertebra)
2. What is the diagnosis ?
3. What is the management of this fairly common condition ?

 

Case 3


A 60 year old male presented to a secondary care centre for changing his urinary catheter. He was catheterized following an episode acute urinary obstruction. He was diagnosed to have benign prostatic hyperplasia and started on medical management, but attempts to void failed multiple times despite optimisation of medications. He was advised continuous bladder drainage until he underwent a definitive procedure. This is an image of his urinary bag.

Questions:

  1. What is the cause for this peculiar colour of urine?
  2. What is the appropriate line of management?

******************************

Answers to CME in images

Case 1

1. Addison’s disease, vitamin B12 deficiency, Grave’s disease, Wilson’s disease and hemochromatosis can all present with hyperpigmentation of the skin.

2. A complete blood count is useful to rule out a macrocytic anemia. Basic electrolytes including sodium and potassium are useful to see if Addison’s disease is a possibility (typically hyponatremia with concurrent hyperkalemia due to lack of aldosterone production). A physical exam is important to look for cirrhosis of the liver (rule out Wilsons or hemochromatosis) or thyromegaly (rule out Grave’s disease). A ferritin level can help to rule out hemochromatosis.

3. Most likely the patient has vitamin B12 deficiency (pernicious anemia being most common cause). Treatment options include 1000 mcg of vitamin B12 injection once daily for 7 days followed by injection of vitamin B12 1000 mcg once weekly for 1 month. This patient was started on daily injections of B12 which should improve her symptoms in 6-8 weeks.

4. Antimalarials (chloroquine, hydroxychloroquine), cancer drugs (bleomycin and busulfan), heavy metals (gold, silver, mercury), minocyline, clofazamine and amiodarone.

Further Reading:

  1. RabiaCherqaoui, Mehreen Husain, Sujay Madduri, Pamela Okolie, Gail Nunlee-Bland, and James Williams, “A Reversible Cause of Skin Hyperpigmentation and Postural Hypotension,” Case Reports in Hematology, vol. 2013, Article ID 680459
  2. Lee SH, Lee WS, Whang KC, Lee SJ, Chung JB. Hyperpigmentation in megaloblastic anemia. Int J Dermatol1988;27:571-5.
  3. Greipp PR. Hyperpigmentation Syndromes (Diffuse Hypermelanosis). Arch Intern Med. 1978;138(3):356-357.

Case contributed by Dr. Christo Philip M.D., Consultant Emergency Medicine physician, Duncan Hospital, Raxaul, Bihar

Case 2
(See images below, compare with earlier images)

The Lumbo-sacral spine radiograph shows an elongated left L5 transverse process causing pseudoarticulation with sacrum raising the suspicion of ‘Bertolotti’s syndrome’.     MRI of lumbo-sacral spine was done to rule out other causes for the pain which showed desiccatory changes in the L4-5 intervertebral disc with associated diffuse disc bulge causing narrowing of bilateral lateral recesses leading to impingement of bilateral L5 traversing nerve roots.

Radiograph of lumbo-sacral spine: Arrow showing elongated left L5 transverse process causing pseudoarthrosis with sacrum.

T2W fat suppressed MRI image confirming the findings seen on the radiograph.


Image 1 (left): T2W sagittal section through the lumbar spine showing T4-5 intervertebral disc bulge (arrow) causing narrowing of the lumbar canal.
Image 2 (right): T2W axial section at T4-5 intervertebral level showing diffuse disc bulge (arrow) causing narrowing of bilateral lateral recesses leading to impingement of bilateral L5 traversing nerve roots.

Discussion:
Although, in the above mentioned case the L4-5 intervertebral disc prolapse may be the cause for the patient’s symptoms, one should always keep in mind the possibility of lumbo-sacral transitional vertebra causing the symptoms, also called Bertolotti’s syndrome.

How common is lumbo-sacral transitional vertebra?
It is estimated that transitional vertebra can be present in between 4 to 36 percent of general population1.

How common is low back pain in patients with lumbo-sacral transitional vertebra?
This is unclear. However, the diagnosis is suggested if no other cause for the pain can be found.

What is Castellvi Classification System?
In 1984 Castellvi reported an imaging classification system for lumbo-sacral transitional vertebra.

Type I: Simply an enlarged L5 transverse process which is not felt to be clinically significant.
Type II: Formation of either a unilateral or bilateral diarthroidal joint between the enlarged transverse process and the sacrum.
Type III: Solid fusion of either unilateral or bilaterally.
Type IV: Mixed with solid fusion on one side and pseudoarthrosis on other side.

What is the management?
Treatment of Bertolotti’s syndrome is similar to patients with non-specific back pain and remains conservative. However, if and when surgical intervention is required remains unclear.

Reference:
1. A Review of Symptomatic Lumbosacral Transitional Vertebrase: Bertolottis Syndrome. Jancuska JM, Spivak JM, Bendo JA. Int J Spine Surg. 2015;9:42. Epub 2015.

Case contributed by Dr. Harshad Vanjare, Assistant Professor,Department of Radio Diagnosis,  Christian Medical College, Vellore

************************************

Case 3

1. The purple discolouration of urine in the bag, among chronically catheterised patients is due to an interesting and quite rare phenomenon called ‘Purple Urine Bag Syndrome (PUBS)’.It was first reported in 1978 and is due to presence of a concomitant Urinary Tract infection 1.Commonly reported organisms include Providencia species, Klebsiella pneumoniaeE coliProteus species, Morganella species, Pseudomonas species and Enterobacter species. It is occasionally difficult to differentiate which organisms are responsible, as isolation of multiple organisms is not uncommon.2

    The exact cause of the colour change in purple urine bag syndrome is still unclear. Tryptophan normally exists in the intestine and is metabolized to indole which is absorbed into the portal system and converted to indicant by the liver. This, in turn, is excreted into the urine where the presence of an alkaline environment and bacteria are capable of metabolizing indicant to indirubin and indigo, which gives the purple hue.1 The indigo can also be present in the catheter itself, giving a blue discolouration3 (Fig 1)1 Constipation, which prolongs tryptophan transit time in the intestine, results in increased indicant levels in urine and is a risk factor for purple urine bag syndrome. Other risk factors include alkaline urine (which predisposes to the growth of contributory microbes) and the use of catheters made of polyvinyl chloride plastic. Women are at greater risk than men for this condition.4 (Fig 2)5


Fig. 1 Pathogenesis of PUBS1

2. Although the unusual discoloration that can be alarming, this syndrome only indicates the presence of an underlying urinary tract infection that can be easily treated. Therefore, clinicians need to be aware of this syndrome and initiate treatment for urinary tract infection as soon as possible, as the outcome may be fatal if it progresses to generalized septicaemia and the standard warning signs of dysuria may not be due to presence of the catheter. Treatment is directed at the underlying UTI as well as control of constipation and good urologic sanitation. The catheter is changed and appropriate antibiotics administered. Good care of the urinary catheters will prevent UTIs and hence this phenomenon as well. Though commonly benign, there have been case reports in the literature of PUBS progressing to Fournier’s gangrene5. Interestingly purple Diaper syndrome has also been reported and is believed to be due to the same mechanism

Risk factors for PUBS Associated mechanism
Female gender UTI more common due to anatomy of urinary tract
Increased Tryptophan in diet More substrate available
Increased urine alkalinity Facilitates indoxyl oxidation
Severe constipation Increased time for bacterial deamination
Chronic indwelling urinary catheter Increased risk of UTI
High urinary bacterial load Bacterial sulfatase/ phosphatase availability
Renal failure Poor clearance f indoxyl sulfate

Fig. 2 – Risk factors and associated mechanisms in PUBS 5

REFERENCES

  1. Purple Urine Bag Syndrome: A Rare and Interesting Phenomenon, Noriko Soffi Harun et al, South Med J. 2007;100(10):1048-1050.
  2. Mantani N, Ochiai H, Imanishi N, et al. A case-control study of purple urine bag syndrome in geriatric wards. J Infect Chemother 2003;9:53-57.
  3. The purple urine bag syndrome: a visually striking side effect of a highly alkaline urinary tract infection Peter Peters Can. Urol. Assoc. J., 2011 Aug; 5(4): 233–234.
  4. Purple urine bag syndromeChe-Kim Tan,et al CMAJ. 2008 Aug 26; 179(5): 491
  5. Purple Urine Bag Syndrome: An Alarming Hue? A Brief Review of the LiteratureFahad Khan et al, International Journal of NephrologyVolume 2011 (2011), Article ID 419213

Case contributed by Dr. Amith Balachandran, Department of Anesthesia, CMC Vellore.

************************************


Medicine and Law

PDF Version

Medicine & The Law
A forum to address your medico-legal questions

‘Medicine and the Law’ is a forum where readers can ask questions pertaining to legal issues they may face during the course of their medical practice. The answers and clarifications are have been kindly provided by D. Samuel Abraham, (M.A., B.L., M. Phil., PGDPM), Legal Advisor to Christian Medical College, Vellore.

Question: Is MBBS degree enough legally for a doctor to do surgeries such as caesarian section (usually done by gynecologist), exploratory laparotomy etc., or do they have to get some kind of certificate (number of surgeries done: 20 etc. from a trainer)?
Dr. Binita Priyambada, Indore, Madhya Pradesh.

Answer: After the year 1995, the service offered by a doctor to a patient became a contract. The contractual obligations prescribe standard care to be given to a patient. What is required is the ordinary skilled man exercising and the special skill that he professes to have. A man need not possess the highest expert skill; it is well established law that it is sufficient if he exercises the ordinary skill of an ordinary competent man exercising that particular art. In a broader sense, “standard care” means a duly qualified person with reasonable skill for treating the particular patient in the opinion of his peer group in that location and in that time coupled with suitable equipment, qualified assistants and quality drug, proper premises etc.

The ‘Bolam Test’ is used to determine if the doctor has practiced standard care and is negligent or not. The Bolam test states that if a doctor is convinced that he is competent to do a particular procedure with his experience and skill, he/she may do it. Further, this test states that “If a doctor reaches the standard of care that is held by a responsible body of medical opinion, he is not negligent“.

Suppose, if in that locality, specialists or more qualified doctors than himself are not available, in a situation where a patient requires immediate care, an ordinary MBBS doctor can attend to the patient after recording all the facts and the situation in the medical records. In case there are many specialists available in that location, he can ONLY direct the patient to get medical help from them.

Ref: Medical Negligence & Compensation, by – Dr.Jegadish Singh and Mr.VishwaBhushan

****************************************

Question:
What is the time limit for preserving medical records?
Dr. Chittaranjan Haldar, Manendragarh, Chhattisgarh.

How long should OPD/IPD records of patients be retained legally? We are told that medico-legal records are to be retained indefinitely. What format can these be stored from the judicial point of view (scanned/ microfilm / paper) ? Dr. Samuel Joseph. Kozhencherry, Kerala.

Answer: As per the Regulation No. 1.3.1 of the Indian Medical Council (Professional Conduct, Etiquette & Ethics) Regulations, 2002, “Every physician shall maintain the medical records pertaining to his/her indoor patients for a period of 3 years from the date of commencement of the treatment in a standard proforma laid down by the Medical Council of India”. However, every State Government has prescribed time limit to retain every category of patient’s medical records. The Tamil Nadu Government has issued orders prescribing a time limit, which is given below. In the absence of specific provisions issued by the respective State Government, this can also be followed by all the hospitals, because it is found reasonable.

  • Non medico legal IP – 3 years
  • Medico legal IP and death cases – 6 years
  • Master case sheet in specialty hospital – 20 years
  • Scientific and research oriented IP – 12 years
  • Pediatric medico legal IP records, death case – 12 years

Ref: Tamil Nadu Government retention policy for Medical Records.

********************************

Question: When a person suffering from some chronic ailment like malignancy/central nervous system ailments etc.  is brought in dead to a hospital and when there is no signs of any foul play on physical examination of the patient in emergency, is it required to initiate MLC  in the case before disposing off the body? Dr. Sourjya Majumdar, Kolkata, West Bengal.

Answer: The case you described need not be reported to Police Authority as it appears to be natural death arising out of chronic ailments. In another scenario, if you find unnatural death or fire burn etc., you are duty bound to inform the Police under the provisions of Sec – 202 of Indian Penal Code 1860. But please understand that doctor is the best judge to decide whether it is natural death or unnatural death; no other person can decide. If a doctor unknowingly or incorrectly decides unnatural death as natural death, he is obliged to give proper reason for the same, if a question is raised later – that is all. This provision is to enable the doctor to bring a particular crime to the notice of prosecutors.

Ref: A hand book of Criminal Law, by Justice G.Ramanujan

***************************

Question: In most medical set ups, the casualty medical officer confirms death on arrival and intimates the relatives of the dead on arrival status. No casualty register entry is made of the case, on the plea that hospital is meant for living people and not for dead ones.  However, police information is given in writing and body retained until police arrive in the case of young deaths, seemingly unnatural/suspicious/violent deaths or injury/trauma cases.  Is this legally correct? If there is no suspicion of unnatural death, is the hospital required to register every ‘brought dead’ patient?

Answer: The following are my clarifications:

1.   If the relatives bring a person under the impression that he/she is alive, but at the outset when the doctor examines the person and finds that he/she is already dead, but at the same time though there is no unnatural or suicidal death you can request the relatives to take back the body without any registration because the registration begins only if you intend to give medical care to a person.

2.   If a person is brought as though he is having life and when the doctor examines he is already dead, but there are symptoms which speak about unnatural death or suicidal death, etc., the doctor has to report to the police under medico legal intimation slip.  Even if the relatives forcibly take back the body, the doctor need not worry as a doctor’s duty ends as soon he sends the report to the police; if the police are interested in investigating the matter they can follow it up. (In a few cases hospital authorities cannot retain the body when an unruly mob insists on taking back the body.   In a few cases even if it is an unnatural death, to make it look like a natural and ordinary death, the body is taken to the hospital to show that the death was natural.)

3.   If a patient is received, who is struggling for life and the doctor starts his treatment and subsequently the patient dies due to the illness, he may release the body without reporting this to the police.  In this connection, he has to register the name of the patient, etc., as he has started the treatment.

4.   The doctor who is working in Casualty need not give Death certificate to a dead body because even though he is competent he cannot correlate the name of the person and the dead body, as he does not know the person in details; only the family doctor who knows the patient can issue Death Certificate.

5.   All the deaths due to accidental death even though they are not accompanied by relatives, should be reported to police as it is a MLC.

In short and in conclusion, a hospital need not register the “brought dead” patient, if there is no suspicion of unnatural death.

*********************************

MEDICO-LEGAL CASE

What is a Medico Legal Case (MLC)?

While prosecuting the accused or perpetrators of crime, the law-enforcing authorities require the aid of medical professionals to prove the changes. For certain types of cases, a professional’s help is essential and without which, the prosecutors may not be able to prove the case before a criminal court. In a criminal court, charges should be proved hundred per cent; otherwise the judges, even though they know that the accused has committed the crime cannot punish, resulting in an acquittal of the accused. A series of acquittals may cause huge crime rates in the society which may lead to fear and uncertainty among the citizens. Therefore, the sovereign is duty bound to protect its citizens by the aid of medical science. The doctor, who is attending a court is not just attending a Government office, but is attending the court for discharging a duty which would enable society to enjoy its full right and liberty without any hindrance. Not all the cases require a doctor’s help; but certain types of cases require doctor’s professional help. These cases are termed “medico-legal cases” (hereafter MLC). There is a misconception in the doctors’ circle that the complaints lodged against them before the consumer forum is a medico-legal case which is not correct. In simple language, the definition would be as follows:

“A medico-legal case is a case of death or injury or illness where the attending doctor, after eliciting history and examining the patient, thinks that some investigation by law enforcement agencies is essential to establish and fix responsibility for the case in accordance with the law of the land. The responsibility to label any case as a medico-legal case (MLC) rests solely with the attending doctor”.

Registration of a Medico Legal Case (MLC)

The decision to register a case as a Medico Legal Case rests solely with the doctor who attends to the case. A doctor must always exercise his judgment whether to refer or not to refer a particular case to the public. In a referred case where an MLC has been registered in a hospital, a fresh registration in the second hospital need not be done.

Generally, the following cases are registered as medico-legal cases:

1. Road traffic and road side accidents

2. Accident or unusual occurrences in a factory

3. All cases of serious injury

4. Suspected homicidal injuries

5. Suspected self-inflicted injuries

6. Suspected attempts to commit suicide

7. Burn injuries due to any cause

8. Suspected or evident poisoning

9. Any injury where foul play is suspected and the injured appears to be either the victim or the culprit in a criminal case

10. Suspected or evident sexual offences

11. Suspected or evident criminal abortions

12. Suspected or evident child abuses

13. Suspected or evident partner abuse

14. Unconscious patients where the cause of unconsciousness is not clear

15. Cases “brought dead” to hospital with improper, inadequate and incomplete history

16. Cases referred by the police or a court of law for some specific legal or medico-legal requirement

There is no stipulated time limit for registering a MLC with the police but within a reasonable time. But it is a settled law by the Supreme Court of India that in a “time of emergency, saving the life of a person is primary and all other procedural matters may wait”. Therefore, doctors shall try to save the life of either the victim or the perpetrator of the crime alike and then give intimation to the police. Except in referred cases U/S 53 of the Criminal Procedure Code, it is better to get consent from the patient / or his / her relatives if he / she is unconscious. If police are bringing an accused or victim for examination or treatment, no consent is required but the doctors / hospital should get an official reference from a Station House Officer (SHO). In the case of an accused referred by jail authorities, a requisition by a Magistrate should be produced by the jail authorities.

Intimation to Police or Medico-Legal Report

It is just an intimation of suspected injury where the doctor thinks an investigation is required. It may contain:

  • Preamble which shall contain date, time and place of examination and the names of individuals, if any, who accompanied or identified
  • Findings or a short narration of injury or suspicious symptoms in the body
  • Opinion as to whether it is a simple or grievous injury.

        Materials or samples found in the body should be kept in a separate plastic bag and sealed. Especially, when the person dies, the blood-stained clothes and other materials found in his / her body should be carefully collected and sealed, then handed over to police. In a few cases seen in private hospitals they put these items in the waste basket which is highly in appropriate because it would be placed before the Magistrate later for proving certain points. Dead bodies of medico-legal cases should be sent to the mortuary for Post mortem examination. A death summary should be prepared in duplicate giving all relevant details of the history, findings and management of the case; it should be handed over to the police.

Source: Human Resource Management in Hospitals by D. Samuel Abraham, (J.R. Publications).



Appendicitis

PDF version

Surgery vs Conservative management for acute appendicitis

Source: Acute Appendicitis – Appendectomy or the “Antibiotics First” Strategy. David R. Flum. N Engl J Med 2015;372:1937-43. Summary prepared by Dr. Sasank K, Department of General Surgery III, CMC,Vellore

Research Question: Should acute appendicitis be managed with surgery or with antibiotics?

Author’s conclusion: Acute appendicitis should be treated with primary appendectomy, preferably via laparoscopic approach. Non-operative treatment may be used as an alternative for specific patients with definite contraindications to surgery. Use of antibiotics-first strategy requires further study into long term outcomes of recurrence and economic burden to the patient.

Background
This article tries to answer the age-old question in surgery- whether to treat appendicitis with primary antibiotic therapy or with primary surgery. This article by Dr. David Flum from the Department of Surgery, University of Washington at Seattle, summarises the existing evidence and guidelines pertaining to this clinical question.

Clinical problem: The estimated lifetime incidence of acute appendicitis ranges from 7 to 14%, based on various socio-demographic factors, with a higher incidence among men. Since 1800s, the standard of care for uncomplicated appendicitis is to undergo an emergent appendectomy. Antibiotics as the first line therapy were recommended for appendicular mass and abscess, with the provision for image guided drainage if required. The alternative approach of “antibiotics-first” therapy for acute appendicitis was first suggested by clinical experience from the Navy and subsequently has been explored by few randomised clinical trials, predominantly from Europe.

Current Practice: Current evidence supports that the diagnosis of acute appendicitis should be a combination of clinical, imaging and laboratory parameters and supports the use of Alvarado scoring system as a predictor. The strongest predictors of acute appendicits have been shown to be migration of pain to the right lower quadrant and vomiting. Among the various imaging techniques available, CT has been shown to have higher sensitivity and specificity than ultrasound examination. However, due to availability and economic constraints, ultrasound is still recommended as first imaging modality for acute appendicitis.

Discussion

According to the current guidelines, appendectomy (open/laparoscopic) is the treatment of choice for acute appendicitis. Laparoscopic appendectomy has been shown to be superior to open approach with lower skin infection rates and economic advantage.

    Trials exploring antibiotics-first strategy were conducted among consenting non-pregnant immunocompetent adults who did not have any features of abscess or perforation on imaging and did not have any features of disseminated peritonitis on local examination. Due to this specific patient profile, these results cannot be easily generalized to all individuals. The protocol tested involved administration of IV antibiotics for 48 hours and continuing of oral antibiotics for 7 days. Real world questions such as compliance and adherence to treatment regimen plague this approach. In addition, they had small sample sizes and did not consistently measure the outcomes, thus limiting comparison. Thus, large scale trials are required to evaluate this protocol in varied clinical scenarios.

    Despite comparable outcomes after the treatment, patients who were treated with antibiotics had a higher risk of recurrent appendicitis and 10-37% of the patients needed an appendectomy within 4-7 months after the first episode. Trial specific data shows that patients initially treated with antibiotics had a crossover rate to the surgery group in up to 53%. However, there was no increase in the rate of perforation in the non-operative arm. Data regarding the economic feasibility is limited. Small trials comparing direct costs of the care at the acute setting have found that treating with antibiotics is better. However, the costs of recurring symptoms with need for multiple admissions needs to be considered.

The question of optimal management of acute appendicitis continues to remain unanswered. Based on the available literature, laparoscopic appendectomy still remains the treatment of choice due to good outcomes with low complication rates. Due to the limited nature of the available evidence, the authors feel that “antibiotics-first” strategy should be currently employed only within the confines of a clinical trial.

Expert Comments

Dr. Sudhakar Chandran, Professor, Dept. of General Surgery, CMC Vellore
Acute appendicitis is a common cause of acute abdomen in young adults and conservative management with antibiotics without an operation may have a role in uncomplicated cases. Comparing operative management with conservative treatment with antibiotics alone is difficult and complex. The rationale behind treating patients with antibiotics is that there may be a subset of patients with acute appendicitis who will respond to medical management. Conservative treatment should be reserved for only those who are high risk for an operation. It should be noted that conservative management of acute appendicitis carries a significant mortality especially in the elderly and immunocompromised. Patients on antibiotic treatment may develop complications requiring intervention. This is likely to increase the treatment cost significantly. Since there is no definite evidence available in the literature on best practice in the management of acute appendicitis a judicious approach towards management of acute appendicitis is recommended.

****************************

Prem Jyoti

PDF Version

Prem Jyoti – A pioneering medical work among Malto tribals

Dr. Isac David and Dr. Vijila Isac

Prem Jyoti Hospital is a 30 bedded healthcare and community health facility situated in Chandragodda, in the Sahibganj district of Jharkhand. Dr. Isac and his wife Dr. Vijila Isac pioneered a medical mission work among the Malto tribals of this region, an extremely backward tribe, afflicted by poverty and disease and living in a land that was for all practical purposes cut off from the rest of civilization until recently. The hospital is part of a larger organization called Emmanuel Hospital Association (EHA) which has 20 hospitals and 35 projects all over India. The pioneering work among the Malto tribals by this humble doctor couple has brought about a remarkable and wholesome transformation in the lives of the villagers. In a candid interview, Dr. Isac David talks about how their work started and grew, the difficulties faced and the impact on the villagers.

 

Would you like to describe the Malto tribal people among whom you work- their land and culture?

The Malto tribe

    We work in a place called Chandragodda in the Sahibganj district of Jharkhand. The district has a population of around one million, of which about 40% are tribals. Our journey began in 1996 when God gave us a burden to reach out to the health needs of a diminishing tribe called the Maltos.

The Maltos are of Dravidian origin. They live in the hills and are called “paharias” or hill people. Their population is about 1 lakh at present. They look very similar to South Indians and even their language has about 300 words that are similar to Tamil and other South Indian languages. Their grammar – cultural practices are also similar to those observed in South India. They are chiefly involved in agriculture but because the land is rocky, the yield is poor. Poverty is a major issue and unscrupulous money lenders take advantage of their situation by lending money at exorbitant rates and cheating them even when they repay their loans. Extreme poverty has in the past led many of the tribals to robbery and dacoity in the surrounding regions.

    Malto society is matriarchal and the prospective bridegroom pays a bride-price for marriage (which may be a few sacks of grains, a pig and a few bottles of liquor).

They have a tradition of welcoming visitors by washing and anointing their feet with oil and garlanding them with wild flowers. They are fond of a kind of black tea with salt and sugar which they serve when welcoming visitors.

A Malto tribal woman
A Malto wedding

 

Foot-washing welcome ceremony

 

What were some of the problems faced by the Malto tribals?

    Illiteracy and lack of access to good health care were major problems. When we started in 1996, the literacy rate was only about 4%. Secondary health care facilities were severely limited and access to health care was even worse. There was only one hospital in the entire district where Caesarean sections were being done until our hospital was started. The immunization coverage was 7%, under-5 mortality rate was 380 per 1000 and infant mortality was around 250 per 1000, maternal mortality rate was 23 per 1000 deliveries (figures of 1997-99). Many children were orphaned due to the high maternal mortality rate, and these infants were often taken care of by their siblings who were themselves children.

Illnesses: Infectious diseases are the main cause of death. The area is hyperendemic for malaria which is a major killer. Kala azar is another very common vector borne disease. Sand flies which transmit the disease thrive in Malto communities because of the high humidity and the fact that animals live along with people in their homes or very close to the home (animals are not kept in separate sheds due to fear of robbers and dacoits). Sandflies grow very well in the cracks and crevices of these mud houses.

Poor nutrition: Though they cultivate maize, vegetables and cow pea-, nutrition is very poor because of recurrent infections. Moreover, because of unsafe drinking water, diarrhoeal diseases are very common. About 85% of children below 5 years are malnourished and one third of children do not even reach the age of 5 years. In the initial days, in the 90s, cholera was very common especially in the rainy season. Entire village populations were sometimes wiped out by cholera. Now, with better health facilities and awareness, cholera is rarely seen. Tuberculosis was also rampant among the tribals.

Access to health care: To reach a health facility the villagers would have to walk for about 2 hours downhill and then travel by the uncertain public transport for another hour to reach the town. When they would reach- the Primary Health Center (PHC), doctors were often absent or medications were unavailable. Private practitioners were not an option because of the unaffordable fees. So most tribal villagers did not approach a health care facility when ill. The first person they approached was usually a witch doctor who practiced magic and used some herbal remedies which were by and large ineffective. Only when a person was well advanced in the course of an illness and nearing death did they think of approaching a doctor. Most people walk for several hours to reach the hospital.

    Access to health-care for villagers is still difficult and primitive. Sick patients were brought in bullock carts, or on a bed suspended by ropes from a bamboo pole. It is difficult to do this because of the hilly terrain and the problems are worse during the monsoons.

    Transport facilities are slightly better now with indigenously made tricycles called ‘Tela gaadis’ available. However the roads are so bad and travel takes so long that it is not uncommon for women to deliver on the way to hospital. I am happy to say that some roads have now been modernized and few four wheelers are also available for transport.



(Images from above down) – Public transport, Transporting the sick in the hills, ‘Tela Gaadi’

How did your work among the Malto tribals start?
The FMPB (Friends Missionary Prayer Band) were the first to start a work for the uplift of the Malto tribals. Seeing the huge health needs in the region, they approached EHA for a health care programme among the Maltos. With the help of EFICOR, funds were obtained from a Canadian Development agency. At the same time, both of us (my wife Vijila and I) had just completed our Family Medicine degrees and were looking for a place where there was a need for doctors. Thus in 1996, EHA in partnership with FMPB and EFICOR, started the health care programme and we were the first doctors.

    We started as a team of five (2 doctors, a pharmacist, a lab technician and a nurse) in a single room clinic with a vision statement of ‘Reaching out with the light of God’s love, to make a difference.’ At first we were intimidated by the whole situation and wondered how five of us could make a difference to 80,000 people scattered in more than 700 villages. However, God gave us the wisdom to select and train local people as Community Health Volunteers to help in taking healthcare to the Malto people.

    In 1999, we started with a 6 bedded health center and saw it grow to 15 beds in 2005 and presently we function as a 30 bedded hospital. Along the way a hostel for nurses, a chapel, dormitory and other buildings were built. Our team has grown from 5 to about 80 at present.

    Our mission is to become a Christ-centered community that reaches out to the poor and the marginalized, especially the Maltos, through quality health care, empowerment of communities, catalyzing transformation, developing local leadership and expertise and to serve as a model that will challenge others to do the same.

Could you describe the healthcare model that you follow?
We have a two-tier system: 1) At the primary level, the community health care programme is run through the help of community health volunteers (CHV) and mobile clinics who bring women needing antenatal checkups and children needing immunization to the hospital.

2) The second tier is the hospital which serves as a secondary care center for those who need inpatient care or diagnostic facilities.

Community health volunteers: Our community health volunteers (CHV) are the backbone of our primary health care system. They are members of the community who are selected and trained to deliver health care. There is a high level of acceptance of these volunteers as they are from the community itself. The role of CHVs is to examine villagers, identify pregnancies and illnesses and bring them to the mobile clinics. They also conduct surveys and report to us every month. As they are mostly illiterate, we developed illustrated reporting formats. Using pictures, they are able to report on vital statistics, births, deaths, pregnancies etc. at our monthly reporting meetings.


Mobile clinics

Since access to healthcare is very difficult, we try to help by reaching out to the villagers by travelling to the community using mobile clinics.

    Though we travel by jeep for one to two hours, to access the villages, the villagers still have to walk 45 minutes to one hour to reach the mobile clinic. In these clinics we have integrated health care where we do antenatal checkups, immunization and patients who need hospital care are either brought directly or referred to the hospital. The mobile clinics are held wherever place is available, sometimes in a school, the verandah of a building or even under the shade of a tree.

Outpatient clinic

    We have an outpatient clinic in the hospital that sees patients who come to us or are referred by our volunteers. Our outpatient clinic was initially manned by two doctors (Dr. Vijila and I) and nurses. From the beginning trained nurse practitioners have been managing the outpatient clinic. They screen patients with infectious diseases and provide antenatal check-ups and health education. Lately, we have had some young doctors who have joined us to help with the work in the hospital and OPD.

In-patient care

    Infectious diseases make up a large number of our inpatients – malaria and kala-azar are very common. Other illnesses we encounter are tuberculosis in various forms (pulmonary, meningitis, pleural effusion), snake bites, septic arthritis, dental problems, pregnancy related problems like eclampsia etc. Tetanus cases are still seen, as immunization coverage is still poor. We are not able to have ventilators for want of regular electrical supply. I remember one young boy who was manually ventilated for 72 hours following a neurotoxic snake bite – fortunately he survived and did well.

    In the initial days, we had 5 deliveries a year. The number has risen to 800 a year in the hospital. Our caesarean rate was around 19-20% but has risen in the last six months to 30% because some PHCs have started functioning in the vicinity and have started referring complicated cases to us. Uterine rupture is often seen (one case every other month) and eclampsia is common.

Community based organizations:

Recently we have started organizing community based initiatives because we realized that health alone will not bring transformation within a community. We are aiming towards -holistic transformation in terms of health, economy and spirituality. Towards this goal, some self-help groups have been formed especially among women in the community to improve agricultural practices and means of livelihood. We try to address social issues like sexual promiscuity, alcoholism, migration to cities for livelihood and child trafficking. We also work along with the Government system to build capacity (through training programmes) and motivate the health staff working there.

Training the next generation of Maltos

We were able to send some of the Malto children who had finished school to nursing schools. Some of the Malto tribal girls themselves have become nurses and serve their community now.

The Hospital in 1996


The Hospital in 2007


How were you able to communicate with villagers who were illiterate and who do not even have a script for their language?

It was difficult and so we had to innovate and do things differently.
Medicine through songs: As many of the Maltos are illiterate, we give them health education through songs. The Maltos are an oral community and songs are the traditional medium of learning. So we composed songs in their local language – to convey health education messages. We found that many of them had difficulty in following the prescribed dosage and duration of medicines. So we formulated a way in which the medicine dosage, frequency and other details were offered to them as songs. So when a patient is diagnosed with an illness and prescribed medicine, our health care volunteers sing out the stanzas of the prescription song to enable them to take their medicine correctly. The health education songs pertaining to the illness (Eg. use of mosquito nets for malaria) are also added on so the patient gets the complete package – prescription plus health education in one brief singing session.

    The Maltos possess a very good sense of humour and are a very innovative community. If given a theme, they are ready with a skit with props within 10 minutes. In the fields, it is easy to gather a group of 30 to 40 people, if we use skits to get the health message across.

    We also designed flash cards to help explain disease prevention measures to the community. We had to design them ourselves because the flash cards that were available were ineffective in conveying the message. So we took photographs of villagers and their surroundings and printed flash cards with those images. These cards were a big hit among the villagers and they came in large crowds to see them as they were seeing photographs of their own community for the first time.

How did you decide to work in this remote region among tribals?
 I am a native of Madurai and I did my MBBS in Madurai Medical College in the year 1984. When I was in medical college, I had a desire to work among the poor. I was invited to go to Oddanchatram, so joined Christian Fellowship Hospital and did a non-formal course with Dr. Rajkumar. The course was later recognized for DNB Family Medicine. My wife Vijila had committed to serve the poor when she was 11 years old. After graduating from MBBS, she too joined the same 2 year Family Medicine programme in Oddanchatram. By the second year, we realized that we both shared the same vision and values and decided to get married.

    After our marriage, we decided on a survey trip to five mission stations. We felt God’s leading to go to the Malto tribals. We got a promise from Isaiah chapter 35:8 – There is a king’s highway and those who travel on it, though they are fools, will not lose direction.

    The place where the Maltos lived was very backward with no infrastructure, transport or facilities and with high levels of poverty and illiteracy but since we felt strongly led by God, we decided to go there. The language and people were strange, the terrain was hilly and the need was vast – we wondered what we could do in this situation? The FMPB was looking for doctors to start a medical work and we were looking at work among the Maltos – so things worked out and we decided to start a medical mission among the Maltos.

How was this passion to work among the poor born?

    I have had this passion since childhood and it developed during my stay in Oddanchatram. We used to go to the hills of Pachalur to conduct medical camps. We walked 7 kms one way in hilly terrain to reach our destination. It was physically tiring but when we met the people, listened to their problems and needs and attended to their illnesses; there was a tremendous sense of fulfillment. This is how it became clear to me that I would work among the most backward and poor people who are in need of health care. I also came to know about the health needs of people in North India through the stories of missionaries who worked in those areas. Vijila had visited and stayed at a mission health centre with Dr. Sam David in a tribal area in Andhra Pradesh, during her MBBS days, and that helped her decide to work among the poor.

What were the initial struggles and how are things now?

    Initially when we started our work among the Maltos in Chandragodda, there were no places to stay. So during the first one and half years, we stayed in a rented house in a nearby town called Barharwa. We started mobile clinics to the village and then started staying for four days in a week among the tribals. An outpatient clinic was held in the town two days of the week and in the tribal village for 4 days in a week. The work among the tribals was started by selecting volunteers from the tribal community and health training was started.

So you actually stayed in the huts of the tribals?

    Yes, we stayed in the huts of the tribals and ate whatever they ate. I would say that was the golden period of our work. It enabled us to understand how the tribals lived, their beliefs and cultural practices and also learnt their language. It did not take us much time to build a rapport with them and start medical work, thanks to the ground work done by missionaries earlier. The tribal people were in fact eager to teach us the language because they had been longing for doctors to work among them.

The hospital was constructed on 6 and ½ acres of land donated by the tribal community. Tribal land cannot be sold but may be donated for a common good. We started the hospital in 1999, three years after starting our work among the tribals.

What were the practical difficulties you faced?

    There were difficulties all along the way. For the first fifteen years, we did not have a steady source of electricity. A generator was used during the outpatient clinic and in case there were any emergency surgeries. We did not have the luxury of electricity where we stayed in the initial days.

A Malto nurse

    Isolation was a major difficulty. We were isolated from the rest of the world due to lack of communication facilities. It was difficult to contact our family or friends when we had trouble or if we simply wanted to talk to someone familiar. There were no landlines for telephone. To make one phone call, I had to travel 16 kms on a motorcycle (which would take one hour) to the nearest railway town. There I would catch a train to the next town (another one-hour journey) to make a phone call. For the last 3 years thankfully, a mobile tower has come up nearby and we are able to make mobile calls. At present, we also have very limited internet facilities – just enough to send and receive emails.

    Sickness was another practical difficulty. I had around 26 attacks of malaria and constant tiredness was a problem. By now, I think I am probably immune to the parasite and do not suffer as much. Education of children was another issue in the remote region. Initially we home schooled both our daughters. Thankfully there are many good residential schools in Tamil Nadu which were especially started to look after children of missionaries and my children have been having a good education. My daughters, on their part are very understanding and they have shown admirable maturity in their studies and attitude towards life. The decision to send our elder daughter was not easy but they themselves decided to move into a residential school.

Were there any disappointments or difficulties that ever made you question your commitment?

    Being a small team, there were difficulties between us occasionally. There were also occasional difficulties with our partner agencies regarding support to our cause. However God has been a rock of strength and we have been encouraged through many friends through their lives and prayers. The Life Revisions seminars held by Dr. K.O. John were very helpful. We also took periodic retreats and breaks to renew our vision and so we did not get burnt out.

What changes have you seen in the Malto villagers through the health care programme over the years?

    Through the community outreach programmes and health education, the health-seeking behavior has definitely improved. This is chiefly due to the efforts of our community health volunteers. Infant mortality rate has reduced in the target villages from around 250 to 68 per thousand. This is a noticeable impact that we have seen. Maternal mortality rate (MMR) has decreased from 46 per thousand to 8 per thousand. We are able to see more women come to us for antenatal check-ups and bringing their children for immunization. The number of hospital deliveries has gone up significantly and this has a significant bearing on the MMR. We have seen an improvement in the economic status of the villagers through our self help groups and through school education. Some of the Malto girls were sent for training in nursing and they have come back as nurses in our hospital. Mariam Malto was our first GNM nurse from the Malto community. She also had RCH training and now helps us as a nurse practitioner in the outpatient clinic and in the mobile clinic.

Our dream

Though we started as a small community health programme, it has grown to the extent that we now serve 5 blocks in the Sahibganj district.

Our dream is that no woman should die in childbirth, that malaria and kala-azar be controlled, that we can start a nursing school that provides ANM training, that we will continue to be a voice for the voiceless, a shelter for the needy, a place of hope and healing and that God’s love and light may flow from Prem Jyoti to the entire district. We dream that we will be able to train Maltos to become doctors and nurses so that they can take over the administration of the hospital and serve their own community.

Though we started off as just two health care professionals, we are able to see young people who have made a long term commitment come and join the team. God is raising up the second generation of doctors and nurses and that is exciting.

We dream of Malto villages becoming like “Heaven on earth” with holistic transformation in their spiritual, physical, social and economic lives. Men and women living with a sense of fulfillment, unity, hope and love, free from exploitation, empowered to claim their entitlements and to pave the way for a brighter future for their children.

The story of Anita Malto
Anita Malto was a lady who was diagnosed to have severe anemia and kala-azar and had a child who was severely malnourished (weighing only 1.5 Kgs). She was brought by one of our community health volunteers (CHV) named Mariam. If it was not for Mariam, this lady would have died along with the baby. Mariam herself is from the Malto tribe who was trained to be a CHV. This is how the mother and child looked when the child was 6 months of age.

Anita Malto and her sick child
The family after a few months
Mariam Malto, Community Health Volunteer (in pink saree) with the mother and child

 

**************************

*****************************************

BEDSIDE ULTRASOUND

PDF Version

BEDSIDE ULTRASOUND
Part 1 – An introduction

Dr. Kishore Kumar Pichamuthu, Professor, Department of Critical Care, CMC, Vellore

Bedside ultrasound in the ICU

Point of care ultrasound in the acutely ill

    The management of an acutely ill patient is often challenging and clinical signs are confusing or difficult to obtain. It is in these very patients however, that rapid and accurate diagnosis can be life-saving. It is here that bedside ultrasound can come to the rescue.

    Ultrasound has evolved to become one of the most versatile modalities for diagnosing and guiding treatment of acutely ill patients. It consists of both cardiac (Echocardiography) and non-cardiac (lung, neuro, abdominal and vascular) ultrasound. Ultrasound is likely to be particularly useful in resource challenged areas as it is non-invasive, economical, repeatable and can be performed at the bedside.

    In this series, we will try to cover the basic uses of ultrasound in acutely ill patients in a practical, handbook fashion. We will have to have a background knowledge of the physics of ultrasound before we start at the bedside. This will be covered here. All this information can also be seen at http://www.criticalecho.com

Table 1 – Uses of bedside ultrasound
Bedside ultrasound can be used for the following, in the ICU:

Hemodynamics

  • Non-invasive assessment of cardiac output
  • Assessing myocardial contractility and regional wall motion abnormalities
  • Volume status assessment
  • Predicting volume responsiveness
  • Diagnosing diastolic ventricular dysfunction and estimating left atrial filling pressures non-invasively
  • Assessing right heart function and diagnosing acute cor pulmonale in ARDS and pulmonary embolism
  • Detecting pericardial effusion and tamponade

Pulmonary

  • Detecting pleural effusion
  • Rapid diagnosis of pneumothorax
  • Diagnosing consolidation and alveolar-interstitial syndrome
  • Differentiating ARDS and pulmonary edema

Vascular

  • Diagnosing deep venous thrombosis

Abdomen

  • Detecting ascites and collections
  • Diagnosing urinary bladder distension and hydronephrosis
  • Studying renal arterial resistivity indices as an indicator of renal blood flow

Resuscitation

  • Differentiating fine ventricular fibrillation from true asytole
  • Diagnosing potentially reversible causes of PEA or asystole such as pericardial tamponade, myocardial infarction, severe hypovolemia, pulmonary embolism or tension pneumothorax – the Focussed Echocardiographic Evaluation in Resuscitation (FEER)
  • Asessing for cardiac standstill to help with prognostication during resuscitation

Neurology

  • Detecting raised ICP using optic nerve sheath diameter
  • Detecting midline shift
  • Assessing adequacy of cerebral blood flow in patients with traumatic and non-traumatic brain injury
  • Diagnosing cerebral circulatory arrest
  • Assessing pupils in patients whose eyelids cannot be opened

Other diagnostic uses

  • Detect fluid in pericardial, perisplenic, perihepatic and pelvic areas in trauma – the Focussed Assessment with Sonography for Trauma (FAST) 
  • Diagnosing sinusitis in intubated patients

Therapeutic

  • Guided arterial and central vascular access
  • For guided thoracocentesis and abdominal paracentesis
  • Pericardiocentesis
  • Bedside Percutaneous nephrostomy
  • Guided drainage of collections


Fig. 1 – Ultrasound images

Lung consolidation

Deep vein thrombosis

Pericardial effusion

Pneumoperitoneum

Intraparenchymal Hematoma in the brain

Pleural effusion


Assessment of size and reaction of pupils

Maxillary sinusitis


BASIC PHYSICS OF ULTRASOUND AND THE DOPPLER PHENOMENON

Medical ultrasound imaging consists of using high pitched sound bouncing off tissues to generate images of internal body structures.

Frequency

Frequency refers to the number of cycles of compressions and rarefactions in a sound wave per second, with one cycle per second being 1 hertz. While the term ultrasound generally refers to sound waves with frequencies above 20,000 Hz (the frequency range of audible sound is 20 to 20,000 Hz), diagnostic ultrasound uses frequencies in the range of 1-10 million (mega) hertz.

Wavelength

The wavelength is the distance travelled by sound in one cycle, or the distance between two identical points in the wave cycle i.e. the distance from a point of peak compression to the next point of peak compression. It is inversely proportional to the frequency. Wavelength is one of the main factors affecting axial resolution of an ultrasound image.

    The smaller the wavelength (and therefore higher the frequency), the higher the resolution, but lesser the penetration. Therefore, higher frequency probes (5 to 10 MHz) provide better resolution but can be applied only for superficial structures and in children. Lower frequency probes (2 to 5MHz) provide better penetration albeit lower resolution and can be used to image deeper structures as used in adult cardiac and abdomen ultrasound.

Propagation velocity

The propagation velocity is the velocity at which sound travels through a particular medium and is dependent on the compressibility and density of the medium. Usually,the harder the tissue, the faster the propagation velocity. The average velocity of sound in soft tissues such as the chest wall and heart is 1540 metres/second.




ULTRASOUND TISSUE INTERACTIONS

    The interaction of ultrasound waves with organs and tissues encountered along the ultrasound beam can be described in terms of attenuation, absorption, reflection, scattering, refraction and diffraction.

Attenuation

Sound energy is attenuated or weakened as it passes through tissue because parts of it are reflected, scattered, absorbed, refracted or diffracted.

Reflection

A reflection of the beam is called an echo and the production and detection of echoes forms the basis of ultrasound. A reflection occurs at the boundary between two materials provided that a certain property of the materials is different. This property is known as the acoustic impedance and is the product of the density and propagation speed. If two materials have the same acoustic impedance, their boundary will not produce an echo. If the difference in acoustic impedance is small, a weak echo will be produced, and most of the ultrasound will carry on through the second medium. If the difference in acoustic impedance is large, a strong echo will be produced. If the difference in acoustic impedance is very large, all the ultrasound will be totally reflected. Typically in soft tissues, the amplitude of an echo produced at a boundary is only a small percentage of the incident amplitudes, whereas areas containing bone or air can produce such large echoes that not enough ultrasound remains to image beyond the tissue interface.



Figure 2: Interactions of Ultrasound with tissue


Figure 3: Production of an echo depending on relative acoustic impedances of the two media: From: Aldrich: Crit Care Med, Volume 35(5) Suppl.May 2007.S131-S137

At a tissue–air interface, 99% of the beam is reflected, so none is available for further imaging. Transducers, therefore, must be directly coupled to the patient’s skin without an air gap. Coupling is accomplished by use of gel between the transducer and the patient.

Scattering
Not all echoes are reflected back to the probe. Some of it is scattered in all directions in a non-uniform manner. This is especially true for very small objects or rough surfaces. The part of the scattering that goes back to reach the transducer and generate images is called backscatter.

Absorption
Tissue absorption of sound energy contributes most to the attenuation of an ultrasound wave in tissues.

Refraction
The change in the direction of a sound wave on being incident upon a tissue interface at an oblique angle is refraction and is determined by Snell’s law.

TRANSDUCERS
Inside the core of the transducer are a number of peizo-electric crystals that have the ability to vibrate and produce sound of a particular frequency when electricity is passed through them. This is how ultrasound waves are formed. These transducers also act as receivers for the reflected echoes as they generate a small electric signal when a sound wave is incident upon it.

Duty factor
In most modes of ultrasound operation, only 1% of the time is spent in generating a pulse of ultrasound waves and 99% of the time is then spent listening for the echoes. This is called the duty factor…1% in such a case.

Pulse repetition frequency (PRF)
The PRF is the number of pulses (send and listen cycles) of ultrasound sent out by the transducer per second. It is dependent on the velocity of sound and on the depth of tissue being interrogated. The deeper the tissue being examined, the longer the transducer has to wait for echoes to come back, hence a lower PRF.

Beam
The ultrasound beam is focused by the transducer so as to be as close to a flat plane as possible. The beam is made up of tens to hundreds of scan lines.

Orientation
There is usually a dot, groove or light on one ends of the transducer to assist orientation. A corresponding marking is also displayed on the screen to help give an orientation to the images.

Resolution

Axial resolution:The ability to resolve objects in the line of the ultrasound beam. Factors affecting axial
resolution include Spatial Pulse Length (SPL) and frequency.

Lateral resolution: Resolution at 90° to the direction of the beam. Factors affecting lateral resolution are width of the beam, distance from the transducer, frequency, side and grating lobe levels.

Temporal resolution: Refers to the ability to detect moving objects in the field of view in their true sequence. The number of frames generated per second (frame rate) determines temporal resolution.


Table 2: Percentage reflection of ultrasound at boundaries 

In the next episode of this article, we will look at knobology, probology, infection control and ergonomics of bedside ultrasound.

CME CLINICAL CONTENT QUIZ CMI 14:1

CMI October 2015 Vol. 14, Issue 1 (CMI 14:1)

INSTRUCTIONS

Please read the articles in ‘Current Medical Issues’ and answer the questions on this page. Only ONE answer is correct in each question. You can then send in your answers to cme@cmcvellore.ac.in

CME CLINICAL CONTENT QUIZ CMI 14:1

  1. Salbutamol should be given through high flow oxygen because
    1. Oxygen acts synergistically
    2. To avoid worsening of V/Q mismatch
    3. Salbutamol reaches alveoli with high flow
    4. Beta agonist effect can mask hypoxemia
  1. Pneumococcal vaccine in the elderly – what is FALSE?
    1. Significantly reduces all-cause pneumonia and mortality rates
    2. Reduces the rate of invasive pneumococcal disease
    3. Cost varies according to type of vaccine
    4. Indicated also in young adults with certain predisposing illnesses.

  2. Which of the following is NOT true about inhaled corticosteroids in childhood asthma?
    1. It is vital for controlling inflammation
    2. Child must rinse mouth after use
    3. They may be given along with Monteleukast in Step 3&4 treatment
    4. It causes long term growth stunting and should be avoided.
  1. There should be suspicion of lung cancer if there is / are
    1. Change in character of cough/ new hemoptysis in a patient with TB
    2. Early pleuritic chest pain as it is the most reliable symptom
    3. Good indicators of TB remission in a person on ATT
    4. Lung lesion in chest x-ray of a young adult.
  1. When managing OP poisoning in the emergency department,
    1. Gastric lavage and induced vomiting is a must in all patients
    2. Avoid endotracheal intubation at all costs
    3. Activated charcoal beyond 1-2 hours after poison consumption is not beneficial
    4. Atropine is reserved for use only if symptoms worsen

  1. What is TRUE in diagnosis of lung cancer?
    1. CT thorax is not necessary if chest x-ray shows a lesion
    2. Sputum cytology is the cheapest and most reliable for diagnosis
    3. EBUS guided needle aspiration gives good tissue yield in lung cancer
    4. Low dose CT is ideal for screening in all individuals.
  1. Management of appendicitis: All are true EXCEPT
    1. migration of pain to the right lower quadrant is a strong predictor of appendicitis
    2. Conservative management should be tried before surgery in every case
    3. CT is more sensitive than ultrasound in diagnosis
    4. Surgery is the treatment of choice
  1. In the diagnosis of asthma in children,
    1. Look for other causes in children with chronic wet cough.
    2. Clinical findings are not as important as chest x-ray findings.
    3. If there is no wheeze, it cannot be asthma
    4. Tightness of chest and chest pain are rare
  1. Regarding asthma exacerbation in children, which of the following is FALSE
    1. Emotions and change in climate are triggers
    2. Viral respiratory infections are common triggers.
    3. Exacerbation requiring hospitalisation in the last one year is a risk factor
    4. Use of two or more classes of asthma drugs is not a risk factor
  1. In the treatment of sepsis,
    1. Low dose long-course steroids are useful
    2. Steroids are contraindicated
    3. High dose bolus dose of steroid is not useful
    4. Blood glucose is stable with steroid therapy



Organophosphate poisoning

PDF Version

Organophosphate poisoning: A case report, overview of management and nursing interventions

Amala Rajan1, Ilavarasi Jesudoss2, Jayarani Premkumar3
1Professor, 2Professor, 3Professor and Head of Medical Nursing, College of Nursing, Christian Medical College, Vellore.
Peer reviewed: Dr. Reginald Alex, Professor, Department of Emergency Medicine, Christian Medical College, Vellore.

Abstract: Organophosphate poisoning is a common cause of acute poisoning in India with high mortality. Prompt recognition and aggressive treatment of acute intoxication is essential to minimize the mortality and morbidity. Nurses play a vital role in the management of poisoning, as it demands close observation, timely administration of antidotes in adequate doses and skilful nursing interventions. This article presents a case report with a literature review of organophosphate poisoning, and its management.

Key words: Organophosphate, poisoning, Anticholinergics, Decontamination.

Abbreviations: AChE – Acetyl cholinesterase, BP – Blood pressure, GCS – Glasgow Coma Scale, HR – Heart rate, IMS- Intermediate syndrome, MAP – Mean Arterial Pressure, OP – Organophosphate, OPIDP-Organophosphate Induced Delayed Polyneuropathy, VAP – Ventilator associated pneumonia

INTRODUCTION

Organophosphates (OP) are commonly used as insecticides and are among the most common suicidal agents in developing countries like Pakistan, Sri Lanka, and the other Asian and South East Asian countries

. Poisoning due to OP is a major health problem as consumption of these insecticides is associated with significant morbidity and mortality. OP poisoning contributes to a large proportion of admissions to hospitals and intensive care units as OPs are comparatively more toxic and easily available than other insecticides like organocarbamates, organochlorides, and pyrethroids.1

    Poisoning is common among the young, especially adolescents and young adults and in farmers, and accounts for 35-40% of all suicidal deaths in India.2 According to John G3from Christian Medical College, Vellore, in the year 2005 alone, 11.7% of total ICU admissions were due to OP poisoning which accounted for 14.6% of Intensive care unit (ICU) deaths. Studies have reported that three million cases of poisoning and forty thousand deaths occur worldwide per year throughout the world, predominantly in the developing countries.(4,5)

TYPES OF ORGANOPHOSPHATES: OP compounds may be divided into two types: diethyl (e.g.chlorpyrifos, diazinon, parathion, phorate and dochlofenthion) and dimethyl (e.g. dimethoate, dichlorvos, fenitrothion, malathion and fenthion)6,9. The route of entry into the body is either through accidental or suicidal ingestion, inhalation or absorption through skin.

PATHOPHYSIOLOGY

    Acetylcholine is a neurotransmitter found in neuromuscular junction and peripheral /central nervous systems. Acetylcholin esterase (AChE) is the enzyme responsible for the degradation of acetylcholine. OPs inhibit and inactivate AChE, leading to accumulation of acetylcholine. This results in overstimulation of the muscarinic and nicotinic receptors in the nervous system leading to toxic effects.(7,8,9)

CLINICAL MANIFESTATIONS

    The onset, severity and duration of OP poisoning depend on the route of exposure and amount of agent involved. Clinical Manifestations of OP poisoning may be summarized as shown in Table 1 (10,9,11)

    The most important sequela in patients with acute OP poisoning is neuromuscular weakness. This requires prolonged ventilation. Based on the time of occurrence of weakness, paralysis may be categorized into two types.
Type I: (Acute paralysis) usually develops within 24-48 hrs. This is due to the persistent depolarization at the neuromuscular junction resulting from blockade of acetylcholine esterase. Some of the important clinical

features are muscle fasciculations, cramps, twitching, and weakness. Paralysis of the respiratory muscles may lead to respiratory failure which requires mechanical ventilation.1,3.

Table: 1 – Symptoms of OP poisoning18

Muscarinic symptoms Nicotinic Symptoms CNS symptoms
Mnemonic
“SLUDGE/

DUMBLES”

Salivation

Lacrimation

Urination

Diaphoresis

GI emptying (vomiting, diarrhoea)

Emesis

Diaphoresis

Urination

Miosis

Bronchorrhea

Lacrimation,

Emesis

Salivation.

Fasciculations
Paralysis

Pallor

Muscle weakness

Hypertension

Tachycardia

Mydriasis (rare)

Unconsciousness
Confusion

Toxic psychosis

Seizures

Fatigue

Respiratory Depression

Dysarthria

Ataxia

Anxiety

Type II: (Intermediate syndrome/ IMS) develops after the acute cholinergic crisis. It occurs 24-96 hours after the poisoning and the predominant muscle groups involved are respiratory, proximal limb muscle and neck flexors. It persists for about 14 – 20 days. One of the earliest manifestations in these patients is the presence of marked weakness of neck flexion with the inability to lift the head from the pillow1,3..

Type III: OP Induced Delayed Polyneuropathy (OPIDP). It can be pure sensory or motor neuropathy occurring 2-3 weeks after the episode of poisoning. It is predominantly distal. Recovery may take 6-12 months.(1,3)

DIAGNOSIS

Diagnosis is based on:

1. History of exposure to a known OP compound.

2. Clinical features: laboured breathing, sweating, miosis (small or pinpoint pupils), bradycardia and typical odour (garlic/ petrol). The nicotinic effects like tachycardia and mydriasis may be seen in some patients (rather than the more common miosis and bradycardia). ( Table 1).

3. Blood levels of serum pseudocholine esterase.

4. The poison can be identified by some poison centers by analyzing the contents of the stomach..1

INVESTIGATIONS

Specific investigations in the Emergency department include:

1. Blood samples for serum pseudocholine esterase, leucocyte count if infection is suspected and electrolytes.

2. ECG &Chest X-ray

MANAGEMENT

The management of OP may be categorized into emergency, general and specific management.

Emergency Management: – OP poisoning is a medical emergency.

1. Initial assessment includes assessment and management of airway, breathing, & circulation. Provide adequate oxygen and ensure a patent airway is maintained (noisy breathing is the best indicator of an obstructed airway).

2. Position the patient in left lateral position to reduce the risk of aspiration.

3. If the patient is drowsy with laboured breathing and has an obstructed airway or poor oxygen saturation, early intubation and ventilation will help overcome the acute crisis.

3. Monitor the vital signs. Arrangements should be made to transfer the patient to ICU if there are signs of low sensorium, laboured breathing, BP less than 90/60 mm Hg or severe muscarinic crisis.

General and specific management: The general principles of management of poisoning have to be carried out without delay. The specific management involves neutralization of the poison using specific antidotes. The principles of management are:

1. Reduce absorption of toxin

2. Increase elimination of the toxin

3. Neutralization (Using specific antidotes)

1. Reduce absorption of toxin

a) Skin Decontamination:

Decontamination of the skin is very important and it should be done very thoroughly to prevent further absorption through the skin. The patient’s clothes are removed and the skin is thoroughly washed with soap and water. Gentle cleaning with soap and water is effective and will not abrade the skin or enhance absorption. Skin folds and underside of fingernails and long hairs require special attention. Ocular decontamination is to be carried out by gently washing eyes with water/normal saline. Health-care personnel should wear protective clothing and glasses. Contaminated clothes, shoes and other leather items must be removed from the patients and placed in a separate bag; these should then be incinerated.

b) Gastrointestinal decontamination:

Gastric decontamination must be done by induced vomiting only if the patient is fully conscious and oriented. Induced vomiting is not recommended if the individual is drowsy, disoriented or has a poor level of consciousness, as there is a risk of aspiration. Gastric lavage is more effective and is safer than induced vomiting. It is most effective within 60 minutes of ingestion of the poison but can be useful even later in the therapy of poisons which delay gastric emptying. The first aspirate of stomach content is preserved and sent for pharmacoanalysis.1,8 Gastric lavage is contraindicated if the GCS score is < 8 as there is risk of aspiration. It may be carried out after intubation & stabilization in patients with low GCS. 3

2. Increase elimination

a) Activated Charcoal: 17. Activated charcoal (0.5-1g/kg) is useful for gastrointestinal decontamination- it is highly absorbent as it has a large surface area. Sodium sulphate or sorbitol may be used as a cathartic.– its use is however not well established10,1. A single dose of activated charcoal without a cathartic (50gm) is enough because it is ineffective beyond 1-2 hours after consumption of the poison. 19 This may be given through a nasogastric tube in an adult who is either intubated or is fully awake and co-operative.17

b) It is a good practice to keep the urine output at the rate of 150-200 ml/hr (2-3ml/kg/hr) with attention to electrolyte balance.3

3. Neutralization (Use of specific antidotes)

a) Inj. Atropine sulphate:

Inj. Atropine sulphate is a life saving antidote. Complete and early atropinisation is an essential and simple part of early management. It reverses the cholinergic features and improves cardiac and respiratory function15

Atropinisation Protocol: There is no uniform guideline available for Atropine administration. However, according to a recent guideline which is being followed in Christian Medical College Hospital, Vellore (see Box 1), a loading dose of Atropine (as a bolus) must be initiated followed by monitoring for atropinisation until full atropinisation is achieved. The usual requirement of atropine is about 5-10 mg/hr3,10. The loading dose is followed by an infusion – this produces less fluctuation in plasma atropine concentration and makes weaning easier. The target heart rate is > 100/min on day2, > 90/min on day 3, and > 80/ min on subsequent days.10,16

After initial stabilization, patient should be assessed for the features of adequacy of atropine infusion (Table 2).7

b)Glycopyrolate: Inj. Glycopyrolate is recommended when there is copious secretion. It has less CNS penetration and may result in less CNS toxicity.11,6

c)Inj. Pralidoxime(PAM): Current WHO guidelines recommend 30mg/kg loading dose of pralidoxime over 10-20 min, followed by continuous infusion of 8-10 mg /kg per hour until clinical recovery.12,11,9,14 However, several studies failed to show benefit.

d) Antibiotics: Antibiotics are not usually indicated for OP poisoning unless there is strong suspicion of aspiration or evidence of infection.

e) Furosemide: Recommended if pulmonary edema persists, even after full atropinisation.11

f) Sedation: Agitation in OP poisoning may indicate over-atropinisation, hypoxemia or distress due to pain/ discomfort. Intubated patients need a combination of an analgesic and a sedative. Inj. Morphine and lorazepam may be used as an infusion. Haloperidol may decrease seizure threshold and not recommended unless patients are unresponsive to other drugs.

Table: 2 Features used to assess atropine adequacy (Target end- points) 12 Features of atropine toxicity
Clear chest on auscultation with no wheeze
Heart rate between > 80 beats/min

Pupils no longer pinpoint

Systolic blood pressure >80mmHg

Dry axillae

Confusion
Pyrexia

Urine retention

Bowel ileus

Hypertension

Tachycardia

Counselling: Counselling to the poisoned patients will reduce the chances of a repeat attempt at poisoning. It also enables the health care personnel to improve the quality of treatment, minimize the cost of therapy and the period of hospitalization.5 Family counselling is mandated; this helps the family members to cope with the situation and accept the patient as he is.13


Case report:

    A 27 year old male presented with alleged history of consumption of parathion along with alcohol following a quarrel at home. He had vomiting and three episodes of generalized tonic-clonic seizures lasting for 2-3 min. He was given a gastric lavage and referred for further management. In the Emergency Department his GCS score was 3/15, pulse-70/min, respiratory rate 14/min, BP-110/70 mmHg, SpO2 -80%. On examination his skin appeared to be flushed, pupils mildly dilated. The rest of the systemic examination was unremarkable. As he developed laboured breathing, emergency endotracheal intubation was done and he was connected to a ventilator. Repeated bolus doses of atropine sulphate were administered till the heart rate reached 110/min. Atropine was continued as an infusion at the rate of 10 ml/ hr.

    Since he had generalized tonic clonic seizures, he was given a loading dose of intravenous phenytoin (15 mg/kg over 30 min) and continued at 5 mg/kg in three divided doses. He was then shifted to the medical intensive care unit for further management. Blood samples were obtained for complete blood count, electrolytes, and arterial blood gas analysis. Serum pseudo cholinesterase level was 800U/L. (Reference interval 3000 to 8000 U/L & in significant poisoning usually <1000 U/L10)..

     Liver function and renal function tests were normal. Due to persistent neck muscle weakness on day 3, long term ventilation was anticipated and hence an early tracheostomy was done.

To maintain the target heart rate, (Day 1- >110/min, day 2 – 100/min, day 3 – 90/min and thereafter heart rate of at least 80/ min) atropine infusion was initiated. Bolus doses of atropine were intermittently administered when required if the heart rate went below the target rate.

Nursing interventions

We approached each of the nursing diagnoses as follows:

1. Nursing diagnosis: Ineffective airway clearance related to presence of copious secretions secondary to OP compound effects.

Expected outcome: – Airway clearance as evidenced by maintenance of SpO2at 90-100% and prevention of aspiration.

Nursing interventions: Endotracheal tube was secured, frequent suctioning was done; humidified oxygen, and salbutamol alternating with nebulization with ipratropium were administered. Atropine infusion was initiated at 10 mg /hr and tapered to 2mg on the fourth day and then discontinued. He was maintained at 45° head end elevation and was positioned laterally. Chest physiotherapy was given to mobilize the secretions.

2. Nursing diagnosis: Risk for injury related to seizure activity.

Expected outcome: –Prevention of seizures and the related injuries.

Nursing implementations: Periodic and regular assessment of GCS score administration of antiepileptic drugs were done. –Additional precautions were initiated with provision of side railed cot, and positioning of patient (left lateral with head elevation at 45 degree). Patient was closely observed.

3. Nursing diagnosis: Decreased cardiac output related to cholinergic effects of OP poisoning.

Expected outcome: Maintenance of cardiac output as evidenced by mean arterial pressure (MAP)>70mm of Hg &heart rate>110/min..

Nursing interventions: Close monitoring of hemodynamic status (blood pressure, MAP and heart rate) . MAP was maintained between 70-80 mmHg. Atropine was administered to maintain the target heart rate [ Day 1: 110/min; Day 2: 100/min; Day 3: 90/min]. Adequate intravenous fluids were administered to prevent dehydration due to salivation & diarrhea.

4. Nursing diagnosis: Risk of fluid volume deficit related to effects of OP poisoning. .

Expected outcome: Normal hydration status.

Nursing interventions: Intravenous fluids were administered as per plan and urine output was monitored. In addition to intravenous fluids, nasogastric feeds were initiated . A cumulative fluid balance sheet was maintained.

5. Nursing diagnosis: Nutritional imbalance related to ‘Nil per oral’ (NPO) status secondary to risk of aspiration.

Expected outcome: Achieve nutrition balance as evidenced by serum Albumin of3.5-5g/dl%, Hb>10g%.

Nursing interventions: Nasogastric aspirations(q4h) were performed for two days to check the gastrointestinal function. Clear fluids were started on day 2 followed by formula feeds (35- 45 kcal/kg/day) with probiotics (q6h).On day 20, tracheostomy was closed and oral feeds were initiated with soft solid followed by normal diet.

6. Nursing diagnosis: Ineffective coping of family: related to guilt, negative feelings and financial crises.

Expected outcome: Enhance the coping ability of the family.

Nursing interventions: Open communication was encouraged among the family members and family counselling was organized. The family members were counselled so they could understand the prognosis by the physician. Arrangements were made for their spiritual comfort.

7. Nursing diagnosis: Risk of complications such as pressure sores, IMS, OPIDP, and ventilator associated pneumonia (VAP) related to poisoning effects and prolonged mechanical ventilation.

Expected outcome: Prevention of complications.

Nursing interventions:

a) Aspiration: The head end of the bed was elevated to 30-45 degree, change of position was carried out before feeds and continuous feeds were given using feed pump which prevented further aspiration.

b) IMS: Assessment was done for breathing pattern & neck muscle weakness for 96 h. Muscle power & reflexes were monitored.

c) OPIDP: The patient was monitored for persistent & delayed onset muscle weakness and seizures. Assessment was done for re-emergence of SLUDGE symptoms.

d) VAP: Standard precautions were followed: The patient was assessed for signs of infection, breathing pattern & characteristics of secretions were monitored; tubing of the ventilator was changed as frequently as possible if sedimented with secretions and suctioning was done as required under aseptic techniques. Adequate chest physiotherapy and nebulisations were given to mobilize the secretions. Progress was monitored using chest X-rays.

e) Pressure sores: Skin integrity was maintained by back care and 2hourly change of position.

Evaluation: Patency of the airway was maintained with regular suctioning and optimal positioning. The targeted heart rate was achieved with administration of atropine. Close monitoring, observation, and timely interventions enabled recovery. Meticulous oral care, nebulization, chest physiotherapy and aseptic techniques were strictly adhered to. He did not develop VAP despite being hospitalized for 24 days. He recovered, was extubated and was referred to a psychiatrist for further counselling.

CONCLUSION:
Poisoning is a common cause of hospital admissions. Caring of patients with OP poisoning is a challenge for nurses. Assessment and prevention of complications is one of the vital roles of the nurse. Appropriate, evidenced based practice will enhance quick recovery, reduce morbidity and mortality. Nurses must ensure that both patients and family members receive counselling, to cope and live in the community.

References:

1. Cherian M A, Roshini C, Peter J V, Cherian A M. Oximes in organophosphorus poisoning. Indian J Crit Care Med; 9:155-163 (2005).

2. Dhanya S P, Dhanya TH, Nair BLC Hema CG. (2009) A Retrospective Analysis of the pattern of poisoning in patients admitted to Medical College hospital, Calicut Medical Journal; 7 :(2) : 3

3. John, G. “Essentials of Critical Care. 8thed (2011), Division of critical care, Christian Medical College, Vellore, India, PP33-1to 33-7.

4. Thundiyil, Stober, Bessbelli, Pronczuk. (2008) Acute pesticide poisoning: a proposed classification 2, Bulletin of the World Health Organisation 86 :(3) pg 161.Retrieved from www.who.int/bulletin/volumes/86/3/07-041814/en/

5. Rajanandh M.G, Santhosh.S, Ramasamy. C, (2013) Prospective analysis of poisoning cases in a super specialty Hospital in India. Journal of Pharmacology and Toxicology 8(2): 60-66.

6. V. Palaniappen. Current Concepts in the Management of Organophosphorus Compound Poisoning available at http://www.apiindia.org/medicine_update_2013/chap95.pdf

7. Jayasinghe, S. S., Fernando, A., Pathirana, K. D., & Gunasinghe, K. K. (2009). Atropine therapy in acute anticholinesterase (Organophosphorus/carbamate) poisoning; adherence to current guidelines. Galle Medical Journal, 14(1), 26–30.www.sljol.info/index.php/GMJ/article/view/1168

8. Kumar, S. V., Fareedullah, M., Sudhakar, Y., Venkateswarlu, B, Kumar,E.A(2010). Current review on organophosphorus poisoning.Arch ApplSci Res, 2(4), 199–215.www.scholarresearchlibrary.com

9. Seabury.W. Robert, Pharm, D. Ross Sulivann. The Newyork State Poison centre. A Quarterly Publication.Vol XVIII No.1.www.upstatepoison.org

10. David.S, (2012) Hand book of Emergency medicine.8th edition. Elsivier Noida, New Delhi.

11. Sundaray N.K, Ratheesh Kumar .J. (2010), Organophosphorous poisoning: Current management guidelines Medicine update volume 20. (5):2 pp420-424

12. Eddleston, M., Dawson, A., Karalliedde, L., Dissanayake, W., Hittarage, A., 3:9Azher, S., & Buckley, N. A. (2004). Early management after self-poisoning with an organophosphorus or carbamate pesticide – a treatment protocol for junior doctors.Critical Care, 8(6), R391–R397.doi:10.1186/cc2953 http://ccforum.com/content/8/6/R391

13. Mishra et al.,(2012)Epidemiological study of Medicolegal organophosphorous poisioning in central region of Nepal. Forensic Research ( 3):9.http://dx.doi.org/10.4172/2157-7145.1000167

14. Shivakumar, K. R. (2006). Organophosphorus poisoning: a study on the effectiveness of therapy with oximes. The Journal of the Association of Physicians of India, 54, 250–1.

15. Organophosphate Toxicity. (2013). Retrieved from http://emedicine.medscape.com/article/167726-overview

16. Kenneth Kartz D & Daniel B. E., (2009) Toxicity, Organophosphate. Last Updated May 13.

17. Management of acute organophosphorus pesticide poisoning, BMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39134.566979.BE (Published 22 March 2007)Cite this as: BMJ 2007;334:629

18. Tafuri, John et al. Organophosphate poisoning. Annals of Emergency Medicine, Volume 16, Issue 2, 193 – 202

19.
Darren M Roberts, Cynthia K Aaron, Management of acute organophosphorus pesticide poisoning, BMJ 2007; 334