We have studied the sedation achieved with a mixture of midazolam (0.56 mg/kg-1) and ketamine (5 mg/kg-1) administered nasally in 30 children weighing less than 16 kg undergoing computerised tomography. Assessment was two fold using a visual analogue scale; the radiologist/radiographer rated the exam from "failed examination" to "perfect working conditions" while the anesthetist's assessment ranged from "poor sedation" to "perfect sedation with clinical well being". This new method proved to be effective alone in 83% of the cases and there were no complications. The rapid onset obtained after intranasal midazolam and ketamine offers advantages over orally or rectally administered drugs. The absence of respiratory depression and oxygen desaturation suggests that this technique is safe and efficient in the CT room with its particular working conditions.

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Background:Pneumocephalus is the presence of air in the cranial cavity. When this intracranial air causes increased intracranial pressure and leads to neurological deterioration, it is known as tension pneumocephalus (TP). TP can be a major life-threatening postoperative complication, especially after evacuation of chronic subdural hematoma. We report a case of TP after evacuation of chronic subdural hematoma and review the literature.Case Description:A 70-year-old man developed right-sided weakness after being admitted with minor head trauma a few weeks earlier. He was found to have a chronic subdural hematoma and underwent burr-hole evacuation. On day 3, he suddenly deteriorated and needed intubation and ventilation. Computerized tomography (CT) of the brain showed typical Mount Fuji’s sign due to TP. Immediately, 20-30 mL of air was aspirated from the intracranial fossa, and a catheter drain was inserted. The patient became fully awake after few hours and was extubated successfully. The drain was removed on day 5, and he was transferred to the ward before being discharged home.Conclusion:TP after evacuation of a chronic subdural hematoma is a neurosurgical emergency and needs immediate resuscitation and therapy; hence it is of vital importance that all acute-care physicians, intensivists and neurosurgeons be aware of this clinical emergency.

Three siblings from consanguineous parents, originating from Tanzania, presented with symptoms of complete or partial agenesis of the corpus callosum. Two males had in addition a sensorimotor neuropathy, moderate mental retardation and skeletal dysmorphism (Andermann syndrome). A study of sural nerve biopsies revealed thickening of the perineurium and reduction in the number of large myelinated fibres with axonal degeneration. Muscle biopsies showed neurogenic atrophy. The Andermann syndrome is autosomal recessive and almost exclusively confined to the region of Charlevoix and Saguenay-Lac-St-Jean (Quebec, Canada). Moreover in families with the Andermann syndrome, no siblings with only agenesis of the corpus callosum have been described.

Dialysis disequilibrium syndrome (DDS) is a central nervous system disorder, which occurs during hemodialysis (HD) or within 24 h following the first HD. DDS commonly occurs in patients suffering from end-stage renal failure undergoing HD for the first time. In a critically ill patient suffering from severe sepsis or septic shock, the combined effects of post-HD brain edema and changes in the brain due to septic encephalopathy, may become amplified leading to DDS. Here we report 2 cases with acute renal failure (ARF), undergoing HD for more than a week and being ventilated and who developed DDS. DDS might have contributed to the sudden deterioration and death in these septic patients. The first case was a 31-year-old male, involved in a motor vehicle accident and had a severe abdominal injury. Underwent laparotomy and hemostasis was achieved. On day 4, the patient developed hemorrhagic shock associated with ARF, which prompted daily HD. On day 8, he went into septic shock. On day 16, 1 h after his daily HD, he became unresponsive and his pupils became dilated and fixed and he expired 2 days later. The second case was a young male who suffered severe abdominal and chest injury after a fall from a height. He developed ARF on day 3 and required HD. On day 9, he had septic shock. Three days later, during his daily HD, he became unconscious and his pupils were not reacting to light and the patient died on day 12.Conclusion: In patients with severe sepsis/septic shock, DDS may occur even after repeated sessions of HD. The acute care physicians, intensivists, and nephrologists should be aware of the risks of DDS.

C. difficile colitis can cause intra-abdominal hypertension (IAH) and ACS. Rapid diagnosis, early aggressive supportive care, metronidazole and prokinetics are necessary to lower the morbidity and mortality of C. difficile colitis associated with IAH and ACS.

2 Yamaguchi T. A colour atlas of clinical parasitology. 1st Ed.

The case is reported of a 30-year-old multigravida, with insignificant history and stable vital signs, admitted to the labour room for normal vaginal delivery of twins. She received combined spinal epidural analgesia (bupivacaine plus fentanyl) for 3 h. Following uneventful delivery she received 0.2 mg methylergonovine maleate, intramuscularly. Nausea and vomiting occurred 70 min after placenta delivery, heart rate decreased, arterial blood pressure increased and there was chest pain. After excluding cardiac ischaemia, 0.5 mg atropine sulphate was administered intravenously. Chest pain improved but heart rate and blood pressure increased more than expected. The patient had mild headache and nausea, and antiemetic 4 mg ondansetron was given intravenously. Continuous monitoring for 4 h showed spontaneous chest pain relief and blood pressure improvement. In conclusion, serious delayed side-effects arising from methylergonovine maleate can occur in young, normal patients and close monitoring is required. Intravenous atropine sulphate following methylergonovine maleate administration may lead to severe hypertension and tachycardia.