Introduction Levothyroxine (T4) overdose is not frequently encountered and for the clinical signs to materialize, the ingested dose, the rate of conversion of T4 to T3 and chronicity of overdose can be held accountable. Case report A 29-year-old female, a known case of hypothyroidism and adjustment disorder, under levothyroxine, propranolol and sertraline, intentionally ingested 2.5 mg of levothyroxine but remained asymptomatic with sudden surge in T4 in initial hours of ingestion which gradually started declining along with reciprocal change in TSH. However, the change in T3 was almost negligible. Discussion T3, the active thyroid hormone, when in excess accounts for toxic effects. The duration during physiological process of deiodination and half life of hormone correlates with onset and duration of symptoms. Propranolol which blocks peripheral conversion of T4 to T3 and sertraline which is also reported to reduce the efficacy of levothyroxine, which is evident from low T3 in thyroid profile, must have led to patient being asymptomatic despite lack of early gastric decontamination. Conclusion Levothyroxine overdose up to 4mg/day may be asymptomatic but in patients with concomitant neurotic or psychiatric illness, who intentionally take it, are also put on drugs like sertraline and propranolol, the effects of which on thyroid hormones must be contemplated for possible explanation of being asymptomatic.

Burst fracture of C5 with traumatic anterior spondyloptosis of C6 and posterior spondylolisthesis of C4 vertebra is an exceedingly rare high energy injury. Treatment includes decompression, reduction, stabilization, and fusion via anterior or posterior or combined anterior-posterior approach with or without prior traction. We report this rare subaxial cervical spine injury associated with quadriplegia managed with combined anterior and posterior instrumented fusion. A multidisciplinary approach with preoperative assessment and planning is crucial in managing cervical spine injury. Immediate postoperative critical care support, rehabilitation, and dedicated nursing care are required for a favorable outcome in traumatic quadriplegia.

Introduction: Central vein catheterization can be introduced in subclavian vein (SCV), internal jugular vein or femoral vein for volume resuscitation and invasive monitoring technique. Due to anatomical advantage and lesser risk of infection subclavian vein is preferred. Either supraclavicular (SC) or infraclavicular (IC) approach could be used for subclavian vein catheterization. The aim of the study was to compare SC and IC approach in ease of catheterization of SCV and record the complications present if any. Methods and materials: This was a hospital based comparative, interventional study conducted from November 2016 to October 2017 in Operation Theater in Bir Hospital. In this study, 70 patients for elective surgical cases meeting the inclusion criteria were randomly enrolled. Then samples were equally divided by lottery into either supraclavicular or infraclavicular approach groups. The Access time, cannulation success rate, attempts made for successful cannulation of vein, easy insertion of catheter and guide wire, approximate inserted length of catheter and associated complications in both groups were recorded. Data was entered in statistical software SPSS 16. Chi-square test was used. P value < 0.05 was considered significant. Results: The mean access time in group SC for SCV catheterization was 2.12 ± 0.81 min compared to 2.83 ± 0.99 min in group IC (p-value= 0.002). The overall success rate in catheterization of the right SCV using SC approach (34 / 35) was better as compared with group IC (33 / 35) using IC approach. First successful attempt in the SC group was 74.28% as compared with 57.14% in the IC group. Conclusion: The SC approach of SCV catheterization can be considered alternative to IC approach in terms of landmark accessibility, success rate and rate of complications.

Hydatid disease is mainly caused by infection with the larval stage of the dog tapeworm Echinococcus granulosus. Infestation by hydatid disease in humans most commonly occurs in the liver (55- 70%) followed by the lung (18- 35%); the two organs can be affected simultaneously in about 5-13% of cases. Hydatid disease is endemic in many parts of the world, including India, Africa, South America, New Zealand, Australia, Turkey and Southern Europe. Hydatid disease is more prevalent in rural areas where there is a closer contact between people and dogs and various domestic animals which act as intermediate vectors. Hydatid disease remains frequent in JUMLA. In Karnali Academy of Health sciences 26 surgeries for hydatid cyst was done between 2016-2018. Hydatid cyst of liver in a child is a challenge to anesthesiologist in a remote city such as Jumla. Anaphylactic and anaphylactoid reactions during anesthesia are a major cause of concern for anesthesiologists. During the perioperative period, any symptomatology relating to sudden onset hemodynamic collapse or increased airway pressures during certain surgical procedures should raise suspicion of anaphylaxis. We report a case of intraoperative sudden anaphylaxis and its management.

Background: Cardiopulmonary resuscitation success rates depend on the knowledge and skills of Adult basic life support (BLS) and advanced life support. The objective of the study was to find the level of awareness on BLS and skills among health personnel working in different departments of a rural teaching hospital. Methods: This descriptive cross-sectional study was conducted in a tertiary care hospital of Karnali Academy of Health Sciences, Jumla, Nepal. The awareness level about BLS was assessed using a structured questionnaire. Health personnel’s previous exposure to BLS and the inclusion of BLS in their curriculum was also assessed. Results: Among 91 participants,74% (n=67) heard about BLS ,64% (n=58)have seen performing and 25%(n=23) have performed CPR. Only 8%(n=7) attended a workshop on BLS. 43% (n=39) answered 100 and 46%(n=42) answered 30 compression per minute in adult during CPR.71%(n=65) knew the ratio of chest compression to breath in adults. Only 41%(n=37) identified anatomy/area  mid-chest for chest compression. Only 40%(n=36)  are familiar to the Heimlich maneuver and  5.5%(n=5) were aware of the sequence of BLS which is Head tilt, chin lift, check the pulse. Seventy-eight percent (n=71) responded that BLS training should be a part of the medical curriculum. Mean awareness of general medicine is significantly lower than the other two groups (P<0.001). Conclusion: The level of awareness and knowledge regarding BLS is different among health personnel. Hospital staff and nursing students had better knowledge regarding BLS than general medicine students.