Acute Disulfiram Poisoning in a Child: A Case Report and Review of Literature.

AIM: To determine the significance of acute disulfiram poisoning in pediatric population. BACKGROUND: Disulfiram poisoning in children is uncommon, can occur in children who have ingested large amount of drug because of careless and unsafe storage. Only few cases have been reported in literature. Although well tolerated by most patients, severe toxic side effects have been also reported including hepatitis, encephalopathy, psychosis, optic, and peripheral neuropathy. CASE DESCRIPTION: This is a case report of disulfiram toxicity in a 4.5-year girl who ingested 4-5 tablets of disulfiram (approximately 1-1.25 g) accidentally and presented with hypoglycemia and encephalopathy. After initial stabilization in emergency room, the child was shifted to intensive care unit (ICU) where the child was managed conservatively. Blood sugars normalized after 8 hours of admission. Magnetic resonance imaging (MRI) brain showed bilateral globus pallidus hyperintensity in T2-weighted (T2W) and diffusion-weighted (DW) images and hypointensity in T1-weighted (T1W) images including diffusion restriction. CONCLUSION: Acute disulfiram poisoning can occur in children who have ingested large amount of drug because of unsafe storage. It can lead to hepatitis, encephalopathy, psychosis, optic, and peripheral neuropathy. Mainstay of treatment is supportive care, airway protection, oxygen, and dextrose-containing intravenous fluid should be given. CLINICAL SIGNIFICANCE: Acute disulfiram poisoning should be an important differential in diagnosis of any child presenting with idiopathic encephalopathy along with extrapyramidal symptoms with basal ganglia signal changes in MRI of brain in a previously healthy child. HOW TO CITE THIS ARTICLE: Bhalla K, Mittal K, Gupta A, Nehra D. Acute Disulfiram Poisoning in a Child: A Case Report and Review of Literature. Indian J Crit Care Med 2020;24(3):203-205.

The Transport Medicine Society Consensus Guidelines for the Transport of Suspected or Confirmed COVID-19 Patients.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes coronavirus disease 2019 (COVID-19) and has been declared as a pandemic. COVID-19 patients may require transport for diagnostic or therapeutic purposes intra- or interhospital or transport from an outside hospital to a healthcare facility. Transport of critically ill or infectious patients is always challenging and involves the integration of various tasks and manpower. The adverse events have been attributed to various factors such as a multidisciplinary team and lack of appropriate communication among team members, absence of equipment, or failure during transport, apart from physiological alteration inherent to the disease of the patient. The transport of COVID-19 patients carries an additional risk of not only the disease itself but also due to the risk of its transmission to the transport team. The human-to-human transmission of the virus can occur via respiratory droplets. So, the person involved in the transport of such patients shall be at risk and warrants appropriate steps for their safety. Appropriate planning by a well-trained transport team is an essence for the safe transport of the suspected or confirmed COVID-19 patients. The Transport Medicine Society guidelines present consensus guidelines for the safe transport of COVID-19 patients. DISCLAIMER: These consensus guidelines are applicable for the safe transport of suspected or confirmed COVID-19 adult patients. These recommendations should be used in conjunction with medical management guidelines and advisories related to COVID-19. These recommendations should be adapted to the local policies prevalent at the workplace and also per agreement among the hospitals for transport (agreement between referring and receiving facilities). With the emergence of new scientific evidence, these guidelines may require modification. HOW TO CITE THIS ARTICLE: Munjal M, Ahmed SM, Garg R, Das S, Chatterjee N, Mittal K, et al. The Transport Medicine Society Consensus Guidelines for the Transport of Suspected or Confirmed COVID-19 Patients. Indian J Crit Care Med 2020;24(9):763-770.

Indian Society of Critical Care Medicine Experts Committee Consensus Statement on ICU Planning and Designing, 2020.

BACKGROUND: Indian Society of Critical Care Medicine (ISCCM) guidelines on Planning and Designing Intensive care (ICU) were first developed in 2001 and later updated in 2007. These guidelines were adopted in India, many developing Nations and major Institutions including NABH. Various international professional bodies in critical care have their own position papers and guidelines on planning and designing of ICUs; being the professional body of intensivists in India ISCCM therefore addresses the subject in contemporary context relevant to our clinical practice, its variability according to specialty and subspecialty, quality, resource limitation, size and location of the institution. Aim: To have a consensus document reflecting the philosophy of ISCCM to deliver safe & quality Critical Care in India, taking into consideration the requirement of regulatory agencies (national & international) and need of people at large, including promotion of training, education and skill upgradation. It also aiming to promote leadership and development and managerial skill among the critical care team. Material and Methods: Extensive review of literature including search of databases in English language, resources of regulatory bodies, guidelines and recommendations of international critical care societies. National Survey of ISCCM members and experts to understand their viewpoints on respective issues. Visiting of different types and levels of ICUs by team members to understand prevailing practices, aspiration and Challenges. Several face to face meetings of the expert committee members in big and small groups with extensive discussions, presentations, brain storming and development of initial consensus draft. Discussion on draft through video conferencing, phone calls, Emails circulations, one to one discussion Result: Based upon extensive review, survey and input of experts' ICUs were categorized in to three levels suitable in Indian setting. Level III ICUs further divided into sub category A and B. Recommendations were grouped in to structure, equipment and services of ICU with consideration of variation in level of ICU of different category of hospitals. Conclusion: This paper summarizes consensus statement of various aspect of ICU planning and design. Defined mandatory and desirable standards of all level of ICUs and made recommendations regarding structure and layout of ICUs. Definition of intensive care and intensivist, planning for strength of ICU and requirement of manpower were also described. HOW TO CITE THIS ARTICLE: Rungta N, Zirpe KG, Dixit SB, Mehta Y, Chaudhry D, Govil D, et al. Indian Society of Critical Care Medicine Experts Committee Consensus Statement on ICU Planning and Designing, 2020. Indian J Crit Care Med 2020;24(Suppl 1):S43-S60.

Aluminum phosphide (celphos) poisoning in children: A 5-year experience in a tertiary care hospital from northern India.

BACKGROUND: Aluminum phosphide (ALP) (celphos) is an agricultural pesticide commonly implicated in poisoning. Literature pertaining to the clinical manifestations and treatment outcome of its poisoning among children is limited. MATERIALS AND METHODS: A retrospective chart review was conducted of the medical records of 30 children aged less than 14 years admitted to pediatric intensive care unit (PICU) of a tertiary care hospital in northern India. Demographic, clinical, and laboratory parameters were recorded. The outcome was categorized into "survivors" and "nonsurvivors." RESULTS: The Mean (SD) age of the enrolled children [19 males (63.3%)] was 8.55 (3.07) years. Among the 30 children, 14 (46.67%) were nonsurvivors and the rest 16 (53.33%) were survivors. Nonsurvivors had ingested significantly higher doses of ALP (P < 0.001), and showed higher time lag to PICU transfer (P 0.031), presence of abnormal radiological findings on chest skiagram (P = 0.007), and a higher Pediatric Risk of Mortality (PRISM) III score (P < 0.001) at admission. Use of magnesium sulfate was associated significantly with survival [odds ratio (OR) (95% CI): 0.11 (0.02-0.66); P 0.016]. CONCLUSION: The present study highlights that survival among children with ALP poisoning is predicted by dose of ALP ingestion, time lag to medical attention, and higher PRISM score at admission. Use of magnesium sulfate could be associated with better survival among them.

Clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock from Rohtak, Haryana: A prospective observational study.

BACKGROUND: Information regarding early predictive factors for mortality and morbidity in sepsis is limited from developing countries. METHODS: A prospective observational study was conducted to determine the clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock. Children aged 1 month to 14 years admitted to a tertiary care pediatric intensive care unit (PICU) with a diagnosis of sepsis, severe sepsis, or septic shock were enrolled in the study. Hemodynamic and laboratory parameters which discriminate survivors from nonsurvivors were evaluated. RESULTS: A total of 50 patients (30 [60%] males) were enrolled in the study, of whom 21 (42%) were discharged (survivors) and rest 29 (58%) expired (nonsurvivor). Median (interquartile range) age of enrolled patients were 18 (6, 60) months. Mortality was not significantly predicted individually by any factor including age (odds ratio [OR] [95% confidence interval [CI]]: 0.96 [0.91-1.01], P = 0.17), duration of PICU stay (OR [95% CI]: 1.18 [0.99-1.25], P = 0.054), time lag to PICU transfer (OR [95% CI]: 1.02 [0.93-1.12], P = 0.63), Pediatric Risk of Mortality (PRISM) score at admission (OR [95% CI]: 0.71 [0.47-1.04], P = 0.07) and number of organ dysfunction (OR [95% CI]: 0.03 [0.01-1.53], P = 0.08). CONCLUSION: Mortality among children with sepsis, severe sepsis, and septic shock were not predicted by any individual factors including the time lag to PICU transfer, duration of PICU stay, presence of multiorgan dysfunction, and PRISM score at admission.

Acute Cerebellitis as a Rare Treatable Cause of Obstructive Hydrocephalus.

Acute cerebellitis commonly presents as acute ataxia in children. Rarely, it can result in obstructive hydrocephalus. We report a 10-year-old boy with Mycoplasma infection-associated acute cerebellitis and obstructive hydrocephalus that responded well to conservative management with no residual neurological deficit. Wide recognition of this treatable clinical entity among neurologist would avert unnecessary investigations and ensure rationale management.

Acute hemorrhagic edema of infancy.

We describe an 18 month old girl with acute hemorrhagic edema of infancy, with palpable erythemaous purpuric rash on face, upper and lower limbs and ear lobules associated with edema and leukocytoclastic vasculitis. There were no systemic complications.

Effect of vitamin D supplementation on moderate to severe bronchial asthma.

OBJECTIVE: To define the therapeutic role of vitamin D in children with moderate to severe bronchial asthma as an adjunct to standard treatment. METHODS: Hundred asthmatic children of either sex, attending the respiratory and asthma clinic were enroled in the study. Diagnosis was made on the basis of history and clinical examination. Randomization was done using sealed opaque envelop method. In addition to the treatment as per GINA guidelines, one group received oral vitamin D3 (Cholecalciferol) 60,000 IU per month for 6 mo and the other group received placebo powder in the form of glucose sachet with a double blinded design. Monthly follow up of every patient was done and during every visit change in severity, level of control, Peak expiratory flow rate (PEFR), steroid dosage, number of exacerbations and number of emergency visits were assessed. RESULTS: Monthly doses of 60,000 IU vitamin D significantly reduced the number of exacerbations as compared to placebo (p = 0.011). PEFR significantly increased in the treatment group (p = 0.000). Monthly doses of vitamin D significantly reduced the requirement of steroids (p = 0.013) and emergency visits (p = 0.015). Control of asthma was achieved earlier in patients who received monthly vitamin D. Vitamin D significantly reduced the level of severity of asthma patients over 6 mo of treatment (p = 0.016). CONCLUSIONS: Vitamin D has a definite role in the management of moderate to severe persistent bronchial asthma as an adjunct to standard treatment.

Evaluation of Integrated Management of Neonatal and Childhood Illness (IMNCI) algorithm for diagnosis and referral in under-five children.

A prospective observational study was conducted on 500 children to evaluate the Integrated Management of Neonatal and Childhood Illnesses (IMNCI) algorithm for diagnosis and referral of children aged 0-59 mo. IMNCI algorithm performed well in diagnosis [except sepsis in 0-7 d (p < 0.01) and malaria in 2-59 mo (p < 0.01)] and referral of under five illnesses. The proportion of children with the mismatch between 'IMNCI' diagnosis and 'Gold Standard' diagnosis were highest (38.7 %) among children 0-7 d of age. The authors conclude that IMNCI algorithm in young children has good sensitivity for referring children with severe illnesses and is a good tool for diagnosis of most of childhood illnesses in under-five children.

Predictors of stress among parents in pediatric intensive care unit: a prospective observational study.

OBJECTIVE: To determine the sociodemographic and clinical factors leading to stress among parents whose children are admitted in pediatric intensive care unit (PICU). METHODS: A prospective observational study was conducted in PICU of a tertiary care hospital of north India. Parents of children admitted to PICU for at least 48 h duration were eligible for participation. At the end of 48 h, parental stress was assessed using parental stress scale (PSS:PICU) questionnaire which was administered to the parents. Baseline demographic and clinical parameters of children admitted to PICU were recorded. The parental stress was compared with demographic and clinical characteristics of children using appropriate statistical methods. RESULTS: A total of 49 parents were finally eligible for participation. Mean (SD) parental stress scores was highest in domains of procedures [1.52 (0.66)] and behavior and emotional [1.32 (0.42)] subscales. Mean (SD) total parental stress score among intubated children [1.31 (0.25)] was significantly more than among non intubated children [0.97 (0.26)] (p < 0.001). However, parental stress score were comparable in terms of gender (p = 0.15) and socioeconomic status (p = 0.32). On subscale analysis, it was found that professional communication is a significant stressor in age groups 0-12 mo [0.61(0.41)] (p = 0.02). It was observed that parents of intubated children were significantly stressed by the physical appearance of their children (p < 0.001), procedures performed on them (p = 0.008) and impairment in parental role (p = 0.002). Total parental stress score had a positive correlation with PRISM score (r = 0.308). CONCLUSIONS: Indian parents are stressed maximally with environment of PICU. Factor leading to parental stress was intubation status of the child and was not affected by gender or socio demographic profile of the parents.

Unusual presentation of Sturge-Weber syndrome: Progressive megalencephaly with bilateral cutaneous and cortical involvement.

The Sturge Weber syndrome is characterized by developmental delay, seizures in infancy, unilateral cutaneous lesions with ipsilateral leptomeningeal enhancement. We report an unusual presentation of Sturge Weber syndrome with bilateral port wine nevus on the trunk and face along with bilateral cortical involvement in a developmentally normal child with progressive megalencephaly.

Intravenous diazepam, midazolam and lorazepam in acute seizure control.

OBJECTIVE: To evaluate the safety and efficacy of three benzodiazepine drugs: Lorazepam, Midazolam and Diazepam, when given parenterally in the control of acute seizure. METHODS: One hundred and twenty children of either sex in the age group 6 month to 14 years brought convulsing to the pediatric emergency services, were enrolled in the study. These were randomised to three equal groups of 40 patients each; Group A-received diazepam, Group B-received midazolam, Group C-received lorazepam. End of seizure episode (clinically) was defined as cessation of visible epileptic phenomenon or return of purposeful response to external stimuli within 15 min of drug administration. A stopwatch was used to measure various time intervals accurately. The patient's vitals were monitored and recorded in a predesigned performa. The primary outcome was the time to seizure cessation and secondary outcome was the side effects of the drugs. Data obtained was analysed statistically using student's t-test and chi-square test. RESULTS: Mean duration to clinical seizure cessation was comparable among the three groups. For diazepam group it was 84.94 ± 38.56 s, for midazolam group it was 92.69 ± 25.97 s, for lorazepam group it was 91.12 ± 23.58 s. Number of patients with any abnormality in seizure cessation were significantly higher in diazepam group [11/40 (27.5%)] when compared to the midazolam [4/40 (10%)] and lorazepam group [2/40 (5%)]. Number of patients requiring 2nd dose to control seizures was significantly higher [4/40 (10%)] in diazepam group when compared to lorazepam group [0/40 (0%)] but diazepam and midazolam and midazolam and lorazepam were comparable in this aspect.All the three drugs were comparable in terms of side effects except excessive somnolence which was significantly higher in diazepam group. CONCLUSIONS: All the three groups were comparable in terms of time to clinical seizure cessation, seizure recurrence and uncontrolled seizures after drug administration. However, number of patients requiring second dose to control seizures were significantly higher in diazepam group when compared to lorazepam group. Excessive somnolence and sedation occurred more frequently with diazepam.

Local skin reaction following an accidental injection from a BCG vaccine in a healthcare worker.

Exposure to blood-borne pathogens from sharp injuries continue to pose a significant risk to healthcare workers (HCW). The number of sharps injuries sustained by HCW is still unclear, primarily due to under-reporting of events. Healthcare professionals are at risk of sustaining such injuries from hollow-bore needles. Sharps injuries are associated with risk of infection with blood-borne pathogens such as human immunodeficiency virus (HIV), hepatitis B virus (HBV) hepatitis C virus (HCV) and other live organisms. Here we are reporting a case of an adverse reaction in a HCW due to an accidental sharps injury by a needle used to administer the Bacillus Calmittee Gurien (BCG) vaccine.