Ventilator-associated pneumonia (VAP) is the most common infection in mechanically ventilated patients, and carries the highest mortality. An early diagnosis and definitive management not only reduces the overall mortality, but also brings down the burden of health care to the patient by reducing the cost, length of Intensive Care Unit (ICU) stay, duration of mechanical ventilation, and so on. Out of the various scoring systems, the Clinical Pulmonary Infection Score (CPIS) calculation for VAP has a good sensitivity (72%) and specificity (85%) and the targeted antibiotic therapy in the appropriate dosage is found to be more beneficial than empirical treatment. Although controversies persist on several issues, preventive strategies like head elevation by 30 degrees, cuff pressure monitoring, avoidance of sedatives and muscle relaxants, and so on, have been found to reduce the occurrence of VAP.

Liver diseases in pregnancy although rare but they can seriously affect mother and fetus. Signs and symptoms are often not specific and consist of jaundice, nausea, vomiting, and abdominal pain.Although any type of liver disease can develop during pregnancy or pregnancy may occur in a patient already having chronic liver disease. All liver diseases with pregnancy can lead to increased maternal and fetal morbidity and mortality. It is difficult to identify features of liver disease in pregnant women because of physiological changes. Physiological changes of normal pregnancy can be confounding with that of sign and symptoms of liver diseases.Telangiectasia or spider angiomas, palmar erythema, increased alkaline phosphatase due to placental secretion, hypoalbuminemia due to hemodilution. These normal alterations mimic physiological changes in patients with decompensated chronic liver disease.Besides all these pathological changes however, blood flow to the liver remains constant and the liver usually remains impalpable during pregnancy. The diagnosis of liver disease in pregnancy is challenging and relies on laboratory investigations. The underlying disorder can have a significant effect on morbidity and mortality in both mother and fetus, and a diagnostic workup should be initiated promptly.If we see the spectrum of liver disease in pregnancy, in mild form there occur increase in liver enzymes to severe form, where liver failure affecting the entire system or maternal mortality and morbidity. It can not only complicate mother's life but also poses burden of life of fetus to growth restriction. Most of the times termination is only answer to save life of mother but sometimes early detection of diseases, preventive measures and available active treatment is helpful for both of the life. Extreme vigilance in recognizing physical and laboratory abnormalities in pregnancy is a prerequisite for an accurate diagnosis. This could lead to a timely intervention and successful outcome.

The gap between the developed and developing nations with regards to maternal mortality and morbidity may have narrowed but still a lot of dedicated work is required to bridge these differences. Obstetrical haemorrhage is the leading cause of maternal deaths in these developing nations especially in India. The most common causes of this fatal haemorrhage are the placental abnormalities which rarely get detected before delivery. Numerous factors have been incremental in the causation of this abnormal placental implantation with resultant complications. The present article is an attempt to review possible predictors of abnormal placental implantation. Also, a genuine attempt has been made to enumerate possible measures to identify the predictors of abnormal placentation during early pregnancy and their suitable prevention and management.

Research Question: What are the various injuries in road traffic crash cases? Objectives: To study various non-fatal injuries in road traffic crash cases. Study Design: Hospital based Descriptive study. Study Population: The study population comprised of 401 consecutive cases of non- fatal injuries involved in road traffic crashes and reported at Indira Gandhi Medical College hospital, Shimla. Study Period : 1 ^st June 2005 to 31 ^st May 2006. Study Variables : Demographic characteristics of the victims, pattern of injuries and hospital stay of the victims. Types of crashes, time, day and month of crashes, vehicles involved in crashes, use of protective gear etc. Statistical Analysis : Percentages, Proportions. Results : 73% of the injured victims were young between 20-49yrs, male to female ratio being 5.3:1.Employees (34.7%) and occupants of transport vehicles (45.9%) constituted the maximum number of the victims. Major injuries (fractures and abd. injuries) were reported in 53.4% of the victims and fractures of lower limb were the commonest of the injuries (26.3%). Use of seat-belt was found to be alarmingly low (14.3%) amongst the four- wheeler users and its non-use was found to be significantly associated with the major injuries. Helmet was used by 36 cases (66.7%) out of total of 54 users of motorized two-wheelers at the time of crash. Human error was the most reported cause of crash (82%) and the most common mode of crash was skidding and/rolling down (55%).23.1% of the drivers were reported to have consumed alcohol at the time of crash.

Background: Obesity is endemic in the United States and obese patients are at increased risk of thromboembolism but little data are available for dosing unfractionated heparin (UFH). We evaluated the relationship between obesity and UFH efficacy during critical illness by examining UFH infusions in non-obese, obese, and morbidly obese critically ill patients. Materials and Methods: Retrospective review of UFH infusions in non-obese, obese, and morbidly obese critically ill patients. Heparin was initiated without a bolus at 16 units/kg/h or 12 units/kg/h in obese and morbidly obese patients. Demographics, UFH dosage/therapy duration, laboratory values, and bleeding events were reviewed for patients receiving UFH for >24 h. Steady state (SS) was defined as the dosage that resulted in three consecutive activated partial thromboplastin times (aPTT) within target range. Results: Sixty-two patients were analyzed including 21 non-obese (mean body mass index (BMI) 24.2 ± 2.3); 21 obese (BMI 34.1 ± 3.1); and 20 morbidly obese (mean BMI 55.3 ± 13.7). Patients had otherwise similar demographics. Although 92% had at least one therapeutic aPTT, only 55% of patients reached SS. Six patients developed minor bleeding, but no major hemorrhagic complications. The dosing of heparin based on actual body weight (units/kg/h) and time to first therapeutic aPTT was similar between groups, but dose was statistically higher at steady state in the non-obese (16.3 ± 5.3 non-obese, 11.6 ± 5.5 obese and 11.1 ± 1.2 obese, P = 0.01) with similar times to steady state. Conclusions: Dosing of UFH in morbidly obese and obese critically ill patients based on actual body weight and a reduced initial dose was associated with similar time to first therapeutic aPTT and steady state.

Background: Limitations of life-support interventions, by either withholding or withdrawing support, are integrated parts of intensive care unit (ICU) activities and are ethically acceptable. The end-of-life legal aspects and practices in United Arab Emirates ICUs are rarely mentioned in the medical literature. The objective of this study was to examine the current practice of limiting futile life-sustaining therapies in our ICU, modalities for implementing of these decisions, and documentations in dying critically ill patients. Materials and Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients' baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Results : The electronic medical records of 67 patients were reviewed. The commonest method of limiting therapy was no escalation 53.6%. Interventions were withheld in 41.5%. "Do not resuscitate" order was documented in only 16.3%. The commonest method of documenting limitation of therapy was discussion with the family and documenting the prognosis and futility of additional therapy (73.3%). Patients who died early (<48 hrs) compared to patients who died late (>48 hrs) of ICU admission received terminal cardiopulmonary resuscitation more frequently (P < 0.007), had less frequent prognosis documentation (P < 0.009), and had more vasopressors administered (P < 0.006). Conclusion : Withholding therapy after discussion with the family was the preferred mode of limiting therapy in a dying patient.

Background: Metabolic acid-base disorders in critically ill patients may not be identified by base excess (BE) approach. Anion gap method can detect approximately 1/3 hidden "gap acidosis." In such conditions, when adjusted for hypoalbuminemia, Fencl-Stewart's approach can reliably detect the hidden abnormal anions. Aim: Evaluate the efficacy of simplified Fencl-Stewart equation in identifying the changes in acid-base status of sepsis patients following resuscitation with two different fluids. Settings and Design: Intensive care unit, randomized, prospective, interventional study. Materials and Methods: Three hundred adult patients of both sexes presenting with abdominal sepsis, requiring fluid resuscitation were randomly assigned into normal saline (NS) and Ringer's lactate (RL) group, each comprising of 150 patients. 20 ml/kg of NS or RL were administered over a period of 30 min. The changes in the acid-base status were calculated applying the simplified Fencl-Stewart equation and was compared with the measured values obtained through arterial blood gas. Statistical Methods: Paired t-test for intra-group while unpaired t-test for inter-group comparison. Results: Blood pH and standard BE decreased and the serum Na ⁺ and Cl⁻ level increased significantly in NS group. The serum albumin level significantly decreased in both the groups. Sodium chloride effect on BE significantly increased in NS group. Albumin effect on BE significantly increased in both the groups. Unmeasured ion effect on BE did not significantly change in both the groups. Measured standard BE level was significantly less as compared to unmeasured anion effect on BE, in both the groups. Conclusion: Simplified Fencl-Stewart equation is effective in identifying a mixed acid-base disorder, which otherwise would remain undetected.

This is a case report of diagnosis and management of masochistic habits, a special type of mechanical trauma to the gingival tissue known as self-inflicted lesions, also termed as gingivitis artefacta. Self-inflicted injuries can be premeditated, accidental, or can also result from an uncommon habit. The purpose of this article is to review clinical findings in a 6-year-old female patient who had a habit of left forearm sucking since birth and also presented with a nail-biting habit which caused a gingival stripping on the left buccal surface of maxillary first and second deciduous molars. A full-arm sleeve was advised to be used for habit breaking, selective grinding of cusps was done of lower left first and second deciduous molars, and also topical anesthetic gel was prescribed.

Snake venom use for recreational purposes has been documented earlier. Willfully subjecting oneself to repeated lethal snake bite as a source of getting relieved of stress and recreation observed in two healthy software engineers, without any underlying psychiatric ailments or comorbidities along with probable mechanisms, are reported. Emergency physicians and practitioners have to be aware of novel methods of exposure to snake venom so as to recognize such cases and treat them accordingly.

Pyrexia can be extremely threatening during the normal progression of pregnancy if it occurs during the early phase of gestation as compared to the latter half of pregnancy. The degree of temperature rise, stage of pregnancy, and duration of the underlying illness are the important determinants for the outcome of pregnancy. Fever, resulting from the intrauterine infections, can be extremely hazardous for the newborn. Any history of fever (>24 h) during pregnancy mandate a complete clinical examination and thorough investigations. We report successful management of a rare case of prolonged high-grade pyrexia with unusual cause during mid-pregnancy.

There are increased reports in the medical literature of brain death during pregnancy. In these rare cases, the decision was either to consider discontinuing homeostatic support and mechanical ventilation with an understanding that the fetus then will also die, or to continue full support in an attempt to prolong pregnancy for the purpose of maintaining the fetus alive until maturity. We report the first case in the United Arab Emirates and in literature of somatic support that extended up to 110 days with the successful delivery of a viable fetus. A 35-year-old woman suffered intracranial hemorrhage during the 16 ^th week of pregnancy that lead to brain death despite maximal surgical and medical management. Upon confirmation of this diagnosis, the patient received full ventilatory and homeostatic support required to prolong gestation and improve the survival prognosis of her fetus. The status of the patient was discussed in a multidisciplinary approach and with the full involvement of her family. Somatic support continued until the patient was 32 of weeks gestation. Obstetric complications of the patient were frequently assessed and managed. Lower segment cesarean section (LSCS) was then performed. A preterm male in breech presentation was delivered with an average weight of 750 gm, and an Apgar score of 6, 7, and 9 at 1, 5, and 10 minutes, respectively. Prolonging somatic support in a pregnant woman with brain death to allow fetal survival resulted in a successful outcome in terms of saving the life of the fetus. The results are consistent with previous published case reports in the literature on the appropriateness and safety of such a strategy that involved an intensive multidisciplinary approach. Despite being a tragedy, maternal death can represent an opportunity to save the life of the fetus and for organ donation. Consensus future recommendations that can guide the management of similar conditions may also be adapted, especially with the growing medical experience in this context.