Letters to Editor
Karasu-Minareci E, Gunay N, Minareci K, Sadan G, Ozbey G. What may be happen after an organophosphate exposure: Acute myocardial infarction? J Forensic Leg Med 2012;19:94-6.
Karki P, Ansari JA, Bhandary S, Koirala S. Cardiac and electrocardiographical manifestations of acute organophosphate poisoning. Singapore Med J 2004;45:385-9.
Ludomirsky A, Klein H, Sarelli P, Becker B, Hoffman S, Taitelman U, et al. Q-T prolongation and polymorphic (torsade de pointes) ventricular arrhythmias associated with organophosphorus poisoning. Am J Cardiol 1982;49:1654-8. Access this article online Quick Response Code: Website: www.onlinejets.org
Cervical spinal cord injury without bone injuries in an alcohol-intoxicated patient with atlantoaxial osteoarthritis Dear Editor, High-level cervical spinal cord injury (CSI) without bony injuries cannot be easily considered in the initial diagnoses for an acutely alcohol-intoxicated patient with an altered mental status. The authors encountered a relatively rare and diagnostically difficult case of CSI at the C1-C2 level without any bony injury, which was caused by atlantoaxial osteoarthritis in an obtunded, alcohol-intoxicated patient after minor blunt trauma. An alcohol-intoxicated 56-year-old male presented at our emergency department with an acutely altered mental status. Several hours before the visit he had ingested a considerable quantity of alcohol, and 1 h before, he had fallen while hugging a friend. After the fall, his friend found him unconscious. Due to the manner in which he fell, it was unlikely that his head has been struck. His initial Glasgow Coma Scale score was three and he was completely unresponsive to any stimulus. It was initially suspected that severely alcohol intoxication or non-traumatic brain lesions such as intracranial hemorrhage or acute stroke, as the causes of his neurologic status, head computed tomography and magnetic resonance imaging (MRI) were performed initially, but returned normal findings. Because he became alert after the MRI scan, a reliable neurologic examination was possible. It revealed no 132
sensory perception in the entire C3 dermatome and decreased sensory perception below the C3 level. Motor power was of grade 0-1 at each joint of both upper limbs and of grade 2-3 at each joint of both lower limbs, then CSI was strongly suspected. A cervical spine X-ray revealed no bony abnormality from C1 to C5 [Figure 1]. Cervical spine MRI revealed cord contusion and subligamentous hemorrhage at the C1-C2 level and bony resorption and sclerotic change of the odontoid process of C2, suggesting C1-C2 instability related to osteoarthritis of unknown cause [Figures 2a, b and 3]. Over time, he became alert; his motor power improved spontaneously to grade 2 in both upper limbs and to grade 4 in both lower limbs. Cervical degeneration is a major cause of CSI without bony injuries. However, in this situation, the C3-4 or C4-5 level is frequently involved and C1-C2 level injuries are relatively rare.[1,2] Interestingly, in our patient, C1-C2 CSI without bony injury developed due to atlantoaxial osteoarthritis with instability after minor blunt trauma. Degenerative arthritis of the atlantoaxial joint has been discussed only infrequently, but it has been established degeneration of articular cartilage, reduction in joint space and
Figure 1: X-ray of the cervical spine, showing no bony abnormality from C1 to C5
a b Figure 2: (a) T-2 weighted sagittal magnetic resonance image (MRI), showing cord contusion (arrowhead) and (b) T-1 weighted sagittal MRI, showing subligamentous hemorrhage (black arrow) at the C1-C2 level Journal of Emergencies, Trauma, and Shock I 7:2 I Apr - Jun 2014
Letters to Editor
Frequent emergency department visits and parents/guardians’ level of awareness of asthma in the pediatric population Figure 3: T-2 weighted axial magnetic resonance image, showing bony resorption and sclerotic change of the odontoid process of C2 (white arrow)
secondary incompetence of ligaments controlling movement can cause atlantoaxial instability. This case emphasizes the importance of considering the possibility of CSI in an obtunded, alcohol-intoxicated patient even when a traumatic event is minor and in the absence of a definite cervical spinal bony injury and C1-C2 CSI without bony injury can develop due to atlantoaxial osteoarthritis after minor blunt trauma. ACKNOWLEDGMENT This work was supported by Inha University Research Grant.
Hyun Min Jung, Jin Hui Paik, Seung Baik Han, Ji Hye Kim Department of Emergency Medicine, College of Medicine, Inha University, Incheon, South Korea E-mail: [email protected]
Morishita Y, Maeda T, Naito M, Ueta T, Shiba K. The pincers effect on cervical spinal cord in the development of traumatic cervical spinal cord injury without major fracture or dislocation. Spinal Cord 2013;51:331-3.
Guo H, Liu J, Qi X, Ning G, Zhang H, Li X, et al. Epidemiological characteristics of adult SCIWORA in Tianjin, China: A preliminary study. Eur Spine J 2012;21:165-71.
Goel A, Shah A, Gupta SR. Craniovertebral instability due to degenerative osteoarthritis of the atlantoaxial joints: Analysis of the management of 108 cases. J Neurosurg Spine 2010;12:592-601. Access this article online Quick Response Code: Website: www.onlinejets.org
Journal of Emergencies, Trauma, and Shock I 7:2 I Apr - Jun 2014
Dear Editor, Childhood asthma is a leading health problem that reasons for vast hospitalization, morbidity, and mortality throughout the world. Literature reports focus on family management of this disease. Hence, the aim of this study was to investigate the awareness of parents/guardians about the disease. In this study, Likert scale questionnaire consisting of 90 questions was served to the parents/guardians accompanying the patients to the Emergency Department (ED) of our University. The correlations between ED admissions and the level of knowledge of the parents/guardians were investigated. Pearson correlation was calculated between the admission frequency and the awareness as a measure of being “aware” or “not aware”. The scores were correlated with the number of ED visits by asthmatic children (r = –0.239, P = 0.046). Our sample included 90 participants. The percentage of illiteracy among the respondents was 12.2. For 70 participants, we calculated Pearson correlation between parents/guardians’ awareness and the admission frequency and the analysis showed a negative correlation of (–0.239, P = 0.046) between the two variables. The questions were classified into three categories as per the original article. The first category constituted seven questions on knowledge of the use of inhalers. The second category constituted six questions, on the etiological factors and the need for hospitalization and use of medicines. The third category constituted four questions; on the participation of asthmatic children in exercise, sports, and smoking at home. Each category was scored separately and then the sum of all categories was calculated. Taken together, negative association was found between the ED visits and the total score of the categories. Nevertheless, the inconclusive results obtained in this study might be related to the small sample size. We recommend further studies to be conducted on a larger sample size.
Abdullah Al-Anazi1, Mohamed Al Moamary2, Taha Ismaeil3, Abdullah Nawash Alanazi4, Lafi Hamdan Olayan5, Abdullah Mayof Alanazi6, Hassan Yassen Abo Noarh7, Shoeb Qureshi8 133
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