‘Sudden death’ is not necessarily sudden
Dr S.K. Jindal

Sudden death is always a devastating event for a family left with an unexpected vacuum. While the death from an accident or a natural disaster is better understood, it is highly enigmatic when it occurs in an otherwise healthy individual except perhaps in the presence of very old age. It is most questionable in the absence of any premonition.

Medically speaking, the so-called "sudden death" is not necessarily sudden like a bolt from the blue. There is generally an underlying medical problem which may not be often known to the person and the family. Even if known, the individual tends to ignore or underplay the presence and potential risks of fatality of the disease. There is a tendency to hide the diagnosis for fear of stigma and other reasons. Congenital diseases and predispositions are frequently responsible for sudden deaths in the young people.

A death following a drug administration is one of the most unexplainable events. It is a nightmare for the person who prescribes and administers the drug. Such deaths are commonly attributed to "drug reactions" as a result of allergic or hypersensitivity phenomenon. Unfortunately, it is often not possible to predict the occurrence of such a reaction. It is generally advisable to test a drug for its potential hyper-sensitivity. This, can, however, be done only for those drugs which are known to cause such reactions (e.g. penicillin). One cannot go on testing all the drugs for an individual. Rarely, even a test dose of such a drug can cause a problem.

Fortunately, the occurrence of fatal reactions following drugs are extremely rare. More importantly, the person who administers the drug through an injectable route should be familiar and equipped with the methods of resuscitation in case of an unfortunate event.

Sudden death in medical language is synonymous with cardiac arrest - cessation of cardiac rhythm or the heart-beat. Cardiac arrest itself is the end result of a problematic event in the body. A massive block of a major blood vessel supplying the heart, the lungs or the brain, or even an attack of a severe fatal asthma may result in cardiac arrest and sudden death.

Major blockade of coronary arteries supplying the heart or of the pulmonary arteries supplying the lungs is frequently the most important cause of sudden fatality in adults. Death in all such cases is determined by the site of the block and the vital area deprived of the blood supply (ischemia). The rate as well as the cause of occlusion are also important. The very first coronary artery block, often referred to as "heart-attack", may prove to be fatal if it remains unattended. Massive pulmonary artery block occurs either in a hospitalised patient or in the presence of an underlying disease. It is rare in healthy people except following a fracture (especially of legs and pelvis), or in women during or after pregnancy.

Cerebal arterial occlusion and brain-ischemia are commonly diagnosed as a "stroke" or a "brain attack". Most such patients develop deficits and/or unconsciousness. A massive stroke will usually culminate in death in a period of a few hours to days.

Congenital heart diseases, especially when unknown, may result in sudden death following an exertional event, or sometimes the absence of a precipitating cause. Narrowing of a heart valve, for example, can cope with the normal blood flow through the heart, but result in sudden obstruction to the increased flow following an exercise. Sometimes, and obstructed forward flow may result in an increased back flow in the lungs, leading to pulmonary edema and sudden death. A congenital heart rhythm disturbance, although rare, may result in dramatic sudden death.

Bronchial asthma is a common medical problem and generally compatible with normal life span and style. It can also be fatal but very rarely. There is small subgroup of patients who are poorly controlled and who suffer from severe attacks of asthma. In a few of such patients, an attack can sometimes be too severe and proves to be fatal before any medical help becomes available. Most of these patients are known to suffer from an unstable disease. It is, therefore, desirable for such patients to keep the injectable medical drugs readily available in pre-filled syringes on their person along with appropriate written instructions. Of course, this type of medical help should always be kept in their homes and schools.

Like asthma, an epilepsy attack may similarly result in sudden collapse. A patient with known epilepsy must be careful to avoid the risky conditions as well as keep the emergency drugs for ready use, as in the case of asthma.

Sudden death following pregnancy, labour, anaesthesia and surgical procedures or following simple diagnostic or treatment procedures is equally tragic, but is known and enigmatic.

Vascular occlusions, reflex phenomena, hypersensitivity reactions and other complications are some of the known causes. There are avoidable as well as unavoidable causes. No doubt, the unexpected loss is irreversible and irreparable for the family, but it is an enigmatic loss of game for the medical fraternity.

The writer is Professor & Head, Department of Pulmonary Medicine, PGI, Chandigarh.

Half asleep seals may solve the mystery of how humans snooze

An international team of biologists has successfully identified some of the brain chemicals that may help clarify some unanswered questions about how humans sleep.

The research — conducted by the University of California, Los Angeles (UCLA) and the University of Toronto — focused on seals and the chemicals found in their brain, as they are able to sleep with half their brain at a time.

Professor John Peever of the University of Toronto said: “Seals do something biologically amazing — they sleep with half their brain at a time. The left side of their brain can sleep while the right side stays awake. Seals sleep this way while they’re in water, but they sleep like humans while on land. Our research may explain how this unique biological phenomenon happens.”

The study’s first author, PhD student Jennifer Lapierre, measured how the brain chemicals change while the seals are asleep and awake. She found that acetylcholine — an important brain chemical — was at low levels on the sleeping side of the brain, but high levels on the waking side. This discovery suggests that acetylcholine may be responsible for brain alertness.

They also discovered — to their surprise — that the chemical serotonin was present in both sides of the brain whether the seal was awake or asleep. It was previously thought that serotonin caused brain arousal.

Researchers hope that the discovery of the chemicals may make a breakthrough in understanding and curing sleeping disorders. The study’s senior author, Jerome Siegel from UCLA’s Brain Research Institute added: “Understanding which brain chemicals function to keep us awake or asleep is a major scientific advance. It could help solve the mystery of how and why we sleep.” — The Independent

How to handle varicose veins
Dr SM Bose

Veins carry blood towards the heart, and arteries carry it away from the heart; and broadly speaking, in this way blood circulation is established in the body.

As the veins carry blood from the tissues after its utilisation of oxygen and other materials, they contain impure blood, except the pulmonary veins in the chest which carry pure blood. In contrast to the arteries, the veins are in large numbers, are thin-walled and blood flows in them under low pressure. In order to have a good and effective venous return from the extremities, both upper and lower ones, there are two sets of veins, superficial and deeper ones, and nature has provided unidirectional valves in these veins so as to avoid reverse flow.

These valves may not be effective because of many reasons and when this happens, then there is stagnation of venous blood the — veins get dilated, distended and tortuous. These are then known as Varicose Veins. The varicosity is commonly seen in lower extremities although these may be seen in any part of the body. For the clarity of description, only the varicosity of the lower limb will be discussed in this article.

Varicosity of lower extremity veins is a unique feature in human beings because of their erect posture.

The Causes:

Multiple reasons may be responsible:

1. Congenital absence of valves in the veins

2. Diseases causing the destruction of inner walls of the veins , common one being thrombophlebitis

3. Pregnancy or swelling inside the lower aspect of the abdomen causing obstruction to the free flow of blood in the major veins of the abdomen.

4. Erect posture for a long time as it happens in the case of police and security personnel.

Symptoms and signs

l The patient may remain asymptomatic — may not have any problem except the the fact that veins of legs may be prominent, particularly in fair-skinned women.

lMay complain of aches, heaviness and discomfort in the legs.

lMay have swelling in the feet particularly after prolonged standing, and especially during evening times.

lThere may be darkening (pigmentation) of the skin in the lower third of the affected leg, just above the ankle joint.

lThe skin may be ulcerated (having wound) and will not heal with usual treatment .

lSmall trivial injury may cause excessive bleeding from the engorged vein. The first aid treatment under such conditions is local pressure; and, if required, a surgeon may have to tie the vein.

Diagnosis

Clinical examination by a competent surgeon can establish the diagnosis but investigations like colour doppler study of the peripheral venous system gives detailed information, which is necessary for satisfactory treatment.

The following features must be determined: Extent and localisation of varicosity, status of the deep venous system, determination of the competence of the main valves in the upper part of the thigh (sapheno – femoral valve) and behind-the-knee joint (sapheno – popliteal valve) and three or four valves present in the leg in the communicating veins between superficial and deep veins.

Correct localisation of the problem is necessary for proper management and also for the prevention of recurrence.

Managenment of varicosity

Treatment of varicose veins depends upon the severity of the problem. Surgical treatment in the form of removal of the varicose vein (stripping), multiple ligation of varicose segments of veins, sclerotherapy (obliteration of the veins with chemical agents) are the common procedures.

Modern methods like radiofrequency, endovenous thermal ablation, endoscopic treatment or Laser ablation of the varicosities are also undertaken.

In addition, supportive measures like the application of elastic bandage or stockings, legs to be elevated while lying down or sitting for a long time, proper dressing of varicose ulcer and other measures may be helpful.

The writer is Senior Consultant Surgeon, IVY Hospital, Mohali, and former Head of Surgery, PGI, Chandigarh. drsmbose@gmail.com