In this study, 100 singleton pregnant women underwent a caesarean delivery under general anaesthesia and were studied in terms of postpartum bleeding using oxytocin or misoprostol. Patients were randomly divided into two equal groups. One group received two tabs of misoprostol 200 microg sublingually and the second group took intravenous infusion of 20 units of oxytocin at the rate of 10 cc/min immediately after delivery until full contraction of the uterine. The amount of blood loss was lower in misoprostol group comparing with oxytocin group (608.91 ml vs 673.9 ml) (p = 0.048) and this difference was statistically significant. The need to give additional oxytocin therapy in oxytocin group (36%) was significantly higher than misoprostol group (14%) (p = 0.032). It seems that the efficacy of sublingual misoprostol is equivalent to that of low dose intravenous oxytocin in reducing postpartum haemorrhage at caesarean section. Misoprostol has some other advantages like long shelf -life, stability at room temperature and oral use.

Background: The present study examined the effect of bilateral infraorbital nerve block with marcaine on hemodynamic changes during sinus endoscopic surgery. Material and Methods: 30 patients underwent sinus endoscopy surgery in two groups: marcaine and normal saline. Ifraorbital nerve block was performed in the first group by injecting 1 ml of 0.5% marcaine for 30 to 40 seconds and in the second group by injecting 1 ml of sterile normal saline. The level of oxygen, pulse rate, and systolic and diastolic blood pressure were measured before anesthesia, 30 minutes and 60 minutes after anesthesia, at the time of completion of recovery surgery and exit from recovery. Results: The mean age of men was 37.29±10.15 and the mean age of women was 38.92±7.60. The mean systolic blood pressure of the marcaine group was less in comparison with the normal saline group 30 minutes (p = 0.001) and 60 minutes after the start of the anesthesia process, as well as at the time of surgery, at the time of entering the recovery and at the time of leaving the recovery (p <0.001). The mean pulse rate of marcaine group was less than normal saline group 30 minutes (p = 0.005) and 60 minutes (p = 0.019) after the start of anesthesia and at the end of surgery (p = 0.007). Conclusion: Bilateral infraorbital nerve block with topical injection of marcaine has a greater effect on lowering systolic and diastolic blood pressure and pulse than normal saline injection.

Dear EditorScuba diving is associated with an important risk of developing decompression sickness secondary to formation of gas bubbles inside the body. The latter is formed mainly by nitrogen in the body on the diver's way to the surface (1,2). In some cases, it might injure the central nervous system. Several decompression cases that have been associated with neurologic symptoms are described in the literature; however, brain multi-infarct with lethal outcome has never been described. A 41-year-old male, came to the ER with clinical suspicion of decompression sickness (he dived for 15 minutes at a depth of 50 m). Among his health history, he was a heavy smoker, 30 minutes after leaving the water; he suddenly had dysarthria and vertigo. Upon admission, the patient had a poor general condition, Glasgow Coma Scale (GCS) 9 points, and horizontal nystagmus with right hemiparesis 4/5. Brain magnetic resonance imaging (MRI) demonstrated multiple cerebral and cerebellar infarctions. Echocardiography did not reveal the presence of patent foramen ovale (Figure 1). The patient was required to be transferred to intensive care unit and to a hyperbaric chamber session. He progressed to hemodynamic instability, dying within 36 hours after admission. Brain multi-infarct and decompression sickness© 2018 The Author(s). Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Decompression sickness is thought to be associated with thrombotic events due to intravascular gas bubbles. It is accepted that mechanical abrasion to vessel's walls may induce endothelial dysfunction and activation of the blood cells that are responsible to start the inflammatory reaction, vasomotor dysfunction, platelet aggregation pathway and coagulopathy. This disease has been classified into two types: type I and II, based on the severity of signs and symptoms. Type I is a mild form that requires less recompression and treatment, type II is associated with neurologic symptoms (3). The latter requires an extensive therapy and may lead to significant neurologic sequelae. Our case report represents a type II decompression sickness. It is known that the delay to start recompression treatment represents a poor prognosis. Early start of hyperbaric therapy will reduce the size of the gas bubbles, improve perfusion and re-oxygenate ischemic tissue before late inflammatory processes might occur. These include cytokines, platelet activation and complement activation (4,5). Ethical issuesNot applicable. Authors' contributionsAll authors contributed equally. Jept Journal of Emergency Practice and TraumaLetter to Editor