Objective: To assess knowledge, attitude, and practice of medical students towards coronavirus disease 2019 (COVID-19). Methods: A self-designed questionnaire was developed and given to the students of a government medical college in Uttarakhand. The demographics, mean knowledge, attitude, and practice of the participants were investigated, and the scores were calculated. t-test and ANOVA were used for statistical analysis. Results: Out of the total participants (n=354), 50.3% were male and 54.5% were 21-23 years. Almost all the participants (96.6%) increase the frequency of washing hands under the influence of COVID-19. Although no significant relationship was found between different religions, age-categories in terms of knowledge, the participants who were aged 21-23 years had higher knowledge. In addition, gender had a significant impact on practice scores (P<0.05) while no demographic variable was found to have a significant relation with attitude score (P>0.05). Conclusions: The majority of the participants had good knowledge, positive attitude, and sufficient practice. Females and males have significantly different practices. Although the results are very positive, it is suggested that people should continue to strengthen knowledge, attitude, and practice towards COVID-19, so that India can win the battle against the disease.

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Pox is an important infection that can cause the acute illness with dermatological manifestation. Apart from the well-known pox infections, the emerging zoonotic pox infections become interesting new issue in infectious medicine. In this short review, the acute illness which results from new important zoonotic pox infections such as monkeypox, cowpox, raccoon pox and buffalopox is discussed and summarized.

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The Coronavirus Disease-2019 (COVID-19) outbreak has become a global health emergency owing to its magnitude, attributed deaths, and its propensity to spread across the world. In-fact, owing to its quick spread across international boundaries and the resulting caseload, the disease has been declared as a Public Health Emergency of International Concern on 30 January 2020. It is worth noting that out of the 395 cases detected in other nations, 165 (41.8%) have a positive history of travel to China. As of now, the World Health Organization has not recommended for any restrictions on the travel or trade aspects, but has clearly specified that implementation of International Health Regulations should be strictly done at the airports and seaports. In conclusion, the COVID- 19 outbreak has created an alarm across the globe as the causative virus is novel in nature. However, strengthening of standard infection control practices and adoption of preventive measures for travelers can significantly minimize the threat of further transmission of the disease.

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Objective: To investigate the protective effects of Aristolochia longa (A. longa) and Aquilaria malaccensis (A. malaccensis) on acute hepatotoxicity induced by lead in female albino rats. Methods: Twenty five (25) apparently healthy female Wistar rats were randomly divided into five groups of five rats in each: control, Pb, Pb + A. longa (Ar), Pb+ A. malaccensis (Aq), and Pb+ A. longa (Ar) + A. malaccensis (Aq) lead (100 mg/kg b.w.) as Pb (C₂H₃O₂)₂ added in their drinking water for 75 days. A. longa (rhizome powder at a dose of 10 g/kg of diet) and A. malaccensis (heartwood powder at a dose 10 g/kg of diet) were added to the feed during the last 15 days of lead exposed in the animals. Results: Obtained results revealed that lead treatment caused a significant increase in serum GOT, GPT and ALP activities and in liver of MDA level and CAT activity. In contrast, it led to an decrease in the liver GOT, GPT and GST activities and in GSH level in rats. Also, the results clearly showed that lead causes alterations of hepatic tissue in comparison with controls. Our results showed that treatment with A. malaccensis and A. longa a partial correction of the previous parameters. The histological observations confirmed the hepatoprotection results by the biochemical parameters. Conclusions: Results demonstrated beneficial effects of A. longa and A. malaccensis treatment in Pb-induced oxidative stress and tissue damage in liver.

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Objective: To explore the toxicological profile of methanol extract of Chlorophytum alismifolium (MECA) tubers in Wistar rats. Methods: MECA was subjected to acute and sub-acute studies which were conducted according to Organization for Economic Co-operation and Development (OECD 425 and 407 guidelines respectively). In the acute toxicity experiment, a limit test (5 000 mg/kg) was administered to five rats and monitored for 2 weeks. The sub-acute studies were conducted on 4 groups of rats. The first group served as control, while the 2^nd, 3^rd and 4^th groups received MECA (150, 300 and 600 mg/kg respectively). The treatments were given orally and daily for 4 weeks. At the end of the experiment (29^th day), the animals were euthanized to obtain blood samples and organs for haematological, biochemical and histological evaluations. Results: Acute toxicity study showed that the oral median lethal dose was >5 000 mg/kg. In the sub-acute studies, the results showed no significant (P>0.05) changes in the haematological, hepatic and renal indices compared to control animals. In the fourth week, a significant (P<0.01) increase in body weight of the rats was observed at 150 mg/kg and 600 mg/kg compared to week one. However, there were no major changes in the organ/ body weights of the rats. Histological examination of the kidney showed slight glomerular adhesion and tubular distortion. Moderate hepatic necrosis was observed at 150 mg/kg and 300 mg/kg. Conclusions: The results of this research revealed that the MECA tubers is virtually non-toxic after acute administration and it has low sub-acute toxicity potential in rats.

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Objective: To evaluate the relationship between biofilm formation and incidence of virulence determinants in clinical isolates of Enterococcus. Methods: In this cross-sectional study, the clinical isolates of Enterococcus strains were collected from the university teaching hospitals in Ahvaz, Iran from June 2017 to June 2018. Then, the prevalence of Enterococcus species, antibiotic resistance, virulence factors, and biofilm-producing ability were determined. Results: Of the 119 tested isolates, 17 (14.3%) were Enterococcus faecalis, 72 (60.5%) were Enterococcus faecium and 30 (25.2%) were other Enterococcus spp. Gelatinase was detected in 97 (81.5%) isolates, enterococcal surface protein in 41 (34.5%) isolates, serine protease in 39 (32.8%) cases, accessory colonization factor in 111 (93.3%) cases and pathogenicity islands in 17 (14.3%) cases. The biofilm formation ability was observed in 75 (63.0%) of all isolates and the association between the presence of enterococcal surface protein gene and biofilm formation was statistically significant. Higher resistance to vancomycin, gentamycin, and teicoplanin was indicated in Enterococcus faecium with 81.8%, 58.4%, and 85.7% resistance rate, respectively. All Enterococcus faecalis isolates were sensitive to teicoplanin and vancomycin. Conclusions: The presence of antibiotic-resistance with several virulence factors in Enterococcus spp has become a concern. High prevalence of enterococcal surface protein gene among biofilm- producing isolates suggests a potential relation between biofilm formation and the enterococcal surface protein gene, and further studies are needed to identify the mechanism of biofilm inhibition.

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SARS-CoV-2 is the causative agent of COVID-19. Since its outbreak in December 2019, COVID-19 has swept the globe. By 17 July 2020, the World Health Organization (WHO) had confirmed 13 119 239 cases and 573 752 deaths, and the numbers are still rising. Current evidence shows that COVID-19 is lower than severe acute respiratory syndrome and Middle East respiratory syndrome in terms of severity and mortality risk, although the infections are particularly more severe in patients with underlying medical conditions. The bulk of COVID-19 patients had close contact with confirmed cases, but an exact origin and specific transmission for COVID-19 are still unknown. As there is no approved antiviral treatment for COVID-19 infection, proper prevention and control practices are essential to control the infection. To have an insight view of COVID-19, we summarized and compared the etiology, clinical manifestations, diagnosis, treatment, and prevention measures of COVID-19, severe acute respiratory syndrome, and Middle East respiratory syndrome.

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Objective: To investigate the improved antitrypanocidal activity and toxicity of diminazene aceturate modified Nano drug in experimental rats. Methods: Aqueous leaf extract of Hyptis suaveolens was used to reduce gold tetrachloride to its nanoparticle size and this was characterized and formulates with naturally synthesized polyhydroxybutyrateas a Nano carrier. A total of thirty ^[30] albino rats were group into 6 (A-F) of 5 rats each & infected intraperitoneally with 0.2 mL of the inoculum containing about 1x10³ Trypanosoma brucei brucei parasites per 0.2 mL of blood. Groups A and B were treated with 3 and 6 minutes released orange PHB, Groups C and D were treated with 15 and 30 minutes released mango PHB formulated tablet while Groups E and F were negative (untreated) and standard drug (Dininazene aceturare) respectively. Results: The free drug and modified orange synthesized polyhydroxy butyrate shows antitrypanocidal activities by reducing the replicating rate of the parasite as compared to infect untreated. While the modified- mango synthesized shows increasing order of replication. There were significant increases in all the haematological parameter evaluated in the infected treated groups compared to infect untreated. But no significant difference (P<0.05) observed in the Catalase activity in the serum and liver of all the groups whereas, the modified orange synthesized shows significant decrease in other enzymes activities evaluated when compared with the free drug, mango synthesized and the infected untreated groups. Conclusion: Orange synthesized modified diminazene aceturate show efficacy as free drug with limited toxicity that can enhance the therapeutic.

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Objective: To investigate the frequency of integrase genes intI1, intI2 and intI3 of Escherichia coli strains, and their association with resistance to routinely used antibiotics. Methods: A total of 120 Escherichia coli strains were collected from patients with urinary tract infection in Ahvaz, Southwest of Iran. Antibiotic susceptibility testing was performed. The presence of intI1, intI2, and intI3 genes was determined by polymerase chain reaction. Results: Antibiotic susceptibility testing disclosed the highest resistance rate to ampicillin (91.7%) followed by trimethoprim/sulfamethoxazole (65.8%), and ceftazidime (56.7%). The imipenem susceptibility rate was 91.7%. IntIl and intI2 were identified in 74 (61.6%) and 8 (6.6%) of Escherichia coli strains, respectively, but intI3 was not found in any isolates. The presence of integrons was significantly associated with resistance to ampicillin, trimethoprim/ sulfamethoxazole, ceftazidime, and ciprofloxacin antibiotics (P<0.05). Conclusions: The high resistant Escherichia coli isolates harboring class 1 integrons (intI1) were detected in patients with urinary tract infection in our region. Therefore, preventive strategies are necessary to restrict further dissemination of resistant strains.

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Acanthamoeba keratitis, a vision-threatening disease, is caused by a free-living amoeba of genus Acanthamoeba. Amoeba is widely distributed all around the world. Several cases of Acanthamoeba keratitis have been reported from the Middle East and Iran as well. The infection is mainly caused by inappropriate use of contact lens; therefore, it is more common among lens wearers. The number of reported cases worldwide is increasing annually due to the increasing number of contact lens wearers for medical or cosmetic reasons. It is known that early diagnosis and treatment can reduce consequent damages, while the delay in these processes will deteriorate the vision. Nowadays contact lens wearing, surgery and use of corticosteroids are known to predispose to Acanthamoeba keratitis, and it was also believed that trauma was the main cause. Increasing public knowledge about Acanthamoeba infection, inquiring the history of patients, clinical signs and laboratory findings can be helpful to early diagnosis and better treatment. Regardless of the increasing knowledge of diagnosis and treatment, this disease is still a challenge. Considering the long curative time, and insufficient efficacy of available treatments, it seems that the prevention is more important than the treatment. This review aimed to explain Acanthamoeba keratitis in the Middle East and Iran from the aspects of epidemiology, diagnosis, and therapeutic treatment.

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Biomarkers have been used to diagnose, prognose, evaluate, and identify the severity and outcomes in traumatic brain injury (TBI) patients. This study explored if it is possible to predict the outcome of TBI patients by estimating the biomarkers in cerebrospinal fluid and serum. We searched data bases and literature about biomarkers, and found forty epidemiologic studies from 92 potentially relevant articles. However, limited data are available about postanoxic encephalopathy. It showed that presently, neurofilament, S100B, glial fibrillary acidic protein, and ubiquitin carboxyl terminal hydrolase-L1 seemed to have the best potential as diagnostic biomarkers for distinguishing focal and diffuse injury, whereas C-Tau, neuron-specific enolase, S100B, glial fibrillary acidic protein, and spectrin breakdown products appear to be candidates for reflective biomarkers of TBI. Point-of-care biomarkers are needed in TBI which is one of the most important additional risk factors in road traffic injuries. In a holistic approach, more researches about biomarkers of TBI are required. These biomarkers are very useful for treatment of patients with TBI.

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Objective: To determine the effect of self-management program on the health status of elderly patients with heart failure. Methods: The present study was a single-blind, randomized clinical trial, and conducted on 90 patients with heart failure of stages II-III at one teaching hospital in eastern Iran in 2017. The participants were randomly assigned into two groups: the intervention group and the control groups, with 45 patients in each group. Self-management programs including awareness and recognition, problem-solving process, diet, exercise, and stress management were carried out. The participants were trained for six weeks and were followed for two months. Data of the health status were collected before, after and eight weeks after intervention by Kansas City Cardiomyopathy Questionnaire. Data analysis by chi-square, independent t-test, Fisher, ANOVA with repeated measures was conducted. Results: Patients in both groups were matched in terms of demographic characteristics before the intervention. There was no significant difference in the mean scores of health status between the two groups (P=0.1) before the intervention. However, the second measurement after intervention showed a significant difference in the mean scores between the two groups (P=0.001). Conclusions: Self-management program can improve the different dimensions of health (except in the subscale of sign and symptoms). Therefore, this supportive method can be used to improve the health of patients and manage problems caused by heart failure.

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Objective: To assess acute otitis media with facial nerve paralysis, its prognosis, and treatment. Methods: It is a retrospective study. Thriteen patients of acute otitis media associated with facial nerve paralysis attended the outpatient department of otorhinolaryngology between May 2017 and April 2019. All patients were clinically assessed with appropriate investigations, prognosis, and treatment. Results: Out of 13 patients, 2 were identified with complete facial paralysis and the remaining 11 patients presented with incomplete paralysis. Medical treatment including antibiotics and corticosteroids failed, while myringotomy and facial nerve decompression were done with a favorable outcome. Eleven patients recovered to grade-I (House-Brackmann) and 2 cases to grade-II (House-Brackmann). Conclusion: Peripheral facial nerve paralysis in acute otitis media is rare. Antibiotics and steroids yield good outcome as conservative management. In case of failure by conservative treatment, facial nerve decompression yields a favorable outcome.

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Objective: To assess the antibacterial activity of 5 selected plants against 4 pathogenic bacteria. Methods: Three solvents with different polarities were used to extract antimicrobial agents from the plants via maceration technique. The agar-disc diffusion technique was adopted to primarily screen antibacterial activities. Broth-dilution assay was employed to determine the minimum inhibitory concentration (MIC) and the minimum bactericidal concentration (MBC). Results: Among all extracts, the ethanol extract of Piper betle Linn showed highest antibacterial activity against Gram-positive and the negative bacteria. MIC and MBC of the ethanol extract of Piper betle Linn against Salmonella typhimurium were the same (1 562.50 mg/L); while it showed the highest MIC and MBC against Pseudomonas aeruginosa of 6 250 mg/L and 12 500 mg/L, respectively. Conclusions: Salmonella typhimurium is the most susceptible bacteria while Pseudomonas aeruginosa is the most resistant bacteria towards the ethanol extract of Piper betle Linn. Piper betle possesses compounds with potential antibacterial activity and might be useful as an alternative to control infectious diseases.

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Acinetobacter baumannii is a major cause of nosocomial infections worldwide. By summarizing the epidemiology, molecular and drug resistance mechanisms, diagnosis and treatment strategies of Acinetobacter baumannii, the clinical outcome is finally improved.

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Rationale: Cope’s sign is reflex bradycardia seen in the patient presenting with symptoms of acute cholecystitis. This bradycardia may be due to vagally mediated cardio-biliary reflex. Many of these reflexes due to acute cholecystitis have similar clinical features (some electrocardiographic changes like bradycardia, complete heart block, and asystole) mimicking that of acute coronary syndrome. Patient’s concern: A 60-year old male presented with symptoms of acute cholecystitis and referred to the emergency department with complete heart block and abdominal pain with hypotension requiring an emergency temporary pacemaker. Diagnosis: Cope’s sign and complete heart block. Intervention: Emergency temporary cardiac pacemaker insertion. Outcomes: The patient was discharged after three days with regular follow-up and advice for laparoscopic cholecystectomy. Lessons: Complete heart block or any symptomatic bradycardia associated with abdominal pain should be under consideration of cholecystitis that may be associated with either presence or absence of gall stones due to cardio biliary reflex.

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Objective: To estimate the frequency of pneumococcal meningitis among patients with bacterial meningitis in Iran. Methods: PubMed, Embase, Web of Science and Scientific Information Database (www.sid.ir) were searched from 2000 to 2016 to identify studies on the frequency or prevalence of pneumococcal meningitis in Iran. Stata 14.0 (StataCorp, College Station, Texas, USA) was used to analyze the data. Results: Of the 131 records identified from the databases, 21 studies fulfilled the eligibility criteria. The analyses showed that 25.0% (95% CI: 19.0-32.0; I²=71%) of the confirmed bacterial meningitis (including children and adults) cases were caused by pneumococcus. Conclusions: The large fraction of meningitis cases caused by pneumococcus demonstrates that pneumococcal meningitis is a major public health problem in Iran, and the introduction of pneumococcal vaccines merits further attention from health authorities.

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Objective: To evaluate the etiology, clinical profile and outcome of acute abdomen presentation in Dengue Fever (DF). Methods: This clinical prospective study was done on confirmed cases of DF admitted in the department of medicine during recent epidemic (September 2015 to November 2016). All patients were evaluated clinically and by laboratory and imaging investigations and followed-up during hospital stay till discharge. The cause of pain abdomen was ascertained by blood tests (amylase, lipase and liver function test etc), radiology (Flat plate abdomen-erect, Ultrasonography of abdomen, CECT abdomen) and/or endoscopy. Results: Out of the 501 patients diagnosed as DF, 165 (32.93%) presented with acute abdomen. Some patients presented in other departments like surgery, gastroenterology and emergency, were later diagnosed as DF on laboratory evaluation. Various causes of acute abdomen in our study were nonspecific severe pain abdomen (67 cases), acute hepatitis (46) one had acute fulminant hepatitis, acute acalculous cholecystitis (31), ascitis (12), acute hyperemic gastritis with malena (5), acute pancreatitis (2), and 1 case each of acute appendicitis and acute jejuno-ileal intussuception. All patients were managed conservatively. One patient of acute pancreatitis died of multi-organ failure. Conclusion: Our study concludes that clinical vigilance about such type of presentations is important as timely recognition can influence outcome and may prevent unwanted surgery.

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Objective: To evaluate the acute toxicity effect of metribuzin at low dose on liver of mother rabbits and its fetus. Methods: Pregnant female rabbits Oryctolagus cuniculus were divided into three groups (n=5). The first group of non-treated pregnancy rabbits served as control; the second group of pregnancy rabbits were treated with 1/100 LD₅₀ of metribuzin and the third group of pregnancy rabbits were treated with 1/50 LD₅₀ of metribuzin. Metribuzin was added in their drinking water for 60 d before and during pregnancy. Levels of liver malondialdehyde, liver glutathione S transferase, serum glutamic oxalacetic transaminase and serum glutamic- pyruvic transaminase were determined. Liver reduced glutathione level was also determined by a colorimetric method. And hepatic homogenate was analyzed by HPLC analysis to determine the existence of traces of metribuzin. Results: Results revealed a significant increase in level of liver malondialdehyde, glutathione S transferase, serum glutamic oxalacetic transaminase and serum glutamic-pyruvic transaminase activities in mother and fetuses rabbits of both metribuzin treatment groups as compared to the control group. However the level of reduced glutathione was decreased in mother and fetuses rabbits of both groups treated with metribuzin compared to control group. Also, the results obtained by HPLC technique showed the presence of trace metribuzin in liver cells of mothers and fetuses rabbits of the both metribuzin treated groups. Conclusions: In conclusion, this study shows that exposure to metribuzin at low concentrations causes a acute toxicity in liver of mother rabbits and its fetus, also the trace of the metribuzin detected in the liver is the origin of possible malformation of the fetuses or abortion of the rabbits.

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Pulmonary embolism (PE), with the incidence of about 60 per 100 000 annually, can be a life- threatening disease if it is not treated promptly. It has been estimated that some 10% of PE patients die within the first hour of the event. Untreated PE has a mortality of about 30%. PE is a condition that is treatable if suspected and diagnosed early. The chest radiograph is still the first investigation that is ordered in patients presenting with cardiorespiratory symptoms or symptoms suggestive of PE. The CXR is also helpful in identifying or excluding other conditions or diagnoses. Thus, knowing and understanding some of the more specific CXR signs can be useful. We suggest that physicians to be aware of and utilize CXR findings such as Palla's sign, Westermark sign and Hamptons hump to help with the diagnosis of PE and to exclude other conditions that can mimic venous thrombo-embolism. Even if these signs are not common, their presence, even in an unsuspected patient without a high pretest probability of PE, should prompt further investigations such as a D-dimer test, lung scintigraphy or computed tomography pulmonary angiography as required.

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The role of laparoscopy in the acute care surgery had significantly increased during the latest years, both as a diagnostic and treatment method of all the upper or lower gastrointestinal pathologies. The objective of the present research is to review the current indications for laparoscopy in bdominal emergencies and to detail the benefits and complications associated with this approach. We have reviewed the relevant literature about this topic published between January 2005 and December 2017, using the PubMed/Medline and Web of Science Core Collection databases. According to the current evidence, we may conclude that the laparoscopic approach is an integral part of the emergency surgery for all the abdominal pathologies. Although laparoscopy requires specialized training and curricula, it brings all the benefits of minimal access in acute care arena.

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Paraquat (PQ, methyl viologen) was widely used in agricultural production throughout the world in 1962 for its efficient herbicidal activity. PQ was also highly toxic drug. About 5 mL medicine including 20% paraquat was life-threatening that can cause poisoning. In 1966, some people died because of PQ poisoning. Most patients had acute respiratory distress syndrome after 2 wk, and 70% of them died due to the lack of effective detoxification drugs. Thus, it was particularly important to understand the pathogenesis of PQ poisoning and give some effective treatments. This article will review the toxicological mechanism and treatment on PQ poisoning of acute lung injury.

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Objective: To investigate the prevalence of viral myocarditis worldwide. Methods: We conducted a systematic search for the prevalence of the most common viruses in myocarditis and 75 studies were included for statistical analysis of the prevalence of adenovirus, hepatitis C virus, cytomegalovirus, Ebola virus, human herpesvirus 6, influenza virus, parvovirus, and non-polio enteroviruses. Results: The highest prevalence was related to B19 (25.0%) and non-polio enteroviruses (18%). The prevalence of human herpesvirus 6, cytomegalovirus, and Ebola virus was12.8%, 5.5%, and 3.1%, respectively. Hepatitis C virus accounted for 6.1% of the disease, the adenoviruses contributed to 5.2% of viral myocarditis. The lowest incidence was related to the influenza virus with 2.0%. Conclusions: Treatment of myocarditis is still problematic and may depend on the etiologic diagnosis. So it is important to know the commonly occurring viral factors in myocarditis and timely diagnosis and treatment are also imperative.

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Levothyroxine intoxication is a rare clinical entity which is usually asymptomatic. However, severe symptoms such as respiratory failure, malignant hyperthermia, seizures, arrhythmia, and coma have been reported. In this case report, a patient who ingested high dose (15 mg) levothyroxine for suicide and admitted to intensive care unit was presented. There was a decrease in Glasgow coma score in the follow-up. The patient was intubated due to acute respiratory failure. Gastric lavage, activated charcoal, methylprednisolone, cholestyramine and therapeuthic plasma exchange were administered. Despite ingestion of high dose of levothyroxine, thyrotoxicosis symptoms resolved with appropriate treatment and the patient was discharged from the intensive care unit.

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The impact of a bullet by firearm is a mortal entity that in recent years has been on the rise due to the increase in crime, confrontations, among other acts of violence. Brain injuries by firearm account for 33.3% of all fatal injuries from this type of weapon. This resulted in a significant number of disabilities with its burden cost at a global level. The types of bullet injuries to the head include: penetrating (inlet without outlet), perforating (through and through), tangential (not enter the skull, causing coupe injury), ricochet (intracranial bouncing of bullet) and careening (rare, enter skull but not brain, runs in the subdural space). There are several situations that can occur once the bullet enters the body or into the intracranial cavity. Unmatched association of the bullet trajectory with the final position of the bullet within the body raise the suspicion for additional phenomena involvement, this can be explained by either internal bullet ricochet or internal bullet migration. The former usually represents an active movement and the latter is a passive movement. Intracranial ricocheting of bullets forms up to 25% of all penetrating bullet injuries to the skull. Such bullets types are commonly tumbling and have an unpredictable trajectory. The surgical management for intracranial bullet injury developed over decades from the time of Harvey Cushing and the World War I till the present. Now, the accepted intervention ranges from simple wound care to a proper surgery that includes hematoma evacuation, removal of only accessible bone fragments and foreign bodies, dural repair and wound debridement with or without decompressive craniectomy. Also, intracranial pressure monitoring is generally indicated. We reported a thirty-three years old male, victim of homicidal bullet injury to the head, presented with Glasgow Coma Scale score of 8 (best eye response: 2, best motor response: 4, best verbal response: 2), upon examination a right parietal (near vertex) inlet without outlet was found. The poor prognostic factors in this patient included bi-hemispheric involvement, associated acute subdural hematoma with interhemispheric extension, ricochet type of injury and effacement of sulci. Intracranial ricocheted-bullet injury is a special entity of bullet injury to the head with its particular ballistics and management that deserve highlighting by the trauma team to gain fluent treatment and better outcome.

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