Indian Journal of Emergency Medicine

Hepatitis E is one of the common forms of acute viral hepatitis in epidemic proportions in India. It has been seen to cause severe Haemolysis when associated with G6PD deficiency which is rarely seen in the northern India. This case report is of a 35 year old male with Hepatits E who presented to the Emergency Room pale and icteric and on evaluation was found to have G6PD deficiency as the cause of severe haemolysis. Therefore, in patients with acute viral hepatitis and severe anaemia with unconjugated hyperbilirubinemia, it becomes a necessity to rule out G6PD deficiency as a cause of the intravascular haemolysis.

Keywords: G6PD Deficiency; Hepatitis E; Viral Hepatitis; Intravascular Haemolysis; Unconjugated Hyperbilirubinemia; Anaemia. 

Glossopharyngeal neuralgia is in itself a rare entity and often remains undiagnosed. Asystole, convulsions, and syncope are associated with glossopharyngeal neuralgia in many patients described in the literature, and this condition is called vagoglossopharyngeal neuralgia. These reactions occur due to the complex anatomical relationship between the intermedius, vagus, and glossopharyngeal nerves leading to difficulties during neurosurgical assessment. Here we report a case of 66 year old male, known case of glossopharyngeal neuralgia, presenting with seizure followed by syncope and later on diagnosed to have prolonged sinus pause.

Keywords: Glossopharyngeal Neuralgia; Sinus Pause. 

Tranexamic acid is widely used as an antifibrinolytic agent in different conditions including menstrual bleeding, trauma, dental procedures etc. though considered safe, its use on a long term basis in an abnormal dose is not without adverse effects. Both arterial and venous thrombosis in different vascular beds has been described with its use. Here in, we report a rare case of bilateral acute lower limb arterial thrombosis in a young female who had used tranexamic acid inadvertently for a long period of time. Our patient presented with sudden onset of weakness of both lower limbs and progressively worsening blackish discoloration ascending from foot to mid leg. Her evaluation revealed bilateral common femoral and superficial femoral arterial occlusion on CT angiogram, moderate renal insufficiency, and evidence of rhabdomyolysis. Her procoagulant screening and connective tissue disease profile were negative. She has been managed with anticoagulation as per hospital protocol and also been given antiplatelets. She progressed to bilateral lower limb gangrene for which fore quarter amputation was done. It is advisable to exercise caution in using long term tranexamic acid usage especially in people who have thombophilic tendencies.

Keywords: Tranexamic Acid; Arterial Thrombosis. 

Fat embolism syndrome is a rare clinical complication of fat embolism which occurs in almost 90% of long bone fractures. Incidence of FES is around 0.2 to 2.5 % in overall cases of fat embolism. Its diagnosis is mainly clinical characterized by triad of respiratory, dermatological and neurological manifestations. We are presenting a case of 20 year young male who suffered traumatic left femoral shaft fracture in RTA. After uneventful 24 hours patient suddenly developed altered sensorium in absence of any respiratory or dermatological manifestation. He was confirmed to have CFE after series of brain imaging and was then managed conservatively for the same to which he responded well.

Keywords: Cerebral Fat Embolism; Fat Embolism Syndrome; Major Trauma; Traumatic Brain Injury. 

Symptomatic supraventricular tachycardia (SVT) is a common presentation in the Emergency Department which can be a lifethreatening condition and this requires immediate intervention. Stable SVTs are commonly treated with Adenosine but adenosine is more effective in AV nodedependant SVTs as it causes transient AV block [1] and causes normalization of the cardiac rhythm. American Heart Association AHA’s ACLS protocol recommends 6mg then 12mg (total 18mg) dose for SVTs [2]. However there is limited data as to how much maximum dose can be given for those SVTs that fail to terminate with standard dosing schedule [1]. This case report describes a 30 years old female with symptomatic SVT which failed to revert with normal dosing of adenosine neither with electrical cardioversion nor with multiple antiarrhythmic drugs but responded only to a much higher dose of adenosine.

Keywords: Supraventricular Tachycardia; AVRT (Atrioventricular ReEntry Tachycardia); AVNRT (Atrioventricular Reentrant Tachycardia); Adenosine; Cardioversion; ACLS (Advanced Cardiac Life Support); AV (Atrioventricular) Block; AHA (American Heart Association); ED (Emergency Department); Refractory; Ursodeoxycholic Acid; WPW Syndrome (Wolf Parkinson White). 

Rhabdomyolysis is the breakdown of skeletal muscle which is found commonly associated with crush injuries, compartment syndromes, strenous exercise and drug abuse but rarely found due to consumption of medications like statins. Here we present a case of a 62 year old male who had presented to the emergency roomwith paraplegic, myalgia and hyperkalemia after about a month of being started on statins. Further clinical and laboratory evaluation were suggestive of a diagnosis of statin induced rhabdomyolysis causing acute renal failure and hyperkalemia. Awareness about the adverse effects of individual statins may help develop a clinical suspicion of rhabdomyolysis among the Emergency physician and also helpother physicians make better decisions in the choice of statin use and promote regular monitoring of CPK levels in preventing incidences of rhabdomyolysis.

Keywords: Rhabdomyolysis; Statins; Acute Renal Failure; Hyperkalemia; Paraplegia; Myalgia. 

A 38 years old female, a known case of MDP/Schizophrenia, was brought to ED with 5 days h/o high fever, tightness of whole body, altered mental status, reduced urine output, inability to eat and speak, following an intake of an atypical antipsychotic Amisulpiride 100mg over period of 23 days prior to symptoms. With the history, physical examination and investigations, a diagnosis of neuroleptic malignant syndrome (NMS) with rhabdomyolysis and acute kidney injury (AKI) was made and supportive treatment started with hydration, dopamine agonism, anticholinergic drugs and urine alkalinization. She started improving after 1 week of aggressive treatment and was discharged in stable condition after 3 weeks.

Keywords: Neuroleptic Malignant Syndrome; Manic Depressive Psychosis; MDP; Schizophrenia; Muscle Rigidity; Rhabdomyolysis; Acute Kidney Injury; Kidney Failure; Amisulpiride; Antipsychotic; Neuroleptic; Idiosyncratic; Dopamine; Dopaminergic; Prolonged QTc; Urine Alkalinization; Creatinine Phosphor Kinase; CPK. 

Abdominal pain is one of most frequently encountered complain in the emergency; poses a diagnostic challenge for the emergency physician as differential diagnosis ranges from benign to life threatening conditions. History, vital signs and physical findings may not point a specific diagnosis and laboratory testing is often not helpful. Especially in females difficulty in physical examination and nonspecific clinical picture may lead to delay in diagnosis. Sometimes patients’ hemodynamic instability limits radiological intervention. Uterine torsion is a rare condition in the non gravid uterus may cause irreversible ischemic damage to the uterus, leading to rapid clinical deterioration, firstly reported by The Times in 1861 [1]. Here we report a case of a young non-gravid woman presenting with acute abdominal pain with hemodynamic instability and upon investigation, she was found to have uterine torsion of uterus due to uterine fibroid.

Keywords: Torsion; Non Gravid Uterus; Ligaments; Fornix. 

Cardiac tamponade is a lifethreatening condition due to abnormal collection of fluid in the pericardial sac causing hemodynamic instability. In trauma it is blood that gets collected in the sac, most commonly due to penetrating chest injuries or less commonly, blunt chest trauma. If this is not diagnosed and intervened timely, this can be rapidly fatal. We are reporting a case of 35 years old male who was involved in a road traffic accident (RTA). He sustained steering wheel injury on his chest and was taken to multiple hospitals where he was managed only conservatively due to missed diagnosis, before presenting to our ED (Emergency Department). He was here diagnosed with cardiac tamponade with obstructive shock and was urgently taken to operation theatre (OT) for pericardial decompression and was saved.

Keywords: Cardiac Tamponade; Thoracic Injury; Hypotension; Obstructive Shock; Beck’s Triad; Muffled Heart Sounds; Pulsus Paradoxus; Electrical Alternans; Kussmaul Sign; Road Traffic Accident (RTA); Controlled Fluid Resuscitation; Thoracotomy; Sternotomy; Pericardiectomy; Pericardiotomy; FAST Scan. 

Acute disseminated encephalomyelitis (ADEM) is a rare disease of central nervous system with a spectrum of presentation. It is a diagnosis of exclusion and relies on neuroimaging which may be normal at the onset. It is a diagnostic challenge at its first attack. The disease is although more common in children it can invariably be present in adults. Here we present a case report of ADEM in a 30 year old female who presented to ER with history of multiple episodes of vomiting followed by sudden onset of dysphasia and other neurological complaints. The patient had a history of recent travel to a pilgrimage where she had enteric fever around 15 days ago. It was our neurology team which correctly recognised and treated it as ADEM. The patient responded well to the treatment and discharged in stable condition after 5days. Sadly the disease had a relapse which now showed no response to iv immunoglobulins, steroids or plasmapheresis. The patient was in the hospital for symptomatic management and is still surviving in the hope of a normal well being.

Keywords: Acute Disseminated Encephalomyelitis; Central Nervous System; Neuroimaging. 

A 31yearold male found unconscious in his parked car on road side was admitted for evaluation and management in the hospital. The patient presented with central and peripheral cyanosis and arterial blood gas (ABG) report revealed 54.4% oxyhaemoglobin, 44.5% methaemoglobin and 1.1% carboxyhaemoglobin. The patient was put on 100% oxygen. Keeping in view the ABG report, the patient was treated as methaemoglobinaemia and started on 1% methylene blue solution intravenously. The patient, on regaining consciousness, told that he had accidently ingested petrol a few hours back. Later on, further investigations revealed that the patient had bite cells in peripheral blood smear suggestive of hemolytic anaemia. The patient informed that he is a known case of Glucose6Phosphate Dehydrogenase (G6PD) deficiency. The patient was managed as a case of petrol ingestion methaemoglobinaemia with G6PD deficiency and discharged from hospital.

Keywords: G6PD Deficiency; Methaemoglobinaemia; Methylene Blue; Petrol Ingestion. 

Posterior wall myocardial infarction (PWMI) accounts for about 1520% of all STEMIs and is usually seen in the context of inferior and/or lateral wall MI [2]. Isolated posterior wall MI are much less common, of about only 3.3% of all myocardial infarcts [1]. The clinical presentation of PWMI may not be very specific and is confusing even for a cardiologist. Moreover the lack of ST elevation in a standard 12lead ECG leads to missed or delayed diagnosis of a true PWMI. We are reporting a case of isolated PWMI in a 65 years old, previously healthy male patient, who presented with only gradual onset shortness of breath, who was later found to have 100% LCx stenosis. We have tried to emphasize some facts that may make the clinicians aware of a possible PWMI.

Keywords: ST Elevation Myocardial Infarction (STEMI); LCx; PWMI; Posterior ECG Leads V7 V8 V9; Right Coronary  Artery (RCA); Left Anterior Descending Artery (LAD); ST Depression; Dominant R Wave; Flip Test; Coronary Angiography (CAG); Troponin I; Percutaneous; Coronary Intervention (PCI); Stenting. 

Scorpion bites are common in India and an important public health hazard in tropical and subtropical regions of India. Though generally bites are harmless, sometimes they can lead to serious sequelae including death. Herein we present a rare case of scorpion sting presenting as myocardial infarction manifesting in the form of asymmetric pulmonary edema after 24 hours of sting along with congestive cardiac failure, successfully treated with non invasive ventilation and inotropes. The etiology of the cardiovascular manifestations in scorpion sting is related to the venom effects on the sympathetic nervous system and the adrenal secretion of the catecholamines as well as to the toxic effects of the venom on the myocardium.

Keywords: Scorpion Sting; Pulmonary Edema; Congestive Cardiac Failure.

Thrombosis of the cranial venous sinuses and the cerebral cortical veins can lead to a distinct cerebrovascular disorder, which unlike arterial stroke, most often affects even young adults and children. Symptoms and clinical courses are highly variable, etiological factors are even more heterogeneous making cerebral cortical vein thrombosis (CVT) a unique clinical entity.We report three cases in which the initial presentation in our Emergency Department (ED) led to suspicion of CVT, had it diagnosed and recognised hyperhomocysteinemia.

Keywords: Cerebral Venous Thrombosis; Hyperhomocysteinemia; Headache. 

Hypoglycemia is defined as random blood sugar equal to or lower than 60mg/dl. The most common cause is medications such as sulfonylurea, biguanides and insulin. Other causes include liver disease, certain tumors, kidney disease, severe infections and starvation. It can be a very common presentation in elderly patients with altered mental status who are on polypharmacy. Investigating recurrent hypoglycemia can be a challenge. Whilst the obvious focus is to rule out an underlying endocrine etiology, a thorough history and recognition of factitious cause is important and worth bearing in mind. This can be difficult to diagnose and often, can only be ruled out by extensive investigations and exclusion of other causes . Patients with clinical hypoglycemia unawareness are at high risk of severe hypoglycemia that requires thirdparty assistance. Hypoglycemia is less frequent in type 2 diabetes than it is in type 1. Populationbased data indicate that the overall event rate for severe hypoglycemia (requiring the assistance of another individual) in insulintreated type 2 diabetes is approximately 30 percent of that in type 1 diabetes (35 versus 115 episodes per 100 patientyears). In this case a young non diabetic female presented to ED in a state of altered mental status with recurrent hypoglycemia, the cause for which was thought to be sepsis and ultimately diagnosed as fulminant hepatic failure. In fulminant hepatic failure there as altered mental status with coagulopathy in setting of acute liver disease. Neurotoxins like ammonia and glutamine with cytokines produce cytogenic and vasogenic effects which leads to cerebral oedema and thus altered sensorium. Patient presents in a state of hepato cellular dysfuction, encephalopathy and cerebral oedema, infections or multi organ failure. The case emphasizes the importance of appropiate history taking and correct differential diagnosis establishment in order to achieve good outcome of a patient with fulminant hepatic failure.

Keywords: Hypoglycemia; Diabetes; Hepatic Failure; Altered Sensorium.

ICH can be spontaneous or traumatic. the most common cause of ICH in adults is trauma(road traffic accident or fall from height) and CVA. In neonates and infants ICH is caused by trauma associated with labor and delivery. Factor VII deficiency presenting as ICH on an infant is a rare entity. Here we present a case of 40 day old male child presenting as seizure which was later diagnosed to have ICH due to severe factor VII deficiency.

Keywords: Intracranial Haemorrhage; Factor VII Deficiency; Seizure; Prothrombin Time; Haemorrhage. 

Malignant hypertension (MHTN) is a hypertensive emergency with end organ dysfunction and MHTN presenting as renal thrombotic microangiopathy is rare. It is characterized by microangiopathic hemolysis, anemia, thrombocytopenia, indirect hyperbilirubinemia and variable degrees of renal failure apart from papilledema and acutely elevated blood pressure. The degree of renal failure may vary depending on the extent of endothelial damage and stimulation of renin angiotensin aldosterone system. Herein, we report a rare case of malignant hypertension in a young boy with renal TMA. He has bilateral papilledema and initial blood pressure of 210/100 mm of Hg. He has features of microangiopathic hemolysis and severe oliguric renal failure. His blood pressure was managed in Emergency Department with IV nitroglycerin and IV labetalol continuous infusion. He was instituted on hemodialysis through right Internal Jugular access and was continued on dialysis for the next two weeks. His blood pressure was managed with oral antihypertensives (Metaprolol (100mg/day), Nifedipine (60mg/day), Hydralazine (100mg/day), Torsemide 40mg/day). He showed good signs of improvement with adequately controlled blood pressure (140/80) and a stable renal function (Ser. Creat of 2.3 mg/dl, during last followup). Unlike Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome complex, renal TMA associated with malignant hypertension will not respond to plasmapheresis and adequate emergent management of blood pressure in emergency department will limit the extent of renal damage. The level of LDH, platelet count and hemoglobin can be used as markers of microangiopathic hemolysis. Renal recovery can vary from complete to partial recovery.

Keywrods: Malignant Hypertension; Mmicroangiopathic Hemolysis; Renal Failure. 

A patient Mr. Satya Narain Chauhan, 67 yrs old male, diagnosed case of DM, Ca prostate presented with complaints of urinary retention and slurring of speech. On examination Mr. Chauhan is having left lower limb weaknessnot able to stand/ walk, midline lumbosacral tenderness present So, Mr. Chauhan was evaluated for spinal cord compression, and to rule out CVA. Patient had sclerotic metastasis in lumbosacral spine, and mass lesion in cerebellum.

Keywords: Carcinoma Prostate; Cerebellum; Hydrocephalus. 

Oneandahalf syndrome is a clinical disorder characterized by an ipsilateral conjugate horizontal gaze palsy and an ipsilateral internuclear ophthalmoplegia. The main causes of this rare syndrome are stroke and multiple sclerosis. Other causes include tumors, AV malformations, basilar artery aneurysms and rarely, vasculitis, brainstem tuberculoma and neurocysticercosis. Here we present a case of 69 year old male patient who presented to emergency with only blurring of vision and was diagnosed to have acute left sided/ paramedian acute dorsal pontine infarct,one and a half syndrome.

Keywords: One and Half Syndrome; Infarct; Pons. 

Acute myocardial infarction (AMI) among young is relatively uncommon. Coronary artery disease (CAD) mostly occurs in persons older than 45 years of age. In recent times, with the advent of sedentary lifestyles, smoking, drug abuse and obesity; among other traditional risk factors; incidence of young patients suffering from acute coronary syndrome in particular acute MI, is on the rise. Atypical presentations and the reluctance to seek medical attention are other contributory factors in young adults. The disease carries significant morbidity, psychological as well and financial effects on the patient and his close ones. Here we have reported a case of a 28 year old male with no known co morbidities presenting to the ED with ongoing chest pain since an hour and h/o diaphoresis. Patient was evaluated in ED, ECG suggestive of progressively increasing ST segment elevation in inferior leads. The patient was evaluated, Coronary angiography was done and found to have an uncommon Apical Left Anterior Descending artery ( Type III or “wraparound” LAD) occlusion leading to an inferior wall MI.

Keywords: Acute MI; Thrombolysis; Coronary Angiography; Troponin I; Angioplasty; AMIAnterior Myocardial Infraction. 

Stroke is often considered as a disease of elder population, being uncommon in young has a large socioeconomic impact to the families by leaving the victim disable before their most productive years. Of all stroke cases, 10% are seen in patients younger than 45 years of age. The risk factors for stroke in young adult patients can be traditional vascular risk factors but rare risk factors are not uncommon. Stroke in young patients; though considered to have a better prognosis than stroke in the older population; can cause significant limitations in quality of life of these patients, with them being at higher risk of cardiovascular events as well as higher death rate. Such patients also have a higher five year risk of recurrent stroke especially if associated with age> 40 years, type 1 DM, history of TIA, Hypertension . Here we present a case report of an Acute left basal ganglia ischemic stroke in a young previously diagnosed hypertensive male, non compliant to antihypertensive medications.

Keywords: Ischemic Stroke; Stroke in Young; Thrombolysis; Vascular Risk Factor; TEETrans Oesophageal Echocardiography. 

Topiramate is an anticonvulsant drug which is also used for migraine prophylaxis. It has many neurological and psychiatric side effects in addition to diarrhoea and weight loss. It can cause serious ocular side effects like sudden dimness of vision secondary to acute narrow angle glaucoma and or myopia. These sideeffects usually occur at more than 200 mg per day dose and after 4 to 6 weeks of starting treatment with the drug. We report a case of 20years old female who developed sudden dimness of vision in both eyes after migraine prophylaxis with topiramate 25 mg daily for seven days. Her cause of this vision problem was secondary acute angle glaucoma and myopia because of topiramate. After stopping the drug her vision became normal within seven days. Clinicians should explain ocular side effects of topiramate and if he/she develops such visual problems, he/she should stop the drug and consult clinician immediately.

Keywords: Rare Ocular Side Effect; Topiramate. 

Myotonic Muscular Dystrophy is inherited form of an autosomal disease which may include cataract, low I.Q., and heart conduction problems. In men their may be early balding and an inability to have children and gastric tract problems are common. It is a form of muscular dystrophy that affects muscles and many other organs in the body. Myotonia means an inability to relax muscles at will, which makes it difficult to relax the fingers after a firm hand grip. Muscular Dystrophy means progressive muscle degeneration leading to weakness and shrinkage of muscle tissues. It is caused by CTG triplet repeat expansion in none coding region of DMPK gene on chromosome 19q13.3, encoding myotonin. Myotonin is required for inter cellular conduction.

Keywords: Myotonic Dystrophy; Myotonia; Autosomal Dominant Disorder; Dmpk Gene; Myotonin. 

Tetanus is an acute disease manifested by skeletal muscle spasm and autonomic system disturbance. A case of tetanus is a medical and social concern due to its high prevalence in developing countries. Tetanus as a disease is very distressing for the caretakers of the patient due to its painful and distressing presentation. A scoring system to monitor the progression or deterioration in the course of the disease was a felt need of the hour. ‘TETPRO’ scoring system was devised for the same. The scoring involved 10 parameters involving assessment of motor and autonomic symptoms. Using this it was very comfortable to monitor the progression of the disease and also for daily counseling the family members regarding the response of the patient and possible outcome.

Keywords: Tetanus; Progression; Deterioration. 

Introduction: AKI occurs predominantly in urban intensive care units and is associated with multiorgan failure and sepsis, high mortality, and occurrence in older populations. While cases of AKI in urban areas of the developing world have similar characteristics to those in the developed world, AKI in rural regions commonly develops in response to a single disease and specific conditions (e.g. gastroenteritis) or infections (e.g. severe malaria, leptospirosis, or hemolytic–uremic syndrome) and in younger otherwise healthy individuals. Methodology: Acute Kidney Injury,the major inclusion and exclusion criteria were identified. Data regarding etiology,clinical features, outcome to treatment were collected over a period of one year from Jan 2011 to Jan 2012 in total of 200 admitted patients. The outcome of the study was analyzed and documented. Results: The youngest person enrolled was 20 yrs and oldest was 86 yrs of age.Amongst the pre renal conditions acute diarrheal diseases are the commonest Oliguria dominate as the most common presenting symptom in patients with AKI. Conclusion: Acute kidney Injury is commonly seen in men than in women below the age group of 50 yrs.

Keywords: Acute Renal Failure; Glomerulonephritis; AKI. 

Introduction: As the patients are the consumers of a Hospital. There is huge importance of evaluating patient services from consumer’s perspective. If we compare what people expected about a health care service with their real experiences, it has been found to influence their over all satisfaction. Aim & Objective: of this study was to find out in which parameters the expectations are high and what are the unmet expectations with respect to the Emergency Department. So that Hospital can find out ways of improvement of the same. Material & Method: Individuals were given pre and post ED visit 12 preformed questionnaires & individual perception scores of questions have statistically analyzed. Results & Discussion: It was found that out of 12 only in 3 questions the post visit experience superseded the previsit expectations. Conclusion: This study gives a scope of discussion for further improvement in quality of healthcare provided in the tertiary healthcare center & paves a path for further studies to occur and help to make policies to give better patient care.

Keywords: Healthcare; Emergency; Intensive Care. 

Organophosphorus chemicals (OPs) are the pesticides most often involved in serious human poisoning in developing countries like India. Treatment of intoxication with OPs conventionally involves atropine for reduction of muscarinic signs and oximes that increase the rate of hydrolysis of the phosphorylated enzyme acetylcholinesterase (AChE). Although oximes (pralidoxime or obidoxime) are traditionally considered specific antidotes and used in the management of such poisoning, their efficacy remains a major issue of debate. Thus, the goal of this clinical study was to elaborate the value of magnesium sulfate (MgSO4) in the management and outcome of acute OP insecticide poisoning. This unicenter, randomized trial study was conducted on patients who were acutely poisoned with OPs and admitted to Kempegowda Institute of Medical Sciences & Hospital. In this study patients where randomly divided into 2 groups (25 patients each). Control group and test group. Control group received conventional management with injection atropine and injection PAM while the test group in addition to above received intravenous Magnesium sulphate. Magnesium sulphate was administered at dose of 4 g/day intravenous infusion over 4 hours within first 24 hours after ingestion. There was a significant decrease in number of days of ventilation (z=2.1, p=0.04) and days of ICU stay(z=4.1, p<0.001) on independent Mann Whitney Tests in patients who received MgSo4 than those who had not received MgSO4. The mortality rate, total atropine required and hospitalization days of patients who received MgSO4 treatment were significantly lower than those who hadnot received MgSO4 (P=<0.05). It is concluded that administration of MgSO4, in a dose of 4 g/day concurrent to conventional therapy, in OP acute human poisoning is beneficial by reducing the hospitalization days and rate of mortality.

Keywords: Human; Magnesium Sulphate; MgSo4; Organophosphate Poisoning; OP; Treatment; Mg2+. 

Context: Pesticide exposures are common health issues in India. Traditionally used pesticides like organophosphates are associated with higher morbidity and mortality. Neonicotinoids are newer class of effective and safer insecticides. However, literature of human exposures is very limited. Aims: To study clinical profile, laboratory features and factors associated with mortality after acute human neonicotinoid exposures. Settings and Design: This retrospective observational study was performed at department of general medicine in rural tertiary care public hospital. Methods and Material: Necessary data of admitted eligible cases of acute neonicotinoid poisoning during five year period of January 2012 to December 2016 were retrieved from medical record section and were analysed. Statistical Analysis: Statistical analyses were performed by using Graph pad prism 5. The incidence of Clinical findings, 95% confidence interval, relative risk, and baseline characteristics of patients were calculated by Wilcoxon rank sum test and chi square test. Statistical significance was established at p < 0.05 and RR values were considered statistically significant if 95% of CI excluded 1%. Results: A total of 141 cases were analyzed. Most exposures involved oral intentional consumptions of Imidacloprid. Clinical manifestations of acute neonicotinoids exposures involved variety of body systems. Severe/fatal cases had higher proportion of respiratory, neurological and cardiovascular manifestations and variety of laboratory and ECG finding. Although most exposures were asymptomatic or nonsevere poisoning, 26 cases had severe poisoning with five deaths. Conclusions: Even though considered as relatively safer insecticides, large intentional consumption can lead to severe poisoning and even death. Supportive treatment is usually sufficient and severe poisoning needs intensive case.

Keywords: Imidacloprid; Insecticide; Neonicotinoid; Poisoning. 

Noninvasive ventilation has been a major advancement in the management of acute exacerbations of chronic obstructive pulmonary disease. It reduces the need for endotracheal intubation, thereby reducing associated complications and hospital cost. The aim of our study is to assess the efficacy of noninvasive ventilation in acute exacerbations of chronic obstructive pulmonary disease with respiratory failure. A total of 86 patients presenting with acute respiratory distress at our emergency room were initially included and evaluated. Non invasive ventilation was initiated in addition to standard medical treatment in all cases. Response to therapy in terms of improvement in patients’ vitals and ABG were sequentially recorded and analyzed. Overall 72.5% (n=29) of the patients improved, whereas 27.5% (n=11) did not improve with NIV among whom 63.63% (n=7) had to be mechanically ventilated. 62.5% (n=25) showed a good ABG response with improvement in pH and decrease in PaCO2 levels. Therefore, NIV should be considered to be the first line of management in acute exacerbations of COPD with respiratory failure.

Keywords: Acute Exacerbation; Chronic Obstructive Pulmonary Disease; Respiratory Failure; NonInvasive Ventilation; Endotracheal Intubation, Arterial Blood Gas.

In a clinical setting, Fever is the most common sign of illness in infants and children and accounts for as many as 20% of pediatric emergency department (ED) visits. Clinical evaluation of febrile illness is guided by history and physical examination, along with judiciously selected screening test. Most of the studies have been done at ambulatory care setting with lack of proper follow up of the patients and accurate data regarding bacterial and viral aetiologies because of the difficulty in making microbiological diagnosis in ambulatory care settings. In this study all children more than 3 months and under the age of 15 years presenting to ED with fever and warranting hospitalization were included and analyzed as regards the spectrum of febrile illness and its correlation with clinical findings at presentation and laboratory investigations at and during the entire hospital stay. Objectives: To study the spectrum of acute febrile illnesses and develop a Clinical and laboratorial correlation in children more than 3 months and under the age of 15 years warranting ER visit and subsequent hospitalization. Methods and Material: It was a Prospective observational unicentric study done at Max Super Speciality Hospital, Shalimarbagh, New Delhi. Data was collected over a period September 2016 to May 2017 from 580 pediatric patients visited to ED and got admitted, as per data collection sheet after the approval by scientific and ethics committee of the institute. Statistical Analysis Used: The collected data was entered in the Excel spreadsheet using Microsoft Excel Software and transferred to Statistics Package for Social Sciences (SPSS) version 20, IBM Inc. for analysis. It was subjected to descriptive statistics for calculation of mean, standard deviation, frequencies and percentages. Summarized data was presented using Tables and Graphs. Shapiro Wilk test was used to check which all variables were following normal distribution. Chisquare test was used for comparison between categorical variables. Pearson’s correlation coefficient (ordinal data) was calculated to measure the strength of a relationship between provisional diagnosis and final diagnosis. Level of statistical significance was set at pvalue less than 0.05. Results: This study was done at a tertiary care hospital where yearly about 14200 patients visited to Emergency, 40% of all attendance is pediatric and among them 60% were prompt by fever. This data was also supported by the previous studies . The majority of the children who presented with fever and got admitted fall under the age group of 415

years which accounts or 76% of the total study population. Male outnumbered females .Male accounts for 67% (n=389) and Female accounts for 33% (n=191) among all total pediatrics hospital admissions. Out of 580 study population in presenting symptoms respiratory predominance was seen (29.1%) which was followed by fever with rash (26.8%). Most common diagnosis documented in our pediatric patients with acute febrile illness were URTI, majority of them presumably viral rhinopharyngitis (26.4%). This was followed by Dengue and dengue like illness and chikungunya each accounts for 13.4% and 21.5% respectively. Enteric fever was the most common diagnosis documented (24.7%) in among all specific bacterial diseases. Electrolyte disturbances specially hyponatremia was observed in 58% of pediatrics patients and was invariably associated with dehydration. Dehydration accounts for 5.7% of total study population. Conclusions: In conclusion, Emergency services are an integrable part of any healthcare infrastructure with almost 40% of being pediatrics attendance. Fever constituted 60% (almost 2/3 rd patients) of febrile illness. Infectious diseases still accounts for the majority of ER attendance. The standard protocol of diagnosis and management if applied well, confirms the diagnosis with accuracy resulting in a favorable outcome

Keywords: Fever without Source (FWS); Serious Bacterial Infection (SBI); Urinary Tract Infection (UTI); Febril Seizure (FS); Emergency Department (ED). 

TRAUMA is the third overall cause of death and the first cause of death before 40 yr of age [1]. Early recognition of haemorrhage and shock in traumatic patients can prevent death, most deaths (80%) occurring within 48 hrs, haemorrhage being the leading cause of death [1]. Estimation of lactate clearance can be used as a diagnostic and prognostic biomarker in case of trauma patients [1]. Aims: To establish the prognostic significance of the lactate clearance in unstable trauma patients. Settings and Design: This is a “prospective observational study“among the patients who presented to the Emergency Department of BGS Global Hospital. Methods and Material: The patients will undergo ABG or VBG, as feasible along with blood lactate estimation which shall be repeated after 4 hours and the lactate clearance is calculated for 4 hrs. Statistical Analysis Used: All quantitative data are analysed using mean, median and standard deviation. All qualitative data are analysed using the chisquare test. Results: According to the lactate clearance values, the death rate was high at higher lactate clearance values and the discharge rate was high with lower lactate clearance values. According to the initial lactate values, the discharge rates are high with low initial lactate levels than at higher initial lactate levels. Conclusion: This study concludes that all the trauma patients with lower Lactate clearance and lower initial lactate levels had better outcome when compared with those who had high lactate clearance and high initial lactate levels at the time of admission.

Keywords: Lactate Clearance; Trauma; Heamorrhage; Shock; Initial Lactate Values. 

Introduction: The most frequent causes of postrenal AKI in the elderly include benign prostatic hypertrophy (BPH) or prostate cancer, retroperitoneal adenopathy or malignancies, pelvic neoplasms, and neurogenic bladder. Although BPH and prostate cancer are common in older men, they cause obstruction in only a minority of cases. In elderly women, pelvic and retroperitoneal malignancies are the most frequent causes of postrenal AKI. Methodology: This study was conducted on 200 admitted patients who presented with Acute Kidney Injury or developed Acute Kidney Injury during the hospital stay in the Department of Medicine. The symptoms, signs and basic lab data like Routine Blood Examination for Hb, TC, DC, ESR & Platelet count; Renal function tests, Liver function tests, Serum Electrolytes & Routine Urine examination, was noted at the time of admission, during the course of hospital stay and at the date of discharge. Specific investigations like USG Abdomen, Renal Biopsy, Arterial Blood Gas analysis was done accordingly to analyze the etiology. Results: Pre renal conditions predominate as the cause for AKI. Post renal causes account for only 2.5% of the total. People above the age group of 50yrs was at an increased risk for the development of AKI. Conclusion: Septic AKI was the commonest cause of increased mortality followed by leptospirosis.

Keywords: AKI; Outcome; Leptospirosis. 

Background: India is estimated to have the highest snakebite mortality in the world. The hitch with determining the optimum ASV dose is that the quantity of venom injected at a bite is very variable. There are very few studies to determine the effective dose of ASV. But recent studies have found that low dose ASV is as good as or even better (lesser complications) than high dose ASV. Despite evidence for smaller doses from evidencebased medicine, most centers are still using large doses. The is a need for investigating in this area to know the effective dose of ASV in management of snake bite patients resulted in taking up of present study. Material and Methods: this study carried out in Medicine department, SIMS, Shimoga for 6 months from January 2017 to June 2017. 100 snakebite patients with haemostatic abnormality admitted to Mc Gann Hospital. A detailed history was taken in all the patients and a through physical examination was done. CBC, RFT, LFT, BT,CT, PT, INR, ECG, is done. The two study groups are 50 consecutive patients formed Group I (Conventional high dose regime (100ml) group). 50 consecutive patients formed Group II (Low dose regimen (30ml) group). Results: The mean age was 37.67 (± 4.56) years. With male to female ratio being 1.3:1. The mean Snakebite to ASV given time was 14.5hours. Average CT (at presentation), Group 122.6 ±7.59 mins. Group 229.47 ±5.59 mins. ASV dose required, Group 1325 ±183 ml. Group 2175.75 ±±87.4 ml. Time lapse for CT normalization, Group 124.97 ±5.58 hrs. Group 214.93 ±4.49 hrs. About 2025% of patients developed acute renal failure [11 (22%) and 5 (10%) patients in groups I and II respectively]. Number of patients died in Group 15 (10%). Group 24 (8%). Conclusion: The observation that very low dose of ASV is adequate to save lives of victims of poisonous snake bites with early hospitalization and good supportive management. This will definitely decreases economic burden on the society.

Keywords: Venom; Snakebite. 

Chest pain is one of the most common presentations in emergency department and India has the highest burden of acute coronary syndrome in the world. Increasing awareness regarding it has lead to increased diagnosed cases and hence people getting early definitive treatment. Various studies have shown that door to balloon time within 90 min increases the survival rate. In this study, we analyse the door to balloon time of 90 min in a tertiary centre hospital for STelevation myocardial infarction.

Keywords: Infarction; STSegment Elevation; ECG. 

Background: Cardiovascular disease is one of the leading causes of morbidity and mortality across the world. World Health Organization (WHO) has declared cardiovascular disease as a modern epidemic. Acute Myocardial Infarction is one of the manifestations of coronary heart disease leading to morbidity and mortality. Arrhythmias and hemodynamic abnormalities in left ventricular dysfunction are the major causes of mortality along with acute myocardial infarction. In majority of the patients with acute myocardial infarction. one of the commonest cause of death is life threatening arrhythmias. Many inorganic salts especially of alkaline elements including sodium and potassium. Material and Methods: Prospective study carried out in Medicine department, SIMS, Shimoga for 6 months from Jan 2017 to June 2017. 50 patients of acute myocardial infaction admitted to intensive coronary care unit, of Shivamogga institute of medical sciences, Shivamogga, irrespective of site of infarction and irrespective of type of arrhythmia were included in the study. Detailed history of each patients was obtained. Thorough physical and systemic examination will was done in all the patients. Routine blood and urine examination was sent. First electrocardiogram was taken at the time of admission. Serial electrocardiograms were taken till patient remained till the time of discharge or death. Serum sodium and potassium was estimated in the manner likes i. At the time of admission to ICCU. ii. At the time of development of arrhythmia or after 24 hours of admission if arrhythmias were not present. Result: 15 patients (30%) of all MI patients found to be hyponatraemic. 10 patients (20%) found to be hypokalaemic. Patients with hyponatremia were not found to have any rhythm disturbance, 3 patients with hypokalemia had frequent ventricular ectopics, 1 patient had atrial fibrillation and 2 patients had ventricular tachycardia. Conclusion: there was no increase in rhythm disturbances in hyponatremic patients, however there was definite correlation with arrhythmias in patient with hypokalemia.

Keywords: Myocardial Infarction; Hyponatremia; Hypokalemia; Arrhythmia.