Indian Journal of Emergency Medicine

Electrocardiogram has been one of the oldest diagnostic modality for myocardial infarction. In last five years, pseudo ST elevation in critically ill patients in the form of “spiked helmet sign” has been studied [1-6]. Spiked helmet sign has been associated with noncardiac illnesswith raised intra-thoracic pressure or raised intraabdominal pressure [1-6]. We report one such case, encountered in our accident and emergency department, with ECG showing spiked helmet sign.

Keywords: Spiked Helmet Sign; Electrocardiogram. 

Background: A 27 years old non diabetic woman with suicidal liraglutide overdose presented in emergency with nausea, vomiting and burning pain abdomen. Case Presentation: We reported her blood glucose of 54 mg/dl in emergency, have given her 25% dextrose intravenous bolus and started her on 10% dextrose intravenous infusion, with other supportive medications. Her symptoms improved with intravenous glucose infusion and blood glucose level maintained normal in next 24 hours. Her liver function test and serum amylase remained within normal range. Conclusion: In our case one episode of hypoglycaemia was reported in emergency (blood glucose 54mg/dl and drowsiness), though hypoglycaemia was never reported in any previous case report of liraglutide overdose. So, hypoglycaemia, though rare, can still be a possible complication of liraglutide overdose.

Keywords: Liraglutide; Hypoglycaemia. 

This 50 year old lady presented to the emergency with history of one episode of syncopal attack followed by fall on the floor and involuntary movement of body parts. No history of vomiting and ENT bleeding. On presentation she was conscious, oriented to time, place and person and her vital status were heamodynamically stable. This case highlights the occurrence of Takotsubo Cardiomyopathy (TCM) in a middle age female patient perimenopausal women.

Keywords: Cardiomyopathies; Cardiogenic Shock; Blunt Cardiac Injury; Stress Cardiomyopathy. 

ATLS guidelines are considered standard for clearing the C-spine all over the world in any trauma patient. As per the guidelines, in patients with dangerous mechanism of injury, CT C-spine is considered as gold standard to clear C-spine in patients with absent initial permanent or transient neurological abnormalities. We are presenting a case of a 62 years old male who suffered from a RTA with dangerous mechanism of injury. Despite clearance of C-spine as per ATLS protocol , patient eventually landed up in quadriplegia; thus raising the question in mind that whether ATLS protocol is enough or we need to think beyond it for decreasing morbidity in such cases.

Keywords: Cervical Spine; Spinal Cord Injury; Acs in Trauma; Quadriplegia; Spine Immobilisation. 

Diabetic ketoacidosis is a life threatning complication of Diabetes Milletus and can be catastrophic if left untreated.Being one of the most common complications but sometime with no clear history and symptoms the diagnosis become difficult. Hence emergency physicians should keep a broad vision while dealing with young patients with high glucose level. Diabetic ketoacidosis may be the first symptom of previously undiagnosed Diabetes. It is diagnosed with combination of Hyperglycemia, Acidosis and Ketonuria. Patients with prolonged acidosis and tendency to hypokalemia should be investigated for consumption of synthetic cannabinoids. No literature till date have showen Metabolic acidosis with PCO2 4.7 mmHg and HCO 3 1.3 mmol/L.

Keywords: Diabetic Ketoacidosis; Hyperglycemia; Acidosis; Ketonuria; Cannabinoids. 

Any organ system in the body can be affected by tuberculosis. While pulmonary tuberculosis is the most common presentation, extrapulmonary tuberculosis including ocular tuberculosis is also an important clinical problem. Most commonly, ocular tuberculosis presents as anterior uveitis or choroiditis which is caused either by hematogenous infection or hypersensitivity after another organ infection. Eyelid involvement by tuberculosis is mostly secondary to orbital tuberculosis and often presents as a draining sinus. Isolated eyelid tuberculosis is however uncommon. We present the case of a 6 year old female with eyelid tuberculosis presenting as chronic non healing skin ulcer.

Keywords: Tuberculosis; Extrapulmonary Tuberculosis; Orbital Tuberculosis; Ocular Tuberculosis; Eyelid Tuberculosis. 

Background: Abdominal wall hematomas are an uncommon cause of acute abdominal pain and are often misdiagnosed as intra-abdominal pathologies. Elderly individuals and those on anticoagulation are more prone. Rectus sheath hematomas are more common as compared to internal oblique hematomas, which are rare. Case Report: We are reporting a rare case of internal oblique hematoma confirmed with contrast enhanced computed tomographic images. The patient was a 60 year old lady, with history of recurrent bouts of cough for one month. She had noticed a sudden onset swelling in the right flank over three day duration. Conclusion: In the emergency medicine department sharp clinical skills and early diagnosis of an anterior abdominal wall hematomacould prevent delay in management of such rare conditions. Internal oblique muscle hematoma should be considered as a differential diagnosis of a lateral abdominal swelling, especially in elderly and those on anticoagulation.

Keywords: Abdominal Pain; Anterior Abdominal Wall Muscle; Rectus Sheath; Internal Oblique Muscle; Hematoma. 

An anticoagulant is a drug (blood thinner) that treats, prevents, and reduces the risk of blood clots-breaking off and traveling to vital organs of the body, which can lead to life threatening situations. Anticoagulants are commonly used medications in the prevention and treatment of thromboembolic disease. Vitamin K antagonists (VKAs), primarily warfarin, have been the most frequently used agents for patients requiring chronic anticoagulation. More recently, newer oral anticoagulants including the direct thrombin inhibitors and factor Xa inhibitors have become available. Bleeding is the major complication of anticoagulant and fibrinolytic therapy. The criteria for defining the severity of bleeding vary considerably between studies, accounting in part for the variation in the rates of bleeding reported. The major determinants of vitamin K antagonist (VKA)-induced bleeding are the intensity of the anticoagulant effect, underlying patient characteristics, and the length of therapy. Iliopsoas hematoma is a rare complication that occurs in patients receiving anticoagulant therapy. The clinical manifestation of iliopsoas hematoma is non-specific. It can mimic orthopedic or neurological disorders, including paraesthesia or paresis of the thigh and leg due to compression of the nerve plexus.

Keywords: Anticoagulant; Vitamin K antagonists (VKAs); Coagulopathy; Newer Oral Anticoagulants; Factor Xa Inhibitors. 

Background: Ventilator associated pneumonia is a hospital acquired infection that develops after 48 hours or more after a patient is intubated with an endotracheal or tracheostomy tube and is put on mechanical ventilation [1]. Ventilator associated pneumonia is most common nosocomial infection in ICU and associated with prolonged hospitalization, increased health care costs, and high attributable mortality. Intubation independently increases the risk of developing nosocomial pneumonia atleast seven fold with a peak incidence occurring around day five of ventilation [2]. Tracheal intubation thwarts cough reflex, compromises mucociliary clearance, injures tracheal epithelial surface, provides a direct conduct for rapid access of bacteria from upper into lower respiratory tract and allows formation of biofilm on Endotracheal tube surface. The combination of these factors puts mechanically ventilated patient at great risk of developing VAP. Aims and Objectives: To study incidence of VAP in ET tube with subglottic suction port versus standard ET tube in cases of O.P poisoning in J.J.M Medical college, Davangere from December 2015-June 2017. Material and Methods: A prospective observational case control study of 80 patients admitted to Red Zone/ICU of J.J.M. Medical College, Davangere. Results: Patients who have presented with Organophosphorous poisoning between the age group of 18 to 60 years who require ventilator support, intubated with standard ET tube and another sub set of patients intubated with ET tube with subglottic suction port were analysed. In this study we found that distribution of various organisms with regards to sputum culture in both groups were pseudomonas being maximum and proteus was found in minimum percentage. When subglottic suction port is used we observed improved patients were 70% and deaths were 30%. When subglottic suction port is not used we observed improved were 55% and death were 45%. Conclusion: VAP is common in patients who are intubated in ICU, which has higher morbidity and mortality among these patients. In our study we observed that atropine usually decreases secretions, but here in this study patient population who were admitted developed secretions instead of adequate atropine dosage and also developed VAP. Use of ET tube with Subglottic suction drainage may prevent VAP in cases of Organo Phosphorous poisoning and also improves patient outcomes.

Keywords: Ventilator Associated Pneumonia; Endotracheal Tube; Subglottic Suction Port. 

Background: Acute poisoning is a medical emergency and preventable cause of morbidity and Mortality. Gastric lavage (GL) is one of the most commonly used decontamination method for poisoning in developing countries despite lack of supporting evidence. This study was designed to evaluate the outcome of patients with acute poisoning treated with GL in regards to timing of the procedure. Methods: In this study, GL was planned to be administered to patients with acute poisoning after initial stabilization. Early GL was defined as GL given within one hour of poison exposure and late GL was referred to performing the procedure after one hour till 12 hours of ingestion. Results: During the study period, 80 patients with acute poisoning received GL comprising of 30 who received early, 50 who received late. 23 patients (29%) died. Mortality, respiratory failure and duration of ICU stay was more in late GL treated patients compared to early GL patients however this was not stastically significant. Conclusion: Since in our study timing of gastric lavage did not create a meaningful difference in the overall mortality, respiratory failure and duration of ICU stay, it would be better that gastric lavage be given to all patients irrespective of early or late arrival without any clinical ambiguity.

Keywords: Gastric Lavage; Respiratory Failure. 

Introduction: In today’s world, all doctors are required to keep their medical knowledge and training up-to-date. Doctors should provide effective treatments based on the ‘best available evidence’. It is widely accepted that evidence-based medicine has contributed significantly to the practice of medicine and advancement of medical science. Every doctor should strive to contribute to the generation of evidence by conducting research. Objectives of the Study: To assess the awareness and knowledge of research skills among post graduate emergency medicine doctors in teaching hospitals of Kolkata and identify any further scope inculcating research skills of emergency medicine residents leading to contribution in health research. Methodology: It is a multicentre, prospective questionnaire survey among post graduate emergency medicine residents of teaching hospitals in Kolkata. The sample size was 100 done during period of 1 year. Discussion: 60.6% were more than 29 years of age and 32% among 26-28. 60% had prior experience of writing research paper and even then 96% wanted to participate in research methodology workshop. 99% knew that research improves outcomes in patient management and that they require continue guidance and supervision during their thesis projects. Only few were able to complete their research work on time. The major reasons cited for poor research activity in our study were inadequate facilities for research and lack of time. In institutional reasons, we found 54% had found inadequate support from mentors or assistants and 20% cited lack of research curriculum. 51% believe that active participation can be done by MCI/DNB and universities by allocating time for research and making it mandatory. Conclusion: The study population was male predominant and young with majority having the background of research knowledge. Most of the participants however agreed that research methodology workshop was needed to improve their knowledge and in fact should be made compulsory in post graduation courses. 97% felt that specific time should be allotted separately during curriculum planning for research. In conclusion research is the realized need among our study population. Steps should be taken for promotion of research among emergency medicine post graduate residents.

Keywords: Research; Emergency; Medicine Residents. 

Background: The proportion of older adults exposed to polypharmacy defined as use of multiple medications, is rapidly increasing in the last two decades. There are many negative medical consequences associated with polypharmacy apart from greater health care costs. Studies in developed world have revealed that people aged 65-69 years fill an average of 14 prescriptions per year and adults aged 80-84 years, and average of 18 prescriptions per year. The reduced homeostatic ability as people age, given changes in pharmacokinetics, pharmacodynamics and physiological reserve affects different regulatory systems in elderly subjects. Aim and Objective: The aim of the present study was to explore level and pattern and; the risk factors of polypharmacy among elderly admitted and discharged in Department of Medicine, Government Medical College, Jammu. Materials and Methods: The prospective study was carried out in the departments of general medicine, in government medical college hospital Jammu. A total of 650 patients who were admitted in the medicine ward of the hospital during this period were studied, out of which 100 patients aged 65 or more were included in the study. Conclusion: Our study suggests that current practice in our hospital is associated with greater polypharmacy and inappropriate medication use. A regular medication chart review particularly in the elderly, by the clinical pharmacist to discontinue unnecessary medication will reduce the polypharmacy and inappropriate medication use.

Keywords: Polypharmacy; Adverse Drug Events; Aging; Geriatrics; Internal Medicine; Multimorbidity.

Altered sensorium is a frequent presentation in emergency department, but the exact etiology of many altered sensorium patients is unknown. Patients present with vague symptoms, thus altered sensorium diagnosis and treatment are highly challenging for emergency physicians. The aim of this study is to provide a framework for the assessment of altered sensorium patients. This assessment should allow providers to better understand the etiology of mental status changes and therefore improve diagnostic skills and management. This is a retrospective record based study. The research duration was from January, 2016 to December 31, 2016. The study involved 9,800 emergency patients, in which 524 (5.34%) were altered sensorium patients. Demographic characteristics, clinical manifestations, assessment approaches, causative factors, emergency treatments and outcomes were collected. In 524 patients with altered sensorium patients recruited, accounting for 5.34% of all emergency department patients, 316 (60%) were male, and 208 (40%) female. Etiologic factors were neurological (n=225; 42.93%) & nonneurological (n=299; 57.07%). Patients with altered sensorium pose a diagnosing difficulty for ED physicians. The most frequently encountered diagnostic categories causing altered sensorium patients were primary CNS disorders, intoxication, organ system dysfunction, and endocrine/metabolic diseases. Altered sensorium is an important warning signal for ED patients because of its potentially fatal and reversible effects. Prompt evaluation and treatment are essential to decrease morbidity and mortality associated with altered sensorium patients.

Keywords: Altered Sensorium; Clinical Profile; Demographic Characteristics; Emergency Department; Etiology.