Indian Journal of Emergency Medicine

Cauda equina syndrome is a clinical syndrome characterized by low back pain, unilateral or bilateral sciatica, motor weakness of lower extremities, saddle anesthesia, bowel and bladder dysfunction and occasionally paraplegia—resulting fromcauda equina compression. It can be described in two forms basedon the onset of signs and symptoms-if symptoms appear within 24 hours then it is acute in onset and if patient develops symptoms after several weeks or months then it is gradual in onset. The sooner it can be diagnosed, the better is the chance that the patient makes a better recovery from symptoms of nerve damage. We present a case of a 24-year old male with history of fall 6 months back who was treated outside with simple analgesics without any surgical intervention. The case was clinically diagnosed in the Emergency Department (ED) as CES and an MRI was ordered which confirmed the diagnosis. The patient was referred to the Neurosurgery Department and operated the next day with good clinical outcome. 

  Background: Deliberate self poisoning are commonly encountered cases at most of the rural Indian Government hospitals. Along with associated morbidity economic burden to the country is immense. Bread winners of family being affected at large scale has socio-economic impact on dependents. Objective: To study the Clinical and Etiological profile of a patients presenting to emergency department in a rural Indian Government hospital with deliberate self poisoning. Material and methods: This was conducted in a rural government district hospital Chamarajanagar, over a period of one year. A total number of 156 patients aged more than 15 years of both genders were included. After initial resuscitation and antidote treatment along with other symptomatic treatment. Detailed history, clinical examination and nature of poisonous material was studied. Psychiatric counselling was done before discharge. Accidental and homicidal poisoning patients were excluded. Results: Out of 156 patients 94 were males (60.25%) and 62 were females (39.79%). Among males age group between 35 to 45 years were most common (38.2%), where as in females age group between 25 to 35 years were most common (38.7%). At extreme age group i.e. between 15 to 25 years and more than 65 years percentage of female patients outnumbered male counterpart. Among clinical symptoms generalised weakness and altered sensorium was most common and Constricted pupil was the most common sign. Conclusion: Deliberate self poisoning leads to significant morbidity and mortality among rural population. Limiting easy access to poisonous  material through government regulations and policies and increasing the public awareness about its ill effects through health education needed. 

Respiratory disorders like Chronic obstructive pulmonary disease (COPD), Bronchial asthma, Interstitial lung diseases (ILD), Post infective fibrosis etc. have been known to be associated with nocturnal hypoxemia, poor sleep quality and disrupted sleep. The sleep related physiological disturbances may be associated with abnormal ventilatory control and upper airway instability during sleep. The study was a prospective study  conducted in the department of Pulmonary Medicine, at a tertiary care hospital. Before proceeding for the study, the proforma and plan of the study were submitted to the Institutional Ethics committee for Research on Human Subjects and approval was obtained. 2 among 23 patients with low risk, 1 among 9 patients with intermediate risk, 12 among 18 patients with high risk on SACS had OSA. Based on the Sleep Apnea Clinical Score (SACS), 23 patients were found to have low risk of OSAS, 9 patients intermediate risk and 18 patients high risk of OSA. 

  Premonitory stroke symptoms are not always found; fewer than 20% of stroke patients have a prior TIA. Focal premonitory symptoms, when present, usually predate infarction rather than haemorrhage. When they occur, they may be so nonspecific that they are not recognized as signs of an impending stroke. Within 90 days after a TIA, the risk of stroke has been reported to be as high as 10% to 20%, and nearly half of these patients will have their stroke in the first 2 days after the TIA. Patients on established coronary artery disease who were on atorvastatin therapy 10 mg for more than 1 year, who developed an ischemic stroke evidenced by CT scan or MRI within 5 years of occurrence of the first coronary event were included. Out of the 50 patients studied 16 were known diabetes patients on treatment accounting to 32% of cases. In our study 38 (74%) CAD patients who developed CVA had positive  history of ischemic events in family and 28 (56%) of the controls that were CAD patients and did not develop CVA had positive family history. 

About 80% of all first ever lifetime strokes are ischemic, 10% are due to primary intracerebral haemorrhage, about 5% are due to subarachanoid haemorrhage and in the remainder there is an uncertainty. After coronary heart disease and all cancers, stroke is the common cause of death in the world causing about 4 million deaths, three quarter of them in developing countries. Personal history regarding dietary habits, smoking, alcohol consumption and tobacco chewing were noted. NIH Stroke Scale was assessed in all patients to assess the neurological disability and its prognosis. Detailed neurological examination was done based on proforma. Among 71 patients 61 patients are alive with significant improvement and 10 patients are expired. Among 10 patients who died, 6 patients are in the age group of more than 60 years and 4 patients are in the age group of 40-60 years. Maximum mortality was seen in the age group of more than 60 years. And no deaths are seen in the age group of less than 40 years. 

 Various genetic and environmental factors influence the etiology and prognosis of diabetes. Important differences in the types and frequency of Diabetes mellitus and its complications have been reported between countries as well as ethnic and cultural groups. Diabetes mellitus was formerly considered a disease of affluent. It has now become apparent that increase in Diabetes mellitus is due to demographic changes, cultural transition and population ageing, urbanization, increased consumption of refined foods, westernization, sedentary habits and over nutrition. In the present study fifty four type 2 diabetes patients who were normotensive and with no symptoms of cardiac disease, were selected for during the study . All patients were evaluated for left ventricular systolic and diastolic dysfunction by echocardiography. In the present study the E/A ratio <1 was seen in 22 (40.7%) of 54 individuals in the Study Group and 3 (5.5%) among the Control Group. The p value <0.001 and is statistically significant. Thus, 22 individuals in Study Group and 3 in Control Group had diastolic dysfunction. Keywords: Systolic and Diastolic Dysfunction; Normotensive Asymptomatic Patients; Type 2 Diabetes Mellitus. 

  Mortality rates for AKI have changed little since the advent of dialysis and have remained at 50%. This curious statistic simply reflects the changing demographics of AKI from community – to hospital – acquired settings. Currently, the mortally rate for hospital – acquired AKI is reported to be as high as 70% and is directly correlated to the severity of the patient’s other disease process. A Hospital based Prospective study was conducted in Department of General Medicine for a 2 year period after taking approval from Hospital Ethics and Research Committee. Urine Albumin was present in 31 (29.8%) patients while pus cells and RBC was present in 17 (16.3%) and 10 (9.6%) patients. Mean S. urea level on admission was 98.05 mg, at discharge it was 53.53 mg. The difference at admission, discharge and was statistically significant. 

Many patients with this form of Diabetes mellitus are obese and obesity itself causes some degree of insulin resistance. Patients who are not obese by traditional weight criteria may have increased percentage of body fat distributed predominantly in the abdominal region. Ketoacidosis seldom occurs in this type of diabetes, it usually arises in association with the stress of another illness such as infection. Out of 240 patients attending diabetic clinic 54 patients were selected. The relevant information was recorded in a pre-tested proforma. After taking detailed history, thorough clinical examination was done according to the proforma. BMI was calculated as weight (kilograms) divided by height (meters) squared. The mean FBS of Study Group was 163.13 with SD 15.06 and the mean PPBS of Study Group 232.35 with SD 35.71. The mean FBS of Control Group was 102.61 with SD 6.07 and the mean PPBS of Control Group was 150.13 with SD 10.64. It is seen that, the mean FBS and PPBS of the Study Group was more than the Control Group. 

Introduction: Diabetes is frequently associated with Mg deficit. The most but not all diabetic subjects have low magnesium (Mg). Hypomagnesaemia has been reported to occur in 25-38% of patients with Type 2 DM especially in those without good metabolic control. Deficiency of Mg may increase the incidence of diabetes mellitus (DM) and occurrence of diabetic complications. It is frequently overlooked and undertreated. A low Mg intake and an increased Mg urinary loss appear to be the most important mechanisms that may favor Mg depletion in patients with type 2 diabetes. Objectives: The present study was conducted with an objective to evaluate the serum magnesium level in type 2 Diabetes mellitus. The present study also attempts to evaluate an association between the serum magnesium levels with duration of diabetes, glycosylated hemoglobin and diabetic complications. Methods and Materials: This is a cross sectional study which was done between July 2016 to August 2017 in Khaja Banda Institute of Medical College and Hospital. A total of 100 Type 2 DM patients were included in the study. The serum blood sugar level, HbA1C (%), magnesium level was estimated and the serum magnesium levels were correlated with the duration of diabetes, glycosylated hemoglobin and diabetic complications. Results: Among the 100 patients, 58% were men and 42% were women. Mean age was 56.98±8.76 years and the mean duration of diabetes were 8.2±4.8 years. The mean glycosylated hemoglobin (HbA1c) was 7.44±1.43%. The mean serum magnesium was 1.78±0.48 mg/dl. Out of 100 patients, 66 patients had normal serum magnesium levels and 34 patients had hypomagnesaemia. There was no correlation between serum magnesium levels with increasing duration of diabetes. Out of the 34 patients who had  hypomagnesaemia, 29 patients had HbA1c > 7%. This correlated between hypomagnesaemia and poor glycemic control in our study. There were 16 patients who had retinopathy, 20 patients had nephropathy and 26 patients had neuropathy. Among the 34 patients, 24 had complications and 10 patients did not have any complications. However there was a weak negative correlation between serum Mg levels (r =-0.110, p =0.004) and diabetic complications. 

Conclusion: Serum magnesium level was low in most of the Type 2 DM patients with poor glycemic control. Mg depletion affects both glycemic regulation and the occurrence of complications. Also, poor glycemic regulation affects serum Mg levels. 

Introduction: Drug overdose continues to be most common causes of acute poisoning all over the world [1]. Acute drug overdosing cases land up in ICU due to quick metabolic derangements and possibility of organ dysfunction [4]. The pattern and nature of drug overdose vary geographically. Aims: To determine the clinical pattern of drug overdose, duration of hospital stay and outcome in terms of discharge or death. Methods: A retrospective review was done of the medical records of 40 adult patients admitted with a diagnosis of acute drug overdose, In a tertiary care Centre excluding patients less than 18 year old and those presenting with only alcohol abuse.
Results: Retrospective study was done in 40 patients. Study shows that, 16 (40%) male patients and 24 (60%) female patients admitted with drug overdose. The individual category of drugs contributing most frequently included Benzodiazepine (22.5%); Antiepileptic (15.0%); Antihypertensive (12.5%); NSAIDS (12.5%); Oral hypoglycaemic agents (10.0%) and Unknown
(12.5%). Out of forty patients, 17 (42.5%) required less than 24 hour of ICU observation, 14 (35.5%) required less than 48 hour of ICU observation and 9 (22.5%) required more than 48 hour of observation. The total in hospital duration due to drug overdose was 2 days (5%), 2 to 6 days (87.5%) and more than 6 days (7.5%). Out of forty patients, 38 (95%) patients treated and got discharged and 2 (5%) patients died. Conclusion: In acute drug poisoning, a high index of clinical suspicion and an early and prompt intensive medical therapy could improve the patient outcome. Thepattern of illicit poisoning warrants the development of suitable preventive measures. In particular there is an imminent need to create awareness in the society to identify the circumstances leading to illicit drug use among the youth.

  Aim: To study the pattern of availability of life saving medicines for better patient care in intensive care unit and radiology department of tertiary care hospital. Design: Retrospective observational study in the past six years (2012-2018). Material and Methods: A team of researchers studied the pattern of availability of routine and life saving medicines in two intensive care units and radiology department of the hospital during the last six years and related it with the newer methods adopted to procure the same. The researchers studied the new and faster methods of procurement adopted in the hospital. The study focused on procurement of drugs for the past three years (2015- 2018) by newer methods and compared to older methods of procurement in the previous three years (2012-2015). The research took place at ten bedded trauma intensive care, seven-bedded First floor ICU and department of radiology for availability of routine and emergency medicines. Statistical Analysis: Categorical variables were presented in number and percentage. The researchers observed significant improvement in availability of life saving and routine medicines in the intensive care unit and radiology department. Results: The research showed satisfactory availability of life saving medicines in the two designated Intensive Care Units and radiology department due to adoption of new and faster methods of procurement in the past three years (2015-2018). Conclusion and Recommendation: Adequate training of staff regarding inventory management and implementation of Public Finance Management Systems led to better management of inventory in main store and concerned departments. 

  Introduction: Sick Euthyroid syndrome is linked with alteration in thyroid function. It is seen in many non-thyroidal illnesses. But its major implications are seen in Acute Myocardial Infarction. Abnormalities of thyroid function tests are seen in this condition. These abnormalities include a decrease in free T3 or both a decrease in FT3 and a decrease in free T4. This has shown to be as a marked prognostic indicator in this Acute Myocardial Infarction. Sick Euthyroid syndrome is contemplated to be ‘benign’. It has been shown for increased morbidity and mortality. This is the reason why this is considered as prognostic marker. Hence the study was conducted to assess the thyroid function in Acute Myocardial Infarction and its further link with immediate out come of patients with Acute Myocardial Infarction. Methods: 50 Consecutive patients of Acute Myocardial Infarction admitted in our institute was our study group. A thorough history, complete clinical work-up, detailed systemic work-up was done. Further investigations such as 2 D Echo to assess left ventricular function, multiple electrocardiograms and Creatinine phosphokinase-MB levels were done. In addition to this from total T3, T4 and TSH were done. These were taken 24-36 hours after onset of chest pain on day. Reports were taken again on day 7. Results: The mean age for males was 58±12 years and 61±9 years in females. The male: female ratio was 2.1:1. There was no significant difference in the mean values of T3, T4 and TSH on days 1 and 7. Statistically significant association which is p<0.05 was observed between the day 1 serum T3 and CK-MB, cardiogenic shock, acute complications and decreased Left ventricular ejection fraction. Conclusion: Abnormal thyroid function in Acute Myocardial Infarction is a poor prognostic indicator. It indicates poorer cardiac function in form of decreased left ventricular ejection fraction. Thus this leads to increased mortality. The sick-euthyroid syndrome is characterized as a decreased free T3 levels that occur in a setting of non-thyroidal illness without any thyroid or hypothalamic-pituitary dysfunction. It most frequently is seen in patients with MI, and is associated with a higher mortality. 

  Background: The cause of idiopathic focal segmental glomerulosclerosis is usually not known. Most of the patients present with primary type. The main clinical feature of FSGS is nephrotic syndrome. It causes about 10 to 15% of cases of nephrotic syndrome. Its increased incidence and high rate of progression to end stage renal disease makes it us an important disease for present study. Method: Thirty five patients of biopsy proven idiopathic FSGN with biochemical and hisptopathological data have been included in this study. All patients were treated on outpatient/inpatient basis. All patients were subjected to detailed general and systemic examination. Patients who had a minimum follow up of 3 months were included in the study. Result: Males are affected more frequently than females. Males were 26 (74%) and females were 9 (26%). The most common presentation was nephritic syndrome in 27 (77%), and clinical feature was proteinuria, in all the patients, hypertension in 16 patients (46%), and hematuria in 16 patients
(46%). 16 patients (46%) progressed to renal failure over a period of 1 to 6 years. Conclusion: Nephrotic range (Nephritic) Proteinuria is the main clinical feature. Response to steroids is variable and unpredictable. Prognosis is better in steroid responsive as compared to non – responsive patients. 

Keywords: Idiopathic Focal Segmental Glomerulosclerosis; Nephritic; Proteinuria; Renal Failure.

  Context: There are several scoring system in the literature to triage and predict prognosis of the patient using simple physiologic parameters. MEWS, REMS, RAPS are few among them. An appropriate scoring system is essential for risk stratification and hospitalisation in a busy Emergency Medicine department. Aims: We aim to compare the performance of MEWS, REMS, RAPS score in predicting mortality among the non-surgical patients presenting to the Emergency room. Settings and design: This prospective study was conducted in an ED of a teritary care hospital during a period of 2 months. Statistical analysis: ROC analysis was used to compare performance of all three scoring system in predicting mortality. Methods and materials: In this prospective study, all patients presenting to the ED with non-surgical complaints during a period of two months. MEWS, REMS, RAPS scores were calculated in the ED itself based on the physiologic parameters at the time of presentation. These patients were later followed up till discharge/death. Results: A total of 120 patients were included in our study, with mean age of 49.2±18.5. 60% of the study populations were males and 42.5% were females. The mortality in our study was around 16.7%. Though AUC of MEWS, REMS, RAPS were 0.73, 0.71, 0.69 respectively, but not significant difference were found between the three scoring system. Conclusion: All scores MEWS, REMS, RAPS performed equal in predicting in-hospital mortality among non- surgical patients presenting to the ED. 

Keywords: MEWS; REMS; RAPS.

  Aims: To assess the prognostic values and predicting in-hospital mortality of patients admitted to ED by Rapid Emergency Medicine Score (REMS) and Hypotension, oxygenation, temperature, ECG abnormality, loss of independence (HOTEL) scores. Methods and Material: Patient presenting to ED were evaluated at admission with detailed history and physical examination. The data of the patients fulfilling the study inclusion criteria were recorded as follows: age; sex; blood pressure; pulse rate; respiratory frequency; temperature; oxygen saturation; Glasgow Coma Scale; ECG findings; and loss of independence. Statistical analysis used: mean and standard deviation for quantitative variables, Chi Square test, a comparison of the diagnostic abilities for each test was performed using the area under the curves (AUC). SPSS for Windows Version 22.0 Released 2013 was used. Results: 100 patients were included in the study, of which 26 died and 74 survived. In predicting the in-hospital mortality, the AUC values of the REMS and HOTEL scores
0.808, (95% CI=0.719-0.879) were (p<0.001) and 0.874, (95% CI=0.794-0.931) were (p<0.001) respectively. Conclusions: The HOTEL score demonstrated the largest AUC (area under curve) of the studied scoring systems for the outcome of mortality. 

Keywords: HOTEL; REMS; Survivors; Nonsurvivors; ED-Emergency
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