Indian Journal of Emergency Medicine

A 46 years old previously healthy female was brought to emergency department (ED) with alleged history of road traffic accident (RTA) while driving a car one hours back. She was initially assymptomatic for about one hours post accident but later deteriorated both hemodynamically and mentation. After aggressive resuscitation as per ATLS protocol, she underwent multiple radiological imaging studies which revealed bilateral carotid and vertebral arteries dissection and severe traumatic brain injury with bilateral peripheral infarction. She was managed conservatively with mechanical ventilation in the intensive care unit.

Reactive hypoglycemia, postprandial hypoglycemia, or sugar crash is characterized by recurrent episodes of symptomatic hypoglycemia occurring within 4 hour after a high carbohydrate meal. The frequent sampling of postprandial blood glucose levels will frequently lead to the value below 50 mg/dl, with no hypothalamic-pituitary-adrenal (HPA) stress to the low blood sugar and do not manifest adrenergic symptoms. HbA1C levels between 5.7%-6.4% are suggestive of pre-diabetes. According to the Centers for Disease Control and Prevention (CDC), about 15-30% people with prediabetes symptoms progress to type 2 diabetes mellitus within 5 years if they fail to make appropriate lifestyle changes.

Delusion of pregnancy is a special form of hypochondriacal / somatic delusion. High potency antipsychotics such as pimozide are indicated in the treatment of delusional disorder. However, the use of Modified Electroconvulsive Therapy (MECT) in delusional disorders has been reported infrequently. We report a case of a 38 years old femalewho presented to the department of Emergency Medicine and then later referred to the Department of Psychiatry. History and mental status examination in the Emergency Department revealed pre-morbid paranoid traits, bad obstetric history and significant interpersonal stressors with her only child and a delusion of pregnancy. A diagnosis of persistent delusional disorder (ICD10) was made. In view of significant hostility and acting out behaviour MECTS were initiated along with antipsychotic Pimozide. Serial evaluation of symptoms was done. The case highlights the successful encapsulation of a delusional belief with MECT and also discusses the psycho-social factors that might have contributed to the evolution of this delusion.

Abdominal pain is one of most frequent presenting complain in ED among adult population. Intussusceptions although rare, can be consider as a cause of bowel obstruction in adults. Its occurrence in adult is not as common as in children; also difficulty to diagnose as patient usually present with nonspecific abdominal pain or features of obstruction. Most sensitive diagnosis is computed tomography and adult intussusceptions rarely resolved without surgical interventions. Delay in diagnosis and treatment may leads to dangerous consequences. Here we have reported a case of 20 year old female with long standing pain abdomen found to have intussusceptions.

Introduction: The delayed presentation of Rectal Injuries / perforations following a blunt trauma to the abdomen adds significantly to the morbidity, mortality and increased hospital stay and pain to the patient. Case Report: A 42 yr old male patient has been admitted in the emergency department with history of blunt abdominal trauma after getting struck between the steering wheel and the drivers seat for a long time in a RTA. His vitals were normal. He was discharged home after the CT scan (both plain and contrast) showed no organ injury as reported by the radiologist. Later after 12 hrs he was readmitted in the emergency with severe abdominal pain and guarding. X- ray erect abdomen showed air under diaphragm and it was later diagnosed as rectal perforation in CT and also taken to OT for surgical repair. Conclusion: Rectal injury or perforation following a blunt abdominal trauma is such a trivial thing in the beginning to find even on CT scans. It takes time to evolve into fully blown acute abdomen with peritonitis. So there is a need for re-evaluation in all patients of blunt abdominal trauma who appears to be normal on investigations out of proportion to the injury that they sustained.

Introduction: Illicit alcohol is spiked with various substances e.g. methanol, solvents, pesticides, sedatives and plant extracts. Patient with poisoning due to illicit alcohol are usually brought to the hospital in inebriated state and diagnosis in these patients becomes a challenge for the emergency physicians. We report our successful management of four patients who presented to us with illicit alcohol poisoning. We also tabulate the differential diagnosis, management and systematic approach to these patients. Material and Method: In July 2018, four patients were admitted in emergency department after consuming illicit alcohol and were managed expectantly. Retrospective review of the hospital record was done to retrieve the emergency department and ICU data. Results: Out of four patients, two were admitted in unconscious state on ventilator while other two were conscious and sober. Apart from methanol, other commonly associated poisoning with illicit alcohol were ruled out. Urine toxicity screen was negative. Two patients on ventilator were managed conservatively in the absence of definitive diagnosis. Both patients gradually improved and recovered uneventfully. On personal communication with bootleggers, it was observed that illicit alcohol is usually spiked with Nitrazepam to enhance the sedative effect. Nitrazepam is usually not detected by routine urine toxicology screen. Conclusion: Apart from methanol, illicit alcohol is spiked with several known and unknown substances. Emergency department physician should be aware of poisoning due to these substances and an approach to an unconscious patient due to consumption of illicit alcohol.

Background: Dengue infections can occur as epidemics in India causing high morbidity and mortality. The awareness of risk factors can help in early recognising and treatment of severe forms and reduction in mortality. Age is one such intrinsic risk factor which can affect the outcome to a significant extent. Objective: To analyse the haematological variables affected by different age groups and its impact by comparison with other similar or clinical studies on complications of dengue. Materials and Methods: A total of 132 serologically proven Dengue positive cases were analysed along with relevant haematology data after tabulation against patients unique hospital identification number, age and sex. The data was collected over a one month period in November 2016 in Haematology Department of KIMS Hospital and Research Centre, Bengaluru. Results: Our study showed an age range between 5 months to 65 years with most patients in the 12-25 years group and an average of 32 years. We had 30% paediatric cases (≤12 years) and 70% non-paediatric cases (>12 years). The male to female ratio was 1.2:1 with a slight male predominance. The analysis of haematocrit patterns in association with age showed 70% paediatric cases with rise in haematocrit above reference range in comparison to 43% in adults. The highest haematocrit was 59.6 in adults as against to 47% in paediatric cases. Total white cell count patterns were uniform in both groups. The lowest count was noted in adults (1100 cells/cumm) as against paediatric (1900 cells/cumm) cases. The differential count showed marginal increase in lymphocytosis in non-paediatric (70%) as against paediatric (63%) cases, whereas neutrophilia (23% vs 50%) in paediatric and non- paediatric cases was more significant. Neutropenia was seen in a higher proportion of non- paediatric (38%) vs paediatric cases (18%). Platelet counts less than 1.0 lakhs/cumm was noted in 98% in non-paediatric as against 90% of paediatric cases. There was a significantly higher proportion of NS1 Antigen positivity noted in non-paediatric (34%) as against paediatric (15%). Paediatric cases had a higher association (85%) with antibody pattern as against non-paediatric (65%) cases. Conclusion: Age has a significant impact as a prognosticator in dengue and can play an important and decisive role in early diagnosis and management of severe cases.

Background: Stroke is a leading cause of mortality among patients presenting to the emergency department with Acute Ischemic Stroke being a significant contributor. Clinical guidelines emphasize the importance of adequate hydration in management of stroke. Dehydration may impair cerebral oxygen delivery and worsen clinical outcome in patients with acute ischemic stroke (AIS). Elevated blood urea nitrogen to creatinine ratio (BUN/Cr) as a marker of dehydration has been associated with poor clinical outcome in emergency department (ED) patients presenting with AIS. Dehydration also attributes to the increased rate of infections and length of hospital stay in patients with AIS. Objectives: To study the association of dehydration markers BUN/Creatinine ratio, plasma osmolality, haematocrit and Caval Index with the outcome in patients with Acute Ischemic Stroke in terms of Mortality and Morbidity (Length of Stay in Hospital) and to correlate the hydration status with the disease progression by using NIHSS score and Modifies Rankin score. Methods and study design: The study was conducted from January 2017 till January 2018 over a period of 1 year. It was a Prospective observational cohort study. Patient included in the study were followed up at 3 and 30 days as per the questionnaire designed for the study after the approval by scientific and ethics committee of the institute. For the purpose of statistical significance we will recruit 64 patients as per the inclusion & exclusion criteria of the study. Data collection was done as per the approved data collection forms for the purpose of study. Patient’s initial, BUN, Creatinine, Urea, Sodium, blood glucose, Caval index (optional) and clinical status was be collected as per NIHSS and Modified rankin scale. The patient was followed up during their duration of stay in the hospital on 1st, 2nd and 3rd day. During the follow up period patients was followed for progression and outcome based on clinical parameters and the mentioned scores. Results and Conclusion: In conclusion, though we were able to associate plasma osmolality and BUN/Creatinine ratio with mortality, length of stay and with poorer outcome in terms of early neurological deterioration; hematocrit and Caval Index failed to associate to significant level to prove as a prognostic marker. Initial risk stratification using the plasma osmolality and BUN/Creatinine ratio may assist with prognostication and help prevent deterioration of the patients with Acute Ischemic Stroke.

Background: To reduce bias in triage validity studies, one should focus on measures that can be obtained directly at triage. Objectives: To study the validity of Emergency Severity Index, Associations of the Emergency Severity Index triage categories with patients' vital signs at triage. Methods and study design: 260 patients were studied from March 2013 to June 2013.Each patient was triaged by the Researcher on duty and assigned a triage category using standard procedures. Immediately after the Researcher finished the triage assessment and reported the ESI triage category, the researcher registered patients’ gender, referrer, main complaint, age and measured vital signs that were measured by the triage nurse. The following vital signs were registered: blood pressure, pulse rate, respiratory rate, oxygen saturation, temperature, the AVPU score ( Alert, Voice, Pain and Unconsciousness), and pain, the data was analyzed using statistical designs and significant co relations between the study parameters were interpreted. Results and Conclusion: There is a significant correlation (p = 0.00) between the ESI scores and WPSS categories the findings of this study support the validity of the ESI as it showed that patients’ vital signs are associated with the ESI triage categories. There were strong associations between the ESI triage categories and patients’ WPSS scores at triage. However, no associations were found between pain scores and ESI triage categories, which indicates that ESI is a good triaging tool and reliability on pain scores should be revalidated.

Aim: The aim of the study is to determine systematically the performance of existing clinical prediction score (SMART_COP, CURB_65, PSI, ATS/ IDSA, SCAP Score) to risk stratify the Emergency department patients with Community acquired pneumonia. Method: This study was conducted on 80 patients presented to the department of emergency medicine, during July 2016 to November 2019. Results: Maximum age group of 51-70 with mean age 57.5 ± 14.78 years. Smoking about 75% males have smoking as risk factor and the most common comorbid condition is hypertension. Among 80 patients, 10 have CURB_65 score of 0, 24 patients have score of 1, 30 patients have score of 2, 11 patients have score of 3, 3 patients have score of 4 and 2 patients have score of 5. Among 80 patients, 19 patients has SCAP major criteria and 36 patients had minor criteria. The mortality was seen in about 10 patients. SMART_COP has highest AUC value among different pneumonia severity score for predicting the need of vasopressor support and SMART_COP score > 5 have good accuracy in predicting the need of vasopressor support in patients with CAP. Conclusion: Early microbiological diagnosis, early antibiotic administration in patients with SMART_COP score > 4 and PSI class 4 and 5 can decrease the morbidity and mortality in CAP patients.

Aim: Current study is designed to determine the significance of Killip classification and blood glucose levels in risk stratification of patients with Myocardial Infarction. Method: 100 patients admitted for the treatment of myocardial infarction during may 2011-2014. These patients were initially given diagnosis of acute MI upon admission to ED. Details regarding 2D echocardiography of the patient is noted. The details of any interventional strategies like CAG, PTCA, CABG were recorded. Results: Out of 100 patients 74 (74%) were males and 26 (26%) were females. Their mean age was 50.15 ± 14.04 years. data showing increase in the mean length of stay with increase in killips classification. Ventilator support is needed in killips classes III and IV patients when compared to killips classes Iand II. The need for ionotropic support increases as killips class advances from class II to IV. In IWMI 73.2% of the cases are of killips class I and 9.8% of the cases are of killips class IV. The high percentage of cases i.e 65.9% in killips class I under went coronary angiogram (CAG). Patients in killips class III has higher rates of readmission when compared to other classes i.e 33.3% of cases. Mortality is high in killips class III (42.9%) and class IV (57.1%). patients with initial high blood glucose values on admission have higher readmission rates. patients with initial high blood glucose values have high mortality rate. The mean age group in patients who were discharged home is 49.73 where as the mean age group in patients who were dead is 55.71. Conclusion: Patients with higher killip class on initial presentation have longer length of stay in hospital and high mortality rate. Combined together, killip classification & blood glucose levels are better indicators of morbidity and mortality than any one factor alone.