Indian Journal of Emergency Medicine

Mountaineering is a favorite adventure sport for many youngsters. In untrained individuals, sudden ascend to high altitudes can cause severe deleterious health issues. Individuals vary in their physiological response for adapting to the low oxygen conditions. Acute altitude illness can present as acute mountain sickness (AMS), high-altitude cerebral edema (HACE) and high-altitude pulmonary edema (HAPE). As emergency physicians, we stand as public health guards and it is our duty to educate people about risks involved in adventure sports. 

Keywords: Acute mountain sickness; High-altitude cerebral edema; Highaltitude pulmonary edema.

Mortality associated with methanol has been of great concern. Methanol is also known as methyl alcohol, wood alcohol, spirit and carbinol. The occurrence of cases has been prevalent in developing nations especially in low socioeconomic status people mainly in countries like India, Cambodia, Kenya, Libya, Indonesia, Equador, Estonia, Nicaragua, Pakistan, Turkey, Uganda; etc. Knowledge of the pathophysiological changes that occur in the body after methanol consumption is essential for all practising doctors. This case report mainly highlights the metabolism of methanol and its physiological effect on the body and management of methanol poisoning. Conversion of methanol to formaldehyde and formic acid by hepatic enzyme alcohol dehydrogenase triggers the onset of clinical symptoms. The appearance of clinical symptoms start as early as 30 min to 12 hour. If left untreated patient may develop uncompensated metabolic acidosis, blindness, seizures, hypoglycemia, and dyselectrolemia. Funduscopic examination and ABG should be carried out. The main stay of treatment is ethanol, folinic acid, aldehyde dehydrogenase inhibitor and hemodialysis. The basic steps in approach must be carried out in the emergency department and followed-up with meticulous monitoring in the intensive care unit for salvage as well as prevention of long-term sequelae. In Tripoli, Libya over 1000 patients were poisoned with a fatality rate of 10%. In Kenya 2 outbreaks resulted in approx. 341 and 126 patients with case fatality rate of 29% and 21% respectively. Ethanol poisoning in Malwani near Malad, Mumbai claimed large number of deaths due to delay in suspecting and diagnosis and delay in management principles of management are designed to tackle this type of disaster in future. There are several guidelines for the management of methanol poisoning, but in India at primary health care resources of investigation and treatment are limited. In India there are also unauthorized production of alcohol, who mixes methanol with alcohol for early kick and secondly it is cheaper than alcohol. Methanol is generally used for solvent in printing and copy solutions, polishes, paints and stabilizers. They are also used as antifreeze and as additive in gasoline. Methanol is known as an industrial alcohol and is mixed up with alcohol and used for medical purpose. Methanol is well absorbed following inhalation, ingestion or cutaneous expression. 

Keywords: Methanol; Mortality; Funduscopic examination; Metabolism.

A 48-year-old male came in ER with c/o hematemesis with bloody diarrhea with severe pain abdomen and vomiting after consuming bottle gourd juice. The patient was resuscitated and stabilized with IV fluids, proton pump inhibitors and anti emetics and shifted to ICU under gastroenterology team for urgent endoscopy and further management and evaluation. 

Keywords: Bottle gourd (Lagenariasiceraria); Cucurbitaceae.

Introduction: Stroke is the primary cause of morbidity and mortality in India. Stroke management depends on neuroimaging and time management in the emergency department. The main aim of the present study is to determine whether Optic Nerve Sheath Diameter (ONSD) could be an early predictor of raised Intracranial Pressure (ICP) before neuroimaging results. Methodology: Computed Tomography (CT) scan was considered to be positive for raised ICP if the findings as cerebral edema, midline shift, mass effect, the collapse of ventricles, and compression of cisterns were present. Modified Rankin Score (mRS), Glasgow Coma Scale (GCS) and National Institute of Health Stroke Scale (NIHSS) were recorded. Results: A total of 66 patients were included with the Mean ± SD age of 62.62 ± 12.29 [Range: 35–85] years. The mean binocular ONSD was significantly higher in raised ICP than without raised ICP on CT imaging (p < 0.0001). The mean of mRS and NIHSS were significantly higher in raised ONSD than normal ONSD (p < 0.0001). The mean binocular ONSD was significantly higher with ventilator support than without ventilator support (p < 0.0001). The mean binocular ONSD had a very strong positive correlation with NIHSS (r = 0.781, p < 0.0001) and a very strong negative correlation with GCS (r = –0.751, p < 0.0001). It was also observed that there was a very strong negative correlation between NIHSS and GCS (r = –0.898, p < 0.0001). The Area Under Curve (AUC) showed that mean ONSD had the highest sensitivity level (100%) than NIHSS (95.83%) and mRS (79.71%) for raised ICP (p < 0.0001). Conclusion: ONSD can be used in the early diagnosis and management of cerebrovascular accident cases and it could be an early indicator of raised Intracranial Pressure (ICP) before neuroimaging results. 

Keywords: Optic nerve sheath diameter; Intracranial pressure; Glasgow Coma Scale; National institute of health stroke scale score; Modified Rankin Score; Computed tomography.

Introduction: Anti-snake venom therapy for snakebite envenomation is as associated with adverse drug reactions. The spectrum of reactions that are seen are wide and inconsistent. Given the annual incidence of snakebites at 2.7 million, and the frequent administration of anti-snake venom, an awareness of types of these reactions is required. Aims: To describe the adverse reactions seen during anti-snake venom therapy and treatment options used. Settings and design: Retrospective cross-sectional design in a Tertiary care Hospital. Methods: For a period of two years from January 1st, 2010 to December 31st, 2011 all cases diagnosed to have ani-snake venom reactions were identified retrospectively. Following identification, case record review was undertaken to collect data regarding the demographics, envenomation, characteristics of the reaction and treatment employed. Statistical analysis used: Descriptive statistics for demographic features of age and sex were obtained. Age was analyzed as a continuous variable and further categorization was done. Proportions of type of envenomation, ADRs and post-reaction medication were also calculated. Results: Forty-one cases were identified to be included in the study population. The mean age was 33 ± 13.3 years. Urticaria, chills, dyspnea/bronchospasm, tachycardia, bradycardia and hypotension were seen in 48.8%, 19.5%, 17.1%, 39%, 19.5% and 51.2% of the population respectively. 34.2% of reactions were treated with a combination of pheniramine, hydrocortisone and epinephrine. Conclusions: The results suggest that there is wide range of possible adverse reactions when anti-snake venom is given. Hypotension is a frequent lifethreatening event and should be watched for. Though therapy is similar in other studies there are no clear guidelines for the same. Premedication needs to be evaluated further. 

Keywords: Adverse drug reactions; Anti-snake venom; Snakebite; envenomation.

Context: There exists a deficiency in literature regarding the importance of procalcitonin in predicting mortality in sepsis patients. Aim: To determine the role of initial procalcitonin in predicting 7-day mortality in sepsis patients. Materials and methods: A prospective observational study was conducted on 200 sepsis patients admitted to the Emergency Department of a Medical College Hospital at Kochi. Blood culture samples and serum procalcitonin samples were withdrawn immediately and sent to lab. Mortality data of those patients were charted at the end of 7 days. Procalcitonin values were compared in both survivors and non survivors using paired Student t-test. p < 0.05 was accepted as statistically significant. Results: Out of the 200 patients, 131 were males and 69 were females. 17% expired and 83% survived at the end of 7 days of hospital stay. Mean procalcitonin value in survivors and non survivors were 16.41 ng/ml and 23.09 ng/ml respectively, which showed statistical significance [p-value = 0.026]. Conclusion: Initial procalcitonin plays an important role in predicting 7-day mortality in sepsis patients. 

Keywords: Sepsis; Procalcitonin; Mortality.

Introduction: Ischemic stroke is an important non communicable disease worldwide. The number of patients suffering stroke due to Type 2 Diabetes Mellitus (T2DM) is expected to further increase with regards to the raising trend of T2DM. Due to the unequivocal association between T2DM and ischemic stroke, it is unclear whether patients with T2DM suffer severe forms of strokes or have worse functional outcome following stroke. Aim of the study: To evaluate the severity of stroke and its functional outcome in patients with T2DM. Materials & method: A prospective study was conducted on 195 patients of suspected stroke, fulfilling the inclusion criteria presenting to the emergency department of our institute during a period of 1 year. Diagnosis of stroke was made by symptoms at presentation and confirmed by CT/MRI brain scan. Data entry was done by Questionnaire on National Institute of Health Stroke Score (NIHSS) at the time of admission and Modified Ranking Stroke Score (mRS) at the time of discharge for each patient and analysis was done using Statistical Package for Social Sciences (SPSS version 20.0). Results: T2DM was present in 54% of study population. Patient with T2DM had high NIHSS at admission; however mRS score at the time of hospital discharge did not differ statistically (p < 0.05). Conclusion: Patients with T2DM suffered a severe form of stroke than non-diabetics. 

Keywords: Acute ischemic stroke; NIHSS; mRS score; Type 2 DM.