Indian Journal of Emergency Medicine

Reversible Cerebral Vasoconstriction Syndromes (RCVS) are a cluster of conditions that show reversible multifocal vasoconstriction of the cerebral arteries with typical manifestations like thunderclap headache and less commonly focal neurologic deficits related to brain edema, stroke, or seizure. We describe a case of 31 year old male staff nurse who arrived at the emergency room for regular morning duty and suddenly became unresponsive. He was immediately intubated and managed following which NCCT brain was taken. It revealed generalized brain edema. Other blood and radiological investigation reports were unremarkable. After ruling out all possible diagnosis he was diagnozed as a case of RCVS. He was well-managed by the emergency team and was discharged in a stable condition with nil neurological deficit.
 

A 71 year old nil comorbid, referred from government hospital after unknown snake bite with acute vision loss 7 hours after snake bite.
Neurological deficits following hematotoxic snake bite are usually due to intracranial hemorrhage as a result of depletion in clotting factors. Ischemic strokes and blindness followed by snake bites are rare. Presentation with cerebro-vascular infarction and blindness are rare and can be attributed to vasculitis/optic neuritis, vasospasm, toxin induced endothelial damage, toxin induced procoagulant effect and disseminated intravascular coagulation.

Pulmonary embolism has a large spectrum of clinical presentations ranging from asymptomatic to sudden death. Sometimes presentation of pulmonary embolism is not classical and rather atypical, like paradoxical embolism. We are presenting a case of pulmonary embolism leading to paradoxical embolism (PDE) presented with seizure disorder due to ischemic stroke and acute life-threatening limb ischemia. In this clinical scenario, early suspicion is very important for prompt therapeutic interventions. This patient was diagnosed timely and managed successfully.

Krait snake bite is a type of emergency which is encountered in emergencies in India especially rural India. Common krait (Bungaruscaeruleus) and cobra (Najanaja) are most commonly found in this part of India. Krait bites tend to cause severe muscle paralysis but if patient receive first aid like ventilatory support and antivenom timely they can recover fully. Autonomic dysfunction resulting in tachycardia at rest, unexpected or unexplained hypertension and sweating has been commonly seen in krait bites. We present a case where a 13 yrs old girl who came with symtpoms of progressive drooping of eyelids, diplopia, difficulty in talking, painful swallowing and severe pain abdomen here considering the clinical scenario of pain abdomen with descending paralysis a possibility of krait bite was considered and pt was given ASV. She started improving from 3rd day and was subsequently discharged on 6th day.
 

Background: Estimation of blood gas values is vital in critically ill patients. The arterial blood gas estimation has some complications. Venous blood gas values can substitute the arterial blood values. This study was undertaken to compare the arterial and venous blood gas values in emergency care setting. Materials and Methods: A cross sectional study was conducted in Emergency Department of Basaveshwara Medical College and Hospital, Chitradurga among 85 patients. The samples were obtained from the artery and central
vein of the patients with 2 mins apart. The sample was sent to the laboratory for estimation of blood gases including pH, pCO2, BE and K+. Results: This study had shown that, pH, pCO2, BE and K+ were correlated significantly but there is slight difference in the K+ between the Arterial and venous blood samples. The central venous sample had shown to have less potassium than the arterial blood. The pH, pCO2 and BE values can be explained physiologically where the pH will be slightly lesser in venous samples and pCO2 will be higher. Conclusion: This study concludes that, there was a good correlation between the arterial and venous pH, pCO2, BE and K+ values.

Background: Acute poisoning has reached the epidemic form which is the main means of deliberate self harm. The gastric lavage at an earliest poison of time is an important additional procedure of decontamination. This study was undertaken mainly to study the effectiveness of early and late gastric lavage in emergency department. Materials and Methods: A prospective study was undertaken among the 90 cases admitted to emergency department over a period of three years. The gastric lavage was performed on all the patients and morbidity and mortality of all the patients was studied with respect to
duration of ventilation, duration of stay in ICU and mortality. Results: Age group of 31–40 years in early gastric lavage and 41–50 years in late group were higher. Males outnumbered females. Almost 69.8% of the patients with early lavage group and 70.2% in the late lavage group had acute poisoning with organophosphorus poison. The mean duration of ventilation in the early lavage group was 1.46 days and late lavage group was 4.53 days which was statistically significant. Mean duration of ICU stay in early lavage group was 6.4 days and in late lavage group was 7.6 days. About 9.3% of the patients in early lavage group and 17% of the late lavage group were died during the course of treatment in the hospital. Conclusion: This study had shown the early gastric lavage may help in reducing the morbidity of the patients with acute poisoning but not mortality of the patient.

Context: There is strong and convincing evidence that B-type Natriuretic
Peptide (BNP) is a reliable and useful biomarker in acute dyspnea due to heart failure (HF) and has a diagnostic as well as prognostic value. when used with clinical information, rapid measurement of BNP may reduce the total treatment cost of patients. Aim: To understand the significance of BNP in predicting the severity of Heart Failure. Materials and Methods: The study was conducted in SDM Hospital, Dharwad, on 100 patients admitted in with features of HF, during the period of one year i.e. from Nov. 2017 to Oct. 2018. Left ventricular ejection fraction (EF) was measured by 2D Echocardiography and EF of above 40% was considered as preserved ejection and lesser than 40% as reduced. Serum BNP levels were estimated and levels higher than 100 pg./ml., were considered to be significant. Statistical analysis used: Data
entry was done using Microsoft Excel and analysis using Statistical Package for Social Sciences (SPSS) version 22. Results: Majority of patients with preserved EF(28/58 patients), who developed signs and symptoms of HF, the levels of serum BNP were in the range of 1000 to 2000 pgs/ml., whereas, majority of patients with reduced EF(29/42 patients ),who developed signs and symptoms of HF, the levels of serum BNP were in the range of 100 to 1000 pgs/ml. Conclusion: In the study, serum BNP levels were found to be highly significant in assessing the severity of heart failure and in management of the patients.
 

Background: Ambulance services are important part of health system in dealing with the emergencies and preventing mortality. The point of care testing of hypoglycaemia helps physicians with rapid results by using commonly ordered tests. This study was mainly taken up to study the role of POCT in diagnosis and providing immediate treatment for hypoglycaemia. Materials and Methods: A prospective study was undertaken in Ambulance services of the emergency department of Basaveshwara Medical College and Hospital, Chitradurga between March 2015 to July, 2019. The patients were subjected for a diagnostic work up by using point of care testing using GRBS. Results: Majority of the patients belonged to 51–60 years of age group, males sex and had diabetes since 11–15 years. The sensitivity of the point of care testing of hypoglycaemia was 78.03% and specificity was 90.21%. The inter
test agreement as indicated by Kappa statistics was 0.69 which is deemed to be good. Conclusion: The point of care testing provides the diagnosis at an earliest point of time and thus helps in early treatment and prevention of mortality.

Background: Acute poisoning is an important medical emergency presenting to the emergency departments. This study was mainly
undertaken to study the clinico epidemiological characteristics and pattern of poisoning in a tertiary care setting. Materials and Methods: A retrospective study was conducted in medical records department of Basaveshwara Medical College and Hospital, Chitradurga in 548 patients of poisoning. The patients were studied in detail with respect to age, sex, occupation, time of presentation, nature of poisoning, GCS and outcome. Results: Majority of the study subjects in this study were young male farmers. The time of presentation was more than 2 hours in more than half of the patients, the GCS was low and around 70% of accidental and intentional poisoning cases survived. Organophosphorous compounds and sedatives were the common poisons in both accidental and intentional poisonings. Conclusion: This study provides an insight of clinico epidemiological knowledge to the emergency physicians about the nature of poisons and presentation to the emergency medicine departments.

Context: There exists a deficiency in literature regarding the impact of
chest radiographic findings on PaCO2 ETCO2 gradient. Aim: To evaluate PaCO2  ETCO2 gradient and it’s correlation with chest radiographic findings, in mechanically ventilated patients. Materials and Methods: A prospective observational study was undertaken on mechanically ventilated adult patients, at an Indian Emergency department. Minimum sample size was 151, derived through a pilot study, with a power of 80% and 95% confidence. Arterial blood gas samples were collected, one each, from selected patients, analyzed and PaCO2 recorded. Highest ETCO2 values and chest radiographic
findings, also recorded simultaneously. Mean ETCO2 and PaCO2 values were compared with chest radiographic findings for radiopaque and radiolucent CXR groups. ETCO2 PaCO2 gradient was analyzed using unpaired Student test, and ETCO2 PaCO2 correlation using Pearson’s correlation coefficient. p value <0.05 was accepted as statistically significant. Results: Mean age of study group was 54.15 ± 17.714 years. Mean PaCO2was significantly elevated in the radiopaque CXR group (55.03 ± 25.70)mmHg , than radiolucent CXR group (39.46 ± 14.77)mmHg, p <0.001. Mean ETCO2 showed no significant variations between the two groups (p 0.261). ETCO2 PaCO2 gradient in
radiolucent CXR and radiopaque CXR respectively were (0.741 ± 5.77,
p<0.001) and (13.28 ± 17.93; p < 0.001). A more statistically significant and promising correlation between arterial PaCO2 and ETCO2 values were obtained in radiolucent CXR (r= 0.928, p< 0.001 ) as compared to radiopaque CXR (r=0.718, p<0.001). Conclusion: ETCO2 values can reliably predict PaCO2, in mechanically ventilated patients with radiolucent chest radiographs.
 

Context: Acetaminophen is an easily available and frequently abused over-the-counter drug both in the western world and India. It is one of the commonest cause of medication-related poisoning in the world. The spectrum of hepatotoxicity associated with Acetaminophen can extend froma mild liver disease to fulminant hepatic failure requiring transplant. The toxic component N-Acetyl-p benzoquinone imine (NAPQI) causes centrilobular hepatic necrosis. This study aims to find the predictor of duration of hospital stay in acute acetaminophen overdose. Aim: The study aims to find correlation between the amount of ingested Acetaminophen and initial International Normalized Ratio (INR) and the latter with duration of hospital stay among patients visiting the Emergency Medicine department (ED) with a single deliberate ingestion of Acetaminophen. Materials and Methods: Settings and Design: This is a retrospective, observational study done among patients presenting to the emergency medicine department in a tertiary care centre in South India with acute single deliberate ingestion of Acetaminophen. Study population belonged to 15-45 years age group. The period of study was during the years 2016-2019. Subjects and Methods: Baseline demographics and clinical characteristics were noted. Correlation between ingested Acetaminophen and initial INR within 24 hours of ingestion and between initial INR and duration of hospital stay was analyzed with scatter plot. Statistical Analysis used: Statistical analysis was done using IBM SPSS version 23.0 (SPSS Inc., Chicago, USA). The categorical variables are represented as percentages and continuous variables are represented as mean ± standard deviation (SD). To test the statistical significance of association of categorical variables, Pearson correlation coefficient (r) was used. A p-value of <0.05 was considered as statistically significant. Results: The present study included 52 patients who deliberately ingested acetaminophen, with 13 males (25%) and 39 females (75%) and mean age of 23.67 ± 6.9 years. History of previous psychiatric illness was noted in 23.1% patients. Gastric lavage and activated charcoal was done in 36 (69.2%) and 13 (25%) patients respectively. Ingested amount of Acetaminophen had statistically significant correlation with initial INR with a p-value of 0.004. It was also noticed that the initial INR value and duration of hospital stay had a statistically significant correlation with P-value of <0.001. Conclusion: The study concludes that there is correlationbetween the dose of Acetaminophen ingested and INR. INR value also had positive correlation with duration of hospital stay.

Background: Stroke is a major public health problem resulting in
permanent disability among the adults. The outcome is often determined by the awareness of the patients, their relatives and general public. This study was mainly taken up to assess the awareness of the general public regarding awareness and the outcome among the general public regarding stroke. Materials and Methods: A community based cross sectional study was undertaken in the field practice areas of department of community medicine, Basaveshwara Medical College and Hospital, Chitradurga. About 520 participants were randomly chosen and administered with the predesigned proforma. Results: The awareness was higher in males, those aged between 41–60 years, Hindus and from urban areas had the awareness regarding organ affected during the time of stroke. Most of the males, aged between
41–60 years, Hindus and equal from rural and urban areas had awareness regarding symptoms of stroke. The awareness regarding risk factors of stroke were present in males, subjects aged between 41–60 years, Hindus and study subjects from the rural areas. About 66.9% of the study subjects opined that the patient should be taken to the hospital immediately after the event. About 68.1% of the study subjects didn’t knew about the treatment of stroke. The critical hour for admitting the patient to hospital was more than 2 hours in 68.5% of the study subjects. Conclusion: The awareness regarding the symptoms and risk factors of stroke was lower in the study group which requires increase in intensity of health education programs.
 

Background: Smoking of cigarette remains the leading cause of preventable premature morbidity and mortality in both developed and developing countries. It is responsible for Coronary heart disease, 90% of chronic obstructive pulmonary diseases and lung cancer. The study is undertaken to highlight the critical effect of smoking. Objectives: 1. Effect of cigarette smoking on Hematological parameters and study them concerning the duration of smoking. 2. To study the Pulmonary function tests to detect emergency lung conditions in smokers with relation to duration and number of cigarettes smoked per day. Methods: A total of 100 healthy subjects (50 smokers) of age group 30-50 years were selected attending the out-patient department of KIMS. The control group (50 non-smokers) subjects were the non-teaching staff of KIMS Medical College. Hematological parameters such as Hb concentration, RBC count, TLC and Platelet count were performed using Hemo auto analyser Sysmex KX-21 and ESR was obtained by Westergren's method. Spirometry was performed using AD instrument. Results: Smoking caused abnormal Hematological parameters, which resulted in increased levels of Hb, RBC count, TLC, Platelet and ESR. (P<0.0001) And it had a negative impact on lung functions when compared to non-smokers. Smokers showed a significantly higher decline in PEFR, FVC, FEV1 and ratio of FEV1/FVC(P<0.001). Conclusion: Results showed abnormal hematological and pulmonary function tests which causes dangerous deterioration of lungs and human body function.

Background: Myocardial infarction is an important acute disease to be
treated in the emergency department. The symptoms of myocardial infarction have shown variation in elder patients in comparison with the younger patients. Materials and Methods: A cross sectional study was conducted in emergency department of Basaveshwara Medical College and Hospital, Chitradurga for a period of three years. About 120 patients attending the department were divided equally in to elder and younger groups. Risk factors, symptoms, time of presentation and type of MI were compared with the young patients. Results: The mean age of the elder patients was 70.1 years and younger group was 38.2 years. The risk factors were not significantly different in both the groups. Majority of the elder patients presented with atypical chest pain and breathlessness and Pain abdomen were the atypical symptoms in the elder patients. The time of presentation was 3–12 hours in both the groups. Anterior and Inferior wall MI was common in both the groups. Conclusion: Myocardial infarction can manifest with atypical symptoms in the elder patients. A thorough knowledge about the symptoms is required for an emergency physician for the better patient management.