Indian Journal of Emergency Medicine

Arterial Thoracic Outlet Syndrome is one of the types of thoracic outlet
syndromes caused by compression of large arteries between the clavicle & first rib. The predominant causes involved are usually repetitive injuries/ sports injuries, motor-vehicle accidents or certain anatomical defects like an extra rib. Patients present with a varied set of non-specific complaints ranging from pain in the neck/shoulder/arms, numbness/tingling of fingers, limb weakness or discoloration, etc. Physical rehabilitation & thrombolysis remains the mainstay of the treatment. Prevention is of course better than the treatment.
 

Keywords: Arterial Thoracic; Outlet Syndrome; Trauma; Thrombolysis

There is a major role of an interventional radiologist in the emergency
department for both diagnosis and emergent interventions. We discuss
three different cases presenting to our emergency department with melena, hemoptysis and a stuck guide wire. All cases with varied presentations were initially evaluated and diagnosed in the emergency room and immediate interventional radiology help was sought. All the three cases were successfully managed and dis-charged from the emergency department.Many of the medical conditions and trauma can present as emergency and require immediate intervention. Involving an interventional radiologist early during emergencies has inspired us to develop the REPAIR initiative where colla-boration of the two specialities has led to remarkable outcomes. It has resulted in significant decrease in morbidity and mortality as well as the length of hospital stay.

Keywords: Emergency department; Interventional radiolog;, Melena;
Hemoptysis.

Lacosamide (LCM), a third generation antiepileptic drug, is used as
an adjunctive therapy or monotherapy in focal seizures. It enhances slow inactivation of voltage gated sodium channels and acts on collapsin-response mediator protein-2. Toxic ingestion of lacosamide has been documented and patients developed severe neurological and cardiac manifestation and few cases were fatal. Currently, there isno antidote for lacosamide poisoning. The poisoned patients are managed conservatively. Inj. sodium bicarbonate therapy was given in few cases to correct for cardiac arrhythmia. In many reported cases multiple tablets were consumed for poisoning except one case report documented isolated ingestion of lacosamide. We report a case
of acute overdose of isolated lacosamide poisoning who was brought to our emergency department in an unresponsive state with a history of seizure.
Keywords: Antiepileptics poisoning; Lacosamide poisoning; Sodium
bicarbonate therapy; Torsades de pointes.

 Arrythmogenic right ventricular dysplasia/cardiomyopathy
(ARVC/D) is an inherited rare cause of cardiomyopathy characterised
by fibro-fatty infiltration of right ventricle. ARVC is an under-recognized
condition,commonly present in young adults with syncope or sudden
cardiac death.Here we present the case of a 20 year old male, presentedwith history of nausea, chest discomfort and loss of consciousness for 2-3 minutes on exertion. History of similar episodes in the past. ECG revealed T wave inversions in precordial leads with poor R wave progression andECHO revealed dilated right ventricle (RV) with moderate RV dysfunction.Diagnosis of ARVD was made and treated with antiarrhythmic drugs and AICD (Automated Implantable Cardioverter Defibrillator). It is important to identify the ECG changes of ARVD,there by preventing the potentially lethal consequences.

Keywords: Arrythmogenic Right Ventricular Dysplasia/Cardiomyopathy
(ARVD/C); Young Adults; Right Ventricle; T wave Inversions; AICD

Poisoning is one of the common modes of suicide in India. Hair dye
poisoning is an uncommon form of poisoning in the west; however, in
some parts of the world such as East Africa and Indian sub-continent
it is not uncommon. The active ingredients causing toxicity includes
paraphenylenediamine (PPD), propylene glycol, liquid paraffin, cetostearyl alcohol, sodium lauryl sulfate and resorcinol. There is no specific antidote for hair dye poisoning and treatment is mainly supportive.We report a case of suicidal ingestion of hair dye that presented with angioneurotic edema and rhabdomyolysis. Our patient improved completely with symptomatic management.

Keywords: Paraphenylenediamine (PPD); Angioneurotic Edema;
Rhabdomyolysis; Symptomatic Management.

Background: Pheochromocytoma is a catecholamine secreting
tumour which imposes multimodal challenges to the anaesthesiologist
in its perioperative management. We report a case of a 12 year old boy
with complaints of palpitations, headache, sweating and sleeplessness.
Pheochromocytoma was diagnosed by 24 hours urine metanephrines,
vanillylmandelic acid and MRI abdomen. The main stay in the surgical
management of pheochromocytoma is preoperative preparation which
determines the outcome. Patient was operated under general anaesthesia with epidural analgesia. Beta blockers, nitroglycerine, sodium nitroprusside and phenylephrine are required to manage the hemodynamic fluctuations and should be used appropriately.

Conclusion: Successful management requires careful preoperative optimization, meticulous intraoperative planning, and hemodynamic management.

Keywords: Atenolol; Metanephrines; Pheochromocytoma; Sodium
nitroprusside; Vanillyl Mandelic Acid.

Novel Coronavirus or SARS-CoV-2 has brought the entire pharmaceutical industry to a halt. The whole world is still awaiting the news of an established treatment modality or a prophylactic vaccination schedule for COVID-19. Researchers all over the world are working tirelessly to find a cure or a vaccine as early as possible to assure humankind of a recovery from this life threatening disease. On the downside, people are desperate to find a solution to this crisis and this has led to introduction of certain drugs in the market that claim to be a remedy for COVID 19. US pharmaceutical company Gilead Sciences Inc. which holds patent of antiviral drug Remdesivir joined hands with Hetero Labs Ltd. and Cipla Ltd., two major pharmaceuticals
companies in India for launching the drug. On June 21, 2020 Hetero Labs Ltd. got the nod from Drugs Controller General of India (DCGI) to market the investigational antiviral medicine Remdesivir for “restricted emergency use” on COVID-19 patients. Remdesivir did not undergo any human clinical trials on Indian patients before its launch which is the protocol for launch of any investigational new drug as per the Central Drugs Standard Control Organization (CDSCO) of India. The medicine has been issued by the FDA with an Emergency Use Authorization (EUA). But it is still concerning if the decision was good enough to use the drug on Indian patients who have an entirely different ethnic background than the American patients. This article is a quick review of the efficacy and safety issues known about Remdesivir till date.

Keywords: Remdesivir Emergency; Approval; Covid 19; India

Aim: Study aimed to study the pattern of various cardiac arrhythmias in
patients with Acute Myocardial Infarction (AMI) along with to study the
incidence of arrhythmia and their nature in relation with the site of infarction and to evaluate prognostic value of arrhythmias in Acute Myocardial Infarction during first 48 hours of hospitalization.

Method: The present study included 100 cases admitted in ED with chest pain and diagnosed as AMI between Oct 2015 and Nov 2017 in narayana medical college and hospital.

Results: In present study 78 cases were males with mean age of 56.33 ± 10.47and 22 were females with mean age of 59.82 ± 10.032. In present study 53% of cases were smokers, 50% patients had hypertension and 48% of patientswere diabetics. Most common site of infarction is Anterior wall followed by inferior wall. Incidence of AWMI was 57%, IWMI 36%, PWMI 4% andLWMI 3%. Most of the cases presented to ED within 8 hours of symptom onset. Most common presenting symptoms were chest pain and sweatings. In present study 61% & 79% of cases constitutes high risk group with TIMI
score ≥ 5 & HEART SCORE ≥ 8 respectively. Over all 58% of cases developed arrrhythmias, of which Tachyarrhythmias were the most common rhythm abnormality. But SB is the most common single arrhythmia type noted in the study and found to be statistically significant. In present study increased risk of arrhythmias were noted in smokers and diabetics. Statistically significant correlation was found between the incidence of arrhythymias and diabetes. Patients with LV dysfunction had increased risk of arrhythmias which was
found to be statistically significant and 53.5% of arrhythmias occurred within 4 hours of presentation to ED. Out of all arrhythmias 55.2% were seen in pre thrombolytic period, among post thrombolytic arrhythmias VPC’s were the most common type and most of them were persistent. In present study overall mortality was 7.0% and most common rhythm abnormality seen in these cases was VF(57.14%). All deaths due to arrhythmias were occured within 4 hours of arrival to ED and 85.71% of these were males and asociated with smoking and diabetes. These patients constitutes to high risk group with TIMI and HS ≥ 8.

Conclusion: Early recognition and management of arrhythmias can significantly modify the morbidity and mortality in AMI patients. All emergency ambulances should be equipped with defibrillators, 12-lead electrocardiographs and staffed with at least one person proficient in
advanced cardiac life support. ECG transmission/ teleconsultation may be useful in preventing delay in recognition and initiation of thrombolytics in AMI patients.

Keywords: Acute Myocardial Infarction; Cardiac Arrhythmias;
Emergency Department.

Aim: study designed to analyse the Procalcitonin for early detection of
sepsis. Method: procalcitonin, blood, urine culture, and ultrasound were
performed and patients were categorized into groups based on PCT levels.
Results: 40% had respiratory infections, 30% showed urinary tract infections,6% gastrointestinal tract infections, 4% soft tissue infections and 6% werewith other types of infections. 84% cases with sepsis and 16% cases with nosepsis. Sepsis was observed in 40 % and septic shock in 44% cases. 36% caseswere died. Acute febrile illness observed in 6 (12%), ARDS and pyelonephritis with sepsis recorded in 4(8%). vasoactive support (VA) was given to 28
patients. 33.3% sepsis cases more than 10ng/ml procalcitonin was observed while none of the cases with no sepsis showed this level. 9.5% and 57.1% patients with sepsis, the procalcitonin level was below 2ng/ml and 2-10ng/ ml respectively. The mean procalcitonin in survivors was 5.47±3.02 ng/mlwhile it is 10.84± 5.66 ng/ml in non survivors. The mean lactate in survivors was 6.68± 2.04 and it is 8.17± 2.02 in non survivors. The mean procalcitonin level was 3.23 ng/ml in APACHE II (Score<10), 7.50 ng/ml in APACHE II (Score10-20) and increased to 10.29 ng/ml in APACHE II (Score>20). The mean procalcitonin level was 4.14 ng/ml in SOFA (Score<10), 9.57 ng/ml in SOFA (Score10-20) and increased to 13.75 ng/ml in SOFA (Score>20).
Conclusion: present study showed that procalcitonin is a useful marker inearly diagnosis of septic shock, help in management.

Keywords: Sepsis, Serum Procalcitonin, APACHE II, Ventillator Support

In today’s setting, one of the great challenges is to fulfil the proper
execution of measurements and compliance of various laboratory
investigations, with the internal and external quality control

specifications. Our aim was to compare the values of the highly critical
parameter potassium(K+) determined with Point of Care Testing
(POCT) devices and central laboratory analysers (ZL) in a highly
vulnerable setting of an emergency department in a tertiary care
hospital and to assess the quality of POC devices performance.

Aim:To find correlation between potassium (K+) determined with Point of
Care Testing (POCT) devices and central laboratory analysers (ZL).

Settings and Design: Prospective observational study, conductedin
524 patients from June 2019 to December 2019 at Dept of Emergency
Medicine ,Amrita Institute of Medical Science (AIMS), Kochi.

Methodsand Material: Data collected from patients satisfying inclusion criteria,24*7 coming Emergency Medicine Department, POCT- (K+) diagnosisis done with System RadiometerABL800 &central laboratory ( K+- ZL)measured with COBAS 800 &(K+) using indirect ion selective electrode(ISE) method. Statistical analysis used: To test the statistical significance of the correlation between K+- ZL & POC-K+, Pearson correlation method is used. To find the agreement between two measurements, intraclasscorrelation coefficient is calculated. P <0.05 was considered statistically significant. Results: The correlation between both the parameters (POC-K+&K+-ZL) was highly significant (r = 0.536, p<0.001) (Fig 2) and the results were showing excellent agreement between POC-Hb & HB-ZL(ICC= 0.536,95% confidence interval (0.47,0.59).

Conclusions:Our comparison of POC devices with central laboratory potassium determination in emergency patients at a tertiary care hospital showed a highly significant correlation between the two analysed potassium concentration measurement methods, using POC devices and the indirection selective electrode (ISE) method

Keywords: Point of care devices; Point of care potassium; Emergency
Medicine.

Background: Ischemic heart disease (IHD) and stroke constitute the
majority of CVD mortality in India (83%), with IHD being predominant.
Objectives: To correlate the level of Hs-crp with risk factors like age ,
hyperlipidemia , obesity and to correlate the level of Hs-CRP with
number of vessel involved and percentage of stenosis.

Material and Methods: This cross sectional study was conducted on patients admittedin the Intensive cardiac Care Unit of Karnataka Institute of MedicalSciences, Hubli between November 2015 – January 2017. A total numberof 110 patients were recruited for the study. Results: Out of the total 110cases 78(70.9%) were male patients and 32(29.1%) female patients. Mostof patients were in age group of 51-60 yrs (40%). 77 patients (70%) were obese BMI>25. 56(52.8%) were SVD,12(11.3%) were DVD,20(18.9%)were TVD, and 18(17%) had normal coronaries. There was significant difference in mean hsCRP with respect to vessel blocked distribution, higher was seen with TVD(6.4mg/l)>DVD(2.7md/l)>SVD(1.3mg/)>normalcoronaries(1.2mg/l) There was positive correlation between hscrp and LDL,TG, and significiant negative correlation with HDL. There was significiant negative correlation of hscrp with EF. Conclusion: It was concluded hsCRP correlates with cardiovascular risk factors like obesity, dyslipedimea. hscrp can predict the number of vessel involved
and indirectly severity of disease. hscrp and EF together could predict
severity of disease.

Keywords: Ischemic Heart Disease; Hs-CRP; Hyperlipidemia;
Obesity; Ejection Fraction.

Background: Dengue is the most rapidly spreading mosquito-borne viraldisease with four serotypes. An estimated 50-100 million cases of denguefever (DF) and about 250,000-500,000 cases of dengue haemorrhagic fever(DHF) occur every year.In Southeast Asia, the average number of casesof DHF per year has increased from 10,000 in the 1950s to over 200,000in the 1990s. Thus, dengue virus remains a major cause of morbidity andmortality in tropical areas. Epidemic DF was common in Asia and Pacificregion throughout the twentieth century.

AIMS & OBJECTIVES: To analyse Mean Platelet Volume and Platelet distribution width as the Predictors of thrombocytopenia and the speed of illness recovery among admitted cases with DF and DHF.To study the early clinical presentation for diagnosis of dengue virus infection. To study the Complications and Prognosis of the illnesses Materials and Methods: The Prospective observational study was done on 100 dengue positive cases during the outbreak of dengue infection over a period of 12 months, from Nov 2017 to October 2018. The platelet parameter like Platelet count, Mean platelet volume, Platelet distribution width were noted using BC 3000 plus Mindray Automated Haematology Analyzer and was compared with severity of disease (DF/DHF/DSS). Results: Relationship between platelet parameters like platelet count, MPV and PDW were made with severity of the disease (DF/DHF/DSS). No Significant difference was observed between severity of the thrombocytopenia and severity of the disease, (P value 0.080686)Dengue positive cases were associated with
low MPV were 13.86% and high PDW values were 43.56%.Even though the increase in the MPV and increase in PDW indicates activation and heralds recovery of platelets, but the correlation between platelet counts and platelet indices like MPV and PDW did not show any significance in our study (p values are 0.710, 0.138 and 0.131 respectively. Conclusion: The study focusesthe importance of platelet parameters in dengue infection. No significant difference was observed between severity of the thrombocytopenia and severity of the disease (P value 0.080686). Platelet count is thus a predictive parameter of DF/DHF/DSS. Low MPV (13fl) shows sensitivity for dengue fever thus reflecting a predictive marker for diagnosing dengue fever inendemic area.

Keywords: Dengue; Platelets; Mean Platelet Volume; Platelet Distribution width.