Indian Journal of Emergency Medicine

A 68 years old male diabetic patient presented to the Emergency Departmentwith chief complaints of slurring of speech and weakness in the left lower limb for 1 day. The patient was also experiencing respiratory symptoms from the last 4-5 days, cough, and dyspnea. On arrival in the emergency department, the patient was pyrexial. Covid-19 rapid antigen test was done was comes to positive. The patient was shifted to covid ICU, a Covid RT PCR sample was sent, and an MRI stroke protocol was planned. MRI BRAIN was suggestive of right-sided lateral medullary infarcts. Right vertebral artery flow void absent. MR ANGIO BRAIN- Eccentric short segment plaque involving the proximal segment of the left subclavian. Eccentric plaques involving the posterior aspect of left proximal ICA left petrous ICA and both cavernous ICA. Lack of flow-related enhancement in right vertebral artery! occluded. Nonvisualized inferior division of right MCA.

Aberrant right subclavian artery (ARSA) is a rare anomaly, in which the right subclavian artery arises directly from the aortic arch instead of originating from the brachiocephalic artery. This anomaly should be taken into consideration during surgical procedures around the esophagus, such as esophagectomy. Any unintentional injury of this artery during surgical procedures could be extremely life-threatening. The patient was an 88-year-old male, known case of hypertension, CAD, COPD, presented with the chief complaint of chest pain for 2 days associated with the history of right-hand weakness and numbness for 1 week. ECG has done suggestive of Sinus Rhythm with LBBB Trop I – 6.1 ng/ml Coronary Angiography LMCA- Normal LAD- Mid LAD 80% stenosis LCX- Proximal 99-100% occluded RCA- normal CT ANGIO right upper limb done findings revealed anomalous retro esophageal course of right subclavian artery with narrowing at its origin and a small thrombus in juxta osteal segment. Thrombus of 6.7 cm long segment of the distal third of right brachial artery with the reformation of brachial artery at the level of elbow joint along with thrombosis of right ulnar artery at a short distance from its origin.

Long RP tachycardia is an uncommon form of supraventricular tachycardia (SVT) that exhibits a longer RP interval than PR interval on 12-lead electrocardiograms (ECG)1. The differential diagnosis of a long RP tachycardia includes the uncommon form of AV nodal reentrant tachycardia (AVNRT), the permanent form of reciprocating tachycardia (PJRT), and atrial tachycardia (AT). Drug responses vary markedly from patient to patient in uncommon SVT. Few small patient cohorts have been studied involving uncommon SVT whose attacks could not be adequately controlled by antiarrhythmic agents2. We present the case of a 47-year-old woman with stable long RP tachycardia refractory to first and second-line treatment in the Emergency Department, who rapidly destabilized to transient heart failure and hemodynamic compromise, ultimately requiring synchronized electrical cardioversion. In our report, we highlight the presentation of long RP tachycardia in the Emergency Department; its management in the acute setting and dealing with its ECG interpretational challenges. Our reasons for highlighting this case are: 1. This is a relatively uncommon ECG presentation to the Emergency Department, which poses its own analytical dif culties. 2. The dynamic nature of drug-resistant tachyarrhythmia in the acute setting makes this case clinically relevant to the Emergency Physician.

Pericardial effusion can present as one of the life-threatening emergencies requiring prompt diagnosis and immediate life-saving measures. We are presenting a case of a large pericardial effusion, tubercular in origin, in a pregnant woman with 31 31-week period of gestation. She presented with acute onset cough, dyspnea, and hemodynamic instability. She was managed successfully with pericardiocentesis and antitubercular therapy and later she had a normal vaginal delivery. Prompt and correct diagnosis and a team-based approach are the key to the management of such patients and a successful outcome.

Near hanging is one of the common modes of suicidal methods presenting to the A&E department. Despite hanging having high fatality rate, survival is possible with early prompt intervention & resuscitation of the victim. To study the injury pattern & analysis of its outcome innear hanging victims presenting to emergency department. Medical records of 30 patients aged between 15&50 years was reviewed retrospectively. Information regarding age, gender, marital status & material used was noted. Outcome of those patients were analyzed maintaining strict confidentiality. Female gender accounted for 16 patients & 14 were males. 54% of patients presented to ED with complete hanging & 46% with partial hanging. 80% (24) patients had a coma scale of (GCS) <8 & all of them required mechanical ventilator support. 60% (18) required <2days of ventilation, 4 patients for 3- 6 days & 2 patients had >7days of ventilator support. Co-morbidities associated were alcohol abuse, seizure disorder, drug abuse, & opioid dependence with uncomplicated withdrawal. Outcome in 66% of patients was good were discharged with minimal or no neurological deficits, 10% died & 24% got discharged against medical advice. Probable cause of death was post near hanging cardiac arrest, hypoxic ischemic injury, seizures, severe metabolic acidosis & brain death. Longer hanging time with severe injury pattern had bad prognosis with increase in morbidity & mortality. However, in spite of low GCS active intervention, resuscitation & aggressive management improved the outcome.

Background: Management of the patients presented with dyspnea can be challenging in emergency department(ED), because differentiating underlying cause can be difficult and time consuming. Point of care ultrasound(POCUS) examination in early evaluation of critical patients have been reported to be helpful in rapid diagnosis of causes of dyspnea which in turn helps in early Resuscitation. Aim: We performed this study to assess utility of POCUS in differentiating causes of dyspnea & compared with final diagnosis at the time of discharge/death. Settings and design: This was a single centre prospective diagnostic study to assess utility of POCUS in dyspnea. It was approved by ethical committee. Materials and methods: The study was conducted at ED of tertiary care government hospital in Central Gujarat from December 2018 to November 2019. All patients presenting with dyspnea to ED were included after written informed consent. Patients’ age < 12 years, Patients not willing for admission, and Patient who took discharge against medical advice /absconded/died before establishing final diagnosis were excluded. Provisional diagnosis made through POCUS was compared with the final diagnosis made by the consultants of respective clinical departments during course of their hospitalization. Statistical analysis and results: 146 patients with dyspnea presenting to ED were included in prospective observational study. True and False positives, sensitivity and specificity were calculated from the analysis of data. Reliability index was calculated on the basis of above data. *Conclusion: This study showed good efficacy of POCUS in differentiating causes of dyspnea when compared with final medical diagnosis. Thus POCUS helps in early resuscitation and management.