Indian Journal of Emergency Medicine

A 20 years female was brought to the Emergency Medicine Department with the complaint of abdominal pain and blood in the stool since morning. There wasa history ofthe second dose of the covid 19 vaccine a month ago and fever the next day. On arrival, she was hemodynamically stable, bilateral purpuric rash was noticed on the bilateral lower limb extending to the thigh. Per abdominal examination was normal. The provisional diagnosis was made as HSP secondary to the covid 19 vaccination. She was treated symptomatically at the emergency room and admitted to the female ward, where she was treated with steroids and supportive care. She was discharged after five days when her symptoms were relieved. This case demonstrates HSP even though rare in an adult can occuras a possible complication of the COVID-19 vaccine and emphasizes the importance of thorough history taking and clinical examination.

Keywords: Henoch-schoenleinpurpura; Vasculitis; Covid 19; Vaccine; Abdominal pain.

Acute a 32 year old male came to emergency department with complaint of diaphoresis, multiple episodes of vomiting associated with lower abdominal pain and a choking sensation that leads him feeling of shortness of breath. On local examination there was no scar marks, no redness on body. On further examination the patient was conscious and little drowsy but in arousable state. On further evaluation, the patient was hypotensive with tachycardia and tachypnoea.

Patient had no known comorbidity. On further assessment patient and his attendant gave history of ingestion of tab Viagra 75 mg orally 5 hours back prior coming to the hospital. As per patient symptoms started after 2 hours of ingestion of tab Viagra 75 mg. Patient was immediately taken on to symptomatic supportive treatment with intravenous fluids, ionotropic support and oxygen support. All relevant investigations sent from emergency department and patient was advised admission in Intensive Care Unit for observation. Patient was discharged after an observation period of 24 hours in haemodynamically stable condition.

Keywords: Sildenafil citrate; Intravenous fluids; Ionotropic support; Oxygen support.

Acute mesenteric ischemia is always an emergency and is associated with a high mortality rate. It predominantly affects elderly people with an underlying cardiovascular disorder. Although most of the cases present with sudden onset of abdominal pain, atypical symptoms including mental confusion, bacteremia, and gastrointestinal (GI) bleeding may be the foremost presentation.1 GI bleeding may be the dominant symptom in rare cases and almost always presents as occult or overt lower GI hemorrhage.

We report the case of a 48-year-old man who presented to the Emergency Department (ED) of a university teaching hospital in northern India with the complaints of progressive abdominal pain and hematemesis.

Our reasons for highlighting this case are:

• The unusual presentation of an often clinically subtle disease made this case especially challenging to diagnose.

• The presence of confounding factors and “red herrings” caused further delay in the diagnosis of mesenteric ischemia.

• Mesenteric ischemia continues to remain a provisional diagnosis of low suspicion in a middle aged individual with abdominal pain and upper gastrointestinal hemorrhage presenting to the ED.

Keywords: Hematemesis; Gastrointestinal hemorrhage; Mesenteric ischemia.

Brachial arterial pseudoaneurysms are rare arterial disorders. Usually, they are always related to myriad underlying pathologies ranging from atherosclerosis, and connective tissue disorders to traumatic injuries as trivial as iatrogenic arterial puncture during phlebotomy. We report a case of a 35-year-old female who presented with ecchymosis all over the distal half of the right arm and proximal forearm with pain and tenderness. She was taking an oral anticoagulant (acenocoumarol 2 mg daily) for thromboprophylaxis of the prosthetic mechanical mitral valve. On baseline investigations, her prothrombin time was more than 90 seconds and her INR was more than 7. On USG, muscular hematoma along with a small pseudoaneurysm measuring 20 mm x 16 mm was detected at midarm. She denied any trauma in past. She was conservatively managed with vitamin K, transfusion of fresh frozen plasma, analgesics, and topical medications. She was discharged from ED after 48 hours of observation.

Keywords: Pseudoaneurysm; Brachial Artery; Coagulopathy

Ingestion of yellow oleander as a mode of suicide is common in India and Southeast Asia. It is associated with severe cardiac toxicity. A combination therapy is suggested in a resource limited setting as Digoxin specific antibody fragments are not easily available for treatment of serious cardiac glycoside poisoning. Severe atrio-ventricular block can be treated with atropine or temporary cardiac pacing. Ventricular tachycardia can be treated with low dose cardioversionand ventricular fibrillation with low dose defibrillation depending on the presentation.

Keywords: Yellow Oleander Poisoning; Digoxin specific antibody fragments; Defibrillation; Cardioversion.

Systemic hypertension has been frequently reported as ischemic cause of sixth nerve palsy, but few rigorous studies have been done to support this study.

Keywords: Sixth Nerve Palsy; Systemic Hypertension.

Many herbal medications are commonly being used as therapeutic remedies for common ailments and are being sold over the counter. Plants contain many active ingredients that can provoke adverse reactions when medicinal herbs are used improperly. The side effects of many medicinal herbs are not widely known and studied.

Here we present a case of two brothers, 32 yrs old patient X and 27 yrs old patient Y, with no known comorbidities, who presented to the ED with history of consumption of Homeopathic cough syrup following which they developed multiple episodes of vomiting, associated with giddiness, restlessness and vague discomfort. On enquiry the content of the medication was found to be Rhustox and Justicia adhatoda.

On presentation, both the patients were drowsy with unrecordable blood pressure. ECG of patient X showed Ventricular Tachycardia. Multiple attempts of electrical cardio version was attempted but unsuccessful, followed by Amiodarone infusion followed by Transvenous pacing but over drive pacing could not be achieved. Subsequently, in view of Intractable VT patient was initiated on Inj Lignocaine infusion which was continued for 6 hours. VT was reverted over a period of next 4 – 6 hours. ECG of patient Y showed Sinus Tachycardia with recurrent VPCs. He was managed conservatively with rate control methods.

Holter study was done for both the patients which was found to be normal. Both of them were discharged in haemo dynamically stable condition on day 3.

Keywords: Coffin; Tragedy; Justicia; Adhatoda; Toxicity.

Introduction Coarctation the aorta is typically thought to be a childhood disease and very rarely present in adults. However, emergency medicine physicians must keep a broad differential diagnosis when faced with a young or elder patient with signs and symptoms of acute congestive heart failure.

Case Report We report a case of a previously healthy male patient who presented to the emergency department with sudden onset of palpitation and ascending pain through lower extremities associated with giddiness and headache. The patient was examined and diagnosed with coarctation of the aorta. Management with interventional procedure was done and patient improved with symptomatic relief.

Discussion Coarctation of the aorta in adults are asymptomatic until an insidious injury occurs and will typically present with rare complains.

Conclusion This case demonstrates the importance of considering advanced imaging as a useful diagnostic tool and importance of early interventional procedure to improve outcome of the patient.

Keywords: Gourd shaped appearance; Post stenotic dilation; Percutaneous catheter balloon dilation with stent placement; Blood pressure difference between the upper and lower extremities and pulse delay; Case report.

To bring to light the greatly hazardous effects of the use of flue less gas geysers in the domestic setting. This article highlights the dangers and illeffects of using gas based geysersin the domestic setting. Over a period of 3months 3cases were seen in ER of Max Hospital which were suspects of CO poisoning due to use of gas geysers with unexplained neurological events while bathing in an ill ventilated bathroom with a functional flue less gas geyser. To increase awareness regarding gas geyser induced epilepsy and associated carbon monoxide intoxication, both of which are entirely preventable conditions. We also wish to emphasize the importance of stringent and universal implementation of gas geyser usage and installation laws.

Keywords: Carbon monoxide; Epilepsy; Gas geyser.

Introduction: Trauma is a major cause of morbidity and mortality in both developed and developing countries. The usual causes are road traffic accidents (RTAs), fall from height, occupational injuries, and assault. According to the World Health Organization report on road safety, RTAs would be the fifth leading cause of death worldwide by the year 2030.1 Occupational injuries leading to disability are also of major concern in a country like India as many industries continue to be unregulated. The majority of trauma deaths occur in the prehospital periods due to insufficient prehospital care where the first 60 min after trauma has been considered as the “golden hour” of trauma.2 It is therefore important to quickly assess the severity of the injury accurately and quickly. This study was done to improve the understanding of the mode of trauma, severity of injuries, and outcome in our hospital so that effective prevention and comprehensive management strategies could be made. We also studied the accuracy of physiologic variables such as respiratory rate, Glasgow coma score (GCS), and systolic blood pressure which are used in the revised trauma score (RTS) in predicting mortality.

Keywords: Accidents; Emergency department; Polytrauma; Head injury; Road traffic accidents (RTA).

Introduction: Suicide is also the second most common cause of injury related death after road traffic injuries. Aim of the present study was to find out the influence of admission clinical variables on outcome of patients admitted to emergency room (ER) with attempted hanging.

Material and Methods: A prospective observational study on patients presenting to emergency medicine department with history of attempted hanging and admitting under ICU/emergency medicine wards of SDM Medical college and Hospital, Dharwad. Study duration were about two years. Patients with >18 years of age with history of attempted hanging presenting to ED were included in our study Patients with GCS of 3/15 with bilateral dilated and non-reactive pupils and patients with history of attempted hanging and already diagnosed with hypoxic brain injury were excluded.

Results: Out of 50, 27 were male and 23 were female with more cases in age group between 21-30 years. Time since incidence was one of the parameter influencing on duration of stay in hospital, which was more in 11 patients who presented after 6 hrs of incidence. 30 patients presented with GCS of less than 8 and all these were intubated. This is most significant parameter to predict duration of hospital stay. Majority of patients had hyperglycemia but that did not influence much on patients stay in hospital. 35 cases had GRBS more than 126mg/dl at the time of presentation. All patients underwent CT Brain with C-spine scan which revealed abnormality in 15 cases. These patients also had more number of hospital stay than compared with normal scan finding cases.

Conclusion: In our study it has been evident that presenting clinical parameters including vital status of the victim, level of sensorium/ severity of brain Injury, non-modifiable factors such as age and initial CT scan findings will guide an emergency physician to explaining prognosis in a case of attempted hanging.

Keywords: Hanging; Suicide; Vitals; Outcome; Risk factors.