Appropriateness of radiographic imaging ordered by emergency physicians: a knowledge-based survey.

OBJECTIVE: To assess the knowledge of physicians working in the emergency department in choosing appropriate diagnostic imaging in different clinical scenarios. Methods: The cross-sectional study was conducted at the Emergency Department of the Aga Khan University Hospital, Karachi, from January 3 to July 2, 2018, and comprised registered medical officers, residents, and consultants of either gender involved in emergency care decision-making. Data was collected using a structured questionnaire that had 10 clinical scenarios based on the American College of Radiology Appropriateness Criteria guidelines. Data was analysed using SPSS 17. RESULTS: Of the 82 participants, 50(61%) were males and 32(39%) were females. The overall mean age was 34.06±6.42 years. Of the total, 50(61%) subjects had appropriate knowledge regarding imaging. The overall mean number of correct responses was 6.90±1.20. Those belonging to the Emergency Medicine specialty had significantly higher odds of having appropriate knowledge compared to participants belonging to other specialties when adjusted for age, gender, position of practice and years of Emergency Medicine training (Odds ratio: 4.73; 95% confidence interval: 1.07-20.91). CONCLUSIONS: Physicians belonging to the Emergency Medicine specialty were more likely to have adequate knowledge regarding imaging appropriateness compared to other specialties.

Bedside index (BISAP) v/s Ranson scores in predicting mortality and severity in patients with acute pancreatitis.

OBJECTIVE: To determine the diagnostic accuracy of the bedside index for severity in acute pancreatitis in comparison with Ranson scores in predicting mortalities and severities in patients with acute pancreatitis. METHODS: The cross-sectional study was conducted at the Department of Emergency Medicine, Aga Khan University Hospital, Karachi, from July 1, 2017, to January 1, 2018, and comprised patients who presented with acute pancreatitis. The bedside index for severity in acute pancreatitis score was applied in the emergency department and the patients were followed up in ward/intensive care unit where Ranson scores were calculated within the following 48 hours. Both the scores were calculated and compared for the prediction of severity and mortality for each patient. Data was analysed using SPSS 20. RESULTS: Of the 136 patients, 88(64.7%) were males and 48(35.3%) were females. The overall mean age was 42.04±16.42 years (16-75 years), On the basis of two scores, mild and moderate acute pancreatitis was diagnosed in 123(90.4%) and 119(87.5%) patients respectively, while severe condition was diagnosed in 13(9.6%) and 17(12.5%) patients respectively. The bedside index had specificity 94.62% compared to 91.54% for Ranson score; sensitivity 100% vs 100%; negative predictive value 100% vs 100%; positive predictive value 46.15% vs 35.29%; and diagnostic accuracy 94.85% vs 91.91%. CONCLUSIONS: The bedside index for severity in acute pancreatitis and Ranson score were both found to be reliable tools in predicting mortalities and severities in patients with acute pancreatitis.

Clinical Decision Unit, an extension of emergency department: An experience and advantage in a tertiary care centre.

OBJECTIVE: To evaluate the clinical decision unit of a tertiary care health facility and to see the disease pattern. . METHODOLOGY: The cross-sectional retrospective study was conducted at the Department of Emergency Medicine, Aga Khan University Hospital, Karachi, from September to October 2011, and comprised data of patients admitted to the clinical decision unit from January to December 2010. The protocols were developed for 7 diseases: acute coronary syndrome, ureteric colic, abdominal pain, bronchial asthma, gastroenteritis with dehydration, headache, and minor head injury. Data-collection proforma recorded demographics, dates of admission, presenting complaints at triage, diagnosis at admission, final disposition and bounce back of the patients. Data was analysed using Microsoft Excel 2007. RESULTS: Of the 1515 patients whose data was analysed, 824(54%) were males. The overall age ranged from newborns to 93 years. Further, 904(60%) patients had presented to the triage counter as P3 category. Acute gastroenteritis was the most common complaint 240(15.84%). Of the total, 1311(87%) were sent home from the clinical decision unit; 39(2.8%) of them bounced back with the same complaint. Overall, 2(0.2%) adult patients expired. CONCLUSIONS: The unit evaluated had a productive initial year. Acute gastroenteritis was the most common protocol in use, but other protocols should also be developed to address local needs.

Prognostic significance of optic nerve sheath diameter on computed tomography scan with severity of blunt traumatic brain injury in the emergency department.

Optic nerve sheath diameter measurement (ONSD) has been associated with identifying the prognosis of traumatic brain injury (TBI) patients. The study was planned to evaluate the prognostic value of ONSD measured on the initial brain computed tomography (CT) scan performed on patients with blunt TBI in the emergency department(ED). This retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of moderate and severe TBI patients from January to December 2014. ONSD for each eye on the initial CT scan and Glasgow Coma Scale (GCS) was measured upon patient presentation. Correlation between presentation GCS and ONSD was done through Pearson's correlation. Receiver operator curve (ROC) analysis was done to measure the predictive values of ONSD for mortality. Of the 276 patients, 211(76%) were males and 65(23%) females. ONSD was measured on 160(58%) patients. The mean ONSD measured on CT scan was 3.8±1. The Pearson's correlation between the severity of brain injury as per GCS at presentation and ONSD was not significant (-0.182). We concluded that ONSD measured on the initial CT brain scan had good association with the severity of blunt TBI in patients presenting to the ED.

Neonatal Purpura Fulminans, a rare genetic disorder due to protein C deficiency: A case report.

Neonatal Purpura Fulminans is a rare and fatal disorder associated with perivascular haemorrhage and disseminated intravascular coagulation. Early clinical recognition, timely investigation and treatment is utmost important. A 6 days old baby boy was brought to emergency with blackish ulcers all over the body. Initially these were over the feet and scalp but later appeared on the abdomen. On examination, child was vitally stable, mildly icteric and had multiple erythematous large bullous blackish lesions on scalp, lower abdomen, perineum, back and soles. Neonatal reflexes and systemic examination was normal. Laboratory investigations showed normal CBC, PT/APTT and Protein S level while Protein C and Antithrombin III levels were low. Neonatal Purpura Fulminans is a life threatening condition and family screening is also mandatory for early recognition of disease in the siblings.

Burn injury characteristics: findings from Pakistan National Emergency Department Surveillance Study.

BACKGROUND: Burn injury is an important yet under-researched area in Pakistan. The objective of this study was to determine the characteristics and associated outcomes of burn injury patients presenting to major emergency departments in Pakistan. METHODS: Pakistan National Emergency Department Surveillance (Pak-NEDS) was a pilot active surveillance conducted between November 2010 and March 2011. Information related to patient demographics, mode of arrival, cause of burn injury, and outcomes was analyzed for this paper. Data were entered using Epi Info and analyzed using SPSS v.20. Ethical approval was obtained from all participating sites. RESULTS: There were 403 burn injury patients in Pak-NEDS, with a male to female ratio 2:1. About 48.9% of the burn injury patients (n = 199) were between 10 - 29 years of age. There was no statistically significant difference between unintentional and intentional burn injury patients except for body part injured (p-value 0.004) and ED disposition (p-value 0.025). Among 21 patients who died, most were between 40 - 49 years of age (61.9%) and suffered from fire burns (81%). CONCLUSION: Burn injuries are a burden on emergency rooms in Pakistan. We were able to demonstrate the significant burden of burn injuries that is not addressed by specialized burn centers.

The pediatric disease spectrum in emergency departments across Pakistan: data from a pilot surveillance system.

BACKGROUND: There is an increasing number of urgently ill and injured children being seen in emergency departments (ED) of developing countries. The pediatric disease burden in EDs across Pakistan is generally unknown. Our main objective was to determine the spectrum of disease and injury among children seen in EDs in Pakistan through a nationwide ED-based surveillance system. METHODS: Through the Pakistan National Emergency Department Surveillance (Pak-NEDS), data were collected from November 2010 to March 2011 in seven major tertiary care centers representing all provinces of Pakistan. These included five public and two private hospitals, with a collective annual census of over one million ED encounters. RESULTS: Of 25,052 children registered in Pak-NEDS (10% of all patients seen): 61% were male, 13% under 5 years, while almost 65% were between 10 to < 16 years. The majority (90%) were seen in public hospital EDs. About half the patients were discharged from the EDs, 9% admitted to hospitals and only 1.3% died in the EDs. Injury (39%) was the most common presenting complaint, followed by fever/malaise (19%) and gastrointestinal symptoms (18%). Injury was more likely in males vs. females (43% vs. 33%; p < 0.001), with a peak presentation in the 5-12 year age group (45%). CONCLUSIONS: Pediatric patients constitute a smaller proportion among general ED users in Pakistan. Injury is the most common presenting complaint for children seen in the ED. These data will help in resource allocation for cost effective pediatric ED service delivery systems. Prospective longer duration surveillance is needed in more representative pediatric EDs across Pakistan.

Bomb blast injuries: an exploration of patient characteristics and outcome using Pakistan National Emergency Departments Surveillance (Pak-NEDS) data.

BACKGROUND: Bomb blast injuries result in premature deaths and burdening of healthcare systems. The objective of this study was to explore the characteristics and outcome of patients presenting to the emergency departments in Pakistan with bomb blast injuries. METHODS: Active surveillance was conducted in seven major emergency departments of Pakistan from November 2010-March 2011. All the sites are tertiary care urban centers. All the patients who presented to the hospital's emergency department (ED) following a bomb blast injury as per self-report or the ambulance personnel were included in the study. Frequency of demographics, injury pattern, and outcomes were calculated. RESULTS: A total of 103 patients with bomb blast injuries presented to the selected emergency departments. The median age of patients was 30 years. Around three-fourth of the patients were males (n = 74, 74.7%). Most of the bomb blast patients were seen in Peshawar (n = 41, 39.8%) and Karachi city (n = 31, 30.1%) and the most common mode of arrival was non-ambulance transport (n = 71, 76.3%). Upper limb injuries (n = 12, 40%) were common in the under 18 age group and lower limb injuries (n = 31, 39.2%) in the 18 years and above group. There were a total of 8 (7.7%) deaths reported out of these 103 patients. CONCLUSION: Bomb blast injuries in Pakistan generally affect young males. Non-ambulance transport is the most common way to access emergency departments (ED). Overall ED mortality is high and capturing data during a disaster in an emergency department is challenging.

Nail as a foreign body in a neonate, an unusual presentation at an unusual age.

Children are prone to ingest substances due to their exploratory nature and tendency to put everything in the mouth. Commonly ingested foreign bodies are coins, batteries and buttons. Foreign body ingestion in neonates is a very rare presentation and always needs important consideration as it can be a part of child abuse and can lead to serious life threatening consequences.

Health care personnel and workplace violence in the emergency departments of a volatile metropolis: results from Karachi, Pakistan.

BACKGROUND: Workplace violence (WPV) is an important challenge faced by health care personnel in the emergency department (ED). STUDY OBJECTIVES: To determine the prevalence and nature of WPV reported by physicians and nurses working in the EDs of four of the largest tertiary care hospitals in Karachi, Pakistan and to understand the mental health impact of experiencing WPV. METHODS: This cross-sectional survey was conducted between September and November 2008 using a widely used questionnaire developed by the World Health Organization. Overall, 266 (86% response rate) questionnaires were included in this study. RESULTS: A total of 44 (16.5%) physicians and nurses said they had been physically attacked, and 193 (72.5%) said that they had experienced verbal abuse in the last 12 months. Among those who reported physical attack, 29.6% reported that the last incident involved a weapon, and in 64% of cases the attacker was a patient's relative. Eighty-six percent thought that the last attack could have been prevented, and 64% said that no action was taken against the attacker. After adjusting for covariates, physicians were less likely than nurses to report physical attack (odds ratio [OR] 0.46; 95% confidence interval [CI] 0.2-1.0), and personnel with greater work experience (OR 4.8; 95% CI 2.0-11.7) and those who said that there were procedures to report WPV in their workplace (OR 3.2; 95% CI 1.6-6.5) were more likely to report verbal abuse. WPV was associated with mental health effects in the form of bothersome memories, super-alertness, and feelings of avoidance and futility. CONCLUSION: WPV is an important challenge in the EDs of large hospitals in Karachi. A majority of respondents feel that WPV is preventable, but only a minority of attackers face consequences.

Mothers' education and working status; do they contribute to corrosive poisoning among paediatric patients of Karachi, Pakistan?

OBJECTIVE: To determine the causative factors behind corrosive poisoning in children like effect of working mothers, their educational status, financial background, family size and number of siblings. METHODS: The multi-centre, prospective, case series of all paediatric patients presenting to the Emergency Department of the National Institute of Child Health and the Aga Khan University Hospital, Karachi from August 2008 to July 2009 is presented. It comprised all paediatric patients with a history of corrosive poisoning at the two hospitals. SPSS 20 was used for statistical analysis. RESULTS: Out of 105 cases, 56(53%) related to the private-sector Aga Khan University Hospital, and 49(47%) to the public-sector National Institute of Child Health. Of the total, 82(78%) were in 1-5 age group; 61 (58%) were males; and 44(42%) were females. While 59 (56.2%) mothers were educated, only 21 (20%) were working. Of the 46 (43.8%) non-educated mothers, 20 (19%) were working. The type of poison was alkali in 81(77%) cases, acid in 23(22%). The corrosive varied from liquid in 80(76%) cases to powder/gel/semi-solid form in 25(24%) exposures. Besides, 65 (61.9%) families had 3 or more siblings, and the age of siblings was less than 10 in 60 (57.14%) cases, In 34 (32.38%) cases, the chemical were kept in the original container, while in 71 (67.61%) cases other commonly used and familiar containers were used to store these chemicals. Kitchen was the most common place with 51 (48.57%) cases. The time of incident was afternoon in 51(48.57%) cases. Majority cases (n=23; 21.9%) occurred in October. CONCLUSIONS: There are multiple contributory factors in corrosive exposure among children rather than the mother's working status and her educational background.

Unintentional, paediatric domestic injury in a semi rural area of Karachi.

OBJECTIVE: To identify the characteristics of unintentional domestic injury in children living in a semi-rural area of Karachi. METHODS: This retrospective descriptive study was carried out at a private hospital located at the northern outskirts of Karachi, Pakistan, from January 2005 to January 2007. We enrolled 271 out-patient children of either gender with a positive injury history. A questionnaire inquiring socio-demographic characteristics, timing of injury, monthly variation, injury pattern and factors was filled out. Descriptive analysis and Chi-square test were applied to find out the statistically significant differences. RESULTS: Among the 271 patients, the male-to-female ratio was 1.2:1. Fall from height 145 (54%) or at the same level 52 (19%) was the commonest form of domestic unintentional injury across all ages. Children younger than 2 years of age, 140 (52%), were more prone to injuries, with 49 (51%) having fallen from the lap. Cuts with sharp domestic utensils were noted in 19 (6%), while 15 (6%) had burns. Submersion in underwater tank was noted in 20 (7%) cases and poisoning in 7 (3%). Majority of the injured children were from the low socio-economic stratum and more injuries, 194 (72%), were reported during the summer months. CONCLUSION: Male children are more prone to suffer unintentional domestic injuries especially during summer vacations. Fall was the commonest pattern noted.

Use of Steroids in COVID-19 Patients: What is known?

COVID-19 pandemic has exaggerated the role of steroids in the standard of care despite minimum direct evidence of their efficacy in COVID-19 patients and their well-known adverse effects. The literature abounds on the side effects of steroids affecting different organ systems of the body. COVID-19 patients, who are on long-term steroids, are more susceptible to their adverse effects. We, herein, briefly review the potential uses and the adverse effects of steroids on different organ systems of the body. Key Words: Steroids, COVID-19, Adverse effects.

Vitamin D (Cholecalciferol) with Low Dose Vitamin C as a Safe and Effective Therapeutic Modality in an Adult with COVID-19 Pneumonia.

This is a case of an elderly female presenting with fever, cough and shortness of breath. On presentation, she had tachypnea and an oxygen requirement of 2 liters through nasal prongs. Her investigations were suggestive of COVID-19 pneumonia with bilateral ground-glass appearance on chest X-ray and a positive nasopharyngeal PCR swab. She had low vitamin D levels on presentation and was given 200,000 units of cholecalciferol, once daily for 3 days with Vitamin C, 500 mg per oral once daily for 7 days. Her symptoms got progressively better and her oxygen requirement diminished on next day. On day 3, her symptoms completely resolved, and her chest X-ray improved. In patients with COVID-19 pneumonia, who are vitamin D deficient, administration of large doses of cholecalciferol for few days can be a safe option to treat mild to moderate COVID-19 pneumonia. Key Words: Vitamin D, COVID-19, Pneumonia, Vitamin C.

Shock Index As A Predictor Of Hyperlactatemia For Early Detection Of Severe Sepsis In Patients Presenting To The Emergency Department Of A Low To Middle Income Country.

BACKGROUND: Early detection of sepsis in the emergency department is of prime importance and requires tools that are time and cost-effective. The Systemic Inflammatory Response Syndrome (SIRS) has been poorly associated with sepsis. Timothy et al in a retrospective analysis of Emergency Department (ED) visit stated estimate of SIRS at 17.8% accounting to an annual yield of 16.6 million adult visits with SIRS per year, among these only 26% accounted as an infectious aetiology of SIRS, trauma being 10% and other causes being rare. Shock index is found to be independently associated with 30-day mortality in a broad population of ED patients including sepsis. With limited health resources in a low to middle income country, focused utilization is important and so is the need for markers that are non-invasive, readily available, cost effective, and easy to interpret. Shock index can serve this purpose as a surrogate marker of disease severity in patients with severe sepsis and thus resulting in early detection of such patients. METHODS: This cross-sectional study was conducted from December 2014 to May 2015 at a tertiary care setup (Aga Khan University Hospital) in Karachi consisting of all septic patients received at the emergency department. Non-probability sampling technique was used. p-value <0.05 was taken as significant. RESULTS: Out of 180 study participants 94 (52.22%) were males while 86 (47.78%) were females. The mean age was 57.48±18.8 years. Cohen's κ was used to determine an agreement between the Shock index and Lactate levels. Shock index with cut off value of > 0.7 was used and moderate to the strong agreement between the two was found with kappa κ = 0.786 which was statistically significant (p=<0.001). Sensitivity was found to be 0.99, specificity 0.75, NPV 0.98, PPV 0.87. CONCLUSIONS: To conclude the shock index has some very favourable features, including availability, low cost, and direct relevance to sepsis in terms of its high validity. A high SI predicts elevated lactate levels in patients with sepsis.

The Utility of Early Warning Score in Adults Presenting With Sepsis in the Emergency Department of a Low Resource Setting.

Background Sepsis is a condition with high mortality and morbidity. Delay in early recognition and prompt management results in higher mortality. There are many clinical scores to identify early sepsis; however, Early Warning Score (EWS) has clinical/physiological parameters that are easy to apply in the ED for timely diagnosis and management. In the present study, we collected information regarding the utilization of EWS in timely identifying the sick patients at triage of a tertiary care center. Methods This study was a descriptive cross-sectional investigation conducted in the ED of Aga Khan University Hospital in Karachi, the largest metropolitan city in Pakistan. A total of 240 participants were selected by non-probability convenient sampling after fulfilling the inclusion criteria. Data collected included EWS criteria, demography, length of hospital stay, patient disposition (ward, intensive care or high dependency area), and differentials like sepsis, severe sepsis or septic shock. Results A total of 240 patients were enrolled, out of which 139 (57.9%) patients were male, and 101 (42.1%) were female with a mean age of 52.7 ± 15.3 years (range: 18 to 80 years). In this study, the length of stay (LOS) was 2.2 ± 1.1 (range: one to six days), and there was an EWS of 8.2 ± 2.6 (4-15). There were 143 patients in the elderly age group > 50 years (59.6%); however, most elderly presented with sepsis among both age groups. The least affected age group was aged 16 to 30 years, with 23 (9.6%) cases. An EWS >7 is best to detect cases with sepsis or severe sepsis with a sensitivity of 98.5% (95% CI: 92.13 to 99.92) and specificity of 89.57% (95% CI: 82.64 to 93.93). Similarly, the EWS for severe sepsis or septic shock was >9 with a sensitivity of 86.76% (95% CI: 76.72 to 92.88) and specificity of 88.24% (95% CI: 78.47 to 93.92). Conclusions This study revealed that the sensitivity and specificity of EWS for the detection of sepsis, severe sepsis and septic shock was found to be high; hence, it could be a valuable and readily useable system for early diagnosis and proper management of sepsis, severe sepsis, and septic shock.

Oral Ondansetron Administration to Dehydrated Children in Pakistan: A Randomized Clinical Trial.

BACKGROUND: Ondansetron is an effective antiemetic employed to prevent vomiting in children with gastroenteritis in high-income countries; data from low- and middle-income countries are sparse. METHODS: We conducted a randomized, double-blind, placebo-controlled superiority trial in 2 pediatric emergency departments in Pakistan. Dehydrated children aged 6 to 60 months with ≥1 diarrheal (ie, loose or liquid) stool and ≥1 vomiting episode within the preceding 4 hours were eligible to participate. Participants received a single weight-based dose of oral ondansetron (8-15 kg: 2 mg; >15 kg: 4 mg) or identical placebo. The primary outcome was intravenous administration of ≥20 mL/kg over 4 hours of an isotonic fluid within 72 hours of random assignment. RESULTS: All 918 (100%) randomly assigned children completed follow-up. Intravenous rehydration was administered to 14.7% (68 of 462) and 19.5% (89 of 456) of those administered ondansetron and placebo, respectively (difference: -4.8%; 95% confidence interval [CI], -9.7% to 0.0%). In multivariable logistic regression analysis adjusted for other antiemetic agents, antibiotics, zinc, and the number of vomiting episodes in the preceding 24 hours, children administered ondansetron had lower odds of the primary outcome (odds ratio: 0.70; 95% CI, 0.49 to 1.00). Fewer children in the ondansetron, relative to the placebo group vomited during the observation period (difference: -12.9%; 95% CI, -18.0% to -7.8%). The median number of vomiting episodes (P < .001) was lower in the ondansetron group. CONCLUSIONS: Among children with gastroenteritis-associated vomiting and dehydration, oral ondansetron administration reduced vomiting and intravenous rehydration use. Ondansetron use may be considered to promote oral rehydration therapy success among dehydrated children in low- and middle-income countries.