On-treatment decline in MELD score predicts one-month transplant-free survival in rodenticidal hepatotoxicity patients treated with low-volume plasma exchange.

BACKGROUND AND AIM: Plasma exchange (PLEX) improves survival in patients with rodenticidal hepatotoxicity. However, predictors of treatment response are unknown. We aimed at assessing predictors of response to PLEX treatment in these patients. METHODS: Patients with rodenticidal hepatotoxicity from 2014 to 2023 managed in our department were included in this study. Kochi criteria (model for end-stage liver disease [MELD] score ≥ 36 or international normalized ratio [INR] ≥ 6 with hepatic encephalopathy [HE]) derived specifically for rodenticidal hepatotoxicity (PubMed IDentifier [PMID]: 26310868) were used to assess need for liver transplantation. We analyzed predictors of survival at one month. ∆Bilirubin, ∆MELD score and ∆INR were calculated as percentage change of the parameter after third PLEX session (or after last PLEX if < 3 PLEX sessions done) from baseline pre-PLEX value. RESULTS: Of 200 patients with rodenticidal hepatotoxicity, 114 patients were treated with low-volume PLEX (PLEX-LV). No patient had liver transplantation. Of 78 patients who fulfilled Kochi criteria, 32 patients were PLEX-LV eligible and underwent PLEX-LV (M: 10; age: 20.5, 7-70 years; median, range; acute liver failure: 24). Twenty-two (69%; acute liver failure: 14) of the 32 patients were alive at one month. Presence of HE (p = 0.03) and ∆MELD (p < 0.001) were significant predictors on univariate analysis, while ∆MELD (aOR = 0.88, 95% CI: 0.79-0.98, p = 0.01) was the only significant independent predictor of one-month transplant-free survival. Area under receiver operating characteristic (ROC) for ∆MELD was 0.93 (95% CI:0.85-1.00) and a decrease of ≥ 20% in MELD score while on PLEX-LV had 90% sensitivity and 90% specificity in predicting one-month survival. CONCLUSIONS: Decline in MELD while on PLEX-LV independently predicted one-month transplant-free survival in rodenticidal hepatotoxicity patients. This may help guide decision on stopping PLEX-LV in patients predicted to respond to treatment and to consider alternate treatment options in non-responders.

EASIER trial (Erector-spinAe analgeSia for hepatopancreaticobiliary pain In the Emergency Room): a single-centre open-label cohort-based randomised controlled trial analysing the efficacy of the ultrasound-guided erector-spinae plane block compared with intravenous morphine in the treatment of acute hepatopancreaticobiliary pain in the emergency department.

BACKGROUND: Ultrasound-guided (USG) erector-spinae plane block (ESPB) may be better than intravenous opioids in treating acute hepatopancreaticobiliary (HPB) pain in the ED. METHODS: This open-label randomised controlled trial was conducted in the ED of a tertiary-care hospital between March and August 2023. All adult patients with severe HPB pain were recruited during times that a primary investigator was present. Unconsenting patients, numeric rating scale (NRS) ≤6, age ≤18 and ≥80 years, pregnant, unstable or with allergies to local anaesthetics or opioids were excluded. Patients in the intervention arm received bilateral USG ESPB with 0.2% ropivacaine at T7 level, by a trained ED consultant, and those in the control arm received 0.1 mg/kg intravenous morphine. Pain on a 10-point NRS was assessed by the investigators at presentation and at 1, 3, 5 and 10 hours after intervention by the treatment team, along with rescue analgesia requirements and patient satisfaction. Difference in NRS was analysed using analysis of co-variance (ANCOVA) and t-tests. RESULTS: 70 participants were enrolled, 35 in each arm. Mean age was 40.4±13.2 years, mean NRS at presentation in the intervention arm was 8.0±0.9 and 7.6±0.6 in the control arm. NRS at 1 hour was significantly lower in the ESPB group (ANCOVA p<0.001). At 1, 3, 5 and 10 hours, reduction of NRS in the intervention arm (7±1.6, 6.7±1.9, 6.6±1.8, 6.1±1.9) was significantly greater than the control arm (4.4±2, 4.6±1.8, 3.7±2.2, 3.8±1.8) (t-test, p<0.001). Fewer patients receiving ESPB required rescue analgesia at 5 (t-test, p=0.031) and 10 hours (t-test, p=0.04). More patients were 'very satisfied' with ESPB compared with receiving only morphine at each time period (p<0.001). CONCLUSION: ESPB is a promising alternative to morphine in those with HPB pain. TRIAL REGISTRATION NUMBER: CTRI/2023/03/050595.

Quantification of Organophosphorus Insecticide Removed by Gastric Lavage in Acutely Poisoned Patients: An Observational Study.

Introduction: The effectiveness of gastric lavage in organophosphorus (OP) poisoning has not been established. We assessed the ability of gastric lavage to remove OP insecticides as a preliminary stage in assessing effectiveness. Patients and methods: Organophosphorus poisoning patients presenting within 6 hours were included, irrespective of prior gastric lavage. A nasogastric tube was placed and gastric contents aspirated, followed by at least three cycles of gastric lavage with 200 mL of water. Samples from the initial aspirate and the first three lavage cycles were sent for identification and quantification of the OP compounds. Patients were monitored for complications of gastric lavage. Results: Around 42 patients underwent gastric lavage. Eight (19.0%) patients were excluded from the study because of a lack of analytical standards for ingested compounds. Insecticides were detectable in the lavage samples of 24 of 34 (70.6%) patients. Lipophilic OP compounds were detected in 23 of 24 patients, while no hydrophilic OP compounds could be detected in six patients with reported ingestion of hydrophilic compounds. For chlorpyrifos poisoning (n = 10), only 0.65 mg (SD 1.2) of the estimated ingested amount (n = 5) of 8,600 mg (SD 3,200) was recovered by gastric lavage. The mean proportion of the compound removed by initial gastric aspirate was 79.4% and subsequent three cycles removed 11.5, 6.6, and 2.7%. Conclusion: Lipophilic OP insecticides could be quantified in the stomach contents of OP poisoning patients with the first aspiration or lavage being most effective. The amount removed was very low; hence, routine use of gastric lavage for OP poisoning patients arriving within 6 hours is unlikely to be beneficial. How to cite this article: Mathansingh AJ, Jose A, Fleming JJ, Abhilash KPP, Chandiraseharan VK, Lenin A, et al. Quantification of Organophosphorus Insecticide Removed by Gastric Lavage in Acutely Poisoned Patients: An Observational Study. Indian J Crit Care Med 2023;27(6):397-402.

The economic impact of a COVID-19 illness from the perspective of families seeking care in a private hospital in India.

Background: The Covid-19 pandemic had a tremendous impact that caused significant morbidity, mortality, and financial stress for families. Our study aimed to determine the Out-of-pocket expenses and economic impact of a Covid-19 illness for households where patients were admitted to a private hospital in India. Methodology: This was a cost-of-illness study from a tertiary care academic institute where adult patients diagnosed with COVID-19 from May 2020 to June 2021 were included. Patients with an admission of less than one day or who had any form of insurance were excluded. The clinical and financial details were obtained from the hospital information system and a cross-sectional survey. This was stratified across three clinical severity levels and two epidemiological waves. Results: The final analysis included 4445 patients, with 73 % admitted in Wave 1 and 99 patients interviewed. For patients with severity levels 1, 2 and 3, the median admission days were 7, 8 and 13 days respectively. The total cost of illness (general category) was $934 (₹69,010), $1507 (₹111,403) and $3611 (₹266,930) and the direct medical cost constituted 66%, 77% and 91% of the total cost for each level respectively. Factors associated with higher admission costs were higher age groups, male gender, oxygen use, ICU care, private admission, increased duration of hospital stay and Wave 2. The median annual household income was $3247 (₹240,000) and 36% of families had to rely on more than one financial coping strategies, loans with interest being the commonest one. The lockdown period affected employment and reduced income for a considerable proportion of households. Conclusion: A Covid admission of higher severity was a significant financial burden on families. The study reaffirms the need for collaborative and sustainable health financing systems to protect populations from hardships.$-US Dollar; ₹- Indian Rupees.

A clinico-epidemiological profile, coinfections and outcome of patients with Influenza Like Illnesses (ILI) presenting to the emergency department during the COVID-19 pandemic.

Background: During the COVID-19 pandemic, many patients presented to the emergency department (ED) with features of Influenza-like illnesses (ILI) and with other atypical presentations. This study was done to determine the etiology, co-infections, and clinical profile of patients with ILI. Methods: This prospective observational study included all patients presenting to the ED with fever and/or cough, breathing difficulty, sore throat, myalgia, gastrointestinal complaints (abdominal pain/vomiting/diarrhea), loss of taste and altered sensorium or asymptomatic patients who resided in or travelled from containment zones, or those who had contact with COVID-19 positive patients during the first wave of the pandemic between April and August 2020. Respiratory virus screening was done on a subset of COVID-19 patients to determine co-infection. Results: During the study period, we recruited 1462 patients with ILI and 857 patients with the non-ILI presentation of confirmed COVID-19 infection. The mean age group of our patient population was 51.4 (SD: 14.9) years with a male predominance (n-1593; 68.7%). The average duration of symptoms was 4.1 (SD: 2.9) days. A sub-analysis to determine an alternate viral etiology was done in 293 (16.4%) ILI patients, where 54 (19.4%) patients had COVID 19 and co-infection with other viruses, of which Adenovirus (n-39; 14.0%) was the most common. The most common symptoms in the ILI-COVID-19 positive group (other than fever and/or cough and/or breathing difficulty) were loss of taste (n-385; 26.3%) and diarrhea (n- 123; 8.4%). Respiratory rate (27.5 (SD: 8.1)/minute: p-value < 0.001) and oxygen saturation (92.1% (SD: 11.2) on room air; p-value < 0.001) in the ILI group were statistically significant. Age more than 60 years (adjusted odds ratio (OR): 4.826 (3.348-6.956); p-value: <0.001), sequential organ function assessment score more than or equal to four (adjusted OR: 5.619 (3.526-8.957); p-value: <0.001), and WHO critical severity score (Adjusted OR: 13.812 (9.656-19.756); p-value: <0.001) were independent predictors of mortality. Conclusion: COVID-19 patients were more likely to present with ILI than atypical features. Co-infection with Adenovirus was most common. Age more than 60 years, SOFA score more than or equal to four and WHO critical severity score were independent predictors of mortality.

Performance of Aerosol Boxes for Endotracheal Intubation during the COVID-19 Pandemic with Systematic Review.

Introduction: In the backdrop of the COVID-19 pandemic, endotracheal intubation using an aerosol box (AB) became the norm in the emergency department (ED) and the intensive care unit. We compared two models of AB with different dimensions to compare and identify a device that helps in reducing viral exposure without compromising successful airway management. Methods: We conducted this prospective observational study for 7 months (October 20-April 21) on 143 patients presenting with an acute airway compromise to the ED. All intubations were performed using one of the two models available. The primary outcome was time taken for intubation (TTI). Results: The overall median time taken to intubate using any AB was 63 (interquartile range [IQR]: 46.2-87.7) s with an 81.9% first-pass success (FPS) rate. TTI for AB I was 67 (IQR: 53-106) s with a 76.3% FPS rate, while TTI for AB II was 57 (IQR: 44-75) s with an 85.9% FPS rate. TTI was much shorter without the use of an AB (34: IQR: 24-53 s) with a 92% FPS rate. Intubations done by emergency physicians with more than 2 years of experience were faster in both with or without AB when compared to intubations done by physicians with <2 years of experience. Conclusion: The use of an AB is associated with a longer TTI when compared to intubations done without an AB. TTI was relatively shorter when more experienced emergency physicians performed intubation. FPS rates were low with intubations done using AB.

Role of Neutrophil Gelatinase-associated Lipocalin (NGAL) and Other Clinical Parameters as Predictors of Bacterial Sepsis in Patients Presenting to the Emergency Department with Fever.

Background: Bacterial sepsis is associated with significant morbidity and mortality. However, to date, there is no single test that predicts sepsis with reproducible results. We proposed that using a combination of clinical and laboratory parameters and a novel biomarker, plasma neutrophil gelatinase-associated lipocalin (NGAL) may aid in early diagnosis. Method: A prospective cohort study was conducted at a tertiary care center in South India (June 2017 to April 2018) on patients with acute febrile episodes fulfilling the Systemic Inflammatory Response Syndrome (SIRS) criteria. Plasma NGAL and standard clinical and laboratory parameters were collected at the admission. Bacterial sepsis was diagnosed based on blood culture positivity or clinical diagnosis. Clinically relevant plasma NGAL cut-off values were identified using the receive operating characteristic (ROC) curve. Clinically relevant clinical parameters along with plasma NGAL's risk ratios estimated from the multivariable Poisson regression model were rounded and used as weights to create a new scoring tool. Results: Of 100 patients enrolled, 37 had bacterial sepsis. The optimal plasma NGAL cut-off value to predict sepsis was 570 ng/mL [area under the curve (AUC): 0.69]. The NGAL sepsis screening tool consists of the following clinical parameter: diabetes mellitus, the presence of rigors, quick sequential organ failure assessment (qSOFA) >2, a clear focus of infection, and the plasma NGAL >570 ng/mL. A score of <3 ruled out bacterial sepsis and a score >7 were highly suggestive of bacterial sepsis with an interval likelihood ratio (LR) of 7.77. Conclusion: The NGAL sepsis screening tool with a score >7 can be used in the emergency department (ED) to identify bacterial sepsis. How to cite this article: Paul A, Newbigging NS, Lenin A, Gowri M, Varghese JS, Nell AJ, et al. Role of Neutrophil Gelatinase-associated Lipocalin (NGAL) and Other Clinical Parameters as Predictors of Bacterial Sepsis in Patients Presenting to the Emergency Department with Fever. Indian J Crit Care Med 2023;27(3):176-182.

Optimizing Surgical Management of Acute Invasive Fungal Sinusitis.

Objective: Early surgical debridement is vital for favorable outcomes in acute invasive fungal sinusitis (AIFS). Our study aimed to propose guidelines with tailored, conservative surgical procedures based on areas of involvement and evaluate their usefulness in avoiding repeated debridement. Methods: This retrospective observational study was conducted on 150 AIFS patients operated on with the proposed surgical guidelines from May to June 2021 at a tertiary care hospital. Data including demography, comorbidities, surgical procedures, revision surgery, and outcome were collected and analyzed. Results: All 150 patients underwent bilateral endoscopic sinonasal debridement. Among them, 108 patients (72%) had current or recent coronavirus disease (COVID) infection. Ninety-two patients (61.3%) required additional procedures based on disease extent. Twenty patients (15.4%) required revision debridement because of progressive or recurrent disease. Mean age of this group was 46.15 (standard deviation ±11.2) years with a strong male predominance (9:1). Seventeen had diabetes mellitus, 12 suffered from active COVID-19 infection and six had received corticosteroids. None of the 31 patients who had recovered from COVID-19 or had no comorbidities required revision surgery. Age, gender, and comorbidities were not significant predictors for revision surgery. Fourteen patients (70%) underwent second surgery within one month of primary surgery. Predominant disease locations were alveolus and palate (55% each), and in 80% the site was uninvolved at primary surgery. The most common revision procedure was inferior partial maxillectomy (60%). At follow-up, all were asymptomatic with no evidence of disease. Conclusion: The proposed surgical guidelines for AIFS allow for adequate surgical debridement with preservation of optimum functional status. Low revision surgery rates and good outcomes with minimal morbidity validate its usefulness.

Code blue: Predictors of survival.

Background and Aims: Code blue is a rapid response system developed for emergency resuscitation and stabilization of any sudden cardiac arrest (SCA) within a hospital. Literatures on outcome and factors predicting mortality from SCA in the Emergency departments (EDs) of India is scant. Material and Methods: This retrospective cohort study included all patients above the age of 15 years who had a code blue declared in the ED between the months of January 2018 and June 2019. Factors related to the sustained return of spontaneous circulation (ROSC) and mortality were analyzed using descriptive-analytic statistics and logistic regressions. Results: This study included 435 patients with a male predominance of 299 (69%). The mean age was 54.5 (SD - 16.5) years. Resuscitation was not attempted for 18 patients because of the terminal nature of the underlying disease. The majority were in-hospital cardiac arrests (74%). The nonshockable rhythm included pulseless electrical activity (PEA) (85.5%) and asystole (14.5%) cases. Shockable rhythms, that is, pulseless ventricular tachycardia/ventricular fibrillation were noted in only 10% (43/417) of cases. ROSC was attained in 184 (44.1%) patients, among which 56 (13.4%) were discharged alive from the hospital. Multivariate logistic regression analysis showed CPR >10 min (odds ratio [OR]: 13.58; 95% CI: 8.39-22.01; P < 0.001) and female gender (OR: 1.89; 95% CI: 1.13-3.17; P = 0.016) to be independent risk factors for failure to achieve ROSC in ED. Conclusion: The initial documented rhythm was nonshockable in the majority of the cases. CPR duration of more than 10 min and female gender were independent risk factors for failure to achieve ROSC in the ED. Nonshockable rhythms have a poorer outcomes than that of shockable rhythms.

Changing trends in the profile of rodenticide poisoning.

Background: Deliberate self-poisoning (DSP) is one of the leading causes of mortality and morbidity, with rodenticides being common compounds used by many victims. However, comprehensive data regarding the spectrum and outcome of rodenticide poisoning is scant. Method: This retrospective study was conducted in the Emergency Department (ED) of a large tertiary care hospital in South India between January 2017 and December 2018. All patients with deliberate consumption of rodenticides were included in the analysis. Results: During the study period, 1802 patients presented with DSP, among which 145 (8%) consumed rodenticide compounds. The mean (SD) age was 27.9 (10.7) years. Young adults (16-30 years) comprised 73% (106/145) of the study population. The majority (87%) were triaged as priority 2, while 10% were triaged as priority 1. Common rodenticide compounds consumed were yellow phosphorous (57%: 82/145), coumarins (12%: 17/145), zinc phosphide (19%: 27/145), and aluminum phosphide (1%: 1/145). A significant proportion of patients (18.6%) were under the influence of alcohol. Among the 73 males, 25 (34.2%) gave a history of co-consumption of alcohol. There was a history of previous DSP attempts in 6%. The majority (68%) of the patients were discharged alive from the hospital, and the in-hospital mortality rate was 9%. Age >30 years (adjusted OR: 2.2; 95% CI: 1.00-5.05; p value: 0.04) was an independent predictor of poor outcome. Conclusion: Rodenticide compound consumption for DSP is prevalent in young adults and is associated with significant mortality, especially with yellow phosphorous poisoning. The current trend in our country of the increasing use of highly fatal phosphorous compounds over the innocuous coumarin derivatives is a cause of grave concern.

Impact of lockdown and unlocking on symptomatology and emergency department visits during the first wave of the COVID-19 pandemic.

Background: The COVID-19 pandemic resulted in a complete nationwide lockdown on March 24, 2020. The months of April and May had stringent lockdown measures followed by a gradual loosening of restrictions in a graded manner. Methods: This observational study was performed in the emergency department (ED) of a tertiary hospital in south India triage Priority 1 and Priority 2 patients presented during the COVID-19 lockdown and unlock periods spanning from April 2020 to August 2020. The three different lockdown periods and the subsequent unlock periods were categorized as lockdown 1 (LD1), lockdown 2 (LD2), lockdown 3 (LD3), and unlock phase (UL), and a 7-day time period in each were taken for 7-day incidence analysis. Results: During the 5-month study period, a total of 1,954 patients were analyzed for the study that included 405, 440, 492, and 617 patients during the 7-day time periods in the LD1, LD2, LD3, and UL periods, respectively. The 7-day incidence of COVID-19 suspects increased significantly by 101.9% from LD1 to UL phases, whereas trauma cases increased by 52.9% in the same two time periods. Compared with LD1, in the UL phase, the 7-day ED admission and in-hospital mortality rates increased by 50.3% and 66.7%, respectively. Conclusion: The number of COVID-19 suspects saw a near-constant increase through the different phases of lockdown, culminating in the UL phase. The stringent lockdown measures resulted in a significant reduction in the incidence of trauma with a rebound increase in the UL phase.

Deliberate self-poisoning and harm: A meticulous quest of methods in vogue.

Background: Deliberate self-poisoning and harm (DSPH) is an unabating problem with a wide variation in the methods used across the world. Hence, this study was conducted to understand the current spectrum of methods used for DSPH by patients in our geographic locality and catchment area with special emphasis on newer compounds and drugs used. Methods: This retrospective study included patients presenting with DSPH to the emergency department (ED) between January 2017 and December 2018. Results: This study included 1802 patients, with a mean age of 32 ± 12.7 years. Of the patients, 85% were in the young to middle age group (16-45 years). Agrochemicals (n = 604, 33.5%), drugs (n = 498, 27.6%), plant toxins (n = 150, 8.3%) and rodenticides (n = 145, 8%) were the predominantly used compounds. The major emergency resuscitation procedures required in the ED were intubation (n = 321, 18%), vasopressor support (n = 73, 4%) and cardiopulmonary resuscitation (n = 27, 1.4%). A quarter (23.2%) was discharged stable from the ED, whereas a further 56.5% were discharged stable after hospital admission. The in-hospital mortality rate was 3% (n = 47). Multivariate logistic regression analysis showed rodenticides (odds ratio (OR): 22.32; 95% confidence interval (CI): 8.05-61.88; P = 0.005) and plant poisons (OR: 23.92; 95% CI: 8.95-63.94; P = 0.005) to be the independent predictors of mortality. Conclusion: DSPH is prevalent in the highly productive young age group. Agrochemical ingestion and drug overdose are the most common methods used, whereas rodenticide and plant poisoning are associated with significant mortality.

Impact of prior vaccination with CovishieldTM and Covaxin® on mortality among symptomatic COVID-19 patients during the second wave of the pandemic in South India during April and May 2021: a cohort study.

BACKGROUND: COVID-19 vaccines were authorised for emergency use to mitigate the impact of the pandemic. This study evaluated the effect of prior vaccination with either Oxford Astra Zeneca's Covishield™ or Bharath Biotech's Covaxin® on mortality among symptomatic COVID-19 patients during the second wave of the pandemic in India. METHODOLOGY: In this cohort study comprising of RT-PCR confirmed symptomatic COVID-19 patients presenting during April and May 2021, the effect of prior vaccination on mortality (primary outcome), need for hospitalization, oxygen therapy, non-invasive ventilation (NIV) and intensive care unit (ICU) admission were assessed and expressed as risk ratio (RR) with 95% confidence intervals (CI). RESULTS: The mean (SD) age of the cohort (n = 4183) was 46.3 (15.5) years; 17.9% (748/4183) had received at least one dose of Covishield™ and 4.8% (201/4183) had received Covaxin®. Mortality was 0.2% (95% CI: 0.2% - 0.7%), 3.5% (1.9-5.2%), 6.2% (0.3-12%) and 12.9% (11.8-14.1%) among fully vaccinated (>2 weeks after two doses), partially vaccinated (>2 weeks after one dose or <2 weeks after two doses), indeterminate (<2 weeks after one dose) and unvaccinated patients respectively. The difference in mortality among unvaccinated vs. fully vaccinated was 12.7% (95% CI: 11.4-13.9%), unvaccinated vs. partially vaccinated was 9.4% (7.4-11.4%) and unvaccinated vs. indeterminate vaccinated was 6.8% (0.8-12.7%). On adjusted analysis, as compared to unvaccinated patients, at least one dose of vaccine reduced the need for hospitalization (RR: 0.40; 95% CI: 0.35-0.47), oxygen (0.33; 0.27-0.40), NIV (0.23; 0.17-0.32), ICU admission (0.18; 0.12-0.27) and mortality (0.18; 0.11-0.29). CONCLUSION: Among symptomatic COVID-19 patients, prior vaccination with Covishield ™ or Covaxin® impacted the severity of illness and reduced mortality during a period of widespread delta variant circulation. Full vaccination conferred greater protection than partial vaccination.

Profile and outcome of COVID-19 patients treated at a secondary hospital in Central India during the second wave of the pandemic.

Background: The second wave of the coronavirus disease 2019 (COVID-19) pandemic resulted in a significant rise in the number of infections and deaths as compared to the first wave. The published literature till now is limited to tertiary hospitals. We did this study to describe the demographic characteristics and outcomes of patients admitted to a secondary care hospital in central India during the second wave of the pandemic. Methods: This was a single-center, retrospective observational study conducted in a secondary hospital in central India. The data of patients with COVID-19 infection admitted between March 25 to May 25, 2021, were retrieved and analyzed. Results: A total of 184 patients were included in the study. The mean age was 54.8 ± 14.5 years. Comorbidities included hypertension (40.2%), diabetes mellitus (29.9%), hypothyroidism (4.3%), and asthma (2.7%). The most common presenting complaints were cough (78.8%), breathlessness (61.4%), and fever (60.9%). The mean duration of symptoms was 5.4 ± 2.6 days. According to High-Resolution Computerised Tomography (HRCT) chest severity score, 29/181 (16%) patients had mild disease, 135/181 (74.5%) patients had moderate disease, and 17/181 (9.5%) patients had severe disease. The majority of the patients received remdesivir (90.2%) and 123 patients (66.8%) received corticosteroids. Half the patients (52.2%; n = 96) required intensive care unit admission, 79.3% (145 patients) required oxygen support, and 8.1% (15 patients) required non-invasive ventilator support. Conclusion: Our study from a secondary hospital setup showed that the second wave was very severe with a high requirement of oxygen support and intensive care monitoring.

Purpura Fulminans and Spotted Fever: A Case Series from South India.

Purpura fulminans (PF) is associated with acute infections such as meningococcal, staphylococcal, streptococcal, and rickettsial infections. However, there are only a few reports of association of PF with rickettsial fever from India. In this case series of seven adults with PF, four were definitive cases of spotted fever as the ompA real-time polymerase chain reaction was positive. The other three adults were probable cases of spotted fever, as they were positive by immunoglobulin M enzyme-linked immunosorbent assay, and their fever subsided within 72 h of rickettsia-specific therapy. Three of the seven patients had peripheral gangrene. These patients, despite presenting with severe spotted fever, had a favorable outcome. This is attributed to the high index of suspicion and early treatment supported by diagnostic assays.

Factors Affecting the Time to First Dose Antibiotic in Sepsis in Acute Emergency.

BACKGROUND: The Surviving Sepsis Campaign recommends the administration of antibiotics within 1 hour of triage time in sepsis patients. The purpose of this study was to determine the factors affecting the time to first dose antibiotics in sepsis patients presenting to the emergency department (ED). METHODS: We conducted a prospective observational study on factors affecting the time to first dose antibiotics in patients with sepsis presenting to the ED over a period of 7 months (July 2019 to January 2020). The purpose of this study was to determine the factors affecting the time to first dose antibiotics in sepsis patients. RESULTS: During the study period, a total of 410 patients with a mean age of 51.6 years were presented to the ED with sepsis. Majority was triaged to priority 1 (84.8%). The median door to antibiotic time was 50 minutes (IQR, 40-90). Two-thirds (68%) of the patients (279) received antibiotics within 60 minutes. The blood culture positivity rate was 22.9%, and the contamination rate was 6%. The most common factors for the delay were atypical presentation (36.6%) and unknown focus of infection (36.6%). Triage to non-acute areas of the ED (priority 2) was associated with delayed antibiotic administration [odds ratio (OR), 7.3; 95% confidence interval (CI), 4.03-13.36; p-value <0.001]. Patients presented with cellulitis and necrotizing soft tissue infection (NSTI) had received antibiotics within an hour compared to other diagnoses (18.3 vs 8.4%; OR, 2.4; 95% CI, 1.2-4.9; p = 0.009). CONCLUSION: Two-thirds of our patients received their first dose of antibiotics within an hour of presentation to the ED. Triage to lower priorities was an independent risk factor for delay in first-dose antibiotic administration, and patients presented with an obvious focus of infections like cellulitis and NSTI received their first dose of antibiotic much earlier when compared to other diagnoses. HOW TO CITE THIS ARTICLE: Joseph JV, Madhiyazhagan M, Roshan R, Dhanapal SG, Arul S, Abhilash KPP. Factors Affecting the Time to First Dose Antibiotic in Sepsis in Acute Emergency. Indian J Crit Care Med 2021;25(10):1155-1160.

Severe or not so severe? The gravity of geriatric trauma.

BACKGROUND: Due to associated comorbidities, the elderly population is more vulnerable to injuries with complications. This study was done to assess the severity of trauma and outcome of injuries among these patients presenting to the Emergency Department (ED). MATERIALS AND METHODS: This was a retrospective cohort study. We included all patients aged more than 60 years, who presented to the ED with trauma in the year 2018. Details of the mode of trauma, severity of injuries and outcome were analysed. RESULTS: During the study period a total of 7666 trauma patients presented to ED, among which 879 (879/7666: 11.4%) were in the geriatric age group. The mean age was 68.9 (SD: 7) years with 90.8% being young-old (60-79 years) and 9.2% being old-old (>80 years). Common modes of injuries were road traffic accidents (RTA) (64%) fall on level ground (FLG) (20%) and fall from height (FFH) (8%). Most of them had Injury Severity Score (ISS) and New Injury Severity Score (NISS) score of 0-7, i.e.: 62% and 51%, respectively. On multivariate logistic regression analysis RTA, FFH FLG and triage priority 1 patients were associated with trauma in the old-old as compared to the young-old age groups significantly. Independent risk factors associated with severe trauma were seen RTA, FLG and priority 1 patients. Forty-four per cent patients were managed by the ED team alone. Trauma speciality departments referred to included orthopaedics (47%), neurosurgery (22%), trauma surgery (14%), plastic surgery (8%) and hand reconstruction surgery (6%). About half of the population under study was discharged stable (44%), of which the majority belonged to the young-old category (44.1%). The in-hospital mortality rate was 0.5% (4/879). CONCLUSION: This study shows the gravity of multiple injuries sustained by the geriatric age group with RTA, FLG and FFH being the predominant causes of trauma. The NISS highlights the severity of injuries in the old and the frail.

Evaluation of Carotid Flow Time to Assess Fluid Responsiveness in the Emergency Department.

BACKGROUND: Assessing fluid responsiveness in critically ill patients is challenging. Objective, noninvasive tests that are easy to perform are needed. Doppler measurements of dynamic carotid artery parameters such as carotid blood flow (CBF) and carotid flow time (CFT) are being studied as the potential indicators of volume responsiveness, but the data supporting its use are sparse. METHODS: This prospective, observational study was conducted in the adult emergency department from June to September 2018. Patients who were prescribed a bolus of 500 ml of crystalloid for any indication were enrolled. Carotid Doppler was performed before and after a fluid bolus to measure the change in CBF and CFT. The aim of our study was to determine if CFT can be used as a marker of fluid responsiveness. RESULTS: During the 4-month study period, 209 patients were recruited through convenient sampling after obtaining informed written consent. 29.6% of patients presented with a mean arterial pressure (MAP) <65, among whom 58.1% had septic shock. The baseline CBF was 643.0 ± 212.7 ml/min, and it was 583.9 ± 207.1 ml/min and 668 ± 210.8 ml/min in hypotensive and normotensive patients, respectively. Considering a >10% increase in CBF as fluid response, there were 59% responders and 41% nonresponders. The MAP increased by 9.5% in the responders, while there was no significant change in CFT after the fluid bolus. There was no difference in CFT among the responders as compared to the nonresponders. There was no correlation between the change of CBF and CFT (r [207] = 0.013, P = 0.061) after the fluid bolus. CONCLUSION: Though easy to perform, CFT is probably not a good indicator of fluid responsiveness.

Changing pattern of trauma during the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic compelled the Indian government to enforce a complete nationwide lockdown on 24th March 2020. METHODS: This retrospective study was done to analyse the profile of trauma patients presenting to the emergency department (ED) from January to August 2020. Data from 69 days of lockdown and 83 days of pre-lockdown periods were used to calculate the 30-day incidence rates. RESULTS: During the 7-month study period, 5220 patients presented to our ED with trauma; 2296 in the prelockdown phase (83 days), 1205 during the lockdown phase (69 days), and 1719 during the postlockdown phase (92 days). There was a significant decrease (36.7%) in the 30-day incidence rate of trauma victims presenting to the ED during the lockdown phase (525) compared with the prelockdown phase (830). The 30-day incidence of road traffic accidents (RTA), fall from height, fall on level ground and other trauma decreased by 53.2%, 26%, 23.2% and 12.9%, respectively, while assault cases increased by 8.3% during the lockdown period as compared with the prelockdown period. During the lockdown period, the 30-day incidence of trauma victims with a positive blood alcohol content decreased by 39.6% with a significant drop in the strict lockdown month of April 2020. CONCLUSIONS: A significant reduction in the incidence rate of trauma victims, especially RTA and geriatric trauma was seen during the gruelling lockdown period of the COVID 19 pandemic.