Efficacy of 10%,25% and 50% dextrose in the treatment of hypoglycemia in the emergency department - A randomized controlled study.

INTRODUCTION: Documented symptomatic hypoglycemia is defined as "event during which typical symptoms of hypoglycemia are accompanied by measured blood glucose of ≤70 mg/dL. Most of the studies and recommendations for the unconscious hypoglycemic adult advocate the use of 25 g of glucose as 50 mL of 50% dextrose solution intravenous or 1 mg of intramuscular glucagon. OBJECTIVE: To compare the efficacy and safety of 5 g boluses of 10%, 25% and 50% dextrose in the treatment of hypoglycemic patients presenting to our emergency department. METHODS: This was a randomized controlled single blinded study. Hypoglycemic patients in altered mental status were randomized into three treatment arms to be administered 10%, 25% or 50% dextrose. 5 g aliquots of intravenous 10%,25% or 50% dextrose were administered over 1 min. Time taken to achieve a Glasgow Coma Scale (GCS) of 15 and median total doses (g) were the primary outcomes. RESULTS: Data of 204 patients were analysed in the study. There was no difference in the median time to achieve a GCS of 15 in all three treatment arms (6 min). Total median dose administered in the 10% and 25% groups was lower than 50% (10 g vs 15 g). Proportion of patients who received the maximum dose of 25 g was higher in the 50% group as compared to 10% and 25% groups (12%, 3%, 4%). CONCLUSION: There was no difference in 10% dextrose and 25% dextrose as compared to 50% dextrose in achieving the baseline mental status (or GCS 15) in the treatment of hypoglycemia in the ED.

Transoral Robotic Surgery for a Rare Case of Venolymphatic Malformation in Parapharyngeal Space.

Venous malformations are low flow endothelial malformations with aberrant and ectatic venous channels. They are defects in vascular growth which causes functional and cosmetic impairment. Gradual growth in size of the lesion occurs due to venous congestion or thrombosis. Venous malformations in parapharyngeal space are a rare entity and are difficult to diagnose. Case Report. 13 year old boy presented with a history of hyposmia and progressive difficulty in breathing for a duration of 2.5 years. MRI face and neck with contrast showed a 4.5 × 4.3x3.6 cm lesion in the left parapharyngeal space. CT angiogram of brain and neck demonstrated a heterogeneously enhancing mass in the left parapharyngeal region. PET scan illustrated an ill-defined mass in the left pre styloid parapharyngeal space. Biopsy from the lesion showed features consistent with venolymphatic malformation. Flexible laryngoscopy showed a bulge over the left soft palate region with narrowing of nasopharyngeal lumen. Patient underwent transoral robotic surgery for complete excision of the mass. Post-operative period was uneventful. He has been on follow up for the past 1 year with no evidence of any residual or recurrent disease. Venolymphatic malformation is a rare lesion in the parapharyngeal space which is difficult to diagnose pre operatively. Surgical excision is the preferred modality of treatment for deep seated lesions in the parapharyngeal space. The advent of transoral robotic surgery have reduced the morbidity and improved clearance for such cases.

Managing Patients With Sympathetic Crashing Acute Pulmonary Edema (SCAPE) Using the SCAPE Treatment Protocol: A Case Series.

Pulmonary edema refers to the accumulation of excessive fluid in the alveolar walls and alveolar spaces of the lungs. It is a life-threatening condition with a high mortality rate and requires immediate assessment and management. Use of intravenous nitroglycerin has been advocated for such cases. The authors present a case series of 3 patients who presented to the emergency department with sympathetic crashing acute pulmonary edema (SCAPE) and were managed with high-dose intravenous nitroglycerin and bilevel positive airway pressure support using the SCAPE treatment protocol, leading to early correction of blood pressure, avoidance of endotracheal intubation, and no episodes of hypotension or rebound hypertension. The authors recommend emergency physicians utilize the SCAPE treatment protocol while managing patients with SCAPE.

Submammary Approach for Harvesting Pectoralis Major Myocutaneous Flap in Females with Oral Cavity Cancers: Report of Technique and Our Experience.

Background: Oral squamous cell carcinoma is one of the most common types of cancers affecting both male and female population worldwide. Currently gold standard for reconstruction of oral cavity defects is free flap reconstruction. However, in developing countries due to large case load, infrastructural and resource constraints, Pectoralis major myocutaneous flap is still widely being used. Harvesting PMMC flap in females is challenging due to thick fat and breast tissue affecting its reliability and also increased donor site morbidity. This article aims at highlighting our experience with harvesting PMMC flap in female patients by submammary approach and its outcomes. Methods: A total of 23 female patients who underwent wide local excision of oral cavity cancers and reconstruction with PMMC flap were included. Data was analysed as mean, median, mode, percentages and statistical averages. Results: Majority of patients belonged to 40-60 years of age group (60.86%). Buccal mucosa was the most common site of primary lesion in 16 patients (69.56%). Out of the 23 patients who underwent PMMC flap reconstruction, recipient site complications were seen in 4 patients including total flap loss in 2 patients (8.69%), minor complications, e.g. infection in 2 patients (8.69%). Donor site morbidity in the form of axillary seroma was seen in only 1 patient (4.34%). Conclusion: In our experience, PMMC flap is still a viable option for reconstruction especially in resource constraint settings. Submammary approach to PMMC flap harvest is a safe technique as it is associated with minimum recipient site complications whilst preserving donor site anatomy and thereby reducing donor site morbidities to minimum.

Contribution of 15 Years (2007-2022) of Indo-US Training Partnerships to the Emergency Physician Workforce Capacity in India.

BACKGROUND: Indo-US Masters in Emergency Medicine (MEM) certification courses are rigorous three-year emergency medicine (EM) training courses that operate as a partnership between affiliate hospitals or universities in the United States with established EM training programs and local partner sites in India. Throughout their 15 years of operation, these global training partnerships have contributed to the EM workforce in India. Our objective in this study was to describe Indo-US MEM program graduates, their work environments, and their contribution to the growth of academic EM and to the coronavirus disease 2019 (COVID-19) response. METHODS: An electronic survey was created by US and Indian MEM course stakeholders and distributed to 714 US-affiliated MEM program graduates. The survey questions investigated where graduates were working, their work environments and involvement in teaching and research, and their involvement in the COVID-19 response. We consolidated the results into three domains: work environment and clinical contribution; academic contribution; and contribution to the COVID-19 response. RESULTS: The survey response rate was 46.9% (335 responses). Most graduates reported working within India (210, 62.7%) and in an emergency department (ED) setting (304, 91.0%). The most common reason for practicing outside of India was difficulty with formal MEM certificate recognition within India (97, 79.5%). Over half of graduates reported dedicating over 25% of their work hours to teaching others about EM (223, 66.6%), about half reported presenting research projects at conferences on the regional, national, or international level (168, 50.5%), and almost all graduates were engaged in treating COVID-19 patients during the pandemic (333, 99.4%). Most graduates agreed or strongly agreed that they were satisfied with their overall MEM training (296, 88.4%) and confident in their ability to practice EM (306, 91.6%). CONCLUSION: Indo-US MEM graduates have made a notable contribution to EM in India through clinical service delivery, teaching, and research, even more essential in the context of the COVID-19 pandemic. The roles of these graduates should be acknowledged and can contribute further to expand EM specialty and systems development across India.

Hirayama Disease: A Rare Case Report and Review.

Hirayama disease, or brachial monomelic amyotrophy, is not a common neurological disease characterized by unilateral or asymmetric bilateral lower motor weakness of distal upper limbs. The basic pathophysiology is compression of the dural sac and spinal cord during flexion of the neck. A case of a 21-year-old male presented with chief complaints of tremors in both hands (right more than left) with gradually progressive weakness of the right hand and forearm. Electromyography (EMG), nerve conduction velocity (NCV), and magnetic resonance imaging (MRI) neck in flexion showed focal atrophy of lower cervical myotomes and confirmed the diagnosis of monomelic amyotrophy.

National Early Warning Score 2 is superior to quick Sequential Organ Failure Assessment in predicting mortality in sepsis patients presenting to the emergency department in India: A prospective observational study.

Background: High in-hospital mortality in sepsis patients remains challenging for clinicians worldwide. Early recognition, prognostication, and aggressive management are essential for treating septic patients. Many scores have been formulated to guide clinicians to predict the early deterioration of such patients. Our objective was to compare predictive values of quick Sequential Organ Failure Assessment (qSOFA) and National Early Warning Score 2 (NEWS2) with respect to in-hospital mortality. Methods: This prospective observational study was conducted in a tertiary care center in India. Adults with suspected infection with at least two Systemic Inflammatory Response Syndrome criteria presenting to the emergency department (ED) were enrolled. NEWS2 and qSOFA scores were calculated, and patients were followed until their primary outcome of mortality or hospital discharge. The diagnostic accuracy of qSOFA and NEWS2 for predicting mortality was analyzed. Results: Three hundred and seventy-three patients were enrolled. Overall mortality was 35.12%. A majority of patients had LOS between 2 and 6 days (43.70%). NEWS2 had higher area under curve at 0.781 (95% confidence interval [CI] (0.59, 0.97)) than qSOFA at 0.729 (95% CI [0.51, 0.94]), with P < 0.001. Sensitivity, specificity, and diagnostic efficiency to predict mortality by NEWS2 were 83.21% (95% CI [83.17%, 83.24%]); 57.44% (95% CI [57.39%, 57.49%]); and 66.48% (95% CI [66.43%, 66.53%]), respectively. qSOFA score had sensitivity, specificity, and diagnostic efficiency to predict mortality of 77.10% (95% CI [77.06%, 77.14%]); 42.98% (95% CI [42.92%, 43.03%]); and 54.95% (95% CI [54.90%, 55.00%]), respectively. Conclusion: NEWS2 is superior to qSOFA in predicting in-hospital mortality for sepsis patients presenting to the ED in India.

Unilateral Traumatic Adrenal Hemorrhage with Shock.

Trauma to the adrenal glands is very rare. The variation in clinical manifestations is marked and markers for its diagnosis being limited, makes it tough to be diagnosed. Computed tomography remains the gold standard for detecting this injury. Prompt recognition and the potential for mortality with adrenal insufficiency can provide the best guidance for the treatment and care of the severely injured. We present a case of a 33-year-old trauma patient who was not responding to the management of his shock. He was finally found to have a right adrenal haemorrhage leading to adrenal crisis. The patient was resuscitated in the Emergency Department but succumbed 10 days post admission.

Biodegradation of Congo Red Dye Using Lysinibacillus Species in a Moving Bed Biofilm Reactor: Continuous Study and Kinetic Evaluation.

The objective of this work was to develop a low-cost and efficient biocarrier for biodegradation of azo dye (i.e., Congo red (CR) dye). The potential bacterial species, i.e., Lysinibacillus fusiformis KLM1 and Lysinibacillus macrolides KLM2, were isolated from the dye-contaminated site. These bacterial species were immobilized onto the polypropylene-polyurethane foam (PP-PUF) and employed in a moving bed biofilm reactor (MBBR) for the treatment of CR dye. The effectiveness of the MBBR was investigated by operating the bioreactor in a continuous mode at various initial CR dye concentrations (50-250 mg/L) for 113 days. The removal efficiency was found in the range of 88.4-64.6% when the initial dye concentration was varied from 50 to 250 mg/L. The maximum elimination capacity (EC) of 213.18 mg/L.d was found at 250 mg/L of CR dye concentration. In addition, the CR dye utilization rate in the MBBR was studied by using two kinetics, namely, first-order and second-order (Grau) models. The high regression coefficients (R2 > 0.97) and the satisfactory root mean square (RMSE) values (0.00096-0.02610) indicated the reasonable prediction of CR dye degradation rate by the Grau model.

Diagnostic Accuracy of Screening of Lip and Oral Cavity Cancers or Potentially Malignant Disorders (PMD) by Frontline Workers: A Systematic Review and Meta-Analysis.

BACKGROUND: Oral cancer screening strategies help reduce associated mortality and could be performed by a trained frontline health worker (FHW). The present review aims to assess the diagnostic accuracy of commonly used screening modalities for oral cancer performed by FHW in apparently healthy individuals. METHODS: Electronic databases PubMed, Scopus, Embase, Cochrane Library, and Google Scholar, were searched. The review included studies conducted where apparently healthy adult individuals were screened by the FHW for cancer or PMD of the lip and oral cavity by any of the four commonly used techniques - Conventional Oral Examination (COE), toluidine blue staining (TBS), Oral Cytology (OC), and Chemiluminescent Illumination (CLI). FINDINGS: A total of 2,413 potentially relevant articles were retrieved from the search, among which five studies for COE were included in the review. Four out of those five studies were done before the year 2000. None of the studies fitted the inclusion criteria for TBS, OC, and CLI. Pooled sensitivity of oral screening by COE performed by an FHW (n=5) was 88.8% (95% CI: 71.6-96.1), whereas pooled specificity was 91.9% (95% CI: 78.3-97.3). On subgroup analysis, the pooled sensitivity and specificity of studies where the prevalence of disease was <50% (n=4) was 84.5% (95% CI: 62.6 - 94.7) and 94.1% (95% CI: 82.2 - 98.2), respectively. INTERPRETATION: COE by trained FHW had high pooled sensitivity and specificity for screening of oral cancer and PMDs. The screening techniques TBS, OC, and CLI, were not studied for mass screening by trained FHW. COE by trained FHW could be utilized for oral screening in limited-resource settings. However, the FHW should be sufficiently trained to get the desired benefits of early detection. FUNDING: Department of Health Research, Ministry of Health & Family Welfare, Government of India.

Rapid Thrombolysis Protocol: Results from a Before-and-after Study.

Objective: Intravenous thrombolysis within 4.5 hours from time of onset has proven benefit in stroke. Universal standard for the door-to-needle (DTN) time is within 60 minutes from the time of arrival of patients to the emergency department. Our rapid thrombolysis protocol (RTPr) was developed with an aim to reduce the DTN time to a minimum by modifying our stroke post-intervention processes. Materials and methods: This before-and-after study was conducted at a single center on patients who received intravenous thrombolysis in the emergency department. Consecutive patients who were thrombolysed using our RTPr (post-intervention group) were compared to the pre-intervention group who were thrombolysed before the implementation of the protocol. The primary outcomes were DTN time, time to recovery, and modified ranking score (mRS) on discharge. Secondary outcomes were mortality, symptomatic intracerebral hemorrhage, and hospital and intensive care unit length of stay. Results: Seventy-four patients were enrolled in each group. Mean DTN time in pre- and post-intervention group was 56.15 minutes (95% CI 49.98-62.31) and 34.91 minutes (95% CI 29.64-40.17) (p <0.001), respectively. In pre-intervention and post-intervention groups, 43.24% (95% CI 32.57-54.59) and 41.89% (95% CI 31.32-53.26) patients, respectively, showed neurological recovery in 24 hours. About 36.49% (95% CI 26.44-47.87) in pre-intervention group and 54.05% (95% CI 42.78-64.93) in post-intervention group had discharge mRS 0-2. Conclusion: The RTPr can be adapted by clinicians and hospitals to bring down the DTN times and improve outcomes for stroke patients. How to cite this article: Verma A, Sarda S, Jaiswal S, Batra A, Haldar M, Sheikh WR, et al. Rapid Thrombolysis Protocol: Results from a Before-and-after Study. Indian J Crit Care Med 2022;26(5):549-554.

Biodegradation of Congo red dye using polyurethane foam-based biocarrier combined with activated carbon and sodium alginate: Batch and continuous study.

Dyes are an important class of organic pollutants and are well known for their adverse effects on aquatic life and human beings. In this work, an effort has been made to treat the dye-containing wastewater using modified biocarriers in packed bed bioreactors (PBBRs). Lysinibacillus sp. immobilized polyurethane foam combined with activated carbon and sodium alginate was used for the biodegradation of Congo red dye. The optimum values of process time, glucose concentration, and dye concentration were obtained to be 4.0 days, 2.0 g/L, and 50 mg/L, respectively. The maximum dye removal efficiency (RE) of 92.63 % was obtained at the optimized conditions. The continuous PBBR offered a maximum RE and elimination capacity of 90.73% and 10.89 mg/L. d, respectively, at an inlet loading rate of 12 mg/L. d. Moreover, the growth kinetic of Lysinibacillus sp. was well predicted by the Andrew-Haldane model with a regression coefficient of 0.98.

Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality.

OBJECTIVES: Emergency department (ED) length of stay (LOS) is defined as the time a patient is registered to the time the patient is shifted to a hospital bed or discharged. Increasing demand for quality emergency care has resulted in increased wait times due to demand and supply mismatch. It is perceived that longer LOS in the ED of critical patients leads to poor outcomes. Our goal was to study the impact of LOS in the ED on the patients who required critical care admissions. METHODS: This was a retrospective study conducted in the ED of a tertiary center. Data were collected using electronic health records (EHR) for patients admitted to the intensive care units (ICUs). Patient's LOS in ED was divided into 0-4, 4-8, 8-12, 12-24, and >24 hours. ED LOS was calculated from the registration time to the time patient was handed over in the ICU. Patients were divided into four categories (1-4) based on their criticality. LOS in ED, mortality, and total hospital LOS were analyzed in the study. RESULTS: Three thousand four hundred and twenty-nine patients were enrolled in the study. Mean age was 62.69 years (95% CI 62.11-63.26). A total of 42.09% (95% CI 40.5-43.8) were Category 1 patients. Overall mortality rate was 52.46% (95% CI 50.79-54.13). LOS of 48.15% (95% CI 46.54-49.88) patients in the ED was between 0 and 4 hours, 19.90% (95% CI 18.62-21.29) between 4 and 8 hours, 8.21% (95% CI 7.35-9.19) between 8 and 12 hours, 15.50% (95% CI 14.34-16.77) between 12 and 24 hours, and 8.13% (95% CI 7.27-9.10) >24 hours. Mortality for LOS of 0-4 hours was 51.30% (95% CI 48.89-53.70), 54.03% (95% CI 50.28-57.73) for 4-8 hours, 48.94% (95% CI 43.16-54.75) for 8-12 hours, 51.50% (95% CI 47.26-55.72) for 12-24 hours, and 60.57% (95% CI 54.73-66.13) for >24 hours. CONCLUSION: We concluded that the longer the critically ill patients are boarded in the ED, the higher is the chance for mortality. Processes should be implemented to ease the throughput from the ED. HOW TO CITE THIS ARTICLE: Verma A, Shishodia S, Jaiswal S, Sheikh WR, Haldar M, Vishen A, et al. Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality. Indian J Crit Care Med 2021;25(11):1221-1225.

High-resolution imaging and fast number estimation of suspended particles using dewetted polymer microlenses in a microfluidic channel.

We have fabricated polymer micro-lens array by self-organized dewetting inside the microchannel, which shows remarkable enhancement in the resolution, contrast and more than 10 times add-on magnification to a microscope. These lenses are demonstrated to resolve sub-micrometer features and detect moving micro-particles when suspension is flown in a microchannel. Polystyrene (PS) micro-lenses are fabricated on a polydimethylsiloxane (PDMS) substrate using the controlled dewetting of PS thin film then this PDMS substrate is used to close the microchannel with inverted micro-lenses on it. An aqueous suspension of polystyrene particles is flown through the microchannel and we have observed the particles through an optical microscope. Focusing and magnification through PS micro-lenses is analyzed to get a quantitative estimate of the particle number density in the solution. This method offers a promising low-cost high throughput solution for determining the approximate number density of flowing particles or suitably stained biological cells. Particularly in a pathology lab it can tremendously increase detection limit by enabling visibility of sub-micrometer pathogens using a standard laboratory microscope.

Bringing Down the Door-to-needle Time: Patient Thrombolysed in 6 Minutes-A Case Report.

INTRODUCTION: It has been clearly established that thrombolysis using recombinant tissue plasminogen activator is strongly beneficial for acute stroke patients. The sensitivity of brain tissue to ischemia causes this time dependence on the effectiveness of recombinant tissue plasminogen activator. Early recognition of stroke and activation of a stroke alert/code are imperative to treat acute stroke patients effectively and to realize positive outcomes. CASE PRESENTATION: A 68-year-old man with right-sided weakness arrived at our emergency room and was thrombolysed in 6 minutes from time of arrival, after ruling out all contraindications. CONCLUSION: The case and our rapid thrombolysis protocol that helped in achieving the 6-minute door-to-needle time are described. A structured protocol is recommended to reduce door-to-needle times for thrombolysis in acute ischemic stroke.

Acute thrombotic occlusion of subclavian artery presenting as a stroke mimic.

It has been well established and widely accepted that thrombolysis using recombinant tissue plasminogen activator (rTPA) is strongly beneficial for acute stroke patients. The sensitivity of brain tissue to ischemia causes this time dependence of the effectiveness of rTPA. Early recognition and management of a stroke is imperative for positive outcomes in such patients. Clinical assessment warrants immediate treatment for patients with suspected stroke. As emergency physicians, an awareness of stroke mimics who might undergo unwarranted investigations and thrombolysis is important. We present a case of an elderly female who presented with sudden onset of left upper limb weakness, was thrombolysed and was subsequently diagnosed with subclavian artery thrombotic occlusion. Acute limb ischemia is a rare cause of a stroke mimic. It would be prudent for emergency physicians to be aware regarding the same, especially in patients presenting with monoplegia.

Reexpansion pulmonary edema: A rare complication of pneumothorax drainage.

Among all the noncardiac causes of pulmonary edema, unilateral reexpansion pulmonary edema is one of the rarest complication of expansion of a collapsed lung. It is largely unknown and a potentially fatal complication. We present the case of a 51-year-old gentleman who presented to our emergency department with shortness of breath. X-ray revealed significant right-sided pneumothorax with associated collapse of the right lung. An intercostal tube was inserted into the right 5th intercostal space and a repeat X-ray revealed well-expanded lung field. Soon, the patient developed increased shortness of breath and hypoxia. Repeat X-ray was suggestive of pulmonary edema. He was started on noninvasive positive pressure ventilation and responded well to it. Emergency physicians should have a high index of suspicion and initiate early management of reexpansion pulmonary edema in patients suffering from pneumothoraces which have undergone drainage.

Reply to in Response to Guidewire Entrapped in the Right Ventricle.

How to cite this article: Verma A, Jaiswal S, Vishen A, Sheikh WR, Haldar M, Ahuja R, et al. Reply to in Response to Guidewire Entrapped in the Right Ventricle. Indian J Crit Care Med 2020;24(7):608.