Pneumomediastinum in an Accidental Chlorine Gas Exposed Victim.

Chlorine is an irritant gas, which is implicated in inhalational exposures and can affect the respiratory system leading to complications. We report a case of a 38-year man who presented in the Emergency Department (ED) after exposure to chlorine gas due to an industrial accident. During the course of ED stay, he developed gradual difficulty in breathing, which on investigation, was found to be related to the complication of pneumomediastinum. The patient required endotracheal intubation, but was difficult to ventilate. Bilateral chest tube insertion was performed, which led to the resolution of the pneumothoraces. The emergency physicians should be aware of such a case so that they can intervene. Key Words: Chlorine, Emergency, Pneumomediastinum, Toxicity.

The Rapid COVID Screening (RCS) Tool.

As the COVID-19 outbreak continues, there is a dire need to organise and allocate resources while optimising costs and time: identification of patients should be rapid and economical. With the current spectrum of clinical presentations of patients with COVID-19, it is important to be thorough while determining symptoms involving the various organ systems including possible contact history. Point-of-care (POC) lung ultrasound has already proven to be a reliable tool in diagnosing lung inflammatory processes: the results are immediate and the examination is safe, repeatable, and cheap. Early use of POC lung ultrasound could prove invaluable in COVID-19 patients, leading to early correct diagnoses and appropriate management. The author suggests a tool that incorporates various aspects in clinical history, POC lung ultrasound findings and hemodynamic parameters for identification and management of patients during the COVID-19 pandemic. Key Words: COVID-19, Sars CoV-2, Emergency department, Screening, Point-of-care, Lung ultrasound.

Thinking of Unilateral Osteitis Condensans Ilii in the Emergency Room: Case of a Young Pregnant Female with Back Pain.

Osteitis condensans ilii (OCI) remains an orthopedic diagnostic dilemma; moreover, such presentation in the emergency room (ER) is unique. Limited awareness about this topic compels emergency and internal medicine physicians to perform extensive investigations which often leads to misdiagnosis. A 23-year pregnant female presented in the Emergency Room with severe low back pain, who was treated conservatively with radiological evidence of OCI. The mainstay treatments are analgesics and physiotherapy. Key Words: Osteitis condensans ilii, Back pain, Pregnancy, Triangular sclerosis.

Hydrogen sulfide gas poisoning in fish garbage room: A report of a fisherman.

We report the case of a fisherman who was exposed to high concentrations of hydrogen sulfide (H2S) gas from the fish garbage room. The patient survived and was discharged with full recovery from the hospital. H2S is a colourless, foul smelling and highly toxic gas next to carbon monoxide, which causes inhalation death. It is a by-product of various industrial processes particularly involves exposure from agriculture, petrochemical industry and organic matter decomposition from sewage processing. It is a by-product of H2S has been referred as the "knock down gas" because inhalation of high concentrations can cause immediate loss of consciousness and death. Although early use of amyl nitrate and hyperbaric oxygen shows some benefit in literature, supportive care remains the mainstay of treatment. Emergency physicians and pre-hospital care personnel are not very familiar with such exposure due to its rarity. This becomes more relevant in the developing world settings where there are rising concerns about the unsafe exposure to hazardous chemicals and its impact on human health. Emergency physicians working in Pakistan should be aware of this entity especially in regard to fishermen presenting to the Emergency Department with such a clinical presentation and its toxic manifestations. This incident also illustrates the need of enforcement of health and safety regulations in the fishing industry.

Overcrowding in the emergency departments: Challenges and opportunities for improvement.

With the advent of Emergency Medicine, one can observe an increase in the number of Emergency Departments (ED) across the country. However, most EDs struggle due to an overwhelming number of patients. Overcrowding can lead to delays in patient care. For a city like Karachi which is an active disaster zone, preemptive preparedness is required in the face of terror threats and such overcrowding needs to be decreased to a bare minimum. The most frequent causes of prolonged length of stay (LOS) in the ED include non-availability of in-hospital beds, delays in response to subspecialty consultations and escalating medical expenses. All of these can negatively impact patient care by putting patient safety at risk and patient care in jeopardy. There is an increased risk of unintentional medical errors and a concomitant increase in unwanted lawsuits. A few simple interventions which may help alleviate this situation to some extent have been discussed.

PAIN ASSOCIATED WITH LIVER BIOPSIES THROUGH PERCUTANEOUS APPROACH UNDER SONO-GRAPHIC GUIDANCE--A CROSS SECTIONAL PILOT STUDY IN A TERTIARY CARE HOSPITAL.

BACKGROUND: Pain is one of the most common and feared complication of percutaneous liver biopsy under local anaesthesia using sonographic guidance. This observational study was set to judge the intensity of pain felt by adult patients presenting for percutaneous liver biopsy with known/suspected underlying hepatic pathology. METHODS: This observational cross sectional study which was piloted on 10% of the original sample size was conducted at Aga Khan University Hospital, Karachi. Study population was the adult patients coming for percutaneous liver biopsy at the Department of Radiology. Descriptive statistics were run, data was checked for normality. Means and Standard deviations were done for continuous variables and where data was skewed, median with inter quartile range was computed. Later data was clumped in categories, frequency and percentages were reported for categorical variables. Graphical representation of data was done. RESULTS: A total of 50 patients were recruited. Minimum pain reported on visual analogue scale (VAS) was 0 and maximum as 4.30% of patients rated 3 and similarly 30% of the people rated 4 on the VAS. Mean pain experienced was 2.7 +/- 1.11 and a median of 3 on VAS. This indicates that a minority of patients in our survey had a complaint of mild pain during the procedure. CONCLUSIONS: Percutaneous liver biopsy is a very safe procedure and minimal pain was felt by a minority of patients whereas the rest showed satisfaction from the procedure with no post procedural complaints.

Accuracy of computed tomography in diagnosing malignancy in solitary pulmonary lesions.

OBJECTIVE: To evaluate accuracy of Computed Tomography (CT) for diagnosing malignancy in solitary pulmonary lesions (SPLs). METHODS: A prospective cross-sectional study was conducted from 20-01-2007 to 30-06-2008 at the Radiology department, Aga Khan University Hospital (AKUH) Karachi. Fifty-three patients with solitary pulmonary lesions (SPLs) seen in prior chest x-rays or chest CT scans were referred to radiology department for CT guided biopsy. CT scan was performed for each patient prior to biopsy and CT evaluation of the SPLs was performed followed by CT guided Biopsy. Histopathological diagnosis of the lesion was taken as the gold standard. RESULTS: CT was found to be 100% sensitive, 30% specific and 87% accurate for diagnosing malignancy in solitary pulmonary lesions while PPV and NPV were 86% and 100% respectively. CONCLUSION: CT scan is highly sensitive yet non-specific and cannot be used as the definitive diagnostic modality for diagnosing malignancy in solitary pulmonary lesions.