High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial.

OBJECTIVES: Sympathetic crashing acute pulmonary edema (SCAPE) is a subset of heart failure with a dramatic presentation. The unique physiology of this condition requires a different management strategy from the conventional practice. The trial objective was to compare the efficacy of high-dose and low-dose GTN in patients with SCAPE. METHODS: This was an open-label randomised control trial conducted in a tertiary care teaching hospital in India from 11 November 2021 to 30 November 2022. Consenting participants were randomised to high-dose GTN or conventional low-dose GTN. The primary outcome was symptom resolution at 6 hours and 12 hours. Secondary outcomes included intubation rates, admission rates, length of hospital stay, and any short-term adverse effects of GTN and major adverse cardiac events (MACE) at 30 days. RESULTS: Fifty-four participants were included (26 high-dose GTN, 26 low-dose GTN). At 6 hours, symptom resolution was seen in 17 patients (65.4%) in the 'high-dose' group, compared with 3 (11.5%) in the 'low-dose' group (p<0.001). At 12 hours, 88.5% of patients had a clinical resolution in the 'high-dose' arm versus 19.5% in 'low-dose' arm . The low-dose group had longer median hospital stay (12 hours vs 72 hours), more frequent MACE (3.8% vs 26.9%, p=0.02) and a higher intubation rate (3.8% vs 19.2%, p=0.08). The only short-term adverse effect seen was a headache in both the groups. CONCLUSION: In SCAPE, patients receiving high-dose GTN (>100 mcg/min) had earlier symptom resolution compared with the conventional 'low dose' GTN without any significant adverse effects. TRIAL REGISTRATION: Clinical trial registry of India (CTRI/2021/11/037902).

The Role of Triple Rule-out CT in an Indian Emergency Setting.

Background: Emergency physicians are acutely aware of the consequences of missing fatal diagnoses for acute non-traumatic chest pain and subjecting patients to over-testing. In the large arsenal of tests that are available to us, a triple rule-out computed tomography (TRO-CT) Angiography is often less pursued, due to concerns about their efficacy and safety or because of nescience. We aim to find the yield of the test in an Indian emergency setting and impart some knowledge about it along the way. Materials and methods: Twenty-six patients who presented to the emergency department of our institute with acute chest pain, with non-specific electrocardiogram (ECG) findings and negative serial troponin I, underwent TRO-CT. HEART scores of all patients, calculated at their presentation, were correlated with TRO-CT findings. Results: Triple rule-out computed tomography angiography was positive in 5 patients (20%), of which 4 cases (16%) were diagnosed to have significant coronary artery disease and one had an acute pulmonary embolism. All 4 patients who had significant coronary artery disease (CAD) diagnosed by TRO-CT had a HEART score of intermediate risk. The mean effective radiation dose of the entire TRO study was 19.024 ± 3.319 mSv (range = 13.89-25.95 mSv). Conclusion: Triple rule-out CT angiography is a useful tool in the evaluation of patients presenting with acute chest pain in the emergency and can be an important adjunct in ruling out significant CAD in intermediate-risk patients. Emergency physicians and young residents need to know about this tool in their armamentarium to tackle doubtful cases. How to cite this article: Pattereth N, Chaliyadan S, Mathew R, Kumar S, Das CJ, Aggarwal P. et al. The Role of Triple Rule-out CT in an Indian Emergency Setting. Indian J Crit Care Med 2023;27(3):190-194.

Impact of personal protective equipment on the effectiveness of chest compression - A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: To assess the impact of personal protective equipment (PPE) on different aspects of chest compression (CC) during cardiopulmonary resuscitation, we conducted this study. METHODS: This systematic review was performed according to the PRISMA. We searched PubMed, EMBASE and Web of Science from inception to June-6, 2020, limiting to the studies that reported the comparison of the effectiveness of CC in terms of CC rate, CC depth, the proportion of adequate CC rate, the proportion of adequate CC depth or proportion of adequate recoil; in study arms with or without PPE. Risk of bias was assessed by the ROB-2 and ROBINS-I tool. Quantitative data synthesis was done using the generic inverse variance method and the fixed-effects model. RESULTS: Five simulation-based studies were finally included. A Significant decrease in CC rate (SMD: -0.28, 95%CI: -0.47 to -0.10) and CC depth (SMD: -0.26, 95%CI: -0.44 to -0.07) were observed in the PPE arm as compared to the no-PPE arm. The difference in CC rate was more prominently seen in adult CPR than in paediatric CPR. Without PPE, the proportion of adequate CC rate delivered was 0.74, which reduced significantly to 0.60 after use of PPE (p - 0.035). Similarly, the proportion of adequate CC depth was significantly lesser (p - 0.001) in PPE arm (0.55), as compared to that of the no-PPE arm (0.78). CONCLUSION: The use of PPE compromises the quality of CC during CPR significantly, and newer ways to deliver chest compression has to be investigated. This study was prospectively registered in PROSPERO (CRD42020192031).

Lung sonographic findings in COVID-19 patients.

OBJECTIVE: The objective of this study was to describe the lung sonographic findings of COVID-19 patients prospectively and investigate its association with disease severity. METHODS: This study was conducted in an emergency department and included consecutively enrolled laboratory confirmed COVID-19 patients. Lung sonography findings were described in all the included patients and analysed with respect to the clinical severity of the patients. RESULTS: 106 patients were included in the study. Common sonographic findings in COVID-19 patients were pleural line irregularity or shredding (70% of patients), followed by B - profile (59%), pleural line thickening (33%), occasional B - lines (26%), sub-pleural consolidations (35%), deep consolidations (6%), spared areas (13%), confluent B - lines or waterfall sign (14%) and pleural effusion (9%). These findings tended to be present more bilaterally and in lower lung zones. Sonographic characteristics like bilateral lung involvement, B - profile, spared areas and confluent B - lines or waterfall sign were significantly associated (p < 0.01) with clinical severity (more frequent with increasing disease severity). CONCLUSION: The lung sonographic findings of COVID-19 were found more bilaterally and in lower lung zones, and specific findings like B - profile, pleural thickening, spared areas and confluent B - lines or waterfall sign were associated with severe COVID-19.

High-Dose Nitroglycerin Bolus for Sympathetic Crashing Acute Pulmonary Edema: A Prospective Observational Pilot Study.

BACKGROUND: Sympathetic crashing acute pulmonary edema (SCAPE) is a severe form of hypertensive acute heart failure with a dramatic presentation. Rapid identification and management in the emergency department (ED) is key to saving these patients and preventing morbidity associated with endotracheal intubation and intensive care treatment. Use of high-dose nitroglycerin (NTG) and noninvasive ventilation (NIV) has been advocated in management of such patients. OBJECTIVE: To study the feasibility and safety of high-dose NTG combined with NIV in SCAPE. METHODS: This was a prospective observational pilot study done in the ED of a tertiary care hospital. All patients were treated with high-dose NTG and NIV. The primary objective was to study the feasibility and safety of the SCAPE management protocol in terms of the outcome of the patient. Resolution of symptoms in 6 h and need for intubation were recorded as endpoints. Any complications associated with high-dose NTG were also recorded. RESULTS: A total of 25 patients were recruited. The mean bolus dose of NTG given was 872 µg, and mean cumulative dose, 35 mg. There was no incidence of hypotension after the bolus dose of nitroglycerin. Eleven patients had resolution of symptoms at 3 h of therapy. Twenty-four patients were discharged from the ED itself after a brief period of observation, and one patient was intubated and shifted to the intensive care unit. CONCLUSION: Use of our specific SCAPE treatment algorithm, which included high-dose NTG and NIV, was safe and provided rapid resolution of symptoms.

Utility of HEART Pathway in Identifying Low-Risk Chest Pain in Emergency Department.

BACKGROUND: Chest pain is a common presenting symptom in the emergency department (ED). The HEART (history, electroencephalogram [ECG], age, risk factors, and troponin I) score, with addition of troponin at 3 h, helps to determine appropriate risk stratification of the patients. OBJECTIVE: This study evaluated the utility of the HEART pathway as a decision aid designed for risk stratification of patients with acute-onset chest pain for early and safe disposition. METHODS: This was a prospective observational study done in a tertiary care center. Focused history, 12-lead ECG, and baseline troponin I level on arrival and at hour 3 were recorded. Subjects were classified as low risk (HEART score 0-3) or high risk (HEART score ≥ 4). Patients with a HEART score of 0-3 with negative troponin I at 3 h were discharged and were followed up for major adverse cardiac events (MACEs) within 30 days of ED presentation. RESULTS: A total of 250 patients were screened for the study, of which 151 were included for the final analysis. One hundred and two patients (68%) were male and 54% of patients were younger than 45 years. HEART scores of 0 (n = 16), 1 (n = 43), 2 (n = 44), and 3 (n = 48) were observed. There was only 1 MACE (0.7%) in 30 days after ED discharge in the study population. The mean length of ED stay in the low-risk group was 4.5 h. CONCLUSIONS: Low-risk patients, as per the HEART pathway, can be discharged safely from the ED, which reduces ED stay and health care resource use.

Prognostic Value of Serum Procalcitonin Levels in Patients With Febrile Neutropenia Presenting to the Emergency Department.

BACKGROUND: Various risk-stratification scores have been developed to identify low-risk febrile neutropenia (FN). The Multinational Association of Supportive Care in Cancer (MASCC) score is a commonly used validated scoring system, although its performance varies due to its subjectivity. Biomarkers like procalcitonin (PCT) are being used in patients with FN to detect bacteremia and additional complications. OBJECTIVE: Our objective was to compare the performance of MASCC score with PCT in predicting adverse outcomes in patients with FN. METHODS: This was a prospective observational study that included chemotherapy-induced FN in hematologic or solid malignancy. The MASCC score, PCT levels, and blood cultures were taken at the first point of contact, and patient treatment was managed according to routine institutional protocol. The primary outcome was mortality at 30 days. RESULTS: A total of 100 patients were recruited, of which 92 had hematologic malignancy and 8 had solid malignancy. Forty-six patients were classified as low risk by MASCC score (≥21). The PCT threshold, 1.42 ng/mL, was taken as a cutoff value, with area under the receiver operating characteristic curve (AUROC) of 0.664 (95% confidence interval [CI] -0.55 to 0.77) for predicting mortality. AUROC for MASCC was 0.586 (95% CI 0.462 to 0.711). CONCLUSIONS: PCT is a useful marker with better prognostic efficacy than MASCC score in patients with FN and can be used as an adjunct to the score in risk-stratifying patients with FN.

CISNE versus MASCC: Identifying low risk febrile neutropenic patients.

OBJECTIVE: Febrile neutropenia though a dreaded complication of chemotherapy, not all patients need inpatient treatment. Risk score indices like MASCC and CISNE have been developed to identify low risk patients eligible for outpatient management. We undertook this study to compare the performances of MASCC and CISNE. METHODS: This was a prospective observational study conducted in a tertiary care centre from August 2017 to April 2019 where patients with chemotherapy induced febrile neutropenia were included. Basic demographic data and primary site of cancer were collected with characteristics required to calculate both MASCC and CISNE scores. The primary outcome measure was 30-day mortality. Apart from the 3 group risk stratification of CISNE, apriori it was decided that two-tier CISNE score will be calculated with 0 or 1 score as low risk and ≥2 as high risk. Descriptive statistics are reported and predictive performance of each score was analysed. RESULTS: Total of 129 patients were recruited. The performance of three-tier CISNE score was more specific (90.6%, 95% CI 76.9-96.9) but sensitivity (25.1%, 95% CI 17.0-36.3) was low compared to that of MASCC score (sensitivity 58.1%, 95% CI 47.0-68.5; specificity 65.1, 95% CI 49.0-78.5%). However, analysis with two-tier CISNE score demonstrated a better sensitivity (56.9%, 95%CI 45.8-67.4). Kappa for agreement between the two scores was 0.520 (95% CI 0.373-0.667, p < 0.001). CONCLUSION: CISNE and MASCC have fair discriminatory power in identifying low risk febrile neutropenia cases. Two group stratification on CISNE scoring will help in better decision making in emergency department.

COVID-19 in health care workers - A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: It is essential to know the proportion of health care workers (HCW) who are COVID 19 positive, as well as the severity and mortality among them. METHODS: This systematic review was performed according to the Preferred Reporting Items for Systematic review and meta-analysis. Databases including PubMed, EMBASE and Web of Science were searched from December-31, 2019 to April-23, 2020. The search was limited to the studies that reported the data on the number of COVID-19 positive healthcare workers, among the COVID-19 positive patients. Case reports, duplicate publications, reviews, and family-based studies were excluded. The methodological quality of studies was assessed by the Appraisal tool for Cross-Sectional Studies (AXIS) tool. RESULTS: In this systematic review and meta-analysis, we pooled eleven studies to investigate the above factors. The overall proportion of HCW who were SARS-CoV-2 positive among all COVID-19 patients was 10.1% (95%CI: 5.3-14.9). This proportion varied according to the country of study i.e. China (7 studies) - 4.2%, 95%CI:2.4-6.0; United States (3 studies) - 17.8%, 95%CI:7.5-28.0; and Italy (1 study) - 9.0%, 95%CI:8.6-9.4. The incidence of severe or critical disease in HCW (9.9%, 95%CI:0.8-18.9) was significantly lower (p < 0.001) than the incidence of severe or critical disease in all COVID-19 positive patients (29.4%, 95%CI:18.6-40.2). Similarly, the mortality among HCW (0.3%, 95%CI:0.2-0.4) was also significantly lower (p < 0.001) as compared to that of all patients (2.3%, 95%CI:2.2-2.4). CONCLUSION: Health care workers who are COVID-19 positive constituted a significant proportion of all COVID-19 patients; but the severity and mortality were lower among them.

Endotracheal Tube Placement Confirmation by Ultrasonography: A Systematic Review and Meta-Analysis of more than 2500 Patients.

BACKGROUND: The integration of point-of-care ultrasound in endotracheal tube placement confirmation has been focus of many recent studies. OBJECTIVES: We sought to determine the diagnostic accuracy of ultrasonography in confirmation of endotracheal intubation compared with standard confirmatory methods. METHODS: We completed an extensive search of PubMed, EMBASE, Cochrane Central, Web of Science, and bibliographies of the selected articles from inception to October 2019. The search was limited to prospective studies conducted in human adults that compared the accuracy of ultrasonography in confirming the endotracheal tube position with a reference standard. The methodologic quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A bivariate random-effects model summarized diagnostic accuracy statistics. Subgroup analyses by ultrasonographic signs, study location, the operator's specialty, types of transducer, the technique of ultrasound confirmation, and clinical setting (cardiac arrest vs. non-cardiac arrest) were performed. RESULTS: Thirty studies involving 2534 patients were selected for this meta-analysis. The estimated pooled sensitivity and specificity for ultrasonography were 0.982 (95% confidence interval [CI] 0.971-0.988) and 0.957 (95% CI 0.901-0.982), respectively. Subgroup analyses did not reveal significant difference by ultrasonographic sign used, location, the sonographer's specialty, transducer type, or ultrasound technique used. Ultrasound was also found to be a useful adjunct in confirming endotracheal tube position in the subgroup of patients with cardiac arrest, with sensitivity of 0.99 (95% CI 0.98-1.00) and specificity of 0.84 (95% CI 0.67-1.00), respectively. CONCLUSIONS: Ultrasonography is a valuable and reliable adjunct for endotracheal tube confirmation, including during cardiac arrest resuscitation.

"Six-dial Strategy"-Mechanical Ventilation during Cardiopulmonary Resuscitation.

As per current guidelines, whenever an advanced airway is in place during cardiopulmonary resuscitation, positive pressure ventilation should be provided without pausing for chest compression. Positive pressure ventilation can be provided through bag-valve resuscitator (BV) or mechanical ventilator (MV), which was found to be equally efficacious. In a busy emergency department, with less trained personnel use of MV is advantageous over BV in terms of reducing human errors and relieving the airway manager to focus on other resuscitation tasks. Currently, there are no guidelines specific to MV settings in cardiac arrest. We present a concept of "six-dial ventilator strategy during CPR" that encompasses the evidence-based settings appropriate during chest compression. We suggest use of volume control ventilation with the following settings: (1) positive end-expiratory pressure of 0 cm of water (to allow venous return), (2) tidal volume of 8 mL/kg with fraction of inspired oxygen at 100% (for adequate oxygenation), (3) respiratory rate of 10 per minute (for adequate ventilation), (4) maximum peak inspiratory pressure or P max alarm of 60 cm of water (to allow tidal volume delivery during chest compression), (5) switching OFF trigger (to avoid trigger by chest recoil), and (6) inspiratory to expiratory time ratio of 1:5 (to provide adequate inspiratory time of 1 second). How to cite this article: Sahu AK, Timilsina G, Mathew R, Jamshed N, Aggarwal P. "Six-dial Strategy"-Mechanical Ventilation during Cardiopulmonary Resuscitation. Indian J Crit Care Med 2020;24(6):487-489.

Point-of-care Ultrasound in Lingual Hematoma.

Isolated tongue hematoma following direct trauma to face is not a common finding. It can cause life-threatening airway obstruction and needs prompt diagnosis and early intervention. We report the case of a 40-year-old male who presented to our hospital with a large tongue swelling after a fall. Bedside point-of-care ultrasound (POCUS) of the tongue revealed a hematoma. This case highlights the use of POCUS for early diagnosis of tongue hematomas.

Atrial Myxoma Presenting as Acute Bilateral Limb Ischemia.

BACKGROUND: Cardiac myxoma is the most common primary benign tumor of the heart and it has diverse clinical presentations. It is known to embolize into systemic circulation. However, presentation with complete occlusion of the aorta is uncommon. CASE REPORT: We report an 18-year-old female who presented to the emergency department with features of acute bilateral limb ischemia. Arterial Doppler ultrasonography showed infrarenal aortic occlusion. A bedside cardiac ultrasound was done in the emergency department which clinched the diagnosis of atrial myxoma. Complete surgical excision of the tumor and subsequent histopathologic examination confirmed the diagnosis of atrial myxoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This report puts emphasis on the fact that atrial myxoma, though rare, may be considered as a source of embolism in patients presenting with acute limb ischemia. The importance of bedside ultrasonography for early diagnosis in such presentations is also highlighted.

A DNA aptamer-based assay for the detection of soluble ST2, a prognostic biomarker for monitoring heart failure.

Heart failure (HF) is emerging as a leading cause of death worldwide. Estimation of BNP levels is a routine diagnosis in these patients. However, in patients having high body-mass index (BMI), renal disease or in geriatric patients, BNP level is reported to be noisy and leads to incongruous conclusion. Thus, for better risk stratification among heart failure patients, it is imperative to look for a superior biomarker. In recent times, sST2 has shown promise as a biomarker. Identifying such biomarkers in peripheral blood of HF patients, need an affine and selective molecular recognition element. Thus, in the current study an aptamer (sS9_P) against sST2 was identified from an aptamer library. Systematic Evolution of Ligands through Exponential enrichment (SELEX) derived aptamer evinced role of its primer binding domains in maintaining its selectivity. This aptamer candidate demonstrated dissociation constant (Kd) in low nanomolar range, and the Limit of Detection (LOD) was ~4 ng. Circular dichroism confirms the formation of complex stem-loop like structure. The well characterized sS9_P aptamer was used in an Aptamer Linked Immobilized Sorbent Assay (ALISA) to detect sST2 level in patients' serum (n = 99). Aptamer sS9_P has shown significant discrimination to differentiate HF patients and healthy volunteers with a reasonable specificity (~83 %) with a modest sensitivity of ~64 %. While sST-2 antibody has shown poor specificity of ~44% but good sensitivity (~87%). The insight obtained from this study indicates that a combination of aptamer and antibody-based assay can be used to design a point-of-care assay for the rapid detection of HF patients in emergency settings.

Performance of qSOFA Score as a Screening Tool for Sepsis in the Emergency Department.

Introduction: Sepsis is the leading cause of mortality, and various scoring systems have been developed for its early identification and treatment. The objective was to test the ability of quick sequential organ failure assessment (qSOFA) score to identify sepsis and predict sepsis-related mortality in the emergency department (ED). Methods: We conducted a prospective study from July 2018 to April 2020. Consecutive patients with age ≥18 years who presented to the ED with a clinical suspicion of infection were included. Sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and odds ratio (OR) for sepsis related mortality on day 7 and 28 were measured. Results: A total of 1200 patients were recruited; of which 48 patients were excluded and 17 patients were lost to follow-up. 54 (45.4%) of 119 patients with positive qSOFA (qSOFA >2) died at 7 days and 76 (63.9%) died at 28 days. A total of 103 (10.1%) of 1016 patients with negative qSOFA (qSOFA score <2) died at 7 days and 207 (20.4%) died at 28 days. Patients with positive qSOFA score were at higher odds of dying at 7 days (OR: 3.9, 95% confidence interval [CI]: 3.1-5.2, P < 0.001) and 28 days (OR: 6.9, 95% CI: 4.6-10.3, P < 0.001). The PPV and NPV with positive qSOFA score to predict 7- and 28-day mortality were 45.4%, 89.9% and 63.9%, 79.6%, respectively. Conclusion: The qSOFA score can be used as a risk stratification tool in a resource-limited setting to identify infected patients at an increased risk of death.

Coupling between Pyroelectricity and Built-In Electric Field Enabled Highly Sensitive Infrared Phototransistor Based on InSe/WSe2/P(VDF-TrFE) Heterostructure.

The assorted utilization of infrared detectors induces the demand for more comprehensive and high-performance electronic devices that work at room temperature. The intricacy of the fabrication process with bulk material limits the exploration in this field. However, two-dimensional (2D) materials with a narrow band gap opening aid in infrared (IR) detection relatively, but the photodetection range is narrowed due to the inherent band gap. In this study, we report an unprecedented attempt at the coordinated use of both 2D heterostructure (InSe/WSe2) and the dielectric polymer (poly(vinylidene fluoride-trifluoroethylene), P(VDF-TrFE)) for both visible and IR photodetection in a single device. The remnant polarization due to the ferroelectric effect of the polymer dielectric enhances the photocarrier separation in the visible range, resulting in high photoresponsivity. On the other hand, the pyroelectric effect of the polymer dielectric causes a change in the device current due to the increased temperature induced by the localized heating effect of the IR irradiation, which results in the change of ferroelectric polarization and induces the redistribution of charge carriers. In turn, it changes the built-in electric field, the depletion width, and the band alignment across the p-n heterojunction interface. Consequently, the charge carrier separation and the photosensitivity are therefore enhanced. Through the coupling between pyroelectricity and built-in electric field across the heterojunction, the specific detectivity for the photon energy below the band gap of the constituent 2D materials can reach up to 1011 Jones, which is better than all reported pyroelectric IR detectors. The proposed approach combining the ferroelectric and pyroelectric effects of the dielectric as well as exceptional properties of the 2D heterostructures can spark the design of advanced and not-yet realized optoelectronic devices.

What do clinical resident doctors think about workplace violence? A qualitative study comprising focus group discussions and thematic analysis from a tertiary care center of India.

Background: Workplace violence (WPV) is a significant problem in both developed and developing countries among healthcare workers. The study aims to examine the perspective of resident doctors on various aspects of WPV to promote a better understanding of the complexity of the problem of WPV at a tertiary care center in India. Material and Methods: Seven focus group discussions were conducted with resident doctors from various departments, which were recruited through convenience and snowball sampling. Discussions were audio recorded and transcribed verbatim to English. Thematic analysis was done using Atlas. ti 8 to generate themes, subthemes, and codes from the discussions. Results: A total of 39 resident doctors with a mean age of 28.0 ± 3.8 years were recruited. The themes that emerged during the analysis are as follows: types of WPV, risk factors for WPV, the impact of WPV, and mitigation strategies for WPV. Conclusion: Exposure to WPV is not uncommon in India. Factors associated from individual to policy level are involved in subjugating the episodes of violence. Findings from this study will contribute in devising mitigation strategies for the same.