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).

Diagnostic Accuracy of Ocular Ultrasonography in Identifying Raised Intracranial Pressure among Pediatric Population.

INTRODUCTION: Role of CT scan, MRI, ophthalmoscopy, direct monitoring by a transducer probe in identifying raised intracranial pressure (ICP) in emergency department is limited. There are few studies correlating elevated optic nerve sheath diameter (ONSD) measured by point of care ultrasound (POCUS) with raised ICP in pediatrics emergencies. We studied the diagnostic accuracy of ONSD, crescent sign, and optic disc elevation in identifying increased ICP in pediatrics. METHODS: Prospective observational study was done between April 2018 and August 2019 after ethics approval. Out of 125 subjects, 40 patients without clinical features of raised ICP were recruited as external controls and 85 with clinical features of raised ICP as study subjects. Their demographic profile, clinical examination, and ocular ultrasound findings were noted. This was followed by CT scan. Out of 85 patients, 43 had raised ICP (cases) and 42 had normal ICP (disease controls). Diagnostic accuracy of ONSD in identifying raised ICP was evaluated using STATA. RESULTS: The mean ONSD in case group was 5.5 ± 0.6 mm, 4.9 ± 0.5 mm in disease control group and external control group was 4.8 ± 0.3 mm. Cut-off of ONSD for raised ICP at ≥4.5 mm had a sensitivity and specificity of 97.67% and 10.98%, while ≥5.0 mm showed a sensitivity and specificity of 86.05% and 71.95%. Crescent sign and optic disc elevation had good correlation with increased ICP. CONCLUSION: ONSD ≥5 mm by POCUS identified raised ICP in pediatric population. Crescent sign and optic disc elevation may function as additional POCUS signs in identifying raised ICP.

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.

Variants of concern responsible for SARS-CoV-2 vaccine breakthrough infections from India.

Emerging reports of SARS-CoV-2 breakthrough infections entail methodical genomic surveillance for determining the efficacy of vaccines. This study elaborates genomic analysis of isolates from breakthrough infections following vaccination with AZD1222/Covishield and BBV152/Covaxin. Variants of concern B.1.617.2 and B.1.1.7 responsible for cases surge in April-May 2021 in Delhi, were the predominant lineages among breakthrough infections.

BRASH Syndrome: A Case Report.

BACKGROUND: BRASH syndrome, a relatively new entity, has been described in the recent literature. It is defined as a combination of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia. Although it is apparent that clinical symptomatology includes shock, it is still unclear whether all patients will initially present with all five components mentioned in the BRASH acronym. CASE REPORT: An elderly woman presented to our Emergency Department (ED) with hyperkalemia, acute renal failure, and metabolic acidosis with bradycardia, which was refractory to antikalemic measures and atropine. The montage of clinical features put together showed a clear picture of BRASH syndrome, which helped us to streamline the management and achieve a better patient outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Renal failure with various metabolic derangements is commonly seen in the ED. We should be aware of this new clinical entity, as its incidence will certainly increase, and the management is a bit different. Prognosis is excellent with timely recognition and management of this rare clinical entity.

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.

"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.

Fasciculating toxicity.

Organophosphorus (OP) compound poisoning with suicidal intent is common. It is one of the frequent cause for admission to hospital Emergencies and intensive care units in our region. We describe here a case of 19-year old girl who presented to the Emergency Department with atypical features of OP poisoning. She had perioral, tongue and lower limb fasciculations along with generalized muscle weakness with no or minimal muscarinic effects. OP poisoning with isolated nicotinic receptor mediated effect is often reported in children but in adult it is extremely rare. Based on history and clinical suspicion of nicotinic receptor mediated effect of OP, she was given intravenous atropine along with other supportive treatment. Patient got completely recovered from fasciculations and her motor weakness improved after 6 h of atropine therapy. Emergency physician should keep a high index of suspicion of isolated nicotinic and ganglionic mediated effect of OP and a trial of atropine should be given to the patient.

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.

Sympathetic crashing acute pulmonary edema.

Sympathetic crashing acute pulmonary edema (SCAPE) is the extreme end of the spectrum of acute pulmonary edema. It is important to understand this disease as it is relatively common in the emergency department (ED) and has better outcomes when managed appropriately. The patients have an abrupt redistribution of fluid in the lungs, and when treated promptly and effectively, these patients will rapidly recover. Noninvasive ventilation and intravenous nitrates are the mainstay of treatment which should be started within minutes of the patient's arrival to the ED. Use of morphine and intravenous loop diuretics, although popular, has poor scientific evidence.

Cardiac tamponade as initial presenting feature of primary hypothyroidism in the ED.

Pericardial effusion is commonly detected in patients with severe hypothyroidism and is typically mild; rarely, it may lead to cardiac tamponade. Cardiac tamponade with myxedema coma as initial presenting feature of previously unrecognized hypothyroidism is rare. This case highlights that previously undiagnosed hypothyroidism can manifest as myxedema coma with shock due to pericardial tamponade particularly in winters because a cold environment can precipitate myxedema.We report an undiagnosed case of primary hypothyroidism who presented to the emergency department for the first time with both cardiac tamponade and myxedema coma. This combination of cardiac tamponade and myxedema coma as the presenting features of primary hypothyroidism has rarely been reported in the literature. The patient was effectively managed with echocardiography-guided pericardiocentesis, levothyroxine, and external rewarming. Cardiac tamponade and myxedema coma as presenting features of previously unrecognized primary hypothyroidism are extremely rare. Urgent bedside echocardiography with pericardiocentesis along with thyroxine therapy is the treatment of choice. It is important to include hypothyroidism as the differential diagnosis in patients with cardiac tamponade and altered level of consciousness especially in winter months.

Full Outline of Unresponsiveness Score versus Glasgow Coma Scale in Predicting Clinical Outcomes in Altered Mental Status.

Introduction: Full outline of unresponsiveness (FOUR) score has advantages over Glasgow Coma Scale (GCS); as it can be used in intubated patients and provides greater neurological details. It has been studied mainly in the trauma and neuroscience setting. Our primary objective was to compare the FOUR versus GCS score as predictors of mortality at 30 days and poor functional outcome at 3 months among nontrauma patients in the emergency department (ED). Methods: This prospective observational study was conducted on adult patients presenting with altered mental status (duration <7 days) in the ED (March 2019-November 2020). Data collection included demographic and clinical features, the GCS and FOUR scores, the feasibility of acquiring and interpreting FOUR on a Likert scale, duration of hospital stay, 30-day mortality, and functional outcome at 3 months on the modified Rankin Scale. Trained emergency medicine residents managing the patient collected the data. The area under receiver's operating characteristics curve (AUROC) was used to compare the accuracy of the GCS and FOUR scores in predicting outcomes. The FOUR score equivalent of GCS cutoffs for categorizing neurological impairment (mild, moderate, and severe) was also investigated. Results: Two hundred and ninety-one patients were included, with a mean age of 50.3 years and 67.4% males. Most patients (40.2%) had altered mental status for 1-3 days and hepatic encephalopathy was the most common ED diagnosis. The mortality at 30 days was 66.7% (194 of 291), and 88% (256 of 291) of patients had poor functional outcomes at 3 months. The AUROCs for predicting 30-day mortality were similar for both the scores (GCS: 0.70, FOUR: 0.71, and the P value for difference: 0.9). Similarly, the AUROCs for predicting 3-month poor functional outcome were 0.683 and 0.669 using GCS and FOUR, respectively, with a nonsignificant difference (P = 0.82). The FOUR score strata of 14-16, 11-13, and 0-10 were found to be equivalent to the GCS scores of 13-15 (mild), 9-12 (moderate), and 3-8 (severe). The feasibility of acquiring and interpreting GCS and FOUR scores on the Likert scale was found to be "easy." Conclusion: The FOUR score is similar to GCS in predicting mortality at 30 days and poor neurological outcomes at 3 months among nontrauma patients of ED. Moreover, it was found that the FOUR score is "easy" to assess and interpret by the emergency residents.

Role of high-dose methylprednisolone in Zargar Grade IIB corrosive esophageal burns: A randomized control study.

OBJECTIVE: The objective of the study is to test the efficacy of high-dose methylprednisolone in the prevention of esophageal stricture after corrosive ingestion. METHODS: This study was a single-center, randomized controlled single-blinded study. Simple randomization was done with 15 adult patients (>18 years) in each arm, who presented with a history of corrosive ingestion within the past 24 h and had esophageal injury of Zargar Grade IIB on endoscopy. Intravenous methylprednisolone 1 g/day for 3 days was given to the intervention arm while 100 mL of normal saline was given as placebo in control arm. Follow-up to diagnose esophageal stricture was done at 8 weeks. RESULTS: Thirty patients (15 in each arm) were recruited for the study. As per the intention to treat analysis, 33% and 46.6% developed stricture in the intervention and control arm, respectively (relative risk [RR] = 0.714; 95% confidence interval 0.29-1.75; P = 0.462). 40% patients in control group and 7.7% in intervention group had undergone feeding jejunostomy, which was statistically significant with a p-value of 0.048. Airway injury showed significant clinical improvement in the intervention arm but the difference was nonsignificant statistically (P = 0.674). There was no increased incidence of hypertension, hyperglycemia, hyponatremia, hyperkalemia, or infections in intervention arm. CONCLUSION: Methylprednisolone does not help in the prevention of stricture formation in corrosive esophageal injury, but it significantly reduces the requirement of feeding jejunostomy and has a beneficial role in treating airway injury.

Comparing commercial versus low-cost gelatinous phantoms for ultrasound-guided needle tracking: A randomized crossover trial, among emergency medicine residents.

OBJECTIVES: The objective of this study was to devise a low-cost indigenous gelatin-based vascular phantom and to compare this newly constructed phantom with a commercially available phantom. METHODS: This was a randomized crossover study conducted at a tertiary care hospital of India. The aim of the study was to develop a prototype low-cost gelatin-based vascular phantom and compare it with a commercially available phantom. Gelatin, psyllium husk, corn starch, antiseptic liquid, food-coloring agent, latex balloons, and metallic containers were used to prepare the gelatin phantom. The newly prepared gelatin model was labeled "Model A" and the commercially available gelatin model was labeled "Model B." Emergency medicine residents (n = 34) who routinely perform ultrasound (USG)-guided invasive procedures were asked to demonstrate USG-guided in-plane and out-of-plane approach of needle-tracking in both the models and fill out a questionnaire on a Likert scale (1-5). An independent supervisor assessed the image quality. RESULTS: The cost of our phantom was USD 6-8 (vs. USD 1000-1200 for commercial phantom). The participants rated the ease of performance and tissue resemblance as 4 (interquartile range [IQR]: 4-5) for both the models "A" and "B." The supervisor rated the overall performance as 4 (IQR: 3-4) for both the models. In all the parameters assessed, model A was noninferior to model B. CONCLUSION: The indigenously developed vascular phantom was noninferior to the commercially available phantom in terms of tissue resemblance and overall performance. The cost involved was a fraction of that incurred with the currently available commercial model. The authors feel that gelatin-based models can be easily prepared in resource-constraint settings which may be used for USG-guided training and medical education in low- and middle-income countries.

Emergency Department Point-of-Care Tests during Cardiopulmonary Resuscitation to Predict Cardiac Arrest Outcomes.

Introduction: This study evaluated the role of point-of-care tests (POCT) such as blood lactate, anion gap (AG), base deficit, pH, N-terminal pro B-type natriuretic peptide (NT-proBNP), and troponin as the predictors of cardiac arrest outcomes in the emergency department (ED). Methods: We conducted a prospective, observational study in the ED of a tertiary care hospital in India. All the adult patients who received cardiopulmonary resuscitation (CPR) in the ED were included in the study. Blood samples were collected within 10 min of initiation of CPR for assay of POCTs. Outcomes assessed were the return of spontaneous circulation (ROSC), 24-h survival, survival to hospital discharge (STHD), survival at 7 days, and favorable neurological outcome (FNO) at day 7 of admission. Results: One hundred and fifty-one patients were included in the study (median age: 50 years, 65% males). Out of 151 cases, ROSC, survival at 7 days, STHD, and FNO was observed in 86 patients, six patients, five patients, and two patients, respectively. "No-ROSC" could be significantly predicted by raised lactate (odds ratio [OR]: 1.14, 95% confidence interval: 1.07-1.22) and NT-proBNP (OR: 1.05, 1.01-1.09) values at the time of cardiac arrest. "24-h mortality" could be significantly predicted by the raised lactate (OR: 1.14, 1.01-1.28), low arterial pH (OR: 0.05, 0.01-0.52), raised AG (OR: 1.08, 1.01-1.15), and lower base deficit (<-15) (OR: 1.07, 1.01-1.14). None of the other POCTs was found to be a predictor of other cardiac arrest outcomes. Conclusion: Among various POCTs, raised lactate assayed within 10 min of cardiac arrest can predict poor outcomes like "no-ROSC" and 24-h mortality.

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.