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BACKGROUND: Prediction of serious outcomes among patients with physiological instability is crucial in airway management. In this study, we aim to develop a score to predict serious outcomes following intubation in critically ill adults with physiological instability by using clinical and laboratory parameters collected prior to intubation. METHOD: This single-center analytical cross-sectional study was conducted in the Emergency Department from 2016 to 2020. The airway score was derived using the transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD) methodology. To gauge model's performance, the train-test split technique was utilized. The discrete random number generation approach was used to divide the dataset into two groups: development (training) and validation (testing). The validation dataset's instances were used to calculate the final score, and its validity was measured using ROC analysis and area under the curve (AUC). By computing the Youden's J statistic using the metrics sensitivity, specificity, positive predictive value, and negative predictive value, the discriminating factor of the additive score was determined. RESULTS: The mean age of the 1021 patients who needed endotracheal intubations was 52.2 years (± 17.5), and 632 (62%) of them were male. In the development dataset, there were 527 (64.9%) physiologically difficult airways, 298 (36.7%) post-intubation hypotension, 124 (12%) cardiac arrest, 347 (42.7%) shock index > 0.9, and 456 [56.2%] instances of pH < 7.3. On the contrary, in the validation dataset, there were 143 (68.4%) physiologically difficult airways, 33 (15.8%) post-intubation hypotension, 41 (19.6%) cardiac arrest, 87 (41.6%) shock index > 0.9, and 121 (57.9%) had pH < 7.3, respectively. There were 12 variables in the difficult airway physiological score (DAPS), and a DAPS of 9 had an area under the curve of 0.857. The accuracy of DAPS was 77%, the sensitivity was 74%, the specificity was 83.3%, and the positive predictive value was 91%. CONCLUSION: DAPS demonstrated strong discriminating ability for anticipating physiologically challenging airways. The proposed model may be helpful in the clinical setting for screening patients who are at high risk of deterioration.
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Paro Cardíaco , Hipotensión , Adulto , Humanos , Masculino , Persona de Mediana Edad , Femenino , Estudios Transversales , Intubación Intratraqueal , Manejo de la Vía Aérea/métodos , Servicio de Urgencia en Hospital , Hipotensión/etiologíaRESUMEN
BACKGROUND: The incidence of heat emergencies, including heat stroke and heat exhaustion, have increased recently due to climate change. This has affected global health and has become an issue of consideration for human health and well-being. Due to overlapping clinical manifestations with other diseases, and most of these emergencies occurring in an elderly patient, patients with a comorbid condition, or patients on poly medicine, diagnosing and managing them in the emergency department can be challenging. This study assessed whether an educational training on heat emergencies, defined as heat intervention in our study, could improve the diagnosis and management practices of ED healthcare providers in the ED setting. METHODS: A quasi-experimental study was conducted in the EDs of four hospitals in Karachi, Pakistan. Eight thousand two hundred three (8203) patients were enrolled at the ED triage based on symptoms of heat emergencies. The pre-intervention data were collected from May to July 2017, while the post-intervention data were collected from May to July 2018. The HEAT intervention, consisting of educational activities targeted toward ED healthcare providers, was implemented in April 2018. The outcomes assessed were improved recognition-measured by increased frequency of diagnosing heat emergencies and improved management-measured by increased temperature monitoring, external cooling measures, and intravenous fluids in the post-intervention period compared to pre-intervention. RESULTS: Four thousand one hundred eighty-two patients were enrolled in the pre-intervention period and 4022 in the post-intervention period, with at least one symptom falling under the criteria for diagnosis of a heat emergency. The diagnosis rate improved from 3% (n = 125/4181) to 7.5% (n = 7.5/4022) (p-value < 0.001), temperature monitoring improved from 0.9% (n = 41/4181) to 13% (n = 496/4022) (p-value < 0.001) and external cooling measure (water sponging) improved from 1.3% (n = 89/4181) to 3.4% (n = 210/4022) (p-value < 0.001) after the administration of the HEAT intervention. CONCLUSION: The HEAT intervention in our study improved ED healthcare providers' approach towards diagnosis and management practices of patients presenting with health emergencies (heat stroke or heat exhaustion) in the ED setting. The findings support the case of training ED healthcare providers to address emerging health issues due to rising temperatures/ climate change using standardized treatment algorithms.
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Agotamiento por Calor , Golpe de Calor , Anciano , Humanos , Calor , Urgencias Médicas , Tratamiento de Urgencia , Golpe de Calor/diagnóstico , Golpe de Calor/terapiaRESUMEN
OBJECTIVE: To determine the clinical characteristics, management and outcomes of patients presenting with chlorine gas exposure in an emergency setting. METHODS: The single-centre, retrospective cross-sectional study was conducted at the emergency department of Aga Khan University Hospital, Karachi, and comprised data of all patients who presented on March 06, 2020, due to acute chlorine gas exposure after a specific industrial accident. Demographic and clinical data was recorded from the medical record files. The association between risk factors and complications was explored. Data was analysed using SPSS 20. RESULTS: There were 51 male patients with a mean age of 33.10±8.37 years. The most commonly affected organ system was respiratory 49(96%), with 43(84.3) having shortness of breath. Eye irritation was found in 44(86.3%) cases and the central nervous system was involved in 14(27.4%). Most of the patients were admitted from the emergency department 36(70%). Regarding treatment, 1(1.9%) patient each required invasive and non-invasive mechanical ventilation. Complications included toxic pneumonitis 3(5.9%) and pneumomediastinum 1(1.7%). No correlation was found between smoking and complications (p>0.05). CONCLUSIONS: Most patients showed complete resolution of symptoms after receiving supportive treatment, while complications were rare and there was no mortality.
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Cloro , Servicio de Urgencia en Hospital , Humanos , Masculino , Adulto Joven , Adulto , Cloro/efectos adversos , Centros de Atención Terciaria , Pakistán/epidemiología , Estudios Retrospectivos , Estudios TransversalesRESUMEN
BACKGROUND: Critically-ill Covid-19 patients require extensive resources which can overburden a healthcare system already under strain due to a pandemic. A good disease severity prediction score can help allocate resources to where they are needed most. OBJECTIVES: We developed a Covid-19 Severity Assessment Score (CoSAS) to predict those patients likely to suffer from mortalities within 28 days of hospital admission. We also compared this score to Quick Sequential Organ Failure Assessment (qSOFA) in adults. METHODS: CoSAS includes the following 10 components: Age, gender, Clinical Frailty Score, number of comorbidities, Ferritin level, D-dimer level, neutrophil/lymphocyte ratio, C-reactive Protein levels, systolic blood pressure and oxygen saturation. Our study was a single center study with data collected via chart review and phone calls. 309 patients were included in the study. RESULTS: CoSAS proved to be a good score to predict Covid-19 mortality with an Area under the Curve (AUC) of 0.78. It also proved better than qSOFA (AUC of 0.70). More studies are needed to externally validate CoSAS. CONCLUSION: CoSAS is an accurate score to predict Covid-19 mortality in the Pakistani population.
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COVID-19 , Sepsis , Adulto , COVID-19/diagnóstico , Servicio de Urgencia en Hospital , Mortalidad Hospitalaria , Humanos , Puntuaciones en la Disfunción de Órganos , Pronóstico , Curva ROC , Estudios RetrospectivosRESUMEN
BACKGROUND: Electroencephalogram and neuroimaging in pediatric patients with new-onset afebrile seizures are performed to detect any underlying pathological severe condition that may require emergent neuro-intervention and guide prognosis. This study aims to determine the predictors of abnormal EEG and neuroimaging in children presenting to the emergency department with new-onset afebrile seizures. METHODS: This single-center cross-sectional study was conducted at a tertiary care hospital in Karachi, Pakistan, from July 01, 2019, to June 30, 2021. All patients aged one month to 18 years who presented with new-onset afebrile seizures were included. Demographic and clinical data were recorded, including age, gender, seizure type, duration of seizure, associated signs and symptoms, and disposition. Multivariable regression analysis was applied to determine the predictors of abnormal EEG and CT scan or MRI findings. RESULTS: Out of 201 participants, most patients were in the infantile age group (41.3%), with an equal gender distribution. The most common type of seizure was generalized onset 152 (75.6%). EEG was performed on a total of 126 patients (62.7%) and out of these patients, 67 patients (53.1%) had abnormal findings. In a multivariable analysis, the age group of 5 to 10 years and seizure duration of more than 5 min were significantly associated with higher odds of abnormal EEG findings. In contrast, only the focal onset of seizure was significantly associated with higher odds of abnormal neuroimaging findings. CONCLUSION: The study emphasizes the need for a protocol regarding the performance of EEG and neuroimaging in children presenting to the ED with new-onset afebrile seizures that would aid emergency physicians in the direction of appropriate management, thus ensuring a better quality of patient care and outcomes.
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Neuroimagen , Convulsiones , Niño , Humanos , Lactante , Preescolar , Estudios Transversales , Convulsiones/diagnóstico por imagen , Convulsiones/etiología , Electroencefalografía , Servicio de Urgencia en Hospital , Estudios RetrospectivosRESUMEN
INTRODUCTION: Emergency department (ED) healthcare workers in Pakistan during the COVID-19 pandemic are facing an acute rise in mental illnesses. In this study, the authors aim to assess the frequency of anxiety and depression among healthcare workers in the ED. METHODS: A cross-sectional online google form-based survey was conducted in the ED of Aga Khan University Hospital, Karachi, Pakistan between July and August 2020. The Hospital Anxiety and Depression (HAD) scale was used for mental illness assessment among ED healthcare workers. Descriptive analysis of grading as per the Likert scale is done through frequencies, means, and standard deviations. Categorical variables were expressed as frequency (%). Mann-Whitney U test was used to compare scores of various groups and sub-groups and the Chi-square test was used to assess the association of depression and anxiety categories among the groups. RESULTS: In the ED, 127 healthcare workers (physicians and nurses) were included in this survey. The median depression score was 8 (IQR 6-10) with 21% (27) falling under depression and 39% (50) under borderline depression. The median anxiety score was 9 (IQR 7-12) with 33% (42) having abnormal, and 38% (48) having borderline anxiety. Healthcare workers working for > 45 h per week have odds of 3.62 [1.374-9.549] of developing depression compared to anxiety with a p-value of 0.009. Similarly, nurses and medical officers develop depression with odds of 2.18 [1.016-4.686] p-value 0.045 and 5.18 [0.197-1.02] p-value 0.002, respectively. CONCLUSION: ED healthcare workers during the COVID-19 pandemic suffered high levels of anxiety and depression, which is a matter of concern. Comprehensive support and training of ED healthcare workers are needed to promote physical and mental well-being and to develop guidelines that should be used during situations that can affect the mental health of healthcare workers.
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Emergency medicine has transitioned from developing to a developed specialty in Pakistan. It is gaining recognition in the national and international arena. Residency in emergency medicine is a tough pathway in which a resident learns and is assessed at multiple levels. The attributes that are needed for an empathetic emergency medicine physician are multifaceted. Chief resident selection has been an important step in postgraduate residency. The selection process was traditionally based on seniority and academic achievements with no consideration for soft skills. In the current write-up, we are proposing an evidence-base sequential chief resident selection process called Chief Resident Election of Emergency Department (CREED). The program was developed keeping in consideration the traditional method of election and interviews with the incorporation of reflexive, leadership, communication, and collaboration skills.
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OBJECTIVE: To evaluate the clinical decision unit of a tertiary care health facility and to see the disease pattern. . METHODOLOGY: The cross-sectional retrospective study was conducted at the Department of Emergency Medicine, Aga Khan University Hospital, Karachi, from September to October 2011, and comprised data of patients admitted to the clinical decision unit from January to December 2010. The protocols were developed for 7 diseases: acute coronary syndrome, ureteric colic, abdominal pain, bronchial asthma, gastroenteritis with dehydration, headache, and minor head injury. Data-collection proforma recorded demographics, dates of admission, presenting complaints at triage, diagnosis at admission, final disposition and bounce back of the patients. Data was analysed using Microsoft Excel 2007. RESULTS: Of the 1515 patients whose data was analysed, 824(54%) were males. The overall age ranged from newborns to 93 years. Further, 904(60%) patients had presented to the triage counter as P3 category. Acute gastroenteritis was the most common complaint 240(15.84%). Of the total, 1311(87%) were sent home from the clinical decision unit; 39(2.8%) of them bounced back with the same complaint. Overall, 2(0.2%) adult patients expired. CONCLUSIONS: The unit evaluated had a productive initial year. Acute gastroenteritis was the most common protocol in use, but other protocols should also be developed to address local needs.
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Unidades de Observación Clínica , Deshidratación/terapia , Gastroenteritis/terapia , Hospitalización/tendencias , Tiempo de Internación/tendencias , Alta del Paciente/tendencias , Dolor Abdominal/epidemiología , Dolor Abdominal/terapia , Síndrome Coronario Agudo/complicaciones , Síndrome Coronario Agudo/diagnóstico , Síndrome Coronario Agudo/epidemiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Asma/epidemiología , Asma/terapia , Dolor en el Pecho/epidemiología , Dolor en el Pecho/etiología , Dolor en el Pecho/terapia , Niño , Preescolar , Protocolos Clínicos , Traumatismos Craneocerebrales/epidemiología , Traumatismos Craneocerebrales/terapia , Deshidratación/epidemiología , Deshidratación/etiología , Sobredosis de Droga/epidemiología , Sobredosis de Droga/terapia , Servicio de Urgencia en Hospital , Femenino , Gastroenteritis/complicaciones , Gastroenteritis/epidemiología , Cefalea/epidemiología , Cefalea/terapia , Humanos , Lactante , Recién Nacido , Masculino , Persona de Mediana Edad , Pakistán/epidemiología , Readmisión del Paciente , Proyectos Piloto , Cólico Renal/epidemiología , Cólico Renal/terapia , Estudios Retrospectivos , Adulto JovenRESUMEN
In the present cross-sectional study we aimed to identify factors associated with morbidity and mortality in patients during the heat wave period (June 17th till 23rd, 2015) in the emergency department. The inclusion criteria of the study was core temperature >38 degree Celsius and signs of dehydration recorded in-patient notes and CNS dysfunction without infection recorded through GCS. Of 400 patients mortality was observed in 50 patients (12.7%) of which majority were males (54%). Of the non-survivors, 27.3% had prior history of cerebrovascular accident. Difference was noted in clinical presentation among non-survivors with unconsciousness (14%) and gasping (12%). Differences were noted in median of platelets [251(190-331) versus 183.5(155-228.5)] and Creatinine [1.1(0.9-1.7) versus 2.1(1.4-2.4)] between survivors and non-survivors. Majority of non-survivors had deranged coagulation profile and hypoxaemia.
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Deshidratación/epidemiología , Servicio de Urgencia en Hospital , Calor Extremo , Trastornos de Estrés por Calor/mortalidad , Adulto , Anciano , Estudios Transversales , Femenino , Fiebre , Escala de Coma de Glasgow , Calor , Humanos , Masculino , Persona de Mediana Edad , Mortalidad , Factores de Riesgo , Accidente Cerebrovascular/epidemiología , Centros de Atención Terciaria , Inconsciencia/epidemiología , Tiempo (Meteorología) , Adulto JovenRESUMEN
OBJECTIVE: To determine the clinical outcome and mean length of hospital stay of paediatric patients with severe blunt traumatic head injury (THI) receiving 3% hypertonic saline (HTS) in the Emergency Department (ED). METHODOLOGY: This case series study was conducted at the Department of Emergency Medicine, Aga Khan University Hospital, Karachi, from 2014 to 2015 via chart review of 105 patients. Detailed history and clinical examination of all paediatric patients aged 2-16 years was recorded which included moderate to severe head injury as classified by the Glasgow Coma Scale (GCS) by the Brain Trauma Foundation. As per routine care after admission of such a patient, for resuscitation 3% HTS was administered. GCS was recorded at 6 hours and at the time of discharge. RESULTS: Of the 105 patients, 76 (72.4%) were male and 29 (27.6%) were female, and the mean age was 61.6+45.9 months. Traumatic brain injury (TBI) was found moderate in 60 (57.1%) cases and severe in 45 (42.9%) of our patients as per the GCS. Six hours after resuscitation with 3% hypertonic saline, 45 (43%) patients normalised as per GCS, 39 (37%) patients had moderate TBI and 21 (20%) had severe TBI. Forty five patients had a hospital stay of 2-3 days. The GCS improved after resuscitation with 3% hypertonic saline in emergency department, with a mean length of stay of 4.6+3.9 and 12.6+10.7 days in moderate and severe head injury respectively with a P value of <0.001, and was normal in 94 (89.5%) patients at the time of discharge. CONCLUSIONS: Paediatric patients with TBI receiving 3% hypertonic saline results in improved GCS and a decrease in the length of hospital stay.
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Lesiones Traumáticas del Encéfalo , Solución Salina Hipertónica , Adolescente , Lesiones Traumáticas del Encéfalo/epidemiología , Lesiones Traumáticas del Encéfalo/terapia , Niño , Preescolar , Servicio de Urgencia en Hospital , Femenino , Escala de Coma de Glasgow , Humanos , Lactante , Tiempo de Internación/estadística & datos numéricos , Masculino , Resucitación/métodos , Estudios Retrospectivos , Solución Salina Hipertónica/administración & dosificación , Solución Salina Hipertónica/uso terapéutico , Centros de Atención Terciaria , Resultado del TratamientoRESUMEN
Optic nerve sheath diameter measurement (ONSD) has been associated with identifying the prognosis of traumatic brain injury (TBI) patients. The study was planned to evaluate the prognostic value of ONSD measured on the initial brain computed tomography (CT) scan performed on patients with blunt TBI in the emergency department(ED). This retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of moderate and severe TBI patients from January to December 2014. ONSD for each eye on the initial CT scan and Glasgow Coma Scale (GCS) was measured upon patient presentation. Correlation between presentation GCS and ONSD was done through Pearson's correlation. Receiver operator curve (ROC) analysis was done to measure the predictive values of ONSD for mortality. Of the 276 patients, 211(76%) were males and 65(23%) females. ONSD was measured on 160(58%) patients. The mean ONSD measured on CT scan was 3.8±1. The Pearson's correlation between the severity of brain injury as per GCS at presentation and ONSD was not significant (-0.182). We concluded that ONSD measured on the initial CT brain scan had good association with the severity of blunt TBI in patients presenting to the ED.
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Lesiones Traumáticas del Encéfalo/diagnóstico por imagen , Hipertensión Intracraneal/diagnóstico por imagen , Vaina de Mielina/patología , Nervio Óptico/diagnóstico por imagen , Heridas no Penetrantes/diagnóstico por imagen , Accidentes de Tránsito , Lesiones Traumáticas del Encéfalo/mortalidad , Lesiones Traumáticas del Encéfalo/fisiopatología , Estudios Transversales , Servicio de Urgencia en Hospital , Femenino , Escala de Coma de Glasgow , Hematoma Epidural Craneal/diagnóstico por imagen , Hematoma Epidural Craneal/mortalidad , Hematoma Epidural Craneal/fisiopatología , Hematoma Subdural/diagnóstico por imagen , Hematoma Subdural/mortalidad , Hematoma Subdural/fisiopatología , Humanos , Hemorragia Intracraneal Traumática/diagnóstico por imagen , Hemorragia Intracraneal Traumática/mortalidad , Hemorragia Intracraneal Traumática/fisiopatología , Presión Intracraneal , Masculino , Persona de Mediana Edad , Nervio Óptico/patología , Tamaño de los Órganos , Pakistán , Peatones , Pronóstico , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Hemorragia Subaracnoidea Traumática/diagnóstico por imagen , Tomografía Computarizada por Rayos XRESUMEN
We put forth the case of a young immunocompetent female who presented with fever and left basal ganglia bleed secondary to vasculitis. After 2 weeks of prednisolone therapy, she continued to deteriorate. MRI scan revealed enhancement of previous hematoma, pus was aspirated surgically and fungal culture grew Chaetomium.
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Absceso Encefálico/microbiología , Chaetomium/patogenicidad , Adulto , Absceso Encefálico/diagnóstico , Femenino , HumanosRESUMEN
Urogenital emergencies demand immediate attention within the field of emergency medicine, encompassing a range of critical conditions from ectopic pregnancies to kidney stones. Timely diagnosis and treatment are vital to prevent potential mortality and morbidity. However, due to the sensitive nature of these disorders and the cultural taboos surrounding them, accessing prompt medical care can be challenging. To bridge this gap, innovative gamification-based learning techniques, such as the Learning Urogenital Diseases in Oddity (LUDO), have been introduced for emergency medicine residents (Chou, What is gamification? Yukai Chou: Gamification and behavioral design, n.d.; Gamification '13: Proceedings of the first international conference on gameful design, research, and applications, 2013).LUDO is a timed, gamified exercise that offers residents an interactive and engaging platform to enhance their clinical knowledge related to urogenital disorders. Adapted from the well-known board game, LUDO fosters learning, collaboration, and cooperation among residents. This format is highly customizable and can be utilized by various learning groups.Participants, emergency medicine residents from different academic years, formed four teams, each distinguished by a unique color. The exercise utilized simple and accessible materials, including a LUDO board, LED stopwatch, laptop, colored hats, and a desk bell. Teams advanced their tokens through the board by correctly answering urogenital disorder-related questions within a specified time frame.LUDO's objectives extended beyond token movement, assessing essential skills such as teamwork, time management, resource utilization, and strategic decision-making. The option to seek external resources, limited to five times per team, added an element of strategy. Facilitators evaluated participants' performance through questionnaires and Likert scales.The results revealed that LUDO effectively promoted teamwork, communication, leadership, and problem-solving among emergency medicine residents. Resident feedback was overwhelmingly positive, with interest in adopting this format for other educational modules. The gamified approach encouraged engagement and motivation, with immediate feedback ensuring continuous learning.In conclusion, the incorporation of the LUDO gamified format provides an enjoyable and interactive learning experience for emergency medicine residents. It enhances engagement, fosters teamwork, and facilitates the rapid assimilation of crucial knowledge related to urogenital diseases. This adaptable approach holds promise for improving resident training in various clinical scenarios.
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Terminal ballistics continues to struggle with bullet trajectory reconstruction and interpretation. This is a case of a young man presented with a very unusual trajectory of a bullet from the left shoulder to the brain parenchyma. The single wound and altered mentation prompted a CT head and neck scan, which revealed a retained bullet in the brain parenchyma, traversing from the left shoulder, across the neck and into the brain without causing significant damage to vital organs. We managed the patient conservatively. Emergency physicians dealing with gunshot injuries should thoroughly search for the bullet in cases where only a single wound is present and the bullet is missing, and they should have a basic understanding of the ballistics to understand the mechanism and injury pattern sustained by the bullet. This atypical ballistic trajectory scenario emphasises the need to exercise vigilance in accurately predicting the trajectory when the ballistic route is unknown.
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Servicio de Urgencia en Hospital , Tomografía Computarizada por Rayos X , Heridas por Arma de Fuego , Humanos , Masculino , Adulto Joven , Encéfalo/diagnóstico por imagen , Hombro/diagnóstico por imagen , Heridas por Arma de Fuego/diagnóstico por imagen , Heridas por Arma de Fuego/complicacionesRESUMEN
Introduction: Gender variation in critically ill adults after resuscitation is reported in many studies. However, this variation is not well established when evaluating the physiological instability in this population. This study aimed to prospectively evaluate the gender variation in serious outcomes by the difficult airway physiological score (DAPS) among critically ill patients requiring endotracheal intubation (ETI). Methods: This is a cohort study conducted from August 2021 to December 2022 in the emergency department of Aga Khan University. The prospective validity of the difficult airway physiological score was derived using retrospective data and includes 12 variables: sex, age, time of intubation, hypotension, respiratory distress, vomiting, shock index >0.9, pH < 7.3, fever, anticipated decline, Glasgow Coma Scale (GCS) < 15, and agitation. The serious outcomes were cardiac arrest, mortality (within 1 hour after intubation in emergency), hypotension (systolic blood pressure <90 mmHg), and oxygen desaturation (SpO2 < 92%). The difference between males and females was assessed using the chi-square test, and the association of gender and serious outcomes was explored using Cox and logistic regression analysis. ROC curve analysis and area under the curve assessed score validity separately in males and females with serious outcomes. Results: We enrolled 326 patients with a mean age of 50.3 (±17.8), with 123 (33.7%) females and 203 (62.2%) males. 198 (60.7%) patients were >45 years old, of which 136 (67%) were male and 62 (50.4%) female. Cardiac arrest was observed in 56 (17.2%), with 24 (19.5%) females and 32 (15.8%) males, p value 0.348. Hypotension after intubation was observed in 132 (40.5%) patients, 56 (45.5%) females and 76 (37.4%) males, p value 0.149. Oxygen saturation (<92%) was observed in 80 (24.5%) patients, 32 (26%) females and 48 (23.6%) males, p value 0.630. In females, the DAPS of 11 had an area under the curve of 0.863 (0.74-0.91). The sensitivity of the score was 84.8%, the specificity was 71.9%, the PPV was 77.8%, and the NPV was 80.4% with an accuracy of 78.9%. In males, the DAPS score of 14 had an area under the curve of 0.892 (0.57-0.75). The sensitivity of the score was 67%, the specificity 93.8%, the PPV 92.2%, and the NPV 72.2% with an accuracy of 79.8%. Conclusions: The Difficult Airway Physiological Score (DAPS) predicts the risk of serious outcomes after intubation with high precision and reliability with different score cutoffs between the two sexes, highlighting the gender variation of a difficult airway.
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BACKGROUND: The aim of our research was to design and evaluate an Artificial Neural Network (ANN) model using a systemic grid search for the early prediction of major adverse cardiac events (MACE) among patients presenting to the triage of an emergency department. METHODS: This is a single-center, cross-sectional study using electronic health records from January 2017 to December 2020. The research population consists of adults coming to our emergency department triage at Aga Khan University Hospital. The MACE during hospitalization was the main outcome. To enhance the architecture of an ANN using triage data, we used a systematic grid search strategy. Four hidden ANN layers were used, followed by an output layer. Following each hidden layer was back normalization and a dropout layer. MACE was predicted using three binary classifiers: ANN, Random Forests (RF), and logistic regression (LR). The overall accuracy, sensitivity, specificity, precision, and recall of these models were examined. Each model was evaluated using the receiver operating characteristic curve (ROC) and an F1-score with a 95% confidence interval. RESULTS: A total of 97,333 emergency department visits were recorded during the study period, with 33% of patients having cardiovascular symptoms. The mean age was 54.08 (19.18) years old. The MACE was observed in 23,052 (23.7%) of the patients, in-hospital (up to 30 days) mortality in 10,888 (11.2%) patients, and cardiac arrest in 5483 (5.6%) patients. The data used for training and validation were 77,866 and 19,467 in an 80:20 ratio, respectively. The AUC score for MACE with ANN was 0.97, which was greater than RF (0.96) and LR (0.96). Similarly, the precision-recall curve for MACE utilizing ANN was greater (0.94 vs. 0.93 for RF and 0.93 for LR). The sensitivity for MACE prediction using ANN, RF, and LR classifiers was 99.3%, 99.4%, and 99.2%, respectively, with the specificities being 94.5%, 94.2%, and 94.2%, respectively. CONCLUSION: When triage data is used to predict MACE, death, and cardiac arrest, ANN with systemic grid search gives precise and valid outcomes and will benefit in predicting MACE in emergency rooms with limited resources that have to deal with a substantial number of patients.
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Point of care ultrasound (POCUS) is "an ultrasonography performed at the bedside in real-time by the treating physician." It is a powerful imaging modality used as an adjunct to physical examination and has gained momentum to become the future stethoscope. By using POCUS, the treating physician performs all image acquisition and interpretation and uses the information immediately to address specific hypotheses and guide the ongoing therapy. There is a shred of solid evidence that POCUS improves the diagnosis and management of acutely unwell patients is expanding rapidly. Due to the rise in the practice of POCUS in clinical medicine, the use of consultative ultrasonographic services has been reduced. The widespread availability of portable ultrasound machines and training an adequate number of clinicians to become competent in performing POCUS is a great challenge. The development of effective competency levels, curriculum, and assessment methods is imperative for the training of POCUS.
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Acute pancreatitis (AP) refers to the acute inflammation of the pancreas; however, if there is concurrent necrosis, it is called necrotizing acute pancreatitis (NAP). The diagnosis is sometimes difficult because it might mimic acute coronary syndrome (ACS). We report a case of a 28-year-old male, who presented to the emergency department (ED) with severe epigastric pain, shortness of breath and diaphoresis for 4-5 h. The initial electrocardiogram (ECG) showed marked sinus bradycardia with an incomplete left bundle branch block. Considering the clinical presentation and ECG changes, he was managed as ACS and was rushed to catheterization laboratory for a coronary angiogram, which was reported normal. Subsequently, his serum pancreatic enzymes were elevated, and computed tomography of the abdomen showed NAP. In ED settings, it is difficult to differentiate between the two, particularly when AP presents with ECG manifestations masquerading as ACS.