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.

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.

Nebulized vs IV Tranexamic Acid for Hemoptysis: A Pilot Randomized Controlled Trial.

BACKGROUND: Tranexamic acid (TA) is used to control bleeding in patients with hemoptysis. However, the effectiveness of the different routes of TA administration has not been studied. RESEARCH QUESTION: Does the nebulized route of TA administration reduce the amount of hemoptysis compared with the IV route in patients presenting to the ED with hemoptysis? STUDY DESIGN AND METHODS: This was a pragmatic, open-label, randomized, parallel, single-center, pilot trial of nebulized TA (500 mg tid) vs IV TA (500 mg tid) in adult patients presenting to the ED with active hemoptysis. The primary outcome was cessation of bleeding at 30 min. Secondary outcomes included amount of hemoptysis at 6, 12, and 24 h; interventional procedures; and side effects of TA. Patients who were hemodynamically unstable or requiring immediate interventional procedure or mechanical ventilation were excluded from the study. RESULTS: Of the 55 patients in each arm, hemoptysis cessation at 30 min following TA administration was significantly higher in the nebulization arm (n = 40) compared with the IV arm (n = 28): χ2 (1, n = 110) = 5.55; P = .0019. Also, hemoptysis amount was reduced significantly in the nebulization arm at all time periods of observation (P value at 30 min = .011, at 6 h = .002, 12 h = .0008, and at 24 h = .005). Fewer patients in the nebulization arm required bronchial artery embolization (13 vs 21; P = .024) and thereby had higher discharge rates from the ED (67.92% vs 39.02%; P = .005). Two patients in the nebulization arm had asymptomatic bronchoconstriction that resolved after short-acting beta-agonist nebulization. No patient discharged from the ED underwent any interventional procedure or revisited the ED with rebleed during the 72 h follow-up period. INTERPRETATION: Nebulized TA may be more efficacious than IV TA in reducing the amount of hemoptysis and need for ED interventional procedures. Future larger studies are needed to further explore the potential of nebulized TA compared with IV TA in patients with mild hemoptysis. CLINICAL TRIAL REGISTRATION: Clinical Trials Registry-India; No.: CTRI/2019/05/019337; URL: http://ctri.nic.in/Clinicaltrials/advancesearchmain.php.

Prospective Validation of a Novel Triage System Developed in a Middle Income Country - AIIMS Triage Protocol.

Introduction: Triage is a crucial process not only to identify sick patients and prioritize prompt management but also to foster efficient resource utilization. In low-and middle-income countries (LMICs) most emergency departments (ED) still have an informal triage process. Although an important element of emergency care, triage research has not been a priority in LMICs, and hence, very few triage systems have been validated. The All India Institute of Medical Sciences (AIIMS) triage protocol or ATP for adult patients was developed by expert consensus at AIIMS using the Delphi method. We attempted a prospective validation of the ATP in terms of mortality and intensive care unit (ICU)/hospital admission at 24 h. Methods: Patients presenting to the ED, who were 14 years and above were included in the study. The patients were followed up at 24 h and their outcome documented on a standardized data collection form. Mortality and ICU admission were noted at 24 h. Results: A total of 15,505 patients were recruited. After exclusion, among 13,754 patients, 6303 (45.83%) were triaged red and 7451 (54.17%) were triaged yellow. Mortality at 24 h was 10.31% (650) in red triaged patients and 0.35% (26) in yellow triaged patients. The 24-h mortality of red triaged patients was significantly higher (P <0.001) than that of yellow triaged patients. The presence of one or more ATP "Red" criteria was 96.2% (95% confidence interval [CI]: 94.42%-97.47%) sensitive and 56.8% (95% CI: 55.92%-57.63%) specific in predicting 24-h mortality. The sensitivity and specificity of ATP "Red" criteria for 24-h ICU admission were 98.5% (95% CI: 97.7%-99.1%) and 59.6% (95% CI: 58.8%-60.5%), respectively. Conclusion: When applied to adult nontrauma patients, ATP had a high accuracy in recognizing sick patients presenting to the ED. A time-tested and validated triage system like ATP may be a good starting point for public hospital EDs in LMICs.

Strengthening emergency care systems to improve patient care for ST-elevation myocardial infarction (STEMI) at a high-volume tertiary care centre in India.

BACKGROUND: ST-elevation myocardial infarction (STEMI) is a highly time-sensitive and life-threatening condition. Early recognition and timely management are challenging in a busy emergency department (ED), especially in low/middle-income countries where emergency systems are often fragmented. The aim of our quality improvement (QI) project was to increase the percentage of patients with STEMI undergoing primary percutaneous coronary intervention (PCI) with door to balloon (D2B) time of <90 min by 30% over 12 months. METHODS: As part of the first step in QI, baseline data were collected at different points in the process of care. Using process maps and fishbone analysis, delays in patient registration, ECG and communication with cardiology were identified as some bottlenecks, and change ideas were tested using plan-do-study-act cycles using point-of-care QI methodology. The majority of the change ideas focused on interventions in the ED like strengthening triage, training frontline staff, early diagnosis and quick transportation of patients. RESULTS: During the baseline phase, 22.22% of patients were found to have a D2B time of <90 min. We achieved an increase of 47.78% in patients receiving PCI within 90 min and hence increased to 70% at the end of the intervention phase. Data collected for 4 months after the intervention phase were found to have sustained the effort. CONCLUSION: Significant improvement in the door to reperfusion time resulted from a meticulous assessment of emergency care processes by drawing process flow chart and implementation of change ideas like introduction of fast-track policy for patients with chest pain, reducing staff turnover in the triage area, formal training of staff, continuous engagement with cardiology team and by interchanging of processes which led to a reduction in time to ECG.

Alleviating Refractory Abdominal Pain in Cholangiocarcinoma Using Erector Spinae Plane Block in the Emergency Department.

BACKGROUND: Acute pain management in the emergency department (ED) is a challenging task, more so in pain due to malignancy. Opioids have life-threatening side effects in ED patients, along with the risk of dependency. Erector spinae plane block (ESPB) is a recently described plane block technique with ease of performance and minimal side effects, making it suitable for emergency settings. CASE REPORT: A 62-year-old male patient recently diagnosed with cholangiocarcinoma presented to the ED with severe right upper abdominal pain. There was no pain relief with high doses of analgesics. ESPB was administered at T7 vertebrae level. The patient's Defense and Veteran Pain Rating Scale score reduced from 8/10 pre-procedure to 3/10 within 15 min, and 2/10 1 h after the procedure. He reported that he had an uninterrupted pain-free sleep after 4 days. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: ESPB is a novel regional analgesia that may help in management of uncontrolled severe pain not relieved with analgesics in patients with cholangiocarcinoma in the ED.

Kounis syndrome and atrial fibrillation after bee sting: A case report.

Bee sting can lead to allergic reactions which can present as life-threatening emergencies. Kounis syndrome is an acute coronary syndrome caused by mast cell activation after exposure to an allergen. Atrial fibrillation (AF) along with Kounis syndrome after allergen exposure is a rare presentation. A 40-year-old male patient presented to the emergency department (ED) with multiple bee stings to the face and neck. He complained of retrosternal chest pain along with facial pain and swelling. An electrocardiogram (ECG) showed AF with ST elevation in aVR and generalized ST segment depression. Troponin levels were elevated. He was diagnosed with Kounis syndrome along with AF secondary to a bee sting. The patient improved symptomatically with removal of stings and conservative management (steroids, antihistamines, antiplatelet drugs). ECG reverted to sinus rhythm and resolution of ST-T changes. He was discharged from the ED in stable condition. The bee sting may lead to significant cardiovascular events such as AF and Kounis syndrome, which require a high index of suspicion and prompt treatment. Kounis syndrome should be suspected in the ED in young patients with no cardiovascular risk factors after exposure to an allergen.

Erector spinae plane block for pain control in patients with pancreatitis in the emergency department.

Nerve blocks are frequently used in emergency department for pain management in patients with fractures. Their utility in medical conditions with severe intactable pain is largely unknown. We report a series of seven patients with pancreatitis who presented with severe abdominal pain (defense and veteran pain rating scale > 7) and had no relief on regular analgesia. They were subjected to erector spinae plane block (ESPB), and reduction in pain score at different time intervals, side effects, and additional analgesic dose requirements were noted. The objective of this case series is to explore the utility of ESPB in patients with pancreatitis.

Advancing emergency airway management by reducing intubation time at a high-volume academic emergency department.

BACKGROUND: Airway management is a life-saving procedure in the emergency department (ED). Hypoxia during rapid sequence intubation (RSI) is associated with high morbidity and mortality. AIM: To decrease the median time of intubation (time from administration of paralytic agent to the successful passage of endotracheal tube) by 40% from baseline 300 s in patients undergoing RSI in the ED. METHODS: A multidisciplinary quality improvement team worked to improve the airway management. The bottle necks identified using process mapping and fish bone analysis were lack of formal training of residents and nursing officers, and communication gap between residents and nursing officers. Change ideas focused on training residents in laryngoscopy and intubation and nursing officers in facilitating airway management by preparation of drugs and equipment; on-site awareness of logistical issues to the residents and nursing officers, introducing airway drug checklist and ensuring availability of difficult airway equipment. RESULTS: After implementation of change ideas there was a significant reduction in intubation time. At the end of first Plan-Do-Study-Act (PDSA) cycle median intubation time was 165 s (IQR 125 s). By the end of last PDSA cycle, median intubation time reduced to 157 s (IQR 66 s). A shift was obtained on the run chart with a new median time of 141.5 s from mid-PDSA 1. The 8-week data after the end of PDSA 3 showed sustainability with median time of 126 s (IQR 42 s). CONCLUSION: A well organised team effort, simple change ideas such as structured training of residents and nursing officers, introduction of airway drug checklist and improved communication can decrease the intubation time in a chaotic ED.

Acute lead poisoning: a diagnostic challenge in the emergency department.

Acute abdominal pain is a common presentation to the emergency department (ED). Ruling out life-threatening causes and giving pain relief are the most important tasks in ED. We describe a 32-year-old man who presented to ED with abdominal pain and vomiting which was unrelieved by usual doses of analgesic. Extensive investigations revealed no significant abnormalities. On further probing, he admitted taking traditional medications for infertility. The toxicological panel revealed a high blood lead level, leading to a diagnosis of acute lead toxicity. Chelation therapy with D-penicillamine was initiated and the patient's abdominal pain resolved within 4 days.