Clinico-Epidemiological Profile, Trends, and Health-Related Outcomes of Snakebite Victims: A One-Year Prospective Study from Eastern India.

INTRODUCTION: Snakebite envenomation is a significant life-threatening public health problem in Southeast Asia (SEA). In this region, India reported the largest number of snakebite deaths from 2000 to 2019 (1.2 million), with an average of 58,000 deaths yearly. METHODS: This prospective observational study was carried out among snakebite victims at the emergency department (ED) of a tertiary care public sector hospital in eastern India. RESULTS: A total of 145 cases of venomous snakebite were investigated. More than half (n = 81, 56%) of the snakebite victims were between 17 to 45 years. Most of the snakebite victims were male (68%) and were farmers (53%) by occupation. The majority of snakebites occurred during the daytime (76%) and while outdoors (67%). Most victims sustained a bite on the lower extremity (71%). The peak incidence of snakebites occurred from June to September (69%). Three-quarters of all patients were unaware of the required first aid measures following a snakebite. Among the 145 venomous snakebites, 48 were presumptively identified as the Indian cobra, 32 by the Indian krait, 56 by the Russel's viper, and 9 by saw-scaled viper. The mean duration from the snakebite to the onset of systemic effects in the Indian cobra was 52 ± 14.28 min, 66 ± 18.35 min in the Indian krait, 42 ± 13.47 min in Russel's viper, and 48 ± 16.38 min in saw-scaled viper. Respiratory failure was the commonly observed complication following an elapid envenomation. The mortality rate was 2.1% among the patients treated with antivenom. CONCLUSIONS: Snakebite is considered an occupational hazard in India, commonly affecting the young population in their productive period. The peak incidence was during monsoon season, and the majority had neurotoxic envenomation following an elapid bite (55%) that contributed to the increased mortality and morbidity among young adults. Of the 145 patients, the majority (84%) recovered fully with treatment; 16% of the victims developed morbidity viz cellulitis, respiratory failure, acute renal failure, compartment syndrome, local tissue necrosis, intracerebral hemorrhage, and disseminated intravascular coagulation. Appropriate first aid measures and timely medical intervention can significantly improve the treatment outcome following snakebites.

Efficacy of metoclopramide for prevention of gastric regurgitation during endotracheal intubation in the emergency department: A randomized controlled trial.

Background: Gastric content regurgitation and aspiration are the dreaded complications of securing the airway. Cricoid pressure hinders intubation and causes lower esophageal sphincter (LES) relaxation. A recent study suggests no added benefit of cricoid pressure in preventing pulmonary aspiration of gastric contents. Metoclopramide increases LES tone, prevents gastroesophageal reflux, and increases antral contractions. Hence, we wanted to study the efficacy of metoclopramide for preventing gastric regurgitation during endotracheal intubation (ETI) in patients presenting to the emergency department (ED). Methods: This study was a randomized controlled trial in patients requiring ETI in the ED. The study participants were randomized to receive either metoclopramide (intervention) 10 mg/2 ml intravenous (IV) bolus or a placebo of normal saline (placebo) 2 ml IV bolus 5 min before rapid sequence induction and intubation. The outcome of the study was the visualization of gastric regurgitation at the glottic opening during direct laryngoscopy at the time of intubation. Results: Seventy-four study participants were randomized and allocated to the metoclopramide group (n = 37) or placebo group (n = 37). Gastric regurgitation at the glottis was noted in three study participants (8%) in the metoclopramide group, and six (16%) in the placebo group (odds ratio [OR] - 0.456; 95% confidence interval [CI] of 0.105-1.981; P = 0.295). The study participants who were intubated in the first attempt had less gastric regurgitation compared to ≥2 attempts (OR 0.031; 95% CI of 0.002-0.511; P = 0.015). Conclusion: There was no decrease in regurgitation with metoclopramide as compared to placebo during ETI in study participants presenting to the ED.

Sonographic Optic Nerve Sheath Diameter as a Guide for Correction of Hyponatremia in the Emergency Department: A Cross-sectional Study.

Background: Monitoring sodium levels during the correction of hyponatremia is essential. There is cell swelling due to the movement of water from extracellular to intracellular by osmotic effect in hyponatremia. The cellular swelling in a closed space causes increased intracranial pressure (ICP). The raised ICP correlates with the optic nerve sheath diameter (ONSD). So, the research question was whether the ONSD can be used as a guide for the correction of hyponatremia. Methods: It was a prospective observational study conducted on patients with serum sodium below 135 mEq/L presented to the emergency department (ED). The ONSD was measured at the time of presentation and discharge of the patient. The receiver operating characteristic curve (ROC) and area under the curve (AUC) were used to test the predictive ability of the ONSD to diagnose hyponatremia. Results: A total of 54 subjects were included in the study. The mean sodium level was 109.3 mEq/L at presentation. The mean ONSD on the right side was 6.24 ± 0.71 mm and on the left side was 6.26 ± 0.64 mm at presentation to ED. The mean ONSD on the right side was 5.81 ± 0.58 mm and on the left side was 5.79 ± 0.56 mm at discharge. The ONSD was not able to predict the sodium level measured both by laboratory and POC methods. Conclusion: The ONSD failed to predict the sodium level in patients with hyponatremia during the correction. The change in ONSD did not correlate with the change in sodium level. How to cite this article: Uttanganakam S, Hansda U, Sahoo S, Shaji IM, Guru S, Topno N, et al. Sonographic Optic Nerve Sheath Diameter as a Guide for Correction of Hyponatremia in the Emergency Department: A Cross-sectional Study. Indian J Crit Care Med 2023;27(4):265-269.

Lithium Toxicity - A Chameleon to Gastrointestinal Vasculitis as an Initial Presenter of Systemic Lupus Erythematosus.

Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease. Gastrointestinal manifesting as nausea, vomiting, and pain abdomen are not so uncommon in SLE flare. However, gastrointestinal intestinal vasculitis as an initial presenter of SLE is very rare. This case report narrated gastrointestinal vasculitis as an initial presentation of systemic lupus erythematous, which mimicked lithium toxicity in a patient of preexisting bipolar disorder who was on long-term lithium therapy. A 26-year-old female presented with abdominal pain and persistent vomiting for 2 months. On further workup, she was antinuclear, anti-Smith, and anti-ds-DNA antibody positive. The serum lithium level was found to be normal computed tomography angiogram of the abdomen suggestive of vasculitis. A final diagnosis of SLE with gastrointestinal vasculitis as an initial presenter was made. She was treated with high-dose corticosteroid, cyclophosphamide, and other supportive care. She improved dramatically and was discharged with an oral corticosteroid, hydroxychloroquine, and ramipril.

A Retrospective Study on Drug and Dietary Patterns in Patients With Severe Rheumatic Valvular Heart Disease in Eastern India.

Background India has a high prevalence of rheumatic valvular heart diseases. Empirical treatment in rheumatic heart disease curtails morbidity and mortality. Less is known about the drug and dietary management of severe rheumatic heart disease at the pretertiary care level, which forms the building stone in the management of rheumatic heart disease. The present study was carried out to evaluate the drug and dietary patterns of patients with severe rheumatic valvular heart disease at a pretertiary care level, which is the backbone of the management of rheumatic heart disease. Methodology This cross-sectional study was carried out in a tertiary care center in Eastern India between May 2020 and May 2022 across 1,264 study subjects. The drug and dietary patterns of the patients with severe rheumatic valvular heart disease during their index visit to the cardiac department were studied and analyzed. Patients aged less than 18 years; patients with mild or moderate rheumatic valvular heart diseases; patients with coexisting end-stage organ disease (chronic liver disease and chronic kidney disease), malignancy, and sepsis; and patients not willing to participate in the study were excluded. Results Most of the patients were on diuretic therapy, and diuretic therapy was overprescribed across the patients with mitral regurgitation, aortic stenosis, and aortic regurgitation. Most of the patients across each spectrum of rheumatic valvular heart disease were lacking the cornerstone therapy such as beta-blockers in mitral stenosis and angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in mitral and aortic regurgitation. The recommended injectable benzathine penicillin prophylaxis was prescribed in a very small number of patients (5%), and most of the patients were on oral penicillin prophylaxis (95%) in spite of its reported high failure rate in prophylaxis. Empirical rationale prescriptions in severe rheumatic valvular heart disease were lacking in the pretertiary care level in Eastern India. Conclusion Each spectrum of severe valvular heart disease was lacking the cornerstone therapy such as beta-blockers in mitral stenosis and ACE inhibitors or angiotensin receptor blockers (ARBs) in mitral and aortic regurgitation along with recommended injectable benzathine penicillin prophylaxis. Diuretics and digoxin were overprescribed across the spectrum of rheumatic heart disease. Improvement of this essential gap in the treatment of severe rheumatic heart disease would bring down morbidity and improve mortality in the future.

Point-of-care versus central laboratory measurements of electrolytes and hemoglobin: A prospective observational study in critically ill patients in a tertiary care hospital.

Background: A blood gas analyzer is a point-of-care (POC) testing device used in the Emergency Department (ED) to manage critically ill patients. However, there were differences in results found from blood gas analyzers for hemoglobin (Hgb) and electrolytes parameters. We conducted a comparative validity study in ED in patients who had requirements of venous gas analysis, complete blood count, and electrolytes. The objective was to find the correlation of Hgb, sodium (Na+), and potassium (K+) values between the blood gas analyzer and laboratory autoanalyzer. Methods: A total of 206 paired samples were tested for Hgb, Na+, and K+. Total 4.6 ml of venous blood was collected from each participant, 0.6 ml was used for blood gas analysis as POC testing and 4 ml was sent to the central laboratory for electrolyte and Hgb estimation. Results: The mean difference between POC and laboratory method was 0.608 ± 1.41 (95% confidence interval [CI], 0.41-0.80; P < 0.001) for Hgb, 0.92 ± 3.5 (95% CI, 0.44-1.40) for Na+, and 0.238 ± 0.62 (95% CI, -0.32-0.15; P < 0.001) for K+. POC testing and laboratory method showed a strong positive correlation with Pearson correlation coefficient (r) of 0.873, 0.928, and 0.793 for Hgb, Na+, and K+, respectively (P < 0.001). Conclusion: Although there was a statistical difference found between the two methods, it was under the United States Clinical Laboratory Improvement Amendment range. Hence, starting the therapy according to the blood gas analyzer results may be beneficial to the patient and improve the outcome.

Study Protocol: IMPETUS: Implementing a Uniform Stroke Care Pathway in Medical Colleges of India: IMPETUS Stroke.

Introduction: In India, a national program for stroke (national programme for the control of cardiovascular diseases, diabetes, cancer, and stroke) and stroke management guidelines exist. Its successful implementation would need an organized system of stroke care in practice. However, many challenges exist including lack of awareness, prehospital notification systems, stroke ready hospitals, infrastructural weaknesses, and rehabilitation. We present here a protocol to investigate the feasibility and fidelity of implementing a uniform stroke care pathway in medical colleges of India. Methods and Analysis: This is a multicentric, prospective, multiphase, mixed-method, quasi-experimental implementation study intended to examine the changes in a select set of stroke care-related indicators over time within the sites exposed to the same implementation strategy. We shall conduct process evaluation of the implementation process as well as evaluate the effect of the implementation strategy using the interrupted time series design. During implementation phase, education and training about standard stroke care pathway will be provided to all stakeholders of implementing sites. Patient-level outcomes in the form of modified Rankin Scale score will be collected for all consecutive patients throughout the study. Process evaluation outcomes will be collected and reported in the form of various stroke care indicators. We will report level and trend changes in various indicators during the three study phases. Discussion: Acute stroke requires timely detection, management, and secondary prevention. Implementation of the uniform stroke care pathway is a unique opportunity to promote the requirements of homogenous stroke care in medical colleges of India.

Comparison of endotracheal intubation with Macintosh versus King Vision video laryngoscope using coronavirus disease 2019 barrier box on manikins: A randomized crossover study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) virus usually spreads through aerosol and close contact. Frontline health-care workers handle aerosol-generating procedures like endotracheal intubation. To reduce this risk, COVID-19 barrier box came into the picture. However, the COVID-19 barrier box may compromise easy and successful intubation, and their limitation must be studied. OBJECTIVES: The objective of this study was to assess the time to successful intubation with or without the COVID-19 barrier box using the Macintosh laryngoscope and King Vision video laryngoscope (KVVL). We also assessed the first-pass success rate, ease of intubation, Cormack-Lehane (CL) grade, and requirement of external laryngeal manipulation. METHODS: We conducted this manikin-based randomized crossover study to assess the time to successful intubation by anesthesiologists (22) and emergency physicians (11) having 1 year or more experience with or without COVID-19 barrier box by using the Macintosh laryngoscope and KVVL. Our study randomized the sequence of the four different intubation scenarios. RESULTS: The comparison of mean duration of intubation between KVVL (13.21 ± 4.05 s) and Macintosh laryngoscope (12.89 ± 4.28 s) with COVID-19 barrier box was not statistically significant (95% confidence interval: 1.21-0.97). The ease of intubation, number of attempts, and requirement of external laryngeal manipulation were not statistically significant. Intubations were statistically significant more difficult with barrier box in view of higher CL grade. CONCLUSION: Time to intubation was longer with COVID-19 barrier box using KVVL as compared to Macintosh laryngoscope which was statistically not significant.

Severe Oleander Poisoning Presenting with Hyperkalaemia and Unusual Electrocardiographic Changes.

BACKGROUND: Hyperkalaemia in oleander (Nerium oleander) poisoning has been associated with a poor prognosis. Different electrocardiographic (ECG) presentations are possible because of vagotonia and hyperkalaemia. METHODS/RESULTS: We report a series of three cases of oleander poisoning in which ECG showed unusual hyperkalaemia features, such as bradyarrhythmia, sinoatrial block, atrioventricular block and junctional rhythm. CONCLUSIONS: If arterial blood gas analysis or laboratory values indicate hyperkalaemia in oleander poisoning, the hyperkalaemia should be treated immediately, even if the ECG does not show typical hyperkalaemia features. LEARNING POINTS: Hyperkalaemia in oleander poisoning is associated with a poor prognosis.Hyperkalaemia should be treated aggressively in oleander poisoning even if the ECG does not show typical features, as mimics other conditions on ECG.

Clinicoepidemiological profile of trauma patients admitting to the emergency department of a tertiary care hospital in eastern India.

CONTEXT: Trauma is an immediate cause of patients flowing to the emergency department of any hospital. Besides epidemiology, clinical profile and treatment strategy forms an important aspect to reflect the gap in the existing public sector health-care system and the requirement. AIMS: To evaluate the clinicoepidemiological profile of trauma patients admitting to an apex trauma hospital in east India. SETTINGS AND DESIGN: A prospective observational study was performed during the time period of December 2018 to July 2019 on trauma patients admitted to the Trauma and Emergency department. METHODS AND MATERIAL: Patient's demographic profile, injury type, mechanism, the vehicle involved in the accident, and transportation were recorded. Various trauma scores (clinical) and outcome measures were recorded. STATISTICAL ANALYSIS USED: Statistical analysis was done by R version 3.6.1. RESULTS: Male: female ratio was 407:93 with the 21-30 age group predominantly. 2-6 PM was the most common time of injury and ambulance was the predominant mode of transport (58%). Road traffic injury (RTI) accounted for 75% victims; two-wheelers (68%) dominated over others. Thirty percent (drivers 18%, pillion riders 12%) were wearing helmet; 41% were wearing seat belts (drivers 34%, passenger 12%). Twenty-five percent of drivers consumed alcohol. The median ± Interquartile range of injury severity score (ISS), revised trauma and trauma score and injury severity score were 17 (11-26), 7.8 (4.1-7.8), and 98.41 (95.95-99.30), respectively. Extremity injury (54% fractures) and head injury (50%) were the frontrunners in the pattern of injury, with half of the victims were polytrauma (ISS > 15). CONCLUSIONS: The injury was prominently RTI and the trauma victims/patients were young male drivers on two wheelers. The focus should be directed to make use of safety measures among the youth.

Aluminium Phosphide-Induced Expression of Covertly Present Brugada Pattern in Electrocardiogram: A Rare Case Report.

Aluminum phosphide is a common suicidal agent in an agrarian country like India. Toxicity is mostly due to the liberation of phosphine gas, which non-competitively inhibits cytochrome oxidase in the mitochondria causing cell hypoxia. It can involve almost any organ in the body, but the most common is cardiovascular system. Various cardiovascular manifestations are hypotension, myocarditis, pericarditis, congestive heart failure, various ECG changes like myocardial infarction, conduction abnormalities, various arrhythmias, and very rarely unmasking of the Brugada pattern. Here we are presenting a case in which the patient developed unmasking of the Brugada pattern in ECG, and gradually he improved symptomatically and ECG wise with conservative treatment. As unmasking of the Brugada pattern in ECG can lead to life-threatening arrhythmias, one has to be cautious and keep this in mind while dealing with a case of aluminum phosphide poisoning.

Intravenous Immunoglobulin-Associated Elevation of Liver Enzymes in Neurological Autoimmune Disorder: A Case Series.

Intravenous immunoglobulin (IVIG) is used in the treatment of a variety of autoimmune neurological disorders and is generally regarded as safe. We present a case series where IVIG causes transaminitis. The adverse effects are mostly due to the stabilizing agent used to prepare the IVIG (e.g., maltose in this series). While the adverse effects are usually self-limiting, physicians should be cautious in administering an IVIG preparation to these patients.

A Rare Case of Multicentric Reticulohistiocytosis with Concurrent Rheumatoid Arthritis.

Multicentric reticulohistiocytosis (MRH) is a rare multisystem macrophage disorder of unknown etiology characterized by papulonodular skin and mucosal lesions, rapidly progressive erosive symmetric polyarthritis, and inflammation of internal organs. Most often, it is misdiagnosed as rheumatoid arthritis (RA). Here, we report the case of a 60-year-old woman found to have features of both MRH and RA with positive rheumatoid factor and high titer of anti-cyclic citrullinated peptide antibody in serum. It was confirmed by a histopathology of skin lesions, which showed diffuse histiocytic infiltrate with multinucleated giant cells. She was treated with methotrexate, hydroxychloroquine, corticosteroids, and nonsteroidal anti-inflammatory drugs and bisphosphonate.