A Comparison between Ultrasound-guided Short-axis Approach and Oblique Axis Approach for Internal Jugular Venous Cannulation in the Emergency Department.

Background: Central venous catheter (CVC) placement is a frequently performed procedure in the emergency department (ED). We aim to compare two different ultrasound (US)-guided techniques, the short-axis (SAX) approach and the oblique axis (OAX) approach for the insertion of internal jugular vein (IJV) catheters in an ED setting. Methods: This prospective, observational study was conducted in the ED of a single tertiary care teaching hospital on patients requiring IJV cannulation. CVC placement was done using both the SAX and OAX approaches as per the ED physician's discretion. Outcome measures included acute complications, successful insertion of an IJV catheter, number of attempts, and access times. The Chi-square test was used to compare the study variables (acute complications, number of cannulation attempts, and successful cannulation) between the two approaches. Mann-Whitney U-test was applied to compare the mean differences of flash time and cannulation time. Results: Sixty patients were enrolled, of which 30 underwent IJV cannulation by the SAX technique and 30 by the OAX technique. We noted a total of 22 acute complications, 56.7% in the SAX group and 16.7% in the OAX group. A significant incidence of posterior venous wall puncture was noted in the SAX group (50.0%). No significant statistical differences were noted on analysis of other outcome measures. Conclusion: The OAX approach is a useful alternative technique to IJV cannulation in the ED setting. Further multicentric studies in this domain will be required to consider this technique as the primary approach to US-guided IJV cannulation in the ED setting.

Chest Compression Fraction and Factors influencing it.

Introduction: Chest compression fraction (CCF) is the cumulative time spent providing chest compressions divided by the total time taken for the entire resuscitation. Targeting a CCF of at least 60% is intended to limit interruptions in compressions and maximize coronary perfusion during resuscitation. We aimed to identify the mean CCF and its relationship with various factors affecting it. Methods: Patients presenting to the emergency department in cardiac arrest at a single center were prospectively included in this study. Resuscitation was provided by trained health-care providers. The feedback device Cprmeter2™ was placed on the patient's sternum at the beginning of resuscitation. The total time taken for the entire resuscitation was noted by the device and CCF calculated. Results: The mean CCF was analyzed using descriptive statistics and was found to be 71.60% ± 7.52%. The total duration of resuscitation (R = -0.55, P = < 0.001, min-max, 2.02-34.31, mean 12.25 ± 6.54), number of people giving chest compressions (R = -0.48, P = < 0.001, min-max, 1-6, mean 4.04 ± 1.12), and total number of team members in resuscitation (R = -0.50, P = < 0.001, min-max, 4-10, mean 6.65 ± 1.32) had negative correlation with CCF. Diurnal variation (day, n = 35; mean 69.20% ± 7% and night, n = 20; mean 75.80% ± 5.6%, P = 0.001) and patients receiving defibrillation (receiving n = 10 mean 67.00% ± 4.11% and not receiving n = 45 mean 72.62 ± 7.42%, P = 0.005) were found to significantly affect CCF. Conclusion: The mean CCF for cardiac arrest patients was well within the targets of guideline recommendation. CCF decreased when resuscitation lasted longer, during daytime when the defibrillator was used, the total team members increased, and also when the number of people giving chest compressions increased. CCF during resuscitation may improve if there is a focus on improving these factors and requires validation in multicentric settings.

Door to balloon time in patients presenting with acute ST elevation myocardial infarction and time factors influencing it; an observational study from a tertiary care teaching hospital in India.

The objective of this prospective observational study was to assess the door-to-balloon time (D2B), in acute ST-segment elevation myocardial infarction (STEMI) patients and the time factors influencing it. The following timeframes were measured during the study: ED to ECG time, ED to coronary care unit time (ED2CCU), consent time, post-consent to balloon time (POSTCONSENT2B) and D2B. Effective D2B was 54 ± 12.2 min. Of the dependent variables, D2B had a strong positive correlation (ρ = 0.903) with consent time. This study sheds light on consent time a previously unrecognized entity as a significantly influencing factor for the D2B time.

Retrospective review of case records of snakebite presenting to a single tertiary care centre over a 5-year period.

Background Snakebite is a disease of the poor, and hospitals catering to these individuals are often resource-constrained. Lack of electronic medical records in these resource-limited settings makes the capture of data even harder. Methods Before establishing a snakebite registry in the region, we did a retrospective case record review of all snakebite victims (n=3229) over 5 years who presented to a single tertiary care centre, catering to one of the largest number of snakebite victims in the country. Results Of the 451 cases, 262 (58.1%) presented to the emergency department within 2 hours of the bite. In 170 instances, the snake was brought along and the species of the snake was recorded. Russell's viper was the most common (130; 76.5%). Blood products were used in 237 (52.5%) patients. Acute kidney injury occurred in 165 (36.6%) patients, of whom 37 (8.2%) required dialysis. The mean (SD) duration of hospital admission was 10.5 (7.4) days. There was a significant correlation between number of snakebites with rainfall and humidity. One hundred and seven cases (3.3%) of snakebite resulted in mortality. A majority of mortality records were not available (88%; 94/107), rendering us incapable of doing reliable mortality data correlations or interpretation. Conclusion Viperidae bites predominate in the region, with renal injury being the most common cause for morbidity. Region-specific, prospective snakebite mapping could be a cost-effective strategy that might help in vulnerability analysis of the region. A multi-centric region-specific snakebite registry encompassing not just the clinico-epidemiological characteristics of snakebite victims, but also the demographic data, the pre-hospital care and local remedial practices, geospatial distribution, anti-snake venom and blood product usage, will help in developing better healthcare strategies for snakebite victims in India.

Survival following intentional succinylcholine injection for self-harm.

Succinylcholine is a short-acting depolarizing neuromuscular blocking agent. We describe a case where the above drug was employed for self-harm by a health-care worker. The patient, a 28-year-old female, was brought to the emergency department (ED) in impending respiratory arrest and altered mental status. On arrival, she had hypoxia, bradycardia, and hypotension. Although the cause for rapid deterioration in this patient was unknown, the ED physician still went ahead by resuscitating the patient's airway, breathing, and circulation. During the course of resuscitation, information was received that an empty ampoule of succinylcholine was recovered from her bathroom. Further clinical examination and laboratory investigations led the treating physicians to suspect deliberate intravenous injection of succinylcholine. She was mechanically ventilated and monitored in the critical care unit. Targeted temperature management was initiated in the ED and was continued for 24 h. The patient was discharged from the hospital without any neurological deficits after 4 days. Patients with acute poisoning are one of the major encounters in ED, and this case highlights the possibility of anesthetic drug misuse in any health-care workers coming to the ED with sudden cardiac arrest, altered sensorium, or abnormal vitals. This is the first report describing the survival of a patient following intentional succinylcholine injection for self-harm.

A Comparison of Internal Jugular Vein Cannulation by Ultrasound-Guided and Anatomical Landmark Technique in Resource-Limited Emergency Department Setting.

BACKGROUND AND OBJECTIVES: Central venous catheter placement is a frequently performed procedure in emergency medicine as well as critical care unit. We aimed to compare real-time ultrasonography (USG)-guided and the traditional anatomical landmark (AL) technique for the insertion of internal jugular vein (IJV) catheters in an emergency department (ED) setting. MATERIALS AND METHODS: Patients requiring IJV catheterization were prospectively recruited over a period of 1 year at a single center. Cannulation was done either by the AL or USG technique, according to ED physician's discretion. A preset pro forma was completed for each central line placed. Variables were compared using the independent t-test, Fisher's exact test, and the nonparametric Mann-Whitney U-test. RESULTS AND DISCUSSION: Seventy patients were enrolled, of which 35 patients underwent IJV cannulation by USG-guided technique (USG group) and 35 patients by the AL technique (AL group). There were a 100% success rate (35/35) for cannulation in the USG group and a 91.4% success rate (32/35) in the AL group. The catheter was placed on the first attempt in 17 (48.6%) patients in the AL group and 32 (91.4%) patients in the USG group. In th AL group, there were three failed cannulation attempts in comparison to the USG group. The mean start to flash time for the AL technique was 16.59 s (±10.67) and 4.86 s (±2.18) in the USG group. The mean cannulation time was 305.88 s (±66.84) in the AL group and 293.03 s (±71.15) in the USG group. A total of seven acute complications were noted, of which 2 (5.7%) in the USG group and 5 (14.3%) in the AL group. CONCLUSION: The real-time USG guided technique significantly reduces the number of attempts to cannulate, has a higher first-pass success rate, a quicker flash time, and fewer complications when compared to the AL technique. In EDs equipped with USG, insertion of IJV catheters under real-time USG guidance should become the standard of care.

Utility of Point-of-Care Lung Ultrasound for Initial Assessment of Acute Respiratory Distress Syndrome Patients in the Emergency Department.

AIM: Lung ultrasound (LUS) has been extensively used in the evaluation of acute respiratory distress syndrome (ARDS) in the critical care setting. In our study, we aim to assess the utility of point-of-care ultrasound (POCUS)-LUS in the initial assessment of ARDS patients presenting to the emergency department (ED). SUBJECTS AND METHODS: We evaluated a prospective convenience sample of 73 adult patients presenting to the ED. The bedside LUS was performed by the trained emergency physician on patients with undifferentiated dyspnea with a clinical diagnosis of ARDS according to the Berlin's criteria. The four major LUS findings were examined on structured 12-zone LUS. The observed profile consisted of A lines, well-separated B lines, coalescent B lines, and consolidation among patients who were clinically diagnosed as ARDS. These LUS findings may vary depending on the severity of ARDS. The findings were analyzed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY, USA). RESULTS: Of the 73 study individuals, majority were male 46 (63%). The distributions of study individuals were as follows: 27% - mild ARDS, 37% - moderate ARDS, and 36% - severe ARDS. Coalescent B lines are present in about 70.4% and 92.3% of moderate and severe ARDS patients, respectively. Consolidations are predominantly present in moderate (100%) and severe (92.3%) ARDS. CONCLUSION: LUS in the initial assessment of patients' with ARDS yielded significant findings in the three clinically designated categories. This study opens up the possibility of using POCUS as an adjunct in the initial assessment of ARDS patient in the ED.

Utility of Clot Waveform Analysis in Russell's Viper Bite Victims with Hematotoxicity.

INTRODUCTION: In Russell's viper bites, due to the lack of a better alternative, whole blood clotting test (WBCT) remains the standard test even though its reliability and sensitivity has been shown to be low. Activated partial thromboplastin time (aPTT)-based clot waveform analysis (CWA) is an optic absorbance assay that can be used as a global clotting test. In this study, the objective was to assess the changes in CWA and to compare CWA to WBCT and aPTT in patients with Russell's viper envenomation. METHODS: The datum was collected prospectively over 2 months as a pilot observational study in a tertiary care center. All proven cases of Russell's viper-envenomated individuals with preliminary CWA data and WBCT were included in the study. The clot wave (CW) of the five individuals, which met all the stringent inclusion criteria, was analyzed and interpreted. RESULTS: CW absorbance sigmoid waveform was deranged in all 5 cases, of which 4 showed a change in CWA even before an abnormal aPTT. Three of the 5 had a normal WBCT but showed early changes in CWA. Atypical biphasic waveform reported in disseminated intravascular coagulation in other prior studies is seen in venom-induced consumptive coagulopathy also. In all patients where a second derivative was plotted, the second (lower) phase of the second derivative showed a slow rise to baseline. CONCLUSION: CWA showed changes which provided information earlier than the conventional coagulation studies in the snakebite victims studied. While aPTT or WBCT reflects clotting time, CWA conveys the dynamic process of clot formation and stabilization. CWA may reveal disorders of clotting in snakebite victims before the conventional tests become abnormal. Future research should assess the speed and accuracy of the test in diagnosing hemotoxic envenomation and its potential role in guiding antivenom therapy.

Factors Affecting Early Treatment Goals of Sepsis Patients Presenting to the Emergency Department.

BACKGROUND AND OBJECTIVES: Sepsis is a major cause of emergency medicine admission. It is associated with high mortality and morbidity. Even though sepsis is common in the Indian subcontinent, there is a paucity of data on the management of sepsis in India. The aim was to study the factors affecting early treatment goals. METHODS: All clinically suspected sepsis patients consenting to be part of the study were included. The diagnosis of sepsis was made by the treating physician in the emergency department as per the Surviving Sepsis Guidelines criteria. All cases were managed as per institutional treatment protocol. The patients were prospectively followed up and the time taken to achieve the goal-directed sepsis bundle documented and analyzed. RESULTS AND DISCUSSION: Of the 75 patients studied, the 3-hour(h) bundles were achieved in 70.7% of cases and 6-h bundles were achieved in 84% of cases. Meantime for obtaining blood culture was 107 min and administration of first dose antibiotics was 134 min. Thirty patients failed to achieve the early treatment goals, of which six were under-triaged, seven due to physicians delay in recognizing sepsis, 11 due to logistical delay, and six were due to financial constraints. CONCLUSION: The sepsis bundle goals were not achieved because of various factors such as under triaging, delay in diagnosis, logistical delay, and financial constraints. Further studies on whether sensitization of medical fraternity about sepsis, implementation of insurance policies for patient care or better point of care diagnostics would aid in achieving the bundles may be evaluated further.

Reliability of Ultrasonography in Confirming Endotracheal Tube Placement in an Emergency Setting.

BACKGROUND AND OBJECTIVES: Over the past few years, ultrasonography is increasingly being used to confirm the correct placement of endotracheal tube (ETT). In our study, we aimed to compare it with the traditional clinical methods and the gold standard quantitative waveform capnography. Two primary outcomes were measured in our study. First was the sensitivity and specificity of ultrasonography against the other two methods to confirm endotracheal intubation. The second primary outcome assessed was the time taken for each method to confirm tube placement in an emergency setting. METHODS: This is a single-centered, prospective cohort study conducted in an emergency department of a tertiary care hospital. We included 100 patients with indication of emergency intubation by convenient sampling. The intubation was performed as per standard hospital protocol. As part of the study protocol, ultrasonography was used to identify ETT placement simultaneously with the intubation procedure along with quantitative waveform capnography (end-tidal carbon dioxide) and clinical methods. Confirmation of tube placement and time taken for the same were noted by three separate health-care staffs. RESULTS AND DISCUSSION: Out of the 100 intubation attempts, five (5%) had esophageal intubations. The sensitivity and specificity of diagnosis using ultrasonography were 97.89% and 100%, respectively. This was statistically comparable with the other two modalities. The time taken to confirm tube placement with ultrasonography was 8.27 ± 1.54 s compared to waveform capnography and clinical methods which were 18.06 ± 2.58 and 20.72 ± 3.21 s, respectively. The time taken by ultrasonography was significantly less. CONCLUSIONS: Ultrasonography confirmed tube placement with comparable sensitivity and specificity to quantitative waveform capnography and clinical methods. But then, it yielded results considerably faster than the other two modalities.

The need for a population-based, dose optimization study for recombinant tissue plasminogen activator in acute ischemic stroke: A study from a tertiary care teaching hospital from South India.

CONTEXT: The guideline recommended dose of intravenous (i.v) recombinant tissue-type plasminogen activator (rt-PA) for acute ischemic stroke is 0.9 mg/kg in the European and American populations. In Asiatic population, some studies have shown that a lower dose of i.v rt-PA is equally efficacious. AIMS: To assess if there is a need for a dose optimization for i.v rt-PA study among Indians. SETTING AND DESIGN: A prospective, observational database of acute stroke cases that presented to a tertiary care institute over a period of 1 year was made. METHODS: The data procured using a prestructured elaborate pro forma. Based on the dose of rt-PA received, the individuals were divided into three groups; Group 1 (0.6-0.7 mg/kg), Group 2 (0.7-0.8 mg/kg), and Group 3 (0.8-0.9 mg/kg). Improvement was assessed in each group and between the thrombolysed and nonthrombolysed individuals. STATISTICAL ANALYSIS USED: The nonparametric Mann-Whitney U-test (Wilcoxon rank-sum test) was applied for assessing improvement of National Institutes of Health Stroke Scale score with significance level of α < 0.05 (P < 0.012) and compliance level at 95%. RESULTS: Between the thrombolysed (n = 46) and nonthrombolysed (n = 113) group, there was a statistically significant neurological improvement in the thrombolysed group. Clinical improvement was noted in 75%, 85.7%, and 66.7% of individuals receiving rt-PA in Groups 1, 2, and 3, respectively. Four out of the five who developed a clinically significant intracranial hemorrhage were thrombolysed at a dose of 0.8-0.9 mg/kg rt-PA (Group 3). CONCLUSION: There is a need for a properly randomized, dose optimization study of i.v rt-PA in the Indian subcontinent.

Factors delaying management of acute stroke: An Indian scenario.

BACKGROUND AND PURPOSE: The purpose of this study was to assess factors causing delay in treatment of acute stroke in a tertiary care institute in South India. METHODS: All clinically suspected cases of acute stroke presenting to the emergency department over a period of 1 year were prospectively followed up and data collected as per a preset pro forma. The various time intervals from stroke onset to definitive management and other pertinent data were collected. The time delays have been evaluated in the decision tree model: Chi-squared Automatic Interaction Detection. Significance was assessed at 5% level of significance (P < 0.05). RESULTS: The mean prehospital time delay for all clinically suspected stroke (n = 361) in our institute was 716 min and the median time 190 min. The mean total in-hospital delay was 94.17 ± 54.5 min and median time being 82 min. The onset of symptoms to first medical contact was the main interval that influenced the prehospital delay. Computed tomographic (CT) diagnosis to stroke unit admission influenced the in-hospital delay the most. CONCLUSIONS: Lack of awareness regarding stroke leads to delayed seeking of treatment for the same. The factors that contribute to the in-hospital delay included patient admission procedure delay, lack of staff to transport the patient, and the distance between the stroke unit and CT room. Educating the community with regard to "stroke" and implementation of a better pre- and in-hospital stroke care system is a need of the hour in the country.

Cleistanthus collinus poisoning: case reports and review of the literature.

We report the cases of two previously healthy young patients who ingested the liquid extracted from the crushed leaves of Cleistanthus collinus (Family: Euphorbiaceae) in an attempt to commit suicide. Both patients developed life threatening complications such as hypokalemia, hypotension, cardiac arrhythmias, neuromuscular weakness, respiratory failure, and renal failure following a transient quiescent period of up to 4 days. Other significant findings noted include leucocytosis, coagulopathy, elevated liver enzymes, hyperchloremic metabolic acidosis, and an alkaline urinary pH. Both patients received supportive care as no specific antidote was available, and ultimately died. We have reviewed the published literature on C. collinus poisoning.