Feasibility of USG-Guided Objective Initial Assessment of Pupillary Size and Pupillary Reflexes Versus Clinical Examination in Patients With Altered Mental Status: A Cross-Sectional Study.

BACKGROUND: Pupillary assessment is an important part of the neurological assessment which provides vital information in critically ill patients. However, clinical pupillary assessment is subjective. The ultrasound-guided pupillary examination is objective. There are limited pieces of literature regarding its use in assessing patients with altered mental status. So, we studied the extent of agreement of B-mode ultrasound with clinical examination for assessment of the pupillary size and reflex in patients with altered mental status. OBJECTIVES: The primary objective was to determine the extent of agreement between clinical examination and ultrasound-based examination for assessing pupillary reflex and size in patients with altered mental status in two settings (trauma and non-trauma patients). METHODS: Exactly 200 subjects (158 males, mean [range] age 43.56 [18-92 years]) with no history of partial globe rupture or dementia were included in this cross-sectional study from March 2019 to March 2020. B-mode ultrasound was performed with the subject's eyes closed using a 7-12 MHz linear probe and a standardized light stimulus. ICC score, paired t-test, kappa, Wilcoxon signed-rank test, and Bland-Altman plots were used for statistical analysis. RESULTS: The clinical-USG agreement for pupillary light reflex examination (Pupillary Diameter [PD] at rest, after direct light stimulation [Dstim ] and consensual light stimulation [Cstim ]) was excellent (ICC, 0.93-0.96). The Kappa coefficient (0.74 ± 0.07) showed an agreement of 87.36% between clinical and USG examination for pupillary reflex (reactive or non-reactive). CONCLUSION: USG-guided pupillary examination proves to be a better adjunct to neurological assessment in patients with altered mental status.

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.

Sensitivity and specificity of waterbath ultrasound technique in comparison to the conventional methods in diagnosing extremity fractures.

INTRODUCTION: Point of care ultrasound (POCUS) has variable diagnostic accuracy in diagnosing fractures. Waterbath technique is a modification of the conventional ultrasound technique which may improve diagnostic accuracy by enhancing image quality. Authors studied the diagnostic accuracy of waterbath technique compared to the final diagnosis based on clinical examination and radiology in the identification of fractures of hand and foot. METHODS: Patients of >18 yrs. age with suspected distal hand and foot fractures presenting to the emergency department of a level 1 trauma center were recruited after informed consent. Unconscious and hemodynamically unstable patients, injuries >72 h old, open fractures, obvious deformities, and old fractures at the affected site were excluded. Cases were subjected to waterbath technique performed by an academic emergency medicine resident and relevant radiographs were ordered and interpreted by an orthopedic specialist. CT/MRI, if done in case of discrepancy, was interpreted by radiologist. The findings of both waterbath technique and radiology were blinded to each other and compared to the final diagnosis made by a cumulative assessment of clinical examination, radiographs, and CT/MRI of the discrepant cases. RESULTS: Waterbath technique identified fractures of hand and foot with sensitivity of 97% (95% CI 90%-100%), specificity 94% (95%CI 81%-99%), PPV 98% (95%CI 91%-99%), NPV 94% (95%CI 79%-98%), LR+ 17.5(95% CI 4.5-67.2), LR- 0.03(95% CI 0.01-0.12) and diagnostic accuracy 96% (95%CI 91%-99%). CONCLUSION: This pilot study has demonstrated the utility of Waterbath technique in the diagnosis of fractures of hand and foot in adults in the ED setting. Future well designed studies are required to explore the potential of this novel technique in both adult and pediatric population.

Indigenously Developed Ultrasound Phantom Model versus a Commercially Available Training Model: Randomized Double-blinded Study to Assess Its Utility to Teach Ultrasound Guided Vascular Access in a Controlled Setting.

Background: The commercially available training phantoms being expensive, homemade models are popular surrogates for training. We intended to study how comparable our indigenously developed ultrasound phantom (IDUP) was with the commercially available model for ultrasound-guided vascular access (USGVA) training. We also assessed the change in confidence among trainees using a 21-h standardized program. Methods: A prospective randomized double-blinded, parallel design study, with sequential allocation, was done after a standardized point of care ultrasound training course. Over three consecutive courses, 48 trainees volunteered to take part in the study. The models (IDUP and commercial phantom) were allocated as model A and model B. In each course, participants were also allotted sequentially to either perform in-plane or out of plane approach first, at the testing stations. Wilcoxon signed-rank test was used to compare pretest with posttest scores. Results: There was a statistically significant difference between IDUP and commercial phantom with respect to the resemblance to human tissue on tactile feedback and ease to perform the procedure. However, both models did not show a statistically significant difference in terms of ease of use, visual resemblance to human tissue, needle visualization, and artifacts on ultrasonography display. A significant change in the confidence levels of participants was seen postcourse. Conclusion: IDUP was a comparable alternative to the commercial model for USGVA training in a resource-limited setting. A 21-h standardized training program improved the trainee's confidence in performing and teaching USGVA.

Lung sonographic findings in COVID-19 patients.

OBJECTIVE: The objective of this study was to describe the lung sonographic findings of COVID-19 patients prospectively and investigate its association with disease severity. METHODS: This study was conducted in an emergency department and included consecutively enrolled laboratory confirmed COVID-19 patients. Lung sonography findings were described in all the included patients and analysed with respect to the clinical severity of the patients. RESULTS: 106 patients were included in the study. Common sonographic findings in COVID-19 patients were pleural line irregularity or shredding (70% of patients), followed by B - profile (59%), pleural line thickening (33%), occasional B - lines (26%), sub-pleural consolidations (35%), deep consolidations (6%), spared areas (13%), confluent B - lines or waterfall sign (14%) and pleural effusion (9%). These findings tended to be present more bilaterally and in lower lung zones. Sonographic characteristics like bilateral lung involvement, B - profile, spared areas and confluent B - lines or waterfall sign were significantly associated (p < 0.01) with clinical severity (more frequent with increasing disease severity). CONCLUSION: The lung sonographic findings of COVID-19 were found more bilaterally and in lower lung zones, and specific findings like B - profile, pleural thickening, spared areas and confluent B - lines or waterfall sign were associated with severe COVID-19.

Endotracheal Tube Placement Confirmation by Ultrasonography: A Systematic Review and Meta-Analysis of more than 2500 Patients.

BACKGROUND: The integration of point-of-care ultrasound in endotracheal tube placement confirmation has been focus of many recent studies. OBJECTIVES: We sought to determine the diagnostic accuracy of ultrasonography in confirmation of endotracheal intubation compared with standard confirmatory methods. METHODS: We completed an extensive search of PubMed, EMBASE, Cochrane Central, Web of Science, and bibliographies of the selected articles from inception to October 2019. The search was limited to prospective studies conducted in human adults that compared the accuracy of ultrasonography in confirming the endotracheal tube position with a reference standard. The methodologic quality of studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. A bivariate random-effects model summarized diagnostic accuracy statistics. Subgroup analyses by ultrasonographic signs, study location, the operator's specialty, types of transducer, the technique of ultrasound confirmation, and clinical setting (cardiac arrest vs. non-cardiac arrest) were performed. RESULTS: Thirty studies involving 2534 patients were selected for this meta-analysis. The estimated pooled sensitivity and specificity for ultrasonography were 0.982 (95% confidence interval [CI] 0.971-0.988) and 0.957 (95% CI 0.901-0.982), respectively. Subgroup analyses did not reveal significant difference by ultrasonographic sign used, location, the sonographer's specialty, transducer type, or ultrasound technique used. Ultrasound was also found to be a useful adjunct in confirming endotracheal tube position in the subgroup of patients with cardiac arrest, with sensitivity of 0.99 (95% CI 0.98-1.00) and specificity of 0.84 (95% CI 0.67-1.00), respectively. CONCLUSIONS: Ultrasonography is a valuable and reliable adjunct for endotracheal tube confirmation, including during cardiac arrest resuscitation.

Gender-based Assessment of Survival in Trauma-hemorrhagic Shock: A Retrospective Analysis of Indian Population.

INTRODUCTION: Trauma-hemorrhagic shock (THS) is a leading cause of death. Female rats and women experience better outcomes in terms of survival after major trauma as compared to males. There are limited data in Indian population. Authors studied the gender-based outcome of patients with Class IV hemorrhagic shock due to blunt trauma and the distribution of factors among males and females which are known to affect outcome. MATERIALS AND METHODS: It was a retrospective study with data of trauma victims between January 2008 and July 2013. Road traffic crash (RTC), fall, or assault of all ages with Class IV hemorrhagic shock on arrival was included in the study, and data were collected on demographic, clinical, and laboratory parameters. Drowning, burns, penetrating injuries, and septic, neurogenic, and cardiogenic shock were excluded from the study. RESULTS: Seven hundred and eighty-one patients were analyzed under three groups: (i) overall group including all patients (n = 781), (ii) male group (n = 609), and (iii) female group (n = 172). After adjusting all variables, mortality was significantly lower in females as compared to males following THS (P < 0.05). Age, blood pressure, pulse, male gender, and fall and RTC as mode of injury (MOI) were independent predictors of mortality (P < 0.05) in overall group. Among males, age, pulse, and RTC as a MOI were significant (P < 0.05), while in females, only systolic blood pressure (SBP) was independent predictor of mortality. CONCLUSION: Females had better survival as compared to males following THS. SBP was an independent predictor of mortality in females with THS.

Epidemiology of traumatic cardiac arrest in patients presenting to emergency department at a level 1 trauma center.

INTRODUCTION: There is a paucity of literature on prehospital care and epidemiology of traumatic cardiac arrest (TCA) in India. This study highlights the profile and characteristics of TCA. METHODS: A retrospective cohort study was conducted to study epidemiological profile of TCA patients ≥1 year presenting to a level 1 trauma center of India. RESULTS: One thousand sixty-one patients were recruited in the study. The median age (interquartile range) was 32 (23-45) years (male:female ratio of 5.9:1). Asystole (253), pulseless electrical activity (11), ventricular fibrillation (six), and ventricular tachycardia (five) were initial arrest rhythm. Road traffic crash (RTC) (57.16%), fall from height (18.52%), and assault (10.51%) were modes of injury. Prehospital care was provided by police (36.59%), ambulance (10.54%), relatives (45.40%), and bystanders (7.47% cases). Return of spontaneous circulation was seen in 69 patients, of which only three survived to hospital discharge. CONCLUSION: RTC in young males was a major cause of TCA. Asystole was the most common arrest rhythm. Police personnel were major prehospital service provider. Prehospital care needs improvement including the development of robust TCA registry.

Role of initial cardiac activity assessed by point-of-care ultrasonography in predicting cardiac arrest outcomes: A prospective cohort study.

OBJECTIVES: This study was conducted to investigate the association between visible cardiac activity in point-of-care ultrasound (POCUS) and outcomes of cardiac arrest such as the return of spontaneous circulation (ROSC), survival to inpatient admission (SIA), and survival to hospital discharge (STHD). METHODS: This was a single-center, prospective cohort study conducted in the emergency department (ED). Adult (age >18 years) patients in cardiac arrest were included in the study. Exclusion criteria of the study were - traumatic arrest, out-of-hospital cardiac arrest resuscitated before ED admission, and patients presenting with initial shockable rhythm. Patients whose ultrasound images could not be obtained and whose resuscitation stopped following POCUS were also excluded from the study. POCUS examination was done after 2 min of initiation of cardiopulmonary resuscitation (CPR) and visible cardiac activity was defined as any visible movement of the myocardium, excluding movement of blood within cardiac chambers, or isolated valve movement. The duration of POCUS examinations was limited to 10 s. The association of initial cardiac activity in POCUS with the outcomes of cardiac arrest was investigated. RESULTS: Out of 140 patients screened, 84 patients were included in the study. Rates of ROSC, SIA, and STHD were found in 23 (27.4%), 9 (10.7%), and 2 (2.4%) patients, respectively. Only 15 out of 84 (17.9%) patients had cardiac activity on the initial POCUS examination. Cardiac activity was seen in 52.2% of patients with ROSC, which was significantly higher (P < 0.001) as compared with the no-ROSC group (4.9%). Unlike the above association, there was no difference in the incidence of initial cardiac activity in patient groups who got admitted (SIA) and discharged (STHD) versus those who died. In the multivariate regression analysis, the duration of CPR and initial cardiac activity significantly predicted the rate of ROSC, with an adjusted odds ratio of 0.93 (95% confidence interval [CI]: 0.86-0.99, P = 0.04) and 24.8 (95% CI: 3.17-89.41, P = 0.002), respectively. None of the variables predicted SIA and STHD. The positive likelihood ratio of cardiac activity for predicting ROSC, SIA, and STHD were 10.6, 2.1, and 2.9, respectively. CONCLUSION: Integration of POCUS in cardiac arrest resuscitation was shown to be helpful in terms of prognostic significance of the presence of initial cardiac activity in terms of ROSC.

Removing Barriers to Emergency Medicine Point-of-Care Ultrasound: Illustrated by a Roadmap for Emergency Medicine Point-of-Care Ultrasound Expansion in India.

Point-of-care ultrasound (PoCUS) has a potentially vital role to play in emergency medicine (EM), whether it be in high-, medium-, or low-resourced settings. However, numerous barriers are present which impede EM PoCUS implementation nationally and globally: (i) lack of a national practice guideline or scope of practice for EM PoCUS, (ii) resistance from non-PoCUS users of ultrasound imaging (USI) and lack of awareness from those who undertake parallel or post-EM patient care, and (iii) heterogeneous pattern of resources available in different institutes and settings. When combined with the Indian Preconception and Prenatal Diagnostic Techniques (PCPNDT) Act, this has led to the majority of India's 1.4 billion citizens being unable to access EM PoCUS. In order to address these barriers (globally as well as with specific application to India), this article outlines the three core principles of EM PoCUS: (i) the remit of the EM PoCUS USI must be well defined a priori, (ii) the standard of EM PoCUS USI must be the same as that of non-PoCUS users of USI, and (iii) the imaging performed should align with subsequent clinical decision-making and resource availability. These principles are contextualized using an integrated PoCUS framework approach which is designed to provide a robust foundation for consolidation and expansion across different PoCUS specialisms and health-care settings. Thus, a range of mechanisms (from optimization of clinical practice through to PoCUS educational reform) are presented to address such barriers. For India, these are combined with specific mechanisms to address the PCPNDT Act, to provide the basis for influencing national legislation and instigating an addendum to the Act. By mapping to the recent Lancet Commission publication on transforming access to diagnostics, this provides a global and cross-discipline perspective for the recommendations.

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.

Point-of-care ultrasonography-assisted nasogastric tube placement in the emergency department: a randomized controlled trial.

BACKGROUND: The complications of a blind procedure for gastric tube placement are well documented. POCUS has been widely used to confirm the position of blindly inserted gastric tubes, and it does not prevent complications caused by the blind method. We performed a randomized controlled trial to compare gastric tube insertion with real-time oesophagus visualization using POCUS to the standard technique. OBJECTIVE: The primary goal of this study was to compare the accuracy of real-time POCUS-guided nasogastric tube (NGT) insertion and confirmation to that of the standard technique. METHODS: It was a prospective, parallel-group, open-label randomized controlled trial with a superiority design. All patients requiring NGT were screened for inclusion and exclusion criteria, and 120 patients were randomly assigned to one of two groups: POCUS ( n = 60) or control ( n = 60). Following the procedures, confirmatory chest radiographs were obtained in both groups. RESULTS: As per protocol, 118 patients were analyzed. In POCUS group, the oesophagus was visualized on POCUS in 56 of 58 patients (96.5%). In 55 of 58 cases (94.8%), an NGT was inserted in real time. Despite visualizing the oesophagus, we fail to insert the tube in one (1.8%). The oesophagus could not be seen on the scan in two cases (3.4%). Chest radiographs confirmed the tube in the stomach in 55 (98.2%). The chest radiograph revealed the tip of the NGT in the stomach in 52 of 60 (86.6%) patients. In seven cases (11.7%), we were unable to insert NGT. On a chest radiograph, one (1.6%) tip of the tube was seen in the right lung and was safely removed. The ultrasound-guided gastric tube insertion had a sensitivity of 96.5% (95% CI, 88-99.6%) and a positive predictive value (PPV) of 98.2% (95% CI, 98.1-98.3%). The conventional technique had 88% (95% CI, 77-95%) sensitivity and a PPV of 98% (95% CI, 97.9-98.2%). CONCLUSION: POCUS enables real-time insertion of a gastric tube with high sensitivity, in a short time with high first-attempt success rate and limited passage-related complications. POCUS should be utilized for NGT insertion whenever expertise is available on the bedside.

ALTERATION OF AKT1-GSK3Β SIGNALING PATHWAY IN TRAUMA HEMORRHAGIC SHOCK PATIENTS.

ABSTRACT: Trauma hemorrhagic shock (THS) is a major cause of death and disability worldwide. It is the leading cause of death with or without sepsis in approximately 50% of patients. In THS, there is an incidence of cellular apoptosis, which contributes majorly to cellular dysfunction, organ failure, and mortality. The Akt (protein kinase B) isoform, Akt1, and glycogen synthase kinase 3ß (Akt1-GSK3ß) signaling pathway controls cell survival and apoptosis. Deleterious consequences of alteration of this signaling system might lead to inflammation, cytokine storm, and other diseases. Hence, in the present study, we investigated the role of this signaling system by measuring the phosphorylation levels of Akt1-GSK3ß. Here, we demonstrated that the downregulation of pAkt1 and upregulation of pGSK3ß in THS were significantly associated with the severity of the shock, apoptosis of immune cells, altered glucose metabolism, inflammation, cytokine storm, hemostasis, and acidosis, causing mortality with or without sepsis. For the first time, this study shows that a dysregulated pAkt1-GSK3ß pathway causes contrasting cell fates in THS, leading to trauma pathology. Hence, the delineation and the implications of this signaling system may provide a new important target for the treatment of THS. In addition, Akt activation may become a potential strategy for increasing the survival rate following THS.

The Emergency Medicine Education and Research by Global Experts (EMERGE) Network: Challenges and Lessons Learned.

INTRODUCTION: The Emergency Medicine Education and Research by Global Experts (EMERGE) network was formed to generate and translate evidence to improve global emergency care. We share the challenges faced and lessons learned in establishing a global research network. METHODS: We describe the challenges encountered when EMERGE proposed the development of a global emergency department (ED) visit registry. The proposed registry was to be a six-month, retrospective, deidentified, minimal dataset of routinely collected variables, such as patient demographics, diagnosis, and disposition. RESULTS: Obtaining reliable, accurate, and pertinent data from participating EDs is challenging in a global context. Barriers experienced ranged from variable taxonomies, need for language translation, varying site processes for curation and transfer of deidentified data, navigating institution- and country-specific data protection regulations, and substantial variation in each participating institution's research infrastructure including training in research-related activities. We have overcome many of these challenges by creating detailed data-sharing agreements with bilateral regulatory oversight agreements between EMERGE and participating EDs, developing relationships with and training health informaticians at each site to ensure secure transfer of deidentified data, and formalizing an electronic transfer process ensuring data privacy. CONCLUSION: We believe that networks like EMERGE are integral to providing the necessary platforms for education, training, and research collaborations for emergency care. We identified substantial challenges in data sharing and variation in local sites' research infrastructure and propose potential approaches to address these challenges.