Rapid Thrombolysis Protocol: Results from a Before-and-after Study.

Objective: Intravenous thrombolysis within 4.5 hours from time of onset has proven benefit in stroke. Universal standard for the door-to-needle (DTN) time is within 60 minutes from the time of arrival of patients to the emergency department. Our rapid thrombolysis protocol (RTPr) was developed with an aim to reduce the DTN time to a minimum by modifying our stroke post-intervention processes. Materials and methods: This before-and-after study was conducted at a single center on patients who received intravenous thrombolysis in the emergency department. Consecutive patients who were thrombolysed using our RTPr (post-intervention group) were compared to the pre-intervention group who were thrombolysed before the implementation of the protocol. The primary outcomes were DTN time, time to recovery, and modified ranking score (mRS) on discharge. Secondary outcomes were mortality, symptomatic intracerebral hemorrhage, and hospital and intensive care unit length of stay. Results: Seventy-four patients were enrolled in each group. Mean DTN time in pre- and post-intervention group was 56.15 minutes (95% CI 49.98-62.31) and 34.91 minutes (95% CI 29.64-40.17) (p <0.001), respectively. In pre-intervention and post-intervention groups, 43.24% (95% CI 32.57-54.59) and 41.89% (95% CI 31.32-53.26) patients, respectively, showed neurological recovery in 24 hours. About 36.49% (95% CI 26.44-47.87) in pre-intervention group and 54.05% (95% CI 42.78-64.93) in post-intervention group had discharge mRS 0-2. Conclusion: The RTPr can be adapted by clinicians and hospitals to bring down the DTN times and improve outcomes for stroke patients. How to cite this article: Verma A, Sarda S, Jaiswal S, Batra A, Haldar M, Sheikh WR, et al. Rapid Thrombolysis Protocol: Results from a Before-and-after Study. Indian J Crit Care Med 2022;26(5):549-554.

Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality.

OBJECTIVES: Emergency department (ED) length of stay (LOS) is defined as the time a patient is registered to the time the patient is shifted to a hospital bed or discharged. Increasing demand for quality emergency care has resulted in increased wait times due to demand and supply mismatch. It is perceived that longer LOS in the ED of critical patients leads to poor outcomes. Our goal was to study the impact of LOS in the ED on the patients who required critical care admissions. METHODS: This was a retrospective study conducted in the ED of a tertiary center. Data were collected using electronic health records (EHR) for patients admitted to the intensive care units (ICUs). Patient's LOS in ED was divided into 0-4, 4-8, 8-12, 12-24, and >24 hours. ED LOS was calculated from the registration time to the time patient was handed over in the ICU. Patients were divided into four categories (1-4) based on their criticality. LOS in ED, mortality, and total hospital LOS were analyzed in the study. RESULTS: Three thousand four hundred and twenty-nine patients were enrolled in the study. Mean age was 62.69 years (95% CI 62.11-63.26). A total of 42.09% (95% CI 40.5-43.8) were Category 1 patients. Overall mortality rate was 52.46% (95% CI 50.79-54.13). LOS of 48.15% (95% CI 46.54-49.88) patients in the ED was between 0 and 4 hours, 19.90% (95% CI 18.62-21.29) between 4 and 8 hours, 8.21% (95% CI 7.35-9.19) between 8 and 12 hours, 15.50% (95% CI 14.34-16.77) between 12 and 24 hours, and 8.13% (95% CI 7.27-9.10) >24 hours. Mortality for LOS of 0-4 hours was 51.30% (95% CI 48.89-53.70), 54.03% (95% CI 50.28-57.73) for 4-8 hours, 48.94% (95% CI 43.16-54.75) for 8-12 hours, 51.50% (95% CI 47.26-55.72) for 12-24 hours, and 60.57% (95% CI 54.73-66.13) for >24 hours. CONCLUSION: We concluded that the longer the critically ill patients are boarded in the ED, the higher is the chance for mortality. Processes should be implemented to ease the throughput from the ED. HOW TO CITE THIS ARTICLE: Verma A, Shishodia S, Jaiswal S, Sheikh WR, Haldar M, Vishen A, et al. Increased Length of Stay of Critically Ill Patients in the Emergency Department Associated with Higher In-hospital Mortality. Indian J Crit Care Med 2021;25(11):1221-1225.

Interrater Reliability of Four Neurological Scales for Patients Presenting to the Emergency Department.

BACKGROUND: Altered mental status (AMS) comprises a group of clinical symptoms rather than a specific diagnosis. A variety of neurological scales have been used to monitor these patients, including the Glasgow coma scale (GCS), AVPU (alert, responds to verbal stimuli, responds to painful stimuli, unresponsive) scale, and ACDU (alert, confused, drowsy, unresponsive) scale. The simplified motor scale (SMS) has been found to be a potential replacement for the GCS. In this study, we compare the interrater reliability of the GCS (individual components), AVPU, ACDU, and SMS to patients presenting to the ED with AMS. MATERIALS AND METHODS: This was a prospective observational study conducted in the emergency department of an urban tertiary-care hospital in New Delhi, India. Patients with AMS (traumatic and nontraumatic) presenting to the ED were assessed by two emergency physicians within 10 minutes of each other using the four neurological scales. Percentage agreement and kappa coefficient score were used to determine interrater reliability for SMS, individual components of GCS, AVPU, and ACDU. RESULTS: The SMS had the best inter-rater percent agreement with 83.91% (95% CI 77.7-88.6%), followed by ACDU which was 76.44% (95% CI 69.0-81.6%), AVPU 75.29% (95% CI 67.8-80.6%), GCS Eye 74.14% (95% CI 66.6-79.6%), GCS Verbal 67.82% (95% CI 60.6-74.3%), and GCS Motor was 64.94% (95% CI 57.6-71.6%).The kappa coefficient for SMS was 0.75 (95% CI 0.67-0.83), followed by GCS Eye which was 0.63 (95% CI 0.54-0.72), AVPU 0.62 (95% CI 0.52-0.72), ACDU 0.60 (95% CI 0.49-0.71), and GCS Verbal 0.58 (0.49-0.66) and GCS Motor was 0.53 (95% CI 0.44-0.63). CONCLUSION: It can be said that SMS has the best interrater reliability in the ED and can be recommended for clinical use in the emergency departments for patients presenting with AMS. HOW TO CITE THIS ARTICLE: Haldar M, Verma A, Jaiswal S, Sheikh WR. Interrater Reliability of Four Neurological Scales for Patients Presenting to the Emergency Department. Indian J Crit Care Med 2020;24(12):1198-1200.

Reply to in Response to Guidewire Entrapped in the Right Ventricle.

How to cite this article: Verma A, Jaiswal S, Vishen A, Sheikh WR, Haldar M, Ahuja R, et al. Reply to in Response to Guidewire Entrapped in the Right Ventricle. Indian J Crit Care Med 2020;24(7):608.

Guidewire Entrapped in the Right Ventricle: A Rare Complication of Hemodialysis Catheter Insertion.

How to cite this article: Verma A, Chitransh V, Jaiswal S, Vishen A, Sheikh WR, Haldar M, et al. Guidewire Entrapped in the Right Ventricle: A Rare Complication of Hemodialysis Catheter Insertion. Indian J Crit Care Med 2020;24(1):80-81.

Ketamine Use allows Noninvasive Ventilation in Distressed Patients with Acute Decompensated Heart Failure.

Acute decompensated heart failure (ADHF) is responsible for a heavy clinical load on busy emergency departments (EDs) across the globe and especially in India. ADHF patients may present with severe respiratory distress, dyspnea, hypoxia, and high and low blood pressures. Managing the airway of such patients can at times be challenging. Nasal cannulae, face mask, and noninvasive positive pressure ventilation (NIPPV) are the cornerstones of providing oxygenation and ventilation to such patients while some extreme cases may require endotracheal intubation and mechanical ventilation. An elderly female in severe respiratory distress and altered sensorium presented to our ED and had to be administered ketamine to facilitate proper NIPPV and avoid mechanical ventilation. She was weaned off the NIPPV in the ED itself over the next four hours. There are some case reports of using ketamine for NIPPV in asthma exacerbations, but none for the use in ADHF. Avoiding invasive mechanical ventilation via endotracheal intubation should be a constant goal and the last resort. How to cite this article: Verma A, Snehy A, et al. Ketamine Use Allows Noninvasive Ventilation in Distressed Patients with Acute Decompensated Heart Failure. Indian J Crit Care Med 2019;23(4): 191-192.

Unilateral Traumatic Adrenal Hemorrhage with Shock.

Trauma to the adrenal glands is very rare. The variation in clinical manifestations is marked and markers for its diagnosis being limited, makes it tough to be diagnosed. Computed tomography remains the gold standard for detecting this injury. Prompt recognition and the potential for mortality with adrenal insufficiency can provide the best guidance for the treatment and care of the severely injured. We present a case of a 33-year-old trauma patient who was not responding to the management of his shock. He was finally found to have a right adrenal haemorrhage leading to adrenal crisis. The patient was resuscitated in the Emergency Department but succumbed 10 days post admission.

National Early Warning Score 2 is superior to quick Sequential Organ Failure Assessment in predicting mortality in sepsis patients presenting to the emergency department in India: A prospective observational study.

Background: High in-hospital mortality in sepsis patients remains challenging for clinicians worldwide. Early recognition, prognostication, and aggressive management are essential for treating septic patients. Many scores have been formulated to guide clinicians to predict the early deterioration of such patients. Our objective was to compare predictive values of quick Sequential Organ Failure Assessment (qSOFA) and National Early Warning Score 2 (NEWS2) with respect to in-hospital mortality. Methods: This prospective observational study was conducted in a tertiary care center in India. Adults with suspected infection with at least two Systemic Inflammatory Response Syndrome criteria presenting to the emergency department (ED) were enrolled. NEWS2 and qSOFA scores were calculated, and patients were followed until their primary outcome of mortality or hospital discharge. The diagnostic accuracy of qSOFA and NEWS2 for predicting mortality was analyzed. Results: Three hundred and seventy-three patients were enrolled. Overall mortality was 35.12%. A majority of patients had LOS between 2 and 6 days (43.70%). NEWS2 had higher area under curve at 0.781 (95% confidence interval [CI] (0.59, 0.97)) than qSOFA at 0.729 (95% CI [0.51, 0.94]), with P < 0.001. Sensitivity, specificity, and diagnostic efficiency to predict mortality by NEWS2 were 83.21% (95% CI [83.17%, 83.24%]); 57.44% (95% CI [57.39%, 57.49%]); and 66.48% (95% CI [66.43%, 66.53%]), respectively. qSOFA score had sensitivity, specificity, and diagnostic efficiency to predict mortality of 77.10% (95% CI [77.06%, 77.14%]); 42.98% (95% CI [42.92%, 43.03%]); and 54.95% (95% CI [54.90%, 55.00%]), respectively. Conclusion: NEWS2 is superior to qSOFA in predicting in-hospital mortality for sepsis patients presenting to the ED in India.

Comparison of the time to successful endotracheal intubation using the Macintosh laryngoscope or KingVision video laryngoscope in the emergency department: A prospective observational study.

OBJECTIVE: Intubation is a skill that must be mastered by the emergency physician (EP). Today, we have a host of video laryngoscopes which have been developed to make intubations easier and faster. It may seem that in a busy emergency department (ED), a video laryngoscope (VL) in the hands of an EP would help him intubate patients faster compared to the traditional direct laryngoscope (DL). Our goal was to compare the time taken to successfully intubate patients coming in ED using King Vision VL (KVVL) and DL. MATERIALS AND METHODS: This was a prospective observational study on patients coming to the ED requiring emergent intubation. They were allocated one to one alternatively into two groups - KVVL and DL. Accordingly, KVVL or DL intubations were carried out by the EPs. Time taken to intubate, first-pass success, and crossover between laryngoscopes were recorded. RESULTS: A total of 350 patients were enrolled in the study. Overall, mean time to intubate patients using the DL was 15.85 s (95% confidence interval [CI] 14.05-17.65), while the meantime with KVVL was 13.75 s (95% CI 12.32-15.18) (P = 0.084). The overall first-pass success rates with DL and KVVL were 89.94% and 85.16%, respectively (P = 0.076). A total of 7.43% (95% CI 5.12-10.66) patients had crossover between laryngoscopes. CONCLUSION: We found the KVVL to have a similar performance to the DL in terms of time for intubations and ease in difficult airways. We consider the KVVL a useful device for EDs to equip themselves with.

Left ventricular pseudoaneurysm post myocardial infarction.

Left ventricular (LV) pseudoaneurysm is a rare and grave complication of acute myocardial infarction. If left undetected, it has an extremely high rate of mortality. It is complicated by a ventricular free wall rupture contained by the pericardium and is characterized by the absence of myocardial tissue in its wall. The clinical presentation of these patients is nonspecific, making the diagnosis challenging. We came across a case of LV pseudoaneurysm diagnosed by transthoracic echocardiography, but unfortunately, the patient passed away within a few hours of presentation in the emergency department. This case depicts the importance of prompt diagnosis and management of such deadly complication.