Ultrasound-guided pericapsular nerve block compared with IV opioids in hip injuries: A randomised controlled trial.

STUDY OBJECTIVES: The study aimed to compare the analgesic effect of USG-guided PENG (Peri capsular nerve group) block with Intravenous Nalbuphine hydrochloride (IVN) in patients with hip fracture coming to the emergency department (ED). The purpose was also to monitor the adverse effects and rescue analgesic requirements in both treatment modalities. METHODS: The study was an open-label randomised controlled trial (RCT) comparing PENG block versus IVN in treating patients with femoral head and neck fractures, as well as pubic rami fracture of the hip (HF). The participants in the PENG group received a USG-guided PENG block by injection of 25 ml of 0.25% bupivacaine, whereas the IVN group received 0.15 mg/kg of nalbuphine. An emergency physician with expertise in ultrasound-guided nerve blocks performed the PENG blocks. The primary outcome was to measure the improvement of the NRS (Numerical rating scale) score at 30 min in both static position (Patient-chosen position for the best comfort) and dynamic position (15-degree passive affected lower limb elevation). Secondary outcomes were to measure static and dynamic NRS pain scores at 2 h, 4 h, and 6 h after intervention in both groups. The requirement for rescue analgesia, adverse events and any block-related complications were also recorded. RESULTS: A total of 60 patients with HF were included in the final analysis. The static and dynamic NRS score was significantly lower in the PENG group compared to the IVN group at 30 min, 2 h, 4 h, and 6 h post-intervention. In the PENG group, the static NRS score was improved by 5.73 ± 1.17, while In the IVN group, the static NRS score was just improved by 2.13 ± 0.97 at 30 min. In the same duration, the Dynamic NRS score in the PENG group was improved by 6.13 ± 1.38, while In the IVN group, it improved just by 2.43 ± 1.28. Rescue analgesia was required in 50.0% of patients in the IVN group but none in the PENG group. Further, no block-related complications or adverse events were observed in the patients of the PENG group. CONCLUSION: The study provides evidence that the ultrasound-guided PENG block has a better analgesic effect and has fewer adverse events than IV opioids in patients with HF.

Comparison of McCoy, Macintosh, and Truview laryngoscope for bougie-aided naso-tracheal intubation: A randomized controlled study.

Background: Video laryngoscopes are commonly used along with Macintosh and McCoy laryngoscopes for Nasotracheal intubation (NTI). The purpose of this study was to evaluate the performance of McCoy, Macintosh, and Truview laryngoscopes during bougie-aided NTI with respect to intubation time, success rate, and hemodynamic changes during the procedure. Methods: Forty-five American Society of Anesthesiologists (ASA) I-II adult patients, with Mallampati grade 1-4, requiring NTI, were enrolled after taking written informed consent. ASA III/IV, restricted mouth opening, and body mass index >30 were excluded from the study. Patients were randomly allocated to intubate with one of the three laryngoscopes (McCoy, Macintosh, and Truview) and the anesthesiologists were well experienced with all of them. The primary outcome was intubation time and secondary outcomes included first attempt success rate, external laryngeal manipulation, Cormack-Lehane (CL) grade, and hemodynamic responses. Results: The intubation time of McCoy, Macintosh, and Truview, was 86.87 ± 15.92, 82.87 ± 16.46, and 79.93 ± 14.53 (mean ± standard deviation) seconds, respectively, which is comparable with Truview being the shortest. CL grade 1 was obtained more in the Truview group (53.3%) compared to the other two groups, while CL grade 3 was obtained in 20% each in McCoy and Macintosh groups. Conclusions: McCoy, Macintosh, and Truview laryngoscopes were comparable in performance during bougie-aided NTI, with Truview having the shortest intubation time and better visualization.

Prehospital care and interfacility transfer of trauma patients before reaching the emergency of a level-1 trauma care center.

Background: Management of trauma patients includes prevention, prehospital care, appropriate resuscitation at a hospital, definitive treatment, and rehabilitation. Timely and adequate care for a trauma patient is paramount, which can dramatically impact survival. This study was planned to assess the proportion of patients who failed to receive adequate prehospital care before reaching our institute. Materials and Methods: A retrospective study was conducted in the trauma and emergency department of a level-1 trauma center in eastern India from February to April 2022. The demographic profile, vital parameters, injury, mode of transport, travel duration, referring hospital, and any interventions as per airway/breathing/circulation/hypothermia were collected. Results: The records of a hundred-two patients who were brought to the trauma and emergency department in the study period were reviewed. Road traffic accident involving two wheelers was the leading cause of injury. Eighty-three percent of the patients were referred from other health centers, of which 49 were referred from district headquarters hospitals. Only three patients out of 14 had been provided with an oropharyngeal airway for whom endotracheal intubation was indicated. Only one among the 41 patients needing Philadelphia collar actually received. Sixteen patients were provided supplemental oxygen out of the 35 for whom it was indicated. Out of 68 patients in whom intravenous cannulation and fluid administration were indicated, only 35 patients had received it. Out of 31 patients with fractures, none were provided immobilization. Conclusion: The care of the trauma patients with respect to airway, breathing, circulation, and fracture immobilization was found to be grossly inadequate, emphasizing the need of structured and protocol based prehospital trauma care.

Granularity mediated multiple reentrances with negative magnetoresistance in disordered TiN thin films.

Granular superconductors are the common examples of experimentally accessible model systems which can be used to explore various fascinating quantum phenomena that are fundamentally important and technologically relevant. One such phenomenon is the occurrence of reentrant resistive states in granular superconductors. Here, we report the observation of multiple reentrant resistive states for a disordered TiN thin film in its temperature and magnetic field dependent resistance measurements, R(T) and R(B), respectively. At each of the peak-temperatures corresponding to the zero-field R(T), a resistance peak appears in the R(B) around zero field which leads to a negative magnetoresistance (MR) region in its surrounding. These low-field negative MR regions appear for both perpendicular and parallel field directions with relatively higher amplitude and larger width for the parallel field. By adopting a granularity-based model, we show that the superconducting fluctuations in granular superconductors may lead to the observed reentrant states and the corresponding negative MR. Here, we propose that the reduction in the density of states in the fermionic channel due to the formation of Cooper pairs leads to the reentrant resistive state and the competition between the conduction processes in the single particle and Cooper channels result into the multiple resistive reentrances.

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.

Ultrasound-guided selective peripheral nerve block compared with the sub-dissociative dose of ketamine for analgesia in patients with extremity injuries.

STUDY OBJECTIVE: To compare the analgesic efficacy of ultrasound-guided selective peripheral nerve block (PNB) and sub-dissociative dose ketamine (SDK) for management of acute pain in patients with extremity injuries presenting to the emergency department (ED). METHODS: This prospective, open-label randomized clinical trial was conducted in the ED of a tertiary care Institute. The patients were provided with either ultrasound-guided selective PNB or SDK. The primary outcome was a reduction in pain in numerical rating scale (NRS) by at least 3 points without rescue analgesia. The secondary outcomes were the need for rescue analgesia, adverse events, and patient satisfaction on either arm. RESULTS: A total of 111 patients with isolated traumatic extremity injuries were included in the final analysis. The NRS score was significantly lower in the PNB group compared to the SDK group at 30, 60,120, 180-, and 240-min post-intervention [group ∼ time interaction, F (5, 647) = 21.53, p ≤ 0.001]. All the patients in the PNB group exhibited primary outcome (NRS ≥3 reductions) at 30 min post-intervention compared with 36 (65%) in the SDK group [-1.02(-1.422,0.622)]. Rescue analgesia was required in 10 (18%) patients in the SDK group compared to none in the PNB group [0.663(0.277,1.050)]. The decrease in NRS score from baseline at 30 min was significantly higher in PNB groups compared to the SDK group [-2.166(-2.640, -1.692)]. The most common side effect reported in the SDK group was dizziness 35(64%), followed by nausea 15(27%). None of the patients in the PNB group reported any complications. Patient satisfaction was higher in the PNB group than SDK group. CONCLUSION: The study provides evidence that ultrasound-guided PNB is superior to SDK in terms of its analgesic efficacy in the management of acute pain due to extremity injuries and is associated with higher patient satisfaction. The need for rescue analgesia was significantly less in the PNB group. SDK was associated with a high incidence of dizziness and nausea.

Comparison of Ultrasound-Guided Anterior, Posterior and Combination of Quadratus Lumborum Block in Laparoscopic Abdominal Surgeries: A Pilot Study.

BACKGROUND: The quadratus lumborum block (QLB) is an effective technique to provide analgesia for upper and lower abdominal surgeries. There are various approaches described in the literature, but the best approach is still to be explored. This study aims to compare the analgesic efficacy of three different approaches of QLBs. METHODS: Sixty-five patients, aged 18-70 years posted for elective laparoscopic abdominal surgery under general anesthesia were enrolled after taking written informed consent. QLB was given using bupivacaine 0.25% 40 mL with injection dexmedetomidine 1 mcg/kg in all the groups. In Group 1 and Group 2, the drug was injected into the anterior and posterior aspects of the muscle respectively. In Group 3, a combination of the anterior-posterior approach was used. Pain scores at various intervals along with analgesic consumption and complications were observed. RESULTS: The demographic variables, hemodynamic parameters, and complications were comparable among the three groups. There were statistically significant differences between treatment groups in fentanyl requirement as assessed using the Kruskal-Wallis test (P = 0.012). Pairwise post-hoc analysis between block groups showed that the differences between Group 1 & Group 2 and Group 2 & Group 3 were significant (P = 0.0098 and P = 0.013). The tramadol requirement was comparable in all the groups (P = 0.75). Patient satisfaction was significantly higher in Group 3 compared to other groups (P = 0.024). CONCLUSION: Further studies can be planned to evaluate the best approach for QLB in terms of perioperative analgesia, which remains a dilemma in this pilot study. The anterior, posterior, and combined anterior-posterior QLB approaches appear equally efficacious as a component of multimodal analgesia in laparoscopic abdominal surgeries.

A retrospective observational study of injury patterns associated with powered circular saw in subjects presenting to the emergency department of a tertiary care hospital.

Background: Powered circular saw-related injuries (PCSRIs) are responsible for a sizable proportion of occupational injuries presented to the emergency department (ED). The present study portrays the mechanisms, injury patterns, epidemiological parameters, and outcomes among subjects presenting with PCSRI to the ED. Methods: This retrospective observational study was conducted in the ED of a tertiary care hospital in eastern India. Clinical records of subjects with PCSRI from June 2019 to June 2022 were reviewed. Data pertaining to patients' demographic profiles and the patterns and mechanisms of injury were retrieved. The Modified Hand Injury Severity Score (MHISS) and the Injury Severity Score (ISS) were calculated. Statistical analysis was performed using R version 4.1.0. Results: A total of 175 subjects' data were analyzed. The median age was 34.5 years, and all subjects were men. The mean year of experience of the subjects was 6.2. The most common job category was carpentry (n = 63 [36%]), followed by "do it yourself work" (n = 26 [14.8%]). One hundred twenty-two (69.7%) subjects had hand injuries (HIs), and the left hand was involved in 85 (69.6%) subjects. The index finger was involved in 36 (29.5%) subjects, followed by the thumb (n = 31 [25.4%]). Laceration (n = 155 [88.5%]) was the most common injury pattern. The subjects' mean ISS and mean MHISS were 8.52 and 45, respectively. Conclusion: PCSRI is associated with moderate-to-severe HIs that are most common in occupational settings. Young male carpenters involved in wood and plywood work are more prone to injuries.

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.

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.

Macintosh laryngoscope versus AMBU King Vision video laryngoscope for endotracheal intubation using a COVID-19 barrier box: A randomized controlled trial.

BACKGROUND: Coronavirus disease 2019 (COVID-19) barrier box is being used by health-care workers for protection against aerosol-transmitted infection. Usually, a Macintosh laryngoscope (MC) or a video laryngoscope (VL) is used for endotracheal intubation (ETI). We aimed to determine the most suitable laryngoscope blade in terms of time to ETI, ease of ETI, and the first-pass success rate. METHODS: American Society of Anesthesiologists Grade I and II patients undergoing surgery under general anesthesia were randomized into the MC and the King Vision VL groups in a 1:1 ratio. ETI was performed using either the MC (the MC group) or the King Vision VL (the VL group) with a COVID-19 barrier box. The first-pass intubation success rate, intubation time, and ease of ETI were analyzed. RESULTS: The first-pass success rate was higher in the MC group (P = 0.43). The mean duration of ETI was 33 s and 47 s in the MC group and VL group, respectively. The difference was statistically significant between the groups (P = 0.002). The ease of ETI was comparable between the groups (P = 0.57), and the Cormack-Lehane grade was significantly different between the groups (P = 0.0025). CONCLUSION: ETI duration was shorter in the MC group than in the VL group. Hence, a MC can be used along with a COVID-19 barrier box by experienced operators for the prevention of aerosol spread.

A robust nitridation technique for fabrication of disordered superconducting TiN thin films featuring phase slip events.

Disorder induced phase slip (PS) events appearing in the current voltage characteristics (IVCs) are reported for two-dimensional TiN thin films produced by a robust substrate mediated nitridation technique. Here, high temperature annealing of Ti/Si3N4 based metal/substrate assembly is the key to produce majority phase TiN accompanied by TiSi2 & elemental Si as minority phases. The method itself introduces different level of disorder intrinsically by tuning the amount of the non-superconducting minority phases that are controlled by annealing temperature (Ta) and the film thickness. The superconducting critical temperature (Tc) strongly depends on Ta and the maximum Tc obtained from the demonstrated technique is about 4.8 K for the thickness range ~ 12 nm and above. Besides, the dynamics of IVCs get modulated by the appearance of intermediated resistive steps for decreased Ta and the steps get more prominent for reduced thickness. Further, the deviation in the temperature dependent critical current (Ic) from the Ginzburg-Landau theoretical limit varies strongly with the thickness. Finally, the Tc, intermediate resistive steps in the IVCs and the depairing current are observed to alter in a similar fashion with Ta and the thickness indicating the robustness of the synthesis process to fabricate disordered nitride-based superconductor.

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.

Large Spinal Abscess in a Neonate.

Spontaneous spinal epidural abscess is rare entity in neonates. These are surgical emergency in which early diagnosis and prompt decompression is necessary to avoid permanent cord damage. The diagnosis is based on clinical findings of paraplegia supported by radiological findings on an MRI. We found a large extra spinal abscess in an infant that on further evaluation showed a communicating epidural component, yet the baby was neurologically intact. The abscess was drained in emergency with clearance of epidural component and appropriate antibiotics instituted for Streptococcus pyogenes as per sensitivity. The patient is doing well at 6 months follow up.

The effect of 'THE MOTOR VEHICLES (AMENDMENT) ACT, 2019' on the clinico-epidemiological profile of road traffic accident patients presenting to a tertiary care trauma centre in Bhubaneswar.

CONTEXT: Road traffic accidents (RTA) are a foremost rising cause of morbidity and mortality in developing countries like India. The Government of India enacted a new motor vehicle amendment act (MVA) on September 1st 2019 that permits heavy penalties for traffic rule offenders. AIMS: To find out the early impact of "THE MOTOR VEHICLES (AMENDMENT) ACT, 2019". SETTINGS AND DESIGN: A retrospective observational study was performed during the time period July to October 2019 on RTA patients admitted to the Trauma and Emergency department. METHODS AND MATERIALS: Patients studied in two groups - One Pre MVA group (n = 371) and one Post MVA group (n = 415). The data were extracted from medical case records of the department and filled up in a structured format. Detailed demographic profile, including the use of safety measure and clinical variables such as the pattern of injury and injury severity scores, were recorded. STATISTICAL ANALYSIS USED: Statistical analysis was done by R version 3.6.1. RESULTS: There is a 41% drop in RTA victims post MVA implementation. Polytrauma reduced (25% vs 45.5%) significantly (P = 0.002) and so was Injury severity score (6.00 vs 13.00). More RTA victims were wearing helmets as compared to previous (42% vs 18%), and there was a steep decline in the alcohol driving (25% vs 10%) between the pre and post MVA group. A significant reduction noted in the under 18 yrs. Two-wheeler riders in the post MVA group compared to earlier (P = 0.016). CONCLUSIONS: The study reveals that there is a commendable reduction in the injury severity, violation of safety gears, alcohol use and rash driving following the implementation of MVA September 2019. Primary care and family physician can play a crucial role in creating public awareness about the personal safety measures, which will help in strengthening of this law to reduce the incidence of RTA and the associated mortality and morbidity.

How much ambulance personnel know about basic life support (BLS)? A hospital-based study from Eastern India.

BACKGROUND: Basic life support (BLS) is an important component of emergency medical management. Ambulance personnel play a key role in resuscitation to save a life before reaching the hospital. We do not have any published data about the level of knowledge on BLS among the ambulance personnel. OBJECTIVE: This study was done with the objective to assess the level of knowledge on BLS among the ambulance personnel. MATERIALS AND METHODS: A cross-sectional study was done in the emergency department (ED) of a tertiary care hospital. Universal sampling was done taking all the personnel of ambulances over the period of one month. Data were collected about the type of vehicle used for ambulance, the number of personnel in an ambulance, educational qualifications, and equipment present in their ambulances. The questionnaire to capture the level of knowledge were based on American Heart Association 2015 guidelines. RESULT: The total number of ambulance arrivals was 729 times. But data analysis was done from 104 ambulances excluding the repeat arrivals and those who did not give consent. There were 62 type-C and D ambulances, and 42 were type-B ambulances. Total of 210 personnel were there in 104 ambulances. Seventy-nine team leaders did not have any paramedical degrees. Fifty-eight team leaders were trained in BLS before working in an ambulance. In spite of this, 66 (63%) team leaders had poor performance (score of 0 to 4). CONCLUSION: The level of knowledge on BLS was poor in more than half of the ambulance personnel. They should be trained regularly on providing BLS.