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Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year. The speed and appropriateness of therapy administered in the initial hours of treatment are likely to influence the outcome. We conducted a study to validate the clinical assessment score named 'quick sequential organ failure assessment' (qSOFA) score for use in the early identification of sepsis patients in the emergency department. Our primary objective was to see the sensitivity and specificity of the qSOFA-score for diagnosing sepsis in the emergency department and our secondary objective was to compare the sensitivity of the qSOFA score with the National Early Warning (NEW) score in patients with sepsis. A prospective observational study was conducted at Max Super Speciality Hospital Saket, New Delhi, from July 2016 to January 2017. Adult patients presenting to the emergency department with clinical signs and symptoms suggestive of infection were enrolled as per the eligibility criteria and divided into two groups on the basis of their qSOFA score at presentation. Out of 120 patients who had a positive qSOFA score 30 were subsequently confirmed as having sepsis whereas in qSOFA negative group 14 patients were subsequently diagnosed as having sepsis. This leads to the fact that although the test has near-acceptable specificity, the sensitivity is quite low. Calculations of the secondary outcome, that is 28-day mortality, revealed that 17 patients out of 120 who had a positive qSOFA score died within 28 days of first presentation whereas in the control group, nine patients had died. This means it successfully predicted mortality in only 17 patients and failed to predict mortality in nine patients out of 26 patients that died. The p-value is 0.097 which indicates both poor sensitivity as well as specificity for predicting mortality. We also compared qSOFA with the NEW score and found the latter to have a better sensitivity for detecting sepsis. This study shows that the qSOFA score, which has been specifically designed for early detection of sepsis patients in the emergency department or a pre-hospital setting in whom infection is suspected on a clinical basis, does not seem to be a good screening tool for early detection of sepsis patients in the emergency department.
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BACKGROUND: The recent United States (US) troop withdrawal out of Afghanistan under a February 2020 US-Taliban agreement and the rapid concurrent collapse of the Afghan military, followed by the ascendance of the Taliban, has placed an international spotlight around the future of South Asian countries. Security threats, in particular, will likely escalate within the region and beyond, with significant concerns around the resurgence of terrorism and violence in the region. This study aims to provide an epidemiological description of all terrorism-related attacks in South Asia sustained from 1970 - 2019. These data will be useful in the development of education programs in Counter-Terrorism Medicine and provide an insight into potential attacks in the future. METHODS: Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events which occurred in Afghanistan, Bangladesh, Bhutan, India, Maldives, Mauritius, Nepal, Pakistan, and Sri Lanka (collectively referred to as South Asia) from January 1, 1970 - December 31, 2019. Primary weapon type, primary target type, country where the incident occurred, and number of deaths and injuries were collated and exported for analysis. RESULTS: In total, 23.69% of all terrorist attacks from 1970-2019 occurred in the South Asia region, causing 96,092 deaths and 141,333 non-fatal injuries. Of those, 50.1% of attacks in South Asia used explosives, 31.9% used firearms, 9.4% used unknown weapons, 5.9% used incendiary attacks, 2.3% were melee attacks, and <0.5% used chemical, biological, and other weapon types. CONCLUSION: Over 88% of the attacks occurred in Afghanistan, Pakistan, and India combined. While there has been a decline in attacks since a peak in 2014, there are concerns of a significant increase in terrorism activity in recent months which could impact an already fragmented health care system. The use of explosives and firearms as attack modalities accounted for 82.0 % of all weapon types used, but the impact of terrorism and conflict expands beyond simple death and casualty tolls.
Subject(s)
Disaster Planning , Explosive Agents , Terrorism , Delivery of Health Care , Humans , Pakistan , Retrospective StudiesABSTRACT
The Chain of Survival in Industrial Emergencies and Disasters is similar to the cardiac arrest chain of survival of the American Heart Association (AHA) and the trauma chain of survival. It is a sequence of five inter-linked rings, which when practiced, decreases the mortality and morbidity in the concerned population. The first ring is Early Prevention, which should be a combined effort of healthcare professionals and industrial authorities. The second ring is Early Recognition. Industrial workers and surrounding communities should be equally trained in hazard and risk analysis along with vulnerability assessment. The third ring is Access to Care by the Early Response System, involving a universal emergency response number and early intervention by on-site trained medical professionals. This ring emphasizes the importance of a link with the surrounding communities, as they are the first responders and the front-line victims. The fourth ring is Early Advanced Care by EMS for transportation to hospitals or by Emergency Department personnel in referral hospitals. The fifth and the last ring is Early Rehabilitation, which includes integrated post emergency care, overall rehabilitation and early return to work. The key to successful implementation of Chain of Survival is to have identified components of care, training and quality monitoring. When practiced diligently, this could help prevent industrial disasters, and mitigate their harmful effects on occurrence.
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Disaster Planning , Disasters , Emergency Medical Services , Emergency Responders , Emergencies , Emergency Treatment , HumansABSTRACT
Health-care systems all over the world are stretched out and being reconfigured to deal with the coronavirus disease 2019 (COVID-19) pandemic. Some countries have flattened the curve, some are still fighting to survive it, and others are embracing the second wave. Globally, there is an urgent need to increase the resilience, capacity, and capability of health-care systems to deal with the current crisis and improve upon the future responses. The epidemiological burden of COVID-19 has led to rapid exhaustion of local response resources and massive disruption to the delivery of care in many countries. Health-care networking and liaison are essential component in disaster management and public health emergencies. It aims to provide logistical support between hospitals; financial support through local or regional governmental and nongovernmental agencies for response; manpower and mechanism for coordination and to implement policies, procedures, and technologies in the event of such crisis.This brief report describes how 4 independent private hospitals in northern India had adopted the principles of health-care networking, pooled their resources, and scaled up 1 of the partner hospitals as Dedicated COVID-19 Hospital (DCH) to treat moderate to severe category of COVID-19 patients. It brings out the importance of a unique coalition between private and public health-care system.
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COVID-19 , Disasters , COVID-19/epidemiology , COVID-19/therapy , Delivery of Health Care , Humans , Pandemics , Public HealthABSTRACT
Development of a successful research program can seem daunting when looked at from the starting line. It will take years if not decades to succeed and become sustainable. It requires local partnerships and mentoring; it mandates the establishment of review boards; it requires national health policies to allow for protected time for research in salaries and for fund granting agencies to be set up; it requires training of researchers and support staff as well as a change in the mindset of clinical staff on the floor. It will almost inevitably require international support of some kind for low- and middle-income country researchers, be it university programs or other academic or private institutions. Success can occur; most likely it will occur by partnering with local research experts outside of emergency medicine in some combination with international networks and mentoring. Perhaps the most critical elements to success are intellectual curiosity and a burning flame of passion - and neither of those carry a financial cost.
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Introduction Without a universal Emergency Medical Services (EMS) system in India, data on the epidemiology of patients who utilize EMS are limited. This retrospective chart review aimed to quantify and describe the burden of disease and patient demographics of patients who arrived by EMS to four Indian emergency departments (EDs) in order to inform a national EMS curriculum. METHODS: A retrospective chart review was performed on patients transported by EMS over a three-month period in 2014 to four private EDs in India. A total of 17,541 patient records were sampled from the four sites over the study period. Of these records, 1,723 arrived by EMS and so were included for further review. RESULTS: A range of 1.4%-19.4% of ED patients utilized EMS to get to the ED. The majority of EMS patients were male (59%-64%) and adult or geriatric (93%-99%). The most common chief complaints and ED diagnoses were neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease. CONCLUSIONS: Neurological, pulmonary, cardiovascular, gastrointestinal, trauma, and infectious disease are the most common problems found in patients transported by EMS in India. Adult and geriatric male patients are the most common EMS utilizers. Emergency Medical Services curricula should emphasize these knowledge areas and skills. Wijesekera O , Reed A , Chastain PS , Biggs S , Clark EG , Kole T , Chakrapani AT , Ashish N , Rajhans P , Breaud AH , Jacquet GA . Epidemiology of Emergency Medical Services (EMS) utilization in four Indian emergency departments. Prehosp Disaster Med. 2016;31(6):675-679.
Subject(s)
Emergency Medical Services/statistics & numerical data , Emergency Service, Hospital/statistics & numerical data , Adolescent , Adult , Aged , Child , Child, Preschool , Female , Hospitals, Private , Humans , India , Infant , Male , Medical Audit , Middle Aged , Retrospective Studies , Young AdultABSTRACT
BACKGROUND: Emergencies such as road traffic accidents (RTAs), acute myocardial infarction (AMI) and cerebrovascular accident (CVA) are the most common causes of death and disability in India. Robust emergency medicine (EM) services and proper education on acute care are necessary. In order to inform curriculum design for training programs, and to improve the quality of EM care in India, a better understanding of patient epidemiology and case burden presenting to the emergency department (ED) is needed. METHODS: This study is a retrospective chart review of cases presenting to the ED at Kerala Institute of Medical Sciences (KIMS), a private hospital in Trivandrum, Kerala, India, from November 1, 2011 to April 21, 2012 and from July 1, 2013 to December 21, 2013. De-identified charts were systematically sampled and reviewed. RESULTS: A total of 1 196 ED patient charts were analyzed. Of these patients, 55.35% (n=662) were male and 44.7% (n=534) were female. The majority (67.14%, n=803) were adults, while only 3.85% (n=46) were infants. The most common chief complaints were fever (21.5%, n=257), renal colic (7.3%, n=87), and dyspnea (6.9%, n=82). The most common ED diagnoses were gastrointestinal (15.5%, n=185), pulmonary (12.3%, n=147), tropical (11.1%, n=133), infectious disease and sepsis (9.9%, n=118), and trauma (8.4%, n=101). CONCLUSION: The patient demographics, diagnoses, and distribution of resources identified by this study can help guide and shape Indian EM training programs and faculty development to more accurately reflect the burden of acute disease in India.
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BACKGROUND: The Broselow™ Pediatric Emergency Tape indicates standardized, pre-calculated medication doses, dose delivery volumes, and equipment sizes using color-coded zones based on height-weight correlations. The present study attempted to provide more evidence on the effectiveness of the Broselow™ Pediatric Emergency Tape by comparing the tape-estimated weights with actual weights. We hypothesized that the Broselow™ Pediatric Emergency Tape would overestimate weights in Indian children aged<10 years, leading to inaccurate dosing and equipment sizing in the emergency setting. METHODS: This prospective study of pediatric patients aged <10 years who were divided into three groups based on actual body weight: <10 kg, 10-18 kg, and >18 kg. We calculated the percentage difference between the Broselow-predicted weight and the measured weight as a measure of tape bias. Concordant results were those with a mean percent difference within 3%. Standard deviation was measured to determine precision. Accuracy was determined as color-coded zone prediction and measured weight concordance, including the percentage overestimation by 1-2 zones. RESULTS: The male-to-female ratio of the patients was 1.3:1. Total agreement between color-coding was 63.18% (κ=0.582). The Broselow™ color-coded zone agreement was 74.8% in the <10 kg group, 61.24% in the 10-18 kg group, and 53.42% in the >18 kg group. CONCLUSIONS: The Broselow™ Pediatric Emergency Tape showed good evidence for being more reliable in children of the <10 kg and 10-18 kg groups. However, as pediatric weight increased, predictive reliability decreased. This raises concerns over the use of the Broselow™ Pediatric Emergency Tape in Indian children because body weight was overestimated in those weighing >18 kg.
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BACKGROUND: The specialty of emergency medicine is in its infancy state in the long history of the Indian health sciences education system. Little analytical published data is available at the moment in India regarding the quality of medical education as perceived by the students. Roff et al. (Med Teach 19: 295-299, 1997) developed a methodology using a Delphi panel to standardize the measurement of medical education known as the Dundee Ready Education Environment Measure (DREEM), which is widely utilized. The purpose of this survey is to investigate student perceptions of medical education environment among emergency medicine residents of an academic medical centre in Northern India using the DREEM tool. METHODS: The DREEM questionnaire was administered to the students undergoing 3-year post-graduate emergency medicine training in our residency programme. A total of 35 students enrolled from all 3 years of the residency programme completed the survey in May 2013. The results were analysed using STATA 9.0. RESULTS: The reliability coefficient which was calculated using Cronbach's alpha for the totality of items of this study was 0.92, which indicates high internal consistency. The mean (95 % CI) for the overall DREEM was 139.8 (133.3, 146.2), which showed excellent educational environment among the medical students. CONCLUSIONS: The DREEM score is a universal tool for assessment of education provided by health science institutes. With a total score of 139.8, the study conducted at our institute showed comparable results to the original DREEM study conducted by Roff et al. The good scores in all the five subscales reveal an excellent educational programme and learning environment as perceived by the students enrolled at our institution.
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BACKGROUND:The Broselow? Pediatric Emergency Tape indicates standardized, pre-calculated medication doses, dose delivery volumes, and equipment sizes using color-coded zones based on height-weight correlations. The present study attempted to provide more evidence on the effectiveness of the Broselow? Pediatric Emergency Tape by comparing the tape-estimated weights with actual weights. We hypothesized that the Broselow? Pediatric Emergency Tape would overestimate weights in Indian children aged<10 years, leading to inaccurate dosing and equipment sizing in the emergency setting. METHODS:This prospective study of pediatric patients aged <10 years who were divided into three groups based on actual body weight:<10 kg, 10–18 kg, and >18 kg. We calculated the percentage difference between the Broselow-predicted weight and the measured weight as a measure of tape bias. Concordant results were those with a mean percent difference within 3%. Standard deviation was measured to determine precision. Accuracy was determined as color-coded zone prediction and measured weight concordance, including the percentage overestimation by 1–2 zones. RESULTS:The male-to-female ratio of the patients was 1.3:1. Total agreement between color-coding was 63.18% (K=0.582). The Broselow? color-coded zone agreement was 74.8% in the <10 kg group, 61.24% in the 10–18 kg group, and 53.42% in the >18 kg group. CONCLUSIONS:The Broselow? Pediatric Emergency Tape showed good evidence for being more reliable in children of the <10 kg and 10–18 kg groups. However, as pediatric weight increased, predictive reliability decreased. This raises concerns over the use of the Broselow? Pediatric Emergency Tape in Indian children because body weight was overestimated in those weighing >18 kg.
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@#BACKGROUND: Emergencies such as road traffic accidents (RTAs), acute myocardial infarction (AMI) and cerebrovascular accident (CVA) are the most common causes of death and disability in India. Robust emergency medicine (EM) services and proper education on acute care are necessary. In order to inform curriculum design for training programs, and to improve the quality of EM care in India, a better understanding of patient epidemiology and case burden presenting to the emergency department (ED) is needed.METHODS: This study is a retrospective chart review of cases presenting to the ED at Kerala Institute of Medical Sciences (KIMS), a private hospital in Trivandrum, Kerala, India, from November 1, 2011 to April 21, 2012 and from July 1, 2013 to December 21, 2013. De-identified charts were systematically sampled and reviewed.RESULTS: A total of 1196 ED patient charts were analyzed. Of these patients, 55.35% (n=662) were male and 44.7% (n=534) were female. The majority (67.14%,n=803) were adults, while only 3.85% (n=46) were infants. The most common chief complaints were fever (21.5%, n=257), renal colic (7.3%,n=87), and dyspnea (6.9%,n=82). The most common ED diagnoses were gastrointestinal (15.5%,n=185), pulmonary (12.3%,n=147), tropical (11.1%,n=133), infectious disease and sepsis (9.9%,n=118), and trauma (8.4%,n=101).CONCLUSION: The patient demographics, diagnoses, and distribution of resources identifi ed by this study can help guide and shape Indian EM training programs and faculty development to more accurately refl ect the burden of acute disease in India.
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BACKGROUND: Hemorrhage is the second leading cause of death in trauma patients preceded only by traumatic brain injury. But hemorrhagic shock is the most common cause of preventable death within 6 hours of admission. Traumatic coagulopathy is a hypocoagulable state that occurs in the most severely injured. International normalized ratio (INR) and its relationship with trauma mortality have not been studied specifically. This study aimed to establish a predictive value of INR for trauma-related mortality. METHODS: A total of 99 trauma patients aged 18-70 years were included in the study. Their INR was determined and patient progression was followed up till death/discharge. According to previous retrospective studies, the cutoff value for INR in our study was kept at 1.5. RESULTS: The total mortality rate of the patients was 16.16% (16/99). The mean INR was 1.45 with a SD of 1.35. INR was deranged in a total of 14 patients (14.14%). Of these patients, 11 died (78.57%) and 3 survived. INR was deranged in 11 (68.75%) of the 16 patients who died, but 5 deaths (31.25%) had normal INR values. The sensitivity of INR was 69% (95%CI 41%-88%) and the specificity 96% (95%CI 90%-99%). The diagnostic accuracy of INR was 92% (95%CI 85%-96%). Positive predictive value and negative predictive value were 79% (95%CI 49%-95%) and 94% (95%CI 87%-98%), respectively. CONCLUSION: Our results showed that INR is a good predictor of mortality in trauma patients.
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BACKGROUND: Hemorrhage is the second leading cause of death in trauma patients preceded only by traumatic brain injury. But hemorrhagic shock is the most common cause of preventable death within 6 hours of admission. Traumatic coagulopathy is a hypocoagulable state that occurs in the most severely injured. International normalized ratio (INR) and its relationship with trauma mortality have not been studied specifically. This study aimed to establish a predictive value of INR for trauma-related mortality. METHODS: A total of 99 trauma patients aged 18–70 years were included in the study. Their INR was determined and patient progression was followed up till death/discharge. According to previous retrospective studies, the cutoff value for INR in our study was kept at 1.5. RESULTS: The total mortality rate of the patients was 16.16% (16/99). The mean INR was 1.45 with a SD of 1.35. INR was deranged in a total of 14 patients (14.14%). Of these patients, 11 died (78.57%) and 3 survived. INR was deranged in 11 (68.75%) of the 16 patients who died, but 5 deaths (31.25%) had normal INR values. The sensitivity of INR was 69% (95%CI 41%–88%) and the specificity 96% (95%CI 90%–99%). The diagnostic accuracy of INR was 92% (95%CI 85%–96%). Positive predictive value and negative predictive value were 79% (95%CI 49%–95%) and 94% (95%CI 87%–98%), respectively. CONCLUSION: Our results showed that INR is a good predictor of mortality in trauma patients.
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BACKGROUND: Stroke is a common presentation in geriatric patients in emergency department but rarely seen in pediatric patients. In case of acute ischemic stroke in pediatric age group, management is different from that of adult ischemic stroke where thrombolysis is a good op. METHODS: We report a case of a 17-year-old male child presenting in emergency with an episode of acute ischemic stroke causing left hemiparesis with left facial weakness and asymmetry. The patient suffered from cyanotic congenital heart disease for which he had undergone Fontan operation previously. He had a history of missing his daily dose of warfarin for last 3 days prior to the stroke. RESULTS: The patient recovered from acute ischemic stroke without being thrombolyzed. CONCLUSION: In pediatric patients, acute ischemic stroke usually is evolving and may not require thrombolysis.
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BACKGROUND: Stroke is a common presentation in geriatric patients in emergency department but rarely seen in pediatric patients. In case of acute ischemic stroke in pediatric age group, management is different from that of adult ischemic stroke where thrombolysis is a good option.METHODS: We report a case of a 17-year-old male child presenting in emergency with an episode of acute ischemic stroke causing left hemiparesis with left facial weakness and asymmetry. The patient suffered from cyanotic congenital heart disease for which he had undergone Fontan operation previously. He had a history of missing his daily dose of warfarin for last 3 days prior to the stroke.RESULTS: The patient recovered from acute ischemic stroke without being thrombolyzed.CONCLUSION: In pediatric patients, acute ischemic stroke usually is evolving and may not require thrombolysis.