Diabetic Ketoacidosis: A Rare Complication of Type 3c Diabetes.

Recently termed pancreoprivic diabetes, type 3c diabetes refers to high blood sugar values secondary to disease of the exocrine pancreas. The disease is most commonly misdiagnosed as type 2 diabetes mellitus (DM) and is overlooked by physicians and the general public. Chronic pancreatitis (CP) accounts for most cases of type 3c diabetes. Diabetic ketoacidosis (DKA) is a rare occurrence in type 3c diabetes as both alpha and beta cell dysfunction occur concurrently. In this case, the major hormones involved in lipolysis and ketone body production would be catecholamines, cortisol, and growth hormone. We report a case of a 37-year-old female with a history of endocrine pancreatic insufficiency secondary to CP who presented with DKA, one of the life-threatening but preventable complications of diabetes. Noncompliance with insulin and concurrent urinary tract infection were the inciting factors. Her condition improved with DKA management according to standard protocol, intravenous antibiotics, and other supportive care. She got discharged after optimization of insulin therapy, with proper advice for home blood sugar monitoring and regular follow-up. A patient with pancreatic pathology may present to the emergency with DKA as the first manifestation, and if not properly evaluated, the diagnosis of type 3c diabetes can be missed.

Thrombotic microangiopathy following a white-lipped pit viper envenomation.

Certain snake envenomation patients with consumptive coagulopathy, termed venom-induced consumption coagulopathy, develop thrombotic microangiopathy (TMA). Due to predominant renal involvement, TMA is said to resemble haemolytic uraemic syndrome and is treated with haemodialysis. We present a case of a young male who presented to the emergency department after being bitten by a white-lipped pit viper (Trimeresurus albolabris). He developed heart failure in addition to acute kidney injury secondary to TMA. He was treated with 30 vials of anti-snake venom according to national guidelines and underwent haemodialysis. Despite haemodialysis, the patient's ventilatory parameters continued to worsen, necessitating invasive mechanical ventilation. Thus, he was initiated on plasma exchange therapy, to which the patient responded well. TMA has not been reported in Trimeresurus envenomations yet, to the best of our knowledge. Additionally, plasma exchange therapy can be considered an adjunctive therapy for snakebite patients who develop TMA.

The diagnostic accuracy of point-of-care ultrasound parameters for airway assessment in patients undergoing intubation in emergency department-an observational study.

BACKGROUND: Endotracheal intubation is an essential resuscitative procedure in the emergency setting. Airway assessment parameters such as the Mallampati classification are difficult to perform in an emergency setting. As point-of-care ultrasound (POCUS) assessment of airway parameters does not require patients to perform any mandatory action, ultrasound may become the potential first-line noninvasive airway assessment tool in the emergency department (ED). The use of POCUS in the ED has not been sufficiently studied. Using POCUS in airway assessment for predicting difficult intubation may be the next step in successful airway management. METHODOLOGY: The study was an observational study conducted at the ED of the All India Institute of Medical Sciences (Rishikesh). The treating emergency physician recorded the patient history and systemic examination along with an indication for intubation. The POCUS assessment of airway parameters pre-epiglottis to epiglottic vocal cord ratio (Pre-E/E-VC), tongue thickness, hyomental distance, and distance from skin to the hyoid bone was performed by the study investigator. During laryngoscopy, Cormack-Lehane (CL) grading was assessed. The data was entered and analyzed. RESULTS: Seventy patients who required intubation in the ED were enrolled in the study. Among the study population, 48.6%, 28.6%, 14.3%, 1.4%, and 7.1% were classified with the following CL grading: 1, 2a, 2b, 3a, and 3b, respectively. At a cutoff of ≥ 1.86, Pre-E/E-VC predicts difficult laryngoscopy (AUC 0.835) with a sensitivity of 83% and a specificity of 94%. At a cutoff of ≥ 5.98 cm, tongue thickness predicts difficult laryngoscopy (AUC 0.78) with a sensitivity of 83% and a specificity of 88%. At a cutoff of hyomental distance ≤ 6 cm, it predicts difficult laryngoscopy with a sensitivity of 83% and a specificity of 88%. All parameters can act as a promising tool for predicting difficult laryngoscopy, with the single best parameter being Pre-E/E-VC. CONCLUSION: Assessment of the airway with POCUS may be helpful to the emergency physician when the clinical airway assessment parameters fail to predict difficult laryngoscopy as most patients requiring intubation are uncooperative. Assessment of the parameters in our study Pre-E/E-VC, tongue thickness, and hyomental distance can act as a promising tool for predicting difficult laryngoscopy in the emergency scenario.

An unusual case of thrombotic storm in an amateur cricketer-a case report.

BACKGROUND: Thrombotic storm is a series of acute to subacute thrombotic events that evolve over a few days to weeks and result in progressive thromboses at multiple sites. There is often a predisposing event to thromboses, such as trauma or infections. Prompt initiation of anti-coagulation can prove life-saving in such patients. CASE REPORT: We describe a previously healthy young male who developed thromboses of the right axillary, brachial, radial, and ulnar arteries while bowling in a cricket match. A few hours later, he developed a stroke involving the right anterior and middle cerebral arteries. His thrombophilia workup was significant for elevated homocysteine levels. Although he had a delayed presentation to our hospital, he was treated with anticoagulation and given a trial of thromboembolectomy, which failed and he had to ultimately undergo a right below-elbow guillotine amputation. CONCLUSION: Thrombotic storm should be recognized promptly in the Emergency Department and timely anticoagulation should be initiated.

Stroke in a patient of anaphylaxis-a case report and brief review.

BACKGROUND: The use of nonionic low-osmolar contrast media has significantly reduced the risk of hypersensitivity reactions. Despite this, severe reactions continue to occur unpredictably. An ischemic stroke in the setting of anaphylaxis is extremely rare. CASE REPORT: A 64-year-old male with no prior allergies went into anaphylactic shock following the administration of iohexol which improved after treatment. He later developed a multi-territorial ischemic stroke. CONCLUSION: An ischemic stroke in the setting of an anaphylaxis is a rare occurrence, which can be attributed to multiple factors in our patient.

Point of care gastric ultrasound to predict aspiration in patients undergoing urgent endotracheal intubation in the emergency medicine department.

BACKGROUND: One significant cause of morbidity and mortality in patients undergoing endotracheal intubation is the aspiration of gastric contents. Its prevalence is more in the emergency than in elective settings. Point-of-care gastric ultrasound (GUS) is a non-invasive bedside ultrasonogram that provides both qualitative and quantitative information about the stomach contents. The diagnostic accuracy of GUS in terms of gastric parameters (measured antral diameters, antral cross-sectional area, and calculated gastric volume) to predict aspiration is yet unknown. We aim to determine this in the patients undergoing urgent emergency intubation (UEI) in the emergency department. METHODOLOGY: A prospective observational study was conducted at the emergency department of a tertiary healthcare center in India. Patients requiring UEI were identified and a bedside gastric ultrasound was done in the right lateral decubitus position using low frequency curved array probe. The qualitative data and the antral diameters (anteroposterior and craniocaudal) were assessed. The patient's clinical parameters and history regarding the last meal were noted. The cross-sectional area of gastric antrum was calculated using CSA = (AP × CC) π/4. The gastric volume is estimated using Perla's formula: GV = 27.0 + 14.6(RLD CSA) -1.28(age). RESULTS: A hundred patients requiring urgent endotracheal intubation were enrolled in the study. Visible aspiration was more in participants with a distended gastric status (χ2 = 16.880, p = < 0.001). The median gastric volume in the patients who aspirated was 146.37 mL, and it ranged from 111.59 mL-201.01 mL. Using ROC analysis, a cut-off of CC diameter ≥ 2.35 cm (sensitivity 88%, specificity 91%) and AP diameter ≥ 5.15 cm (sensitivity 88%, specificity 87%) predicts aspiration. A calculated USG CSA cut-off ≥ 9.27cm2 (sensitivity 100%, specificity 87%) and an USG gastric volume ≥ 111.594 mL (sensitivity 100%, a specificity 92%) predicts aspiration. CONCLUSION: Point-of-care gastric ultrasound is an useful non-invasive bedside tool for risk stratification for aspiration in busy emergency rooms. We present threshold gastric antral parameters that can be used to predict aspiration along with its diagnostic accuracy. This can help the treating ED physician take adequate precautions, decide on intubation techniques and treatment modifications to aid in better patient management.

Treatment Modalities in Calcium Channel Blocker Overdose: A Systematic Review.

Calcium channel blocker poisoning is one of the most common poisonings encountered which presents with life-threatening complications. However, there is no unified approach for treating these patients in the existing literature. This study aimed to assess the effects of different treatment modalities used in calcium channel blocker poisoning, as reported by previous studies. The primary outcomes studied were mortality and hemodynamic parameters after treatment. The secondary outcomes were the length of hospital stay, length of intensive care unit stay, duration of vasopressor use, functional outcomes, and serum calcium channel blocker concentrations. A thorough literature search was performed through Ovid, PubMed, Cochrane Library, and Google Scholar from January 2014 to December 31, 2022, to identify all studies analyzing the effects of the treatment of calcium channel blocker poisoning on the desired outcomes. Two reviewers reviewed 607 published articles from January 2014 to December 2022 to identify studies analyzing the effects of the treatment of calcium channel blocker poisoning on desired outcomes. In this review, 18 case reports, one case series, and one cohort study were included. Most patients were treated with an injection of calcium gluconate or calcium chloride. The use of calcium along with dopamine and norepinephrine was found to have lower mortality rates. A few patients were also treated with injection atropine for bradycardia. High-dose insulin therapy was used in 14 patients, of whom two did not survive. In the cohort study, 66 calcium channel blocker toxicity patients were included. These patients were treated with high-dose insulin therapy. A total of 11 patients with calcium channel blocker toxicity succumbed. Although it was found to be associated with improved hemodynamic parameters and lower mortality, side effects such as hypokalemia and hypoglycemia were noted. Intravenous lipid emulsion therapy (administered to eight patients), extracorporeal life support (used in three patients with refractory shock or cardiac arrest), injection glucagon, methylene blue, albumin infusion, and terlipressin were associated with a lower mortality rate as well as improvement in hemodynamic parameters. None of the case reports provided any information on end-organ damage on long-term follow-up.

A Rare Life-Threatening Presentation of Shoulder Pain: Cervical Epidural Hematoma.

Shoulder pain is a common complaint of patients presenting to emergency department. Various conditions, intrinsic and extrinsic to the shoulder, can result in shoulder pain. Some of these extrinsic conditions can pose a threat to life. We present a case of a young, previously healthy male who initially had bilateral shoulder pain, later developed quadriparesis, and was ultimately diagnosed with a spontaneous cervical epidural hematoma. He underwent an emergency C7-T1 laminectomy with hematoma evacuation and had a full recovery. Cervical epidural hematoma is a rare surgical emergency where timely diagnosis and treatment are crucial.

Management of Snakebite-Induced Thrombotic Microangiopathy (TMA) With Plasmapheresis.

Snakebites affect a lot of people in India. Of these, the hemotoxic snakebites may induce a consumptive coagulopathy, which has been termed now as "Venom-Induced Consumptive Coagulopathy" (VICC). Some patients with VICC develop Thrombotic Microangiopathy (TMA). The primary end-organ damage in TMA is renal, for which hemodialysis is the mainstay of treatment. Recently there has been some focus on plasma exchange as an adjunctive treatment for TMA. Here we present a case of a young male who developed snakebite-induced TMA and who was successfully managed with plasma exchange.

Intractable hiccups as the harbinger of a diffuse pontine glioma.

Hiccups are experienced by people of all ages. While acute hiccups are benign and self-limited, persistent and intractable hiccups can sometimes signal a serious disease. We present a young previously healthy man who complained of only hiccups for 4 months and later developed a severe headache and projectile vomiting. His systemic examination was within normal limits. Brain imaging revealed a diffuse pontine glioma with mild hydrocephalus.

An Evaluation of the Predictive Value of Sepsis Patient Evaluation in the Emergency Department (SPEED) Score in Estimating 28-Day Mortality Among Patients With Sepsis Presenting to the Emergency Department: A Prospective Observational Study.

Background and objective Sepsis is a life-threatening medical emergency and a significant cause of mortality. Risk stratification scores for sepsis can be unsuitable for use in the emergency department (ED) due to their complexity, and an appropriate solution has yet to be found. In this study, the predictive value of the Sepsis Patient Evaluation in the Emergency Department (SPEED) score in estimating 28-day mortality was assessed among patients with sepsis presenting to the ED, in order to determine its suitability as an efficient risk stratification system. Materials and methods This was a single-center, prospective observational study conducted at an urban tertiary care center. We included patients presenting to the ED with suspected or confirmed sepsis who met the inclusion and exclusion criteria of our study. The patients were evaluated with the following scoring systems on arrival: the SPEED score; Predisposition, Infection, Response, and Organ dysfunction (PIRO) score; and Mortality in Emergency Department Sepsis (MEDS) score; the patients were subsequently followed up on the 28th day to record the final outcomes with regard to mortality and discharge rates. Results This study included 127 patients in total. The median age of the study population was 49 years, and the 28-day mortality rate was 50.4%. The area under the receiver operating characteristic (AUROC) curve for the SPEED score for predicting mortality was 0.899 (95% CI: 0.847-0.951). In comparison, the AUROC for MEDS and PIRO scores was 0.857 (95% CI: 0.793-0.92) and 0.895 (95% CI: 0.838-0.951), respectively. Based on the DeLong test, no significant difference was found in the diagnostic performances with respect to these scores. Conclusion The SPEED score is a simple and handy parameter that can be used for the early and appropriate risk stratification of patients with sepsis in the ED.

Post-COVID-19 Guillain-Barré Syndrome: A Case Report With Literature Review.

Coronavirus disease 2019 (COVID-19) predominantly affects the respiratory system with manifestations ranging from a mild upper respiratory tract infection to severe acute respiratory distress syndrome. Neurological manifestations of COVID-19 are mainly thrombotic manifestations affecting the nervous system; however, demyelinating manifestation has been less defined. Although some recent studies have described the association between COVID-19 and Guillain-Barré syndrome (GBS), the strength of association and features of GBS in this setting are not yet clear. Here, we report one adult case of COVID-19 infection presenting with acute GBS, which was not preceded by any other respiratory, gastrointestinal, or other systemic infections. We performed a literature search in Medline via PubMed using the keywords or MeSH terms "COVID-19" or "SARS-CoV-2" and "Guillain-Barré syndrome" and "AIDP" and "AMAN," "Miller-Fischer syndrome" or "MFS." We reviewed 99 case reports, 38 reviews, and two meta-analyses. Several published reports have described a possible association between GBS and COVID-19 infection.

Prognostication of COVID-19 patients using ROX index and CURB-65 score - A retrospective observational study.

Objectives: Coronavirus disease-2019 (COVID-19) disease has overwhelmed the healthcare infrastructure worldwide. The shortage of intensive care unit (ICU) beds leads to longer waiting times and higher mortality for patients. High crowding leads to an increase in mortality, length of hospital stays, and hospital costs for patients. Through an appropriate stratification of patients, rational allocation of the available hospital resources can be accomplished. Various scores for risk stratification of patients have been tried, but for a score to be useful at primary care level, it should be readily available at the bedside and be reproducible. ROX index and CURB-65 are simple bedside scores, requiring minimum equipment, and investigations to calculate. Methods: This retrospective, record-based study included adult patients who presented to the ED from May 1, 2020 to November 30, 2020 with confirmed COVID-19 infection. The patient's clinical and demographic details were obtained from the electronic medical records of the hospital. ROX index and CURB-65 score on ED arrival were calculated and correlated with the need for hospitalization and early (14-day) and late (28-day) mortality. Results: 842 patients were included in the study. The proportion of patients with mild, moderate and severe disease was 46.3%, 14.9%, and 38.8%, respectively. 55% patients required hospitalization. The 14-day mortality was 8.8% and the 28-day mortality was 20.7%. The AUROC of ROX index for predicting hospitalization was 0.924 (p < 0.001), for 14-day mortality was 0.909 (p < 0.001) and for 28-day mortality was 0.933 (p < 0.001). The AUROC of CURB-65 score for predicting hospitalization was 0.845 (p < 0.001), for 14-day mortality was 0.905 (p < 0.001) and for 28-day mortality was 0.902 (p < 0.001). The cut-off of ROX index for predicting hospitalization was ≤18.634 and for 14-day mortality was ≤14.122. Similar cut-off values for the CURB-65 score were ≥1 and ≥2, respectively. Conclusion: ROX index and CURB-65 scores are simple and inexpensive scores that can be efficiently utilised by primary care physicians for appropriate risk stratification of patients with COVID-19 infection.

Association of haematological biomarkers with severity of COVID-19 pneumonia.

BACKGROUND: Coronavirus disease 2019 (COVID-19) was first reported in Wuhan, China in December 2019. It is caused by SARS-CoV-2, a beta coronavirus. In this study, we assessed the association of biomarkers such as neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR) and lymphocyte monocyte ratio (LMR) with the severity of COVID-19 in patients. METHODS: This retrospective observational study was carried out at a tertiary care hospital of the sub-Himalayan region of Uttarakhand over a period of six months from May to October 2020. A total of 350 patients with confirmed RT-PCR COVID-19 infection were included in the study. Detailed clinical, demographic and biochemical data of each patient was obtained from the hospital record section after permission from the Institute Ethical Committee. NLR, PLR and LMR ratios were calculated and compared with the outcomes in each patient. The patients were subdivided into two sub-groups: those with saturation less than 94% and those with saturation more than 94%. The patients were categorised as mild (with SpO2 of > 94%) and moderate-severe (with SpO2 of ≤94%) based on oxygen saturation. RESULTS: A total of 350 patients with Covid-19 pneumonia were enrolled in the study. The mean age of the patients with oxygen saturation of ≤94% was 54.91 ± 13.29 years, which was comparable to the other group. Absolute neutrophil count (ANC) and NLR were significantly higher in patients with a saturation of < 94%. However, LMR and PLR were significantly lower in the group with saturation of <94%. Thus, a significant association was found between haematological inflammatory ratios and the severity of COVID-19 infection. CONCLUSION: NLR, LMR and PLR ratios can be utilised as point of care markers to assess severity in patients with COVID-19 pneumonia.

COVID-19-Associated Pneumomediastinum and Pneumothorax: A Case Series.

Coronavirus disease-19 (COVID-19) causes mild to moderate illness in most patients but in some cases a severe illness may manifest. Such patients usually present with hypoxaemic respiratory failure due to acute lung injury caused by a viral infection and host-mediated cytokine storm. The characteristic radiographic findings are ground-glass opacities with consolidation in posterior basal areas of bilateral lungs and rarely pneumothorax (PTX) and pneumomediastinum (PM). The incidence of these findings was notably higher in the second wave of the pandemic in India in 2021 as compared to the first wave in 2020. The etiopathogenesis of this life-threatening condition can be due to Macklin phenomenon post-cytokine-mediated diffuse alveolar injury, patient self-inflicted lung injury (P-SILI), and barotrauma in mechanically ventilated patients. The presence of pneumomediastinum is associated with higher mortality rates, prolonged intensive care unit (ICU) stays making it a poor prognostic marker. There is no consensus regarding its management in COVID-19 patients although both aggressive and conservative strategies have been tried.

Unusual case of recurrent hypoglycaemia in multiple bee sting envenomation.

A bee sting can result in allergic and toxin-mediated local manifestations like pain, swelling, redness and itching to serious systemic effects like acute kidney injury (AKI), pancreatitis, Kounis syndrome and stroke. Melittin and phospholipase A2, which make up 62% of honeybee venom, have vasoactive, haemolytic properties causing severe AKI. Its role in lowering blood glucose in diabetics is an interesting research topic. We report an elderly herdsman, a known diabetic on irregular oral hypoglycaemic drugs, who presented with altered mental status due to hypoglycaemia. On further prodding, a recent multiple bee sting attack 5 days ago was found which was followed by altered coloured urine for 2 days for which no medical attention was sought. Additional analyses revealed reticulocytosis, azotemia and high serum creatine phosphokinase. The patient was treated with dextrose infusion, antihistamines, fluids and haemodialysis. Renal failure resolved completely and the patient was discharged in a stable condition.