Role of high-dose methylprednisolone in Zargar Grade IIB corrosive esophageal burns: A randomized control study.

OBJECTIVE: The objective of the study is to test the efficacy of high-dose methylprednisolone in the prevention of esophageal stricture after corrosive ingestion. METHODS: This study was a single-center, randomized controlled single-blinded study. Simple randomization was done with 15 adult patients (>18 years) in each arm, who presented with a history of corrosive ingestion within the past 24 h and had esophageal injury of Zargar Grade IIB on endoscopy. Intravenous methylprednisolone 1 g/day for 3 days was given to the intervention arm while 100 mL of normal saline was given as placebo in control arm. Follow-up to diagnose esophageal stricture was done at 8 weeks. RESULTS: Thirty patients (15 in each arm) were recruited for the study. As per the intention to treat analysis, 33% and 46.6% developed stricture in the intervention and control arm, respectively (relative risk [RR] = 0.714; 95% confidence interval 0.29-1.75; P = 0.462). 40% patients in control group and 7.7% in intervention group had undergone feeding jejunostomy, which was statistically significant with a p-value of 0.048. Airway injury showed significant clinical improvement in the intervention arm but the difference was nonsignificant statistically (P = 0.674). There was no increased incidence of hypertension, hyperglycemia, hyponatremia, hyperkalemia, or infections in intervention arm. CONCLUSION: Methylprednisolone does not help in the prevention of stricture formation in corrosive esophageal injury, but it significantly reduces the requirement of feeding jejunostomy and has a beneficial role in treating airway injury.

High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial.

OBJECTIVES: Sympathetic crashing acute pulmonary edema (SCAPE) is a subset of heart failure with a dramatic presentation. The unique physiology of this condition requires a different management strategy from the conventional practice. The trial objective was to compare the efficacy of high-dose and low-dose GTN in patients with SCAPE. METHODS: This was an open-label randomised control trial conducted in a tertiary care teaching hospital in India from 11 November 2021 to 30 November 2022. Consenting participants were randomised to high-dose GTN or conventional low-dose GTN. The primary outcome was symptom resolution at 6 hours and 12 hours. Secondary outcomes included intubation rates, admission rates, length of hospital stay, and any short-term adverse effects of GTN and major adverse cardiac events (MACE) at 30 days. RESULTS: Fifty-four participants were included (26 high-dose GTN, 26 low-dose GTN). At 6 hours, symptom resolution was seen in 17 patients (65.4%) in the 'high-dose' group, compared with 3 (11.5%) in the 'low-dose' group (p<0.001). At 12 hours, 88.5% of patients had a clinical resolution in the 'high-dose' arm versus 19.5% in 'low-dose' arm . The low-dose group had longer median hospital stay (12 hours vs 72 hours), more frequent MACE (3.8% vs 26.9%, p=0.02) and a higher intubation rate (3.8% vs 19.2%, p=0.08). The only short-term adverse effect seen was a headache in both the groups. CONCLUSION: In SCAPE, patients receiving high-dose GTN (>100 mcg/min) had earlier symptom resolution compared with the conventional 'low dose' GTN without any significant adverse effects. TRIAL REGISTRATION: Clinical trial registry of India (CTRI/2021/11/037902).

Emergency Department Point-of-Care Tests during Cardiopulmonary Resuscitation to Predict Cardiac Arrest Outcomes.

Introduction: This study evaluated the role of point-of-care tests (POCT) such as blood lactate, anion gap (AG), base deficit, pH, N-terminal pro B-type natriuretic peptide (NT-proBNP), and troponin as the predictors of cardiac arrest outcomes in the emergency department (ED). Methods: We conducted a prospective, observational study in the ED of a tertiary care hospital in India. All the adult patients who received cardiopulmonary resuscitation (CPR) in the ED were included in the study. Blood samples were collected within 10 min of initiation of CPR for assay of POCTs. Outcomes assessed were the return of spontaneous circulation (ROSC), 24-h survival, survival to hospital discharge (STHD), survival at 7 days, and favorable neurological outcome (FNO) at day 7 of admission. Results: One hundred and fifty-one patients were included in the study (median age: 50 years, 65% males). Out of 151 cases, ROSC, survival at 7 days, STHD, and FNO was observed in 86 patients, six patients, five patients, and two patients, respectively. "No-ROSC" could be significantly predicted by raised lactate (odds ratio [OR]: 1.14, 95% confidence interval: 1.07-1.22) and NT-proBNP (OR: 1.05, 1.01-1.09) values at the time of cardiac arrest. "24-h mortality" could be significantly predicted by the raised lactate (OR: 1.14, 1.01-1.28), low arterial pH (OR: 0.05, 0.01-0.52), raised AG (OR: 1.08, 1.01-1.15), and lower base deficit (<-15) (OR: 1.07, 1.01-1.14). None of the other POCTs was found to be a predictor of other cardiac arrest outcomes. Conclusion: Among various POCTs, raised lactate assayed within 10 min of cardiac arrest can predict poor outcomes like "no-ROSC" and 24-h mortality.

Performance of qSOFA Score as a Screening Tool for Sepsis in the Emergency Department.

Introduction: Sepsis is the leading cause of mortality, and various scoring systems have been developed for its early identification and treatment. The objective was to test the ability of quick sequential organ failure assessment (qSOFA) score to identify sepsis and predict sepsis-related mortality in the emergency department (ED). Methods: We conducted a prospective study from July 2018 to April 2020. Consecutive patients with age ≥18 years who presented to the ED with a clinical suspicion of infection were included. Sensitivity, specificity, positive predictive value (PPV), negative predictive values (NPV), and odds ratio (OR) for sepsis related mortality on day 7 and 28 were measured. Results: A total of 1200 patients were recruited; of which 48 patients were excluded and 17 patients were lost to follow-up. 54 (45.4%) of 119 patients with positive qSOFA (qSOFA >2) died at 7 days and 76 (63.9%) died at 28 days. A total of 103 (10.1%) of 1016 patients with negative qSOFA (qSOFA score <2) died at 7 days and 207 (20.4%) died at 28 days. Patients with positive qSOFA score were at higher odds of dying at 7 days (OR: 3.9, 95% confidence interval [CI]: 3.1-5.2, P < 0.001) and 28 days (OR: 6.9, 95% CI: 4.6-10.3, P < 0.001). The PPV and NPV with positive qSOFA score to predict 7- and 28-day mortality were 45.4%, 89.9% and 63.9%, 79.6%, respectively. Conclusion: The qSOFA score can be used as a risk stratification tool in a resource-limited setting to identify infected patients at an increased risk of death.

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.

The Role of Triple Rule-out CT in an Indian Emergency Setting.

Background: Emergency physicians are acutely aware of the consequences of missing fatal diagnoses for acute non-traumatic chest pain and subjecting patients to over-testing. In the large arsenal of tests that are available to us, a triple rule-out computed tomography (TRO-CT) Angiography is often less pursued, due to concerns about their efficacy and safety or because of nescience. We aim to find the yield of the test in an Indian emergency setting and impart some knowledge about it along the way. Materials and methods: Twenty-six patients who presented to the emergency department of our institute with acute chest pain, with non-specific electrocardiogram (ECG) findings and negative serial troponin I, underwent TRO-CT. HEART scores of all patients, calculated at their presentation, were correlated with TRO-CT findings. Results: Triple rule-out computed tomography angiography was positive in 5 patients (20%), of which 4 cases (16%) were diagnosed to have significant coronary artery disease and one had an acute pulmonary embolism. All 4 patients who had significant coronary artery disease (CAD) diagnosed by TRO-CT had a HEART score of intermediate risk. The mean effective radiation dose of the entire TRO study was 19.024 ± 3.319 mSv (range = 13.89-25.95 mSv). Conclusion: Triple rule-out CT angiography is a useful tool in the evaluation of patients presenting with acute chest pain in the emergency and can be an important adjunct in ruling out significant CAD in intermediate-risk patients. Emergency physicians and young residents need to know about this tool in their armamentarium to tackle doubtful cases. How to cite this article: Pattereth N, Chaliyadan S, Mathew R, Kumar S, Das CJ, Aggarwal P. et al. The Role of Triple Rule-out CT in an Indian Emergency Setting. Indian J Crit Care Med 2023;27(3):190-194.

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.

Prospective Validation of a Novel Triage System Developed in a Middle Income Country - AIIMS Triage Protocol.

Introduction: Triage is a crucial process not only to identify sick patients and prioritize prompt management but also to foster efficient resource utilization. In low-and middle-income countries (LMICs) most emergency departments (ED) still have an informal triage process. Although an important element of emergency care, triage research has not been a priority in LMICs, and hence, very few triage systems have been validated. The All India Institute of Medical Sciences (AIIMS) triage protocol or ATP for adult patients was developed by expert consensus at AIIMS using the Delphi method. We attempted a prospective validation of the ATP in terms of mortality and intensive care unit (ICU)/hospital admission at 24 h. Methods: Patients presenting to the ED, who were 14 years and above were included in the study. The patients were followed up at 24 h and their outcome documented on a standardized data collection form. Mortality and ICU admission were noted at 24 h. Results: A total of 15,505 patients were recruited. After exclusion, among 13,754 patients, 6303 (45.83%) were triaged red and 7451 (54.17%) were triaged yellow. Mortality at 24 h was 10.31% (650) in red triaged patients and 0.35% (26) in yellow triaged patients. The 24-h mortality of red triaged patients was significantly higher (P <0.001) than that of yellow triaged patients. The presence of one or more ATP "Red" criteria was 96.2% (95% confidence interval [CI]: 94.42%-97.47%) sensitive and 56.8% (95% CI: 55.92%-57.63%) specific in predicting 24-h mortality. The sensitivity and specificity of ATP "Red" criteria for 24-h ICU admission were 98.5% (95% CI: 97.7%-99.1%) and 59.6% (95% CI: 58.8%-60.5%), respectively. Conclusion: When applied to adult nontrauma patients, ATP had a high accuracy in recognizing sick patients presenting to the ED. A time-tested and validated triage system like ATP may be a good starting point for public hospital EDs in LMICs.

Clinical characteristics and outcome of patients presenting to emergency department during the second wave of COVID-19.

Background: COVID 19 resurgence in multiple waves and the highly infectious variant of SARS-CoV-2 (B.1.617) has wreaked havoc across healthcare systems in India. We conducted a study to delineate the clinico-epidemiological profile of COVID-19 patients in this second wave of the pandemic. Methods: This was a retrospective, single centre, observational study at the Emergency Department(ED) of a teaching institute in North India. The ED health records were screened for patient files with the diagnosis of COVID -19, age > 14 years, presenting from 10th April to 30th of May. ED clinical notes, disposition, and mortality data were retrieved and analysed. Results: 1647 files were screened and 253 eligible patients of COVID-19 were included in the study. 60% patients were male, mean age (+ SD) was 54 (+ 14.8 years). Shortness of breath (74.7%), fever (71.9%), cough (57.7%) were the common presenting symptoms. 20% of patients were nil comorbid; Diabetes (44.7%) and Hypertension (41.5%) were the common comorbid illnesses. 73.1% patients had severe COVID illness, 39.9% had oxygen saturation <90% on arrival and 33.2% had <70%. More than 90% patients required respiratory support on arrival. 25% of people presented to hospital after home isolation, of which 81% had severe COVID at presentation. 39 % patients of mild illness had received corticosteroids. Conclusion: The second wave of COVID-19 with rapid upsurge of cases overwhelmed the healthcare system with a higher proportion of severe COVID-19 cases and higher mortality, thus stressing the need for prior planning, preparation and strengthening healthcare systems across tiers.

Strengthening emergency care systems to improve patient care for ST-elevation myocardial infarction (STEMI) at a high-volume tertiary care centre in India.

BACKGROUND: ST-elevation myocardial infarction (STEMI) is a highly time-sensitive and life-threatening condition. Early recognition and timely management are challenging in a busy emergency department (ED), especially in low/middle-income countries where emergency systems are often fragmented. The aim of our quality improvement (QI) project was to increase the percentage of patients with STEMI undergoing primary percutaneous coronary intervention (PCI) with door to balloon (D2B) time of <90 min by 30% over 12 months. METHODS: As part of the first step in QI, baseline data were collected at different points in the process of care. Using process maps and fishbone analysis, delays in patient registration, ECG and communication with cardiology were identified as some bottlenecks, and change ideas were tested using plan-do-study-act cycles using point-of-care QI methodology. The majority of the change ideas focused on interventions in the ED like strengthening triage, training frontline staff, early diagnosis and quick transportation of patients. RESULTS: During the baseline phase, 22.22% of patients were found to have a D2B time of <90 min. We achieved an increase of 47.78% in patients receiving PCI within 90 min and hence increased to 70% at the end of the intervention phase. Data collected for 4 months after the intervention phase were found to have sustained the effort. CONCLUSION: Significant improvement in the door to reperfusion time resulted from a meticulous assessment of emergency care processes by drawing process flow chart and implementation of change ideas like introduction of fast-track policy for patients with chest pain, reducing staff turnover in the triage area, formal training of staff, continuous engagement with cardiology team and by interchanging of processes which led to a reduction in time to ECG.

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.

SARS-CoV-2 Omicron Variant Wave in India: Advent, Phylogeny and Evolution

SARS-CoV-2 evolution has continued to generate variants, responsible for new pandemic waves locally and globally. Varying disease presentation and severity has been ascribed to inherent variant characteristics and vaccine immunity. This study analyzed genomic data from 305 whole genome sequences from SARS-CoV-2 patients before and through the third wave in India. Delta variant was responsible for disease in patients without comorbidity(97%), while Omicron BA.2 caused disease primarily in those with comorbidity(77%). Tissue adaptation studies brought forth higher propensity of Omicron variants to bronchial tissue than lung, contrary to observation in Delta variants from Delhi. Study of codon usage pattern distinguished the prevalent variants, clustering them separately, Omicron BA.2 isolated in February grouped away from December strains, and all BA.2 after December acquired a new mutation S959P in ORF1b (44.3% of BA.2 in the study) indicating ongoing evolution. Loss of critical spike mutations in Omicron BA.2 and gain of immune evasion mutations including G142D, reported in Delta but absent in BA.1, and S371F instead of S371L in BA.1 could possibly be due to evolutionary trade-off and explain very brief period of BA.1 in December 2021, followed by complete replacement by BA.2.

Variants of concern responsible for SARS-CoV-2 vaccine breakthrough infections from India.

Emerging reports of SARS-CoV-2 breakthrough infections entail methodical genomic surveillance for determining the efficacy of vaccines. This study elaborates genomic analysis of isolates from breakthrough infections following vaccination with AZD1222/Covishield and BBV152/Covaxin. Variants of concern B.1.617.2 and B.1.1.7 responsible for cases surge in April-May 2021 in Delhi, were the predominant lineages among breakthrough infections.

BRASH Syndrome: A Case Report.

BACKGROUND: BRASH syndrome, a relatively new entity, has been described in the recent literature. It is defined as a combination of bradycardia, renal failure, atrioventricular nodal blockade, shock, and hyperkalemia. Although it is apparent that clinical symptomatology includes shock, it is still unclear whether all patients will initially present with all five components mentioned in the BRASH acronym. CASE REPORT: An elderly woman presented to our Emergency Department (ED) with hyperkalemia, acute renal failure, and metabolic acidosis with bradycardia, which was refractory to antikalemic measures and atropine. The montage of clinical features put together showed a clear picture of BRASH syndrome, which helped us to streamline the management and achieve a better patient outcome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Renal failure with various metabolic derangements is commonly seen in the ED. We should be aware of this new clinical entity, as its incidence will certainly increase, and the management is a bit different. Prognosis is excellent with timely recognition and management of this rare clinical entity.

Prognostic Value of Serum Procalcitonin Levels in Patients With Febrile Neutropenia Presenting to the Emergency Department.

BACKGROUND: Various risk-stratification scores have been developed to identify low-risk febrile neutropenia (FN). The Multinational Association of Supportive Care in Cancer (MASCC) score is a commonly used validated scoring system, although its performance varies due to its subjectivity. Biomarkers like procalcitonin (PCT) are being used in patients with FN to detect bacteremia and additional complications. OBJECTIVE: Our objective was to compare the performance of MASCC score with PCT in predicting adverse outcomes in patients with FN. METHODS: This was a prospective observational study that included chemotherapy-induced FN in hematologic or solid malignancy. The MASCC score, PCT levels, and blood cultures were taken at the first point of contact, and patient treatment was managed according to routine institutional protocol. The primary outcome was mortality at 30 days. RESULTS: A total of 100 patients were recruited, of which 92 had hematologic malignancy and 8 had solid malignancy. Forty-six patients were classified as low risk by MASCC score (≥21). The PCT threshold, 1.42 ng/mL, was taken as a cutoff value, with area under the receiver operating characteristic curve (AUROC) of 0.664 (95% confidence interval [CI] -0.55 to 0.77) for predicting mortality. AUROC for MASCC was 0.586 (95% CI 0.462 to 0.711). CONCLUSIONS: PCT is a useful marker with better prognostic efficacy than MASCC score in patients with FN and can be used as an adjunct to the score in risk-stratifying patients with FN.

Acute lead poisoning: a diagnostic challenge in the emergency department.

Acute abdominal pain is a common presentation to the emergency department (ED). Ruling out life-threatening causes and giving pain relief are the most important tasks in ED. We describe a 32-year-old man who presented to ED with abdominal pain and vomiting which was unrelieved by usual doses of analgesic. Extensive investigations revealed no significant abnormalities. On further probing, he admitted taking traditional medications for infertility. The toxicological panel revealed a high blood lead level, leading to a diagnosis of acute lead toxicity. Chelation therapy with D-penicillamine was initiated and the patient's abdominal pain resolved within 4 days.

Utility of HEART Pathway in Identifying Low-Risk Chest Pain in Emergency Department.

BACKGROUND: Chest pain is a common presenting symptom in the emergency department (ED). The HEART (history, electroencephalogram [ECG], age, risk factors, and troponin I) score, with addition of troponin at 3 h, helps to determine appropriate risk stratification of the patients. OBJECTIVE: This study evaluated the utility of the HEART pathway as a decision aid designed for risk stratification of patients with acute-onset chest pain for early and safe disposition. METHODS: This was a prospective observational study done in a tertiary care center. Focused history, 12-lead ECG, and baseline troponin I level on arrival and at hour 3 were recorded. Subjects were classified as low risk (HEART score 0-3) or high risk (HEART score ≥ 4). Patients with a HEART score of 0-3 with negative troponin I at 3 h were discharged and were followed up for major adverse cardiac events (MACEs) within 30 days of ED presentation. RESULTS: A total of 250 patients were screened for the study, of which 151 were included for the final analysis. One hundred and two patients (68%) were male and 54% of patients were younger than 45 years. HEART scores of 0 (n = 16), 1 (n = 43), 2 (n = 44), and 3 (n = 48) were observed. There was only 1 MACE (0.7%) in 30 days after ED discharge in the study population. The mean length of ED stay in the low-risk group was 4.5 h. CONCLUSIONS: Low-risk patients, as per the HEART pathway, can be discharged safely from the ED, which reduces ED stay and health care resource use.

"Six-dial Strategy"-Mechanical Ventilation during Cardiopulmonary Resuscitation.

As per current guidelines, whenever an advanced airway is in place during cardiopulmonary resuscitation, positive pressure ventilation should be provided without pausing for chest compression. Positive pressure ventilation can be provided through bag-valve resuscitator (BV) or mechanical ventilator (MV), which was found to be equally efficacious. In a busy emergency department, with less trained personnel use of MV is advantageous over BV in terms of reducing human errors and relieving the airway manager to focus on other resuscitation tasks. Currently, there are no guidelines specific to MV settings in cardiac arrest. We present a concept of "six-dial ventilator strategy during CPR" that encompasses the evidence-based settings appropriate during chest compression. We suggest use of volume control ventilation with the following settings: (1) positive end-expiratory pressure of 0 cm of water (to allow venous return), (2) tidal volume of 8 mL/kg with fraction of inspired oxygen at 100% (for adequate oxygenation), (3) respiratory rate of 10 per minute (for adequate ventilation), (4) maximum peak inspiratory pressure or P max alarm of 60 cm of water (to allow tidal volume delivery during chest compression), (5) switching OFF trigger (to avoid trigger by chest recoil), and (6) inspiratory to expiratory time ratio of 1:5 (to provide adequate inspiratory time of 1 second). How to cite this article: Sahu AK, Timilsina G, Mathew R, Jamshed N, Aggarwal P. "Six-dial Strategy"-Mechanical Ventilation during Cardiopulmonary Resuscitation. Indian J Crit Care Med 2020;24(6):487-489.

The INDUSEM Position Paper on the Emerging Electronic Waste Management Emergency.

Electronic waste or e-waste is a serious and concerning issue globally. Exponential increase in the production of these instrument have created a man-made problem of e-waste; United Nations has called it as "tsunami of e-waste." Informal management and unsafe disposals have compounded the problem further. The hazardous chemicals, metals, and organic pollutants released from e-waste can lead to serious health consequences such as organ damage, genetic defects, neuropsychiatric illness, and cancer. Problem of e-waste is colossal and should be seen as major public health emergency. In India, use of electronic instrument has increased considerably with less focus on formal waste management and safe disposal. This has created a major health hazard. International health agencies, Indian Council of Medical Research, e-waste regulating bodies, academic institutes, and various government and non-government organizations should join hands together to effectively manage the problems of e-waste. Swacch Bharat Abhiyan started by the honorable Prime Minster should consider e-waste as the top most priority in terms of its safe management and disposal.