A Case of Cobra Bite in a Term Pregnant Woman: The Obstetric and Wound Management Challenges.

Snake envenomation is a rare incident during pregnancy and potentially challenging to manage. Snakebites in pregnancy may lead to several complications such as teratogenicity, miscarriage, antepartum hemorrhage, and even intrauterine fetal death. Here, we report a case of a pregnant woman who presented to our emergency department with signs of systemic envenomation following an Indian cobra bite on her foot, highlighting the key obstetric and wound management challenges. She complained of severe pain at the site of the bite and progressive swelling, abdominal pain, and multiple episodes of vomiting, which started 45 min after the bite. She received 10 vials of polyvalent antivenom from a primary hospital and was then referred to our center. The patient underwent emergency cesarean section and later fasciotomy with free-flap reconstruction at the bitten site due to local tissue necrosis. The case was successfully managed by a multidisciplinary team consisting of an emergency physician, obstetrician, and plastic surgeon, saving 2 lives and the limb of the patient.

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.

Reply: Optic Nerve Sheath Diameter in Hyponatremia: A Closer Look.

How to cite this article: Hansda U, Shaji IM, Uttanganakam S. Reply: Optic Nerve Sheath Diameter in Hyponatremia: A Closer Look. Indian J Crit Care Med 2023;27(6):453.

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.

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.

Epidemiology of mass casualty incidents in a tertiary care trauma center in eastern India: A retrospective observational study.

OBJECTIVES: Disasters and mass casualty incidents (MCIs) that cause substantial mortality and morbidity have been increasing worldwide. The emergency department (ED) services manage MCIs by optimizing triage and providing health care with required resources. The present study attempted to describe the epidemiological characteristics and outcomes of MCIs presenting to the ED. METHODS: The present retrospective observational study was conducted at the ED of a tertiary care hospital on patients of MCI for 4 years from 2017 to 2021. The data were extracted from the ED disaster records and other paper-based patient records. Information on patient demography, date and time of arrival, mode of transport, method of arrival (direct or referral), type and mechanism of MCI, ED management, and outcome were recorded. Statistical analysis was performed using R, version 4.1.0. RESULTS: Analysis of 21 MCIs was conducted. Road traffic accidents (RTAs) were the predominant cause of MCIs. The majority of MCI victims, except for those of blast injuries, were men. The victims in medical emergencies were significantly younger than those in other MCI groups (P < 0.001). The majority of patients were brought to ED through ambulance services (n = 120 [47.1%]), followed by private vehicles (n = 112 [44.2%]). Most of the MCI victims (n = 143 [56.2%]) were brought to the ED during evening hours (4 pm-8 pm). The majority of victims belonged to the "Red" triage category (n = 110 [43.3%]). The injury severity score was significantly higher (P = 0.014) in the disaster group than in other trauma MCI groups (20 vs. 17). Autorickshaw occupants were the most common victims of mass casualty RTAs (n = 38 [40%]). Suturing (n = 97 [50%]) and dressing (n = 167 [88%]) were the most common ED procedures required by the victims of trauma MCIs. Of the total, 167 (66%) patients were discharged from the ED, 47 (19%) patients were admitted to wards, 13 (5%) patients were admitted to intensive care units, and 24 (9%) patients got referred to other centers. In addition, two patients died in the ED during treatment, whereas one patient was brought dead. CONCLUSIONS: RTAs dominate the MCIs and are affecting the young producative male population. The present study exhibited the severity of the cases in MCIs and their impact in the health-care setting, therefore signifying the importance of standardized MCI management protocols.