Differentiating Cardiac and Pulmonary Causes of Dyspnea Using Ultrasonography and Dyspnea Discrimination Index.

BACKGROUND: One of the most common reasons for emergency room (ER) visits is acute dyspnea. The challenge is in differentiating a cardiac and pulmonary cause of acute breathlessness. Hence, we have studied the effectiveness of the dyspnea discrimination index (DDI) used in conjunction with ultrasonography (USG) in distinguishing between cardiac and pulmonary causes of dyspnea. METHODS: This was a prospective study conducted in the ER and general medicine wards to evaluate the efficacy of the DDI and USG in dyspneic patients. Data were entered in a standard data sheet and analysis was done using SPSS software. RESULTS: The majority of the patients were between the ages of 45 and 60, with a male predominance. Risk factors like smoking were more common in the pulmonary group (36%). Pulmonary cause of breathlessness was seen in 62% of patients and cardiac pathology was noted in 28%. The mean (SD) DDI value and DDI% are as follows: pulmonary group (DDI)-5.47 (SD: 2.82); cardiac group (DDI)-8.34 (SD: 3.75); pulmonary group (DDI%)-1.31 (SD: 0.68); cardiac group (DDI%)-2.34 (SD: 1.14). There was a significant difference in DDI% between the pulmonary and cardiac groups (p = 0.001). DDI was found to have a sensitivity and specificity of 77.3% and 70%, respectively. While for DDI%, sensitivity and specificity were 72.7% and 72%, respectively. Lung USG had 98% sensitivity and 95.5% specificity, with a narrow confidence interval. The positive likelihood ratio was noted to be 21.6, indicating a very high post-test probability. CONCLUSION: The DDI and USG in conjunction had good discriminative power, when it came to distinguishing between cardiac and pulmonary causes of dyspnea. USG had a high specificity and sensitivity, making it suitable for identifying the cause of dyspnea in a tertiary care ER setting. HOW TO CITE THIS ARTICLE: Chandy GM, Sathyendra S, Pichamuthu K, Hazra D, Abhilash KPP. Differentiating Cardiac and Pulmonary Causes of Dyspnea Using Ultrasonography and Dyspnea Discrimination Index. Indian J Crit Care Med 2022;26(1):33-38.

Surgical Outcome of Basal Ganglia Hemorrhage: A Retrospective Analysis of Nearly 3,000 Cases over 10 Years.

Background Basal ganglia hemorrhage (BGH) is a severe neurologic condition associated with significant morbidity and mortality, and its optimal management remains a topic of debate. Our study assessed the surgical outcomes of BGH patients at the 3-month mark using the modified Rankin Scale (mRS). Methods This retrospective observational study was conducted over 10 years at an advanced neuro-specialty hospital in Eastern India, including patients who underwent decompressive craniotomy and hematoma evacuation. Variables were systematically coded and analyzed to evaluate the postoperative outcome with age (in years), preoperative motor (M) status, and hematoma volume. Results This study enrolled 2,989 patients with a mean age of 59.62 (standard deviation: 9.64) years, predominantly males ( n = 2,427; 81.2%). Hypertension (1,612 cases) and diabetes mellitus (1,202 cases) were the most common comorbidities. Common clinical presentations included ipsilateral weakness (1,920 cases) and/or altered mental status (1,670 cases). At the 3-month mark postsurgery, 2,129 cases (71.2%) had a favorable outcome based on mRS, while 389 cases (13.0%) had an unfavorable outcome. The regression equation showed that age was inversely related to the percentage of individuals achieving a favorable outcome. It also revealed that the preoperative motor score was positively correlated with favorable outcomes. Hematomas smaller than 60 mL had better outcomes, with 1,311 cases (69.1%) classified as good outcomes and 337 cases (17.8%) as bad outcomes. Fatal outcomes related to the illness were observed in 471 patients (15.8%) within the study population. Conclusion Surgery for BGH showed a substantial improvement in outcomes, particularly in patients with M5/M4 motor status. The preoperative motor score (M status) emerged as a crucial predictor of favorable neurological outcomes. Age and hematoma volume, however, were found to be nondefinitive factors in determining good outcomes.

Prospective review of 188 cases of epistaxis presenting to the emergency department: Etiology and outcome.

Background: Due to a myriad of risk factors, epistaxis is a very frequent presentation to the emergency room (ER). This study aims to ascertain the prevalence of epistaxis in our population, risk factors, effectiveness of ER treatment, complications, and ER outcome. Materials and Methods: This was a prospective observational study performed in the ER of a referral tertiary care center in south India. Data were categorized, coded, and analyzed to determine the objective of the study. Results: During the study's six-month duration, 188 (0.6%) patients presented with epistaxis. The mean age was 42.9 (SD: 16.49) years, with a male preponderance of 143 (76.1%). A majority of these patients (n: 156; 82.9%) were triaged as priority II, with hypertension (n: 53, 28.2%) as the commonest comorbidities. Trauma-related epistaxis (n: 107, 56.9%) was the most frequent cause. Anterior nasal packing was carried out for 85 (45.2%) patients, posterior nasal packing was carried out for one (0.5%) patient, and bleeding had spontaneously resolved in the majority (n: 102; 54.3%) patients. Seven (3.7%; p-value: 0.001) patients had recurrent epistaxis, and of those, three (1.6%) required urgent resuscitation with crystalloid fluid and blood products. Two of these patients had bleeding dyscrasias, four had history of trauma, and one patient presented with uncontrolled hypertension. Two (1.1%) patients came back to us with recurrent bleeding within 12 h of discharge. Majority (69.2%; 130) were discharged stable, (23.9%; 45) were admitted for observation and (6.9%; 13) were discharged against medical advice. There was no mortality among these study populations. Conclusion: Middle-young, aged males most commonly presented with epistaxis. Most of them were secondary to trauma. Anterior nasal bleeding was the most common source and hemostasis could be obtained by anterior nasal packing. Majority could be discharged stable from the ER. However, this cohort had seen patients in life-threatening conditions, so the severity cannot be overlooked.

Prevalence of Hypocortisolemia in Patients with Sepsis or Septic Shock (The HIS Study) Presenting to the Emergency Department.

Background: Cortisol response to stressors (hypothalamic-pituitary-adrenal axis, autonomic nervous system, and immune system) plays a vital role in maintaining stable metabolic homeostasis. This study was done to assess the prevalence of hypocortisolemia in patients presenting to ED with sepsis and/or septic shock. Methods: This prospective observational study was done from July 2020 to April 2021. Serum cortisol levels were measured in patients with sepsis and septic shock, and their clinical and laboratory profile was categorized, coded, and analyzed. Results: Ninety-eight patients were included, of which serum Cortisol <10 µg/dl was noted in 7 (7.2%) patients. The cohort's mean age was 52.9 (SD: 15.3) years with a male predominance (n-61; 62.2%). Most common presenting complaint was fever (n-52; 53.1%), followed by abdominal pain (n-24; 24.5%), and breathing difficulty (n-14; 14.3%). Systolic blood pressure <90 mmHg and tachycardia were seen in 63 patients (64.3%). Assessment of diet and native medication use did not demonstrate a predisposition to hypocortisolemia. The median (IQR) arterial lactate values were lower in the hypocortisolemic group: 2.2 (1.2-2.5) as compared to the non-hypocortisolemic group: 3.7 (2.2-8.0). Patients with septic shock without hypocortisolemia were noted to have a higher mean lactate level (2.6 ± 1.3 Vs 5.4 ± 3.9) and lower platelet counts compared to those with low cortisol levels. Patients with normal cortisol levels (n-38; 38.8%) still had low ACTH values. Conclusion: The prevalence of hypocortisolemia was lower when compared to other Indian studies. Diet and native medication use do not predispose Indians to hypocortisolemia.