Prognostication and Prediction of Outcomes in Patients with Organophosphorus and Carbamate Poisoning: A Prospective Cohort Study.

Background: Organophosphorus (OP) and carbamate poisoning are significant concerns in developing nations. This study evaluates the effectiveness of the ChE check mobile, a cholinesterase-rapid bedside diagnostic test, in the diagnosis and management of OP and carbamate poisoning. Materials and methods: We conducted this prospective observational study, involving patients with OP and carbamate poisoning over 1 year (June 2016 to June 2017) at a single tertiary care center. Levels of RBC cholinesterase (E-AChE), butyl cholinesterase (BChE), and various other determinants were systematically coded and analyzed. Results: The study population (n = 60) consisted primarily of males (n = 43; 71.7%), with a mean age of 30.6 (SD: 13.7) years. Monocrotophos (n = 10; 20.4%) and carbofuran (n = 4; 8.1%) were the commonest OP and carbamate compounds, respectively. The median initial atropinization dose was 10 (IQR: 0, 61.5) mg, with a median total administered atropine dose of 116 (IQR: 32, 320) mg. A significant negative correlation was found between E-AChE levels and both the initial atropinization dose (ρ: -0.653, p-value < 0.001) and total atropine requirement (ρ: -0.659, p-value < 0.001) during admission. An E-AChE cut-off of 4 units/g hemoglobin provided an area under the curve of 0.73 (sensitivity: 80.0%, specificity: 68.6%, p-value < 0.001) for predicting moderate to severe peradeniya organophosphorus poisoning. Conclusion: The check mobile device can be a valuable tool for prognosticating patients. There was a significant correlation between low E-AChE levels and the atropine requirement and severity. How to cite this article: Jha A, Hazra D, Yadav B, Zachariah A, Alex R. Prognostication and Prediction of Outcomes in Patients with Organophosphorus and Carbamate Poisoning: A Prospective Cohort Study. Indian J Crit Care Med 2024;28(2):141-147.

Impact of Fatigue on Emergency Physicians' Decision-making for Computed Tomographic Scan Requests and Inpatient Referrals: An Observational Study from a Tertiary Care Medical Center of the Sultanate of Oman.

Objective: Multiple factors contribute to decision fatigue experienced by emergency physicians (EPs). This study examines the association between decision fatigue and the frequency of computed tomographic (CT) scan requests and inpatient referrals among EPs. Methods: This retrospective database analysis was done for 3 months. Scans and inpatient referral requests were coded and analyzed to assess the impact of physician fatigue on decision-making. Subsequently, the outcomes were evaluated. Results: The majority of patients (n = 481; 51.1%) had a CT brain request. Among these requests, the morning shift (8:00 a.m.-3:00 p.m.) accounted for the highest number (n = 400; 42.5%), followed by the evening shift (3:00-11:00 p.m.) (n = 345; 36.7%). Approximately one-third of the patients (n = 301; 31.9%) had positive CT scan findings. Statistical analysis comparing the first and the second halves of each shift did not reveal significant variations in the percentage of negative CT results (p-value: 0.093). Inpatient referral was necessary for over half of the patients (n = 1,048; 52.7%), and the majority of these referrals (n = 778; 74.2%) were deemed necessary for treatment under various surgical or medical specialties. There was a statistically significant difference in the proportion of negative inpatient referrals between the first and the second halves of the afternoon shift (p-value < 0.001). Conclusions: Fatigue among EPs was observed, leading to more frequent consultations without inpatient admission during the latter half of the afternoon shift. However, the study found no significant impact of decision fatigue on CT scan decision-making. How to cite this article: Al-Arimi AH, Hazra D, Al-Alawi AKA. Impact of Fatigue on Emergency Physicians' Decision-making for Computed Tomographic Scan Requests and Inpatient Referrals: An Observational Study from a Tertiary Care Medical Center of the Sultanate of Oman. Indian J Crit Care Med 2023;27(9):620-624.

Unveiling the Crystal Ball: Predictors of Adverse Outcomes in Intracerebral Hemorrhage Patients.

Introduction: Intracerebral hemorrhage (ICH) is a severe form of stroke with substantial morbidity and mortality worldwide. Despite its impact, research has often focused on ischemic strokes, making ICH an essential area to explore. Methods: A retrospective cohort study spanning 5 years was conducted in an Oman-based tertiary care teaching hospital's emergency room. Data from patients diagnosed with spontaneous ICH, confirmed by cranial CT scans, were analyzed. Ethical approval was obtained. Results: Among 163 emergency room (ER)-presented patients with ICH, 89 met the inclusion criteria. Most were male (69.66%), with hypertension (69/89) and diabetes mellitus (43/89) being common comorbidities. Hematoma size was a crucial predictor of poor outcomes, especially for larger hematomas (>60 cm³). Midline shift, intraventricular hemorrhages, elevated systolic and diastolic blood pressure, and low Glasgow Coma Scale (GCS) scores were significantly associated with unfavorable outcomes. However, variables such as age, gender, history of heart disease, hypertension, diabetes, and anticoagulant use did not show significant associations with disability outcomes. Favorable outcomes (mRS <3) were observed in 47.2% of patients, while 30.3% had a major disability (mRS 3-5), and 22.5% succumbed to their illness (mRS 6). Conclusion: This study enhances our understanding of ICH outcomes, highlighting the importance of hematoma size, midline shift, intraventricular hemorrhage, blood pressure control, and GCS scores in predicting disability. Future research could explore additional prognostic factors and interventions for ICH patients. How to cite this article: Al-Alawi AKA, Hazra D, Al-Hassani MJK, Al-Jamoudi ASA. Unveiling the Crystal Ball: Predictors of Adverse Outcomes in Intracerebral Hemorrhage Patients. Indian J Crit Care Med 2023;27(12):895-901.

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.

Code blue: Predictors of survival.

Background and Aims: Code blue is a rapid response system developed for emergency resuscitation and stabilization of any sudden cardiac arrest (SCA) within a hospital. Literatures on outcome and factors predicting mortality from SCA in the Emergency departments (EDs) of India is scant. Material and Methods: This retrospective cohort study included all patients above the age of 15 years who had a code blue declared in the ED between the months of January 2018 and June 2019. Factors related to the sustained return of spontaneous circulation (ROSC) and mortality were analyzed using descriptive-analytic statistics and logistic regressions. Results: This study included 435 patients with a male predominance of 299 (69%). The mean age was 54.5 (SD - 16.5) years. Resuscitation was not attempted for 18 patients because of the terminal nature of the underlying disease. The majority were in-hospital cardiac arrests (74%). The nonshockable rhythm included pulseless electrical activity (PEA) (85.5%) and asystole (14.5%) cases. Shockable rhythms, that is, pulseless ventricular tachycardia/ventricular fibrillation were noted in only 10% (43/417) of cases. ROSC was attained in 184 (44.1%) patients, among which 56 (13.4%) were discharged alive from the hospital. Multivariate logistic regression analysis showed CPR >10 min (odds ratio [OR]: 13.58; 95% CI: 8.39-22.01; P < 0.001) and female gender (OR: 1.89; 95% CI: 1.13-3.17; P = 0.016) to be independent risk factors for failure to achieve ROSC in ED. Conclusion: The initial documented rhythm was nonshockable in the majority of the cases. CPR duration of more than 10 min and female gender were independent risk factors for failure to achieve ROSC in the ED. Nonshockable rhythms have a poorer outcomes than that of shockable rhythms.

Impact of the Lockdown due to COVID-19 Pandemic on the Spectrum and Outcome of Trauma in India.

Background: As a pre-emptive measure against the rampaging severe acute respiratory syndrome coronavirus 2 (SARS CoV-2), the Government of India ordered an unprecedented but imperative step of a nationwide lockdown on 22nd March, 2020. The entire month of April 2020 remained in a complete national lockdown. Methodology: We conducted this retrospective study to compare the spectrum and outcome of trauma victims who presented to our emergency department (ED) from April 2020 (lockdown period) to a similar season matched control arm of April 2018 (non-lockdown period). Results: Our study groups included 403 trauma victims (trauma prevalence: 9.7%) from April 2020 as compared to 667 trauma victims (trauma prevalence: 10.8%) from April 2018 with an absolute decrease of -39.6% during the lockdown month. The intense lockdown resulted in an absolute decrease in the number of road traffic accidents (RTA) (-75.1%), sports-related injuries (-81.8%), bull gore injuries (-64.3%), workplace-related injuries (-50.0%), and fall from height (-3.5%). However, an absolute increase in the number of falls on level ground (FLG) (+95.7%), domestic trauma (+91.4%), and burn (+37.5%) patients were noted during the lockdown period. The proportion of trauma victims under the influence of alcohol, as determined by a positive blood alcohol content, was significantly lower in the lockdown period [adjusted OR: 0.34 (95% CI: 0.17-0.67); p-value: 0.002] as were RTAs [adjusted OR: 0.44 (95% CI: 0.31-0.62); p-value: <0.001], FLG [adjusted OR: 1.87 (95% CI: 1.14-3.06); p-value: 0.0], and head injuries [adjusted OR: 0.21 (95% CI: 0.13-0.3); p-value: <0.001]. Conclusion: During the stringent lockdown period of April 2020, there was a significant absolute decrease in the number of trauma victims, especially RTAs. The intense lockdown resulted in a significant decrease in the proportion of trauma victims under the influence of alcohol, head injuries, fractures, and dislocations. How to cite this article: Hazra D, Jindal A, Fernandes JP, Abhilash KPP. Impact of the Lockdown due to COVID-19 Pandemic on the Spectrum and Outcome of Trauma in India. Indian J Crit Care Med 2021;25(3): 273-278.

Prevalence, Spectrum, and Outcome of Deliberate Self-harm Presenting to Emergency Department during COVID-19 Pandemic of 2020.

BACKGROUND: The coronavirus disease-2019 (COVID-19) pandemic, and the lockdown imposed, has had profound social and economic consequences and thereby implications on psychological health. This study aims to understand the effects of the pandemic and the lockdown on the prevalence, spectrum, and outcome of patients presenting with deliberate self-harm (DSH) to the emergency department (ED). MATERIALS AND METHODS: This was a retrospective, observational study done in the ED of a tertiary care hospital in South India on DSH victims presenting from January to August 2020, spanning the prelockdown, lockdown, and unlock phases of the pandemic, and compared with data from a similar period in 2018. RESULTS: Our study population included 507 DSH victims (prevalence: 1.2%) from January to August 2020. The percentage of DSH cases showed a slight increase among the prelockdown (203/17,234: 1.18%), the lockdown (179/14,687: 1.22%), and the unlock phases (125/9,977: 1.25%). There was a female preponderance (286/507: 56.4%), and the mean age was 33.2 years. Of the 507 patients, 369 (72.8%) were admitted and 19 (3.7%) died. The lockdown period in 2020 showed a 40.9% absolute decrease in the number of DSH victims presenting to the ED as compared to an equivalent period in 2018. The proportion of patients taking plant poisons was significantly lower [odds ratio (OR) 0.38, 95% confidence intervals (CI) 0.18-0.81, p = 0.012] and that of corrosive ingestion was significantly higher (OR 2.94, 95% CI 1.57-5.48, p = 0.001) in the lockdown phase as compared to a lockdown-control phase of 2018. CONCLUSION: There was a reduction in the absolute number of patients presenting with DSH to the ED during January-August 2020, and more so during the lockdown phase (March 24-June 30), as compared to a similar period in 2018. There was no significant difference in the hospital outcome of DSH patients between the two periods. HOW TO CITE THIS ARTICLE: John SM, John A, Hazra D, Murugan S, Abhilash KPP. Prevalence, Spectrum, and Outcome of Deliberate Self-harm Presenting to Emergency Department during COVID-19 Pandemic of 2020. Indian J Crit Care Med 2021;25(12):1387-1394.

Changing pattern of trauma during the COVID-19 Pandemic.

BACKGROUND: The COVID-19 pandemic compelled the Indian government to enforce a complete nationwide lockdown on 24th March 2020. METHODS: This retrospective study was done to analyse the profile of trauma patients presenting to the emergency department (ED) from January to August 2020. Data from 69 days of lockdown and 83 days of pre-lockdown periods were used to calculate the 30-day incidence rates. RESULTS: During the 7-month study period, 5220 patients presented to our ED with trauma; 2296 in the prelockdown phase (83 days), 1205 during the lockdown phase (69 days), and 1719 during the postlockdown phase (92 days). There was a significant decrease (36.7%) in the 30-day incidence rate of trauma victims presenting to the ED during the lockdown phase (525) compared with the prelockdown phase (830). The 30-day incidence of road traffic accidents (RTA), fall from height, fall on level ground and other trauma decreased by 53.2%, 26%, 23.2% and 12.9%, respectively, while assault cases increased by 8.3% during the lockdown period as compared with the prelockdown period. During the lockdown period, the 30-day incidence of trauma victims with a positive blood alcohol content decreased by 39.6% with a significant drop in the strict lockdown month of April 2020. CONCLUSIONS: A significant reduction in the incidence rate of trauma victims, especially RTA and geriatric trauma was seen during the gruelling lockdown period of the COVID 19 pandemic.

An Elucidation of Pattern of Injuries in Patients with Fall from Height.

BACKGROUND: Fall from height (FFH) is the second most common cause of trauma presenting to the emergency department (ED). They account for majority of the polytrauma cases. This study was done to determine the pattern of injuries sustained due to FFH and outcome. MATERIALS AND METHODS: This was a retrospective observational study of all patients with history of FFH presenting to the ED of a large tertiary care hospital in South India. Details of the incident, fall height, injuries, and outcome were noted and analyzed. RESULTS: This study cohort included 861 patients with a mean age was 36.2 (SD 20.8) years. A male predominance (74%) was noted. Majority of the patients, i.e., 62%, were triaged as priority 2, depending on the hemodynamic stability. Approximately a quarter (26%) sustained injury to the lower limbs with 18% sustaining spinal cord injury (SCI). Among the patients suffering SCI (35%), patients were further categorized in the American Spinal cord Injury Association (ASIA) classification. New Injury Severity Score (NISS) was more than 8 in 47% of the total study population. Majority of the patients, i.e., 62%, were discharged stable from ED after primary care with a plan of follow-up in the outpatient department. One-third (30%) of the total patients required hospital admission and among them 20% of the patients had to undergo major surgical intervention. The rest were either discharged stable or left against medical advice (LAMA) after primary care. The in-hospital mortality rate was 1.04%. CONCLUSION: This study has expressed the pattern of injuries in patients with FFH. An alarmingly high number of young adults with significant lower limbs and spinal injuries were noted. We observed that with increase in fall height there was a proportional increase in SCI and decrease in lower limb injuries. HOW TO CITE THIS ARTICLE: Lohanathan A, Hazra D, Jyothirmayi CA, Kundavaram AP. An Elucidation of Pattern of Injuries in Patients with Fall from Height. Indian J Crit Care Med 2020;24(8):683-687.

Does apneic oxygenation with nasopharyngeal cannula during intubation improve the oxygenation in patients with acute hypoxemic respiratory failure compared to the standard bag valve mask preoxygenation? An open-labeled randomized control trial.

OBJECTIVES: In the context of acute hypoxemic respiratory failure (AHRF), ensuring effective preoxygenation and apneic oxygenation emerges as the pivotal approach ensuring for averting hypoxemic adverse events during endotracheal intubation. To investigate this, we conducted an open-label randomized controlled trial, aiming to assess the comparative effectiveness of nasopharyngeal high-flow oxygenation in conjunction with Bag-Valve-Mask (BVM) versus standard BVM preoxygenation in patients experiencing AHRF within the emergency department (ED). METHODS: This prospective single-center, open-labeled, randomized controlled trial enrolled patients aged 18 years and above requiring rapid sequence intubation due to AHRF in the ED. Participants were randomly assigned in a 1:1 ratio to either the intervention arm (involving nasopharyngeal high-flow oxygenation and BVM preoxygenation) or the control arm (involving BVM preoxygenation alone). RESULTS: A total of 76 participants were enrolled in the study, evenly distributed with 38 individuals in each arm. Median (interquartile range [IQR]) SpO2 at 0 min postintubation was 95.5 (80%-99%) versus 89 (76%-98%); z-score: 1.081, P = 0.279 in the intervention and control arm, respectively. The most common postintubation complications included hypoxia (intervention arm: 56.7% vs. control arm: 66.7%) and circulatory/hypoxic arrest (intervention arm: 39.5% vs. control arm: 44.7%). There were no adverse complications in 36.7% (n = 11) of patients in the intervention arm. Despite the best possible medical management, almost half (52.6%) of patients in the intervention arm and 47.4% of patients in the control arm succumbed to their illnesses in the ED. CONCLUSION: The primary outcome revealed no statistically significant difference between the two arms. However, patients in the intervention arm exhibited fewer intubation-related adverse effects.

Subthalamic Deep Brain Stimulation in Parkinson's Disease: A Boon or Bane - A Single Centre Retrospective Observational Study from India.

Background Subthalamic deep brain stimulation (STN-DBS) for refractory Parkinson's disease (PD) is more of a modality of treatment that is empirical, for which a physiological explanation is being sought. This study was done to determine the outcome and complications of patients undergoing STN-DBS for PD. Methods This retrospective observational cohort study was conducted in an advanced neuromedicine facility in eastern India for 9 years (August 2013-August 2022), which included all patients undergoing STN-DBS. Results A total of 53 patients were operated on during the study period. The mean age group of the study population was 60.5 (standard deviation [SD]: 8.2) years with a male (33 [62.3%]) predominance. The most common presenting complaints included rigidity and hypokinesia (27), severe dyskinesia (21), and tremors (17). During the postoperative period, rigidity and hypokinesia (21), severe dyskinesia (16), and tremors (12) improved significantly in a subset of the patients. The majority (45 [84.9%]) of these cases received bilateral monopolar simulation, whereas three patients (5.7%) had bilateral bipolar stimulation. Unilateral bipolar stimulation was used in five (9.4%) patients. In the immediate postoperative period, they were initiated on limb, speech, and swallowing therapy as indicated. Surgery-related complications were seen in five (9.4%) cases. At 6 months of follow-up, a significant improvement in the Unified PD rating scale component (mainly motor examination and complication of PD therapy) was noted in the majority (36 [67.9%]) of patients. One patient developed neuroleptic malignant syndrome and succumbed to his illness on the fourth postoperative day. Conclusion Given these findings, STN-DBS appears to be a good, safe, and effective treatment for a subset of medically refractory PD with an overall improvement in two-thirds of the study cohort and less than 10% risk of complications.

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.

Performance of Aerosol Boxes for Endotracheal Intubation during the COVID-19 Pandemic with Systematic Review.

Introduction: In the backdrop of the COVID-19 pandemic, endotracheal intubation using an aerosol box (AB) became the norm in the emergency department (ED) and the intensive care unit. We compared two models of AB with different dimensions to compare and identify a device that helps in reducing viral exposure without compromising successful airway management. Methods: We conducted this prospective observational study for 7 months (October 20-April 21) on 143 patients presenting with an acute airway compromise to the ED. All intubations were performed using one of the two models available. The primary outcome was time taken for intubation (TTI). Results: The overall median time taken to intubate using any AB was 63 (interquartile range [IQR]: 46.2-87.7) s with an 81.9% first-pass success (FPS) rate. TTI for AB I was 67 (IQR: 53-106) s with a 76.3% FPS rate, while TTI for AB II was 57 (IQR: 44-75) s with an 85.9% FPS rate. TTI was much shorter without the use of an AB (34: IQR: 24-53 s) with a 92% FPS rate. Intubations done by emergency physicians with more than 2 years of experience were faster in both with or without AB when compared to intubations done by physicians with <2 years of experience. Conclusion: The use of an AB is associated with a longer TTI when compared to intubations done without an AB. TTI was relatively shorter when more experienced emergency physicians performed intubation. FPS rates were low with intubations done using AB.

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.

A clinico-epidemiological profile, coinfections and outcome of patients with Influenza Like Illnesses (ILI) presenting to the emergency department during the COVID-19 pandemic.

Background: During the COVID-19 pandemic, many patients presented to the emergency department (ED) with features of Influenza-like illnesses (ILI) and with other atypical presentations. This study was done to determine the etiology, co-infections, and clinical profile of patients with ILI. Methods: This prospective observational study included all patients presenting to the ED with fever and/or cough, breathing difficulty, sore throat, myalgia, gastrointestinal complaints (abdominal pain/vomiting/diarrhea), loss of taste and altered sensorium or asymptomatic patients who resided in or travelled from containment zones, or those who had contact with COVID-19 positive patients during the first wave of the pandemic between April and August 2020. Respiratory virus screening was done on a subset of COVID-19 patients to determine co-infection. Results: During the study period, we recruited 1462 patients with ILI and 857 patients with the non-ILI presentation of confirmed COVID-19 infection. The mean age group of our patient population was 51.4 (SD: 14.9) years with a male predominance (n-1593; 68.7%). The average duration of symptoms was 4.1 (SD: 2.9) days. A sub-analysis to determine an alternate viral etiology was done in 293 (16.4%) ILI patients, where 54 (19.4%) patients had COVID 19 and co-infection with other viruses, of which Adenovirus (n-39; 14.0%) was the most common. The most common symptoms in the ILI-COVID-19 positive group (other than fever and/or cough and/or breathing difficulty) were loss of taste (n-385; 26.3%) and diarrhea (n- 123; 8.4%). Respiratory rate (27.5 (SD: 8.1)/minute: p-value < 0.001) and oxygen saturation (92.1% (SD: 11.2) on room air; p-value < 0.001) in the ILI group were statistically significant. Age more than 60 years (adjusted odds ratio (OR): 4.826 (3.348-6.956); p-value: <0.001), sequential organ function assessment score more than or equal to four (adjusted OR: 5.619 (3.526-8.957); p-value: <0.001), and WHO critical severity score (Adjusted OR: 13.812 (9.656-19.756); p-value: <0.001) were independent predictors of mortality. Conclusion: COVID-19 patients were more likely to present with ILI than atypical features. Co-infection with Adenovirus was most common. Age more than 60 years, SOFA score more than or equal to four and WHO critical severity score were independent predictors of mortality.

A single - center retrospective observational study on patients undergoing Encephalo-Duro-Arterio -Myo-Synangiosis in patients with moyamoya disease.

BACKGROUND: Many cases of moyamoya disease are refractory to conventional medical therapy, hence surgical revascularization techniques have emerged as one of the primary choices of treatment. In this study, we present the functional and angiographic outcomes of patients undergoing encephalo-duro-arterio-myo-synangiosis (EDAMS). METHODS: This is a retrospective observational cohort study, done over 8 years (2012-2020) in a neurological center in Eastern India. Data were retrieved from the hospital's electronic system, recorded in a standard data abstract sheet, and analyzed. RESULTS: This study included 75 patients, with a male (n = 42; 56.0%) preponderance. Majority belonged to the pediatric age group (≤18 years) (n = 70; 93.3%); remaining adult population included 5 (6.6%) patients. The most common presenting complaint was that of an ischemic cerebrovascular accident (CVA) (n = 57; 76.0%). Symptomatic hemispheres (n = 69; 92.0%) were treated and later followed if they had progressed to bilateral disease formation. Preoperative DSA showed 50 (71.4%) to have Suzuki grade 3 type of angiographic findings. Postoperative complications included worsening unilateral hemiparesis 4 (40%), slurring of speech (n = 2; 20.0%), hematoma (n = 2; 20.0%), and surgical site infection (n = 2; 20.0%). One patient succumbed to his illness on the second postoperative day. A postoperative angiogram showed regression of moyamoya vessels in the majority (n = 69; 93.3%) of patients. All (n = 74; 100%) had an intensification of transdural vessels; none had a regression. None of the study participants showed an intensification of moyamoya vessels. Many of our patients (83.8%) had a good grade of revascularization (modified Matsushima and Inaba A and B), while 16.2% had low-grade revascularization (grade C). On assessing outcomes using a modified Rankin Score, a large number of our patients had an excellent (n = 45, 60%) neurological outcomes. CONCLUSION: There was a bimodal age distribution with most of them presenting with ischemic CVA. This procedure (EDAMS) had good angiographic (Matsushima and Inaba) and functional (modified Rankin Score) outcomes.

A Rare Case Report of an Intradural Left Cerebellopontine Angle Chordoma.

Intracranial intradural chordomas are rare entities constituting 1 to 3% of primary bone tumors. The mainstay of treatment remains aggressive resection of the lesion followed by adjuvant radiation therapy. We hereby report a case of a 70-year-old gentleman with intracranial, intradural chordoma arising from the left cerebellopontine angle. We hope to add to the existing minimal literature on this subject by highlighting this case, the first reported one from Asia.

Three waves, three vaccines, three COVID-19 infections - Saga of a frontline health care worker during the pandemic.

The COVID-19 pandemic affected millions around the globe, with front line healthcare workers (HCW) amongst the most vulnerable. The Emergency Department (ED) was the first line of care for all patients infected with the virus, making HCWs in the ED one of the most exposed populations during the pandemic. We highlight the case of a 35-year-old ED physician who developed COVID-19 infections on three separate instances during the peaks of each wave despite the usage of personal protective equipment and being triple vaccinated.

A Retrospective analysis of the profile of trauma victims presenting to an emergency department in South India.

Background: Trauma is a leading cause of morbidity and mortality in both developed and developing countries. Methodology: This retrospective observational study was done in the Emergency Department (ED) of a tertiary care trauma center in Southern India in 2018 (January to December). Results: During the study period of 1 year, the ED attended 74,466 patients which included 7675 (10.3%) trauma patients. The mean age was 35.3 (SD: 18.5) years with three-fourth (76.6%) being males. Pediatric/adolescents (age ≤18 years) and geriatric age groups (age ≥60 years) comprised 16.7% and 11.8% cases, respectively. Road traffic accidents (RTA) (66%) were the predominant mode of injury followed by falls (fall from height: 8.6% and fall on level ground: 7.8%). Among the RTAs, the majority were two-wheelers related (73.8%), followed by pedestrian injuries (9.4%) and four-wheelers injuries (7.2%). Bivariate and multivariate logistic regression analysis showed pedestrian injuries, low Glasgow Coma Scale (GCS), and hypotension at arrival as independent predictors of hospital mortality. The in-hospital mortality rate was 0.7%. A quarter (24%; n = 1841) of the patient's population was solely managed by the ED team and discharged stable, while 2179 (28.4%) victims required hospital admission. Conclusion: Trauma is a major cause of mortality especially among the breadwinners of families in India with almost half being due to two-wheeler accidents. Efficient ED professionals and a multispecialty team of trauma surgeons, neurosurgeons, and orthopedics handle the major load of acute trauma. Pedestrian injuries, low GCS, and hypotension at arrival are independent predictors of in-hospital mortality.