Improvement in the diagnosis and practices of emergency healthcare providers for heat emergencies after HEAT (heat emergency awareness & treatment) an educational intervention: a multicenter quasi-experimental study.

BACKGROUND: The incidence of heat emergencies, including heat stroke and heat exhaustion, have increased recently due to climate change. This has affected global health and has become an issue of consideration for human health and well-being. Due to overlapping clinical manifestations with other diseases, and most of these emergencies occurring in an elderly patient, patients with a comorbid condition, or patients on poly medicine, diagnosing and managing them in the emergency department can be challenging. This study assessed whether an educational training on heat emergencies, defined as heat intervention in our study, could improve the diagnosis and management practices of ED healthcare providers in the ED setting. METHODS: A quasi-experimental study was conducted in the EDs of four hospitals in Karachi, Pakistan. Eight thousand two hundred three (8203) patients were enrolled at the ED triage based on symptoms of heat emergencies. The pre-intervention data were collected from May to July 2017, while the post-intervention data were collected from May to July 2018. The HEAT intervention, consisting of educational activities targeted toward ED healthcare providers, was implemented in April 2018. The outcomes assessed were improved recognition-measured by increased frequency of diagnosing heat emergencies and improved management-measured by increased temperature monitoring, external cooling measures, and intravenous fluids in the post-intervention period compared to pre-intervention. RESULTS: Four thousand one hundred eighty-two patients were enrolled in the pre-intervention period and 4022 in the post-intervention period, with at least one symptom falling under the criteria for diagnosis of a heat emergency. The diagnosis rate improved from 3% (n = 125/4181) to 7.5% (n = 7.5/4022) (p-value < 0.001), temperature monitoring improved from 0.9% (n = 41/4181) to 13% (n = 496/4022) (p-value < 0.001) and external cooling measure (water sponging) improved from 1.3% (n = 89/4181) to 3.4% (n = 210/4022) (p-value < 0.001) after the administration of the HEAT intervention. CONCLUSION: The HEAT intervention in our study improved ED healthcare providers' approach towards diagnosis and management practices of patients presenting with health emergencies (heat stroke or heat exhaustion) in the ED setting. The findings support the case of training ED healthcare providers to address emerging health issues due to rising temperatures/ climate change using standardized treatment algorithms.

Impact of heat waves on patients presenting to the emergency department of a tertiary care hospital - A single center cross-sectional study.

In the present cross-sectional study we aimed to identify factors associated with morbidity and mortality in patients during the heat wave period (June 17th till 23rd, 2015) in the emergency department. The inclusion criteria of the study was core temperature >38 degree Celsius and signs of dehydration recorded in-patient notes and CNS dysfunction without infection recorded through GCS. Of 400 patients mortality was observed in 50 patients (12.7%) of which majority were males (54%). Of the non-survivors, 27.3% had prior history of cerebrovascular accident. Difference was noted in clinical presentation among non-survivors with unconsciousness (14%) and gasping (12%). Differences were noted in median of platelets [251(190-331) versus 183.5(155-228.5)] and Creatinine [1.1(0.9-1.7) versus 2.1(1.4-2.4)] between survivors and non-survivors. Majority of non-survivors had deranged coagulation profile and hypoxaemia.

Prognostic significance of optic nerve sheath diameter on computed tomography scan with severity of blunt traumatic brain injury in the emergency department.

Optic nerve sheath diameter measurement (ONSD) has been associated with identifying the prognosis of traumatic brain injury (TBI) patients. The study was planned to evaluate the prognostic value of ONSD measured on the initial brain computed tomography (CT) scan performed on patients with blunt TBI in the emergency department(ED). This retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of moderate and severe TBI patients from January to December 2014. ONSD for each eye on the initial CT scan and Glasgow Coma Scale (GCS) was measured upon patient presentation. Correlation between presentation GCS and ONSD was done through Pearson's correlation. Receiver operator curve (ROC) analysis was done to measure the predictive values of ONSD for mortality. Of the 276 patients, 211(76%) were males and 65(23%) females. ONSD was measured on 160(58%) patients. The mean ONSD measured on CT scan was 3.8±1. The Pearson's correlation between the severity of brain injury as per GCS at presentation and ONSD was not significant (-0.182). We concluded that ONSD measured on the initial CT brain scan had good association with the severity of blunt TBI in patients presenting to the ED.

Hydrogen sulfide gas poisoning in fish garbage room: A report of a fisherman.

We report the case of a fisherman who was exposed to high concentrations of hydrogen sulfide (H2S) gas from the fish garbage room. The patient survived and was discharged with full recovery from the hospital. H2S is a colourless, foul smelling and highly toxic gas next to carbon monoxide, which causes inhalation death. It is a by-product of various industrial processes particularly involves exposure from agriculture, petrochemical industry and organic matter decomposition from sewage processing. It is a by-product of H2S has been referred as the "knock down gas" because inhalation of high concentrations can cause immediate loss of consciousness and death. Although early use of amyl nitrate and hyperbaric oxygen shows some benefit in literature, supportive care remains the mainstay of treatment. Emergency physicians and pre-hospital care personnel are not very familiar with such exposure due to its rarity. This becomes more relevant in the developing world settings where there are rising concerns about the unsafe exposure to hazardous chemicals and its impact on human health. Emergency physicians working in Pakistan should be aware of this entity especially in regard to fishermen presenting to the Emergency Department with such a clinical presentation and its toxic manifestations. This incident also illustrates the need of enforcement of health and safety regulations in the fishing industry.

Sepsis management: An evidence-based approach.

The Surviving Sepsis Campaign (SSC) guidelines have outlined an early goal directed therapy (EGDT) which demonstrates a standardized approach to ensure prompt and effective management of sepsis. Having said that, there are barriers associated with the application of evidence-based practice, which often lead to an overall poorer adherence to guidelines. Considering the global burden of disease, data from low- to middle-income countries is scarce. Asia is the largest continent but most Asian countries do not have a well-developed healthcare system and compliance rates to resuscitation and management bundles are as low as 7.6% and 3.5%, respectively. Intensive care units are not adequately equipped and financial concerns limit implementation of expensive treatment strategies. Healthcare policy-makers should be notified in order to alleviate financial restrictions and ensure delivery of standard care to septic patients.

Overcrowding in the emergency departments: Challenges and opportunities for improvement.

With the advent of Emergency Medicine, one can observe an increase in the number of Emergency Departments (ED) across the country. However, most EDs struggle due to an overwhelming number of patients. Overcrowding can lead to delays in patient care. For a city like Karachi which is an active disaster zone, preemptive preparedness is required in the face of terror threats and such overcrowding needs to be decreased to a bare minimum. The most frequent causes of prolonged length of stay (LOS) in the ED include non-availability of in-hospital beds, delays in response to subspecialty consultations and escalating medical expenses. All of these can negatively impact patient care by putting patient safety at risk and patient care in jeopardy. There is an increased risk of unintentional medical errors and a concomitant increase in unwanted lawsuits. A few simple interventions which may help alleviate this situation to some extent have been discussed.

PAIN ASSOCIATED WITH LIVER BIOPSIES THROUGH PERCUTANEOUS APPROACH UNDER SONO-GRAPHIC GUIDANCE--A CROSS SECTIONAL PILOT STUDY IN A TERTIARY CARE HOSPITAL.

BACKGROUND: Pain is one of the most common and feared complication of percutaneous liver biopsy under local anaesthesia using sonographic guidance. This observational study was set to judge the intensity of pain felt by adult patients presenting for percutaneous liver biopsy with known/suspected underlying hepatic pathology. METHODS: This observational cross sectional study which was piloted on 10% of the original sample size was conducted at Aga Khan University Hospital, Karachi. Study population was the adult patients coming for percutaneous liver biopsy at the Department of Radiology. Descriptive statistics were run, data was checked for normality. Means and Standard deviations were done for continuous variables and where data was skewed, median with inter quartile range was computed. Later data was clumped in categories, frequency and percentages were reported for categorical variables. Graphical representation of data was done. RESULTS: A total of 50 patients were recruited. Minimum pain reported on visual analogue scale (VAS) was 0 and maximum as 4.30% of patients rated 3 and similarly 30% of the people rated 4 on the VAS. Mean pain experienced was 2.7 +/- 1.11 and a median of 3 on VAS. This indicates that a minority of patients in our survey had a complaint of mild pain during the procedure. CONCLUSIONS: Percutaneous liver biopsy is a very safe procedure and minimal pain was felt by a minority of patients whereas the rest showed satisfaction from the procedure with no post procedural complaints.

Traumatic optic neuropathy from an air gun pellet injury: a case report.

Orbital apex fractures are a debilitating condition that can cause vision problems and are often associated with intracranial injury. Traumatic Optic Neuropathy (TON), which results in vision loss following a traumatic injury to the optic nerve, can be caused by various mechanisms, but most cases involve injuries to the globe, orbit, or adnexa. We are reporting a case of an 18 year old male with a history of an air gun being accidentally discharged into his left eye. He was evaluated and found to have an Orbital apex fracture with left eye TON. Patient was administered high dose steroids. Detailed evaluation by Ophthalmology revealed a left eye traumatic stage I macular hole which was conservatively treated with visual improvement reported during patient follow up.

Carotidynia presenting as an atypical cause of unilateral neck pain in the emergency department.

Carotidynia is a rare presentation of atypical neck and face pain, which is due to inflammation around the carotid artery. Symptoms can get aggravated by head and neck movements, jaw movements and deglutition. It is usually a self- limiting illness, and it is treated conservatively with analgesics. Because of it is rarity, and partly due to physician's lack of understanding, it remains underdiagnosed. Our case report aims to shed light on the importance of how its diagnosis cannot be missed.

Pneumomediastinum in an Accidental Chlorine Gas Exposed Victim.

Chlorine is an irritant gas, which is implicated in inhalational exposures and can affect the respiratory system leading to complications. We report a case of a 38-year man who presented in the Emergency Department (ED) after exposure to chlorine gas due to an industrial accident. During the course of ED stay, he developed gradual difficulty in breathing, which on investigation, was found to be related to the complication of pneumomediastinum. The patient required endotracheal intubation, but was difficult to ventilate. Bilateral chest tube insertion was performed, which led to the resolution of the pneumothoraces. The emergency physicians should be aware of such a case so that they can intervene. Key Words: Chlorine, Emergency, Pneumomediastinum, Toxicity.

Accuracy of computed tomography in diagnosing malignancy in solitary pulmonary lesions.

OBJECTIVE: To evaluate accuracy of Computed Tomography (CT) for diagnosing malignancy in solitary pulmonary lesions (SPLs). METHODS: A prospective cross-sectional study was conducted from 20-01-2007 to 30-06-2008 at the Radiology department, Aga Khan University Hospital (AKUH) Karachi. Fifty-three patients with solitary pulmonary lesions (SPLs) seen in prior chest x-rays or chest CT scans were referred to radiology department for CT guided biopsy. CT scan was performed for each patient prior to biopsy and CT evaluation of the SPLs was performed followed by CT guided Biopsy. Histopathological diagnosis of the lesion was taken as the gold standard. RESULTS: CT was found to be 100% sensitive, 30% specific and 87% accurate for diagnosing malignancy in solitary pulmonary lesions while PPV and NPV were 86% and 100% respectively. CONCLUSION: CT scan is highly sensitive yet non-specific and cannot be used as the definitive diagnostic modality for diagnosing malignancy in solitary pulmonary lesions.

Streptococcal Pharyngitis: Delving Deeper than the Throat.

Acute rhabdomyolysis and elevated transaminases during streptococcal pharyngitis are rare presentations. The proposed pathophysiological mechanisms include direct bacterial invasion and toxin generation. Physicians should be aware of the association between these infections and the above-mentioned complications to facilitate optimal treatment of these patients. We present the case of a 18-years-old gentleman with ß-haemolytic streptococcal pharyngitis complicated by rhabdomyolysis and elevated liver function tests. Such high levels of creatine phosphokinase of 111856 IU/L and elevated liver function tests with aspartate aminotransferase (AST) of 1862 U/L and alanine aminotransferase (ALT) of 1003 U/L in streptococcal pharyngitis is rare to find in the literature. He was treated with aggressive intravenous hydration, antibiotics and hemodialysis. Key Words: Rhabdomyolysis, ß-haemolytic Streptococci, Creatine phosphokinase, Liver function tests.

Acute Urinary Retention: Should We Call it a Manifestation of Appendicitis?

Acute urinary retention (AUR) is a fairly common presentation in the elderly; but interesting to be noted in a healthy young individual as a manifestation of acute appendicitis. We present a case of a 32-year gentleman with decreased urine output with mild tenderness at the supra-pubic region; which was later on, shifted to the right iliac fossa. Computed tomography of the abdomen showed acute appendicitis. Emergency physicians are challenged to recognize the uncommon presentation of acute appendicitis and need to be reminded of this common complaint as a rare presentation of it. This case also stresses on the repeated abdominal examinations to seek diagnostic clarity. Key Words: Appendicitis, Acute urinary retention, Repeat abdominal examination.

The Rapid COVID Screening (RCS) Tool.

As the COVID-19 outbreak continues, there is a dire need to organise and allocate resources while optimising costs and time: identification of patients should be rapid and economical. With the current spectrum of clinical presentations of patients with COVID-19, it is important to be thorough while determining symptoms involving the various organ systems including possible contact history. Point-of-care (POC) lung ultrasound has already proven to be a reliable tool in diagnosing lung inflammatory processes: the results are immediate and the examination is safe, repeatable, and cheap. Early use of POC lung ultrasound could prove invaluable in COVID-19 patients, leading to early correct diagnoses and appropriate management. The author suggests a tool that incorporates various aspects in clinical history, POC lung ultrasound findings and hemodynamic parameters for identification and management of patients during the COVID-19 pandemic. Key Words: COVID-19, Sars CoV-2, Emergency department, Screening, Point-of-care, Lung ultrasound.

Optimising Ventilator Use during the COVID-19 Pandemic.

Hypoxemia is the most common cause for hospitalization in COVID-19 patients. Acute hypoxemic respiratory failure or acute respiratory distress syndrome (ARDS) is the most common complication in COVID-19 patients. Close monitoring of respiratory decompensation is essential. Supplemental oxygen, high flow nasal canula, non-invasive ventilation and endotracheal intubation are the most commonly suggested methods to improve oxygenation. Early intubation with pre-oxygenation, modified rapid sequence intubation and intubation using a video laryngoscope has been advised as a strategy including lung protective ventilation, prone position ventilation, adequate sedation and extracorporeal membrane oxygenation. Strict personal precautions and challenges related to airway management has been currently studied. The authors summarize here the issues of mechanical ventilation and some strategies to resolve them. Key Words: Mechanical ventilation, COVID-19, Hypoxemia.

Thinking of Unilateral Osteitis Condensans Ilii in the Emergency Room: Case of a Young Pregnant Female with Back Pain.

Osteitis condensans ilii (OCI) remains an orthopedic diagnostic dilemma; moreover, such presentation in the emergency room (ER) is unique. Limited awareness about this topic compels emergency and internal medicine physicians to perform extensive investigations which often leads to misdiagnosis. A 23-year pregnant female presented in the Emergency Room with severe low back pain, who was treated conservatively with radiological evidence of OCI. The mainstay treatments are analgesics and physiotherapy. Key Words: Osteitis condensans ilii, Back pain, Pregnancy, Triangular sclerosis.

Comparison of qSOFA and SOFA score for predicting mortality in severe sepsis and septic shock patients in the emergency department of a low middle income country.

OBJECTIVE: We aimed to determine a comparison between the Quick Sequential Organ Failure Assessment (qSOFA) score and existing Sequential Organ Failure Assessment (SOFA) score when applied to severe sepsis & septic shock patients in the Emergency Department (ED) for prediction of in-hospital mortality in the setting of a tertiary care hospital ED in a low-middle income country. METHOD: We conducted a prospective observational cohort study on 760 subjects. The qSOFA, SOFA score and in-hospital mortality were assessed by area under the receiver operating curve (AUROC). We calculated sensitivity and specificity for each score for outcomes at cut-offs of 0.92 and 0.63 for qSOFA and SOFA in Severe Sepsis respectively and 0.89 and 0.63 for qSOFA and SOFA in Septic shock respectively. RESULTS: In patients with severe sepsis, the AUROC of qSOFA for predicting mortality in subjects was 0.92 (95% CI; 0.89-0.94) with 96% sensitivity and 87% specificity in comparison to the AUROC of SOFA score which was 0.63 (95% CI; 0.55-0.70 with 71% sensitivity and 57% specificity. In patients with septic shock, the AUROC of qSOFA for predicting mortality in subjects was 0.89 (95% CI; 0.85-0.92) with 92% sensitivity and 85% specificity in comparison to the AUROC of SOFA score which was 0.63 (95% CI; 0.55-0.70 with 70% sensitivity and 59% specificity. CONCLUSION: Our study concludes that qSOFA score is an effective tool at predicting in hospital mortality in comparison to SOFA score when applied to severe sepsis and septic shock patients in the setting of a tertiary care hospital ED of a low-middle income country however, further studies are needed before application for this purpose.