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Objective: Intravenous thrombolysis within 4.5 hours from time of onset has proven benefit in stroke. Universal standard for the door-to-needle (DTN) time is within 60 minutes from the time of arrival of patients to the emergency department. Our rapid thrombolysis protocol (RTPr) was developed with an aim to reduce the DTN time to a minimum by modifying our stroke post-intervention processes. Methods: This before-and-after study was conducted at a single center on patients who received intravenous thrombolysis in the emergency department. Consecutive patients who were thrombolysed using our RTPr (post-intervention group) were compared to the pre-intervention group who were thrombolysed before the implementation of the protocol. The primary outcomes were DTN time, time to recovery, and modified ranking score (mRS) on discharge. Secondary outcomes were mortality, symptomatic intracerebral hemorrhage, and hospital and intensive care unit length of stay. Results: Seventy-four patients were enrolled in each group. Mean DTN time in pre- and post-intervention group was 56.15 minutes (95% CI 49.98--62.31) and 34.91 minutes (95% CI 29.64--40.17) (p <0.001), respectively. In pre-intervention and post-intervention groups, 43.24% (95% CI 32.57--54.59) and 41.89% (95% CI 31.32--53.26) patients, respectively, showed neurological recovery in 24 hours. About 36.49% (95% CI 26.44--47.87) in pre-intervention group and 54.05% (95% CI 42.78--64.93) in post-intervention group had discharge mRS 0--2. Conclusion: The RTPr can be adapted by clinicians and hospitals to bring down the DTN times and improve outcomes for stroke patients. [ABSTRACT FROM AUTHOR]

Objectives: Emergency department (ED) length of stay (LOS) is defined as the time a patient is registered to the time the patient is shifted to a hospital bed or discharged. Increasing demand for quality emergency care has resulted in increased wait times due to demand and supply mismatch. It is perceived that longer LOS in the ED of critical patients leads to poor outcomes. Our goal was to study the impact of LOS in the ED on the patients who required critical care admissions. Methods: This was a retrospective study conducted in the ED of a tertiary center. Data were collected using electronic health records (EHR) for patients admitted to the intensive care units (ICUs). Patient's LOS in ED was divided into 0--4, 4--8, 8--12, 12--24, and >24 hours. ED LOS was calculated from the registration time to the time patient was handed over in the ICU. Patients were divided into four categories (1--4) based on their criticality. LOS in ED, mortality, and total hospital LOS were analyzed in the study. Results: Three thousand four hundred and twenty-nine patients were enrolled in the study. Mean age was 62.69 years (95% CI 62.11--63.26). A total of 42.09% (95% CI 40.5--43.8) were Category 1 patients. Overall mortality rate was 52.46% (95% CI 50.79--54.13). LOS of 48.15% (95% CI 46.54--49.88) patients in the ED was between 0 and 4 hours, 19.90% (95% CI 18.62--21.29) between 4 and 8 hours, 8.21% (95% CI 7.35--9.19) between 8 and 12 hours, 15.50% (95% CI 14.34--16.77) between 12 and 24 hours, and 8.13% (95% CI 7.27--9.10) >24 hours. Mortality for LOS of 0--4 hours was 51.30% (95% CI 48.89--53.70), 54.03% (95% CI 50.28--57.73) for 4--8 hours, 48.94% (95% CI 43.16--54.75) for 8--12 hours, 51.50% (95% CI 47.26--55.72) for 12--24 hours, and 60.57% (95% CI 54.73--66.13) for >24 hours. Conclusion: We concluded that the longer the critically ill patients are boarded in the ED, the higher is the chance for mortality. Processes should be implemented to ease the throughput from the ED. [ABSTRACT FROM AUTHOR]

Background: Altered mental status (AMS) comprises a group of clinical symptoms rather than a specific diagnosis. A variety of neurological scales have been used to monitor these patients, including the Glasgow coma scale (GCS), AVPU (alert, responds to verbal stimuli, responds to painful stimuli, unresponsive) scale, and ACDU (alert, confused, drowsy, unresponsive) scale. The simplified motor scale (SMS) has been found to be a potential replacement for the GCS. In this study, we compare the interrater reliability of the GCS (individual components), AVPU, ACDU, and SMS to patients presenting to the ED with AMS. Materials and methods: This was a prospective observational study conducted in the emergency department of an urban tertiary-care hospital in New Delhi, India. Patients with AMS (traumatic and nontraumatic) presenting to the ED were assessed by two emergency physicians within 10 minutes of each other using the four neurological scales. Percentage agreement and kappa coefficient score were used to determine interrater reliability for SMS, individual components of GCS, AVPU, and ACDU. Results: The SMS had the best inter-rater percent agreement with 83.91% (95% CI 77.7-88.6%), followed by ACDU which was 76.44% (95% CI 69.0-81.6%), AVPU 75.29% (95% CI 67.8-80.6%), GCS Eye 74.14% (95% CI 66.6-79.6%), GCS Verbal 67.82% (95% CI 60.6-74.3%), and GCS Motor was 64.94% (95% CI 57.6-71.6%).The kappa coefficient for SMS was 0.75 (95% CI 0.67-0.83), followed by GCS Eye which was 0.63 (95% CI 0.540.72), AVPU 0.62 (95% CI 0.52-0.72), ACDU 0.60 (95% CI 0.49-0.71), and GCS Verbal 0.58 (0.49-0.66) and GCS Motor was 0.53 (95% CI 0.44-0.63). Conclusion: It can be said that SMS has the best interrater reliability in the ED and can be recommended for clinical use in the emergency departments for patients presenting with AMS. [ABSTRACT FROM AUTHOR]

Verma et al. meticulously prevented the further complications once they recognize the entrapped guidewire in the right ventricle. Authors were very correct to mention overzealous insertion of the guidewire without watching the monitor, which may lead to such complications; however, every time monitor is not available for assistance. The Seldinger technique is routinely used for inserting central venous (CV) and hemodialysis (HD) catheters; however, both are different entities and their designs and lengths including of their guidewires vary. During guidewire insertions, simply adhering to the safe length may prevent or minimize many guidewire-related complications. [ABSTRACT FROM AUTHOR]

Acute decompensated heart failure (ADHF) is responsible for a heavy clinical load on busy emergency departments (EDs) across the globe and especially in India. ADHF patients may present with severe respiratory distress, dyspnea, hypoxia, and high and low blood pressures. Managing the airway of such patients can at times be challenging. Nasal cannulae, face mask, and noninvasive positive pressure ventilation (NIPPV) are the cornerstones of providing oxygenation and ventilation to such patients while some extreme cases may require endotracheal intubation and mechanical ventilation. An elderly female in severe respiratory distress and altered sensorium presented to our ED and had to be administered ketamine to facilitate proper NIPPV and avoid mechanical ventilation. She was weaned off the NIPPV in the ED itself over the next four hours. There are some case reports of using ketamine for NIPPV in asthma exacerbations, but none for the use in ADHF. Avoiding invasive mechanical ventilation via endotracheal intubation should be a constant goal and the last resort. [ABSTRACT FROM AUTHOR]