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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.

Background: Leptospirosis is a zoonotic disease which requires laboratory diagnosis for confirmation. Materials and Methods: In this study serum samples from adults with acute undifferentiated fever (duration ≤15 days) were tested for IgM antibodies to Leptospira by ELISA, PCR for rrs gene and loop-mediated isothermal amplification (LAMP) assay for LipL32 and LipL41. Results: Among the 150 sera tested, three were positive by PCR, LAMP and IgM ELISA/modified Faines' criteria, two by only PCR; seven only by LAMP assay and forty fulfilled modified Faine's criteria (illness clinically compatible and IgM ELISA positive for leptospirosis). Clinical correlation revealed renal compromise, low platelet count and severe jaundice were significantly related to leptospirosis (P < 0.05). Conclusion: This study suggests that LAMP assay could be useful for diagnosis of leptospirosis during the 1st week of illness whereas IgM ELISA forms the mainstay of diagnosis from the 2nd week onward. Further studies especially community based, comparing ELISA, PCR, LAMP, culture and microscopic agglutination test are required to evaluate the veracity of these findings.

Background: Deliberate self-harm (DSH) is a major under-recognized epidemic in the low- and middle-income countries. This is a large retrospective study form the Emergency Department (ED) of Tertiary Care Center of South India to describe the clinicodemographic features of DSH cases. Materials and Methods: This is a retrospective study conducted at ED of Christian Medical College, Vellore, India from January 01, 2011 to December 31, 2013. All cases of DSH were included in the study. The demographic details, mode of DSH and clinical outcome were extracted from the electronic medical record. Descriptive statistics are presented. Chi-square test was used to compare categorical variables. For all tests, a two-sided P ≤ 0.05 was considered statistically significant. Results: Total of 1228 patients were admitted to ED for DSH during the study period. Male and female occurred in equal ratio. More than half of the cases occurred among age group below 30 years. Consumption of pesticides (agricultural chemicals) was the single most common mode of DSH (46%), especially among men, followed by medication overdose (29.8%). Consumption of plant poison and tablet overdose was higher among women. Overall mortality due to DSH was low (1.5%) in our study. Conclusion: DSH is under-recognized major public health problem in low-middle income countries like India. Most cases occur among young and productive age group and in equal frequencies among men and women. Timely and the appropriate institution of treatment can decrease the morbidity and mortality due to DSH remarkably.

Background: Emergency department (ED) revisits are an important measure of health-care quality provided by any medical center. This study analyzes the profile and outcome of patients revisiting the ED within 72 h at a tertiary care center in South India. Methods: This was a retrospective cohort study done on all patients presenting to ED within 72 h of their first visit over 5 months. Unavoidable revisits and the factors associated with them were categorized, coded, and analyzed. Results: The ED revisit rate was 2.9% (900/30409). Based on standard triaging criteria, patients during their first visit were triaged as follows: 8.2% as priority 1, 32% as priority 2, and 58.2% as priority 3. During the revisit, they were triaged as follows: 12.9% (+3.7% increase) as priority 1, 36.9% (+4.9% increase) as priority 2 and 49.1% (-9.1% decrease) as priority 3. Approximately a quarter (27%) of the patients had to be prioritized higher on their revisit. Abdominal pain (18.3%), vomiting/diarrhea (11.7%), bleeding from the previous wound site (10.5%), and fever (9%) were the most common presenting complaints. Avoidable revisits included 13.4% (n = 121) patients. Multivariate logistic regression analysis showed age >40 years (adjusted odds ratio [OR]: 1.60; 95% confidence interval [CI]: 1.04-2.46; P: 0.031) and abdominal pain (adjusted OR: 2.07;95% CI: 1.40-3.08; P: <0.001) to be independent predictors of unavoidable ED revisits. In addition, age >40 years (adjusted OR: 3.53; 95% CI: 2.12-5.88; P: <0.001) and fever (adjusted OR: 0.57;95% CI: 0.37-0.90; P: 0.015) were found to be independent risk factors for patients revisiting as priority 1 versus other priorities. Among the revisiting patients, 15.4% required admission. Conclusion: Gastrointestinal symptoms and fever were found to be the most common symptoms that warranted a revisit. Abdominal pain and age >40 years were found to be associated with higher odds of an unavoidable revisit. In addition, age >40 years and fever were associated with sicker patients on revisits. [ABSTRACT FROM AUTHOR]

Scrub typhus is endemic in large parts of India and can cause multi-organ failure and death. Acute pancreatitis as a complication is very rare and is potentially fatal. This case series describes seven adult patients who presented with an acute febrile illness and were diagnosed to have scrub typhus with acute pancreatitis. The mean age of the seven patients with acute pancreatitis was 49.4 years, and mean duration of fever prior to presentation was 7.7 days. All seven patients had abdominal pain, and three had a pathognomonic eschar. The mean serum lipase level was 1,509 U/L (normal value:

Introduction: The effectiveness of gastric lavage in organophosphorus (OP) poisoning has not been established. We assessed the ability of gastric lavage to remove OP insecticides as a preliminary stage in assessing effectiveness. Patients and methods: Organophosphorus poisoning patients presenting within 6 hours were included, irrespective of prior gastric lavage. A nasogastric tube was placed and gastric contents aspirated, followed by at least three cycles of gastric lavage with 200 mL of water. Samples from the initial aspirate and the first three lavage cycles were sent for identification and quantification of the OP compounds. Patients were monitored for complications of gastric lavage. Results: Around 42 patients underwent gastric lavage. Eight (19.0%) patients were excluded from the study because of a lack of analytical standards for ingested compounds. Insecticides were detectable in the lavage samples of 24 of 34 (70.6%) patients. Lipophilic OP compounds were detected in 23 of 24 patients, while no hydrophilic OP compounds could be detected in six patients with reported ingestion of hydrophilic compounds. For chlorpyrifos poisoning (n = 10), only 0.65 mg (SD 1.2) of the estimated ingested amount (n = 5) of 8,600 mg (SD 3,200) was recovered by gastric lavage. The mean proportion of the compound removed by initial gastric aspirate was 79.4% and subsequent three cycles removed 11.5, 6.6, and 2.7%. Conclusion: Lipophilic OP insecticides could be quantified in the stomach contents of OP poisoning patients with the first aspiration or lavage being most effective. The amount removed was very low; hence, routine use of gastric lavage for OP poisoning patients arriving within 6 hours is unlikely to be beneficial. [ABSTRACT FROM AUTHOR]

Background: During the COVID-19 pandemic, there was a necessary division of the emergency department (ED) into the COVID suspect zone and a green zone based on a modified "The" Christian Medical college (CMCTS). Triaging was initially done based on the epidemiological criteria and evolved into symptom-based assessment when community transmission began. Methodology: This retrospective study included all patients who were triaged in the ED from April 2020 to December 2020. Data were collected from the ED triage software and were analyzed to determine the performance of the modified triage criteria in admitting patients to the ED. Results: Forty-three thousand patients were triaged during the study. Of which 35.9% (n = 15429) were sent to the COVID suspect zone and 64.1% (n = 27571) to the green zone. Of the 8490 (55%) nasopharyngeal swab reverse transcription polymerase chain reaction (RT-PCR) tests done in the COVID suspect zone, 61.4% were positive for COVID-19 while only 9.2% (n = 274) of 2866 tested in the green zone were positive. COVID-19 positivity was the highest in the mid-pandemic months of July, August, and September 2020. In the COVID suspect zone, factors for predicting a negative RT-PCR result were priority 1 presentation and early and late pandemic presentations. The positive predictive value of our modified triage criteria during the pandemic was 85% with a higher accuracy during the peak of the first wave (July-September 2020). Conclusion: The modified CMCTS successfully segregated COVID-19-positive patients from the COVID-19 negative patients during the first wave of the COVID-19 in 2020. The CMCTS criteria can be easily adopted or adapted in other hospitals in India in case of future waves of COVID-19. [ABSTRACT FROM AUTHOR]

Background: Patients with malignancies present to the emergency department (ED) with a varied spectrum of presentations. Data on oncological emergencies are scant; hence, we aimed to determine the profile, outcome, and awareness of their treatment of patients with malignancies presenting to the ED. Methodology: This prospective observational study was conducted in the adult ED of a large tertiary care hospital in South India between February and August of 2018. A convenient sample of patients presenting to the ED with a known or newly diagnosed malignancy was included in the study after obtaining written informed consent. Results: During the study, we recruited 110 patients presenting to the ED. The mean age of the patients was 48 (15.9) years. There was a female preponderance (56.4%). A quarter of the patients had malignancy of the genitourinary tract while 10% had breast carcinoma and 9% had bronchogenic carcinoma. Vomiting (44%) was the most common symptom at presentation followed by fever (39%) and abdominal pain (38%). Anemia (81%) and hyponatremia (54.5%) were the most common laboratory abnormalities. Antiemetics (61%), antibiotics (32%), and nonsteroidal anti-inflammatory drugs (27%) were the most commonly used medications. Chemotherapy-related complications (35.5%) and mass effects (28%) were the most common reasons for ED visits. The majority (83%) were previously diagnosed with malignancies. Most patients were aware of the duration (86%) and common side effects of chemotherapy (79%). However, most were unaware of the chemotherapy drugs' names (25%) and how to manage side effects (54%). Sixty percent required admission and three patients died during their in-hospital stay. Conclusion: Gastrointestinal symptoms and fever are the most common causes of presentation to the ED among patients with malignancies. Although most patients were aware of the duration and side effects of treatment, half of them were ignorant of the emergency first aid for side effects of the medications they were on. [ABSTRACT FROM AUTHOR]

Scrub typhus is an acute febrile illness usually presenting with fever, myalgia, headache, and a pathognomonic eschar. Severe infection may lead to multiple organ failure and death. Gastrointestinal tract involvement in the form of gastric mucosal erosions and ulcerations owing to vasculitis resulting in gastrointestinal bleeding is common. This process may worsen a pre-existent asymptomatic peptic ulcer, causing duodenal perforation, and present as an acute abdomen requiring surgical exploration. We report the case of a patient with no previous symptoms or risk factors for a duodenal ulcer, who presented with an acute duodenal perforation, probably precipitated by scrub typhus infection.

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. [ABSTRACT FROM AUTHOR]

Background: The Surviving Sepsis Campaign recommends the administration of antibiotics within 1 hour of triage time in sepsis patients. The purpose of this study was to determine the factors affecting the time to first dose antibiotics in sepsis patients presenting to the emergency department (ED). Methods: We conducted a prospective observational study on factors affecting the time to first dose antibiotics in patients with sepsis presenting to the ED over a period of 7 months (July 2019 to January 2020). The purpose of this study was to determine the factors affecting the time to first dose antibiotics in sepsis patients. Results: During the study period, a total of 410 patients with a mean age of 51.6 years were presented to the ED with sepsis. Majority was triaged to priority 1 (84.8%). The median door to antibiotic time was 50 minutes (IQR, 40-90). Two-thirds (68%) of the patients (279) received antibiotics within 60 minutes. The blood culture positivity rate was 22.9%, and the contamination rate was 6%. The most common factors for the delay were atypical presentation (36.6%) and unknown focus of infection (36.6%). Triage to non-acute areas of the ED (priority 2) was associated with delayed antibiotic administration [odds ratio (OR), 7.3; 95% confidence interval (CI), 4.03-13.36; p-value <0.001]. Patients presented with cellulitis and necrotizing soft tissue infection (NSTI) had received antibiotics within an hour compared to other diagnoses (18.3 vs 8.4%; OR, 2.4; 95% CI, 1.2-4.9; p = 0.009). Conclusion: Two-thirds of our patients received their first dose of antibiotics within an hour of presentation to the ED. Triage to lower priorities was an independent risk factor for delay in first-dose antibiotic administration, and patients presented with an obvious focus of infections like cellulitis and NSTI received their first dose of antibiotic much earlier when compared to other diagnoses. [ABSTRACT FROM AUTHOR]

Background: Assessing fluid responsiveness in critically ill patients is challenging. Objective, noninvasive tests that are easy to perform are needed. Doppler measurements of dynamic carotid artery parameters such as carotid blood flow (CBF) and carotid flow time (CFT) are being studied as the potential indicators of volume responsiveness, but the data supporting its use are sparse. Methods: This prospective, observational study was conducted in the adult emergency department from June to September 2018. Patients who were prescribed a bolus of 500 ml of crystalloid for any indication were enrolled. Carotid Doppler was performed before and after a fluid bolus to measure the change in CBF and CFT. The aim of our study was to determine if CFT can be used as a marker of fluid responsiveness. Results: During the 4-month study period, 209 patients were recruited through convenient sampling after obtaining informed written consent. 29.6% of patients presented with a mean arterial pressure (MAP) <65, among whom 58.1% had septic shock. The baseline CBF was 643.0 ± 212.7 ml/min, and it was 583.9 ± 207.1 ml/min and 668 ± 210.8 ml/min in hypotensive and normotensive patients, respectively. Considering a >10% increase in CBF as fluid response, there were 59% responders and 41% nonresponders. The MAP increased by 9.5% in the responders, while there was no significant change in CFT after the fluid bolus. There was no difference in CFT among the responders as compared to the nonresponders. There was no correlation between the change of CBF and CFT (r [207] = 0.013, P = 0.061) after the fluid bolus. Conclusion: Though easy to perform, CFT is probably not a good indicator of fluid responsiveness. [ABSTRACT FROM AUTHOR]

BACKGROUND: Medication-related visits (MRV) to the Emergency Department (ED) are substantial though weakly recognized and intervened. Data from developing countries on the prevalence of MRV-related ED admissions are scanty. This study is first of its kind in India to estimate the prevalence of MRV, its severity and the factors contributing to these visits. METHODOLOGY: This prospective observational study was done in the ED of an apex tertiary care center in August 2018. A convenient cross-sectional sample of patients presenting with emergencies regarding drug use or ill-use were included and a questionnaire filled after obtaining a written informed consent. RESULTS: During the study period, a cross-sectional sample of 443 patients was studied and the prevalence of MRV was 27.1% (120/443). The mean age was 55 (standard deviation: 15) years with a male preponderance (60.8%). Triage priority I patients comprised 39.1%. Common presenting complaints included vomiting (25%), seizure (20.8%), giddiness (20%), and abdomen pain (17.5%). Less than ½ (43.3%) were compliant to prescribed medication. The most common reasons for MRV were failure to receive drugs/noncompliance (47.5%), subtherapeutic dosage (25%), and adverse drug reaction (16.7%). Severity of MRV was classified as mild (50%), moderate (38.3%), and severe (11.7%). Out of these visits, 71 (59.2%) were deemed preventable. Three-fourths (73.3%) were stabilized and discharged from the ED. CONCLUSION: The fact that a quarter of the ED visits are due to MRV and that more than half of them are preventable is quite alarming. Diligent patient education by the treating physicians may perhaps help in decreasing the incidence of this deleterious event. [ABSTRACT FROM AUTHOR]

Background: Sudden cardiac arrest (SCA) requiring cardiopulmonary resuscitation (CPR) is one of the common emergencies encountered in the emergency department (ED) of any hospital. Although several studies have reported the predictors of CPR outcome in general, there are limited data from the EDs in India. Materials and Methods: This retrospective study included all patients above 18 years with SCA who were resuscitated in the ED of a tertiary care hospital with an annual census of 60,000 patients between August 2014 and July 2015. A modified Utstein template was used for data collection. Factors relating to a sustained return of spontaneous circulation and mortality were analyzed using descriptive analytic statistics and logistic regressions. Results: The study cohort contained 254 patients, with a male predominance (64.6%). Median age was 55 (interquartile range: 42-64) years. Majority were in-hospital cardiac arrests (73.6%). Only 7.4% (5/67) of the out-of-hospital cardiac arrests received bystander resuscitation before ED arrival. The initial documented rhythm was pulseless electrical activity (PEA)/asystole in the majority (76%) of cases while shockable rhythms pulseless ventricular tachycardia/ventricular fibrillation were noted in only 8% (21/254) of cases. Overall ED-SCA survival to hospital admission was 29.5% and survival to discharge was 9.9%. Multivariate logistic regression analysis showed age ≥65 years (odds ratio [OR]: 12.33; 95% confidence interval [CI]: 1.38-109.59; P = 0.02) and total duration of CPR >10 min (OR: 5.42; 95% CI: 1.15-25.5; P = 0.03) to be independent predictors of mortality. Conclusion: SCA in the ED is being increasingly seen in younger age groups. Despite advances in resuscitation medicine, survival rates of both in-hospital and out-of-hospital SCA remain poor. There exists a great need for improving prehospital care as well as control of risk factors to decrease the incidence and improve the outcome of SCA. [ABSTRACT FROM AUTHOR]

Malaria is endemic in large parts of India and can cause multiorgan failure and death. Acute pancreatitis as a complication is rare and is potentially fatal. This case series describes five adult patients between 2005 and 2010 who presented with a short duration febrile illness and diagnosed to have malaria with acute pancreatitis. The mean age of the five patients with acute pancreatitis was 40.4 years and four of them were males. None of them were alcohol consumers and did not have any other risk factor for acute pancreatitis. Plasmodium falciparum was responsible for all the cases. Pancreatic enzymes were significantly elevated in all the patients with a mean serum lipase level of 1795 U/L (normal value: <190 U/L) and a mean serum amylase level of 584 U/L (normal value: <100 U/L). Ultrasonography evidence of acute pancreatitis (bulky pancreas) was seen in two patients, and a further two patients had minimal left-sided pleural effusion. Thrombocytopenia (platelet count <100,000/cumm), renal dysfunction (serum creatinine >1.4 mg/dl), and hyperbilirubinemia were seen in all the patients. One patient died due to multiorgan failure. Acute pancreatitis is a very rare complication of malaria, and a high index of suspicion is required in patients presenting with severe malaria and abdominal pain. [ABSTRACT FROM AUTHOR]

Background: Trauma is an increasing cause of morbidity and mortality in India. This study was done to improve the understanding of the mode of trauma, severity of injuries, and outcome of trauma victims in our hospital. Materials and Methods: This was a retrospective observational study of all adult trauma patients more than 18-year-old presenting to our emergency department (ED). Details of the incident, injuries, and outcome were noted. Results: The ED attended to 16,169 patients during the 3-month study period with 10% (1624/16,169) being adult trauma incidents. The gender distribution was 73.6% males and 26.4% females. The mean age was 40.2 ± 16.7 years. The median duration from time of incident to time of arrival to the ED was 3 h (interquartile range [IQR]: 1.5-6.5) for priority one patients, 3 h (IQR: 1.5-7.7) for priority two patients, and 1.5 h (IQR: 1-7) for priority three patients. The average number of trauma incidents increased by 28% during the weekends. Road traffic accident (RTA) (65%) was the most common mode of injury, followed by fall on level ground (13.5%), fall from height (6.3%), work place injuries (6.3%), and others. Traumatic brain injury was seen in 17% of patients while 13.3% had polytrauma with two-wheeler accidents contributing to the majority. The ED team alone managed 23.4% of patients while the remaining 76.6% required evaluation and treatment by the trauma, surgical teams. The in-hospital mortality rate was 2.3%. Multivariate analysis showed low Glasgow coma score (odds ratio [OR]: 0.65, 95% confidence interval [CI]: 0.55-0.76, P < 0.001) and high respiratory rate (OR: 1.15, 95% CI: 1.07-1.24, P < 0.001) to be independent predictors of mortality among polytrauma victims. Conclusions: RTA and falls are the predominant causes of trauma. A simple physiological variable-based scoring system such as the revised trauma score may be used to prioritize patients with polytrauma. [ABSTRACT FROM AUTHOR]

Carbamazepine overdose usually presents with neurological manifestations such as ataxia, seizures and altered sensorium or cardiac manifestations that include tachycardia, hypotension and ventricular extra-systoles. We report a patient with carbamazepine overdose who manifested recurrent hypoglycemia on the third and fourth day following ingestion that resolved with supportive therapy. [ABSTRACT FROM AUTHOR]

Objective: Early surgical debridement is vital for favorable outcomes in acute invasive fungal sinusitis (AIFS). Our study aimed to propose guidelines with tailored, conservative surgical procedures based on areas of involvement and evaluate their usefulness in avoiding repeated debridement., Methods: This retrospective observational study was conducted on 150 AIFS patients operated on with the proposed surgical guidelines from May to June 2021 at a tertiary care hospital. Data including demography, comorbidities, surgical procedures, revision surgery, and outcome were collected and analyzed., Results: All 150 patients underwent bilateral endoscopic sinonasal debridement. Among them, 108 patients (72%) had current or recent coronavirus disease (COVID) infection. Ninety-two patients (61.3%) required additional procedures based on disease extent. Twenty patients (15.4%) required revision debridement because of progressive or recurrent disease. Mean age of this group was 46.15 (standard deviation ±11.2) years with a strong male predominance (9:1). Seventeen had diabetes mellitus, 12 suffered from active COVID-19 infection and six had received corticosteroids. None of the 31 patients who had recovered from COVID-19 or had no comorbidities required revision surgery. Age, gender, and comorbidities were not significant predictors for revision surgery. Fourteen patients (70%) underwent second surgery within one month of primary surgery. Predominant disease locations were alveolus and palate (55% each), and in 80% the site was uninvolved at primary surgery. The most common revision procedure was inferior partial maxillectomy (60%). At follow-up, all were asymptomatic with no evidence of disease., Conclusion: The proposed surgical guidelines for AIFS allow for adequate surgical debridement with preservation of optimum functional status. Low revision surgery rates and good outcomes with minimal morbidity validate its usefulness., Competing Interests: Conflict of Interest: The authors have no conflicts of interest to declare., (©Copyright 2023 by Turkish Otorhinolaryngology-Head and Neck Surgery Society / Turkish Archives of Otorhinolaryngology is published by Galenos Publishing House.)

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., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Family Medicine and Primary Care.)

Background: Bacterial sepsis is associated with significant morbidity and mortality. However, to date, there is no single test that predicts sepsis with reproducible results. We proposed that using a combination of clinical and laboratory parameters and a novel biomarker, plasma neutrophil gelatinase-associated lipocalin (NGAL) may aid in early diagnosis., Method: A prospective cohort study was conducted at a tertiary care center in South India (June 2017 to April 2018) on patients with acute febrile episodes fulfilling the Systemic Inflammatory Response Syndrome (SIRS) criteria. Plasma NGAL and standard clinical and laboratory parameters were collected at the admission. Bacterial sepsis was diagnosed based on blood culture positivity or clinical diagnosis. Clinically relevant plasma NGAL cut-off values were identified using the receive operating characteristic (ROC) curve. Clinically relevant clinical parameters along with plasma NGAL's risk ratios estimated from the multivariable Poisson regression model were rounded and used as weights to create a new scoring tool., Results: Of 100 patients enrolled, 37 had bacterial sepsis. The optimal plasma NGAL cut-off value to predict sepsis was 570 ng/mL [area under the curve (AUC): 0.69]. The NGAL sepsis screening tool consists of the following clinical parameter: diabetes mellitus, the presence of rigors, quick sequential organ failure assessment (qSOFA) >2, a clear focus of infection, and the plasma NGAL >570 ng/mL. A score of <3 ruled out bacterial sepsis and a score >7 were highly suggestive of bacterial sepsis with an interval likelihood ratio (LR) of 7.77., Conclusion: The NGAL sepsis screening tool with a score >7 can be used in the emergency department (ED) to identify bacterial sepsis., How to Cite This Article: Paul A, Newbigging NS, Lenin A, Gowri M, Varghese JS, Nell AJ, et al. Role of Neutrophil Gelatinase-associated Lipocalin (NGAL) and Other Clinical Parameters as Predictors of Bacterial Sepsis in Patients Presenting to the Emergency Department with Fever. Indian J Crit Care Med 2023;27(3):176-182., Competing Interests: Source of support: Institutional post-graduation thesis fund. Conflict of interest: None, (Copyright © 2023; The Author(s).)

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., Competing Interests: There are no conflicts of interest., (Copyright: © 2023 Journal of Global Infectious Diseases.)

Background: The second wave of the coronavirus disease 2019 (COVID-19) pandemic resulted in a significant rise in the number of infections and deaths as compared to the first wave. The published literature till now is limited to tertiary hospitals. We did this study to describe the demographic characteristics and outcomes of patients admitted to a secondary care hospital in central India during the second wave of the pandemic., Methods: This was a single-center, retrospective observational study conducted in a secondary hospital in central India. The data of patients with COVID-19 infection admitted between March 25 to May 25, 2021, were retrieved and analyzed., Results: A total of 184 patients were included in the study. The mean age was 54.8 ± 14.5 years. Comorbidities included hypertension (40.2%), diabetes mellitus (29.9%), hypothyroidism (4.3%), and asthma (2.7%). The most common presenting complaints were cough (78.8%), breathlessness (61.4%), and fever (60.9%). The mean duration of symptoms was 5.4 ± 2.6 days. According to High-Resolution Computerised Tomography (HRCT) chest severity score, 29/181 (16%) patients had mild disease, 135/181 (74.5%) patients had moderate disease, and 17/181 (9.5%) patients had severe disease. The majority of the patients received remdesivir (90.2%) and 123 patients (66.8%) received corticosteroids. Half the patients (52.2%; n = 96) required intensive care unit admission, 79.3% (145 patients) required oxygen support, and 8.1% (15 patients) required non-invasive ventilator support., Conclusion: Our study from a secondary hospital setup showed that the second wave was very severe with a high requirement of oxygen support and intensive care monitoring., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

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., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Anaesthesiology Clinical Pharmacology.)

Background: The COVID-19 pandemic resulted in a complete nationwide lockdown on March 24, 2020. The months of April and May had stringent lockdown measures followed by a gradual loosening of restrictions in a graded manner., Methods: This observational study was performed in the emergency department (ED) of a tertiary hospital in south India triage Priority 1 and Priority 2 patients presented during the COVID-19 lockdown and unlock periods spanning from April 2020 to August 2020. The three different lockdown periods and the subsequent unlock periods were categorized as lockdown 1 (LD1), lockdown 2 (LD2), lockdown 3 (LD3), and unlock phase (UL), and a 7-day time period in each were taken for 7-day incidence analysis., Results: During the 5-month study period, a total of 1,954 patients were analyzed for the study that included 405, 440, 492, and 617 patients during the 7-day time periods in the LD1, LD2, LD3, and UL periods, respectively. The 7-day incidence of COVID-19 suspects increased significantly by 101.9% from LD1 to UL phases, whereas trauma cases increased by 52.9% in the same two time periods. Compared with LD1, in the UL phase, the 7-day ED admission and in-hospital mortality rates increased by 50.3% and 66.7%, respectively., Conclusion: The number of COVID-19 suspects saw a near-constant increase through the different phases of lockdown, culminating in the UL phase. The stringent lockdown measures resulted in a significant reduction in the incidence of trauma with a rebound increase in the UL phase., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

Background: Deliberate self-poisoning and harm (DSPH) is an unabating problem with a wide variation in the methods used across the world. Hence, this study was conducted to understand the current spectrum of methods used for DSPH by patients in our geographic locality and catchment area with special emphasis on newer compounds and drugs used., Methods: This retrospective study included patients presenting with DSPH to the emergency department (ED) between January 2017 and December 2018., Results: This study included 1802 patients, with a mean age of 32 ± 12.7 years. Of the patients, 85% were in the young to middle age group (16-45 years). Agrochemicals (n = 604, 33.5%), drugs (n = 498, 27.6%), plant toxins (n = 150, 8.3%) and rodenticides (n = 145, 8%) were the predominantly used compounds. The major emergency resuscitation procedures required in the ED were intubation (n = 321, 18%), vasopressor support (n = 73, 4%) and cardiopulmonary resuscitation (n = 27, 1.4%). A quarter (23.2%) was discharged stable from the ED, whereas a further 56.5% were discharged stable after hospital admission. The in-hospital mortality rate was 3% (n = 47). Multivariate logistic regression analysis showed rodenticides (odds ratio (OR): 22.32; 95% confidence interval (CI): 8.05-61.88; P = 0.005) and plant poisons (OR: 23.92; 95% CI: 8.95-63.94; P = 0.005) to be the independent predictors of mortality., Conclusion: DSPH is prevalent in the highly productive young age group. Agrochemical ingestion and drug overdose are the most common methods used, whereas rodenticide and plant poisoning are associated with significant mortality., Competing Interests: There are no conflicts of interest., (Copyright: © 2022 Journal of Family Medicine and Primary Care.)

Background: Due to associated comorbidities, the elderly population is more vulnerable to injuries with complications. This study was done to assess the severity of trauma and outcome of injuries among these patients presenting to the Emergency Department (ED)., Materials and Methods: This was a retrospective cohort study. We included all patients aged more than 60 years, who presented to the ED with trauma in the year 2018. Details of the mode of trauma, severity of injuries and outcome were analysed., Results: During the study period a total of 7666 trauma patients presented to ED, among which 879 (879/7666: 11.4%) were in the geriatric age group. The mean age was 68.9 (SD: 7) years with 90.8% being young-old (60-79 years) and 9.2% being old-old (>80 years). Common modes of injuries were road traffic accidents (RTA) (64%) fall on level ground (FLG) (20%) and fall from height (FFH) (8%). Most of them had Injury Severity Score (ISS) and New Injury Severity Score (NISS) score of 0-7, i.e.: 62% and 51%, respectively. On multivariate logistic regression analysis RTA, FFH FLG and triage priority 1 patients were associated with trauma in the old-old as compared to the young-old age groups significantly. Independent risk factors associated with severe trauma were seen RTA, FLG and priority 1 patients. Forty-four per cent patients were managed by the ED team alone. Trauma speciality departments referred to included orthopaedics (47%), neurosurgery (22%), trauma surgery (14%), plastic surgery (8%) and hand reconstruction surgery (6%). About half of the population under study was discharged stable (44%), of which the majority belonged to the young-old category (44.1%). The in-hospital mortality rate was 0.5% (4/879)., Conclusion: This study shows the gravity of multiple injuries sustained by the geriatric age group with RTA, FLG and FFH being the predominant causes of trauma. The NISS highlights the severity of injuries in the old and the frail., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Family Medicine and Primary Care.)

Competing Interests: There are no conflicts of interest.

Background: Despite the improvement in prehospital care in the last decade in India through dedicated ambulance services, airway management is often performed by undertrained or untrained personnel and remains teetering to the edge of collapse. This study aimed at assessing the airway status in critically ill patients at their arrival to the Emergency Department (ED)., Methods: This prospective study included all triage priority I patients presenting to the ED during August 2017 and September 2017. Details of their airway status at arrival to the ED was noted. The severity at presentation and outcome of patients brought in ambulances and private vehicles were determined using descriptive analytic statistics and bivariate logistic regression analysis., Results: The study included 450 patients, with a male predominance (65.3%). Only a third (31%) of patients were brought in ambulances with a reminder through various means of transport. Compared to patients brought by private vehicles, patients brought to the ED by ambulances had a higher odds of being hypoxic at ED arrival [OR: 1.63 (95% CI: 1.08-2.46); P value: 0.01] and requiring invasive ventilation on arrival to the ED [OR: 2.36 (95% CI: 1.46-3.80) P value: < 0.001]. Overall, 55.7% (248/450) required hospital admission while 21% (95/450) were discharged stable from the ED after resuscitation and stabilization by the ED team. The overall mortality rate was 11.1% (50/450), with 13.5% (19/144) of those brought by ambulances and 10% (31/309) of those brought by private vehicles succumbing to their illness in the hospital., Conclusion: Private vehicles still remain the predominant mode of prehospital transport though ambulances are used to transport sicker patients. More than half the critically ill patients remained hypoxic on arrival to the ED. Our study clearly highlights the glaring deficiency in airway status at ED arrival and stresses the urgent need to improve prehospital care., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Family Medicine and Primary Care.)

Background: Assessing fluid responsiveness in critically ill patients is challenging. Objective, noninvasive tests that are easy to perform are needed. Doppler measurements of dynamic carotid artery parameters such as carotid blood flow (CBF) and carotid flow time (CFT) are being studied as the potential indicators of volume responsiveness, but the data supporting its use are sparse., Methods: This prospective, observational study was conducted in the adult emergency department from June to September 2018. Patients who were prescribed a bolus of 500 ml of crystalloid for any indication were enrolled. Carotid Doppler was performed before and after a fluid bolus to measure the change in CBF and CFT. The aim of our study was to determine if CFT can be used as a marker of fluid responsiveness., Results: During the 4-month study period, 209 patients were recruited through convenient sampling after obtaining informed written consent. 29.6% of patients presented with a mean arterial pressure (MAP) <65, among whom 58.1% had septic shock. The baseline CBF was 643.0 ± 212.7 ml/min, and it was 583.9 ± 207.1 ml/min and 668 ± 210.8 ml/min in hypotensive and normotensive patients, respectively. Considering a >10% increase in CBF as fluid response, there were 59% responders and 41% nonresponders. The MAP increased by 9.5% in the responders, while there was no significant change in CFT after the fluid bolus. There was no difference in CFT among the responders as compared to the nonresponders. There was no correlation between the change of CBF and CFT ( r [207] = 0.013, P = 0.061) after the fluid bolus., Conclusion: Though easy to perform, CFT is probably not a good indicator of fluid responsiveness., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Medical Ultrasound.)

Background: Paediatric injuries are a major cause of mortality and disability worldwide and account for a significant burden on countries like India with limited resources. There are very few studies from developing nations describing the outcome of paediatric trauma., Methodology: This retrospective study was done to assess the pattern and outcome of unintentional paediatric trauma in the paediatric population. The patients were categorised into four age groups of <1 year, 1-5 years, 6-10 years and 11-15 years. The data were compared regarding the mode of trauma, new injury severity score (NISS), type of injury and place of injury among different age groups., Results: A total of 1587 paediatric patients below 15 years of age presenting in the Emergency Department of CMC, Vellore were studied over a period of 1 year. Two-thirds were boys (1039: 66.6%). Fall on level ground (28.2%) and road traffic accidents (RTA) (26.5%) were the two most common modes of injury. A gradual change in the place of incident from home to the road with advancing age was noticed. The upper limb (30.8%) and the face (26.2%) were the most common parts of the body to be injured. One-third (35.8%) of the sustained serious injuries was a fracture or a dislocation. RTA (OR: 1.56; 95%CI: 1.08-2.26) and age ≥5 years (OR: 1.17; 95%CI: 1.08-1.26) were found to be independent predictors of severe injury (NISS >8). Only 15% required hospital admission., Conclusion: Fall on level ground and RTAs are the most common modes of injury in the paediatric population. The place of injury shows a gradual change from the confines of home to the open dangerous roads and playgrounds with increasing age with RTA and age ≥5 years being independent predictors of severe injury., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Family Medicine and Primary Care.)

Background: Deliberate self-harm (DSH) is one of the leading causes of mortality and morbidity in India. Agrochemicals are the most commonly used compounds for DSH. The spectrum of Agrochemicals in use varies from region to region and time period with newer compound being regularly introduced into the market., Methodology: This retrospective cohort study included patients presenting with agrochemical poisoning to the ED during January 2017 to December 2018. Patient data was retrieved form the ED triage registry software and clinical workstation, following which their hospital outcome was determined., Results: During the study period, 1802 patients presented with DSH among which Agrochemical poisoning comprised 33.5% (604/1802). The mean age was 31 years and incidence of agrochemical poisoning was found to be higher in young adults (16-30 years-55.8%). The prevalence was more common in males (62.4%). The common agrochemical compounds consumed were insecticides (91%), herbicides (4.3%), fungicides (1.5%), fertilizer (1.5%), and plant growth regulators (1.5%). Majority (80.96%) of the patients were discharged alive from the hospital, 17% left against medical advice due to bad prognosis and 12 patients (2%) died in the hospital., Conclusion: Insecticides (mainly Organophosphates) are the most common agrochemicals used for DSH. Their management is better understood leading to better outcomes compared to other chemicals. The proportion of agrochemical use in DSH has reduced over the last decade. Imidacloprid (Insecticide) and Plant growth regulators are the new compounds for which appropriate management is not yet established and more research is needed., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Family Medicine and Primary Care.)

Background: A ground-level fall is one of the most common modes of injury sustained across all age groups. For older adults, ground level falls can result in multiple injuries and are associated with significant morbidity and mortality., Methodology: This retrospective observational study included all patients presenting with fall from a ground level to our emergency department (ED) from January 2018 to December 2018. Demographics, details of incident, severity of injury, and outcome were analyzed., Results: During the study period, 596 patients with a mean age of 40.9 (standard deviation [SD]: 25.9) years were included in the analysis. A quarter (23%) were aged less than 15 years, while the elderly (>60 years) comprised of 29.5%. Half the patients were triaged as priority 2 (53.8%). The lower limbs (36.6%), upper limbs (23.9%), and face (15.3%) were the body areas that were most commonly injured. The new injury severity score (NISS) was more than 8 in 28% of patients. Multivariate logistic regression analysis showed the elderly (>60 years) to have a higher odds (2.51 95% confidence interval [CI]: 1.57-4.02) of sustaining a fracture of a dislocation. One fifth of the patients (120/596; 20.1%) required hospital admission with only one fatality. Fifteen patients (2.5%) left the hospital against medical advice. Two-thirds (66.3%) required only conservative management, while 19.9% required major surgical intervention., Conclusion: A ground-level fall is a common mode of injury in children (<15 years) and the elderly (>60 years). The extremities and face are the most common areas of the body that are prone to injuries. Age-friendly infrastructure modifications at home, work places, and in public areas for elders and ensuring playground safety for children are the needs of the hour to decrease falls on level ground., Competing Interests: There are no conflicts of interest., (Copyright: © Journal of Family Medicine and Primary Care.)