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   Table of Contents - Current issue
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October-December 2022
Volume 22 | Issue 4
Page Nos. 169-232

Online since Saturday, October 1, 2022

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INVITED REVIEW ARTICLES  

Use of infection biomarkers in the emergency department p. 169
Hasan Selcuk Ozger, Esin Senol
DOI:10.4103/2452-2473.357347  
The use of infection biomarkers in the emergency department is discussed in terms of their possible contributions to diagnostic-prognostic uncertainties, appropriate antibiotic treatments, and triage and follow-up planning. Procalcitonin (PCT), C-reactive protein (CRP), proadrenomedullin (proADM), and presepsin are among the most discussed infection biomarkers for use in the emergency department. Due to the variable sensitivity results and cutoff values, there are insufficient data to recommend the widespread use of CRP and procalcitonin (PCT) for the diagnosis and prognosis of infection in the emergency department. However, these biomarkers can be used for appropriate antibiotic use in selected infection groups, such as community-acquired pneumonia, especially to reduce unnecessary antibiotic prescribing. With its prognostic superiority over other biomarkers and its contribution to prognostic score systems in community-acquired pneumonia (CAP), proADM can be used to predict hospitalization, preferably within the scope of clinical studies. Although presepsin has been shown to have some advantages over other biomarkers to rule out sepsis, there are insufficient data for its clinical use in the emergency department.
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User's guide to sample size estimation in diagnostic accuracy studies p. 177
Haldun Akoglu
DOI:10.4103/2452-2473.357348  
Sample size estimation is an overlooked concept and rarely reported in diagnostic accuracy studies, primarily because of the lack of information of clinical researchers on when and how they should estimate sample size. In this review, readers will find sample size estimation procedures for diagnostic tests with dichotomized outcomes, explained by clinically relevant examples in detail. We hope, with the help of practical tables and a free online calculator (https://turkjemergmed.com/calculator), researchers can estimate accurate sample sizes without a need to calculate from equations, and use this review as a practical guide to estimating sample size in diagnostic accuracy studies.
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ORIGINAL ARTICLES Top

Airway management practices among emergency physicians: An observational study p. 186
M Jishnu, Sanjeev Bhoi, Ankit Kumar Sahu, Soorya Suresh, Praveen Aggarwal
DOI:10.4103/2452-2473.357351  
OBJECTIVES: Emergency airway management is an integral part of patient stabilization. It is an essential skill for an emergency physician to master. There is a paucity of literature on airway management from low-to-middle-income countries like India where emergency medicine (EM) specialty is still in its infancy. We conducted this study to identify the existing airway management practices among emergency physicians in our tertiary care center. This study could pave the way for national airway registries. METHODS: This prospective, observational study was conducted in the emergency department (ED) of a tertiary care center in India for 16 months. We included 166 patients who underwent emergency endotracheal intubation in the ED, irrespective of their age or underlying condition. The patients were observed for 15 min after intubation to identify any associated adverse events. We collected data about patients' demographic profile, indication for intubation, techniques of airway management, medications used, specialty of the physician performing intubation, use of preintubation and postintubation checklists, vitals before and after intubation, and any adverse events following intubation. RESULTS: A total of 166 patients who required definite airway management in the ED were recruited for the study. The mean age of patients was 45.5 ± 20.1 years. Males comprised 61.4% of the patients. One hundred and forty-four patients were nontrauma cases and the remaining 22 cases were related to trauma. The most common indication for emergency airway management was altered mental status among nontrauma encounters and traumatic brain injury among trauma patients. Rapid sequence intubation (RSI) was the most common method employed (72.9% of cases). The most common agents used for induction and paralysis were etomidate and rocuronium, respectively. Direct laryngoscope was used in about 95% of cases. The first pass success rate in our study was 78.3%. EM residents were able to perform orotracheal intubation for all patients and none required a surgical airway. The incidence of adverse events within 15 min of intubation was 58.4%. Common complications observed were desaturation, right mainstem bronchus intubation, and equipment failure. Postintubation cardiac arrest occurred in around 5% of cases. CONCLUSION: RSI remains the most common method employed for emergency airway management. There exists heterogeneity in the practice and its associated complications. Hence, regular surveillance, quality improvement, and training are imperative to provide good patient care.
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Changing spectrum of acute poisoning in North India: A hospital-based descriptive study p. 192
Ashok Kumar Pannu, Ashish Bhalla, Vitla Vamshi, Manish Kumar Upadhyay, Navneet Sharma, Susheel Kumar
DOI:10.4103/2452-2473.357627  
OBJECTIVES: Evaluating local trends and continued monitoring of patterns of acute poisoning are essential for prompt recognition of the toxidromes, the establishment of immediate treatment facilities (e.g., antidote availability), and effective preventive strategies (e.g., governmental regulation on hazardous substances marketing). We aimed to describe the prevalence of the various types of poisoning and associated case fatality in our academic hospital in North India. METHODS: A prospective observational descriptive study was conducted, enrolling patients aged ≥13 years with acute poisoning for 17 months from December 2016 to December 2017 and from September 2019 to December 2019, for a total of 17 months. RESULTS: Four hundred and two patients were enrolled (median age 28 years; 63.2% males). Majority of the acute poisoning cases resulted from ingestion (n = 391, 97.3%) and the primary intention was most commonly self-harm (n = 314, 78.1%). The major types of poisoning were pesticide (n = 264, 65.7%), drug overdose (n = 77, 19.2%), and corrosive ingestion (n = 31, 7.7%). Pesticides included insecticides (n = 146, 36.3%; cholinesterase inhibitors, n = 91), fungicides (n = 76, 18.9%; all aluminum phosphide), herbicides (n = 22, 5.5%; paraquat, n = 19), and rodenticides (n = 20, 5.0%; coumarin-derived substances, n = 12). Benzodiazepines (n = 33) and opioids (n = 25) were frequent causes of drug overdose. 95.3% (n = 379) received preliminary treatment at the previous health-care center, including gastric lavage (n = 239) and antidotes (n = 73). In-hospital case fatality rate was 17.3% (n = 58). CONCLUSION: Herbicide ingestion and opioid overdose are emerging threats with a gradual decline in organophosphate and aluminum phosphide poisoning. Despite improving management of acute poisoning, the overall case fatality rate remains substantial.
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Results of an advanced nursing triage protocol in emergency departments p. 200
Songül Biskin Cetin, Oktay Eray, Sengül Erdal Akiner, Meral Gözkaya, Özlem Yigit
DOI:10.4103/2452-2473.357349  
OBJECTIVES: The increasing number of patients admitted to emergency departments (EDs) and overcrowding of EDs lead to a global problem. Advanced nursing triage is an important solution in facilitating patient and time management, also increasing the efficiency of the ED. This study was conducted to predict the possible effects of applying advanced nursing triage modeling with predetermined protocols during the current nursing triage in the ED. METHODS: This was a descriptive and cross-sectional study. An advanced “triage assessment protocol,” which was developed previously, was hypothetically applied for 5 days by triage nurses in the adult ED of a university hospital. The hypothetical application was tested by triage nurses in all shifts. The nurses recorded the examination or treatment options which they thought to apply for the patient on the study form. The data recorded on the advanced triage evaluation protocol form by the triage nurses were compared with the patient outcomes and physician examination/treatment requests in the Hospital Information Management System by the researchers. RESULTS: In the study, it was determined that the rate of examination/treatment that could be requested according to the advanced nursing triage protocol was 46%. There were a good level of agreement on X-ray and a moderate level of agreement on urinary test and urinary beta- Human chorionic gonadotropin (hCG) test between physicians and triage nurses regarding examination/treatment requests. In addition, it was found that there was a 61.2% of agreement on decisions made for patients aged between 18 and 35. The rate of agreement between doctors and nurses regarding a gluco-stick request for patients admitted outside the prime time (92.2%) was found to be significantly higher (87.9%) than for patients admitted during prime time (P = 0.046). CONCLUSION: “Advanced triage” practices recommended for busy EDs were tested “hypothetically” at the national level due to the lack of legal regulations and were found to be compatible with the actual results of physicians' practices at an acceptable level, especially for selected medical conditions. The method used in this study can be useful in planning the transition to “advanced triage” practices. These results can show the readiness of nurses for the transition to this practice.
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Ultrasound-guided estimation of internal jugular vein collapsibility index in patients with shock in emergency department p. 206
Hannah Joyke Chawang, Nidhi Kaeley, Bharat Bhushan Bhardwaj, Udit Chauhan, Himanshi Baid, Reshma Asokan, Santosh Sadashiv Galagali
DOI:10.4103/2452-2473.357352  
OBJECTIVE: To correlate ultrasound-guided estimation of Internal Jugular Vein Collapsibility Index (IJV-CI) with inferior vena cava CI (IVC-CI) and invasively monitored central venous pressure (CVP) in patients with shock in the emergency medicine department. METHODS: A prospective observational study was done in the emergency department (ED). The study was conducted over 15 months (November 2019 to April 2021). It included patients more than 18 years presenting to the ED in shock. The IJV and IVC diameter and cross-sectional area were measured using ultrasound. The corresponding collapsibility indexes were then calculated and correlated with the invasively monitored CVP of the patient. Data were then analyzed using the Statistical Package for the Social Science (SPSS): Version 23 for windows. Pearson's correlation was used between CVP and collapsibility indexes. RESULTS: The mean (±standard deviation) age of the patients was 49.01 (±15.6). There was a 47 (64%) male predominance which outnumbered females 26 (36%). The correlation coefficient was statistically significant between CVP and the collapsibility indices for various IJV and IVC parameters. The highest correlation (r = −0.541, P = 0.005) was seen between IVC-CI (CI 5) and CVP. This was followed by a correlation seen at a 30° position for IJV CI (cross-sectional area) with CVP (r = −0.453, P = 0.001). Similarly, the correlation between IJV CI (AP diameter) and CVP, followed (r = −0.412, P = 0.008) was statistically significant. CONCLUSION: Both IJV and IVC collapsibility indices correlated significantly with invasively measured CVP. Hence, they present as an effective tool in fluid resuscitation in patients with shock in ED.
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Current status of acute ischemic stroke management in Iran: Findings from a single-center study p. 213
Hesamedin Askari-Majdabadi, Zahra Basereh, Amin Soheili, Kelly Powers, Mohsen Soleimani, Majid Mirmohammdkhani, Tahoura Afshari Saleh
DOI:10.4103/2452-2473.357344  
OBJECTIVES: This study investigated the current status of acute ischemic stroke (AIS) management in an Iranian emergency department (ED). METHODS: A descriptive study using a retrospective chart review was conducted on medical records of 270 patients with AIS who presented to the ED of a tertiary university hospital in the northeast of Iran from March 22 to September 22, 2019. The steps of this review process included instrument identification, medical records retrieval, data extraction, and data verification. RESULTS: Of patients with AIS, 88.9% (n = 240) did not receive stroke code activation. For the 11.1% of patients (n = 30) who received activation, 7% of codes (n = 19) were canceled by the acute stroke team and IV recombinant tissue plasminogen activator (r-tPA) was only administered for 4.1% of patients (n = 11). ED arrival outside 4.5 h from symptom onset was the main barrier to IV r-tPA administration for 83.8% of potentially eligible patients with AIS (n = 217). The median door-to-needle time was 70 min (interquartile range: 47–90 min). CONCLUSIONS: There was a better clinical performance in terms of critical time goals in potentially eligible patients with AIS if managed with stroke team activation compared to no stroke team activation.
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CASE REPORTS Top

Tachycardia origin prediction using point of care ultrasound (TOP-UP) - A novel technique p. 221
Sasikumar Mahalingam, Gunaseelan Rajendran, Balamurugan Nathan, Manu Ayyan, Vivekanandan Muthu Pillai
DOI:10.4103/2452-2473.357346  
Narrow complex tachycardia (NCT) is often due to supraventricular tachycardia (SVT). SVT with aberrancy, preexcitation, paced rhythm, rate-dependent bundle branch block, preexisting conduction defects or SVT due to drugs, and electrolyte abnormality can also be wide complex. Wide-complex tachycardia (WCT) is often ventricular tachycardia (VT), but fascicular VT (fVT) can present as NCT. Thus, WCT can be either VT or SVT. This has been a perplexing problem for the emergency physician for ages. Here, in this case series, we describe the novel use of point-of-care ultrasound to differentiate SVT from VT.
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Localized tetanus mimics acute perforated viscus: A diagnostic challenge and review of case reports p. 226
Iqlima Idris, Mohamad Masykurin Mafauzy, Kamarul Aryffin Baharuddin, Farah Alwi, Wan Syahmi Wan Mohamad
DOI:10.4103/tjem.tjem_68_22  
Abdominal tetanus is the rarest presentation of localized tetanus in which other muscles are not involved. Proper diagnosis is challenging as it mimics acute abdomen. We describe the challenges in diagnosing this atypical localized tetanus in an adult and a review of case reports. Our patient is a 40-year-old male who presented to the emergency department with generalized abdominal pain for 3 days. His physical examination revealed a guarded abdomen with tenderness in the epigastric region, while systemic examinations were unremarkable. The initial diagnosis was acute abdomen with suspected perforated viscus. Subsequently, he developed arching of the back on day 3 of admission with markedly elevated serum creatine kinase levels. A diagnosis of localized tetanus was made, and an uneventful recovery was achieved after management. Clinicians should be aware of the atypical presentations of abdominal tetanus as it mimics acute abdomen. Early recognition and initiation of treatment significantly reduce morbidity and mortality risks.
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A rare case: Descending necrotizing mediastinitis p. 230
Barış Murat Ayvaci, Eren Gökdağ
DOI:10.4103/2452-2473.357345  
Descending necrotizing mediastinitis (DNM) is one of the most critical, and often lethal forms of mediastinitis that develop because of the downward spread of deep neck infections. In this article, we wanted to discuss a case report with DNM secondary to retropharyngeal abscess detected in the emergency department, in accordance with the literature. A 51-year-old male patient presented to the hospital with complaints of fever, sore throat when swallowing, and swelling in the neck. He had no history of any disease, trauma, or surgical intervention. On physical examination of our patient, diffuse hyperemia and edema in the pharyngeal area were detected with swelling, edema, redness, and warmth in the neck, which can be felt on both sides of the trachea with palpation. DNM diagnosis was made by detecting retropharyngeal abscess extending to the mediastinum, mediastinal air images and increased density in adipose tissue with intravenous (IV) contrast-enhanced neck and thorax computed tomography (CT). DNM patients most frequently present with complaints of fever, odynophagia, dyspnea, cervical edema, and pain. The most important clinical finding is edema and hyperemia in the pharynx. Our patient presented to the emergency department with complaints of fever, sore throat when swallowing, and neck swelling, and on physical examination, edema, hyperemia, and temperature increase in the neck region were observed together with hyperemia and edema in the pharyngeal area. Laboratory examinations showed high leukocyte count and C-reactive protein levels. The patient was diagnosed with DNM by performing IV contrast-enhanced cervicothoracic CT imaging and underwent an operation. It should be borne in mind that patients who present to the emergency room with fever, odynophagia, and neck swelling may have a rare but seriously life-threatening DNM.
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