The Study of Rapid Ultrasound in Shock in Patients of Undifferentiated Hypotension Presenting to Emergency Department

Background: Patients with hypotension or shock usually have high mortality rates, and use of traditional physical examination techniques only may be misleading for rapid diagnosis and treating the same. RUSH (Rapid Ultrasound for Shock and Hypotension) protocol is used in patients with undifferentiated shock to improve accurate diagnosis of shock. Methods: A prospective observational study was done from April to June 2022 at emergency department in 100 patients who presented with hypotension. This included patients who had systolic blood pressure (SBP) of <90 mmHg, along with tachypnoea and tachycardia. Patients RUSH examination was performed. The patients were followed up to document their final diagnosis. Results: In our study, the mean age of patients with hypotension was 58.8±8.7 years with male preponderance of 53%. The hypovolemic shock (40%) was found to be the most common subtype of shock. 86% of patients were correctly diagnosed with RUSH study. The sensitivity, specificity, PPV and NPV of RUSH in shock patients was 36.69%, 25.7%, 26.5%, 87.25% respectively and disease prevalence 31.5% and accuracy 68.75%.Cohens Kappa index was 0.5 showed a moderate agreement of the RUSH protocol in diagnosis of causes of shock with the final diagnosis. Conclusion: This study advocates the use of RUSH protocol in patients presenting with undifferentiated hypotension in the emergency department. It narrows the possible differentials of shock and guides the emergency physician to an early initial therapy, thereby improving the final outcome of patient.

Comparing the Prognosticative Value of APACHE II and mSOFA Scores in Critically Ill Patients: A Prospective Study

Objective: Several predictive scoring systems measuring disease severity are used to predict outcomes, typically mortality, of critically ill patients in the intensive care unit (ICU). Two common validated predictive scoring systems include acute physiology and chronic health evaluation II (APACHE II) and modified sequential organ failure assessment score (mSOFA). To compare performance of APACHE II and mSOFA score in critically ill patients regarding the outcomes in the form of morbidity and mortality in ICU. Methods: This prospective observational clinical study was conducted on 100 patients over 6 months. For each patient, APACHE II score on day of admission and serial mSOFA scores on day 0, 3, 7 and 10 were calculated and compared. Results: The age of the non-survivors was significantly older than survivors was (57.1±11.76 and 54.28±15.16). [In our study we found that the mean length of ICU stay of non-survivors was (5.41±4.81) & survivors(8.63± 4.81) days.] In our study mortality rate was 40%.The APACHE II score with cut-off point of 23 demonstrated a sensitivity rate of 98.33% & specificity rate of 17.5%, accuracy of 66.00%. Serial mSOFA scores with cut-off of 11 on day0, day3, day7 better differentiated survivors from non-survivors with 98.3% sensitivity, 27.5% specificity and 70% accuracy. Conclusion: Both APACHE II and mSOFA scores can help ICU physicians as a significant predictive marker for mortality in critically ill patients. The serial measurement of mSOFA score in the first week is a better mortality predictor tool than APACHE II score in critically ill patients.

Epidemiological study of Paediatric Seizures and Its Management in Paediatric Emergency Department.

Introduction: Pediatric seizures are a common occurrence and frequent presentation to emergency department (ED). Seizures result from paroxysmal involuntary disturbance of brain function. The history and physical examination guide us to manage and assist in differentiating seizures from nonepileptic disorders. Methodology: This study was carried out to know the trends of paediatric seizures and their management in ED. We had included all patients less than 12 years of age with seizures, admitted to our hospital's pediatric ED between May and August 2012. All demographic findings, seizure characteristics and laboratory findings were recorded. Results: A total of 53 children were enrolled in the study of which 38 (71.7%) children were male and 15 (28.3%) were female. The mean age of presentation was 2.42 years. 66.7% of patients had generalized seizures and 33.3% of patients had partial seizures. Out of total study population, 49% had febrile seizures and 20.8% had afebrile seizures. The majority of seizures (69.8%) lasted less than 10 minutes of which 54% were afebrile. Status epilepticus (SE) was found most commonly in 30.2% children. Out of 16 patients with SE 10 (62.5%) were less than two years of age. The common causes of SE were fever, Central Nervous System (CNS) infection, and epilepsy, accounting for 31.3%, 37.5% and 31.2% respectively. The children with underlying CNS abnormalities (cerebral palsy) had poorer outcomes. Mortality found in SE (9.4%) was related to an acute neurologic insult or a chronic CNS condition. Metabolic abnormalities were detected in 28.3% patients. The frequency of metabolic abnormalities was significantly higher in patients under two years of age (66.7%). 53.7% had hypocalcemia, 33.3% had hypoglycaemia and 20% had hyponatremia. MRI (Magnetic resonance imaging) of brain or EEG (electroencephalogram) or both was carried out in only 13.2% patients. 85% of patients had undergone laboratory investigations. Lumbar puncture was performed in 26.4% patients.

Comparison of epidural ropivacaine and bupivacaine for lower limb surgery.

Aims and objectives: to compare efficacy, potency, onset of action, effective duration of analgesia, sensory and motor block, peri operative haemodyamic parameters and complications following epidural bupivacaine and ropivacaine. Methods and material: sixty patients of asa i and ii scheduled for lower limb surgery were included in double blind randomized comparison of epidural ropivacaine 0.75% and bupivacaine 0.5%. we divided patients in two groups. group a patients were given inj. bupivacaine 0.5% 20 ml and group b patients were given inj. ropivacaine 0.75% 20 ml via epidural route. we recorded time of onset, highest level, peak and duration for motor and sensory block along with haemodyamic changes and side effects for both drugs. Summary: mean time to initial onset of adequate level of sensory block(t10) was. 21.76±3.37 min in group a and 22.53± 3.09 min in group b(p>0.05). total duration of sensory block was 403±16.70 min in group a and 413.5±24.67 min in group b (p=0.0007). mean time to initial onset of motor block was 12.13±2.16 in group a and 14.4±3.79 min in group b(p<0.05). peak motor blockade was achieved in 30.17±3.82 min in group a and 29.97±3.27 min in group b (p>0.05). total duration of motor block was 292±21.92 min in group a and 262.5±31.03 min in group b(p 0.0007).Conclusion: ropivacaine is safer and effective alternative to bupivacaine in epidural anesthesia.

Anatomical variations of the internal jugular vein in relation to carotid artery : an ultrasound study.

Background: In developing country like India, central venous catheter is still inserted using anatomical landmark guidance with success rate up to 97.6% and complications up to 15%. Aims & Objective: This study was aimed to determine the anatomical variations of the internal jugular vein (IJV) in relation with carotid artery (CA) with the help of 2-D ultrasound. Material and Methods: This prospective randomized study was conducted in a teaching and tertiary care hospital on 100 young healthy volunteers of either sex, aged 20 years to 40 years. Each volunteer was placed supine with 15˚ down trendlenberg position with 45˚ neck rotation on contra-lateral side. Linear array probe with 7.5 M Hz of “Sonosite Micromaxx” ultrasound machine was placed perpendicular to the apex of the triangle formed by two heads of sternocleidomastoid muscle and clavicle. Vessels were visualized in transverse section in 2-D ultrasound. Exact location of IJV was identified in relation to the CA on ultrasound and recorded as lateral, antero-lateral, anterior, medial, and posterior. The diameter of IJV and CA, distance from skin to IJV were recorded on both sides of neck for each volunteer. Anterior position of IJV in relation to CA was defined as dangerous position. Small sized IJV was defined as diameter ≤7 mm. Data were analyzed using Graphpad prism software version 5.1. P value < 0.05 was taken as significant. Results: The mean diameter of IJV was 13.23 (2.52) mm in right and 10.25(2.29) mm in left side of neck (p=0.0001). Small sized IJV was in 1% in right and 8% in left side (p=0.0349). 15% and 28% of volunteers had dangerous position of IJV in relation to CA on right and left side of neck respectively (p=0.0381). Conclusion: Significant number of healthy young volunteers had anatomical variations in terms of size and position of IJV (left side > right side) in relation of CA by ultrasound screening. Thus, anatomical landmarks are not sufficient, alternative measures like ultrasound scanning should be implemented prior to catheterization to identify the individual with potentially difficult catheterization.