Presentation, treatment profiles, and outcome of snake bite patients presented in emergency department at a tertiary hospital in Eastern Nepal.

Background: Snake bite is one of the most common animal bites in Nepal. Different species of snake cause different clinical presentations. The incidence of snakebite is very high in rural Nepal. The objectives were to assess the presenting pattern, demographic profile, outcome, and treatment profiles of snakebite victims admitted to the emergency ward. Materials and Methods: A retrospective cross-sectional study was conducted among the patients who presented in emergency department with alleged history of snake bites from 2015 to 2016. The patient's record files were reviewed and the relevant data were recorded on a self-designed proforma. Descriptive statistics were calculated using SPSS version 11.5. Results: Out of 137 snakebite victims, 73 (53.3%) were female. The mean age was 35.17 ± 18.27 years. The upper limb (59%) was the most common site for snake bites followed by the lower limb (35.1%). Fifty patients (36.2%) were bitten by snakes during night (20.00-2.59 AM). Twenty-eight (20.4%) patients presented with ptosis as the most common sign and symptom followed by diplopia (15.3%). Out of 137 patients, 39 (28.5%) were admitted, 65 (47.4%) discharged, and 12 (8.8%) patients expired. Antisnake venom was given to 30 patients among which 23 patients (76.7%) were improved. Conclusions: Snake bite is one of the major problems in rural Nepal. It can be easily managed if treatment is given properly and in a timely manner. The importance of effective first aid management and effective treatment have to be disseminated among the peoples in rural areas via social media and radio.

Intentional pesticide poisoning and pesticide suicides in Nepal.

INTRODUCTION: Intentional pesticide poisoning is a major clinical and public health problem in agricultural communities in low and middle income countries like Nepal. Bans of highly hazardous pesticides (HHP) reduce the number of suicides. We aimed to identify these pesticides by reviewing data from major hospitals across the country and from forensic toxicology laboratories. METHODS: We retrospectively reviewed medical records of 10 hospitals for pesticide poisoned patients and two forensic laboratories of Nepal from April 2017 to February 2020. The poison was identified from the history, referral note, and clinical toxidrome in the hospitals and from gas chromatography analysis in the laboratories. Data on demographics, poison, and patient outcome were recorded on a data collection sheet. Simple descriptive analysis was performed. RESULTS: Among hospital cases (n = 4148), the commonest form of poisoning was self-poisoning (95.8%) while occupation poisoning was rare (0.03%). Case fatality was 5.3% (n = 62). Aluminum phosphide (n = 38/62, 61.3%) was the most commonly identified lethal pesticide for deaths. Forensic toxicology laboratories reported 2535 deaths positive for pesticides, with the compounds most commonly identified being organophosphorus (OP) insecticides (n = 1463/2535; 57.7%), phosphine gas (n = 653/2535; 25.7%; both aluminum [11.8%] and zinc [0.4%] phosphide) and organochlorine insecticides (n = 241/2535; 9.5%). The OP insecticide most commonly identified was dichlorvos (n = 273/450, 60.6%). CONCLUSION: The data held in the routine hospital medical records were incomplete but suggested that case fatality in hospitals was relatively low. The pesticides identified as causing most deaths were dichlorvos and aluminum phosphide. Since this study was completed, dichlorvos has been banned and the most toxic formulation of aluminum phosphide removed from sale. Improving the medical record system and working with forensic toxicology laboratories will allow problematic HHPs to be identified and the effects of the bans in reducing deaths monitored.

Metoclopramide-induced acute dystonic reactions: a case report.

BACKGROUND: Acute dystonic reactions caused by drugs are uncommon in daily practice, whether in outpatient or in emergency settings. Such types of unfavorable reaction may cause the treating physician's working diagnosis to be misled at a certain point. CASE PRESENTATION: A 25-year-old Hindu female from Dharan with no previous medical history was being treated for acid peptic disease. Her local physician prescribed oral tablet metoclopramide 10 mg three times a day for 7 days and tablet pantoprazole 40 mg once daily for 7 days. After 24 hours of ingestion of 10 mg of tablet metoclopramide, she was admitted to our Koirala Institute of Health Sciences emergency department with sudden history of facial twitching, slurred speech, and abnormal tongue protrusion. Metoclopramide-induced acute dystonic reaction was diagnosed. After resuscitation, her symptoms reduced quickly, and she was successfully discharged home the same day. CONCLUSIONS: Early diagnosis would be aided by the use of clinical background along with focus on drug history usage, preventing life-threatening pitfalls. To decrease the acute dystonic reaction associated with metoclopramide use, higher frequency of prescription patterns should be taken into account.

Patients Understanding of their Diagnosis and Treatment Plans During Discharge in Emergency Ward in a Tertiary Care Centre: A Qualitative Study.

INTRODUCTION: Many patients do not understand their emergency care plan or their discharge instructions. Patients should understand both the care that they received and their discharge instructions. Patients' knowledge of the diagnosis and treatment plan is an integral component of patient education. The objective of the study is to identify and describe the areas of patients' understanding and confusion about emergency care and discharge instructions at the BP Koirala Institute of Health Sciences, Dharan, Nepal. METHODS: A qualitative study involving 426 patients discharged from the emergency unit of BPKIHS using a semi-structured questionnaire. Cases who are Leaving against medical advice, absconded cases and those patients who came just for vaccination are excluded from the study. The ethical approval for this study was received from the institutional review committee of B P Koirala Institute of Health Sciences, Dharan [Ref: IRC/0752/016]. RESULTS: There were 256 (60.1%) of men in this study. More than half of the participants reported not being able to read English. More than 90% of the respondents reported they could not read their prescription at all. While patient could point out their understanding of their diagnosis at discharge, most of them could not tell the names and the dosage of all the drugs prescribed to them at discharge. More than 95% of the patients could not tell the most common side effects of the drugs that they are prescribed. CONCLUSIONS: There is a need to further explore the factors influencing the understanding of the patients regarding their treatment plan. Interventions to understand the health literacy needs and ways to improve the health literacy of the patients are needed.

Anaphylactic reactions due to pantoprazole: case report of two cases.

BACKGROUND: Drug-induced hypersensitivity reaction is of great clinical significance in therapeutics. The objective of this reporting of two cases is to show that anaphylaxis reaction can occur with pantoprazole. CASE SUMMARIES: A 38-year-old female reported to the emergency ward in a critical condition, with a history of periorbital edema, edema of the skin, pruritus, nausea, vomiting, and difficulty breathing 20 minutes after ingestion of a pantoprazole 40 mg tablet. A 32-year-old female reported to the emergency ward in a critical condition, with complaints of rashes all over the body, itching on the whole body, and swollen lips and eyes after ingestion of a pantoprazole 40 mg tablet. CONCLUSION: It is necessary for all health care providers to know that pantoprazole can cause anaphylaxis, which is a life-threatening reaction, and to be cautious while prescribing it.

Patterns of Injury and Mortality in Pediatric Patients Attending Emergency Department in a Tertiary Care Center in Eastern Nepal.

INTRODUCTION: Trauma is a major and increasing global health concern in the recent world. It is now the leading cause of death among people less than 18 years old. The aim of this study is to analyze all injuries from trauma-related causes among children and adolescents under 18 years old of age. METHODS: This is a retrospective cross sectional study done in Emergency Department of B.P. Koirala Institute of Health Sciences. Patients aged less than 16 years were included with history of trauma from January 1st 2013 to 31st December 2013.The details of patient were taken from computerized medical records of the hospital. The demographic data, pattern of injury, mode of injury, diagnosis and outcomes were tabulated in Microsoft Excel. RESULTS: Total 3958 pediatrics patient were enrolled in this study with Male: Female=3.6:1 and Mean age 9.6±3.2 years. The common modes of injury were fall injury 2596 (65.6%) and RTAs 1176 (29.7%). Whereas the commonest patters were Fractures 1385 (35%) and Soft Tissue Injuries 784 (19.8%). CONCLUSIONS: Fall Injury and Road Traffic Accidents are major and serious problem for children in Low Income countries like Nepal.

Time to analgesia in an emergency department in Eastern Nepal.

OBJECTIVES: Nepal is a least developed country, with limited healthcare resources. An 18 month Fellowship in Emergency Medicine has contributed some improvements to care. This study assessed time to first analgesia in higher and lower acuity patients. METHODS: A prospective observational study of 101 patients in each of the Australasian Triage Scale (ATS) 2, 3 and 100 in ATS 4 was undertaken at B.P. Koirala Institute of Health Sciences. Convenience sampling was used coinciding with researcher's duty hours. Pain scores and time to analgesia were recorded. RESULTS: A total of 302 patients were included. The doctors identified pain in 274 (90%, 95% confidence interval [CI] 86.74-93.65), severity recorded in 92 (30.5%, 95% CI 25-36). Median time from triage to analgesia was 30 min (interquartile range [IQR] 15-60) for ATS 2 patients, 60 min (IQR 40-70) for ATS 3 and 69 min (IQR 45-116) for ATS 4. Tramadol was the analgesic used most commonly (33%), followed by diclofenac (25%), morphine (16%), paracetamol (14%) and ketamine (2%). Analgesia was provided to 212 (70%, 95% CI 64.6-75.2), 65 (30.66%, 95% CI 24.5-37.3) with ATS 2, 85 (40%, 95% CI 33.4-47) with ATS 3 and 62 (29.2%, 95% CI 23.2-35.8) with ATS 4. A total of 44 patients (20.7%, 95% CI 15.5-26.8) with mild, 101 (47.6%, 95% CI 40.7-54.6) with moderate and 60 (28.3%, 95% CI 22.3-34.8) with severe pain received analgesics. CONCLUSION: Time to analgesia for triage score 2 is lower compared to higher triage score. However, a large proportion of patients still do not receive analgesia. This is likely addressed by using a combination of strategies.

Jejunal perforation due to ingested buffalo bone mimicking acute appendicitis.

BACKGROUND: Foreign body ingestion is seen quite frequently in clinical practice, intestinal perforation due to this is rare. The foreign body often mimics another cause of acute abdomen and requires an emergency surgical intervention. The majority of patients do not recall ingesting sharp foreign bodies. CASE PRESENTATION: We report an interesting case of a fifty five year-old man who presented with pain in the right iliac fossa with localised tenderness which was clinically diagnosed as acute appendicitis. During the operation, the presence of purulent collection and the inflamed bowel with flakes raised suspicion of bowel perforation. The assessment of the proximal small bowel revealed two small perforations in the jejunum. A hard, bony and sharp object was extracted and the perforations were closed. Post-operative recovery was uneventful. Detailed food history was taken following the recovery of the patient from surgery. It revealed the history ingestion of home prepared buffalo meat. The extracted object was identified as 'buffalo bone' by the patient and the care taker of the patient. The jejunum was perforated by the ingested buffalo bone causing local peritonitis in right iliac fossa. CONCLUSION: Intestinal perforation by ingested foreign bodies should be suspected in acute abdomen. It requires a high degree of suspicion and awareness on the part of the clinician.

Thoraco- abdominal impalement injury: a case report.

BACKGROUND: Impalement injury is an uncommon presentation in the emergency department (ED), and penetrating thoraco-abdominal injuries demand immediate life-saving measures and prompt care. Massive penetrating trauma by impalement in a pediatric case represents a particularly challenging presentation for emergency providers in non-trauma center settings. CASE PRESENTATION: We report a case of 10 year old male who presented in our ED with an alleged history of fall from an approximately 15 foot tall coconut tree, landing over an upright bamboo stake approximately 50 centimeter long, resulting in a trans-abdomino, trans-thoracic injury. In addition to prompt resuscitation and hospital transfer, assessment of damage to vital structures in conjunction with surgical specialty consultation was an immediate goal. CONCLUSION: This article describes a case study of an impalement injury, relevant review of the available literature, and highlights the peculiar strategies required in the setting of a resource limited ED.

Parenteral organophosphorus poisoning in a rural emergency department: a case report.

BACKGROUND: Poisoning is a common presentation in the emergency department. Oral exposures to organophosphorus compounds are especially frequent in rural and agricultural regions of South Asia and throughout the developing world. CASE PRESENTATION: Here we report a case of deliberate self-harm with an organophosphorus pesticide via the relatively uncommon parenteral route. A young woman injected herself with chlorpyriphos. Although the cholinergic effects were mild, cellulitis and abscess development were noted as a result. CONCLUSION: Resource limited agricultural countries like Nepal present health care workers with numerous challenges in poisoning management. This case represents a rare but potentially morbid method of agrochemical poison exposure.

Penetrating orbit injury: challenge to emergency medicine.

BACKGROUND: Penetrating orbital injuries pose a serious threat to vision, ocular motility, and in some cases, life. The setting and causes of eye injury are diverse, but previous studies have demonstrated that the risk and type of injury is often correlated with age, gender, and race. Pediatric ocular injury is often accidental and may be preventable. A focused history and prompt ocular examination are essential to immediate management. CASE PRESENTATION: This article describes a case of protruding foreign body-related penetrating orbit injury with a retained foreign body in a 4-year-old male from a town in the eastern part of Nepal. The child presented to the emergency with foreign body in situ without receiving any pre emergency care without any medical attendance. The patient was managed with non-operative removal of foreign body in the emergency. The case discussion will review the initial presentation, examination, resultant management decisions, and final outcome. CONCLUSION: Foreign body presentations may be diverse and non-operative management may be considered in selected cases. Resource availability and conditions at presentations may also influence the management decisions. This case presentation has described such a scenario in developing country like Nepal and is expected to be interest across various medical specialties.

Use of analgesia in an emergency department.

INTRODUCTION: Pain is a common presentation to the emergency department but often overlooked with little research done on the topic in Nepal. We did an observational retrospective study on 301 patients in the emergency ward of BP Koirala Institute of Health Sciences with the objective of finding the practice of analgesia. The specific focus was on the time to analgesia, drugs for analgesia and method of pain assessment. METHODS: Case file analysis of patients discharged home after presenting with pain was performed. Time to analgesia and other factors were analyzed with descriptive statistics. RESULTS: Diclofenac injection intramuscular (80%) was the commonest analgesic used. Assessment methods and record keeping were poor. Pain in the abdomen was the commonest. The median time to analgesia from triage was 45 minutes (IQR 30 to 80) and the median time to analgesia from doctor evaluation was 40 minutes (IQR 20 to 70). CONCLUSIONS: Time to analgesia from triage and doctors assessment in our set up is comparable to others. The quality of documentation is poor. Problems with pain identification and assessment may lead to inadequate analgesia so reinforcing the use of pain descriptor at triage itself with pain score would be helpful in adopting a protocol based management of pain.