Ivabradine for inappropriate sinus tachycardia-induced symptomatic Mobitz type I atrio-ventricular block: a case summary.

Background: Inappropriate sinus tachycardia (IST) is characterized by a continuum of symptoms, and the aetiology of IST is imprecise. IST-induced autonomic dysfunction is well known, but IST-induced atrio-ventricular block is not reported to our knowledge. Case summary: A 67-year-old female presented with a 4-day history of random intermittent difficulty in breathing, chest tightness, palpitations, and dizziness, with a recorded heart rate of 30 beats per minute (BPM) on home monitoring equipment. The initial electrocardiogram (ECG) demonstrated sinus rhythm with intermittent Mobitz type I second degree atrio-ventricular (AV) block, with continuous cardiac monitoring demonstrating frequent episodes of Wenckebach phenomenon throughout the day, with a sinus rate of 100-120 BPM. Echocardiogram showed no significant structural abnormalities. The patient was on bisoprolol, and hence, it was suspected Wenckebach may be due to that and so stopped. However, there was no tangible effect on rhythm 48 hours after stopping bisoprolol, leading to a suspicion of IST-induced Mobitz type I second degree AV block; and so decided to introduce ivabradine 2.5 mg twice daily. After 24 hours of Ivabradine, the patient remained in sinus rhythm with no documented episodes of Wenckebach phenomenon on cardiac monitor, a finding subsequently confirmed by 24-hour Holter monitoring. During a recent follow-up visit in clinic, the patient remained symptom-free, with an ECG demonstrating sinus rhythm at a physiological rate. Discussion: Mobitz type I second degree AV block is usually due to reversible conduction block at the level of the AV node whereby malfunctioning AV nodal cells tend to progressively fatigue until they fail to conduct an impulse. Under conditions of increased vagal tone and autonomic dysfunction, Wenckebach occurrence will be increased. Thus, selective impulse conduction within the sinoatrial (SA) node by ivabradine to reduce beat conduction to the AV node in patients with IST/dysautonomia-induced Mobitz type I AV will reduce the occurrence of Wenckebach.

Oxygen Administration under Surgical Face Mask in COVID-19 Patients: A Game Changer.

COVID-19 is a multifaceted infectious disease. The development of hypoxemic respiratory failure is not uncommon during the course of illness in some of them. The objectives of the present study were to assess the effect of the addition of a surgical face mask while delivering oxygen via nasal cannula in hypoxemic COVID-19 patients and highlight on the advantages and patient's comforts. We prospectively assessed 30 consecutive conscious and hypoxemic COVID-19 patients, requiring oxygen via nasal cannula. The mean PaO2 without and with surgical face mask were 52 (+9) and 83 (-12) mm Hg respectively in the cohort, and the elevation in oxygen saturation was statistically significant (p <0.001). The present results encourage the delivery of oxygen under the surgical face mask in symptomatic COVID-19 patients, as it improves oxygen saturation and prevents aerosol dispersion with no change in PaCO2. The other advantages of this method are a reduction in the total requirement of oxygen per patient, better utilization of scarce resources, and lessening of the expenses incurred for oxygen. HOW TO CITE THIS ARTICLE: Senthilkumaran S, Koushik M, Meenakshisundaram R, Jena NN, Thirumalaikolundusubramanian P. Oxygen Administration under Surgical Face Mask in COVID-19 Patients: A Game Changer. Indian J Crit Care Med 2021;25(11):1286-1287.

Not Touching the Face is Harder Than It Sounds: Need for an Intervention.

In the novel coronavirus (COVID-19) pandemic, preventive medicine has taken center stage, as there is no vaccine or specific antiviral drug regime used to treat patients. Public health authorities and governments are recommending the practice of social distancing and hand hygiene. Hands are a common vector for the transmission of infection, and frequent face touching is extremely common among the public. We developed and applied a new method to prevent face touching which is of utmost importance to break its cycle and subsequent inoculation of the virus through mucous membranes, thus reducing the risk of transmission of COVID-19. HOW TO CITE THIS ARTICLE: Senthilkumaran S, Arathisenthil SV, Meenakshisundaram R, Thirumalaikolundusubramanian P. Not Touching the Face is Harder Than It Sounds: Need for an Intervention. Indian J Crit Care Med 2020;24(8):662-663.

Status of Acute Myocardial Infarction in Southern India During COVID-19 Lockdown: A Multicentric Study.

There has been a reduction in the reported cases of acute myocardial infarction (MI) across the globe during the outbreak of coronavirus disease 2019 (COVID-19) (severe acute respiratory distress syndrome coronavirus 2). An attempt was made to find out the number of acute MI cases treated during the COVID-19 lockdown period (April 2020) and highlight the possible reasons for the changes in the occurrence. A multicentric retrospective observational study was performed to collect the selected data from 12 private hospitals distributed in 4 cities-Madurai, Trichy (Thiruchirapalli), Erode, and Salem-of the Tamil Nadu state in southern India. There was a significant (P<.001) reduction in ST-segment elevation MI (STEMI), non-STEMI (NSTEMI), and total (STEMI and NSTEMI together) cases during the lockdown period (April 1 to 30, 2020) as compared with no-lockdown periods such as January and February 2020 and April 2019 and April 2018 in all cities, whereas the reduction was not significant for NSTEMI in Trichy when data for the lockdown period was compared with those for January and February 2020. Overall, there is a reduction in acute MI cases, which may be due to alterations in modifiable risk factors during the COVID-19 lockdown period. Hence, implementation of public education and polices on controlling modifiable risk factors is likely to pay dividends.

Severe hypertension in elapid envenomation.

Snakebite is not an uncommon medical emergency in India; however, symptoms of autonomic dysfunction in snakebite are rare. The elapid snake envenomation is a frequent occurrence in India, and the krait bite is prevalent in the south Indian region. Here, we present three cases of snakebite with severe hypertension and requiring intravenous nitroglycerin (NTG). As the level of blood pressure (BP) decreased significantly following antisnake venom (ASV) injection in all three cases, it is likely that snake venom-induced dysautonomia might have contributed to severe hypertension in such patients. Clinical and therapeutic challenges of these cases are highlighted, so that practitioners coping with medical emergencies in resource-limited situations can consider snake (krait) bite in the differential diagnosis, and also manage effectively according to corroborative clinical evidences.

Isolated thigh pain in myocardial infarction.

The referred pain of angina to upper half of the body is well known. However, isolated pain in the thigh as a presenting symptom in myocardial infarction is neither considered nor discussed at all. Here, we report a middle-aged man without demonstrable risk factors who presented to the emergency department for isolated bilateral anteromedial thigh pain. He was diagnosed with acute inferior wall myocardial infarction. After thrombolysis, the thigh pain improved. The probable mechanism for this is attributable to radiation of pain via sensory cardiac fibers that is present in the lumbar sympathetic ganglia, which resulted in pain.

Acute renal failure in acute poisoning: prospective study from a tertiary care centre of South India.

BACKGROUND: Cases of people presenting with poisoning are likely to develop acute renal failure (ARF), which may be due to multiple mechanisms/aetiologies. These cases need careful observation and appropriate treatment. OBJECTIVE: To find the risk of ARF among acute poisoning cases, identify the underlying causes and to analyse the outcome. MATERIAL AND METHODS: In this prospective study with nested case control, 1,250 cases admitted to the Poison Control, Training and Research Centre of Government General Hospital, Madras Medical College were monitored and evaluated for development of ARF. Patients with history of diabetes/hypertension, known chronic kidney disease, chronic NSAID therapy, those on drugs that increase serum creatinine by inhibiting creatinine secretion and other co-morbid illnesses were excluded. Data were interpreted after subjecting them to bivariate logistic regression and then step wise multivariate analysis. RESULTS: Thirty-two cases developed ARF. Twenty-four were due to snake bite, the rest due to chemical poisons. Chances of developing ARF were greater (6.15%) among the poisoning due to bites and stings than chemical poisoning (0.9%). Five in the former and seven in the latter expired. Among cases bitten by snakes, only 22 (7%) cases bitten by Russell Viper Daboia russelii developed renal failure. Copper sulphate and rat killer poisonings were the commonest causes of chemical induced ARF, dichromate, indigenous medicines and vasmol 33 (paraphenelyne diamine) were the least causes for ARF. None of the patients with organophosphate developed ARF nor did any of the 150 admitted for overdose of medicines developed ARF. CONCLUSION: The risk of ARF among the cases of poisoning was 2.5%. The outcome of ARF among bites and stings was better than chemical poisoning, and the difference was highly significant (p= 0.005, OR = 0.04-1.0, 95% CI = 0.004-0.38). Early recognition and appropriate measures reduce the occurrence of ARF.