The diagnostic accuracy of point-of-care ultrasound parameters for airway assessment in patients undergoing intubation in emergency department-an observational study.

BACKGROUND: Endotracheal intubation is an essential resuscitative procedure in the emergency setting. Airway assessment parameters such as the Mallampati classification are difficult to perform in an emergency setting. As point-of-care ultrasound (POCUS) assessment of airway parameters does not require patients to perform any mandatory action, ultrasound may become the potential first-line noninvasive airway assessment tool in the emergency department (ED). The use of POCUS in the ED has not been sufficiently studied. Using POCUS in airway assessment for predicting difficult intubation may be the next step in successful airway management. METHODOLOGY: The study was an observational study conducted at the ED of the All India Institute of Medical Sciences (Rishikesh). The treating emergency physician recorded the patient history and systemic examination along with an indication for intubation. The POCUS assessment of airway parameters pre-epiglottis to epiglottic vocal cord ratio (Pre-E/E-VC), tongue thickness, hyomental distance, and distance from skin to the hyoid bone was performed by the study investigator. During laryngoscopy, Cormack-Lehane (CL) grading was assessed. The data was entered and analyzed. RESULTS: Seventy patients who required intubation in the ED were enrolled in the study. Among the study population, 48.6%, 28.6%, 14.3%, 1.4%, and 7.1% were classified with the following CL grading: 1, 2a, 2b, 3a, and 3b, respectively. At a cutoff of ≥ 1.86, Pre-E/E-VC predicts difficult laryngoscopy (AUC 0.835) with a sensitivity of 83% and a specificity of 94%. At a cutoff of ≥ 5.98 cm, tongue thickness predicts difficult laryngoscopy (AUC 0.78) with a sensitivity of 83% and a specificity of 88%. At a cutoff of hyomental distance ≤ 6 cm, it predicts difficult laryngoscopy with a sensitivity of 83% and a specificity of 88%. All parameters can act as a promising tool for predicting difficult laryngoscopy, with the single best parameter being Pre-E/E-VC. CONCLUSION: Assessment of the airway with POCUS may be helpful to the emergency physician when the clinical airway assessment parameters fail to predict difficult laryngoscopy as most patients requiring intubation are uncooperative. Assessment of the parameters in our study Pre-E/E-VC, tongue thickness, and hyomental distance can act as a promising tool for predicting difficult laryngoscopy in the emergency scenario.

Stroke in a patient of anaphylaxis-a case report and brief review.

BACKGROUND: The use of nonionic low-osmolar contrast media has significantly reduced the risk of hypersensitivity reactions. Despite this, severe reactions continue to occur unpredictably. An ischemic stroke in the setting of anaphylaxis is extremely rare. CASE REPORT: A 64-year-old male with no prior allergies went into anaphylactic shock following the administration of iohexol which improved after treatment. He later developed a multi-territorial ischemic stroke. CONCLUSION: An ischemic stroke in the setting of an anaphylaxis is a rare occurrence, which can be attributed to multiple factors in our patient.

Point of care gastric ultrasound to predict aspiration in patients undergoing urgent endotracheal intubation in the emergency medicine department.

BACKGROUND: One significant cause of morbidity and mortality in patients undergoing endotracheal intubation is the aspiration of gastric contents. Its prevalence is more in the emergency than in elective settings. Point-of-care gastric ultrasound (GUS) is a non-invasive bedside ultrasonogram that provides both qualitative and quantitative information about the stomach contents. The diagnostic accuracy of GUS in terms of gastric parameters (measured antral diameters, antral cross-sectional area, and calculated gastric volume) to predict aspiration is yet unknown. We aim to determine this in the patients undergoing urgent emergency intubation (UEI) in the emergency department. METHODOLOGY: A prospective observational study was conducted at the emergency department of a tertiary healthcare center in India. Patients requiring UEI were identified and a bedside gastric ultrasound was done in the right lateral decubitus position using low frequency curved array probe. The qualitative data and the antral diameters (anteroposterior and craniocaudal) were assessed. The patient's clinical parameters and history regarding the last meal were noted. The cross-sectional area of gastric antrum was calculated using CSA = (AP × CC) π/4. The gastric volume is estimated using Perla's formula: GV = 27.0 + 14.6(RLD CSA) -1.28(age). RESULTS: A hundred patients requiring urgent endotracheal intubation were enrolled in the study. Visible aspiration was more in participants with a distended gastric status (χ2 = 16.880, p = < 0.001). The median gastric volume in the patients who aspirated was 146.37 mL, and it ranged from 111.59 mL-201.01 mL. Using ROC analysis, a cut-off of CC diameter ≥ 2.35 cm (sensitivity 88%, specificity 91%) and AP diameter ≥ 5.15 cm (sensitivity 88%, specificity 87%) predicts aspiration. A calculated USG CSA cut-off ≥ 9.27cm2 (sensitivity 100%, specificity 87%) and an USG gastric volume ≥ 111.594 mL (sensitivity 100%, a specificity 92%) predicts aspiration. CONCLUSION: Point-of-care gastric ultrasound is an useful non-invasive bedside tool for risk stratification for aspiration in busy emergency rooms. We present threshold gastric antral parameters that can be used to predict aspiration along with its diagnostic accuracy. This can help the treating ED physician take adequate precautions, decide on intubation techniques and treatment modifications to aid in better patient management.

Difficult Mask Ventilation in Penetrating Facial Trauma Due to Animal Attack: A Unique Challenge in the Emergency Department.

Penetrating facial trauma can be a life-threatening condition, especially due to its impact on the airway. In a facial trauma, there is a distortion in the basic anatomy of the affected, making it a particularly difficult situation for managing the airway. Challenging intubation scenarios have been widely explored in the literature; however, difficult to ventilate situations have been undermined. We describe a case of a 35-year-old female who presented with a history of animal attack on the face. The extent of penetrating facial trauma warranted the need to secure the airway. Preserving spontaneous breathing and using an oral endotracheal tube for oxygenation saved the airway manager from cannot intubate and cannot oxygenate situation in a facial trauma patient. Difficult to mask ventilate while arranging for a definitive airway can be more pressing and challenging for the emergency physician. It also jeopardizes the patient's life, whose survival may only depend on acquiring the patency of the airway. Facial trauma patients may be conscious and spontaneously breathing, leading to the missed or delayed intervention in the airway; hence, prompt assessment and management of the airway in all facial trauma are of utmost importance.

Intractable hiccups as the harbinger of a diffuse pontine glioma.

Hiccups are experienced by people of all ages. While acute hiccups are benign and self-limited, persistent and intractable hiccups can sometimes signal a serious disease. We present a young previously healthy man who complained of only hiccups for 4 months and later developed a severe headache and projectile vomiting. His systemic examination was within normal limits. Brain imaging revealed a diffuse pontine glioma with mild hydrocephalus.

Post-COVID-19 Guillain-Barré Syndrome: A Case Report With Literature Review.

Coronavirus disease 2019 (COVID-19) predominantly affects the respiratory system with manifestations ranging from a mild upper respiratory tract infection to severe acute respiratory distress syndrome. Neurological manifestations of COVID-19 are mainly thrombotic manifestations affecting the nervous system; however, demyelinating manifestation has been less defined. Although some recent studies have described the association between COVID-19 and Guillain-Barré syndrome (GBS), the strength of association and features of GBS in this setting are not yet clear. Here, we report one adult case of COVID-19 infection presenting with acute GBS, which was not preceded by any other respiratory, gastrointestinal, or other systemic infections. We performed a literature search in Medline via PubMed using the keywords or MeSH terms "COVID-19" or "SARS-CoV-2" and "Guillain-Barré syndrome" and "AIDP" and "AMAN," "Miller-Fischer syndrome" or "MFS." We reviewed 99 case reports, 38 reviews, and two meta-analyses. Several published reports have described a possible association between GBS and COVID-19 infection.

An Unusual Case of Persistent Hypoglycemia in Scrub Typhus.

Acute fever is a common worldwide issue among patients presenting to the emergency department. Main tropical fevers presenting as acute fever are malaria, dengue fever, typhoid, scrub typhus, and leptospirosis. Scrub typhus is a zoonotic disease caused by Orientia tsutsugamushi, which is endemic in many parts of India. Its clinical presentation varies significantly from undifferentiated fever and fever with thrombocytopenia to meningoencephalitis. Persistent hypoglycemia in scrub typhus has not yet been reported. Here we report a case of a 27-year-old male who presented with altered mental status after seven days of scrub typhus diagnosis. Diagnosis of hypoglycemia (random blood sugar of 37 mg/dL) was made at triage. Altered mental status responded to dextrose, but despite meals and treatment, hypoglycemia persisted. The cause for persistent hypoglycemia remained unexplained as most laboratory panels for hypoglycemia were either normal or did not fit into a particular cause.

Extracranial Internal Carotid Aneurysm Manifesting With Tinnitus: A Rare Presentation.

A 19-year-old male presented with a history of pulsatile tinnitus on the left side after he underwent drainage for a tonsillar swelling. He had noticed a painless neck swelling one month ago that was associated with difficulty in swallowing. His physician had made a diagnosis of peritonsillar abscess, and drainage had been performed. After the procedure, the swelling had progressed further, leading to drooling of saliva and disabling tinnitus. When he presented to the emergency, local examination revealed a pulsatile neck swelling with peritonsillar mass. CT angiography/digital subtraction angiography (DSA) of the neck and brain revealed a large aneurysm of the distal cervical segment of the left internal carotid artery (ICA). The patient successfully underwent an urgent open repair. This case highlights the importance of a thorough history and examination in identifying a rare cause of pulsatile tinnitus. A stepwise approach to determine the reason behind tinnitus revealed an underlying ICA aneurysm of the extracranial segment.

Prognostication of COVID-19 patients using ROX index and CURB-65 score - A retrospective observational study.

Objectives: Coronavirus disease-2019 (COVID-19) disease has overwhelmed the healthcare infrastructure worldwide. The shortage of intensive care unit (ICU) beds leads to longer waiting times and higher mortality for patients. High crowding leads to an increase in mortality, length of hospital stays, and hospital costs for patients. Through an appropriate stratification of patients, rational allocation of the available hospital resources can be accomplished. Various scores for risk stratification of patients have been tried, but for a score to be useful at primary care level, it should be readily available at the bedside and be reproducible. ROX index and CURB-65 are simple bedside scores, requiring minimum equipment, and investigations to calculate. Methods: This retrospective, record-based study included adult patients who presented to the ED from May 1, 2020 to November 30, 2020 with confirmed COVID-19 infection. The patient's clinical and demographic details were obtained from the electronic medical records of the hospital. ROX index and CURB-65 score on ED arrival were calculated and correlated with the need for hospitalization and early (14-day) and late (28-day) mortality. Results: 842 patients were included in the study. The proportion of patients with mild, moderate and severe disease was 46.3%, 14.9%, and 38.8%, respectively. 55% patients required hospitalization. The 14-day mortality was 8.8% and the 28-day mortality was 20.7%. The AUROC of ROX index for predicting hospitalization was 0.924 (p < 0.001), for 14-day mortality was 0.909 (p < 0.001) and for 28-day mortality was 0.933 (p < 0.001). The AUROC of CURB-65 score for predicting hospitalization was 0.845 (p < 0.001), for 14-day mortality was 0.905 (p < 0.001) and for 28-day mortality was 0.902 (p < 0.001). The cut-off of ROX index for predicting hospitalization was ≤18.634 and for 14-day mortality was ≤14.122. Similar cut-off values for the CURB-65 score were ≥1 and ≥2, respectively. Conclusion: ROX index and CURB-65 scores are simple and inexpensive scores that can be efficiently utilised by primary care physicians for appropriate risk stratification of patients with COVID-19 infection.

Cardiovascular manifestations of COVID-19: A case series.

COVID-19 is known to present with respiratory symptoms, which can lead to severe pneumonia and respiratory failure. However, it can have multisystem complications such as cardiovascular and neurological manifestations. Cardiovascular complications of SARS-CoV-2 infection are still underreported in India. We have compiled four cases received in our emergency department with different cardiovascular manifestations at presentation and were diagnosed with COVID-19. The cardiovascular manifestations reported by previous studies comprise myocarditis, cardiogenic shock, arrhythmias, pulmonary embolism, deep vein embolism, acute heart failure, and myocardial infarction. Hence, a thorough cardiac examination with ECG correlations and point of care cardiac markers should be done in all the patients with COVID-19 infection. Immediate initiation of prophylactic anticoagulation in COVID-19 hospitalized patients is mandatory. Geriatric patients and those with co-morbidities can have a fulminant course of illness; so our treatment protocol should be more vigilant in these patients. However, most importantly, we must not forget the significance of bedside echocardiography, lung ultrasound, and point of care markers.