Comparing Sensitivity and Specificity of Ultrasonography With Chest Radiography in Detecting Pneumothorax and Hemothorax in Chest Trauma Patients: A Cross-Sectional Diagnostic Study.

Background Thoracic trauma accounts for 20-25% of all traumas and is the third most frequent cause of death, after abdominal injury and head trauma. In the Emergency Department (ED), shifting an unstable patient to the X-ray room for detecting pneumothorax and hemothorax is always risky and bedside X-ray causes radiation exposure not only to the particular patient but also to the surrounding patients in a congested and busy ED. This can be avoided by using bedside ultrasonography (USG) as the initial imaging modality in chest trauma patients. Objective To compare the sensitivity and specificity of ultrasonography and chest radiography in detecting pneumothorax and hemothorax in chest trauma patients. Methods This cross-sectional diagnostic study was conducted for a period of one year at Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India, a tertiary care centre. All consecutive patients (n=255) with a suspected history of chest trauma were included in the study. The patients were evaluated bedside using USG by point of care ultrasonography trained emergency medicine physician and subsequently underwent chest radiography for documentation of pneumothorax and hemothorax. Sensitivity and specificity were calculated for ultrasonography and chest X-ray (CXR) compared with the composite gold standard (chest radiography and computed tomography thorax). Results Of the 255 patients, 89% were males. The mean age of the patients was 43.46 (standard deviation 16.3). Road traffic accident (RTA) was the most common mode of injury (81%). The median (interquartile range) time interval between injury and arrival at the hospital was four hours (2.5-7). About 16.1% of the patients had subcutaneous emphysema. About 88.2% of the patients were hemodynamically stable and 78% of the patients had associated other system injuries. The sensitivity and specificity of USG in detecting pneumothorax were 85.7% and 95.3% respectively and that of CXR were 71.4% and 100% respectively. Our study found that the sensitivity and specificity of USG in detecting hemothorax were 79% and 97.9% respectively and that of CXR were 62.9% and 100% respectively. Even in the subset of patients in whom a computed tomography scan was done, the sensitivity of USG was higher than that of CXR in detecting pneumothorax and hemothorax. The specificity of USG in detecting pneumothorax was the same as that of CXR and the specificity of USG in detecting hemothorax was higher than that of CXR in that subset of patients. Conclusion The sensitivities of USG in detecting pneumothorax and hemothorax were higher than that of CXR. The specificities of USG in detecting pneumothorax and hemothorax were comparable to that of CXR. Hence bedside USG performed by emergency physician during resuscitation helps in rapid diagnosis and early management of chest trauma patients.

Clinico-Demographic Profile and Factors Affecting Duration of Hospital Stay Among Burn Patients in an Emergency Department of a Tertiary Care Center, South India: A Hospital-Based Cross-Sectional Study.

Background Burns continue to be a serious public health problem in India. It persists as an endemic disease in spite of implementing various preventive measures at the individual and community levels. Etiology and factors influencing burns are varied. There is a paucity of data regarding the clinico-demographic profile of burns disease, especially from emergency tertiary care settings in India. Objective To assess the proportion of burn patients having longer hospital stays (>1 week) and the influence of clinico-demographic factors associated with it among the burn patients presenting to the emergency department of a tertiary care institute in south India. Methodology An institution-based cross-sectional analytical study was conducted among burns patients attending the Emergency Medicine Department (EMD) of a tertiary care center between January 2017 and December 2017. Information on clinico-demographic profile and duration of hospital stay were captured using semi-structured data collection proforma. Results All the 327 burns injury patients who presented to our EMD during the study period were included. Among the 327 patients, 259 (79%) were admitted to the EMD. Among 259 admitted patients, 142 (55%) patients were discharged home. Among these 142 patients, 106 (74.6%; 95%CI 66.8-81.2) had longer hospital stays (more than one week). Female gender and facial/inhalational burns were found to have an independent effect on the length of hospital stay even after adjusted analysis. Conclusion Length of hospital stay is independently influenced by female gender and facial/inhalational burns. This study also identified the need for better home safety, child-proofing, proper pre-hospital care, and dedicated burns units in the community.

The Effect of Simulated Patient Death on Learner's Stress and Knowledge Retention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

Making the simulated patient die is one of the controversial decisions in healthcare simulation. Some experts believe that we should never make the manikin die as they believe the facilitator is deceiving the learners, whereas other groups of experts believe that there are advantages in making the simulated patient die as it provides a valuable learning experience to the learners, and it is as close to reality as possible. Hence, we undertook this review to know whether simulated patient mortality benefits the learners. A systematic literature search was performed in Embase, Scopus, PubMed Central, CENTRAL, MEDLINE, and Google Scholar. Randomized controlled trials assessing the learner's stress and knowledge retention when the simulated patient dies were eligible for inclusion. Comparative intervention effect estimates obtained from meta-analyses were represented as pooled standardized mean difference (SMD) with a 95% CI. Six studies with 384 participants (learners) were eligible for the analysis. All the studies had some concerns when the risk of bias was assessed. In the simulated patient mortality group, the learners experienced higher stress as assessed compared to the group where the simulated patient survives. The two groups' pooled mean difference for anxiety and stress levels was 0.63 (0.17-1.09). Three out of five studies showed improved knowledge retention in the simulated mortality group, one showed no difference, and one showed decreased knowledge retention in the simulated mortality group. The stress response of learners when exposed to simulated mortality during a simulation session is higher than the simulated survival group. However, this increased stress response is processed by the students differently. Some students will thrive when increased stress is presented to them, while some students perceive it negatively. Thus, this increased stress response can lead to knowledge retention if the timing of the stress response happens mainly during debriefing for select students. The role of the facilitator is also important as skilled debriefers will be able to use this increased stress to their advantage to increase knowledge retention. Thus, simulated mortality can be used as an effective stressor for increasing knowledge retention during the debriefing phase for select students by a skilled debriefer. This study would aid the simulation policymakers, simulation faculties, and simulation researchers in the impact of simulated patient death and learners' stress response. If the simulation scenario is designed well with robust pre-briefing, this increased stress response can enhance learning and knowledge retention during debriefing.

A Prospective Observational Study of Endotracheal Intubation Practices in an Academic Emergency Department of a Tertiary Care Hospital in South India.

INTRODUCTION: Airway management is the first critical step to be addressed in the airway, breathing, and circulation algorithm for stabilizing critically ill patients. Since the emergency department (ED) is the primary contact of these patients in health care, doctors in the ED should be trained to perform advanced airway management. In India, emergency medicine has been recognized as a new specialty by the Medical Council of India (now the National Medical Commission) since 2009. Data related to airway management in the ED in India is sparse. METHODS: We conducted a one-year prospective observational study to establish descriptive data regarding endotracheal intubations performed in our ED. Descriptive data related to intubation was collected using a standardized proforma that was filled by the physician performing intubation. RESULTS: A total of 780 patients were included, of which 58.8% were intubated in the first attempt. The majority (60.4%) of the intubations were performed in non-trauma patients and the remaining 39.6% in trauma patients. Oxygenation failure was the most common indication (40%) for intubation followed by a low Glasgow coma scale (GCS) score (35%). Rapid sequence intubation (RSI) was performed in 36.9% of patients, and intubation was done with sedation only in 36.9% of patients. Midazolam was the most commonly used drug - either alone or in combination with other drugs. We found a strong association of first-pass success (FPS) with the method of intubation, Cormack-Lehane grading, predicted difficulty in intubation, and experience of the physician performing the first attempt of intubation (P<0.05). Hypoxemia (34.6%) and airway trauma (15.6%) were the most commonly encountered complications. CONCLUSION: Our study showed an FPS of 58.8%. Complications were seen in 49% of intubations. Our study highlights the areas for quality improvement in intubation practices in our ED, like the use of videolaryngoscopy, RSI, airway adjuncts like stylet and bougie, and intubation by more experienced physicians in patients with anticipated difficult intubation.

The ABCDE (Avoid Shaming/Personal Opinions, Build a Rapport, Choose a Communication Approach, Develop a Debriefing Content, Ensure the Ergonomics of Debriefing) Approach: A Simplified Model for Debriefing During Simulation in Emergency Medicine.

Several debriefing models have been described in the literature. However, all these debriefing models are designed in the general medical education format. Hence, for people involved in patient care and clinical teaching, sometimes it may become tedious and difficult to incorporate these models. In the following article, we describe a simplified model for debriefing using the well-known mnemonic ABCDE. The ABCDE approach is expanded as follows: A - Avoid Shaming/Personal Opinions, B - Build a Rapport, C - Choose a Communication Approach, D - Develop a Debriefing Content, and E - Ensure the Ergonomics of Debriefing. The unique thing about this model is that it provides a debriefing approach as a whole rather than only the delivery. It deals with human factors, educational factors, and ergonomics of debriefing, unlike other debriefing models. This approach can be used for debriefing by simulation educators in the field of emergency medicine and also by educators in other specialties.

Unusual Presentation of a Common Diagnosis in a Patient With Chronic Kidney Disease.

This case report describes a patient in their 40s with chronic kidney disease who presented to the emergency department with acute-onset breathlessness for 2 hours.

Tachycardia origin prediction using point of care ultrasound (TOP-UP) - A novel technique.

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.

A Rare Case of Limb-Threatening Injury Secondary to Extrinsic Vascular Compression Following Crocodile Bite.

Crocodile bites lead to fatal and nonfatal outcomes in humans. Mugger crocodiles (Crocodylus palustris) and saltwater crocodiles (Crocodylus porosus) are common in India. Most crocodile bites can cause severe injuries, especially to the extremities, due to the substantial bite force of the crocodile, which typically leads to extensive tissue damage, fractures, amputations, and vascular injuries. We report the case of a crocodile bite victim who presented with features of acute limb ischemia, was found to have vascular thrombosis of the common femoral artery, and was experiencing complete compression of the femoral vein due to external vascular compression by a hematoma. We discuss various injury mechanisms sustained in crocodile bites and the roles of point-of-care ultrasound and continuous tomography angiography, which could help identify these injuries. After thrombectomy and hematoma evacuation the patient recovered and was discharged without any physical dysfunction.

Defective barcode sign - A newer sonographic sign in hydropneumothorax.

Effusive pneumothorax can be hemopneumothorax, pyopneumothorax, or hydropneumothorax depending on the type of fluid compartment within the pleural cavity. Hydropneumothorax is the abnormal collection of air and serous fluid within the pleural cavity. Here, we report a case of a 34-year-old male who presented to the emergency department with cough and breathlessness. We did bedside point-of-care ultrasound-assisted clinical evaluation as the patient was vitally unstable, which showed "hydro point" and "defective barcode sign," which suggested hydropneumothorax. We present these clinical evaluation details, imaging/sonographic findings, and patient management in this case report.

Cardiac tamponade due to right atrial rupture.

Cardiac tamponade is a cardiac emergency that requires urgent intervention. Cardiac tamponade due to penetrating cardiac injury requires urgent thoracotomy. As per the guidelines, pericardiocentesis can be done as a bridge to thoracotomy. However, no clear guidelines exist on the management of cardiac tamponade due to blunt cardiac injury. In the following case report, we propose a management plan for blunt cardiac injury in the emergency department. In the following case report, we describe a patient with a road traffic accident who had a blunt cardiac injury and had cardiac tamponade for whom we did not do emergency pericardiocentesis. Instead, we managed the patient with iv fluids and blood transfusion and the patient was taken up for immediate emergency thoracotomy. Not all cardiac tamponade requires pericardiocentesis. Cardiac tamponade due to injury to the low-pressure system can be best managed by initial resuscitation followed by emergency thoracotomy. We also propose a management plan for managing a patient with cardiac tamponade due to blunt cardiac injury when the injury can be visible in the low-pressure chambers.

Designing a universal tool for developing content of debriefing: The how and what questions.

Objectives: Clear and specific content for debriefing promotes learning and reflection for the learner. Currently, there is no universal tool for developing the content for debriefing. Methods: We developed a tool for debriefing that can be applied for developing content for debriefing, which can be used for instructor-led and within-team debriefing. These tools include two sets of eight questions, namely, the how and the what questions. Results: We used these tools in our monthly simulation activities and got a favorable response from the residents who used them. Conclusions: The how question deals with human factors, and the what questions deal with educational factors.

'Hydro-point' - The forgotten and unspoken entity in hydropneumothorax.

Effusive pneumothorax is an abnormal collection of air and fluid within the pleural space: blood, pus, or serous fluid. Thus, effusive pneumothorax can be categorized as hemopneumothorax, pyopneumothorax, or hydropneumothorax, depending on the type of fluid accumulation. Hydropneumothorax is a clinical condition defined by the presence of air and serous fluid within the pleura space. Hydropneumothorax is one of the common respiratory emergencies encountered in the emergency department in India. Etiologies can be classified into infectious and non-infectious causes, among which tuberculosis being the most common one. Point of care ultrasound (POCUS) can help diagnose hydropneumothorax at the bedside rather than shift the patient for an X-ray. Here, we describe a case of hydropneumothorax, which was diagnosed using POCUS by characteristic sonographic signs, namely "Hydro-point" and "barcode-hydro point-sinusoidal sign." Sonographic hydro-point is the transition zone of the air-fluid interface, which is seen in hydropneumothorax. Targhetta et al., in 1992, introduced the term "Hydro-point" in lung ultrasound for diagnosing hydropneumothorax but has been under-reported/unspoken much in the literature. With the use of POCUS, we diagnosed and stabilized the patient in the Emergency Department.

Stanford - A Aortic Dissection Presenting as a Triple Mimic and Role of Point of Care Ultrasound in Deciphering It.

Aortic dissection (AD) is a great imitator, and its diagnosis is quite challenging due to its varied presentations and unreliable clinical findings. Based on the literature search we found, this is the first case report of Stanford-A/DeBakey Type 1 AD reported as a triple mimic, namely stroke, acute limb ischemia, and pericarditis. Here, we describe the case of a 46-year-old male who presented to our emergency department with features suggestive of acute pericarditis, cerebrovascular accident, acute limb ischemia, which could have been attributed to athero-thrombo-embolic disease and AD could have been possibly missed. However, point-of-care ultrasound helped us in the diagnosis of this highly lethal condition.

Need for a Change - Extended-FAST to Extended Diaphragmatic-FAST.

Post-traumatic hypoxia can be due to different causes, namely airway problems, pneumothorax, hemothorax, lung contusion, flail chest, traumatic diaphragmatic injuries (TDI), aspiration due to low sensorium, a respiratory paradox in cervical spine injury, severe hypotension, etc., It is a great challenge to identify the cause of hypoxia in a trauma setting because the contributing factors can be multiple or can be a remote cause, which is often missed out. Here, we describe a 50-year-old female who presented to our emergency department with Post-traumatic hypoxia whose sensorium, blood pressure, chest X-ray, E-FAST computed tomography of brain, and other baseline investigation were completely normal, diagnosed later as TDI with the help of diaphragmatic ultrasound and computed tomography of thorax.

Mechanodefibrillator dissociation due to prolonged sinus arrest / Mecano disociación del desfibrilador debido a un paro sinusal prolongado

To the editor, Sinus arrest and cardiac arrest are two different terms which are often confused by many. This confusion often leads to inappropriate cardiopulmonary resuscitation (CPR) when patient is connected to defibrillator. Sinus arrest is defined as transient pause in Sino-atrial firing for more than 3 s1. When sinus arrest occurs, other latent pacemakers (atrial myocardium, cells nearby atrioventricular node, and His purkinje system) usually starts firing until Sino-atrial node recover. Sinus arrest can be prolonged till other pacemakers starts firing2. Cardiac arrest occurs when these latent pacemakers does not take up the job of alternate firing. Prolonged sinus arrest in a defibrillator may look like a cardiac arrest which might lead to unnecessary CPR. Here, we would like the put forward a new term “mechano - defibrillator dissociation” which occurs because of prolonged sinus arrest. We should be aware this, so that inappropriate CPR could be avoided. We, emergency physician also faced similar situation while resuscitating a patient because of mechano - defibrillator dissociation caused by prolonged sinus arrest/pseudo cardiac arrest. A 52-year-old male diabetic, hypertensive, and chronic alcoholic came to our emergency department (ED) with history of giddiness, syncope, and palpitation. On arrival to ED, patient was drowsy, diaphoretic, and hypotensive. Patient was connected to defibrillator which showed a heart rate of 35/min and saturation was 90% in room air. ECG showed complete heat block (CHB) and point of care echocardiography showed reduced ejection fraction.