Caught in the Clot: A Case Report of Arrested Pulmonary Embolism.

Pulmonary embolism (PE) is a life-threatening condition resulting from the obstruction of pulmonary arteries by blood clots, usually originating from deep veins. Symptoms of PE might vary from nothing to sudden death. Clinically, individuals may present very differently. When a diagnosis of PE is suspected, any possible life-saving intervention must be implemented because survival from cardiac arrest following PE is often quite low. Although there are not many randomized controlled trials that provide guidelines for treating suspected PE in cardiac arrest victims, the few published case reports and other minor studies suggest that thrombolysis and other therapies are associated with good outcomes. We report a patient with PE who presented in cardiac arrest with its clinical, electrographic, and radiologic findings, along with the appropriate therapy chosen based on hemodynamic stability. It is important to intervene early to prevent severe complications and improve the patient's outcomes.

Novel use of motor-sparing genicular nerve blocks for knee injuries in the emergency department.

Knee injuries are quite prevalent in the Emergency Department (ED) and often present with severe pain, necessitating effective pain management strategies. Traditional pain management approaches, including opioid medications, may carry undesirable side effects and potential risks, leading to the growing interest in non-opioid alternatives. Nerve blocks have emerged as promising options for targeted pain relief in the ED. Motor-sparing nerve blocks have gained importance due to their ability to provide effective analgesia without compromising motor function [1]. The case series demonstrates the successful use of ultrasound-guided genicular nerve blocks(GNB) in the Emergency Department, providing targeted pain relief without compromising motor function. GNBs offer a valuable alternative to traditional nerve blocks(femoral, fascia iliaca, adductor canal) and opioid-based pain control strategies in the ED. As the evidence base grows, GNBs may become a more established component of ED pain management protocols, enhancing patient outcomes and safety in the management of acute knee injuries. The incorporation of ultrasound-guided motor-sparing nerve blocks in ED pain management protocols may hold great promise in optimising pain control and enhancing patient comfort. Trial Registration: N/A.

Capnography as a tool for triaging and diagnosis of diabetic ketoacidosis in the emergency department: A prospective observational study.

OBJECTIVES: The cornerstone of management of acidosis in a patient with diabetic ketoacidosis (DKA) has traditionally been carried out by blood gas analysis, which is expensive and associated with significant risk. It is against this background that the correlation between end-tidal carbon dioxide (EtCO2), blood pH, and EtCO2 bicarbonate levels was analyzed. The predictive value of EtCO2 was also analyzed in the diagnosis of DKA. Finally, we aimed to determine the value of EtCO2 as a screening test for the exclusion of DKA. MATERIALS AND METHODS: This was a prospective cohort study carried out in the emergency department of a tertiary care teaching hospital from September 2020 to September 2021. Patients with suspected DKA underwent simultaneous blood gas collection and EtCO2 analysis. RESULTS: A total of 123 patients with blood sugar levels >250 mg/dl and moderate-to-large (≥2+) urine ketones were studied. A cut-off value of EtCO2 ≤24 was determined to rule in DKA with a sensitivity of 93.02% and specificity of 91.9%. EtCO2 >26 could effectively rule out the diagnosis of DKA with sensitivity of 98.8% and specificity of 75.7%. A significant linear correlation between pH and EtCO2 (P < 0.0001, r = 0.82) and HCO3 and EtCO2 (r = 0.896, P < 0.0001) was found. CONCLUSIONS: EtCO2 values ≤24 can accurately identify patients with DKA in the presence of elevated blood sugar and urinary ketones and must be considered a valuable addition to the diagnostic criteria. EtCO2 values >26 can be an effective triaging tool for ruling our DKA. A significant linear correlation between pH and EtCO2 and pH and HCO3 was observed. EtCO2 can be considered a surrogate marker for the degree of response to the treatment in DKA.

Two Cases of Dextromethorphan Overdose Reversed by Naloxone.

We present two rare cases highlighting the rare toxicological manifestation of dextromethorphan (DXM). The DXM toxicity profile is predominantly hallucinations, agitation, irritability with seizures, and coma in severe overdose. The cases that follow are unique in the sense that both patients had features of opioid toxidrome, rarely manifested in DXM abuse. A young male and female in their mid-20s and early 30s, respectively, were brought to the emergency room for their excessive somnolence; both had reduced respiratory rate, bilaterally small pupils (sluggish reactive to light), and the rest of their examination findings were unremarkable. Primary stabilization in the form of noninvasive ventilation (NIV) trial and subsequent rapid sequence intubation (RSI) for persistent respiratory depression. Followed by the exhaustive exclusion of differentials, opioid-like toxidrome was treated with naloxone, and both patients made a good recovery and were discharged home in good health. The emergency physician should be prepared for the rare toxicological manifestations of commonly available over-the-counter medications among the youth. These case reports highlight the role of naloxone in DXM toxicity reversal.

Impact of COVID-19 lockdown on self-harm and violence among patients presenting to the emergency department.

IMPORTANCE: Considering the resurgence of COVID19 and the rapid spread of new and deadlier strains across the globe understanding the incidence and pattern of violence and self harm tendencies during this period might help in formulating better contingency plans for future lockdowns. A deeper look at the available data shows that there is a significant dearth of research into self-harm & violence during the COVID-19 pandemic. OBJECTIVE: To identify the incidence and sociodemographic characteristics of self-harm and violence during the COVID19 lockdown and compare with a control group from the previous year. DESIGN: A cross-sectional retrospective observational study. SETTING: Tertiary care teaching hospital. PARTICIPANTS: All patients presenting to the emergency department (ED) with self harm and violence during the COVID-19 lockdown period between March 24-June 30, 2020 and March 24-June 30, 2019. EXPOSURE: The COVID-19 lockdown period. MAIN OUTCOME (S) AND MEASURE (S): The hypothesis being tested was formulated before the study. The null hypothesis tested was a decline in number of self-harm and violence cases during the lockdown. RESULTS: A total of 828 patients were analysed over both the time periods, out of which 30% (248) were females while 70% (580) were males. Increases in self-harm and violence were 12.71% and 95.32% respectively per 1000 ED admissions. A significant correlation was found between the COVID-19 lockdown and the increased incidence (X2 (1, N = 828) = 9.2, p < .05). An increase of violence by known individuals and between partners was seen. Intimate partner violence also increased to 7%. X2 (3, N = 662) = 21.03, p < .05. In the self harm dataset an increase in mortality, ICU admissions and decision to leave against medical advice was noted (X2 (4, N = 166) = 24.49, p < .05). Increase in the use of alcohol prior to acts of self harm and violence was noted. CONCLUSIONS: Increase in the incidence of cases of self-harm and violence reported to the ED was noted during the lockdown period. Upgradation of health-care and law enforcement infrastructure maybe needed to deal with similar circumstances in a more efficient manner. TRIAL REGISTRATION: N/A.

Using Canadian CT head rule in a developing nation: Validation and comparing utilisation by emergency physicians and neurosurgeons.

OBJECTIVE: The objective of this study was to test the validity of the Canadian CT Head rule (CCHR) in cases of minor traumatic brain injury (TBI) in an Indian emergency department (ED). A secondary objective was to compare of the patterns of neuroradiology references between the emergency physician (EP) and the neurosurgeon. METHODS: The study was prospectively conducted between July 2019 and July 2020. Patients satisfying the inclusion criteria were subjected to CCHR and the result was documented. The neurosurgeon was consulted for the final decision. In case of disagreement between the neurosurgeon and the EP, the decision of neuro-radiology was taken by the neurosurgeon. RESULTS: A total of 101 patients satisfied the inclusion criteria. 62 subjects fulfilled the CCHR. Out of 62 subjects who fulfilled the CCHR criteria, 46 (74.1%) were reported to have normal CT scans, while 16 had either haemorrhages (n = 12) or contusions (n = 4). All the subjects who didn't fulfil the CCHR (n = 39), were reported to have normal CT scans. The EPs used CCHR in all cases of mild TBI while the neurosurgeons chose to get CT brains in all the subjects based of clinical gestalt. CCHR had an observed sensitivity of 100% and specificity of 45.8%. CONCLUSION: The CCHR has 100% sensitivity as a screening tool for patients requiring CT brains in case of TBI though the specificity is found to be rather low (45.8%). EPs show a higher level of awareness and inclination to use CDRs in cases of minor TBI to direct the decision for neuro-radiology, in comparison to neurosurgeons. ED residents reported comfort in mobile application based usage of the rule.

Degradation of tarballs using associated bacterial consortia.

Tarballs are semi-solid blobs of crude-oil formed in marine environment. Microbial degradation of tarballs is poorly understood, though there are indications that tarball-associated microbes can degrade recalcitrant hydrocarbons present in tarballs. In this study, 38 tarball-associated bacteria from Betul beach, Goa, India were initially screened for crude oil degradation. Based on preliminary studies and literature survey, four bacterial strains, Alcanivorax sp. Betul-O, Marinobacter sp. Betul-26, Pseudomonas sp. Betul-14, and Pseudomonas sp. Betul-M were selected for bacterial consortia preparation. Eleven bacterial consortia were prepared and studied for degradation of n-alkanes and polycyclic aromatic hydrocarbon compounds (PAHs) of tarballs based on gravimetric and GC-MS-MS analyses. The bacterial consortia depleted 53.69-97.78% and 22.78-61.98% of n-alkanes and PAH compounds, respectively, within 45 days. Bacterial consortium comprising Pseudomonas sp. Betul-14, Pseudomonas sp. Betul-M, and Alcanivorax sp. Betul-O exhibited promising tarball degradation abilities with 97.78% and 61.98% degradation of n-alkanes and PAH, respectively, within 45 days. Further research is required to obtain insights into degradation products and possible pathways involved.

Phylogenetic characterization of culturable bacteria and fungi associated with tarballs from Betul beach, Goa, India.

Tarballs are semisolid blobs of crude oil, normally formed due to weathering of crude-oil in the sea after any kind of oil spills. Microorganisms are believed to thrive on hydrocarbon-rich tarballs and possibly assist in biodegradation. The taxonomy of ecologically and economically important tarball-associated microbes, however, needs improvement as DNA-based identification and phylogenetic characterization have been scarcely incorporated into it. In this study, bacteria and fungi associated with tarballs from touristic Betul beach in Goa, India were isolated, followed by phylogenetic analyses of 16S rRNA gene and the ITS sequence-data to decipher their clustering patterns with closely-related taxa. The gene-sequence analyses identified phylogenetically diverse 20 bacterial genera belonging to the phyla Proteobacteria (14), Actinobacteria (3), Firmicutes (2) and Bacteroidetes (1), and 8 fungal genera belonging to the classes Eurotiomycetes (6), Sordariomycetes (1) and Leotiomycetes (1) associated with the Betul tarball samples. Future studies employing a polyphasic approach, including multigene sequence-data, are needed for species-level identification of culturable tarball-associated microbes. This paper also discusses potentials of tarball-associated microbes to degrade hydrocarbons.

Diversity of bacteria and fungi associated with tarballs: Recent developments and future prospects.

Tarballs are formed by weathering of crude oil in marine environment. They are transported from open ocean to the shores by sea currents and waves. Tarball pollution is a major concern to global marine ecosystem. Microbes such as bacteria and fungi are known to be associated with tarballs. They presumably play an important role in tarball degradation and some are potential human and animal pathogens. This paper highlights the recent studies on tarball-associated bacteria and fungi. Future perspectives on diversity, ecology and possible applications of tarball-associated microbes in bioremediation of beached tarballs have been discussed.

The ITS-based phylogeny of fungi associated with tarballs.

Tarballs, the remnants of crude oil which change into semi-solid phase due to various weathering processes in the sea, are rich in hydrocarbons, including toxic and almost non-degradable hydrocarbons. Certain microorganisms such as fungi are known to utilize hydrocarbons present in tarballs as sole source of carbon for nutrition. Previous studies have reported 53 fungal taxa associated with tarballs. There is apparently no gene sequence-data available for the published taxa so as to verify the fungal identification using modern taxonomic tools. The objective of the present study is to isolate fungi from tarballs collected from Candolim beach in Goa, India and investigate their phylogenetic diversity based on 5.8S rRNA gene and the flanking internal transcribed spacer regions (ITS) sequence analysis. In the ITS-based NJ tree, eight tarball-associated fungal isolates clustered with 3 clades of Dothideomycetes and 2 clades of Saccharomycetes. To the best of our knowledge, this is the first study that has employed ITS-based phylogeny to characterize the fungal diversity associated with tarballs. Further studies are warranted to investigate the role of the tarball-associated fungi in degradation of recalcitrant hydrocarbons present in tarballs and the role of tarballs as carriers of human pathogenic fungi.