An unusual case of thrombotic storm in an amateur cricketer-a case report.

BACKGROUND: Thrombotic storm is a series of acute to subacute thrombotic events that evolve over a few days to weeks and result in progressive thromboses at multiple sites. There is often a predisposing event to thromboses, such as trauma or infections. Prompt initiation of anti-coagulation can prove life-saving in such patients. CASE REPORT: We describe a previously healthy young male who developed thromboses of the right axillary, brachial, radial, and ulnar arteries while bowling in a cricket match. A few hours later, he developed a stroke involving the right anterior and middle cerebral arteries. His thrombophilia workup was significant for elevated homocysteine levels. Although he had a delayed presentation to our hospital, he was treated with anticoagulation and given a trial of thromboembolectomy, which failed and he had to ultimately undergo a right below-elbow guillotine amputation. CONCLUSION: Thrombotic storm should be recognized promptly in the Emergency Department and timely anticoagulation should be initiated.

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.

Correlation and agreement between arterial and venous blood gas analysis in patients with hypotension-an emergency department-based cross-sectional study.

BACKGROUND: Blood gas analysis is integral to assessing emergency department (ED) patients with acute respiratory or metabolic disease. Arterial blood gas (ABG) is the gold standard for oxygenation, ventilation, and acid-base status but is painful to obtain. Peripheral venous blood gas (VBG) is a valuable alternative as it is less painful and easy to collect. The comparability of ABG and VBG was studied in various conditions. But in hypotension, previous findings were inconsistent. So, we studied the correlation and agreement between ABG and VBG in hypotensive patients. METHODOLOGY: The study was conducted at the emergency department of a tertiary healthcare center in Northern India. Patients with hypotension above 18 years who satisfied the inclusion criteria were clinically evaluated. Patients who require ABG as a part of routine care were sampled. ABG was collected from the radial artery. VBG was obtained from the cubital or dorsal hand veins. Both samples were collected within 10 min and were analyzed. All ABG and VBG variables were entered in premade proforma. The patient was then treated and disposed of according to institutional protocol. RESULTS: A total of 250 patients were enrolled. The mean age was 53.25 ± 15.71 years. 56.8% were male. The study included 45.6% septic, 34.4% hypovolemic, 18% cardiogenic, and 2% obstructive shock patients. The study found a strong correlation and agreement for ABG and VBG pH, pCO2, HCO3, lactate, sodium, potassium, chloride, ionized calcium, blood urea nitrogen, base excess, and arterial/alveolar oxygen ratio. Hence, regression equations were made for the aforementioned. There was no correlation observed between ABG and VBG pO2 and SpO2. Our study concluded that VBG could be a reasonable alternative for ABG in hypotensive patients. We can also mathematically predict values of ABG from VBG using regression equations derived. CONCLUSIONS: ABG sampling causes most unpleasant experiences to patients and is associated with complications like arterial injury, thrombosis, air or clotted-blood embolism, arterial occlusion, hematoma, aneurysm formation, and reflex sympathetic dystrophy. The study has shown strong correlations and agreements for most ABG and VBG parameters and can predict ABG mathematically using regression formulas formulated from VBG. This will decrease needle stick injury, consume less time, and make blood gas evaluation easy in hypotensive settings.

Point of care ultrasound as initial diagnostic tool in acute dyspnea patients in the emergency department of a tertiary care center: diagnostic accuracy study.

BACKGROUND: Dyspnea is one of the common symptoms patients present to the emergency department (ED). The broad spectrum of differentials often requires laboratory and radiological testing in addition to clinical evaluation, causing unnecessary delay. Point of care ultrasound (PoCUS) has shown promising results in accurately diagnosing patients with dyspnea, thus, becoming a popular tool in ED while saving time and maintaining safety standards. Our study aimed to determine the utilization of point of care ultrasound in patients with acute dyspnea as an initial diagnostic tool in our settings. METHODOLOGY: The study was conducted at the emergency department of a tertiary healthcare center in Northern India. Adult patients presenting with acute dyspnea were prospectively enrolled. They were clinically evaluated and necessarily investigated, and a provisional diagnosis was made. Another EP, trained in PoCUS, performed the scan, blinded to the laboratory investigations (not the clinical parameters), and made a PoCUS diagnosis. Our gold standard was the final composite diagnosis made by two Emergency Medicine consultants (who had access to all investigations). Accuracy and concordance of the ultrasound diagnosis to the final composite diagnosis were calculated. The time to formulate a PoCUS diagnosis and final composite diagnosis was compared. RESULTS: Two hundred thirty-seven patients were enrolled. The PoCUS and final composite diagnosis showed good concordance (κ = 0.668). PoCUS showed a high sensitivity for acute pulmonary edema, pleural effusion, pneumothorax, pneumonia, pericardial effusion, and low sensitivity for acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and acute respiratory distress syndrome (ARDS)/acute lung injury (ALI). High overall specificity was seen. A high positive predictive value for all except left ventricular dysfunction, pericardial effusion, non-cardiopulmonary causes of dyspnea, and a low negative predictive value was seen for pneumonia. The median time to make a PoCUS diagnosis was 16 (5-264) min compared to the 170 (8-1346) min taken for the final composite diagnosis. Thus, time was significantly lower for PoCUS diagnosis (p value <0.001). CONCLUSION: By combining the overall accuracy of PoCUS, the concordance with the final composite diagnosis, and the statistically significant reduction in time taken to formulate the diagnosis, PoCUS shows immense promise as an initial diagnostic tool that may expedite the decision-making in ED for patients' prompt management and disposition with reliable accuracy.

Rupture of sinus of Valsalva aneurysm: a rare cause of acute ischaemic chest pain in the emergency department.

Acute chest pain is a leading cause of emergency department (ED) visits in the adult population. However, patients with a life-threatening cause of chest pain comprise only a small fraction, hence identification of those who need immediate intervention is very important. One rare cause is rupture of the aneurysm, which may present with a wide variety of symptomatology, including anginal chest pain. In a busy ED, evaluation of chest pain suggestive of myocardial ischaemia needs to cater to early identification of acute coronary syndrome (ACS), limit over investigating patients for low or intermediate probability of ACS and appropriate decision making for discharge, to reduce ED over boarding. Validated scores for evaluating the low or intermediate probability chest pain like the HEART pathway may miss such rare diagnoses in the absence of ECG changes, requiring high degree of suspicion and individualisation of patient care.

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.

Prevalence and pattern of geriatric emergencies in a teaching hospital of North India.

INTRODUCTION: Changing demographic patterns worldwide and improvement in healthcarehas contributed to increasing visits to the emergency department byelderly patients. Geriatric patients usually have multiple co-morbidities and declining physiological functional status. This complex interplay of various factors requires a specific and curated approach from the emergency physicians. Our aim was to study the pattern and prevalence of geriatric emergencies and the profile of infectious and non-infectious causes of fever in geriatric population in our tertiary care center. MATERIALS AND METHODS: This retrospective descriptive study was carried out at a tertiary care hospital of north India and included all patients aged more than 18 years who visited the emergency department over a period of six months (July 2018 to December 2018). Detailed data regarding demographic, clinical and diagnosis was obtained retrospectively from the hospital records system. The patients were divided into two groups, age less than 60 years and elderly patients more than 60 years of age for comparison. RESULTS: A total of 24768 patients above the age of 18 years visited the emergency department over a period of six months. Out of which 5399 (27.5%) patients belonged to the geriatric age group more than 60 years of age. 2474 (45.8%) geriatric age group patientswere triaged to critical areas level one and level two as compared to 4668 (24.1%) patients aged less than 60 years. Ninety (1.8%) geriatric patients succumbed to death as compared to 77 (0.4%) patients aged less than 60 years. 651 (21.9%) geriatric patients were shifted to intensive care unit as opposed to 1038 (14.8%) patients of the younger age group.226 (4.2%) geriatric patients presented with fever in the emergency department.116 (73.4%) patients having underlying co-morbidities , had fever due to infectious causes whereas 42 ( 26.5%) patients had fever due to non-infectious causes. CONCLUSION: The clinical presentation mortality and morbidity pattern of geriatric patients differs significantly from that of younger population and requires a customized approach and dedicated emergency setups.

Intractable hypocalcemic seizures with neuropsychiatric symptoms- An under-diagnosed case.

Idiopathic hypoparathyroidism is one of the important and treatable causes of hypocalcaemia. Patients with hypocalcaemia as a consequence of hypoparathyroidism can have varied neuropsychiatric presentations such as intractable seizures, depressive symptoms, psychosis, generalized parasthesias and extrapyramidal syndrome. Many times these patients are being wrongly treated as a case of depression without addressing the underlying cause. We present a case of 26-year-old female patient who presented in emergency with multiple episodes of complex partial seizures since the last 6 months and under the treatment for depression for 2 years. She was diagnosed as a case of hypocalcemia and hypoparathyroidism was considered as the underlying cause.

A case of organophosphate poisoning with intermediate syndrome and acute pancreatitis - A rare complication.

Organophosphate (OP) poisoning is one of the serious occupational hazards worldwide and easily accessible pesticides for suicidal poisoning. It is associated with high mortality and morbidity. OP poisoning is characterized by three main syndromes - cholinergic syndrome, intermediate syndrome and syndrome of delayed polyneuropathy. Other rare complications of OP poisoning are arrhythmias, pancreatitis and hepatic dysfunction. We present 46-year-old male patient with history of OP poisoning, who developed features of intermediate syndrome and pancreatitis. The patient was immediately intubated and managed on mechanical ventilation. Patient was given symptomatic treatment and recovered completely on day 14 of illness.

Post-traumatic diaphragmatic hernia: Diagnostic dilemma in primary care.

Diaphragmatic hernia (DH) is a common condition following blunt trauma to upper abdomen and is also a commonly missed diagnosis. Its early anticipation in post-traumatic setting is very important to avoid any further life-threatening sequelae. X-ray chest with a nasogastric tube is a simpler way to diagnose this condition. CT scan is a gold standard tool to confirm diagnosis. Due to wide availability of ultrasound (US) in emergency room (ER), this tool will decide the correct way of further evaluation avoiding unnecessary delays in management. We present a case of a diaphragmatic hernia followed by blunt injury abdomen with multiple herniated abdominal contents successfully managed by early intervention.