The Efficacy of Vision, Aphasia, Neglect Assessment in Predicting Emergent Large Vessel Occlusion in Patients Presenting with a Cerebrovascular Accident to the Emergency Department.

Background: Early identification of patients with an emergent large vessel occlusion (ELVO) ischemic stroke is crucial in the Emergency Department (ED), as they are the ideal candidates for endovascular therapy.With this study, we have attempted to use Vision, Aphasia, Neglect (VAN) screening tool in the ED for rapid identification of ELVO ischemic stroke and compared its performance with the National Institute of Health Stroke Severity (NIHSS) scale. Materials and methods: A prospective observational study was conducted in the ED of a tertiary care hospital over 18 months among all suspected stroke patients. Vision, aphasia, neglect and NIHSS scores were calculated on arrival. Magnetic resonance imaging + magnetic resonance angiography (MRI + MRA) were taken as gold standard. Results: This study found that VAN identified ELVO with 85.19% sensitivity (p-value < 0.0001), 88.64% specificity (p-value < 0.0001), and 87% diagnostic accuracy, with respect to the gold standard test. Vision, aphasia, neglect had a positive predictive value (PPV) and negative predictive value (NPV) of 82.14% and 90.7%, respectively. Time taken to perform VAN score in the ED was on average 2 minutes. National Institute of Health Stroke Severity detected ELVO with a sensitivity of 88%, specificity of 51.11%, a PPV of 53.33%, and a NPV of 88.4%. Diagnostic accuracy was 66%, and it took approximately 5 minutes to perform. When both scores were applied together for ELVO detection, NPV was 100%. Conclusion: Vision, Aphasia, Neglect score as well as NIHSS scale are both tools for clinical prediction of ELVO with VAN having a better diagnostic accuracy and utility as a screening tool in the ED. How to cite this article: Krishnan A, Srinivasarangan M, Jagadish S, Bheemanna AS, Sivasankar A. The Efficacy of Vision, Aphasia, Neglect Assessment in Predicting Emergent Large Vessel Occlusion in Patients Presenting with a Cerebrovascular Accident to the Emergency Department. Indian J Crit Care Med 2023;27(7):475-481.

Establishing Self-Harm Registers: The Role of Process Mapping to Improve Quality of Surveillance Data Globally.

Self-harm registers (SHRs) are an essential means of monitoring rates of self-harm and evaluating preventative interventions, but few SHRs exist in countries with the highest burden of suicides and self-harm. Current international guidance on establishing SHRs recommends data collection from emergency departments, but this does not adequately consider differences in the provision of emergency care globally. We aim to demonstrate that process mapping can be used prior to the implementation of an SHR to understand differing hospital systems. This information can be used to determine the method by which patients meeting the SHR inclusion criteria can be most reliably identified, and how to mitigate hospital processes that may introduce selection bias into these data. We illustrate this by sharing in detail the experiences from a government hospital and non-profit hospital in south India. We followed a five-phase process mapping approach developed for healthcare settings during 2019-2020. Emergency care provided in the government hospital was accessed through casualty department triage. The non-profit hospital had an emergency department. Both hospitals had open access outpatient departments. SHR inclusion criteria overlapped with conditions requiring Indian medicolegal registration. Medicolegal registers are the most likely single point to record patients meeting the SHR inclusion criteria from multiple emergency care areas in India (e.g., emergency department/casualty, outpatients, other hospital areas), but should be cross-checked against registers of presentations to the emergency department/casualty to capture less-sick patients and misclassified cases. Process mapping is an easily reproducible method that can be used prior to the implementation of an SHR to understand differing hospital systems. This information is pivotal to choosing which hospital record systems should be used for identifying patients and to proactively reduce bias in SHR data. The method is equally applicable in low-, middle- and high-income countries.

Diagnostic Accuracy of Ultrasound Measurements of Anterior Neck Soft Tissue in Determining a Difficult Airway.

CONTEXT: Airway management in the emergency department is challenging because conventional screening tools cannot be applied. Therefore, a rapid noninvasive means of identifying a difficult airway will be advantageous for emergency physicians. AIMS: The aim of this study is to examine the association between ultrasound measurements of anterior neck soft tissue and difficult airway as judged by the Cormack Lehane grading. SETTINGS AND DESIGN: A prospective study was done for 18 months on patients requiring intubation presenting to the emergency medicine department. SUBJECTS AND METHODS: Ultrasound measurements of anterior neck soft tissue were obtained in 60 cases at the levels of thyrohyoid membrane, hyoid bone, and vocal cords. Another examiner who was blinded to the ultrasound measurements performed endotracheal intubation and noted Cormack-Lehane grading. STATISTICAL ANALYSIS USED: Descriptive statistics such as mean, standard deviation, frequency, and percentage were used. Inferential statistics such as Student's t-test and receiver operating characteristic (ROC) curve analysis were done using the SPSS software version 22. RESULTS: The thickness of anterior neck soft tissues at the level of hyoid bone in difficult patients was 0.73 cm (95% confidence interval = 0.65-0.80) compared to easy patients 0.47 cm (95% confidence interval = 0.44-0.51) with a P = 0.001 and at the level of thyrohyoid membrane in difficult patients it was 1.83 cm (95% confidence interval = 1.7-1.89) compared to easy patients 1.46 cm (95% confidence interval = 1.41-1.51) with a P = 0.001. Area under the ROC curve was significant at all the three levels with the highest at the level of thyrohyoid membrane 0.99 and least at the level of vocal cords 0.79, the area under the curve was 0.92 at the level of hyoid bone. CONCLUSIONS: Sonographic measurements of the anterior neck soft tissue can be used as a screening tool by an emergency physician to detect difficult intubation.

Reliability of Emergency Department Diagnosis in Identifying the Etiology of Nontraumatic Undifferentiated Hypotension.

INTRODUCTION: Nontraumatic undifferentiated hypotension is one of the common and challenging critical presentations in the emergency department (ED) due to the difficulty in diagnosing the etiology of shock. In the present study, an attempt was made to test point-of-care ultrasound (PoCUS) as an early approach to improve the accuracy of diagnosis and to narrow the differentials in cases of nontraumatic undifferentiated hypotension. MATERIALS AND METHODS: This is a prospective explorative study conducted in the ED of a tertiary care hospital over a period of 18 months. A total of 100 patients were included in the study. All patients >18 years of age with systolic blood pressure <90 mm Hg with at least one sign or symptom of hypoperfusion were included in the study. Patients referred from another hospital as shock, history of trauma, and history suggestive of orthostatic hypotension and presented with symptomatic postural hypotension as the only chief complaint were excluded. All the patients who met the inclusion/exclusion criteria underwent detailed clinical and multi-organ PoCUS evaluation by two different observers. Assessment of the lungs, cardia, abdomen, aorta, inferior vena cava (IVC), and leg veins during the PoCUS examination was done. A third observer combined the clinical evaluation and the PoCUS findings. All patients were followed through for their final diagnosis at the time of discharge. First, the diagnosis after clinical evaluation alone was compared to the final diagnosis. Then the diagnoses based on the findings of PoCUS alone were compared with the final diagnosis. Last, the diagnosis obtained on combining the data of clinical evaluation with that of PoCUS was compared to the final diagnosis. The data were analyzed based on their reliability indices, accuracy, and the Cohen's kappa coefficient. RESULTS: Diagnoses based on clinical evaluation alone and POCUS alone were found to be accurate in 45% and 47% of patients, respectively. But on combining the findings of clinical evaluation with PoCUS, the accuracy increased to 89%. The most common etiology of shock was found to be distributive shock present in 38% of patients with sepsis being the most common subtype. In patients with obstructive shock, combined clinical evaluation with PoCUS was in perfect agreement with Cohen's kappa coefficient (κ) = 1 and those with distributive shock were in substantial agreement with Cohen's kappa coefficient (κ) = 0717. The overall kappa correlation of the combined evaluation with PoCUS was 0.89, which shows an almost perfect agreement with the final diagnosis. CONCLUSION: This study demonstrates the accuracy and reliability of PoCUS as an easy and valuable bedside tool when added to the clinical evaluation. It helps in narrowing the differentials and thereby guiding early goal-directed therapy in nontraumatic, undifferentiated hypotension patients presenting to the ED. HOW TO CITE THIS ARTICLE: Javali RH, Loganathan A, Srinivasarangan M, Akkamahadevi P, Ganesha BS, Nisarg S, et al. Reliability of Emergency Department Diagnosis in Identifying the Etiology of Nontraumatic Undifferentiated Hypotension. Indian J Crit Care Med 2020;24(5):313-320.

Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score and Trauma and Injury Severity Score for Mortality Prediction in Elderly Trauma Patients.

OBJECTIVES: This study tests the accuracy of the Injury Severity Score (ISS), New Injury Severity Score (NISS), Revised Trauma Score (RTS) and Trauma and Injury Severity Score (TRISS) in prediction of mortality in cases of geriatric trauma. DESIGN: Prospective observational study. MATERIALS AND METHODS: This was a prospective observational study on two hundred elderly trauma patients who were admitted to JSS Hospital, Mysuru over a consecutive period of 18 months between December 2016 to May 2018. On the day of admission, data were collected from each patient to compute the ISS, NISS, RTS, and TRISS. RESULTS: Mean age of patients was 66.35 years. Most common mechanism of injury was road traffic accident (94.0%) with mortality of 17.0%. The predictive accuracies of the ISS, NISS, RTS and the TRISS were compared using receiver operator characteristic (ROC) curves for the prediction of mortality. Best cutoff points for predicting mortality in elderly trauma patient using TRISS system was a score of 91.6 (sensitivity 97%, specificity of 88%, area under ROC curve 0.972), similarly cutoff point under the NISS was score of 17(91%, 93%, 0.970); for ISS best cutoff point was at 15(91%, 89%, 0.963) and for RTS it was 7.108(97%,80%,0.947). There were statistical differences among ISS, NISS, RTS and TRISS in terms of area under the ROC curve (p <0.0001). CONCLUSION: TRISS was the strongest predictor of mortality in elderly trauma patients when compared to the ISS, NISS and RTS. HOW TO CITE THIS ARTICLE: Javali RH, Krishnamoorthy et al. Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score and Trauma and Injury Severity Score for Mortality Prediction in Elderly Trauma Patients. Indian J of Crit Care Med 2019;23(2):73-77.

A Clinical Study on the Initial Assessment of Arterial Lactate and Base Deficit as Predictors of Outcome in Trauma Patients.

BACKGROUND: Trauma is a leading cause of mortality in India. Outcomes can be improved by early recognition of hemorrhagic shock and expedited management. At present, we rely on traditional vital signs, which are not sensitive measures. Point of care biochemical markers have been emerging as prognostic markers in trauma, but have not been studied in Indian setting. AIMS: This study aims to study the association between arterial lactate and base deficit (BD) at emergency department (ED) admission and 24 h outcome in trauma patients at risk of hemodynamic compromise. MATERIALS AND METHODS: This was a prospective observational study on 100 trauma patients at risk of hemodynamic compromise in tertiary care center ED. Arterial blood gas analysis at admission and 24 h outcomes were noted and statistically analyzed. RESULTS: Arterial lactate ≥4 mmol/L (sensitivity 100% and specificity 85.9%), BD ≥12 mEq/L (sensitivity 87.5% and specificity 82.6%) had more sensitivity than vital signs for predicting 24 h mortality. Higher lactate and BD were associated with increased blood transfusion requirement. Best cutoff values for predicting transfusion were lactate ≥2.9 mmol/L (sensitivity 65.2% and specificity 90.7%), BD ≥8 mEq/L (sensitivity 78.3% and specificity 75.9%). BD-based classification was comparable to ATLS classification in predicting mortality and determining transfusion requirements. Patients with higher arterial lactate and BD were found to have higher 24 h Intensive Care Unit (ICU) admission. CONCLUSION: Emergency admission arterial lactate and Base Deficit are useful predictors of mortality, need for blood transfusion and ICU admission at 24 h. It can be used to triage, identify shock early, assess transfusion requirement, and prognosticate trauma patients.

Studying Protocol-Based Pain Management in the Emergency Department.

BACKGROUND: Majority of the patients presenting to emergency department (ED) have pain. ED oligoanalgesia remains a challenge. AIMS: This study aims to study the effect of implementing a protocol-based pain management in the ED on (1) time to analgesia and (2) adequacy of analgesia obtained. SETTINGS AND DESIGN: Cross-sectional study in the ED. METHODS: Patients aged 18-65 years of age with pain of numeric rating scale (NRS) ≥4 were included. A series of 100 patients presenting before introduction of the protocol-based pain management were grouped "pre-protocol," and managed as per existing practice. Following this, a protocol for management of all patients presenting to ED with pain was implemented. Another series of 100 were grouped as "post-protocol" and managed as per the new pain management protocol. The data of patients from both the groups were collected and analyzed. STATISTICAL ANALYSIS USED: Descriptive statistical tests such as percentage, mean and standard deviation and inferential statistical tests such as Pearson coefficient, Student's t-test were applied. Differences were interpreted as significant when P < 0.05. RESULTS: Mean time to administer analgesic was significantly lesser in the postprotocol group (preprotocol 20.30 min vs. postprotocol 13.05 min; P < 0.001). There was significant difference in the pain relief achieved (change in NRS) between the two groups, with greater pain relief achieved in the postprotocol group (preprotocol group 4.6800 vs. postprotocol group 5.3600; P < 0.001). Patients' rating of pain relief (assessed on E5 scale) was significantly higher in the postprotocol group (preprotocol 3.91 vs. postprotocol 4.27; P = 0.001). Patients' satisfaction (North American Spine Society scale) with the overall treatment was also compared and found to be significantly higher in postprotocol group (mean: preprotocol 1.59 vs. postprotocol 1.39; P = 0.008). CONCLUSION: Protocol-based pain management provided timely and superior pain relief.

Efficacy of Mannheim Peritonitis Index (MPI) Score in Patients with Secondary Peritonitis.

BACKGROUND: Despite advances in diagnosis, management and critical care of patients with peritonitis due to hollow viscus perforation, prognosis remains poor. Early assessment by scoring systems will influence the management and prognosis. AIM: Evaluation of Mannheim Peritonitis Index (MPI) score for predicting the outcome in patients with peritonitis. MATERIALS AND METHODS: Prospective study of 50 patients admitted and operated for peritonitis in JSS Medical College Hospital. The structured scoring system i.e. MPI was applied along with other clinical and biochemical parameters recorded in pre-structured proforma. Data was analysed for predicting mortality and morbidity using EPI info and SPSS software. RESULTS: The overall mortality and morbidity was 14% and 38% respectively. MPI scores of ≤ 20, 21-29, and ≥ 30 had a mortality of 5%, 14%, and 50% respectively. MPI score of 25 had highest sensitivity of 72.09% and specificity of 71.43% in predicting mortality, 80.65% sensitivity and 57.89% specificity for morbidity. MPI score of > 25 were associated with 6.45 times higher risk of mortality (p=0.03), 5.72 times higher risk of morbidity (p=0.005) compared to patients with MPI score ≤ 25. CONCLUSION: MPI is disease specific, easy scoring system for predicting the mortality in patients with secondary peritonitis. Increasing scores are associated with poorer prognosis, needs intensive management and hence it should be used routinely in clinical practice.