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   Table of Contents - Current issue
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July-September 2022
Volume 22 | Issue 3
Page Nos. 119-168

Online since Friday, July 1, 2022

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INVITED REVIEW ARTICLE  

Use of stroke scales in clinical practice: Current concepts p. 119
Antonio Siniscalchi
DOI:10.4103/2452-2473.348440  
With stroke being the leading global cause of disability in adults, the use of clinical rating scales in stroke patients is important not only for diagnostic and therapeutic purposes but also for prognostic and care implications. Scales that quantify neurological disability can be particularly useful for assessing and guiding decisions in acute management and rehabilitative treatment. We analyzed and discussed some of the main rating scales most used in stroke in clinical practice, which measure both acute neurological deficit and functional outcome in stroke. In acute stroke, it is that in most cases, the scales evaluate a neurological deficit attributable to an alteration of the anterior and not posterior circulation and most of them assess a moderate stroke rather than a mild or severe one. In a rehabilitation treatment, they are sometimes too simplified; thus, the patient can reach a near-normal score and can have significant cognitive deficits that can affect both the possibility of communication and the reliability of responses. A patient with autonomy in the activities of daily living may not be completely autonomous. In future, the use of composite rating scales could be useful for a detailed measurement of neurological deficits in acute stroke and better assess the efficacy of a treatment and functional outcome.
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ORIGINAL ARTICLES Top

Comparison of pain and extent of anesthesia in digital blocks for isolated finger lacerations: A randomized controlled trial p. 125
Ali Jarragh, Ali Lari, Waleed Burhamah, Mohammed Alherz, Abdullah Nouri, Yahia Alshammari, Ameer Al-Jasim, Sulaiman AlRefai, Naser Alnusif
DOI:10.4103/tjem.tjem_344_21  
OBJECTIVES: Digital injuries are among the most common presentations to the emergency department. In order to sufficiently examine and manage these injuries, adequate, prompt, and predictable anesthesia is essential. In this trial, we aim to primarily compare the degree of pain and anesthesia onset time between the two-injection dorsal block technique (TD) and the single-injection volar subcutaneous block (SV) technique. Further, we describe the temporal and anatomical effects of both techniques for an accurate delineation of the anesthetized regions. METHODS: This is a single-center prospective randomized controlled trial involving patients presenting with isolated wounds to the fingers requiring primary repair under local anesthesia. Patients were randomized to either the SV or TD blocks. The primary outcome was procedure-related pain (Numerical Rating Scale). Further, we assessed the extent of anesthesia along with the anesthesia onset time. RESULTS: A total of 100 patients were included in the final analysis, 50 on each arm of the study. The median pain score during injection was significantly higher in patients who received TD block than patients who received SV block (median [interquartile range] = 4 [2.25, 5.00] vs. 3.00 [2.00, 4.00], respectively, P = 0.006). However, anesthesia onset time was not statistically different among the groups (P = 0.39). The extent of anesthesia was more predictable in the dorsal block compared to the volar block. CONCLUSION: The single-injection volar subcutaneous blocks are less painful with a similar anesthesia onset time. Injuries presenting in the proximal dorsal region may benefit from the two-injection dorsal blocks, given the anatomical differences and timely anesthesia of the region.
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The acute effect of systemic blood pressure reduction on intraocular pressure in hypertensive patients p. 131
Canan Tiambeng, Ali Batur, Özlem Dikmetas, Nalan Metin Aksu
DOI:10.4103/2452-2473.348441  
OBJECTIVES: Previous studies have shown an association between systemic hypertension and intraocular pressure (IOP). We analyzed the relationship between the decreases of the blood pressure (BP) and IOP in hypertensive patients. METHODS: The study includes a total of 214 patients: 158 hypertensive and 56 normotensive patients as study and control groups, respectively. The IOP of each eye in both the groups was measured once with a noncontact tonometer at presentation and an hour after BP reduction to normal in the study group. We analyzed the reduction in IOP with decreasing BP. RESULTS: In the study group, the mean IOP was 15.29 ± 4.05 mmHg in the right and 15.11 ± 3.78 mmHg in the left eyes. The mean IOP measured an hour after the patients became normotensive was 13.78 ± 4.06 mmHg in the right and 13.51 ± 3.82 in the left eyes. There was a statistically significant decrease in the IOPs (P < 0.001). The mean IOP in the control group was 13.54 ± 3.51 mmHg in the right and 13.20 ± 3.33 mmHg in the left eyes. The mean IOP at presentation in the study and control groups was found to be significantly different (P < 0.001). CONCLUSIONS: Patients in the study group showed a significantly higher IOP compared to patients in the normotensive group. Furthermore, patients in the study group showed a significant reduction in IOP after BP reduction. This may indicate that uncontrolled hypertension poses a risk for prolonged higher IOP. Prolonged higher IOP can be considered a risk factor for the glaucoma.
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Evaluation of forensic cases presented to the pediatric emergency department p. 137
İlknur Arslan, Kübra İrday Demir
DOI:10.4103/2452-2473.348432  
OBJECTIVE: Child forensic cases constitute an essential part of emergency presentations. The most crucial point is that the correct planning of protective and preventive activities depends on the correct analysis of the problem; therefore, there is a need for studies on childhood forensic cases. This study aimed to obtain data on the etiological characteristics of forensic cases presented to the pediatric emergency department. We believe that the collected data will guide the social measures in preventing forensic cases. METHODS: This retrospective study consists of forensic cases aged from 1 month to 18 years and presented to the pediatric emergency service of Adana City Training and Research Hospital between January 1, 2018, and December 31, 2019. The general forensic examination report of the cases was surveyed. RESULTS: For this study, 6577 general forensic examination reports were surveyed. 40% of the patients were females, and 60% were males. Traffic accidents were the most common (35.1%) cause of the emergency presentation, which was followed by assault (16.5%), fall from height (9.2%), accidental drug-caustic corrosive substance intake (7.8%), early pregnancy (7.4%), blunt or sharp force injuries (6.3%), electrical burn injuries (5.7%), suicide (5.1%), carbon monoxide-food poisoning (2.7%), and others that consisted of work accident, firearm injury, substance ingestion, suffocation, animal attack, sudden death, and missing child (4.2%). CONCLUSIONS: This most extensive study with 6577 cases has several important implications. First of all, traffic accidents continue to be an important public health problem today. Second, cases presented to the emergency department due to assault and blunt or sharp force injuries constitute an important part of forensic cases, and children who are driven to violence and crime in childhood are a situation that requires immediate action. Our third yet most important result is that early pregnancy is a much ignored social problem despite its importance.
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Characteristics of pediatric COVID-19 patients admitted to the emergency department and factors associated with pneumonia p. 143
Ali Yurtseven, Caner Turan, Gizem Güner Özenen, Halit Işik, Zümrüt Şahbudak Bal, Rüçhan Sertöz, Eylem Ulaş Saz
DOI:10.4103/2452-2473.348434  
OBJECTIVES: Coronavirus disease 2019 (COVID-19) that causes a respiratory illness, continues to be a global pandemic. In this study, we purpose to identify the features of children with COVID-19 and the factors affecting disease severity. METHODS: This is a retrospective, observational study was conducted on patients who presented with suspicion of COVID-19 from April 1, 2020, to March 31, 2021, at a tertiary care medical center in Turkey. The characteristics of 640 children who were confirmed to have COVID-19 by real-time reverse transcription-polymerase chain reaction were retrieved from medical records. RESULTS: The mean age of the cases was 10 ± 6 years, and 56% of them were male. Seasonal difference did not affect the number of cases. The majority of the cases (n = 501, 78%) were infected by family members. Fever (67%) and cough (38%) were common complaints. The mean duration of fever was 1.9 ± 1.1 days. One-fourth of the cases were asymptomatic, 462 (72%) had mild upper respiratory tract infections, and 18 (3%) had pneumonia. Patients with pneumonia were more likely to have comorbidities and had a longer fever duration (both P < 0.001). Fever, cough, and respiratory distress were more common in patients with pneumonia (P = 0.010, P = 0.023, and P < 0.001, respectively). The mean C-reactive protein (CRP) value of the patients with pneumonia was significantly higher than that of the others (P < 0.001). A total of 70 (11%) complicated patients were hospitalized, 5 of them requiring intensive care admission. All hospitalized patients were discharged with recovery. CONCLUSIONS: Although pediatric COVID-19 patients tended to have a mild disease, some children with comorbidities can still develop a severe illness. CRP value is a useful indicator in the diagnosis of COVID-19 pneumonia. Furthermore, the prevalence rate of COVID-19 did not decrease with hot seasons.
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Comparison of endotracheal intubation with Macintosh versus King Vision video laryngoscope using coronavirus disease 2019 barrier box on manikins: A randomized crossover study p. 149
Satyabrata Guru, Neha Singh, Sangeeta Sahoo, Upendra Hansda, Chittaranjan Mohanty
DOI:10.4103/2452-2473.348436  
BACKGROUND: Coronavirus disease 2019 (COVID-19) virus usually spreads through aerosol and close contact. Frontline health-care workers handle aerosol-generating procedures like endotracheal intubation. To reduce this risk, COVID-19 barrier box came into the picture. However, the COVID-19 barrier box may compromise easy and successful intubation, and their limitation must be studied. OBJECTIVES: The objective of this study was to assess the time to successful intubation with or without the COVID-19 barrier box using the Macintosh laryngoscope and King Vision video laryngoscope (KVVL). We also assessed the first-pass success rate, ease of intubation, Cormack–Lehane (CL) grade, and requirement of external laryngeal manipulation. METHODS: We conducted this manikin-based randomized crossover study to assess the time to successful intubation by anesthesiologists (22) and emergency physicians (11) having 1 year or more experience with or without COVID-19 barrier box by using the Macintosh laryngoscope and KVVL. Our study randomized the sequence of the four different intubation scenarios. RESULTS: The comparison of mean duration of intubation between KVVL (13.21 ± 4.05 s) and Macintosh laryngoscope (12.89 ± 4.28 s) with COVID-19 barrier box was not statistically significant (95% confidence interval: 1.21–0.97). The ease of intubation, number of attempts, and requirement of external laryngeal manipulation were not statistically significant. Intubations were statistically significant more difficult with barrier box in view of higher CL grade. CONCLUSION: Time to intubation was longer with COVID-19 barrier box using KVVL as compared to Macintosh laryngoscope which was statistically not significant.
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CASE REPORTS Top

Myocutaneous cysticercosis – A hidden worm caught by an ultrasound p. 156
Guguloth Ramesh Babu, Sasikumar Mahalingam, Yogesh Naik, Mounika Gara, Thirumoorthy Ramamoorthy
DOI:10.4103/2452-2473.348435  
Cysticercosis is one of the common parasitic infections that can affect many sites in the human body, though often seen in the brain and the eyes. Myocutaneous form of cysticercosis is often rare since most of them are asymptomatic and often go unnoticed. They often present to the emergency department due to pain over the lesion or central nervous manifestations. Here, we report a case of subcutaneous swelling, initially thought of as lipoma/abscess, later diagnosed as cysticercosis with the ultrasound. Myocutaneous cysticercosis can mimic various conditions such as lipoma, abscess, epidermoid cyst, ganglion, tuberculous lymphadenitis, pyomyositis, or fat necrosis. Hence, differentiating this from others in the clinical setting is essential because treatment modality is different.
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A rare complication of cardiopulmonary resuscitation applied during transportation by ambulance: A case report of flail chest p. 159
Güner Yurtsever, Adnan Yamanoglu, Ejder Saylav Bora, Fatih Esad Topal
DOI:10.4103/2452-2473.348437  
Cardiopulmonary resuscitation (CPR) to be applied during patient transfer by ambulance differs from CPR applied in the field or in the hospital in terms of physical condition. Especially the deeper and faster chest compressions recommended in the latest CPR guidelines, when administered during ambulance transport, may result in a further increase in traumatic CPR complications. However, in the current CPR guidelines, there are no clear recommendations regarding additional measures that can be taken to reduce the complications and increase the efficiency of CPR during patient transport. In this study, a case of flail chest that developed after short-term CPR application during ambulance transport is presented. The aim of this study was to evaluate the flail chest complication and solution suggestions that may occur due to chest compressions applied during transportation.
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A successfully treated Brugada syndrome presenting in ventricular fibrillation preceded by fever and concomitant hypercalcemia p. 163
Hiroki Nakamura, Yoshikazu Sato, Ryoko Ishii, Yuichi Araki
DOI:10.4103/2452-2473.348439  
Brugada syndrome (BS) is a genetic channelopathy syndrome that causes fatal cardiac dysrhythmias and sudden death. Fever and antiarrhythmics are aggravating factors of BS. There are many reports about BS preceded by fever but fewer reports on BS caused by hypercalcemia (HC). Here, we describe a unique case of BS preceded by concurrent fever and HC. A 46-year-old male visited the emergency department for malaise and fever. During admission, he suddenly developed cardiac arrest and ventricular fibrillation (VF). After resuscitation, electrocardiogram (ECG) showed “coved-type” ST elevation in V1 and V2, which led to the diagnosis of BS. This ST change declined after the fever subsided. He also had HC at the same time. After admission, he developed septic shock. We started treatment assuming that it was caused by the aggravation of ulcerative colitis, and liver abscess was revealed on contrast-enhanced computed tomography. After the infection was controlled, we implanted an implantable cardioverter defibrillator (ICD) and he was discharged. The cause of HC appeared to be an ectopic parathyroid adenoma, and calcium was normalized after tumor resection. In addition, this patient had nonfunctional pituitary adenoma and a nonfunctional adrenal tumor. His condition was indicative of multiple endocrine neoplasia type 1. This patient had BS presenting as VF induced by fever due to liver abscess and early repolarization, increasing the risk of arrhythmic events to carry out ICD implantation. HC can contribute to induce arrhythmia.
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The acute motor axonal neuropathy variant of Guillain–Barré Syndrome diagnosed after ankle trauma p. 166
Omer Yusuf Erdurmus, Abdullah Erhan, Sinan Genc, Ahmet Burak Oguz, Ayca Koca, Müge Günalp, Onur Polat
DOI:10.4103/tjem.tjem_2_22  
A case of Guillain–Barré syndrome (GBS) was diagnosed in a patient admitted to the emergency department (ED) after ankle trauma was presented. GBS is generally defined as immune-mediated peripheral neuropathy that develops after an infection. Our patient presented to ED with ankle trauma that developed after fatigue. Lateral, medial, and posterior malleolar fractures were detected in the ankle. The patient with loss of motor strength in the distal muscles was diagnosed with acute motor axonal neuropathy variant of GBS. After GBS treatment, the patient's loss of muscle strength regressed, and then surgical treatment was performed. We aimed to present this case report, which emphasizes the systematic approach of the emergency physician without having a large differential diagnosis list.
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