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   Table of Contents - Current issue
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October-December 2020
Volume 20 | Issue 4
Page Nos. 157-206

Online since Wednesday, October 7, 2020

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INVITED REVIEW ARTICLE  

Practical considerations for postarrest targeted temperature management p. 157
Isabelle Mullen, Benjamin S Abella
DOI:10.4103/2452-2473.297466  
Out-of-hospital cardiac arrest remains a major challenge worldwide, with survival to discharge rates of <20% in the great majority of countries. Advancements in prehospital care, including increasing deployment of automated external defibrillators and improvements in bystander cardiopulmonary resuscitation, have led to more victims achieving return of spontaneous circulation (ROSC), yet the majority of patients with ROSC suffer in-hospital mortality or significant neurologic injuries that persist after discharge. This postarrest morbidity and mortality is largely due to a complex syndrome of mitochondrial dysfunction, inflammatory cascades and cellular injuries known as the postcardiac arrest syndrome (PCAS). The management of PCAS represents a formidable task for emergency and critical care providers. A cornerstone of PCAS treatment is the use of aggressive core body temperature control using thermostatically controlled devices, known as targeted temperature management (TTM). This therapy, demonstrated to be effective in improving both survival and neurologic recovery by several randomized controlled trials nearly 20 years ago, remains a major topic of clinical investigation. Important practical questions about TTM remain: How soon must providers initiate the therapy? What TTM goal temperature maximizes benefit while limiting potential adverse effects? How long should TTM therapy be continued in patients following resuscitation? In this review, we will address these issues and summarize clinical research over the past decade that has added to our fund of knowledge surrounding this important treatment of patients following cardiac arrest.
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ORIGINAL ARTICLES Top

Factors affecting the accuracy of nurse triage in tertiary care emergency departments p. 163
Songül Biskin Cetin, Oktay Eray, Fatma Cebeci, Mustafa Coskun, Meral Gozkaya
DOI:10.4103/2452-2473.297462  
OBJECTIVES: The accuracy and duration of triage is vital in emergency departments. However, patient density, diversity of cases, and time pressure make triage difficult. Triage performed properly and at the right time prevents patients from experiencing any untoward incidents that may occur because of waiting. Therefore, the study aimed to share the data obtained from the Hospital Information Management System (HIMS) regarding the accuracy and duration of nurse triage in an adult emergency department. METHODS: This descriptive and cross-sectional study evaluated the accuracy and duration of triage decisions made by nurses for patients admitted to an adult emergency department between June 15 and July 15, 2019. Statistical analysis was performed using Statistical analysis was performed using SPSS software version 23.00. RESULTS: The study included the data of 7705 adult patients. The accuracy rate of nurse triage was 59.3% (n = 4566), and the average duration of triage was 1.52 ± 2.10 min. It was observed that the average duration of accurate triage decisions was longer in patients with triage category 3. A statistically significant relationship was determined between the accuracy of nurse triage and the duration of triage, years of seniority of the nurse, and shifts (P < 0.05). CONCLUSIONS: The accuracy and duration of nurse triage in the hospital where the study was conducted can be evaluated via the HIMS. In order to increase the accuracy of nurse triage in the emergency department, it is necessary to employ experienced and trained nurses, develop computer-based support systems, and increase the number of nurses working in shifts providing care to a large number of patients.
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Intranasal midazolam sedation as an effective sedation route in pediatric patients for radiologic imaging in the emergency ward: A single-blind randomized trial p. 168
Masoud Mayel, Mehdi Ahmadi Nejad, Mehdi Sadeghi Khabaz, Maliheh Sadat Bazrafshani, Ehsan Mohajeri
DOI:10.4103/2452-2473.297461  
OBJECTIVES: Prevention and reduction of pain, anxiety, and fear during medical procedures is one of the most important factors that should be considered in pediatric emergencies. The aim of this study was to compare the efficacy of oral versus intranasal midazolam in sedation during radiologic imaging in the largest province of Iran, Kerman. MATERIALS AND METHODS: Eighty children were enrolled in this single-blind clinical trial based on convenience sampling and were divided into two groups receiving 0.5 mg/kg midazolam in oral route administration and 0.2 mg/kg midazolam in intranasal route administration. Finally, 75 patients remained for evaluating medication acceptability, sedation level, onset time of sedation, additional sedative dose, adverse effects of sedation, and provider satisfaction. RESULTS: Children in the intranasal group accepted medication more easily (89.8% vs. 36.9%; P≤ 0.001), while these children received a lower sedation dose, but the sedation level in both methods was similar (P = 0.72). Our findings showed that children in the intranasal sedation group had a faster onset of sedation compared to the oral group (17.94 ± 8.99 vs. 34.50 ± 11.45; P≤ 0.001). The frequency of midazolam side effects had no difference between the groups (29.7% vs. 15.8%; P = 0.15). CONCLUSION: Intranasal midazolam with a lower sedation dose induces a faster onset and better acceptance. Intranasal midazolam can be used as an effective sedative method for pediatric patients, especially in emergency wards.
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Comparison of the effectiveness of endotracheal tube holder with the conventional method in a manikin model Highly accessed article p. 175
Karn Suttapanit, Chaiyaporn Yuksen, Kasamon Aramvanitch, Thitapohn Meemongkol, Arnon Chandech, Benjamat Songkathee, Promphet Nuanprom
DOI:10.4103/2452-2473.297470  
OBJECTIVES: Endotracheal tube (ETT) displacement occurs by improper fixation. To fix an ETT, many types of fixation tools are employed. Thomas tube holder is one of the fixation tools widely used in many countries. This study aims to compare the ETT fixation using the Thomas tube holder with the conventional method (adhesive tape) in a mannequin model. METHODS: The fixation tools were random, using the box of six randomizes to Thomas tube holder and conventional method. After fixation, the mannequin model was being logged roll, chest compression by automated chest compression machine, and transported by the paramedic. The time to ETT fixation and displacements were recorded. RESULTS: The mean time (standard deviation) to fixate an ETT was shorter (33.0 s [7.3]) with a Thomas tube holder compared to adhesive tape (52.6 s [7.3], P < 0.001). The number and proportion of the ETT displacements were significantly less with Thomas tube holder compared to adhesive tape during log roll (16, 35.6% vs. 29, 64.4%, P = 0.011), chest compression with automated machine (23, 51.1% vs. 37, 82.2%, P = 0.003), and transport (26, 57.8% vs. 40, 88.9%, P = 0.002). CONCLUSION: The Thomas tube holder is more effective than adhesive tape in preventing ETT displacement in a mannequin subjected to log roll, chest compressions, and transportation.
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Assessment of factors affecting mortality in geriatric patients with warfarin overdose p. 180
Seda Dagar, Emine Emektar, Hüseyin Uzunosmanoglu, Yunsur Cevik
DOI:10.4103/2452-2473.297463  
OBJECTIVES: The aim of the present study was to perform a demographic analysis of complications and to determine the factors affecting in-hospital mortality in geriatric patients with warfarin overdose. MATERIALS AND METHODS: All patients aged 65 years or older using warfarin with an international normalized ratio (INR) level above 3.5 IU between 01.01.2014 and 01.01.2018 were included in the study. Characteristics of patients with in-hospital mortality and surviving patients were compared. Multivariate regression analysis was used to assess the predictors for in-hospital mortality. RESULTS: A total of 302 geriatric patients included in the study for statistical analyses. Bleeding rate was 14.2%. A comparison of patient characteristics for in-hospital mortality (survivor vs. nonsurvivor) revealed significant differences for age, gender, chronic renal failure history, creatinine, aspartate aminotransferase (AST), and alanine aminotransferase levels (P < 0.05). A multivariate logistic regression analysis was performed. It was found that elevated AST (P = 0.029, odds ratio [OR]: 1.004, 95% confidence intervals [CIs]; 1.001–1.007) and creatinine (P = 0.045, OR: 2.36, 95% CIs; 1.02–5.48) levels as well as advanced age (P = 0.031, OR: 1.11, 95% CIs; 1.01–1.22) and male gender (P = 0.017, OR: 5.48, 95% CIs; 1.35–22.1) had a negative impact on survival. CONCLUSION: Our study results revealed that male gender, advanced age, and hepatic and renal dysfunctions were the predictors of in-hospital mortality in the elderly with warfarin overdose. In order to avoid serious warfarin-related complications in the older age groups, particularly when there is renal or hepatic dysfunction, patients should be informed about minor warning side effects of warfarin, INR levels should be more frequently checked, and patients should have more strict follow-up schedules.
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Hands-only cardiopulmonary resuscitation training for schoolchildren: A comparison study among different class groups p. 186
Roshan Mathew, Ankit Kumar Sahu, Nirmal Thakur, Aaditya Katyal, Sanjeev Bhoi, Praveen Aggarwal
DOI:10.4103/2452-2473.297464  
BACKGROUND AND AIM: Up to 70% of out-of-hospital cardiac arrests are witnessed by family members, friends, and other bystanders. These bystanders can play a vital role in delivering help, before professional help arrives. Mandatory nationwide training of schoolchildren has shown the highest impact in improving the bystander cardiopulmonary resuscitation (CPR) rate. In our study, we compared the competency of different classes of schoolchildren from middle school onward in learning hands-only CPR. MATERIALS AND METHODS: This study was conducted in four schools. Schoolchildren were divided into three groups as middle school (6th to 8th standard) (MS), secondary school (9th and 10th standard) (SC), and senior secondary school (11th and 12th standard) (SN). Training module consisted of slide presentation on “hands-only CPR” of 1 h, video demonstration of 30 min, and hands-on session of 2.5 h. Students were then individually assessed for the skills. RESULTS: A total of 810 children were enrolled and trained. Initial approach was performed correctly by 68% of MS, 79.3% of SC, and 82.4% of SN school children, whereas 49.4% of MS, 61.3% of SC, and 72.5% of SN correctly performed chest compression in terms of rate, depth, and duration. Median compression depth and maximum duration of CPR achieved were significantly different across class groups (P < 0.001) Compression depth and duration of chest compression were positively correlated with children's age, height, weight, and body mass index (P < 0.001). CONCLUSION: Theoretical training on hands-only CPR can be started at the middle school level, and practical training can be incorporated in school curricula from secondary school.
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CASE REPORTS Top

Survival following intentional succinylcholine injection for self-harm p. 193
Meenhas Oravil Kunhahamed, Vimal Koshy Thomas, Siju Varghese Abraham, Babu Urumese Palatty, Shibu C Kallivalappil
DOI:10.4103/2452-2473.297468  
Succinylcholine is a short-acting depolarizing neuromuscular blocking agent. We describe a case where the above drug was employed for self-harm by a health-care worker. The patient, a 28-year-old female, was brought to the emergency department (ED) in impending respiratory arrest and altered mental status. On arrival, she had hypoxia, bradycardia, and hypotension. Although the cause for rapid deterioration in this patient was unknown, the ED physician still went ahead by resuscitating the patient's airway, breathing, and circulation. During the course of resuscitation, information was received that an empty ampoule of succinylcholine was recovered from her bathroom. Further clinical examination and laboratory investigations led the treating physicians to suspect deliberate intravenous injection of succinylcholine. She was mechanically ventilated and monitored in the critical care unit. Targeted temperature management was initiated in the ED and was continued for 24 h. The patient was discharged from the hospital without any neurological deficits after 4 days. Patients with acute poisoning are one of the major encounters in ED, and this case highlights the possibility of anesthetic drug misuse in any health-care workers coming to the ED with sudden cardiac arrest, altered sensorium, or abnormal vitals. This is the first report describing the survival of a patient following intentional succinylcholine injection for self-harm.
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Reexpansion pulmonary edema: A rare complication of pneumothorax drainage p. 196
Shivani Sarda, Ankur Verma, Sanjay Jaiswal, Wasil Rasool Sheikh
DOI:10.4103/2452-2473.297469  
Among all the noncardiac causes of pulmonary edema, unilateral reexpansion pulmonary edema is one of the rarest complication of expansion of a collapsed lung. It is largely unknown and a potentially fatal complication. We present the case of a 51-year-old gentleman who presented to our emergency department with shortness of breath. X-ray revealed significant right-sided pneumothorax with associated collapse of the right lung. An intercostal tube was inserted into the right 5th intercostal space and a repeat X-ray revealed well-expanded lung field. Soon, the patient developed increased shortness of breath and hypoxia. Repeat X-ray was suggestive of pulmonary edema. He was started on noninvasive positive pressure ventilation and responded well to it. Emergency physicians should have a high index of suspicion and initiate early management of reexpansion pulmonary edema in patients suffering from pneumothoraces which have undergone drainage.
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A rare cause of pediatric acute pancreatitis: Perindopril intoxication p. 199
Merve Misirlioglu, Dincer Yildizdas, Faruk Ekinci, Ozden Ozgur Horoz, Ahmet Yontem
DOI:10.4103/2452-2473.297465  
Acute pancreatitis is a reversible inflammatory condition of the pancreas. It usually develops on the basis of trauma, structural abnormalities, and chronic systemic diseases. A definitive causal correlation between a drug and acute pancreatitis is quite difficult for clinicians. Drugs play a vital role in the etiology in approximately 10% of children with pancreatitis. More than 50 drugs including angiotensin-converting enzyme inhibitors have been reported to cause pancreatic damage. There was no pediatric case report developed pancreatitis following perindopril use. A pediatric case of pancreatitis following perindopril intake was presented in this article to emphasize pancreatitis, which is one of the complications that may occur after drug intake.
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Peripartum cardiomyopathy with preeclampsia in a parturient: A case report with literature review p. 202
Divya Sethi, Naveen Kumar
DOI:10.4103/2452-2473.297467  
Peripartum cardiomyopathy (PPCM) is a rare disease of unknown cause that affects women of childbearing age. A high index of suspicion should be maintained in the pregnant and peripartum woman who presents with sudden cardiac decompensation without any prior history of cardiac disease. The diagnosis can be confirmed with echocardiographic evidence of global left ventricular dysfunction. Timely diagnosis and institution of therapy for heart failure can avoid adverse outcomes in a parturient with PPCM. In this case report, we describe the management of primigravida presenting to the hospital's emergency department with acute cardiac failure and respiratory distress due to PPCM. The case also highlights that though preeclampsia and PPCM are two separate entities, these can coexist in the same parturient due to the common pathophysiological mechanism. In the review, the recommended medical management of heart failure in PPCM with the “BOARD” (Bromocriptine, Oral heart failure drugs, Anticoagulants, Vasorelaxing agents, and Diuretics) scheme is discussed.
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ERRATUM Top

Erratum: Hepatic hydatid cyst presenting as a cutaneous fistula p. 206

DOI:10.4103/2452-2473.297471  
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