Biomarkers of Diseases: Their Role in Emergency Medicine

Biomarkers have been playing an increasingly significant role in clinical decision making processes worldwide. Numerous studies are being undertaken across the globe in the elusive search for the ideal biomarker for each clinical condition. In the emergency department, where rapid diagnosis of various diseases like acute coronary syndromes, pulmonary embolism, heart failure, sepsis, acute renal failure etc. is of utmost importance, specific biomarkers can expedite the time to diagnosis and treatment. To enumerate, the following biomarkers have proved their worth within the setting of emergency departments across the world. The role of cardiac troponins and CK-MB has been well established in the clinical algorithms to detect myocardial infarction. Newer markers like Heart Fatty Acid Binding Protein (H-FABP), BNP, Pro BNP as well as Ischemia modified albumin (IMA) are coming into the fray in the detection of cardiovascular emergencies, especially in the detection of heart failure. Novel biomarkers like Mid-region Proadrenomedullin (MR-proADM) are found to be useful in sepsis along with Tumour necrosis factor-alpha (TNF-alpha), Interleukins and Presepsin in burns patients. Human neutrophil gelatinase-associated lipocalin (NGAL) levels can detect renal failure much earlier than conventional methods. S100 calcium binding protein B (S100B) has been found to be useful in detection of CNS injury and hence can be used to avoid unnecessary radiation to patients in the form of CT scans. Point of care testing of many of these biomarkers in the Emergency department itself paves way for a revolutionary step in faster emergency care delivery and better patient outcomes

Acute Kidney Injury in Severe Trauma Patients; a Record-Based Retrospective Study

Introduction: Acute kidney injury (AKI) is a common and devastating clinical issue in the community associated with high rates of morbidity and mortality. Objective: We aimed at estimating the frequency and levels of severity of AKI in trauma patients requiring hospital admission using the RIFLE criteria and assess their outcome. Method: Our retrospective record based study enrolled data of 80 participants aged 18-59 years who presented to the emergency department of KIMS hospital following an acute traumatic event. Participants with pre-existing renal dysfunction, chronic heart failure and chronic liver disease were excluded. Tests of significance were Chi square and independent sample t test, a p<0.05 was considered statistically significant. Results: Participants with AKI had significantly lower age (p=0.02) and lower revised trauma score (RTS) (p=0.01). Significant association of AKI with hypotension (p=0.01) and Glasgow coma scale (GCS) (p=0.008) was observed. No association of AKI with gender was observed (p=0.6). None of the AKI patients required renal replacement therapy and all participants attained normal renal function at discharge. Significantly longer mean duration of hospital stay (14.4 days) was observed among AKI patients (p=0.02). Totally, 6.3 % mortality was observed among both participants with and without AKI. Conclusion: Forty percent of acute trauma patients had AKI (in risk and injury category); but none were in failure, loss or end stage renal disease. No association of AKI and mortality was observed. AKI was associated with age, RTS, hypotension and GCS

Electrical Storm in the Absence of a Structural Heart Disease in a Young Girl

A 14-year-old girl presented to the emergency department (ED) with a history of three episodes of seizure-like activity and no comorbidities at 2 am. The first episode had occurred at 6 am, the second at 12 pm and the third two hours before presenting to the ED. Each episode lasting less than 5 minutes, was associated with the limb and spinal rigidity and extension, the up-rolling of eyeballs and urinary incontinence. The patient reported no history of fever, recent trauma, previous febrile seizures, prodromal symptoms, tongue bite, headache or physical excretion before the episodes. No postictal confusion or tonic-clonic movements and significant family history were also reported. The initial examination found her to be conscious, oriented and hemodynamically stable, and the results of her systemic examinations were normal without any significant positive findings. Evaluation of the patient initiated with the provisional diagnosis of new-onset seizures, followed by performing a computed tomography (CT) scan of the head, which was normal and ruled out any intra-cranial pathology. The results of the blood test involving serum electrolytes, calcium and magnesium were also normal. Abrupt polymorphic ventricular tachycardia (VT) was identified on the monitor (figure 1) as a few second-episodes of posturing and stretching of the body with no peripheral and central pulses during the examination in the ED. The patient came around after undergoing cardiopulmonary resuscitation immediately followed by defibrillation at 200 J and reverting the rhythm to sinus. The patient had recurrent episodes of pulseless polymorphic VT, which required ten times of defibrillation for one hour and antiarrhythmic drug therapy with IV bolus of 300 mg and then again 150 mg amidaraone, and then infusion of 1 mg of magnesium sulfate diluted in 10 ml of D5W and also administration of 1 mg/kg of lidocaine. The patient was electively intubated and ventilated under deep sedation, and transferred to the cardiac care unit (CCU). The two-dimensional echocardiography findings were revealed normal-sized heart chambers and good left ventricular function. Blood levels of high-sensitivity troponin I and CK-MB were also in their normal range. Despite performing repeated defibrillation and anti-arrhythmic therapy, the patient showed repeated episodes of pulseless VT. She was therefore referred to a higher-level center to be administered with left stellate ganglion block (LSGB). She withstood the procedure, and discharged from the hospital after a ten-day follow-up. An implantable cardioverter-defibrillator (ICD) was later planned for the patient, and she continued with taking oral antiarrhythmic drugs

Accuracy of Extended Focused Assessment with Sonography in Trauma (e-FAST) Performed by Emergency Medicine Residents in a Level One Tertiary Center of India

Introduction: It could be claimed that extended focused assessment with sonography for trauma (e-FAST) is the most important use of ultrasound in every emergency department (ED). It is a rapid, repeatable, non-invasive bedside method that was designed to answer one single question, which is, “whether free fluid is present in the peritoneal, pleural and pericardial cavity or not?” This examination may also be used to evaluate the lungs for pneumothorax. Objective: The current comparative study was conducted to assess the accuracy and reproducibility of e-FAST performed by emergency medicine residents (EMRs) and radiology consultants (RCs) in multiple trauma patients. Method: This diagnostic accuracy study was conducted prospectively in patients presenting over a period of 12 months from January 1, 2013, to December 31, 2013 to the ED of Kerala Institute of Medical Sciences (KIMS), Kerala, India. All multiple trauma patients older than 18 years of age presenting within 24 hours of their traumatic event, who underwent both e-FAST and thoracoabdominal computed tomography (CT) scan were included. The e-FAST exams were first performed by the EMRs and then by RCs. The thoracoabdominal CT scan findings were considered as the gold standard. The results were compared between both groups to assess the inter-observer variability. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were calculated both for EMRs and RCs. Results: In the study period, 150 patients with a mean age of 42.06 ± 18.1 years were evaluated (76.7% male). Only 19 cases (12.7%) had a history of fall from a height, and the others were admitted due to RTA. Thirty-four cases (22.7%) did not require surgery; but the others underwent various interventions. Both EMRs and RCs reported positive findings in 20 cases (13.3%) and negative findings in 130 cases (86.7%). The correlation of e-FAST done by EMRs with that by RCs was 100%. E-FAST exam had a sensitivity of 90.4%, specificity 99.2%, PPV 95.0%, NPV 98.4%, and accuracy 98%, both for EMRs and RCs. Conclusion: Based on the findings, the sensitivity, specificity, and accuracy of e-FAST exams performed by EMRs were equal to those performed by RCs. It seems that e-FAST performed by EMRs were almost accurate during the initial trauma resuscitation in the ED of a level one trauma center in India

Acute Kidney Injury in Severe Trauma Patients; a Record-Based Cross-Sectional Study

Introduction: Acute kidney injury (AKI) is a common and devastating clinical issue in the community associated with high rates of morbidity and mortality. Objective: We aimed at estimating the frequency and levels of severity of AKI in trauma patients requiring hospital admission using the RIFLE criteria and assess their outcome. Method: Our retrospective record based study enrolled data of 80 participants aged 18-59 years who presented to the emergency department of KIMS hospital with acute trauma. Participants with pre-existing renal dysfunction, congestive cardiac failure and chronic liver disease were excluded. Tests of significance were Chi square and independent sample t test, a p<0.05 was considered statistically significant. Results: Participants with AKI had significantly lower age (p=0.02), lower revised trauma score (RTS) (p=0.01). Significant association of AKI with hypotension (p=0.01) and Glasgow coma scale (GCS) (p=0.008) was observed. No association of AKI with gender was observed (p=0.6). None of the AKI patients required renal replacement therapy and all participants attained normal renal function at discharge. Significantly longer mean duration of hospital stay (14.4 days) was observed among AKI patients (p=0.02). 6.3 % mortality was observed among participants with and without AKI. Conclusion: Forty percent of acute trauma patients had AKI (in risk and injury category); but none were in failure, loss or end stage renal disease. No association of AKI and mortality was observed. AKI was associated with age, RTS, hypotension and GCS

Efficacy of a Multi-Level Pilot Intervention (“Harmony”) to Reduce Discrimination Faced by Men Who Have Sex with Men and Transgender Women in Public Hospitals in India: Findings from a Pre- and Post-Test Quasi-Experimental Trial among Healthcare Workers

Reducing the stigma and discrimination faced by men who have sex with men (MSM) and transgender women (TGW) in healthcare settings is key to improving health outcomes. Using a one-group pre- and post-test design, we tested the efficacy of a theory-informed, multi-level pilot intervention (“Harmony”) among 98 healthcare workers (HCWs) to reduce sexual orientation and gender identity (SOGI)-related stigma and discrimination faced by MSM and TGW in two public hospitals. The intervention contained group-level (a half-day workshop) and individual-level (four videos) components. Using multi-level modelling, we compared knowledge, attitudes, and comfort level among HCWs across three timepoints: pre-intervention, post-intervention, and follow-up (2 months after the intervention). Client surveys were conducted among 400 MSM/TGW (two independent samples of 200 MSM/TGW) attending the intervention hospitals, before the intervention among HCWs and three months after the intervention. Generalised estimating equations assessed service users’ satisfaction with hospital services, discrimination experiences, and positive interactions with HCWs. Significant changes were observed in primary outcomes: 30% increase in positive attitude scores (incidence rate ratio (IRR) = 1.30, 95% CI 1.13–1.49) and 23% increase in the proportion of HCWs reporting being comfortable in providing care to MSM/TGW (IRR = 1.23, 95% CI 0.03–1.68). Similarly, there was a significant improvement in secondary outcomes (scores): support for non-discriminatory hospital policies (IRR = 1.08, 95% CI 1.004–1.15), the importance of asking SOGI questions in clinical history (IRR = 1.17, 95% CI 1.06–1.29), and perceived self-efficacy in providing clinical care (IRR = 1.13, 95% CI 1.01–1.27). Service users’ data provided corroborative evidence for intervention efficacy: e.g., 14% increase in the proportion of MSM reporting overall satisfaction with hospital services and 6% and 15% increase in the scores of positive interactions with HCWs in the combined sample of MSM/TGW and TGW, respectively. The Harmony intervention showed preliminary evidence for improving positive attitudes, comfort level, and understanding of the healthcare issues of MSM/TGW among HCWs, warranting large-scale implementation research