Cardiopulmonary resuscitation outcomes in the emergency department of a tertiary health care centre in north India

Background: The purpose of this study was to examine the outcomes of cardiopulmonary resuscitation (CPR) including return of spontaneous circulation (ROSC), survival to hospital discharge and neurological outcome in the emergency department (ED). Methods: This prospective observational study included 233 patients with 51 cases of Out-Of-Hospital Cardiac arrests (OHCA) and 182 cases of In-Hospital cardiac arrests (IHCA). The study was performed in the ED of a tertiary health care centre in North India from July 2018 to June 2021. Results: The majority of the study subjects (67.8%) were males, and the median age of patients was 47 years. 35.6% of cases (N=83) had a sustained ROSC after the first attempt of CPR. Survival to inpatient admission was seen in 20.2% of cases (N=47), and survival to hospital discharge was observed in 3.9% of cases (N=9). Out of 9 cases who survived, 7 cases (3%) were discharged with good neurological outcomes (mRS 0-2). For OHCA, the predictors of survival were witnessed arrest (Odds Ratio [OR]=4.58, 95% CI: 1.08-19.38),  bystander CPR (OR=3.78, 95% CI: 1.78-18.13), and time to reach the hospital (OR=0.70, 95% CI: 0.55-0.89). Whereas in IHCA, patients with initial shockable rhythm had increased odds of survival (OR=1.49, 95% CI: 1.35-1.74). Conclusion: In our study, in contrast to the developed countries, the survival to hospital discharge in cardiac arrest patients presenting to ED was very low. Therefore, this study proposes the development of a robust cardiac arrest registry in India, to address the gaps in the existing knowledge and facilitate future research

Development of a self-assessment tool for resident doctors’ communication skills in India

Purpose Effective communication skills are essential for resident doctors to provide optimum patient care. This study was conducted to develop and validate a questionnaire for the self-assessment of resident doctors’ communication skills in India. Methods This was a mixed-methods study conducted in 2 phases. The first phase consisted of questionnaire development, including the identification of relevant literature, focus group discussions with residents and experts from clinical specialties, and pre-testing of the questionnaire. The second phase involved administering the questionnaire survey to 95 residents from the Departments of Medicine, Emergency Medicine, Pediatrics, and Surgery at the All India Institute of Medical Sciences, New Delhi, India in April 2019. Internal consistency was tested and the factor structure was analyzed to test construct validity. Results The questionnaire consisted of 3 sections: (A) 4 items on doctor-patient conflicts and the role of communication skills in avoiding these conflicts, (B) 29 items on self-assessment of communication skills in different settings, and (C) 8 items on barriers to practicing good communication skills. Sections B and C had good internal consistency (Cronbach α: 0.885 and 0.771, respectively). Section C had a 2-factor solution, and the barriers were classified as ‘training’ and ‘infrastructure’ factors. Conclusion This appears to be a valid assessment tool of resident doctors’ communication skills, with potential utility for identifying gaps in communication skills and developing communication skills modules

Severe hypoglycemia masquerading as cerebellar stroke

Hypoglycemia is a common presenting feature of diabetes in the emergency department. Cardiovascular and neuroglycopenia features are well documented in the literature. We here report a case of 55-year-old female who came to our emergency with clinical features suggestive of cerebellar stroke. Laboratory investigations revealed severe hypoglycemia. The cerebellar signs and symptoms improved completely with intravenous dextrose infusion. Her MR imaging and Doppler of carotid and vertebrobasilar arteries were noncontributory. Hypoglycemia causes behavioral changes, confusion, loss of consciousness, and seizures. It is also well known to cause hemiplegia and aphasia. Hypoglycemia presenting as cerebellar stroke is rarely reported in the literature. This case highlights an uncommon manifestation of a common clinical condition. Physician must rule out hypoglycemia in every stroke patients

Alzheimer disease in post-menopausal women: Intervene in the critical window period

Alzheimer disease (AD) is a crippling neurodegenerative disorder. It is more common in females after menopause. Estrogen probably has a protective role in cognitive decline. Large amount of research has been carried out to see the benefits of hormone replacement therapy with regards to Alzheimer still its neuroprotective effect is not established. Recent studies suggest a reduced risk of AD and improved cognitive functioning of post-menopausal women who used 17 β-estradiol in the critical period. Use of 17 β-estradiol in young and healthy post-menopausal women yields the maximum benefit when the neurons are intact or neuronal stress has just started. Hence intervention in the critical period is key in the prevention or delay of AD in post-menopausal women

Ethical issues in electronic health records: A general overview

Electronic health record (EHR) is increasingly being implemented in many developing countries. It is the need of the hour because it improves the quality of health care and is also cost-effective. Technologies can introduce some hazards hence safety of information in the system is a real challenge. Recent news of security breaches has put a question mark on this system. Despite its increased usefulness, and increasing enthusiasm in its adoption, not much attention is being paid to the ethical issues that might arise. Securing EHR with an encrypted password is a probable option. The purpose of this article is to discuss the various ethical issues arising in the use of the EHRs and their possible solutions

Deliberate self-harm with parenteral chlorpyrifos: a case report

AbstractOrganophosphate (OP) pesticide poisoning is one of the most common poisonings in India. Most self-poisoning involves pesticide ingestion. Parenteral pesticide poisoning is unusual. Here we report a case of a middle-aged man who presented with history of deliberate self-harm by injecting chlorpyrifos. The patient presented to the Emergency Department with cholinergic symptoms and blisters and ulcers on the right arm. This case represents an uncommon mode of OP pesticide toxicity and distinctive set of local complications secondary to injection

Emergency department point-of-care tests during cardiopulmonary resuscitation to predict cardiac arrest outcomes

Introduction: This study evaluated the role of point-of-care tests (POCT) such as blood lactate, anion gap (AG), base deficit, pH, N-terminal pro B-type natriuretic peptide (NT-proBNP), and troponin as the predictors of cardiac arrest outcomes in the emergency department (ED). Methods: We conducted a prospective, observational study in the ED of a tertiary care hospital in India. All the adult patients who received cardiopulmonary resuscitation (CPR) in the ED were included in the study. Blood samples were collected within 10 min of initiation of CPR for assay of POCTs. Outcomes assessed were the return of spontaneous circulation (ROSC), 24-h survival, survival to hospital discharge (STHD), survival at 7 days, and favorable neurological outcome (FNO) at day 7 of admission. Results: One hundred and fifty-one patients were included in the study (median age: 50 years, 65% males). Out of 151 cases, ROSC, survival at 7 days, STHD, and FNO was observed in 86 patients, six patients, five patients, and two patients, respectively. “No-ROSC” could be significantly predicted by raised lactate (odds ratio [OR]: 1.14, 95% confidence interval: 1.07–1.22) and NT-proBNP (OR: 1.05, 1.01–1.09) values at the time of cardiac arrest. “24-h mortality” could be significantly predicted by the raised lactate (OR: 1.14, 1.01–1.28), low arterial pH (OR: 0.05, 0.01–0.52), raised AG (OR: 1.08, 1.01–1.15), and lower base deficit (<−15) (OR: 1.07, 1.01–1.14). None of the other POCTs was found to be a predictor of other cardiac arrest outcomes. Conclusion: Among various POCTs, raised lactate assayed within 10 min of cardiac arrest can predict poor outcomes like “no-ROSC” and 24-h mortality

Full Outline of Unresponsiveness Score versus Glasgow Coma Scale in Predicting Clinical Outcomes in Altered Mental Status

Introduction: Full outline of unresponsiveness (FOUR) score has advantages over Glasgow Coma Scale (GCS); as it can be used in intubated patients and provides greater neurological details. It has been studied mainly in the trauma and neuroscience setting. Our primary objective was to compare the FOUR versus GCS score as predictors of mortality at 30 days and poor functional outcome at 3 months among nontrauma patients in the emergency department (ED). Methods: This prospective observational study was conducted on adult patients presenting with altered mental status (duration <7 days) in the ED (March 2019–November 2020). Data collection included demographic and clinical features, the GCS and FOUR scores, the feasibility of acquiring and interpreting FOUR on a Likert scale, duration of hospital stay, 30-day mortality, and functional outcome at 3 months on the modified Rankin Scale. Trained emergency medicine residents managing the patient collected the data. The area under receiver’s operating characteristics curve (AUROC) was used to compare the accuracy of the GCS and FOUR scores in predicting outcomes. The FOUR score equivalent of GCS cutoffs for categorizing neurological impairment (mild, moderate, and severe) was also investigated. Results: Two hundred and ninety-one patients were included, with a mean age of 50.3 years and 67.4% males. Most patients (40.2%) had altered mental status for 1–3 days and hepatic encephalopathy was the most common ED diagnosis. The mortality at 30 days was 66.7% (194 of 291), and 88% (256 of 291) of patients had poor functional outcomes at 3 months. The AUROCs for predicting 30-day mortality were similar for both the scores (GCS: 0.70, FOUR: 0.71, and the P value for difference: 0.9). Similarly, the AUROCs for predicting 3-month poor functional outcome were 0.683 and 0.669 using GCS and FOUR, respectively, with a nonsignificant difference (P = 0.82). The FOUR score strata of 14–16, 11–13, and 0–10 were found to be equivalent to the GCS scores of 13–15 (mild), 9–12 (moderate), and 3–8 (severe). The feasibility of acquiring and interpreting GCS and FOUR scores on the Likert scale was found to be “easy.” Conclusion: The FOUR score is similar to GCS in predicting mortality at 30 days and poor neurological outcomes at 3 months among nontrauma patients of ED. Moreover, it was found that the FOUR score is “easy” to assess and interpret by the emergency residents