Acute Medical Emergencies Research Articles

Importance of research for the specialty of Emergency Medicine in India

Emergency Medicine (EM) is a relatively new specialty that is expanding at a phenomenal pace across the world. Within the international community, leaders in medicine, health economics, public health, and government have recognized the importance of developing systems that respond to acute medical and surgical emergencies, and that emergency medicine is a unique discipline that possesses the body of knowledge necessary to respond to these life-threatening crises. Many countries have already recognized the specialty of EM and offer specific training programs to develop a cadre of physicians with the knowledge and skills to care for patients presenting with emergent medical problems. As India enters the 21st century, Emergency Medicine has now been recognized as its own specialty. This recognition comes with the responsibility for developing a skilled approach to the emergency patient in the Indian setting. The unique issues that surround the Indian patient, from access to care, to cultural issues, to finances, can best be addressed by physicians who work in this environment. The International Summit on Emergency Management and Trauma (ISEMT 2014) is one of many new Emergency Medicine conferences that has encouraged India’s core of EM physicians and researchers to address novel clinical issues, collect data, and share these findings amongst themselves. By conducting research in India in the field of emergency medicine, India will be better poised to address the needs of the general population in the coming years. The abstracts selected for presentation at the ISEMT2014 give an invaluable insight into the breadth and diversity of contemporary emergency and trauma care in India. The reason they are so important is that all research is about testing and showing that each of us is practicing the science of medicine to the best of our abilities. Whilst the case report is a popular first step, it cannot demonstrate cause and effect. Retrospective analysis begins to align information with outcome, but is still fraught with many biases. Prospective data collection is the most worthy goal, aimed at testing a hypothesis with exact methodology around sample size, variables, confounders and statistical analysis. These abstracts show clear and purposeful steps in the right direction. Only half of the submitted ISEMT 2014 abstracts were chosen for presentation, and they were selected by a panel of distinguished judges who serve on the editorial board of several prominent international EM journals. It is our sincere hope that these abstracts will be published in peer-reviewed journals around the world and begin to define emergency medicine research in India. We encourage the great work that is now being done in the field of EM, and look forward to even greater collaboration and research in the near future.

Prevalence and recognition of alcoholism in emergency department patients.

Alcohol addiction is very common in India, and is a major risk factor and etiology of many acute medical and surgical emergencies. Alcohol addiction history is frequently missed by medical team in emergency department. The present study is to investigate the prevalence of alcoholism among emergency department patients and to determine its rate of recognition by the medical team. It is double blind cross-sectional study done in a 750 bedded tertiary care hospital (Mamata general hospital, Khammam). The study population consisted of all patients admitted in the emergency room and who stayed in the hospital for a minimum period of 24 hours between 1(st) March 2013 and 30(th) April 2013. Total of 144 patients were interviewed, 62 (43.05%) were identified as alcoholics in emergency department by treating doctors. On reviewing the records additional 11 (7.63%) were identified as alcoholics, out of which 2 (1.38%) were fulfilling the criteria for severe alcoholism. Alcoholism is often not investigated and diagnosed on hospital admission. Standardized diagnostic tool will improve the identification of alcoholic patients. This is the first step to reduce alcohol consumption and offer appropriate treatment to these patients.

Snake bite poisoning: A neglected life-threatening occupational hazard

Snake bite poisoning: A neglected life-threatening occupational hazard

Glucose as a risk predictor in acute medical emergency admissions

AimsThe aims of this study were to examine the relationship between admission blood glucose and mortality in a large, unselected cohort of acutely ill medical patients and to assess the impact of diabetes on this relationship. MethodsWe studied the broad pattern of acute medical admissions over an eight year period and the impact of admission serum glucose on in-hospital mortality. Significant predictors of outcome, including acute illness severity and co-morbidity, were entered into a multivariate regression model, adjusting the univariate estimates of the glycaemic status on mortality. ResultsThere were 45,068 consecutive acute medical emergency admissions between 2005 and 2012. The normoglycaemic (>4.0 ≤7.0mmol/l) cohort (86%) had a 3.9% in-hospital mortality. Both hypoglycaemia (OR: 3.23: 95% CI: 2.59–4.04; p<0.001) and hyperglycaemia (OR: 2.1; 95% CI: 1.9–2.4; p<0.001) predicted an increased risk of an in-hospital death. Neither of these increased risks were fully adjusted nor explained by a highly predictive outcome model, using multiple acute illness parameters. Hyperglycaemia did not carry similar adverse prognostic implications for patients with diabetes. ConclusionIn patients without diabetes, an abnormal serum glucose is independently predictive of an increased mortality among the broad cohort of acute emergency medical patients. Similar disturbances of glucose homeostasis for patients with diabetes do not confer equivalent adverse prognostic implications.

Who Wants to be an Acute Medic? A Survey of Junior Doctors Attitudes Towards and Beliefs Surrounding a Career in Acute Medicine

Aim: Survival of Acute Medicine (AM) depends on successful recruitment. Local juniors were unaware of training requirements and opportunities in AM. We conducted a survey to establish whether this was a nationwide issue. Methods: A survey was distributed nationally with participants responding to statements on a Likert Scale. Results: 397 responses from four deaneries were received. 50% of respondents were unaware of AM training opportunities. 20% of juniors did not know of entry requirements for training. Juniors felt that becoming a medical registrar would discourage them from careers in AM. Discussion: This study reveals poor awareness of training opportunities in AM and reluctance to pursue the medical registrar role, which is unrelated to confidence in dealing with acute medical emergencies. Promotional work will be invaluable in future workforce planning.

Ecstasy use and serotonin syndrome: a neglected danger to adolescents and young adults prescribed selective serotonin reuptake inhibitors

At present, there are scarce clinical and basic lab data concerning the risk of acute serotonin toxicity from selective serotonin reuptake inhibitors (SSRIs) and 3,4-methylenedioxymethamphetamine (MDMA, ecstasy) co-administration. The health care community can strongly benefit from efforts to address the high risks associated with serotonin syndrome from this specific drug combination. The aim of this work is to review the risk of serotonin syndrome in adolescents and young adults prescribed with SSRIs and are concurrently using ecstasy. An electronic search of the major behavioral science bibliographic databases (Pubmed, PsycINFO, Medline) was conducted to retrieve peer-reviewed articles, which detail the clinical characteristics, biological mechanisms and social implications of SSRIs, MDMA, and their potential synergism in causing serotonin syndrome in the pediatric and young adult population. Search terms included "serotonin syndrome", "ecstasy", "MDMA", "pediatric", and "SSRI". Additional references were incorporated from the bibliographies of these retrieved articles. MDMA, in combination with the widely-prescribed SSRI antidepressant class, can lead to rapid, synergistic rise of serotonin (5-HT) concentration in the central nervous system, leading to the acute medical emergency known as serotonin syndrome. This review addresses such complication through an exploration of the theoretical mechanisms and clinical manifestations of this life-threatening pharmacological interaction. The increasing incidences of recreational ecstasy use and SSRI pharmacotherapy among multiple psychiatric disorders in the adolescent population have made this an overlooked yet increasingly relevant danger, which poses a threat to public health. This can be curbed through further research, as well as greater health care provision and attention from a regulatory body owing.

Accidental ingestion of orthodontic band loop

Any object routinely placed into or removed from the oral cavity during dental or surgical procedures can be aspirated or swallowed. Handling of small instruments or appliances requires special care, particularly when the patient is supine or semi-supine. Prevention of such incidence by the mandatory use of precautions during all dental procedures is the best approach. This case report describes an accidental swallowing of a piece of orthodontic band material and its management, and up-to-date knowledge on prevention and management of foreign body ingestion. Clinical Relevance: Many complications can arise during regular dental care procedures. Aspiration or ingestion of foreign bodies has the potential of resulting in acute medical and life-threatening emergencies as it can be a cause of accidental death. Also, in supine or semi-supine patients, the risk of aspiration or ingestion is increased. Readers should understand that aspiration or ingestion of foreign bodies is a significant medical emergency and should keep themselves updated on how to avoid and manage such an emergency.

Empirical use of anti-snake venom in the early morning neuroparalysis

Background: Snake bite is a common acute medical emergency, which can present with atypical symptoms in the pediatric age group. Objective: The objective of the present study is to determine the outcome of patients presenting in the early morning with acute onset of atypical symptoms, no history of snake bite or bite marks be considered as a snake bite and treat with anti-snake venom (ASV) and mechanical ventilation. Materials and Methods: The prospective interventional study conducted over a 6 year period between January 2006 and December 2012 at a Rural Health Center in Maharashtra. Results: Out of 41 patients, 28 (68%) were males and 13 (32%) were females with a mean age of 8.59 ± 3.23 and 8.46 ± 2.96 years, respectively. Patients presented between 12 midnight to 7 a.m. with the maximum presentation between 2 a.m. and 4 a.m. (54%). Patients presented with vague complaints such as abdominal pain (60.97%), unconsciousness (17.07%), vomiting (12.19%) and abnormal sensation over body (7.31%) and convulsion (2.43%). All patients were treated with 15 units of ASV and needed mechanical ventilation within 6 h of admission. Duration of ventilation ranged from 36 h to 168 h with and an average of 115 ± 34.753 h. Hospital stay varied from 5 days to 17 days with a mean of 10.892 ± 3.361 days. All patients responded to treatment and there was 1 (2.43%) death owing to the aspiration pneumonitis. Conclusion: Diagnosis of possible snake bite should strongly be considered when patient presents in the early morning with acute onset of atypical symptoms and without any underlying illness, especially krait bite. The study concludes that timely interventions with a bolus dose of ASV and ventilation can definitely save many lives.

Traditional Herbal Medicines for the Treatment of Snake Bite and Scorpion Sting by the Tribes of South Surguja, Chhattisgarh, India

Snake bite is a common acute medical emergency faced by rural population in tropical and subtropical countries and in humid climate; therefore, people need to counter these types of emergencies. The Cherwa and Pando tribes were surveyed during June to July 2008, to gather information on the traditional uses of medicinal plants used in health care by them. Tribes of South Surguja use 10 plants for snake bite and 05 plants for scorpion sting. A particular family uses a particular variety of a plant species as a tradition for treatment of snake bite and scorpion sting. The study indicates that tribes depend on medicinal plants for health care.

Acute dystonic reaction as medical emergency: A report of two cases

Drug-induced dystonic reactions are common presentations to the emergency department. Two cases of acute dystonic reactions presenting as acute medical emergency illustrate the associated fatality and possibility of misdiagnosis. This case series reports two cases of medication-induced (haloperidol and metoclopramide) acute dystonic reactions presenting with torticollis, tongue protrusion, and respiratory distress which resolved with the administration of intramuscular biperiden and oxygen by facemask. In developing countries like Nigeria where atypical anti-psychotic medications with fewer and lesser troublesome side effects are not affordable to many, the training of physicians and other doctors should adequately include a high degree of clinical suspicion and knowledge of management of acute dystonic reactions.

The Febrile Patient with Neutropenia

Fever in a neutropenic patient is an acute medical emergency. This article considers the diagnosis, investigation and management of neutropenic sepsis, along with the clinical challenges that an acute physician may face when treating patients presenting with this condition.

PROVISION OF COMMUNITY‐WIDE BENEFITS IN PUBLIC HEALTH INTERVENTION RESEARCH: THE EXPERIENCE OF INVESTIGATORS CONDUCTING RESEARCH IN THE COMMUNITY SETTING IN SOUTH ASIA

This article describes the types of community-wide benefits provided by investigators conducting public health research in South Asia as well as their self-reported reasons for providing such benefits. We conducted 52 in-depth interviews to explore how public health investigators in low-resource settings make decisions about the delivery of ancillary care to research subjects. In 39 of the interviews respondents described providing benefits to members of the community in which they conducted their study. We returned to our narrative dataset to find answers to two questions: What types of community-wide benefits do researchers provide when conducting public health intervention studies in the community setting, and what reasons do researchers give when asked why they provided community-wide benefits? The types of community-wide benefits delivered were directed to the health and well-being of the population. The most common types of benefits delivered were the facilitation of access to health care for individuals in acute medical need and emergency response to natural disasters. Respondents' self-reported reasons when asked why they provided such benefits fell into 2 general categories: intrinsic importance and instrumental importance.

PTU-263 Is it time for gastroenterology and general medicine to go their separate ways?

IntroductionCurrently most gastroenterologists within the UK are general physicians with a specialist interest in gastroenterology (85%) and most gastroenterology (GI) trainees train for dual accreditation in GI and general internal...

Allgemeine Notfälle in der täglichen dermatologischen Praxis

Many patients and their companions who present daily in dermatological clinics and private practices may have numerous non-dermatological comorbidities, which can cause medical emergencies. Additionally several dermatologic diagnostic or therapeutic procedures which are commonly performed can cause life-threatening complications. Therefore dermatologists can be confronted with acute medical emergencies at any time. Mostly these are internal medicine emergencies. Therefore dermatologists must have the basic emergency medical knowledge; emergency situations should be practiced regularly and this training documented for quality control measures. Every practice must be able to deliver life-saving care until trained emergency medical personnel arrive. The general emergency procedures are presented below and the practical approach is illustrated at different cardinal symptoms such as impaired consciousness, respiratory disorders or cardiocirculatory disorders.

Disaster Metrics: Quantification of Acute Medical Disasters in Trauma-Related Multiple Casualty Events through Modeling of the Acute Medical Severity Index

The interaction between the acute medical consequences of a Multiple Casualty Event (MCE) and the total medical capacity of the community affected determines if the event amounts to an acute medical disaster. There is a need for a comprehensive quantitative model in MCE that would account for both prehospital and hospital-based acute medical systems, leading to the quantification of acute medical disasters. Such a proposed model needs to be flexible enough in its application to accommodate a priori estimation as part of the decision-making process and a posteriori evaluation for total quality management purposes. The concept proposed by de Boer et al in 1989, along with the disaster metrics quantitative models proposed by Bayram et al on hospital surge capacity and prehospital medical response, were used as theoretical frameworks for a new comprehensive model, taking into account both prehospital and hospital systems, in order to quantify acute medical disasters. A quantitative model called the Acute Medical Severity Index (AMSI) was developed. AMSI is the proportion of the Acute Medical Burden (AMB) resulting from the event, compared to the Total Medical Capacity (TMC) of the community affected; AMSI = AMB/TMC. In this model, AMB is defined as the sum of critical (T1) and moderate (T2) casualties caused by the event, while TMC is a function of the Total Hospital Capacity (THC) and the medical rescue factor (R) accounting for the hospital-based and prehospital medical systems, respectively. Qualitatively, the authors define acute medical disaster as "a state after any type of Multiple Casualty Event where the Acute Medical Burden (AMB) exceeds the Total Medical Capacity (TMC) of the community affected." Quantitatively, an acute medical disaster has an AMSI value of more than one (AMB / TMC > 1). An acute medical incident has an AMSI value of less than one, without the need for medical surge. An acute medical emergency has an AMSI value of less than one with utilization of surge capacity (prehospital or hospital-based). An acute medical crisis has an AMSI value between 0.9 and 1, approaching the threshold for an actual medical disaster. A novel quantitative taxonomy in MCE has been proposed by modeling the Acute Medical Severity Index (AMSI). This model accounts for both hospital and prehospital systems, and quantifies acute medical disasters. Prospective applications of various components of this model are encouraged to further verify its applicability and validity.

Paramedics’ perceptions of Their Role in Palliative Care: Analysis of Focus Group Transcripts

Paramedics play an important role in out-of-hospital health care. They provide unscheduled care, assisting both patients with minor injuries and those experiencing life-threatening emergencies. Increasingly, paramedics are called on to manage chronic and complex health needs, including symptom relief for patients at the end of life. However, paramedics may not be well prepared to offer palliative care, as practice guidelines and education tend to focus on the management of acute medical emergencies and major trauma. Emergency medical services that employ paramedics rarely have practice guidelines or protocols that deal specifically with palliative care.

Managing medical crises: the experiences of people affected by Motor Neurone Disease and their carers

AbstractMotor neurone disease (MND) is a non-curative neurodegenerative disorder that has a rapidly progressive course. Due to the direct and indirect symptoms of the disease, people living with MND can suffer from a range of acute medical emergencies throughout the course of their illness. The majority of people are cared for at home and during an acute incident need to access crisis intervention services, i.e., out-of-hours doctors/nurses, or ambulance services. There is limited knowledge and literature on the experiences of patients and carers of using these services.This qualitative study explored the experiences of people with MND and their family carers who had accessed a crisis intervention service during a medical emergency. Semi-structured interviews were conducted with seven people with MND; five family carers, and two bereaved family carers. The majority of participants were satisfied with the service they received. Issues relating to negative experiences included a lack of clear information ab...

Does Palliative Care Have a Future in the Emergency Department? Discussions With Attending Emergency Physicians

ContextPalliative care focuses on the relief of pain and suffering and achieving the best possible quality of life for patients. Although traditionally delivered in the inpatient setting, emergency departments (EDs) are a new focus for palliative care consultation teams. ObjectivesTo explore attitudes and beliefs among emergency care providers regarding the provision of palliative care services in the ED. MethodsThree semistructured focus groups were conducted with attending emergency physicians from an academic medical center, a public hospital center, and a community hospital. The discussions were digitally recorded and transcribed to conduct a thematic analysis using grounded theory. A coding scheme was iteratively developed to subsequently identify themes and subthemes that emerged from the interviews. ResultsTwenty emergency physicians participated (mean age 41 years, range 31–61 years, median practice time nine years, 40% female). Providers acknowledged many benefits of palliative care presence in the ED, including provision of a specialized skill set, time to discuss goals of care, and an opportunity to intervene for seriously ill or injured patients. Providers believed that concerns about medicolegal issues impaired their ability to forgo treatments where risks outweigh benefits. Additionally, the culture of emergency medicine—to provide stabilization of acute medical emergencies—was sometimes at odds with the culture of palliative care, which balances quality of life with the burdens of invasive treatments. Some providers also felt it was the primary physician's responsibility, and not their own, to address goals of care. Finally, some providers expressed concern that palliative care consultation was only available on weekdays during daytime hours. Automatic consultation based on predetermined criteria was suggested as a way to avoid conflicts with patients and family. ConclusionEmergency providers identified many benefits to palliative care consultation. Solving logistical problems and developing clear indications for consultation might help increase the use of such services.

Monitoring for teratogenic signals: Pregnancy registries and surveillance methods

Pregnant women should have access to medications that have been adequately studied for use to facilitate evidence-based risk-benefit discussions with their health care providers. Pregnant women experience acute medical emergencies, have existing conditions that require continued medical treatment or may develop pregnancy-induced conditions, making drug use during pregnancy unavoidable. Drug labeling is the primary source of information about a drug's use. The safety and efficacy data found in the label is derived from well-controlled clinical trials conducted prior to a drug's approval. However, pregnant women are rarely enrolled in clinical trials unless a product is specifically indicated for a pregnancy-related condition. Consequently, information regarding a product's use during pregnancy is usually collected postapproval. Current data collection tools include pregnancy exposure registries, retrospective cohort studies, pregnancy surveillance programs, case-control studies, spontaneous reports of adverse events and case reports. Each tool has strengths and limitations in its ability to detect teratogenic signals. Combinations of different sources of data are necessary to acquire the most complete picture of potential teratogenic risk, as no single method can capture all desired data to help pregnant patients and women of child bearing potential make appropriate risk benefits decisions along with their health care providers.

A discursive exploration of the practices that shape and discipline nurses’ responses to postoperative delirium

A discursive exploration of the practices that shape and discipline nurses' responses to postoperative delirium Although delirium is classified as a medical emergency, it is often not treated as such by health care providers. The aim of this study was to critically examine, through a poststructural, Foucauldian concept of discourse, the language practices and discourses that shape and discipline nurses' care of older adults with postoperative delirium (POD) with a purpose to question accepted nursing practice. The study was based on data collected from face-to-face, in-depth, personal interviews with six nurses who work on an acute postoperative patient care unit. Five analytic readings of the data identified two prominent discourses at work in nursing practice which influenced the care of patients with POD. These were identified as discourses of legitimacy/illegitimacy and discourses of nursing work. Through the process of poststructural analysis it became evident that one overriding discourse - the biomedical/scientific discourse - served to direct, legitimize and govern all other discourses. The findings of this study have implications for nursing knowledge and practice, length of hospital stay and improved patient outcomes. This study builds on previous work and is the first study to conduct a discourse analysis illuminating nurses' responses to POD through comparison with other acute medical emergencies from a poststructural perspective.