Muhammad Akbar Baig

Validating a point of care lactate meter in adult patients with sepsis presenting to the emergency department of a tertiary care hospital of a low- to middle-income country

BACKGROUND Timely identification of high blood lactate levels in septic patients may allow faster detection of those patients requiring immediate resuscitation. Point-of-care (POC) testing is being increasingly utilized in the emergency department (ED). We examined the accuracy and time-saving effect of a handheld POC lactate device for the measurement of fingertip and whole blood lactate as compared with reference laboratory blood testing in septic ED patients. METHODS A convenience sample of adult ED patients receiving serum lactate testing were enrolled prospectively in the ED of a multidisciplinary tertiary care hospital serving the population of one of the major cities of Pakistan. Participants underwent fingertip POC lactate measurement with a portable device simultaneous whole blood sampling for analysis by both the POC lactate device and standard laboratory method. Lactate measurements were compared by intraclass correlation (ICC) and Bland and Altman plots. RESULTS Forty-three septic patients were included in the study. The fingertip POC & whole blood POC lactate measurements each correlated tightly with the reference method (ICC=0.93 & ICC=0.92, respectively). Similarly at 6 hours, the fingertip POC & whole blood POC lactate measurements demonstrated satisfactory correlation with the reference method (ICC=0.95 & ICC=0.97, respectively). CONCLUSION Fingertip POC lactate measurement is an accurate method to determine lactate levels in septic ED patients.

To CPR or not to CPR? That is the question

As emergency physicians, we stand at the frontlines of managing the acute patient. When an unresponsive patient is rushed into the emergency department (ED) and the family demands immediate attention, there is always the question of instituting cardiopulmonary resuscitation (CPR). In situations like these, an advance directive—a legal document in which a person outlines his or her end-of-life care—can be helpful.1 Providing life-sustaining treatment was one of the ethical challenges …

Comparison of qSOFA and SOFA score for predicting mortality in severe sepsis and septic shock patients in the emergency department of a low middle income country

Objective We aimed to determine a comparison between the Quick Sequential Organ Failure Assessment (qSOFA) score and existing Sequential Organ Failure Assessment (SOFA) score when applied to severe sepsis & septic shock patients in the Emergency Department (ED) for prediction of in-hospital mortality in the setting of a tertiary care hospital ED in a low-middle income country. Method We conducted a prospective observational cohort study on 760 subjects. The qSOFA, SOFA score and in-hospital mortality were assessed by area under the receiver operating curve (AUROC). We calculated sensitivity and specificity for each score for outcomes at cut-offs of 0.92 and 0.63 for qSOFA and SOFA in Severe Sepsis respectively and 0.89 and 0.63 for qSOFA and SOFA in Septic shock respectively. Results In patients with severe sepsis, the AUROC of qSOFA for predicting mortality in subjects was 0.92 (95% CI; 0.89–0.94) with 96% sensitivity and 87% specificity in comparison to the AUROC of SOFA score which was 0.63 (95% CI; 0.55–0.70 with 71% sensitivity and 57% specificity. In patients with septic shock, the AUROC of qSOFA for predicting mortality in subjects was 0.89 (95% CI; 0.85–0.92) with 92% sensitivity and 85% specificity in comparison to the AUROC of SOFA score which was 0.63 (95% CI; 0.55–0.70 with 70% sensitivity and 59% specificity. Conclusion Our study concludes that qSOFA score is an effective tool at predicting in hospital mortality in comparison to SOFA score when applied to severe sepsis and septic shock patients in the setting of a tertiary care hospital ED of a low-middle income country however, further studies are needed before application for this purpose.

Erythrodermic Psoriasis with Superimposed Fungal Infection: A Presentation in the Emergency Room

Erythrodermic psoriasis or erythroderma is a life-threatening, generalized exfoliative dermatitis involving majority of the body surface. A detailed evaluation is required for the identification of its underlying cause to successfully treat and prevent its relapse. We present a case of erythroderma in our local setting and review this disease in terms of the importance of immediate diagnosis and therapy for improved patient survival.

Evolution of Emergency Medicine in Pakistan –A Fellow’s Perspective

Emergency medicine is a dynamic specialty focused on the rapid identification, evaluation, and treatment of patients who are acutely ill or injured. Due to immense demand, this field has systematically developed and is now offered as structured training in Pakistan. As the first fellow to have attained the reputed fellowship in this field from the College of Physicians and Surgeons of Pakistan, I would like to compare our nation’s training program to those of countries where emergency medicine has already been established for almost half of a century. I will also generally discuss this field for newcomers interested in pursuing it as a career.

Fungal endocarditis presenting with right lumbar pain and femoral artery ischemia – An unusual case report

Fungal endocarditis is a rare entity which has a poor outcome. Our case reports an atypical presentation of similar pathology now presenting with femoral artery ischemia in an immune competent individual. A 62-year Asian male presented with sudden onset of right sided lumbar pain. Initial clinical exam was consistent with right sided renal colic. Intravenous analgesia did not relieve the pain. Repeat clinical examination revealed absent right femoral artery pulsation. The patient underwent a Computerized tomography angiography of right lower extremity. Echocardiogram revealed valvular vegetations that were later revealed to be because of Aspergillus Terreus. This case highlights the atypical presentation of a rare fungal endocarditis in an immune competent individual presenting with right sided lumbar pain. This case is of particular interest for emergency physicians who are at the forefront and may require to deal with such presentations.

Cerebral Venous Sinus Thrombosis with Tentorial Haemorrhagic Infarctions in Combined Proteins Deficiency and Hyperhomocysteinemia Treated with Anticoagulation- Limited Evidence with Good Results: A Case Report

We are presenting a case of a 40-year-old lady who presented with sudden loss of consciousness. Computed Tomography scan of her brain revealed the presence of blood in her sub-arachnoid space on her right hemisphere, cerebral oedema, and cerebral venous sinus thrombosis later magnetic Resonance Imaging revealed extensive cerebral venous sinuses thrombosis formation associated with supra and infra-tentorial haemorrhages. Elevated levels of plasma homocysteine and deficient levels of protein S. Patient was anticoagulated with warfarin and INR was monitored. She recovered successfully with no complication of anticoagulation observed. The use of anticoagulation had a favourable outcome in our patient but the evidence of its use lacking to date.

Community emergency medicine: Benefits and challenges of screening for elder abuse in the emergency department of a developing country.

As people live longer and fewer babies are born, the elderly became the fastest and largest growing population of the world, expected to increase further from 86 million in 2005 to 394 million in 2050 worldwide. Older patients represent a large bulk of the population arriving in emergency departments (EDs) all over the world.[1] They use hospitals more frequently than younger patients, have more hospital admissions from the ED and more prolonged hospital stays.[2] Elder abuse is defined as a single, or repeated, act which causes harm or distress to an older person and it can occur within any relationship where there is an expectation of trust from the elder person’s perspective.[3,4] The ED setting is a particularly important environment being the first point of contact with formal services for the abused elderly population.[5] Careful consideration is demanded when older people attend the ED, with particular attention paid to assessment of subjective and objective data in terms of manifestations and potential indicators of abuse. There are no reliable elder abuse and neglect prevalence and incidence figures from Pakistan. There is also a lack of specific healthcare institutions and reporting systems for dealing with elder abuse in the country. In the present article we will be discussing the factors responsible for the ED presentation of elder abuse, reasons why such abuse is not reported and communication strategies that could be applied in screening for elder abuse.