The interesting study by Mitra et al. in this issue explores this newly developed pain assessment tool— Behavior pain assessment tool (BPAT) for critical patients who cannot communicate. The authors explored the tool in a prospective survey in 400 adults, noncomatose intensive care unit (ICU) patients. BPAT scoring was done within 2–3 hours of admission in ICU, followed by every day in the morning, and also before and after ICU procedures associated with pain. The BPAT scoring was done by untrained senior residents independent of each other. Majority of the patients had BPAT score of ≤3 (initial score in 83.5% and baseline score in 74.5% patients). In all, 56.5% patients had a postprocedure pain score of ≤3, highlighting the role of institutional sedation–analgesia protocol, as all patients received either morphine or fentanyl infusion along with midazolam infusion. Grimace was the most liked behavior (67%) by the observers, whereas closed eyes was the least liked (59%). Closed eyes behavior was felt to have poor utility in paralyzed, ventilated patients. Authors feel that as verbal and bodily responses could not be assessed in these patients, the BPAT can be further modified to observe pain in such patients. The behaviors like verbal complaints, muscle rigidity, and clenched fist were also liked less. For most behavior patterns liked by observers, the κ coefficient was quite high (>0.9). The BPAT tool was found easy to understand (93.3%) and apply (91.8%) by untrained observers. Most observers (59.25%) considered that the time spent on calculating BPAT was short, although the timelines have not been defined. The study again confirms that sedated, paralyzed, and ventilated patients are the most difficult group for assessment of pain. Interobserver variability may lead to subjective bias. The study has not looked at the impact of BPAT scoring on reduction or adjustment of opioid needs of these patients. Further studies may throw more light on the practical applications of BPAT score, and comparative studies between BPAT, behavioral pain scale (BPS), and critical-care pain observation tool (CPOT) would be very interesting.

Recent trials have failed to show a survival benefit from the early initiation of dialytic therapies in acute kidney injury (AKI), but the problem has not been studied in pregnancy-related AKI. While the KDIGO criteria have not been validated in pregnancy-related acute kidney injury (PRAKI), additionally both fetal and maternal outcomes require to be studied. The short observational study by Banerjee et al. contains some interesting observations.

Scoring systems in intensive care units allow assessment of the severity of disease and predicting mortality. They also help in allocation of resources and benchmarking performance when compared to other units and hence to development of skills within a unit. Their use needs to go beyond just mortality prediction and unit statistics. The data collected are useful for resource allocation, unit audits, comparison with local units as well as for quality improvement programs and education.

Introduction: COVID-19 has been declared a pandemic by the World Health Organization (WHO). Many of the COVID-19 patients develop acute respiratory distress syndrome (ARDS) and require ventilatory support based on their severity for which conventional strategies are being used along with few newer strategies. We conducted this multicenter survey to know the physician's current ventilation strategies adopted for the care of COVID-19 patients. Materials and methods: The survey was conducted after taking the ethical committee clearance. The web-based multicenter, cross-sectional questionnaire study was sent to physicians, who were involved in the management of COVID-19 patients. The questionnaire was segregated into three parts: part one consisted of general information and consent form, part two was concerned regarding demographic characteristics, and part three was concerned about their practices and strategies for ventilation of COVID-19 patients. Results: A total of 223 responders replied for the questionnaire; 190 participated in the study saying that they are involved in the management of COVID-19 patients. The answers to the questionnaires were expressed as a percentage of total responses. 86% of the respondents said they have a designated intensive care unit (ICU) and 89% of the responders said they have an intubation/extubation protocol for suspect/confirmed COVID-19 patients. The responses of junior residents (JRs), senior residents (SRs), assistant professors/junior consultants, and professors/consultants were analyzed separately, and a few significant differences were observed. 39% of JRs were aware of prone ventilation as the most effective rescue ventilation strategy compared to 69% of consultants/professors. Extracorporeal membranous oxygenation (ECMO) strategy was also more significant in consultants/professors (40%) vs JRs (12%). The responders were also diverged based on medical college and corporate hospitals, and their responses were noted. Most commonly, responders in the corporate hospitals had a facility to ventilate COVID-19 patients in a negative pressure isolation facility compared to a nonnegative pressure room isolation facility in medical colleges. Conclusion: Most of the responders were practicing ventilation strategies in a standard manner. JRs need to undergo further training in a few aspects of the ventilatory management, and also, they need to update themselves with newer treatment modalities as they keep evolving. Medical colleges are providing at par facility compared to corporate hospitals except for few advance care facilities. Clinical significance: This study highlights the current practice of ventilatory management of COVID-19 patients, which is satisfactory. The survey can be used to develop study tools, to educate resident doctors, to further improve quality of care of critical COVID-19 patients.

Aims and objective: To study the effects of various components of “metabolic resuscitation” on the shock reversal among patients with septic shock Introduction: Sepsis is characterized by dysregulated host response to infection. Mitochondrial dysfunction which occurs early in sepsis is associated with multiorgan dysfunction. Therapies such as adequate resuscitation, early administration of antibiotics, and aggressive monitoring reduced mortality substantially but it still remains high for those with septic shock. Combination of vitamin C, hydrocortisone, and thiamine improved outcome in a retrospective study, but how effective is this therapy in isolation compared to combination has to be known before implementation. Materials and methods: This study is single-center, prospective, randomized nonblinded trial done in septic shock patients admitted to the medical intensive care unit. Subjects were randomized to three groups of hydrocortisone (H), hydrocortisone, ascorbic acid (HA), hydrocortisone, ascorbic acid, thiamine (HAT). Following randomization, they received hydrocortisone 200 mg over 24 hours as infusion, intravenous ascorbic acid 1.5 g every 6 hours, thiamine 200 mg twice daily as allotted and continued till shock reversal or death. Primary outcome is time to shock reversal and secondary outcome is time to vasopressor dose reduction from hemodynamic SOFA score 4–3. Results: Twenty seven subjects were randomized into 3 groups of 9 each, of which 17 (63%) patients met primary outcome and secondary outcome has been studied in 16 (59%) patients. Eight patients (29.5%) died and did not meet either outcome and two patients (7.5%) met secondary outcome but not primary outcome because of discharge to other hospital. There is no difference in time to shock reversal [mean, SD in H (7422, 8348), HA (2528, 3086), HAT (1860, 749), p value 0.17]. There is no difference in time to shock reversal from hemodynamic SOFA 4–3 [mean, SD in H (4935, 6406), HA (2310, 2515), HAT (1800, 1282), p value 0.35]. Conclusion: In patients with septic shock, there is no difference in time to shock reversal comparing individual components of metabolic resuscitation.

Background: Sepsis remains a leading cause of death worldwide despite advances in management strategies. Preclinical and observational studies have found mortality benefit with high-dose vitamin C in sepsis. Our study aims to prospectively evaluate the effect of intravenous hydrocortisone, vitamin C [ascorbic acid (AA)], and thiamine (HAT) administration in reducing inpatient all-cause mortality among patients with septic shock. Materials and methods: Our single-center, prospective, open-label, randomized controlled trial recruited patients with admitting diagnosis of septic shock and assigned eligible patients (1:1) into either intervention (HAT) or control group (routine). The HAT group received intravenous combination of vitamin C (1.5 g every 6 hours), thiamine (200 mg every 12 hours), and hydrocortisone (50 mg every 6 hours) within 6 hours of onset of septic shock admission. The treatment was continued for at least 4 days, in addition to the routine standard of care provided to the control group. Thiamine and hydrocortisone use in control arm was not restricted. Vitamin C levels were estimated at baseline and at the end of the 4 days of treatment for both groups. The primary outcome evaluated was mortality during inpatient stay. Results: Among 90 patients enrolled, 88 patients completed the study protocol. The baseline characteristics between the HAT (n = 45) and the routine (n = 43) groups were comparable. The all-cause mortality in the HAT cohort was 57% (26/45) compared to 53% (23/43) in the routine care group (p = 0.4, OR 1.19, 95% CI 0.51–2.76). The time to reversal of septic shock was significantly lower in the HAT (34.58 ± 22.63 hours) in comparison to the routine care (45.42 ± 24.4 hours) (p = 0.03, mean difference −10.84, 95% CI −20.8 to −0.87). No significant difference was observed between the HAT and the routine care with respect to changes in sequential organ failure assessment (SOFA) scores at 72 hours (2.23 ± 2.4 vs 1.38 ± 3.1), the use of mechanical ventilation (48% vs 46%), and mean Vasoactive Inotropic Score (7.77 ± 12.12 vs 8.86 ± 12.5). Conclusion: Intravenous administration of vitamin C, thiamine, and hydrocortisone did not significantly improve the inpatient all-cause mortality among patients with septic shock. Clinical significance: HAT protocol does not reduce hospital mortality but decreases time to shock reversal in septic shock.

In the novel coronavirus (COVID-19) pandemic, preventive medicine has taken center stage, as there is no vaccine or specific antiviral drug regime used to treat patients. Public health authorities and governments are recommending the practice of social distancing and hand hygiene. Hands are a common vector for the transmission of infection, and frequent face touching is extremely common among the public. We developed and applied a new method to prevent face touching which is of utmost importance to break its cycle and subsequent inoculation of the virus through mucous membranes, thus reducing the risk of transmission of COVID-19.

Background: Burnout, a state of physical and emotional exhaustion, in healthcare workers (HCWs) is a major concern. The prevalence of burnout, due to COVID-19 pandemic in India, is unknown. We therefore conducted this survey. Materials and methods: A questionnaire-based survey using Copenhagen Burnout Inventory was carried out among HCWs looking after COVID-19 patients. Questionnaire was sent to the HCWs, using WhatsApp Messenger, and voluntary participation was sought. We received responses from 2026 HCWs. Burnout was assessed in personal, work, and client-related (COVID-19 pandemic-related) domains. Burnout was defined at a cut-off score of 50 for each domain. Results: The prevalence of personal burnout was 44.6% (903), work-related burn-out was only 26.9% (544), while greater than half of the respondents (1,069, 52.8%) had pandemic-related burnout. Younger respondents (21–30 years) had higher personal and work-related burnout. The prevalence of personal and work-related burnout was significantly (p < 0.01) higher among females. The doctors were 1.64 times, and the support staff were 5 times more likely to experience pandemic-related burnout. Conclusion: There is a significant prevalence of burnout during the COVID-19 pandemic among HCWs, in particular, doctors and support staff. Female respondents had higher prevalence. We suggest that the management should be proactive and supportive in improving working conditions and providing assurance to the HCWs. The long-term effects of the current pandemic need to be assessed later.

Objectives: Mottling score is estimated from 0–5 according to mottling over the knee and described as clinical evaluation of tissue perfusion. This score was developed with ancient definitions of sepsis without lactate level, a major prognostic parameter when superior to 2 mmol/L. This study describes mottling incidence and mottling score in septic shock patients according to lactate level. Materials and methods: We reanalyzed our prospective study in a French tertiary hospital in the intensive care unit (ICU) which studied mottling score and thermography correlation. Patients admitted to septic shock diagnosis and requiring vasoactive drugs were included. We recorded hemodynamic variables, mottling score, and lactate. Data collection was realized at ICU admission (H0) and after six hours (H6). Results: Forty-three patients were included. Mean age was 67 (±4), mean sequential organ failure assessment (SOFA) score was 11 (8–12), and SAPS II 58 ±20. Mortality rate at day 28 was 30%. Among patients with lactate ≥2 mmol/L, mottling was more prevalent in 82.6% vs 47.4% (p value = 0.016), and at H6 mottling score was higher (p value = 0.009). Although, mottling incidence was not different between dead (85%) and survivors (81%; p value = 0.795). Conclusion: A new sepsis definition implies a new epidemiology in mottling according to lactate threshold. Patients with lactate ≥2 mmol/L presented a higher incidence and score of mottling. However, mortality was not influenced by mottling in this study. Clinical significance: • Arterial lactate is a major prognostic parameter when superior to 2 mmol/L. • A new definition of sepsis was published in 2016 with a new paradigm and epidemiology of septic shock • Patients with lactate ≥2 mmol/L presented a higher incidence and score of mottling. • Mottling score is a clinical sign of microcirculatory alteration, related to lactate level in septic shock.

Introduction: Obstetric patients are a special group of patients whose management is challenged by concerns for fetal viability, altered maternal physiology, and diseases specific to pregnancy. Materials and methods: A prospective analysis of all obstetric patients admitted to the critical care department was done to assess reasons for transfer to the critical care unit (CCU) and the interventions required for management of these patients. Results: Between June 2013 and September 2017, obstetric admission comprised 95 women (5.9%) of the total critical care admissions. There were 77 patients (81.1%) who were discharged from the hospital and 18 patients (18.9%) died. In most of the cases, the primary reasons for shifting the patient to the CCU were severe preeclampsia with pulmonary edema (22.1%), eclampsia (8.4%), acute respiratory distress syndrome (ARDS) (14.7%), and hypovolemic shock in antepartum hemorrhage (APH) and postpartum hemorrhage (PPH) (10.5 and 13.7%, respectively). It was seen that 73 patients (76.8%) required ventilator support, 58 patients (57.4%) required vasopressor support, and intensive hemodynamic monitoring and blood/blood products were transfused in 55 patients (54.5%). The need for ventilator support was more in patients with a lower PaO₂/FiO₂ and a higher APACHE II score. Patients with a high severity of illness score and a lower PaO₂/FiO₂ had higher odds of requiring vasopressors. Low hemoglobin at the time of transfer to the CCU and a prolonged hospital stay were found to predict the need for blood transfusion. Conclusion: Obstetric patients are susceptible to critical illnesses but timely management improves the outcome of these young women.

Background: Fall from height (FFH) is the second most common cause of trauma presenting to the emergency department (ED). They account for majority of the polytrauma cases. This study was done to determine the pattern of injuries sustained due to FFH and outcome. Materials and methods: This was a retrospective observational study of all patients with history of FFH presenting to the ED of a large tertiary care hospital in South India. Details of the incident, fall height, injuries, and outcome were noted and analyzed. Results: This study cohort included 861 patients with a mean age was 36.2 (SD 20.8) years. A male predominance (74%) was noted. Majority of the patients, i.e., 62%, were triaged as priority 2, depending on the hemodynamic stability. Approximately a quarter (26%) sustained injury to the lower limbs with 18% sustaining spinal cord injury (SCI). Among the patients suffering SCI (35%), patients were further categorized in the American Spinal cord Injury Association (ASIA) classification. New Injury Severity Score (NISS) was more than 8 in 47% of the total study population. Majority of the patients, i.e., 62%, were discharged stable from ED after primary care with a plan of follow-up in the outpatient department. One-third (30%) of the total patients required hospital admission and among them 20% of the patients had to undergo major surgical intervention. The rest were either discharged stable or left against medical advice (LAMA) after primary care. The in-hospital mortality rate was 1.04%. Conclusion: This study has expressed the pattern of injuries in patients with FFH. An alarmingly high number of young adults with significant lower limbs and spinal injuries were noted. We observed that with increase in fall height there was a proportional increase in SCI and decrease in lower limb injuries.

Introduction and objective: Pregnancy-related acute kidney injury (PRAKI) is one of the most important cause of maternal and fetal morbidity and mortality. Some of the reasons behind PRAKI may be due to sepsis, postpartum hemorrhage, preeclampsia, thrombotic microangiopathies (TMA), and acute fatty liver of pregnancy (AFLP). The timing of initiation of renal replacement therapy (RRT) for better patient outcome is still debatable. We conducted this study to establish whether earlier initiation of RRT in PRAKI improves fetomaternal survival compared to a more conservative approach. Materials and methods: This is a prospective study, where patients were screened at a multispecialty tertiary care hospital in north India for 1 year. The patients were divided into two groups: early RRT and standard AKI treatment. The demographic profile and clinical characteristics of the patients in terms of age, parity access to antenatal care, fetal outcome, urine output, hematological and biochemical profiles, RRT, duration of hospitalization, recovery of renal function, and patients survival were recorded. Results: This prospective study conducted included 13 patients in the early RRT group and 23 patients in the standard group. Considering the fetal outcome, the number of fetal deaths in early RRT group were 14.29%, whereas for the standard group it was 85.71%. In all, 75% of early RRT group and 25% of standard group had normal term delivery. Probability test applied showed they were statistically significant. One maternal mortality was there in the standard group. The indices of maternal outcome in PRAKI patients were found to be statistically insignificant. Conclusion: The planning of RRT whether early or late does not make a difference in maternal mortality or morbidity. The fetal outcome is significantly better for patients with early RRT than conservative treatment in PRAKI.

Introduction: Unnoticed and unrelieved pain is one of the main sources of psychological and physiological stress for intensive care unit (ICU) patients. The eight-item behavior pain assessment tool (BPAT) is a multicountry validated tool to assess pain in ICU patients. However, its feasibility and clinical utility for ICU patients in India need further research. Aims and objectives: The Aims and objectives of the study were to assess pain using BPAT and its clinical utility in pain assessment and management in ICU patients. Materials and methods: Following ethical approval, 400 consecutive adult patients admitted in the ICUs in a tertiary care teaching hospital were assessed for pain severity using BPAT at intake, baseline pain and procedural pain. Patients <18 years and in deep coma on the Glasgow coma scale were excluded from the study. The patients with BPAT score ≥4 were given opioid analgesic, and their pain was reassessed after 2–3 hours. A feedback regarding feasibility and clinical utility was filled by the doctors. Results: High interrater agreement for BPAT was observed with excellent kappa coefficients (>0.85) for each item. The BPAT significantly guided the pain management (p < 0.0001). More than 90% of doctors found BPAT easy to understand and use. In most of the cases (95.5%), doctors agreed that BPAT can improve the clinical management of ICU patients. Conclusion: The BPAT is a reliable, brief, and an easy-to-use pain assessment tool, which clinicians can use for guiding pain assessment and management in the ICU setting on a routine basis. Clinical significance: We recommend implementing BPAT in the clinical practice for better pain assessment and control in ICU patients.

Aims and objectives: Utility of pediatric logistic organ dysfunction-2 (PELOD-2) score on day 1 within 1 hour of admission in predicting mortality in children admitted in pediatric intensive care unit (PICU). Background: Various scoring systems aid to evaluate the patient's mortality risk in the intensive care unit (ICU) by assigning a score and predicting the outcome. Critically ill children are characterized by large variations in the normal body homeostasis. These variations can be estimated by the change of the physiological variables from the normal range. Various scores are constructed from deviations of these changed variables. One such score, the PELOD-2 score, is used to predict mortality of patients admitted in PICU. Materials and methods: This study was carried out at a tertiary care center in central India to study the utility of PELOD-2 score within 1 hour of admission to predict mortality in patients admitted in PICU. Results: Total 129 patients were included in this study with mean age of 67 months. The system with highest admission was central nervous system with 42 children and 16.6% mortality, whereas those 7 patients with hematological system involvement had highest mortality of 28.5%. The mortality rate was 15.55%. In our study for PELOD-2 within 24 hours of admission, the area under receiver operating curve was 0.87 and the Hosmer–Lemeshow test was p = 0.42. Conclusion: Pediatric logistic organ dysfunction-2 score in our study had significant association with mortality along with the Hosmer–Lemeshow goodness-of-fit test showing a good prediction of mortality.

Aims and objectives: Sedatives and analgesics are commonly used in pediatric intensive care units during minor invasive procedures. Here, we aimed to measure the changes in end-tidal carbon dioxide (EtCO₂) levels with different sedation/analgesic drug administrations (midazolam, ketamine, midazolam + ketamine/fentanyl) during central venous catheterization. Materials and methods: This prospective study included 44 patients who needed sedation/analgesia for central venous catheterization. Patients were sedated with midazolam, ketamine, or midazolam + fentanyl/ketamine. End-tidal carbon dioxide values were measured before and after sedation–analgesia with nasal cannula and recorded from the capnograph. Oxygen saturation (SO₂) was monitored by pulse oximetry. Whether respiratory depression occurred during the process was recorded. Results: During the procedure, 15 (34%) patients were given 0.1 mg/kg dose of midazolam described as group I, 18 (41%) patients were given 1 mg/kg dose of ketamine only described as group II, and 11 (25%) patients who could not be effective sedated with a single sedative–analgesic agent were given either 1 mg/kg dose of ketamine or 2 μg/kg dose of fentanyl together with 0.1 mg/kg dose of midazolam described as group III. According to our findings, hypoxia (54.5%) and hypercarbia (45.5%) were detected higher in group III but it was not statistically significant (p = 0.255, p = 0.364). Hypercarbia was detected in 29.5% patients, in 62% of these patients hypercarbia was accompanied by hypoxia, and 38% had only hypercarbia. When presedation and postsedation EtCO₂ values were compared, we detected a statistically significant difference in all groups. Conclusion: We detected hypercarbia unaccompanied by hypoxemia in 38% patients. And we think that we have identified these patients early due to measurement of EtCO₂ by nasal cannula. This study demonstrated that EtCO₂ monitoring via nasal cannula is a feasible and practical way to follow ventilation during sedation/analgesia.

Enteral nutrition (EN) has host of benefits to offer to critically ill patients and is the preferred route of feeding over parenteral nutrition. But along with the many outcome benefits of enteral feeding come the potential for adverse effects that includes gastrointestinal (GI) disturbances mainly attributed to contaminated feeds. Currently, EN is practiced using blenderized/kitchen prepared feeds or scientifically developed commercial feeds. Commercial feeds based on their formulation may be divided as ready-to-mix powder formulas or ready-to-hang sterile liquid formulas. A holistic view on potential sterility of EN from preparation to patient delivery would be looked upon. These sterility issues may potentially result in clinical complications, and hence process-related errors need to be eliminated in hospital practice, since immunocompromised intensive care unit patients are at high risk of infection. This review intends to discuss the various EN practices, risk of contamination, and ways to overcome the same for better nutrition delivery to the patients. Among the various types of enteral formulas and delivery methods, this article tries to summarize several benefits and risks associated with each delivery system using the currently available literature.

Aim: To use ultraviolet (UV) radiations in an indigenous method for sterilization of respirators for reuse during COVID-19 outbreak. Background: COVID-19 outbreak has infected more than 200 countries. In India, till now, more than 100,000 cases have been reported. Healthcare workers are at high risk of developing infections being in the frontline of taking care of COVDI-19 cases. The demands of personal protective equipment (PPE) are increasing, but the same is not matched with supply due to various reasons. In such scenarios, reusing respirators and face shields is an alternative. UV radiations have quick action and are able to preserve the quality of respirators. We have developed a UV box for surface sterilization of respirators with an intention to reuse. Technique: A thermocol box was taken from the central drug store and was fitted with two UV tubes of 254 nm wavelength procured from local service center of water purifiers. The position of the two tubes was such that one was near the base while other was fixed at the top. An aluminum mesh frame was placed in the middle of the box to act as a platform. The roof of the box was converted into a lid. The effectiveness of assembly was tested using culture of Escherichia coli and Staphylococcus aureus. In addition, a biological indicator tube containing test strip with spores of Bacillus atrophaeus was also exposed to UV light for a predefined duration, which did not show any color change after incubation for 48 hours. Conclusion: Our prototype assembly with supported efficacy from microbiological tests is an option for use of UV light within available resources for disinfection and reuse of scarce supplies of personal protective equipment. Clinical significance: UV box can help in meeting the demand supply deficit for respirators, face shields, and goggles that are paramount for the protection of HCW.

Coagulase-negative Staphylococcus (CoNS) represents one of the major nosocomial pathogen in multimorbid, immunosuppressed patients, especially with device-associated infections, often presenting with a diagnostic dilemma and aggressive antibiotic resistance. We report a case of a healthy young man with no comorbidities who succumbed to an extensive abdominal infection with Staphylococcus epidermidis and Staphylococcus schleiferi after an uneventful diagnostic procedure, despite aggressive antibiotic therapy and surgical source control. Early identification, diagnosis, and aggressive management of CoNS species is warranted depending on clinical scenario and should not be viewed as mere skin contaminants or physiological colonization.

Nicotine is one of the most easily accessible, commonly abused drugs worldwide and if taken in overdose can cause serious clinical presentation, including cardiac arrhythmias and neurotoxicity mediated through oxidative stress. Its toxicity though rare can cause sudden deaths by cardiovascular arrest, respiratory muscle paralysis, and/or central respiratory failure. Here, we describe a case of intentional fatal ingestion of nicotine sulfate decoction used as a mean for fatal suicidal attempt by a 15-year-old adolescent male who was suffering from childhood-onset depression since about 3 months. He developed drooling of saliva, syncopal attacks, paroxysmal episodes of hematemesis, abdominal pain, signs and symptoms of hypoxia, nonfatal atrial tachycardia, and encephalopathy after ingestion of heavy dose of nicotine-containing concoction; however, he recovered successfully within 24–48 hours without any significant cardiac, respiratory, or neurological deficits (except short-term verbal memory). Authors discussed the details of management and reasons behind the reversible encephalopathy and molecular mechanism of nicotine toxicity.

Generalized tonic–clonic seizures (GTCS) result in diverse physiological alterations that are mostly short-lived and rarely lead to immediate serious consequences. Some early serious complications reported are head trauma and aspiration. While most cases of seizures are diagnosed readily from clinical history, some cases remain indolent and present later. A brain hemorrhage can have varied manifestations that warrant every clinician to be vigilant in diagnosis and management to prevent life-threatening complications. Furthermore, many reports have described seizures in patients operated for subdural hematoma (SDH), but to the best of our knowledge, none reveals SDH after the seizure. We encountered an unexpected incident of severe SDH in a 32-year-old adult following witnessed GTCS.

Acute intermittent porphyria (AIP) is an acute neurovisceral porphyria caused due to inherited deficiency of porphobilinogen deaminase (also called hydroxymethylbilane synthase) (HMBS) in the heme biosynthesis pathway. AIP is rarely associated with posterior reversible encephalopathy syndrome (PRES), which is a clinicoradiological condition caused by the failure of the posterior circulation to autoregulate, resulting in cerebral edema, headaches, nausea, and seizures. AIP should be considered when a patient presents with unexplained abdominal pain and seizures. This association is important because drugs used in the management of seizures may worsen an attack of AIP. This case report describes a young woman who presented with AIP and PRES with seizures.

Introduction: Aluminum phosphide poisoning (ALP) has a high-mortality rate despite intensive care management, primarily because it causes severe myocardial depression. This case report highlights the subset of ALP patients presenting as ST elevation myocardial infarction (STEMI) with profound myocardial dysfunction and multiorgan failure and successfully treated with extracorporeal membrane oxygenation (ECMO), trimetazidine, and magnesium. Case description: A 25-year-old man without any comorbidities was brought to emergency department with dyspnea and hypotension. His electrocardiograph (ECG) revealed STEMI with elevated troponin levels, arterial blood gas (ABG) showed severe metabolic acidosis, and echocardiography (echo) revealed ejection fraction 15%. He was initiated on venoarterial (VA) ECMO in view of refractory hypotension. History of consumption of three tabs of celphos was revealed later by the family members. He progressed to cardiogenic shock, arrhythmias, respiratory failure, acute kidney injury with severe lactic acidosis, liver injury, pancreatitis, and disseminated intravascular coagulation (DIC). He was successfully supported by ECMO, hemodialysis, magnesium, trimetazidine, N-acetyl cysteine, inotropes, and blood products. He was weaned off ECMO on day 6 and was discharged home on day 12. Despite his severe and confounding clinical presentation, he had complete normalization of end-organ dysfunction with no neurological sequela. This case demonstrates the high index of suspicion required for ALP, given the potential for rapid progression and severe multiorgan toxicity. This report also highlights the importance of early referral to a tertiary care center with ECMO capability and also the role of magnesium and trimetazidine to suppress arrhythmias. Conclusion: Aluminum phosphide poisoning can present as STEMI with cardiogenic shock resulting in acute kidney injury, liver injury, pancreatitis, and DIC. Venoarterial ECMO provides an effective means of support until the recovery of organ function. Trimetazidine and magnesium are helpful in suppressing fatal arrhythmias. This report emphasizes that early recognition and early institution of ECMO can save many young lives who succumb to toxic effects of this poison.

Polymyositis (PM) is an uncommon inflammatory myopathy that affects striated muscles. It causes weakness of the limb girdles, neck, and pharyngeal muscles. We are presenting a case of PM which manifested after intrauterine death (IUD). The patient was referred to our hospital for breathing difficulty, 4 days after delivery of a dead fetus. Initially, she was treated in line of puerperal sepsis and peripartum cardiomyopathy. Patient's cardiopulmonary functions improved but she had persistent high-grade fever. Gross muscle weakness was found on day 5 of admission, involving all four limbs, predominantly in proximal muscles and she had dark colored urine. Laboratory tests revealed myoglobinuria, high serum creatine phosphokinase (CPK) levels, and high lactate dehydrogenase (LDH) levels. Polymyositis diagnosed on the basis of high CPK levels, magnetic resonance imaging (MRI) of cervical spine, electromyography (EMG), and muscle biopsy findings. We question, whether the PM could be pathogenically related to the pregnancy? Literature review of the previously reported cases of PM/dermatomyositis and our case report suggests that pregnancy can trigger the new onset of PM.

During this coronavirus disease-19 (COVID-19) pandemic, all the countries are emphasizing on procurement of more and more sophisticated machineries for the intensive care unit (ICU) like ventilators. But do all countries have to follow the same? The requirements are different for low- and middle-income countries like India, which are resource limited. The ventilators require oxygen supply and manpower to function which are deficient in these countries. These countries might do well only by procurement of oxygen delivery machinery, as most of the patients of COVID require oxygen only. Only approx. Five percent of COVID-19 patients require ventilators. Moreover, the patients on ventilators have high mortality. Thus, low-resource countries need to redefine their priority as to how to utilize their resources. This manuscript emphasizes the need for the same.

Aim: To highlight the occurrence of cardiac arrest due to hyperkalemia in diabetic ketoacidosis (DKA). Background: Diabetic ketoacidosis is a commonly encountered condition. These patients can have normal or mildly elevated levels of potassium. Our patient had severe hyperkalemia due to DKA resulting in cardiac arrest. Her high potassium diet and use of angiotensin receptor blocker along with acute kidney injury (AKI) would have also contributed to hyperkalemia. Case description: A 58-year-old female, known case of diabetes mellitus on insulin therapy and hypertension on telmisartan, presented with nausea, vomiting, and abdominal pain. She was diagnosed to have DKA with AKI precipitated by missed insulin and urinary tract infection. She was also on high potassium diet. Her electrocardiogram showed sinus bradycardia with prolonged QRS interval. Her potassium levels were elevated. She soon went into asystole and cardiac arrest and was resuscitated. Diabetic ketoacidosis protocols were followed along with antibiotics, and the patient improved. Conclusion: Severe hyperkalemia in DKA is uncommon, and this hyperkalemia resulting in cardiac arrest is an unreported scenario. Potassium correction along with DKA management protocol forms the mainstay of treatment. Clinical significance: Mild to moderate elevation in serum potassium occurs frequently in DKA. However, severe hyperkalemia is uncommon and is likely to be the result of insulin deficiency, acidosis, hyperosmolality, severe dehydration, and renal potassium retention. Such elevated level of potassium requires urgent correction in order to prevent cardiac arrest.