ObjectiveWe 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.MethodWe 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.ResultsIn 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.ConclusionOur 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.

Introduction Motorcycles are an inexpensive and popular mode of transportation in Karachi, Pakistan, despite the increasing number of motor vehicle injuries. Although motorcycle-related injuries have been studied previously, to our knowledge, there are no published reports on the orthopedic injuries associated with motorcycles crashes. Methods We conducted a cross-sectional study of medical records of patients with motorcycle-related injuries in 2015, at the Aga Khan University in Karachi, Pakistan. We reviewed the patient demographic and medical data, helmet use, the Glasgow coma score, the spectrum of injuries, length of stay, specific injury diagnosis, and final disposition of patients. Data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY). Results We identified 450 motorcycle crash injuries. Ninety percent of these victims were males, and 81% were driving at the time of the crash. More than 50% of crashes involved patients age under 29 years, and most crashes (35%) involved patients in the third decade of life. We observed that 6.8% of accidents involved patients younger than 10 years of age. For all the motorcycle-related injuries, 45% occurred during the weekend (Saturday and Sunday). Helmets were worn by only 7% of patients. The most common types of collisions were motorcycle versus car followed by lone motorcycle fall. Of the injuries sustained, the cumulative frequency of orthopedic injuries was the highest (63%), of which 34% were lower limb injuries and 29% were upper limb injuries. The second highest frequency of injuries were head injuries (46%). We also found that 85% motorcycle injury victims sustained fractures. Conclusion The frequency of motorcycle-related injuries was high among young adults, and closed fractures of the lower limbs were the most common orthopedic injuries related to motorcycle crashes. Use of helmets among motorcyclists needs to be reinforced to prevent head injuries. We suggest motorcyclists to use protective clothes and motorcycle sidebars to prevent fractures of the lower limb. Further research is needed to determine the type of fractures, type of head injuries, surgical interventions required, and morbidity and mortality in motorcycle-related injuries and whether designing separate lanes for motorcycles will reduce the burden of these injuries on the healthcare system.

BackgroundOrthopedic surgeries are usually associated with excessive blood loss which leads surgeons to overestimate need for blood transfusions and over ordering of blood. The cross matched blood, when not used, leads to the wastage of blood bank resources in terms of time, money and manpower. The objective of this study was to investigate the compliance to previously proposed MSBOS and to provide updated recommendations for all orthopedic procedures.MethodsA retrospective analysis was conducted between 1st June 2015 and 31st May 2016. Patients admitted to the orthopedic surgery service for whom blood products were requested were included. Cross Match/Transfusion (CT) Ratio, Transfusion Index and Transfusion Probability were calculated. Values of < 2.5, > 0.5 and > 30% respectively, were taken as standards. Maximum Surgical Blood Ordering Schedule (MSBOS) was proposed based upon these calculations using Mead’s criteria.ResultsSix hundred and ninety-nine patients were sampled after implementing exclusion criteria. The overall CT ratio was 4.87, transfusion index was 0.55 and transfusion probability was 25%. A compliance rate of 24.6% was observed with the reference CT ratio of 2.5. Highest CT ratio was calculated for arthroscopic procedures while tumor resection had the lowest ratio. Age, procedure performed, ASA status and use of tourniquet were found to be significantly associated with CT ratio being greater or less than 2.5.ConclusionResults showed significant wastage of blood products and non-compliance with blood ordering guidelines. Hence there is need for large scale prospective studies to establish MSBOS and ensure its compliance.

Background: CO 2 narcosis, often induced by injudicious use of oxygen and opioids, may result in ICU admission, intubation and additional costs. The development is insidious. Currently, there is no method for early detection. Methods:A retrospective cohort study of patients with hypercapnia admitted between June 2013 and June 2016 to a single hospital was performed. Presence of pre-defined CO 2 narcosis was determined on chart review by agreement of two reviewers. Patients were divided into derivation and validation groups, and a scoring system for prediction of CO 2 narcosis was developed and verified.Results: 607 patients with significant hypercapnia (PaCO 2 >50 mmHg) were identified, and 188 were determined to have CO 2 narcosis. Initial serum bicarbonate, use of supplemental oxygen, use of opioids, and BMI were found to be independent predictors. A CO 2 narcosis scoring system (0-7 points) was developed in the derivation group and then verified. The scoring system stratified patients into low risk (0-2 points, 0% likelihood), intermediate risk (3-4 points, 11-27% likelihood) and high risk (5-7 points, 52-100% likelihood). Patients with CO 2 narcosis have a higher probability of ICU admission, intubation and prolonged hospital stay. Judicious use of oxygen and opioids, and early interventions based on this risk stratification scheme, might prevent this condition. Conclusion:This CO 2 narcosis scoring system might be useful for prediction and risk stratification of CO 2 narcosis.dioxide (PaCO 2 )>50 mmHg on arterial blood gas (ABG) testing; (2) adults ≥ 18 years old; and (3) inpatient status. Exclusion criteria were:(1) venous blood gas samples; (2) erroneous data entry; (3) index PaCO 2 obtained immediately after cardiac arrest; (4) actively dying patients; and (5) intubation with mechanical ventilation.

We present a rare case of unilateral anterior jugular venous phlebectasia in an 82-year-old female patient presenting as a soft cystic lump in the anterior aspect of the neck increasing in size during straining and valsalva manoeuvre. Although cases of internal and external jugular phlebectasia have been reported, as far as we are aware no case of anterior jugular phlebectasia has been reported in the literature previously.