Anas Mohammed Muthanikkatt

Anisocoria following severe head injury is traditionally interpreted as an impending neurological emergency, often prompting immediate empiric intervention

Objective: To evaluate the effectiveness of a theory-informed, iterative implementation strategy (IS) to improve point-of-care ultrasound (POCUS) documentation compliance among emergency medicine (EM) residents according to American College of Emergency Physicians (ACEP) guidelines in a high-volume emergency department (ED). Methods: We conducted a 19-month (December 2023–June 2025) mixed-methods implementation study at a tertiary academic ED in India. The Consolidated Framework for Implementation Research (CFIR) and Expert Recommendations for Implementing Change guided six iterative IS phases, including education, co-design, workflow optimisation and audit/feedback. Participants were EM residents. The primary outcome was the proportion of POCUS examinations achieving ≥80% compliance with ACEP documentation standards. Compliance trends were analysed across phases and summarised using proportions and medians with IQRs. Qualitative data from five focus group discussions were analysed using CFIR to identify barriers, facilitators and mechanisms of change. Quantitative and qualitative findings were integrated using a joint display. Results: We assessed 3074 POCUS examinations. The proportion of scans achieving ≥80% compliance increased from 0% at baseline to 35.1% postimplementation. Median compliance rose from 24% (IQR 17–34) to 69% (IQR 54–84). Compliance followed a nonlinear trajectory. Initial phases showed minimal gains (0%–8.7%) due to workflow barriers. A marked acceleration occurred during IS-5 (22.5%) following the introduction of a user-designed, single multimodal form and gamification. Qualitative analysis demonstrated a shift from initial resistance (CFIR: compatibility, complexity) to normalisation (implementation climate), although technical challenges with image archiving persisted. Discussion: User-centred co-design and peer engagement were key to the improvement, although persistent infrastructure challenges limited further gains and highlighted the need for informatics-enabled solutions. This study demonstrates that low-cost, context-sensitive strategies can enhance POCUS documentation effectively in high-volume, resource-constrained EDs. Conclusions: A multifaceted, iterative IS guided by theoretical frameworks significantly improved POCUS documentation compliance. User-centred design and participatory engagement were critical mechanisms for sustainable practice change in a resource-variable EM setting. Trial registration number: CTRI/2024/03/063671.

Study Objective: We evaluated the efficacy and safety of ultrasound‐guided pericapsular nerve group (PENG) block for initial pain management in adult emergency department (ED) patients with hip fractures. Methods: This prospective, randomized, double‐blinded, controlled trial was conducted at a tertiary care academic ED. Adult patients (≥ 18 years) with traumatic hip fractures and Numerical Rating Scale (NRS) pain scores > 4 were randomized to ultrasound‐guided PENG block with bupivacaine or sham procedure. Both groups received standard intravenous analgesia. The primary outcome was the difference in NRS scores over 3 h. Secondary outcomes included total rescue analgesia (morphine equivalents) and adverse events. Results: Of 167 screened, 80 patients were enrolled (40 per group). Pain scores were significantly lower in the PENG block group at 30 min (mean difference [MD] −3.2; 95% confidence interval [CI]‐4.2 to −2.2), 60 min (MD −3.1; 95% CI −4.1 to −2.1), and 120 min (MD −2.0; 95% CI −2.6, −1.4), compared with sham. Total rescue analgesia was significantly lower in the PENG block group (MD −4.6 mg morphine equivalents; 95% CI −6.2 to −3.1). No significant adverse events were reported, such as hematoma, quadriceps weakness, signs of local anesthetic systemic toxicity (LAST), or significant opioid‐related adverse events. Conclusion: In adult ED patients with hip fractures, ultrasound‐guided PENG block significantly reduced pain scores and opioid requirements compared with sham, with no significant adverse events reported. PENG block may be an effective, opioid‐sparing analgesic strategy for acute hip fractures in the ED. Trial Registration: Clinical Trial Registry‐India: CTRI/2023/08/056595

Melioidosis is a disease endemic to India but often goes unrecognized, leading to considerable illness and death. We present the case of a 31-year-old man who had a fever of unknown origin, abnormal renal and liver function tests, and negative tests for dengue, typhoid, leptospirosis, and scrub typhus. Imaging revealed multiple splenic infarcts. Initially suspected to be malaria due to its prevalence in South India, further investigation uncovered pneumonia along with several liver and splenic abscesses, raising the possibility of melioidosis. Blood culture eventually identified Burkholderia pseudomallei, confirming the diagnosis. As malaria cases decline in Southeast Asia, emergency physicians should consider melioidosis in their differential diagnosis of acute febrile illnesses, especially in endemic areas. Early detection and prompt antibiotic treatment are vital for managing this often under-recognized disease with a high fatality rate. Thus, melioidosis should be considered in patients with unexplained fever in endemic regions, as early diagnosis and intervention can be life-saving.

Objectives: The objective was to study the effect of serial night shifts on the cognitive, psychomotor, and moral performance of emergency medicine residents of an academic Emergency Medicine Department.Methods: This prospective case‐crossover study compared emergency medicine residents' sleep time, subjective sleepiness, cognitive function, moral judgment, and psychomotor skills after 5 consecutive days versus night shifts using sleep diaries, activity monitors, and multiple performance tests. Paired t‐tests and Wilcoxon signed‐rank tests were used to analyze data based on normality. Correlation analysis was done using Spearman's correlation test. Subgroup analysis was also performed to find any difference based on gender and year of residency.Results: Twenty‐seven emergency medicine residents participated (13 males, 48.1%). The distribution across residency years was as follows: 44.4% in their first year, 25.9% in their second year, and 29.6% in their third year. Following five consecutive night shifts, total sleep duration decreased significantly from 338.1 ± 67.8 to 307.4 ± 71.0 min (p < 0.001), while subjective sleepiness scores increased from 9.6 ± 3.3 to 13.6 ± 4.6. Psychomotor performance and reaction times did not significantly differ between night and day shifts. However, working memory declined, assessed by self‐paced three‐back test scores (median [IQR] 517.1 [471.9–546.7] vs. 457.6 [334.4–508.8]; p = 0.034) and interference test scores (445.5 ± 59.9 vs. 407.2 ± 56.8; p < 0.001), along with moral judgment (median [IQR] 19 [18–28] vs. 15 [11–21]; p = 0.010) after serial night shifts. No correlations existed between performance measures nor differences based on gender or residency year.Conclusions: Residents sleep less following night versus day shifts, reporting the highest sleepiness levels after 5 consecutive nights. Despite this, psychomotor performance and reaction times did not significantly differ. However, considerable reductions occurred in moral judgment, working memory, and interference test performance after serial night shifts.

Introduction: Acquired idiopathic laryngomalacia causing dynamic airway collapse is rare in adolescents and may be overlooked because it mimics more common causes of acute dyspnoea and stridor in the emergency department (ED). Airway point-of-care ultrasound (POCUS) provides a rapid, non-invasive means to visualize dynamic supraglottic obstruction when laryngoscopy is not immediately feasible or tolerated. Case Report: A 13-year-old boy presented with sudden-onset respiratory distress and dyspnoea that worsened on lying flat and improved when sitting upright, without history of fever, trauma, allergy, or foreign body aspiration, and with similar prior self-limiting episodes. He was anxious with nasal flaring, subcostal retractions, tachypnoea, tachycardia, distended neck veins, and a squeaky tracheal inspiratory sound, yet he maintained normal oxygen saturation with equal air entry on auscultation. Airway POCUS showed abnormal downward displacement of the epiglottis with every distressful inspiration, indicating dynamic airway collapse, and non-contrast computed tomography of the neck demonstrated a heart-shaped, mid-epiglottis deformity consistent with acquired idiopathic laryngomalacia. The patient was given supportive treatment to reduce mucosal oedema, resulting in gradual symptom resolution, and after two days of observation and otorhinolaryngology evaluation he was discharged in stable condition. Conclusion: Acquired idiopathic laryngomalacia should be considered in adolescents with unexplained positional respiratory distress and discordant findings of significant work of breathing but preserved oxygenation. Airway point-of-care ultrasound can delineate real-time dynamic laryngeal abnormalities at the bedside, thereby facilitating early diagnosis and appropriate management of dynamic airway collapse in the emergency department.