Emergency medicine in Ayurveda

Principles of Diagnosis and Management of medical emergencies in Ayurveda

(This article is based on a lecture delivered by Dr. Upendra Dixit, Chief consultant, Dixit Ayurveda, Goa, India., in Prof.M.S.Baghel Memorial Lecture Series on October 09, 2021.)

Contributors

Section/Chapter/topic	Concepts and Contemporary Practices -Nidana Chikitsa /Emergency medicine
Author	Dixit U.1
Reviewers	Basisht G.2
Editors	Deole Y.S.2,Basisht G.2
Affiliations	1Chief consultant, Dixit Ayurveda, Goa, India. 2Charak Samhita Research, Training and Development Centre, I.T.& R.A., Jamnagar, Gujarat, India
Correspondence email:	carakasamhita@gmail.com
Date of first publication:	December 10, 2021
DOI	Under process

The Atharvaveda quotes assurance statements by the sages to the person on the death bed.

“Do not fear. You won’t die. We will save your life. “[Atharva veda 5.30.8]

Ashtanga Hridaya quotes, Ayurveda can save the life of a person from the noose of death by using various measures. [A.Hr.Uttara tantra 44/74]

It shows that medical emergency measures were handled successfully in ancient times to save human lives. Though no science can completely assure to prevent death, the physician has to try to save a life until the last breath. The physician is required to study the management of medical emergencies to find better, safe, and cost-effective healthcare solutions to save lives.

References of emergency conditions in Ayurveda texts

The word ‘atyaya’ is used to denote destruction or death. [Chakrapani, Cha.Sa. Sharira Sthana 1/50] [Dlahana, Su.Da. Sharira Sthana 10/19-20]. The word ‘atyayika’ denotes the quickest possible treatment done to protect life without any delay. [Dallhana, Su.Sa. Sharira Sthana. 8/5] [Hemadri A.Hr.Sutra Sthana 2/33] Therefore, the medicines to be used in medical emergencies shall be ready with the physician for first aid emergency treatment, even if the patient is to be referred to higher critical care centers.

The word niratyaya explains how diet, various activities, and treatments can be performed in such a safe way that complications leading to severe consequences and emergencies can be prevented.

Medical emergencies

American college of emergency physicians has listed 1733 emergency conditions. It shows the scope of emergencies occurring in various medical fields. From this, we can understand that emergency medicine is a vast field. Ayurveda has a lot of potential to contribute to medical emergencies. However, it is not much explored in the current practices of Ayurveda. Although a few Ayurveda consultants are working in this field. Recently AVP research foundation, Coimbatore has undertaken a project on Ayurvedic emergency medicine. Not much literature is available to study the subject of management of emergency conditions through Ayurveda. A series of articles entitled ‘Basic principles of emergency treatment of Ayurveda’, published in AYU Journal written by Vaidya Mhaiskar V.B. is one of the best sources to learn this topic. Ayurveda especially Brihat Trayi (texts termed as a great triad) provides lot of references regarding emergency conditions and their treatment. Here are a few examples:

The condition of Vata dominant prameha (obstinate urinary disorders including diabetes) is incurable and has potential of causing emergency conditions. [Cha.Sa. Nidana Sthana 4/38]

The pitta dominant gulma should be treated as an emergency condition. [Cha.Sa.Chikitsa Sthana 5/114]

The cough (kasa) due to chest injury shall be treated as an emergency condition. [Cha.Sa. Chikitsa Sthana 8/134]

The erysipelas (visarpa) due to vitiation of all dosha is considered as an emergency condition. [Cha.Sa.Chikitsa Sthana 21/41]

The physician shall treat weak patients with utmost care to prevent complications. [Cha.Sa. Vimana Sthana 8/94]

In an emergency condition, one should administer the purification therapies (shodhana) with great care. [Cha.Sa.Vimana Sthana 8/127]

For understanding emergency treatment , all such references need to be compiled and thoroughly studied. The author has made efforts in this regard.

Causative factors of emergency or life-threatening condition

From all textual references, it can be understood that certain factors cause most emergencies. They are as below:

• Marma (vital organs)

• Rakta (blood)

• Oja (immunity and essence of body tissues)

• Udaka (fluid)

• Prana vayu (a type of vata dosha)

• Pranavaha Srotasa (respiratory system transporting vital air)

• Agni (digestion and metabolism)

• Udana vayu (a type of vata dosha)

• Dhatu gata avastha (state of the affliction of tissues)

• Shulopahatava ( Pain threshold or severity)

• Upadrava jushtata (comorbid conditions or complications of various diseases)

• Janapadodhwasa (epidemics and pandemic conditions)

Concept of prana in Ayurveda

The term prana is used for the vitality of life or life force. It is essential to understand the concept of prana and its importance in life-threatening emergency conditions.There are twelve sites of vitality (prana). Ayurvedic texts use the word ‘Prana’ as a synonym for certain body constituents. Prana is also used as a prefix to the names of certain body constituents.This indicates these body constituents are most vital, for saving a life. Agni, Soma, Vayu, Sattva, Rajas, Tamas, Atma and Pancha mahabhuta.[Su.Sa.Sharira Sthana 4/3]

The two temples, the three vital organs, the throat, rakta dhatu (blood), shukra dhatu (reproductive tissue), oja (the vital essence), and the anus are ten sites of life forces (prana).[Cha.Sa.Sutra Sthana 29/3]

Prana vayu is one of the five types of Vata dosha[Cha.Sa. Chikitsa Sthana28/234].Food (anna)[Cha.Sa.Chikitsa Sthana.24.60], water (udaka)[A.S.Sutra Sthana.6.11], and strength or immunity (balam) are factors influencing vitality[Dalhana on Su.Sa.Sutra Sthana 17/13].

The vitality from external sources or nature (bahya prana) and internal vitality (abhyantara prana) sustain human life. The vitality from external sources or nature is converted into internal vitality through channels of transportation and transformation of vitality (pranavaha srotasa) [Su.Sa.Sutra Sthana 17/13]. The vitality especially depends on blood tissue (rakta)[Cha.Sa.Sutra Sthana 24/4], essence (oja) (Chakrapani on Cha.Sa.Sutra Sthana28/4], digestion, and metabolism (agni)[Cha.Sa.Chikitsa Sthana15/3,4]. It is presented through sensory and motor organs (indriya)[Cha.Sa.Sutra Sthana1/48].

Injury to the umbilicus (nabhi)[Su. Sa.Sharira Sthana 7/5], channels carrying nutrient fluid (rasavaha srotasa)[Su. Sa.Sharira Sthana 9/12], blood vessels (sira) can lead to sudden death(Dalhana on Su.Sa.Sharira Sthana 7/5].

Commonly observed clinical features in an emergency:

• Acute and severe pain in vital organs like cardiac pain or abdominal pain etc. as observed in trimarmiya chikitsa chapter of charak Samhita. It is mentioned as sahasa daruna marmaruja.

• Acute hemorrhage or excessive bleeding (sahasa atyartha raktasrava)

• Dyspnoea (shvasakashta)

• Sudden loss of sensation (sahasa indriyanasha)

• Unconsciousness (sanjna nasha)

• Syncope (moorchha)

• Acute organ failure

• Clinical features of the affliction of vital organs can cause death within seven days (sadya pranahara marma) like loss of perception, sudden vomiting, excess perspiration, a sudden feeling of heaviness [A.Sa.Sharira Sthana 7/47]

The clinical features of near-death patients are described in chapters of Indriya Sthana.

Diagnostic tools

• In addition to the above clinical features, arishta or fatal signs observed in the patients are tools to diagnose emergency conditions. These appear suddenly, without any known cause, with the constantly deteriorating condition of the patient.

• Changes in breathing patterns or respiration can indicate emergency conditions. Guidelines about this can be referred from the clinical features of affection of channels of transportation and transformation of prana (pranavaha srotasa). [Cha.Sa. Vimana Sthana 5/8]The patterns of respiration are described under types of shwasa like maha (a type of shwasa disease), urdhva (a type of shwasa disease) and chhinna (a type of shwasa disease) shwasa [Cha.Sa.Chikitsa Sthana 17] can be studied to understand emergency conditions resulting into death.

• Dehydration status – can be understood from the clinical features of affection of channels of transportation and transformation of udaka (udakavaha srotasa). [Cha.Sa.Vimana Sthana 5/8]

• Consequences of excessive emesis and purgation (atiyoga of vamana and virechana) are described showing emergency conditions. Effects ranging from mild degrees like dryness in the throat to severe effects like dilatation of pupil as precursor to death are described. [A.Sa.Sutra Sthana 27/20]

• Status of consciousness and orientation

Consequences of the affliction of marma

Injury to different vital structures (marma) can have various consequences. Certain marma called 'sadyopranahara marma’ can lead to death instantaneously or within a week. General signs and symptoms can guide about injury to marma, and accordingly the patient can be cared for. The clinical features are numbness of the body (deha supti), heaviness, confusional state, desire of cold things, excess perspiration, syncope, vomiting, dyspnoea, [A. Sa. Sharira sthana 7/47]

Injury to marma causes vasodilatation and profuse bleeding. This may lead to death. [A.Hr.Sharira Sthana 4/65]

Clinical assessment - Nadi (pulse examination)

Texts like Yogaratnakar etc. describe pulse examination. Here certain readings about pulse can indicate emergency conditions and imminent death of the patient. E.g. the pulse is irregular and unstable in case of emergency conditions. [Yoga Ratnakar] The other clinical parameters can be implied to assess critical conditions.

Life-threatening conditions

Certain diseases are specifically mentioned as resulting in death. In this regard, the following chapters shall be studied in depth to understand critical conditions in Ayurveda.

• Jwara specifically sannipatika jwara (due to combination of all dosha) [Cha.Sa.Chikitsa Sthana 3]

• Shwasa and Hikka (respiratory failure) [Cha.Sa.Chikitsa Sthana 17]

• Sanyasa (coma) [Cha.Sa.Sutra Sthana 24]

• Visarpa (eryspelas) [Cha.Sa.Chikitsa Sthana 21]

Medical ethics in critical conditions

The patient on the death bed may not survive due to his predestined life span. However, the physician shall treat the patient till the last breath with a hope of life. Proper consent shall be taken from the close relatives of the patient after informing them of details about the critical condition. [A.Sa.Sha.7/75]

Management of emergency conditions

The principles of management of emergency conditions include:

• Protecting prana and marma (vital organs and structures) especially heart, brain, and urinary system

• Use of antidotes or medicines used in poisoning (agada)

• Protection and enhancement of oja (essence) and strength or immunity (bala)

• Protection and maintenance of digestion and metabolism (agni)

• Protection of sensory and motor organs (indriya) that are sites of consciousness (chetana)

Emergency medicine kit

A kit of potent Ayurveda medicines shall always be ready with the physicians. It consists of the following:

• Honey

• Ardraka sattva or ginger juice

• Levigating stone

• Suvarna sutashekhara pottali

• Hemagarbha pottali

• Trailokya Chintamani rasa pottali

• Other life-saving medicines and instruments

To make proper use of these medicines to save the life of the patients, it is necessary to understand the exact mode of action of these medicines. With such knowledge, the physician can select appropriate medicine in the appropriate conditions. Here is a summary of the mode of action of these three most important medicines-

1. Hemagarbha

• The veiling of tamas (inertia) on intellect (buddhi) and mind (mana) is removed and consciousness is regained and maintained.

• Indriya (sense organs) are activated.

• Chhedana (pertusion) of kapha dosha removes obstruction in the movement of vata dosha

• Restore normal movement of vata, by correcting avasada (slackening) – especially of prana, udana, and samana.

• Maintains and increases heart rate, pulse rate, and heart rate in case of avasada (slackening)

• Activates and promotes agni (deepana)

• Specially used in Shlaishmika (kapha dominant), Antrika (intestinal affliction), and shvasanaka sannipata (respiratory affliction), tamaka-maha and urdhva shvasa, sanyasa etc.

2. Trailokyachintamani rasa

• Removes the veiling of abnormal kapha dosha

• Restores normal movements of vata dosha, by correcting avasada(slackening)

• Agni- dhatvagni deepana ( activates- ignites agni)

• Instantaneously increases oja

• Destroys visha(~ poisons/toxins)

• Protects heart and senses

• Specially used in shlaishmika and shvasanaka sannipata.

• Hridroga caused by obstruction of channels (srotas) by kapha, ama, etc., Also in Hridroga caused by sudden depletion of oja or psychological factors like grief etc.

• By controlling actions of prana, activities of senses(indriya) are maintained, Avasada(slackening) is removed, which controls and maintains normal functions of the heart and lungs.

• Provides immediate relief in hritshoola(angina)

• Controls actions of vyana, thereby the actions of muscles

• Vishanashaka (destroys toxins)

• Specially used in critical conditions of hemiplegia (pakhaghata) and other vata dominant vyadhi, in patients with severe debility

3. Suvarna Sootashekhara

• Best medicine for restoring the normalcy of all three dosha.

• Maintains and regulates normal functions of all five types of vata dosha.

• By regulating actions of prana, regulates functions of senses(indriya), mind(mana), and intelligence(buddhi)

• By regulating the actions of prana, regulates heart and respiration rate.

• By regulating actions of samana, causes agni deepti(activates- ignites agni), regulates secretions of pitta dosha, regulates gastrointestinal motility, regulates assimilation, separation, and absorption process (sarakitta vibhajana)

• Samana, regulates sweating and maintenance of body temperature and energy levels.

• Vyana, regulates circulation, sweating and bleeding process, movements of muscles, and other physical activities.

• Apana, regulates defecation, micturition, etc. processes.

• Performs pachana of sama pitta, especially with amla, drava, and visra guna.

• Controls kapha

• Destroys visha(~ poisons/toxins)

These pharmacological activities are observed in clinical experiences. More research on experimental models can be done on these medicines. Usually, these medicines are levigated on a specific levigating stone and applied on the gums of unconscious patients. For levigation, a small drop of honey and in specific conditions, 2-3 drops of ginger juice are used. The medicine is in minute quantity, so chances of entering into the respiratory tract are minimum. The medicine starts showing its actions within a few seconds. Many of such patients are in the intensive care unit (I.C.U.), on monitors. In such patients, the changes in heart rate, blood pressure, respiratory rate, etc. are observed instantaneously. Eg. The hemagarbha pottali was observed to instantaneously increase heart rate and improve the rate of respiration after application on gums in intensive care patients. Further research is needed to study the exact mode of action of these medicines.

Ayurveda has described the criteria for prognosis of patients. Charaka Samhita presents a separate section on the prognosis of the patients and specific signs and symptoms observed in the critical patients (arishta), indicating certain death in the near future. In such patients, a complete cure is not possible. But even in these patients, it is observed that the life span can be extended for some time with Ayurvedic emergency medicines. If such signs and symptoms(Arishta), are not observed, the patient can survive for a longer period.

Importance of food

Food plays an essential role in maintaining vitality in critical conditions. If the food is not given as per the digestive capacity (agni) of the patient, then it leads to the formation of toxic metabolites (ama). This further blocks the channels of transportation of nutrients (srotasa) and worsens the condition. Therefore, easy-to-digest food like green gram soup (mudga yusha) is advisable to be given in critical cases. The wholesome food that is suitable to the patient and helpful in treating underlying disease conditions is advised.

Experience-based evidence

It is difficult to maintain documentation of all cases while managing emergency medical conditions because the priority of the physician at that time is to save the life of the patient. There are further limitations to access case records of the patients from hospitals. The author has tried to maintain the records, as far as possible. The author has treated more than 170 critical patients in intensive care units of various hospitals in Goa and outside. In many of these patients, when the ongoing modern medical treatment was not showing the desired effects, Ayurvedic treatment was given as an adjuvant. Some patients were treated with Ayurvedic treatment only. Even during the pandemic of SARS COVID 19, around 40 patients showed better improvement when Ayurvedic treatment was given as an adjuvant to the modern medicines

Acute conditions

Ayurveda has the potential to treat various acute conditions. For this, various methods of management and quick-acting medicines are available. The author has experienced various such conditions like high fevers, acute asthmatic exacerbation, hiccups, hypertension and hypotension, diarrhea including cholera, and gastroenteritis. In such acute conditions, it is experienced that Ayurveda has quick-acting medicines by which improvements can be observed right from the first dose, and within a few minutes changes are noted.

Case reports of critical cases

Following case reports are available with necessary investigation reports, discharge summaries and videos wherever necessary.

Case 1

A 68-year-old male patient with a history of hypertension for 10 years, alcoholic liver disease, cirrhosis, and adenocarcinoma of stomach was treated with ayurvedic treatments. He was in a comatosed state after suffering from seizures, cerebrovascular stroke due to intracranial hemorrhage, and hemiplegia. He was not responding to modern treatment in the hospital ICU, therefore was taken for home care treatment. Then onwards he was only on Ayurvedic treatment. The patient was treated with medicines like sutendra rasayana with honey, Arpisa rasayana, a combination of dhatri, raktapachaka and dhamasa . tapyadi loha, swarna raja vangeshwara rasa, haridra ghana, kukkuta nakhi, rasa sindura with honey. The patient regained consciousness in three to four days and was relieved of major symptoms. He survived for more than one and a half years.

Case 2

A thirty-year old male patient suffered from a road traffic accident. He was in a coma due to traumatic brain injury. The injury included 10x,2x deep lacerated wound on right side forehead, brain contusion at the frontal lobe, and intraventricular bleeding on the right side. Since he was not responding to ongoing treatment in the ICU, in addition to the conventional treatment, the patient was treated with Ayurvedic medicines like swarna sindoora (30 mg) mixed with haridra ghana and honey applied on the gums of the patient. The patient became semiconscious in two days and improved in orientation, too. The patient was further treated with Yogendra rasa (60 mg). He regained consciousness and recovered completely.

Case 3

A 43-year-old male patient suffered from skull and facial bones fractures due to a road traffic accident 10 years ago. He suffered from epilepsy and was taking treatment. The patient-reported history of excess mental stress, excess fasting (paryushana upavasa in the Jain tradition), anorexia, and anger. He suffered from convulsions and became unconscious due to intracerebral hemorrhage of 7.9 x 5.6 cm size in right temporoparietal region. Fever and sepsis-like conditions were observed. Since he was not responding to the ongoing ICU treatment, he was treated with Ayurvedic medicines like sindura bhushana mixed with haridra ghana every four hours applied on gums. Medicated water processed with gold (Suvarna siddha jala) and green gram soup was given to the patient through Ryle’s tube. Jaymangal rasa and guduchi ghana was added to treat fever. The fever subsided in one day and subsequently, the patient started maintaining oxygen levels. The life support system was taken off. The orientation and consciousness improved significantly in a week of treatment. Arpisa rasayana, Jaymangal rasa, vara, and raktapachaka medicines were continued for the next two weeks, till the complete recovery of the patient. Significant clinical improvement in neurological functions was observed in this patient. The patient recovered completely and he is well to date.

Case 4

During May and June 2021, the author treated more than 30 ICU patients of COVID 19. Here, Ayurvedic treatment was given as adjuvant treatment, along with the ongoing ICU treatment. It was observed that with adjuvant Ayurvedic treatment, the patients had better and quicker improvement and better survival chances.

A 72 years male patient with h/o DM, HTN, IHD, PTCA was COVID +_ve, admitted in the hospital with HRCT score 17/25, CORAD scores 6, and SPO2 84. He was suffering from high fever, breathing difficulty, and severe debility. Since expected improvement was not observed even after 9 days of conventional treatment, Ayurvedic treatment was started as an adjuvant. Sootashekhara with Vasa, Haridra, Kantakari, Saptaparnadi thrice a day was prescribed. Triphala with Arogyavardhini and Rasapachaka were given in between meals. Jayamangal Rasa with Rasaka was given two times in the morning and evening. Fever subsided within 2 days. After which, mahalakshmivilasa was added. He started maintaining O2 levels and the mask was removed within 6 days. He recovered completely.

There is a wide scope of research on the role of Ayurveda medicines in the treatment of critical and medical emergency conditions. It can be helpful to provide a safe, cost-effective, and better solution to extend life with a higher survival chance.

References