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 Table of Contents    
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 4  |  Issue : 4  |  Page : 494-500
Designing, managing and improving the operative and intensive care in polytrauma


1 Departments of Anaesthesiology & Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
2 Departments of Obstetrics & Gynaecology, Gian Sagar Medical College and Hospital, Banur, Punjab, India
3 Department of Community Medicine, Gian Sagar Medical College and Hospital, Banur, Punjab, India
4 Departments of Maxillofacial and Oral Surgery, Gian Sagar Dental College and Hospital, Ram Nagar, Banur, Punjab, India

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Date of Submission24-Nov-2010
Date of Acceptance24-Feb-2011
Date of Web Publication24-Oct-2011
 

   Abstract 

Background and Context : Polytrauma is a leading cause of mortality in the developing countries and efforts from various quarters are required to deal with this increasing menace. Aims and Objectives : An attempt has been made by the coordinated efforts of the intensive care and trauma team of a newly established tertiary care institute in designing and improving the trauma care services to realign its functions with national policies by analyzing the profile of polytrauma victims and successfully managing them. Materials and Methods : A retrospective analysis was carried out among the 531 polytrauma admissions in the emergency department. The information pertaining to age and gender distribution, locality, time to trauma and initial resuscitation, cause of injury, type of injury, influence of alcohol, drug addiction, presenting clinical picture, Glasgow Coma score on admission and few other variables were also recorded. The indications for various operative interventions and intensive care unit (ICU) admissions were analyzed thoroughly with a concomitant improvement of our trauma care services and thereby augmenting the national policies and programs. A statistical analysis was carried out with chi-square and analysis of variance ANOVA tests, using SPSS software version 10.0 for windows. The value of P<0.05 was considered significant and P<0.0001 as highly significant. Results : Majority of the 531 polytrauma patients hailed from rural areas (63.65%), riding on the two wheelers (38.23%), and predominantly comprised young adult males. Fractures of long bones and head injury was the most common injury pattern (37.85%) and 51.41% of the patients presented with shock and hemorrhage. Airway management and intubation became necessary in 42.93% of the patients, whereas 52.16% of the patients were operated within the first 6 hours of admission for various indications. ICU admission was required for 45.76% of the patients because of their deteriorating clinical condition, and overall,ionotropic support was administered in 55.93% of the patients for successful resuscitation. Conclusions : There is an urgent need for proper implementation ofpre-hospital and advanced trauma life support measures at grass-root level. Analyzing the profile of polytrauma victims at a national level and simultaneously improving the trauma care services at every health center are very essential to decrease the mortality and morbidity. The improvement can be augmented further by strengthening the rural health infrastructure, strict traffic rules, increasing public awareness and participation and coordination among the various public and private agencies in dealing with polytrauma.

Keywords: Accidents, intensive care, polytrauma, resuscitation, triage

How to cite this article:
Bajwa SS, Kaur J, Bajwa SK, Kaur G, Singh A, Parmar S S, Kapoor V. Designing, managing and improving the operative and intensive care in polytrauma. J Emerg Trauma Shock 2011;4:494-500

How to cite this URL:
Bajwa SS, Kaur J, Bajwa SK, Kaur G, Singh A, Parmar S S, Kapoor V. Designing, managing and improving the operative and intensive care in polytrauma. J Emerg Trauma Shock [serial online] 2011 [cited 2018 Dec 10];4:494-500. Available from: http://www.onlinejets.org/text.asp?2011/4/4/494/86642



   Introduction Top


The growing number of vehicles in India has outpaced the planning, construction and widening of roads. The increased congestion on these narrow roads has led to increased spurts in the number of accidents, accounting for almost 7% of the world's total accidents. Patients succumbing to the injuries sustained during these accidents have pushed polytrauma among the top 10 leading causes of mortality in our country. [1],[2],[3] The northward going statistics of polytrauma adds to the burden on health care resources of various hospitals. The scarce resources and efforts spent on these patients prove to be futile many a times because of delayed admission, lack of proper pre-hospital care and associated complications which cause irreversible damage. [4] The altered patho-physiological state due to hemorrhage, associated head injuries, cardiothoracic trauma, neurogenic or distributive shock leads to a wide spectrum of complications like ischemia, reperfusion injury, tissue hypoxia and metabolic acidosis which ultimately affects multiorgan physiological functions. [5]

Mortality and morbidity statistics are not just limited to delay in admission, but certain other factors also influence and determine the various treatment patterns and intervention strategies. The biggest of them all is the lack of awareness and implementation of pre-hospital trauma life support (PHTLS) guidelines. The implementation and execution of the various modalities to tackle the ever growing challenges of polytrauma are far behind the desired pace of their functioning. The existing system of polytrauma care management is quite rudimentary and mainly confined to densely populated areas of cities. [3],[6] Though several scoring systems have been formulated to assess the severity of injuries in these polytrauma patients, there is no general consensus among the priorities of different scores. The triage has to be carried out on patient to patient basis in the majority of instances. Due to the nature of injuries in polytrauma, there is often a conflict among clinicians of different specialities in adopting a particular patient to their respective units. The scenario is quite common even in the large institutions where no special department for trauma care exists. Ultimately, it leads to a major delay in carrying out appropriate decision and intervention for the urgently required treatment. [7]


   Materials and Methods Top


After obtaining the permission from the concerned authority of the institution, the hospital records of all the 531 patients admitted with polytrauma in the emergency department from 20 December 2006 to 31 August 2010 were checked. The information pertaining to age and gender distribution, locality, time to trauma and initial resuscitation, cause of injury, type of injury, influence of alcohol, drug addiction, presenting clinical picture, Glasgow Coma score (GCS) on admission and few other variables was also recorded. A retrospective statistical analysis was carried out for all the patients who sustained polytrauma and who either underwent emergency operative procedure or were directly admitted to intensive care unit (ICU) from the emergency or after the operative procedure.

At the time of admission to emergency ward, all the patients were examined simultaneously by the doctors of concerned speciality, and they were the part of the hospital trauma team. The trauma team at our institute comprises an anesthesiologist, neurosurgeon, orthopedician, general surgeon, and emergency physician, besides the well-trained paramedical staff and personnel who have been given special training in the trauma and disaster management.

After the initial resuscitation, all the relevant investigations were carried out as per the institution protocols. These protocols were an amalgamation of various scores and guidelines such as injury severity score, GCS, advanced trauma life support guidelines, etc. The radiological and other investigations as well as deteriorating clinical parameters were the chief determinants for various immediate operative interventions. The main criteria for ICU admission comprised compromised airway/respiratory difficulty, GCS less than 12, deteriorating clinical condition and the clinical assessment by the intensivist.

The methodology of treatment in ICU was basically supportive and symptomatic besides mechanical ventilation as and when required. Strict vigil monitoring, both invasive and non-invasive, was carried out on a patient to patient basis, which included non-invasive blood pressure (NIBP), pulse oximetry (SpO2), heart rate (HR), respiratory rate (RR), ECG, central venous pressure (CVP) and occasional arterial line, depending upon the specific requirement in a particular patient. All the routine and specific investigations were carried out in the ICU everyday as per the clinical condition of the patients. The treatment comprised antibiotics, gastric prophylaxis drugs, other supportive medications, fluids, enteral and parenteral nutrition, blood and its component therapy, general nursing care, etc., all of which were given after a thorough discussion with the attending team of doctors.

At the end of study, all the data were compiled and arranged systematically. A statistical analysis was carried out with chi-square and analysis of variance (ANOVA) tests, using SPSS software version 10.0 for windows. The value of P<0.05 was considered significant and P<0.0001 as highly significant.


   Results Top


A total of 1963 trauma patients were admitted to the emergency ward of our institute from 20 December 2006 to 31 August 2010. Out of these, 531 were polytrauma patients who sustained fractures of long bones, head injury, chest injury or internal organ injury. Majority of these cases were of roadside accidents that were brought either by relatives and friends or by the passerby and police personnel. In majority of the cases, trauma ambulance of our institution was pressed into service. The demographic profile of these polytrauma patients is as shown in [Table 1].
Table 1: Demographic characteristics of the polytrauma patients


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The demographic profile of our patients throws a light on some significant facts. The number of patients who suffered roadside accidents was significantly higher (65.34%) in the age group of 15-35 years (P<0.0001). The male gender predominance (92.84%) among these victims was highly significant statistically (P<0.0001). Another finding of statistical significance (P<0.0001) was that majority of these victims (63.65%) belonged to rural background. The mean time for initiation of resuscitative efforts from the time of injury was estimated at about 31.68 min with a standard deviation of 7.42 [Table 2].
Table 2: Cause of injury and neurological status on admission


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The number of two-wheeler victims (38.23%) was significantly higher than the cyclists/pedestrians (26.18%) and the persons on four wheelers (24.67%) like cars, jeeps, etc., who sustained injuries during roadside accidents. There were few patients who were admitted with sustained polytrauma after a fall from a height (4.9%) or after having sustained multiple injuries due to firing of bullets, crushing by the machines or multiple stab injuries (6.02%). All these patients were reported to the police after admission from the medico-legal perspectives. The mean GCS in these patients was estimated at 9.7 [Table 3].
Table 3: Nature of injuries sustained by the patients


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The nature of injuries among these patients showed a variety of patterns. Two hundred and one patients suffered fractures of long bone and head injuries, while 41 patients suffered head injuries with maxillofacial trauma only. Eighty-eight (16.57%) patients suffered abdomino-thoracic injuries along with fracture long bones with or without cranio-facial injury component as compared to 63 (11.86%) patients sustaining blunt abdomino-thoracic injuries with or without cranio-facial trauma. Among 531patients, there were 138 patients who suffered exclusive long bones' fracture only without any other major trauma [Table 4].
Table 4: Depicting the initial clinical profile of the patient on admission


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The presenting clinical picture of these patients exhibited a huge diversity. Majority of these patients (51.41%) had severe hemorrhage and had developed a state of circulatory shock on admission. Ear, nose and throat bleeding was present in a significant percentage of population (43.50%) as also the loss of consciousness on admission. A hundred and six patients presented with chest injuries and associated breathing difficulties as compared to 87 patients with abdominal pain and evidence of internal hemorrhage. Associated pelvic fracture and spine injury component was present in 13.37 and 6.78% of patients, respectively. Majority of these patients presented with associated superficial bruises, abrasions, lacerations and external soft tissue injury [Table 5].
Table 5: Diagnostic and therapeutic interventions performed after admission in polytrauma patients


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In 228 (42.93) patients, immediate airway protection and intubation was mandatory on account of their airway trauma, respiratory distress, deteriorating clinical condition, intra-oral bleed and progressively decreasing GCS. Among the 531 admissions, immediate emergency operative intervention was required in 277 (52.16%) patients who had sustained head injuries and blunt abdomino-thoracic injuries. Delayed operative intervention was carried out for 163 patients, majority of whom had suffered long bones' fractures only. The clinical condition of 243 patients mandated ICU admission, especially in patients with severe head injuries. Chest tube insertion was necessitated in 61 patients due to the presenting pneumo-hemothorax. Conservative management was carried out in 91 patients. Immediate blood transfusion was required in 388 patients either due to presenting picture of severe hemorrhage or due to ongoing losses in the emergency trauma ward. Mild to full ionotropic support was required to maintain hemodynamic stability in 297 of the patients.


   Discussion Top


Beyond the functioning purview of the large institutions and hospitals, there are no universally established guidelines and protocols to provide a sound and effective pre-hospital care to these patients in the developing nations like India. The functional consequences of the system get reflected in patients getting least skilled care that in fact deserves the utmost attention. The disintegrated rural health infrastructure, semi-trained service providers, lack of proper diagnostic and resuscitative facilities, poor means of transportation, ineffective communication and lack of coordination among various health set-ups build up such circumstances which lead to below par care of these trauma victims. Though government of India, health ministry and medical education department have come out with various educational and training programs from time to time, unfortunately they have been successful only to a limited extent and lot is still desired to be done to strengthen these initiatives at grass-root level. Particular attention has to be paid to the adequate provision of infrastructure and facilities to strengthen the pre-hospital care as 70% of our population resides in rural areas and they receive the least benefits of our health system. Not only the polytrauma victims but also the other patients who require urgent medical attention fail to get the same due to lack of nationwide integration of our health services. In spite of so many surveys, studies and analysis which had been carried out, we are still at the same platform where we used to be about a decade earlier.

Successful resuscitation of polytrauma patients is determined by various clinical parameters, coordination among a dedicated team of doctors and paramedics, availability of specialized services including trauma intensive care facilities besides a well-developed transfusion unit. In developing nations like India, advanced trauma management infrastructure backed up by intensive care facilities is available in only a few selected health centers and 65-70% of the population residing in the rural areas is deprived of the advanced and timely provision of these services many a times. [6],[8] The concept of "TRIAGE" and "GOLDEN HOUR" in the management of patients with polytrauma takes a backseat when such patients are first attended at these peripheral public and private health centers. Even the assessment of such patients is sometimes very complicated as majority of these patients are either under the influence of alcohol or have associated head injuries. To add insult to the injury, the shortage of specialized staff and services at these health centers is responsible for the poor implementation and execution of advance trauma life saving (ATLS) guidelines, thus leading to inflation of mortality and morbidity statistics. The wide variations in the set protocols from institution to institution and the various other socioeconomic factors make it extremely difficult to implement the polytrauma guidelines of the developed nations in developing countries. [1]

Pre-hospital care is an important determinant as far as the prognosis and outcome in the polytrauma patients is concerned. [9],[10] On the lines of ATLS, PHTLS guidelines have also been formulated and various courses and training programs are being successfully carried out throughout the world. The essence of these pre-hospital trauma guidelines revolves around the basic life support and the various measures to be adopted for airway, breathing and circulation control (ABC). The ultimate goals of pre-hospital care are rapid and accurate assessment, identification of shock and hypoxemia, initiation of intervention techniques and rapid and safe transportation. [11] These guidelines have to be properly taught and disseminated at grass-root level so as to make them successful and to establish a universal protocol for trauma patients in developing countries. Many a times, these patients can be saved just by adopting the minor precautions and measures based on this PHTLS guidelines.

The one big solution is the extensive training of paramedics in the transportation and resuscitation of critically injured patients. Our institute has come out with a novel and innovative reform as we have started a 1-year international academic and practical course in critical care for technicians and paramedics in collaboration with a Canadian University. This project is the first of its kind in the country, and the basic aim is to train these primary caregivers with the best of knowledge and practices of both the developing and the developed world. We believe and hope that this will go a long way in delivering quality pre-hospital services to the patients requiring emergency care. Similar course for critical care and emergency nursing is in the pipeline manly to deal with emergency crisis and disasters. Such projects can be easily undertaken by most of the private and government institutes and will definitely provide our society an increasing number of competent pre-hospital caregivers.

Trauma centers require a properly built infrastructure to manage patients of multiple injuries and mass disaster. [12] We have tried to build our trauma ICU on the international guidelines in spite of the fact that our organization is just 4 years old. An anesthesiologist is a very important and vital part of this trauma management team which also comprisesan emergency physician, a neurosurgeon, an orthopedician and personnel from various surgical specialties. The anesthesia and intensive care staff has been well trained in dealing with polytrauma and disaster management. Majority of the patients who sustain multiple injuries often require operative intervention. The prognostic factors in these patients are influenced by the timely surgical interventions, specifically in patients with blunt abdomino-thoracic and head injuries. [13] The timely control of hemorrhage, restoration of intravascular volume and hemostasis determine the extent of morbidity and mortality in polytrauma patients. [5] Going out of the purview of guidelines, sometimes, the overaggressive approach in resuscitation of these patients can cause transfusion-related complications. [14] Thus, it becomes mandatory that polytrauma patients be handled with utmost care and clinical precision. Patients admitted with associated pelvic fractures are the most difficult to manage as the signs and symptoms of such injuries invariably simulate the intra-abdominal injuries. The diagnosis and management of such injuries in these circumstances is very challenging as one has to be clinically very sound and systematic in the assessment and examination of polytrauma patients. The most challenging aspects in the management of polytrauma patients in our country are reflected by the problems and difficulty in accessibility, affordability, timeliness, quality and rehabilitation process of these life-saving services. We have achieved greater heights in raising the standards of provision of medical services in the last two decades, but still emergencies and polytrauma management are neglected to a large extent. As a result, we have not been successful in fully implementing and executing WHO's essential trauma care guidelines in our country. [6]

The predominance of young adult males in our study affirms the fact that this age group is highly vulnerable to accidents as they are the one who are quite dynamic and mobile, especially in pursuit of jobs and earnings. [15],1[6],[17] This age group is the main breadwinner of their family, and majority of the important works, tasks and traveling chores are performed by the younger population. The enthusiastic nature and casual attitude toward safe driving makes this group quite vulnerable to roadside accidents. Another big factor is the prevalence of chronic drug addiction and alcoholism among the present youth, which is clearly shown by the statistical finding of approximately 46.70% of these polytrauma victims, who arrived in the emergency department with acute intoxication.

Majority of the polytrauma victims (63.65%) in our study belonged to the rural background. These statistics highlight one very important aspect that the entire national highways pass through the villages and the shortage of minimum safety barriers is responsible for such accidents. [8] The narrower roads, congested traffic, lack of proper driving sense and attitude, over-speeding, road rage, improper lighting of the roads, lenient legislations and laws related to the punishments for breaking the traffic rules are some of the additional factors which inflate the figures of the accidents. As majority of the population involved in accidents hails from a rural background, adequate measures should be taken at the village level, especially on the highways, to prevent this big menace which accounts for so many lives lost.

The majority of the polytrauma patients were riding on motorbikes, which again reflects the increased risk of accidents among two-wheeler riders, especially if they are driving without wearing a helmet which was a statistical finding in almost 48% of the two-wheeler victims. Though the numbers of victims were comparable between the cyclists/pedestrians and four-wheeler passengers, a statistically significant difference could not be derived from these facts. Fall from a height also accounted for 4.9 of the polytrauma patients, while stab, gunshot, machine injuries, etc., accounted for 6% of the total polytrauma patients. The construction of new massive buildings in and around the institution was mainly responsible for the accidents related to the fall from a height and machine injuries. Our institution has launched various social awareness programs in the adjoining villages for the improvement of emergency health care with coordinated efforts from the village leaders. These programs encourage increased participation of villagers in helping the timely transportation of emergency cases to the hospital, enforcing the respect for traffic laws and legislations at their respective villages, early medical assistance for drug addicts and alcoholics, encouraging blood donation practices, increased coordination in strengthening the health services at village levels, etc. Similar efforts by other health centers can tide over the present public health crisis to a large extent and can strengthen our national health programs at grass-root level. We have launched various programs and health schemes at our institute, especially for the economic backward sections, in line with national programs and missions, and the administrators are in continuous touch with the state and central governments for smoother implementation and functioning of these health benefit schemes.

The golden hour concept is very important when dealing with any type of emergency case. [6] The average mean time of arrival of these patients from the site of accident to the hospital and the beginning of initial resuscitation was 21.68 min. We have provided four ambulances to police and social organizations at various focal points for the early transportation of trauma victims, along with the helpline numbers of the hospital. The prognosis of patients with polytrauma and blunt or penetrating injuries generally gets improved if they get a timely treatment and support of intensive care facilities. [18],[19] We recorded a mean GCS of 9.7 among our patents. The lower value of GCS can primarily be ascribed to the large number of patients having been admitted with altered sensorium associated with head injuries and the alleged alcohol intake. The degree of head injury varied from mild to severe along with associated maxilla-facial trauma in quite a few patients. A large number of patients underwent emergency surgical operations within the first 6 hours. The main factors mandating emergency intervention and exploration included abdominal viscus injury and head trauma with progressively deteriorating clinical condition.

The decision for operative intervention in polytrauma patients has to be taken with absolute clinical precision keeping in mind the damage control concept. This concept dictates that the patient's clinical condition is optimized first before undertaking any operative intervention for life-threatening injuries. [4] Majority of the patients who presented with hemorrhagic shock had multiple fractures of the long bones and intra-abdominal bleed. Out of 273 patients, 37 died during initial resuscitation in spite of all the dedicated efforts our trauma team.

The management of polytrauma patients invariably requires the intensive care back-up facilities. A dedicated intensive care unit team is not just a big blessing but also an essentiality, as these multi-injuries victims require aggressive management of their clinical condition and a thorough monitoring to detect any timely complication. Achieving a clinically stable condition in these patients requires quality nursing care and skilled hands. The nursing staff in the last four years since inception of the intensive care unit has gained a lot of experience in managing polytrauma victims with an emphasis on invasive monitoring, fluid administration, blood transfusion, drug administration, temperature regulation, and general nursing care. The work culture in our ICU comprises establishing a good rapport by the doctors and the staff with the relatives of the patient. The system aims at a transparent methodology of treatment mainly achieved by a verbal communication in local vernacular about the present treatment plan and the prognosis of the patient. This has popularized the ICU treatment in the adjoining areas and has indirectly helped in improving our services as well as built a faith among the local population and has removed a negative thinking pattern attached to the results and treatment pattern in ICU. The coordination in the team work of our ICU has improved by leaps and bounds ever since it came into existence. All its team members, be it the neurosurgeon, cosmetic surgeon, maxillofacial surgeon, intensivists or any other specialist, have worked in a non-tiring manner to bring the desired results with a lot of dedicated efforts. Betterment of the patients in polytrauma injuries invariably requires a lot of cohesiveness and understanding in improving the outcome among various specialties. [20],[21]

Some of the patients who were operated for blunt or penetrating injuries did require mechanical ventilation postoperatively as they were very sick. The availability of 24-hour services of senior intensivists had further helped in building the faith among team members and improving the outcome as it ensured the delivery of quality intensive care treatment. The free availability and the round-the-clock presence of an intensivist does help in a marked reduction of mortality and morbidity in polytrauma patients. [22] Similarly, round-the-clock availability of a neurosurgeon and trauma team services has shown improved outcome in such patients as is also the case in our setting. [23],[24] Timely interventions by the concerned surgical team supported by the Intensive Care Unit result in decreased mortality, shorter hospital stay, decreased burden of ICU costs on the relatives, optimal utilization of hospital resources and minimal incidence of complications and nosocomial infections. [25],[26],[27]

Majority of our polytrauma victims were referred from the smaller private clinics after administration of primary first aid care. These nursing homes do not admit patients as such because of shortage of adequate trauma resuscitation facilities and infrastructure as well as a fear of medico-legal implications.

Even during the initial stages of the establishment of our institute, many patients left against medical advice, which revealed a lack of awareness among the lesser educated rural population, poverty and non-coordinated efforts of our hospital staff, as a result of which trauma care management team came into existence.

The rural health infrastructure has to be strengthened in regards to primary care of such patients, especially those sustaining life-threatening injuries. The necessary steps should aim at strengthening the essential procedures during this pre-hospital care which include control of bleeding, primary stabilization of fractured bones, stabilization of cervical spine, protection of airway and similar other such interventions. If these protocols and guidelines are thoroughly followed, then the application of ATL Sprinciples in tertiary care hospitals will be associated with a better prognosis and outcome in polytrauma patients. [6],[28]


   Conclusions Top


There is an urgent need for proper implementation ofpre-hospital and advanced trauma life support measures at grass-root level. Analyzing the profile of polytrauma victims at a national level and simultaneously improving the trauma care services at every health center are very essential to decrease the mortality and morbidity due to accidents. The improvement can be augmented further by strengthening the rural health infrastructure, strict traffic rules, and increasing public awareness. No matter how many studies are undertaken in defining and re-defining the profile of polytrauma patients, but the underlying one big fact is that no improvement in the management of these salvageable patients can be made without a multimodal approach and well-coordinated efforts between the government and various other agencies, both private and public. These co-ordinated efforts should aim at precise identification of the weaknesses and shortcomings in the existing polytrauma care management system and then chalk out plans and policies to effectively handle the growing menace of polytrauma at a much larger level, specifically in the rural areas.

 
   References Top

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Correspondence Address:
Sukhminderjit Singh Bajwa
Departments of Anaesthesiology & Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0974-2700.86642

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusions
    References
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