Background : Bedside ultrasound (BUS) can effectively identify fractures in the emergency department (ED). Aim: To assess the diagnostic accuracy of BUS for fractures in pediatric trauma patients. Setting and Design : Prospective observational study conducted in the ED. Material and Methods : Pediatric patients with upper and lower limb injuries requiring radiological examination were included. BUS examinations were done by emergency physicians who had undergone a brief training. X-rays were reviewed for the presence of fracture and the results of BUS and radiography were compared. Statistical analysis: STATA version 11 was used for statistical analysis of the data. Results : Forty-one patients were enrolled in the study. The sensitivity of the BUS in detecting fracture was 89% [95% confidence interval (CI): 51% to 99%] and the specificity was 100% (95% CI: 87% to 100%). The positive predictive value of BUS was 100% and negative predictive value was 97%. Conclusion : BUS can be utilized by emergency physicians after brief training to accurately identify long bone fractures in the pediatric age-group.

Introduction: Trauma and injury severity score (TRISS), introduced in 1981 is a combination index based on revised trauma score (RTS), injury severity score (ISS) and patient's age. In this study we have used TRISS method to predict the outcome in trauma cases. Materials and Methods : 1000 consecutive cases of trauma of adult age group admitted in casualty of Dayanand Medical College and Hospital Ludhiana, from 1/7/2000 onwards. Revised Trauma Score, Injury Severity Score and Age Index were recorded from which TRISS was determined. The performance of TS, ISS and TRISS as predictors of survival was evaluated using the misclassification rate, the information gain and the relative information gain. Results : The majority of the patients were men (83.7%) and in the age group of 20-50 years. Road traffic collisions (72%) were the most common cause of trauma. The mortality rate was 4.1%. Using PER method, the TRISS method was found to have information gain of 0.049 and a relative information gain of 0.41. Conclusions : The revised trauma score (RTS) ranged from 2.746 to 7.8408.There was a graded increase in mortality with decreasing RTS score.

Background : This study reviews our 10-year institutional experience with damage control management and investigates risk factors for early mortality. Materials and Methods : The trauma registry of our level I trauma centre was utilized to identify all patients from 01/96 through 12/05 who underwent initial damage control procedures. Demographics, clinical and physiological parameters, and outcomes were abstracted. Patients were categorized as either early survivors (surviving the first 72 hours after admission) or early deaths. Results : During the study period, 319 patients underwent damage control management. Overall, 52 patients (16.3%) died (early deaths) and 267 patients (83.7%) survived the first 72 hours (early survivors). Early deaths showed significantly deranged serum lactate (5.81±0.55 vs. 3.46±0.13 mmol/L; P<0.001), base deficit (10.10±0.95 vs. 4.90±0.28 mmol/L; P<0.001) and pH (7.16±0.03 vs. 7.29±0.01; P<0.001) levels compared to early survivors on hospital admission. An International Normalized Ratio >1.2, base deficit >3 mmol/L, head Abbreviated Injury Scale ≥3, body temperature <35°C, serum lactate >6 mmol/L, and hemoglobin <7 g/dL proved to be independent risk factors for early mortality on hospital admission. Conclusions : Several risk factors for early mortality such as severe head injury and the lethal triad (coagulopathy, acidosis and hypothermia) in patients undergoing damage control procedures were identified and should trigger the trauma surgeon to maintain aggressive resuscitation in the intensive care unit.

Objective : To study the incidence, pattern and outcome of stab injuries attending a North London Teaching Hospital over a 3-year (2006-2008) period. Materials and Methods : A retrospective review of collected data from the Hospital database was conducted. The database contains comprehensive medical records for all patients attended by the trauma team for deliberate stab injuries. It is updated by the surgical team after each admission. All patients with deliberate penetrating injury who were attended by the service between 1 January 2006 and 31 December 2008 were identified. Patients who died in the prehospital phase, those managed exclusively by the emergency department and limb injuries without vascular compromise were excluded from the study. Results : Six hundred and nineteen patients with stab injuries (following knife crime) from North London attended the Hospital in the above period. One hundred and thirty-seven paients required surgical admission. Two were cases of self-inflicted knife injuries. Over the 3-year period the percentage of victims below 20 years of age is increasing. Ninety-three percent of knife crime occured between 6 pm and 6 am; recently moving toward week days from weekend period. Conclusions : The overall rate of penetrating injuries (stab injuries) is slowly declining. Timely cardiothoracic support facility is vital in saving lives with major cardiac stab injuries. Although alcohol drinking restriction has been lifted, most cases of stabbings are still occurring out-of-hours when surgical personnel are limited.

Background : Injuries in hands and forearms may cause significant discomfort and disability. Aim : To evaluate the accuracy of preoperative clinical examination in depicting lesions caused by penetrating wounds of hands or forearms. Setting and Design : This prospective study was conducted from August 2006 to September 2009 at Kashani University Hospital, Isfahan University of Medical Sciences, Iran. Materials and Methods : Two hundred and fifty patients with clean penetrating injury to the hand/forearm were enrolled in this study. After patient's data registration, a careful clinical examination and routine exploration without expansion of wound were done by an orthopedic resident. Each tendon was tested at each joint level. Nerves were evaluated with a two-point discrimination test, and arteries were tested with palpable pulses. Surgical exploration was done by a single hand surgeon in operation room. Accuracy of clinical examination was compared to surgical examination. Results : During the study period, 180 (72%) males and 70 (28%) females with mean age of 28±4 years participated. The preoperative examination showed a predominance of the volar zone IV injuries followed by volar zone II, III, thumb zone II, volar zone V and thumb zone III. Despite the enough accuracy of preoperative examinations in dorsal side injuries of hands and forearms (error rate = 8.3%), the preoperative examinations significantly underestimated the amount of damage to soft tissues on the volar side of hands and forearms (error rate = 14%). Conclusions : The precise surgical evaluations should be considered in patients with penetrating injury to the hand or forearm, especially in those with volar side injuries.

Background : Severe bleeding as a result of trauma frequently leads to poor outcome by means of direct or delayed mechanisms. Prehospital fluid therapy is still regarded as the main option of primary treatment in many rescue situations. Our study aimed to assess the influence of prehospital fluid replacement on the posttraumatic course of severely injured patients in a retrospective analysis of matched pairs. Materials and Methods : We reviewed data from 35,664 patients recorded in the Trauma Registry of the German Society for Trauma Surgery (DGU). The following patients were selected: patients having an Injury Severity Score >16 points, who were ≥16 years of age, with trauma, excluding those with craniocerebral injuries, who were admitted directly to the participating hospitals from the accident site. All patients had recorded values for replaced volume and blood pressure, hemoglobin concentration, and units of packed red blood cells given. The patients were matched based on similar blood pressure characteristics, age groups, and type of accident to create pairs. Pairs were subdivided into two groups based on the volumes infused prior to hospitalization: group 1: 0-1500 (low), group 2: ≥2000 mL (high) volume. Results : We identified 1351 pairs consistent with the inclusion criteria. Patients in group 2 received significantly more packed red blood cells (group 1: 6.9 units, group 2: 9.2 units; P=0.001), they had a significantly reduced capacity of blood coagulation (prothrombin ratio: group 1: 72%, group 2: 61.4%; P≤0.001), and a lower hemoglobin value on arrival at hospital (group 1: 10.6 mg/dL, group 2: 9.1 mg/dL; P≤0.001). The number of ICU-free days concerning the first 30 days after trauma was significantly higher in group 1 (group 1: 11.5 d, group 2: 10.1 d; P≤0.001). By comparison, the rate of sepsis was significantly lower in the first group (group 1: 13.8%, group 2: 18.6%; P=0.002); the same applies to organ failure (group 1: 36.0%, group 2: 39.2%; P≤0.001). Conclusion : The high amounts of intravenous fluid replacement was related to early traumatic coagulopathy, organ failure, and sepsis rate.

Aims : Minor head injury (MHI) is a common injury seen in Emergency Departments (ED). Computed tomography (CT) scan of the brain is a good method of investigation to diagnose intracranial lesions, but there is a disagreement about indications in MHI patients. We surveyed the post-traumatic symptoms, signs or past historical matters that can be used for the indication of brain CT scan. Materials and Methods : All patients with MHI who were older than 2 years, had a Glasgow Coma Scale (GCS) score ≥13 and were referred to the ED, underwent brain CT scan. Data on age, headache, vomiting, loss of consciousness (LOC) or amnesia, post-traumatic seizure, physical evidence of trauma above the clavicles, alcohol intoxication, and anticoagulant usage were collected. The main outcome measure was the presence of lesions related to the trauma in brain CT scan. For categorical variables, Chi-square test was used. Results : Six hundred and forty-two patients were examined by brain CT scan after MHI, and 388 patients (60.4%) did not have any risk indicator. Twenty patients (3.1%) had abnormal brain CT scans. The logistic regression model showed that headache (P=0.006), LOC or amnesia (P=0.024) and alcohol (P=0.036) were associated with abnormal brain CT. Conclusions : We suggested that abnormal brain CT scan related to the trauma after MHI can be predicted by the presence of one or more of the following risk indicators: Headache, vomiting, LOC or amnesia, and alcohol intoxication. Thus, if any patient has these indicators following MHI, he must be considered as a high-risk MHI.

Background : Exsanguinating hemorrhage is the major cause of death in patients with pelvic ring disruption. Aims : The aim of this study was to document outcomes after the stabilization of pelvic ring injuries by a C-clamp and control of hemorrhage by pelvic packing. Physiological parameters were tested as prognostic factors. Setting and Design : This was a retrospective study at a level I trauma center. The study period was from January 1996 to December 2007. Materials and Methods : Fifty patients with pelvic ring disruption and hemorrhagic shock were analyzed. The pelvic rings were fixed by a C-clamp, and patients with ongoing hemorrhage underwent laparotomy and extra- and/or intra-peritoneal pelvic packing. Clinical parameters (heart rate, mean arterial pressure) and physiological parameters (lactate levels, hemoglobin, hematocrit) were documented at admission and at different time points during the initial treatment (1, 2, 3, 4, 6, 8, and 12h after admission). Results : Within 12 h of admission, 16 patients died (nonsurvivors) due to hemorrhagic shock (n=13) or head injuries (n=3). In this group, 12 patients underwent laparotomy with pelvic packing. Thirty-four patients survived the first 12 h (early survivors) after fixation by a C-clamp and additional packing in 23 patients. Four of these patients died 12.3±7.1 days later due to multiple organ failure (n=3) or severe head injury (n=1). The blood lactate level at admission was significantly higher in the group of nonsurvivors (7.2±0.8 mmol/L) compared to the early survivors (4.3±0.5 mmol/L, P<0.05). While hemoglobin values improved within the first 2 h in nonsurvivors, lactate levels continued to increase. Conclusion : Pelvic packing in addition to the C-clamp fixation effectively controls severe hemorrhage in patients with pelvic ring disruption. Early sequential measurements of blood lactate levels can be used to estimate the severity of shock and the response to the shock treatment.

Aim : There has been a steep rise in incidence of liver injury in the past few years because of increase in incidence of road traffic accidents. The aim of this study was to evaluate the role of non-operative management of liver injury due to blunt abdominal trauma. Materials and Methods : All patients with liver injury from blunt trauma abdomen were studied between January 2000 and January 2010. A total of 152 patients with liver injury were put on conservative management. Hundred and three (67.77%) patients were males and 49 (32.23%) were females with an age range of 15-60 years (32.8 years). Most of the injuries were because of road traffic accidents (81.57%). Liver injuries were graded according to Moore's classification using computed tomography. Patients with Grade V and VI were excluded from the study. Patients who were unstable hemodynamically on admission were also excluded from the study. Results : There was no mortality in our series. Eight patients needed exploration because they developed hemodynamic instability. Four of the patient developed post-operative liver abscess which was treated conservatively. Conclusion : Non-operative management of liver injury due to blunt trauma abdomen is a safe, effective and treatment modality of choice in hemodynamically stable Moore's grade I to Grade IV injury.

Introduction : Critically ill patients are common in emergency medicine, and require expert care to maximize patient outcomes. However, little data is available on the provision of critical care in the ED. The goal of this study is to describe the management of critically ill patients in the ED via a survey of Canadian emergency physicians. Materials and Methods : A survey of attending physician members of CAEP was conducted by email. The survey was developed by the authors and internal validity was established prior to survey deployment. Data on physician demographics, hospital resources, use of invasive procedures, vasopressor/inotropic medications, length of stay in the ED and patient responsibility were assessed. Results : The survey response rate was 22.9%, with the majority of respondents possessing speciality training in EM (73.5%). Respondents indicated that critically ill patients were commonly managed in the ED, with 68.5% reporting >6 critically ill patients per month, and 12.4% indicating > 20 patients per month. Respondents indicated that the majority of critically ill patients remained in the ED for 1-4 hours (70%) after resuscitation, yet 18% remained in the ED for >5 hours. Patients with a "respiratory" etiology were the most common critically ill patient population reported, followed by "cardiovascular", "infectious" and "traumatic illness". Direct laryngoscopy was frequently performed (66.9%> 11 in the year prior to the survey) in the year prior to the survey, while other invasive procedures and vasopressor/inotropic medications were utilized less often. EM physicians were responsible for the management of critically ill patients in the ED, even after consultation to an inpatient service, and were often required to provided acute care to critically ill patients admitted to an ICU, yet remaining in the ED prior to transfer (20% reported > 50% of the time). Conclusion : Our survey demonstrates that critically ill patients are common in Canadian ED's, and that EMP's are often responsible to provide care for prolonged period of time. In addition, the use of invasive procedures other then direct laryngoscopy was variable. Further research is warranted to determine the impact of delayed transfer and ED physician management of critically ill patients in the ED.

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.

Understanding the basic physics of ultrasound is essential for acute care physicians. Medical ultrasound machines generate and receive ultrasound waves. Brightness mode (B mode) is the basic mode that is usually used. Ultrasound waves are emitted from piezoelectric crystals of the ultrasound transducer. Depending on the acoustic impedance of different materials, which depends on their density, different grades of white and black images are produced. There are different methods that can control the quality of ultrasound waves including timing of ultrasound wave emission, frequency of waves, and size and curvature of the surface of the transducer. The received ultrasound signal can be amplified by increasing the gain. The operator should know sonographic artifacts which may distort the studied structures or even show unreal ones. The most common artifacts include shadow and enhancement artifacts, edge artifact, mirror artifact and reverberation artifact.

Ultrasound is a modality now available to all physicians and can help in making rapid decisions, particularly with critically ill patients. This article reviews the basis of the use of sonography for the diagnosis of pneumothorax.

Pregnant women are at an increased risk of a number of conditions that are associated with bleeding. Conditions such as ectopic pregnancy, retained products of conception, placenta previa, abruptio placentae, morbid adhesion of the placenta, and postpartum hemorrhage can be associated with massive bleeding that endangers the maternal life and health. Screening, early detection, and prevention play a key role in reducing maternal morbidity and mortality caused by these conditions. Ultrasound, in experienced hands, is an effective tool that can assist in diagnosing many of these obstetrical conditions. The advances in technology and the non-invasive nature of ultrasound examination have made it popular in our daily obstetrical practice. The review discusses the role of ultrasound in the most common life-threatening conditions during pregnancy.

Detection of intraperitoneal free air is important for the diagnosing of life-threatening conditions in patients with acute abdominal pain. Point-of-care ultrasound is an extension of the clinical examination in patients presenting with acute abdomen. Failure of sonographers to detect intraperitoneal free air was clinically considered as a limitation of abdominal ultrasound. It is now increasingly appreciated that ultrasound may detect intraperitoneal free air. Emergency physicians should be familiar with the sonographic features of intraperitoneal free air which may be essential to recognize bowel perforation. Herein we review the literature on the sonographic findings of intraperitoneal free air and the technical manoeuvres that can improve clinicians' detection of intraperitoneal free air using point-of-care ultrasound.

Duodenal perforation following blunt abdominal trauma is an extremely rare and often overlooked injury leading to increased mortality and morbidity. We report two cases of isolated duodenal injury following blunt abdominal trauma and highlight the challenges associated with their management. In both these patients, the diagnosis of the duodenal injuries was delayed, leading to prolonged hospital stay. The first patient had two perforations, one on the anterior and the other on the posterior wall of the duodenum, of which the posterior perforation was missed at initial laparotomy. In the other patient, the duodenal injury was missed during the initial assessment in the emergency department. He returned to the emergency department 24 hours after discharge with abdominal pain and vomiting. During trauma related laparotomy, complete kocherization (mobilization) of the duodenum must be mandatory, even in the presence of obvious injury on its anterior wall. We emphasize on keeping the management protocol simple by a "triple tube decompression", i.e. duodenorrhaphy (simple closure), tube gastrostomy, reverse tube duodenostomy and a feeding jejunostomy.

We present a case of a 55-year-old woman with episodes of recurrent pulmonary edema that was diagnosed to have a large left atrial myxoma using bedside transthoracic echocardiography. This case illustrates the importance of a screening focused ultrasound examination of involved systems by emergency physicians in detecting causes for emergency clinical presentations.

A 38-year-old intoxicated man presented to the emergency department with a painful, swollen left knee and inability to ambulate after being tackled to the ground. The patient was uncooperative, and physical examination of the lower extremities was limited by his intoxication. Radiographic examination of the knee was unremarkable. Ultrasound of the knee revealed a quadriceps tendon rupture. The sonographic features of quadriceps tendon rupture are described, as is the role ultrasound plays in the assessment of a swollen, painful knee.

Erroneous positioning of central venous catheters in small tributaries of large central veins is a rare occurrence. We describe two such unusual incidents involving cannulation of the small tributaries of left brachiocephalic vein. Malposition was suspected when the central venous waveform could not be obtained despite all attempts. Unusual central venous waveforms may indicate central venous catheter malposition, and these waveforms have not previously been described.