Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
Coverpage
October-December 2018
Volume 11 | Issue 4
Page Nos. 241-297

Online since Friday, November 23, 2018

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EDITORIAL  

Studies on the epidemiology of trauma: The first step in systems planning and system evaluation p. 241
Timothy Craig Hardcastle
DOI:10.4103/JETS.JETS_61_17  
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REVIEW ARTICLE Top

Going forward with Pokemon Go p. 243
Yvette Chong, Dean Krishen Sethi, Charmaine Hui Yun Loh, Fatimah Lateef
DOI:10.4103/JETS.JETS_87_17  
Pokemon Go is an augmented reality (AR) game which combines the use of smart mobile technology with physical exploration in the real world. It was a global phenomenon that rocked the world since 2016. Across boundaries and nations, the young and seniors were actively downloading and playing, joining the intrend gaming community. Was it a fleeting fad or a more sustainable activity? This paper discusses the literature currently available on this interesting phenomenon: its effect on physical and mental health as well as some documented hazards and distractions. From the review, Pokemon Go demonstrates that cleverly implemented AR games can reach millions of people and trigger substantial behavioral changes. AR games can help increase physical activities and exercise provided people's interest can be sustained.
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ORIGINAL ARTICLES Top

Road traffic injuries: A study on severity and outcome among inpatients of a tertiary care level hospital of West Bengal, India p. 247
Satabdi Mitra, Aditya Prasad Sarkar, Asit Baran Saren, Dibakar Haldar, Indrajit Saha, Gautam Narayan Sarkar
DOI:10.4103/JETS.JETS_138_17  
Background: Road traffic injuries (RTIs) are a complex phenomenon caused by nonlinear combination and interaction of man, vehicles, road, and environment. Aim: This study aims to find out the outcome and severity of RTI in a district of West Bengal, India. Settings and Design: A cross-sectional study was conducted among inpatients of Departments of Surgery and Orthopedics of Bankura Sammilani Medical College and Hospital, West Bengal, India. Materials and Methods: The study was conducted for 1 year interviewing 295 RTI selected through scheduled sampling. Information pertaining to demographic and correlates of RTI was collected by face to face and over telephone using semi-structured questionnaire. Nine-item Simplified Injury Severity Scale (SISS) was used to assess injury severity. Internal consistency of SISS scale was showed by Cronbach's alpha and association with the correlates was done by Mann–Whitney U-test. Statistical Analysis Used: With SPSS version 22.0, binary logistic regression, and Mann–Whitney U-test. Results and Conclusion: Fatal outcome in terms of death and permanent disability was 34.24% and they had higher marginally significant (P = 0.06), SISS score (45.17 ± 12.59). Participants with absence of protective devices, presence of comorbidities, drunkenness, with accidents over national highways, in-between 6 am and 6 pm, mechanized two-wheelers, and nonreceipt of first aid were found to have significantly high scores compared to their counterpart. SISS, as a proxy measure of severity assessment, could throw a light on it and awareness generation and legislative stringency might be need of the hour for the country.
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International classification of diseases-based audit of the injury database to understand the injury distribution in patients who have sustained a head injury (International Classification of Diseases Codes: S00-S09) p. 253
Mitasha Singh, Ranabir Pal, Pradeep Yarasani, Prashant Bhandarkar, Ashok Munivenkatappa, Amit Agrawal
DOI:10.4103/JETS.JETS_90_17  
Background: Traumatic brain injury (TBI) is the leading cause of mortality, morbidity, and disability globally. Methods for a reliable prediction of outcomes on the admission of TBI cases are of great clinical relevance to stakeholders. Objectives: This study used the International Classification of Diseases-10 codes (S00-S09) for analysis of injury distribution of TBI patients and attempted to find the prognostic predictors of Glasgow coma scale (GCS) in the outcome from readily accessible parameters. Methods: The data were reanalyzed from the Towards Improved Trauma Care Outcomes (TITCO) project from India. TITCO is the prospective, observational, multicenter trauma registry, contained data of trauma patients admitted to four public university hospitals in Mumbai, Delhi, and Kolkata collected from October 2013 to September 2015. Results: Among 8525 cases under study, low GCS scores before admission, which was dependent on the demographic variables and related risk factors occurring at the time of injury, were important in the prognostic predictors of mortality. However, survival probability during hospitalization remained uniformly uncertain for the elderly. Death as outcome of injury was dependent on the average intensity of injury, GCS on admission, critical injury severity score, and intubation within 1 h of admission and between 1 and 24 h of admission. These factors emerged as the independent predictors of fatality. The time of the day of injury did not yield any significant association with low GCS or demise in our study. Conclusions: GCS <8, i.e., severe at the time of admission, was an unfavorable predictor of in-hospital mortality.
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World Academic Council of Emergency Medicine experience document: Implementation of point-of-care thromboelastography at an academic emergency and trauma center p. 265
Bianca M Wahlen, Ayman El-Menyar, Ruben Peralta, Hassan Al-Thani
DOI:10.4103/JETS.JETS_134_17  
Background: We aimed to discuss the initial experience of the implementation of point-of-care thromboelastography (POC-TEG) at the Level 1 Trauma Center of an academic health institution in Qatar. Materials and Methods: A TEG protocol was developed and tailored to our hospital requirements and patient population, after an exhausting review of the literature and international published protocols, including a synthesis of a preexisting TEG protocol from our heart hospital. To successfully achieve the incorporation of point-of-care testing (POCT) in our clinical practice, a multidisciplinary organizational and education approach is required. The education and training of the physicians in this POCT modality during the first 3 months period has been described in detail. Results: A TEG protocol has been developed and implemented according to hospital standards. Ten physicians from the department of trauma surgery have been trained over a 3-month period to perform the daily quality control as well as the patient samples in order to provide a 24/7 service. In patients with major trauma, brain injury, bleeding, sepsis, and coagulopathy are the most important determinants of the clinical course and outcomes. Viscoelastic whole-blood assays have already proved their values in cardiac as well as liver surgery. Therefore, this POCT-directed approach would be considered as a part of the goal-directed management in severe polytrauma patients. Conclusions: Our experience shows that implementation of POC-TEG program is feasible and it is a promising tool in the management of major trauma patients with a potential compromised coagulation. However, further prospective research projects and well-trained personnel still warranted.
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The eminence of neutrophil-lymphocyte count ratio in predicting bacteremia for community-acquired infections at an emergency medicine department in a tertiary care setting p. 271
Vishnu Manohar, Bharath Prasad S, Shilpa Raj, TP Sreekrishnan, KP Gireesh Kumar
DOI:10.4103/JETS.JETS_72_17  
Introduction: The changes in the white blood cells counts and other blood parameters are well-recognized feature in sepsis. A ratio between neutrophils and lymphocytes can be used as a screening marker in sepsis. Even though new markers such as Procalcitonin and adrenomedullin have been rolled out in the field, implementation of these markers has been hindered by cost, accessibility, and proper validation. We looked for the ability of simple neutrophil-lymphocyte count ratio (NLCR) when compared to the gold standard blood culture method in predicting bacteremia, on patients presented to emergency department (ED) with features of suspected community-acquired infections. Materials and Methods: A comparative study done on 258 adult patients, admitted with suspected features of community-acquired infections. The study group included all patients who had positive blood culture results on index presentation at ED. Patients with hematological, chronic liver and retroviral diseases, patients receiving chemotherapy, and steroid medications were excluded from the study. The study group was compared with gender- and age-matched control group who were also admitted with a suspicion of the same, but in whom the blood culture results were negative. Results: There was no statistically significant difference for predicting bacteremia by NLCR (>4.63) and culture positivity methods (P = 1.00). NLCR of > 4.63 predicts bacteremia with an accuracy of 84.9%. Conclusion: In our setting, NLCR performs equally well with culture positivity, in detecting severe infection at the early phase of disease. The NLCR may, therefore, be used as a suitable screening marker at ED for suspected community-acquired infections.
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Electrocardiogram-guided technique: An alternative method for confirming central venous catheter tip placement p. 276
Arun Kumar Krishnan, Priya Menon, KP Gireesh Kumar, TP Sreekrishnan, Manish Garg, S Vijay Kumar
DOI:10.4103/JETS.JETS_122_17  
Background: The current standard followed for assessing central venous catheter (CVC) tip placement location is through radiological confirmation using chest X-ray (CXR). Placement of CVCs under electrocardiogram (ECG) guidance may save cost and time compared to CXR. Objective: The objective of this study is to compare the accurate placement of the CVC tip using anatomical landmark technique with ECG-guided technique. Another objective is to compare CVC placement time and postprocedural complications between the two techniques. Methods and Materials: A total of 144 adult individuals, who were critically ill and required CVC placement in the Emergency Department, were included for the study. Study duration was 6 months. Anatomical landmark and ECG-guided groups were assigned 72 participants each. Analyses were performed using t and Chi square-tests. Results: It was observed that 13 (18%) in the landmark technique were malpositioned as compared to none in the ECG-guided technique (P = 0.000). The landmark group had 22 (30.6%) participants with arrhythmias during the procedure, compared to none in the ECG-guided group (P = 0.000). The landmark group revealed that 30 (41.7%) of the CVC were overinserted and required immediate repositioning, compared to none in the ECG-guided group (P = 0.000). Conclusion: ECG-guided technique was found to be more accurate for CVC tip placement than the anatomical landmark technique. Furthermore, the ECG-guided technique was more time-effective and had less complications than the anatomical landmark technique. Hence, ECG-guided CVC placement is relatively accurate, efficient, and safe and can be considered as an alternative method to conventional radiography for confirmation of CVC tip placement.
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Epidemiological and clinical profile of fatality in vulnerable road users at a high volume trauma center p. 282
Angeline Neetha Radjou, S Mohan Kumar
DOI:10.4103/JETS.JETS_55_17  
Background: Motorized two-wheelers, pedestrians, and cyclists are termed vulnerable road users (VRUs).Globally up to 50% of road deaths involve VRU and up to 80% in developing and rapidly motorizing economies. Objective: The objective of this study is to study the prehospital and clinical profile of fatally injured VRU. This would help in informed decision-making regarding prevention and trauma care infrastructure. Materials and Methods: A hospital-based study was performed at a Trauma Centre in Puducherry from January 2013 to June 2014 (18 months). Puducherry is a union territory of India in the state of Tamil Nadu. A total of 193 deaths due to Road traffic accident were included in this study. The demographics, prehospital findings, and the clinical progress of fatally injured VRU are described. Results: More than 80% of road traffic collision/crash deaths involved VRU of which the elderly comprised a significant proportion. Alcohol was a serious issue even in the elderly pedestrian. This study revealed specific injury patterns and severity. Head injury was the most common cause of death. Early deaths, that is within 24 h of injury was common at 50%. Conclusion: The majority of deaths were in the early phase of trauma hence mandating a strong call for prevention, along with strengthening of trauma care.
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Our experience with management and outcome of isolated traumatic brain injury patients admitted in Intensive Care Unit p. 288
Reyaz Ahmed Para, Arif Hussain Sarmast, Mohammad Akbar Shah, Toufeeq Ahmad Mir, Abdul Waheed Mir, Suhail Sidiq, Abdul Qayoom Lone, Altaf Umer Ramzan
DOI:10.4103/JETS.JETS_34_17  
Introduction: Traumatic brain injury (TBI) is a major cause of death and disability throughout the world. Commonly used predictors of outcome both individually or in combination include age, Glasgow Coma Scale score, pupillary reactivity, early hypoxia, and hypotension. Most of the studies previously done to examine risk factors for mortality in severe TBI were done in the setting of polytrauma. Aims and Objectives: The aim and objective of this study was to do an in-depth analysis of various factors associated with the management and outcome of patients with isolated TBI admitted in an Intensive Care Unit (ICU). Materials and Methods: A total of seventy adult patients who were admitted to Intensive Critical Care Unit (ICU) with isolated TBI were selected during a 12-month period from January 2016 to December 2016. This is a prospective analytical study and parameters studied included age, sex, cause of admission classified by type of trauma, premorbid functional status, acute and chronic comorbidities, brain noncontrast computed tomography scan data, Glasgow Coma Scale (GCS), hemodynamic status, respiratory status, and mechanical ventilation, blood gases, serum electrolytes, serum glucose, hemoglobin, leukocyte and platelet counts, renal function, and urinary output. Results: The study population consisted of 46 (65.7%) males and 24 (34.2%) females. The mean age was 35.5 years (range, 18–65 years). The most common mode of trauma was road traffic accident (43.6%) followed by fall from height (35.7%). Statistically insignificant relationship (P < 0.05) was seen with sex and mode of injury among survivors and nonsurvivors; however, 61.9% of patients with age ≥40 years died (P < 0.005). Among clinical parameters at admission to ICU, low GCS, hypotension (mean arterial pressure ≤80 mmHg), hypoxia (pO2 ≤60 mmHg, spO2 ≤90 mmHg), and nonreacting pupils were significantly associated with increased mortality (P < 0.05). Conclusion: Isolated TBI still continues to have a good amount of morbidity and mortality which perhaps can be reduced by strict adherence to guidelines of management.
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Nonoperative management of blunt splenic trauma: Outcomes of Gelfoam embolization of the splenic artery p. 293
Carl Freeman, Vicki Moran, Adam Fang, Heidi Isreal, Shuran Ma, Kena Vyas
DOI:10.4103/JETS.JETS_97_17  
Context: Nonoperative management (NOM) is the standard of care in hemodynamically stable trauma patients with blunt splenic injury. Gelfoam splenic artery embolization (SAE) is a treatment option used in trauma patients. Aims: The primary aim of this study was to retrospectively examine the use and outcomes of Gelfoam SAE in adult patients with blunt splenic injury. Settings and Design: One hundred and thirty-two adult patients with blunt splenic injury admitted to a Level 1 trauma center between January 2014 and December 2015 were included in the study. Patients treated with Gelfoam SAE, NOM, and splenectomies were reviewed. Descriptive statistics including patient age, Glasgow Coma Scale, Injury Severity Score (ISS), hospital days, Intensive Care Unit (ICU) days, splenic grade, and amount of blood products administered were recorded. Complications, defined as any additional factors that contributed to the patient's overall length of hospital stay, were compared between the three groups. Technical aspects of Gelfoam SAE and associated complications were reviewed. Subjects and Methods: Gelfoam SAE was performed in 25 (18.9%) of the 132 patients. Gelfoam SAE patients had fewer ICU days compared with those patients who had a splenectomy or NOM. There was no statistical difference in complications between patients who underwent Gelfoam SAE and those who did not. Patients who underwent Gelfoam SAE tended to have fewer complications including deep venous thrombosis's, PE, and infections and yielded no complications in 64% of the Gelfoam group. Statistical Analysis: Statistical analysis included descriptives, ANOVA, and nonparametric tests as appropriate. Conclusion: Gelfoam SAE can be used for blunt splenic injury for intermediate ISS and splenic grade as it reduced hospital and ICU days.
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