Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
April-June 2020
Volume 13 | Issue 2
Page Nos. 105-173

Online since Wednesday, June 10, 2020

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What's new in emergencies, trauma and shock? Trauma-associated venous thromboembolism: A potentially preventable cause of morbidity and mortality p. 105
Kunal Mahajan
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All india institute of medical sciences triage protocol (ATP): ATP of a busy emergency department Highly accessed article p. 107
Ankit Kumar Sahu, Sanjeev Bhoi, Sagar Galwankar, Praveen Aggarwal, Lakhiram Murmu, Jamshed Nayer, Tej Prakash Sinha, Prakash Ranjan Mishra, Meera Ekka, Akshay Kumar
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Management algorithm for subclinical hypoxemia in coronavirus disease-2019 patients: Intercepting the “Silent Killer” Highly accessed article p. 110
Sagar C Galwankar, Lorenzo Paladino, David F Gaieski, K D. P. W. B. Nanayakkara, Salvatore Di Somma, Joydeep Grover, Stanislaw P Stawicki
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Cardiovascular-Thoracic surgeons stepping in as trauma surgeons: The ideal prescription for trauma care in India Highly accessed article p. 114
Siddharth Pramod Dubhashi, Sagar Galwankar, Sameer Bhate, Anand Sancheti, Harinder Singh Bedi
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Face to face with coronavirus disease 19: Maintaining motivation, psychological safety, and wellness p. 116
Fatimah Lateef
Emerging infectious diseases have the potential to spread across borders extremely quickly. This was seen during the severe acute respiratory syndrome (SARS) outbreak and now, coronavirus disease (COVID 19) (novel coronavirus) pandemic. For outbreaks and pandemics, there will be behavioral, affective, and cognitive changes and adaptation seen. This may be prominent in frontline workers and healthcare workers (HCWs), who work in high-risk areas, as well as people in general. What represents the psychology and mindset of people during a pandemic? What is needed to allay anxieties and instill calm? What will be needed to keep the motivation levels of people and HCW high so that they continue to function optimally? Which motivation theory can be used to explain this and how do employers and management utilize this in their approach/strategies in planning for an outbreak? Finally, the impact of culture, in the various contexts, cannot be overlooked in crisis and pandemic management. The author is a senior emergency physician in Singapore, who has been through SARS and now the COVID pandemic. She has been instrumental in sharing some of the changes and practices implemented in Singapore, since SARS 17 years ago, until now. Besides being a full-time practicing emergency physician, the author is also an elected Member of the Singapore Parliament for the last 14 years. She shares her views on an aspect often overlooked during a pandemic: psychological wellness and motivations of people, including for HCW at the frontline.
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Clinical Characteristics, Management Practices, and In-hospital Outcomes among Trauma Patients with Venous Thromboembolism p. 124
Gustav Strandvik, Ayman El-Menyar, Mohammad Asim, Sagar Galwankar, Hassan Al-Thani
Background: We aimed to assess the clinical characteristics, management practices, and inhospital outcomes of venous thromboembolism (VTE) among trauma patients. Methods: A retrospective analysis of all trauma patients with documented venous thromboembolic events in a level 1 trauma center was conducted. Patients were categorized into two groups based on the primary initial presentation postinjury (deep-vein thrombosis [DVT] or pulmonary embolism [PE]). Results: Across the study period, a total of 662 patients were confirmed to have DVT and 258 patients were diagnosed with acute PE. Among them, 84 patients were identified to have trauma-associated VTE; 56 (8.5%) had DVT and 28 (10.9%) had PE. Two patients who initially presented with DVT developed PE on follow-up. There were 38 females and 46 males with a mean age of 46 ± 18 years. Abnormal coagulation profile was reported as 7 protein C deficiencies, 5 protein S deficiencies, 6 homocystinemia, 4 antithrombin III deficiency, 4 lupus anticoagulant, and 2 Factor V Leiden. Age, sex, obesity, D-dimer level, and treatment (except for heparin) were comparable between the two groups; whereas protein S deficiency, prior history of PE, bedridden status, congestive heart failure, and history of recent surgery, were more evident in the PE group. The incidence of postthrombotic syndrome was significantly higher in the DVT group. Overall mortality rate was 8.3% (DVT; 8.9% vs. PE; 7.1%, respectively = 0.78). Conclusion: Coagulation profile plays an important role in posttraumatic thromboembolic disease. A thorough assessment for features of thromboembolic disorders is warranted in polytrauma patients to avoid missing this potentially life-threatening diagnosis. Larger studies are needed for better understanding and management of VTE in trauma.
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Studying the Clinical Data of COVID Positive patients admitted to a tertiary care academic hospital p. 131
Julio Arrieta, Sagar Galwankar, Natalia Lattanzio, Darrel Ray, Amit Agrawal
Background: At the time this data was studied in Florida, USA was expecting a surge in number of COVID patients. We are hereby presenting analysis of clinical data collected from the first 30 COVID positive patients admitted to our teaching hospital in Sarasota Florida. Methods: The present study was conducted at a not-for-profit 839-bed level-2 regional trauma center, level-3 neurointensive intensive care unit (ICU), and comprehensive stroke and cardiovascular center located on Florida's Central Gulf Coast. It was a single-center, retrospective review of the first 30 patients with reverse transcriptase–polymerase chain reaction confirmed 2019-nCoV infection between March and April 2020. Deidentified patient demographic data, abnormal admission laboratory and radiology findings, treatment medications received, need for mechanical ventilation, complications, and final outcome were recorded. Results: A total of 30 patients were included who were admitted during the study period. Majority of the patients (86%) were elderly, males were 57%, and the average age was 70 years (range, 38–90). About 43% had any travel history outside the region and most (83%) had a comorbidity. Fever, cough, and shortness of breath were common presenting symptoms. About 33% of the patients required ICU at presentation. Abnormal imaging on presentation was present in 80% of the patients and 42% of them had nonspecific bilateral opacities. Complications seen included acute hypoxic respiratory failure (43%), renal failure (13%), septic shock (10%), cytokine storm (3%), and cardiomyopathy (3%). All nonsurvivors developed acute respiratory distress syndrome prior to death. Of the survivors, 21 (70%) were relieved and were discharged. Conclusion: The most common presenting symptoms included fever, cough, and shortness of breath. Patients who required ICU admission at presentation had a worse prognosis. Those with greater severity of symptoms were mainly elderly patients among which the most common comorbidity was hypertention followed by cardiac disease.
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Clinical characteristics predict the yield of head computed tomography scans among intoxicated trauma patients: Implications for the initial work-up p. 135
Matthew K McIntyre, Nikathan S Kumar, Elizabeth H Tilley, David J Samson, Rifat Latifi
Background and Aims: Alcohol intoxication may confound the clinical assessment of the trauma patient. Head computed tomography (h-CT) is the standard imaging technique to rule out intracranial injury in most intoxicated trauma patients. The objective of this study was to determine whether certain clinical findings (computed clinical score [CCS]) could predict the h-CT yield, admission, and neurosurgical consultation (NSC) among intoxicated trauma patients. Materials and Methods: This is a 4-year retrospective cohort study (2013–2017) of trauma patients who presented to our level 1 trauma center emergency department with alcohol intoxication. For each patient, a computed clinical score (CCS) was generated based on the following findings: age ≥50 years, Glasgow Coma Scale <13, evidence of trauma above the clavicles, amnesia, loss of consciousness, headache, vomiting, and seizures. The primary endpoints were NSC, admission, and acute h-CT finding. Univariate and multivariate regressions were used to compare predictors of the primary endpoints. Results: We identified 437 intoxicated trauma patients (median age: 35 years [interquartile range: 25–50]; 71.9% men; median blood alcohol content: 207.8 mg/dL). One hundred and twenty-four (30.4%) patients had acute findings on h-CT, 351 (80.3%) were admitted, and 112 (25.6%) received NSC. On multivariate analysis, CCS was the only predictor of acute h-CT (odds ratio [OR] =1.6; 95% confidence interval [CI]: 1.3–2.0;P < 0.0001) and the best predictor of admission (OR = 1.6; 95% CI: 1.3–1.9;P < 0.0001) and NSC (OR = 1.8; 95% CI: 1.5–2.3;P < 0.0001). Conclusions: One-third of intoxicated trauma patients have acute findings on h-CT. While the CCS was the best predictor of acute h-CT findings, hospital admission, and NSC, h-CT scanning should continue to be a standard of care.
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Fall related injuries in elderly patients in a tertiary care centre in Beirut, LebanonFall-related Injuries in Elderly Patients: A descriptive study from the emergency department of a tertiary care center in Beirut, Lebanon p. 142
Raed A Ismail, Rayan H El Sibai, Alik V Dakessian, Rana H Bachir, Mazen J El Sayed
Context: Falls cause significant morbidity and mortality, constituting 38.9% of trauma visits to the emergency department (ED) in Lebanon. Elderly have increased risk of falls due to co-morbidities. Injury-related deaths are most common in developing countries, and few studies have examined falls internationally. Aims: Describe characteristics, injury patterns, and outcomes of elderly treated for fall injuries at a tertiary care center in Lebanon. Settings and Design: Retrospective observational chart review of elderly presenting after a fall to the ED. Subjects and Methods: Retrospective observational study of elderly (≥65 years) patients who presented to the ED at a tertiary care center in Lebanon with the chief complaint of “fall” over a 6-year period. Statistical Analysis Used: Descriptive analysis. Results: Two hundred and thirty-five patients were included; mean age was 78.1 (±7.2) years with female predominance (60.5%). Falls occurred at home (99.2%) and from ground level (96.4%). Patients presented by private transport (85.8%). The initial impact was to the head in 31.2% of patients with 47.8% on antiplatelet/anticoagulation therapy. Imaging includes extremity X-ray (46.6%) and head/cervical spine computed tomography (39.5%). Dispositions included home (58.9%), regular floor (23.3%), operating room (7.9%), and intensive care unit (5.9%). Pelvic/hip repair was the most common surgical procedure. Most injuries were nonlife-threatening. Overall mortality was 2%. Conclusions: Falls have a high impact on the elderly population in Lebanon, with most occurring at home, resulting in pelvic/hip injuries and a mortality of 2%. There is a need to implement multifaceted fall prevention programs to mitigate such injuries and improve patient safety and outcomes.
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Pediatric risk of mortality III score – Predictor of mortality and hospital stay in pediatric intensive care unit p. 146
Amarpreet Kaur, Gurmeet Kaur, Shashi Kant Dhir, Seema Rai, Amanpreet Sethi, Avneet Brar, Paramdeep Singh
Background: Pediatric Risk of Mortality (PRISM) III score is one of the widely used scoring systems to quantify critical illness in the pediatric age group. This study was carried out to find the association of PRISM III score with the outcome (discharge/mortality) and also hospital stay in survivors and nonsurvivors. Setting: The study was conducted in a tertiary care hospital from January 2014 to June 2015. Materials and Methods: A total of 524 patients were admitted, and after excluding the patients who met the exclusion criteria, 486 patients were analyzed. Statistical Analysis: Logistic regression was used to find the association of variables under the PRISM III score with mortality. Linear regression was used to find the association of PRISM III score with length of stay. Results: Mortality was 31%; male: female ratio was 1.5:1. Maximum patients presented with respiratory system involvement (26.3%), and maximum mortality (20.3%) was observed in the patients with respiratory involvement. Discrimination by the model between mortality and survival was excellent (receiver operating characteristic curve [0.903]). Maximum risk of mortality was noticed in mechanically ventilated patients (odds ratio [OR]: 10.87) followed by lower systolic blood pressure (OR: 2.72), deranged prothrombin time, partial thromboplastin time (OR: 1.50), deranged mental status (OR: 1.41), and tachycardia (OR: 1.37). Length of stay (LOS) in patients increased till PRISM III score of 25. Average LOS in survivors was 4.327 days which was not accounted by difference in PRISM III score between different patients. With each unit increase in PRISM III score, LOS increased by 5 h. Conclusions: PRISM III score has excellent capacity to discriminate between survival and mortality. PRISM III score can be used to predict LOS among survivors.
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Sedation patterns and hyperosmolar therapy in emergency departments were associated with blood pressure variability and outcomes in patients with spontaneous intracranial hemorrhage p. 151
Tina Nguyen, Kanisha Pope, Paul Capobianco, Mimi Cao-Pham, Soha Hassan, Matthew J Kole, Claire O'Connell, Aaron Wessell, Jonathan Strong, Quincy K Tran
Background: Spontaneous intracranial hemorrhage (sICH) is associated with high mortality. Little information exists to guide initial resuscitation in the emergency department (ED) setting. However, blood pressure variability (BPV) and mechanical ventilation (MV) are known risk factors for poor outcome in sICH. Objectives: The objective was to examine the associations between BPV and MV in ED (EDMV) and between two ED interventions – post-MV sedation and hyperosmolar therapy for elevated intracranial pressure – and BPV in the ED and in-hospital mortality. Methods: We retrospectively studied adults with sICH and external ventricular drainage who were transferred to a quaternary academic medical center from other hospitals between January 2011 and September 2015. We used multivariable linear and logistic regressions to measure associations between clinical factors, BPV, and outcomes. Results: We analyzed ED records from 259 patients. There were 143 (55%) EDMV patients who had more severe clinical factors and significantly higher values of all BPV indices than NoEDMV patients. Two clinical factors and none of the severity scores (i.e., Hunt and Hess, World Federation of Neurological Surgeons Grades, ICH score) correlated with BPV. Hyperosmolarity therapy without fluid resuscitation positively correlated with all BPV indices, whereas propofol infusion plus a narcotic negatively correlated with one of them. Two BPV indices, i.e., successive variation of blood pressure (BPSV) and absolute difference in blood pressure between ED triage and departure (BPDepart − Triage), were significantly associated with increased mortality rate. Conclusion: Patients receiving MV had significantly higher BPV, perhaps related to disease severity. Good ED sedation, hyperosmolar therapy, and fluid resuscitation were associated with less BPV and lower likelihood of death.
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Role of inhaled corticosteroids for asthma exacerbation in children: An updated meta-analysis p. 161
Kanlayanee Sawanyawisuth, Paiboon Chattakul, Sittichai Khamsai, Watchara Boonsawat, Arinrada Ladla, Verajit Chotmongkol, Panita Limpawattana, Jarin Chindaprasirt, Vichai Senthong, Chalongchai Phitsanuwong, Kittisak Sawanyawisuth
Background: Several studies showed that inhaled corticosteroids (ICS) may be a potential treatment in acute asthma exacerbation in children. This study was an update meta-analysis on the roles of ICS in the management of acute asthma exacerbation in children presenting to the hospital. Materials and Methods: Published articles with key words of ICS for asthma exacerbation, asthma attacks, and acute asthma in children aged under 18 years in the hospital setting with outcome of hospital admission between 2009 and 2018 were enrolled. The databases used in this study were Medline, Scopus, and Web of Science. Odds ratio of comparison between ICS and other treatments on hospital admissions was calculated. Results: There were 311 eligible studies met the searching criteria; seven eligible studies for the analysis; comprised of three meta-analysis and four added studies. The ICS had a significant reduction in hospital admission compared with placebo in overall with odds ratio of 0.63 (95% confidence interval [CI]: 0.41–0.96) and in moderate-to-severe group with odds ratio of 0.17 (95% CI: 0.05–0.51). Comparing with systemic corticosteroid (SC), ICS had significantly lower hospital admissions overall and in mild-to-moderate group with odds ratios of 0.63 and 0.26, respectively. The combination of ICS and SC had odds ratio of 0.75 (95% CI: 0.57–0.99) over SC in moderate-to-severe asthma exacerbation. Conclusions: ICS significantly reduced hospital admission in asthma exacerbation in children. It may be used alone for mild-to-moderate asthma exacerbation and combination with SC for moderate-to-severe asthma exacerbation.
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Trimeresurus malabaricus bites: Need of species-specific management for snakebites p. 167
M Harikrishnan, K Vimal Rohan, S Manu Ayyan
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Multiple rib fractures in severe kyphoscoliosis: A question mark spine p. 168
Ravneet Kaur Gill, Uma Rathi, Ashwani Mudgal, Charmila Choudhary
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Coronavirus-19 pandemic: A two-step triage protocol for emergency department p. 169
Roshan Mathew, Tej Prakash Sinha, Ankit Kumar Sahu, Sanjeev Bhoi, Sagar Galwankar
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Case of anaphylactic shock after ruptured hydatid cyst of liver: A nightmare to emergency physicians p. 171
Neha Gupta, Rahul Katiyar, Vipin Kumar Singh
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Proctoring hydroxychloroquine consumption for health-care workers in india as per the revised national guidelines p. 172
Vivek Chauhan, Sagar Galwankar, Sunil Raina, Vimal Krishnan
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