Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
April-June 2019
Volume 12 | Issue 2
Page Nos. 95-166

Online since Thursday, May 30, 2019

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What's new in emergencies trauma and shock? Point of care imaging in out-of-hospital cardiac arrest p. 95
Vivek Chauhan
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Alcohol and drug testing in the national trauma data bank: Does it matter? p. 97
Adel Elkbuli, Brianna Dowd, Rudy Flores, Dessy Boneva, Shaikh Hai, Mark Mckenney
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Recreational drugs and outcomes in trauma patients p. 98
Quinn Fujii, Andrew McCague
Objective: The objective of the study is to determine if marijuana, methamphetamine, or cocaine is associated with worse outcomes following trauma. Methods: A retrospective cross-sectional study was conducted on 731 trauma patients. Data collected from Natividad Medical Center's trauma registry were used to analyze reports of adult patients from July 1, 2014, to July 1, 2017. Analyzed endpoints were mortality, rates of major trauma, mean Injury Severity Score (ISS), and length of stay (LOS). Results: Odds ratios for mortality contained null value in each group. Odds ratios for suffering major trauma for marijuana and amphetamines were 1.2 and 2.6, respectively.P values for ISS were >0.05 for each group.P values for LOS were >0.05 for marijuana and cocaine and 0.01 for amphetamines. Conclusions: A positive screen for marijuana, amphetamine, or cocaine is not associated with increased mortality for victims of trauma. Amphetamines are associated with higher rates of major trauma and longer LOS. Marijuana is associated with higher rates of major trauma. Cocaine is not associated with the likelihood of suffering major trauma or length of stay.
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Evaluation of traumatic spine by magnetic resonance imaging and its correlation with cliniconeurological outcome p. 101
Bukke Ravindra Naik, Anil Kumar Sakalecha, Shivaprasad Gangadhar Savagave
Background: Spinal trauma is associated with long-term disability. Early detection can lead to prompt and accurate diagnosis, expeditious management, and avoidance of unnecessary procedures. Magnetic resonance imaging (MRI) helps to accurately depict the presence and extent of spinal cord injury (SCI) in these patients. Purpose: This study was aimed to look for various MRI findings which are predictive of initial neurological deficit in patients with spinal trauma and to correlate the findings with resultant neurological outcome. Materials and Methods: The present study was conducted over a period of 18 months from January 2016 to June 2017 in 57 patients with spinal trauma who underwent MRI spine. Neurological status of patients was assessed at the time of admission and discharge in accordance with the American Spine Injury Association (ASIA) impairment scale. Various MRI parameters were evaluated for correlation with the severity of the spinal injury. Results: Patients with cord transection, cord hemorrhage, and epidural hematoma had initial high-grade ASIA impairment scale. Patients with cord transection and cord hemorrhage did not show any improvement in their neurological status during their hospital stay. Patients with only cord edema and epidural hematoma showed favorable neurological outcome. Cord contusion showed lesser neurological recovery, as compared with cord edema and normal cord. Conclusion: MRI findings in acute SCI correlated well with the initial neurological deficits on admission and at the time of discharge. MRI should be recommended in all patients with suspected spinal trauma both as a diagnostic and prognostic indicator.
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Factors affecting mortality following necrotizing soft-tissue infections: Randomized prospective study p. 108
Sukha Ram Barupal, Murari Lal Soni, Rekha Barupal
Background and Aim: Necrotizing soft-tissue infections (NSTIs) are common in the Indian subcontinent and are associated with high morbidity and mortality. The aim of this paper was to correlate clinical factors and Acute Physiology Health and Chronic Health Evaluation (APACHE) II score with mortality following NSTI. Methodology: Patients presenting to our tertiary-care center between November 1, 2014, and December 1, 2016, with NSTI and between the age of 15 and 90 years were included and entered into a prospectively maintained database. Fifty random patients were selected from the database and were divided according to the survival outcome into two groups: Group 1-survivors and Group 2-nonsurvivors. The two groups were compared for clinical factors and APACHE II score to identify the variable which correlated with the survival. Results: Mean age of the study cohort (n = 50, 44 males) was 50.8 ± 17.1 years. Fournier's gangrene was the most common manifestation (64%), followed by lower limb (14%). Infection was leading cause (34%) followed by trauma (16%) and prior surgery (14%). There were 16 in-hospital deaths (32%). Two groups were similar regarding age and sex. At presentation, nonsurvival group had significantly higher body surface area involvement (P = 0.001), anemia (P = 0.023), metabolic acidosis (P < 0.0001), serum creatinine (P = 0.007), and mean APACHE II score (P < 0.001). There was no difference between time from presentation to the first debridement. Conclusions: We found that APACHE II is a significant predictor of mortality. Early diagnosis and prompt aggressive treatment is the only way to improve outcome. Further studies with larger sample size are warranted.
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Gunshot injuries in Lebanon: Does intent affect characteristics, injury patterns, and outcomes in victims? p. 117
Hady Zgheib, Sami Shayya, Cynthia Wakil, Rana Bachir, Mazen J El Sayed
Introduction: Lebanon lacks a national database of gunshot injuries (GSIs), which limits injury prevention initiatives. Objectives: This study examines patient characteristics, injury patterns, and clinical outcomes in GSI victims and evaluates the impact of intent on clinical outcomes with the aim of improving awareness among emergency department (ED) physicians about the importance of inquiring about intent to predict prognosis. Materials and Methods: We conducted a retrospective cohort study of GSI victims presenting to the ED of a tertiary care center in Beirut, Lebanon. Descriptive and bivariate analyses were done to identify differences based on intent. Results: A total of 83 patients were included, 59% with intentional GSI, 22% with unintentional GSI, and 19% with unspecified intent. They were mostly males (89.2%), with a mean age of 31.7 years, and mostly presenting during summer seasons. Females were more commonly victims of unintentional GSI. All victims sustaining multiple GSIs were in the intentional group. When compared to unintentional GSI, intentional and unspecified GSIs were found to result in more ICU admissions (46.9%, 31.3%, and 16.7%,P = 0.096), significantly longer hospital stays (18.2, 26.3, and 5.6 days;P = 0.001) and higher mortality (11.6%, 18.2%, and 6.7%;P = 0.747). The rates of surgical procedures were similar between the three groups although more victims of intentional and unspecified GSI underwent multiple surgeries. Conclusion: GSIs have different features, resource utilization, and clinical outcomes depending on the intentionality of injuries. All GSI victims suffer from substantial morbidity and mortality, but intentionally harmed victims sustain more severe injuries with worse outcomes.
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Understanding the knowledge and attitude of prehospital sepsis care among emergency medical service personnel p. 123
Hadeel Sameeh Ghazal, Atheer Abdulaziz Alkhunein, Ahmed Abdullah Alkhazi, Salman Abdulmajeed Aldeheshi, Faisal Ahmed M. Alhusain, Nawfal Al Jerian
Background: Sepsis represents a huge burden for the health-care system. Septic patients presented by emergency medical services (EMS) are usually sicker in comparison to patients arriving by other means. Knowledge of sepsis is a key factor in recognizing and providing the appropriate care; it is not the only barrier as EMS providers do not have access to the proper diagnostic investigation. This work highlighted the level of knowledge, awareness, and attitude of EMS providers regarding prehospital care of sepsis in Riyadh, Saudi Arabia. Methods: This study was a cross-sectional study that conducted among EMS personnel of Saudi Red Crescent Authority and King Abdulaziz Medical City. One hundred and ninety-seven individuals were sampled (99 were technicians and 98 were paramedics). Results: Most participants (71%) were aware of the term “sepsis;” however, only 48% of participants correctly defined sepsis (30% between emergency medical technicians [EMTs] vs. 66% paramedics group,P < 0.01). Paramedics were noted to have a better understanding of signs, symptoms, and management of sepsis. Most of the participants thought that sepsis can be identified during prehospital care (55%) and 75% suggested that they should be involved in the management of septic patients. About 80% responded that their intervention would result in a better outcome for patients and would influence the behavior of emergency department medical care. Most of the participants (83%) were willing to be actively engaged in the prehospital care of septic patients. Conclusion: This study showed an insufficient level of knowledge and awareness regarding sepsis care in the EMS field in Saudi Arabia. Paramedics had more knowledge and awareness about sepsis care compared to EMT personnel. Future work should focus on exploring the reasons behind this, as well as implementing plans to improve education about sepsis for EMS personnel.
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Do the care process and survival chances differ in patients arriving to a level 1 Indian trauma center, during-hours and after-hours? p. 128
Kapil Dev Soni, Santosh Mahindrakar, Gaurav Kaushik, Subodh Kumar, Sushma Sagar, Amit Gupta
Introduction: Trauma systems vary in performance during different time periods and may affect the patient outcomes, especially in resource-limited settings. The present study was undertaken to study the pattern, epidemiological profile, processes of care variations of trauma victims presenting during-hours and after-hours in a level 1 trauma Center of a lower middle-income country. Methodology: Retrospective analyses of prospectively collected data registry at a single tertiary care center. Data collected from 2013 to 2015 were analyzed. Patients with a history of trauma and admission to the center or death between arrival and admission were included. Isolated limb injury and patients dead on arrival were excluded. Results: Of 4692, 1789 (38.1%) patients arrived and were admitted during-hours and 2903 (61.9%) after-hours. The overall in-hospital mortality was 14.9% in the cohort. Moreover, it was 16.10% during after-hours in comparison to 13.0% during-hours. The Revised Trauma Score was statistically different during-hours and after-hours suggesting patients with greater physiological derangement after-hours. The Kaplan–Meier survival curves for 7 days were comparable in two groups with the log-rank test of 078. The proportion of initial radiological investigations (chest X-ray, focused assessment sonography in trauma [FAST], and computerized tomography [CT] scans) was ranged from 84.9% for CT scans in the cohort to 99.3% for FAST. Conclusions: Processes of care do not differ significantly for the patients admitted at a level 1 trauma center irrespective of time of the day. Although survival probability for the initial 7 days of follow-up is comparable between two groups; however, for 30 and 90 days of follow-up they are significantly different between during-hours and after-hours, likely due to injury severity.
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An analysis using modified rapid ultrasound for shock and hypotension for patients with endogenous cardiac arrest p. 135
Youichi Yanagawa, Hiromichi Ohsaka, Hiroki Nagasawa, Ikuto Takeuchi, Kei Jitsuiki, Kazuhiko Omori
Aims: We prospectively investigated whether or not a rapid ultrasound for shock and hypotension (RUSH) examination is useful for managing patients with endogenous cardiac arrest (CA). Settings and Design: A prospective medical chart review in a single hospital. Materials and Methods: From March 2016 to December 2017, we performed a modified RUSH for all patients with out-of-hospital endogenous CA. We investigated the frequency of positive findings on modified RUSH and what kind of diseases could most easily be pinpointed as the cause of CA by the modified RUSH. Results: During the investigation period, 194 participants were enrolled in the present study. They were primarily male, with an average age of 68.8-year-old, and 178/194 (91.7%) died as outpatients. The most frequent cause of CA was cardiogenic, followed by aortic disease, respiratory failure, and stroke except for unknown. There were 14/26 (54%) aortic disease patients who showed positive RUSH findings. Among cases of the aortic disease, only aortic dissections had positive findings. Aside from aortic disease, there were no cases of positive findings of the modified RUSH among the remaining diseases, and all patients with positive findings died. Only pulseless electrical activity (PEA) was a statistically significant factor for positive findings of the modified RUSH in cases of the aortic disease. Conclusions: The present study revealed that, among patients with out-of-hospital endogenous CA, modified RUSH is useful for diagnosing ascending aortic dissection for the detection of hemothorax and/or cardiac tamponade, especially with PEA.
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The influence of cervical collar immobilization on optic nerve sheath diameter p. 141
Joseph Yard, Peter B Richman, Ben Leeson, Kimberly Leeson, Guy Youngblood, Jose Guardiola, Michael Miller
Background: Prior research has revealed that cervical collars elevate intracranial pressure (ICP) in patients with traumatic brain injury. Two recent small studies evaluated the change in optic sheath nerve diameter (ONSD) measured by ultrasound as a proxy for ICP following cervical collar placement in healthy volunteers. Objective: We sought to validate the finding that ONSD measured by ultrasound increases after cervical collar placement within an independent data set. Methods: This was a prospective, crossover study involving volunteers. Participants were randomized to either have the ONSD measured first without a cervical collar or initially with a cervical collar. Two sonographers performed independent ONSD diameter measurements. Continuous data were analyzed by matched-paired t-tests. Alpha was set at 0.05. The primary outcome parameter was the overall mean difference between ONSD measurements with the cervical collar on and off. Multiple linear regression was performed to examine the relationship between variables and the primary outcome parameter. Results: There were 30 participants enrolled in the study. Overall mean ONSD for participants without the collar was 0.365 ± 0.071 cm and with the collar was 0.392 ± 0.081 cm. The mean change in ONSD for participants with and without the collar was 0.026 ± 0.064 cm (95% confidence interval of difference: 0.015–0.038;P < 0.001). Multiple regression analysis did not identify any variables associated with the variation in ONSD observed for collar versus noncollar. Conclusions: We confirmed that ONSD does vary by a measurable amount with placement of a rigid cervical collar on healthy volunteers when assessed by ultrasound.
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A comprehensive analysis of traumatic rib fractures in an acute general hospital in Singapore p. 145
A K Ishara Maduka, George J Lin, Woan Wui Lim, Daniel Jin Keat Lee, Min Li Kang, Kumaresh Venkatesan, Ming Hui Wong, Jerry Goo Tiong Thye
Background: Rib fractures are common sequelae after blunt chest wall trauma. They can occur in isolation or association with life-threatening injuries to the head, thorax, and abdomen and may be complicated by hemothorax, pneumothorax, or lung contusions. Contiguous rib fractures can result in flail chest, which is associated with increased morbidity and mortality. This study aims to compare the risk factors, treatment modalities, and outcomes between patients with flail chest and nonflail chest postblunt trauma. Patients and Methods: Data were retrospectively collected from all patients admitted with rib fractures from January 2016 to December 2016 to the Department of General Surgery, Khoo Teck Puat Hospital, Singapore. The outcomes identified were mortality, pain scores on injury day 1, 3, 5, and 7, injury severity score, duration of mechanical ventilation, worst partial pressure arterial oxygen/fraction of inspired oxygen (PaO2/FiO2) ratio, length of intensive care unit (ICU) stay, and pulmonary complications. Results: Motor vehicle accident was the most common cause of rib fractures (63.1%, n = 123). Patients with flail chest had more associated pneumothorax (53.8% vs. 35.2%) and lung contusions (53.8% vs. 30.2%) compared to those without flail chest and underwent more investigations such as inpatient-computed tomography scans (76.9% vs. 59.3%), interventions such as chest tube insertion (61.5% vs. 19.8%), and ICU admission (46.1 vs. 13.7%). Patients also had higher pain scores, used more analgesic modalities, and had increased inpatient mortality (30.8% vs. 4.4%). Conclusion: Flail chest is associated with higher morbidity and mortality. Proactive management from a multidisciplinary team such as identification of high-risk patients in particular patients with flail chest, early admission to critical care, and protocols including multimodal pain management, respiratory support, and rehabilitation should be instituted.
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WACEM consensus paper on deep venous thrombosis after traumatic spinal cord injury p. 150
Boris Vladimir Cabrera Nanclares, Huber Said Padilla-Zambrano, Ayman El-Menyar, Luis Rafael Moscote-Salazar, Sagar Galwankar, Ranabir Pal, Amrita Ghosh, Amit Agrawal, Mendoza-Flórez Romario
The risk and outcome of deep vein thrombosis (DVT) in patients who sustained spinal cord injury (SCI) remain a challenge. We aimed to assess the incidence, risk, burden, and prophylaxis of DVT after SCI. Thirty-nine studies were identified from among 250 relevant articles based on firstly, broad criterion of DVT among SCI cases. secondly, “risk factors” impacting DVT, thirdly, published reports from apex bodies of global importance such as World Health Organization, Centre for disease control, Atlanta USA, and others were given due weightage for their authenticity. SCI is characterized by loss of motor, sensory, and autonomic function with partial or total damage of the anatomical structure leading to increased risk of thrombogenesis. SCIs present a higher risk of venous DVT constituting 9.7% of deaths in the 1st year of follow-up. Currently, prophylaxis with mechanical methods, vena cava filters and antithrombotic chemoprophylaxis in SCI are interventions for the management of DVT. DVT in SCI patients is not uncommon and needs a high index of suspicion and implementation of institutional prophylaxis protocol.
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2019 WACEM - Academic college of emergency experts consensus recommendations on admission criteria to pediatric intensive care unit from the emergency departments in India p. 155
AV Lalitha, Bernhard Fassl, Ramon E Gist, Binita R Shah, Nitin Chawla, Ajay Singh, Arun Baranawal, Shivakumar Shamarao, Raghavendra Vanaki, Prashant Mahajan, Reena Patel, Vivek Chauhan, Prerna Batra, Abhijeet Saha, Sagar Galwankar, Santosh Soans
There is a global variation in policies that define clear indications for pediatric intensive care unit (PICU) admissions. In resource-limited countries where PICU service availability is limited, the admission criteria to PICU are urgently needed to optimize the utilization of available intensive care services and to maximize patient benefit. The objective of these consensus recommendations on PICU admission criteria is to provide a framework and reference for future policy development by professional societies and governments. Design: The consensus recommendations were developed by a multidisciplinary consensus task force comprised of international experts in pediatric critical care, emergency medicine, trauma, critical care, and health policy stakeholders during the 2016 annual INDUSEM WORLD CONGRESS in Bengaluru, India. Measurements and Main Results: A task force steering committee completed a global literature search about PICU admission criteria development, reviewed PICU admission guidelines published by a variety of professional organizations worldwide, and performed a literature review of relevant publications. The objectives of this task force is to provide a framework for validated approach to determine appropriateness of intensive care unit (ICU) admission in India (resource-limited setting) based on (a) prioritization modeling; (b) general clinical criteria; (c) clinical and objective parameters; and (d) other criteria. The expert consensus panel then discussed and ranked proposed criteria according to scientific evidence, the current standard of care, and expert opinion in the context of the Indian health system. The general subject was addressed in sections: admission criteria and benefits of different levels of care. Following the appraisal of the literature, discussion, and consensus, recommendations were written. Conclusion: Although these are consensus recommendations, the subjects addressed encompass complex ethical and medicolegal aspects of patient care that affect daily clinical practice. The scarcity of high-quality evidence made it difficult to answer all the questions asked related to ICU admission. Despite these limitations, the members of the task force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission process. This publication is designed to assist in future development of health policies to ensure effective resource allocation, maximize healthcare benefits, and improve access to quality care for children.
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The art of healing, emergency minds - A concept book p. 163
Murtuza Ghiya, Suhas Chandran, M Kishor
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All consolidations are not infective: Look beyond ARDS p. 164
Mohammed Ismail Nizami, M Rahul Rohan, Ashima Sharma
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Multiple injuries sustained when hit by a truck while playing the smartphone game Pokemon Go p. 165
Ken-Ichi Muramatsu, Hiromichi Ohsaka, Norihito Takahashi, Youichi Yanagawa
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