Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
October-December 2017
Volume 10 | Issue 4
Page Nos. 167-217

Online since Thursday, October 12, 2017

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What's new in emergencies trauma and shock - Adequate pain management in the emergency department - A dream come true! p. 167
Sandeep Sahu
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Emergency departments need psychiatric emergency protocols! p. 169
Bhavesh Jarwani
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Management of psychiatric emergencies in free-standing emergency departments: a paradigm for excellence? p. 171
Veronica Tucci, Syed Moiz Ahmed, David Hoyer, Nidal Moukaddam
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Emergency physician screening and management of trauma patients with alcohol involvement p. 174
Kai H Lee, James B Olsen, Jiandong Sun
Background: Alcohol screening and brief intervention (SBI) in trauma patients has been reported in literature to be effective in changing harmful drinking patterns and injury recurrence. Despite good evidence that SBI can benefit patients and provide a more holistic care, it is not routinely implemented in acute medical settings in Australia, in particular emergency departments (EDs). Objective: This paper aims to assess the knowledge, confidence, and practice of alcohol SBI in trauma patients by emergency physicians throughout Australia and New Zealand through an online survey. Methods: Major EDs in Australia and Zealand were approached to participate in an online survey. Results from the survey were analyzed using simple descriptive summary statistics. Results: Fifty-eight physicians participated in the online survey. Almost all physicians reported at least 10% of all patients managed in ED had traumatic injuries and 35% had alcohol involvement. About 66% were consultant physicians and 84% had 5 or more years of practice. Sixty-four percent agreed to have adequate training in SBI, 22% had adequate time and resources, 47% would like more training in patient screening, and 72% were more likely to deliver SBI in 5 min. Limited time and resources were seen as major barriers. It was found that better understating of SBI may lead to higher confidence and more practice, or vice versa. Conclusion: High proportion of participants in this survey felt under-equipped to deliver SBI due to time limitation, perceived lack of resources, unsuitable environment, and supportive staff. There exists an opportunity to develop a shortened and efficient SBI program that can improve utilization of SBI in an emergency setting.
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Studying protocol-based pain management in the emergency department p. 180
Akkamahadevi Patil, Madhu Srinivasarangan, Prithvishree Ravindra, Harshit Mundada
Background: Majority of the patients presenting to emergency department (ED) have pain. ED oligoanalgesia remains a challenge. Aims: This study aims to study the effect of implementing a protocol-based pain management in the ED on (1) time to analgesia and (2) adequacy of analgesia obtained. Settings and Design: Cross-sectional study in the ED. Methods: Patients aged 18–65 years of age with pain of numeric rating scale (NRS) ≥4 were included. A series of 100 patients presenting before introduction of the protocol-based pain management were grouped “pre-protocol,” and managed as per existing practice. Following this, a protocol for management of all patients presenting to ED with pain was implemented. Another series of 100 were grouped as “post-protocol” and managed as per the new pain management protocol. The data of patients from both the groups were collected and analyzed. Statistical Analysis Used: Descriptive statistical tests such as percentage, mean and standard deviation and inferential statistical tests such as Pearson coefficient, Student's t-test were applied. Differences were interpreted as significant when P < 0.05. Results: Mean time to administer analgesic was significantly lesser in the postprotocol group (preprotocol 20.30 min vs. postprotocol 13.05 min; P < 0.001). There was significant difference in the pain relief achieved (change in NRS) between the two groups, with greater pain relief achieved in the postprotocol group (preprotocol group 4.6800 vs. postprotocol group 5.3600; P < 0.001). Patients' rating of pain relief (assessed on E5 scale) was significantly higher in the postprotocol group (preprotocol 3.91 vs. postprotocol 4.27; P = 0.001). Patients' satisfaction (North American Spine Society scale) with the overall treatment was also compared and found to be significantly higher in postprotocol group (mean: preprotocol 1.59 vs. postprotocol 1.39; P = 0.008). Conclusion: Protocol-based pain management provided timely and superior pain relief.
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Like the eye of the tiger: Inpatient Psychiatric facility exclusionary criteria and its “Knockout” of the emergency psychiatric patient p. 189
Veronica Tucci, John Liu, Anu Matorin, Asim Shah, Nidal Moukaddam
Context: Over 6% of all emergency department (ED) visits in the United States involve primary mental health or behavioral issues. The patients are stabilized in the ED but frequently require admission to an inpatient psychiatric unit or institution for longer term treatment and management. To facilitate this process, an emergency physician (EP) must first “medically clear” the patient as stable for transfer. At present, there is no interdisciplinary consensus regarding the necessary elements of the medical clearance or stability assessment process. In addition to satisfy the vague requirement for medical clearance, the EP must abide by the rules of the inpatient facilities before his/her patient is accepted. Settings and Design: This manuscript summarizes the admission exclusionary criteria of inpatient psychiatric units in the Houston–Galveston metro area. Subjects and Methods: we pooled the exclusionary criteria of all the facilities patients with mental illness can be sent to in the Houston-Galveston metropolitan area, and divided those criteria by categories. Results: Pooled exclusionary criteria congregate into 1. preexisting or current medical condition and capabilities (e.g. hypertensive urgency, pregnancy, acute alcohol intoxication), 2. exclusionary criteria related to administrative burdens that may impact staffing or require advanced equipment/training e.g. autism spectrum disorders, intellectual disabilities, respiratory isolation or daily hemodialysis, 3. laboratory and ancillary testing required by inpatient facilities before acceptance of the patient. Conclusions: Of the inpatient units in the Houston-Galveston area, facilities lack a unified staffing model, ancillary services, but the various challenges (e.g., limited staffing and ancillary services) and different skills offered (e.g., geriatric care) are reflected in exclusionary criteria in a partially overlapping, but not fully uniform, way. The variation in number and kinds of exclusionary criteria further complicate the admission process and often serve as a bottleneck in the securing an inpatient bed.
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Serum cortisol level in indian patients with severe sepsis/septic shock p. 194
Ragavendra Suresh, Naveet Wig, Prasan Kumar Panda, VP Jyotsna, PK Chaturvedi, RM Pandey
Background: The relationship between cortisol level and sepsis is not known in Indian patients of severe sepsis/septic shock. Aims: The study was done to determine the optimal range of cortisol levels, defining the adrenocortical response, and predicting the mortality, if possible, in the above type of patients. Settings and Designs: The study was a single-centered prospective cohort study, conducted in a tertiary referral center, North India. Materials and Methods: Sixty patients with severe sepsis (n = 30) and septic shock (n = 30) were recruited. Basal and postcosyntropin (1 μg)-stimulated cortisol levels were measured, and all patients were closely monitored with daily assessments of clinical and laboratory variables. Western diagnostic criteria were followed for defining adrenal insufficiency (AI). The end point was the survival assessed at day 28 or death, whichever came earlier. Results: The mean basal (T0) and poststimulation (T30) cortisol levels were 31.77 ± 15.9 μg/dL and 37.58 ± 17.31 μg/dL, respectively. In all sepsis patients, 48.33% qualified as AI at T0 ≤ 24 μg/dL, 61.67% at delta cortisol (Δ = T30-T0) ≤7 μg/dL, and 78.33% at Δ ≤9 μg/dL. Using receiver operating characteristic curve, the area under the curve (AUC) was 0.4954, signifying poor prediction to death. Conclusions: Indians have completely different characteristics of cortisol levels in sepsis patients, in comparison to the Western data. They have higher range of basal cortisol levels, higher percentage of AI, and an inability to predict mortality with the cortisol levels. Hence, there is requirement of an international study to confirm the dichotomy of the results.
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Quantifying Burnout among Emergency Medicine Professionals p. 199
William Wilson, Jeffrey Pradeep Raj, Girish Narayan, Murtuza Ghiya, Shakuntala Murty, Bobby Joseph
Background: Burnout is a syndrome explained as serious emotional depletion with poor adaptation at work due to prolonged occupational stress. It has three principal components namely emotional exhaustion(EE), depersonalization(DP) and diminished feelings of personal accomplishment(PA). Thus, we aimed at measuring the degree of burnout in doctors and nurses working in emergency medicine department (EMD) of 4 select tertiary care teaching hospitals in South India. Methods: A cross sectional survey was conducted among EMD professionals using a 30-item standardized pilot tested questionnaire as well as the Maslach burnout inventory. Univariate and Multivariate analyses were conducted using binary logistic regression models to identify predictors of burnout. Results: Total number of professionals interviewed were 105 of which 71.5% were women and 51.4% were doctors. Majority (78.1%) belonged to the age group 20-30 years. Prevalence of moderate to severe burnout in the 3 principal components EE, DP and PA were 64.8%, 71.4% and 73.3% respectively. After multivariate analysis, the risk factors [adjusted odds ratio (95% confidence intervals) for DP included facing more criticism [3.57(1.25,10.19)], disturbed sleep [6.44(1.45,28.49)] and being short tempered [3.14(1.09,9.09)]. While there were no statistically significant risk factors for EE, being affected by mortality [2.35(1.12,3.94)] and fear of medication errors [3.61(1.26, 10.37)] appeared to be significant predictors of PA. Conclusion: Degree of burn out among doctors and nurses is moderately high in all of the three principal components and some of the predictors identified were criticism, disturbed sleep, short tempered nature, fear of committing errors and witnessing death in EMD.
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Necrotizing fasciitis: How reliable are the cutaneous signs? Highly accessed article p. 205
Ho Jun Kiat, Yap Hui En Natalie, Lateef Fatimah
Necrotizing fasciitis (NF) is a surgical emergency. It is often aggressive and characterized by the rapidly progressive inflammatory infection of the fascia that causes extensive necrosis of the subcutaneous tissue and fascia, relatively sparing the muscle and skin tissue. As the disease progresses, thrombosis of the affected cutaneous perforators subsequently devascularizes the overlying skin. The course indeed can be a fulminant one. The diagnosis of NF, especially in the early stages, is extremely challenging, and it can be very close in presentation to other skin and subcutaneous tissue infections. The primary site of the pathology is the deep fascia. Necrosis of the tissues and fascia may manifest as erythema without sharp margins, swelling, warmth, shiny, and exquisitely tender areas. Pain out of proportion to physical examination findings may be observed. The subcutaneous tissue may be firm and indurated such that the underlying muscle groups cannot be distinctly palpated. Eventually, as the overlying skin is stripped of its blood supply, skin necrosis ensues and hemorrhagic bullae form. Bacteremia and sepsis invariably develop when the infection is well established. This paper discusses some of issues related to the cutaneous signs found in NF and also provides a review the current, available literature on the subject matter.
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Biliary complications after hepatic trauma in children p. 211
Riccardo Guanà, Carbonaro Giulia, Andrea Brunati, Salvatore Garofalo, Jurgen Schleef
Aim of the Study: In pediatric patients with liver trauma and hemodynamic stability, conservative treatment is acknowledged as the gold standard. Patients and Methods: We conducted a retrospective analysis of 116 consecutive pediatric patients (<14-year-old) observed at our institution for closed abdominal trauma from January 2010 to January 2016. Among these, 16 patients (13%) had hepatic trauma Grade II or more, according to Moore liver trauma injury score. Results: Only one patient underwent surgery for hemodynamic instability; all others children received conservative treatment according to the American Paediatric Surgical Association guidelines. Three patients had a biliary complication (2, 5%). two patients treated surgically by drainage insertion and one was managed conservatively. Conclusions: Biliary complications of liver trauma in children may require aggressive surgical approach in selective patients.
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Isolated traumatic basal ganglia hematoma in children p. 215
Sushanta K Sahoo, Sidharth Vankipuram, Chhitij Srivastava
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A case of traumatic vacuum phenomenon in the sleeve of a nerve root due to nerve root avulsions p. 216
Hiromichi Ohsaka, Chikato Hayashi, Kazuhiko Omori, Youichi Yanagawa
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