Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
Coverpage
 2020
Volume 13 | Issue 1
Page Nos. 1-103

Online since Thursday, March 19, 2020

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EDITORIAL  

What's new in emergencies, trauma and shock? developing competency in injury prevention p. 1
Sunil Kumar Raina
DOI:10.4103/JETS.JETS_38_19  
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EXPERT COMMENTARY Top

Making roads safe for children using integrated multi-stakeholder competency building approach p. 3
Sunil Kumar Raina
DOI:10.4103/JETS.JETS_99_19  
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SPECIAL ARTICLE Top

Maximizing learning and creativity: Understanding psychological safety in simulation-based learning p. 5
Fatimah Lateef
DOI:10.4103/JETS.JETS_96_19  
Psychological safety refers to the belief that one can express oneself without fear of the negative consequences or feedback that their speech, comment, or action might generate. It is about the willingness of learners or workers in an organization, in expressing themselves physically, cognitively, and emotionally. Psychological safety is very dynamic and will continue to evolve and change, with the interplay of a variety of external and internal factors affecting the individual, the organization, or the community. It is also closely linked to the culture in the organization, the institution, or the department. It has become a new norm, especially in high-frequency, high-intensity, and high-performance institutions and workplaces, that psychological safety must be mainstreamed and should not be just an incidental element. It also serves as a foundation for effective learning. When people feel safe and comfortable, they are more open to development, growth, and negotiating change. This is a current opinion piece by the author, who is the Director of The SingHealth Duke NUS Institute of Medical Simulation in Singapore. This is the largest and most comprehensive facility in Singapore, which is also the largest in South-East Asia. It has accreditation by the Society for Simulation in Healthcare. The paper is unique in sharing the perspectives of psychological safety in simulation-based education as well as many of the issues related to culture, which can trump strategy. Characteristics and attributes for facilitators, team training and dynamics, as well as the issue of power and hierarchy are also addressed.
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Safer roads to school p. 15
Amit Agrawal, Sanjeev Bhoi, Sagar Galwankar, Ranabir Pal, Harsh Deora, Amrita Ghosh, Luis Rafael Moscote-Salazar
DOI:10.4103/JETS.JETS_71_19  
Any and all advances made by medical science cannot solve the problem of road traffic injuries (RTIs) in school-going children, especially if the only concerned people are those of the medical fraternity. Children are a vulnerable part of the traveling population and thus have been persistent due to the callous nature of the citizens and policy makers toward road safety and injury prevention. In our multicultural and multilingual country, there is a need for multistakeholder initiative with a countrywide presence if we are to stem the rise of mortality and morbidity due to these accidents. The first question we need to ask is how to prevent road traffic accidents and improve the condition of our roads. Pediatric RTIs are eternal problem of industrial revolution with complications and effects that may affect individual and society with increase in the number of motorized communications. Dedicated capacity building is urgently need who should be able to provide the necessary care to the injured children at the road crash spot as well as should be informed where to take the injured child and whom to contact in the dedicated injury care center while transporting the victims of situations.
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POSITION PAPER Top

Novel coronavirus (COVID-19): Leveraging telemedicine to optimize care while minimizing exposures and viral transmission Highly accessed article p. 20
Vivek Chauhan, Sagar Galwankar, Bonnie Arquilla, Manish Garg, Salvatore Di Somma, Ayman El-Menyar, Vimal Krishnan, Joel Gerber, Reuben Holland, Stanislaw P Stawicki
DOI:10.4103/JETS.JETS_32_20  
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The INDUSEM position paper on the emerging electronic waste management emergency p. 25
Nayer Jamshed, Praveen Aggarwal, Sagar Galwankar, Sanjeev Bhoi
DOI:10.4103/JETS.JETS_139_19  
Electronic waste or e-waste is a serious and concerning issue globally. Exponential increase in the production of these instrument have created a man-made problem of e-waste; United Nations has called it as “tsunami of e-waste.” Informal management and unsafe disposals have compounded the problem further. The hazardous chemicals, metals, and organic pollutants released from e-waste can lead to serious health consequences such as organ damage, genetic defects, neuropsychiatric illness, and cancer. Problem of e-waste is colossal and should be seen as major public health emergency. In India, use of electronic instrument has increased considerably with less focus on formal waste management and safe disposal. This has created a major health hazard. International health agencies, Indian Council of Medical Research, e-waste regulating bodies, academic institutes, and various government and non-government organizations should join hands together to effectively manage the problems of e-waste. Swacch Bharat Abhiyan started by the honorable Prime Minster should consider e-waste as the top most priority in terms of its safe management and disposal.
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ORIGINAL ARTICLES Top

An epidemiological study of injuries in Karnali, Nepal p. 30
Deepak Sharma, Prem Prasad Panta, Kapil Amgain
DOI:10.4103/JETS.JETS_14_19  
Background: Trauma, a major public health concern in remote highlands of Nepal, has led to considerable morbidity and mortality. The study elucidates the pattern and characteristics of trauma at the only tertiary care hospital in the Karnali province, Nepal. Materials and Methods: Case records of all injured patients who presented to the emergency department from January to December 2018 were analyzed for demographic data, types of injuries, body parts injured, the outcome of the treatment, and distribution of injuries with respect to age and sex. Results: A total of 460 injured patients (age: 26.5 ± 19.67 years, range: 0.5–84) were studied consisting of 282 (61.3%) males and 178 (38.7%) females, with a male-to-female ratio being 1.58:1 (P = 0.001). Unintentional injuries were the predominant form of trauma (n = 383, 84.1%), with fall (n = 194, 42.2%), road traffic crashes (RTC) (n = 161, 35%), and physical assaults (n = 73, 15.9%) being the top three leading causes in order. Fall injury and RTC were most prevalent in children, accounting 12.8% (59) and 9.3% (43) of the total injuries, respectively. The physical assaults were predominant (n = 23, 5%) in adults (20–29 years). Male patients significantly outnumbered females for all types of injuries. Soft tissue followed by head and extremities was the most common site of injuries. Conclusion: Trauma in Karnali is a predominantly early age male occurrence, with fall injury being the leading etiological factor, followed by injuries due to RTC and physical assaults. Soft tissue, head, and extremities were the major sites of injuries. Reducing fall injuries, RTC, and physical assaults will likely reduce mortality and morbidity due to trauma in this province.
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Marijuana screening and trauma outcomes p. 35
Quinn Fujii, Issak Olsen, Andrew McCague
DOI:10.4103/JETS.JETS_6_19  
Objective: The objective of this study was to determine if positive marijuana toxicology screen is associated with worse outcomes following trauma. Methods: A 3-year retrospective study was conducted on adult trauma patients using a Level II trauma registry. Patients were included if they had marijuana toxicology results available and were excluded if they tested positive for polysubstance. Endpoints of interest were mortality, injury severity score, length of stay (LOS), Glasgow coma Scale, and blood requirements. Results: Three hundred and eighty-one patients met the criteria. There was no difference between the two groups with regard to mortality (1.63% vs. 3.05%, odds ratio [OR]: 0.52 [0.13–2.14]) or LOS (1 day vs. 1 day, P = 0.125), and P > 0.05 for all other metrics besides age (31.53 years vs. 50.20 years, P = 0). OR for suffering major trauma in patients <55 years was 2.26 (16.88% vs. 8.26%, OR: 2.26 [1.02–5.01]), and patients 55 years and older were more likely to present with lower blood pressure (129.12 mmHg vs. 140.85 mmHg, P = 0.002) and higher heart rate (95.25 bpm vs. 83.47 bpm, P = 0.026). Conclusions: A positive screen for marijuana in the setting of a trauma is not associated with increased mortality or hospital LOS. These results warrant further investigation of the effects of marijuana on trauma outcomes.
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Spectrum of ocular injuries and visual outcome following firework injury to the eye p. 39
Neethu Ann Kurien, Jayanthi Peter, Pushpa Jacob
DOI:10.4103/JETS.JETS_62_18  
Background: Ocular injury due to fireworks requires urgent ophthalmic assessment and management to preserve vision. Methods: Spectrum of injury, type of intervention, visual outcome, and reasons for visual loss were assessed in consecutive patients presenting over 2 years with firework-related eye injury. The final visual outcome was recorded as best-corrected visual acuity. Results: In the 96 patients (75 males) enrolled, 122 eyes were involved. Twenty-six patients had bilateral eye injury. The median (interquartile) age was 14 (8, 28.5) years. Injuries occurred during Diwali festival (59.4%) and funeral processions (20.8%); over half (53.8%) were bystanders. Injury was due to negligence (78%), device malfunction (12.5%), and attempts to reignite (5.2%) or recover failed device (4.2%). Presenting symptoms were redness (100%), pain (97%), watering (86%), and reduced vision (77%). Facial laceration, contusion, or hematoma occurred in 13 patients. The most frequent adnexal and ocular surface injuries were lid burns (57.3%), edema (44.2%), charred eyelashes (24.6%), and laceration (13.9%). Open-globe injury occurred in 8 eyes. Common anterior segment injuries were corneal epithelial defect (51.6%) and hyphema (20.5%). Posterior segment injuries included commotio retinae (13.1%) and Berlin's edema (7.4%). Surgical treatment was required in 15 eyes; 107 (88%) were managed conservatively. At study completion, of the 99 eyes evaluated, 21 had reduced visual acuity (<6/6) including 7 with monocular blindness. Factors associated with poor vision were open-globe injury (P < 0.001) and poor initial visual acuity (P = 0.05). Conclusions: Open-globe injury and poor visual acuity at presentation predict the final visual outcome. Monocular blindness following firecracker injury is common.
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Increase in fibrinogen degradation product levels 5 days after a traumatic insult p. 45
Hiroki Nagasawa, Kazuhiko Omori, Ikuto Takeuchi, Youichi Yanagawa
DOI:10.4103/JETS.JETS_105_19  
Context: Few reports have investigated the time course of fibrinogen (or fibrin) degradation product (FDP) levels for trauma patients in the subacute phase. Aims: This study aimed to investigate the time course of the FDP levels among patients with moderate and severe trauma in the subacute phase. Settings and Design: A retrospective medical chart review in a single hospital. Subjects and Methods: From September 2017 to March 2018, a medical chart review was retrospectively performed for all patients with trauma who were admitted to our department, and these patients were included as participants in the present study. We collected the data on each patient's sex, age, presence of head injury, mechanism of injury, Glasgow Coma Scale on arrival, systolic blood pressure, heart rate, type of injury (blunt versus penetrating), injury severity score, complication of infection, surgical procedure, duration of admission, survival rate, and FDP level from the 1st to 7th hospital day. The average level of FDP on each hospital day was compared with that on the previous day. Statistical Analysis Used: The statistical analyses were performed using a paired Student's t-test. P < 0.05 was considered to indicate a statistically significant difference. Results: From the 1st to 4th hospital day, the average level of FDP significantly diminished day by day. However, from the 5th hospital day, the average level significantly increased. This trend persisted even after excluding the complications of infection and surgical procedures performed between the 2nd and 7th hospital day. Conclusions: Among trauma patients, the average level of FDP significantly diminished day by day from the admission to the 4th hospital day; however, from the 5th hospital day, the average level significantly increased. Further studies are needed to determine the time course of FDP or D-dimer levels in the long term and when FDP levels return to normal limits.
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Caval aortic index: A novel tool for fluid assessment in obstetric emergencies p. 50
Lakshmi Priya Menon, Jayaraj Mymbilly Balakrishnan, William Wilson, Mariam Koshi Thomas
DOI:10.4103/JETS.JETS_136_18  
Background: Uncorrected maternal hypotension occurring during obstetric emergencies may result in maternal and fetal morbidity. Fluid status of the pregnant mother is a major variable which affects the maternal hemodynamics during patient management, and there is no objective assessment tool for the same. A relatively new sonographic parameter, the inferior vena cava aorta (IVC/Ao) diameter index or caval aortic index, showed promise in this regard, and its application was studied in obstetric patients. Methodology: A prospective analytical study was conducted involving 50 pregnant and 50 nonpregnant women of reproductive age group. Using both subxiphoid and transhepatic views, their normal fasting caval aortic indices were determined from the ratio of mean IVC diameter to the mean aortic diameter. Descriptive and inferential statistical analyses were carried out accordingly. Results: Normal IVC/Ao diameter index for nonpregnant healthy women of reproductive age was 1.11 ± 0.29 in the subxiphoid view and 1.21 ± 0.33 in the transhepatic view. The difference between the two views was not statistically significant. IVC/Ao diameter index for a normal term pregnant woman was 1.03 ± 0.26, and term pregnancy does not significantly cause variation in the index. Conclusions: Caval aortic index is a useful noninvasive tool to assess volume status and guide fluid management in pregnant women presenting to the emergency department, and the transhepatic view is comparable to the traditional subxiphoid view for the measurement of the same.
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Manipulation of breath alcohol tests: Can specific techniques alter breath alcohol content? p. 54
Brian Kelly, Jason Black, Jill Stoltzfus, Holly A Stankewicz
DOI:10.4103/JETS.JETS_4_19  
Objective: The most common form of measurement of breath alcohol content (BrAC) is through the use of a diode catheter. This study aims to test the accuracy of breath alcohol analysis through different manipulations. Methods: BrAC was measured after individuals consumed each standardized beer until they reached a 0.1 BrAC. Then, the individuals were breath analyzed while not providing full effort, using the side of their mouths, immediately after hyperventilating, 5 and 10 min after hyperventilation, immediately after a sip of water, and 5 min after that water. Results: There were 54 individuals. Two baselines were used as the controls. The first baseline was a mean BrAC of. 104 with standard deviation of +0.008 for poor effort, side of mouth, and hyperventilating. The second baseline used for drinking water manipulations was a BrAC of 0.099 + 0.11. Poor effort (mean + standard deviation: 0.099 ± 0.10, P < 0.0001), immediately after hyperventilating (0.086 ± 0.011, P < 0.0001), 5 min after hyperventilating (0.099 ± 0.009, P < 0.0001), and 10 min after hyperventilating (0.099 ± 0.011, P < 0.0001) were all found to be statistically significant in their ability to lower BrAC. Both immediately after water (0.084 ± 0.011, P < 0001) and 5 min after drinking water (0.096 ± 0.13, P < 0.0001) were found to have significantly altered the BrAC. Conclusion: Our research shows that manipulations can alter BrAC readings significantly. Breath analyzer operators should be cognizant of these methods that may lead to falsely lower BrAC readings.
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Emergency airway management: A look into the practice, rate of success, and adverse events of 94 endotracheal intubations p. 58
Fiqry Fadhlillah, Sarah Bury, Ewa Grocholski, Mike Dean, Ali Refson
DOI:10.4103/JETS.JETS_100_19  
Context: Endotracheal intubation in the critically unwell is a life-saving procedure, frequently performed in the emergency department (ED). The 4th National Audit Project (NAP4) of the Royal College of Anaesthetists and Difficult Airway Society, however, highlighted the deficiencies that could have led to serious harm. In direct response to NAP4, a 2018 guideline was published on the management of intubations in critically ill adults. Aims: This study describes the current practice of endotracheal intubation, in comparison to the published 2018 guideline. Settings and Design: A retrospective observational study in an ED of a district general hospital in Greater London. Subjects and Methods: Adult attendances from September 1, 2017, to September 1, 2018 (> 18 years old) fulfilling the search criteria were reviewed, producing 1553 case notes. These cases were individually reviewed by the authors. Statistical Analysis Used: Mann–Whitney U-test. Results: There were 94 intubations, male to female ratio 1.8:1. The most common indication was for airway protection (n = 35), followed by respiratory failure (n = 23). There were 31 first-pass intubation successes. Intensivists performed most of the intubations (n = 66), followed by anesthetists (n = 13), and ED physicians (n = 10), but with no significant difference between the response rates of ED and external physicians (P = 0.0477). Propofol was the induction drug of choice (n = 37), with rocuronium the paralyzing agent of choice (n = 42). Altogether, there were eight complications reported. Conclusions: This study provides an overview of the intubation practices in a single-center ED. Non-ED physicians perform the majority of intubations, with a variety of induction and paralyzing agents being used. It adds to the growing call for better standardization and provision of care to patients with a deteriorating airway and the continued auditing of practice.
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Profile of pediatric trauma among the patients attending emergency department in a tertiary care hospital in South India p. 62
K. N. J. Prakash Raju, S Jagdish, G Krishna Kumar, D Anandhi, Jency Antony
DOI:10.4103/JETS.JETS_149_18  
Background: Pediatric trauma is emerging as an epidemic worldwide; the epidemiology of pediatric trauma is different in different parts of the world. There are very few studies describing the pediatric trauma in developing countries. Objectives: The objectives of this study were to assess the type, mechanism, and extent of trauma among pediatric trauma patients and its association with clinical outcome. Methodology: This was a prospective observational study conducted in the department of emergency medicine and trauma at a tertiary care hospital in South India from September 2015 to March 2017. All children aged <12 years with a history of injuries irrespective of the cause for attending our trauma center were included in the study. Observations and Results: Of the 911 children enrolled, 63.9% sustained injuries at home. The leading modes of injury were fall at level ground (26.9%), road traffic accidents (RTAs) (25.5%), and fall from height (16.8%). Majority of RTA victims were two-wheeler pillion riders (40.5%) and pedestrians (31.9%). Nearly 49% of children had head and maxillofacial injuries. Polytrauma was found in 3.6% of children. Based on the Pediatric Trauma Score (PTS), 72.6% of children had mild trauma and 6.1% severe trauma. Totally, 18.9% of children required inpatient management, 7.5% surgical intervention, and 1.8% expired. Conclusions: Most of injuries in children occurred at home. This was followed by injuries on road. The leading cause of polytrauma was RTA. RTA victims were more likely to have severe injuries and poor outcome. They were more likely to require inpatient management compared to those who fell from height or fell at level ground. Glasgow Coma Scale and PTS may be used reliably to assess the severity of injuries sustained by children.
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A survey of emergency providers regarding the current management of anterior shoulder dislocations p. 68
DN Baden, MH Roetman, T Boeije, N Mullaart-Jansen, MD Burg
DOI:10.4103/JETS.JETS_87_18  
Background: Anterior shoulder dislocations (ASDs) are frequent painful injuries commonly treated in the emergency department. The last decade new potentially less traumatic and painful reduction techniques for ASDs have been introduced. Recent literature comparing best reduction techniques, medication use, and approaches is limited. To better guide future research including the use of these newer techniques, information about the current use of different reduction techniques and medication is needed. Methods: Our primary aim was to survey the techniques used by emergency practitioners to reduce ASDs. Our secondary objective was to gather data on medication usage during reduction. To these ends, we surveyed members of the Netherlands Society of Emergency Physicians. Results: Forty-four percent of respondents reported using a traction-based technique (Hippocrates or Stimson). Biomechanical techniques were used by 40% of respondents. Twelve percent reported using the Kocher leverage-based technique. Five percent of the techniques used could not be classified. A wide variety of procedural sedation and pain management interventions were reported, with an opioid and propofol being used most commonly. Approximately 9% of the reductions were attempted without any medications. Conclusions: To our knowledge, this is the first study of its kind on ASD management by emergency practitioners. Our results indicate that Dutch emergency practitioners employ all three classes of reduction techniques: traction-countertraction most commonly, closely followed by biomechanical techniques. Medication use during repositioning varied widely. Per our survey, emergency practitioners are desirous of an evidence-based guideline for ASD management.
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Profiling cycling trauma throughout the body with and without helmet usage in a large united states health-care network p. 73
Shanna Elizabeth Williams, Laura Cook, Tyler Goff, Reema Kashif, Rachel Nelson, Melissa Janse
DOI:10.4103/JETS.JETS_65_18  
Background: This study aimed to characterize bodily injury patterns associated with helmet usage by comparing trauma sustained by helmeted and helmetless cyclists admitted to a large US health-care system. Materials and Methods: A prospective trauma registry associated with a large regional United States health-care network was queried for bicycle injuries resulting in hospital admission over a 5-year period. Data pertaining to helmet usage, demographics, injury description (s), Abbreviated Injury Scale score, Injury Severity Score, and hospital length of stay were collected from 140 patients treated for bicycle-related injuries. Mann–Whitney tests were performed. Results: Fifty-six of the injured cyclists were helmeted (40%) and 84 were not helmeted (60%). A significantly greater proportion of helmeted cyclists exhibited abrasions and a higher incidence of injury across all injury types (P = <0.001 and 0.003). The number and severity of injury to the external body (P = <0.001 and 0.001) and overall injury severity (P = 0.004) for patients with multiple injuries were also significantly greater among helmeted cyclists. Helmeted cyclists did demonstrate significantly shorter hospital stays (P = 0.021). Conclusion: While the helmeted and helmetless riders admitted to the emergency department exhibit few differences in injury patterns, when significant injury differences were detected, they were more prevalent in helmeted riders. These differences were represented by minor-to-moderate injuries relative to morbidity and mortality, suggesting that the trauma profile of the helmeted and helmetless riders is relatively comparable. Yet, helmetless wearers did have significantly longer hospital stays, which may indicate underlying health disparities and/or behavioral differences.
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Evaluation of wait time in the children's emergency and outpatient units of a tertiary hospital in Southeast Nigeria p. 78
Ikenna Kingsley Ndu, Chidiebere D I. Osuorah, Ogechukwu F Amadi, Uchenna Ekwochi, Bismark C Ekeh, Obinna C Nduagubam, Ifeyinwa B Okeke
DOI:10.4103/JETS.JETS_139_18  
Background: Promptness of intervention in the emergency room (ER) or outpatient unit is a major determinant of outcome in acutely ill children. Time is, therefore, of the essence in trying to reduce complications and mortality associated with children. Methods: This was a cross-sectional study conducted in the children ER and the children outpatient unit of the Enugu State University Teaching Hospital (ESUTH), Enugu, Southeast Nigeria. Waiting time defined as the time between arrival and doctor consultation was calculated. Results: A total of 248 respondents were enrolled during the study period. In the emergency unit, majority (67.5%) of the respondents' sick children were attended to almost immediately, while 13.3% and 19.3% waited for ≤10 and >10 min, respectively, before being attended to by a doctor. The mean waiting time in the emergency unit was approximately 9.27 ± 29.2 min (95% confidence interval [CI]: 2.90–15.65 min) with a range of 0–56 min. In the outpatient unit, the mean waiting time was 12.67 ± 15.3 min (95% CI: 10.31–15.01 min) with a time range of 5–245 min. Eighty-five (51.5%) of the 165 respondents waited for <10 min, 60 (36.4%) waited for between 10 and 30 min, while 20 (12.1%) waited for >30 min before their sick children were attended by a doctor. Conclusion: The mean waiting times reported in this study in the emergency and outpatient units of the ESUTH were within acceptable standards. However, there were cases where the waiting time in both children's units was exceptionally long. There is need for continued monitoring and evaluation of waiting times in these units for prompt attention to patients.
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CASE REPORTS Top

Stability of surgical rib fixation hardware after repeat chest trauma p. 84
Jackson Rucker Staggers, Patrick B Dennis, Evert A Eriksson
DOI:10.4103/JETS.JETS_67_19  
Surgical management of rib fractures has long been a controversial topic, but improvements in rib plating technology have led to a recent increase in interest among surgeons. Unfortunately, follow-up data are limited in patients following rib fracture plating. We present a unique case of an adult male who had multiple ribs plated for symptomatic rib fracture nonunions and developed periprosthetic fractures following repeat trauma several months later. A 57-year-old male with a history of trauma was treated for symptomatic nonunion of several left lateral ribs with surgical rib fixation. He tolerated the procedure well and had significant improvement in his symptoms on follow-up. Several months later, he was hit by a motor vehicle while riding his bicycle. He was found to have flail chest with lateral segmental rib fractures of the first through second ribs, posterior periprosthetic fractures of the seventh through tenth ribs, and lateral fractures of the eleventh and twelfth ribs. The rib plating hardware was completely intact, except for a single displaced seventh rib screw. To our knowledge, this is the first case report of repeat chest trauma following rib plating. Interestingly, the patient developed posterior periprosthetic fractures, and hardware was completely intact except for a single screw that was displaced. The goal of this report is to describe the unique fracture pattern of a flail chest with prior rib plating and to describe potential revision plating techniques and complications that surgeons may encounter in the management of trauma patients with prior rib plating.
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Noniatrogenic colorectal barotrauma with extraperitoneal rectal injury p. 88
Mohamed Javid, Shanthi Ponnandai Swaminathan, Vikas Kawarat, Arun Victor Jebasingh, Manivannan Velayutham
DOI:10.4103/JETS.JETS_156_19  
We present the case of a 22-year-old male who presented to us with abdomen discomfort with subcutaneous emphysema in the abdomen and lower chest, following a prank played by his friend who had inserted a nozzle through his anal orifice and pumped high-pressure condensed air through it. Computed tomography showed evidence of air pockets in the ischiorectal fossa and pelvis. Intraoperatively, we found large-bowel and small-bowel distension with large-bowel serosal tears and rectal tears. The tears were primarily sutured and a transverse loop colostomy was fashioned to facilitate healing of rectal wounds and to relieve the distension. The colostomy was closed after 8 weeks. The postoperative period turned out to be uneventful. We intend to present this case to sensitize the readers about the unusual mode of presentation and our management which we hope would help the medical fraternity who might encounter similar scenarios.
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Abstracts for the 37th annual emergencies in medicine conference p. 91
Sukaina Ali Alali, Lorenzo Paladino, CAPT Sally Tamayo, Timothy E Van Meter, Daniel R Bensimhon, Sam Adelman, Abraham Akbar, Nathan Douglas Vandjelovic, Christopher Voigt, Zubaid Rafique, John Riordan, W Frank Peacock
DOI:10.4103/JETS.JETS_15_20  
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IMAGE IN CLINICAL MEDICINE Top

Corneal perforation and blindness from extreme proptosis p. 96
Colin Bacorn, Lily Koo Lin
DOI:10.4103/JETS.JETS_146_19  
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LETTERS TO EDITOR Top

Isolated quadriceps weakness: A case of hypokalemic periodic paralysis p. 97
Ritika Agarwal, Ravinder Singh Aujla, Amit Gupta
DOI:10.4103/JETS.JETS_119_19  
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A case of triphasic anaphylaxis p. 98
Ikuto Takeuchi, Ken-Ichi Muramatsu, Hiroki Nagasawa, Youichi Yanagawa
DOI:10.4103/JETS.JETS_132_19  
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Transient left hemiparesis due to aortic dissection p. 99
Ken-Ichi Muramatsu, Hiroki Nagasawa, Ikuto Takeuchi, Youichi Yanagawa
DOI:10.4103/JETS.JETS_144_19  
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Impalement Injury Diagnosed at the Scene by a Portable X-Ray System Transported by a Physician-Staffed Helicopter p. 101
Hiromichi Ohsaka, Kazuhiko Omori, Ikuto Takeuchi, Youichi Yanagawa
DOI:10.4103/JETS.JETS_164_19  
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Winning together: Novel coronavirus (COVID-19) infographic Highly accessed article p. 103
Stanislaw P Stawicki, Sagar C Galwankar
DOI:10.4103/0974-2700.281047  
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