Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
Coverpage
October-December 2019
Volume 12 | Issue 4
Page Nos. 225-285

Online since Monday, November 18, 2019

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EDITORIAL  

What's new in emergencies, trauma and shock? Using queuing theory to optimize the emergency department triage process p. 225
Leon D Sanchez, Joshua W Joseph
DOI:10.4103/JETS.JETS_61_19  
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EXPERT COMMENTARY Top

Gunshot wounds – From Lebanon, via Syria, to the streets of your city! p. 227
Timothy Craig Hardcastle
DOI:10.4103/JETS.JETS_22_19  
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POSITION PAPER Top

The 2019 WACEM and academic college of emergency experts india position paper on developing the academic department of space medicine in India – The time has come! Highly accessed article p. 229
Vivek Chauhan, Sagar Galwankar, Kishore K Deepak, Anant Mohan, Randeep Guleria, Sanjeev Bhoi, Praveen Aggarwal
DOI:10.4103/JETS.JETS_126_19  
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The 2019 WACEM expert document on the framework for setting up a simulation centre Highly accessed article p. 232
Fatimah Lateef, Shanqing Yin, Madhavi Suppiah
DOI:10.4103/JETS.JETS_102_19  
Almost every institution and academic medical center has its own simulation center today. It seems to have become a prerequisite and is incorporated into the guidelines of setting up new centers as well as in the upgrading and enhancement plans of existing institutions. In considering this, it is critical to consider the needs and demands of the healthcare population and staff the center will be serving. Setting up a simulation center is not an endeavor to be undertaken lightly. It entails a sustainable commitment in terms of political will, professional, educational and financial commitments. On the other hand, setting up a simulation center can be the most worthwhile and rewarding experience if the objectives and goals are met and effective learning occurs. The latter is an important element to be considered in the step toward nurturing an effective healthcare practitioner. In this paper, the principle author, who is the Director of the SingHealth Duke NUS Institute of Medical Simulation (SIMS) in Singapore, shares her views and experience of leading a world-class simulation facility. She has been involved in SIMS from its conception and is a strong advocate of medical education and lifelong learning. At the end of this paper, she shares a Checklist which puts together all the important considerations for anyone or any institution what is looking at setting up a simulation facility, a simulation-based training program, or even upgrading and upscaling their current simulation centre.
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The 2019 WACEM expert document on hybrid simulation for transforming health-care simulation through “mixing and matching” p. 243
Fatimah Lateef, Xin Yi Too
DOI:10.4103/JETS.JETS_112_19  
With the multitude of options available under the umbrella of “simulation” today, we have a larger repertoire of choices in our educational journey and outreach. These provide a platform for us to really transform health-care simulation from the traditional, unimodality simulation, to more complex, high fidelity, integrated, and engaging multimodality techniques. The main thrust must be to enhance clinical decision-making in patient care, to solve real-world clinical problems. Hybrid simulation (HS) utilizes at least two different simulation modalities, whereby combining them will enable one type of simulation modality to enhance the other, with the proper alignment, coordination, and interfacing between the modalities. Although the term is often used interchangeably, HS is slightly different from multimodality simulation. The latter refers to the use of multiple types of simulation in the same scenario or place. The main objectives for using HS have to be as follows: (1) for the acquisition of knowledge and skills by the best combination of methodologies, (2) for clinical performance improvement at all levels of care through the creation of as close as possible to real-world situation and problems, (3) to be able to sustain motivation and passion of our spectrum learners in their educational continuum, and (4) to provide a rich, exciting, and stimulating learning platform and environment, which can trigger deep learning and understanding. This article will also share some examples and cases utilizing HS in transforming health-care simulation.
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ORIGINAL RESEARCH PAPERS Top

Utility of point-of-care lung ultrasound for initial assessment of acute respiratory distress syndrome patients in the emergency department p. 248
A Sanjan, S Vimal Krishnan, Siju V Abraham, Babu Urumese Palatty
DOI:10.4103/JETS.JETS_47_19  
Aim: Lung ultrasound (LUS) has been extensively used in the evaluation of acute respiratory distress syndrome (ARDS) in the critical care setting. In our study, we aim to assess the utility of point-of-care ultrasound (POCUS)-LUS in the initial assessment of ARDS patients presenting to the emergency department (ED). Subjects and Methods: We evaluated a prospective convenience sample of 73 adult patients presenting to the ED. The bedside LUS was performed by the trained emergency physician on patients with undifferentiated dyspnea with a clinical diagnosis of ARDS according to the Berlin's criteria. The four major LUS findings were examined on structured 12-zone LUS. The observed profile consisted of A lines, well-separated B lines, coalescent B lines, and consolidation among patients who were clinically diagnosed as ARDS. These LUS findings may vary depending on the severity of ARDS. The findings were analyzed using IBM SPSS Statistics for Windows, Version 24.0 (IBM Corp., Armonk, NY, USA). Results: Of the 73 study individuals, majority were male 46 (63%). The distributions of study individuals were as follows: 27% – mild ARDS, 37% – moderate ARDS, and 36% – severe ARDS. Coalescent B lines are present in about 70.4% and 92.3% of moderate and severe ARDS patients, respectively. Consolidations are predominantly present in moderate (100%) and severe (92.3%) ARDS. Conclusion: LUS in the initial assessment of patients' with ARDS yielded significant findings in the three clinically designated categories. This study opens up the possibility of using POCUS as an adjunct in the initial assessment of ARDS patient in the ED.
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Is emergency department thoracotomy effective in trauma resuscitation? The retrospective study of the emergency department thoracotomy in trauma patients at thammasat university hospital, Thailand p. 254
Amonpon Kanlerd, Nattida Sapsamarn, Karikarn Auksornchart
DOI:10.4103/JETS.JETS_36_19  
Introduction: The survival rate after the emergency department thoracotomy (EDT) in trauma patients varies from the previous study as 1.6% in blunt injury and 11.2% in penetrating injury. Most of the data came from Europe, the US, South Africa, and Japan. This study aims to identify the success of EDT of trauma patients at Thammasat University Hospital, Thailand, and to evaluate the effectiveness of EDT. This study may be representative data for Southeast Asia. Materials and Methods: This retrospective review of 21 consecutive EDT cases which performed by our staffs and chief of general surgery residents between June 2009 and July 2016. Age, gender, injury mechanisms, injury sites, patient transport methods, initial vital signs, fluids and blood component requirements, resuscitation times, laboratory results, and injury severity scores were all analyzed. Results: Of the 21 EDT cases, one patient was excluded due to being a nontraumatic case. The remaining twenty patients were primarily young (mean 36.5 years), male (85%), suffering from blunt injuries (75%), of which 45% were predominantly thoracic injuries. Most of the patients presented without any sign of life (75%), and the total time for resuscitation was 43.5 ± 19.6 min. Seven patients (35%) had the return of spontaneous circulation (ROSC) and were successful in being brought to the operating room. Unfortunately, all patients passed away within 24 h of the operation. Conclusions: The ROSC rate of EDT in this study was 35%, but with no survival benefit. Therefore, we cannot guarantee that EDT serves as an effective life-saving procedure. However, EDT may play a significant role in treating extremis injured patients.
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Neutrophil gelatinase-associated lipocalin as an early diagnostic biomarker of acute kidney injury in snake bite p. 260
Subramanian Senthilkumaran, Ponniah Thirumalaikolundusubramanian, Namasivayam Elangovan
DOI:10.4103/JETS.JETS_32_18  
Background: Snakebite envenomation is a major public health problem in the developing world, and the effects of viper envenomation on renal tissues leading to acute kidney injury (AKI) are well known. However, the usefulness of neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker to detect AKI in viper envenomation cases were not studied much. Aims and Objectives: The present study was undertaken to find out plasma NGAL levels and assess its usefulness among the hospitalized Viperidae group of snakebite victims in predicting acute kidney injury. Materials and Methods: The plasma NGAL level was estimated within 6–8 h of all the 184 cases of viper bites along with other laboratory parameters. Results: It was elevated much before the elevation of serum creatinine levels, irrespective of the age, gender, and bite to hospital time. The sensitivity and specificity was 99.37 and 96.15, respectively. Elevated plasma NGAL levels in viper bite helped not only to detect AKI early but also assisted to plan for appropriate intervention. Conclusion: It is suggested to include estimation of plasma NGAL in the point of care testing, especially in emergency settings handling snakebite cases. However, more studies are recommended to find out its serial levels in snakebite cases following different kinds of snake envenomation with different clinical and laboratory manifestations in different age groups and gender belonging to different population so as to arrive at valid conclusions.
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Last breath in the emergency department p. 263
Aakriti Jain, Noella Nathaniel Sase, Anne Rhea Mathew, Immanuel Judson Paul, Paul Prabhakar Abhilash Kundavaram, Priya Ganesan
DOI:10.4103/JETS.JETS_147_18  
Background: Early and aggressive time to intervention has been shown to increase the odds of survival and decrease mortality in critically ill patients. Since emergency medicine is a nascent specialty in India, a review and assessment of the mortality profile in the Emergency Department (ED) would help improve the quality of care. Aims: The aim of the study is to determine the mortality profile and causes of preventable deaths at large ED in South India. Methods: This retrospective chart review was conducted between January and December 2017. Patients admitted with Triage priority 1 and priority 2 of our ED, who died, despite treatment, were recruited in the study. Two ED consultants blinded from each other, independently audited all the charts to determine preventable and nonpreventable causes of death. Results: There were a total of 69,369 patients during the study period who presented to the ED. Despite resuscitation 189 (0.7%) died, the mortality rate was 2.43%. Cardiac-related (32%) and sepsis-related (31%) causes were the most common cause of death, 23.8% were due to preventable causes and 16.9% of which were due to inappropriate management. In patients with sepsis, the odds of death due to preventable causes were significantly high (odds ratio 4.31, 95% confidence intervals: 1.96–9.47; P < 0.001). Conclusions: Cardiac- and sepsis-related causes of death, together accounted for most of the mortality. In patients with sepsis, the odds of death due to preventable causes were more than four times higher than those without preventable causes.
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Application of queuing theory to optimize the triage process in a tertiary emergency care (“ER”) department p. 268
Atilio Moreno-Carrillo, Lina María Ávila Arenas, Julián Andrés Fonseca, Camilo Andrés Caicedo, Sandra Verónica Tovar, Oscar Mauricio Muñoz-Velandia
DOI:10.4103/JETS.JETS_42_19  
Context: Time from triage to patient care is usually evaluated, but time elapsed between the arrival of patient to emergency room (ER) and triage (pretriage) is not usually measured. Aims: The present study evaluates how the application of the queuing (or “waiting line”) theory in the triage process can generate effective strategies to improve patient care in the ER. Settings and Design: A “before-and-after” study was conducted in the ER of the Hospital Universitario San Ignacio, a tertiary emergency care in Bogotá, Colombia. Subjects and Methods: The pretriage time was evaluated, and queuing theory was applied to the evaluation; according to the results, the number and distribution of the necessary nursing personnel were determined. Statistical Analysis Used: The change in waiting times was compared using a paired t-test. Results: In a first 7 months evaluation period, 89,898 patient visits were considered, with an average pretriage time of 22.15 min. According to the arrival distribution by hours and days of the week and considering the results of the calculations made using queuing theory, the number of nurses needed in the service per hour was determined for each day of the week, and schedule changes were implemented without increasing staff. In a second similar evaluation period, 94,497 patient visits were considered demonstrating a reduction of the pretriage time to 7.5 min (mean difference 14.64 min, 95% confidence interval 14.42–14.85, P < 0.001). Conclusions: The use of queuing theory in the planning of the daily personnel requirements in the triage area of ER can reduce the pretriage time by 65% without incurring additional cost.
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Effect of prehospital transport factors on shock index, serum lactate, and mortality in children with septic shock: A prospective observational study p. 274
Jhuma Sankar, Rashmi Ranjan Das, Archana Singh
DOI:10.4103/JETS.JETS_129_18  
Context: Many children with septic shock either present late or are recognized late due to various reasons. Shock index (SI) is a valuable screening tool in dentifying high-risk septic patients in emergency department. Whether prehospital transport factors affect SI and clinical outcomes has not been evaluated. Aim: Our aim was to evaluate if prehospital transport-related factors such as mode of transport and referral from another hospital affect the admission SI and mortality in children with septic shock. Settings and Design: Prospective observational study conducted over 1-year period in the Pediatric Emergency and Intensive Care Unit of a tertiary care teaching hospital. Subjects and Methods: Children < 17 years of age were evaluated. Data collection included referral status, mode of transport, physiologic (SI and serum lactate), and clinical parameters. Statistical Analysis Used: Student's t-test was used for analyzing continuous variables. Chi-square/Fischer's exact test was used for analysis of categorical variables. P < 0.05 was considered as statistically significant. Results: Of 51 children, 21 (41%) were referred from other hospitals. Of these, less than half were transported by ambulance unaccompanied by any healthcare personnel. Twenty-six children (43%) died, of which 15 (71%) were referred. The median serum lactate, SI, and mortality were significantly higher in those referred. On multivariate analysis of factors associated with mortality, elevated SI and/or lactate >4 mmol/L and the “referral” status remained significant after adjusting for baseline variables and illness severity. Conclusions: Children with septic shock referred from other hospitals had higher SI, serum lactate, and mortality rates. Our study highlights the need for improving prehospital care and transportation in children with septic shock.
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Emergency department interventions and their effect on delirium's natural course: The folly may be in the foley p. 280
Christopher B Noel, Jamie R Cirbus, Jin H Han
DOI:10.4103/JETS.JETS_137_17  
Background: Delirium frequently affects older emergency department (ED) patients and has been associated with accelerated cognitive and functional decline, increased length of stay (LOS), and higher in- and out-of-hospital mortality. Objectives: Care provided in the ED may have downstream effects on delirium duration during hospitalization. This study aimed to identify the modifiable factors of ED care associated with delirium duration in patients admitted to the hospital through the ED. Materials and Methods: This prospective cohort study enrolled ED patients who were 65 years and older and admitted to the hospital. Delirium was determined in the ED and during the first 7 days of hospitalization using the modified Brief Confusion Assessment Method. All delirious patients and a random selection (17%) of nondelirious patients were also enrolled. ED LOS, opioid administration, benzodiazepine administration, anticholinergic medication administration, and bladder catheter placement were obtained by medical record review. Multivariable proportional odds logistic regression was performed to determine if each of the factors was associated with delirium duration after adjusting for age, dementia, baseline function, comorbidity burden, severity of illness, nursing home residence, and central nervous system insult. Results: A total of 228 patients were enrolled. ED bladder catheter placement was significantly associated (adjusted proportional odds ratio = 3.1, 95% confidence interval: 1.3 to 7.4) with increased delirium duration after adjusting for confounders. ED LOS, opioid administration, benzodiazepine administration, and anticholinergic burden, however, were not. Conclusions: ED bladder catheter placement was significantly associated with delirium duration and may present an opportunity for intervention.
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