Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
Coverpage
July-September 2020
Volume 13 | Issue 3
Page Nos. 175-235

Online since Friday, September 18, 2020

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EDITORIAL  

What's new in emergencies trauma and shock – Diagnosing intracranial hypertension p. 175
Vivek Chauhan, Sagar Galwankar
DOI:10.4103/JETS.JETS_151_20  
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REVIEW ARTICLE Top

The need for a physiological classification of hemorrhagic shock Highly accessed article p. 177
Fabrizio Giuseppe Bonanno
DOI:10.4103/JETS.JETS_153_19  
Classifications mean to conceptualize in a cluster and rapidly summarize the assessment and management of a clinical scenario. In the specific case of a hemorrhagic shock (HS), a classification should serve the purpose of allowing a rapid clinical assessment of the shock level and the earliest or right timing of source control, possibly also on whether to apply damage control surgery (DCS) strategy or not. ATLS® classification of HS is not sensitive and specific enough to help decision-making in reference to the timing of management, based only on the amount of blood loss that may be or may not rightly estimated, for example, blood loss on the floor in penetrating injuries before theatre. Moreover, it focuses also on other parameters, which are taken singularly, instead of the individual generalized physiological response to hemorrhage, which is the core by definition of the derangement we call “shock.” It is unhelpful, difficult, and impractical to apply as well. A new classification, which may well be called as the “physiological HS classification” or “therapeutic HS classification,” was proposed since 2010, following the new developments on microcirculation and an already going-on sensible praxis among some trauma surgeons. It bases on some physiological considerations such as the significance of fluid-blood resistant hypotension, body natural hemostatic mechanisms, the right definition of shock, and the relevance that hemorrhage-triggered ischemia-reperfusion toxemia and systemic inflammatory response have in critical illness scenarios as secondary insults from ischemia, which is what we mean to prevented with DCS. The key factor remains the persistence of hypotension, following fluid challenge.
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ORIGINAL ARTICLES Top

Relationship of optic nerve sheath diameter and intracranial hypertension in patients with traumatic brain injury p. 183
Ammar Al-Hassani, Gustav Strandvik, Sheraz Abayazeed, Khalid Ahmed, Ayman El-Menyar, Ismail Mahmood, Suresh Kumar Arumugam, Mohammad Asim, Syed Nabir, Nadeem Ahmed, Zahoor Ahmed, Hassan Al-Thani
DOI:10.4103/JETS.JETS_103_19  
Background: to study the association between optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) in patients with moderate-to-severe brain injury. Patients and Methods: A retrospective cohort study of traumatic brain injury (TBI) patients was conducted between 2010 and 2014. Data were analyzed and compared according to the ICP monitoring cutoff values. Outcomes included intracranial hypertension (ICH) and mortality. Results: A total of 167 patients with a mean age of 33 ± 14 years, of them 96 had ICP monitored. ICP values correlated with ONSD measurement (r = 0.21, P = 0.04). Patients who developed ICH were more likely to have higher mean ONSD (P = 0.01) and subarachnoid hemorrhage (SAH) (P = 0.004). Receiver operating curve for ONSD showed a cutoff value of 5.6 mm to detect ICH with sensitivity 72.2% and specificity 50%. Age and ICP were independent predictors of inhospital mortality in multivariate model. Another model with same covariates showed ONSD and SAH to be independent predictors of ICH. Simple linear regression showed a significant association of ONSD with increased ICP (β = 0.21, 95% confidence interval 0.25–5.08, P = 0.03). Conclusions: ONSD is a simple noninvasive measurement on initial CT in patients with TBI that could be a surrogate for ICP monitoring. However, further studies are warranted.
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Evaluation of bedside sonographic measurement of optic nerve sheath diameter for assessment of raised intracranial pressure in adult head trauma patients p. 190
Alvin Mathews, Srihari Cattamanchi, Tamilanbu Panneerselvam, Ramakrishnan V Trichur
DOI:10.4103/JETS.JETS_94_19  
Aim: The aim was to evaluate the use of bedside sonographic measurement of the optic nerve sheath diameter (ONSD) in the assessment of elevated intracranial pressure in patients with head injury coming to the emergency department (ED). Methods: A prospective study of ED patients presenting with a history of acute head injury, an ocular ultrasound was performed for ONSD measurement, followed by a computed tomography (CT) of the brain. Three measurements were taken for each eye, then, the mean binocular ONSD measurement for each patient was obtained to ensure accuracy. A mean bipolar ONSD >5 mm was considered abnormal. Results: A total of 175 patients were considered for the study. Of 175 patients, only 56 (32%) had intracranial pathology detected on CT brain with mean ONSD of 5.7 mm (standard deviation [SD]: 0.59). The mean ONSD for 119 (68%) patients, who had normal CT brain, was 4.5 mm (SD: 0.42). The mean ONSD measured for the right eye was 4.86 mm with SD 0.88, and the mean ONSD for the left eye was 4.90 mm with SD 0.85. When comparing ONSD measurement with CT findings of raised intracranial pressure, the ONSD sensitivity was 87.5% (95% confidence interval [CI]: 85%–96%) and specificity was 94.1% (95% CI: 85%–96%), with a positive predictive value of 87.5% and a negative predictive value of 94.1%. The area under the receiver operator characteristic curve obtained was 0.90 (95% CI: 0.85–0.96). Conclusion: The study has shown a bedside measurement of ONSD through sonography as an efficient tool to assess elevations in intracranial pressure in head injury patients.
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Local tranexamic acid for local hemostasis in an animal liver injury model p. 196
Shahram Paydar, Mohammad Yasin Karami, Golnoush Sadat Mahmoudi Nezhad, Rouhollah Rezaei, Alireza Makarem, Ali Noorafshan, Shahin Mohseni
DOI:10.4103/JETS.JETS_17_19  
Background: Hyperfibrinolysis is a state of increased clot resolution often seen in trauma patients with ongoing hemorrhage. Tranexamic acid (TXA) inhibits fibrinolysis preventing clot resolution affecting hemorrhage continuation and is used by intravenous administration. Aims: The purpose of this study was to evaluate the local tranexamic acid application for hemostatic control in an experimental animal liver injury model. Settings and Design: This study was an experimental prospective treatment study to check the local TXA effects on liver injury. This study was approved by the Ethics Committee. Materials and Methods: Twenty adult male Sprague-Dawley white rats were equally randomized to two groups after a standardized liver injury was conducted under anesthesia. One group were “liver-packed” with gauze (TXA [−]) and the other group with gauze soaked in TXA (TXA [+]). Bleeding from the injured middle liver lobe was measured at 2 and 15 min, and at 48h second-look surgery, with euthanasia conducted at 14 days. The liver was sent for histopathological and stereological analysis. Statistical Analysis and Results: There was no difference in bleeding at 2 or 15 min after packing; however, larger amount of free blood at 48 h in the TXA (−) group was noticed. Five animals in the TXA (−) were alive at 14 days compared to eight animals in the TXA (+) group. Significantly larger volume density of fibrosis, granulation tissue, and amorphous tissue were seen in the TXA (+) group compared to the TXA (−) group at the stereological analysis. Conclusion: Local TXA application on the injured liver surface might offer better hemostatic control than packing alone. Further studies are mandated before the clinical application of our findings.
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Variability in current trauma systems and outcomes p. 201
Adel Elkbuli, Brianna Dowd, Rudy Flores, Dessy Boneva, Mark McKenney
DOI:10.4103/JETS.JETS_49_19  
Background: Complication rates may be indicative of trauma center (TC) performance. The complication rates between Level 1 and 2 TCs at the national level are unknown. Our study aimed to determine the relationship between American College of Surgeons (ACS)-verified and state-designated TCs and complications. Study Design and Methods: This was a cohort review of the National Sample Program (NSP) from the National Trauma Data Bank, the world's largest validated trauma database. TCs were categorized by ACS or state Level 1 or 2. TCs not categorized as Level 1 or 2 were excluded. All 22 complications provided by the NSP were analyzed. Chi-squared analysis was used with statistical significance defined asP < 0.05.Results: Of the 94 TCs in the NSP, 67 had ACS and 80 had state designations of Level 1 or 2. There were 38 ACS Level 1 TCs treating 87,340 patients and 29 ACS Level 2 TCs treating 35,763. There were 45 state Level 1 TCs treating 106,640 and 35 state Level 2 TCs treating 43,290. ACS Level 1 TCs had significantly higher complications compared to ACS Level 2 TCs (13.5% [11,776/87,340] vs. 10.1% [3,606/35,763],P < 0.0001). In addition, state Level 1 TCs had significantly more complications compared to state Level 2 TCs (4.4% [4,681/106,640] vs. 1.6% [673/43,290],P < 0.0001). Conclusion: Both ACS and state Level 2 TCs had significantly lower complication rates than ACS and state Level 1 TCs. Further investigations should look for the source and impact of this difference.
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Ultrasound-guided serratus anterior plane block for rib fracture-associated pain management in emergency department p. 208
Subhankar Paul, Sanjeev Kumar Bhoi, Tej Prakash Sinha, Gaurav Kumar
DOI:10.4103/JETS.JETS_155_19  
Context: Traumatic Rib fractures are common and painful conditions to present in the emergency department. Ultrasound-guided serratus anterior plane block (SAPB) is a newer technique which is being used for managing postthoracotomy, thoracoscopic surgery, or post mastectomy pain by the anesthetists. However, we have recently started utilizing this novel technique in our emergency department for rib fracture patients with severe pain. Settings and Methods: We present a case series of 10 patients of multiple rib fractures (MFRs) with persistent Defense and Veterans Pain Rating Scale 7 or more even after intravenous analgesics where this block was applied by trained emergency physicians (EP). Results: Following SAPB median (± IQR) pain score reduction was 5 (±4) at 30 min and 7.5 (±2) after 60 min of administering the block. There were no incidences of block failure or block-related complications in our series. Conclusions: Ultrasound-guided SAPB can be used safely by trained EP in the emergency department to relieve acute severe analgesic-resistant pain in MFR patients.
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Characterization of acidosis in trauma patient p. 213
Gregory S Corwin, Kevin W Sexton, William C Beck, John R Taylor, Avi Bhavaraju, Benjamin Davis, Mary K Kimbrough, Joseph C Jensen, Anna Privratsky, Rotnald D Robertson
DOI:10.4103/JETS.JETS_45_19  
Background: Recent data suggest that acidosis alone is not a good predictor of mortality in trauma patients. Little data are currently available regarding factors associated with survival in trauma patients presenting with acidosis. Aims: The aims were to characterize the outcomes of trauma patients presenting with acidosis and to identify modifiable risk factors associated with mortality in these patients. Settings and Design: This is a retrospective observational study of University of Arkansas for Medical Sciences (UAMS) trauma patients between November 23, 2013, and May 21, 2017. Methods: Data were collected from the UAMS trauma registry. The primary outcome was hospital mortality. Analyses were performed using t-test and Pearson's Chi-squared test. Simple and multiple logistic regressions were performed to determine crude and adjusted odds ratios. Results: There were 532 patients identified and 64.7% were acidotic (pH < 7.35) on presentation: 75.9% pH 7.2–7.35; 18.5% pH 7.0–7.2; and 5.6% pH ≤ 7.0. The total hospital mortality was 23.7%. Nonsurvivors were older and more acidotic, with a base deficit >−8, Glasgow Coma Scale (GCS) ≤ 8, systolic blood pressure ≤ 90, International Normalized Ratio (INR) >1.6, and Injury Severity Score (ISS) >15. Mortality was significantly higher with a pH ≤ 7.2 but mortality with a pH 7.2–7.35 was comparable to pH > 7.35. In the adjusted model, pH ≤ 7.0, pH 7.0–7.2, INR > 1.6, GCS ≤ 8, and ISS > 15 were associated with increased mortality. For patients with a pH ≤ 7.2, only INR was associated with increase in mortality. Conclusions: A pH ≤ 7.2 is associated with increased mortality. For patients in this range, only the presence of coagulopathy is associated with increased mortality. A pH > 7.2 may be an appropriate treatment goal for acidosis. Further work is needed to identify and target potentially modifiable factors in patients with acidosis such as coagulopathy.
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The use of evaluation tool for ultrasound skills development and education to assess the extent of point-of-care ultrasound adoption in lebanese emergency departments p. 219
Imad A El Majzoub, Hani N Hamade, Rola A Cheaito, Basem F Khishfe
DOI:10.4103/JETS.JETS_111_19  
Background: Previously acknowledged as “bedside ultrasound”, point-of-care ultrasound (PoCUS) is gaining great recognition nowadays and more physicians are using it to effectively diagnose and adequately manage patients. To measure previous, present and potential adoption of PoCUS and barriers to its use in Canada, Woo et al established the questionnaire “Evaluation Tool for Ultrasound skills Development and Education” (ETUDE) in 2007. This questionnaire sorted respondents into innovators, early adopters, majority, and nonadopters. Objectives: In this article, we attempt to evaluate the prevalence of PoCUS and the barriers to its adoption in Lebanese EDs, using the ETUDE. Materials and Methods: The same questionnaire was again utilized in Lebanon to assess the extent of PoCUS adoption. Our target population is emergency physicians (EPs). To achieve a high response rate, hospitals all over Lebanon were contacted to obtain contact details of their EPs. Questionnaires with daily reminders were sent on daily basis. Results: The response rate was higher in our population (78.8%) compared to Woo et al's (36.4%), as the questionnaire was sent by email to each physician with subsequent daily reminders to fill it. In fact, out of the total number of the surveyed (85 physicians), respondents were 67, of which 76.1% were males and of a median age of 43. Using ETUDE, results came as nonadopters (47.8%), majority (28.3%), early adopters (16.4%), and innovators (7.5%). Respondents advocated using PoCUS currently and in the future in five main circumstances: focused assessment with sonography in trauma (FAST) (current 22.9%/future 62.9%), first-trimester pregnancy (current 17.1%/future 68.6%), suspected abdominal aortic aneurysm (current 5.7%/future 51.4%), basic cardiac indications (current 8.6%/future 57.1%), and central venous catheterization (current 22.9%/future 85.7%). Conclusion: This study is the first to tackle the extent of use and the hurdles to PoCUS adoption in Lebanese emergency medicine practice, using ETUDE. The findings from this study can be used in Lebanon to strengthen PoCUS use in the future.
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CASE REPORTS Top

Electric shock for a patient with ventricular fibrillation during air evacuation using a helicopter p. 224
Ikuto Takeuchi, Youichi Yanagawa, Mitsuhiro Takeuchi, Satoru Suwa
DOI:10.4103/JETS.JETS_157_19  
A 73-year-old male suddenly felt chest pain and nausea in his home. The fire department requested the dispatch of a physician-staffed helicopter. When the medical staff of the helicopter checked him, his 12-lead electrocardiogram showed ST elevation at the II, III, and aVF leads. After being fitted with pads for monitoring and defibrillation, he was transferred to the helicopter. Before landing at the base hospital a few minutes later, his electrocardiogram suddenly demonstrated ventricular fibrillation (VF). The patient received an electric shock. When the helicopter landed on the base hospital, he still showed VF. After being directly transferred to the catheter room, he received advanced cardiac life support with percutaneous cardiopulmonary support. A trans-arterial coronary angiogram revealed total occlusion of the right coronary artery. After recanalization of the occluded artery, he regained spontaneous circulation. He received intensive care, including targeted temperature management, and he regained consciousness and achieved social rehabilitation. We herein report the first case of VF safely treated with an electric shock during air evacuation by a rotary-wing aircraft in the English literature. Preparations in advance are necessary to perform electric shock safely during a flight aboard rotary-wing aircraft.
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Difficulties in the management of impalement injuries sustained in rural India p. 227
Radhikaraj Coimbatore Govindaraju, Jayateerth Munavalli
DOI:10.4103/JETS.JETS_163_19  
Impalement injury is said to occur when a blunt force causes a long object to penetrate a body part resulting in retention of the object in situ. We report two unusual cases of impalement from rural India: one, chest impalement by a hunting spear and the other, an extremity impalement by a rotatory tiller blade. Thoracic impalement injuries are very rare, and there is only one other published report of chest impalement by a spear (trident) in the modern era. There are only two published reports of extremity impalement by a rotatory tiller blade. We also describe the difficulties encountered in their management. Patient-1 sustained accidental impalement to the right hemithorax by a spear used for hunting wild boars, leaving a meter long shaft protruding from his body. This necessitated his transfer to the hospital on the cargo bay of a pickup truck and also precluded complete radiological investigations before surgery. In addition, the reversed barbed tip of the spear made the extraction difficult. Patient-2 sustained impalement through the right knee by a rotatory tiller blade which bound him to the machine. The blade had to be disconnected from the shank assembly of the tiller to extricate him. Due to the proximity of the blade to the popliteal vessels, vascular control was necessary before extraction. Both the patients took several hours to reach the hospital as the accident occurred in remote rural areas. However, both had a successful outcome after surgical removal of the impaled object by a multidisciplinary involvement. We also have reviewed the published literature and given our suggestions for the management of these unusual and difficult injuries.
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LETTERS TO EDITOR Top

Outcomes associated with femoral vein segmental oversew/ligation in penetrating trauma p. 231
Michael James Ramdass, Richard Spence, Patrick Harnarayan
DOI:10.4103/JETS.JETS_50_20  
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The impact of the “Weekend Effect” on emergency exploratory laparotomy surgeries outcomes at an urban level 1 trauma center Highly accessed article p. 232
Adel Elkbuli, Sarah Zajd, Brianna Dowd, Shaikh Hai, Dessy Boneva, Mark McKenney
DOI:10.4103/JETS.JETS_8_20  
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Blast injury of the scrotum p. 233
Siddharth Pramod Dubhashi, Atri Kumar, Rahul Kadam
DOI:10.4103/JETS.JETS_59_20  
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Inadequate management of patients with acute aortic symptoms before transfer from emergency departments p. 234
Quincy K Tran, Anne M Walker, Emilie Berman, Roumen Vesselinov, Mark Rose, Laura Tiffany, Vera Bzhilyanskaya, Sean Naimi, Zain Alam, Norhan Abdalla, Saman Tanveer, Ji Sun Yi, Tucker Lurie, Jon Mark Hirshon
DOI:10.4103/JETS.JETS_4_20  
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