Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) are increasingly recognized as potential complications in intensive care unit (ICU) patients. ACS and IAH affect all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. ACS/IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of ACS/IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. We start this article with a brief historic review on ACS/IAH. Then, we present the definitions concerning parameters necessary in understanding ACS/IAH. Finally, pathophysiology aspects of both phenomena are presented, prior to exploring the various facets of ACS/IAH management.

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Fat embolism syndrome (FES) is defined as an uncommon life-threatening disease process consisting of pulmonary, central nervous system (CNS), and cutaneous manifestations. The pathophysiology of this secondary injury is poorly understood. In the setting of the multiply injured patient, the diagnosis of FES is difficult to ascertain. A case report of a posttraumatic death caused by acute dissemination of diffuse fat emboli to the brain and lungs in the absence of a right-to-left heart defect after femur fracture is presented. The transesophageal echo cardiogram with bubble study failed to demonstrate an intracardiac defect or AV malformation in the lung further supporting a biochemical process. The acute decompensation of the patient within 2 h of the injury would favor mechanical emboli. Supportive care continues to be the mainstay of treatment for FES. Cerebral fat embolism should be considered in traumatically injured patients with unexplained decline in their neurologic examination. Cerebral fat embolism may occur without an intracardiac shunt.

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Acute aortic dissection an extremely severe condition having a high risk of mortality. The classic symptom may mimic other conditions such as myocardial ischemia, leading to misdiagnosis. Coronary malperfusion associated with aortic dissection is relatively rare, but when it occurs, it may have a fatal result for the patient. The diagnosis of acute coronary syndrome may lead to the inappropriate administration of thrombolytic or anticoagulant treatment resulting in catastrophic consequences. Emergency imaging techniques help to guide the correct diagnosis. Transthoracic echocardiography is useful as a first imaging test, and may be followed by transesophageal echocardiography, or other imaging techniques. Surgery represents the treatment for these patients. However, with the aim to stabilize the patient and to reduce myocardial damage, initial preoperative endovascular coronary intervention has been reported.

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Aim : This study was designed to evaluate the incidence of severe ocular injuries associated to maxillofacial fractures and report their management in the Emergency Department. Patients and Methods : Among the 1779 patients admitted for maxillofacial fractures, those with partial or total loss of vision at the time of emergency consultation were included in the study. Data collected from the patients' medical records included age, gender, mechanism of injury, location and type of facial fractures, type of ocular injuries and cause of blindness, methods of treatment, and days of hospitalization. Results : Forty patients (2.2%), 32 men and 8 women, ranging from 17 to 85 years of age, presented with severely reduced vision or blindness associated to fractures of the facial middle third with involvement of one or more orbital walls, mainly caused by motor vehicle and work accidents. In 18 patients, severe ocular injuries were determined by direct lesion of the globe, in 14 by direct or indirect traumatic optic neuropathy and in 8 by a retrobulbar hematoma. Direct lesion of the eyeball was treated by prompt repair or enucleation of the globe, though no or little recovery of vision was obtained. Ophthalmologic and/or maxillofacial treatment of the anterior compartment lesions of the eye allowed a partial or total recovery of the vision. A partial or total recovery of the vision was observed in almost all the patients with indirect traumatic optic neuropathy after administration of steroids according to NASCIS II protocol. Likewise, an evident improvement of the vision was obtained by immediate drainage of retrobulbar hematoma. Conclusions : Early diagnosis of the nature of the ophthalmic injury and treatment are important, and involvement of the ophthalmologist is mandatory.

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Background : Drainage of ascitic fluid is a common practice in order to relief the respiratory discomfort of patients. Aim: To determine the relation between the intra-abdominal pressure (IAP) and extracted volume of the ascitic fluid, in order to calculate abdominal compliance (Cabd). Settings and Design : A study was designed at AHEPA University Hospital and analysed with prospectively collected data. Materials and Methods : Fifteen patients with tension ascites that had transcutaneous drainage with a wide catheter. The ascitic fluid removed was measured, while the IAP and a Visual Analogue Scale (VAS) score for dyspnea were recorded before and 15 min after the puncture. Cabd was calculated. Statistical Analysis : The data were analysed with descriptive statistics, paired Student's t-test and Pearson coefficiency. Results : The predrainage IAP was 18.26 mmHg (SD 1.67 mmHg), while the postdrainage was 14.46 mmHg (SD 1.34 mmHg) (P<0.001). The mean volume of ascitic fluid removed was 1624 mL (SD 861 mL). Cabd after drainage was 414.01 mL/mmHg (SD 139.15 mL/mmHg). A linear correlation was found between ascitic fluid removal and IAP variations. The dyspnea VAS score was 7.5 (SD=0.8) before the drainage and 4.3 (SD=1.0) after the drainage (P<0.001). Conclusions : The drainage of ascitic fluid reduces IAP, facilitating in this way respiration. Moreover, IAP variation seems to be in linear relation with the volume of ascitic fluid removed. This linear relation between IAP and volume may probably predict the Cabd quite accurately and vice versa. However, larger studies are necessary to safely draw predicting ΔIAP - ΔV (Cabd) diagrams, and determine the optimal ascitic fluid removal to achieve best comforting of the patient and slower fluid reformation.

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Shock syndromes are of three types namely cardiogenic, hemorrhagic and inflammatory. They differ in physiological and pathological pathways and clinical presentations. The Management also differs considerably. In hemorrhagic shock there is a failure of the peripheral circulation that has its initial deranged variables in the blood volume and venous return while in cardiogenic Shock there is primary pump failure where the cardiac output/mean arterial pressure are deranged. Contrary to this in Inflammatory Shock the microcirculation is affected while the initial deranged macrocirculation variable is the total peripheral resistance hit by systemic inflammatory response. various toxins and pathways play a role in these differing presentations. In the article below an effort has been made to understand the Physiology and Pathology behind different types of shocks.

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Despite advances in critical care facilities and ventilation therapies acute respiratory distress syndrome (ARDS) is associated with high mortality rates. The condition can stem from a multitude of causes including pneumonia, septicemia and trauma ultimately resulting in ARDS. ARDS is characterized by respiratory insufficiency with severe hypoxemia or hypercapnia. The treatment strategy depends on the knowledge of the underlying disease. But lung-protective ventilation with adjusted positive end-expiratory pressure remains the most effective therapeutic tool despite advances in prone positioning, inhalation of nitric oxide and the use of steroids. Newer modalities including extracorporeal membrane oxygenation (ECMO) and pumpless extracorporeal lung assist (PECLA) are being increasingly introduced in critical care settings as rescue therapies in patients who fail to respond to conservative measures. We describe here the introduction and advances of both ECMO and PECLA in the management of ARDS.

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Background : Although most medical centers are equipped for 24-h care, some "middle of the night" services may not be as robust as they are during daylight hours. This would have potential impact upon certain outcome measurements in trauma patients. The purpose of this paper was to assess the effect of patient arrival time at hospital emergency departments on in-hospital survival following trauma. Materials and Methods : Data of patients, 18 years of age or older, with no evidence that they were transferred to or from that center were obtained from the National Trauma Data Bank Version 7.0. Patients meeting the above criteria were excluded if there was no valid mortality status, arrival time information, injury severity score, or trauma center designation. The primary analyses investigated the association of arrival time and trauma center level on mortality. Relative risks of mortality versus patient arrival time and trauma level were determined after controlling for age, gender, race, comorbidities, injury, region of the country, and year of admission. Results : In total, 601,388 or 71.7% of the 838,284 eligible patients were retained. The overall in-hospital mortality rate was 4.7%. The 6 p.m. to 6 a.m. time period had a significantly higher adjusted relative risk for in-hospital mortality than the 6 a.m. to 6 p.m. time frame (ARR=1.18, P<0.0001). This pattern held across trauma center levels, but was the weakest at Level I and the strongest at Level III/IV centers (Level I: ARR=1.10, Level II: ARR=1.14, and combined Level III/IV: ARR=1.32, all P<0.0001). Conclusion : Hospital arrival between midnight and 6 a.m. was associated with a higher mortality rate than other times of the day. This relationship held true across all trauma center levels. This information may warrant a redistribution of hospital resources across all time periods of the day.

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Given the increasing number of operational nuclear reactors worldwide, combined with the continued use of radioactive materials in both healthcare and industry, the unlikely occurrence of a civilian nuclear incident poses a small but real danger. This article provides an overview of the most important historical, medical, and scientific aspects associated with the most notable nuclear incidents to date. We have discussed fundamental principles of radiation monitoring, triage considerations, and the short- and long-term management of radiation exposure victims. The provision and maintenance of adequate radiation safety among first responders and emergency personnel are emphasized. Finally, an outline is included of decontamination, therapeutic, and prophylactic considerations pertaining to exposure to various radioactive materials.

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Background : Uncontrolled hemorrhage is one of the leading causes of death in both combat and civilian trauma. This study was designed to compare the arterial blood pressures at which rebleeding occurred when a hemostatic agent, ExcelArrest™, was used compared with a standard pressure dressing. Materials and Methods : This study was a prospective, experimental, and mixed research design. Swine were assigned to one of two groups: ExcelArrest™ (n=5) or a control consisting of standard pressure dressings (n=5). Investigators generated a complex groin injury. The femoral artery and vein were transected and allowed to bleed for 60 s in each pig. After 60 s, ExcelArrest™ was poured into the wound. The control group underwent the same procedures, but without treatment with the hemostatic agent. After 5 min of direct pressure, a standard pressure dressing was applied. After 30 min, dressings were removed and the systolic blood pressure (SBP) was increased incrementally using intravenous phenylephrine until rebleeding occurred. Statistical Analysis : A multivariate ANOVA and a least significant difference were used to analyze the data. Results : ExcelArrest™ was more effective in preventing rebleeding compared to a standard pressure dressing (P<0.05). The means and standard deviations in mmHg for SBP and mean arterial pressure (MAP) for rebleeding were as follows: ExcelArrest™ (SBP=206.4, SD±11.6; MAP=171.4, SD±12.5); for the control group (SBP=89.40±3.58, MAP=58.60±12.86). Conclusions : ExcelArrest™ was more effective in preventing rebleeding compared to the standard dressing with elevated blood pressures. There may be protective benefits in using this hemostatic agent against elevated blood pressures provided by ExcelArrest™.

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Aim : Treatment of maxillofacial firearm injuries is still controversial with regard to timing of management. We postulate that not all maxillofacial firearm injuries need be delayed and that many may be treated early. To this end, a 19-year retrospective study was undertaken seeking to evaluate patients treated for firearm injuries to the facial skeleton at our center. The criteria which dictated when to operate are presented as are the results, benefits, and outcomes of the patients treated acutely. Patients and Methods : From 1991 to 2010, 51 patients with maxillofacial firearm injuries were treated; 30/51 patients received early primary repair and simultaneous open reduction for facial fractures. These underwent primary debridement and arch bar placement followed by open reduction of fractures (with or without osteosynthesis) and primary wound closure. Patient age ranged from 8 to 50 years, with a mean age of 24.4΁7.8 years. Primary early intervention was done when there was no gross infection, no bone comminution or extensive soft tissue avulsion (precluding wound coverage), and when general health, concomitant injuries requiring more urgent attention or those requiring major grafts did not preclude this. Primary intervention included extensive oral and extraoral irrigation (dilute hydrogen peroxide + povidone iodide), debridement of the facial wound, removal of floating fragments (teeth particles, debris, and shell fragments) precluding viable bone within the wound, access to the bone, finding the scattered bone segments and putting them back into place to restore bone continuity. Projectiles beyond the wound were not searched for. Tooth roots within the alveolus were not extracted at this stage. In addition to arch bars, titanium miniplates or wire osteosynthesis was done when necessary. All wounds were closed primarily (using local advancement flaps when necessary) and all patients were placed on antibiotics (cephalosporin + aminoglycoside or ciprofloxacin) upon admission. Results : Of 51 patients, 30 were treated acutely and 21 warranted delayed intervention. In the acute-treated group, 6/30 patients had minor complications such as scarring and wound discharge. Early intervention for firearm wounds to the face was effective for facial firearm injuries in selected cases. This resulted in restoration of occlusion and continuity of the jaw, fixation of luxated teeth, early return of function, prevention of segment displacement and tissue contracture, less scarring, and decreased the need for major bone graft reconstruction later on. Those treated secondarily were only debrided and had arch bars placed. Definitive treatment of hard and soft tissue management was rendered in another subsequent operation. Bone reduction was more difficult because of scarring, and displacement of remaining segments. No significant differences were noted in terms of infection or other major complications. Conclusions : Firearm wounds were associated with a high incidence of maxillofacial injuries requiring surgical intervention. Many may be treated definitively and acutely with procedures designed to repair both bone and soft tissue injuries simultaneously aiming to restore bony continuity, esthetics and function using the tissues at hand (especially in the mandible). Early treatment is advocated because the course of healing is not disrupted with another subsequent operation (in the same wound) and because it may decrease hospital stay without increasing patient morbidity in selected patients. Patients with residual defects can be treated later as out-patients.

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Background : Laparoscopic surgeries are the second most common cause of postoperative nausea and vomiting (PONV), which would cause unexpected delay in hospital discharge. This study intends to compare the efficacy and safety of the combination of ondansetron and dexamethasone with ondansetron alone given as prophylaxis for PONV in adults undergoing elective laparoscopic surgery. Materials and Methods : One hundred adult patients undergoing elective laparoscopic surgeries were selected and were randomly divided into 2 groups of 50 each. Group I received 4 mg of ondansetron intravenously (i.v.), whereas Group II received ondansetron 4 mg and dexamethasone 4 mg i.v. just before induction of anesthesia. Postoperatively, the patients were assessed for episodes of nausea, vomiting, and need for rescue antiemetic at intervals of 0-2, 3, 6, 12, and 24 h. Postoperative pain scores and time for the first analgesic dose were also noted. Results : Results were analyzed statistically. Complete response defined as no nausea or emesis and no need for rescue antiemetic during first 24 h, was noted in 76% of patients who received ondansetron alone, while similar response was seen in 92% of patients in combination group. Rescue antiemetic requirement was less in combination group (8%) as compared with ondansetron group. Conclusion : Combination of ondanserton and dexamethasone is more effective in preventing post operative nausea vomiting in patients undergoing laparoscopic surgery than ondansetron alone.

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Background : Missile cardiovascular injuries have taken an epidemic proportion in Kashmir valley since the eruption of militancy in 1990. Present study was undertaken to analyse the pattern, presentation and management of missile cardiovascular injuries. Patients and Methods : Three hundred and eighty-six patients with missile cardiovascular injuries since Jan 1996 to Oct 2008 were studied retrospectively. All patients of cardiovascular injuries due to causes other than missiles were excluded from the study. Results : All patients of missile cardiac injuries were treated by primary cardiorrhaphy. Right ventricle was the most commonly affected chamber. Left anterior thoracotomy was most common approach used. Most of the patients of missile vascular group were treated by reverse saphenous vein graft or end-to-end anastomosis. Most common complication was wound infection (20.83%) followed by graft occlusion (1.94%) in missile vascular group. Amputation rate was 4.66%. Amputation rate was higher in patients with delay of >6 hours and associated fractures. Conclusion : Missile cardiac injuries should be operated early without wasting time for investigations. Clinical status at arrival, time interval till management, nature of injury and associated injuries, tell upon the mortality. Missile vascular injury needs prompt resuscitation and revascularization at the earliest. Time interval till revascularization and associated fractures has a bearing on mortality and morbidity.

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The clinical aspects of shock syndromes are described from their inception as compensated physiology to a stage of decompensation. The clinical significance of hypotension, fluid-responsive and non fluid-responsive hypotension, is discussed. Untimely or inadequate treatment leads to persistent subclinical shock despite adjustments of the macrohemodynamic variables, which evolves in a second hit of physiological deterioration if not aggressively managed. Irreversible shock ensues as consequence of direct hit or as result of inadequate or delayed treatment and is characterized by drug-resistant hypotension.

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The World Federation of Hemophilia estimates that more than 350,000 people globally have a form of the disease. Hemophilia A is a bleeding disorder that has a spectrum of manifestations ranging from persistent bleeding after minor trauma to spontaneous hemorrhage. We report a case of a male patient with hemophilia A who received general anesthesia for removal of foreign body from the nose. There was no excessive blood loss during surgery. Perioperatively, the patient received recombinant factor VIII coverage. Rest of the postoperative course was uneventful. Literature on the clinical management of patient with hemophilia A are reviewed and considerations for perioperative preparation and management of hemophilic patient are presented.

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Endovascular treatment of post-traumatic pseudoaneurysms has become a viable, less invasive option when compared to open repair. Due to the relative youth of this technology, studies have yet to be concluded on the long-term patency of stent grafts in this population. For this reason, concern exists with endovascular stent placement in the young trauma patient. In this study, we present a case and review the literature on a post-traumatic pseudoaneurysm of the posterior tibial artery in a 19-year-old man treated with an endovascular stent.

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It is important to consider several differential diagnoses in a patient presenting with altered sensorium following surgery. Fat embolism syndrome (FES) is a serious condition that needs to be excluded. Although criteria for diagnosis of FES are available, all patients may not satisfy them. We discuss a patient who presented with an incomplete triad of the FES, where the diagnosis was supported by transcranial doppler monitoring of microembolic signals and magnetic resonance imaging.

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Patient expectation in health care continues to increase and this is something that needs to be managed adequately in order to improve outcomes and decrease liability. Understanding patients' expectations can enhance their satisfaction level. In the environment of the Emergency Department, with the acutely ill, serious and time-dependent issues as well as high level of stress, managing patient expectations can indeed be challenging. This paper discusses patients expectations and proposes implementation of elements of patient-centered care and value-based care into our existing health care systems today.

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Background : The contemplation for the salvage operations and the nonoperative treatment for the pediatric splenic injuries had increasingly been suggested as the standard case management. Objectives : The study was carried out to identify the risk factors, the presentations, the severities and outcome of the interventions of blunt splenic injuries in the children and adolescents. Materials and Methods : This retrospective review was carried out in a tertiary care hospital in Sikkim on the children and adolescents admitted with splenic injury from January 2005 to December 2009. Splenic injuries were graded with the American Association for the Surgery of Trauma Splenic Injury Scale followed by the operative and nonoperative managements (NOM). Results : Overall 147 cases with the abdominal trauma were diagnosed with splenic injury. Of them, males reported in higher numbers; three-fourths were adolescents with preponderance above 16 years of age. Majority of the cases [n=91(61.90%)] were due to fall from heights and others from road traffic accidents. Immediate surgical interventions was instituted in the hemodynamically unstable cases (n=87) NOM failed in 27 patients; of them eight cases underwent splenectomy, and 19 underwent surgical salvage; 33 were closely followed up by conservative approach with both clinical and CT criteria. Total number of cases in grade III and above was significantly higher than with lower grades of injury. Conclusions : In total 95(64.63%) of the cases were managed with total splenectomy; 19 cases in the initial nonsurgical group underwent salvage operation and 33 cases received NOM.

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Aim : To determine factors associated with poor outcome in children suffering traumatic head injury (HI). Materials and Methods : A retrospective study over an 8-year period including 454 children with traumatic HI admitted in the Intensive Care Unit of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. Prognosis was defined according Glasgow outcome scale (GOS) performed after hospital discharge by ICU and pediatric physicians. Results : There were 313 male (68.9%) and 141 female patients. Mean age (±SD) was 7.2±3.8 years, the main cause of trauma was traffic accidents (69.4%). Mean Glasgow coma scale (GCS) score was 8±3, mean injury severity score (ISS) was 26.4±8.6, mean pediatric trauma score (PTS) was 4±2 and mean pediatric risk of mortality (PRISM) was 11.1±8. The GOS performed within a mean delay of 7 months after hospital discharge was as follow: 82 deaths (18.3%), 5 vegetative states (1.1%), 15 severe disabilities (3.3%), 71 moderate disabilities (15.6%) and 281 good recoveries (61.9%). Multivariate analysis showed that factors associated with poor outcome (death, vegetative state or severe disability) were: PRISM ≥24 (P=0.03; OR: 5.75); GCS ≤8 (P=0.04; OR:2.42); Cerebral edema (P=0.03; OR:2.23); lesion type VI according to Traumatic Coma Data Bank Classification (P=0.002; OR:55.95); Hypoxemia (P=0.02; OR:2.97) and sodium level >145 mmol/l (P=0.04; OR: 4.41). Conclusions : A significant proportion of children admitted with HI were found to have moderate disability at follow-up. We think that improving prehospital care, establishing trauma centers and making efforts to prevent motor vehicle crashes should improve the prognosis of HI in children.

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Chest trauma is one important factor for total morbidity and mortality in traumatized emergency patients. The complexity of injury in trauma patients makes it challenging to provide an optimal oxygenation while protecting the lung from further ventilator-induced injury to it. On the other hand, lung trauma needs to be treated on an individual basis, depending on the magnitude, location and type of lung or chest injury. Several aspects of ventilatory management in emergency patients are summarized herein and may give the clinician an overview of the treatment possibilities for chest trauma victims.

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Traumatic pulmonary artery or vein pseudoaneurysms are extremely rare and angiographic management is gaining grounds. These pseudoaneurysms are caused by both penetrating and blunt chest trauma. We presents a unique case of coexisted pulmonary vein and artery pseudoaneurysm due to penetrating chest trauma managed by angioembolization and inferior vena cava filter insertion for concomitant deep vein thrombosis (DVT) due to contraindication to anticoagulation. The present case represents only the second case of coexisted pulmonary vein and artery pseudoaneurysm and the first with associated DVT making management decision complicated.

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Traumatic manubriosternal dislocation is a rare lesion. In the literature, only a few case reports of patients treated surgically are published. In this case, we report an unstable posterior dislocation of the manubriosternal joint in a 50-year-old women caused by direct trauma. An open reduction was performed, and the manubriosternal joint was fixed by two staples. We are the first to use this alternative technique. At the last follow-up, the result was very good without complication.

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Traumatic brain injury is the most common cause of morbidity and mortality in children. However, it is still challengeable to early predict the outcome of individual patients with severe head injuries. Glasgow outcome scale is the most widely used scoring system in evaluating neurological outcome for head injury patients. Moreover, it is likely to underestimate morbidity and is not always readily applicable in children. It is an important issue to develop a practical, reliable and valid neurological outcome instrument in children in forwarding research.

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Background : The willingness of healthcare workers to risk their lives for a patient with a potentially fatal, communicable disease is a major concern, especially during a pandemic where the need for adequate staffing is crucial and where the public atmosphere might enhance anxiety and fear of exposure. Objective : To examine the relationships between the willingness of healthcare workers to risk their lives for a patient with a potentially fatal A/H1N1 flu, and knowledge of personal protection against infection, and trust in colleagues, workplace preparedness and the effectiveness of safety measures, during the winter A/H1N1 pandemic in Israel. Materials and Methods : A questionnaire was distributed to healthcare workers in 21 hospitals in Israel between 26 November 2009 and 10 December 2009 (the peak of the winter A/H1N1 flu outbreak). The questionnaire was completed by 1147 healthcare workers. Results : Willingness to risk one's life for a patient was significantly lower in females, respondents of younger age (18-24 years), administrative staff, and those with a non-academic education, as well as among those with a less knowledge about safety measures and among those with less trust in colleagues, in work place preparedness, and in the effectiveness of safety measures. Conclusions : Willingness to risk one's life for a patient is related to knowledge of safety measures, and trust in colleagues and work place preparedness. Education programs to enhance trust in colleagues, improve work place preparedness, and safety measures are recommended, especially for healthcare workers who are young, inexperienced, female, or administrative staff.

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