Journal of Emergencies, Trauma, and Shock
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   2009| September-December  | Volume 2 | Issue 3  
    Online since August 31, 2009

 
 
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SYMPOSIUM ON COMMON PRACTICES FOR UNCOMMON PROBLEMS IN ACUTE MEDICINE
Acute management of vascular air embolism
Nissar Shaikh, Firdous Ummunisa
September-December 2009, 2(3):180-185
DOI:10.4103/0974-2700.55330  PMID:20009308
Vascular air embolism (VAE) is known since early nineteenth century. It is the entrainment of air or gas from operative field or other communications into the venous or arterial vasculature. Exact incidence of VAE is difficult to estimate. High risk surgeries for VAE are sitting position and posterior fossa neurosurgeries, cesarean section, laparoscopic, orthopedic, surgeries invasive procedures, pulmonary overpressure syndrome, and decompression syndrome. Risk factors for VAE are operative site 5 cm  above the heart, creation of pressure gradient which will facilitate entry of air into the circulation, orogenital sex during pregnancy, rapid ascent in scuba (self contained underwater breathing apparatus) divers and barotrauma or chest trauma. Large bolus of air can lead to right ventricular air lock and immediate fatality. In up to 35% patient, the foramen ovale is patent which can cause paradoxical arterial air embolism. VAE affects cardiovascular, pulmonary and central nervous system. High index of clinical suspicion is must to diagnose VAE. The transesophgeal echocardiography is the most sensitive device which will detect smallest amount of air in the circulation. Treatment of VAE is to prevent further entrainment of air, reduce the volume of air entrained and haemodynamic support. Mortality of VAE ranges from 48 to 80%. VAE can be prevented significantly by proper positioning during surgery, optimal hydration, avoiding use of nitrous oxide, meticulous care during insertion, removal of central venous catheter, proper guidance, and training of scuba divers.
  12 11,195 358
EKG PEARL
Wellen's syndrome: An ominous EKG pattern
Nicole E Mead, Kelly P O'Keefe
September-December 2009, 2(3):206-208
DOI:10.4103/0974-2700.55347  PMID:20009314
Wellen's syndrome is a characteristic T-wave on an electrocardiogram during a pain-free period in a patient with intermittent chest pain. This finding suggests a high-degree stenosis of the proximal left anterior descending (LAD) coronary artery that will soon result in an acute anterior wall myocardial infarction (MI) if the patient is not urgently catheterized and the occlusion opened. This case report discusses a young male patient with no known cardiac disease with an EKG that demonstrates the classic Wellen's T-waves. He was urgently taken to cardiac catheterization and his 95% proximal LAD stenosis was reduced via drug-eluding stent. Through knowledge of Wellen's T-waves, more anterior wall MIs can be prevented.
  7 9,611 529
BASIC SCIENCE RESEARCH
Angiotensin-converting enzyme gene polymorphism in hypertensive rural population of Haryana, India
Sumeet Gupta, Bimal K Agrawal, Rajesh K Goel, Prabodh K Sehajpal
September-December 2009, 2(3):150-154
DOI:10.4103/0974-2700.55323  PMID:20009302
Background: Essential hypertension is a complex genetic disorder influenced by diverse environmental factors. Of the various physiological pathways affecting the homeostasis of blood pressure, the renin-angiotensin system (RAS) is known to play a critical role. Angiotensin-I converting enzyme (ACE) is a significant component of RAS and an insertion/deletion (I/D) polymorphism in its gene has been implicated in predisposition to hypertension. Objective: The present study is aimed to determine the association, if any, of ACE I/D polymorphism with essential hypertension in a rural population of Haryana, India. Materials and Methods: The blood samples were collected from the patients visiting M. M. Institute of Medical Sciences, Mullana, Haryana. DNA from the patients (106) and control (110) specimens were isolated, amplified by PCR and analyzed employing agarose gel electrophoresis. Results: There was no significant difference in the distribution of DD, II and I/D genotypes of ACE polymorphism in essential hypertensive patients (28.8, 25.5, and 46.2%) and their ethnically matched normal control (24.5, 30, and 45.5), respectively. The two groups also presented with very similar allelic frequencies and were also found to be in Hardy-Weinberg equilibrium. Conclusions: The present study demonstrates that ACE I/D polymorphism is not a risk factor for essential hypertension in the hitherto unstudied rural population of Haryana.
  5 4,192 265
SHOCK SCENARIOS
Abdominal pregnancy as a cause of hemoperitoneum
Sheikh Muzamil Shafi, Misbha Afsheen Malla, Parvaiz Ahmed Salaam, Omer Shareef Kirmani
September-December 2009, 2(3):196-198
DOI:10.4103/0974-2700.55342  PMID:20009311
The coexistence of intrauterine and extrauterine pregnancy, the heterotopic pregnancy, is a rare obstetric phenomenon. The preoperative diagnosis of this condition is very difficult; leading to a higher maternal morbidity and fetal loss. We experienced a case of intrauterine pregnancy and ruptured abdominal pregnancy implanted on the illeocaecal region in a 26-year-old primiparous woman. She was clinically misdiagnosed as a case of ruptured ectopic pregnancy, but ultrasonography showed it to be a case of heterotopic pregnancy. Subsequently, the patient was subjected to laparotomy and the ruptured abdominal pregnancy was evacuated. She continued with the intrauterine pregnancy till term and delivered a healthy female baby. Although this condition is unusual, any general surgeon in the emergency department must be aware of this complication and its management, which is often initially misdiagnosed.
  4 5,429 142
SYMPOSIUM ON COMMON PRACTICES FOR UNCOMMON PROBLEMS IN ACUTE MEDICINE
Managing human bites
Pradnya D Patil, Tanmay S Panchabhai, Sagar C Galwankar
September-December 2009, 2(3):186-190
DOI:10.4103/0974-2700.55331  PMID:20009309
Human bites are frequently overlooked in making a diagnosis in the emergency room. They are particularly notorious due to the polymicrobial nature of human saliva inoculated in the wound and the risk they pose for transmission of infectious diseases. Early treatment, appropriate prophylaxis and surgical evaluation are the key to achieving desired treatment outcomes. Through this article, we have tried to summarize the diagnostic features, complications as well as the recommended treatment alternatives for human bites based on the current available evidence.
  4 9,221 181
ORIGINAL ARTICLES
Etiological characterization of acute poisonings in the emergency department
Malek Khlifi, Leslie Zun, Giffe Johnson, Raymond Harbison
September-December 2009, 2(3):159-163
DOI:10.4103/0974-2700.50878  PMID:20009304
Introduction: An investigation of emergency department (ED) poisonings was conducted to characterize poisoning demographics and evaluate correlations with select co-morbidities. Methods: The study population evaluated consisted of 649 poisoning cases admitted between 2004 and 2007 to an inner-city, level 1 emergency department. Results: Ethnicity, age, and gender had a substantial impact on the population distribution as poisoning cases were predominantly African Americans (79.9%) between 36 and 45 years old with a 1:3 male to female ratio. Intentional illicit drug overdose was the most prevalent cause of poisoning, heroin being the most frequent substance found in 35.4% ( n = 230) of cases, followed by cocaine overdose at 31.7% ( n = 206), concomitant heroin and cocaine overdose at 4.3% ( n = 28), multiple drug poisoning at 5.5% ( n = 36), and antidepressant/antipsychotic poisoning at 6% ( n = 39). Significant correlations were found between heroin poisoning and asthma (F = 20.29, DF = 1, P = 0.0001), cocaine poisoning and hypertension (F = 33.34, DF = 1, P = 0.0001), and cocaine poisoning and cardiovascular disease (F = 35.34, DF = 1, P = 0.0001). A change in the pattern of illicit drug use from injection to inhalation was detected and the resulting increase of inhalation and insufflation of illicit substances may partially explain the correlation found between heroin use and asthma. Conclusions: These results provide supporting evidence that deliberate poisoning with illicit drugs remains a serious healthcare issue that significantly aggravates co-morbidities and raises treatment costs by increasing both the rate of hospitalization and hospital length of stay.
  3 4,129 244
SHOCK SCENARIOS
Wunderlich's syndrome and hemorrhagic shock
Massimo Medda, Stefano CM Picozzi, Giorgio Bozzini, Luca Carmignani
September-December 2009, 2(3):203-205
DOI:10.4103/0974-2700.55346  PMID:20009313
We report a case of Wunderlich's syndrome in an obese woman associated with massive retroperitoneal hemorrhage. Stable hemodynamic patient condition was obtained by selective arterial embolization. Since the first embolization of a renal angiomyolipoma in 1976 by Moorhead et al., highly selective renal arterial embolization of angiomyolipoma with rupture has become a procedure that offers greater efficacy, particularly in life-threatening cases.
  3 4,227 107
SYMPOSIUM ON COMMON PRACTICES FOR UNCOMMON PROBLEMS IN ACUTE MEDICINE
Managing a wooden foreign body in the neck
Rakesh Kumar Singh, Sangita Bhandary, Prahlad Karki
September-December 2009, 2(3):191-195
DOI:10.4103/0974-2700.55340  PMID:20009310
An interesting case is presented of a wooden foreign body in the neck entering through the right lower vestibule of the mouth. The foreign body traveled subcutaneously in the neck and got stuck in the clavicle, without damaging any vital structures. In this case, the authors highlight the mode of entry of the foreign body, the peculiarity of the wooden foreign body, the management protocol and the outcomes of the penetrating neck injury by the wooden stick.
  2 3,172 100
LETTERS TO EDITOR
Emergency central venous catheterization revisited
Sandeep Sahu, Indu Lata, Shikha Sachan, RK Singh
September-December 2009, 2(3):218-219
DOI:10.4103/0974-2700.55348  PMID:20009320
  1 2,711 89
SHOCK SCENARIOS
Gastrointestinal stromal tumors and shock
Karim Ibn Majdoub Hassani, Fatim Zahra Zahid, Abdelmalek Ousadden, Khalid Mazaz, Khalid Ait Taleb
September-December 2009, 2(3):199-202
DOI:10.4103/0974-2700.55344  PMID:20009312
Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumor of the gastrointestinal tract. Clinically, they are associated with nonspecific symptoms, but some patients can present gastrointestinal bleeding with shock. We report two cases of GIST of the small bowel, revelated by hemorrhagic shock secondary to acute bleeding, succesfully treated by emergency surgery.
  1 3,388 105
CASE REPORT
Cut throat zone II neck injury and advantage of a feeding jejunostomy
Laleng M Darlong, Neizekhotuo B Shunyu, Rubul Das, Saikat Mallik
September-December 2009, 2(3):213-215
DOI:10.4103/0974-2700.55353  PMID:20009317
Penetrating neck injuries account for 5-10% of trauma cases and are potentially life threatening. We report a case of cut- throat zone II neck injury in a 45-year-old male extending up to posterior pharyngeal wall and exposing the underlying cervical vertebra. Tracheostomy was done and wound repair was started from the posterior aspect in layers using 3-0 Vicryl. Intraoperatively, a conscious decision was taken for a feeding jejunostomy for postoperative feeding, which was likely to be prolonged, in view of sensory-nerve damage along the transected pharynx. Prolonged use of Nasogastric tube for postoperative feeding was thus avoided and the discomfort, risk of aspiration and foreign body at injury site eliminated. One week postoperative, the patient experienced severe bouts of coughing and restlessness on oral intake; during this period enteral nutrition was maintained through feeding jejunostomy. At the time of discharge at 1 month, the patient was accepting normal diet orally and was detubated and vocalizing normally. We conclude that postoperative nutrition is an important area to be considered for deep neck wound with nerve injuries due to delayed tolerance to oral feeding till the regeneration of sensory nerves. A feeding jejunostomy or feeding gastrostomy performed simultaneously in such patients with nerve injuries is far superior over nasogastric-tube feeding when prolonged postoperative feeding is expected.
  - 3,790 107
CONFERENCE SUMMARY
Florida Emergency Physicians 9 th Annual Symposium on Emergency Medicine, April 8-11 2009
Dale S Birenbaum, Peter M DeBlieux
September-December 2009, 2(3):220-223
At the Florida Emergency Physicians Annual Symposium on Emergency Medicine, several important updates that could have a direct impact on patient care were presented by nationally recognized leaders in emergency medicine, critical care and trauma. All the topics presented were relevant to more than one specialty and included detailed discussions on optimal ventilator tidal volume, tissue oxygen saturation, ideal blood sugar levels, timing of intubation, appropriate blood transfusions and vasopressor use in the critical care patient. This article will focus on three aspects: Optimal ventilator tidal volume in the critical care patient, the use of a new hemostatic agent for hemorrhage control and vasopressor use in the early resuscitation of hemorrhagic shock.
  - 2,369 84
EDITORIAL
What is new in emergencies, trauma and shock? Studying stress in emergency medicine
Luciano Santana-Cabrera
September-December 2009, 2(3):147-149
DOI:10.4103/0974-2700.55322  PMID:20009301
  - 5,941 425
EXPERT COMMENTARY
Hospital design for better infection control
Fatimah Lateef
September-December 2009, 2(3):175-179
DOI:10.4103/0974-2700.55329  PMID:20009307
The physical design and infrastructure of a hospital or institution is an essential component of its infection control measure. Thus is must be a prerequisite to take these into consideration from the initial conception and planning stages of the building. The balance between designing a hospital to be an open, accessible and public place and the control to reduce the spread of infections diseases is a necessity. At Singapore General Hospital, many lessons were learnt during the SARS outbreak pertaining to this. During and subsequent to the SARS outbreak, many changes evolved in the hospital to enable us to handle and face any emerging infectious situation with calm, confidence and the knowledge that staff and patients will be in good stead. This paper will share some of our experiences as well as challenges
  - 5,402 228
LETTERS TO EDITOR
Ileosigmoid knot strangles the sigmoid
Fatima Ezzahra Zahid, Karim Ibn Majdoub, Jihane Lamrani, Khalid Mazaz
September-December 2009, 2(3):216-217
DOI:10.4103/0974-2700.55351  PMID:20009318
  - 2,867 84
Isolated transverse process fracture of the lumbar vertebrae
Amit Agrawal, Sandeep Srivastava, Anand Kakani
September-December 2009, 2(3):217-218
DOI:10.4103/0974-2700.55350  PMID:20009319
  - 10,235 364
ORIGINAL ARTICLES
Comparison of two different types of heat and moisture exchangers in ventilated patients
Syed Moied Ahmed, Jyotsna Mahajan, Abu Nadeem
September-December 2009, 2(3):164-169
DOI:10.4103/0974-2700.55327  PMID:20009305
Study Objectives: To compare the efficacy of two different types of Heat and Moisture Exchangers (HME filters) in reducing transmission of infection from the patient to ventilator and vice versa and also its cost effectiveness. Design: Randomized, controlled, double blind, prospective study. Patients and Methods: 60 patients admitted to the ICU from May 1, 2007 to July 31, 2007 of either sex, age ranging between 20 and 60 years, requiring mechanical ventilation were screened for the study. Following intubation of the patients, the HME device was attached to the breathing circuit randomly by the chit-in-a box method. The patients were divided into two groups according to the HME filters attached. Results: Both the groups were comparable with respect to age and sex ratio. In Type A HME filters, 80% showed growth on the patient end within 24 h and in 27% filters, culture was positive both on the patient and the machine ends. The organisms detected were Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa and co-related with the endotracheal aspirate culture. After 48 h, 87% filters developed organisms on the patient end, whereas 64% filters were culture positive both on the patient and the machine end. In Type B HME filters, 70% showed growth on patient's end after 24 h. Organisms detected were S. aureus, E. coli, P. aeruginosa and Acinetobacter. Thirty percent of filters were culture negative on both the patient and machine ends. No growth was found on the machine end in any of the filters after 24 h. After 48 h, 73% of the filters had microbial growth on the patient end, whereas only 3% filters had growth (S. aureus) on the machine end only. Seven percent had growth on both the patient as well as the machine ends. The microorganisms detected on the HME filters co-related with the endotracheal aspirate cultures. Conclusion: HME filter Type B (study group) was significantly better in reducing contamination of ventilator from the patient as compared to Type A (control group), which was routinely used in our ICU. Type B filter was found to be effective for at least 48 h. This study can also be applied to patients coming to emergency department (ED) and requiring emergency surgery and postoperative ventilation; and trauma patients like flail chest, head injury etc. requiring ventilatory support to prevent them from acquiring ventilator-associated pneumonia (VAP).
  - 3,980 135
Emergency medical epidemiology in Assam, India
Sahoo Saddichha, Mukul Kumar Saxena, Vibha Pandey, Mithilesh Methuku
September-December 2009, 2(3):170-174
DOI:10.4103/0974-2700.55328  PMID:20009306
Background: Assam, with its capital in Dispur has one of the highest rates of infant and maternal mortality in India. Being under both tribal and hilly regions, it has lacked adequate healthcare and emergency services. We therefore aimed to conduct a cross-sectional survey of medical emergencies and identify various types of emergencies presenting to emergency departments, prior to launching emergency services across the state. Materials and Methods: On a prospective basis and using a stratified random sampling design, all emergencies presenting to the three government hospitals in Guwahati, Assam, which handle 90% of all emergencies currently, were studied on specially designed datasheets in order to collect data. Emergency medical technicians (EMTs) were placed in the Casualty of the medical colleges and recorded all emergencies on the datasheet. The collected data was then analysed for stratification and mapping of emergencies. In addition, retrospective data for a period of 15 days was collected from the emergency case registers of all three hospitals and the adjoining district civil hospitals, in order to give a wider perspective of the nature of emergencies. Results: A total of 2169 emergencies were recorded over a seven-day prospective and fifteen-day retrospective period. Guwahati Medical College Hospital attended to majority of emergencies (42%), which were mainly of the nature of pregnancies (22.7%), accidents (12.2%) or assaults (15.4%) and fever related. Maximum emergencies also presented from the border districts, and occurred among young males in the age group of 19-45 years. Males were also more prone to accidents and assaults, while females presented with pregnancies as emergencies. Conclusion: Potential emergency services need to target young pregnant females. Law and order needs to be also tightened in order to curb accidents and assaults among young males.
  - 4,003 109
A cross-sectional study of the self-report of stress among emergency department patients
Ted D Nirenberg, Janette Baird, Magdalena Harrington, Michael J Mello, Robert Woolard, Richard Longabaugh
September-December 2009, 2(3):155-158
DOI:10.4103/0974-2700.55325  PMID:20009303
Background: There is a lack of information about the prevalence of stress and types of stressors experienced by Emergency Department (ED) patients. Objective: The present aim is to study the prevalence of stress, types of stressful situations and the relationship with other health issues within the ED population. Materials and Methods: This is a cross-sectional study performed in an ED at a level-1 urban trauma center for four months. An anonymous survey was offered to adult non critically ill patients who were admitted in the ED. They were divided on the basis of gender, age and level of stress and were asked about their demographics, reasons for their ED visit and health issues including stress, tobacco, alcohol and marijuana use, weight concern and health. Chi-square for the categorical variables and unpaired t-tests for continuous variables were conducted. Results: We interviewed 1797 patients, over 66% reported that they felt stressed on at least a weekly basis, and over 45% indicated that they felt stressed more than twice per week. While both young and old were equally stressed, females reported significantly more stress. Family, finances and work are the most frequently cited stressors. Different age groups reported different types of stressors. Overall, those patients reporting being stressed more frequently reported more high risk behaviors including cigarette and marijuana use and health problems including being overweight, being depressed, and having sleeping problems and chronic fatigue. Conclusions: Considering the high frequency of ED patients that report frequent stress and high risk behaviors, their ED visit may be an excellent opportunity to provide a referral or an intervention for stress reduction.
  - 4,012 210
PICTORIAL EDUCATION
Periorbital swelling in emergency room: Get your eyes in
S SenthilKumaran, N Balamurgan, K Arthanari, P Thirumalaikolundusubramanian
September-December 2009, 2(3):209-210
DOI:10.4103/0974-2700.55349  PMID:20009315
Facial swelling and eye pain are very common patient complaints in Emergency Departments. Clinical evidence and investigations play a crucial role in making the correct diagnosis which impacts the final disposition and management of the patient. We present a case of a patient who presented with facial swelling and headache.
  - 5,549 106
Sudden unilateral visual field loss
Robin G Jones, Adrian Peall
September-December 2009, 2(3):211-212
DOI:10.4103/0974-2700.55352  PMID:20009316
We report a classical case of branch retinal artery occlusion (BRAO) in the acute setting and review the literature relating to the diagnostic, therapeutic and prognostic facets of this condition. BRAO can cause sudden visual loss and is not an infrequent presentation to emergency medical services. BRAO may indicate predisposing and related conditions capable of significant morbidity and mortality. Although current therapeutic practices in the acute setting are of uncertain benefit, conservative measures may be attempted in the emergency room by a nonophthalmologist with the aim of dislodging the causative embolus. Regardless of the current means of acute management, anitplatelet therapy and cardiovascular risk management remain the mainstay of treatment for BRAO. The potential for life-threatening systemic associations necessities investigation and multidisciplinary input.
  - 3,478 118
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