Journal of Emergencies, Trauma, and Shock
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   2013| January-March  | Volume 6 | Issue 1  
    Online since January 22, 2013

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Blast injuries to the hand: Pathomechanics, patterns and treatment
Souvik Adhikari, Tibar Bandyopadhyay, Tapan Sarkar, Jayanta Kumar Saha
January-March 2013, 6(1):29-36
Purpose: To characterize the common patterns of injury in detail in cases of blast injuries to the hand and to outline the possible pathomechanics of these patterns of injury while describing the treatment modalities for the same as practiced in our center. Materials and Methods: A review of admitted patients in our department from september 2009 through december 2010 of blast injuries to the hand was made. Each patient had a careful characterization of their injuries as mild, moderate or severe with the help of X-rays, clinical photographs and operative notes. The treatment of these patients during hospital stay was also documented. Results: Of the 55 patients studied, 5 patients suffered mild injuries with no bony injuries or dislocations, 26 patients had moderate injuries characterized by fractures and dislocations in addition to soft tissue injuries and 24 patients had severe injuries characterized by variable degrees of amputations. The most common injury type was to the radial aspect of the hand characterized by a first web split and a dislocation of the CMC joint of the thumb associated with fracture of the central metacarpals and amputations of the index and long fingers in some cases. Injury to the ulnar aspect was rare. Injuries were treated by repair as well as replacement done mostly in a serial fashion. Conclusion: Depending on the mode of injury, blast injuries to the hand can have varying patterns of injury, which can have important implications in the treatment and rehabilitation of a patient.
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Pre-hospital transport times and survival for Hypotensive patients with penetrating thoracic trauma
Mamta Swaroop, David C Straus, Ogo Agubuzu, Thomas J Esposito, Carol R Schermer, Marie L Crandall
January-March 2013, 6(1):16-20
Background: Achieving definitive care within the "Golden Hour" by minimizing response times is a consistent goal of regional trauma systems . This study hypothesizes that in urban Level I Trauma Centers, shorter pre-hospital times would predict outcomes in penetrating thoracic injuries. Materials and Methods: A retrospective cohort study was performed using a statewide trauma registry for the years 1999-2003 . Total pre-hospital times were measured for urban victims of penetrating thoracic trauma. Crude and adjusted mortality rates were compared by pre-hospital time using STATA statistical software. Results: During the study period, 908 patients presented to the hospital after penetrating thoracic trauma, with 79% surviving . Patients with higher injury severity scores (ISS) were transported more quickly. Injury severity scores (ISS) ≥16 and emergency department (ED) hypotension (systolic blood pressure, SBP <90) strongly predicted mortality (P < 0.05 for each) . In a logistic regression model including age, race, and ISS, longer transport times for hypotensive patients were associated with higher mortality rates (all P values <0.05). This was seen most significantly when comparing patient transport times 0-15 min and 46-60 min (P < 0.001). Conclusion: In victims of penetrating thoracic trauma, more severely injured patients arrive at urban trauma centers sooner . Mortality is strongly predicted by injury severity, although shorter pre-hospital times are associated with improved survival . These results suggest that careful planning to optimize transport time-encompassing hospital capacity and existing resources, traffic patterns, and trauma incident densities may be beneficial in areas with a high burden of penetrating trauma.
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Blunt abdominal trauma with transanal small bowel evisceration
Noushif Medappil, Adiga K Prashanth, Abdul Latheef
January-March 2013, 6(1):56-57
Small bowel evisceration through the anus can occur spontaneously or post traumatically. Traumatic transanal small bowel evisceration results from iatrogenic injuries, suction injuries, and blunt abdominal trauma (BAT). We report a 48-year-old female who presented with evisceration of small intestinal loops through the anus following BAT and discuss the etiologies and mechanisms of injury of this rare presentation.
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Evaluating trauma center structural performance: The experience of a Canadian provincial trauma system
Lynne Moore, André Lavoie, Marie-Josée Sirois, Bonnie Swaine, Valérie Murat, Natalie Le Sage, Marcel Emond
January-March 2013, 6(1):3-10
Background: Indicators of structure, process, and outcome are required to evaluate the performance of trauma centers to improve the quality and efficiency of care. While periodic external accreditation visits are part of most trauma systems, a quantitative indicator of structural performance has yet to be proposed. The objective of this study was to develop and validate a trauma center structural performance indicator using accreditation report data. Materials and Methods: Analyses were based on accreditation reports completed during on-site visits in the Quebec trauma system (1994-2005). Qualitative report data was retrospectively transposed onto an evaluation grid and the weighted average of grid items was used to quantify performance. The indicator of structural performance was evaluated in terms of test-retest reliability (kappa statistic), discrimination between centers (coefficient of variation), content validity (correlation with accreditation decision, designation level, and patient volume) and forecasting (correlation between visits performed in 1994-1999 and 1998-2005). Results: Kappa statistics were >0.8 for 66 of the 73 (90%) grid items. Mean structural performance score over 59 trauma centers was 47.4 (95% CI: 43.6-51.1). Two centers were flagged as outliers and the coefficient of variation was 31.2% (95% CI: 25.5% to 37.6%), showing good discrimination. Correlation coefficients of associations with accreditation decision, designation level, and volume were all statistically significant (r = 0.61, -0.40, and 0.24, respectively). No correlation was observed over time (r = 0.03). Conclusion: This study demonstrates the feasibility of quantifying trauma center structural performance using accreditation reports. The proposed performance indicator shows good test-retest reliability, between-center discrimination, and construct validity. The observed variability in structural performance across centers and over-time underlines the importance of evaluating structural performance in trauma systems at regular intervals to drive quality improvement efforts.
  3,580 19 3
Complex developmental abnormality of the atlas mimicking a Jefferson fracture: Diagnostic tips and tricks
Mario Ganau, Roberto Spinelli, Leonello Tacconi
January-March 2013, 6(1):47-49
Congenital atlas abnormalities are rare - often asymptomatic - findings, not requiring any specific treatment. They are frequently discovered, by chance, in trauma patients, in the course of the radiological work flow at the Emergency Department. In these cases they may represent a diagnostic challenge, since physicians are expected to differentiate them from complex C1 fractures (isolated Jefferson's fractures or associated with Anderson and d'Alonzo's fractures) requiring surgical treatment. Although difficult to identify, a correct diagnosis is mandatory in order to optimize the patient's treatment. In this article we report a case of congenital atlas abnormality, and discuss the tips and tricks to make a correct differential diagnosis through the most appropriate clinical and radiological work flow.
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Emergency thoracotomies: Two center study
Sameh Ibrahim Sersar, Mohammed Adel AlAnwar
January-March 2013, 6(1):11-15
Introduction and Aim: Emergency thoracotomy is performed either immediately at the scene of injury, in the emergency department or in the operating room. It aims to evacuate the pericardial tamponade, control the haemorrhage, to ease the open cardiac massage and to cross-clamp the descending thoracic aorta to redistribute blood flow and maybe to limit sub-diaphragmatic haemorrhage, bleeding and iatrogenic injury are the common risk factors. We aimed to review our experience in the field of emergency thoracotomies, identify the predictors of death, analyze the early results, detect the risk factors and asses the mortalities and their risk factors. Patients and Methods: Our hospital records of 197 patients who underwent emergency thoracotomy were reviewed. We retrospectively analyzed a piece of the extensive experience of the Mansoura University Hospitals and Mansoura Emergency Hospital; Egypt and Saudi German Hospitals; Jeddah in the last 12 years in the management of trauma cases for whom emergency thoracotomy. The aim was to analyse the early results of such cases and to detect the risk factors of dismal prognosis. Results: Our series included 197 cases of emergency thoractomies in Mansoura; Egypt and SGH; Jeddah; KSA in the last 12 years. The mean age of the victims was 28 years and ranged between 5 and 62 years. Of the 197 patients with emergency thoracotomy, the indications were both penetrating and blunt chest trauma, iatrogenic and postoperative hemodynamito a surgical cause. The commonest indication was stab heart followed by traumatic diaphragmatic ruptures. Conclusion: The results of emergency thoracotomy in our series were cooping with the results of other reports, mainly due to our aggressive measures to achieve rapid stabilization of the hemodynamic condition. We emphasize the importance of emergency medicine education programs on rapid diagnosis of traumatic injuries with early intervention, and adequate hemodynamic and respiratory support. Emergency thoracotomy has an important role in emergency big volume hospitals and can save a lot of lives. Outcome can be improved by increasing the learning curve and the integrated cooperation of the emergency and surgical teams.
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Spontaneous esophageal perforation (Boerhaave syndrome): Diagnosis with CT-esophagography
Massimo Tonolini, Roberto Bianco
January-March 2013, 6(1):58-60
Spontaneous esophageal perforation (Boerhaave syndrome) is a very uncommon, life-threatening surgical emergency that should be suspected in all patients presenting with lower thoracic-epigastric pain and a combination of gastrointestinal and respiratory symptoms. Variable clinical manifestations and subtle or unspecific radiographic findings often result in critical diagnostic delays. Multidetector computed tomography complemented with CT-esophagography represents the ideal "one-stop shop" investigation technique to allow a rapid, comprehensive diagnosis of BS, including identification of suggestive periesophageal abnormalities, direct visualization of esophageal perforation and quantification of mediastinitis.
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To determine the accuracy of focused assessment with sonography for trauma done by nonradiologists and its comparative analysis with radiologists in emergency department of a level 1 trauma center of India
Sanjeev Bhoi, Tej P Sinha, Radhakrishnan Ramchandani, Lalit Kurrey, Sagar Galwankar
January-March 2013, 6(1):42-46
Background: Focused assessment with sonography for trauma (FAST) is an important skill during trauma resuscitation. Use of point of care ultrasound among the trauma team working in emergency care settings is lacking in India. Objective: To determine the accuracy of FAST done by nonradiologists (NR) when compared to radiologists during primary survey of trauma victims in the emergency department of a level 1 trauma center in India. Materials and Methods: A prospective study was done during primary survey of resuscitation of nonconsecutive patients in the resuscitation bay. The study subjects included NR such as one consultant emergency medicine, two medicine residents, one orthopedic resident and one surgery resident working as trauma team. These subjects underwent training at 3-day workshop on emergency sonography and performed 20 supervised positive and negative scans for free fluid. The FAST scans were first performed by NR and then by radiology residents (RR). The performers were blinded to each other's sonography findings. Computed tomography (CT) and laparotomy findings were used as gold standard whichever was feasible. Results were compared between both the groups. Intraobserver variability among NR and RR were noted. Results: Out of 150 scans 144 scans were analyzed. Mean age of the patients was 28 [1-70] years. Out of 24 true positive patients 18 underwent CT scan and exploratory laparotomies were done in six patients. Sensitivity of FAST done by NR and RR were 100% and 95.6% and specificity was 97.5% in both groups. Positive predictive value among NR and RR were 88.8%, 88.46% and negative predictive value were 97.5% and 99.15%. Intraobserver performance variation ranged from 87 to 97%. Conclusion: FAST performed by NRs is accurate during initial trauma resuscitation in the emergency department of a level 1 trauma center in India.
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A schizophrenic patient with cerebral infarctions after hemorrhagic shock
Youichi Yanagawa, Keiichiro Ohara, Yasutaka Tanaka, Ryota Tanaka
January-March 2013, 6(1):53-55
We herein report the fourth case of cerebral infarction, concomitant with hemorrhagic shock, in English literature. A 33-year-old male, who had been diagnosed with schizophrenia and given a prescription for Olanzapine, was discovered with multiple self-inflicted bleeding cuts on his wrist. On arrival, he was in hemorrhagic shock without verbal responsiveness, but his vital signs were normalized following infusion of Lactate Ringer's solution. The neuroradiological studies revealed multiple cerebral ischemic lesions without any vascular abnormality. He was diagnosed with speech apraxia, motor aphasia, and dysgraphia, due to multiple cerebral infarctions. As there was no obvious causative factor with regard to the occurrence of cerebral infarction in the patient, the hypoperfusion due to hemorrhagic shock, and the thromboembolic tendency due to Olanzapine, might have acted together to lead to the patient's cerebral ischemia.
  2,503 22 -
All that wheezes is not asthma
Girish Narayan, GK Narayana, K Prabhakar
January-March 2013, 6(1):61-62
  2,488 17 -
Spontaneous liver rupture: A report of two cases
Myla Yacob, Mark R Jesudason, Sukria Nayak
January-March 2013, 6(1):50-52
Spontaneous bleeding due to a non traumatic liver rupture is a rare occurrence. However, it is associated with high morbidity and mortality. Usually the predisposing factors are like Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome in pregnant women and other liver diseases. It is generally diagnosed by imaging studies such as ultra sonogram or computerized tomogram (CT). Due to its rarity no standard treatment has been described. Here, we report two cases of spontaneous rupture of normal liver in two young males. They presented with severe shock and hemoperitoneum. The diagnosis was confirmed by CT. They were managed surgically. In case of hemoperitoneum, spontaneous liver rupture should be considered. An early aggressive resuscitation and appropriate intervention gives better outcome.
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Blood transfusion therapy for traumatic cardiopulmonary arrest
Yoshihiro Moriwaki, Mitsugi Sugiyama, Yoshio Tahara, Masayuki Iwashita, Takayuki Kosuge, Hiroshi Toyoda, Shinju Arata, Noriyuki Suzuki
January-March 2013, 6(1):37-41
Background: Blood transfusion therapy (BTT), which represents transplantation of living cells, poses several risks. Although BTT is necessary for trauma victims with hemorrhagic shock, it may be futile for patients with blunt traumatic cardiopulmonary arrest (BT-CPA). Materials and Methods: We retrospectively examined the medical records of consecutive patients with T-CPA. The study period was divided into two periods: The first from 1995-1998, when we used packed red cells (PRC) regardless of the return of spontaneous circulation (ROSC), and the second from 1999-2004, when we did not use PRC before ROSC. The rates of ROSC, admission to the ICU, and survival-to-discharge were compared between these two periods. Results: We studied the records of 464 patients with BT-CPA (175 in the first period and 289 in the second period). Although the rates of ROSC and admission to the ICU were statistically higher in the first period, there was no statistical difference in the rate of survival-to-discharge between these two periods. In the first period, the rate of ROSC was statistically higher in the non-BTT group than the BTT group. However, for cases in which ROSC was performed and was successful, there were no statistical differences in the rate of admission and survival-to-discharge between the first and second group, and between the BTT and non-BTT group. Conclusion: Our retrospective consecutive study shows the possibility that BTT before ROSC for BT-CPA and a treatment strategy that includes this treatment improves the success rate of ROSC, but not the survival rate. BTT is thought to be futile as a treatment for BT-CPA before ROSC.
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What's new in emergencies, trauma, and shock? Correlating rapid prehospital transport and survival
Mazen J El Sayed
January-March 2013, 6(1):1-2
  2,120 17 -
Incidence, clinical predictors and outcome of acute renal failure among North Indian trauma patients
Medha , Arulselvi Subramanian, Ravindra Mohan Pandey, Chhavi Sawhney, Ashish Dutt Upadhayay, Venencia Albert
January-March 2013, 6(1):21-28
Context: There is a need for identifying risk factors aggravating development of acute renal failure after attaining trauma and defining new parameters for better assessment and management. Aim of the study was to determine the incidence of acute renal failure among trauma patients, and its correlation with various laboratory and clinical parameters recorded at the time of admission and in-hospital mortality. Subjects and Methods: The retrospective cohort study included admitted 208 trauma patients over a period of one year. 135 trauma patients at the serum creatinine level >2.0 mg/dL were enrolled in under the group of acute renal failure. 73 patients who had normal creatinine level made the control group. They were further assessed with clinical details and laboratory investigations. Results: Incidence of acute renal failure was 3.1%. There were 118 (87.4%) males and average length of stay was 9 (1, 83) days. Severity of injury (ISS, GCS) was relatively more among the renal failure group. Renal failure was transient in 35 (25.9%) patients. They had higher incidence of bone fracture (54.0%) (P = 0.04). Statistically significant association was observed between patients with head trauma and mortality 72 (59.0%) (P = 0.001). Prevalence of septic 24 (59.7%) and hemorrhagic 9 (7.4%) shock affected the renal failure group. Conclusion: Trauma patients at the urea level >50 mg/dL, ISS >24 on the first day of admission had 23 times and 7 times the risk of developing renal failure. Similarly, patients with hepatic dysfunction and pulmonary dysfunction were 12 times and 6 times. Patients who developed cardiovascular dysfunction, hematological dysfunction and post-trauma renal failure during the hospital stay had risk for mortality 29, 7 and 8 times, respectively. The final prognostic score obtained was: 14*hepatic dysfunction + 11*cISS + 18*cUrea + 12*cGlucose + 10*pulmonary dysfunction. Optimal score cut-off for prediction of renal failure was found to be ≥25 with specificity, sensitivity and positive likelihood ratio to be 84.9%, 78.4% and 3.9, respectively.
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Perforated peptic ulcer: Determinants of outcome and mortality
Offir Ben-Ishay, Hany Bahouth, Yoram Kluger
January-March 2013, 6(1):61-61
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