Journal of Emergencies, Trauma, and Shock
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   2018| July-September  | Volume 11 | Issue 3  
    Online since October 1, 2018

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Camphor poisoning: A rare cause of acute symptomatic seizures in children
Prannoy George Mathen, TP Sreekrishnan, KP Kumar, Naveen Mohan
July-September 2018, 11(3):228-229
DOI:10.4103/JETS.JETS_21_18  PMID:30429634
Camphor is a toxic compound easily available over the counter, which can cause fatal seizures in children when ingested. It is available in several forms and is commonly used in Indian households, especially for religious rituals and for its cough-suppressive and nasal-decongestant effect. The toxic effect remains unknown in most homes. Seizures are usually well controlled with intravenous benzodiazepines, and recurrences of seizures are rarely reported.
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Abstracts for the 36th annual emergencies in medicine conference
Frank Peacock, Lorenzo Paladino, Sarathi Kalra
July-September 2018, 11(3):233-237
The 36th Annual Emergencies in Medicine Conference was held at the Hyatt Centric Hotel in Park City, Utah, from February 25 to March 1, 2018. The conference is designed by Emergency Medicine physicians to be short, engaging, and informative. Conference involved a series of fast-paced 30-min lectures from international leaders in Emergency Medicine about cutting-edge research. The following were the abstracts that were presented at the conference. There was a competition for the best abstract, determined by a vote of all the conference attendees, for which the winner received the title of “2018 Best Emergencies in Medicine Abstract,” and a cash award of $500. This year the award went to “Stethoscope Cleaning Practices: The Dirty 3rd Hand of Modern Medicine.”
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An unusual case of commotio cordis resulting in ventricular flutter
Brooke T Davey, Carolina Quintana, Shailendra Upadhyay
July-September 2018, 11(3):225-227
DOI:10.4103/JETS.JETS_78_17  PMID:30429633
A 16-year-old male developed palpitations immediately following chest impact with a soccer ball. The patient was noted to have ventricular flutter in a delayed presentation that was successfully treated. While ventricular fibrillation is the predominant arrhythmia following commotio cordis, ventricular flutter may occur as well. Ventricular flutter may be better tolerated in a young athletic individual with structurally normal heart and may lead to a delayed presentation.
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Utility of clot waveform analysis in Russell's viper bite victims with hematotoxicity
Siju V Abraham, Aboobacker Mohamed Rafi, S Vimal Krishnan, Babu Urumese Palatty, Susheela J Innah, Jerry Johny, Salish Varghese
July-September 2018, 11(3):211-216
DOI:10.4103/JETS.JETS_43_17  PMID:30429630
Introduction: In Russell's viper bites, due to the lack of a better alternative, whole blood clotting test (WBCT) remains the standard test even though its reliability and sensitivity has been shown to be low. Activated partial thromboplastin time (aPTT)-based clot waveform analysis (CWA) is an optic absorbance assay that can be used as a global clotting test. In this study, the objective was to assess the changes in CWA and to compare CWA to WBCT and aPTT in patients with Russell's viper envenomation. Methods: The datum was collected prospectively over 2 months as a pilot observational study in a tertiary care center. All proven cases of Russell's viper-envenomated individuals with preliminary CWA data and WBCT were included in the study. The clot wave (CW) of the five individuals, which met all the stringent inclusion criteria, was analyzed and interpreted. Results: CW absorbance sigmoid waveform was deranged in all 5 cases, of which 4 showed a change in CWA even before an abnormal aPTT. Three of the 5 had a normal WBCT but showed early changes in CWA. Atypical biphasic waveform reported in disseminated intravascular coagulation in other prior studies is seen in venom-induced consumptive coagulopathy also. In all patients where a second derivative was plotted, the second (lower) phase of the second derivative showed a slow rise to baseline. Conclusion: CWA showed changes which provided information earlier than the conventional coagulation studies in the snakebite victims studied. While aPTT or WBCT reflects clotting time, CWA conveys the dynamic process of clot formation and stabilization. CWA may reveal disorders of clotting in snakebite victims before the conventional tests become abnormal. Future research should assess the speed and accuracy of the test in diagnosing hemotoxic envenomation and its potential role in guiding antivenom therapy.
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Assessment and management of hypotension in the elderly patient
Himanshu L Kataria, Marc A Jacobson
July-September 2018, 11(3):221-224
DOI:10.4103/JETS.JETS_18_17  PMID:30429632
Introduction: Elderly patients often present to the emergency department (ED) with nonspecific signs of infection and excessive fluid loss, with limited research into their management. The purpose of this audit was to assess the initial management of hypotensive elderly patients in the ED: observations within 15 min, fluid challenge within 1 h, time to assessment by a physician, and initial management of septic shock. Subjects and Methods: Online patient systems were reviewed to find 40 patients >65 years old who were hypotensive (systolic blood pressure <100 mmHg or diastolic blood pressure <60 mmHg) in the ED between 1st October 2015 and 16th November 2015. This data were used to perform a retrospective audit to assess their management. Results: Forty hypotensive patients were identified with an average age of 79.6, with 55% being male. Eighty-three percent had their observations recorded within 15 min of presentation, 35% had their observations repeated within 1 h, and 35% were fluid challenged within 1 h. Nearly 60% patients were reviewed within 1 h by a physician. About 33% patients were in septic shock with 41% receiving IVF within 1 h, and all 40 patient receiving antibiotics. Discussion: The majority of patients had their observations performed within 15 min; however, a smaller percentage was fluid challenged within 1 h with their observations rechecked. Despite a sepsis pathway, hypotensive patients were still not receiving fluids within the hour. Conclusion: Developing a fast-track protocol for hypotensive elderly patients in the ED could improve initial rehydration management and ensure observations are reported in a timely manner.
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Magnitude and spectrum of injuries sustained in road traffic accidents among two wheeler riders and correlation with helmet use
Sanjeev Bhoi, Ajai Singh, Tej Prakash Sinha, Ranabir Pal, Sagar Galwankar, Arushi Baluja, Sabir Ali, Vidhu Sharma, Amit Agrawal
July-September 2018, 11(3):160-164
DOI:10.4103/JETS.JETS_119_17  PMID:30429621
Background: Helmet, as a protective gear to prevent fatal injuries while riding two-wheelers, needs to be evaluated by quality data. The aim of the study was to find out spectrum of injuries sustained with downstream outcomes in relation to acceptable ways of use of crash-proof helmet among motorized two-wheeler riders compared to nonuse following road traffic accidents. Methods: The present study was an analytical cross-sectional multicentric study conducted at three dedicated trauma care centers of India: (a) Jai Prakash Narayan Apex Trauma Center, All India Institute of Medical Sciences, New Delhi, (b) King George's Medical University, Lucknow, Uttar Pradesh, and (c) Narayana Medical College and Hospital, Nellore, Andhra Pradesh. Detailed information was collected on correct use of crash-proof helmets versus nonusers. Results: Among 317 traumatic brain injury victims (mean age 31.4 ± 12.5 years; range 11–70 years; highest (38%) in the 21–30 years age group), majority were from urban areas (84%), were brought directly to trauma center (76%), and were “Drivers” (73.50%), and their vision was “normal with or without using corrective lenses” (96%). Two-thirds of the victims were carrying “Formal driving licenses,” one-thirds were “Primary earning member of the family,” and one-tenths were under influence of alcohol. Half of the two-wheeler riders were using helmet, still lesser fastened helmet properly (45%), and few others used ISI quality “Crash proof” (38.5%). Helmet use during accidents had significantly better outcomes and significantly low clinical symptoms such as loss of consciousness, vomiting, ear/nose/oral bleed, headache, seizures with associated bony, abdominal, and chest injuries. Conclusions: Helmets have protective effects on riders if helmets are of crash-proof quality, fastened properly, and consistently used even for short spells and distances of rides.
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Clinical profile and autopsy findings in fatal head injuries
R Joseph Alexis, S Jagdish, Sanjay Sukumar, Vinay R Pandit, C Palnivel, M Jency Antony
July-September 2018, 11(3):205-210
DOI:10.4103/JETS.JETS_127_17  PMID:30429629
Aims: This study aims to correlate the autopsy findings with the clinical picture and imaging report in fatal head injury patients. Settings and Design: A descriptive study conducted at tertiary care hospital in South India from July 2015 to December 2016. Patients and Methods: All patients with head injuries who were admitted to our Emergency and Trauma Centre and underwent autopsy were included in the study. A structured pro forma was used for collecting information. Autopsy findings were considered as a gold standard to correlate with antemortem findings in fatal head injury. The data were analyzed with EpiData and OpenEpi statistical analyzing software. Results: Of the 303 fatal head injury patients, a majority were males and age group between 21 and 40 years. Eighty-eight percent (267/303) of fatal head injuries were due to road traffic accidents. Twenty-five of the 303 patients reached our center within 1 h (golden hour) of trauma. Of the 303 fatal head injuries, 153 (50.5%) died within 24 h of reaching our center. The most common autopsy finding in this study was subarachnoid hemorrhage (SAH) (247/303, 81.3%). Diagnostic accuracy of Epi dural hemorrhage (EDH) antemortem had the highest value (98.35%). SAH had least diagnostic accuracy value (45.72). subdural hemorrhage (SDH) had highest sensitivity (57.02%). EDH had higher specificity (100%). Significant SDH, SAH, and brain contusions were not detected during antemortem evaluation. Conclusions: Our study revealed that among fatal head injury patients, half of them died within first 24 h after reaching to tertiary care center. Diagnostic accuracy to detect extradural hemorrhage antemortem had the highest value and SAH had least diagnostic accuracy value. Significant subdural hemorrhage, subarachniod hemorrhage, and brain contusion were not detected during antemortem evaluation. Expertise in interpretation of imaging, adequate clinical examination, proper documentation, and early resuscitation may reduce the chances of missed injuries in head injury patients.
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Road traffic injuries and fatalities among drivers distracted by mobile devices
Natasa Zatezalo, Mete Erdogan, Robert S Green
July-September 2018, 11(3):175-182
DOI:10.4103/JETS.JETS_24_18  PMID:30429624
Context: With increasing ownership of mobile devices (i.e., cell phones and smartphones), it is important to better understand the role of these devices in motor vehicle collision (MVC)-related trauma. Aims: The primary objective was to synthesize evidence on the proportion of drivers injured or killed in an MVC attributed to driver distraction by a mobile device. As a secondary objective, we assessed for associations between injury risk and mobile device use while driving. Settings and Design: This study was a systematic review. Subjects and Methods: We searched five electronic databases (PubMed, Embase, CINAHL, TRIS, and Web of Science) and the gray literature to identify reports of drivers injured (regardless of the severity) or killed in MVCs attributed to mobile device-related distraction by the driver. We evaluated study and driver characteristics, as well as associations between injury risk and mobile device use by drivers. Statistical Analysis Used: Descriptive statistics were used to report study characteristics. The proportion of injuries related to driver distraction by mobile devices was calculated for each study. Results: Overall, 4907 articles were screened, of which 13 met eligibility criteria. The median proportion of distracted-driving-related trauma was 3.4% (range: 0.04% to 44.7%). Three studies evaluated the association between mobile device use and road traffic injury; all found use of a mobile device while driving significantly increased crash risk. Conclusions: The proportion of road traffic injuries and fatalities attributed to driver distraction by a mobile device ranges from 0.04% to 44.7%. Studies were subject to limitations in the collection of reliable data on distraction-related MVCs.
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Fatal acute myocardial infarction after multiple blunt injuries involving the chest
Kei Fujiwara, Hiromichi Ohsaka, Shunsuke Madokoro, Youichi Yanagawa
July-September 2018, 11(3):230-232
DOI:10.4103/JETS.JETS_39_18  PMID:30429635
The patient was a 60-year-old male fell whose head and left chest hit the ground after falling from a height of 2 m. He complained of the left shoulder and chest pain after regaining consciousness. On arrival, he showed left bloody otorrhea, left chest tenderness, and a limited range of motion due to the left shoulder pain. Emergency chest roentgenography revealed multiple left rib fractures, left clavicular fracture with decreased radiolucency in the left lung field, suggesting lung contusion. When the patient was being transported for computed tomography, he suddenly displayed ventricular tachycardia with pulse and subsequently became VF storm, which required percutaneous cardiopulmonary support. The coronary angiogram showed complete obstruction of the branch of the anterior descending artery. Coronary angioplasty resulted in recanalization; however, massive hemorrhage from the left ear was recognized. Computed tomography revealed traumatic subarachnoid hemorrhage and left massive hemothorax requiring thoracostomy. Massive hemorrhage from the left ear and left thoracic cavity continued after the patient was transported to the coronary care unit. He underwent massive transfusion; however, he died on the same day.
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The incidence and outcome differences in severe sepsis with and without lactic acidosis
Pratik B Doshi, Adam Y Park, Rosa C Banuelos, Bindu H Akkanti, Bryan F Darger, Annamaria Macaluso, Manoj Thangam, Kimberly A Chambers
July-September 2018, 11(3):165-169
DOI:10.4103/JETS.JETS_102_17  PMID:30429622
Introduction: To compare the incidence, characteristics, and outcomes of lactate expressors and nonexpressors in patients with severe sepsis and septic shock. Methods: This is a retrospective cohort study of patients with severe sepsis and septic shock who presented over a 40-month period to an academic tertiary care center. Primary outcome of interest was in-hospital mortality. Secondary outcomes were hospital length of stay (LOS), Intensive Care Unit (ICU) LOS, and escalation of care. Results: Three hundred and thirty-eight patients met inclusion criteria and were divided into a lactate expressor group (n = 197; initial lactate ≥2.5 mmol/L) and a nonexpressor group (n = 141; lactate <2.5 mmol/L). The mortality rate was 46.2% for lactate expressors and 24.8% for nonexpressors. There were no significant differences in hospital or ICU LOS. The escalation-of-care rate in the severe sepsis nonexpressor group was more than double that found in the expressor group: 16.5% versus 6.2% (P = 0.040). The two groups had baseline differences: expressor group had a higher median Acute Physiology and Chronic Health Evaluation II (APACHE II) illness severity score, and nonexpressors had an increased prevalence of comorbid conditions. APACHE II score (odds ratio [OR] 1.10 (1.07–1.14), P < 0.001) and being in the expressor group (OR 1.72 [1.03–2.89], P = 0.039) increased the odds of mortality. Conclusions: In patients with severe sepsis and septic shock, lactate nonexpressors are common. Although the mortality in this cohort is less than its counterparts who present with lactate elevation, it is still significant which warrants vigilance in their care.
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Functional outcomes in moderate-to-severe traumatic brain injury survivors
Ammar Al-Hassani, Gustav F Strandvik, Ayman El-Menyar, Amit R Dhumale, Mohammed Asim, Ahmed Ajaj, Wafa Al-Yazeedi, Hassan Al-Thani
July-September 2018, 11(3):197-204
DOI:10.4103/JETS.JETS_6_18  PMID:30429628
Introduction: We aimed to analyze the functional outcomes based on the admission characteristics in individuals with moderate-to-severe traumatic brain injury (TBI) over a 5-year period. Methods: A retrospective cohort study was conducted to assess the cognitive, physical, and functional outcomes based on traditional and novel metrics used in potential outcome prediction. Results: A total of 201 participants were enrolled with a mean age of 31.9 ± 11.9 years. Glasgow Coma Score (GCS) at emergency department did not correlate with the functional independence measure (FIM) score or Ranchos Los Amigos (RLA) scores at discharge. The absolute functional gain was significantly higher in individuals who sustained TBI with RLA 4–5 (34.7 ± 18.8 vs. 26.5 ± 15.9, P = 0.006). Participants with RLA 4–5 on admission to rehabilitation showed good correlation with the absolute FIM gain. On multivariate regression analysis, only age (odds ratio 0.96; 95% confidence interval: 0.93–0.98; P = 0.005) was found to be the independent predictor of good functional outcome. Conclusions: Initial GCS is not a predictor of functional outcome in individuals who sustained TBI. Consideration of age and development of novel functional measures might be promising to predict the outcomes in individuals with moderate-to-severe TBI.
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From emergency department to intensive care unit, does the delay matter to trauma patients?
Kapil Dev Soni, Gaurav Kaushik, Amit Gupta, Vishwajeet Singh, Subodh Kumar, Sushma Sagar
July-September 2018, 11(3):189-192
DOI:10.4103/JETS.JETS_132_17  PMID:30429626
Introduction: Emergency department (ED) overcrowding with critically ill trauma patients has been a major concern globally. It has been shown that longer stays in the hospital before Intensive Care Unit (ICU) admission have a higher mortality rate. Objective: The objective of this study was to find whether the delay in ICU admission from ED is associated with significant mortality in a trauma patient. Methods: A prospective trauma registry data of 232 patients collected from the ED of JPNATC trauma center between September 2015 and March 2016 were used in the study. The study participants were all admitted trauma patients. Dead-on-arrival patients were excluded from the study. Results: All included patients had a blunt injury at the time of arrival. Of 232 patients, 66 died during treatment and 166 were discharged. Of these, 196 (84.5%) were male and 36 (15.5%) were female. Most of the patients among 66 who died were referred from different hospitals; however, most survivors arrived directly at JPNATC as compared to another group (P < 0.001). Waiting time in ED was calculated by the difference between arrival time and ED disposition time. There was statistically significant difference found in ED waiting time in both the groups (P = 0.015); however, the odds ratio is closer to 1, that is, 0.998. Similarly, age, gender, oxygen saturation, Glasgow Coma Scale, ICU stay days, heart rate, referring status, and injury severity score were found to be significant at the level of 25% under univariate analysis. Conclusion: The ED delay is not associated with adverse outcome in terms of mortality. Other factors may play a much greater role in determining the prognosis.
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The effect of head rotation on the relative vascular anatomy of the neck: Implications for central venous access
Raymond L Merritt, Michael E Hachadorian, Kristof Michaels, Eric Zevallos, Kubwimana M Mhayamaguru, Zuheily Closser, Charlotte Derr
July-September 2018, 11(3):193-196
DOI:10.4103/JETS.JETS_5_18  PMID:30429627
Context: Previous studies have shown that safe venous cannulation is difficult when the internal jugular vein (IJV) overlies the carotid artery (CA) as the probability of inadvertent arterial penetration is greatly increased. Aims: The goal of this study was to examine the anatomical relationships of the IJV and CA as a function of the degree of head rotation in order to minimize the risk for CA puncture. Settings and Design: Our study was a prospective study using a sample of 496 Emergency Department patients. Methods and Material: The anatomic relationships of the right and left IJVs and CAs were recorded with head rotation at three different positions. Patients who had the IJV in a 45 to 135 degree relationship to the CA were deemed to be in the high-risk zone for arterial puncture. Statistical Analysis: Chi square, ANOVA. Results: Right IJVs were in the high risk zone for 39.5%, 47.8% and 60.9% of cases at 0, 45 and 80 degrees of head rotation, respectively (P < 0.001). Left IJVs were in the high risk zone for 59.1%, 69.2% and 80.0% at 0, 45 and 80 degrees of head rotation, respectively. (P < 0.001). Conclusions: Head rotation should be minimized during IJV cannulation to decrease the overlap of CA by IJV. Cannulation of the left IJV appears to carry a higher degree of risk as compared to the right IJV. Placing the head in neutral position, avoiding rotation, and using ultrasound guidance are recommended to minimize complications during central venous access.
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Patterns of zygomatic complex bone fracture in Saudi Arabia
Dawood Ali-Alsuliman, El-Hakim Ibrahim, Ramat Oyebunmi Braimah
July-September 2018, 11(3):170-174
DOI:10.4103/JETS.JETS_12_18  PMID:30429623
Introduction: Zygomatic bone (ZB), also known as the cheekbone, articulates with the maxilla, temporal sphenoid, and the frontal bones. It forms the prominence of the cheek and part of the orbit, and because of its prominence, it is susceptible to trauma. The aim of this study was to present the pattern of ZB fracture in a country in the Middle East. Patients and Methods: The medical records of all trauma cases admitted to the Department of Oral and Maxillofacial Surgery Ward, Riyadh Dental Centre, King Saud Medical City, Riyadh, Saudi Arabia, were reviewed and all cases with ZB fractures were included in this study from December 2002 to December 2012. Data were analyzed using SPSS version 16 (SPSS Inc., Chicago, IL, USA). The results were presented as simple frequencies and percentages. Results: A total of 1487 patients had maxillofacial trauma and 306 cases were diagnosed with ZB fractures during the study. There were 271 (88.6%) males and 35 (11.4%) females with male: female ratio of 7.7:1. Age group of 21–30 years has the highest number of fracture cases (133 [43.5%]). Road traffic accident (RTA) remained the leading etiology of zygomatic complex fracture (ZMCF; 221 [72.2%]). August has been observed to be associated with the highest cases of ZMCF (40 [13.1%]). The years 2005 and 2006 recorded the highest frequency of ZMCF cases (46 [15.0%] and 44 [14.4%], respectively). Conclusion: The results of this study showed that RTA is the leading cause of ZB fractures followed by assaults. The most commonly fractured site was the zygomaticomaxillary. Proper road traffic regulation is paramount to help reduce maxillofacial trauma.
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Impact of automated external defibrillator as a recent innovation for the resuscitation of cardiac arrest patients in an Urban City of Japan
Ikuto Takeuchi, Hiroki Nagasawa, Kei Jitsuiki, Akihiko Kondo, Hiromichi Ohsaka, Youichi Yanagawa
July-September 2018, 11(3):217-220
DOI:10.4103/JETS.JETS_79_17  PMID:30429631
Context/Aims: We retrospectively analyzed the characteristics of prehospital care for cardiopulmonary arrest (CPA) to identify the predictors of a good recovery (GR) among the recent changes in the management of Japanese prehospital care. Settings and Design: This study was a retrospective medical chart review. Subjects and Methods: We reviewed the transportation records written by emergency medical technicians and the characteristics of prehospital management of out-of-hospital (oh) CPA described by the Sunto-Izu Fire Department from April 2016 to March 2017. The cases were divided into two groups: a GR group (cerebral performance category of 1–3 at 1 month after CPA) and a poor recovery (PR) group. Results: During the analysis period, there were 545 cases of CPA. The average age in the GR group (n = 19) was significantly younger than that in the PR group. The proportions of patients with witnessed collapse, automated external defibrillator (AED) executed by a bystander, ventricular fibrillation during prehospital cardiopulmonary resuscitation (CPR), defibrillation-induced cardioversion, cardiogenic arrest, and oh-return of spontaneous circulation (ROSC) were significantly greater in the GR group than in the PR group. The proportions of telephone CPR conducted by operator, instrumentally secured airways, and administration of epinephrine were significantly smaller in the GR group than in the PR group. A multivariate analysis showed that the significant predictors of GR were bystander AED, ROSC, not instrumentally secured airway, and younger age. Conclusions: This study showed that patients with CPA who were younger, underwent AED executed by a bystander, and obtained oh-ROSC had a higher chance of a favorable outcome.
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Whats new in emergencies trauma and shock? Autopsy in fatal head injuries
Amit Agrawal, Luis Rafael Moscote-Salazar
July-September 2018, 11(3):153-153
DOI:10.4103/JETS.JETS_2_18  PMID:30429618
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A rare case of spontaneous massive retroperitoneal hemorrhage due to idiopathic lumbar artery bleed
Kunal Nandy, Maitreyi Patel, Aparna Deshpande
July-September 2018, 11(3):238-239
DOI:10.4103/JETS.JETS_56_18  PMID:30429636
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The new paradigm in community-based care: Managing mindset and expectations
Fatimah Lateef
July-September 2018, 11(3):156-159
DOI:10.4103/JETS.JETS_51_18  PMID:30429620
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Smooth transitions in critical care
Ariel L Shiloh
July-September 2018, 11(3):154-155
DOI:10.4103/JETS.JETS_44_17  PMID:30429619
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Resuscitation of out-of-hospital cardiac arrest victims in Lebanon: The experience and views of prehospital providers
Mohamad H Haidar, Samar Noureddine, Mona Osman, Hussain Isma'eel, Mazen El Sayed
July-September 2018, 11(3):183-188
DOI:10.4103/JETS.JETS_101_17  PMID:30429625
Background: The survival rate of out-of-hospital cardiac arrest (OHCA) victims in Lebanon is much lower than those seen internationally. In this study, we examined the attitudes and practices of prehospital providers in resuscitation. Methods: We devised a cross-sectional survey with questions adopted from the literature including a study out of Lebanon. Questionnaires were mailed to 300 volunteers who were recruited from 10 centers of local emergency medical services (EMS). Results: A total of 258 questionnaires were returned (86% response rate). Most participants (>80%) were younger than 30 years, and males (60%). Over half reported witnessing up to 10 arrests per year, with 72.5% reporting prehospital return of spontaneous circulation in <6% of cases. Futile resuscitation was frequently (91%) practiced. Participants believed resuscitation should be withdrawn when prolonged (55.4%) or in the presence of advanced directives (34.1%) or terminal illness (27.5%). Reported resuscitation challenges were related to the reaction of witnesses (70.1%), to delay in calling EMS (84.4%), and to traffic delays (30%). Participants recommended training lay persons in resuscitation (79%), training prehospital providers in advanced airway management (68.2%) and intravenous skills (60.1%), providing medications in ambulances (57.7%), and adjusting traffic laws (52%). Conclusion: Prehospital providers in Lebanon face several challenges in their resuscitation practices. A multi-faceted strategy to improve resuscitation practices is needed in Lebanon. In addition to policy development, structural changes should be put in place for improved outcomes in OHCA victims.
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