Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
January-March 2021
Volume 14 | Issue 1
Page Nos. 1-71

Online since Tuesday, March 23, 2021

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What's new in emergencies trauma and shock? resuscitative thoracotomy in emergency room - selective not obligatory Highly accessed article p. 1
Mansoor Khan, Salomone Di Saverio
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Simulation centers and simulation-based education during the time of COVID 19: A multi-center best practice position paper by the world academic council of emergency medicine p. 3
Fatimah Lateef, Madhavi Suppiah, Shruti Chandra, Too Xin Yi, Willy Darmawan, Brad Peckler, Veronica Tucci, Alfredo Tirado, Lorraine Mendez, Lisa Moreno, Sagar Galwankar
COVID 19 struck us all like a bolt of lightning and for the past 10 months, it has tested our resilience, agility, creativity, and adaptability in all aspects of our lives and work. Simulation centers and simulation-based educational programs have not been spared. Rather than wait for the pandemic to be over before commencing operations and training, we have been actively looking at programs, reviewing alternative methods such as e-learning, use of virtual learning platforms, decentralization of training using in situ simulation (ISS) modeling, partnerships with relevant clinical departments, cross-training of staff to attain useful secondary skills, and many other alternatives and substitutes. It has been an eye-opening journey as we maximize our staff's talent and potential in new adoptions and stretching our goals beyond what we deemed was possible. This paper shares perspectives from simulation centers; The SingHealth Duke NUS Institute of Medical Simulation which is integrated with an Academic Medical Center in Singapore, The Robert and Dorothy Rector Clinical Skills and Simulation Center, which is integrated with Thomas Jefferson University, Oakhill Emergency Department, Florida State University Emergency Medicine Program, Florida, USA and The Wellington Regional Simulation and skills center. It describes the experiences from the time when COVID 19 first struck countries around the world to the current state whereby the simulation centers have stWWarting functioning in their “new norm.” These centers were representative examples of those in countries which had extremely heavy (USA), moderate (Singapore) as well as light (New Zealand) load of COVID 19 cases in the nation. Whichever categories these centers were in, they all faced disruption and had to make the necessary adjustments, aligning with national policies and advisories. As there is no existing tried and tested model for the running of a simulation center during an infectious disease pandemic, this can serve as a landmark reference paper, as we continue to fine-tune and prepare for the next new, emerging infectious disease or crisis.
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A national study of emergency thoracotomy for trauma Highly accessed article p. 14
Christopher K Hansen, Patrick W Hosokawa, Robert C Mcintyre, Christopher McStay, Adit A Ginde
Introduction: The role of resuscitative thoracotomy in the emergency department (ED) for patients that have suffered severe thoracoabdominal trauma has been the subject of much debate. Most studies that characterize emergency thoracotomy are from urban, academic, and trauma centers. We sought to describe patient and hospital characteristics of a nationally representative sample of ED thoracotomy (EDT). Methods: The health-care cost and utilization project 2013 National ED Sample (NEDS) and the 2013 National Inpatient Sample (NIS) maintained by the agency for health-care research and quality were used to generate a nationally representative estimate of resuscitative thoracotomies performed in the ED. We obtained patient demographics and clinical characteristics and compared the descriptive statistics of the two datasets. Results: The NEDS dataset identified 124 unsuccessful EDTs, whereas the NIS dataset identified 77 admissions for thoracotomy. When weighted to create a national estimate, these represent 952 emergency thoracotomies performed in the US in 2013. Most were male (82.5% and 88.2% in NEDS and NIS, respectively). In addition, 32.9% and 36.4% in NEDS and NIS, respectively, were between the ages of 20 and 29. The majority of thoracotomies were performed at metropolitan teaching hospitals (64.2% and 75.3%, NEDS and NIS, respectively). The mean total ED charges for patients who had an unsuccessful thoracotomy were $32,664 and the mean total inpatient charges were $141,215. Conclusion: Nearly 1000 thoracotomies are performed annually on the day of presentation to U. S. hospitals. Although emergency thoracotomy for trauma is an infrequently performed procedure, it almost always occurs at an urban, high volume, and level I or level II trauma centers.
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Hand injuries of coal miners in Southern West Virginia: A pilot study on health-care resources in Southern West Virginia p. 18
Ravi Viradia, Frank H Annie, Maher Kali, Frederic Pollock, John David Hayes
Introduction: Distance and other factors may play a significant role in both the implementation of care and the number of secondary health outcomes. The distance from an injury site can play a substantial impact on the mortality of different injuries and access to health-related services. Within this study, we sought to understand the effect of the site to treating center distance and access to relevant health-care services on effect and secondary injuries of coal mining-related injuries. Methods: We evaluated patient demographics, coal mining locations, and patient outcomes. This study is a retrospective review of patients with coal mining hand injuries included in our Level 1 trauma database as well as the amount of health-related resources defined by WV GIS Health Care (Hospitals). The sample consists of coal mine workers. All patients had to meet the study criteria and were admitted during the study period of January 1, 2005, through March 31, 2015. We then were able to locate the coal mines where these coal miners were injured based on information from their medical records and the availability of health-care resources (hospitals) around the zones of injury, as well as health-related resources from the WV GIS database. The sample size was n = 104. Data were collected in an Excel spreadsheet. Stata 11.2 was used to conduct a multinomial logistic regression. A hub analysis was performed to understand the overall distance associated with the injury site and care using Arch GIS 10.6. A hotspot analysis was also performed in order to understand the differences of different zones of concern of injury sites in Southern West Virginia, from January 1, 2005, to March 31, 2015. Results: Variables collected are as follows: a total number of coal miners were 104, with an average age of miners being similar in age demographics at 19–62. Coal mines are registered on the map with relevance to injury based on location; severity scale is presented. The most common injuries were fractures at 42.3% (47/104) followed by amputations at 26.9% (28/104). The index finger had an overall higher rate of injury at 28.8% (30/104). To understand the overall impact of specific injuries of coal miners based on the location, we peered into the number of injuries sustained at particular sites over the 10 years. Within this, the attached group, the average distance per injury to a medical center that was able to assist with hand injuries, was 46.1 miles. The shortest distance was within one mile of the center, and the most prolonged distance was 83.3 miles. The highest concentration of coal mining injuries were over 5 miles away from any health care organizations. The at-risk area of coal mining injuries was identified at (P = 0.001) and outside of health-care resources that can be seen within the hotspot analysis tested within this analysis. Conclusion: Specific injuries appear to be more at risk on different portions of the hand, as described in our initial data analysis. We also found that particular coal mines seem to harbor more coal mining hand injuries. Rural health care has the challenge of injuries occurring at extended distances and requires that treatment becomes as efficient as possible to maximize the chances of a full recovery. Aim and Objectives: The objective of this study is to understand if the distance between the location of injury and trauma center plays a role in the outcome of coal mines related to hand injuries treated at Charleston Area Medical Center.
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A study of the pattern of injuries sustained from road traffic accidents caused by impact with stray animals p. 23
Chitta Ranjan Mohanty, Rakesh Vadakkethil Radhakrishnan, Mantu Jain, Prakash Kumar Sasmal, Upendra Hansda, Sunil Krishna Vuppala, Sunil Kumar Doki
Background: The incidence of road traffic accidents (RTA) is increasing every day, especially in developing nations. Amongst various attributable factors, the menace of the stray animals remains one of the most underrecognized factors leading to animal-vehicle collision (AVC). Objectives: Our prospective cross-sectional study aims to survey the incidence of RTA attributable to stray animals and record the pattern of injuries along with other epidemiological parameters. Methods: The present study was conducted at a tertiary care trauma centre located in a major city of eastern India, between June 2019 and March 2020. Variables like demographic details, type of vehicle and injury with severity score, use of safety gear including types of stray animals were collected and analysed. Results: A total of 185 patients had suffered RTA due to AVC during the study period. The median age of occurrence was 29.0 years. The evening was the most frequent time of accidents (4 PM to 8 PM) with two-wheelers affected in 92% of cases. Stray dogs account for 69% of cases followed by cattle 21% cases. 41% of all RTA victims had polytrauma. Patients with RTA due to impact with ox were found to have higher injury severity score (ISS). The ISS comparison between two-wheeler drivers with and without helmet and influence of alcohol were statistically significant (P<0.01). Conclusion: The study highlights an alarming incidence of RTA due to stray animals roaming freely on roads, thus adding significant morbidity and costs to the society. There is a need of the hour for imposing stringent measures from the appropriate authority, including public awareness to make sustainable action plans to prevent animal homelessness and wander freely on streets and major roads.
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An assessment of management strategies for adult patients with foreign-body sensation in the neck p. 28
Nidhi Garg, Ryan N Lee, Renee Pekmezaris, Sanjey Gupta
Objectives: Patients come to the emergency department (ED) for the evaluation of foreign-body sensation in the neck. Given the dearth of clinical studies for this complaint, these patients are treated subjectively by different providers. We aim to propose a treatment approach that results in the timely diagnosis and removal of foreign bodies by comparing the common radiologic studies used in the ED for this complaint, determining the utility of consults, and providing an approach that minimizes length of stay. Methods: We conducted a retrospective cohort study of adults between January 2014 and December 2015 presenting to LIJ and NSUH EDs with a chief complaint of foreign-body sensation in the pharynx, larynx, or esophagus. Fifty unique cases were studied. Consultations with ear, nose, and throat (ENT) and/or gastrointestinal, any imaging studies used, and time until discharge from the hospital were the primary exposures studied. The time for each diagnostic path for successful removal of a foreign body was compared for each case. Results: Three common diagnostic approaches were identified. The most common pathway (six cases) had an ENT consult for removal of the foreign body, with an average time to discharge of 188 min. Another common pathway (four cases) began with a neck X-ray followed by an ENT consult, with an average time of 327 min. The third common approach (6 cases) involved no imaging studies or consults, with an average time of 166 min. Neck X-ray (20 cases) was found to have a sensitivity of 43% and a specificity of 83%. The sensitivity of neck computed tomography (CT) (15 cases) had a sensitivity of 91% and a specificity of 50%. Chest X-ray (15 cases) was found to have a sensitivity of just 17%. Chest CT (3 cases) had a sensitivity of 67%. Conclusion: Based on our data, we recommend that an attempt to localize the foreign body be completed by the emergency physician. If an initial attempt does not resolve the sensation, an ENT consult to remove the possible object should be initiated. Only after failure by ENT should radiological imaging be considered.
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Diagnostic accuracy of ultrasound measurements of anterior neck soft tissue in determining a difficult airway p. 33
Madhu Srinivasarangan, P Akkamahadevi, Veeresh C Balkal, Rameshbabu Homanna Javali
Context: Airway management in the emergency department is challenging because conventional screening tools cannot be applied. Therefore, a rapid noninvasive means of identifying a difficult airway will be advantageous for emergency physicians. Aims: The aim of this study is to examine the association between ultrasound measurements of anterior neck soft tissue and difficult airway as judged by the Cormack Lehane grading. Settings and Design: A prospective study was done for 18 months on patients requiring intubation presenting to the emergency medicine department. Subjects and Methods: Ultrasound measurements of anterior neck soft tissue were obtained in 60 cases at the levels of thyrohyoid membrane, hyoid bone, and vocal cords. Another examiner who was blinded to the ultrasound measurements performed endotracheal intubation and noted Cormack–Lehane grading. Statistical Analysis Used: Descriptive statistics such as mean, standard deviation, frequency, and percentage were used. Inferential statistics such as Student's t-test and receiver operating characteristic (ROC) curve analysis were done using the SPSS software version 22. Results: The thickness of anterior neck soft tissues at the level of hyoid bone in difficult patients was 0.73 cm (95% confidence interval = 0.65–0.80) compared to easy patients 0.47 cm (95% confidence interval = 0.44–0.51) with a P = 0.001 and at the level of thyrohyoid membrane in difficult patients it was 1.83 cm (95% confidence interval = 1.7–1.89) compared to easy patients 1.46 cm (95% confidence interval = 1.41–1.51) with a P = 0.001. Area under the ROC curve was significant at all the three levels with the highest at the level of thyrohyoid membrane 0.99 and least at the level of vocal cords 0.79, the area under the curve was 0.92 at the level of hyoid bone. Conclusions: Sonographic measurements of the anterior neck soft tissue can be used as a screening tool by an emergency physician to detect difficult intubation.
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Laboratory risk indicator for necrotizing fasciitis score and patient outcomes p. 38
Jun Fujinaga, Akira Kuriyama, Tetsunori Ikegami, Mutsuo Onodera
Context: The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score helps to diagnose necrotizing soft-tissue infection (NSTI). The LRINEC score has been reported to be associated with poor prognosis, although few studies have evaluated this association. Aims: We aimed to describe the characteristics of NSTI and assess whether the LRINEC score was associated with mortality and amputation. Settings and Design: We conducted a retrospective observational study from January 2007 to May 2018, in a Japanese tertiary care hospital. Subjects and Methods: Patients with NSTI were identified through our hospital database using the discharge diagnosis. We extracted data on patient characteristics, laboratory examinations, microbiological information, treatment, and in-hospital mortality. Statistical Analysis Used: We estimated the odds ratios (ORs) and associated 95% confidence intervals (CIs) for in-hospital mortality using logistic regression models. Results: We identified 58 patients. The median LRINEC score was 8 (interquartile range [IQR]: 6–9). Forty-four patients (75.9%) scored 6 or more. The eight patients with amputations had a median score of 6 (IQR: 4.5–7.5) versus 8 (IQR: 7–9) for patients who underwent debridement (P = 0.091). Survivors and nonsurvivors had median scores of 8 (IQR: 6–9) and 6 (IQR: 5–8), respectively (P = 0.148). The OR for mortality in patients with liver cirrhosis was 10.5 (95% CI: 1.00–110.36; P = 0.050). Conclusions: There was no association between the LRINEC score and patients' outcomes: mortality and amputation. Further studies are warranted to evaluate the utility of the LRINEC score and factors associated with poor prognosis in patients with NSTI.
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Correlation between alcohol use disorders, blood alcohol content, and length of stay in trauma patients p. 42
Wirachin Hoonpongsimanont, Ghadi Ghanem, Soheil Saadat, Maria Nguyen, Christine Louis, Preet K Sahota, Leila Danishgar, Christy Carroll, Cristobal Barrios, Shahram Lotfipour
Background: Patients with an alcohol use disorder (AUD) have an increased risk of developing complications during their hospital stays; however, how AUD impacts the length of stay (LOS) and the utilization of hospital resources remains inconclusive. Aim: This study aimed to identify the associations between AUD, defined by self-reported alcohol consumption, blood alcohol content (BAC), and hospital LOS (HLOS) including intensive care unit (ICU) LOS in the trauma patient population. Study Design: We conducted a retrospective study analyzing data obtained from 2010 to 2018 at a university-based, level-one trauma emergency department. We identified 1689 adult trauma patients who completed the AUDs identification test (AUDIT) and were admitted to the hospital. We retrieved BAC, age, gender, LOS, and injury severity score (ISS) from the patient charts. The independent samples' median test was used to assess the association of HLOS and ICULOS with ISS, BAC levels, or AUDIT scores. Results: ISS was directly associated with higher HLOS (P < 0.001) and ICULOS (P < 0.001); however there was no statistically significant association between AUDIT scores and ICULOS (P = 0.21) or HLOS (P = 0.86). There was also no statistically significant association between BAC and HLOS (P = 0.09) or ICULOS (P = 0.07). Conclusions: Our study found no associations between AUDIT, BAC, and both hospital and ICU LOS in trauma patients even though the literature supported an increased risk of medical complications in the AUD patients.
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Hemosuccus pancreaticus: Culprit of life-threatening upper gastrointestinal bleeding in acute pancreatitis p. 48
Abhishek Singhai, Piyush Manoria, Rishabh Bose
Hemosuccus pancreaticus (HP), a term used for upper gastrointestinal bleeding (UGIB) from the ampulla of Vater through the pancreatic duct, is most commonly caused by the rupture of aneurysm of the splenic artery associated with acute or chronic pancreatitis. It is a rare cause of UGIB, and estimates of its rate (1/1500) are based on small case series. Because of its rarity, the diagnosis is easily overlooked. Here, we have described a case of alcohol-induced acute pancreatitis that developed hemorrhagic shock due to HP.
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Body packer syndrome p. 51
Akant Arora, Sandeep Jain, Ayush Srivastava, Manish Mehta, Kartik Pancholy
“Body packers” are persons who voluntarily or through coercion, swallow or insert drug-filled packets into body cavity, generally in an attempt to smuggle them across secure borders. The drugs most often involved in body packing are heroin and cocaine. Body packers can present in the emergency department as a result of ruptured drug packets, bowel obstruction, or for medicolegal purposes. Suspected cases are diagnosed with X-ray and computed tomography scan of the abdomen. Symptomatic patients require urgent removal of packets. We present a case of foreign national male in whom a drug packet got ruptured and 49 other packets were retrieved with help of laxatives and manual evacuation.
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The use of point-of-care blood gases for critically injured patients at a Level 1 trauma center p. 53
Demi Beneru, Jeremy Hsu, Andrew R Coggins
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Indirect carotico-cavernous fistula following trivial trauma causing secondary glaucoma p. 54
Bijnya Birajita Panda, Ashok Kumar Nanda
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Heterochromia iridum with sudden vision loss in an elderly man – A trick to treat p. 56
Bijnya Birajita Panda, Sanghamitra Kanungo, Ashok Kumar Nanda
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Spontaneous pneumomediastinum in a young female p. 57
Priyanka Modi, Prakash Ranjan Mishra, Ankit Kumar Sahu, Sanjeev Bhoi
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Successful observational management of a patient with blunt abdominal trauma with the traumatic vacuum phenomenon p. 58
Youichi Yanagawa, Hiroki Nagasawa, Kei Jitsuiki, Kazuhiko Omori
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Abstracts for the 38th annual emergencies in medicine conference p. 61
Sukaina Ali Alali, Jean W Hsu, Abraham Akbar, Robert D Welch, Joseph Gibbs, Charles V Pollack, J Fanikos, E Chebolu, Jennifer Nguyen, Gregory J Fermann, Mufaddal Jivanjee, James Williams, Bryan F Imhoff, Kristin L Rising, R Isaacs, Teo Zhongyang, Charles E Mahan, Tinh Le, Lauren Rosenblatt, I Gueye, W Frank Peacock
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