Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
October-December 2020
Volume 13 | Issue 4
Page Nos. 237-322

Online since Monday, December 7, 2020

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Whats new in emergency trauma and shock? The choice of hyperosmolar agent in emergency department p. 237
Vivek Chauhan
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Infection control measures, in situ simulation, and failure modes and effect analysis to fine-tune change management during COVID-19 Highly accessed article p. 239
Fatimah Lateef, Stanislaw P Stawicki, Lee Man Xin, S Vimal Krishnan, A Sanjan, Freston Marc Sirur, Jayaraj Mymbilly Balakrishnan, Rose V Goncalves, Sagar Galwankar
Coronavirus disease 2019 (COVID-19) was an impetus for a multitude of transformations – from the ever-changing clinical practice frameworks, to changes in our execution of education and research. It called for our decisiveness, innovativeness, creativity, and adaptability in many circumstances. Even as care for our patients was always top priority, we tried to integrate, where possible, educational and research activities in order to ensure these areas continue to be harnessed and developed. COVID-19 provided a platform that stretched our ingenuity in all these domains. One of the mnemonics we use at SingHealth in responding to crisis is PACERS: P: Preparedness (in responding to any crisis, this is critical) A: Adaptability (needed especially with the ever-changing situation) C: Communications (the cornerstone in handling any crisis) E: Education (must continue, irrespective of what) R: Research (new opportunities to share and learn) S: Support (both physical and psychological). This article shares our experience integrating the concept of simulation-based training, quality improvement, and failure mode analysis.
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The impact of the COVID 19 pandemic on emergency department attendance: What seems to be keeping the patients away? Highly accessed article p. 246
Fatimah Lateef
During outbreaks such as severe acute respiratory syndrome and COVID 19, many Emergency Departments across the world had a reduction in the general attendance, including the attendance of more serious and critical diagnoses. Here, the author shares the numbers seen at Singapore General Hospital, the largest public hospital in Singapore during the period of February to June 2020. The reduction ranged from 13% to 28% compared to the same period in 2019, before the outbreak. Patient and healthcare system-related factors which may have caused these observations are discussed. The author also puts forth the Behavioral Immune System and Response mechanism as a possible explanation for patients staying away from the hospitals during the outbreak.
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Comparison of weight-based dosing versus fixed dosing of 23.4% hypertonic saline for intracranial pressure reduction in patients with severe traumatic brain injury p. 252
Kirsten Busey, Jason Ferreira, Petra Aldridge, Marie Crandall, Donald Johnson
Context: Hypertonic saline (HTS) is a pharmacologic therapy used in patients with severe traumatic brain injuries to decrease intracranial pressure (ICP) associated with cerebral edema. Aims: The purpose of this study was to compare ICP reduction between fixed doses of 23.4% HTS and weight-based doses. Setting and Design: This was a retrospective study that included adult patients at a level 1 trauma center who had nonpenetrating traumatic brain injury, an ICP monitor, and received at least one dose of 23.4% HTS. Subjects and Methods: Doses were classified as either high weight-based (>0.6 ml/kg), low weight-based (<0.6 ml/kg), or standard fixed dose (30 ml). Only doses given within 5 days post-injury were evaluated. Percent reduction in ICP was compared pre- and post-dose between dosing groups, and each dose was evaluated as a separate episode. Statistical Analysis: The primary and secondary endpoints for the study were analyzed using mixed-model, repeated-measures analysis of covariance. Results: A total of 97 doses of HTS were evaluated. The primary endpoint of ICP reduction showed a 42.5% decrease in ICP after the administration of a high weight-based dose, a 36.7% reduction after a low weight-based dose, and a 31.5% reduction after a fixed dose. There was no significant relationship between dose group and percent change in ICP (P = 0.25). A sub-analysis of doses received within 48 h postinjury found a significant relationship between both dose group and percent change in ICP, and initial ICP and percent change in ICP (P = 0.04, and <0.0001 respectively). Conclusions: Our data did not show a significant difference between fixed- and weight-based doses of 23.4% HTS for ICP reduction.
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Evaluation of patients record and its implications in the management of trauma patients p. 257
Anant Gupta, Kanika Jain, Sanjeev Bhoi
Introduction: A medical record audit is a type of quality assurance task which involves formal reviews and assessments of medical records to identify where a medical organization stands in relation to compliance and standards. A study was carried out with the objective to document the audit of the medical records in a tertiary care trauma center and suggest the corrective measures and preventive measures in case of lacunae. Methodology: A retrospective study was conducted in an apex trauma care facility of New Delhi. All the admissions on disaster bed from October 1, 2015, to December 31, 2015, were evaluated. A list of 106 admissions were made using the online software at the trauma center. The files were taken from the medical record departments and compared using a checklist prepared in accordance with the guidelines laid down by the Joint Commission International. Results: A total of 106 admissions on disaster bed from October 1, 2015, to December 31, 2015, were evaluated. The average length of stay for the disaster beds was 11.7 days and the mortality rate was 9.5%. Signature of the patient and doctor and name of the witness were missing in more than 50% of the cases of consent. Discharge summary in which the investigation details, signature of the doctor, and contact number in case of an emergency were not documented. In the miscellaneous records, transfer (61%) and referral (42%) were not documented properly. Conclusion: The average length of stay for the disaster beds was 11.7 days. Maximum admissions were under the neurosurgery department. The filing and assembling of records were poor. Signature of the patient and doctor and name of the witness were missing in more than 50% of the consent forms. There was no anesthesia consent form used. The doctor daily records were poor, while the nursing records were well maintained. It is recommended to have a periodic weekly auditing to minimize chances of deficiency/misplacing of records. Periodic training sessions and workshops should be organized.
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Patient safety during rapid sequence intubation when using succinylcholine instead of nondepolarizing paralytic agents: Should we change a common rapid sequence intubation pathway? p. 264
Jason W Wilson, James P Gillen, Tucker Maute
Background: Succinylcholine is a depolarizing agent used for rapid sequence intubation (RIS). While the agent is the most widely used drug of choice in most emergency departments (EDs), the adverse effect profile is lengthy compared to nondepolarizing paralytic agents included rocuronium and vecuronium. Objectives: Our objective in this analysis is to detect potential safety signals and differences in safety related outcomes between patients that received succinylcholine compared to those that received rocuronium or vecuronium when undergoing RSI. Specifically, we asked whether there was a difference in all-cause mortality, whether succinylcholine was used in patient later found to have contraindications to the medication, as well as differences in the rates of rescue airway or difficult airway algorithms utilized. Methods: We utilize two clinical cases as a framework to review adverse events among ED patients undergoing RSI when using succinylcholine compared to nondepolarizing agents over a 7 years’ period at our institution as part of a quality review project. The review is retrospective and does not allow us to link adverse events specifically with drug but, instead, considers aggregate level event frequency. Results: From January 31, 2013, to January 31, 2018, there were 36,059 intubations with paralytics in the ED (75.39% with succinylcholine and 24.61% with rocuronium or vecuronium). There was no evidence of death or associated adverse events in 98.49% of patients. Of 36,059 intubations, 14 patients expired, representing 0.039% of all RSI encounters. There were 39/100,000 total deaths during RSI events. There was a higher rate of mortality in the combined vecuronium/rocuronium group (90/100,000) compared to the sample of patients intubated with succinylcholine (22/100,000). Conclusions: While the succinylcholine adverse effect profile is concerning, data from our institution does not support removal of the agent as an available option for RSI as the mortality rate among patients receiving succinylcholine was lower than that of patients receiving non-depolarizing agents. Patient level data will be needed in future work to further understand why the all-cause mortality rate was higher in the group receiving rocuronium or vecuronium and whether those patients had increased risk of mortality from underlying disease at time of presentation.
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Mortality profile of geriatric trauma at a level 1 trauma center p. 269
Sanjeev Lalwani, Sakshi Gera, Chhavi Sawhney, Purva Mathur, Parin Lalwani, Mahesh Chandra Misra
Background: The management of geriatric trauma patients is challenging because of the altered physiology and co-existent medical conditions. To study the in-hospital mortality profile of geriatric trauma victims and the parameters associated with the mortality, we conducted this retrospective analysis. Methods: In a retrospective review of geriatric trauma admissions (above 60 years) over a 3-year period, we studied the association of age, gender, comorbidities, mechanism of injury (MOI), Glasgow coma score (GCS), injury severity score (ISS), systolic blood pressure, and hemoglobin (Hb) level on admission with hospital mortality. Univariate and Multivariable logistic regression was used to estimate odds and find independent associated parameters. P < 0.05 was considered as statistically significant. Results: Out of 881 patients, 208 (23.6%) patients died in hospital. The most common MOI was fall (53.3%) followed by motor vehicle collision (31.1%) and other mechanisms (14.5%). The in-hospital mortality was significantly higher and adjusted odds ratio (OR) for mortality were higher for male gender (2.11 [1.04–4.26]), higher ISS (6.75 [2.07–21.95] for ISS >30), low GCS (<8) (4.6 [2.35–8.97]), low Hb (<9) (1.68 [0.79–3.55]), hypotension on admission (32.42 [10.89–96.52]) as compared to other groups. Adjusted OR was 3.19 (1.55–6.56); 7.67 (1.10–53.49); 1.13 (0.08–17.12) for co-existent cardiovascular, renal, and hepatic comorbidities, respectively. Conclusion: Male gender, higher ISS, low GCS, low Hb, hypotension on admission, co-existent cardiovascular, renal and hepatic comorbidities are associated with increased mortality in geriatric trauma patients.
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Hospital seeing more personal mobility device accidents and serious injuries despite active mobility act p. 274
Wey Ting Lee, Tiong Thye Goo, Woan Wui Lim, Hong Chuen Toh, Yu Yasai
Introduction: E-scooters or personal mobility devices (PMDs) have recently been growing in popularity in Singapore. These devices can be especially helpful for those who have reduced mobility or who need to move between several relatively near locations multiples times per day or who simply appreciate the added convenience of having another transportation option. The increasing popularity of PMD has met with growing public concern over safety. Singapore government passed the Active Mobility Act (AMA) in January 2017 to regulate the usage of PMD. In Khoo Teck Puat Hospital, PMD-related accident has increased year on year by 20%–30%. Our study is to compare the incidence and severity of PMD-related accidents before and after the implementation of the AMA. Materials and Methods: A retrospective study of patients presented to the emergency department (ED) of Khoo Teck Puat Hospital for PMD-related accidents between November 2014 and October 2017. In year 1 of the study, we included patients presenting between November 2014 and October 2015. In years 2 and 3, we included patients presenting between November 2015 and October 2016 and November 2016 and October 2017, respectively. Data collected included demographic information, type of device used and impact, outcome, and injury severity score (ISS). Results: A total of 697 PMD-related accidents were seen in our center. We observed an increasing trend of accidents with significant injuries. There were 157 accidents reported in year 1, 233 in year 2, and 307 in year 3. The mean age of patients increased from 28 ± 15 years (range, 5–89 years) in year 1 to 33 ± 15 years (range, 4–83 years). Most patients were males (61.8% in year 1, 76.8% in year 2, and 73.3% in year 3) and Chinese (55.4% in year 1, 62.7% in year 2, and 65.5% in year 3), followed by Malays, Indians, and others. Devices commonly associated with injury were E-scooters, skateboards, and E-bicycles. E-scooters accidents had increased drastically from 12.1% in year 1 to 58.3% in year 3, but E-bicycles and other PMD accidents had decreased in year 3. Most patients were injured from falling off their devices (83.4% in year 1, 83.7% in year 2, and 79.5% in year 3), followed by collisions. Most patients arrived to the ED with own transports and were triaged to the patient acuity category 3 or 4. Most injuries were mild, with ISS <9 (97.5% in year 1 and 94.9% and 94.1% in year 2 and 3, respectively). The most common PMD-related injuries involved external injuries, followed by upper and lower extremities injuries. For more severe injuries (ISS ≥9), the number had increased from 4 in year 1 to 18 in year 3. Most patients were discharged. The number of patients required admissions increased from 12 to 44 in year 3, with two high-dependency or intensive care unit admissions. The mean hospital stay reduced from 5.0 ± 6.0 days to 3.6 ± 4.1 days, with the survival rate remained at 100%. There was only one fatality was reported in year 2. Conclusion: There is an increase in injuries and severity of PMD accidents despite AMA being implemented in January 2017. More need to be done to ensure the safety of PMD-related use in Singapore footpaths and roads.
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The effect of illegal drug screening results and chronic drug use on perioperative complications in trauma p. 279
John T Culhane, Carl A Freeman
Context: Illegal drug use and need for surgery are common in trauma. This allows examination of the effects of perioperative drug use. Aim: The aim was to study the effects of illegal drug use on perioperative complications in trauma. Setting and Design: Propensity-matched analysis of perioperative complications between drug screen-positive (DSP) and drug screen-negative (DSN) patients from the National Trauma Data Bank (NTDB). Methods: The NTDB reports drug screening as a composite. We compared complications for DSP, DSN, and specific chronic drug disorders. Time to first procedure was analyzed to determine whether delay to surgery was associated with reduced complications. Statistics: Logistic regression with 11 predictor variables was used to calculate propensity scores. Categorical and continuous variables were compared using Chi-square and Student’s t-test, respectively. Results: 752,343 patients (21.9%) were tested for illegal drugs. DSP was protective for mortality-relative risk (RR) 0.84 (P < 0.001) and arrhythmia RR 0.87 (P = 0.02). All complications (AC) were higher for DSP with a RR of 1.08 (P < 0.001). Cocaine, cannabis, and opioids were associated with reduced mortality. Cocaine was associated with increased myocardial infarction (MI). All four chronic drug disorders were associated with markedly higher arrhythmia. All except cannabis were associated with higher AC. Mortality was significantly lower for DSP for every time interval until first procedure. Continuous-time until procedure was associated with increased MI and arrhythmia. Conclusions: DSP was protective of mortality and cardiac complications. Drug disorders were protective for mortality but increased arrhythmia and AC. Delay until the surgery does not diminish cardiac or overall risk.
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The impact of interdisciplinary care on cost reduction in a geriatric trauma population p. 286
Andrew A Francis, Joyce E. M. Wall, Andrew Stone, Michael P Dewane, Ann Dyke, Shea C Gregg
The current growth of the geriatric population and increased burden on trauma services throughout the United States (US) has created a need for systems that can improve patient care and reduce hospital costs. We hypothesize that the multidisciplinary services provided through the Geriatric Injury Institute (GII) can reduce hospital costs, improve patient triage throughput, and decrease hospital length of stay (LOS). Methods and Material: We performed a single-center, retrospective chart review of our Level II trauma center registry and electronic medical records of patients ages 65 and older who satisfied trauma activation/code criteria between July 1, 2014, to June 30, 2016 (N = 663). Patients presenting from July 1, 2014, to June 30, 2015, were grouped as Pre-GII, while those presenting from July 1, 2015, to June 30, 2016, were grouped as Post-GII. Primary outcomes were emergency department (ED) triage time, overall LOS, and hospital costs. Secondary outcomes included patient disposition, mortality, and health assessments. Statistical comparisons were made using a one-way analysis of variance and Mann-Whitney U test. Results: Pre-GII vs. Post-GII average ages and the Injury Severity Score (ISS) were not statistically different (p>0.05). The average LOS was similar between the Pre-GII and Post-GII groups (4.64 ± 4.42 days vs. 4.26 ± 5.58 days, p = 0.48). More patients were discharged earlier (≤ 4 days; 64% vs. 73%) as well as discharged to home (37% vs. 45%) in the Post-GII group. The total cost savings were $53,000 with a median savings of $1061 per patient ($8808 vs. $7747, p = 0.04). Savings were highest during the first two days of admission (p = 0.03). The reduction in ED triage time was not significant (310.7 minutes vs 219. 8 minutes, p > 0.05). Conclusion: With the increase in geriatric trauma, innovative models of care are needed. Our study suggests that the GII multidisciplinary approach to trauma services can lower overall hospital costs.
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Prehospital traction splint use in midthigh trauma patients p. 296
Danielle Campagne, Kathleen Cagle, Jannet Castaneda, Lori Weichenthal, Megann Young, Peter Anastopoulos, Susanne Spano
Context: Traction splint (TS) use during emergency medical system transport has been theorized to relieve pain, limit continued injury from loose bone fragments, and decrease potential bleeding space in the injured thigh. Aims: This study aimed to evaluate the benefit of prehospital TS (PTS) application, using data from the trauma registry at a large Level 1 trauma center. Methods: A retrospective review of patients from the NTRACS© and Trauma One© registry at an American College of Surgeons-verified Level 1 trauma center was conducted. All patients treated between the years 2001 and 2011 who were assigned a diagnosis International Classification of Diseases-9 code of 821.01 (closed fracture of shaft and femur) and 821.11 (open fracture of shaft and femur) (femur fracture [FF]) were included. Statistical Analysis: All categorical variables between the first groups were compared using Pearson’s Chi-square and Fisher’s exact test analysis. Comparisons were made using unpaired t-tests and Mann–Whitney test or Kruskal–Wallis one-way ANOVA, followed by Dunn’s post hoc pairwise comparisons. Results: Patients with a TS and those without indicated that the patients with no traction split (NTS) had sustained injuries beyond a FF (14.43 ± 9.740 vs. 18.59 ± 12.993, P < 0.001). The three groups of TS placement (PTS, hospital, and NTS) only used patients with Injury Severity Score < 9 (n = 218). Hospital length of stay (LOS) was found to be significant (P = 0.05) between the patients who received a hospital TS (3.10 ± 1.709) and NTS (5.42 ± 5.144). Conclusion: PTS can lower LOS and mortality. Further research is needed to confirm these findings.
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Rapid nuclear medicine blood volume analysis for emergency assessment p. 301
David Sadowsky, Abel Suarez-Mazon, Charles Lugo, Tariq Rashid, Jennifer Wu, Perry Gerard, Matty Mozzor
Assessment of fluid status can play a critical role in the diagnosis and management of emergent conditions such as trauma, shock, decompensated heart failure, syncope, and hypertension. Unfortunately, common methods are all qualitative and/or indirect, and often inaccurate. With the recent introduction of a modernized method of nuclear medicine blood volume analysis (NM-BVA), offering results in 90 min or less as well as improved precision and ease of performance, this decade-old technique is for the first time a viable tool in the emergent setting. In this review, we discuss the history of NM-BVA, the modern method, and our institution’s experience implementing this method.
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Grade IV liver injury following mechanical cardiopulmonary resuscitation with postoperative three-dimensional evaluation p. 306
Paolo Aseni, Federico Vezzulli, Francesco Rizzetto, Simone Cassin, Sofia Rantas, Alberto Cereda, Osvaldo Chiara, Angelo Vanzulli, Maurizio Vertemati
A 48-year-old female presented to the emergency department with chest pain and collapsed at the front desk. She was reanimated with mechanical chest compression, and after coronary angiography, a left anterior descending/diagonal bifurcation mini-crush stenting was performed. Few hours after the procedure, the patient showed severe hypotension. Abdominal ultrasound and computed tomography (CT) scan evidenced a massive subcapsular liver hematoma (Grade IV, American association for the surgery of trauma (AAST) liver injury scale) of the right lobe with extrahepatic blushing. Transhepatic embolization was attempted but without benefit, so the patient underwent emergency laparotomy for damage control surgery with perihepatic packing. After hemodynamic stabilization, right hepatectomy was performed with a favorable outcome and full recovery. The patient CT scan was retrospectively processed to obtain a virtual model visualizable through a head-mounted display. The virtual reconstruction could improve the comprehension of the injury and the liver surgical anatomy for educational purpose, and it could represent a new tool for preoperative planning.
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Triple blow injury to a limb: Ipsilateral hip and knee dislocation with vascular occlusion p. 309
Mantu Jain, Siddhartha Sathia, Rudra Pratap Mahapatra, Shakti Swaroop, Sunil Kumar Doki
Ipsilateral hip and knee dislocation (double blow) occurring simultaneously during trauma are rare occurrences that are associated with secondary complications. These are high energy injuries that warrant acute emergency management more so if associated with vascular compromise. We encountered a poly trauma patient having a combined right anterior hip and ipsilateral knee dislocation with vascular occlusion at popliteus level apart from associated segmental radius fracture of the left upper limb. This young patient presented after 22 h being referred form elsewhere making the situation critical to the surgical team. An attempted thrombolysis was done but as gangrenous changes started, we ended up in a below knee amputation. This case highlights a typical scenario in a developing country where facilities involving super specialty services are scarce and even patients are complacent about need for emergent referral. All this adds to surgical dilemma as guidelines are unclear for the best treatment.
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Memory T-waves, a rare cause of T-wave inversion in the emergency department p. 312
R Gunaseelan, M Sasikumar, K Aswin, B Nithya, N Balamurugan, M Vivekanandan
One of the rare causes of diffuse T-wave inversion (TWI) in electrocardiogram (ECG) is memory T-waves. This should be considered among the differentials of diffuse TWI in ECG of patients presenting to the emergency department (ED), especially when they have previous episodes of ventricular tachycardia (VT) or pacemaker implantation or Wolff-Parkinson-White syndrome. These TWIs are benign and do not require any treatment. However, it is of paramount importance for the emergency physician to differentiate it from ischemia-related T-wave changes. In the following case series, we report three cases of memory T-waves. Two of the cases had TWI in leads II, III, aVF, and V3 to V6 following reversion of VT. The other patient, with a? VVI (Left ventricle paced, Left ventricle sensed, Inhibition to sensing) pacemaker, had memory T-waves in the ECG taken during normal sinus rhythm. In all the three patients, we considered memory T-waves to be the possible cause of TWI. The electrocardiographic diagnostic criteria for memory T-waves are positive T in lead aVL and positive/isoelectric T in the lead I; and precordial TWI >inferior TWI. These criteria are 92% sensitive and 100% specific. In the following case series, we also provide an algorithmic approach for patients with suspected memory T-waves in their 12-lead ECG when they present to the ED.
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Assessment of ganga hospital open injury severity score of limbs p. 317
K Naveen Kumar, Harish Y S. Shivanna, TN Santhosh Kumar, Pratheeksh
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Chest trauma management with small-bore chest tube p. 318
Yuki Yoshioka, Hisashi Ishikura
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Predictors of failure of nonoperative management in spleen trauma p. 319
Hakim Zenaidi, Imen Ben Ismail, Saber Rebii, Ayoub Zoghlami
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Winning Together: C3T2 Updated COVID-19 Infographic p. 321
Stanislaw P Stawicki, Annelies L de Wulf, Thomas J Papadimos, Nicholas Taylor, Michael S Firstenberg, Sagar C Galwankar
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