Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
Coverpage
April-June 2021
Volume 14 | Issue 2
Page Nos. 73-120

Online since Friday, June 25, 2021

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EDITORIAL  

What's new in emergencies, trauma, and shock: Trauma admissions during Covid-19 lockdown p. 73
Sara S Soliman, Louis T DiFazio, Daniel Hakakian, Joseph Buchsbaum, Poya Pourghaderi, Zoltan H Nemeth
DOI:10.4103/JETS.JETS_18_21  
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ORIGINAL ARTICLES Top

How a pandemic changes trauma: epidemiology and management of trauma admissions in the UK during COVID-19 lockdown p. 75
Debashis Dass, Eamon Ramhamadany, Siddarth Govilkar, John-Henry Rhind, David Ford, Rohit Singh, Geraint Thomas, Paul Cool
DOI:10.4103/JETS.JETS_137_20  
Introduction: On June 24 in the United Kingdom, there were 277,989 cases of COVID-19 and 39,369 deaths recorded. The government enforced a complete lockdown on March 23 that resulted in cessation of all elective admissions on 24th onward, with only acute trauma cases being admitted to hospital. This study aims to characterize the changes in trauma admissions during the first 5-week lockdown period. The hypothesis states that there would be a significant reduction in overall orthopedic trauma admissions, polytrauma, and high-energy outdoor trauma during this COVID-19 period. Methods: All trauma admissions over nearly a 5-week period from March 23, 2020, to April 26, 2020, were collated as the “COVID cohort” and compared to the “control” group of patients from the same hospitals 1 year before between March 23, 2019, and April 26, 2019. Spinal admissions and pediatrics were excluded from the study as they were managed in other regional units. Results: There was a 56% reduction in trauma admissions during the COVID-19 lockdown (133 vs. 304). A majority of the COVID cohort were admitted with fractures (89 vs. 164, P = 0.017, Chi-square test) from home with low-energy falls. Overall, fewer operations were performed than the year before. However, a greater proportion of admitted patients had a surgical orthopedic intervention rather than admission and nonoperative management. Conclusions: There was a reduction in admissions as well as reductions in high energy and occupational injuries. Elderly patients continued to fall at home or in care, sustaining hip fractures. This vulnerable group requires beds, orthogeriatric management followed by surgical intervention and social care. Orthogeriatric services must be maintained to ensure the best clinical outcomes for this group.
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Predictive factors for failure of limb salvage in blunt leg trauma associated with vascular injuries p. 80
Nabil A Al-Zoubi, Nawaf J Shatnawi, Yousef Khader, Mowafeq Heis, Abdelwahab J Aleshawi
DOI:10.4103/JETS.JETS_37_20  
Introduction: Blunt leg trauma is common; however, it is rarely associated with significant vascular injury. This study was undertaken to determine the risk factors attributed to failure of limb salvage in acute postoperative period in blunt leg trauma with vascular injuries after revascularization. Methods: A retrospective analysis was conducted of all patients with blunt leg trauma involving bone and soft tissue associated with vascular injuries. They were studied in terms of demographic data, associated comorbidities, mechanism of trauma, associated extra leg injuries, type and nature of bone fractures, soft-tissue injuries, nerve injuries, time of ischemia, Injury Severity Score (ISS), Mangled Extremity Severity Score (MESS), injured vascular segments, modality of vascular repair, modality of bone fixation, thrombosis at the site of vascular repair, complications, limb salvage failure, and mortality. Results: Vascular injuries were identified in 45 arterial segments and 9 popliteal veins among 31 patients. The patients were 93% male, with a mean age of 31 years. The MESS ranged from 6 to 11, and the ISS ranged from 9 to 41. The main pathology of the injured vessels was contusion/thrombosis in 28 legs, which were repaired by interposition-reversed long saphenous vein graft. Seven patients developed postoperative thrombosis and underwent thrombectomy/embolectomy. Failure of limb salvage occurred in seven limbs with no mortality. Conclusions: Severe multi-segmental bone fractures, prolong ischemic time of >10 h, and MESS of ≥9 are significant predictors of limb loss in patients with blunt leg trauma in association with vascular injuries.
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Cattle-related trauma: A 5-year retrospective review in a adult major trauma center p. 86
John-Henry Rhind, Dominic Quinn, Lucy Cosbey, Douglas Mobley, Ingrid Britton, Justin Lim
DOI:10.4103/JETS.JETS_92_20  
Introduction: Bovine injuries are a common and significant cause of trauma, often requiring admission and operative treatment. We review all bovine-related injuries over 5 years, both emergency and general practitioner (GP) referrals at an adult major trauma center in England. Methods: Retrospective evaluation was undertaken using the keywords through radiology referrals and hospital admissions speciality databases. By searching patient notes, demographics were collected as well as the mechanism and the situation of injury; trauma scores were calculated using: injury severity score (ISS) and probability of survival (Ps19). The results were divided into emergency patients and GP referrals. Results: Sixty-seven patients were identified retrospectively over 5 years, 44 emergency patients (including 23 major traumas), and 23 GP referrals. Combined (emergency and GP) mean age 52 years old; 67% male; and mean ISS 11. Most common combined mechanism of injury, kicked (n = 23). In emergency patients, trampling injuries were the most common. Eighty-six percent of the trampled patients were major traumas and associated with increased ISS (mean 13). Indirect injuries mainly involved farm gates (92%). Seventy-three percent of bull-related injuries were major traumas and had increased ISS scores (mean 17). Orthopaedics was the most common admitting speciality followed by cardiothoracic and neurosurgery. In emergency patients, fractures were the most common primary injury (n = 20), upper limb followed by spine. In GP, soft-tissue injuries were the most common primary injury. Seventy percent of the emergency referrals required admission and 50% operations. Fracture fixation was the most common operative procedure. Only, one GP referral required an operation. There were significant delays in GP patients presenting. Two patients had a Ps19 score <90. There were two mortalities. Conclusion: Cattle-related injuries are a significant cause of severe morbidity and mortality. They are under-reported. Patterns of injury are similar to high-velocity road traffic collisions and bull-related injuries or trampling in particular, should alert the clinician to more significant trauma. Farm gates are a frequent cause of trauma associated with cattle. GP referrals with ongoing symptoms for more than 2 weeks seeking medical advice should alert the clinician to a more serious diagnosis.
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Adrenal gland trauma: An observational descriptive analysis from a level 1-trauma center p. 92
Hassan Al-Thani, Moamena El-Matbouly, Ayman El-Menyar, Ammar Al-Hassani, Hisham Jogol, Ahmed El-Faramawy, Tariq Siddiqui, Husham Abdelrahman
DOI:10.4103/JETS.JETS_63_20  
Introduction: We aimed to describe the presentation, classification, and outcome of traumatic adrenal injury in a single Level-1 trauma center. Methods: A retrospective study was conducted to include all patients identified to have adrenal trauma from 2011 to 2014. Data were retrieved from charts and electronic medical records for all patients with adrenal trauma with a 3-year follow-up for mortality. Results: A total of 116 patients who were admitted with adrenal injury (12.9% of abdominal trauma and 20% of total solid organ injury admissions) were included in the study, 104 were males and 12 were females. In our population, 86% of adrenal injuries involved the right adrenal gland, 14% in the left, and 12% had bilateral injuries. The majority of associated injuries were rib fractures accounting for 42%, while 37% had associated lung injuries, and 35% had head injuries. As per the American Association for the Surgery of Trauma classification, 46% of adrenal traumas were grade one. Of all adrenal trauma, 25 patients were operated (21%), whereas the majority were admitted to the intensive care unit or surgical ward. Surgical interventions were indicated for associated injury to the bowel, spleen, diaphragm, mesentery, kidneys, or inferior vena cava. One patient underwent angioembolization of the adrenal vessels due to contrast leak. The mortality rate was 14.6%, and no further mortality was reported during a 3-year follow-up. On multivariable analysis, admission systolic blood pressure, Glasgow Coma Scale, and injury severity score were predictors of hospital mortality. Conclusions: Adrenal injury is not rare and often unilateral with right-sided predominance. Associated injuries influence the clinical findings, management, and outcome. Surgical interventions are rarely required except for few cases of active bleeding. Long-term outcome postadrenal injury is still not well studied.
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Major trauma in elderly patients: Worse mortality and outcomes in an Italian trauma center p. 98
Gabriele Savioli, Iride Francesca Ceresa, Sarah Macedonio, Sebastiano Gerosa, Mirko Belliato, Sabino Luzzi, Alice Giotta Lucifero, Federica Manzoni, Giovanni Ricevuti, Maria Antonietta Bressan
DOI:10.4103/JETS.JETS_55_20  
Introduction: Major trauma is the leading cause of mortality in the world in patients younger than 40 years. However, the proportion of elderly people who suffer trauma has increased significantly. The purpose of this study is to assess the correlation of old age with mortality and other unfavorable outcomes. Methods: We assessed on one hand, anatomical criteria such as ISS values and the number of body regions affected, on the other hand, hemodynamic instability criteria, various shock indices, and Glasgow Coma Scale. Finally, we also evaluated biochemical parameters, such as lactate, BE, and pH values. We conducted a prospective and monocentric observational study of all the patients referred to the Emergency Department of the IRCCS Fondazione Policlinico S. Matteo in Pavia for major trauma in 13 consecutive months: January 1, 2018–January 30, 2019. We compared the elderly population (>75 years) and the younger population (≤75). Results: We included 501 patients, among which 10% were over the age of 75 years. The mortality rate was higher among the older patients than among the younger (4% vs. 1.33%; P = 0.050). Hemodynamic instability was more common in the older patients than in the younger (26% vs. 9%; P < 0.001). More older patients (44%) had an ISS >16, in comparison with 32% of younger patients (P = 0.01). Conclusions: The elderly showed worse outcomes in terms of mortality, hospitalization rate, hemodynamic instability criteria, and anatomical and biochemical parameters.
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Prevalence and risk factors of obstructive sleep apnea in hypertensive emergency p. 104
Sittichai Khamsai, Sitthan Kachenchart, Bundit Sawunyavisuth, Panita Limpawattana, Jarin Chindaprasirt, Vichai Senthong, Verajit Chotmongkol, Patnarin Pongkulkiat, Kittisak Sawanyawisuth
DOI:10.4103/JETS.JETS_47_20  
Introduction: Obstructive sleep apnea (OSA) is a common factor associated with hypertensive crises. There is limited evidence of prevalence and risk factors of OSA in hypertensive emergency. Methods: This study recruited adult patients who diagnosed as hypertensive emergency and tested for OSA. The study period was between July 2019 and January 2020. The patients were categorized as OSA and non-OSA groups by the evidence from polysomnography. Prevalence and risk factors for OSA were executed. Results: During the study, there were 52 eligible patients. Of those, 30 patients (57.69%) were diagnosed with OSA. The stepwise logistic regression analysis for predicting OSA had two remaining factors: body mass index and diastolic blood pressure. Only body mass index was independently associated with OSA with an adjusted odds ratio of 1.166 (95% confidence interval of 1.033, 1.316). The body mass index of 25.02 kg/m2 gave sensitivity and specificity of 80.00% and 59.09%, respectively. The area under the receiver operating characteristic curve was 70.98%. Conclusion: OSA had high incidence rate in patients with hypertensive emergency. High body mass index was a predictor for OSA associated with hypertensive emergency.
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CASE REPORTS Top

Microwave treatment of cold injuries p. 108
Eugene V Gavrilin, Grigory E Dunaevskiy, Vladimir B Antipov
DOI:10.4103/JETS.JETS_142_20  
In spite of the fact that extremity frostbites are a widespread type of injuries in many countries, specialized equipment for frostbite treatment is lacking. Treatment is carried out by conservative methods. The best results are obtained by using thermal isolation of injured tissues and activation of internal warming. It is proposed to initiate deep warming of frostbitten extremities on exposure to low-power microwave radiation. A microwave chamber has been developed to implement this technique. The efficiency of the approach was earlier demonstrated on animals. An example is given of successful treatment of a cold injury of patient hands and feet that allowed amputation to be avoided.
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Role of intercostal artery embolization in management of traumatic hemothorax p. 111
Rahul Lohan, Kheng Song Leow, Marc Weijie Ong, Tiong Thye Goo, Sundeep Punamiya
DOI:10.4103/JETS.JETS_157_20  
Intercostal artery bleeding from trauma can result in potentially fatal massive hemothorax. Traumatic hemothorax has traditionally been treated with tube thoracostomy, video-assisted thoracoscopic surgery, or thoracotomy. Transcatheter arterial embolization (TAE), a well-established treatment option for a variety of acute hemorrhage is not widely practiced for the management of traumatic hemothorax. We present 2 cases of delayed massive hemothorax following chest trauma which were successfully managed by transarterial embolization of intercostal arteries. The published studies are reviewed and a systematic approach to the selection of patients for TAE versus emergency thoracotomy is proposed.
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LETTERS TO EDITOR Top

Ruptured hydatid cyst into the peritoneal cavity: An ultimate multidisciplinary emergency p. 117
Atef Mejri, Khaoula Arfaoui
DOI:10.4103/JETS.JETS_162_20  
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A successful outcome in a case of cardiac arrest due to drowning with severe acidosis p. 118
Youichi Yanagawa, Kei Jitsuiki, Yoshihiro Kushida, Kazuhiko Omori
DOI:10.4103/JETS.JETS_174_20  
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A conservatively managed case of intentionally ingested razor blades in a mentally challenged adolescent p. 119
S Manwar Ali, Pradeep K Singh, Sanhita Panigrahi, Birendra D Manohar
DOI:10.4103/JETS.JETS_177_20  
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