Journal of Emergencies, Trauma, and Shock
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Simulation-based learning: Just like the real thing
Fatimah Lateef
October-December 2010, 3(4):348-352
DOI:10.4103/0974-2700.70743  PMID:21063557
Simulation is a technique for practice and learning that can be applied to many different disciplines and trainees. It is a technique (not a technology) to replace and amplify real experiences with guided ones, often "immersive" in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion. Simulation-based learning can be the way to develop health professionals' knowledge, skills, and attitudes, whilst protecting patients from unnecessary risks. Simulation-based medical education can be a platform which provides a valuable tool in learning to mitigate ethical tensions and resolve practical dilemmas. Simulation-based training techniques, tools, and strategies can be applied in designing structured learning experiences, as well as be used as a measurement tool linked to targeted teamwork competencies and learning objectives. It has been widely applied in fields such aviation and the military. In medicine, simulation offers good scope for training of interdisciplinary medical teams. The realistic scenarios and equipment allows for retraining and practice till one can master the procedure or skill. An increasing number of health care institutions and medical schools are now turning to simulation-based learning. Teamwork training conducted in the simulated environment may offer an additive benefit to the traditional didactic instruction, enhance performance, and possibly also help reduce errors.
  120 19,897 68
Management of penetrating brain injury
Syed Faraz Kazim, Muhammad Shahzad Shamim, Muhammad Zubair Tahir, Syed Ather Enam, Shahan Waheed
July-September 2011, 4(3):395-402
DOI:10.4103/0974-2700.83871  PMID:21887033
Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of Guidelines for the Management of Penetrating Brain Injuryin 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on Guidelines for the Management of Penetrating Brain Injury and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI patients. Cerebral angiography is recommended in patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI patients.
  47 17,339 39
Managing aluminum phosphide poisonings
Mohan Gurjar, Arvind K Baronia, Afzal Azim, Kalpana Sharma
July-September 2011, 4(3):378-384
DOI:10.4103/0974-2700.83868  PMID:21887030
Aluminum phosphide (AlP) is a cheap, effective and commonly used pesticide. However, unfortunately, it is now one of the most common causes of poisoning among agricultural pesticides. It liberates lethal phosphine gas when it comes in contact either with atmospheric moisture or with hydrochloric acid in the stomach. The mechanism of toxicity includes cellular hypoxia due to the effect on mitochondria, inhibition of cytochrome C oxidase and formation of highly reactive hydroxyl radicals. The signs and symptoms are nonspecific and instantaneous. The toxicity of AlP particularly affects the cardiac and vascular tissues, which manifest as profound and refractory hypotension, congestive heart failure and electrocardiographic abnormalities. The diagnosis of AlP usually depends on clinical suspicion or history, but can be made easily by the simple silver nitrate test on gastric content or on breath. Due to no known specific antidote, management remains primarily supportive care. Early arrival, resuscitation, diagnosis, decrease the exposure of poison (by gastric lavage with KMnO 4 , coconut oil), intensive monitoring and supportive therapy may result in good outcome. Prompt and adequate cardiovascular support is important and core in the management to attain adequate tissue perfusion, oxygenation and physiologic metabolic milieu compatible with life until the tissue poison levels are reduced and spontaneous circulation is restored. In most of the studies, poor prognostic factors were presence of acidosis and shock. The overall outcome improved in the last decade due to better and advanced intensive care management.
  44 11,590 44
Sonographic diagnosis of pneumothorax
Lubna F Husain, Laura Hagopian, Derek Wayman, William E Baker, Kristin A Carmody
January-March 2012, 5(1):76-81
DOI:10.4103/0974-2700.93116  PMID:22416161
Lung sonography has rapidly emerged as a reliable technique in the evaluation of various thoracic diseases. One important, well-established application is the diagnosis of a pneumothorax. Prompt and accurate diagnosis of a pneumothorax in the management of a critical patient can prevent the progression into a life-threatening situation. Sonographic signs, including 'lung sliding', 'B-lines' or 'comet tail artifacts', 'A-lines', and 'the lung point sign' can help in the diagnosis of a pneumothorax. Ultrasound has a higher sensitivity than the traditional upright anteroposterior chest radiography (CXR) for the detection of a pneumothorax. Small occult pneumothoraces may be missed on CXR during a busy trauma scenario, and CXR may not always be feasible in critically ill patients. Computed tomography, the gold standard for the detection of pneumothorax, requires patients to be transported out of the clinical area, compromising their hemodynamic stability and delaying the diagnosis. As ultrasound machines have become more portable and easier to use, lung sonography now allows a rapid evaluation of an unstable patient, at the bedside. These advantages combined with the low cost and ease of use, have allowed thoracic sonography to become a useful modality in many clinical settings.
  43 11,175 44
A biomarker panel to discriminate between systemic inflammatory response syndrome and sepsis and sepsis severity
Chamindie Punyadeera, E Marion Schneider, Dave Schaffer, Hsin-Yun Hsu, Thomas O Joos, Fabian Kriebel, Manfred Weiss, Wim FJ Verhaegh
January-March 2010, 3(1):26-35
DOI:10.4103/0974-2700.58666  PMID:20165718
Introduction: In this study, we report on initial efforts to discover putative biomarkers for differential diagnosis of a systemic inflammatory response syndrome (SIRS) versus sepsis; and different stages of sepsis. In addition, we also investigated whether there are proteins that can discriminate between patients who survived sepsis from those who did not. Materials and Methods: Our study group consisted of 16 patients, of which 6 died and 10 survived. We daily measured 28 plasma proteins, for the whole stay of the patients in the ICU. Results: We observed that metalloproteinases and sE-selectin play a role in the distinction between SIRS and sepsis, and that IL-1α, IP-10, sTNF-R2 and sFas appear to be indicative for the progression from sepsis to septic shock. A combined measurement of MMP-3, -10, IL-1α, IP-10, sIL-2R, sFas, sTNF-R1, sRAGE, GM-CSF, IL-1β and Eotaxin allows for a good separation of patients that survived from those that died (mortality prediction with a sensitivity of 79% and specificity of 86%). Correlation analysis suggests a novel interaction between IL-1a and IP-10. Conclusion: The marker panel is ready to be verified in a validation study with or without therapeutic intervention
  39 7,286 225
Abdominal compartment syndrome - Intra-abdominal hypertension: Defining, diagnosing, and managing
Theodossis S Papavramidis, Athanasios D Marinis, Ioannis Pliakos, Isaak Kesisoglou, Nicki Papavramidou
April-June 2011, 4(2):279-291
DOI:10.4103/0974-2700.82224  PMID:21769216
Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) are increasingly recognized as potential complications in intensive care unit (ICU) patients. ACS and IAH affect all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. ACS/IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of ACS/IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. We start this article with a brief historic review on ACS/IAH. Then, we present the definitions concerning parameters necessary in understanding ACS/IAH. Finally, pathophysiology aspects of both phenomena are presented, prior to exploring the various facets of ACS/IAH management.
  38 13,867 43
Evaluating the validity of multiple imputation for missing physiological data in the national trauma data bank
Lynne Moore, James A Hanley, Andre Lavoie, Alexis Turgeon
May-August 2009, 2(2):73-79
DOI:10.4103/0974-2700.44774  PMID:19561964
Background: The National Trauma Data Bank (NTDB) is plagued by the problem of missing physiological data. The Glasgow Coma Scale score, Respiratory Rate and Systolic Blood Pressure are an essential part of risk adjustment strategies for trauma system evaluation and clinical research. Missing data on these variables may compromise the feasibility and the validity of trauma group comparisons. Aims: To evaluate the validity of Multiple Imputation (MI) for completing missing physiological data in the National Trauma Data Bank (NTDB), by assessing the impact of MI on 1) frequency distributions, 2) associations with mortality, and 3) risk adjustment. Methods: Analyses were based on 170,956 NTDB observations with complete physiological data (observed data set). Missing physiological data were artificially imposed on this data set and then imputed using MI (MI data set). To assess the impact of MI on risk adjustment, 100 pairs of hospitals were randomly selected with replacement and compared using adjusted Odds Ratios (OR) of mortality. OR generated by the observed data set were then compared to those generated by the MI data set. Results: Frequency distributions and associations with mortality were preserved following MI. The median absolute difference between adjusted OR of mortality generated by the observed data set and by the MI data set was 3.6% (inter-quartile range: 2.4%-6.1%). Conclusions: This study suggests that, provided it is implemented with care, MI of missing physiological data in the NTDB leads to valid frequency distributions, preserves associations with mortality, and does not compromise risk adjustment in inter-hospital comparisons of mortality.
  34 6,889 271
Breaking bad news education for emergency medicine residents: A novel training module using simulation with the SPIKES protocol
Inchoel Park, Amit Gupta, Kaivon Mandani, Laura Haubner, Brad Peckler
October-December 2010, 3(4):385-388
DOI:10.4103/0974-2700.70760  PMID:21063562
Breaking bad news (BBN) in the emergency department (ED) is a common occurrence. This is especially true for an emergency physician (EP) as there is little time to prepare for the event and likely little or no knowledge of the patients or family background information. At our institution, there is no formal training for EP residents in delivering bad news. We felt teaching emergency medicine residents these communication skills should be an important part of their educational curriculum. We describe our experience with a defined educational program designed to educate and improve physician's confidence and competence in bad news and death notification. A regularly scheduled 5-h grand rounds conference time frame was dedicated to the education of EM residents about BBN. A multidisciplinary approach was taken to broaden the prospective of the participants. The course included lectures from different specialties, role playing for three short scenarios in different capacities, and hi-fidelity simulation cases with volatile psychosocial issues and stressors. Participants were asked to fill out a self-efficacy form and evaluation sheets. Fourteen emergency residents participated and all thought that this education is necessary. The mean score of usefulness is 4.73 on a Likert Scale from 1 to 5. The simulation part was thought to be the most useful (43%), with role play 14%, and lecture 7%. We believe that teaching physicians to BBN in a controlled environment is a good use of educational time and an important procedure that EP must learn.
  34 9,998 64
Simulation-based team training at the sharp end: A qualitative study of simulation-based team training design, implementation, and evaluation in healthcare
Sallie J Weaver, Eduardo Salas, Rebecca Lyons, Elizabeth H Lazzara, Michael A Rosen, Deborah DiazGranados, Julia G Grim, Jeffery S Augenstein, David J Birnbach, Heidi King
October-December 2010, 3(4):369-377
DOI:10.4103/0974-2700.70754  PMID:21063560
This article provides a qualitative review of the published literature dealing with the design, implementation, and evaluation of simulation-based team training (SBTT) in healthcare with the purpose of providing synthesis of the present state of the science to guide practice and future research. A systematic literature review was conducted and produced 27 articles meeting the inclusion criteria. These articles were coded using a low-inference content analysis coding scheme designed to extract important information about the training program. Results are summarized in 10 themes describing important considerations for what occurs before, during, and after a training event. Both across disciplines and within Emergency Medicine (EM), SBTT has been shown to be an effective method for increasing teamwork skills. However, the literature to date has underspecified some of the fundamental features of the training programs, impeding the dissemination of lessons learned. Implications of this study are discussed for team training in EM.
  33 18,784 61
Patient expectations and the paradigm shift of care in emergency medicine
Fatimah Lateef
April-June 2011, 4(2):163-167
DOI:10.4103/0974-2700.82199  PMID:21769199
Patient expectation in health care continues to increase and this is something that needs to be managed adequately in order to improve outcomes and decrease liability. Understanding patients' expectations can enhance their satisfaction level. In the environment of the Emergency Department, with the acutely ill, serious and time-dependent issues as well as high level of stress, managing patient expectations can indeed be challenging. This paper discusses patients expectations and proposes implementation of elements of patient-centered care and value-based care into our existing health care systems today.
  32 7,385 18
Mortality rates following trauma: The difference is night and day
Kenneth A Egol, Anthony M Tolisano, Kevin F Spratt, Kenneth J Koval
April-June 2011, 4(2):178-183
DOI:10.4103/0974-2700.82202  PMID:21769202
Background : Although most medical centers are equipped for 24-h care, some "middle of the night" services may not be as robust as they are during daylight hours. This would have potential impact upon certain outcome measurements in trauma patients. The purpose of this paper was to assess the effect of patient arrival time at hospital emergency departments on in-hospital survival following trauma. Materials and Methods : Data of patients, 18 years of age or older, with no evidence that they were transferred to or from that center were obtained from the National Trauma Data Bank Version 7.0. Patients meeting the above criteria were excluded if there was no valid mortality status, arrival time information, injury severity score, or trauma center designation. The primary analyses investigated the association of arrival time and trauma center level on mortality. Relative risks of mortality versus patient arrival time and trauma level were determined after controlling for age, gender, race, comorbidities, injury, region of the country, and year of admission. Results : In total, 601,388 or 71.7% of the 838,284 eligible patients were retained. The overall in-hospital mortality rate was 4.7%. The 6 p.m. to 6 a.m. time period had a significantly higher adjusted relative risk for in-hospital mortality than the 6 a.m. to 6 p.m. time frame (ARR=1.18, P<0.0001). This pattern held across trauma center levels, but was the weakest at Level I and the strongest at Level III/IV centers (Level I: ARR=1.10, Level II: ARR=1.14, and combined Level III/IV: ARR=1.32, all P<0.0001). Conclusion : Hospital arrival between midnight and 6 a.m. was associated with a higher mortality rate than other times of the day. This relationship held true across all trauma center levels. This information may warrant a redistribution of hospital resources across all time periods of the day.
  31 3,915 17
Acute management of vascular air embolism
Nissar Shaikh, Firdous Ummunisa
September-December 2009, 2(3):180-185
DOI:10.4103/0974-2700.55330  PMID:20009308
Vascular air embolism (VAE) is known since early nineteenth century. It is the entrainment of air or gas from operative field or other communications into the venous or arterial vasculature. Exact incidence of VAE is difficult to estimate. High risk surgeries for VAE are sitting position and posterior fossa neurosurgeries, cesarean section, laparoscopic, orthopedic, surgeries invasive procedures, pulmonary overpressure syndrome, and decompression syndrome. Risk factors for VAE are operative site 5 cm  above the heart, creation of pressure gradient which will facilitate entry of air into the circulation, orogenital sex during pregnancy, rapid ascent in scuba (self contained underwater breathing apparatus) divers and barotrauma or chest trauma. Large bolus of air can lead to right ventricular air lock and immediate fatality. In up to 35% patient, the foramen ovale is patent which can cause paradoxical arterial air embolism. VAE affects cardiovascular, pulmonary and central nervous system. High index of clinical suspicion is must to diagnose VAE. The transesophgeal echocardiography is the most sensitive device which will detect smallest amount of air in the circulation. Treatment of VAE is to prevent further entrainment of air, reduce the volume of air entrained and haemodynamic support. Mortality of VAE ranges from 48 to 80%. VAE can be prevented significantly by proper positioning during surgery, optimal hydration, avoiding use of nitrous oxide, meticulous care during insertion, removal of central venous catheter, proper guidance, and training of scuba divers.
  31 13,100 365
Management of liver trauma in adults
Nasim Ahmed, Jerome J Vernick
January-March 2011, 4(1):114-119
DOI:10.4103/0974-2700.76846  PMID:21633579
The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of the liver and use of atriocaval shunt are rarely indicated.
  28 9,972 44
Emergency management of fat embolism syndrome
Nissar Shaikh
January-April 2009, 2(1):29-33
DOI:10.4103/0974-2700.44680  PMID:19561953
Fat emboli occur in all patients with long-bone fractures, but only few patients develop systemic dysfunction, particularly the triad of skin, brain, and lung dysfunction known as the fat embolism syndrome (FES). Here we review the FES literature under different subheadings. The incidence of FES varies from 1-29%. The etiology may be traumatic or, rarely, nontraumatic. Various factors increase the incidence of FES. Mechanical and biochemical theories have been proposed for the pathophysiology of FES. The clinical manifestations include respiratory and cerebral dysfunction and a petechial rash. Diagnosis of FES is difficult. The other causes for the above-mentioned organ dysfunction have to be excluded. The clinical criteria along with imaging studies help in diagnosis. FES can be detected early by continuous pulse oximetry in high-risk patients. Treatment of FES is essentially supportive. Medications, including steroids, heparin, alcohol, and dextran, have been found to be ineffective.
  27 56,434 1,062
Cardiac arrest in children
Erika E Tress, Patrick M Kochanek, Richard A Saladino, Mioara D Manole
July-September 2010, 3(3):267-272
DOI:10.4103/0974-2700.66528  PMID:20930971
Major advances in the field of pediatric cardiac arrest (CA) were made during the last decade, starting with the publication of pediatric Utstein guidelines, the 2005 recommendations by the International Liaison Committee on Resuscitation, and culminating in multicenter collaborations. The epidemiology and pathophysiology of in-hospital and out-of-hospital CA are now well described. Four phases of CA are described and the term "post-cardiac arrest syndrome" has been proposed, along with treatment goals for each of its four phases: immediate post-arrest, early post-arrest, intermediate and recovery phase. Hypothermia is recommended to be considered as a therapy for post-CA syndrome in comatose patients after CA, and large multicenter prospective studies are underway. We reviewed landmark articles related to pediatric CA published during the last decade. We present the current knowledge of epidemiology, pathophysiology and treatment of CA relevant to pre-hospital and acute care health practitioners.
  27 7,273 102
Human factors in resuscitation: Lessons learned from simulator studies
S Hunziker, F Tschan, NK Semmer, MD Howell, S Marsch
October-December 2010, 3(4):389-394
DOI:10.4103/0974-2700.70764  PMID:21063563
Medical algorithms, technical skills, and repeated training are the classical cornerstones for successful cardiopulmonary resuscitation (CPR). Increasing evidence suggests that human factors, including team interaction, communication, and leadership, also influence the performance of CPR. Guidelines, however, do not yet include these human factors, partly because of the difficulties of their measurement in real-life cardiac arrest. Recently, clinical studies of cardiac arrest scenarios with high-fidelity video-assisted simulations have provided opportunities to better delineate the influence of human factors on resuscitation team performance. This review focuses on evidence from simulator studies that focus on human factors and their influence on the performance of resuscitation teams. Similar to studies in real patients, simulated cardiac arrest scenarios revealed many unnecessary interruptions of CPR as well as significant delays in defibrillation. These studies also showed that human factors play a major role in these shortcomings and that the medical performance depends on the quality of leadership and team-structuring. Moreover, simulated video-taped medical emergencies revealed that a substantial part of information transfer during communication is erroneous. Understanding the impact of human factors on the performance of a complex medical intervention like resuscitation requires detailed, second-by-second, analysis of factors involving the patient, resuscitative equipment such as the defibrillator, and all team members. Thus, high-fidelity simulator studies provide an important research method in this challenging field.
  27 7,190 69
Pre-hospital transport times and survival for Hypotensive patients with penetrating thoracic trauma
Mamta Swaroop, David C Straus, Ogo Agubuzu, Thomas J Esposito, Carol R Schermer, Marie L Crandall
January-March 2013, 6(1):16-20
Background: Achieving definitive care within the "Golden Hour" by minimizing response times is a consistent goal of regional trauma systems . This study hypothesizes that in urban Level I Trauma Centers, shorter pre-hospital times would predict outcomes in penetrating thoracic injuries. Materials and Methods: A retrospective cohort study was performed using a statewide trauma registry for the years 1999-2003 . Total pre-hospital times were measured for urban victims of penetrating thoracic trauma. Crude and adjusted mortality rates were compared by pre-hospital time using STATA statistical software. Results: During the study period, 908 patients presented to the hospital after penetrating thoracic trauma, with 79% surviving . Patients with higher injury severity scores (ISS) were transported more quickly. Injury severity scores (ISS) ≥16 and emergency department (ED) hypotension (systolic blood pressure, SBP <90) strongly predicted mortality (P < 0.05 for each) . In a logistic regression model including age, race, and ISS, longer transport times for hypotensive patients were associated with higher mortality rates (all P values <0.05). This was seen most significantly when comparing patient transport times 0-15 min and 46-60 min (P < 0.001). Conclusion: In victims of penetrating thoracic trauma, more severely injured patients arrive at urban trauma centers sooner . Mortality is strongly predicted by injury severity, although shorter pre-hospital times are associated with improved survival . These results suggest that careful planning to optimize transport time-encompassing hospital capacity and existing resources, traffic patterns, and trauma incident densities may be beneficial in areas with a high burden of penetrating trauma.
  26 5,313 19
Emergency treatment of a snake bite: Pearls from literature
Syed Moied Ahmed, Mohib Ahmed, Abu Nadeem, Jyotsna Mahajan, Adarash Choudhary, Jyotishka Pal
July-December 2008, 1(2):97-105
DOI:10.4103/0974-2700.43190  PMID:19561988
Snake bite is a well-known occupational hazard amongst farmers, plantation workers, and other outdoor workers and results in much morbidity and mortality throughout the world. This occupational hazard is no more an issue restricted to a particular part of the world; it has become a global issue. Accurate statistics of the incidence of snakebite and its morbidity and mortality throughout the world does not exist; however, it is certain to be higher than what is reported. This is because even today most of the victims initially approach traditional healers for treatment and many are not even registered in the hospital. Hence, registering such patients is an important goal if we are to have accurate statistics and reduce the morbidity and mortality due to snakebite. World Health Organization/South East Asian Region Organisation (WHO/SEARO) has published guidelines, specific for the South East Asian region, for the clinical management of snakebites. The same guidelines may be applied for managing snakebite patients in other parts of the world also, since no other professional body has come up with any other evidence-based guidelines. In this article we highlight the incidence and clinical features of different types of snakebite and the management guidelines as per the WHO/SEARO recommendation.
  26 22,822 599
Outcomes and complications of open abdomen technique for managing non-trauma patients
Kritaya Kritayakirana, Paul M Maggio, Susan Brundage, Mary-Anne Purtill, Kristan Staudenmayer, David A Spain
April-June 2010, 3(2):118-122
DOI:10.4103/0974-2700.62106  PMID:20606786
Background : Damage control surgery and the open abdomen technique have been widely used in trauma. These techniques are now being utilized more often in non-trauma patients but the outcomes are not clear. We hypothesized that the use of the open abdomen technique in non-trauma patients 1) is more often due to peritonitis, 2) has a lower incidence of definitive fascial closure during the index hospitalization, and 3) has a higher fistula rate. Methods : Retrospective case series of patients treated with the open abdomen technique over a 5-year period at a level-I trauma center. Data was collected from the trauma registry, operating room (OR) case log, and by chart review. The main outcome measures were number of operations, definitive fascial closure, fistula rate, complications, and length of stay. Results : One hundred and three patients were managed with an open abdomen over the 5-year period and we categorized them into three groups: elective (n = 31), urgent (n = 35), and trauma (n = 37). The majority of the patients were male (69%). Trauma patients were younger (39 vs 53 years; P < 0.05). The most common indications for the open abdomen technique were intraabdominal hypertension in the elective group (n = 18), severe intraabdominal infection in the urgent group (n=19), and damage control surgery in the trauma group (n = 28). The number of abdominal operations was similar (3.1−3.7) in the three groups, as was the duration of intensive care unit (ICU) stay (average: 25−31 days). The definitive fascial closure rates during initial hospitalization were as follows: 63% in the elective group, 60% in the urgent group, and 54% in the trauma group. Intestinal fistula formation occurred in 16%, 17%, and 11%, respectively, in the three groups, with overall mortality rates of 35%, 31%, and 11%. Conclusion : Intra-abdominal infection was a common reason for use of the open abdomen technique in non-trauma patients. However, the definitive fascial closure and fistula rates were similar in the three groups. Despite differences in indications, damage control surgery and the open abdomen technique have been successfully transitioned to elective and urgent non-trauma patients.
  22 6,397 160
Acute lung injury and acute respiratory distress syndrome
Maximillian Ragaller, Torsten Richter
January-March 2010, 3(1):43-51
DOI:10.4103/0974-2700.58663  PMID:20165721
Every year, more information accumulates about the possibility of treating patients with acute lung injury or acute respiratory distress syndrome with specially designed mechanical ventilation strategies. Ventilator modes, positive end-expiratory pressure settings, and recruitment maneuvers play a major role in these strategies. However, what can we take from these experimental and clinical data to the clinical practice? In this article, we discuss substantial options of mechanical ventilation together with some adjunctive therapeutic measures, such as prone positioning and inhalation of nitric oxide.
  22 7,320 204
Principles of diagnosis and management of traumatic pneumothorax
Anita Sharma, Parul Jindal
January-June 2008, 1(1):34-41
DOI:10.4103/0974-2700.41789  PMID:19561940
Presence of air and fluid with in the chest might have been documented as early as Fifth Century B.C. by a physician in ancient Greece, who practiced the so-called Hippocratic succession of the chest. This is due to a development of communication between intrapulmonary air space and pleural space, or through the chest wall between the atmosphere and pleural space. Air enters the pleural space until the pressure gradient is eliminated or the communication is closed. Increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (noniatrogenic and iatrogenic) pneumothorax. Clinical spectrum of pneumothorax varies from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination. Simple erect chest radiograph is sufficient though; many investigations are useful in accessing the future line of action. However, in certain life-threatening conditions obtaining imaging studies can causes an unnecessary and potential lethal delay in treatment.
  21 20,818 585
Role of pyruvate dehydrogenase complex in traumatic brain injury and Measurement of pyruvate dehydrogenase enzyme by dipstick test
Pushpa Sharma, Brandi Benford, Zhao Z Li, Geoffrey SF Ling
May-August 2009, 2(2):67-72
DOI:10.4103/0974-2700.50739  PMID:19561963
Objectives: The present study was designed to investigate the role of a mitochondrial enzyme pyruvate dehydrogenase (PDH) on the severity of brain injury, and the effects of pyruvate treatment in rats with traumatic brain injury (TBI). Materials and Methods: We examined rats subjected to closed head injury using a fluid percussion device, and treated with sodium pyruvate (antioxidant and substrate for PDH enzyme). At 72 h post injury, blood was analyzed for blood gases, acid-base status, total PDH enzyme using a dipstick test and malondialdehyde (MDA) levels as a marker of oxidative stress. Brain homogenates from right hippocampus (injured area) were analyzed for PDH content, and immunostained hippocampus sections were used to determine the severity of gliosis and PDH E1-∞ subunit. Results: Our data demonstrate that TBI causes a significant reduction in PDH enzyme, disrupt-acid-base balance and increase oxidative stress in blood. Also, lower PDH enzyme in blood is related to the increased gliosis and loss of its PDH E1-∞ subunit PDH in brain tissue, and these effects of TBI were prevented by pyruvate treatment. Conclusion: Lower PDH enzyme levels in blood are related to the global oxidative stress, increased gliosis in brain, and severity of brain injury following TBI. These effects can be prevented by pyruvate through the protection of PDH enzyme and its subunit E-1.
  20 6,187 327
Pain management in the emergency department and its relationship to patient satisfaction
La Vonne A Downey, Leslie S Zun
October-December 2010, 3(4):326-330
DOI:10.4103/0974-2700.70749  PMID:21063553
Background : Pain is the most common reason due to which patients come to the emergency department (ED). Aim : The purpose of this study was to measure the correlation, if any, between pain reduction and the level of satisfaction in patients who presented to the ED with pain as their chief complaint. Materials and Methods : This study used a randomly selected group of patients who presented to the ED with pain of 4 or more on the Visual Analogue Pain Scale (VAS) as their chief complaint to a level one adult and pediatric trauma center. Instruments that were used in this study were the VAS, Brief Pain Inventory (BPI), and the Medical Interview Satisfaction Scale (MISS). They were administered to patients by research fellows in the treatment rooms. Statistical analysis included frequencies, descriptive, and linear regression. This study was approved by the Internal Review Board. Results : A total of 159 patients were enrolled in the study. All patients were given some type of treatment for their pain upon arrival to the ED. A logistic regression showed a significant relationship to reduction in pain by 40% or more and customer service questions. Conclusions : A reduction in perceived pain levels does directly relate to several indicators of customer service. Patients who experienced pain relief during their stay in the ED had significant increases in distress relief, rapport with their doctor, and intent to comply with given instructions.
  20 7,654 69
Assessment of community healthcare providers ability and willingness to respond to emergencies resulting from bioterrorist attacks
Jeffery S Crane, James D McCluskey, Giffe T Johnson, Raymond D Harbison
January-March 2010, 3(1):13-20
DOI:10.4103/0974-2700.55808  PMID:20165716
Introduction: Previous findings have demonstrated that preparedness and planning within the public health system are inadequately developed to respond to an act of biological or chemical terrorism. Methods:This investigation used Internet-based surveys to assess the level of preparedness (PL) and willingness to respond (WTR) to a bioterrorism attack, and identify factors that predict PL and WTR among Florida community healthcare providers. Invitations were sent to 22,800 healthcare providers in Florida, which resulted in 2,279 respondents. Results: Respondents included physicians (n=604), nurses (n=1,152), and pharmacists (n=486). The results indicated that only 32% of Florida healthcare providers were competent and willing to respond to a bioterrorism attack, 82.7% of providers were willing to respond in their local community, and 53.6% within the State. Respondents were more competent in administrative skills than clinical knowledge (62.8% vs. 45%). Areas in which respondents had the highest competency were the initiation of treatment and recognition of their clinical and administrative roles. Areas in which respondents showed the lowest competency were the ability to identify cases and the ability to communicate risk to others. About 55% of the subjects had previous bioterrorism training and 31.5% had conducted emergency drills. Gender, race, previous training and drills, perceived threats of bioterrorism attack, perceived benefits of training and drills, and feeling prepared were all predictors of overall preparedness. Conclusions: The findings suggest that only one-third of Florida community healthcare providers were prepared for a bioterrorism attack, which is an insufficient response rate to effectively respond to a bioterrorism incident.
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Dengue shock
Senaka Rajapakse
January-March 2011, 4(1):120-127
DOI:10.4103/0974-2700.76835  PMID:21633580
Shock syndrome is a dangerous complication of dengue infection and is associated with high mortality. Severe dengue occurs as a result of secondary infection with a different virus serotype. Increased vascular permeability, together with myocardial dysfunction and dehydration, contribute to the development of shock, with resultant multiorgan failure. The onset of shock in dengue can be dramatic, and its progression relentless. The pathogenesis of shock in dengue is complex. It is known that endothelial dysfunction induced by cytokines and chemical mediators occurs. Diagnosis is largely clinical and is supported by serology and identification of viral material in blood. No specific methods are available to predict outcome and progression. Careful fluid management and supportive therapy is the mainstay of management. Corticosteroids and intravenous immunoglobulins are of no proven benefit. No specific therapy has been shown to be effective in improving survival.
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