Journal of Emergencies, Trauma, and Shock
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  Citation statistics : Table of Contents
   2011| January-March  | Volume 4 | Issue 1  
    Online since February 18, 2011

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The impact of antiplatelet therapy on pelvic fracture outcomes
Jonathan M Christy, S Peter Stawicki, Amy M Jarvis, David C Evans, Anthony T Gerlach, David E Lindsey, Peggy Rhoades, Melissa L Whitmill, Steven M Steinberg, Laura S Phieffer, Charles H Cook
January-March 2011, 4(1):64-69
DOI:10.4103/0974-2700.76841  PMID:21633571
Introduction : Despite increasing use of antiplatelet agents (APA), little is known regarding the effect of these agents on the orthopedic trauma patient. This study reviews clinical outcomes of patients with pelvic fractures (Pfx) who were using pre-injury APA. Specifically, we focused on the influence of APA on postinjury bleeding, transfusions, and outcomes after Pfx. Methods : Patients with Pfx admitted during a 37-month period beginning January 2006 were divided into APA and non-APA groups. Pelvic injuries were graded using pelvic fracture severity score (PFSS)-a combination of Young-Burgess (pelvic ring), Letournel-Judet (acetabular), and Denis (sacral fracture) classifications. Other clinical data included demographics, co-morbid conditions, medications, injury severity score (ISS), associated injuries, morbidity/mortality, hemoglobin trends, blood product use, imaging studies, procedures, and resource utilization. Multivariate analyses for predictors of early/late transfusions, pelvic surgery, and mortality were performed. Results : A total of 109 patients >45 years with Pfx were identified, with 37 using preinjury APA (29 on aspirin [ASA], 8 on clopidogrel, 5 on high-dose/scheduled non-steroidal anti-inflammatory agents [NSAID], and 8 using >1 APAs). Patients in the APA groups were older than patients in the non-APA group (70 vs. 63 years, P < 0.01). The two groups were similar in gender distribution, PFSS and ISS. Patients in the APA group had more comorbidities, lower hemoglobin levels at 24 h, and received more packed red blood cell (PRBC) transfusions during the first 24 h of hospitalization (all, P < 0.05). There were no differences in platelet or late (>24 h) PRBC transfusions, blood loss/transfusions during pelvic surgery, lengths of stay, post-ED/discharge disposition, or mortality. In multivariate analysis, predictors of early PRBC transfusion included higher ISS/PFSS, pre-injury ASA use, and lower admission hemoglobin (all, P < 0.03). Predictors of late PRBC transfusion included the number of complications, gender, PFSS, and any APA use (all, P < 0.05). Mortality was associated with pelvic hematoma/contrast extravasation on imaging, number of complications, and higher PFSS/ISS (all, P < 0.04). Conclusions : Results of this study support the contention that preinjury use of APA does not independently affect morbidity or mortality in trauma patients with Pfx. Despite no clinically significant difference in early postinjury blood loss, pre-injury use of APA was associated with increased likelihood of receiving PRBC transfusion within 24 h of admission. Furthermore, multivariate analyses demonstrated that among different APA, only preinjury ASA (vs. clopidogrel or NSAID) was associated with early PRBC transfusions. Late transfusion was associated with the use of any APA, complications, higher PFSS, and need for pelvic surgery.
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A case of organophosphate poisoning presenting with seizure and unavailable history of parenteral suicide attempt
Vinay Pandit, Shubha Seshadri, SN Rao, Charmaine Samarasinghe, Ashwini Kumar, Rohith Valsalan
January-March 2011, 4(1):132-134
DOI:10.4103/0974-2700.76825  PMID:21633583
Organophosphate (OP) poisoning is common in India. Only few case reports of parenteral OP poisoning have been described. We report a case of self-injected methyl parathion poisoning, presenting after four days with seizure, altered sensorium, and respiratory distress which posed a diagnostic and therapeutic dilemma. Despite nonavailability of history of OP poisoning, he was treated based on suspicion and showed a good clinical response to treatment trial with atropine and pralidoxime, and had a successful recovery. Atypical presentations may be encountered following parenteral administration of OP poison, and even a slight suspicion of this warrants proper investigations and treatment for a favorable outcome. Persistently low plasma cholinesterase level is a useful marker for making the diagnosis.
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Management of ureteral calculi and medical expulsive therapy in emergency departments
CM Stefano Picozzi, Carlo Marenghi, Stefano Casellato, Cristian Ricci, Maddalena Gaeta, Luca Carmignani
January-March 2011, 4(1):70-76
DOI:10.4103/0974-2700.76840  PMID:21633572
Introduction : Ureteral stones are a common problem in daily emergency department practice. Patients may be offered medical expulsive therapy (MET1) to facilitate stone expulsion and this should be offered as a treatment for patients with distal ureteral calculi, who are amenable to waiting management. Emergency department clinicians and family practitioners are often in the front line regarding the diagnosis and treatment of symptomatic nephrolithiasis and this commentary is dedicated to them because their decisions directly influence the outcome of the acute stone episode and appropriate referral patterns. Materials and Methods : The aim of this systematic review and meta-analysis was to understand the role of MET in the treatment of obstructing ureteral calculi. A bibliographic search covering the period from January 1980 to March 2010 was conducted in PubMed, MEDLINE and EMBASE. The searches were restricted to publications in English. This analysis is based on the 21 studies that fulfilled the predefined inclusion criteria. Results : A metaregression analysis of expulsion time showed a statistically significant advantage in the experimental group, in which the mean expulsion time was 6.2 days compared to 10.3 days in controls. The treatment effect on expulsion rate (P = 0.53) was partially lost as the size of the stones decreased because of the high spontaneous expulsion rate of small stones and the expulsion time was not influenced by pharmacological treatment (P = 0.76) if the stone size was smaller than 5 mm. Analysis of the tamsulosin database : A total of 1283 participants were included in the 17 studies. These studies showed that compared to standard therapy or placebo, tamsulosin had significant benefits, being associated with both a higher stone expulsion rate (P < 0.001) and reduction of the expulsion time (P = 0.02). Reductions in the need for analgesic therapy, hospitalization and surgery are also shown. Analysis of the nifedipine database : The number of participants in each trial ranged from 25 to 70. Compared to standard therapy, the use of nifedipine significantly improved the spontaneous stone expulsion rate (P < 0.001). The mean expulsion time was slightly, but not statistically significantly, different (P = 0.19) between the treatment and control groups. A possible benefit of nifedipine, in terms of significantly reducing the doses of analgesics required, was reported in three studies. There was no difference between the tamsulosin- and nifedipine-treated groups with regard to expulsion time (P = 0.17) or expulsion rate (P = 0.79). Conclusions : Despite all its advantages, MET is rarely used, representing a failure of the translation of medical science into practice. These data raise concerns not only about the quality of care of patients who could benefit from resolution of stones without anaesthetic and surgical risks but also with regard to potential cost savings. MET should be offered as a treatment for patients with distal ureteral calculi who are amenable to a waiting management.
  9 5,203 21
Traumatic anterior abdominal wall hernia: A report of three rare cases
Rikki Singal, Usha Dalal, Ashwani Kumar Dalal, Ashok Kumar Attri, Raman Gupta, Anupama Gupta, Bikash Naredi, Deepesh Benjamin Kenwar, Samita Gupta
January-March 2011, 4(1):142-145
DOI:10.4103/0974-2700.76832  PMID:21633587
Traumatic abdominal wall hernia is a rare condition that can follow any blunt trauma. Associated intra-abdominal injuries are infrequent. In this study, we are reporting three cases, diagnosed as abdominal wall hernia associated with herniation of bowel loops due to blunt trauma. In one case, injury of the herniated bowel was seen. In western medical literature, only few cases have been reported especially with intra-abdominal injuries.
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Liver transplantation for hepatic trauma: Discussion about a case and its management
Charles Honoré, Arnaud DeRoover, Nathalie Gilson, Olivier Detry
January-March 2011, 4(1):137-139
DOI:10.4103/0974-2700.76828  PMID:21633585
Liver transplant for trauma is a rare condition with 19 cases described in the literature. We report the case of a 16-year-old patient who suffered a gradeV liver injury with a vena cava tear after a car crash. After a computerized tomography (CT) scan, the patient was directly sent to the operating room where the surgeon performed a right hepatectomy extended to segment IV with a venous repair under discontinued hilar clamping. On day five, the patient developed acute liver failure and was put on an emergency transplant waiting list. He had a successful liver transplant 2 days later. Fifteen months after his transplant, the patient is alive and asymptomatic. This case report focuses on the patient's initial management, the importance of damage control surgery and the circumstances which finally led to the transplant.
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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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Pediatric trauma mortality by type of designated hospital in a mature inclusive trauma system
Rachid Amini, André Lavoie, Lynne Moore, Marie-Josée Sirois, Marcel Émond
January-March 2011, 4(1):12-19
DOI:10.4103/0974-2700.76824  PMID:21633561
Background : Previous studies have shown divergent results regarding the survival of injured children treated at pediatric trauma centers (PTC) and adult trauma centers (ATC). Aims : (1) To document, in a regionalized inclusive trauma system, at which level of trauma centers were the injured children treated and (2) to compare the in-hospital mortality over five levels of trauma care, ranging from pediatric level I trauma centers (PTC) to designated local trauma hospitals (level IV) for the whole study sample and for subgroups of severely injured children and head trauma. Materials and Methods : A retrospective analysis included data on 11,053 injured children (age ≤16 years) treated between April 1998 and March 2005 in 58 designated trauma hospitals in the province of Quebec, Canada. Multiple imputation was used to handle missing physiological data and multivariate logistic regression was used to compare mortality over levels of care. Results : PTC treated 52.2% of the children. Children treated at PTC were more often transferred from another hospital (73%) and were more severely injured. ATC level I, II, III and IV centers treated, respectively, 3.0%, 16.2%, 24.3% and 4.3% of children. Compared with children treated at a PTC, the risk of mortality was higher for children treated at each other ATC, i.e. level I (adjusted odds ratio [OR] = 3.1; 95% confidence interval [CI]: 1.3-7.5), level II (OR = 2.5; 95% CI: 1.3-5.0), level III (OR = 5.2; 95% CI: 2.1-13.1) and level IV (OR = 9.9; 95% CI: 2.4-41.3). Similar findings were observed among the subsamples of children who were more severely injured (Injury Severity Score >15) and who sustained head injuries. Conclusions : In our trauma system, PTC cared for more than half of the injured children and patients treated there have better survival than those treated at all other levels of ATC.
  6 4,500 31
Analysis of the pattern of maxillofacial fractures in north western of Iran: A retrospective study
Ali Hossein Mesgarzadeh, Mohamadreza Shahamfar, Samira feizi Azar, Jafar Shahamfar
January-March 2011, 4(1):48-52
DOI:10.4103/0974-2700.76837  PMID:21633568
Background : Maxillofacial fractures can lead to substantial long-term functional, esthetic and psychological complications. Aim : The aim of this study is to evaluate these injuries in a Turkish Iranian population. Materials and Methods : A retrospective study of 170 patients with 210 maxillofacial fractures admitted to the emergency department of a central referral emergency hospital in the area over a 5 year period is presented. Patients' data included demographic information, etiology, site and associated injuries and complications. Results : Road traffic accident was the commonest cause (40%) and the age group of 21-30 comprised the biggest group (30%). Mandibular fractures outnumbered midface fractures (150vs.60). Ramus (21.5%) and zygoma (26.5%) were the commonest fracture regions respectively in mandible and midface. Male: female ratio was 3.8:1 Almost half of patients (46%) had sustained associated injuries most of which was soft tissue laceration of the face (17.5%). 22 patient (13%) had associated complication and the hemorrhage was the commonest form of that (9%). Conclusion : It seems that road traffic accidents continue to be the leading cause of maxillofacial fractures and there is an urgent need to implement enhanced regulations and monitoring on motor vehicular traffic.
  6 3,741 15
Transfusion protocol in trauma
Paramjit Kaur, Sabita Basu, Gagandeep Kaur, Ravneet Kaur
January-March 2011, 4(1):103-108
DOI:10.4103/0974-2700.76844  PMID:21633577
Blood and blood components are considered drugs because they are used in the treatment of diseases. As with any drug, adverse effects may occur, necessitating careful consideration of therapy. Like any other therapeutic decision, the need for transfusion should be considered on the basis of risks and benefits and alternative treatments available to avoid over- and under-transfusion. This review is focused on the blood transfusion protocol in trauma patients with hemorrhagic shock. Besides, issues related to emergency and massive transfusion have also been elaborated. We conducted a comprehensive MEDLINE search and reviewed the relevant literature, with particular reference to emergency medical care in trauma.
  6 7,329 28
Vascular injuries after bear attacks: Incidence, surgical challenges and outcome
Mohd Lateef Wani, Abdul Gani Ahangar, Gh Nabi Lone, Reyaz Ahmad Lone, Hakeem Zubair Ashraf, Abdul Majeed Dar, MA Bhat, Shyam Singh, Akram Hussain Bijli, Ifat Irshad
January-March 2011, 4(1):20-22
DOI:10.4103/0974-2700.76827  PMID:21633562
Background : Bear mauling is rarely reported in medical literature due to its rare occurrence. Present study was undertaken to describe the pattern and management of bear maul vascular injuries in Kashmir. Methods : Study of patients with bear maul vascular injury from 1st Jan 2004 to 31st Dec. 2008. Fifteen patients with bear maul vascular injury were studied. All patients of bear maul without vascular injury were excluded from the study. Results : Most of the patients were treated by reverse saphenous vein graft or end to end anastomosis. Most common complication was wound infection (20%) followed by graft occlusion (13.33%). There was no operative death. Conclusion : Bear attacks are very common in Kashmir. Vascular injury due to bear maul needs prompt resuscitation and revascularization. Results are very good provided timely intervention for revascularization is done.
  5 4,655 15
A primer on burn resuscitation
Ferdinand K Bacomo, Kevin K Chung
January-March 2011, 4(1):109-113
DOI:10.4103/0974-2700.76845  PMID:21633578
Since the early 1900s, the scope of burn resuscitation has evolved dramatically. Due to various advances in pre-hospital care and training, under-resuscitation of patients with severe burns is now relatively uncommon. Over-resuscitation, otherwise known as "fluid creep", has emerged as one of the most important problems during the initial phases of burn care over the past decade. To avoid the complications of over-resuscitation, careful hourly titration of fluid rates based on compilation of various clinical end points by a bedside provider is vital. The aim of this review is to provide a practical approach to the resuscitation of severely burned patients.
  5 14,251 47
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.
  5 9,496 44
Impact of general versus epidural anesthesia on early post-operative cognitive dysfunction following hip and knee surgery
Sripurna Mandal, Mina Basu, Jyotirmay Kirtania, Debabrata Sarbapalli, Ranabir Pal, Sumit Kar, Kanak Kanti Kundu, Ujjal Sarkar, Sampa Dutta Gupta
January-March 2011, 4(1):23-28
DOI:10.4103/0974-2700.76829  PMID:21633563
Background : Post-operative cognitive dysfunction is the subtle cerebral complication temporally seen following surgery. The aim of this study was to compare the influence of either general anesthesia (GA) or epidural anesthesia (EA) on the early post-operative neurocognitive outcome in elderly (>59 years) subjects undergoing hip and knee surgery. Methods : A total of 60 patients were recruited in a prospective, randomized, parallel-group study, comparable by age and sex. They were enrolled and randomized to receive either EA (n = 30) or GA (n = 30). All of them were screened using the Mini Mental State Examination (MMSE), with components of the Kolkata Cognitive Screening Battery. The operated patients were re-evaluated 1 week after surgery using the same scale. The data collected were analyzed to assess statistical significance. Results : We observed no statistical difference in cognitive behavior in either group pre-operatively, which were comparable with respect to age, sex and type of surgery. Grossly, a significant difference was seen between the two groups with respect to the perioperative changes in verbal fluency for categories and MMSE scores. However, these differences were not significant after the application of the Bonferroni correction for multiple analyses, except the significant differences observed only in the MMSE scores. Conclusions : We observed a difference in cognitive outcome with GA compared with EA. Certain aspects of the cognition were affected to a greater extent in this group of patients undergoing hip and knee surgery.
  4 5,339 33
Neuroprotective effect of wormwood against lead exposure
O Kharoubi, M Slimani, A Aoues
January-March 2011, 4(1):82-88
DOI:10.4103/0974-2700.76834  PMID:21633574
Background : Lead poisoning is a potential factor in brain damage, neurochemical dysfunction and severe behavioral problems. Considering this effect, our study was carried out to investigate the effects of wormwood to restore enzymes activities, lipid peroxidation and behavioral changes induced by lead. Methods : Thirty Wistar rats were divided into five groups (n = 6 in each group): three groups exposed to 750 ppm of lead acetate in the drinking water for 11 weeks and two groups as control. Aqueous wormwood extract (200 mg/kg body weight) was administrated to intoxicated (Pb(-)+A.AB) and control groups (A.AB) for four supplemental weeks. Activities of acetylcholinesterase (AchE), monoamine oxidase (MAO) and thiobarbituric acid-reactive substances (TBARS) level were determined in the hypothalamus, hippocampus, cortex and striatum of male rats and the grooming and locomotors activity were defined in all groups. Results: The intoxicated group (Pb) has a significantly increased TBARS value compared with the control in all brain regions (P < 0.05) and, after treatment with the wormwood extract, a significant reduction was noted. The enzyme activity decreased significantly (P < 0.05) in the Pb group compared with the control, essentially for the hippocampus (AchE: -57%, MAO: -41%) and the striatum (AchE: -43%, MAO: -51%). After wormwood extract administration, the AchE and MAO activity were significantly increased in all brain regions compared with the Pb group (P < 0.05). The behavioral test (locomotors and grooming test) indicates a significant hyperactivity in the Pb group compared with the control group. After treatment with wormwood extract, the Pb(-)+A.Ab indicates a lower activity compared with Pb. Conclusion : These data suggest that wormwood extract may play a very useful role in reduction of the neurotoxicological damage induced by lead.
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A clinico-epidemiologic study of 892 patients with burn injuries at a tertiary care hospital in Punjab, India
Ashok K Gupta, Sanjeev Uppal, Ramneesh Garg, Ashish Gupta, Ranabir Pal
January-March 2011, 4(1):7-11
DOI:10.4103/0974-2700.76820  PMID:21633560
Aim : To analyze the causes, demographic and socio-cultural aspects, and the magnitude of burn injuries prospectively and to evaluate the outcome of treatment of patients admitted to burns ICU of tertiary care hospital. Materials and Methods : A total of 892 burn patients admitted over a period of 6 years from January 2002 to December 2007 at tertiary care hospital in Punjab, India, were analyzed. Results : 54% patients were males. A majority of the patients, 704(79%), were in the age group of 15-45 years. Six hundred and thirty-four patients (72%) sustained flame burns, while 17% and 7% sustained electrical and scald burns, respectively. A total of 470(53%) patients sustained major two to three degree flame burns involving more than 45% of total body surface area (TBSA). The mortality rate was 40%, i.e. 357 patients died of burns and its related problems, in our study. Six hundred and thirty-nine patients (72%) sustained burns in closed space of which 331 patients (52%) sustained burns in kitchen. Seven hundred and seventy-nine patients sustained accidental burns. Burn victims were mainly Hindus and Sikhs. The mean hospital stay varied depending upon the percentage of burns. On an average, a patient with >45% TBSA burns received 15 whole blood transfusions. Split skin grafting was done in 416 patients. Most common complication encountered during their hospital stay was wound infection which was seen in 671 patients, followed by ARDS in 221 patients. The most common organisms causing wound infection were Pseudomonas and Acinetobacter. Conclusion : Developing country like India need an aggressive public education program so that people become more literate about various etiological factors causing burns and means of preventing them. Also needed are burn care hospitals which are easily accessible and affordable.
  3 4,778 29
Isolated traumatic head injury in children: Analysis of 276 observations
Mabrouk Bahloul, Hedi Chelly, Anis Chaari, Imen Chabchoub, Sondes Haddar, Leila Herguefi, Hassen Dammak, Chokri Ben Hamida, Hichem Ksibi, Hatem Kallel, Noureddine Rekik, Mounir Bouaziz
January-March 2011, 4(1):29-36
DOI:10.4103/0974-2700.76831  PMID:21633564
Background : To determine predictive factors of mortality among children after isolated traumatic brain injury. Materials and Methods : In this retrospective study, we included all consecutive children with isolated traumatic brain injury admitted to the 22-bed intensive care unit (ICU) of Habib Bourguiba University Hospital (Sfax, Tunisia). Basic demographic, clinical, biochemical, and radiological data were recorded on admission and during ICU stay. Results : There were 276 patients with 196 boys (71%) and 80 girls, with a mean age of 6.7 ± 3.8 years. The main cause of trauma was road traffic accident (58.3%). Mean Glasgow Coma Scale score was 8 ± 2, Mean Injury Severity Score (ISS) was 23.3 ± 5.9, Mean Pediatric Trauma Score (PTS) was 4.8 ± 2.3, and Mean Pediatric Risk of Mortality (PRISM) was 10.8 ± 8. A total of 259 children required mechanical ventilation. Forty-eight children (17.4%) died. Multivariate analysis showed that factors associated with a poor prognosis were PRISM > 24 (OR: 10.98), neurovegetative disorder (OR: 7.1), meningeal hemorrhage (OR: 2.74), and lesion type VI according to Marshall tomographic grading (OR: 13.26). Conclusion : In Tunisia, head injury is a frequent cause of hospital admission and is most often due to road traffic injuries. Short-term prognosis is influenced by demographic, clinical, radiological, and biochemical factors. The need to put preventive measures in place is underscored.
  3 4,424 20
Injuries due to fall make summer time power outages a potential public health issue
Muhammad S Shamim, Uzma R Khan, Junaid A Razzak, Jooma Rasheed
January-March 2011, 4(1):147-148
DOI:10.4103/0974-2700.76817  PMID:21633590
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An arrowhead found incidentally in the chest during workup for unrelated disease after 22-years of initial injury
Shilpi Singh Gupta, Onkar Singh, Sumit Shukla, Raj Kumar Mathur
January-March 2011, 4(1):148-149
DOI:10.4103/0974-2700.76819  PMID:21633591
  2 2,549 11
Current practice and the role of the CT in the management of penetrating liver injuries at a Level I trauma center
Beat Schnüriger, Peep Talving, Raffaella Barbarino, Galinos Barmparas, Kenji Inaba, Demetrios Demetriades
January-March 2011, 4(1):53-57
DOI:10.4103/0974-2700.76838  PMID:21633569
Background : The liberal utilization of computed tomography (CT) has significantly contributed to overall improvements in trauma care. However, the role and the current practice of the CT examinations in the management of patients with penetrating liver injuries are scantily documented. Aims : This study was aimed to assess the current practice and the role of the admission and follow-up CT in patients with penetrating liver injuries. Setting and Design : This is a retrospective study at a Level I trauma center. Study period is from 01/2005 to 12/2007. Methods : All patients with penetrating liver injuries were analyzed. Results : Overall, 178 patients with penetrating liver injuries were assessed. A total of 123 (69.1%) patients underwent emergent laparotomy without preoperative CT due to signs of peritonitis (47.8%), hypotension (16.3%), or a GCS of ≤8 (5.1%). In this group of patients, no nontherapeutic laparotomy occurred. The remaining 55 (30.9%) patients underwent CT scan evaluation on admission. Of these, 54.5% were selected for nonoperative management (NOM). Sensitivity and specificity of the admission CT to predict a positive laparotomy was 95.7% and 90.6%, respectively. Overall, 80.6% of isolated liver injuries were successfully managed nonoperatively. Thirty-three (18.5%) patients died within 72 h. In the remaining 145 patients, 33 liver-related complications occurred in 17.2% (25 of 145) of patients. Conclusion : Two-thirds of patients with penetrating liver injuries require emergent laparotomy, mainly due to associated injuries. The remaining one-third of patients, however, is amenable for an admission CT, which reliably predicts successful NOM. Moderate or severe injuries require follow-up CT because of the high incidence of asymptomatic liver-related complications.
  2 1,822 12
Pediatric cardiac emergencies: Children are not small adults
Aisha Frazier, Elizabeth A Hunt, Kathryn Holmes
January-March 2011, 4(1):89-96
DOI:10.4103/0974-2700.76842  PMID:21633575
Compared with adults, cardiac emergencies are infrequent in children and clinical presentation is often quite variable. In adults, cardiac emergencies are most commonly related to complications of coronary artery disease; however, in pediatric cases, the coronaries are only rarely the underlying problem. Pediatric cardiac emergencies comprise a range of pathology including but not limited to undiagnosed congenital heart disease in the infant; complications of palliated congenital heart disease in children; arrhythmias related to underlying cardiac pathology in the teenager and acquired heart disease. The emergency room physician and pediatric intensivist will usually be the first and second lines of care for pediatric cardiac emergencies and thus it is imperative that they have knowledge of the diverse presentations of cardiac disease in order to increase the likelihood of delivering early appropriate therapy and referral. The objective of this review is to outline cardiac emergencies in the pediatric population and contrast the presentation with adults.
  2 15,823 49
Heparin-induced thrombocytopenia
Nissar Shaikh
January-March 2011, 4(1):97-102
DOI:10.4103/0974-2700.76843  PMID:21633576
In the last 7 decades heparin has remained the most commonly used anticoagulant. Its use is increasing, mainly due to the increase in the number of vascular interventions and aging population. The most feared complication of heparin use is heparin-induced thrombocytopenia (HIT). HIT is a clinicopathologic hypercoagulable, procoagulant prothrombotic condition in patients on heparin therapy, and decrease in platelet count by 50% or to less than 100,000, from 5 to 14 days of therapy. This prothrombotic hypercoagulable state in HIT patient is due to the combined effect of various factors, such as platelet activation, mainly the formation of PF4/heparin/IgG complex, stimulation of the intrinsic factor, and loss of anticoagulant effect of heparin. Diagnosis of HIT is done by clinical condition, heparin use, and timing of thrombocytopenia, and it is confirmed by either serotonin release assay or ELISA assay. Complications of HIT are venous/arterial thrombosis, skin gangrene, and acute platelet activation syndrome. Stopping heparin is the basic initial treatment, and Direct Thrombin Inhibitors (DTI) are medication of choice in these patients. A few routine but essential procedures performed by using heparin are hemodialysis, Percutaneous Coronary Intervention, and Cardiopulmonary Bypass; but it cannot be used if a patient develops HIT. HIT patients with unstable angina, thromboembolism, or indwelling devices, such as valve replacement or intraaortic balloon pump, will require alternative anticoagulation therapy. HIT can be prevented significantly by keeping heparin therapy shorter, avoiding bovine heparin, using low-molecular weight heparin, and stopping heparin use for flush and heparin lock.
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Treatment of major vein injury with the hemostatic fleece TachoSil by interposing a peritoneal patch to avoid vein thrombosis: A feasibility study in pigs
Einar B Dregelid, Gustav Pedersen
January-March 2011, 4(1):77-81
DOI:10.4103/0974-2700.76822  PMID:21633573
Background : Vein lacerations in awkward locations are difficult to repair and carry high mortality. The hemostatic fleece, TachoSil, is effective in preventing intraoperative bleeding in different settings, but has not been recommended for use in large vein injury. TachoSil with a peritoneal patch interposed to avoid vein thrombosis has been reported as a method to obtain hemostasis in vein laceration, but further studies of this method are needed. Materials and Methods : A 1.5 × 1 cm defect was created in the vena cava in five pigs. A 26 × 32 mm peritoneal patch was applied on the coagulant side of a 48 × 48 mm TachoSil sheet, and used to cover the defect. Light compression with a wet sponge was applied for 3 min. No vascular suturing was performed. Results : Successful hemostasis was obtained in four out of the five pigs although the minimum TachoSil gluing zone surrounding the peritoneal patch was only 0-2 mm. The fifth pig died of hemorrhage 30 min after surgery due to a 4-mm stretch with no TachoSil gluing zone outside the peritoneal patch. At six days postoperatively the peritoneal patch was well integrated into the vein wall. After 28 days, the peritoneal patch was almost indiscernible from surrounding vein endothelium. Conclusions : Vein wall defects can be repaired using TachoSil with a peritoneal patch interposed to prevent contact between the thrombogenic TachoSil sheet and the vein lumen. An adequate TachoSil gluing zone all around the patch is essential.
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Glycopyrrolate in toxic exposure to ammonia gas
A Bhalla, S Mahi, N Sharma, S Singh
January-March 2011, 4(1):140-141
DOI:10.4103/0974-2700.76830  PMID:21633586
Ammonia (NH 3 ) is a highly water-soluble, colorless, irritant gas with a unique pungent odor. Liquid ammonia stored under high pressure is still widely used for refrigeration in cold stores used for storing grains. Severe toxicity may occur following accidental exposure. We report an interesting case of accidental exposure to ammonia treated with glycopyrrolate along with other supportive measures.
  1 2,862 17
What's new in Emergencies, Trauma and Shock? Anesthesia, surgery and postoperative cognition
Ramesh Ramaiah
January-March 2011, 4(1):1-2
DOI:10.4103/0974-2700.76816  PMID:21633558
  1 3,092 25
Gastrothorax or tension pneumothorax: A diagnostic dilemma
Sarvesh P Singh, Subin Sukesan, Usha Kiran, Neeti Makhija
January-March 2011, 4(1):128-129
DOI:10.4103/0974-2700.76821  PMID:21633581
Gastrothorax, a rare complication following thoracoabdominal aortic aneurysm repair, is reported. The clinical features of a gastrothorax and tension pneumothorax are similar and thus, a gastrothorax can masquerade as a tension pneumothorax. The diagnosis is made by a high level of clinical suspicion, chest X-ray shows a distended stomach with air fluid levels and a computerised tomography is useful in assessing the diaphragm and establishing the positions of the various intra-abdominal organs. Also, the risk of an intercostal drainage tube placement and the role of nasogastric tube in avoiding the development of a tension gastrothorax is highlighted.
  - 3,418 18
Retroperitoneal vascular malformation mimicking incarcerated inguinal hernia
Indu Bhushan Dubey, Anuj Sharma, Ajay Kumar Singh, Debajyoti Mohanty
January-March 2011, 4(1):130-131
DOI:10.4103/0974-2700.76823  PMID:21633582
A 30-year-old man presented to the Department of Surgery with a painful groin swelling on right side. Exploration revealed a reddish-blue hemangiomatous mass in the scrotum extending through inguinal canal into the retroperitoneum. On further dissection swelling was found to be originating from right external iliac vein. The swelling was excised after ligating all vascular connections. The histopathological examination of excised mass confirmed the diagnosis of venous variety of vascular malformation. This is the first reported case of vascular malformation arising from retroperitoneum and extending into inguinoscrotal region, presenting as incarcerated inguinal hernia.
  - 3,799 16
Adhesive bowel obstruction? Not always
D Mittapalli, BJ Sebastian, E Leung, N Barnes, P S P Senapati
January-March 2011, 4(1):135-136
DOI:10.4103/0974-2700.76826  PMID:21633584
A 58-year-old man presented acutely with features of post-surgical adhesive small bowel obstruction. Following an unsuccessful trial of conservative management, computed tomography (CT) of the abdomen was performed. This revealed a mass in the ileocaecal region, for which he underwent a subsequent right hemicolectomy. Histology revealed diffuse B-cell Non-Hodgkin's lymphoma of the terminal ileum. Confounding obstructive lesion of the intestine in patients with a history of previous laparotomy is extremely uncommon. Early high resolution imaging may predict diagnosis and consolidate clinical management plans.
  - 2,655 19
JETS policy on plagiarism and academic dishonesty
Veronica Tucci, Sagar Galwankar
January-March 2011, 4(1):3-6
DOI:10.4103/0974-2700.76818  PMID:21633559
  - 3,251 19
Kenji Kawamukai, Filippo Antonacci, Sergio Nicola Forti Parri, Salomone Di Saverio, Maurizio Boaron
January-March 2011, 4(1):146-146
DOI:10.4103/0974-2700.76813  PMID:21633588
  - 3,327 14
Self-inflicted intracranial self-injury
Matthew M Large, Olav B Nielssen, Nicholas Babidge
January-March 2011, 4(1):147-147
DOI:10.4103/0974-2700.76814  PMID:21633589
  - 2,499 15
Initial systolic blood pressure and ongoing internal bleeding following torso trauma
Daniel S Kassavin, Yen-Hong Kuo, Nasim Ahmed
January-March 2011, 4(1):37-41
DOI:10.4103/0974-2700.76833  PMID:21633565
Objective : Recent studies have suggested that an initial systolic blood pressure (SBP) in the range of 90-110 mmHg in a trauma patient may be indicative of hypoperfusion and is associated with poor patient outcome. However, the use of initial SBP as a surrogate for predicting internal bleeding is yet to be validated. The purpose of this study was to assess the presenting SBPs in patients with torso trauma and evidence of ongoing internal hemorrhage. Setting and Design : This was a retrospective chart review conducted at the Level II Trauma Center. Materials and Methods : Adult patients who sustained trauma and underwent chest and/or abdominal computed tomography (CT) scans and angiography were included in the study. Demographic and clinical information was extracted from patients who had CT scan and angiography. Extravasation of contrast material on CT scan and angiography was considered positive for ongoing internal bleeding. Results : From January 2002 through July 2007, a total of 113 consecutive patients were included in this study. Forty-seven patients had evidence of ongoing internal bleeding (41.6%; 95% confidence interval: 32.4%, 51.2%). When comparing patients with and without ongoing bleeding, these two groups were similar in their gender, race, pulse, injury severity score and shock index. However, bleeding patients were typically older [mean (standard deviation): 44.5 (20.5) vs 37.3 (19.1) years; P = 0.051], had a lower initial SBP [116.2 (36.0) vs 130.0 (30.4) mmHg; P = 0.006] and had a higher Glasgow coma scale (GCS) [13.1 (4.0) vs 12.1 (4.4); P = 0.09]. From a multivariate logistic regression analysis, older age (P = 0.046) and lower SBP (P = 0.01) were significantly associated with bleeding, when controlled for gender, race and GCS. Among the 47 patients with ongoing bleeding, only seven patients (15%) had a SBP lower than 90 mmHg and 25 patients (53%) had a SBP higher than or equal to 120 mmHg. The spleen was the most frequently injured organ identified with active bleeding. Conclusions : Initial SBP cannot predict the ongoing internal bleeding.
  - 3,684 13
Prediction of difficult intubations using conventional indicators; Does rapid sequence intubation ease difficult intubations? A prospective randomised study in a tertiary care teaching hospital
Lakshmi Gangadharan, C Sreekanth, Mabel C Vasnaik
January-March 2011, 4(1):42-47
DOI:10.4103/0974-2700.76836  PMID:21633566
Background : Endotracheal intubations performed in the Emergency Department. Aims : To assess whether conventional indicators of difficult airway can predict a difficult intubation in the Emergency Setting and to investigate the effect of rapid sequence intubation (RSI) on ease of intubation. Settings and Design : A prospective randomized study was designed involving 60 patients requiring intubation, over a period of 4 months. Materials and Methods : Demographic profile, details of methods used, airway assessment, ease of intubation, and Cormack and Lehane score were recorded. Airway assessment score and ease of intubation criteria were devised and assessed. Statistical Analysis : Descriptive statistical analysis was carried out. Chi-square/2 × 2, 2 × 3, 3 × 3, Fisher Exact test have been used to find the significance of study parameters on categorical scale between two or more groups. Results : Patients with a Mallampatti score of three or four were found to have worse laryngoscopic views (Cormack-Lehane score, 3 or 4). Of all airway indicators assessed, an increased Mallampatti score was found to have significant correlation with increased difficulty in intubation. The use of RSI was associated with better laryngoscopic views, and easier intubations. Conclusions : An airway assessment using the Mallampatti score is invaluable as a tool to predict a difficult airway and should be performed routinely if possible. RSI aids intubation ease. If not otherwise contraindicated, it should be performed routinely for all intubations in the ED.
  - 4,161 22
Determinants of mortality in trauma patients following massive blood transfusion
Kanchana Rangarajan, Arulselvi Subramanian, Ravindra Mohan Pandey
January-March 2011, 4(1):58-63
DOI:10.4103/0974-2700.76839  PMID:21633570
Aim : This study was designed to find out the factors influencing mortality in trauma patients receiving massive blood transfusion (MBT). Materials and Methods : Records of all patients admitted during December 2007 to November 2008 at a Level I Trauma Center emergency and who underwent massive transfusion (≥10 units of packed red cells in 24 h) were retrospectively analyzed. Death during the hospital stay was considered as the study outcome and various demographic, laboratory, and clinical parameters were included as its potential determinants. Statistical Analysis : Bivariate and multivariate logistic regression analyses were done to identify the risk factors associated with mortality. Results : Of the 4054 transfused patients who were admitted to the trauma center during the study period, 71 (1.8%) patients underwent massive transfusion. Of this, there were 37 survivors and 34 nonsurvivors (48%). The median overall ISS was 27 (22-34). The patients who died had shorter mean length of hospital stay, shorter mean duration of intensive care unit (ICU) stay, and low admission Glasgow Coma Scale (GCS) compared to the survivors (P < 0.01). The mean prothrombin time (PT) and the mean activated partial thromboplastin time was significantly high (P < 0.01) among nonsurvivors. Total leukocyte count (TLC ≥ 10,000 cells/cubic mm), GCS ≤ 8, the presence of coagulopathy and major vascular surgery were the four independent determinants of mortality in multivariate logistic regression analysis. The FFP:PRBC (fresh frozen plasma:packed red cells) ratio and PC:PRBC (platelet concentrate:packed red cells) ratio calculated in our study was not statistically significant in correlation to the in hospital mortality. Conclusions : Overall mortality among the MBT patients was comparable with the studies in the literature. Mortality is not affected by the amount of packed red cells given in the first 12 h and the total number of packed red cells transfused. Prospective studies are required to further validate the determinants of mortality and establish guidelines for MBT.
  - 4,637 31
Retraction Notice

January-March 2011, 4(1):47-47
  - 1,986 11
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