Journal of Emergencies, Trauma, and Shock
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   2017| July-September  | Volume 10 | Issue 3  
    Online since August 8, 2017

 
 
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ORIGINAL ARTICLES
Patterns of ocular trauma among the elderly in a South-American urban area and the association between eye traumas with sleep disorders
Sergio Henrique N Moreira, Niro Kasahara
July-September 2017, 10(3):111-115
DOI:10.4103/JETS.JETS_90_16  PMID:28855772
Aims: Eye trauma in the older population can lead to blindness. Sleep deterioration is associated with increased risk of occupational injuries. The purpose of the study was to assess the epidemiology of ocular trauma in the elderly population and to evaluate the relationship between eye trauma and sleep quality. Settings and Design: This was a cross-sectional, observational hospital based study done in a Sao Paulo, Brazil. Subjects and Methods: Patients with ocular trauma aged 60 years who attended the Eye Trauma Service of the Santa Casa de Sao Paulo Central Hospital were included. All subjects underwent a complete eye examination and answered to the Pittsburgh Sleep Quality Index (PSQI) questionnaire. The results were compared with an age and gender matched control group. Results: Eighty-nine patients with ocular trauma were included in the epidemiological study, 71 (80%) were male and 18 (20%) were female. The patients' ages ranged from 60 to 90 years (65.7 ± 7.1 years). Most accidents occurred at home and were of mild severity. The control group had a global PSQI score of 1.21 ± 1.37, whereas in the ocular trauma group the score was 3.11 ± 3.63 (P < 0.038). A post hoc analysis including only patients with severe trauma, the PSQI score was 8.80 ± 2.44 (P < 0.000). Conclusion: The elderly population represents an important group of ocular trauma in their own peculiar characteristics. Elderly victims of ocular trauma, particularly serious eye injury, have worse sleep quality than subjects of the same age.
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Characteristics and management of blunt renal injury in children
Yuichi Ishida, Alan H Tyroch, Nader Emami, Susan F McLean
July-September 2017, 10(3):140-145
DOI:10.4103/JETS.JETS_93_16  PMID:28855777
Background: Renal trauma in the pediatric population is predominately due to blunt mechanism of injury. Our purpose was to determine the associated injuries, features, incidence, management, and outcomes of kidney injuries resulting from blunt trauma in the pediatric population in a single level I trauma center. Methods: This was a retrospective chart and trauma registry review of all pediatric blunt renal injuries at a regional level I trauma center that provides care to injured adults and children. The inclusion dates were January 2001–June 2014. Results: Of 5790 pediatric blunt trauma admissions, 68 children sustained renal trauma (incidence: 1.2%). Only two had nephrectomies (2.9%). Five renal angiograms were performed, only one required angioembolization. Macroscopic hematuria rate was significantly higher in the high-grade injury group (47% vs. 16%; P = 0.031). Over half of the patients had other intra-abdominal injuries. The liver and spleen were the most frequently injured abdominal organs. Conclusion: Blunt renal trauma is uncommon in children and is typically of low American Association for the Surgery of Trauma injury grade. It is commonly associated with other intra-abdominal injuries, especially the liver and the spleen. The nephrectomy rate in pediatric trauma is lower compared to adult trauma. Most pediatric blunt renal injury can be managed conservatively by adult trauma surgeons.
  8,015 38 -
The value of arterial blood gas parameters for prediction of mortality in survivors of out-of-hospital cardiac arrest
Katharina Isabel von Auenmueller, Martin Christ, Benjamin Michel Sasko, Hans-Joachim Trappe
July-September 2017, 10(3):134-139
DOI:10.4103/JETS.JETS_146_1  
Context: Sudden cardiac death is one of the leading causes of death in Europe, and early prognostication remains challenging. There is a lack of valid parameters for the prediction of survival after cardiac arrest. Aims: This study aims to investigate if arterial blood gas parameters correlate with mortality of patients after out-of-hospital cardiac arrest. Materials and Methods: All patients who were admitted to our hospital after resuscitation following out-of-hospital cardiac arrest between January 1, 2008, and December 31, 2013, were included in this retrospective study. The patient's survival 5 days after resuscitation defined the study end-point. For the statistical analysis, the mean, standard deviation, Student's t-test, Chi-square test, and logistic regression analyses were used (level of significance P< 0.05). Results: Arterial blood gas samples were taken from 170 patients. In particular, pH <7.0 (odds ratio [OR]: 7.20; 95% confidence interval [CI]: 3.11–16.69; P< 0.001) and lactate ≥ 5.0 mmol/L (OR: 6.79; 95% CI: 2.77–16.66; P< 0.001) showed strong and independent correlations with mortality within the first 5 days after hospital admission. Conclusion: Our study results indicate that several arterial blood gas parameters correlate with mortality of patients after out-of-hospital resuscitation. The most relevant parameters are pH and lactate because they are strongly and independently associated with mortality within the first 5 days after resuscitation. Despite this correlation, none of these parameters by oneself is strong enough to allow an early prognostication. Still, these parameters can contribute as part of a multimodal approach to assessing the patients' prognosis.
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Older age, comorbid illnesses, and injury severity affect immediate outcome in elderly trauma patients
Dvora Kirshenbom, Zila Ben-Zaken, Nehama Albilya, Eva Niyibizi, Miklosh Bala
July-September 2017, 10(3):146-150
DOI:10.4103/JETS.JETS_62_16  PMID:28855778
Introduction: Trauma in elderly population is frequent and is associated with significant mortality, not only due to age but also due to complicated factors such as the severity of injury, preexisting comorbidity, and incomplete general assessment. Our primary aim was to determine whether age, Injury Severity Score (ISS), and preexisting comorbidities had an adverse effect on the outcome in patients aged 65 years and above following blunt trauma. Methods: We included 1027 patients aged ≥65 years who were admitted to our Level I Trauma Center following blunt trauma. Patients' charts were reviewed for demographics, ISS, mechanism of injury, preexisting comorbidities, Intensive Care Unit and hospital length of stay, complications, and in-hospital mortality. Results: The mean age of injured patients was 78.8 ± 8.3 years (range 65–109). The majority of patients had mild injury severity (ISS 9–14, 66.8%). Multiple comorbidities (≥3) were found in 233 patients (22.7%). Mortality during the hospitalization stay (n = 35, 3.4%) was associated with coronary artery disease, renal failure, dementia, and warfarin use (P < 0.05). Chronic anticoagulation treatment was recorded in 13% of patients. The addition of a single comorbidity increased the odds of wound infection to 1.29 and sepsis to 1.25. Both age and ISS increased the odds of death as −1.08 and −2.47, respectively. Conclusions: Our analysis shows that age alone in elderly trauma population is not a robust measure of outcome, and more valuable predictors such as injury severity, preexisting comorbidities, and medications are accounted for adverse outcome. Trauma care in this population with special considerations should be tailored to meet their specific needs.
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Dual antiplatelet therapy and the severity risk of lower intestinal bleeding
Neal Carlin, Fady Asslo, Raymund Sison, Hamid Shaaban, Walid Baddoura, Faiza Manji, Joseph Depasquale
July-September 2017, 10(3):98-102
DOI:10.4103/JETS.JETS_110_15  PMID:28855770
Background: Dual antiplatelet (Plt) therapy with aspirin and clopidogrel is recommended for up to 1 year following acute coronary syndrome. Many of these cardiac patients are also on anithrombotic therapy like warfarin. Lower gastrointestinal bleeding (LGIB) is the main adverse event of this treatment. Aims: The main purpose of this study was to analyze the relationship of dual anti-Plt therapy and the risk of LGIB. Methods: Patients' electronic charts were reviewed to include a total of 19 variables, which included age, sex, ethnicity, daily use aspirin of any dose, daily use of clopidogrel, use of nonsteroidal anti-infl ammatory drugs (NSAIDs) at least twice in the last week prior to admission and the daily use of anticoagulants (warfarin, heparin), and were obtained from history and physical examination reports, lab transcripts and procedural reports. Settings/Design: A retrospective cohort study of the records of 3436 patients admitted to our hospital from January 1, 2009, to December 31, 2011, was evaluated. All the patients included were admitted through the emergency department with complaints of or relating to LGIB. The primary outcome studied was severe LGIB as defined by the requirement of at least two units of packed red blood cells and/or a decrease in the hematocrit of 20% or more or recurrent bleeding after 24 h of clinical stability with additional transfusions required. Other outcomes included surgical intervention. Statistical Methods/Analysis: Univariate analysis using t-test on continuous variables and Chi-square test on categorical variables were done before carrying out logistic regression analysis. Logistic regression analyses were conducted to measures of association between the variables and LGIB. Logistic regression analysis was not carried for surgical intervention and death because none of the variables was significant from univariate tests. Results: A total of 511 patients were found to have true LGIB. Among these subjects, 61 were shown to be on dual or multiple antithrombotic therapies. Further exploration revealed that while the use of multiple blood thinning agents may, in fact, pose a significant risk to overall LGIB, it did not significantly increase the risk for severe bleeding as outlined above. Conclusion: The use of multiple blood thinning agents does not significantly increase the risk for severe LGIB.
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Surgery goes social: The extent and patterns of social media utilization by major trauma, acute and critical care surgery societies
Jawad M Khalifeh, Haytham M. A. Kaafarani
July-September 2017, 10(3):103-110
DOI:10.4103/JETS.JETS_53_16  PMID:28855771
Context and Aims: The evolving influence of social media in trauma, acute, and critical care surgery (TACCS) cannot be ignored. We sought to investigate the extent and patterns of use of social networks by major regional, national and international TACCS societies. Materials and Methods: The two leading social networking sites, Facebook (FB) and Twitter (TW), were thoroughly examined for the presence of official accounts for each of the major TACCS societies. An official FB or TW account was defined as one which has a blue verified badge and/or is linked the society's official website. For societies with confirmed official accounts, the extent and patterns of use of the two platforms were systematically examined over a 2-week period through: (1) manual inspection of the societies' FB and TW pages, (2) the SQLite database containing downloaded samples of posts, and (3) the TW analytics database, symplur.com. Standardized social media metrics were calculated for each society. Posted content was categorized as being: (1) society news updates, (2) event announcements, or (3) general medical information. Results: From a total of 64 TACCS societies, only 27 (42%) had FB and/or TW accounts. Ten out of the 12 American societies had accounts compared to 13/39 of European, 2/9 of Australasian, and 0/2 of international societies. For the societies with social media presence, the mean numbers of monthly tweets and FB posts per society were 22 and 8, respectively. We summarize the FB and TW activity of the studied TACCS societies. Most tweets/posts were society news updates and event announcements intended to the society's constituents not the general public. A text cloud was constructed to summarize the major featured topics. Conclusion: Less than half of the TACCS societies are currently using social media; those that do are arguably underutilizing its potential. Non-American societies in particular lag behind in their use of social networking.
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Studying morbidity and predicting mortality in patients with blunt chest trauma using a novel clinical score
Priyadarshini Manay, Rajeev R Satoskar, V Karthik, Ram P Prajapati
July-September 2017, 10(3):128-133
DOI:10.4103/JETS.JETS_131_16  PMID:28855775
Background: A departmental audit in March 2015 revealed significant mortality rate of 40% in blunt chest trauma patients (much greater than the global 25%). A study was thus planned to study morbidity and predictors of mortality in blunt chest trauma patients admitted to our hospital. Methods: This study was a prospective observational study of 139 patients with a history of blunt chest trauma between June 2015 and November 2015 after the Institutional Ethics Committee approval in April 2015. The sample size was calculated from the prevalence rate in our institute from the past medical records. Results: The morbidity factors following blunt chest injuries apart from pain were need for Intensive Care Unit stay, mechanical ventilation, and pneumonia/acute respiratory distress syndrome. Significant predictors of mortality in our study were SpO2 <80 at the time of presentation, Glasgow coma scale ≤ 8, patients with four or more rib fractures, presence of associated head injury, Injury Severity Score >16, and need for mechanical ventilation. By calculating the likelihood ratios of each respiratory sign, a clinical score was devised. Conclusion: The modifiable factors affecting morbidity and mortality were identified. Mild to moderate chest injury due to blunt trauma is difficult to diagnose. The restoration of respiratory physiology has not only significant implications on recovery from chest injury but also all other injuries. It is our sincere hope that the score we have formulated will help reduce mortality and morbidity after further trials.
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POSITION PAPER
The 2017 International Joint Working Group white paper by INDUSEM, The Emergency Medicine Association and The Academic College of Emergency Experts on establishing standardized regulations, operational mechanisms, and accreditation pathways for education and care provided by the prehospital emergency medical service systems in India
Veronica Sikka, V Gautam, Sagar Galwankar, Randeep Guleria, Stanislaw P Stawicki, Lorenzo Paladino, Vivek Chauhan, Geetha Menon, Vijay Shah, RP Srivastava, BK Rana, Bipin Batra, OP Kalra, P Aggarwal, Sanjeev Bhoi, S Vimal Krishnan
July-September 2017, 10(3):154-161
DOI:10.4103/JETS.JETS_7_17  PMID:28855780
The government of India has done remarkable work on commissioning a government funded prehospital emergency ambulance service in India. This has both public health implications and an economic impact on the nation. With the establishment of these services, there is an acute need for standardization of education and quality assurance regarding prehospital care provided. The International Joint Working Group has been actively involved in designing guidelines and establishing a comprehensive framework for ensuring high-quality education and clinical standards of care for prehospital services in India. This paper provides an independent expert opinion and a proposed framework for general operations and administration of a standardized, national prehospital emergency medical systems program. Program implementation, operational details, and regulations will require close collaboration between key stakeholders, including local, regional, and national governmental agencies of India.
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ORIGINAL ARTICLES
Correlation of venous lactate and time of death in emergency department patients with noncritical lactate levels and mortality from trauma
Ashika Jain, Adam Aluisio, Bonny J Baron, Richard Sinert, Saman Sarraf, Eric Legome, Valery Roudnitsky, Leon Boudourakis, Shahriar Zehtabchi
July-September 2017, 10(3):93-97
DOI:10.4103/JETS.JETS_68_16  PMID:28855769
Background: Serum venous lactate (LAC) levels help guide emergency department (ED) resuscitation of patients with major trauma. Critical LAC level (CLAC, ≥4.0 mmol/L) is associated with increased disease severity and higher mortality in injured patients. The characteristics of injured patients with non-CLAC (NCLAC) (<4.0 mmol/L) and death have not been previously described. Objectives: (1) To describe the characteristics of patients with venous NCLAC and death from trauma. (2) To assess the correlation of venous NCLAC with time of death. Methods: A retrospective cohort study at an urban teaching hospital between 9/2011 and 8/2014. Inclusion: All trauma patients (all ages) who presented to the ED with any injury and met all criteria: (1) Venous LAC drawn at the time of arrival that resulted in an NCLAC level; (2) were admitted to the hospital; (3) died during their hospitalization. Exclusion: CLAC. Outcome: Correlation of NCLAC and time of death. Data were extracted from an electronic medical record by trained data abstractors using a standardized protocol. Cross-checks were performed on 10% of data entries and inter-observer agreement was calculated. Data were explored using descriptive statistics and Kaplan–Meier curves were created to define survival estimates. Data are presented as percentages with 95% confidence interval (CI) for proportions and medians with quartiles for continuous variables. Kaplan–Meier curves with differences in time to events based on LAC are used to analyze the data. Results: A total of 60 patients met the inclusion criteria. The median age was 52 years (quartiles: 30, 75) and 73% were male (age range 2–92). The median LAC in the overall cohort was 1.9 mmol/L (quartiles: 1.5, 2.1). Sixteen patients (27%) died during the first 24 h with 5 (31%) due to intracranial hemorrhage. The median survival time was 5.6 days (134.4 h) (95% CI: 2.3–12.6). Conclusions: In trauma patients with NCLAC who died during the index hospitalization, the median survival time was 5.6 days, approximately one-third of patients died within the first 24 h. These findings indicate that relying on a triage NCLAC level alone may result in underestimating injury severity and subsequent morbidity and mortality.
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Effectiveness and safety of polygeline in patients with hypovolemia due to trauma
Ajai Singh, Sabir Ali, Rohita Shetty
July-September 2017, 10(3):116-120
DOI:10.4103/JETS.JETS_120_16  PMID:28855773
Background: This retrospective study examined the effectiveness and safety of polygeline in adult patients with hypovolemia due to traumatic injury. Materials and Methods: Polygeline was administered after evaluating the amount of blood loss and estimating hematological and biochemical parameters. Changes in vital signs, serum electrolytes, arterial pH, and serum lactate were evaluated. The safety was evaluated by recording the adverse events if any. Results: Sixty patients with the mean age 37.5 ± 11.26 years were included in the study. All patients had blood loss <20%. The mean total polygeline administered was 1025.0 ± 464.18 ml. Blood transfusion was required in 3.33% of patients. Diastolic, systolic, and mean arterial blood pressure and pulse rate significantly increased after 1 h of polygeline administration (P < 0.0001). There was a trend toward increase in urine output (P = 0.0715) after 1 h. The improvement in vital parameters was consistent at 6, 14, and 18 h after administration of polygeline. Arterial pH significantly increased from 7.2 ± 0.12 to 7.3 ± 0.11 after 1 h of administration (P < 0.0001) and was consistent till 24 h (P = 0.035). Blood lactate decreased after 1 h (P < 0.0001). Changes in laboratory parameters were not clinically significant. After mean duration hospital stay of 10.5 ± 4.63 days all patients were discharged without any clinically significant abnormality or adverse event. Conclusion: Polygeline improved hemodynamic stability in patients with hypovolemia due to traumatic injury. The improvement was seen within 1 h (golden hour) of polygeline administration and maintained consistently. Polygeline can be safely administered to patients with traumatic injury to improve hemodynamic parameters and achieve stability.
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CASE SERIES
Trauma team activation: Not just for trauma patients
Phoenix Vuong, Jason Sample, Mary Ellen Zimmermann, Pierre Saldinger
July-September 2017, 10(3):151-153
DOI:10.4103/JETS.JETS_147_16  PMID:28855779
Specialized trauma teams have been shown to improve outcomes in critically injured patients. At our institution, an the American College of Surgeons Committee on trauma level I Trauma center, the trauma team activation (TTA) criteria includes both physiologic and anatomic criteria, but any attending physician can activate the trauma team at their discretion outside criteria. As a result, the trauma team has been activated for noninjured patients meeting physiologic criteria secondary to nontraumatic hemorrhage. We present two cases in which the trauma team was activated for noninjured patients in hemorrhagic shock. The utilization of the TTA protocol and subsequent management by the trauma team are reviewed as we believe these were critical factors in the successful recovery of both patients. Beyond the primary improved survival outcomes of severely injured patients, trauma center designation has a “halo effect” that encompasses patients with nontraumatic hemorrhage.
  2,738 15 -
EDITORIAL
Whats new in emergencies trauma and shock? Age and trauma: Geriatric trauma patients and geriatric trauma ward services
Christian Zeckey, Christian Kammerlander
July-September 2017, 10(3):89-90
DOI:10.4103/0974-2700.212495  PMID:28855767
  2,612 16 -
ORIGINAL ARTICLES
Studying the variability in patient inflow and staffing trends on Sundays versus other days in the academic emergency department
KT Madavan Nambiar, Nisanth Menon Nedungalaparambil, Ottapura Prabhakaran Aslesh
July-September 2017, 10(3):121-127
DOI:10.4103/JETS.JETS_139_16  PMID:28855774
Background: Resource limitation, staff deficiency, and variability in patient inflow contribute to emergency department (ED) overcrowding, associated with delayed care, poor care, and poor patient outcomes. This study seeks to describe and analyze patient inflow variability and staffing trends on Sundays versus other days in a tertiary academic ED from South India. Methods: Patient inflow and staffing data for 2 years were collected from hospital records, cross-checked, and statistically analyzed using Epi Info 7.0. Results: Significant increase in patient inflow (45.6%) was noted on Sundays compared to other days (155.9 [95% confidence interval (CI): 152.75–159.05] vs. 107.1 [95% CI: 105.98–108.22]; P< 0.001), with higher inflow in the morning shifts (67.4 [95% CI: 65.41–69.45] vs. 32.1 [95% CI: 31.45–32.70]; P< 0.001). All categories of ED staff were deficient across all shifts (2.1 [95% CI: 2.05–2.15] tier-2 physicians, 4.9 [95% CI: 4.86–4.94] nurses, and 1.9 [95% CI: 1.88–1.92] nurse assistants on an average), especially tier-1 physicians (0.3 [95% CI: 0.24–0.36] on Sundays and 0.5 [95% CI: 0.48–0.52] on other days; P< 0.001). Patient-per-hour (PPH)-per-provider based on patient arrival rate was generally high. PPH per tier-1 physician was the highest, being 10.6 (95% CI: 9.95–11.14) versus 5.4 (95% CI: 5.26–5.59; P< 0.001) in the morning and 7.2 (95% CI: 6.95–7.45) versus 6.6 (95% CI: 6.43–6.74; P = 0.08) in the evening shifts on Sundays and other days, respectively. Conclusions: There were deficiencies in all categories of ED staff on all days, and this was pronounced on Sundays due to significantly higher patient inflow. Inadequate ED staffing, especially due to a significant dearth of tier-1 physicians is a pointer toward quality compromise in developing EDs. Authors recommend adequate staff deployment in developing EDs for optimum quality care. This should be implemented such that staffing is based on expected patient inflow so that a PPH-per-provider goal of 2.5 is targeted across all shifts.
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EXPERT COMMENTARY
Developing emergency and trauma systems internationally: What is really needed for better outcomes?
Mazen J El Sayed
July-September 2017, 10(3):91-92
DOI:10.4103/JETS.JETS_63_16  PMID:28855768
  2,238 16 -
LETTERS TO EDITOR
An evolving difficult airway
N Midhun Mohan, SM Linu
July-September 2017, 10(3):164-165
DOI:10.4103/JETS.JETS_41_17  PMID:28855783
  2,114 15 -
A pregnant woman with pneumomediastinum after tooth treatment
Kouhei Ishikawa, Kazuhiko Omori, Hiromichi Ohsaka, Youichi Yanagawa
July-September 2017, 10(3):162-163
DOI:10.4103/JETS.JETS_28_17  PMID:28855781
  1,814 15 -
A case of tetraplegia after Proteus mirabilis infection
Kei Jitsuiki, Kouhei Ishikawa, K Kazuhiko Omori, Youichi Yanagawa
July-September 2017, 10(3):163-164
DOI:10.4103/JETS.JETS_4_17  PMID:28855782
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