Showing papers in "Journal of Emergencies, Trauma, and Shock in 2012"

Sonographic diagnosis of pneumothorax

Abstract: 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.

Hemostatic resuscitation with plasma and platelets in trauma.

Abstract: Background: Continued hemorrhage remains a major contributor of mortality in massively transfused patients and controversy regarding the optimal management exists although recently, the concept of hemostatic resuscitation, i.e., providing large amount of blood products to critically injured patients in an immediate and sustained manner as part of an early massive transfusion protocol has been introduced. The aim of the present review was to investigate the potential effect on survival of proactive administration of plasma and/or platelets (PLT) in trauma patients with massive bleeding. Materials and Methods: English databases were searched for reports of trauma patients receiving massive transfusion (10 or more red blood cell (RBC) within 24 hours or less from admission) that tested the effects of administration of plasma and/or PLT in relation to RBC concentrates on survival from January 2005 to November 2010. Comparison between highest vs lowest blood product ratios and 30-day mortality was performed. Results: Sixteen studies encompassing 3,663 patients receiving high vs low ratios were included. This meta-analysis of the pooled results revealed a substantial statistical heterogeneity (I 2 = 58%) and that the highest ratio of plasma and/or PLT or to RBC was associated with a significantly decreased mortality (OR: 0.49; 95% confidence interval: 0.43-0.57; P<0.0001) when compared with lowest ratio. Conclusion: Meta-analysis of 16 retrospective studies concerning massively transfused trauma patients confirms a significantly lower mortality in patients treated with the highest fresh frozen plasma (FFP) and/or PLT ratio when compared with the lowest FFP and/or PLT ratio. However, optimal ranges of FFP: RBC and PLT : RBC should be established in randomized controlled trials.

Point-of-care ultrasound in critically ill patients: Where do we stand?

Abstract: Experience over the last 25 years has shown that point-of-care ultrasound is a very useful tool when used by nonradiologists. Its value will be optimized by understanding its limitations and by adopting a focused binary decision making approach to answer specific questions without going into detailed radiological studies. Point-of-care ultrasound became an extension of the clinical examination. There are extensive efforts trying to design low-cost portable ultrasound systems by changing the transducer design, the transmission and reception circuitry needs, or the beam forming algorithms which may lead to horizontal expansion of the use of reliable non expensive portable ultrasound machines. The successful story of using ultrasound by nonradiologists, the advanced technology, and the refinement of the educational methods will encourage future clinicians to use ultrasound in their domains.

Strategies for coping with stress in emergency medicine: Early education is vital

Abstract: Introduction: Physician burnout has received considerable attention in the literature and impacts a large number of emergency medicine physicians, but there is no standardized curriculum for wellness in resident education. A culture change is needed to educate about wellness, adopt a preventative and proactive approach, and focus on resiliency. Discussion: We describe a novel approach to wellness education by focusing on resiliency rather than the unintended endpoint of physician burnout. One barrier to adoption of wellness education has been establishing legitimacy among emergency medicine (EM) residents and educators. We discuss a change in the language of wellness education and provide several specific topics to facilitate the incorporation of these topics in resident education. Conclusion: Wellness education and a culture of training that promotes well-being will benefit EM residents. Demonstrating the impact of several factors that positively affect emergency physicians may help to facilitate alert residents to the importance of practicing activities that will result in wellness. A change in culture and focus on resiliency is needed to adequately address and optimize physician self-care.

The role of bedside ultrasound in the diagnosis of pericardial effusion and cardiac tamponade

Abstract: This review article discusses two clinical cases of patients presenting to the emergency department with pericardial effusions. The role of bedside ultrasound in the detection of pericardial effusions is investigated, with special attention to the specific ultrasound features of cardiac tamponade. Through this review, clinicians caring for patients with pericardial effusions will learn to rapidly diagnose this condition directly at the bedside. Clinicians will also learn to differentiate between simple pericardial effusions in contrast to more complicated effusions causing cardiac tamponade. Indications for emergency pericardiocentesis are covered, so that clinicians can rapidly determine which group of patients will benefit from an emergency procedure to drain the effusion.

The role of ultrasound in the management of intestinal obstruction.

Abstract: Intestinal obstruction (IO) is a common cause of acute abdominal pain. The recent increased use of sonography in the initial evaluation of abdominal pain has made point-of-care ultrasound a valuable tool for the diagnosis of IO. Sonography is as sensitive, but more specific, than plain abdominal X-ray in the diagnosis of IO. Point-of-care ultrasound can answer specific questions related to IO that assist the acute care physician in critical decision making. Sonography can also help in the resuscitation of patients by serial measurement of the IVC diameter. We review the sonographic findings of IO and the role of point-of-care ultrasound in the management of patients having IO.

Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians.

Abstract: Background: Patients require procedural sedation and analgesia (PSA) for the treatment of acute traumatic injuries. PSA has complications. Ultrasound (US) guided peripheral nerve block is a safe alternative. Aim: Ultrasound guided nerve blocks for management of traumatic limb emergencies in Emergency Department (ED). Setting and Design: Prospective observational study conducted in ED. Materials and Methods: Patients above five years requiring analgesia for management of limb emergencies were recruited. Emergency Physicians trained in US guided nerve blocks performed the procedure. Statistical analysis: Effectiveness of pain control, using visual analogue scale was assessed at baseline and at 15 and 60 minutes after the procedure. Paired t test was used for comparison. Results: Fifty US guided nerve blocks were sciatic- 4 (8%), femoral-7 (14%), brachial- 29 (58%), median -6 (12%), and radial 2 (4%) nerves. No patients required rescue PSA. Initial median VAS score was 9 (Inter Quartile Range [IQR] 7-10) and at 1 hour was 2(IQR 0-4). Median reduction in VAS score was 7.44 (IQR 8-10(75%), 1-2(25%) (P=0.0001). Median procedure time was 9 minutes (IQR 3, 12 minutes) and median time to reduction of pain was 5 minutes (IQR 1,15 minutes). No immediate or late complications noticed at 3 months. Conclusion: Ultrasound-guided nerve blocks can be safely and effectively performed for upper and lower limb emergencies by emergency physicians with adequate training.

Evaluation of the revised trauma and injury severity scores in elderly trauma patients.

Abstract: Background: Severity-of-illness scoring systems have primarily been developed for, and validated in, younger trauma patients Aims: We sought to determine the accuracy of the injury severity score (ISS) and the revised trauma score (RTS) in predicting mortality and hospital length of stay (LOS) in trauma patients over the age of 65 treated in our emergency department (ED) Materials and Methods: Using the Illinois Trauma Registry, we identified all patients 65 years and older treated in our level I trauma facility from January 2004 to November 2007 The primary outcome was death; the secondary outcome was overall hospital length of stay (LOS) We measured associations between scores and outcomes with binary logistic and linear regression Results: A total of 347 patients, 65 years of age and older were treated in our hospital during the study period Median age was 76 years (IQR 69-82), with median ISS 13 (IQR 8-17), and median RTS 78 (IQR 71-78) Overall mortality was 24% A higher value for ISS showed a positive correlation with likelihood of death, which although statistically significant, was numerically small (OR=110, 95% CI 106 to 113, P<0001) An elevated RTS had an inverse correlation to likelihood of death that was also statistically significant (OR=048, 95% CI 039 to 058, P<0001) Total hospital LOS increased with increasing ISS, with statistical significance decreasing at the highest levels of ISS, but an increase in RTS not confirming the predicted decrease in total hospital LOS consistently across all ranges of RTS Conclusions: The ISS and the RTS were better predictors of mortality than hypothesized, but had limited correlation with hospital LOS in elderly trauma patients Although there may be some utility in these scores when applied to the elderly population, caution is warranted if attempting to predict the prognosis of patients

Pediatric trauma in sub-Saharan Africa: Challenges in overcoming the scourge.

Abstract: All over the world, pediatric trauma has emerged as an important public health problem. It accounts for the highest mortality in children and young adults in developed countries. Reports from Africa on trauma in the pediatric age group are few and most have been single center experience. In many low-and middle-income countries, the death rates from trauma in the pediatric age group exceed those found in developed countries. Much of this mortality is preventable by developing suitable preventive measures, implementing an effective trauma system and adapting interventions that have been implemented in developed countries that have led to significant reduction in both morbidity and mortality. This review of literature on the subject by pediatric and orthopedic surgeons from different centers in Africa aims to highlight the challenges faced in the care of these patients and proffer solutions to the scourge.

Using thrombolytics in frostbite injury

Abstract: Until recently, the treatment of frostbite injuries has been limited to supportive care only, with mediocre outcomes. The use of thrombolytic therapy has been presented in a limited fashion in the literature since 2005. This case study describes the work-up and treatment of a patient with severe frostbite injury who received tPA. We then discuss thrombolytic therapy in more detail, with particular attention to the two studies outlining different treatment regimens.

Hemorrhagic shock: The "physiology approach".

Abstract: A shift of approach from 'clinics trying to fit physiology' to the one of 'physiology to clinics', with interpretation of the clinical phenomena from their physiological bases to the tip of the clinical iceberg, and a management exclusively based on modulation of physiology, is finally surging as the safest and most efficacious philosophy in hemorrhagic shock. ATLS® classification and recommendations on hemorrhagic shock are not helpful because antiphysiological and potentially misleading. Hemorrhagic shock needs to be reclassified in the direction of usefulness and timing of intervention: in particular its assessment and management need to be tailored to physiology.

Maximum surgical blood ordering schedule in a tertiary trauma center in northern India: A proposal

Abstract: Context: Over ordering of blood is a common practice in elective surgical practice. Considerable time and effort is spent on cross-matching for each patient undergoing a surgical procedure. Aims: The aim of this study was to compile and review the blood utilization for two key departments (Neurosurgery and Surgery) in a level 1 trauma center. A secondary objective was to formulate a rational blood ordering practice for elective procedures for these departments. Materials and Methods: Analysis of prospectively compiled blood bank records of the patients undergoing elective surgical, neurosurgical procedures was carried out between April 2007 and March 2009. Indices such as the cross-matched/transfused ratio (C/T ratio), transfusion index and transfusion probability were calculated. The number of red cell units required for each procedure was calculated using the equation proposed by Nuttall et al, using preoperative hemoglobin and postoperative hemoglobin for each elective surgical procedure. Results: There were 252 surgery patients (age range: 2-80 years) in the study. One thousand and eighty-eight units of blood were cross-matched, 432 were transfused (CT ratio 2.5). 44.0% patients did not require transfusion during entire hospital stay. Three (50%) elective procedures had CT ratio >2.5and 4 (66.6%) elective procedures had TI 2.5, with five of them exceeding 4. In procedures like spinal instrumentation the CT ratio was <2.5 and 10 (90.9%) of elective procedures had TI <0.5. Conclusions: In this study 40% and 22% of cross-matched blood was being utilized for elective general surgery and neurosurgical procedures, respectively. The calculated required blood units for all elective Trauma surgery procedures were more than 2 units. The calculated required blood units were less than 0.5 units in four of the 11 neurosurgical procedures, and hence only one unit should be arranged for them. It is crucial for every institutional blood bank to formulate a blood ordering schedule. Regular auditing and periodic feedbacks are also vital to improve the blood utilization practices.

Venous thromboembolic events in isolated severe traumatic brain injury.

Abstract: Objective: The purpose of this study was to investigate the effect of prophylactic anticoagulation on the incidence of venous thromboembolic events (VTE) in patients suffering from isolated severe traumatic brain injury (TBI). Materials and Methods: Retrospective matched case-control study in adult patients sustaining isolated severe TBI (head AIS ≥3, with extracranial AIS ≤2) receiving VTE prophylaxis while in the surgical intensive care unit from 1/2007 through 12/2009. Patients subjected to VTE prophylaxis were matched 1:1 by age, gender, glasgow coma scale (GCS) score at admission, presence of hypotension on admission, injury severity score, and head abbreviated injury scale (AIS) score, with patients who did not receive chemical VTE prophylaxis. The primary outcome measure was VTE. Secondary outcomes were SICU and hospital length of stay (HLOS), adverse effects of anticoagulation, and mortality. Results: After propensity matching, 37 matched pairs were analysed. Cases and controls had similar demographics, injury characteristics, rate of craniotomies/craniectomies, SICU LOS, and HLOS. The median time of commencement of VTE prophylaxis was 10 days. The incidence of VTE was increased 3.5-fold in the controls compared to the cases (95% CI 1.0-12.1, P =0.002). The mortality was higher in patients who did not receive anticoagulation (19% vs. 5%, P =0.001). No adverse outcomes were detected in the anticoagulated patients. Conclusion: Prophylactic anticoagulation decreases the overall risk for clinically significant VTE in patients with severe isolated TBI. Prospective validation of the timing and safety of chemical VTE prophylaxis in these instances is warranted.

Cleistanthus collinus poisoning

Abstract: Cleistanthus collinus, a toxic shrub, is used for deliberate self-harm in rural South India. MEDLINE (PUBMED) and Google were searched for published papers using the search/ MeSH terms "Cleistanthus collinus," "Euphorbiaceae," "Diphyllin," "Cleistanthin A," Cleistanthin B" and "Oduvanthalai." Non-indexed journals and abstracts were searched by tracing citations in published papers. The toxic principles in the leaf include arylnaphthalene lignan lactones - Diphyllin and its glycoside derivatives Cleistanthin A and B. Toxin effect in animal models demonstrate neuromuscular blockade with muscle weakness, distal renal tubular acidosis (dRTA) and type 2 respiratory failure with conflicting evidence of cardiac involvement. Studies suggest a likely inhibition of thiol/thiol enzymes by the lignan-lactones, depletion of glutathione and ATPases in tissues. V-type H+ ATPase inhibition in the renal tubule has been demonstrated. Mortality occurs in up to 40% of C. collinus poisonings. Human toxicity results in renal tubular dysfunction, commonly dRTA, with resultant hypokalemia and normal anion gap metabolic acidosis. Aggressive management of these metabolic derangements is crucial. Acute respiratory distress syndrome (ARDS) is seen in severe cases. Cardiac rhythm abnormalities have been demonstrated in a number of clinical studies, though the role of temporary cardiac pacemakers in reducing mortality is uncertain. Consumption of decoctions of C. collinus leaves, hypokalemia, renal failure, severe metabolic acidosis, ARDS and cardiac arrhythmias occur in severe poisonings and predict mortality. Further study is essential to delineate mechanisms of organ injury and interventions, including antidotes, which will reduce mortality.

Evaluation of amylase and lipase levels in blunt trauma abdomen patients

Abstract: Background: There are studies to prove the role of amylase and lipase estimation as a screening diagnostic tool to detect diseases apart from acute pancreatitis However, there is sparse literature on the role of serum and urine amylase, lipase levels, etc to help predict the specific intra-abdominal injury after blunt trauma abdomen (BTA) Aim: To elucidate the significance of elevation in the levels of amylase and lipase in serum and urine samples as reliable parameters for accurate diagnosis and management of blunt trauma to the abdomen Materials and Methods: A prospective analysis was done on the trauma patients admitted in Jai Prakash Narayan Apex Trauma Center, AIIMS, with blunt abdomen trauma injuries over a period of six months Blood and urine samples were collected on days 1, 3, and 5 of admission for the estimation of amylase and lipase, liver function tests, serum bicarbonates, urine routine microscopy for red blood cells, and complete hemogram Clinical details such as time elapsed from injury to admission, type of injury, trauma score, and hypotension were noted Patients were divided into groups according to the single or multiple organs injured and according to their hospital outcome (dead/discharged) Wilcoxon's Rank sum or Kruskal-Wallis tests were used to compare median values in two/three groups Data analysis was performed using STATA 110 statistical software Results: A total of 55 patients with median age 26 (range, 6-80) years, were enrolled in the study Of these, 80% were males Surgery was required for 20% of the patients Out of 55 patients, 42 had isolated single organ injury [liver or spleen or gastrointestinal tract (GIT) or kidney] Patients with pancreatic injury were excluded In patients who suffered liver injuries, urine lipase levels on day 1, urine lipase/amylase ratio along with aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) on days 1, 3, and 5, were found to be significant Day 1 serum amylase, AST, ALT, hemoglobin, and hematocrit levels were found significant in patients who had spleen injury Serum amylase levels on day 5 and ALP on day 3 were significant in patients who had GIT injury Urine amylase levels on day 5 were found to be statistically significant in patients who had kidney injury In patients with isolated organ injury to the liver or spleen, the levels of urine amylase were elevated on day 1 and gradually decreased on days 3 and 5, whereas in patients with injury to GIT, the urine amylase levels were observed to gradually increase on days 3 and 5 Conclusion: Although amylase and lipase levels in the serum and urine are not cost-effective clinical tools for routine diagnosis of extra-pancreatic abdominal injuries in BTA, but when coupled with other laboratory tests such as liver enzymes, they may be significant in predicting specific intra-abdominal injury

Complications of bystander cardiopulmonary resuscitation for unconscious patients without cardiopulmonary arrest

Abstract: Background: Insufficient knowledge of the risks and complications of cardiopulmonary resuscitation (CPR) may be an obstructive factor for CPR, however, particularly for patients who are not clearly suffering out of hospital cardiopulmonary arrest (OH-CPA). The object of this study was to clarify the potential complication, the safety of bystander CPR in such cases. Materials and Methods: This study was a population-based observational case series. To be enrolled, patients had to have undergone CPR with chest compressions performed by lay persons, had to be confirmed not to have suffered OHCPA. Complications of bystander CPR were identified from the patients' medical records and included rib fracture, lung injury, abdominal organ injury, and chest and/or abdominal pain requiring analgesics. In our emergency department, one doctor gathered information while others performed X-ray and blood examinations, electrocardiograms, and chest and abdominal ultrasonography. Results: A total of 26 cases were the subjects. The mean duration of bystander CPR was 6.5 minutes (ranging from 1 to 26). Nine patients died of a causative pathological condition and pneumonia, and the remaining 17 survived to discharge. Three patients suffered from complications (tracheal bleeding, minor gastric mucosal laceration, and chest pain), all of which were minimal and easily treated. No case required special examination or treatment for the complication itself. Conclusion: The risk and frequency of complications due to bystander CPR is thought to be very low. It is reasonable to perform immediate CPR for unconscious victims with inadequate respiration, and to help bystanders perform CPR using the T-CPR system.

Presentation and outcome of traumatic spinal fractures.

Abstract: Background: Motor vehicle crashes and falls account for most of the spine fractures with subsequent serious disability. Aim: To define the incidence, causes, and outcome of spinal fractures. Materials and Methods: Data were collected retrospectively from trauma registry database of all traumatic spinal injuries admitted to the section of trauma surgery in Qatar from November 2007 to December 2009. Results: Among 3712 patients who were admitted to the section of trauma surgery, 442 (12%) injured patients had spinal fractures with a mean age of 33.2 ± 12 years. The male to female ratio was 11.6:1. Motor vehicle crashes (36.5%) and falls from height (19.3%) were the leading causes of cervical injury (P = 0.001). The injury severity score ranged between 4 and 75. Nineteen percent of cases with cervical injury had thoracic injury as well (P = 0.04). Lumber injury was associated with thoracic injury in 27% of cases (P < 0.001). Combined thoracic and lumber injuries were associated with cervical injury in 33% of cases (P < 0.001). The total percent of injuries associated with neurological deficit was 5.4%. Fifty-three cases were managed surgically for spine fractures; 14 of them had associated neurological deficits. Overall mortalityrate was 5%. Conclusions: Spine fractures are not uncommon in Qatar. Cervical and thoracic spine injuries carry the highest incidence of associated neurological deficit and injuries at other spinal levels. Young males are the most exposed population that deserves more emphasis on injury prevention programs in the working sites and in enforcement of traffic laws.

Incarcerated recurrent Amyand's hernia

Abstract: Amyand's hernia is a rarity and a recurrent case is extremely rare. A 71-year-old male with a previous history of right inguinal hernia repair presented to the emergency department with a 1-day history of pain in the right groin. A physical examination revealed a nonreducible right inguinal hernia. A computed tomography scan showed a 1.3-cm appendix with surrounding inflammation within a right inguinal hernia. An emergent right groin exploration revealed an incarcerated and injected non-perforated appendix and an indirect hernia. Appendectomy was performed through the groin incision, and the indirect hernia defect was repaired with a biological mesh (Flex-HD). We hereby present this unique case - the first reported case of recurrent Amyand's hernia and a literature review of this anatomical curiosity.

Ventricular septal defect following blunt chest trauma

Abstract: We present a 32-year-old male with ventricular septal defect (VSD) following blunt chest trauma. Traumatic VSD is a rare but potentially life-threatening injury, the severity, course and presentation of which are variable. While the diagnosis of myocardial injury may be challenging, cardiac troponins are useful as a screening and diagnostic test. The proposed pathophysiological mechanisms in the development of traumatic VSD are early mechanical rupture and delayed inflammatory rupture. We conducted a literature review to investigate the pathogenesis, distribution of patterns of presentation, and the associated prognoses in patients with VSD following blunt chest trauma. We found that traumatic VSDs diagnosed within 48 hours were more likely to be severe, require emergency surgery and were associated with a higher mortality. Children with traumatic VSDs had an increased mortality risk. Smaller lesions may be managed conservatively but should be followed up to detect late complications. In both groups elective repair was associated with a good outcome.

Correlation of C-reactive protein to severity of symptoms in acute influenza A infection.

Abstract: Background: Currently there is no objective measure to determine disease severity in patients with acute influenza infection. During acute viral infections, C-reactive protein (CRP) has been shown to be elevated. Aim: To study the relationship between the symptoms of acute influenza A infection and correlate them with the level of inflammation as measured by serum CRP levels. Settings and Design: Prospective study. Materials and Methods: We enrolled a convenience sample of adults presenting to an urban academic emergency department (ED), who had positive Enzyme-linked immunosorbent assay detection of the influenza A antigen. The subjects were excluded if they had immunosuppression, liver disease or were currently taking antiviral medication. A previously validated severity of symptom (SOS) score was calculated by asking the participants to record the severity of seven symptoms associated with influenza infection. The subjects had the serum C-reactive protein (CRP) levels tested during their ED visit. Statistical Analysis: A linear regression model was used with CRP as a predictor of the SOS score. Pearson's product-moment coefficient was used to measure the dependence between the two quantities. Results: Thirty-two subjects were enrolled from January through March 2009, and of those, eight patients were excluded from the analysis, leaving 24 study subjects: 58% were women, of ages 18 to 63 years, with a mean age of 31 years (95% CI 25, 37). The mean SOS score was 14.1 ranging from 6 to 21 (95% CI 12.6, 26.4). The mean CRP score was 24.6 ranging from 0 to 64.7 (95% CI 15.8, 33.4). The correlation coefficient between the SOS score and CRP levels was r = 0.65 (P=0.00056). Conclusion: The severity of symptoms associated with acute influenza A infection correlateswith the serum CRP levels.

Teamwork in the trauma room evaluation of a multimodal team training program

Abstract: Introduction: Poor teamwork leads to preventable medical errors, and thus negatively impacts medical care. One way to improve teamwork is training. A multimodality team training program was designed to impact the attitudes and behavior of first-year residents who will encounter medical situations in the trauma room. The training program included low-fidelity role plays, lectures, and high-fidelity simulation with feedback. Materials and Methods: The training program was a one-day workshop that was conducted twice, once for each of the two groups over two days at the beginning of the academic year in July. A total of 41 first-year interns (10 Emergency Medicine and 31 Surgery) were recruited for participation. Participants completed a Situational judgment test (SJT) on trauma teamwork before training. The training began with a low-fidelity simulation that served as an icebreaker to team concepts. Subsequently, a lecture with discussion provided key points regarding teamwork in the trauma room. A high-fidelity simulation then allowed participation in one of four trauma room scenarios with medical expert debriefing. The course concluded with a course summary and an assessment of participant attitudes regarding training along with a second administration of SJT. Results: Participant reactions to the training were positive overall. Results of SJT showed a positive effect for team training in three of the four possible comparisons. Conclusion: The program was well received by the residents. Results suggest that a comprehensive training approach using role play, lecture, and simulation can positively affect behavioral choices for teamwork in the trauma room.

Different causes of referral to ophthalmology emergency room.

Abstract: Background: Eye-related complaints compose approximately 1-6% of complaints of patients referring to general emergency ward around the world. Eye injuries are the most common cause of referral to eye emergency ward. To understand the impact of eye injuries in Iran and to plan preventive strategies, it is important to understand the complete magnitude of the problem with regard to true population-based data and standard reproducible definitions. Aim: The main goal of this study was to identify the major causes of referrals to eye emergency ward in patients with eye-related complaints in an eye referral Hospital in Iran. Settings and Design: In a cross-sectional study, 3150 patients who referred to Farabi Hospital emergency ward, Tehran, Iran, from January to December 2007 were included in the study and their detailed information were recorded. Materials and Methods: The patients' demographic data, medical history and final diagnosis were recorded in a questionnaire. Results: The mean age of patients was 33.2±16.8 years and 2380 patients (75.6%) were males. While 299 patients (9.5%) were referred for non-urgent reasons, work-related injuries were the most common cause of referral (955 patients; 30.3%). In patients referred due to trauma (1950 patients), work-related injuries occurred in 955 patients (49%) and occurred accidentally (by chance) in 819 patients (42%). The majority of patients referred with traumatic injuries were males (1708 patients; 87.6% versus 242 patients; 12.4%). The most common etiologies of eye trauma (1950 patients) were metal filings (814 patients; 41.8%), blunt trauma (338 patients; 17.3%), fireworks (236 patients; 12.1%) and sharp objects (222 patients; 11.4%). Globe injury was diagnosed in 1865 patients (95.7%) of trauma cases. In patients referred due to non-traumatic reason (1200 patients), eye infection occurred in 482 patients (40.2%) and 299 patients (24.9%) were referred for non-urgent reasons. There was little difference between the frequency of non-trauma-related problems among genders (672 male patients; 56% versus 528 female patients; 44%). Conclusions: This study identified multiple risk factors whose presence significantly increases severity of an eye injury. Male gender, youth and unprotected eyes during high-risk activities such as sports and certain jobs are risk factors for eye injuries. In patients referred due to non-traumatic reasons, males and females are similar. Considerable proportion of non-trauma-related problems was due to eye infection, that one of the most important reasons may be connected to the increasing use of contact lenses in our target population. Thereupon, we need for further educative and preventive interventions at the level of general population.

Use of a furosemide drip does not improve earlier primary fascial closure in the open abdomen.

Abstract: Background: The furosemide drip (FD), in addition to improving volume overload respiratory failure, has been used to decrease fluid in attempts to decrease intra-abdominal and abdominal wall volumes to facilitate fascial closure. The purpose of this study is to evaluate the FD and the associated rate of primary fascial closure following trauma damage control laparotomy (DCL). Materials and Methods: From January 2004 to September 2008, a retrospective review from a single institution Trauma Registry of the American College of Surgeons dataset was performed. All DCLs greater than 24 h who had a length of stay for 3 or more days were identified. The study group (FD+) and control group (FD-) were compared. Demographic data including age, sex, probability of survival, red blood cell transfusions, initial lactate, and mortality were collected. Primary outcomes included primary fascial closure and primary fascial closure within 7 days. Secondary outcomes included total ventilator days and LOS. Results: A total of 139 patients met inclusion criteria: 25 FD+ and 114 FD-. The 25 FD+ patients received the drug at a median 4 days post DCL. Demographic differences between the groups were not significantly different, except that initial lactate was higher for FD- (1.7 vs 4.0; P=0.03). No differences were noted between groups regarding successful primary fascial closure (FD+ 68.4% vs FD- 64.0%; P=0.669), or closure within 7 days (FD+13.2% vs FD- 28.0%; P=0.066) of original DCL. FD+ patients suffered more open abdomen days (4 [2-7] vs 2 [1-4]; P=0.001). FD+ did not demonstrate an association with primary fascial closure [Odds ratio (OR) 1.5, 95% confidence interval (CI) 0.260-8.307; P=0.663]. FD+ patients had more ventilator days and longer Intensive Care Unit (ICU)/hospital LOS (P<0.01). Conclusion: FD use may remove excess volume; however, forced diuresis with an FD is not associated with an increased rate of primary closure after DCL. Further studies are warranted to identify ICU strategies to facilitate fascial closure in DCL.

Interval appendectomy in adults: A necessary evil?

Abstract: The management of appendiceal mass remains a matter of major controversy in the current literature. Currently, initial nonoperative management followed by interval appendectomy is favored over immediate appendicectomy. However, the necessity of doing an interval appendectomy has been questioned - is it a necessary evil? The present review revisits the above controversy, evaluates the current literature, assesses the need for interval appendectomy in adults, and provides recommendations.

Injury-related mortality audit in a regional trauma center at Puducherry, India

Abstract: BACKGROUND: There is an alarming trend of injuries leading to poor outcome of victims in India. OBJECTIVE: To study the profile of patients who died due to trauma and to identify factors involved in both pre-hospital and hospital care. MATERIALS AND METHODS: A hospital-based study was performed at a trauma center in Puducherry from June 2009 to May 2010. Patients who had at least one sign of life on admission and later died were included. The demographic characteristics, injury mechanism, nature and site of injury, influence of alcohol, pre-hospital time and care, distance traveled, number of referrals, time spent in study hospital, cause of death, and missed injuries revealed at post mortem were noted. RESULTS: Of the 204 fatal cases, most were between 25-65 years of age (77%); sustained injuries over weekends (36%) and between 4 pm and midnight (41%); had at least one halt in a medical facility before reaching definitive care (56%); and died within a week (63%). Adults (25-65 y) sustained most injuries (77%) on two wheelers. In those aged over 65 years, 79 percent were pedestrians. Road traffic injuries were responsible for 82 % of deaths; 16 percent were reportedly under the influence of alcohol at the time of injury. Mean delay from the time of accident to admission was 14.9 hours and median distance traveled was 30 kilometers. Head injury was the most common (66%) cause of death. Post mortem revealed skull fractures (37%), while missed injuries were noted in 8 percent, mostly involving the cervical spine and chest wall. CONCLUSION: The problem of trauma care needs to be addressed urgently in this part of southern India to reduce mortality and morbidity. Language: en

Ketotic hyperglycemia with movement disorder.

Abstract: Chorea, hemichorea-hemiballismus and severe partial seizures may be the presenting features of nonketotic hyperglycemia in older adults with type 2 diabetes, but cases in young adults with type 1 diabetes are rare. We hereby report a very rare case of diabetic ketosis with movement disorder in a young patient.

Who killed Rambhor?: The state of emergency medical services in India.

Abstract: In India, the healthcare delivery system starts up from the sub-center at the village level and reaches up to super specialty medical centers providing state of the art emergency medical services (EMS). These highest centers, located in big cities, are considered the last referral points for the patients from nearby cities and states. As the incidents of rail and road accidents have increased in recent years, the role of EMS becomes critical in saving precious lives. But when the facilities and management of these emergency centers succumbs before the patient, then the question arises regarding the adequate availability and quality of EMS. The death of an unknown common man, Rambhor, for want of EMS in three big hospitals in the national capital of India put a big question on the "health" of the emergency health services in India. The emergency services infrastructure seems inadequate and quality and timely provision of EMS to critical patients appears unsatisfactory. There is lack of emergency medicine (EM) specialists in India and also the postgraduation courses in EM have not gained foot in our medical education system. Creation of a Centralized Medical Emergency Body, implementation of management techniques, modification of medical curriculum, and fixing accountability are some of the few steps which are required to improve the EMS in India.

Broken tracheostomy tube: A fractured mandate.

Abstract: Tracheostomy is a common airway procedure for life support. This procedure is safe, although occasional early and late complications are known to occur. Fracture and hence aspiration of a tracheostomy tube in the tracheobronchial tree is a rare late complication, which can be potentially life threatening. Published reports of a fractured tracheostomy tube presenting as a foreign body in the tracheobronchial tree are few. The most common dislodged sites reported were the trachea and the right main bronchus, the inner flange in our patient was lodged in the trachea and the left main bronchus. Foreign-body aspiration is a serious medical emergency demanding timely recognition and prompt action as was successfully done in our patient. Therapeutic rigid bronchoscopic removal is the mainstay of treatment. A periodic review of the techniques of tracheostomy care including timely check-ups for signs of wear and tear can possibly eliminate such avoidable late complications.

Thermometry in children

Abstract: Accurate measurement of temperature is important for detection of fever and hypothermia in pediatric patients. Ideal temperature-measurement technique should be safe, easy, noninvasive, cost effective, time efficient, and should precisely reflect core body temperature. Pulmonary artery is the closest to hypothalamus and best reflects the core temperature. Other sites used are distal esophagus, urinary bladder and nasopharynx. All these methods are invasive and difficult to use in clinical practice. Amongst the noninvasive methods, rectal thermometry is considered to be the closest to core temperature, but it has its own drawbacks. With the current evidence available, tympanic artery thermometry for children more than 2 years of age and temporal artery thermometry in all age groups are taking precedence over other methods.