Journal of Emergencies, Trauma, and Shock
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   Table of Contents - Current issue
July-September 2021
Volume 14 | Issue 3
Page Nos. 121-192

Online since Thursday, September 30, 2021

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What's new in emergencies, trauma, and shock: Head Injury in anticoagulated patients – an enigma p. 121
Vivek Chauhan
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Acute and delayed intracranial hemorrhage in head-injured patients on warfarin versus direct oral anticoagulant therapy p. 123
Patrick G Hughes, Scott M Alter, Spencer W Greaves, Benjamin A Mazer, Joshua J Solano, Richard D Shih, Lisa M Clayton, Nhat Q Trinh, Lawrence Lottenberg, Mary J Hughes
Introduction: Direct oral anticoagulant (DOAC) use for thrombosis treatment and prophylaxis is a popular alternative to warfarin. This study compares rates of traumatic intracranial hemorrhage (ICH) for patients on anticoagulant therapies and the effect of combined anticoagulant and antiplatelet therapies. Methods: A retrospective observational study of trauma patients was conducted at two level I trauma centers. Patients aged ≥18 years with preinjury use of an anticoagulant (warfarin, rivaroxaban, apixaban, or dabigatran) who sustained a blunt head injury within the past day were included. Patients were evaluated by head CT to evaluate for ICH. Results: Three hundred and eighty-eight patients were included (140 on warfarin, 149 on a DOAC, and 99 on combined anticoagulant and antiplatelet therapies). Seventy-nine patients (20.4%) had an acute ICH, while 16 patients (4.1%) had a delayed ICH found on routine repeat CT. Those on combination therapy were not at increased risk of acute ICH (relative risk [RR] 0.90, confidence interval [CI]: 0.56–1.44; P > 0.5) or delayed ICH (RR 2.19, CI: 0.84–5.69; P = 0.10) compared to anticoagulant use only. Those on warfarin were at increased risk of acute ICH (RR 1.75, CI: 1.10–2.78, P = 0.015), but not delayed ICH (RR 0.99, CI 0.27–3.59, P > 0.5), compared to those on DOACs. No delayed ICH patients died or required neurosurgical intervention. Conclusion: Patients on warfarin had a higher rate of acute ICH, but not delayed ICH, compared to those on DOACs. Given the low rate of delayed ICH with no resultant morbidity or mortality, routine observation and repeat head CT on patients with no acute ICH may not be necessary.
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Pediatric mortality at pediatric versus adult trauma centers p. 128
Mazhar Khalil, Ghayth Alawwa, Frederique Pinto, Patricia A O'Neill
Introduction: Pediatric trauma centers (PTCs) were created to address the unique needs of injured children with the expectation that outcomes would be improved. However, prior studies to evaluate the impact of PTCs have had conflicting results. Our study was conducted to further clarify this question. We hypothesize that severely injured children ≤ 14 years of age have better outcomes at PTCs and that better survival may be due to higher emergency department (ED) survival rates than at adult trauma centers (ATCs). Methods: A retrospective analysis of severely injured children (ISS>15) ≤18 years of age entered into the National Trauma Data Bank (NTDB) between 2011 and 2012 was performed. Subjects were stratified into 2 age cohorts; young children (0-14 years) and adolescents (15-18 years). Primary outcomes were emergency department (ED) and in-patient (IP) mortality. Secondary outcomes included in-hospital complications, hospital and ICU length of stay, and ventilator days. Outcome differences were assessed using multilevel logistic and negative binomial regression analyses. Results: A total of 10,028 children were included. Median ISS was 22 (Interquartile range 17-29). Adjusting for confounders on multivariate analysis, children ≤ 14 had lower odds of ED (0.42[CI 0.25-0.71], p=0.001) and IP mortality (0.73[CI 0.5-0.9], p=0.02) at PTCs. There were no differences in odds of ED mortality (0.81 [CI 0.5-1.3], p=0.4) or IP mortality (1.01 [CI 0.8-1.2], p=0.88) for adolescents between centers. There were no differences in complication rates between PTCs and ATCs (OR 0.86 [CI 0.69-1.06], p=1.7) but children were more likely to be discharged to home and have more ICU and ventilator free days if treated at a PTC. Conclusion: Young children but not adolescents have better ED survival at PTCs compared to ATCs.
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Traumatic optic neuropathy management: A Survey assessment of current practice patterns p. 136
Colin Bacorn, Megan V Morisada, Raj D Dedhia, Toby O Steele, Edward Bradley Strong, Lily Koo Lin
Introduction: The treatment of traumatic optic neuropathy (TON) is highly controversial with a lack of substantiated evidence to support the use of corticosteroids or surgical decompression of the optic nerve. The aim of the study was to determine if there was a general consensus in the management of TON despite controversy in the literature. Methods: An anonymous survey of members of the American Society of Ophthalmic Plastic and Reconstructive Surgery and the North American Neuro-Ophthalmology Society regarding their practice patterns in the management of patients with TON was performed. Results: The majority of 165 respondents indicated that they treated TON with corticosteroids (60%) while a significant minority (23%) performed surgical interventions (P < 0.0001). Subgroup analysis comparing rates of treatment with steroids among oculoplastic surgeons and neuro-ophthalmologists (67% vs. 47%) was not significant (Fisher's Exact test [FET], P =0.11) while results did suggest that a higher proportion of oculoplastic surgeons (33%) than neuro-ophthalmologists (11%) recommended surgical intervention (FET, P =0.004). In cases where visual acuity exhibited a downward trend treatment with steroids was the most commonly employed management. In general, neuro-ophthalmologists trended toward observation over treatment in TON patients with stable visual acuity while oculoplastic surgeons favored treatment with corticosteroids. Conclusions: In spite of the lack of class I evidence supporting intervention of TON, the majority of respondents were inclined to offer corticosteroid treatment to patients whose visual acuity showed progressive decline following injury.
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Beyond mortality: Does trauma-related injury severity score predict complications or lengths of stay using a large administrative dataset p. 143
Nakosi Stewart, James G MacConchie, Roberto Castillo, Peter G Thomas, James Cipolla, Stanislaw P Stawicki
Introduction: Despite its shortcomings, trauma-related injury severity score (TRISS) correlates well with mortality in large trauma datasets. The aim of this study was to determine if TRISS correlates with morbidity and hospital lengths of stay using data from an institutional registry at a Level I Trauma Center. We hypothesized that higher TRISS correlates with increased complications and longer hospital stays. Methods: A retrospective review of our institutional registry was performed, examining all trauma admissions between January 1999 and June 30, 2015. Out of a total of 32,026 patient records, TRISS data were available in 23,205 cases. Abstracted data included patient age, gender, ISS, TRISS, presence of complication, Glasgow Coma Scale (GCS), hospital length of stay, intensive care unit LOS, step-down unit LOS, functional independence measure, and 30-day mortality. Results: TRISS was highly predictive of mortality, with the AUC value of 0.95 (95% confidence interval 0.936–0.954, P < 0.01) compared to ISS (AUC 0.794), GCS (AUC 0.827), and age (AUC 0.650). TRISS also performed better than the other variables in terms of the ability to predict morbidity events (AUC 0.813). TRISS was comparable to ISS in terms of prediction of ICU admission (AUC 0.801 versus 0.811, respectively). After correcting for patient age and gender, higher TRISS significantly correlated with longer hospital stays. Conclusions: Despite previous criticisms, we found that TRISS is superior to ISS for mortality and morbidity prediction. TRISS correlated significantly with a hospital, step down, and ICU lengths of stay using a large administrative dataset.
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Evaluation of splenic artery embolization technique for blunt trauma p. 148
Akshaar N Brahmbhatt, Bishoy Ghobryal, Patrick Wang, Shahzaib Chughtai, Nana Ohene Baah
Introduction: Evaluate outcomes and radiation exposure across different splenic artery embolization (SAE) techniques for splenic injuries secondary to blunt trauma. Methods: This retrospective cohort study included patients 18 years of age or older who underwent SAE for splenic injury after blunt trauma from January 2011 to June 2019. Results: Sixty patients underwent angiography for splenic injury after blunt traumatic injury. Forty-four patients were embolized. Seventeen patients underwent proximal SAE, and 23 underwent distal SAE. Four patients had a combination of proximal and distal SAE. Eleven patients had subsequent major complications requiring splenectomy. There was no significant difference in major complication rate when comparing proximal SAE 29.4% versus distal SAE 21.7%. No significant difference was noted across the two groups with respect to age or grade of injury. There was a statistically significant difference (P = 0.004) in fluoroscopy time between the proximal 10.1 ± 4.2 min and distal group 17.8 ± 8.7 min. No statically significant difference was found in major complications when comparing coil versus gel foam embolization. Conclusion: Proximal SAE is associated with a significantly lower fluoroscopy time (P = 0.004). Complication rates are similar after proximal and distal SAE. No significant difference was found in major complication rates comparing coil versus gel foam embolization. Minor complications more commonly occurred after proximal embolization with gel-foam.
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The 2021 toolkit for emergency preparedness and mitigation to combat surge of pediatric COVID-19 patients in India: The world health organization collaborating center for emergency and trauma in South East Asia recommendations p. 153
Sagar Galwankar, Dheeraj Shah, Ramon E Gist, Ami P Shah, S Vimal Krishnan, Bonnie Arquilla, Prerna Batra, Abhijeet Saha, Sanjeev Bhoi, Tej Prakash Sinha, Amit Agrawal
The authors of this toolkit focus on children under the age of 18 comprising approximately 41% of the total population in India. This toolkit has been created with an objective to prepare, mitigate the effects of any surge of COVID-19 in our communities, and help to optimally utilize the scarce resources. The toolkit design suggests the manpower, equipment, laboratory support, training, consumables, and drugs for a 10-bedded pediatric emergency room, 25-bedded COVID pediatric intensive care unit, and 75-bedded COVID pediatric high dependency unit/ward as defined for a 100-bedded facility. A dedicated and detailed chapter is included to address the psychological needs of the children. These data can be modified for other department sizes based on the facilities, needs, local environment, and resources available.
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The world health organization collaborating center for emergency and trauma (WHO-CCET) in South East Asia, the world academic council of emergency medicine (WACEM), and The American college of academic international medicine (ACAIM) 2021 framework for using telemedicine technology at healthcare institutions p. 173
Veronica Sikka, Salvatore Di Somma, Sagar C Galwankar, Sagar Sinha, Nidhi Garg, Neilesh Talwalkar, Sona Garg, Prashant Mahajan, Vivek Chauhan, Lisa Moreno-Walton, Siddharth Dubhashi, Vibha Dutta, Venkataramanaiah Saddikuti, Prabath W B. Nanayakkara, Joydeep Grover, Ketan Paranjape, Sarman Singh, Pushpa Sharma1, Sanjeev Bhoi, Tejprakash Sinha, Stanislaw P Stawicki, Manish Garg, Indrani Sardesai
The coronavirus disease 2019 crisis has forced the world to integrate telemedicine into health delivery systems in an unprecedented way. To deliver essential care, lawmakers, physicians, patients, payers, and health systems have all adopted telemedicine and redesigned delivery processes with accelerated speed and coordination in a fragmented way without a long-term vision or uniformed standards. There is an opportunity to learn from the experiences gained by this pandemic to help shape a better health-care system that standardizes telemedicine to optimize the overall efficiency of remote health-care delivery. This collaboration focuses on four pillars of telemedicine that will serve as a framework to enable a uniformed, standardized process that allows for remote data capture and quality, aiming to improve ongoing management outside the hospital. In this collaboration, we recommend learning from this experience by proposing a telemedicine framework built on the following four pillars-patient safety and confidentiality; metrics, analytics, and reform; recording of audio-visual data as a health record; and reimbursement and accountability.
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Abstracts for the 39th emergencies in medicine conference p. 180
Sukaina Ali Alali, Tinh Le, M DeVogelaere, Richard Nowak, S Scott Sutton, Kerri Coakley, Zubaid Rafique, Frank Peacock
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Anesthetic management of thoracic trauma by an arrow p. 184
Satyasish Kabi, Arun Kumar Sahu, Bishnu Prasad Mohapatra, Kalyani Bala Nayak
Arrow injuries are rare not only in developed but developing nations as well. Generally used in the sport of archery, arrows are also used as a means of combat in insurgency-ridden regions of India. We report a case of penetrating thorax injury with an arrow lodged close to pericardium in an Oriya woman, referred 15 h after the injury. After a successful surgical intervention with meticulous coordination between the anesthesiologist and surgeon, the patient was discharged after 7 days without complication.
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Stanford - A aortic dissection presenting as a triple mimic and role of point of care ultrasound in deciphering it p. 187
Sasikumar Mahalingam, Gunaseelan Rajendran, Nithya Balaraman, Kiran Kumar, Ajithkumar Rajendran, Balamurugan Nathan, Manu Ayyan, Vishwanath Balassoundaram, Mounika Gara, Praveen Kumar
Aortic dissection (AD) is a great imitator, and its diagnosis is quite challenging due to its varied presentations and unreliable clinical findings. Based on the literature search we found, this is the first case report of Stanford-A/DeBakey Type 1 AD reported as a triple mimic, namely stroke, acute limb ischemia, and pericarditis. Here, we describe the case of a 46-year-old male who presented to our emergency department with features suggestive of acute pericarditis, cerebrovascular accident, acute limb ischemia, which could have been attributed to athero-thrombo-embolic disease and AD could have been possibly missed. However, point-of-care ultrasound helped us in the diagnosis of this highly lethal condition.
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Mechanisms and patterns of animal-related injuries in patients admitted to a major trauma center in central India p. 190
Abdul Haque M Quraishi, Ashvin Damdoo, Shruti Srinivasan, Girish Umare, Pankaj Tongse
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Concurrence of intracranial hemorrhaging and stanford type a acute aortic dissection p. 191
Hiromichi Ohsaka, Kei Jitsuiki, Daigo Takahashi, Youichi Yanagawa
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