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2011| July-September | Volume 4 | Issue 3
Online since
August 16, 2011
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SYMPOSIUM ON EMERGENCY NEUROSCIENCES
Management of penetrating brain injury
Syed Faraz Kazim, Muhammad Shahzad Shamim, Muhammad Zubair Tahir, Syed Ather Enam, Shahan Waheed
July-September 2011, 4(3):395-402
DOI
:10.4103/0974-2700.83871
PMID
:21887033
Penetrating brain injury (PBI), though less prevalent than closed head trauma, carries a worse prognosis. The publication of
Guidelines for the Management of Penetrating Brain Injury
in 2001, attempted to standardize the management of PBI. This paper provides a precise and updated account of the medical and surgical management of these unique injuries which still present a significant challenge to practicing neurosurgeons worldwide. The management algorithms presented in this document are based on
Guidelines for the Management of Penetrating Brain Injury
and the recommendations are from literature published after 2001. Optimum management of PBI requires adequate comprehension of mechanism and pathophysiology of injury. Based on current evidence, we recommend computed tomography scanning as the neuroradiologic modality of choice for PBI patients. Cerebral angiography is recommended in patients with PBI, where there is a high suspicion of vascular injury. It is still debatable whether craniectomy or craniotomy is the best approach in PBI patients. The recent trend is toward a less aggressive debridement of deep-seated bone and missile fragments and a more aggressive antibiotic prophylaxis in an effort to improve outcomes. Cerebrospinal fluid (CSF) leaks are common in PBI patients and surgical correction is recommended for those which do not close spontaneously or are refractory to CSF diversion through a ventricular or lumbar drain. The risk of post-traumatic epilepsy after PBI is high, and therefore, the use of prophylactic anticonvulsants is recommended. Advanced age, suicide attempts, associated coagulopathy, Glasgow coma scale score of 3 with bilaterally fixed and dilated pupils, and high initial intracranial pressure have been correlated with worse outcomes in PBI patients.
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PRACTITIONER SECTION
Managing aluminum phosphide poisonings
Mohan Gurjar, Arvind K Baronia, Afzal Azim, Kalpana Sharma
July-September 2011, 4(3):378-384
DOI
:10.4103/0974-2700.83868
PMID
:21887030
Aluminum phosphide (AlP) is a cheap, effective and commonly used pesticide. However, unfortunately, it is now one of the most common causes of poisoning among agricultural pesticides. It liberates lethal phosphine gas when it comes in contact either with atmospheric moisture or with hydrochloric acid in the stomach. The mechanism of toxicity includes cellular hypoxia due to the effect on mitochondria, inhibition of cytochrome C oxidase and formation of highly reactive hydroxyl radicals. The signs and symptoms are nonspecific and instantaneous. The toxicity of AlP particularly affects the cardiac and vascular tissues, which manifest as profound and refractory hypotension, congestive heart failure and electrocardiographic abnormalities. The diagnosis of AlP usually depends on clinical suspicion or history, but can be made easily by the simple silver nitrate test on gastric content or on breath. Due to no known specific antidote, management remains primarily supportive care. Early arrival, resuscitation, diagnosis, decrease the exposure of poison (by gastric lavage with KMnO
4
, coconut oil), intensive monitoring and supportive therapy may result in good outcome. Prompt and adequate cardiovascular support is important and core in the management to attain adequate tissue perfusion, oxygenation and physiologic metabolic milieu compatible with life until the tissue poison levels are reduced and spontaneous circulation is restored. In most of the studies, poor prognostic factors were presence of acidosis and shock. The overall outcome improved in the last decade due to better and advanced intensive care management.
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SYMPOSIUM ON EMERGENCY NEUROSCIENCES
Pediatric head trauma
George A Alexiou, George Sfakianos, Neofytos Prodromou
July-September 2011, 4(3):403-408
DOI
:10.4103/0974-2700.83872
PMID
:21887034
Head injury in children accounts for a large number of emergency department visits and hospital admissions. Falls are the most common type of injury, followed by motor-vehicle-related accidents. In the present study, we discuss the evaluation, neuroimaging and management of children with head trauma. Furthermore, we present the specific characteristics of each type of pediatric head injury.
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ORIGINAL ARTICLES
Analyzing fat embolism syndrome in trauma patients at AIIMS Apex Trauma Center, New Delhi, India
Babita Gupta, Nita D'souza, Chhavi Sawhney, Kamran Farooque, Ajeet Kumar, Pramendra Agrawal, MC Misra
July-September 2011, 4(3):337-341
DOI
:10.4103/0974-2700.83859
PMID
:21887021
Background
: Fat embolism syndrome (FES) is a constellation of symptoms and signs subsequent to orthopedic trauma.
Materials and Methods
: The clinical profile of FES in the trauma population was studied over 2 years and 8 months.
Results
: The incidence of FES among all patients with long bone and pelvic fractures was 0.7% (12). The mean injury severity score was 10.37 (SD 1.69) (range 9-14). The diagnosis of FES was made by clinical and laboratory criteria. Hypoxia was the commonest presentation (92%). The average days of onset of symptoms were 3.5 (SD1.29) days. Management included ventilator support in 75%, average ventilator days being 7.8 (SD 4.08) days. The average ICU stay and hospital stay were 9.1 days and 29.7 days, respectively. A mortality of 8.3% (1) was observed.
Conclusion
: Fat embolism remains a diagnosis of exclusion and is a clinical dilemma. Clinically apparent FES is unusual and needs high index of suspicion, especially in long bone and pelvic fractures.
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SYMPOSIUM ON EMERGENCY NEUROSCIENCES
Caring for cerebral venous sinus thrombosis in children
Mubashira Hashmi, Mohammad Wasay
July-September 2011, 4(3):389-394
DOI
:10.4103/0974-2700.83870
PMID
:21887032
Cerebral venous sinus thrombosis in children is increasingly recognized as diagnostic tools and clinical awareness has improved. It is a multifactorial disease where prothrombotic risk factors and predisposing clinical conditions usually in combination constitute the underlying etiology. Clinical features range from headache, seizures to comatose state. Although symptomatic treatment involving control of infections, seizures and intracranial hypertension is uniform, use of anticoagulation and local thrombolytic therapy is still controversial. Morbidity and mortality can be significant and long-term neurological sequelae include developmental delay, sensorimotor and visual deficits and epilepsy.
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CASE SERIES
Adult necrotizing enterocolitis and non occlusive mesenteric ischemia
Sanoop Koshy Zachariah
July-September 2011, 4(3):430-432
DOI
:10.4103/0974-2700.83881
PMID
:21887043
Adult necrotizing enterocolitis and non occlusive mesenteric ischemia are rare causes of acute abdomen in adults. Accurate preoperative diagnosis is often difficult in these cases. Here, four cases of massive bowel necrosis with varying segments of small and large bowel involvement are described, all of whom underwent surgery. These cases give an opportunity to review the literature on such lethal diseases including non occlusive intestinal necrosis, neonatal necrotizing enterocolitis and adult necrotizing enterocolitis. The similarities and differences in etiology, pathophysiology, clinical and radiological findings are discussed.
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ORIGINAL ARTICLES
Tight blood glucose control in trauma patients: Who really benefits?
Evert A Eriksson, David A Christianson, Wayne E Vanderkolk, Bruce W Bonnell, James E Hoogeboom, Mickey M Ott
July-September 2011, 4(3):359-364
DOI
:10.4103/0974-2700.83864
PMID
:21887026
Background
: This study was designed to evaluate the effect of intensive insulin control (IIT) on outcomes for traumatically injured patients as a function of injury severity score (ISS) and age.
Patients and Methods
: A retrospective review of 2028 adult trauma patients admitted to the surgical intensive care unit (SICU) in a Level I trauma center was performed. Data were collected from a 48-month period before (Pre-IIT) (goal blood glucose 80-200 mg/dL) and after (Post-IIT) (goal blood glucose level 80-110 mg/dL), an IIT protocol was initiated. Patients were stratified by age and ISS. The primary endpoint was mortality.
Results
: There were 784 Pre-IIT and 1244 Post-IIT patients admitted. There was no significant difference between Pre-IIT vs. Post-IIT for the mechanism of injury or ISS. Values for the Pre-IIT group were significantly higher for mortality (21.5% vs. 14.7%,
P
<0.001) and hospital, but not ICU length of stay were decreased. A significant improvement in mortality was demonstrated between Pre-IIT vs. Post-IIT stratified within the age groups of 41-50, 51-60, and 61 but not the groups 18-30 and 31-40. Mean glucose levels (mg/dL) decreased significantly after the institution of IIT (144.7±1.4 vs. 130.9±0.9;
P
<0.001). In addition, the occurrence per patient of blood glucose levels <40 mg/dL increased (0.77% vs. 2.86%;
P
=0.001) and blood glucose levels greater than 200 mg/dL was similar (39.1% vs. 38.8%;
P
=0.892) in the Pre-IIT and Post-IIT groups, respectively. Glycemic variability, reflected by the standard deviation of each patient's mean glucose level during ICU stay, as well as mean glucose level were lower in survivors than in nonsurvivors. Finally, multivariable logistic regression analysis identified both mean glucose level and glycemic variability as independent contributors to the risk of mortality.
Conclusions
: The implementation of IIT has been associated with a decrease in both hospital length of stay as well as mortality. Average glucose value and glucose variability are independent predictors of survival. Trauma patients with moderate, severe, and very severe injuries benefit most from IIT. These observational data suggest that patients over 40 years of age benefited a great deal more than their younger counterparts from IIT. This study supports the need for a randomized controlled trial to investigate the role of IIT in traumatically injured patients.
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Experience of using local flaps to cover open lower limb injuries at an Indian trauma center
PR Boopalan, Manasseh Nithyananth, VT Titus, Vinoo Mathew Cherian, Thilak S Jepegnanam
July-September 2011, 4(3):325-329
DOI
:10.4103/0974-2700.83806
PMID
:21887018
Background
: Optimal care of open, high-velocity, lower limb injury requires surgical skills in debridement, skeletal stabilization, and in providing appropriate soft tissue cover. Timely coordination between orthopedic and plastic surgeons, though ideal, is often difficult. In our center, orthopedic surgeons undertake comprehensive treatment of open fractures including soft tissue cover. We reviewed the results of the local flaps of lower limb, done by orthopedic surgeons.
Materials and Methods
: We retrospectively reviewed the results of the lower limb flaps done between January 2005 and December 2006. All flaps done at and below the level of knee were included.
Results
: There were 105 patients with 120 flaps during this period. Two patients with two flaps were lost to follow-up. The average age was 32 years. Sixty-four patients had Type IIIB Gustilo and Anderson injuries. Thirty-nine patients had isolated soft tissue injuries. The indications for flaps were exposed bone, tendon, and joint in 45, 11, and 12, respectively, or a combination in 35 patients. The flaps done were 51 reverse sural artery, 35 gastrocnemius, 25 local fasciocutaneous, and seven foot flaps. The flap dimensions ranged from 2 Χ 2 to 30 Χ 15 cm. Ninety-three flaps (79%) healed primarily. Among 25 flaps (21%) with necrosis, 14 flaps required secondary split skin graft for healing, while the other nine flaps healed without further surgery.
Conclusion
: Appropriate soft tissue cover provided by orthopedic surgeons can help in providing independent, composite care of lower limb injuries.
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TOXICOLOGY TALES
Organophosphate acetylcholine esterase inhibitor poisoning from a home-made shampoo
Yair Sadaka, Arnon Broides, Raffi Lev Tzion, Matitiahu Lifshitz
July-September 2011, 4(3):433-434
DOI
:10.4103/0974-2700.83893
PMID
:21887044
Organophosphate acetylcholine esterase inhibitor poisoning is a major health problem in children. We report an unusual cause of organophosphate acetylcholine esterase inhibitor poisoning. Two children were admitted to the pediatric intensive care unit due to organophosphate acetylcholine esterase inhibitor poisoning after exposure from a home-made shampoo that was used for the treatment of head lice. Owing to no obvious source of poisoning, the diagnosis of organophosphate acetylcholine esterase inhibitor poisoning in one of these patients was delayed. Both patients had an uneventful recovery. Organophosphate acetylcholine esterase inhibitor poisoning from home-made shampoo is possible. In cases where the mode of poisoning is unclear, direct questioning about the use of home-made shampoo is warranted, in these cases the skin and particularly the scalp should be rinsed thoroughly as soon as possible.
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CASE REPORTS
Nasal leech infestation causing persistent epistaxis
Kalra Sarathi
July-September 2011, 4(3):413-414
DOI
:10.4103/0974-2700.83875
PMID
:21887037
Foreign bodies in the nasal cavity are commonly encountered as a cause of epistaxis; however, nasal leech infestation as a cause of unilateral persistent epistaxis is very rare. Examination of nasal cavity revealed fleshy material in the left nostril, which was identified as leech. The leech was removed with the help of an artery forceps following irrigation of the left nostril with normal saline and adopting wait-and-watch policy. In developing countries, leech infestation as a cause of epistaxis should be suspected in patients with lower socioeconomic status or in those living in rural areas who give history of drinking polluted water from, or bathing in, stagnant ponds and puddles.
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Infantile trauma due to a rat bite
Sidharth Kumar Sethi, Abhijeet Saha, Mayuri Karela, Nand Kishore Dubey
July-September 2011, 4(3):409-410
DOI
:10.4103/0974-2700.83873
PMID
:21887035
We present two cases of extreme neglect with injuries. These are perfect examples of gender bias. Our first case is a 20-day-old female neonate was brought to the pediatric emergency department with multiple rat bites to the face. A 9-month-old female infant was brought to the emergency care division with multiple rat bites on the eyes and upper extremities. These cases point towards the existing gender bias and extreme social neglect of females in the Indian society.
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GRAND ROUNDS CASE
A 31-year-old female with fever and back pain
Noushif Medappil, Prashanth Adiga
July-September 2011, 4(3):385-388
DOI
:10.4103/0974-2700.83869
PMID
:21887031
Primary pyomyositis is a suppurative infection of striated muscle, the diagnosis of which is overlooked or delayed due to its rarity and vague clinical presentation. Though rare in the United States and temperate zones, pyomyositis is more frequently reported from tropical countries. The exact pathogenesis of pyomyositis is uncertain in most cases. The disease progresses through three stages with characteristic features and require a high index of suspicion to institute stage-wise treatment. Newer imaging methods, particularly magnetic resonance imaging, have facilitated the accurate diagnosis of the infection and of the extent of involvement. Early recognition with appropriate antibiotics in the pre-suppurative stage and prompt surgical intervention in the late stages form the corner stone of treatment. Delay in diagnosis can result in increased morbidity and mortality, especially in diabetics and immunocompromised state. Here, we report a case of primary paraspinal pyomyositis in a middle-aged female and emphasize the importance of early diagnosis and treatment.
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ORIGINAL ARTICLES
Combining white blood cell count and thrombosis for predicting in-hospital outcomes after acute myocardial infraction
Atooshe Rohani, Vahid Akbari, Karim Moradian, Janmohammad Malekzade
July-September 2011, 4(3):351-354
DOI
:10.4103/0974-2700.83862
PMID
:21887024
Introduction
: Admission white blood cell (WBC) count and thrombosis in myocardial infarction (TIMI) risk score have been associated with adverse outcomes after acute myocardial infarction (AMI). This study investigated the joint effect of WBC count and TIMI risk score on predicting in-hospital outcomes in patients with AMI.
Materials and Methods
: WBC count and TIMI risk score were measured at the time of hospital admission in 70 patients with AMI. Echocardiogram was done on prior to discharge by a cardiologist and ejection fraction (EF) was determined according to the Simpson formula. Patients were stratified into tertiles (low and high) based on WBC count and TIMI risk score.
Results
: Patients with a high WBC count had a 5.0-fold increase in-hospital congestive heart failure and 2.2 increases in mortality compared with those with a low WBC count. Patients with a high TIMI risk score had a 10-fold increase in congestive heart failure presentation and mortality compared with those with a low TIMI risk score. When a combination of different strata for each variable was analyzed, a stepwise increase in mortality was seen. There were a few number of patients with a high WBC count and low TIMI risk score or with a low WBC count and high TIMI risk score. These patients had an intermediate risk, whereas those with a high WBC count and TIMI risk score had the highest risk.
Conclusion
: These findings suggested that a simple combination of WBC count and TIMI risk score might provide further information for predicting outcomes in patients with AMI.
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CASE REPORTS
Management of paroxysmal hypertension due to incidental pheochromocytoma in pregnancy
Indu Lata, Sandeep Sahu
July-September 2011, 4(3):415-417
DOI
:10.4103/0974-2700.83876
PMID
:21887038
A 25-year-old, full-term pregnant woman diagnosed with pre-eclampsia was referred to our tertiary care hospital with severe resistant hypertension. Her blood pressure remained labile despite the usual medications, which led to the suspicion of an underlying endocrinological problem. Further biochemical and radiological investigations confirmed the diagnosis of pheochromocytoma. The patient was invasively monitored and treated with alpha blockade, beta blocker, and vasodilators. The primary goals for the management of pheochromocytoma in pregnancy are early diagnosis, avoidance of a hypertensive crisis during delivery, and definitive surgical treatment. This case illustrates that one needs to be cautious when such a presentation of paroxysmal hypertension is present. With a multidisciplinary team approach, proper planning, and adequate preoperative medical management, pheochromocytoma in pregnancy can be managed successfully.
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Severe hypothermia in a patient with spinal cord injury without radiological abnormality
Travis M Smith, Alexander S Berk, Hiten Upadhyay
July-September 2011, 4(3):421-424
DOI
:10.4103/0974-2700.83878
PMID
:21887040
We report a case of a 64-year-old caucasian male who was transported to the emergency department (ED) after being found unconscious on the side of the road. On arrival to the ED the patient went into ventricular fibrillation and advanced cardiac life support was started at that time. Thirty minutes into the resuscitation, after multiple rounds of code drugs and defibrillation attempts, the patient was found to be severely hypothermic with a rectal temperature of 24.9°C (76.9°F). Through the use of passive and active re-warming measures the patient's temperature increased enough to allow successful cardioversion and stabilization. Within minutes of cardiac stabilization the patient regained consciousness and was able to follow commands, but was found to be paralyzed from the neck down. Subsequent CT scans revealed no acute fractures, subluxations or acute spinal cord injury. This case represents the rare finding of severe hypothermia secondary to occult spinal cord injury. Case report was taken from case at Bayfront Hospital, St. Petersburg, Florida.
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LETTERS TO EDITOR
Atraumatic spontaneous rupture of the non-gravid uterus
Fernando A Herrera, Aladdin H Hassanein, Vishal Bansal
July-September 2011, 4(3):439-439
DOI
:10.4103/0974-2700.83896
PMID
:21887047
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ORIGINAL ARTICLES
Profiling genitourinary injuries in United Arab Emirates
Fayez T Hammad, Hani O Eid, Ashraf F Hefny, Fikri M Abu-Zidan
July-September 2011, 4(3):342-345
DOI
:10.4103/0974-2700.83860
PMID
:21887022
Background
: The epidemiology of genitourinary (GU) organ injury following general trauma is not well-studied especially in the Middle East.
Patients and Methods
: All patients with GU injuries from the Trauma Registry of Al-Ain Hospital were studied. The registry data was prospectively collected from March 2003 to March 2006.
Results
: Out of 2573 patients in the registry, 22 had GU injuries (incidence: 0.9%, 2.0 per 100,000 inhabitants per year). Road traffic collision was the most frequent mechanism of injury (50% of all cases). 41% of injuries were renal. In 73% of patients, GU injuries were associated with other organ injuries, the most frequent of which were injuries to the other abdominal and pelvic organs (94%). The mean Injury Severity Score, mean total hospital stay, the percentage of patients who required intensive care unit (ICU) admission were higher in patients with GU injuries compared to non-GU patients (17.1 vs. 5.5 (P 0.001), 15.4 vs. 9.2 days (P 0.040) and 43% vs. 8%, (P 0.0001), respectively.
Conclusions
: The incidence of trauma-related GU injuries in the current study appears to be comparable to those reported from the West. Patients with GU organ injuries tend to have more severe trauma compared to other patients. Road traffic collision was the most common mechanism of injury and the kidney was the most frequently injured organ.
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Characteristic of victims of family violence seeking care at health centers in Maputo, Mozambique
Eunice Abdul Remane Jethá, Catherine A Lynch, Debra E Houry, Maria Alexandra Rodrigues, Baltazar Chilundo, Scott M Sasser, David W Wright
July-September 2011, 4(3):369-373
DOI
:10.4103/0974-2700.83866
PMID
:21887028
Background
: Family violence (FV) is a common, yet often invisible, cause of violence. To date, most literature on risk factors for family, interpersonal and sexual violence is from high-income countries and might not apply to Mozambique.
Aims
: To determine the individual risk factors for FV in a cohort of patients seeking care for injuries at three health centers in Maputo, Mozambique.
Setting and Design
: A prospective multi-center study of patients presenting to the emergency department for injuries from violence inflicted by a direct family member in Maputo, Mozambique, was carried out.
Materials and Methods
: Patients who agreed to participate and signed the informed consent were verbally administered a pilot-tested blank-item questionnaire to ascertain demographic information, perpetrator of the violence, historical information regarding prior abuse, and information on who accompanied the victim and where they received their initial evaluation. De-identified data were entered into SPSS 13.0 (SPSS, version 13.0) and analyzed for frequencies.
Results
: During the 8-week study period, 1206 assault victims presented for care, of whom 216 disclosed the relationship of the assailant, including 92 being victims of FV (42.6%). The majority of FV victims were women (63.0%) of age group 15-34 years (76.1%) and were less educated (84%) compared to national averages. Of the patients who reported assault on a single occasion, most were single (58.8%), while patients with multiple assaults were mostly married (63.2%). Most commonly, the spouse was the aggressor (50%) and a relative accompanied the victim seeking care (54.3%). Women most commonly sought police intervention prior to care (63.2%) in comparison to men (35.3%).
Conclusion
: In Mozambique, FV affects all ages, sexes and cultures, but victims seeking care for FV were more commonly women who were less educated and poorer.
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Indicators of potential for rupture for ectopics seen in the emergency department
La Vonne A Downey, Leslie S Zun
July-September 2011, 4(3):374-377
DOI
:10.4103/0974-2700.83867
PMID
:21887029
Background
: Emergency departments (ED) frequently evaluate patients with probable ectopic pregnancies who go home and may rupture. It would be beneficial to know which patient factors are associated with rupture and which are not.
Objectives
: The purpose of this study was to determine which ED patients with ectopic pregnancies are at risk for rupture.
Materials and Methods
: This study was a retrospective chart review of all women aged ≥18 years during a 5-year period who were diagnosed with ectopic pregnancy to a level I ED. Data collected included basic demographic information, medical, surgical, obstetric and gynecologic history, social and sexual history, findings on physical examination, and laboratory values such as urine pregnancy test, b-hCG, and complete blood count.
Results
: There was a significant difference using a multivariate regression analysis with 95% CI in history findings of abdominal pain, nausea, vomiting, and urinary tract symptoms. There was a significant difference in physical examination of pulse, diastolic pressure, abdominal tenderness, peritoneal signs, cervical motion tenderness, and adnexal tenderness. There was also a significant difference in b-hCG, hemoglobin and hematocrit results and ultrasound findings of free peritoneal fluid, intrauterine pregnancy and cardiac findings between those who ruptured and those who did not. None of these tests was able to differentiate those that would go on to rupture.
Conclusion
: The result of the study did not find any single sign, symptom, or test that could reliably differentiate patients who have a ruptured ectopic from those who do not. However, b-hCG over 1500 mIU was the best variable in explaining the variation between those who would or would not go on to rupture after their ED visit.
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TOXICOLOGY TALES
DORMEX
®
-hydrogen cyanamide poisoning
Sunil Holavanahalli Sheshadri, Uchil Sudhir, Shiva Kumar, Punith Kempegowda
July-September 2011, 4(3):435-437
DOI
:10.4103/0974-2700.83894
PMID
:21887045
Case reports of acute and chronic exposure to hydrogen cyanamide (DORMEX
;
) have been reported but mainly as a result of occupational or accidental exposure and without any mortality. We report a case of acute hydrogen cyanamide poisoning in a young male due to suicidal intent. The patient was managed under intensive care with all the standard protocols for detoxification. However, in spite of aggressive management, patient could not be rescued. An extensive literature search did not yield any similar case reports. Hence, we report this case to the medical community to be aware of the entity.
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ORIGINAL ARTICLES
Neurological outcomes of neurosurgical operations for multiple trauma elderly patients in Hong Kong
George K.C Wong, Colin A Graham, Elsie Ng, Janice H.H Yeung, Timothy H Rainer, Wai S Poon
July-September 2011, 4(3):346-350
DOI
:10.4103/0974-2700.83861
PMID
:21887023
Background
: We aimed to investigate neurological outcomes in elderly patients with multiple trauma, and to review their clinical outcomes following neurosurgical operations.
Patients and Methods
: The study was conducted in a regional trauma center in Hong Kong. We collected prospective data on consecutive trauma patients from January 2001 to December 2008. Patients with multiple trauma (as defined by Injury Severity Score of 15 or more), with both head injury and extracranial injury, were included for analysis.
Results
: Age over 65 years, admission Glasgow Coma Scale (GCS), and Injury Severity Score were significantly poor prognostic factors in logistic regression analysis. Eleven (32%) of the 34 patients aged over 65 who underwent neurosurgical operations attained favorable neurological outcomes (GCS 4-5) at 6 months.
Conclusions
: Age was an important prognostic factor in multiple trauma patients requiring neurosurgical operations. Future randomized controlled clinical trials should be designed to recruit elderly patients (such as age between 65 and 75 years) at clinical equipoise for traumatic hematoma (such as subdural hematoma or traumatic intracerebral hematoma) evacuation and assess the quality of life, neurological, and cognitive outcomes.
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Studying patients of severe traumatic brain injury with severe abdominal injury in Japan
Youichi Yanagawa
July-September 2011, 4(3):355-358
DOI
:10.4103/0974-2700.83863
PMID
:21887025
Background
: Characteristics of extracranial injury in patients with diffuse axonal injury (DAI) have not been clarified.
Materials and Methods
: This retrospective study reviewed medical records from January 2003 to December 2007. Subjects comprised 35 patients meeting the following criteria: 1) head injury without mass lesion; 2) Glasgow coma scale (GCS) on arrival <15; and 3) magnetic resonance imaging (MRI) examination including T2*-weighted imaging. Subjects were divided into two groups: severe traumatic brain injury (TBI) group (patients with GCS ≤8,
n
=19) and moderate TBI group (patients with GCS >8,
n
=16)
Results
: Shock index (heart rate/systolic blood pressure) was significantly higher in the severe TBI group than in the moderate TBI group, while base excess on arrival was significantly lower in the severe TBI group than in the moderate TBI group. The abbreviated injury scale (AIS) for the face, thorax, extremities and external structures showed no significant differences between the severe TBI group, but AIS for the abdomen and the sum of extracranial AIS was greater in the severe TBI group than in the moderate TBI group. Duration of hospitalization was longer and outcomes were worse in the severe TBI group than in the moderate TBI group.
Conclusion
: Because patients with severe TBI are more likely to have abdominal injury than patients with moderate TBI, physicians should be aware of the potential for such complications when treating severe TBI.
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Correlates of new onset peripheral nerve injury in comatose psychotropic drug overdose patients
Youichi Yanagawa
July-September 2011, 4(3):365-368
DOI
:10.4103/0974-2700.83865
PMID
:21887027
Aims
: To investigate the relationship between the duration of comatose state, severity of rhabdomyolysis and frequency of peripheral nerve injury (PNI) in patients following psychotropic drug overdose.
Materials and Methods
: Medical charts were retrospectively reviewed for 41 patients admitted for disturbance of consciousness induced by an overdose of psychotropic drugs with rhabdomyolysis between October 2004 and February 2010. Subjects were divided into PNI group (
n=
9) and non-PNI control group (
n=
32).
Results
: Mean interval between drug ingestion and arrival, frequency of pressure ulcers, CK level at the time of patient's arrival and maximum CK level during hospitalization, duration of hospitalization and morbidity rate were all significantly higher in the PNI group than in the control group.
Conclusion
: In patients with a psychotropic drug overdose leading to a comatose state, the longer the comatose state, the more likely that pressure ulcers and PNI will occur.
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CASE REPORTS
A rare complication of laparoscopic surgery
Nissar Shaikh, Husham Abdul Rahman, Yolande Hanssens, Sunil John
July-September 2011, 4(3):418-420
DOI
:10.4103/0974-2700.83877
PMID
:21887039
Gallstone disease is one of the most common problems affecting the digestive tract. Symptomatic patients are advised to undergo laparoscopic cholecystectomy (LC), which is considered the gold standard of care in these patients. LC has clear advantages over traditional surgery such as a shorter hospital stay, an earlier return to work and better patient satisfaction. Despite LC being a common surgical procedure, it is not totally free from complications. These include cardiorespiratory problems, biliary leakage, peritonitis, hemorrhage and superior mesenteric artery (SMA) occlusion. We report an unusual and fatal complication of LC, being SMA thrombosis complicated by multiple intra-abdominal collections, abdominal compartment syndrome, multiorgan failure and septic shock.
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Utilization of alteplase in trauma victim with an open abdomen
Sharolyn L Martin, Geno M Tellez
July-September 2011, 4(3):427-429
DOI
:10.4103/0974-2700.83880
PMID
:21887042
Trauma victims with multisystem injuries are at risk for the development of deep vein thrombosis and pulmonary embolus (PE). The use of thrombolytic therapy remains very controversial and not well-documented in both the postsurgical and trauma subset of patients. Major trauma, surgery or head injury have been noted as absolute contraindications to thrombolysis in acute myocardial infarction. The decision to utilize thrombolytic therapy cannot be algorithmic; it must be based on the assessment findings for each individual patient. The risk to benefit ratio should be the major consideration to ensure the best possible outcome is granted. Treating injured patients experiencing high-risk PE causing an immediate threat to life may necessitate forming a comparative view of the adverse events associated with thrombolytic medications.
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LETTERS TO EDITOR
The falciform ligament sign of pneumoperitoneum
Akira Hokama, Mitsuteru Nakamura, Fukunori Kinjo, Jiro Fujita
July-September 2011, 4(3):440-440
DOI
:10.4103/0974-2700.83897
PMID
:21887048
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ABSTRACTS
Abstract
July-September 2011, 4(3):441-445
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CASE REPORTS
Surviving a delayed trans-diaphragmatic hepatic rupture complicated by an acute superior vena cava and thoracic compartment syndromes
Michael W Parra, Edgar B Rodas, Jakub P Bartnik, Ivan Puente
July-September 2011, 4(3):425-426
DOI
:10.4103/0974-2700.83879
PMID
:21887041
We describe the first reported survivor of a delayed trans-diaphragmatic hepatic rupture complicated by acute superior vena cava (SVCS) and thoracic compartment syndromes (TCS). A thirty one year old male was involved in a boating accident. The patient was diagnosed with a grade IV liver laceration, which was initially managed with both angio-embolization and open surgical repair. Exactly one month from admission, the patient presented with an abrupt cardiac arrest, which was further complicated by a SVCS and TCS. The SVCS was managed with bilateral thoracostomies which revealed a delayed trans-diaphragmatic hepatic rupture into the right chest cavity. The TCS was managed with a decompressive thoraco-abdominal incision. The patient survived and is now leading a normal life. Our success was largely due to an integrated trauma system of physicians, nurses and technicians that prompted the early recognition of two potentially life threatening complications of a delayed trans-diaphragmatic hepatic rupture.
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Bitemporal compression injury to the head
Fatimah Lateef
July-September 2011, 4(3):411-412
DOI
:10.4103/0974-2700.83874
PMID
:21887036
Most cranio-cerebral injuries seen in the emergency department are caused by acceleration-deceleration or a direct impact mechanism. Compression or crush injury to the head is less commonly seen. A crush injury occurs when a body part is subjected a degree of force or pressure, usually after being trapped between two heavy objects or hard surfaces. We describe here a case of accidental bitemporal and facial compression injury in a young lady.
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EDITORIAL
What's new in Emergencies, Trauma, and Shock? Pragmatic possibilities of predicting post-STEMI complications using TIMI scores and leukocyte counts
Keng Sheng Chew
July-September 2011, 4(3):323-324
DOI
:10.4103/0974-2700.83805
PMID
:21887017
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2,766
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LETTERS TO EDITOR
Double-lumen endobronchial tube and alternatives in massive hemoptysis: How do you want to save lives?
Schaal Jean-Vivien, Dubost Clément, Tourtier Jean-Pierre, Auroy Yves
July-September 2011, 4(3):438-438
DOI
:10.4103/0974-2700.83895
PMID
:21887046
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ORIGINAL ARTICLES
Comparing the results penetrating colon injuries based on intervention by surgeons with different levels of experience in West Indies
Vijay Naraynsingh, Michael J Ramdass
July-September 2011, 4(3):330-332
DOI
:10.4103/0974-2700.83832
PMID
:21887019
Background
: Numerous studies have established the safety of primary repair for civilian penetrating colonic injuries with little data exploring the experience of surgeon performing the procedure. Owing to financial, staff and administrative constraints in the developing world, surgeons-in-training sometimes find themselves faced with having to perform major surgery for penetrating colonic injuries with no experienced surgeon in attendance, but available for advice via phone. With this thought, we collected retrospective data to analyse our outcomes based on this practice.
Materials and Methods
: Over a 10-year period 62 patients with penetrating colonic trauma underwent laparotomies with analysis done on 53 cases. Severity of injury, grade of operating surgical staff and outcome were noted. Outcomes of "inexperienced surgeons" and "experienced surgeons" were compared to determine if a difference exists in outcome based on experience or grade of surgeon.
Results
: A total of 53 patients with penetrating colon injures underwent primary repair and/or anastomosis with 18 (34%) performed by "inexperienced surgeons" and 35 (66%) by "experienced surgeons". There was one death unrelated to colon trauma with an "inexperienced surgeon" and one anastomotic leak in a patient operated on by an "experienced surgeon".
Conclusion
: This data supports previous reports on the safety of primary repair for penetrating colonic injuries and raises the point that in cases of lower severity of injury inexperienced surgeons have similar results to experienced surgeons with regard to primary repair.
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Profiling pediatric patients involved in automobile crashes in Japan
Youichi Yanagawa
July-September 2011, 4(3):333-336
DOI
:10.4103/0974-2700.83838
PMID
:21887020
Introduction
: There is little data concerning the injuries induced by being run over in children.
Problem
: Characteristics of injuries suffered in children by being run over were investigated.
Materials and Methods
: Between January 1998 and December 2007, the medical charts were retrospectively reviewed to investigate characteristics of the injuries in pediatric patients run over by a car. Patients meeting the following criteria were included: (1) age ≤ 12 years old; (2) the patient was struck by an automobile. The subjects were divided into three groups by the mechanisms of injury: (1) run over; (2) carried away; (3) contact.
Results
: Twelve patients had been run over, 44 patients were carried away and 44 patients had been hit by a car (contact). The average age in the run over group was the lowest, followed by that in the carried away group and that in the contact group was the highest. The children's coma score and injury severity score were not significantly different among the three groups; however, the average chest abbreviated injury score was the highest in the run over group, followed by that in the carried away group and that in the contact group was the lowest. The average duration of admission and survival rate among three groups, were not significantly different.
Conclusion
: The patients who were injured due to being run over by a car, tended to be younger and to have severe chest injury.
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© 2008 Journal of Emergencies, Trauma, and Shock | Published by Wolters Kluwer -
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Online since 15
th
April, 2008