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2015| October-December | Volume 8 | Issue 4
Online since
October 7, 2015
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REVIEW ARTICLES
Pediatric open globe injury: A review of the literature
Xintong Li, Marco A Zarbin, Neelakshi Bhagat
October-December 2015, 8(4):216-223
DOI
:10.4103/0974-2700.166663
PMID
:26604528
Open globe injury (OGI) is a severe form of eye trauma estimated at 2-3.8/100,000 in the United States. Most pediatric cases occur at home and are the result of sharp object penetration. The aim of this article is to review the epidemiology, diagnosis, management, and prognosis of this condition by conducting a systematic literature search with inclusion of all case series on pediatric OGI published between 1996 and 2015. Diagnosis of OGI is based on patient history and clinical examination supplemented with imaging, especially computed tomography when indicated. Few prospective studies exist for the management of OGI in pediatric patients, but adult recommendations are often followed with success. The main goals of surgical management are to repair the open globe and remove intraocular foreign bodies. Systemic antibiotics are recommended as medical prophylaxis against globe infection, or endophthalmitis. Other complications are similar to those seen in adults, with the added focus of amblyopia therapy in children. Severe vision decline is most likely due to traumatic cataracts. The ocular trauma score, a system devised to predict final visual acuity (VA) in adults, has proven to be of prognostic value in pediatric OGI as well. Factors indicating poor visual prognosis are young age, poor initial VA, posterior eye involvement, long wound length, globe rupture, lens involvement, vitreous hemorrhage, retinal detachment, and endophthalmitis. A thorough understanding of OGI and the key differences in epidemiology, diagnosis, management, and prognosis between adults and children is critical to timely prevention of posttraumatic vision loss early in life.
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ORIGINAL ARTICLES
Frequency, causes and pattern of abdominal trauma: A 4-year descriptive analysis
Suresh Arumugam, Ammar Al-Hassani, Ayman El-Menyar, Husham Abdelrahman, Ashok Parchani, Ruben Peralta, Ahmad Zarour, Hassan Al-Thani
October-December 2015, 8(4):193-198
DOI
:10.4103/0974-2700.166590
PMID
:26604524
Background:
The incidence of abdominal trauma is still underreported from the Arab Middle-East. We aimed to evaluate the incidence, causes, clinical presentation, and outcome of the abdominal trauma patients in a newly established trauma center.
Materials and Methods:
A retrospective analysis was conducted at the only level I trauma center in Qatar for the patients admitted with abdominal trauma (2008-2011). Patients demographics, mechanism of injury, pattern of organ injuries, associated extra-abdominal injuries, Injury Severity Score (ISS), Abbreviated Injury Scale, complications, length of Intensive Care Unit, and hospital stay, and mortality were reviewed.
Results:
A total of 6888 trauma patients were admitted to the hospital, of which 1036 (15%) had abdominal trauma. The mean age was 30.6 ± 13 years and the majority was males (93%). Road traffic accidents (61%) were the most frequent mechanism of injury followed by fall from height (25%) and fall of heavy object (7%). The mean ISS was 17.9 ± 10. Liver (36%), spleen (32%) and kidney (18%) were most common injured organs. The common associated extra-abdominal injuries included chest (35%), musculoskeletal (32%), and head injury (24%). Wound infection (3.8%), pneumonia (3%), and urinary tract infection (1.4%) were the frequently observed complications. The overall mortality was 8.3% and late mortality was observed in 2.3% cases mainly due to severe head injury and sepsis. The predictors of mortality were head injury, ISS, need for blood transfusion, and serum lactate.
Conclusion:
Abdominal trauma is a frequent diagnosis in multiple trauma and the presence of extra-abdominal injuries and sepsis has a significant impact on the outcome.
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REVIEW ARTICLES
Comorbidity polypharmacy score and its clinical utility: A pragmatic practitioner's perspective
Stanislaw P Stawicki, Sarathi Kalra, Christian Jones, Carla F Justiniano, Thomas J Papadimos, Sagar C Galwankar, Scott M Pappada, John J Feeney, David C Evans
October-December 2015, 8(4):224-231
DOI
:10.4103/0974-2700.161658
PMID
:26604529
Modern medical management of comorbid conditions has resulted in escalating use of multiple medications and the emergence of the twin phenomena of multimorbidity and polypharmacy. Current understanding of how the polypharmacy in conjunction with multimorbidity influences trauma outcomes is limited, although it is known that trauma patients are at increased risk for medication-related adverse events. The comorbidity-polypharmacy score (CPS) is a simple clinical tool that quantifies the overall severity of comorbidities using the polypharmacy as a surrogate for the "intensity" of treatment necessary to adequately control chronic medical conditions. Easy to calculate, CPS is derived by counting all known pre-injury comorbid conditions and medications. CPS has been independently associated with mortality, increased risk for complications, lower functional outcomes, readmissions, and longer hospital stays. In addition, CPS may help identify older trauma patients at risk of post-emergency department undertriage. The goal of this article was to review and refine the rationale for CPS and to provide an evidence-based outline of its potential clinical applications.
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ORIGINAL ARTICLES
Effects of a hospital-wide introduction of a massive transfusion protocol on blood product ratio and blood product waste
Kirsten Balvers, Michiel Coppens, Susan van Dieren, Ingeborg H.M. van Rooyen-Schreurs, Henriëtte J Klinkspoor, Sacha S Zeerleder, Holger M Baumann, J Carel Goslings, Nicole P Juffermans
October-December 2015, 8(4):199-204
DOI
:10.4103/0974-2700.166597
PMID
:26604525
Background:
Massive transfusion protocols (MTPs) are increasingly used in the transfusion practice and are developed to provide the standardized and early delivery of blood products and procoagulant agents and to supply the transfusion of blood products in a well-balanced ratio.
Aim:
The aim of this study was to investigate the effect of a hospital-wide introduction of an MTP on blood product ratio and a waste of blood products.
Materials and Methods:
Retrospective analysis was performed to compare the transfusion practice in massive bleeding patients before and after the introduction of an MTP and between the use of an MTP and transfusion off-protocol. Massive bleeding was defined as an administration of ≥5 units of red blood cells (RBCs) within 12 h.
Results:
Of 547 massively transfused patients, 192 patients were included in the pre-MTP period and 355 patients in the MTP period. The ratio of RBC to fresh frozen plasma (FFP) and the platelets transfused shifted significantly toward 1:1:1 in the MTP period (
P
= 0.012). This was mainly caused by a shift in RBC: FFP ratio (
P
= 0.014). An increase in the waste of blood products was observed, most notably FFPs (
P
= 0.026). Extending the storage time after thawing reduced the waste of FFPs from 11% to 4%.
Conclusion:
Hospital-wide introduction of an MTP is an adequate way to achieve a well-balanced transfusion ratio of 1:1:1. This comes at the cost of an increase in the waste of FFPs, which is lowered after extending the duration of storage time after thawing.
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Extra-peritoneal pressure packing without external pelvic fixation: A life-saving stand-alone surgical treatment
Guy Ron, Dan Epstein, Peleg Ben-Galim, Yoram Klein, Alexander Kaban, Shaul Sagiv
October-December 2015, 8(4):181-187
DOI
:10.4103/0974-2700.166586
PMID
:26604522
Purpose:
Traditional maneuvers aim to decrease retroperitoneal bleeding in hemodynamically unstable multi-trauma patients with unstable pelvic fractures, are reportedly successful in approximately only 50%. The life-saving effect of extra-peritoneal pressure packing (EPPP) is based on direct compression and control of both venous and arterial retroperitoneal bleeders. This study describes the safety and efficacy of emergent EPPP employment, as a stand-alone surgical treatment, that is, carried out without external pelvic fixation or emergent angiography.
Materials and Methods:
A retrospective chart review of all hemodynamic unstable, multi-trauma patients with mechanically unstable pelvic fractures treated by the EPPP technique at our medical center between the years 2005 and 2011. Survival rates, clinical, and physiological outcomes were followed prospectively.
Results:
Twenty-five of the 181 pelvic fracture patients had biomechanically unstable fractures that required surgical fixation. Fourteen of those 25 patients had deteriorating hemodynamic instability from massive pelvic bleeding which was resistant to resuscitation, and they underwent EPPP, as a stand-alone treatment. The procedure successfully achieved hemodynamic stability in all 14 patients and obviated the early mortality associated with massive pelvic bleeding. Three of these patients eventually succumbed to their multiple injuries.
Conclusion:
Implementation of EPPP improved all measured physiological outcome parameters and survival rates of hemodynamically unstable multi-trauma patients with unstable pelvic fractures in our trauma center. It provided the unique advantage of directly compressing the life-threatening retroperitoneal bleeders by applying direct pressure and causing a tamponade effect to stanch venous and arterial pelvic blood flow and obviate the early mortality associated with massive pelvic bleeding.
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Comparison of three supraglottic airway devices for airway rescue in the prone position: A manikin-based study
Babita Gupta, Surender Gupta, Bijaya Hijam, Pallavi Shende, Vimi Rewari
October-December 2015, 8(4):188-192
DOI
:10.4103/0974-2700.166589
PMID
:26604523
Background:
Accidental extubation during surgery in prone position can be life-threatening. Supraglottic airway devices (SAD) have been used successfully in such situations to rescue the airway. However, which SAD would be most appropriate in this setting has not been described in the literature.
Aims:
The aim of our study was to determine the most appropriate SAD for securing airway in a prone position during accidental extubation.
Materials and Methods:
In the study, Airway Trainer (Laerdal) manikin was used for studying insertion of three SADs; I-gel, Laryngeal Mask Airway ProSeal™ (PLMA) and LMA Classic™ (CLMA) in the prone position. Forty anesthesia resident doctors participated in this study. The time taken for insertion; ease of insertion and ventilation; bronchoscopic view; and insertion score were compared among the three groups.
Results:
The time taken for I-gel insertion was significantly lesser (12.89 ± 3.94 seconds) as compared to CLMA (17.07 ± 3.5 seconds) and PLMA (25 + 4.78 seconds). Least resistance was encountered in the insertion of I-gel, while maximum resistance was experienced in PLMA group (22.5% vs. 90%). The maneuver required for optimal positioning was observed in 27.5% of PLMA insertion, 2.5% in CLMA while no maneuver was required in any of the I-gel insertion. Ease of ventilation was comparable in all three SADs. The bronchoscopic view and insertion score were significantly higher with I-gel as compared to CLMA and PLMA.
Conclusion:
All three SADs were successful as rescue devices during accidental extubation in the prone position. However, the ease of insertion was maximum with I-gel, followed by CLMA and PLMA.
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3
CASE REPORTS
Trauma triggering thyrotoxic crisis with lactic acidosis
Jennifer S Prosser, Dan K Quan
October-December 2015, 8(4):232-234
DOI
:10.4103/0974-2700.161656
PMID
:26604530
Thyrotoxic crisis (TC) is defined as a life-threatening exacerbation of the hyperthyroid state that causes multiple autonomic and metabolic disturbances. It is considered to be an endocrine emergency that must be urgently diagnosed and treated. We describe a case of TC precipitated by trauma with a resultant lactic acidosis. The patient is a 24-year-old male with a history of hyperthyroidism who presented to the emergency department following a motor vehicle accident. The patient was initially tachycardic and hypertensive, however, was afebrile. Initial laboratory analysis showed an anion gap of 26, lactic acid 7.6, free T4 5.61 and thyroid stimulating hormone < 0.015. A diagnosis of TC was made, and he was treated with intravenous fluids, propranolol, and methimazole with improvement of tachycardia and lactic acidosis. We discuss the features of this case, which reviews the presentations of TC as well as its metabolic sequelae.
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LETTERS TO EDITOR
Physical trauma in epilepsy: Characteristics and implications in a Nigerian adolescent with severe generalized epilepsy
Edwin E Eseigbe, Folorunsho T Nuhu, Taiwo L Sheikh, Okechukwu J Oguizu
October-December 2015, 8(4):240-242
DOI
:10.4103/0974-2700.161661
PMID
:26604535
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Successful use of high-dose insulin therapy in atenolol overdose refractory to conventional management
Ravikanti Karthik, Hari Prasad, AK Seetharam, NT Murali Mohan, Gaganam Trimurthy, Siddraj Wali
October-December 2015, 8(4):242-243
DOI
:10.4103/0974-2700.161662
PMID
:26604536
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ORIGINAL ARTICLES
The usefulness of brain natriuretic peptide level in diagnosis and prognosis of patients admitted to critical care unit with shortness of breath
Yazan Abdeen, Parijat Sen, Syed Safdar, Ram Katapally, Ahmad Abu Arqoob, Daphne Macbruce, Hamid Shaaban, Marc Adelman
October-December 2015, 8(4):205-209
DOI
:10.4103/0974-2700.166611
PMID
:26604526
Background:
Brain Natriuretic Peptide (BNP) is a polypeptide secreted by the ventricles as a response to cardio-myocyte stretching. Due to its cardiac origin and correlation with volume overload it has been successfully used for a long time in diagnosing and prognosticating Cardiogenic Pulmonary Edema.
Materials and Methods:
In this retrospective cohort study, an attempt was made to observe any correlation between admission BNP levels with APACHE II scores and length of ICU stay, in patients admitted with dyspnea to the ICU of a community based hospital.
Results/Conclusion:
This study showed no significant correlation between length of stay in an ICU and admission BNP levels in dyspneic patients. Independent variables such as age and gender failed to show any coorelation either.
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Adverse events and outcomes of procedural sedation and analgesia in major trauma patients
Robert S Green, Michael B Butler, Samuel G Campbell, Mete Erdogan
October-December 2015, 8(4):210-215
DOI
:10.4103/0974-2700.166612
PMID
:26604527
Context:
Trauma patients requiring procedural sedation and analgesia (PSA) may have increased risk of adverse events (AEs) and poor outcomes.
Aims:
To determine the incidence of AEs in adult major trauma patients who received PSA and to evaluate their postprocedural outcomes.
Settings and Design:
Retrospective analysis of adult patients (age >16) who received PSA between 2006 and 2014 at a Canadian academic tertiary care center.
Materials and Methods:
We compared the incidence of PSA-related AEs in trauma patients with nontrauma patients. Postprocedural outcomes including Intensive Care Unit admission, length of hospital stay, and mortality were compared between trauma patients who did or did not receive PSA.
Statistical Analysis Used:
Descriptive statistics and multivariable logistic regression.
Results:
Overall, 4324 patients received PSA during their procedure, of which 101 were trauma patients (107 procedures). The majority (77%) of these 101 trauma patients were male, relatively healthy (78% with American Society of Anesthesiologists Physical Status [ASA-PS] 1), and most (85%) of the 107 procedures were orthopedic manipulations. PSA-related AEs were experienced by 45.5% of the trauma group and 45.9% of the nontrauma group. In the trauma group, the most common AEs were tachypnea (23%) and hypotension (20%). After controlling for age, gender, and ASA-PS, trauma patients were more likely than nontrauma patients to develop hypotension (odds ratio 1.79; 95% confidence interval 1.11-2.89).
Conclusion:
Although trauma patients were more likely than nontrauma patients to develop hypotension during PSA, their outcomes were not worse compared to trauma patients who did not have PSA.
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LETTERS TO EDITOR
The outstanding diagnosis
Tanmay S Panchabhai, Debabrata Bandyopadhyay, Gustavo Heresi, Aanchal Kapoor
October-December 2015, 8(4):244-245
DOI
:10.4103/0974-2700.161657
PMID
:26604538
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A case of tension pyothorax with septic shock
Kouhei Ishikawa, Munechika Hara, Shin-ichiro Iwakami, Youichi Yanagawa
October-December 2015, 8(4):244-244
DOI
:10.4103/0974-2700.161663
PMID
:26604537
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EDITORIAL
What's new in emergencies, trauma and shock? Extraperitoneal pelvic pressure packing: Placing this procedure in context
Timothy Craig Hardcastle
October-December 2015, 8(4):179-180
DOI
:10.4103/0974-2700.166585
PMID
:26604521
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LETTERS TO EDITOR
Transient paraplegia in an elderly due to lightning injury: An unusual cause
Mohamad Gouse, Justin Arockiaraj, Ronald Khanapur, Gangadaran Srinivasan
October-December 2015, 8(4):238-239
DOI
:10.4103/0974-2700.166743
PMID
:26604533
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1
"The best is nothing": Non-operative management of hemodynamically stable grade V liver trauma
Gregorio Tugnoli, Francesco Cinquantini, Carlo Coniglio, Andrea Biscardi, Alice Piccinini, Giovanni Gordini, Salomone Di Saverio
October-December 2015, 8(4):239-240
DOI
:10.4103/0974-2700.166756
PMID
:26604534
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1
Rudimentary horn pregnancy mimicking an acute abdomen in the emergency department
Bedia Gülen, Mustafa Serinken, Ertan Sonmez, Güleser Akpinar, Özgür Söğüt
October-December 2015, 8(4):237-238
DOI
:10.4103/0974-2700.166737
PMID
:26604532
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CASE REPORTS
A case of luftsichel sign for left upper lobe collapse
Erden Erol Ünlüer, Behzat Özkan, Fatih Esad Topal, Nuri Nazif Altiner, Arif Karagöz
October-December 2015, 8(4):235-236
DOI
:10.4103/0974-2700.166732
PMID
:26604531
The differential diagnosis of dyspnea in Emergency Department (ED) patients is broad and atelectasis is one of the differentials among these. We present a 29-year-old women presented to our ED for evaluation of shortness of breath. On her chest examination, air entry and breath sounds were diminished on the left side but normal on the right. A posteroanterior chest radiograph showed radioluscent area in the upper zone of the left lung, around the aortic arch and also hyperdens area neighbouring this, like covered by a veil. Luftsichel sign together with this hiperdensity were consistent with the diagnose of left lung upper lobe collapse. The Luftsichel sign represents the hyperexpanded superior segment of the left lower lobe interposed between the atelectatic left upper lobe and aortic arch. Patient was discharged to home with chest physiotherapy and breathing exercises together with analgesic prescreption.
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© 2008 Journal of Emergencies, Trauma, and Shock | Published by Wolters Kluwer -
Medknow
Online since 15
th
April, 2008