Journal of Emergencies, Trauma, and Shock
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Policies and programs for road safety in developing India
Nishi Mittal
January-June 2008, 1(1):42-49
DOI:10.4103/0974-2700.41790  PMID:19561941
  83,732 256 3
Emergency management of fat embolism syndrome
Nissar Shaikh
January-April 2009, 2(1):29-33
DOI:10.4103/0974-2700.44680  PMID:19561953
Fat emboli occur in all patients with long-bone fractures, but only few patients develop systemic dysfunction, particularly the triad of skin, brain, and lung dysfunction known as the fat embolism syndrome (FES). Here we review the FES literature under different subheadings. The incidence of FES varies from 1-29%. The etiology may be traumatic or, rarely, nontraumatic. Various factors increase the incidence of FES. Mechanical and biochemical theories have been proposed for the pathophysiology of FES. The clinical manifestations include respiratory and cerebral dysfunction and a petechial rash. Diagnosis of FES is difficult. The other causes for the above-mentioned organ dysfunction have to be excluded. The clinical criteria along with imaging studies help in diagnosis. FES can be detected early by continuous pulse oximetry in high-risk patients. Treatment of FES is essentially supportive. Medications, including steroids, heparin, alcohol, and dextran, have been found to be ineffective.
  58,654 1,415 30
Injuries, negative consequences, and risk behaviors among both injured and uninjured emergency department patients who report using alcohol and marijuana
Robert Woolard, Janette Baird, Michael J Mello, Christina Lee, Magda Harington, Ted Nirenberg, Bruce Becker, Lynn Stein, Richard Longabaugh
January-April 2009, 2(1):23-28
DOI:10.4103/0974-2700.44679  PMID:19561952
Background: Brief intervention (BI) to reduce hazardous drinking and negative consequences such as injury has been effective when given in the emergency department (ED). The effectiveness and effect of BI has varied between injured and uninjured ED patients. This study compares injured and uninjured ED patients who admit to alcohol and marijuana use to determine their need and their readiness for BI. Patients and Methods: Participants volunteered to enter a randomized controlled trial of BI to reduce hazardous alcohol and marijuana use. Adult ED patients who had had alcohol in the last month and smoked marijuana in the last year were recruited. Those patients who were admitted to hospital, were under police custody, or were seeking treatment for substance use or psychiatric disorder were excluded. Research assistants interviewed participants using a validated questionnaire. Data were analyzed using SAS (version 9.1). Binominal tests of proportions, t-test analyses, and transformations were conducted as appropriate. Results: Injured (n = 249) and uninjured (n = 266) study participants reported very high, statistically equivalent (P > 0.05), rates of binge drinking (4-5 days/month), marijuana use (13 days/month), driving under the influence of marijuana or alcohol (>49% in the last 3 months), injury (>83% in the last year), and other negative consequences (>64% in the last 3 months) prior to their ED visit. These behaviors and the consequences demonstrate a need for change. Both injured and uninjured subjects were ready to change (>56%) and confident they could change (>91%) alcohol and marijuana use. Discussion: ED patients who admit to alcohol and marijuana use also use other hazardous substances and participate in high-risk behaviors. In both injured and uninjured patients who admit using alcohol and marijuana, the ED visit is an opportunity to deliver BI to reduce alcohol and marijuana use and associated risk behaviors and the subsequent injury and negative consequences. Given their risk behaviors and experience of negative consequences, members of both injured and uninjured groups have an equal need for BI. Fortunately, in both groups, a high number of members express motivation to change.
  41,620 184 6
Pattern, severity, and management of cranio-maxillofacial soft-tissue injuries in Port Harcourt, Nigeria
Akinbami Babatunde Olayemi, Akadiri Oladimeji Adeniyi, Udeabor Samuel, Obiechina Ambrose Emeka
October-December 2013, 6(4):235-240
DOI:10.4103/0974-2700.120362  PMID:24339654
Background: The pattern of craniofacial soft-tissue injuries occurring either in isolation or in association with fractures vary in different societies and is multiply influenced. The effects are enormous because of the prominence of the face; therefore, the purpose of this study was to document any changing pattern, severity and management of these craniofacial injuries in our center. Patients and Method: Cranio-maxillofacial region was classified into upper, middle and lower face. The cause, type, and site of the injuries were documented. Gunshot injuries were further categorized as penetrating, perforating or avulsions. Further, classification of injuries into mild, moderate, and severe was carried out based on multiple factors. Result: A total of 126 patients with soft-tissue injuries presented to our hospital out of which 85 (67.5%) were males and 41 (32.5) were females. The age range of the patients was between 10 months and 90 years with a mean ± SD of 26.4 ± 15.5 years. Road traffic accident was the most common etiology of which vehicular accidents constituted 50 (54.9%) and the motorcycle was 2 (2.2%). Assault contributed 16 (17.6%) while cases due to gun shots were 13 (14.3%). A total of 19 (15.1%) patients had associated head injuries, 11 (8.7%) patients had craniofacial fractures involving any of the bones while 3 (2.4%) patients had limb fractures and 2 (1.6%) patients had rib fractures. There were 51 (41.8%) cases classified as mild injuries, 37 (30.3%) cases as moderate injuries and 24 (19.7%) cases as severe injuries. Total of 126 cases managed, 121 (96.0%) received primary closure of the wounds while 5 (4.0%) received delayed closure under general anesthesia.
  41,257 80 5
Use of antiemetics in children with acute gastroenteritis: Are they safe and effective?
Jacob Manteuffel
January-April 2009, 2(1):3-5
DOI:10.4103/0974-2700.44674  PMID:19561947
The use of antiemetics is a controversial topic in treatment of pediatric gastroenteritis. Although not recommended by the American Academy of Pediatrics, antiemetics are commonly prescribed by physicians. A review of the literature shows side effects of promethazine, prochlorperazine, and metoclopramide are common and potentially dangerous. Ondansetron has recently been studied as an adjunct to oral rehydration therapy in treatment of acute gastroenteritis with mild to moderate dehydration. Although studies are limited, early research suggests the medication is safe when used in a single dose and can be effective to prevent vomiting, the need for intravenous fluids, and hospital admission.
  29,129 659 4
The role of bedside ultrasound in the diagnosis of pericardial effusion and cardiac tamponade
Adam Goodman, Phillips Perera, Thomas Mailhot, Diku Mandavia
January-March 2012, 5(1):72-75
DOI:10.4103/0974-2700.93118  PMID:22416160
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.
  25,589 151 19
Emergency treatment of a snake bite: Pearls from literature
Syed Moied Ahmed, Mohib Ahmed, Abu Nadeem, Jyotsna Mahajan, Adarash Choudhary, Jyotishka Pal
July-December 2008, 1(2):97-105
DOI:10.4103/0974-2700.43190  PMID:19561988
Snake bite is a well-known occupational hazard amongst farmers, plantation workers, and other outdoor workers and results in much morbidity and mortality throughout the world. This occupational hazard is no more an issue restricted to a particular part of the world; it has become a global issue. Accurate statistics of the incidence of snakebite and its morbidity and mortality throughout the world does not exist; however, it is certain to be higher than what is reported. This is because even today most of the victims initially approach traditional healers for treatment and many are not even registered in the hospital. Hence, registering such patients is an important goal if we are to have accurate statistics and reduce the morbidity and mortality due to snakebite. World Health Organization/South East Asian Region Organisation (WHO/SEARO) has published guidelines, specific for the South East Asian region, for the clinical management of snakebites. The same guidelines may be applied for managing snakebite patients in other parts of the world also, since no other professional body has come up with any other evidence-based guidelines. In this article we highlight the incidence and clinical features of different types of snakebite and the management guidelines as per the WHO/SEARO recommendation.
  24,368 1,017 32
Simulation-based learning: Just like the real thing
Fatimah Lateef
October-December 2010, 3(4):348-352
DOI:10.4103/0974-2700.70743  PMID:21063557
Simulation is a technique for practice and learning that can be applied to many different disciplines and trainees. It is a technique (not a technology) to replace and amplify real experiences with guided ones, often "immersive" in nature, that evoke or replicate substantial aspects of the real world in a fully interactive fashion. Simulation-based learning can be the way to develop health professionals' knowledge, skills, and attitudes, whilst protecting patients from unnecessary risks. Simulation-based medical education can be a platform which provides a valuable tool in learning to mitigate ethical tensions and resolve practical dilemmas. Simulation-based training techniques, tools, and strategies can be applied in designing structured learning experiences, as well as be used as a measurement tool linked to targeted teamwork competencies and learning objectives. It has been widely applied in fields such aviation and the military. In medicine, simulation offers good scope for training of interdisciplinary medical teams. The realistic scenarios and equipment allows for retraining and practice till one can master the procedure or skill. An increasing number of health care institutions and medical schools are now turning to simulation-based learning. Teamwork training conducted in the simulated environment may offer an additive benefit to the traditional didactic instruction, enhance performance, and possibly also help reduce errors.
  24,207 930 158
Principles of diagnosis and management of traumatic pneumothorax
Anita Sharma, Parul Jindal
January-June 2008, 1(1):34-41
DOI:10.4103/0974-2700.41789  PMID:19561940
Presence of air and fluid with in the chest might have been documented as early as Fifth Century B.C. by a physician in ancient Greece, who practiced the so-called Hippocratic succession of the chest. This is due to a development of communication between intrapulmonary air space and pleural space, or through the chest wall between the atmosphere and pleural space. Air enters the pleural space until the pressure gradient is eliminated or the communication is closed. Increasing incidence of road traffic accidents, increasing awareness of healthcare leading to more advanced diagnostic procedures, and increasing number of admissions in intensive care units are responsible for traumatic (noniatrogenic and iatrogenic) pneumothorax. Clinical spectrum of pneumothorax varies from asymptomatic patient to life-threatening situations. Diagnosis is usually made by clinical examination. Simple erect chest radiograph is sufficient though; many investigations are useful in accessing the future line of action. However, in certain life-threatening conditions obtaining imaging studies can causes an unnecessary and potential lethal delay in treatment.
  22,606 1,101 29
Traumatic injuries in patients with diabetes mellitus
Ayman El-Menyar, Ahammed Mekkodathil, Hassan Al-Thani
April-June 2016, 9(2):64-72
DOI:10.4103/0974-2700.179461  PMID:27162438
Diabetes mellitus (DM) is associated with increased in-hospital morbidity and mortality in patients sustained traumatic injuries. Identification of risk factors of traumatic injuries that lead to hospital admissions and death in DM patients is crucial to set effective preventive strategies. We aimed to conduct a traditional narrative literature review to describe the role of hypoglycemia as a risk factor of driving and fall-related traumatic injuries. DM poses significant burden as a risk factor and predictor of worse outcomes in traumatic injuries. Although there is no consensus on the impact and clear hazards of hyperglycemia in comparison to the hypoglycemia, both extremes of DM need to be carefully addressed and taken into consideration for proper management. Moreover, physicians, patients, and concerned authorities should be aware of all these potential hazards to share and establish the right management plans.
  23,134 101 7
Acute gastric dilatation in a patient with anorexia nervosa binge/purge subtype
Ailis M Tweed-Kent, Peter J Fagenholz, Hasan B Alam
October-December 2010, 3(4):403-405
DOI:10.4103/0974-2700.70774  PMID:21063567
Acute gastric dilatation is a rare complication of anorexia nervosa binge/purge subtype that results from gastrointestinal abnormalities, including decreased gastric motility and delayed gastric emptying. Early diagnosis and intervention is critical since delay may result in gastric necrosis, perforation, shock, and death. We report a 26-year-old female with anorexia nervosa binge/purge subtype, who presented with abdominal pain and nausea after a binge episode. Abdominal radiography and computed tomography showed a grossly dilated stomach measuring 32 cm Χ 17.9 cm consistent with acute gastric dilatation. She underwent exploratory laparotomy with gastrotomy and gastric decompression, and recovered uneventfully. Initially, the patient denied the binge episode, as many patients with eating disorders do, but later revealed an extensive history of anorexia nervosa binge/purge subtype. This case stresses the importance of obtaining a thorough history of eating disorders and maintaining a high index of suspicion for acute gastric dilatation in young women who present with abdominal pain and distention.
  21,886 80 13
Leptospirosis: The "mysterious" mimic
Ricardo Izurieta, Sagar Galwankar, Angela Clem
January-June 2008, 1(1):21-33
DOI:10.4103/0974-2700.40573  PMID:19561939
Leptospirosis is a potentially fatal bacterial disease that can display a wide array of clinical presentations thus mimicking better-known illnesses. Although, leptospirosis is primarily a zoonotic disease, it frequently inflicts severe illness and death on communities around the globe. A comprehensive overview of the disease in wake of the 2006 outbreaks in India is hereby presented and discussed.
  20,284 526 18
Simulation-based team training at the sharp end: A qualitative study of simulation-based team training design, implementation, and evaluation in healthcare
Sallie J Weaver, Eduardo Salas, Rebecca Lyons, Elizabeth H Lazzara, Michael A Rosen, Deborah DiazGranados, Julia G Grim, Jeffery S Augenstein, David J Birnbach, Heidi King
October-December 2010, 3(4):369-377
DOI:10.4103/0974-2700.70754  PMID:21063560
This article provides a qualitative review of the published literature dealing with the design, implementation, and evaluation of simulation-based team training (SBTT) in healthcare with the purpose of providing synthesis of the present state of the science to guide practice and future research. A systematic literature review was conducted and produced 27 articles meeting the inclusion criteria. These articles were coded using a low-inference content analysis coding scheme designed to extract important information about the training program. Results are summarized in 10 themes describing important considerations for what occurs before, during, and after a training event. Both across disciplines and within Emergency Medicine (EM), SBTT has been shown to be an effective method for increasing teamwork skills. However, the literature to date has underspecified some of the fundamental features of the training programs, impeding the dissemination of lessons learned. Implications of this study are discussed for team training in EM.
  19,552 131 34
Acute scrotal bleeding
Sudip Kumar Ghosh, Debabrata Bandyopadhyay
October-December 2010, 3(4):416-417
DOI:10.4103/0974-2700.70778  PMID:21063571
We report a case of acute scrotal hemorrhage from multiple angiokeratomas on scrotum, because of the rarity of the condition and to emphasize the importance of considering this condition in the evaluation of acute scrotal bleeding.
  19,433 75 -
The advent of ECMO and pumpless extracorporeal lung assist in ARDS
IA Hamid, AS Hariharan, NR Ravi Shankar
April-June 2011, 4(2):244-250
DOI:10.4103/0974-2700.82212  PMID:21769212
Despite advances in critical care facilities and ventilation therapies acute respiratory distress syndrome (ARDS) is associated with high mortality rates. The condition can stem from a multitude of causes including pneumonia, septicemia and trauma ultimately resulting in ARDS. ARDS is characterized by respiratory insufficiency with severe hypoxemia or hypercapnia. The treatment strategy depends on the knowledge of the underlying disease. But lung-protective ventilation with adjusted positive end-expiratory pressure remains the most effective therapeutic tool despite advances in prone positioning, inhalation of nitric oxide and the use of steroids. Newer modalities including extracorporeal membrane oxygenation (ECMO) and pumpless extracorporeal lung assist (PECLA) are being increasingly introduced in critical care settings as rescue therapies in patients who fail to respond to conservative measures. We describe here the introduction and advances of both ECMO and PECLA in the management of ARDS.
  19,152 66 7
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 Injuryin 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.
  18,797 220 61
Delirium in the intensive care unit
Suresh Arumugam, Ayman El-Menyar, Ammar Al-Hassani, Gustav Strandvik, Mohammad Asim, Ahammed Mekkodithal, Insolvisagan Mudali, Hassan Al-Thani
January-March 2017, 10(1):37-46
DOI:10.4103/0974-2700.199520  PMID:28243012
Delirium is characterized by impaired cognition with nonspecific manifestations. In critically ill patients, it may develop secondary to multiple precipitating or predisposing causes. Although it can be a transient and reversible syndrome, its occurrence in Intensive Care Unit (ICU) patients may be associated with long-term cognitive dysfunction. This condition is often under-recognized by treating physicians, leading to inappropriate management. For appropriate management of delirium, early identification and risk factor assessment are key factors. Multidisciplinary collaboration and standardized care can enhance the recognition of delirium. Interdisciplinary team working, together with updated guideline implementation, demonstrates proven success in minimizing delirium in the ICU. Moreover, should the use of physical restraint be necessary to prevent harm among mechanically ventilated patients, ethical clinical practice methodology must be employed. This traditional narrative review aims to address the presentation, risk factors, management, and ethical considerations in the management of delirium in ICU settings.
  18,030 510 22
Management of maxillofacial trauma in emergency: An update of challenges and controversies
Anson Jose, Shakil Ahmed Nagori, Bhaskar Agarwal, Ongkila Bhutia, Ajoy Roychoudhury
April-June 2016, 9(2):73-80
DOI:10.4103/0974-2700.179456  PMID:27162439
Trauma management has evolved significantly in the past few decades thereby reducing mortality in the golden hour. However, challenges remain, and one such area is maxillofacial injuries in a polytrauma patient. Severe injuries to the maxillofacial region can complicate the early management of a trauma patient owing to the regions proximity to the brain, cervical spine, and airway. The usual techniques of airway breathing and circulation (ABC) management are often modified or supplemented with other methods in case of maxillofacial injuries. Such modifications have their own challenges and pitfalls in an already difficult situation.
  18,038 471 12
A 19-year-old male with palpitations
Shailendra Upadhyay, Shweta Upadhyay
January-June 2008, 1(1):55-57
DOI:10.4103/0974-2700.41792  PMID:19561944
A 19-year-old male presented to the emergency department (ED) following intermittent episodes of palpitations. Classical "epsilon waves" noted on his initial electrocardiogram prompted an evaluation for arrhythmogenic right ventricular dysplasia (ARVD). The diagnosis was confirmed with magnetic resonance imaging of the heart and stress test. A prompt recognition and management of this condition in the ED helped prevent significant mortality that may be associated with ARVD.
  16,769 326 -
Pediatric cardiac emergencies: Children are not small adults
Aisha Frazier, Elizabeth A Hunt, Kathryn Holmes
January-March 2011, 4(1):89-96
DOI:10.4103/0974-2700.76842  PMID:21633575
Compared with adults, cardiac emergencies are infrequent in children and clinical presentation is often quite variable. In adults, cardiac emergencies are most commonly related to complications of coronary artery disease; however, in pediatric cases, the coronaries are only rarely the underlying problem. Pediatric cardiac emergencies comprise a range of pathology including but not limited to undiagnosed congenital heart disease in the infant; complications of palliated congenital heart disease in children; arrhythmias related to underlying cardiac pathology in the teenager and acquired heart disease. The emergency room physician and pediatric intensivist will usually be the first and second lines of care for pediatric cardiac emergencies and thus it is imperative that they have knowledge of the diverse presentations of cardiac disease in order to increase the likelihood of delivering early appropriate therapy and referral. The objective of this review is to outline cardiac emergencies in the pediatric population and contrast the presentation with adults.
  16,825 156 4
Physiopathology of shock
Fabrizio Giuseppe Bonanno
April-June 2011, 4(2):222-232
DOI:10.4103/0974-2700.82210  PMID:21769210
Shock syndromes are of three types namely cardiogenic, hemorrhagic and inflammatory. They differ in physiological and pathological pathways and clinical presentations. The Management also differs considerably. In hemorrhagic shock there is a failure of the peripheral circulation that has its initial deranged variables in the blood volume and venous return while in cardiogenic Shock there is primary pump failure where the cardiac output/mean arterial pressure are deranged. Contrary to this in Inflammatory Shock the microcirculation is affected while the initial deranged macrocirculation variable is the total peripheral resistance hit by systemic inflammatory response. various toxins and pathways play a role in these differing presentations. In the article below an effort has been made to understand the Physiology and Pathology behind different types of shocks.
  15,232 364 16
A primer on burn resuscitation
Ferdinand K Bacomo, Kevin K Chung
January-March 2011, 4(1):109-113
DOI:10.4103/0974-2700.76845  PMID:21633578
Since the early 1900s, the scope of burn resuscitation has evolved dramatically. Due to various advances in pre-hospital care and training, under-resuscitation of patients with severe burns is now relatively uncommon. Over-resuscitation, otherwise known as "fluid creep", has emerged as one of the most important problems during the initial phases of burn care over the past decade. To avoid the complications of over-resuscitation, careful hourly titration of fluid rates based on compilation of various clinical end points by a bedside provider is vital. The aim of this review is to provide a practical approach to the resuscitation of severely burned patients.
  15,143 111 11
Abdominal compartment syndrome - Intra-abdominal hypertension: Defining, diagnosing, and managing
Theodossis S Papavramidis, Athanasios D Marinis, Ioannis Pliakos, Isaak Kesisoglou, Nicki Papavramidou
April-June 2011, 4(2):279-291
DOI:10.4103/0974-2700.82224  PMID:21769216
Abdominal compartment syndrome (ACS) and intra-abdominal hypertension (IAH) are increasingly recognized as potential complications in intensive care unit (ICU) patients. ACS and IAH affect all body systems, most notably the cardiac, respiratory, renal, and neurologic systems. ACS/IAH affects blood flow to various organs and plays a significant role in the prognosis of the patients. Recognition of ACS/IAH, its risk factors and clinical signs can reduce the morbidity and mortality associated. Moreover, knowledge of the pathophysiology may help rationalize the therapeutic approach. We start this article with a brief historic review on ACS/IAH. Then, we present the definitions concerning parameters necessary in understanding ACS/IAH. Finally, pathophysiology aspects of both phenomena are presented, prior to exploring the various facets of ACS/IAH management.
  14,871 195 45
World Academic Council of Emergency Medicine experience document: Implementation of point-of-care thromboelastography at an academic emergency and trauma center
Bianca M Wahlen, Ayman El-Menyar, Ruben Peralta, Hassan Al-Thani
October-December 2018, 11(4):265-270
DOI:10.4103/JETS.JETS_134_17  PMID:30568368
Background: We aimed to discuss the initial experience of the implementation of point-of-care thromboelastography (POC-TEG) at the Level 1 Trauma Center of an academic health institution in Qatar. Materials and Methods: A TEG protocol was developed and tailored to our hospital requirements and patient population, after an exhausting review of the literature and international published protocols, including a synthesis of a preexisting TEG protocol from our heart hospital. To successfully achieve the incorporation of point-of-care testing (POCT) in our clinical practice, a multidisciplinary organizational and education approach is required. The education and training of the physicians in this POCT modality during the first 3 months period has been described in detail. Results: A TEG protocol has been developed and implemented according to hospital standards. Ten physicians from the department of trauma surgery have been trained over a 3-month period to perform the daily quality control as well as the patient samples in order to provide a 24/7 service. In patients with major trauma, brain injury, bleeding, sepsis, and coagulopathy are the most important determinants of the clinical course and outcomes. Viscoelastic whole-blood assays have already proved their values in cardiac as well as liver surgery. Therefore, this POCT-directed approach would be considered as a part of the goal-directed management in severe polytrauma patients. Conclusions: Our experience shows that implementation of POC-TEG program is feasible and it is a promising tool in the management of major trauma patients with a potential compromised coagulation. However, further prospective research projects and well-trained personnel still warranted.
  14,645 57 1
Acute management of vascular air embolism
Nissar Shaikh, Firdous Ummunisa
September-December 2009, 2(3):180-185
DOI:10.4103/0974-2700.55330  PMID:20009308
Vascular air embolism (VAE) is known since early nineteenth century. It is the entrainment of air or gas from operative field or other communications into the venous or arterial vasculature. Exact incidence of VAE is difficult to estimate. High risk surgeries for VAE are sitting position and posterior fossa neurosurgeries, cesarean section, laparoscopic, orthopedic, surgeries invasive procedures, pulmonary overpressure syndrome, and decompression syndrome. Risk factors for VAE are operative site 5 cm  above the heart, creation of pressure gradient which will facilitate entry of air into the circulation, orogenital sex during pregnancy, rapid ascent in scuba (self contained underwater breathing apparatus) divers and barotrauma or chest trauma. Large bolus of air can lead to right ventricular air lock and immediate fatality. In up to 35% patient, the foramen ovale is patent which can cause paradoxical arterial air embolism. VAE affects cardiovascular, pulmonary and central nervous system. High index of clinical suspicion is must to diagnose VAE. The transesophgeal echocardiography is the most sensitive device which will detect smallest amount of air in the circulation. Treatment of VAE is to prevent further entrainment of air, reduce the volume of air entrained and haemodynamic support. Mortality of VAE ranges from 48 to 80%. VAE can be prevented significantly by proper positioning during surgery, optimal hydration, avoiding use of nitrous oxide, meticulous care during insertion, removal of central venous catheter, proper guidance, and training of scuba divers.
  13,934 485 41
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