Journal of Emergencies, Trauma, and Shock
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   2018| January-March  | Volume 11 | Issue 1  
    Online since February 19, 2018

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Prehospital Ultrasound in Trauma: A Review of Current and Potential Future Clinical Applications
Tharwat El Zahran, Mazen J El Sayed
January-March 2018, 11(1):4-9
DOI:10.4103/JETS.JETS_117_17  PMID:29628662
Ultrasound (US) is an essential tool for evaluating trauma patients in the hospital setting. Many previous in-hospital studies have been extrapolated to out of hospital setting to improve diagnostic accuracy in prehospital and austere environments. This review article presents the role of prehospital US in blunt and penetrating trauma management with emphasis on its current clinical applications, challenges, and future implications of such use.
  12,238 62 5
Cardiopulmonary Resuscitation: Unusual Techniques for Unusual Situations
Vidhu Bhatnagar, Kavitha Jinjil, Deepak Dwivedi, Rohit Verma, Urvashi Tandon
January-March 2018, 11(1):31-37
DOI:10.4103/JETS.JETS_58_17  PMID:29628666
Background: The cardiopulmonary resuscitation (CPR) in prone position has been dealt with in 2010 American Heart Association (AHA) guidelines but have not been reviewed in 2015 guidelines. The guidelines for patients presenting with cardiac arrest under general anesthesia in lateral decubitus position and regarding resuscitation in confined spaces like airplanes are also not available in AHA guidelines. This article is an attempt to highlight the techniques adopted for resuscitation in these unusual situations. Aims: This study aims to find out the methodology and efficacy in nonconventional CPR approaches such as CPR in prone, CPR in lateral position, and CPR in confined spaces. Methods: We conducted a literature search using MeSH search strings such as CPR + Prone position, CPR + lateral Position, and CPR + confined spaces. Results: No randomized controlled trials are available. The literature search gives a handful of case reports, some simulation- and manikin-based studies but none can qualify for class I evidence. The successful outcome of CPR performed in prone position has shown compressions delivered on the thoracic spine with the same rate and force as they were delivered during supine position. A hard surface is required under the patient to provide uniform force and sternal counter pressure. Two rescuer technique for providing successful chest compression in lateral position has been documented in the few case reports published. Over the head CPR and straddle (STR), CPR has been utilized for CPR in confined spaces. Ventilation in operating rooms was taken care by an advanced airway in situ. Conclusion: A large number of studies of high quality are required to be conducted to determine the efficacy of CPR in such positions.
  7,132 70 12
Bilateral Hip Dislocation: An Indicator for Emergent Full-Body Computed Tomography Scan in Polytraumatized Patients? A Case Report and Review of the Literature
Benjamin Rufer, Marius Johann Baptist Keel, Beat Schnüriger, Moritz Caspar Deml
January-March 2018, 11(1):53-56
DOI:10.4103/JETS.JETS_12_17  PMID:29628670
We present a rare case of traumatic bilateral asymmetric hip dislocation with pelvic fractures and a traumatic diaphragmatic hernia. A 53-year-old machinist was transferred to our emergency department with the suspicion of a bilateral hip dislocation after he was trapped between an elevator and the roof. Immediate closed reduction of the hips was not performed because of the expected risk of increasing hemodynamic instability with muscular relaxation. An emergent full-body computed tomography (CT) scan was made to assess injuries with need for further operative treatment. Thus, closed reduction of both hips was finally performed in the OR directly before the laparotomy for the diaphragmatic repair and the osteosynthesis of the anterior pelvic ring. A 12-month follow-up showed good general health condition with asymptomatic situation of the hip joints and the abdomen. The diagnostic work-up of patients with severe trauma is still debated, a randomized controlled trial showed no reduction of the in-hospital mortality with immediate full-body CT scan compared to a conventional radiological work-up. Traumatic hip dislocations (THDs) are always due to high-energy trauma and additional injuries are frequent. To attempt a closed reduction of THD, under general anesthesia can be life-threatening with unrecognized associated injuries. Therefore, THD can serve as selection criteria for immediate full-body CT scan to facilitate diagnosis and treatment of associated injuries sustained by the patient.
  3,717 20 -
Evaluation of Change in Knowledge and Attitude of Emergency Medicine Residents after Introduction of a Rotation in Emergency Medical Services and Disaster Medicine
Nawfal Aljerian, Aamir Omair, Sami A Yousif, Abdulrahman S Alqahtani, Faisal A Alhusain, Bader Alotaibi, Mohammad F Alshehri, Majed Aljuhani, Saad Albaiz, Yasser Alaska, Abdullah F Alanazi
January-March 2018, 11(1):42-46
DOI:10.4103/JETS.JETS_67_17  PMID:29628668
Background: Saudi Board of Emergency Medicine (SBEM) graduates are involved in a 1-month rotation in emergency medical services (EMSs) and disaster medicine. The purpose of this study was to evaluate change in knowledge and attitude of EM residents after the introduction of the EMS and disaster medicine rotation. Materials and Methods: The study included 32 3rd-year SBEM residents. A pretest/posttest design and a five-point Likert scale were used. The data included a response to a questionnaire developed by EMS and disaster experts. The questionnaire was distributed on the 1st day of the rotation and 45 days after. Satisfaction questionnaires were distributed after the rotation. The data were analyzed using SPSS 20. Results: Twenty-five residents responded to the satisfaction survey (75%). The overall satisfaction with the course modules was high; the course content showed the highest level of satisfaction (96%), and the lowest satisfaction was for the air ambulance ride outs (56%). The results of the pre-/post-test questionnaire showed an increase of 18.5% in the residents mean score (P < 0.001). In the open-ended section, the residents requested that the schedule is distributed before the course start date, to have more field and hands-on experience, and to present actual disaster incidents as discussion cases. The residents were impressed with the organization and diversity of the lectures, and to a lesser extent for the ambulance ride outs and the mass casualty incident drill l. Seventy-one percent indicated that they would recommend this course to other residents. Conclusion/Recommendation: This study showed that a structured course in EMS and disaster medicine had improved knowledge and had an overall high level of satisfaction among the residents of the SBEM. Although overall satisfaction and improvement in knowledge were significant, there are many areas in need of better organization.
  3,594 38 1
The Intensive Care Unit Perspective of Becoming a Level I Trauma Center: Challenges of Strategy, Leadership, and Operations Management
Richard H Savel, Wess Cohen, Dena Borgia, Ronald J Simon
January-March 2018, 11(1):65-70
DOI:10.4103/JETS.JETS_9_17  PMID:29628674
The primary purpose of this narrative is to elucidate the numerous significant changes that occur at the intensive care unit (ICU) level as a medical center pursues becoming a Level I trauma center. Specifically, we will focus on the following important areas: (1) leadership and strategy issues behind the decision to move forward with becoming a trauma center; (2) preparation needed to take a highly functioning surgical ICU and align it for the inevitable changes that happen as trauma go-live occurs; (3) intensivist staffing changes; (4) roles for and training of advanced practice practitioners; (5) graduate medical education issues; (6) optimizing interactions with closely related services; (7) nursing, staffing, and training issues; (8) bed allocation issues; and (9) reconciling the advantages of a “unified adult critical care service” with the realities of the central relationship between trauma and surgical critical care.
  3,502 24 -
Computed Tomography Profile and its Utilization in Head Injury Patients in Emergency Department: A Prospective Observational Study
Archana Waganekar, Jagadish Sadasivan, A Sathia Prabhu, KT Harichandrakumar
January-March 2018, 11(1):25-30
DOI:10.4103/JETS.JETS_112_17  PMID:29628665
Context: Based on Glasgow Coma Scale (GCS), head injury can be classified as minor (GCS 13–15), moderate (GCS 9–12), and severe (GCS 3–8). There is a lot of controversy in the use of computed tomography (CT) in head injury patients. Aims: This study was intended to estimate the rate of CT positivity in head injury patients and to define the criteria for doing CT in head injury patients. Settings and Design: This was a prospective observational study in the emergency department (ED) over a 12-month period. Subjects and Methods: Study involved all head injury patients attending ED. Risk factors studied were a loss of consciousness (LOC), vomiting, seizures, ear bleed, nosebleed, external injuries, and alcohol intoxication. Statistical Analysis Used: Comparison of CT positivity with the patient's demographics and clinical characteristics was carried out using Chi-square. Results: A total of 1782 patients were included in this study. Overall CT positivity was 50.9%. In minor head injury (MHI), CT positivity rate was 38%. The study showed significant association of CT positivity with five variables: LOC >5 min, vomiting, seizures, ear bleed, and nosebleed. Conclusions: From the study, we recommend following: CT is indicated in all patients with moderate and severe head injury (GCS ≤12). Low threshold for taking CT is advisable in elderly and alcohol-intoxicated patients. In MHI, CT is indicated if any one of the following risk factors are present: LOC >5 min, history of vomiting, history of seizures, history of ear bleed, and history of nosebleed.
  3,086 33 2
The “Case-Based Learning Conference” Model at EMINDIA2017: A Novel Implementation of Problem-Based Educational Paradigm
Vivek Chauhan, Sagar Galwankar, Stanislaw P Stawicki, Naman Agrawal, S Vimal Krishnan, Sanjeev Bhoi, Tej Prakash Sinha, Praveen Aggarwal
January-March 2018, 11(1):61-64
DOI:10.4103/JETS.JETS_81_17  PMID:29628673
INDUSEM was established as an INDO-US Satellite Knowledge Network in 2005. It brought together the academic leaders and innovators from India and the US with the goal of creating collaborative synergies and creative solutions to advance the knowledge and science of emergency medicine (EM) in India. Since 2005, the leadership of INDUSEM devoted substantial resources, effort, and expertise to ensure that newly implemented clinical institutes and training programs have the necessary resources and logistical support to effectively advance EM and Traumatology Sciences in India. As a result, significant synergies and progress were achieved toward establishing EM training programs and building clinical infrastructure through education, grant funding, research, skills development, bidirectional collaborations, and sustained influence on public health policy development. As INDUSEM's mission matures, its efforts will increasingly focus on creating long-term sustainability across clinical, didactic, educational, outreach, health policy, and research domains. In this joint statement, the authors describe the evolution of INDUSEM's institution of INDO-US Summit into the World Academic Congress of EM , with the parallel inception of an India-centric academic enterprise, EMINDIA.
  3,053 23 -
Scrotal Reconstruction with Integra Following Necrotizing Fasciitis
Briar L Dent, Anant Dinesh, Khuram Khan, Ryan Engdahl
January-March 2018, 11(1):57-59
DOI:10.4103/JETS.JETS_62_17  PMID:29628671
Scrotal loss from Fournier's gangrene can be a devastating injury with esthetic and functional consequences. Local reconstructive options can be limited by the presence of infection or the loss of neighboring tissue from debridement. IntegraTM bilayer matrix wound dressing is a well-established reconstructive modality, but only one report exists of its use in scrotal reconstruction and this was not in the setting of Fournier's gangrene. We report the successful use of Integra and a subsequent split-thickness skin graft for reconstruction of the anterior scrotum and coverage of the exposed testes in a 43-year-old man who developed Group A Streptococcus necrotizing fasciitis of his right lower extremity, groin, and scrotum requiring serial operative debridements. Stable testicular coverage was achieved with closely matched skin and minimal donor-site morbidity. Further study and a larger sample size will be necessary to better understand the advantages and disadvantages of scrotal reconstruction with Integra.
  3,048 22 2
7.5% NaCl Resuscitation Leads to Abnormal Clot Fibrinolysis after Severe Hemorrhagic Shock and its Correction with 7.5% NaCl Adenosine, Lidocaine, and Mg2+
Hayley Louise Letson, Geoffrey Phillip Dobson
January-March 2018, 11(1):15-24
DOI:10.4103/JETS.JETS_84_17  PMID:29628664
Background: Hyperfibrinolysis is a common complication of hemorrhagic shock. Our aim was to examine the effect of small-volume 7.5% NaCl adenosine, lidocaine, and Mg2+ (ALM) on fibrinolysis in the rat model of hemorrhagic shock. Methods: Rats were anesthetized and randomly assigned to one of four groups: (1) baseline, (2) shock, (3) 7.5% NaCl controls, and (4) 7.5% NaCl ALM. Animals were bled for 20 min (42% blood loss) and left in shock for 60 min before resuscitation with 0.3 ml intravenous bolus 7.5% NaCl ± ALM. Rats were sacrificed at 5, 10, 15, 30, and 60 min for rotation thromboelastometry and 15 and 60 min for ELISA analyses. Results: After hemorrhagic shock, 7.5% NaCl failed to resuscitate and exacerbated coagulopathy and fibrinolysis. At 15 and 60 min, the activation as extrinsically-activated test using tissue factor (EXTEM) with aprotinin to inhibit fibrinolysis (APTEM) test showed little or no correction of fibrinolysis, indicating a plasmin-independent fibrinolysis. Clots also had ~ 60% lower fibrinogen (fibrin-based EXTEM activated test with platelet inhibitor cytochalasin D A10) and 36%–50% reduced fibrinogen-to-platelet ratio (11%–14% vs. 22% baseline). In contrast, 7.5% NaCl ALM resuscitated mean arterial pressure and attenuated hyperfibrinolysis and coagulopathy by 15 min. Correction was associated with lower plasma tissue factor, higher plasminogen activator inhibitor-1, and lower D-dimers (5% of controls at 60 min). Platelet selectin fell to undetectable levels in ALM animals, which may imply improved endothelial and platelet function during resuscitation. Conclusions: Small-volume 7.5% NaCl resuscitation exacerbated coagulopathy and fibrinolysis that was not corrected by APTEM test. Fibrinolysis appears to be associated with altered fibrin structure during early clot formation and elongation. In contrast, 7.5% NaCl ALM rapidly corrected both coagulopathy and hyperfibrinolysis.
  3,001 19 1
Distribution of Laboratory Parameters in Trauma Population
Prashant Bhandarkar, Ranabir Pal, Ashok Munivenkatappa, Nobhojit Roy, Vineet Kumar, Amit Agrawal
January-March 2018, 11(1):10-14
DOI:10.4103/JETS.JETS_70_17  PMID:29628663
Background: Biochemical laboratory investigations help plan optimum management and communication in short- as well as long-term outcome to trauma victims. Objective: To assess the status of real-time values of biochemical laboratory investigations of different trauma patients and their association with overall mortality. Materials and Methods: Data based on prospective, observational registry of “Towards Improved Trauma Care Outcomes” (TITCO) from four Indian city hospitals. Hemoglobin, hematocrit, random blood sugar, blood urea nitrogen (BUN), and serum creatinine of patients on admission were recorded. Logistic regression was applied with all biochemical investigation as independent variable and overall mortality as dependent variable. Results: Among 17047 trauma patients, 3456 with available laboratory result details were considered for this study. Overall mortality was 20% (range 14%–21%). For the higher laboratory results, value mortality was 21%–70%, with highest death (70%) for higher hemoglobin patients, followed by hematocrit (44%) and then creatinine (43%). Odds of high hemoglobin compared to normal were 15.20; odds of higher and lower of normal creatinine were 3.80 and 1.65 and for BUN were 2.17 and 1.92, respectively. Gender-wise significant difference was in overall female mortality (29%)% compared males (18%). Similar differences were replicated with results of each laboratory tests. Conclusion: The study ascertained the composite additional explanatory values of laboratory parameters in predicting outcome among injured patients in our population from Indian settings.
  2,968 24 1
Early Predictive Factors of Hypofibrinogenemia in Acute Trauma Patients
Angeline Neetha Radjou
January-March 2018, 11(1):2-3
DOI:10.4103/JETS.JETS_83_17  PMID:29628661
  2,872 22 1
Whats New in Emergencies, Trauma and Shock? Computed Tomography Profile and its Utilization in Traumatic Brain Injury
Amit Agrawal, Luis Rafael Moscote-Salazar
January-March 2018, 11(1):1-1
DOI:10.4103/JETS.JETS_125_17  PMID:29628660
  2,765 20 -
Early Predictive Factors of Hypofibrinogenemia in Acute Trauma Patients
Shahram Paydar, Behnam Dalfardi, Zahra Shayan, Leila Shayan, Jalal Saem, Shahram Bolandparvaz
January-March 2018, 11(1):38-41
DOI:10.4103/JETS.JETS_37_17  PMID:29628667
Background: Uncontrolled hemorrhage still remains a major cause of trauma-associated mortality. The events resulting in acute traumatic coagulopathy, particularly hypofibrinogenemia, make control of bleeding difficult. It is essential to timely predict, diagnose, and manage trauma-induced coagulopathy. Aims: The aim of this study is to determine clinical and easily available laboratory variables that are predictive of hypofibrinogenemia in acute trauma patients. Settings and Design: This 2-year retrospective work examined the data of major trauma patients that were referred to Shahid Rajaee Hospital's emergency room in hemorrhagic shock condition. Materials and Methods: Fibrinogen level was assessed for these patients on their arrival at our facility. Along with clinical and routine paraclinical variables, we evaluated the predictive value of these variables for a fibrinogen level below 100 mg/ml. Results: A total of 855 cases were included (females: 16.4%; and males: 83.6%) in the study. The mean ± SD age was 36 ± 17.9 years, and the mean ± SD injury severity score was 12.2 ± 9. Motor vehicle accident was the most common cause of injury. Three factors, including arterial pH (cut off point = 7.34; area under the curve [AUC]: 0.59), base excess (cutoff point = −4.3; AUC: 0.60), and patients' gender had a significant association with the fibrinogen level under 100 mg/ml. When three factors of pH, BE, and patients' gender are being assessed simultaneously, the AUC became 0.62 (the predictive ability improved). Conclusions: Variables, including arterial pH, BE level, and patients' gender have predictive value for fibrinogen transfusion in trauma.
  2,650 30 3
Variation in the Practice of Central Venous Catheter and Chest Tube Insertions among Surgery Residents
Edward Eun Cho, Elizabeth Bevilacqua, Jeffrey Brewer, James Hassett, Weidun Alan Guo
January-March 2018, 11(1):47-52
DOI:10.4103/JETS.JETS_124_15  PMID:29628669
Objectives: Central venous catheter (CVC) and chest tube (CT) insertions are common bedside procedures frequently performed by surgery residents. Despite published guidelines, variability in the practice exists. We sought to characterize the surgery residents' practice patterns surrounding these two bedside procedures. Materials and Methods: Over the last 1½ months of the academic year in 2012 and 2013, surgery residents across the US were surveyed online. Participants reported levels of agreement for 15 questions in a 5-point Likert scale format. Results: A total of 219 residents completed the survey. Majority of residents agreed that they received appropriate education and training. Over half of the respondents reported that they did not have attending staff physician's supervision during the procedures. Junior residents felt less confident in performing CVC or CT insertions. Those younger than 29 years old and of female sex were also less confident in performing CT insertion. Although almost all residents reported using maximal sterile barrier precautions, 7% reported not securing their gowns and another 7% reported inadequate draping of patients. About ⅓ reported no hand cleansing before the procedures. Those from community programs compared to university programs less frequently used antibiotics. Sixty-five percent of residents reported routine use of ultrasound for CVC insertion. Conclusion: Surgery residents do not strictly adhere to the guidelines for CVC and CT insertions, and there is substantial variation in the practice of the procedures, which may contribute to complications associated with these procedures. This survey opens new areas for in-service education, feedback, and practices for these procedures to reduce the risk of complications, especially the infectious one.
  2,597 26 1
Globe Luxation and Optic Nerve Avulsion by Dog Bite
Justin B Hellman, Lily Koo Lin
January-March 2018, 11(1):60-60
DOI:10.4103/JETS.JETS_107_17  PMID:29628672
  2,213 24 1
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