Emergencies, Trauma, and Shock

What's new in emergencies trauma and shock? Point of care imaging in out-of-hospital cardiac arrest Vivek Chauhan Journal of Emergencies, Trauma, and Shock 2019 12(2):95-96

Alcohol and drug testing in the national trauma data bank: Does it matter? Adel Elkbuli, Brianna Dowd, Rudy Flores, Dessy Boneva, Shaikh Hai, Mark Mckenney Journal of Emergencies, Trauma, and Shock 2019 12(2):97-97

Recreational drugs and outcomes in trauma patients Quinn Fujii, Andrew McCague Journal of Emergencies, Trauma, and Shock 2019 12(2):98-100 Objective: The objective of the study is to determine if marijuana, methamphetamine, or cocaine is associated with worse outcomes following trauma. Methods: A retrospective cross-sectional study was conducted on 731 trauma patients. Data collected from Natividad Medical Center's trauma registry were used to analyze reports of adult patients from July 1, 2014, to July 1, 2017. Analyzed endpoints were mortality, rates of major trauma, mean Injury Severity Score (ISS), and length of stay (LOS). Results: Odds ratios for mortality contained null value in each group. Odds ratios for suffering major trauma for marijuana and amphetamines were 1.2 and 2.6, respectively.P values for ISS were >0.05 for each group.P values for LOS were >0.05 for marijuana and cocaine and 0.01 for amphetamines. Conclusions: A positive screen for marijuana, amphetamine, or cocaine is not associated with increased mortality for victims of trauma. Amphetamines are associated with higher rates of major trauma and longer LOS. Marijuana is associated with higher rates of major trauma. Cocaine is not associated with the likelihood of suffering major trauma or length of stay.

Evaluation of traumatic spine by magnetic resonance imaging and its correlation with cliniconeurological outcome Bukke Ravindra Naik, Anil Kumar Sakalecha, Shivaprasad Gangadhar Savagave Journal of Emergencies, Trauma, and Shock 2019 12(2):101-107 Background: Spinal trauma is associated with long-term disability. Early detection can lead to prompt and accurate diagnosis, expeditious management, and avoidance of unnecessary procedures. Magnetic resonance imaging (MRI) helps to accurately depict the presence and extent of spinal cord injury (SCI) in these patients. Purpose: This study was aimed to look for various MRI findings which are predictive of initial neurological deficit in patients with spinal trauma and to correlate the findings with resultant neurological outcome. Materials and Methods: The present study was conducted over a period of 18 months from January 2016 to June 2017 in 57 patients with spinal trauma who underwent MRI spine. Neurological status of patients was assessed at the time of admission and discharge in accordance with the American Spine Injury Association (ASIA) impairment scale. Various MRI parameters were evaluated for correlation with the severity of the spinal injury. Results: Patients with cord transection, cord hemorrhage, and epidural hematoma had initial high-grade ASIA impairment scale. Patients with cord transection and cord hemorrhage did not show any improvement in their neurological status during their hospital stay. Patients with only cord edema and epidural hematoma showed favorable neurological outcome. Cord contusion showed lesser neurological recovery, as compared with cord edema and normal cord. Conclusion: MRI findings in acute SCI correlated well with the initial neurological deficits on admission and at the time of discharge. MRI should be recommended in all patients with suspected spinal trauma both as a diagnostic and prognostic indicator.

Factors affecting mortality following necrotizing soft-tissue infections: Randomized prospective study Sukha Ram Barupal, Murari Lal Soni, Rekha Barupal Journal of Emergencies, Trauma, and Shock 2019 12(2):108-116 Background and Aim: Necrotizing soft-tissue infections (NSTIs) are common in the Indian subcontinent and are associated with high morbidity and mortality. The aim of this paper was to correlate clinical factors and Acute Physiology Health and Chronic Health Evaluation (APACHE) II score with mortality following NSTI. Methodology: Patients presenting to our tertiary-care center between November 1, 2014, and December 1, 2016, with NSTI and between the age of 15 and 90 years were included and entered into a prospectively maintained database. Fifty random patients were selected from the database and were divided according to the survival outcome into two groups: Group 1-survivors and Group 2-nonsurvivors. The two groups were compared for clinical factors and APACHE II score to identify the variable which correlated with the survival. Results: Mean age of the study cohort (n = 50, 44 males) was 50.8 ± 17.1 years. Fournier's gangrene was the most common manifestation (64%), followed by lower limb (14%). Infection was leading cause (34%) followed by trauma (16%) and prior surgery (14%). There were 16 in-hospital deaths (32%). Two groups were similar regarding age and sex. At presentation, nonsurvival group had significantly higher body surface area involvement (P = 0.001), anemia (P = 0.023), metabolic acidosis (P < 0.0001), serum creatinine (P = 0.007), and mean APACHE II score (P < 0.001). There was no difference between time from presentation to the first debridement. Conclusions: We found that APACHE II is a significant predictor of mortality. Early diagnosis and prompt aggressive treatment is the only way to improve outcome. Further studies with larger sample size are warranted.

Gunshot injuries in Lebanon: Does intent affect characteristics, injury patterns, and outcomes in victims? Hady Zgheib, Sami Shayya, Cynthia Wakil, Rana Bachir, Mazen J El Sayed Journal of Emergencies, Trauma, and Shock 2019 12(2):117-122 Introduction: Lebanon lacks a national database of gunshot injuries (GSIs), which limits injury prevention initiatives. Objectives: This study examines patient characteristics, injury patterns, and clinical outcomes in GSI victims and evaluates the impact of intent on clinical outcomes with the aim of improving awareness among emergency department (ED) physicians about the importance of inquiring about intent to predict prognosis. Materials and Methods: We conducted a retrospective cohort study of GSI victims presenting to the ED of a tertiary care center in Beirut, Lebanon. Descriptive and bivariate analyses were done to identify differences based on intent. Results: A total of 83 patients were included, 59% with intentional GSI, 22% with unintentional GSI, and 19% with unspecified intent. They were mostly males (89.2%), with a mean age of 31.7 years, and mostly presenting during summer seasons. Females were more commonly victims of unintentional GSI. All victims sustaining multiple GSIs were in the intentional group. When compared to unintentional GSI, intentional and unspecified GSIs were found to result in more ICU admissions (46.9%, 31.3%, and 16.7%,P = 0.096), significantly longer hospital stays (18.2, 26.3, and 5.6 days;P = 0.001) and higher mortality (11.6%, 18.2%, and 6.7%;P = 0.747). The rates of surgical procedures were similar between the three groups although more victims of intentional and unspecified GSI underwent multiple surgeries. Conclusion: GSIs have different features, resource utilization, and clinical outcomes depending on the intentionality of injuries. All GSI victims suffer from substantial morbidity and mortality, but intentionally harmed victims sustain more severe injuries with worse outcomes.

Understanding the knowledge and attitude of prehospital sepsis care among emergency medical service personnel Hadeel Sameeh Ghazal, Atheer Abdulaziz Alkhunein, Ahmed Abdullah Alkhazi, Salman Abdulmajeed Aldeheshi, Faisal Ahmed M. Alhusain, Nawfal Al Jerian Journal of Emergencies, Trauma, and Shock 2019 12(2):123-127 Background: Sepsis represents a huge burden for the health-care system. Septic patients presented by emergency medical services (EMS) are usually sicker in comparison to patients arriving by other means. Knowledge of sepsis is a key factor in recognizing and providing the appropriate care; it is not the only barrier as EMS providers do not have access to the proper diagnostic investigation. This work highlighted the level of knowledge, awareness, and attitude of EMS providers regarding prehospital care of sepsis in Riyadh, Saudi Arabia. Methods: This study was a cross-sectional study that conducted among EMS personnel of Saudi Red Crescent Authority and King Abdulaziz Medical City. One hundred and ninety-seven individuals were sampled (99 were technicians and 98 were paramedics). Results: Most participants (71%) were aware of the term “sepsis;” however, only 48% of participants correctly defined sepsis (30% between emergency medical technicians [EMTs] vs. 66% paramedics group,P < 0.01). Paramedics were noted to have a better understanding of signs, symptoms, and management of sepsis. Most of the participants thought that sepsis can be identified during prehospital care (55%) and 75% suggested that they should be involved in the management of septic patients. About 80% responded that their intervention would result in a better outcome for patients and would influence the behavior of emergency department medical care. Most of the participants (83%) were willing to be actively engaged in the prehospital care of septic patients. Conclusion: This study showed an insufficient level of knowledge and awareness regarding sepsis care in the EMS field in Saudi Arabia. Paramedics had more knowledge and awareness about sepsis care compared to EMT personnel. Future work should focus on exploring the reasons behind this, as well as implementing plans to improve education about sepsis for EMS personnel.

Do the care process and survival chances differ in patients arriving to a level 1 Indian trauma center, during-hours and after-hours? Kapil Dev Soni, Santosh Mahindrakar, Gaurav Kaushik, Subodh Kumar, Sushma Sagar, Amit Gupta Journal of Emergencies, Trauma, and Shock 2019 12(2):128-134 Introduction: Trauma systems vary in performance during different time periods and may affect the patient outcomes, especially in resource-limited settings. The present study was undertaken to study the pattern, epidemiological profile, processes of care variations of trauma victims presenting during-hours and after-hours in a level 1 trauma Center of a lower middle-income country. Methodology: Retrospective analyses of prospectively collected data registry at a single tertiary care center. Data collected from 2013 to 2015 were analyzed. Patients with a history of trauma and admission to the center or death between arrival and admission were included. Isolated limb injury and patients dead on arrival were excluded. Results: Of 4692, 1789 (38.1%) patients arrived and were admitted during-hours and 2903 (61.9%) after-hours. The overall in-hospital mortality was 14.9% in the cohort. Moreover, it was 16.10% during after-hours in comparison to 13.0% during-hours. The Revised Trauma Score was statistically different during-hours and after-hours suggesting patients with greater physiological derangement after-hours. The Kaplan–Meier survival curves for 7 days were comparable in two groups with the log-rank test of 078. The proportion of initial radiological investigations (chest X-ray, focused assessment sonography in trauma [FAST], and computerized tomography [CT] scans) was ranged from 84.9% for CT scans in the cohort to 99.3% for FAST. Conclusions: Processes of care do not differ significantly for the patients admitted at a level 1 trauma center irrespective of time of the day. Although survival probability for the initial 7 days of follow-up is comparable between two groups; however, for 30 and 90 days of follow-up they are significantly different between during-hours and after-hours, likely due to injury severity.

An analysis using modified rapid ultrasound for shock and hypotension for patients with endogenous cardiac arrest Youichi Yanagawa, Hiromichi Ohsaka, Hiroki Nagasawa, Ikuto Takeuchi, Kei Jitsuiki, Kazuhiko Omori Journal of Emergencies, Trauma, and Shock 2019 12(2):135-140 Aims: We prospectively investigated whether or not a rapid ultrasound for shock and hypotension (RUSH) examination is useful for managing patients with endogenous cardiac arrest (CA). Settings and Design: A prospective medical chart review in a single hospital. Materials and Methods: From March 2016 to December 2017, we performed a modified RUSH for all patients with out-of-hospital endogenous CA. We investigated the frequency of positive findings on modified RUSH and what kind of diseases could most easily be pinpointed as the cause of CA by the modified RUSH. Results: During the investigation period, 194 participants were enrolled in the present study. They were primarily male, with an average age of 68.8-year-old, and 178/194 (91.7%) died as outpatients. The most frequent cause of CA was cardiogenic, followed by aortic disease, respiratory failure, and stroke except for unknown. There were 14/26 (54%) aortic disease patients who showed positive RUSH findings. Among cases of the aortic disease, only aortic dissections had positive findings. Aside from aortic disease, there were no cases of positive findings of the modified RUSH among the remaining diseases, and all patients with positive findings died. Only pulseless electrical activity (PEA) was a statistically significant factor for positive findings of the modified RUSH in cases of the aortic disease. Conclusions: The present study revealed that, among patients with out-of-hospital endogenous CA, modified RUSH is useful for diagnosing ascending aortic dissection for the detection of hemothorax and/or cardiac tamponade, especially with PEA.

The influence of cervical collar immobilization on optic nerve sheath diameter Joseph Yard, Peter B Richman, Ben Leeson, Kimberly Leeson, Guy Youngblood, Jose Guardiola, Michael Miller Journal of Emergencies, Trauma, and Shock 2019 12(2):141-144 Background: Prior research has revealed that cervical collars elevate intracranial pressure (ICP) in patients with traumatic brain injury. Two recent small studies evaluated the change in optic sheath nerve diameter (ONSD) measured by ultrasound as a proxy for ICP following cervical collar placement in healthy volunteers. Objective: We sought to validate the finding that ONSD measured by ultrasound increases after cervical collar placement within an independent data set. Methods: This was a prospective, crossover study involving volunteers. Participants were randomized to either have the ONSD measured first without a cervical collar or initially with a cervical collar. Two sonographers performed independent ONSD diameter measurements. Continuous data were analyzed by matched-paired t-tests. Alpha was set at 0.05. The primary outcome parameter was the overall mean difference between ONSD measurements with the cervical collar on and off. Multiple linear regression was performed to examine the relationship between variables and the primary outcome parameter. Results: There were 30 participants enrolled in the study. Overall mean ONSD for participants without the collar was 0.365 ± 0.071 cm and with the collar was 0.392 ± 0.081 cm. The mean change in ONSD for participants with and without the collar was 0.026 ± 0.064 cm (95% confidence interval of difference: 0.015–0.038;P < 0.001). Multiple regression analysis did not identify any variables associated with the variation in ONSD observed for collar versus noncollar. Conclusions: We confirmed that ONSD does vary by a measurable amount with placement of a rigid cervical collar on healthy volunteers when assessed by ultrasound.

Alexandros Sfakianakis
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