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2.  A systematic review of the need for MRI for the clearance of cervical spine injury in obtunded blunt trauma patients after normal cervical spine CT 
Clearance of cervical spine injury (CSI) in the obtunded or comatose blunt trauma patient remains controversial. In patients with unreliable physical examination and no evidence of CSI on computed tomography (CT), magnetic resonance imaging of the cervical spine (CS-MRI) is the typical follow-up study. There is a growing body of evidence suggesting that CS-MRI is unnecessary with negative findings on a multi-detector CT (MDCT) scan. This review article systematically analyzes current literature to address the controversies surrounding clearance of CSI in obtunded blunt trauma patients. A literature search through MEDLINE database was conducted using all databases on the National Center for Biotechnology Information (NCBI) website ( for keywords: “cervical spine injury,” “obtunded,” and “MRI.” The search was limited to studies published within the last 10 years and with populations of patients older than 18 years old. Eleven studies were included in the analysis yielding data on 1535 patients. CS-MRI detected abnormalities in 256 patients (16.6%). The abnormalities reported on CS-MRI resulted in prolonged rigid c-collar immobilization in 74 patients (4.9%). Eleven patients (0.7%) had unstable injury detected on CS-MRI alone that required surgical intervention. In the obtunded blunt trauma patient with unreliable clinical examination and a normal CT scan, there is still a role for CS-MRI in detecting clinically significant injuries when MRI resources are available. However, when a reliable clinical exam reveals intact gross motor function, CS-MRI may be unnecessary.
PMCID: PMC4231259  PMID: 25400384
Blunt trauma; cervical spine CT and MRI; obtunded
3.  Outpatient follow-up after traumatic injury: Challenges and opportunities 
It has been shown that rates of ambulatory follow-up after traumatic injury are not optimal, but the association with insurance status has not been studied.
To describe trauma patient characteristics associated with completed follow-up after hospitalization and to compare relative rates of healthcare utilization across payor types.
Setting and Design:
Single institution retrospective cohort study.
Materials and Methods:
We compared patient demographics and healthcare utilization behavior after discharge among trauma patients between April 1, 2005 and April 1, 2010. Our primary outcome of interest was outpatient provider contact within 2 months of discharge.
Statistical Analysis:
Multivariate logistic regression was used to determine the association between characteristics including insurance status and subsequent ambulatory and acute care.
We reviewed the records of 2906 sequential trauma patients. Patients with Medicaid and those without insurance were significantly less likely to complete scheduled outpatient follow-up within 2 months, compared to those with private insurance (Medicaid, OR 0.67, 95% CI 0.51-0.88; uninsured, OR 0.29, 95% CI 0.23-0.36). Uninsured and Medicaid patients were twice as likely as privately insured patients to visit the Emergency Department (ED) for any reason after discharge (uninsured patients (Medicaid, OR 2.6, 95% CI 1.50-4.53; uninsured, OR 2.10, 94% CI 1.31-3.36).
We found marked differences between patients in scheduled outpatient follow-up and ED utilization after injury associated with insurance status; however, Medicaid seemed to obviate some of this disparity. Medicaid expansion may improve outpatient follow-up and affect patient outcome disparities after injury.
PMCID: PMC4231260  PMID: 25400385
Follow-up; health care costs; re-injury; trauma
4.  Patterns and outcomes of medical admissions in the accident and emergency department of a tertiary health center in a rural community of Ekiti, Nigeria 
Low and middle-income countries like Nigeria face many challenges in emergency medical care owing to poor treatment facilities and inadequately trained personnel. Most Nigerians live in rural areas. The disease and death burdens in accident and emergency departments in this setting have not been closely studied.
To determine the basic demographics, disease burden, and outcomes for accident and emergency admissions.
Settings and Design:
This retrospective study was carried out on patients admitted to an accident and emergency department.
Materials and Methods:
A retrospective review of medical admissions to the accident and emergency wards of the Federal Medical Centre, Ido-Ekiti, Ekiti State, southwest Nigeria, between January 2010 and December 2012.
Statistical analysis used:
The data were analyzed using SPSS Version 16 software. The results were presented in descriptive and tabular forms.
In all, 2922 patients were admitted during the study period (age range, 11-100 years; mean, 51.89 ± 20.11 years). There were 1679 (57.5%) males and 1243 (42.5%) females, with a ratio of 1.4:1. Young adults (aged 40 years and under) formed the highest age group (46.8%). The number of patients admitted for non-communicable diseases were high (1989 patients: 68.07%). Among non-communicable diseases, cardiovascular disorders were the most frequent (797; 27.28%). The most common cause of deaths was cardiovascular disease (33.5%).
Young adults and males were the groups most commonly admitted. Non-communicable diseases were more frequent than communicable diseases. The proportion of patients discharged against medical advice and fatalities requires urgent attention.
PMCID: PMC4231261  PMID: 25400386
Emergency; medicine; Nigeria; patient outcome; rural community
5.  Prevalence and consequences of positive blood alcohol levels among patients injured at work 
The aim of this study was to characterize positive blood alcohol among patients injured at work, and to compare the severity of injury and outcome of blood alcohol concentration (BAC) positive and negative patients.
Settings and Design:
A retrospective cohort study was performed at a Level 1 academic trauma center. Patients injured at work between 01/01/07 and 01/01/12 and admitted with positive (BAC+) vs negative (BAC−) blood alcohol were compared using bivariate analysis.
Out of 823, 319 subjects were tested for BAC (38.8%), of whom 37 were BAC+ (mean 0.151 g/dL, range 0.015-0.371 g/dL). Age (41 years), sex (97.2% men), race, intensive care unit (ICU) and hospital length of stay (LOS), and mortality were similar between groups. Nearly half of BAC+ cases were farming injuries (18, 48.6%): Eight involved livestock, five involved all-terrain vehicles (ATVs), three involved heavy equipment, one fell, and one had a firearm injury. Eight (21.6%) were construction site injuries involving falls from a roof or scaffolding, five (13.5%) were semi-truck collisions, four (10.8%) involved falls from a vehicle in various settings, and two (5.4%) were crush injuries at an oilfield. BAC+ subjects were less likely to be injured in construction sites and oilfields, including vehicle-related falls (2.3 vs 33.9%, P < 0.0001). Over half of BAC+ (n = 20, 54%) subjects were alcohol dependent; three (8.1%) also tested positive for cocaine on admission. No BAC+ subjects were admitted to rehabilitation compared to 33 (11.7%) of BAC− subjects. Workers’ compensation covered a significantly smaller proportion of BAC+ patients (16.2 vs 61.0%, P < 0.0001).
Alcohol use in the workplace is more prevalent than commonly suspected, especially in farming and other less regulated industries. BAC+ is associated with less insurance coverage, which probably affects resources available for post-discharge rehabilitation and hospital reimbursement.
PMCID: PMC4231262  PMID: 25400387
Alcohol use; blood alcohol concentration; trauma; work-related injuries
6.  Does intrapleural length and position of the intercostal drain affect the frequency of residual hemothorax? A prospective study from north India 
Thoracic trauma causes significant morbidity; however, many deaths are preventable and few patients require surgery. Intercostal chest drainage (ICD) for hemo/pneumothorax is simple and effective; the main problem is residual hemothorax, which can cause lung collapse and empyema.
Our study aimed to analyze the relationship between radiological chest tube parameters (position and intrathoracic length) and the frequency of residual hemothorax.
Settings and Design:
This prospective analytical study was conducted in a large tertiary care hospital in north India over 2 years till March 2013.
Materials and Methods:
Patients of chest trauma aged 18-60 years, with hemothorax or hemopneumothorax requiring ICD insertion were included in the study. Bedside ICD insertion was performed as per current standards. Immediate post-ICD chest radiographs were used to record lung status and ICD position (chest tube zone and intrapleural length). Residual hemothorax was defined as any collection identified on radiological investigations after 48 hours of ICD placement.
Statistical Analysis:
Univariate analysis was performed with the chi-square test or Student's t-test as appropriate, while multivariate analysis using stepwise logistic regression; a P-value < 0.05 was significant.
Out of 170 patients of chest trauma, 154 underwent ICD insertion. Most patients were young (mean age: 31.7 ± 12 years) males (M:F = 14:1). Ninety-seven patients (57.1%) had isolated chest injuries. Blunt trauma (n = 119; 77.3%) and motor vehicle accidents (n = 72; 46.7%) were the commonest causes. Mean hospital stay was 9 ± 3.94 days, and mortality 2/154 (1.1%). Residual hemothorax was seen in 48 (31%). No ICD zone or length was significantly associated with residual hemothorax on univariate or multivariate analysis.
Intrapleural ICD zone or length does not affect the frequency of residual hemothorax.
PMCID: PMC4231263  PMID: 25400388
Chest trauma; intrapleural chest tube parameters; residual hemothorax
7.  Carbon monoxide poisoning in Beirut, Lebanon: Patient's characteristics and exposure sources 
Carbon monoxide (CO) poisoning is a preventable disease. Patients present with nonspecific symptoms post CO exposure. Causal factors are well described in developed countries, but less in developing countries.
This study examined the characteristics of patients with CO poisoning treated at a tertiary care center in Beirut, Lebanon, and their association with the CO poisoning source.
Materials and Methods:
A retrospective chart review of all patients who presented to the Emergency Department (ED) of the American University of Beirut Medical Center (AUBMC) over 4-year period and for whom a carboxyhemoglobin (CO-Hb) level was available. Patients with CO poisoning diagnosis were included in the study. Patients’ characteristics and their association with CO poisoning source were described.
Twenty-seven patients were treated for CO poisoning during the study period, 55% of whom were males. Headache was the most common presenting symptom (51.9%). Burning charcoal indoors was the most common causal factor (44.4%), whereas fire-related smoke was another causal factor. The median arterial CO-Hb level on presentation for all cases was 12.0% (interquartile range (IQR) 7.3–20.2). All patients received normobaric oxygen therapy. No complications were documented in the ED. All patients were discharged from the ED with a median ED length of stay of 255 min (IQR 210-270). Young females were more likely to present with CO poisoning from burning charcoal indoors than from another cause.
CO poisoning in Beirut, Lebanon is mainly due to charcoal burning grills used indoors and to fire-related smoke. A clinically significant association was present between gender and CO poisoning source. An opportunity for prevention is present in terms of education and increased awareness regarding CO emission sources.
PMCID: PMC4231264  PMID: 25400389
Carbon monoxide poisoning; charcoal; developing countries; fire; Lebanon
8.  Risky locations for out-of-hospital cardiopulmonary arrest in a typical urban city 
The aim of this study is to clarify the circumstances including the locations where critical events resulting in out-of-hospital cardiopulmonary arrest (OHCPA) occur.
Materials and Methods:
Subjects of this population-based observational case series study were the clinical records of patients with nontraumatic and nonneck-hanging OHCPA.
Of all 1546 cases, 10.3% occurred in a public place (shop, restaurant, workplace, stations, public house, sports venue, and bus), 8.3% on the street, 73.4% in a private location (victim's home, the homes of the victims’ relatives or friends or cheap bedrooms, where poor homeless people live), and 4.1% in residential institutions. In OHCPA occurring in private locations, the frequency of asystole was higher and the outcome was poorer than in other locations. A total of 181 OHCPA cases (11.7%) took place in the lavatory and 166 (10.7%) in the bathroom; of these, only 7 (3.9% of OHCPA in the lavatory) and none in the bath room achieved good outcomes. The frequencies of shockable initial rhythm occurring in the lavatory and in bath room were 3.7% and 1.1% (lower than in other locations, P = 0.011 and 0.002), and cardiac etiology in OHCPA occurring in these locations were 46.7% and 78.4% (the latter higher than in other locations, P < 0.001).
An unignorable population suffered from OHCPA in private locations, particularly in the lavatory and bathroom; their initial rhythm was usually asystole and their outcomes were poor, despite the high frequency of cardiac etiology in the bathroom. We should try to treat OHCPA victims and to prevent occurrence of OHCPA in these risky spaces by considering their specific conditions.
PMCID: PMC4231265  PMID: 25400390
Bathroom; lavatory; OHCPA; out-of-hospital cardiopulmonary arrest; the relation between outcome and location
9.  Abdominal injury patterns in patients with seatbelt signs requiring laparotomy 
We analyzed our series of patients with seatbelt signs (bruising) that underwent laparotomy in order to correlate injury pattern with clinical course and outcome.
Materials and Methods:
Retrospective analysis of patients with seatbelt signs presenting to the level 1 Trauma Unit between 2005 and 2010 was performed. We evaluated the nature of injuries during laparotomy associated with seatbelt signs and their treatment and complications.
There were 41 patients, 25 (61%) male, with a median age of 26 years. Median injury severity score (ISS) was 25 (range 6–66) and overall mortality was 10% (four patients). Patients were classified into three groups according to time from injury to surgery. Median time to surgery for the immediate group (n = 12) was 1.05 h, early group (n = 22) was 2.7 h, and delayed group (n = 7) was 19.5 h. Patients in the immediate group tended to have solid organ injuries; whereas, patients in the delayed group had bowel injury. Patients with solid organ injuries were found to be more seriously injured and had higher mortality (P < 0.01) and morbidity compared with patients with the “classic” bowel injury pattern associated with a typical seatbelt sign.
Our data suggest that there is a cohort of patients with seatbelt injury who have solid organ injury requiring urgent intervention. Solid organ injuries associated with malpositioned seatbelts lying higher on the abdomen tend to result in hemodynamic instability necessitating immediate surgery. They have more postoperative complications and a greater mortality. Seatbelt signs should be accurately documented after any car crash.
PMCID: PMC4231266  PMID: 25400391
Bowel injury; laparotomy; seat belt; seat belt sign; solid organ injury
10.  Effectiveness of local anesthesia with lidocaine in chronic opium abusers 
It had been demonstrated that chronic opium abusers have lower pain thresholds compared with than non-abusers.
This study aimed to compare the required dose of lidocaine, a common local anesthetic drug, with regard to the onset of anesthesia in opium abusers with that in non-abusers undergoing similar suturing of minor hand lacerations.
Materials and Methods:
In this study, 109 opium abusers and 91 non-abusers underwent similar suturing for hand lacerations known as digital block. We explained the patients that their case records would remain confidential and admitting to any history of opioid abuse could assist in alleviating any pain associated with the procedure.
There was no statistically significant difference between the two groups with regard to age, gender, and cause of injury (P > 0.05). We found a significantly longer duration of onset of analgesia in nonopioid abusers (5.42 ± 1.93 min) than that in abusers (10.30 ± 1.79 min) (P < 0.001). In addition, the lidocaine dose administered to abusers (6.67 ± 1.21 ml) was higher (4.07 ± 1.26) as well as statistically significant (P < 0.001) than that in non-abusers.
The findings from this study suggest a longer duration of onset of anesthesia and requirement of a higher lidocaine dose in opium abusers compared with nonopioid abuser. Moreover, chronic opium abusers (4-5 years) experienced significantly higher time of onset of anesthesia compared with nonchronic abusers. This outcome may be useful in selecting a more suitable local anesthetic protocol in such patients.
PMCID: PMC4231267  PMID: 25400392
Lidocaine; local anesthesia; opium abuse
11.  Pre-injury beta blocker use does not affect the hyperdynamic response in older trauma patients 
Trauma dogma dictates that the physiologic response to injury is blunted by beta-blockers and other cardiac medications. We sought to determine how the pre-injury cardiac medication profile influences admission physiology and post-injury outcomes.
Materials and Methods:
Trauma patients older than 45 evaluated at our center were retrospectively studied. Pre-injury medication profiles were evaluated for angiotensin-converting enzyme inhibitors / angiotensin receptor blockers (ACE-I/ARB), beta-blockers, calcium channel blockers, amiodarone, or a combination of the above mentioned agents. Multivariable logistic regression or linear regression analyses were used to identify relationships between pre-injury medications, vital signs on presentation, post-injury complications, length of hospital stay, and mortality.
Records of 645 patients were reviewed (mean age 62.9 years, Injury Severity Score >10, 23%). Our analysis demonstrated no effect on systolic and diastolic blood pressures from beta-blocker, ACE-I/ARB, calcium channel blocker, and amiodarone use. The triple therapy (combined beta-blocker, calcium channel blocker, and ACE-I/ARB) patient group had significantly lower heart rate than the no cardiac medication group. No other groups were statistically different for heart rate, systolic, and diastolic blood pressure.
Pre-injury use of cardiac medication lowered heart rate in the triple-agent group (beta-blocker, calcium channel blocker, and ACEi/ARB) when compared the no cardiac medication group. While most combinations of cardiac medications do not blunt the hyperdynamic response in trauma cases, patients on combined beta-blocker, calcium channel blocker, and ACE-I/ARB therapy had higher mortality and more in-hospital complications despite only mild attenuation of the hyperdynamic response.
PMCID: PMC4231268  PMID: 25400393
Beta-blockers; cardiac medication; geriatric trauma; hyperdynamic response
12.  Unexpected traumatic rupture of left atrium mimicking aortic rupture 
Left atrial (LA) rupture is rare following blunt chest injury. We describe a case of blunt LA rupture that was treated surgically. This report is intended to alert practitioners for a need of a close multiple disciplinary collaborations among them for optimal management of patients with this type of trauma; because other non-cardiac injuries involving the head, abdomen, or extremities are considered covariates for in-hospital mortality. As in the present case, the patient eventually died from associated extrathoracic injuries. The diagnosis of LA rupture is by exclusion. However, the initial radiological reading may be misinterpreted, because this injury can easily be mistaking for an aortic rupture. The final reappraisal of the chest imaging studies should be interpreted by a skilled radiologist to avoid misdiagnosis. Subtle radiological features can help distinguish aortic thoracic injury as illustrated in this patient. These factors may be useful to the practicing surgeon in deciding surgical approach.
PMCID: PMC4231269  PMID: 25400394
Aortic rupture; blunt trauma; left atrial rupture; mediastinal hematoma
13.  Successful use of N-acetyl cysteine and activated recombinant factor VII in fulminant hepatic failure and massive bleeding secondary to dengue hemorrhagic fever 
Consensus on management of complicated cases of dengue infection is evolving. Dengue hemorrhagic fever (DHF) occasionally progress to fulminant liver failure with high fatality rate. Inadvertent use of blood products to control massive bleeding in dengue shock syndrome may worsen fluid overload and subsequently the multi-organ dysfunction. We report a case of 37-years-old Sri Lankan man who developed fulminant liver failure and massive bleeding associated with DHF, subsequently recovered completely with supportive measures including administration of N-acetyl cysteine and activated recombinant factor VII. In conclusion, prevention of ischemic injury to liver and adoption of early aggressive supportive measures in complicated cases of dengue hemorrhagic fever is crucial for a favorable outcome. Indications for rFVIIa to arrest uncontrolled internal bleeding and use of NAC in non-acetaminophen-induced acute liver failure in complicated DHF are a platform for discussion.
PMCID: PMC4231270  PMID: 25400395
Activated recombinant factor VII; dengue; fulminant hepatic failure; N-acetyl cysteine
14.  Severe esophageal injuries caused by accidental button battery ingestion in children 
Button batteries represent a low percentage of all foreign bodies swallowed by children and esophageal location is even less frequent. However, these cases are more likely to develop severe injuries. The aim of this essay is to report three cases treated in our institution and review previous reports.
Material and Methods:
Chart review and literature search.
Case Reports:
We treated three children between 2-7- years old with button batteries lodged at esophagus. They all presented esophageal burns (EB), which evolved in esophageal stenosis in two out of the three cases.
We found 29 more cases in literature and the injuries included EB, esophageal perforation (EP) and tracheoesophageal fistula (TEF).
Swallowed button batteries rarely remain in esophagus, but these cases present a higher risk of tisular damage. Injuries can take place even after few hours; and therefore, endoscopy must be performed as soon as possible. Further study on button batteries’ safety and the establishment of a maximum size for them would be good preventive measures.
PMCID: PMC4231271  PMID: 25400396
Button battery; esophageal burn; esophageal foreign body
15.  The intramedullary nailing using a single knee incision for treatment of extraarticular floating knee (nine cases) 
Floating knee injuries are uncommon and complex injuries. Management of this injury has been variously described in the literature.
We present the outcome of the intramedullary nailing using a single knee incision for treatment of extraarticular floating knee.
Materials and Methods:
We report a retrospective series of nine patients with extraarticular floating knee.
There were seven men and two women with an average age of 35 years. At least one of the fractures was open in three cases. The average Injury Severity Score was 17. According to Fraser's classification, 100% of the cases are type I. All our patients were treated by the intramedullary nailing using a single knee incision. The mean operating time was 146 min. The mean follow-up is 19 months. According to the Karlström criteria, the end results were excellent in two cases, good in four, acceptable in two, and poor in one. Bone union was achieved in eight cases with an average period of 93 days.
The intramedullary nailing using a single knee incision has shown in this series better results.
PMCID: PMC4231272  PMID: 25400397
Femur fracture; floating knee; intramedullary nailing; single knee incision; tibia fracture
16.  PTSD in post-road traffic accident patients requiring hospitalization in Indian subcontinent: A review on magnitude of the problem and management guidelines 
Traumatic events after a road traffic accident (RTA) can be physical and/or psychological. Posttraumatic stress disorder (PTSD) is one of the major psychological conditions which affect accident victims. Psychological issues may not be addressed in the emergency department(ED) immediately. There have been reports about a mismatch between the timely referrals from ED to occupational or primary care services for these issues. If left untreated, there may be adverse effects on quality of life (QOL) and work productivity. Hospital expenses, loss of income, and loss of work could create a never ending cycle for financial difficulties and burden in trauma victims. The aim of our review is to address the magnitude of PTSD in post-RTA hospitalized patients in Indian subcontinent population. We also attempted to emphasis on few management guidelines. A comprehensive search was conducted on major databases with Medical Subject Headings (MeSH) term ‘PTSD or post-traumatic stress’ and Emergency department and vehicle or road or highway or automobile or car or truck or trauma and India. Out of 120 studies, a total of six studies met our inclusion criteria and were included in the review. Our interpretation of the problem is that; hospital expenditure due to trauma, time away from work during hospitalization, and reduction in work performance, are three major hits that can lead RTA victims to financial crisis. Proposed management guidelines are; establish a coordinated triage, implementing a screening tool in the ED, and provide psychological counseling.
PMCID: PMC4231273  PMID: 25400398
Guidelines; hospitalization; India; magnitude; post-traumatic stress disorder; PTSD; road traffic accidents; RTA
17.  Capnography during cardiopulmonary resuscitation: Current evidence and future directions 
Capnography continues to be an important tool in measuring expired carbon dioxide (CO2). Most recent Advanced Cardiac Life Support (ACLS) guidelines now recommend using capnography to ascertain the effectiveness of chest compressions and duration of cardiopulmonary resuscitation (CPR). Based on an extensive review of available published literature, we selected all available peer-reviewed research investigations and case reports. Available evidence suggests that there is significant correlation between partial pressure of end-tidal CO2 (PETCO2) and cardiac output that can indicate the return of spontaneous circulation (ROSC). Additional evidence favoring the use of capnography during CPR includes definitive proof of correct placement of the endotracheal tube and possible prediction of patient survival following cardiac arrest, although the latter will require further investigations. There is emerging evidence that PETCO2 values can guide the initiation of extracorporeal life support (ECLS) in refractory cardiac arrest (RCA). There is also increasing recognition of the value of capnography in intensive care settings in intubated patients. Future directions include determining the outcomes based on capnography waveforms PETCO2 values and determining a reasonable duration of CPR. In the future, given increasing use of capnography during CPR large databases can be analyzed to predict outcomes.
PMCID: PMC4231274  PMID: 25400399
Capnography; cardiac arrest; cardiopulmonary resuscitation; end-tidal carbon dioxide
19.  Ultrasound witnessed cardiac arrest in the ICU 
PMCID: PMC4231276  PMID: 25400401
21.  Early initiation of prophylactic heparin in severe traumatic brain injury is associated with accelerated improvement on brain imaging 
Venous thromboembolic prophylaxis (VTEp) is often delayed following traumatic brain injury (TBI), yet animal data suggest that it may reduce cerebral inflammation and improve cognitive recovery. We hypothesized that earlier VTEp initiation in severe TBI patients would result in more rapid neurologic recovery and reduced progression of brain injury on radiologic imaging.
Study Design:
Medical charts of severe TBI patients admitted to a level 1 trauma center in 2009-2010 were queried for admission Glasgow Coma Scale (GCS), head Abbreviated Injury Scale, Injury Severity Score (ISS), osmotherapy use, emergency neurosurgery, and delay to VTEp initiation. Progression (+1 = better, 0 = no change, −1 = worse) of brain injury on head CTs and neurologic exam (by bedside MD, nurse) was collected from patient charts. Head CT scan Marshall scores were calculated from the initial head CT results.
A total of 22, 34, and 19 patients received VTEp at early (<3 days), intermediate (3-5 days), and late (>5 days) time intervals, respectively. Clinical and radiologic brain injury characteristics on admission were similar among the three groups (P > 0.05), but ISS was greatest in the early group (P < 0.05). Initial head CT Marshall scores were similar in early and late groups. The slowest progression of brain injury on repeated head CT scans was in the early VTEp group up to 10 days after admission.
Early initiation of prophylactic heparin in severe TBI is not associated with deterioration neurologic exam and may result in less progression of injury on brain imaging. Possible neuroprotective effects of heparin in humans need further investigation.
PMCID: PMC4126111  PMID: 25114421
Heparin; intracranial hemorrhage; traumatic brain injury; VTE prophylaxis
22.  Acute Flaccid paralysis in adults: Our experience 
Acute flaccid paralysis (AFP) is a complex clinical syndrome with a broad array of potential etiologies that vary with age. We present our experience of acute onset lower motor neuron paralysis.
Materials and Methods:
One hundred and thirty-three consecutive adult patients presenting with weakness of duration less than four weeks over 12 months period were enrolled. Detailed history, clinical examination, and relevant investigations according to a pre-defined diagnostic algorithm were carried out. The patients were followed through their hospital stay till discharge or death.
The mean age was 33.27 (range 13-89) years with male preponderance (67.7%). The most common etiology was neuroparalytic snake envenomation (51.9%), followed by Guillain Barre syndrome (33.1%), constituting 85% of all patients. Hypokalemic paralysis (7.5%) and acute intermittent porphyria (4.5%) were the other important conditions. We did not encounter any case of acute polio mylitis in adults. In-hospital mortality due to respiratory paralysis was 9%.
Neuroparalytic snakebite and Guillain Barre syndrome were the most common causes of acute flaccid paralysis in adults in our study.
PMCID: PMC4126112  PMID: 25114422
Guillain Barre syndrome; lower motor neuron; neuroparalytic snakebite; paralysis; weakness
23.  Ultrasound: A novel tool for airway imaging 
The scope of ultrasound is emerging in medical science, particularly outside traditional areas of radiology practice.
We designed this study to evaluate feasibility of bedside sonography as a tool for airway assessment and to describe sonographic anatomy of airway.
Settings and Design:
A prospective, clinical study.
Materials and Methods:
We included 100 adult, healthy volunteers of either sex to undergo airway imaging systemically starting from floor of the mouth to the sternal notch in anterior aspect of neck by sonography.
We could visualize mandible and hyoid bone as a bright hyperechoic structure with hypoechoic acoustic shadow underneath. Epiglottis, thyroid cartilage, cricoid cartilage, and tracheal rings appeared hypoechoic. Vocal cords were visualized through thyroid cartilage. Interface between air and mucosa lining the airway produced a bright hyperechoic linear appearance. Artifacts created by intraluminal air prevented visualization of posterior pharynx, posterior commissure, and posterior wall of trachea.
Ultrasound is safe, quick, noninvasive, repeatable, and bedside tool to assess the airway and can provide real-time dynamic images relevant for several aspects of airway management.
PMCID: PMC4126113  PMID: 25114423
Airway; sonography; ultrasound
24.  Arrival time pattern and waiting time distribution of patients in the emergency outpatient department of a tertiary level health care institution of North India 
Emergency Department (ED) of tertiary health care institute in India is mostly overcrowded, over utilized and inappropriately staffed. The challenges of overcrowded EDs and ill-managed patient flow and admission processes result in excessively long waits for patients.
The objective of the present study was to analyze the patient flow system by assessing the arrival and waiting time distribution of patients in an Emergency out Patient Department (EOPD).
Materials and Methods:
This short cross-sectional descriptive study was conducted in the EOPD of a Tertiary level health care Institution in North India in the month of May, 2011. The data was obtained from 591 patients, who were present in the EOPD during the month of May, 2011. The waiting time, inter arrival time between two consecutive patients were calculated in addition to the daily census data (discharge rate, admission rate and transfer out rates etc.) of the emergency.
Arrival time pattern of patients in the EOPD was highly stochastic with the peak arrival hours to be 9.00-12.00 h in which around 26.3% patients arrived in the EOPD. The primary waiting areas of patients included patients under observation (29.6%); waiting for routine diagnostic tests (16.4%) and waiting for discharge (14.6%). Around 71% patients were waiting due to reasons within emergency complex.
The patient flow of the ED could only be addressed by multifaceted, multidisciplinary and hospital wide approach.
PMCID: PMC4126114  PMID: 25114424
Emergency department; inter arrival gap; overcrowding; patient flow; waiting time
25.  Awareness about basic life support and emergency medical services and its associated factors among students in a tertiary care hospital in South India 
The knowledge and skills about the basic life support (BLS) and the advanced life support are the most important determining factors of the cardiopulmonary resuscitation (CPR) success rates. Objectives: To determine the level of awareness on BLS and skills among undergraduate and postgraduate students of medical and dental profession, as well as nursing students and interns in a tertiary care hospital.
Materials and Methods:
This descriptive cross-sectional study was conducted in a tertiary care hospital in South India. The awareness level on BLS and factors associated which include age, sex, level of training (undergraduate, internship, and postgraduate groups), course of study (nursing, dental, and medical groups), and previous exposure to BLS were assessed by using a structured questionnaire. The association of these variables with awareness level was assessed by independent t test, analysis of variance, and linear regression analysis.
Among 520 study subjects, 229 were students, 171 were interns, and 120 were postgraduate students. The overall mean score of awareness was 4.16 ± 1.40 (score range: 0-10). Age, sex, level of training, course of study, and previous exposure to BLS were significantly associated with awareness level in univariate analysis (P < 0.05). Linear regression model also showed that all the above variables were significantly associated with awareness level (P < 0.05). About 322 (61.9%) subjects attributed lack of awareness about BLS to lack of available professional training. About 479 (92.1%) responded that BLS training should be a part of medical curriculum.
Awareness level on BLS is below average indicating the importance of professional training at all levels in a tertiary care health institution.
PMCID: PMC4126115  PMID: 25114425
Awareness; basic life support (BLS); BLS; cardio-pulmonary resuscitation (CPR); CPR; India

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