Trauma is one of the leading causes of death and disability in Indian population.
To correlate various variables like epidemiology, clinical status, severity of TBI & associated co-morbid conditions and its outcome.
Settings and Design:
This study involved retrospective collection, prospective management and follow up of 796 cases of TBI admitted to the neurosurgery department of a tertiary care hospital in New Delhi during one year study duration.
Materials and Methods:
All the relevant variables recorded and analyzed with Glasgow Outcome Scale (GOS) in 6 months into 3 groups i.e. group 1 (GOS-1/Dead), group 2 (GOS-2&3/Bad) and group 3- (GOS-3&4/good).
Compiled data collected, analyzed and difference between two proportions was analyzed using Chi Square test.
This study included 791 cases with 569 (72%) males and 222 (28%) females with average age of 24 years. Fall from height was the main cause of TBI (56%) followed by road traffic injury (RTI) (36%). Majority (61%) patients reached the hospital within 6 hours of injury out of which 27% patients were unconscious. As per Glasgow coma scale mild, moderate & severe grade of TBI was seen in 62%, 22% &16% cases respectively. Radiological examination of other body parts revealed injuries in 11% cases. Only 11% cases required surgical management, rest was managed conservatively. Good outcome noted in 80% cases and 20% cases expired. Average duration of hospital stay was 5 days. According to multivariate analysis, the factors which correlated with poor prognosis are presence of radiological injuries to other body parts, GCS, abnormal cranial nerve examination, abnormal plantar and abnormal pupillary reflex. (P < 0.05)
TBI predominantly affects young male population and most of these are preventable. Early transportation to the hospital and first aid results in good outcome. Mortality increases with the severity of TBI and associated injuries therefore multimodality approach in polytrauma is essential.
Epidemiology; traumatic brain injury; Glasgow outcome score; multimodality approach; TBI is a significant public health problem worldwide and requires appropriate attention from researchers and policy makers regionally through the development of ongoing surveillance programs and the implementation of effective evidence — based interventions. By improving our system with better reporting and documentation of cases, we will be able to make a better plan to decrease the incidence of TBI and their timely appropriate multimodality approaches to achieve better outcome of these cases within our limited resources.
Prior to the widespread use of computed tomography (CT) scan imaging, lower rib fractures diagnosed on chest X-rays (CXRs) were considered a risk factor for abdominal solid organ injury (ASOI). However, CXRs miss about 50% of the rib fractures that are detected on CT scans. We hypothesized that these “occult” rib fractures would not be predictive for ASOI.
Materials and Methods:
Retrospective review of a level I trauma center's database identified all adult blunt trauma patients (n = 11,170) over a 5-year period. Data were abstracted for demographics, injury severity score, presence of ASOI, extremity, pelvic and spine fractures as well as presence and location of rib fractures.
Rib fractures correlated with the presence of ASOI, regardless of whether they were diagnosed by CXR or CT scan alone (P < 0.01). Middle (3-7) and lower (8-12) rib fractures, especially, correlated with the presence of ipsilateral ASOI (P < 0.0001).
Although CT scan detects more rib fractures than CXR, rib fractures remain a marker for increased likelihood of ASOI regardless of the modality by which they are diagnosed. Patients with rib fractures also have a greater incidence of spine and pelvic fractures. As the trauma community debates moving away from routine whole-body CT imaging towards a more selective approach, these results suggest that any clinical suspicion of rib fractures, despite a negative CXR, may warrant further investigation.
Computed tomography; liver; rib fracture; solid organ injury; spleen; trauma; whole-body scan
Insulin has been shown to exert positive inotropic effects in several in vivo
ex vivo models and in human hearts. Resuscitation following hemorrhagic shock results in myocardial contractile dysfunction. However, the optimal timing for treatment with insulin for the cardioprotection effects is unclear.
The objective of this study was to test the hypothesis that treatment with insulin before resuscitation provides better cardioprotection than treatment with insulin after resuscitation.
Materials and Methods:
Rats were assigned to 3 experimental groups (n = 6 per group): (1) Hemorrhagic shock and resuscitation, (2) hemorrhagic shock resuscitated then treated with insulin and (3) hemorrhagic shock treated with insulin before resuscitation. Rats were hemorrhaged for 60 min to rach mean arterial blood pressure of 40 mmHg. Rats were resuscitated in vivo by reinfusion of the shedded blood to restore normotension and monitored for 60 min. Rats were treated or not with insulin 200 μU/g body weight intramuscularly either before or after resuscitation. The maximum of the left ventricular developed pressure (+dP/dt) was measured for 60 min in the isolated perfused hearts using the Langendorff method. Blood samples were obtained for measurements of tumor necrosis factor-alpha (TNF-α).
Treatment with insulin before resuscitation following hemorrhagic shock significantly elevated max dP/dt compared with insulin treatment after resuscitation and the untreated group. TNF-α levels were lower in the insulin treatment before resuscitation compared to the treatment after resuscitation and the untreated group.
Insulin treatment before resuscitation following hemorrhagic shock provides better cardiac protection than treatment with insulin after resuscitation, as evidenced by the improved myocardial contractility, preservation of myocardial structure. The mechanism of cardiac protection involves decrease in the inflammatory response to shock by lowering the levels of TNF.
Contractility; hemorrhage; insulin; resuscitation; shock
The use of ultrasound imaging before or during vascular cannulation greatly improves first-pass success and reduces complications, but this skill must then be combined with manual dexterity to perform the three dimensional (3D) procedure of placing a catheter into the deep veins while analyzing the 2D images. Hence this study is an attempt to still decrease the above mentioned limitation of guided deep vein cannulation by slight modification in the insertion technique.
Aims and objectives:
Aims to compare the ultrasound guided deep vein cannulation by conventional insertion technique(CIT) v/s ultrasound guided perpendicular insertion technique (PIT). Main comparison parameters here are number of attempts required, time taken for successful insertion, vessel counter puncture, arterial puncture and other known mechanical complications of deep venous cannulation.
Material and method:
Prospective, non randomized cross sectional study, done over 200 patients in two arms. Data-analysed by epi2k and state-9 software.
Total number of insertions were 64 by CIT v/s 136 by the PIT. Mean of number of attempts required were 1.918 with the CIT v/s 1.106 for the PIT method. Mean of time of cannulation was 78.62 + 18 sec with CIT while it was 66.98 + 12 sec for PIT and this was statistically significant(P = 0.041). Incidence of vessel counter-puncture was much lower in PIT as compared to CIT (6.1 % v/s 16.2%). 5.9% cannulation done by CIT had arterial puncture v/s 0.8% with the PIT. Not a single episode of any other mechanical complications with either of the method.
USG guided perpendicular method is less time consuming, less number of attempts are required and there are less chances of arterial picture or vessel counter puncture.
Attempts; Emergency Medicine Department; perpendicular method; ultrasound-guided
We aimed to analyze the pattern and outcome of traumatic neck injury (TNI) in a small population.
Materials and Methods:
It is a retrospective analysis of all TNI patients who were admitted to the trauma center between 2008 and 2012. Patients’ demographics, details of TNI, associated injuries, hospital course, and mortality were analyzed.
A total of 51 TNI cases were included revealing an overall incidence of 0.61/100,000 population. The mean age was 31 ± 9 years. The most frequent mechanism of injury was motor vehicle crash (29.4%) followed by stab (17.6%), machinery injury (17.6%), fall (9.8%), and assault (7.8%). Larynx, thyroid gland, trachea, jugular veins, and carotid were the commonly injured structures. The majority of cases had Zone II TNI whereas isolated injury was observed in 11 cases. TNI were mainly presented with active bleeding (38%), hypovolemic shock (16%) and respiratory distress (16%). Surgical interventions mainly included simple repair and closure (53%), vein ligation (12%), repair of major arteries (4%), tracheal repair (6%), larynx and hypopharynx repair (4%), and repair of parotid gland (2%). Neck exploration was performed in 88%, and emergency tracheostomy was required in 18% of cases. Overall mortality rate was 11.8%, of which five patients had associated injuries, and one had isolated TNI.
TNI are not frequent but represent an alarming serious entity in Qatar. Patients with persistent signs of major injuries should undergo early operative interventions. Moreover, the effective injury prevention program should be developed to minimize these preventable injuries in the majority of cases.
Complications; management; neck injury; outcome; trauma
To determine the optimal effective dose of sodium pyruvate in maintaining the vital signs following hemorrhagic shock (HS) in rats.
Materials and Methods:
Anesthetized, male Sprague-Dawley rats underwent computer-controlled HS for 30 minute followed by fluid resuscitation with either hypertonic saline, or sodium pyruvate solutions of 0.5 M, 1.0 M, 2.0 M, and 4.0 M at a rate of 5ml/kg/h (60 minute) and subsequent blood infusion (60 minute). The results were compared with sham and non- resuscitated groups. The animals were continuously monitored for mean arterial pressure, systolic and diastolic pressure, heart rate, pulse pressure, temperature, shock index and Kerdo index (KI).
The Sham group remained stable throughout the experiment. Non-resuscitated HS animals did not survive for the entire experiment due to non-viable vital signs and poor shock and KI. All fluids were effective in normalizing the vital signs when shed blood was used adjunctively. Sodium pyruvate 2.0 M was most effective, and 4.0 M solution was least effective in improving the vital signs after HS.
Future studies should be directed to use 2.0 M sodium pyruvate adjuvant for resuscitation on multiorgan failure and survival rate in HS.
Blood infusion; kerdo index; sodium pyruvate; hemorrhagic shock; resuscitation
A group of multidisciplinary sonologists conduct weekly Intensive Care Unit (ICU) rounds consisting of ultrasound examinations on select patients recommended by the critical care staff. This image was acquired on a 51-year-old male in the ICU with known valve vegetations, and a pleural adhesion was incidentally discovered on ultrasound.
Pleural effusion; thoracostomy; ultrasound
We present the case history of a post motor vehicle crash victim with lower extremity fractures and decreased blood flow. Emergent Angipgraphy revealed a foreign body which was later operated and removed. The case emphasizes that High-speed motor vehicle accidents commonly lead to penetrating injury from objects within and outside of the vehicle.
Motor vehicle accident; penetrating trauma; vascular injury
Bittern is made from marine water after extraction of salt, and its major components include magnesium chloride, magnesium sulfate, potassium chloride, sodium chloride and magnesium bromide. For a long time, it has been used as the main ingredient of tofu coagulant and chemical weapons. A 73-year-old woman arrived to the emergency department after a suicide attempt by drinking an unknown amount bittern. She complained of dizziness, general weakness, and altered mental state (Glasgow Coma Scale (GCS) 13/15). The brain computed tomography (CT) and magnetic resonance imaging (MRI) showed no abnormality. But blood chemistry showed hypermagnesemia ([Mg2+] 7.8 mEq/L) and hypernatremia ([Na+] 149 mEq/L). Electrocardiograph showed QT prolongation of 0.482 s. Electrolyte imbalances were corrected following adequate fluid therapy and injection of calcium gluconate. The patient recovered/was subsequently discharged without any complications. Electrolyte imbalances are a common presentation following bittern poisoning. Severe side effects like respiratory depression, hypotension, arrhythmia, bradycardia, and cardiac arrest can also occur. Patients will require immediate fluid therapy and correction of electrolyte imbalances. The symptoms vary depending on the electrolyte levels. It is mandatory to closely monitor the electrolyte levels and electrocardiograph in these patients.
Complications; hypermagnesemia; poisoning
Coronary artery (CA) dissection following blunt chest trauma is a life-threatening and rare event. Its occurrence in the setting of a contact sport like rugby is even less common. We report on two cases of young adult presenting with segment elevation myocardial infarction related to CA dissection following rugby game. Both were successfully treated with stent implantation. We discuss the mechanism, diagnosis, and optimal management of blunt chest trauma-induced CA dissection.
Blunt chest trauma; coronary artery dissection; myocardial infarction
A 2½-year-old male child with a prior history of a left anatomic hemispherectomy to treat refractory epilepsy fell down two steps, striking his head on the ipsilateral side of the hemispherectomy. He presented with non-consolable crying and emesis. CT scan of the head demonstrated a left frontal epidural hematoma beneath the site of his prior craniectomy. The patient was initially treated by close observation. However, due to an increase in the hematoma from 29.5 to 49.3 ml over a 12-hour period along with the patient's lack of clinical improvement, surgical evacuation was performed. Intraoperatively, the source of the hemorrhage was found to be the skull fracture. Postoperatively, he returned to his neurologic baseline and was discharged home on postoperative day 3.
Epidural hematoma; head trauma; hemispherectomy
Impalement injuries in children may be deeper and more complicated than anticipated. We experienced two cases of accidental impalement injuries, one was through the oral cavity and the other was to the neck. We review these cases and the management of these types of injuries. Case series. In case 1, a 20-month-old girl fell from the table with a toothbrush in her mouth. She was conscious, without any apparent neurologic or vascular injuries. Examination revealed a 2 mm laceration with a small hematoma in the right posterior pharyngeal wall. Contrast-enhanced computed tomography (CECT) revealed an air tract penetrating between the mandibular ramus and cervical vertebrae, passing by the carotid sheath, and reaching under the skin of the right posterior neck. Surgical emphysema was extended from the pharynx to the mediastinum. In case 2, a 3-year-old girl fell while holding a pencil. Physical examination revealed a 5 mm laceration in front of her right ear lobe accompanied by a small hematoma. Her facial movement was asymmetric, and she could not close her right eye. CECT showed swelling of the right parotid gland with heterogeneous enhancement and free air just in front of the right carotid sheath, which suggested the object penetrated through the parotid gland. A diagnosis of peripheral facial nerve injury was made. Physicians need to be aware of the potentially life-threatening complications of impalement injuries in children, as well as the specific complications related to proximity to specific anatomic structures.
Case series; children; complication; computed tomography angiography; impalement injury