Emergencies, Trauma, Shock

Whats New in Emergencies, Trauma and Shock? Is Intracranial Pressure Monitoring Essential in the Management of Traumatic Brain Injury? Dhaval P Shukla, Amit Agrawal Journal of Emergencies, Trauma, and Shock 2019 12(1):1-2

Compliance with 6 h-Sepsis Resuscitation Bundle of Surviving Sepsis Campaign before and after Resident Physicians' Training: A Quality Improvement Interventional Study among Indian Patients Swaroop K Raj, Prasan Kumar Panda, Naveet Wig, Praveen Agarwal, RM Pandey Journal of Emergencies, Trauma, and Shock 2019 12(1):3-9 Background: Surviving sepsis campaign (SSC) recommends 6 h-sepsis resuscitation bundle for severe sepsis (now termed “sepsis” after the Sepsis-3 definition) or septic shock. The study was done to assess the guideline compliance in Indian patients before and after the resident physicians' training and their impact on the survival. Subjects and Methods: Prospective interventional study (time series design) was conducted. Resident physicians, who were regularly managing the patients of severe sepsis/septic shock, were trained by providing the education and feedback on the guideline compliance at 6-month intervals for three quality improvement (QI) phases. Case details of preintervention and QI phases' patients were reviewed as per the quality indicators, defined by SSC guideline, and compared. Results: The baseline compliance of composite six components of 6 h-sepsis resuscitation bundle was low and significantly increased on postintervention (baseline 0% to 18% at QI 3 (P for trend = 0.01). The compliance of individual components was improved too: serum lactate measurement (26%, P = 0.002), obtaining blood culture (28%, P = 0.003), antibiotic administration (2%, P = 0.56), provision of fluid bolus (60%, P = 0.02), attainment of target central venous pressure (50%, P = 0.03), and optimization of central venous oxygen saturation (20%, P = 0.21). The hospital mortality showed a decreasing trend (18%, P = 0.06). Patients compliant to composite bundle got the mortality benefit (odds ratios = 0.25, 95% [confidence interval, 0.07–0.9]). The study, however, did not show any benefits of mean hospital/Intensive Care Unit (ICU) length of stay. Conclusions: The study establishes lack of acceptance to the prevailing guideline; however, it has shown a significant improvement in adaptation and mortality benefit without reducing mean hospital/ICU length of stay after physicians' repeated educational programs. The barriers to implementation of the prevalent guideline should be searched out in further trials.

Utility of point-of-care ultrasound in differentiating causes of shock in resource-limited setup H Humbal Rahulkumar, Parikh Rina Bhavin, K Patel Shreyas, H Pancholi Krunalkumar, Saxena Atulkumar, Chawada Bansari Journal of Emergencies, Trauma, and Shock 2019 12(1):10-17 Background: Delivering early diagnosis of shock in resource-limited setting is challenging, especially with limited availability of point-of-care laboratory and radiological diagnostic facilities. There is growing urgency to provide point-of-care diagnosis and treatment for time-sensitive condition like shock. Aims: We tried to evaluate the application of point-of-care ultrasound (Rapid Ultrasound for Shock and Hypertension [RUSH] protocol) considering different disease cohort and practice realities in our setup. Settings and Design: This study was a single-center prospective diagnostic study to check the diagnostic accuracy of point-of-care ultrasound (RUSH protocol). This study was approved by the ethics committee. Materials and Methods: The study was conducted at the emergency medicine department of a tertiary care government hospital in Central Gujarat from November 16 to October 17. All adult patients with clinical features of shock with systolic blood pressure <90 mmHg and shock index >1 presenting to emergency department were included as participants. The results of point-of-care ultrasound (RUSH protocol) were compared with the diagnosis given by consultants of respective department as per standard departmental practices. Statistical Analysis and Results: A total of 130 patients were enrolled in this study. Mean time taken to examine by the point-of-care Ultrasound (RUSH protocol) was 12 min (range 11–14 min). Kappa index was 0.860. This protocol was able to correctly diagnose 100% of obstructive shock, 96.3% of cardiogenic shock, 94.4% of hypovolemic shock, 80.9% of mixed type of shock, and 75% of distributive type of shock. Conclusion: This study highlights the role of point-of-care ultrasound (RUSH protocol) for early diagnosis of the shock etiology in emergency medicine department. Diagnosis using point-of-care ultrasound (RUSH protocol) significantly agreed with medical diagnosis. It showed good efficacy of point-of-care ultrasound (RUSH protocol) to differentiate causes of shock with good accuracy except distributive shock.

The Association of Intracranial Pressure Monitoring and Mortality: A Propensity Score-Matched Cohort of Isolated Severe Blunt Traumatic Brain Injury Rebecka Ahl, Babak Sarani, Gabriel Sjolin, Shahin Mohseni Journal of Emergencies, Trauma, and Shock 2019 12(1):18-22 Background: Intracranial pressure (ICP) monitoring in traumatic brain injury (TBI) is common. Yet, its efficacy varies between studies, and the actual effect on the outcome is debated. This study investigates the association of ICP monitoring and clinical outcome in patients with an isolated severe blunt TBI. Patients and Methods: Patients were recruited from the American College of Surgeons-Trauma Quality Improvement Program database during 2014. Inclusion criteria were limited to adult patients (≥18 years) who had a sustained isolated severe intracranial injury (Abbreviated Injury Scale [AIS] head of ≥3 and Glasgow Coma Scale [GCS] of ≤8) following blunt trauma to the head. Patients with AIS score >0 for any extracranial body area were excluded. Patients' demographics, injury characteristics, interventions, and outcomes were collected for analysis. Patients receiving ICP monitoring were matched in a 1:1 ratio with controls who were not ICP monitored using propensity score matching. Results: A total of 3289 patients met inclusion criteria. Of these, 601 (18.3%) were ICP monitored. After propensity score matching, 557 pairs were available for analysis with a mean age of 44 (standard deviation 18) years and 80.2% of them were male. Median GCS on admission was 4[3,7], and a third of patients required neurosurgical intervention. There were no statistical differences in any variables included in the analysis between the ICP-monitored group and their matched counterparts. ICP-monitored patients required significantly longer intensive care unit and hospital length of stay and had an increased mortality risk with odds ratio of 1.6 (95% confidence interval: 1.1–2.5, P = 0.038). Conclusion: ICP monitoring is associated with increased in-hospital mortality in patients with an isolated severe TBI. Further investigation into which patients may benefit from this intervention is required.

An Analysis of the Economic Burden of the Trauma Services at a Level 1 Public Sector Trauma Center in South Asia Namrata Makkar, Amit Gupta, Shrey Modi, Dinesh Bagaria, Subodh Kumar, Sunil Chumber Journal of Emergencies, Trauma, and Shock 2019 12(1):23-29 Background: Incidence of road traffic injuries (RTIs) is increasing and accounting for country's 3% gross domestic product. It is crucial to perform a cost analysis of trauma systems to allocate resources judiciously. Aim and Objectives: To study the economic burden of trauma care on the patient attending a level I trauma center including stratification of costs according to injury. Materials and Methods: This is a prospective study, with patients of polytrauma (Injury Severity Score >16) admitted in the center. Cost analysis (cost descriptive study) was done by calculating direct costs to hospital by bottom-up microcosting considering fixed and recurrent costs including reference unit prices (RUPs). According to the anatomical site of injuries, major injury groups (MIGs) costs were also analyzed. Results: The demographics including mode of injury were similar to other studies. The RUP's and MIG's were defined which represented majority of the sample size. Due to highly subsidized nature of services in this Government institute, the cost to patient is less compared to other countries. Still, the total expenditure incurred by the low-income group was higher than the minimum wages at that time. The creation of plausible RUP's and the grouping of MIG's can help in reducing the costs by targeting and implementing strategic cost reduction measures. Conclusion: The study has shown that microcosting is feasible. Considering the low-income population demanding trauma services, further efforts are required to reduce costs substantially.

Delirium incidence and risk factors in adult critically ill patients in Saudi Arabia Akram Mohammad Rasheed, Mohammad Amirah, Mohammad Abdallah, Adel M Awajeh, PJ Parameaswari, Abdulrhman Al Harthy Journal of Emergencies, Trauma, and Shock 2019 12(1):30-34 Background: Delirium in intensive care units (ICUs) is associated with long ICU stay, long hospital stay and increased costs of treatment. Unfortunately, delirium in ICU is significantly underestimated and overlooked by healthcare providers. Aims: The aim of this tudy is to determine the incidence and associated risk factors of delirium among critically ill patients in Saudi Arabia. Methods: This is a prospective study. Patients were assessed for delirium using the confusion assessment method for the ICU. Delirium was the independent variable in this study. Results: Fifty-nine patients (17.3%) showed positive delirium at least once compared to 283 patients (82.7%) who did not show positive delirium. Certain factors for delirium found to be significantly correlated with delirium (P < 0.005); including receiving sedation, mode of sedation, receiving mechanical ventilation, resistance to mechanical ventilator, and baseline Glasgow Coma Scale. Conclusion: Delirium occurred in >17% of our ICU patients. More efforts should be directed to consider ICU delirium and to minimize its triggering factors.

Changing aspects in the management of splenic injury patients: Experience of 129 isolated splenic injury patients at level 1 trauma center from India Dinesh Bagaria, Atish Kumar, Amulya Ratan, Amit Gupta, Abhinav Kumar, Subodh Kumar, Biplab Mishra, Sushma Sagar Journal of Emergencies, Trauma, and Shock 2019 12(1):35-39 Background: The spleen is most the commonly injured solid organ in abdominal trauma. Operative management (OM) has been challenged by several studies favoring successful non-OM (NOM) aided by modern era interventional radiology. The results of these studies are confounded by associated injuries impacting outcome. The aim of this study is to compare NOM and OM for isolated splenic injury in an Indian Level 1 Trauma Center. Materials and Methods: This is a retrospective analysis of prospective database. Results: A total of 1496 patients were admitted with abdominal injuries. One hundred and twenty-nine patients admitted with diagnosis of isolated splenic injury from January 2009 to December 2016 were included in the study. RTIs, followed by falls from height, were the most common mechanisms of injury. Ninety-two (71.3%) patients with isolated splenic trauma were successfully managed nonoperatively. Thirty-seven (28.7%) required surgery, of which three were due to the failure of NOM. Three patients in the nonoperative group underwent splenectomy later, giving an overall success rate of 96.8% for NOM. Patients with isolated splenic trauma requiring OM had higher grade splenic injury (Grade 4/5), higher blood transfusion requirements (P < 0.001), and prolonged Intensive Care Unit and hospital stay in comparison to patients in the nonoperative group. No patient died in the NOM group; two patients died in the splenectomy group due to hemorrhagic shock and acute respiratory distress syndrome, respectively. Conclusion: Although NOM is successful in most patients with blunt isolated splenic injuries, careful selection is the most important factor dictating the success of NOM.

Clinical presentation and management of pelvic Morel–Lavallee injury in obese patients Mohammed Muneer, Ayman El-Menyar, Husham Abdelrahman, Musab Ahmed Murad, Sara M Al Harami, Ahmed Mokhtar, Mahwish Khawar, Ahmed Awad, Mohammad Asim, Rifat Latifi, Hassan Al-Thani Journal of Emergencies, Trauma, and Shock 2019 12(1):40-47 Introduction: Morel–Lavallee lesion (MLL) is an infrequent or underreported serious consequence of closed degloving injuries. We aimed to describe the clinical presentation and management of pelvic MLL in obese patients. Materials and Methods: A retrospective analysis was conducted for pelvic trauma patients with a diagnosis of MLL between 2010 and 2012. Patients' demographics, presentations, management, and outcomes were analyzed and compared based on the body mass index (BMI) and injury severity. Results: Of 580 patients with pelvic region injuries, 183 (31.5%) had MLL with a mean age of 30.1 ± 12.2 years. The majority (75.4%) of MLL patients had a BMI ≥30 and 44% patients had pelvic fracture. Based on the initial clinical examination, MLL was diagnosed in 84% of patients and clinically missed in 16% of patients. Nonoperative management (NOM) was performed in 93.4% of patients, while primary surgical intervention was indicated in 6.6% of patients. Failed NOM was observed in seven cases, of them five were obese. The overall mortality in MLL patients was 12.6% and the frequency of deaths was nonsignificantly higher in Grade I obese patients. Multivariate analysis showed that injury severity score (odds ratio [OR]: 1.25, 95% confidence interval [CI]: 1.05–1.50) and Glasgow coma scale (OR: 0.72, 95% CI: 0.56–0.92) were the predictors of mortality in patients with MLL irrespective of BMI. Conclusions: One-third of pelvic region injuries have MLL and three-quarter of them are obese. This significant association of obesity and MLL needs further prospective evaluation.

A comparison of nonobese versus obese emergency department patient satisfaction scores utilizing Standard U.S. hospital survey query methodology Christopher Mock, Justin Hensley, K Tom Xu, Peter B Richman Journal of Emergencies, Trauma, and Shock 2019 12(1):48-53 Background: Prior research reveals that overweight patients have higher emergency department (ED) utilization rates, longer length of stay, and face increased misdiagnosis risk. Objective: The objective of this study was to evaluate the association between obesity and ED patient satisfaction. Methods: This study was a cross-sectional study. A convenience sample of inner-city ED patients completed a written survey, then rated overall satisfaction with ED care (10-point scale), and rated components of satisfaction (4-point scale; never to always). Body mass index (BMI) was calculated using triage records (obesity = BMI >30). Results: Five hundred and sixty-four patients were included in the study group (50.5%: obese, 55.4%: female, mean age: 43.2 ± 25.4 years). With respect to overall visit satisfaction (rating 8 or greater on 10-point scale), bivariate analysis revealed no differences between nonobese versus obese patients (74.6% vs. 73.9%; P = 0.85). There were no significant differences for score of 4 (always) for components of ED satisfaction: physician courtesy (87.9% vs. 90.4%; P = 0.34), nurse courtesy/respect (89.2% vs. 88.7%; P = 0.87), doctor listened (85.4% vs. 87.1%; P = 0.5), doctor explained (80.2% vs. 85.0%; P = 0.14), and recommend to friend (72.5% vs. 81.1%; P = 0.02). Within our multivariate model, obesity was not associated with overall satisfaction (scores of 8 or greater) (P = 0.97; odds ratio = 0.99 [95% confidence interval = 0.65–1.5]). Conclusions: Despite research that suggests that overweight patients have characteristics of their ED visit that might increase dissatisfaction risk, we found no difference in satisfaction scores between nonobese and obese patients.

Costs and Characteristics of Undocumented Immigrants Brought to a Trauma Center by Border Patrol Agents in Southern Texas Evan Kane, Peter B Richman, K Tom Xu, Scott Krall, Osbert Blow Journal of Emergencies, Trauma, and Shock 2019 12(1):54-57 Background: The objective of this study was to evaluate the costs, characteristics, and outcomes of patients brought to a Texas trauma center emergenct department after apprehension by Border Patrol (BP)/Immigration and Customs Enforcement (BP/ICE). Materials and Methods: This is a secondary analysis of a trauma registry/financial records (1/1/11-12/31/14). Data were extracted utilizing a structured form. A multivariate ordinary least square was estimated to identify variables associated with hospital charges. Results: A total of 128 patients were enrolled as the study group; mean age was 28.6 ± 6 years, 20.3% were female, 100% were Hispanic, the most common mechanism of injury (MOI) was motor vehicle crash (75%), and mean charge was $162,152 ± $295,441. Mean length of stay (LOS) was 13.2 ± 29.8 days; 92.2% survived to discharge. Bivariate analysis revealed that MOI differed by gender (P = 0.021). In the multivariate analysis, the only variable that associated with increased charge was LOS. Total charges for the 128 patients were $20.6M, total costs were $4.5M, and total payments were $0.99M. Conclusions: Undocumented immigrants apprehended by BP/ICE and brought to our trauma center utilized significant health-care resources.