- Home
- Search Results
Search Results
Filter :
FILTER BY keyword:
- trauma [22]
- management [2]
- Addis Ababa [1]
- Age [1]
- Arabian camels [1]
- BPPV [1]
- Case report [1]
- Computed Tomography [1]
- Dix–Hallpike maneuver [1]
- Doha [1]
- ECMO [1]
- Entonox [1]
- Ethiopia [1]
- Hamad General Hospital [1]
- Hamad Medical Corporation [1]
- Hyoid [1]
- Middle East [1]
- Mobile apps [1]
- Qatar [1]
- Qatar Health [1]
- RISCII [1]
- Saudi Arabia [1]
- Scapula, [1]
- Spinal cord injury without radiographic abnormality [1]
- TRISS [1]
- Wildlife-vehicle collision [1]
- accident [1]
- airway [1]
- amputation [1]
- analgesia [1]
- [+] More [-] Less
FILTER BY author:
- Ayman El-Menyar [3]
- Hassan Al-Thani [3]
- Biswadev Mitra [2]
- Sandro Rizoli [2]
- Abdallah Allam [1]
- Abdulaziz F. Ahmed [1]
- Abdullah Al Shimemeri [1]
- Adrian S. Dragovic [1]
- Ahad Kanbar [1]
- Ahmad Naeem Mahdi Al-Fattal [1]
- Ahmed El-Faramawy [1]
- Ahmed Faidh Ramzee [1]
- Ali Ait Hssain [1]
- Alireza Heidari [1]
- AlleaBelle Bradshaw [1]
- Alvaro Taype-Rondan [1]
- Amr Fares [1]
- Arun Ilancheran [1]
- Ashok Parchani [1]
- Avi Bhavaraju [1]
- Cangitaa Arumugam [1]
- Chaiyut Thanapaisal [1]
- Cristina Torres-Mallma [1]
- Dan L Deckelbaum [1]
- Divya Karna [1]
- Dominique Shum-Tim [1]
- Ebrahim Al-shami [1]
- Faisal Ahmed [1]
- Fatima Rahman [1]
- Fawaz Mohammed [1]
- [+] More [-] Less
FILTER BY date:
FILTER BY language:
FILTER BY content type:
FILTER BY publication:
FILTER BY affiliation:
- [1]
- 1Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar [1]
- 1Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia [1]
- 1Sociedad Científica de Estudiantes de Medicina de la Universidad de San Martín de Porres, Universidad de San Martín de Porres, Lima, Peru [1]
- 2Clinical Research, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar [1]
- 2Department of Otolaryngology, The Royal Victorian Eye and Ear Hospital, Melbourne, Victoria, Australia [1]
- 2Faculty of Medicine, Universidad de San Martín de Porres, Lima, Peru [1]
- 3CRONICAS Center of Excellence for Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru [1]
- 3Department of Anaesthesia & Perioperative Medicine, The Alfred Hospital, Melbourne, Victoria, Australia [1]
- 4Department of Epidemiology & Preventive Medicine, Monash University, Clayton, Victoria, Australia [1]
- 5National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia [1]
- 6Academic Board of Anaesthesia and Perioperative Medicine, Monash University, Clayton, Victoria, Australia [1]
- Al Kindy Teaching Hospital, Baghdad, Iraq. [1]
- Ambulance Service, Hamad Medical Corporation, Doha, Qatar E-mail: [email protected] [1]
- Chaiprakarn Hospital, Chiang Mai, Thailand [1]
- Clinical Medicine, Weill Cornell Medical College, Doha, Qatar [1]
- Department of Emergency Medicine, College of Medicine, University of Jeddah, Jeddah, Saudi Arabia [1]
- Department of Emergency Medicine, HGH, Doha, Qatar [1]
- Department of Emergency Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur E-mail: [email protected] [1]
- Department of General Surgery, School of Medicine, Ibb University of Medical Science, Ibb, Yemen E-mail: [email protected] [1]
- Department of General Surgery, School of Medicine, Ibb University, Ibb, Yemen*Correspondence: Yasser Obadiel [email protected] [1]
- Department of General Surgery, School of Medicine, Sana’a University, Sana’a, Yemen [1]
- Department of Oral Pathology, College of Dentistry, Mustansiriyah University, Baghdad, Iraq. Email: [email protected] [1]
- Department of Orthopedy, School of Medicine, Ibb University of Medical Sciences, Ibb, Yemen [1]
- Department of Surgery, Acute Care Surgery, HGH, Doha, Qatar [1]
- Department of Surgery, Faculty of Medicine, Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand Email: [email protected] [1]
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC, United States Email: [email protected] [1]
- Department of Surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar [1]
- Department of Surgery, Trauma Surgery Section, Qatar Trauma registry, HGH, Doha, Qatar [1]
- Department of Surgery, Trauma surgery Section, Clinical research, HGH, Doha, Qatar E-mail: [email protected] [1]
- [+] More [-] Less
FILTER BY article type:
FILTER BY access type:
Subclavian artery injury following blunt trauma: A report of three cases
Subclavian artery injuries are rare in blunt chest trauma constituting just 1–2 percent of all acute vascular injuries. The diagnosis of injury to the subclavian artery is challenging as a good percentage of patients with such vascular injuries have palpable distal pulses no signs of any external local trauma and associated injuries often divert the attention of treating physicians. Subclavian artery injuries are the second most common injuries to occur to the aortic arch vessels. The mechanism of injury to these vessels varies from deceleration to traction on upper extremity and neck. Angiography is vital in diagnosis and surgical planning of these patients depends on the site and side of the vascular injuries. Early surgical treatment is an important part of management of these patients. Endovascular treatment is of value in a selected subgroup of subclavian artery injury patients. Reported mortality of subclavian artery injuries varies according to haemodynamic status of patient time of presentation and other associated injuries. A high degree of suspicion is key to diagnosing these vascular injuries. Early appropriate surgical repair of vascular injury in combination with aggressive treatment of associated injuries is important for the optimal outcome of these cases. Here we report three cases of subclavian artery injury which were successfully treated in Hamad General Hospital by vascular surgery and intensive care teams.
A review of large animal vehicle accidents with special focus on Arabian camels
Traffic accidents resulting from the collision of motor vehicles with wildlife occur worldwide. In the United States Canada Europe the Middle East and Australia these collisions usually involve deer moose camels and kangaroos. Because these are large animals the collisions are frequently associated with high morbidity and mortality rates. Camel-vehicle collisions in the Middle East—especially Saudi Arabia—have risen to such disturbing proportions that definitive action is necessary for mitigating the trend. Arabian camels weighing up to 726 kg form a crucial part of the socio-cultural experience in Saudi Arabia where about half a million of them are found. Saudi Arabia presents a case of habitat fragmentation especially in rural communities where good road systems coexist with domesticated camels. This environment has made camel-vehicle collisions inevitable and in 2004 alone two hundred such cases were reported. Injuries are directly related to the size of the camel the speed of the vehicle passengers' use or avoidance of seat belts and the protective reflex movements taken to avoid collision. Cervical and dorsal spinal injuries especially fractured discs head and chest injuries are the most commonly reported injuries and the fatality rate is four times higher than for other causes of traffic accidents. Various mitigation measures are considered in the present work including measures to improve driver's visibility; the construction of highway fencing; under- and over-passes allowing free movement of camels; the use of reflective warning signs and awareness programs.
Disconnect between available literature and clinical practice: Exploring gaps in the management of t-BPPV in the emergency department
Background: Healthcare costs associated with the diagnosis of benign paroxysmal positional vertigo (BPPV) alone approach $2 billion per year in the United States. Post-traumatic BPPV (t-BPPV) is well recognized and can be managed with simple bedside physical maneuvers. Despite the availability of literature and clear guidelines supporting this approach physical maneuvers are underutilized. The aim of this study was to explore the reasons for this practice disagreement. Methods: A cross-sectional survey of emergency physicians (EP) and non-emergency physicians (Non-EPs) managing head injury patients was conducted. The survey questions were aimed to explore the attitude of these frontline healthcare providers towards the diagnosis and management of t-BPPV in head injury patients. Results: A total of 102 physicians completed the survey. Of them male physicians constituted 87.2% and the majority were working as emergency physicians (80.4%). Although nearly three-fourths (72.5%; n = 74) of the participants admitted that it is important to explore the possibility of t-BPPV in patients with head injury only one-fifth of the participating physicians (20.6%; 21 of 102) confirmed that they would investigate for t-BPPV. A lack of knowledge about t-BPPV in more than half of the study participants (55.9%; n = 57) was the main reason for them not probing the possibility of t-BPPV. Conclusion: To close the gap between available evidence-based guidelines and actual clinical practice there is a need for raising awareness about this condition. Addressing the training needs of frontline healthcare providers to use physical maneuvers such as Dix–Hallpike (DHM) and canalith repositioning (CRP) maneuvers in the management of t-BPPV is an important step that needs to be taken.
Features of mobile provider education applications for prehospital trauma life support
Many educational tools are used for prehospital trauma life support (PHTLS) training including mobile apps. This study describes the currently available mobile apps for PHTLS training. Systematic searches in the Apple Store Google Play Store and BlackBerry World were conducted in December 2015. Two researchers performed all searches independently and collected their findings in different databases which were later compared. Finally a descriptive analysis was carried out. A total of 41 mobile apps that fulfilled the inclusion criteria were found. Among these 97.5% (n = 40) were in English 58.5% (n = 24) were updated in 2015 and 51.2% (n = 21) were not free. Of the 20 free apps 85% (n = 17) did not require an internet connection for any function 70% (n = 14) had no videos or animation 10% (n = 2) had any game and 70% (n = 14) had no institutional certification. In conclusion it was found that PHTLS apps usually lack interactive content and institutional certification which should be taken into consideration by users and researchers.
Avulsion of the right main bronchus due to blunt trauma
Tracheobronchial disruption is an uncommon injury usually associated with severe blunt thoracic trauma. It rarely occurs in isolation. We report a case of isolated avulsion of the right main bronchus occurring after a high-speed car collision with severe head injury. Management of this condition is briefly discussed.
Critique of “Identifying the bleeding trauma patient: predictive factors for massive transfusion in an Australasian trauma population”
Background: Military and civilian data would suggest that hemostatic resuscitation results in improved outcomes for exsanguinating patients. However identification of those patients who are at risk of significant hemorrhage is not clearly defined. We attempted to identify factors that would predict the need for massive transfusion (MT) in an Australasian trauma population by comparing those trauma patients who did receive massive transfusion with those who did not. Methods: Between 1985 and 2010 1686 trauma patients receiving at least 1 U of packed red blood cells were identified from our prospectively maintained trauma registry. Demographic physiologic laboratory injury and outcome variables were reviewed. Univariate analysis determined significant factors between those who received MT and those who did not. A predictive multivariate logistic regression model with backward conditional stepwise elimination was used for MT risk. Statistical analysis was performed using SPSS PASW. Results: MT patients had a higher pulse rate lower Glasgow Coma Scale (GCS) score lower systolic blood pressure lower hemoglobin level higher Injury Severity Score (ISS) higher international normalized ratio (INR) and longer stay. Initial logistic regression identified base deficit (BD) INR and hemoperitoneum at laparotomy as independent predictive variables. After assigning cutoff points of BD being greater than 5 and an INR of 1.5 or greater a further model was created. A BD greater than 5 and either INR of 1.5 or greater or hemoperitoneum was associated with 51 times increase in MT risk (odds ratio 51.6; 95% confidence interval 24.9Y95.8). The area under the receiver operating characteristic curve for the model was 0.859. Conclusion: From this study a combination of BD INR and hemoperitoneum has demonstrated good predictability for MT. This tool may assist in the determination of those patients who might benefit from hemostatic resuscitation.
Management of traumatic hyoid bone fractures: A case series
Purpose: Hyoid bone fractures are uncommon reported mainly in cases of hanging. There is a paucity of reports involving other mechanisms and only a handful of case reports are available to guide the management of these fractures especially within the emergency department setting. This study focused on identifying optimal initial airway management and subsequent treatment of patients with hyoid fractures. Methods: Patients presenting to an adult major trauma referral centre between January 2007 and July 2014 with a diagnosis of hyoid bone fracture were identified. Patient records were reviewed retrospectively. Results: Of the 19 patients identified 16 cases were secondary to blunt force trauma. Motor vehicle crashes accounted for eight of the 19 cases. All patients with major trauma were intubated as part of their initial airway management while 50% of the minor trauma patients were intubated. Only one patient underwent surgical repair of the hyoid bone. Most patients experienced excellent outcomes with no hyoid fracture-related complications. Conclusion: Early intubation for suspected hyoid fractures is advised for those with a penetrating mechanism of injury clinical features of airway compromise and severe associated injuries. Conservative nonsurgical management of hyoid fractures remains the mainstay of management. A minimum 24-hour period of observation for patients who are not managed with endotracheal intubation is advised.
Indications for blood transfusion following trauma - a pilot study
Background: Indications for blood transfusion during trauma resuscitation remain poorly understood. This study aimed to objectively determine the range of factors that lead to initiation of blood transfusion during trauma resuscitation. Design and method: This was a prospective observational pilot study. A questionnaire was distributed to all clinicians following any transfusion of packed red blood cells during trauma resuscitation. The questionnaire focused on the clinicians’ opinion regarding the indication for red cell transfusion. Results: Complete data on 37 individual episodes of transfusion initiation in the Emergency Department were collected. The most commonly used pre-hospital factors that influenced initiation of transfusion was a pre-hospital systolic blood pressure (SBP) of < 100 mm Hg (65%) pre-hospital tachycardia (38%) or estimated blood loss of >1 L (30%) by paramedics. On arrival to hospital the activation of a massive transfusion protocol was the commonest indication for transfusion followed by a positive FAST examination (43%) low systolic blood pressure (35%) tachycardia (32%) or pallor (35%). Blood tests to guide initiation of transfusion were less commonly used with 9 (24%) patients transfused for a low haemoglobin level and 6 (16%) patients transfused for coagulopathy. Conclusions: A combination of objective pre- and in-hospital vital signs together with subjective indicators such as pallor and estimation of blood loss guided initiation of transfusion following injury.
Trauma intensive care unit (TICU) at Hamad General Hospital
Trauma is a leading cause of mortality and morbidity worldwide and thus represents a great global health challenge. The World Health Organization (WHO) estimated that 9% of deaths in the world are the result of trauma.1 In addition approximately 100 million people are temporarily or permanently disabled every year.2 The situation is no different in Qatar and injury related morbidity and mortality is increasing in the entire region with road traffic collisions (RTCs) being the most common mechanism.1
It is well recognized now that trauma care provided in high-volume dedicated level-one trauma centers improves outcome. Studies have also looked at what are the components of a trauma system that contribute to their effectiveness2. However in general it usually implies a high-volume of cases dedicated full-time trauma qualified professionals a solid pre-hospital system a multidisciplinary team and excellent rehabilitation services.
Similarly critically injured trauma patients managed in a dedicated trauma intensive care unit (TICU) has been shown to improve outcomes especially for polytrauma patients with traumatic brain injury (TBI).3 In fact the American College of Surgeons (ACS) Committee on Trauma requires verified trauma centers to have a designated ICU and that a trauma surgeon be its director.4 Furthermore studies have shown that for TBI it is not necessary for this ICU to be a neurocritical care unit but rather it should be a unit that is dedicated to trauma that has standardized protocols for TBI management.56 In fact the outcomes are better in the latter with lower mortality in multiple-injured patients with TBI when admitted to a TICU (versus a medical-surgical ICU or neurocritical care unit).3 These benefits were shown to increase with increased injury severity. The proposed reason for this is thought to be due to the associated injuries being managed better.7
The aim of this editorial is to describe the TICU at Hamad General Hospital (HGH) at Hamad Medical Corporation (HMC) including a comparison of its data and outcomes with other similar trauma centers in the world. The Qatar Trauma Registry as well as previous publications from our Trauma Center18 were used to obtain HGH TICU and worldwide Level-1 Trauma Center standards respectively.
With respect to HGH the TICU is part of an integrated trauma program the only level-1 trauma centre in Qatar. It provides the highest standard of care for critically-ill trauma patients admitted at HGH striving to achieve the best outcomes excellence in evidence-based patient care up to date technology and a high level of academics in research and teaching. This integrated program includes an excellent pre-hospital unit emergency and trauma resuscitation unit TICU trauma step-down unit (TSDU) inpatient ward and rehabilitation unit.
The new TICU is a closed 19-bed unit that was inaugurated in 2016 is managed 24/7 by highly qualified and experienced intensivists (9 senior consultants and consultants) along with 24 well-trained and experienced associate consultants or specialists and fellows and residents in training as well as expert nursing staff (1:1 nurse to patient ratio) and allied health professionals (respiratory therapists pharmacists dieticians physiotherapists occupational therapists social workers case managers and psychologists). It is supported by all medical and surgical subspecialty services.
It is equipped with the latest state-of-the-art technology and equipment including ‘intelligent ventilators” neuro-monitoring devices ultrasound point-of-care testing such as arterial blood gas and rotational thromboelastrometry (ROTEM) and video airway devices.
The TICU is a teaching unit linked to the HMC Medical Education department with presence of fellows and residents (see below for details). Medical students (Clerkship level) from Weill-Cornell Medicine Qatar also complete a one-week rotation in the TICU as part of their exposure to critical care. The first batch of clerks from Qatar University College of Medicine are expected to start rotating in the TICU soon.
The Trauma Critical Care Fellowship Program (TCCFP) is an ACGME (Accreditation Council for Graduate Medical Education) fellowship that was established over seven years ago. To date over 40 physicians from both within and out of the trauma department have completed the program. Up to seven fellows including international candidates are trained each year. A number of physicians have succeeded in gaining the European Diploma of Intensive Care Medicine (EDIC). The program continues to attract many applicants from various specialties including surgery anesthesia and emergency medicine. An increasing number of international physicians from Europe and South America have expressed interest in applying for our fellowship. The first international fellows are likely to join us from early 2020.
Residents (from general surgery ER ENT plastics orthopedics and neurosurgery) rotate (one to three months’ rotations) in the TICU and are actively part of the clinical team.
There were 568 admissions to the TICU in 2018. The patients admitted were either mainly polytrauma patients with varying degrees and combinations of head chest abdominal pelvic spine and orthopedic injuries or isolated-TBI. Of these patients 378 were severely injured with an injury severity score (ISS)9 greater than 16.
According to previously published data from our Trauma Centre18 our mortality rates (overall approximately 6-7% as well as when looked at in terms of early and late deaths) compare favorably with other trauma centers around the world when looking at similarly sized retrospective studies.
The TICU continues to be an active member of the Critical Care Network of HMC.10 This network involves all of the ICU's in all the HMC facilities. The main processes that the TICU is presently involved in as part of this network are: patient flow clinical practice guidelines evaluation and procurement of technologies HMC sepsis program and in general taking part in any process that pertains to critical care at HMC.
A number of quality improvement projects are being undertaken in the TICU. Examples of such projects include:
- - Decreasing rates of infection in TICU - Score-guided sedation orders to decrease sedation use ventilator days and length of stay - Reducing blood taking and associated costs - Sepsis alert response and bundle compliance - Medical and surgical management of rib fractures
Similarly many research projects are taking place in the TICU in coordination with the Trauma Research program and often in collaboration with other departments (local and international). Examples of some of the research projects include:
- - The “POLAR” study (RCT on Hypothermia in TBI)11 - B-blockers in TBI (RCT-ongoing) - Tranexamic acid (TXA) for bleeding in trauma (RCT-ongoing)
The team is also involved in conducting systematic reviews in relation to the role of transcranial doppler in TBI12 sepsis in TBI patients (ongoing) self-extubation in TBI patients13 safety and efficacy of phenytoin in TBI (ongoing) and optic nerve diameter for predicting outcome in TBI (submitted).
The TICU at HGH is a high-volume high acuity unit that manages all the severely injured trauma patients in Qatar. It is well staffed with highly trained and qualified personnel and utilizes the latest in technology and state-of-the-art equipment.
It performs very well when compared to other similar units in the world and achieves a comparable or even lower mortality rate.
With continued great support from the hospital corporation administration and Ministry of Public Health the future goals of the TICU will be to maintain and improve upon the high standards of clinical care it provides as well as perform a high quality and quantity of research quality improvement initiatives and educational work in order for it to be amongst the best trauma critical care units in the world.
Comparing nebulized ketamine with Entonox for acute traumatic pain in the Emergency Department: A pilot randomized trial
Background: In this study we compared the efficacy patient satisfaction and adverse effects of nebulized ketamine to those of Entonox in reducing acute traumatic pain in the Emergency Department. Methods: This was a randomized single-centre pilot study. Eligible patients were selected from triage and divided into two groups which was nebulized ketamine and Entonox. Nebulized ketamine 50 mg (mean 0.7 mg/kg for an average adult) was administered in a concentration of 5 mL of 10 mg/mL diluted with 1 mL normal saline in a nebulizer. Entonox delivery was self-regulated by the patients. The primary outcome was efficacy of pain reduction according to the visual analogue scale (VAS) in 30 minutes. Adverse effects were monitored in both the groups. Results: A total of 26 patients were divided equally into two groups with n = 13 for each group. Mean reduction in VAS after 5 and 30 minutes was 0.62 ± 0.77 mm and 28.5 ± 12.1 mm for nebulized ketamine and 0.46 ± 0.78 mm and 30 ± 5.8 mm for Entonox. No significant difference was seen in pain reduction (5 min p = 0.616 30 min p = 0.684). Mean satisfaction with analgesia according to a Likert scale of 1 to 6 was ketamine 4.92 ± 0.64 and Entonox 5.0 ± 0.41 (p = 0.718). No serious adverse events were reported. Conclusion: Nebulized ketamine is a comparable substitute to Entonox in managing acute traumatic pain in the Emergency Department. Further studies are required on the use of inhaled ketamine as an adjunct in managing severe pain and reducing the need for opioids.
Penetrating trauma to scrotum and penis caused by a gunshot in 17-year old man: A case report
Penetrating trauma to male external genitalia is a rare trauma case. It accounts for 20% of all genitourinary trauma cases and penile involvements are presented between 10- 16% of all cases. Male genital trauma is considered a urological emergency due to the high risk of infection sexual dysfunction and infertility. In this work a 17-year-old male patient presented with scrotal and penile injuries due to a low-velocity gunshot wound. Genital examination revealed tissue loss in the foreskin glans anterior urethra (distal third) cavernous corpora and total loss of right testis with a scrotal laceration. The patient was treated with partial penectomy penile reconstruction and urethral repair with an excellent uneventful postoperative cosmetic and functional outcome. In conclusion penetrating male external genital injuries are rare with extremely serious consequences due to the functional psychological and aesthetic consequences. The best treatment with penile reconstruction and urethral and cavernous corpora repair may be achieved.
ECMO in trauma patients: Future may not be bleak after all!
In the USA trauma represents the leading cause of death between the ages of 1 and 46 years and contributed to 192000 deaths in 2014.1 Major trauma is also responsible for significant disabilities and increased hospital length of stay (LOS) and represents a huge financial burden. Acute respiratory failure (ARF) is multifactorial in trauma patients with diverse underlying pathophysiological mechanisms. In a blunt thoracic injury all the chest compartments can be affected and are directly responsible for mortality of 20–25%.2 Two main mechanisms contribute to pulmonary injury; the first mechanism is a direct trauma leading to contusion intra-alveolar hemorrhage and aspiration pneumonia. Some of the mechanical injuries to the chest (pneumothorax hemothorax airways injury) are reversible by various interventions (pleural drains surgical airway repair etc.). The second mechanism is an indirect immunological lung injury which may result from extrapulmonary trauma and/or the required management of trauma patients (massive transfusion fluid overload ventilator lung induced injury etc.) leading to acute respiratory distress syndrome (ARDS). Extracorporeal membrane oxygenation (ECMO) is an attractive therapy in ARF. In 1972 the first successful use of ECMO was in a 24-year-old polytrauma patient who developed a “shock lung syndrome”.3 However subsequent results in the next two to three decades were disappointing. The H1N1 influenza epidemic with a high number of young patients with severe respiratory failure led to resurgence of ECMO use. ECMO has been successfully used in severe ARDS secondary to the influenza A (H1N1) epidemic in 2009 with acceptable outcomes. A large multicenter trial (CESAR trial) in the UK showed that referral and transfer of patients to severe respiratory failure centers with ECMO capabilities reduced mortality in severe ARDS patients.4 Despite these encouraging results and use of ECMO worldwide for severe ARDS use of ECMO in trauma patient is poorly studied. Severe ARF requiring mechanical ventilation (MV) in trauma patients is associated with high mortality and increased hospital LOS. In patients with severe impaired gas exchange despite optimized MV ECMO is proposed to avoid injurious lung ventilation. It is prudent to start ECMO at an earlier stage to avoid irreversible MV-induced pulmonary injury in these cases. In severe thoracic trauma cases requiring lung resection or progressive lung fibrosis with severely limited reserve ECMO may prove to be the main therapy as a bridge to lung transplant. The heterogeneity and complexity of trauma patients make ECMO use challenging in trauma cases with uncertain benefit/risk balance and multidisciplinary decision-making becomes extremely important on a case-by-case basis. Among trauma patients with ARF those with a traumatic brain injury represent a specific group as their prognosis is mainly dependent on neurological recovery. These patients may require earlier ECMO support compared with non-brain-injured patients to prevent secondary neurological injury from severe hypoxemia hypercapnic acidosis and worsening cerebral edema from fluid overload. Indeed the combination of gas exchange alteration from respiratory failure and intracerebral pathology leads to a difficult challenge in ventilatory management of these patients. The usual dilemma of lung-protective versus neuroprotective ventilation creates contradictory goals. A high PEEP strategy permissive hypercapnia and permissive hypoxemia are well-accepted strategies for ARDS management but may lead to secondary neurological insult in brain-injured patients. Munoz-Bendix and colleagues showed in their study that intracerebral pressure can be decreased by the PaCO2 control with ECMO support in trauma patients which is a major goal of neuroprotective ventilation in these patients.5 ECMO in brain-injured patient is an attractive option as it allows the combination of neuroprotective and lung-protective ventilator strategies at the same time. The goal of ECMO is to support the patients who have good functional prognosis from their neurological injury. Unfortunately this prognostication is not easy in brain-injured patients at the time when they are in need of ECMO. Better prognostic predictors in brain-injured patients may help the healthcare teams to improve the selection of patients who will benefit from ECMO.
ECMO use is limited in trauma patients particularly those with traumatic brain injury complicated pelvic fractures or major vascular injuries in view of fear of serious bleeding during systemic anticoagulation. However with improved ECMO circuit technology (newer pump systems reduced circuit area newer biocompatible circuit material heparin coating etc.) and a relatively high blood flow during veno-venous (VV) ECMO thrombotic complications during heparin-free ECMO runs are relatively uncommon. In the literature there are many reports of prolonged heparin-free ECMO use in patients with trauma as well as other pathologies with high risk of bleeding complications with excellent outcomes and no serious thrombotic complications.6–9 Recently a systematic review of the literature with an aggregated total of 215 trauma patients showed an overall survival to discharge ranging from 50 to 79%;10 however this work suffered from various limitations. All studies included were retrospective and included a maximum of five patients per year per center. Most of the studies with a high number of patients were performed over many years making definitive conclusions difficult to formulate as the ECMO management and techniques and ICU approaches have evolved over the years. An interesting cohort study using data from two American centers compared 76 trauma patients on MV and 26 who required VV extracorporeal life support (ECLS).11 There were no differences between the two groups regarding ventilator days intensive care unit LOS and hospital LOS. However when ECLS patients were severity matched to patients on MV a better survival was demonstrated in the ECLS group. These are very encouraging results but there were multiple limitations and lot of questions remained unanswered. Further studies are needed to define the appropriate time to initiate ECMO proper patient selection and outcome data beyond survival to hospital discharge including functional and psychosocial outcomes particularly in brain-injured patients. The holy grail of ECMO use in trauma patients is the optimal timing to initiate this therapy. ECMO is a complex treatment modality which involves a multiprofessional team of clinicians and financial and physical resources for its optimal implementation. The use of ECMO in inappropriate patient at an inappropriate time may lead to poor outcomes with wastage of precious healthcare resources. Unfortunately several large ECMO centers do not have a level 3 trauma center and at the same time multiple trauma centers do not have any ECMO service. Therefore studies from centers with combined trauma and ECMO services are really needed to demonstrate their complementary positive impact on the care of trauma patients. Trauma patients should be considered as a genuine group to benefit from ECMO support. Beside the encouragement of centers to publish their individual experiences a multidisciplinary task force under the aegis of ELSO may be a reasonable approach to conduct studies to answer the unresolved questions of ECMO use in trauma patients. A reasonable first phase towards this goal would be to create a specific registry for interested centers with experience in trauma care as well as ECMO capabilities. The management of these patients is complex and needs a multidisciplinary team approach with experience of trauma teams as well as intensivists and an ECMO team with a reasonable patient volume. The specific pathways created by collaboration of ECMO specialists perfusionists intensivists emergency room physicians trauma surgeons and interventional radiologists will lead to improved patient care as well as valuable data to optimize the care of these patients in the future. The time has come not to deny the lifesaving ECMO therapy to trauma patient based on our perceived notions and prejudices. Indeed the decision to start ECMO in trauma patients is not easy and straightforward and needs input from multidisciplinary team members but should be considered for each patient on an individual basis and may lead to very satisfying outcome in these mostly young patients. The need for more data and more outcome-based well-designed studies are needed to better define the role of ECMO in the care of trauma patients. The ECMO community should work in harmony to achieve this goal. The future of ECMO in trauma patients may prove to be bright after all.
Qatar Health 2020: A global conference setting the tone to host one of the most popular sporting competitions in the world
Welcome to this special issue of the Journal of Emergency Medicine Trauma and Acute Care (JEMTAC) dedicated primarily to Qatar Health 2020 Conference and presenting a selection of abstracts on various topics in response to a late call for free paper oral or poster presentation submissions (Table 1). Qatar Health 2020 was a collaborative event between Hamad Medical Corporation and the Qatar Ministry of Public Health chaired by Dr. Abdul Wahab Al Musleh and organized as a multidisciplinary academic meeting open to healthcare professionals and experts from different backgrounds and countries. The theme of the congress was “Mass gatherings Healthcare Services: Emergency and Disaster Management” in preparation for the FIFA World Cup 2022 and also concentrates on presenting best practices and evidence of a trauma system approach to mass casualty events.
Hosting one of the most popular sporting events in the world is a significant undertaking that requires a lot of preparation at a national level to ensure the well-being of athletes supporters and various professional groups and volunteers supporting such activity whilst also still providing the required services to the rest of the population. Mass gathering medicine is defined as “the public health challenges to hosting events attended by a large enough number of people at a specific site for a defined period of time likely to strain both the planning and response to the mass gathering of a community state or nation.”1 Whether it is in relation to the potential spread of infectious diseases terrorist attacks or accidents medical preparedness and emergency response are key23. The range of submissions received for Qatar Health 2020 in connection with the known and potential impact of mass gatherings in terms of healthcare response is a testimony of the importance of good preparation which involves a significant ramp up in healthcare manpower and physical resources public health campaigns interagency collaboration considerations for the environmental and cultural context and exercises to test and rehearse plans (Table 2).
This special issue also includes two abstracts from the first Qatar Trauma Nurse Symposium which took place at the end of 2019 and was jointly organized by the Trauma Nursing Department and the Nursing and Midwifery Education and Research Department of Hamad Medical Corporation under the leadership of Ms. Asmaa Mosa Al-Atey.
Finally we would like to close this editorial by wishing success to the resurging JEMTAC journal and congratulating all participants that made Qatar Health 2020 Conference and the Qatar Trauma Nurse Symposium such successful events. We look forward to featuring the work presented at future events held in Qatar as well as full articles directly submitted to the journal for Open Access publication. The Editorial Board will endeavor within the next couple of years to make it a regular publication with good quality and informative contents for everyone interested in emergency medicine trauma acute and pre-hospital care.
Diagnosis, management and outcome of Spinal Cord Injury without Radiographic Abnormalities (SCIWORA) in adult patients with trauma: a case series
Background: Spinal cord injury without radiographic abnormality (SCIWORA) in adults causes diagnostic and prognostic dilemma as radiography and/or computed tomography does not clearly detect bone lesions during the initial assessment. Herein we report our experience on 11 spinal cord injury cases without radiographic abnormality regarding the clinicoradiological features management and outcomes.
Methods: We conducted a case series of adult patients with SCIWORA who were admitted at the level 1 trauma center at Hamad General Hospital from January 2008 to July 2018. All patients underwent initial head and spine X-ray imaging computed tomography magnetic resonance imaging and 12 months of clinical follow-up.
Results: Eleven patients (mean age 46.5 ± 14.4 years) met the criteria of SCIWORA. The neurologic status on admission and 12 months after hospital discharge were classified according to the American Spinal Injury Association (ASIA) impairment scale (AIS). On admission 6 (54.5%) patients had ASIA grade C: 2 (18.2%) each had AIS grade D and B and 1 (9.1%) had AIS grade A. Five cases were treated conservatively with rehabilitation and physiotherapy and five were treated surgically by anterior cervical discectomy with fusion. One patient who declined surgery was managed with a sternal occipital mandibular immobilizer brace and underwent rehabilitation.
Conclusion: SCIWORA requires higher clinical suspicion and thorough neurological and radiologic assessment to prevent secondary spinal cord injuries and complications.
Years of Life Lost due to accidents and injuries in Iran: A trend of five years (2014–2018)
Background: Accidents and injuries are known around the world as the leading cause of disability and mortality. Objective: This study aimed to investigate the epidemiology of deaths due to accidents and injuries and years of life lost due to it. Methods: The method used in this research is the documentary method analysis. The study population was all deaths recorded in the Statistics and Performance Analysis Unit of Golestan University of Medical Sciences during the years 2014–2018. Results: During the years 2014 to 2018 more than 4318 deaths due to accidents occurred in Golestan province of which 76.3% were related to men and 23.7% were related to women. There were about 99531 years of life lost due to premature death during the study period with the proportion of men (75737 years 16 per 1000) higher than women (23794 years 5.1 per 1000). Conclusion: Promoting knowledge and education especially in the younger age group interventions to solve accident-prone areas adopting policies to reduce traffic accidents and lack of easy access to pesticides teaching safety principles are also recommended.
Scapular Fractures at a Level 1 Trauma Center: A Cross-Sectional Study
Purpose: Scapular fractures are uncommon injuries that account for up to 1% of all fractures and 5% of all shoulder girdle fractures. Moreover most of the evidence on the treatment of scapular fractures stems from case series with paucity of comparative studies. Despite the lack of standardized criteria for the operative treatment of scapular fractures a set of suggested radiological parameters has been recently reported. The primary aim of this study was to compare the treatment implemented for scapular fractures in comparison with standard published criteria. The secondary aim was to investigate epidemiological parameters of scapular fractures at a level 1 trauma center.
Methods: In this cross-sectional study of scapular fractures at a level 1 trauma center data were collected between December 2012 and January 2016. Data of all scapular fractures that presented to our center were retrospectively collected through electronic medical records. Identified cases of scapular fractures were then evaluated whether surgical treatment was indicated in accordance with recent standard operative criteria. Percentages were used to express the number of cases that were operatively indicated according to the predefined criteria and the number of cases operatively treated at our institution.
Results: A total of 52 patients met the inclusion criteria of having scapular fractures documented on radiography and Computed tomography (CT). The mean age of the patients was 38.5 years with the majority being men (92.3%). The most common mechanism of injury was a fall from a considerable height in 26% of the cases. Of the included patients 53.8% were polytraumatized and the most frequent concomitant traumatic injury was rib fractures (26.9%). Only 33% of intra-articular glenoid fractures with significant displacement were treated operatively. Furthermore non-operative treatment was undertaken in indicated extra-articular scapular body and neck fractures acromion or coracoid process fractures or superior shoulder suspensory complex double disruptions.
Conclusion: A significant discrepancy was found between the treatments implemented at our institution and the current standard criteria for the operative treatment of scapular fractures. This study emphasizes the need to educate surgeons on scapular fractures and to treat such fractures in accordance with standard published criteria. Furthermore scapular fractures that require surgery should be referred to a surgeon experienced in scapular fracture fixation.
Comparison between RISC II and TRISS in predicting 30-day mortality in primary trauma patients admitted at a university hospital in northeastern Thailand
Injection of rat mesenchymal stem cells leads to their homing and differentiation in the liver in a blunt liver trauma model
Background: The liver heals remarkably after different forms of injury. However healing can be lengthy following high-grade injuries. We hypothesize that injected mesenchymal stem cells (MSCs) could locate in the liver and differentiate into hepatocytes after blunt trauma using a rat liver trauma model.
Methods: Blunt liver trauma was induced in Lewis rats. MSCs were transfected with LacZ retrovirus so that they express the beta-galactosidase enzyme giving their nuclei a blue color on light microscopy. Each rat received a dose of MSCs (n = 6 × 106) within 24 h of trauma. Through different steps of the experiment the route of injection was the tail vein (TV) in nine rats the portal vein (PV) in 19 rats and directly to the injured liver (DI) in four rats. Rats were euthanized at 48 h or 7 days after the injection of MSCs. Livers were harvested and examined under light microscopy to identify the MSCs.
Results: Liver sections showed localization and migration of MSCs to trauma sites in the PV group euthanized at 48 h (3/10 rats). Some MSCs differentiated into hepatocytes. Similar findings were present in 1/9 rats euthanized at 7 days in the PV group. There was no evidence of MSC localization in TV and DI groups.
Discussion: MSCs can locate and differentiate into liver-like cells in blunt liver injury. Portal vein injection of MSC has emerged as the most effective method of delivery to the liver among the other methods. Optimizing homing to injured tissue and evaluating differentiated stem cell functionality are future areas of research.
Patient Age and Gender Analysis of Oral and Maxillofacial Clinical Conditions in Iraq: A Retrospective Study
Background This study aims at assessing the age and gender distribution among patients with various clinical conditions who sought treatment at the Department of Oral and Cranio-maxillofacial Surgery in Al Kindy Teaching Hospital in Baghdad Iraq.
Methods The research data for this study was obtained from the Department of Oral and Cranio-maxillofacial Surgery at Al Kindy Teaching Hospital in Baghdad Iraq. The data was collected between April 2019 and February 2020 involving 1443 patients spanning various age groups from infants to 85-year-olds. The patients are categorized based on age sex and diagnosis using the International Classification of Diseases. The diagnosed diseases were classified according to the Contemporary Oral and Maxillofacial Surgery textbook guidelines.
Results The majority of patients are in their second decades and most of the samples that attended the hospital are from the male category female patients had to do with temporomandibular problems trauma and surgical extraction. In contrast the most common category among male patients is trauma followed by jaw fractures. Trauma Follow-up Facial Palsy Ranula Trigeminal Neuralgia and Parotid Gland Swelling were all significantly different between males and females when compared on their own in each category.
Conclusions Males exhibit a higher hospital attendance rate compared to females with males being more prone to oral trauma while females are more susceptible to temporomandibular joint disorders. Young children have a greater likelihood of experiencing trauma rather than jaw fractures due to the presence of a thicker adipose tissue layer and the absence of paranasal sinus pneumatization.
A brief review of the Arkansas trauma system
Trauma care is a vital part of the US healthcare system given that it is the leading cause of death for non-elderly individuals. The need for improved systems of trauma care—particularly in rural areas—has been acknowledged over recent years. Arkansas was one of several states to build a trauma system in the 2000s and demonstrated its economic and health benefits through research after implementation. In this article we briefly review the history of rural trauma care in the United States leading up to the creation of the Arkansas Trauma System (ATS) discuss the development and components of the ATS and focus on future directions and needs. The lessons learned from the system developed in Arkansas and the work yet to be done are generalizable to other states with large rural populations.