Journal of Emergency Medicine, Trauma and Acute Care - Volume 2012, Issue 1

All terrain vehicle (ATV) use is increasing at a rapid pace in settings without proper safety regulations.

Aim: To define injury patterns, impairments, and outcomes among patients injured in ATV crashes; to determine prevalence of protective equipment use; and to define the potential role of injury prevention in addressing the problem.

Methods: During a recent 10 month period, 56 patients were reported as injured in ATV crashes seriously enough to require admission and were prospectively entered into a study-specific database. Patient demographics, site of crash, prior ATV experience, and use of safety equipment were recorded. Injuries were characterized by body system and tabulated. Outcomes, including deaths and impairments, were defined.

Results: There were 47 males (84%) and 9 females (16%). Most injuries occurred in patients older than 18 years, but 20% occurred in children less than 14 years of age. Helmet use was confirmed in 12%. Three patients died (5% mortality). Significant disability occurred in 19 patients (34%) and was permanent in 4 (7%). Head, face and musculoskeletal injuries were most common.

Conclusions: ATV crashes can cause serious injuries including death and permanent disability. The lack of awareness of the injury potential for this popular recreational activity has escalated the risk of injury, and the absence of safety programs and regulations has further aggravated the problem. Based on these data, a public education program, compulsory use of helmets and other protective clothing, and penalties for non-compliance should be implemented. Interventions at recreation sites and the point of ATV sale may be most beneficial.

Snakebites are a common environmental hazard in many regions of the world. The objectives were to study the epidemiology, clinical, laboratory features of snakebites, the pattern of management with its outcome, and studying the association between the presenting clinical and initial laboratory findings with the outcome.

Method: a retrospective, hospital-based study was conducted from March 1997–April 2001 at the Saudi Hospital in the Hajjah governorate, Yemen Republic. The demographics, clinical, laboratory, management, outcome data and selected variables were collected for detecting any association between the degree of acuity of snakebites and the outcome.

Results: The data of 186 patients was collected over the period of 4 years. Eighty three percent of snakebite victims were below 40 years of age and males made up 73.7% of all cases. The average incidence was 43 cases per year, with the highest number of cases recorded in July–October. Local swelling then redness was the most common clinical features and the systemic hematological manifestations were double the neurological signs. Lower limbs were involved in 55% of cases. Anemia, leukocytosis, leucopenia and thrombocytopenia were recorded in 34%, 28%, 11% and 8% of cases respectively. Abnormal coagulation was seen in 30% of patients. Admission was necessitated for one third of patients. Surgical assessment was required for 15% of patients. Antivenom was administered for 80% but only 31.7% received this within the first 8 h. Blood products were used for 42% of patients. The complications from the snakebites were recorded in 26% of all cases. There was a statistically significantly association between the rate of complications and the presence of more than three clinical and laboratory findings on arrival. The overall mortality rate was 3.7%.

Conclusion: Snakebites are an important public health problem with a relatively high rate of mortalities and other complications associated with delay in the administration of antivenom. Acknowledging more than three clinical and/or laboratory manifestations on arrival to hospital might help in anticipating clinically important complications.

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.

Objective: The objective of this study was to analyze cases that had left the Pediatric Emergency Center Al Sadd, Doha (PEC) against medical advice, with the aim of developing policies to help reduce this occurrence. Methodology: All patients that were admitted to the main PEC observation room for treatment and/or investigation and subsequently left against medical advice from February 18, 2007 to June 18, 2007, were followed by a phone call, and a questionnaire, which was completed by the departmental patient representative. Results: 99,133 patients attended the facility during the study period. Of those, 106 left the facility against medical advice. Ninety-four guardians were successfully contacted. 90% of the cases were in children below 2 years of age. In 87% of the cases the mother was the main decision maker for leaving against medical advice. Domestic obligations were the leading cause of DAMA (discharge against medical advice), reported in 45% of the cases. Respondents reported that the consequences of DAMA were well explained by medical staff before they left the facility however, they had not met with the departmental patient representative during their stay. Conclusion: As the majority of DAMA cases occurred in infants, medical staff should address the concerns of this group early on in the course of treatment. Maintaining communication and providing support, in particular for mothers of higher risk groups may help to reduce the rate of DAMA cases.

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.

Malignancy in undescended testis is well documented. We present a rare case—of seminoma in an adult male found in an intra abdominal testis—that is associated with ipsilateral renal agenesis and absence of ipsilateral seminal vesicle.

We report a case of a sixty-two-year-old man who presented to the emergency department with severe right iliac fossa pain. The patient was clinically diagnosed as having acute appendicitis and was referred for an abdominal CT scan. Abdominal CT revealed a Spigelian hernia with Richter-type herniation of the small bowel without any significant bowel obstruction. The patient underwent immediate surgical repair and the postoperative course was uneventful. This is a rare association of two rare conditions mimicking a common disease such as appendicitis.

We report a case of Bochdalek hernia of the diaphragm in an adult who presented with acute upper abdominal pain and vomiting. We report this case because it is a rare condition, with little more than 100 cases reported in the literature [1]. Moreover, this is a condition mostly found in neonates and children, rarely carrying over into adulthood. This case details how to recognize the condition and how a lack of awareness around it carries a real and a serious potential for misdiagnosis.

We report a case of bilateral Purtscher’s retinopathy in a young man following a motor vehicle rollover accident. Decreased vision was noticed on the fifth day following the trauma. Visual acuity in the right eye was close counting finger, and left eye, counting finger one meter. There was no evidence of direct ocular, head or facial trauma. Purtscher flecken, pre-retinal and retinal hemorrhages were present in both eyes. The right eye showed optic disc edema and more extensive areas of capillary dropout. Patient was treated with intravenous methyl prednisolone. After 5 weeks the right eye vision improved to counting finger one meter and left eye improved to 6/18. Early detection, proper documentation and treatment of the underlying causes in these cases is very important in order to avoid medico-legal pitfalls.

Intrathoracic bleeding may occur following blunt chest trauma, and can be classified as minimal, moderate or massive, according to the amount of blood present. The diagnosis of hemothorax is established by clinical examination, plain chest radiograph or, more recently, by ultrasound of the chest [1]. Computed tomography of the chest helps to define the nature of the chest injury but is not indicated in all patients because of lack of availability, radiation dose and expense [2]. Significant intrathoracic bleeding following chest trauma going unrecognized for more than 2–3 days is highly unusual [3]. A trauma patient who presented with symptomatic massive hemothorax 12 days post-injury is herein reported.

Background: The natural history and optimal management of retained hemothorax (RH) after chest tube placement is unknown. The intent of our study was to determine practice patterns used and identify independent predictors of the need for thoracotomy.

Methods: An American Association for the Surgery of Trauma multicenter prospective observational trial was conducted, enrolling patients with placement of chest tube within 24 h of trauma admission and RH on subsequent computed tomography of the chest. Demographics, interventions, and outcomes were analyzed. Logistic regression analysis was used to identify the independent predictors of successful intervention for each of the management choices chosen and complications.

Results: RH was identified in 328 patients from 20 centers. Video-assisted thoracoscopy (VATS) was the most commonly used initial procedure in 33.5%, but 26.5% required two and 5.4% required three procedures to clear RH or subsequent empyema. Thoracotomy was ultimately required in 20.4%. The strongest independent predictor of successful observation was estimated volume of RH≤300 cc (odds ratio [OR], 3.7 [2.0–7.0]; ). Independent predictors of successful VATS as definitive treatment were absence of an associated diaphragm injury (OR, 4.7 [1.6–13.7]; ), use of periprocedural antibiotics for thoracostomy placement (OR, 3.3 [1.2–9.0]; ), and volume of RH≤900 cc (OR, 3.9 [1.4–13.2]; ). No relationship between timing of VATS and success rate was identified. Independent predictors of the need for thoracotomy included diaphragm injury (OR, 4.9 [2.4–9.9]; ), RH>900 cc (OR, 3.2 [1.4–7.5]; ), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2–4.6]; ). The overall empyema and pneumonia rates for RH patients were 26.8% and 19.5%, respectively.

Conclusion: RH in trauma is associated with high rates of empyema and pneumonia. VATS can be performed with high success rates, although optimal timing is unknown. Approximately, 25% of patients require at least two procedures to effectively clear RH or subsequent pleural space infections and 20.4% require thoracotomy.

Background: Percutaneous tracheostomy is a routine procedure in the intensive care unit (ICU). Some surgeons perform percutaneous tracheostomies using bronchoscopy believing that it increases safety. The purpose of this study was to evaluate percutaneous tracheostomy in the trauma population and to determine whether the use of a bronchoscope decreases the complication rate and improves safety.

Methods: A retrospective review was completed from January 2007 to November 2010. Inclusion criteria were trauma patients undergoing percutaneous tracheostomy. Data collected included age, Abbreviated Injury Score by region, Injury Severity Score, ventilator days, and outcomes. Complications were classified as early (occurring within <24 h) or late (>24 h after the procedure).

Results: During the study period, 9,663 trauma patients were admitted, with 1,587 undergoing intubation and admission to the ICU. Tracheostomies were performed in 266 patients and 243 of these were percutaneous; 78 (32%) were performed with the bronchoscope (Bronch) and 168 (68%) without bronchoscope (No Bronch). There were no differences between the groups in Abbreviated Injury Score by region, Injury Severity Score, probability of survival, ventilator days, and length of ICU or overall hospital stay. There were 16 complications, 5 (Bronch) and 11 (No Bronch). Early complications were primarily bleeding (Bronch 3% vs. No Bronch 4%, not statistically significant). Late complications included tracheomalacia, tracheal granulation tissue, bleeding, and stenosis; Bronch 4% versus No Bronch 3%, (not statistically significant). One major complication occurred, with loss of airway and cardiac arrest, in the bronchoscopy group.

Conclusion: Percutaneous tracheostomy was safely and effectively performed by an experienced surgical team both with and without bronchoscopic guidance with no difference in the complication rates. This study suggests that the use of bronchoscopic guidance during tracheostomy is not routinely required but may be used as an important adjunct in selected patients, such as those with HALO cervical fixation, obesity, or difficult anatomy.

We present the case of a 25 year-old man who had a splenectomy five years previously following a road traffic accident (RTA). He presented to our A&E department one evening with fever and upper abdominal pain associated with nausea & vomiting. Clinical examination was unremarkable. Initial investigations revealed only pyuria. He was treated symptomatically along with parenteral antibiotic and admitted to the general medical ward. Within few hours he deteriorated rapidly with septic shock, multi-organ failure, disseminated intravascular coagulation (DIC) and eventually cardio-respiratory arrest. Despite all resuscitative measures he died within few hours of admission.

Splenectomized patients are prone to develop severe infection, including sepsis and meningitis, due to OPSI, or overwhelming post-splenectomy infection. Presentation may be mild, but the course is rapid and the prognosis is very poor, even in young people. It is important that splenectomized patients receive vaccines according to guidelines, take antibiotic prophylaxis and are educated to seek medical attention at the earliest sign of even minor infections.

Angioedema is a rare but potentially life threatening condition commonly associated with angiotensin-converting enzyme inhibitors (ACEIs). The incidence is approximately 0.1–0.2% and may occur within the first week to several years of taking an ACEI. We present a case of a 37-year-old African American male who was uneventfully taking a drug combination of quinapril and hydrochlorothiazide. When his medication was changed to lisinopril he developed an acute swelling of his lower lip and chin on fifth dose. The angioedema subsided within 24 hours after discontinuation of lisinopril. Therefore, this suggests that future treatment with ACEIs, as well as angiotensin receptor blockers (ARBs), is not recommended in this type of patient.

Objectives: To assess urinary calculi and the secondary signs of obstruction, in patients referred from the accident and emergency department, by unenhanced computed tomography examination and to review the radiation dose the patients received with the use of automatic dose modulation technique, care dose 4D. Material and methods Medical records of unenhanced multi-slice computed tomography (MSCT) examinations for 114 patients referred to the emergency department for analysis of suspected urinary calculi were reviewed retrospectively. Their treatment involved automatic tube current modulation, a dose reduction method (care dose 4D), in Hamad General Hospital. The cases were analyzed for the presence of stones, size, site, density and the secondary signs of obstruction, namely hydronephrosis, hydroureter, perinephric fat stranding, peri-ureteric fat stranding and renal enlargement. A search for alternate diagnosis was made if no stone was found. The final diagnosis was noted from the discharge summary in medical records. The radiation dose, Computed Tomographic Dose Index volume (CTDI) and Dose Length Product (DLP) in each patient was recorded from patient protocol. Results Of 114 patients referred to CT scan for suspected urinary calculi, between March and June 2008, urinary calculi were noted in 75.4%. An alternate diagnosis was offered to 5.3% and a diagnosis of normal was given to 19.3%. The size of stones detected varied from 2 mm–35 mm. Density of stones varied from 110–1250 hounsfield units (HU). Solitary stones were seen in 54.4% of cases observed and multiple stones in 22%. Renal stones were observed in 6.1% of cases, urteric stones in 26.3%, vesico-uretric junction stones in 18.4%, multiple sites in 23.7%. Hydronephrosis was seen in 68% of cases, hydroureter in 63%, perinephric fat stranding in 51%, periureteral fat stranding in 34%, ureteric rim sign in 28% and renomegaly in 24%.

Time interval between onset of symptoms to imaging varied from 4 to 12 hours. The radiation dose, CTDI, ranged from 6.5–15.8 mGy and DLP from 257 to 918 mGy/cm with the use of automatic tube current modulation, care dose 4D. Final diagnosis and MSCT diagnosis were in concordance in 86 (75% of) patients of renal calculi and alternate diagnosis in 6 (5.3%) of patients and normal in rest of the patients. Conclusion In clinically-suspected urinary calculi, unenhanced MSCT of abdomen with the use of care dose 4D, an automatic tube current modulation technique, is a fast and reliable investigation in an emergency setting to detect stones and secondary signs of obstruction. It offers alternate diagnosis with substantial reduction in radiation dose—both the computed tomography dose index (CTDI) and dose length product (DLP).

Objectives: To determine the factors associated with a poor final visual outcome following a non-perforating traumatic hyphema. Methods: The in-patient records of all traumatic hyphema patients admitted to the Department of Ophthalmology of the Hamad Medical Centre (HMC) in Doha, Qatar, were retrospectively reviewed for a four-year period from January 2004 to March 2008. One hundred and seventeen patients who did not meet the exclusion criteria were divided into two groups based on their final visual outcome post-treatment. Group 1 (good outcome) consisted of 100 patients with a visual acuity (VA) of 6/18 or better and group 2 (worse outcome) consisted of 17 patients with a VA of less than 6/18. The two groups were compared to determine the factors associated with a poor final visual outcome. Results: Group 2 patients had an 82.3% incidence of complications after a traumatic hyphema compared with a 21% incidence in group 1. Of these complications, secondary glaucoma and rebleeding were significantly associated with a worse final visual outcome. Trauma from projectiles or blows did not differ significantly in their effect on the final visual outcome, although blow injuries had a greater impact on the final visual outcome. Posterior segment injuries were associated with a worse visual outcome. Conclusion: It was concluded that secondary glaucoma, rebleeding, and posterior segment injuries are factors associated with a poor final visual outcome.

Background: Safety data on recombinant activated factor VII (rFVIIa, NovoSeven; Novo Nordisk A/S, Bagsværd, Denmark) in actively hemorrhaging trauma patients are limited. We present detailed safety data from a large multicenter, randomized, placebo-controlled phase III study (the CONTROL trial). Methods: Data from 560 patients were analyzed. Subjects were monitored for adverse events (AEs) after rFVIIa or placebo administration. Incidences, timing, and presence of risk factors were reported by site investigators, supported by external study monitors and overseen by an independent Data Monitoring Committee. Results: There were no differences in overall mortality, organ system failure, or AEs, serious AEs, or medical events of special interest. Arterial and venous thromboembolic (TE) events and their risk factors were similar in both groups. The greatest risk factor for TE events was a chest injury requiring mechanical ventilation >3 days (86%). There were four site investigator-reported myocardial infarctions in the rFVIIa group of which only one met diagnostic criteria preestablished by the Data Monitoring Committee. There were no reported myocardial infarctions in the placebo group. Troponins were increased in 30% of all patients. The rate of acute respiratory distress syndrome was lower in the rFVIIa (3.0%) than in the placebo (7.2%) group (). Conclusions: This represents the largest placebo-controlled dataset of rFVIIa use in trauma patients to date. In this prospective study of critically bleeding trauma patients, rFVIIa use was associated with an imbalance of investigator-reported Acute myocardial infarction/non-ST segment elevation myocardial infarction (AMI/NSTEMI), but was not associated with an increased risk for other AEs, including TE complications.

We report a 45 year-old male patient who presented to the emergency department of Hamad General Hospital with recurrent severe low back pain. Clinical examination revealed characteristic deposition of blue-brownish pigment in the sclera and ear. X-ray revealed diffuse intervertebral disc calcification. Alkaptonuria was suspected and the diagnosis was confirmed by detection of high levels of homogentisic acid in the urine.

Sigmoid volvulus is an important surgical emergency which requires rapid detorsion of the affected bowel. Prompt diagnosis is crucial. It should be one of the differentials to be considered in patients presenting with abdominal distension and signs of intestinal obstruction. This case presentation serves to highlight one such example; the clinical presentation, radiological findings and management are discussed.

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.

Objective: To assess the occurrence and severity of thrombocytopenia in hospitalized vivax malaria patients. Design and setting: Retrospective and descriptive hospital based case series from March 2005 to March 2007, conducted in the medical unit of Al Khor Hospital. Patients and methods: Seventy-eight patients with peripheral smear positive were enrolled in the study. Peripheral smear examination for malaria parasites was used as the method of choice for the diagnosis of malaria. Hematological parameters were determined by using an automated analyzer. Low platelet counts were re-evaluated by manual methods. Results: Study sample was 78 patients, of which 65 patients (83.3%) were thrombocytopenic. Of these, 41 patients (52.6%) had mild thrombocytopenia, 23 patients (29.5%) had moderate thrombocytopenia and 1 patient (1.3%) had severe thrombocytopenia. All patients (100%) were male. Conclusion: High prevalence of thrombocytopenia was seen in vivax malaria patients, making it a common hematological feature in vivax malaria.

Accidental loss of a part of a peripheral intravenous cannula is an uncommon event. We report a case of an accidentally missed particle of a peripheral venous cannula presenting as a foreign body in the subcutaneous tissue, three months after the event that dislodged it. We explore this in terms of its diagnosis and management.

A 72-year-old man presented with constipation. He was hypertensive and suffered from chronic constipation. On arrival, the patient was fully conscious, and his vital signs were stable. He requested an enema because this treatment had proved effective in the past. On physical examination, a hard palpable mass was detected in the lower abdomen. Computed tomography was performed with contrast media. It revealed an abdominal aortic aneurysm (AAA) and bilateral internal iliac artery aneurysms (IIAAs); the latter obstructing the sigmoid colon. We believe that this obstruction was the cause of constipation. The patient underwent Y-graft replacement for the treatment of the AAA and bilateral IIAAs. The surgery was successful, and constipation has not recurred since. As constipation is the most common digestive disorder in the general population, all physicians should be aware that chronic constipation can be caused by bilateral IIAAs.