Journal of Emergency Medicine, Trauma and Acute Care - الأعداد السابقة

Background: Hollow viscus perforation is one of Pakistan’s most commonly encountered surgical emergencies. Gastroduodenal perforations account for the most common site of perforations worldwide. However, the Pakistani population has a different pattern.

Objective: The aim of this study was to determine the clinico-pathologic features of patients and the effectiveness of surgical options in the emergency management of bowel perforation.

Materials and Methods: This retrospective, observational study was conducted at the Department of General Surgery, Unit-III, Lahore General Hospital, Lahore from January 1, 2021 to December 31, 2021. Data on demographic profiles, clinical presentation, risk factors, site of perforation, and surgical details of 73 patients with gastrointestinal perforation admitted via emergency were collected and analyzed using the Microsoft Excel (Microsoft Corp., Redmond, WA) spreadsheet.

Results: There were 74% females out of the 73 included cases. Perforation was most common among the age group of 21–25 years. Abdominal pain was present in all patients, followed by vomiting in 46.6% of cases. Guarding was observed as the most common sign in 78.1% of patients. The ileum was the most common site of perforation in 41.1% of cases, while typhoid was the most common cause of bowel perforation in 20.5% of patients. In 42.5% of cases, stoma was made, followed by primary closure in 16.4% of patients.

Conclusion: This study shows an increased incidence of perforation in the ileum in the Pakistani population, different from the rest of the world and common in youth. An increased incidence of perforation due to typhoid highlights the prevalence and inadequate treatment of this disease.

Background: Firearms cause severe injuries that require a large amount of healthcare resources. In Canada, few studies describe the incidence and outcomes of gun violence treated in our trauma centers.

Objective: From trauma registry data, we describe the demographic, social, and medical characteristics of patients presenting to the hospital with gunshot wounds. In particular, we describe their injury severity, resuscitative interventions, hospitalizations, and outcomes.

Results: From 2012 to 2022, Edmonton’s two trauma centers saw 367 patients injured by firearms, predominately young males. Assault was a more common intent for injury (76%) than self-harm, accident, or law enforcement (16%, 6%, and 2%, respectively). Handguns were the most common weapon identified. Resuscitative procedures for these patients were common, including endotracheal intubation, chest decompression, and blood administration. Overall mortality was 24% with most deaths occurring on the first day. In those who survived beyond that, hospitalization duration averaged 21 days. Only 53% were discharged to routine self-care.

Conclusion: Gun violence is an uncommon presentation in Edmonton’s trauma centers. Healthcare resource utilization is expected to be high, especially on the first day.

Purpose: Unstable intertrochanteric (IT) fractures are common orthopedic injuries in the elderly people with high morbidity. The treatment of unstable IT fractures with sliding hip screw (SHS) is still controversial. The purpose of our study is to assess the outcomes of conventional SHS in unstable IT fractures in comparison to stable ones.

Methods: A total of 35 stable and 23 unstable IT fracture cases were treated with SHS between January 2017 and December 2018. Patients were evaluated for infection, revision rate, screw cut-out, development of post-traumatic arthritis or heterotopic ossification, and mortality.

Results: The mean age of the patients at the time of surgery was 69.8 and 73.9 years for stable and unstable IT fractures, respectively, with 38 males (25 stable vs. 13 unstable) and 20 females (10 in each group). The mean follow-up was 42.2 and 49.4 weeks in stable and unstable IT fractures, respectively. We found a significant association between the occurrence of screw cut-out in unstable fractures compared to stable ones (17.4% vs. 0%, respectively, p = 0.01). There was an obvious trend for nonunion and higher revision rates in unstable IT fractures (17.4% vs. 2.9%, p = 0.056). Logistic regression analysis did not reveal any statistically significant confounder that might affect the rates of fracture union or revision rates. Post-traumatic arthritis and heterotopic ossification occurred in one case of unstable IT fracture. There were no reported cases of infection.

Conclusion: There are higher risks of screw cut-out, nonunion, and the need for revision when the SHS is used to treat unstable IT fractures.

Background and Aims: Drowning is defined as a process with consequences ranging from death to survival without continuous injury. This study was conducted to determine the mortality rate and the years of life lost (YLL) due to drowning in Fars Province.

Methods: All deaths due to drowning in Fars Province were obtained from the electronic population-based death registration system (EDRS). Crude and age-standardized mortality rate, YLL, and YLL rate data were calculated, and joinpoint regression was used to examine the trend.

Results: During the study period (2004–2019), 910 deaths due to drowning occurred in Fars Province. Of these, 80.5% (733 cases) were reported in men and 41.0% (373 cases) were in the age group of 15–29 years. Crude mortality rate had decreasing trends in male and stable trends in female. The total YLL due to drowning during the 16-year study period were 19,583 (0.62 per 1000 people) in men and 4797 (0.15 per 1000 people) in women. According to the joinpoint regression analysis, the 16-year trend of YLL rate due to premature mortality in males was decreasing. The annual percent change (APC) was -6.0% [95% confidence interval (95% CI) -8.4 to -3.5, p < 0.001] and stable trends in female (APC = - 5.4%; 95% CI -11.8 to 1.4, p = 0.108).

Conclusion: Although the trend of crude and standardized mortality rates and YLL due to drowning in men decreased during 2004–2019, these trends have been constant in women. Therefore, the need to invest in the implementation and evaluation of drowning prevention interventions cannot be ignored.

Background: Surgical site infections (SSIs) after appendectomies constituted a significant patient safety issue and impacted the efficiency of healthcare. Various risk factors had been linked to SSI after appendectomies, including risk to patients and procedures, and compliance with infection control practices. This study aimed at identifying the risk factors for SSI in appendectomies due to acute appendicitis in a single facility in Qatar.

Methods: A historical observational study of appendectomies performed from January 2013 to February 2023 at a single facility in Qatar was conducted. Demographics, surgical procedure data, compliance with antibiotic prophylaxis, and histopathological findings were recorded from the patient’s electronic medical records.

Results: A total of 2377 appendectomies and 52 SSIs were described, mainly in male patients (93.3%) with a mean age of 32.4 years and non-complicated appendicitis (66.7%). SSI risk was 3.86 times higher when appendicitis was perforated in comparison to other appendicitis types [odds ratio (OR) = 3.86; 95% confidence interval (95% CI) OR 1.93–7.70]. Procedures longer than 81 minutes had 4.84 times more SSI risk (OR = 4.84; 95% CI 2.25–10.42), the improper timing of antibiotic prophylaxis had 5.97 times higher SSI risk (OR = 5.97; 95% CI 1.10–32.56), and the improper antibiotic selection had 9.08 times higher SSI risk (OR = 9.08; 95% CI 1.81–45.42).

Conclusion: This study identifies the risk factors linked to SSI risk, including perforated appendectomies, longer surgical procedures, and improper timing and selection of antibiotic prophylaxis. The infection control program should focus on interventions to improve compliance with antibiotic prophylaxis and evaluate additional strategies to minimize the SSI risk in complicated appendicitis.

Objective: The aim of this study was to determine the association of HbA1c with coronary artery disease (CAD) in non-diabetic patients undergoing coronary artery angiography.

Methods: This cross-sectional study was conducted on 265 individuals referred to an educational heart hospital affiliated with Urmia University of Medical Sciences, north of Iran. Participants were selected through a convenient sampling method. Patients underwent angiography, and CAD disease severity for them was computed using a GSS score. The association of HbA1c and other variables on CAD disease severity was investigated.

Results: A total of 265 non-diabetic diabetic patients with a mean age of 59.36 years were investigated. The mean body mass index was 26.42 kg/m² and the mean left ventricular ejection fraction (LVEF) was 48.62%. The mean score of the Geriatric Scoring System in patients was 31.28. As the GSS score increased, HbA1c was significantly increased as well. HbA1c had an appropriate value in the diagnosis of severe CAD, and the best cutoff point for this assessment was 6.15%. In addition, HbA1c had an appropriate value in the diagnosis of mild CAD, but cigarette use and hypertension had no significant effect on this association.

Conclusion: HbA1c with cutoff points mentioned was an appropriate factor to determine the severity of CAD in non-diabetic patients; therefore, it is recommended to use that to determine disease severity, and in patients with high levels of HbA1c, close follow-up and treatment need to be done to decrease the complications and mortality.

A failed airway is defined as an unsuccessful intubation. It is a rare occurrence in the emergency department (ED) and always poses a challenge to emergency physicians. The ‘can’t intubate, can ventilate’ situation is one of the two ways a failed airway can occur in ED. Here, we present a case of failed emergency endotracheal intubation due to unanticipated subglottic stenosis. An elderly presented to a district hospital (without specialist) with acute bronchospasm, in which he was treated as severe exacerbation of chronic obstructive pulmonary disease (COPD). Despite maximal medical therapy, symptoms worsen, requiring intubation for airway protection. Standard rapid sequence intubation (RSI) was performed, with a good view of glottic opening; however endotracheal tube (ETT) size 7.5 could not be passed beyond the larynx. Several attempts using smaller-size ETTs still failed. A laryngeal mask airway (LMA) was inserted as a rescue device for ventilation. The patient was then sent to our centre for further evaluation and treatment. Initial examination in our ED revealed an elderly that was sedated and ventilated through LMA. Ventilation and oxygenation via the LMA were adequate. Diagnostic endoscopy was performed through LMA using flexible intubating scope which showed subglottic stenosis around 2cm below the vocal cord. The patient was referred to the Ear, Nose and Throat (ENT) team, where emergency tracheostomy was then performed in operating theatre. He was discharged well after 14 days of admission and given follow-up for his COPD and tracheostomy care.

Background: Patients with acute limb ischemia (ALI) are being treated using both open and endovascular procedures, with technological developments making treatments simpler and safer. However, the most significant improvements in outcomes for these patients will come from timely diagnosis, followed by quick and standardized therapy to reduce the likelihood of limb loss and subsequent sequels. The study sought to explore the clinical presentation and treatment outcome of open surgical revascularization for ALI in a resource-limited setting.

Method: Between June 2019 and December 2022, a retrospective study including all patients presenting with ALI and treated with urgent revascularization at Al-Thora General Hospital, Sana’a, Yemen, was performed. All patients were classified using Rutherford’s ALI categorization. Demographic parameters, clinical data, treatment details, and outcomes were obtained from patient medical profiles. The main outcome was organ/patient survival and amputation 30 days following surgery. Secondary outcomes included factors associated with amputation.

Result: Overall, 91 ALI patients were treated with urgent open revascularization during the study period. The mean age of patients was 55.9 ± 11.5 years, and most cases (61.5%) were male patients. The duration of symptoms was longer than 36 h in 29 cases (31.9%). Comorbidities such as ischemic heart disease, hypertension, diabetes mellitus, hyperlipidemia, cerebrovascular disease, congestive heart failure, renal impairment, atrial fibrillation, and history of malignancy were present in 61 (67.0%), 76 (83.5%), 56 (61.5%), 49 (53.8%), 11 (12.1%), 21 (23.1%), 25 (27.5%), 47 (51.6%), and 8 (8.8%) cases, respectively. Sensory impairment was seen in 30 (33.0%) cases. Thrombosis etiology was the most common ALI causes (80.2%). In laboratory results, high C-reactive protein (CRP) levels, low hemoglobin levels (anemia), and low albumin levels were present in 15 (16.5%), 15 (16.5%), and 8 (8.8%), respectively. Most ALI (85.7%) were occurred in lower extremity. Additionally, 61 (67.0%) cases were in the Rutherford IIb stages. All cases were undergoing open surgical revascularization and fasciotomy was made in 6 (6.6%) cases. The amputation-free survival rate was 76.9% at 30 days follow-up. The 30-day outcome was amputation in 21 (23.1%) cases and death in one case. In univariate analysis, current smoking, history of diabetes, hemodialysis, history of malignancy, atrial fibrillation, sensory impairment, prolonged symptoms duration (>36 h), elevated CRP (>5 mg/L), advanced ALI stage (Rutherford’s class IIb), fasciotomy, and thrombosis etiology were associated with revascularization failure and amputation and were statistically significant (all p-values < 0.05).

Conclusion: In this study, despite no endovascular treatment offered, the application of the standard treatment—open surgical revascularization—in patients with ALI represents the key to success for limb salvage with acceptable amputation rates even in a resource-limited setting. Additionally, independent risk factors for amputation were current smoking, history of diabetes, hemodialysis, history of malignancy, atrial fibrillation, sensory impairment, prolonged symptoms duration (>36 h), elevated CRP (>5 mg/L), advanced ALI stage, fasciotomy, and thrombosis etiology. Advanced tailoring revascularization strategy and timing for the proper patient and comorbidities treatment could potentially improve amputation-free survival in ALI patients. Future studies should incorporate both limb severity and anatomic staging to best guide clinical decision-making in ALI.

Introduction: Congenital diaphragmatic hernia (CDH) is a rare, potentially life-threatening condition characterized by abdominal organs protruding into the thoracic cavity due to diaphragmatic abnormality.

Presentation of Case: The 13-year-old male from Ahmedabad presented with increasingly worsening dyspnea and intermittent left-sided chest discomfort, diagnosed with a left-sided CDH involving the entire kidney, bowel loops, left splenic flexure, and pancreatic tail, undergoing successful exploratory laparotomy and closure of the defect with an uneventful recovery.

Discussion: CDH, typically detected shortly after birth, could manifest with varied symptoms and was associated with life-threatening conditions but, in some cases, remained unidentified until adulthood, with potential risk factors including maternal factors and alternatives in diagnosis encompassing various thoracic conditions.

Conclusion: The diaphragmatic defect requiressurgical management, highlighting the importance of safe surgical techniques and contributing to the limited documentation of cases in Gujarat, India.

Purpose: Difficult mask ventilation occurs due to the inability to form a seal between the patient’s face and the mask. The NuMask® is an intraoral mask with a flange that forms a seal against the buccal gum line. We aimed to compare the intraoral mask and conventional face mask for ventilation of the lungs of patients under general anesthesia.

Methods: This randomized crossover study was conducted on 40 adults who were not anticipated to be difficult to mask ventilate. In Group CI, mask ventilation was done using a conventional face mask for 1 min and then an intraoral mask for 1 min. In Group IC, mask ventilation was done using an intraoral mask first and then a conventional face mask. An anesthesia ventilator was used to deliver pressure-controlled ventilation with a target pressure of 15 cm H2O and a respiratory rate of 10 bpm during mask ventilation. The primary outcome was expired minute volume obtained using both devices.

Results: The expired minute volume using conventional face mask was 6328 ± 2509 mL in Group CI (Conventional Intraoral) and 6289 ± 1735 mL in Group IC (Intraoral Conventional) (p = 0.954). The expired minute volume using intraoral mask was 6154 ± 1905 mL in Group CI and 6501 ± 2013 mL in Group IC (p = 0.578). Overall, expired minute volume was comparable using conventional face mask and intraoral mask, i.e., 6308 ± 2129 and 6328 ± 1942 mL, respectively (p = 0.93). The end-tidal carbon dioxide during mask ventilation was also similar (p = 0.107). There was no trauma to face, lips, gums, or teeth in any patient.

Conclusion: Both conventional face mask and intraoral mask were comparable for the ventilation of the lungs of patients without anticipated difficult mask ventilation under general anesthesia.