TRAUMA MONTHLY
Year:2015 | Volume:20 | Issue:1|Papers Count:10

Background: Rapid ultrasound in shock (RUSH) is the most recent emergency ultrasound protocol, designed to help clinicians better recognize distinctive shock etiologies in a shorter time frame.Objectives: In this study, we evaluated the accuracy of the RUSH protocol, performed by an emergency physician or radiologist, in predicting the type of shock in critical patients.Patients and Methods: An emergency physician or radiologist performed the RUSH protocol for all patients with shock status at the emergency department. All patients were closely followed to determine their final clinical diagnosis. The agreement between the initial impression provided by RUSH and the final diagnosis was investigated by calculating the Kappa index. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of RUSH for diagnosis of each case.Results: We performed RUSH on 77 patients. Kappa index was 0.71 (P Value=0.000), reflecting acceptable general agreement between initial impression and final diagnosis. For hypovolemic, cardiogenic and obstructive shock, the protocol had an NPV above 97% yet it had a lower PPV. For shock with distributive or mixed etiology, RUSH showed a PPV of 100% but it had low sensitivity. Subgroup analysis showed a similar Kappa index for the emergency physician and radiologist (0.70 and 0.73, respectively) in performing rush.Conclusions: This study highlights the role of the RUSH exam performed by an emergency physician, to make a rapid and reliable diagnosis of shock etiology, especially in order to rule out obstructive, cardiogenic and hypovolemic shock types in initial exam of shock patients.

As we all well know, the trauma surgeon is oftentimes over-stressed because of high workload and numerous professional responsibilities; thus, it is not surprising that he or she unknowingly neglects the much-needed occasional release of physical and mental stress. A buildup of stress is detrimental to health and impairs both manual and mental function. It has been reported that doctors practicing in stressful medical professions are often over-stressed with limited ability to work efficiently (1-3). It is therefore imperative that surgeons take time off periodically to get away and release stress. Where can the surgeon go to recuperate? How about back to nature? In this issue, we present part two of a series of editorials wherein we will introduce national resort destinations and attractions for relaxation and recuperation of the weary and over-worked trauma surgeon.

Background: Controlling superficial bleeding, despite all the progress in surgical science, is still a challenge in some settings.Objectives: This study assesses the hemostatic effects of ferric chloride and compares it with the standard method (suturing technique) to control superficial bleeding.Materials and Methods: In this animal model study, 60 male Wistar rats were used. An incision, 2 cm long and 0.5 cm deep was made on rat skin and the hemostasis time was recorded using ferric chloride at different concentrations (5%, 10%, 15%, 25%, and 50%) and then using a control (i.e. control of bleeding by suturing). The skin tissue was examined for pathological changes. Finally, the obtained data were entered into SPSS (ver. 16) and analyzed using Kruskal-Wallis test, Mann-Whitney, Kolmogorov-Smirnov, and Wilcoxon signed ranks test.Results: The hemostasis time for the ferric chloride concentration group was significantly less than for the control group (P < 0.001).Conclusions: Ferric chloride may be an effective hemostatic agent to control superficial bleeding in rats.

Background: Controlling parenchymal hemorrhage, especially in liver parenchyma, despite all the progress in surgical science, is still one of the challenges surgeons face. Therefore, search for an effective method to control hepatic bleeding is an important research priority.Objectives: This study attempted to determine the haemostatic effect of ferric sulfate and compare it with the standard method (suturing technique).Materials and Methods: In this animal model study, 60 male Wistar rats were used. An incision (2 cm in length and 1.2 cm in depth) was made on each rat’s liver and the hemostasis time was measured using ferric sulfate with different concentrations (5%, 10%, 15%, 25%, and 50%) and then using simple suturing. The liver tissue was assessed for pathological changes.Results: In all the groups, complete hemostasis occurred. Hemostasis times of different concentrations of ferric sulfate were significantly less than those of the control group (P<0.001).Conclusions: Ferric sulfate was effective in controlling hepatic bleeding in rats.

Background: The knee joint is the largest and the most complex joint of the human body. It is not covered by any thick muscular covering anteriorly.Objectives: The purpose of this study was to explore the diagnostic capabilities of clinical examination, magnetic resonance imaging (MRI), and arthroscopy in traumatic disorders of the knee joint, to seek correlation between clinical findings, MRI findings and arthroscopic.Patients and Methods: A total of 26 patients with a presentation suggestive of traumatic knee pathology were studied prospectively. A detailed history was taken and relevant clinical examination was done, which was followed by MRI of the knee. The patients were scheduled for arthroscopy under general/spinal anesthesia, whenever indicated.Results: Keeping arthroscopic examination as standard, the correlation between clinical and arthroscopy showed a sensitivity of 80%, specificity of 86%, accuracy of 63.16%, negative predictive value of 93.48%; whereas MRI vs. arthroscopy showed a sensitivity of 74.42%, specificity of 93.10%, accuracy of 84.21%, and negative predictive value of 88.04%.Conclusions: The clinical examination is an important and accurate diagnostic modality for evaluation of traumatic derangement of the knee joint. It is noninvasive, easy, available, and valuable diagnostic modality. The MRI is an accurate diagnostic modality. It can be used whenever there is an uncertain indication for arthroscopy. However, costs have to be kept in mind, especially in patients with low socio-economic status.

Background: Uncontrolled hemorrhage is a well-recognized cause of mortality in trauma victims and the control of active hemorrhage is among the initial steps in resuscitation.Objectives: The purpose of this study was to assess the role of a hemostatic agent "celox" in the management of civilian stab-wound trauma.Patients and Methods: In this clinical trial study, 160 patients with penetrating limb trauma were randomly allocated to either the control or intervention group (n=80, each group). Controls were treated with the simple pressure dressing, while the celox-coated gauze was used in the intervention group. The time for achievement of hemostasis and the amount of bleeding were recorded. Data were analyzed using SPSS Version 21 and Stata 13. A P value of less than 0.05 was considered statistically significant.Results: The mean age of participants was 30.5 and the majority of patients were male (90.6%). The forearm and distal leg were the most sites of injury. Hemostasis was achieved within 5 minutes in 32.5% of the control group and 51.3% of the intervention group. Using the celox-coated gauze significantly reduced the time to hemostasis (P=0.01). Moreover, the blood loss was significantly lower in the celox group compared to the controls (P<0.05).Conclusions: Using the celox-coated gauze is able to achieve hemostasis in penetrating limb trauma faster than the conventional pressure bandage. Further research is required to clarify the subset of patients who will benefit the most from this effect in the emergency department.

Background: Fractures of the knee account for about 6% of all trauma admissions. While its management is mostly focused on fracture treatment, it is not the only factor that defines the final outcome.Objectives: This study aimed to study objective and subjective outcomes after proximal tibial versus distal femoral fractures in terms of knee instability and health-related quality of life.Patients and Methods: This retrospective, cross-sectional, cohort study was carried out on 80 patients with either isolated proximal tibial (n=42) or distal femoral (n=38) fractures, who underwent open reduction and internal fixation. All the fractures were classified based on the Schatzker and AO classification for tibial plateau and distal femoral fractures, respectively. The patients were followed and examined by an orthopedic knee surgeon for clinical assessment of knee instability. In their last follow-up visit, these patients completed a Lysholm knee score and the short-form (SF) 36 health survey.Results: Among the 42 tibial plateau fractures, 25% were classified as Schatzker type 2. Of the 38 distal femoral fractures, we did not find any type B1 or B3 fractures. The overall prevalence of anterior and posterior instability was 42% and 20%, respectively. Medial Collateral Ligament (MCL) and Lateral Collateral Ligament (LCL) injuries were detected clinically in 50% and 28%, respectively. The incidence rates of ligament injuries in tibial plateau fractures were as follows: Anterior Collateral Ligament (ACL) 26%, Posterior Collateral Ligament (PCL) 7%, MCL 24%, and LCL 14%. Medial collateral ligament injury was the most common in the Schatzker type 2 (50% of the injuries). Distal femoral fractures were associated with ACL injury in 16%, PCL in 13%, MCL in 26% and LCL in 14%. However, final knee range of motion (ROM) and function (Lysholm score) were not associated with fracture location. No statistically significant difference was observed between the two groups, except for the valgus stress test at 30°knee flexion, which was more positive in tibial fractures. All eight domains of SF-36 score in the distal femoral and proximal tibial fractures were significantly different from the normal values, however, there were no statistically significant differences between femoral and tibial fracture scores.Conclusions: Although ROM is acceptable in knee joint fractures, instability is common. However, it seems that knee function and quality of life are not associated with the location of the fracture.

Background: Peripheral nerve repair with sufficient functional recovery is an important issue in reconstructive surgery. Stem cells have attracted extensive research interest in recent years.Objectives: The purpose of this study was to compare the vein conduit technique, with and without the addition of mesenchymal stem cells in gap-less nerve injury repair in rats.Materials and Methods: In this study, 36 Wistar rats were randomly allocated to three groups: In the first group, nerve repair was performed with simple neurorrhaphy (control group), in the second group, nerve repair was done with vein conduit over site (vein conduit group) and in the third group, bone marrow stem cells were instilled into the vein conduit (stem cell group) after nerve repair with vein conduit over site. Six weeks after the intervention, the sciatic function index, electrophysiological study and histological examination were performed.Results: All animals tolerated the surgical procedures and survived well. The sciatic function index and latency were significantly improved in the vein conduit (P=0.04 and 0.03, respectively) and stem cell group (P=0.02 and 0.03, respectively) compared with the control group. No significant difference was observed in sciatic function and latency between the vein conduit and stem-cell groups. Moreover, histological analysis showed no significant difference in regenerative density between these two groups.Conclusions: The results of this study showed that the meticulous microsurgical nerve repair, which was performed using the vein tubulization induced significantly better sciatic nerve regeneration. However, the addition of bone marrow mesenchymal stem cell to vein conduit failed to promote any significant changes in regeneration outcome.

Background: Effective first aid and transportation influences injury-induced mortality. But few qualitative studies have been conducted so far in this area.Objectives: The aim of this study was to identify the content of the first aid and patient transportation course based on experience gained from the Iran-Iraq war.Patients and Methods: This was a conventional qualitative content analysis study; a purposeful sample of 14 first aid and transportation experts who had worked during the Iran-Iraq war was recruited. We collected and analyzed the study data by using the semi-structured interview method and the conventional content analysis approach respectively. Each interview transcript was reviewed several times. Words, sentences, and paragraphs were labeled with codes. Codes were compared with each other and categorized according to their similarities. Similar sub-categories and categories were also grouped together and formed themes.Results: Study participants’ experiences of wartime first aid and transportation (FAT) education fell into two main themes including ‘the congruence of education and educational needs’ and ‘managers’ engagement in FAT education. The four main categories of these two themes were use of appropriate educational facilities, adopting effective teaching strategies, universal FAT education and specialized training skills.Conclusions: The two key requirements of the first aid and transportation courses are practicality and managerial engagement. We developed and provided specific guidance of FAT curriculum by using the study findings. This curriculum is recommended for educating FAT staffs, paramedics, emergency technicians, and military nurses.

Background: Providing care for patients with chronic disability affects caregivers’ social lives and relationships and can lead to poor health and lower quality of life.Objectives: In this study, our goal was to assess the quality of life in spouses of war veterans with bilateral lower limb amputations to find factors affecting caregivers’ quality of life.Patients and Methods: In a cross-sectional study, spouses of 244 veterans with war-related bilateral lower limb amputations for at least one year were invited to participate in this study; 189 couples accepted to participate. Information about age, gender, education level, duration of time since amputation, duration of care provided by the spouses and SF-36 questionnaire for both veterans and their spouses were collected.Results: The average age of spouses was 47 years and duration of care provided by spouses was 25 years. We found lower scores for general health domains in amputees’ spouses compared to the general population. Factors correlated with both Physical Component Summary (PCS) and Mental Component Summary (MCS) included the duration of care, duration of marriage, spouses’ education level and the veterans’ PCS and MCS scores. Veterans’ age, spouses’ age and the number of children only correlated with PCS. Veterans’ education level only correlated with MCS. In multivariable analysis, only spouses’ education level correlated with MCS and the veterans’ PCS only correlated with that of spouses.Conclusions: The quality of life of amputees and their spouses were closely correlated; therefore, any improvement in one is likely to improve the other. In addition, lower education level should be considered as a risk factor for poorer quality of life in amputees’ spouses.