Bulletin of Emergency And Trauma
Volume:8 Issue: 2, Apr 2020

To compare the outcome of distal locked and unlocked intramedullary nailing in patients with intertrochanteric fractures through systematic review and meta-analysis of randomized and non-randomized clinical trials. 

Randomized or non-randomized controlled studies comparing the effects of unlocked and locked nails for treatment of intertrochanteric fractures were searched using the search strategy of Cochrane collaboration up to April 2019. Four eligible studies involving 691 patients were included. Their methodological quality was assessed, and data were extracted independently for meta-analysis.

The results showed that the unlocked group has significantly less operative time (MD: -8.08; 95%CI -11.36 to -4.79; P< 0.00001), fluoroscopy time (MD: -7.09, 95%CI -7.09 to -4.79; p<0.00001), length of incision (MD: -2.50, 95%CI 2.85 to -2.14; p< 0.00001) than the locked group. The complication rate was significantly higher in the locking group (OR: 0.55, 95%CI 0.26 to 1.15; p=0.03). No significant differences were found in the Harris hip score between the two groups (MD: 0.68, 95% CI -0.83 to 2.19, p<0.08).

The present meta-analysis suggests that intramedullary nailing without distal locking is reliable and acceptable option for treating intertrochanteric fracture. The advantages are reduced operative time, decreased fluoroscopy time, smaller size of incision and decreased complication rate. However, owing to the low-quality evidence currently available, additional high quality Randomized controlled trials are needed to confirm these findings.

To examine all aspects affecting the functioning of the system and the most important factors in its assessment through a systematic review during 1990 to 2017.

This systematic review of the current literature study was conducted during July 2017, and all articles, books, guidelines, manuals and dissertations pertaining to the Incident Command System were analyzed. A total of articles and relevant documents were identified and finally these articles, which we found, were analyzed based on the specified indicators.

In this research 992 articles and relevant documents were identified and eventually, 48 articles were included and analyzed. The results were categorized into 6 main groups including 65 subgroups and 221 variables: features  of hospital incident command system (14 subgroups and 53 variables), strengths of the system (15 subgroups and 70 variables), weaknesses of the system (10 subgroups and 15 variables), factors influencing the system's performance improvement (12 subgroups and 42 variables), factors that reduce the  effectiveness of system  include 11 subgroups (10 internal factors and 1 external factor) and 22 variables and important factors in assessing system performance (2 sub-groups and 19 variables).

According to the results, Evaluating the effectiveness of a hospital accident command system (HICS) in a valid method can improve the efficiency of this system. In this appraisal, hospital managers and health decision-makers should consider principles, characteristics, strengths and weakness of it.

To investigate the effect of intravenous regional anesthesia with single-cuff forearm tourniquet and hematoma block on intraoperative and postoperative pain intensity of patients with distal radial bone fracture. In this randomized clinical trial, a total number of 52 patients with distal radius fractures were randomly assigned to receive either a traditional Bier block with 3 mg.kg-1 lidocaine (D group) or a single-cuff forearm tourniquet intravenous regional anesthesia with 1.5 mg.kg-1 lidocaine and a hematoma block with 10 mL 0.5% bupivacaine (S group). Pain intensity score of numerical rating scale (NRS) was measured hourly for 6 hours, then every two hours till 12th hour and every 4 hours until 24th postoperative hour. Total morphine consumption in the first 24 hours after surgery, its side effects and the patients’ global satisfaction were assessed in each group. Mean total morphine consumption during the first 24 hours after surgery was 11.68±7.88 mg in group D and 7.12±4.42 mg in group S (p=0.13). Pain intensity score of NRS both during recovery room and surgical ward stay was less in S group compared to D group (0.016 and 0.02, respectively). Intravenous regional anesthesia with single cuff forearm tourniquet and hematoma block compared to the traditional Bier block reduced intraoperative and postoperative pain intensity more effectively in patients with distal fracture of the radius bone and also reduced morphine consumption during the first 24 hours after surgery. Clinical Trial Registry: IRCT201604223213N4

To investigate the relationship between end-tidal CO2 (ETCO2) and serum lactate and their predictive role in hospital mortality of intubated multiple trauma patients.

In a cohort study, intubated multiple trauma patients who referred to the emergency department for two years were enrolled. After orotracheal intubation using Rapid Sequence Intubation (RSI) method, ETCO2 was immediately measured by capnography. Blood samples for serum lactate measurements were sent to the laboratory, immediately after intubation. Data collection was done using the questionnaire, and the patients were followed using their medical records.

Totally, 250 patients were included with hospital mortality of 14.8% (n=37). Using Pearson correlation, an inverse relationship was noticed between serum lactate and ETCO2, immediately (p<0.0001, r=-0.65). In adjusted multivariate analysis, three variables including heart rate (HR), serum lactate and ETCO2 showed a significant relationship with hospital mortality, respectively (p=0.007, p=0.009, p=0.023, respectively). Receiver operating characteristic curve illustrated an area under the curve (AUC) of 0.93, 0.96, and 0.97 for HR, lactate, and ETCO2, respectively.

ETCO2 post-intubation and serum lactate may be considered as prognostic factors for intubated multiple trauma patients referring to the emergency department, which can give the clinician an important clue in early prediction of the hospital mortality.

To compare the effectiveness of surgical intervention to conservative treatment in patients with thoracolumbar fracture and thoracolumbar injury classification and severity score (TLICS) of 4.

Twenty-five patients with TLICS 4 were enrolled in this non-randomized clinical trial. Based on clinical symptoms and radiologic findings, patients were considered under surgical or conservative treatments. The JOA Back Pain Evaluation Questionnaire (JOABPEQ) was assessed at baseline and at 3, 6, 12 months after treatment. A 20-point improvement from the baseline JOABPEQ scores was considered as clinical success in both the conservative and surgery groups. Additionally, residual canal, angulations and height loss were determined in all patients.

Eight patients received conservative and 17 surgical treatment. Both study groups were comparable regarding the baseline characteristics. Both study demonstrated treatment success, regarding functional recovery when compared to baseline (p<0.001). However, those undergoing surgical intervention had significantly better JOABPEQ score (p<0.001) and higher residual canal (p=0.042) when compared to those receiving conservative therapy. The success rate of treatment was comparable between the two study groups in 6- (p=0.998) and 12-month (p=0.852) intervals; however, surgical therapy had significantly higher success arte in 3-month interval (p=0.031).

Our findings revealed that surgical treatment was preferred more in comparison to conservative treatment in patients with TLICS 4. Additionally, residual canal might be a modifying factor to decide the ideal therapeutic approach. Clinical Trial Registry: IRCT2017010920258N25

To develop a self-completion pedestrians’ red-light violation behavior questionnaire (PRVBQ) based on the theory of planned behavior (TPB) and assess the content validity and reliability.

This study was conducted in three phases of (i) PRVBQ development study; (ii) Content validity study including face validity; and (iii) Reliability assessment. The directed content analysis method was used for the analysis of the qualitative interviews. The item impact score was used for face validity. Content validity index (CVI) in the item level and average scale level, and content validity ratio (CVR) were determined. Intra-class Correlation Coefficient (ICC), and Cronbach’s alpha was assessed for test-retest reliability and internal consistency respectively.

Draft questionnaire including 86 items was constructed. Sixteen items were eliminated due to low face and content validity, remaining 70 items in total. The PRVBQ was rated as having good content validity (individual items CVI ranged from .80 to 1, and overall PRVBQ CVI-Average=0.95, p=0.05). The direct measures (reflective indicators) showed excellent internal consistency with Cronbach’s alpha=0.9. All items showed excellent agreement.

This study using a comprehensive process of development and assessment of content validity and reliability developed a content valid and reliable questionnaire predicting pedestrians’ red light violation behavior.

To assess whether intentional traumatic injuries are associated with higher mortality rate when compared to unintentional injuries. Data from SweTrau (Swedish National Trauma Registry). Information regarding age, gender, injury severity score (ISS), new injury severity score (NISS), Glasgow coma scale (GCS), systolic blood pressure, and respiratory rate were collected via “SweTrau”. “Mortality within 30 days of injury” was defined as having been registered as dead within 30 days following the injury. Intentional injuries compared to non-intentional injuries. Multivariate regression analysis was conducted. Stepwise forward and backward regression was conducted. A total number of 3875 patients were included. There were 3613 (93%) non-intentional and 262 (7%) intentional patients. The 30-day mortality rate was higher in the intentional group compared to non-intentional group, 10% vs. 4% (p<0.001). Patients in the intentional group were younger than the non-intentional group, at 39±18 vs. 47±21 years old (p<0.001). In both, the forward and backward tests injury intention remained statistically significant with OR 2 (CI 1.1-3.7). Shock (OR 4.7, CI 2.9-7.8), Severe Head Injury (OR 8.9, CI 5.3-14.7), Age ≥ 60 (OR 6.7, CI 4.1-10.8), ISS ≥16 (OR 10.8, CI 6.9-16.9) and ASA (OR 3.5, CI 2.2-5.7) were other factors affecting mortality. Injury intention was an independent factor contributing to mortality in our study. This particular cohort needs further attention during trauma management with a holistic insight to improve their survival.

To evaluate the diagnostic accuracy of history taking and physical examination in the patients with traumatic rib fractures. In a cross-sectional study, all patients with multiple traumas who referred to the emergency department were evaluated for the mechanism of injury, chief complaints, vital signs and oxygen saturation. History taking and physical examination were performed according to Barbara Bates reference. Fracture was diagnosed based on chest x-ray results and CT scan, if needed. The results were analyzed by receiver operating characteristic (ROC) curves and area under the curve (AUC) analysis. Isolated rib fractures of thoracic bones were found in 8 out of 99 subjects with mean age of 33.4±19.43 years. In the sensitivity analysis of history taking and physical exam tests, the highest sensitivity was chest tenderness and deformity with 100% sensitivity for each one and the lowest was for the dyspnea with 28.10%; however, the highest sensitivity was for dyspnea with 62.50% sensitivity; and pulmonary hearing aid and chest deformity were not specific (0%). For heart rate, AUC analysis was significant. Heart rate above 80/min was associated with 87.5% sensitivity and 62.5% specificity for rib fractures. Proper and physical examination and history taking can help to detect rib fractures with high sensitivity and specificity denoting to the importance of the issue; while, radiographic or surgical approval is required to diagnose rib fractures.

To evaluate the accuracy of the five-level triage system using the emergency severity index (ESI) and to determine the compliance of the triage level with patient outcomes. This was a cross-sectional study which was performed in the emergency department of Imam Reza Hospital of Mashhad during 2017. We included all the adult patients (≥15 years of age) referring to the emergency department. The data were recorded in a questionnaire containing three sections including demographic information, results of triage by ESI and final outcome of the patient. Patients referred to the triage unit were simultaneously triaged by triage nurse and some emergency medicine physicians. The triage was performed by a nurse with an emergency medicine physician (EMP) was considered as a gold standard and the outcome was compared in 24 hours later. Overall, we included 400 patients with a mean age of 46.40 ± 18.52 years among whom there were 211 (52.8%) men and 189 (47.3%) women. Finally, 123 patients were hospitalized, 12 died, 256 were discharged by a physician, and 9 people left the hospital with their own consent. The calculated weight kappa was used to determine the agreement between the observers (nurse triage and physician) at 0.701 so that the agreement between the triage performed by a nurse and an EMP was in an excellent level (p<0.001). There was a significant relationship between the triage levels (determined by physicians) and the outcome of the patient (p<0.001), and the five-level system had a high overlap and significant relation with patient's outcome. The results of the current study revealed that the five-level triage system using the ESI has a high accuracy in triage and estimates the patient outcomes effectively and thus, could be used as an effective system in hospital triage.

The aim of the current study was to describe lung ultrasonography (LUS) characteristics and to evaluate the agreement between LUS and chest radiography (CXR) in diagnosis of four conditions causing most acute dyspnea in children, namely, pneumonia, pleural effusion, pneumothorax and acute pulmonary edema in children at a teaching hospital in Vietnam. We reviewed the records of the chidren between January and June 2018, who presented to emergency department (ED) or pediatric intensive care unit (PICU) at children hospital 1 (CH1) with acute dyspnea and had final diagnosis of one of four etiologies including pneumonia, pleural effusion, pneumothorax and acute pulmonary edema. All patients underwent CXR and LUS at the time of admission. Eighty-one children with acute dyspnea including pneumonia (n=65, 80%), pleural effusion (n=9, 11%), pneumothorax (n=3, 4%) and acute pulmonary edema (n=4, 5%) were enrolled. LUS was identified among 100% of cases with pleural effusion and pneumothorax (CXR only showed 73.3% and 50%, respectively); 92.3% of cases with pneumonia (CXR showed 93.8%) and only 75% of cases with acute pulmonary edema (CXR showed 50%). When comparing LUS with CXR, we noticed a good agreeement between the 2 methods in the diagnosis of pneumonia (kappa=0.64, p<0.001). LUS was shown to be a feasible and non-invasive technique which can help clinicians to comfirm the etiology of acute pulmonary dyspnea.

Injury to the femoral artery usually occurs either in open penetrating injuries or in association with fractures, but is unlikely with closed blunt trauma without fracture. We reported a 24-year-old female with a right-sided closed complete rupture of the superficial femoral artery without any bone injury and contralateral femoral shaft fracture following riding a bike and hitting by a tractor over both lower limbs. The right thigh and knee were swollen and tender with absent distal pulses without any knee instability. The left lower limb was shorter with crepitus and abnormal movement in the left thigh and intact distal pulses. Radiographs showed left femoral shaft fracture and no bony injury on the right lower limb. Angiogram showed non-opacification of the right distal superficial femoral artery. Fogartisation of distal and proximal ends were done and femoral artery was reconstructed using reversed saphenous vein interposition graft. So the clinical necessity of looking routinely for any arterial injury, even in cases of blunt trauma without bony injury is of great importance.

Laryngocele is not a common clinical entity that presents itself in a trauma setting. In the literature, there are currently two types of laryngocele, internal and mixed. Laryngocele may be congenital or acquired, and most often will present later in life. Traumatic laryngocele has only been reported three times in the literature before. Herein, we report a rare case of a 22-year-old woman who presents with bilateral laryngocele secondary to sustained direct trauma. Neck Ct-scan revealed bilateral laryngocele being responsible for her dysphagia and dysphonia. She was monitored in the hospital for further exacerbation of her symptoms with feared airway occlusion in mind. On hospital day three, her dysphagia had resolved and her dysphonia had significantly improved. A second CT, revealed resolution of left laryngocele with the right decreased in size since the initial presentation. She was followed and had complete resolution of symptoms one week after the injury.