Trauma Monthly
Volume:20 Issue: 4, Nov-Dec 2015

Nonlinear analysis of heart rate variability (HRV) has been recently used as a predictor of prognosis in trauma patients.

We applied nonlinear analysis of HRV in patients with blunt trauma and intraperitoneal bleeding to assess our ability to predict the outcome of conservative management.

An analysis of electrocardiography (ECG) from 120 patients with blunt trauma was conducted at the onset of admission to the emergency department. ECGs of 65 patients were excluded due to inadequacy of noise-free length. Of the remaining 55 patients, 47 survived (S group) and eight patients died in the hospital (Non-S group). Nineteen patients were found to have intra-abdominal bleeding, eight of which ultimately underwent laparotomy to control bleeding (Op group) and 11 underwent successful non-operative management (non-Op). Demographic data including vital signs, glasgow coma scale (GCS), arterial blood gas and injury severity scores (ISS) were recorded. Heart rate complexity (HRC) methods, including entropy, were used to analyze the ECG.

There were no differences in age, gender, heart rate (HR) and blood pressure between the S and Non-S groups. However, approximate entropy, used as a method of HRC measurement, and GCS were significantly higher in S group, compared to the Non-S group. The base deficit and ISS were significantly higher in the Non-S group. Regarding age, sex, ISS, base deficit, vital signs and GCS, no difference was found between Op and Non-Op groups. Approximate entropy was significantly lower in the Op group, compared to the Non-Op group.

The loss of HRC at the onset of admission may predict mortality in patients with blunt trauma. Lower entropy, in recently admitted patients with intra-abdominal bleeding, may indicate laparotomy when the vital signs are stable.

Nicotinamide (NA), the active form of vitamin-B3, is hypothesized to have positive effects on the process of wound healing; it has anti-inflammatory, antioxidant, and immunomodulatory properties, as well as an epithelization inducing action.

In the present study, we aimed to determine the effects of topical administration of NA on skin wounds, based on histomorphometrical and pathological criteria.

In this study, 36 male Sprague-Dawley rats (220 ± 20 g each), with 1 cm2 circular full-thickness wounds on their backs were divided into three groups (n = 12): NA group, was treated daily with a Nicotinamide 2% gel , untreated group (control), and base group, which were treated with the vehicle (base) of the gel (carboxymethylcellulose). Skin biopsies were prepared for microscopic analyses. Inflammation, granulation tissue formation, ulceration, epithelization, wound closure rate, fibroblast proliferation, collagen synthesis, and vascularization were studied criteria.

The results revealed that besides improving the wound healing by its anti-inflammatory, antioxidant, and epithelization inducing effects, NA also improved tissue regeneration through the increment of fibroblast proliferation, collagen synthesis, and vascularization.

In spite of the few reported side effects, NA can be introduced as an effective agent on the wound healing process, an adjuvant therapy and possibly a treatment by itself. However, its chemical characteristics, as well as possible adverse effects warrants further research.

Needle-Stick Injuries (NSIs) are among the hazards and problems that can expose health workers to infections.

This study aimed to determine the rate of NSIs in a teaching hospital in Tehran, Iran.

This cross-sectional, analytical and descriptive study was conducted at one of the teaching hospitals in Tehran, Iran, in 2013. The study population was 344 employees in various occupational groups selected via census. Data were collected using a researcher-made questionnaire. The collected data were analyzed using some statistical tests, including independent-samples t-test with SPSS software version 21.0.

The results showed that only 50.2% of injuries had been reported; 67.8% of all participants (n = 211) had at least one NSI. Most NSIs had been reported in the emergency department (33.5%). Most participants mentioned the injection syringe needles as the main cause of their injuries (71.1% of all NSIs). Among NSIs, those caused by insulin syringe needles (6.2%) were the second cause. In this study, females had NSIs more than males. There was a statistically significant relationship between sex and the rate of NSIs (P < 0.05).

Considering the high rate of occupational injuries, further preventive measures should be implemented to prevent these injuries from occurring. Providing initial and continuing training for employees is very important. Directing special attention to emergency department employees may be effective in reducing occupational injuries.

Intra-articular fracture of the distal radius is extremely common; however, the management of this fracture is controversial.

With regard to the importance of intra-articular fracture of the distal radius and the best treatment method for the fracture, we sought to assess the success rate following the treatment of comminuted intra-articular fractures of the distal radius via closed reduction and use of a mini-external fixator.

This longitudinal retrospective study was undertaken at our department of orthopedics via assessment of radiographs and patient files of those referred from 2006 to 2013. Radiographic criteria included the degree of angulation and shortening of the radius. Data were analyzed using SPSS 18 software and were presented as mean ± standard deviation (SD). The significance level was set at P ≤ 0.05.

Overall, ≥ 2 mm shortening of the radius was seen in 28% of the patients, 53% had 2 - 5 mm radial shortening and 19% of the patients had more than 5 mm shortening of the radius. Most of the participants had acceptable outcomes. The mean angulation was 6.28 ± 2.85 degrees and the mean shortening was 3.92 ± 2.22. Thirty-nine percent of the patients had an angulation of less than 5 mm, 56% and 5% had an angulation of 5 - 10 mm and more than 10 mm, respectively.

The results of our study showed that the mini-external fixator is a good and effective treatment option for obtaining radial length, angulation and bony union in intra-articular fractures of the distal radius.

Monopolar surgery is applied mostly in major operations, while bipolar is used in delicate ones. Attention must be paid in electrosurgery application to avoid electrical burns.

We aimed to assess factors associated with electrosurgery burns in cardiac surgery operating rooms.

This was a case-control study in which two groups of 150 patients undergoing cardiac surgery in Imam Khomeini Hospital were recruited. Several factors like gender, age, operation duration, smoking, diseases, infection, atopia, , immunosuppressive drugs use, hepatic cirrhosis, and pulmonary diseases were compared between the two groups. Patients were observed for 24 hours for development of any burn related to the operation. Data was analyzed using SPSS v.11.5, by Chi square and T-test.

Patients in the two groups were similar except for two factors. DM and pulmonary diseases which showed significant differences (P = 0.005 and P = 0.002 respectively). Seventy-five patients from controls and 35 from the study group developed burns, which was significant (P ˂ 0.0001).

None of the factors were significantly related to developing burns. The differences between the two groups highlights the importance of systems modifications to lessen the incidence of burns.

Trauma is the leading cause of death in United States in the younger population. Cardiac trauma is common following blunt chest injuries and is associated with high morbidity and mortality. This study discusses various multidetector computed tomography (MDCT) findings of cardiac trauma. Cardiac injuries are broadly categorized into the most commonly occurring blunt cardiac injury and the less commonly occurring penetrating injury. Signs and symptoms of cardiac injury can be masked by the associated injuries. Each imaging modality including chest radiographs, echocardiography, magnetic resonance imaging and MDCT has role in evaluating these patients. However, MDCT is noninvasive; universally available and has a high spatial, contrast, and temporal resolution. It is a one stop shop to diagnose and evaluate complications of cardiac injury. MDCT is an imaging modality of choice to evaluate patients with cardiac injuries especially the injuries capable of causing hemodynamic instability

Facial paralysis is common following accidents, trauma, viral infection or tumors.

A 24-year-old male patient was referred to us with a history of sharp penetrating trauma to the right temporal region causing unilateral paralysis of the muscles of the right forehead. He was unable to scowl or elevate his right eyebrow and there were no folds on his right forehead. Anastomosis of branches of the temporal nerve was done one month after trauma following regular physical therapy sessions, outcome was good and paralysis of the muscles of the right forehead improved after several months.

Immediate repair of the facial nerve injury will improve the process of recovery and rehabilitation of the face and forehead muscles and may play a very important role in the patient’s mental satisfaction and improve their quality of life.

The reattachment of a dental fragment may be performed for treatment of traumatized anterior teeth, both in cases of simple coronal fracture (enamel and superficial dentin) and in those with complicated coronal fracture (deep dentin with pulp exposure). A major part of this procedure is the adhesion technique, which was described for the first time by Buonocore in 1955. This clinical case demonstrates the use of Er:YAG and Nd:YAG lasers in fragment reattachment of a traumatically fractured anterior tooth with pulp exposure, describes their advantages and highlights the steps involved in their use.

A 14-year-old patient who came to our clinic with a traumatic crown fracture of the permanent, right central incisor is described. The patient had preserved the fragment that had broken off into his mouth and it was rebonded to the tooth using lasers (LightWalker device; Fotona, Ljubljana, Slovenia) with the following parameters: Er:YAG, SSP mode; 200 mJ; 10 Hz; quasi-contact tipless handpiece; Nd:YAG, SP mode; 4 W; 40 Hz; 300 μm contact fiber. The whole procedure was performed without the need for anesthesia.

The patient reported that he did not feel pain or discomfort throughout the intervention. Follow-up visits performed after one, three, six, twelve, and sixteen months demonstrated vitality of the tooth the absence of complications, as well as good esthetic results. Laser technology may be used in the treatment of traumatic anterior teeth injury with advantages in terms of quality of the restoration, esthetic results, and patient comfort.

Treatment of forearm fracture nonunion is challenging. Several surgical techniques for the treatment of forearm nonunion have been reported.

The aim of this prospective study was to evaluate the effects of the radial forearm bone graft technique in cases with forearm nonunion.

We treated 7 patients with forearm nonunions via radial forearm bone flap and internal plate fixation. On the preoperative examination and last follow-up, the quick disabilities of the arm, shoulder, and hand (Q-DASH) score, elbow, forearm and wrist arches of motion and grip force were measured. At the final follow-up, radiographic union and patient satisfaction and return to work were assessed.

The mean follow-up duration was 34 ± 23 months. The Q-DASH scores improved from 70 ± 6 points preoperatively to 13 ± 15 points at final follow-up (P < 0.01). The preopetative range of motion (ROM) was 101 ± 26 degrees; whereas the final forearm ROM was 140 ± 17 (P = 0.01). All nonunions united uneventfully (range 3-6 months). At the last follow-up, the grip force was 83% of uninjured extremity and all patients were satisfied with the outcome of the operation.

Radial forearm bone flap is a safe, useful and novel technique in cases with forearm nonunion.

Few studies worldwide have shown that climate factors such as temperature and humidity may contribute to injuries and sudden death. However, to the best of our knowledge no studies have been conducted on climate and traumatic deaths in Iran.

The aim of this study was to investigate the relationship between temperature and humidity and trauma deaths in Kerman, Iran. Materials and Materials: In this study, data of all trauma deaths from March 2006 to February 2011 were collected from the Kerman Health Ministry and categorized by causes. Trauma deaths were extracted and matched with data regarding temperature and humidity obtained from the Kerman Meteorology Office during the same time period. Negative binomial regression and Spearman correlation analysis were used to analyze the data using STATA10 and MiniTab16.

The findings of this study showed that the overall mortality caused by trauma is higher in the warm season. The highest correlation between mortality and temperature was seen in ages over 60 years (r = 0.301, P = 0.020) in trauma deaths and was statistically significant. An inverse significant correlation was observed between the incidence of trauma deaths and humidity and was highest in the over 60-year age group (r = -0.336, P = 0.009). The regression results also revealed an inverse significant relationship between humidity and trauma deaths in the over 60-year age group.

High temperatures and low humidity increased the risk of trauma deaths in our study. However, more studies are needed to document this.

Emergency Department (ED) is considered to be the heart of a hospital. Based on many studies, a well-organized physical environment can enhance efficacy.

In this study, we aimed to investigate the influence of physical environment in EDs on efficacy.

This analytical cross-sectional study was conducted via the faculty members of the ED and residents of Shahid Beheshti University of Medical Sciences in Tehran, Iran. Data were collected using a predefined questionnaire. Descriptive statistics and ANOVA were used to analyze the data.

Sixty-two participants, including 21 females and 41 males, completed the questionnaires. The mean age of the participants was 37 years (SD: 8.42). The mean work experience was 8 years (SD: 4.52) and all the studied variables varied within a range of 3.3 - 4.2. Time indices had the highest mean among variables followed by capacity, work space, treatment units, critical care units and, triage indices, respectively.

In general, time indices including length of patient stay in the ED and space capacity, emphasizing the need to address these shortcomings.

The current approach in stab wounds of the anterior abdominal wall is still unclear.

The goal of this study was to evaluate serial clinical examinations of patients with abdominal wall stab wounds referred to Poursina Hospital in Rasht.

In a cross sectional study, 100 cases with stab wounds to the anterior abdominal wall were examined serially (admission time, 4, 8, 12, and 24 hours) after wound exploration. Serial hemoglobin test was performed every 8 hours. Laparotomy was performed in cases who were not hemodynamically stable or who showed symptoms of peritonitis. The results were analyzed with SPSS software version 21.

Ninety-one men (91%) and 9 women (9%) with mean age of 27 ± 10.7 years were included. Coexisting injuries were prevalent in 12 cases. The duration of hospitalization was 1 day in 31%, 2 days in 30%, 3 - 4 days in 32% and more than 5 days in 7%. Late laparotomy was performed 12 hours after admission in 8% of patients due to peritonitis. There was visceral damage in these cases. No mortality occurred. The cost and duration of hospitalization was significantly higher in cases with coexisting injuries and those who underwent laparotomy.

It seems serial clinical examinations are safe and decrease the cost and duration of hospitalization in stable patients with anterior abdominal wall stab wounds.

There are two main areas within emergency care which focus on departmental and staff preparedness in biological incidents. Despite the importance, little is known about the nurse’s preparedness in facing these events.

The aim of this study was to assess the effect of two teaching methods (multimedia instructional module versus lecture presentation) on nurse’s competency in biological incidents.

In this quasi-experimental study, 90 nurses were randomly divided into three groups (lecture presentation, multimedia- compact disk, and control). Data were collected by thirty-four multiple-choice questions for measuring knowledge, and a visual analogue scale graded 0 - 100 for assessing attitude. Data were analyzed using a paired t-test and one-way ANOVA with SPSS version 17.0. A P value less than 0.05 was considered as statistically significant.

The results revealed no statistically significant difference in nurse’s competency mean scores between the lecture and multimedia CDs groups.

It is recommended to use multimedia CDs for in-service education of nurses.

Obstructed defecation syndrome (ODS) occurs in about 7% of adults; it seems that the etiology of pelvic floor disorders is multifactorial. Pregnancy and childbirth damage to the pelvic nerve and muscles are proposed causes for this condition. The precise role of vaginal delivery (VD) is not clearly defined, although in recent studies association of pelvic floor disorder with Operative vaginal delivery and episiotomy has been proposed.

In this prospective study, we assessed the outcome of stapled transanal rectal resection (STARR) in females with one of the two modes of delivery (VD or caesarean section (C/S).

We used Longo’s ODS score for the assessment of the severity of pelvic floor malfunction. Stapled Trans Anal Rectal Resection (STARR) procedure was performed using two circular staplers. Follow-up was done 12 months after the discharge. To assess the role of episiotomy in patient with VD, we divided them into two subgroups; females who had VD with episiotomy (Vd + epi) and females who had VD alone. Data were analyzed using SPSS version 20 software. P values less than 0.05 were considered statistically significant.

In 30 consecutive females undergoing STARR for the treatment of ODS, who enrolled in this prospective study, 19 (63.3%) had Vaginal Delivery VD and 11 (36.7%) had Cesarean Section (C/S). The ODS score before the surgery was higher in females who had C/S, although there was no significant difference between VD and C/S groups in terms of the percentage of the ODS score improvement after the STARR surgery.

Higher ODS score in females who had C/S showed that C/S could not protect the pelvic organ from pregnancy and delivery trauma. It seems that episiotomy has a protective effect during VD; it can reduce the severity of trauma in pelvic organs during childbearing

Posttraumatic stress disorder (PTSD) is a disabling and prevalent psychiatric disorder with limited effective treatment options. In addition to the clinical features of the disease, pathologic changes in the electroencephalogram (EEG), including decreased alpha power, have been reported.

To determine if magnetic brain stimulation can induce normalization of EEG abnormalities and improve clinical symptoms in PTSD in a preliminary, open-label evaluation.

We reviewed prospectively-collected data on 21 veterans that were consecutively-treated for PTSD. Magnetic resonance therapy (MRT) was administered for two weeks at treatment frequencies based on frequency-domain analysis of each patient’s dominant alpha-band EEG frequencies and resting heart rate. Patients were evaluated on the PTSD checklist (PCL-M) and pre- and posttreatment EEGs before and after MRT.

Of the 21 patients who initiated therapy, 16 completed treatment. Clinical improvements on the PCL-M were seen in these 16 patients, with an average pre-treatment score of 54.9 and post-treatment score of 31.8 (P < 0.001). In addition, relative global EEG alphaband (8 - 13 Hz) power increased from 32.0 to 38.5 percent (P = 0.013), and EEG delta-band (1 - 4 Hz) power decreased from 32.3 percent to 26.8 percent (P = 0.028).

These open-label data show trends toward normalization of EEG and concomitant clinical improvement using magnetic stimulation for PTSD.

Context: Despite advancements in the science of surgery, minimizing bleeding from parenchymal tissue of the liver continues to be one of the challenges surgeons are facing to protect patients’ lives. However, the number of surgeries needing incisions in the liver tissue, e.g. metastatectomy, is constantly increasing. Evidence Acquisition: A MEDLINE and conventional search of the past 50 years of the medical literature was performed to identify relevant articles on hemostasis in the liver parenchymal tissue.

The studies that have been published on hemostasis in the liver parenchymal tissue can be classified into 3 categories: 1. surgical procedures; 2. methods affecting body hemodynamic; 3. pharmacological methods. The purpose of these studies are to identify the best therapeutic approaches that not only minimize the bleeding, but also save the maximum amount of the liver tissue and minimize the use of partial liver resections.

The excessive blood loss and the long time needed to control the bleeding during liver surgery impose several side effects and complications on patients. Topical hemostatic agents such as ferric chloride, potassium aluminum sulfate (alum) and aluminum chloride are safely applicable in patients. These agents might be used along with other current methods to minimize the blood loss and the need for blood products during liver surgeries.

Despite the ongoing advances in surgical procedures and promising progress in bioengineering techniques, auricular reconstruction remains a significant challenge in plastic surgery. There are different causes for acquired auricular defects, including trauma, tumor ablation and burns. The management options for upper, middle and lower third auricular defects are briefly reviewed in the current paper.

Original research papers investigating the plastic surgeons, otolaryngologists and maxillofacial surgeons in approaching the complicated issue of auricular reconstruction published from January 1995 to December 2014 were aggregated and used in the current study.

Utilizing autologous stem cell populations to treat craniofacial defects is a promising field of ongoing investigations. Studies show that cartilage stem/progenitor cells (CSPCs) are highly chondrogenic and can produce elastic reconstructive material with long-term tissue restoration.

Auricular reconstruction surgery is a challenging plastic procedure that requires great expertise and expert knowledge of the various techniques available. Novel techniques in the fields of reconstructive bioengineering and regenerative medicine are promising but further research is required before widespread clinical application.

Trauma is the third leading cause of death. In this regard, vascular injury plays a leading role in of morbidity and mortality rates.

The present study aimed to assess the prevalence of vascular injuries and results of vascular reconstruction at a referral hospital in northern Iran.

A retrospective observational study assessed 88 consecutive patients with vascular injury admitted to Poursina Hospital, Rasht in northern Iran, from October 2007 to October 2009. All study information was collected retrospectively from hospital charts.

Most of the affected patients (87/88) were male with a mean age of 29.12 ± 11.20 years. The mechanism of injury in 39.8% was blunt trauma and penetrating trauma in the rest. Of the 53 injured by penetrating trauma (60.2%), the most common cause was stabbing (94.3%). The most common cause of blunt trauma was road traffic accidents (93.1%). The most common mechanism for vascular injuries in upper extremities was penetrating trauma (86.0%) and in lower extremities was blunt trauma (60.0%). Fasciotomy was performed in 16 patients (18.2%) mostly in the lower extremities. Major amputation was required in 10% of the patients. In upper extremities, the most common type of revascularization was end to end anastomosis, followed by inter-position graft. The most common type of reconstruction in the lower extremity was bypass graft. All patients who underwent major amputation were admitted to the center with a delay of more than 6 hours after injury.

Major vascular injuries in our center occurred in young men, frequently because of stab wounds. Popliteal injuries mostly caused by motor vehicle accidents was the second most common arterial injury, followed by combined ulnar and radial injuries. Vascular reconstruction in the first hours after trauma may prevent many unnecessary and preventable amputation procedures.

Natural and man-made disasters affect people, communities, and health systems. Nurses play a key role in the health system and must be prepared for appropriate response in disasters.

This study was done to assess the current knowledge of nurses in emergency departments for disaster preparedness.

This cross-sectional study was conducted on 110 emergency nurses working in teaching hospitals affiliated to the Iran University of Medical Sciences, Tehran, Iran. A questionnaire was used to collect data and the data were then analyzed using descriptive and inferential statistics with SPSS software version 16.0.

Based on the findings, most of the participants (64.5%) were aged 30 - 39 years old. 84% of the cases were female and 97.3% had a bachelor’s degree. The average perceived knowledge of nurses was 2.43 ± 1.01. The nurses had the highest familiarity with triage and lowest knowledge in epidemiology and decision-making.

Lack knowledge of nurses regarding response to disaster situations indicates inefficiencies in the current system. Therefore, it is recommended to organize more workshops, annual training courses, and maneuvers based on staff needs and formulate continuous education courses for nurses.