Trauma Monthly
Volume:17 Issue: 2, Jan-Feb2012

Vascular injury presents a great challenge to the emergency resident because these injuries require urgent intervention to prevent loss of life or limb. Sometimes serious vascular injury presents with only subtle or occult signs or symptoms. The patient may present weeks or months after initial injury with symptoms of vascular insufficiency, embolization, pseudoaneurysm, arteriovenous fistula etc. Although the majority of vascular injuries are caused by penetrating trauma from gunshot wounds, stabbing or blast injury, the possibility of vascular injury needs to be considered in patients presenting with displaced long bone fractures, crush injury, prolonged immobilization in a fixed position by tight casts or bandages and various invasive procedures. iatrogenic vascular injuries constitute about 10% of cases in most series; however the incidence is an increasing trend because more endovascular procedures such as angioplasty and cardiac catheterization are being performed routinely. Civilian trauma is more frequently seen in young males. However, it can occur at any age due to road accidents, firearms, bomb blasts and diagnostic procedures. Most of the time, civilian trauma causes less tissue damage. There is an epidemic of vascular injuries in Kashmir valley because of problems in law and order in the past two decades. This review deals with the topic in detail.

Rapid Response Teams (RRTs) assess patients during early phases of deterioration to reduce patient morbidity and mortality.

This study aimed to evaluate the ability of earlier medical intervention by a RRT prompted by clinical instability in patients to reduce the incidence of and mortality from unexpected cardiac arrest at our hospital.

A nonrandomized, population-based study before 2008 and after 2010 introduction of the Rapid Response Teams in a 300 bed private hospital. All patients were admitted to the hospital in 2008 (n = 25348) and 2010 (n = 28024). RRT (One doctor, one senior intensive care nurse and one staff nurse) attended to clinically unstable patients immediately with resuscitation drugs, fluid, and equipment. Response was activated by the bedside nurse or doctor according to predefined criteria. Main outcome measures were incidence and outcome of unexpected cardiac arrest.

The incidence of unexpected cardiac arrest was 17 per 1000 hospital admissions (431 cases) in 2008 (before RRT intervention) and 12.45 per 1000 admissions (349 cases) in 2010 (after intervention), with mortality being 73.23% (274 patients) and 66.15% (231 patients) respectively. After adjustment for case mix the intervention was associated with a 19% reduction in the incidence of unexpected cardiac arrest (odds ratio 0.81, 95% confidence interval 0.65-0.98).

The RRT was able to detect preventable adverse events and reduce the mortality and incidence of unexpected cardiac arrests.

The increase in intestinal permeability following damage to the intestinal mucosa in any surgical procedure, trauma or fasting is well- known.

Our objective was to experimentally evaluate whether antioxidant consumption is associated with decreased intestinal damage in intestinal surgical procedures.

Forty rabbits were used to compare the pathological changes in the intestine after consumption of dextrose water 5% (D5W), black tea and orange juice in fasting and in cases with intestine resection and anastomosis. They were divided in to five groups as shams (GI), NPO (G II), D5W (GIII), black tea (GIV) and orange juice groups (GV). In GII to GV group with median laparotomy, a 2 cm segment of jejunum was resected and ends of the bowel were anastomosed. Postoperatively, animals fasted for five days. Animals in GII were killed after five days of fasting. On day five case groups were given free access to drinking D5w (GIII), black tea solution (G IV) and orange juice (GV) for a further 7 days. On day 8, animals were reoperated and the repaired segment of intestine was removed. Morphologic data were compared in groups.

There were 8 rabbits in each group. There was a significant difference in villi lengths in the groups (P = 0.003). GV rabbits had obvious recovery of the villous architecture.

Orange juice as a source of vitamin C may be an appropriate liquid for postoperative recovery following intestinal surgery.

Isolated small gut mesentery injury after blunt abdominal trauma from the steering wheel in road traffic accidents is rare. These are always challenging to diagnose and pose a diagnostic dilemma.

To study the pattern of small gut mesenteric injury by steering wheel blunt abdominal trauma in road traffic accidents in patients who had laparotomy.

A 10-year retrospective study was done to study isolated small gut mesentery injury.

All patients who had isolated mesenteric small gut injury were males. Jejunal mesentery was involved in 13 whereas 4 had ileal mesentery injury. Tear were longitudinal or transverse.

Isolated small mesentery injury after blunt abdominal trauma from the steering wheel in road traffic accidents is rare. Tears are either longitudinal or transverse. Suture repair is to be done. Delay in reaching hospital or reaching the diagnosis could lead to morbidity and mortality. Isolated mesenteric injury should be considered in any patient with blunt abdominal trauma from steering wheel injury with no evidence of any solid organ injury in unstable patients.

Amputation and pain may have considerable impact on health-related quality of life.

The purpose of this study was to assess the impact of pain on health-related quality of life in a population of war related bilateral lower limb amputees.

The Veterans and Martyrs Affairs Foundation (VMAF) database documented 578 patients with bilateral lower limb amputation; 335 consented to the study (response rate = 58%). The majority of participants in the sample were males (96.7%). Types of pain were investigated using a questionnaire. Health-related quality of life (HRQOL) was investigated using the sf-36 questionnaire.

About two third of amputees reported phantom pain 66.7% (n = 223) and vertebral column pain 60.9% (n = 204). The most common type of pain was lumbosacral pain 52.8 % (n = 177) followed by neck 18.2 % (n = 61) and thoracic pain 9.6% (n = 32). Back pain affected on vitality, social function, mental health and mental component scale in our cases (P < 0.05). Neck pain affected all components of health-related quality of life (P < 0.05). Thoracic pain affected quality of life significantly (P < 0.05). The results obtained from logistic regression analysis indicated that none of the three spinal column pains including neck, thoracic and lumbosacral pain resulted in poor physical or mental component scales.

This study revealed that bilateral lower limb amputees suffer from different types of pain and poor health-related quality of life. Therefore, the assessment and management of all types of pain are necessary to improve quality of life in veterans.

Vascular injury represents less than 1% of all injuries, but deserves special attention because of its severe complications. Amputation or retention of a painful functionless limb is the most untoward result of severe vascular injury or inadequate treatmet. Thus, vascular injury needs a judicious and multidimensional approach.

This retrospective study was done to asess the outcome of minor modifications of the methodology of extremity fasciotomy by making it liberal with respect to incision and definition.

Out of 55 patients in 2008, 45 patients (Group A) had either no fasciotomy or limited primary fasciotomy, 10 patients (Group B) had primary liberal fasciotomy. Another group from 2008 onwards had undergone primary liberal fasciotomy in all the 45 patients (Group C).

In group A, we had 5 amputations and one death. In group B, there were no amputations or deaths and from group C, we had one amputation and no deaths.

Blunt and distal traumatic vascular injury of the extremities and its repair should always combined with primary liberal fasciotomy, which although increases manageable morbidity, avoids disability (functional as well as anatomical).

Primary hyperhidrosis (P.H.H.) is characterized by excessive sweating in certain parts of body. It’s estimated prevalence is 0%-6.1% in different populations. In Asian population its prevalence is around 3%. In 57% of cases, there is a positive family history.

To evaluate and compare the early and late satisfaction, outcomes and complications of thoracoscopic sympathectomy and sympathicotomy in the treatment of primary hyperhidrosis.

From April 2007 to January 2011, we prospectively treated 60 primary hyperhidrosis patients via thoracoscopic surgery. The first 30 patients underwent sympathectomy and the next 30 patients underwent sympathicotomy. We evaluated early and late satisfactions, outcomes and complications on the first visit (5-8days) following surgery and 12 months after surgery, for all patients.

The mean operative time was 66.3 minutes in sympathicotomy group and 110.8 minutes in sympathectomy group (P < 0.001). There were no significant differences between the two groups in overall early and late satisfaction, gustatory sweating, pompholyx and post-operative pain. There was comparatively less early and late compensatory sweating (C.S.), and other adverse influences of C.S. in the sympathicotomy group.

Because of shorter operative time, less C.S. and less adverse influence of C.S., sympathicotomy seems a better treatment for primary hyperhidrosis, compared with sympathectomy

Carpal tunnel syndrome (CTS) is common in the industrial setting. However, there is a controversy about the sole role of occupational ergonomic hazards in CTS.

This study was conducted among assembling workers of a detergent factory and computer users with the aims of A) determination of CTS prevalence and B) evaluation of personal risk factors and level of exposure to occupational risk factors via Quick Exposure Check (QEC)).

In this descriptive cross-sectional study, 906 cases (332 assembling workers and 574 computer workers) were enrolled. CTS was assessed by symptoms on the Katz hand diagram and physical examination. QEC technique was applied to evaluate physical exposure to the risk factors.

According to this study, the prevalence of probable CTS was 14% in men and 8.9% in women; the rate of probable CTS was significantly higher in assembly workers than in computer users (P < 0.001). Mean age and work duration in the probable CTS group was statistically higher than in non-CTS group. But both groups were in the same range (fewer than 30, P = 0.024, 0.004); BMI in the probable CTS group was slightly lower than in non CTS group, but BMI in both groups were in the normal range. Wrist ratio > 0.7 correlated with increased risk of probable CTS (P < 0.001) Prevalence of probable CTS was significantly higher in third and fourth levels of QEC (P < 0.001).

Although this article had limitations, our findings suggest that the level of occupational exposure is an indicator of CTS development.

Modern medicine owes much to the endeavours and contributions made by the ancients that are unfortunately anonymous or even neglected intentionally today. This study was done to give attention to "the ancient golden times", as the author believes it deserves the nomination, to give credit to the manner our ancient physicians and masters practiced medicine and managed traumas in particular in a way that remains still unrivalled. Undoubtedly such masters as Galen of Pergamon, Hippocrates, Paul of Aegina and Avicenna paved the road for the so-called modern medicine and trauma surgery. Focus of this study is on Ibn Sina or Avicenna as the westerners call him and his methods in handling traumas of any kind and with any severity in the eleventh century based on the teachings handed down to him from the ancients; but he was not a mere imitator. What made him Avicenna was his genius talent in arranging the puzzles in such a way that was not even imagined by the others.

Pseudoaneurysms (PSA) of deep femoral artery (DFA) have been reported following penetrating and blunt trauma to the thigh and orthopedic procedures of the proximal femur. We describe a case of pseudoaneurysm of DFA as a late complication of limb trauma which was confirmed by exploration in an urgent surgery. After two operations successful surgical repair was performed.

Necrotizing fasciitis is a rare, life-threatening infection most commonly seen in patients with diabetes mellitus, intravenous drug abuse, and immunocompromised conditions. The extremities are the primary sites of involvement in as many as two thirds of the cases. In a significant proportion of patients, the extremities are involved as a result of trauma, needle puncture or extravasation of drugs. The infection is usually polymicrobial. Treatment involves broad-spectrum antibiotics and multiple surgical debridements or amputation. We present a patient with necrotizing fasciitis of the upper limb and present our experience with this often lethal condition.