Archives of Trauma Research
Volume:1 Issue: 3, Jul-Sep 2012

Diaphragmatic hernia after blunt trauma is an uncommon and often undiagnosed condition.. We aimed to review patients who presented with delayed blunt traumatic hernia of diaphragm..Patients and In this retrospective study, the medical records of six patients treated for blunt diaphragmatic hernias who were admitted to Kashan Shahid Beheshti hospital between June 2007 and June 2011 were analyzed.. Six patients with mean age of 41 years were included in the study. Male to female ratio was 2:1. Mean duration between trauma and admission to the hospital was 6.5 years (2 – 26 years). Five patients had left-sided diaphragmatic hernia. Chest X-ray was obtained from all patients which was diagnostic in 50 percent of the cases (n = 4). Additional diagnostic imaging with computerized tomography (CT) was used in six patients and upper gastrointestinal (GI) contrast study was performed in one patient. All patients underwent thoracotomy incision. Mesh repair was utilized in one patient. The mean hospitalization time was 14.1 days. There was one postoperative death (16.7%).. Late presentation of blunt diaphragmatic hernia is an uncommon and challenging situation for the surgeon. Prompt diagnosis and treatment prevent serious morbidity and mortality associated with complications such as gangrene and perforation of herniated organ.

Neurosurgical treatment and the severity of head injury (HI) can have remarkable effect on patients’ neuropsychiatric outcomes.. This research aimed to study the effect of these factors on cognitive functioning, general health and incidence of mental disorders in patients with a traumatic brain injury (TBI).Patients and In this descriptive, longitudinal study, 206 TBI patients entered the study by consecutive sampling; they were then compared according to neurosurgery status and severity of their HI. Both groups underwent neurosurgical and psychological examinations. The Mini Mental State Examination (MMSE) and General Health Questionnaire–28 items (GHQ-28) were administered to the study participants. At follow-up, four months later, the groups underwent a structured clinical interview by a psychiatrist based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria regarding the presence of mental disorders. Analysis of covariance (ANCOVA) and multivariate analysis of covariance (MANCOVA) were performed and adjusted for the effect of confounding variables (age, gender, Glasgow outcome scale (GOS), and level of education). The severity of HI had the most significant effect for the following variables; cognitive functioning and physical symptoms (P < 0.05). The effect of the neurosurgical treatment factor was not significant; however, the interaction effect of the two variables on social dysfunction, and total score of the GHQ-28 questionnaire appeared to be significant (P < 0.05). Fisher's exact test indicated that after a four month follow-up period, no significant differences were seen between the two groups (with or without neurosurgery) in the incidence of mental disorders, while x2 Test showed that having a more severe HI is significantly correlated with the incidence of mental disorders (P < 0.01). The implications of this study should be discussed with an emphasis on negative, effective factors on the cognitive – behavioral and neuropsychiatric outcomes of a TBI.

Patients, who receive care in an Emergency Department (ED), are usually unattended while waiting in queues.. This study was done to determine, whether the application of queuing theory analysis, might shorten the waiting times of patients admitted to emergency wards.Patients and This was an operational study to use queuing theory analysis in the ED. In the first phase, a field study was conducted to delineate the performance of the ED and enter the data obtained into simulator software. In the second phase, "ARENA" software was used for; modeling, analysis, creating a simulation and improving the movement of patients in the ED. Validity of the model was confirmed through comparison of the results with the real data using the same instrument. The third phase of the study concerned modeling in order to assess the effect of various operational strategies, on the queue waiting time of patients who were receiving care in the ED. In the first phase, it was shown that 47.7% of the 3000 patient records were cases referred for trauma treatment, and the remaining 52.3% were referred for non-trauma services. A total of 56% of the cases were male and 44% female. Maximum input was 4.5 patients per hour and the minimum input was 0.5 per hour. The average length of stay for patients in the trauma section was three hours, while for the non-trauma section it was four hours. In the second phase, modeling was tested with common scenarios. In the third phase, the scenario with the addition of one or more senior emergency resident(s) on each shift resulted in a decreased length of stay from 4 to 3.75 hours. Moreover, the addition of one bed to the Intensive Care Unit (ICU) and/or Critical Care Unit (CCU) in the study hospital, reduced the occupancy rate of the nursing service from 76% to 67%. By adding another clerk to take electrocardiograms (ECG) in the ED, the average time from a request to performing the procedure is reduced from 26 to 18 minutes. Furthermore, the addition of 50% more staff to the laboratory and specialist consultations led to a 90 minute reduction in the length of stay. It was also shown that earlier consultations had no effect on the length of stay.. Application of queuing theory analysis can improve movement and reduce the waiting times of patients in bottlenecks within the ED throughput.

Tonsillectomy is a common procedure causing considerable postoperative pain. The current study aimed to compare the efficacy between gabapentin and diclofenac on pain and opioid requirements. The current study aimed to compare the analgesic effect of gabapentin and diclofenac on pain after tonsillectomy,with the control group.Patients and In this double-blind, placebo-controlled clinical trial, 90 patients aged 10-25 years, ASA classes I and II were randomly selected to receive 20 mg/kg oral gabapentin (n = 30), 1.0 mg / kg rectal diclofenac (n = 30) or placebo (n = 30) preoperatively. Pain was evaluated postoperatively on a visual analogue scale at 2, 6, 12 and 24 h. Opioid consumption in the first 24 h after surgery and the side effects were also recorded. There was no significant difference in terms of age, sex, and time of surgery in the three groups. Patients in the gabapentin and diclofenac groups had significantly lower pain scores at all-time intervals than those in the placebo group. The total meperidine consumed in the gabapentin (14.16 ± 6.97 P = 0.001) and diclofenac (16.66 ± 8.95, P = 0.004) groups was significantly less than that of the placebo (33.4 ± 13.97) group. The frequency of side effects such as vomiting, dizziness, and headache was not significantly different among groups.. It was concluded that gabapentin and diclofenac reduced postoperative pain and opioid consumption, without obvious side effects.

Drowning is a serious but neglected health problem in low-and middle-income countries.. To describe the effectiveness of drowning prevention program on the reduction of drowning mortality rates in rural settings at the north of Iran, and guide its replication, elsewhere..Patients and This interventional design included pre- and post-intervention observations in the rural area of the Caspian Sea coastline without a comparison community. Cross-sectional data were collected at pre- and post-intervention phases. Outcome evaluation was based on a four-year-period (March 2005-March 2009) utilizing drowning registry data for the north of Iran.. The implementation program increased the rate of membership in an organization responsible for promoting safety in high risk areas near the Caspian Sea. Compared to a WHO standardized population, drowning incidence in rural areas of the study demonstrated a continuous decrease in age-specific drowning rate among the oldest victims with a gradual decline during the implementation. In the study area, the epidemiological aspects of the study population were exposed and contributing factors were highlighted.. This study showed that the promotion of passive interventions had a greater effect on drowning rate than that of active interventions.

Injury is one of the leading causes of morbidity and mortality in the world, and the home is one of the most common places for these types of injuries. This study is designed to investigate the epidemiology of home-related injuries in Kashan, Iran.Patients and This investigation is a retrospective cross-sectional study on existing data from the data bank of the Trauma Research Center at Kashan University of Medical Sciences during a six-year period. Demographic data such as; sex, age, place of residence, educational and occupational status, injury mechanism, injured organs and injury outcomes, were analyzed using a chi-squared test and P < 0.05 was considered significant. The number of home injuries was 10 146 in total, that included about 25.2% of all injuries in Kashan City. Most of the injured people were men (58.3%), 87.4% lived in the city and 18.6% were aged more than 64 years. The majority (42.7%) had a primary or secondary school education and 27.2% were housewives. Falling from a height was the most common cause of injury (55.3%). Limbs were the most common body region that was injured (73.7%). Young men (under 15 years) and older women (over 65 years) had more injuries, especially from falls. There was a statistically significant difference between the sex and age of the injured people (P = 0.000), sex and injury mechanism (P = 0.000), and also between the injury mechanism and sex in age groups (P = 0.000(. The most common injury mechanism in regard to home accidents was falls; therefore fall-related injury prevention programs should be designed to make homes safer and education should focus on changes in lifestyle to reduce fall susceptibility

A 36-year-old male patient with posttraumatic cervical cord damage and resultant quadriparesis, demonstrated hypotension and periods of bradycardia. For most of his two-month stay in the Intensive Care Unit (ICU), he was dependent on dopamine support to maintain hemodynamic stability. Keeping in mind evidence from the literature, that electrostimulation of acupoints Neiguan (PC - 6) and Jianshi (PC - 5) has therapeutic efficacy in restoring hypotension, we treated this patient with two six-hour periods of electrostimulation at these acupoints. We noted beneficial hemodynamic effects, with a resultant successful withdrawal of dopamine support lasting for up to 48 hours. This case report demonstrates the therapeutic efficacy of electrostimulation of PC - 5 and PC - 6 acupoints to wean a patient off chronic dopamine support, and this warrants further investigation.

Posttraumatic intravasation of fat and debris can lead to a cascade of events. Hydroxyethyl starches (HES) markedly suppress neutrophil influx by decreasing pulmonary capillary permeability and facilitating tissue oxygenation by improving microcirculation. It was hypothesized that in hypoxemic femur injury patients undergoing operative stabilization, HES administration will prevent the deterioration of respiratory variables and facilitates recovery. This prospective, double-blind, randomized preliminary study, enrolled twenty posttraumatic hypoxemic patients (room air PaO2 < 70 mmHg, Schonfeld fat embolism index score (SS) > 5) scheduled for femur fracture stabilization under general anesthesia. Patients were allocated to receive either; 6% HES 130/0.42, 15mL/kg or 0.9% normal saline (NS) to maintain their central venous pressure (CVP) 12 + 2 mm Hg. Blood was transfused according to the maximum allowable blood loss and by serial hematocrit estimations. Perioperative Glasgow Coma Scale (GCS), physiological variables, arterial oxygen saturation (SpO2), arterial blood gas (ABG), SS and P/F ratios were recorded until recovery. The partial pressure of oxygen in arterial blood / fraction of inspired oxygen ratio (PaO2/FiO2) improved from a preoperative value of 273.33 ± 13.05 to 435.70 in the 6% Hydroxyethyl starch group (HES) and from 275.24 ± 15.34 to 302.25 ± 70.35 in the NS group over a period of six days (P values =0.970, 0.791, 0.345, 0.226, 0.855, 0.083, 0.221). Time taken to achieve a P/F ratio > 300 and for persistent reduction of Murray’s lung injury score (LIS) were comparable (P = 0.755 and 0.348, respectively). The number of; ventilator, intensive care unit (ICU) and hospital stay days, did not differ (P value = 0.234, 1.00, 0. 301, respectively). There were no adverse sequelae or mortalities. A trend showing relatively fast improvement in the P/F ratio and an early reduction in LIS values was observed in hypoxemic, femur injury patients receiving intraoperative colloid supplementation.

Laceration of the hand extensor tendons is common in the upper extremities, causing soft tissue trauma. These tendons, because of their superficial location and lying adjacent to bones, have a greater tendency to be injured than flexor tendons. The aim of this study was to determine the results of primary repairs of lacerated extensor tendons of the fingers, with respect to the zone of injury, and also whether the results are different according to the anatomical zone in which they occur.Patients and During a period of two years and four months, 32 patients with open wounds and lacerated extensor tendons of the hand were hospitalized and underwent surgery. Repairs were done by a modified Kessler technique using 0 - 4 nylon suture. After repairing, the wrist was splinted for four weeks. Patients were followed-up for 12 months and the results were evaluated according to the Miller’s scoring system. A total of 72 extensor tendons were repaired. The mean age of the patients was 24.6 years. The best results were obtained in zones; 3 and 5 (84% and 88% respectively),and the worst results were seen in zones: 1, 2 and 4, P = 0.01. Wound infections or re-ruptures were not seen. Repair of extensor tendon cuts on the dorsal surface of the hand and forearm were associated with better results in zones: 3 and 5 than in zones;1, 2 and 4.Repair by the modified Kessler suture method provides proper stability at the site of the tendon cut.

We read with interest the article by Rimaz et al.(1). However, there are few queries. We would like to know about the duration of burn injuries. Pain threshold can vary among patients suffering from acute burns posted for first debridement before eschar formation in comparison to patient posted for second or third debridement (2). Similarly, a patient with previous exposure to anesthesia is expected to be more familiar to the setting and the use of Patient Controlled Analgesia (PCA) devices. It appears unethical to not provide any pain relief for patients with up to 35% of total body surface area burns (3). As a result, all the patients excluding patients with daily intake of analgesics, need to be justified. Alternatively, withholding the night dose of analgesic would have sufficed. All the patients enrolled in the study were ASA I or II with lower extremity burn injuries. What was the position of the patient during surgery? In hemodynamically stable, compliant patients, the procedure could have been safely performed under regional anesthesia i.e. a combination of low-dose spinal with lumbar epidural anesthesia or a regional block with adjuvants can be tried for long-term pain relief (4). This could further be supplemented with intravenous sedation and analgesia, a cost-effective alternative of general anesthesia. Moreover, continuous infusion of local anesthetics along with adjuvants via epidural or peripheral route are suggested to be used for postoperative pain relief. Another advantage of this technique is the reduced incidence of postoperative nausea and vomiting. While using regional anaesthetic regimen, preoperative administration of oral gabapentin tablet would lead to reduced postoperative morphine consumption for analgesic purpose. Abstract reads that pain was assessed on a visual analogue scale at rest and during movement at different time intervals before the operation. Please correct this statement to 1, 4, 8, 12, 16, 20 and 24 h after the operation.

Dear Editor,To the Editor – Rimaz and Colleagues should be congratulated on their report of the effect of Gabapentin on postoperative burn patients (1). There are few points concerning the pharmacokinetic properties of Gabapentin on postoperative burn patients that are worth considering. Firstly, Richardson (2) reminded us to observe pathophysiological changes that follow burn injury before prescribing any drug to a burn patient. During the first 48 h, decreased organ blood supply will reduce clearance of drugs, but the subsequent hypermetabolic phase (48 h after injury) is associated with increased clearance. Variations in levels of acute phase plasma proteins lead to changes in drug binding and free fractions available for end action. The review by Kong and Irwin (3) stated that Gabapentin is not bound to plasma proteins. It is extensively distributed in human tissues and fluid after administration. Gabapentin is not metabolized and does not induce hepatic microsomal enzymes. It is eliminated unchanged in the urine and any unabsorbed drug is excreted in the faeces. Elimination rate constant, plasma clearance, and renal clearance are linearly related to creatinine clearance. Therefore, dose adjustment is necessary in patients with compromised renal function. Secondly, stress ulcer prophylaxis which is commonly prescribed in burn patients could affect renal clearance of Gabapentin. For example, Cimetidine, a H2 receptor blocker, decreases the renal clearance of Gabapentin by 12% when administered concomitantly (3). Thirdly, delirium is a concern in both burn and postoperative patients (4). In Leung’s pilot study, there was significantly less delirium in patients having perioperative Gabapentin (P = 0.045) in the dose of 900 mg started 1 – 2 h before spinal surgery and continued for the first 3 postoperative days. The mechanism of Gabapentin reducing postoperative delirium is unknown. It could possibly be related to its opioid sparing effect (5).

We read with interest the article by Rimaz and coworkers about the beneficial effect of preoperative oral administration of a high single dose (1200 mg) of gabapentin on postoperative pain scores and morphine consumptionin patients undergoing surgical debridement of burn wounds (1). The effect of preoperative administration oforal gabapentin in order to reduce postoperative painscores and opioid consumption was analyzed in severalstudies. A systematic review of randomized controlled trials published by Ho and coworkers has shown that, in different types of surgery, the preoperative administration of a single dose of 1200 mg oral gabapentin produced a significant reduction in pain intensity at rest compared with placebo in the early and late postoperative period at6 and 24 h after administration, respectively. In addition, some similar studies showed a significant reduction inopioid consumption and a delayed request for analgesia(2). As regard to the adverse effects, the administrationof 1200 mg of oral gabapentin did not show significant differences with respect to placebo in a large part of published studies. Indeed, as highlighted by Turan and coworkers, the treatment group showed fewer episodes ofvomiting and urinary retention, probably due to lower consumption of opioids in the postoperative period (3). However, administration of a single dose of 1200 mg oforal gabapentin in the preoperative period showed no serious adverse effects in the treated patients. The analysisof available data has revealed a number of limitations, in particular due to the different type of surgery. An interesting systematic review published by Mathiesen et al. focused on the use of gabapentin in the preoperative period in relation to the surgical procedures. Reported datashowed that preoperative gabapentin administration in different dosages appears to be particularly effective inreducing postoperative opioid consumption particularly after abdominal hysterectomy and spinal surgery, while the use in other sort of surgeries revealed no significant results. In addition, a reduction in pain scores was demonstrated mostly in early postoperative period, probablydue to higher gabapentin plasmatic level in the earlypostoperative phase (4). At a single preoperative oraldose of 1200 mg, gabapentin showed conflicting results in relation to different types of surgeries, with promising evidences only in abdominal hysterectomy, spinal surgery, radical mastectomy, thyroid and ear-nose throat surgery. However, these results should be confirmed by further investigations using the same methodology, in particular with respect to the type of anesthesia and rescue analgesia in the postoperative period. Currently, there are no other publications on the use of preoperative gabapentin in postoperative pain in burned patients.In this regard, we agree with the authors that the burnwounds, in relation to the particular type of damage, may benefit from perioperative administration of an anti-hyperalgesic drug. In fact, some nerve endings of skin nociceptors after burns are still intact or only partiallyinjured and continue to generate pain impulses leadingto primary hyperalgesia (5). However, further studies are needed to confirm these results, especially focused on the dose-response relationship of preoperative gabapentin, looking for the lowest effective dose.