Sushma Sagar

Post-traumatic skin and soft tissue infection due to Aeromonas hydrophila.

We report a case of posttraumatic skin and soft tissue infection in a patient who sustained laceration after being hit by a water tanker. Aeromonas hydrophila was isolated from pus and was identified to the species level by Vitek 2 and a battery of biochemical tests. The patient responded to thorough drainage, debridement of wound and 2 weeks of intravenous antibiotics. The patient was taken up for split skin grafting of the raw area. She was discharged with satisfactory graft uptake after 1 week without any further antibiotics advice. Follow-up after 3 weeks was satisfactory with healthy cover on the raw area and normal weight bearing on the left leg.

Nonoperative Management of Traumatic Chylothorax

Chylothorax is known for its rarity, and its diagnosis following blunt chest trauma is exceptional. Only a small number of cases have been reported in the literature. Severe consequences, such as cardiopulmonary abnormalities and metabolic, nutritional, and immunologic disorders, can result from chylothorax. Management of chylothorax is challenging. It can either be managed nonoperatively or surgically. Surgical treatment is required in cases of persistent or high output fistulae. We report here in three cases of blunt trauma chest following road traffic crash associated with chylothorax. All of them were successfully managed nonoperatively with inter costal tube drainage and supportive treatment sans need of any operative intervention.

Helicobacter pylori in gallbladder mucosa in patients with gallbladder disease

BackgroundHelicobacter species have been found to be associated with biliary tract diseases. This prospective study was done to determine the prevalence of H. pylori in the biliary tract of patients suffering from gallbladder disease.MethodsForty-nine patients undergoing laparoscopic/open cholecystectomy for benign biliary tract diseases were investigated with urea breath test for H. pylori infection of gastric antrum. Bile and gallbladder tissues were studied for presence of H. pylori by rapid urease test, histopathological examination, culture and PCR analysis. Gallbladder specimens from two patients who underwent Whipple’s operation and from 10 cadavers were studied as controls.ResultsThe mean (SD) age of patients was 42.4 (11.1) years. Urea breath test was positive in 17 (34.6%) cases. Rapid urease test was negative in all the cases. There was no evidence of H. pylori infection of gallbladder on histopathological examination using H&E, Giemsa and Warthin Starry stains. H. pylori DNA were detected in 16 patients (32.6%) and none of the 12 controls by PCR analysis (p = 0.025). The presence of H. pylori DNA in bile and/or gallbladder was associated with positive urea breath test, (p < 0.0001). Other factors like age, gender, jaundice and cholestasis were not associated with H. pylori infection of bile and gallbladder.ConclusionsNearly three quarters of patients with positive urea breath test have detectable H. pylori DNA in gallbladder tissue. The significance of these findings needs to be further evaluated.

Operative management of splenic injury in a patient with proteus syndrome.

A 20-year-old female with Proteus syndrome sustained splenic injury after fall from a bike. She was initially managed non-operatively at a different hospital for three days and was then referred to our level I trauma center in view of increasing abdominal pain and distention. On admission in the Emergency Department (ED), her pulse rate was 120 per minute and blood pressure was 108/68 mm Hg. Clinical examination showed a distended abdomen with left hypochondrial pain. Ultrasonogram (USG) and Computed Tomography (CT) of the abdomen showed splenomegaly and grade III splenic injury with significant hemoperitoneum. Her hemoglobin was 2.9 g/dl with packed cell volume (PCV) of 12%. In view of low hemoglobin and possibility of pathologic spleen, splenectomy was done. Microscopic examination of the spleen showed hemangiolymphangioma. The patient was discharged on the 5th post-operative day and is doing well at 6 months of follow-up.

Burden of maxillofacial trauma at level 1 trauma center.

There is an upward trend in facial injuries following changes in population pattern, increasing industrialization and urbanization, hence maxillofacial trauma is becoming a burden and a leading medical problem in emergency rooms worldwide. This study was performed to evaluate the pattern of maxillofacial fractures, associated injuries, and treatment used at Jai Prakash Narayan Apex Trauma Center (JPNATC), All India Institute of Medical Sciences (AIIMS), New Delhi, India, between January 2007 and June 2010. The study provides basis for establishment of trauma as major etiology of maxillofacial injuries and planning for preventive strategies. A retrospective study of patients seen and treated at JPNATC, AIIMS, New Delhi, between January 2007 and June 2010 was performed. Data extracted from patient records included etiology, age, sex, types and sites of fractures, treatment modality, and concomitant injuries. There were 795 fractures of the maxillofacial skeleton and 86 concomitant injuries from 542 patients. Road traffic accident (RTA) (56.8%) was the most common etiologic factor, followed by falls (22.3%) and fights (18.5%). The age range was from 3 to 75 years (mean, 34.7 years) with a peak incidence in the third decade with a male-to-female ratio of 3.7:1. The most common location of maxillofacial fractures was the mandible 615 (77%) and middle third 180 (23%). With regard to mandibular fractures, the body (29.6%) was the most common site, followed by the angle (24.4%), ramus (19.5%), dentoalveolar (14.6%), symphysis (11.0%), condyle (0.8%) while in the middle third, the nasal bone (36.7%) was the most common, followed by zygomatic bone (27.8), Lefort II (14.4), Lefort I (7.8%), dentoalveolar (10.0%), and Lefort III (3.3%). Majority of the patients were treated by open reduction and internal fixation (70.6). Concomitant injuries were 84 (10.8%) with orthopedic injuries accounting for the majority (63.9%). Head injury was associated in 16.3% of cases. RTA was the major etiologic factor of maxillofacial injuries in our setting and the young adult males were the main victims. Henceforth, establishment of regionalized, efficient, and focused trauma centers in various parts of the country particularly for acute trauma should be emphasized. Also, the laws regarding the precautions such as seat belts, speed limits, and traffic rules must be observed strictly to reduce the incidence of RTA.

Post traumatic buccal fat pad injury in a child: a missed entity in ER.

Maxillofacial injuries in the paediatric age group is common and traumatic herniation of buccal fat pad represents one of the few sequel to facial injuries which can easily be missed during primary or secondary survey in the emergency department, especially in young patients. The uncommon occurrence and thus lack of knowledge, often alarms the parents and/or attending physian alike with the presence of a tumor like lesion within the oral cavity in the post-traumatic period. The following case report describes one such incidence of traumatic extrusion of the buccal fat pad into the oral cavity while addressing the need to reinforce the practice of thorough clinical examination before managing any patient.

Penetrating neck injury: Collaterals for another life after ligation of common carotid artery and subclavian artery

Neck, being not protected by skeleton, is vulnerable to external trauma and injury which involves blood vessels, trachea, esophagus and other endocrine and nervous system organs. Vascular injuries can not only cause potentially life-threatening hemorrhage but also need profound surgical expertise in management. Development of collateral circulation in neck is well known; however, there is scarcity of literature on the role of collateral formation in neck trauma. Here, we present a unique case of penetrating gunshot injury to neck with right common carotid and right subclavian artery injury with hemorrhagic shock managed with ligation of these vessels as a life-saving procedure. The patient presented with no neurological or motor deficits in immediate postoperative period owing to the collateral circulation between right vertebral artery and right common carotid and right subclavian artery.

Psychological effects of amputation: A review of studies from India

Amputation is a major health burden on the families, society, and on medical services as well. Traumatic limb amputation is a catastrophic injury and an irreversible act which is sudden and emotionally devastating for the victims. In addition, it causes inability to support self and the family and driving many patients toward various psychiatric disorders. Extensive information regarding the effects of amputation has not been ascertained and therefore it was decided to do a systematic review. The goal of this review was to provide comprehensive information of peer-reviewed papers examining the psychological distress among amputees in India. A search of the literature resulted in a total of 12 articles with varied sample size from 16 to 190. The sample has been largely comprised males with lower limb amputation caused by primarily traumatic ones, i.e., motor vehicle accident, railway track accidents, machinery injury, blasts, etc., The prevalence of psychiatric disorders among amputees has been found to be in the range of 32% to 84% including depression rates 10.4%–63%, posttraumatic stress disorder 3.3%–56.3%, and phantom limb phenomenon 14%–92%. Although the studies reported that symptoms of anxiety and depression become better over the course of time, however surgical treatment providers need to liaise with psychiatrists and psychologists to support and deal with the psychological disturbances.

Traumatic cardiac injury: Experience from a level-1 trauma centre

Purpose Traumatic cardiac injury (TCI) is a challenge for trauma surgeons as it provides a short therapeutic window and the management is often dictated by the underlying mechanism and hemodynamic status. The current study is to evaluate the factors influencing the outcome of TCI. Methods Prospectively maintained database of TCI cases admitted at a Level-1 trauma center from July 2008 to June 2013 was retrospectively analyzed. Hospital records were reviewed and statistical analysis was performed using the SPSS version 15. Results Out of 21 cases of TCI, 6 (28.6%) had isolated and 15 (71.4%) had associated injuries. Ratio between blunt and penetrating injuries was 2:1 with male preponderance. Mean ISS was 31.95. Thirteen patients (62%) presented with features suggestive of shock. Cardiac tamponade was present in 12 (57%) cases and pericardiocentesis was done in only 6 cases of them. Overall 19 patients underwent surgery. Perioperatively 8 (38.1%) patients developed cardiac arrest and 7 developed cardiac arrhythmia. Overall survival rate was 71.4%. Mortality was related to cardiac arrest (p = 0.014), arrhythmia (p = 0.014), and hemorrhagic shock (p = 0.04). The diagnostic accuracy of focused assessment by sonography in trauma (FAST) was 95.24%. Conclusion High index of clinical suspicion based on the mechanism of injury, meticulous examination by FAST and early intervention could improve the overall outcome.

Are falls more common than road traffic accidents in pediatric trauma? Experience from a Level 1 trauma centre in New Delhi, India.

Purpose The epidemiology of pediatric trauma is different in different parts of the world. Some researchers suggest falls as the most common mechanism, whereas others report road traffic accidents (RTAs) as the most common cause. The aim of this study is to find out the leading cause of pediatric admissions in Trauma Surgery in New Delhi, India. Methods Inpatient data from January 2012 to September 2014 was searched retrospectively in Jai Prakash Narayan Apex Trauma Centre Trauma Registry. All patients aged 18 years or less on index presentation admitted to surgical ward/ICU or later taken transfer by the Department of Trauma Surgery were included. Data were retrieved in predesigned proformas. Information thus compiled was coded in unique alphanumeric codes for each variable and subjected to statistical analysis using SPSS version 21. Results We had 300 patients over a 33 month period. Among them, 236 (78.6%) were males and 64 (21.3%) females. Overall the predominant cause was RTAs in 132 (43%) patients. On subgroup analysis of up to 12 years age group (n = 147), the most common cause was found to be RTAs again. However, falls showed an incremental upward trend (36.05% in up to 12 age group versus 27% overall), catching up with RTAs (44.89%). Pediatric Trauma Score (PTS) ranged from 0 to 12 with a mean of 8.12 ± 2.022. 223 (74.33%) patients experienced trauma limited to one anatomic region only, whereas 77 (25.66%) patients suffered polytrauma. 288 patients were discharged to home care. Overall, 12 patients expired in the cohort. Median hospital stay was 6 days (range 1–182). Conclusion Pediatric trauma is becoming a cause of increasing concern, especially in the developing countries. The leading cause of admissions in Trauma Surgery is RTAs (43%) as compared to falls from height (27%); however, falls from height are showing an increasing trend as we move to younger age groups. Enhancing road safety alone may not be a lasting solution for prevention of pediatric trauma and local injury patterns must be taken into account when formulating policies to address this unique challenge.