Tej Prakash Sinha

Feasibility and safety of ultrasound-guided nerve block for management of limb injuries by emergency care physicians.

Background: Patients require procedural sedation and analgesia (PSA) for the treatment of acute traumatic injuries. PSA has complications. Ultrasound (US) guided peripheral nerve block is a safe alternative. Aim: Ultrasound guided nerve blocks for management of traumatic limb emergencies in Emergency Department (ED). Setting and Design: Prospective observational study conducted in ED. Materials and Methods: Patients above five years requiring analgesia for management of limb emergencies were recruited. Emergency Physicians trained in US guided nerve blocks performed the procedure. Statistical analysis: Effectiveness of pain control, using visual analogue scale was assessed at baseline and at 15 and 60 minutes after the procedure. Paired t test was used for comparison. Results: Fifty US guided nerve blocks were sciatic- 4 (8%), femoral-7 (14%), brachial- 29 (58%), median -6 (12%), and radial 2 (4%) nerves. No patients required rescue PSA. Initial median VAS score was 9 (Inter Quartile Range [IQR] 7-10) and at 1 hour was 2(IQR 0-4). Median reduction in VAS score was 7.44 (IQR 8-10(75%), 1-2(25%) (P=0.0001). Median procedure time was 9 minutes (IQR 3, 12 minutes) and median time to reduction of pain was 5 minutes (IQR 1,15 minutes). No immediate or late complications noticed at 3 months. Conclusion: Ultrasound-guided nerve blocks can be safely and effectively performed for upper and lower limb emergencies by emergency physicians with adequate training.

Diagnostic accuracy of bedside emergency ultrasound screening for fractures in pediatric trauma patients

Background: Bedside ultrasound (BUS) can effectively identify fractures in the emergency department (ED). Aim: To assess the diagnostic accuracy of BUS for fractures in pediatric trauma patients. Setting and Design: Prospective observational study conducted in the ED. Material and Methods: Pediatric patients with upper and lower limb injuries requiring radiological examination were included. BUS examinations were done by emergency physicians who had undergone a brief training. X-rays were reviewed for the presence of fracture and the results of BUS and radiography were compared. Statistical analysis: STATA version 11 was used for statistical analysis of the data. Results: Forty-one patients were enrolled in the study. The sensitivity of the BUS in detecting fracture was 89% [95% confidence interval (CI): 51% to 99%] and the specificity was 100% (95% CI: 87% to 100%). The positive predictive value of BUS was 100% and negative predictive value was 97%. Conclusion: BUS can be utilized by emergency physicians after brief training to accurately identify long bone fractures in the pediatric age-group.

Assessment of ultrasound as a diagnostic modality for detecting potentially unstable cervical spine fractures in pediatric severe traumatic brain injury: A feasibility study

Background: Early cervical spine clearance is extremely important in unconscious trauma patients and may be difficult to achieve in emergency setting. Objectives: The aim of this study was to assess the feasibility of standard portable ultrasound in detecting potentially unstable cervical spine injuries in severe traumatic brain injured (TBI) patients during initial resuscitation. Materials and Methods: This retro-prospective pilot study carried out over 1-month period (June-July 2013) after approval from the institutional ethics committee. Initially, the technique of cervical ultrasound was standardized by the authors and tested on ten admitted patients of cervical spine injury. To assess feasibility in the emergency setting, three hemodynamically stable pediatric patients (≦18 years) with isolated severe head injury (Glasgow coma scale ≤8) coming to emergency department underwent an ultrasound examination. Results: The best window for the cervical spine was through the anterior triangle using the linear array probe (6-13 MHz). In the ten patients with documented cervical spine injury, bilateral facet dislocation at C5-C6 was seen in 4 patients and at C6-C7 was seen in 3 patients. C5 burst fracture was present in one and cervical vertebra (C2) anterolisthesis was seen in one patient. Cervical ultrasound could easily detect fracture lines, canal compromise and ligamental injury in all cases. Ultrasound examination of the cervical spine was possible in the emergency setting, even in unstable patients and could be done without moving the neck. Conclusions: Cervical ultrasound may be a useful tool for detecting potentially unstable cervical spine injury in TBI patients, especially those who are hemodynamically unstable.

Integration of point-of-care ultrasound during rapid sequence intubation in trauma resuscitation

Introduction: Airway and breathing management play critical role in trauma resuscitation. Early identification of esophageal intubation and detection of fatal events is critical. Authors studied the utility of integration of point-of-care ultrasound (POCUS) during different phases of rapid sequence intubation (RSI) in trauma resuscitation. Methods: It was prospective, randomized single-centered study conducted at the Emergency Department of a level one trauma center. Patients were divided into ultrasonography (USG) and clinical examination (CE) arm. The objectives were to study the utility of POCUS in endotracheal tube placement and confirmations and identification of potentially fatal conditions as tracheal injury, midline vessels, paratracheal hematoma, vocal cord pathology, pneumothorax, and others during RSI. Patient >1 year of age were included. Time taken for procedure, number of incorrect intubations, and pathologies detected were noted. The data were collected in Microsoft Excel spread sheets and analyzed using Stata (version 11.2, Stata Corp, Texas, U. S. A) software. Results: One hundred and six patients were recruited. The mean time for primary survey USG versus CE arm was (20 ± 10.01 vs. 18 ± 11.03) seconds. USG detected four pneumothorax, one tracheal injury, and one paratracheal hematoma. The mean procedure time USG versus CE arm was (37.3 ± 21.92 vs. 58 ± 32.04) seconds. Eight esophageal intubations were identified in USG arm by POCUS and two in CE arm by EtCO2 values. Conclusion: Integration of POCUS was useful in all three phases of RSI. It identified paratracheal hematoma, tracheal injury, and pneumothorax. It also identified esophageal intubation and confirmed main stem tracheal intubation in less time compared to five-point auscultation and capnography.

Gender-based assessment of survival in trauma-hemorrhagic shock: a retrospective analysis of Indian population

Introduction: Trauma-hemorrhagic shock (THS) is a leading cause of death. Female rats and women experience better outcomes in terms of survival after major trauma as compared to males. There are limited data in Indian population. Authors studied the gender-based outcome of patients with Class IV hemorrhagic shock due to blunt trauma and the distribution of factors among males and females which are known to affect outcome. Materials and Methods: It was a retrospective study with data of trauma victims between January 2008 and July 2013. Road traffic crash (RTC), fall, or assault of all ages with Class IV hemorrhagic shock on arrival was included in the study, and data were collected on demographic, clinical, and laboratory parameters. Drowning, burns, penetrating injuries, and septic, neurogenic, and cardiogenic shock were excluded from the study. Results: Seven hundred and eighty-one patients were analyzed under three groups: (i) overall group including all patients (n = 781), (ii) male group (n = 609), and (iii) female group (n = 172). After adjusting all variables, mortality was significantly lower in females as compared to males following THS (P < 0.05). Age, blood pressure, pulse, male gender, and fall and RTC as mode of injury (MOI) were independent predictors of mortality (P < 0.05) in overall group. Among males, age, pulse, and RTC as a MOI were significant (P < 0.05), while in females, only systolic blood pressure (SBP) was independent predictor of mortality. Conclusion: Females had better survival as compared to males following THS. SBP was an independent predictor of mortality in females with THS.

Epidemiology of traumatic cardiac arrest in patients presenting to emergency department at a level 1 trauma center.

Introduction: There is a paucity of literature on prehospital care and epidemiology of traumatic cardiac arrest (TCA) in India. This study highlights the profile and characteristics of TCA. Methods: A retrospective cohort study was conducted to study epidemiological profile of TCA patients ≥1 year presenting to a level 1 trauma center of India. Results: One thousand sixty-one patients were recruited in the study. The median age (interquartile range) was 32 (23–45) years (male:female ratio of 5.9:1). Asystole (253), pulseless electrical activity (11), ventricular fibrillation (six), and ventricular tachycardia (five) were initial arrest rhythm. Road traffic crash (RTC) (57.16%), fall from height (18.52%), and assault (10.51%) were modes of injury. Prehospital care was provided by police (36.59%), ambulance (10.54%), relatives (45.40%), and bystanders (7.47% cases). Return of spontaneous circulation was seen in 69 patients, of which only three survived to hospital discharge. Conclusion: RTC in young males was a major cause of TCA. Asystole was the most common arrest rhythm. Police personnel were major prehospital service provider. Prehospital care needs improvement including the development of robust TCA registry.

Is it the time to integrate "sono cardiopulmonary resuscitation" in cardiopulmonary resuscitation algorithm of traumatic cardiac arrest?

Sir, American Heart Association 2010 advanced cardiac arrest life support (ACLS) guidelines have stressed on the quality of cardiopulmonary resuscitation (CPR) by monitoring various physiological parameters such as end-tidal CO2. However, there is a paucity of literature about how to early and effectively identify and manage the potentially treatable causes of cardiac arrest (5 “H” and 5 “T”) as per ACLS algorithm.[1] The term “sono CPR” refers to applications of ultrasonography (USG) while performing CPR. The point of care USG may be performed during the brief pauses taken for pulse and rhythm check, after every 2 min of a CPR cycle. Hence, chest compressions are not interrupted nor there is any deviation from the standard ACLS guidelines. Authors practice AIIMS-CLIP, a protocol which refers to sequential scanning of cardiac (C) and lung (L) windows followed by an assessment of inferior vena cava (IVC) diameter using USG. Using “sono CPR,” approximately 40% of the potentially treatable causes (5 “H” and 5 “T”) of cardiac arrest may be assessed and managed in time. In traumatic cardiac arrest (TCA), cardiac scan can detect tamponade (T) and pulmonary thromboembolism (T), lung scan can detect tension pneumothorax (T), and IVC scan can detect hypovolemia (H). From the prognostic point of view, a cardiac scan showing the absence of cardiac motion during resuscitation of patients in cardiac arrest would be highly predictive of inability to achieve a return of spontaneous circulation and a poor prognosis.[2,3,4,5] Ultrasound evaluation of cardiac contractility increases the success rate of accomplished CPR.[5] In the light of above knowledge, would it be right to keep ourselves blind regarding detectable and treatable causes of cardiac arrest while performing CPR and awaiting for the cardiac activity to return or to actively use “sono CPR” and search for treatable causes so that timely intervention could be done? Future research may explore the integration of point of care sonography as an adjunct to CPR in TCA. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Pelvic fracture and urogenital injuries

Pelvic injuries occur in major crash accidents. Injury to the bladder and membranous urethra are the commonest associated urogenital injuries. More and more urethral injuries are being managed conservatively in the acute phase for fear of hemorrhage and infection, which may result in late sequel of urethral injuries. The definitive surgery can be delayed in favor of simple.

(A61) Prospective Evaluation of “Focused Assessment with Sonography for Trauma” Done by Emergency Physicians, and its Comparative Analysis with Radiologist's Performance

Objective The objective of this study was to determine the accuracy of emergency physicians in detecting free fluid in the abdomen when compared to radiologists during w primary survey of trauma victims by focused assessment with sonography for trauma (FAST) scan in the emergency department. Methods This prospective study was performed during a primary survey of the resuscitation of non-consecutive patients in the resuscitation bay. The study subjects included emergency physicians (EP) [one emergency medicine (EM) consultant, two EM residents, one orthopedic resident, and one surgical resident] who underwent training at a three-day workshop on emergency sonography and performed 10 supervised positive and negative scans for free fluid. The FAST scans were performed by the EPs and then by the radiology resident (RR). Both were blinded to each others sonography findings. Computed tomography (CT) scan and laparatomy findings were used as gold standard. Results were compared between both groups. Intra-observer variability among EPs and level of agreement between EPs and RRs were assessed. Results One hundred fifty scans performed by EPs and RRs were analyzed. The mean age of the patients was 28 [1–70] years. Out of 24 true positive patients, 18 underwent CT scan, and exploratory laparatomy was done in six patients. Intra-observer performance variation ranged from 87–97%. The sensitivity of FAST performed by EP and RR was 100%. The specificity of FAST by EPs was 95.4% vs. 98.4% by RRs. The level of agreement was 100%. Conclusions This study proves that FAST scan performed by EPs who are trained in short course of ultrasonography can be reliable and accurate when compared to a qualified radiologist.

(P2-73) Ocular Nerve Sheath Diameter for Evaluation of Raised Intracranial Pressure in Patients Presenting to the Emergency Department - A Prospective, Observational Study

Background Ultrasonography of optic nerve sheath diameter (ONSD) may be useful in detecting raised intracranial pressure (ICP) in head injury (HI). There is limited data from India. Objective The objective of this study was to evaluate the utility of measuring ONSD for diagnosis of raised intracranial pressure in HI victims in the emergency department. Methods Fifty-two HI patients presenting between February to August 2009 were included, A CT head scan was performed and simultaneous ocular ultrasound was done by an emergency physician who had underwent goal-directed training in ophthalmic sonography by a linear probe of 10 MHz. An ONSD greater than > 5 mm for patients > 15 years of age, 4.5 mm for 1–15 years of age, and 4 mm for infants were considered abnormal. The two modalities of diagnosis were compared. Results The median age was 30 years (Range = 0.25–72 years). A total of 90.4% were male and 9.6% were female. A total of 71.2% had severe HI, 19.2% had moderate HI, and 9.6% had mild HI. A raised ICP based on CT findings was present in 42 (80.8%) patients. Mean optic nerve diameter in patients with raised ICP was 5.11 + 1.56 mm compared to 5.04 + 1.6 mm in patients with no features of raised ICP. Sensitivity and specificity of ONSD as a screening test for detection of raised intracranial pressure were 57.1% and 40%, respectively with a positive predictive value and negative predictive value of 80% and 18.1%, respectively. Conclusions The evaluation of the ONSD diameter is a simple and non-invasive potential tool in initial assessment of raised intracranial pressure.