Hemodynamic Changes Following Routine Fluid Resuscitation in Patients With Blunt Trauma

Background

The management of trauma patients is often difficult. The American college of surgeons suggests using advanced trauma life support (ATLS) measures. ATLS is regarded as the gold standard for the resuscitation of cases with acute life threatening injuries.

Objectives

To assess the change in base excess (BE) values and central venous pressure (CVP) one and six hours after injection of 1000 cc normal saline in trauma patients admitted to the ICU.

Patients and Methods

According to the inclusion and exclusion criteria, patients were randomly selected to participate in the project. Inclusion criteria included trauma patients admitted to the ICU with a CVP line and who had indication for hydration. In trauma patients, at the zero time period, BP, PR, RR and CVP were measured, and a blood gas test was used to assess Hb, pH, BE, PO₂, HCO₃ and PCO₂. Then 1000 cc of normal saline was injected, and after one and six hours, the same values were re-evaluated.

Results

The mean age of the patients was 38.1 ± 3.9 (range 15 - 60). The mean duration of hospitalization was 7.4 ± 4.4 (range 1 - 21) days. The mean ISS for these patients was 14.33 ± 5.3. BE changes in both groups of patients, based on Hb primary division, showed a significant difference (P ≤ 0.05). The results showed that there was no significant relation between the measured ISS and the changes in base values (P ≥ 0.05).

Conclusions

According to our results, the infusion of one liter normal saline will cause a statistically significant decrease only in BD, after one hour, in patients with moderate to severe ISS. The changes in SBP, PR, CVP and also pH, HCO₃ and Hb were not statistically remarkable.

Epidemiological characteristics of fatal pedestrian accidents in Fars Province of Iran: a community-based survey

OBJECTIVE

To determine the epidemiological characteristics of fatal pedestrian accidents in Fars Province of Iran.

METHODS

This cross-sectional study was conducted in Fars Province of Iran during a 29-month period from March 2009 to July 2011. The data were from the Fars Forensic Medicine Registry. In 4 923 recorded road traffic accident fatalities, 971 deaths were due to pedestrian accidents. The demographic and accident-related information were analyzed by SPSS version 11.5. P value less than 0.05 was considered significant.

RESULTS

The mean age of decedents was (47.2+/-26.2) years, ranging from 6 months to 103 years old. Males accounted for 69.8% of all deaths. Fatal accidents were most common in September; 56.1% of the fatal injuries occurred on intracity roads and 33.1% on extracity roads. Fatal head injuries were present in 60.54% of cases. Evaluation of the injury site and the cause of death found that they were significantly associated with age, interval between injury and death. Besides, the type of roads played an important role in mortality.

CONCLUSION

Although the clinical management of trauma patients has been improved in our country in the recent decade, decreasing the burden of injuries needs coordination among trauma system organizations.

Fatal motorcycle accidents in Fars Province, Iran: a community-based survey

OBJECTIVE

To identify the main characteristics of victims of motorcycle accidents in Fars Province, Iran.

METHODS

This cross-sectional study was conducted in Fars Province which has the fourth largest population of all 31 provinces in Iran from March 2009 to June 2010. We included data from all 542 recorded cases of fatalities due to motor vehicle accidents. Data were recorded from the forensic medicine registry consisting of demographic and accident-related information. Demographic information consisted of name, age, sex, status of fatal victim (motorcycle driver vs passenger) and educational level.

RESULTS

Of the 2 345 autopsy records from the forensic medicine archives, 542 (23.1%) gave the cause of death as motor vehicle accidents. Mean age of these victims was (31.4+/-6.5) years, and the male to female ratio was 28. Head injury was the most common cause of death in these victims, and overall they tended to have a low level of education. Motorcycle accidents frequently involved younger age groups (15-35 years), and head trauma related with non-use of a helmet was the most common cause of death.

CONCLUSIONS

Head injury is frequent among victims in the province we studied. This situation may be related to the victims' low socioeconomic status and little education regarding traffic laws leading to speeding and disregard of these laws along with their weak enforcement.

Cranioplasty Results after Application of Anti-adhesive Films (OrthoWrap™) in Traumatic Decompressive Craniectomy

OBJECTIVE

To determine the effects of application of anti-adhesive films (OrthoWrap™) in traumatic decompressive craniectomy on prevention of adhesion formation and facilitation of subsequent cranioplasty.

METHODS

This was a retrospective cohort study being performed in ShahidRajaei hospital (Shiraz Level I trauma center) during a 12-month period (from March 2012 to April 2013) including 93 patients undergoing traumatic decompressivecraniectomy.Patients who received OrthoWrap™ during the initial craniectomy (n=44) were compared to those who did not (n=49). Two study groups were matched regarding the baseline characteristics. The perioperative indices including the surgical time, amount of bleeding, transfusion and 6-month Glasgow Outcome Scale (GOS) were compared between two study groups.

RESULTS

There was no significant difference between two study groups regarding the baseline characteristics. We found that the cranioplasty duration (113.3±33.2 vs. 146.9±34.9 minutes; p<0.001) and amount of intraoperative bleeding (182.1±98.3 vs. 270.6±77.6 mL; p=0.043) was significantly lower in those who had OrthoWrap™ compared to control group. The final GCS (p=0.052) as well as GOSE (p=0.653) was comparable between groups. The infection rate was comparable between two study groups (p=0.263).

CONCLUSION

Application of OrthoWrap™ during decompressive craniectomy in those with severe traumatic brain injury is associated with shorter duration of operation and less intraoperative bleeding in subsequent cranioplasty. Infection rate and neurologic outcome was comparable between study groups.

Management of Deep Vein Thrombosis (DVT) Prophylaxis in Trauma Patients

Deep vein thrombosis (DVT) and pulmonary embolism (PTE) are known as venous thromboembolism (VTE). DVT occurs when a thrombus (a blood clot) forms in deep veins of the body, usually in the lower extremities. It can cause swelling or leg pain, but sometimes may occur with no symptoms. Awareness of DVT is the best way to prevent the VTE. Patients with trauma are at increased risk of DVT and subsequent PE because of coagulopathy in patients with multiple trauma, DVT prophylaxis is essential but the VTE prophylaxis strategy is controversial for the trauma patients. The risk factors for VTE includes pelvic and lower extremity fractures, and head injury.

Epidemiology, Regional Characteristics, Knowledge, and Attitude Toward Female Genital Mutilation/Cutting in Southern Iran

INTRODUCTION

Female genital mutilation/cutting (FGM/C), also known as female circumcision, is an ancient traditional procedure that involves partial or total removal of the female external genitalia for nonmedical reasons. Although it is well described in African and some Arabic countries, data from Iran are scarce.

AIM

To describe the epidemiology, regional characteristics, knowledge, and attitude toward FGM/C in Southern Iran.

METHODS

This cross-sectional study was conducted during a 36-month period from 2010 to 2013 in Hormozgan, a southern province of Iran near the Persian Gulf. We included 780 women in six major rural areas of the province who referred to healthcare centers for vaccination, midwifery, or family planning services. All participants underwent complete pelvic examination to determine the type of FGM. The questionnaire consisted of several sections such as demographic and baseline characteristics, and two self-report sections addressing the knowledge and attitude toward FGM/C and its complications. Baseline sociodemographic characteristics including age, educational level, marital status, religion, and nationality were the independent variables.

RESULTS

Among the participants, 535 (68.5%) had undergone FGM/C. FGM/C was associated with higher age (P = 0.002), Afghan nationality (P = 0.003), Sunni Islam as religion (P = 0.019), illiteracy (P < 0.001), and family history of FGM/C in mother (P < 0.001), sister (P < 0.001), and grandmother (P < 0.001). Ancient traditions in the area (57.1%) were mentioned as the most important factor leading to FMG/C. Urinary tract infection was the most common reported complication (60.4%).

CONCLUSION

FGM/C is a common practice in rural areas of Southern Iran. It is associated with increased age, illiteracy, Sunni Islam religion, Afghan nationality, and positive family history. Lack of knowledge toward FGM/C is the main cause of its high prevalence and continuation in the area.

Effect of immobilization on urine calcium excretion in orthopedic patients with pelvic fracture treated by skin traction

Objectives: To determine the effects on urine calcium excretion of immobilization by skin traction in patients with pelvic fracture. Methods: In a prospective study, a consecutive series of patients with pelvic fracture treated by skin traction were enrolled. Serum (calcium, phosphorous, alkaline phosphatase, sodium, potassium, uric acid, BUN, creatinine) and fasting urine calcium, creatinine, sodium, potassium and uric acid were checked within 48 hours of hospitalization and at 7, 14 and 21 days of immobilization and then after 3 months of mobilization. Trends in changes of variables were recorded. Results: Fifty five patients were enrolled in this study; they were 45 (81.8%) males and 10 (18.2%) females with a mean age 19.4 ± 12.7 years. We found that serum levels of calcium (p = 0.004), phosphorous (p = 0.047) and alkaline phosphatase (p = 0.001) increased significantly during the 3 weeks of immobilization. In the same way, urine calcium/ urine creatinine ratio increased significantly in the study period (p = 0.004). No symptomatic renal stone formation was observed during the study period. Conclusions: Immobilization even in short term causes hypercalciuria in orthopedic patients. Although it is transient and improves with subsequent mobilization, it is needed to be considered specifically by the team caring for this group of patients.

Effectiveness of topical curcumin for treatment of mastitis in breastfeeding women: a randomized, double-blind, placebo-controlled clinical trial

OBJECTIVE

To determine the efficacy of topical curcumin in reducing breast inflammation in women suffering from lactational mastitis.

METHODS

A randomized double-blind, placebo-controlled study including 63 breastfeeding women with lactational mastitis were randomly assigned to receive curcumin topical cream, one pump every 8 hours for 3 days (n=32) or topical moisturizer as placebo (n=31). Using an index for severity of breast inflammation, all of the patients had moderate breast inflammation before entering the study. The outcome of treatment was evaluated using the same index at 24, 48 and 72 hours of starting the treatment.

RESULTS

There was no significant difference between two study groups regarding the baseline characteristics such as age (p=0.361) and duration of lactation (p=0.551). After 72-hour of therapy, patients in curcumin groups had significantly lower rate of moderate (p=0.019) and mild (p=0.002) mastitis. Patients in curcumin group had significantly lower scores for tension (p<0.001), erythema (p<0.001) and pain (p<0.001), after 72-hour of treatment.

CONCLUSION

The results of the current study indicate that topical preparation of curcumin successfully decrease the markers of lactational mastitis such as pain, breast tension and erythema within 72 hours of administration without side effects. Thus, topical preparation of curcumin could be safely administered for those suffering from lactational mastitis after excluding infectious etiologies.

Isolated Post-Traumatic Syringobulbia; Case Report and Review of the Literature

Syringobulbiais very rare condition defined as slit-like fluid cavity in the brain stem. Several conditions have been reported to be associated with syringobulbia including neoplasms, spinal cord traumas or lesions such as tethered cord, hind-brain herniation, infections such as meningitis and in isolation. Although post-traumatic syringomyelia has been wieldy described previously, traumatic brain injury has not been reported as the mechanism and etiology of isolated syringobulbia. We herein report a 24-year old man with previous history of severe traumatic brain injury who presented with recent onset inability to walk or coordinate movements, ataxia, dysphonia, dysarthria, bilateral third nerve palsy with fixed dilated pupils and eyes deviated outward and downward. He was further diagnosed to have isolated syringobulbia extending to upper pons and lower midbrain. Isolated post-traumatic syringobulbia is extremely rare condition presenting insidiously with cranial nerve palsies, ataxia and dysarthria.

Effects of Intracranial Pressure Monitoring on Outcome of Patients with Severe Traumatic Brain Injury; Results of a Historical Cohort Study

OBJECTIVE

To investigate the effects of intracranial pressure (ICP) monitoring on mortality rate and functional outcome of patients with severe traumatic brain injury (TBI).

METHODS

This was historical cohort study being performed in Nemazee hospital of Shiraz during a 4-year period (from 2006 to 2010) including those patients with severe TBI who had undergone care based on ICP monitoring (case group) or clinical evaluation (control group).Patients and controls were matched regarding the age, sex, initial GCS, initial pupils, and CT findings. The functional outcome, complications and mortality rate were recorded and compared between those who underwent ICP monitoring and those who did not.

RESULTS

There was no significant difference between two study groups regarding the baseline characteristics. The rate of meningitis was significantly higher in those who underwent Ventriculostomy and ICP monitoring when compared to those who were managed without ICP monitoring. [14 (23.3%) vs. 7 (11.6%); p=0.041]. We found that the mortality rate (28.3% vs. 11.6%; p=0.172) as well as the frequency of persistent vegetative state (5.0% vs. 5.0%; p=0.998) were comparable between two study groups. However the frequency of severe disability was higher in control group compared to case group (26.7% vs. 15.0; p=0.046). In the same way, the frequency of good recovery (26.7% vs. 15.0; p=0.046) and favorable outcome (51.7% vs. 33.3%; p=0.021) was significantly higher in case group.

CONCLUSION

Care based on ICP monitoring in patients with severe TBI was associated with increased frequency of good recovery and favorable outcome and decreased frequency of moderate disability. However higher meningitis rate was associated with Ventriculostomy and ICP monitoring.

Time analysis of fatal traffic accidents in Fars Province of Iran

OBJECTIVE

To analyze the time factor in road traffic accidents (RTAs) in Fars Province of Iran.

METHODS

This study was conducted in Fars Province, Iran from November 22, 2009 to November 21, 2011. Victims'information consisted of age, sex, death toll involving dri- vers or passengers of cars, motorcycles and pedestrians, and site of injury etc. Accidents were analyzed in relation to hour of the day, season of the year, lighting condition including sunrise, sunset, daytime and nighttime.

RESULTS

A total of 3 642 deaths (78.3% were males, and the ratio of males to females was about 3.6:1) were studied regarding their autopsy records. There was a steady increase in fatal accidents occurring at midnight to 15:59. The risk of being involved in a fatal traffic accident was higher for those injured between 4:00 to 7:59 than at other times (OR equal to 2.13, 95% CI 1.85-2.44). The greatest number of fatal RTAs took place in summer. Mortalities due to RTA during spring and summer were more pronounced at 20:00 to 23:59 and midnight to 3:59, whereas mortalities in fall and winter were more pronounced from 12:00 to 15:59.

CONCLUSION

The high mortality rate of RTA is a major public health problem in Fars Province. Our results indicate that the time is an important factor which contributes to road traffic deaths.

Mycotic Aneurysm of External Carotid Artery following Traumatic Brain Injury: Case Report and Review of Literature

Mycotic aneurysm of external carotid artery is extremely rare. We herein report a case of external carotid artery (ECA) aneurysm following severe traumatic brain injury. A 24-year-old man with severe traumatic brain injury (TBI) following a car accident was referred to Rajaee Trauma Center Emergency Room affiliated to Shiraz University of Medical Sciences in Shiraz, Iran. He underwent ventriculostomy on arrival for intracerebral pressure (ICP) monitoring and for a second time due to hydrocephalus following decompressive craniectomy. He developed fulminant meningitis and ventriculitis during his hospital course. A bulged pulsatile lesion under the frontotemporal scalp resulted into the suspicion to underlying vascular pathology. Six-vessel angiography of brain was done which revealed mycotic aneurysm of external carotid artery. The patient underwent a two-week course of a combination of intravenous antibiotics. Follow-up angiography was performed which confirmed successful treatment of mycotic aneurysm of ECA. Mycotic aneurysm of ECA is extremely rare. To our knowledge, this is the first report of mycotic aneurysm of ECA following severe TBI which was successfully treated with antimicrobial therapy.

Epidemiological and Clinical Features of Cervical Column and Cord Injuries; A 2-Year Experience from a Large Trauma Center in Southern Iran

OBJECTIVE

To describe the epidemiological characteristics of patients with cervical spine injury admitted to Rajaee hospital, Shiraz, Iran.

METHODS

This cross-sectional study includes all patients admitted with impression of cervical column injury with or without cervical cord injury from October 2009 to March 2012 to our level I trauma center in Shiraz. We recorded the patients' characteristics including age, sex, marital status, mechanism of injury, level of injury, concomitant injury, treatment(non-operative or operative) and clinical outcome. The data were described and compared with the international literature.

RESULTS

Among 261 patients referred with impression of spinal cord injury, the diagnosis of spinal column injury (with or without spine cord injury) was confirmed in 206 patients. The mean age of patients was 37.2±15.9 years with Male/Female ratio of 3:1. Car turn-over  and car-collisions were the leading causes of injury. The most common spine fracture was C6 vertebra involving 60 (29.1%) patients. Fracture of upper and lower extremities were the most concomitant fractures observed in 31(15.1%) patients. Open surgery was performed in 65(31.6%).Mortality rate was 7.3% (15 patients).Patients with brain, lung and cord injuries had increased risk of death, among 15 deaths,9 patients had brain injury, 5 individuals had lung injury and 10 patients suffered from cord injury.

CONCLUSION

Cervical spine injuries mostly affect young males, and comprise 206 (10%) cases out of 2100 spine injuries in our country. Preventive measures should be taken to reduce cervical spine injuries especially in young age group.

The diminishing trend of β-thalassemia in Southern Iran from 1997 to 2011: the impact of preventive strategies

The marginal zones of the Caspian Sea and the Persian Gulf have a higher prevalence of thalassemia compared to other regions of Iran. This disease has disabled many people and resulted in increasing health care costs. The aim of this study was to assess the incidence of β-thalassemia (β-thal) and to evaluate the outcome of applied preventive strategies over a 14-year period in Fars Province, Southern Iran. This cross-sectional study comprised all new cases of β-thal recorded during 1997-2011. The data were obtained from the Non-Communicable Diseases Surveillance Department of Shiraz University of Medical Sciences, Shiraz, Iran, and are presented as mean ± standard deviation (SD). The Fars Health Network System screened 840 686 males and females applying for marriage certificates. Among the carriers, 50.5% cancelled their marriages, 42.5% married, and 7.0% did not show up at the clinics. The rate of cancelled marriages has reduced since 2000, when marriage candidates were given the option of prenatal diagnosis. From 2000 to 2011, a total of 3539 married couples were referred for prenatal diagnosis. Of these, 806 fetuses were found to carry thalassemia and 800 aborted. It is impressive to note that while 101 cases of thalassemia were recorded in 1997, this figure was reduced to two cases by 2011. This study has established that an integrated primary health care approach, with good infrastructure for implementing successful strategies, can significantly reduce the incidence of β-thal.

Double versus single cervical cerclage for patients with recurrent pregnancy loss: a randomized clinical trial

AIM

To compare the effectiveness of the double cervical cerclage method versus the single method in women with recurrent second-trimester delivery.

METHOD

In this randomized clinical trial, we included 33 singleton pregnancies suffering from recurrent second-trimester pregnancy loss (≥2 consecutive fetal loss during second-trimester or with a history of unsuccessful procedures utilizing the McDonald method), due to cervical incompetence. Patients were randomly assigned to undergo either the classic McDonald method (n = 14) or the double cerclage method (n = 19). The successful pregnancy rate and gestational age at delivery was also compared between the two groups.

RESULTS

The two study groups were comparable regarding their baseline characteristics. The successful pregnancy rate did not differ significantly between those who underwent the double cerclage method or the classic McDonald cerclage method (100% vs 85.7%; P = 0.172). In the same way, the preterm delivery rate (<34 weeks of gestation) was comparable between the two study groups (10.5% vs 35.7%; P = 0.106). Those undergoing the double cerclage method had longer gestational duration (37.2 ± 2.6 vs 34.3 ± 3.8 weeks; P = 0.016).

CONCLUSION

The double cervical cerclage method seems to provide better cervical support, as compared with the classic McDonald cerclage method, in those suffering from recurrent pregnancy loss, due to cervical incompetence.