Primary vs delayed primary closure in patients undergoing lower limb amputation following trauma: A randomised control study

Lower limb crush injury is a major source of mortality and morbidity in trauma patients. Complications, especially surgical site infections (SSIs) are a major source of financial burden to the institute and to the patient as it delays rehabilitation. As such, every possible attempt should be made to reduce any complications. We, thus, aimed to compare the outcomes in early vs delayed closure of lower extremity stumps in cases of lower limb crush injury requiring amputation, so as to achieve best possible outcome. A randomised controlled study was conducted in the Division of Trauma Surgery & Critical Care at Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi from 1 September 2018 to 30 June 2019 and included patients undergoing lower limb amputation below hip joint. Patients were randomised in two groups, in one group amputation stump was closed primarily, while in the second group delayed primary closure of stump was performed. We compared rate of SSI, length of hospital stay, and number of surgeries in both the groups. Fifty-six patients with 63 amputation stumps were recruited in the study. Mean age of patients in the study was 34 years, of which about 95% patients were males. The most common mechanism of injury was road traffic injury in 66% of patients. Mean injury severity score was 12.28 and four patients had diabetes preoperatively. Total 63 extremities were randomised with 30 cases in group I and 33 cases in group II as per computer-generated random number. Above knee amputations was commonest (57.14%) followed by below knee amputations (33.3%). Two patients died in the current study. In group I, In-hospital infection was detected in 7 cases (23.3%) and in group II 9 cases (27.3%) had SSI during hospital admission (P > .05). Mean hospital stay in group I was 10.32 ± 7.68 days and in group II was 11 ± 8.17 days (P > .05). Road traffic injuries and train-associated injuries are a major cause of lower limb crush injuries, leading to limb loss. Delayed primary closure of such wounds requires extra number of surgical interventions than primary closure. There is no difference in extra number of surgical interventions required in both the groups. Thus, primary closure can be safely performed in patients undergoing lower limb amputations following trauma, provided that a good lavage and wound debridement is performed.

Anti-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) antibody in necrotizing myopathy: treatment outcomes, cancer risk, and role of autoantibody level

Objective: To evaluate clinical associations of anti-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) antibody (Ab) and statin exposure in necrotizing myopathy (NM) patients. Methods: NM without a known myositis-specific autoantibody (MSA) was ascertained from a large single-centre myositis database between 1985 and 2012. A comparison NM cohort included 32 anti-SRP⁺ autoantibody patients, and other control groups included 74 non-NM myositis patients and 21 non-myositis controls. Sera from all cases and controls were tested using a validated anti-HMGCR enzyme-linked immunosorbent assay. Clinical features including statin use and anti-HMGCR Ab status were compared between cases and controls. Results: Of the 256 NM muscle biopsies reviewed, only 48 subjects with available sera were identified as traditional MSA-negative NM. Anti-HMGCR positivity was significantly (p < 0.001) associated with MSA-negative NM [48% (23/48)] compared to all of the myositis and non-myositis controls [5% (6/127)]. Most anti-HMGCR Ab-positive NM patients had high titres of anti-HMGCR (83%) and a history of statin exposure (78%), along with severe muscle weakness, high creatine kinase (CK) levels (90% ≥ 5000 IU/L), a paucity of other organ manifestations, and the need for immunosuppression with prednisone and methotrexate, but generally favourable outcomes. Anti-HMGCR serum levels were associated with baseline CK levels but not muscle weakness. Conclusion: HMGCR Ab-positive NM patients are associated with statin exposure, have severe muscle weakness and high CK at presentation, lack other organ manifestations, and generally have favourable outcomes from immunosuppression. Anti-HMGCR Abs should be assessed in MSA-negative NM patients, particularly those with a history of statin exposure.

Atypical presentation of thyroid storm: a diagnostic dilemma

Thyroid storm (accelerated hyperthyroidism) is an uncommon life-threatening emergency. The diagnosis is difficult and at times delayed owing to atypical presentation. Early diagnosis is the key to its successful management. We came across a patient who had presentations of acute abdomen but later diagnosed in thyroid storm. Multiorgan involvement leads all resuscitative measures futile and prevented us to salvage the patient.

Prone Positioning for Management of Fat Embolism Syndrome in a Patient with Spine Fracture; An Unusual Scenario and Review of Literature

Fat embolism syndrome is a rare but fatal complication seen commonly in patients with polytrauma. Its earliest manifestation is hypoxemia due to deposition of fat globules in pulmonary circulation which can progress to severe acute respiratory distress syndrome, the treatment of which is mainly supportive. We describe the case of a 17-year-old male who was admitted in our intensive care unit (ICU) for severe hypoxemia due to fat embolism. He had burst fracture of 5th lumbar vertebra with canal compromise along with other fractures. Failing conventional ventilation, the patient was placed in prone position taking proper precautions in positioning giving due consideration to his unstable lumbar spine. There was no neurological insult and in the next two days, he was weaned off from the ventilator. Though prone position is relatively contraindicated in patients with unstable spine, we employed early prone positioning taking adequate precautions, the benefit of which we believe outweighed the risk.

Clinical characteristics and management of patients with fat embolism syndrome in level I Apex Trauma Centre

PURPOSE

Fat embolism syndrome (FES) is systemic manifestation of fat emboli in the circulation seen mostly after long bone fractures. FES is considered a lethal complication of trauma. There are various case reports and series describing FES. Here we describe the clinical characteristics, management in ICU and outcome of these patients in level I trauma center in a span of 6 months.

METHODS

In this prospective study, analysis of all the patients with FES admitted in our polytrauma intensive care unit (ICU) of level I trauma center over a period of 6 months (from August 2017 to January 2018) was done. Demographic data, clinical features, management in ICU and outcome were analyzed.

RESULTS

We admitted 10 cases of FES. The mean age of patients was 31.2 years. The mean duration from time of injury to onset of symptoms was 56 h. All patients presented with hypoxemia and petechiae but central nervous system symptoms were present in 70% of patients. The mean duration of mechanical ventilation was 11.7 days and the mean length of ICU stay was 14.7 days. There was excellent recovery among patients with no neurological deficit.

CONCLUSION

FES is considered a lethal complication of trauma but timely management can result in favorable outcome. FES can occur even after fixation of the fracture. Hypoxia is the most common and earliest feature of FES followed by CNS manifestations. Any patient presenting with such symptoms should raise the suspicion of FES and mandate early ICU referral.

Does Real Time Ultrasonography Confer Any Benefit During Bronchoscopy Guided Percutaneous Tracheostomy: A Preliminary, Randomized Controlled Trial

Background

There are studies comparing USG guided percutaneous dilatational tracheostomy (PDT) with bronchoscopy guided PDT. We have compared USG guided PDT to conventional landmark guided PDT using bronchoscopy in both the groups.

Objective

The primary outcome was the time of procedure and the secondary outcome was incidence of complications in USG guided PDT in comparision to the conventional PDT.

Materials and Methods

Seventy adult patients were randomly allocated in two groups, i.e., conventional landmark percutaneous dilatational tracheostomy (PDT) and ultrasonography (USG) guided PDT. Demographic data, injury severity score, time taken for the procedure, attempts of tracheal puncture, major and minor complications, and outcome were compared.

Results

The median time taken for the procedure was 12 minutes [min., max.; 8, 20] in conventional group 1 and 16 minutes [9, 24] in group 2 (USG guided) which was statistically significant. Minor bleeding was seen in 7 (20%) patients in group 1 and only in 4 patients (11.5%) in group 2. The rate of other complications and the long term outcome were similar in both the groups.

Conclusion

The use of real time USG during PDT may confer advantage over conventional PDT when using bronchoscopy in terms of decreasing the incidence of minor bleeding but duration of the procedure gets prolonged.

How to cite this article

Aggarwal R, Soni KD, Goyal K, Singh GP, Sokhal N, Trikha A. Does Real Time Ultrasonography Confer Any Benefit During Bronchoscopy Guided Percutaneous Tracheostomy: A Preliminary, Randomized Controlled Trial. Indian J Crit Care Med 2019;23(5):236–238.

Impact of monocytic cytokines in polytrauma patients with orthopedics injures

OBJECTIVE

Orthopedic injuries are a growing epidemic affecting predominantly, the young population, after trauma. Polytrauma patients with a femoral fracture and with Injury Severity Score of >15 are of special concern because of complications like Systemic inflammatory response syndrome (SIRS), Multi-organ dysfunction syndrome (MODS) and sepsis. Against this background. We aimed to assess the role of monocytic cytokines in the development of complications in patients, having isolated diapheseal fracture of femur as compared to those having diapheseal fracture of femur along with ISS score >15.

METHODOLOGY

Patients were divided into to two groups: in first group, only those patients who had isolated femur fracture were included (named as 'Group A'). In the second groups patients having femur fracture along with ISS >15 at the time of admission (named as 'Group B'), were included. The study used flowcytometry based intracellular cytokine assay to circumvent the problem associated with extracellular cytokine assay.

RESULTS AND CONCLUSION

A total of 20 patients aged between 20 and 55 years, presenting to the emergency department within 24 h of injury were enrolled in Group 'A' and 'B' as per criteria mentioned above. Intracellular expression of cytokines in isolated femur fracture tends to normalize towards healthy control in the late phase of trauma. Elevated levels of IL-8 and IL-6 levels in late phase (Day 10) of trauma. IL-8 and IL-6 may increases to compensate the higher levels of IL-1β. The effect of cytokines on the severity of injury was observed. This complex action of immune cells and proinflammatory cytokines were seen in initial and later stage of trauma.

Understanding the effect of nanowire orientation on time evolution of Raman spectra from laser irradiated InAs nanowire surface

We investigate differences observed in the time evolution of Raman spectra for differently oriented (in plane) InAs nanowires (NWs), using polarized Raman spectroscopy. Specially designed polarized Raman spectroscopy experiments elucidate that laser irradiation leads to the formation of an oriented crystalline oxide film on the InAs NW surface. Both the formation of oriented crystalline oxides and Raman selection rules leading to the presence/absence of oxide peaks in the unpolarized Raman spectra are uncommon occurrences and can lead to incorrect interpretations of the oxidation process, if not looked into carefully. Further, the specially designed heating and cooling experiments for a mixed phase (wurtzite + zinc blende) InAs NW revealed the formation of specific allotropes of elemental As, i.e. gray-As (rhombohedral) and black-As (orthorhombic: metastable) at low (700-950 K) and high simulated temperatures (1000-1300 K) on the InAs NW surface, respectively. Both have high electrical conductivity due to a layered structure and control over the growth of only a few layers using laser irradiation envisages properties similar to graphene. This kind of surface of InAs NWs has the potential for novel device applications, where a semiconductor-insulator-metal heterostructure is required.

Challenges in Management of Pediatric Life-threatening Neck and Chest Trauma

Introduction:

Neck and thoracic trauma in children pose unforeseen challenges requiring variable management strategies. Here, we describe some unusual cases.

Patients and Methods:

Pediatric cases of unusual neck and thoracic trauma prospectively managed from April 2012 to March 2014 at a Level 1 trauma center were studied for management strategies, outcome, and follow-up.

Results:

Six children with a median age of 5.5 (range 2–10) years were managed. Mechanism of injury was road traffic accident, fall from height and other accidental injury in 2, 3 and 1 patient respectively. The presentation was respiratory distress and quadriplegia, exposed heart, penetrating injury in neck, dysphagia and dyspnea, and swelling over the chest wall in 1, 1, 1, 2 and 1 cases respectively. Injuries included lung laceration, open chest wall, vascular injury of the neck, tracheoesophageal fistula (2), and chest wall posttraumatic pyomyositis. One patient had a flare of miliary tuberculosis. Immediate management included chest wall repair; neck exploration and repair, esophagostomy, gastroesophageal stapling, and feeding jejunostomy (followed by gastric pull-up 8 months later). Chest tube insertion and total parenteral nutrition was required in one each. 2 and 4 patients required tracheostomy and mechanical ventilation. The patient with gastric pull-up developed a stricture of the esophagogastric anastomosis that was revised at 26-month follow-up. At follow-up of 40–61 months, five patients are well. One patient with penetrating neck injury suffered from blindness due to massive hemorrhage from the vascular injury in the neck and brain ischemia with only peripheral vision recovery.

Conclusion:

Successful management of neck and chest wall trauma requires timely appropriate decisions with a team effort.

Colistin-resistant Klebsiella pneumoniae in Surgical Polytrauma Intensive Care Unit of Level-1 Trauma Center: First Case Series from Trauma Patients in India

Introduction:

There have been isolated case reports and reports of outbreak of colistin-resistant Klebsiella from various parts of the world but only two from India and that too from oncology centers. We report cluster of colistin-resistant Klebsiella pneumonia bloodstream infection cases from our surgical trauma Intensive Care Unit.

Methodology:

The study was carried out in surgical ICU of Level-I trauma center. Retrospective analysis of all the five patients with CRK was done. Demographic data, antibiotic exposure throughout the hospital stay, hospital course, and clinical outcome were analyzed.

Results:

Out of 5 patients, 4 were young males (mean age of 23.5 years) without comorbidities and had undergone exploratory laparotomy following blunt trauma abdomen. 3 patients were chronic patients and had been on carbapenem and colistin 11–20 days before isolation whereas 2 patienst had isolation of CRK just within 7 days of admission. Out of the five patients, 3 patients survived and 2 had fatal outcome.

Conclusions:

CRK is an emerging and challenging pathogen in polytrauma victims. There was an outbreak of CRK in our ICU that could be contained with infection control measures.

Percutaneous dilatational tracheostomy through paramedian technique and lateral approach in a patient with cervical esophagostomy-a case report

BACKGROUND

Percutaneous dilatational tracheostomy (PDT) is a common surgical procedure and established as first choice for securing the airway in critically ill patients needing prolonged mechanical ventilation. There are case reports of open tracheostomy through paramedian approach without complications. This case report presents a case of PDT through paramedian approach.

CASE REPORT

An 18 year old female, case of firearm injury underwent cervical esophagostomy on the left side of neck approaching midline. So we perform PDT through paramedian technique and lateral approach safely with use of real time ultrasound and fiberoptic bronchoscope.

DISCUSSION

PDT can be done through paramedian technique and lateral approach to trachea safely with help of ultrasound and fiberoptic bronchoscope in the conditions where midline approach is not feasible and unsafe.