[Emergency room management : in the era of the White Paper, S3 guidelines, Advanced Trauma Life Support® and TraumaNetwork DGU® of the German Society of Trauma Surgery]

A Case of Symmetrical Bilateral Bifocal Femur Fracture with Bilateral Patella Fracture - A Case Report!

Introduction

Bilateral bifocal femur fractures occur as a result of high-velocity trauma mainly road traffic accidents with dashboard injuries or fall from height. These fractures can result in high morbidity or mortality as they are usually presented with hypovolemic shock or fatal fat embolism syndrome.

Case Report

We present a 47-year-old male with a history of fall from 35 feet. He sustained a symmetrical intertrochanteric femur fracture with a diaphyseal femur fracture with a bilateral patella fracture. There was no evidence of any head injury or spinal fracture. The patient reached the emergency room in hypotension and was maintaining saturation on room air. The patient was admitted to the intensive care unit; hypotension was corrected overnight and was operated on after 24 h with bilateral intramedullary long proximal femoral nail and tension band wiring for the bilateral patella fractures. At 1-year follow-up, he was able to do his daily activities with minimal limitation.

Conclusion

Bilateral bifocal femur fractures result from a high-velocity trauma. In such injuries, careful evaluation of all the systems should be performed to find out concomitant injuries. Single-staged surgical intervention decreases the morbidities of the subsequent surgeries, helps in a rehabilitation hospital stay as well as financially suitable for the patient.

Mechanical Injury among Medicolegal Cases in the Department of Emergency in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction

A medico-legal issue arises whenever an injured person visits a hospital. Therefore, all physicians who treat such patients have a legal duty to accurately document injuries as part of medical treatment. The study aimed to find out the prevalence of mechanical injury among medicolegal cases in the Department of Emergency in a tertiary care centre.

Methods

A descriptive cross-sectional study was conducted among patients admitted to the Emergency Department of a tertiary centre from May 2018 to April 2020 after obtaining ethical approval from the Institutional Review Committee (Reference number: 356). Convenience sampling method was used among patients who met the eligibility criteria. All relevant data were extracted using hospital records. Point estimate and 95% Confidence Interval were calculated.

Results

Out of 3486 medicolegal cases registered in the Department of Emergency, 856 (24.55%) (28.37-29.96 at 95% Confidence interval) were cases of mechanical injuries. Males 616 (71.96%) outnumbered females for all types of mechanical injuries. Road Traffic Accident 527 (61.56%) was the leading cause of injury and lacerations 351 (29.52%) were the most common pattern of injury. The majority 628 (73.36%) of the injuries were simple in nature.

Conclusions

The prevalence of mechanical injuries among medicolegal cases was similar in our study compared to other studies done in similar settings. The majority of the injuries were caused by traffic accidents, which could have been prevented if a safe system approach to road safety was followed.

Keywords

accidents; documentation; forensic medicine; injuries; Nepal.

[Resuscitation room diagnostics]

CLINICAL PROBLEM

The indication for resuscitation room care is an acute (potentially) life-threatening patient condition. Typical causes for this are polytrauma, acute neurological symptoms, acute chest and abdominal pain or the cause remains unclear at first. The care is always provided in a suitably composed interdisciplinary team. This requires cause-specific standards tailored to the care facility and requires a mutual understanding of the partners involved with regard to specialist interests and care processes.

STANDARD RADIOLOGICAL METHODS

Whole-body CT is established for polytrauma imaging and usually each institution has already defined an institutional standard. For the other causes, first imaging with CT is just as common, but the protocols and procedures to be used are often not as clear as in the case of polytrauma.

METHODICAL INNOVATION AND EVALUATION

For polytrauma service, ATLS and procedures according to ABCDE already serve as a largely standardized framework in the resuscitation room. For every other group of causes, comparable concepts should be developed and institutionally strive for objectification of continuous improvement. This refers not only to the resuscitation room stay but also to the interfaces before and after resuscitation room service.

PRACTICAL RECOMMENDATIONS

After the patient has arrived, it has to be determined whether the assessment of a vital risk is retained. If so, institutionally defined care standards must be followed for the various causes. This concerns the interface logistics, the definition of a team leader including associated tasks, the supply processes including the CT examination protocols as well as the close communication.

A Systematic Review of Neuroprotective Strategies during Hypovolemia and Hemorrhagic Shock

Severe trauma constitutes a major cause of death and disability, especially in younger patients. The cerebral autoregulatory capacity only protects the brain to a certain extent in states of hypovolemia; thereafter, neurological deficits and apoptosis occurs. We therefore set out to investigate neuroprotective strategies during haemorrhagic shock. This review was performed in accordance to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Before the start of the search, a review protocol was entered into the PROSPERO database. A systematic literature search of Pubmed, Web of Science and CENTRAL was performed in August 2017. Results were screened and evaluated by two researchers based on a previously prepared inclusion protocol. Risk of bias was determined by use of SYRCLE’s risk of bias tool. The retrieved results were qualitatively analysed. Of 9093 results, 119 were assessed in full-text form, 16 of them ultimately adhered to the inclusion criteria and were qualitatively analyzed. We identified three subsets of results: (1) hypothermia; (2) fluid therapy and/or vasopressors; and (3) other neuroprotective strategies (piracetam, NHE1-inhibition, aprotinin, human mesenchymal stem cells, remote ischemic preconditioning and sevoflurane). Overall, risk of bias according to SYRCLE’s tool was medium; generally, animal experimental models require more rigorous adherence to the reporting of bias-free study design (randomization, etc.). While the individual study results are promising, the retrieved neuroprotective strategies have to be evaluated within the current scientific context—by doing so, it becomes clear that specific promising neuroprotective strategies during states of haemorrhagic shock remain sparse. This important topic therefore requires more in-depth research.

[Emergency room management of multiple trauma : ATLS® and S3 guidelines]

Trauma management in the emergency room is an important part of the treatment chain of the severely injured. Important decisions with respect to diagnostics and treatment must be made under time pressure. Successful trauma management in the emergency room requires a hospital tailored treatment protocol. This written protocol needs consent from all participating disciplines and must be known by all members of the resuscitation team. The ATLS® and the recently published clinical practice guidelines on multiple trauma can be of help in order to establish or update such protocols. In order to continuously evaluate and improve performance in the emergency room local quality circles are needed that truly follow that aim. Important factors are reliability of agreement between the different disciplines and continuous communication of results to the team members. In order to be successful such quality circles need people that care.