Current Issue : April - June Volume : 2019 Issue Number : 2 Articles : 7 Articles
Flail chest occur after blunt trauma to the thorax. Most often treatment of\nflail chest is conservative with analgesia and respiratory support, if needed.\nNew plate systems and surgical approaches have improved outcomes after\nsurgery. Surgical treatment of flail chest is associated with a reduced risk of\nsevere pneumonia, shorter time with mechanical ventilation and a reduced\nlength of stay in the Intensive Care Unit (ICU) compared to conservative\ntreatment. However, currently approximately 1% of patients with flail chest\nundergo surgery. We are presenting two cases of flail chest treated surgically\nby fixating the most dislocated posterior fractures. One patient avoided mechanical\nventilation, and the other patient was quickly weaned from respirator\nafter surgery. We found that surgical stabilization of posterior fractures in\npatients with flail chest is a safe method with a high possibility of positive\noutcomes for the patients. Surgical stabilization of flail chest is indicated in\npatients with consistent pain (case 1) and increased risk of pneumonia, respiratory\nfailure or prolonged mechanical ventilation (case 2). Furthermore, it\nwas possible to achieve stable thorax wall by only fixating the most dislocated\nposterior fractures in the flail segment....
Background: We aimed to describe diagnosed acute coronary syndrome (ACS) and its care management and\noutcomes in emergency departments (EDs) and to determine related cardiovascular risk factors (CVRFs).\nMethods: We conducted a cross sectional multicenter study that included 1173 adults admitted to EDs for acute\nchest pain (ACP) in 2015 at 14 sites in Tunisia. Data included patientsâ?? baseline characteristics, diagnosis, treatment\nand output.\nResults: ACS represented 49.7% of non-traumatic chest pain [95% CI: 46.7â??52.6]; 74.2% of ACS cases were unstable\nangina/non-ST-segment-elevation myocardial infarction (UA/NSTEMI). Males represented 67.4% of patients with ACS\n(p < 0.001). The median age was 60 years (IQR 52â??70). Emergency medical service transportation was used in 11.9%\nof cases. The median duration between chest pain onset and ED arrival was two hours (Inter quartile ranges (IQR)\n2â??4 h). The age-standardized prevalence rate was 69.9/100,000 PY; the rate was 96.24 in men and 43.7 in women. In\nthe multivariable analysis, CVRFs related to ST segment elevation myocardial infarction were age correlated to sex\nand active smoking. CVRFs related to UA/NSTEMI were age correlated to sex, familial and personal vascular history\nand type 2 diabetes. We reported 27 cases of major adverse cardiovascular events (20.0%) in patients with STEMI\nand 36 in patients with UA/NSTEMI (9.1%).\nConclusion: Half of the patients consulting EDs with ACP had ACS. Emergency medical service transportation calls\nwere rare. Management delays were acceptable. The risk of developing an UA/NSTEMI was equal to the number of\nCVRFs + 1. To improve patient outcomes, it is necessary to increase adherence to international management\nguidelines....
This work aims to describe a well standardized therapeutic path in reference\nto the article â??Osteopathy and Emergency: A Model of Osteopathic Treatment\nAimed at Managing the Post-Traumatic Stressâ??Part 1 in the form of a\npractical guide for manual therapist , Open Journal of Therapy and Rehabilitation\n, Vol . 10, No. 7, July 2018, https://doi.org/10.4236/health.2018.107074â? .\nThe osteopathic manipulative treatment (OMT) approach we propose can be\ncomplementary to the psychological therapy in use today, and consists of ten\nstandardized techniques directed to the anatomical structures more involved\nin the stress answer. This protocol was designed to improve and sustain the\nmanagement of subjects exposed to extraordinary exogenous stress or\npost-traumatic stress disorder patients (PTSD)....
Patterns of discharge location may be evident based on the â??sicknessâ? profile of the patient. This study sought to evaluate the\nability of the STTGMA tool, a validated mortality risk index for middle-aged and geriatric trauma patients, to predict discharge\nlocation in a cohort of low-energy elderly hip fracture patients, with successful discharge planning measured by readmission rates.\nLow-energy hip fracture patients aged 55 years and older were prospectively followed throughout their hospitalization. On initial\nevaluation in the Emergency Department, each patientâ??s age, comorbidities, injury severity, and functional status were utilized\nto calculate a STTGMA score. Discharge location was recorded with the primary outcome measure of an unsuccessful discharge\nbeing readmission within 30 days. Patients were risk stratified into minimal-, low-, moderate-, and high-risk STTGMA cohorts. A\np-value of <0.05 was considered significant for all statistical tests. 408 low-energy hip fractures were enrolled in the study with\na mean age of 81.3Â}10.6 years. There were 214 (52.5%) intertrochanteric fractures, 167 (40.9%) femoral neck fractures, and 27\n(6.6%) subtrochanteric femur fractures.There was no difference in readmission rates within STTGMA risk cohorts with respect to\ndischarge location; however, among individual discharge locations there was significant variation in readmission rateswhen patients\nwere risk stratified. Overall, STTGMA risk cohorts appeared to adequately risk-stratify readmission with 3.5% of minimal-risk\npatients experiencing readmission compared to 24.5% of moderate-risk patients. Specific cohorts deemed high-risk for readmission\nwere adequately identified.TheSTTGMAtool allows for prediction of unfavorable discharge location in hip fracture patients. Based\non observations made via the STTGMA tool, improvements in discharge planning can be undertaken to increase home discharge\nand to more closely track â??high-riskâ? discharges to help prevent readmissions....
Objective: To retrospectively analyse the use of imaging studies in the Emergency\nDepartment of community hospitals using evidence based guidelines\nand clinical judgement. Methods: Medical records of 661 patients who visited\nthe Emergency Department (ED) in 2015 and underwent imaging studies\nwere reviewed. The Canadian Association of Radiologists, American College\nof Radiologists and Choosing Wisely Canada guidelines were used to determine\nthe appropriateness of imaging studies. The use of prior patient imaging,\nthe rate at which studies were repeated and the respective impacts on patient\nmanagement of the imaging studies were also examined. Results: Of the\n1056 imaging studies reviewed, 228 (22%) were found to be clinical situations\nwhere no imaging study was indicated while 168 (16%) were considered a\nsuboptimal choice of imaging study or modality. When no study was recommended,\na positive impact on the diagnosis was noted in 105 (46%) cases and\non patient management 83 (36%) times. Notably, 219 (21%) patients had a\nrelevant examination performed in the last 30 days, and 147 (14%) reports\nnoted that the results of the prior study also concurred with the imaging\nstudy evaluated. Conclusion: In this study, 228 (22%) radiographs and CT\nstudies, excluding MVC related imaging and extremity imaging, were not indicated\nbased on appropriateness criteria and consequently had a limited impact\non patient management. This supports the need for increased clinical\ndecision support for ED physicians, regional health information exchanges\nand consideration of Computerized Physician Order Entry in the ED with\nembedded appropriateness criteria at the point of ordering....
Background: Secondary insults (SI), such as hypotension, hypoxia, and intracranial hypertension frequently occur\nafter traumatic brain injury (TBI), and have a strong impact on patientsâ?? clinical outcomes. The aim of this study is to\nexamine the trajectories of SI from the early phase of injury in the prehospital setting to hospital admission in a\ncohort of TBI patients.\nMethods: This is a retrospective, observational, single centre study on consecutive patients admitted from 1997 to\n2016 to the Neuro Intensive Care Unit (NICU) at San Gerardo Hospital, in Monza, Italy. Trajectories of SI from the\nprehospital to hospital settings were defined as â??sustainedâ?, â??resolvedâ?, â??new eventâ?, and â??noneâ?. Univariate and\nmultivariate logistic regression analyses were performed to correlate SI trajectories to a 6-months outcome.\nResults: Nine hundred sixty-seven patients were enrolled in the final analysis. About 20% had hypoxic or\nhypotensive events and 30.7% of patients had pupillary abnormalities. Hypotension and hypoxia were associated\nwith an unfavourable outcome when â??sustainedâ? and â??resolvedâ?, while pupillary abnormalities were associated with\na poor outcome when â??sustainedâ? and as â??new eventsâ?. After adjusting for confounding factors, 6-month mortality\nstrongly correlated with â??sustainedâ? hypotension (OR 11.25, 95% CI, 3.52â??35.99), â??sustainedâ? pupillary abnormalities\n(OR 2.8, 95% CI, 1.51â??5.2) and â??new eventâ? pupillary abnormalities (OR 2.8, 95% CI, 1.16â??6.76).\nConclusions: After TBI, sustained hypotension and pupillary abnormalities are important determinants for patientsâ??\noutcomes. Early trajectories define the dynamics of SI and contribute to a better understanding of how early\nrecognition and treatments in emergency settings could impact on 6-month outcomes and mortality....
The traumatic break of the ascending aorta is rare. We bring report the case\nof a 40-year-old man, a victim of accident of the public highway having\ncaused a break of the posterior face of the ascending aorta. The explorations\nscanno graphique and per operating highlighted this break. The treatment\nconsisted of an edge-to-edge direct suture of the ascending aorta....
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