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   Table of Contents - Current issue
Coverpage
October-December 2018
Volume 8 | Issue 4
Page Nos. 181-217

Online since Tuesday, December 18, 2018

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EDITORIAL  

What's new in critical illness and injury science? The association between initial blood alcohol concentration and polysubstance use may be indicative of a gateway drug effect p. 181
Victor R Davila, David L Stahl, Sujatha P Bhandary, Thomas J Papadimos
DOI:10.4103/IJCIIS.IJCIIS_80_18  
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ORIGINAL ARTICLES Top

Caregivers satisfaction with intensive care unit services in tertiary care hospital p. 184
Ramappa M Thimmapur, Prabhu Raj, Birudu Raju, TR Kanmani, N Krishna Reddy
DOI:10.4103/IJCIIS.IJCIIS_25_18  
Background: Caregivers play a vital role in intensive care unit (ICU) because critically ill patients cannot make their own decisions due to their illness. Measuring family satisfaction on quality of ICU care is essential. Hence, the current paper aimed to measure the family caregiver satisfaction in ICU care in tertiary care hospital. Methods: The study adopted descriptive research design conducted from July 2016 to January 2017 at ICU in Emergency and Trauma Care center. A total number of 60 consented caregivers were recruited. An Internationally validated Family satisfaction survey questionnaire (FS) was used. Continuous variables of the data were described by mean standard deviation and categorical variables by frequency (%). Normality of the continuous variables was checked by Shapiro–Wilk test. Kruskal–Wallis test was used to compare the average FS score between the groups. Results: Results showed that caregiver age was ranged between 25 and 66 years with mean age 40 (±19). Among the caregivers, 75% were male and 25% were female of which 75% were married and remaining were unmarried. Around half of the caregivers (48.3) were educated up to primary or secondary and 26.7% had higher secondary education level. About 46.7% involved in manual laborers and 36.7% were working in the private sector. Family members had taken primary caregiving role without prior experience (81.7%) at ICU. Almost 95% of the caregivers were highly satisfied with ICU care and only 5% were not satisfied. Conclusion: Majority of caregivers are satisfied with ICU care. However, adequate measures need to be taken to ensure the complete satisfaction among caregivers at ICU.
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Knowledge, attitude, and clinical skill of emergency medical technicians from Tehran emergency center in trauma exposure p. 188
Khosro Shakeri, Masoud Fallahi-Khoshknab, Hamidreza Khankeh, Mohammadali Hosseini, Mohammad Heidari
DOI:10.4103/IJCIIS.IJCIIS_33_18  
Introduction: Prehospital care is the first part of the trauma treatment and care system. Diagnostic and therapeutic measures taken before these patients arrive at the hospital plays significantly reduce mortality and improve their outcomes. Therefore, the present study aimed to determine the knowledge, attitude, and clinical skill of emergency medical technicians in Tehran Emergency Center in trauma exposure. Methods: In this descriptive study, 213 participants were selected through stratified random sampling. Data were collected using a four-part questionnaire including demographic information, trauma knowledge questionnaire, trauma attitude questionnaire, and a clinical skill checklist. To compare the level of knowledge, attitude, and clinical skills on the one hand and demographic variables, on the other hand, independent samples t-test and one-way ANOVA were utilized. Then, to examine the normality of data distribution, Kolmogorov–Smirnov test with Bonferroni post hoc test was used to compare mean scores on different levels of the variables in questionnaires. Data were analyzed in SPSS/17 using descriptive and inferential statistics. Results: Results showed that the majority of participants (81.1%) had an average knowledge of trauma. Examining their attitude regarding trauma revealed that the majority (88.3%) had a positive attitude toward trauma and taking care of trauma patients. Moreover, the skill of 62.4% of technicians regarding trauma was good. Based on Pearson's correlation, significant positive correlations existed between scores of knowledge and scores of attitude (r = 0.186, P < 0.05), scores of knowledge and scores of clinical skill (r = 0.333, P < 0.05), and scores of attitude and scores of clinical skill (r = 0.258, P < 0.05). Conclusion: According to the results, emergency medical technicians in Tehran had a good level of knowledge, attitude, and clinical skills in trauma exposure. However, to maintain and enhance the level of knowledge and skills, in-service training should be continued more vigorously and periodically evaluated in the clinical practice.
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Assessment of acute kidney injury in neurologically and traumatically injured intensive care patients receiving large vancomycin doses p. 194
Casey C May, Beth L Erwin, Margaret Childress, Josh Cortopassi, Garrett Curtis, Tyson Kilpatrick, Jennifer Taylor, Bonnie Vance, Doug Wylie
DOI:10.4103/IJCIIS.IJCIIS_39_18  
Background: Previous reports note that in a mixed patient population, vancomycin doses >4 g/day are associated with increased rates of acute kidney injury (AKI). Objective: The objective of the study is to determine if vancomycin regimens >4 g/day are associated with a higher incidence of AKI in neurocritical care unit (NCCU) and trauma/burn Intensive Care Unit (TBICU) patients. Materials and Methods: This single-centered, retrospective study enrolled adult patients initiated on vancomycin in the NCCU and TBICU at an academic medical center during 2016. Based on maximum steady-state dose exposure, patients were separated into two groups: ≤4 g/day and >4 g/day. The primary outcome of incidence of AKI was defined by the AKI Network criteria. Results: A total of 284 patients were screened for eligibility; 165 patients met inclusion criteria, 98 patients received ≤4 g/day and 67 patients received >4 g/day. The >4 g/day group had a lower mean age (32.6±11.1 vs. 47.8±16.2, P < 0.001), included more male patients (81% vs. 60%, P = 0.008), were more often treated for a central nervous system infection (31% vs. 11%, P = 0.001), had, on average, more concomitant use of nephrotoxic drugs (2.2±1.2 vs. 1.8±0.9, P = 0.02) and had a higher exposure to contrast (94% vs. 79%, P < 0.001). The primary outcome of AKI occurred in 14 patients receiving ≤4 g/day and five patients receiving >4 g/day which was not statistically significant (14% vs. 7%, P = 0.22). Conclusions: Our results indicate that administering >4 g/day of vancomycin to achieve therapeutic vancomycin troughs does not appear to lead to an increased incidence of AKI in a mixed NCCU and TBICU population.
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Exploring the association between initial serum alcohol concentration and polysubstance use: More than a simple “gateway drug” effect? p. 201
Ashley Jordan, Philip Salen, Thomas R Wojda, Marissa S Cohen, Aliaskar Hasani, Joshua Luster, Jacqueline Seoane, Stanislaw P Stawicki, Holly Stankewicz
DOI:10.4103/IJCIIS.IJCIIS_65_18  
Introduction: Polysubstance abuse (PSA) is a significant problem affecting our society. In addition to negatively affecting the health and well-being of substance users, alcohol and/or drug abuse is also associated with heavy injury burden. The goal of this study was to determine if elevated serum alcohol (EtOH) levels on initial trauma evaluation correlate with the simultaneous presence of other substances of abuse (SOAs). We hypothesized that PSA would be more common among patients who present with EtOH levels in excess of the legal blood alcohol content (BAC) (≥0.10%). Methods: An audit of trauma registry records from January 2009 to June 2015 was performed. Abstracted data included patient demographics, BAC measurements, all available formal determinations of urine/serum “drug screening,” Glasgow Coma Scale (GCS) assessments, injury mechanism/severity, and 30-day mortality. Stratification of BAC was based on the 0.10% cutoff. Parametric and nonparametric statistical testing was performed, as appropriate, with significance set at α = 0.05. Results: We analyzed 1550 patients (71% males, mean age: 38.7 years) who had both EtOH and SOA screening. Median GCS was 15 (interquartile range [IQR]: 14–15). Median ISS was 9 (IQR: 5–17). Overall 30-day mortality was 4.25%, with no difference between elevated (≥0.10) and normal (<0.10) EtOH groups. For the overall study sample, the median BAC was 0.10% (IQR: 0–0.13). There were 1265 (81.6%) patients with BAC <0.10% and 285 (18.4%) patients with BAC ≥0.10%. The two groups were similar in terms of mechanism of injury (both, ~95% blunt). Patients with BAC ≥0.10% on initial trauma evaluation were significantly more likely to have the findings consistent with PSA (e.g., EtOH + additional substance) than patients with BAC <0.10% (377/1265 [29.8%] vs. 141/285 [49.5%], respectively, P < 0.001). Among polysubstance users, BAC ≥0.10% was significantly associated with cocaine, marijuana, and opioid use. Conclusions: This study confirms that a significant proportion of trauma patients with admission BAC ≥0.10% present with the evidence of additional substance use. Cocaine and opioids were most strongly associated with acute alcohol intoxication. Our findings support the need for further research in this important area of public health concern. In addition, specific efforts should focus on primary identification, remediation of withdrawal symptoms, prevention of drug-drug interactions, and early PSA intervention.
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CASE REPORTS Top

Osborne waves in the hot summer p. 207
Modupeola Diyaolu, Ted Shaub, Michael S Firstenberg
DOI:10.4103/IJCIIS.IJCIIS_59_18  
Osborn waves are produced when the J-point deviates from baseline. While there are many known causes of Osborne waves, hypothermia remains the most common. Previous studies have been inconsistent about the risk of Osborne waves progressing to a deadly arrhythmia. Commonly, once patients are rewarmed, they no longer exhibit Osborne waves or experience cardiac arrhythmias. This patient presented with hypothermia on a hot, humid August day demonstrating two factors known to cause Osborne waves – hypothermia and hypocalcemia. While replenishing the calcium was beneficial, providing ventilator support and active rewarming remained the mainstays of treatment.
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Pneumoscrotum: Value as an early diagnostic sign of tension pneumothorax in blunt thoracic trauma p. 210
Ammar Humayun, Louis F Chai, Matthew E Pontell, Marcin A Jankowski
DOI:10.4103/IJCIIS.IJCIIS_52_18  
Pneumoscrotum is a rare complication that can result from various etiologies and can be essential in the diagnosis of those causative factors, especially life-threatening ones such as infection or trauma. We present here a case of a patient who presented in posttraumatic cardiac arrest and an extensive, grossly obvious, and rapidly expanding pneumoscrotum. Based on our patient's clinical presentation and a history of a high-speed mechanism with obvious torso trauma, a diagnosis of tension pneumothorax was quickly made resulting in immediate treatment. We review the existing literature and highlight the importance of pneumoscrotum in aiding with differential diagnosis. The presence of pneumoscrotum is often benign; however, in the right clinical setting, it can be an extremely important and useful clinical tool for the early identification and timely treatment of life-threatening diagnoses, such as tension pneumothorax.
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CLINICAL IMAGE: REPUBLICATION Top

Critical aortic stenosis p. 214
Robert D Cooper, Julian Macedo, David P Bahner
DOI:10.4103/IJCIIS.IJCIIS_79_18  
A case of a 52-year-old male with ventricular tachycardia and atrial fibrillation associated with aortic stenosis is outlined. Focused cardiac ultrasound images obtained in the emergency department are presented. A discussion of aortic stenosis and emergency ultrasound in the above clinical context is included. Republished with permission from: Cooper RD, Macedo J, Bahner DP. Bedside sonography primer: Critical aortic stenosis. OPUS 12 Scientist 2011;5:11-2.
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LETTER TO THE EDITOR Top

Lethal cardiac tamponade after misplacement of a dialysis catheter p. 216
Jenna Elizabeth Zauk, Thomas John Papadimos
DOI:10.4103/IJCIIS.IJCIIS_18_18  
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