Rapid sequence induction (RSI) in trauma patients:Insights from healthcare providers / 世界急诊医学杂志（英文）

BACKGROUND@# We aimed to describe the current practice of emergency physicians and anaesthesiologists in the selection of drugs for rapid-sequence induction (RSI) among trauma patients.@*METHODS@# A prospective survey audit was conducted based on a self-administered questionnaire among two intubating specialties. The preferred type and dose of hypnotics, opioids, and muscle relaxants used for RSI in trauma patients were sought in the questionnaire. Data were compared for the use of induction agent, opioid use and muscle relaxant among stable and unstable trauma patients by the intubating specialties.@*RESULTS@#A total of 102 participants were included; 47 were anaesthetists and 55 were emergency physicians. Propofol (74.5%) and Etomidate (50.0%) were the most frequently used induction agents. Significantly higher proportion of anesthesiologist used Propofol whereas, Etomidate was commonly used by emergency physicians in stable patients (P=0.001). Emergency physicians preferred Etomidate (63.6%) and Ketamine (20.0%) in unstable patients. The two groups were comparable for opioid use for stable patients. In unstable patients, use of opioid differed significantly by intubating specialties. The relation between rocuronium and suxamethonium use did change among the anaesthetists. Emergency physicians used more suxamethonium (55.6% vs. 27.7%, P=0.01) in stable as well as unstable (43.4 % vs. 27.7%, P=0.08) patients.@*CONCLUSION@# There is variability in the use of drugs for RSI in trauma patients amongst emergency physicians and anaesthesiologists. There is a need to develop an RSI protocol using standardized types and dose of these agents to deliver an effective airway management for trauma patients.

Descriptive analysis of right and left-sided traumatic diaphragmatic injuries; case series from a single institution

Objective: To investigate the presentation, management and outcomes of left and right-sided traumatic diaphragmatic injury [TDI] in a single level I trauma center

Methods: This cross-sectional study was conducted during a 7-year period from 2008 to 2015 in a level I trauma center in Qatar. We included all the patients who presented with TDIs during the study period. Data included demographics, mechanism of injury, associated injuries, initial vitals, emergency department disposition, length of ICU and hospital stay, ventilator days, management, and outcomes. The variables were analyzed and compared for patients with left [LTDI] and right [RTDI]

Results: A total of 52 TDI cases [79% LTDI and 21% RTDI] were identified with a mean age of 31 +/- 11. LTDI patients were more likely to have higher Injury severity scores [p=0.50] and greater AAST organ injury scoring [p=0.661 for all] than RTDI patients. Surgical repair was performed for 85% LTDI vs. 73% RTDI [p=0.342]. Recurrent DIs was reported only in LTDI [5.1% vs. 0.0%; p=0.911]. Twelve patients died [9 LTDI and 3 RTDI], of them 5 had associated head injury

Conclusion: This single-institution study confirms that LTDI are more commonly diagnosed than RTDI. Exploratory laparotomy is the most frequent procedure considered for the management of diaphragmatic injuries in the emergency settings. To improve outcomes in patients presenting with TDI, large prospective multicenter studies are needed to standardize the TDI management protocols including the diagnostic workup, timing of surgical intervention, and the most appropriate approach of treatment

Khat use: history and heart failure

Recent reports suggest that 20 million people worldwide are regularly using khat as a stimulant, even though the habit of chewing khat is known to cause serious health issues. Historical evidence suggests khat use has existed since the 13[th] century in Ethiopia and the southwestern Arabian regions even before the cultivation and use of coffee. In the past three decades, its availability and use spread all over the world including the United States and Europe. Most of the consumers in the Western world are immigrant groups from Eastern Africa or the Middle East. The global transport and availability of khat has been enhanced by the development of synthetic forms of its active component. The World Health Organization considers khat a drug of abuse since it causes a range of health problems. However, it remains lawful in some countries. Khat use has long been a part of Yemeni culture and is used in virtually every social occasion. The main component of khat is cathinone, which is structurally and functionally similar to amphetamine and cocaine. Several studies have demonstrated that khat chewing has unfavorable cardiovascular effects. The effect on the myocardium could be explained by its effect on the heart rate, blood pressure, its vasomotor effect on the coronary vessels, and its amphetamine-like effects. However, its direct effect on the myocardium needs further elaboration. To date, there are few articles that contribute death among khat chewers to khat-induced heart failure. Further studies are needed to address the risk factors in khat chewers that may explain khat-induced cardiotoxicity, cardiomyopathy, and heart failure

Clinical presentation, management, and outcome of patients with incidental renal angiomyolipoma in Qatar

Our study aimed to analyze the clinical presentation, management, and outcome of renal angiomyolipoma patients incidentally detected upon computed tomography [CT] examination. Between 2004 and 2008, all patients who underwent abdominal CT examination for any reason at the radiology department at Hamad General Hospital, Qatar were retrospectively reviewed. The diagnosis of renal angiomyolipoma was based on abdominal CT evaluation. Angiomyolipoma patients were followed-up by CT evaluation as per standard care for three years to observe any change in size and outcome. A total of 13,115 patients were screened, of which 56 [40 females and 16 males] had renal angiomyolipoma. The mean age of patients was 52 +/- 13 years with 46% Qatar nationals. The majority [95%] of cases had unilateral tumors [52% right-sided and 43% left-sided]. Twenty-six cases showed increase in tumor size and the median increase was 0.5cm [0.1-3.6]. Surgical intervention was required in four [7%] cases with tumor size >/=4cm. The overall mortality on follow-up was 7%. The cause of death included metastasis, renal failure, hepatic failure and mesenteric thromboembolism. Renal angiomyolipoma is an uncommon benign tumor with an overall prevalence of 0.4% in Qatar. It has characteristic clinical features and its recognition is often challenging for proper clinical diagnosis and treatment in asymptomatic patients. Asymptomatic patients need regular radiological surveillance. In contrast, surgical interventions are mainly required in symptomatic patients with increased tumor size [>/=4cm]. Timely diagnosis and treatment is necessary to avoid complications such retroperitoneal hemorrhage and renal impairment

Predictors of reintubation in trauma intensive care unit: Qatar experience

To determine the causes, predictors and outcomes of reintubation. Retrospective analysis of data collected from the trauma data base registry was conducted to identify the extubation failure cases in Trauma ICU at Hamad General Hospital, the only Level I trauma center in Qatar between January 2009 and December 2010. Demographics, mechanism of Injury, complications, injury severity score [ISS], Glasgow Coma Scale [GCS], ICU-length of stay [LOS], and mortality were analyzed among trauma patients who need reintubation within 48 hrs after extubation [group 1] compared to successfully extubated patients [group 2]. A total of 954 patients were admitted to the trauma ICU, of which 343 were intubated orotracheally. The mean age of patients was 32 +/- 12 years with male predominance [95%]. Motor vehicle crash [41%], pedestrian injury [20%] and falls [18%] were the most common mechanisms of injury. Reintubation [group 1] was required in 24 patients [7%]. Patients in group 1 had higher rate of head injury mainly SAH [88%], pneumonia [79%] and pulmonary contusion [58%]. The mean ICU-LOS was higher in the reintubated patients [p=0.010] in comparison to group 2. Forty-six percent of reintubated patients required tracheostomy. The mean age, ISS, GCS and tube size was comparable among the two groups. Furthermore, reintubation was not associated with higher mortality rate [p=0.910]. However, Ventilator-associated pneumonia [VAP] [odd ratio=3.61 [95% CI 1.25-10.44]; p=0.020] and ventilator days [odd ratio=1.09 [95% CI 1.024-1.153]; p=0.006] were independent predictors of reintubation by multivariate analysis. Re-intubation is associated with increased ICU-LOS and need for tracheostomy. VAP and prolonged intubation are independent predictors of re-intubation. Our finding addresses the value of prevention and early treatment of infection in intubated patients. This study may represent an audit of local practice as well

observational study of outcome following surgical repair of traumatic diaphragmatic rupture

This study was conducted in a level I trauma centre to review the outcome of surgical repair of Traumatic Diaphragmatic Rupture [TDR] and to identify the predictors of mortality and hospital stay. Between January 1990 and January 2001, consecutive patients with TDR and ISS [Injury Severity Score] > 12 were identified from a prospective trauma registry. Hospital charts of all eligible patients were reviewed for demographic data, mechanism of injury, mode of diagnosis, type of surgical repair, need for ventilatory support, ICU and hospital stay and mortality. We conducted a stepwise regression analysis [logistic regression for mortality, and multiple regressions for hospital stay]. Of the 59 patients included in the study 44 [75%] were males. Their mean age was 43 +/- 18 years and their average ISS was 39 +/- 15 Blunt injuries [85%] and left sided ruptures [73%] were the most common. Frontal and side impacts were equally distributed. Twenty eight [66%] patients were drivers. Forty five [79%] patients were ventilated following the diaphragm repair. A significantly higher proportion of patients with blunt injuries required ventilatory support compared with penetrating injuries [93% vs. 38%, p <0.05]. The mortality rate was 7%. Older age was a significant predictor of mortality [Odds ratio = 1.2, 95% CI = 1.1-1.4, P = 0.04]. ISS [Odds ratio =1.1, 95% CI = 0.98 -1.2, P = 0.08] and need for ventilation [Odds ratio=1.02, 95% CI = 0.97-1.12, P=0.09] revealed trends towards mortality, but were not statistically significant. Hospital stay was predicted by the ISS [B=0.09, P=0.05] score and need for postoperative ventilatory support [B=0.26, P=0.04]. This is the largest Canadian series from a single trauma centre. it revealed that older age is a major predictor of mortality whereas the need for ventilatory support did not predict the overall mortality