Azharuddin’s son Ayazuddin a victim of missed resuscitation during the Golden Hour?

Health Care, Medicine, Social Health Community 558 Comments

Ayazuddin (19), son of former cricketer and Moradabad MP Mohammad Azharuddin, died on 16th September (2011) five days after being critically injured in a road accident in Hyderabad. He was critically injured when his 1000 CC Suzuki skidded on the Outer Ring Road at Puppalguda on Sunday. His cousin died on the same day.

Ayazuddin suffered a cardiac arrest on his way to the hospital. He responded to resuscitation and was later operated on to stop the bleeding from his lung and kidney. His kidneys were also damaged. Commuters on the route alerted the police and a patrol vehicle from a nearby police station arrived soon. The police team failed to get an ambulance and had to take the profusely bleeding cousins in their patrol vehicle to the hospital, losing an hour in the process.

Medically the lesson is that opportunity to save him was list as the precious first hour was missed of resuscitation.  The “Golden Hour” concept emphasizes the increased risk of death and the need for rapid intervention during the first hour of care following major trauma. Rapid intervention improves the outcome of injured patients (obstructed airway, tension pneumothorax, severe hemorrhage).

Death in road traffic accident can be a part of trimodal distribution of mortality (death at the scene; death 1 to 4 hours after injury; and death weeks later, generally in an intensive care setting) or bimodal distribution (death at the scene or within the first 4 hours).

The current thinking is that relatively few patients die after the first 24 hours following injury. The large majority of deaths occurs either at the scene or within the first four hours after the patient reaches a trauma center. This is true only when the patient gets medical care within the first hour. The care involves fluid resuscitation and control of the bleeding.

Intensive medical treatment prevents second stroke not intra cranial stenting

Health Care, Medicine, Social Health Community 1,530 Comments

Patients at a high risk for a second stroke who received intensive medical treatment had fewer strokes and deaths than patients who received a brain stent in addition to the medical treatment. The investigators published the results in the online first edition of the New England Journal of Medicine.

The National Institute of Neurological Disorders and Stroke (NINDS), part of the National Institutes of Health, funded the trial. The medical regimen included daily blood-thinning medications and aggressive control of blood pressure and cholesterol.

New enrolment in the study was stopped in April because early data showed significantly more strokes and deaths occurred among the stented patients at the 30-day mark compared to the group who received the medical management alone.

In addition to the intensive medical program, half of the patients in the study received an intervention of a self-expanding stent that widens a major artery in the brain and facilitates blood flow. One possible explanation for the higher stroke rate in the stented group is that patients who have had recent stroke symptoms sometimes have unstable plaque in their arteries which the stent could have dislodged, the study authors suggest. The study device, the Gateway-Wingspan intracranial angioplasty and stenting system, is the only system currently approved by the U.S. Food and Drug Administration (FDA) for certain high-risk stroke patients. The study participants were in the highest risk category, with blockage or narrowing of arteries of 70 to 99 percent.

Intensive medical management included a daily dosage of 325 milligrams of aspirin; 75 milligrams a day of Clopidogrel, for 90 days after enrollment; and aggressive management of key stroke risk factors—high blood pressure and high levels of low density lipoprotein (LDL), the unhealthy form of cholesterol. All patients also participated in a lifestyle modification program which focused on quitting smoking, increasing exercise, and controlling diabetes and cholesterol.

“The SAMMPRIS study results have immediate implications for clinical practice. Stroke patients with recent symptoms and intracranial arterial blockage of 70 percent or greater should be treated with aggressive medical therapy alone.

[New England Journal of Medicine, published online September 7, 2011].

Delhi Blast Update: How to handle blast injuries

Health Care 385 Comments

Blast injuries can be of four types.

1. Primary blast injuries are the injuries to the hollow gas-filled organs like the lungs, ear drum or intestines leading to their rupture. These occur as a direct result of the impact of the over pressurized blast wave on the body.

2. Secondary blast injuries occur due to flying debris and bomb fragments leading to penetration or penetrating injuries such as to the eyes.

3. Tertiary blast injuries occur when individuals are thrown by the blast wind leading to fractures as a result of the fall.

4. Quaternary blast injuries are due to direct effect of burn or crush injuries.

The most important triage to manage blast injuries is not to waste energies and resources on patients with non-serious injuries. The first thing is to check for eardrum rupture and signs of respiratory imbalance. Their absence indicates a non-serious injury.

All patients exposed to a blast must have eardrum examination as the first step. If the ear drums are intact, the patient can be discharged with first-aid treatment. If ear drum is ruptured, an X-ray chest should be done immediately. All such patients should be observed for eight hours as primary blast injuries are notorious for delayed presentation.

Doctors should therefore focus only on two exams: otoscopic ear exam and pulse oximetry. Blast lung injury is unlikely without tympanic or ear membrane rupture. This is used as a screening procedure for admitting a patient. Decreased oxygen saturation on pulse oximetry signals early blast lung injury, even before symptoms become apparent. Half of all initial casualties seek medical care over first hour. Double this number after one hour and you will know the total casualties. This formula is often used by the media to predict the tolls. It is also useful to predict demand for care and resource needs. Always expect upside down triage as the most severely injured arrive after the less injured who self-transport to the closest hospitals.

With the increasing use of explosives in terrorist events in our country in recent times, doctors, especially Emergency Doctors, should undergo orientation training every six months so that they are prepared and better equipped to manage several casualties all at one time.

About the author: Dr K K Aggarwal is Padmashri and Dr B C Roy National Awardee, President Heart Care Foundation of India, Dean Board of Medical Education Moolchand Medcity, Sr. Physician & Cardiologist, Chairman Ethics Committee Delhi Medical Council, Visiting professor Clinical Research DIPSAR, Past President Delhi Medical Association and Past Academic and Research Wing Heads IMA.

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