Search

Introduction Scalds from hot tap water can have devastating consequences and lifelong impact on survivors. The aims of this study were to (i) describe the frequency, demographic profile, injury event characteristics, and in-hospital outcomes for people with tap water scalds admitted to Australian and New Zealand burn centres; and (ii) determine whether there was variation in the frequency and epidemiological characteristics of tap water scalds between jurisdictions. Methods Data were extracted from the Burns Registry of Australia and New Zealand for people with tap water scalds admitted to Australian or New Zealand burn centres between January 1, 2010 and December 31, 2018. Demographic, injury severity and event characteristics, surgical intervention, and in-hospital outcomes were investigated. Results There were 650 people with tap water scalds admitted to Australian and New Zealand burn centres during the study period. Australians with tap water scalds (median [IQR] 29 [1–69] years) were older than New Zealanders (2 [1–36] years). Most tap water scalds occurred in the home, and 92% of these occurred in the bathroom. More than 55% of injuries occurred due to the accidental alteration of water temperature at the tap fixture. Two thirds of patients underwent a surgical wound procedure. The overall mortality rate was 3.7%, and the median hospital length of stay was 8.8 days. Conclusion Tap water scalds remain a public health problem in Australia and New Zealand. Our research highlights where gaps in current heated water regulations in residential homes perpetuate risks of tap water scalds, particularly in high-risk groups at the extremes of age. Extending current heated water regulations to include all Australia and New Zealand homes is required urgently, in conjunction with design safety improvements, and ongoing education of key stakeholders.

In addition to revealing the cracks in global health care, emergency preparedness, and response systems, COVID-19 also exposed the lack of capacity to run chemical plants safely under such conditions. On 7th May 2020, self-polymerization runaway reaction from an atmospheric storage tank in a polymer facility triggered the release of styrene to the atmosphere, resulting in 12 fatalities and hospitalization of more than 1000 individuals. A similar incident had happened 35 years back at Bhopal involving the release of methyl isocyanate resulting in one of the deadliest process safety incidents to date. Therefore, it is very important to understand the causal factors so that such high-risk incidents can be prevented in future. This paper presents a comprehensive investigative study of styrene gas leak at Vizag with special emphasis on probabilistic risk analysis of the loss of containment. Hazard perception study was performed to understand the possible hazardous scenarios in bulk styrene storage facilities for preventing such catastrophic recurrences. Energy barrier analysis was performed to study the inadequacy of pro-active and reactive barriers with respect to the accident case study. The analysis also considers the escalation factors resulting from extremities of COVID-19 lockdown. The self-polymerization reaction that resulted in toxic styrene dispersion was preventable owing to the advancements in safety engineering and loss prevention since Bhopal Gas Tragedy (1984). Based on the investigative analysis, it can be pointed out that this accident would have occurred even in the absence of COVID-19 restrictions, mainly due to negligence and complacency shown towards safety by the company’s management.

Introduction Non-accidental trauma (NAT) affects 2 per 100,000 children annually in the US and may go unrecognized. The aim of this study to quantify the burden of NAT and to evaluate regional variations in mortality. Methods The Kids Inpatient Database (2000–2012) was queried for pediatric patients presenting with a diagnosis of NAT. Data was obtained on demographic, clinical and hospital-level characteristics. Primary outcome measure was mortality. Multivariable logistic regression models for age, sex, race/ethnicity, insurance status, income quartile, hospital volume, region (Northeast, South, West and Midwest), teaching status, and injury severity scores. Results NAT represented 1.92% (n = 15,999) of all trauma patients. Mortality rates were 3.98% for patients presenting with NAT. African American children had a higher likelihood of mortality compared to White children (OR[95%CI]:1.35[1.03–1.79]), however, this effect was not statistically significant for patients being treated at designated children's hospitals (OR[95%CI]:1.23(0.78–1.95) and urban facilities (OR[95%CI]:1.30[0.99–1.72]). Statistically significant regional variations in mortality, lost significance for patients treated at designated children's hospitals (p > 0.05). Conclusion NAT has devastating consequences and is associated with a high mortality rate. Treatment at designated children's hospitals results in the loss of variation in mortality, resulting in diminished disparities and improved outcomes. These findings align with current trends towards the “regionalization of pediatric health care” and reflects the value of regional transfer centers that are.

Encounters between marine animals and humans can result in critical injury and fatal complications. We highlight a 20-y-old male who sustained a penetrating injury to the neck as a result of impalement by needlefish (Tylosurus sp) while snorkeling. He sustained a penetrating injury in the posterior triangle of the neck. On presentation, he was stabilized and received empirical antibiotics, analgesia, and antitetanus toxoid injection before being transferred to a tertiary center. On presentation to the tertiary hospital, the patient was hemodynamically stable with no clinical evidence of injury to surrounding neck structures, and this was confirmed using computed tomography. The patient underwent local wound exploration and retrieval of the needlefish beak under general anesthesia. The wound was left open to heal by secondary intention. The patient was discharged with oral antibiotics and went on to make a complete recovery.

High-pressure injection injuries with paint have long been heralded as a condition requiring timely and aggressive debridement with relatively poor functional outcomes and a significant proportion of patients progressing to require amputation of the involved digit or limb. Catheter irrigation is regularly used in the treatment of common hand infections and wounds. However, this has not been described for the treatment of paint injection injuries. We describe a case of a young painter who sustained an accidental water-based paint injection injury and was successfully treated with minimally invasive surgical debridement augmented by the use of catheter irrigation, despite a delayed presentation. The patient had regained full function of his hand by four months from the index presentation and returned to work. We illustrate how not all high-pressure injection injuries require an extensive incision and that catheter irrigation can be a significant tool to augment a minimally invasive approach.

An infusion of 100cc of 0,2% potassium chloride was accidental performed through a thoracic epidural catheter, inserted to perioperative analgesia, to a 66years old man who was scheduled for right hemicolectomy, 48hours after surgery. Paresis of upper limbs, flaccid paralysis of lower limbs and a sensitive level at T8 was observed. An epidural lavage with an initial dose of 20cc of saline was slowly injected, followed for a saline infusion of 20cc per hour. Neurologic signs were totally reverted some hours later and 24hours after the incident the physical exam was normal. We reviewed the clinical presentation of the complication and its mechanisms, the more frequent clinical evolution, as well as treatment measures and strategies to prevent the incident.

The survival of completely buried victims in an avalanche mainly depends on burial duration. Knowledge is limited about survival probability after 60 min of complete burial. We aimed to study the survival probability and prehospital characteristics of avalanche victims with long burial durations. We retrospectively included all completely buried avalanche victims with a burial duration of ≥60 min between 1997 and 2018 in Switzerland. Data were extracted from the registry of the Swiss Institute for Snow and Avalanche Research and the prehospital medical records of the physician-staffed helicopter emergency medical services. Avalanche victims buried for ≥24 h or with an unknown survival status were excluded. Survival probability was estimated by using the non-parametric Ayer-Turnbull method and logistic regression. The primary outcome was survival probability. We identified 140 avalanche victims with a burial duration of ≥60 min, of whom 27 (19%) survived. Survival probability shows a slight decrease with increasing burial duration (23% after 60 min, to

The Malaysian construction industry plays a vital role in the economic growth of the country. However, on the other side, the annually increasing number of fatality and accidental rates on the construction sites are a serious concern, and statistics are alarming. This study has been administered with the help of questionnaire survey comprising of ten groups, including sixty-two critical safety factors. These factors were identified from the literature, and questionnaire feedback was collected from contractors, clients and consultants for this study. The outcome of this study revealed that the “fall from roofs/floor (working at height or open edges without using fall-protection systems)” is the topmost critical factor among the identified high ranked ten critical safety factors, which usually causes accidents in high-rise building projects. This study gives a clear picture of critical safety factors with practical knowledge to construction safety managers which would make the execution of building projects safer.

Fecal incontinence is a highly prevalent and debilitating condition that negatively impacts quality of life. The etiology is often multifactorial and treatment can be hindered by lack of understanding of its mechanisms and available treatment options. This article reviews the evidence-based update for the management of fecal incontinence.

While suicide is recognised as one of the leading causes of death in Australia, it is often presumed that fatal road crashes are primarily accidental in nature. However, international research has indicated that deliberate attempts at self-harm while driving may account for between 1.1% and 7.4% of road crashes. Despite the personal and financial costs associated with such events, few studies have examined the extent of motor vehicle suicides (MVS) or the circumstances surrounding such incidents in Australia. Given this, the current study reviewed coronial, police and toxicology findings of 762 motor vehicle fatalities in Queensland (Australia) during the period 2011 to 2015 to determine the frequency of confirmed cases and explore the prevalence (and characteristics) of possible MVS that remain undetected. In total, 22 confirmed cases were identified, and such events shared significant similarities with 14 possible events, including evidence of recent emotional upset, adversity and mental health diagnoses. In contrast, differences between the groups were limited to confirmed cases being more likely to involve males and contain a suicide note or evidence of past suicidality, while possible cases were more likely to involve a multiple vehicle impact with a truck. Importantly, crucial information regarding the deceased’s psychological state and life circumstances (e.g., psychological autopsy) was not reported in many cases. Corresponding qualitative analysis of the coroners final determination (between the two groups) revealed the occurrence of the word suicide to occur seven times (31.8%) among confirmed cases and five times (35.7%) for possible casers. Furthermore, the coroners final determination of intent to suicide was open or undetermined in six of the possible cases (43%), which further suggests a reluctance (or procedural uncertainty) to categorically identify MVS. The paper further reviews the main findings, illuminates core challenges associated with identifying MVS and proposes a need for future investigations to incorporate a more standardised and evidence-based approach in order to effectively identify such events.

Local anesthesia is administered for most dental treatments. Although the development of disposable needles has decreased the incidence of needle breakage, needle breakage in the oral cavity after local anesthesia is a common complication with the potential to cause serious complications, including injury to vital structures in rare cases. Therefore, the needle should be immediately removed if it breaks during surgery. In this report, we present a case of needle breakage during local anesthesia administered for treatment of a right mandibular third molar lesion that was removed one week later. An image examination just before surgery is essential.

Caffeine is a common stimulant consumed daily worldwide and available in a wide variety of over-the-counter formulations. It is a mild central nervous system stimulant when used in recommended doses. However, it can be fatal if taken as an intentional or accidental overdose. We report a case of a 48-year-old lady with depression and post-traumatic stress disorder who consumed a significant overdose of caffeine, triggered by the stress that she had contracted coronavirus disease 19. This led to significant cardiovascular and central nervous system toxicity. The condition was identified early and managed appropriately with early β-blockers and gastric decontamination, which saved her life. There are few studies with regard to such modalities on treatment for caffeine overdose; our patient responded rapidly and favourably to the treatment. Why should an emergency physician be aware of this? Caffeine overdose is uncommon but one that clinicians should be aware of. Early identification and intervention with β-adrenergic antagonists and activated charcoal is paramount in caffeine toxicity.

Previous studies have reported inconsistent results on the mortality from trauma among psychiatric patients comparing to non-psychiatric population, which may be partly explained by the inclusion of both suicidal and accidental trauma. This study aimed to investigate the association of psychiatric diagnoses on admission with the outcomes of hospitalized patients for accidental trauma, namely road traffic injury.Detailed information of patients aged 15 years or older who were hospitalized for road traffic injury between 2004 and 2017 was extracted from the Japan Trauma Data Bank. The primary outcome was to compare in-hospital mortality between patients with and without a psychiatric disorder. We also conducted a subgroup analysis among patients with and without a serious head injury.Altogether, 85,069 patients were included. Of these, 3,895 patients (4.6%) had a psychiatric diagnosis. The in-hospital mortality rate was significantly lower among patients with a psychiatric diagnosis than those without (5.4% vs. 8.3%; adjusted odds ratio [OR] 0.57, 95% confidence interval [CI] 0.47-0.70, p0.001). In a subgroup analysis of patients with a serious head injury, in-hospital mortality was significantly lower in patients with a psychiatric diagnosis than in those without (10.5% vs. 17.3%; adjusted OR 0.48, 95% CI 0.37-0.62, p0.001); in-hospital mortality of patients without a serious head injury showed no differences between patients with or without a psychiatric diagnosis (2.8% vs. 3.5%; adjusted OR 0.84, 95% CI 0.61-1.16, p=0.295).In-hospital mortality from road traffic injury was significantly lower among patients with a psychiatric diagnosis than those without, which was primarily evident in a subgroup of patients with a serious head injury. While further replication is necessary, results might be indicative of the neuroprotective effect of psychotropic medications.

Displacement of a mandibular third molar into a fascial space is a relatively rare event with potentially serious complications. The surgical procedure to remove a displaced tooth, or part thereof from these spaces may be difficult due to poor access and an abundance of vital structures within these spaces. Here, we present two cases of submandibular displacement, suggest an intra-oral approach and algorithm to help guide practitioners with management of displaced third molars in the submandibular space.

Background: The imapct of Kangaroo Mother Care (KMC) in neonates is positively reported in the literature. However,several challenges hindered the wide-scale application of this practice. Objectives: To assess the levels of knowledge and competency of kangaroo mother care (KMC) among nurses and to identify the potential barriers to practice. Methodology: Structured web-based questionnaires were submitted to nurses working at neonatal intensive care units (NICUs) located in Riyadh, Saudi Arabia. The participants were asked to answer 23 questions distributed in four main domains, namely, demographic data, knowledge about KMC, practice levels, and barriers to KMC practice. For answers to the knowledge and barriers to practice domains, the mean scores (standard deviations) were calculated to present participants’ perceptions and beliefs from 1 (strongly disagree) to 5 (strongly agree). Results: Two hundred nine NICU nurses responded (95.2% females, 89.5% working in a government hospital, 69.9% obtained a Bachelor’s degree). The majority of respondents perceived KMC as promoting maternal-infant bonding (4.47 ± 1.3) and enhancing successful breastfeeding (4.44 ± 0.9), while there were considerable uncertainties about KMC application in infants weighing

Introduction Accidental falls are the most common causes of injury among infants. Due to their limited ability to move independently, falling from bed or other types of furniture (such as sofas or armchairs) is considered the most common reason for such injury. However, little is known about the frequency and types of injury associated with this type of fall among infants. This study aimed to determine the incidence and characteristics of injury among infants presented at emergency departments (ED) after falling from bed or similar furniture. Methods The retrospective analysis of infants under one year old presenting at ED after falling from bed (or similar furniture) was performed over a four-year period (2016–2019). Patient demographics, incidence and patterns of injury, outcomes, and ED resources use were evaluated as part of the study. Results In total, 1,439 infants were included in the study, of whom 782 (54.3%) were male and 657 (45.7%) female. The median age of the patients was 7 months (interquartile range [IQR]: 6–9 months). More than half the infants (n = 812, 56.4%) had minor injuries, such as abrasions, bruising, contusions, and lacerations. There were significant injuries for 135 (9.4%) infants. The most common fracture was skull fracture (n = 59, 4.1%), followed by proximal fracture of the upper extremities (n = 26, 1.8%). Six (0.4%) patients had radial head subluxation. Traumatic brain injury featured for 30 (2.1%) infants (intracranial hemorrhage/cerebral contusion). While the majority of patients (n = 1352, 94%) were discharged from ED, 86 (6%) infants were hospitalized, all due to head injuries. A neurosurgical intervention was performed with three (0.2% of all patients) of the hospitalized patients. Conclusion Falling from bed causes skull fractures, traumatic brain injury, and long bone fractures among infants. Therefore, campaigns should be organized to raise awareness of these risks among parents and caregivers of infants. In addition, the use of safety equipment (such as bed rails) and creating a safe environment can help prevent significant injuries.

Intracranial subdural haematoma is a rare, but potentially lethal complication of neuraxial procedures. Considering the high frequency of neuraxial techniques in the obstetric population, parturients are more susceptible to this fearful complication. The diagnosis is often masked and delayed because it shares similar clinical characteristics with posdural puncture headache, with headache being the most common symptom. This case report describes a timely diagnosis and successful management of an intracranial subdural haematoma, after unintentional dural puncture during labour epidural analgesia. Postpartum headache following epidural analgesia, remains a clinical challenge for the caring team, requiring a close follow-up and awareness for non-benign causes that require prompt management, avoiding devastating consequences.

Background/Purpose There remains a lack of data on the utility of viscoelastic tests in managing abused patients. We hypothesize that abnormalities on admission thrombelastography (TEG) will differ in abused patients compared to those accidentally injured. Methods Pediatric trauma patients (≤ 10 years old) who had an admission TEG at a Level I pediatric trauma center (2010–2020) were included and stratified into two cohorts: abuse versus accidental trauma. TEG abnormalities were based on the institution's normative values and compared between the groups. Results Of 41 children included, 21 sustained abuse. Five abused patients and three accidentally injured patients died. Abused children showed a hypercoagulable pattern on viscoelastic testing with TEG when compared to those accidentally injured, as demonstrated by a short R-time (67% vs. 30%, p = 0.040) and an increased alpha angle (47% vs. 0%, p = 0.001). There was no significant difference in the MA and LY30 values between the two groups. In a multivariable model, only an abnormal alpha angle remained associated with abuse [odds ratio (OR) 0.17 (confidence intervals (CI) 0.02–0.92)]. In a separate multivariable model, only an abnormal MA was associated with mortality [OR 18.97 (CI 1.93–475.47), p = 0.025]. Conclusions Our data suggest that hemostasis is significantly different in abused children relative to those who are accidentally injured. Type of Study Retrospective Comparative Study. Level of Evidence Level III.

Firearm injuries (GSW) are a growing public health concern and leading cause of morbidity and mortality among children, yet predictors of injury remain understudied. This study examines the correlates of pediatric GSW within our county.We retrospectively queried an urban Level 1 trauma center registry for pediatric (0-18 years) GSW from September 2013 to January 2019, examining demographic, clinical, and injury information. We used a geographic information system to map GSW rates and perform spatial and spatiotemporal cluster analysis to identify zip code "hot spots."393 cases were identified. The cohort was 877% male, 87% African American, 10% Hispanic, and 22% Caucasian/Other. Injuries were 92% violence-related and 4% accidental, with 63% occurring outside school hours. Mortality was 12%, with 53% of deaths occurring in the resuscitation unit. Zip-level GSW rates ranged from 0 to 9 (per 1000 18 years) by incident address and 0-6 by home address. Statistically significant hot spots were in predominantly underserved African American and Hispanic neighborhoods.Geodemographic analysis of pediatric GSW injuries can be utilized to identify at-risk neighborhoods. This methodology is applicable to other metropolitan areas where targeted interventions can reduce the burden of gun violence among children.Retrospective study.Level III.

Calcium channel blockers (CCBs) have seen an increase in rate of non-therapeutic exposure that is both accidental and intentional in nature. Patients experiencing the toxic effects of a CCB overdose are resource intensive and can quickly outstrip the capabilities of local health systems, necessitating transfer to larger tertiary or quaternary care centers. We present a case of intentional non-dihydropyridine CCB overdose and toxicity in a 20-year-old patient requiring initial stabilization at a referring critical access emergency department with continuation of treatment and support during a 60-minute rotor wing transport from the referring hospital to an academic quaternary care center. Emphasis is placed on the unique challenges in resuscitation and ongoing critical care administration during the transport phase of care. Proper stabilization of patients, planning, and consideration of potential problems associated with transport can help minimize stresses and risk of the transport, improving the outcome of extremely ill patients even under challenging circumstances.

Embarrassment is commonly felt by older adults experiencing a fall, and embarrassment may cause older adults to adopt maladaptive behaviors by not implementing fall prevention strategies. Clarifying the concept of embarrassment for nursing and defining the concept as it relates to accidental falls and fall prevention among older adults was conducted using Walker and Avant's eight-step concept analysis process. The proposed definition of embarrassment experienced by older adults in relation to accidental falls is: The feeling of physical discomfort and exposure in a social situation due to the loss of control and self-esteem, as well as the inconsistency between one's personal identity as an independent and dignified person and the accidental fall or near fall behavior that threatens independence and dignity leading to emotional distress. Nurses recognizing older adults' potential fall-related embarrassment may increase older adults' adherence to fall prevention strategies and improve health outcomes.

The cerebellum plays an important role in motor and nonmotor systems, with damage resulting in clinical manifestations presenting as weakness, ataxia, dysarthria, and nystagmus. There are numerous environmental and industrial agents as well as medications that, through either accidental or intentional use, can result in a range of neurologic presentations. The variability in the presentation is important to recognize promptly so that early cessation in exposure, use, or abuse can be initiated to reduce the severity of symptoms. Recognition of an agent causing the particular pathology is important so that the route of exposure, and subsequent treatment options can be identified.

The Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act established a community care program allowing veterans to receive care outside Veteran Affairs Medical Centers (VAMCs). We sought to compare patient safety and satisfaction indicators from VAMCs and surrounding non-VAMCs (non-VAs).We identified VAMCs with at least one non-VA acute care hospital within 25 miles in three geographic regions (West/Southwest, New England, and Deep South). Children's, specialty, and critical access hospitals were excluded. Using publicly available Hospital Compare data, we analyzed VAMC and surrounding non-VA performance in postsurgical patient safety indicator (PSI) events and Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scores and hospital star ratings.The 34 VAMCs performed better than 319 surrounding non-VAs in rates of wound dehiscence, accidental lacerations, and perioperative hemorrhage/hematoma as well as composite PSI rating (P 0.05). VAMCs performed significantly better than non-VAs (18.0 versus 51.4 events per 1000 patients, P 0.001) in composite surgery-specific PSIs. When comparing mean linear Hospital Consumer Assessment of Healthcare Providers and Systems score star ratings (1-5 scale), VAMCs had similar performance in overall hospital rating compared with non-VAs (3.28 versus 3.38, P = 0.48) and summary rating of hospital stays (2.87 versus 2.92, P = 0.69). When compiled patient satisfaction star ratings were compared, there was no difference (2.96 versus 2.97, P = 0.9). VAMCs performed worse than non-VAs in "would recommend" ratings (2.7 versus 3.13, P = 0.007).Across disparate regions, VAMCs match or outperform neighboring non-VAs in surgical quality metrics and patient satisfaction ratings. Veterans receiving surgical care at VAMCs may receive equivalent or better care than at non-VAs.

Background In the United States, over 1 million burns require medical treatment each year. Chemical burns represent an infrequent but devastating percentage of all burns, which account for a large proportion of all burn-related deaths. Of the various causes of chemical burns, sulfuric acid is most commonly involved in occupational and accidental burns, and even cases of assault. Case Report We describe the case of a 27-year-old man who presented to our Emergency Department (ED) after an assault with sulfuric acid. During his presentation, particular attention and care was given to his decontamination, airway management, and correction of life-threatening metabolic derangements. After stabilization in the ED he survived an extensive hospital admission. Why Should an Emergency Physician Be Aware of This? Patient outcomes and prognosis after chemical burns are dependent on prompt recognition/suspicion and rapid initiation of treatment. Even with prompt treatment, severe physiologic and psychologic injuries often afflict the patient. While encountering these devastating injuries, the emergency physician must carry a heightened sense of care and protection for both patient and staff to ensure optimum outcomes.

Background Posterior decompression and fusion surgery is one of the most commonly performed surgeries for thoracolumbar tuberculosis with destruction of vertebral bodies. Tuberculosis causes gross destruction of the vertebral bodies and surrounding tissue, making them friable. Case Description We present an unusual but dreaded complication which we encountered during posterior decompression and instrumentation surgery in a 65-year-old woman with T10-11 tuberculosis of the spine. During surgical exposure, while reflecting posterior paraspinal muscles on the left side, there was an accidental slip of the Cobb elevator around the transverse process to the extent of two-thirds of its length on the left side anteriorly. The instrument was immediately withdrawn. There was no active bleeding in the field. The rest of the surgery was uneventful. In the postoperative period, however, the patient developed severe abdominal pain with abdominal distention. General surgery opinion was immediately taken and the patient was immediately investigated in the form of a computed tomography scan. It was found that there was a traumatic laceration of the pancreas. The patient underwent emergency exploratory laparotomy and repair of the pancreatic laceration. The patient required intensive monitoring and critical care unit stay and ultimately went on to recover fully over the next few weeks. Conclusions This case illustrates the possibility of pancreatic injury should always be kept in mind if the patient develops acute abdominal discomfort in the postoperative period. Also, a multidisciplinary approach along with intensive care backup and vigilant postoperative monitoring is of utmost importance, especially when an unusual event has occurred during the surgery.

Fractures of the femur present some unique challenges to the treating orthopaedic surgeon. Non-accidental injury must always be considered. There are various modalities that can be used in the management of shaft fractures and these should be treated with careful consideration of not just the fracture pattern but also the patient's age, weight, bone maturity and social circumstances. Treatment options include: Pavlik harness, traction, spica casting, elastic nailing, sub-muscular plating, external fixation and intramedullary nailing. Selection of one treatment option over another should be done with full involvement of the patient and family. Femoral neck fractures, whilst rare, are associated with high-energy trauma and generally need to be treated as emergencies. Accurate anatomical reduction and fixation is crucial; despite this they have high rates of complications and these patients should be followed up for an extended period of time.

Background Drowning is still a major cause of accidental death worldwide. In 1997, Szpilman proposed a classification of drowning that has become the reference. As considerable efforts have been made to improve prevention and care, it seemed appropriate to reassess the prognosis and clinical presentation of drowning patients more than 20 years after this first publication. The aim of this study is to provide a reappraisal of patients who need advanced health care and a precise description of their respective neurologic, respiratory, and hemodynamic profiles. Methods This retrospective study was conducted over four consecutive summer periods between 2014 and 2017 in ICUs located in France, French Polynesia, and the French Antilles. Patients were classified according to the drowning classification system proposed by Szpilman. Results During the study period, 312 drowning patients were admitted with severe clinical presentation (grades 2-6). All patients benefited from rapid extraction from the water ( Conclusions On the basis of these results, drowning-related cardiac arrest is still the prognosis cornerstone. For other victims, the prognosis was better than previously expected, which strengthens the importance of specialized intervention to interrupt the drowning process.

Summary The aim was to examine the descriptive data on intracranial hemorrhage related to fatal non-accidental head injury (NAHI) in a pediatric population that had undergone forensic pathological examination. This retrospective and multicentric study included all infants who died because of intracranial hemorrhage attributed to NAHI. Sixty-seven infants were included with a median age of 3.8 months. Forty-two percent of infants had been subjected to an isolated shaking incident, and 58% had an identified impact with or without shaking. Twenty-two percent of children had an associated fracture. Thirty percent of infants had a past history of NAHI. There was no significant statistical difference between shaking and impact concerning the gravity of the injuries. We observed considerable variability in the samples available for the forensic pathological expert examination, even though the autopsy was performed in three major French centers.

To explore the impact of an intensive self-management education strategy on seizure frequency and quality of life in patients with epileptic seizures with prodromes or precipitating factors. The intensive self-management education included monthly education sessions on prodromes and precipitating factors aiming to help patients to adopt self-management strategies.Adult patients with epilepsy (PWE) able to identify prodromes or precipitating factors of their seizures were randomly assigned to an intensive education group (IEG) (n = 45) or a regular education group(REG) (n = 47). All patients received a single face-to-face self-management education session at the time of enrollment. Both groups of patients received monthly telephone follow-up for 1 year. PWE in the IEG received intensive education during each follow-up call. Primary outcomes were seizure frequency, quality of life(Quality of life in epilepsy-31 inventory scores, QOLIE 31), and drug adherence(Morisky medication adherence scale,MMAS).At the end of the 1-year follow-up period, seizure frequency in the IEG was significantly lower than at baseline (p0.001), but not in the REG(p = 0.085). Quality of life had improved significantly in the IEG (p0.001), but not in the REG (p = 0.073). Drug adherence was better in the IEG than in the REG (p = 0.003), and there were fewer accidental injuries in the IEG than the REG (p = 0.031).In PWE aware of seizure prodromes or precipitating factors, intensive self-management education may reduce seizure frequency, improve quality of life, increase adherence with antiepileptic medication and reduce accidental injuries caused by seizures.

Background Accidental awareness during general anaesthesia (AAGA) is a complex and rare outcome to investigate in surgical patient populations, particularly obstetric patients. We report the protocol of the Direct Reporting of Awareness in Maternity patients (DREAMY) study, illustrating how the research was designed to address practical and methodological challenges for investigating AAGA in an obstetric cohort. Methods This is the trial protocol of a prospective, multicentre cohort study of patients undergoing obstetric surgery under general anaesthesia. Accidental awareness during general anaesthesia will be detected using three repetitions of standardised direct questioning over 30 days, with responses indicating memories during general anaesthesia verified using structured interviews. Reports will be adjudicated, then classified, in accordance with pre-defined and pre-validated structures, including the Michigan Awareness Classification tool. Quantitative data will be collected on general anaesthesia conduct for all participants. This descriptive study is being conducted in England and aims to recruit a minimum of 2015 patients. Results The DREAMY study was prospectively registered (ClinicalTrials.gov Identifier: NCT03100396) and ethical approval granted. Participant recruitment began in May 2017 and one year follow up concluded in August 2019. Publication of the results is anticipated in 2020. Conclusions The DREAMY study will provide data on incidence, experience and implications of AAGA for obstetric patients, using a robust methodology that will reliably detect and translate subjective AAGA reports into objective outcomes. In addition, the study is expected to improve vigilance for AAGA in participating hospitals and encourage adoption of recommendations for support of patients experiencing AAGA.

Larry Johns, Esquire’s impressive career as a lawyer propelled his involvement in numerous legal battles that centered on exposure to environmental harms. Here, Dr. Stephanie Malin interviews Larry Johns to discuss the accidental Baneberry venting disaster during that underground nuclear test, the subsequent Baneberry legal case and outcomes that ensued, and legacies of nuclear contamination and environmental injustice. The interview focuses on Larry’s twenty-five year battle for justice for two workers impacted by the botched detonation of the Baneberry nuclear test, and what this signifies for other people and communities with their own nuclear legacies. Larry reflects on institutional barriers that limit people’s abilities to access useful and accurate information regarding safety and health risks and the ways that federal denial of negligence – as well as a refusal to acknowledge links between workers’ cancers and exposure to fallout – ultimately shaped the outcomes of this case. This interview reminds us of the important ways that institutions shape environmental risks and (in)equality and how these institutions can be even more accountable for and effective in protecting public health and the environment.

The purpose of this study is to characterize the epidemiology, injury patterns, outcomes and trends of non-accidental trauma (NAT) in the United States using a large national database.Children15 years presenting after NAT were identified in the 2007-2014 National Trauma Databank research datasets. Clinical and outcome data were analyzed using descriptive statistics, chi-square and logistic regression.Of 678,503 children admitted for traumatic injuries, 3% (19,149) were victims of NAT. The majority (95%) were under 5 years and 71% under 1 year old. The majority (59%) were male. The median injury severity score (ISS) was 10 (IQR:5-19). African Americans were disproportionally affected (27% vs 17% of all traumas), and the majority had public or no insurance (85%). Incidence was highest in the midwest and lowest in the northeast regions of the country, although trends varied over time. NAT resulted in 43% of trauma deaths in children1 year and 31% of trauma deaths in children5. Traumatic brain injury (TBI) was the most commonly encountered diagnosis (50%). Polytrauma was common, and certain injury patterns were identified. Urgent operation was required in 6%, 43% were admitted to intensive care, and 9% died. Mortality was independently associated with TBI, thoracic injury, hollow viscus injury and older age.Non-accidental trauma is a leading cause of trauma mortality in young children. Multiple injuries are common, requiring comprehensive evaluation and early surgical involvement. The data presented in this study could serve as a guide to target injury prevention efforts.III STUDY TYPE: Prognostic and Epidemiological.

The hospital admission rate for anaphylaxis is increasing especially among the youngest children and food is the leading cause of anaphylaxis in children. In 2014, an emergency action plan for accidental food allergic reactions in children has been proposed to the medical community by the French Allergology Society. Since its publication, new information (dissemination of recommendations on the management of anaphylaxis, provision of a new dosage of 0.5 mg epinephrine in one of the autoinjector available in France, confirmation of the lack of evidence of the effectiveness of oral corticosteroids in anaphylaxis, experience gained on the use of the current action plan…) has led to an update of the initial emergency action plan. As a result, the “Allergy at school” working group, in conjunction with the task forces“Food allergy” working group of the French Allergology Society, supported by various learned societies, medical and patients’ associations, is proposing an update of the emergency action plan in case of allergic reaction in children and adolescents. The aim of this initiative is to harmonize current practices and to improve the quality of the management of allergic emergencies. The present manuscript combines a rationale on the contents of the emergency kit and the epinephrine autoinjectors.

Background Falls from height are a common cause of death and disability. Falls from height can be divided between accidental and suicide attempts. The aim of this study is to ascertain the demographic characteristics of these patients, and to identify the fracture patterns. Methods In this retrospective cross sectional comparative study we present 244 patients who sustained injuries as a result of a fall from height. They were divided into those with accidental falls (n = 180, group I) and those with suicide attempts (n = 64, group II). Data collected included age, gender, associated trauma, injury severity score (ISS), Glasgow Coma Scale (GCS), haemodynamic status, length of intensive care unit (ICU) and hospital stay. The diagnosis of mental disorder was ascertained by psychiatric specialists using the criteria of the International Classification of Disease Ninth Version Clinical Modification (ICD - 9CM). Postoperative follow-up ranged from 12 months to 10 years. Results The injuries sustained were as follows: Abdominal trauma in 9 cases (5 in group I, 4 in II), thoracic trauma in 81 cases (49 in group I, 32 in II), head injury in 23 cases (7 in group I, 16 in II), 383 extremities fractures (184 in group I, 199 in II) and 133 spinal fractures (101 in group I, 32 in II). Twenty-one patients died in hospital while 223 patients survived to hospital discharge. The mean height from which the fall occurred was 5.4 m (range, 3 - 25 m). The mean Injury Severity Score was 19 (range, 6 to 58) for all fall victims. Conclusions Patients following an accidental high fall mostly had upper limb fractures. Patients following a suicidal high fall mostly had lower limb fractures, pelvis, spinal fractures and head injuries. Spinal fractures are common either when the fall is accidental or following suicide attempt.

Highlights • An unusual case of peripheral arterial disease with an aortobifemoral bypass graft. • Aortobifemoral bypass grafts preserve flow to the lower extremities. • Surgical implants in cadavers create a unique learning experience. • Transformation of a traditional dissection class into an inquiry-based learning. • Clinical cases incorporated in the anatomy curriculum promote active-learning., Introduction An unusual vascular implant found during routine cadaver dissection influenced instructors and students to learn more about the underlying disease and the surgical technique used to treat this disorder triggering an inquiry-based learning. Presentation of case This report describes a case of peripheral arterial disease (PAD) with an aortobifemoral arterial bypass implant that was never found before in any of the previously dissected cadavers at Gannon University. Discussion PAD develops due to impaired blood flow to the lower extremities that causes numbness, weakness, and lower leg pain. The treatments can aim to improve the long-term cardiovascular outcomes. If therapeutic medications do not improve outcomes of PAD, revascularization by endovascular repair or aortofemoral bypass grafting is considered. Conclusion We would like to note that accidental discoveries of pathologies or surgical procedures during routine cadaveric dissections present a unique possibility for inquiry-based learning among future healthcare providers.

OBJECTIVES: To compare caregiver features and caregiving arrangements of children with physical abuse versus accidental injuries. STUDY DESIGN: Data came from a prospective, observational, multicenter study investigating bruising and psychosocial characteristics of children younger than 4 years of age. Using logistic regression, we examined how abuse vs accidental injury and severity of injury were associated with caregiver sex, relation to the child, whether caregiving arrangements were different than usual at the time of injury, and length of the main caregiver’s relationship with his/her partner. RESULTS: Of 1,615 patients, 24% were determined to have been physically abused. Abuse was more likely when a male caregiver was present (OR = 3.31, [2.38, 4.62). When the male was the boyfriend of the mother (or another female caregiver), the odds of abuse were very high (OR = 169.2 [61.3, 614.0]). Severe or fatal injuries were also more likely when a male caregiver was present. In contrast, abuse was substantially less likely when a female caregiver was present (OR = 0.25, [0.17, 0.37]) with the exception of a female babysitter (OR = 3.87 [2.15, 7.01]). Caregiving arrangements that were different than usual and caregiver relationships

Highlights • As per the available literature this is the first case of COVID 19 positive patient with gunshot injury. • Delay in emergency surgeries should be avoided in view of awaited COVID report. • Universal precaution and multidisciplinary approach have pivotal role in surgical care during COVID-era., Introduction A challenging situation lies in front of every surgeon to perform emergency surgeries in a pandemic scenario. Gunshot injuries in a COVID-19 affected individual increases the chances of post-operative morbidity and mortality. Such cases require multidisciplinary approach with an advanced COVID care for the satisfactory outcome. Case presentation We present a case of 30-year-old male with an alleged history of an accidental fire arm injury. His rapid antigen for COVID was positive. Contrast enhanced computed tomogram (CECT) abdomen was suggestive of multiple bowel injuries. Emergency exploratory laparotomy confirmed multiple bowel perforations with no associated solid organ injury. Perforated sites were sealed by primary repair and loop ileostomy was performed. Patient was discharged on post-operative Day 17 with satisfactory clinical improvement. Discussion Deleterious effects of COVID-19 has questioned the reliance on health care system across the globe. Pulmonary complications affect the post-operative course in patients undergoing surgery. However not every patient with peri operatively detected COVID-19 will have complicated post-operative course. Managing such patients with perioperative COVID-19 is an uphill task. Hemodynamic instability and clinical signs of peritonitis mandates the operative management. Multidisciplinary approach with advanced post-operative COVID care is required for satisfactory outcome. Conclusion Management of patients undergoing emergency procedure with peri-operative COVID 19 is challenging for the attending surgeon. Consider all surgical emergencies as COVID positive unless proved otherwise. Multidisciplinary approach for management of COVID-19 infection along with good post-operative care is required.

Individuals with food allergy are at risk for accidental exposures, potentially resulting in allergic reactions that may cause significant morbidity and mortality. Dining out, including restaurants or take-out, account for a large proportion of severe reactions. Errors due to gaps in knowledge or miscommunication can easily occur on behalf of food-allergic individuals or restaurant staff, resulting in accidental exposures and allergic reactions. Improved legislation, training of restaurant staff, and practitioner-guided education are recommended to reinforce patient safety and prevent severe allergic reactions. This Work Group Report provides guidance with specific practices that practitioners may recommend, and that patients and restaurant staff may employ, for prevention and treatment of food-allergic reactions in restaurants.

Objective To report a case of accidental cannabidiol (CBD) oil overdose in a pediatric patient. Background CBD is one of over 100 pharmacologically active compounds in the marijuana plant (Cannabis sativa). Its absence of psychoactive effects and the abundance of anecdotal claims of effectiveness across a wide variety of conditions in both mainstream and social media have created an incredible amount of public interest in CBD oil in recent years. Such interest has led to increased consumer availability. Despite this increased access, such sales remain illegal at the federal level. While sales of CBD products not approved by the Food and Drug Administration continue to rise, purity, potency, labeling, and delivery devices remain inconsistent. This may lead to an increased risk of adverse events. The following report describes a case of accidental CBD overdose in a pediatric patient leading to a stay in the pediatric intensive care unit. Case summary The patient initially presented to the urgent care and was quickly transferred to the emergency department after being found unresponsive after administration of a dose of CBD oil earlier in the day. After arrival, his mental status and respiratory drive continued to deteriorate, and he was ultimately intubated. He was eventually extubated and transferred out of the pediatric intensive care unit after 48 hours and discharged after 72 hours. This patient was found to have a urine 9-carboxy-11-nor-Δ-9-tetrahydrocannabinol concentration of 123 ng/mL, suggestive of consumption of a substantial amount of tetrahydrocannabinol. However, samples from the same batch ingested by the patient were tested by both the manufacturer and U.S. Food and Drug Administration and contained only trace amounts of THC. Practice implications As CBD oil use continues to rise, health care professionals should have an adequate understanding of current clinical evidence and state and federal legislation to counsel patients on CBD use in a practical and compassionate manner.

Objective To describe the implementation of a statewide pharmacy program called ONE Rx (Opioid and Naloxone Education) within community pharmacies. Setting Thirty community pharmacies. Practice description Community pharmacies throughout the state of North Dakota were invited to participate. Pharmacists in North Dakota can legally prescribe and dispense naloxone. Practice innovation ONE Rx is a statewide program that provides pharmacists with the education and tools to screen every patient who was prescribed an opioid medication for the risk of opioid misuse and accidental overdose. The goal of ONE Rx is to prevent opioid misuse and accidental overdose through patient screening and individualized education and intervention within the community pharmacy. Evaluation Outcomes to measure the implementation of ONE Rx included the number of pharmacists and technicians who participated in the training, the number of pharmacies who chose to implement ONE Rx, and the number of patients screened for the risk of opioid misuse and accidental overdose. Results The ONE Rx training was completed by 240 pharmacists and 41 registered pharmacy technicians. Thirty community pharmacies implemented the program between October 2018 and May 2019, and more than 1700 patients were screened for the risk of opioid misuse and accidental overdose. Conclusion A statewide program to screen for opioid misuse and accidental overdose was successfully implemented.

Highlights • Rectal barotrauma is a rare pathology that need a multidisciplinary approach. • Laparoscopic surgery is feasible approach in colonic injuries due to barotrauma. • Delaying its diagnosis and management has critical consequences for this type of patient., In the XIX century, the surgeon faces surgical challenges due to the creation of new technologies. Accidental or compressed air-induced injury to the colon and rectum is rare. We present the case of a 45-year-old patient who consults the emergency department, then a high-pressure rectal pneumatic trauma, with clinical findings of peritonism, managed with a Hartmann-type colostomy. and anterior resection of the rectum using laparoscopy, with findings of rectosigmoid perforation. With this, it can be demonstrated that minimally invasive surgery is a feasible approach in hemodynamically unstable patients without contraindication for pneumoperitoneum.

Background Since the first report about nail gun injuries in 1959, there has been an average of approximately 37,000 patients hurt by nail guns and treated in emergency departments. Carotid arterial injury by nail gun has been reported, but vertebral artery damage is extremely rare. Case Description A 42-year-old man was transported to the emergency department after suffering an accidental self-inflicted nail gun injury to the left lateral aspect of his neck. Radiographic imaging of the cervical spine revealed a 3.1-cm metallic nail in the C5 region. A computed tomography (CT) angiogram revealed the nail passing through the left C5 transverse foramen and compressing the left vertebral artery. He was immediately brought to the operating room for removal of the nail. At 1-month follow-up, the patient did not have any neck complaints and postoperative CT angiogram indicated the patient was asymptomatic with no signs of complication or infection. Conclusions Based on our experience and a review of the literature, in terms of treating a nail gun injury to the cervical spine, we would like emphasize that preoperative CT scan or CT angiogram is necessary to assess the location and shape of the nail, especially nails with barbers or washers. Improving awareness of the risk from accidental nail gun trauma may lead to better prevention of this rare but potentially life-threatening injury.

Background Third molar extraction is one of the most common procedures performed by oral surgeons, however with rare complications. The accidental displacement of a maxillary third molar into the infratemporal fossa (ITF) is a rare complication that can occur even with experienced surgeons. Case presentation We describe the case of a 17-year-old patient whose right upper third molar was accidentally pushed to the ITF associated with a cellulitis and the late discovery of a textiloma (a surgical gauze). Conclusions Extraction of third molars is a safe surgical procedure when performed in appropriate conditions. The diagnosis of textiloma following a maxillo-facial surgery is extremely rare. It is important to take into account this possibility in order to avoid delaying treatment when it occurs.

Accidents are the fourth cause of death, after heart disease, cancer and stroke, ±50 increases per year 100,000 population each year, 3% of the causes of death are due to direct spinal cord trauma, 2% due to multiple trauma. Attitudes or responses are very closely related to the handling of pre-hospital prevention of cervical injury in traffic accident patients because a positive response will affect the accuracy in handling pre-hospital prevention of cervical injury in traffic accident patients. This study aims to determine the relationship of perceptions with public attitudes about the handling of pre-hospital prevention of cervical injury in traffic accident patients in the village of Watdek, Southeast Maluku. The design of this study is a correlation with approach cross sectional. The sample size is 67 respondents. Sampling using simple random sampling, data collection using questionnaires and calculation processes using the test chi-square using SPSS 18.0 α 0.05 error. The results of this study showed that most 32 respondents had sufficient perceptions and 13 of them had negative attitudes in handling pre-hospitals cervical injury prevention and a small proportion of respondents (5 respondents) had good perceptions and positive attitudes. A good perception, especially in the pre-hospital treatment of cervical injury prevention in traffic accident patients will be intelligence, especially a positive response if you meet with an accidental community with the attitude that is in accordance with the first limping procedure in patients with cervical injury. So that the action can help patients before arriving at a health facility.

The accidental use of drugs is an unacceptable mistake in medicine, but the misuse of different agents has been reported frequently in the literature. While performing local anesthesia before starting dental treatment, the injection of a wrong agent, as a result of confusing the liquid in the syringe may cause local and systemic complications. Sudden swelling, intense pain, and severe allergic reactions may develop in the patient. A complication causing soft tissue necrosis is presented in this case report in which Ethylenediaminetetraacetic acid (EDTA) was accidentally injected instead of an anesthetic solution. This case report is unique because it is the first to report an inadvertent injection of EDTA in dentistry.

A variety of chemicals have been linked to occupational liver diseases, including several solvents and mixtures thereof, pesticides, and metals. Workplace exposures have been associated with virtually the entire spectrum of acute and chronic liver diseases. However, their prevalence is inadequately quantified and their epidemiology limited. Occupational liver diseases may result from high accidental or from prolonged lower level exposures. Whereas the former is uncommon and easily recognised, the latter are relatively more frequent but often overlooked because they may display normal values of conventional markers, have an insidious onset and be asymptomatic or be obfuscated and confounded by concurrent conditions. In addition, specific tests of toxicity are not available, histopathology may not be revealing and the assessment of internal dose of chemicals is usually not decisive. Given these circumstances, the diagnosis of these liver disorders is challenging, one of exclusion and often requires an interdisciplinary approach. These recommendations offer a classification of the type of liver injuries associated with occupational exposures - based in part on the criteria for drug-induced liver injury - a grading of their severity, and the diagnostic and preventive criteria for chemically induced occupational liver disease.

Poisoning with chemical agents was once thought to be confined to the battlefield. However, over the past decade there has been an increase in the use of chemical weapon agents and toxic industrial chemicals as weapons of terror. As well as use during conflict, these poisons have been used in other attacks with deadly effects. These agents require particular treatments that fall out with standard medical practice to reduce harm and prevent contamination of medical treatment facilities. The risk of a mass casualty incident with a deliberate or accidental release is a possibility.

Hanging is a form of death caused by constriction of the neck by a ligature, where the constricting force is derived from the gravitational drag of the victim's body weight. Death by hanging is common amongst those victims of suicide and the overall rates of death by this mean has increased in the United Kingdom. Hanging deaths are becoming increasingly important to pathologists who may be required to conduct a post-mortem examination on such victims. A crucial aspect of the post-mortem examination in deaths caused by hanging is the detection and documentation of both external and internal injuries. Injuries play a decisive role in determining the manner of death, particularly if doubt exists as to whether the cause is suicidal, accidental or by homicide. Although there are no standards specifically directed at post-mortem examination in cases of fatal hanging to assist pathologists in identifying, describing and appreciating the gravity of their findings, general autopsy guidelines are published by the Royal College of Pathologists and are applicable to deaths by this means. Whilst the incidence of external injuries in hanging is consistent across the literature, significant variation exists regarding the presence of internal injuries, particularly fractures to bony and cartilaginous structures in the neck. A recent publication observed especially low fracture rates at autopsy, contradicting many previous studies including a pilot study conducted in Liverpool. Although various explanations exist, differences in dissection techniques could be important. In cases where the quality of the autopsy methods used is less certain, important internal injuries may remain undetected. Providing a good quality service includes auditing of that service. Auditing of the practices by pathologists regarding their description and detection of injuries in hanging cases may help evaluate and improve the standards of the post-mortem examination and subsequent reporting and also clarify the current uncertainty regarding internal injuries. A greater understanding of the pattern of injuries sustained in hanging may inform pathologists about what findings to anticipate and potentially improve identification of these injuries.