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Background: We aimed to investigate the incidence of new acute myocardial infarction (AMI), in patients with Coronavirus disease (COVID-19) who had old MI. We hypothesized that COVID-19 increases the rate of repeated AMI in this population regardless of age and gender., Methods: A retrospective analysis was conducted for adult patients admitted with COVID-19 and developed thromboembolic event (TEE) in 2020. Patients were categorized based on the history of old MI, new MI, age, and gender., Results: Among 16,903 patients with COVID-19 who were admitted, 210 (1.2%) developed TEE (89% were males, 55% were <55 years old, and 80.5% had an old MI). COVID-19 was severe in 32% of cases. AMI occurred in 160 patients (42.5% STEMI and 57.5% NSTEMI). In patients with prior MI, 92.5% developed another AMI. NSTEMI was higher in patients with severe COVID-19 than STEMI (33% vs 21%). Patients with severe COVID-19 had higher mortality (39.4% vs 5.6%), fewer rates of prior MI (74% vs 83%), hypertension (40% vs 60%), and STEMI (31.8% vs 46.5%) than mild COVID-19 patients. On multivariable analysis, COVID-19 severity was an independent predictor of mortality (OR10; 95%CI 1.62-67.19) after adjustment for age, gender, diabetes mellitus, C-reactive protein, serum Ferritin, Procalcitonin, and Fibrinogen values, and prior or new MI., Conclusions: Patients with old MI could develop a new AMI in 80% of COVID-19. However, the mortality was higher in patients without a history of MI due to the severity of COVID-19. Attention should be given to patients who possess thrombotic risk factors in pandemics., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2024.)

Chylothorax is the accumulation of lymphatic fluid (chyle) within the pleural space. There are multiple causes, including traumatic and non-traumatic mechanisms. Trauma can cause disruption of the thoracic duct either by direct damage or indirect crushing or avulsion mechanisms. Non-traumatic causes include infections, inflammatory processes, malignancies, and iatrogenic injury (during surgery or central venous access). The traditional management of traumatic chylothorax has been either a conservative approach, including complete Nil Per Os (NPO), or a low-fat diet with medium-chain triglyceride supplementation with the administration of somatostatin or its analog, octreotide, versus a surgical approach consisting of thoracic duct ligation. Recently a less invasive approach via thoracic duct embolization has gained popularity. There have been a few reports of the successful use of an α 1-adrenergic agonist (midodrine) as an adjunct in the conservative approach. We describe the utility of midodrine in three cases of chylothorax and propose a management algorithm., Learning Points: The initial diagnosis of chylothorax is based on clinical suspicion and proper imaging.The clinical success of midodrine use as a first-line medical treatment for chylothorax will support the use of midodrine before considering invasive procedures.We propose a management algorithm for patients with chylothorax that will stimulate researchers to conduct prospective studies to assess its efficacy., Competing Interests: Conflicts of Interests: The Authors declare that there are no competing interests., (© EFIM 2024.)

Background: Airbags have significantly reduced the morbidity and mortality associated with trauma following motor vehicle crashes. However, airbags can also be associated with unusual and complex patterns of injuries which could be fatal in some cases., Methods: We collected data and described a series of six cases of penetrating injuries related to airbag deployment that were treated at the Hamad Trauma Center (HTC) of Hamad Medical Corporation which is the only level 1 trauma center in the country., Results: The penetrating injuries were caused by a metal fragment from the inflator component of the airbag which acted as a projectile and was associated with two fatalities. Four of the victims were involved in head on collisions. Most injuries were directly attributable to the airbag projectile, and they occurred in vehicles that were 9 years or more since manufacture., Conclusion: This case series would help the trauma healthcare providers to better understand the airbag-related injuries which influence the management approach for road traffic injuries associated with penetrating trauma. Also, it would bring attention to injury prevention teams as well as state and industrial authorities to reevaluate safety standards in vehicles. Sharing this information with local authorities who govern product safety standards and recalls is essential to ensure that more safety actions are taken to prevent further airbag deployment injuries., Competing Interests: The authors declare no conflict of interest., (© 2023 The Author(s).)

Background: Pulmonary lacerations caused by an avulsion force on an adhesion between the lung and chest wall following blunt thoracic injury are very rare. They may result in pneumothorax and/or hemothorax and may not be immediately apparent clinically or radiologically., Case Presentation: We present the case of a healthy 34-year-old male who sustained blunt thoracic injury. He was clinically stable, and his initial routine images were unremarkable. The patient was discharged home on the same day. He presented a week later with a massive hemothorax requiring surgical intervention which revealed bleeding from an avulsed adhesion between the lung and chest wall. Bleeding was successfully controlled by hemostatic agent, and the patient had an uneventful recovery., Conclusion: Hemothorax requiring intervention from an avulsed adhesion may occur following blunt thoracic trauma. Initial imaging and clinical finding may be misleading. Close follow up and adequate patient education should be ensured prior to discharge following seemingly trivial trauma., Competing Interests: All the authors have no conflict of interest and financial issue to disclose., (© 2023 The Authors.)

Introduction: Acute kidney injury (AKI) indicates an impairment of the renal function following blunt trauma. It is multifactorial and associated with an increased risk of morbidity and mortality. The incidence and risk factors of AKI in young patients with trauma are not well-described. This study aimed to evaluate the incidence, clinical characteristics, and outcomes of post-traumatic AKI. We hypothesized that AKI is associated with worse outcomes in patients with trauma., Methods: This was a retrospective study of all adult trauma patients admitted to a level 1 trauma center between 2011 and 2021. AKI was diagnosed on the basis of the Kidney Disease Improving Global Outcomes criteria. Data were collected and analyzed for patients with and without AKI using chi-square test and Student's t-test. Multivariate logistic regression analysis and Kaplan-Meier curves were performed., Results: A total of 17,341 patients with trauma were evaluated, of which 140 (0.8%) developed AKI. Patients with AKI were older (40 ± 20 versus 32 ± 16 y), had more comorbidities, and had a higher injury severity score (ISS) and in-hospital mortality (65% versus 3.2%) than non-AKI patients. Direct trauma to the kidney was reported in only nine (6.4%) patients in the AKI group. Among patients with AKI, nonsurvivors had a higher ISS and were more likely to have hypotension, elevated serum lactate, positive troponin, and a lower platelet-to-lymphocyte ratio than survivors. Multiple logistic regression analyses showed that age, ISS, acute respiratory distress syndrome, blood transfusion, diabetes mellitus, onadmission Glasgow coma scale score, and shock index were predictors of AKI in trauma patients, whereas ISS (odds ratio (OR) = 1.05; 95% confidence interval (CI):1.003-1.100; P = 0.03), serum lactate level (OR = 1.25; 95% CI: 1.019-1.533; P = 0.03), and hypotension (OR = 3.22; 95% CI: 1.044-9.945; P = 0.04) were independent predictors of mortality in patients with posttraumatic AKI. Kaplan-Meier survival analysis showed significant differences in mortality among the three stages of AKI (P = 0.03), with the worst outcome in stage III. However, after adjusting for age, hypotension, and ISS, the Cox regression model showed that only stage I had better survival than stages II and III, whereas no survival difference was noted between stages II and III (P = 0.06)., Conclusions: AKI in young trauma patients is uncommon and associated with a prolonged hospital course and higher mortality. This study identified factors that independently predicted the development of AKI and its outcomes in patients with trauma. However, further prospective and multicenter studies are required to minimize the incidence and complications of posttraumatic AKI., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Femur shaft factures (FSF) are common injuries following high-energy mechanisms mainly involving motor vehicle crashes (MVC). We evaluated the timings of nailing management and analyzed the pattern of fracture union and outcome in a level 1 trauma center., Methods: This was a retrospective observational study of all the admitted trauma patients who sustained femoral fractures between January 2016 and September 2020. Data were analyzed and compared based on time to Intramedullary Nailing (IMN) (<12 h, 12-24 h and >24 h) and outcomes of FSF (union, delayed union and nonunion)., Results: A total of 668 eligible patients were included in the study, of which the majority were males (90.9%) with a mean age of 34.5 ± 15.8, and 54% of the injuries were due to MVCs. The chest (35.8%) was the most commonly associated injured body region, followed by the pelvis (25.9%) and spine (25.4%). Most of femur fractures (93.3%) were unilateral, and 84.4% were closed fractures. The complete union of fractures was observed in 76.8% of cases, whereas only 4.2% and 3.3% cases had delayed union and nonunion, respectively, on the clinical follow-up. Patients in the delayed IMN (>24 h) were severely injured, had bilateral femur fracture ( p = 0.001) and had higher rate of external fixation, blood transfusion, pulmonary complications and prolonged hospitalization. Non-union proportion was greater in those who had IMN <24 h, whereas a delayed union was greater in IMN done after 24 h ( p = 0.5). Those with a nonunion femur fracture were more likely to have bilateral fracture ( p = 0.003), frequently had retrograde nailing ( p = 0.01), and high-grade femur fracture (AO type C; p = 0.04)., Conclusion: This study showed that femur fracture is not uncommon (8.9%), which is manifested with the variety of clinical characteristics, depending on the mechanism, management and outcome in our center. Bilateral fracture, retrograde nailing and AO classification type C were the significant risk factors of non-union in patients with diaphyseal fractures. The timing of IMN has an impact on the fracture union; however, it is not a statistically significant difference. Therefore, the treating physicians should consider the potential risk factors for a better outcome by careful selection of treatment in sub-groups of patients.

Isolated pancreatic transection is a rare surgical condition that occurs more commonly following blunt abdominal trauma. It carries a high degree of morbidity and mortality, and the management remains a source of debate as universally accepted guidelines are not well established owing to the paucity in clinical experience and large series. We presented a case of an isolated pancreatic transection following blunt abdominal trauma. The surgical management of pancreatic transection has evolved over the decades from aggressive approaches to more conservative measures. Given the lack of large series and clinical experience, no universal consensus exists, except for applying damage control surgery and resuscitation principles in critically unstable patients. For transections of the main pancreatic duct, most recommend excision of the distal pancreas. Concerns over the iatrogenic complications of wide excisions, particularly diabetes mellitus, have led to reconsideration and more conservative approaches, but it may fail in some cases., (Published by Oxford University Press and JSCR Publishing Ltd. © The Author(s) 2023.)

Background: We aimed to explore the impact of the emergency department length of stay (EDLOS) on the outcome of trauma patients., Methods: A retrospective study was conducted on all trauma patients requiring hospitalization between 2015 and 2019. Patients were categorized into 4 groups based on the EDLOS (<4 h, 4-12 h,12-24 h, and >24 h). Data were analyzed using Chi-square test (categorical variables), Student's t -test (continuous variables), correlation coefficient, analysis of variance and multivariate logistic regression analysis for identifying predictors of short EDLOS and hospital mortality., Results: The study involved 7,026 patients with a mean age of 32.1±15.6 years. One-fifth of patients had a short EDLOS (<4 h) and had higher level trauma team T1 activation (TTA-1), higher Injury Severity Score (ISS), higher shock index (SI), and more head injuries than the other groups ( P =0.001). Patients with an EDLOS >24 h were older ( P =0.001) and had more comorbidities ( P =0.001) and fewer deaths ( P =0.001). Multivariate regression analysis showed that the predictors of short EDLOS were female gender, GCS, SI, hemoglobin level, ISS, and blood transfusion. The predictors of mortality were TTA-1 (odds ratio [ OR ]=4.081, 95% CI : 2.364-7.045), head injury ( OR =3.920, 95% CI : 2.413-6.368), blood transfusion ( OR =2.773, 95% CI : 1.668-4.609), SI ( OR =2.132, 95% CI : 1.364-3.332), ISS ( OR =1.077, 95% CI : 1.057-1.096), and age ( OR =1.040, 95% CI : 1.026-1.054)., Conclusions: Patients with shorter EDLOS had different baseline characteristics and hospital outcomes compared with patients with longer EDLOS. Patients with prolonged EDLOS had better outcomes; however, the burden of prolonged boarding in the ED needs further elaboration., Competing Interests: Conflicts of interest: This study was presented in part at the 2022 Academic Surgical Congress 1-3 February 2022, Orlando, FL, USA. The authors have no conflicts of interest and no financial issues to disclose., (Copyright: © World Journal of Emergency Medicine.)

Background: We aimed to study the presentation, management, and outcomes of patients with a pancreatic traumatic injury., Methods: We retrospectively analyzed data for all patients who were admitted with pancreatic injuries between 2011 and 2017 at the only level 1 trauma center in the country., Results: There were 71 patients admitted with pancreatic trauma (0.6% of trauma admissions and 3.4% of abdominal injury admissions) with a mean age of 31 years. Sixty-two patients had pancreatic injury grade I-II and nine had injury grade III-IV. Thirty-eight percent had Glasgow Coma Scale (GCS) <9 and 73% had injury Severity Score (ISS) >16. The level of pancreatic enzymes was significantly proportional to the grade of injury. Over half of patients required laparotomy, of them 12 patients had an intervention on the pancreas. Eight patients developed complications related to pancreatic injuries ranging from pancreatitis to pancreatico-cutaneous fistula while 35% developed hemorrhagic shock. Mortality was 31% and regardless of the grade of injury, the mortality was associated with high ISS, low GCS, and presence of hemorrhagic shock., Conclusion: Pancreatic injuries following blunt trauma are rare, and the injured subjects are usually young men. However, most injuries are of low-grade severity. This study shows that regardless of the pancreatic injury grade on-admission shock, higher ISS and lower GCS are associated with worse in-hospital outcomes. Non-operative management (NOM) may suffice in patients with lower grade injuries, which may not be the case in patients with higher grade injuries unless carefully selected., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Al-Thani, Ramzee, Al-Hassani, Strandvik and El-Menyar.)

Background: We aimed to assess the prognostic value of Rotterdam and Marshall scoring systems to predict in-hospital mortality in patients with traumatic brain injury (TBI). Methods: A retrospective analysis was conducted for patients with TBI who underwent head computerized tomography (CT) scan at a Level I trauma center between 2011 and 2018. Receiver operating characteristic (ROC) curves were used to determine the cutoff values for predicting in-hospital mortality. Results: A total of 1035 patients with TBI were included with a mean age of 30 years. The mean Rotterdam and Marshall scores were higher among non-survivors ( p = .001). Patients with higher Rotterdam (>3) or Marshall (>2) CT scores were older, had higher injury severity scores and in-hospital mortality and had lower GCS and blood ethanol levels than those with lower scores. The cutoff point of Rotterdam score was 3.5 (sensitivity, 61.2%; specificity, 85.6%) and Marshall score was 2.5 (74.3% sensitivity and 76.3% specificity). Multivariable logistic regression analyses showed that Marshall and Rotterdam scoring systems were independent predictors of mortality (odds ratio 8.4; 95% confidence interval 4.95-14.17 and odds ratio 4.4; 95% confidence interval 2.36-9.39, respectively). Conclusion: Rotterdam and Marshall CT scores have independent prognostic values in patients with TBI even in alcoholic patients.

Abdominal symptoms in patients with hematological malignancies can occur due to an array of pathologies. Two diagnoses with similar presentation albeit, generally opposite treatment modalities, are typhlitis (inflammation of cecum) and acute appendicitis. Both diagnoses have to be kept in mind in such a patient presenting with right lower quadrant (RLQ) pain. Sagacious clinical judgment along with the aid of radiological imaging may help in differentiating between the two conditions. We present a case of a young male with chronic myeloid leukemia (CML) on imatinib, diagnosed and started on therapy four years earlier, who presented with symptoms of RLQ pain not typical of acute appendicitis. The accurate diagnosis was made with the assistance of ultrasound (US) imaging and prompt surgical therapy was instituted followed by a smooth postoperative recovery., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2020, Ramzee et al.)

Jejunoileal diverticulosis (JID) is a rare and nonspecific symptomatic disease. It is usually an acquired condition associated with false diverticula and integrated with colonic diverticulosis which can be diagnosed incidentally or later with complications. A sixty-nine-year-old male presented with sudden onset generalized abdominal pain. Computed tomography (CT) imaging was suggestive of ileal diverticulitis with localized perforation. The patient was treated conservatively with IV fluids and antibiotics and kept nil per orem for three days and discharged after symptoms subsided. The patient returned with a similar presentation but with a greater intensity. CT with oral contrast revealed evidence of distal ileal perforation. The terminal ileum was resected, and a double barrel ileostomy was created. Six months later, the stoma was reversed after resecting 50 cm of proximal terminal ileum which included all diverticula. The patient had a smooth postoperative recovery. Small bowel diverticulitis is generally managed conservatively unless the patient's clinical condition mandates urgent exploration. This report may add knowledge and lead to a change in clinical practice., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2020 Ahmed Faidh Ramzee et al.)

Background: Stress-induced myocardial injury is not well-studied in patients with head injury. We aimed to assess the prognostic implication of positive (+ve) Troponins (Tn) measurements by conventional (cTnT) versus High-Sensitivity (HsTnT) assay in patients with traumatic brain injury (TBI)., Methods: A retrospective analysis was conducted for patients who were admitted with TBI. Patient demographics, clinical presentation, troponin assay results, TBI lesions, and hospital outcomes were analyzed and compared based on troponin assay (cTnT versus HsTnT)., Results: Across the study period, 654 patients with TBI had troponin levels measured within 24 h postinjury (cTnT=252 and HsTnT=402). The mean age was 31 years and 46% had positive troponins. There were 147 deaths (22.5%); of them 54% had +ve HsTnT, 23% had +ve cTnT, 16% had -ve cTnT and 7% had -ve HsTnT). When the troponins were tested ≤4 h postinjury, the mortality was 10.2% in patients with -ve cTnT and 4% in patients with -ve HsTnT. There was no documented obvious direct trauma to the heart. Overall, patients with positive troponins had lower Glasgow Coma Scale (GCS), higher Injury Severity Scores and higher rates of brain edema (P=0.001), pneumonia and sepsis (P=0.001) than those with negative troponin results. In two different models, multivariate regression analysis showed that +ve cTnT and +ve HsTnT were independent predictors of mortality (OR 4.02, 95% CI: 1.72-9.39) and (OR 4.31; 95% CI: 1.76-10.57); respectively, after adjusting for age, injury severity scores, GCS at ED, head AIS, pneumonia, ARDS, surgical interventions, and chest injury., Conclusions: Although the positivity of any troponin assay is associated with high mortality post-TBI, the use of HsTnT relatively outperforms the conventional troponin assay for early risk stratification and detection of stress-induced myocyte injury in patients with TBI.

Background: We proposed a novel prognostic tool for the prediction of in-hospital mortality based on a combination of hemodynamic parameters and biomarkers in patients with traumatic brain injury (TBI). We hypothesized that a combination of shock index (SI) with high sensitive troponin T (HsTnT), the Bio-Shock Index (Bio-SI), has better prognostic power than its individual components., Methods: A retrospective chart review was conducted (2011-2018) for patients with TBI. Patients were categorized into 2 groups (low and high Bio-SI) based on the receiver operating characteristic curve., Results: A total of 2619 patients were admitted with TBI, and 1471 fulfilled the inclusion criteria and 73% had high Bio-SI (≥10). High Bio-SI values were associated with more intraventricular hemorrhage (P = 0.001), brain edema (P = 0.001), and had lower mean arterial pressure (P = 0.001), admission Glasgow Coma Scale score (P = 0.001), and higher SI (P = 0.001), serum lactate (P = 0.001), HsTnT values (P = 0.001), and Rotterdam score (P = 0.03). Patients with high Bio-SI had a prolonged hospital (P = 0.003) and intensive care unit stay (P = 0.001); longer ventilatory days (P = 0.001) and had higher rates of pneumonia (P = 0.001), sepsis (P = 0.001), and in-hospital mortality (P = 0.001). The Bio-SI showed high sensitivity and negative predictive value (91.4% and 94.4%, respectively) as compared with elevated SI (50.2% and 87.6%, respectively) and positive troponin (79.7% and 93.7%, respectively)., Conclusions: The Bio-SI is potentially a better tool than its individual components to predict in-hospital mortality among patients with TBI; however, HsTnT alone outperforms SI. Prospective studies and multicenter trials studying troponin levels and SI in all patients with TBI with the inclusion of outcome scores will prove or disprove the predictability of the new index., (Copyright © 2019 Elsevier Inc. All rights reserved.)