There have been multiple incidents where doctors have been assaulted by patient relatives and hospital facilities have been vandalized. This has led to mass agitations by Physicians across India. Violence and vandalism against health-care workers (HCWs) is one of the biggest public health and patient care challenge in India. The sheer intensity of emotional hijack and the stress levels in both practicing HCWs and patient relative's needs immediate and detail attention. The suffering of HCWs who are hurt, the damage to hospital facilities and the reactionary agitation which affects patients who need care are all together doing everything to damage the delivery of health care and relationship between a doctor and a patient. This is detrimental to India where illnesses and Injuries continue to be the biggest challenge to its growth curve. The expert group set by The Academic College of Emergency Experts and The Academy of Family Physicians of India makes an effort to study this Public Health and Patient Care Challenge and provide recommendations to solve it.

Post traumatic stress disorder is a psychiatric disease that is usually precipitated by life threatening stressors. Myocardial infarction, especially in the young can count as one such event. The development of post traumatic stress after a coronary event not only adversely effects psychiatric health, but leads to increased cardiovascular morbidity and mortality. There is increasing evidence that like major depression, post traumatic stress disorder is also a strong coronary risk factor. Early diagnosis and treatment of this disease in patients with acute manifestations of coronary artery disease can improve patient outcomes.

Organ procurement (OP) from donors after brain death and circulatory death represents the primary source of transplanted organs. Despite favorable laws and regulations, OP continues to face challenges for a number of reasons, including institutional, personal, and societal barriers. This focused review presents some of the key components of a successful OP program at a large, high-performing regional health network. This review focuses on effective team approaches, aggressive resuscitative strategies, optimal communication, family support, and community outreach efforts.

Introduction: In most countries, occurrence of traffic causalities is high in pedestrians. The aim of this study is to geographically analyze the traffic casualties in pedestrians in downtown Tehran city. Methods: The study population consisted of traffic injury accidents in pedestrians occurred during 2015 in Tehran city. Data were extracted from offices of traffic police and municipality. For analysis of environmental factors and site of accidents, ordinary least square regression models and geographically weighted regression were used. Fitness and performance of models were checked using the Akaike information criteria, Bayesian information criteria, deviance, and adjusted R². Results: Totally, 514 accidents were included in this study. Of them, site of accidents was arterial streets in 370 (71.9%) cases, collector streets in 133 cases (25.2%), and highways in 11 cases (2.1%). Geographical units of traffic accidents in pedestrians had statistically significant relationship with a number of bus stations, number of crossroads, and recreational areas. Conclusion: Distribution of injury traffic accidents in pedestrians is different in downtown Tehran city. Neighborhoods close to markets are considered as most dangerous neighborhoods for injury traffic accidents. Different environmental factors are involved in determining the distribution of these accidents. The health of pedestrians in Tehran city can be improved by proper traffic management, control of environmental factors, and educational programs.

Background: Good quality information on characteristics of victims, types, and frequency of injuries, causes of accidents, vehicles involved in injury and outcome is essential for understanding and planning required for managing the trauma epidemic. The objective of this study was to describe the characteristics of trauma victims admitted to King George's Medical University trauma center. Methods: This observational study enrolled trauma victims over a 1-year period. Characteristics recorded were age, sex, systolic blood pressure at admission, respiratory rate at admission, Glasgow Coma Scale (GCS) score at the time of admission, time since injury to admission, referral, specific injury, Injury Severity Score (ISS), chronic medical condition, mechanism of injury, and the regions involved. Outcome at the end of hospital stay was recorded. Results: A total of 3280 injuries were recorded in 2288 patients. Mean age 40.81 ± 16.3 years, predominantly male (83.57%), mean ISS 12.56 ± 7.3, mean GCS 12.20 ± 4.1. Mean time to admission (hospitalization) to trauma center was 54.22 ± 185.2 h. Head was the most commonly involved region (32.44%). Patients referred from peripheral hospitals had significantly lower GCS, higher time to admission to trauma center, and longer duration of hospital stay. Road traffic accidents were responsible for 1514 (66.40%) injuries. Five hundred and ten (22.37%) patients sustained injury due to a fall. Three hundred and ninety (68.59%) patients were discharged, 67 (11.69%) left the hospital against medical advice, 8 absconded from the trauma center, and 104 expired within the hospital. Conclusion: Traumatic brain injuries and orthopedic injuries constitute a majority of injured admitted to the trauma center. Motorcycle collision with other vehicles and pedestrian hits by other vehicles are the most common causes of traumatic brain injuries. In contrast to west, the most common cause of spinal cord injury was falls. Pedestrians, bicyclists, and motorcyclists are the vulnerable road users. Long time to admission is an alarming finding.

Background: A drug shortage of cisatracurium led to use of atracurium as an alternative neuromuscular blocker (NMB). Cisatracurium may be preferred due to less histamine release and potentially less hypotension. The study purpose is to compare the incidence of hypotension with continuous infusion atracurium to continuous infusion cisatracurium in ICU patients. Materials and Methods: This retrospective cohort analysis reviewed 119 ICU patients who received either continuous infusion atracurium (56) or cisatracurium (63). The primary outcome was the incidence of hypotension (mean arterial pressure <60mmHg). Secondary outcomes included: incidence of blood pressure decrease of >20% from baseline, time to first hypotensive episode, treatment for hypotension during NMB use, hospital mortality, ICU and hospital length of stay (LOS), duration of mechanical ventilation (MV), and NMB duration. Results: Hypotension occurred in 64.3% of atracurium patients and 58.7% of cisatracurium patients (P = 0.58), with 60.7% experiencing >20% drop in blood pressure in atracurium group and 54.0% in cisatracurium (P = 0.58). Median time to first hypotensive episode was 9.4[Interquartile range 1.17-19.7] hours atracurium and 4.4[1.5-13.9] hours cisatracurium (P = 0.36). There were no differences between atracurium and cisatracurium groups respectively for median ICU LOS (10.5 days and 12.4 days, P = 0.34), hospital LOS (14.0 days and 17.7 days, P = 0.37), MV duration (9.3 days and 10.5 days, P = 0.43), infusion duration (34.5 hours and 25 hours P = 0.27), or hospital mortality (62.5% and 53.9%, P = 0.336). Hypotension treatment was similar between groups. Conclusions: The incidence of hypotension was similar between atracurium and cisatracurium. Critical drug shortages may provide an opportunity to study alternative drug therapy.

Neuroleptic malignant syndrome (NMS) is a life-threatening neurological disorder associated with the use of antipsychotic medications. Many of its classic signs, such as fever and altered mental status, are nonspecific in trauma intensive care unit (ICU) patients, and its rarity makes it a difficult diagnosis in this population. However, delays in treatment can be costly both in terms of hospital resources and patient outcomes. We herein report a case of a 54-year-old trauma patient with NMS precipitated by a combination of cocaine withdrawal and neuroleptic medications. Few cases of NMS in the intubated polytrauma patient have been described in the literature previously. Given the poor outcomes associated with this disorder, ICU patients would benefit from risk stratification and avoidance of neuroleptic medications in those at highest risk for NMS, particularly patients who are withdrawing from dopaminergic agents.

Successful treatment of traumatic hemothoraces is imperative to reduce morbidity and mortality among patients. Treatment modalities range from more conservative to invasive measures, including antibiotic therapy, thoracostomy tube placement, video-assisted thoracoscopic surgery, or thoracotomy. Various studies have documented success in using fibrinolytics such as tissue plasminogen activator (tPA) in conjunction with deoxyribonuclease administered through a chest tube to resolve a hemothorax. The optimal dose and frequency of fibrinolytic therapy have not yet been determined although most studies report administering therapy two times a day for 3 days. We report a successful case of a one-time dose of fibrinolytic therapy through thoracostomy tube which could support that a single dose may be ideal and sufficient enough to resolve a hemothorax. We also performed this in the acute postoperative period, which has not been well studied, and believe fibrinolytic therapy can be safe to use in this setting.

Intraventricular rupture of craniopharyngioma cysts is an unusual event which is associated with a high risk of loculated or communicating hydrocephalus. A 75-year-old woman presented at the Emergency Department of our hospital with mental status deterioration due to chemical ventriculitis and acute hydrocephalus following the intraventricular rupture of a craniopharyngioma cyst. The patient was treated with stress-dose steroid therapy. In addition, she underwent placement of an external ventricular drain and endoscopy-assisted intra-cystic placement of an Ommaya reservoir for the aspiration of the cystic fluid. The patient's condition improved; she was shunted in an expeditious fashion and discharged from the Intensive Care Unit within 2 weeks of her admission with the reservoir in place for the continued drainage of the cyst.