Objective: To describe and compare the work of breathing (WOB) during spontaneous breathing under four conditions: (1) breathing through a tracheostomy tube with an inflated cuff, (2) breathing through the upper airway (UA) with a deflated cuff and occluded tube, (3) breathing through the UA with an occluded cuffless tube, and (4) postdecannulation. Patients and Methods: Patients who tolerated an occluded cuffless tube were included. Ventilatory variables and esophageal pressure were recorded. The pressure-time product (PTP), PTP/min, and PTP/min/tidal volume (PTP/min/VT) were measured. Each condition was measured for 5 min with a 15 min time interval between evaluations. Quantitative data are expressed as mean ± standard deviation. Single-factor analysis of variance was used, and the Games-Howell test was used for post hoc analysis of comparisons between group means (P ≤ 0.05). Results: Eight patients were studied under each of the four conditions described above. Statistically significant differences were found for PTP, PTP/min, and PTP/min/VT. In the post hoc analysis for PTP, significant differences among all conditions were found. For PTP/min, there was no significant difference between Conditions 2 and 4 (P = 0.138), and for PTP/min/VT, there was no significant difference between Conditions 1 and 2 (P = 0.072) or between Conditions 2 and 3 (P = 0.106). A trend toward a higher PTP, PTP/min, and PTP/min/VT was observed when breathing through a cuffless tracheostomy tube. Conclusion: The four conditions differed with respect to WOB. Cuff inflation could result in a reduced WOB because there is less dead space. Cuffless tracheostomy tubes generate increased WOB, perhaps due to the material deformity caused by body temperature.

Context: The epidemiology and outcome of critical illness in Mongolia remain undefined. Aim: The aim of this study was to evaluate the epidemiology and outcome of critical illness in Mongolia. Settings and Design: This is a multicenter, prospective, observational cohort study including 19 Mongolian centers. Materials and Methods: Demographic, clinical, and outcome data of patients >15 years admitted to the Intensive Care Units (ICUs) were collected during a 6-month period. Statistical Analysis: Descriptive methods, Mann–Whitney-U test, Fisher's exact or Chi-square test, and logistic regression analyses were used for statistical analysis. Results: Two thousand and thirty-two patients (53.6% male) with a median age of 49 years (36–62 years) were included. The most frequent ICU admission diagnoses were stroke (17.4%), liver failure (9.2%), heart failure (9%), infection (8.3%), severe trauma (7.5%), traumatic brain injury (7.1%), acute abdomen (7%), pre-eclampsia/eclampsia (5.8%), renal failure (3.9%), and postoperative care following elective and emergency surgeries (3.2%). ICU mortality was 23.5% in the study population and 26.6% when maternal cases were excluded. The five ICU admission diagnoses with the highest ICU mortality were lung tuberculosis (51.9%), traumatic brain injury (42.1%), liver failure (33.7%), stroke (31.9%), and infection (30.8%). The five ICU admission diagnoses causing most death cases were stroke (n = 113), liver failure (n = 63), traumatic brain injury (n = 61), infection (n = 52), and acute abdomen (n = 38). Conclusion: Critical illness in Mongolia affects younger patients compared to high-income countries. ICU admission diagnoses are similar with a particularly high incidence of stroke and liver failure. ICU mortality is approximately 25% with most deaths caused by stroke, liver failure, and traumatic brain injury.

Background: Dexmedetomidine is commonly used for sedation in the Intensive Care Unit (ICU), and its use may be associated with hypotension. We sought to determine predictors of dexmedetomidine-associated hypotension. Methods: Retrospective, single-center study of 283 ICU patients in four adults ICUs over a 12 month period. Univariate analyses were performed to determine factors associated with dexmedetomidine-related hypotension. Risk factors significant at the 0.20 level in the univariate analysis were considered for inclusion into a step-wise multiple logistical regression model. Results: Hypotension occurred in 121 (42.8%) patients with a median mean arterial pressure (MAP) nadir of 54 mmHg. Univariate analyses showed an association between hypotension and age (P = 0.03), Acute Physiology and Chronic Health Evaluation II (APACHE II) score (P = 0.02), baseline MAP (<0.001), admission to the cardiothoracic ICU (P = 0.05), history of coronary artery disease (P = 0.02), and postcardiac surgery (P = 0.0009). Admission to the medical ICU was associated with a decrease in development in hypotension (P = 0.03). There was a trend for hypotension with weight (P = 0.09) and history of congestive heart failure (P = 0.12) Only MAP prior to initiation (odds ratio [OR] 0.97, 95% confidence interval [95% CI] 0.95–0.99;P < 0.0001), APACHE II scores (OR 1.06, 95% CI 1.01–1.12;P= 0.017), and history of coronary artery disease (OR 0.48, 95% CI 0.26–0.90,P= 0.022) were independently associated with hypotension by multivariable analysis. Conclusions: Dexmedetomidine-associated hypotension is common. Preexisting low blood pressure, history of coronary artery disease, and higher acuity were identified as independent risk factors for dexmedetomidine-associated hypotension.

Introduction: In North India snake bite deaths are predominantly seen with neurotoxic envenomations (NEs) whereas in South India the hemotoxic envenomation (HE) is more common. Krait is responsible for most deaths in North India. It bites people sleeping on the floors, mostly at night. We describe the profile of venomous snake bites over 1 year in 2013. Materials and Methods: The study was conducted in a rural tertiary care hospital in North India. Demographics, circumstances of bite, envenomation, first aid, delay, consultation, treatment, anti-venom, and outcomes were recorded for all victims of snake bite. We included all consecutive adult (>18 years) venomous snake bite victims admitted from January to December 2013. Results: A total of 91 patients with venomous snake bites were included in the study. Pure NEs were 41 (45.1%), pure HE in 31 (34.1%), 7 (7.7%) had mixed NE + HE, and 12 (13.2%) had only local swelling. Forty patients (44%) were bitten during sleep presenting as NE (92.5%), NE + HE (5%), and HE (2.5%). Findings in the 51 patients (56%) bitten during activity were HE (58.8%), local swelling (23.5%), NE + HE (9.8%), and NE (7.8%) (P < 0.0001). First aid was sought by 24 NE patients out of which 23 (96%) went to alternate practitioners or religious healers. Conclusion: Almost all (97.5%) bites during sleep resulted in NE in our study. About 96% of NE sought first aid from alternate practitioners or religious healers in hope of some magical treatment. Thus, a deadly combination of krait bite during sleep and wrong health seeking behavior is responsible for high mortality krait bites in this region. Mass public awareness regarding krait bites can prevent mortality in many such cases.

Background: Hemorrhagic shock (HS) is the major leading cause of death after trauma. Up to 50% of early deaths are due to massive hemorrhage. Excessive release of pro-inflammatory cytokine and hypercatecholamine induces hematopoietic progenitor cells (HPCs) apoptosis, leading to multiorgan failure and death. However, still, result remains elusive for hematopoietic stem cells (HSCs) behavior in trauma HS (T/HS). Objectives: Therefore, our aim was to evaluate thein vitro HSCs behavior with or without recombinant human erythropoietin (rhEPO), recombinant human granulocyte macrophage-colony-stimulating factor (rhGM-CSF), recombinant human interleukin-3 (rhIL-3) alone, and combination with rhEPO + rhGM-CSF + rhIL-3 (EG3) in T/HS patients. Methodology: Bone marrow (BM) aspirates (n = 14) were collected from T/HS patients, those survived on day 3. BM cells were cultured for HPCs: Colony-forming unit-erythroid (CFU-E), burst-forming unit-erythroid (BFU-E), and colony-forming unit-granulocyte, monocyte/macrophage colonies growth. HPCs were counted with or without rhEPO, rhGM-CSF, rhIL-3 alone, and combination with EG3 in T/HS patients. Results: BM HSCs growth significantly suppressed in T/HS when compared with control group (P < 0.05). In addition, CFU-E and BFU-E colony growth were increased with additional growth factor (AGF) (rhEPO, rhGM-CSF, and rhIL-3) as compared to baseline (without AGF) (P < 0.05). Conclusion: Suppressed HPCs may be reactivated by addition of erythropoietin, GM-CSF, IL-3 alone and with combination in T/HS.

Background: A reliable prediction of outcome for the victims of traumatic brain injury (TBI) on admission is possible from concurrent data analysis from any systematic real-time registry. Objective: To determine the clinical relevance of the findings from our TBI registry to develop prognostic futuristic models with readily available traditional and novel predictors. Materials and Methods: Prospectively collected data using predesigned pro forma were analyzed from the first phase of a trauma registry from a South Indian Trauma Centre, compatible with computerized management system at electronic data entry and web data entry interface on demographics, clinical, management, and discharge status. Statistical Analysis: On univariate analysis, the variables with P < 0.15 were chosen for binary logistic model. On regression model, variables were selected with test of coefficient 0.001 and with Nagelkerke R ² with alpha error of 5%. Results: From 337 cases, predominantly males from rural areas in their productive age, road traffic injuries accounted for two-thirds cases, one-fourths occurred during postmonsoon while two-wheeler was the most common prerequisite. Fifty percent of patients had moderate to severe brain injury; the most common finding was unconsciousness followed by vomiting, ear bleed, seizures, and traumatic amnesia. Fifteen percent required intracranial surgery. Patients with severe Glasgow coma scale score were 4.5 times likely to have the fatal outcome (P = 0.003). Other important clinical variables accountable for fatal outcomes were oral bleeds and cervical spine injury while imperative socio-demographic risk correlates were age and seasons. Conclusion: TBI registry helped us finding predictors of clinical relevance for the outcomes in victims of TBI in search of prognostic futuristic models in TBI victims.

Background: Acute lower extremity compartment syndrome (CS) is a condition that untreated causes irreversible nerve and muscle ischemia. Treatment by decompression fasciotomy without delay prevents permanent disability. The use of intracompartmental pressure (iCP) measurement in uncertain situations aids in diagnosis of severe leg pain. As an infrequent complication of lower extremity trauma, consequences of CS include chronic pain, nerve injury, and contractures. The purpose of this study was to observe the clinical and functional outcomes for patients with lower extremity CS after fasciotomy. Methods: Retrospective chart analysis for patients with a discharge diagnosis of CS was performed. Physical demographics, employment status, activity at time of injury, injury severity score, fracture types, pain scores, hours to fasciotomy, iCP, serum creatine kinase levels, wound treatment regimen, length of hospital stay, and discharge facility were collected. Lower extremity neurologic examination, pain scores, orthopedic complications, and employment status at 30 days and 12 months after discharge were noted. Results: One hundred twenty-four patients were enrolled in this study. One hundred and eight patients were assessed at 12 months. Eighty-one percent were male. Motorized vehicles caused 51% of injuries in males. Forty-one percent of injuries were tibia fractures. Acute kidney injury occurred in 2.4%. Mean peak serum creatine kinase levels were 58,600 units/ml. Gauze dressing was used in 78.9% of nonfracture patients and negative pressure wound vacuum therapy in 78.2% of fracture patients. About 21.6% of patients with CS had prior surgery. Nearly 12.9% of patients required leg amputation. Around 81.8% of amputees were male. Sixty-seven percent of amputees had associated vascular injuries. Foot numbness occurred in 20.5% of patients and drop foot palsy in 18.2%. Osteomyelitis developed in 10.2% of patients and fracture nonunion in 6.8%. About 14.7% of patients underwent further orthopedic surgery. At long-term follow-up, 10.2% of patients reported moderate lower extremity pain and 69.2% had returned to work. Conclusion: Escalation in leg pain and changes in sensation are the cardinal signs for CS rather than reliance on assessing for firm compartments and pressures. The severity of nerve injury worsens with the delay in performing fasciotomy. Standardized diagnostic protocols and wound treatment strategies will result in improved outcomes from this complication.

Background: Femur fracture (FF) is a common injury, and intramedullary nailing (IMN) is the standard surgical fixation. However, the time of intervention remains controversial. We aimed to describe the reamed IMN (rIMN) timing and hospital outcomes in trauma patients presenting with FF. Materials and Methods: A retrospective analysis was conducted for all patients admitted with FF and they underwent fixation at level 1 trauma unit between January 2010 and January 2012. Patients were divided into Group I with early rIMN (<12 h) and Group II with late rIMN (≥12 h). Patients' demographics, clinical presentations, mechanism of injury, pulmonary complications, organ failure, length of stay, and mortality were described. Results: A total of 307 eligible patients with FF were identified (156 patients in Group I and 151 patients in Group II). Patients in Group II were older (36 ± 18 vs. 29 ± 9;P= 0.001) and had higher rate of polytrauma (35% vs. 18%,P= 0.001), head injury (5% vs. 12%,P= 0.68) and bilateral FF (10.7% vs. 5.1%;P= 0.07) in comparison to Group I. Group II had longer stay in Intensive Care Unit (7 [1–56] vs. 2 [1–17] days;P= 0.009) and hospital (13 [2–236] vs. 9 [1–367];P= 0.001). There were no significant differences in outcomes between the two groups in terms of sepsis, renal failure, fat embolism, adult respiratory distress syndrome and death. Conclusions: Based on this analysis, we believe that early rIMN is safe in appropriately selected cases. In patients with traumatic FFs, early rIMN is associated with low hospital complications and shorter hospital stay. The rate of pulmonary complications is almost the same in the early and late group. Further prospective randomized studies with large sample size would be ideal using the information garnered from the present study.

Introduction: Exsanguinating pelvic fractures are still associated with a significant mortality rate of 28-60%. Extraperitoneal pelvic packing (EPP) has been proposed as an optimal method of early haemorrhage control. The aim of this study was to determine the effect of EPP compared with angioembolization as a primary intervention for patients with exsanguinating pelvic fracture. Method: A prospective observational trial was performed at Westmead Hospital between September 2011 and May 2014. Adult patients with exsanguinating pelvic fracture were allocated into one of two treatment groups determined by the primary/initial haemorrhage control technique: 1. EPP followed by angioembolization or 2. Angioembolization alone. The intervention was determined by the on-call surgeon's proficiency with EPP. Demographic, clinical and laboratory data were collected. Univariate analysis of the two groups was performed with Student's t-test, Mann-Whitney-U test and Fisher's exact test. Results: 24 exsanguinating pelvic fracture cases were included. 14 underwent EPP while 10 underwent angioembolization as the primary intervention. Although not statistically significant, the EPP group was more severely injured (Injury Severity Score 32 vs. 23), more acidotic (base deficit 7.9 vs. 6.2), and more hypotensive (Systolic Blood Pressure 74.2 vs. 84.3). Despite these differences, mortality was reduced (7.1% vs. 30%, not significant). Time to EPP compared with angioembolization was reduced (67.6 vs. 130.2 minutes,P= 0.017). Pre-angioembolization transfusion requirement was also reduced with EPP (0.032 vs. 0.052 units/min,P= 0.04). Arterial injury was found in 51% of the EPP group. There were no significant differences in complication rates between the groups. Conclusion: EPP appears to be a safe and efficient technique for primary haemorrhage control in exsanguinating pelvic fractures. Given the high rate of associated arterial injury, EPP should be considered as the first part of a “damage control” approach for exsanguinating pelvic fractures.

There are many complications associated with the left ventricular assist devices (LVADs), including gastrointestinal bleeding (GIB). We present a case of a pseudo colonic mass visualized on colonoscopy during workup for GIB in an LVAD patient necessitating a right colectomy with final pathology negative for malignancy. A review of the literature in regards to the pathology, diagnosis, and treatment of this interesting condition is included.