Publications by authors named "Ammar Al-Hassani"

28 Publications

  • Page 1 of 1

Adrenal Gland Trauma: An Observational Descriptive Analysis from a Level 1-Trauma Center.

J Emerg Trauma Shock 2021 Apr-Jun;14(2):92-97. Epub 2021 Apr 27.

Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar.

Introduction: We aimed to describe the presentation, classification, and outcome of traumatic adrenal injury in a single Level-1 trauma center.

Methods: A retrospective study was conducted to include all patients identified to have adrenal trauma from 2011 to 2014. Data were retrieved from charts and electronic medical records for all patients with adrenal trauma with a 3-year follow-up for mortality.

Results: A total of 116 patients who were admitted with adrenal injury (12.9% of abdominal trauma and 20% of total solid organ injury admissions) were included in the study, 104 were males and 12 were females. In our population, 86% of adrenal injuries involved the right adrenal gland, 14% in the left, and 12% had bilateral injuries. The majority of associated injuries were rib fractures accounting for 42%, while 37% had associated lung injuries, and 35% had head injuries. As per the American Association for the Surgery of Trauma classification, 46% of adrenal traumas were grade one. Of all adrenal trauma, 25 patients were operated (21%), whereas the majority were admitted to the intensive care unit or surgical ward. Surgical interventions were indicated for associated injury to the bowel, spleen, diaphragm, mesentery, kidneys, or inferior vena cava. One patient underwent angioembolization of the adrenal vessels due to contrast leak. The mortality rate was 14.6%, and no further mortality was reported during a 3-year follow-up. On multivariable analysis, admission systolic blood pressure, Glasgow Coma Scale, and injury severity score were predictors of hospital mortality.

Conclusions: Adrenal injury is not rare and often unilateral with right-sided predominance. Associated injuries influence the clinical findings, management, and outcome. Surgical interventions are rarely required except for few cases of active bleeding. Long-term outcome postadrenal injury is still not well studied.
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http://dx.doi.org/10.4103/JETS.JETS_63_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8312916PMC
April 2021

Relationship of Optic Nerve Sheath Diameter and Intracranial Hypertension in Patients with Traumatic Brain Injury.

J Emerg Trauma Shock 2020 Jul-Sep;13(3):183-189. Epub 2020 Sep 18.

Department of Surgery and, Hamad General Hospital, Doha, Qatar.

Background: to study the association between optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) in patients with moderate-to-severe brain injury.

Patients And Methods: A retrospective cohort study of traumatic brain injury (TBI) patients was conducted between 2010 and 2014. Data were analyzed and compared according to the ICP monitoring cutoff values. Outcomes included intracranial hypertension (ICH) and mortality.

Results: A total of 167 patients with a mean age of 33 ± 14 years, of them 96 had ICP monitored. ICP values correlated with ONSD measurement ( = 0.21, = 0.04). Patients who developed ICH were more likely to have higher mean ONSD ( = 0.01) and subarachnoid hemorrhage (SAH) ( = 0.004). Receiver operating curve for ONSD showed a cutoff value of 5.6 mm to detect ICH with sensitivity 72.2% and specificity 50%. Age and ICP were independent predictors of inhospital mortality in multivariate model. Another model with same covariates showed ONSD and SAH to be independent predictors of ICH. Simple linear regression showed a significant association of ONSD with increased ICP (β = 0.21, 95% confidence interval 0.25-5.08, = 0.03).

Conclusions: ONSD is a simple noninvasive measurement on initial CT in patients with TBI that could be a surrogate for ICP monitoring. However, further studies are warranted.
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http://dx.doi.org/10.4103/JETS.JETS_103_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717459PMC
September 2020

Traumatic Kidney Injury: An Observational Descriptive Study.

Urol Int 2020 17;104(1-2):148-155. Epub 2019 Dec 17.

Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar.

Background: Trauma is a major cause of death and disability worldwide. Renal injuries account for 8-10% of abdominal trauma. We aimed to describe the incidence, presentation, and management of traumatic kidney injury in our institution.

Methods: This is a retrospective analysis of all patients admitted with traumatic kidney injury at a level 1 trauma center between January 2014 and December 2017.

Results: During a period of 3 years, a total of 152 patients with blunt renal trauma were admitted to a level 1 trauma center; 91% of these were males, with a mean age of 32.8 ± 13.7 years. Motor vehicle crashes accounted for 68% of cases, followed by fall from height (23%). Seventy-one percent of patients had associated chest injuries, 38% had pelvis injuries, and 32% had head injury. Associated abdominal injuries included the liver (35%) and spleen (26%). The mean abdominal abbreviated injury scale was 2.8 ± 1.0; and for those with severe renal injury, it was 3.9 ± 0.9. The mean injury severity score was 24.9 ± 13.7 (31.8 ± 14.2 with renal vs. 21.9 ± 12.9 without renal injury, p = 0.004). Most of the patients were treated conservatively (93%), including severe renal injuries (grades IV and V), and 7% had surgical exploration, mainly those with severe injuries (grades IV and V). The mortality rate was 11%.

Conclusions: High-grade renal injuries in hemodynamically stable patients can be managed conservatively. A multidisciplinary approach coordinated by trauma, urology, and radiology services facilitates the care of these patients in our trauma center.
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http://dx.doi.org/10.1159/000504895DOI Listing
February 2021

Evolution of The Qatar Trauma System: The Journey from Inception to Verification.

J Emerg Trauma Shock 2019 Jul-Sep;12(3):209-217

Department of Surgery, Universidad Nacional Pedro Henriquez Urena, School of Medicine, Santo Domingo, Dominican Republic.

Traumatic injuries accounted for substantial burden of morbidity and mortality (M and M) worldwide. Despite better socioeconomic conditions and living standards, the incidence of trauma is rising in the Eastern Mediterranean Region (EMR). Road traffic injuries are the leading cause of the high fatality rate in young economically productive adults in our region. The provision of trauma care at high-volume, accredited trauma center by a team of dedicated full-time professional health-care providers has been shown to improve the quality of care and the outcomes for trauma victims. With persistent hard work and effective leadership, in Qatar, the Trauma Section has evolved into a well-reputed and internationally recognized Center of Excellence in Trauma Care, Hamad Level 1 Trauma Center. In 2014, Qatar Trauma System was accredited with Trauma Distinction Award by the Accreditation Canada International, for high-quality trauma care of severely injured patients; first in the Middle East. The Hamad Trauma Center is committed to the advancement of trauma care in different aspects right from the immediate prehospital care to the subsequent hospital-based care, involving diagnosis, treatment, support, rehabilitation, and community reintegration of the patients and injury prevention. Our trauma system has gradually embedded with a structured and matured research unit with dedicated clinicians and academic researchers. The trauma team embodies the 21-century paradigm of translational research and injury prevention by going well beyond the bedside, out into the populations that need it most. The trauma system's future vision relies on the evidence-based health-care service and better outcomes; state-of-the-art infrastructure and multidimensional collaborations with health care and governmental services to minimize the burden of M and M caused by traumatic injury in the State of Qatar and to fulfill the population health enhancement strategy.
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http://dx.doi.org/10.4103/JETS.JETS_56_19DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6735200PMC
September 2019

Prevalence and patterns of maxillofacial trauma: a retrospective descriptive study.

Eur J Trauma Emerg Surg 2019 Jun 21. Epub 2019 Jun 21.

Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar.

Introduction: We aimed to describe the prevalence and pattern of maxillofacial trauma in Qatar.

Methods: This is a retrospective study of trauma registry data at Hamad General Hospital during the period from January 2011 to December 2014. The study included all traumatic maxillofacial patients who underwent CT scan and were admitted during the study period.

Results: A total of 1187 patients with maxillofacial injuries were included in the study and 18.5% of all trauma admissions were related to maxillofacial injuries. Young age and males were predominantly affected. Mechanisms of injury were mainly traffic-related and fall. Orbital injuries were the commonest followed by maxillary injuries. The median and range face abbreviated injury score (AIS) was 2 [1-3] with 66% had a score of 2. Maxillofacial fractures were frequently associated with traumatic brain injuries. One out of five patients was managed with surgery and had median length of stays in ICU and hospital 5 and 7 days, respectively. Overall, in-hospital mortality was 8.3%. Mortality in isolated maxillofacial was low (0.3%) in comparison to 15% in polytrauma patients (p = 0.001). Multivariable regression analysis showed that Injury Severity Score, face AIS and Glasgow Coma Scale were predictors of mortality with age-adjusted odd ratio of 1.15, 2.48 and 0.82; respectively.

Conclusions: Maxillofacial trauma requiring admission is not uncommon in our trauma center and mostly it is mild to moderate in severity. Associated injuries are present in most of the maxillofacial injured patients and further diagnostic investigations should be part of the assessment in maxillofacial injuries.
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http://dx.doi.org/10.1007/s00068-019-01174-6DOI Listing
June 2019

Functional Outcomes in Moderate-to-Severe Traumatic Brain Injury Survivors.

J Emerg Trauma Shock 2018 Jul-Sep;11(3):197-204

Department of Surgery, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar.

Introduction: We aimed to analyze the functional outcomes based on the admission characteristics in individuals with moderate-to-severe traumatic brain injury (TBI) over a 5-year period.

Methods: A retrospective cohort study was conducted to assess the cognitive, physical, and functional outcomes based on traditional and novel metrics used in potential outcome prediction.

Results: A total of 201 participants were enrolled with a mean age of 31.9 ± 11.9 years. Glasgow Coma Score (GCS) at emergency department did not correlate with the functional independence measure (FIM) score or Ranchos Los Amigos (RLA) scores at discharge. The absolute functional gain was significantly higher in individuals who sustained TBI with RLA 4-5 (34.7 ± 18.8 vs. 26.5 ± 15.9, = 0.006). Participants with RLA 4-5 on admission to rehabilitation showed good correlation with the absolute FIM gain. On multivariate regression analysis, only age (odds ratio 0.96; 95% confidence interval: 0.93-0.98; = 0.005) was found to be the independent predictor of good functional outcome.

Conclusions: Initial GCS is not a predictor of functional outcome in individuals who sustained TBI. Consideration of age and development of novel functional measures might be promising to predict the outcomes in individuals with moderate-to-severe TBI.
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http://dx.doi.org/10.4103/JETS.JETS_6_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6182963PMC
November 2018

Postoperative complications of intestinal anastomosis after blunt abdominal trauma.

Eur J Trauma Emerg Surg 2020 Jun 24;46(3):599-606. Epub 2018 Sep 24.

Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar.

Background: Intestinal disruption following blunt abdominal trauma (BAT) continues to be associated with significant morbidity and mortality despite the advances in resuscitation and management. We aim to analyze the management and postoperative outcomes of intestinal injuries secondary to blunt abdominal trauma.

Method: We retrospectively reviewed all adult patients with intestinal injuries who underwent laparotomy for BAT between December 2008 and September 2015 at Level I trauma center. Data included demographics, mechanism of injury, site (small and large intestine), type of repair, (enterorrhaphy and resection with anastomosis), type of anastomosis (hand-sewn or stapled anastomoses), need for damage control laparotomy, postoperative complications, and mortality. Data were analyzed and compared for postoperative complications.

Results: A total of 160 patients with bowel injuries were included with mean age of 33 years, and 95.6% were males. Injuries involving small bowel, colon, and combined small and large bowel were found in 57.5%, 33.1%, and 9.4%, respectively, with only two duodenal and one rectal injury cases. There were 46.3% patients underwent debridement and primary closure, while 53.8% required resection with anastomosis. Anastomoses were side-to-side stapled in 79.1%, hand-sewn in 14.0%, and combination in 7.0% of patients. The overall postoperative complications (17.5%) in terms of wound infection (n = 16), intra-abdominal abscess (n = 13), and anastomotic leak (n = 13). There were two deaths occurred because of bowel injury complications. Need for blood transfusion, high serum lactate, number of re-laparotomies, and mortality were significantly associated with postoperative complications. On multivariate regression analysis, serum lactate (OR 1.27; 95% CI 1.01-1.60; p = 0.04) was found to be the independent predictor of postoperative complications.

Conclusion: Repair of traumatic blunt bowel injury remains a surgical challenge.
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http://dx.doi.org/10.1007/s00068-018-1013-9DOI Listing
June 2020

Risk factors for ventilator-associated pneumonia in trauma patients: A descriptive analysis.

World J Emerg Med 2018 ;9(3):203-210

Trauma Surgery Section, Department of Surgery, Hamad General Hospital, Doha, Qatar.

Background: We sought to evaluate the risk factors for developing ventilator-associated pneumonia (VAP) and whether the location of intubation posed a risk in trauma patients.

Methods: Data were retrospectively reviewed for adult trauma patients requiring intubation for > 48 hours, admitted between 2010 and 2013. Patients' demographics, clinical presentations and outcomes were compared according to intubation location (prehospital intubation [PHI] vs. trauma room [TRI]) and presence vs. absence of VAP. Multivariate regression analysis was performed to identify predictors of VAP.

Results: Of 471 intubated patients, 332 patients met the inclusion criteria (124 had PHI and 208 had TRI) with a mean age of 30.7±14.8 years. PHI group had lower GCS (=0.001), respiratory rate (=0.001), and higher frequency of head (=0.02) and chest injuries (=0.04). The rate of VAP in PHI group was comparable to the TRI group (=0.60). Patients who developed VAP were 6 years older, had significantly lower GCS and higher ISS, head AIS, and higher rates of polytrauma. The overall mortality was 7.5%, and was not associated with intubation location or pneumonia rates. In the early-VAP group, gram-positive pathogens were more common, while gram-negative microorganisms were more frequently encountered in the late VAP group. Logistic regression analysis and modeling showed that the impact of the location of intubation in predicting the risk of VAP appeared only when chest injury was included in the models.

Conclusion: In trauma, the risk of developing VAP is multifactorial. However, the location of intubation and presence of chest injury could play an important role.
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http://dx.doi.org/10.5847/wjem.j.1920-8642.2018.03.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5962455PMC
January 2018

Clinical and Radiological Presentations and Management of Blunt Splenic Trauma: A Single Tertiary Hospital Experience.

Med Sci Monit 2017 Jul 12;23:3383-3392. Epub 2017 Jul 12.

Department of Surgery, Hamad Medical Corporation, Doha, Qatar.

BACKGROUND Splenic injury is the leading cause of major bleeding after blunt abdominal trauma. We examined the clinical and radiological presentations, management, and outcome of blunt splenic injuries (BSI) in our institution. MATERIAL AND METHODS A retrospective study of BSI patients between 2011 and 2014 was conducted. We analyzed and compared management and outcome of different splenic injury grades in trauma patients. RESULTS A total of 191 BSI patients were identified with a mean (SD) age of 26.9 years (13.1); 164 (85.9%) were males. Traffic-related accident was the main mechanism of injury. Splenic contusion and hematoma (77.2%) was the most frequent finding on initial computerized tomography (CT) scans, followed by shattered spleen (11.1%), blush (11.1%), and devascularization (0.6%). Repeated CT scan revealed 3 patients with pseudoaneurysm who underwent angioembolization. Nearly a quarter of patients were managed surgically. Non-operative management failed in 1 patient who underwent splenectomy. Patients with grade V injury presented with higher mean ISS and abdominal AIS, required frequent blood transfusion, and were more likely to be FAST-positive (p=0.001). The majority of low-grade (I-III) splenic injuries were treated conservatively, while patients with high-grade (IV and V) BSI frequently required splenectomy (p=0.001). Adults were more likely to have grade I, II, and V BSI, blood transfusion, and prolonged ICU stay as compared to pediatric BSI patients. The overall mortality rate was 7.9%, which is mainly association with traumatic brain injury and hemorrhagic shock; half of the deaths occurred within the first day after injury. CONCLUSIONS Most BSI patients had grade I-III injuries that were successfully treated non-operatively, with a low failure rate. The severity of injury and presence of associated lesions should be carefully considered in developing the management plan. Thorough clinical assessment and CT scan evaluation are crucial for appropriate management of BSI.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5519223PMC
http://dx.doi.org/10.12659/msm.902438DOI Listing
July 2017

Single Versus Multiple Solid Organ Injuries Following Blunt Abdominal Trauma.

World J Surg 2017 11;41(11):2689-2696

Department of Surgery, Trauma Surgery Section, HGH, Doha, Qatar.

Background: We aimed to describe the pattern of solid organ injuries (SOIs) and analyze the characteristics, management and outcomes based on the multiplicity of SOIs.

Methods: A retrospective study in a Level 1 trauma center was conducted and included patients admitted with blunt abdominal trauma between 2011 and 2014. Data were analyzed and compared for patients with single versus multiple SOIs.

Results: A total of 504 patients with SOIs were identified with a mean age of 28 ± 13 years. The most frequently injured organ was liver (45%) followed by spleen (30%) and kidney (18%). One-fifth of patients had multiple SOIs, of that 87% had two injured organs. Patients with multiple SOIs had higher frequency of head injury and injury severity scores (p < 0.05). The majority of SOIs were treated nonoperatively, whereas operative management was required in a quarter of patients, mostly in patients with multiple SOIs (p = 0.01). Blood transfusion, sepsis and hospital stay were greater in multiple than single SOIs (p < 0.05). The overall mortality was 11% which was comparable between the two groups. In patients with single SOIs, the mortality was significantly higher in those who had pancreatic (28.6%) or hepatic injuries (13%) than the other SOIs.

Conclusion: SOIs represent one-tenth of trauma admissions in Qatar. Although liver was the most frequently injured organ, the rate of mortality was higher in pancreatic injury. Patients with multiple SOIs had higher morbidity which required frequent operative management. Further prospective studies are needed to develop management algorithm based on the multiplicity of SOIs.
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http://dx.doi.org/10.1007/s00268-017-4087-3DOI Listing
November 2017

Delirium in the Intensive Care Unit.

J Emerg Trauma Shock 2017 Jan-Mar;10(1):37-46

Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation, Doha, Qatar.

Delirium is characterized by impaired cognition with nonspecific manifestations. In critically ill patients, it may develop secondary to multiple precipitating or predisposing causes. Although it can be a transient and reversible syndrome, its occurrence in Intensive Care Unit (ICU) patients may be associated with long-term cognitive dysfunction. This condition is often under-recognized by treating physicians, leading to inappropriate management. For appropriate management of delirium, early identification and risk factor assessment are key factors. Multidisciplinary collaboration and standardized care can enhance the recognition of delirium. Interdisciplinary team working, together with updated guideline implementation, demonstrates proven success in minimizing delirium in the ICU. Moreover, should the use of physical restraint be necessary to prevent harm among mechanically ventilated patients, ethical clinical practice methodology must be employed. This traditional narrative review aims to address the presentation, risk factors, management, and ethical considerations in the management of delirium in ICU settings.
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http://dx.doi.org/10.4103/0974-2700.199520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5316795PMC
March 2017

Early and late intramedullary nailing of femur fracture: A single center experience.

Int J Crit Illn Inj Sci 2016 Jul-Sep;6(3):143-147

Department of Orthopedic Surgery, Al-Wakra Hospital, Hamad Medical Corporation, Doha, Qatar.

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; = 0.001) and had higher rate of polytrauma (35% vs. 18%, = 0.001), head injury (5% vs. 12%, = 0.68) and bilateral FF (10.7% vs. 5.1%; = 0.07) in comparison to Group I. Group II had longer stay in Intensive Care Unit (7 [1-56] vs. 2 [1-17] days; = 0.009) and hospital (13 [2-236] vs. 9 [1-367]; = 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.
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http://dx.doi.org/10.4103/2229-5151.190649DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5051057PMC
October 2016

Patterns and management of degloving injuries: a single national level 1 trauma center experience.

World J Emerg Surg 2016 27;11:35. Epub 2016 Jul 27.

Trauma Surgery Section, Hamad General Hospital, Doha, Qatar.

Background: Degloving soft tissue injuries (DSTIs) are serious surgical conditions. We aimed to evaluate the pattern, management and outcome of DSTIs in a single institute.

Methods: A retrospective analysis was performed for patients admitted with DSTIs from 2011to 2013. Presentation, management and outcomes were analyzed according to the type of DSTI.

Results: Of 178 DSTI patients, 91 % were males with a mean age of 30.5 ± 12.8. Three-quarter of cases was due to traffic-related injuries. Eighty percent of open DSTI cases were identified. Primary debridement and closure (62.9 %) was the frequent intervention used. Intermediate closed drainage under ultrasound guidance was performed in 7 patients; however, recurrence occurred in 4 patients who underwent closed serial drainage for recollection and ended with a proper debridement with or without vacuum assisted closure (VAC). Closed DSTIs were mainly seen in the lower extremity and back region and initially treated with conservative management as compared to open DSTIs. Infection and skin necrosis were reported in 9 cases only. Open DSTIs were more likely involving head and neck region and being treated by primary debridement/suturing and serial debridement/washout with or without VAC. All-cause DSTI mortality was 9 % that was higher in the closed DSTIs (19.4 vs 6.3 %; p = 0.01).

Conclusion: The incidence of DSTIs is 4 % among trauma admissions over 3 years, with a greater predilection to males and young population. DSTIs are mostly underestimated particularly in the closed type that are usually missed at the initial presentation and associated with poor outcomes. Treatment guidelines are not well established and therefore further studies are warranted.
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http://dx.doi.org/10.1186/s13017-016-0093-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4962500PMC
July 2016

The Challenging Buried Bumper Syndrome after Percutaneous Endoscopic Gastrostomy.

Case Rep Gastroenterol 2016 May-Aug;10(2):224-32. Epub 2016 May 26.

Trauma Surgery Section, Department of Surgery, Hamad General Hospital (HGH), Doha, Qatar.

Buried bumper syndrome (BBS) is a rare complication developed after percutaneous endoscopic gastrostomy (PEG). We report a case of a 38-year-old male patient who sustained severe traumatic brain injury that was complicated with early BBS after PEG tube insertion. On admission, bedside PEG was performed, and 7 days later the patient developed signs of sepsis with rapid progression to septic shock and acute kidney injury. Abdominal CT scan revealed no collection or leakage of the contrast, but showed malpositioning of the tube bumper at the edge of the stomach and not inside of it. Diagnostic endoscopy revealed that the bumper was hidden in the posterolateral part of the stomach wall forming a tract inside of it, which confirmed the diagnosis of BBS. The patient underwent laparotomy with a repair of the stomach wall perforation, and the early postoperative course was uneventful. Acute BBS is a rare complication of PEG tube insertion which could be manifested with severe complications such as pressure necrosis, peritonitis and septic shock. Early identification is the mainstay to prevent such complications. Treatment selection is primarily guided by the presenting complications, ranging from simple endoscopic replacement to surgical laparotomy.
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http://dx.doi.org/10.1159/000446018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4939666PMC
July 2016

Clinical Presentation and Time-Based Mortality in Patients With Chest Injuries Associated With Road Traffic Accidents.

Arch Trauma Res 2016 Mar 23;5(1):e31888. Epub 2016 Jan 23.

Trauma Surgery Section, Hamad General Hospital, Doha, Qatar.

Background: Blunt chest trauma (BCT) poses significant morbidity and mortality worldwide.

Objectives: We investigated the clinical presentation and outcome of BCT related to road traffic accidents (RTA).

Patients And Methods: A retrospective observational analysis for patients who sustained BCT secondary to RTA in terms of motor vehicle crash (MVC) and pedestrian-motor vehicle accidents (PMVA) who were admitted to the trauma center at Hamad general hospital, Doha, Qatar, between 2008 and 2011.

Results: Of 5118 traumatic injury cases, 1004 (20%) were found to have BCT secondary to RTA (77% MVC and 23% PMVA). The majority were males (92%), and expatriates (72%). Among MVCs, 84% reported they did not use protective devices. There was a correlation between chest abbreviated injury score (AIS) and injury severity scoring (ISS) (r = 0.35, r(2) = 0.12, P < 0.001). Regardless of mechanism of injury (MOI), multivariate analysis showed that the head injury associated with chest AIS and ISS was a predictor of mortality in BCT. Overall mortality was 15%, and the highest rate was observed within the first 24 hours post-trauma.

Conclusions: Blunt chest trauma from RTA represents one-fifth of the total trauma admissions in Qatar, with a high overall mortality. Pedestrians are likely to have more severe injuries and higher fatality rates than MVC victims. Specific injury prevention programs focusing on road safety should be implemented to minimize the incidence of such preventable injuries.
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http://dx.doi.org/10.5812/atr.31888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4853503PMC
March 2016

Frequency, causes and pattern of abdominal trauma: A 4-year descriptive analysis.

J Emerg Trauma Shock 2015 Oct-Dec;8(4):193-8

Department of Surgery, Trauma Surgery Section, Hamad Medical Corporation (HMC), Doha, Qatar.

Background: The incidence of abdominal trauma is still underreported from the Arab Middle-East. We aimed to evaluate the incidence, causes, clinical presentation, and outcome of the abdominal trauma patients in a newly established trauma center.

Materials And Methods: A retrospective analysis was conducted at the only level I trauma center in Qatar for the patients admitted with abdominal trauma (2008-2011). Patients demographics, mechanism of injury, pattern of organ injuries, associated extra-abdominal injuries, Injury Severity Score (ISS), Abbreviated Injury Scale, complications, length of Intensive Care Unit, and hospital stay, and mortality were reviewed.

Results: A total of 6888 trauma patients were admitted to the hospital, of which 1036 (15%) had abdominal trauma. The mean age was 30.6 ± 13 years and the majority was males (93%). Road traffic accidents (61%) were the most frequent mechanism of injury followed by fall from height (25%) and fall of heavy object (7%). The mean ISS was 17.9 ± 10. Liver (36%), spleen (32%) and kidney (18%) were most common injured organs. The common associated extra-abdominal injuries included chest (35%), musculoskeletal (32%), and head injury (24%). Wound infection (3.8%), pneumonia (3%), and urinary tract infection (1.4%) were the frequently observed complications. The overall mortality was 8.3% and late mortality was observed in 2.3% cases mainly due to severe head injury and sepsis. The predictors of mortality were head injury, ISS, need for blood transfusion, and serum lactate.

Conclusion: Abdominal trauma is a frequent diagnosis in multiple trauma and the presence of extra-abdominal injuries and sepsis has a significant impact on the outcome.
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http://dx.doi.org/10.4103/0974-2700.166590DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4626935PMC
November 2015

Tramadol in traumatic brain injury: Should we continue to use it?

J Anaesthesiol Clin Pharmacol 2015 Jul-Sep;31(3):344-8

Department of Surgery, Section of Trauma Surgery, Hamad General Hospital (HGH), Doha, Qatar ; Department of Surgery, University of Arizona, Tucson, AZ, USA.

Background And Aims: Tramadol is commonly used to treat moderate to moderately-severe pain in adults. We aimed to analyze the clinical relevance of tramadol use during weaning and extubation in patients with traumatic brain injury (TBI).

Material And Methods: A retrospective observational study was conducted and included all the intubated TBI patients at the level I trauma center between 2011 and 2012. Data included patient's demographics, mechanism of injury (MOI), Glasgow Coma Scale (GCS), injury severity score, length of Intensive Care Unit (ICU) stay length of stay (LOS), agitation scale, analgesics, failure of extubation and tracheostomy. Patients were divided into two groups based on whether they received tramadol (Group 1) or not (Group 2) during ventilatory weaning. Chi-square and Student's t-tests were used for categorical and continuous variables; respectively. Logistic regression analysis was performed for predictors of agitation in ICU.

Results: The study included 393 TBI patients; the majority (96%) was males with a mean age of 33.6 ± 14 years. The most common MOI were motor vehicle crash (39%), fall (29%) and pedestrian (17%). The associated injuries were mainly chest (35%) and abdominal (16%) trauma. Tramadol was administered in 51.4% of TBI patients. Tracheostomy was performed in 12.4% cases. Agitation was observed in 34.2% cases. Group 1 patients had significantly lower age (31.6 ± 12.4 vs. 35.7 ± 15.6; P = 0.005) and head AIS (3.5 ± 0.8 vs. 3.9 ± 0.9; P = 0.001) compared to Group 2. The incidence of agitation, ICU and hospital LOS were higher in Group 1. Failure of extubation and tracheostomy were reported more frequently in Group 1 (P = 0.001). On multivariate analysis, tramadol use was an independent predictor for agitation (adjusted odds ratio 21; P = 0.001), followed by low GCS.

Conclusion: Patients with TBI who received tramadol are more likely to develop agitation, undergo tracheostomy and to have longer hospital LOS. Therefore, an extensive risk-benefit assessment would help to attain maximum efficacy of the drug in TBI patients.
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http://dx.doi.org/10.4103/0970-9185.161670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541181PMC
September 2015

Blunt splenic trauma: Assessment, management and outcomes.

Surgeon 2016 Feb 30;14(1):52-8. Epub 2015 Aug 30.

Department of Surgery, Trauma Surgery, Hamad General Hospital, Doha, Qatar.

Background: The approach for diagnosis and management of blunt splenic injury (BSI) has been considerably shifted towards non-operative management (NOM). We aimed to review the current practice for the evaluation, diagnosis and management of BSI.

Methods: A traditional narrative literature review was carried out using PubMed, MEDLINE and Google scholar search engines. We used the keywords "Traumatic Splenic injury", "Blunt splenic trauma", "management" between December 1954 and November 2014.

Results: Most of the current guidelines support the NOM or minimally approaches in hemodynamically stable patients. Improvement in the diagnostic modalities guide the surgeons to decide the timely management pathway Though, there is an increasing shift from operative management (OM) to NOM of BSI; NOM of high grade injury is associated with a greater rate of failure, prolonged hospital stay, risk of delayed hemorrhage and transfusion-associated infections. Some cases with high grade BSI could be successfully treated conservatively, if clinically feasible, while some patients with lower grade injury might end-up with delayed splenic rupture. Therefore, the selection of treatment modalities for BSI should be governed by patient clinical presentation, surgeon's experience in addition to radiographic findings.

Conclusion: About one-fourth of the blunt abdominal trauma accounted for BSI. A high index of clinical suspicion along with radiological diagnosis helps to identify and characterize splenic injuries with high accuracy and is useful for timely decision-making to choose between OM or NOM. Careful selection of NOM is associated with high success rate with a lower rate of morbidity and mortality.
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http://dx.doi.org/10.1016/j.surge.2015.08.001DOI Listing
February 2016

Delayed bile leak in a patient with grade IV blunt liver trauma: A case report and review of the literature.

Int J Surg Case Rep 2015 6;14:156-9. Epub 2015 Aug 6.

Department of surgery, Trauma Surgery Section, Hamad General Hospital (HGH), Doha, Qatar; Clinical Medicine, Weill Cornell Medical College, Doha, Qatar.

Introduction: Delayed bile leak following blunt liver trauma is not common.

Presentation Of Case: We presented a case report and literature review of delayed bile leak in a young male patient who presented with grade IV blunt liver injury following a motor vehicle collision; he was a restrained driver who hit a fixed object. Physical examination was unremarkable except for revelaed tachycardia, right upper quadrant abdominal tenderness, and open left knee fracture. A diagnosis of grade IV multiple liver lacerations with large hemo-peritoneum was made and urgent exploratory laparotomy was performed. The patient developed a biloma collection post- operatively. He underwent endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct stenting. His recovery was uneventful, and he was discharged home after 1 month.

Discussion: This is a rare case with no intra or extra hepatic biliary radicle injury seen on magnetic resonance cholangiopancreatography (MRCP) and no evidence of leak by ERCP. A review of the literature to highlight the incidence of delayed bile leak revealed only few reported cases.

Conclusion: Our findings demonstrate the need for prompt diagnosis and treatment of delayed bile leak in blunt liver injuries. When these principles are followed, a successful outcome is possible.
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http://dx.doi.org/10.1016/j.ijscr.2015.08.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4573864PMC
September 2015

External air compression: A rare cause of blunt esophageal injury, managed by a stent.

Int J Surg Case Rep 2014 27;5(9):620-3. Epub 2014 Jun 27.

Trauma Surgery Section, Hamad General Hospital, Doha, Qatar.

Introduction: Blunt esophageal injuries secondary to external air compression of anterior chest and abdomen complicated with esophageal perforation are uncommon events associated with worse outcomes.

Presentation Of Case: We reported a rare case of esophageal perforation following an external air-compression injury along with the relevant review of literatures. The patient presented with chest pain and shortness of breath and was managed with tube thoracostomy, followed by thoracotomy and eventually with temporary endoscopic stenting.

Discussion: In such trauma case, the external pressurized air forms a shock wave which usually directed to the hollow viscus. Patients with external air-compression injury presented with chest pain and pneumothorax should be suspected for esophageal perforation.

Conclusion: High index of suspicion is needed for early diagnosis of esophageal perforation after blunt trauma. Appropriate drainage, antibiotic and temporary endoscopic esophageal stenting may be an optimal approach in selected patients, especially with delayed diagnosis.
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http://dx.doi.org/10.1016/j.ijscr.2014.06.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4200878PMC
September 2014

Significance of computed tomography finding of intra-abdominal free fluid without solid organ injury after blunt abdominal trauma: time for laparotomy on demand.

World J Surg 2014 Jun;38(6):1411-5

Trauma Intensive Care Unit, Section of Trauma, Department of Trauma, Surgery, Hamad Medical Corporation, PO Box 3050, Doha, Qatar,

Background: Optimal management of patients with intra-abdominal free fluid found on computed tomography (CT) scan without solid organ injury remains controversial.

Objective: The purpose of this study was to determine the significance of CT scan findings of free fluid in the management of blunt abdominal trauma patients who otherwise have no indications for laparotomy.

Methods: During the 3-year study period, all patients presenting with blunt abdominal trauma who underwent abdominal CT examination were retrospectively reviewed. All hemodynamically stable patients who presented with abdominal free fluid without solid organ injury on CT scan were analyzed for radiological interpretation, clinical management, operative findings, and outcome.

Results: A total of 122 patients were included in the study, 91 % of whom were males. The mean age of the patients was 33 ± 12 years. A total of 34 patients underwent exploratory laparotomy, 31 of whom had therapeutic interventions. Small bowel injuries were found in 12 patients, large bowel injuries in ten, and mesenteric injuries in seven patients. One patient had combined small and large bowel injury, and one had traumatic gangrenous appendix. In the remaining three patients, laparotomy was non-therapeutic. A total of 36 patients had associated pelvic fractures and 33 had multiple lumbar transverse process fractures.

Conclusion: Detection of intra-peritoneal fluid by CT scan is inaccurate for prediction of bowel injury or need for surgery. However, the correlation between CT scan findings and clinical course is important for optimal diagnosis of bowel and mesenteric injuries.
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http://dx.doi.org/10.1007/s00268-013-2427-5DOI Listing
June 2014

Dilemma of blunt bowel injury: what are the factors affecting early diagnosis and outcomes.

Am Surg 2013 Sep;79(9):922-7

Section of Trauma, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar.

Blunt bowel and mesenteric injury (BBMI) is frequently a difficult diagnosis at initial presentation. We aimed to study the predictors for early diagnosis and outcomes in patients with BBMI. Data were collected retrospectively from the database registry between January 2008 and December 2011 in the only Level I trauma unit in Qatar. Patients with BBMI were divided into Group A (surgically treated within 8 hours) and Group B (treated after 8 hours). Data were analyzed and χ2, Student's t test, and multivariate regression analysis were performed appropriately. Among 984 patients admitted with blunt abdominal trauma (BAT), 11 per cent had BBMI with mean age of 35 ± 9.5 years. Polytrauma and isolated bowel injury were identified in 53 and 42 per cent, respectively. Mean Injury Severity Score (ISS) was higher in Group A in comparison to Group B (18 ± 11 vs. 13 ± 8; P = 0.02). Presence of pain and seatbelt sign (P = 0.02) were evident in Group B. Hypotension (P = 0.004) and hypothermia (P = 0.01) were prominent in Group A. The rate of positive Focused Assessment Sonography for Trauma was greater in Group A (P = 0.001). Among operative findings, bowel perforation was more frequent in Group B (P = 0.04), whereas mesenteric full-thickness hematoma was significantly higher in Group A. Pelvic fracture was more frequent finding in Group A (P = 0.005). The overall mortality rate was 15.6 per cent. In patients with BAT, the presence of abdominal pain, hypotension, ISS greater than 16, hypothermia, pelvic fracture, and mesenteric hematoma might help in early diagnosis of BBMI. Moreover, base deficit and mean ISS were independent predictors of mortality. Delayed operative interventions greater than 8 hours increased morbidity rate but had no significant impact on mortality.
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September 2013

Epidemiology of workplace-related fall from height and cost of trauma care in Qatar.

Int J Crit Illn Inj Sci 2013 Jan;3(1):3-7

Department of Surgery, Section of Trauma Surgery, Hamad General Hospital, Doha, Qatar.

Background: This study was designed to identify the incidence, injury patterns, and actual medical costs of occupational-related falls in Qatar, in order to provide a reference for establishing fall prevention guidelines and recommendations.

Settings And Design: Retrospective database registry review in Level 1 Trauma Center at Tertiary Hospital in Qatar.

Materials And Methods: During a 12-month period between November 1(st) 2007 and October 31(st) 2008, construction workers who fell from height were enrolled. A database was designed to characterize demographics, injury severity score (ISS), total hospital length of stay, resource utilization, and cost of care.

Statistical Analysis: Data were presented as proportions, mean ± standard deviation or median and range as appropriate. In addition, case fatality rate and cost analysis were obtained from the Biostatistics and finance departments of the same hospital.

Results: There were 315 fall-related injuries, of which 298 were workplace related. The majority (97%) were male immigrants with mean age of 33 ± 11 years. The most common injuries were to the spine, head, and chest. Mean ISS was 16.4 ± 10. There was total of 29 deaths (17 pre-hospital and 12 in-hospital deaths) for a case fatality rate of 8.6%. Mean cost of care (rounded figures) included pre-hospital services Emergency Medical Services (EMS), trauma resuscitation room, radiology and imaging, operating room, intensive care unit care, hospital ward care, rehabilitation services, and total cost (123, 82, 105, 130, 496, 3048,434, and 4418 thousand United States Dollars (USD), respectively). Mean cost of care per admitted patient was approximately 16,000 USD.

Conclusions: Falling from height at a construction site is a common cause of trauma that poses a significant financial burden on the health care system. Injury prevention efforts are warranted along with strict regulation and enforcement of occupational laws.
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http://dx.doi.org/10.4103/2229-5151.109408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665115PMC
January 2013

Concurrent rib and pelvic fractures as an indicator of solid abdominal organ injury.

Int J Surg 2013 17;11(6):483-6. Epub 2013 Apr 17.

Section of Trauma Surgery, Hamad General Hospital, Qatar.

Objectives: To study the association of solid organ injuries (SOIs) in patients with concurrent rib and pelvic fractures.

Methods: Retrospective analysis of prospectively collected data from November 2007 to May 2010. Patients' demographics, mechanism of injury, Injury severity scoring, pelvic fracture, and SOIs were analyzed. Patients with SOIs were compared in rib fractures with and without pelvic fracture.

Results: The study included 829 patients (460 with rib fractures ± pelvic fracture and 369 with pelvic fracture alone) with mean age of 35 ± 12.7 years. Motor vehicle crashes (45%) and falls from height (30%) were the most common mechanism of injury. The overall incidence of SOIs in this study was 22% (185/829). Further, 15% of patient with rib fractures had associated pelvic fracture. SOI was predominant in patients with concurrent rib fracture and pelvic fracture compared to ribs or pelvic fractures alone (42% vs. 26% vs. 15%, respectively, p = 0.02).

Conclusions: Concurrent multiple rib fractures and pelvic fracture increases the risk of SOI compared to either group alone. Lower RFs and pelvic fracture had higher association for SOI and could be used as an early indicator of the presence of SOIs.
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http://dx.doi.org/10.1016/j.ijsu.2013.04.002DOI Listing
March 2014

Left internal mammary artery injury requiring resuscitative thoracotomy: a case presentation and review of the literature.

Case Rep Surg 2012 4;2012:459841. Epub 2012 Dec 4.

Section of Trauma, Department of Surgery, Hamad General Hospital (HGH), Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar.

Background. Penetrating injuries to the chest and in particular to the heart that results in pericardial tamponade and cardiac arrest requires immediate resuscitative thoracotomy as the only lifesaving technique and should be performed without delay. Objective. To describe an external cardiac tamponade caused by massive tension hemothorax from penetrating injury of the left internal mammary artery (LIMA). Method. A case presentation treated at the Level I trauma center at Hamad General Hospital, in Doha, Qatar and review of the literature on LIMA injuries reported cases. Results. LIMA injury as a cause of hemothorax is not uncommon, but to our knowledge our case is the first massive tension hemothorax with witnessed cardiac arrest reported in the literature requiring emergency thoracotomy, performed in trauma room, with full recovery. Conclusion. Injury to the LIMA with massive tension hemothorax requires immediate resuscitative thoracotomy.
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http://dx.doi.org/10.1155/2012/459841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3541570PMC
January 2013

Clinical management of occult hemothorax: a prospective study of 81 patients.

Am J Surg 2011 Jun;201(6):766-9

Section of Trauma Surgery, Department of Surgery, Hamad General Hospital, Doha, Qatar.

Background: Intrapleural blood detected by computed tomography scan, but not evident on plain chest radiograph, defines occult hemothorax. This study determined the role for tube thoracostomy.

Methods: Hemothorax was quantified on computed tomography by measuring the deepest lamellar fluid stripe at the most dependent portion. Data were collected prospectively on demographics, injury mechanism/severity, chest injuries, mechanical ventilation, hospital length of stay, complications, and outcome. Indications for tube thoracostomy were recorded.

Results: Tube thoracostomy was avoided in 67 patients (83%). Indications for chest tube placement included progression of hemothorax (8), desaturation (4), and delayed hemothorax (2). Patients with intrapleural fluid thickness greater than 1.5 cm were 4 times more likely to require tube thoracostomy.

Conclusions: Occult hemothorax can be managed successfully without tube thoracostomy in most cases. Mechanical ventilation is not an indication for chest tube placement. Accompanying occult pneumothorax may be expected in 50% of cases, but did not affect clinical management.
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http://dx.doi.org/10.1016/j.amjsurg.2010.04.017DOI Listing
June 2011

Rib fracture patterns predict thoracic chest wall and abdominal solid organ injury.

Am Surg 2010 Aug;76(8):888-91

Section of Trauma Surgery, Department of Surgery, Hamad General Hospital Doha, Qatar.

Blunt trauma patients with rib fractures were studied to determine whether the number of rib fractures or their patterns were more predictive of abdominal solid organ injury and/or other thoracic trauma. Rib fractures were characterized as upper zone (ribs 1 to 4), midzone (ribs 5 to 8), and lower zone (ribs 9 to 12). Findings of sternal and scapular fractures, pulmonary contusions, and solid organ injures (liver, spleen, kidney) were characterized by the total number and predominant zone of ribs fractured. There were 296 men and 14 women. There were 38 patients with scapular fracture and 19 patients with sternal fractures. There were 90 patients with 116 solid organ injuries: liver (n = 42), kidney (n = 27), and spleen (n = 47). Lower rib fractures, whether zone-limited or overlapping, were highly predictive of solid organ injury when compared with upper and midzones. Scapular and sternal fractures were more common with upper zone fractures and pulmonary contusions increased with the number of fractured ribs. Multiple rib fractures involving the lower ribs have a high association with solid organ injury, 51 per cent in this series. The increasing number of rib fractures enhanced the likelihood of other chest wall and pulmonary injuries but did not affect the incidence of solid organ injury.
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August 2010
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