Letters to the Editor
a
b
Figure 1: (a) Antero-posterior radiograph of the abdomen showing two all pins, one in the duodenum (arrow) and another in the distal jejunum (block arrow), confirmed intraoperativety (b) Anteroposterior radiograph of the neck showing multiple similar all pins (arrows) in the pharyngeal region and parapharyngeal soft tissues
underwent radiograph of the neck which also revealed five ball pins similar to the other ones [Figure 1b]. The X‑rays were shown to the parents, as it was difficult to explain the presence of so many pins at different places in the body. The parents were also surprised but simultaneously anxious and apprehensive. They were unable to answer the questions related to the pins. Repeated history taking revealed dubious and conflicting statements from the parents regarding the onset of the infant’s illness. When it was told to them that it could be a medicolegal case, then only they admitted that they have committed it purposefully. Based on these findings, age of the infant and conflicting history given by the parents, “battered baby syndrome” was diagnosed and child social service was alerted. The all pins were surgically removed from pharynx and the bowel. The infant was discharged after 1 week of hospital stay, after counselling of parents and support from social service team. In India, every two out of three children are victims of physical, emotional, or sexual abuse.[3] Out of these, every 89% of the crimes are perpetrated by family members. The world’s highest number of working children is in India. While evaluating a case of child abuse or battered baby syndrome, the age of the child, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered. Following risk factors have been described in literature as the risk factors for child abuse − lack of family and social support, domestic violence at home, history of abuse in the primary caregiver, parental substance abuse,
having a young mother, being a twin, excessive crying by the child, age under 18 months, and hyperactivity.[4] Studies show that systematic screening in emergency departments is effective in increasing the detection of suspected child abuse, which can be reinforced by a legal requirement as well as staff training. Accurate diagnosis and timely intervention are important, because children returned to abusive homes without intervention face a 50% chance of repeated abuse and a 10% chance of death.[4] Early identification of abusive situations has an impressive impact on outcome, because appropriate intervention is effective in reducing the recurrence rate to less than 10%. Shasanka Shekhar Panda, Pankaj Kumar Mohanty1, Meely Panda2, Rashmi Ranjan Das3, Arundeep Arora4
4
Departments of Pediatric Surgery, Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India, 1 Department of Pediatrics, Neonatology division, Manipal Hospital, Bangalore, India, 2Department of Community Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, 3Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, India Address for correspondence: Dr. Shasanka Shekhar Panda, Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi - 110029, India. E-mail: [email protected]
REFERENCES 1. 2.
3. 4.
Lynch MA. Child abuse before Kempe: An historical literature review. Child Abuse Negl 1985;9:7‑15. Runyon D, Wattam C, Ikeda R, Hassan F, Ramiro L. Child abuse and neglect by parents and other caregivers. In: Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World Report on Violence and Health. Geneva: World Health Organization; 2002. p. 59‑86. Child abuse: India 2007 – Ministry of women and child development, Government of India. Available from: http://wcd.nic.in/childabuse. pdf [Lastaccessed on: 07-09-2013]. Friedman LS, Sheppard S, Friedman D. A retrospective cohort study of suspected child maltreatment cases resulting in hospitalization. Injury 2012;43:1881‑7. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.152355
New year’s eve pediatric celebratory gunshot wound Dear Editor, On New Year’s Eve in 2011, a 12‑year‑old boy was transferred to the level 1 trauma center after he collapsed in a field with blood perfusing from his head; he had 66
been watching fireworks with his family. Airway, breathing, and circulation were intact. The Glasgow coma scale (GCS) eye, verbal, and motor subscores were 1, 1, and 5, respectively. He was able to move his extremities
International Journal of Critical Illness and Injury Science | Vol. 5 | Issue 1 | Jan-Mar 2015
Letters to the Editor
Figure 1: Foreign body in maxillary sinus consistent with metallic object (i.e. bullet)
Figure 2: Metallic foreign body in right maxillary sinus
and respond to all stimuli. On the secondary survey, blood was present in his ear canals and nose. The right eye was marked with proptosis and infraorbital ecchymosis. The bilateral upgoing plantar reflex (Babinski’s sign) was noted. Initial laboratory examination was unremarkable. FAST exam was negative. The CT head study is shown in Figures 1 and 2. Based on the findings, the child was diagnosed with neurological trauma secondary to gunshot wound.
as soot deposits, seared wound edges, or tattoos from gunpowder deposits.[5] Victims and eyewitnesses do not report hearing any related sound prior to the impact or any confrontation, as was reported in this case.
Standard in all head celebratory gunshot injuries (CGIs) and gunshot wounds (GSWs), consultations with trauma surgery, pediatric surgery, neurosurgery, and admission to pediatric ICU were expedited, followed by intensive therapy. The patient experienced full neurological recovery. This case necessitated the basic understanding of physics, wound ballistics, unique considerations of CGIs, and associated legal issues. In general, the amount of energy transferred to the tissue is of greater importance than velocity. At the top of its parabolic flight, the combustive force equals the gravitational force and air resistance, creating a velocity of zero. Throughout this time‑specific period, random external forces (wind patterns) change its flight trajectory.[1] This is supported by injury data.[2]
There are two notable legal considerations. First, most states have mandatory gunshot wound reporting. Various organizations voluntarily report and compile information nationally (Centers for Disease Control, etc). Additionally, emergency physicians can serve as witnesses in legal proceedings, sometimes 6–12 months after the patient is discharged, although rare in case of CGIs. Clinical findings and sensitive patient information can be utilized. This calls for prudent documentation and acquiring additional forensic education as needed.[5] Physicians should continue to be stewards of patient privacy considering potential media involvement. Finally, preventative local advocacy efforts against CGIs can be strengthened with physician involvement. CGIs, although rare, present unique challenges in medical assessment, treatment, and documentation that have implications in daily clinical practice and future legal proceedings. Jonathan W Meadows, Veronica T Tucci1, Dainius A Drukteinis2, Kevin Farquharson2
Department of Emergency Medicine, Tampa General Hospital, Tampa, Florida, USA, 1Department of Medicine, Baylor College of Medicine, Houston, Texas, 2Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
In general, injury includes the following:The bullet pierces the skin and skull, causing a beveling or a crater defect and the formation of a tunnel that is 3–4 times its diameter due to cavitation and other injury mechanisms.[3,4] Irregular bone fragments pass through the tissue. Periorbital ecchymosis (“raccoon eyes”) occurs due to orbital plate fractures or increasing cerebrospinal pressure. [3] If there is an exit wound, it would generally form on the skull’s outer surface in the form of a crater due to the tumbling trajectory in situ.[3] Identifying CGI entrance and exit wounds is challenging due to the lack of forensic information such
Address for correspondence: Mr. Jonathan W Meadows, 15 West 139th Street Apt: 7H, New York, NY - 10037, USA. E-mail: [email protected]
REFERENCES 1. 2.
Volgas DA, Stannard JP, Alonso JE. Ballistics: A primer for the surgeon. Injury 2005;36:373‑9. Centers for Disease Control and Prevention (CDC). New year’s eve injuries
International Journal of Critical Illness and Injury Science | Vol. 5 | Issue 1 | Jan-Mar 2015
67
Letters to the Editor
3. 4. 5.
caused by celebratory gunfire‑‑Puerto Rico, 2003. MMWR Morb Mortal Wkly Rep 2004;53:1174‑5. Shkrum MJ, Ramsay DA. Forensic Pathology of Trauma: Common Problems for the Pathologist. Totowa: Humana Press; 2007. p. 332‑3, 338. Tintinalli JE, Stapczynski JS, MA OJ, Cline DM, Cydulka R, Meckler GD, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw Hill Medical; 2011. p. 1703. Apfelbaum JD, Shockley LW, Wahe JW, Moore EE. Entrance and exit gunshot wounds: Incorrect terms for the emergency department? J Emerg Med 1998;16:741‑5.
Access this article online Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.152356
Concomittant chronic lymphocytic leukemia and colon cancer a patient presenting with ileus Dear Editor, Herein, we aim to report a case presenting concomitantly with ileuses and diagnosed with chronic lymphocytic leukemia (CLL) and colon cancer. A 66‑year‑old male patient was admitted to the emergency department with the complaints of vomiting for the last 5 days, flatulence, and inability to defecate. Laboratory findings were as follows: Hemoglobin, 11.6 g/dl; hematocrit, %35.9; white blood cell, 177.500/ml; lymphocyte, 118.925/ml; neutrophil, 2,124/ml; and platelet, 182.000/mm3. Computed tomography scans of the abdomen revealed a mass structure in the sigmoid region. On the peripheral smear, there was a domination of mature lymphocytes, and the patient was diagnosed as CLL. Urgent surgery was performed, and a tumoral mass was observed at the descending colon–sigmoid colon junction. The pathological diagnosis was adenocarcinoma. The present case is notable because synchronous CLL and colon cancer were observed. Colon adenocarcinoma might have developed as a secondary malignancy due to the prolonged presence of any immunosuppressant caused by CLL itself or in the form of a second primary as a result of a common gene such as p53 mutation involved in the carcinogenesis of both diseases.[1‑3]
Zerrin Demirturk, Tuba Hacibekiroglu1, Ayhan Akpinar2
Departments of Intensive Care, 1Hematology, 2General Surgery, Edirne Public Hospital, Turkey Address for correspondence: Dr. Tuba Hacibekiroglu, Department of Hematology, Edirne Public Hospital, Turkey. E‑mail: [email protected]
REFERENCES 1. 2. 3.
Mellemgaard A, Geisler CH, Storm HH. Risk of kidney cancer and other second solid malignancies in patients with chronic lymphocytic leukemia. Eur J Haematol 1994;53:218‑22. Hisada M, Biggar RJ, Greene MH, Fraumeni JF Jr, Travis LB. Solid tumors after chronic lymphocytic leukemia. Blood 2001;98:1979‑81. Kyasa MJ, Hazlett L, Parrish RS, Schichman SA, Zent CS. Veterans with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) have a markedly increased rate of second malignancy, which is the most common cause of death. Leuk Lymphoma 2004;45:507‑13.
Access this article online Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.152357
Prevalence of derangement of coagulation profile in surgical patients and its outcome in India Dear Editor, Patients of trauma surgical emergencies have a deranged coagulation profile at the time of admission, and, if misdiagnosed, the complications are numerous.[1] Prompt and proper identification of the underlying cause of these coagulation abnormalities is required,[2] since each coagulation disorder necessitates very different therapeutic management strategies. In a resource‑constraint 68
environment and developing countries, the basic tests for coagulation in practice are prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT). From June 2013 until September 2013, 100 patients admitted to the surgical emergency unit of the trauma center at KGMU were enrolled into four groups: Group 1
International Journal of Critical Illness and Injury Science | Vol. 5 | Issue 1 | Jan-Mar 2015
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
a
b
Figure 1: (a) Antero-posterior radiograph of the abdomen showing two all pins, one in the duodenum (arrow) and another in the distal jejunum (block arrow), confirmed intraoperativety (b) Anteroposterior radiograph of the neck showing multiple similar all pins (arrows) in the pharyngeal region and parapharyngeal soft tissues
underwent radiograph of the neck which also revealed five ball pins similar to the other ones [Figure 1b]. The X‑rays were shown to the parents, as it was difficult to explain the presence of so many pins at different places in the body. The parents were also surprised but simultaneously anxious and apprehensive. They were unable to answer the questions related to the pins. Repeated history taking revealed dubious and conflicting statements from the parents regarding the onset of the infant’s illness. When it was told to them that it could be a medicolegal case, then only they admitted that they have committed it purposefully. Based on these findings, age of the infant and conflicting history given by the parents, “battered baby syndrome” was diagnosed and child social service was alerted. The all pins were surgically removed from pharynx and the bowel. The infant was discharged after 1 week of hospital stay, after counselling of parents and support from social service team. In India, every two out of three children are victims of physical, emotional, or sexual abuse.[3] Out of these, every 89% of the crimes are perpetrated by family members. The world’s highest number of working children is in India. While evaluating a case of child abuse or battered baby syndrome, the age of the child, the overall injury pattern, the stated mechanism of injury, and pertinent psychosocial factors must all be considered. Following risk factors have been described in literature as the risk factors for child abuse − lack of family and social support, domestic violence at home, history of abuse in the primary caregiver, parental substance abuse,
having a young mother, being a twin, excessive crying by the child, age under 18 months, and hyperactivity.[4] Studies show that systematic screening in emergency departments is effective in increasing the detection of suspected child abuse, which can be reinforced by a legal requirement as well as staff training. Accurate diagnosis and timely intervention are important, because children returned to abusive homes without intervention face a 50% chance of repeated abuse and a 10% chance of death.[4] Early identification of abusive situations has an impressive impact on outcome, because appropriate intervention is effective in reducing the recurrence rate to less than 10%. Shasanka Shekhar Panda, Pankaj Kumar Mohanty1, Meely Panda2, Rashmi Ranjan Das3, Arundeep Arora4
4
Departments of Pediatric Surgery, Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India, 1 Department of Pediatrics, Neonatology division, Manipal Hospital, Bangalore, India, 2Department of Community Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India, 3Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, India Address for correspondence: Dr. Shasanka Shekhar Panda, Department of Paediatric Surgery, All India Institute of Medical Sciences, New Delhi - 110029, India. E-mail: [email protected]
REFERENCES 1. 2.
3. 4.
Lynch MA. Child abuse before Kempe: An historical literature review. Child Abuse Negl 1985;9:7‑15. Runyon D, Wattam C, Ikeda R, Hassan F, Ramiro L. Child abuse and neglect by parents and other caregivers. In: Krug EG, Dahlberg LL, Mercy JA, Zwi AB, Lozano R, editors. World Report on Violence and Health. Geneva: World Health Organization; 2002. p. 59‑86. Child abuse: India 2007 – Ministry of women and child development, Government of India. Available from: http://wcd.nic.in/childabuse. pdf [Lastaccessed on: 07-09-2013]. Friedman LS, Sheppard S, Friedman D. A retrospective cohort study of suspected child maltreatment cases resulting in hospitalization. Injury 2012;43:1881‑7. Access this article online
Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.152355
New year’s eve pediatric celebratory gunshot wound Dear Editor, On New Year’s Eve in 2011, a 12‑year‑old boy was transferred to the level 1 trauma center after he collapsed in a field with blood perfusing from his head; he had 66
been watching fireworks with his family. Airway, breathing, and circulation were intact. The Glasgow coma scale (GCS) eye, verbal, and motor subscores were 1, 1, and 5, respectively. He was able to move his extremities
International Journal of Critical Illness and Injury Science | Vol. 5 | Issue 1 | Jan-Mar 2015
Letters to the Editor
Figure 1: Foreign body in maxillary sinus consistent with metallic object (i.e. bullet)
Figure 2: Metallic foreign body in right maxillary sinus
and respond to all stimuli. On the secondary survey, blood was present in his ear canals and nose. The right eye was marked with proptosis and infraorbital ecchymosis. The bilateral upgoing plantar reflex (Babinski’s sign) was noted. Initial laboratory examination was unremarkable. FAST exam was negative. The CT head study is shown in Figures 1 and 2. Based on the findings, the child was diagnosed with neurological trauma secondary to gunshot wound.
as soot deposits, seared wound edges, or tattoos from gunpowder deposits.[5] Victims and eyewitnesses do not report hearing any related sound prior to the impact or any confrontation, as was reported in this case.
Standard in all head celebratory gunshot injuries (CGIs) and gunshot wounds (GSWs), consultations with trauma surgery, pediatric surgery, neurosurgery, and admission to pediatric ICU were expedited, followed by intensive therapy. The patient experienced full neurological recovery. This case necessitated the basic understanding of physics, wound ballistics, unique considerations of CGIs, and associated legal issues. In general, the amount of energy transferred to the tissue is of greater importance than velocity. At the top of its parabolic flight, the combustive force equals the gravitational force and air resistance, creating a velocity of zero. Throughout this time‑specific period, random external forces (wind patterns) change its flight trajectory.[1] This is supported by injury data.[2]
There are two notable legal considerations. First, most states have mandatory gunshot wound reporting. Various organizations voluntarily report and compile information nationally (Centers for Disease Control, etc). Additionally, emergency physicians can serve as witnesses in legal proceedings, sometimes 6–12 months after the patient is discharged, although rare in case of CGIs. Clinical findings and sensitive patient information can be utilized. This calls for prudent documentation and acquiring additional forensic education as needed.[5] Physicians should continue to be stewards of patient privacy considering potential media involvement. Finally, preventative local advocacy efforts against CGIs can be strengthened with physician involvement. CGIs, although rare, present unique challenges in medical assessment, treatment, and documentation that have implications in daily clinical practice and future legal proceedings. Jonathan W Meadows, Veronica T Tucci1, Dainius A Drukteinis2, Kevin Farquharson2
Department of Emergency Medicine, Tampa General Hospital, Tampa, Florida, USA, 1Department of Medicine, Baylor College of Medicine, Houston, Texas, 2Department of Emergency Medicine, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
In general, injury includes the following:The bullet pierces the skin and skull, causing a beveling or a crater defect and the formation of a tunnel that is 3–4 times its diameter due to cavitation and other injury mechanisms.[3,4] Irregular bone fragments pass through the tissue. Periorbital ecchymosis (“raccoon eyes”) occurs due to orbital plate fractures or increasing cerebrospinal pressure. [3] If there is an exit wound, it would generally form on the skull’s outer surface in the form of a crater due to the tumbling trajectory in situ.[3] Identifying CGI entrance and exit wounds is challenging due to the lack of forensic information such
Address for correspondence: Mr. Jonathan W Meadows, 15 West 139th Street Apt: 7H, New York, NY - 10037, USA. E-mail: [email protected]
REFERENCES 1. 2.
Volgas DA, Stannard JP, Alonso JE. Ballistics: A primer for the surgeon. Injury 2005;36:373‑9. Centers for Disease Control and Prevention (CDC). New year’s eve injuries
International Journal of Critical Illness and Injury Science | Vol. 5 | Issue 1 | Jan-Mar 2015
67
Letters to the Editor
3. 4. 5.
caused by celebratory gunfire‑‑Puerto Rico, 2003. MMWR Morb Mortal Wkly Rep 2004;53:1174‑5. Shkrum MJ, Ramsay DA. Forensic Pathology of Trauma: Common Problems for the Pathologist. Totowa: Humana Press; 2007. p. 332‑3, 338. Tintinalli JE, Stapczynski JS, MA OJ, Cline DM, Cydulka R, Meckler GD, editors. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw Hill Medical; 2011. p. 1703. Apfelbaum JD, Shockley LW, Wahe JW, Moore EE. Entrance and exit gunshot wounds: Incorrect terms for the emergency department? J Emerg Med 1998;16:741‑5.
Access this article online Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.152356
Concomittant chronic lymphocytic leukemia and colon cancer a patient presenting with ileus Dear Editor, Herein, we aim to report a case presenting concomitantly with ileuses and diagnosed with chronic lymphocytic leukemia (CLL) and colon cancer. A 66‑year‑old male patient was admitted to the emergency department with the complaints of vomiting for the last 5 days, flatulence, and inability to defecate. Laboratory findings were as follows: Hemoglobin, 11.6 g/dl; hematocrit, %35.9; white blood cell, 177.500/ml; lymphocyte, 118.925/ml; neutrophil, 2,124/ml; and platelet, 182.000/mm3. Computed tomography scans of the abdomen revealed a mass structure in the sigmoid region. On the peripheral smear, there was a domination of mature lymphocytes, and the patient was diagnosed as CLL. Urgent surgery was performed, and a tumoral mass was observed at the descending colon–sigmoid colon junction. The pathological diagnosis was adenocarcinoma. The present case is notable because synchronous CLL and colon cancer were observed. Colon adenocarcinoma might have developed as a secondary malignancy due to the prolonged presence of any immunosuppressant caused by CLL itself or in the form of a second primary as a result of a common gene such as p53 mutation involved in the carcinogenesis of both diseases.[1‑3]
Zerrin Demirturk, Tuba Hacibekiroglu1, Ayhan Akpinar2
Departments of Intensive Care, 1Hematology, 2General Surgery, Edirne Public Hospital, Turkey Address for correspondence: Dr. Tuba Hacibekiroglu, Department of Hematology, Edirne Public Hospital, Turkey. E‑mail: [email protected]
REFERENCES 1. 2. 3.
Mellemgaard A, Geisler CH, Storm HH. Risk of kidney cancer and other second solid malignancies in patients with chronic lymphocytic leukemia. Eur J Haematol 1994;53:218‑22. Hisada M, Biggar RJ, Greene MH, Fraumeni JF Jr, Travis LB. Solid tumors after chronic lymphocytic leukemia. Blood 2001;98:1979‑81. Kyasa MJ, Hazlett L, Parrish RS, Schichman SA, Zent CS. Veterans with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) have a markedly increased rate of second malignancy, which is the most common cause of death. Leuk Lymphoma 2004;45:507‑13.
Access this article online Website: www.ijciis.org
Quick Response Code:
DOI: 10.4103/2229-5151.152357
Prevalence of derangement of coagulation profile in surgical patients and its outcome in India Dear Editor, Patients of trauma surgical emergencies have a deranged coagulation profile at the time of admission, and, if misdiagnosed, the complications are numerous.[1] Prompt and proper identification of the underlying cause of these coagulation abnormalities is required,[2] since each coagulation disorder necessitates very different therapeutic management strategies. In a resource‑constraint 68
environment and developing countries, the basic tests for coagulation in practice are prothrombin time (PT), international normalized ratio (INR), and activated partial thromboplastin time (aPTT). From June 2013 until September 2013, 100 patients admitted to the surgical emergency unit of the trauma center at KGMU were enrolled into four groups: Group 1
International Journal of Critical Illness and Injury Science | Vol. 5 | Issue 1 | Jan-Mar 2015
Copyright of International Journal of Critical Illness & Injury Science is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
