Biomedical subjects
Hans Husum
Publications and source records attributed to Hans Husum.
Postinjury malaria: experiences of doctors in Battambang Province, Cambodia.
Quantitative studies indicate that one-third of trauma victims in malaria endemic areas of Cambodia develop postinjury malaria. The main aim of this study was to assess the medical significance of the complication. All local doctors with trauma care surgical experience in the Battambang Province of Cambodia were interviewed regarding their experiences with postinjury malaria (n = 18). The qualitative data were processed according to the Editing Style Analysis method. In the study area, postinjury malaria has been a well-known complication to trauma doctors for years. Local doctors claim that the complication is more common in severe as compared to moderate trauma. The complication is reported to adversely affect the general condition of trauma patients, increasing the risk of wound infections, and delaying postoperative recovery. It was found that the informants draw exclusively on personal clinical experience regarding this clinical knowledge, asserting that postinjury malaria is not taught at local medical schools. The study indicated that post-injury malaria is a significant complication to trauma where falciparum malaria is endemic. The knowledge of postinjury malaria in the study area seemed to be non-institutional; the informants' assessments were exclusively based on their personal clinical experience.
Hypertonic saline for prehospital treatment of traumatic brain injury.
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Post-injury malaria: a risk factor for wound infection and protracted recovery.
OBJECTIVE: To assess the impact of post-injury falciparum malaria on morbidity parameters in Cambodia. METHOD: Retrospective study of 227 trauma patients managed at a surgical centre in Battambang, Cambodia. RESULTS: Within 10 days of the injury, 42.7% of the study population developed symptomatic malaria. In patients with post-injury malaria, the rate of wound infection was 36.1% compared with 10.0% in patients without symptomatic malaria (95% confidence interval for difference 15.2-36.9%). The average hospital stay in the post-injury malaria group was 31.2 days compared with 19.4 days in the patients without the complication (95% confidence interval for difference 7.2-16.4 days). CONCLUSION: Symptomatic malaria after trauma is common in Cambodia. Post-injury malaria seems to increase the risk of wound infection, delays postoperative recovery, and thus adds to the burden of trauma.
Prehospital tourniquets: there should be no controversy.
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Training pre-hospital trauma care in low-income countries: the 'Village University' experience.
A prospective study was carried out of the health effects and sustainability of a low-cost trauma training program for non-graduate village healthcare workers. From 1996 to 1999, a core group of 44 health workers from mine-infested rural communities in Cambodia and Northern Iraq were trained and equipped to deliver low-cost life support to trauma victims. They in turn trained a network of 2800 layman village first responders. Training was done in makeshift camps at village level ('Village Universities'). A total of 813 patients were managed by the rural rescue system from 1997 to 1999. The mortality rate for trauma victims decreased from 22.6% in 1997 to 13.7% in 1999 (95% CI for difference 1.8% to 16.0%). Management by village first responders had a significant impact on in-field response times and trauma mortality. The rescue system replicated itself during the study period as an indicator of sustainability. The study showed that after trauma care training at rural makeshift training centers, non-graduate health workers can build efficient and sustainable rural rescue systems.
Respiratory rate as a prehospital triage tool in rural trauma.
BACKGROUND: Where trauma systems do not exist, such as in low-income countries, the aim of prehospital triage is identification of trauma victims with high priority for forward resuscitation. The present pilot study explored the accuracy of simple prehospital triage tools in the hands of nongraduate trauma care providers in the minefields of North Iraq and Cambodia. METHODS: Prehospital prediction of trauma death and major trauma victims (Injury Severity Score > 15) was studied in 737 adult patients with penetrating injuries and long evacuation times (mean, 6.1 hours). RESULTS: Both the respiratory rate and the full Physiologic Severity Score predicted trauma death with high accuracy (area under the curve for receiver-operating characteristic plots at 0.9) and significantly better than other physiologic indicators. The accuracy in major trauma victim identification was moderate for all physiologic indicators (area under the receiver-operating characteristic curve, 0.7-0.8). CONCLUSION: Respiratory rate > 25 breaths/min may be a useful triage tool for nongraduate trauma care providers where the scene is chaotic and evacuations long. Further studies on larger cohorts are necessary to validate the results.
Rural prehospital trauma systems improve trauma outcome in low-income countries: a prospective study from North Iraq and Cambodia.
BACKGROUND: A five-year prospective study was conducted in North Iraq and Cambodia to test a model for rural prehospital trauma systems in low-income countries. RESULTS: From 1997 to 2001, 135 local paramedics and 5,200 lay First Responders were trained to provide in-field trauma care. The study population comprised 1,061 trauma victims with mean evacuation time 5.7 hours. The trauma mortality rate was reduced from pre-intervention level at 40% to 14.9% over the study period (95% CI for difference 17.2-33.0%). There was a reduction in trauma deaths from 23.9% in 1997 to 8.8% in 2001 (95% CI for difference 7.8-22.4%), and a corresponding significant improvement of treatment effect by year. The rate of infectious complications remained at 21.5 percent throughout the study period. CONCLUSION: Low-cost rural trauma systems have a significant impact on trauma mortality in low-income countries.
Land mine injuries: a study of 708 victims in North Iraq and Cambodia.
OBJECTIVE: The aim of this study was to explore the effect of low-cost prehospital trauma systems on trauma outcome in land mine victims and to study prehospital risk indicators for better triage of land mine injuries. METHODS: A 5-year prospective study of the effect of in-field advanced life support provided by local paramedics was conducted in mine-infested areas in North Iraq and Cambodia. RESULTS: After implementation of a rural rescue system, there was a significant reduction in trauma mortality from 26.2% in 1997 to 11.8% in 2001 (95% confidence interval for difference, 5.1%-23.6%). The mortality rate was significantly higher in fragmentation mine victims, 25.2%, as compared with blast mine victims, 5.7% (95% confidence interval for difference, 14.4%-24.6%). The severity of associated fragment injuries in patients with traumatic amputations is a solid risk predictor (area under the curve in receiver operating characteristics plots > 0.9). CONCLUSIONS: Low-cost prehospital trauma systems improve trauma outcome in land mine victims where prehospital transit times are high. The fragment wounds represent the main challenge for trauma care providers.
Chronic pain in land mine accident survivors in Cambodia and Kurdistan.
The aims of the study were to study chronic pain in land mine accident survivors, and to study the impact of trauma and trauma care parameters on chronic pain. The level of chronic pain was registered (patient-rated and by clinical examination) in 57 severely injured adult land mine accident survivors in Cambodia and Northern Iraq more than one year after the accident. As all study patients had been managed by a standardized trauma system, we could assess the impact of injury severity and primary trauma care on chronic pain. 64% of the study patients (n=36) had chronic pain syndromes (non-significant difference between the two countries). 68% of the amputees (19 out of 28) had phantom limb pain. Pre-injury trauma exposure, the severity of the actual trauma, and the quality of trauma care had no impact on end point chronic pain. In 85% of cases (n=48), the economic standing of the patients' family had deteriorated after the accident. Patient-rated loss of income correlated with the rate of chronic pain syndromes.
Postinjury malaria: a study of trauma victims in cambodia.
BACKGROUND: The pattern of host defense against plasmodium is comparable to the immune response to bacterial infection. Posttraumatic immunosuppression may therefore cause relapses of malaria secondary to trauma and trauma surgery in asymptomatic carriers of the parasites in endemic areas. To our knowledge this has not been validated in epidemiologic studies. METHODS: Postinjury malaria was registered retrospectively in 342 land mine and war victims from malaria-endemic areas in Cambodia. The incidence rate was analyzed in terms of age, gender, preinjury endemicity, evacuation times, anatomic injury severity, systolic blood pressure at admission, blood transfusion, and duration of the first surgical intervention as independent variables. RESULTS: The rate of postinjury malaria in the study patients was 33.3% (95% CI, 28.3-38.3%). Injury Severity Score (ISS) and surgical operation time were risk factors (area under the curve in receiver operating characteristic plots were 0.73 and 0.79, respectively). The impact of the other risk factors was nonsignificant. CONCLUSION: Despite difficulties in diagnosing postoperative malaria in endemic areas, the study demonstrates that the rate of postinjury malaria is high. The results legitimate controlled trials of immediate postinjury chemoprophylaxis to severely injured in endemic areas. The authors recommend staged surgical operations with brief primary interventions in victims with severe injuries.
Preventing post-injury hypothermia during prolonged prehospital evacuation.
INTRODUCTION: Post-injury hypothermia is a risk predictor in trauma patients whose physiology is deranged. The aim of the present study was to examine the effect of simple, in-field, hypothermia prevention to victims of penetrating trauma during long prehospital evacuations. METHODS: A total of 170 consecutively injured landmine victims were included in a prospective, clinical study in Northern Iraq and Cambodia. Thirty patients were provided with systematic prehospital hypothermia prevention, and for 140 patients, no preventive measures were provided. RESULTS: The mean value for the time from injury to hospital admission was 6.6 hours (range: 0.2-72). The incidence of hypothermia (oral temperature < 36 degrees C) before prevention/rewarming was 21% (95% confidence interval: 15% to 28%). The Prevention Group had a statistically significant lower rate of hypothermia on hospital admission compared to the control group (95% confidence interval for difference: 6% to 24%). CONCLUSION: Simple, preventive, in-field measures help to prevent hypothermia during protracted evacuation, and should be part of the trauma care protocol in rural rescue systems.
Injury Severity Score versus New Injury Severity Score for penetrating injuries.
INTRODUCTION: The New Injury Severity Score (NISS) was introduced in 1997 to improve outcome prediction based on anatomical severity scoring in trauma victims. Studies on populations of blunt trauma victims indicate that the NISS, predicts better than the Injury Severity Score (ISS) mortality post-injury, which is why the NISS has been recommended as the new "gold standard" for severity scoring. However, so far the accuracy of the NISS for penetrating injuries has not been validated against the ISS. METHODS: ISS and NISS scores were collected retrospectively for 1,787 war- and landmine victims in North Iraq. All victims only had penetrating injuries. The two tests were compared for prediction of short-term mortality and post-operative complications using Receiver Operating Characteristics (ROC) analysis. RESULTS: Both the ISS and the NISS predicted mortality with high accuracy (ROC area under curve 0.9). There were no significant differences between the two tests. The predictive accuracy for post-operative complications was moderate for both tests (ROC-AUC < 0.8), with the NISS performing significantly better than the ISS. CONCLUSION: The NISS does not perform better than the ISS in penetrating injuries. However, this study was done on a low-risk trauma population, thus the results should not be extrapolated to high severity trauma. Due to statistical shortcomings in studies previously published, studies on far larger cohorts are necessary before the NISS should be adopted as the new "gold standard" for severity scoring.
Mortality in land-mine accidents in Iran.
OBJECTIVE: To study the rate of prehospital mortality before establishment of a rescue system for victims of land-mines in Iran. METHOD: Survey at rural clinics in mine-affected areas, and retrospective review of public patient records. RESULTS: A total of 36.4% of casualties from land-mines in the study area died during the period of 1989-1999. The mortality seems highest in those victims who were torso injured. CONCLUSION: The mortality rate from accidents involving land-mines in the study area was high. Most fatalities seemingly occurred in the prehospital setting.
[Trauma care in low-income countries--a collective concern in a village. Care of landmine injuries in North Iraqi countryside].
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