A B C Dengue: a case of multifactorial shock due to major trauma and dengue infection

A B C Dengue: a case of multifactorial shock due to major trauma and dengue infection | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report A B C Dengue: a case of multifactorial shock due to major trauma and dengue infection Bui Hai Hoang, Thomas Vu Tang, Nguyen Dai Nghia Phan, Anh Dung Nguyen, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4178610/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 16 Jul, 2024 Read the published version in International Journal of Emergency Medicine → Version 1 posted 13 You are reading this latest preprint version Abstract Objective: We report on a case of severe dengue diagnosed in a patient with major trauma and illustrate some of the potential challenges and considerations in the clinical management of such cases. Method: Case report from Hanoi, Vietnam Results: A 49-year-old female presented following road trauma incident requiring urgent laparotomy. Her recovery in Intensive Care Unit was complicated by the development of Dengue Shock Syndrome. Conclusions: Dengue Shock Syndrome may complicate fluid management and bleeding control in major trauma cases. trauma dengue INTRODUCTION Dengue is the most common arboviral illness reported globally, endemic to most tropical and sub-tropical regions of the world ( 1 ). The Dengue flavivirus is transmitted by the A aegypti mosquito with an incubation period of one to two weeks. Although most dengue cases result in a mild, self-limiting febrile illness, around 5% develop severe dengue, characterised by severe vomiting, haemorrhagic manifestations (petechial rash, gastrointestinal bleeding), which may lead to dengue shock syndrome (DSS) characterised by refractory hypotension and multiorgan dysfunction in less than 1% of cases with a mortality of around 25% ( 2 ). There are no reports of intercurrent severe dengue infection complicating cases of major trauma. These cases are likely to become more prevalent in the coming decade as cases of Dengue continue to increase due to urbanisation, international travel and climate change. We report on a case of severe dengue diagnosed in a patient with major trauma and illustrate some of the potential challenges and considerations in the clinical management of such cases. CASE A 49-year-old female self-presented to an emergency department of a tertiary hospital in Hanoi Vietnam with severe right flank pain after being struck by a motorcycle as a pedestrian. Her medical background comprised chronic hepatitis B infection with no other known comorbidities. On examination, her Glasgow Coma Scale (GCS) was 15, blood pressure was 120/70 mmHg, oxygen saturations were 98% on room air, afebrile, respiratory rate 28 breathes/min, and heart rate 89 bpm. During ED assessment her blood pressure fell to 80/50 mmHg. Imaging revealed grade V right kidney injury, subcapsular laceration grade III liver injury, rib fracture of ribs 10, 11, and 12 on the right, and fractures of vertebrae T12 to L2 with no clinical evidence of spinal cord injury. Injury Severity Score was estimated to be 34. She was given 2L of crystalloid, 2 units of fresh frozen plasma and 2 units of packed red cells in the emergency department before urgent transfer to the operating room for emergency trauma laparotomy with repair of descending duodenum (segment D2), formation of jejunostomy and right total nephrectomy followed by Intensive Care Unit admission. On day 4 of admission, the patient developed a fever of 38.7 degrees Celsius which persisted to day 7, when her fever reached 40 degrees C despite prophylactic broad-spectrum antibiotics. During this time, her haemoglobin had dropped from 124 to 70 g/L, platelets from 368 to 62 g/L, white cell count decreased from 24.3 to 6.4 g/L, creatinine increased from 72 to 124 umol/L, urea from 8.8 to 20.8 mmol/L. Blood pressure in ICU dropped from 115/60 to 90/60 mmHg on day 7 of admission. Dengue was suspected once she developed fever because of a concurrent seasonal epidemic of Dengue in Hanoi at the time and her NS1 antigen test returned positive for Dengue virus on day 4 post operation. IgM and IgG for Dengue were also positive. On day 7 she was diagnosed with DSS. She developed ascites and pulmonary oedema on day 10 which was treated with a trial of frusemide but subsequently became anuric on day 12 requiring continuous venovenous hemofiltration. The patient was extubated on day 19 of admission and transferred out of ICU the following day. DISCUSSION The differential diagnoses of shock during the acute and perioperative phase of major trauma in the context of this case were broad and multifactorial, including ongoing haemorrhage, sepsis due to intraabdominal collections or nosocomial pneumonia, systemic inflammatory response syndrome, fat embolism and concurrent infections ( 3 ). The pathogenesis of DSS involves increased vascular permeability, thrombocytopaenia and leukopenia which can complicate ongoing recovery from major trauma. Hypovolemic shock seen in DSS results due to gastrointestinal losses, fluid shifts, ongoing bleeding and multiorgan dysfunction ( 4 ). This patient faced several challenges with respect to fluid management. Initially, she required management of haemorrhagic shock secondary to major trauma. However, with the onset of DSS, judicious administration of intravenous fluids in conjunction with vasopressor support were required to manage third spacing fluid shifts and pulmonary oedema. Our patient tested positive for both Dengue IgM and IgG, suggesting previous infection. It is known that previous Dengue Infection increases the risk of severe dengue with subsequent infections with a different serotype of Dengue virus ( 2 ). CONCLUSION We report a rare case of multi-factorial shock, involving both major trauma and concurrent severe dengue infection. Judicious fluid management, vasopressor and renal support, and diligence in suspecting concurrent infection in such cases is important in achieving good patient outcomes. Declarations Ethical Approval: Ethics approval was obtained from the Hanoi Medical University Hospital Human Ethics Research Committee. The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. Written informed consent was obtained from the patient for participation in the case report and for publication. All patient information is kept confidential. The manuscript was completed once the patient was discharged from the hospital. Consent for publication: Written informed consent was obtained from the patient for publication of this study and accompanying images. Consent to participate: Written informed consent was obtained from the participant. Ethics committee: Not applicable. Funding: The authors do not have any funding sources. Availability of data and materials: The information generated during and analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. References Khan MB, Yang Z-S, Lin C-Y, Hsu M-C, Urbina AN, Assavalapsakul W, et al. Dengue overview: An updated Systemic Review. Journal of Infection and Public Health. 2023 Oct;16(10):1625–42. doi:10.1016/j.jiph.2023.08.001. Chagas GCL, Rangel AR, Noronha LM, Veloso FCS, Kassar SB, Oliveira MJC, Meneses GC, da Silva Junior GB, Daher EF. Risk factors for mortality in patients with dengue: A systematic review and meta-analysis. Trop Med Int Health. 2022 Aug;27(8):656-668. doi: 10.1111/tmi.13797. Epub 2022 Jul 11. PMID: 35761748. Luo J., Chen D., Tang L., Deng H., Zhang C., Chen S., et al. Multifactorial shock: A neglected situation in polytrauma patients. Journal of Clinical Medicine. 2022 Nov 18;11(22):6829. doi:10.3390/jcm11226829. McBride A, Chanh HQ, Fraser JF, Yacoub S, Obonyo NG. Microvascular dysfunction in septic and dengue shock: Pathophysiology and implications for Clinical Management. Global Cardiology Science and Practice. 2020 Nov 30;2020(2):e202029. doi:10.21542/gcsp.2020.29. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 16 Jul, 2024 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Revision requested 17 Jun, 2024 Reviews received at journal 28 May, 2024 Reviews received at journal 26 May, 2024 Reviewers agreed at journal 23 May, 2024 Reviews received at journal 22 May, 2024 Reviewers agreed at journal 21 May, 2024 Reviewers agreed at journal 18 May, 2024 Reviewers agreed at journal 17 May, 2024 Reviewers agreed at journal 14 May, 2024 Reviewers invited by journal 14 May, 2024 Editor assigned by journal 11 Apr, 2024 Submission checks completed at journal 11 Apr, 2024 First submitted to journal 27 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4178610","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":290015363,"identity":"e1c6c405-ec1b-4933-9a43-5289fa98b2de","order_by":0,"name":"Bui Hai Hoang","email":"","orcid":"","institution":"Hanoi Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Bui","middleName":"Hai","lastName":"Hoang","suffix":""},{"id":290015364,"identity":"b6360c9e-3e04-4c95-ac87-698ba63b75e5","order_by":1,"name":"Thomas Vu Tang","email":"","orcid":"","institution":"University of Tasmania","correspondingAuthor":false,"prefix":"","firstName":"Thomas","middleName":"Vu","lastName":"Tang","suffix":""},{"id":290015365,"identity":"9c1afa87-235e-4f2c-a7fd-b94a762d491f","order_by":2,"name":"Nguyen Dai Nghia Phan","email":"","orcid":"","institution":"Hanoi Medical University","correspondingAuthor":false,"prefix":"","firstName":"Nguyen","middleName":"Dai Nghia","lastName":"Phan","suffix":""},{"id":290015366,"identity":"51f1ea65-1421-4665-87de-5a4289e78a59","order_by":3,"name":"Anh Dung Nguyen","email":"","orcid":"","institution":"Hanoi Medical University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Anh","middleName":"Dung","lastName":"Nguyen","suffix":""},{"id":290015367,"identity":"e1185118-5e33-4fb9-9305-718313f38773","order_by":4,"name":"Michael Minh Quoc Dinh","email":"data:image/png;base64,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","orcid":"","institution":"RPA Green Light Institute","correspondingAuthor":true,"prefix":"","firstName":"Michael","middleName":"Minh Quoc","lastName":"Dinh","suffix":""}],"badges":[],"createdAt":"2024-03-27 23:59:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4178610/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4178610/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12245-024-00673-7","type":"published","date":"2024-07-16T16:13:23+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":61595340,"identity":"65632888-4dd9-443c-a4ac-36af68bfb4a3","added_by":"auto","created_at":"2024-08-01 17:22:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":173931,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4178610/v1/e3fea848-da92-4e43-8413-93f69ffe3104.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A B C Dengue: a case of multifactorial shock due to major trauma and dengue infection","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eDengue is the most common arboviral illness reported globally, endemic to most tropical and sub-tropical regions of the world (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). The Dengue flavivirus is transmitted by the \u003cem\u003eA aegypti\u003c/em\u003e mosquito with an incubation period of one to two weeks. Although most dengue cases result in a mild, self-limiting febrile illness, around 5% develop severe dengue, characterised by severe vomiting, haemorrhagic manifestations (petechial rash, gastrointestinal bleeding), which may lead to dengue shock syndrome (DSS) characterised by refractory hypotension and multiorgan dysfunction in less than 1% of cases with a mortality of around 25% (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThere are no reports of intercurrent severe dengue infection complicating cases of major trauma. These cases are likely to become more prevalent in the coming decade as cases of Dengue continue to increase due to urbanisation, international travel and climate change. We report on a case of severe dengue diagnosed in a patient with major trauma and illustrate some of the potential challenges and considerations in the clinical management of such cases.\u003c/p\u003e "},{"header":"CASE","content":"\u003cp\u003eA 49-year-old female self-presented to an emergency department of a tertiary hospital in Hanoi Vietnam with severe right flank pain after being struck by a motorcycle as a pedestrian. Her medical background comprised chronic hepatitis B infection with no other known comorbidities. On examination, her Glasgow Coma Scale (GCS) was 15, blood pressure was 120/70 mmHg, oxygen saturations were 98% on room air, afebrile, respiratory rate 28 breathes/min, and heart rate 89 bpm. During ED assessment her blood pressure fell to 80/50 mmHg. Imaging revealed grade V right kidney injury, subcapsular laceration grade III liver injury, rib fracture of ribs 10, 11, and 12 on the right, and fractures of vertebrae T12 to L2 with no clinical evidence of spinal cord injury. Injury Severity Score was estimated to be 34.\u003c/p\u003e\u003cp\u003eShe was given 2L of crystalloid, 2 units of fresh frozen plasma and 2 units of packed red cells in the emergency department before urgent transfer to the operating room for emergency trauma laparotomy with repair of descending duodenum (segment D2), formation of jejunostomy and right total nephrectomy followed by Intensive Care Unit admission.\u003c/p\u003e\u003cp\u003eOn day 4 of admission, the patient developed a fever of 38.7 degrees Celsius which persisted to day 7, when her fever reached 40 degrees C despite prophylactic broad-spectrum antibiotics. During this time, her haemoglobin had dropped from 124 to 70 g/L, platelets from 368 to 62 g/L, white cell count decreased from 24.3 to 6.4 g/L, creatinine increased from 72 to 124 umol/L, urea from 8.8 to 20.8 mmol/L. Blood pressure in ICU dropped from 115/60 to 90/60 mmHg on day 7 of admission.\u003c/p\u003e\u003cp\u003eDengue was suspected once she developed fever because of a concurrent seasonal epidemic of Dengue in Hanoi at the time and her NS1 antigen test returned positive for Dengue virus on day 4 post operation. IgM and IgG for Dengue were also positive. On day 7 she was diagnosed with DSS. She developed ascites and pulmonary oedema on day 10 which was treated with a trial of frusemide but subsequently became anuric on day 12 requiring continuous venovenous hemofiltration. The patient was extubated on day 19 of admission and transferred out of ICU the following day.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe differential diagnoses of shock during the acute and perioperative phase of major trauma in the context of this case were broad and multifactorial, including ongoing haemorrhage, sepsis due to intraabdominal collections or nosocomial pneumonia, systemic inflammatory response syndrome, fat embolism and concurrent infections (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe pathogenesis of DSS involves increased vascular permeability, thrombocytopaenia and leukopenia which can complicate ongoing recovery from major trauma. Hypovolemic shock seen in DSS results due to gastrointestinal losses, fluid shifts, ongoing bleeding and multiorgan dysfunction (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). This patient faced several challenges with respect to fluid management. Initially, she required management of haemorrhagic shock secondary to major trauma. However, with the onset of DSS, judicious administration of intravenous fluids in conjunction with vasopressor support were required to manage third spacing fluid shifts and pulmonary oedema. Our patient tested positive for both Dengue IgM and IgG, suggesting previous infection. It is known that previous Dengue Infection increases the risk of severe dengue with subsequent infections with a different serotype of Dengue virus (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eWe report a rare case of multi-factorial shock, involving both major trauma and concurrent severe dengue infection. Judicious fluid management, vasopressor and renal support, and diligence in suspecting concurrent infection in such cases is important in achieving good patient outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthical Approval: Ethics approval was obtained from the Hanoi Medical University Hospital Human Ethics Research Committee.\u0026nbsp;The study was performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.\u0026nbsp;Written informed consent was obtained from the patient for participation in the case report and for publication.\u0026nbsp;All patient information is kept confidential. The manuscript was completed once the patient was discharged from the hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u003c/em\u003e Written informed consent was obtained from the patient for publication of this study and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent to participate:\u0026nbsp;\u003c/em\u003eWritten informed consent was obtained from the participant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics committee: Not applicable.\u003c/p\u003e\n\u003cp\u003eFunding:\u0026nbsp;The authors do not have any funding sources.\u003c/p\u003e\n\u003cp\u003eAvailability of data and materials:\u0026nbsp;The information generated during and analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eKhan MB, Yang Z-S, Lin C-Y, Hsu M-C, Urbina AN, Assavalapsakul W, et al. Dengue overview: An updated Systemic Review. Journal of Infection and Public Health. 2023 Oct;16(10):1625\u0026ndash;42. doi:10.1016/j.jiph.2023.08.001.\u003c/li\u003e\n \u003cli\u003eChagas GCL, Rangel AR, Noronha LM, Veloso FCS, Kassar SB, Oliveira MJC, Meneses GC, da Silva Junior GB, Daher EF. Risk factors for mortality in patients with dengue: A systematic review and meta-analysis. Trop Med Int Health. 2022 Aug;27(8):656-668. doi: 10.1111/tmi.13797. Epub 2022 Jul 11. PMID: 35761748.\u003c/li\u003e\n \u003cli\u003eLuo J., Chen D., Tang L., Deng H., Zhang C., Chen S., et al. Multifactorial shock: A neglected situation in polytrauma patients. Journal of Clinical Medicine. 2022 Nov 18;11(22):6829. doi:10.3390/jcm11226829.\u003c/li\u003e\n \u003cli\u003eMcBride A, Chanh HQ, Fraser JF, Yacoub S, Obonyo NG. Microvascular dysfunction in septic and dengue shock: Pathophysiology and implications for Clinical Management. Global Cardiology Science and Practice. 2020 Nov 30;2020(2):e202029. doi:10.21542/gcsp.2020.29.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"trauma, dengue","lastPublishedDoi":"10.21203/rs.3.rs-4178610/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4178610/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eWe report on a case of severe dengue diagnosed in a patient with major trauma and illustrate some of the potential challenges and considerations in the clinical management of such cases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod: \u003c/strong\u003eCase report from Hanoi, Vietnam\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eA 49-year-old female presented following road trauma incident requiring urgent laparotomy. Her recovery in Intensive Care Unit was complicated by the development of Dengue Shock Syndrome.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eDengue Shock Syndrome may complicate fluid management and bleeding control in major trauma cases.\u003c/p\u003e","manuscriptTitle":"A B C Dengue: a case of multifactorial shock due to major trauma and dengue infection","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-15 16:27:54","doi":"10.21203/rs.3.rs-4178610/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-17T15:14:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-28T04:30:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-26T08:50:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222314168618042879849630305200563187493","date":"2024-05-23T08:14:29+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-22T08:10:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"155384008130945206012283687681925765827","date":"2024-05-21T11:14:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"191811890997393978387704932344450452454","date":"2024-05-18T22:26:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"198657531025214648134832987997923246840","date":"2024-05-17T06:16:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"334432789756461602500143390594341159695","date":"2024-05-14T23:54:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-14T17:52:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-04-11T08:18:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-04-11T08:18:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2024-03-27T23:52:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4efa6f61-e0cd-42c1-94c7-db5964d0a8cb","owner":[],"postedDate":"April 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-01T16:20:38+00:00","versionOfRecord":{"articleIdentity":"rs-4178610","link":"https://doi.org/10.1186/s12245-024-00673-7","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2024-07-16 16:13:23","publishedOnDateReadable":"July 16th, 2024"},"versionCreatedAt":"2024-04-15 16:27:54","video":"","vorDoi":"10.1186/s12245-024-00673-7","vorDoiUrl":"https://doi.org/10.1186/s12245-024-00673-7","workflowStages":[]},"version":"v1","identity":"rs-4178610","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4178610","identity":"rs-4178610","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}