Reciprocal Abstracts

Editor’s note: The Hong Kong Journal of Emergency Medicine has partnered with a small group of selected journals of international emergency medicine societies to share from each a highlighted research study, as selected monthly by their editors. Our goals are to increase awareness of our readership to research developments in the international emergency medicine literature, promote collaboration among the selected international emergency medicine journals, and support the improvement of emergency medicine worldwide, as described in the WAME statement at http://www.wame.org/about/policy-statements#Promoting%20Global%20Health. Abstracts are reproduced as published in the respective participating journals and are not peer reviewed or edited by the Hong Kong Journal of Emergency Medicine.

African Journal of Emergency Medicine

The official journal of the African Federation for Emergency Medicine, the Emergency Medicine Association of Tanzania, the Emergency Medicine Society of South Africa, the Egyptian Society of Emergency Medicine, the Libyan Emergency Medicine Association, the Ethiopian Society of Emergency Medicine Professionals, the Sudanese Emergency Medicine Society, the Society of Emergency Medicine Practitioners of Nigeria and the Rwanda Emergency Care Association

(The print version of this article has been scheduled for September 2022)

The ethical considerations for emergency care research in low- and middle-income countries: a scoping review of the published literature

Hirner S, Saunders C, Stassen W

Afr J Emerg Med 2022; 12(1): 71–76

https://doi.org/10.1016/j.afjem.2021.12.001

Introduction: Research studies on emergency care in low- and middle-income countries (LMICs) face many ethical considerations, including obtaining valid informed consent from vulnerable patients. This study aims to describe the body of literature related to the ethical considerations associated with emergency care research in low- and middle-income settings.

Methods: A scoping review was conducted to identify literature published between 2000 and 2020 related to ethical considerations associated with emergency care research in the LMIC setting. Titles and abstracts were screened in duplicate, and full texts were reviewed and extracted by the principal author.

Results: In total, 1087 articles were identified and 17 articles were included. Major themes identified in the literature included risk versus benefit assessments, patient vulnerabilities, consent, community engagement, clinical roles, ancillary care provision, and regulation of research. Alternative models of consent are often used in emergency care research, including surrogate consent, community consent, and waiver of consent. Challenges and best practices with these alternative models of consent in LMICs are discussed.

Discussion: Gaps remain in the literature describing the ethics of emergency care research in LMICs, including clear guidelines for protecting vulnerable patients and designing ethical consent processes. Best practices identified include community engagement for designing research studies, identifying acceptable risk profiles, and allocating benefits. Continuous and rigorous assessment of the quality of consent is also needed.

Reproduced with permission

(The print version of this article has been scheduled for October 2022)

Trauma training in low- and middle-income countries: a scoping review of ATLS alternatives

Brown HA, Tidwell C, Prest P

Afr J Emerg Med 2022; 12(1): 53–60

https://doi.org/10.1016/j.afjem.2021.11.004

Introduction: Trauma training for front-line providers is a critical component of injury mitigation and trauma systems strengthening. Although the Advanced Trauma Life Support (ATLS) course is standard in much of the world, cost and administrative barriers are prohibitive to deploying the course in many low- and middle-income countries (LMICs). The purpose of this study was to identify alternative trauma training courses used in LMICs by scoping review and compare their effectiveness.

Methods: Several peer-reviewed and gray literature databases were searched for relevant articles describing trauma training courses for front-line medical providers in LMICs. Studies were included if: performed in a LMIC, utilized a general trauma training course other than ATLS, trainees were hospital-based medical providers, and study included some type of outcome measure.

Results: A total of 34 manuscripts met inclusion criteria. The majority of courses were novel, hospital-initiated courses and ranged in length from 1 day to 1 week. Physicians were the most common target audience, followed by medical students and nurses. Courses were taught in 24 different countries throughout the Middle East, Asia, Latin America and Africa. Comparison of pre- and post-test knowledge was the most common metric used and nearly all courses demonstrated a statistically significant knowledge gain. One study demonstrated a reduction in mortality for injured patients after course implementation. The majority of courses were a collaboration between universities in a high income country and local faculty/practitioners in the LMIC where the course was taught. Reported cost per participant ranged from $10 to $232 USD.

Conclusions: Several trauma courses are currently being utilized in LMICs effectively with increases in knowledge gained and at a lower reported cost than ATLS. More research is needed to link trauma training courses to patient outcomes.

Reproduced with permission

Annals of Emergency Medicine

(The print version of this article has been scheduled for September 2022)

Intranasal topical application of tranexamic acid in atraumatic anterior epistaxis: a double-blind randomized clinical trial

Milad Hosseinialhashemi, Reza Jahangiri, Ali Faramarzi, Naeimehossadat Asmarian, Yaaghoob Khosravi, Mohammadreza Khademalizadeh, Sarvin Sajedianfard, Maryam Kherad, Amir Soltaniesmaeili, Amirhossein Babaei

Study objective: To determine the effectiveness of intranasal topical application of tranexamic acid in reducing the need for anterior nasal packing and determine the number of episodes of rebleeding in adult patients presenting with spontaneous atraumatic anterior epistaxis.

Methods: This study was a double-blind randomized trial conducted from September to November 2021 in the ENT emergency department, Khalili Hospital, Shiraz, Iran. Cotton pledgets soaked in either phenylephrine and lidocaine (control group) or tranexamic acid with phenylephrine and lidocaine (intervention group) were inserted into the patients’ nostrils for 15 min. The primary outcome was the need for anterior nasal packing. The secondary outcomes were staying in the ED for more than 2 h, needing electrical cauterization, and rebleeding within 24 h and 1 to 7 days of the first referral to the ED. The trial was registered with the Iranian Registry of Clinical Trials (IRCT20210403050815 N1).

Results: A total of 240 patients (120 in each group) were enrolled in this study. Tranexamic acid was associated with a lower rate of need for anterior nasal packing (50.0% versus 64.2%; odds ratio (OR), 0.56; 95% confidence interval (CI): 0.33–0.94). There were no significant differences between the 2 groups in terms of the need for electrical cauterization and the rate of rebleeding within 1 to 7 days. Tranexamic acid was associated with a lower rate of stay in the ED for more than 2 h (9.2% versus 20.8%; OR: 0.38; 95% CI: 0.18–0.82) and rebleeding in 24 h (15.0% versus 30%; OR: 0.41; 95% CI: 0.22–0.78) compared with Q3 the rates in the control group.

Conclusion: Intranasal topical application of tranexamic acid is associated with a lower rate of need for anterior nasal packing and a shortened stay in the ED; it may be considered a part of the treatment for atraumatic anterior epistaxis

How to cite this article:

Hosseinialhashemi M, Jahangiri R, Farmarzi A, et al. Intranasal topical application of tranexamic acid in atraumatic anterior epistaxis: a double-blind randomized clinical trial. Ann Emerg Med 2022. DOI: 10.1016/j.annemergmed.2022.04.010.

(The print version of this article has been scheduled for October 2022)

Impact of ambient temperature on five emergency drugs aboard an emergency medical car over a 1-year period

Claire Welter, Karin Roschel, Serge Schneider, Claude Marson, Pascal Stammet

Study objective: Drugs in emergency medical service (EMS) cars are often exposed to temperature variations that could affect the stability of these drugs. We aimed to study the influence of real-life temperature exposure on the stability of 5 drugs onboard an EMS vehicle.

Methods: Concentrations of active principles of 5 emergency drugs (amiodarone, rocuronium, fentanyl, succinylcholine, and epinephrine) aboard an EMS vehicle were analyzed every 3 months up to 1 year. The samples were compared to the same drugs stored for 1 year either at room temperature or in a refrigerator in the pharmacy. Succinylcholine was additionally analyzed once a week for 4 weeks after being taken out of the refrigerator. The dosage of the active principle was measured using high-pressure Q5 liquid chromatography coupled with ultraviolet detection.

Results: After the 12-month period, all drugs from the EMS car, except succinylcholine, presented concentrations still above 90% of the concentrations measured at the start of the project. Concentrations ranged from 96.3% to 103%. For succinylcholine at 12 months, the remaining concentration was 89%. Temperatures in the EMS car ranged from 13.9 C to 33.9 C (median, 22.8 C (interquartile range: 20.5 C–25.8 C)).

Conclusion: In real-life conditions, amiodarone, rocuronium, fentanyl, succinylcholine, and epinephrine onboard an EMS vehicle did not suffer pharmacologically relevant degradation from temperature variations. All concentrations measured remained in the specification intervals given by the manufacturers.

How to cite this article:

Welter C, Roschel K, Schneider S, et al. Impact of ambient temperature on five emergency drugs aboard an emergency medical car over a one-year period. Ann Emerg Med 2022. DOI: 10.1016/j.annemergmed.2022.05.001.

Canadian Journal of Emergency Medicine

http://caep.ca/resources/cjem/

SEPTEMBER 2022:

Safely reducing abdominal/pelvic computed tomography imaging in pediatric trauma: a quality improvement initiative

Suzanne Beno, Felicia Paluck, Talia Greenspoon, Daniel Rosenfield, Tania Principi

Beno S, Paluck F, Greenspoon T, et al. Safely reducing abdominal/pelvic computed tomography imaging in pediatric trauma: a quality improvement initiative. Can J Emerg Med 2022. DOI: 10.1007/s43678-022-00311-2.

Objective: Intra-abdominal injury (IAI) occurs in less than 15% of pediatric trauma activations but can be life-threatening. Computed tomography (CT) imaging is commonly ordered in pediatric trauma, even when IAI risk is low. We aimed to reduce abdominal/pelvic CT rates in children at very low risk for intra-abdominal injury requiring trauma activation at our pediatric trauma center.

Methods: We implemented a quality improvement initiative using the Model for Improvement in children 0–15.99 years of age who activated a trauma response and were evaluated for intra-abdominal injury. Interventions included clinical decision support, institutional education, and individual audit and feedback. Our primary outcome was abdominal/pelvic CT rate in patients at very low risk for intra-abdominal injury. Balancing measures included CT scans ordered within 24 h of Emergency Department (ED) assessment and return to ED or hospitalization within 72 h for missed intra-abdominal injury. Statistical process control was used to evaluate rates over time.

Results: The baseline period (1 April 2016 to 30 November 2017) included 359 trauma patients with a CT rate of 26.8% (95% CI: 20.5%–33.8%) in those at low risk for intra-abdominal injury. The intervention period (1 December 2017 to 31 December 2019) included 445 patients with a CT rate in low risk patients of 6.8% (95% CI: 3.2%–12.6%), demonstrating an absolute reduction of 20.0% (95% CI: 12.2%–27.7%, P < 0.05). Interventions resulted in a significant decrease in abdominal/pelvic CT imaging corresponding with special cause variation. No clinically significant intra-abdominal injuries were missed.

Conclusions: This quality improvement initiative reduced abdominal/pelvic CT rates in pediatric trauma patients at low risk for intra-abdominal injury without any missed cases of significant injury. Leveraging standardized decision tools to reduce unnecessary CT imaging can be successfully accomplished without compromising care.

Keywords: Intra-abdominal injury, pediatric, quality improvement, CT imaging, low risk

Emergencias

SEPTEMBER 2022:

Efficiency of screening for human immunodeficiency virus infection in emergency departments: a systematic review and meta-analysis

Juan González del Castillo, Manuel Enrique Fuentes Ferrer, Cristina Fernández Pérez, Germán Molina Romera, María José Núñez Orantos, Vicente Estrada Pérez

Cited: González Del Castillo J, Fuentes Ferrer ME, Fernández Pérez C, et al. Efficiency of screening for human immunodeficiency virus infectionin emergency departments: a systematic review and meta-analysis. Emergencias 2022; 34: 204–212.

http://emergencias.portalsemes.org/descargar/eficiencia-del-cribado-de-vih-en-urgencias-revisin-sistemtica-y-metanlisis/

Background and objective: The rates of undiagnosed and late-diagnosed human immunodeficiency virus (HIV) infection are high. Screening for HIV infection in hospital emergency departments (EDs) could offer a way to increase the number of diagnoses. Our aim was to analyze whether universal hospital ED screening for HIV is efficient.

Methods: We followed the guidelines for Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). PubMed, the Cochrane Library, LILACS, Scopus, EMBASE, and the Web of Science were searched using the following terms: “HIV infections/epidemiology,” “AIDS serodiagnosis,” “emergency service, hospital,” “prevalence,” and “mass screening/methods.” The searches were limited to a 5 year time frame (2016–2020); only publications in English or Spanish were collected. We included studies of universal HIV screening among hospital ED patients and evaluated them using the Quality Assessment Tool for Quantitative Studies.

Results: A total of 273 articles were identified. Twelve met the inclusion criteria. The studies analyzed 103 731 patient samples and yielded 652 new HIV diagnoses. A random effects model estimated an overall new-diagnosis prevalence of 0.60% (95% CI: 0.39%–0.84%). The heterogeneity statistic I2 was high, at 90.02% (P < .001). Estimates of prevalence based on studies were carried out in Europe, the United States, and Africa were, respectively, 0.48% (95% CI: 0.13%–1.03%), 0.54% (95% CI: 0.33%–0.40%), and 5.6% (95% CI: 3.37%–9.2%). The studies received quality ratings of moderate or strong.

Conclusion: Although the reviewed studies applied various screening strategies to identify new HIV diagnoses, our findings support the conclusion that universal screening is efficient.

Keywords: Undiagnosed human immunodeficiency virus (HIV) infection, Late HIV diagnosis, HIV screening

OCTOBER 2022

Ability of lactate, procalcitonin, and criteria defining sepsis to predict 30-day mortality, bacteremia, and microbiologically confirmed infection in patients with infection suspicion treated in Emergency Departments

Rafael Rubio-Díaz, Agustín Julián-Jiménez, Juan González del Castillo, Eric Jorge García-Lamberechts, Itziar Huarte Sanz, Carmen Navarro Bustos, Francisco Javier Candel González, Pedro Beneyto Martín, en nombre del grupo INFURG-SEMES

Cited: Rubio-Díaz R, Julián-Jiménez A, González Del Castillo J, et al. Ability of lactate, procalcitonin, and criteria defining sepsis to predict 30 day mortality, bacteremia, and microbiologically confirmed infection in patients with infection suspicion treated in Emergency Departments. Emergencias 2022; 34: 181–189.

http://emergencias.portalsemes.org/descargar/capacidad-del-lactato-procalcitonina-y-de-los-criterios-definitorios-de-sepsis-para-predecir-mortalidad-a-30-das-bacteriemia-o-infeccin-confirmada-microbiolgicamente-en-los-pacientes-atendidos-por-sospecha-de-infeccin-en-urgencias/

Objectives: To evaluate lactate, procalcitonin, criteria defining systemic inflammatory response syndrome (SIRS), and the Quick Sepsis-Related Organ Failure Assessment (qSOFA) and compare their ability to predict 30-day mortality, infection with microbiologic confirmation, and true bacteremia in patients treated for infection in hospital emergency departments.

Methods: Prospective multicenter observational cohort study. We enrolled a convenience sample of patients aged 18 years or older attended in 71 Spanish emergency departments from October 1, 2019, to March 31, 2020. Each model’s predictive power was analyzed with the area under the receiver operating characteristic curve (AUC), and predetermined decision points were assessed.

Results: A total of 4439 patients with a mean (SD) age of 18 years were studied; 2648 (59.7%) were men and 459 (10.3%) died within 30 days. True bacteremia was detected in 899 (20.25%), and microbiologic confirmation was on record for 2057 (46.3%). The model that included the qSOFA score (>= 2) and lactate concentration (>= 0.738 mmol/L; 95% CI: 0.711–0.765 mmol/L) proved to be the best predictor of 30-day mortality, with an AUC of 0.890 (95% CI: 0.880–0.901). The model that included the SIRS score (>= 2) and procalcitonin concentration (>= 0.51 ng/mL) proved to be the best predictor of true bacteremia and microbiologic confirmation, with an AUC of 0.713 (95% CI, 0.698–0.728).

Conclusions: A qSOFA score of 2 or more plus lactate concentration (>= 0.738 mmol/L) predict 30 day mortality better than the combination of a SIRS score of 2 or more and procalcitonin concentration. A SIRS score of 2 or more plus procalcitonin concentration (>= 0.51 ng/mL) predict true bacteremia and microbiologic confirmation.

Keywords: Sepsis. Biological markers. Lactic acid. Procalcitonin. Bacteremia. Diagnosis. Prognosis. Mortality. Systemic inflammatory response syndrome (SIRS). Quick Sepsis-Related Organ Failure Assessment (qSOFA). Emergency department.

Emergency Medicine Journal

September 2022

Prognostic value of National Early Warning Scores (NEWS2) and component physiology in hospitalized patients with COVID-19: a multicentre study

Scott LJ, Tavaré A, Hill EM, Jordan L, Juniper M, Srivastava S, Redfern E, Little H, Pullyblank A

Background: National Early Warning Scores (NEWS2) are used to detect all-cause deterioration. While studies have looked at NEWS2, the use of virtual consultation and remote monitoring of patients with COVID-19 mean there is a need to know which physiological observations are important.

Aim: To investigate the relationship between outcome and NEWS2, change in NEWS2 and component physiology in COVID-19 inpatients.

Methods: A multi-center retrospective study of electronically recorded, routinely collected physiological measurements between March and June 2020. First and maximum NEWS2, component scores and outcomes were recorded. Areas under the curve (AUCs) for 2-day, 7-day and 30-day mortality were calculated.

Results: Of 1263 patients, 26% died, 7% were admitted to intensive care units (ICUs) before discharge and 67% were discharged without ICU. Of 1071 patients with initial NEWS2, most values were low: 50% NEWS2 = 0–2, 27% NEWS2 = 3–4, 14% NEWS2 = 5–6 and 9% NEWS2 = 7+. Maximum scores were: 14% NEWS2 = 0–2, 22% NEWS2 = 3–4, 17% NEWS2 = 5–6 and 47% NEWS2 = 7+. Higher first and maximum scores were predictive of mortality, ICU admission and longer length of stay. AUCs based on 2 day, 7 day, 30 day and any hospital mortality were 0.77 (95% CI: 0.70–0.84), 0.70 (0.65–0.74), 0.65 (0.61–0.68) and 0.65 (0.61–0.68), respectively. The AUCs for 2-day mortality were 0.71 (0.65–0.77) for supplemental oxygen, 0.65 (0.56–0.73) oxygen saturation and 0.64 (0.56–0.73) respiratory rate.

Conclusion: While respiratory parameters were most predictive, no individual parameter was as good as a full NEWS2, which is an acceptable predictor of short-term mortality in patients with COVID-19. This supports recommendation to use NEWS2 alongside clinical judgment to assess patients with COVID-19.