Bystander Assistance for Trauma Victims in Low- and Middle-Income Countries: A Systematic Review of Prevalence and Training Interventions.

OBJECTIVE: Lack of organized prehospital care may contribute to the disproportionate burden of trauma-related deaths in low- and middle-income countries (LMICs). The World Health Organization (WHO) recommends bystander training in basic principles of first aid and victim transport; however, prevalence of bystander or layperson assistance to trauma victims in LMICs has not been well-described, and organized reviews of existing evidence for bystander training are lacking. This systematic review aims to 1) describe the prevalence of bystander or layperson aid or transport for trauma victims in the prehospital setting in LMICs and 2) ascertain impacts of bystander training interventions in these settings. METHODS: A systematic search of OVID Medline, Cochrane Library, and relevant gray literature was conducted. We included 1) all studies detailing prevalence of bystander-administered aid or transport for trauma victims in LMICs and 2) all randomized controlled trials and observational studies evaluating bystander training interventions. We extracted study characteristics, interventions, and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS: Sixty-two studies detailed prevalence of bystander transport and aid. Family members, police, and bus or taxi drivers commonly transported patients; a majority of patients, up to >94%, received aid from bystanders. Twenty-four studies examined impacts of training interventions. Only one study looked at transport interventions; the remainder addressed first aid training. Interventions varied in content, duration, and target learners. Evidence was generally of low quality, but all studies demonstrated improvements in layperson knowledge and skills. Five studies reported a mortality reduction. CONCLUSIONS: Heterogeneity in data reporting and outcomes limited formal meta-analysis. However, this review shows high rates of bystander involvement in prehospital trauma care and transport in LMICs and highlights the need for bystander training. Bystander training in these settings is feasible and may have an important impact on meaningful outcomes such as mortality. Categories of involved bystanders varied by region and training interventions should be targeted at relevant groups. "Train the trainer" models appear promising in securing community engagement and maximizing participation. Further research is needed to examine the value of bystander transport networks in trauma.

Establishing the Effectiveness of Interventions Provided to First Responders to Prevent and/or Treat Mental Health Effects of Response to a Disaster: A Systematic Review.

OBJECTIVES: This review systematically explores the current available evidence on the effectiveness of interventions provided to first responders to prevent and/or treat the mental health effects of responding to a disaster. METHODS: A systematic review of Medline, Scopus, PsycINFO, and gray literature was conducted. Studies describing the effectiveness of interventions provided to first responders to prevent and/or treat the mental health effects of responding to a disaster were included. Quality was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria, and the Critical Appraisal Skills Programme (CASP) checklist. RESULTS: Manuscripts totaling 3869 met the initial search criteria; 25 studies met the criteria for in-depth analysis, including 22 quantitative and 3 qualitative studies; 6 were performed in low- and middle-income countries (LMICs); 18 studies evaluated a psychological intervention; of these, 13 found positive impact, 4 found no impact, and 1 demonstrated worsened symptoms after the intervention. Pre-event trainings decreased psychiatric symptoms in each of the 3 studies evaluating its effectiveness. CONCLUSIONS: This review demonstrates that there are likely effective interventions to both prevent and treat psychiatric symptoms in first responders in high-, medium-, and low-income countries.

Lactate and hypotension as predictors of mortality after in-hospital cardiac arrest.

AIM: Guidance on post-cardiac arrest prognostication is largely based on data from out-of-hospital cardiac arrest (OHCA), despite clear differences between the OHCA and in-hospital cardiac arrest (IHCA) populations. Early prediction of mortality after IHCA would be useful to help make decisions about post-arrest care. We evaluated the ability of lactate and need for vasopressors after IHCA to predict hospital mortality. METHODS: Single center retrospective observational study of adult IHCA patients who achieved sustained return of spontaneous circulation (ROSC), required mechanical ventilation peri-arrest and had a lactate checked within 2 h after ROSC. We evaluated the association of post-ROSC lactate and need for vasopressors with mortality using multivariate logistic regression. RESULTS: A total of 364 patients were included. Patients who received vasopressors within 3 h after ROSC had significantly higher mortality compared to patients who did not receive vasopressors (58% vs. 43%, p = 0.03). Elevated lactate level was associated with mortality (44% if lactate <5 mmol/L, 58% if lactate 5-10 mmol/L, and 73% if lactate >10 mmol/L, p < 0.01). A multivariable model with lactate group and post-ROSC vasopressor use as predictors demonstrated moderate discrimination (AUC 0.64 [95%CI:0.59-0.70]). Including other variables, the most parsimonious model included lactate, age, body mass index, race, and history of arrhythmia, cancer and/or liver disease (AUC 0.70 [95% CI: 0.64-0.75]). CONCLUSION: Post-ROSC lactate and need for vasopressors may be helpful in stratifying mortality risk in patients requiring mechanical ventilation after IHCA.

Advanced airway management during adult cardiac arrest: A systematic review.

AIM: To systematically review the literature on advanced airway management during adult cardiac arrest in order to inform the International Liaison Committee of Resuscitation (ILCOR) consensus on science and treatment recommendations. METHODS: The review was performed according to PRISMA guidelines and registered on PROSPERO (CRD42018115556). We searched Medline, Embase, and Evidence-Based Medicine Reviews for controlled trials and observational studies published before October 30, 2018. The population included adult patients with cardiac arrest. Two investigators reviewed studies for relevance, extracted data, and assessed the risk of bias of individual studies. RESULTS: We included 78 observational studies and 11 controlled trials. Most of the observational studies and all of the controlled trials only included patients with out-of-hospital cardiac arrest. The risk of bias for individual observational studies was overall assessed as critical or serious, with confounding and selection bias being the primary sources of bias. Three of the controlled trials, all published in 2018, were powered for clinical outcomes with two comparing a supraglottic airway to tracheal intubation and one comparing bag-mask ventilation to tracheal intubation. All three trials had some concerns regarding risk of bias primarily due to lack of blinding and variable adherence to the protocol. Clinical and methodological heterogeneity across studies, for both the observational studies and the controlled trials, precluded any meaningful meta-analyses. CONCLUSIONS: We identified a large number of studies related to advanced airway management in adult cardiac arrest. Three recently published, large randomized trials in out-of-hospital cardiac arrest will help to inform future guidelines. Trials of advanced airway management during in-hospital cardiac arrest are lacking.

Vasopressors during adult cardiac arrest: A systematic review and meta-analysis.

AIM: To systematically review the literature on the use of vasopressors during adult cardiac arrest to inform an update of international guidelines. METHODS: PRISMA guidelines were followed. We searched Medline, Embase, Web of Science, CINAHL, and the Cochrane Library for controlled trials and observational studies. The population included adults with cardiac arrest in any setting. Pairs of investigators reviewed studies for relevance, extracted data, and assessed the risk of bias for individual studies. Certainty of evidence was evaluated using GRADE for controlled trials and meta-analyses were performed when at least two studies could be pooled. RESULTS: We included 15 controlled trials and 67 observational studies. The majority of studies included out-of-hospital cardiac arrest only. Meta-analyses were performed for two controlled trials comparing epinephrine to placebo, three comparing vasopressin to epinephrine, and three comparing epinephrine plus vasopressin to epinephrine only. All controlled trials ranged between low to some concern in risk of bias. The certainty of evidence ranged from very low to high. Risk of bias for observational studies was generally critical or serious, largely due to confounding and selection bias. CONCLUSIONS: Controlled trial data suggest that epinephrine improves return of spontaneous circulation, survival to hospital discharge, and 3-month survival in out-of-hospital cardiac arrest. The improvement in short-term outcomes appeared more pronounced for non-shockable rhythms. Differences in long-term neurological outcome did not reach statistical significance, although there was a signal toward improved outcomes. Controlled trial data indicated no benefit from vasopressin with or without epinephrine compared to epinephrine only.

A study of central corneal thickness in glaucoma and nonglaucoma patients in a West African population.

PURPOSE: To compare central corneal thickness (CCT) in high-tension glaucomatous eyes and nonglaucomatous eyes with normal intraocular pressure (IOP) and to determine if there is any correlation between CCT and severity of glaucoma, as indicated by vertical cup-to-disc ratio. METHODS: A case-control study that involved 506 subjects at the Korle-Bu Teaching Hospital, Accra, Ghana, from August 2006 to July 2007. The cases were patients with (high tension and IOP more than 21 mm Hg) primary open-angle glaucoma, and the controls were patients with normal IOP (less than 21 mm Hg) and no evidence of glaucoma. The main outcome measures were CCT, as measured by ultrasonic pachymetry (model DGH 55 pachmate), and vertical cup-to-disc ratio. RESULTS: Five hundred six subjects were recruited: 253 cases (506 eyes) and 253 controls (505 eyes). The mean CCT of the right eye for the glaucoma cases was 524.28 µm [95% confidence interval (CI), 4.44; SD, 36.85] and for the controls was 530.00 µm (95% CI, 4.56; SD, 35.75). The mean CCT of the left eye for the glaucoma cases was 524.70 µm (95% CI, 4.48; SD, 36.20) and for the controls was 531.06 µm (95% CI, 4.40; SD, 35.52). The relation between CCT and cupping determined by Pearson correlation coefficient yielded values of -0.09 and 0.01 for the right and left eyes, respectively. CONCLUSION: There was no significant difference between mean CCT of cases and controls in the right eye (P = 0.08), but there was a weakly significant difference in the CCT of the left eye (P = 0.05). Also, there was no correlation between cup-to-disc ratio and CCT.