Safety of Bioplasma FDP and Hemopure in rhesus macaques after 30% hemorrhage.

Objectives: Prehospital transfusion can be life-saving when transport is delayed but conventional plasma, red cells, and whole blood are often unavailable out of hospital. Shelf-stable products are needed as a temporary bridge to in-hospital transfusion. Bioplasma FDP (freeze-dried plasma) and Hemopure (hemoglobin-based oxygen carrier; HBOC) are products with potential for prehospital use. In vivo use of these products together has not been reported. This study assessed the safety of intravenous administration of HBOC+FDP, relative to normal saline (NS), in rhesus macaques (RM). Methods: After 30% blood volume removal and 30 minutes in shock, animals were resuscitated with either NS or two units (RM size adjusted) each of HBOC+FDP during 60 minutes. Sequential blood samples were collected. After neurological assessment, animals were killed at 24 hours and tissues collected for histopathology. Results: Due to a shortage of RM during the COVID-19 pandemic, the study was stopped after nine animals (HBOC+FDP, seven; NS, two). All animals displayed physiologic and tissue changes consistent with hemorrhagic shock and recovered normally. There was no pattern of cardiovascular, blood gas, metabolic, coagulation, histologic, or neurological changes suggestive of risk associated with HBOC+FDP. Conclusion: There was no evidence of harm associated with the combined use of Hemopure and Bioplasma FDP. No differences were noted between groups in safety-related cardiovascular, pulmonary, renal or other organ or metabolic parameters. Hemostasis and thrombosis-related parameters were consistent with expected responses to hemorrhagic shock and did not differ between groups. All animals survived normally with intact neurological function. Level of evidence: Not applicable.

Effect of the COVID-19 pandemic on emergency department attendances for pediatric injuries in Mozambique's central hospitals: an interrupted time series and a comparison within the restriction periods between 2019 and 2020.

Objectives: Hospital-based studies indicate that restriction measures imposed during the COVID-19 pandemic have affected the number and characteristics of pediatric injuries. However, few studies have been conducted in resource-poor countries. This study aimed to determine whether injury-related emergency department (ED) attendances in Mozambique were affected during the restriction periods in 2020 and how the pattern of injury changed. Methods: Mozambique faced two restriction periods in 2020. An interrupted time series was applied to weekly data of pediatric injuries from the ED records of four central hospitals in Mozambique in 2019 and 2020. Weekly numbers of injuries were modeled using a Poisson regression model to estimate the effect of COVID-19 restrictions on trends over calendar time. Then, for each restriction period, differences in injury mechanisms, severity, need for surgery, and intensive care unit (ICU) attendances were compared between 2019 and 2020. Results: During the 76 weeks preceding the restrictions, there was a stable trend in ED attendances. The weekly number dropped by 48.7% after implementation of the first restrictions. By the end of 2020, the weekly numbers were back to the levels observed before the restrictions. Road traffic injuries (RTIs) and falls dropped during the first restriction period and RTIs and burns during the second. There was an increase of 80% in ICU attendances in all periods of 2020 at three hospitals during the first and second restriction periods. Conclusion: The COVID-19 restrictions yielded a reduction in the weekly number of pediatric injuries seen at Mozambique's central hospitals, above all RTIs and falls. The drop reflects reductions in visits most importantly for RTIs, falls, and burns, but was accompanied by an increase in the proportion of ICU cases. This effect was not maintained when the restrictions were relaxed. Whether this reflects reduced exposure to injury or hesitancy to seek care remains to be determined. Level of evidence: Level III, retrospective study with up to two negative criteria.

Operative Trauma Courses: A Scoping Review to Inform the Development of a Trauma Surgery Course for Low-Resource Settings.

BACKGROUND: A multitude of operative trauma courses exist, most of which are designed for and conducted in high-resource settings. There are numerous barriers to adapting such courses to low- and low-middle-income countries (LMICs), including resource constraints and contextual variations in trauma care. Approaches to implementing operative trauma courses in LMICs have not been evaluated in a structured manner. METHODS: We conducted a scoping review of the literature including databases (e.g., PubMed, Web of Science, EMBASE), grey literature repositories, and structured queries of publicly available course materials to identify records that described operative trauma courses offered since 2000. RESULTS: The search identified 3,518 non-duplicative records, of which 48 relevant reports were included in analysis. These reports represented 23 named and 11 unnamed operative trauma courses offered in 12 countries. Variability existed in course format and resource requirements, ranging from USD 40 to 3,000 per participant. Courses incorporated didactic and laboratory components, which utilized simulations, cadavers, or live animals. Course content overlapped significantly but was not standardized. Data were lacking on course implementation and promulgation, credentialing of instructors, and standardized evaluation metrics. CONCLUSIONS: While many operative trauma courses have been described, most are not directly relatable to LMICs. Barriers include cost-prohibitive fees, lack of resources, limited data collection, and contextual variability that renders certain surgical care inappropriate in LMICs. Gaps exist in standardization of course content as well as transparency of credentialing and course implementation strategies. These issues can be addressed through developing an open-access operative trauma course for low-resource settings.

Development and evaluation of deep learning algorithms for assessment of acute burns and the need for surgery.

Assessment of burn extent and depth are critical and require very specialized diagnosis. Automated image-based algorithms could assist in performing wound detection and classification. We aimed to develop two deep-learning algorithms that respectively identify burns, and classify whether they require surgery. An additional aim assessed the performances in different Fitzpatrick skin types. Annotated burn (n = 1105) and background (n = 536) images were collected. Using a commercially available platform for deep learning algorithms, two models were trained and validated on 70% of the images and tested on the remaining 30%. Accuracy was measured for each image using the percentage of wound area correctly identified and F1 scores for the wound identifier; and area under the receiver operating characteristic (AUC) curve, sensitivity, and specificity for the wound classifier. The wound identifier algorithm detected an average of 87.2% of the wound areas accurately in the test set. For the wound classifier algorithm, the AUC was 0.885. The wound identifier algorithm was more accurate in patients with darker skin types; the wound classifier was more accurate in patients with lighter skin types. To conclude, image-based algorithms can support the assessment of acute burns with relatively good accuracy although larger and different datasets are needed.

Prolonged casualty care: Extrapolating civilian data to the military context.

BACKGROUND: Civilian and military populations alike are increasingly faced with undesirable situations in which prehospital and definitive care times will be delayed. The Western Cape of South Africa has some similarities in capabilities, injury profiles, resource limitations, and system configuration to US military prolonged casualty care (PCC) settings. This study provides an initial description of civilians in the Western Cape who experience PCC and compares the PCC and non-PCC populations. METHODS: We conducted a 6-month analysis of an ongoing, prospective, large-scale epidemiologic study of prolonged trauma care in the Western Cape (Epidemiology and Outcomes of Prolonged Trauma Care [EpiC]). We define PCC as ≥10 hours from injury to arrival at definitive care. We describe patient characteristics, critical interventions, key times, and outcomes as they may relate to military PCC and compare these using χ 2 and Wilcoxon tests. We estimated the associations between PCC status and the primary and secondary outcomes using logistic regression models. RESULTS: Of 995 patients, 146 experienced PCC. The PCC group, compared with non-PCC, were more critically injured (66% vs. 51%), received more critical interventions (36% vs. 29%), and had a greater proportionate mortality (5% vs. 3%), longer hospital stays (3 vs. 1 day), and higher Sequential Organ Failure Assessment scores (5 vs. 3). The odds of 7-day mortality and a Sequential Organ Failure Assessment score of ≥5 were 1.6 (odds ratio, 1.59; 95% confidence interval, 0.68-3.74) and 3.6 (odds ratio, 3.69; 95% confidence interval, 2.11-6.42) times higher, respectively, in PCC versus non-PCC patients. CONCLUSION: The EpiC study enrolled critically injured patients with PCC who received resuscitative interventions. Prolonged casualty care patients had worse outcomes than non-PCC. The EpiC study will be a useful platform to provide ongoing data for PCC relevant analyses, for future PCC-focused interventional studies, and to develop PCC protocols and algorithms. Findings will be relevant to the Western Cape, South Africa, other LMICs, and military populations experiencing prolonged care. LEVEL OF EVIDENCE: Therapeutic/care management; Level IV.

Prehospital triage tools across the world: a scoping review of the published literature.

BACKGROUND: Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics. METHODS: A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews. RESULTS: Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools' ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools' diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools' prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge. CONCLUSIONS: The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear 'gold-standard' singular prehospital triage tool for acute undifferentiated patients. TRIAL REGISTRATION: Not applicable.

Essential Emergency and Critical Care: a consensus among global clinical experts.

BACKGROUND: Globally, critical illness results in millions of deaths every year. Although many of these deaths are potentially preventable, the basic, life-saving care of critically ill patients are often overlooked in health systems. Essential Emergency and Critical Care (EECC) has been devised as the care that should be provided to all critically ill patients in all hospitals in the world. EECC includes the effective care of low cost and low complexity for the identification and treatment of critically ill patients across all medical specialties. This study aimed to specify the content of EECC and additionally, given the surge of critical illness in the ongoing pandemic, the essential diagnosis-specific care for critically ill patients with COVID-19. METHODS: In a Delphi process, consensus (>90% agreement) was sought from a diverse panel of global clinical experts. The panel iteratively rated proposed treatments and actions based on previous guidelines and the WHO/ICRC's Basic Emergency Care. The output from the Delphi was adapted iteratively with specialist reviewers into a coherent and feasible package of clinical processes plus a list of hospital readiness requirements. RESULTS: The 269 experts in the Delphi panel had clinical experience in different acute medical specialties from 59 countries and from all resource settings. The agreed EECC package contains 40 clinical processes and 67 requirements, plus additions specific for COVID-19. CONCLUSION: The study has specified the content of care that should be provided to all critically ill patients. Implementing EECC could be an effective strategy for policy makers to reduce preventable deaths worldwide.

Preventing avoidable hospital admissions after emergency care in humanitarian settings: a cross-sectional review of Médecins Sans Frontières emergency departments.

OBJECTIVES: The aim of this study was to describe the types of emergency departments (EDs), and the acuity, types and disposition of conditions managed at Médecins Sans Frontières (MSF)-supported EDs in humanitarian settings. DESIGN, SETTING, PARTICIPANTS AND OUTCOME MEASURES: This was a multicentre, cross-sectional review of visits to MSF-supported EDs from 1 January 2014 to 31 December 2018. EDs were classified into advanced-level, general-level, paediatric and trauma. Variables analysed included: age group, condition, acuity and ED disposition. Frequencies and percentages stratified by ED type or region were reported. RESULTS: MSF supported 26 EDs in 12 countries, with a total of 1 388 698 visits between 2014 and 2018. Most patients were discharged home (n=1 097 456, 79%), with nearly 0% mortality (n=4692). The majority of visits at general-level and paediatric EDs were for medical conditions (n=600 088, 78% and n=45 276, 96%, respectively), while nearly half of advanced-level EDs visits were for surgical conditions (n=201 189, 48%). Almost all visits to trauma EDs were for surgical conditions (n=148 078, 98%). Overall, most surgical conditions were traumatic injuries (n=484 008, 94%), the majority unintentional (n=425 487, 82%). The top three most common classified medical conditions were respiratory infections, malaria and diarrhoea. CONCLUSIONS: EDs are critical in improving the agility and access to emergency care (EC) in humanitarian settings. This study demonstrated that EC provision resulted in the majority of patients being discharged from EDs, helping prevent avoidable hospital admissions. These results could help better understand the healthcare needs of vulnerable populations, improve responsiveness to emergency conditions and support programmatic planning in humanitarian settings.

Emergency healthcare needs in the Lavender Hill suburb of Cape Town, South Africa: a cross-sectional, community-based household survey.

OBJECTIVE: Emergency care is a key component of healthcare systems, but little is known about its real impact on communities. This study evaluated access, utilisation and barriers to healthcare, and specifically emergency care, in the low socioeconomic Cape Town suburb of Lavender Hill. DESIGN: A cross-sectional, community-based household survey. SETTING: Lavender Hill suburb in the Cape Flats of Cape Town, South Africa. PARTICIPANTS: Two-stage cluster sampling was used to identify approximately 13 households in each of 46 clusters, for a total of 608 households. A senior householder responded on behalf of each household surveyed. PRIMARY OUTCOME MEASURES: Access to, utilisation of and unmet needs related to healthcare at large and emergency care. RESULTS: In August 2018, 608 households were surveyed, encompassing 2754 individuals, with a response rate of 96.4%. Almost a quarter of respondents (n=663, 24.1%) used the healthcare system within the last year. Female gender, advancing age, lower levels of education, recipients of disability grants, smaller household sizes and living in formal dwellings were factors associated with increased risk of unmet healthcare and emergency care needs. Only a small proportion of respondents (n=39, 1.4%) reported having unmet emergency healthcare needs, with wait times at facilities (n=9, 23.1%), emergency medical service delays (n=7, 17.9%) and personal safety (n=6, 15.4%) being prominent. There was a high prevalence of chronic medical conditions (hypertension, diabetes and dyslipidaemias) and recent deaths predominantly from trauma and malignancy. CONCLUSION: The emergency healthcare needs of the community appear to be well catered for, although community expectations may not be high and many barriers exist, particularly in accessing emergency care-be it via ambulance services or at healthcare facilities-and caring for chronic diseases in the ageing population. The Lavender Hill community could benefit from programmes addressing chronic disease management and emergency care delivery within the community.

Reliability and validity of emergency department triage tools in low- and middle-income countries: a systematic review.

OBJECTIVE: Despite the universal acknowledgment that triage is necessary to prioritize emergency care, there is no review that provides an overview of triage tools evaluated and utilized in resource-poor settings, such as low- and middle-income countries (LMICs). We seek to quantify and evaluate studies evaluating triage tools in LMICs. METHODS: We performed a systematic review of the literature between 2000 and 2015 to identify studies that evaluated the reliability and validity of triage tools for adult emergency care in LMICs. Studies were then evaluated for the overall quality of evidence using the GRADE criteria. RESULTS: Eighteen studies were included in the review, evaluating six triage tools. Three of the 18 studies were in low-income countries and none were in rural hospitals. Two of the six tools had evaluations of reliability. Each tool positively predicted clinical outcomes, although the variety in resource environments limited ability to compare the predictive nature of any one tool. The South African Triage Scale had the highest quality of evidence. In comparison with high-income countries, the review showed fewer studies evaluating reliability and presented a higher number of studies with small sample sizes that decreased the overall quality of evidence. CONCLUSION: The quality of evidence supporting any single triage tool's validity and reliability in LMICs is moderate at best. Research on triage tool applicability in low-resource environments must be targeted to the actual clinical environment where the tool will be utilized, and must include low-income countries and rural, primary care settings.

Analysis of risk factors, presentation, and in-hospital events of very young patients presenting with ST-elevation myocardial infarction.

INTRODUCTION: In the Indian subcontinent and Arab Gulf, coronary artery disease is affecting younger persons at greater rates. Few studies have focused on young ST-elevation myocardial infarction (STEMI) patients in these regions. We examine the clinical profile and treatment of STEMI patients aged <40 years. METHODS: Participants consisted of 77 STEMI patients, aged <40 years, admitted to hospitals in Abu Dhabi. Data were collected using electronic medical records. Descriptive statistics were calculated for STEMI profile, medical history, risk factors, in-hospital events, and treatment. RESULTS: Smoking was prevalent (61.0%). Beta blockers were frequently prescribed (90.7%); aspirin infrequently (12%). Of patients without history of each condition, 36.7% were diagnosed in-hospital with hypertension, 28.6% with elevated low-density lipoprotein, and 18.8% with lowered high-density lipoprotein. CONCLUSIONS: Among young adults who use tobacco, there is a need for improved screening for risk factors. Earlier detection and treatment of dyslipidemia and hypertension could prevent acute cardiac events among individuals aged <40 years with multiple risk factors.

Adherence to Referral Criteria at Admission and Patient Management at a Specialized Burns Centre: The Case of the Red Cross War Memorial Children's Hospital in Cape Town, South Africa.

Referral guidelines for burn care are meant to assist in decision-making as regards patient transfer and admissions to specialized units. Little is known, however, concerning how closely they are followed and whether they are linked to patient care. This is the object of the current study, focused on the paediatric burns centre of the Red Cross War Memorial Children's Hospital in Cape Town, South Africa. All patients admitted to the centre during the winters of 2011-2015 (n = 1165) were included. The patient files were scrutinized to clarify whether the referral criteria in place were identified (seven in total) and to compile data on patient and injury characteristics. A case was defined as adherent to the criteria when at least one criterion was fulfilled and adherence was expressed as a percentage with 95% confidence intervals, for all years aggregated as well as by year and by patient or injury characteristics. The association between adherence to any individual criterion and hospital care (surgery or longer length of stay) was measured using logistic regressions. The overall adherence was 93.4% (100% among children under 2 years of age and 86% among the others) and it did not vary remarkably over time. The two criteria of "injury sustained at a specific anatomical site" (85.2%) and "young age" (51.9%) were those most often identified. Children aged 2 years or older were more likely to undergo surgery or to stay longer than those of young age (although a referral criterion) and so were those with higher injury severity (a referral criterion). In this specialized paediatric burns centre, children are admitted mainly according to the guidelines. However, given the high prevalence of paediatric burns in the region and the limited resources at the burns centre, adherence to the guidelines need to be further studied at all healthcare levels in the province.

Physician perceptions and recommendations about pre-hospital emergency medical services for patients with ST-elevation acute myocardial infarction in Abu Dhabi.

INTRODUCTION: Physician perceptions about emergency medical services (EMS) are important determinants of improving pre-hospital care for cardiac emergencies. No data exist on physician attitudes towards EMS care of patients with ST-Elevation Myocardial Infarction (STEMI) in the Emirate of Abu Dhabi. OBJECTIVES: To describe the perceptions towards EMS among physicians caring for patients with STEMI in Abu Dhabi. METHODS: We surveyed a convenience sample of physicians involved in the care of patients with STEMI (emergency medicine, cardiology, cardiothoracic surgery and intensive care) in four government facilities with 24/7 Primary PCI in the Emirate of Abu Dhabi. Surveys were distributed using dedicated email links, and used 5-point Likert scales to assess perceptions and attitudes to EMS. RESULTS: Of 106 physician respondents, most were male (82%), practicing in emergency medicine (47%) or cardiology (44%) and the majority (63%) had been in practice for >10 years. Less than half of the responders (42%) were "Somewhat Satisfied" (35%) or "Very Satisfied" (7%) with current EMS level of care for STEMI patients. Most respondents were "Very Likely" (67%) to advise a patient with a cardiac emergency to use EMS, but only 39% felt the same for themselves or their family. Most responders were supportive (i.e. "Strongly Agree") of the following steps to improve EMS care: 12-lead ECG and telemetry to ED by EMS (69%), EMS triage of STEMI to PCI facilities (65%), and activation of PCI teams by EMS (58%). Only 19% were supportive of pre-hospital fibrinolytics by EMS. There were no significant differences in the responses among the specialties. CONCLUSIONS: Most physicians involved in STEMI care in Abu Dhabi are very likely to advise patients to use EMS for a cardiac emergency, but less likely to do so for themselves or their families. Different specialties had concordant opinions regarding steps to improve pre-hospital EMS care for STEMI.