Clinical Risk Factors Associated with Poor Outcomes in Snake Envenoming: A Narrative Review.

Snakebite-related fatalities disproportionately affect populations in impoverished socio-economic regions, marked by limited access to adequate healthcare and constrained antivenom availability. Early medical intervention is pivotal in mitigating mortality and morbidity associated with snakebite envenoming (SBE). While clinical assessment remains fundamental in treating SBE, this review aims to spotlight objective parameters that could also affect outcomes. Selected studies that identify factors associated with poor outcomes are predominantly region-specific, single-site, and observational, yet collectively reveal similar findings. They consistently report factors such as treatment delays, susceptibility in vulnerable groups such as children and pregnant women, as well as various biochemical and haematological abnormalities. Acute kidney injury (AKI), low platelets, leucocytosis, abnormal coagulation, and elevated creatine kinase (CK) all show an association with poor outcomes. Furthermore, recognising rare and unusual SBE presentations such as adrenal insufficiency, severe hypertension, intracranial haemorrhage, acute angle closure glaucoma, and bowel ischaemia also has a bearing on outcomes. Despite the integration of these parameters into clinical decision tools and guidelines, the validation of this evidence is limited. This review underscores the imperative for high-quality, multi-centre studies aligned with consensus-driven Core Outcome Sets (COS) and Patient-Reported Outcome Measures (PROMS) to validate and strengthen the current evidence.

Ultrasound Directed Reduction of Colles' type distal radial fractures in ED (UDiReCT): a feasibility randomised controlled trial.

BACKGROUND: There is a high rate of surgical fixation of displaced Colles' type distal radial wrist fractures despite fracture manipulation in the ED. Point-of-care ultrasound has been used to guide ED manipulations but its effect on the quality of fracture reduction or subsequent need for surgical fixation is unknown. This study aims to assess the feasibility of conducting a definitive randomised controlled trial to assess the use of ultrasound to guide these fracture manipulations. METHODS: We conducted a pragmatic randomised controlled feasibility trial in two EDs in England over a 6-month period (7 October 2019 to 6 April 2020). Adult patients with wrist fractures undergoing manipulation in the ED were randomised 1:1 to ultrasound-guided distal radial fracture manipulation or manipulation with sham ultrasound. The primary outcome for this study was trial recruitment rate. Other measures were recorded to assess potential future definitive trial outcomes and feasibility. RESULTS: Of 120 patients meeting inclusion criteria, 48 (40%) were recruited and randomised in the two centres, giving overall recruitment rates of 0.3 and 1.8 participants per week at each site, respectively, and 1 participant per week overall. The most common reason that patients were not included was research staff availability. After 6 weeks, six patients in each group (26% intervention, 24% control) had undergone surgical fixation, with 98% data completeness for this potential definitive trial primary outcome. Randomisation, blinding and data collection processes were effective but there were data limitations in the X-ray assessment of fracture positions. CONCLUSION: A definitive study of a similar design would be feasible within UK ED practice but organisational factors and research staff availability should be considered when estimating the predicted recruitment rate and required sites. 6-week surgical fixation rate was the most reliable outcome measure. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03868696).

Ultrasound in forearm fractures: a pragmatic study assessing the utility of Point of Care Ultrasound (PoCUS) in identifying and managing distal radius fractures.

BACKGROUND: Point of Care Ultrasound (PoCUS) is a safe, non-invasive tool for identifying distal radius fractures and can potentially be utilised to assist clinicians to reduce displaced fractures. We aim to test whether PoCUS is accurate to identify distal radius fractures and to determine how PoCUS performs as a tool to confirm a successful fracture reduction. METHODS: A pragmatic prospective observational study was done in adult patients presenting with forearm injuries resulting in Colle's type distal radius fractures. Adults who presented to the emergency department (ED) with a suspected distal forearm fracture from August 2018 to July 2019 were conveniently sampled for inclusion into the study when a trained ED ultra-sonographer was available. PoCUS scans over the point of maximal tenderness were done using a high frequency linear transducer (7.5-10 mHz) prior to X-ray. Patients who required a manipulation of the fracture had a second ultrasound scan immediately after the procedure before the second X-ray was ordered. PoCUS scans were compared to X-rays for accuracy in both groups. RESULTS: Fractures were identified in 44 out of 47 included patients using both PoCUS and X-ray modalities. This showed a sensitivity of 100% (95% CI: 90-100%) and specificity of 100% (95% CI: 31-100%). Fracture manipulation was required in 35 out of 44 patients. The sensitivity and specificity of PoCUS in determining alignment accuracy when compared to X-ray were 100% (95% CI: 83-100%) and 64% (95% CI: 32-88%) respectively. The PPV and NPV were 86% (95% CI: 66-95%) and 100% (95% CI: 56-100%) respectively. Ten out of 44 (23%) patients with distal radius fractures ultimately required an Open Reduction and Internal Fixation (ORIF). CONCLUSION: Our study supports the use of PoCUS for identifying distal radius forearm fractures and may have some value in assisting clinicians to determine post reduction success. We still advocate using standard X-ray radiographs to confirm successful or adequate cortical alignment following a manipulation.

Prospective review of cytotoxic snakebite envenomation in a paediatric population.

Cytotoxic snakebite envenomation is prevalent in Kwazulu-Natal and may be associated with significant physical disability. The aim of this study was to provide an overview of the effects of cytotoxic envenomation in children. The patient population were all patients attending the Emergency Department at Ngwelezana Tertiary Hospital with snakebite from December 2014 to March 2015. All children 13 years or younger presenting with painful progressive swelling (PPS) following snakebite were included in this study. They were further classified according to severity: mild, moderate and severe. Patient demographic and clinical data was collected prospectively. Fifty-one children were included in this study. Nine were classified as mild, 24 as moderate and 18 as severe. The median time of presentation after bite was 6 h in the mild group, 7 h in the moderate group and 12 h in the severe group. There was a positive correlation between increasing severity and INR (p=< .00001) and no correlation between WCC (p = .175) or renal function and severity (p = .963). A total of 11 children (22%) developed an acute kidney injury (AKI). A total of 23/51 patients received antivenom; 25% of patients with moderate cytotoxicity and 94% of patients with severe cytotoxicity. Thirteen percent developed allergic reactions (3/23) and 57% (13/23) anaphylaxis. A total of 15 patients underwent one or more procedures on their affected limbs. There was one recorded mortality during this period, related to severe anaphylaxis following antivenom administration. Access to healthcare for antivenom administration is often delayed and ongoing education within affected areas is advised. Whilst majority of snakebite victims can be adequately managed with basic supportive measures, early identification of severe envenomation is crucial to enable timeous antivenom administration and prevention of further complications such as compartment syndrome and loss of limb. Hypersensitivity reactions are alarmingly common following antivenom administration in children and strict protocols should be followed when administering antivenom.

Evaluation of a novel approach to recognising community-acquired paediatric sepsis at ED triage by combining an electronic screening algorithm with clinician assessment.

OBJECTIVE: We report the utilisation and impact of a novel triage-based electronic screening tool (eST) combined with clinical assessment to recognise sepsis in paediatric ED. METHODS: An electronic sepsis screening tool was implemented in the paediatric EDs of two large UK secondary care hospitals between June 2018 and January 2019. Patients eligible for screening were children < 16 years of ages excluding those with minor injuries or who were brought directly to resuscitation. Subsequently, a retrospective evaluation was performed to determine the performance of the tool alone and in combination with clinical assessment after triage, to identify septic patients, using sensitivity, specificity, positive, negative predictive values (PPV and NPV) and likelihood ratios. RESULTS: 19 912 children were triaged during the study period, of whom 90 (0.45%) were classified as having sepsis. 99% of all eligible patients were screened. The eST alerted for 2651 (13.3%) patients. After immediate physician assessment, 151 were treated for sepsis in the ED, of whom 70 had a final diagnosis of sepsis. Eight patients who were not thought to be septic returned with sepsis within 24 hours. The eST showed a sensitivity of 86.7% (95% CI 77.5% to 92.6%), specificity 87.0% (95% CI 86.5% to 87.5%), PPV 2.94% (95% CI 2.35% to 3.68%), NPV 99.9% (95% CI 99.8% to 99.9%) which improved with combined clinical assessment to a sensitivity of 90.0% (95% CI 81.4% to 95.0%), specificity 99.4 (95% CI 99.3% to 99.5%), PPV 42.0 (95% CI 35.0% to 49.3%) and NPV 99.9% (95% CI 99.9% to 99.9%). CONCLUSION: Utilisation of a novel triage-based eST allowed sepsis screening in over 99% of eligible patients. The screening tool showed good accuracy to recognise sepsis at triage in the ED, which was augmented further by combining it with clinician assessment. The screening tool requires further refinement through multicentre evaluation to avoid missing sepsis cases.

Building a visual aid for a triage tool in a developing health service.

Resources in the modern day emergency department are often stretched, and this holds true more so in developing services. With limited manpower, it is essential that efficient tools are created so that processes can be run safely. Here we pilot the use of a vital signs matrix in a medical camp in Dhaka to screen patients at triage. We further modified this matrix to include the National Early Warning Score as our recording of the NEWS have remained poor in triage. A trial and validation study for the use of this matrix in an NHS setting is currently underway.

Ultrasound findings in 42 patients with cytotoxic tissue damage following bites by South African snakes.

BACKGROUND: Snakebites that have cytotoxic venom can cause significant soft tissue swelling. Assessing the site and degree of swelling using ultrasound as a non-invasive technique would be an important tool for instituting appropriate treatment. METHODS: Forty-two patients who presented to a referral hospital in South Africa with cytotoxic swelling of the limbs from snakebite were assessed using ultrasound. The envenomed limb of each patient was scanned at the point of maximal swelling and compared with the unaffected limb at the same site. Data were presented as an expansion coefficient defined as the ratio of the thickness of tissue structure (subcutaneous tissue or muscle compartment) in the envenomed limb to that in the unaffected limb. A p value of 0.05 was regarded as significant, and 95% CIs were expressed throughout. RESULTS: The majority of bites were in the upper limb (27/42). Twenty-five patients were children less than 12 years. Tissue expansion was noted in both the subcutaneous and muscle compartments of the envenomed limbs. The site of swelling was predominantly in the subcutaneous tissues, while swelling in muscle compartment was limited (the mean expansion coefficient for subcutaneous tissues was 2.0 (CI 1.7 to 2.3) vs 1.06 (CI 1.0 to 1.1), respectively). The difference between the groups was significant (p<001). One case, confirmed as compartment syndrome, showed marked swelling in the muscle group. CONCLUSIONS: Basic ultrasound techniques may be used to identify the site and degree of tissue swelling from cytotoxic envenomation. It is a non-invasive, painless procedure that can assist the clinician to assess the injured limb and may also be of benefit to monitor the progression of swelling.

Classifying snakebite in South Africa: Validating a scoring system.

OBJECTIVE: To develop and validate a scoring system for managing snakebites in South Africa (SA). METHODS: We studied all snakebite admissions to a regional hospital in KwaZulu-Natal, SA. The primary outcome was an active treatment intervention (ATI) defined as antivenom treatment or any surgical procedure. The development cohort consisted of 879 patients with snakebite who presented to the Ngwelezane Hospital Emergency Department from December 2008 to December 2013. Factors predictive of ATI and the optimal cut-off score for predicting an ATI were identified. These factors were then used to develop a standard scoring system.  The score was then tested prospectively for accuracy in a new validation cohort consisting of 100 patients admitted for snakebite to our unit from 1 December 2014 to 31 March 2015. Accuracy of the score was determined. RESULTS: Of 879 snakebite admissions, 146 in the development cohort and 40 of 100 in the development validation cohort reached the primary endpoint of an ATI. Six risk predictors for ATI were identified from the development cohort: age <14 years (odds ratio (OR) 2.13), delay to admission >7 hours (OR 4.63), white cell count >10 × 109/L (OR 3.15), platelets <92 × 109/L (OR 2.35), haemoglobin <7.1 g/dL (OR 5.68), international normalised ratio >1.2 (OR 2.25).  Each risk predictor was assigned a score of 1; receiver operating characteristic curve analysis returned a value of >4 out of 6 as the optimal cut-off for prediction of an ATI (area under the curve 0.804; 95% confidence interval 0.758 - 0.84). Testing of the score on the validation cohort produced a specificity of 96.6% and a sensitivity of 22.5%. The positive predictive value and negative predictive value were 81.8% and 65.2%, respectively. CONCLUSION: Our results show that the identified score is a useful adjunct to clinical assessment in managing snakebite. Its value is greatest when used in those patients who fall in the mild to moderate clinical category. Until our severity score has been validated (or modified) for use across SA, we propose to name it the Zululand Severity Score; a true SA Severity Score may follow.

Interpersonal violence as a major contributor towards the skewed burden of trauma in KwaZulu-Natal, South Africa.

BACKGROUND: Trauma is one of the foremost causes of death worldwide, but there is a paucity of data on demographics and injury patterns in developing countries. OBJECTIVES: To quantify and describe the major trauma burden at a regional hospital in KwaZulu-Natal (KZN), South Africa (SA), over a 5-year period. METHODS: Ngwelezane Hospital is a large regional hospital in northern KZN. A database is maintained of all major trauma patients admitted to the Emergency Department (ED) resuscitation unit. Statistical analysis was performed to quantify the burden of trauma and analyse trends in these data. RESULTS: Over a 5-year period, 3 735 major trauma patients were admitted to the ED resuscitation unit. Analysis showed a male predominance, with a mean patient age of 28.6 years. An average of 62 patients per month were admitted, the rate peaking over the holiday seasons. Trauma secondary to interpersonal violence (IPV) predominated. A disproportionately high level of pedestrian-motor vehicle collisions (PMVCs) in relation to total road traffic collisions was noted. Blunt force trauma secondary to motor vehicle collisions was the leading cause of death, while blunt force trauma secondary to PMVC s carried the highest mortality rate. CONCLUSION: This study highlights the high incidences of both IPV and PMVCs typical of trauma in an SA setting. The demographics and injury patterns noted may be used to drive public health interventions to address this burden of trauma.

Simplifying trauma airway management in South African rural hospitals.

South African emergency centres witness high levels of trauma. Successfully managing a compromised trauma airway requires considerable skill and expertise. In the rural healthcare setting, clinics and hospitals are often staffed by junior doctors without formal advanced airway training. Current airway management algorithms tend to ignore lack of resources and skill. We therefore propose a simplified guideline for the rural hospital practitioner. Our algorithm offers a step-by-step approach, with the aim of providing an easy sequence to follow that will ensure successful airway management and patient safety. The lack of advanced airway equipment in most rural hospitals is taken into consideration.

Self-reported versus administrative identification of American Indian and Alaska Native arrestees: effects on relative estimates of illicit drug use and alcohol abuse.

Arrestee Drug Abuse Monitoring program data were used to consider the effects of two methods of racial classification upon estimates of illicit drug use and alcohol abuse among American Indian/Alaska Native (AI/AN) arrestees. Overall, compared to arrestees who self-identified as Black, White, Asian/Pacific Islander, or Hispanic, arrestees self-identifying as AI/AN were most likely to be identified administratively as something other than AI/AN. Results of 'difference of difference' analyses indicate that differences in estimates of AI/AN versus non-AI/AN arrestees' illicit drug use and alcohol abuse were much more extreme when identification was based on administrative records than when based upon arrestees' self-reports.

Emergency focussed assessment with sonography in trauma (FAST) and haemodynamic stability.

BACKGROUND: Focussed assessment with sonography in trauma (FAST) has assumed a key role in the rapid non-invasive assessment of thoracoabdominal trauma and assists in decreasing disposition time. This study evaluates FAST's efficacy with respect to haemodynamic stability in a South African emergency department (ED). METHODS: Data were collected prospectively by four emergency medicine doctors trained in emergency ultrasonography. FAST scans were performed by one ED doctor and timings, scan result and disposition were recorded. Patient haemodynamic stability was assessed by the emergency doctor performing the scan; subjectively at the time of scanning and objectively using calculation of the shock index. All scan results were subsequently verified by a second ED doctor in a blinded fashion and by CT scanning or operative intervention when clinically indicated. RESULTS: 166 FAST scans were conducted of which 36 (21.7%) were positive. Mean age was 30.6 years (SD 12.8). 74.1% of patients sustained blunt traumatic injury. Doctors' subjective haemodynamic stability assessments had higher specificity, sensitivity and predictive values than shock index alone. Haemodynamic instability and a positive FAST result were significantly related (p=0.004). Sensitivities and specificities of FAST scans for blunt and penetrating trauma were 93.1% and 100%, and 90.0% and 100%, respectively. Corresponding values for pneumothoraces were 84.6% and 100%. DISCUSSION: This study showed a valuable role for FAST in all traumas, particularly in haemodynamic compromise. As an addition to the physician's repertoire of bedside assessment tools, it improves diagnostic capabilities in comparison with simple haemodynamic assessments alone.

Demographics and management of dog bite victims at a level two hospital in KwaZulu-Natal.

INTRODUCTION: Dog bites are a significant cause of morbidity and mortality worldwide, particularly where rabies is endemic. There is also a significant financial burden attached to prophylactic treatment to diminish the risk of rabies infection. KwaZulu-Natal (KZN) has a high incidence of human rabies yet little is known about the demographics of dog bites in the province. OBJECTIVES: To analyse the demographics of dog bites in Northern KZN. METHODS: Records of all dog bites presenting to the main referral hospital in Northern KZN between August 2007 and September 2011 were analysed. RESULTS: We collected data for 821 instances of dog bite. Male children aged 6 - 10 years are most likely to present with dog bites, while women >40 years are more likely to present than men in the same age bracket. Whilst initial vaccine administration is high (98%) with all grades of bite, only 82% of grade 3 bites receive immunoglobulin. CONCLUSION: Our results correlate well with two large studies of the demographics of dog bites, but are the first to show a reverse in male preponderance of presentations above the age of 40 years. Reasons for low rates of immunoglobulin administration in grade 3 bites are discussed. Finally, methods are suggested to improve data collection and the care of patients presenting with dog bites.

Alcohol controls and violence in Nunavut: a comparison of wet and dry communities.

OBJECTIVES: The purpose of this study was to determine if communities in Nunavut that prohibit the importation of alcoholic beverages have less violence relative to communities that allow alcohol importation. STUDY DESIGN: A retrospective cross-sectional study based on community-level records of violent crimes known to the police. METHODS: Violence was measured using community-level records of homicide, assault and sexual assault as reported to the Royal Canadian Mounted Police in 23 communities in Nunavut for the years 1986 to 2006. Crude-rate comparisons were made between wet communities (which allow alcohol importation) and dry communities (which prohibit alcohol importation) and contrasted with national rates for context. RESULTS: Wet communities in Nunavut recorded rates of violent crime that were higher than the rates recorded by dry communities. Relative to dry communities, wet communities' overall sexual assault rate was 1.48 (95% CI = 1.38-1.60) times higher, the serious assault rate was 2.10 (95% CI = 1.88-2.35) times higher and the homicide rate was 2.88 (95% CI = 1.18-8.84) times higher. Although safer than wet communities, dry communities reported rates of violence that were higher than national rates including a serious assault rate that was double the national rate (3.25 per 1,000 vs. 1.44 per 1,000) and a sexual assault rate that was at least seven times as high as the national rate (7.58 per 1,000 vs. 0.88 per 1,000). CONCLUSIONS: As elsewhere in the Arctic, communities in Nunavut that prohibited alcohol were less violent than those that allowed alcohol importation. Even with prohibition, dry communities recorded rates of violence much greater than the national average.

FAST scanning in the developing world emergency department.

OBJECTIVES: To assess the utility of an existing ultrasound machine for the purposes of focused assessment sonography in trauma (FAST) scanning in a developing world emergency department (ED). DESIGN: Prospective study undertaken over a 12-month period. Trauma patients attending the ED were FAST scanned by one of three trained emergency medicine doctors. SETTING: The ED at a government hospital in rural KwaZulu-Natal (KZN), the referral centre for 22 peripheral hospitals. SUBJECTS: All patients presenting to the ED who had sustained abdominal or thoracic trauma. OUTCOME MEASURES: Scans were recorded as positive or negative for free intra-abdominal or pericardial fluid. All results were confirmed by computed tomography, laparotomy or a second trained ED ultrasonographer, followed by a period of clinical observation. RESULTS: 72 FAST scans were included, 52 for blunt trauma and 20 for penetrating trauma. Of the 72 scans, 15 (20.8%) were positive. FAST scanning had 100% specificity and overall sensitivity of 71.4%. When considering blunt trauma alone the sensitivity improved to 81.3%, while in penetrating trauma it was much poorer (62.5%). CONCLUSIONS: We propose a valuable role for FAST scanning in all peripheral hospitals for the assessment of patients sustaining blunt trauma. In rural areas with limited resources FAST scans may assist in the appropriate timely transfer of trauma patients for further imaging or definitive surgical intervention.

The validity of injury surveillance system measures of assault: a lesson from the study of violence in Alaska.

This article considers the validity of estimates of intentional violence using a statewide injury recording system: the Alaska Trauma Registry (ATR). One benefit of using data from an injury surveillance system is that its records are generated without police involvement, thereby reducing the likelihood of undercounting. However, there is reason to suspect that measures of violence derived from injury surveillance systems do not accurately measure underlying levels of assault in a population and are instead partly a reflection of influential patient characteristics. The ATR was used to compare assault injury cases of Alaska Natives with those of non-Natives to determine if patient characteristics varied between racial groups and to determine if those characteristics served to bias comparisons of injury rates. Results indicate that differences in assault injury rates are partly attributable to a greater proportion of Alaska Native patients being hospitalized for injuries of only minor or moderate severity.

Intimate partner violence against Athabaskan women residing in interior Alaska: results of a victimization survey.

A survey instrument mirroring the National Violence Against Women Survey was administered in person to measure the incidence and prevalence of intimate partner violence against Athabaskan women residing in the interior of Alaska. Roughly two thirds of respondents (63.7%) reported an intimate partner assault victimization at some point in their adult lifetime, and 18% of the respondents reported that they had been physically assaulted by an intimate partner in the year preceding the survey. Findings revealed that intimate partner assault victimization is more prevalent and is considerably more frequent when compared to that reported for American women in general.