Comparison of adult weight estimation methods for use during emergency medical care.

OBJECTIVE: Many emergency drug and fluid doses are weight dependent in adults, but in resuscitation and low-resource settings it can be impractical or impossible to weigh a patient. It is especially important to obtain accurate weight estimation for dose calculations for emergency drugs with narrow therapeutic ranges. Several weight estimation methods have been proposed for use in adults, but none is widely established. The aim of this study was to compare the accuracy of adult weight estimation methods. METHODS: Demographic and body measurement data were obtained from the US National Health and Nutrition Examination Survey (NHANES), and 7 previously published weight estimation methods were used to estimate the weight for each individual. The primary outcomes were the proportions of estimates within 10% and 20% of actual weight (P10, P20). An acceptable accuracy was predetermined to be P10 = 70% and P20 = 95%. RESULTS: The data set included 5158 adults (51.2% women) with sufficient data to calculate all weight estimation methods. The Lorenz method performed best (P10 = 86.8%, P20 = 99.4%) and met the standard of acceptability across sex and body mass index subgroups. The Mercy and PAWPER XL-MAC methods performed acceptably in non-obese adults. CONCLUSION: The ideal weight estimation method should be accurate, rapid, simple, and feasible. This study has demonstrated the accuracy of 7 methods. The Lorenz method performed best but is complex and likely to be difficult to apply in resuscitation settings. Other simpler and quicker methods are at least as accurate as the best methods widely used in children, and there is potential for further calibrating these for use in adults before validation in real-world studies.

Characteristics, physiology and mortality of intubated patients in an emergency care population in sub-Saharan Africa: a prospective cohort study from Kigali, Rwanda.

BACKGROUND: Formalised emergency departments (ED) are in early development in sub-Saharan Africa and there are limited data on emergency airway management in those settings. This study evaluates characteristics and outcomes of ED endotracheal intubation, as well as risk factors for mortality, at a teaching hospital in Rwanda. METHODS: This was a prospective observational study of consecutive patients requiring endotracheal intubation at the University Teaching Hospital of Kigali ED conducted between 1 January and 31 December 2017. A standardised data collection tool was used to record patient demographics, preintubation clinical presentation, indication for intubation, vital signs. medications and equipment used, and periintubation complications. The primary outcome was in-hospital mortality. Univariate associations were determined for risks of mortality. RESULTS: Of 198 intubations were analysed, 72.7% were male and the median age was 35 years (IQR 23-51). Airway protection was the most common indication for intubation (73.7%). Rapid sequence intubation was performed in 74.2% of cases; sedative-only facilitated intubation in 20.6% and non-drug assisted in 5.2%. The most common agents used were Ketamine for sedation (85.4%) and vecuronium for paralysis (65.7%). All patients were successfully intubated within three attempts, 85.4% on the first attempt. During intubation, 23.1% of patients experienced hypoxia, 6.7% aspiration and 3.6% cardiac arrest. Median ED length of stay was 2 days. Outcome data were available for 164 patients of whom 67.7% died. Bonferroni-corrected univariate analysis demonstrated that mortality was associated with higher postintubation shock index (p=0.0007) and lower postintubation systolic blood pressure (SBP) (p=0.0006). CONCLUSION: The first-attempt and overall success rates for intubation in this ED in Rwanda were comparable to those in high-income countries (HIC). Mortality postintubation is associated with lower postintubation SBP and higher postintubation shock index. The high complication and mortality rates suggest the need for better resources and training to address differences in compared with HIC.

Accuracy of weight estimation methods in adults, adolescents and children: a prospective study.

INTRODUCTION: Weight estimation of both adult and paediatric patients is often necessary in emergency or low-resource settings when it is not possible to weigh the patient. There are many methods for paediatric weight estimation, but no standard methods for adults. PAWPER and Mercy tapes are used in children, but have not been assessed in adults. The primary aim of this study was to assess weight estimation methods in patients of all ages. METHODS: Patients were prospectively recruited from emergency and outpatient departments in Kigali, Rwanda. Participants (or guardians) were asked to estimate weight. Investigators collected weight, height, mid-arm circumference (MAC) and humeral-length data. In all participants, estimates of weight were calculated from height and MAC (PAWPER methods), MAC and humeral length (Mercy method). In children, Broselow measurements and age-based formulae were also used. The primary outcome measure was the proportion of estimates within 20% of actual weight (p20). RESULTS: We recruited 947 participants: 307 children, 309 adolescents and 331 adults. For p20, the best methods were: in children, guardian estimate (90.2%) and PAWPER XL-MAC (89.3%); in adolescents, PAWPER XL-MAC (91.3%) and guardian estimate (90.9%); in adults, participant estimate (98.5%) and PAWPER XL-MAC (83.7%). In all age groups, there was a trend of decreasing weight estimation with increasing actual weight. CONCLUSION: This prospective study of weight estimation methods across all age groups is the first adult study of PAWPER and Mercy methods. In children, age-based rules performed poorly. In patients of all ages, the PAWPER XL-MAC and guardian/participant estimates of weight were the most reliable and we would recommend their use in this setting.

Impact of ultrasound on management for dyspnea presentations in a Rwandan emergency department.

BACKGROUND: The complexity of diagnosis for critically ill dyspnea presentations in the emergency department remains a challenge. Accurate and rapid recognition of associated life-threatening conditions is paramount for timely treatment. Point-of-care ultrasound (POCUS) has been shown to impact the diagnosis of dyspnea presentations in resource-rich settings, and may be of greater diagnostic benefit in resource-limited settings. METHODS: We prospectively enrolled a convenience sample of 100 patients presenting with dyspnea in the Emergency Department at University Teaching Hospital of Kigali (UTH-K) in Rwanda. After a traditional history and physical exam, the primary treating team listed their 3 main diagnoses and ranked their confidence accuracy in the leading diagnosis on a Likert scale (1-5). Multi-organ ultrasound scans performed by a separate physician sonographer assessed the heart, lungs, inferior vena cava, and evaluated for lower extremity deep vein thrombosis or features of disseminated tuberculosis. The sonographer reviewed the findings with the treating team, who then listed 3 diagnoses post-ultrasound and ranked their confidence accuracy in the leading diagnosis on a Likert scale (1-5). The hospital diagnosis at discharge was used as the standard in determining the accuracy of the pre- and post-ultrasound diagnoses. RESULTS: Of the 99 patients included in analysis, 57.6% (n = 57) were male, with a mean age of 45 years. Most of them had high-level acuity (54.5%), the dyspnea was of acute onset (45.5%) and they came from district hospitals (50.5%). The most frequent discharge diagnoses were acute decompensated heart failure (ADHF) (26.3%) and pneumonia (21.2%). Ultrasound changed the leading diagnosis in 66% of cases. The diagnostic accuracy for ADHF increased from 53.8 to 100% (p = 0.0004), from 38 to 85.7% for pneumonia (p = 0.0015), from 14.2 to 85.7% for extrapulmonary tuberculosis (p = 0.0075), respectively, pre and post-ultrasound. The overall physician diagnostic accuracy increased from 34.7 to 88.8% pre and post- ultrasound. The clinician confidence in the leading diagnosis changed from a mean of 3.5 to a mean of 4.7 (Likert scale 0-5) (p < 0.001). CONCLUSIONS: In dyspneic patients presenting to this Emergency Department, ultrasound frequently changed the leading diagnosis, significantly increased clinicians' confidence in the leading diagnoses, and improved diagnostic accuracy.

Agreement between capillary and venous lactate in emergency department patients: prospective observational study.

OBJECTIVES: Capillary blood lactate testing with handheld analysers has great advantages to reduce the time needed for clinical decisions, and for extended use in the prehospital setting. We investigated the agreement of capillary lactate measured using handheld analysers (CL-Nova and CL-Scout+ measured by Nova and Lactate Scout+ analyzers) and the reference venous level assessed using a point-of-care testing (POCT) blood gas analyser (VL-Ref). DESIGN: A prospective observational study. SETTING: A university teaching hospital emergency department in Hong Kong. PARTICIPANTS: Patients triaged as 'urgent' (Category 3 of a 5-point scale), aged ≥18 years during 2016 were eligible. 240 patients (mean age 69.9 years) were recruited. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was the agreement of the capillary blood lactate level measured by handheld lactate analyser when compared with the reference standard technique, namely venous blood samples obtained by venepuncture and analysed using the blood gas analyser. The secondary outcome measure was the difference in values of venous lactate using blood gas analysers and handheld lactate analysers. RESULTS: The results of VL-Ref ranged from 0.70 to 5.38 mmol/L (mean of 1.96 mmol/L). Regarding capillary lactate measurements, the bias (mean difference) between VL-Ref and CL-Scout+ was -0.22 with 95% limits of agreement (LOA) of -2.17 to 1.73 mmol/L and the bias between VL-Ref and CL-Nova was 0.46, with LOA of -1.08 to 2.00 mmol/L. For venous lactate, results showed the bias between VL-Ref and VL-Scout+ was 0.22 with LOA being -0.46 to 0.90 mmol/L, and the bias between VL-Ref and VL-Nova was 0.83 mmol/L with LOA -0.01 to 1.66 mmol/L. CONCLUSION: Our study shows poor agreement between capillary lactate and reference values. The study does not support the clinical utility of capillary lactate POCT. However, venous lactate measured by Scout+ handheld analyser may have potential for screening patients who may need further testing. TRIAL REGISTRATION NUMBER: NCT02694887.

An unusual cause of recurrent laryngospasm: A case report.

INTRODUCTION: Laryngospasm is a partial or complete closure of the vocal cords, causing stridor and then complete airway obstruction. We present an unusual case of recurrent laryngospasm following cervical spine trauma. CASE REPORT: A 41-year-old pedestrian was hit by a car sustaining several spine fractures including a comminuted fracture of C1. These were initially unrecognised, and his cervical spine was not immobilised. During this time the patient experienced three episodes of laryngospasm requiring intubation. On day 11 his fractures were identified, and a Philadelphia collar was placed. He made a full recovery without any neurological sequelae. DISCUSSION: Laryngospasm is a recognised complication of anaesthesia and intubation. This case illustrates that this life-threatening complication can also follow cervical fractures, and reinforces the need for prompt and careful review of imaging to identify such fractures in trauma patients, especially those with stridor.

Estimating children's weight in a Rwandan emergency centre.

INTRODUCTION: Most drugs, fluids and ventilator settings depend on the weight of a paediatric patient. However, knowledge of the weight is often unavailable as the urgency of the situation may impede measurement. The most common methods for paediatric weight estimation are based on height or age. This study aimed to compare the accuracy of various weight estimation methods and to derive a dedicated age-based tool within a Rwandan setting. METHODS: This was a retrospective study using age, weight and height data from randomly selected charts of Rwandan children, aged between one and ten years, who attended the paediatric emergency centre, Centre Hospitalier Universitaire de Kigali, Rwanda. Weights were estimated using four versions of the Broselow Tape and several age-based formulae. Linear regression was used to derive a new age-based weight estimation formula, the Rwanda Rule. Weight estimations were then compared with actual weight using Bland-Altman analysis, and the proportions of estimates within 10 and 20% of actual weight. RESULTS: There were 327 children included in the study. The derived Rwanda Rule was: weight (kg) = [1.7 × age (years)] + 8. This formula and the original Advanced Paediatric Life Support formula (weight = [2 × age] + 8) performed similarly. Both were better than other age-based formulae (69% of estimates within 20% of actual weight). All editions of the Broselow Tape performed better than age-based rules. The 1998 version performed best with 84.8% of estimates within 20% of actual weight. DISCUSSION: This study is the first to compare paediatric weight estimation methods in Rwanda. Locally, and until we have evidence from further research that other methods are superior, we would advise use of the 1998 Broselow Tape in children aged one to ten years old. Where the Broselow Tape is not available, the original Advanced Paediatric Life Support formula should be used.

Major incident simulation in Rwanda: A report of two exercises.

INTRODUCTION: Healthcare systems must be equipped to handle major incidents. Few have been described in the African setting, including in Rwanda. The purpose of this case report was to describe and discuss two major incident simulations in Rwanda with different challenges. CASE REPORT: We report two recent major incident exercises conducted in Rwanda, in 2017. The exercises exemplify two different types of multiple casualty incidents requiring the deployment of extra-ordinary resources, one due to the location of the incident (off-shore), and the other due to the large volume of casualties. Both exercises required extensive multi-agency planning and training beforehand, as part of an increasing awareness of the need for preparedness for these types of incidents. CONCLUSION: The exercises demonstrated the need for a standardised, physiological method of triage based on clinical needs; this is in order to maximise the number of lives saved. Triage training should be an integral part of further major incident exercises, which should be conducted regularly.

Oral paracetamol and/or ibuprofen for treating pain after soft tissue injuries: Single centre double-blind, randomised controlled clinical trial.

BACKGROUND: Soft tissue injuries commonly present to the emergency department (ED), often with acute pain. They cause significant suffering and morbidity if not adequately treated. Paracetamol and ibuprofen are commonly used analgesics, but it remains unknown if either one or the combination of both is superior for pain control. OBJECTIVES: To investigate the analgesic effect of paracetamol, ibuprofen and the combination of both in the treatment of soft tissue injury in an ED, and the side effect profile of these drugs. METHODS: Double-blind, double dummy, placebo-controlled randomised controlled trial. 782 adult patients presenting with soft tissue injury without obvious fractures attending the ED of a university hospital in the New Territories of Hong Kong were recruited. Patients were randomised using a random number table into three parallel arms of paracetamol only, ibuprofen only and a combination of paracetamol and ibuprofen in a 1:1:1 ratio. The primary outcome measure was pain score at rest and on activity in the first 2 hours and first 3 days. Data was analysed on an intention to treat basis. RESULTS: There was no statistically significant difference in pain score in the initial two hours between the three groups, and no clinically significant difference in pain score in the first three days. CONCLUSION: There was no difference in analgesic effects or side effects observed using oral paracetamol, ibuprofen or a combination of both in patients with mild to moderate pain after soft tissue injuries attending the ED. TRIAL REGISTRATION: The study is registered with ClinicalTrials.gov (no. NCT00528658).

The accuracy of Broselow pediatric emergency tape in estimating body weight of pediatric patients.

[No Abstract Available].

Ascariasis and hyperosmolar hyperglycemic state: a surprising ultrasound finding in the emergency department.

BACKGROUND: We report the ultrasound finding of ascariasis in a patient with hyperosmolar hyperglycemic state (HHS). Although ascariasis is common in low-resource settings, there has been no previous report associating ascariasis with HHS. CASE PRESENTATION: A 26-year-old Rwandan man was admitted to the emergency department in coma, with a glycemia of 600 mg/dl. He was resuscitated with fluids, intubated and ventilated, and treated with insulin and antibiotics. On day 3, an ascaris worm was passed via his nasogastric tube, and abdominal ultrasound revealed a heavy worm load. He was treated with albendazole and eventually made a full recovery. CONCLUSIONS: This is the first report of ascariasis as a potential cause of HHS, and we recommend that emergency practitioners consider early abdominal ultrasound in patients with hyperglycemic emergencies in areas with a high prevalence of ascariasis.

The normal ranges of cardiovascular parameters measured using the ultrasonic cardiac output monitor.

The ultrasonic cardiac output monitor (USCOM) is a noninvasive transcutaneous continuous wave Doppler method for assessing hemodynamics. There are no published reference ranges for normal values in adults (aged 18-60 years) for this device. This study aimed to (1) measure cardiovascular indices using USCOM in healthy adults aged 18-60 years; (2) combine these data with those for healthy children (aged 0-12), adolescents (aged 12-18), and the elderly (aged over 60) from our previously published studies in order to present normal ranges for all ages, and (3) establish normal ranges of USCOM-derived variables according to both weight and age. This was a population-based cross-sectional observational study of healthy Chinese subjects aged 0.5-89 years in Hong Kong. USCOM scans were performed on all subjects, to produce measurements including stroke volume, cardiac output, and systemic vascular resistance. Data from previously published studies (children, adolescents, and the elderly) were included. Normal ranges were defined as lying between the 2.5th and 97.5th percentiles. A total of 2218 subjects were studied (mean age = 16.4, range = 0.5-89; 52% male). From previous studies, 1197 children (aged 0-12, 55% male), 590 adolescents (aged 12-18, 49% male), and 77 elderly (aged 60-89, 55% male) were included. New data were collected from 354 adults aged 18-60 (47% male). Normal ranges are presented according to age and weight. We present comprehensive normal ranges for hemodynamic parameters obtained with USCOM in healthy subjects of all ages from infancy to the elderly.

Mid-arm circumference can be used to estimate weight of adult and adolescent patients.

OBJECTIVES: Many drug and fluid regimens in emergency medicine are weight dependent in adults, but no standard adult weight estimation tools exist. Paediatric weight is often estimated in emergency situations using methods based on age or height when direct measurement is not possible, and recently, methods based on mid-arm circumference (MAC) have also been developed. The aim of this study was to derive and validate an accurate MAC-based method for weight estimation for use in all age groups. METHODS: Data were obtained from the US National Health and Nutrition Examination Survey (NHANES). MAC-based methods of weight estimation were derived in 8498 subjects (5595 adults aged 16-80 years, 2903 children aged 1-15.9 years) from the NHANES 2011-2012 dataset, using linear regression. NHANES 2009-2010 was used for validation in 9022 subjects (6049 adults aged 16-79 years, 2973 children aged 1-15.9 years). RESULTS: A simplified method of MAC-based weight estimation was derived from linear regression equation: weight in kg=4×MAC (in cm)-50. On validation, results in children aged 1-10.9 years were poor. In adults and children aged 11-15.9 years, over 60%, 90% and 98% of estimates fell, respectively, within 10%, 20% and 30% of actual weights when using the simplified formula. CONCLUSIONS: In this description of a method for estimating weight in adults, we have derived and validated a simplified formula that is at least as precise in adults and adolescents as commonly used paediatric weight estimation tools in children.