Hemoperitoneum among Pediatric Abdominal Trauma Patients Visiting in Emergency Department of a Tertiary Care Centre: A Descriptive Cross-sectional study.

Introduction: Pediatric abdominal trauma presents a major challenge for first-line responders in the Emergency Department for assessment and management. The Focused assessment sonography for trauma is a readily available, easy-to-use, and affordable tool for detecting hemoperitoneum during the initial assessment of trauma in the Emergency Department for adult traumatic patients. The aim of this study was to find the prevalence of hemoperitoneum among pediatric abdominal trauma patients visiting the Emergency Department of tertiary care centre through Focused assessment with sonography for trauma examination technique. Methods: This was a descriptive cross-sectional study conducted in the Emergency Department of a tertiary care hospital from 7 April 2019 to 7 April 2020. Among 413 pediatric trauma patients, 93 children (1 to 17 years) admitted to the Emergency Department who underwent focused assessment with sonography for trauma examination were included in the study. Ethical approval was obtained from the Institutional Review Committee (Approval number: 111/19). Convenience sampling was used. Point estimate and 90% Confidence Interval were calculated. Results: Among 93 children receiving focused assessment with sonography for trauma imaging in the Emergency Department with a history of blunt abdominal trauma, the prevalence of hemoperitoneum was 18 (19.34%) (12.61-26.09, 90% Confidence Interval). Conclusions: The prevalence of hemoperitoneum was similar to other studies conducted in a similar setting. Keywords: blunt injuries; emergency medicine; focused assessment with sonography for trauma.

Intentional pesticide poisoning and pesticide suicides in Nepal.

INTRODUCTION: Intentional pesticide poisoning is a major clinical and public health problem in agricultural communities in low and middle income countries like Nepal. Bans of highly hazardous pesticides (HHP) reduce the number of suicides. We aimed to identify these pesticides by reviewing data from major hospitals across the country and from forensic toxicology laboratories. METHODS: We retrospectively reviewed medical records of 10 hospitals for pesticide poisoned patients and two forensic laboratories of Nepal from April 2017 to February 2020. The poison was identified from the history, referral note, and clinical toxidrome in the hospitals and from gas chromatography analysis in the laboratories. Data on demographics, poison, and patient outcome were recorded on a data collection sheet. Simple descriptive analysis was performed. RESULTS: Among hospital cases (n = 4148), the commonest form of poisoning was self-poisoning (95.8%) while occupation poisoning was rare (0.03%). Case fatality was 5.3% (n = 62). Aluminum phosphide (n = 38/62, 61.3%) was the most commonly identified lethal pesticide for deaths. Forensic toxicology laboratories reported 2535 deaths positive for pesticides, with the compounds most commonly identified being organophosphorus (OP) insecticides (n = 1463/2535; 57.7%), phosphine gas (n = 653/2535; 25.7%; both aluminum [11.8%] and zinc [0.4%] phosphide) and organochlorine insecticides (n = 241/2535; 9.5%). The OP insecticide most commonly identified was dichlorvos (n = 273/450, 60.6%). CONCLUSION: The data held in the routine hospital medical records were incomplete but suggested that case fatality in hospitals was relatively low. The pesticides identified as causing most deaths were dichlorvos and aluminum phosphide. Since this study was completed, dichlorvos has been banned and the most toxic formulation of aluminum phosphide removed from sale. Improving the medical record system and working with forensic toxicology laboratories will allow problematic HHPs to be identified and the effects of the bans in reducing deaths monitored.

Emergency medical dispatcher training as a strategy to improve pre-hospital care in low- and middle-income countries: the case study of Nepal.

BACKGROUND: Low- and middle-income countries (LMICs) often face significant challenges related to providing effective pre-hospital care services. Barriers to providing care include lack of financial resources, poor road infrastructure, lack of trained first responders and ambulance staff, and issues regarding coordination/communication between different entities involved in Emergency Medical Services. Prior initiatives to characterize and improve the state of pre-hospital care in LMICs have largely focused on improving access to high-quality ambulance services by providing training programs to community first responders and ambulance staff on how to recognize and manage key emergency conditions. In this article, we discuss an alternative strategy for improving pre-hospital care: the creation of a context-specific Emergency Medical Dispatcher (EMD) training curriculum and program. METHODS: We describe the current pre-hospital care setting in Nepal, the process of creating and piloting the Nepal-specific EMD training manual, and the early impact of its implementation. RESULTS: The 30-h EMD training was designed, piloted, and revised in collaboration with the three largest EMS organizations in Nepal. The training is now required for all dispatchers at the Dhulikhel Hospital Dispatch Center, one of the largest ambulance dispatch networks in Nepal. Dispatchers are trained in the following knowledge and skill areas: telecommunication guidelines, triaging and documentation procedures, delivery of Basic Life Support instructions to callers, other medical and trauma-condition specific instructions, and limited resource management. The short-term positive impacts of the training's implementation include improved documentation procedures, better prioritization of ambulance resources, delivery of Basic Life Support instructions to callers, and improved communication between dispatch, responders, and healthcare facilities. CONCLUSIONS: Context-specific Emergency Medical Dispatch training programs, which aim to optimize the emergency resources available in resource-limited settings, present a promising low-cost, high-impact interventional strategy to strengthen the pre-hospital care systems in low- and middle-income countries.

Pediatric Patients in a Local Nepali Emergency Department: Presenting Complaints, Triage and Post-Discharge Mortality.

Background. In low-income countries, pediatric emergency care is largely underdeveloped although child mortality in emergency care is more than twice that of adults, and mortality after discharge is high. Aim. We aimed at describing characteristics, triage categories, and post-discharge mortality in a pediatric emergency population in Nepal. Methods. We prospectively assessed characteristics and triage categories of pediatric patients who entered the emergency department (ED) in a local hospital. Patient households were followed-up by telephone interviews at 90 days. Results. The majority of pediatric emergency patients presented with injuries and infections (~40% each). Girls attended ED less frequent than boys. High triage priority categories (orange and red) were strong indicators for intensive care need and for mortality after discharge. Conclusion. The study supports the use and development of a pediatric triage systems in a low-resource general ED setting. We identify a need for interventions that can reduce mortality after pediatric emergency care. Interventions to reduce pediatric emergency disease burden in this setting should emphasize prevention and effective treatment of infections and injuries.

Diagnostic performance of the extended focused assessment with sonography for trauma (EFAST) patients in a tertiary care hospital of Nepal.

BACKGROUND: Thoracoabdominal trauma presents a diagnostic challenge for the emergency physician. The introduction of bedside ultrasonography (USG) provides a screening tool to detect hemoperitoneum, hemothorax, pneumothorax and pericardial effusion in torso injuries. AIM: To evaluate the accuracy of extended focused assessment with sonography for trauma (EFAST) for chest and abdominal injuries performed by first responders in a tertiary care hospital of Nepal. METHODS: This was a prospective study including all trauma patients who obtained either an Injury Severity Score ≥15 or direct trauma to the trunk in 1 year period in the emergency department (ED) of Dhulikhel Hospital-Kathmandu University Hospital. The results of the EFAST were then compared with contrast-enhanced CT (CECT), radiology ultrasound (USG)/chest X-ray, or intraoperative findings when the EFAST was positive. The negative EFAST cases were observed for a minimum of 4 hours in the ED. Descriptive statistics and sensitivity, specificity, positive predictive value, negative predictive value and accuracy were calculated. RESULTS: Out of 267 cases, 261 patients underwent an EFAST examination. The sensitivity and specificity were 94.8% and 99.5%, respectively. The negative predictive value was 98.53% whereas the positive predictive value was 98.21%. The overall accuracy was 99.4%. CONCLUSION: The results of this study suggest that EFAST examination performed by first-line healthcare providers is a useful method for assessment of thoracic and abdominal injuries. EFAST was found to have a high specificity (99.5%) and positive predictive value (98.21%) which indicates that it is an effective technique for detecting intra-abdominal or thoracic injuries. However, the effectiveness of EFAST is limited by its being operator dependent, and thereby human error. For negative EFAST cases, we recommend a monitoring period of at least 4 hours, serial fast scan, or further investigation through other methods such as a CECT. LEVEL OF EVIDENCE: Level I.

Presenting complaints and mortality in a cohort of 22 000 adult emergency patients at a local hospital in Nepal.

BACKGROUND: There is a need to develop sustainable emergency health care systems in low-resource settings, but data that analyses emergency health care needs in these settings are scarce. We aimed at assessing presenting complaints (PCs) and post-discharge mortality in a large emergency department population in Nepal. METHODS: Characteristics of adult patients who entered the emergency department (ED) in a hospital in Nepal were prospectively recorded in the local emergency registry from September 2013 until December 2016. To assess post-ED mortality, patient households were followed-up by telephone interviews at 90 days. RESULTS: In 21892 included adults, the major PC categories were injuries (29%), abdominal complaints (23%), and infections (16%). Median age was 40 years and sex distribution was balanced. Among 3793 patients followed at 90 days, 8% had died. For respiratory and cardiovascular PCs, 90-day mortality were 25% and 23%. The highest mortality was in individuals with known chronic lung disease, in this group 32% had died by 90 days of ED discharge, regardless of PC. In women, illiteracy compared to literacy (adjusted odds ratio (aOR) = 7.0, 95% confidence interval (CI) = 2.1-23.6) and being both exposed to tobacco-smoking and traditional cooking stove compared to no smoke (aOR = 2.8, 95% CI = 1.6-4.9) were associated with mortality. The mortality was much higher among family-initiated discharged patients (17%, aOR = 5.4, 95% CI = 3.3-8.9) compared to doctor-initiated discharged (3%). CONCLUSIONS: Our report suggests that nearly one in ten patients seeking emergency health care died within 90 days. This finding is alarming and novel. Post-discharge studies need to be replicated and appropriate follow-up programs in low-resource settings where primary health care is underdeveloped are urgently needed.

Interdisciplinary in situ simulation-based medical education in the emergency department of a teaching hospital in Nepal.

BACKGROUND: Simulation is well established as an effective strategy to train health care professionals in both technical and nontechnical skills and to prevent errors. Despite its known efficacy, adequate implementation is restricted due to the financial burden in resource-limited settings like ours. We therefore pursued to introduce cost-effective in situ simulation (ISS) in the emergency department (ED) to explore its impact on perception and learning experience among multidisciplinary health care professionals and to identify and remediate the latent safety threats (LST). METHODS: This is a prospective cross-sectional study with a mixed method research design, which was conducted in the ED of Dhulikhel Hospital-Kathmandu University Hospital. The pretest questionnaire was used to determine baseline knowledge, attitude, and confidence of the staff. The ISS with minimal added cost was conducted involving multidisciplinary healthcare workers. The LSTs were recorded and appropriate remediation was performed. Voluntary post simulation feedback was collected after the sessions. RESULTS: Overall 56 staff participated in at least one of the 35 simulation sessions, among which 45 (80%) responded to the questionnaires`. Twenty participants (45.5%) were reluctant to use the defibrillator. The self-reported confidence level of using defibrillator was low 29 (64.6%). The knowledge score ranged from 0 to 8 with the median score of 3 and a mean of 3.29 ± 1.8. There was no statistically significant difference in knowledge scores among participants of different occupational backgrounds, previous training, duration of work experience, and previous use of a defibrillator. A total of 366 LSTs {individual (43%), medication (17%), equipment (4%), and system/team (36%)} were identified (10.45 LST per ISS). The overall feedback from the participants was positive. Eighty percent of participants reported increased skills to use a defibrillator, and 82% reported increased confidence for managing such cases. They also agreed upon the need and continuity of such type of simulation in their workplace. CONCLUSIONS: The baseline knowledge score and the confidence level of the staff were low. Self-reported feedback suggested increased confidence level and teamwork skills after ISS. It promoted identification and remediation of latent safety threats. ISS serves as a cost-effective powerful educational model that can be implemented even in settings where finances and space are limited.

Prevalence of Dyspnea among Patients Attending the Emergency Department of a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

INTRODUCTION: Dyspnea is a common presenting complaint in the emergency department worldwide and a diagnostic challenge for emergency physicians. Our study aims to find the prevalence of dyspnea among patients attending emergency department in our hospital. METHODS: A descriptive cross-sectional study was conducted in the emergency department of Dhulikhel hospital from May 2019 to July 2019 after ethical approval from the institutional review committee. Total 1200 samples were collected by consecutive sampling method. All patients were triaged in the emergency department as a part of regular protocol. The participants were included in the study after obtaining an informed consent from the patient or caretaker (if the patient were not able to provide it). Point estimate at 95% confidence interval was calculated along with frequency and proportion for binary data. The statistical analysis was done using R version 3.5.3 (2019-03-11). RESULTS: The prevalence of dyspnea among patients attending emergency department of a tertiary care hospital was 107 (8.9%) (4.6%-13.2%) at 95% confidence interval. The patients triaged into red, orange and yellow categories were 14 (13.1%), 50 (46.7%) and 43 (40.2%) respectively. Median age was 64 years and 74 (69%) were ≥60 years. Sixty-seven (62.6%) were females and 40 (37.4%) were males. Forty-four (41.1%) arrived by ambulance. Most commonly associated symptoms were cough and fever 59 (51.1%) and 44 (41.1%) respectively. CONCLUSIONS: The prevalence of dyspnea among patients attending emergency department of our hospital is higher compared to that of other studies. This warrants structured and prompt management of dyspnea for quality improvement.

Impact of 2015 earthquakes on a local hospital in Nepal: A prospective hospital-based study.

INTRODUCTION: Natural disasters pose a great challenge to the health systems and individual health facilities. In low-resource settings, disaster preparedness systems are often limited and not been well described. Two devastating earthquakes hit Nepal within a 17-days period in 2015. This study aims to describe the burden and distribution of emergency cases to a local hospital. METHODS: This is a prospective observational study of patients presenting to a local hospital for a period of 21 days following the earthquake on April 25, 2015. Demographic and clinical information was prospectively registered for all patients in the systematic emergency registry. Systematic telephone interviews were conducted in a random sample of the patients 90 days after admission to the hospital. RESULTS: A total of 2,003 emergency patients were registered during the period. The average daily number of emergency patients during the first five days was almost five times higher (n = 150) than the pre-incident daily average (n = 35). The majority of injuries were fractures (58%), 348 (56%) in the lower extremities. A total of 345 surgical procedures were performed and the hospital treated 111 patients with severe injuries related to the earthquake (compartment syndrome, crush injury, and internal injury). Among those with follow-up interviews, over 90% reported that they had been severely affected by the earthquakes; complete house damage, living in temporary shelter, or loss of close family member. CONCLUSION: The hospital experienced a very high caseload during the first days, and the majority of patients needed orthopaedic services. The proportion of severely injured and in-hospital deaths were relatively low, probably indicating that the most severely injured did not reach the hospital in time. The experiences underline the need for robust and easily available local health services that can respond to disasters.