Are adults just big kids? Can the newer paediatric weight estimation systems be used in adults?

BACKGROUND: The weight of a patient is an important variable that impacts on their medical care. Although some drugs are prescribed on a so-called 'adult dose' basis, we know that adults come in all shapes and sizes - a 'one-dose-fits-all' approach is not necessarily appropriate. As a measured weight may not always be available, an alternative method of accurately estimating weight is required. OBJECTIVES: To assess and compare the accuracy of weight estimations in adults by patient self-estimation, the Mercy method, Buckley method, Broca index and PAWPER XL-MAC (paediatric advanced weight prediction in the emergency room eXtra length/eXtra large mid-arm circumference) method. METHODS: This was a prospective, cross-sectional study conducted at a tertiary academic hospital in a metropolitan area of Johannesburg, South Africa. Anthropometric variables of height, abdominal circumference, thigh circumference, mid-arm circumference and humeral length were measured. These variables were then applied to the various weight estimation methods and compared with the patient's actual weight. RESULTS: There were 188 adult patients included in the study. None of the methodologies evaluated in this study achieved the recommended >70% of weight estimations within 10% of the patient's actual weight (PW10). The Mercy method was the closest to achieving greater than the recommended 95% for weight estimation falling within 20% of the patient's actual weight (PW20). The PW20 for the Mercy method was 91.5%. The PAWPER XL-MAC and patient self-estimate methods achieved a PW20 of 85.1% and 86.1%, respectively. The Broca and Buckley methods performed poorly overall. CONCLUSIONS: None of the evaluated weight estimation methodologies was accurate enough for use in adult weight estimation. The Mercy and PAWPER XL-MAC methodologies both showed significant promise for use in adult weight estimation, but need further refinement. Although patient self-estimates were similarly accurate to those found in previous studies, they were not an accurate option; self-estimations would remain the first choice if the patient was able to provide such an estimation. The Broca index and Buckley method cannot be recommended owing to their poor performance.

Emergency Medicine Society of South Africa guidelines for the training and credentialing in emergency point-of-care ultrasound.

This is the second guideline from the Emergency Medicine Society of South Africa (EMSSA) on the use of emergency point-of-care ultrasound in South Africa. It supersedes and replaces the guidelines produced in 2009. This document contains information on the changes from the 2009 guidelines and details of the training and credentialing processes recommended by EMSSA. It also contains detailed information on the curricula of the Core Emergency Point-of-Care Ultrasound and Advanced Emergency Point-of-Care Ultrasound courses.

Analysis of the airway registry from an academic emergency department in South Africa.

BACKGROUND: Airway management is an essential skill for doctors working in the emergency department (ED). Safety and efficacy are crucial to its success. Analysis of an airway registry can provide feedback that can be used for quality improvement purposes. OBJECTIVES: To examine the first airway registry from an ED in South Africa (SA), a low- to middle-income country (LMIC), and compare the findings with international data. METHODS: A retrospective analysis of 13 months' data from the airway registry of an academic ED with an annual census of 60 000 patients. Data analysed included demographics, indications for intubation, intubator training level, type of intubation device, number of attempts, adverse events, pre-oxygenation methods, and drug and intravenous fluid use. RESULTS: A total of 321 intubations were included. The majority of the patients (71.6%) had non-traumatic indications for intubation. The overall first-pass intubation success (FPS) rate for doctors was 81.8%. Although this rate is lower than the mean rate suggested in an international meta-analysis (84.1%), it is within the 95% confidence interval (80.1 - 87.4%). Overall FPS rates showed no difference between video laryngoscopy (81.7%) compared with direct laryngoscopy (73.3%) (p-value 0.079), although better glottic views were obtained with video laryngoscopy (80.5% were Cormack-Lehane grade 1). Analysis of pre-oxygenation methods found that although sicker patients had received more aggressive pre-oxygenation, e.g. with non-invasive or bag-mask ventilation techniques, they still desaturated more often (35.8% and 62.5%, respectively) than less sick patients who received simple non-rebreather facemask pre-oxygenation (4.5%). CONCLUSIONS: This analysis of the first airway registry from an SA ED highlights that airway management in an LMIC can be performed on par with accepted international standards. It serves as a good baseline for further research into airway management in other LMICs and provides useful feedback for quality improvement purposes.

Let's get physical: A prospective pedometer study of doctors working in a South African emergency department.

BACKGROUND: The positive impact of physical activity and exercise on health is well known. Individuals who walk at least 10 000 steps per day are likely to meet recommended physical activity guidelines. Very little is known about the physical activity levels of doctors at work, in particular those working in emergency departments (EDs). OBJECTIVES: To determine how many steps per shift were taken by doctors in a South African (SA) ED. Secondary objectives were to assess what factors influenced the number of steps taken. METHODS: This was a prospective observational cohort study in a tertiary academic teaching hospital ED in Johannesburg over a 1-month period. Doctors wore pedometers during their day shifts in the ED and the number of steps taken during their shifts was measured, as well as the number and triage category of patients seen and whether cardiopulmonary resuscitation (CPR) was performed. RESULTS: The median (interquartile range) number of steps taken per shift was 6 328 (4 646 - 8 409). The number of steps taken exceeded the 10 000-step target in only 11.7% of shifts. The overall mean (standard deviation (SD)) number of steps per hour was 744 (490). Factors that significantly increased the number of steps taken included shift duration, number of patients seen who were triaged yellow, and performance of CPR in a shift. Each additional hour of shift led to a mean (SD) increase of 575 (115) steps. Each additional yellow patient seen led to a mean (SD) increase of 118 (108) steps. The mean (SD) number of steps for a shift with CPR was significantly higher (8 309 (850) steps) than for a shift without CPR (6 496 (384) steps). CONCLUSIONS: Doctors working in an SA ED are not achieving the daily recommended number of steps while at work. The increased risk of ill health and burnout in an already high-risk specialty heightens the importance of exercise and physical activity that needs to be achieved outside the workplace.

A comparison of four weight estimation systems for paediatric resuscitation.

BACKGROUND: One of the most important parameters that must be obtained when resuscitating a critically ill or injured paediatric patient is their weight. The best known paediatric weight estimation system is arguably the Broselow Tape, but the tape has been shown to be very inaccurate. The aim of this study was to determine and compare the accuracy of the Broselow tape, a modified Broselow tape system, the PAWPER XL tape and the hanging leg weight technique for potential utilisation in the paediatric resuscitation setting. METHOD: A convenience sample of 200 children between the ages of 1 month and 16 years were enrolled. All the children's weights were estimated using the Broselow tape, a habitus-modified Broselow tape system, the PAWPER XL tape and the hanging leg weight technique. Overall accuracy was evaluated using the percentage of weight estimations falling within 10% of actual weight (PW10). RESULTS: The PAWPER XL tape performed the best, whilst the hanging leg weight technique performed the poorest with PW10s of 74% and 19.5%, respectively. The Broselow tape with and without habitus-modification only showed modest accuracy, with PW10s of 61.7% and 59.1% respectively. CONCLUSION: The PAWPER XL tape performed significantly better than other weight estimation systems and is most appropriate for use in South African paediatric emergencies. The habitus-modified Broselow system produced only modest improvement in overall weight estimation accuracy of the Broselow tape.

The effect of different forms of heparin on point-of-care blood gas analysis.

BACKGROUND: Point-of-care blood gas analysis plays an integral role in the management of critically ill and injured patients presenting to the emergency department (ED). While the use of specially manufactured syringes containing electrolyte-balanced dried heparin is recommended when processing these specimens, alternatives including manually self-prepared syringes washed with liquid heparin or heparin vacutainers are still often used. OBJECTIVES: To assess the effect of two concentrations of liquid heparin and the use of heparin vacutainers on the reliability of blood gas analysis results compared with the recommended standard of dried heparin syringes in the ED setting. METHODS: Blood samples were drawn from 54 patients attending a tertiary-level hospital ED. Individual samples were distributed equally among each of four different collection devices: a dried heparin syringe, self-prepared syringes washed separately with 1 000 IU/mL and 5 000 IU/mL liquid heparin, and a heparin vacutainer. Results obtained from the standard dried heparin syringes were compared with those from the other three methods. RESULTS: For both the liquid heparin cohorts, partial pressure of carbon dioxide (pCO2), potassium (K+), sodium (Na+), ionised calcium (iCa2+) and haemoglobin had >20% of results falling beyond the total allowable error. iCa2+ and K+ results were most affected in the 5 000 IU/mL cohort and iCa2+ and Na+ in the 1 000 IU/ml cohort. pCO2, pH and iCa2+ were the most significantly affected in the heparin vacutainer cohort. CONCLUSIONS: Use of liquid heparin can result in significant negative bias in the majority of blood gas analytes, especially electrolytes. Heparin vacutainer use can result in unacceptable variations in the respiratory analytes. While standard dried heparin syringes may not always be available, it is of vital importance that practitioners be aware of these biases and limitations when using substitutes.

High positive computed tomography yields in the emergency department might not be a positive finding.

BACKGROUND: There is growing pressure to reduce unnecessary computed tomography (CT) imaging requests that the radiology department receives from the emergency department (ED); however, information on acceptable usage rates and diagnostic yields remains scanty. OBJECTIVES: To describe the indications, clinical categories and positive yield rates of patients receiving CT scans in the ED. METHODS: A retrospective record review was done of all patients who received CT scans at an urban, adult academic ED during a 4-month period. Primary outcomes were to establish CT scan usage and positive yield rates. Other outcomes included analysis of indications, demographics and anatomical areas scanned. RESULTS: Scans (n=1 010) were analysed. The median age of patients was 36 (range 4 - 93) years. Male patients received 64.3% of all scans, as well as 75.7% of the scans performed for trauma. The majority of the scans were for trauma patients. However, non-trauma patients had a higher positive yield; the non-trauma positive yield rate was 61.8% compared with the trauma positive yield rate of 47.1% (p<0.001). The majority of scans performed were of the head (58%) and neck (20%), with lowest positive yield rates of 48.9% and 17%, respectively. The overall CT scan usage rate was 4.6% and overall positive rate 53.8%. CONCLUSION: A negative CT scan does not necessarily mean that the test was not indicated. Higher positive yield rates may reflect insufficient use of CT scanning by the ED. Local guidelines should be established to ensure judicious and effective clinical use of CT scans.

Development and validation of a method to estimate body weight in critically ill children using length and mid-arm circumference measurements: The PAWPER XL-MAC system.

BACKGROUND: Erroneous weight estimation during the management of emergency presentations in children may contribute to patient harm and poor outcomes. The PAWPER (Paediatric Advanced Weight Prediction in the Emergency Room) XL tape is an accurate length-based, habitus-modified weight estimation device, but is vulnerable to errors if subjective visual assessments of children's body habitus are incorrect or erratic. OBJECTIVE: Mid-arm circumference (MAC) has previously been used as a surrogate indicator of habitus, and the objective of this study was to determine whether MAC cut-off values could be used to predict habitus scores (HSs) to create an objective and standardised weight estimation methodology, the PAWPER XL-MAC method. METHODS: The PAWPER XL-MAC model was developed by creating MAC ranges for each HS in each weight segment of the tape. This model was validated against two samples, the National Health and Nutrition Examination Survey datasets and data from two previous PAWPER tape studies. The primary outcome measure was to achieve >70% of estimations within 10% of measured weight (PW10 >70%) and >95% within 20% of measured weight (PW20 >95%) for children aged 0 - 18 years. RESULTS: The PAWPER XL-MAC model achieved very high accuracy in the three validation datasets (PW10 79.2%, 79.0% and 81.9%) and a very low critical error rate (PW20 98.5%, 96.0% and 98.0%). This accuracy was maintained across all ages and in all habitus types, except for the severely obese. CONCLUSIONS: The PAWPER XL-MAC model proved to be a very accurate, fully objective, standardised system in this study. It has the potential to be accurate across a wide variety of populations, even when used by those not experienced in visual assessment of habitus.

The accuracy of nurse performance of the triage process in a tertiary hospital emergency department in Gauteng Province, South Africa.

BACKGROUND: Triage in the emergency department (ED) is necessary to prioritise management according to the severity of a patient's condition.The South African Triage Scale (SATS) is a hospital-based triage tool that has been adopted by numerous EDs countrywide.Many factors can influence the outcome of a patient's triage result, and evaluation of performance is therefore pivotal. OBJECTIVES: To determine how often patients were allocated to the correct triage category and the extent to which they were incorrectly promoted or demoted, and to determine the main reasons for errors in a nurse-led triage system. METHODS: Triage forms from a tertiary hospital ED in Gauteng Province, South Africa, were collected over a 1-week period and reviewed retrospectively. RESULTS: A total of 1 091 triage forms were reviewed. Triage category allocations were correct 68.3% of the time. Of the incorrect category assignments, 44.4% of patients were promoted and 55.6% demoted. Patients in the green category were most commonly promoted (29.4%) and patients who should have been in orange were most commonly demoted (35.0%). Trauma patients were more likely to be incorrectly promoted and non-trauma patients to be incorrectly demoted. Mistakes were mainly due to discriminator errors (57.8%), followed by numerical miscalculations (21.5%). The leading omitted discriminators were 'abdominal pain', 'chest pain' and 'shortness of breath'. CONCLUSIONS: Mis-triaging using the SATS can be attributed to incorrect or lack of discriminator use, numerical miscalculations and other human errors. Quality control and quality assurance measures must target training in these areas to minimise mis-triage in the ED.

The accuracy of nurse performance of the triage process in a tertiary hospital emergency department in Gauteng Province, South Africa

Background. Triage in the emergency department (ED) is necessary to prioritise management according to the severity of a patient's condition.The South African Triage Scale (SATS) is a hospital-based triage tool that has been adopted by numerous EDs countrywide.Many factors can influence the outcome of a patient's triage result, and evaluation of performance is therefore pivotal.Objectives. To determine how often patients were allocated to the correct triage category and the extent to which they were incorrectly promoted or demoted, and to determine the main reasons for errors in a nurse-led triage system.Methods. Triage forms from a tertiary hospital ED in Gauteng Province, South Africa, were collected over a 1-week period and reviewed retrospectively.Results. A total of 1 091 triage forms were reviewed. Triage category allocations were correct 68.3% of the time. Of the incorrect category assignments, 44.4% of patients were promoted and 55.6% demoted. Patients in the green category were most commonly promoted (29.4%) and patients who should have been in orange were most commonly demoted (35.0%). Trauma patients were more likely to be incorrectly promoted and non-trauma patients to be incorrectly demoted. Mistakes were mainly due to discriminator errors (57.8%), followed by numerical miscalculations (21.5%). The leading omitted discriminators were 'abdominal pain', 'chest pain' and 'shortness of breath'.Conclusions. Mis-triaging using the SATS can be attributed to incorrect or lack of discriminator use, numerical miscalculations and other human errors. Quality control and quality assurance measures must target training in these areas to minimise mis-triage in the ED

Peri-mortem laparotomy in a patient with a ruptured intra-abdominal pregnancy

Introduction :Intra-abdominal pregnancies can present at an advanced stage of pregnancy and can have the potential for life-threatening rupture and haemorrhage. The purpose of this case report was to discuss the early recognition and prompt management options of a patient with a life threatening ruptured intra-abdominal pregnancy.Case report:We report what we believe to be the first case of a patient who presented with an intra-abdominal pregnancy who underwent a peri-mortem laparotomy in the Emergency Centre following a cardiac arrest; and who exhibited a return to spontaneous circulation (ROSC).Conclusion: Peri-mortem laparotomy/thoracotomy coupled with high quality CPR and resuscitation may be lifesaving in a patient with a life threatening ruptured intra-abdominal pregnancy