Alcohol use is associated with intracranial hemorrhage in older emergency department head trauma patients.

Objectives: Falls are common in adults aged 65 years and older and are the leading cause of traumatic brain injuries in this age group. Alcohol use may increase the risk of falls as well as the severity of resultant injuries. The aim of this study was to examine the association between self-reported alcohol use and the prevalence of intracranial hemorrhage (ICH) in this patient group. Methods: This was a secondary analysis of the Geriatric Head Trauma Short Term Outcomes Project (GREAT STOP), a study of older adults with blunt head trauma from a fall. We determined the characteristics of every fall event, including patient demographics and medical history, and clinical signs and symptoms related to head trauma. Self-reported alcohol use was categorized as none, occasionally, weekly, or daily. We defined ICH as any acute ICH detected by computed tomography scan. We evaluated the association between alcohol use frequency and ICH, adjusted for patient factors and head injury risk factors. Results: Of 3128 study participants, 18.2% (n = 567) reported alcohol use: 10.3% with occasional use, 1.9% with weekly use, and 6.0% with daily use. ICH was more common in patients who used alcohol (20.5%, 22.0%, and 25.1% for occasional, weekly, and daily alcohol users, respectively, vs. 12.0% for non-users, p < 0.001). The frequency of alcohol use was independently associated with ICH, adjusted for patient and head injury risk factors. The adjusted odds ratios (with 95% confidence intervals) for occasional, weekly, and daily alcohol users increased from 2.0 (1.5‒2.8) to 2.1 (1.1‒4.1) and 2.5 (1.7‒3.6), respectively, and showed the characteristics of dose‒response effect. Conclusions: Alcohol use in older adult emergency department patients with head trauma is relatively common. Self-reported alcohol use appears to be associated with a higher risk of ICH in a dose-dependent fashion. Fall prevention strategies may need to consider alcohol mitigation as a modifiable risk factor.

The Florida Geriatric Head Trauma CT Clinical Decision Rule.

BACKGROUND: Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults. METHODS: We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort. RESULTS: Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention. CONCLUSIONS: The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.

Educational concepts: A longitudinal interleaved curriculum for emergency medicine residency training.

Traditionally, emergency medicine (EM) residency programs teach non-adult emergency department activities (such as pediatric EM, point-of-care ultrasound [PoCUS], emergency medical services, and others) in a block format. In this way, a resident may have a 1-month pediatric EM rotation and then not have any further pediatric EM exposure until their next pediatric rotation 6‒9 months later. Furthermore, some rotations are only allotted for 1-month during the entire residency. A first-year EM resident may have their only formal PoCUS rotation early in the first year of training when their overall skills are developing, and their level of understanding and retention of information may not be optimal at that juncture of their residency training. This is far from ideal from an educational perspective. Learning scientists have now suggested that a longitudinal interleaved curriculum has substantial advantages over the traditional block format. This curriculum allows for a "spaced retrieval" practice that enhances retention of material and develops thinking processes that are important in clinical practice. The increased continuity of clinical experience has been shown to improve educational outcome and learner satisfaction. We developed a novel longitudinal interleaved curriculum for our EM resident trainees. This curriculum encompasses the entire 3 years of residency training and has the goals of increasing EM knowledge and clinical skills and being excellent preparation for board certification examinations. This concept has clear educational benefits. While adapting an existing medical training program would be challenging, a longitudinal curriculum could be phased in to replace a traditional EM curriculum.

'It's a difficult situation to be an asylum seeker in the UK. It's not easy at all': An exploration of the social and psychological impact of seeking asylum in Wales.

Wales has been committed to receiving asylum seekers and resettling refugees in towns and cities, and these numbers are increasing on a yearly basis. However, many people seeking asylum feel disempowered by the disabling policies of the Home Office, leading to social and economic hardship for this population. This qualitative study aimed to capture the voices of this under-served group through in-depth, semi structured interviews to gain contextual understanding of the social and psychological challenges experienced by people seeking asylum in Wales. The findings suggest that many asylum seekers and refugees relied on their social support networks to compensate for the limited welfare offered to them by the asylum system. Changes to the asylum process and policies are needed for Wales to achieve its goal of ensuring that people seeking asylum are supported to rebuild their lives and make a full contribution to the Welsh society.

The accuracy of total body weight estimation in adults - A systematic review and meta-analysis.

BACKGROUND: Weight estimation is required in adult patients when weight-based medication must be administered during emergency care, as measuring weight is often impossible. Inaccurate estimations may lead to inaccurate drug doses, which may cause patient harm. Little is known about the relative accuracy of different methods of weight estimation that could be used during resuscitative care. The aim of this study was to evaluate the performance and suitability of existing weight estimation methods for use in adult emergency care. METHODS: A systematic literature search was performed for suitable articles that studied the accuracy of weight estimation systems in adults. The study characteristics, the quality of the studies, the weight estimation methods evaluated, the accuracy data, and any information on the ease-of-use of the method were extracted and evaluated. RESULTS: A total of 95 studies were included, in which 27 different methods of total body weight estimation were described, with 42 studies included in the meta-analysis. The most accurate methods, determined from the pooled estimates of accuracy (the percentage of estimates within 10% of true weight, with 95% confidence intervals) were 3-D camera estimates (88.8% (85.8 to 91.8%)), patient self-estimates (88.7% (87.7 to 89.7%)), the Lorenz method (77.5% (76.4 to 78.6%)) and family estimates (75.0% (71.5 to 78.6%)). However, no method was without significant potential limitations to use during emergency care. CONCLUSION: Patient self-estimations of weight were generally very accurate and should be the method of choice during emergency care, when possible. However, since alternative estimation methods must be available when confused, or otherwise incapacitated, patients are unable to provide an estimate, alternative strategies of weight estimation should also be available.

Is there evidence that length-based tapes with precalculated drug doses increase the accuracy of drug dose calculations in children? A systematic review.

Objective: The use of pediatric length-based weight estimation tapes with precalculated drug doses is advocated by major advanced life support organizations, but concerns have been raised on the accuracy of these systems. The objective of this systematic review was to collect, review, evaluate, and create a synthesis of the current literature to establish whether there is high-quality evidence for use of lengthbased tapes in accurate drug dose administration. A further objective was to determine how these tapes compare to other dosing aids. Methods: Eligible studies were identified and analyzed if they were peer reviewed, full text articles containing original data. Studies including any form of length-based precalculated drug dosing methodology in children aged 0 to 18 years were included. Results: Eighteen studies met the inclusion criteria. The most studied of the tapes was the Broselow tape in 16 studies (88.9%). When these tapes were used on their own without additional reference material, they produced a substantial number of potentially harmful dosing errors (>20% error). No tape was superior to another. Using the tapes was better than using no dosing aid but was inferior to using both comprehensive drug dosing guides and novel color-coded medication administration systems. Conclusion: There was no high-quality evidence that the use of length-based tapes with precalculated drug doses leads to accurate drug dosing. However, comprehensive drug dosing systems were more effective at reducing dosing errors than were length-based tapes on their own. The confounding effect of weight estimation accuracy on drug dosing accuracy has not been sufficiently studied.

Weight Estimation for Drug Dose Calculations in the Prehospital Setting - A Systematic Review.

BACKGROUND: Weight estimation is required to enable dose calculations for weight-based drugs administered during emergency care. The accuracy of the estimation will determine the accuracy of the administered dose. This is an important matter of patient safety. The objective of this systematic review was to collect, review, evaluate, and create a synthesis of the current literature focusing on the accuracy of weight estimation in the prehospital environment. METHODS: This systematic review followed the PRISMA guidelines. Studies were identified and included if they were peer reviewed, full length, published in English, and contained original data. Studies utilizing any form of weight estimation methodology in the prehospital setting (in children or adults) were included. Data on the quality of the studies and accuracy of the weight estimation systems were extracted. Common themes were also identified. RESULTS: Twenty-five studies met the inclusion criteria, with only nine studies (36.0%) containing useful weight estimation accuracy data. The overall quality of the studies was poor. The Broselow tape and paramedic estimates were the most studied methods of weight estimation, but there was insufficient evidence to support conclusions about accuracy. The major themes identified included the importance of accurate weight estimation and drug dosing as critical matters of patient safety, and the need for training to ensure these processes are performed accurately. CONCLUSIONS: There were limited robust data identified on the accuracy of different weight estimation methods used in the prehospital setting. Future high-quality clinical research in this area is of critical importance to ensure patient safety in the prehospital environment.

Estimating Lean Body Weight in Adults With the PAWPER XL-MAC Tape Using Actual Measured Weight as an Input Variable.

Introduction Accurate drug dose calculation in obese patients requires an estimation of lean body weight (LBW) for dosing hydrophilic medications. Inaccurate weight estimates during the management of critically ill obese adults may contribute to inaccurate drug doses and consequential poor outcomes. Existing methods of LBW estimation or measurement may be very difficult or impossible to use during emergency care. A point-of-care model that could provide rapid, accurate estimates of LBW would, therefore, be of significant clinical value. Methods A model was derived based using the adult version of the PAWPER XL-MAC tape. This derived model used recumbent length and measured total body weight (TBW) to estimate LBW. The derived model was used to generate LBW estimations in a random sample from National Health and Nutrition Examination Survey (NHANES) datasets (n=33,215). The benchmark outcome measure was to achieve >95% of LBW estimations within 20% of DXA-measured fat-free mass (P20>95%) and >70% of estimations within 10% of DXA-measured fat-free mass (P10>70%). Results The new model achieved a P20 of 99.7% and a P10 of 86.4% for LBW in the pooled sample and exceeded the minimum accuracy standards. This accuracy was maintained in both sexes, all ages, all ethnic groups, all lengths and in all habitus types. Conclusions The modified PAWPER XL-MAC model, using TBW as an input variable, proved to be an accurate method of LBW estimation. It could potentially have an important role in facilitating emergency drug dose calculations in critically ill or injured obese adult patients.

Development and Validation of a Length- and Habitus-Based Method of Ideal and Lean Body Weight Estimation for Adults Requiring Urgent Weight-Based Medical Intervention.

BACKGROUND AND OBJECTIVE: Accurate drug dosing in obese patients requires an estimation of ideal body weight (IBW) or lean body weight (LBW) for dosing hydrophilic medications. Erroneous weight estimates during the management of adults requiring weight-based treatment may contribute to poor outcomes. Existing methods of IBW and LBW estimation or measurement are very difficult to use during emergency care. A new point-of-care model would be useful to provide rapid estimates of IBW and LBW for this purpose. METHODS: A model was derived based on the PAWPER XL-MAC tape, a pediatric weight estimation system which uses recumbent length and mid-arm circumference to estimate IBW and LBW. The new adult model was used to generate IBW and LBW estimations for a derivation sample (n = 33155) and a validation sample (n = 5926) from National Health and Nutrition Examination Survey (NHANES) datasets. The model was developed in two steps, with calibration at each step, before being validated on an unused dataset. The outcome measure was to achieve >95% of IBW and LBW estimations within 20% of recognized reference standards (P20 > 95%) and >70% of estimations within 10% of these standards (P10 > 70%). RESULTS: The new model achieved a P20 of 100% and a P10 of 99.9% for IBW and a P20 of 98.3% and a P10 of 78.3% for LBW. This accuracy was maintained in both sexes, all ages, all ethnic groups, all lengths, and in all habitus types, except for the severely obese female subgroup. CONCLUSIONS: The modified PAWPER XL-MAC model proved to be an accurate method of IBW and LBW estimation. It could, therefore, have an important role in facilitating emergency drug dose calculations in obese adult patients.

Development and validation of a length- and habitus-based method of total body weight estimation in adults.

BACKGROUND: Erroneous weight estimation during the management of emergency presentations in adults may contribute to patient harm and poor outcomes. Patients can often not be weighed during emergencies and a weight estimation is required to facilitate weight-based therapies. Many existing methods of weight estimation are either unacceptably inaccurate or very difficult to use during the provision of emergency care. METHODS: The weight estimation system developed in this study was based on and modified from the PAWPER XL-MAC method, a pediatric weight estimation system that uses recumbent length and mid-arm circumference (MAC) to predict total body weight. This model was validated in the 2015-2018 National Health and Nutrition Examination Survey (NHANES) datasets. The primary outcome measure was to achieve >95% of estimations within 20% of measured weight (P20 > 95%). RESULTS: The modified PAWPER XL-MAC model achieved a P20 of 96.0% and a P10 of 71.3% in the validation dataset (N = 11,520). This accuracy (P20 > 95%) was maintained in both sexes, all ages, all ethnic groups, all lengths and in all habitus-types, except for the subgroup of severely obese individuals. CONCLUSIONS: The modified PAWPER XL-MAC model proved to be a very accurate method of weight estimation. It is more accurate than most other published reports of existing methods of weight estimation, except for patients' own estimations. It therefore could have a role in facilitating emergency drug dose calculations, if prospective studies bear out the accuracy found in this study.

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.

Management of acute fever in children: Consensus recommendations for community and primary healthcare providers in sub-Saharan Africa.

Fever is one of the most common reasons for unwell children presenting to pharmacists and primary healthcare practitioners. Currently there are no guidelines for assessment and management of fever specifically for community and primary healthcare workers in the sub-Saharan Africa region. This multidisciplinary consensus guide was developed to assist pharmacists and primary healthcare workers in sub-Saharan Africa to risk stratify and manage children who present with fever, decide when to refer, and how to advise parents and caregivers. Fever is defined as body temperature ≥ 37.5 °C and is a normal physiological response to illness that facilitates and accelerates recovery. Although it is often associated with self-limiting illness, it causes significant concern to both parents and attending healthcare workers. Clinical signs may be used by pharmacy staff and primary healthcare workers to determine level of distress and to distinguish between a child with fever who is at high risk of serious illness and who requires specific treatment, hospitalisation or specialist care, and those at low risk who could be managed conservatively at home. In children with warning signs, serious causes of fever that may need to be excluded include infections (including malaria), non-infective inflammatory conditions and malignancy. Simple febrile convulsions are not in themselves harmful, and are not necessarily indicative of serious infection. In the absence of illness requiring specific treatment, relief from distress is the primary indication for prescribing pharmacotherapy, and antipyretics should not be administered with the sole intention of reducing body temperature. Care must be taken not to overdose medications and clear instructions should be given to parents/caregivers on managing the child at home and when to seek further medical care.

Human Factor Errors in the use of the PAWPER Tape Systems: An Analysis of Inter-Rater Reliability.

Background International guidelines have promoted the use of length-based tapes for emergency weight estimation in children. This is primarily because of a perception that more modern methods might require more training than can practically be achieved. This study aimed to evaluate the inter-rater reliability of novice users of the PAWPER XL (paediatric advanced weight-prediction in the emergency room) tape as an indicator of the ability to use the device effectively with limited training. Methods This was a secondary analysis of unpublished data from three previous studies. Inter-rater reliability analyses were performed for each study for the accuracy of weight estimations and for the assignment of body habitus score. Inter-rater reliability was analysed using percentage agreement and Cohen's Kappa for Study 1 and intraclass correlation (ICC) for Study 2 and Study 3. A value of <0.7 was considered to indicate inadequate agreement, 0.7 to 0.89 was considered to indicate good agreement and ≥0.9 was considered to indicate excellent agreement. Main Results A total of 7034 data points were available for analysis in the three studies. In Study 1, the percentage agreement of an accurate weight estimation in 50 children, with two raters, was 47/50 (94%) with a Cohen's Kappa of 0.93 (0.81 - 1.0). In Study 2, the ICC for 6720 habitus score assessments, with 112 raters, was 0.73 (0.68 - 0.80). In Study 3, the ICC for 264 weight estimations (in terms of an accurate weight estimation, with 33 raters) was 0.88 (0.72 - 0.97). Conclusions There was good inter-rater reliability in the assessment of habitus and the accuracy of weight estimation for the PAWPER XL tape in this secondary analysis. The findings suggest that reasonable proficiency with the system can be achieved with minimal training. It is therefore unlikely that systems such as this require too much training to be practical in emergency care.

Erratum to "Paediatric weight estimation practices of advanced life support providers in Johannesburg, South Africa" [Afr Am J Emerg Med 8 (2018) 51-54].

[This corrects the article DOI: 10.1016/j.afjem.2018.01.003.].

The utility of pediatric age-based weight estimation formulas for emergency drug dose calculations in obese children.

OBJECTIVES: In obese children, when drug therapy is required during emergency care, an estimation of ideal body weight is required for certain drug dose calculations. Some experts have previously speculated that age-based weight estimation formulas could be used to predict ideal body weight. The objectives of this study were to evaluate how accurately age-based formulas could predict ideal body weight and total body weight in obese children. METHODS: Three age-based weight estimation formulas were evaluated in a secondary analysis, using a pooled sample of children from 3 academic emergency departments in South Africa. The estimates produced by the 3 formulas (and the PAWPER XL tape as a control) were compared against measured total body weight and ideal body weight. The percentages of estimates falling within 10% of the standard weight were used as the primary outcome measure (PW10). RESULTS: This study included 1026 children. For ideal body weight estimations in obese children, the old Advanced Life Support formula, the new Advanced Life Support formula, and the Best Guess formula achieved PW10s (with 95% confidence intervals [CIs]) of 29% (27.2%, 30.8%), 41.4% (38.9%, 43.9%), and 48.3% (45.3%, 51.3%), respectively. For total body weight estimations, the formulas achieved PW10s of 3.6% (3.4%, 3.8%), 5.2% (4.9%, 5.5%), and 19.0% (17.8%, 20.2%). The PAWPER XL tape achieved an accuracy of ideal body weight estimation of 100% (93.9%, 100%) and total body weight estimation of 49.7% (46.7%, 52.7%) in obese children. CONCLUSIONS: The age-based formulas were substantially less accurate at estimating total body weight and ideal body weight than existing length-based methods such as the PAWPER XL tape, and should not be used for this purpose.

Drug dosing errors in simulated paediatric emergencies - Comprehensive dosing guides outperform length-based tapes with precalculated drug doses.

BACKGROUND: The accuracy of drug dosing calculations during medical emergencies in children has not been evaluated extensively. The objectives of this study were to evaluate the accuracy of drug dose calculations using the Broselow tape, the PAWPER XL tape plus its companion drug-dosing guide, a custom-designed mobile phone app and no drug-dosing aid (control group). METHODS: This was a prospective study in which 32 emergency medicine volunteers participated in eight simulations of common paediatric emergency conditions, using children models. The participants used the three methods to estimate the children's weight and calculate drug doses. The accuracy of and time taken for the drug dose determinations were then evaluated for each of the methods. RESULTS: The overall accuracy of drug dose determinations was extremely and potentially dangerously low in the control group in which no dosing guide was used as well as in the Broselow tape group (<20% of doses were correct). The accuracy was significantly higher with the PAWPER XL tape group and the mobile app group (47% and 31% respectively). The times taken to obtain the required information did not differ in a clinically meaningful magnitude. CONCLUSIONS: Both an accurate weight estimation and a dosing guide with comprehensive information were necessary to produce an accurate prescription. The information on the Broselow tape was not sufficient for this purpose. The current guidelines recommending the use of tapes with limited information should be revised. The results from the comprehensive dosing guides were substantially better, but still had a lower proportion of accurate prescriptions than desirable. The role of training in every aspect of the emergency paediatric weight estimation and drug dosing procedure cannot be underestimated and should be routine in any environment where emergency care may be needed.