Future directions for emergency medical services development in low- and middle-income countries.

The lack of prehospital care access in low- and middle-income countries is one of the greatest unmet needs and, therefore, one of the most urgent priorities in global health. Establishing emergency medical services in low- and middle-income countries poses significant challenges and complexities, requiring solutions tailored to prevailing conditions, informed by needs assessments, and adapted to meet local demands in a culturally appropriate and sustainable manner. In areas without existing emergency medical services, patients must rely on informal networks of untrained bystanders and community members to provide first aid and transport to definitive care. Since 2005, training lay first responders has been recommended by the World Health Organization as the first step toward formal emergency medical services development. However, efforts to formalize lay first responders networks have not expanded with the increasing need for prehospital emergency care in low- and middle-income countries, despite their potential. The rapid expansion of communication technologies like mobile smartphones penetrating resource-limited settings offers effective and inexpensive options for dispatching and coordinating lay first responders that were not previously available. These technologies can also be used for more advanced emergency medical services, obviating expensive communications and dispatch infrastructure. Despite disproportionately bearing the global injury burden, lay first responders frequently lack accurate and comprehensive surveillance data secondary to widespread underreporting, especially for non-fatal events. Lay first responders expand surveillance, which may inform future targeted prevention efforts, assisting in the development of tailored countermeasures suited to local hazards and diseases. Emergency medical services development in low- and middle-income countries involves a strategic approach focused on understanding the unique needs of diverse communities, requiring broad stakeholder involvement to create a sense of ownership to maintain volunteer networks and enhance sustainability. By embracing these relatively low-cost, bottom-up strategies, low- and middle-income countries can develop more accessible, efficient, and community-oriented emergency medical systems, ultimately improving public health outcomes and averting preventable deaths to address the emergency burden.

TraumaLink: A Community-Based First-Responder System for Traffic Injury Victims in Bangladesh.

INTRODUCTION: Road traffic injuries are a rapidly growing epidemic in low- and middle-income countries (LMICs). However, many countries lack formal prehospital emergency medical services, often leaving victims without access to first aid when it can be most effective in preventing death or disability. METHODS: To address the lack of a dedicated prehospital emergency medical system in Bangladesh, we developed TraumaLink, a community-based network of volunteer first responders for traffic injury victims. The service uses an emergency hotline number and 24-hour call center with local first responders who are trained in basic trauma first aid, given essential medical supplies, and dispatched to crash scenes through mobile phone text message notifications. We designed the training curriculum to teach simple lifesaving skills that people with any level of education and no prior medical background could learn and perform. We retrospectively analyzed data originally collected for quality monitoring and evaluation to provide a descriptive analysis of the program's impact. RESULTS: During the first 6 years, operations were expanded from a 14-km section of 1 highway to 135 km on 3 national highways, and free care was provided to 3,119 patients involved in 1,544 crashes. All calls to the service received a response, and in 88% of cases, first responders were at the scene in 5 minutes or less. Most patients were young adult men, and 76% of victims transported to the hospital arrived there within 30 minutes of the crash. Assessments of injury severity at the accident scene aligned closely with patient dispositions, reflecting the accuracy of these triage decisions. CONCLUSION: The strong community support and rapid, reliable volunteer responses suggest that this flexible and scalable model could be expanded throughout Bangladesh and adapted for other LMICs that face similar challenges with traffic injury victims.

Intravenous levetiracetam in the rat pilocarpine-induced status epilepticus model: behavioral, physiological and histological studies.

PURPOSE: Status epilepticus is a neurological emergency associated with neuronal injury, lasting behavioral disturbance, and a high rate of mortality. Intravenous levetiracetam (LEV), an anti-epileptic drug approved to treat partial seizures, has recently been introduced. We sought to determine the effect of LEV administered intravenously in a chemoconvulsant model of status epilepticus. METHODS: We examined the effect of intravenous LEV in the rat lithium-pilocarpine model of status epilepticus. Ten or 30 min after the onset of behavioral status epilepticus, animals were treated with LEV (200-1200 mg/kg i.v.) administered in a single bolus. Behavioral responses were recorded. Selected animals had continuous EEG recording before, during and after the administration of LEV. Some animals were sacrificed 24 h after the experiment and processed for histochemical assessment of neuronal injury. RESULTS: When administered 30 min after the onset of behavioral epileptic seizures, transient attenuation of ictal behavior was observed in animals treated with 800 mg/kg or more of LEV. The duration of behavioral attenuation increased sharply as the dose rose to 1000 mg/kg or higher, from a mean of 4-23.6 min. When administered 10 min after seizure onset, 400 mg/kg of LEV resulted in transient ictal behavioral attenuation, and higher doses caused relatively longer periods of attenuation. Pretreatment with LEV prior to pilocarpine also delayed the onset of seizures. EEG recordings, however, showed no significant attenuation of ictal discharge. By contrast, TUNEL staining demonstrated less neuronal injury in hippocampii and other limbic structures in animals that responded behaviorally to LEV. CONCLUSIONS: Intravenous administration of LEV in a chemoconvulsant model of status epilepticus results in attenuation of behavioral manifestations of seizure discharge and in reduction of neuronal injury but does not significantly alter ictal discharge recorded by EEG.

Seizure visits in US emergency departments: epidemiology and potential disparities in care.

INTRODUCTION: While epilepsy is a well-characterized disease, the majority of emergency department (ED) visits for "seizure" involve patients without known epilepsy. The epidemiology of seizure presentations and national patterns of management are unclear. The aim of this investigation was to characterize ED visits for seizure in a large representative US sample and investigate any potential impact of race or ethnicity on management. METHODS: Seizure visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1993 to 2003 were analysed. Demographic factors associated with presentation, neuroimaging and hospital admission in the USA were analysed using controlled multivariate logistic regression. RESULTS: Seizure accounts for 1 million ED visits annually [95% confidence interval (CI): 926,000-1,040,000], or 1% of all ED visits in the USA. Visits were most common among infants, at 8.0 per 1,000 population (95% CI: 6.0-10.0), and children aged 1-5 years (7.4; 95% CI: 6.4-8.4). Seizure was more likely among those with alcohol-related visits [odds ratio (OR): 3.2; 95% CI: 2.7-3.9], males (OR: 1.4; 95% CI: 1.3-1.5) and Blacks (OR: 1.4; 95% CI: 1.3-1.6). Neuroimaging was used less in Blacks than Whites (OR: 0.6; 95% CI: 0.4-0.8) and less in Hispanics than non-Hispanics (OR: 0.6; 95% CI: 0.4-0.9). Neuroimaging was used less among patients with Medicare (OR: 0.4; 95% CI: 0.2-0.6) or Medicaid (OR: 0.5; 95% CI: 0.4-0.7) vs private insurance and less in proprietary hospitals. Hospital admission was less likely for Blacks vs Whites (OR: 0.6; 95% CI: 0.4-0.8). CONCLUSION: Seizures account for 1% of ED visits (1 million annually). Seizure accounts for higher proportions of ED visits among infants and toddlers, males and Blacks. Racial/ethnic disparities in neuroimaging and hospital admission merit further investigation.