Non-traumatic chest pain in patients presenting to an urban emergency Department in sub Saharan Africa: a prospective cohort study in Tanzania.

BACKGROUND: Non-traumatic chest pain (NTCP) is a common reason for emergency department (ED) attendance in high-income countries, with the primary concern focused on life threatening cardiovascular diseases. There is general lack of data on aetiologies, diagnosis and management of NTPC in Sub Sahara African (SSA) countries. We aimed to describe evaluation, diagnosis and outcomes of adult patients presenting with NTCP to an urban ED in Tanzania. METHOD: This was a prospective observational cohort study of consecutive adult (≥18 years) patients presenting with non-traumatic chest pain to the Emergency Medicine Department (EMD) of Muhimbili National Hospital (MNH) in Dar es salaam from September 2017 to April 2018. Structured case report form was used to collected demographics, clinical presentation, investigations, diagnosis, and EMD disposition and in hospital mortality. We determined frequency of NTCP among our patients, aetiologies, 24-h and 7-day in-hospital mortality, and predictors for mortality. RESULTS: We screened 29,495 adults attending EMD-MNH during the study and 389 (1.3%) presented with NTCP of these, 349 (90%) were enrolled. The median age was 45 (IQR 29-60) years and 177 (50.7%) were female. Overall, 69.1% patients received electrocardiography (ECG) in the EMD and 34.1% had a troponin test. Heart failure and pulmonary tuberculosis (PTB) were the leading hospital diagnoses (12.6% each), followed by chronic kidney disease (10%) and acute coronary syndrome (ACS) (9.6%). Total of 167 (48%) patients were admitted, and the 24-h and 7-day in-hospital mortality were 5 (3%) and 16 (9.6%) respectively. Univariate risk factors for mortality were a Glasgow Coma Scale of < 15 [RR = 3.4 (95%CI 3.2-23)], Acute Coronary Syndrome [RR = 5.7 (95% CI 1.7-11.8) and Troponin > 0.04 ng/ml [RR 2.9 (95%CI 1.2-7.3)]. Features distinguishing cardiovascular from other causes were: bradycardia [RR = 2.6 (95%CI 2.1-3.2)], heart beat awareness [RR = 2.3 (95%CI 1.7-3.2)] and history of diabetic mellitus [RR = 2.2 (95% CI 1.6-3.0)]. CONCLUSION: In this ED of SSA country, heart failure and pulmonary tuberculosis were the leading causes of NCTP, and ACS was present in 9.6%. NTCP in this setting carries high mortality, and ACS was the leading risk factor for death. ED providers in SSA must increasingly consider cardiovascular causes of NTCP.

Respiratory compromise in children presenting to an urban emergency department of a tertiary hospital in Tanzania: a descriptive cohort study.

BACKGROUND: Respiratory compromise is the leading cause of cardiac arrest and death among paediatric patients. Emergency medicine is a new field in low-income countries (LICs); the presentation, treatment and outcomes of paediatric patients with respiratory compromise is not well studied. We describe the clinical epidemiology, management and outcomes of paediatric patients with respiratory compromise presenting to the first full-capacity Emergency Department in Tanzania. METHODS: This was a prospective cohort study of paediatric patients (< 18 years) with respiratory compromise (respiratory distress, respiratory failure or respiratory arrest) presenting to the Emergency Medicine Department of Muhimibili National Hospital (EMD-MNH) in Dar es Salaam, from July-November 2017. A standardized case report form was used to record demographics, presenting clinical characteristics, management and outcomes. Primary outcomes were hospital mortality and secondary outcomes were EMD mortality, 24-h mortality, incidence of cardiac arrest in the EMD, length of stay, ICU admission, and risk factors for mortality. RESULTS: We enrolled 165 children; their median age was 12 months [IQR: 4-36 months], and 90 (54.4%) were male. At presentation 92 (55.8%) children were in respiratory failure. Oxygen therapy was initiated for 143 (86.7%) children, among which 21 (14.7%) were intubated. The most common aetiologies were pneumonia followed by congenital heart disease and sepsis. The majority 147 (89.1%) of children were admitted to the hospital, with 20 (12%) going to ICU. Four (2%) children were discharged from EMD and 14 (8.5%) died in the EMD. In the EMD, 18 children developed cardiac arrest, with two surviving to hospital discharge. Overall 51 (30.9%) children died; 84% of deaths were in children under five years. Risk of mortality was increased in children presenting with decreased consciousness (RR = 2.2 (1.4-3.4)), hypoxia RR = 2.6 (1.6-4.4)) or bradypnoea (RR = 3.9 (2.9-5.0)), and those who received CPR (RR = 3.7 (2.7-5.2)) and intubation (RR = 3.1 (2.1-4.5)). CONCLUSIONS: In this EMD of a LICs, respiratory compromise in children carries high mortality, with children of young age being the most vulnerable. Many children arrived in respiratory failure and few children received ICU care. Outcomes can be improved by earlier recognition to prevent cardiac arrest, and more intensive treatment, including ICU and assisted ventilation.

Profile and outcome of patients with emergency complications of renal failure presenting to an urban emergency department of a tertiary hospital in Tanzania.

BACKGROUND: Renal failure carries high mortality even in high-resource countries. Little attention has been paid to renal failure patients presenting acutely in emergency care settings in low-to-middle income countries (LMIC). Our aim was to describe the profile, management strategies and outcome of renal failure patients presenting with indications for emergent dialysis to an urban Emergency Department (ED) in a tertiary public hospital in Tanzania. METHODS: This was a prospective cohort study of consecutive patients (age ≥ 15 yrs) presenting to the Emergency Medicine Department of Muhimbili National Hospital from September 2017 to February 2018. All patients with renal failure and complications requiring acute dialysis were included. A structured data collection sheet was used to gather demographics, clinical presentation, management strategies and outcomes. Data were summarized with descriptive statistics. Logistic regressions were performed to determine factors associated with receiving dialysis and with mortality. RESULTS: We enrolled 146 patients, median age was 49 years (IQR 32-66 years), and 110 (75.3%) were male. Shortness of breath 67 (45.9%) and reduced urine output 58 (39.7%) were the most common presenting complaints. The most common complications were hyperkalemia 77 (53%), uremic encephalopathy 66 (45%) and pulmonary edema 54 (37%). All patients were hospitalized, and 61 (42%) received dialysis. Overall mortality was 39% (57 patients); the mortality in non-dialysed patients was 53% vs. 20% (p < 0.0005) in those receiving dialysis. 54% of patients with health insurance were dialyzed, compared to 39% who paid out of pocket (adjusted OR = 0.3, 95%CI: 0.1-0.9). Patients (≥55 years) were less likely to be dialysed (adjusted OR = 0.2 [0.1-0.9]). Independent predictors of mortality were vomiting (OR = 6.2, 95%CI: 1.8-22.2), oliguria (OR = 3.4, 95%CI: 1.2-9.5), pulmonary edema (OR = 4.6, 95%CI: 1.6-14.3), creatinine level > 1200umol/L (OR = 5.0 95%CI: 1.4-18.2), and not receiving dialysis (OR = 8.0, CI: 2.7-23.5). Female sex had a lower risk of dying (OR = 0.13, CI: 0.03-0.5). CONCLUSIONS: In this ED in LIC, acute complications of renal failure created a need for ED stabilization and emergent dialysis. Overall in-hospital mortality was high; significantly higher in undialysed patients. Future studies in LICs should focus on identification of categories of patients that will do well with conservative therapy.