Darryl Wood

The effectiveness of the South African Triage Score (SATS) in a rural emergency department

BACKGROUND. The Modified Early Warning Score (MEWS) is used to monitor medical inpatients in hospitals in the developed world. The South African Triage Score (SATS) was developed from the MEWS, and its use throughout South Africa has been proposed. OBJECTIVES. We aimed to assess the effectiveness of the SATS in an emergency department (ED) in a rural setting in KwaZulu-Natal (KZN). METHODS. A prospective cross-sectional study undertaken over a 1-month period in June 2009 of patients in the ED of a government hospital in rural KZN, the referral centre for 22 peripheral hospitals. Data capture included physiological parameters, mobility and trauma scores, a list of selected clinical conditions (physician discriminator list), MEWS and SATS scores, final clinical diagnosis, and outcome in the ED (death, hospital admission or discharge). Outcome measures were under- and over-triage rates according to both systems. RESULTS. Over the study period, 589 patients were triaged and their data analysed. The MEWS under-triaged 15.1% (over-triaged 8.3%) of cases that needed admission, compared with an under-triage rate of 4.4% (over-triage rate 4.3%) when the SATS was used. CONCLUSION. Our study supports use of the SATS as a primary triage score in South African urban and rural hospitals. The SATS is superior to the MEWS as a triage scoring system in a rural hospital ED in KZN, its rates of under- and over-triage falling within the limits of the American College of Surgeons Committee on Trauma (ACSCOT) guidelines.

FAST scanning in the developing world emergency department

OBJECTIVES To assess the utility of an existing ultrasound machine for the purposes of focused assessment sonography in trauma (FAST) scanning in a developing world emergency department (ED). DESIGN Prospective study undertaken over a 12-month period. Trauma patients attending the ED were FAST scanned by one of three trained emergency medicine doctors. SETTING The ED at a government hospital in rural KwaZulu-Natal (KZN), the referral centre for 22 peripheral hospitals. SUBJECTS All patients presenting to the ED who had sustained abdominal or thoracic trauma. OUTCOME MEASURES Scans were recorded as positive or negative for free intra-abdominal or pericardial fluid. All results were confirmed by computed tomography, laparotomy or a second trained ED ultrasonographer, followed by a period of clinical observation. RESULTS 72 FAST scans were included, 52 for blunt trauma and 20 for penetrating trauma. Of the 72 scans, 15 (20.8%) were positive. FAST scanning had 100% specificity and overall sensitivity of 71.4%. When considering blunt trauma alone the sensitivity improved to 81.3%, while in penetrating trauma it was much poorer (62.5%). CONCLUSIONS We propose a valuable role for FAST scanning in all peripheral hospitals for the assessment of patients sustaining blunt trauma. In rural areas with limited resources FAST scans may assist in the appropriate timely transfer of trauma patients for further imaging or definitive surgical intervention.

Severe snakebites in northern KwaZulu-Natal: treatment modalities and outcomes

OBJECTIVE We aimed to study the outcomes of severe snakebites in patients admitted to Ngwelezana Hospital in north-eastern KwaZulu-Natal, the seasonal variations, and the effectiveness and complications of antivenom. DESIGN A prospective observational outcomes study was conducted over one year (1 June 2007 to 31 May 2008). The study group was from the north-eastern KwaZulu-Natal region of South Africa, with a population of approximately 3 million people, and included all patients bitten by snakes and admitted to the Ngwelezana Hospital Emergency Medicine Unit (EMU). Departmental practice guidelines were documented and followed. OUTCOME MEASURES End-points for patient outcomes included transfer from the EMU to the ward, discharge home from the EMU, and follow-up of patients who required surgery or ICU care. RESULTS A total of 243 snakebite patients were recorded. The highest incidence was in the summer months; 46 (18.93%) patients experienced one or more severe complications; 29 (11.93%) patients received some form of definitive management in hospital; and 22 (9.05%) of the latter patients received antivenom. Antivenom was administered to more children than adults. Adverse reactions to antivenom were common: an allergic response occurred in 4 (15.4%) patients, and anaphylaxis in 6 (23.1%); the highest incidence occurred in the <10-year-old age group. No deaths were recorded. CONCLUSIONS Snakebites are common in the summer months in north eastern KwaZulu-Natal. Children are particularly vulnerable to snakebites and the effects of antivenom. Adverse reactions to antivenom are common. Severe snakebites that require antivenom should be managed in a hospital setting with advanced airway support. The syndromic approach to treatment is simple and effective.

Emergency focussed assessment with sonography in trauma (FAST) and haemodynamic stability

Background Focussed assessment with sonography in trauma (FAST) has assumed a key role in the rapid non-invasive assessment of thoracoabdominal trauma and assists in decreasing disposition time. This study evaluates FASTs efficacy with respect to haemodynamic stability in a South African emergency department (ED). Methods Data were collected prospectively by four emergency medicine doctors trained in emergency ultrasonography. FAST scans were performed by one ED doctor and timings, scan result and disposition were recorded. Patient haemodynamic stability was assessed by the emergency doctor performing the scan; subjectively at the time of scanning and objectively using calculation of the shock index. All scan results were subsequently verified by a second ED doctor in a blinded fashion and by CT scanning or operative intervention when clinically indicated. Results 166 FAST scans were conducted of which 36 (21.7%) were positive. Mean age was 30.6 years (SD 12.8). 74.1% of patients sustained blunt traumatic injury. Doctors’ subjective haemodynamic stability assessments had higher specificity, sensitivity and predictive values than shock index alone. Haemodynamic instability and a positive FAST result were significantly related (p=0.004). Sensitivities and specificities of FAST scans for blunt and penetrating trauma were 93.1% and 100%, and 90.0% and 100%, respectively. Corresponding values for pneumothoraces were 84.6% and 100%. Discussion This study showed a valuable role for FAST in all traumas, particularly in haemodynamic compromise. As an addition to the physicians repertoire of bedside assessment tools, it improves diagnostic capabilities in comparison with simple haemodynamic assessments alone.

Crush Syndrome in the rural setting

Crush syndrome (CS) a form of traumatic rhabdomyolysis, can have fatal consequences often because the early manifestations are not recognised and there are delays in appropriate treatment. Recent publications on CS in the Emergency Medicine Journal have reported cases following earthquakes in China.1 2 These studies highlighted the prolonged exposure of patients to crushing injuries before getting in-hospital medical …

Interpersonal violence as a major contributor towards the skewed burden of trauma in KwaZulu-Natal, South Africa

BACKGROUND Trauma is one of the foremost causes of death worldwide, but there is a paucity of data on demographics and injury patterns in developing countries. OBJECTIVES To quantify and describe the major trauma burden at a regional hospital in KwaZulu-Natal (KZN), South Africa (SA), over a 5-year period. METHODS Ngwelezane Hospital is a large regional hospital in northern KZN. A database is maintained of all major trauma patients admitted to the Emergency Department (ED) resuscitation unit. Statistical analysis was performed to quantify the burden of trauma and analyse trends in these data. RESULTS Over a 5-year period, 3 735 major trauma patients were admitted to the ED resuscitation unit. Analysis showed a male predominance, with a mean patient age of 28.6 years. An average of 62 patients per month were admitted, the rate peaking over the holiday seasons. Trauma secondary to interpersonal violence (IPV) predominated. A disproportionately high level of pedestrian-motor vehicle collisions (PMVCs) in relation to total road traffic collisions was noted. Blunt force trauma secondary to motor vehicle collisions was the leading cause of death, while blunt force trauma secondary to PMVC s carried the highest mortality rate. CONCLUSION This study highlights the high incidences of both IPV and PMVCs typical of trauma in an SA setting. The demographics and injury patterns noted may be used to drive public health interventions to address this burden of trauma.

Snakebite in north-eastern South Africa: clinical characteristics and risks for severity

Objectives: To identify the toxicity profile of snakebites and to assess clinical severity. Methods: An analysis of all patients admitted to Ngwelezane Hospital’s Emergency Department with a diagnosis of snakebite over five years was done. All patients were admitted, assessed and standard haematological and biochemical tests were done. Patients were observed for a minimum of 12 hours’ observation. Results: In total, 879 cases were analysed. Envenomation was identified in over two-thirds of admissions. Cytotoxic snakebites accounted for 98% of envenomations. Only four cases of haemotoxic bleeding and five cases of neurotoxicity were admitted. Abnormal laboratory indices correlated with severity: INR > 1.5 (odds ratio 2.25, CI 1.12–4.53; p = 0.023), platelets < 100x109/L (OR 2.35, CI 1.01– 5.49; p = 0.048), haemoglobin concentration < 8.0 g/dL (OR 5.68, CI 2.15–15.00; p < 0.001) and leucocyte count > 10x109 (OR 3.15, CI 1.89– 5.26, p < 0.001). Children and delays to admission correlated to and were predictors of severity. Conclusion: Two-thirds of patients who present to hospital with snakebite will have symptoms of envenomation, with the overwhelming majority having been bitten by cytotoxic species. Some factors correlate to severity and may be useful for anticipating the patient’s clinical course.

Ultrasound findings in 42 patients with cytotoxic tissue damage following bites by South African snakes

Background Snakebites that have cytotoxic venom can cause significant soft tissue swelling. Assessing the site and degree of swelling using ultrasound as a non-invasive technique would be an important tool for instituting appropriate treatment. Methods Forty-two patients who presented to a referral hospital in South Africa with cytotoxic swelling of the limbs from snakebite were assessed using ultrasound. The envenomed limb of each patient was scanned at the point of maximal swelling and compared with the unaffected limb at the same site. Data were presented as an expansion coefficient defined as the ratio of the thickness of tissue structure (subcutaneous tissue or muscle compartment) in the envenomed limb to that in the unaffected limb. A p value of 0.05 was regarded as significant, and 95% CIs were expressed throughout. Results The majority of bites were in the upper limb (27/42). Twenty-five patients were children less than 12 years. Tissue expansion was noted in both the subcutaneous and muscle compartments of the envenomed limbs. The site of swelling was predominantly in the subcutaneous tissues, while swelling in muscle compartment was limited (the mean expansion coefficient for subcutaneous tissues was 2.0 (CI 1.7 to 2.3) vs 1.06 (CI 1.0 to 1.1), respectively). The difference between the groups was significant (p<001). One case, confirmed as compartment syndrome, showed marked swelling in the muscle group. Conclusions Basic ultrasound techniques may be used to identify the site and degree of tissue swelling from cytotoxic envenomation. It is a non-invasive, painless procedure that can assist the clinician to assess the injured limb and may also be of benefit to monitor the progression of swelling.