Junaid Abdul Razzak

Early versus late pre-intensive care unit admission broad spectrum antibiotics for severe sepsis in adults.

BACKGROUNDnSevere sepsis and septic shock have recently emerged as particularly acute and lethal challenges amongst critically ill patients presenting to the emergency department (ED). There are no existing data on the current practices of management of patients with severe sepsis comparing early versus late administration of appropriate broad spectrum antibiotics as part of the early goal-directed therapy that is commenced in the first few hours of presentation.nnnOBJECTIVESnTo assess the difference in outcomes with early compared to late administration of antibiotics in patients with severe sepsis in the pre-intensive care unit (ICU) admission period. We defined early as within one hour of presentation to the ED.nnnSEARCH STRATEGYnWe searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 1, 2009); MEDLINE (1990 to February 2010); EMBASE (1990 to February 2010); and ISI web of Science (February 2010). We also searched for relevant ongoing trials in specific websites such as www.controlled-trials.com; www.clinicalstudyresults.org; and www.update-software.com. We searched the reference lists of articles. There were no constraints based on language or publication status.nnnSELECTION CRITERIAnWe planned to include randomized controlled trials of early versus late broad spectrum antibiotics in adult patients with severe sepsis in the ED, prior to admission to the intensive care unit.nnnDATA COLLECTION AND ANALYSISnTwo authors independently assessed articles for inclusion.nnnMAIN RESULTSnWe found no studies that satisfied the inclusion criteria.nnnAUTHORS CONCLUSIONSnBased on this review we are unable to make a recommendation on the early or late use of broad spectrum antibiotics in adult patients with severe sepsis in the ED pre-ICU admission. There is a need to do large prospective double blinded randomized controlled trials on the efficacy of early (within one hour) versus late broad spectrum antibiotics in adult severe sepsis patients. Since it makes sense to start antibiotics as soon as possible in this group of seriously ill patients, administering such antibiotics earlier as opposed to later is based on anecdotal suboptimal evidence.

Initial results of Pakistan's first road traffic injury surveillance project

Our aim is to report the findings of the initial three years of road traffic injuries (RTI) surveillance at Karachi and to compare it with previously published RTI-related data from Pakistan and other low-and middle-income countries. Data were collected through the RTI surveillance programme at Karachi (RTIRP) from the five biggest emergency departments of the city, which receive almost all the major emergencies of the city for the period September 2006 till September 2009. A total of 99,272 victims were enlisted by the RTIRP during the study period. Annual incidence of RTI is calculated to be 184.3 per 100,000 populations and mortality is 5.7 per 100,000 populations. Eighty nine per cent of victims are male and 73% are between 15 and 44 years of age. Commonest road user to be affected is riders of two wheelers (45%). Only 7% of affected motorcyclists were found to be wearing helmets at the time of the accident. Trends of injuries remained uniform over the years. Most frequent injuries were external wounds, followed by orthopaedic injuries. On the basis of our surveillance system, we have presented the largest RTI-related data from a metropolitan city of Pakistan to date.

Alcohol and marijuana use while driving-an unexpected crash risk in Pakistani commercial drivers: a cross-sectional survey

BackgroundA significant proportion of road traffic crashes are attributable to alcohol and marijuana use while driving globally. Sale and use of both substances is illegal in Pakistan and is not considered a threat for road traffic injuries. However literature hints that this may not be the case. We did this study to assess usage of alcohol and marijuana in Pakistani commercial drivers.MethodsA sample of 857 commercial bus and truck drivers was interviewed in October 2008 at the largest commercial vehicle station in Rawalpindi and Islamabad, Pakistan. Time location cluster sampling was used to select the subjects and a structured questionnaire was used to assess the basic demographic profile, substance abuse habits of the drivers while on the road, and reasons for usage of illicit substances while driving were recorded. Self reported information was collected after obtaining informed consent. Chi square and fisher exact tests were used to assess differences between groups and logistic regression was used to identify significant associations between driver characteristics and alcohol and marijuana use.ResultsAlmost 10% of truck drivers use alcohol while driving on Pakistani roads. Marijuana use is almost 30% in some groups. Statistically different patterns of usage are seen between population subgroups based on age, ethnicity, education, and marital status. Regression analysis shows association of alcohol and marijuana use with road rage and error behaviours, and also with an increased risk of being involved in road crashes. The reported reasons for using alcohol or marijuana show a general lack of awareness of the hazardous nature of this practice among the commercial driver population.ConclusionAlcohol and marijuana use is highly prevalent in Pakistani commercial drivers. The issue needs to be recognized by concerned authorities and methods such as random breath tests and sobriety check points need to be employed for proper law enforcement.

Cardiopulmonary resuscitation: outcome and its predictors among hospitalized adult patients in Pakistan

IntroductionOur aim was to study the outcomes and predictors of in-hospital cardiopulmonary resuscitation (CPR) among adult patients at a tertiary care centre in Pakistan.MethodsWe conducted a retrospective chart review of all adult patients (age ≥14 years), who underwent CPR following cardiac arrest, in a tertiary care hospital during a 5-year study period (June 1998 to June 2003). We excluded patients aged 14xa0years or less, those who were declared dead on arrival and patients with a “do not resuscitate” order. The 1- and 6-month follow-ups of discharged patients were also recorded.ResultsWe found 383 cases of adult in-hospital cardiac arrest that underwent CPR. Pulseless electrical activity was the most common initial rhythm (50%), followed by asystole (30%) and ventricular tachycardia/fibrillation (19%). Return of spontaneous circulation was achieved in 72% of patients with 42% surviving more than 24xa0h, and 19% survived to discharge from hospital. On follow-up, 14% and 12% were found to be alive at 1 and 6xa0months, respectively. Multivariable logistic regression identified three independent predictors of better outcome (survival >24 h): non-intubated status [adjusted odds ratio (aOR):3.1, 95% confidence interval (CI):1.6–6.0], location of cardiac arrest in emergency department (aOR: 18.9, 95% CI:7.0–51.0) and shorter duration of CPR (aOR:3.3, 95% CI:1.9–5.5).ConclusionOutcome of CPR following in-hospital cardiac arrest in our setting is better than described in other series. Non-intubated status before arrest, cardiac arrest in the emergency department and shorter duration of CPR were independent predictors of good outcome.

Epidemiology of major incidents: an EMS study from Pakistan.

BackgroundA major incident is defined as an event that owing to the number of casualties has the potential to overwhelm the available resources. This paper attempts to describe the incidence and epidemiology of major incidents dealt with by a government-run emergency medical service (EMS) in the Punjab province of Pakistan, a developing country in South Asia. A major incident in this EMS is defined as any incident that produces three or more patients, or any incident in which extraordinary resources are needed.MethodsAll the calls received by an EMS Rescue 1122 were studied over a 6-month period. Calls that were defined as major incidents were identified, and further details were sought from the districts regarding these incidents. Questions specifically asked were the type of incident, time of the incident, response time for the incident, the resources needed, and the number of dead and injured casualties. Retrospective data were collected from the submitted written reports.ResultsRoad traffic crashes (RTCs) emerged as the leading cause of a major incident in the province of Punjab and also led to the greatest number of casualties, followed by fire incidents. The total number of casualties was 3,380, out of which 73.7% were RTC victims. There was a high rate of death on the scene (10.4%). Certain other causes of major incidents also emerged, including violence, gas explosions and drowning.ConclusionRoad traffic crashes are the most common cause of a major incident in developing countries such as Pakistan. Injury prevention initiatives need to focus on RTCs.

Splenic Injury After Blunt Abdominal Trauma: An Unusual Presentation

BACKGROUNDnThe spleen is the most commonly injured viscus in blunt abdominal trauma. Abdominal pain with left upper quadrant tenderness or signs of peritonitis in a patient with history of trauma is the most common presentation of this condition.nnnOBJECTIVEnTo describe an unusual presentation of splenic rupture in a patient with history of motor vehicle crash and blunt abdominal trauma.nnnCASE REPORTnA young man was brought to the Emergency Department with a history of being in a motor vehicle crash 10 h earlier. He experienced gradually worsening difficulty breathing while sitting or lying down for the previous 4 h, although he was asymptomatic in the upright position. He was transported to the hospital standing upright, supported by two men, on the open back of a vehicle normally used to transport cattle. The patient was found to have left upper quadrant abdominal tenderness on examination and free fluid in the pelvis on the focused abdominal sonography for trauma examination done while the patient was standing. A grade III splenic injury with hemoperitoneum was diagnosed on computed tomography scan and the patient was treated with splenectomy.nnnCONCLUSIONnWe report an unusual presentation of a splenic injury in a young man who had symptoms only in the supine position.

Commercial vehicles and road safety in Pakistan: exploring high-risk attributes among drivers and vehicles

Road traffic injuries are on the rise in developing countries with a disproportionately high number of crashes involving commercial vehicles. Baseline information on risk factors is necessary to develop targeted prevention programmes. A survey of commercial drivers was conducted at the largest bus and truck station in Rawalpindi, Pakistan. Structured interviews elicited information from 857 drivers on their socio-demographics, high-risk driving behaviours, fatigue, use of drugs while driving, vehicle maintenance and health conditions, as well as crash involvement. A binary logistic regression analysis was used to investigate the factors associated with crash involvement in the last five years. Overall, 92 (11.2%) drivers reported having had a road crash in the last 5 years. Factors independently associated with the occurrence of crashes were alcohol use (OR 2.2, 95% CI 1.1–4.4), poor vehicle maintenance (OR 3.4, 95% CI 1.7–7.01) and lack of seat belt use (OR 2.7, 95% CI 1.3–5.6). The high prevalence of high-risk attributes in the study population indicates a great need for targeted risk prevention.

Injuries due to fall make summer time power outages a potential public health issue

Falls are a significant cause of morbidity and mortality, especially in children and in under-developed countries. Unexpected power outages in Karachi have become a frequent problem. This study was carried out at Jinnah Postgraduate Medical Centre, Karachi, to explore an association between increasing power outages and frequency of falls. Data for all injuries were collected prospectively, and the year 2006 was chosen for analysis at it had worst power outages. Injuries were classified as those occurring in summer (April to July) or winter (December to March) and were compared between the two seasons. Total injuries in study duration was 2599, mean age was 21 ± 18 years (male:female 3.2:1) and 43% of victims were children. Injuries in two seasons were comparable (summer 1266, winter 1333) but injuries due to fall were more in summer (574 versus 470, OR= 1.5; 95% CI = 1.3, 1.8), especially in children (P = 0.001). Frequency of falls were much more in 2006 as compared with either 2005 (OR = 1.59; 95% CI = 1.37, 1.83) or 2004 (OR = 1.22; 95% CI = 1.05, 1.42). Karachis hot and humid climate and frequent power outages encourages families to spend time on rooftops or balconies, or to leave the windows open. Understandably, we found a higher frequency of falls, especially of children in all summer months, observations shown by others as well. However, to the best of our knowledge, this is the first study which points toward a possible association between increasing power outages and falls, especially involving children, implying power outages as a potential health hazard. On a similar note but in an area with cold climate, investigators have previously found an association between power outages and heater related injuries. Larger, more in depth, prospective studies are recommended to validate our findings. Language: en

The relationship between four-wheel drives and risky driving behaviours

BACKGROUND: Given the increased number of four wheel drive (4WD) vehicles in Qatar and their involvement in crashes, casualties and road fatalities, it is important to understand the association between risky driving behavior and 4WD crashes. Aim/Objective: This study aimed to determine the association between risky driving behaviours and 4WD vehicles and its impact on road traffic accidents in the State of Qatar. MATERIALS AND METHODS: A cross sectional survey was conducted using a multistage stratified cluster sampling technique to recruit 1824 drivers of two wheel drive (small cars) and 4WD across different primary health centres (PHCs) in Qatar. The Driver Behaviour Questionnaire (DBQ) and Driver Skill Inventory (DSI) were used to collect the data. Information regarding socio-demographic and road traffic crashes during last three years was also obtained. Multivariate logistic regression was used to analyse the data. RESULTS: 762 (41.8%) owned 4WD vehicles. Drivers of 4WD were significantly higher between 30-50 years age (P CONCLUSION: The drivers of 4WD cars are at higher risk of crashes as compared to the drivers of small cars. Also, they have significantly more traffic violations, lapses, and errors. Future interventions and control measures should target the drivers of 4WD for better results. Language: en

Administración inmediata versus tardía de antibióticos de amplio espectro antes del ingreso a la unidad de cuidados intensivos para la sepsis severa en adultos

Resumen Antecedentes La sepsis grave y el shock septico han surgido recientemente como retos particularmente agudos y letales en los pacientes en estado critico que se presentan al servicio de urgencias (SU). No hay datos sobre las practicas actuales para el tratamiento de los pacientes con sepsis grave que comparen la administracion inmediata versus tardia de los antibioticos de amplio espectro apropiados como parte del tratamiento precoz dirigido al objetivo, que comienza en las primeras horas de presentacion. Objetivos Evaluar la diferencia de los resultados de la administracion inmediata versus tardia de antibioticos en los pacientes con sepsis grave antes del ingreso en la unidad de cuidados intensivos (UCI). Se definio inmediata como la primera hora despues de la presentacion en el SU. Estrategia de busqueda Se realizaron busquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL) (The Cochrane Library numero 1, 2009); MEDLINE (1990 hasta febrero 2010); EMBASE (1990 hasta febrero 2010); e ISI web of Science (febrero 2010). Tambien se hicieron busquedas de ensayos relevantes en curso en sitios web especificos como www.controlled-trials.com ; www.clinicalstudyresults.org ; y www.update-software.com . Se hicieron busquedas en las listas de referencias de articulos. No hubo restricciones basadas en el idioma o en el estado de la publicacion Criterios de seleccion Se planeo incluir ensayos controlados aleatorios de la administracion inmediata versus tardia de antibioticos de amplio espectro en pacientes adultos con sepsis grave en el SU, antes del ingreso a la unidad de cuidados intensivos. Obtencion y analisis de los datos Dos autores, de forma independiente, evaluaron los articulos para la inclusion Resultados principales No se encontraron estudios que cumplieran los criterios de inclusion. Conclusiones de los autores Basado en esta revision no se pueden hacer recomendaciones sobre el uso inmediato o tardio de los antibioticos de amplio espectro en los pacientes adultos con sepsis grave en el SU antes del ingreso en la UCI. Es necesario realizar ensayos controlados aleatorios doble ciegos prospectivos amplios sobre la eficacia de la administracion inmediata (en una hora) versus tardia de antibioticos de amplio espectro en los pacientes adultos con sepsis grave. Como tiene sentido comenzar los antibioticos tan pronto como sea posible en este grupo de pacientes gravemente enfermos, la administracion inmediata de tales antibioticos en contraposicion a la administracion tardia se basa en pruebas anecdoticas suboptimas.