Global research highlights - June 2018

Every quarter, the African Journal of Emergency Medicine, in partnership with several other regional emergency medicine journals, publishes abstracts from each respective journal. Abstracts are not necessarily linked to open access papers, but where green access is available it is linked to.  Click 'Read More' to read further.

An Observational Study to Determine if Routinely Sending Patients Home With a 24-Hour Supply of Topical Tetracaine from the Emergency Department for Simple Corneal Abrasion Pain Is Potentially Safe
From: Waldman N, et al. Ann Emerg Med. 2018 Jun;71(6):767-78. 
doi.org/10.1016/j.annemergmed.2017.02.016
​Study objective
To determine if the number of emergency department (ED) rechecks, persistent fluorescein uptake, ophthalmology referrals, or complications would be affected by the prescription of topical tetracaine for pain relief from simple corneal abrasions (SCAs).
Methods
This retrospective cohort study was conducted in an ED where policy change allowed physicians to use topical tetracaine hydrochloride 1% eye drops for 24 hours for pain treatment for patients with corneal abrasions. Outcomes were compared between patients who did or did not received tetracaine (adjusting for the propensity for treatment).
Results
Of 1,576 initial ED presentations, 532 were SCAs, with 1,044 deemed nonsimple corneal abrasions (NSCAs). Tetracaine was dispensed at the initial visit for 303 SCA presentations (57%) and inappropriately for 141 NSCA presentations (14%). There were no serious complications or uncommon adverse events attributed to tetracaine for all SCAs and NSCAs combined (0/459; upper 95% confidence interval [CI] 0.80%). The relative risks (RRs) of ED recheck and fluorescein staining were increased overall among patients who received tetracaine (RR 1.67, 95% CI 1.25 to 2.23; and RR 1.65, 95% CI 1.07 to 2.53 for recheck and staining, respectively). However, the relative risks for only SCAs receiving tetracaine was 1.16 (95% CI 0.69 to 1.93) and 0.77 (95% CI 0.37 to 1.62), respectively. Referrals to ophthalmology were significantly decreased for all patients (SCAs and NSCAs) dispensed tetracaine (relative risk 0.33; 95% CI 0.19 to 0.59). The number of complications was too small to permit modeling.
Conclusion
There was no evidence that up to 24-hour topical tetracaine for the treatment of pain caused by SCA was unsafe; however, CIs were wide and some increased risks were observed for NSCAs.
Reproduced with permission

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Validation of an uncertainty of illness scale adapted to use with Spanish emergency department patients and their accompanying relatives or friends.
Brito-Brito PR, et al. Emergencias. 2018;30:105-14
Objective
To validate a Spanish adaptation of the Mishel Uncertainty of Illness Scale for use with emergency-department (ED) patients and their accompanying relatives or friends (ESINESU).
Methods
We first developed a version of the questionnaire for Spanish ED situations. Next we assessed the content validity index for each of its items, revised it, and reassessed its face validity to produce a second version, which we then piloted in 20 hospital ED patients. A third revised version was then validated in a population of 320 adults (160 patients and 160 accompanying persons) who attended the ED between November 2015 and September 2016. The 12-item ESINESU (60 points) was administered by 2 nurses while the patients and accompanying persons were in the ED. We gathered sociodemographic and clinical data as well as the subjects’ perception about the information they were given.
Results
The mean (SD) uncertainty score among patients was 29 (11) points. Accompanying persons had a mean score of 36 (13) points. Factorial analysis confirmed the instrument’s construct validity, finding that both dimensions of the original Mishel scale (complexity and ambiguity) were present in 6 items each. Factorial analysis explained 60% of the total variance in the patient version and 67% of the variance in the version for accompanying persons. Reliability statistics were good, with Cronbach’s α values ranging from 0.912 to 0.938. Split-half reliability statistics ranged from 0.901 to 0.933. Correlations were significant in the analysis of convergent validity.
Conclusion
The ESINESU questionnaire may prove to be a simple, valid, and reliable way for assessing uncertainty in patients and their accompanying friends or relatives attending Spanish EDs.
Reproduced with permission

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Inter-rater and intrarater reliability of the South African Triage Scale in low-resource settings of Haiti and Afghanistan
Dalwai M, et al. Emerg Med J. 2018 Jun;35(6):379-383. doi.org/10.1136/emermed-2017-207062
​Objective
The South African Triage Scale (SATS) has demonstrated good validity in the EDs of Médecins Sans Frontières (MSF)-supported sites in Afghanistan and Haiti; however, corresponding reliability in these settings has not yet been reported on. This study set out to assess the inter-rater and intrarater reliability of the SATS in four MSF-supported EDs in Afghanistan and Haiti (two trauma-only EDs and two mixed (including both medical and trauma cases) EDs).
Methods
Under classroom conditions between December 2013 and February 2014, ED nurses at each site assigned triage ratings to a set of context-specific vignettes (written case reports of ED patients). Inter-rater reliability was assessed by comparing triage ratings among nurses; intrarater reliability was assessed by asking the nurses to retriage 10 random vignettes from the original set and comparing these duplicate ratings. Inter-rater reliability was calculated using the unweighted kappa, linearly weighted kappa and quadratically weighted kappa (QWK) statistics, and the intraclass correlation coefficient (ICC). Intrarater reliability was calculated according to the percentage of exact agreement and the percentage of agreement allowing for one level of discrepancy in triage ratings. The correlation between years of nursing experience and reliability of the SATS was assessed based on comparison of ICCs and the respective 95% CIs.
Results
A total of 67 nurses agreed to participate in the study: In Afghanistan there were 19 nurses from Kunduz Trauma Centre and nine from Ahmed Shah Baba; in Haiti, there were 20 nurses from Martissant Emergency Centre and 19 from Tabarre Surgical and Trauma Centre. Inter-rater agreement was moderate across all sites (ICC range: 0.50–0.60; QWK range: 0.50–0.59) apart from the trauma ED in Haiti where it was moderate to substantial (ICC: 0.58; QWK: 0.61). Intrarater agreement was similar across the four sites (68%–74% exact agreement); when allowing for a one-level discrepancy in triage ratings, intrarater reliability was near perfect across all sites (96%–99%). No significant correlation was found between years of nursing experience and reliability.
Conclusion
The SATS has moderate reliability in different EDs in Afghanistan and Haiti. These findings, together with concurrent findings showing that the SATS has good validity in the same settings, provide evidence to suggest that SATS is suitable in trauma-only and mixed EDs in low-resource settings.
Reproduced with permission

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Bamboo snake (Trimeresurus albolabris) bite in Hong Kong and its
prognostic factors for local complications with surgical intervention,
coagulopathy and thrombocytopenia
Suen PY. Hong Kong J Emerg Med. 2017;24:79-84. ​doi.org/10.1177/102490791702400205
​Introduction
Bamboo snake bite accounts for the majority of venomous snake bites in Hong Kong. The objectives of this study were to evaluate the clinical features and outcomes of Bamboo snake bite in Hong Kong and to identify its prognostic factors for local complications requiring surgical intervention, coagulopathy and thrombocytopenia.
Methods
It was a retrospective cohort study conducted in a regional hospital of Hong Kong from 1st January 2001 to 31st December 2015.
Results
Sixty-three subjects were in the final analyses. The mean age was 60 years old. The incidences of swelling, local bruises, blistering, regional lymphadenopathy and local necrosis were 90.5%, 33.3%, 6.3%, 1.6% and 3.2% respectively. The incidences of local complications with surgical intervention, coagulopathy and thrombocytopenia were 6.3%, 13% and 13% respectively. Univariate analysis showed only local necrosis (p=0.003) was significantly associated with local complications with surgical intervention; and only cardiovascular disturbance due to snakebite envenomation (p=0.002) was significantly associated with coagulopathy; and no significantly associated factor was found for thrombocytopenia. There were no case with systemic bleeding and death after Bamboo snake bite. There was no case with allergic reaction after the use of antivenom.
Conclusions
Local necrosis is significantly associated with surgical intervention. Cardiovascular disturbance is significantly associated with coagulopathy. Allergic reaction after the use of antivenom is rare in Hong Kong.
Reproduced with permission

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