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

ResumenAntecedentesLa sepsis grave y el shock séptico han surgido recientemente como retos particularmente agudos y letales en los pacientes en estado crítico que se presentan al servicio de urgencias (SU). No hay datos sobre las prácticas actuales para el tratamiento de los pacientes con sepsis grave que comparen la administración inmediata versus tardía de los antibióticos de amplio espectro apropiados como parte del tratamiento precoz dirigido al objetivo, que comienza en las primeras horas de presentación.ObjetivosEvaluar la diferencia de los resultados de la administración inmediata versus tardía de antibióticos en los pacientes con sepsis grave antes del ingreso en la unidad de cuidados intensivos (UCI). Se definió inmediata como la primera hora después de la presentación en el SU.Estrategia de búsquedaSe realizaron búsquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL) (The Cochrane Library número 1, 2009); MEDLINE (1990 hasta febrero 2010); EMBASE (1990 hasta febrero 2010); e ISI web of Science (febrero 2010). También se hicieron búsquedas de ensayos relevantes en curso en sitios web específicos como www.controlled-trials.com; www.clinicalstudyresults.org; y www.update-software.com. Se hicieron búsquedas en las listas de referencias de artículos. No hubo restricciones basadas en el idioma o en el estado de la publicaciónCriterios de selecciónSe planeó incluir ensayos controlados aleatorios de la administración inmediata versus tardía de antibióticos de amplio espectro en pacientes adultos con sepsis grave en el SU, antes del ingreso a la unidad de cuidados intensivos.Obtención y análisis de los datosDos autores, de forma independiente, evaluaron los artículos para la inclusiónResultados principalesNo se encontraron estudios que cumplieran los criterios de inclusión.Conclusiones de los autoresBasado en esta revisión no se pueden hacer recomendaciones sobre el uso inmediato o tardío de los antibióticos 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 administración inmediata (en una hora) versus tardía de antibióticos de amplio espectro en los pacientes adultos con sepsis grave. Como tiene sentido comenzar los antibióticos tan pronto como sea posible en este grupo de pacientes gravemente enfermos, la administración inmediata de tales antibióticos en contraposición a la administración tardía se basa en pruebas anecdóticas subóptimas.Resumen en términos sencillosEvaluar el momento óptimo de administrar los antibióticos a los pacientes con sepsis en el servicio de urgenciasLa sepsis es un trastorno médico grave caracterizado por una respuesta inflamatoria a una infección que puede afectar todo el cuerpo. El paciente puede desarrollar una respuesta infamatoria a los microbios en su sangre, orina, pulmones, piel u otros tejidos. La sepsis es una enfermedad grave con una tasa de mortalidad muy alta si no se trata. La mayoría de los pacientes con sepsis requieren antibióticos y el ingreso en una unidad de cuidados intensivos (UCI). No puede aún precisarse la rapidez con que los antibióticos de amplio espectro deben ser administrados. El tratamiento con antimicrobianos de amplio espectro se define como una combinación de antibióticos que actúan contra una amplia gama de bacterias que causan la enfermedad, suele reducir las tasas de mortalidad en los pacientes con sepsis, sepsis grave o shock séptico. Se realizó una revisión sistemática de la literatura mediante búsquedas en bases de datos fundamentales de materiales de alta calidad, publicados y no publicados, sobre el momento de administrar los antibióticos en el servicio de urgencias antes del ingreso en la UCI. Estas búsquedas no mostraron ensayos controlados aleatorios (ECA) sobre el momento de administrar tratamiento con antibióticos de amplio espectro en esta población. Se llegó a la conclusión de que es necesario realizar estudios observacionales de cohortes, a falta de ECA, aunque carezcan de la precisión de los ECA. También se concluyó que lo mejor es administrar los antibióticos inmediatamente. Es importante comprender que el reloj comienza a andar cuando el paciente llega al SU y se detiene cuando comienza a administrarse el antibiótico. El período antes de ingresar a la unidad de cuidados intensivos es el tiempo que se pasa en la sala o en el SU antes de ingresar a la UCI, donde se ingresa la mayoría de los pacientes con sepsis grave. La revisión tuvo un propósito definido muy específico, porque se centró sólo en los pacientes con sepsis grave y en encontrar sólo ECA. La ausencia de ECA puede implicar, en sí, la naturaleza complicada de la pregunta de estudio, ya que puede ser éticamente equivocado asignar al azar a tales pacientes a un brazo de tratamiento aparentemente inferior

Effectiveness of helmets in preventing severe injuries in a setting with poorly enforced quality standards

Helmets save lives, yet many countries do not have laws about their quality assessment or how they should be worn. We assessed the effectiveness of helmet use in preventing injuries in such a setting. The data were extracted from a large road traffic injury surveillance study in Karachi, Pakistan. We assessed the association of wearing helmets with several injury outcomes including deaths, injury severity (via New Injury Severity Score, NISS ≥ 9) and moderate or severe injury (via Abbreviated Injury Score, AIS ≥ 2) to head, face, or other regions of the body. The data about helmet use was available for about 109,210 riders injured between January 2007 and December 2013. Only 6% of riders wore helmets, whereas this proportion was less than one percent in pillion riders and women. The rates were also lower among those aged 18 years or younger (1%) and those aged 18 to 25 years (4%). About 2% of riders died; 34% had an injury to the head region, 30% to face, 1% to chest, 5% to abdominal, 46% to extremities, and 61% to external body regions. Likelihood of dying was low among helmet users (adjusted odds ratio [aOR] = 0.37, 95% confidence interval [CI] = 0.28 to 0.50). Helmets reduced the likelihood of moderate to severe injuries to the head (aOR = 0.68, 95% CI = 0.58 to 0.80) but not to the face region (aOR = 1.37, 95%CI = 1.17 to 1.62). Helmet users also had severer injuries in other body regions except for chest injuries. Helmets prevented deaths and severe head injuries but had limited effectiveness in preventing facial injuries in this setting with poor helmet use standards. More work is needed to understand the helmet wearing and rider behaviours in helmet users in this setting

Firearm Injuries Presenting to a Tertiary Care Hospital of Karachi, Pakistan

Background: Violence is a public health problem in low and middle income countries. Our study attempted to define the circumstances, risk groups, extent and severity of firearm-related injuries in Patients coming to the Aga Khan University Hospital (AKUH) Karachi, Pakistan. Methods: This was a retrospective study conducted in the department of Emergency Medicine (EM) at AKUH Karachi, Pakistan. Past medical records of all Patients who were injured by firearms and were presented to the AKUH Emergency Department (ED) from June 2002 till May 2007 were reviewed. Data were recorded on the basic demographics of injured, length of hospital stay, body parts injured and the outcome (alive vs. dead). Results: Total of 286 Patients with firearm injuries were identified. Majority of them were males (92%, n=264). More than half of the Patients (63%) were in the age group of 21-40 years. Upon arrival to the hospital 85% (n=243) of Patients had Glasgow Coma Scale (GCS)\u3e= 13. The mean injury severity score (ISS) was found to be 6 (SD 4). The length of hospital stay of Patients ranged from 0 to 54 days with a mean of 7 days. Lower limb were the most affected body parts (30%, n=86) followed by abdomen pelvis (27%, n=77). Seven percent (n=21) of the Patient who were brought to the hospital were labeled as deceased on arrival . Most of the injuries were caused during the act of robbery (40%, n=103) in the city. Conclusions: Robbery was the most common cause of firearm injuries. Lower limb, abdomen and pelvis were the most affected body regions. Educational efforts, and individual, community and societal approaches are needed to alleviate firearm-related injuries

Abdominal pain with rigidity secondary to the anti-emetic drug metoclopramide

We report a case of abdominal pain with rigidity, mimicking an acute abdomen, caused by metoclopramide, a common anti-emetic drug. Extrapyramidal symptoms are commonly reported side-effects of this medication. They generally include involuntary movements of limbs, torticollis, oculogyric crisis, rhythmic protrusion of tongue, trismus, or dystonic reactions resembling tetanus, etc. Abdominal rigidity due to this medication, resembling an acute abdomen, has not been reported previously. This case report illustrates the importance of considering medication side-effects when evaluating a patient with abdominal pain and rigidity

Physical and mental health impacts of COVID-19 on healthcare workers: A scoping review

Background: Coronavirus disease (COVID-19) pandemic has spread to 198 countries, with approximately 2.4 million confirmed cases and 150,000 deaths globally as of April 18. Frontline healthcare workers (HCWs) face a substantially higher risk of infection and death due to excessive COVID-19 exposure. This review aimed at summarizing the evidence of the physical and mental health impacts of COVID-19 pandemic on health-care workers (HCWs).Methods: We used the Arksey O\u27Malley framework to conduct a scoping review. A systematic literature search was conducted using two databases: PubMed and Google Scholar. We found 154 studies, and out of which 10 met our criteria. We collected information on the date of publication, first author\u27s country, the title of the article, study design, study population, intervention and outcome, and key findings, and divided all research articles into two domains: physical and mental health impact.Results: We reviewed a total of 154 articles from PubMed (126) and Google Scholar (28), of which 58 were found to be duplicate articles and were excluded. Of the remaining 96 articles, 82 were excluded after screening for eligibility, and 4 articles did not have available full texts. Ten full-text articles were reviewed and included in this study. Our findings identified the following risk factors for COVID-19-related health impact: working in a high-risk department, diagnosed family member, inadequate hand hygiene, suboptimal hand hygiene before and after contact with patients, improper PPE use, close contact with patients (≥ 12 times/day), long daily contact hours (≥ 15 h), and unprotected exposure. The most common symptoms identified amongst HCWs were fever (85%), cough (70%), and weakness (70%). Prolonged PPE usage led to cutaneous manifestations and skin damage (97%), with the nasal bridge (83%) most commonly affected site. HCWs experienced high levels of depression, anxiety, insomnia, and distress. Female HCWs and nurses were disproportionately affected.Conclusion: The frontline healthcare workers are at risk of physical and mental consequences directly as the result of providing care to patients with COVID-19. Even though there are few intervention studies, early data suggest implementation strategies to reduce the chances of infections, shorter shift lengths, and mechanisms for mental health support could reduce the morbidity and mortality amongst HCWs