Ultrasound for identification of pleural fluid in pneumonia

It can be difficult to definitively differentiate between pleural effusion and empyema versus infiltrate alone on plain chest radiographs of patients. However, this is a clinically important distinction that drives optimal therapy, as large fluid collections are unlikely to resolve with antibiotic therapy alone and usually require drainage. Case report: A four-year-old male arrived for evaluation of 5  days of fever and cough. The cough was non-productive and associated with postural difficulty in breathing, which improved when leaning on his right side. Vital signs revealed tachycardia, tachypnoea, afebrile, and SpO2 100% at room air. Physical examination revealed an alert patient in moderate to severe respiratory distress, nasal flaring, and purulent rhinorrhoea bilaterally. Lung examination revealed a dull percussion note over the right lung field and significantly decreased air entry. A chest radiograph revealed a large area of opacity involving the right chest. The working diagnosis was right-sided pneumonia with empyema. The differential diagnosis included tuberculosis with pleural effusion. A focused bedside ultrasound revealed dense lung consolidation without significant associated fluid collection. Given this additional diagnostic information, the management planned was altered and the intercostal drain placement aborted. Discussion: Sonographic evaluation of the lungs is well described in medical literature and has been used in patients to assess for pneumothorax, pleural effusion, pulmonary oedema, and lung consolidation. Even in settings where advanced imaging options are available, emergency sonography has several features that make it an attractive option for the acute care provider. In the resource-limited setting, the utility of emergency sonography is enhanced, especially when other imaging modalities are unavailable or cost prohibitive. Focused point-of-care sonography is a useful adjunct to clinical examination that may augment clinical decision-making and safely avoid unnecessary invasive procedures

Medical evaluation abnormalities in acute psychotic patients seen at the emergency department of Muhimbili national hospital in Dar es Salaam, Tanzania

Prior studies have shown varied rates of medical pathology in patients presenting to acute care settings with psychotic symptoms, and there is almost no literature from the sub-Saharan Africa region. We investigated the yield of physical examination and laboratory testing among patients presenting with acute psychosis to an urban ED in Dar es Salaam. Methods: This was a prospective observational study of patients presenting to the ED at Muhimbili National Hospital with acute psychosis. A standardized data form was used to prospectively collect demographics, history, physical examination, and diagnostic test results. Data were entered into Excel (Microsoft Corporation, Redmond, WA, USA) and analysed with SAS (SAS Institute Inc., Cary, NC, USA). Results: We enrolled 252 participants from August to October 2012, mean age 32 (±11) years, and 69% male. Overall, 161 (64%) had a history of psychiatric illness and 137 (54%) were on psychiatric medication. Comorbidities included dementia (6), HIV (5), recent trauma (5), diabetes (2), CVA (1), and other chronic medical conditions (21). The most common physical examination findings were skin abnormalities (11% of patients), including infections, bruises, cuts, lacerations and rashes. Of patients undergoing laboratory investigations, 39/206 (19%) had abnormal lab findings and 27/39 (69%) were clinically significant, including positive HIV tests (9), abnormal blood chemistries (7), positive malaria tests (5), abnormal full blood picture (4), and abnormal blood glucose levels (3). Conclusions: In our cohort, history and physical examination findings were not sufficient to rule out serious medical conditions among patients presenting with acute psychosis. The observed rate of laboratory abnormalities was higher than previously published rates from high-resource settings. Based on our findings, patients presenting with psychosis to an acute care facility in this region should be evaluated with physical examination and laboratory studies to rule out serious underlying medical pathology

Descriptive analysis and lessons learned from the disaster medical response to an urban building collapse

An effective disaster medical response plan is imperative for any established emergency medicine program. Here we describe the response to an urban building collapse in Dar es Salaam, Tanzania, including a description of the event, type and severity of casualties, and lessons learned. Methods: We interviewed members of the medical response team and reviewed the treatment records and the results of the investigation. Results: Several local hospitals sent personnel to assist at the site. The Muhimbili National Hospital Emergency Department (ED) sent staff to establish triage and provide stabilizing medical care, while another team remained in the ED and prepared to treat survivors. Of fifty nine casualties, 37 were dead at the scene. The most common injuries among the survivors were musculoskeletal and soft tissue trauma, including fractures, lacerations, and degloving injuries. All were stabilized on-site prior to transport to the hospital. The search and rescue efforts were hampered by a lack of resources. Heavy machinery, sufficient to clear the rubble and facilitate rescue efforts, was not immediately available. Private engineering companies later provided this equipment. Protective gear, such as hard hats, gloves, and boots were not available, thus some responders were injured while clearing the rubble and three were bitten by police dogs. Family members gathered at the scene to await news of survivors and some developed respiratory distress due to the dusty environment while others syncopized. The investigation revealed that the building was licensed for 10 floors, but construction continued illegally to 16 floors. Structural factors contributing to the collapse included poorly mixed concrete and substandard steel bars. Conclusions: This event highlights the importance of a well-developed disaster response plan, including coordination of medical and rescue workers. Additional policy and advocacy issues identified include the need for building safety code enforcement and available rescue supplies, equipment, and machinery

The systemic inflammatory response syndrome as a predictor of mortality among febrile children in the emergency department

Sepsis is defined as a known or suspected infection in a patient with elements of the systemic inflammatory response syndrome (SIRS). Septic patients present with a variety of clinical manifestations, but temperature dysregulation, tachycardia, tachypnoea, and an abnormal white blood cell (WBC) count are considered cardinal components of SIRS. We investigated the predictive value of SIRS criteria for in-hospital mortality among febrile children under 5 years old presenting to the Emergency Department (ED) at Muhimbili National Hospital in Dar es Salam, Tanzania. Methods: This was a descriptive cohort study of febrile children under 5 years, presenting to our ED. Providers prospectively completed a standardized data sheet. Outcome data was obtained from hospital records and telephone follow-up. Study data were entered into Excel (Microsoft, Redmond, WA, USA) and analysed in SAS 9.3 (Cary, North Carolina, USA). Results: We enrolled 105 patients between August and November 2012. The median age was 14 months, with 80% over 6 months old, and 63.8% were male. 57 (54.3%) children were referred from outside facilities. The overall mortality rate was 19%, and 90% of children who died had  ⩾ 2 SIRS criteria. Mortality in children with ⩾2 SIRS criteria (in addition to fever) was significantly higher (27.7% versus 5%) than in those with 0–1 SIRS criteria, and children with fever and  > 2 SIRS criteria were seven times more likely to die (OR 7.05, p = 0.01). 85 children were discharged from the hospital, and of the 64 (75.3%) children we were able to reach after discharge, all were alive at 14 day telephone follow-up. 19/85 children who survived to hospital discharge were lost to follow up. Conclusion: SIRS criteria may be helpful to predict febrile children at high risk of mortality. Further studies are needed to validate these findings in larger cohorts

Clinical presentation, diagnostic evaluation, treatment and diagnoses of febrile children presenting to the emergency department at Muhimbili national hospital in Dar es Salaam, Tanzania

While there are many guidelines for the ED evaluation of febrile children, these are largely derived and validated in high-resource settings. There is limited literature documenting recommended or actual management in resource-limited settings. We describe the presentation, diagnostic evaluation, treatment, and ED diagnoses of febrile children under 5 years old presenting to an urban emergency department in Dar es Salaam. Methods: This was a prospective observational study of children under 5 with fever or reported fever at Muhimbili National Hospital (MNH) ED. Treating physicians prospectively completed a standardized data form. Results: We enrolled 105 children, median age 14 months, with 80% >6 months, and 64% male. Presenting symptoms included poor feeding (47.6%) vomiting (42.9%), cough (34.3), difficulty breathing (28.6%), and diarrhoea (22.9%). 78% had vital sign abnormalities and 82% had abnormal physical examination. Among those undergoing point-of care testing, 11/105 tested (10.5%) had hypoglycaemia, 9/103 (8.7 %) were malaria positive, 17/30 (56.7%) had positive urine dipstick testing, and 5/26 tested (19.2%) were HIV positive. Laboratory-based tests included CBC and chemistry (each performed in 95.2%), VBG (56.2%), CSF (5.7%), blood culture (5.7%), urine culture (10.5%), CSF culture (1.9%), and CXR of chest (25.7%) and abdomen (3.8%). Interventions included antibiotics (70%), antimalarial (12%), IV fluids (54%), and antipyretics (41%). Top ED diagnoses included malaria (24.3%), pneumonia (15.2%), septicaemia (9.5%), urinary tract infections (7.6%), acute watery diarrhoea with dehydration (6.7%), meningitis (4.8%), anaemia (4.8%), skin and soft tissue infections (4.8%), bowel obstructions (3.8%), and pulmonary tuberculosis, sickle cell disease, and hepatitis (2.9% each). Laboratory-based tests were often abnormal; culture results were often unavailable; Conclusion: A wide range of presentations and management were documented. There was a high rate of positive diagnostic test results. Malaria and pneumonia were top diagnoses, but a wide range of infections were diagnosed