Rapid Resuscitation with Small Volume Hypertonic Saline Solution for Patients in Traumatic Haemorrhagic Shock

Background: Haemorrhagic shock is a major cause of morbidity and mortality worldwide. Trauma and its complications account for one in ten deaths worldwide and are the leading cause of death in those below 45 years of age in developed countries. Survival of the shocked patient is influenced by the speed and efficiency with which resuscitation is carried out. Rapid infusion of a small volume of 7.5% hypertonic saline (HSS) has been shown to result in immediate restoration of circulating volume and tissue perfusion but results of investigation of its use remain inconclusive. The objective of this study was to determine the clinical outcomes of infusing locally made 7.5% HSS in patients with haemorrhagic shock.Methods: During a six-month period, all adult trauma patients coming to the casualty with haemorrhagic shock were enrolled into the study. A detailed clinical assessment was performed, and respiratory and cardiovascular vital signs were recorded. Five millilitres of venous blood was drawn for determination of Haematocrit, haemoglobin, serum electrolytes and creatinine. A rapid infusion of 250mls of HSS was given intravenously followed three to five minutes later by recording the vital signs again and drawing another 5 mls of blood for a repeat of the laboratory tests. Recovery from shock was followed by standard fluid infusion. Additional or alternative resuscitation and other therapeutic measures were taken as indicated. Recording of the vital signs was continued at four hourly intervals for 24 hours. The data were entered into a computer data base and analysed.Results: Forty five patients were enrolled and resuscitated with 250 mls 7.5% HSS. Among the studied patients, 88.9% recovered from shock immediately after being infused with 7.5% HSS. Of patients with a single injury, 96.6% recovered from shock whereas only 75% of those with multiple injuries recovered. Eighty percent of patients survived beyond 24 hours post resuscitation. While 93.1% of patients with a single injury survived beyond 24 hours, only 56.3% of those who sustained multiple injuries did so.Conclusion: Rapid resuscitation with HSS has demonstrated clinical benefits in initial treatment of traumatic hemorrhagic shock in patients admitted to the emergency room. Further investigation of the effects of HSS resuscitation is warranted

Immediate post operative complications and associated factors as seen at Muhimbili National Hospital operation theatres, Dar es Salaam, Tanzania

Introduction: The subject of postoperative complication and prevention has continued to generate interest in the last decade. Unfortunately, very few data are available locally to assess the extent of problems and measures designed to address them. This study was designed to identify immediate post-operative complications and associated factors in patients admitted at operation theatre recovery rooms of Muhimbili National Hospital, Dar es Salaam, Tanzania.Methods: A prospective study was conducted over a six-month period from July 2007 to January 2008 on patients who underwent various types of surgical operations under regional or general anaesthesia admitted to these recovery rooms. Complications were documented according to predefined criteria and were critically evaluated.Results: Out of total of 265 patients recruited, 87.5% had some form of complication. Pain was the commonest complication occurring in 40.8% patients. 37.0% patients had complications referable to the respiratory system, 30.6% patients each had abnormal cardiovascular parameters and shivering, 26.0% patients had hypothermia, 9.8% patients had nausea and/or vomiting, 6.0% patients presented with restlessness, 5.3% patients presented with abnormalities referable to central nervous system and 1.6%patients presented with other problems. Many patients had more than one complication.Conclusions: This study has shown that despite of recent advances in anaesthetic techniques and the introduction of newer anaesthetic drugs, the incidence of post anaesthetic complications is high in our environment. Therefore a large study is needed to know exact incidence of complications in these patients.Key words: Pain, Post Operative Complications, Cardiovascular, Respiratory, Central Nervous System, Post Operative Nausea and Vomiting,Post Anaesthesia Care Unit, Intensive Care Unit, American Society of Anaesthesiology, Muhimbili National Hospital

Rapid Resuscitation with Small Volume Hypertonic Saline Solution for Patients in Traumatic Haemorrhagic Shock.

Background: Haemorrhagic shock is a major cause of morbidity and mortality worldwide. Trauma and its complications account for one in ten deaths worldwide and are the leading cause of death in those below 45 years of age in developed countries. Survival of the shocked patient is influenced by the speed and efficiency with which resuscitation is carried out. Rapid infusion of a small volume of 7.5% hypertonic saline (HSS) has been shown to result in immediate restoration of circulating volume and tissue perfusion but results of investigation of its use remain inconclusive. The objective of this study was to determine the clinical outcomes of infusing locally made 7.5% HSS in patients with haemorrhagic shock. Methods: During a six-month period, all adult trauma patients coming to the casualty with haemorrhagic shock were enrolled into the study. A detailed clinical assessment was performed, and respiratory and cardiovascular vital signs were recorded. Five millilitres of venous blood was drawn for determination of Haematocrit, haemoglobin, serum electrolytes and creatinine. A rapid infusion of 250mls of HSS was given intravenously followed three to five minutes later by recording the vital signs again and drawing another 5 mls of blood for a repeat of the laboratory tests. Recovery from shock was followed by standard fluid infusion. Additional or alternative resuscitation and other therapeutic measures were taken as indicated. Recording of the vital signs was continued at four hourly intervals for 24 hours. The data were entered into a computer data base and analysed. Results: Forty five patients were enrolled and resuscitated with 250 mls 7.5% HSS. Among the studied patients, 88.9% recovered from shock immediately after being infused with 7.5% HSS. Of patients with a single injury, 96.6% recovered from shock whereas only 75% of those with multiple injuries recovered. Eighty percent of patients survived beyond 24 hours post resuscitation. While 93.1% of patients with a single injury survived beyond 24 hours, only 56.3% of those who sustained multiple injuries did so. Conclusion: Rapid resuscitation with HSS has demonstrated clinical benefits in initial treatment of traumatic hemorrhagic shock in patients admitted to the emergency room. Further investigation of the effects of HSS resuscitation is warranted

Role of Dexamethasome in Prevention of Post-operative Retching and Vomiting Among Children Undergoing Adeno-Tonsillectomy at Muhimbili National Hospital, Dar Es Salaam, Tanzania

Background: Disease in adenoids and tonsils are among the most common problems in paediatrics. Adenotonsillectomy is usually accompanied by significant post operative retching and vomiting. Objective: The aim of the study was to evaluate the role of dexamethasone in prevention of postoperative retching and vomiting (PORV) among paediatric patients undergoing adenotonsillectomy. Methods: This was a single blinded clinical trial study to find out the extent and risk factors of postoperative nausea and vomiting at Muhimbili National Hospital, (MNH.) Results: A total of 94 patients were eligible for the study, the overall proportions of retching and vomiting were 31.91% and 12.77 respectively. More complications of retching and vomiting occurred at the recovery room compared to the ward, which were 30.85% and 8.51% vs. 9.57 and 4.26% respectively. Conclusion: In general patients who received dexamethasone had lower incidence of PORV compared to the controls, however this finding was not statistically significant and did not show to have any effect in the prevention of PORV.Key words: Retching and vomiting, adenotonsillectomy, dexamethasone

Management of patients with non-traumatic hypotension presenting at emergency department Muhimbili national hospital

Hypotension is associated with high morbidity and mortality among emergency department (ED) patients. The diagnostic workup and management may vary greatly based on suspected aetiology and regional burden of disease. Little is known about ED diagnostic evaluation, treatment, and discharge diagnoses of patients with non-traumatic hypotension in sub-Saharan Africa. Objectives: This study aims to characterize the diagnostic test utilization, treatment, and final ED diagnosis for patients presenting to the Muhimbili ED with non-traumatic hypotension. Methodology: A prospective descriptive cohort study was carried out from April to November 2012 at Muhimbili ED. Adult 65 patients with non-traumatic hypotension were enrolled. Data collected included history, physical examination findings, diagnostic testing, and final ED diagnosis. Follow-up data included hospital length of stay, discharge diagnosis, and 24-h and in-hospital mortality. Results: 53 of 65 patients (88%) were referred from other hospitals, and 12 (18%) were self-referred. Mean SBP at arrival was 84 mmHg. 54 (83%) patients had ECGs done, of which 32 (59%) were abnormal. Bedside Ultrasound done in all 65, with 45 (69%) abnormal. 15(23%) received X-rays, abnormal in 11(73%). All patients underwent laboratory work up. Only 20 (38%) of the 53 referred patients received fluids prior to arrival. In the ED 63 patients (97%) received fluids. Mean SBP after intervention was 91 mmHg (median 90 mmHg). The mean hospital stay was 2 days in those who died and 4 days for those who survived to discharge. In 78%, the ED diagnosis matched hospital discharge diagnosis. Overall mortality in this study was 26% (17) patients, with 7 (48%) of these deaths occurring in the first 24 h . Conclusion: The most common diagnostic tests performed in the ED were Ultrasound, ECG, plain X-Rays and bedside bloods. There was a high overall mortality in these patients with almost half within the first 24 h

Paediatric trauma causes, patterns and early intervention at the Muhimbili national hospital emergency department in Dar es Salaam, Tanzania

Trauma remains the leading cause of death and disability in paediatric and adolescent population worldwide, though most of the childhood injury burden rests in low-income and middle-income countries. Many paediatric deaths attributable to trauma are preventable, and morbidity may be greatly reduced by early intervention, but efforts in sub-Saharan Africa are hampered by a lack of regional data to guide interventions. Methods: This was a prospective descriptive cohort study of children under 18 years of age based in the Emergency Department (ED) at Muhimbili National Hospital (MNH) in Dar es Salaam. We used standardized trauma data collection embedded within the clinical chart to assess the mechanism and pattern of injury, and collected follow-up data on interventions performed in the first 24 h after presentation. Results: We enrolled 509 children from August to December 2012, 65.6% male and 34.4% were female. The majority (98.6%) sustained unintentional injuries. 31% of injured children were under the age of 5 years, 28.5% were between 5 and 9 years, and 21.0% were 10–14 years. Motor traffic accident (MTA) was the most common mechanism (40.9%) followed by falls (38.3%) and burns (14.5%). The majority of MTAs (54.3%) were a result of pedestrians struck by vehicles. Fractures and dislocations of upper and lower limbs were the most common injuries (45%) followed by traumatic brain injuries (19%) and burns (14.5%). Only 10% of patients were discharged home from the EMD. Top mechanisms and patterns varied when sub stratified by age quartiles. Conclusion: Childhood injury accounts for a substantial burden of disease at the MNH ED, with MTA being the most common mechanism overall, and with mechanisms and patterns varying by age

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

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