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Sepsis represents a continuum of illness due to systemic inflammation caused by an infection that requires prompt recognition and treatment. While sepsis is a significant cause of death worldwide, its mortality is believed to be disproportionately high in low- and middle-income countries (LMICs). Since 1992, its definition has become standardized, and beginning in 2002, an international collaboration has produced a set of consensus guidelines on the optimal management of septic patients. Based on new evidence, significant updates have been made since then. It is known that application of a bundled approach to patient care with the use of specific resuscitation endpoints to guide therapy leads to significant reductions in mortality from sepsis. However, it is also recognized that the implementation of such interventions in LMICs is extremely challenging. Consequently, a body of literature on practical guidelines for sepsis in developing countries has emerged. This article provides a review of the evidence for the best practice of sepsis management, with recommendations for resource-limited settings.

Chronic obstructive pulmonary disease (COPD) is a preventable condition affecting more than 230 million people globally, and is expected to become the world’s third largest cause of mortality by 2030. Despite this fact, it is thought to be widely underdiagnosed and underreported across the African continent. This presents a challenge to emergency medicine (EM) providers in the region, who are faced with treating large numbers of patients presenting with exacerbation of previously undiagnosed COPD. This is complicated by other factors, including lack of public awareness, high prevalence of other chronic respiratory illnesses, and difficulties in access to healthcare. The purpose of this paper is to outline the current state of research and international guidelines surrounding the management of acute exacerbation of COPD in the emergency centre. Strict adherence to international guidelines for management of acute exacerbation of COPD may be difficult for many African providers given factors affecting diagnosis, treatment, and access to care for many Africans suffering from COPD. Research looking into the role of the African EM practitioner in providing more cost-effective means of diagnosis and treatment of COPD is limited.

Introduction: In 2002, the West-African nation of Gabon established an emergency medical system (EMS), Service d’Aide Médicale Urgente (SAMU), in Libreville, yet few people access it. Our objective was to describe Libreville residents’ knowledge and attitudes toward the SAMU in an effort to understand why this service is underutilized. Methods: Qualitative interviews consisting of nine open-ended questions were conducted on a convenience sample of twenty patients, three visitors and two patient/visitor dyads at the Jeanne Ebori Hospital Emergency Centre in October 2009. Eligible subjects arrived in vehicles other than the SAMU and were ill enough to require hospital admission. Exclusion criteria were: under 21 years old, unable to speak French, or medically unstable. A bilingual team member audio-recorded the interviews in French and transcribed them into English. Investigators organized text into codes, then into themes and theoretical constructs. Intercoder agreement was excellent. Data were collected until theoretical saturation was achieved. Results: Analysis of data revealed no difference in response between patients and visitors. People underused SAMU because of financial costs, lack of awareness of the program, use of traditional modes of transportation, infrastructure flaws, perceived response times and other misconceptions. Conclusion: We identified remediable barriers to EMS (SAMU) access in Libreville, Gabon: lack of awareness, misperceptions, established alternatives, and cost. Interventions and future investigations designed to increase EMS utilization in Gabon should target these four areas.

Asthma is a chronic, reversible obstructive disease that when in exacerbation can present to the emergency department in a spectrum of severity. Prompt recognition of the potentially severely ill asthmatic requires a careful history and physical exam while considering alternative diagnoses for the presenting symptoms. Early administration of salbutamol and corticosteroids is indicated in almost all patients with other medications such as ipratropium and magnesium and supportive modalities like BiPAP reserved for sicker patients. The global impact of asthma is increasing, especially amongst children. While the benign clinical presentation is most common and mortality has decreased in recent decades due to improved recognition and care, the ubiquity of the condition and frequent lack of regular outpatient management contribute to the disease claiming 250,000 lives worldwide annually. The emergency physician must be prepared to assess and appropriately manage both the young child with a mild wheeze and the adult in respiratory failure.

The prevalence of cardiovascular disease is growing rapidly in developing countries, leading to an increasing incidence of acute coronary syndrome (ACS). The modalities available for diagnosing and treating this disease continue to evolve, and considerations must be made of local resources when making diagnostic and therapeutic choices. This article provides an evidence-based guide to the management of ACS, with specific recommendations for clinicians working in low and middle-income countries (LAMICs). Diagnosis of ACS, including both non ST-elevation (NSTE) and ST elevation (STE) ACS, focuses on risk stratification, vigilance for subtle or atypical presentations, and consideration of alternative causes of chest pain. The diagnostic process involves assessment of risk factors, knowledge of high yield history and physical exam findings (including variations that may exist in various populations), and utilization of appropriate diagnostic tests. Aspirin should be used as initial treatment in conjunction with an additional anti-platelet drug. Prasugrel is preferred over clopidogrel if the patient is having STE-ACS and planned for percutaneous coronary intervention (PCI). Bivalirudin should be the first choice for anti-coagulation in STE-ACS, followed by enoxaparin (which does not require a drip), and then unfractionated heparin. For the patient with NSTE-ACS and an increased bleeding risk, fondaparinux should be considered in place of enoxaparin. Oxygen should be administered to patients with breathlessness, signs of heart failure, shock, or arterial oxyhemoglobin saturation less than 94%. Beta blockade should be given if there are no signs of instability such as heart rate greater than 100 beats per minute or hypotension. Nitrates or morphine may be given to control symptoms, but do not confer morbidity or mortality advantages and are therefore not critical if a patient is comfortable. PCI should be performed if indicated and available. Fibrinolysis should be administered instead if delay to PCI would be greater than 90 min. Abstract La prévalence des maladies cardiovasculaires connaît une croissance rapide dans les pays en développement, entraînant une incidence croissante du syndrome coronarien aigu (SCA). Les modalités de diagnostic et de traitement de cette maladie continuent d’évoluer, et il convient de tenir compte des ressources locales lors de la réalisation d’un diagnostic et la détermination des options thérapeutiques. Cet article constitue un guide à la prise en charge du SCA fondé sur l’expérience, et fournit des recommandations spécifiques destinées aux médecins hospitaliers travaillant dans les pays à bas et moyen revenu. Le diagnostic du SCA, y compris les SCA sans élévation du ST et avec élévation du ST, se concentre sur la stratification du risque, la vigilance relative aux manifestations subtiles ou atypiques, et la prise en considération d’autres causes des douleurs poitrinaires. Le processus de diagnostic implique l’évaluation des facteurs de risque, la connaissance des antécédents médicaux défavorables et les conclusions de l’examen physique (des variantes étant susceptibles d’exister dans les différentes populations), ainsi que l’utilisation de tests de diagnostic appropriés. Il est recommandé d’utiliser de l’aspirine à titre de traitement initial, parallèlement à un antiagrégant plaquettaire supplémentaire. Le prasugrel est préféré au clopidogrel si le patient présente un SCA avec élévation du ST et qu’une intervention coronaire percutanée (ICP) est prévue. La bivalidurine devrait être le premier choix pour éviter la coagulation dans les SCA avec élévation du ST, suivie de l’enoxaparine (qui ne nécessite pas de perfusion), puis d’héparine non fractionnée. Pour les patients présentant un SCA sans élévation du ST et en cas de risque de saignement accru, le fondaparinux devrait être envisagé à la place de l’énoxaparine. Les patients souffrant de dyspnée, présentant des signes d’insuffisance cardiaque, de choc ou de saturation oxyhémoglobinée artérielle inférieure à 94% doivent se voir administrer de l’oxygène. Des bêtabloquants ne devraient être administrés que dans le cas où aucun signe d’instabilité n’est observé, comme un rythme cardiaque supérieur à 100 pulsations par minute ou de l’hypotension. Des nitrates ou de la morphine peuvent être administrés afin de contrôler les symptômes mais n’apportent aucun bénéfice en termes de morbidité ou de mortalité, et ne sont donc pas essentiels si le patient n’est pas mal à l’aise. Une ICP ne devrait être réalisée que si cela est indiqué et qu’une telle intervention est disponible. Une fibrinolyse devrait être réalisée à la place si le délai pour réaliser une ICP est supérieur à 90 min.

Despite the frequency and severity of burns in Low Income Countries, including many in Africa, there is a paucity of research and funding for these populations to aid in prevention, treatment and recovery of burn patients. The objectives of this paper are four-fold. First, by addressing the pathophysiology of burns the reader may strengthen understanding of the clinical progression of burns. Second, through describing proper assessment of burn patients one will learn how to decide if patients can be discharged, admitted or transferred to burn centre. Third, the inclusion of treatments solidifies the steps necessary to manage a patient in a hospital setting. Lastly, the overall goal of the paper, is to raise awareness that more research, publication and funding is required to create a better understanding of burns in Africa and why they continue to be devastating social and economic burdens.

The first detailed cases of crush syndrome were described in 1941 in London after victims trapped beneath bombed buildings presented with swollen limbs, hypovolemic shock, dark urine, renal failure, and ultimately perished. The majority of the data and studies on this topic still draw from large databases of earthquake victims. However, in Africa, a continent with little seismic activity, the majority of crush syndrome cases are instead victims of severe beatings rather than earthquake casualties, and clinical suspicion by emergency personnel must be high in this patient group presenting with oliguria or pigmenturia. Damaged skeletal muscle fibres and cell membranes lead to an inflammatory cascade resulting in fluid sequestration in the injured extremity, hypotension, hyperkalemia and hypocalcemia and their complications, and renal injury from multiple sources. Elevations in the serum creatinine, creatine kinase (CK), and potassium levels are frequent findings in these patients, and can help guide critical steps in management. Fluid resuscitation should begin prior to extrication of trapped victims or as early as possible, as this basic intervention has been shown to in large part prevent progression of renal injury to requiring haemodialysis. Alkalinization of the urine and use of mannitol for forced diuresis are recommended therapies under specific circumstances and are supported by studies done in animal models, but have not been shown to change clinical outcomes in human crush victims. In the past 70 years the crush syndrome and its management have been studied more thoroughly, however clinical practice guidelines continue to evolve.

Copyright of African Journal of Emergency Medicine is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of African Journal of Emergency Medicine is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of African Journal of Emergency Medicine is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of African Journal of Emergency Medicine is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Abstract: The prevalence of cardiovascular disease is growing rapidly in developing countries, leading to an increasing incidence of acute coronary syndrome (ACS). The modalities available for diagnosing and treating this disease continue to evolve, and considerations must be made of local resources when making diagnostic and therapeutic choices. This article provides an evidence-based guide to the management of ACS, with specific recommendations for clinicians working in low and middle-income countries (LAMICs). Diagnosis of ACS, including both non ST-elevation (NSTE) and ST elevation (STE) ACS, focuses on risk stratification, vigilance for subtle or atypical presentations, and consideration of alternative causes of chest pain. The diagnostic process involves assessment of risk factors, knowledge of high yield history and physical exam findings (including variations that may exist in various populations), and utilization of appropriate diagnostic tests. Aspirin should be used as initial treatment in conjunction with an additional anti-platelet drug. Prasugrel is preferred over clopidogrel if the patient is having STE-ACS and planned for percutaneous coronary intervention (PCI). Bivalirudin should be the first choice for anti-coagulation in STE-ACS, followed by enoxaparin (which does not require a drip), and then unfractionated heparin. For the patient with NSTE-ACS and an increased bleeding risk, fondaparinux should be considered in place of enoxaparin. Oxygen should be administered to patients with breathlessness, signs of heart failure, shock, or arterial oxyhemoglobin saturation less than 94%. Beta blockade should be given if there are no signs of instability such as heart rate greater than 100 beats per minute or hypotension. Nitrates or morphine may be given to control symptoms, but do not confer morbidity or mortality advantages and are therefore not critical if a patient is comfortable. PCI should be performed if indicated and available. Fibrinolysis should be administered instead if delay to PCI would be greater than 90min. Abstract La prévalence des maladies cardiovasculaires connaît une croissance rapide dans les pays en développement, entraînant une incidence croissante du syndrome coronarien aigu (SCA). Les modalités de diagnostic et de traitement de cette maladie continuent d’évoluer, et il convient de tenir compte des ressources locales lors de la réalisation d’un diagnostic et la détermination des options thérapeutiques. Cet article constitue un guide à la prise en charge du SCA fondé sur l’expérience, et fournit des recommandations spécifiques destinées aux médecins hospitaliers travaillant dans les pays à bas et moyen revenu. Le diagnostic du SCA, y compris les SCA sans élévation du ST et avec élévation du ST, se concentre sur la stratification du risque, la vigilance relative aux manifestations subtiles ou atypiques, et la prise en considération d’autres causes des douleurs poitrinaires. Le processus de diagnostic implique l’évaluation des facteurs de risque, la connaissance des antécédents médicaux défavorables et les conclusions de l’examen physique (des variantes étant susceptibles d’exister dans les différentes populations), ainsi que l’utilisation de tests de diagnostic appropriés. Il est recommandé d’utiliser de l’aspirine à titre de traitement initial, parallèlement à un antiagrégant plaquettaire supplémentaire. Le prasugrel est préféré au clopidogrel si le patient présente un SCA avec élévation du ST et qu’une intervention coronaire percutanée (ICP) est prévue. La bivalidurine devrait être le premier choix pour éviter la coagulation dans les SCA avec élévation du ST, suivie de l’enoxaparine (qui ne nécessite pas de perfusion), puis d’héparine non fractionnée. Pour les patients présentant un SCA sans élévation du ST et en cas de risque de saignement accru, le fondaparinux devrait être envisagé à la place de l’énoxaparine. Les patients souffrant de dyspnée, présentant des signes d’insuffisance cardiaque, de choc ou de saturation oxyhémoglobinée artérielle inférieure à 94% doivent se voir administrer de l’oxygène. Des bêtabloquants ne devraient être administrés que dans le cas où aucun signe d’instabilité n’est observé, comme un rythme cardiaque supérieur à 100 pulsations par minute ou de l’hypotension. Des nitrates ou de la morphine peuvent être administrés afin de contrôler les symptômes mais n’apportent aucun bénéfice en termes de morbidité ou de mortalité, et ne sont donc pas essentiels si le patient n’est pas mal à l’aise. Une ICP ne devrait être réalisée que si cela est indiqué et qu’une telle intervention est disponible. Une fibrinolyse devrait être réalisée à la place si le délai pour réaliser une ICP est supérieur à 90min. [Copyright &y& Elsevier]

Copyright of African Journal of Emergency Medicine is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Copyright of African Journal of Emergency Medicine is the property of Elsevier B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)