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Background Globally, millions of people die and many more develop disabilities resulting from injuries each year. Most people who die from injuries do so before they are transported to hospital. Thus, reliable, pragmatic, and evidence-based prehospital guidance for various injuries is essential. We systematically mapped and described prehospital clinical practice guidelines (CPGs) for injuries in the global context, as well as prioritised injury topics for guidance development and adolopment. Methods This study was sequentially conducted in three phases: a scoping review for CPGs (Phase I), identification and refinement of gaps in CPGs (Phase II), and ranking and prioritisation of gaps in CPGs (Phase III). For Phase I, we searched PubMed, SCOPUS, and Trip Database; guideline repositories and websites up to 23rd May 2021. Two authors in duplicate independently screened titles and abstract, and full-text as well as extracted data of eligible CPGs. Guidelines had to meet 60% minimum methodological quality according to rigour of development domain in AGREE II. The second and third phases involved 17 participants from 9 African countries and 1 from Europe who participated in a virtual stakeholder engagement workshop held on 5 April 2022, and followed by an online ranking process. Results Fifty-eight CPGs were included out of 3,427 guidance documents obtained and screened. 39/58 (67%) were developed de novo compared to 19 that were developed using alternative approaches. Twenty-five out of 58 guidelines (43%) were developed by bodies in countries within the WHO European Region, while only one guideline was targeted to the African context. Twenty-five (43%) CPGs targeted emergency medical service providers, while 13 (22%) targeted first aid providers (laypeople). Forty-three CPGs (74%) targeted people of all ages. The 58 guidance documents contained 32 injury topics. Injuries linked to road traffic accidents such as traumatic brain injuries and chest injuries were among the top prioritised topics for future guideline development by the workshop participants. Conclusion This study highlights the availability, gaps and priority injury topics for future guideline development/adolopment, especially for the African context. Further research is needed to evaluate the recommendations in the 58 included CPGs for possible adaptation to the African context.

Introduction Prehospital care is integral in addressing sub-Saharan Africa's (SSA) high injury and illness burden. Consequently, robust, high-quality prehospital guidance documents are needed to inform care. These guidance documents include, but are not limited to, clinical practice guidelines (CPGs), protocols and algorithms that are contextually appropriate for SSA. However, SSA prehospital guidance mostly originates from the ‘Global North,’ with limited guidance for Africa by Africans. To strengthen prehospital clinical practice in SSA, we described and appraised all prehospital SSA guidance documents informing clinical decision making. Methods We conducted a scoping review of prehospital-relevant guidance documents, including CPGs, algorithms, protocols and position statements originating from SSA. We performed a comprehensive literature search in various databases (PUBMED and SCOPUS), guideline clearing houses (Scottish Intercollegiate Guidelines Network, Trip, and Guidelines International Network), journals, various forms of grey literature and contacted experts. Guidance document screening and data extraction was done independently, in duplicate and reviewed by a third author. Guidance quality was then determined using the AGREE II tool and data were analysed using simple descriptive statistics. Results We included 51 guidance documents from 13 countries across SSA after screening 2320 potential documents. The majority of guidance documents lacked an evidence foundation, made recommendations based on expert input, and were predominantly end-user presentations such as algorithms or protocols. Overall, reporting quality was poor, specifically for critical domains such as rigour of development; however, clarity of presentation was generally strong. Guidance topics were focused around resuscitation and common diseases (both communicable and non-communicable) with major gaps identified across a variety of topics; such as mental health for example. Conclusion The majority of prehospital clinical guidance from SSA provides clinicians with excellent ready to use end-user material. Conversely, most of the guidance documents lack an appropriate evidence foundation and fail to transparently report the guidance development process, highlighting the need to strengthen and build guideline development capacity to promote the transition from eminence-based to evidence-based guidance for prehospital care in SSA. Guideline developers, professional societies and publishers need to be aware of international and local guidance document development and reporting standards in order to produce guidance we can trust.

Introduction Trauma scoring systems are widely used in emergency settings to guide clinical decisions and to predict mortality. It remains unclear which system is most suitable to use for patients with gunshot injuries at district-level hospitals. This study compares the Triage Early Warning Score (TEWS), Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Kampala Trauma Score (KTS) and Revised Trauma Score (RTS) as predictors of mortality among patients with gunshot injuries at a district-level urban public hospital in Cape Town, South Africa. Methods Gunshot-related patients admitted to the resuscitation area of Khayelitsha Hospital between 1 January 2016 and 31 December 2017 were retrospectively analysed. Receiver Operating Characteristic (ROC) analysis were used to determine the accuracy of each score to predict all-cause in-hospital mortality. The odds ratio (with 95% confidence intervals) was used as a measure of association. Results In total, 331 patients were included in analysing the different scores (abstracted from database n = 431, excluded: missing files n = 16, non gunshot injury n = 10, African relevance • Gunshot injuries most often occurs in young males. • Trauma scores can be used to prognosticate patients in order to allocate appropriate resources. • Accuracy-related data of trauma scores in entry-level hospitals is limited.

Introduction: An adaptive guideline development method, as opposed to a de novo guideline development, is dependent on access to existing high-quality up-to-date clinical practice guidelines (CPGs). We described the characteristics and quality of CPGs relevant to prehospital care worldwide, in order to strengthen guideline development in low-resource settings for emergency care. Methods: We conducted a descriptive study of a database of international CPGs relevant to emergency care produced by the African Federation for Emergency Medicine (AFEM) CPG project in 2016. Guideline quality was assessed with the AGREE II tool, independently and in duplicate. End-user documents such as protocols, care pathways, and algorithms were excluded. Data were imported, managed, and analysed in STATA 14 and R. Results: In total, 276 guidelines were included. Less than 2% of CPGs originated from low- and middle income-countries (LMICs); only 15% (n = 38) of guidelines were prehospital specific, and there were no CPGs directly applicable to prehospital care in LMICs. Most guidelines used de novo methods (58%, n = 150) and were produced by professional societies or associations (63%, n = 164), with the minority developed by international bodies (3%, n = 7). National bodies, such as the National Institute for Health and Care Excellence (NICE) and the Scottish Intercollegiate Guidelines Network (SIGN), produced higher quality guidelines when compared to international guidelines, professional societies, and clinician/academic-produced guidelines. Guideline quality varied across topics, subpopulations and producers. Resource-constrained guideline developers that cannot afford de novo guideline development have access to an expanding pool of high-quality prehospital guidelines to translate to their local setting. Discussion: Although some high-quality CPGs exist relevant to emergency care, none directly address the needs of prehospital care in LMICs, especially in Africa. Strengthening guideline development capacity, including adaptive guideline development methods that use existing high-quality CPGs, is a priority. Keywords: Emergency care, Prehospital, Guideline development, Scoping, Guideline quality

Editor’s note: EMJ has partnered with the journals of multiple international emergency medicine societies to share from each a highlighted research study, as selected by their editors. This edition will feature an abstract from each publication.

Emergency Medical Services are ideally placed to provide relief of acute pain and discomfort. The objectives of this study were to describe pre-hospital pain management practices by Emergency Medical Services in the Western Cape, South Africa.A retrospective, descriptive survey was undertaken of analgesic drug administration by advanced life support paramedics. Patient care records generated in the City of Cape Town during an 11-month period containing administrations of morphine, ketamine, nitrates and 50% nitrous oxide/oxygen were randomly sampled. Variables studied were drug dose, dose frequency, and route of administration, patient age, gender, disorder and call type as well as qualification and experience level of the provider.A total of 530 patient care records were included (n = 530). Morphine was administered in 371 (70%, 95% CI 66-74) cases, nitrates in 197 (37%, 95% CI 33-41) and ketamine in 9 (1.7%, 95% CI 1-3) cases. A total of 5 mg or less of morphine was administered in 278 (75%, 95% CI 70-79) cases, with the median dose being 4 mg (IQR 3-6). Single doses were administered to 268 (72.2%, 95% CI 67-77) morphine administrations, five (56%, 95% CI 21-86) ketamine administrations and 161 (82%, 95% CI 76-87) of nitrate administrations. Chest pain was the reason for pain management in 226 (43%) cases. Advanced Life Support Providers had a median experience level of two years (IQR 2-4).Pre-hospital acute pain management in the Western Cape does not appear to conform to best practice as Advanced Life Support providers in the Western Cape use low doses of morphine. Chest pain is an important reason for drug administration in acute pre-hospital pain. Multimodal analgesia is not a feature of care in this pre-hospital service. The development of a Clinical Practice Guideline for and training in pre-hospital pain should be viewed as imperative.Les services d'aide médicale d'urgence sont dans une position idéale pour atténuer les douleurs aigues et la gêne. Les objectifs de cette étude étaient de décrire la gestion préhospitalière de la douleur par les services d'aide médicale d'urgence dans la province du Cap occidental, en Afrique du Sud.Une étude rétrospective et descriptive a été réalisée sur l'administration d'analgésiques par des auxiliaires médicaux spécialisés en réanimation. Les dossiers médicaux des patients générés dans la ville du Cap sur une période de 11 mois indiquant l'administration de morphine, de kétamine, de nitrates et d'un mélange de protoxyde d'azote/oxygène à 50 % ont été échantillonnés de manière aléatoire. Les variables étudiées étaient la dose de médicament, la fréquence d'administration des doses et la voix d'administration, l'âge du patient, son sexe, le trouble dont il souffre et le type d'appel, ainsi que les qualifications et le niveau d'expérience de l'administrateur.Au total, 530 dossiers médicaux de patients ont été inclus (n = 530). De la morphine a été administrée dans 371 (70 %, IC 95% 66–74) cas, du protoxyde d'azote dans 197 (37 %, IC 95 % 33–41) cas et de la kétamine dans 9 (1,7 %, IC 95 % 1–3) cas. Un total de 5 mg de morphine ou moins a été administré dans 278 (75 %, IC 95 % 70–79) cas, la dose moyenne étant de 5 mg (IIQ 3–6). Des doses uniques ont été administrées pour 268 (72,2 %, IC 95 %, 67–77) administrations de morphine, cinq (56 %, IC 95 % 21–86) administrations de kétamine et 161 (82 %, IC 95 % 76–87) administrations de protoxyde d'azote. Les douleurs thoraciques étaient la raison de l'administration d'analgésiques dans 226 (43 %) cas. Les auxiliaires médicaux spécialisés en réanimation disposaient d'un niveau d'expérience moyen de deux ans (IIQ 2–4).La gestion préhospitalière de la douleur aiguë dans la province du Cap occidental ne semble pas se conformer aux meilleures pratiques, car les auxiliaires médicaux spécialisés en réanimation utilisent de faibles doses de morphine. Les douleurs thoraciques constituent une raison importante de l'administration d'analgésiques pour le traitement préhospitalier de la douleur aiguë. L'analgésie multimodale n'est pas une caractéristique des soins dans ce service préhospitalier. Le développement de Directives pratiques cliniques pour la formation à la gestion préhospitalière de la douleur devrait être considéré comme un impératif.

IntroductionMajor-incident triage ensures effective emergency care and utilization of resources. Prehospital emergency care providers are often the first medical professionals to arrive at any major incident and should be competent in primary triage. However, various factors (including level of training) influence their triage performance.Hypothesis/ProblemThe aim of this study was to determine the difference in major-incident triage performance between different training levels of prehospital emergency care providers in South Africa utilizing the Triage Sieve algorithm.MethodsThis was a cross-sectional study involving differently trained prehospital providers: Advanced Life Support (ALS); Intermediate Life Support (ILS); and Basic Life Support (BLS). Participants wrote a validated 20-question pre-test before completing major-incident training. Two post-tests were also completed: a 20-question written test and a three-question face-to-face evaluation. Outcomes measured were triage accuracy and duration of triage. The effect of level of training, gender, age, previous major-incident training, and duration of service were determined.ResultsA total of 129 prehospital providers participated. The mean age was 33.4 years and 65 (50.4%) were male. Most (n=87; 67.4%) were BLS providers. The overall correct triage score pre-training was 53.9% (95% CI, 51.98 to 55.83), over-triage 31.4% (95% CI, 29.66 to 33.2), and under-triage 13.8% (95% CI, 12.55 to 12.22). Post-training, the overall correct triage score increased to 63.6% (95% CI, 61.72 to 65.44), over-triage decreased to 17.9% (95% CI, 16.47 to 19.43), and under-triage increased to 17.8% (95% CI, 16.40 to 19.36). The ALS providers had both the highest likelihood of a correct triage score post-training (odds ratio 1.21; 95% CI, 0.96-1.53) and the shortest duration of triage (median three seconds, interquartile range two to seven seconds; P=.034). Participants with prior major-incident training performed better (P=.001).ConclusionAccuracy of major-incident triage across all levels of prehospital providers in South Africa is less than optimal with non-significant differences post-major-incident training. Prior major-incident training played a significant role in triage accuracy indicating that training should be an ongoing process. Although ALS providers were the quickest to complete triage, this difference was not clinically significant. The BLS and ILS providers with major-incident training can thus be utilized for primary major-incident triage allowing ALS providers to focus on more clinical roles.AlenyoAN, SmithWP, McCaulM, Van HovingDJ. A comparison between differently skilled prehospital emergency care providers in major-incident triage in South Africa. Prehosp Disaster Med. 2018;33(6):575–580.

Objectives Methods on developing new (de novo) clinical practice guidelines (CPGs) have received substantial attention. However, the volume of literature is not matched by research into alternative methods of CPG development using existing CPG documents—a specific issue for guideline development groups in low- and middle-income countries. We report on how we developed a context specific prehospital CPG using an alternative guideline development method. Difficulties experienced and lessons learnt in applying existing global guidelines’ recommendations to a national context are highlighted. Results The project produced the first emergency care CPG for prehospital providers in Africa. It included > 270 CPGs and produced over 1000 recommendations for prehospital emergency care. We encountered various difficulties, including (1) applicability issues: few pre-hospital CPGs applicable to Africa, (2) evidence synthesis: heterogeneous levels of evidence classifications and (3) guideline quality. Learning points included (1) focusing on key CPGs and evidence mapping, (2) searching other resources for CPGs, (3) broad representation on CPG advisory boards and (4) transparency and knowledge translation. Re-inventing the wheel to produce CPGs is not always feasible. We hope this paper will encourage further projects to use existing CPGs in developing guidance to improve patient care in resource-limited settings. Electronic supplementary material The online version of this article (10.1186/s13104-018-3210-3) contains supplementary material, which is available to authorized users.

In South Africa, trauma is a major concern, with violence and road traffic accidents being the fifth and seventh leading causes of death, respectively. Antifibrinolytic agents have been used in trauma and major surgery to prevent fibrinolysis and reduce blood loss. We highlight an updated Cochrane review investigating the effect of antifibrinolytic drugs in patients with acute traumatic injury. The review authors conducted comprehensive literature searches in January 2015 with regard to all randomised controlled trials comparing antifibrinolytic agents after acute traumatic injury. Three randomised controlled trials, of which two (n=20 451) assessed the effect of tranexamic acid (TXA), were included. The authors concluded that TXA safely reduces mortality in trauma with bleeding without increasing the risk of adverse events. TXA should be administered as early as possible, and within 3 hours of injury. There is still uncertainty with regard to the effect of TXA on patients with traumatic brain injury; however, ongoing randomised controlled trials should shed more light on this.

Background Early thrombolysis for individuals experiencing a myocardial infarction is associated with better mortality and morbidity outcomes. While traditionally thrombolysis is given in hospital, pre-hospital thrombolysis is proposed as an effective intervention to save time and reduce mortality and morbidity in individuals with ST-elevation myocardial infarction (STEMI). Despite some evidence that pre-hospital thrombolysis may be delivered safely, there is a paucity of controlled trial data to indicate whether the timing of delivery can be effective in reducing key clinical outcomes. Objectives To assess the morbidity and mortality of pre-hospital versus in-hospital thrombolysis for STEMI. Search methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (OVID), EMBASE (OVID), two citation indexes on Web of Science (Thomson Reuters) and Cumulative Index to Nursing and Allied Health Literature (CINAHL) for randomised controlled trials and grey literature published up to June 2014. We also searched the reference lists of articles identified, clinical trial registries and unpublished thesis sources. We did not contact pharmaceutical companies for any relevant published or unpublished articles. We applied no language, date or publication restrictions. The Cochrane Heart Group conducted the primary electronic search. Selection criteria We included randomised controlled trials of pre-hospital versus in-hospital thrombolysis in adults with ST-elevation myocardial infarction diagnosed by a healthcare provider. Data collection and analysis Two authors independently screened eligible studies for inclusion and carried out data extraction and 'Risk of bias' assessments, resolving any disagreement by consulting a third author. We contacted authors of potentially suitable studies if we required missing or additional information. We collected efficacy and adverse effect data from the trials. Main results We included three trials involving 538 participants. We found low quality of evidence indicating uncertainty whether pre-hopsital thrombolysis reduces all-cause mortality in individuals with STEMI compared to in-hospital thrombolysis (risk ratio 0.73, 95% confidence interval 0.37 to 1.41). We found high-quality evidence (two trials, 438 participants) that pre-hospital thrombolysis reduced the time to receipt of thrombolytic treatment compared with in-hospital thrombolysis. For adverse events, we found moderate-quality evidence that the occurrence of bleeding events was similar between participants receiving in-hospital or pre-hospital thrombolysis (two trials, 438 participants), and low-quality evidence that the occurrence of ventricular fibrillation (two trials, 178 participants), stroke (one trial, 78 participants) and allergic reactions (one trial, 100 participants) was also similar between participants receiving in-hospital or pre-hospital thrombolysis. We considered the included studies to have an overall unclear/high risk of bias. Authors' conclusions Pre-hospital thrombolysis reduces time to treatment, based on studies conducted in higher income countries. In settings where it can be safely and correctly administered by trained staff, pre-hospital thrombolysis may be an appropriate intervention. Pre-hospital thrombolysis has the potential to reduce the burden of STEMI in lower- and middle-income countries, especially in individuals who have limited access to in-hospital thrombolysis or percutaneous coronary interventions. We found no randomised controlled trials evaluating the efficacy of pre-hospital thrombolysis for STEMI in lower- and middle-income countries. Large high-quality multicentre randomised controlled trials implemented in resource-constrained countries will provide additional evidence for the efficacy and safety of this intervention. Local policy makers should consider their local health infrastructure and population distribution needs. These considerations should be taken into account when developing clinical guidelines for pre-hospital thrombolysis.

Introduction Unnecessary spinal cord immobilisation is a common problem in South Africa, even though out-of hospital spinal clearance is becoming standard of care in international emergency medical care (EMC) communities. Large numbers of unnecessary spinal immobilisations, in low risk trauma patients, result in an increased health and economic burden in both the in-hospital and out-of hospital settings. Currently, informal spinal clearance is being practiced in South Africa creating large practice variation, potential patient safety compromise and probable economic burden. An evidence-based out-of hospital spinal clearance algorithm would minimise the unnecessary hospitalisation of low risk spinal patients. Our objectives included: (i) To provide an accurate and reproducible algorithm to identify and correctly refer clinically relevant spinal injury in the out-of hospital setting and (ii) To inform policy makers of best practice for spinal cord clearance through evidence informed decision making and provide implementation and evaluation recommendations. This document provides recommendations for a spinal clearance guideline for South Africa and includes implementation strategies and evaluation criteria. Methods A Population, Intervention, Professionals, Outcomes and Health Context (PIPOH) research question was designed to answer the guideline topic. The literature was systematically searched for spinal clearance guidelines or recommendations. These were screened, appraised and adapted by a specialist emergency care review group using the Appraisal of Guidelines Research and Evaluation (AGREE II) and ADAPTE tools recommended for guideline adaptation and development. The results were filtered by the primary author using pre-defined selection criteria. Results A total of 8 guidelines met the inclusion criteria. Each guideline was independently assessed by two emergency care specialists using the AGREE II tool. A forum discussion was held to adapt the included guidelines to the local out-of hospital needs. Emergency care policy stakeholders and operational and student paramedics were asked to review and comment on the adapted algorithm. Conclusion An out-of hospital spinal clearance guideline was developed with evaluation and implementation strategies for the out-of hospital context. The author would like to acknowledge the South African Cochrane Centre and Dr Tamara Kredo for their support.

Infection is a complication of open fractures. Early administration of intravenous (IV) antibiotics providing cover against gram positive and negative organisms has been shown to be the single most important factor in reducing infection rate in patients with open (compound) fractures. A delay of more than three hours from injury (open fractures or war wounds including fractures) to antibiotic administration is associated with a significantly higher infection rate. The purpose of this study is to identify the proportion of patients in a suburban sample that experience delay of more than 3 hours in antibiotic administration after open fracture. The authors hope to clarify if there would be opportunity and value in pre-hospital antibiotic administration in significantly shortening the delay. Methods: A retrospective and prospective descriptive study was conducted of all patients with open fractures of the limbs or girdles arriving via ambulance at a single district hospital in a suburban area in KwaZulu-Natal, South Africa from May to December 2012. Data analysed with descriptive statistics using STATA 11. Results: 38 patients were identified from May to December 2012. The median total time from injury to antibiotics was 465 min (7.5 h) (Q1 = 230 min, Q3 = 615). Administration of antibiotics was delayed beyond 3 h in 78.9% (95% confidence interval (CI) 65.3 – 92.52) of patients and beyond 6 h in 60.5% (95% CI 44.2 – 76.8). A median of 164 min (Q1 = 115, Q3 = 222) was spent out of hospital with emergency medical care practitioners (EMCPs) being in attendance for a median of 56 min (Q1 = 37, Q3 = 64). The longest delay occurred after arrival at the hospital with a median of 363 min (Q1 = 171, Q3 = 505) until antibiotic administration. 26.3% of patients were transported directly from scene of injury to the hospital, while the remainder first presented to a clinic. Conclusions: There is much room for improvement within the study hospital and its drainage clinics in preventing delay in antibiotic administration. However, although much of the delay occurred due to clinic and in-hospital delays, there is also a hypothetical window available to pre-hospital healthcare providers where antibiotics may be administered which would dramatically decrease the time interval and bypass many of the difficulties encountered in-hospital. It would be safer to consider introducing IV antibiotics to the advanced scope of EMCP practise only; due to need to manage complications of antibiotics. Before considering introducing antibiotics to EMCP spectrum of care, efficacy, safety and cost-effectiveness studies would need to be undertaken. Randomised controlled trials are also recommended to determine the effect on reducing delay, infection and occurrence of adverse events.