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Introduction: In high-income settings, vasopressor administration to treat haemodynamic instability through a central venous catheter (CVC) is the preferred standard. However, due to lack of availability and potential for complications, CVCs are not widely used in low- and middle-income countries. This prospective cohort study evaluated the use of peripheral vasopressors and associated incidence of extravasation events in patients with haemodynamic instability at the Centre Hospitalier Universitaire Kigali, Rwanda. Methods: Patients ≥18 years of age receiving peripheral vasopressors in the emergency centre (EC) or intensive care unit (ICU) for >1 hour were eligible for inclusion. The primary outcome was extravasation events. Patients were followed hourly until extravasation, medication discontinuation, death, or CVC placement. Extravasation incidence with 95% confidence intervals (CI) were calculated using Poisson exact tests. Results: 64 patients were analysed. The median age was 49 (Interquartile Range [IQR]:33-65) and 55% were female. Distributive shock was the most frequent aetiology (47%). Intravenous (IV) location was most commonly antecubital fossa/upper arm (31%) and forearm/hand (43%). IV gauges ≤18 were used in 58% of locations. Most patients were treated with adrenaline (66%) and noradrenaline (41%), and 11% received multiple vasopressors. The median treatment duration was 19 hours (IQR:8.5-37). Treatment discontinuation was predominantly due to mortality (41%) or resolution of instability (36%). There were two extravasation events (2.9%), both limited to soft tissue swelling. Extravasation incidence was 0.8 events per 1000 patient-hours (95% CI:0.2-2.2). Conclusion: Extravasation incidence with peripheral vasopressors was low, even with long use durations, suggesting peripheral infusions may be an acceptable approach when barriers exist to CVC placement.

Introduction: Injuries cause significant burdens in sub-Saharan Africa. In Rwanda, national regulations to reduce COVID-19 altered population mobility and resource allocations. This study evaluated epidemiological trends and care among injured patients preceding and during the COVID-19 pandemic at the Centre Hospitalier Universitaire de Kigali (CHUK) in Kigali, Rwanda. Methods: This prospective interrupted cross-sectional study enrolled injured adult patients (≥15 years) presenting to the CHUK emergency department (ED) from January 27th-March 21st (pre-COVID-19 period) and June 1st-28th (intra-COVID-19 period). Trained study personnel continuously collected standardized data on enrolled participants through the first six-hours of ED care. The Kampala Trauma Score (KTS) was calculated as a metric of injury severity. Case characteristics prior to and during the pandemic were compared, statistical differences were assessed using χ2 or Fisher's exact tests. Results: Data were collected from 409 pre-COVID-19 and 194 intra-COVID-19 cases. Median age was 32, with a male predominance (74.3%). Road traffic injuries (RTI) were the most common injury mechanism pre-COVID-19 (47.8%) and intra-COVID-19 (53.6%) (p = 0.27). There was a significant increase in the number of transfer cases during the intra-COVID-19 period (52.1%) versus pre-COVID-19 (41.3%) (p = 0.01). KTS was significantly lower among intra-COVID-19 patients (p = 0.04), indicating higher severity of presentation. In the intra-COVID-19 period, there was a significant increase in the number of surgery consultations (40.7%) versus pre-COVID-19 (26.7%) (p

Background: Injuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K). Methods: Data were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI). Results: From the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids. Conclusions: Injured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.

Abstract Background Emergency care is a new but growing specialty across Africa where medical conditions have been estimated to account for 92% of all disability-adjusted life years. This study describes the epidemiology of medical emergencies and the impact of formalized emergency care training on patient outcomes for medical conditions in Rwanda. Methods A retrospective cohort study was performed using a database of randomly sampled patients presenting to the emergency center (EC) at the University Teaching Hospital of Kigali. All patients, > 15 years of age treated for medical emergencies pre- and post-implementation of an Emergency Medicine (EM) residency training program were eligible for inclusion. Patient characteristics and final diagnosis were described by time period (January 2013–September 2013 versus September 2015–June 2016). Univariate chi-squared analysis was performed for diagnoses, EC interventions, and all cause EC and inpatient mortality stratified by time period. Results A random sample of 1704 met inclusion with 929 patients in the pre-residency time period and 775 patients in the post-implementation period. Demographics, triage vital signs, and shock index were not different between time periods. Most frequent diagnoses included gastrointestinal, infectious disease, and neurologic pathology. Differences by time period in EC management included antibiotic use (37.2% vs. 42.2%, p = 0.04), vasopressor use (1.9% vs. 0.5%, p = 0.01), IV crystalloid fluid (IVF) use (55.5% vs. 47.6%, p = 0.001) and mean IVF administration (2057 ml vs. 2526 ml, p < 0.001). EC specific mortality fell from 10.0 to 1.4% (p < 0.0001) across time periods. Conclusions Mortality rates fell across top medical diagnoses after implementation of an EM residency program. Changes in resuscitation care may explain, in part, this mortality decrease. This study demonstrates that committing to emergency care can potentially have large effects on reducing mortality.

Introduction: While trauma prognostication and triage scores have been designed for use in lower-resourced healthcare settings specifically, the comparative clinical performance between trauma-specific and general triage scores for risk-stratifying injured patients in such settings is not well understood. This study evaluated the Kampala Trauma Score (KTS), Revised Trauma Score (RTS), and Triage Early Warning Score (TEWS) for accuracy in predicting mortality among injured patients seeking emergency department (ED) care at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda. Methods: A retrospective, randomly sampled cohort of ED patients presenting with injury was accrued from August 2015–July 2016. Primary outcome was 14-day mortality and secondary outcome was overall facility-based mortality. We evaluated summary statistics of the cohort. Bootstrap regression models were used to compare areas under receiver operating curves (AUC) with associated 95% confidence intervals (CI). Results: Among 617 cases, the median age was 32 years and 73.5% were male. The most frequent mechanism of injury was road traffic incident (56.2%). Predominant anatomical regions of injury were craniofacial (39.3%) and lower extremities (38.7%), and the most common injury types were fracture (46.0%) and contusion (12.0%). Fourteen-day mortality was 2.6% and overall facility-based mortality was 3.4%. For 14-day mortality, TEWS had the highest accuracy (AUC = 0.88, 95% CI, 0.76–1.00), followed by RTS (AUC = 0.73, 95% CI, 0.55–0.92), and then KTS (AUC = 0.65, 95% CI, 0.47–0.84). Similarly, for facility-based mortality, TEWS (AUC = 0.89, 95% CI, 0.79–0.98) had greater accuracy than RTS (AUC = 0.76, 95% CI, 0.61–0.91) and KTS (AUC = 0.68, 95% CI, 0.53–0.83). On pairwise comparisons, RTS had greater prognostic accuracy than KTS for 14-day mortality (P = 0.011) and TEWS had greater accuracy than KTS for overall (P = 0.007) mortality. However, TEWS and RTS accuracy were not significantly different for 14-day mortality (P = 0.864) or facility-based mortality (P = 0.101). Conclusion: In this cohort of emergently injured patients in Rwanda, the TEWS demonstrated the greatest accuracy for predicting mortality outcomes, with no significant discriminatory benefit found in the use of the trauma-specific RTS or KTS instruments, suggesting that the TEWS is the most clinically useful approach in the setting studied and likely in other similar ED environments.

Introduction: Suicide is the 10 th leading cause of death in the United States, with firearms reported as the cause of death in up to 50% of these cases. Our goal was to evaluate the feasibility of the Counseling on Access to Lethal Means intervention in the Emergency Department (CALM-ED) by non-physician personnel. Methods: We conducted this single-center, prospective, quality improvement study (QI) in an urban, academic ED with over 90,000 annual patient visits. The study looked at adult patients who were discharged after presenting to the ED with suicidal crisis. Assessment of access to lethal means was conducted at the bedside, followed by a counseling session regarding safe storage of lethal means and follow-up via telephone call 48–72 hours after ED discharge. We collected data on patient’s sociodemographics, psychiatric history, access to lethal means, lethal means storage methods, the patient’s specific plans for lethal means storage after discharge, and post-discharge follow-up care. Results: Of 215 eligible patients, 166 voluntarily agreed to participate in CALM-ED, of whom 84 (51%) reported access to lethal means. Following the intervention, 75% of patients described a specific storage plan for their lethal means. Patients with and without access to firearms were equally likely to participate in the follow-up telephone call. Conclusion: An ED-based CALM QI intervention is feasible for implementation by non-physician personnel and is well received by patients and families. This intervention has the potential to help saves lives at times of suicide crisis.

Introduction: Suicide is the 10th leading cause of death in the United States. An estimated 50% of these deaths are due to firearms. Suicidal ideation (SI) is a common complaint presenting to the emergency department (ED). Despite these facts, provider documentation on access to lethal means is lacking. Our primary aim was to quantify documentation of access to firearms in patients presenting to the ED with a chief complaint of SI. Methods: This was a cross-sectional study of consecutive patients, nearly all of whom presented to an academic, urban ED with SI during July 2014. We collected data from all provider documentation in the electronic health record. Primary outcome assessed was whether the emergency physician (EP) team documented access to firearms. Secondary outcomes included demographic information, preexisting psychiatric diagnoses, and disposition. Results: We reviewed 100 patient charts. The median age of patients was 38 years. The majority of patients had a psychiatric condition. EPs documented access to firearms in only 3% of patient charts. Conclusion: EPs do not adequately document access to firearms in patients with SI. There is a clear need for educational initiatives regarding risk-factor assessment and counseling against lethal means in this patient cohort.