Malignant hyperthermia, a rare perioperative complication: case series and literature review.

Malignant hyperthermia is a rare complication of general anesthesia appearing as an acute and potentially lethal hypermetabolic state in people carrying a genetic anomaly expressed in skeletal muscles. Malignant hyperthermia has been scarcely described in sub-Saharan Africa. Herein, we present three cases of malignant hyperthermia occurring in the perioperative period in Cameroon. The authors wish to draw attention to the clinical presentation of this rare but potentially lethal emergency, for timely diagnosis, management and follow-up geared at preventing perioperative mortality.

Palliative and end-of-life care in COVID-19 management in sub-Saharan Africa: a matter of concern.

The COVID-19 pandemic has strained health care systems beyond capacity resulting in many people not having access to life-sustaining measures even in well-resourced countries. Palliative and end-of-life care are therefore essential to alleviate suffering and ensure a continuum of care for patients unlikely to survive. This is challenging in sub-Saharan Africa where lack of trained teams on basic palliative care and reduced access to opioids limit implementation of palliative and end-of-life care. At the same time, health care providers have to cope with local cultural conceptions of death and absence of advance care directives.

Retraction Note: Severe Viperidae envenomation complicated by a state of shock, acute kidney injury, and gangrene presenting late at the emergency department: a case report.

The authors have retracted this case report [1] because the head of the snake shown in Figure 1 and described as being that of a viper (Echis occellatus) is identical to the head of a snake shown in Figure 1 of a different case report [2] where it was identified as being Naja melanoleuca, a member of the Elapidae family.

Anaesthesiologist-intensivist phycisians at the core of the management of critically ill COVID-19 patients in Africa: persistent challenges, some resolved dilemma and future perspective.

Unlike developed countries which have purely intensivists also called critical care physicians or intensive care physicians to manage critically ill patients like those with severe forms of COVID-19, the practice of critical care medicine in Africa is coined to anaesthesiology. Hence, anaesthesiologist-intensivist physicians are the medical specialists taking care of critically ill COVID-19 patients in Africa. Likewise, unlike intensive care units (ICUs) in high income countries, those in most African countries face the challenge of a lack of emergency drugs and resuscitation equipment, limited health infrastructure and understaffed and underfunded health care systems. The COVID-19 pandemic is an unprecedented one faced by intensivists in high-income countries and anaesthesiologist-intensivist phycisians in Africa. Infected patients with severe forms of the disease like those having grave COVID-19 complications like massive pulmonary embolism, severe cardiac arrhythmias, cardiogenic shock, septic shock, acute kidney injury or acute respiratory distress syndrome require ICU admission for better management. Both intensivists or anaesthesiologist-intensivist physicians have the peculiarity of securing the airways of critically COVID-19 patients and providing respiratory support with mechanical ventilation after laryngoscopy and endotracheal intubation when needed. In so doing, they can easily be infected from respiratory droplets or aerosols expired by the COVID-19 patients. Hence, in Africa, anaesthesiologist-intensivist phycisians have a higher risk of contracting COVID-19 compared to other health professionals. It's worth to mention that the COVID-19 pandemic struck African anaesthesiologist-intensivist phycisians and ICUs when there were neither prepared skillfully or lacked the required ICU capacity to meet the demands of thousands of severe COVID-19 African patients. These further weakened the already strained health systems in Africa. It required a lot of creativity, engineering skills and courage for these ill prepared African anaesthesiologist-intensivist physicians to provide care to these critically ill patients and improve their outcomes as the pandemic progressed. However, despites the numerous efforts made in African anaesthesiologist-Intensivist phycisians to care for critically ill COVID-19 patients, the pandemic is spreading at a rapid rate across Africa. There is an urgent need for African health authorities to anticipate on how to scale up the future high ICU capacity needs and limited ICU workforce, infrastructure and equipment to manage severe forms of COVID-19 in future. It cannot be overemphasized that these severe forms of COVID-19 are potentially fatal and are a major contributor to the death toll of the COVID-19 pandemic.

A comparative analysis of the diagnostic performances of four clinical probability models for acute pulmonary embolism in a sub-Saharan African population: a cross-sectional study.

BACKGROUND: The diagnosis of acute pulmonary embolism (PE) is one of the most challenging in emergency settings where prompt and accurate decisions need to be taken for life-saving purposes. Here, the assessment of the clinical probability of PE is a paramount step in its diagnosis. Although clinical probability models (CPM) for PE are routinely used in emergency departments (EDs) of low-resource settings, few studies have cited their diagnostic performances in sub-Saharan Africa (SSA). We aimed to comparatively assess the accuracy of four CPM in the diagnosis of acute PE in sub-Saharan Africans. METHODS: We carried out a cross-sectional study to compare the sensitivity, specificity, positive and negative predictive values and accuracy of four CPM namely; the Wells, simplified Wells, revised Geneva and the simplified revised Geneva (SRG) Scores to computed tomography pulmonary angiography (CTPA) in all adults patients with suspected PE admitted to the EDs of the Gynaeco-obstetric and Paediatric Hospital of Yaoundé and the Yaoundé Central Hospital in Cameroon between January 1, 2017 and April 30, 2018. RESULTS: In total, we enrolled 30 patients with clinical suspicion of acute PE. PE was confirmed on CTPA in 16 (53.3%) cases. Their mean age was 53.7 ± 15.5 years and 36.7% were males. All four scores had a diagnostic performance superior to 50% in all criteria assessed. The simplified Wells score had the highest sensitivity (62.5%) followed by the Wells score (56.3%). The SRG score had the highest specificity (71.4%). The score with highest PPV was the SRG score (66.7%) and that with the highest NPV was the Wells score (56.3%). Overall the models with the highest accuracies were the Wells and SRG scores (60% for each). CONCLUSION: All CPM had a suboptimal diagnostic performance, perhaps highlighting the need of a more optimal CPM for acute PE in SSA. However, the Wells and the SRG scores appeared to be most accurate than the other two scores in the ED. Hence, both or either of them may be used in first intention to predict PE and guide which ED patients should undergo further investigations in an emergency SSA setting.

Knowledge, attitudes, and practices of Cameroonian physicians with regards to acute pain management in the emergency department: a multicenter cross-sectional study.

INTRODUCTION: Pain is the most frequent presenting complaint in patients consulting or admitted to the emergency department (ED). Thus, its acute management is often done by physicians working in the ED. These clinicians are often general practitioners and not emergency medicine physicians in resource-poor settings. Hence, a mastery of pain management by these physicians may be important in relieving acute pain. We aimed to assess the knowledge, to determine the attitudes and practices of physicians in the management of pain in EDs of Cameroon. METHODS: We carried out a prospective cross-sectional study over 4 months in the year 2018. We enrolled all consenting physicians who were neither emergency medicine doctors nor anesthesiologists working at the EDs of five tertiary hospitals of Cameroon. Using a validated and pretested structured questionnaire, data on the knowledge, attitudes, and practices of acute pain management at the ED by these clinicians were studied. We used an externally validated score to assess the knowledge as either poor, insufficient, moderate or good. RESULTS: A total of 58 physicians were included; 18 interns or residents and 39 general practitioners. Their mean age was 28.6 ± 3 years and their average number of years of practice was 2.9 years. The level of knowledge was rated "poor" in 77.6% of physicians. Being a general practitioner was significantly associated with a poor level of knowledge (p = 0.02; OR = 5.1). We found a negative and significant correlation between knowledge and years of practice (p = 0.04; r2 = 0.06). More than three-quarter (82.8%) of participants used a pain scale to evaluate the severity of pain. The most used scale was the Visual Analog Scale (56.9%). The most frequently used analgesic was paracetamol (98.3%), although only 3.5% of physicians correctly knew its half-life, delay of onset of action and duration of action. CONCLUSION: These findings suggest that physicians in EDs of Cameroon have poor knowledge and suboptimal practices in pain management. General practice and a greater number of professional experience seemed to favour these attitudes. Overall, there is an urgent need for refresher courses in acute pain management for physicians working in these resource-limited EDs.

Severe Viperidae envenomation complicated by a state of shock, acute kidney injury, and gangrene presenting late at the emergency department: a case report.

BACKGROUND: Snake envenomation is an underestimated pathology in sub-Saharan Africa associated with severe emergencies, and even death in case of late presentation. We herein present a case of severe envenomation managed at the surgical emergency department of the Yaoundé Central Hospital. CASE PRESENTATION: We report a case of a 47-year-old female farmer with no relevant past history who sustained a snakebite by an Echis occellatus viper during an agricultural activity. Her initial management consisted in visiting a traditional healer who administered her some herbal remedies orally and applied a white balm on the affected limb. Due to progressive deterioration of her condition, she was rushed to our surgical department where she arrived 20 h after the snakebite incident. On admission she presented in a state of shock (suggestive of an anaphylactic shock), coagulopathy, renal impairment, and gangrene of the entire right upper limb. Emergency management consisted of fluid resuscitation, repeated boluses of adrenaline, a total of three vials of polyvalent anti-venom sera, promethazine, analgesics, corticosteroids, and administration of fresh frozen plasma. Within four hours of emergency department hospitalisation she developped signs of sepsis and persistent hypotension refractory to fluid resuscitation, suggestive of an associated septic shock. Management pursued with antiobiotherapy and administration of noradrenaline through an electric pump syringe to achieve a mean arterial blood pressure above 65 mmHg. The patient deceased at the 10th hour of hospitalisation in a state of circulatory collapse unresponsive to vasopressors, coagulopathy, renal failure, sepsis and gangrene of the right forearm. CONCLUSION: The authors highlight this unusual presentation but equally pinpoint how late presentation to the emergency department, harmful tradition practices, poverty and cultural beliefs can adversely affect the prognosis of snakebite in our setting.

Facteurs d'allongement du delai d'admission des brules graves a l'Hopital Central de Yaounde

Objectifs : Le but de cette etude etait de determiner les facteurs d'allongement du delai d'admission des brules graves en reanimation a Hopital Central de Yaounde. Patients et methodes : Il s'agi d'une etude prospective; descriptive et analytique; qui a couvert la periode allant du 1er janvier 2012 au 31 decembre 2013. Nous avons inclus 57 patients admis en reanimation pour une brulure grave et chez ces patients; nous avons analyse les donnees sociodemographiques; les caracteristiques de la brulure; les donnees sur la prise en charge prehospitaliere et l'admission en reanimation (date; heure). Resultats : Les accidents domestiques etaient en tete des circonstances de survenue (77;2) et la brulure thermique par ebouillantement etait la plus frequentes (61;4 ). La prise en charge medicale etait inexistante sur les lieux de l'accident; les patients n'avaient recu que des traitements traditionnels. Les patients etaient transportes par des vehicules non medicalises vers des centres de soins peripheriques en premiere reference (79); ou ils ont ete retenus pendant au moins 24 heures avant leur transfert secondaire a l'Hopital Central de Yaounde. Le delai d'admission en reanimation etait superieur a 12 heures (79); cet allongement etant du a la retention des victimes dans les centres de soins peripheriques; a l'automedication et aux pratiques traditionnelles; aux difficultes de transfert des patients liees aux moyens financiers limites et a l'ignorance. Conclusion : Le brule grave necessite une prise en charge precoce et adequate. Une chaine de secours devrait etre mise en place pour ameliorer la qualite la prise en charge initiale