SPECIAL CONTRIBUTION
Global Emergency Medicine: A Review of
the Literature from 2018
Indi Trehan, MD, MPH, DTM&H1,2 , Maxwell Osei-Ampofo, MChB, MPH, MBA3,
Kamna S. Balhara, MD, MA4 , raden J. Hexom, MD5, Sean M. Kivlehan, MD, MPH6,7,
Payal Modi, MD, MSc8, Amelia Y. Pousson, MD, MPH9, Anand Selvam, MD, MSc,
DTM&H10, Nana Serwaa A. Quao, MD11, Daniel K. Cho12, Torben K. Becker, MD,
PhD13 , and Adam C. Levine, MD, MPH14 on behalf of the Global Emergency Medicine
Literature Review (GEMLR) Group
ABSTRACT
Objectives: The Global Emergency Medicine Literature Review (GEMLR) conducts a systematic annual search of
peer-reviewed and gray literature relevant to global emergency medicine (EM) to identify, review, and disseminate
the most rigorously conducted and widely relevant research in global EM.
Methods: An electronic search of PubMed, a comprehensive retrieval of articles from specific journals, and
search of the gray literature were conducted. Title and abstracts retrieved by these searches were screened by a
total of 22 reviewers based on their relevance to the field of global EM, across the domains of disaster and
humanitarian response (DHR), emergency care in resource-limited settings (ECRLS), and emergency medicine
development (EMD). All articles that were deemed relevant by at least one reviewer, their editor, and the
managing editor underwent formal scoring of overall methodologic quality and importance to global EM. Two
independent reviewers scored all articles; editors provided a third score in cases of widely discrepant scores.
Results: A total of 19,102 articles were identified by the searches and, after screening and removal of
duplicates, a total of 517 articles underwent full review. Twenty-five percent were categorized as DHR, 61% as
ECRLS, and 15% as EMD. Inter-rater reliability testing between the reviewers revealed a Cohen’s kappa score of
0.213 when considering the complete score or 0.426 when excluding the more subjective half of the score. A
total of 25 articles scored higher than 17.5 of 20; these were selected for a full summary and critique.
Conclusions: In 2018, the total number of articles relevant to global EM that were identified by our search
continued to increase. Studies and reviews focusing on pediatric infections, several new and traditionally
underrepresented topics, and landscape reviews that may help guide clinical care in new settings represented the
majority of top-scoring articles. A shortage of articles related to the development of EM as a specialty was identified.
From the 1Lao Friends Hospital for Children, Luang Prabang, Lao PDR; the 2Department of Pediatrics, Washington University in St. Louis, St.
Louis, MO; the 3Emergency Medicine Directorate, Komfo Anokye Teaching Hospital, and the Department of Anaesthesia and Intensive Care,
Kwame Nkrumah University of Science and Technology, Kumasi, Ghana; the 4Department of Emergency Medicine, Johns Hopkins University, Bal-
timore, MD; the 5Department of Emergency Medicine, Rush University Medical Center, Chicago, IL; the 6Department of Emergency Medicine, Brig-
ham and Women's Hospital, Boston, MA; the 7Harvard Humanitarian Initiative, Cambridge, MA; the 8Department of Emergency Medicine,
University of Massachusetts, Worcester, MA; the 9Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD; the 10Depart-
ment of Emergency Medicine, Yale University, New Haven, CT; the11Department of Emergency Medicine, Korle Bu Teaching Hospital (NSAQ),
Accra, Ghana; 12Brown University, Providence, RI; the13Department of Emergency Medicine, University of Florida, Gainesville, FL; and the
14Department of Emergency Medicine, Brown University, Providence, RI.
Received May 25, 2019; revision received July 6, 2019; accepted July 12, 2019.
Global Emergency Medicine Literature Review (GEMLR) Group members are listed in Appendix A.
The authors have no relevant financial information or potential conflicts to disclose.
Author contributions: study concept and design—IT, TKB, and ACL; acquisition of data—DKC; analysis and interpretation of data—IT, MOA,
KSB, BJH, SMK, PM, AYP, AS, NSAQ, and DKC; drafting of the manuscript—IT; critical revision of the manuscript for important intellectual con-
tent—IT, SMK, TKB, and ACL; and statistical expertise—IT.
Supervising Editor: Michael S. Runyon, MD.
Address for correspondence and reprints: Indi Trehan, MD, MPH, DTM&H; e-mail: indi@alum.berkeley.edu.
ACADEMIC EMERGENCY MEDICINE 2019;26:1186–1196.
ISSN 1553-2712 © 2019 by the Society for Academic Emergency Medicine
1186 doi: 10.1111/acem.13832
ACADEMIC EMERGENCY MEDICINE • October 2019, Vol. 26, No. 10 • www.aemj.org 1187
The Global Emergency Medicine Literature Review developments in the field. This is not a formal system-(GEMLR) began in 2005 with a goal of improv- atic review or meta-analysis, as we do not aim to syn-
ing the practice of emergency medicine (EM) world- thesize the literature around a specific topic or
wide by facilitating global EM practitioners’ awareness research question; GEMLR conducts a separate annual
of the most current and important research published systematic review for that purpose.17,18
in global settings. We work to identify and consolidate
the relevant global EM literature into a format that is
METHODS
readily available to academicians, practitioners, and
public policy personnel. Each year, a panel of review- Full details of our procedures are available in Data
ers and editors is recruited to screen and critique liter- Supplement S1 (available as supporting information
ature identified from a systematic electronic and in the online version of this paper, which is available
manual literature search. While the definition of glo- at http://onlinelibrary.wiley.com/doi/10.1111/acem.
bal EM is open to interpretation, we consider it to be 13832/full). Significant changes from prior years’
the practice and development of EM in settings with- methodology included how articles with widely dis-
out robust or mature EM systems commonly seen in crepant reviewer scores are handled and how articles
resource-rich western countries. written by members of the editorial board are handled
The GEMLR seeks to identify the most relevant in terms of managing potential conflicts of interest. In
practice-changing articles by systematically scouring the past, articles that were cowritten by members of
both the peer-reviewed and the gray literature via a the editorial board were automatically excluded, but as
comprehensive search strategy. Gray literature, repre- this may have excluded some high-quality articles, our
senting material produced specifically to share research new conflict of interest policy allows for these articles
and clinical guidelines outside of the peer-reviewed lit- to be included if three other senior members of the
erature, represents an important contribution to sys- review independently agree that such articles were
tematic reviews.1 Given the amount of global EM screened and scored appropriately without favorable
research conducted by government agencies, non- bias given to the authors.
governmental organizations, and other entities, manu- All participants in the review are unpaid volunteers
ally searching for this information has the potential to selected based on their experience providing frontline
identify important practice-changing findings. emergency care and education around the world. This
Major goals of this review are to illustrate best prac- year’s panel of 27 reviewers, seven editors, and five
tices, stimulate research, and promote further profes- editorial board members included physicians practicing
sionalization in the field of global EM through the in Australia, Canada, Egypt, Ethiopia, Ghana, Haiti,
identification of important new publications that focus Laos, and the United States. The full list of partici-
on emergency care in the global context, especially disas- pants is available in Appendix A.
ter and humanitarian response, emergency care in
resource-limited settings, and the development of EM as Peer-reviewed Literature Search
a clinical discipline worldwide.2 The review has a struc- PubMed was searched in two blocks: the first block
ture and guidelines refined over more than a decade to covered publications included in Medline from Jan-
bring reproducibility to the process, but we acknowledge uary 1 to August 31, 2018, and the second from
that there is an inherent subjectivity to any such endea- September 1 to December 31, 2018. The search for
vor. Nevertheless, this is a subjectivity we aim to mini- original research and review articles that contained at
mize by using the collective experience of more than two least one “emergency medicine” search term plus one
dozen clinicians with vast knowledge and training in “global” search term (Data Supplement S2). Addition-
global EM who provide feedback on the literature with ally, all articles published during 2018 in certain jour-
multiple layers of review and feedback. nals that have traditionally published a large number
Given the ever-increasing onslaught of medical liter- of global EM articles were retrieved to ensure that no
ature and the ever-increasing contribution of emer- relevant articles from these journals were missed by
gency conditions to global morbidity and mortality the Medline search. The journals included in this
worldwide,3 we aim to provide a highly curated annual comprehensive retrieval process were Academic Emer-
resource4–16a starting point—for our colleagues world- gency Medicine, African Journal of Emergency Medicine,
wide to explore and understand important new Annals of Emergency Medicine, Bulletin of the World
1188 Trehan et al. • GLOBAL EMERGENCY MEDICINE LITERATURE REVIEW 2018
Health Organization, Emergency Medicine Journal, The or review (RE) articles. Articles were also categorized
Lancet, and Prehospital and Disaster Medicine. as being most relevant to disaster and humanitarian
Based on the linguistic abilities of our team this response (DHR), emergency care in resource-limited
year, we restricted our searches to articles published in settings (ECRLS), or emergency medicine development
English, French, Portuguese, and Spanish. All studies (EMD). DHR articles include research on the care of
were limited to human subjects only; news articles, civilian populations in conflict; disaster migration,
editorials, case reports, commentaries, and letters to assessment, and response; and the health care of refu-
the editor were excluded. gees and internally displaced people. ECRLS articles
focus on research to improve our understanding or
Gray Literature Search management of acute conditions in resource-limited
The Web sites of a list of academic, think tank, gov- settings. EMD articles include research on the develop-
ernment, United Nations, and nongovernmental orga- ment of EM as a specialty, EM training programs, and
nizations known to conduct significant global health emergency medical care systems in countries without
research or implementation work (Data Supple- advanced health care systems and fully developed EM
ment S3) were methodically searched by two reviewers. systems.
This year, the Emergency Nutrition Network and Part- Each full-text article was independently scored by
ners In Health were added to this search. Specifically, two reviewers using a predefined grading scale that
needs assessments, program monitoring, evaluation assessed each article’s clarity, design, ethics, impor-
reports, topic reviews, white papers, conference pro- tance, and impact. Each of these topic areas was
ceedings, and any other work that may be relevant to scored, totaling a final score range from 0 to 20 (Data
the field of global EM were sought. Supplement S4). These criteria are designed to help
identify methodologically sound and scientifically
Article Screening impactful research in the field of global EM.
The titles and abstracts of articles identified by these The differences between the two scores for each arti-
three search strategies were distributed among the cle were then calculated, and the median and standard
reviewers for initial screening based on their relevance deviation (SD) of these differences computed. Those
to the field of global EM. Those articles that were articles whose scores differed by more than two SDs
selected by the reviewers were further reviewed by an from the median were then rescored by an editor
editor, and this year additionally by the assistant using the same 0 to 20 scale. The arithmetic mean of
managing editor and managing editor for appropriate- these three scores was then calculated and assigned as
ness. The articles that made it through this screening the final article score.
process were then selected for scoring.
Full Article Review
Article Scoring Articles with scores in the top 5% of all scores were
The full text of articles selected for scoring were then selected for full formal review. These articles were
obtained and classified as either original research (OR) then distributed to reviewers who wrote one-page
Table 1
Summary Statistics for Article Scoring
Scores
Number (%) Minimum 25th Percentile Median 75th Percentile Maximum
Total 517 (100) 5 12 14 15.5 20
Article category
Disaster and humanitarian response (DHR) 129 (25.0) 5 11.5 13.5 15 18.5
Emergency care in resource-limited settings (ECRLS) 313 (60.5) 5.67 12.5 14 15.75 20
Emergency medicine development (EMD) 75 (14.5) 5 11.5 13 14.5 17
Type of research article
Original research (OR) article 400 (77.4) 5 12 14 15.25 19.5
Review (RE) article 117 (22.6) 6 12 14.5 16.5 20
ACADEMIC EMERGENCY MEDICINE • October 2019, Vol. 26, No. 10 • www.aemj.org 1189
Table 2
Global Emergency Medicine Literature Review 2018 Articles
First OR or
Category Author Title Journal RE Summary
Disaster and Boulton22 Prehospital haemostatic dressings for trauma: a Emerg Med J RE Hemostatic dressings in the prehospital environment are effective, but this systematic
humanitarian systematic review review was unable to identify a superior type.
response Eckert23 Health-related disaster communication and social Health RE This review applies rigorous methodology to analyze the existing quantitative and
(DHR) media: mixed-method systematic review Commun qualitative literature regarding the use of social media in health disasters.
Moham- Domains and indicators of resilient children in natural Int J Prev RE This meta-analysis and qualitative evaluation of literature regarding children in natural
madinia24 disasters: a systematic literature review Med disasters investigates the various methods used to assess “resiliency” and
summarizes the categories in a framework.
Singh25 Evaluating the effectiveness of sexual and PLoS ONE RE This broad review of 40 years of literature on sexual and reproductive health in
reproductive health services during humanitarian humanitarian crises highlights evidence-based interventions useful for designing
crises: a systematic review future programs.
Emergency Balk30 Lung ultrasound compared to chest X-ray for Pediatr RE Although chest X-ray is the standard imaging modality for diagnosing pediatric
care in diagnosis of pediatric pneumonia: a meta-analysis Pulmonol community-acquired pneumonia, it has many limitations and is often inaccessible in
resource- resource-limited settings. The review demonstrates that lung ultrasound may be a
limited feasible alternative that is more sensitive than chest x-ray in the diagnosis of pediatric
settings pneumonia.
(ECRLS) Bilal31 Evaluation of standard and mobile health-supported Am J Trop OR Utilizing a mobile health-supported tool, nurses assessed dehydration status of both
clinical diagnostic tools for assessing dehydration in Med Hyg pediatric and adult patients with diarrheal illness in a rural hospital. This study
patients with diarrhea in rural Bangladesh reported superior interobserver agreement with the mobile tool than standard
evaluation methods.
Broccoli44,45 Essential medicines for emergency care in Africa Emerg Med J; RE This review proposes an essential medicines list (EML) specifically for emergency care
Afr J Emerg in resource-constrained settings. Through structured literature review and expert
Med consensus, the authors present an EML for emergency care in Africa composed of
213 medicines, 25 of which are new to the emergency-focused EML.
Chowdhury42 Salbutamol in acute organophosphorus insecticide Clin Toxicol OR This pilot, proof-of-concept, dose–response randomized controlled trial reports no
poisoning - a pilot dose-response phase II study (Phila) significant difference in resuscitation parameters and outcomes when adding
nebulized salbutamol to the standard treatment of acute self-inflicted
organophosphate poisoning in a tertiary care center in Bangladesh.
Dahn46 Acute care for the three leading causes of mortality Int J Crit Illn RE Diagnostic and therapeutic interventions for acute presentations related to the three
in lower-middle-income countries: a systematic Inj Sci leading causes of mortality in lower-middle-income countries (ischemic heart disease,
review stroke, and lower respiratory infections) are available and effective, but data are
lacking outside of Asia.
E Silva43 Safety and efficacy of intravenous lidocaine for pain Ann Emerg RE IV lidocaine has been used effectively as an analgesic in well-controlled outpatient and
management in the emergency department: a Med inpatient settings; however, its efficacy and safety in the ED has not been
systematic review established. This review shows that more study is needed before it can be
recommended for an ED population.
Fleischmann- The global burden of paediatric and neonatal sepsis: Lancet Respir RE This systematic review and meta-analysis estimated the population-based incidence of
Struzek37 a systematic review Med sepsis among neonates and children globally, but was only able to use data from
high-income settings, thereby limiting generalizability.
Freedman32 Oral ondansetron administration to nondehydrated Ann Emerg OR Nondehydrated children in Pakistan with vomiting as a result of acute gastroenteritis
children with diarrhea and associated vomiting in Med do not benefit from a single oral dose of ondansetron. Ondansetron in these children
emergency departments in Pakistan: a randomized did not decrease the use of IV fluids.
controlled trial
Fuchs38 Reviewing the WHO guidelines for antibiotic use for Paediatr Int RE A systematic review of recent literature and guidelines regarding antibiotic treatment
sepsis in neonates and children Child Health regimens for bacterial sepsis in neonates and young children in low- and middle-
income communities recommends no change in practice.
(Continued)
1190 Trehan et al. • GLOBAL EMERGENCY MEDICINE LITERATURE REVIEW 2018
Table 2. (continued)
First OR or
Category Author Title Journal RE Summary
Howie28 Zinc as an adjunct therapy in the management of J Glob Health OR Providing zinc supplementation to children in Gambia who were being treated for
severe pneumonia among Gambian children: severe pneumonia did not have an impact on treatment failure rates.
randomized controlled trial
Iro35 Rapid intravenous rehydration of children with acute BMC Pediatr RE There is very limited evidence, including a paucity of high-quality studies in low-
gastroenteritis and dehydration: a systematic review income settings, in support of the WHO guideline for rapid IV rehydration in children
and meta-analysis with severe dehydration due to acute gastroenteritis.
Kailemia36 Caregiver oral rehydration solution fluid monitoring Int Health OR When children’s caregivers use a chart to monitor the administration of oral
charts versus standard care for the management of rehydration solution, there is a reduction in the amount of dehydration in children with
some dehydration among Kenyan children: a diarrhea.
randomized controlled trial
Morton39 The early recognition and management of sepsis in Int J Environ RE The first review of early sepsis interventions in adults in sub-Saharan Africa found that
sub-Saharan African adults: a systematic review Res Public protocolized care may be associated with higher mortality, although this conclusion is
and meta-analysis Health based on only two of three high-quality studies from the region.
Nainggolan41 The tolerability and efficacy of oral isotonic solution Indian J OR This small single-blind randomized controlled trial comparing oral isotonic solution to
versus plain water in dengue patients: a randomized Community oral plain water for the treatment of dengue found no statistically significant
clinical trial Med differences in efficacy or tolerability of the two solutions.
Nayani29 The clinical respiratory score predicts paediatric BMC Pediatr OR The Clinical Respiratory Score (CRS) is a triage tool previously studied only in high-
critical care disposition in children with respiratory income settings related to specific respiratory diseases. In this study, the authors
distress presenting to the emergency department validated its expanded use through a prospective
observational study of pediatric patients who presented to the ED with a variety of
diagnoses in a single-center tertiary care ED in Pakistan.
Nepal40 Tenecteplase versus alteplase for the Cureus RE The current evidence for efficacy and safety of IV tenecteplase in comparison to IV
management of acute ischemic stroke in a low- alteplase as thrombolytic therapy for acute ischemic stroke is reviewed. Tenecteplase
income country-Nepal: cost, is a reasonable alternative to alteplase, especially in low-income settings.
efficacy, and safety
Pe
rez- Smectite for acute infectious diarrhoea in children Cochrane RE Smectite may reduce duration of diarrhea by 24 hours and increase clinical resolution
Gaxiola33 Database by day 3 after treatment but conclusions are based on low-quality evidence and trials
Syst Rev at high risk of bias.
Sadruddin27 Comparison of 3 days amoxicillin versus 5 days co- Clin Infect Dis OR A 3-day course of amoxicillin reduced treatment failure and improved compliance
trimoxazole for treatment of fast-breathing when compared to a 5-day course of cotrimoxazole in children younger than 5 years
pneumonia by community health workers in children of age with fast-breathing pneumonia.
aged 2–59 months in Pakistan: a cluster-
randomized trial
Shrestha26 Estimating the weight of children in Nepal by World J OR The PAWPER XL tape allows more accurate weight estimation of children presenting
Broselow, PAWPER XL and Mercy method Emerg Med for medical care in Nepal compared to the Broselow tape and Mercy method.
Vecino- Effective interventions for unintentional injuries: a Lancet Glob RE This systematic review summarizes injury reduction interventions that have effectively
Ortiz47 systematic review and mortality impact assessment Health reduced mortality, as well as the number of lives that could be saved annually by
among the poorest billion these interventions if they were implemented for the world’s poorest billion people.
Williams34 Guidelines for the management of paediatric cholera Paediatr Int RE After a thorough systematic review, the authors recommend a change in practice by
infection: a systematic review of the evidence Child Health proposing that a single dose of azithromycin
be recommended as first-line treatment of cholera in children.
OR = original research article; RE = review article.
ACADEMIC EMERGENCY MEDICINE • October 2019, Vol. 26, No. 10 • www.aemj.org 1191
summaries of these articles, including a summary of As has been the case with previous years’ reviews,
the key findings and a critique of the results. These the articles that scored highest continued to be domi-
full reviews were then edited for style, content, consis- nated by those classified as ECRLS. No EMD articles
tency, and objectivity by an editor and the managing scored in the top 5% of all articles, which we believe
editor, as needed, prior to publication as part of this reflects a shortage in the field and thus an opportunity
review. for further research or descriptive studies about the
advancement and implementation of emergency care
around the world. Most of the highly scored articles
RESULTS
this year were review articles, which may represent a
A total of 15,893 articles were identified by the Med- maturation of the relevant literature to the degree that
line search; an additional 3,098 articles were identified high-quality comprehensive syntheses and analyses of
by the comprehensive retrieval process of select journals existing literature are being published.
and 19 articles were identified by the gray literature A significant limitation of the study is the relatively
search. Among these, 25 were written in French, 16 in low interobserver agreement between each set of two
Portuguese, and 51 in Spanish. After duplicates were reviewers that scored the 517 articles selected for full
screened and removed, a total of 517 articles underwent review. A significant portion of this discrepancy arises
full scoring (Table 1; Data Supplement S5). from the more subjective “importance” and “impact”
Inter-rater reliability for reviewer scoring, measured components of the scoring rubric (Data Supple-
using weighted Cohen’s kappa19,20 was 0.213 (95% ment S4). This can be viewed as a disadvantage of the
confidence interval [CI] = 0.160 to 0.267), generally study methods and will warrant increased training for
considered “fair” reliability for such studies.21 Much of consistency and uniform comprehension and interpre-
the variability in reviewer scores stemmed from the tation of the scoring rubric for future reviews. One
more subjective “importance” and “impact” scores might also consider these discrepancies to be an
(Data Supplement S4). When these two components advantage, as this reflects the diversity of backgrounds
of the overall scores were excluded, the weighted and experiences of the GEMLR reviewers who trained
Cohen’s kappa improved considerably to 0.426 (95% and practice in such a wide variety of different settings
CI = 0.372 to 0.479). around the world. The top-scoring articles thus truly
The threshold score that identified at most 5% of reflect a consensus among diverse reviewers and edi-
the top-scoring articles was identified as the cutoff for tors of what are indeed the most impactful global EM
full reviews. For this year’s review, the threshold was articles from the prior year.
17.5, which identified a total of 25 articles (4.8% of
the 517 scored) for full review (Table 2; Data Supple- Disaster and Humanitarian Response
ment S6). Of these 25 articles, four (16%) were cate- All four DHR articles identified as top-scoring were
gorized as DHR and 21 (84%) as ECRLS; no articles review articles. While not entirely unique to global
from the gray literature search or in the EMD category EM, Boulton et al.22 reviewed various types of prehos-
achieved the threshold score for full review this year. pital hemostatic dressings for trauma and found little
Nine articles (36%) were original research articles and specific evidence to support one type of dressing over
16 (64%) were review articles. Full summaries and another but that there was the most experience and
critical analyses of these top-scoring 25 global EM arti- success with QuickClot combat gauze. Given the
cles of 2018 identified by our search are available as potentially long delay in transport for definitive trauma
Data Supplement S7. care in global settings, this finding has potentially
important impact in global trauma settings where a
selection of hemostatic dressings must be made; cost
DISCUSSION
and availability would of course still have to be
The number of articles identified by our search as rele- addressed.
vant to global EM increased by 7.3% compared to last The other three DHR articles that scored highly
year’s search; however, the addition of a third screen- focused on what might be considered relatively new
ing step to verify the relevance of articles to global EM topics in global EM. Eckert et al.23 reviewed the role
decreased the number of articles for formal scoring by of social media in health emergencies—this has grow-
39%. ing influence across all of our lives, but especially so
1192 Trehan et al. • GLOBAL EMERGENCY MEDICINE LITERATURE REVIEW 2018
in developing countries where access to other media Nayani et al.29 validated the Clinical Respiratory Score
may be limited, delayed, or censored. Although the in children presenting to a single ED in Pakistan for
data in this study was mostly from richer countries, determining its predictive value for admission to a criti-
no doubt social media will become continue to gain cal care unit of the hospital. A simple and affordable
influence globally and will be increasingly used in scoring system such as this one has great potential for
emergencies. Awareness of the benefits in informing helping with triage and appropriate resource utilization.
the public and the potential harms of spreading misin- A review by Balk et al.30 found higher sensitivity using
formation is important to all practitioners of global ultrasound compared to X-ray for diagnosing pediatric
EM. community-acquired pneumonia, which may help
An increasing trend in literature on mental health increase rates of pneumonia diagnosis and appropriate
was exemplified by Mohammadinia et al.24 who treatment worldwide. This is an excellent example of
attempted to understand what factors into resilience an affordable technology that can be used to democra-
among children in natural disasters. They found a tize and improve care in resource-limited settings.
multitude of domains to consider but no perfect defi- Another effective use of novel technology was
nition. Finally, Singh et al.25 reviewed 40 years of liter- demonstrated by Bilal et al.31 who tested the use of a
ature on sexual and reproductive health to highlight novel mobile phone application for diagnosing dehy-
specific interventions that may be useful for future pro- dration in children and adults in Bangladesh. The
gramming in this domain in humanitarian crises. technology was a significant improvement in assessing
the degree of dehydration, particularly in adults and
Emergency Care in Resource-limited older children. Several other important articles study-
Settings ing pediatric gastroenteritis, the second largest cause of
This year’s ECRLS articles were dominated by those pediatric mortality, were also identified.
most relevant to pediatric EM. Recognizing that accu- In terms of treatment, Freedman et al.32 con-
rate weight measurement is fundamental to pediatric ducted a rigorous, placebo-controlled RCT in Pak-
care, Shrestha et al.26 showed that the novel PAWPER istan demonstrating that ondansetron was of little
XL tape facilitated accurate rapid visual weight estima- benefit to nondehydrated children with gastroenteritis
tion in a population of Nepali children presenting for in the emergency setting. Given the cost of this medi-
emergency care. This method has great potential for cation and the assumption that it would be widely
improved accuracy of dosing and selection of appropri- useful across many populations, this is important,
ately sized equipment not only in populations where widely generalizable, evidence that can help limit the
children are malnourished, but also in populations use of a potentially expensive medication that may
where a growing number of children are overweight/ not provide significant clinical benefit in this setting.
obese as well. P
erez-Gaxiola et al.33 conducted a rigorous Cochrane
Four articles focused on pediatric pneumonia, which Review of the added benefit of smectite, a clay min-
remains the leading cause of death among children eral that may adsorb toxin, to the treatment regimen
worldwide. Sadruddin et al.27 demonstrated in a clus- for children with diarrhea. The review was limited by
ter-randomized pragmatic trial that a 3-day course of low-quality evidence and trials at high risk of bias but
amoxicillin was superior to a 5-day course of cotrimox- there was the implication of enough equipoise to jus-
azole for children with fast-breathing pneumonia trea- tify a rigorously conducted trial with clearer enroll-
ted in the community. This has significant potential ment, methods, and outcome measures. With regard
for changing worldwide treatment patterns and addi- to a specific infection, Williams et al.34 reviewed
tionally help decrease cost and increase compliance. recent microbiologic and clinical literature to identify
Howie et al.28 conducted a multicenter, placebo-con- the optimal antimicrobial treatment regimen for pedi-
trolled, double-blind, randomized controlled trial atric cholera infection. After a thorough review that
(RCT) of zinc added to routine care for community-ac- leaned heavily on data from adult patients and with
quired pneumonia in The Gambia. Although there significant consideration to rising rates of antimicro-
was no decrease in failure rates, this may have been bial resistance, the authors conclude that single-dose
due to a relatively low rate of baseline zinc deficiency, azithromycin is the best antibiotic regimen for chil-
which should motivate a similar study in a population dren with cholera that balances effectiveness with
where zinc deficiency is a more pervasive problem. practical delivery.
ACADEMIC EMERGENCY MEDICINE • October 2019, Vol. 26, No. 10 • www.aemj.org 1193
Iro et al.35 attempted to identify RCTs that would Another RCT for an important global EM topic
provide evidence for or against the World Health was conducted by Chowdhury et al.42 who studied the
Organization (WHO) recommendation for rapid intra- effect of salbutamol (albuterol) on organophosphate
venous (IV) fluid resuscitation for children with severe poisoning. This pilot study proved to be too small
dehydration due to acute gastroenteritis. There were and limited to demonstrate any difference in efficacy
no trials identified in resource-poor settings and only between placebo, 2.5 mg of salbutamol, and 5 mg of
three trials identified overall, none of which produced salbutamol. This does not exclude the possibility that
evidence to support the current WHO recommenda- salbutamol would be effective in this setting, but this
tion, once again demonstrating that clinical evidence was not proven in this case. E Silva43 conducted a
from resource-rich settings may not necessarily apply comprehensive review of the use of IV lidocaine for
directly to resource-limited settings in all cases. pain management of several common acute conditions
Kailemia et al.36 conducted a creative RCT wherein with the intention of providing an alternative to opi-
children’s caregivers documented oral rehydration solu- ates. This is a potentially powerful alternative interven-
tion intake and symptoms during the course of treat- tion in a time of the global opiate crisis, but also
ment for diarrhea and dehydration. This task-shifting important in places around the world where opiates
activity proved effective in reducing the rates of dehy- may not be available. Unfortunately, no clear evidence
dration and hospitalization. This may be generalizable was found to show its safety and usefulness in the ED
to other settings and leveraged to help improve patient setting yet.
care and efficiency for other illnesses also. Finally, three “big picture” landscape reviews scored
Two reviews related to pediatric sepsis were also highly and were evaluated in full. Broccoli et al.44,45
selected for full review. Fleischmann-Struzek et al.37 summarized the process by which an essential medici-
conducted a systematic review and meta-analysis to nes list (EML) for emergency care providers in Africa
attempt to define the burden of pediatric and neonatal was created through a series of consensus meetings.
sepsis worldwide. However, significant limitations in This list has tremendous importance for planners who
the availability of literature and data from low-income may want to start EDs and plan for emergency care in
settings greatly limited the review’s generalizability and places where this development has been relatively
provides what is really a lower estimate for pediatric decentralized and variable from setting to setting.
sepsis. Fuchs et al.38 conducted a thorough systematic Dahn et al.46 undertook a comprehensive landscape
review of appropriate antibiotics for pediatric sepsis in review of acute clinical care for emergency conditions
lower-middle-income countries (LMICs) and found no that contribute most to morbidity and mortality in
specific evidence to warrant a change in WHO guideli- LMICs. This review provides a good starting point for
nes or common clinical practice. practitioners entering the field and also highlights the
With regard to adult patients, Morton et al.39 con- need for more contextual local data, as the review was
ducted the first review of bundled interventions against mostly only able to identify data from Asian settings.
sepsis among adults in sub-Saharan Africa and found Vecino-Ortiz et al.47 conducted a comprehensive
that this protocolized care actually results in higher review of interventions to prevent unintentional inju-
mortality, emphasizing the importance of local data ries in LMICs and estimate how many lives might be
used to generate local protocols rather than universally saved if all of these interventions were able to be
applied bundles. Nepal et al.40 reviewed tenecteplase implemented throughout countries where the world’s
as a thrombolytic agent for acute ischemic stroke. poorest billion live.
When compared to the more widely used alteplase,
they found it to be a justifiable alternative in resource-
CONCLUSIONS
limited settings, given its safety and efficacy profiles as
well as lower cost. Nainggolan et al.41 conducted a The 2018 Global Emergency Medicine Literature
pilot study comparing oral isotonic solution to water Review again identified several hundred articles related
for hydration in adults with dengue. Although this to global EM. The highest scoring articles were all in
very small trial did not demonstrate any statistically sig- DHR and ECRLS. New technologies and traditionally
nificant benefits from the oral isotonic solution, there less studied topics were well represented, including
were small trends toward secondary benefits that are social media, mental health, sexual and reproductive
worth exploring in a larger trial. health, and pain management. This year’s top-scoring
1194 Trehan et al. • GLOBAL EMERGENCY MEDICINE LITERATURE REVIEW 2018
articles were dominated by pediatric infectious emer- 14. Becker TK, Hansoti B, Bartels S, et al. Global emergency
gencies, including pneumonia, gastroenteritis, and sep- medicine: a review of the literature from 2015. Acad
sis. Several high-quality reviews that help define Emerg Med 2016;23:1183–91.
fundamental issues in the field were also identified 15. Becker TK, Hansoti B, Bartels S, et al. Global emergency
that may provide concrete guidance as global EM medicine: a review of the literature from 2016. Acad
develops standardized care models. Overall, the clini- Emerg Med 2017;24:1150–60.
16. Becker TK, Trehan I, Hayward AS, et al. Global emer-
cal research literature in global EM is robust and
gency medicine: a review of the literature from 2017. Acad
growing despite many barriers,48 although large room Emerg Med 2018;25:1287–98.
for growth remains for data emanating from resource- 17. Balhara KS, Silvestri DM, Tyler Winders W, et al. Impact
limited settings. of nutrition interventions on pediatric mortality and nutri-
tion outcomes in humanitarian emergencies: a systematic
REFERENCES review. Trop Med Int Health 2017;22:1464–92.
18. Balhara KS, Bustamante ND, Selvam A, et al. Bystander
1. Paez A. Gray literature: an important resource in system- assistance for trauma victims in low- and middle-income
atic reviews. J Evid Based Med 2017;10:233–40. countries: a systematic review of prevalence and training
2. Hansoti B, Aluisio AR, Barry MA, et al. Global health interventions. Prehosp Emerg Care 2019;23:389–410.
and emergency care: defining clinical research priorities. 19. Cohen J. Weighted kappa: nominal scale agreement with
Acad Emerg Med 2017;24:742–53. provision for scaled disagreement or partial credit. Psychol
3. Razzak J, Usmani MF, Bhutta ZA. Global, regional and Bull 1968;70:213–20.
national burden of emergency medical diseases using speci- 20. Maclure M, Willett WC. Misinterpretation and misuse of
fic emergency disease indicators: analysis of the 2015 glo- the kappa statistic. Am J Epidemiol 1987;126:161–9.
bal burden of disease study. BMJ Glob Health 2019;4: 21. Kundel HL, Polansky M. Measurement of observer agree-
e000733. ment. Radiology 2003;228:303–8.
4. Levine AC, Gadiraju S, Goel A, et al. International emer- 22. Boulton AJ, Lewis CT, Naumann DN, Midwinter MJ.
gency medicine: a review of the literature. Acad Emerg Prehospital haemostatic dressings for trauma: a systematic
Med 2007;14:182–3. review. Emerg Med J 2018;35:449–57.
5. Levine AC, Goel A, Keay CR, et al. International emer- 23. Eckert S, Sopory P, Day A, et al. Health-related disaster
gency medicine: a review of the literature from 2006. Acad communication and social media: mixed-method system-
Emerg Med 2007;14:1190–3. atic review. Health Commun 2018;33:1389–400.
6. Levine AC, Becker J, Lippert S, et al. International emer- 24. Mohammadinia L, Ardalan A, Khorasani-Zavareh D, et al.
gency medicine: a review of the literature from 2007. Acad Domains and indicators of resilient children in natural disas-
Emerg Med 2008;15:860–5. ters: a systematic literature review. Int J Prev Med 2018;9:54.
7. Lippert S, Levine AC, Becker J, et al. International emer- 25. Singh NS, Smith J, Aryasinghe S, et al. Evaluating the
gency medicine: a review of the literature from 2008. Acad effectiveness of sexual and reproductive health services
Emerg Med 2009;16:1335–40. during humanitarian crises: a systematic review. PLoS
8. Aschkenasy M, Arnold K, Foran M, et al. International One 2018;13:e0199300.
emergency medicine: a review of the literature from 2010. 26. Shrestha K, Subedi P, Pandey O, et al. Estimating the
Acad Emerg Med 2011;18:872–9. weight of children in Nepal by Broselow, PAWPER XL
9. Foran M, Levine A, Lippert S, et al. International emer- and Mercy method. World J Emerg Med 2018;9:276–81.
gency medicine: a review of the literature from 2009. Acad 27. Sadruddin S, Khan IU, Fox MP, et al. Comparison of 3
Emerg Med 2011;18:86–92. days amoxicillin versus 5 days co-trimoxazole for treatment
10. Schroeder ED, Jacquet G, Becker TK, et al. Global emer- of fast-breathing pneumonia by community health workers
gency medicine: a review of the literature from 2011. Acad in children aged 2–59 months in Pakistan: a cluster-ran-
Emerg Med 2012;19:1196–203. domized trial. Clin Infect Dis 2018 [Epub ahead of print].
11. Jacquet GA, Foran M, Bartels S, et al. Global emergency 28. Howie S, Bottomley C, Chimah O, et al. Zinc as an
medicine: a review of the literature from 2012. Acad adjunct therapy in the management of severe pneumonia
Emerg Med 2013;20:835–43. among Gambian children: randomized controlled trial. J
12. Becker TK, Jacquet GA, Marsh R, et al. Global emergency Glob Health 2018;8:010418.
medicine: a review of the literature from 2013. Acad 29. Nayani K, Naeem R, Munir O, et al. The clinical respira-
Emerg Med 2014;21:810–7. tory score predicts paediatric critical care disposition in
13. Becker TK, Bartels S, Hansoti B, et al. Global emergency children with respiratory distress presenting to the emer-
medicine: a review of the literature from 2014. Acad gency department. BMC Pediatr 2018;18:339.
Emerg Med 2015;22:976–84.
ACADEMIC EMERGENCY MEDICINE • October 2019, Vol. 26, No. 10 • www.aemj.org 1195
30. Balk DS, Lee C, Schafer J, et al. Lung ultrasound com- 44. Broccoli MC, Pigoga JL, Nyirenda M, Wallis L, Calvello
pared to chest x-ray for diagnosis of pediatric pneumonia: Hynes EJ. Essential medicines for emergency care in
a meta-analysis. Pediatr Pulmonol 2018;53:1130–9. Africa. Emerg Med J 2018;35:412–9.
31. Bilal S, Nelson E, Meisner L, et al. Evaluation of standard 45. Broccoli MC, Pigoga JL, Nyirenda M, Wallis LA, Calvello
and mobile health-supported clinical diagnostic tools for Hynes EJ. Essential medicines for emergency care in
assessing dehydration in patients with diarrhea in rural Africa. Afr J Emerg Med 2018;8:110–7.
Bangladesh. Am J Trop Med Hyg 2018;99:171–9. 46. Dahn CM, Wijesekera O, Garcia GE, Karasek K, Jacquet
32. Freedman SB, Soofi SB, Willan AR, et al. Oral ondanse- GA. Acute care for the three leading causes of mortality in
tron administration to nondehydrated children with diar- lower-middle-income countries: a systematic review. Int J
rhea and associated vomiting in emergency departments Crit Illn Inj Sci 2018;8:117–42.
in Pakistan: a randomized controlled trial. Ann Emerg 47. Vecino-Ortiz AI, Jafri A, Hyder AA. Effective interven-
Med 2019;73:255–65. tions for unintentional injuries: a systematic review and
33. Perez-Gaxiola G, Cuello-Garcia CA, Florez ID. Perez-Pico mortality impact assessment among the poorest billion.
VM. Smectite for acute infectious diarrhoea in children. Lancet Glob Health 2018;6:e523–34.
Cochrane Database Syst Rev 2018;4:CD011526. 48. Levine AC, Barry MA, Agrawal P, et al. Global health
34. Williams PC, Berkley JA. Guidelines for the management and emergency care: overcoming clinical research barriers.
of paediatric cholera infection: a systematic review of the Acad Emerg Med 2017;24:484–93.
evidence. Paediatr Int Child Health 2018;38:S16–31.
35. Iro MA, Sell T, Brown N, Maitland K. Rapid intravenous
rehydration of children with acute gastroenteritis and dehy- Appendix A
dration: a systematic review and meta-analysis. BMC Pedi-
Global Emergency Medicine Literature Review
atr 2018;18:44.
(GEMLR) Group (in alphabetical order) members:
36. Kailemia M, Kariuki N, Laving A, Agweyu A, Wamalwa
D. Caregiver oral rehydration solution fluid monitoring Holly Bannon-Murphy, MBBS, Emergency and
charts versus standard care for the management of some Trauma Centre, Alfred Health, Melbourne, Australia
dehydration among Kenyan children: a randomized con- Susan A. Bartels, MD, MPH, FRCPC, Department
trolled trial. Int Health 2018;10:442–50. of Emergency Medicine and Department of Public
37. Fleischmann-Struzek C, Goldfarb DM, Schlattmann P, Health Sciences, Queen’s University, Kingston, Ontar-
et al. The global burden of paediatric and neonatal sepsis: io, Canada
a systematic review. Lancet Respir Med 2018;6:223–30. Temesgen Beyene, MD, Department of Emergency
38. Fuchs A, Bielicki J, Mathur S, Sharland M, Van Den Medicine, Addis Ababa University, Addis Ababa,
Anker JN. Reviewing the WHO guidelines for antibiotic Ethiopia
use for sepsis in neonates and children. Paediatr Int Child Joseph Bonney, MBChB, MPH, Emergency Medi-
Health 2018;38:S3–15. cine, Komfo Anokye Teaching Hospital, Kumasi,
39. Morton B, Stolbrink M, Kagima W, Rylance J, Mortimer Ghana
K. The early recognition and management of sepsis in
Amanda T. Collier, MD, DTM&H, Department of
sub-Saharan African adults: a systematic review and meta-
analysis. Int J Environ Res Public Health 2018;15. Emergency Medicine, Queen’s University, Kingston,
40. Nepal G, Kharel G, Ahamad ST, Basnet B. Tenecteplase Ontario, Canada
versus alteplase for the management of acute ischemic Jolene Cook, MD, Department of Emergency Medi-
stroke in a low-income country-Nepal: cost, efficacy, and cine, Dalhousie University, Halifax, Canada, Hôpital
safety. Cureus 2018;10:e2178. Universitaire de Mirebalais, Mirebalais, Haiti, and
41. Nainggolan L, Bardosono S, Ibrahim Ilyas EI. The tolera- Emergency Health Services, Government of Nova Sco-
bility and efficacy of oral isotonic solution versus plain tia, Halifax, Nova Scotia, Canada
water in dengue patients: a randomized clinical trial. Jonathan W. Dyal, MD, MPH, Department of
Indian J Community Med 2018;43:29–33. Emergency Medicine, Brigham and Women’s Hospi-
42. Chowdhury FR, Rahman MM, Ullah P, et al. Salbutamol in tal, Boston, MA
acute organophosphorus insecticide poisoning - a pilotdose-re- Kayla T. Enriquez, MD, MPH, Department of
sponse phase ii study. Clin Toxicol (Phila) 2018;56:820–7.
Emergency Medicine, University of California, San
43. E Silva LO, Scherber K, Cabrera D, et al. Safety and effi-
Francisco, San Francisco, CA
cacy of intravenous lidocaine for pain management in the
emergency department: a systematic review. Ann Emerg Danica J. Gomes, MD, MSc, Centers for Disease
Med 2018;72:135–44. Control and Prevention, Atlanta, GA
1196 Trehan et al. • GLOBAL EMERGENCY MEDICINE LITERATURE REVIEW 2018
Alison S. Hayward, MD, MPH, Department of Charlotte M. Roy, MD, Section of Emergency Med-
Emergency Medicine, Brown University, Providence, RI icine, University of Chicago, Chicago, IL
Wesam M. A. Ibrahim, MBBCh, MSc, Depart- Megan M. Rybarczyk, MD, MPH, Department of
ment of Emergency Medicine and Traumatology, Emergency Medicine, Brigham and Women’s Hospi-
Tanta University, Tanta, Egypt tal, Boston, MA
Devin M. Keefe, MD, Department of Emergency Megan L. Schultz, MD, MA, Department of Pedi-
Medicine, Portsmouth Regional Hospital, Portsmouth, atrics, Medical College of Wisconsin, Milwaukee, WI
NH Kimberly A. Stanford, MD, Section of Emergency
J. Austin Lee, MD, MPH, Department of Emergency Medicine, University of Chicago, Chicago, IL
Medicine, University of Virginia, Charlottesville, VA Lara D. Vogel, MD, MBA, Harvard Affiliated
Sangil Lee, MD, MS, Department of Emergency Emergency Medicine Residency Program, Boston, MA
Medicine, University of Iowa, Iowa City, IA Alex H. Wang, MD, Department of Emergency
Richard Lowsby, MBChB, FRCEM, DTMH, Emer- Medicine, University of Connecticut, Hartford, CT
gency Department, Mid Cheshire Hospitals NHS Ayalew Zewdie, MD, Department of Emergency
Foundation Trust, Cheshire, UK Medicine and Critical Care, St. Paul’s Hospital Mil-
Rishi P. Mediratta, MD, MSc, MA, Department of lennium Medical College, Addis Ababa, Ethiopia
Pediatrics, Stanford University, Stanford, CA
Carl T. Mickman, MD, Department of Emergency
Supporting Information
Medicine, Mount Sinai Hospital, New York, NY
Benjamin D. Nicholson, MD, Department of Emer- The following supporting information is available in
gency Medicine, Boston Medical Center, Boston, MA the online version of this paper available at http://
Gerard M. O’Reilly, MBBS, FACEM, MPH, MBio- onlinelibrary.wiley.com/doi/10.1111/acem.13832/full
stat, PhD, Emergency and Trauma Centre, The Data Supplement S1. GEMLR 2018 Procedure
Alfred, and School of Public Health and Preventive Manual.
Medicine, Monash University, Melbourne, Australia Data Supplement S2. Medline search terms.
Pryanka Relan, MD, MPH, Emergency Medicine, Data Supplement S3. Gray literature sources.
Emory Healthcare Network, Atlanta, GA Data Supplement S4. GEMLR scoring criteria.
Kyle T. Ragins, MD, MBA, Department of Emer- Data Supplement S5. Complete database of all 517
gency Medicine, University of California at Los Ange- identified global EM articles for 2018.
les, Los Angeles, CA Data Supplement S6. Flow diagram of articles
Eleanor A. Reid, MD, MSc, DTM&H, Department selected for review.
of Emergency Medicine, Yale University, New Haven, Data Supplement S7. Full summaries and critical
CT analyses of the top-scoring GEMLR articles of 2018.