Tetanus is a potentially fatal condition that is rare in urban environments but is seen in developing countries and post-natural-disaster. Therefore, the purpose of this report was to review the epidemiology, pathogenesis, and management of tetanus in the trauma patient.

A thorough literature review was conducted to look for the most current and thorough guidelines on the prophylaxis and treatment of tetanus. PUBMED (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), MEDLINE (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), and Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom) databases were searched for articles in English, published from 2005 to 2015, using the keywords “Tetanus,” “Trauma/Surgery,” and “Disaster.” Controlled trials, randomized controlled trials, trials of adult patients, published guidelines, expert opinions, and review articles were selected and extracted.

Current vaccination schedules in developed countries provide prophylaxis for tetanus. However, when severe natural disasters occur, many patients may not be able to provide a reliable vaccination history. In these situations, tetanus immune globulin (TIG) is indicated; if resources are not limited, both tetanus toxoid and TIG should be given to those with high-risk wounds. If resources are limited, TIG should be reserved for those that would benefit most or those least likely to have the protective antibodies.

Although tetanus is a disease that has a low incidence in the developed world due to high rates of immunization, during large-scale natural disasters, compounding factors like the types of injuries, lack of medical services and supplies, and the delay in treatment associated with an already low immunization rate result in an increased incidence and outbreaks of the disease that has higher mortality in an underdeveloped society. It is important for the urban physician that cares for trauma and critical patients to become familiar with the protocols for treatment and immunization of patients that have tetanus-prone wounds, as well as recognize the potential for outbreaks in the settings of major natural disasters.

FinkelsteinP, TeischL, AllenCJ, RuizG. Tetanus: A Potential Public Health Threat in Times of Disaster. Prehosp Disaster Med. 2017;32(3):339–342.

During a refugees’ mass-gathering incident in Kos Island, Greece, Médecins Sans Frontières (MSF; Brussels, Belgium) teams provided emergency medical care. A case report of the event focusing on difficulties encountered by the interpreters during triage and emergency response was prepared.

Data collected during the event were reviewed from the patient’s register and qualitative interviews were obtained from the MSF interpreters involved in the response. In addition, a description of the event and a literature review were included.

Total consultations were 49 patients, mainly from Syria, with an average age of 25 years. During triage, 20 patients were tagged green with only minor injuries; 11 patients were tagged yellow, mostly due to heat exhaustion, but also a hypertensive crisis, a diabetic, a pregnant woman with abdominal pain, and a peptic ulcer exacerbation. The remaining 18 patients were tagged red and diagnosed with heat syncope, except from a case of epileptic seizures and an acute chest pain patient. Interpreters were insufficient in number to accompany each doctor and every nurse providing care during the event. In addition, they were constantly disturbed by both refugees and fellow medical team members demanding their service. Interpreters had to triage and prioritize where to go and for whom to interpret.

Interpreters are an integral part of a proper refugee reception system. They should be included in authorities planning where mass gatherings of refugees are expected. Appropriate training may be needed for interpreters to develop skills useful in mass gatherings and similar prehospital settings in order to better coordinate with the medical team.

AlexakisLCPapachristouABaruzziCKonstantinouA. The Use of Interpreters in Medical Triage during a Refugee Mass-Gathering Incident in Europe. Prehosp Disaster Med. 2017;32(6):684–687.

The objective of this study was to evaluate the effect of the Stop Stroke (Pulsara; Bozeman, Montana USA) medical application on door-to-needle (DTN) time in patients presenting to the emergency department (ED) with an acute ischemic stroke (AIS).

This was a retrospective cohort study of the Good Shepherd Health System (Longview, Texas USA) stroke quality improvement dashboard for a 25-month period from February 2012 through February 2014. Data analysis includes all data from Center for Medicare and Medicaid Services (CMS; Baltimore, Maryland USA) reportable cases receiving Tissue Plasminogen Activator (TPA) for AIS during the study period. The primary outcome was mean DTN times before and after initiating Stop Stroke. Secondary outcome was the effect on the DTN≤60-minute benchmark.

During the study period, there were 533 stroke activations (200 before Stop Stroke implementation and 333 after). A total of 68 patients meeting inclusion criteria were analyzed (34 pre-app and 34 post- app). The observed mean DTN times post-app decreased 21 minutes (77 to 56 minutes), a 28% improvement (P=.001). Further, the patients meeting DTN≤60 minutes improved from 32% (11 of 34) to 82% (28 of 34) after the app’s implementation.

In this cohort of patients with AIS, Stop Stroke improved mean DTN times and number of patients treated within 60 minutes of arrival. These results demonstrate the app’s effect of increasing awareness of suspected AIS and improving coordination of care, evidenced by the magnitude of its effect on treatment times.

DicksonR, NedelcutA, McPeek NedelcutM. Stop Stroke: A Brief Report on Door-to-Needle Times and Performance After Implementing an Acute Care Coordination Medical Application and Implications to Emergency Medical Services. Prehosp Disaster Med. 2017;32(3):343–347.

Mass-casualty (MASCAL) events are known to occur in the combat setting. There are very limited data at this time from the Joint Theater (Iraq and Afghanistan) wars specific to MASCAL events. The purpose of this report was to provide preliminary data for the development of prehospital planning and guidelines.

Cases were identified using the Department of Defense (DoD; Virginia USA) Trauma Registry (DoDTR) and the Prehospital Trauma Registry (PHTR). These cases were identified as part of a research study evaluating Tactical Combat Casualty Care (TCCC) guidelines. Cases that were designated as or associated with denoted MASCAL events were included.

Fifty subjects were identified during the course of this project. Explosives were the most common cause of injuries. There was a wide range of vital signs. Tourniquet placement and pressure dressings were the most common interventions, followed by analgesia administration. Oral transmucosal fentanyl citrate (OTFC) was the most common parenteral analgesic drug administered. Most were evacuated as “routine.” Follow-up data were available for 36 of the subjects and 97% were discharged alive.

The most common prehospital interventions were tourniquet and pressure dressing hemorrhage control, along with pain medication administration. Larger data sets are needed to guide development of MASCAL in-theater clinical practice guidelines.

SchauerSG, AprilMD, SimonE, MaddryJK, CarterR III, DelorenzoRA. Prehospital Interventions During Mass-Casualty Events in Afghanistan: A Case Analysis. Prehosp Disaster Med. 2017;32(4):465–468.

Indoor mold levels typically increase after natural disasters, flooding, and water damage. Eurotium herbariorum is the sexual stage of Aspergillus glaucus.

A 66-year-old, Japanese male, ex-smoker had been diagnosed with bronchial asthma when he was five years old; he achieved remission at the age of 13 years. He was displaced from his home during the Great East Japan Earthquake on March 11, 2011 and moved to temporary housing in Miyagi Prefecture in June 2011. He experienced the first episode of chest tightness, coughing, and wheezing in February 2012, when he again was diagnosed as having bronchial asthma. Mycofloral surveillance detected high counts of Eurotium in the air of his bedroom, kitchen, and living room, with a maximal fungal count of 163,200 colony-forming units per cubic meter (CFU/m3). Although Cladosporium and Penicillium typically predominate in the indoor air of residential dwellings, only low levels of these organisms were present in the patient’s home. Morphologic identification confirmed the isolates as E. herbariorum. The patient had positive reactions to E. herbariorum in skin prick testing and the presence of antigen-specific precipitating antibodies to E. herbariorum. Computed tomography of the chest in August 2013 revealed central bronchiectasis and bronchial wall thickening. The patient experienced late reactions after provocation testing with E. herbariorum.

This report presents the rare case of a patient who developed allergic bronchopulmonary mycosis (ABPM) due to exposure to E. herbariorum during temporary housing after the Great East Japan Earthquake.

OshikataC, WatanabeM, SaitoA, IshidaM, KobayashiS, KonumaR, KamataY, TerajimaJ, ChoJ, YanaiM, TsurikisawaN. Allergic Bronchopulmonary Mycosis due to Exposure to Eurotium herbariorum after the Great East Japan Earthquake. Prehosp Disaster Med. 2017;32(6):688–690.