George Oosthuizen

The spectrum and outcome of burns at a regional hospital in South Africa

INTRODUCTION Burns remain a major cause of morbidity and mortality in Southern Africa. The more vulnerable of our population, namely the urban poor, children and epileptics, are most often affected. This audit documents our experience with burns in a busy regional hospital in Southern Africa. PATIENTS AND METHODS A prospective data base was maintained from September 2006 to February 2008 of all burn wound patients admitted in Edendale hospital. Standard demographic data, detailed description of the burn, surgical intervention, outcome and length of stay are recorded. The size and depth of the burn, as well as the initial fluid management are also recorded. RESULTS A total of 450 patients were admitted. Two hundred and thirty-five were male. There were 203 burnt children with an average age of 3 years (range 6 months to 12 years). Average age for adults was 40 years (range 13-82 years). The average surface area burnt in children was 7.5% versus 23% in adults. Of those who died, the average surface area burnt was 54%. In adults the average burn depth was superficial in 30%, deep dermal in 20% and full thickness in 50%. The aetiology of the burn was flame 70%, hot water 25% and miscellaneous 5%. In children the breakdown of burn depth was superficial in 77%, deep dermal in 15% and full thickness in 8%. The aetiology was hot water 83%, fire 6%, electrical 6% and miscellaneous 5%. The last mentioned included hot oil or porridge (15), electrical (10), chemical (6), flash burns (8) and lightning (4). Fifty percent of adults were epileptic and had sustained their burn wound during a seizure. In this group, over 40% had previously sustained burns. Fifteen percent had a delayed presentation on an average of 11 days. Hospital stay averaged 68 days (3.5 days per percent burn: range 1-161 days). Two hundred and two (45%) patients required skin grafting. The average time from burn to graft was 51 days (range 12-138). There were 40 deaths (9%) with an average age of 50 years (range 6 months to 82 years) and an average total burn surface area of 50% (range 14-85%). Aetiology of the burn in the deaths was fire in 30, lightning 4 and hot water 6. Cause of death was burn wound sepsis in 38 and inadequate resuscitation in 2. CONCLUSION Young children and epileptics are particularly vulnerable to sustaining burns. Our hospital sees a large number of burns predominantly involving smaller surface areas. Patients with small burns have a prolonged hospital stay and delayed grafting due to a conservative surgical approach and lack of resources. Large burns are fatal in our hands.

The spectrum of diaphragmatic injury in a busy metropolitan surgical service.

INTRODUCTION The diaphragm may be injured by penetrating or blunt trauma. Diaphragmatic breach without visceral injury or herniation may be difficult to detect due to a paucity of clinical signs and herniation may be misdiagnosed following the erroneous interpretation of chest radiology. If not recognized there is a considerable risk of late morbidity and mortality. This prospective study reviews our experience with diaphragmatic injury in a busy general surgical service with a large trauma component. METHODOLOGY A trauma database is maintained by the general surgical service of the Pietermaritzburg metropolitan complex. All patients who sustained a diaphragmatic injury between September 2006 and September 2007 were included in this study. RESULTS A total of 54 patients with diaphragmatic injury were treated in the period under review. There were three broad groups, namely those with simple breach of the diaphragm (37), acute diaphragmatic hernias (11) and chronic diaphragmatic hernias (6). Thirty-seven patients had a diaphragmatic breach confirmed at either laparotomy or laparoscopy. The mechanisms of injury were stab (24), gunshot wound (10), blunt trauma (2), and shotgun (1). There were seven (19%) deaths. In 19 asymptomatic patients laparoscopy was performed because of the presence of a stab wound to the left thoraco-abdominal region. Five (38%) of these patients were shown to have a diaphragmatic breach at laparoscopy. Eleven patients presented with an acute diaphragmatic hernia. The mechanisms of injury were stab (5), blunt trauma (5), and gunshot (1). The hernia contents were stomach (10), colon (1), and spleen (2). The operative approach was a laparotomy in 10 patients and a thoraco-laparotomy in one. Six patients presented with a chronic diaphragmatic hernia of longer than six months duration. The mechanisms of injury were stab (4), blunt trauma (1) and gunshot wound (1). The average delay from injury to presentation was 3.5 years. The contents were colon (3) and stomach (3). All were managed by laparotomy. CONCLUSION If there is an established indication for laparotomy diaphragmatic breach is usually recognized and dealt with appropriately although failure to follow standard principles may result in the injury being overlooked. Isolated diaphragmatic injury without associated visceral damage cannot be diagnosed clinically or radiologically. Direct video-endoscopic inspection confirms or excludes the diagnosis and has a high pick up rate. Diaphragmatic herniation can present acutely after trauma or at a time remote from the original injury. Acute diaphragmatic injury may be confused with other pathologies and there is a risk of inappropriate intervention. Most diaphragmatic hernias can be repaired via laparotomy.

The hospital cost of road traffic accidents at a South African regional trauma centre: A micro-costing study

BACKGROUND Road traffic crashes are responsible for a vast amount of death and disability in developing countries. This study uses a bottom up, micro-costing approach to determine the cost of road traffic related crashes in South Africa. METHODS Using the data from one hundred consecutive RTC related admissions to a regional hospital in South Africa we performed a bottom up costing study. To calculate costs patients were reviewed every 48 h and all interventions were recorded for each individual patient. Prices of interventions were obtained from hospital pricelists. A total cost was calculated on an individual basis. RESULTS The total cost of in-patient care for these patients was US

A randomized trial evaluating a cognitive simulator for laparoscopic appendectomy.

6,98,850. Upper limb injuries were the most expensive, and the total cost increased with the number of body regions injured. The biggest expenditure was on ward overheads (

A multi faceted quality improvement programme results in improved outcomes for the selective non-operative management of penetrating abdominal trauma in a developing world trauma centre.

2,81,681). Ninety operations were performed - the total cost of theatre time was

An audit of penetrating neck injuries in a South African trauma service.

1,48,230 and the cost of orthopaedic implants was

Penetrating cardiac injuries and the evolving management algorithm in the current era

1,26,487. CONCLUSION The cost of care of a RTC victim is significant. In light of the high numbers of RTC victims admitted over the course of the year this is a significant cost burden for a regional hospital to bear. This cost must be taken into account when allocating hospital budgets.

Patterns of injury seen in road crash victims in a South African trauma centre

Background:  The Integrated Cognitive Simulator (ICS) is a software application that integrates text, anatomy, video and simulation for training clinical procedures. The aim of this randomized controlled trial was to determine the usability of the ICS laparoscopic appendectomy module, and to determine its effectiveness in training the cognitive skills required for the procedure.

Correlation Between ATLS Training and Junior Doctors' Anatomical Knowledge of Intercostal Chest Drain Insertion

INTRODUCTION The selective non-operative management (SNOM) of penetrating abdominal trauma (PAT) is well established in our environment. As a quality-improvement initiative, we aimed to re-evaluate patient outcomes with PAT. This follows the application of new imaging and diagnostic modalities using protocolised management algorithms. METHODOLOGY A prospectively maintained digital registry was retrospectively interrogated and all patients with PAT treated by our service from January 2012 to March 2013 were included in this study. RESULTS A total of 325 patients sustained PAT during the fourteen-month study period. This included 238 SWs, 80 GSWs and 7 impalement injuries. 11 patients had eviscerated bowel, and 12 had eviscerated omentum. A total of 123 patients (38%) were selected for a trial of SNOM. This included 103 SWs, 15 GSWs and 5 impalement injuries. Emergency laparotomy was performed on 182 patients (115 SWs, 65 GSWs and 2 impalement injuries) and 21 patients with left sided thoraco-abdominal SWs underwent definitive diagnostic laparoscopy (DL). SNOM was successful in 122 cases (99%) and unsuccessful in one case (1%). In the laparotomy group 161 (88%) patients underwent a therapeutic procedure, in 12 cases (7%) the laparotomy was non-therapeutic and in 9 cases (5%) the laparotomy was negative. In the laparoscopy group (24), two patients required conversion for colonic injuries and one for equipment failure. Seven (33.3%) laparoscopies were therapeutic with the identification and intra-corporeal repair of seven left hemi-diaphragm injuries. CONCLUSION We have improved our results with the SNOM of PAT and have also managed to safely and successfully extend the role of SNOM to abdominal GSWs. We have selectively adopted newer modalities such as laparoscopy to assess stable patients with left thoraco-abdominal SWs and abdominal CT scan for the SNOM of abdominal GSWs.

Tension gastrothorax-colothorax secondary to traumatic diaphragmatic hernia.

INTRODUCTION This study reviews and validates the practice of selective non-operative management (SNOM) of penetrating neck injury (PNI) in a South African trauma service and reviews the impact new imaging modalities have had on the management of this injury. METHODOLOGY This study was performed within the Pietermaritzburg Metropolitan Trauma Service, in the city of Pietermaritzburg, Kwazulu-Natal, South Africa. A prospectively maintained trauma registry was retrospectively interrogated. All patients with PNI treated over a 46-month period were included within the study. RESULTS A total of 510 patients were included in the study. There were 452 stab wounds (SW) and 58 gunshot wounds (GSW). A total of 202 (40%) patients sustained isolated PNI, the remaining 308 (60%) patients sustained trauma to at least one additional anatomical region. An airway injury was identified in 29 (6%) patients; a pharyngo-oesophageal injury in 41 (8%) patients and a vascular injury in 86 (17%) patients. Associated injuries included three penetrating cardiac injuries (PCI) and 146 patients with haemo-pneumothoraces. Of the total cohort, 387 patients (76%) underwent CT Angiography (CTA), of which 70 (18%) demonstrated a vascular injury. Formal catheter directed angiogram (CDA) was performed on 16 patients with positive CTA but confirmed injury in only half of these patients. Of 212 patients (42%) who underwent water-soluble contrast swallow (WS-swallow), an injury was demonstrated in 29 (14%) cases. A total of 401 (79%) patients were successfully managed conservatively for PNI and 109 (21%) surgically or by endovascular intervention. Only five (1.2%) patients failed a trial of SNOM and required surgery. The in-hospital mortality rate was 2%. No deaths could be attributed to a failure of SNOM. CONCLUSION SNOM of PNI is a safe and appropriate management strategy. The conservative management of isolated pharyngeal injuries is well supported by our findings but the role of conservative treatment of oesophageal injuries needs to be further defined. The SNOM of small non-destructive upper airway injuries seems to be a safe strategy, while destructive airway injuries require formal repair. Imaging merely for proximity, is associated with a low yield. CTA has a significant false positive rate and good clinical assessment remains the cornerstone of management.