Jocinta Odendaal

Mechanical complications of central venous catheterisation in trauma patients.

INTRODUCTION Central venous catheterisation (CVC) is a commonly performed procedure in a wide variety of hospital settings and is associated with appreciable morbidity. There is a paucity of literature focusing on mechanical complications specifically in the trauma setting. The aim of our study was to determine the spectrum of mechanical complications in a high‐volume trauma centre in a developing world setting where ultrasound guidance was not available. METHODS A retrospective study was performed analysing data from a four‐year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. RESULTS A total of 178 mechanical complications (18%) occurred in 1,015 patients undergoing CVC: 117 pneumothoraces, 25 malpositions, 18 catheter dislodgements, 14 arterial cannulations, one air embolism, one chylothorax, one pleural cannulation and one retained guide‐wire. The internal jugular vein (IJV) approach was associated with a higher overall complication rate than the subclavian vein (SCV) approach (24% vs. 13%, p<0.001). Pneumothorax (73% vs. 57%, p<0.001) and arterial cannulation (15% vs. 0%, p<0.001) were more common with the IJV. Catheter dislodgement (21% vs. 0%, p<0.001) was more common with the SCV. Junior doctors performed 66% of the CVCs and this was associated with a significantly higher complication rate (20% vs. 12%, p<0.001). CONCLUSIONS CVC carries appreciable morbidity, with pneumothorax being the most frequent mechanical complication. The SCV was the most commonly used approach at our institution. The majority of CVCs were performed by junior doctors and this was associated with a considerable complication rate.

Civilian cerebral gunshot wounds: a South African experience

Cerebral gunshot wounds represent one of the most lethal forms of traumatic brain injury, but there is a paucity of literature on the topic, especially from the developing world. We reviewed our experience and describe the spectrum and outcome of civilian cerebral gunshot wounds in a major metropolitan trauma centre in South Africa.

The correlation between ATLS and junior doctors’ anatomical knowledge of central venous catheter insertion at a major trauma centre in South Africa

OBJECTIVE To review the ability of junior doctors (JDs) in identifying the correct anatomical site for central venous catheterization (CVC) and whether prior Advanced Trauma Life Support (ATLS) training influences this. DESIGN We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact site for CVC insertion via the internal jugular (IJV) and the subclavian (SCV) approach. This study was conducted in a large metropolitan university hospital in South Africa. RESULTS A total of 139 JDs were included. Forty-four per cent (61/139) were males and the mean age was 25 years. There were 90 PGY1s (65%) and 49 PGY2s (35%). Overall, 32% (45/139) were able to identify the correct insertion site for the IJV approach and 60% (84/139) for the SCV approach. Of the 90 PGY1s, 34% (31/90) correctly identified the insertion site for the IJV approach and 59% (53/90) for the SCV approach. Of the 49 PGY2s, 29% (14/49) correctly identified the insertion site for the IJV approach and 63% (31/49) for the SCV approach. No significant difference between PGY1 and 2 were identified. Those with ATLS provider training were significantly more likely to identify the correct site for the IJV approaches [OR=4.3, p=0.001]. This was marginally statistically significant (i.e. p>0.05 but <0.1) for the SCV approach. CONCLUSIONS The majority of JDs do not have sufficient anatomical knowledge to identify the correct insertion site CVCs. Those who had undergone ATLS training were more likely to be able to identify the correct insertion site.

The impact of mechanism on the management and outcome of penetrating colonic trauma

INTRODUCTION In light of continuing controversy surrounding the management of penetrating colonic injuries, we set out to compare the outcome of penetrating colonic trauma according to whether the mechanism of injury was a stab wound or a gunshot wound. METHODS Our trauma registry was interrogated for the 5‐year period from January 2012 to December 2016. All patients over the age of 18 years with penetrating trauma (stab or gunshot) and with intraoperatively proven colonic injury were reviewed. Details of the colonic and concurrent abdominal injuries were recorded, together with the operative management strategy. In‐hospital morbidities were divided into colon‐related and non‐colon related morbidities. The length of hospital stay and mortality were recorded. Direct comparison was made between patients with stab wounds and gunshot wounds to the colon. RESULTS During the 5‐year study period, 257 patients sustained a colonic injury secondary to penetrating trauma; 95% (244/257) were male and the mean age was 30 years. A total of 113 (44%) sustained a gunshot wound and the remaining 56% (144/257) sustained a stab wound. Some 88% (226/257) of all patients sustained a single colonic injury, while 12% (31/257) sustained more than one colonic injury. A total of 294 colonic injuries were found at laparotomy. Multiple colonic injuries were less commonly encountered in stab wounds (6%, 9/144 vs. 19%, 22/113, P < 0.001). Primary repair was more commonly performed for stab wounds compared with gunshot wounds (118/144 vs. 59/113, P < 0.001). Patients with gunshot wounds were more likely to need admission to intensive care, more likely to experience anastomotic failure, and had higher mortality. CONCLUSIONS It would appear that colonic stab wounds and colonic gunshot wounds are different in terms of severity of the injury and in terms of outcome. While primary repair is almost always applicable to the management of colonic stab wounds, the same cannot be said for colonic gunshot wounds. The management of colonic gunshot wounds should be examined separately from that of stab wounds.

Developing a simplified clinical prediction score for mortality in patients with cerebral gunshot wounds: The Maritzburg Score

INTRODUCTION Cerebral gunshot wounds are highly lethal and literature on the clinical scores for mortality prediction is limited. MATERIALS AND METHODS A retrospective study was undertaken over a 5‐year period at the Pietermaritzburg Metropolitan Trauma Service in South Africa. A simplified clinical prediction score was developed based on clinical and/or physiological variables readily available in the resuscitation room. RESULTS A total of 102 patients were included; 92% (94/102) were male and the mean age was 29 years; 22% (22/102) died during the admission. The presence of visible brain matter (odds ratio 12.4, P = 0.003) and motor score less than 5 (odds ratio 89.6, P < 0.001) allows the prediction success of 92% (sensitivity 73% and specificity 98%). The area under the receiver operating characteristic curve was 94% (95% confidence interval 88‐100%, P < 0.001). CONCLUSIONS The presence of visible brain matter, together with a motor score of less than 5, allows accurate identification of non‐survivors of cerebral gunshot wounds. Further study is required to validate this score.