Timothy Craig Hardcastle

Guideline for the assessment of trauma centres for South Africa.

INTRODUCTION Trauma is a well-known leading cause of unnatural death and disability in South Africa. Internationally the trend is moving toward systematised care. AIM To revise the Trauma Centre Criteria of the Trauma Society of South Africa and align these with the terminology and modern scope of emergency care practice, using best-care principles as a prelude to the development of trauma systems in South Africa. METHODOLOGY Revision of existing documents of the Trauma Society of South Africa, the Emergency Medicine Society of South Africa and the Critical Care Society of Southern Africa, where these are relevant to the care of trauma. The committee attempted to harmonise these criteria with the goals of the World Health Organization essential trauma care guidelines for trauma centres and trauma systems. Wide expert consultation was undertaken to refine the criteria before final compilation. RESULTS AND RECOMMENDATIONS Four levels of trauma care facility are outlined, with the criteria focusing on the trauma-specific requirements of the facilities and their place in the greater trauma system. Accreditation of hospitals according to the criteria will allow for appropriate transfer and designation of patient destination for trauma patients and will improve the quality of care provided. The criteria address structural, process and human resource requirements and medical aspects for the accreditation of various level of trauma centre. CONCLUSION There is a great opportunity to apply best practice criteria to improve the care of trauma in South Africa and improve patient outcome.

The incidence and outcomes of acute kidney injury amongst patients admitted to a level I trauma unit

PURPOSE This study aimed to identify the incidence and outcomes of patients with trauma related acute kidney injury (AKI), as defined by RIFLE criteria, at a single level I trauma centre and trauma ICU. METHODS We performed a retrospective observational study of 666 patients admitted to a trauma ICU from a level I trauma unit from March 2008 to March 2011. We conducted multivariable logistic regression to identify independent predictors for AKI and mortality. RESULTS The overall incidence of AKI was 15% (n=102). Median injury severity score (ISS) was 25 (inter quartile range [IQR] 16-34) and mean age was 39 (SD 16.3) in the AKI group. Thirteen patients (13%) were referred with rhabdomyolysis associated renal Failure. Overall mortality in the AKI group was 57% (n=58) but was significantly lower in the rhabdomyolysis Failure group (23% versus 64%; p=0.012). AKI was independently associated with older age, base excess (BE)<-12 (odd ratio [OR] 22.9, 95% confidence interval [CI] 1.89-276.16), IV contrast administration (OR 2.7 95% CI 1.39-5.11) and blunt trauma (OR 2.2 95% CI 1.04-4.71). AKI was an independent predictor of mortality (OR 8.5, 95% CI 4.51-15.95). Thirty-nine (38%) patients required renal replacement therapy. CONCLUSIONS AKI in critically ill trauma patients is an independent risk factor for mortality and is independently associated with increasing age and low BE. Renal replacement therapy utilisation is high in this group and represents a significant health care cost burden.

An Assessment of the Hospital Disease Burden and the Facilities for the In-hospital Care of Trauma in KwaZulu-Natal, South Africa

BackgroundTrauma is a significant cause of morbidity and mortality in South Africa. The present study was designed to review the hospital trauma disease burden in light of the facilities available for the care of the injured in KwaZulu-Natal (KZN), South Africa’s most populous province.The primary outcomes were the annual hospital burden of trauma in KZN, determined through data extrapolation, and evaluation of the data in light of available hospital facilities within the province of KZN, a developing province. The data were obtained through review of the trauma load in relation to all emergency cases at all levels of hospitals.MethodsHospital administrators in KZN were requested to submit trauma caseloads for the months of March and September 2010. Caseloads were reviewed to determine the trauma load for the province per category using two extrapolation methods to determine the predicted range of annual incidence of trauma, intentional versus non-intentional trauma ratios and population-related incidence of trauma. The results were GIS mapped to demonstrate variations across districts. Hospital data were obtained from assessments of structure, process, and personnel undertaken prior to a major sporting event. These were compared to the ideal facilities required for accreditation of trauma care facilities of the Trauma Society of South Africa and other established documents.ResultsData were obtained from 36 of the 47 public hospitals in KZN that manage acute emergency cases. The predicted annual trauma incidence in KZN ranges from 124,000 to 125,000, or 12.9 per 1,000 population. This would imply a national public hospital trauma load on the order of at least 750,000 cases per year. Most hospitals are required to treat trauma; however, within KZN many hospitals do not have adequate personnel, medical equipment, or structural integrity to be formally accredited as trauma care facilities in terms of existing criteria.ConclusionsThere is a significant trauma load that consumes vital emergency center resources. Most hospitals will need extensive upgrading to provide appropriate care for trauma. An inclusive trauma system needs to be formalized and funded, especially in light of the planned National Health Insurance for South Africa

Direct admission versus inter-hospital transfer to a level I trauma unit improves survival: An audit of the new Inkosi Albert Luthuli Central Hospital trauma unit

OBJECTIVE To audit the performance of a new level I trauma unit and trauma intensive care unit. METHODS Data on patients admitted to the level I trauma unit and trauma intensive care unit at Inkosi Albert Luthuli Central Hospital, Durban, from March 2007 to December 2008 were retrieved from the hospital informatics system and an independent database in the trauma unit. RESULTS Four hundred and seven patients were admitted; 71% of admissions were inter-hospital transfers (IHT) and 29% direct from scene (DIR). The median age was 27 years (range 1 - 83), and 71% were male. Blunt injury accounted for 66.3% of admissions and penetrating trauma for 33.7%. Of the former, motor vehicle-related injury accounted for 87.4%, with 81% of paediatric admissions due to pedestrian-related injuries. The median injury severity score (ISS) for the entire cohort was 22 (survivors 18, deaths 29; p<0.001). Patients in the DIR group had a significantly higher mean ISS compared with the IHT group (DIR 25, IHT 20; p<0.02). The overall mortality rate was 26.3%. There were 37 deaths (31.1%) in the DIR group and 70 (24.3%) in the IHT group (p=0.19). In patients surviving more than 12 hours the overall mortality rate was 21.1% (DIR 13.7%, IHT 23.5%; p=0.042). CONCLUSIONS Trauma is a major cause of premature death in the young. Despite a significantly higher median ISS in direct admissions, there was no difference in mortality. Of those surviving more than 12 hours, patients admitted directly had a significant decrease in mortality. Dedicated trauma units improve outcome in the critically injured.

The 11P's of an Afrocentric trauma system for South Africa - time for action!

A trauma system involves the interaction of prehospital care, emergency centre care and definitive care (including prevention and rehabilitation services), providing an organised approach to acutely injured patients within a defined geographical area, from primary care to advanced care. Trauma is, after infectious disease, the second leading cause of death and disability in Africa, and must therefore feature on the national health agendas of all African countries. The requirements for developing cost-efficient, patient-centred trauma systems relevant to South Africa are outlined (each item commencing with a P, and hence the title).

Epidemiology and referral patterns of burns admitted to the Burns Centre at Inkosi Albert Luthuli Central Hospital, Durban

RATIONALE The epidemiology, referral patterns and outcome of patients admitted to a tertiary burns unit in southern Africa were reviewed. MATERIALS AND METHODS The charts of all patients with thermal injury presenting to the Burns Centre at Inkosi Albert Luthuli Central Hospital (IALCH) between 1 January 2008 and 31 December 2010 were reviewed. Information collected included age, gender, past medical history, cause of burn, size of burn, presence of inhalation injury, time before admission, time to excision, length of hospital stay, complications and mortality. FINDINGS Four hundred and sixty two patients were admitted, 296 (58%) children and 193 (42%) adults. The female-male ratio was 1:1.13. The mean total body surface area (TBSA) burned was 12% (interquartile range 8-25%) for children and 18% (interquartile range 10-35%) for adults. Common causes for the burns were in children: hot liquids (71%) and open flame (24%). Major causes in adults were: open fire (68%) and hot liquids (25%). Epilepsy was a contributing factor in 12.7%. Inhalation injury was seen in 13.6% of adults and 14.3% of children with a flame burn. Forty-four percent of referrals from general surgical units were for burns <30% in adults, and 30% for burns <10% in children. More than one in four patients was referred between 1 and 6 weeks post-injury. Overall mortality was 9.1% (5.7% in children and 15.1% in adults). Complications occurred in 21.6% of children and 36.7% in adults, the most common being lung complications such as ARDS and infection, severe sepsis, skin graft failure and contractures. The length of stay was 1 day/% TBSA burn for all burns in children and for burns between 10 and 49% in adults. CONCLUSIONS The epidemiology and outcome of severe burns referred to the Burns Centre at IALCH is similar to those in other units in Africa. The management and referral of burns patients by other hospitals are inappropriate in a significant number of patients.

Reaching consensus on the physiotherapeutic management of patients following upper abdominal surgery : a pragmatic approach to interpret equivocal evidence

BackgroundPostoperative pulmonary complications remain the most significant cause of morbidity following open upper abdominal surgery despite advances in perioperative care. However, due to the poor quality primary research uncertainty surrounding the value of prophylactic physiotherapy intervention in the management of patients following abdominal surgery persists. The Delphi process has been proposed as a pragmatic methodology to guide clinical practice when evidence is equivocal.MethodsThe objective was to develop a clinical management algorithm for the post operative management of abdominal surgery patients. Eleven draft algorithm statements extracted from the extant literature by the primary research team were verified and rated by scientist clinicians (n = 5) in an electronic three round Delphi process. Algorithm statements which reached a priori defined consensus-semi-interquartile range (SIQR) < 0.5-were collated into the algorithm.ResultsThe five panelists allocated to the abdominal surgery Delphi panel were from Australia, Canada, Sweden, and South Africa. The 11 draft algorithm statements were edited and 5 additional statements were formulated. The panel reached consensus on the rating of all statements. Four statements were rated essential.ConclusionAn expert Delphi panel interpreted the equivocal evidence for the physiotherapeutic management of patients following upper abdominal surgery. Through a process of consensus a clinical management algorithm was formulated. This algorithm can now be used by clinicians to guide clinical practice in this population.

Deaths at a Level 1 Trauma Unit: A clinical finding and post-mortem correlation study

BACKGROUND Missed injuries continue to cause deaths amongst trauma patients. Regardless of the definition of missed injuries, it is important to identify all injuries at any stage in the care of trauma patients in order to improve patient outcome. This study was performed to evaluate to what extent missed injuries contribute to a fatal outcome at a new Level 1 Trauma Unit. METHODS The medical records and autopsy reports of all trauma patients who died at the IALCH trauma unit from March 2007 through August 2009 were reviewed. The mortality rate and incidence of missed injuries were determined. A missed injury was defined as one that was found at autopsy but was not mentioned in the medical records or in any ante mortem radiological report. This excluded minor injuries such as superficial contusions and minor lacerations, which are sometimes not included in the case notes during resuscitation. Deaths due to trauma are considered unnatural and legal provisions require that all unnatural deaths undergo medico-legal postmortem examination. The study was approved by the UKZN Biomedical Research Ethics Committee. RESULTS Five hundred and forty-seven patients were admitted to the trauma unit of which 135 (24.7%) demised. Three patients were excluded, due to inability to retrieve their autopsy reports, leaving a study group of 132 patients in which there were 100 males and 32 females. The mean age was 33.2 years, mean ISS was 34.0. A total of 26 missed injuries were found in 14 patients, giving a total incidence of 10.6%. Three percent had missed injuries that were variously deemed to be possibly related, probably related, or related to the fatal outcome, whether the deaths were deemed preventable or not. Severe physiological derangement which precluded any imaging before death may have caused the injury to be overlooked. The thorax was the anatomical region where most injuries were missed. CONCLUSIONS A number of injuries remain undetected in trauma care and are found only at autopsy, emphasizing that the autopsy remains an important tool in evaluating trauma care. However, in only a few patients did the missed injuries have a detrimental effect on outcome.

Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons

PurposeThe incidence of gunshot wounds from civilian firearms is increasing. Despite this fact, guidelines on indications for bullet removal are scarce. In this analysis, we combine an overview of the available literature in these rare entities with our experiences in our own clinical practices.MethodsWe conducted a systematic literature search of computerized bibliographic databases (Medline, EMBASE, and the Cochrane Central Register). The local experience of the authors was reviewed in light of the available literature.Results145 full-text articles were suitable for further evaluation. Only six retrospective studies were available, and no prospective study could be retrieved. Most of the articles were case reports. In the South African co-author’s own clinical practice, approximately 800 patients are treated per year with gunshot wounds.ConclusionsIn summary, there are only a few clear indications for bullet removal. These include bullets found in joints, CSF, or the globe of the eye. Fragments leading to impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed. Rare indications are lead poisoning caused by a fragment, and removal that is required for a medico-legal examination. In all other cases the indication should be critically reviewed.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections

Intra-abdominal infections (IAIs) are common surgical emergencies and have been reported as major contributors to non-trauma deaths in the emergency departments worldwide.The cornerstones of effective treatment of IAIs are early recognition, adequate source control, and appropriate antimicrobial therapy. Prompt resuscitation of patients with ongoing sepsis is of utmost important.In hospitals worldwide, non-acceptance of, or lack of access to, accessible evidence-based practices and guidelines result in overall poorer outcome of patients suffering IAIs.The aim of this paper is to promote global standards of care in IAIs and update the 2013 WSES guidelines for management of intra-abdominal infections.