Wanda Bekker

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.

INTRODUCTIONnThe 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.nnnMETHODOLOGYnA 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.nnnRESULTSnA 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.nnnCONCLUSIONnWe 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.

The spectrum and outcome of surgical sepsis in Pietermaritzburg, South Africa

BACKGROUNDnSepsis is a leading cause of morbidity and mortality worldwide, and the incidence appears to be increasing. In the resource-limited environment in low- and middle-income countries, the management of surgical sepsis (SS) continues to represent a significant portion of the workload for most general surgeons.nnnOBJECTIVEnTo describe the spectrum of SS seen at a busy emergency department, and categorise the outcomes.nnnMETHODSnThe Pietermaritzburg Metropolitan Trauma Service (PMTS) and Pietermaritzburg Metropolitan Surgical Service (PMSS) in KwaZulu-Natal Province, South Africa (SA), maintain a prospective electronic registry. All patients with features of sepsis among emergency general surgical patients >15 years of age admitted to the PMSS over the period January 2012 - January 2015 were identified. From this cohort, all patients with sepsis that required surgical source control or who had a documented surgical source of sepsis (i.e. had SS) were selected for analysis.nnnRESULTSnOf a total of 6 020 adult surgical patients on the database, a cohort of 1 240 acute surgical patients with features of sepsis were identified, and 675 with SS were then analysed further. Of the 675 patients, 49.2% were male, and the mean age was 46 years (standard deviation (SD) 19); 47.0% presented to the PMSS directly from within the metropolitan area, while the remaining 53.0% were referred from hospitals outside the area. Physiological parameters (mean values) on presentation were as follows: systolic blood pressure 123 mmHg (standard deviation (SD)xa023), respiratory rate 22 breaths/min (SD 5.2), heart rate 107 bpm (SD 19), temperature 37°C (SD 2) and white cell count 20 × 109/L (SD 8). Of the patients, 21.6% were known to be HIV-positive, 13.5% (91/675) were negative and 64.9% were of unknown status; 57.6% had intra-abdominal sepsis, 26.1% diabetes-related limb sepsis and the remaining 16.3% soft-tissue infections; 17.5% required intensive care unit admission, with a mean length of stay of 4 days (SD 4), and 30.7% developed complications. In this last group (n=207), a total of 313xa0morbidities were identified. The overall mortality rate was 12.7% (86/675). The mortality rate for intra-abdominal sepsis was 13.1%, for diabetic foot sepsis 14.2% and for necrotising fasciitis 27.3%.nnnCONCLUSIONSnThe spectrum of SS in SA is different to that seen in the developed world. Intra-abdominal sepsis is the most common SS and is overwhelmingly caused by acute appendicitis. Diabetic foot infection is a major cause of SS, reflecting the increasing burden of non-communicable chronic diseases in SA.

Can We Train Military Surgeons in a Civilian Trauma Center

IntroductionThe objective of this study was to review the trauma workload and operative exposure in a major South African trauma center and provide a comparison with contemporary experience from major military conflict.Materials and methodsAll patients admitted to the PMTS following trauma were identified from the HEMR. Basic demographic data including mechanism of injury and body region injured were reviewed. All operative procedures were categorized. The total operative volume was compared with those available from contemporary literature documenting experience from military conflict in Afghanistan. Operative volume was converted to number of cases per year for comparison.ResultsDuring the 4-year study period, 11,548 patients were admitted to our trauma center. Eighty-four percent were male and the mean age was 29xa0years. There were 4974 cases of penetrating trauma, of which 3820 (77%) were stab wounds (SWs), 1006 (20%) gunshot wounds (GSWs) and the remaining 148 (3%) were animal injuries. There were 6574 cases of blunt trauma. The mechanism of injuries was as follows: assaults 2956, road traffic accidents 2674, falls 664, hangings 67, animal injuries 42, sports injury 29 and other injuries 142. A total of 4207 operations were performed. The volumes per year were equivalent to those reported from the military surgical literature.ConclusionSouth Africa has sufficient burden of trauma to train combat surgeons. Each index case as identified from the military surgery literature has a sufficient volume in our center. Based on our work load, a 6-month rotation should be sufficient to provide exposure to almost all the major traumatic conditions likely to be encountered on the modern battlefield.

The Selective Non-operative Management of Penetrating Cervical Venous Trauma is Safe and Effective

BackgroundThis paper reviews our experience with penetrating cervical venous trauma and aims to validate the selective non-operative management (SNOM) of these injuries.MethodsThis was a retrospective review of a prospectively maintained registry. All patients presenting alive with an injury to the internal jugular vein, subclavian vein or innominate vein following a PNI were reviewed for a 6-year period.ResultsAmong 817 patients admitted for the management of PNI, 76 (9.3%) had a venous injury. Of these, 37 (48.7%) patients were managed non-surgically, 20 (26.3%) required immediate surgical exploration, seven of whom had an associated arterial injury, and 19 (25%) underwent surgery following a diagnostic CTA, 16 of whom had an associated arterial or aero-digestive injury. In total, only 16 (21.1%) of the 76 patients required exploration for venous injury alone. The majority (63.2%) of patients had a history of severe bleeding or hemodynamic instability prior to arrival, but only 20 (26.3%) required immediate exploration. Two (2.6%) patients died as a result of venous injury. No patients developed complications related to the venous injury.ConclusionsSNOM is applicable to a well-defined subset of patients with isolated penetrating cervical venous trauma to the IJV and SCV identified on CTA.

Lessons learnt from the Pietermaritzburg experience with damage control laparotomy for trauma

Introduction The modern concept of damage control surgery (DCS) for trauma was first introduced less than three decades ago. This audit aims to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to distil the pertinent teaching lessons from this experience. Methods All patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry of the Pietermaritzburg Metropolitan Trauma Service, South Africa. Physiological parameters and visceral injuries were assessed. Statistical analysis was performed using STATA V.15.0. Results A total of 562 patients underwent trauma laparotomy during the period under review. The mechanism was penetrating trauma in 81% of cases (453/562). A great proportion of trauma victims were male (503/562, 90%), with a mean age of 29.5±10.8. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. Out of the 99 who required DCS, there were 32 mortalities (32%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28±0.15) with a raised lactate (5.25u2009mmol/L±3.71). Our primary repair rates for enteric injuries were surprisingly high. Conclusion Just under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient.

Acute Kidney Injury on Presentation to a Major Trauma Service is Associated with Poor Outcomes

BACKGROUNDnThis study sought to describe the burden of disease of acute kidney injury (AKI) among adult South African trauma patients who presented to a tertiary level trauma service.nnnMETHODSnThe trauma database was interrogated for the period from December 2012 to July 2017. All patients over the age of 18 y, who were admitted following trauma, were included. Outcome data were reviewed. This included in-hospital mortality, need for intensive care unit admission, and length of stay. AKI was defined according to the latest Kidney Disease Improving Global Outcomes guidelines using the presentation serum creatinine.nnnRESULTSnA total of 7613 patients were admitted for trauma over the period under review. Four thousand two hundred sixty-six patients were suitable for analysis. A total of 238 (5.6%) patients presented with AKI, 149 (62.6%) had stage 1 AKI, 40 (16.8%) had stage 2 AKI, and 49 (20.6%) had stage 3 AKI. There was a higher incidence of AKI in patients with blunt trauma. The length of stay, need for intensive care unit admission, and mortality were significantly higher in patients presenting with AKI than in those who did not present with AKI. There were 172 deaths (4.0%). The patients who died were older and had significantly higher Injury Severity Score than survivors. They were more acidotic on presentation, had lower Glasgow Coma Scale, and were more likely to be hypotensive on presentation. They also were significantly more likely to have AKI on presentation. (30.2% versus 5.6% Pxa0<xa00.001). AKI on presentation was an independent risk factor for mortality (odds ratio 3.038 95% confidence interval 1.260-7.325).nnnCONCLUSIONSnAKI is common in patients presenting to our center with acute trauma. The presence of AKI is associated with increased morbidity and mortality. Efforts must be directed to improving recognition of at-risk patients. Prompt referral and adequate resuscitation of trauma patients before transfer must be prioritized.

Defining an intra-operative blunt mesenteric injury grading system and its use as a tool for surgical-decision making

BACKGROUNDnThe mesentery may be injured in trauma and few grading systems describe mesenteric injury severity. We aimed to develop and validate an intra-operative mesenteric injury grading system.nnnMETHODSnA modified Delphi technique was used to generate an intraoperative grading system for blunt mesenteric injury called the mesenteric injury score (MIS). We performed a retrospective review (2010-2016) of patients >15 years old with blunt abdominal trauma. Patient demographics, injury severity score (ISS) and mechanism, clinical, operative, and outcome data were abstracted. The intraoperative grading system was used to describe patient outcomes including duration of stay and management approach. We compared the correlation of abdominal abbreviated injury score, Blunt Injury Prediction Score (BIPS) and the MIS with clinical outcomes using Spearmans rho.nnnRESULTSnThere were fifty-one patients of which 86% were male. Injury mechanisms included motor vehicle accidents (nu2009=u200937, 73%), pedestrian vehicle accidents (nu2009=u20097, 13%), assaults (nu2009=u20094, 8%), falls (nu2009=u20092, 4%), and a single airplane crash (2%). Median [IQR] ISS was 16 [10-25] and GCS at hospital admission was 15 [15-15]. The median [IQR] international normalized ratio was 1.2 [1.1-1.5], lactate was 2.7 [1.7-4.9], and hemoglobin was 11.4 [8.6-12.2]. The distributions of MIS included Grade I (3, 5%), Grade II (10, 20%), Grade III (10, 20%), Grade IV, 5 (10%), and Grade V (23, 45%). Increasing mesenteric injury grade was associated with longer duration of stay, need for bowel resection, and damage control laparotomy.nnnCONCLUSIONSnWe developed an intra-operative mesenteric injury grading system (MIS) and provided an initial retrospective validation using a series of patients with blunt abdominal trauma. The proposed MIS corresponded with both the AIS and the BIPS. Future study comparing cross sectional imaging and operative findings based on MIS criteria is needed.

Management of intra-abdominal vascular injury in trauma laparotomy: a South African experience

BACKGROUNDnIntra-abdominal vascular injury (IAVI) is uncommon but continues to be associated with high mortality rates despite technological advances in the past decades. In light of these ongoing developments, we reviewed our contemporary experience with IAVI in an attempt to clarify and refine our management strategies and the outcome of these patients.nnnMETHODSnWe retrospectively reviewed the charts of all patients admitted between January 2011 and December 2014 at a major trauma centre in South Africa who were found to have an IAVI during laparotomy for trauma. We collected demographic and clinical data including mechanism of injury, location and severity of the injury, concurrent injuries, physiologic parameters and clinical outcome.nnnRESULTSnWe identified 110 patients with IAVIs, of whom 98 had sustained penetrating injuries (55 gunshot wounds and 43 stab wounds). There were 84 arterial injuries (including 21 renal and 17 mesenteric) and 74 venous injuries (including 21 renal and 17 inferior vena caval). Combined venous and arterial injuries were found in almost one-third of patients (34 [30.9%]). Fifty-seven patients (51.8%) required intensive care admission. The overall mortality rate was 28.2% (31 patients); the rate was 62% for aortic injuries and 47% for inferior vena cava injuries. Liver injury, large bowel injury, splenic injury and elevated lactate level were all associated with a statistically significantly higher mortality rate.nnnCONCLUSIONnThe mortality rate for IAVI remains high despite decades of operative experience in high-volume centres. Open operative techniques alone are unlikely to achieve further reduction in mortality rates. Integration of endovascular techniques may provide an alternative strategy to improve outcomes.

The spectrum and outcome of blunt trauma related enteric hollow visceral injury

INTRODUCTION This audit focused on patients who sustained enteric injury following blunt abdominal trauma. METHODS Our prospectively maintained electronic registry was interrogated retrospectively, and all patients who had sustained blunt abdominal trauma between December 2011 and January 2016 were identified. RESULTS Overall, 2,045 patients had sustained blunt abdominal trauma during the period under review. Seventy per cent were male. The median age was 28 years. Sixty patients (2.9%) sustained a small bowel injury (SBI). Thirty‐five of these were peritonitic on presentation. All patients with a SBI had a chest x‐ray and free air was present in seven. In 18 patients with a SBI, computed tomography (CT) was performed, which revealed isolated free fluid in 12 and free intraperitoneal air in 5. In five cases, the CT was normal. A total of 32 patients (1.5%) sustained blunt duodenal trauma (BDT). All patients with BDT had a chest x‐ray on presentation. Free intraperitoneal air was not present in any. CT was performed on 17 patients with BDT. This revealed isolated free fluid or retroperitoneal air in 12. The median delay between injury and presentation for these enteric injures was 15.5 hours (interquartile range [IQR]: 8‐25 hours) while between presentation at hospital and operation, the median delay was 6 hours (IQR: 3‐13 hours). CONCLUSIONS Blunt trauma related enteric hollow visceral injury remains associated with delayed diagnosis and significant morbidity. It can be caused by a disparate array of mechanisms and is difficult to diagnose even with modern imaging strategies.

Defining the need for surgical intervention following a snakebite still relies heavily on clinical assessment: The experience in Pietermaritzburg, South Africa

BACKGROUNDnThis audit of snakebites was undertaken to document our experience with snakebite in the western part of KwaZulu-Natal (KZN) Province, South Africa (SA).nnnOBJECTIVEnTo document our experience with snakebite in the western part of KZN, and to interrogate the data on patients who required some form of surgical intervention.nnnMETHODSnA retrospective study was undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, SA. The Hybrid Electronic Medical Registry was reviewed for the 5-year period January 2012 - December 2016. All patients admitted to the service for management of snakebite were included.nnnRESULTSnThe offending snake is rarely identified, and the syndromic approach is now the mainstay of management. Most envenomations seen during the study period were cytotoxic, presenting with painful progressive swelling (PPS). We did not see any purely neurotoxic or haemotoxic envenomations. Antivenom is required for a subset of patients. The indications are essentially PPS that increases by >15xa0cm over an hour, PPS up to the elbow or knee after 4 hours, PPS of the whole limb after 8 hours, threatened airway, shortness of breath, associated clotting abnormalities and compartment syndrome. If no symptoms have manifested within 1 hour of a snakebite, clinically significant envenomation is unlikely to have occurred. Antivenom is associated with a high rate of anaphylaxis and should only be administered when absolutely indicated, preferably in a high-care setting under continuous monitoring. The need for surgery is less well defined. Urgent surgery is indicated for compartment syndrome of the limb, which is a potentially life- and limb-threatening condition. Its diagnosis is usually made clinically, but this is difficult in snakebites. Morbidity and cost increase dramatically once fasciotomy is required, as evidenced by much longer hospital stay. There is frequently a degree of cross-over between cytotoxicity and haemotoxicity in envenomations that require fasciotomy, which means that fasciotomy may result in catastrophic bleeding and should be preceded by the administration of antivenom, especially in patients with a low platelet count or a high international normalised ratio. Physiological and biochemical markers are unhelpful in assessing the need for fasciotomy. Objective methods include measurement of compartment pressures and ultrasound.nnnCONCLUSIONnThe syndromic management of snakebite is effective and safe. There is a high incidence of anaphylactic reactions to antivenom, and its administration must be closely supervised. In our area we overwhelmingly see cytotoxic snakebites with PPS. Surgery is often needed, and we need to refine our algorithms in terms of deciding on surgery.