An overview of penetrating traumatic brain injuries at a major civilian trauma centre in South Africa

Background: This study reviews our experience with penetrating Traumatic Brain Injury (TBI) in order to define and describe the injury pattern and the outcome. A secondary aim of this study was to review the use of the Motor Score (M Score) and the Simplified Motor Score(SMS) to assess and triage patients with penetrating TBI. Methods: All patients with a TBI secondary to a penetrating mechanism were identified from the Hybrid Electronic Medical Registry at Pietermaritzburg Metropolitan Trauma Service (PMTS) from January 2012 to December 2014. Standard demographic data, need for neuro-surgical intervention, location of external wounds, CT findings and mortality where analysed. The Glasgow Coma Scale (GCS) M score and SMS score were specifically evaluated to determine the relationship between the individual motor component and patient outcome. Results: Over the two-year period January 2012­December 2014, a total of 384 patients were admitted following a penetrating TBI. There were 350 males and 34 females and of this total 7 (1.82%) died. The mechanism of injury was axe (30), bottle (34), gunshot wound (GSW)(22) and stab wound (298). The average age for axe injuries was 27 and bottle injuries was 30. The average age for firearms and knives was 29 and 30 respectively. Surgery was not required for 76.67% of patients. The need for surgery varied according to mechanism of injury. Axe injuries were treated non-operatively in 47.83%, bottle injuries in 87.50%, firearms 70% and knife injuries were treated non-operatively in 86.84% of cases.The overall survival rate for a penetrating head injury in this population is 98.16%. There were a total of 368 patients with a motor score of 6 of which one died. The survival rate was 99.7% and the mortality rate 0.3%. There were only 6 patients with a motor score of 5 and only 2 with a motor score of 4. The survival rate for both these groups was 100%. There was a total of 6 patients with a motor score of 1. There was a 100% mortality rate is this group. Conclusion: Penetrating TBI has a good prognosis. The vast majority of cases do not require neuro-surgical intervention. Poor motor score is associated with a poor outcome

An analysis of adverse events and human error associated with the imaging of patients at a major trauma centre in South Africa

Background. There is growing realisation that human error contributes significantly to morbidity and mortality in modern healthcare. A number of taxonomies and classification systems have been developed in an attempt to categorise errors and quantify their impact.Objectives. To record and identify adverse events and errors as they impacted on acute trauma patients undergoing a computed tomography (CT) scan, and then quantify the effect this had on the individual patients. It is hoped that these data will provide evidence to develop error prevention programmes designed to reduce the incidence of human error.Methods. The trauma database was interrogated for the period December 2012 - April 2017. All patients aged >18 years who underwent a CT scan for blunt trauma were included. All recorded morbidity for these patients was reviewed.Results. During the period under review, a total of 1 566 patients required a CT scan at our institution following blunt trauma. Of these, 192 (12.3%, 134 male and 58 female) experienced an error related to the process of undergoing a CT scan. Of 755 patients who underwent a CT scan with intravenous contrast, detailed results were available for 312, and of these 46 (14.7%) had an acute deterioration in renal function. According to Chang's taxonomy, physical harm occurred as follows: grade I n=6, grade II n=62, grade III n=45, grade IV n=11, grade V n=27, grade VI n=21, grade VII n=15, grade VIII n=3 and grade IX n=2. Adverse events were performing an unnecessary scan (n=24), omitting an indicated scan (n=23), performing the scan incorrectly (n=8), scanning the wrong body part (n=7), equipment failure (n=18), omitting treatment following the scan (n=6), incorrect interpretation of the scan (n=65), deterioration during the scan (n=6) and others (n=35). The setting for the error was the ward (n=19), the radiology suite (n=126), the emergency department (n=45) and the operating theatre (n=2). The staff responsible for the adverse events were medical (n=155), nursing (n=4) and radiology staff (n=15). There were 67 errors of commission and 125 errors of omission. The primary cause was a planning problem in 78 cases and an execution problem in 114.Conclusions. Errors and adverse events related to obtaining a CT scan following blunt polytrauma are not uncommon and may impact significantly on the patient. Communication is essential to eliminate errors related to performing the wrong type of scan. The commonest errors relate to misinterpretation of the scan

Is direct consultant supervision of all trauma laparotomies necessary?

Introduction: This study examines the nature of trauma laparotomies performed primarily by trainees and those performed under the direct supervision of a consultant. Materials and Methods: A retrospective review was undertaken at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. All patients who underwent a trauma laparotomy were included. Admission physiology, organ injury and outcome were assessed. Statistical comparison using STATA was performed. Chi-squared analysis was used for categorical variables and unpaired T-test for physiology. Results: A total of 562 patients for trauma laparotomy were identified. Ninety percent (506/562) were male and the mean age was 30 years. The in hospital mortality was 7% (40/562). A consultant was present at 35% of cases (197/562). Consultant-lead operations were found to have a higher rate of mortality 16% vs 2% (32/197 vs 8/365: p < 0.001) and ICU 45% vs 25% (89/197 vs 91/365: p < 0.001) than trainee only.Significant differences in many parameters of admission physiology were identified. Consultant-lead procedures had a higher lactate (3.7 vs 2.9: p 0.0043), respiratory rate (RR) (22 vs 20: p 0.0005), heart rate (HR) (102 vs 96: p 0.0035) and a lower systolic blood pressure (SBP) (115 vs 122: p 0.0001) diastolic blood pressure (DBP) (69 vs 73: p 0.0350) pH (7.34 vs 7.36: p 0.0216) base excess (BE, mEq/L) (-4.1 vs -2.5: p 0.0036) and bicarbonate (HCO3, mEq/L) (21.3 vs 22.5: p 0.0043) than trainee only procedures. Consultants were more likely to be called in for a gunshot than a stab wound (p < 0.001).Of the solid organ injuries, consultants are more likely to be called in for cases with liver injury 23% vs 16% (45/197 vs 58/365: p 0.005) and pancreatic injury 15% vs 3% (30/197 vs 11/365: p < 0.001). Conclusion: Trainees can safely undertake a subset of trauma laparotomies. However, patients with deranged physiology and complex hepatobiliary injuries should be operated on directly by a consultant

A selective vacuum assisted mesh mediated fascial traction approach following temporary abdominal containment for trauma laparotomy is effective in achieving closure

Background: Definitive primary abdominal closure is often not possible nor desirable following trauma laparotomy. In such situations, temporary abdominal containment (TAC) is necessary. This audit reviews our experience with TAC and interrogates our use of the Vacuum Assisted Mesh Mediated Fascial Traction approach (VAMMFT) to achieve delayed closure of the Open Abdomen (OA). Methods: We conducted a retrospective study over a 4-year period of trauma patients who underwent a trauma laparotomy and who required a TAC. Results: Over the four-year period, 596 patients underwent a laparotomy for trauma. Of these trauma laparotomies, 463 (78%) underwent primary closure and 133 (22%) required a TAC. Of these 133 patients who required a TAC, 37 died, 41 underwent delayed primary fascial closure at repeat laparotomy and 55 were left with an OA. Of this cohort of 55 patients, 15 underwent a VAMMFT procedure. The VAMMFT procedure yielded a 60% closure rate, with failure to close being due to late mesh insertion and sepsis. Conclusion: Our initial results with VAMMFT are encouraging. The technique appears to be effective and safe. Ongoing audit will allow us to accrue more patients and to better refine our algorithms and strategies

The spectrum and outcome of paediatric traumatic brain injury in KwaZulu-Natal Province, South Africa has not changed over the last two decades

Objectives. This retrospective review of a prospectively entered and maintained hybrid electronic trauma registry was intended to develop a comprehensive overview of traumatic brain injury (TBI) in children and adolescents and to compare it with previous audits from our local environment and from other developing world centres. All TBI patients admitted to hospital were included in this study. We reviewed the age, gender, outcomes, radiological findings and treatment of the patients.Methods. All patients aged ≤18 years old who were admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS) with TBI between December 2012 and December 2016 were included in this audit. Results. During the 4-year period under review, a total of 563 children and adolescents were treated for TBI by the PMTS. The median age was 6.4 years and 29% (n=165) were females. The mechanism of TBI was blunt trauma in 96% (n=544) of cases, with 4% (n=19) suffering penetrating trauma. The penetrating mechanisms included impalement by a cow horn and miscellaneous injuries due to saws, axes, barbed wire, spades, stones and knives. The blunt mechanisms included falls (n=102), assaults (n=108), collapse of a building (n=28), bicycle-related injury (n=14), falling off a moving vehicle (n=280), motor vehicle accident (MVA; n=59), pedestrian vehicle accident (PVA; n=183) and animal-related injuries (n=8). There were 454 (80%) mild, 67 (12%) moderate and 42 (7%) severe cases of TBI. A total of 48 patients were admitted to the intensive care unit and 23 were admitted to the high care unit. Nine patients died. All the deaths were in the MVA and PVA group. The spectrum of TBI as diagnosed on computed tomography scans was nonspecific cerebral contusion (n=92), depressed skull fracture (n=70), sub-arachnoid haemorrhage (n=60), extradural haemorrhage (n=41), intracerebral haemorrhage (n=19), free air (n=19), subdural haemorrhage (n=13), intraventricular haemorrhage (n=9). A total of 62 (11%) patients required surgery.Conclusion. There is a significant burden of paediatric TBI in Pietermaritzburg. The majority of TBI was related to blunt trauma and assaults were very common. Although the short-term outcomes are good, the long-term consequences are poorly understood. Injury prevention programmes are needed to help reduce this burden of disease and a nationwide trauma registry is long overdue