Traumatic false aneurysms in Port Moresby

@# Background: Trauma is responsible for about 30% of surgical admissions in Port Moresby. Vascular injuries are frequently missed due to inadequate assessment by primary health care workers and often present late with large aneurysms which are difficult to manage. The aim of this study was to identify the patterns of morbidity associated with traumatic false aneurysms complicating vascular injuries in Port Moresby General Hospital from January 1995 to July 1999. Methods: A surgical database with 11,004 records was used to identify patients with a diagnosis of false aneurysm. Charts of patients with gunshot wounds, knife wounds and compound fractures were also reviewed to identify further cases with vascular injury. Results: 51 patients were found to have had documented evidence of vascular injury requiring surgical repair within the study period. 21 patients with traumatic false aneurysm presented to Port Moresby General Hospital. 17 of the 21 patients were aged 11 to 40 years. There was only one female patient. Stab wounds (50%) were the commonest mode of injury followed by lacerations (23%) and fish bites (14%). The calf (42%), forearm (13%) and the head (13%) were the commonest sites involved. The time from insult to admission varied from 4 days to 11 years with the modal time being 14 days. Most patients presented with hard signs of false aneurysms (94%) and 81% of the patients were treated within five days. Ligation (67%) was the commonest operation, followed by excision (43%) and vascular repair (19%). There were no deaths or amputations in any of the patients with false aneurysms. Conclusion: False aneurysms are a not infrequent complication of vascular injuries. Greater awareness of the possibility of vascular injury is needed. Patients in Port Moresby often present after considerable delay. However, the diagnosis can be made clinically and the results of surgical exploration are good. Although colour Doppler ultrasound is a useful investigation it sometimes fails to identify the aneurysm because it requires blood flow to be present in the aneurysm.

Trauma in Papua New Guinea: what do we know and where do we go?

@#Trauma is a major health problem in Papua New Guinea. Injuries are the commonest cause of death in the productive age group of 15-44 years. Trauma is the leading cause of surgical death in Port Moresby General Hospital. The common causes of injury are road traffic accidents, domestic violence, criminal assault, tribal fights, accidents at home and at work, burns and falls. This review summarizes what has been published on the different causes of trauma in Papua New Guinea. Though much has been written little has been done to implement the recommendations made. Papua New Guinea needs a spinal unit and it needs burns units in its major hospitals. There should be better facilities for rehabilitation. Little has been done to curb tribal fighting and domestic violence. Road traffic fatalities have at least remained static in the last decade and wearing seat belts is now compulsory, but the law must be enforced. Driving after drinking alcohol must be stopped and protective roll bars or cages must be fitted to all open-back utility vehicles which carry passengers. Progress requires vision and commitment by surgeons, leaders in public health, hospital administrators and politicians.

Head injuries in Papua New Guinea

@#Head injuries are the commonest cause of death in the surgical wards in Port Moresby and the commonest cause of death in road accidents. Three prospective and retrospective studies performed over the last decade aimed to determine the pathology and outcome in 274 head injuries admitted to Goroka in 1988-1991 (4 years) and Port Moresby in 1984-1985 and 1992-1993 (total 2.5 years). Head injuries were managed by general surgeons without CT scanning or intracranial pressure monitoring. There were 196 adults and 78 (28%) children; 195 were male and 79 female. Assaults (32%), motor vehicle accidents (49%) and falls (17%) were the commonest modes of injury. The case fatality rate was 21% (57 of 274 cases). Six of the deaths were avoidable. The fatality rates for admission Glasgow Coma Scores of 3-5, 6-8 and over 9 were 81%, 21% and 3% respectively. Two patients died of infection complicating open depressed fractures. The case fatality rate for extradural haematoma was 20% and subdural haematoma 67%. Nine patients died of associated abdominal injuries. Most of the deaths were unavoidable because of the severity of primary brain injury. The speed of diagnosis and quality of care could have been improved but the most important area is management of the airway. General surgeons properly trained in trauma care (which includes emergency airway management) are well able to cope with the majority of head-injured patients in Papua New Guinea.

Surgery, surgical pathology and HIV infection: lessons learned in Zambia

@#HIV (human immunodeficiency virus) infection is prevalent in many areas of sub-Saharan Africa. Seropositivity rates reach 10-15% in urban adults, 21% in critically ill adults and 30% in surgical inpatients aged 21-40 years. AIDS (acquired immune deficiency syndrome) is a multisystem disease which presents to the surgeon with a wide range of pathologies including Kaposi's sarcoma, lymphadenopathy and sepsis. The more common sites for sepsis are the female genital tract, anorectum, pleural cavity, soft tissues (necrotizing fasciitis) and bone and joints. To prevent iatrogenic HIV infection more use should be made of autologous blood. Occupational exposure to HIV infection can be minimized by double-gloving, protecting the eyes when operating and ensuring that theatre gowns are waterproof. The risk of HIV infection from a needlestick injury is 0.4%. Although contact with blood during a surgical procedure is common, the risk is lower than for a hollow needlestick injury. PIP: In Zambia, 10-15% of urban adults are reported HIV positive, as are over 80% of prostitutes. The HIV seroprevalence rate in a Lusaka hospital's intensive care unit was 21% (27% for surgical and 18% for trauma admissions). HIV-infected patients could be clinically recognized by risk factors or symptoms and signs: weight loss, chronic cough, chronic diarrhea, sepsis, septic arthritis, subacute hematogenous osteomyelitis, a history of sexually transmitted diseases (STDs), death of a spouse or of a child under age 2, recent pregnancy unable to go to term, poor quality or thin hair, appearance of aging beyond years, mental slowness, persistent or unexplained fever, lymphadenopathy, aggressive atypical Kaposi's sarcoma, oral thrush, hairy leukoplakia of the tongue, shingles scars, and scars of maculopapular dermatitis. Common sites for HIV-related sepsis are the female genital tract, anorectum, pleural cavity, soft tissues (e.g., necrotizing fascitis), and bone and joints. Autologous blood transfusion and use of donor blood screened for HIV antibodies, preferably limited to emergencies, would reduce the likelihood of iatrogenic HIV transmission. Surgeons should wear two pairs of gloves, a waterproof gown, and goggles to protect themselves from HIV transmission. If they have skin rashes, cuts, or abrasions on the hands or arms, they should not perform operations. Proper cleaning and disinfection of endoscopes are required. The risk of infection from a needle stick is small ( 0.4%).