High-grade renal trauma in children and adolescents can be successfully managed non-operatively.

BACKGROUND: This paper reviews our experience with management of renal injuries in children and adolescents with a focus on the outcome of non-operative management (NOM). METHODS: Retrospective review of the clinical characteristics, injury grade (I-III, low grade and IV and V high grade), management and outcomes of children ≤ 18 years old with renal trauma presenting to a major trauma centre in South Africa between December 2012 and October 2020. RESULTS: Sixty-one children with a renal injury were identified with a median age of 13 (range 0-18) years. Forty-five were boys; blunt and penetrating mechanisms of trauma were sustained by 55 (90%) and six (10%) children, respectively. The median American Association for the Surgery of Trauma (AAST) grade of renal injury was 3 (range 1-5): this included eight (13%) with grade I, six (10%) with grade II, 17 (28%) with grade III, 20 (46%) with grade IV and 10 (16%) with grade V injuries. Forty children (66%) were successfully managed non-operatively and 21 required a laparotomy; of these six (28%) required nephrectomy. The overall renal salvage rate was 55/61 (90%). Children who required laparotomy were significantly more likely to have sustained a penetrating mechanism of injury (24% vs 2%) and have greater length of hospital stay (median 9 vs 3 days) compared to children managed non-operatively (p < 0.05). Children who underwent a nephrectomy had a significantly greater length of hospital stay (median 9 vs 4 days, p = 0.03); however, their demographics, outcomes developed complications. Two children (3%) died; one managed non-operatively and one with a laparotomy. CONCLUSION: Paediatric renal trauma can be successfully managed non-operatively in over two-thirds of cases in this middle-income country. High grade of renal injury does not absolutely predict need for surgery or nephrectomy and can be managed non-operatively.

The neglected epidemic of trauma from interpersonal violence against the elderly in South Africa.

BACKGROUND: Geriatric injuries comprise a significant burden in the developed world but much less are known in the developing world setting. This study aims to review our experience of geriatric injuries with a focus on interpersonal violence (IPV) managed at a major trauma centre in South Africa. METHODS: This was a retrospective study on all patients who were aged > 65 years admitted to our trauma centre from January 2013 to December 2020, based in Pietermaritzburg, South Africa. RESULTS: Over the 8-year study period, 323 cases were included (62% male, mean age 72 years). Mechanism of injury: 80% blunt, 16% penetrating and 4% others. The median injury severity score (ISS) was 9. The median Charlson comorbidity index (CCI) for all 323 cases was 3. Diabetes (n = 53) was the most prevalent comorbidity which was followed by pulmonary disease (n = 23), cerebral vascular accidents (n = 16) and myocardial infarction (n = 15). Fifteen patients were on antiretroviral therapy (5%). Twenty-four per cent required surgical intervention. Eight per cent of cases experienced one or more complications. Twenty-five per cent (80/323) were related to IPV, 61% (49/80) of these were penetrating injuries and the remaining 31 cases were blunt injuries. Of the 49 cases of penetrating injuries, 33 were gunshot wounds (GSWs) and 16 were stab wounds (SWs) (1 GSW and 2 SWs were self-inflicted and were not included in IPV). Those cases that resulted from IPV were significantly more likely to require operative intervention, experience complications and longer lengths of hospital stay. Geriatric patients had poorer outcomes than non-geriatric patients and rural geriatric patients had worse outcomes than urban geriatric patients. CONCLUSION: Although the burden of geriatric trauma in South Africa appears to be relatively low, it is associated with significant morbidity and mortality. Trauma from interpersonal violence is especially common and is associated with significantly worse outcomes than that of non-interpersonal violence-related trauma. Elderly rural trauma victims have worse outcomes than their urban counterparts.

The quest to improve outcomes for abdominal wall incisional hernia repair in Pietermaritzburg: between Scylla and Charybdis.

BACKGROUND: The repair and outcomes of incisional abdominal wall hernias have not yet been benchmarked to allow comparison with recommended best practice in a South African context. This study aimed to address his deficit. METHOD: Patients who underwent an incisional hernia repair between December 2012 and December 2018 were analysed in respect to the following variables: demographics, comorbidities, indication for surgery, site, size, surgical approach, mesh usage, operating times, complications and 30-day mortality. RESULTS: Of the cohort of 224 patients, 185 underwent elective repair. There were 152 open and 72 laparoscopic procedures, and 17 patients (8%) required a repeat operation with an overall in-hospital mortality rate of 6% (13). Eight patients developed an enteric leak. There were nine cardiovascular complications, 24 respiratory complications, 22 surgical site infections and 13 patients developed an acute kidney injury (AKI). There were 39 emergency operations. The emergency cohort were older than the elective with a higher rate of cardiovascular or surgical (CVS) complications and AKI. Eight patients developed an enteric leak. Mortality rates of were significantly higher in the emergency operation cohort compared to the elective group (18% vs 3%). The 13 in-hospital deaths were older, more likely to have undergone an emergency operation, to be diabetic (46% vs 10%), hypertensive (92% vs 33%), have a bowel anastomosis (39% vs 9%), experience an enteric leak (46% vs 1%) and require repeat operation than the patients who survived. CONCLUSION: Incisional abdominal wall hernias are difficult to manage as the patients often have several comorbidities which when coupled with an emergency operation leads to poor outcomes. Improving outcomes requires strategies that address comorbidities and shift the focus to elective rather than emergency repair.

Childhood and adolescent trauma in Pietermaritzburg is a neglected sub-epidemic within a larger epidemic and warrants a dedicated service.

BACKGROUND: This study reviews our experience with paediatric trauma to help plan and strengthen ongoing strategies to deal with trauma in our region. METHODS: All children and adolescents less than 18 years of age who were admitted to our centre following trauma between December 2012 and October 2020 were reviewed. RESULTS: Over the 8-year period, 2 091 children were admitted with trauma to Grey's Hospital. There were 1 479 (71%) male patients, median age: 10 years. One thousand four hundred and fifty-eight (70%) patients were referral from rural regions. In 1 597 (76%) patients, the mechanism of injury was blunt trauma. A total of 387 (19%) patients underwent a surgical intervention, whilst 1 641 (78%) patients were managed non-operatively. In 63 patients, management records were missing. Multiple patients required multiple surgical procedures. A total of 144 patients had a laparotomy, 70 a soft tissue debridement procedure, 40 an orthopaedic procedure, 53 a neurosurgical procedure, which included 37 patients who underwent craniotomy, and 18 patients underwent a fasciotomy for compartment syndrome. There were 82 patients who required miscellaneous procedures. A total of 213 (10%) patients required ICU admission. There were 48 (2.3%) deaths. CONCLUSION: The volume of child and adolescent trauma managed is significant and suggests that a dedicated paediatric trauma service in the region is warranted. It is hoped that future partnering with appropriate stakeholders will allow this service to continue to mature and provide leadership in all aspects of care of injured children in the region.

The spectrum of blunt abdominal trauma in Pietermaritzburg.

BACKGROUND: This study reviews the Pietermaritzburg Metropolitan Trauma Service (PMTS) experience with the management of blunt abdominal trauma (BAT). METHODS: A retrospective review of the hybrid electronic medical registry (HEMR) between December 2012 and September 2019 was conducted. All patients admitted following BAT were included. RESULTS: During the study period, 1 123 BAT patients were managed by the PMTS. The mean age was 29.19 years (SD 14.03). Of these admissions, 73.6% were male. The most common mechanism was road traffic crashes (RTCs) - 435 motor vehicle collisions (MVCs) and 250 pedestrian vehicle collisions (PVCs). There were 186 assaults, 118 falls, 62 community assaults, 22 accidents related to agriculture, construction or industry, 11 sporting injuries, nine animal injuries, seven patients injured by falling objects, five injured by trains, two hangings, one burn-related fall and two other causes. The mechanism of injury was unknown in 22 cases. There were 445 abdominal CT scans and 270 whole body CT scans. Surgical management was required for 395 patients. There were 259 index laparotomies and 176 repeat laparotomies. Four patients underwent selective arterial embolisation. Laparoscopy was undertaken in ten, and subsequently converted to laparotomy in five. There were 106 orthopaedic operations. Hospital stay ranged from 0-155 days (median stay three days). ICU admission was required in 24.9% of patients. The mortality rate was 7.5%. CONCLUSION: BAT is common in South Africa. Whilst the vast majority of patients require non-operative treatment, a welldefined subset require a laparotomy. Imaging is central to the management of patients with BAT.

A review of blunt pelvic injuries at a major trauma centre in South Africa.

BACKGROUND: The collective five-year experience with the acute management of pelvic trauma at a busy South African trauma service is reviewed to compare the usefulness and applicability of current grading systems of pelvic trauma and to review the compliance with current guidelines regarding pelvic binder application during the acute phase of resuscitation. METHODS: A retrospective review was conducted over a 5-year period from December 2012 to December 2017 on all polytrauma patients who presented with a pelvic fracture. Mechanism of injury and presenting physiology and clinical course including pelvic binder application were documented. Pelvic fractures were graded according to the Young- Burgess and Tile systems. RESULTS: There was a cohort of 129 patients for analysis. Eighty-one were male and 48 female with a mean age was 33.6 ± 13.1 years. Motor vehicle-related collisions (MVCs) were the main mechanism of injury (50.33%) and pedestrian vehicle collisions (PVCs) were the second most common (37.98%). The most common associated injuries were abdominal injuries (41%), chest injury (37%), femur fractures (21%), tibia fractures (15%) and humerus fracture (14.7%). Thirty patients in this cohort (23%) underwent a laparotomy. They were mainly in the Tile B (70%) and lateral compression (63%) groups. Nine patients underwent pelvic pre-peritoneal packing. Thirty-five (27%) patients were admitted to ICU. Fifteen (12%) patients died. The Young-Burgess classification had a greater accuracy in predicting death than the Tile classification. Forty per cent of deaths occurred in ICU, 33% died secondary to a traumatic brain injury (TBI). Twenty per cent died in casualty and 6.6% in the operating room from ongoing haemorrhage. A pelvic binder was not applied in 66% of patients. In the 34% of patients who had a pelvic binder applied, it was applied post CT scan in 24.8%, in the pre-hospital setting in 7.2%, and on arrival in 2.4% of patients. In 73% of deaths, a binder was not applied, and of those deaths, 54% showed signs of haemodynamic instability. CONCLUSION: It would appear that our application of pelvic binders in patients with acute pelvic trauma is ad hoc. Appropriate selection of patients, who may benefit from a binder and it's timely application, has the potential to improve outcome in these patients.

Selective Nonoperative Management of Abdominal Stab Wounds with Isolated Omental Evisceration is Safe: A South African Experience.

BACKGROUND AND AIMS: Selective nonoperative management of abdominal stab wound is well established, but its application in the setting of isolated omental evisceration remains controversial. The aim of the study is to establish the role of selective nonoperative management in the setting of isolated omental evisceration. MATERIALS AND METHODS: A retrospective study was conducted over an 8-year period from January 2010 to December 2017 at a major trauma center in South Africa to determine the outcome of selective nonoperative management. RESULTS: A total of 405 consecutive cases were reviewed (91% male, mean age: 27 years), of which 224 (55%) cases required immediate laparotomy. The remaining 181 cases were observed clinically, of which 20 (11%) cases eventually required a delayed laparotomy. The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), 3-6 h in 6% (14/244), 6-12 h 2% (4/244), and 12-18 h in 1% (2/244). There was no significant difference between the immediate laparotomy and the delayed laparotomy group in terms of length of stay, morbidity, or mortality. Ninety-eight percent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic. CONCLUSION: Selective nonoperative management for abdominal stab wound in the setting of isolated omental evisceration is safe and does not result in increased morbidity or mortality. Clinical assessment remains valid and accurate in determining the need for laparotomy but must be performed by experienced surgeons in a controlled environment.

The scourge of knife crime: trends in knife-related assault managed at a major centre in South Africa.

BACKGROUND: Knife wounds are common and represent a major burden to the South African healthcare system. This study reviews trends in spectrum, management and outcome of these injuries at a single trauma centre in KwaZulu-Natal(KZN). METHOD: The regional hybrid electronic registry (HEMR) was reviewed for the period January 2013 - December 2018, and all patients who suffered a knife-related assault were identified and reviewed. RESULTS: During the period under review, a total of 2117 patients suffered a knife-related assault. Regions injured were as follows: head 445, neck 572, face 258, chest 939, abdomen 649, pelvic/urogenital 49, upper limb 418, and lower limb 105. The median ISS was 9 (4-10). Imaging comprised 1242 chest X-rays, 315 abdominal X-rays, 162 abdominal ultrasounds/ FAST, and 929 CT scans of which 634 were CT angiograms. A total of 783 (37%) patients required an operation. The rate of laparotomy was 447/649 (69%) and of thoracotomy/sternotomy/thoracoscopy 95/939 (10%). The rate of vascular exploration for upper and lower limb vascular injury was 101/523 (19%). Mortality was 49/2117 (2.3%).. CONCLUSION: Although our clinical outcomes over this period appear to be consistent, suggesting a familiarity with managing knife-related trauma, the persistently high rate of knife-related injury suggests that we have failed to develop a preventative strategy to try and reduce this scourge.

Trauma in pregnancy at a major trauma centre in South Africa.

BACKGROUND: Trauma in pregnancy poses a unique challenge to clinicians. Literature on this topic is limited in South Africa (SA). OBJECTIVES: To review our institution's experience with the management of trauma in pregnancy in a developing-world setting. METHODS: This study was based at Grey's Hospital, Pietermaritzburg, SA. All pregnant patients who were admitted to our institution following trauma between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry (HEMR). RESULTS: During the 6-year study period, 2 990 female patients were admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS), of whom 89 were pregnant. The mean age of these patients was 25.64 (range 17 - 43) years. The mechanism of injury was road traffic crash (RTC) in 39, stab wounds (SW) in 19, assault other than SW or gunshot wounds (GSW) in 19, GSW in 8, snake bite in 5, impalement in 1, dog bite in 1, hanging in 1, sexual assault in 1 and a single case of a patient being hit by a falling object. A subset of patients sustained >1 mechanism of injury. Thirty patients were managed operatively. The mean time of gestation was 19.16 (5 - 36) weeks. Three patients died, and there were 16 fetal deaths (including 3 lost after the mother's death). Forty-five fetuses were recorded as surviving at discharge, while 25 fetal outcomes were not specifically recorded. There were 2 threatened miscarriages and/or patients with vaginal bleeding, 1 positive pregnancy test with no recorded outcome and no premature births as a result of trauma. CONCLUSIONS: Trauma in pregnancy is relatively uncommon and mostly due to a RTC or deliberately inflicted trauma. Fetal outcome is largely dependent on the severity of the maternal injury, with injuries requiring laparotomy leading to a high fetal mortality rate.

Hanging-related injury in Pietermaritzburg, South Africa.

BACKGROUND: Hanging is a common form of self-harm, and emergency care physicians will not infrequently be called upon to manage a survivor.Despite the relative frequency of the injury, there is a paucity of literature on the topic and the spectrum and incidence of associated injuries are poorly described. OBJECTIVES: To review experience with management of victims of hanging at a major trauma centre in South Africa. METHODS: All patients treated by the Pietermaritzburg Metropolitan Trauma Service following a hanging incident between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry. Basic demographics were recorded, and the management and outcome of each patient were noted. RESULTS: During the 6-year period under review, a total of 154 patients were seen following a hanging incident. The mean age was 29.4 years. There were 24 females (15.6%) and 130 males (84.4%). The vast majority (n=150; 97.5%) had attempted suicide, and only 4 hangings (2.5%) were accidental. A total of 92 patients (60.9%) had consumed alcohol prior to the incident. There were 23 patients with a Glasgow Coma Score (GCS) <9 (severe traumatic brain injury (TBI)), 14 with a GCS of 9 - 12 (moderate TBI) and 117 with a GCS >12 (mild TBI). A total of 7 patients (4.5%) required intensive care unit admission, and 25 (16.2%) required intubation. The following extracranial injuries were documented on computed tomography scans: hyoid bone fractures (n=2), cervical spine fracture (n=10), mandible fracture (n=4) and oesophageal injury (n=1). Intracranial pathology was evident on 27.0% of scans, with the most common finding being global cerebral ischaemia. The mortality rate was 2.5% (4/154). CONCLUSIONS: Hanging is a common mechanism of self-harm. It is associated with significant injuries and mortality. The acute management of hanging should focus on airway protection followed by detailed imaging of the head and neck. Further work must attempt to include mortuary data on hanging.

Correlation between the level of the external wound and the internal injury in penetrating neck injury does not favour an initial zonal management approach.

BACKGROUND: Many current protocols for managing penetrating neck injuries (PNIs) still suggest zonal approaches. This study was undertaken to determine the correlation between the zone of the external wound and the level of the internal injury, and to verify whether a 'no-zone' approach to PNI is valid. METHODS: Patients admitted with a PNI to a tertiary trauma care centre between January 2011 and May 2018 were identified from a trauma database. Those with confirmed injury to the vascular system or an aerodigestive tract injury (ADTI) were included in the study. The medical records of each patient were reviewed with regard to the zone of the external wound and the level of internal injury, and the findings were compared. RESULTS: In the period under review, 1075 patients were treated for a PNI. Of these, 298 (27·7 per cent) had a confirmed vascular injury or ADTI and were included in the cohort. In 176 patients (59·1 per cent) the site of the internal injury was in the same zone as the external wound. In a further 70 patients (23·5 per cent) there was no correlation between the site of the internal injury and the external wound, and in the remaining 52 patients (17·4 per cent) the correlation could not be determined. In this cohort, all clinically assessable patients with significant injuries had either physical signs suggestive of injury or deep surgical emphysema on radiological examination. CONCLUSION: An approach to PNI based on zones is questionable, and this study supports a no-zone approach based on imaging guided by clinical examination.

ANTECEDENTES: Muchos protocolos actuales para el manejo de lesiones penetrantes en el cuello (penetrating neck injury, PNI) aún proponen un enfoque zonal. Este estudio se llevó a cabo para determinar la correlación entre la zona de la herida externa y el nivel de la lesión interna y para comprobar si sería válido un enfoque "sin zonas" para la PNI. MÉTODOS: Los pacientes con PNI ingresados en un centro terciario de traumatología entre enero de 2011 y mayo de 2018 fueron identificados a partir de la base de datos del centro. Se incluyeron pacientes con lesión confirmada vascular o lesión del tracto aero-digestivo (aero-digestive tract injury, ADTI). Se revisaron las historias clínicas de cada paciente con respecto a la zona de la herida externa y el nivel de lesión interna, comparándose dichos hallazgos. RESULTADOS: En el período de estudio, 1.075 pacientes fueron tratados por una PNI. De estos, 298 (27,7%) tenían una lesión vascular o una ADTI confirmadas y se incluyeron en la cohorte. En 176 pacientes (59,1%), la lesión interna estaba localizada en la misma zona de la herida externa. En otros 70 pacientes (23,5%), no hubo correlación entre la localización de la lesión interna y la herida externa y en los 52 pacientes restantes (17,4%) no se pudo determinar dicha correlación. En esta cohorte, todos los pacientes clínicamente evaluables con lesiones significativas presentaban signos físicos sugestivos de lesión o enfisema profundo con indicación quirúrgica en el examen radiológico. CONCLUSIÓN: El enfoque de la PNI basado en zonas es cuestionable y este estudio apoya un enfoque de "sin zonas" basado en pruebas de imágen basadas en los hallazgos clíncos.

Predictors of the need for surgery in upper gastrointestinal bleeding in a resource constrained setting: the Pietermaritzburg experience.

BACKGROUND: This review from a tertiary centre in South Africa aims to describe the spectrum and outcome of upper gastrointestinal bleeding (UGIB) and identify risk factors for surgical management and death. METHODS: This was a retrospective review of a prospectively entered database of all adults presenting with UGIB between December 2012 and December 2016. Demographics, presenting physiology, risk assessment scores, outcomes of endoscopy endo-therapy and surgery were reviewed. Comparisons were made between patients who required operative therapy and those who did not, and between survivors and non-survivors. RESULTS: During the review period, 632 patients were admitted with suspected UGIB. Out of these, 406 (64%) had an identifiable potential source of bleeding and 226 (36%) had no identifiable potential source of UGIB. The latter were excluded from further analysis. Of the 406 patients with a potential source of haemorrhage, there were 249 males (61%) and 157 females (39%). Nine of these were expedited directly to the operating room and never underwent an endoscopy. Of the 397 (98%) who had upper endoscopy 107 (26%) had endotherapy. Forty-six patients (11%) required surgery. They had significantly higher shock index (SI), increased need for transfusion, higher international normalised ratio (INR) and higher serum lactate than the non-operative group. Nine patients went to the operating room without endoscopy. Of the 46 patients who required surgery, 37 underwent an attempt at endoscopic intervention. Transfusion and transfusion volume increased the probability of requiring a laparotomy (p = 0.015) and (0.003) respectively. The independent predictors of need for operation were a raised shock index or serum lactate and Forrest Ia and Ib ulcers. Thirty-nine patients died, giving a mortality rate of 9.6%; ten had a gastric ulcer and 16 had a duodenal ulcer. Survival was significantly higher in the non-operative group (93.1% versus 68.2%; p < 0.001). The odds ratio for mortality in the laparotomy group is 6.73, 95% CI (3.15-14.17). Receiver operator curve (ROC) analysis showed that the pre-endoscopic Rockall score (PER), total Rockall score (TR) and the SI were poor predictors of mortality. CONCLUSION: Patients with UGIB in our setting are younger than in high-income countries (HIC) and a larger number fail endoscopic therapy and require open surgery. The mortality in this subset is very high. Detailed analysis of failed endotherapy has the potential to reduce mortality.

A comparison of blunt and penetrating pancreatic trauma.

BACKGROUND: This project reviews our experience with managing pancreatic trauma from 2012 to 2018. METHODS: All patients over the age of 15 years with a pancreatic injury during the period December 2012-December 2018 were retrieved from the Hybrid Electronic Medical Registry at Grey's Hospital and reviewed. RESULTS: During the study period 161 patients sustained a pancreatic injury. The mechanism of trauma was penetrating in 86 patients (53%) and blunt in 75 (47%). The blunt mechanisms included MVA in 27, PVA in 15, falls in four and assaults in the remaining 29. There were 52 stab wounds and 34 gunshot wounds of the pancreas. A total of 26 patients (16%) were shocked on presentation with a systolic blood pressure of 90 mm Hg or less. The median injury severity score was 16. There were 90 patients with American Association for the Surgery of Trauma (AAST) grade I injury to the pancreas, 36 AAST grade II, 27 AAST grade III, 7 AAST grade IV and a single AAST grade V. Fifty-four patients (34%) were initially treated non-operatively of which three eventually required surgery. Of the patients who required surgery, 26 (16%) underwent a distal pancreatectomy. The remainder simply underwent pancreatic drainage. The overall mortality rate was 13% (21/161). The operative mortality was 11% (18/161). Thirteen patients (8%) with penetrating injuries and eight patients (5%) with blunt injuries died. Of the 21 patients who died, 14 had multiple injuries. Five patients died due to overwhelming sepsis. One patient died due to hypovolemic shock and another due to a traumatic brain injury. CONCLUSION: Our centre not infrequently deals with pancreatic trauma secondary to both blunt and penetrating trauma. We follow the general principles outlined in the literature. Despite this, pancreatic trauma is still associated with significant morbidity and mortality.

Trauma patterns during the COVID-19 lockdown in South Africa expose vulnerability of women.

BACKGROUND: Trauma care places a significant burden on the South African (SA) healthcare system, and this has not changed significantly in recent history. We speculated that the COVID-19 lockdown regulations (travel restriction and alcohol ban) would affect trauma patterns. OBJECTIVES: To compare the burden and nature of trauma over the COVID-19 lockdown period with the equivalent period over the past 5 years using routinely collected data from the Pietermaritzburg Metropolitan Trauma Service in KwaZulu-Natal Province, SA. METHODS: All trauma patients admitted to Grey's Hospital in Pietermaritzburg between 23 March 2015 and 31 May 2020 were identified and reviewed. RESULTS: A total of 8 859 trauma patients were admitted over the 6-year period, with a total of 1 676 admitted during the periods 23 March - 31 May. These 1 676 formed the study cohort. Of these patients, 998 had sustained blunt trauma, 665 penetrating trauma, and 13 a combination of blunt and penetrating trauma. A total of 14 categories of blunt trauma were reviewed, of which the three most common were assault, motor vehicle accidents (MVAs) and pedestrian vehicle accidents (PVAs). Between 23 March and 31 May 2020, a total of 23 patients were victims of blunt assault. The median number of assault victims over the equivalent period during the previous 5 years was 48. The 5 preceding years had a median of 56 MVAs and 33 PVAs, compared with 23 and 10 during the lockdown. The median number of gunshot wound (GSW) victims for the preceding years was 41, compared with 30 during the lockdown. During the lockdown, 24 stab wound victims were admitted, compared with a median of 73 for the preceding years. The proportion of females who sustained penetrating trauma and blunt assault increased significantly during the lockdown. The proportion of females sustaining a GSW or blunt trauma secondary to an MVA remained constant. CONCLUSIONS: The study showed that during the period of lockdown in SA there was a significant decrease in MVAs, PVAs and interpersonal violence. Assaults involving a knife seemed to decrease dramatically, but the rate of GSWs remained constant.

The Combined SIRS + qSOFA (qSIRS) Score is More Accurate Than qSOFA Alone in Predicting Mortality in Patients with Surgical Sepsis in an LMIC Emergency Department.

BACKGROUND: qSOFA has been proposed as a prognostic tool in patients with sepsis. This study set out to assess the sensitivity of several scores, namely: the pre-ICU qSOFA, the qSOFA with lactate (qSOFA L), SIRS score, qSOFA + SIRS score (qSIRS) and qSIRS with lactate (qSIRS L) in predicting in-hospital mortality in patients with surgical sepsis as well as the sensitivity of these scores in predicting high-grade sepsis. The secondary aim was to determine which of these scores is best suited to predict high-grade surgical sepsis. METHODS: This was a retrospective cohort study that was conducted between December 2012 and August 2017 in a public metropolitan surgical service. Data from patients aged > 13 years, who were admitted to the hospital and who had an emergency surgical procedure for source control were retrieved from a prospectively maintained hybrid electronic database. The qSOFA, qSOFA plus lactate (qSOFA L), SIRS and qSOFA + SIRS (qSIRS), as well as the qSIRS plus lactate (qSIRS L), were calculated for each patient. A lactate level that was greater than 2mmol/L was deemed to be a positive finding. Any score ≥2 was deemed to be a positive score. The outcome measure was in-hospital mortality. The prognostic value of qSOFA, qSOFA L, SIRS, qSIRS and qSIRS L was studied. Receiver operating characteristic analyses were performed to determine the area under the curve (AUC), sensitivity, specificity and positive and negative likelihood ratios for positive qSOFA, qSOFA L, SIRS, qSIRS, and qSIRS L. Contingency tables were used to calculate the sensitivity, specificity, PPV and NPV for predicting severe or high-grade surgical sepsis. RESULTS: There were a total number of 1884 patients in the sample group of whom 855 were female (45.4%). The median patient age was 36 years (IQR 23-56). A total of 1489 patients (79%) were deemed to have high-grade sepsis based on an advanced EGS AAST grading, whilst 395 patients (21%) had low-grade sepsis. A total of 71 patients died (3.8%). Of these patients who died, 67 (94.4%) had high-grade sepsis and 4 (5.6%) had low-grade sepsis. The mortality rate in the high-grade sepsis group was 4.5%, whilst the mortality rate in the low-grade sepsis group was 1%. The scores with the greatest accuracy in predicting mortality were qSIRS (AUROC 0.731, 95% CI 0.68-0.78), followed by SIRS (AUROC 0.70, 95% CI 0.65-0.75). The qSOFA and qSOFA L were the least accurate in predicting mortality (AUROC 0.684, 95% CI 0.63-0.74 for both). The addition of lactate had no significant effect on the accuracy of the five scores in predicting mortality. Patients with a qSOFA ≥ 2 have an increased risk of dying (OR 5.8), as do patients with a SIRS score ≥2 (OR 2.7). qSIRS L had the highest sensitivity (69%) in predicting the presence of high-grade surgical sepsis, followed by qSIRS (65.5% sensitivity). qSOFA showed a very low sensitivity of only 4.5% and a high specificity of 99.2%. The addition of lactate to the score marginally improved the sensitivity. Lactate of 2mmol/L or more was also an independent predictor of high-grade sepsis. CONCLUSION: The qSIRS score is most accurate in predicting mortality in surgical sepsis. The qSOFA score is inferior to both the SIRS and the qSIRS scores in predicting mortality. The qSIRS score with the addition of lactate to the qSIRS score made it the most sensitive score in predicting high-grade surgical sepsis.

Traumatic renal injury: Five-year experience at a major trauma centre in South Africa.

BACKGROUND: This study is intended to assess the current optimal management of traumatic renal injuries (TRIs), with a focus on high-grade and penetrating injuries. METHODS: The Pietermaritzburg Metropolitan Trauma Service registry was interrogated retrospectively for patients managed for TRI between 1 January 2012 and 31 December 2016. RESULTS: Of 13,315 inured patients treated by the PMTS, 223 (1.7%) had TRIs with an incidence of 1.5 per 100,000 population per year. The majority were males between 20 and 39 years of age. The distribution of mechanism of injury was 56.1% (n = 125) blunt and 43.9% (n = 98) penetrating trauma with no association between mechanism and grade of injury. Penetrating trauma was associated with hollow viscus and diaphragm injuries and blunt trauma with solid organ injuries. A total of 118 patients (52.9%) were managed non-operatively, 60 (26.9%) were not explored at operation, 27 (12.1%) underwent initial nephrectomy and 8 (3.6%) underwent renorraphy. Low-grade injuries (AAST I and II) and high-grade injuries (AAST III-V) were managed without renal intervention (non-operatively or not explored at laparotomy for associated injuries) in 88.7% (n = 87) and 72.0% (n = 91) of cases respectively. Blunt and penetrating injuries were managed without renal intervention in 87.9% (n = 109) and 70% (n = 69) of cases respectively. The initial nephrectomy rate was 1% (n = 1) and 20.6% (n = 26) for low- and high-grade injuries respectively, and 6.5% (n = 8) and 19% (n = 19) for blunt and penetrating injuries respectively. High grade (AAST III-V) injury (OR 14.94; 95% CI 3.36 - 66.34; p<0.001), penetrating mechanism (OR 4.99; 95% CI 1.98 - 12.52; p = 0.001) and metabolic acidosis (OR 2.73; 95% CI 1.04 - 7.20; p = 0.042) were significant risk factors for nephrectomy. Four patients (1.8%) underwent ureteral stent insertion and 2 (0.9%) underwent embolisation. The failure rate of initial non-operative management was 1.1%. The mortality rate was 8.1% (n = 18), but no patients with solitary renal injuries died. CONCLUSION: Even in high-grade injuries and penetrating trauma, the majority of patients with TRI can be managed non-operatively or with the assistance of endourological or endovascular techniques, with good outcomes. Risk factors for nephrectomy include the presence of high-grade injuries, penetrating trauma and metabolic acidosis on presentation.

A review of geriatric injuries at a major trauma centre in South Africa.

BACKGROUND: Trauma in South Africa (SA) has been referred to as a malignant epidemic, but the impact of trauma on the elderly has tended to be overlooked. OBJECTIVES: To address this deficit by focusing on trauma victims aged ≥65 years. METHODS: All patients aged ≥65 years who were admitted to Grey's Hospital, Pietermaritzburg, SA, following trauma between December 2012 and January 2019 were reviewed. RESULTS: Over the 6-year study period, a total of 281 patients aged ≥65 years were admitted to Grey's Hospital following trauma. There were 150 males (53.4%) and 97 females (34.5%). The sex of 34 patients was unknown. The average age was 72 years (range 65 - 97). There were 226 cases of blunt trauma, 42 cases of penetrating trauma (including two incidents of impalement following blunt trauma) and 15 cases of other types of trauma. The most common causes of blunt trauma were accidental falls (n=76), motor vehicle accidents (n=46), pedestrian vehicle accidents (n=32) and falls from a height (n=23). Gunshot wounds (n=22) and knife wounds (n=14) were the most common forms of penetrating trauma. Other trauma mainly comprised dog bites (n=6) and snakebites (n=6). There were 72 incidents of assault (25.6% of total cases). The majority of assaults were committed by a single perpetrator, and the perpetrator was frequently known to the victim. There were no significant differences in the proportions of penetrating, blunt and other trauma injuries between males and females. A total of 44 patients (15.7%) required surgical intervention, and 41 patients (14.6%) experienced complications during their hospitalisation. Respiratory, renal and cardiac complications were most frequent, and 5 patients had a cardiac arrest. Seven experienced acute kidney injury. Seventeen patients (6.0%) required intensive care unit admission and 5 (1.8%) required ventilation. Patients stayed in hospital for an average of 2.96 days (range 0 - 39). Of the patients, 241 (85.8%) survived, 32 (11.4%) died and 8 (2.9%) had an unknown outcome. CONCLUSIONS: Geriatric trauma in SA is relatively rare, but will increase as the population ages. There is a high incidence of assault as a mechanism, highlighting the fact that elderly people are a vulnerable group. Managing these patients is challenging and is associated with significant morbidity and mortality.

Compliance with the Surviving Sepsis Campaign guidelines for early resuscitation does not translate into improved outcomes in patients with surgical sepsis in South Africa.

INTRODUCTION: This project set out to audit our compliance with the 3-hour bundles of care for surgical sepsis and to interrogate how compliance or non-compliance impacts on the outcome of surgical sepsis in our institution. METHODS: All emergency surgical patients over the age of fifteen years were reviewed. All patients who fulfilled the ACCP/SCCM criteria for sepsis or septic shock, with a documented surgical source of infection, were identified for review. RESULTS: A total of 677 septic patients with a documented surgical source of sepsis were included. Of the 677 patients, 53% (360/677) had intra-abdominal sepsis, 17% (116/677) had diabetic-related limb sepsis and the remaining 30% (201) had soft tissue infections. A total of 585 operative procedures were performed. Compliance with all components of the 3-hour bundle metrics was achieved in 379/677 patients (56%), and not achieved in 298/677 patients (44%). The only significant difference between the compliant and the non-compliant groups was respiratory rate greater than 22 breaths/minute (131 vs 71, p = 0.002) in the compliant cohort. Amongst the compliant cohort 77/379 patients (20%) required admission to ICU, whilst 41/298 patients (14%) in the non-compliant cohort required admission to ICU. This difference was statistically different (p = 0.026). There was no difference in the median length of hospital stay (6 days) between the two groups. Fifty-five patients in the compliant cohort died (15%), whilst 31 (10%) of the patients in the non-compliant cohort died. This difference was not statistically different (p = 0.111). CONCLUSION: Compliance with the SCC 3-hour bundle did not seem to improve mortality outcomes in our setting. This observation cannot be adequately explained with our current data and further work looking at management of surgical sepsis in our setting is required. Time to surgical source control is probably the single most important determinant of outcome in patients with surgical sepsis and other aspects of the care bundle are of secondary importance.

Discrepancy in clinical outcomes of patients with gunshot wounds in car hijacking: a South African experience.

INTRODUCTION: Discrepancy in outcomes between urban and rural trauma patients is well known. We reviewed our institutional experience with the management of gunshot wounds (GSWs) in the specific setting of car hijacking and focused on clinical outcome between rural and urban patients. METHODS: A retrospective review was conducted at a major trauma centre in South Africa over an 8-year period for all patients who presented with any form of GSWs in car hijacking settings. Specific clinical outcomes were compared between rural and urban patients. RESULTS: A total of 101 patients were included (74% male, mean age 34 years). Fifty-five per cent were injured in rural areas and the remaining 45% (45/101) were in the urban district. Mean time from injury to arrival at our trauma centre was 11 hours for rural and 4 hours for urban patients (p < 0.001). Seventy-six per cent (76/101) sustained GSWs to multiple body regions. Sixty-three of the 101 (62%) patients required one or more operative interventions. In individual logistic regressions adjusted for sex and number of regions injured, rural patients were 9 (95% CI: 1.9-44.4) and 7 (95% CI: 2.1-24.5) times more likely than urban patients to have morbidities or required admissions to intensive care respectively. The risk of death in rural patients was 36 (95% CI: 4.5-284.6) times higher than that of urban patients. CONCLUSION: Patients who sustained GSWs in carjacking incidents that occurred in rural areas are associated with significantly greater morbidity and mortality compared with their urban counterparts. Delay to definitive care is likely to be the significant contributory factor, and improvement in prehospital emergency medical service is likely to be beneficial in improving patient outcome.