Left pulmonary artery bullet embolism following a penetrating cardiac gunshot injury.

INTRODUCTION: Bullet emboli occur when bullets migrate from an entry point to an abnormal endpoint via blood vessels or bowel. Most result from low-velocity, small calibre civilian gunshots. Although rare, when it does occur, it commonly embolises to the arterial system. Many times, these are amenable to removal and recovery. CASE REPORT: We present a case of a haemodynamically unstable polytrauma patient with a pulmonary artery projectile embolus following a penetrating trans-thoracic cardiac gunshot wound. CONCLUSION: A brief overview of the literature regarding bullet emboli is provided in light of this unusual case, focusing specifically on thoracic bullet emboli. A high index of suspicion should be raised when the number of entry and exit wounds are incongruent, bullet location does not align with anticipated trajectory, or serial radiographs demonstrate missile migration. Radiological evaluation and bullet retrieval are dependent on haemodynamic stability of the patient.

Validating the utilisation of venous bicarbonate as a predictor of acute kidney injury in crush syndrome from sjambok injuries.

BACKGROUND: Crush injury secondary to sjambok beatings is a well-described phenomenon in southern Africa. Owing to a number of factors, it can result in acute kidney injury (AKI). In 1992, Muckart et al. described a risk stratification system using venous bicarbonate (VB) that can be used in the management of these patients. OBJECTIVE: To validate this score in the modern era of AKI risk stratification. METHODS: A retrospective study was performed on a local trauma database from June 2010 to December 2012. All patients with crush injury from sjambok/blunt instrument beatings were included in the analysis. VB was compared with the Kidney Disease Improving Global Outcomes scoring system for AKI. Serum base excess (BE) and creatine kinase were also examined as biomarkers. The endpoints were the need for renal replacement therapy (RRT) and mortality. RESULTS: Three hundred and ten patients were included. The overall mortality rate was 1.9%, 14.8% of patients had AKI, and 3.9% required RRT. Both VB and BE performed well in RRT prediction, with areas under the receiver operating characteristic curve of 0.847 (95% confidence interval (CI) 0.756 - 0.938; p<0.001) and 0.871 (95% CI 0.795 - 0.947; p<0.001), respectively. The sensitivity and specificity of BE were 83.3% and 80.2% at an optimal cut-point of -7.25 mmol/L, while those of VB were 83.3% and 79.5% at an optimal cut-point of 18.85 mmol/L. VB was significantly different across the AKI risk groups (p<0.001), in keeping with the original Muckart risk stratification system. CONCLUSION: The risk stratification score using VB is valid and should continue to be used as a tool in the management of patients with sjambok injuries. BE performs well in predicting the need for RRT, with a value of <-7.25 mmol/L indicating severe injury.

Surviving Sepsis in the Intensive Care Unit: The Challenge of Antimicrobial Resistance and the Trauma Patient.

Sepsis in the intensive care unit (ICU) presents a great challenge to any critical care clinician. Patients admitted to the ICU are especially vulnerable to sepsis due to the nature of the underlying pathology that warranted admission to the ICU and deranged physiological function coupled with invasive procedures. Nosocomial infections are common in patients admitted to the ICU, and with these infections come the burden of multidrug-resistant organisms. Antimicrobial resistance (AMR) is now a global emergency that warrants the attention of every health-care professional. AMR has escalated to epic proportions and solutions to this problem are now a matter of "life and death." The ICU also represents the "breeding ground" of antibiotic-resistant organisms due to the high broad-spectrum antibiotic consumption. Many would argue that broad-spectrum antimicrobials are overprescribed in this patient population, but do all patients admitted to the ICU warrant such therapy? Is there evidence that narrower-spectrum antimicrobial agents can be employed in specific ICU populations coupled with surveillance strategies? The aims of this review are to focus on strategies with the aim of optimizing antimicrobial use within ICUs, and to highlight the importance of differentiating ICU populations with regard to the use of antimicrobial agents.

Ventilation in Trauma Patients: The First 24 h is Different!

INTRODUCTION: Ventilation of major trauma patients is often needed in both the acute (emergency department and early ICU phase) and subsequent phases of trauma care for those who need ICU admission. What is unclear is whether ICU ventilation strategies should be directly extrapolated to the acute phase of treatment. METHODS: This paper reviews the ARDS.net study, highlights recent developments in ventilation strategies, and provides practical ventilation guidance to the trauma surgeon for acute phase (in the ED or ICU) and the subsequent phase of ICU care. RESULTS: The acute phase of care in the ED and the ICU is different from the subsequent phases of ICU care as the lung is more recruitable and there are other aspects of resuscitation from metabolic acidosis and traumatic brain injury, which require a different ventilation strategy to the traditional ARDS.net approach. DISCUSSION AND CONCLUSION: The acute phase is different from the subsequent phase of care and there appears to be some inappropriate extrapolation of ICU practice to the acute phase. Application of the proposed ventilation strategies should ensure an optimal outcome. It is important to treat patients as individuals during assessment and treatment.

Endotracheal tube cuff pressures and tube position in critically injured patients on arrival at a referral centre: Avoidable harm?

INTRODUCTION: The consequences of excessive endotracheal tube (ETT) cuff pressure are known and have long-term effects; however less attention is placed upon cuff pressure and tube position pre-hospital and in emergency centre. The aim of this study was to evaluate the ETT cuff pressure and tube position on arrival of all patients admitted to the Trauma Unit at Inkosi Albert Luthuli Central Hospital, both from scene and inter-hospital transfers to determine the median cuff-pressure and if there were differences between the two groups. METHODS: Data from Trauma Unit patients are entered into a prospective; UKZN approved (BE207-09) Trauma Database. Data on 65 admissions between April and December 2014 were reviewed to determine the arrival cuff pressure and tube position. Data captured included patient age, cuff pressure, where and who intubated the patient, and time since intubation to cuff pressure check. Data were analysed by descriptive statistics and Student's t-test for continuous data. RESULTS: Most patients had sustained motor vehicle related trauma, with a male predominance. Equal numbers were intubated pre-hospital versus the in-hospital group. Eighty percent of ETT's were placed in the correct anatomical location, however only 23% of cuff pressures were found to be within the safe pressure limits. ETT cuff pressures were excessive in the pre-hospital ALS group more often than the facility-intubation group (p = 0.042). There were fatal complications related to supra-glottic intubations resulting in aspiration pneumonia, highlighting the need for X-ray confirmation of tube position. CONCLUSION: Most patients, whether intubated on-scene or at hospital have ETT cuff pressures that are excessive, with the potential for ischaemic necrosis of the tracheal mucosa. ETT cuff manometry should be standard of care for all prehospital and in-hospital intubations where the tube will remain in situ for any prolonged period of time. Before inter-facility transfer ETT position should be confirmed radiologically.

INTRODUCTION: Les conséquences d'une pression excessive du brassard de sonde endotrachéale (ETT) sont connues et ont des effets à long terme; mais une moindre attention est accordée à la pression du brassard et à la position de la sonde avant l'hospitalisation et au service d'urgence. Le but de cette étude était d'évaluer la pression du brassard de l'ETT et la position de la sonde à l'arrivée de tous les patients admis au Service de traumatologie de l'Hôpital central Inkosi Albert Luthuli, amenés directement du lieu de l'accident ou venant des transferts entre hôpitaux, afin de déterminer la pression de brassard médiane et s'il existe des différences entre les deux groupes de patients. MÉTHODES: Les données tirées des patients du Service de traumatologie sont saisies dans une base de données de traumatologie prospective validée par l'UKZN (BE207-09). Les données de 65 admissions entre avril et décembre 2014 ont été examinées afin de déterminer la pression du brassard et la position de la sonde à l'arrivée. Les données saisies incluaient l'âge du patient, la pression du brassard, qui avait intubé le patient et où, et le temps écoulé entre l'intubation et le contrôle de la pression du brassard. Les données ont été analysées selon des statistiques descriptives et le test t de Student sur les données continues. RÉSULTATS: La plupart des patients avaient subi des traumatismes liés à des véhicules motorisés, avec une prédominance masculine. Un nombre équivalent avaient été intubés avant l'hospitalisation par rapport au groupe intubé à l'hôpital. Quatre-vingt pour cent des ETT avaient été positionnés dans la bonne position anatomique, mais il a été constaté que seulement 23% des pressions de brassard se situaient dans la fourchette de sécurité des limites de pression. Les pressions de brassard d'ETT étaient plus souvent excessives au sein du groupe en réanimation d'urgence intubé en pré-hospitalisation que celles du groupe intubé au centre (p = 0.042). Des complications mortelles liées à des intubations supraglottiques résultant en une pneumonie par aspiration ont été constatées, ce qui souligne la nécessité d'une confirmation par radiographie de la position de la sonde. CONCLUSION: La plupart des patients intubés, qu'ils l'aient été sur place ou à l'hôpital, présentent une pression de brassard d'ETT qui est excessive, avec un potentiel de nécrose ischémique de la muqueuse trachéale. La manométrie du brassard de l'ETT doit être la norme de soins pour tous les soins pré hospitaliers et à l'hôpital lors des intubations prévoyant que la sonde restera en place pendant une longue période. Avant un transfert entre établissements, la position de l'ETT doit être confirmée radiologiquement.

The wrong and wounding road: Paediatric polytrauma admitted to a level 1 trauma intensive care unit over a 5-year period.

BACKGROUND: Injury in childhood is a major cause of potentially preventable morbidity and mortality. In order to implement effective preventive strategies, epidemiological data on mechanisms of injury and outcome are essential. OBJECTIVES: To assess the causation, severity of injury, morbidity and mortality of paediatric trauma admitted to a level 1 trauma intensive care unit (TICU). METHODS: Children were defined as being <16 years of age. The study covered the 5-year period January 2008-December 2012. Eligible patients were identified from a prospective database maintained in the level 1 TICU at Inkosi Albert Luthuli Central Hospital, Durban, South Africa. Data extracted were referral source, mechanism of injury, age and gender distribution, injury severity score (ISS), anatomical distribution of injury and mortality. RESULTS: A total of 181 patients admitted during the study period accounted for 15.9% of all admissions. There were 84 females (46.4%) and 97 males (53.6%), with a median age of 7 years (interquartile range (IQR) 4-10). Sources of admission were directly from the scene in 38 cases (21.0%), from a primary healthcare facility in 47 (26.0%), from a regional hospital in 56 (31.0%) and from a tertiary facility in 40 (22.0%). Mortality rates according to location of transfer were regional hospital 8 deaths (30.8%), tertiary facility 7 (26.9%), primary health clinic 7 (26.9%), and from the scene 4 (15.4%). Mechanisms of injury were pedestrian-motor vehicle collision (PMVC) in 105 cases (58.0%), motor vehicle passenger in 38 (21.0%), non-vehicular blunt trauma in 18 (10.0%), gunshot wounds (GSWs) in 12 (6.6%), stab wounds in 6 (3.3%), bull goring in 1 (0.5%) and bicycle accident 1 (0.5%). The median ISS for all admissions was 25 (IQR 16-38). ISSs were >25 in 98 patients (54.1%), 16-25 in 51 (28.2%), 9-15 in 9 (4.9%) and <9 in 13 (7.2%); 61.9% of patients had head injuries, 48.1% injuries to the extremities, 41.4% abdominal trauma, 40.3% thoracic trauma, 20.4% external soft-tissue trauma, 9.9% cervical injury and 9.4% facial trauma. There were 26 deaths (14.4%), of which PMVCs accounted for 16 (61.5%), motor vehicle passengers for 7 (26.9%), blunt trauma for 2 (7.7%) and GSWs for 1 (3.8%). The majority of deaths (92%) were of patients with an ISS>25. Of the 26 patients who died, 88.4% had a head injury, 46.2% an extremity injury, 38.5% an external injury, 34.6% abdominal or chest injuries, 19.2% neck injury and 11.5% facial injury. CONCLUSIONS: Motor vehicle-related injuries, especially PMVCs, dominate severe paediatric trauma and there is an urgent need for more road traffic education and stringent measures to decrease the incidence and associated morbidity and mortality.

Holes in the heart: an atlas of intracardiac injuries following penetrating trauma.

OBJECTIVES: The extraordinarily high rate of penetrating heart injuries in South Africa provides a substantial denominator from which we derive a subset of patients with intracardiac lesions as a result of these injuries. The surgical literature, which consists largely of case reports and case series, describing various patterns of injury is dated and a review of management in the era of modern imaging and surgical techniques is warranted. METHODS: A retrospective observational chart review of all patients with intracardiac injuries following penetrating trauma who were referred to the Department of Cardiothoracic Surgery at Inkosi Albert Luthuli Central Hospital in Durban, South Africa, during the 10-year period between July 2003 and July 2013 was performed. The spectrum of pathology encountered included ventricular septal defects, valve apparatus lacerations, intracardiac fistulae, ventricular aneurysms and retained intracardiac missiles. RESULTS: Of the 17 patients, 10 required operative repair of the intracardiac lesions using cardiopulmonary bypass, with no early mortality noted. Seven patients were treated non-operatively, for reasons that varied from insignificant haemodynamic shunts to advanced human immunodeficiency virus (HIV) infection. The in-hospital mortality in this group consisted of 1 patient, who was moribund at presentation. CONCLUSIONS: The referral of patients for the repair of intracardiac injuries following penetrating cardiac trauma is often delayed. Symptoms of cardiac failure should be optimized medically prior to undertaking definitive surgical repair, thereby also allowing for detailed preoperative imaging to guide appropriate intervention. Utilizing standard principles of intracardiac shunt repair, as well as contemporary valve repair techniques, favourable surgical outcomes may be reproduced. Percutaneous catheter device techniques may prove useful in patients deemed unsuitable for surgical repair, such as patients with sternal wound sepsis.

Base deficit as an early marker of coagulopathy in trauma.

BACKGROUND: The acute coagulopathy of trauma is associated with hypoperfusion, metabolic acidosis and an increased mortality rate. Biochemical markers of hypoperfusion, namely base deficit (BD) and lactate, are commonly used to assess the degree of hypoperfusion. Early identification of hypoperfusion and acidosis using BD and lactate may help predict the development of coagulopathy in trauma patients and direct therapy. OBJECTIVES: To identify whether a correlation exists between BD, lactate, injury severity, early-onset coagulopathy and mortality. METHODS: A retrospective chart analysis was undertaken of patients transferred directly from scene to the level I trauma unit at Inkosi Albert Luthuli Central Hospital, Durban, South Africa, from 2007 to 2008. Patients with evidence of hypoperfusion were selected. Hypoperfusion was defined as a base deficit >-2 and coagulopathy as an International Normalized Ratio (INR) of >1.2. BD, lactate, chloride, temperature, Injury Severity Score (ISS), INR and mortality were recorded in this cohort. Student's t-test and Fisher's exact test were used for continuous and categorical variables, respectively. Correlation curves were used to determine the degree of association between the variables BD, lactate and ISS with respect to the INR. A p-value of <0.05 was considered statistically significant. RESULTS: Of the 28 patients, males (n=18) accounted for 64.3% of admissions. The mean age was 31 years (range 1 - 75 years, median 30 years). The mechanism of injury was penetrating trauma in 5 cases (17.9%) and blunt trauma in 23 (82.1%). The median ISS was 24 (range 4 - 59). In 16 patients (57.1%) the INR was within normal limits, but in 12 (42.9%) it was over 1.2. There was a significant correlation between BD, ISS and INR (r=0.393; p=0.019 and r=0.565, respectively; p<0.001). Lactate showed a weak and non-significant association with the INR (r=0.232; p=0.18). There were a total of 12 deaths (42.8%) in this cohort of patients with biochemical evidence of hypoperfusion. There was a significant increase in mortality in patients with evidence of hypoperfusion and an elevated INR (75.0% v. 18.7%; p=0.006). CONCLUSION: BD but not lactate correlates with the development of the coagulopathy of trauma. The ISS showed a significant correlation with coagulation disturbances, and the combination of hypoperfusion and coagulopathy was associated with a significant increase in mortality.

Introducing video-assisted thoracoscopy for trauma into a South African township hospital.

BACKGROUND: The use of video-assisted thoracoscopic surgery (VATS) is well established in trauma practice. This modality is readily available to centers with well-equipped operating facilities but may be challenging to introduce into resource-constrained institutions such as many South African township hospitals. We implemented VATS for retained post-traumatic pleural collections in our institution in 2007, and we have now performed an audit of the first 3 years of our experience. METHODS: A retrospective chart review was conducted of all patients who had undergone VATS from June 2007 to May 2010, and statistical analysis was performed to elucidate the findings. RESULTS: Forty-three patients were examined, 40 of whom (93 %) were male. The mean age was 32 years (range: 15-52 years). Thirty-five patients (81 %) had stab injuries, 6 (14 %) had blunt injuries, and 2 (4 %) had gunshot wounds. Mean time from injury to VATS was 12.4 days (range: 3-31 days). Thirteen patients (30 %) had empyema at the time of VATS. The mean time from VATS to discharge was 9 days (range: 3-30 days). The postoperative complication rate was 14 % and included pneumonia (n = 3) and re-collections (n = 3, two of which were managed by reinsertion of a chest drain, and one cleared without further intervention). Further analysis revealed a longer postoperative length of stay when empyema was present at VATS (8 days for no empyema vs. 11 days when empyema was present; p = 0.027). The incidence of empyema increased progressively the longer the delay between injury and VATS (0 % for VATS performed in week 1, 32 % for VATS in week 2, 50 % for VATS in week 3, and 60 % for VATS beyond week 3; p = 0.019). The incidence of empyema increased when >1 chest drain was inserted prior to VATS (15 % for 0-1 chest drain vs. 43 % for >1 chest drain; p = 0.043). CONCLUSIONS: Introducing VATS for retained post-traumatic collections into a relatively resource-constrained township hospital in South Africa is safe and effective. Consideration should be given to performing VATS early and avoiding the use of a second and third chest drain for retained collections. This approach may lead to decreased incidence of empyema and shorter overall hospital stay.

Early fracture stabilisation in the presence of subclinical hypoperfusion.

INTRODUCTION: In polytrauma patients with an injury severity score (ISS)>16, early long bone and pelvic fracture fixation within 24h after injury has been shown to be beneficial. In contrast, surgery in the presence of subclinical hypoperfusion (SCH), defined as normal vital signs with a serum lactate≥2.5mmol/L may be detrimental. This study aimed to investigate the effect of fracture fixation in polytrauma patients with SCH. METHODS: We undertook a database review extracting 88 polytrauma patients with a new injury severity score (NISS)>16 with significant long bone or pelvic fractures (extremity NISS≥9) who underwent surgical fracture stabilisation within 48h of injury. In the group of patients with normal vital signs (mean arterial pressure≥60mmHg and heart rate≤110 beats/min) we compared outcomes between those with a normal preoperative lactate (<2.5mmol/L) and those with a raised lactate (≥2.5mmol/L). RESULTS: Of the 36 patients with normal preoperative vital signs, 17 had normal lactates (control group) and 19 abnormal lactates (SCH group). There were no significant differences in the method of fixation or theatre time between the groups. The SCH group required more inotropic support in the first 24h post surgery (p=0.02) and had higher sequential organ failure assessment (SOFA) scores on day 3 (p=0.003). Although not reaching mathematical significance those with SCH required on average 10 days longer on mechanical ventilation. CONCLUSION: Early fracture fixation in patients with SCH as defined by normal vital signs and a lactate≥2.5mmol/L is associated with significant postoperative morbidity. Consideration should be given to delaying surgery in this cohort.

The prehospital burden of disease due to trauma in KwaZulu-Natal: the need for Afrocentric trauma systems.

BACKGROUND: Trauma is one of the leading prehospital disease profiles in South Africa in general and in KwaZulu-Natal (KZN) in particular. The present study was designed to review the prehospital burden of injury in KZN, identify trauma burden to ambulance ratios, analyze system deficiencies, and propose a prehospital trauma system that is Afrocentric in nature. METHODS: Approval from the relevant ethics authorities was obtained. Using a convenience data set all Emergency Medical Service (EMS) call data for the months of March and September 2010 were reviewed for the three main EMS providers in KZN. Data were extrapolated to annual data and placed in the context of population, ambulance service, and facility. The data were then mapped for area distribution and prehospital workload relative to the entire province. Questionnaire-based assessments of knowledge and deficiencies of the current system were completed by senior officers of the provincial system as part of the analysis of the current system. RESULTS: The total annual call burden for trauma ranges between 94,840 and 101,420, or around 11.6 trauma calls per thousand of the population per year. Almost 70 % of calls were either for interpersonal intentional violence or vehicular collisions. Only 0.25 % of calls involved aeromedical resources. Some 80 % of patients were considered to be moderately to seriously injured, yet only 41 % of the patients were transported to a suitable level of care immediately, with many going to inappropriate lower level care facilities. Many rural calls are not attended within the time norms accepted nationally. Deficiencies noted by the questionnaire survey are the general lack of a bypass mechanism and the feeling among staff that most EMS bases do not have a bypass option or feel part of a system of care, despite large numbers of staff having been recently trained in triage and major trauma care. CONCLUSIONS: The prehospital trauma burden in KZN is significant and consumes vital resources and gridlocks facilities. A prehospital trauma system that is financially sustainable and meets the needs of the trauma burden is proposed to enable Afrocentric emergency care planning for low and middle income regions.

Pelvic fractures at a new level 1 trauma centre: who dies from pelvic trauma? The Inkosi Albert Luthuli Central Hospital experience.

OBJECTIVE: To identify the incidence of pelvic trauma, causes of death and factors predicting death with pelvic fractures. METHODS: All pelvic fractures were retrospectively identified from a registry spanning from March 2007 to August 2009. Data was captured on a proforma. Data for survivors, non-survivors and a subgroup with pelvic injury as the underlying cause of death were compared. RESULTS: Pelvic fracture incidence was 16% of major trauma cases. Patient with pelvic fractures had 31% mortality and 9% pelvic fracture-induced mortality. Motor vehicle collisions were the commonest external cause of pelvic fractures (59%); however, the highest mortality was from falls >6 m. The Injury Severity Score (ISS) was 29 in survivors, 36 in non-survivors, and 54 in the pelvic death subgroup. Type C fracture was a predictor of mortality (P = 0.135). 53% of the cases required transfusion in the first 24 hours. The pelvic death subgroup received a mean of 10.7 units of blood, versus 4 units for survivors and 3.7 units for non-survivors (P = 0.259). CONCLUSION: The overall incidence of pelvic fracture and associated mortality were higher than previously reported. Fracture severity and falls from heights are associated with additional injuries (higher ISS) and mortality. More severe fractures cause deaths directly attributable to the pelvic injury. The requirement for major blood transfusions for pelvic fracture hemorrhage was related to mortality. Female patients appeared to fare worse than males.

Fracture stabilisation in a polytraumatised African population--a comparison with international management practice.

INTRODUCTION: Fracture management in polytrauma patients has favoured early definitive fracture fixation with some authors advocating a staged management approach in these potentially unstable patients. We aimed to investigate the timing of surgical fracture stabilisation in polytrauma patients with significant orthopaedic injuries in a Level 1 trauma unit in South Africa (RSA) and to compare its performance with Level 1 trauma units in the USA and Europe. MATERIALS AND METHODS: A retrospective review was performed extracting polytrauma patients with a New Injury Severity Score (NISS) ≥ 15, with significant pelvic or long bone fractures managed surgically. We compared these data with recently published data from the USA and Europe. RESULTS: Over a 3 year period pedestrian (46.3%) and motor vehicle or motorcycle accidents (40.7%) were the predominant mechanisms of injury in the 123 eligible patients. Compared to international data, patients were significantly younger (32.41 years (SD 13.4) vs. USA 44.1 years (SD 16.39) and Germany 41.2 years (SD 15.35), p < 0.001); and had a higher NISS score (RSA 31.93 (10.3), USA 27.4 (8.65), Germany 29.4 (6.88), p = 0.007). Less definitive fixation took place in the first 24h (RSA 37.4%, USA 57.1%, Germany 65.6%, p < 0.001), but overall definitive fixation took place earlier (RSA 3.6 days (SD 4.39), USA 5.5 days (SD 4.2), Germany 6.6 days (SD 8.7), p = 0.001). CONCLUSION: In a developing country when compared to international trauma centres, less primary definitive fixation was performed in the first 24h.

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.