Critical care burden of skin and soft tissue infection in Central Australia: More than skin deep.

OBJECTIVE: To describe the epidemiology, critical care resource use of and outcomes from an intensive care admission for a skin or soft tissue infection in Central Australia. DESIGN: Retrospective database review of prospectively collected data identifying all patients requiring admission for a life-threatening illness related to a skin or soft tissue infection. SETTING: Intensive care unit Alice Springs Hospital. PARTICIPANTS: All patients admitted with a primary diagnosis of skin or soft tissue infection between 2010 and 2016. MAIN OUTCOME MEASURE: Annualised incidence of skin or soft tissue infection requiring intensive care. Secondary outcomes examined resource use (length of stay, mechanical ventilation) and a description of the microbiology of skin or soft tissue infection in Central Australia. RESULTS: There were 80 admissions to the intensive care unit over the sampling period, yielding an annualised incidence of 24.2 intensive care unit admissions per 100 000 population. Eighty-five per cent were Indigenous with high rates of co-morbid disease including poorly controlled type 2 diabetes, haemodialysis-dependent chronic kidney disease and co-infection with human T-cell lymphocytic virus. The predominant type of skin or soft tissue infection was abscess, predominantly below the waist. Gram-positive cocci comprised 50% of the organisms cultured, and 20% of organisms were multi-resistant. Mortality was 0% and 1.3% at 28 and 90 days respectively. CONCLUSION: The annualised incidence of skin or soft tissue infection requiring intensive care support in Central Australia is higher than expected. This probably reflects the high burden of chronic disease and poor living conditions. While there is no mortality burden associated with skin or soft tissue infection in Central Australia, there is substantial morbidity. The data from this study adds weight to the call for improved primary health resources for this group.

Does surgical decompression in Ludwig's angina decrease hospital length of stay?

INTRODUCTION: Ludwig's angina (LA) is an uncommon and potentially life-threatening condition of the upper aero-digestive tract that often requires the coordinated efforts of the surgical, anesthetic and intensive care teams to optimize management. The purpose of the present study was to investigate the documented clinical features and the surgical and airway management of LA at Alice Springs Hospital for the purpose of assessing surgical outcomes with particular reference to length of stay (LOS). METHODS: Retrospective chart review from January 1998 to January 2008 examined patients admitted with LA at Alice Springs Hospital. Documented clinical features, interventions, and operative findings including floor of mouth swelling, Mallampati score, and airway compromise were collected. Outcomes, with particular respect to LOS, for those who received intravenous (IV) or inhalational induction and those that received awake fibre-optic intubations were compared. RESULTS: Of 30 patients with LA, 28 (93%) were managed with operative drainage with a LOS in the intensive care unit (ICU) of 2 days and a hospital LOS of 5 days. Seven received awake fibre-optic intubation and 21 had IV or inhalational anesthesia with none requiring tracheotomy. There was no statistical difference in LOS between those patients whose microbiological culture results showed no growth and those whose cultures had positive growth. DISCUSSION: Management was generally operative decompression with IV antibiotics. LOS is not affected by the presence or absence of culture positive infection. It is proposed that operative intervention is safe, effective, and is associated with shorter patient stays in the intensive care unit and the hospital overall.

The growing burden of injuries and trauma in Alice Springs.

In Alice Springs, assault and attempted homicide, self-harm and attempted suicide and transportation accidents contribute substantially to the burden of disease, especially among the aboriginal population who are poor and disadvantaged. While road traffic accidents and self-inflicted injuries are the leading causes of injury-related deaths worldwide, violence is a major factor in Alice Springs trauma. Violence accounted for more than half the annual trauma case load. Aboriginal Central Australians bear a disproportionate risk of injury and illness compared to their non-aboriginal counterparts. Rampant alcoholism and social and family breakdown are thought to be significant contributors to the high incidence of violence in Alice Springs. There were 2,800 trauma admissions to Alice Springs hospital in 2006 compared to 1,800 admissions in 2003. Geographical location often limits timeliness, access and level of health care available to rural and isolated regions of central Australia. Solutions to the trauma epidemic in our Remote indigenous population must look past the Emergency and Surgical Departments that care for the injured to the individual, community, environmental, social and economic factors that underpin the traumas. Traumatic injury and death maybe the most preventable of all health issues. While tremendous resources are spent caring for injured patients in hospital, less attention is paid towards gaining a better understanding of injury prevention.

Epidemic of stab injuries: an Alice Springs dilemma.

This study is unique in that it strives to unfold, perhaps for the first time, the problem of stab injuries and resultant significant mortality and morbidity within the Aboriginal population of Central Australia. Demographic features presented in the study are quite different from other published Australasian and overseas experiences. There were 1550 stab injury admissions to Alice Springs Hospital during a 7-year period (July 1998 to June 2005). Thirty-two patients were dead before arrival, and there were only three deaths in the hospital during the period of study. The most unique demographic feature was that 99.99% were Aborigines, 53% were women and the most common location of injury was in town camps and homes. The mean age of this population was 31 years, and the average length of stay in hospital was 3 days. The most common site of the stab injuries was the thigh with a total of 605 (38%). Stab injuries to the abdomen were significantly low with 68 (<1%). Twenty-one per cent (332) presented 24 h to 10 days after stabbing. Another 21% (335) absconded before the completion of treatment. Of the victims, 31% (481) were under the influence of alcohol. Twenty per cent (311) of the patients presented with repeat stabbings during the study period. Traditional punishment is still practised in Central Australia and thus explains the high number of thigh injuries. A particular pattern of traditional stab injuries was also noted; medial thigh to kill, posterior thigh to permanently disable and lateral thigh to punish. Rampant alcoholism and social and family breakdown are thought to be significant contributors to the high incidence of violence in Alice Springs. There were only five firearm traumas during this period, two were self-inflicted and three were accidental.

New method of abdominoplasty for morbidly obese patients.

INTRODUCTION: We report two cases of morbidly obese patients with huge infected abdominal aprons who underwent apronectomies at Alice Springs Hospital, Northern Territory, Australia. We describe a novel technique which to date has not been described in the available literature. Patients afflicted by morbid obesity with large aprons can be incapacitated by immobility as well as suffer from recurrent infections. Apronectomy in this situation can be difficult because of the heavy weight of the apron. METHOD: This technique involves the use of a small crane and large orthopaedic K-nails. Two K-nails were inserted into the apron and attached to a small crane. This facilitated the elevation and manipulation of the apron during surgical dissection. The abdominal tissue removed from the female and male weighed 30 kg and 64 kg, respectively. The wounds were closed primarily and drained by three large bore suction drains. RESULTS: The female patient had a largely uneventful postoperative course with a minor wound infection that resolved with conservative treatment. The other patient required a more protracted course of antibiotics for his more severe infection. Mobility was markedly improved in both individuals. CONCLUSION: This novel technique can be used successfully for severely morbidly obese individuals and can significantly reduce the surgeon's and assistants' difficulty in manipulating and handling a heavy apron during dissection.