Penetrating colonic trauma and damage control surgery: Anastomosis or stoma?

BACKGROUND: The management of colon injuries in damage control surgery (DCS) remains controversial. METHODS: A retrospective study investigating outcomes of penetrating colonic trauma in patients who survived beyond the initial repeat laparotomy (IRL) after DCS was performed. Patients over 18 years with penetrating colon injury and who underwent DCS from 2012 to 2020 were included from our electronic trauma registry. Demographic data, admission physiology and Injury Severity Score (ISS) were reviewed. Patients were classified into three groups: primary repair of non-destructive injuries at DCL, delayed anastomosis of destructive injuries at IRL and diversion of destructive injuries at IRL. Outcomes observed included leak rates, length of intensive care unit stay, length of hospital stay, morbidities, mortality and colon-related mortality. RESULTS: Out of 584 patients with penetrating colonic trauma, 89 (15%) underwent DCS. After exclusions, 74 patients were analysed. Mean age was 32.8 years (SD 12.5); 67 (91%) were male. Mechanism of injury was gunshot in 63 (85%) and stab 11 (15%) patients. Seventeen patients underwent primary repair at DCS, of which one leaked. Twenty patients underwent delayed anastomosis at IRL. Of these, five (25%) developed leaks. Mortality was significantly higher for those with an anastomotic leak compared to those without (p < 0.001). Thirty-seven patients were diverted at IRL. Overall mortality (p = 0.622) and colon-related mortality (p = 0.592) were not significantly different across groups. CONCLUSION: Delayed anastomosis at IRL following DCL was associated with a leak rate of 25% in this study. When anastomotic leak did occur, it was associated with significant mortality. Delayed anastomosis should only be undertaken in highly selected patients.

Prospective review of cytotoxic snakebite envenomation in a paediatric population.

Cytotoxic snakebite envenomation is prevalent in Kwazulu-Natal and may be associated with significant physical disability. The aim of this study was to provide an overview of the effects of cytotoxic envenomation in children. The patient population were all patients attending the Emergency Department at Ngwelezana Tertiary Hospital with snakebite from December 2014 to March 2015. All children 13 years or younger presenting with painful progressive swelling (PPS) following snakebite were included in this study. They were further classified according to severity: mild, moderate and severe. Patient demographic and clinical data was collected prospectively. Fifty-one children were included in this study. Nine were classified as mild, 24 as moderate and 18 as severe. The median time of presentation after bite was 6 h in the mild group, 7 h in the moderate group and 12 h in the severe group. There was a positive correlation between increasing severity and INR (p=< .00001) and no correlation between WCC (p = .175) or renal function and severity (p = .963). A total of 11 children (22%) developed an acute kidney injury (AKI). A total of 23/51 patients received antivenom; 25% of patients with moderate cytotoxicity and 94% of patients with severe cytotoxicity. Thirteen percent developed allergic reactions (3/23) and 57% (13/23) anaphylaxis. A total of 15 patients underwent one or more procedures on their affected limbs. There was one recorded mortality during this period, related to severe anaphylaxis following antivenom administration. Access to healthcare for antivenom administration is often delayed and ongoing education within affected areas is advised. Whilst majority of snakebite victims can be adequately managed with basic supportive measures, early identification of severe envenomation is crucial to enable timeous antivenom administration and prevention of further complications such as compartment syndrome and loss of limb. Hypersensitivity reactions are alarmingly common following antivenom administration in children and strict protocols should be followed when administering antivenom.

Aortic balloon occlusion (REBOA) in pelvic ring injuries: preliminary results of the ABO Trauma Registry.

EndoVascular and Hybrid Trauma Management (EVTM) has been recently introduced in the treatment of severe pelvic ring injuries. This multimodal method of hemorrhage management counts on several strategies such as the REBOA (resuscitative endovascular balloon occlusion of the aorta). Few data exist on the use of REBOA in patients with a severely injured pelvic ring. The ABO (aortic balloon occlusion) Trauma Registry is designed to capture data for all trauma patients in hemorrhagic shock where management includes REBOA placement. Among all patients included in the ABO registry, 72 patients presented with severe pelvic injuries and were the population under exam. 66.7% were male. Mean and median ISS were respectively 43 and 41 (SD ± 13). Isolated pelvic injuries were observed in 12 patients (16.7%). Blunt trauma occurred in 68 patients (94.4%), penetrating in 2 (2.8%) and combined in 2 (2.8%). Type of injury: fall from height in 15 patients (23.1%), traffic accident in 49 patients (75.4%), and unspecified impact in 1 patient (1.5%). Femoral access was gained pre-hospital in 1 patient, in emergency room in 43, in operating room in 12 and in angio-suite in 16. REBOA was positioned in zone 1 in 59 patients (81,9%), in zone 2 in 1 (1,4%) and in zone 3 in 12 (16,7%). Aortic occlusion was partial/periodical in 35 patients (48,6%) and total occlusion in 37 patients (51,4%). REBOA associated morbidity rate: 11.1%. Overall mortality rate was 54.2% and early mortality rate (≤ 24 h) was 44.4%. In the univariate analysis, factors related to early mortality (≤ 24 h) are lower pH values (p = 0.03), higher base deficit (p = 0.021), longer INR (p = 0.012), minor increase in systolic blood pressure after the REBOA inflation (p = 0.03) and total aortic occlusion (p = 0.008). None of these values resulted significant in the multivariate analysis. In severe hemodynamically unstable pelvic trauma management, REBOA is a viable option when utilized in experienced centers as a bridge to other treatments; its use might be, however, accompanied with severe-to-lethal complications.

Feasibility and Clinical Outcome of Reboa in Patients with Impending Traumatic Cardiac Arrest.

BACKGROUND: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) may improve Systolic Blood Pressure (SBP) in hypovolemic shock. It has, however, not been studied in patients with impending traumatic cardiac arrest (ITCA). We aimed to study the feasibility and clinical outcome of REBOA in patients with ITCA using data from the ABOTrauma Registry. METHODS: Retrospective and prospective data on the use of REBOA from 16 centers globally were collected. SBP was measured both at pre- and post-REBOA inflation. Data collected included patients' demography, vascular access technique, number of attempts, catheter size, operator, zone and duration of occlusion, and clinical outcome. RESULTS: There were 74 patients in this high-risk patient group. REBOA was performed on all patients. A 7-10Fr catheter was used in 66.7% and 58.5% were placed on the first attempt, 52.1% through blind insertion and 93.2% inflated in Zone I, 64.8% for a period of 30 to 60 min, 82.1% by ER doctors, trauma surgeons, or vascular surgeons. SBP significantly improved to 90 mm Hg following the inflation of REBOA. 36.6% of the patients survived. CONCLUSIONS: Our study has shown that REBOA may be performed in patients with ITCA, SBP can be elevated, and 36.6% of the patients survived if REBOA placement is successful.

Rib fracture fixation as a tool for extubation in a resource-poor environment.

An elderly female with multiple comorbidities was involved in a pedestrian vehicle accident and sustained blunt chest trauma, arriving at a resource-poor hospital in rural South Africa. She had multiple bilateral rib fractures with a unilateral flail segment that caused her to develop respiratory failure. She was intubated and sent to the intensive care unit (ICU) for ventilation. She developed hospital and ventilator acquired pneumonia. She subsequently had hypoxic arrests on two separate occasions and two failed extubations. Despite inadequate access to provisions, this patient was taken to theatre for rib fracture fixation as an attempt to improve her lung function and get her off the ventilator. She was extubated two days after the procedure and discharged from ICU 4 days thereafter. On her follow-up, she reported that she had returned to normal daily living and tasks.

The spectrum of injuries resulting from abdominal stab wounds with isolated omental evisceration: A South African experience.

INTRODUCTION: The spectrum of injury associated with anterior abdominal stab wounds (SWs) is well established. The literature in the specific setting of isolated omental evisceration is limited. MATERIALS AND METHODS: We reviewed our experience of 244 consecutive patients with established indications for laparotomy over an eight year period at a major trauma centre in South Africa. RESULTS: Of the 244 patients (93% male, mean age: 27 years), 224 (92) underwent immediate laparotomy (IL). Twenty were initially observed and eventually required a laparotomy (delayed laparotomy, DL). The mean time from injury to decision for laparotomy was <3 h in 92% (224/244), <6 h in 6% (14/244), <12 h 2% (4/244) and <18 h in 1% (2/244). Ninety-eight per cent (238/244) of laparotomies were positive and 96% of the positive laparotomies (229/238) were considered therapeutic. The mostly commonly injured organ encountered on laparotomy were small bowel, stomach and colon. CONCLUSIONS: The most commonly injures encountered are intestinal and gastric. Clinicians must remain vigilant as injuries may be subtle.

Bishop-Koop jejunostomy in an adult following proximal small bowel anastomotic breakdown.

This case involves a proximal penetrating small bowel injury and the use of a Bishop-Koop anastomosis in a 33-year-old man. This case highlights the use of alternative methods used to prevent a proximal small bowel stoma in a rural setting. The Bishop-Koop anastomosis was originally designed for neonates in cases of intestinal anomalies such as atresia, volvulus and apple-peel syndrome. A literature search for the use of the Bishop-Koop anastomosis in adults, although scanty, is included in this article. We believe this article will benefit readers and that this method may be considered in breakdown of proximal small bowel injuries, to prevent a high-output stoma.

Management of intra-abdominal vascular injury in trauma laparotomy: a South African experience.

BACKGROUND: Intra-abdominal vascular injury (IAVI) is uncommon but continues to be associated with high mortality rates despite technological advances in the past decades. In light of these ongoing developments, we reviewed our contemporary experience with IAVI in an attempt to clarify and refine our management strategies and the outcome of these patients. METHODS: We retrospectively reviewed the charts of all patients admitted between January 2011 and December 2014 at a major trauma centre in South Africa who were found to have an IAVI during laparotomy for trauma. We collected demographic and clinical data including mechanism of injury, location and severity of the injury, concurrent injuries, physiologic parameters and clinical outcome. RESULTS: We identified 110 patients with IAVIs, of whom 98 had sustained penetrating injuries (55 gunshot wounds and 43 stab wounds). There were 84 arterial injuries (including 21 renal and 17 mesenteric) and 74 venous injuries (including 21 renal and 17 inferior vena caval). Combined venous and arterial injuries were found in almost one-third of patients (34 [30.9%]). Fifty-seven patients (51.8%) required intensive care admission. The overall mortality rate was 28.2% (31 patients); the rate was 62% for aortic injuries and 47% for inferior vena cava injuries. Liver injury, large bowel injury, splenic injury and elevated lactate level were all associated with a statistically significantly higher mortality rate. CONCLUSION: The mortality rate for IAVI remains high despite decades of operative experience in high-volume centres. Open operative techniques alone are unlikely to achieve further reduction in mortality rates. Integration of endovascular techniques may provide an alternative strategy to improve outcomes.

CONTEXTE: Les lésions vasculaires intraabdominales (LVIA) sont rares, mais elles sont toujours associées à un taux de mortalité élevé, malgré les progrès technologiques des dernières décennies. À la lumière de ces renseignements, nous avons passé en revue l'expérience récente en matière de LVIA afin de clarifier et de parfaire nos stratégies de prise en charge et d'améliorer les résultats des patients. MÉTHODES: Nous avons examiné de manière rétrospective les dossiers de tous les patients admis entre janvier 2011 et décembre 2014 dans un grand centre de traumatologie d'Afrique du Sud chez qui une laparotomie a révélé la présence d'une LVIA. Nous avons recueilli des données démographiques et cliniques portant notamment sur le mécanisme lésionnel, la localisation et la gravité de la lésion, les blessures concomitantes, les paramètres physiologiques et l'issue clinique. RÉSULTATS: Nous avons recensé 110 patients atteints de LVIA, dont 98 avaient subi des blessures par pénétration (55 causées par un projectile d'arme à feu et 43 par une arme blanche). Nous avons dénombré 84 lésions artérielles (dont 21 rénales et 17 mésentériques) et 74 lésions veineuses (dont 21 rénales et 17 touchant la veine cave inférieure). Dans l'ensemble, nous avons constaté des lésions veineuses et artérielles chez près du tiers des patients (34 patients, soit 30,9 %). Cinquante-sept patients (51,8 %) ont dû être admis à l'unité des soins intensifs. Le taux de mortalité global était de 28,2 % (31 patients); il était de 62 % pour les cas de lésions aortiques et de 47 % pour les lésions touchant la veine cave inférieure. Les lésions au foie, au gros intestin et à la rate ainsi que les taux élevés de lactate ont tous été associés à une hausse statistiquement significative du taux de mortalité. CONCLUSION: Le taux de mortalité associé aux LVIA reste élevé malgré des décennies d'expérience chirurgicale dans des centres de traumatologie traitant un grand nombre de patients. Les techniques opératoires ouvertes seules sont peu susceptibles de donner lieu à une baisse de ce taux. L'intégration des techniques endovasculaires pourrait constituer une solution de rechange pour améliorer les résultats.

Selective nonoperative management of pharyngoesophageal injuries secondary to penetrating neck trauma: A single-center review of 86 cases.

BACKGROUND: This article describes our experience with penetrating pharyngoesophageal injuries (PEI) in the light of a selective conservative approach, and has the objective to define criteria for nonoperative management (NOM). METHODS: This retrospective single-center review of patients with penetrating neck injury treated for confirmed PEI over a 6-year period aimed to test our proposed hypothesis that NOM is safe for hemodynamically stable patients with PEI, who have no competing indications for exploration, have no established sepsis, and who have a water-soluble contrast swallow either showing no- or a contained extravasation. RESULTS: Eighty-six (9%) patients with PEI (oropharynx, 17; hypopharynx, 40; esophagus, 29) of 948 patients with penetrating neck injury were included. Of the cohort 38 (44%) underwent NOM (oropharynx, 15 [88%]; hypopharynx, 18 [45%]; esophagus, 5 [17%]), and 48 (56%) were managed operatively. The median length of stay was 12 days (interquartile range, 19-8). Fifteen (17%) had a persistent leak and six (7%) mediastinitis. Five (6%) patients died but only one (1%) had isolated PEI. Retrospectively, 27 patients fulfilled our proposed criteria for NOM of which 23 had been treated actively by NOM (oropharynx, 8; hypopharynx, 12; esophagus, 3). For these patients, the length of stay was 10.0 days (interquartile range, 13-6), and none developed deep wound sepsis, mediastinitis, persistent leaks, or died. Of the remaining patients treated by NOM without fulfilling the proposed criteria, two were palliated (esophagus) and 13 were managed actively (oropharynx, 7; hypopharynx, 6). Only four of these patients (oropharynx, 1; hypopharynx, 3) were assessed with water-soluble contrast swallow, which showed noncontained extravasation, and three complicated with persistent leaks. CONCLUSION: Nonoperative management of PEI is safe for a carefully selected subgroup of patients. However, most injuries to the caudal part of the cervical digestive tract mandate urgent exploration. LEVEL OF EVIDENCE: Clinical Management Study, Level V evidence.

The Selective Non-operative Management of Penetrating Cervical Venous Trauma is Safe and Effective.

BACKGROUND: This paper reviews our experience with penetrating cervical venous trauma and aims to validate the selective non-operative management (SNOM) of these injuries. METHODS: This was a retrospective review of a prospectively maintained registry. All patients presenting alive with an injury to the internal jugular vein, subclavian vein or innominate vein following a PNI were reviewed for a 6-year period. RESULTS: Among 817 patients admitted for the management of PNI, 76 (9.3%) had a venous injury. Of these, 37 (48.7%) patients were managed non-surgically, 20 (26.3%) required immediate surgical exploration, seven of whom had an associated arterial injury, and 19 (25%) underwent surgery following a diagnostic CTA, 16 of whom had an associated arterial or aero-digestive injury. In total, only 16 (21.1%) of the 76 patients required exploration for venous injury alone. The majority (63.2%) of patients had a history of severe bleeding or hemodynamic instability prior to arrival, but only 20 (26.3%) required immediate exploration. Two (2.6%) patients died as a result of venous injury. No patients developed complications related to the venous injury. CONCLUSIONS: SNOM is applicable to a well-defined subset of patients with isolated penetrating cervical venous trauma to the IJV and SCV identified on CTA.

Gastric Perforation After a Dog Attack.

Dog bites are a major cause of injury, especially in the pediatric population. Common anatomic sites of dog bites on children are the peripheries and the head and neck. The torso is reportedly injured less frequently, and only 2 cases of intra-abdominal injury secondary to dog bites have been reported. We recently encountered a 3-year-old boy presenting with peritonitis who had sustained multiple dog bites to his trunk and upper limbs. Emergency laparotomy was performed. Surgical findings revealed penetration of the peritoneum and single perforation of the anterior gastric wall with multiple tooth marks; thus, the gastric perforation was debrided and repaired. After receiving rabies prophylaxis and amoxicillin-clavulanate, the patient had an uneventful postoperative course. The principles of management of dog bites include debridement of wounds and use of prophylactic antibiotics. Because rabies is always fatal, postexposure prophylaxis should be considered in appropriate cases. Dog bites can be life-threatening, and prevention is the best approach to solve this problem. Clinicians need to be aware that some dog bites can be devastating and should be familiar with the principles of managing these wounds.

The role of computed tomography angiography in the detection of aerodigestive tract injury following penetrating neck injury.

BACKGROUND: The purpose of this study was to audit our experience with computed tomography angiography (CTA) for the detection of aerodigestive tract injury (ADTI) following penetrating neck injury (PNI) and to assess the significance of deep surgical emphysema on CTA. METHODS: A prospectively maintained trauma registry at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa was retrospectively interrogated. The data of all patients with PNI investigated with CTA over a 4-y period were reviewed. All findings of deep surgical emphysema were correlated to an aggregate standard of reference for ADTI as demonstrated by results from clinical examination, surgical neck exploration, endoscopy or contrasted swallow to determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of this finding. RESULTS: A total of 383 patients underwent a CTA for PNI. A total of 94 vascular injuries were identified on 78 positive CTA studies. The sensitivity and specificity of CTA in detecting a vascular injury were 94.4% and 96.7%. Of the 383 patients investigated a total of 38 patients were diagnosed with digestive tract injury (DTI), and all of these patients were found to have deep surgical emphysema on CTA, except for one patient with a clinically insignificant oral cavity injury. Another 126 patients also had deep surgical emphysema on CTA but no DTI. The sensitivity, specificity, PPV, and NPV of deep surgical emphysema for the diagnosis of confirmed DTI in PNI were therefore 97.4%, 63.5%, 22.7%, and 99.5%, respectively. The sensitivity and NPV were, however, 100% when clinically insignificant injuries were excluded. Including patients with confirmed airway injuries and excluding all patients with pneumothoraces yielded a sensitivity, specificity, PPV, and NPV of 94.1%, 71.9%, 30.0%, and 98.9%, respectively, for the identification of ADTI. When excluding surgically irrelevant injuries, the sensitivity and NPV were again both 100%. CONCLUSIONS: CTA for PNI has a high sensitivity and specificity for demonstrating vascular injury. The absence of deep surgical emphysema in the deep cervical fascial planes virtually excludes surgically significant ADTI. The presence of deep surgical emphysema is nonspecific but warrants further investigation.

Selective non-operative management of stab wounds to the posterior abdomen is safe: the Pietermaritzburg experience.

INTRODUCTION: The selective non-operative management (SNOM) of stab injuries of the anterior abdomen is well established, but its application to the posterior abdomen remains controversial. MATERIALS AND METHODS: A retrospective review of 1013 patients was undertaken at a major trauma service in South Africa over a five-year period. RESULTS: Ninety per cent of patients were males, and the mean age was 25 years. The mean time from injury to presentation was 4h and 73% of all injuries were inflicted by knives. A total of 9% (93) of patients required a laparotomy [Group A] and 82% (833) were successfully observed without the need for operative intervention [Group B]. CT imaging was performed on 52 patients (5%) who had haematuria [Group C], 25 (3%) who had neurological deficits [Group D], and 10 (1%) with retained weapon injuries [Group E]. The accuracy of physical examination for identifying the presence of organ injury was 88%. All observed patients who required laparotomy declared themselves within 24h. There were no mortalities as direct result of our current management protocol. CONCLUSIONS: Selective management based on active clinical observation and serial physical examination is safe, and when coupled with the judicious use of advanced imaging, is a prudent and reliable approach in a resource constrained environment.

Correlation between ATLS training and junior doctors' anatomical knowledge of intercostal chest drain insertion.

OBJECTIVE: To review the ability of junior doctors (JDs) in identifying the correct anatomical site for intercostal chest drain insertion and whether prior Advanced Trauma Life Support (ATLS) training influences this. DESIGN: We performed a prospective, observational study using a structured survey and asked a group of JDs (postgraduate year 1 [PGY1] or year 2 [PGY2]) to indicate on a photograph the exact preferred site for intercostal chest drain insertion. SETTING: This study was conducted in a large metropolitan university hospital in South Africa. RESULTS: A total of 152 JDs participated in the study. Among them, 63 (41%) were men, and the mean age was 24 years. There were 90 (59%) PGY1 doctors and 62 (41%) PGY2 doctors. Overall, 28% (42/152) of all JDs correctly identified the site that was located within the accepted safe triangle. A significantly higher proportion of PGY2 doctors selected the correct site when compared with PGY1 doctors (39% vs 20%, p = 0.026). Those who had prior ATLS provider training were 6.8 times more likely to be able to identify the correct site (RR = 6.8, 95% CI: 3.7-12.5). CONCLUSIONS: Most of the JDs do not have sufficient anatomical knowledge to identify the safe insertion site for intercostal chest drain. Those who had undergone ATLS training were more likely to be able to identify the safe insertion site.

Prophylactic antibiotics for tube thoracostomy may not be appropriate in the developing world setting.

INTRODUCTION: Prophylactic antibiotics for tube thoracostomy (TT) for the prevention of post-traumatic empyema (PTE) remain controversial. Literature specifically focusing on the developing world setting is limited. MATERIALS AND METHODS: A retrospective study was conducted over a four-year period on patients managed with TT alone in which prophylactic antibiotics was not utilised. We documented the actual incidence of PTE in a high volume trauma service in South Africa. RESULTS: A total of 1002 patients who had TT in the trauma room were eligible for inclusion. Ninety-one percent (912/1002) were males and the mean age for all patients was 26 years (SD 7). Seventy-five percent (755/1002) sustained penetrating trauma (PT), while the remaining 25% (247/1002) sustained blunt trauma (BT). Six hundred and twenty patients (62%) sustained HTXs and the remaining 382 patients (38%) had PTXs. Of the 1002 patients who underwent TT, 15 (1.5%, 95% CI: 0.8-2.5%) developed PTE. The incidence of empyema in those with PT was 1.9% (14/755) and 0.4% (1/247) for BT. This difference was not statistically significant (p=0.166). All 15 patients who developed PTE were males, with a mean age of 31 years (SD 6). All 15 patients had HTX as the initial thoracic pathology. This difference was highly statistically significant when compared to PTX (p=0.002). The mean length of hospital stay was 11 days (SD 7). There were no mortalities in these patients. CONCLUSIONS: In our setting where prophylactic antibiotics are not routinely used, the actual incidence of PTE in our population is extremely low. In the absence of further definitive evidence to support its use, routine prophylactic antibiotics for TT is difficult to justify in a developing world setting at present.

Isolated free intra-abdominal fluid on CT in blunt trauma: The continued diagnostic dilemma.

PURPOSE: The clinical significance of isolated free fluid (FF) without solid organ injury on computed to- mography (CT) continues to pose significant dilemma in the management of patients with blunt abdominal trauma (BAT). METHODS: We reviewed the incidence of FF and the clinical outcome amongst patients with blunt abdominal trauma in a metropolitan trauma service in South Africa. We performed a retrospective study of 121 consecutive CT scans over a period of 12 months to determine the incidence of isolated FF and the clinical outcome of patients managed in a large metropolitan trauma service. RESULTS: Of the 121 CTs, FF was identified in 36 patients (30%). Seven patients (6%) had isolated FF. Of the 29 patients who had free fluid and associated organ injuries, 33 organ injuries were identified. 86% (25/ 29) of all 29 patients had a single organ injury and 14% had multiple organ injuries. There were 26 solid organ injuries and 7 hollow organ injuries. The 33 organs injured were: spleen, 12; liver, 8; kidney, 5; pancreas, 2; small bowel, 4; duodenum, 1. Six (21%) patients required operative management for small bowel perforations in 4 cases and pancreatic tail injury in 2 cases. All 7 patients with isolated FF were initially observed, and 3 (43%) were eventually subjected to operative intervention. They were found to have an intra-peritoneal bladder rupture in 1 case, a non-expanding zone 3 haematoma in 1 case, and a negative laparotomy in 1 case. Four (57%) patients were successfully managed without surgical interventions. CONCLUSIONS: Isolated FF is uncommon and the clinical significance remains unclear. Provided that reli- able serial physical examination can be performed by experienced surgeons, an initial non-operative approach should be considered.

What is the yield of routine chest radiography following tube thoracostomy for trauma?

INTRODUCTION: Routine chest radiography (CXR) following tube thoracostomy (TT) is a standard practice in most trauma centres worldwide. Evidence supporting this routine practice is lacking and the actual yield is unknown. MATERIALS AND METHODS: We performed a retrospective review of 1042 patients over a 4-year period who had a routine post-insertion CXR performed in accordance with current ATLS® recommendations. RESULTS: A total 1042 TTs were performed on 1004 patients. Ninety-one per cent of patients (913/1004) were males, and the median age for all patients was 24 years. Seventy-five per cent of all injuries (756/1004) were from penetrating trauma, and the remaining 25% (248/1004) were from blunt. The initial pathologies requiring TT were: haemopneumothorax: 34% (339/1042), haemothroax: 31% (314/1042), simple pneumothorax: 25% (256/1042), tension pneumothorax: 8% (77/1042) and open pneumothorax: 5% (54/1042). One hundred and three patients had TTs performed on clinical grounds alone without a pre-insertion CXR [Group A]. One hundred and ninety-one patients had a pre-insertion CXR but had persistent clinical concerns following insertion [Group B]. Seven hundred and ten patients had pre-insertion CXR but no clinical concerns following insertion [Group C]. Overall, 15% (152/1004) [9 from Group A, 111 from Group B and 32 from Group C] of all patients had their clinical management influenced as a direct result of the post-insertion CXR. CONCLUSIONS: Despite the widely accepted practice of routine CXR following tube thoracostomy, the yield is relatively low. In many cases, good clinical examination post tube insertion will provide warnings as to whether problems are likely to result. However, in the more rural setting, and in resource challenged environments, there is a relatively high yield from the CXR, which alters management. Further prospective studies are needed to establish or refute the role of the existing ATLS® guidelines in these specific environments.

Laparoscopy in the diagnosis and repair of diaphragmatic injuries in left-sided penetrating thoracoabdominal trauma: laparoscopy in trauma.

BACKGROUND: Diaphragmatic injuries from penetrating thoracoabdominal trauma are notoriously difficult to detect with clinical and radiological evaluation. The aim of this study was to establish the incidence of diaphragmatic injury from penetrating thoracoabdominal trauma, clinical and radiological features predictive of a diaphragmatic injury and the feasibility of laparoscopic repair. METHODS: This is a prospective consecutive case series conducted in a metropolitan hospital complex. Fifty five patients were enrolled into the study and underwent a standardized laparoscopic procedure. Only stable patients were selected and right-sided penetrating thoracoabdominal injuries were excluded. The patients' clinical details, radiological findings, operative procedure, treatment of the diaphragmatic injury and complications were collected and analysed. RESULTS: There were a total of 55 patients, of whom, 22 (40 %) had diaphragmatic injuries. The mean age was 26.3 ± 7.8 years (range 15-44) with a male:female ratio of 10:1. The causes of injury were stab in 54 (98.2 %) patients and firearm in one (1.8 %). Twenty six (47.3 %) patients had positive radiological findings, of which 10 (38.5 %) had a diaphragmatic injury. There were 6 (27.3 %) associated intra-abdominal injuries. Twenty one (95.5 %) of 22 patients with diaphragmatic injuries were successfully repaired laparoscopically. Mean duration of procedure with diaphragmatic repair was 74.9 ± 22.5 min compared to 38.3 ± 16.9 min without diaphragmatic repair. Six patients (10.9 %) had minor intra-operative complications. There were no deaths. Hospital stay was 2.9 ± 3.4 days. CONCLUSIONS: Diaphragmatic injury was present in 40 % of patients with left-sided thoracoabdominal injury. Radiological findings were not reliable in predicting diaphragmatic injury. The majority of these injuries can be safely repaired laparoscopically.

Penetrating cardiac injuries and the evolving management algorithm in the current era.

BACKGROUND: Penetrating cardiac injuries carry a significant mortality, especially if operative intervention is delayed because of diagnostic difficulties. METHODS AND MATERIALS: We reviewed our experience of 134 consecutive cases over a 6 year period. For the initial 5 years, the diagnosis was based on clinical grounds only. During the final year of study, focused ultrasound focused abdominal sonar for trauma (FAST) and subxiphoid pericardial window were introduced. RESULTS: Ninety-six per cent (128/134) were males and the overall mean age was 27 y. Eighty-four per cent (112/134) sustained isolated cardiac injury and the remaining sixteen per cent (22/134) had concurrent injuries elsewhere. A total of 10 FAST's were performed and the sensitivity was 20%. Fifteen subxiphoid pericardial window were performed (8 had diagnostic uncertainty, 2 with double jeopardy, and 5 with delayed tamponade) and had a sensitivity of 100%. The survival rate for the 109 patients from the pre-adjunct period was 83% and 88% for the 25 patients in the post-adjunct period, which was not statistically significant (P value = 0.765). There was no significant difference in the complication rate, mean intensive care unit stay, or mean total hospital stay. CONCLUSIONS: Penetrating cardiac injuries are highly lethal. A high index of suspicion, coupled with early operative intervention remains the key in securing the survival of these patients.