The utility of serial chest X-rays for detection of delayed pneumothorax, haemothorax or haemopneumothorax following penetrating thoracic injury.

INTRODUCTION: Penetrating thoracic injuries are a common presentation in Emergency Departments in South Africa with pneumothorax, haemothorax and haemopneumothorax (PTX/HTX/HPTX) a cause of morbidity and mortality. Serial chest X-rays (CXRs) are used to assess patients with penetrating thoracic injury without PTX/HTX/HPTX on initial CXR in order to increase sensitivity and thus detection of PTX/HTX/HPTX. This study aimed to assess the utility of serial CXRs to detect a delayed presentation of PTX/HTX/HPTX following penetrating thoracic injury. METHODS: This retrospective observational study analysed data from Helen Joseph Hospital Emergency Department, Johannesburg, South Africa for patients presenting with penetrating thoracic injury over a 2-year period for whom the initial CXR was negative for a PTX/HTX/HPTX to determine the utility of serial CXRs for detection of a delayed presentation of PTX/HTX/HPTX. RESULTS: 118 patients, the majority of which had penetrating trauma secondary to a stab wound, were included in the study. Eight (7%) had a PTX/HTX/HPTX detected on subsequent investigation. Three (3%) patients with normal initial CXRs and three (3%) patients with abnormal initial CXRs had a PTX/HPX/HPTX detected on serial CXRs. Two (2%) delayed presentations of PTX/HTX/HPTX were noted on computerised tomography (CT) scan only. Six patients had an intercostal drain (ICD) inserted and were admitted; 2 patients (those with PTX/HTX/HPTX noted on CT only) were managed conservatively. Three patients (3%) had an ICD inserted to manage a delayed presentation of PTX/HTX/HPTX with a normal initial CXR. DISCUSSION: Only 3% of patients with normal initial CXRs required intervention. CONCLUSIONS: It is recommended that patients for whom the presentation CXR shows an abnormality undergo serial CXRs. Given the low incidence of PTX/HTX/HPTX in patients with a normal presentation CXR, along with the resource implications of serial CXRs, it may be prudent to discharge patients with thorough counselling and advice to return for review if warranted.

Hyperlactataemia with acute kidney injury following community assault: cause or effect?

BACKGROUND: Crush injury is a common presenting clinical problem in South African trauma patients, causing acute kidney injury (AKI). It has been theorised previously that the AKI was not due to an anaerobic phenomenon. A previous local study noted the presence of a mild hyperlactataemia among patients with crush syndrome, but the significance and causes of this was not fully explored. This study aimed to examine the incidence of hyperlactataemia in patients with crush syndrome presenting to a busy emergency department (ED) in rural South Africa. METHOD: The study was conducted at Edendale Hospital in KwaZulu-Natal province in South Africa from 1 June 2016 to 31 December 2017. All patients from the ED who had sustained a crush injury secondary to a mob assault were included in the study. Patients with GCS on arrival of < 13 or polytrauma were excluded from analysis. The primary outcome of interest was the presence of hyperlactataemia (> 2.0mmol/L) on presentation. The Kidney Disease Improving Global Outcomes (KDIGO) criteria were used to diagnose and stage AKI as a secondary outcome. RESULTS: A total of 84 patients were eligible for analysis. Sixty-nine (82%) patients presented with hyperlactataemia. The median serum lactate was 4.9mmol/L (IQR 2.3-7.2mmol/L). Fifteen (18%) patients were diagnosed with AKI on presentation according to serum creatinine. Ten patients were diagnosed as Stage 1, three were Stage 2 and two Stage 3 AKI respectively. There was no difference in the incidence of AKI in patients with or without hyperlactataemia (p = 0.428). Time from injury to presentation was a median 365 minutes (IQR 180-750 minutes). Six (7%) patients were admitted to high care unit and nine (11%) were admitted to the intensive care unit (ICU). No patients died within 48 hours of admission. Two patients received renal replacement therapy during the first 48 hours of admission to hospital. CONCLUSION: Hyperlactataemia is a common feature of patients presenting to the ED following crush syndrome secondary to beatings received during interpersonal violence. The origin of this hyperlactataemia is currently unknown. Further research needs to be conducted into the origin of the hyperlactataemia and its clinical significance. In this cohort, the utilisation of RRT was low but the incidence of AKI was high and developed rapidly following the injury. The utilisation of RRT also needs to be further studied in larger patient populations in South Africa to make local clinical recommendations for use.

Pneumomediastinum and pneumopericardium following blunt thoracic trauma: much ado about nothing?

PURPOSE: Pneumomediastinum is the hallmark of intrathoracic aerodigestive trauma, but rare following blunt injury. AIM: review of blunt thoracic trauma (BTC) for the incidence and outcome of patients with pneumomediastinum or pneumopericardium (PM/PC) on Computerised Tomographic scanning. METHODS: Admissions to the level I trauma ICU at IALCH, Durban, ZA following BTC from April 2007 to March 2014. Patients with Chest-CT-scan were analysed. Variables included age, sex, mechanism of injury, and Injury Severity Score (ISS). Specific injury patterns: isolated thoracic trauma, flail chest, bilateral injury and presence of haemothorax or pneumothorax were analysed. RESULTS: Three hundred and eighty-nine patients were included. Males (70.9%) accounted for the majority of patients. The median Injury Severity Score was 32 (IQR 24-41). Motor vehicle collisions accounted for 94% of injury mechanisms. Twenty-three (5.9%) were identified with pneumomediastinum, 6 (1.5%) with both pneumomediastinum and pneumopericardium, and 1 (0.2%) with isolated pneumopericardium. No patient required surgery for thoracic trauma. Increasing age (p < 0.001) and a flail chest (p = 0.005) were significant associations. The mortality rate was almost identical in those with or without air within the mediastinum. No patient died from a missed mediastinal aero-digestive injury. CONCLUSION: The presence of PM/PC following BTC is incidental and benign. Increased injury severity with a flail chest is associated with a significant increase in the presence of free gas within the mediastinum. In the absence of complications, no obvious injury to the intrathoracic aero-digestive tract on CT scanning, and no difference in mortality, a conservative management policy is warranted.

Acute Kidney Injury on Presentation to a Major Trauma Service is Associated with Poor Outcomes.

BACKGROUND: This study sought to describe the burden of disease of acute kidney injury (AKI) among adult South African trauma patients who presented to a tertiary level trauma service. METHODS: The trauma database was interrogated for the period from December 2012 to July 2017. All patients over the age of 18 y, who were admitted following trauma, were included. Outcome data were reviewed. This included in-hospital mortality, need for intensive care unit admission, and length of stay. AKI was defined according to the latest Kidney Disease Improving Global Outcomes guidelines using the presentation serum creatinine. RESULTS: A total of 7613 patients were admitted for trauma over the period under review. Four thousand two hundred sixty-six patients were suitable for analysis. A total of 238 (5.6%) patients presented with AKI, 149 (62.6%) had stage 1 AKI, 40 (16.8%) had stage 2 AKI, and 49 (20.6%) had stage 3 AKI. There was a higher incidence of AKI in patients with blunt trauma. The length of stay, need for intensive care unit admission, and mortality were significantly higher in patients presenting with AKI than in those who did not present with AKI. There were 172 deaths (4.0%). The patients who died were older and had significantly higher Injury Severity Score than survivors. They were more acidotic on presentation, had lower Glasgow Coma Scale, and were more likely to be hypotensive on presentation. They also were significantly more likely to have AKI on presentation. (30.2% versus 5.6% P < 0.001). AKI on presentation was an independent risk factor for mortality (odds ratio 3.038 95% confidence interval 1.260-7.325). CONCLUSIONS: AKI is common in patients presenting to our center with acute trauma. The presence of AKI is associated with increased morbidity and mortality. Efforts must be directed to improving recognition of at-risk patients. Prompt referral and adequate resuscitation of trauma patients before transfer must be prioritized.

Practicing medicine on the high seas: a review of South African doctors' careers in cruise ship medicine.

BACKGROUND: There has been an increase in the number of South African doctors working in the field of maritime medicine on board cruise ships. Despite this, there is a paucity of literature available addressing the epidemiology, level of expertise and continued medical education (CME) activities of cruise ship medicine. We aim to describe the demographics, qualifications and level of experience of South African doctors embarking on a career as a cruise ship doctor and assess ongoing CME and the future careers of doctors post cruise ship medicine. MATERIALS AND METHODS: A survey was distributed to doctors either currently employed or previously employed as a cruise ship doctor from July 2012 to June 2017. The data obtained was used to describe the characteristics of South African doctors working in the field of cruise ship medicine. RESULTS: Of the 65 respondents, 61.5% were female. The majority of doctors were aged between 25 and 40 years. All South African doctors held a Bachelor of Medicine and Bachelor of Surgery degree, or equivalent, as a primary medical qualification and 46% held a Diploma in Primary Emergency Care prior to working at sea. The majority of doctors obtained certification in Basic Life Support, Advanced Cardiac Life Support, Paediatric Advanced Life Support and Advanced Trauma Life Support prior to joining cruise ship medicine. A wide range of courses and diplomas were undertaken by these doctors whilst working at sea. The majority of doctors opted for short to medium term contracts before returning to South Africa to pursue a land-based career, often by enrolling in postgraduate specialist training programmes. CONCLUSIONS: Maritime medicine is an emerging field of emergency medicine in South Africa and requires a high standard of competence. A robust CME programme exists whilst working at sea. Most South African doctors return to South Africa to pursue a land based career, alleviating the potential concern that South Africa is permanently losing doctors to cruise ship medicine.

Critical care admission of South African (SA) surgical patients: Results of the SA Surgical Outcomes Study.

BACKGROUND: Appropriate critical care admissions are an important component of surgical care. However, there are few data describing postoperative critical care admission in resource-limited low- and middle-income countries. OBJECTIVE: To describe the demographics, organ failures, organ support and outcomes of non-cardiac surgical patients admitted to critical care units in South Africa (SA). METHODS: The SA Surgical Outcomes Study (SASOS) was a 7-day national, multicentre, prospective, observational cohort study of all patients ≥16 years of age undergoing inpatient non-cardiac surgery between 19 and 26 May 2014 at 50 government-funded hospitals. All patients admitted to critical care units during this study were included for analysis. RESULTS: Of the 3 927 SASOS patients, 255 (6.5%) were admitted to critical care units; of these admissions, 144 (56.5%) were planned, and 111 (43.5%) unplanned. The incidence of confirmed or strongly suspected infection at the time of admission was 35.4%, with a significantly higher incidence in unplanned admissions (49.1 v. 24.8%, p<0.001). Unplanned admission cases were more frequently hypovolaemic, had septic shock, and required significantly more inotropic, ventilatory and renal support in the first 48 hours after admission. Overall mortality was 22.4%, with unplanned admissions having a significantly longer critical care length of stay and overall mortality (33.3 v. 13.9%, p<0.001). CONCLUSION: The outcome of patients admitted to public sector critical care units in SA is strongly associated with unplanned admissions. Adequate 'high care-dependency units' for postoperative care of elective surgical patients could potentially decrease the burden on critical care resources in SA by 23%. This study was registered on ClinicalTrials.gov (NCT02141867).

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.

Hypoxaemia on arrival in a multidisciplinary intensive care unit.

BACKGROUND: Transport of the critically ill patient poses the risk of numerous complications. Hypoxaemia is one such serious adverse event and is associated with potential morbidity and mortality. It is, however, potentially preventable. OBJECTIVE: To determine the incidence of hypoxaemia on arrival in a tertiary multidisciplinary intensive care unit (ICU) and to identify risk factors for this complication. METHOD: A retrospective observational study was conducted at King Edward VIII Hospital, Durban, South Africa, from May 2013 to February 2014. RESULTS: Hypoxaemia occurred in 15.5% of admissions sampled. Statistically significant risk factors for hypoxaemia on univariate analysis (p<0.05) included lack of peripheral capillary oxygen saturation (SpO2) monitoring, transfer by an intern as opposed to other medical/paramedical staff, and transfer from internal medicine. Use of neuromuscular blockers and transfer from theatre were protective. Binary logistic regression analysis revealed lack of SpO2 monitoring to be the only significant independent predictor of hypoxaemia (odds ratio 6.1; 95% confidence interval 1.5 - 24.5; p=0.02). CONCLUSION: Hypoxaemia is common on admission to the ICU and may be prevented by simple interventions such as appropriate transport monitoring.