Non-trauma surgical emergencies in adults: Spectrum, challenges and outcome of care.

INTRODUCTION: Significant deaths of between 21% and 38% occur from non-trauma surgical conditions in the accident and emergency room. Access to emergency surgical care is limited in many developing countries including Nigeria. We aimed to study the spectrum of non-trauma surgical emergencies, identify challenges in management and evaluate outcomes. METHODS: A one year prospective cohort study of all non-trauma emergencies in adults seen at the surgical emergency room of LASUTH from 1st October, 2011 to 30th September, 2012 was conducted. Data was analyzed using SPSS version 15.0. RESULTS: Of a total of 7536 patients seen, there were 7122 adults. Those with non-trauma conditions were 2065 representing 29% of adult emergencies. Age ranged between 15 and 97 years and male to female ratio was 1.7:1. Acute abdomen (30%), urological problems (18%) and malignancies (10%) were the most common. Among 985 patients requiring admission only 464 (47%) were admitted while the remaining 53% were referred to other centers. Emergency surgical intervention was carried out in 222 patients representing 48% of admitted patients. There were 12 (24%) non-trauma deaths in the emergency room. They were due to acute abdomen and malignancies in half of the cases. CONCLUSION: Facilities for patients needing emergency care were inadequate with more than half of those requiring admission referred. Attention should be paid to the provision of emergency surgical services to the teeming number of patients seen on yearly basis in the Teaching Hospital.

Pre-hospital care in Nigeria: a country without emergency medical services.

OBJECTIVES: Efficient pre-hospital transport (emergency medical services, EMS) is associated with improved outcomes in road traffic injuries (RTI). This study aims to discover possible interventions in the existing mode of transport. METHODS: Persons bringing all RTI victims to the Emergency room (ER) over a 4-year period and the injury arrival intervals were noted prospectively. FINDINGS: There were 2,624 patients (1,886 males and 738 females); only 2,046 (78%) had clear documentations of three categories of persons bringing victims to ER: Relatives (REL, 1,081, 52.83%); Police/Federal Road Safety Corps (P/F, 827, 40.42%) and Bystanders (BS, 138, 6.74%). No intervention was provided during transport: Within 1 hour, 986 victims (48.2% of 2,046) arrived ERbrought by P/F (448, 21.9%), REL (439, 21.5% of 2,046), and BS (99, 4.8%). These figures, in each instance, represent 40.6 % of total victims brought by REL; 54.2% by P/F and 71.7% by BS. However, after 6 hours, REL were the main active group as they brought 94.5% (359 of 380) patients of this period. In 91 victims (4.4%) the injury arrival time was not captured. CONCLUSION: This study has identified three groups of persons involved in pre-hospital transport with nearly 50% getting to ER within 1 hour without any intervention or prior notification of ER. Absence of EMS obscures pre-hospital death records. The P/F responsible for only 40% of transport should be trained and equipped to offer basic trauma life support (BTLS). The REL and BS (both responsible for 60% of transport) represent a pool of volunteers for BTLS to be trained.

Motorcycle injuries in a developing country and the vulnerability of riders, passengers, and pedestrians.

At a Nigerian university hospital, none of the motorcyclists who presented over a 12 month period had been wearing a helmet, and of the eight patients who died, seven had head injuries. Of the five collision types described, the rate of motorcycle-other vehicle collisions was highest at 40.6%, while the motorcycle-pedestrian rate was 23.4%. Measures to prevent these collisions might reduce overall crashes by 64%; in addition, helmet law should be enforced.

Pre-hospital care of the injured in South Western Nigeria: a hospital based study of four tertiary level hospitals in three states.

Pre-hospital care in developing worlds has been found to be grossly deficient compared to high income countries. The pre-hospital care given to road accident victims attending the casualty departments of four tertiary level hospitals in South Western Nigeria was assessed using a one-page pro-forma. 1996 patients with injuries from road crashes were seen in the hospitals, only 172 had any form of pre-hospital care, just 160 were transported in ambulances and none had any form of organized pre-hospital care. The mean arrival time in the hospital after crashes was 93.6 minutes and there was a high rate (29.5%) of inter-hospital referral. For every Revised Trauma Score (RTS), the Probability of survival (Ps) of the patients was higher than the Ps of patients from high income countries.

Surgical emergencies in a Nigerian university hospital.

An audit of surgical emergencies was carried out to monitor acute trauma care and determine areas needing clinical improvement. This is essential for the development of institutional and national health policies on trauma and non-trauma diseases. All patients attending the surgical Accident and Emergency were studied prospectively from September 1999 to August 2000 to obtain their age, sex and diagnosis and to determine causes and injury-arrival time for trauma cases and the outcome of care for all cases. Out of 2,455 patients comprising 1,696 males and 759 females (M:F = 2.2:1) age range two weeks to 95 years, trauma accounted for 1,679 (68.4%). The median age (and the mode) of presentation overall and in males was in the third decade. Females had a 'plateau' age of presentation for the first four decades before the gradual fall to zero. Superficial skin trauma (lacerations, abrasions and bruises) represents the commonest presentation (16.1%) followed by fractures (13.9%), acute abdominal conditions (7.6%), head injury, HI (5.5%), multiple injury (4.1%), urinary retention (3.3%), burns and scalds (3.3%) and others. Eight-one patients died, comprising 54 males and 27 females, out of which 64 were trauma related deaths. Most common causes of death were HI (35 patients, 43.2%) and septicaemia (13 patients, 16.0%). Late presentation and poor finances contributed to the deaths in patients with septicaemia. Trauma is an important entity in our emergency practice. Prompt access to surgical care should reduce the morbidity and mortality from acute abdominal conditions and HI. The high incidence of urinary retention requires further analysis. Statistics of this nature can aid planning of care delivery and study of preventable deaths.

Epidemiology of trauma deaths.

OBJECTIVES: This study was done to highlight the pattern and distribution of trauma deaths in a Nigerian teaching hospital in order to enhance trauma research, improve treatment strategies and prevent trauma deaths. PATIENTS AND METHODS: a prospective data collection was done for 24 months beginning September 1999 detailing the age, sex, occupation, diagnosis, mechanism of trauma, injury-arrival time, and circumstances of death and determining retrospectively the severity of trauma using Revised Trauma Score (RTS), Injury Severity Score (ISS) and Trauma and Injury Severity Score (TRISS). RESULTS: There were 129 deaths but 84 (65.1%) had sufficient data for trauma scoring. Male:Female ratio was 60:24 = 2.5:1. The age range was 2.95 years, mean 36.8 +/- 15.2 years for males and 45.5 +/- 23.0 years for females. Two thirds (66.7%) of the deaths occurred among traders/business 27.4%, artisans 20.2%, drivers and students 9.5% each. Three quarters of the deaths (75.0%, 63) were in patients involved in road traffic accidents (RTA) followed by violent trauma (10.7%), falls 9.5% and burns 4.8%. The trauma deaths include head injury (26 deaths, 31.0%), multiple injuries (30.0%), fractures (13.1%), cervical spine injury (10.7), gunshot injuries (8.3%), burns (4.8%) and others (5.0%). Sixty-two patients (73.8%) reached the hospital within 6 hours of the injury. The patients were brought by the Police, Good Samaritans or relatives in nearly equal proportions. The mean RTS, ISS and TRISS probability of survival scores were 5.16, 25 and 67% for males but 6.0, 22 and 75% for females, respectively. CONCLUSIONS: The pattern and distribution of trauma revealed a typical trauma death is a male aged below 40 years, who is a trader/businessman involved in RTA or violent trauma. Despite a probability of survival above 60% and majority of the patients getting to hospital within 6 hours, the inadequate A and E care has thrown up possibilities for prevention of trauma death, improving treatment strategies and enhancing trauma research.

A new classification of osteomyelitis for developing countries.

BACKGROUND: The term osteomyelitis (OSM) was first coined by Nelaton in 1844. Waldvogel et al, Cierny-Mader, May et al classifications of OSM from developed countries and Meier et al's from Nigeria have been described. OBJECTIVE: This new classification was developed to highlight significant pathology seen in developing countries not covered by existing classifications. DESIGN: A prospective study. SETTING: University of Ilorin Teaching Hospital, Ilorin, Nigeria. SUBJECTS: All OSM patients treated from January 1998 to June 2000. MAIN OUTCOME MEASURES: Age, sex, clinical features, radiographs and treatment offered were analysed. Five stages were recognised: stage 0 (potential OSM with bone contamination), stage I (early or acute OSM), stage II (intermediate OSM with subperiosteal abscess), stage III (lateorchronic OSM with sequestrum and subdivided into IIIa 'curable', IIIb 'controllable', IIIc 'complicated'). Stage IV (compound OSM) with joint involvement: IVa, if anatomical and IVb if physiological. Patients' haemoglobin (Hb) status is added to the staging, for example stage II (Hb SS). RESULTS: All 271 patients comprising 198 males and 73 females (M: F = 2.7: 1) with age range 2-48 years (mean 29.4 +/- 12.2) were studied. Only 93 patients had Hb genotype done; only 42 had Hb S. The stage O had 184 patients (120 open fractures and 64 bone operations). Stage I had nine patients, stage II 19 patients, stage III 51 patients and stage IV eight. CONCLUSIONS: This new staging incorporates pre-emptive OSM seen in developing countries where certain practices, if unchecked lead to OSM. The severity of OSM featuring florid disease not common in the developed world, and for which existing classifications did not accommodate, is included.

Diabetic foot in Nigeria--a review article.

Numerous institutional reports from Nigeria on diabetic foot (DF) have appeared showing variations from one institution to another in the last 40 years. In the author's opinion, this is the first overall review on DF care in Nigeria to put all the pictures together and then compare with global literature. The reports showed varied male-female preponderance, occurrence mainly among the low socioeconomic group patients, mostly involved in one form of trading or another, with a peak incidence in the 6th decade, up from the 5th decade of the past. There is also a rising incidence of DF which has recently become an important indication for lower limb amputation in Nigeria. This review also discusses the peculiar situations of DF in Nigeria in relation to aetiopathogenesis, staging and classification, non-operative and operative treatment, and the way forward to reduce morbidity and mortality and improve the present disappointing outcome of care of DF patients in Nigeria. The roles of interventional radiology and revascularisation in DF management are highlighted.

Tuberculosis of the spine in Ilorin, Nigeria.

BACKGROUND: Data on tuberculosis (TB) of the spine from Nigeria is scanty despite the endemicity of the disease. OBJECTIVE: To highlight hospital data on spinal tuberculosis. DESIGN: A ten-year retrospective study of records on spinal TB from the medical records, orthopaedic and medical wards was done. The clinical notes, radiographs and haematology results of the patients were analysed. SETTING: University of Ilorin Teaching Hospital, Ilorin, Nigeria. SUBJECTS: All patients treated for spinal TB in the hospital from January 1990 to December 1999 were studied. RESULTS: Fifty patients were seen, 24 males and 26 females, age range 1.5-70 years (mean 27.1 +/- 22.8 years). Peak prevalence (30%) was in the first decade. Twenty seven patients had complete clinical data in their case notes. Twelve patients had paraplegia and three had concomitant pulmonary TB. The lumbar spine was the commonest site of involvement. Two thirds (18 patients) had positive mantoux test. Twenty three patients had chemotherapy but a third was lost to follow up within two months. Twenty one patients (77.8%) had difficulty obtaining the prescribed drugs due to financial difficulties. No patient had surgical intervention. CONCLUSION: Spinal TB is still a common disease in Nigeria with unacceptable laxity in control measures. There is need for patient health education, contact tracing, provision of free anti-TB drugs and a general improvement in the economy to reduce the prevalence of spinal TB in the country.

The scope of amputations in a Nigerian teaching hospital.

In developing countries, amputations have been performed due to trauma and infections; whereas in developed counties, trauma, diabetes and peripheral vascular diseases are the usual indications. Current practice in Nigeria suggests a change of relative indications, hence, this study. A five-year (July 1994 to June 1999) review of amputation records from the medical records, operating theatre, wards and physiotherapy department was carried out retrospectively. Amputation types, age, sex and indications were analysed. Fifty-eight amputations were performed in 56 patients (47 males, nine females, M: F = 5.2 : 1, age range 7-70 years, mean 33.3 +/- S.D 18.2). There were 42 lower and 16 upper limbs. Trauma accounted for 48.3%; followed by diabetes (29.3%), tumours (12.1%), infections (8.6%) and one indeterminate cause (1.7%). There was bias for sex, age and type of extremity as trauma was the commonest indication in male patients aged 30 years and below (and in the upper limb) whereas diabetes predominated in female patients above 30 years (and in the lower limb). Infection, as an indication for amputation, has now become a rear guard indication. Diabetes, previously uncommon, now appears in the forefront. These findings call for early detection and aggressive management of diabetic foot lesions.

Surgical morbidity and mortality pattern in the accident and emergency room--a preliminary report.

BACKGROUND AND PURPOSE: A prospective review of surgical patients attending the Accident and Emergency room was carried out to determine the pattern of morbidity and mortality in order to guide planning and provision of surgical services and improve on the quality of care available. METHODS: Patients were entered into a data sheet from September 1999; a preliminary report of the first six months is presented. RESULTS: There were 1,209 patients (850 males and 359 females, M:F = 2.2:1) with 46 different presentations. Age range was 2 weeks to 95 years. The mode and median age was in the third decade. Morbidity from trauma was 70.5%, 44.5% from Road Traffic Accident while mortality from trauma was 2.6% (32 patients). Nearly half of the mortality (47.2%) was head injury related. CONCLUSION: The commonest presentation was lacerations (19.4%) from which there was no mortality while head injury, multiple injury and multiple fractures that accounted for 14.7% morbidity had 61.1% mortality. These figures are helpful in planning services delivery and in focusing and improving on the mortality-prone presentations.

Mortality in childhood head injury in Ibadan.

The clinical records of patients who were 15 years and younger and who attended our casualty department between July 1989 and June 1990 because of head injury were retrospectively analysed in order to determine the mortality rate and evaluate the management of the patients prior to death. One hundred and sixty such patients were identified. They comprised 5.7% of the 2,812 children and 2% of all patients seen during this period. There were 20 deaths in this group, giving a mortality of 12.5%. This rate was greater than that for all patients in this age group (1.3%) and all age groups (1.2%) of patients attending the casualty department during this period. Whereas, children with head injury comprised 2% (160/8,192) of all patients, the deaths in this group comprised 19% (10/107) of all deaths in casualty during this period. Of the 12 patients for whom case records were available, 8 were seen elsewhere before referral. Four patients talked prior to death, suggesting the existence of a treatable mass lesion, while 8 patients were in coma from the onset of head injury to the time of death. Airway management was inadequate in all the patients. The interval to death was less than 2 hours in 7 patients. Only 4 of the patients were evaluated by the neurosurgical service prior to death. These observations suggest that: (1) head injury is a cause of high mortality among children attending our casualty department; (2) there are preventable factors contributing to death.