Management of the mass casualty from the 2001 Jos crisis.

BACKGROUND: We report our experience in the hospital management of mass casualty following the Jos civil crisis of 2001. MATERIALS AND METHODS: A retrospective analysis of the records of patients managed in the Jos civil crisis of September 2001, in Plateau State, Nigeria. Information extracted included demographic data of patients, mechanisms of injury, nature and site of injury, treatment modalities and outcome of care. RESULTS: A total of 463 crisis victims presented over a 5 day period. Out of these, the records of 389 (84.0%) were available and analyzed. There were 348 (89.5%) males and 41 females (10.5%) aged between 3 weeks and 70 years, with a median age of 26 years. Most common mechanisms of injury were gunshot in 176 patients (45.2%) and blunt injuries from clubs and sticks in 140 patients (36.0%). Debridement with or without suturing was the most common surgical procedure, performed in 128 patients (33%) followed by exploratory laparotomy in 27 (6.9%) patients. Complications were documented in 55 patients (14.1%) and there were 16 hospital deaths (4.1% mortality). Challenges included exhaustion of supplies, poor communication and security threats both within the hospital and outside. CONCLUSION: Most patients reaching the hospital alive had injuries that did not require lifesaving interventions. Institutional preparedness plan would enable the hospital to have an organized approach to care, with better chances of success. More effective means of containing crises should be employed to reduce the attendant casualty rate.

Multiple familial trichoepithelioma: a case report and review of literature.

OBJECTIVE: Multiple familial trichoepitheliomas are rare autosomal dominant skin disease that is rarely reported from this part of the world. The lesions resemble other types of skin diseases that present with papules and nodules. PATIENT AND METHOD: This is case report of a patient who presented with multiple facial papules and nodules. He wanted treatment to improve his facial (cosmetic) appearance. RESULTS: A 36 year old single male with a 25 years history of multiple facial papules and nodules. Similar lesions were present in other members of the family. He had several treatments including that for leprosy. Histologically the lesions showed keratinized stratified squamous epithelium overlying proliferating packets of basoloid cells with hyper chromatic nuclei, along with several keratin horn cysts and moderate stroma infiltrate of chronic inflammatory cells. Based on the history and the histology a diagnosis of multiple familial trichoepithelioma was made. CONCLUSION: For a diagnosis of multiple familial trichoepithelioma to be made in patients presenting with multiple facial papules and nodules a high index of suspicion is needed. This is more so if there is a history of similar lesions in the family.

Cervical necrotizing fasciitis: case series and review of literature.

INTRODUCTION: Cervical necrotizing fasciitis is a fatal and rapid multi- bacteria infection causing extensive necrosis of the subcutaneous tissues and fascial planes with resultant skin gangrene and associated systemic manifestation. The aim of the present study is to report four cases of cervical necrotizing fascitis highlighting their source. METHOD: The case notes of the patients were retrieved and reviewed, literature search was done using Medline, journals available and various texts. RESULTS: Most often the cause of cervical necrotizing fascitis is of dental origin. The diagnosis depends mainly on clinical features and a high index of suspicion because the clinical features maybe innocuous at the early stage. CONCLUSION: Despite aggressive management with liberal wound debridement, intravenous antibiotics, and nutritional support, the mortality was still high due to late presentation.

Congenital amputation involving the hands and feet: a case report.

BACKGROUND: Congenital amputation of the limbs is not uncommon. However, it is very rare when this involves both the upper and lower limbs. METHOD: This is a case report of a child who presented with congenital amputation involving both the upper and lower limbs. RESULTS: The patient was a 10-day-old baby girl that was delivered by a 21-year-old woman. She is the first and only child of the woman, whose pregnancy was uneventful and was carried to term. There is no family history of congenital anomalies. The findings on examination were: amputation of the index, middle and ring fingers at the level of metacarpophalangeal joints on both hands and a partial amputation (at the level of the middle phalanx) of the left little finger. There were forefoot amputations on both lower limbs. Scars were noticed over the amputation stumps with no associated congenital anomaly. CONCLUSION: Congenital amputation involving all limbs as an isolated entity is a rare condition; the cause of which is probably as a result of congenital amniotic bands.

Anaesthetic management of mentosternal contractures where resources are limited.

OBJECTIVE: Perioperative airway management in postburn mentosternal contractures often pose great challenges to the anaesthetist as well as the plastic surgeon. This is more so where resources are limited. METHOD: Patients with postburn mentosternal contracture who had surgery between January 2000 and December 2006 at the Jos University Teaching Hospital, Jos Nigeria were retrospectively reviewed. The information obtained from the anaesthetic chart as well as the patients' case notes included demographic data, type of anaesthetic induction and maintenance as well as the type of airway management. RESULTS: There were 15 patients (12 males and 3 females), aged between 6 and 65 years. A total of 17 procedures were performed on the patients. Five of the patients were induced with ketamine and maintained with the same drug until adequate release was achieved. In five others the release were done under inhalational anaesthesia using a facemask after induction with ketamine. Six of the cases had laryngeal mask airway (LMA) inserted while one patient had a tracheostomy under local anaesthesia. After adequate release endotracheal tubes were inserted except in those who had LMA which were maintained to the end of the surgery. The rest of the procedure was then continued under general inhalational anaesthesia. CONCLUSION: Fixed flexion deformities in postburn mentosternal contractures could present serious airway challenges to the attending anaesthetist during contracture release and skin cover. This could be overcome by the use of ketamine, inhalational anaesthesia as well as the use of LMA before contracture release.

Anaesthetic management of mentosternal contractures where resources are limited

Objective: Perioperative airway management in postburn mentosternal contractures often pose great challenges to the anaesthetist as well as the plastic surgeon. This is more so where resources are limited. Method: Patients with postburn mentosternal contracture who had surgery between January 2000 and December 2006 at the Jos University Teaching Hospital, Jos Nigeria were retrospectively reviewed. The information obtained from the anaesthetic chart as well as the patients' case notes included demographic data, type of anaesthetic induction and maintenance as well as the type of airway management. Results: There were 15 patients (12 males and 3 females), aged between 6 and 65 years. A total of 17 procedures were performed on the patients. Five of the patients were induced with ketamine and maintained with the same drug until adequate release was achieved. In five others the release were done under inhalational anaesthesia using a facemask after induction with ketamine. Six of the cases had laryngeal mask airway (LMA) inserted while one patient had a tracheostomy under local anaesthesia. After adequate release endotracheal tubes were inserted except in those who had LMA which were maintained to the end of the surgery. The rest of the procedure was then continued under general inhalational anaesthesia. Conclusion: Fixed flexion deformities in postburn mentosternal contractures could present serious airway challenges to the attending anaesthetist during contracture release and skin cover. This could be overcome by the use of ketamine, inhalational anaesthesia as well as the use of LMA before contracture release

Dupuytren's contracture in a patient with type 2 diabetes mellitus--a case report.

BACKGROUND: Dupuytren's contracture is one of the manifestations of the hand syndrome in diabetes mellitus (DM). Its occurrence in diabetes mellitus is not commonly reported in this environment. This report aims to highlight the occurrence of Dupuytren's contracture as a rare manifestation of diabetic hand syndrome in a patient with type 2 DM. METHOD: The case note of a patient with type 2 DM who developed Dupuytren's contracture in both hands and the available literature on the subject were reviewed. RESULT: A 62-year-old Nigerian male Islamic Cleric with type 2 DM for sixteen years on follow-up at the Diabetes clinic of the Jos University Teaching Hospital (JUTH), Jos, developed flexion deformity involving both palms. His symptoms had progressed gradually over the preceding nine months before presentation. Physical examination revealed bilateral Dupuytren's contracture of the palms with hyperkeratosis and flexion deformities of the fingers. He was admitted to the surgical ward of JUTH and had surgery in the right hand. He is to have surgery in the left hand on a later date. CONCLUSION: Dupuytren's contracture is a rare presentation of diabetic hand syndrome. A careful hand examination by physicians in all DM patients for early diagnosis and treatment is recommended.

Intensive care unit admissions in the Jos University Teaching Hospital.

OBJECTIVE: To determine the pattern of admissions to the intensive care unit (ICU) of the Jos University Teaching Hospital (JUTH), a tertiary level referral hospital. METHOD: This is a retrospective study of the record of patients admitted between January 1994 and December 2002 to the ICU of the Jos University Teaching Hospital. The information obtained from the admission/discharge record as well as the patients' case notes included demographic data, working diagnosis, type of treatment, length of stay (LOS) in the ICU and outcome. RESULT: A total of 738 patients were admitted over this period and comprised 403 males (54.6%) and 335 females (45.6%) giving a male: female ratio of 1.2:1. The age ranged from one day to 98 years with a mean of 28.3 +/- 19.8 years. Postoperative surgical patients accounted for 48.2% of all admissions, while 15.2% were medical cases. Other indications for admissions included polytrauma (9.5%), Obstetrics and Gynaecological complications (16.1%) and burns (11%). The length of stay (LOS) in the unit ranged from 1 to 56 days, with a mean of 4.5 +/- 5.1 days. A total of 241 patients died while on admission giving an overall mortality of 42.8%. Postoperative surgical admissions accounted for 38.6% of deaths followed by burn and polytraumatised patients with 23.2% and 11.6% respectively. The lowest mortality of 8.7% was in the obstetrics and gynaecology patients. CONCLUSION: The pattern of admission into the unit and the outcome of treatment has not significantly changed after 1-2 decade of an initial report. There is need to increase the number and quality of equipment to cope with the increasing need for ICU care, as well as draw up a policy on the type of cases to be managed in order to improve the out come of care.

Paediatric blunt abdominal trauma: challenges of management in a developing country.

BACKGROUND: In developed countries, the availability of advanced imaging techniques has reduced the necessity for laparotomy following blunt abdominal trauma in children. Laparotomy rates still remain high in developing countries where these advanced imaging techniques are lacking. A simple management protocol to identify patients who require laparotomy could reduce the laparotomy rate in children with blunt abdominal trauma in these countries. PATIENTS/METHODS: This is a review of children aged 15 years or below managed in our institution over a 5 1/2-year period for blunt abdominal trauma. The children were divided into two groups. Group A consisted of children managed from January 1999 - December 2000. During this period, there was no protocol. Group B consisted of children managed from January 2001 - June 2004. During this period, a simple management protocol was introduced. The laparotomy rates in the two groups were analysed using a simple chi-square. RESULTS: A total of 48 children, representing 63 % of children with abdominal trauma during the study period, were examined (Group A 17; Group B 31). Their ages ranged from 1.5 years - 15 years (median 9 years). Thirty-four were boys, 14 were girls (M:F = 2.4:1). Road traffic accidents accounted for 38 (79.1 %) and falls from heights for 9 cases (18.75 %), and one boy with a hydronephrotic kidney fell off the staircase at home. The diagnosis was clinical, supported by abdominal ultrasound scan (USS) and plain abdominal film. Twenty-eight (58.3 %) children had laparotomy (15 in Group A; 13 in Group B). There was a statistically significant difference in the laparotomy rates between Group A and B (p < 0.01). Nineteen children were managed nonoperatively (2 in Group A; 17 in Group B); one child died before an operation could be performed. There were 59 abdominal organ injuries in 45 children. In 2 children, ultrasound could not diagnose any organ injury. There were 33 splenic injuries; 15 children had splenic conservation, 7 underwent a splenectomy, while 10 were managed nonoperatively. One child with splenic injury died before operation. Of 7 liver injuries, 4 required suturing of lacerations, 1 subcapsular haematoma was left undisturbed at laparotomy, while 2 were managed nonoperatively. There were 4 pancreatic injuries. Three were managed nonoperatively, while 1 associated with duodenal injury had a laparotomy. All 6 gastrointestinal injuries had laparotomy. There were 5 renal injuries: 3 had laparotomy with suturing, while 2 were managed nonoperatively. There were 4 bladder injuries: 2 had laparotomy with suprapubic catheter insertion, while 2 were managed nonoperatively. There were 7 retroperitoneal haematomas in association with other organ injuries. Associated injuries included head injury in 2, long bone fracture in 2, spinal injury and chest trauma in 1 each. There were 4 deaths, 1 before surgery could be performed. CONCLUSION: Blunt abdominal trauma in children resulted mainly from road traffic accidents. The use of a simple protocol supported by ultrasound scan could reduce the laparotomy rate in countries with limited facilities.

Isolated bilateral macrostomia : case series and review of literature

Macrostomia is a rare congenital anomaly of the face; especially the isolated type. This report aims to document our experience inmanaging this rare pathology. All consecutive cases of children managed for isolated bilateral macrostomia at the Jos University Teaching Hospital were retrospectively reviewed. Five patients; aged between 10 weeks and 30 months were managed. They were all females and presented with bilateral symmetrical transverse lateral facial cleft (macrostomia). There were no associated anomalies; and no family history of facial clefts or any other congenital anomaly. All the patients had repair of the defect under a general anaesthesia with satisfactory outcome. Macrostomia can present as an isolated entity. The final outcome of the repair depends on the technique of repair; function of the orbicularis oris muscle and the quality of scar

Management of Conjoined Twins : a Report of Two Sets

Background: Conjoined twinning is a rare congenital anomaly. We present here; our experience in the management of two sets of conjoined twins at a Teaching Hospital in north central Nigeria. Method: Data of conjoined twins managed at the Jos University Teaching Hospital in 1987 and 2004 were retrospectively collated and analyzed. Result: Two sets of pyopagus tetrapus conjoined twins were managed within the period; one was a set of triplets. The conjoined pairs in both sets of twins were females. None of the twins was diagnosed prenatally. Both sets of conjoined twins were delivered spontaneously by vaginal route. Emergency surgical separation was undertaken in both sets be- cause of deteriorating anencephaly in one twin in the first set and anorectal malformation and intestinal obstruction in one twin in the second set. Both sets of twins died after separation. Conclusion: Our experience showed that separation of conjoined twins may be associated with high mortality. Sepsis and electrolyte imbalance appear to be the major causes of morbidity and mortality; particularly when the resultant skin defects are large

Typhoid intestinal perforation in north central Nigeria.

BACKGROUND: Typhoid intestinal perforation is a surgical problem with severe morbidity and high mortality in North Central Nigeria. PATIENTS AND METHODS: In order to determine the pattern and the prognostic indices, we studied 101 patients with typhoid intestinal perforation managed over a ten-year period RESULTS: Children constituted 49% of the cases and majority (78%) of the patients were in the low socio-economic strata. The incidence peaked to 67% between November and March - the dry season in Nigeria. The male/female ratio was 1.9:1 with a mean age of 19 years and a mean hospitalization period of 18 days. There were 167 perforations; four involved the large bowel and appendix, and in 72.2% cases, the perforation was single. The mortality rate was 13.9%, affected mostly children and significantly worsened by prolonged perforation-surgery interval > 72 hours, jaundice, convulsion, ASA V, faecal peritonitis and re-exploration for early intra-peritoneal complications. Morbidity rate was 65.3% and significantly affected more children than adults and associated with perforation-surgery interval of between 24 and 72 hours, haematochezia and multiple perforations. Moribund patients fared better when operated upon under local anaesthesia with adequate analgesia. The least traumatic but effective surgical procedure that could seal the perforations and keep the peritoneum clean gave the best results. Children who survived up to 5 days and adults who survived up to 10 days after surgery had better chances of survival. CONCLUSION: The most significant prognostic factor is late presentation which prolongs perforation-surgery interval and the other complication and mortality indices are directly influenced by it.

Arteriovenous fistula for patients on long term haemodialysis in jos, Nigeria.

BACKGROUND: The introduction of haemodialysis has prolonged the lives of patients with end-stage-renal disease (ESRD). To maintain them on long-term dialysis, vascular access procedures are required. OBJECTIVES: To describe the experience with arteriovenous fistula (AVF) from a developing country. METHODS: Eighty-two AVF were created in 74 patients on maintenance haemodialysis. They all had side-to-end AVF using prolene 7/0 monofilament suture for anastomoses. RESULTS: There were 55 males and 19 females with a male: female ratio of 2.9:1. The ages ranged from 18 to 70 years with a mean of 43.4 "12.1 years. Most of the AVF created were on the left upper limbs with the radio-cephalic and brachio-cephalic accounting for more than 70% . Eight patients developed thrombosis of the veins used for the AVF and one developed a pseudo aneurysm. CONCLUSIONS: Arteriovenous fistula makes long-term haemodialysis feasible. It can be created easily and has a low rate of complications.

Testicular torsion on the Jos Plateau.

In order to determine the pattern and the factors that influenced outcome, we retrospectively studied fifty-seven patients with torsion of the testis admitted to the Jos University Teaching hospital between August 1993 and July 2001. The age ranged from 2 to 55 years with a mean of 22.7 years. Majority (79%) of the patients were in the second and third decades of life. The main suspected precipitating factors in this study were cold weather and scrotal trauma: in 28% of the cases no cause could be ascertained. Eight (14%) patients presented within 4 hours and 35 (61%) presented after 24 hours of the onset of symptoms. Both sides were equally affected. Testicular pain, retraction and scrotal swelling were the most common presenting complaints. The highest incidence 65%) occurred between November and February when the weather on the Jos plateau is coldest. At surgery, 34 (60%) patients were found to have associated congenital anomalies; in 22 (39%) patients, the testis was non-viable. There was no mortality in this series and the complications were superficial wound infection (14%), testicular atrophy (7%) and sub-fertility (16%). High index of suspicion in a patient with acute scrotum, prompt and effective surgery will improve testicular salvage.

Mass casualty management: Jos University Teaching Hospital experience.

Three experiences of management of mass casualties in Jos University Teaching Hospital were analysed. Classification into minor, moderate and major mass casualties was done using multiple criteria of number of casualties, number of doctors required to contain the situation, number of nurses and paramedical staff, degree of distruption of hospital services and time required to handle the immediate stabilisation of the casualties. The classification recognises a category called "regional disaster" and attempts to enunciate a principle of initiation, mobilisation and co-ordination of management of such disasters among hospitals and human and material resources within the region. It is envisaged that coalescence of "regional disaster preparedness" would from the bedrock of national ambulance services system.

Marfan's syndrome presenting with abdominal aortic aneurysm: a case for vigilance.

We present the case of a 16-year old student with Marfan's syndrome and abdominal aortic aneurysm who presented with a diagnostic conundrum. He presented with a three months history of progressive painful left upper abdominal mass and back pain. It became severe in the last two weeks before presentation and was associated with constipation. This mass was thought to be of splenic origin but the initial ultrasound suggested a pancreatic pseudocyst. Review of his previous hospital record revealed that he had been treated for severe myopia which started at infancy. Another opthalmic review at our centre revealed bilateral ectopia lentis. He had no cardiac signs and no family history of cardiovascular diseases. He is the 6th of 8 siblings, all the family members are alive and healthy except one sibling who died at 7 months. The diagnosis of abdominal aortic aneurysm was only made at laparotomy and confirmed by on-table aortogram. He had excision of the aneurysmal sac and replacement with on-lay dacron tube graft. He died on the 4th post-operative day. A diagnosis of abdominal aortic aneurysm was not made at initial presentation because of the rarity of this condition in our environment and incompetence of the ultrasonographer. Aortic aneurysm in Marfan's syndrome is commonly found in the thoracic part of the aorta, however in this case, it is abdominal. A high index of suspicion is necessary to avoid missing this pathology, therefore the need for vigilance.

Adult intussusception: the Jos experience.

Twenty two consecutive cases of adult intussusception managed between January 1990 and December 1998 at Jos University Teaching Hospital formed the basis of this study. Thirteen (59.1%) of the patients were males and 9(40.9%) females, with a male to female ratio of 1:4:1 and a mean age of 49.6 years. Most patients were referred late to our service as a result of poor index of suspicion and misdiagnosis. Laparotomy was done in all the cases and in 5(22.7%) patients no cause could be found, but in the remaining 17(77.3%) definite causes were identified which were mainly polyps in 7(31.8%) patients and colonic malignancies in 4(18%). The ileocolic intussusception was the commonest variety. Sixteen (72.7%) patients had bowel resection for colonic carcinoma, gangrenous bowel and irreducibility of the intussusception while manual reduction was successful in the other 6(27.3%) patients. The morbidity rate was 22.7% and the complications were wound infection and adhesive intestinal obstruction. Two deaths were recorded with a mortality rate of 9.1%. The pattern of adult intussusception as seen in the western world was observed in this tropical highland.

Immediate mass casualty management in Jos University Teaching Hospital: a successful trial of Jos protocol.

Traumatic, injuries arising from high velocity means of mobility, increased industrialization, frequent ethnic and religious classes and terrorist activities by way of bomb blasts, etc., often result in sudden unexpected mass casualty presenting to a given secondary or tertiary health institution. The successful management of such situation involves multidimensional and multidisciplinary approach anchored on awareness, preplanning and alertness. In response to the challenge, the orthopaedic and trauma unit of Jos University Teaching Hospital worked out the "Jos Protocol" which embodies the principle and strategy for mass casualty management and response to field distress call to the hospital within the practical limitations of our infrastructure. On the sixth of April, 1997 a vehicular collision in a neighbouring village resulted in twenty nine severely injured patients being rushed to the hospital's accident and emergency unit. By activating the protocol and utilizing the cascade call our system, mutual aid, hospital mobilization, reach out system, modified hospital triage, team work, effective manoeuvers and treatment modification, the immediate rescucitation and stabilization of patients was achieved in five hours. The working team comprised fifteen doctors and some hospital workers who could be reached on a weekend. Out of the mortality of 6 patients, 3 died in the triage zone while 3 were brought in dead. The difficulties encountered during the management and recommendation for improved immediate mass casualty management are discussed. Further, we believe that it has become necessary for every secondary and tertiary health institution to work out a mass casualty management protocol adapted to its peculiar working circumstances. A case is made for the establishment of regional disaster committees.

Childhood intussusception: a 9-year review.

Sixty-four consecutive cases of intussusception in 48 infants and 16 older children managed at Jos University Teaching Hospital between January 1990 and December 1998 are reviewed. The age range was between 3 months and 15 years (mean 2.2 years) and the male to female ratio was 3.6:1. The quartet of abdominal pain, bloody mucoid stools, abdominal mass and palpable rectal mass was present in 70% compared with the classical triad (abdominal pain, bloody mucoid stools and abdominal mass) which occurred in only 32%. All the children had surgery. In 26 (41%) of the children, no associated cause was found, in three polyps formed the lead point and in five children a buried appendicectomy stump formed the lead point. In 30 (47%) other children, mesenteric lymphadenopathy and inflamed Peyer's patches were noted. Ileo-colic intussusception occurred in 32 (50%) children. Manual reduction was successful in 67%. Bowel resection for gangrene, irreducibility and an iatrogenic colonic tear was done in 30% of patients. Two (3%) had spontaneous reductions. There were four deaths. The commonest complications were wound infection and adhesive intestinal obstruction.