Sedation and analgesia in the trauma intensive care unit of Inkosi Albert Luthuli Central Hospital - the effect of anti-retroviral therapy: A retrospective chart analysis.

PURPOSE: Adequate access to antiretrovirals (ARV) has improved the longevity and quality of life of people living with the human immunodeficiency virus(HIV). Antiretrovirals are known to cause multiple drug-drug interactions. It was noted clinically that patients on ARVs appeared to be more difficult to sedate. This begs the question of the clinical impact of these drug interactions, should clinicians adjust sedative dosages when managing patients on ARVs? This study aimed to investigate the presence of and measure the differences in sedation and analgesic utilisation between polytrauma patients on ARVs and those not on ARVs. METHODS: This retrospective observational chart review included consecutive adult polytrauma patients admitted to the Trauma ICU IALCH between January 2016 and December 2019. HIV status and ARV use was documented. The total sedation per drug utilised at 24, 48 and 72-hour interval was calculated and tabulated accordingly. Drug utilisation was compared to ARV status. RESULTS: A total of 216 adult polytrauma patients were included in the study. A total of 44 patients were HIV positive and 172 were HIV negative. Of the HIV positive patients 41 (93.2%) were on ARVs. Multiple comparisons were confirmed, however the primary analysis compared HIV negative patients with HIV positive patients on ARV. Total morphine, ketamine, midazolam and propofol doses were all numerically greater in patients on ARVs, although none of these reached statistical significance. The use of morphine rescue boluses during the first 72 h of ICU admission and the doses of ketamine and propofol on ICU day 3 were significantly greater in those on ARVs. CONCLUSION: The data analysis showed that patients on ARVs required higher doses of some analgesia and sedation in ICU and lower doses of midazolam. This needs to be considered when sedating patients in a setting with a high HIV prevalence.

Interpretation of emergency CT angiograms in vascular trauma - vascular surgeon vs radiologist.

BACKGROUND: This study aims to investigate any discrepancy in interpretation of computed tomography (CT) angiograms (CTA) in suspected traumatic arterial injury by vascular specialists and radiology specialists, and the influence of any discrepancies on patient outcome. METHODS: A prospective observational comparative study of 6-month duration was undertaken at a tertiary hospital in Durban, South Africa. Haemodynamically stable patients with suspected isolated vascular trauma admitted to a tertiary vascular surgery service who underwent a CTA on admission were reviewed. The interpretations of CTAs were compared between vascular surgeons, vascular trainees and radiology trainees with the consultant radiologist report as the gold standard comparator. RESULTS: Of 131 CTA consultant radiologist reports, the radiology registrar concurred with 89%, which was less than the vascular surgeon who correctly interpreted 120 out of 123 negative cases with three false positives. There were no false negatives or descriptive errors. A 100% sensitivity (95% CI 63.06-100) and 97.62% (95% CI 93.20-99.51) specificity was noted for the vascular surgeon. Overall agreement was 97.71 % with Cohen's kappa value = 0.83 (95% CI 0.64-1.00) indicating very good agreement. Apart from three negative direct angiograms, patient management and outcome were not impacted by the vascular surgeons' errors in interpretation. CONCLUSION: There is very good inter-observer agreement in the interpretation of CTAs in trauma between the vascular surgeon and radiologist with no negative impact on patient outcome.

The spectrum and outcome of paediatric emergency surgical admissions - a regional hospital analysis.

BACKGROUND: Improving emergency surgical care for children requires information on the causes of admissions and the variables affecting outcome. There is a lack of such data in the South African context. METHODS: This retrospective study was conducted from January 2016 to December 2017. Data was collected on all children (< 12 years of age) requiring admission with emergency surgical conditions. Infrastructure and staffing ratios were determined prior to data collection. Information was sourced from admission and discharge books, patient files and theatre registers. Variables of age, sex, referral source, diagnosis, length of stay, surgical treatment and outcome including death were collected. RESULTS: Four hundred and thirty-five of the 1 048 children (42%) admitted were in the 0-2-year age group. Trauma (258), sepsis (564) and burns (226) were the main causes. The median hospital stay was 3 days (IQR 2-5), however, for burns patients, the median stay was 4 days (IQR 2-9). Surgery was performed on 279 (27%) admissions. Eight (0.8%) died, six of which were due to burns. Clinical status prior to death was poorly documented. A dedicated high care unit and burns isolation rooms were lacking. Surgeon/population and child/nurse ratios were respectively 1.48/100 000 and 7-12/1. CONCLUSION: This study found that the emergency paediatric surgical burden is significant. Sepsis and trauma combined are the leading cause of emergency admissions. Burns had the highest mortality. Although mortality was low, improvements of staff to patient ratios and the institution of an early warning system could reduce mortality.

Establishing a South African national framework for COVID-19 surgical prioritisation.

BACKGROUND: Since the start of the COVID-19 pandemic, surgical operations have been drastically reduced in South Africa (SA). Guidelines on surgical prioritisation during COVID-19 have been published, but are specific to high-income countries. There is a pressing need for context-specific guidelines and a validated tool for prioritising surgical cases during the COVID-19 pandemic. In March 2020, the South African National Surgical Obstetric Anaesthesia Plan Task Team was asked by the National Department of Health to establish a national framework for COVID-19 surgical prioritisation. OBJECTIVES: To develop a national framework for COVID-19 surgical prioritisation, including a set of recommendations and a risk calculatorfor operative care. METHODS: The surgical prioritisation framework was developed in three stages: (i) a literature review of international, national and local recommendations on COVID-19 and surgical care was conducted; (ii) a set of recommendations was drawn up based on the available literature and through consensus of the COVID-19 Task Team; and (iii) a COVID-19 surgical risk calculator was developed and evaluated. RESULTS: A total of 30 documents were identified from which recommendations around prioritisation of surgical care were used to draw up six recommendations for preoperative COVID-19 screening and testing as well as the use of appropriate personal protective equipment. Ninety-nine perioperative practitioners from eight SA provinces evaluated the COVID-19 surgical risk calculator, which had high acceptability and a high level of concordance (81%) with current clinical practice. CONCLUSIONS: This national framework on COVID-19 surgical prioritisation can help hospital teams make ethical, equitable and personalised decisions whether to proceed with or delay surgical operations during this unprecedented epidemic.

Intensive care unit hospitalisation costs associated with road traffic crashes at a central hospital in KwaZulu-Natal for the 2017/18 financial year.

BACKGROUND: The financial and physical impacts of road traffic crashes are borne by the individual, the extended family, society, the health sector and the economy of the country. The main contributors to these costs are the loss of productivity and the accrual of ongoing healthcare costs over a long-term period. There is limited information available on the cost of admitting seriously injured patients post accidents to a central hospital intensive care unit. METHODS: Cost data was obtained from the electronic database for all patients admitted for more than 24 hours to the trauma intensive care unit at Inkosi Albert Luthuli Central Hospital. A mixed costing approach was used. Data was collected on surgical procedures, imaging, laboratory tests, trauma receiving fees, pharmaceuticals, goods and services and compensation of employees. RESULTS: The total cost of treating road traffic crash patients for the 2017/18 financial year equated to R21 140 475.49. The three main cost drivers comprised the compensation of employees (R12 135 848.41; 57.4%), goods and services (R5 083 182.12; 24%) and surgery costs (R1 429 321.00; 6.8%). The average cost per admission was R163 879.65, with the average cost per inpatient day equating to R12 727.56. Male patients admitted from motorcycle crashes had the highest cost per admission, followed by motor vehicle crashes and pedestrian vehicle crashes. CONCLUSION: The cost and burden associated with road traffic crashes is reflective of national and international trends and will require a comprehensive strategy to reduce accidents as well as better management at the scene and at lower levels of care.

Comparative outcome analysis of trauma and non-trauma emergency laparotomy using a modified NELA tool format.

BACKGROUND: Emergency laparotomy (EL) encompasses a diverse range of procedures that general surgeons commonly perform for both trauma and non-trauma related conditions in South Africa (SA). Despite differences in the underlying pathology and influence of the surgical procedure, these patients share one care pathway for preoperative, operative and postoperative care. This study reviewed patients undergoing trauma EL and non-trauma EL in a general surgery setting at a rural KwaZulu-Natal tertiary hospital to compare results between the groups using a modified National Emergency Laparotomy Audit (NELA) tool format. METHODS: Consecutive adult patients undergoing midline EL at Ngwelezana Hospital between 1 March and 31 May 2018 were included. Patient factors analysed were demographic data (age, gender) and risk factors: National Confidential Enquiry into Perioperative Deaths (NCEPOD) grade, American Society of Anesthesiologists (ASA) grade, and comorbidity. Process of care factors included grade of the physician, time to surgery, time of surgery and duration of surgery. The primary outcome measure was mortality. Secondary outcome measures were intensive care unit (ICU) admissions, complications, and length of stay (LOS) > 14 days. RESULTS: The study included 110 participants who met the inclusion criteria representing a total of 174 laparotomies. The trauma EL group had lower ASA grades (p = 0.003), less comorbidities (p = 0.002), more often went to theatre within six hours (42/56; 75.0%) (p < 0.001), more admissions to ICU (23/56; 41.1%) (p < 0.001), more complications (29/56; 51.8%) (p = 0.039), and higher length of stay > 14 days (16/56; 28.6%) (p = 0.037). CONCLUSION: The trauma EL group represents a high-risk group for morbidity and mortality at Ngwelezana Hospital.

The value of immediate postoperative radiographs following fluoroscopically-guided orthopaedic surgery in a polytrauma ICU setting in KwaZulu-Natal, South Africa.

BACKGROUND: Radiographic imaging remains a cornerstone of orthopaedic practice. Traditional control X-Rays are routinely requested after procedures. These X-rays may add little value in post-op evaluation of trauma ICU patients, in light of intra-operative screening already performed and reviewed, but has high potential morbidity risk. AIM: The aim is to determine if patients undergoing extra-articular fracture fixation, with fluoroscopic image guidance, require any management change due to immediate check x-rays findings. METHOD: Electronic patient and imaging records from January 2015 to November 2019 at a Trauma-specific ICU at a Trauma Society of South Africa accredited, Level 1 Trauma Unit were reviewed retrospectively. All patients matching the inclusion criteria were evaluated to determine if there were any complications and changes in management after the check X-Rays. RESULTS: There were 103 ICU patients identified with a mean age of 32 years (3 to 94). Fifty-seven percent had fluoroscopy images as well as post-operative check x-rays and 51.5% had only check X-rays. Only two cases needed revision surgery based on the control x-ray findings. The post-operative x-ray did not alter the management of 98.1% of our patients. CONCLUSION: In this study, routine post-op check x-rays did not add significant additional information to warrant early additional surgical intervention especially in ICU patients with adequate intra-operative fluoroscopy images. This investigation should be ordered for individual patients based on clinical grounds. This will help minimize patient exposure to avoidable radiation, labour intensive transfers to the radiology department, and decrease investigations that have financial implications but with limited benefits.

Renal trauma in a Trauma Intensive Care Unit population.

BACKGROUND: For the majority of renal injuries, non-operative management is the standard of care with nephrectomy reserved for those with severe trauma. This study in a dedicated Trauma Intensive Care Unit (TICU) population aimed to assess the outcomes of renal injuries and identify factors that predict the need for nephrectomy. METHODS: Patients, older than 18 years, admitted to TICU from January 2007 to December 2014 who sustained renal injuries had data extracted from the prospectively collected Class Approved Trauma Registry (BCA207-09). Patients who underwent surgical intervention for the renal injury or received non-operative management were compared. The key variables analysed were: patient demographics, mechanism of injury, grade of renal injury, presenting haemoglobin, initial systolic blood pressure, Injury Severity Score and Renal Injury AAST Grade on CT scan in patients who did not necessarily require immediate surgery, or at surgery in those patients who needed emergency laparotomy. RESULTS: There were 74 confirmed renal injuries. There were 42 low grade injuries (grade I-III) and 32 high grade injuries (5 grade IV and 27 grade V). Twenty-six (35%) had a nephrectomy: 24 with grade V injuries and 2 with grade IV injuries required nephrectomy. Six patients in the high injury grade arm had non-operative management. A low haemoglobin, low systolic blood pressure, higher injury severity score, and a high-grade renal injury, as well as increasing age were positive predictors for nephrectomy in trauma patients with renal injury. CONCLUSION: Non-operative management is a viable option with favourable survival rates in lower grade injury; however, complications should be anticipated and managed accordingly. High grade injuries predict the need for surgery.

The prevalence of sodium abnormalities in moderate to severe traumatic brain injury patients in a level 1 Trauma unit in Durban.

BACKGROUND: The prevalence of sodium abnormalities in the moderate to severe brain injury patient is not known in the South African population. METHOD: Patients admitted to the trauma intensive care unit between January 2013 and June 2015 with moderate to severe traumatic brain injury were included in the study. Descriptive statistics, tests of association and tests of differences were used. RESULTS: There were 184 patients with 143 (77.7%) males and 41 (22.3%) females. Abnormal sodium was present in 126 (68.4%), 61 of whom had hyponatremia and 65 hypernatremia, a prevalence of 33.1% and 35.3% respectively. Of the 65 patients with hypernatremia, 52 (80%) had dehydration, 7 (10.7%) had diabetes insipidus (DI) and 6 (9.3%) had hyperosmolar therapy as the cause. Of the 61 patients with hyponatremia, the commonest cause was fluid overload in 47 patients (77.1%) with SIADH in 11 (18%) and CSWS in 3 (4.9%). Death occurred in 34 (18.5%) patients and diagnosis was found to be significantly associated with mortality (p = 0.01), the most common diagnoses amongst those who died being dehydration (29.4%), fluid overload (17.7%) and DI (14.7%). CONCLUSION: The prevalence of sodium abnormalities was 126 (68.4%) patients of whom 61 (33.1%) had hyponatremia and 65 (35.3%) hypernatremia. In those patients who survived, a later onset was related to a better outcome. The GOS in DI tended to be worse.

Five year review of open radical nephrectomies at a regional hospital in South Africa: room for improvement.

BACKGROUND: To review the presentation and outcomes of patients undergoing open radical nephrectomy (ORN) for renal cell carcinoma (RCC) at a regional hospital in KwaZulu-Natal, South Africa. METHOD: A retrospective chart review was performed of patients having undergone nephrectomy at St Aidan's hospital between 2010 and 2015, focusing on those with RCC. Demographic, operative, histopathology and outcomes data were collected. RESULTS: Fifty-two patients (51%) had ORN for suspected malignant disease. Forty-one RCCs were found including one incidental finding at simple nephrectomy. Data was insufficient to assess risk factors for RCC. HIV positive patients tended to present earlier (45 vs. 53 years). The mean tumour size was 10 cm and organ confined disease was present in 73.2% of patients. Only 11 patients (26.8%) had pT1 disease. The high-grade complication rate was 9.8%, in-hospital mortality rate 4.9% and transfusion rate 51.2%. The median operating time was 1h 50min and length of hospital stay 13 days. CONCLUSION: Open radical nephrectomy is the standard surgical treatment for RCC at regional level in South Africa. Patients tend to present at a younger age, particularly if HIV positive, and with large tumours. Further research into risk factors for RCC in the South African population is needed. There are high complication and transfusion rates in patients undergoing ORN. Review of accessibility of blood at St Aidan's hospital and revision of the transfusion protocol is suggested. A followup study to assess the feasibility and cost-effectiveness of laparoscopic nephrectomy in the resource-constrained South African environment is necessary.

Erratum to: The management of intra-abdominal infections from a global perspective: 2017 WSES guidelines for management of intra-abdominal infections.

[This corrects the article DOI: 10.1186/s13017-017-0141-6.].

Positron emission tomography/computed tomography scanning for the diagnosis of occult sepsis in the critically injured.

BACKGROUND: Although the site of nosocomial sepsis in the critically ill ventilated patient is usually identifi able, it may remain occult, despite numerous investigations. The rapid results and precise anatomical location of the septic source using positron emission tomography (PET) scanning, in combination with computed tomography (CT), has promoted this modality as the diagnostic tool of choice for pyrexias of unknown origin. METHOD: The objective of this study was to report our experience using PET/CT scanning for the localisation of a septic focus in critically injured patients in whom no source could be identifi ed using conventional investigations. RESULTS: Two patients with gunshot wounds and two who had sustained multiple fractures following motor vehicle collisions developed pyrexias of unknown origin during their stay in the trauma intensive care unit. Routine screening for a septic focus was unrewarding, and 18F-fl uorodeoxyglucose PET/CT scanning was used to identify the possible source. PET/CT scanning identifi ed the septic focus in all patients. Abscesses were drained successfully in those with penetrating trauma and in one with blunt polytrauma. Pulmonary tuberculosis, not apparent on initial radiology, was identifi ed using PET/CT in one patient with blunt thoracic trauma. CONCLUSION: PET/CT scanning appears to both confi rm and localise the source of sepsis in a variety of pathologies in critically ill patients who develop pyrexias for which no source can be identifi ed by conventional screening techniques.

Validation of the mortality prediction equation for damage control surgery in an independent severe trauma population.

BACKGROUND: A prediction model was developed in Cape Town which utilised age, preoperative lowest pH and lowest core body temperature to derive an equation for the purpose of predicting mortality in damage control surgery. It was shown to reliably predict death despite damage control surgery. The equation derivation dataset and the validation set showed the equation to have 100% positive predictive value (PPV) for both datasets and 24% sensitivity. The aim of the study was to validate the prediction model in an independent dataset from a prospective trauma registry. METHOD: Retrospective analysis of an ethics-approved prospectively collected database and electronic medical records was performed on trauma patients undergoing damage control surgery at the Inkosi Albert Luthuli Central Hospital, Durban, between 2007 and 2013. Age, lowest preoperative core body temperature and the pH of the patients were analysed using the previously derived equation. The output from the equation was then classified as a prediction of death, based on the obtained values, and then compared to the actual outcome of whether the patients survived or died. RESULTS: A total of 48 patient records were analysed in the study. Twenty-nine patients in the cohort died. The equation predicted mortality in only four cases, of whom three died and one survived (75% PPV and 10% sensitivity). The unexpected survivor reduced the PPV to 75%, compared to 100% PPV achieved in the original study. CONCLUSION: The results of this study were inconsistent with those of the original study, and the 0.500 cut-off value used in the equation yielded PPV and sensitivity which were relatively non-clinically useful for the average patient in this cohort.

Vascular injuries following blunt polytrauma.

INTRODUCTION: Motor vehicle collisions account for the majority of blunt vascular trauma. Much of the literature describes the management of these injuries in isolation, and there is little information concerning the incidence and outcome in patients suffering multiple trauma. This study was undertaken to describe the spectrum of blunt vascular injuries in polytrauma patients. PATIENTS AND METHODS: All patients who had sustained blunt vascular trauma over a 6-year period (April 2007-March 2013) were identified from a prospectively gathered database at the Level I Trauma Unit, Inkosi Albert Luthuli Central Hospital, Durban, South Africa. The retrieved data consisted of age, sex, mechanism of injury, referral source, Injury Severity Score (ISS), New Injury Severity Score (NISS), time from injury to admission, surgical intervention and outcome. The initial investigation of choice for patients sustaining multiple injuries was computed tomography (CT) angiography if they were physiologically stable, followed by directed angiography if there was doubt concerning any vascular lesion. If technically feasible, endovascular stenting was the preferred option for both aortic and peripheral vascular injuries. RESULTS: Of 1,033 patients who suffered blunt polytrauma, 61 (5.9 %) sustained a total of 67 blunt vascular injuries. Motor vehicle collisions accounted for 92 % of the injuries. The median ISS was 34 [interquartile range (IQR) 24-43]. The distribution of blunt vascular injuries was extremity (21), thorax (20), abdomen and pelvis (19), and head and neck (7). Endovascular repair was employed in 12 patients (ten blunt aortic injury, one carotid-cavernous sinus fistula, one external iliac artery). Of the extremity injuries, primary amputation was undertaken in 8 (38.1 %) and secondary amputation in 2 (9.5 %). The total amputation rate was 48 %. There were 17 (28.3 %) deaths, of which 11 (64.7 %) were directly attributable to the vascular injury and 6 (35.3 %) of these occurred on the operating table from exsanguination, the majority from injuries to the abdominal vena cava. CONCLUSIONS: Blunt vascular injury is uncommon in the patient with multiple trauma but confers substantial morbidity and mortality. In those cases with peripheral injuries, delays in referral to definitive care frequently exceed the ischaemic time, resulting in a high rate of amputations. Central injuries, especially those of the vena cava, account for the majority of directly attributable deaths.

Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons.

PURPOSE: The incidence of gunshot wounds from civilian firearms is increasing. Despite this fact, guidelines on indications for bullet removal are scarce. In this analysis, we combine an overview of the available literature in these rare entities with our experiences in our own clinical practices. METHODS: We conducted a systematic literature search of computerized bibliographic databases (Medline, EMBASE, and the Cochrane Central Register). The local experience of the authors was reviewed in light of the available literature. RESULTS: 145 full-text articles were suitable for further evaluation. Only six retrospective studies were available, and no prospective study could be retrieved. Most of the articles were case reports. In the South African co-author's own clinical practice, approximately 800 patients are treated per year with gunshot wounds. CONCLUSIONS: In summary, there are only a few clear indications for bullet removal. These include bullets found in joints, CSF, or the globe of the eye. Fragments leading to impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed. Rare indications are lead poisoning caused by a fragment, and removal that is required for a medico-legal examination. In all other cases the indication should be critically reviewed.

Genomic analysis of genetic heterogeneity and evolution in high-grade serous ovarian carcinoma.

Resistance to chemotherapy in ovarian cancer is poorly understood. Evolutionary models of cancer predict that, following treatment, resistance emerges either because of outgrowth of an intrinsically resistant sub-clone or evolves in residual disease under the selective pressure of treatment. To investigate genetic evolution in high-grade serous (HGS) ovarian cancers, we first analysed cell line series derived from three cases of HGS carcinoma before and after platinum resistance had developed (PEO1, PEO4 and PEO6; PEA1 and PEA2; and PEO14 and PEO23). Analysis with 24-colour fluorescence in situ hybridisation and single nucleotide polymorphism (SNP) array comparative genomic hybridisation (CGH) showed mutually exclusive endoreduplication and loss of heterozygosity events in clones present at different time points in the same individual. This implies that platinum-sensitive and -resistant disease was not linearly related, but shared a common ancestor at an early stage of tumour development. Array CGH analysis of six paired pre- and post-neoadjuvant treatment HGS samples from the CTCR-OV01 clinical study did not show extensive copy number differences, suggesting that one clone was strongly dominant at presentation. These data show that cisplatin resistance in HGS carcinoma develops from pre-existing minor clones but that enrichment for these clones is not apparent during short-term chemotherapy treatment.

Imaging the oesophagus after penetrating cervical trauma using water-soluble contrast alone: simple, cost-effective and accurate.

AIM: This audit aims to gauge the safety and efficacy of iso-oncotic water-soluble contrast media as the sole imaging evaluation of the distal pharynx and cervical oesophagus after penetrating cervical trauma. METHODS: A retrospective audit was performed over a 4-year period of all patients with penetrating cervical trauma to zones 1 and 2 of the neck who were subjected to imaging evaluation as part of a selective non-operative management policy for penetrating cervical trauma. The outcome was reviewed and the sensitivity, specificity and predictive values of the investigation were determined. The surgical management of identified injuries is also described. RESULTS: Four hundred and sixty-five contrast studies were included with 11 studies positive for pathology (9 injuries, 2 incidental findings). Surgery was undertaken in 4 patients with cervical oesophageal injuries and conservative management was carried out in 5 cases of distal pharyngeal injury. No missed injuries and no significant adverse events were identified during the study period. CONCLUSION: A contrast study of the oesophagus with water-soluble iso-oncotic contrast media as the sole diagnostic imaging modality is safe (avoiding the risk of aspiration pneumonia), reliable (identifying all injuries) and cost-efficient (avoiding the need for additional expensive investigations) in cases of penetrating cervical trauma.

Trauma unit emergency doctor airway management.

OBJECTIVES: To audit indications for and practice (in terms of training/qualification) of definitive airway management compared with current UK practices. DESIGN: Consecutive observational study. SETTING: Tygerberg Academic Hospital Trauma Service, Western Cape. SUBJECTS: All trauma patients either arriving intubated or requiring intubation at the Trauma unit during the period 1 - 31 August 2006. OUTCOME MEASURES: A data collection proforma was completed either at the time of intubation or from medical records. Results. Fifty-seven patients required definitive airway management. In the unit 32 patients (56%) were intubated by emergency medicine registrars or medical officers, with rapid sequence intubations (RSIs) in all 32 (100%). Seven patients (12.3%) were intubated by paramedics pre-hospital, and 18 patients (31.6%) were intubated at referring hospitals by non-anaesthetists. Endotracheal intubation was successful in 55 patients (96.4%). Two patients (3.6%) could not be intubated and therefore underwent surgical cricothyroidotomy at the unit. Clinical outcomes included 12 patients (21%) extubated for ward transfer, 7 patients (12.3%) admitted to an intensive care unit (ICU), 21 patients (36.8%) taken for surgery, and 17 patients (29.8%) died. Motor vehicle accident (MVA) was the predominant mechanism of injury, accounting for 30 (52.6%) patients, while 16 patients (28.1%) had penetrating injuries (gunshot and/or stab wounds), 6 patients (10.5%) had blunt trauma, and the remaining 5 patients (8.8%) suffered serious burns. CONCLUSION: The most common indication for intubation was a Glasgow Coma Score (GCS) of less than 8, typically in the polytrauma patient with suspected head injury due to MVA. Emergency doctors managed 100% of definitive airway in-hospital, and RSI was the favoured method. This differs greatly from the UK where non-anaesthetists only perform between 31% and 56% of trauma intubations, with the rest performed by anaesthetists. Outcome was, however, similar to that described in the literature.

Traumatic abdominal wall hernia--four cases and a review of the literature.

OBJECTIVE: To review blunt traumatic abdominal wall hernias (TAWHs) in our institution. METHOD: Retrospective review of blunt abdominal trauma cases over a 6-month period. RESULTS: Four patients with TAWH were identified. The mean age was 36 years. Three had been involved in vehicular collisions, and 1 had been assaulted with a large stone. All were diagnosed on presentation, 3 by computed tomography scan and 1 clinically. Two were repaired as emergencies, and 1 was repaired after 4 months. The 4th patient refused surgery. CONCLUSION: This uncommon injury requires a high index of suspicion and a low threshold for intervention. CT scan offers the best imaging potential.