Interpersonal Violence-Related Trauma Among South African Children.

INTRODUCTION: Injuries account for a major portion of disability-adjusted life years in children globally, and low-and middle-income countries are disproportionally affected. While injuries due to motor vehicle collisions and self-harm have been well-characterized in pediatric populations in South Africa, injuries related to interpersonal violence (IPV) are less understood. Our study aims to characterize patterns of injury, management, and outcomes for pediatric patients presenting with IPV-related injuries in a South African trauma center. METHODS: We performed a retrospective review of trauma patients ≤18 y of age presenting to the Pietermaritzburg Metropolitan Trauma Service in Gray's Hospital in South Africa from 2012 to 2022, comparing those with injuries resulting from IPV to those with non-IPV injuries. Patients' and injury pattern characteristics and outcomes were descriptively analyzed. RESULTS: Out of 2155 trauma admissions, 500 (23.2%) had IPV-related injuries. Among patients with IPV-related injuries, the median age was 16.0 y. 407 (81.4%) patients were male. 271 (54.2%) patients experienced blunt trauma, 221 (44.2%) had penetrating trauma, and 3 (0.6%) suffered both. The most common weapons were knives (21.6%), stones (11.2%), and firearms (11.0%). The most commonly injured regions were the head (56.4%), abdomen (20.8%), and thorax (19.2%). 19.6% underwent surgical intervention, and 14.4% were referred out for subspecialty care. 1.4% patients died, and 1.2% returned to Pietermaritzburg Metropolitan Trauma Service within 30 d of discharge. CONCLUSIONS: IPV patients are a distinctive subgroup of pediatric trauma patients with different demographics, patterns of injury, and clinical needs. Further research is needed to better understand the unique needs of this neglected population.

AAST grade of liver injury is not the single most important consideration in decision making for liver trauma.

BACKGROUND: The liver is one of the most injured organs in both blunt and penetrating trauma. The aim of this study was to identify whether the AAST liver injury grade is predictive of need for intervention, risk of complications and mortality in our patient population, and whether this differs between blunt and penetrating-trauma mechanisms. METHODS: Retrospective review of all liver injuries from a single high-volume metropolitan trauma centre in South Africa from December 2012 to January 2022. Inclusion criteria were all adults who had sustained traumatic liver injury. Patients were excluded if they were under 15 years of age or had died prior to operation or assessment. Statistical analysis was undertaken using both univariate and multivariate models. RESULTS: 709 patients were included, of which 351 sustained penetrating and 358 blunt trauma. Only 24.3 % of blunt compared to 76.4 % of penetrating trauma patients underwent laparotomy (p< 0.001). In blunt trauma, increasing AAST grade correlated directly with rates of laparotomy with an odds ratio of 1.7 (p < 0.001). In penetrating trauma, there was no statistical significance between increasing AAST grade and the rate of laparotomy. The rate of bile leak was 4.5 % (32/709) and of rebleed was 0.7 % (5/709). Five patients underwent ERCP and endoscopic sphincterotomy for bile leak, and three required angio-embolization for rebleeding. Increasing AAST grades were significantly associated with the odds of bile leak in both blunt and penetrating trauma. There was a statistically significant increase in the odds of a rebleed with increasing AAST grade in penetrating trauma. Five patients rebled, of which three died. Seven patients developed hepatic necrosis. Seventy-six patients died (10 %). There were 34/358 (9 %) deaths in the blunt cohort and 42 /351 (11 %) deaths in the penetrating trauma cohort. CONCLUSION: AAST grade in isolation is not a good predictor of the need for operation in hepatic trauma. Increasing AAST grade was not found to correlate with increased risk of mortality for both blunt and penetrating hepatic trauma. In both blunt and penetrating trauma, increasing AAST grade is significantly associated with increased bile leak. The need for ERCP and endoscopic sphincterotomy to manage bile leak in our setting is low. Similarly, the rate of rebleeding and of angioembolization was low.

Point of care ultrasound and sub-xiphoid window reduce uncertainty in the management of potential dual-cavity injuries in patients with torso stab wounds.

INTRODUCTION: This paper reviews our experiences with the management of patients with torso stab wounds and potential injuries in both the chest and abdomen over the last decade. The aim of the project is to clarify our approach and provide an evidence base for clinical algorithms. We hypothesize that there is room for our clinical algorithms to be further refined in order to address the diverse, life threatening injuries that can result from stab wounds to the torso. METHODS: Patients with one or more torso stab wounds, and a potential injury in both the chest and the abdomen were identified from a local database for the period December 2012 to December 2020. RESULTS: A total of 899 patients were identified. The mean age was 29 years (SD = 9) and 93% of patients were male. Amongst all patients, 686 (76%) underwent plain radiography, 207 (23%) a point of care ultrasound assessment, and 171 (19%) a CT scan. Following initial resuscitation, assessment and investigation, a total of 527 (59%) patients proceeded to surgery. A total of 185 patients (35%) underwent a semi elective diagnostic laparoscopy to exclude an occult diaphragm injury. Of the 342 who underwent an emergency operation, 9 patients (1%) required thoracotomy or sternotomy exclusively, 299 patients (33%) required a laparotomy exclusively and 34 patients (4%) underwent some form of dual cavity exploration. In total, there were 16 deaths, a mortality rate of 2%. The use of laparoscopy, point of care ultrasound and subxiphoid pericardial window increased over the period of this study. CONCLUSIONS: Patients with torso stab wounds and potential injuries above and below the diaphragm are challenging to manage. The highly structured clinical algorithm of the ATLS course should be complemented by the use of point of care ultrasound and sub-xiphoid window to assess the pericardium. These adjuncts reduce the likelihood of negative exploration and incorrect operative sequencing.

Broad Responses and Attitudes to Having Music in Surgery (The BRAHMS Study): An Australia and Aotearoa New Zealand Perspective.

Background: Surgery is a stressful exercise, and the experience of occupational stress may have impacts on surgical performance, and surgeon well-being. Music is played in operating theatres (OTs) throughout the world, and while it may improve surgical performance, and reduce clinician stress within the OT, concerns exist over its distracting and noise-creating properties. Methods: In this prospective observational study, between May to August 2022, Vascular, General and Paediatric surgeons and registrars in Australia and Aotearoa New Zealand (AoNZ) responded to a survey investigating the way they use music, and their perceptions and attitudes towards its effect on the OT environment. Binomial logistic regression and Chi squared tests of association were performed, accepting p < 0.05 as significant. Results: In this cohort of 120 surgeons, 45 % were vascular specialists, 30 % were female and 59 % were consultant surgeons. The most commonly preferred music genres were easy listening and pop. Over 75 % of surgeons enjoyed having music in their OTs with the majority reporting it improved their temperament, how mentally fatiguing a procedure felt and how anxious or stressed they felt. Vascular surgeons were more likely to believe music had a positive influence on communication than their general and paediatric surgery colleagues (p < 0.01). Registrars had significantly higher odds of believing music had a positive effect on their temperament, and how stressed and anxious they felt when operating, when compared to consultants (p < 0.05). Conclusions: This study provides a window into the surgeons' use of and attitudes towards intra-operative background music and its effect on stress and cognitive load in Australia and AoNZ. While overall, music is viewed positively by this cohort, there was some difference seen across specialties and level of experience. Further subjective and objective data in this field may provide useful information to guide hospital policy and inform pathways for clinician wellbeing.

A decade long overview of damage control laparotomy for abdominal gunshot wounds.

PURPOSE: Over the last three decades, damage control laparotomy (DCL) has become important in the management of abdominal gunshot wounds (GSW). This paper reviews the experience of a single institution over a decade with the use of DCL for GSW of the abdomen. METHODS: Longitudinal data (2013-2022) was collected from the Hybrid Electronic Medical Registry database to identify all patients with an abdominal GSW over the study period. The data was stratified based on patients who underwent DCL and those who did not. Descriptive analysis was completed to summarise the raw data. Univariate and multivariate analysis was completed to identify variables associated with undergoing DCL. RESULTS: There were 135 patients (32%) who underwent DCL and 290 patients (68%) who did not. Colonic, small bowel, mesenteric, hepatic, pancreatic and intra-abdominal vessel injuries were associated with the need for DCL (P<0.05). In total, 85 of the 135 (63%) patients who underwent DCL required more than one damage control technique. There were 45 (33%) mortalities in the DCL group compared to 16 mortalities (6%) in the non-DCL group (P<0.001). CONCLUSION: One third of patients who underwent a laparotomy following a gunshot wound to the abdomen had a DCL. The indications for DCL include both physiological criteria and injury patterns. DCL is associated with significant morbidity and mortality. Efforts need to be directed towards refining the indications for DCL in this group of patients to prevent inappropriate application of this potentially lifesaving technique.