Outcomes of penetrating carotid artery injuries: A South African multicentre study.

BACKGROUND: This multicenter study examines the contemporary management of penetrating carotid artery injury (PCAI) to identify trends in management, outcomes, and to determine prognostic factors for stroke and death. METHODS: Data from three large urban trauma centers in South Africa were retrospectively reviewed for patients who presented with PCAI from 2012 to 2020. RESULTS: Of 149 identified patients, 137 actively managed patients were included. Twenty-four patients (17.9%) presented in coma and 12 (9.0%) with localizing signs (LS). CT angiography was performed on admission for 120 (87.6%) patients. Thirty patients (21.9%) underwent nonoperative management, 87 (63.5%) open surgery, and 20 (14.6%) endovascular stenting. Eighteen patients (13.1%) died, and 15 (12.6%) surviving patients had strokes. Ligation was significantly related to death and reperfusion to survival. A mechanism of gunshot wound, occlusive injuries, a threatened airway, a systolic blood pressure <90 mmHg, hard signs of vascular injury, a low GCS, coma, a CT brain demonstrating infarct, a high injury severity score and shock index, a low pH or HCO3, and an elevated lactate were significant independent prognostic factors for death. Ligation was unsurvivable in all patients with severe neurological deficits, whereas reperfusion procedures resulted in survival in 63% (12/19) patients with coma and 78% (7/9) with LS although with high stroke rates (coma: 25.0%, LS: 85.7%). CONCLUSIONS: Outcomes in PCAI, including patients with severe neurological deficit and stroke, are better when reperfused. Reperfusion holds the best promise of survival and ligation should be reserved for technically inaccessible bleeding injuries.

Tracking the Trauma Epidemic in KwaZulu-Natal, South Africa.

BACKGROUND: Trauma remains an important cause of morbidity and mortality in South Africa, but attempts to track the epidemic are often based on mortality data, or derived from individual health facilities. This project is based on the routine collection of trauma data from all public health facilities in the province of KwaZulu-Natal (KZN), between 2012 and 2022. METHODS: Hospital level data on trauma over the past ten years was drawn from the district health information system (DHIS). Data relating to assaults, gunshots and motor vehicle collisions (MVCs) were recorded in the emergency rooms, whilst data on admissions are recorded in the wards and intensive care units. RESULTS: There were 1,263,847 emergency room visits for assaults, gunshots and MVCs over the ten-year period and trauma admissions ranged between four and five percent of the total number of hospital admissions annually. There was a dramatic decrease in trauma presentations and admissions over 2020/2021 as a result of the COVID lockdowns. Over the entire period, intentional injury was roughly twice as frequent as non-intentional injury. Intentional trauma had an almost equal ratio of blunt assault to penetrating assault. Gunshot-related assault increased dramatically over the 2021/2022 collecting period. CONCLUSIONS: The burden of trauma in KZN remains high. The unique feature of this burden is the excessively high rate of intentional trauma in the form of both blunt and penetrating mechanisms. Developing injury-prevention strategies to reduce the burden of interpersonal violence is more difficult than for unintentional trauma.

Despite Major Therapeutic Advances, Vena Caval Trauma Remains Associated with Significant Morbidity and Mortality.

BACKGROUND: Penetrating inferior vena caval injuries remain a challenging operative entity. This study reviews our local experience with the injury over a nine-year period and attempts to contextualize it within the published literature that emanates from South Africa on the topic. METHODS: A single-centre retrospective review of prospectively collected data was performed of all patients who underwent a laparotomy for a penetrating IVC injury. Descriptive statistics were calculated for demographics, clinical and biochemical parameters, intraoperative data, ICU admission and outcomes. RESULTS: During the nine-year period, thirty-five patients sustained penetrating injuries to the IVC. Mechanism of injury included 25 low velocity gunshots (71%) and 10 stab wounds (29%). The anatomical location included two (6%) supra-renal, six (17%) juxta-renal and 27 (77%) infra-renal injuries. Venorrhaphy was performed in 22 cases (63%) and ligation in 13 (37%). Average ICU stay was 5.4 days. Thirteen patients died (37%), of which six (46%) died within 24 h of arrival. CONCLUSION: Despite dramatic improvements in surgical trauma care over the last four decades, penetrating injury to the IVC carries a high mortality rate ranging from 31 to 37%. It is unlikely that further improvements can be achieved by refining operative techniques and approaches to resuscitation. Future endeavours must focus on applying the burgeoning understanding of endovascular surgery to these injuries.

High grade renal trauma: Does the mechanism of penetrating injury influence renal salvage rate?

BACKGROUND: Most of the data on high grade Traumatic renal injuries (TRI) has come from centres which predominantly encounter blunt trauma. Blunt and penetrating mechanisms are not analogous, and it is imprudent to blindly extrapolate management strategies between the two groups. In addition, within the broad group of penetrating mechanisms of injury there are also major differences between gunshot wounds (GSW) and stab wounds (SW). The aim of this comparative study of GSW and SW to the kidney is to quantify the impact of the mechanism of injury on nephrectomy rate in high grade TRI. METHODS: A prospective trauma registry was interrogated retrospectively. All patients sustaining a high grade (Grade III to V) penetrating TRI were included. The diagnosis was made either with cross-sectional imaging or intra-operative findings. The nephrectomy rate of the different mechanisms of penetrating (GSW vs SW) TRI was compared in each grade. RESULTS: A total of 28 GSW and 27 SW causing high grade TRIs (Grade III-V) were included over the 85 months of the study. GSW lead to a higher nephrectomy rate than SWs 50.0 vs 19%, (p = 0.023). When comparing grade for grade, Grade III: 20.0 (GSW) vs 21% (SW), (p = 1). Grade IV: 71 (GSW) vs 17%, (SW) (p = 0.058) and Grade V: 100 (GSW) vs 0%, (SW) (p = 0.28). When comparing Grade IV - V together, the difference is 85 (GSW) vs 15%, (SW) (p = 0.001). CONCLUSION: On a grade to grade comparison GSWs have a much higher risk for nephrectomy than SW's in grade IV and V TRI. TRI secondary to GSWs appears to be an independent risk factor for nephrectomy in high grade injuries. The mechanism of penetrating TRI should be considered in future management algorithms and clinical approaches.

A comparison of base deficit and vital signs in the early assessment of patients with penetrating trauma in a high burden setting.

INTRODUCTION: An assessment of physiological status is a key step in the early assessment of trauma patients with implications for triage, investigation and management. This has traditionally been done using vital signs. Previous work from large European trauma datasets has suggested that base deficit (BD) predicts clinically important outcomes better than vital signs (VS). A BD derived classification of haemorrhagic shock appeared superior to one based on VS derived from ATLS criteria in a population of predominantly blunt trauma patients. The initial aim of this study was to see if this observation would be reproduced in penetrating trauma patients. The power of each individual variable (BD, heart rate (HR), systolic blood pressure (SBP), shock index(SI) (HR/SBP) and Glasgow Coma Score (GCS)) to predict mortality was then also compared. METHODS: A retrospective analysis of adult trauma patients presenting to the Pietermaritzburg Metropolitan Trauma Service was performed. Patients were classified into four "shock" groups using VS or BD and the outcomes compared. Receiver Operator Characteristic (ROC) curves were then generated to compare the predictive power for mortality of each individual variable. RESULTS: 1863 patients were identified. The overall mortality rate was 2.1%. When classified by BD, HR rose and SBP fell as the "shock class" increased but not to the degree suggested by the ATLS classification. The BD classification of haemorrhagic shock appeared to predict mortality better than that based on the ATLS criteria. Mortality increased from 0.2% (Class 1) to 19.7% (Class 4) based on the 4 level BD classification. Mortality increased from 0.3% (Class 1) to 12.6% (Class 4) when classified based by VS. Area under the receiver operator characteristic (AUROC) curve analysis of the individual variables demonstrated that BD predicted mortality significantly better than HR, GCS, SBP and SI. AUROC curve (95% Confidence Interval (CI)) for BD was 0.90 (0.85-0.95) compared to HR 0.67(0.56-0.77), GCS 0.70(0.62-0.79), SBP 0.75(0.65-0.85) and SI 0.77(0.68-0.86). CONCLUSION: BD appears superior to vital signs in the immediate physiological assessment of penetrating trauma patients. The use of BD to assess physiological status may help refine their early triage, investigation and management.

The role of computed tomography angiography in the detection of aerodigestive tract injury following penetrating neck injury.

BACKGROUND: The purpose of this study was to audit our experience with computed tomography angiography (CTA) for the detection of aerodigestive tract injury (ADTI) following penetrating neck injury (PNI) and to assess the significance of deep surgical emphysema on CTA. METHODS: A prospectively maintained trauma registry at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa was retrospectively interrogated. The data of all patients with PNI investigated with CTA over a 4-y period were reviewed. All findings of deep surgical emphysema were correlated to an aggregate standard of reference for ADTI as demonstrated by results from clinical examination, surgical neck exploration, endoscopy or contrasted swallow to determine the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of this finding. RESULTS: A total of 383 patients underwent a CTA for PNI. A total of 94 vascular injuries were identified on 78 positive CTA studies. The sensitivity and specificity of CTA in detecting a vascular injury were 94.4% and 96.7%. Of the 383 patients investigated a total of 38 patients were diagnosed with digestive tract injury (DTI), and all of these patients were found to have deep surgical emphysema on CTA, except for one patient with a clinically insignificant oral cavity injury. Another 126 patients also had deep surgical emphysema on CTA but no DTI. The sensitivity, specificity, PPV, and NPV of deep surgical emphysema for the diagnosis of confirmed DTI in PNI were therefore 97.4%, 63.5%, 22.7%, and 99.5%, respectively. The sensitivity and NPV were, however, 100% when clinically insignificant injuries were excluded. Including patients with confirmed airway injuries and excluding all patients with pneumothoraces yielded a sensitivity, specificity, PPV, and NPV of 94.1%, 71.9%, 30.0%, and 98.9%, respectively, for the identification of ADTI. When excluding surgically irrelevant injuries, the sensitivity and NPV were again both 100%. CONCLUSIONS: CTA for PNI has a high sensitivity and specificity for demonstrating vascular injury. The absence of deep surgical emphysema in the deep cervical fascial planes virtually excludes surgically significant ADTI. The presence of deep surgical emphysema is nonspecific but warrants further investigation.

Analysis of 5 years of morbidity and mortality conferences in a metropolitan South African trauma service.

BACKGROUND: Since 2008 the Pietermaritzburg Metropolitan Trauma Service (PMTS) has run a structured, self-reporting, metropolitan morbidity and mortality conference (MMC). In 2012 a hybrid electronic medical registry (HEMR) was introduced to capture routine data and to generate reports on morbidity and mortality. This paper reviews our experience in setting up a metropolitan MMC and compares the quality of the reported morbidity data from the pre- and post-HEMR era. METHODS: We compared data from the MMC before and after the introduction of the HEMR to audit the impact of these meetings on the reporting and analysis of surgical morbidity and mortality in our service. RESULTS: During the 4-year period from 2008 to 2011, a total of 208 MMCs were held. A total of 10 682 patients were admitted by the PMTS during that period, of whom 87% were males, and the mean age was 26 years. Penetrating trauma accounted for 40.9% (4 344/10 628) of the total workload. A total of 432 (4.1%) morbidities were identified. Of these, 36.6% (158) were related to human error, 32% (138/432) were related to surgical pathologies and the remaining 31.9% (136/432) were related to systemic diseases. There was an exponential increase in the reporting of morbidity each year. The total in-hospital mortality was 3% (358/10 682). Following the introduction of the HEMR, from 2012 to 2014, 6 217 patients were admitted. A total of 1 314 (21.1%) adverse events and 315 (5.1%) deaths were recorded by the HEMR. The adverse events were divided into 875 'pathology-related' morbidities and 439 'error-related' morbidities. CONCLUSIONS: The development of the MMC led to increased reporting of morbidity and mortality. The introduction of the HEMR resulted in a dramatic improvement in the capturing of morbidity and mortality data, suggesting that a paper-based self-reporting system tends to underestimate morbidity. Over one-third of all morbidities were related to human error. Common morbidities have been identified.

Self-expanding metal stent placement for oesophageal cancer without fluoroscopy is safe and effective.

BACKGROUND: Self-expanding metal stents (SEMS) are widely used to palliate patients with oesophageal cancer. Placement is usually done under endoscopic and fluoroscopic guidance. We have developed an exclusively endoscopic technique to deploy these stents. This article documents the technique and periprocedural experience. PATIENTS AND METHODS: All patients who had SEMS placement for oesophageal cancer at Grey's Hospital, Pietermaritzburg, South Africa, over a 5-year period (2007-2011) were reviewed. Stenting was performed without radiological guidance using the technique documented in this article. At endoscopy, the oesophageal lesion was identified, dilated over a guidewire if necessary, and a partially covered stent was passed over the wire and positioned and deployed under direct vision. Data were captured from completed procedure forms and included demographics, tumour length, the presence of fistulas, stent size and immediate complications. RESULTS: A total of 480 SEMS were inserted, involving 453 patients, of whom 43 required repeat stenting. There were 185 female patients (40.8%) and 268 male patients (59.2%). The mean age was 60 years (range 38 - 101). There were 432 black patients (95.4%), 15 white patients (3.3%) and 6 Indian patients (1.3%). The reasons for palliative stenting were distributed as follows: age>70 years n=95 patients, tumour>8 cm n=142, tracheo-oesophageal fistula (TOF) n=29, and unspecified n=170. One patient refused surgery, and one stent was placed for a post-oesophagectomy leak. Repeat stenting was for stent migration (n=15), tumour overgrowth (n=26) and a blocked stent and a stricture (n=1 each). Complications were recorded in six cases (1.3%): iatrogenic TOF (n=2), false tracts (n=3) and perforation (n=1). All six were nevertheless successfully stented. There was no periprocedural mortality. CONCLUSION: The endoscopic placement technique described is a viable and safe option with a low periprocedural complication rate. It is of particular use in situations of restricted access to fluoroscopic guidance.

Trauma quality improvement: The Pietermaritzburg Metropolitan Trauma Service experience with the development of a comprehensive structure to facilitate quality improvement in rural trauma and acute care in KwaZulu-Natal, South Africa.

Improving the delivery of efficient and effective surgical care in rural South Africa is a mammoth task bedevilled by conflict between the stakeholders, who include rural doctors, surgeons, ancillary staff, researchers, educators and administrators. Management training is not part of most medical school curricula, yet as they progress in their careers, many clinicians are required to manage a health system and find the shift from caring for individual patients to managing a complex system difficult. Conflict arises when management-type interventions are imposed in a top-down manner on surgical staff suspicious of an unfamiliar field of study. Another area of conflict concerns the place of surgical research. Researchers are often accused of not being sufficiently focused on or concerned about the tasks of service delivery. This article provides an overview of management theory and describes a comprehensive management structure that integrates a model for health systems with a strategic planning process, strategic planning tools and appropriate quality metrics, and shows how the Pietermaritzburg Metropolitan Trauma Service in KwaZulu-Natal Province, South Africa, successfully used this structure to facilitate and contextualise a diverse number of quality improvement programmes and research initiatives in the realm of rural acute surgery and trauma. We have found this structure to be useful, and hope that it may be applied to other acute healthcare systems.

Tick-box admission forms improve the quality of documentation of surgical emergencies, but have limited impact on clinical behaviour.

INTRODUCTION: We used modern error theory to develop a tick-box admission form for emergency surgical patients. The tick boxes were designed to actively direct care down appropriate clinical algorithms by encouraging staff to make decisions based on recorded clinical data. OBJECTIVE: To audit the effect of these tick-box forms on the quality of documentation and of the resuscitation process. METHODS: We designed and implemented a standardised tick-box admission form, and audited its impact by comparing 100 emergency surgical admissions before the intervention with 100 thereafter. We assessed the quality of the documentation in both groups and analysed the effect of use of the tick-box admission form and the decision nodes on the clinical behaviour of the admitting clinicians. RESULTS: The introduction of standardised tick-box admission forms dramatically improved the quality of documentation of acute surgical admissions. However, the impact of the decision nodes on clinical behaviour was less obvious. We demonstrated a tendency to cognitive dissonance in that, even though clinicians recorded abnormal physiological data, they did not consistently interpret this information correctly. CONCLUSIONS: Although the use of tick-box admission forms improves the quality of documentation, the impact on clinical behaviour is less certain. Quality improvement is a multifactorial endeavour, and without a pervasive culture of patient safety, tick-boxes alone may well be ineffective.

Surgical outreach in rural South Africa: are we managing to impart surgical skills?

BACKGROUND: The Department of Health in KwaZulu-Natal (KZN) has run a surgical outreach programme for over a decade.Objective. To quantify the impact of the outreach programme by analysing its effect on the operative capacity of a single rural health district. METHODS: During 2012, investigators visited each district hospital in Sisonke Health District (SHD), KZN to quantify surgery undertaken by resident staff between 1998 and 2013. Investigators also reviewed the operative registers of the four district hospitals in SHD for a 6-month period (March - August 2012) to document the surgery performed at each hospital. The number of staff who attended specialist-based teaching was recorded in an attempt to measure the impact of each visit. RESULTS: From 1998 to 2013, 35 385 patients were seen at 1 453 clinics, 5 199 operations were performed and 1 357 patients were referred to regional hospitals. A total of 3 027 staff attended teaching ward rounds and teaching sessions. In the four district hospitals, 2 160 operations were performed in the 6-month period. There were 653 non-obstetrical operations and the obstetric cases comprised 1 094 caesarean sections, 55 sterilisations and 370 evacuations of the uterus. CONCLUSION: The infrastructure is well established and the outreach programme is well run and reliable. The clinical outputs of the programme are significant. However, the impact of this programme on specific outcomes is less certain. This raises the question of the future strategic choices that need to be made in our attempts to improve access to surgical care.

Emergency operation for penetrating thoracic trauma in a metropolitan surgical service in South Africa.

INTRODUCTION: This audit examines our total experience with penetrating thoracic trauma. It reviews all the patients who were brought alive to our surgical service and all who were taken directly to the mortuary. The group of patients who underwent emergency operation for penetrating thoracic trauma is examined in detail. METHODOLOGY: A prospective trauma registry is maintained by the Pietermaritzburg Metropolitan Complex. This database was retrospectively interrogated for all patients requiring an emergency thoracic operation for penetrating injury from July 2006 till July 2009. A retrospective review of mortuary data for the same period was undertaken to identify patients with penetrating thoracic trauma who had been taken to the forensic mortuary. RESULTS: Over the 3-year period July 2006 to July 2009, a total of 1186 patients, 77 of whom were female, were admitted to the surgical services in Pietermaritzburg with penetrating thoracic trauma. There were 124 gunshot wounds and 1062 stab wounds. A total of 108 (9%) patients required emergency operation during the period under review. The mechanism of trauma in the operative group was stab wounds (n = 102), gunshot wound (n = 4), stab with compass (n = 1), and impalement by falling on an arrow (n = 1). Over the same period 676 persons with penetrating thoracic trauma were taken to the mortuary. There were 135 (20%) gunshot wounds of the chest in the mortuary cohort. The overall mortality for penetrating thoracic trauma was 541 (33%) of 1603 for stab wounds and 135 (52%) of 259 for gunshot wounds of the chest. Among the 541 subjects with stab wounds from the mortuary cohort, there were 206 (38%) with cardiac injuries. In the emergency operation group there were 11 (10%) deaths. In 76 patients a cardiac injury was identified. The other injuries identified were lung parenchyma bleeding (n = 12) intercostal vessels (n = 10), great vessels of the chest (n = 6), internal thoracic vessel (n = 2), and pericardial injury with no myocardial injury (n = 2). Most patients reached the hospital within 60 minutes of sustaining their injury. A subset of 12 patients had much longer delays of 12 to 24 hours. Surgical access was via median sternotomy in 56 patients and lateral thoracotomy in 52. The overall mortality for penetrating cardiac trauma in our series was 217 (76%) of 282. CONCLUSIONS: Penetrating thoracic trauma has a high mortality rate of 30% for subjects with stab wounds and 52% for those with gunshot wounds. Less than a quarter of patients with a penetrating cardiac injury reach the hospital alive. Of those who do and who are operated on, about 90 percent will survive. Other injuries necessitating emergency operation are lung parenchyma, intercostal vessels and internal thoracic vessels, and great vessels of the thorax. Gunshot wounds of the thorax remain more lethal than stab wounds.