The Role for Preperitoneal Pelvic Packing in Low-to-Middle-Income Countries: A 16-Year Experience at a Johannesburg Trauma Unit.

INTRODUCTION: Preperitoneal pelvic packing for early pelvic haemorrhage control reduces mortality. Bleeding noted with pelvis fractures is predominantly due to associated venous complex injuries. More studies are advocating for angiography as first-line therapy for haemodynamic instability in pelvic fractures; however, these facilities are not in abundance in middle- and low-income countries. We hypothesized that PPP improves outcomes under these circumstances. METHODS: Retrospective analysis of data from the patients charts over a period of 16 years from 01 January, 2005 to 31 December, 2020. All patients over the age of 18 years who presented with haemodynamic instability from a pelvic fracture and required PPP were included. The demographics, physiological parameter in emergency department, blood products transfused, morbidity and mortality were analysed. RESULTS: There were 110 patients identified in the study period who underwent pelvic preperitoneal packing for refractory shock or ongoing bleeding. The majority (75.5%) of patients were men (n = 83). The median age was 38 years. The most common mechanism of injury was pedestrian vehicle collision (51%), followed by motor vehicle collisions (27.3%). The median ISS and NISS were 35 and 40, respectively. The median RTS in ED was 4.8(3-6.8). None of our patients rebleed after pack removal and no one needed repacking or adjunct angioembolization in our study group. The in-hospital mortality rate was 43.6% (n = 48) in patients who underwent preperitoneal pelvic packing. The operating room table mortality was 20% (n = 22/110), and the mortality rate of those who survived to ICU transfer was 29.5% (n = 26/88). CONCLUSIONS: Pelvic preperitoneal packing has a role in the acute management of haemodynamically abnormal patients with pelvic fractures in our environment. In the absence of immediate angioembolization, preperitoneal packing can be lifesaving.

Introduction of Laparoscopy in an Urban High-Volume Sub-Saharan Trauma Centre.

INTRODUCTION: Trauma is a major disease burden in low and middle-income countries like South Africa. Abdominal trauma is one of the leading reasons for emergency surgery. The standard of care for these patients is a laparotomy. In selected trauma patients, laparoscopy has both diagnostic and therapeutic usage. The trauma burden and the number of cases seen in a busy trauma unit make laparoscopy challenging. AIM: We wanted to describe our journey with laparoscopy in the management of abdominal trauma in a busy urban trauma unit in Johannesburg, South Africa. METHODS: We reviewed all trauma patients who underwent diagnostic laparoscopy (DL) or therapeutic laparoscopy (TL) between 01 January 2017 and 31 October 2020 for blunt and penetrating abdominal trauma. The demographic data, indications for laparoscopy, injuries identified, procedures performed, intraoperative laparoscopic complications, conversion to laparotomy, morbidity, and mortality were evaluated. RESULTS: A total of 54 patients who had laparoscopy were included in the study. The median age was 29 years (IQR 25-25). Most injuries were penetrating 85.2% (n = 46/54) and 14.8% blunt trauma. Most patients were males, 94.4% (n = 51/54). Indications for laparoscopy included diaphragm evaluation (40.7%), pneumoperitoneum for evaluation of potential bowel injury (16.7%), free fluid with no evidence of solid organ injury (12.9%) and colostomy (5.5%). There were 8 (14.8%) cases converted to laparotomy. There were no missed injuries or mortality in the study group. CONCLUSION: Laparoscopy in selected trauma patients is safe even in a busy trauma unit. It is associated with less morbidity and shortened hospital length of stay.

Outcomes of Cardiac Gunshot Injuries Presenting at an Urban Trauma Facility in Johannesburg, South Africa.

BACKGROUND: Gunshot wounds to the heart are regarded as one of the most lethal penetrating injuries. There has been an increase in gunshot wounds to the chest in our institution in recent years. Injuries to the heart caused by gunshot wounds can be challenging, with patients arriving in hospital in different physiological states. We report our trauma unit's experience with civilian gunshot wounds to the heart. METHODS: A retrospective review from January 2005 till December 2018 of those 18 years of age and above who presented to our hospital with penetrating cardiac injuries over eight years was done. Those who presented with a carotid pulse and a cardiac rhythm were included in the study. Blood pressure of less than 90 mmHg was considered as haemodynamic instability. Demographics, physiological parameters, injuries sustained, preferred surgical access to the chest, and type of surgery were analysed. The complications during their hospital stay and outpatient clinic were documented. The incidences of in-hospital mortality were also noted. Descriptive statistics with STATA version 15 were conducted. A p-value of < 0.05 was considered statistically significant. RESULTS: A total of 37 patients were enroled in the study; four were excluded for incomplete data. All presented directly from the scene, with a median age of 30 (IQR 24-36). Haemodynamic instability was in 64% of the cases. The most common injured chamber was the right ventricle (75.7%). There were only two complications recorded; local wound sepsis and empyema. All survivors received a post-surgical echocardiogram. The overall survival rate was 18.9% (n = 7). Of the ten that required emergency room thoracotomy, only one survived to discharge. CONCLUSION: Gunshot wounds to the heart have a mortality rate greater than 80% in those arriving alive. Only one in ten of those who meet the strict criteria for emergency room thoracotomy survive hospitalisation. The local complication rate was low.

Slow down with that full bladder: A case report describing an intraperitoneal bladder rupture repaired laparoscopically.

INTRODUCTION: Intraperitoneal bladder rupture requires surgical repair (1). Historically these injuries were treated via laparotomy and open repair (1). There are only a few case reports of laparoscopic bladder repair reported in the literature. Our case adds to an already existing body of limited data especially with such an unusual presentation. With all the advantages minimally invasive surgery offer and the simplicity of the procedure, we recommend laparoscopic repair of isolated intraperitoneal bladder rupture in all trauma patients who are haemodynamic stable. PRESENTATION OF CASE: This was a case of a twenty-three-year-old female who had underwent successful laparoscopic repair following an intraperitoneal bladder rupture secondary to blunt abdominal trauma. DISCUSSION: Technological advancements in laparoscopic surgery and increase in surgeon experience have contributed to the change in approach to patients with traumatic intraperitoneal bladder rupture (1, 2). Previously, associated intra-abdominal injuries had precluded surgeons to pursue laparoscopic repair (1). Laparoscopic exploration has however proven to be safe, effective, and feasible with decreased post-operative pain and wound sepsis, decreased length of stay and improved cosmetic outcome (1-3). CONCLUSION: Laparoscopic repair of intra-peritoneal bladder injuries should be the approach of choice in an appropriate setting in the haemodynamically stable patient.

Incidental aortic coarctation in traumatic subclavian artery injury.

Subclavian artery injuries are complex and challenging due to anatomy and exposure during surgery. The surgical management depends on the mechanism of injury, the patient's haemodynamic stability and other injuries sustained. If control of bleeding is lost during surgery, it results in immediate exsanguination, with high mortality and morbidity rates. New techniques with endovascular surgery have changed the approach and outcome of these injuries. In this case report, an incidental finding of coarctation of the aorta in a 32-year-old man after sustaining a gunshot to the chest, with a subsequent subclavian artery injury is reported.