The sensitivity of a neck CT scan in detecting pneumothoraces in nonpenetrating trauma.

BACKGROUND: The trauma-related pneumothorax is a common intrathoracic injury and can go undetected with detrimental outcomes. Chest computed tomography (CT) investigation in low- to middle-income countries (LMIC) is not always readily available during emergency situations and increased workloads. However, alternative investigations all have limitations in including pneumothoraces. Patients may have trauma indications for CT of the head and neck. The neck CT scan may hold an extra potential advantage in pneumothorax detection. This study aimed to assess its sensitivity in pneumothorax detection in nonpenetrating trauma. METHODS: A retrospective study was conducted from 1 January 2016 to 31 December 2021. All adult patients sustaining nonpenetrating injuries, and investigated with chest and neck CT scans were included. The chest CT scan was the gold standard against,which the neck CT scan was compared to determine the accuracy of pneumothorax detection. Stata version 16 was used for descriptive statistical analysis, and a p-value of 0.05 was considered statistically significant. RESULTS: One thousand ninety three were eligible for evaluation; 204 (18.66%) pneumothoraces were detected on chest CT scans, 200 (98.0%) of which were also detected on the neck CT scan, producing a sensitivity of 98.0% (95% CI 95.1-99.5%) and a specificity of 100% (95% CI 99.6-100%). Most pneumothoraces were detected at T1 level (45.09%), followed by T2 (43.62%). CONCLUSION: The neck CT scan has demonstrated high sensitivity and specificity in pneumothorax detection. Thus, it may be used as an additional tool for those who could not receive or do not need a formal chest CT but have an indication for neck CT scans.

Biochemical markers in emergency thoracic surgery in penetrating trauma.

BACKGROUND: Violent interpersonal acts account for a large proportion of unnatural deaths in South Africa. A significant proportion of unnatural deaths are due to penetrating thoracic trauma and preventable haemorrhage. Current indications for emergent thoracotomy are unreliable. We propose the use of lactate, shock index (SI) and base deficit (BD) as a triage tool in patients with penetrating thoracic injuries to identify those requiring surgical intervention. METHODS: A review of the trauma registry of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) was carried out between March 2011 and March 2016. Four hundred and ninety (490) patients were collected consisting of a non-operative group of 246 patients and an operative group of 244 patients. We compared lactate, SI and BD independently and within panels to ascertain which would best predict the need for operative intervention in these patients. Abnormal was defined as lactate ≥ 4 mmol/l, SI ≥ 0.8 and BD ≤ -4 mmol/l. RESULTS: Of the 490 patients, lactate (p < 0.001), SI (p < 0.001) and BD (p < 0.001) differed significantly between operative and non-operative groups. Statistical significance was lost (p = 0.34) once BD was analysed in combination with lactate and SI. Lactate alone was a strong predictor of the need for intervention (area under the curve (AUC) = 0.814). The strongest predictor was a combined panel of lactate and SI (AUC = 0.8308, p < 0.001). CONCLUSION: Lactate and SI in combination are useful as triage tools, and could assist in decision making, by predicting which patients are more likely to require surgical intervention.

The mortality rate of patients with open abdomen and contributing factors - a three-year audit in a major academic trauma unit.

BACKGROUND: Damage control surgery (DCS) is a widely used approach in trauma. An open abdomen carries complications, increased morbidity and mortality. This study aims to quantify the mortality rate, determine contributory factors and factors influencing the decision to perform DCS and assess morbidity in patients undergoing open abdomen. METHODS: A retrospective review was conducted on 205 patients in Charlotte Maxeke Johannesburg Academic Hospital Trauma Unit. The mortality rate was evaluated over a 24-hour, 7-day and 28-day period. Data were collected by a data collection sheet from 1 January 2016 to 31 December 2018. RESULTS: Of the 205 patients, 193 were male and the median age was 34.34 years. Penetrating trauma was the most predominant mechanism of injury in 162 (79%), with gunshot injuries seen in the majority (130/162). The mortality rate was 55/205 (26.8%) for open abdomen patients, 19/55 (34.5%) within the first 24 hours, 22/55 (40%) in the 24-hours to 7-days period, and 14/55 (25.4%) in the 8-day to 28-day period. Statistically significant factors contributing to mortality were haemodynamic instability, hypothermia, coagulopathy, massive transfusion, vasopressors, and significant associated injuries. Morbidities were entero-atmospheric fistula (EAF) in 7.3% (Clavien-Dindo grade IIIa), surgical site infection in 45.3% (Clavien-Dindo grade I) and ventral hernia in 10.24% (Clavien-Dindo grade IIIb). CONCLUSION: Most open abdomens were performed in males, with gunshot injuries being the most common mechanism. The majority of mortalities were within the 24-hours to 7-days period. The most common morbidity associated with an open abdomen was surgical site infection.

Analysis of Surgical Mortalities Using the Fishbone Model for Quality Improvement in Surgical Disciplines.

BACKGROUND: The healthcare industry is complex and prone to the occurrence of preventable patient safety incidents. Most serious patient safety events in surgery are preventable. AIM: This study was conducted to determine the rate of occurrence of preventable mortalities and to use the fishbone model to establish the main contributing factors. METHODS: We reviewed the records of patients who died following admission to the surgical wards. Data regarding their demography, diagnosis, acuity, comorbidities, categorization of death and contributing factors were extracted from the Research Electronic Data Capture (REDCap) database. Factors which contributed to preventable and potentially preventable mortalities were collated. The fishbone model was used for root cause analysis. The study received prior ethical clearance (M190122). RESULTS: Records of 859 mortalities were found, of which 65.7% (564/859) were males. The median age of the patients who died was 49 years (IQR: 33-64 years). The median length of hospital stay before death was three days (IQR: 1-11 days). Twenty-four percent (24.1%) of the deaths were from gastrointestinal (GIT) emergencies, 18.4% followed head injury and 17.0% from GIT cancers. Overall, 5.4% of the mortalities were preventable, and 41.1% were considered potentially preventable. The error of judgment and training issues accounted for 46% of mortalities. CONCLUSION: Most surgical mortalities involve males, and around 46% are either potentially preventable or preventable. The majority of the mortality were associated with GIT emergencies, head injury and advanced malignancies of the GIT. The leading contributing factors to preventable and potentially preventable mortalities were the error of judgment, inadequate training and shortage of resources.

Surgical rib fixation as an alternative method of treatment for multiple rib fractures: an audit of results compared with traditional medical management.

BACKGROUND: Rib fractures are a common cause of morbidity and chronic pain, delaying return to normal activities. Reports suggest that surgical fixation improves acute and long-term outcomes. METHODS: A single centre retrospective review of multiple rib fractures, comparing the outcomes of cases managed using surgical fixation with cases managed only with best medical therapy (BMT) over 2 years. RESULTS: Thirty-five patients with rib fractures were admitted over the study period. The most common causes of rib fractures were motorcycle crashes (34.2%) and falls (31.4%). Fourteen patients had surgery. There were no differences between the two groups regarding the number of fractured ribs, injury severity score (ISS), ICU or hospital length of stay. The median numeric pain visual analogue scale (VAS) on admission was eight points for non-ventilated patients. In the surgical group the median VAS significantly fell to a median of 2 points in the first 24 hours after surgery (p = 0.04). Only two out of 25 major complications were directly attributable to the surgery for rib fixation. Patients managed without surgery needed significantly longer time to return to normal activities compared to those who had surgery (median 7 weeks versus 3 weeks, p = 0.03). CONCLUSIONS: Our preliminary results suggest that rib fixation should be considered a treatment alternative in patients with multiple rib fractures.

Laparoscopic repair of a delayed traumatic bladder injury.

SUMMARY: Isolated bladder injuries from falls are not common; we report a laparoscopic bladder repair in a patient with delayed presentation. There are about 20 case reports of laparoscopic repair of traumatic bladder reported in the literature, but none with such a delayed presentation. We describe the technique of laparoscopic bladder repair. The delay in the presentation might have facilitated laparoscopic repair as it might have excluded bowel injuries.

An analysis of air-crash injury patterns presenting at a level 1 trauma unit in Johannesburg, a retrospective cohort study.

BACKGROUND: In the twenty-first century, transportation disasters and subsequent injuries are on the rise, in particular air travel, and, thus, contributing significantly to the morbidity and mortality. Aviation injuries are not common in South Africa, injuries and outcomes of patients involved in aircraft crashes are unknown. We aimed to describe the injury patterns, and mortality rate resulting from air crashes presenting at a level 1 trauma centre in Johannesburg, South Africa. METHODS: Data was collected between January 2011 and December 2019. The hospital trauma database was used to obtain data related to patients who were involved in aircraft crashes. Their demographics, type of related aircraft, injuries sustained, injury severity score (ISS), new injury severity score (NISS), revised trauma score (RTS) surgical intervention carried out, length of stay in ICU, length of hospital stay, morbidities, 28-day mortality and outcomes (discharge/death). RESULTS: Fifty-two (52) patients (mean age was 44,8 years) were identified. The mean ISS was 9, and NISS was 11. Patients were occupants of civilian, non-commercial, powered aircraft. Fixed wing constituted 63,46%, followed by helicopters 21,15% and 7,69%. Spinal injuries were the most common injury in our patients, followed by soft tissue injuries and rib fractures. The median hospital stay was 10 ± 22 days. The overall in-hospital mortality rate was 7.7. CONCLUSION: Majority of patients sustained musculoskeletal injuries. We suggest that these injured patients should be managed at a Level 1 facility in view of combined multiple injuries sustained during the crash.

Procalcitonin-guided antibiotic therapy for suspected and confirmed sepsis of patients in a surgical trauma ICU: a prospective, two period cross-over, interventional study.

BACKGROUND: Biomarkers like procalcitonin (PCT) are an important antimicrobial stewardship tool for critically ill patients. There is little evidence regarding the use of PCT-guided antibiotic algorithms in developing countries. Evidence is also lacking for PCT-based antibiotic algorithms in surgical trauma patients admitted to the intensive care unit (ICU). METHODS: A prospective, two period cross-over study was conducted in a surgical trauma intensive care unit in South Africa. In the first period, 40 patients were recruited into the control group and antibiotics were discontinued as per standard of care. In the second period, 40 patients were recruited into the procalcitonin group and antibiotics were discontinued if the PCT decreased by ≥ 80% from the peak PCT level, or to an absolute value of less than 0.5 µg/L. Antibiotic duration of treatment was the primary outcome. Patients were followed up for 28 days from the first sepsis event. RESULTS: For the first sepsis event the PCT group had a mean antibiotic duration of 9.3 days while the control group had a mean duration of 10.9 days (p = 0.10). Patients in the intervention group had higher mean (SD) antibiotic free days alive of 7.7 (6.57) days compared to the control group mean (SD) of 3.8 (5.22) days, (p = 0.004). In-hospital mortality rate was lower in the intervention group (15%) compared to the control group (30%) and was statistically significant (p = 0.045). CONCLUSION: There was no significant difference in duration of antibiotic treatment between the two groups. However, the PCT group had more antibiotic free days alive and lower in-hospital mortality compared to the control group.

Empirical antibiotic choice alters microbiological outcomes: Findings from comparative antibiograms in a trauma intensive care unit.

Background: Inappropriate empirical antibiotics promote antibiotic resistance. Antibiograms guide empirical antibiotic therapy by outlining the percentage susceptibility of each pathogen to individual antibiotics. In 2016, the Trauma Intensive Care Unit at Charlotte Maxeke Johannesburg Academic Hospital escalated empirical antibiotic therapy for nosocomial infections from piperacillin-tazobactam to imipenem plus amikacin. Objectives: This study assessed the impact of escalation in empirical antimicrobial treatment on organism prevalence and resistance profile. Methods: A retrospective analysis of bacterial and fungal microscopy, culture and susceptibility reports from the laboratory information system of the National Health Laboratory Services, from 1 January 2015 to 31 December 2015 and 1 January 2017 to 31 December 2017, was conducted. Data were de-duplicated according to standard guidelines. Fisher's exact test was used to determine p-values. Results: Organism prevalence shifted between the years, with a 2.7% increase in streptococci (p=0.0199), 1.7% increase in Candida auris (p=0.0031) and 4.6% and 4.4% reduction in Acinetobacter baumannii (p=0.0508) and Pseudomonas aeruginosa (p=0.0196), respectively. Similarly, there was a change in the resistance profile, with a 28.9% reduction in multi-drug resistant (MDR) A. baumannii (p=0.0001), 60.4% reduction in MDR P. aeruginosa (p=0.0001) and a 6.5% increase in carbapenem-resistant Enterobacterales (p=0.007). The predominant specimen type differed between the years, with significantly more pus, tissue and fluid samples and fewer respiratory samples sent for investigation in 2017 than 2015. Conclusion: Escalation in the use of empirical antibiotics showed a change in organism prevalence and an improvement in the susceptibility profile of MDR non-fermenters. Contributions of the study: Current literature on the effects of antibiogram-guided empirical antibiotics is scarce within the South African context. This study shows how antibiograms are an effective antimicrobial stewardship strategy to reduce antimicrobial resistance rates by guiding appropriate choice of empirical antibiotics.