Case study: Boomslang envenomation in North-Eastern South Africa.

Boomslang (Dispholidus typus) bites are rare in South Africa. This snake's venom is known to be potently haemotoxic, producing a consumptive coagulopathy through the activation of clotting factors II, X, and possibly IX. Monovalent Boomslang antivenom, produced by the South African Vaccine Producers, is highly effective in treating patients who present with haemotoxic envenomation. The majority of health care centres in South Africa do not stock this antivenom due to cost concerns and because envenomation from this snake is so infrequent; this may have lethal consequences for a patient presenting to any such a centre. The usual antivenom dose for effective treatment of a Boomslang bite is two 10 ml vials. We present a case of severe Boomslang envenomation, secondary to a man being bitten on bilateral upper limbs while inside his house, which required three vials of antivenom to treat effectively.

Spontaneous pneumomediastinum in two young women.

SUMMARY: Spontaneous pneumomediastinum (SPM) is a rare benign condition which must be differentiated from secondary pneumomediastinum due to chest trauma, abscess formation or Boerhaave's syndrome. We present two young women with SPM due to chronic self-induced vomiting and starvation associated with psychosis and pregnancy-associated vomiting respectively. This report highlights the exclusionary diagnostic pathway, the principles of conservative management and the need for a tailored multidisciplinary approach to enhance patient recovery and prevent future recurrence.

The spectrum, management and outcome of cellulitis in subtropical South Africa.

BACKGROUND: This study aimed to ascertain the microbiology, severity stratification, and clinical outcomes of cellulitis based on our current management for comparison with international reports. METHODS: A retrospective chart review was conducted of all patients with cellulitis treated by the department of surgery at Ngwelezana Hospital over an 18-month period. Severity of cellulitis was graded, and a comparison was made of the Eron and Modified Dundee classifications. Superficial swabs were taken for culture on patients who had cellulitis with open wounds or blisters. Culture results, antibiotics used, need for surgical intervention, and length of hospital stay were documented and analysed. RESULTS: One hundred and thirty-four patients had cellulitis. Severity grading for classes I-IV in the Eron classification was 3%, 57%, 39% and 1%, respectively, and for the Modified Dundee classification, 47%, 11%, 38%, and 4%, respectively. Co-amoxiclav was the most used antibiotic (73%). Superficial skin swabs were taken from 49 patients and 34 cultured 44 specific organisms. The most common organism identified was Staphylococcus aureus (30%). Several gram-negative and anaerobic organisms were cultured. Fifty-three patients required surgical debridement of the infected area and one patient required an above-knee amputation. Mean hospital stay for patients who did not receive surgical intervention was 6 days (IQR 3) and 7 days (IQR 4) for those who did. There were no deaths. CONCLUSION: The Dundee classification triages fewer patients as class 2 severity than the Eron system and its use has the potentail to reduce the number of patients hospitalised. Gram-positive organisms predominated in those cultured, but gram-negative cultures were frequent compared to other reported series. Co-amoxiclav is effective as first-line antimicrobial therapy in our environment.

A retrospective study of antivenom-associated adverse reaction and anaphylaxis at Ngwelezana Hospital, South Africa.

BACKGROUND: Snakebite victims are commonly seen in KwaZulu-Natal Hospitals, with only a minority of patients requiring antivenom. This study reviewed antivenom-associated adverse events at our institution, after administration of the South African Vaccine Producers (SAVP) polyvalent antivenom. METHODS: A retrospective review, over 52 months (January 2016-April 2020), of patients who received antivenom. Demographics, clinical details and clinical course following antivenom administration were analysed. RESULTS: Emergency department doctors treated 758 snakebites; 156 patients were admitted of which 51 (33%) received antivenom. Indications for antivenom included: neurotoxicity (24%), haemotoxicity (18%) and significant cytotoxicity (58%). Antivenom-associated adverse events occurred in 61% of patients; with 47% developing anaphylaxis requiring adrenaline infusion. There was a higher incidence of anaphylaxis in children (57%) than in adults (40%), p = 0.55. There was no association between antivenom dose and anaphylaxis. No benefit was noted with adrenaline premedication (p = 0.64), nor with the addition of antihistamine or steroid pre-medicants to adrenaline (p = 0.61). Multivariable logistic regression identified age as a predictor for anaphylaxis, but not dose or duration of antivenom and not any particular form of premedication. Intubation was required in 29% of patients developing anaphylaxis. There were no deaths and all patients made full recovery. CONCLUSION: Almost half of the patients at Ngwelezana hospital in Kwazulu-Natal receiving the SAVP polyvalent antivenom developed anaphylaxis requiring adrenaline infusion, with children at higher risk. The administration of this antivenom must only be given for valid indications, in a high-care environment by medical personnel ready to manage anaphylactic shock. The addition of antihistamine and corticosteroids to adrenaline for premedication has no added benefit.

Penetrating colon trauma - outcomes related to single versus multiple colonic injuries.

INTRODUCTION: There is no conclusive evidence to guide surgical management in the presence of multiple colonic injuries as opposed to a single colonic injury, and whether multiple colonic suture lines are associated with worse outcomes than single suture lines. AIM: We reviewed the outcomes of penetrating colonic trauma in relation to whether patients had single versus multiple colonic suture lines (primary repair or anastomosis) following laparotomy. METHODS: A retrospective study was conducted at a major trauma centre in South Africa from 2012-2020 for all patients over 18 years who had sustained penetrating colon injury. RESULTS: 541 cases were included: 409 with single suture line and 54 with multiple suture lines. There were no differences between groups in terms of mechanism of injury (gunshot vs stab; p = 0.328), Injury Severity Score (p = 0.071), or Penetrating Abdominal Trauma Index (p = 0.396). Admission lactate was worse for multiple suture line patients (p = 0.049), but no other blood gas parameters were different, and there was no higher incidence of damage control surgery (p = 0.558) or ICU admission (p = 0.156) for this group. There was a higher rate of diversion in the multiple suture line group (p < 0.001). Univariable logistic regression did not show an increased risk of gastro-intestinal complications, suture line leak rate, or mortality for multiple suture lines compared to single. CONCLUSION: It appears that there is no appreciable difference in outcome between patients with a single colonic suture line compared to patients with more than one suture line following trauma laparotomy. In light of this, each injury should be treated on its own merit, in the context of the patient's overall physiological condition, without undue fear of leaving the patient with more than one colonic suture line. However, judicious use of diversion remains advisable.

Penetrating colon trauma-the effect of concomitant small bowel injury on outcome.

INTRODUCTION: There is limited evidence to suggest that patients with penetrating colon injury have higher complication rates when there is concomitant small bowel (SB) injury. AIM: We performed a retrospective study looking at outcomes of penetrating colonic trauma in patients with- and without concomitant SB injury. METHODS: We interrogated our electronic registry over an eight-year period (2012-2020) for all patients over 18 years who had sustained penetrating colon injury and who had survived beyond 72 h. Demographic data, admission physiology, and Injury Severity Score (ISS) were recorded. Two groups of patients were observed: those with colonic injury (no SB injury) and those with combined colon and SB injury. Outcomes observed included leak rates, length of Intensive Care Unit (ICU) stay, length of hospital stay (LOS), morbidity and mortality. RESULTS: A total of 450 patients were eligible for analysis, of which 257 had colon injury without SB injury and 193 had a combination of colon and SB injury. There was no difference in mechanism of injury between groups. Admission physiology was similar between groups but arterial blood gas values were worse in the combined group. Rates of damage control surgery and ICU admission were higher in the combined group. Primary repair was done in equal proportions between groups but anastomosis was more frequently performed in the combined group. There was no difference in complication rates, including gastro-intestinal complications and suture line leaks. Length of ICU stay, LOS, and mortality were similar between groups. Univariable analysis demonstrated that the presence of concomitant small bowel injury was not an independent risk factor for colonic suture line failure or death. CONCLUSION: There is no evidence from this data that the presence of a combined penetrating colon and SB injury should change management priorities. Each injury should be treated on its own merit, in the context of the patient's physiology.

Penetrating Colon Trauma-the Effect of Injury Location on Outcomes.

BACKGROUND: There is limited evidence to suggest that the more distal a penetrating colonic injury, the poorer its expected outcome, prompting consideration of diversion rather than anastomosis when faced with left colonic injury. The clinical outcomes of penetrating colonic trauma in relation to their anatomical location within the colon were reviewed. METHODS: A review was performed over eight years (2012-2020) of all patients over 18 years who had sustained penetrating colon injury and presented to our trauma centre in South Africa. Direct comparison was made between right colon vs left colon injuries. RESULTS: A total of 450 patients were included; right colon: 260, left colon: 190. Gunshots predominated in the right colon, and the PATI was higher in this group. There were minimal differences in admission physiology and blood gas parameters between groups, but higher damage control surgery and ICU admission rates for the right colon group. There were similar rates of primary repair, anastomosis, and stoma between groups. Leak rates were no different between the two groups, and although overall complication rates were higher for the right colon, there was no difference with regard to gastro-intestinal and other complications, nor for mortality. While regression analysis did identify PATI to be a risk factor for overall complications and mortality, it failed to do so for anastomotic leak. CONCLUSION: Our study did not demonstrate any difference in anastomotic leak rates or mortality between right vs left colonic injury. We recommend that all colonic injuries should be treated on their own merit, balanced against the patient's condition, regardless of anatomical location within the colon.

Venous bicarbonate and creatine kinase as diagnostic and prognostic tools in the setting of acute traumatic rhabdomyolysis.

BACKGROUND: Myorenal or crush syndrome often develops following soft-tissue traumatic injury. It is a spectrum of disease that may result in severe renal dysfunction and kidney injury requiring renal replacement therapy. OBJECTIVES: To review a large cohort of patients with so-called myorenal or crush syndrome and assess the biochemical markers of venous bicarbonate and creatine kinase as predictors for the development of acute kidney injury (AKI). METHODS: All patients with myorenal syndrome who presented to Khayelitsha District Hospital, Cape Town, South Africa (SA), and Ngwelezana Hospital, Empangeni, KwaZulu-Natal, SA, between January and December 2017 were identified and reviewed. RESULTS: A total of 212 patients were included in the study. At both hospitals, 94% of the patients were male. Using the Pearson correlation coefficient, we compared creatinine kinase (CK) against serum creatinine. The mean CK level was 5 311.8 U/L and the mean creatinine level 133.457 µmol/L. The r-value was 0.2533. Although this is a technically positive correlation, the relationship between the variables is weak. Using the Pearson R Calculator, we inserted the r-value to calculate the p-value. The p-value was 0.000208. When comparing venous bicarbonate (HCO3) against creatinine, the mean HCO3 level was 22.296 mmol/L and the mean creatinine level 162.053 µmol/L. The r-value was -0.3468. Although this is a technically negative correlation, the relationship between the variables is weak. Using the Pearson R Calculator, we inserted the r-value to calculate the p-value. The p-value was 0.000013. The inverse ratio shown with HCO3 v. creatinine, although still a weak correlation, is significantly better in predicting an increase in creatinine compared with the weak positive correlation of CK v. creatinine. CONCLUSIONS: Although both venous HCO3 and CK showed a weak correlation with creatinine, the former performed significantly better in predicting AKI. In a resource-constrained system, we recommend that HCO3 be measured to assess patients with crush injury and that CK be regarded as a complementary modality.

Falanga: The clinical correlates of surgical outcomes as a result of foot whipping in a resource poor setting.

BACKGROUND: Falanga is a punishment that involves hitting the bare soles of a person's feet. The consequences of this punishment may be limb and life-threatening. Post-traumatic acute kidney injury (AKI) secondary to rhabdomyolysis is a well-documented complication. Patients often require prompt surgical intervention and renal replacement therapy (RRT). The clinical and biochemical presentation of these patients and subsequent outcomes are poorly understood. AIMS: This prospective observational study describes the clinical presentation and effects of foot whipping on patient outcomes. METHODOLOGY: Prospective data were collected over a one-year period for 135 patients presenting following blunt force assault admitted to a single centre. Presenting clinical characteristics and patient outcomes were recorded and correlations between presenting clinical characteristics and surgical and clinical outcomes were assessed. RESULTS: Of 138 patients presenting following blunt force assault 96% were male with a mean age of 28.8 ± 8.01. Thirty-six out of the 138 patients presenting following blunt force assault had received foot-whipping only (falanga group, FG). Ten of these 36 patients in the FG group required surgical intervention, with one requiring a below knee amputation, compared with only two patients who required surgical intervention in the group who experienced blunt force trauma not restricted to foot whipping (Sjambok group). Average length of stay was 4 days (range 2-38) in FG group compared with 5 (range 1-21) in SG group, with no mortalities in either group. For patients in the FG, Hb was higher at presentation compared to patients in the SG group (135.2 33.7 vs 124.2 21.3, p = 0.03) and correlated positively with the need for surgical intervention (r = 0.6, p < 0.01). In this same group, the presenting characteristics of CK (4251.3 3087.4, p = 0.1 vs 7422.6 12347.7, p = 0.1) and urine output (0.95 0.4 vs 0.7 0.4) positively correlated with RRT [CK r = 0.6, p < 0.01, UO r = 0.46, p < 0.01]. CONCLUSION: Patients who present following falanga frequently require surgical intervention and the related healthcare utilisation and morbidity is high. Clinical indicators of a greater systemic injury at presentation may correlate with an increased likelihood of requiring surgical intervention or RRT.

Using fresh frozen plasma as an emergency treatment modality for hypertriglyceridaemic acute pancreatitis in a resource-constrained environment: A case report and review of literature.

Hypertriglyceridaemia is associated with severe disease such as coronary disease, cerebral vascular accidents and acute pancreatitis. Severe hypertriglyceridaemia is defined as a serum triglyceride value of >55 mmol/L. Hypertriglyceridaemic acute pancreatitis, often found in pregnancy, has a higher mortality rate than the other causes of acute pancreatitis. The cornerstone of treatment is to lower the triglyceride level as quickly as possible. In a resource-constrained environment, plasma exchange is not a viable option. Therefore, exploring the possible efficacity of directly infusing fresh frozen plasma is applicable to rural emergency medicine and may lead to more definitive research. In our case study, we used fresh frozen plasma to enhance the removal of triglyceride because it contains lipoprotein lipase.

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.

Skin-only closure as a temporary abdominal closure technique in a rural setting - exploring role and safety profile.

BACKGROUND: Acute laparotomy for trauma or sepsis often prevents definitive closure due to need for relook laparotomy or to prevent abdominal compartment syndrome. Skin-only closure is widely used in our setting. In this study, we review the safety and effectiveness of this technique. METHODS: Patients presenting with intra-abdominal pathology undergoing acute laparotomy and then subsequent skinonly closure using 2-0 prolene were included in the study and followed postoperatively for a three-month period for adverse events stratified by Clavien-Dindo grading, and rate of definitive closure. RESULTS: During the study period, twenty-five patients underwent emergent laparotomy and skin-only closure. The median age of patients undergoing skin-only closure was 27 years (standard deviation 9.1). Six patients presented with major trauma and 19 presented with sepsis. Twenty-one patients underwent subsequent fascial closure. One patient was unable to undergo fascial closure and was managed as a planned ventral hernia. Fourteen patients developed a postoperative complication. There were no deaths and no readmissions to intensive care. Three further patients developed a ventral hernia. CONCLUSION: Skin-only closure, in carefully selected patients, is a feasible alternative to other temporary abdominal closure techniques in a resource-constrained setting.

Correlation between the level of the external wound and the internal injury in penetrating neck injury does not favour an initial zonal management approach.

BACKGROUND: Many current protocols for managing penetrating neck injuries (PNIs) still suggest zonal approaches. This study was undertaken to determine the correlation between the zone of the external wound and the level of the internal injury, and to verify whether a 'no-zone' approach to PNI is valid. METHODS: Patients admitted with a PNI to a tertiary trauma care centre between January 2011 and May 2018 were identified from a trauma database. Those with confirmed injury to the vascular system or an aerodigestive tract injury (ADTI) were included in the study. The medical records of each patient were reviewed with regard to the zone of the external wound and the level of internal injury, and the findings were compared. RESULTS: In the period under review, 1075 patients were treated for a PNI. Of these, 298 (27·7 per cent) had a confirmed vascular injury or ADTI and were included in the cohort. In 176 patients (59·1 per cent) the site of the internal injury was in the same zone as the external wound. In a further 70 patients (23·5 per cent) there was no correlation between the site of the internal injury and the external wound, and in the remaining 52 patients (17·4 per cent) the correlation could not be determined. In this cohort, all clinically assessable patients with significant injuries had either physical signs suggestive of injury or deep surgical emphysema on radiological examination. CONCLUSION: An approach to PNI based on zones is questionable, and this study supports a no-zone approach based on imaging guided by clinical examination.

ANTECEDENTES: Muchos protocolos actuales para el manejo de lesiones penetrantes en el cuello (penetrating neck injury, PNI) aún proponen un enfoque zonal. Este estudio se llevó a cabo para determinar la correlación entre la zona de la herida externa y el nivel de la lesión interna y para comprobar si sería válido un enfoque "sin zonas" para la PNI. MÉTODOS: Los pacientes con PNI ingresados en un centro terciario de traumatología entre enero de 2011 y mayo de 2018 fueron identificados a partir de la base de datos del centro. Se incluyeron pacientes con lesión confirmada vascular o lesión del tracto aero-digestivo (aero-digestive tract injury, ADTI). Se revisaron las historias clínicas de cada paciente con respecto a la zona de la herida externa y el nivel de lesión interna, comparándose dichos hallazgos. RESULTADOS: En el período de estudio, 1.075 pacientes fueron tratados por una PNI. De estos, 298 (27,7%) tenían una lesión vascular o una ADTI confirmadas y se incluyeron en la cohorte. En 176 pacientes (59,1%), la lesión interna estaba localizada en la misma zona de la herida externa. En otros 70 pacientes (23,5%), no hubo correlación entre la localización de la lesión interna y la herida externa y en los 52 pacientes restantes (17,4%) no se pudo determinar dicha correlación. En esta cohorte, todos los pacientes clínicamente evaluables con lesiones significativas presentaban signos físicos sugestivos de lesión o enfisema profundo con indicación quirúrgica en el examen radiológico. CONCLUSIÓN: El enfoque de la PNI basado en zonas es cuestionable y este estudio apoya un enfoque de "sin zonas" basado en pruebas de imágen basadas en los hallazgos clíncos.

Primary repair of duodenal injuries: a retrospective cohort study from a major trauma centre in South Africa.

BACKGROUND AND AIMS: The management of duodenal trauma remains controversial. This retrospective audit of a prospectively maintained database was intended to clarify the operative management of duodenal injury at our institution and to assess the risk factors for leak following primary duodenal repair. MATERIALS AND METHODS: This was a retrospective study undertaken at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa. Operative techniques used for duodenal repair were recorded. Our primary outcome was duodenal leak in the postoperative period. Patients from January 2012 to December 2016 were included. All duodenal injuries were graded according to the American Association for the Surgery of Trauma (AAST) grading. Only patients who had a primary repair were included in the final analysis. RESULTS: During the five-year data collection period, a total of 562 patients underwent a trauma laparotomy; of which 94 patients sustained a duodenal injury. A primary pyloric exclusion and gastro-jejunostomy (PEG) was performed in three patients. These three were then excluded from further analysis. Of the 91 primary duodenal repairs, seven (8%) subsequently leaked. These were managed by PEG in three and by secondary repair and para-duodenal drainage in four. The two physiological parameters most associated with subsequent leak were lactate and pH level. There was a significantly higher mortality rate for those who leaked vs those who did not leak. Chi-squared test revealed a significant difference in the leak rate between AAST I (0%), AAST-II (1.6%) and AAST-3 (66.7%) grade injuries (p <0.01). CONCLUSION: The trend towards primary repair of duodenal injuries appears to be justified. However duodenal leak remains a significant risk in certain high risk patients and strategies to manage injuries in this subset requires further work.

Preparing Japanese surgeons for potential mass casualty situations will require innovative and systematic programs.

INTRODUCTION: The ongoing state of global geo-political instability means that it is prudent to prepare civilian surgeons to manage major military-type trauma. Japan has enjoyed a prolonged period of peace and consequently it is unlikely that surgeons will have been exposed to a sufficient volume of cases. This study reviews the state of trauma training and preparedness in Japan and reviews the trauma workload of a major Japanese emergency medical center and compared with a major South African trauma center with the intention of quantifying and comparing the time needed to gain adequate exposure to major trauma at the two centers. MATERIALS AND METHODS: The literature describing the surgical burden from a number of recent military missions was reviewed and the core surgical skills to manage military-type injuries were identified. We then went on to review all patients admitted to both Kurashiki Central Hospital (KCH) and Pietermaritzburg Metropolitan Trauma Service (PMTS) following trauma between the period September 2015 and August 2016. The burden of trauma at each center was quantified and the number of core surgical competencies or procedures performed at each center was then reviewed. These were then compared with the number of the core procedures which were performed on the reported military missions. RESULTS: Three reports on military surgical missions were reviewed. These came from the Dutch, French and British military surgical services. The average number of each core procedures performed on each reported military surgery mission are tabulated in the text. The most common procedures were wound debridement and orthopedic fixation, followed by trauma laparotomy, neck exploration and thoracotomy. During the 12 month study period, 309 trauma patients were admitted to KCH. Of which 206 (67%) were male, and the mean age was 57 years. There were 10 penetrating injuries and 299 blunt injuries. Of the penetrating injuries there were no gunshot wounds. The mechanisms of injury for blunt trauma were as follows: Road traffic accidents (RTAs); 141 (47%), fall; 136 (46%) and other injuries; 22 (7%). In the same period, 2887 trauma patients were admitted by the PMTS. There were 1244 cases (43%) of penetrating trauma and 1644 cases (57%) of blunt trauma in PMTS. The mechanisms of injury for penetrating trauma were as follows: stab wounds (SWs); 955 (77%), gunshot wounds (GSWs); 252 (20%), and other injuries; 37 (3%) and for blunt trauma were as follows: assault; 739 (45%), RTAs; 669 (41%), fall; 166 (10%), and other injuries; 70 (4%). The exposure to all the key competencies required to manage trauma is overwhelmingly greater in South Africa than in Japan. The length of time needed to obtain an equivalent trauma exposure to that achieved in South Africa, working in Japan is prohibitively long. CONCLUSION: Trauma training in Japan is hamstrung by a lack of clinical material as well as by systematic factors. Training a trauma surgeon is difficult. Developing a trauma system in the country may help address some of these deficits. South Africa in contrast has a huge burden of trauma and sufficient infrastructure to ensure that surgeons working there have adequate exposure to major trauma. Developing an academic exchange program between Japan and South Africa may allow for the transfer of trauma experience and skills between the two countries.

A selective non-operative approach to thoracic stab wounds is safe and cost effective - a South African experience.

INTRODUCTION: Penetrating thoracic trauma is common and costly. Injuries are frequently and selectively amenable to non-operative management. Our selective approach to penetrating thoracic trauma is reviewed and the effectiveness of our clinical algorithms confirmed. Additionally, a basic cost analysis was undertaken to evaluate the financial impact of a selective nonoperative management approach to penetrating thoracic trauma. MATERIALS AND METHODS: The Pietermaritzburg Metropolitan Trauma Services electronic regional trauma registry hybrid electronic medical records were reviewed, highlighted all penetrating thoracic traumas. A micro-cost analysis estimated expenses for active observation, tube thoracostomy for isolated pneumothorax greater than 2 cm and tube thoracostomy for haemothorax. Routine thoracic computed tomography does not form part of these algorithms. RESULTS: Isolated thoracic stab wounds occurred in 589 patients. Eighty per cent (472 cases) were successfully managed nonoperatively. Micro-costing shows that active observation costs 4,370 ZAR (£270), tube thoracostomy for isolated pneumothorax costs 6,630 ZAR (£400) and tube thoracostomy for haemothorax costs 21,850 ZAR (£1,310). DISCUSSION: Penetrating thoracic trauma places a striking financial burden on our limited resources. Diligent and serial clinical assessments, alongside basic radiology and stringent management criteria, can accurately stratify patients to correct clinical algorithms. CONCLUSION: Selective nonoperative management for penetrating thoracic trauma is safe and effective. Routine thoracic computed tomography is unnecessary in all patients with isolated thoracic stab wounds, which can be reserved for a select group who are identifiable clinically. Routine thoracic computed tomography would not be financially prudent across Pietermaritzburg Metropolitan Trauma Services. Government action is required to reduce the overall incidence of such trauma to save resources and patients.

A raised serum lactate level is an independent predictor of in-hospital mortality in patients with isolated cerebral gunshot wounds.

BACKGROUND: Cerebral gunshot wounds (CGSWs) represent a highly lethal form of traumatic brain injury, and triaging these patients is difficult. The prognostic significance of the serum lactate level in the setting of CGSWs is largely unknown. OBJECTIVES: To examine the relationship between elevated serum lactate levels and mortality in patients with isolated CGSWs. METHODS: A retrospective review of the regional trauma registry was undertaken at the Pietermaritzburg Metropolitan Trauma Service, South Africa, over a 5-year period from 1 January 2010 to 31 December 2014. All patients with an isolated CGSW were included. RESULTS: A total of 102 patients with isolated CGSWs were identified. Of these, 92.2% (94/102) were male. The mean age (standard deviation) was 29 (8) years, and the in-hospital mortality rate was 21.6% (22/102). The mean serum lactate level was significantly higher among non-survivors than among survivors (6.1 mmol/L v. 1.3 mmol/L; p<0.001). Lactate levels among non-survivors were <2 mmol/L in 4.5%, 2 - 3.99 mmol/L in 9.1%, 4 - 5.99 mmol/L in 36.4% and ≥6 mmol/L in 50.0%. The odds ratio for mortality with a lactate level of 4 - 5.99 mmol/L was 67 (95% confidence interval (CI) 1.7 - 2 674.2), while for a lactate level of ≥6 mmol/L it was 1 787 (95% CI 9.0 - 354 116.1). The serum lactate level accurately predicted mortality even after adjustment for other variables. Based on a receiver operating curve analysis, an optimal cut-off of 3.3 mmol/L for serum lactate as a predictor for mortality was identified (area under the curve = 0.957). CONCLUSIONS: CGSWs are associated with significant mortality, and a raised serum lactate level appears to be an independent predictor of in-hospital mortality. It is a potentially useful adjunct in the resuscitation room for identifying patients with a very poor prognosis.

Computed Tomography Angiography is the Definitive Vascular Imaging Modality for Penetrating Neck Injury: A South African Experience.

BACKGROUND AND AIMS: Computed tomography angiography has become central to the diagnostic algorithm for penetrating neck injury, but despite its widespread use the literature to support this adoption is limited. We reviewed our experience with computed tomography angiography for the identification of vascular trauma in hemodynamically stable patients with penetrating neck injury at a major trauma center in South Africa. MATERIALS AND METHODS: A prospectively kept trauma registry capturing data in real time was retrospectively reviewed. All patients with penetrating neck injury investigated with computed tomography angiography as the initial vascular investigation during a 47-month period were included. RESULTS: A total of 380 patients were included. Indications for computed tomography angiography were as follows: hard signs (13), soft signs (201), no signs but proximity/zone I or III wounds (141), and undefined signs of vascular injury (25). Of the 380 scans, 7 (1.8%) were indeterminate, 299 (78.7%) negative, and 74 (19.5%) positive for a vascular injury (54 arterial and 20 isolated venous injury). Eight were false positive and 4 false negative. The sensitivity, specificity, positive, and negative predictive values for detecting arterial injury were 93.9%, 97.5%, 85.2%, and 99.1%, respectively. Overall, the yield for demonstrating "true arterial injury" was 12.1% (46/380); hard signs: 76.9% (10/13), soft signs: 16.4% (33/201), and no signs: 2.1% (3/141) which all were secondary to gunshot wounds). Only 8.4% (32/380) required intervention for arterial injury and none for isolated venous injury (hard signs: 62.0%, soft signs: 11.4%, and no signs: 0.7%). No serious complications resulted from computed tomography angiography. CONCLUSION: Computed tomography angiography is a safe and effective imaging modality for the investigation of vascular trauma post penetrating neck injury. Asymptomatic patients with stab wounds do not need to be imaged regardless of proximity concerns. Symptomatic stable patients including a subgroup with hard signs should be imaged rather than explored. Computed tomography angiography provides an interventional road map and can identify injuries amenable to endovascular or conservative management.

Validation of the Baragwanath mortality prediction score for cerebral gunshot wounds: the Pietermaritzburg experience.

INTRODUCTION: Cerebral gunshot wounds (GSW) are highly lethal injuries. To date, only one clinical scoring system to predict mortality in a developing world setting has been described. This is the Baragwanath mortality prediction score ("ABC": admission blood pressure, brain matter spillage and consciousness level). MATERIALS AND METHODS: We performed a retrospective review of prospectively entered data for a cohort of patients with isolated cerebral GSWs over a 5-year period (January 2010-December 2014) in our institution. We aimed to validate the Baragwanath ABC mortality prediction score in our population. RESULTS: During the 5-year study period, 102 patients with isolated cerebral GSWs were reviewed, 22% (22/102) of which died. Based on the total ABC score (1-5), the mortality was 0% for 1, 21% for 2, 67% for 3, 92% for 4, and 100% for 5. The ABC score has a sensitivity of 82% (95% CI 60-95%), specificity of 96% (95% CI 89-99%), PPV of 86% (95% CI 66-96%) and NPV of 95% (95% CI 86-99%). CONCLUSIONS: The Baragwanath mortality prediction score accurately predicts non survival of patients with a cerebral GSW in our patient cohort. Further validation studies in other populations are required before this system can be widely adopted.