The Combined SIRS + qSOFA (qSIRS) Score is More Accurate Than qSOFA Alone in Predicting Mortality in Patients with Surgical Sepsis in an LMIC Emergency Department.

BACKGROUND: qSOFA has been proposed as a prognostic tool in patients with sepsis. This study set out to assess the sensitivity of several scores, namely: the pre-ICU qSOFA, the qSOFA with lactate (qSOFA L), SIRS score, qSOFA + SIRS score (qSIRS) and qSIRS with lactate (qSIRS L) in predicting in-hospital mortality in patients with surgical sepsis as well as the sensitivity of these scores in predicting high-grade sepsis. The secondary aim was to determine which of these scores is best suited to predict high-grade surgical sepsis. METHODS: This was a retrospective cohort study that was conducted between December 2012 and August 2017 in a public metropolitan surgical service. Data from patients aged > 13 years, who were admitted to the hospital and who had an emergency surgical procedure for source control were retrieved from a prospectively maintained hybrid electronic database. The qSOFA, qSOFA plus lactate (qSOFA L), SIRS and qSOFA + SIRS (qSIRS), as well as the qSIRS plus lactate (qSIRS L), were calculated for each patient. A lactate level that was greater than 2mmol/L was deemed to be a positive finding. Any score ≥2 was deemed to be a positive score. The outcome measure was in-hospital mortality. The prognostic value of qSOFA, qSOFA L, SIRS, qSIRS and qSIRS L was studied. Receiver operating characteristic analyses were performed to determine the area under the curve (AUC), sensitivity, specificity and positive and negative likelihood ratios for positive qSOFA, qSOFA L, SIRS, qSIRS, and qSIRS L. Contingency tables were used to calculate the sensitivity, specificity, PPV and NPV for predicting severe or high-grade surgical sepsis. RESULTS: There were a total number of 1884 patients in the sample group of whom 855 were female (45.4%). The median patient age was 36 years (IQR 23-56). A total of 1489 patients (79%) were deemed to have high-grade sepsis based on an advanced EGS AAST grading, whilst 395 patients (21%) had low-grade sepsis. A total of 71 patients died (3.8%). Of these patients who died, 67 (94.4%) had high-grade sepsis and 4 (5.6%) had low-grade sepsis. The mortality rate in the high-grade sepsis group was 4.5%, whilst the mortality rate in the low-grade sepsis group was 1%. The scores with the greatest accuracy in predicting mortality were qSIRS (AUROC 0.731, 95% CI 0.68-0.78), followed by SIRS (AUROC 0.70, 95% CI 0.65-0.75). The qSOFA and qSOFA L were the least accurate in predicting mortality (AUROC 0.684, 95% CI 0.63-0.74 for both). The addition of lactate had no significant effect on the accuracy of the five scores in predicting mortality. Patients with a qSOFA ≥ 2 have an increased risk of dying (OR 5.8), as do patients with a SIRS score ≥2 (OR 2.7). qSIRS L had the highest sensitivity (69%) in predicting the presence of high-grade surgical sepsis, followed by qSIRS (65.5% sensitivity). qSOFA showed a very low sensitivity of only 4.5% and a high specificity of 99.2%. The addition of lactate to the score marginally improved the sensitivity. Lactate of 2mmol/L or more was also an independent predictor of high-grade sepsis. CONCLUSION: The qSIRS score is most accurate in predicting mortality in surgical sepsis. The qSOFA score is inferior to both the SIRS and the qSIRS scores in predicting mortality. The qSIRS score with the addition of lactate to the qSIRS score made it the most sensitive score in predicting high-grade surgical sepsis.

The Hybrid Electronic Medical Registry Allows Benchmarking of Quality of Trauma Care: A Five-Year Temporal Overview of the Trauma Burden at a Major Trauma Centre in South Africa.

INTRODUCTION: This study is a five-year follow-up of previously published review of the trauma workload at our institution. It aims to provide evidence about the quality of trauma care delivered by a major academic trauma service in South Africa to provide a temporal analysis of trauma trends in the city of Pietermaritzburg. MATERIALS AND METHODS: All trauma patients admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS) for the period December 2012-April 2018 were retrieved from the Hybrid Electronic Medical Registry (HEMR) for analysis. RESULTS: Over the five-year period, a total of 8722 trauma patients were admitted to Grey's Hospital. There were 7242 (83.0%) males. The average age was 29.66 years. A total of 1719 (19.7%) patients less than 19 years of age, 377 (4.3%) older than 60 years of age and 1480 (17.0%) female patients were admitted following trauma. Table 3 breaks down the mechanism of trauma. A total of 5027 patients sustained blunt trauma (57.6%), and 3334 (38.5%) sustained penetrating trauma. A total of 4808 patients sustained intentional trauma implying that 55.1% of all trauma was secondary to grievous bodily harm or assault either in the form of a stab wound or GSW or of an assault. There was a total of 2232 road traffic-related incidents, of which 37.9% (845) were pedestrian victims. The mortality rate for all trauma admissions was 4.5% (396). Of these 396 deaths, 64 (16.2%) were classified at the morbidity and mortality conference as being avoidable. CONCLUSIONS: The HEMR has allowed us to track the burden of trauma presenting to our institution over a five-year period. This confirms previous studies over shorter time periods from our institution. The pattern of trauma has remained consistent, and the previously described high levels show no sign of decreasing. Interventions to try and reduce this burden are urgently required.

Can We Train Military Surgeons in a Civilian Trauma Center?

INTRODUCTION: The objective of this study was to review the trauma workload and operative exposure in a major South African trauma center and provide a comparison with contemporary experience from major military conflict. MATERIALS AND METHODS: All patients admitted to the PMTS following trauma were identified from the HEMR. Basic demographic data including mechanism of injury and body region injured were reviewed. All operative procedures were categorized. The total operative volume was compared with those available from contemporary literature documenting experience from military conflict in Afghanistan. Operative volume was converted to number of cases per year for comparison. RESULTS: During the 4-year study period, 11,548 patients were admitted to our trauma center. Eighty-four percent were male and the mean age was 29 years. There were 4974 cases of penetrating trauma, of which 3820 (77%) were stab wounds (SWs), 1006 (20%) gunshot wounds (GSWs) and the remaining 148 (3%) were animal injuries. There were 6574 cases of blunt trauma. The mechanism of injuries was as follows: assaults 2956, road traffic accidents 2674, falls 664, hangings 67, animal injuries 42, sports injury 29 and other injuries 142. A total of 4207 operations were performed. The volumes per year were equivalent to those reported from the military surgical literature. CONCLUSION: South Africa has sufficient burden of trauma to train combat surgeons. Each index case as identified from the military surgery literature has a sufficient volume in our center. Based on our work load, a 6-month rotation should be sufficient to provide exposure to almost all the major traumatic conditions likely to be encountered on the modern battlefield.

Lessons learnt from the Pietermaritzburg experience with damage control laparotomy for trauma.

INTRODUCTION: The modern concept of damage control surgery (DCS) for trauma was first introduced less than three decades ago. This audit aims to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to distil the pertinent teaching lessons from this experience. METHODS: All patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry of the Pietermaritzburg Metropolitan Trauma Service, South Africa. Physiological parameters and visceral injuries were assessed. Statistical analysis was performed using STATA V.15.0. RESULTS: A total of 562 patients underwent trauma laparotomy during the period under review. The mechanism was penetrating trauma in 81% of cases (453/562). A great proportion of trauma victims were male (503/562, 90%), with a mean age of 29.5±10.8. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. Out of the 99 who required DCS, there were 32 mortalities (32%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28±0.15) with a raised lactate (5.25 mmol/L±3.71). Our primary repair rates for enteric injuries were surprisingly high. CONCLUSION: Just under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient.

High-grade renal trauma in children and adolescents can be successfully managed non-operatively.

BACKGROUND: This paper reviews our experience with management of renal injuries in children and adolescents with a focus on the outcome of non-operative management (NOM). METHODS: Retrospective review of the clinical characteristics, injury grade (I-III, low grade and IV and V high grade), management and outcomes of children ≤ 18 years old with renal trauma presenting to a major trauma centre in South Africa between December 2012 and October 2020. RESULTS: Sixty-one children with a renal injury were identified with a median age of 13 (range 0-18) years. Forty-five were boys; blunt and penetrating mechanisms of trauma were sustained by 55 (90%) and six (10%) children, respectively. The median American Association for the Surgery of Trauma (AAST) grade of renal injury was 3 (range 1-5): this included eight (13%) with grade I, six (10%) with grade II, 17 (28%) with grade III, 20 (46%) with grade IV and 10 (16%) with grade V injuries. Forty children (66%) were successfully managed non-operatively and 21 required a laparotomy; of these six (28%) required nephrectomy. The overall renal salvage rate was 55/61 (90%). Children who required laparotomy were significantly more likely to have sustained a penetrating mechanism of injury (24% vs 2%) and have greater length of hospital stay (median 9 vs 3 days) compared to children managed non-operatively (p < 0.05). Children who underwent a nephrectomy had a significantly greater length of hospital stay (median 9 vs 4 days, p = 0.03); however, their demographics, outcomes developed complications. Two children (3%) died; one managed non-operatively and one with a laparotomy. CONCLUSION: Paediatric renal trauma can be successfully managed non-operatively in over two-thirds of cases in this middle-income country. High grade of renal injury does not absolutely predict need for surgery or nephrectomy and can be managed non-operatively.

A ten year review of civilian iliac vessel injuries from a single trauma centre.

OBJECTIVE: To report the surgical management and outcome of iliac vessel (IV) injuries in a civilian trauma centre with a high incidence of penetrating trauma. DESIGN, PATIENTS AND METHODS: A retrospective record review of patients with IV injuries treated between January 2000 and December 2009. RESULTS: Sixty nine patients, 59 with gunshot wounds, sustained 108 iliac vessel injuries. Mean revised trauma and injury severity scores was 7.06 and 28.4, respectively. Twenty nine patients required damage control laparotomy. Common or external iliac arteries were repaired by primary repair (10), temporary shunt with delayed graft (6), interposition graft (5) or ligation if limb non-viable (3). Forty-seven patients had injuries to the common or external iliac vein, 42 were ligated. Mortality was 25% and 6 survivors required amputation. CONCLUSIONS: In a stable patient a primary arterial repair is preferred but a temporary shunt can be a life and limb saving option in the unstable patient. Ligating the common or external iliac veins is associated with a low incidence of prolonged leg swelling.

Striking a balance between usability and quality control in electronic health records.

BACKGROUND: This project is the first formal usability review of the hybrid electronic medical registry (HEMR) since its implementation in 2012. METHODS: A synchronous usability evaluation by novice operators was followed by a survey of veteran users. The usability evaluation was done by moderated think-aloud interview while completing tasks for a mock patient. The veteran survey was paper-based and focused on satisfaction of the system. RESULTS: A total of 141 comments on system errors were identified by the novice doctors. These consisted of 123 unique problems, of which three were hardware faults and were thus excluded. The identified issues were categorised into errors of control (27%), minimalist (21%), error (17%), match (13%), flexibility, visibility and consistency (9% each), and history (4%). Every unique usability violation was evaluated by the three experts who agreed that 82 of the 141 errors (58%) were valid and applicable. The other 59 items were rejected, not only because of the inability to reproduce some errors or programme shortcomings, but also because a series of "hurdles" were purposely included in the software to decrease cognitive dissonance and reduce error by the users. The survey of veteran users showed high levels of contentment with the system with regards to efficiency, satisfaction and preference. CONCLUSION: Despite many usability complaints by novices, almost half of them were rejected. Although usability in electronic health systems is important, it can often be sacrificed for more imperative aims such as safety, error filtering and clinical decision support.

Management of penetrating thoracic trauma with retained knife blade: 15-year experience from a major trauma centre in South Africa.

INTRODUCTION: This study reviews our experience with the management a retained knife in the setting of thoracic stab wounds. METHODS: A retrospective study was conducted at a major trauma in South Africa over a 15-year period from January 2004 to December 2018. RESULTS: There were 40 patients, of whom 37 were males (93%). Median age was 24 years; 78% of cases (31 of 40) were a retained knife and 23% (9 of 40) were a retained blade. The locations of the stab wounds were 19 (48%) anterior and 21 (53%) posterior. Plain x-ray was performed in 85% (34) of patients and computed tomography angiography was performed in 85% (34). Six patients had haemodynamic instability and were expedited to the operating room without further imaging. Three of these had cardiac tamponade and three a massive haemothorax. Simple extraction and wound exploration were performed in 58% (23 of 40) of cases and the remaining 43% (17 of 40) required operative exploration and extraction. The operative approach was anterolateral thoracotomy in nine cases, posterolateral thoracotomy in four and median sternotomy in three cases. One patient required extraction and concurrent vertebral laminectomy due to cord compression. Twelve patients (30%) experienced complications (nine wound sepsis and three hospital-acquired pneumonia). There was one mortality (3%). The median length of hospital stay was 6 days. CONCLUSION: Uncontrolled extraction of a retained thoracic knife outside the operating room must be avoided. An unstable patient should proceed directly for operative exploration. For stable patients, cross-sectional imaging will allow for planned extraction in operating room.

An audit of trauma laparotomy in children and adolescents highlights the role of damage control surgery and the need for a trauma systems approach to injury in this vulnerable population.

BACKGROUND: This study reviews the indications and outcome of emergency laparotomy for paediatric trauma in a South African trauma centre. METHODS: This was a retrospective study of all children less than 18 years of age who underwent an emergency laparotomy for trauma between December 2012 and October 2020 at Grey's Hospital in Pietermaritzburg. RESULTS: During the eight-year period under review, a total of 136 children of which 107 were male underwent a laparotomy for trauma. The median age was 14 years. There were 80 (57.1%) blunt mechanisms, and the rest were penetrating mechanisms. A total of 46 (33%) patients required ICU admission. Thirty-four patients developed a complication. These included nine cases of pneumonia, one case of renal failure, two patients developed abdominal collections, three woundrelated complications, three neurological complications and one miscellaneous complication. There were seven (5%) deaths. The penetrating cohort were older than the blunt cohort. Solid viscera were more likely to be injured in the blunt cohort and hollow viscera more likely in the penetrating cohort. A total of 16 (11%) patients underwent damage control surgery (DCS). Of this cohort, there were three female children. Six sustained blunt trauma and ten penetrating trauma. A total of six (37%) of these children died. CONCLUSION: Emergency laparotomy for trauma in children is not infrequent in Pietermaritzburg and there is a high incidence of penetrating trauma in this cohort. The response to increased degrees of physiological derangement is the application of DCS. Ongoing efforts to develop and strengthen a paediatric trauma service appear to be justified.

The management of ocular and peri-ocular trauma needs to be co-ordinated according to ATLS principles and requires multi-disciplinary collaboration.

INTRODUCTION: This project set out to focus on ocular (globe) and peri-ocular trauma and to describe the spectrum of injuries seen in a busy South African trauma unit and to document their management and outcome. RESULTS: During the period November 2012 to April 2020, a total of 12 115 patients were managed by the Pietermaritzburg Metropolitan Trauma Service (PMTS) at Greys Hospital in Pietermaritzburg, South Africa. Of these 2194 (11%) sustained ocular or peri-ocular injury. Of these 2194 patients, 1069 (83%) were male. 83% of injuries (n=1076) were classified as primarily blunt injury and 17% as a primarily sharp/penetrating mechanism. A substantial number of patients required a life-saving emergency intervention. These included resuscitation in 242 cases (19%) and active airway intervention was in 290 (22%). In total 919 (71%) patients required urgent surgery to the peri-ocular region. Slightly over half (55%) of these the surgery was performed by a single discipline. The rest needed procedures by two or more disciplines. The disciplines involved included ophthalmology, maxillofacial, plastic, ENT and neurosurgery. Plastic surgery was involved in 683 cases (53%). A total of 341 distant surgeries were required - These included orthopaedic operations, laparotomy and vascular operations. Of the 1294 cases in this study, 42 (3%) died before discharge and 99 (8%) were discharged with a GCS lower than 10. The primary skill set for management of these injuries is identified. CONCLUSION: Although the management of immediate life and organ threatening injuries takes priority, ocular and peri-ocular trauma may damage a number of important structures and their comprehensive management requires a multi-disciplinary team of specialists or, in austere environments, a font-line medical team with a diverse skill set.

The spectrum of blunt abdominal trauma in Pietermaritzburg.

BACKGROUND: This study reviews the Pietermaritzburg Metropolitan Trauma Service (PMTS) experience with the management of blunt abdominal trauma (BAT). METHODS: A retrospective review of the hybrid electronic medical registry (HEMR) between December 2012 and September 2019 was conducted. All patients admitted following BAT were included. RESULTS: During the study period, 1 123 BAT patients were managed by the PMTS. The mean age was 29.19 years (SD 14.03). Of these admissions, 73.6% were male. The most common mechanism was road traffic crashes (RTCs) - 435 motor vehicle collisions (MVCs) and 250 pedestrian vehicle collisions (PVCs). There were 186 assaults, 118 falls, 62 community assaults, 22 accidents related to agriculture, construction or industry, 11 sporting injuries, nine animal injuries, seven patients injured by falling objects, five injured by trains, two hangings, one burn-related fall and two other causes. The mechanism of injury was unknown in 22 cases. There were 445 abdominal CT scans and 270 whole body CT scans. Surgical management was required for 395 patients. There were 259 index laparotomies and 176 repeat laparotomies. Four patients underwent selective arterial embolisation. Laparoscopy was undertaken in ten, and subsequently converted to laparotomy in five. There were 106 orthopaedic operations. Hospital stay ranged from 0-155 days (median stay three days). ICU admission was required in 24.9% of patients. The mortality rate was 7.5%. CONCLUSION: BAT is common in South Africa. Whilst the vast majority of patients require non-operative treatment, a welldefined subset require a laparotomy. Imaging is central to the management of patients with BAT.

Childhood and adolescent trauma in Pietermaritzburg is a neglected sub-epidemic within a larger epidemic and warrants a dedicated service.

BACKGROUND: This study reviews our experience with paediatric trauma to help plan and strengthen ongoing strategies to deal with trauma in our region. METHODS: All children and adolescents less than 18 years of age who were admitted to our centre following trauma between December 2012 and October 2020 were reviewed. RESULTS: Over the 8-year period, 2 091 children were admitted with trauma to Grey's Hospital. There were 1 479 (71%) male patients, median age: 10 years. One thousand four hundred and fifty-eight (70%) patients were referral from rural regions. In 1 597 (76%) patients, the mechanism of injury was blunt trauma. A total of 387 (19%) patients underwent a surgical intervention, whilst 1 641 (78%) patients were managed non-operatively. In 63 patients, management records were missing. Multiple patients required multiple surgical procedures. A total of 144 patients had a laparotomy, 70 a soft tissue debridement procedure, 40 an orthopaedic procedure, 53 a neurosurgical procedure, which included 37 patients who underwent craniotomy, and 18 patients underwent a fasciotomy for compartment syndrome. There were 82 patients who required miscellaneous procedures. A total of 213 (10%) patients required ICU admission. There were 48 (2.3%) deaths. CONCLUSION: The volume of child and adolescent trauma managed is significant and suggests that a dedicated paediatric trauma service in the region is warranted. It is hoped that future partnering with appropriate stakeholders will allow this service to continue to mature and provide leadership in all aspects of care of injured children in the region.

A review of blunt pelvic injuries at a major trauma centre in South Africa.

BACKGROUND: The collective five-year experience with the acute management of pelvic trauma at a busy South African trauma service is reviewed to compare the usefulness and applicability of current grading systems of pelvic trauma and to review the compliance with current guidelines regarding pelvic binder application during the acute phase of resuscitation. METHODS: A retrospective review was conducted over a 5-year period from December 2012 to December 2017 on all polytrauma patients who presented with a pelvic fracture. Mechanism of injury and presenting physiology and clinical course including pelvic binder application were documented. Pelvic fractures were graded according to the Young- Burgess and Tile systems. RESULTS: There was a cohort of 129 patients for analysis. Eighty-one were male and 48 female with a mean age was 33.6 ± 13.1 years. Motor vehicle-related collisions (MVCs) were the main mechanism of injury (50.33%) and pedestrian vehicle collisions (PVCs) were the second most common (37.98%). The most common associated injuries were abdominal injuries (41%), chest injury (37%), femur fractures (21%), tibia fractures (15%) and humerus fracture (14.7%). Thirty patients in this cohort (23%) underwent a laparotomy. They were mainly in the Tile B (70%) and lateral compression (63%) groups. Nine patients underwent pelvic pre-peritoneal packing. Thirty-five (27%) patients were admitted to ICU. Fifteen (12%) patients died. The Young-Burgess classification had a greater accuracy in predicting death than the Tile classification. Forty per cent of deaths occurred in ICU, 33% died secondary to a traumatic brain injury (TBI). Twenty per cent died in casualty and 6.6% in the operating room from ongoing haemorrhage. A pelvic binder was not applied in 66% of patients. In the 34% of patients who had a pelvic binder applied, it was applied post CT scan in 24.8%, in the pre-hospital setting in 7.2%, and on arrival in 2.4% of patients. In 73% of deaths, a binder was not applied, and of those deaths, 54% showed signs of haemodynamic instability. CONCLUSION: It would appear that our application of pelvic binders in patients with acute pelvic trauma is ad hoc. Appropriate selection of patients, who may benefit from a binder and it's timely application, has the potential to improve outcome in these patients.

Trauma patterns during the COVID-19 lockdown in South Africa expose vulnerability of women.

BACKGROUND: Trauma care places a significant burden on the South African (SA) healthcare system, and this has not changed significantly in recent history. We speculated that the COVID-19 lockdown regulations (travel restriction and alcohol ban) would affect trauma patterns. OBJECTIVES: To compare the burden and nature of trauma over the COVID-19 lockdown period with the equivalent period over the past 5 years using routinely collected data from the Pietermaritzburg Metropolitan Trauma Service in KwaZulu-Natal Province, SA. METHODS: All trauma patients admitted to Grey's Hospital in Pietermaritzburg between 23 March 2015 and 31 May 2020 were identified and reviewed. RESULTS: A total of 8 859 trauma patients were admitted over the 6-year period, with a total of 1 676 admitted during the periods 23 March - 31 May. These 1 676 formed the study cohort. Of these patients, 998 had sustained blunt trauma, 665 penetrating trauma, and 13 a combination of blunt and penetrating trauma. A total of 14 categories of blunt trauma were reviewed, of which the three most common were assault, motor vehicle accidents (MVAs) and pedestrian vehicle accidents (PVAs). Between 23 March and 31 May 2020, a total of 23 patients were victims of blunt assault. The median number of assault victims over the equivalent period during the previous 5 years was 48. The 5 preceding years had a median of 56 MVAs and 33 PVAs, compared with 23 and 10 during the lockdown. The median number of gunshot wound (GSW) victims for the preceding years was 41, compared with 30 during the lockdown. During the lockdown, 24 stab wound victims were admitted, compared with a median of 73 for the preceding years. The proportion of females who sustained penetrating trauma and blunt assault increased significantly during the lockdown. The proportion of females sustaining a GSW or blunt trauma secondary to an MVA remained constant. CONCLUSIONS: The study showed that during the period of lockdown in SA there was a significant decrease in MVAs, PVAs and interpersonal violence. Assaults involving a knife seemed to decrease dramatically, but the rate of GSWs remained constant.

Penetrating trauma in children and adolescents in Pietermaritzburg.

BACKGROUND: This project aims to review the spectrum and outcome of penetrating trauma in children and adolescents with the objective of defining the extent of the problem and of developing strategies to reduce the incidence and severity of this form of trauma. METHODS: All patients less than eighteen years of age who were admitted to the Pietermaritzburg Metropolitan Trauma Service (PMTS) following penetrating trauma between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry (HEMR). RESULTS: During the five-year period under review, a total of 164 patients less than eighteen years of age sustained penetrating trauma and were admitted to the PMTS. There were 138 males and 26 females. The mean age was 13.29 years and the median age 15 years. There were 70 stab wounds (SW) and 73 gunshot wounds (GSW). There were 21 non-intentional impalement injuries. The mean ISS was 9.04 and the median was 9. A total of 155 plain X-rays were performed, 50 CT scans and 51 CT angiograms in this cohort of patients. Only two ultrasound examinations were performed. A total of 76 patients required an operation, which included 50 laparotomies. Of the patients who underwent a laparotomy, 18 required a repeat laparotomy. There were 46 other procedures undertaken in this cohort of patients, which included two thoracotomies, three laparoscopies and two thoracotomies. The median hospital stay was 2 days and 17 (10%) patients required ICU admission and 7 (4%) died. CONCLUSION: Penetrating trauma in children and adolescents is associated with significant mortality and morbidity. There are similarities with the management of these injuries in adults, but further work is required to ensure that paediatric management algorithms are evidence based.

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.

Complications of local anaesthesia. An observational study.

OBJECTIVES: Local anaesthesia is increasingly used by dental hygienists. As little is known about the incidence of adverse effects during and after the administration of local anaesthetics, we evaluated side-effects associated with local anaesthesia. METHODS: A prospective observational study was conducted using standard criteria among a group of 103 patients receiving mandibular block anaesthesia. RESULTS: Physical reactions like clenching fists (14.5%), moaning (12.6%) and turning pale (7.8%) were frequently observed. Patients (3.8%) showed a painful reaction because of needle contact with a nerve or the periosteum. Systemic complications were not observed. After the injection, 41.7% said they felt tense during the administration; 4.9% of the patients reported swallowing problems and 3.9% a tachycardia. CONCLUSIONS: These results suggest that administration of local anaesthesia has a small risk of adverse events. Complications, if they occur, seem minor and transient in nature.

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.

Trauma electives in South Africa provide valuable training for international surgeons.

BACKGROUND: Trauma electives in South Africa (SA) are common and many foreign-based surgeons have undertaken such electives over the past 3 decades. Despite this, little academic attention has been paid to these electives, which remain largely informal and unstructured. This project aims to redress this deficit. OBJECTIVES: To investigate and document the extent of trauma clinical electives and to assess their impact on the careers of foreign surgeons who have undertaken such electives. METHODS: A mixed methods-style questionnaire was compiled, which sought to document the demographics of surgeons undertaking an SA trauma clinical elective, the trauma clinical experience they had prior to the elective, as well as the volume of experience they acquired during the elective. RESULTS: Sixty questionnaires were sent out and 21 were completed. There were 16 male and 5 female respondents. Only 17 had undertaken a formal trauma rotation before their elective in SA. The mean number of major resuscitations managed prior to rotating through surgery departments in SA was 15, and the mean number managed during a 12-month rotation in SA was 204. It would take each respondent 14 years in their country of origin to acquire an equivalent level of exposure to major resuscitation. During the year before their elective, each surgeon had been exposed to a mean number of the following: 0.5 gunshot wounds (GSWs), 2 stab wounds (SWs), 0.1 blast injuries and 19 road traffic accidents (RTAs). The equivalent mean number for their year in SA was 106 GSWs, 153 SWs, 4 blast injuries and 123 RTAs. The time necessary to achieve a similar level of exposure to their SA experience if they had remained in their country of origin was 213 years for GSWs, 73 years for SWs, 41 years for blast injuries and 7 years for RTAs. Compared with their SA elective, it would take each respondent 3 years to insert as many central venous lines, 9 years to perform the same number of tube thoracostomies, 9 years to manage as many surgical airways, 18 years to explore as many SWs of the neck and 93 years to explore as many GSWs of the neck. Furthermore, it would take 33 years to see and perform as many laparotomies for SWs to the abdomen, 374 years to perform an equivalent number of GSWs to the abdomen and 34 years of experience to perform as many damage-control laparotomies in their countries of origin. In terms of vascular trauma, it would take 23 years to see as many vascular injuries secondary to SWs and 77 years to see an equivalent number of vascular injuries secondary to GSWs. CONCLUSIONS: A trauma clinical elective in SA provides an unparalleled exposure to almost all forms of trauma in conjunction with a well-developed academic support programme. Formalising these trauma electives might allow for the development of exchange programmes for SA trainees who wish to acquire international exposure to advanced general surgical training.

Quantifying the burden of trauma imaging on the CT scan service at a major trauma centre in South Africa.

BACKGROUND: Imaging is an integral part of trauma management and the huge burden of trauma in South Africa places substantial pressures on radiology resources. This study aims to provide a holistic overview of the burden of trauma imaging and the cost of trauma to a busy CT scanning facility at a tertiary hospital in South Africa. METHOD: We set out to describe and quantify the impact of blunt poly-trauma on CT scanning services at Grey's Hospital in Pietermaritzburg. We aimed to provide a holistic assessment in terms of use of equipment and staff, cost to the hospital and overall usage of CT scanning. RESULTS: Over the four-year study period, 1572 patients required a CT scan following blunt torso trauma (mean age: 30 years, 81% males). Of the 1572 patients, 625 had a chest radiograph (40%), 383 a cervical spine X-ray (24%), 347 a pelvic X-ray (22%), 292 a skull X-ray (18%), 193 a limb X-ray (12%), 133 an abdominal radiograph (8%), and 86 a FAST scan (5%). The 1572 CT included: 967 head, 568 neck, 65 chest, 241 abdominal, 228 pelvic, 12 upper limb, 38 lower limb and 394 had full body (Pan) CT scan. The mean total cost of the CT scanning for blunt poly-trauma is ZAR 12 000. The total cost of CT scanning for blunt poly-trauma is 0.92% of the total hospital expenditure. Roughly 7.8% of the total hours worked by the CT scanner over the time period under review was dedicated to blunt poly-trauma. CONCLUSION: Blunt poly-trauma is a preventable disease, which has a major financial impact on the healthcare system in general. This study has documented the tremendous burden it places on an already stretched CT scanning service.