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Background: The phenomenon of extrajudicial "mob justice" and community assault (CA) has been documented in news reports and anecdotes from a number of low- and middle-income countries, but there is little literature on its burden on trauma systems. This study reviews a single center's management of CA victims and compares the spectrum of injuries seen following mob assault with those sustained via other forms of interpersonal violence (IPV).Methods: Clinical data, injury details, and mortality among injured patients (age≥18) hospitalized in a South African tertiary referral center from 2012-2018 were abstracted. Patients with penetrating injury or missing ISS were excluded. CA was determined at time of admission by either self-designation or by patients' escorts. Univariate analyses compared the presentation and outcomes for CAs and non-CAs.Results: Overall, CA constituted 5% of total trauma admissions and 8% of IPV-related admissions during the study period. Of 1,323 incidents of blunt injury following IPV, 239 (18%) were CAs. One in two CA victims (n=119, 50%) were struck by an identifiable weapon. Patients injured in CA were more frequently male (97% vs 85%), presented with ISS>15 (28% vs 21%), and had a shock index>0.9 (25% vs 19%) compared to non-CA (all p<0.001). Rates of operative intervention, ICU admission, and mortality did not differ (all p>0.05). CAs were more likely to be complicated by acute kidney injury (9% vs 1%, p<0.001) but less likely to involve neurologic complications (3% vs 10%. P<0.001) compared to non-CAs. Acute kidney injury in CA showed a pattern of significant musculocutaneous injury with rhabdomyolysis.Conclusion: CA contributes considerably to the high rates of IPV in a single South African center. Victims of such assaults sustain more severe injury with unique mechanisms and subsequent complications. This evidence supports the need to strengthen local governance and improve law enforcement efforts to prevent such violence. [ABSTRACT FROM AUTHOR]

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

Introduction: Penetrating gastric injury (PGI) is common and although primary repair is sufficient for most injuries, several areas surrounding the peri-operative management remain contentious. This study reviews our experience in the management of PGI and review the clinical outcome at a major trauma centre in South Africa.Materials and Methods: A retrospective study was conducted from January 2012 to April 2020 at a major trauma centre in South Africa.Results: 210 cases were included (184 male, median age: 30 years). Mechanism of injury was 59% stab wounds (SWs) and 41% gunshot wounds (GSWs). The AAST grade was predominantly (92%) grade 2 for all cases. 20% (41/210) were isolated gastric injuries. All cases underwent primary repair and there were no cases of suture line failure. Eleven cases (5%) had one or more injuries not identified at the index laparotomy: 7 were unidentified gastric injuries and the remaining 4 were unidentified non gastric injuries. There was no association between unidentified injuries and mechanism of injury or outcome. Fifty-seven (27%) cases experienced one or more complications. Eighty-two cases (39%) required intensive care unit admission. The overall median length of hospital stay was 7 (IQR 4-11) days. The overall mortality was 14%. GSW injuries were more likely to have additional organ injury, higher ISS and PATI scores, longer length of hospitalization, higher likelihood of ICU stay, greater morbidity and mortality than SW injuries. There was a slight increase in the wound sepsis rate as number of associated extra gastric injuries increased but this was not statistically significant. There was no difference in wound overall sepsis rate between SW and GSW injuries (2% vs 8%, p=0.121).Conclusions: Primary repair alone is sufficient for most PGI, but laparotomy is associated with high incidence of unidentified injury and surgeons must to be cognisant of the likelihood of these occult injuries. [ABSTRACT FROM AUTHOR]

Introduction: Gallbladder trauma is a rare injury. This study aimed to describe the significance of these injuries and the appropriate management strategies.Methods: A retrospective study was undertaken at a major trauma centre in South Africa and included all patients diagnosed with a gallbladder injury between January 2012 and October 2020.Results: A total of 51 cases were included (88% male, mean age: 38 years), with 44 (86%) penetrating trauma cases [28 stab wounds (SW), 16 sustained gunshot wounds (GSW)]. Of the 7 (13%) blunt trauma cases, five were involved in a motor vehicle crash, and two were injured via assault. All patients underwent laparotomy. Full-thickness gallbladder laceration or perforation was the most common type of injury (84%) and all patients with a gallbladder perforation or laceration had a cholecystectomy at index operation. Two out of 5 patients with a gallbladder contusion were managed conservatively without a cholecystectomy and the remaining three had evidence of gallbladder necrosis which were managed with cholecystectomy. Associated extrahepatic bile duct injuries occurred in 4% of cases, and 18 cases (35%) required intensive care unit (ICU) admission. The overall mortality was 8%.Conclusion: Gallbladder injury is rare but when encountered implies a significant degree of trauma. Although cholecystectomy is usually definitive, there is an association with other occult extra-hepatic biliary tract injuries. The severity of the associated injuries usually determines patient outcomes. [ABSTRACT FROM AUTHOR]

• Primary repair is increasingly being used to manage rectal injuries, however, faecal diversion remains the main stay of rectal trauma management in our environment. • Rectal injuries are associated with high levels of morbidity such as sepsis and urogenital complications. • Rectal injury must be actively excluded in patients sustaining penetrating injuries to the pelvis, buttocks, perineal, or inguinal region or those who have experienced significant blunt trauma to the pelvis and perineum. This paper provides an overview of a single centre's experience with rectal injury over a decade. It hopes to use this data to provide context to our current approach to managing these injuries in the civilian setting. All patients with rectal trauma were identified from the Hybrid Electronic Medical Registry (HEMR). During the study period, a total of 88 patients with rectal injuries were admitted to Grey's Hospital in Pietermaritzburg. There were 80 (91 %) males and 8 (9 %) females. The median age was 31 (15–63) years. There were 9 (10 %) blunt mechanisms, 76 (86 %) penetrating mechanisms and 3 (4 %) combined blunt and penetrating mechanisms. Gunshot wounds accounted for the majority of sustained rectal trauma (71 %). There were 57 (65 %) extra-peritoneal injuries, 24 (27 %) intraperitoneal injuries and 7 (8 %) combined injuries. The grade of injury, according to the AAST grading system, was as follows, AAST 1: 16 (18 %), AAST 2: 63 (72 %), AAST 3: 7 (8 %), and AAST 4: 2 (2 %). Pre-sacral drainage and distal rectal washout were not performed. Almost all (55/57) of the extra-peritoneal rectal injuries were managed with proximal diversion (PD). There were five primary repairs (PR) performed in the extra-peritoneal rectal injury cohort. In four of these cases, this was accompanied by a PD. Of the 24 intraperitoneal rectal injuries, 15 underwent PR, of which 11 were performed in conjunction with PD. In total, 20 intraperitoneal rectal injuries underwent PD. All seven combined rectal injuries underwent PD, and three of the combined rectal injuries underwent PR with PD. There was urogenital tract associated morbidity in 8 %, gastrointestinal tract related morbidity in 8 % and septic complications in 11 %. Rectal trauma is still associated with a high rate of rectal/urogenital and infection related morbidity. Although pre-sacral drainage and distal stump washout have been largely abandoned in civilian practice, faecal diversion currently remains the cornerstone of the management of rectal trauma in our environment. Although there was a low rate of intra-abdominal septic complications in patients who had undergone diversion, this needs to be balanced against the low rate of stoma reversal. [ABSTRACT FROM AUTHOR]

• Thoracoabdominal gunshot wounds continue to be associated with significant morbidity and mortality in comparison with isolated chest or abdominal trauma. • There is ongoing confusion around the management of thoracoabdominal gunshot wounds due to the complexity of clinical decision-making regarding the use of CT imaging prior to cavity-opening. This is further complicated by having to decide which cavity to prioritize first. • The use of CT imaging allows for increased use of minimalistic and non-operative approaches to the management of thoracoabdominal gunshot wounds. The management of thoracoabdominal (TA) gunshot wounds (GSW) remains challenging. This study reviewed our experience with treating such injuries over a decade. A retrospective study was conducted at a major trauma centre in South Africa over a ten-year period from December 2012 to January 2022. Two hundred sixteen cases were included (male: 85 %, mean age: 33 years). Median RTS: 8 and median ISS: 17 (IQR: 10–19). The mean value of physiological parameters: Heart Rate (HR): 98/min, Systolic Blood Pressure (SBP): 119 mmHg, Temperature (T): 36.2 °C, pH: 7.35, Lactate 3.7 mmol/l. Ninety-nine (46 %) underwent a CT scan of the torso. One hundred fifty-four cases (69 %) were managed operatively: thoracotomy only [5/154 (3 %)], laparotomy only [143/154 (93 %)], and combined thoracotomy and laparotomy [6/154 (4 %)]. Those who had surgery following preoperative CT had a lower rate of dual cavity exploration (2 % vs 4 %, p = 0.51), although it did not reach statistical significance. The overall morbidity was 30 % (69). 82 % required intensive care (ICU) admission. The mean length of hospital stay was 14 days. The overall mortality was 13 % (28). Over the 10-year study period, there was a steady increase in the number of cases of TA GSWs managed at our institution. Over the study period, an increasing use of CT was noted, along with a steady reduction in the proportion of operations performed. Thoraco-abdominal GSWs remain challenging to manage and continue to be associated with significant morbidity and mortality. The increased use of CT scans has reduced the degree of clinical confusion around which body cavity to prioritize, leading to an apparent decrease in dual cavity exploration, and has allowed for the increased use of minimalistic and non-operative approaches. [ABSTRACT FROM AUTHOR]

Introduction: The management of rectal trauma remains controversial. There are three modalities which have been used to manage these injuries; proximal diversion (PD), washout of the distal rectum (DRW) and presacral drainage (PSD). The EAST group tentatively advocate mandatory proximal diversion for extraperitoneal rectal injuries and omitting DRW or PSD. Other authors have suggested that diversion can be eschewed in patients with an intraperitoneal injury which can be primarily repaired. In light of all these controversies, this project set out to review our experience with rectal injuries over the last seven years with the objective of reviewing our use of PD, PSD and DRW.Methods: Patients aged greater than or equal to 15 years with rectal injuries during December 2012 to July 2019 were included. Patient demographics, mechanism of injury, management strategy (operative or non-operative), complications, patient residential status (urban or rural), hospital and intensive care duration of stay, and 30-day mortality rates were assessed.Results: During the study period, a total of 51 patients with a rectal injury were treated. There were 45 (88%) males and the median age was 29 (22-39) years. There were 7 (14%) blunt mechanisms, 41 (80%) penetrating mechanisms and 3 (6%) combined blunt and penetrating mechanisms. The median ISS was 13 (9-18). Of the 50 rectal injuries ultimately treated at our institution, there were 31 extraperitoneal and 14 intraperitoneal injuries. There were five combined intra and extraperitoneal injuries. A total of 21 rigid sigmoidoscopies and a single flexible sigmoidoscopy were performed. A total of 24 patients underwent a CT scan. There were 13 primary repairs and 45 PD. A single patient required a PSD. Of the 34 documented complications, 15 (44%) were related to sepsis and can be attributed to the rectal injury. The overall mortality rate was 11.8%.Conclusions: Rectal injuries are associated with significant septic related morbidity and mortality. Although we have begun to avoid diversion in a small subset of patients with an intraperitoneal injury, we continue to perform PD for the vast majority of patients with a rectal injury. We do not perform DRW and PSD is used in highly selective cases. [ABSTRACT FROM AUTHOR]

Introduction: Pneumoperitoneum on chest radiograph (CXR) following abdominal stab wounds (SW) is generally considered as surrogate evidence of viscus perforation and an absolute indication for laparotomy. The exact yield of this radiographic finding is unknown.Materials and Methods: A retrospective study was conducted on all patients who presented with abdominal SW with no peritoneal signs but had pneumoperitoneum alone who underwent mandatory laparotomy from December 2012 to October 2020 at a major trauma centre in South Africa.Results: During the 8-year study period, 55 patients were included (91% male, mean age: 24 years). Laparotomy was positive in 67% (37/55). Of the 37 positive laparotomies, 28 (76%) were considered therapeutic and the remaining 9 (24%) were nontherapeutic. The negative laparotomy rate was 33%. A total of 52 organ injuries were identified at laparotomy in the 37 positive laparotomies. Twenty-five per cent (14/55) of patients experienced complications. The complication rate of the subgroup of 18 patients who had a negative laparotomy was 33% (6/18). Two per cent (1/55) of all 55 patients required intensive care admission. The mean length of hospital stay was 6 days. There were no mortalities in this cohort.Conclusions: Pneumoperitoneum alone in patients with no peritoneal signs on initial assessment following abdominal SW cannot be considered an absolute indication for operative exploration. Up to one third of patients have no intra-abdominal injuries. This specific subgroup of patients can potentially be managed by a selective non-operative management approach. [ABSTRACT FROM AUTHOR]

Background: The mesentery may be injured in trauma and few grading systems describe mesenteric injury severity. We aimed to develop and validate an intra-operative mesenteric injury grading system.Methods: A modified Delphi technique was used to generate an intraoperative grading system for blunt mesenteric injury called the mesenteric injury score (MIS). We performed a retrospective review (2010-2016) of patients >15 years old with blunt abdominal trauma. Patient demographics, injury severity score (ISS) and mechanism, clinical, operative, and outcome data were abstracted. The intraoperative grading system was used to describe patient outcomes including duration of stay and management approach. We compared the correlation of abdominal abbreviated injury score, Blunt Injury Prediction Score (BIPS) and the MIS with clinical outcomes using Spearman's rho.Results: There were fifty-one patients of which 86% were male. Injury mechanisms included motor vehicle accidents (n = 37, 73%), pedestrian vehicle accidents (n = 7, 13%), assaults (n = 4, 8%), falls (n = 2, 4%), and a single airplane crash (2%). Median [IQR] ISS was 16 [10-25] and GCS at hospital admission was 15 [15-15]. The median [IQR] international normalized ratio was 1.2 [1.1-1.5], lactate was 2.7 [1.7-4.9], and hemoglobin was 11.4 [8.6-12.2]. The distributions of MIS included Grade I (3, 5%), Grade II (10, 20%), Grade III (10, 20%), Grade IV, 5 (10%), and Grade V (23, 45%). Increasing mesenteric injury grade was associated with longer duration of stay, need for bowel resection, and damage control laparotomy.Conclusions: We developed an intra-operative mesenteric injury grading system (MIS) and provided an initial retrospective validation using a series of patients with blunt abdominal trauma. The proposed MIS corresponded with both the AIS and the BIPS. Future study comparing cross sectional imaging and operative findings based on MIS criteria is needed. [ABSTRACT FROM AUTHOR]

Introduction: Organ evisceration following abdominal stab wound (SW) is currently considered as an absolute indication for mandatory laparotomy due to the high incidence of associated intra-abdominal injuries, but literature describing the spectrum of organ injury encountered is limited.Materials and Methods: We reviewed our experience of 301 consecutive patients who were subjected to mandatory laparotomy over an eight-year period at a major trauma centre in South Africa.Results: Of the 301 patients with organ evisceration, 92% were male (mean age: 28 years). Ninety per cent (270/301) of the laparotomies were positive (85% (229/270) therapeutic, 15% (41/270) non-therapeutic). The frequencies of eviscerated organs were small bowel (70%), large bowel (26%), and stomach 3%. Three (1%) patients had combined evisceration of more than one of the above organs. The most commonly injured organs were small bowel and large bowel. The mean length of hospital stay was nine days. Seven patients required intensive care admission. The morbidity rate was 21% and mortality was 2%.Conclusions: The spectrum of injury associated with abdominal SW with organ evisceration is similar to smaller published series. Multiple organ injuries are common. The most commonly eviscerated organs were small bowel, large bowel and stomach, while the most commonly injured organs were small bowel and large bowel. [ABSTRACT FROM AUTHOR]