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Background: The foley catheter balloon tamponade (FCBT) has been widely employed in the management of trauma. This study reviews our cumulative experience with the use of FCBT in the management of patients presenting with a penetrating neck injury (PNI). Methods: A retrospective study was conducted at a major trauma centre in South Africa over a 9-year period from January 2012 to December 2020. All patients who presented with a PNI who had FCBT were included. Results: A total of 1581 patients with a PNI were managed by our trauma centre, and 44 (3%) patients had an FCBT. Of the 44 cases of FCBT, stab wounds accounted for 93% (41/44) and the remaining 7% were for gunshot wounds. Seventy-five per cent of all FCBT (33/44) were inserted at a rural hospital prior to transfer to our trauma centre; the remaining 25% (11/44) were inserted in our resuscitation room. The success rate of FCBT was 80% (35/44), allowing further CT with angiography (CTA) to be performed. CTA findings were: 10/35 (29%) positive, 18/35 (51%) negative, and 7/35 (20%) equivocal. Fifteen patients required additional intervention (open surgery or endovascular intervention). The overall morbidity was 14% (6/44). Eighteen per cent required intensive care unit admission. The median length of stay was 1 day. The overall mortality rate was 11% (5/44). Conclusion: FCBT is a simple and effective technique as an adjunct in the management of major haemorrhage from a PNI. In highly selective patients, it may also be used as definitive management. [ABSTRACT FROM AUTHOR]

Background: This study aimed to review our decade-long experience with the management of abdominal gunshot wounds (GSWs), to document trends in our approach and to develop an evidence base for our contemporary management algorithms in a major trauma in South Africa. Materials and methods: This was a retrospective study that included all adult patients with abdominal GSWs between January 2013 and October 2020 managed at a major trauma centre in South Africa. Result: Five hundred and ninety-six cases were included (87% male, mean age: 32 years). The median Injury Severity Score (ISS) was 12. 52% (309/596) of cases had indications of immediate laparotomy and proceeded directly to the operating room without any CT imaging. Of this cohort, the laparotomy was positive in 292 and in the remainder (5%) was negative. Of the remaining 287 cases, 209 underwent a CT scan (35%). 78 were managed without any CT imaging. Of the 78 who did not undergo CT scan, all were managed without any operation and discharged home well. Of the 209 who underwent CT scan, 99 were observed and only one case in this group subsequently required a laparotomy. The remaining 110 cases underwent a laparotomy, which was negative in 7. There were correlations with increasing use of CT, as well as a decrease in those proceeding directly to laparotomy. The overall morbidity rate was 8% (47/596). 32% (190/596) require intensive care unit (ICU) admission. The overall mortality rate was 8% (67/596). Conclusions: The management of abdominal GSWs has continued to evolve. There is now a well-defined role for selective non-operative management in this group of patients and relies on accurate CT assessment. CT scan is now an important component in the management of abdominal GSW even in our resource-constrained environment. [ABSTRACT FROM AUTHOR]

Background: The use of video-assisted thoracoscopic surgery (VATS) is well established in trauma practice. This modality is readily available to centers with well-equipped operating facilities but may be challenging to introduce into resource-constrained institutions such as many South African township hospitals. We implemented VATS for retained post-traumatic pleural collections in our institution in 2007, and we have now performed an audit of the first 3 years of our experience. Methods: A retrospective chart review was conducted of all patients who had undergone VATS from June 2007 to May 2010, and statistical analysis was performed to elucidate the findings. Results: Forty-three patients were examined, 40 of whom (93 %) were male. The mean age was 32 years (range: 15-52 years). Thirty-five patients (81 %) had stab injuries, 6 (14 %) had blunt injuries, and 2 (4 %) had gunshot wounds. Mean time from injury to VATS was 12.4 days (range: 3-31 days). Thirteen patients (30 %) had empyema at the time of VATS. The mean time from VATS to discharge was 9 days (range: 3-30 days). The postoperative complication rate was 14 % and included pneumonia ( n = 3) and re-collections ( n = 3, two of which were managed by reinsertion of a chest drain, and one cleared without further intervention). Further analysis revealed a longer postoperative length of stay when empyema was present at VATS (8 days for no empyema vs. 11 days when empyema was present; p = 0.027). The incidence of empyema increased progressively the longer the delay between injury and VATS (0 % for VATS performed in week 1, 32 % for VATS in week 2, 50 % for VATS in week 3, and 60 % for VATS beyond week 3; p = 0.019). The incidence of empyema increased when >1 chest drain was inserted prior to VATS (15 % for 0-1 chest drain vs. 43 % for >1 chest drain; p = 0.043). Conclusions: Introducing VATS for retained post-traumatic collections into a relatively resource-constrained township hospital in South Africa is safe and effective. Consideration should be given to performing VATS early and avoiding the use of a second and third chest drain for retained collections. This approach may lead to decreased incidence of empyema and shorter overall hospital stay. [ABSTRACT FROM AUTHOR]

Background: The pediatric resuscitation and trauma outcome (PRESTO) model was developed to aid comparisons of risk-adjusted mortality after injury in low- and middle-income countries (LMICs). We sought to validate PRESTO using data from a middle-income country (MIC) trauma registry and compare its performance to the Pediatric Trauma Score (PTS), Revised Trauma Score, and pediatric age-adjusted shock index (SIPA). Methods: We included children (age < 15 years) admitted to a single trauma center in South Africa from December 2012 to January 2019. We excluded patients missing variables necessary for the PRESTO model—age, systolic blood pressure, pulse, oxygen saturation, neurologic status, and airway support. Trauma scores were assigned retrospectively. PRESTO's previously high-income country (HIC)-validated optimal threshold was compared to MIC-validated threshold using area under the receiver operating characteristic curves (AUROC). Prediction of in-hospital death using trauma scoring systems was compared using ROC analysis. Results: Of 1160 injured children, 988 (85%) had complete data for calculation of PRESTO. Median age was 7 (IQR: 4, 11), and 67% were male. Mortality was 2% (n = 23). Mean predicted mortality was 0.5% (range 0–25.7%, AUROC 0.93). Using the HIC-validated threshold, PRESTO had a sensitivity of 26.1% and a specificity of 99.7%. The MIC threshold showed a sensitivity of 82.6% and specificity of 89.4%. The MIC threshold yielded superior discrimination (AUROC 0.86 [CI 0.78, 0.94]) compared to the previously established HIC threshold (0.63 [CI 0.54, 0.72], p < 0.0001). PRESTO showed superior prediction of in-hospital death compared to PTS and SIPA (all p < 0.01). Conclusion: PRESTO can be applied in MIC settings and discriminates between children at risk for in-hospital death following trauma. Further research should clarify optimal decision thresholds for quality improvement and benchmarking in LMIC settings. [ABSTRACT FROM AUTHOR]

Introduction: We aimed to expand on the global surgical discussion around splenic trauma in order to understand locally and clinically relevant factors for operative (OP) and non-operative management (NOM) of splenic trauma in a South African setting. Methods: A retrospective cohort study was performed using 2013–2017 data from the Pietermaritzburg Metropolitan Trauma Service. All adult patients (≥15 years) were included. Those managed with OP or NOM for splenic trauma were identified and analyzed descriptively. Multiple logistic regression analysis identified patients and clinical factors associated with management type. Results: There were 127 patients with splenic injury. Median age was 29 [19–35] years with 42 (33%) women and 85 (67%) men. Blunt injuries occurred in the majority (81, 64%). Organ Injury Scale (OIS) grades included I (25, 20%), II (43, 34%), III (36, 28%), IV (15, 11%), and V (8, 6%). Nine patients expired. On univariate analysis, increasing OIS was associated with OP management, need for intensive care unit (ICU) admission, and hospital and ICU duration of stay, but not mortality. In patients with a delayed compared to early presentation, ICU utilization (62% vs. 36%, p = 0.008) and mortality (14% vs. 4%, p = 0.03) were increased. After adjusting for age, sex, presence of shock, and splenic OIS, penetrating trauma (adjusted odds ratio, 5.7; 95%CI, 1.7–9.8) and admission lactate concentration (adjusted odds ratio, 1.4; 95%CI 1.1–1.9) were significantly associated with OP compared to NOM (p = 0.002; area under the curve 0.81). Conclusions: We have identified injury mechanism and admission lactate as factors predictive of OP in South African patients with splenic trauma. Timely presentation to definitive care affects both ICU duration of stay and mortality outcomes. Future global surgical efforts may focus on expanding non-operative management protocols and improving pre-hospital care in patients with splenic trauma. [ABSTRACT FROM AUTHOR]

Background: Surgical 'never events' have serious adverse outcomes for patients. A never event can be defined as a serious, avoidable patient safety incident that would not occur if necessary preventative measures are implemented. The literature from South Africa on this topic is limited. This study aims to understand these never events in our setting and to develop a taxonomy to classify these events which facilitates the development of strategies to prevent and reduce the incidence and impact of surgical never events. Materials and methods: A retrospective review was undertaken over a 5-year period (December 2012–December 2017) at the Pietermaritzburg Metropolitan Surgical Service, South Africa. All morbidities and surgical never events recorded on the Hybrid Electronic Medical Registry (HEMR) were retrieved and analyzed. Results: A total of 20,432 patient admissions were captured on HEMR, and total of 7187 morbidities were recorded. Of these morbidities, 61.6% were in males and 38.3% in females. Patients admitted to general surgery accounted for 62.7% of the total, and trauma surgery and pediatric surgery accounted for 33.6% and 3.8%, respectively, of the total number of morbidities. Of these 7187 morbidities, a total of 79 never events were identified: 53 (67.1%) in males and 26 (32.9%) in females. Of all morbidities reported, 1.1% (79/7187) constituted a never event. The rate of never events for all admissions was (79 never events/20,432 admissions) or 0.39%. Among the 79 never events, general surgery patients experienced 47 (59.5%), trauma surgery 25 (31.6%), and pediatric surgery 7 (8.9%). In addition to these 79 never events, a total of 126 near misses were identified, of which 80 (63.5%) occurred in males. Conclusion: Surgical morbidity is common and has a substantial impact of both the individual patient and society as a whole. Robust reporting mechanisms are needed to capture data, and these data must feed into evidence-based strategies to reduce the incidence and impact of this morbidity. Our systems ensure that our incidence of surgical never events is relatively low, but ongoing efforts must be made to ensure that we drive this level down even further. [ABSTRACT FROM AUTHOR]

Background: Snake envenomation is associated with major morbidity especially in low- and middle-income countries and may require fasciotomy. We determined patient factors associated with the need for fasciotomy after venomous snake bites in children located in KwaZulu-Natal, South Africa. Methods: Single institutional review of historical data (2012–2017) for children (<18 years) sustaining snake envenomation was performed. Clinical data, management, and outcomes were abstracted. Syndromes after snake bite were classified according to Blaylock nomenclature: progressive painful swelling (PPS), progressive weakness (PW), or bleeding (B), as it is difficult to reliably identify the species of snake after a bite. Comparative and multivariable analyses to determine factors associated with fasciotomy were performed. Results: There were 72 children; mean age was 7 (±3) years, 59% male. Feet were most commonly affected (n = 27, 38%) followed by legs (n = 18, 25%). Syndromes (according to Blaylock) included PPS (n = 63, 88%), PW (n = 5, 7%), and B (n = 4, 5%). Eighteen patients underwent fasciotomy, and one required above knee amputation. Nine patients received anti-venom. Few patients (15%) received prophylactic beta-lactam antibiotics. Hemoglobin < 11 mg/dL, leukocytosis, INR >1.2, and age-adjusted shock index were associated with fasciotomy. On regression, age-adjusted shock index and hemoglobin concentration < 11 mg/dL, presentation >24 h after snake bite, and INR >1.2 were independently associated with fasciotomy. Model sensitivity was 0.89 and demonstrated good fit. Conclusions: Patient factors were associated with the fasciotomy. These factors, coupled with clinical examination, may identify those who need early operative intervention. Improving time to treatment and the appropriate administration of anti-venom will minimize the need for surgery. Level of evidence: III [ABSTRACT FROM AUTHOR]

Purpose: There is a lack of data-driven, risk-adjusted mortality estimates for injured children outside of high-income countries (HIC). To inform injury prevention and quality improvement efforts, an upper middle-income country (UMIC) pediatric trauma registry was compared to that of a HIC.Methods: Clinical data, injury details, and mortality of injured children (< 18 years) hospitalized in two centers (USA and South African (SA)) from 2013 to 2017 were abstracted. Univariate and multivariable analyses evaluated risk of mortality and were expressed as odds ratios (OR) with 95% confidence intervals (CI).Results: Of 2089 patients, SA patients had prolonged transfer times (21.1 vs 3.4 h) and were more likely referred (78.2% vs 53.9%; both p < 0.001). Penetrating injuries were more frequent in SA (23.2% vs 7.4%, p < 0.001); injury severity (9 vs 4) and shock index (0.90 vs 0.80) were greater (both p < 0.001). SA utilized cross-sectional imaging more frequently (66.4% vs 37.3%, p < 0.001). In-hospital mortality was similar (1.9% SA, 1.3% USA, p = 0.31). Upon multivariable analysis, ISS > 25 [210.50 (66.0-671.0)] and penetrating injury [5.5 (1.3-23.3)] were associated with mortality, while institution [1.7 (0.7-4.2)] was not.Conclusions: Despite transfer time, the centers demonstrated comparable survival rates. Comparison of registry data can alert clinicians to problematic practice patterns, assisting initiatives to improve trauma systems. [ABSTRACT FROM AUTHOR]