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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]

Background: Penetrating injuries to the buttock are relatively rare but are associated with significant morbidity. This study aimed to review our experience in managing penetrating trauma to the buttocks to contextualize the injury, document the most common associated injuries, and generate an algorithm to assist with the management of these patients. Methods: A retrospective study was conducted at a major trauma center in South Africa over 8 years (January 2012 to January 2020). All patients presenting with a penetrating buttock injury were included. Results: Our study included 40 patients. Gunshot wounds accounted for 93% (37/40), stab wounds accounted for 5% (2/40), and 1 case was gored by a cow. The majority (98%) underwent further investigation in the form of imaging or endoscopy. Forty percent (16/40) required surgical intervention. Of these 16 cases, 14 required a laparotomy, and 2 required gluteal exploration. Fifty-six percent (9/16) required a stoma. Five percent (2/40) experienced one or more complications, both of whom had stomas. The median length of stay for all patients was 3 days, whereas for the patients with stomas was 7 days. There were no ICU admissions or mortality in this study. Only 3 of the 9 stomas were reversed, and the median time to reversal was 16 months. Conclusion: Penetrating trauma to the buttock may result in injuries to surrounding vital structures, which must be actively excluded. Rectal injury was the most common injury, and most required a defunctioning colostomy as part of the management resulting in significant morbidity. [ABSTRACT FROM AUTHOR]

Background: This study reviews our experience with combined cardiac and abdominal stab wounds over 12 years and reviews how changes in technology and clinical approaches have impacted our management of these patients. Materials and Methods: A retrospective cohort study was conducted from January 2008 to January 2020 at a major trauma centre in South Africa. All patients with concurrent SWs to the chest and the abdomen and required both a thoracotomy for cardiac injury and a laparotomy for an intra-abdominal injury at the same setting were included. Results: Twenty-two cases were identified (100% male, mean age: 27 years). Mean values of admission physiology: systolic blood pressure (SBP): 85 mmHg, pH: 7.2, base excess: −10.2 mmol/L and serum lactate 6.7 mmol/L. Thirty-two percent (7/22) of cases underwent a Focused Assessment with Sonography in Trauma (FAST) scan (5 positive and 2 negative). All 7 cases had intraoperatively confirmed cardiac injuries. The thoracotomy first approach was used in 18 cases (82%), and the laparotomy first approach was used in the remaining 4 cases (18%). Nineteen (86%) of the 22 laparotomies were positive. A total of 6 patients (27%) experienced one or more complications. The mean length of hospital stay was 9 days. The overall mortality was 18% (4/22) and all mortality occurred prior to 2013. Discussion: Double jeopardy is still associated with an increased risk of mortality. The use of FAST and Subxiphoid Pericardial Windows (SPWs) have reduced clinical uncertainty, decreasing the need for concomitant thoracotomy and laparotomy to be performed. [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]

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]

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]

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: Over the last 50 years, the gold standard for paediatric trauma management has grown to be non‐operative management. This study reviews a South African experience with paediatric splenic trauma in order to benchmark this against the international standard and to identify discrepancies in access to care and in surgical outcomes. Methods: This was a retrospective study conducted at a major trauma centre in South Africa. All children less than 18 years of age who were admitted to our trauma centre following trauma between December 2012 and October 2020 were identified and all those who sustained splenic trauma were reviewed. Results: Of the 66 patients reviewed, 48 (72%) were male, and the median age was 12 years (0–18 years). Thirty‐three (51%) were of rural origin and 61 (93%) sustained blunt trauma. Only eight (12%) had an isolated splenic injury, while the remaining 58 (88%) had other associated injuries. Forty‐five patients (68%) were managed non‐operatively whilst the remainder were subjected to laparotomy. Five (7%) required a splenectomy and one required angio‐embolisation. Twenty‐six patients (39%) required intensive care unit (ICU) admission: 15 (37%) in the non‐operative cohort required ICU admission and eight (40%) in the laparotomy group required ICU admission. Twenty‐eight (42%) patients required ventilatory support. Median length of stay was 5.5 days. Four (6%) patients died. Conclusions: Although non‐operative management of paediatric splenic trauma can be undertaken successfully by adult trauma surgeons in a middle‐income country such as South Africa, there remains room for improvement. To achieve splenic salvage rates comparable to those in dedicated paediatric trauma centres in high‐income countries will require systematic quality improvement programmes. [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]

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]

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: 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]

Objective: Routine immobilisation of the cervical spine in trauma has been a long established practice. Very little is known in regard to its appropriateness in the specific setting of isolated traumatic brain injury secondary to gunshot wounds (GSWs). Methods: A retrospective study was conducted over a 5 year period (January 2010 to December 2014) at the Pietermaritzburg Metropolitan Trauma Service, Pietermaritzburg, South Africa in order to determine the actual incidence of concomitant cervical spine injury (CSI) in the setting of isolated cerebral GSWs. Results: During the 5 year study period, 102 patients were included. Ninety‐two per cent (94/102) were male and the mean age was 29 years. Ninety‐eight per cent of the injuries were secondary to low velocity GSWs. Twenty‐seven (26%) patients had cervical collar placed by the Emergency Medical Service. The remaining 75 patients had their cervical collar placed in the resuscitation room. Fifty‐five (54%) patients had a Glasgow Coma Scale (GCS) of 15 and underwent plain radiography, all of which were normal. Clearance of cervical spine based on normal radiography combined with clinical assessment was achieved in all 55 (100%) patients. The remaining 47 patients whose GCS was <15 all underwent a computed tomography (CT) scan of their cervical spine and brain. All 47 CT scans of the cervical spine were normal and there was no detectable bone or soft tissue injury noted. Conclusion: Patients who sustain an isolated low velocity cerebral GSW are highly unlikely to have concomitant CSI. Routine cervical spine immobilisation is unnecessary, and efforts should be directed at management strategies aiming to prevent secondary brain injury. Further studies are required to address the issue in the setting of high velocity GSWs. [ABSTRACT FROM AUTHOR]

Background Cerebral gunshot wounds represent one of the most lethal forms of traumatic brain injury, but there is a paucity of literature on the topic, especially from the developing world. We reviewed our experience and describe the spectrum and outcome of civilian cerebral gunshot wounds in a major metropolitan trauma centre in South Africa. Methods This was a retrospective study of all patients with isolated cerebral gunshot wounds managed by the Pietermaritzburg Metropolitan Trauma Service over a 5-year period from 2010 to 2014. Results One hundred and two patients were included, 92% (94/102) were male and the mean age was 29 years. Fifty-four per cent (55/102) of all patients were from urban areas. The mean time from injury to arrival was 6 h (standard deviation: 5) for urban patients and 15 h (standard deviation: 5.2) for rural patients ( P < 0.001). Ninety-four per cent (94/102) of all injuries were related to interpersonal violence and involved low velocity firearms. Twenty per cent of all patients (20/102) had a Glasgow Coma Scale 3-8, 20% (20/102) 9-12 and 61% (61/102) 12-15. All 102 patients underwent computed tomography scans. Thirty per cent (31/102) required neurosurgical interventions. The overall mortality rate was 22% (22/102). There was a significant difference in mortality between urban and rural patients (9% versus 36%, P < 0.001). Conclusions Cerebral gunshot wounds are associated with significant mortality and protracted delay to definitive care is common in our setting. Those who survive the delayed transfer to definitive care generally do well and have reasonably good clinical outcomes. [ABSTRACT FROM AUTHOR]