Background: The Groote Schuur Hospital Trauma Unit is a high-volume referral center where patient... more Background: The Groote Schuur Hospital Trauma Unit is a high-volume referral center where patient volumes may be related to temporal and environmental factors. Objective: This audit aimed to determine if numbers of patients presenting after motor vehicle collisions (MVCs) and interpersonal violence (IPV) were related to temporal factors, weather variables and important soccer matches. Method: Numbers of patients presenting to the unit per shift over 17 months were obtained from unit logs. Weather data, local soccer match locations and results, and information regarding public holidays and long weekends were obtained for the relevant shifts. Average daily attendances for IPV-related injuries and MVCs were compared across the various external factors described. Poisson regression models were fitted and used to express the relative incidence of attendances. These results are expressed using incidence rate ratios (IRRs). Results: For the study period, 7 350 attendances due to IPV-related injuries, and 3 188 injuries due to MVCs were recorded. Weekdays, long-weekend nights and month-end weekends had increased MVC-related attendance. Precipitation also increased attendances related to MVCs. Public holidays had less MVC-related attendance. IPV-related attendances were increased at night, on long weekends, and on month-end weekends. Weekend shifts were busier than weekday shifts, particularly at month-end. Long weekends showed similar trends to ordinary weekends, and public holidays showed similar trends to ordinary weekdays. Increasing temperatures are associated with increased attendances. Soccer matches and their outcomes have no significant effect on IPV-related attendances. Conclusion: Temporal and weather factors can help predict which trauma unit shifts will be busiest.
South Africa has one of the most violent societies worldwide. The national homicide rate is 34 pe... more South Africa has one of the most violent societies worldwide. The national homicide rate is 34 per 100 000; young males form the majority of this cohort. Comprehensive injury surveillance in low and middle-income countries is limited and there is paucity of data describing the epidemiology and outcomes of intentional injuries within the juvenile population. Ethical approval was obtained for this study. The Electronic Trauma Health Registry (eTHR) Application of the Trauma Centre at Groote Schuur Hospital in Cape Town was interrogated over an 18-month period (April 2014 - December 2016) for all patients (aged 12-19 years) treated for non-accidental trauma. The data was then analysed using descriptive statistics. Over the study period, 2903 juvenile patients were admitted to the trauma centre. Intentional injuries (= 1387; 47.8%) accounted for nearly half of the study cohort. Complete datasets were available for 1295 patients. Within this cohort 210 (16.2%) patients were victims of gang‑related violence. Penetrating injuries were seen in 878 (67.8%) patients, of whom 401 (45.7%) sustained knife injuries and 329 patients (37.5%) sustained gunshot wounds. The most affected body region was the head (n= 388; 30%), followed by the thorax (n= 311; 24%). Permanent disability resulting directly from injury was seen in 5.2% (n = 66) of the patients who survived (n= 1266) and the overall mortality was 2.2% (n = 29). Intentional injuries are common within the juvenile population group in Cape Town. Penetrating injuries and gang-related activities account for a large subset of these patients. Whilst the overall mortality is only 2.2%, the permanent disability rate is 5.2% and is likely to have significant public health and economic ramifications for the South African health care system in the future.
The role of nonoperative management for penetrating kidney injuries is unknown. Therefore, we rev... more The role of nonoperative management for penetrating kidney injuries is unknown. Therefore, we review the management and outcome of penetrating kidney injuries at a center with a high incidence of penetrating trauma. Data from all patients presenting with hematuria and/or kidney injury discovered on imaging or at surgery admitted to the trauma center at Groote Schuur Hospital in Cape Town, South Africa during a 19-month period (January 2007 to July 2008) were prospectively collected and reviewed. These data were analyzed for demographics, injury mechanism, perioperative management, nephrectomy rate and nonoperative success. Patients presenting with hematuria and with an acute abdomen underwent a single shot excretory urogram. Those presenting with hematuria without an indication for laparotomy underwent computerized tomography with contrast material. A total of 92 patients presented with hematuria following penetrating abdominal trauma. There were 75 (80.4%) proven renal injuries. Of the patients 84 were men and the median age was 26 years (range 14 to 51). There were 50 stab wounds and 42 gunshot renal injuries. Imaging modalities included computerized tomography in 60 cases and single shot excretory urography in 18. There were 9 patients brought directly to the operating room without further imaging. A total of 47 patients with 49 proven renal injuries were treated nonoperatively. In this group 4 patients presented with delayed hematuria, of whom 1 had a normal angiogram and 3 underwent successful angioembolization of arteriovenous fistula (2) and false aneurysm (1). All nonoperatively managed renal injuries were successfully treated without surgery. There were 18 nephrectomies performed for uncontrollable bleeding (11), hilar injuries (2) and shattered kidney (3). Post-nephrectomy complications included 1 infected renal bed hematoma requiring percutaneous drainage. Of the injuries found at laparotomy 12 were not explored, 2 were drained and 5 were treated with renorrhaphy. Penetrating trauma is associated with a high nephrectomy rate (24.3%). However, a high nonoperative success rate (100%) is achievable with minimal morbidity (9%).
The injured patient must be taken to the most appropriate hospital and not the closest. A more li... more The injured patient must be taken to the most appropriate hospital and not the closest. A more liberal use of the CT head is required in children after head trauma. An open mouth view is not accurate in the intubated patient. A CT scan may be used to determine the need for angiography and contrast studies in the stable patient with the transmediastinal gunshot wound. Damage control surgery is an attempt to control bleeding and prevent contamination as rapidly as possible.
Resume Introduction Le but de cette etude, issue d’une large base de donnees prospectives, etait ... more Resume Introduction Le but de cette etude, issue d’une large base de donnees prospectives, etait d’evaluer la morbidite et la mortalite des traumatismes isoles du pancreas. Methode Les complications etaient classees selon la classification de Dindo-Clavien et celle de l’International Study Group of Pancreatic Surgery (ISGPS). Le grade de l’atteinte du canal de Wirsung etait evalue selon la classification de Takishima modifiee. Les criteres de jugement principaux etaient la morbidite globale et specifique et la mortalite. Resultats Quatre cent quarante-huit patients etaient traites pour un traumatisme du pancreas de 1990 a 2014 dont 49 pour traumatisme isole du pancreas (âge median de 30 ans [extremes 13–68], 41 [83,7 %] etaient des hommes, et 43 traumatismes etaient fermes). Trente-quatre (70 %) patients ont ete operes en urgence, 20 ont eu une pancreatectomie distale (ou gauche) et 14 un simple drainage de la loge pancreatique. Quinze patients (30 %) ont ete pris en charge secondairement pour un pseudokyste non resolutif ou une fistule pancreatique : 5 avaient des lesions du canal de Wirsung grade 4A-B et ont du etre operes, 10 avaient des lesions grade 3A-B et ont ete traites endoscopiquement avec succes. Cinquante-cinq pour cent des patients ont eu une complication postoperatoire et deux patients (4 %) sont decedes pour une cause extra-pancreatique. Conclusion Notre etude suggere que la mortalite apres traumatisme isole du pancreas est faible mais la morbidite reste elevee. Deux tiers des patients sont operes et un tiers est traite endoscopiquement. L’importance des lesions pancreatiques peut renseigner si un traitement endoscopique peut etre efficace.
Clinically evaluable patients without hemodynamic instability and/or peritonitis can safely be co... more Clinically evaluable patients without hemodynamic instability and/or peritonitis can safely be considered for a trial of nonoperative management. Patients with abdominal SWs undergo serial clinical examination and delayed diagnostic laparoscopy for evaluation of the left diaphragm for left thoracoabdominal injuries and CT scanning for suspected solid organ injury. Patients with GSWs to the abdomen require CT scanning to map the missile trajectory. Those with extraperitoneal trajectories and solid organ injury should undergo serial clinical examination, while those with suspicious findings for hollow-viscus injury require prompt laparotomy. Selective nonoperative management of penetrating abdominal trauma, with or without solid organ injury, with or without advanced CT technology, is still based largely on the findings from serial clinical examinations.
Background: The aim of the study was to present the surgical management of injuries to the abdomi... more Background: The aim of the study was to present the surgical management of injuries to the abdominal vena cava (AVC) and to identify clinical and physiological factors and management strategies which affect the outcome. Method: A retrospective review was conducted of AVC injuries in patients attending the trauma centre at Groote Schuur Hospital, Cape Town, from January 2003 to December 2011. Demographic data, mechanism and agent of injury, level of injury, physiological parameters, associated injuries, trauma scores, management strategy, morbidity and mortality, and length of hospital stay were taken from the trauma centre's operative databank at Groote Schuur Hospital. Results: Thirty-fi ve patients with AVC injuries were identifi ed. There were 33 penetrating injuries (94%). Gunshot wounds accounted for 28 of them (85%). There were 19 (54%) infrarenal, 9 (26%) juxtarenal, 3 (7%) suprarenal and 4 (11%) retrohepatic AVC injuries. Most patients were treated with ligation (66%). There were 17 (49%) deaths. There were signifi cant differences in the preoperative systolic blood pressure (p = 0.044), number of red cell units transfused (p = 0.001), serum lactate (p = 0.007), arterial pH (p = 0.002) and preoperative temperature (p = 0.000) between the survivors and non-survivors. There was also a signifi cant difference in ligation versus repair between the two groups (p = ≤ 0.000). There was no difference in the injury severity, level of injury and the number of associated injuries between survivors and non-survivors. Conclusion: AVC injuries are associated with high mortality. Patients presenting with clinical and physiological evidence of shock and who require "damage control" surgery are more likely to suffer a worse outcome, particularly when multiple physiological deragements are present. Patients who died often have severe associated injuries.
South African journal of surgery. Suid-Afrikaanse tydskrif vir chirurgie, 2016
Enhanced recovery after surgery (ERAS) programmes employed in elective surgery have provided stro... more Enhanced recovery after surgery (ERAS) programmes employed in elective surgery have provided strong evidence for decreased lengths of hospital stay without increase in postoperative complications. The aim of this study was to explore the role and benefits of ERAS implemented in patients undergoing emergency laparotomy for penetrating abdominal trauma. Institutional University of Cape Town Human Research Ethics Committee (UCT-HREC) approved study. A prospective cohort of 38 consecutive patients with isolated penetrating abdominal trauma undergoing emergency laparotomy were included in the study. The enhanced recovery protocols (ERPs) included: early urinary catheter removal, early nasogastric tube (NGT) removal, early feeding, early mobilisation/physiotherapy, early intravenous line removal and early optimal oral analgesia. This group was compared to a historical control group of 40 consecutive patients undergoing emergency laparotomy for penetrating abdominal trauma, prior to the in...
Background: The Groote Schuur Hospital Trauma Unit is a high-volume referral center where patient... more Background: The Groote Schuur Hospital Trauma Unit is a high-volume referral center where patient volumes may be related to temporal and environmental factors. Objective: This audit aimed to determine if numbers of patients presenting after motor vehicle collisions (MVCs) and interpersonal violence (IPV) were related to temporal factors, weather variables and important soccer matches. Method: Numbers of patients presenting to the unit per shift over 17 months were obtained from unit logs. Weather data, local soccer match locations and results, and information regarding public holidays and long weekends were obtained for the relevant shifts. Average daily attendances for IPV-related injuries and MVCs were compared across the various external factors described. Poisson regression models were fitted and used to express the relative incidence of attendances. These results are expressed using incidence rate ratios (IRRs). Results: For the study period, 7 350 attendances due to IPV-related injuries, and 3 188 injuries due to MVCs were recorded. Weekdays, long-weekend nights and month-end weekends had increased MVC-related attendance. Precipitation also increased attendances related to MVCs. Public holidays had less MVC-related attendance. IPV-related attendances were increased at night, on long weekends, and on month-end weekends. Weekend shifts were busier than weekday shifts, particularly at month-end. Long weekends showed similar trends to ordinary weekends, and public holidays showed similar trends to ordinary weekdays. Increasing temperatures are associated with increased attendances. Soccer matches and their outcomes have no significant effect on IPV-related attendances. Conclusion: Temporal and weather factors can help predict which trauma unit shifts will be busiest.
South Africa has one of the most violent societies worldwide. The national homicide rate is 34 pe... more South Africa has one of the most violent societies worldwide. The national homicide rate is 34 per 100 000; young males form the majority of this cohort. Comprehensive injury surveillance in low and middle-income countries is limited and there is paucity of data describing the epidemiology and outcomes of intentional injuries within the juvenile population. Ethical approval was obtained for this study. The Electronic Trauma Health Registry (eTHR) Application of the Trauma Centre at Groote Schuur Hospital in Cape Town was interrogated over an 18-month period (April 2014 - December 2016) for all patients (aged 12-19 years) treated for non-accidental trauma. The data was then analysed using descriptive statistics. Over the study period, 2903 juvenile patients were admitted to the trauma centre. Intentional injuries (= 1387; 47.8%) accounted for nearly half of the study cohort. Complete datasets were available for 1295 patients. Within this cohort 210 (16.2%) patients were victims of gang‑related violence. Penetrating injuries were seen in 878 (67.8%) patients, of whom 401 (45.7%) sustained knife injuries and 329 patients (37.5%) sustained gunshot wounds. The most affected body region was the head (n= 388; 30%), followed by the thorax (n= 311; 24%). Permanent disability resulting directly from injury was seen in 5.2% (n = 66) of the patients who survived (n= 1266) and the overall mortality was 2.2% (n = 29). Intentional injuries are common within the juvenile population group in Cape Town. Penetrating injuries and gang-related activities account for a large subset of these patients. Whilst the overall mortality is only 2.2%, the permanent disability rate is 5.2% and is likely to have significant public health and economic ramifications for the South African health care system in the future.
The role of nonoperative management for penetrating kidney injuries is unknown. Therefore, we rev... more The role of nonoperative management for penetrating kidney injuries is unknown. Therefore, we review the management and outcome of penetrating kidney injuries at a center with a high incidence of penetrating trauma. Data from all patients presenting with hematuria and/or kidney injury discovered on imaging or at surgery admitted to the trauma center at Groote Schuur Hospital in Cape Town, South Africa during a 19-month period (January 2007 to July 2008) were prospectively collected and reviewed. These data were analyzed for demographics, injury mechanism, perioperative management, nephrectomy rate and nonoperative success. Patients presenting with hematuria and with an acute abdomen underwent a single shot excretory urogram. Those presenting with hematuria without an indication for laparotomy underwent computerized tomography with contrast material. A total of 92 patients presented with hematuria following penetrating abdominal trauma. There were 75 (80.4%) proven renal injuries. Of the patients 84 were men and the median age was 26 years (range 14 to 51). There were 50 stab wounds and 42 gunshot renal injuries. Imaging modalities included computerized tomography in 60 cases and single shot excretory urography in 18. There were 9 patients brought directly to the operating room without further imaging. A total of 47 patients with 49 proven renal injuries were treated nonoperatively. In this group 4 patients presented with delayed hematuria, of whom 1 had a normal angiogram and 3 underwent successful angioembolization of arteriovenous fistula (2) and false aneurysm (1). All nonoperatively managed renal injuries were successfully treated without surgery. There were 18 nephrectomies performed for uncontrollable bleeding (11), hilar injuries (2) and shattered kidney (3). Post-nephrectomy complications included 1 infected renal bed hematoma requiring percutaneous drainage. Of the injuries found at laparotomy 12 were not explored, 2 were drained and 5 were treated with renorrhaphy. Penetrating trauma is associated with a high nephrectomy rate (24.3%). However, a high nonoperative success rate (100%) is achievable with minimal morbidity (9%).
The injured patient must be taken to the most appropriate hospital and not the closest. A more li... more The injured patient must be taken to the most appropriate hospital and not the closest. A more liberal use of the CT head is required in children after head trauma. An open mouth view is not accurate in the intubated patient. A CT scan may be used to determine the need for angiography and contrast studies in the stable patient with the transmediastinal gunshot wound. Damage control surgery is an attempt to control bleeding and prevent contamination as rapidly as possible.
Resume Introduction Le but de cette etude, issue d’une large base de donnees prospectives, etait ... more Resume Introduction Le but de cette etude, issue d’une large base de donnees prospectives, etait d’evaluer la morbidite et la mortalite des traumatismes isoles du pancreas. Methode Les complications etaient classees selon la classification de Dindo-Clavien et celle de l’International Study Group of Pancreatic Surgery (ISGPS). Le grade de l’atteinte du canal de Wirsung etait evalue selon la classification de Takishima modifiee. Les criteres de jugement principaux etaient la morbidite globale et specifique et la mortalite. Resultats Quatre cent quarante-huit patients etaient traites pour un traumatisme du pancreas de 1990 a 2014 dont 49 pour traumatisme isole du pancreas (âge median de 30 ans [extremes 13–68], 41 [83,7 %] etaient des hommes, et 43 traumatismes etaient fermes). Trente-quatre (70 %) patients ont ete operes en urgence, 20 ont eu une pancreatectomie distale (ou gauche) et 14 un simple drainage de la loge pancreatique. Quinze patients (30 %) ont ete pris en charge secondairement pour un pseudokyste non resolutif ou une fistule pancreatique : 5 avaient des lesions du canal de Wirsung grade 4A-B et ont du etre operes, 10 avaient des lesions grade 3A-B et ont ete traites endoscopiquement avec succes. Cinquante-cinq pour cent des patients ont eu une complication postoperatoire et deux patients (4 %) sont decedes pour une cause extra-pancreatique. Conclusion Notre etude suggere que la mortalite apres traumatisme isole du pancreas est faible mais la morbidite reste elevee. Deux tiers des patients sont operes et un tiers est traite endoscopiquement. L’importance des lesions pancreatiques peut renseigner si un traitement endoscopique peut etre efficace.
Clinically evaluable patients without hemodynamic instability and/or peritonitis can safely be co... more Clinically evaluable patients without hemodynamic instability and/or peritonitis can safely be considered for a trial of nonoperative management. Patients with abdominal SWs undergo serial clinical examination and delayed diagnostic laparoscopy for evaluation of the left diaphragm for left thoracoabdominal injuries and CT scanning for suspected solid organ injury. Patients with GSWs to the abdomen require CT scanning to map the missile trajectory. Those with extraperitoneal trajectories and solid organ injury should undergo serial clinical examination, while those with suspicious findings for hollow-viscus injury require prompt laparotomy. Selective nonoperative management of penetrating abdominal trauma, with or without solid organ injury, with or without advanced CT technology, is still based largely on the findings from serial clinical examinations.
Background: The aim of the study was to present the surgical management of injuries to the abdomi... more Background: The aim of the study was to present the surgical management of injuries to the abdominal vena cava (AVC) and to identify clinical and physiological factors and management strategies which affect the outcome. Method: A retrospective review was conducted of AVC injuries in patients attending the trauma centre at Groote Schuur Hospital, Cape Town, from January 2003 to December 2011. Demographic data, mechanism and agent of injury, level of injury, physiological parameters, associated injuries, trauma scores, management strategy, morbidity and mortality, and length of hospital stay were taken from the trauma centre's operative databank at Groote Schuur Hospital. Results: Thirty-fi ve patients with AVC injuries were identifi ed. There were 33 penetrating injuries (94%). Gunshot wounds accounted for 28 of them (85%). There were 19 (54%) infrarenal, 9 (26%) juxtarenal, 3 (7%) suprarenal and 4 (11%) retrohepatic AVC injuries. Most patients were treated with ligation (66%). There were 17 (49%) deaths. There were signifi cant differences in the preoperative systolic blood pressure (p = 0.044), number of red cell units transfused (p = 0.001), serum lactate (p = 0.007), arterial pH (p = 0.002) and preoperative temperature (p = 0.000) between the survivors and non-survivors. There was also a signifi cant difference in ligation versus repair between the two groups (p = ≤ 0.000). There was no difference in the injury severity, level of injury and the number of associated injuries between survivors and non-survivors. Conclusion: AVC injuries are associated with high mortality. Patients presenting with clinical and physiological evidence of shock and who require "damage control" surgery are more likely to suffer a worse outcome, particularly when multiple physiological deragements are present. Patients who died often have severe associated injuries.
South African journal of surgery. Suid-Afrikaanse tydskrif vir chirurgie, 2016
Enhanced recovery after surgery (ERAS) programmes employed in elective surgery have provided stro... more Enhanced recovery after surgery (ERAS) programmes employed in elective surgery have provided strong evidence for decreased lengths of hospital stay without increase in postoperative complications. The aim of this study was to explore the role and benefits of ERAS implemented in patients undergoing emergency laparotomy for penetrating abdominal trauma. Institutional University of Cape Town Human Research Ethics Committee (UCT-HREC) approved study. A prospective cohort of 38 consecutive patients with isolated penetrating abdominal trauma undergoing emergency laparotomy were included in the study. The enhanced recovery protocols (ERPs) included: early urinary catheter removal, early nasogastric tube (NGT) removal, early feeding, early mobilisation/physiotherapy, early intravenous line removal and early optimal oral analgesia. This group was compared to a historical control group of 40 consecutive patients undergoing emergency laparotomy for penetrating abdominal trauma, prior to the in...
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