Biochemical markers in emergency thoracic surgery in penetrating trauma

BACKGROUND

Violent interpersonal acts account for a large proportion of unnatural deaths in South Africa. A significant proportion of unnatural deaths are due to penetrating thoracic trauma and preventable haemorrhage. Current indications for emergent thoracotomy are unreliable. We propose the use of lactate, shock index (SI) and base deficit (BD) as a triage tool in patients with penetrating thoracic injuries to identify those requiring surgical intervention.

METHODS

A review of the trauma registry of the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) was carried out between March 2011 and March 2016. Four hundred and ninety (490) patients were collected consisting of a non-operative group of 246 patients and an operative group of 244 patients. We compared lactate, SI and BD independently and within panels to ascertain which would best predict the need for operative intervention in these patients. Abnormal was defined as lactate ≥ 4 mmol/l, SI ≥ 0.8 and BD ≤ -4 mmol/l.

RESULTS

Of the 490 patients, lactate (p < 0.001), SI (p < 0.001) and BD (p < 0.001) differed significantly between operative and non-operative groups. Statistical significance was lost (p = 0.34) once BD was analysed in combination with lactate and SI. Lactate alone was a strong predictor of the need for intervention (area under the curve (AUC) = 0.814). The strongest predictor was a combined panel of lactate and SI (AUC = 0.8308, p < 0.001).

CONCLUSION

Lactate and SI in combination are useful as triage tools, and could assist in decision making, by predicting which patients are more likely to require surgical intervention.

Time for a paradigm shift in shared decision-making in trauma and emergency surgery? Results from an international survey

BACKGROUND

Shared decision-making (SDM) between clinicians and patients is one of the pillars of the modern patient-centric philosophy of care. This study aims to explore SDM in the discipline of trauma and emergency surgery, investigating its interpretation as well as the barriers and facilitators for its implementation among surgeons.

METHODS

Grounding on the literature on the topics of the understanding, barriers, and facilitators of SDM in trauma and emergency surgery, a survey was created by a multidisciplinary committee and endorsed by the World Society of Emergency Surgery (WSES). The survey was sent to all 917 WSES members, advertised through the society's website, and shared on the society's Twitter profile.

RESULTS

A total of 650 trauma and emergency surgeons from 71 countries in five continents participated in the initiative. Less than half of the surgeons understood SDM, and 30% still saw the value in exclusively engaging multidisciplinary provider teams without involving the patient. Several barriers to effectively partnering with the patient in the decision-making process were identified, such as the lack of time and the need to concentrate on making medical teams work smoothly.

DISCUSSION

Our investigation underlines how only a minority of trauma and emergency surgeons understand SDM, and perhaps, the value of SDM is not fully accepted in trauma and emergency situations. The inclusion of SDM practices in clinical guidelines may represent the most feasible and advocated solutions.

Emergency Room Thoracotomy (ERT): A retrospective audit of results

Background: An Emergency Room Thoracotomy (ERT) is a resource-intensive, high-risk procedure in which rapid decision-making is essential. In a resource-constrained system, identification of the group of patients that could achieve the best outcome will avoid futile use. Incorporating physiological and metabolic parameters at the time of arrival to the emergency department into the management algorithm may assist with better patient selection and could improve outcomes. Material and Methods: A retrospective review of the results of subjects who underwent Emergency Room Thoracotomy at a Level 1 Academic Trauma Center over a 13-year period (01 January 2005 to 31 December 2017) was conducted. Mechanism of injury, physiological and metabolic parameters, anatomical injuries, Injury Severity Score (ISS), calculated Revised Trauma score (cRTS), volume and type of fluids administered, and mortality were analyzed comparing survivors and non-survivors. Results: One hundred and ten (n=110) patients underwent ERT during the study period. Variables such as the mechanism of injury, physiological and metabolic parameters, type, and volume of fluids administered did not show any statistically significant influence in the final outcome. Penetrating cardiac and chest trauma had better survival (40.6 % and 20 % respectively) compared to those with thoraco-abdominal, abdominal, pelvic, and femoral vessel trauma. Overall survival was 21,8%. Conclusions: In a resource-constrained environment an Emergency Room Thoracotomy should be performed in patients with a thoracic injury, especially cardiac, to achieve the best possible outcome.

Low central venous oxygen saturation in haemodynamically stabilized trauma patients is associated with poor outcome

BACKGROUND

Central venous oxygen saturation (ScvO(2)) is suggested to reflect the adequacy of oxygen delivery, and the main objective of the present study was to determine whether ScvO(2) is associated with outcome in haemodynamically stabilized trauma patients.

METHODS

Haemodynamically unstable trauma patients receiving a central venous line within 1 h of admission were eligible for inclusion in this prospective observational study. The mean arterial pressure (MAP), lactate and ScvO(2) were recorded at inclusion and every 6 h for 36 h or until lactate was <2.0 mmol/l and ScvO(2) was >75% in two consecutive measurements. Patients with a MAP of ≥70 mmHg were considered to be haemodynamically stabilized. The outcome measure was complications defined as infections, delta sequential organ failure assessment score of >0, and mortality.

RESULTS

Fifty patients with a median new injury severity score of 27 (17-34) were analysed. Complications occurred in 33 patients. An association between ScvO(2) following resuscitation to MAP ≥70 mmHg and complications was detected with an odds ratio of 0.94 (95% confidence interval; 0.89-0.99). This association was also significant when adjusted for injury severity. The result implies that a low ScvO(2) value is associated with more complications. The optimal cut-off for ScvO(2) to discriminate between patients who did or did not develop complications was found to be 66.5% (56-86%).

CONCLUSIONS

These data suggest that low ScvO(2) in haemodynamically stabilized patients is associated with a poor outcome and that ScvO(2) represents a potential endpoint of resuscitation in trauma patients.

Strengthening care of injured children globally

Part of the solution to the growing problem of child injury is to strengthen the care that injured children receive. This paper will point out the potential health gains to be made by doing this and will then review recent advances in the care of injured children in individual institutions and countries. It will discuss how these individual efforts have been aided by increased international attention to trauma care. Although there are no major, well-funded global programmes to improve trauma care, recent guidance documents developed by WHO and a broad network of collaborators have stimulated increased global attention to improving planning and resources for trauma care. This has in turn led to increased attention to strengthening trauma care capabilities in countries, including needs assessments and implementation of WHO recommendations in national policy. Most of these global efforts, however, have not yet specifically addressed children. Given the special needs of the injured child and the high burden of injury-related death and disability among children, clearly greater emphasis on childhood trauma care is needed. Trauma care needs assessments being conducted in a growing number of countries need to focus more on capabilities for care of injured children. Trauma care policy development needs to better encompass childhood trauma care. More broadly, the growing network of individuals and groups collaborating to strengthen trauma care globally needs to engage a broader range of stakeholders who will focus on and champion the improvement of care for injured children.

Establishing the evidence base for trauma quality improvement: a collaborative WHO-IATSIC review

BACKGROUND

Quality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs.

METHODS

The review was based on a PubMed search of all articles reporting an outcome from a trauma QI program.

RESULTS

Thirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings.

CONCLUSIONS

Trauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes.

Effect of penetrating trunk trauma on the recovery of adult survivors: a pilot study

Gunshot and/or stab wounds to the trunk are injuries seen in South African hospitals. Patients are managed in the intensive care unit. Prolonged mechanical ventilation with immobilization results in some degree of muscle dysfunction. Our goal was to determine if patients recover adequately spontaneously following critical illness. No formal rehabilitation programmes exist in South Africa for these patients following discharge. A prospective, observational study was conducted. Patients were recruited from three ICUs in Johannesburg. Lung function tests, dynamometry, quality of life, 6-minute-walk, and oxygen uptake tests were performed over 6 months following discharge from the hospital. The control group consisted of existing data for healthy volunteers. Distance walked during 6-minute-walk test was significantly reduced for the study group compared to the control group (1 month [p = 0.00251]; 6 months [p = 0.0355]). At 1 month there was a significant reduction in quadriceps and triceps strength for the study group compared to the control group (p = 0.0089; p = 0.0246, respectively). Quadriceps strength remained significantly reduced for the study group (3 months [p = 0.0489]). No difference in muscle strength was detected between the groups at 6 months. Actual and predicted residual volumes differed significantly for the study group (1 month [p = 0.0034]; 6 months [p = 0.0157]). A trend of muscle weakness (to 3 months), poor exercise capacity, and abnormal lung volumes was identified. A formal rehabilitation programme may be needed to address these disabilities.

The Use of Low Dosage X-Ray (Lodox/Statscan) in Major Trauma: Comparison Between Low Dose X-Ray and Conventional X-Ray Techniques

BACKGROUND

Patients presenting with major trauma normally require resuscitation, usually carried out according to techniques laid down by the Advanced Trauma Life Support (ATLS) Program of the American College of Surgeons. Techniques normally suggested include the routine radiology of the cervical spine, chest and pelvis. This can sometimes be time consuming and may not return helpful information in all cases.

METHODS

This paper describes the use of a new low dose X-ray technique (Lodox/Statscan to perform these X-rays, and compares their interpretation by both radiologists and trauma surgeons with images obtained from conventional X-rays. The time taken for the respective images to be obtained was measured.

RESULTS

There was no difference in the amount of information obtained.

CONCLUSION

The use of the Lodox allowed a substantial reduction in the time taken for resuscitation, without prejudice to diagnostic radiology.

Overview of the Essential Trauma Care Project

The Essential Trauma Care (EsTC) Project represents an effort to set reasonable, affordable, minimum standards for trauma services worldwide and to define the resources necessary to actually provide these services to every injured person, even in the lowest-income countries. An emphasis is improved organization and planning, at minimal cost. The EsTC Project is a collaborative effort of the World Health Organization and the International Association for Trauma Surgery and Intensive Care, an integrated society within the International Society of Surgery-Société Internationale de Chirurgie. A milestone of the project has been the release of Guidelines for Essential Trauma Care. This establishes 11 core Essential Trauma Care services that can be considered "The Rights of the Injured." To assure these services, Guidelines delineates 260 items of human and physical resources that should be in place at the spectrum of health facilities globally. These are delineated in a series of flexible resource tables, to be adjusted based on an individual country's circumstances. Guidelines is intended to serve as both a planning guide and an advocacy statement. It has been used to catalyze improvements in trauma care in several countries. It has stimulated five national-level consultation meetings on trauma care, which constituted the highest governmental attention yet devoted to trauma care in those countries. At these meetings, the EsTC resource templates were adjusted to local circumstances and implementation strategies developed. Future efforts need to emphasize more on-the-ground implementation in individual countries, greater linkages with prehospital care, and wider political endorsement, such as by passage of a World Health Assembly resolution.

Advancing Essential Trauma Care through the Partner Organizations: IATSIC, ISS-SIC, and WHO

The publication Guidelines for Essential Trauma Care offers an opportunity to improve trauma care services in an affordable and sustainable fashion, primarily through improved organization and planning. The publication will be useful, however, only if it actually catalyzes improvements in trauma care in health care facilities in individual countries, especially those low- and middle-income countries with the greatest needs. There is much that can be done to make this happen on the part of the partners that created these recommendations, including IATSIC (International Association for Trauma Surgery and Intensive Care); ISS-SIC (International Society of Surgery-Société Internationale de Chirurgie); and WHO (World Health Organization). This includes such activities as organizing multi-sectoral stakeholders' meetings to adapt the Essential Trauma Care (EsTC) criteria to local needs; conducting trauma care needs assessments to identify priorities for low-cost improvements; having surgical colleges and societies throughout the world endorse the Guidelines; lobbying ministries of health to incorporate the EsTC recommendations into health policy; and seeking to integrate the EsTC recommendations into the 2-year action plans of WHO country offices. In all of these activities, surgeons and others who care for the injured can play a pivotal role, especially working collaboratively with their own ministries of health and WHO country offices.

Preparing and responding to mass casualties in the developing world

Disasters, albeit on a small scale, are an everyday event in Africa. They contribute to depriving millions of Africans of access to basic services, often considered rights in more affluent societies. The massive amounts of aid donated during disasters, could be limited by strengthening systems of disaster preparedness beforehand. Current, disease-specific programs can not achieve this goal. The Essential Trauma Care Program of the WHO, and the International Association of Trauma Surgery and Intensive Care provides a template on which to build affordable systems of disaster preparedness.

Essential Trauma Care: strengthening trauma systems round the world

Injury has become a major cause of death and disability world-wide. Systematic approaches to its prevention and treatment are needed. In terms of treatment, there are many low-cost improvements that could be made particularly in low- and middle-income countries to strengthen their trauma systems. These can be formalised under "Essential Trauma Care" programme, similar to other global programmes for major public health problems. World Health Organisation (WHO), leading the initiative in this direction, convened a meeting at Geneva in June 2002, involving Injuries and Violence Prevention Department of the WHO, the Working Group for Essential Trauma Care of the International Association for Trauma and Surgical Intensive Care (IATSIC), representatives of other organisations and trauma care clinicians representing Africa, Asia, and Latin America. The meeting developed a preliminary list of Essential Trauma Care services and a model template for the skills and equipment needed to assure them. It is intended to be used to assist individual countries in planning their own trauma care services.

Death and injury on duty--a study of South African police officers

OBJECTIVES

Sections of contemporary South African society are characterised by high levels of crime and interpersonal conflict. The South African Police Service (SAPS) is in the front line, with many deaths and injuries occuring among serving officers in recent years. The circumstances and nature of the injuries sustained by these officers have received little attention in the medical literature.

DESIGN

A retrospective review of all injured SAPS members was undertaken at a single level one trauma centre in Johannesburg between June 1993 and June 2002. The following factors were recorded: demographics, mechanism and anatomical site of injury, mode of transportation to hospital, whether personal protection had been used, mortality, and return to work.

RESULTS

One hundred and thirty-four SAPS personnel were admitted over a 9-year period. The majority (95%) were male and the median age was 31 years. One hundred and thirty-two were on duty and two were in transit to a place of duty when injured. Ninety-two (69%) were injured by gunshot, (including 3 attempted suicides and 9 injuries due to negligent discharge), 2 members were stabbed, 31 were involved in motor vehicle accidents, 2 in motorbike accidents, 1 member was struck by a car while directing traffic, 3 officers were injured by falls from a height, 2 members were injured in helicopter crashes, and 1 member required treatment for gas inhalation. Documentation on whether some form of personal protection was worn at the time of injury was only available for 43 of the 92 cases of gunshot wounds (47%); of these, only 15 (35%) were wearing a bulletproof vest. Use or non-use of a seat belt was documented by hospital staff for only 6 of the 31 officers (19%) injured in motor vehicle accidents. None of the 6 officers had been restrained by a seatbelt. Nineteen SAPS personnel (14%) died of their injuries, but the majority of surviving members returned to duty.

CONCLUSION

There is an unacceptably high level of violence in South African society today and SAPS members regularly have to deal with dangerous or violent situations. There is a clear need to introduce a reporting system within the SAPS to record the use of personal protection by officers. Education needs to target SAPS members in order to enhance their use of personal protection. There is a further need to design and implement personal protection that will be universally acceptable by SAPS members.

Trauma care systems in South Africa

AIM

To provide an overview of the provision of trauma care in South Africa, a middle income country emerging into a democratic state.

METHODS

Literature review.

CONCLUSIONS

South Africa is gripped by an almost hidden epidemic of intentional and non-intentional injury, largely driven by alcohol and substance abuse, against a background of poverty and rapid urbanisation. Gross inequities exist in the provision of trauma care. Access to pre-hospital care and overloading of tertiary facilities are the major inefficiencies to be addressed. The burden of disease due to trauma presents unique opportunities for reconstruction and clinical research.

The malignant epidemic--changing patterns of trauma

OBJECTIVES AND SETTING

The worldwide burden of trauma is increasing, but is unequally distributed between nations. Trauma in South Africa targets the young and productive in society and imposes a major burden on the health infrastructure. We undertook a review of injury trends among patients attending the Johannesburg Hospital Trauma Unit (JHTU) and the Johannesburg Medicolegal Laboratory (JMLL) in order to document the evolution in patterns of trauma over a 17-year period of great social and political change.

DESIGN, SUBJECTS AND OUTCOME MEASURES

This was a retrospective review of all priority-one patients attending the JHTU from January 1985 to December 2001. The JHTU trauma database was used to retrieve information on patient demographics, wound mechanism and injury severity. The database at the JMLL, maintained since 1996, was examined and the manner and place of death were analysed.

RESULTS

The JHTU has seen an unprecedented increase in the number of trauma patients over the last 17 years. The patients' demographic profiles have altered and injury is now predominantly due to interpersonal violence. Unnatural deaths examined at the JMLL have declined by 19% since 1996; however, the proportion of those deaths due to gunshot wounds has risen.

CONCLUSIONS

The social and political changes in South Africa in recent years have led to changes in the injury profiles seen at the JHTU. Part of the increase can be explained by desegregation and a reduction in the provision of local hospital services; however, the impact of urbanisation within South Africa, cross-border migration and the high incidence of substance abuse are recognised. Evidence supports the implementation of legislative, environmental, social and behavioural interventions to contain and reduce the incidence and impact of violence and injury. Concerted efforts must be made at all levels to curb South Africa's trauma epidemic.

Penetrating vascular trauma in Johannesburg, South Africa

An awareness that time crucially affects outcome underpins the principles of management of vascular injury. Patients with hard signs of vascular injury should undergo urgent exploration. Soft signs mandate investigation, and arteriography is still the standard of care. Noninvasive vascular imaging may prove its worth in the future. All patients with penetrating arterial injury should receive broad-spectrum antibiotic prophylaxis. Early repair of carotid artery injury provides the best likelihood of a neurologically intact survivor. There is a definite and emerging role of endovascular therapy both for difficult access injuries and for the later complications of vascular injury, such as false aneurysm and arteriovenous fistulas. The experimental and clinical evidence for the use of intraluminal shunts in peripheral vascular injury is compelling, and experience in their use is accumulating. Vascular trauma is complex and ideally is carried out by experts in a multidisciplinary environment; resuscitation and prompt revascularization are likely to lead to satisfactory outcomes. The major trauma load in South Africa represents an unparalleled experience in management of vascular injury, which seems likely to continue for the foreseeable future.

Evolving concepts in the management of colonic injury

PURPOSE

The management of colonic injury has changed in recent years. This study sought to evaluate current surgical management of injuries to the colon in a busy urban trauma centre, in the light of our increasing confidence in primary repair and evolving understanding of the concepts and practice of damage control surgery.

METHODS

A retrospective analysis was made of consecutive patients presenting with colonic injury from January 1 to December 31 1998. Patients without full-thickness lesions of the colon were excluded, as were patients who died within 24 h of admission. Demographic data, wounding patterns and clinical course were studied.

RESULTS

One hundred twenty-seven patients were analyzed. Management without colostomy was achieved in 84% of cases. Patients who underwent diversion of the faecal stream had increased morbidity and hospital stay compared to equivalent patients who were repaired primarily. The important subgroup of patients who underwent damage control or abbreviated laparotomy is discussed.

CONCLUSION

This study further strengthens the validity of direct repair or resection and primary anastomosis for colonic injury. Strategies to deal with the subgroup of patients at very high risk of postoperative complications are suggested.

Transmediastinal gunshot injuries

BACKGROUND

Transmediastinal gunshot injuries are a rarely reported injury. Until recently, assessment of the thoracic aorta by angiography preceded the investigation of the esophagus. This order has been recently debated.

METHODS

There were 118 patients with potential transmediastinal injuries included in this retrospective study. Unstable patients who were unresponsive to resuscitation were taken to the operating room without previous investigation. Stable patients were routinely investigated initially for injury of the aorta and then for injury of the esophagus.

RESULTS

There were 51 patients who underwent urgent thoracotomy/sternotomy. In 27, the hemorrhage was of mediastinal origin; 17 of these patients died of intraoperative bleeding. Eight of the patients had aortic injury, and only one of this group survived. There were 57 stable patients who were investigated initially for injury of the aorta by angiography. It was positive in only one patient who underwent an operation with good results. An investigation of the esophagus followed and revealed esophageal injury in 17 patients. All of them were treated operatively, 15 of them with satisfactory outcome.

CONCLUSIONS

Angiography should at present precede esophageal investigations. There is a need for shortening the time between admission and operation. Other modalities that could expedite the investigation of the thoracic aorta and the esophagus should be prospectively evaluated in multi-center studies.

Reviewing the process and outcome of hospital care in Europe: the tracer method

A method is described for reviewing and comparing the process and outcome of hospital care, which involves collecting data on a consecutive series of patients with the same medical condition. Criteria for choice of tracer condition are given, and illuminated with reference to fractured neck of femur. The method has been developed in the context of the European Collaborative Health Services Studies, and participants from five countries have been involved. It is concluded that the method is practicable and succeeds in its objectives. The role of health care managers is one of stimulus and support to doctors and nurses who might be interested in carrying out such studies, and a set of stages from the initial idea for a study, through study design and data collection to conclusions for practical change, is described.