Abdominal stab wounds with retained knife: 15 years of experience from a major trauma centre in South Africa

INTRODUCTION

This study reviews our cumulative experience with the management of patients presenting with a retained knife following an abdominal stab wound (SW).

METHODS

A retrospective study was conducted at a major trauma centre in South Africa over a 15-year period from July 2006 to December 2020 including all patients who presented with a retained knife in the abdomen following a SW.

RESULTS

A total of 42 cases were included: 37 males (93%) with a mean age of 26 years. A total of 18 knives (43%) were in the anterior abdomen and 24 were posterior abdomen. Plain radiography was performed in 88% (37/42) of cases and computed tomography was performed in 81% (34/42); 90% (38/42) underwent extraction in the operating theatre. Laparotomy was performed in 62% (26/42). Of all the laparotomies performed, 77% (20/26) were positive for intra-abdominal organ or visceral injury. Overall morbidity was 31%. There were two mortalities (5%). Laparotomy was less commonly required for the posterior abdomen (33% (8/24) vs 100% (18/18), p<0.001). For retained knives in the anterior abdomen, 72% (13/18) of the laparotomies were positive for intra-abdominal organ or visceral injury. For the posterior abdomen, 7 of the 8 (88%) were positive for intra-abdominal organ or visceral injury. There were no differences in the need for intensive care unit admission, length of hospital stay, morbidities or mortalities.

CONCLUSIONS

Uncontrolled extraction of a retained knife in the abdomen outside of the operating theatre must be avoided. Retained knives in the anterior abdomen usually require formal laparotomy, but this is generally not required for posterior abdomen.

Use of Intermittent Aortic Balloon Occlusion: Report from the ABO Trauma Registry

Background: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a helpful adjunct in the managementof hemorrhagic shock due to bleeding in the abdomen or pelvis. Ischemia distal to the occlusion is a concern;intermittent aortic balloon inflation (i-REBOA) is a novel way to achieve decreased ischemia time.Methods: This study was conducted using data from the multinational ABO Trauma Registry. All patients enteredbetween January 2016 and December 2019 were included.Results: The sample consisted of 157 patients. There were 57 patients in the i-REBOA group (36%) and 100 in theREBOA group (64%). The groups were similar in gender (P = 0.50), age (P = 0.17), mechanism of injury (P = 0.42), andinjury severity score (P = 0.13). The levels of international normalized ratio (INR) (P < 0.01), activated partial thromboplastintime (aPTT) (P < 0.01) and lactate (P = 0.02) were higher in the i-REBOA group. Total balloon inflation times werelonger in the i-REBOA group (P < 0.01). Major complication rates did not differ between groups. Mortality rates betweengroups were similar in the Emergency Department (ED) (3.8% for i-REBOA vs 10.1%; P = 0.17), within 24 hours (43.4% fori-REBOA vs 38.2%; P = 0.54), and at 30 days (63.6% for i-REBOA vs 48.4%; P = 0.07).Conclusions: The data from this registry show that i-REBOA is currently being used and may allow for longer totalballoon inflation times without higher morbidity or mortality rates.

Penetrating colon trauma-the effect of concomitant small bowel injury on outcome

INTRODUCTION

There is limited evidence to suggest that patients with penetrating colon injury have higher complication rates when there is concomitant small bowel (SB) injury.

AIM

We performed a retrospective study looking at outcomes of penetrating colonic trauma in patients with- and without concomitant SB injury.

METHODS

We interrogated our electronic registry over an eight-year period (2012-2020) for all patients over 18 years who had sustained penetrating colon injury and who had survived beyond 72 h. Demographic data, admission physiology, and Injury Severity Score (ISS) were recorded. Two groups of patients were observed: those with colonic injury (no SB injury) and those with combined colon and SB injury. Outcomes observed included leak rates, length of Intensive Care Unit (ICU) stay, length of hospital stay (LOS), morbidity and mortality.

RESULTS

A total of 450 patients were eligible for analysis, of which 257 had colon injury without SB injury and 193 had a combination of colon and SB injury. There was no difference in mechanism of injury between groups. Admission physiology was similar between groups but arterial blood gas values were worse in the combined group. Rates of damage control surgery and ICU admission were higher in the combined group. Primary repair was done in equal proportions between groups but anastomosis was more frequently performed in the combined group. There was no difference in complication rates, including gastro-intestinal complications and suture line leaks. Length of ICU stay, LOS, and mortality were similar between groups. Univariable analysis demonstrated that the presence of concomitant small bowel injury was not an independent risk factor for colonic suture line failure or death.

CONCLUSION

There is no evidence from this data that the presence of a combined penetrating colon and SB injury should change management priorities. Each injury should be treated on its own merit, in the context of the patient's physiology.

Management of penetrating thoracic trauma with retained knife blade: 15-year experience from a major trauma centre in South Africa

INTRODUCTION

This study reviews our experience with the management a retained knife in the setting of thoracic stab wounds.

METHODS

A retrospective study was conducted at a major trauma in South Africa over a 15-year period from January 2004 to December 2018.

RESULTS

There were 40 patients, of whom 37 were males (93%). Median age was 24 years; 78% of cases (31 of 40) were a retained knife and 23% (9 of 40) were a retained blade. The locations of the stab wounds were 19 (48%) anterior and 21 (53%) posterior. Plain x-ray was performed in 85% (34) of patients and computed tomography angiography was performed in 85% (34). Six patients had haemodynamic instability and were expedited to the operating room without further imaging. Three of these had cardiac tamponade and three a massive haemothorax. Simple extraction and wound exploration were performed in 58% (23 of 40) of cases and the remaining 43% (17 of 40) required operative exploration and extraction. The operative approach was anterolateral thoracotomy in nine cases, posterolateral thoracotomy in four and median sternotomy in three cases. One patient required extraction and concurrent vertebral laminectomy due to cord compression. Twelve patients (30%) experienced complications (nine wound sepsis and three hospital-acquired pneumonia). There was one mortality (3%). The median length of hospital stay was 6 days.

CONCLUSION

Uncontrolled extraction of a retained thoracic knife outside the operating room must be avoided. An unstable patient should proceed directly for operative exploration. For stable patients, cross-sectional imaging will allow for planned extraction in operating room.

Refeeding syndrome in surgical patients post initiation of artificial feeding, a prospective cohort study in a low-income country

BACKGROUND & AIMS

South Africa's inequitable history has contributed to a malnourished population, further aggravated by high levels of violence and economic uncertainty culminating in a population suffering the sequelae of poverty. The perceived notion is that malnutrition places the South African population at greater risk for development of refeeding syndrome. This study aimed to identify the incidence of refeeding syndrome in the South African population.

METHODS

All patients admitted into the surgical intensive care unit from 1 November 2019 to 30 September 2020, were screened using the National Institute for Health and Care Excellence (NICE) refeeding risk criteria. Patients started on artificial feeds with one or more risk factors were included in the study. The syndrome was confirmed using the King's College criteria and compared with the American Society for Parenteral and Enteral Nutrition (ASPEN) criteria for refeeding syndrome.

RESULTS

200 Patients were included in this study. The median age of the sample population was 41 years (IQR 30-58) with a male predominance (63%). All patients included had one or more risk factors and 62 (31%) of patients fulfilled the NICE criteria. The sensitivity of the NICE criteria was 33% and specificity was 70%. The most common risk factors identified were little or no nutritional intake for >5 days (55%) followed by a history of alcohol abuse, drugs including insulin, chemotherapy, diuretics or antacids (18%). Specificity values for all risk factors were >80% apart from little or no nutritional intake for >5 days which had a specificity of 64.2%. Sensitivity values for all risk factors were low. 84.5% of patients received artificial nutritional support in the form of enteral feeds, 9% parenteral and 6.5% both enteral and parenteral feeds. A total of 146 patients required electrolyte supplementation. Three patients fulfilled the King's College criteria and one subsequently died. In comparison, 25 patients fulfilled the ASPEN criteria and 3 demised.

CONCLUSION

Due to the low sensitivity and specificity of the NICE criteria, we advise that it be used merely as a guideline to identify patients at risk of refeeding syndrome and one should remain vigilant in patients with any risk factors present. Due to the small number of patients who fulfilled the King's College criteria and significant difference in incidence when compared to the ASPEN definition, a conclusion regarding the accuracy of both diagnostic criteria could not be made. We recommend a review of the current definition and a global adoption of an agreed criteria for the estimation of the true prevalence.

Penetrating colonic trauma and damage control surgery: Anastomosis or stoma?

BACKGROUND

The management of colon injuries in damage control surgery (DCS) remains controversial.

METHODS

A retrospective study investigating outcomes of penetrating colonic trauma in patients who survived beyond the initial repeat laparotomy (IRL) after DCS was performed. Patients over 18 years with penetrating colon injury and who underwent DCS from 2012 to 2020 were included from our electronic trauma registry. Demographic data, admission physiology and Injury Severity Score (ISS) were reviewed. Patients were classified into three groups: primary repair of non-destructive injuries at DCL, delayed anastomosis of destructive injuries at IRL and diversion of destructive injuries at IRL. Outcomes observed included leak rates, length of intensive care unit stay, length of hospital stay, morbidities, mortality and colon-related mortality.

RESULTS

Out of 584 patients with penetrating colonic trauma, 89 (15%) underwent DCS. After exclusions, 74 patients were analysed. Mean age was 32.8 years (SD 12.5); 67 (91%) were male. Mechanism of injury was gunshot in 63 (85%) and stab 11 (15%) patients. Seventeen patients underwent primary repair at DCS, of which one leaked. Twenty patients underwent delayed anastomosis at IRL. Of these, five (25%) developed leaks. Mortality was significantly higher for those with an anastomotic leak compared to those without (p < 0.001). Thirty-seven patients were diverted at IRL. Overall mortality (p = 0.622) and colon-related mortality (p = 0.592) were not significantly different across groups.

CONCLUSION

Delayed anastomosis at IRL following DCL was associated with a leak rate of 25% in this study. When anastomotic leak did occur, it was associated with significant mortality. Delayed anastomosis should only be undertaken in highly selected patients.

Prospective review of cytotoxic snakebite envenomation in a paediatric population

Cytotoxic snakebite envenomation is prevalent in Kwazulu-Natal and may be associated with significant physical disability. The aim of this study was to provide an overview of the effects of cytotoxic envenomation in children. The patient population were all patients attending the Emergency Department at Ngwelezana Tertiary Hospital with snakebite from December 2014 to March 2015. All children 13 years or younger presenting with painful progressive swelling (PPS) following snakebite were included in this study. They were further classified according to severity: mild, moderate and severe. Patient demographic and clinical data was collected prospectively. Fifty-one children were included in this study. Nine were classified as mild, 24 as moderate and 18 as severe. The median time of presentation after bite was 6 h in the mild group, 7 h in the moderate group and 12 h in the severe group. There was a positive correlation between increasing severity and INR (p=< .00001) and no correlation between WCC (p = .175) or renal function and severity (p = .963). A total of 11 children (22%) developed an acute kidney injury (AKI). A total of 23/51 patients received antivenom; 25% of patients with moderate cytotoxicity and 94% of patients with severe cytotoxicity. Thirteen percent developed allergic reactions (3/23) and 57% (13/23) anaphylaxis. A total of 15 patients underwent one or more procedures on their affected limbs. There was one recorded mortality during this period, related to severe anaphylaxis following antivenom administration. Access to healthcare for antivenom administration is often delayed and ongoing education within affected areas is advised. Whilst majority of snakebite victims can be adequately managed with basic supportive measures, early identification of severe envenomation is crucial to enable timeous antivenom administration and prevention of further complications such as compartment syndrome and loss of limb. Hypersensitivity reactions are alarmingly common following antivenom administration in children and strict protocols should be followed when administering antivenom.

The spectrum of animal related injuries managed at a major trauma centre in South Africa

BACKGROUND

Humans come into contact and interact with an array of animals in a number of areas and environments. We set out to review our experience with animal-related injuries in Pietermaritzburg, KwaZulu-Natal, South Africa.

METHOD

All patients who sustained an injury secondary to an interaction with an animal in the period December 2012-December 2017 were identified from the Hybrid Electronic Medical Registry (HEMR).

RESULTS

There were 104 patients in the study sample. The mean age of patients in the study was 32.8 years, with a range from 1 to 76 years old. 75% (n = 78) were male and 25% (n = 26) female. Out of the 104 animal-related injuries, 67 were blunt trauma, 39 penetrating trauma and 3 a combination of blunt and penetrating trauma. The species causing trauma included dogs (53), horses (29), cows (18), buffalo (1), warthog (1), impala (1) and a single goat (1). The median time from injury to hospitalisation was 46.62 hours (range from 0 to 504 hours). Injuries occurred to the head (n = 32), face (n = 9), neck (n = 32), abdomen (n = 22), urogenital system (n = 6), upper limb (n = 39) and lower limb (n = 39). The Injury Severity Score (ISS) mean for the patients was 8.16, the range 1-4, the median 9 and the standard deviation 6.88. In 49 patients the treatment was non-operative. In the remaining 55 patients, a total of 68 operative procedures were required. Operations included wound debridement/surgical washout (n = 38), laparotomy (n = 9), arterial repair/ligation (n = 8), skin graft (n = 4), craniotomy (n = 5), fasciotomy (n = 2), amputation (n = 1), and placement of an ICP monitor (n = 1). 49 of these operations were for patients with dog bite injuries. The mean hospital stay was 0.13 days with a range of 0-4 days. Four patients were admitted to the Intensive Care Unit (ICU) and two patients died.

CONCLUSION

Human interactions with animals may result in injuries which require surgical treatment. The most common animal injury is a dog bite but in the case of the larger domestic farm animals, blunt force type injuries and goring can result in significant injuries which require complex surgical interventions.

Damage control or definitive repair? A retrospective review of abdominal trauma at a major trauma center in South Africa

Background

This study set out to review a large series of trauma laparotomies from a single center and to compare those requiring damage control surgery (DCS) with those who did not, and then to interrogate a number of anatomic and physiologic scoring systems to see which best predicted the need for DCS.

Methods

All patients over the age of 15 years undergoing a laparotomy for trauma during the period from December 2012 to December 2017 were retrieved from the Hybrid Electronic Medical Registry (HEMR) at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, namely the DCS and non-DCS cohort, based on what was recorded in the operative note. These groups were then compared in terms of demographics and spectrum of injury, as well as clinical outcome. The following scores were worked out for each patient: Penetrating Abdominal Trauma Index (PATI), Injury Severity Score, Abbreviated Injury Scale-abdomen, and Abbreviated Injury Scale-chest.

Results

A total of 562 patients were included, and 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. The mechanism was penetrating trauma in 81% of cases (453 of 562). A large proportion of trauma victims were male (503 of 562, 90%), with a mean age of 29.5±10.8. An overall mortality rate of 32% was recorded for DCS versus 4% for non-DCS (p<0.001). In general patients requiring DCS had higher lactate, and were more acidotic, hypotensive, tachycardic, and tachypneic, with a lower base excess and lower bicarbonate, than patients not requiring DCS. The most significant organ injuries associated with DCS were liver and intra-abdominal vascular injury. The only organ injury consistently predictive across all models of the need for DCS was liver injury. Regression analysis showed that only the PATI score is significantly predictive of the need for DCS (p=0.044). A final multiple logistic regression model demonstrated a pH <7.2 to be the most predictive (p=0.001) of the need for DCS.

Conclusion

DCS is indicated in a subset of severely injured trauma patients. A pH <7.2 is the best indicator of the need for DCS. Anatomic injuries in themselves are not predictive of the need for DCS.

Levels of evidence

Level III.

Laparotomy for organ evisceration from abdominal stab wounds: A South African experience

INTRODUCTION

Organ evisceration following abdominal stab wound (SW) is currently considered as an absolute indication for mandatory laparotomy due to the high incidence of associated intra-abdominal injuries, but literature describing the spectrum of organ injury encountered is limited.

MATERIALS AND METHODS

We reviewed our experience of 301 consecutive patients who were subjected to mandatory laparotomy over an eight-year period at a major trauma centre in South Africa.

RESULTS

Of the 301 patients with organ evisceration, 92% were male (mean age: 28 years). Ninety per cent (270/301) of the laparotomies were positive (85% (229/270) therapeutic, 15% (41/270) non-therapeutic). The frequencies of eviscerated organs were small bowel (70%), large bowel (26%), and stomach 3%. Three (1%) patients had combined evisceration of more than one of the above organs. The most commonly injured organs were small bowel and large bowel. The mean length of hospital stay was nine days. Seven patients required intensive care admission. The morbidity rate was 21% and mortality was 2%.

CONCLUSIONS

The spectrum of injury associated with abdominal SW with organ evisceration is similar to smaller published series. Multiple organ injuries are common. The most commonly eviscerated organs were small bowel, large bowel and stomach, while the most commonly injured organs were small bowel and large bowel.

Lessons learnt from the Pietermaritzburg experience with damage control laparotomy for trauma

INTRODUCTION

The modern concept of damage control surgery (DCS) for trauma was first introduced less than three decades ago. This audit aims to describe the spectrum and outcome of patients requiring DCS, to benchmark our experience against that reported from other centres and countries and to distil the pertinent teaching lessons from this experience.

METHODS

All patients over the age of 15 years undergoing a laparotomy for trauma over the period from December 2012 to July 2016 were retrieved from the trauma registry of the Pietermaritzburg Metropolitan Trauma Service, South Africa. Physiological parameters and visceral injuries were assessed. Statistical analysis was performed using STATA V.15.0.

RESULTS

A total of 562 patients underwent trauma laparotomy during the period under review. The mechanism was penetrating trauma in 81% of cases (453/562). A great proportion of trauma victims were male (503/562, 90%), with a mean age of 29.5±10.8. A total of 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. Out of the 99 who required DCS, there were 32 mortalities (32%). The mean physiological parameters for the DCS patient demonstrated acidosis (pH 7.28±0.15) with a raised lactate (5.25 mmol/L±3.71). Our primary repair rates for enteric injuries were surprisingly high.

CONCLUSION

Just under 20% of trauma laparotomies require DCS. In this cohort of patients, the mortality rate is just under one-third. Further attention must be paid to refining the appropriate indications for DCS as the margin for error in such a cohort is very small and poor decision-making is difficult to correct. The major lesson from this analysis is that the decision to perform DCS must be made early and communicated appropriately to all those managing the patient.