Trauma Care in Low- and Middle-Income Countries

Financial toxicity and acute injury in the Kilimanjaro region: An application of the Three Delays Model

BACKGROUND

Trauma and injury present a significant global burden-one that is exacerbated in low- and middle-income settings like Tanzania. Our study aimed to describe the landscape of acute injury care and financial toxicity in the Kilimanjaro region by leveraging the Three Delays Model.

METHODS

This cross-sectional study used an ongoing injury registry and financial questionnaires collected at Kilimanjaro Christian Medical Centre (KCMC) in Moshi, Tanzania from December 2022 until March 2023. Financial toxicity measures included catastrophic expenditure and impoverishment, in accordance with World Health Organization standards. Descriptive analysis was also performed.

FINDINGS

Most acute injury patients that presented to the KCMC Emergency Department experienced financial toxicity due to their out-of-pocket (OOP) hospital expenses (catastrophic health expenditure, CHE: 62.8%; impoverishment, IMP: 85.9%). Households within our same which experienced financial toxicity had more dependents (CHE: 18.4%; IMP: 17.9% with ≥6 dependents) and lower median monthly adult-equivalent incomes (CHE: 2.53 times smaller than non-CHE; IMP: 4.27 times smaller than non-IMP). Individuals experiencing financial toxicity also underwent more facility transfers with a higher surgical burden.

INTERPRETATION

Delay 1 (decision to seek care) and Delay 2 (reaching appropriate care facility) could be significant factors for those who will experience financial toxicity. In the Tanzanian healthcare system where national health insurance is present, systematic expansions are indicated to target those who are at higher risk for financial toxicity including those who live in rural areas, experience unemployment, and have many dependents.

Sedation and analgesia in the trauma intensive care unit of Inkosi Albert Luthuli Central Hospital - the effect of anti-retroviral therapy: A retrospective chart analysis

PURPOSE

Adequate access to antiretrovirals (ARV) has improved the longevity and quality of life of people living with the human immunodeficiency virus(HIV). Antiretrovirals are known to cause multiple drug-drug interactions. It was noted clinically that patients on ARVs appeared to be more difficult to sedate. This begs the question of the clinical impact of these drug interactions, should clinicians adjust sedative dosages when managing patients on ARVs? This study aimed to investigate the presence of and measure the differences in sedation and analgesic utilisation between polytrauma patients on ARVs and those not on ARVs.

METHODS

This retrospective observational chart review included consecutive adult polytrauma patients admitted to the Trauma ICU IALCH between January 2016 and December 2019. HIV status and ARV use was documented. The total sedation per drug utilised at 24, 48 and 72-hour interval was calculated and tabulated accordingly. Drug utilisation was compared to ARV status.

RESULTS

A total of 216 adult polytrauma patients were included in the study. A total of 44 patients were HIV positive and 172 were HIV negative. Of the HIV positive patients 41 (93.2%) were on ARVs. Multiple comparisons were confirmed, however the primary analysis compared HIV negative patients with HIV positive patients on ARV. Total morphine, ketamine, midazolam and propofol doses were all numerically greater in patients on ARVs, although none of these reached statistical significance. The use of morphine rescue boluses during the first 72 h of ICU admission and the doses of ketamine and propofol on ICU day 3 were significantly greater in those on ARVs.

CONCLUSION

The data analysis showed that patients on ARVs required higher doses of some analgesia and sedation in ICU and lower doses of midazolam. This needs to be considered when sedating patients in a setting with a high HIV prevalence.

Challenges in traumatic spinal cord injury care in developing countries - a scoping review

Objective

To evaluate the leading challenges in developing countries' traumatic spinal cord injury (TSCI) care.

Methods

We conducted a systematic search in electronic databases of PubMed, SCOPUS, Web of Science, EMBASE, and Cochrane Library on 16 April 2023. Studies that investigated challenges associated with the management of TSCI in developing countries were eligible for review. We extracted related outcomes and categorized them into four distinct parts: injury prevention, pre-hospital care, in-hospital care, and post-hospital care.

Results

We identified 82 articles that met the eligibility criteria including 13 studies on injury prevention, 25 on pre-hospital care, 32 on in-hospital care, and 61 on post-hospital care. Challenges related to post-hospital problems including the personal, financial, and social consequences of patients' disabilities and the deficiencies in empowering people with TSCI were foremost studied. Lack of trained human resources, insufficient public education and delays in care delivery were barriers in the acute and chronic management of TSCI. A well-defined pre-hospital network and standard guidelines for the management of acute neurotrauma are needed. Critical challenges in injury prevention include deficiencies in infrastructure and supportive legislation.

Conclusion

Studies focusing on injury prevention and pre-hospital care in TSCI management in developing countries warrant further investigation. It is imperative to develop systematic and evidence-based initiatives that are specifically tailored to the unique circumstances of each country to address these challenges effectively. By understanding the primary obstacles, policymakers and healthcare providers can establish goals for improving education, planning, legislation, and resource allocation.

Age-Specific Differences in Laryngotracheal Trauma Characteristics: A Retrospective Study of Clinical Profiles, Outcomes, and Mortality Risk

Background: Laryngotracheal trauma is associated with a substantial risk of mortality. Age can be a critical factor in trauma management, as older adults often have diminished airway protective reflexes and preexisting respiratory conditions. Objective: This study aimed to characterize the clinical profiles and outcomes in different age groups of adult patients with laryngotracheal trauma using data from the National Trauma Data Bank (NTDB). Methods: We retrospectively analyzed the NTDB and included adult patients (aged ≥ 18 years) who had laryngotracheal fractures (closed or open) and were admitted directly after the injury. The patients were categorized into different age groups for analysis. A multivariate logistic regression analysis was performed to assess whether the elderly population (age ≥ 65 years) was predisposed to post-trauma death under care. Results: The study included 1171 patients, with the following age distributions: 13.7% aged 18-24 years, 21.6% aged 25-34 years, 55.2% aged 35-64 years, and 9.6% aged ≥ 65 years. Notable differences were observed in comorbidities, mechanisms, types of injuries, and associated injuries among age groups. There was no significant trend in airway surgical outcomes according to age. In-hospital mortality was highest among patients aged ≥ 65 years (22.3%), compared to 14.4% for those aged 18-24 years. Regression analysis indicated that age ≥ 65 was an independent mortality predictor. Conclusions: These findings underscore significant age-related differences in the presentation and outcomes of laryngotracheal trauma, emphasizing the need for age-specific treatment protocols, primarily to address the elevated risk among elderly patients.

Penetrating abdominal stab and gunshot injuries: 10-year experience of a secondary public hospital located in a suburban area with solo surgeons

OBJECTIVE

Trauma care systems are life-saving significant implementations of a country's healthcare systems. Trauma care requires well-established trauma settings and organizations with experienced trauma teams including experienced emergency medicine, surgery and anesthesiology staff. This study aimed to investigate the outcomes of penetrating abdominal injuries treated by solo surgeons in a suburban area.

METHODS

Medical records of the patients who were admitted to the emergency department with penetrating abdominal injuries between January 2012 and December 2021 were retrospectively analyzed. Patients were evaluated based on their injury sites and treatment approaches.

RESULTS

In total, 110 patients with anterior abdominal penetrating injuries were enrolled in the study; 83 (75.4%) were stabbed and 27 (24.6%) had gunshot wounds. According to the injury site, there were 90 (81.8%) anterior; 11 (11%) right thoracoabdominal and 9 (7.2%) left thoracoabdominal injuries. Fifty-one (61.4%) stab wounds were treated with immediate laparotomy and 21 (41.1%) of these operations resulted in negative or nontherapeutic laparotomy. Also, 32 (38.6%) stab wounds were managed nonoperatively; three (9.3%) failed conservative management and received delayed laparotomy. All gunshot wounds were treated with immediate laparotomy and 14.8% resulted in either negative or nontherapeutic laparotomy. On-call surgeons were found to be more prone to perform immediate laparotomy on weekends when they were on call for 48 or 72 hours.

CONCLUSION

Being a solo surgeon may increase negative laparotomy rates of penetrating abdominal injuries. This high percentage (41.1%) of negative laparotomy rates can be reduced by establishing well-organized trauma teams.

Care of Injured Children Compared to Adults at District and Regional Hospitals in Ghana and the Impact of a Trauma Intake Form: A Stepped-Wedge Cluster Randomized Trial

BACKGROUND

This study aimed to determine the effectiveness of a standardized trauma intake form (TIF) to improve achievement of key performance indicators (KPIs) of initial trauma care among injured children, compared to adults, at non-tertiary hospitals in Ghana.

METHODS

A stepped-wedge cluster randomized trial was performed with research assistants directly observing the management of injured patients before and after introducing the TIF at emergency units of 8 non-tertiary hospitals for 17.5 months. Differences in outcomes between children and adults in periods before and after TIF introduction were determined with multivariable logistic regression. Differences in outcomes among children after TIF introduction were determined using generalized linear mixed regression.

RESULTS

Management of 3889 injured patients was observed; 757 (19%) were children <18 years. Trauma care KPIs at baseline were lower for children compared to adults. Improvements in primary survey KPIs were observed among children after TIF introduction. Examples include airway assessment [279 (71%) to 359 (98%); adjusted odds ratio (AOR): 74.42, p = 0.005)] and chest examination [225 (58%) to 349 (95%); AOR 53.80, p = 0.002)]. However, despite these improvements, achievement of KPIs was still lower compared to adults. Examples are pelvic fracture evaluation [children: 295 (80%) vs adults: 1416 (88%), AOR: 0.56, p = 0.001] and respiratory rate assessment (children: 310 (84%) vs adults: 1458 (91%), AOR: 058, p = 0.030).

CONCLUSIONS

While the TIF was effective in improving most KPIs of pediatric trauma care, more targeted education is needed to bridge the gap in quality between pediatric and adult trauma care at non-tertiary hospitals in Ghana and other low- and middle-income countries.

TYPE OF STUDY

Stepped-wedged cluster randomized controlled trial.

LEVEL OF EVIDENCE

I.

Global Initiative for Children's Surgery (GICS) Pediatric Trauma Care Initiative: A Call for a Comprehensive Approach to a Global Problem

INTRODUCTION

Trauma is a major problem which has a significant health, social, and economic impact. Particularly, pediatric trauma carries substantial mortality and morbidity. This is a great concern for subspecialized general and pediatric surgeons. Therefore, a global initiative for pediatric trauma care is warranted and should be initiated.

AIM

The international association "Global Initiative for Children's Surgery" (GICS) would like to propose and organize a children's trauma care (CTC) initiative. This initiative should comprehensively address pediatric trauma management globally, especially in low- and middle-income countries (LMICs). The initiative seeks to achieve a structured cooperation and collaboration with respective sister organizations and local stakeholders.

METHODS

The initiative will address these relevant aspects: 1. first aid; 2. prehospital primary trauma care; 3. hospital primary trauma care; 4. advanced care (ATLS); 5. diagnostic facilities; 6. operation room (OR) equipment; 7. specialized surgical services; 8. rehabilitation; 9. registry, research, and auditing; 10. specialization in pediatric trauma; 11. capacity and confidence building in pediatric trauma; 12.

PREVENTION

The GICS CTC provided activities have been recorded and evaluated in a structured manner. This statement paper is based on data of a narrative review as well as expert opinions.

RESULTS

The Trauma Working Group of GICS provided specialized trauma prevention leaflets available for translation to different languages. A one-day children's primary trauma course has been designed to be delivered at the physical GICS meetings. Exercising advocacy, the group addressed several meetings on prevention of pediatric trauma, which included the 75th United Nations General Assembly (UNGA) (2020), GICS IVth meeting in Johannesburg (2020), Norwich (UK) Joint SPRINT Symposium on Pediatric Surgery for Pediatricians (2021), the second online Pan African Pediatric Surgical Association (PAPSA) meeting (2021), the seventh World Congress of the World Federation of Associations of Pediatric Surgeons (WOFAPS) in Prague (2022), and GICS pediatric trauma webinar (2023). Additionally, the working group participated in the preparations of a pediatric trauma module for the World Health Organization (WHO) and published several related studies. The contents of the selected articles added relevant information to the categories stated above.

CONCLUSIONS

The CTC initiative of GICS is proposed as a mean to address pediatric trauma comprehensively through a process of collaboration and advocacy with existing organizations to achieve awareness, health education, prevention, health, and training. Further, it will support the provision of suitable facilities to health institutions. The establishment of a specialization in pediatric trauma is encouraged. GICS CTC initiative aims to improve pediatric trauma care in LMICs by developing injury prevention strategies; optimizing the use of locally available resources; obtaining commitment by LMICs governments; improvement in all fields of hospital care; improvements in infrastructure, education and training, and attention to data registry and research.

The Global Macroeconomic Burden of Burn Injuries

BACKGROUND

Standardized estimates of global economic losses from burn injuries are lacking. The primary objective of this study was to determine the global macroeconomic consequences of burn injuries and their geographic distribution.

METHODS

Using the Institute of Health Metrics and Evaluation database (2009 and 2019), mean and 95% uncertainty interval (UI) data on incidence, mortality, and disability-adjusted life-years (DALYs) from injuries caused by fire, heat, and hot substances were collected. Gross domestic product (GDP) data were analyzed together with DALYs to estimate macroeconomic losses globally using a value of lost welfare approach.

RESULTS

There were 9 million global burn cases (95% UI, 6.8 to 11.2 million) and 111,000 deaths from burns (95% UI, 88,000 to 132,000 deaths) in 2019, representing a total of 7.5 million DALYs (95% UI, 5.8 to 9.5 million DALYs). This represented welfare losses of $112 billion (95% UI, $78 to $161 billion), or 0.09% of GDP (95% UI, 0.06% to 0.13%). Welfare losses as a share of GDP were highest in low- and middle-income countries (LMICs) of Oceania (0.24%; 95% UI, 0.09% to 0.42%) and Eastern Europe (0.24%; 95% UI, 0.19% to 0.30%) compared with high-income country regions such as Western Europe (0.06%; 95% UI, 0.04% to 0.09%). Mortality-incidence ratios were highest in LMIC regions, highlighting a lack of treatment access, with southern sub-Saharan Africa reporting a mortality-incidence ratio of 40.1 per 1000 people compared with 1.9 for Australasia.

CONCLUSIONS

Burden of disease and resulting economic losses because of burn injuries are substantial worldwide and are disproportionately higher in LMICs. Possible effective solutions include targeted education, advocacy, and legislation to decrease incidence and investing in existing burn centers to improve treatment access.

Community support for injured patients: A scoping review and narrative synthesis

BACKGROUND

Community-based peer support (CBPS) groups have been effective in facilitating access to and retention in the healthcare system for patients with HIV/AIDS, cancer, diabetes, and other communicable and non-communicable diseases. Given the high incidence of morbidity that results from traumatic injuries, and the barriers to reaching and accessing care for injured patients, community-based support groups may prove to be similarly effective in this population.

OBJECTIVES

The objective of this review is to identify the extent and impact of CBPS for injured patients.

ELIGIBILITY

We included primary research on studies that evaluated peer-support groups that were solely based in the community. Hospital-based or healthcare-professional led groups were excluded.

EVIDENCE

Sources were identified from a systematic search of Medline / PubMed, CINAHL, and Web of Science Core Collection.

CHARTING METHODS

We utilized a narrative synthesis approach to data analysis.

RESULTS

4,989 references were retrieved; 25 were included in final data extraction. There was a variety of methodologies represented and the groups included patients with spinal cord injury (N = 2), traumatic brain or head injury (N = 7), burns (N = 4), intimate partner violence (IPV) (N = 5), mixed injuries (N = 5), torture (N = 1), and brachial plexus injury (N = 1). Multiple benefits were reported by support group participants; categorized as social, emotional, logistical, or educational benefits.

CONCLUSIONS

Community-based peer support groups can provide education, community, and may have implications for retention in care for injured patients.

A qualitative assessment of Ukraine's trauma system during the Russian conflict: experiences of volunteer healthcare providers

BACKGROUND

The Russian Federation's invasion of Ukraine is characterized by indiscriminate attacks on civilian infrastructure, including hospitals and clinics that have devastated the Ukrainian health system putting trauma care at risk. International healthcare providers responded to the need for help with the increasing numbers of trauma patients. We aimed to describe their experiences during the conflict to explore the gaps in systems and care for trauma patients to refine the Global Trauma System Evaluation Tool (G-TSET) tool.

METHODS

We conducted qualitative key informant interviews of healthcare providers and business and logistics experts who volunteered since February 2022. Respondents were recruited using purposive snow-ball sampling. Semi-structured, in-depth interviews were conducted virtually from January-March 2023 using a modified version of the G-TSET as an interview guide. Interviews were transcribed verbatim and deductive thematic content analysis was conducted using NVivo.

FINDINGS

We interviewed a total of 26 returned volunteers. Ukraine's trauma system is outdated for both administrative and trauma response practices. Communication between levels of the patient evacuation process was a recurrent concern which relied on handwritten notes. Patient care was impacted by limited equipment resources, such as ventilators, and improper infection control procedures. Prehospital care was described as highly variable in terms of quality, while others witnessed limited or no prehospital care. The inability to adequately move patients to higher levels of care affected the quality of care. Infection control was a key issue at the hospital level where handwashing was not common. Structured guidelines for trauma response were lacking and lead to a lack of standardization of care and for trauma. Although training was desired, patient loads from the conflict prohibited the ability to participate. Rehabilitation care was stated to be limited.

CONCLUSION

Standardizing the trauma care system to include guidelines, better training, improved prehospital care and transportation, and supply of equipment will address the most critical gaps in the trauma system. Rehabilitation services will be necessary as the conflict continues into its second year.

Sustainable surgical resource initiative for Haiti: the SSRI-Haiti project

In response to the 2010 earthquake and subsequent cholera epidemic, St Luke's Medical Center was established in Port-au-Prince, Haiti. Here, we describe its inception and evolution to include an intensive care unit and two operating rooms, as well as the staffing, training and experiential learning activities, which helped St Luke's become a sustainable surgical resource. We describe a three-phase model for establishing a sustainable surgical centre in Haiti (build facility and acquire equipment; train staff and perform surgeries; provide continued education and expansion including regular specialist trips) and we report a progressive increase in the number and complexity of cases performed by all-Haitian staff from 2012 to 2022. The results are generalised in the context of the 'delay framework' to global health along with a discussion of the application of this three-phase model to resource-limited environments. We conclude with a brief description of the formation of a remote surgical centre in Port-Salut, an unforeseen benefit of local competence and independence. Establishing sustainable and collaborative surgery centres operated by local staff accelerates the ability of resource-limited countries to meet high surgical burdens.

Perioperative mortality among trauma patients in Northwest Ethiopia: a prospective cohort study

Trauma is the leading cause of mortality in persons under 45 and a significant public health issue. Trauma is the most frequent cause of perioperative mortality among all surgical patients. Little is known about perioperative outcomes among trauma patients in low-income countries. This study aimed to assess the incidence and identify predictors of perioperative mortality among adult trauma victims at Tibebe Ghion Specialised Hospital. From June 1, 2019, to June 30, 2021, a prospective cohort study was conducted at Tibebe Ghion Specialized Hospital. Demographic, pre-hospital and perioperative clinical data were collected using an electronic data collection tool, Research Electronic Data Capture (REDCap). Cox proportional hazard model regression was used to assess the association between predictors and perioperative mortality among trauma victims. Crude and adjusted hazard ratio (HR) with a 95% confidence interval (CI) was computed; a p-value < 0.05 was a cutoff value to declare statistical significance. One thousand sixty-nine trauma patients were enrolled in this study. The overall incidence of perioperative mortality among trauma patients was 5.89%, with an incidence rate of 2.23 (95% CI 1.74 to 2.86) deaths per 1000 person-day observation. Age ≥ 65 years (AHR = 2.51, 95% CI: 1.04, 6.08), patients sustained blunt trauma (AHR = 3.28, 95% CI: 1.30, 8.29) and MVA (AHR = 2.96, 95% CI: 1.18, 7.43), trauma occurred at night time (AHR = 2.29, 95% CI: 1.15, 4.56), ASA physical status ≥ III (AHR = 3.84, 95% CI: 1.88, 7.82), and blood transfusion (AHR = 2.01, 95% CI: 1.08, 3.74) were identified as a significant predictor for perioperative mortality among trauma patients. In this trauma cohort, it was demonstrated that perioperative mortality is a healthcare burden. Risk factors for perioperative mortality among trauma patients were old age, patients sustaining blunt trauma and motor vehicle accidents, injuries at night, higher ASA physical status, and blood transfusion. Trauma care services need improvement in pre-hospital and perioperative care.

Trauma and sexual abuse in children-Epidemiology, challenges, management strategies and prevention in lower- and middle-income countries

Trauma is rising as a cause of morbidity and mortality in lower- and middle-income countries (LMIC). This article describes the Epidemiology, Challenges, Management strategies and prevention of pediatric trauma in lower- and middle-income countries. The top five etiologies for non-intentional injuries leading to death are falls, road traffic injuries, burns, drowning and poisoning. The mortality rate in LMICs is twice that of High-Income Countries (HICs) irrespective of injury severity adjustment. The reasons for inadequate care include lack of facilities, transportation problems, lack of prehospital care, lack of resources and trained manpower to handle pediatric trauma. To overcome these challenges, attention to protocolized care and treatment adaptation based on resource availability is critical. Training in management of trauma helps to reduce the mortality and morbidity in pediatric polytrauma cases. There is also a need for more collaborative research to develop preventative measures to childhood trauma.

The History and Evolution of the West African College of Surgeons/Jos University Teaching Hospital Trauma Management Course

BACKGROUND

Inadequate trauma care training opportunities exist in Low- and Middle-Income Countries. Jos University Teaching Hospital and the West African College of Surgeons (WACS) have synergized, over the past 15 years, to introduce a yearly, certified, multidisciplinary Trauma Management Course. We explore the history and evolution of this course.

METHODS

A desk review of course secretariat documents, registration records, schedules, pre- and post-course test records, post-course surveys, and account books complemented by organizer interviews was carried out to elaborate the evolution of the Trauma Management Course.

RESULTS

The course was started as a local Continuing Medical Education program in 2005 in response to recurring cycles of violence and numerous mass casualty situations. Collaborations with WACS followed, with inclusion of the course in the College's yearly calendar from 2010. Multidisciplinary faculty teach participants the concepts of trauma care through didactic lectures, group sessions, and hands-on simulation within a one-week period. From inception, there has been a 100% growth in lecture content (from 15 to 30 lectures) and in multidisciplinary attendance (from 23 to 133 attendees). Trainees showed statistically significant knowledge gain yearly, with a mean difference ranging from 10.1 to 16.1% over the past 5 years. Future collaborations seek to expand the course and position it as a catalyst for regional emergency medical services and trauma registries.

CONCLUSIONS

Multidisciplinary trauma management training is important for expanding holistic trauma capacity within the West African sub-region. The course serves as an example for Low- and Middle-Income contexts. Similar contextualized programs should be considered to strengthen trauma workforce development.

National Trauma Registries in LMICs: Long-Overdue Priority Comment on "Neurotrauma Surveillance in National Registries of Low- and Middle-Income Countries: A Scoping Review and Comparative Analysis of Data Dictionaries"

The burden of trauma-related mortality is inversely related to income on an individual and national scale. Barthélemy et al highlight the significant variation of neurotrauma data included in national injury registries of low- and middle-income countries (LMICs) when compared to the World Health Organization (WHO) minimal dataset for injury (MDI). Moreover, the authors emphasize that the non-existence and underutilization of nationally standardized trauma registries hinder the data-driven identification of factors contributing to neurotrauma and subsequent attempts to improve neurotrauma care. Establishing a nationally standardized trauma registry should be prioritized by all stakeholders involved in curbing trauma-related mortality and building research capacity in LMICs. In this commentary, previous successful efforts to establish and maintain robust registries in LMICs through local and international partnerships are highlighted. The lessons and challenges chronicled in establishing such registries can inform future efforts to implement a nationally standardized trauma registry.

Abdominal Trauma Imaging in a Nigerian Tertiary Hospital-Our Experience with 87 Adult Patients

Introduction

Abdominal trauma is a major cause of morbidity and mortality in low- and medium-income countries (LMICs). Abdominal trauma imaging is important in determining the location and severity of organ injury, the need for surgery, and the identification of complications. The choice of imaging in abdominal trauma in LMICs is influenced by peculiar problems, which include the availability of imaging modality, expertise, and cost. There are few reports on options of trauma imaging in LMICs, and this study aimed to identify and characterise the type of imaging done for patients presenting with abdominal trauma at the University of Ilorin Teaching Hospital.

Materials and Methods

This was a retrospective observational study of patients with abdominal trauma who presented at the University of Ilorin Teaching Hospital from 2013 to 2019. Records were identified, and data were extracted and analysed.

Results

A total of 87 patients were included in the study. There were 73 males and 14 females. The abdominal ultrasound was the commonest modality done in 36 (41%) patients, whereas abdominal computed tomography was done in five (6%) patients. Eleven patients (13%) had no imaging done, and 10 of these patients proceeded to having surgery. In patients with intraoperative finding of perforated viscus, the sensitivity of radiography was 85% and specificity was 100%, whereas that of the ultrasound was 86.7% and 50% for sensitivity and specificity, respectively. The ultrasound scan was the commonest imaging done for patients who presented with features of haemorrhage (P = 0.04), odds ratio (OR) = 1.29 (95% confidence interval [CI] = 1.08-1.6), and patients with severe injury, P = 0.03, OR = 2.07 (95% CI = 1.06-4.06). Gender (P = 0.64), shock at presentation (P = 0.19), and mechanism of injury (P = 0.11) did not influence the choice of imaging.

Conclusions

Abdominal trauma imaging in this setting was majorly via ultrasound and abdominal radiographs. Factors suggested to influence the pattern of abdominal trauma imaging in LMICs include the availability of specific imaging modality, cost, lack of standardisation and definite abdominal trauma protocols.

Early Mortality Risk in Acute Trauma Patients: Predictive Value of Injury Severity Score, Trauma Index, and Different Types of Shock Indices

Objective: This study aimed to explore the predictive value of the Injury Severity Score (ISS), Trauma Index (TI) and different types of shock indices (SI) on the early mortality risk of acute trauma patients. Methods: Clinical data of acute trauma patients who met the inclusion and exclusion criteria of this study and were treated in the hospital from January 2020 to December 2020 were retrospectively collected, including gender, age, trauma mechanism, severe injury site, ISS, TI, admission vital signs, different types of shock indices (SI), death within 7 days, length of hospital stay, and Glasgow Outcome Score (GOS). The predictive value of the Injury Severity Score, Trauma Index, and different types of shock indices on the risk of early mortality in patients with acute trauma were compared using relevant statistical methods. Results: A total of 283 acute trauma patients (mean age 54.0 ± 17.9 years, 30.74% female) were included, and 43 (15.19%) of the patients died during 7 days of hospitalization. The admission ISS, TI, SI, MSI, and ASI in the survival group were significantly lower than those in the death group, and the difference was statistically significant (p < 0.05). Meanwhile, different trauma assessment tools included in the study have certain predictive value for early mortality risk of trauma patients. Conclusions: The TI indicates a better capability to predict the risk of early death in patients with acute trauma. As the most sensitive predictor, the SI has the greatest reference value in predicting the risk of early death in patients with traumatic shock.

Characteristics of road traffic mortality and distribution of healthcare resources in Thailand

Road traffic mortalities (RTMs), a leading cause of death globally, mostly occur in low- and middle-income countries, and having sufficient healthcare resources could lower the number of these fatalities. Our study aimed to illustrate the incidence of RTMs per 100,000 population and to compare the distribution of healthcare resources from 2011 to 2021 with rates of RTMs in the 77 provinces of Thailand. We divided the population into adults (≥ 15 years) and children (0-14 years). Lorenz curve and Gini coefficient were used to measure the level of distribution and equality of hospital resources and in relation to RTMs across the country. The average number of deaths was 30.34 per 100,000 per year, with male predominance. The RTM rates for adults and children were 32.71 and 19.08 per 100,000 respectively, and motorcycle accidents accounted for the largest percentage of deaths across all age groups. The Gini coefficient showed that operating rooms (0.42) were the least equally distributed hospital resource, while physicians were the most equally distributed (0.34). Anomalies were identified between the distribution of RTMs and available hospital resources. We hope our study will be beneficial in reallocating these resources more fairly to reflect the different numbers of traffic accidents in each province with the aim of reducing lower traffic-related deaths.