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Ntola VC, Hardcastle TC, Nkwanyana NM. Management of vascular injuries on ICU patients: KZN experience. Injury 2024; 55:111418. [PMID: 38336574 DOI: 10.1016/j.injury.2024.111418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/10/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024]
Abstract
BACKGROUND Vascular injury management remains an extremely challenging task. The fundamental principles of management are bleeding arrest and flow restoration, to avoid death and amputation. With advances in medicine, there has been a shift from ligation to primary repair which has resulted in a fall in amputation rate from 50 % in World War II to less than 2 % in civilian injuries. METHOD A retrospective cross-sectional study was conducted on ICU requiring polytrauma patients with vascular trauma admitted between January 2013 and December 2021. Additional data were collected prospectively from January 2022 to December 2022. All data was from an ethics approved Trauma Registry. The injury was either confirmed by imaging or via exploration. The pre-designed data proforma acquired the following variables: age, mechanism of injury, injured vessel, associated injury, management of the vessel, and management of the associated injury. The data were analysed using Stata version 17 (StataCorp, College Station TX). Frequencies and percentages were calculated to summarise numerical data An ethical clearance was granted by the University of KwaZulu-Natal BREC (BREC 0004353/2022) and the KZN Department of Health. All data were de-identified in the data collection sheet. RESULTS There were 154 arterial injuries and 39 venous injuries. The majority, 77 (50 %) of arterial injuries were managed via open strategies, and 36 (23 %) were managed via endovascular intervention. The majority, 20 (51 %) of venous injuries underwent open ligation, and 12 (31 %) were managed non-surgically. The highest number of endovascular interventions was observed in aortic injuries. For a total of 25 aortic injuries, 22 (83 %) were managed endovascular (TEVAR) and 2 (8 %) were managed non-operatively. CONCLUSION The choice between the endovascular and open approach depends on the injured blood vessel. The majority of venous injuries were treated with open ligation in this cohort.
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Affiliation(s)
- V C Ntola
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa.
| | - T C Hardcastle
- Department of Surgery, University of KwaZulu-Natal, Durban, South Africa; Trauma and Burns Service, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - N M Nkwanyana
- School of Nursing and Public Health, University of KwaZulu-Natal, South Africa
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Parag P, Hardcastle TC. Interpretation of emergency CT angiograms in vascular trauma - vascular surgeon vs radiologist. S AFR J SURG 2023; 61:77-82. [PMID: 37381804 DOI: 10.36303/sajs.3852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND This study aims to investigate any discrepancy in interpretation of computed tomography (CT) angiograms (CTA) in suspected traumatic arterial injury by vascular specialists and radiology specialists, and the influence of any discrepancies on patient outcome. METHODS A prospective observational comparative study of 6-month duration was undertaken at a tertiary hospital in Durban, South Africa. Haemodynamically stable patients with suspected isolated vascular trauma admitted to a tertiary vascular surgery service who underwent a CTA on admission were reviewed. The interpretations of CTAs were compared between vascular surgeons, vascular trainees and radiology trainees with the consultant radiologist report as the gold standard comparator. RESULTS Of 131 CTA consultant radiologist reports, the radiology registrar concurred with 89%, which was less than the vascular surgeon who correctly interpreted 120 out of 123 negative cases with three false positives. There were no false negatives or descriptive errors. A 100% sensitivity (95% CI 63.06-100) and 97.62% (95% CI 93.20-99.51) specificity was noted for the vascular surgeon. Overall agreement was 97.71 % with Cohen's kappa value = 0.83 (95% CI 0.64-1.00) indicating very good agreement. Apart from three negative direct angiograms, patient management and outcome were not impacted by the vascular surgeons' errors in interpretation. CONCLUSION There is very good inter-observer agreement in the interpretation of CTAs in trauma between the vascular surgeon and radiologist with no negative impact on patient outcome.
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Affiliation(s)
- P Parag
- Department of Radiology, Inkosi Albert Luthuli Central Hospital, South Africa and Department of Radiology, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, South Africa
| | - T C Hardcastle
- Trauma and Burns Services, Inkosi Albert Luthuli Central Hospital, South Africa and Department of Trauma and Surgery, Nelson R Mandela, School of Clinical Medicine, University of KwaZulu-Natal, South Africa
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Hardcastle TC, Kajee M, Lachenicht K, Van der Walt N. Approach to the diagnosis and management of snakebite envenomation in South Africa in humans. S Afr Med J 2023; 113:10-18. [PMID: 37170609 DOI: 10.7196/samj.2023.v113i5.666] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 01/13/2023] [Indexed: 05/13/2023] Open
Abstract
Snakebites occur in the community, not in the Emergency Unit. As such it is important to understand the first-aid concepts and pre-hospital emergency care aspects of this neglected disease. This article will highlight the concepts for emergency care within the context of the current pre-hospital arena and in light of the recent South African Snakebite Symposium consensus meeting held in July 2022, where wilderness rescue, emergency medical services and other medical participants agreed through evidence review and consensus debate on the current best approaches to care of the snakebite victim outside the hospital environment.
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Affiliation(s)
- T C Hardcastle
- Dept of Health KwaZulu-Natal, Surgical Sciences - UKZN, Health Sciences DUT.
| | - M Kajee
- 4. Registered Nurse. SASS organizing committee, Gauteng.
| | - K Lachenicht
- Emergency Care Practitioner, Rocket HEMS, Gauteng.
| | - N Van der Walt
- Emergency Care Practitioner, Access Professional Development, Vereeniging.
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R M, Pap R, Hardcastle TC. Variables required for the audit of quality completion of patient report forms by EMS—A scoping review. Afr J Emerg Med 2022; 12:438-444. [DOI: 10.1016/j.afjem.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 07/22/2022] [Accepted: 09/27/2022] [Indexed: 11/01/2022] Open
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Kabongo K, Naidoo N, Hardcastle TC. The spectrum and outcome of paediatric emergency surgical admissions - a regional hospital analysis. S AFR J SURG 2022; 60:124-127. [PMID: 35851367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Improving emergency surgical care for children requires information on the causes of admissions and the variables affecting outcome. There is a lack of such data in the South African context. METHODS This retrospective study was conducted from January 2016 to December 2017. Data was collected on all children (< 12 years of age) requiring admission with emergency surgical conditions. Infrastructure and staffing ratios were determined prior to data collection. Information was sourced from admission and discharge books, patient files and theatre registers. Variables of age, sex, referral source, diagnosis, length of stay, surgical treatment and outcome including death were collected. RESULTS Four hundred and thirty-five of the 1 048 children (42%) admitted were in the 0-2-year age group. Trauma (258), sepsis (564) and burns (226) were the main causes. The median hospital stay was 3 days (IQR 2-5), however, for burns patients, the median stay was 4 days (IQR 2-9). Surgery was performed on 279 (27%) admissions. Eight (0.8%) died, six of which were due to burns. Clinical status prior to death was poorly documented. A dedicated high care unit and burns isolation rooms were lacking. Surgeon/population and child/nurse ratios were respectively 1.48/100 000 and 7-12/1. CONCLUSION This study found that the emergency paediatric surgical burden is significant. Sepsis and trauma combined are the leading cause of emergency admissions. Burns had the highest mortality. Although mortality was low, improvements of staff to patient ratios and the institution of an early warning system could reduce mortality.
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Affiliation(s)
- K Kabongo
- Department of Surgery, Nelson R Mandela School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, South Africa
| | - N Naidoo
- Department of Surgery, Nelson R Mandela School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, South Africa
| | - T C Hardcastle
- Department of Surgery, Nelson R Mandela School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, South Africa
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Pillay RC, Kista Y, Hardcastle TC, Mohamed O. Intensive care unit hospitalisation costs associated with road traffic crashes at a central hospital in KwaZulu-Natal for the 2017/18 financial year. S AFR J SURG 2021; 59:47-51. [PMID: 34212570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND The financial and physical impacts of road traffic crashes are borne by the individual, the extended family, society, the health sector and the economy of the country. The main contributors to these costs are the loss of productivity and the accrual of ongoing healthcare costs over a long-term period. There is limited information available on the cost of admitting seriously injured patients post accidents to a central hospital intensive care unit. METHODS Cost data was obtained from the electronic database for all patients admitted for more than 24 hours to the trauma intensive care unit at Inkosi Albert Luthuli Central Hospital. A mixed costing approach was used. Data was collected on surgical procedures, imaging, laboratory tests, trauma receiving fees, pharmaceuticals, goods and services and compensation of employees. RESULTS The total cost of treating road traffic crash patients for the 2017/18 financial year equated to R21 140 475.49. The three main cost drivers comprised the compensation of employees (R12 135 848.41; 57.4%), goods and services (R5 083 182.12; 24%) and surgery costs (R1 429 321.00; 6.8%). The average cost per admission was R163 879.65, with the average cost per inpatient day equating to R12 727.56. Male patients admitted from motorcycle crashes had the highest cost per admission, followed by motor vehicle crashes and pedestrian vehicle crashes. CONCLUSION The cost and burden associated with road traffic crashes is reflective of national and international trends and will require a comprehensive strategy to reduce accidents as well as better management at the scene and at lower levels of care.
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Affiliation(s)
- R C Pillay
- Department of Public Health Medicine, School of Nursing and Public Health, Howard College, South Africa
| | - Y Kista
- Department of Public Health Medicine, School of Nursing and Public Health, Howard College, South Africa
| | - T C Hardcastle
- Trauma Service, Inkosi Albert Luthuli Central Hospital, South Africa and Department of Surgery, Nelson R Mandela School of Clinical Medicine, University of KwaZulu-Natal, South Africa
| | - O Mohamed
- Department of Public Health Medicine, School of Nursing and Public Health, Howard College, South Africa
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Naidoo R, Faurie MP, Oosthuizen GV, Hardcastle TC. Comparative outcome analysis of trauma and non-trauma emergency laparotomy using a modified NELA tool format. S AFR J SURG 2021; 59:12-19. [PMID: 33779099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Emergency laparotomy (EL) encompasses a diverse range of procedures that general surgeons commonly perform for both trauma and non-trauma related conditions in South Africa (SA). Despite differences in the underlying pathology and influence of the surgical procedure, these patients share one care pathway for preoperative, operative and postoperative care. This study reviewed patients undergoing trauma EL and non-trauma EL in a general surgery setting at a rural KwaZulu-Natal tertiary hospital to compare results between the groups using a modified National Emergency Laparotomy Audit (NELA) tool format. METHODS Consecutive adult patients undergoing midline EL at Ngwelezana Hospital between 1 March and 31 May 2018 were included. Patient factors analysed were demographic data (age, gender) and risk factors: National Confidential Enquiry into Perioperative Deaths (NCEPOD) grade, American Society of Anesthesiologists (ASA) grade, and comorbidity. Process of care factors included grade of the physician, time to surgery, time of surgery and duration of surgery. The primary outcome measure was mortality. Secondary outcome measures were intensive care unit (ICU) admissions, complications, and length of stay (LOS) > 14 days. RESULTS The study included 110 participants who met the inclusion criteria representing a total of 174 laparotomies. The trauma EL group had lower ASA grades (p = 0.003), less comorbidities (p = 0.002), more often went to theatre within six hours (42/56; 75.0%) (p < 0.001), more admissions to ICU (23/56; 41.1%) (p < 0.001), more complications (29/56; 51.8%) (p = 0.039), and higher length of stay > 14 days (16/56; 28.6%) (p = 0.037). CONCLUSION The trauma EL group represents a high-risk group for morbidity and mortality at Ngwelezana Hospital.
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Affiliation(s)
- R Naidoo
- Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa and Department of General Surgery, Ngwelezana Hospital, South Africa
| | - M P Faurie
- Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa and Faurie, Skinner and Partners Inc., Busamed Hillcrest Private Hospital, South Africa
| | - G V Oosthuizen
- Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa and Department of General Surgery, Ngwelezana Hospital, South Africa
| | - T C Hardcastle
- Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa and Trauma Service, Inkosi Albert Luthuli Central Hospital, South Africa
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Naidoo R, Faurie MP, Oosthuizen GV, Hardcastle TC. Comparative outcome analysis of trauma and non-trauma emergency laparotomy using a modified NELA tool format. S AFR J SURG 2021. [DOI: 10.17159/2078-5151/2021/v59n1a3421] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pillay V, Pillay M, Hardcastle TC. Renal trauma in a Trauma Intensive Care Unit population. S AFR J SURG 2019; 57:29-32. [PMID: 31773929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND For the majority of renal injuries, non-operative management is the standard of care with nephrectomy reserved for those with severe trauma. This study in a dedicated Trauma Intensive Care Unit (TICU) population aimed to assess the outcomes of renal injuries and identify factors that predict the need for nephrectomy. METHODS Patients, older than 18 years, admitted to TICU from January 2007 to December 2014 who sustained renal injuries had data extracted from the prospectively collected Class Approved Trauma Registry (BCA207-09). Patients who underwent surgical intervention for the renal injury or received non-operative management were compared. The key variables analysed were: patient demographics, mechanism of injury, grade of renal injury, presenting haemoglobin, initial systolic blood pressure, Injury Severity Score and Renal Injury AAST Grade on CT scan in patients who did not necessarily require immediate surgery, or at surgery in those patients who needed emergency laparotomy. RESULTS There were 74 confirmed renal injuries. There were 42 low grade injuries (grade I-III) and 32 high grade injuries (5 grade IV and 27 grade V). Twenty-six (35%) had a nephrectomy: 24 with grade V injuries and 2 with grade IV injuries required nephrectomy. Six patients in the high injury grade arm had non-operative management. A low haemoglobin, low systolic blood pressure, higher injury severity score, and a high-grade renal injury, as well as increasing age were positive predictors for nephrectomy in trauma patients with renal injury. CONCLUSION Non-operative management is a viable option with favourable survival rates in lower grade injury; however, complications should be anticipated and managed accordingly. High grade injuries predict the need for surgery.
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Affiliation(s)
- V Pillay
- Department of General Surgery, University of KwaZulu-Natal, South Africa
| | - M Pillay
- Department of Virology, Inkosi Albert Luthuli Central Hospital, South Africa
| | - T C Hardcastle
- Department of Surgery, University of KwaZulu-Natal, South Africa
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Gounder MG, Hardcastle TC, Muckart DJJ. A review of the complications encountered in a quaternary trauma intensive care unit in South Africa. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2019/v57n1a2733] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Mayet MC, Hardcastle TC, Muckart DJJ. Intra-abdominal injury identified by CTA in stable blunt polytrauma patients. S AFR J SURG 2019. [DOI: 10.17159/2078-5151/2019/v57n1a2715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Singh A, Urry RJ, Hardcastle TC. Five year review of open radical nephrectomies at a regional hospital in South Africa: room for improvement. S AFR J SURG 2018; 56:35-39. [PMID: 29638091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND To review the presentation and outcomes of patients undergoing open radical nephrectomy (ORN) for renal cell carcinoma (RCC) at a regional hospital in KwaZulu-Natal, South Africa. METHOD A retrospective chart review was performed of patients having undergone nephrectomy at St Aidan's hospital between 2010 and 2015, focusing on those with RCC. Demographic, operative, histopathology and outcomes data were collected. RESULTS Fifty-two patients (51%) had ORN for suspected malignant disease. Forty-one RCCs were found including one incidental finding at simple nephrectomy. Data was insufficient to assess risk factors for RCC. HIV positive patients tended to present earlier (45 vs. 53 years). The mean tumour size was 10 cm and organ confined disease was present in 73.2% of patients. Only 11 patients (26.8%) had pT1 disease. The high-grade complication rate was 9.8%, in-hospital mortality rate 4.9% and transfusion rate 51.2%. The median operating time was 1h 50min and length of hospital stay 13 days. CONCLUSION Open radical nephrectomy is the standard surgical treatment for RCC at regional level in South Africa. Patients tend to present at a younger age, particularly if HIV positive, and with large tumours. Further research into risk factors for RCC in the South African population is needed. There are high complication and transfusion rates in patients undergoing ORN. Review of accessibility of blood at St Aidan's hospital and revision of the transfusion protocol is suggested. A followup study to assess the feasibility and cost-effectiveness of laparoscopic nephrectomy in the resource-constrained South African environment is necessary.
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Affiliation(s)
- A Singh
- Department of Urology, Greys Hospital and Nelson R. Mandela School of Medicine, University of KwaZulu-NatalDepartment of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban
| | - R J Urry
- Department of Urology, Greys Hospital and Nelson R. Mandela School of Medicine, University of KwaZulu-NatalDepartment of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban
| | - T C Hardcastle
- Nelson R. Mandela School of Medicine, University of KwaZulu-Natal; Trauma Surgery Training Unit, Department of Surgery, University of KwaZulu-Natal and Trauma Service, Inkosi Albert Luthuli Central Hospital
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Bakkai A, Hardcastle TC, Sibanda W. Fracture patterns and complications related to pedestrian-vehicle collision victims in a public Level-1 Trauma Centre ICU population. SA orthop j 2018. [DOI: 10.17159/2309-8309/2018/v17n2a5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Singh A, Urry RJ, Hardcastle TC. Five year review of open radical nephrectomies at a regional hospital in South Africa: room for improvement. S AFR J SURG 2018. [DOI: 10.17159/2078-5151/2018/v56n1a2195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Saloojee A, Skinner DL, Loots E, Hardcastle TC, Muckart DJJ. Hepatic dysfunction: A common occurrence in severely injured patients. Injury 2017; 48:127-132. [PMID: 27599394 DOI: 10.1016/j.injury.2016.08.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/12/2016] [Accepted: 08/26/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hepatic dysfunction (HD) is a common finding in critically ill patients. The underlying pathophysiological process is one of either cholestasis or hypoxic liver injury (HLI). Using serum bilirubin, our study aimed to determine the incidence of HD in a critically ill trauma population, identify risk factors and analyse the impact on outcomes. METHODS A retrospective observational study was performed on all patients admitted to the Level 1 Trauma Unit ICU at Inkosi Albert Luthuli Central Hospital in Durban, South Africa (IALCH) from 01/01/2012 until 31/12/2012. HD was defined as a total bilirubin greater than 34.2μmol/l (2mg/dL). Additional demographic, physiological, biochemical, and pharmaceutical risk factors for hepatic dysfunction were identified and recorded. RESULTS Two hundred and twenty five patients were included in the study of whom 48 (21.3%) developed HD. An increased duration of ventilation (median 15days [inter-quartile range 6-19] vs 6days [IQR 3-11] p<0.001), prolonged length of stay (median 19days [IQR 8.5-31] vs 7days [IQR 3-13] p<0.001), and higher mortality rate (31.3% vs. 14.7% p=0.01) were all significantly associated with HD. Shock on admission was twice as common in patients developing HD (p<0.001). The only drugs associated with HD were piperacillin-tazobactam (p<0.001) and enalapril (p=0.04). On multivariable analysis however, HD was not associated with mortality. CONCLUSION HD was common in our study population, and was associated with other organ dysfunction, increased mortality and length of stay.
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Affiliation(s)
- A Saloojee
- Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - D L Skinner
- Department of Anaesthetics and Critical Care, Perioperative Research Group, University of KwaZulu-Natal, South Africa.
| | - E Loots
- Department of Surgery, Inkosi Albert Luthuli Central Hospital and University of KwaZulu-Natal, South Africa
| | - T C Hardcastle
- University of KwaZulu-Natal Trauma Surgery Training Unit, Deputy Director: IALCH Trauma Service and Trauma ICU, KwaZulu-Natal Department of Health, South Africa
| | - D J J Muckart
- Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
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Oshun N, Hardcastle TC. Validation of the mortality prediction equation for damage control surgery in an independent severe trauma population. S AFR J SURG 2015; 53:39-41. [PMID: 28240481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND A prediction model was developed in Cape Town which utilised age, preoperative lowest pH and lowest core body temperature to derive an equation for the purpose of predicting mortality in damage control surgery. It was shown to reliably predict death despite damage control surgery. The equation derivation dataset and the validation set showed the equation to have 100% positive predictive value (PPV) for both datasets and 24% sensitivity. The aim of the study was to validate the prediction model in an independent dataset from a prospective trauma registry. METHOD Retrospective analysis of an ethics-approved prospectively collected database and electronic medical records was performed on trauma patients undergoing damage control surgery at the Inkosi Albert Luthuli Central Hospital, Durban, between 2007 and 2013. Age, lowest preoperative core body temperature and the pH of the patients were analysed using the previously derived equation. The output from the equation was then classified as a prediction of death, based on the obtained values, and then compared to the actual outcome of whether the patients survived or died. RESULTS A total of 48 patient records were analysed in the study. Twenty-nine patients in the cohort died. The equation predicted mortality in only four cases, of whom three died and one survived (75% PPV and 10% sensitivity). The unexpected survivor reduced the PPV to 75%, compared to 100% PPV achieved in the original study. CONCLUSION The results of this study were inconsistent with those of the original study, and the 0.500 cut-off value used in the equation yielded PPV and sensitivity which were relatively non-clinically useful for the average patient in this cohort.
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Affiliation(s)
- N Oshun
- General Surgery, University of KwaZulu-Natal, Durban, South Africa
| | - T C Hardcastle
- Trauma Unit, Inkosi Albert Luthuli Central Hospital; University of KwaZulu-Natal, Durban, South Africa
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Skinner DL, Laing GL, Rodseth RN, Ryan L, Hardcastle TC, Muckart DJJ. Blunt cardiac injury in critically ill trauma patients: a single centre experience. Injury 2015; 46:66-70. [PMID: 25264354 DOI: 10.1016/j.injury.2014.08.051] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 08/13/2014] [Accepted: 08/31/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE This study describes the incidence and outcomes of blunt cardiac injury (BCI) in a single trauma intensive care unit (TICU), together with the spectrum of thoracic injuries and cardiac abnormalities seen in BCI. METHODS We performed a retrospective observational study of 169 patients with blunt thoracic trauma admitted from January 2010 to April 2013. BCI was diagnosed using an elevated serum troponin in the presence of either clinical, ECG or transthoracic echocardiography (TTE) abnormalities in keeping with BCI. The mechanism of injury, associated thoracic injuries and TTE findings in these patients are reported. RESULTS The incidence of BCI among patients with blunt thoracic trauma was 50% (n=84). BCI patients had higher injury severity scores (ISS) (median 37 [IQR 29-47]; p=0.001) and higher admission serum lactate levels (median 3.55 [IQR 2.4-6.2], p=0.008). In patients with BCI, the median serum TnI level was 2823ng/L (IQR 1353-6833), with the highest measurement of 64950ng/L. TTEs were performed on 38 (45%) patients with BCI, of whom 30 (79%) had abnormalities. Patients with BCI had a higher mortality (32% vs. 16%; p=0.028) and trended towards a longer length of stay (17.0 days [standard deviation (SD) 13.5] vs. 13.6 days [SD 12.0]; p=0.084). CONCLUSIONS BCI was associated with an increased mortality and a trend towards a longer length of stay in this study. It is a clinically relevant diagnosis which requires a high index of suspicion. Screening of high risk patients with significant blunt thoracic trauma for BCI with serum troponins should be routine practise. Patients diagnosed with BCI should undergo more advanced imaging such as TTE or TOE to exclude significant cardiac structural injury.
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Affiliation(s)
- D L Skinner
- Department of Critical Care, King Edward VIII Hospital, P/Bag X02 Congella 4013, Durban, KwaZulu-Natal 4083, South Africa; Perioperative Research Group, Department of Anaesthetics & Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
| | - G L Laing
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - R N Rodseth
- Perioperative Research Group, Department of Anaesthetics & Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Department of Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - L Ryan
- Perioperative Research Group, Department of Anaesthetics & Critical Care, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - T C Hardcastle
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Level I Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
| | - D J J Muckart
- Department of Surgery, Nelson R. Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa; Level I Trauma Unit and Trauma Intensive Care, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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Muckart DJJ, Pillay B, Hardcastle TC, Skinner DL. Vascular injuries following blunt polytrauma. Eur J Trauma Emerg Surg 2014; 40:315-22. [DOI: 10.1007/s00068-014-0382-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/20/2014] [Indexed: 10/25/2022]
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Dienstknecht T, Horst K, Sellei RM, Berner A, Nerlich M, Hardcastle TC. Indications for bullet removal: overview of the literature, and clinical practice guidelines for European trauma surgeons. Eur J Trauma Emerg Surg 2011; 38:89-93. [PMID: 26815824 DOI: 10.1007/s00068-011-0170-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2011] [Accepted: 11/28/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE The incidence of gunshot wounds from civilian firearms is increasing. Despite this fact, guidelines on indications for bullet removal are scarce. In this analysis, we combine an overview of the available literature in these rare entities with our experiences in our own clinical practices. METHODS We conducted a systematic literature search of computerized bibliographic databases (Medline, EMBASE, and the Cochrane Central Register). The local experience of the authors was reviewed in light of the available literature. RESULTS 145 full-text articles were suitable for further evaluation. Only six retrospective studies were available, and no prospective study could be retrieved. Most of the articles were case reports. In the South African co-author's own clinical practice, approximately 800 patients are treated per year with gunshot wounds. CONCLUSIONS In summary, there are only a few clear indications for bullet removal. These include bullets found in joints, CSF, or the globe of the eye. Fragments leading to impingement on a nerve or a nerve root, and bullets lying within the lumen of a vessel, resulting in a risk of ischemia or embolization, should be removed. Rare indications are lead poisoning caused by a fragment, and removal that is required for a medico-legal examination. In all other cases the indication should be critically reviewed.
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Affiliation(s)
- T Dienstknecht
- Department of Orthopaedic Trauma, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany.
| | - K Horst
- Department of Orthopaedic Trauma, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany
| | - R M Sellei
- Department of Orthopaedic Trauma, University of Aachen Medical Center, 30 Pauwels Street, 52074, Aachen, Germany
| | - A Berner
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - M Nerlich
- Department of Trauma Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - T C Hardcastle
- Departments of Health KZN and Surgery, Trauma Service, University of Kwazulu-Natal, Inkosi Albert Luthuli Central Hospital, Durban, South Africa
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Nel L, Jones LW, Hardcastle TC. Imaging the oesophagus after penetrating cervical trauma using water-soluble contrast alone: simple, cost-effective and accurate. Emerg Med J 2009; 26:106-8. [DOI: 10.1136/emj.2008.063958] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Hardcastle TC. Re: Pleural decompression and drainage during trauma reception and resuscitation [Injury 2008;39:9-20]. Injury 2009; 40:110-1; author reply 111. [PMID: 19070852 DOI: 10.1016/j.injury.2008.06.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Revised: 05/08/2008] [Accepted: 06/20/2008] [Indexed: 02/02/2023]
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Hardcastle TC. What's in a name? Terminology in emergency care in South Africa. S Afr Med J 2008; 98:658. [PMID: 19115497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
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Hardcastle TC, Goff T. Trauma unit emergency doctor airway management. S Afr Med J 2007; 97:864-867. [PMID: 17985058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
OBJECTIVES To audit indications for and practice (in terms of training/qualification) of definitive airway management compared with current UK practices. DESIGN Consecutive observational study. SETTING Tygerberg Academic Hospital Trauma Service, Western Cape. SUBJECTS All trauma patients either arriving intubated or requiring intubation at the Trauma unit during the period 1 - 31 August 2006. OUTCOME MEASURES A data collection proforma was completed either at the time of intubation or from medical records. Results. Fifty-seven patients required definitive airway management. In the unit 32 patients (56%) were intubated by emergency medicine registrars or medical officers, with rapid sequence intubations (RSIs) in all 32 (100%). Seven patients (12.3%) were intubated by paramedics pre-hospital, and 18 patients (31.6%) were intubated at referring hospitals by non-anaesthetists. Endotracheal intubation was successful in 55 patients (96.4%). Two patients (3.6%) could not be intubated and therefore underwent surgical cricothyroidotomy at the unit. Clinical outcomes included 12 patients (21%) extubated for ward transfer, 7 patients (12.3%) admitted to an intensive care unit (ICU), 21 patients (36.8%) taken for surgery, and 17 patients (29.8%) died. Motor vehicle accident (MVA) was the predominant mechanism of injury, accounting for 30 (52.6%) patients, while 16 patients (28.1%) had penetrating injuries (gunshot and/or stab wounds), 6 patients (10.5%) had blunt trauma, and the remaining 5 patients (8.8%) suffered serious burns. CONCLUSION The most common indication for intubation was a Glasgow Coma Score (GCS) of less than 8, typically in the polytrauma patient with suspected head injury due to MVA. Emergency doctors managed 100% of definitive airway in-hospital, and RSI was the favoured method. This differs greatly from the UK where non-anaesthetists only perform between 31% and 56% of trauma intubations, with the rest performed by anaesthetists. Outcome was, however, similar to that described in the literature.
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Affiliation(s)
- T C Hardcastle
- Department of Surgery, Stellenbosch University, W Cape, South Africa.
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Hardcastle TC, Du Toit DF, Malherbe C, Coetzee GN, Hoogerboord M, Warren BL, Modin CC. Traumatic abdominal wall hernia--four cases and a review of the literature. S AFR J SURG 2005; 43:41-3. [PMID: 16035382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
OBJECTIVE To review blunt traumatic abdominal wall hernias (TAWHs) in our institution. METHOD Retrospective review of blunt abdominal trauma cases over a 6-month period. RESULTS Four patients with TAWH were identified. The mean age was 36 years. Three had been involved in vehicular collisions, and 1 had been assaulted with a large stone. All were diagnosed on presentation, 3 by computed tomography scan and 1 clinically. Two were repaired as emergencies, and 1 was repaired after 4 months. The 4th patient refused surgery. CONCLUSION This uncommon injury requires a high index of suspicion and a low threshold for intervention. CT scan offers the best imaging potential.
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Affiliation(s)
- T C Hardcastle
- Department of Surgery and Section of Trauma, Stellenbosch University, Tygerberg, W Cape
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Hardcastle TC. Alcohol use among Cape Peninsula adolescents. S Afr Med J 1994; 84:172. [PMID: 7740360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
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