The spectrum and outcome of paediatric traumatic brain injury in KwaZulu-Natal Province, South Africa has not changed over the last two decades

Objectives. This retrospective review of a prospectively entered and maintained hybrid electronic trauma registry was intended to develop a comprehensive overview of traumatic brain injury (TBI) in children and adolescents and to compare it with previous audits from our local environment and from other developing world centres. All TBI patients admitted to hospital were included in this study. We reviewed the age, gender, outcomes, radiological findings and treatment of the patients.Methods. All patients aged ≤18 years old who were admitted by the Pietermaritzburg Metropolitan Trauma Service (PMTS) with TBI between December 2012 and December 2016 were included in this audit. Results. During the 4-year period under review, a total of 563 children and adolescents were treated for TBI by the PMTS.  The median age was 6.4 years and 29% (n=165) were females. The mechanism of TBI was blunt trauma in 96% (n=544) of cases, with 4% (n=19) suffering penetrating trauma. The penetrating mechanisms included impalement by a cow horn and miscellaneous injuries due to saws, axes, barbed wire, spades, stones and knives. The blunt mechanisms included falls (n=102), assaults (n=108), collapse of a building (n=28), bicycle-related injury (n=14), falling off a moving vehicle (n=280), motor vehicle accident (MVA; n=59), pedestrian vehicle accident (PVA; n=183) and animal-related injuries (n=8). There were 454 (80%) mild, 67 (12%) moderate and 42 (7%) severe cases of TBI. A total of 48 patients were admitted to the intensive care unit and 23 were admitted to the high care unit. Nine patients died.  All the deaths were in the MVA and PVA group. The spectrum of TBI as diagnosed on computed tomography scans was nonspecific cerebral contusion (n=92), depressed skull fracture (n=70), sub-arachnoid haemorrhage (n=60), extradural haemorrhage (n=41), intracerebral haemorrhage (n=19), free air (n=19), subdural haemorrhage (n=13), intraventricular haemorrhage (n=9). A total of 62 (11%) patients required surgery.Conclusion. There is a significant burden of paediatric TBI in Pietermaritzburg. The majority of TBI was related to blunt trauma and assaults were very common.  Although the short-term outcomes are good, the long-term consequences are poorly understood. Injury prevention programmes are needed to help reduce this burden of disease and a nationwide trauma registry is long overdue.

Venous bicarbonate and creatine kinase as diagnostic and prognostic tools in the setting of acute traumatic rhabdomyolysis

Background. Myorenal or crush syndrome often develops following soft-tissue traumatic injury. It is a spectrum of disease that may result in severe renal dysfunction and kidney injury requiring renal replacement therapy.Objectives. To review a large cohort of patients with so-called myorenal or crush syndrome and assess the biochemical markers of venous bicarbonate and creatine kinase as predictors for the development of acute kidney injury (AKI).Methods. All patients with myorenal syndrome who presented to Khayelitsha District Hospital, Cape Town, South Africa (SA), and Ngwelezana Hospital, Empangeni, KwaZulu-Natal, SA, between January and December 2017 were identified and reviewed.Results. A total of 212 patients were included in the study. At both hospitals, 94% of the patients were male. Using the Pearson correlation coefficient, we compared creatinine kinase (CK) against serum creatinine. The mean CK level was 5 311.8 U/L and the mean creatinine level 133.457 μmol/L. The r-value was 0.2533. Although this is a technically positive correlation, the relationship between the variables is weak. Using the Pearson R Calculator, we inserted the r-value to calculate the p-value. The p-value was 0.000208. When comparing venous bicarbonate (HCO3) against creatinine, the mean HCO3 level was 22.296 mmol/L and the mean creatinine level 162.053 μmol/L. The r-value was –0.3468. Although this is a technically negative correlation, the relationship between the variables is weak. Using the Pearson R Calculator, we inserted the r-value to calculate the p-value. The p-value was 0.000013. The inverse ratio shown with HCO3 v. creatinine, although still a weak correlation, is significantly better in predicting an increase in creatinine compared with the weak positive correlation of CK v. creatinine.Conclusions. Although both venous HCO3 and CK showed a weak correlation with creatinine, the former performed significantly better in predicting AKI. In a resource-constrained system, we recommend that HCO3 be measured to assess patients with crush injury and that CK be regarded as a complementary modality

Hanging-related injury in Pietermaritzburg, South Africa

Background. Hanging is a common form of self-harm, and emergency care physicians will not infrequently be called upon to manage a survivor.Despite the relative frequency of the injury, there is a paucity of literature on the topic and the spectrum and incidence of associated injuries are poorly described.Objectives. To review experience with management of victims of hanging at a major trauma centre in South Africa.Methods. All patients treated by the Pietermaritzburg Metropolitan Trauma Service following a hanging incident between December 2012 and December 2018 were identified from the Hybrid Electronic Medical Registry. Basic demographics were recorded, and the management and outcome of each patient were noted.Results. During the 6-year period under review, a total of 154 patients were seen following a hanging incident. The mean age was 29.4 years. There were 24 females (15.6%) and 130 males (84.4%). The vast majority (n=150; 97.5%) had attempted suicide, and only 4 hangings (2.5%) were accidental. A total of 92 patients (60.9%) had consumed alcohol prior to the incident. There were 23 patients with a Glasgow Coma Score (GCS) <9 (severe traumatic brain injury (TBI)), 14 with a GCS of 9 - 12 (moderate TBI) and 117 with a GCS >12 (mild TBI). A total of 7 patients (4.5%) required intensive care unit admission, and 25 (16.2%) required intubation. The following extracranial injuries were documented on computed tomography scans: hyoid bone fractures (n=2), cervical spine fracture (n=10), mandible fracture (n=4) and oesophageal injury (n=1). Intracranial pathology was evident on 27.0% of scans, with the most common finding being global cerebral ischaemia. The mortality rate was 2.5% (4/154).Conclusions. Hanging is a common mechanism of self-harm. It is associated with significant injuries and mortality. The acute management of hanging should focus on airway protection followed by detailed imaging of the head and neck. Further work must attempt to include mortuary data on hanging.

Validation of the Simplified Motor Score in patients with traumatic brain injury at a major trauma centre in South Africa

Background. This study used data from a large prospectively entered database to assess the efficacy of the motor score (M score) component of the Glasgow Coma Scale (GCS) and the Simplified Motor Score (SMS) in predicting overall outcome in patients with traumatic brain injury (TBI).Objective. To safely and reliably simplify the scoring system used to assess level of consciousness of trauma patients in the acute setting.Methods. A retrospective observational review of the Pietermaritzburg Metropolitan Trauma Service hybrid electronic medical registry database was performed during the period January 2013 - December 2015. Patients were classified into three groups using their GCS as an injury severity score. These were mild TBI (GCS 13 - 15), moderate TBI (GCS 9 - 12) and severe TBI (GCS <9). The Glasgow M score was specifically evaluated to determine the relationship between the individual motor component and patient outcome.Results. GCS scores and M scores were analysed in a total of 830 patients. There was a decline in survival rate when the M score on admission was ≤4. The decline was more significant when the M score was ≤3. Survival rates were 26.8% (11/41) for patients with an M score of 1, 63.6% (14/22) for those with a score of 2, 56.5% (13/23) for those with a score of 3, 80.0% (20/25) for those with a score of 4, and 95.5% (121/128) for those with a score of 5. Of 591 patients with an M score of 6, 580 (98.1%) survived. Mortality rose dramatically with declining SMS. This was highly significant. When the M score was plotted against mortality in 830 patients, there was a correct prediction in 769 cases (accuracy 92.7%, sensitivity 67.6%, specificity 95%). The area under the receiver operating characteristic (ROC) curve was 0.9037, with a standard deviation (area) of 0.0227. When comparing the SMS against mortality, the accuracy was 77.1%, the sensitivity 84.5% and the specificity 76.4%. The fitted ROC area was 0.891 and the empirical ROC area 0.86.Conclusion. The M score component of the GCS and the SMS accurately predict outcome in patients with TBI. In cases where the full GCS is difficult to assess, the M score and SMS can be used safely as a triage tool.

An analysis of adverse events and human error associated with the imaging of patients at a major trauma centre in South Africa

Background. There is growing realisation that human error contributes significantly to morbidity and mortality in modern healthcare. A number of taxonomies and classification systems have been developed in an attempt to categorise errors and quantify their impact.Objectives. To record and identify adverse events and errors as they impacted on acute trauma patients undergoing a computed tomography (CT) scan, and then quantify the effect this had on the individual patients. It is hoped that these data will provide evidence to develop error prevention programmes designed to reduce the incidence of human error.Methods. The trauma database was interrogated for the period December 2012 - April 2017. All patients aged >18 years who underwent a CT scan for blunt trauma were included. All recorded morbidity for these patients was reviewed.Results. During the period under review, a total of 1 566 patients required a CT scan at our institution following blunt trauma. Of these, 192 (12.3%, 134 male and 58 female) experienced an error related to the process of undergoing a CT scan. Of 755 patients who underwent a CT scan with intravenous contrast, detailed results were available for 312, and of these 46 (14.7%) had an acute deterioration in renal function. According to Chang’s taxonomy, physical harm occurred as follows: grade I n=6, grade II n=62, grade III n=45, grade IV n=11, grade V n=27, grade VI n=21, grade VII n=15, grade VIII n=3 and grade IX n=2. Adverse events were performing an unnecessary scan (n=24), omitting an indicated scan (n=23), performing the scan incorrectly (n=8), scanning the wrong body part (n=7), equipment failure (n=18), omitting treatment following the scan (n=6), incorrect interpretation of the scan (n=65), deterioration during the scan (n=6) and others (n=35). The setting for the error was the ward (n=19), the radiology suite (n=126), the emergency department (n=45) and the operating theatre (n=2). The staff responsible for the adverse events were medical (n=155), nursing (n=4) and radiology staff (n=15). There were 67 errors of commission and 125 errors of omission. The primary cause was a planning problem in 78 cases and an execution problem in 114.Conclusions. Errors and adverse events related to obtaining a CT scan following blunt polytrauma are not uncommon and may impact significantly on the patient. Communication is essential to eliminate errors related to performing the wrong type of scan. The commonest errors relate to misinterpretation of the scan

Theology at the University of Pretoria - 100 years: (1917-2017) Past, present and future

In this scholarly book, a century’s theology presented by the Faculty of Theology at the University of Pretoria, is celebrated. All authors are academics or research associates of the University of Pretoria. A historical and futuristic overview with perspectives from the past, present and future, are examined. The past is not only portrayed by means of societal and scientific contributions and achievements, but the authors also reflect on malfunctions, ill behaviour and disappointments of church and theology, presented at the University of Pretoria within the South African context over 100 years. The book commences with a chapter in which institutional transformation is discussed, as well as the changes that demonstrate the role of the Faculty of Theology within a secular state university. It includes an explanation of the importance of research impact, research productivity and research reputation. Among various discipline indicators, the category Theology and Religion Studies plays a significant role in the measurement of world university rankings of universities. With regard to scientific and encyclopaedic content, the book focuses on the theological disciplines presented in the academic curricula: first the biblical sciences (Old and New Testament Studies), then the historical disciplines (Systematic Theology, Church History and Church Polity), and finally the practical disciplines (Practical Theology, Science of Religion and Missiology). The role of Religion Studies in a newly established Faculty of Theology and Religion not only enhances the diversity of interreligious tolerance and an atmosphere of dialogue, but it serves as platform to interconnect with the fields of Humanities, Social and Natural Sciences and other academic disciplines. In the conclusive part of the book, contributions highlight the role of the centres in the Faculty (Centre for Contextual Ministry and Centre for Sustainable Communities), as well as the continental and international footprints of the two theological journals whose title ownership is attached to the Faculty of Theology of the University of Pretoria, namely HTS Theological Studies and Verbum et Ecclesia. The methodology comprised in all the chapters amounts to a literature and contextual study. Since the book describes the histories of formal academic departments, these texts are of a descriptive, interpretative and critical character. Reference is made in some chapters to exegetical methods, like the historical critical methods. The target audience of the book is academic scholars and theologians, who specialise in the different fields of Theology, the Humanities and other Social Sciences. The book is also accessible to scholars of other academic disciplines outside these disciplines. The book comprises original research by several authors and is not plagiarised from other scientific publications of this nature

An overview of penetrating traumatic brain injuries at a major civilian trauma centre in South Africa

CITATION: Buitendag, J. J. P., et al. 2019. An overview of penetrating traumatic brain injuries at a major civilian trauma centre in South Africa. South African Journal of Surgery, 57(1):37-42, doi:10.17159/2078-5151/2018/v57n1a2711.The original publication is available at http://www.scielo.org.zaENGLISH ABSTRACT: This study reviews our experience with penetrating Traumatic Brain Injury (TBI) in order to define and describe the injury pattern and the outcome. A secondary aim of this study was to review the use of the Motor Score (M Score) and the Simplified Motor Score (SMS) to assess and triage patients with penetrating TBI METHODS: All patients with a TBI secondary to a penetrating mechanism were identified from the Hybrid Electronic Medical Registry at Pietermaritzburg Metropolitan Trauma Service (PMTS) from January 2012 to December 2014. Standard demographic data, need for neuro-surgical intervention, location of external wounds, CT findings and mortality where analysed. The Glasgow Coma Scale (GCS) M score and SMS score were specifically evaluated to determine the relationship between the individual motor component and patient outcome RESULTS: Over the two-year period January 2012-December 2014, a total of 384 patients were admitted following a penetrating TBI. There were 350 males and 34 females and of this total 7 (1.82%) died. The mechanism of injury was axe (30), bottle (34), gunshot wound (GSW) (22) and stab wound (298). The average age for axe injuries was 27 and bottle injuries was 30. The average age for firearms and knives was 29 and 30 respectively Surgery was not required for 76.67% of patients. The need for surgery varied according to mechanism of injury. Axe injuries were treated non-operatively in 47.83%, bottle injuries in 87.50%, firearms 70% and knife injuries were treated non-operatively in 86.84% of cases. The overall survival rate for a penetrating head injury in this population is 98.16%. There were a total of 368 patients with a motor score of 6 of which one died. The survival rate was 99.7% and the mortality rate 0.3%. There were only 6 patients with a motor score of 5 and only 2 with a motor score of 4. The survival rate for both these groups was 100%. There was a total of 6 patients with a motor score of 1. There was a 100% mortality rate is this group. CONCLUSION: Penetrating TBI has a good prognosis. The vast majority of cases do not require neuro-surgical intervention. Poor motor score is associated with a poor outcomehttp://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000100007Publishers versio

An analysis of adverse events and human error associated with the imaging of patients at a major trauma centre in South Africa

CITATION: Bashir, A. A., et al . 2019. An analysis of adverse events and human error associated with the imaging of patients at a major trauma centre in South Africa. South African Medical Journal, 109(9):693-697, doi:10.7196/SAMJ.2019.v109i9.13726.The original publication is available at http://www.samj.org.zaBackground. There is growing realisation that human error contributes significantly to morbidity and mortality in modern healthcare. A number of taxonomies and classification systems have been developed in an attempt to categorise errors and quantify their impact. Objectives. To record and identify adverse events and errors as they impacted on acute trauma patients undergoing a computed tomography (CT) scan, and then quantify the effect this had on the individual patients. It is hoped that these data will provide evidence to develop error prevention programmes designed to reduce the incidence of human error. Methods. The trauma database was interrogated for the period December 2012 - April 2017. All patients aged >18 years who underwent a CT scan for blunt trauma were included. All recorded morbidity for these patients was reviewed. Results. During the period under review, a total of 1 566 patients required a CT scan at our institution following blunt trauma. Of these, 192 (12.3%, 134 male and 58 female) experienced an error related to the process of undergoing a CT scan. Of 755 patients who underwent a CT scan with intravenous contrast, detailed results were available for 312, and of these 46 (14.7%) had an acute deterioration in renal function. According to Chang’s taxonomy, physical harm occurred as follows: grade I n=6, grade II n=62, grade III n=45, grade IV n=11, grade V n=27, grade VI n=21, grade VII n=15, grade VIII n=3 and grade IX n=2. Adverse events were performing an unnecessary scan (n=24), omitting an indicated scan (n=23), performing the scan incorrectly (n=8), scanning the wrong body part (n=7), equipment failure (n=18), omitting treatment following the scan (n=6), incorrect interpretation of the scan (n=65), deterioration during the scan (n=6) and others (n=35). The setting for the error was the ward (n=19), the radiology suite (n=126), the emergency department (n=45) and the operating theatre (n=2). The staff responsible for the adverse events were medical (n=155), nursing (n=4) and radiology staff (n=15). There were 67 errors of commission and 125 errors of omission. The primary cause was a planning problem in 78 cases and an execution problem in 114. Conclusions. Errors and adverse events related to obtaining a CT scan following blunt polytrauma are not uncommon and may impact significantly on the patient. Communication is essential to eliminate errors related to performing the wrong type of scan. The commonest errors relate to misinterpretation of the scan.http://www.samj.org.za/index.php/samj/article/view/12689Publisher's versio

The spectrum of self inflicted injuries managed at a major trauma centre in South Africa

CITATION: Moffatt, S. E., et al. 2019. The spectrum of self inflicted injuries managed at a major trauma centre in South Africa. South African Journal of Surgery, 57(2):65-69, doi:10.17159/2078-5151/2019/v57n2a2897.The original publication is available at http://www.scielo.org.zaENGLISH ABSTRACT: Self-harm behaviour is a major public health problem that is commonly underreported. This study reviews the spectrum of these self inflicted injuries managed by a major trauma centre in South Africa. METHODS: A retrospective review of the regional trauma registry was undertaken over a five-year period from December 2012 to December 2017 at the Pietermaritzburg Metropolitan Trauma Service (PMTS) in South Africa. All patients who were admitted after they had sustained an injury as a result of self-harm were included. RESULTS: During the five-year study period, a total of 179 patients were included. The mean age was 29 years (SD12) and there were 139 (77%) males and 40 (23%) females. Of these, 16 had a previously established psychiatric diagnosis and two had a prior history of having sustained self-harm. The previously diagnosed psychiatric illnesses included mood dysphoria disorders (5), schizophrenia (3), substance abuse and dependency (1), anti-social personality disorder (1) and unspecified (6). The mechanism was penetrating trauma in 47 (26%). The penetrating mechanisms included stab wounds (SW) in 33, gunshot wounds (GSW) in 10, broken glass in 2 and a single impalement. Blunt mechanisms accounted for the remaining 131 (73%) injuries. The most common mechanism of blunt self-harm was hanging in 101 patients. This was followed by vehicular related trauma (8), jumping in front of a train (1) and jumping from a height (1). In 17 patients the exact mechanism of the blunt trauma was unclear. There was no statistical difference in the mechanism of injury between male and female patients. There were 38 (28%) men and 9 (23%) women who sustained a penetrating injury and there were 100 (72%) male and 31 (78%) female patients who had a blunt mechanism of injury. A total of 53 CT scans were obtained, 40 chest X-rays, 9 abdominal X-rays and 2 ultrasounds. There were 113 neck injuries, 68 head injuries, 24 abdominal injuries, 15 upper limb and 15 lower limb injuries and four facial injuries. A total of 32 operations were performed. These included laparotomy (14), neck exploration (5), tracheostomy (4). A total of 22 patients developed a complication CONCLUSION: Self-inflicted injury is not uncommon and frequently requires investigation and or surgical treatment. Patients who sustain such an injury constitute a distinct vulnerable group who are under researched. Future research on this vulnerable patient group is needed.http://www.scielo.org.za/scielo.php?script=sci_abstract&pid=S0038-23612019000200013Publishers versio