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) 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

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

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

CITATION: Wessels, E. U., et al. 2019. The spectrum of animal related injuries managed at a major trauma centre in South Africa. South African Journal of Surgery, 57(3):54-58, doi:10.17159/2078-5151/2019/v57n3a2854 .The original publication is available at http://www.scielo.org.zaENGLISH ABSTRACT: Humans come into contact and interact with an array of animals in a number of areas and environments. We set out to review our experience with animal-related injuries in Pietermaritzburg, KwaZulu-Natal, South Africa METHODS: All patients who sustained an injury secondary to an interaction with an animal in the period December 2012-December 2017 were identified from the Hybrid Electronic Medical Registry (HEMR RESULTS: There were 104 patients in the study sample. The mean age of patients in the study was 32.8 years, with a range from 1 to 76 years old. 75% (n = 78) were male and 25% (n = 26) female. Out of the 104 animal-related injuries, 67 were blunt trauma, 39 penetrating trauma and 3 a combination of blunt and penetrating trauma. The species causing trauma included dogs (53), horses (29), cows (18), buffalo (1), warthog (1), impala (1) and a single goat (1). The median time from injury to hospitalisation was 46.62 hours (range from 0 to 504 hours). Injuries occurred to the head (n = 32), face (n = 9), neck (n = 32), abdomen (n = 22), urogenital system (n = 6), upper limb (n = 39) and lower limb (n = 39). The Injury Severity Score (ISS) mean for the patients was 8.16, the range 1-4, the median 9 and the standard deviation 6.88. In 49 patients the treatment was non-operative. In the remaining 55 patients, a total of 68 operative procedures were required. Operations included wound debridement/surgical washout (n = 38), laparotomy (n = 9), arterial repair/ligation (n = 8), skin graft (n = 4), craniotomy (n = 5), fasciotomy (n = 2), amputation (n = 1), and placement of an ICP monitor (n = 1). 49 of these operations were for patients with dog bite injuries. The mean hospital stay was 0.13 days with a range of 0-4 days. Four patients were admitted to the Intensive Care Unit (ICU) and two patients died CONCLUSION: Human interactions with animals may result in injuries which require surgical treatment. The most common animal injury is a dog bite but in the case of the larger domestic farm animals, blunt force type injuries and goring can result in significant injuries which require complex surgical interventions.http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0038-23612019000300010&lng=en&nrm=isoPublishers versio