Pan computed tomography for blunt polytrauma: Are we doing too many?

Background. Pan computed tomography (CT) is widely used in the evaluation of  patients with blunt polytrauma, but there is growing concern about the radiation risks imposed.Objectives. To ascertain whether we were possibly overutilising pan CT in our  trauma service, and whether we could safely cut down on scans without missing significant injuries.Methods. We audited all pan scans performed in the Metropolitan Trauma Service, Pietermaritzburg, South Africa, during the 12-month period 1 January - 31  December 2012. An analysis was done to determine what injuries were identified and how these findings influenced our management.Results. Of the 140 pan scans, 108 (77.1%) influenced management. These  included the following components: 62 brain scans (44.3%), 16 cervical spine scans (11.4%), 50 chest scans (35.7%) and 31 abdominal scans (22.1%). The remaining 32 pan scans (22.9%) did not influence management. However, it turned out that many of these ‘clinically negative’ scans were in fact clinically important, ruling out injury in patients in whom clinical assessment was regarded as unreliable: 3 patients (2.1%) were hypoxic and had to be sedated, intubated and ventilated; 14 (10.0%) had a Glasgow Coma Score (GCS) of <15; and 9 (6.4%) had major  distracting injuries. This left only 6 pan scans (4.3%) that were not regarded as clinically helpful.Conclusion. In our setting, the majority of pan scans influence management. By  ruling out significant injuries, clinically negative scans are valuable in patients who are obtunded, intubated and ventilated, or have major distracting injuries. In  patients with a GCS of 15, not sedated and ventilated and with no major distracting injuries, clinical assessment and alternative imaging modalities may suffice

An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa

Introduction Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. Methods This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. Results A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20–29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the ‘triangle of safety’ but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. Conclusions ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation

A raised serum lactate level is an independent predictor of in-hospital mortality in patients with isolated cerebral gunshot wounds

Background Cerebral gunshot wounds (CGSWs) represent a highly lethal form of traumatic brain injury, and triaging these patients is difficult. The prognostic significance of the serum lactate level in the setting of CGSWs is largely unknown. Objectives To examine the relationship between elevated serum lactate levels and mortality in patients with isolated CGSWs. Methods A retrospective review of the regional trauma registry was undertaken at the Pietermaritzburg Metropolitan Trauma Service, South Africa, over a 5-year period from 1 January 2010 to 31 December 2014. All patients with an isolated CGSW were included. Results A total of 102 patients with isolated CGSWs were identified. Of these, 92.2% (94/102) were male. The mean age (standard deviation) was 29 (8) years, and the in-hospital mortality rate was 21.6% (22/102). The mean serum lactate level was significantly higher among non-survivors than among survivors (6.1 mmol/L v. 1.3 mmol/L; p<0.001). Lactate levels among non-survivors were <2 mmol/L in 4.5%, 2 - 3.99 mmol/L in 9.1%, 4 - 5.99 mmol/L in 36.4% and ≥6 mmol/L in 50.0%. The odds ratio for mortality with a lactate level of 4 - 5.99 mmol/L was 67 (95% confidence interval (CI) 1.7 - 2 674.2), while for a lactate level of ≥6 mmol/L it was 1 787 (95% CI 9.0 - 354 116.1). The serum lactate level accurately predicted mortality even after adjustment for other variables. Based on a receiver operating curve analysis, an optimal cut-off of 3.3 mmol/L for serum lactate as a predictor for mortality was identified (area under the curve = 0.957). Conclusions CGSWs are associated with significant mortality, and a raised serum lactate level appears to be an independent predictor of in-hospital mortality. It is a potentially useful adjunct in the resuscitation room for identifying patients with a very poor prognosis

An audit of the complications of intercostal chest drain insertion in a high volume trauma service in South Africa

INTRODUCTION: Intercostal chest drain (ICD) insertion is a commonly performed procedure in trauma and may be associated with significant morbidity. METHODS: This was a retrospective review of ICD complications in a major trauma service in South Africa over a four-year period from January 2010 to December 2013. RESULTS: A total of 1,050 ICDs were inserted in 1,006 patients, of which 91% were male. The median patient age was 24 years (interquartile range [IQR]: 20–29 years). There were 962 patients with unilateral ICDs and 44 with bilateral ICDs. Seventy-five per cent (758/1,006) sustained penetrating trauma and the remaining 25% (248/1006) sustained blunt trauma. Indications for ICD insertion were: haemopneumothorax (n=338), haemothorax (n=314), simple pneumothorax (n=265), tension pneumothorax (n=79) and open pneumothorax (n=54). Overall, 203 ICDs (19%) were associated with complications: 18% (36/203) were kinked, 18% (36/203) were inserted subcutaneously, 13% (27/203) were too shallow and in 7% (14/203) there was inadequate fixation resulting in dislodgement. Four patients (2%) sustained visceral injuries and two sustained vascular injuries. Forty-one per cent (83/203) were inserted outside the ‘triangle of safety’ but without visceral or vascular injuries. One patient had the ICD inserted on the wrong side. Junior doctors inserted 798 ICDs (76%) while senior doctors inserted 252 (24%). Junior doctors had a significantly higher complication rate (24%) compared with senior doctors (5%) (p<0.001). There was no mortality as a direct result of ICD insertion. CONCLUSIONS: ICD insertion is associated with a high rate of complications. These complications are significantly higher when junior doctors perform the procedure. A multifaceted quality improvement programme is needed to improve the situation

Antenatal depression and suicidal ideation among rural Bangladeshi women: a community-based study.

Depression during pregnancy is a significant public health problem because of its negative effects on the health of both mother and infant. Data on its prevalence and determinants are lacking in Bangladesh. To estimate the prevalence of depression during pregnancy and to identify potential contributory factors among rural Bangladeshi women, a community-based study was conducted during 2005 in Matlab sub-district, a rural area of eastern Bangladesh. Three hundred and sixty-one pregnant women were identified through an existing health and demographic surveillance system covering a population of 110,000 people. The women were interviewed at home at 34–35 weeks of pregnancy. Information on risk factors was collected through structured questionnaires, with the Bangla version of the Edinburgh Postnatal Depression Scale (EPDS-B) used to measure their psychological status. Both univariate analysis and multivariate logistic regression were applied using the SPSS 15.0 statistical software. The prevalence of depression at 34–35 weeks pregnancy was 33% (95% CI, 27.6–37.5). After adjustment in a multivariate logistic regression model, a history of being beaten by her husband either during or before the current pregnancy had the highest association with depression followed by having an unhelpful or unsupportive mother-in-law or husband, and family preference for a male child. Of the antenatally depressed women, 17 (14%) admitted to thoughts of self-harm during the pregnancy. This paper further explores the reasons why women have considered some form of self-harm during pregnancy. Depression during pregnancy is common among Bangladeshi women, with about a third being affected. The study highlights the need to allocate resources and develop strategies to address depression in pregnancy