Evidence-based medicine – are we boiling the frog?

Evidence-based medicine has been defined as ‘The conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.’ There are two major assumptions in this statement. First, it is assumed that the evidence is in fact the best. Unfortunately this is not necessarily so, and published evidence is affected by bias, sponsorship, and blind faith in mathematical probability which may not be clinically relevant. Second, the evidence is population based and may not be applicable to the individual, and blind adherence to this concept may cause harm. We must not abandon clinical experience and judgement in favour of a series of inanimate data points. Medicine is an uncertain science.

The wrong and wounding road: Paediatric polytrauma admitted to a level 1 trauma intensive care unit over a 5-year period

Background. Injury in childhood is a major cause of potentially preventable morbidity and mortality. In order to implement effective preventive strategies, epidemiological data on mechanisms of injury and outcome are essential.Objectives. To assess the causation, severity of injury, morbidity and mortality of paediatric trauma admitted to a level 1 trauma intensive care unit (TICU).Methods. Children were defined as being <16 years of age. The study covered the 5-year period January 2008 - December 2012. Eligible patients were identified from a prospective database maintained in the level 1 TICU at Inkosi Albert Luthuli Central Hospital, Durban, South Africa. Data extracted were referral source, mechanism of injury, age and gender distribution, injury severity score (ISS), anatomical distribution of injury and mortality.Results. A total of 181 patients admitted during the study period accounted for 15.9% of all admissions. There were 84 females (46.4%) and 97 males (53.6%), with a median age of 7 years (interquartile range (IQR) 4 - 10). Sources of admission were directly from the scene in 38 cases (21.0%), from a primary healthcare facility in 47 (26.0%), from a regional hospital in 56 (31.0%) and from a tertiary facility in 40 (22.0%). Mortality rates according to location of transfer were regional hospital 8 deaths (30.8%), tertiary facility 7 (26.9%), primary health clinic 7 (26.9%), and from the scene 4 (15.4%). Mechanisms of injury were pedestrian-motor vehicle collision (PMVC) in 105 cases (58.0%), motor vehicle passenger in 38 (21.0%), non-vehicular blunt trauma in 18 (10.0%), gunshot wounds (GSWs) in 12 (6.6%), stab wounds in 6 (3.3%), bull goring in 1 (0.5%) and bicycle accident 1 (0.5%). The median ISS for all admissions was 25 (IQR 16 - 38). ISSs were >25 in 98 patients (54.1%), 16 - 25 in 51 (28.2%), 9 - 15 in 9 (4.9%) and <9 in 13 (7.2%); 61.9% of patients had head injuries, 48.1% injuries to the extremities, 41.4% abdominal trauma, 40.3% thoracic trauma, 20.4% external soft-tissue trauma, 9.9% cervical injury and 9.4% facial trauma. There were 26 deaths (14.4%), of which PMVCs accounted for 16 (61.5%), motor vehicle passengers for 7 (26.9%), blunt trauma for 2 (7.7%) and GSWs for 1 (3.8%). The majority of deaths (92%) were of patients with an ISS >25. Of the 26 patients who died, 88.4% had a head injury, 46.2% an extremity injury, 38.5% an external injury, 34.6% abdominal or chest injuries, 19.2% neck injury and 11.5% facial injury.Conclusions. Motor vehicle-related injuries, especially PMVCs, dominate severe paediatric trauma and there is an urgent need for more road traffic education and stringent measures to decrease the incidence and associated morbidity and mortality

Validating the utilisation of venous bicarbonate as a predictor of acute kidney injury in crush syndrome from sjambok injuries

Background. Crush injury secondary to sjambok beatings is a well-described phenomenon in southern Africa. Owing to a number of factors, it can result in acute kidney injury (AKI). In 1992, Muckart et al. described a risk stratification system using venous bicarbonate (VB) that can be used in the management of these patients.Objective. To validate this score in the modern era of AKI risk stratification.Methods. A retrospective study was performed on a local trauma database from June 2010 to December 2012. All patients with crush injury from sjambok/blunt instrument beatings were included in the analysis. VB was compared with the Kidney Disease Improving Global Outcomes scoring system for AKI. Serum base excess (BE) and creatine kinase were also examined as biomarkers. The endpoints were the need for renal replacement therapy (RRT) and mortality.Results. Three hundred and ten patients were included. The overall mortality rate was 1.9%, 14.8% of patients had AKI, and 3.9% required RRT. Both VB and BE performed well in RRT prediction, with areas under the receiver operating characteristic curve of 0.847 (95% confidence interval (CI) 0.756 - 0.938; p<0.001) and 0.871 (95% CI 0.795 - 0.947; p<0.001), respectively. The sensitivity and specificity of BE were 83.3% and 80.2% at an optimal cut-point of –7.25 mmol/L, while those of VB were 83.3% and 79.5% at an optimal cut-point of 18.85 mmol/L. VB was significantly different across the AKI risk groups (p<0.001), in keeping with the original Muckart risk stratification system.Conclusion. The risk stratification score using VB is valid and should continue to be used as a tool in the management of patients with sjambok injuries. BE performs well in predicting the need for RRT, with a value of <–7.25 mmol/L indicating severe injury.

Guideline for the assessment of trauma centres for South Africa

INTRODUCTION: Trauma is a well-known leading cause of unnatural death and disability in South Africa. Internationally the trend is moving toward systematised care. AIM: To revise the Trauma Centre Criteria of the Trauma Society of South Africa and align these with the terminology and modern scope of emergency care practice, using best-care principles as a prelude to the development of trauma systems in South Africa. METHODOLOGY: Revision of existing documents of the Trauma Society of South Africa, the Emergency Medicine Society of South Africa and the Critical Care Society of Southern Africa, where these are relevant to the care of trauma. The committee attempted to harmonise these criteria with the goals of the World Health Organization essential trauma care guidelines for trauma centres and trauma systems. Wide expert consultation was undertaken to refine the criteria before final compilation. RESULTS AND RECOMMENDATIONS: Four levels of trauma care facility are outlined, with the criteria focusing on the trauma-specific requirements of the facilities and their place in the greater trauma system. Accreditation of hospitals according to the criteria will allow for appropriate transfer and designation of patient destination for trauma patients and will improve the quality of care provided. The criteria address structural, process and human resource requirements and medical aspects for the accreditation of various level of trauma centre. CONCLUSION: There is a great opportunity to apply best practice criteria to improve the care of trauma in South Africa and improve patient outcome

Guideline for the assessment of trauma centres for South Africa

Introduction. Trauma is a well-known leading cause of unnatural death and disability in South Africa. Internationally the trend is moving toward systematised care. Aim. To revise the Trauma Centre Criteria of the Trauma Society of South Africa and align these with the terminology and modern scope of emergency care practice, using best-care principles as a prelude to the development of trauma systems in South Africa. Methodology. Revision of existing documents of the Trauma Society of South Africa, the Emergency Medicine Society of South Africa and the Critical Care Society of Southern Africa, where these are relevant to the care of trauma. The committee attempted to harmonise these criteria with the goals of the World Health Organization essential trauma care guidelines for trauma centres and trauma systems. Wide expert consultation was undertaken to refine the criteria before final compilation. Results and recommendations. Four levels of trauma care facility are outlined, with the criteria focusing on the trauma-specific requirements of the facilities and their place in the greater trauma system. Accreditation of hospitals according to the criteria will allow for appropriate transfer and designation of patient destination for trauma patients and will improve the quality of care provided. The criteria address structural, process and human resource requirements and medical aspects for the accreditation of various level of trauma centre. Conclusion. There is a great opportunity to apply best practice criteria to improve the care of trauma in South Africa and improve patient outcome