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A Retrospective Review of Abdominal Trauma at a Major Trauma Center in South Africa

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A Retrospective Review of Abdominal Trauma at a Major Trauma Center in South Africa Open access 4th World Trauma Congress Article Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2018-000235 on 16 April 2019. Downloaded from Damage control or definitive repair? A retrospective review of abdominal trauma at a major trauma center in South Africa Ross Weale, 1 Victor Kong,2,3 Johan Buitendag,4 Abraham Ras,4 Joanna Blodgett,5 Grant Laing,3 John Bruce,3 Wanda Bekker,3 Vassil Manchev,3 Damian Clarke2,3 1Department of Surgery, North ABSTRact principle underlying DCS is that prolonged oper- Western Deanery, Manchester, Background This study set out to review a large ations in trauma patients with profound physio- United Kingdom logic derangements and complex injuries must be 2Department of Surgery, series of trauma laparotomies from a single center and University of the Witwatersrand, to compare those requiring damage control surgery avoided, in lieu of an abbreviated operation which Johannesburg, South Africa (DCS) with those who did not, and then to interrogate a controls bleeding and soiling. Once this has been 3Department of Surgery, number of anatomic and physiologic scoring systems to achieved, the patient’s physiology must be aggres- University of KwaZulu Natal, see which best predicted the need for DCS. sively restored, and only then can the temporized Durban, South Africa 4Department of Surgery, Methods All patients over the age of 15 years injuries be managed definitively. It must be under- Stellenbosch University, Cape undergoing a laparotomy for trauma during the period stood that the majority of trauma patients do not Town, South Africa from December 2012 to December 2017 were retrieved require DCS and should still undergo definitive 5Department of Epidemiology, from the Hybrid Electronic Medical Registry (HEMR) surgery. Deciding when DCS is indicated requires University College London, clinical judgment. Essentially there are two factors London, United Kingdom at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, which must be considered, namely the extent of the Correspondence to namely the DCS and non-DCS cohort, based on what anatomic injury as well as the extent of the physi- Dr Victor Kong, Department was recorded in the operative note. These groups were ologic derangement. Most guidelines have focused of Surgery, University of the then compared in terms of demographics and spectrum on physiologic criteria for deciding on the need Witwatersrand, 29 Princess of injury, as well as clinical outcome. The following for DCS.4–8 Physiologic criteria can be accurately of Wales Terrace, Parktown, quantified and include preoperative and intraop- copyright. Johannesburg, 2193, South scores were worked out for each patient: Penetrating Africa; victorywkong@ yahoo. Abdominal Trauma Index (PATI), Injury Severity Score, erative hypothermia (median temperature <34°C), com Abbreviated Injury Scale-abdomen, and Abbreviated acidosis (median pH <7.2), and/or coagulopathy. Injury Scale-chest. There is a degree of latitude allowed if these param- Received 13 September 2018 Results A total of 562 patients were included, and 99 eters rapidly improve. If they deteriorate or remain Revised 8 January 2019 Accepted 20 January 2019 of these (18%) had a DCS procedure versus 463 (82%) static, then damage control is mandated. However, non-DCS. The mechanism was penetrating trauma in in recent large surveys and scoping reviews, it has 81% of cases (453 of 562). A large proportion of trauma emerged that numerous authors include other victims were male (503 of 562, 90%), with a mean age criteria such as injury patterns, failure to control of 29.5±10.8. An overall mortality rate of 32% was bleeding by conventional methods, administration of a large volume of packed red blood cells, the recorded for DCS versus 4% for non-DCS (p<0.001). http://tsaco.bmj.com/ In general patients requiring DCS had higher lactate, inability to achieve a tension-free abdominal wall and were more acidotic, hypotensive, tachycardic, closure, or the onset of an abdominal compart- and tachypneic, with a lower base excess and lower ment syndrome during attempted abdominal wall bicarbonate, than patients not requiring DCS. The most closure, as well as the necessity to reassess bowel significant organ injuries associated with DCS were liver viability, as indications for DCS.4–8 These criteria and intra-abdominal vascular injury. The only organ injury are important, but some of them are subjective and consistently predictive across all models of the need for difficult to define. In light of this, this study set DCS was liver injury. Regression analysis showed that out to review a large series of trauma laparotomies on September 29, 2021 by guest. Protected only the PATI score is significantly predictive of the need from a single center and to compare those requiring for DCS (p=0.044). A final multiple logistic regression DCS with those who did not, and then to interro- model demonstrated a pH <7.2 to be the most predictive gate a number of anatomic and physiologic scoring (p=0.001) of the need for DCS. systems to see which ones best predicted the need Conclusion DCS is indicated in a subset of severely for DCS. It was hoped that the use of a defined injured trauma patients. A pH <7.2 is the best indicator anatomic scoring system in determining the need © Author(s) (or their of the need for DCS. Anatomic injuries in themselves are for DCS would help quantify the anatomic indica- employer(s)) 2019. Re-use not predictive of the need for DCS. tions for DCS, and thus standardize practice and permitted under CC BY-NC. No Levels of evidence Level III. reduce individual center and surgeon variability. commercial re-use. See rights and permissions. Published by BMJ. Clinical setting To cite: Weale R, Kong V, INTRODUCTION Kwa Zulu Natal Province (KZN) is located on Buitendag J, et al. Trauma Damage control surgery (DCS) was first intro- the east coast of South Africa and has a popula- Surg Acute Care Open duced as a concept less than three decades ago, and tion of over 11 million people. Fifty percent of 2019;4:e000235. since that time has become widely accepted.1–3 The the population resides in rural areas. The city of Weale R, et al. Trauma Surg Acute Care Open 2019;4:e000235. doi:10.1136/tsaco-2018-000235 1 Open access Trauma Surg Acute Care Open: first published as 10.1136/tsaco-2018-000235 on 16 April 2019. Downloaded from Pietermaritzburg is the largest city in the interior of the prov- Table 1 Presenting demographics and physiology for DCS vs. non- ince and has a population of one million people. The Pieter- DCS cases maritzburg Metropolitan Trauma Service (PMTS) provides trauma care to the city of Pietermaritzburg, KZN, South Africa, DCS Non-DCS as well as to the predominantly rural western third of the prov- Total=562 (%) 99 (18) 463 (82) ince. It also serves as the referral center for 19 other rural Sex male/female (%) 84/15 (85/15) 419/44 (90/10) hospitals within the western third of the province, and has a Mean age (±SD) 33.6 (±12.3) 28.6 (±10.3) total catchment population of over three million people. Over 50% of all trauma managed at our centre are due to penetrating DCS Non-DCS injuries. This is a direct reflection of the very high incidence Physiology n (SD) n (SD) P value of interpersonal violence, criminal and gang related activities Lactate 5.25 (±3.71) 2.63 (±2.55) <0.001 rampant throughout the region. The PMTS is one of the largest SBP 110 (±24) 122 (±19) <0.001 academic trauma center in Western KZN. It is headed by a full DBP 63 (±21) 72 (±16) <0.001 time Professor of Surgery (DLC) and five sub-specialist fellow- HR 109 (±23) 96 (±21) <0.001 ship trained attending trauma surgeons directly oversee the care of all trauma patients. The house staff is composed of surgical RR 25 (±8) 20 (±5) <0.001 SpO 94 (±7) 96 (±4) <0.001 interns, residents, career medical officers, fellows and interna- 2 tional medical graduate (IMG) doctors of varying levels of skill pH 7.28 (±0.15) 7.38 (±0.09) <0.001 who rotate through a number of subspecialist units during their pO2 10.7 (±6) 10.8 (±6) 0.895 training. Our trauma center is a nationally accredited training pCO2 5.3 (±1.6) 5.2 (±1.0) 0.182 institute for specialist training in General Surgery and sub-spe- BE −7.14 (±0.72) −2.06 (±5.52) <0.001 cialist fellowship training in Trauma Surgery for both local and HCO 18.86 (±5.65) 22.83 (±4.15) <0.001 international doctors. The PMTS maintains a prospectively 3 entered hybrid electronic medical registry (HEMR). All surgical Mortality 32 (32) 19 (4) <0.001 patients are captured on this system. Length of hospital stay 16 (±11) 10 (±7) <0.001 (days) 2 METHODS Statistical comparison is made using unpaired t-test for continuous variables and χ test for categorical variables. All patients over the age of 15 years undergoing a laparotomy Bold values indicate statistical significance at the 5% level for trauma during the period from December 2012 to December BE, base excess (mEq/L); DBP, diastolic blood pressure; DCS, damage control surgery; 2017 were retrieved from the HEMR. They were divided into copyright. HCO3, serum bicarbonate (mEq/L); HR, heart rate (per minute); RR, respiratory rate two cohorts, namely the DCS and non-DCS cohort, based on (per minute); SBP, systolic blood pressure; SpO2, oxygen saturation (%); pCO2, partial what was recorded in the operative notes. These groups were pressure of carbon dioxide (mm Hg); pO2, partial pressure of oxygen (mm Hg).
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