Rudo Pswarayi

Background. Emergency resuscitative thoracotomies (ERTs) are life-saving procedures for traumatic cardiac arrest or severe haemorrhage, but their outcomes remain variable and are influenced by several factors, including timing, mechanism of injury and the presence of initial signs of life. Studies on ERT outcomes predominantly originate from well-resourced settings, leaving a gap in understanding their effectiveness in resource-constrained environments. Objective. To conduct a prospective audit of ERTs performed at a level 1 trauma unit over a 1-year period (1 April 2023 - 31 March 2024), assessing initial presentation characteristics, indications for ERT and subsequent outcomes in terms of survival and complications. Methods. A prospective analysis of 19 consecutive patients who underwent ERT was performed. Data included demographics, mechanism of injury, initial physiological parameters, ERT indications, resuscitation times, blood product transfusions, complications and survival to discharge. Results. The study comprised predominantly male patients (94.74%) with a wide age range (19 - 68 years). Penetrating trauma was the most common mechanism of injury (94.44%). An association was observed between shorter interval between fluid resuscitation time and commencement of ERT time and survival. Elevated lactate levels and acidosis were more frequent in non-survivors. A high mortality rate was noted (only one patient survived). Conclusion. This study did not find statistically significant results, but recognising the importance of prompt and ongoing resuscitation in improving survival after ERT is consistent with existing literature. However, the small sample size significantly limits the ability to apply these findings to other cases. Larger studies are necessary to definitively establish the impact of factors such as resource limitations on ERT outcomes in under-resourced settings. The high mortality rate highlights the need for focused research into improving patient selection criteria, optimising ERT techniques and addressing resource constraints in developing countries.

Background: Trauma injury scoring systems are essential for standardized assessment, treatment decisions, and outcome prediction in trauma patients. The mechanism, Glasgow Coma Scale (GCS), age, and arterial pressure (MGAP) score offers a simplified approach that is particularly beneficial in resource-limited settings. This study aims to determine the association between the MGAP scoring system and mortality outcomes in trauma patients presenting to the trauma emergency unit (TEU) in a resource-limited setting. Objective: To determine the association between the MGAP scoring system and mortality outcomes in trauma patients presenting to the trauma emergency unit (TEU) in a resource-limited setting. Methods: A retrospective record review was conducted on priority 1 (P1) trauma patients aged 18 years or older who presented to the TEU of a hospital between 1 January 2022 and 31 December 2022. Data extracted from the TEU resuscitation register included age, sex, mechanism of injury, blood pressure (BP), and Glasgow Coma Scale (GCS). The primary outcome was survival versus death. MGAP scores were calculated, and statistical analyses were performed to assess the association between MGAP scores and mortality. Results: A total of 1220 patients were included in this study. The analysis revealed a statistically significant association between MGAP scores and mortality (p < 0.0001). Lower MGAP scores were associated with higher mortality rates. Specifically, patients with MGAP scores ≤ 18 had a mortality rate of 48.1%, while those with scores between 19 and 22 had a mortality rate of 23.5%. The mortality rate was 2.2% for MGAP scores between 23 and 29, and 0% for scores ≥ 30. GCS score and systolic blood pressure were also significantly associated with mortality (p < 0.0001 and p < 0.05, respectively), while the mechanism of injury was not significantly associated with mortality. Conclusions: The MGAP score is a valuable tool for risk stratification in trauma patients in resource-constrained settings, demonstrating a strong inverse correlation with mortality outcomes. Its simplicity and reliance on readily available parameters make it particularly useful for rapid triage and resource allocation in LMICs. These findings support the implementation of the MGAP score in trauma triage protocols and highlight the need for further research to validate its performance in diverse LMIC settings and explore its potential for integration into national trauma care guidelines.

Introduction: Penetrating traumatic aortic arch injuries are rare due to the protective effect of surrounding structures. The choice between open surgical repair and endovascular repair depends on several factors including the patient’s hemodynamic status, anatomical considerations, and available expertise. However, these injuries remain associated with significant mortality, emphasizing the need for swift intervention and careful patient selection. Long-term follow-up is also essential to monitor potential complications such as stent migration or endoleaks in cases managed with endovascular repair. Importance: This case report highlights the challenges in managing delayed presentations of penetrating traumatic aortic arch injuries, emphasizing the importance of a multidisciplinary approach and the potential for nonoperative management in carefully selected patients. Case presentation: A 38-year-old male presented to a regional hospital 1 day after sustaining a left precordial stab wound. Initial assessment revealed hemodynamic instability (hypotension, tachycardia), and a left-sided hemothorax requiring drainage. Imaging (chest X-ray, computed tomography [CT] angiography) revealed an acute traumatic aortic injury involving the distal aortic arch near the left subclavian artery origin, characterized by an intimal flap, mural thrombus, a small pseudoaneurysm, and a mediastinal hematoma. Clinical discussion: After stabilization and transfer to a Level 1 trauma center, the patient was managed conservatively with serial CT angiography monitoring. Over a period of several weeks, the pseudoaneurysm remained stable without evidence of expansion, ultimately leading to successful nonoperative management. The patient was discharged with ongoing outpatient follow-up. Conclusion: This case demonstrates the successful nonoperative management of a delayed presentation of penetrating traumatic aortic arch injury. Careful patient selection, close multidisciplinary monitoring, and serial imaging are essential components of this approach. While this less invasive strategy avoids the risks associated with open or endovascular procedures, close monitoring for complications and timely intervention remain critical for optimal outcomes. Further research is needed to better define the indications for and outcomes of conservative management in such cases.

Trauma mortality exhibits three peaks: immediate, early, and late post-traumatic. Early deaths are often due to haemorrhage and central nervous system injury, whereas late deaths are associated with sepsis and multi-organ failure. The neutrophil-lymphocyte ratio (NLR) is a readily available and inexpensive marker of inflammation, and its prognostic value under various conditions has been established. However, the predictive ability of the NLR in trauma mortality remains unclear, with conflicting results from previous studies. This study aimed to investigate the correlation between NLR (on admission and at 48-hour post-admission) and trauma outcomes. This retrospective study analysed data of trauma patients (≥ 18 years old) of which 372 were admitted to a level one trauma unit between January and June 2017. The data collected included demographics, mechanism of injury, injury severity score (ISS), new injury severity score (NISS), abbreviated injury scale (AIS), hospital length of stay (LOS), hospital disposition, and NLR values on admission and at 48 hours. Logistic regression models were used to analyse the association between the NLR and mortality, controlling for age, sex, ISS, and AIS. The sample size was calculated based on the anticipated mortality rate and desired power. The study included 288 patients for admission NLR analysis and 165 patients for the 48-hour NLR analysis. While factors such as ISS, NISS, emergency department (ED) probability of survival, NISS EU probability, and hospital disposition significantly predicted mortality, NLR at both 24 and 48 hours was not significantly associated with mortality. Although NLR showed good diagnostic accuracy, it did not improve the predictive power of the models, including established prognostic factors. The small sample size for 48-hour NLR analysis is a limitation. Although the NLR is a simple indicator of systemic inflammation, this study found that it does not independently predict mortality in trauma patients when other established prognostic markers are included. These findings suggest that NLR has limited additional prognostic value in this context, highlighting the importance of incorporating established injury severity scores and other clinical factors for accurate mortality risk assessment. Further research with larger sample sizes is needed to confirm these findings and explore the potential role of the NLR in predicting other trauma outcomes.

Background: Penetrating cardiac injuries (PCIs) remain a significant surgical challenge, characterized by high mortality rates, particularly in young adult males. The mechanism of injury (gunshot wound vs. stab wound) significantly influences outcomes. Importance: This study presents two cases of left ventricle PCIs, emphasizing the need for prompt diagnosis and intervention. The rising incidence of PCI necessitates a high index of suspicion based on clinical findings and basic imaging to facilitate timely surgical intervention and potentially improve survival. Case series: Two patients presented within 48 hours at a South African hospital. Case 1 involved a 32-year-old male with a stab wound to the anterior left ventricle, injuring the left anterior descending artery. Case 2 involved a 26-year-old male with a gunshot wound (GSW) to the posterior left ventricle. Both underwent immediate surgical repair. Discussion: The clinical presentations, diagnostic approaches (including eFAST), and operative techniques are described. Postoperative courses varied significantly; one patient developed complications including severe hypertension and Takotsubo cardiomyopathy, while the other had an uncomplicated recovery. A literature review highlights inconsistencies in reported PCI incidence and mortality, largely attributed to small sample sizes and methodological limitations in previous studies. Conclusion: The increased frequency of GSWs and stab wounds causing PCIs underscores the importance of a high index of suspicion supported by clinical findings and basic imaging to enable rapid surgical intervention. This expeditious approach could potentially improve mortality rates. Further research with larger, well-designed studies is crucial to refine our understanding of PCI management and improve outcomes.

Background: Trauma is a significant public health challenge, particularly in low- and middle-income countries (LMICs), including South Africa, where it contributes to substantial morbidity, mortality, and economic burden. Accurate data on trauma epidemiology is crucial for informing prevention and care strategies. Purpose: This study aimed to describe the epidemiology of trauma patients presenting to one of the largest tertiary care public hospitals in Johannesburg, South Africa, focusing on injury patterns and outcomes. Methods: This retrospective observational study analysed data from the hospital's trauma registry for patients presenting between January 2022 and June 2022. Data collected included demographics, injury mechanisms, and outcomes (admission to ward, ICU, theatre, discharge, death). Results: A total of 377 trauma patients were included in the study. The majority were adult males (79.84% adults, 83.82% males). The most common injury patterns were stabbing (32.63%), gunshot wounds (14.59%), and assaults (13.53%). No significant association was found between patient demographics (sex and age group) and outcome. Conclusion: This study confirms the significant burden of trauma in a large urban centre in South Africa, particularly among young adult males, with interpersonal violence being a major contributing factor. The high prevalence of violence-related injuries underscores the importance of implementing and strengthening public health interventions aimed at preventing violence.

Blunt intrathoracic tracheal injuries are rare, even among blunt chest trauma patients. An early diagnosis based on a high index of suspicion allows for timely surgical management of potentially fatal airway trauma, thereby improving overall outcomes. Diagnosing these injuries can be difficult due to their nonspecific clinical features and the occasional difficulty in radiologic diagnosis. If a patient exhibits respiratory compromise with difficult ventilation and poor lung expansion, despite the insertion and management of an intercostal drain following high-energy blunt trauma, there should be a heightened suspicion of potential airway trauma. The aim of primary repair is to restore airway integrity and to minimize the loss of pulmonary parenchyma function. This case report discusses the rare clinical presentation of a patient with blunt trauma to the intrathoracic airway, the surgical management thereof, and his overall outcome. Although blunt traumatic injuries of the trachea are extremely rare and often fatal, early surgical intervention can potentially reduce the risk of mortality.

The dress code for surgeons has evolved over time from formal suit-and-tie to crisp white coat, and currently to various forms of smart-casual attire; however, there is no stipulated or rigid uniform guideline. It is important to explore and discuss the various forms of attire in relation to patients' ideals and perceptions of a surgeon. An observational study in the form of a paper-based questionnaire was carried out at the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), Chris Hani Baragwanath Academic Hospital (CHBAH) and Wits Donald Gordon Medical Centre (WDGMC). Seven questions (Q1-Q7) were posed with various dress categories to select from in each question, namely: formal, smart, smart-casual and scrubs. Descriptive analysis of the survey responses, and the determination of the association between survey responses and a) hospital, b) gender, c) age group was performed. Fisher's exact test was used where the requirements for the chi-square test could not be met. Attire groups with n < 15 were not analysed. The strength of the associations was measured by Cramer's V and the phi coefficient respectively. Data analysis was carried out using SAS v9.4 for Windows. A 5% significance level was used. A total of 387 questionnaires were filled out with a total of 376 fully completed and eligible samples in consenting participants of 18 years and older. In all seven questions, scrubs were the preferred attire. Overall, for Q1-Q5 and Q7, after scrubs, smart was the next most popular attire. For Q6, after scrubs, smart, smart-casual and formal were all popular, indicating some leeway on weekends and public holidays. There was a significant association between each of the responses to the question and hospital (p < 0.0001). At CHBAH, patients preferred scrubs more and smart attire less, compared to CMJAH and WDGMC. At CMJAH, preference for formal attire was greater when compared to the other two hospitals. Overall, patients preferred their surgeons to be dressed in scrubs as this attire easily identified surgeons and instilled confidence in the wearer.

Introduction: Pneumatosis Cystoides Intestinalis (PCI) is a fairly rare condition that is, however, becoming of increasing incidence. It is difficult to ascertain as many patients are asymptomatic, but, in adults, if it does present it usually presents in the fifty-to-eighty years age groups. Importance: It may be primary (15% - idiopathic and benign condition) or secondary (85% - usually in neonates and due to necrotising enterocolitis) but the aetiology is unclear, with some theories that have been put forward. Many consider its pathogenesis to be due to increased intra-luminal intestinal pressure and, therefore, build-up of gas from commensal gut bacteria. Imaging and histology are important in diagnosis. Case presentation: This case presentation explores the complicated presentation of a patient with PCI and his management, thereof, in order to review the appropriate investigations and the subsequent options of management. Conclusion: Because it is a poorly understood condition with varying presentations, it is often misdiagnosed. The diagnosis is critical to allow the correct and most appropriate management to be carried out: non-surgical supportive care versus surgical intervention with resection and stoma or anastomosis. HIGHLIGHTS Pneumatosis cystoides intestinalis: presentation and management of a complicated case. Pneumatosis Cystoides Intestinalis (PCI) is a fairly rare condition and is difficult to diagnose as many patients are asymptomatic. Imaging and histology are key the in diagnosis and subsequent non-surgical versus surgical management. This case presentation explores the complicated presentation of a patient with PCI and his management, along with some associated concurrent diagnoses.

Introduction: Le Fort fractures occur in approximately 20% of facial fractures and result from a high velocity/force mechanism of injury. In those rare 20% occurrences, the Le Fort III fractures are the least common and are highly associated with injuries of the cervical spine, intracranial, and internal neck structures. Importance: This makes them difficult to manage and requiring a definitive sequence of resuscitation and thorough secondary and tertiary surveys thereafter. The morbidity and mortality of these severe fractures is high but with appropriate resuscitation and adequate stabilization of the fracture, this may be improved on and lowered. Case presentation: A male sustaining multiple stabs to the face presents to a level one trauma emergency unit haemodynamically unstable/abnormal with a threatened airway and stridor. Discussion: This case report walks through step-by-step the management approaches at each stage thereby assessing and managing the outcomes of each diagnosis. Conclusion: Le Fort III fractures are rare but critical injuries that require intensive resuscitation and a multidisciplinary approach to achieve wholistic and appropriate management of these patients. Adequate initial resuscitation and stabilization of fractures may improve the morbidity and mortality of these sever injuries.