BackgroundThis study set out to review a large series of trauma laparotomies from a single center and to compare those requiring damage control surgery (DCS) with those who did not, and then to interrogate a number of anatomic and physiologic scoring systems to see which best predicted the need for DCS.MethodsAll patients over the age of 15 years undergoing a laparotomy for trauma during the period from December 2012 to December 2017 were retrieved from the Hybrid Electronic Medical Registry (HEMR) at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. They were divided into two cohorts, namely the DCS and non-DCS cohort, based on what was recorded in the operative note. These groups were then compared in terms of demographics and spectrum of injury, as well as clinical outcome. The following scores were worked out for each patient: Penetrating Abdominal Trauma Index (PATI), Injury Severity Score, Abbreviated Injury Scale-abdomen, and Abbreviated Injury Scale-chest.ResultsA total of 562 patients were included, and 99 of these (18%) had a DCS procedure versus 463 (82%) non-DCS. The mechanism was penetrating trauma in 81% of cases (453 of 562). A large proportion of trauma victims were male (503 of 562, 90%), with a mean age of 29.5±10.8. An overall mortality rate of 32% was recorded for DCS versus 4% for non-DCS (p<0.001). In general patients requiring DCS had higher lactate, and were more acidotic, hypotensive, tachycardic, and tachypneic, with a lower base excess and lower bicarbonate, than patients not requiring DCS. The most significant organ injuries associated with DCS were liver and intra-abdominal vascular injury. The only organ injury consistently predictive across all models of the need for DCS was liver injury. Regression analysis showed that only the PATI score is significantly predictive of the need for DCS (p=0.044). A final multiple logistic regression model demonstrated a pH <7.2 to be the most predictive (p=0.001) of the need for DCS.ConclusionDCS is indicated in a subset of severely injured trauma patients. A pH <7.2 is the best indicator of the need for DCS. Anatomic injuries in themselves are not predictive of the need for DCS.Levels of evidenceLevel III.

Hanging is a common form of self-harm, and emergency care physicians will not infrequently be called upon to manage a survivor. [1-4] 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. Our current algorithm for the management of this injury is based on the resuscitation protocols of the Advanced Trauma Life Support (ATLS) Course, which essentially emphasise maintenance of an adequate airway while ensuring that the cervical spine is immobilised and protected. Once this has been achieved, all hanging victims have a contrast-enhanced computed tomography (CT) scan of the head and neck to exclude major intracranial lesions and assess the cervical spine, aerodigestive tract and carotid arteries. Many of the potential injuries to these structures are occult in that they are difficult to detect clinically and potentially serious. Blunt pressure on the carotid vessels may result in the formation of an intimal tear, creating a highly thrombogenic surface in the carotid vessel that may result in a cerebral embolus or complete occlusion of the carotid vessel. This injury may have significant sequelae if undetected and untreated. [1-4] Objectives In the light of the above, we set out to review our experience with the management of hanging victims, to establish the yield from contrast CT scans of the head and neck in these patients, and to compare our findings with the international literature. Methods Clinical setting The study was undertaken at the Pietermaritzburg Metropolitan Trauma Service (PMTS), South Africa. The PMTS provides definitive trauma care to the city of Pietermaritzburg, the capital of KwaZulu-Natal (KZN) Province, and tertiary trauma care to western KZN, with a total catchment population of >3 million people. The PMTS maintains a regional trauma registry, the Hybrid Electronic Medical Registry (HEMR). All patients who present to our trauma centre are prospectively entered into the database, and the information recorded includes details regarding injury mechanism, operative intervention, patient progress and clinical outcomes. Ethics approval for the maintenance of the HEMR has been formally endorsed by the Biomedical Research Ethics Committee of the University of KwaZulu-Natal (ref. no. BCA221/13). Management of hanging All patients presenting to the PMTS are managed according to ATLS principles. The airway is secured while maintaining inline stabilisation of the cervical spine. If a patient is unable to protect This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

Background: Self-harm behaviour is a major public health problem that is commonly underreported. This study reviews the spectrum of these self inflicted injuries managed by a major trauma centre in South Africa. Methods: A retrospective review of the regional trauma registry was undertaken over a five-year period from December 2012 to December 2017 at the Pietermaritzburg Metropolitan Trauma Service (PMTS) in South Africa. All patients who were admitted after they had sustained an injury as a result of self-harm were included. Results: During the five-year study period, a total of 179 patients were included. The mean age was 29 years (SD12) and there were 139 (77%) males and 40 (23%) females. Of these, 16 had a previously established psychiatric diagnosis and two had a prior history of having sustained self-harm. The previously diagnosed psychiatric illnesses included mood dysphoria disorders (5), schizophrenia (3), substance abuse and dependency (1), antisocial personality disorder (1) and unspecified (6). The mechanism was penetrating trauma in 47 (26%). The penetrating mechanisms included stab wounds (SW) in 33, gunshot wounds (GSW) in 10, broken glass in 2 and a single impalement. Blunt mechanisms accounted for the remaining 131 (73%) injuries. The most common mechanism of blunt self-harm was hanging in 101 patients. This was followed by vehicular related trauma (8), jumping in front of a train (1) and jumping from a height (1). In 17 patients the exact mechanism of the blunt trauma was unclear. There was no statistical difference in the mechanism of injury between male and female patients. There were 38 (28%) men and 9 (23%) women who sustained a penetrating injury and there were 100 (72%) male and 31 (78%) female patients who had a blunt mechanism of injury. A total of 53 CT scans were obtained, 40 chest X-rays, 9 abdominal X-rays and 2 ultrasounds. There were 113 neck injuries, 68 head injuries, 24 abdominal injuries, 15 upper limb and 15 lower limb injuries and four facial injuries. A total of 32 operations were performed. These included laparotomy (14), neck exploration (5), tracheostomy (4). A total of 22 patients developed a complication. Conclusion: Self-inflicted injury is not uncommon and frequently requires investigation and or surgical treatment. Patients who sustain such an injury constitute a distinct vulnerable group who are under researched. Future research on this vulnerable patient group is needed.

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.

Background: This study reviews our experience with penetrating Traumatic Brain Injury (TBI) in order to define and describe the injury pattern and the outcome. A secondary aim of this study was to review the use of the Motor Score (M Score) and the Simplified Motor Score (SMS) to assess and triage patients with penetrating TBI. Methods: All patients with a TBI secondary to a penetrating mechanism were identified from the Hybrid Electronic Medical Registry at Pietermaritzburg Metropolitan Trauma Service (PMTS) from January 2012 to December 2014. Standard demographic data, need for neuro-surgical intervention, location of external wounds, CT findings and mortality where analysed. The Glasgow Coma Scale (GCS) M score and SMS score were specifically evaluated to determine the relationship between the individual motor component and patient outcome. Results: Over the two-year period January 2012-December 2014, a total of 384 patients were admitted following a penetrating TBI. There were 350 males and 34 females and of this total 7 (1.82%) died. The mechanism of injury was axe (30), bottle (34), gunshot wound (GSW) (22) and stab wound (298). The average age for axe injuries was 27 and bottle injuries was 30. The average age for firearms and knives was 29 and 30 respectively. Surgery was not required for 76.67% of patients. The need for surgery varied according to mechanism of injury. Axe injuries were treated non-operatively in 47.83%, bottle injuries in 87.50%, firearms 70% and knife injuries were treated nonoperatively in 86.84% of cases. The overall survival rate for a penetrating head injury in this population is 98.16%. There were a total of 368 patients with a motor score of 6 of which one died. The survival rate was 99.7% and the mortality rate 0.3%. There were only 6 patients with a motor score of 5 and only 2 with a motor score of 4. The survival rate for both these groups was 100%. There was a total of 6 patients with a motor score of 1. There was a 100% mortality rate is this group. Conclusion: Penetrating TBI has a good prognosis. The vast majority of cases do not require neuro-surgical intervention. Poor motor score is associated with a poor outcome.