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SAMJ: South African Medical Journal

versão On-line ISSN 2078-5135
versão impressa ISSN 0256-9574

SAMJ, S. Afr. med. j. vol.105 no.12 Pretoria Dez. 2015

 

Discussion

We found that the majority (83.8%) of ECHOs had a positive impact on patients referred to a district hospital - a proportion much higher than that previously reported in developed country settings of 32 - 76%.[12,13] The diversity of patients' ages, comorbidities and sources of referral revealed the broad value of this investigative modality.

The value of a prospective study is that single ECHO assessment in a non-tertiary setting can immediately address a focused, clinical question or suspicion raised, and may have an immediate impact. Our definition of impact is different from previous larger impact studies, undertaken either in tertiary settings or in community hospitals with specialised cardiology services.[12,13] A few older studies done at district hospitals either reviewed the impact more than 30 years ago, using only M-mode ECHO, or focused on intensive care units.[3,15,16] The lack of generalisability to current district hospital practice seems obvious, especially in resource-constrained settings.

We have established the role of ECHO in causing de-escalation in therapy and continuation of management at district hospital level. This potential for decreasing referral to tertiary specialists seems similar to other studies.[7,9,16] Previous studies have cautioned against undervaluing a study with normal findings.[8,11,17] This latter benefit was confirmed in 32.9% (n=69) of all the participants referred, without escalating management. Its use in screening prescreened patients is evident, with a particularly high impact level in all paediatric patients, mainly aiding in de-escalation of services relating to a murmur that had been auscultated prior to referral. This has been undervalued by previous studies.[12,15] Our study has shown that impact does not necessarily translate into a change in management -many patients without a change in clinical status require follow-up, which is seen as a valid indication in itself in early and late stages of cardiac disease.[14]

The major change in management proved to be rational prescription of medication. The other main benefit was determining which patients required up-referral to tertiary services, e.g. for cardiac surgery.

AUC are not used in SA. Nevertheless, only one participant's indication could not be classified according to AUC, as the referral was for possible cardiac cause for seizures. This indicates the high level of appropriate use of ECHOs in our district hospital. The most common indication was suspected valve disease. Its significance could not be statistically linked to impact, perhaps owing to the small sample size achieved. New information gathered was nevertheless significant for mitral stenosis and aortic regurgitation, mirroring the finding of a previous audit of the beneficial value of ECHO in assessing diastolic (more than systolic) murmurs.[15] Three adult participants but no paediatric patients were newly diagnosed with rheumatic heart disease. A recent study in SA has shown the decrease in rheumatic heart disease in children in SA, which may be due to improved access to healthcare and an improved socioeconomic environment.'181 The use of ECHO as a screening tool for rheumatic heart disease has yet to be translated into impact on prognosis and effective secondary prophylaxis for subclinical disease. Results suggest that adults may benefit from screening more than children.[19]

Of all indications for ECHO, assessment of regional wall motion abnormalities and suspected hypertensive heart disease were statistically significantly associated with impact. The value of ECHO in defining prognosis in these two conditions has been described previously. [20,21] One study found that the evaluation of wall motion abnormalities constitutes the most statistically significant, independent prognostic data provided by TTE.[20] Although screening of all hypertensive patients has been recommended, as left ventricular hypertrophy itself implies a worse prognosis,[22] others assert that ECHO confirmation would probably not intensify the treatment of the hypertension itself.[22,23]

In our study, heart failure was the major indication for ECHO, as was the case in a systematic review of patients referred for OAE from primary care.[23] The role of TTE in providing new information in this context is nonetheless unsurpassed, by detecting LV dysfunction and either establishing or confirming the cause of failure.[17] This is of particular value in our setting, where heart failure is usually diagnosed and monitored by clinical means only. Despite two-thirds of the cohort having a smoking history, low numbers of cases of COPD and its complications were reported. Screening for and assessing cardiac complications, such as cor pulmonale and pulmonary hypertension, in patients with COPD can be useful, as both infer increased morbidity and mortality.'[24] The diagnosis of a clinically unsuspected atrial myxoma in this small cohort was a finding that would otherwise have remained undetected.

Discrepancies between the results of the TTEs and the assessment of the referring clinician prior to the test were confirmed, as per previous studies.[25,26] It appears that the positive impact of TTE is independent of the clinical accuracy of the referring doctor. On the other hand, a lack of impact was nonetheless associated with accurate pre-referral assessment. This may indicate that a thorough history and physical examination may lessen the need for a diagnostic test.[25] Thirty-nine percent of the ECHOs disproved the pre-referral diagnosis.

In some of the participants who had had previous TTEs, repeat ECHO nevertheless had an important clinical impact. An earlier study found that the added diagnostic value of a repeat ECHO is significantly independent of whether the test had been performed previously.[25]

Approximately one-fifth of patients were referred from the hospital's emergency department; this may indicate the need for training in question-focused, point-of-care studies. A review of TTEs performed by non-cardiologists showed an active change in management in 16 - 37% of patients in an emergency setting.[9]

Failure of referral of patients from primary healthcare facilities was found despite doctors being free to refer patients directly for TTEs; it is not clear whether the medical staff were unaware of the existence of the service. Notably, among the few patients in this study cohort who were referred from community healthcare settings, the ECHOs had an important impact.

The waiting time for the next available appointment was six times as long as the recommended time period of 2 weeks advised by the National Institute for Care Excellence guidelines for patients with chronic heart failure and after myocardial infarction.[27] A Dutch study of OAE reports a waiting time of 5 weeks.[7] In developing countries, a lack of resources and scarce skills may be the reason for this long waiting time. The poor socioeconomic status of our participants, including pensioners and those receiving disability grants, suggests a reliance on public sector facilities. The poor attendance for TTE appointments shows the undervaluing of this restricted resource. Non-attendance is often due to lack of funds for transport. Having this service only at a distant tertiary centre may add to poor attendance.

 

Study limitations

Our study does have limitations. The participants were referred from the hospital ward or outpatient departments and had been prescreened after being admitted via the emergency department or referred from a primary healthcare facility. This may overvalue the impact owing to a lower incidence of negative findings. Patients with acute cardiac illness, such as heart failure or myocardial infarction, may be more likely to benefit from ECHO. The inclusion of hospitalised patients probably increased the likelihood of appropriate referrals by doctors.[11] The ECHOs were performed by an experienced cardiologist, with this specialist assessment in itself likely to have an impact on patient management, causing impact to be overestimated. The risk of possible bias exists, as the cardiologist was involved in the clinical decision-making process and management of participants. The study size was smaller than initially anticipated, mainly because of patients defaulting on their appointments.

Following the participants' completion of the questionnaires, all data were checked to correlate with the clinical information in their folders. This allowed for more accurate analysis of the patient characteristics and the echocardiograms as well as their indications. Fifteen patient folders were missing and were not checked retrospectively.

The downstream risks of TTE, such as incorrect interpretation and residual anxiety despite a normal study, should not be disre-garded.[1,14,28]

It would be important to gain insight into whether clinical impact and changes in management eventually translate into improved health outcomes in primary healthcare. These effects could be assessed in a follow-up study. Other than its clinical impact, the cost implications of a restricted resource should be studied. The benefits of more accurate diagnosis, improving rational drug prescription and decreasing the burden on the tertiary healthcare system should be evaluated. A patient-centred approach can also evaluate patients' own perception of impact on their illness.

 

Conclusion

Echocardiography had a positive impact on patient management in a district hospital setting. Limited access for patients may negatively impact on their management, as a valuable contribution of TTEs to overall management was found. A normal ECHO is important in offering reassurance to patients and diagnostic assistance to the referring doctor, and aiding in referral back to the primary level of care. In the overburdened public health sector, where continuity of care is frequently a problem, it may reduce time and costs. By providing an ECHO service in non-tertiary settings, patients can be screened and more appropriately referred to scarce upstream specialists and subspecialist departments.

Training in interpretation and accreditation in the use of ECHO should be a priority for teaching and academic facilities, especially for personnel working in general, emergency and family medicine. The prospect of hand-held devices would definitely enhance access, but may compromise quality.

Policy makers should be alerted to the added value offered by an ECHO assessment. The rapidly growing burden of NCDs should encourage investment in such service-based interventions to local communities.[4] District hospitals can establish protocols in the communities they serve, to assist with procurement and referrals from primary health care.

Acknowledgements. H Carrara assisted with the statistical analysis. D Lunga collected data as research assistant.

Funding. A research grant was obtained from the Department of Public Health and Family Medicine of the University of Cape Town.

 

References

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2. Chung J. Echocardiography in 2009: State of the art. J Invasive Cardiol 2009;21(7):346-351.         [ Links ]

3. Brown AK, Anderson V. The use of cross-sectional echocardiography in a general hospital. J Postgrad Med 1980;56:221-228.         [ Links ]

4. Mayosi BM, Flisher AJ, Lalloo UG, et al. The burden of non-communicable diseases in South Africa. Lancet 2009;374(9693):934-947. [http://dx.doi.org/10.1016/S0140-6736(09)61087-4]        [ Links ]

5. Puoane TR, Tsolekile LP, Calbick S, et al. Chronic non-communicable diseases in South Africa: Progress and challenges. In: Padarath A, English R, eds. South African Health Review 2012/13. Durban: Health Systems Trust, 2013. http://www.hst.org.za/publications/south-african-health-review-2012/13 (accessed 13 August 2013).         [ Links ]

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7. Van Gurp N, Boonman-De Winter LJM, Meijer Timmerman Thijssen DW, Stoffers HEJH. Benefits of an open access echocardiography service: A Dutch prospective cohort study. Neth Heart J 2013;21(9):399-405. [http://dx.doi.org/10.1007/s12471-013-0416-9]        [ Links ]

8. Rao A, Henton D, Walsh J. Evolving trends in open access echocardiography - experience over eight years. http://www.priory.com/med/echo.pdf (accessed 13 August 2013).         [ Links ]

9. Haji DL, Royse A, Royse CF. Review article: Clinical impact of non-cardiologist-performed transthoracic echocardiography in emergency medicine, intensive care medicine and anaesthesia. Emerg Med Australas 201335(1):4-12. [http://dx.doi.org/10.1111/1742-6723.12033]        [ Links ]

10. Xiao HB, Sethi A. Community echocardiography. Clinical Focus Primary Care 2006;1(3):88-93.         [ Links ]

11. Alqarqaz M, Koneru J, Mahan M, Ananthasubramaniam K. Applicability, limitations and downstream impact of echocardiography utilization based on the appropriate-use criteria for transthoracic and transoesophageal echocardiography. Int J Cardiovasc Imaging 201228(8):1951-1958. [http://dx.doi.org/10.1007/s10554-012-0008-6]        [ Links ]

12. Matulevicius SA, Rohatgi A, Das SR, Price AL, de Luna A, Reimold SC. Appropriate use and clinical impact of transthoracic echocardiography. JAMA Intern Med 2013;173(17):1600-1607. [http://dx.doi.org/10.1001/jamainternmed.2013.8972]        [ Links ]

13. Ballo P, Bandini F, Capecchi I, et al. Application of 2011 American College of Cardiology Foundation/American Society of Echocardiography Appropriateness Use Criteria in hospitalized patients referred for transthoracic echocardiography in a community setting. J Am Soc Echocardiogr 2012;25(6):589-598. [http://dx.doi.org/10.1016/j.echo.2012.03.006]        [ Links ]

14. Douglas PS, Garcia MJ, Haines DE, et al. ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 appropriate use criteria for echocardiography: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Critical Care Medicine, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 2011;57(9):1126-1166. Published online before print 19 November 2010. [http://dx.doi.org/10.1016/j.jacc.2010.11.002]        [ Links ]

15. Pollick C. Echocardiography in a district general hospital. Postgrad Med J 1978;54(631):297-301. [http://dx.doi.org/10.1136/pgmj.54.631.297]        [ Links ]

16. Orme RML, Oram MP, McKinstry CE. Impact of echocardiography on patient management in the intensive care unit: An audit of district general hospital practice. Br J Anaesth 2009;102(3):304-344. [http://dx.doi.org/10.1093/bja/aen378]        [ Links ]

17. Chambers J, Fuat A, Liddiard S, et al. Community echocardiography for heart failure: A consensus statement from representatives of the British Society of Echocardiography, British Heart Failure Society, CHD collaborative and Primary Care Cardiovascular Society. Br J Cardiol 2004;11(5):399-402.         [ Links ]

18. Cilliers AM. Rheumatic fever and rheumatic heart disease in Gauteng on the decline: Experience at Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa. S Afr Med J 2014;104(9):632-634. [http://dx.doi.org/10.7196/SAMJ.8318]        [ Links ]

19. Zühlke L, Mayosi BM. Echocardiography screening for subclinical rheumatic heart disease remains a research tool pending studies of impact of prognosis. Curr Cardiol Rep 2013;15(3):343. [http://dx.doi.org/10.1007/s11886-012-0343-1]        [ Links ]

20. Madsen BK, Egeblad H, Hojberg S, et al. Prognostic value of echocardiography compared to other clinical findings. Cardiology 1995;86(2):157-162. [http://dx.doi.org/10.1159/000176863]        [ Links ]

21. Weissman NJ, Ristow B, Schiller NB. Role of echocardiography in acute myocardial infarction. http://www.uptodatecom/contents/role-of-echocardiography-in-acute-myocardial-infarction.htm (accessed 10 December 2013).         [ Links ]

22. Amidon TM, Chou TM, Foster E, Kee LL. Role of echocardiography in primary care medicine: Controversies in hypertension, atrial fibrillation, stroke and endocarditis. West J Med 1996;164(3):269-275. [http://dx.doi.org/10.1111/j.1540-8175.2000.tb01151]        [ Links ]

23. Khunti K. Systematic review of open access echocardiography for primary care. Eur J Heart Fail 2004;6(1):79-83. [http://dx.doi.org/10.1016/j.ejheart.2003.10.002]        [ Links ]

24. Gupta NK, Kamar Agrawal R, Srivastav AB, Ved ML. Echocardiographic evaluation of heart in chronic obstructive pulmonary disease and its co-relation with the severity of disease. Lung India 2011;28(2):105-109. [http://dx.doi.org/10.4103/0970-2113.80321]        [ Links ]

25. Krumholz HM, Douglas PS, Goldman L, Waksmonski C. Clinical utility of transthoracic two-dimensional and Doppler echocardiography. J Am Coll Cardiol 1994;24(1):125-131. [http://dx.doi.org/10.1016/0735-1097(94)90552-5]        [ Links ]

26. Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA 1997;278(21):717-722. [http://dx.doi.org/10.1001/jama.1997.03550210037021]        [ Links ]

27. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. http://www.nice.org.uk/guidance/cg108/chapter/key-priorities-for-implementation (accessed 29 October 2014).         [ Links ]

28. McDonald IG, Daly J, Jelinek VM, Panetta F, Gutman JM. Opening Pandora's box: The unpredictability of reassurance by a normal test. BMJ 1996;313(7053):329-332.         [ Links ]

 

 

Accepted 25 June 2015.

 

 

Corresponding author: W F Bedeker (wfbedeker@gmail.com)

^rND^sFeigenbaum^nH^rND^sChung^nJ^rND^sBrown^nAK^rND^sAnderson^nV^rND^sMayosi^nBM^rND^sFlisher^nAJ^rND^sLalloo^nUG^rND^sPuoane^nTR^rND^sTsolekile^nLP^rND^sCalbick^nS^rND^sDe Vries^nE^rND^sRaubenheimer^nP^rND^sKies^nB^rND^sBurch^nVC^rND^sVan Gurp^nN^rND^sBoonman-De Winter^nLJM^rND^sMeijer Timmerman Thijssen^nDW^rND^sStoffers^nHEJH^rND^sRao^nA^rND^sHenton^nD^rND^sWalsh^nJ^rND^sHaji^nDL^rND^sRoyse^nA^rND^sRoyse^nCF^rND^sXiao^nHB^rND^sSethi^nA^rND^sAlqarqaz^nM^rND^sKoneru^nJ^rND^sMahan^nM^rND^sAnanthasubramaniam^nK^rND^sMatulevicius^nSA^rND^sRohatgi^nA^rND^sDas^nSR^rND^sPrice^nAL^rND^sde Luna^nA^rND^sReimold^nSC^rND^sBallo^nP^rND^sBandini^nF^rND^sCapecchi^nI^rND^sDouglas^nPS^rND^sGarcia^nMJ^rND^sHaines^nDE^rND^sPollick^nC^rND^sOrme^nRML^rND^sOram^nMP^rND^sMcKinstry^nCE^rND^sChambers^nJ^rND^sFuat^nA^rND^sLiddiard^nS^rND^sCilliers^nAM^rND^sZühlke^nL^rND^sMayosi^nBM^rND^sMadsen^nBK^rND^sEgeblad^nH^rND^sHojberg^nS^rND^sAmidon^nTM^rND^sChou^nTM^rND^sFoster^nE^rND^sKee^nLL^rND^sKhunti^nK^rND^sGupta^nNK^rND^sKamar Agrawal^nR^rND^sSrivastav^nAB^rND^sVed^nML^rND^sKrumholz^nHM^rND^sDouglas^nPS^rND^sGoldman^nL^rND^sWaksmonski^nC^rND^sMangione^nS^rND^sNieman^nLZ^rND^sMcDonald^nIG^rND^sDaly^nJ^rND^sJelinek^nVM^rND^sPanetta^nF^rND^sGutman^nJM^rND^1A01^nN^sNaidoo^rND^1A02^nD J J^sMuckart^rND^1A01^nN^sNaidoo^rND^1A02^nD J J^sMuckart^rND^1A01^nN^sNaidoo^rND^1A02^nD J J^sMuckart

RESEARCH

 

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

 

 

N NaidooI; D J J MuckartII

IMB ChB; Department of Surgery, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
IIFRCS, MMSc Crit Care (SA); Department of Surgery, School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

 

 


ABSTRACT

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.


 

 

Paediatric trauma is a major cause of potentially preventable disability and mortality in South Africa (SA).[1] In developing countries, infection and infestation account for the majority of deaths in the first 5 years of life,[2] and much effort has been put into reducing these causes. Death from trauma extends for another decade, but despite this childhood injury continues to receive scant attention[3] and prevention remains rudimentary. The extent of paediatric trauma in Africa as a whole is unknown and an appeal has been made to document the burden of this problem.[4] The limited information available suggests that motor vehicle collisions (MVCs), drowning and burns are the three commonest mechanisms causing severe injury.[3] Although falls account for the majority of childhood injuries,[5] MVCs are the major cause of severe morbidity and mortality. The majority involve pedestrians (PMVCs), and traumatic brain injury accounts for up to 80% of childhood trauma deaths.[6-9]

In addition to the burden of motor vehicle-related injuries, studies from Nigeria and SA have shown that gunshot wounds (GSWs) in infants and children are a tragic emerging mechanism of injury.[8,10,11]

Although the number of hospital admissions following GSWs in Cape Town decreased between 2000 and 2007, the vast majority of deaths occurred before treatment could be instituted and a steady increase in admissions was seen in the subsequent 3 years.[11]

Africa has the dubious label of being the most dangerous place in the world for a child,[12] and prevention and political will to back up the necessary policies are the most cost-effective methods of reducing trauma-related deaths.[4] To that end, information documenting causation, morbidity and mortality are essential for planning, implementation and evaluation of preventive measures. We therefore undertook an analysis of a prospective database of paediatric admissions to a level 1 (tertiary) trauma intensive care unit (TICU) to determine the commonest causes of injury, severity of injury and outcome.

 

Patients and methods

The study was approved by the University of KwaZulu-Natal Bioethics Committee (BREC 286/14) and conducted in the level 1 TICU at Inkosi Albert Luthuli Central Hospital, an academic tertiary hospital in Durban, SA. The TICU is an integral part of the trauma unit, which also houses resuscitation rooms equipped to the standard of the intensive care unit (ICU) and two dedicated trauma theatres. Subspecialists in critical care and trauma surgery, whose training includes the management of paediatric trauma, staff the trauma unit and TICU. There is no distinct referral pattern, and the unit accepts patients directly from the scene and from any health facility throughout KwaZulu-Natal Province (KZN). Burn injuries and drownings were excluded, as the former are managed in a separate burns unit and the latter in the medical ICU. All patients <16 years of age admitted to the TICU during the 5-year period January 2008 - December 2012 were identified from the unit database, which is collated by senior trauma staff on a daily basis and is independent of the hospital's electronic records system. Information extracted included referral source, age, gender and mechanism of injury (defined as MVC (pedestrian or passenger), non-vehicular blunt trauma in the form of falls and assault, GSWs, stab wounds, and other mechanisms). The injury severity score (ISS),[13] anatomical distribution of injuries and mortality during the hospital stay were computed. Quintile age divisions into 0 - 5, 6 - 10 and 11 - 15 years were analysed.

Categorical data were analysed using the χ2 or Fisher's exact test and continuous data by either Student's f-test or analysis of variance if there were more than two groups for comparison. A p-value of <0.05 was considered significant. Privacy and confidentiality was maintained and no patient was identified by name.

 

Results

A total of 1 138 patients were admitted to the unit during the study period, of whom 181 (15.9%) were <16 years of age. The age and gender distribution, ISS and mechanism of injury are shown in Table 1 according to quintiles of age. There were 84 females (46.4%) and 97 males (53.6%), with no significant difference in gender distribution. The majority of admissions were a result of blunt trauma (89.5%), with MVCs, a combination of pedestrians and passengers, accounting for 79% of all injuries.

 

 

PMVC dominance was maintained across all quintiles of age and for every year analysed (Fig. 1). Half of the pedestrian injuries arose in the middle quintile of 6 - 10 years of age. Penetrating trauma accounted for 10.5% of admissions, most commonly following GSWs. The majority of admissions (54.1%) were in the profound ISS category, and 149 patients (82.3%) had an ISS of >16. An average of 2.3 anatomical body regions were injured per child, with a total of 419 injuries. The anatomical distribution according to the six ISS body regions is shown in Fig. 2. Admission sources were regional hospital 56 cases (31.0%), primary healthcare facility 47 (26.0%), tertiary facility 40 (22.0%), and from the scene 38 (21.0%).

 

 

 

 

Mortality rates relative to mechanism, severity of injury and admission source are shown in Table 2. Ninety-two percent of deaths were in the profound injury severity category, which had a 24.5% mortality rate (p<0.001). One child in the mild injury group died having developed acute kidney injury following blunt assault with widespread soft-tissue trauma, for which the ISS can only score one point. The remaining death was of a 7-year-old with moderate traumatic brain injury and a fractured femur, but who was HIV-positive on highly active antiretroviral therapy and severely malnourished on admission.

 

 

There was no significant association of outcome with source of admission, although the mortality rate for direct admissions from the scene was on average 30% lower than that for interhospital transfers. MVCs accounted for 88.4% of deaths. Mortality rates did not differ significantly according to mechanism of injury, although PMVCs had the highest mortality rate per mechanism of injury. Of the 181 injured children, 112 (61.9%) had traumatic brain injury, of the 26 who died 23 (88.4%) had associated head trauma, and in 18 deaths (69.2%) severe traumatic brain injury was the primary cause. The commonest anatomical combination of injuries according to the ISS distribution was head, extremity and external.

 

Discussion

On 19 and 20 November 2009, a Global Ministerial Conference on road safety was held in Moscow, which culminated in a declaration inviting the United Nations General Assembly to declare a decade of action for road safety. The General Assembly recognised (Resolution 64/255) that the number of road traffic deaths is unacceptably high, with an estimated 1.24 million lives lost in 2010, a trend which if ignored would result in 1.9 million deaths every year to 2020. Furthermore, it was noted that only 7% of the world's population is covered by adequate laws that address behavioural risk factors including the non-use of helmets, safety belts and child restraints, driving under the influence of alcohol and drugs, inappropriate and excessive speed, and inappropriate use of cell phones while driving. Concern was also expressed that worldwide, half of all road traffic deaths involve pedestrians, motorcyclists and cyclists, and that in some developing countries there is inadequate infrastructure and a lack of policies to protect vulnerable road users. On 11 May 2011 the United Nations launched its programme 'Decade of Action for Road Safety 2011 - 2020'.

Almost half that decade has passed, and our results reflect that motor vehicle-related collisions in SA continue unabated to destroy the lives of children and their families. SA ranks among the top ten countries with the highest road traffic fatality rate per 100 000 of the population, and is the second highest in Africa.[14] One of the Millennium Development Goals identified in 2006 was a 50% reduction in road traffic fatalities by 2015, using 2007 as the benchmark year. Unfortunately there has been little if any improvement. Between March 2010 and March 2011 there was actually an increase in fatalities of 15%.[15] On average, there were 1 150 motor vehicle-related fatalities per month, equivalent to almost 38 per day. Paediatric pedestrian fatalities accounted for almost 25% of all pedestrian-related deaths, exceeded only by male pedestrian deaths in the 25 - 45-year age group. A similar distribution is found among passenger fatalities, with the most vulnerable paediatric age group being the second quintile of life. Unlike most of the other provinces in SA, where passengers accounted for the majority of deaths, in KZN the highest number of deaths occurred in pedestrians. Overall KZN was the worst-performing province, with a continuous increase in the quarterly number of road fatalities exceeding the set quarterly targets for the province.

Although we found no statistically significant differences in mortality in relation to referral source, the proportion of deaths among patients admitted directly from the scene was on average 30% lower than among those referred from other facilities. Time to definitive care is an important determinant of outcome. The difference between time to admission to the trauma unit from the scene compared with interhospital transfer is 6 hours,[16] owing to a lack of adequately skilled prehospital personnel. Trauma contributes to 60% of the prehospital workload in KZN. Regardless of injury severity, the majority of patients are transported to district hospitals, which have limited imaging and surgical facilities.[17] If outcome is to be improved, delays in transfer to an appropriate level of care must be minimised, multiple transfers between health facilities discouraged, and standard referral patterns abandoned.[17]

Importantly, our mortality statistics do not reflect the extent of the trauma problem, as our results exclude deaths at the scene and address only critically injured children admitted to a level 1 TICU. For every severely injured child there are many more who have suffered less devastating injuries and are admitted to regional or district hospitals. A 10-year analysis at Red Cross War Memorial Children's Hospital in Cape Town documented almost 70 000 injured children, of whom 40% had sustained moderate or severe trauma.[5] Furthermore, many of those who survive are permanently disabled as a result of severe traumatic brain injury,[3,4] and in the public sector have little access to adequate rehabilitation facilities. The psychological, physical and economic burdens that are imposed on the individual, the family and society are incalculable.

In 2004 the National Department of Transport released a report estimating the costs of road traffic casualties.[18] Based on the value of lost output or productivity, by making use of average life expectancy, employment rate and income of the population, the average unit human casualty cost was ZAR500 000 per fatality, ZAR200 000 per serious injury and ZAR114 000 per slight injury. Given the annual fatality rate of 14 000 and a conservative estimate of three serious injuries per fatality, the annual costs are exorbitant.

In keeping with the United Nations concerns and the most recent South African National Road Agency report,[19] our results confirm that PMVCs dominate severe childhood injuries, being almost three times as common as severe injuries of paediatric passengers. Increasing urbanisation, coupled with a lack of road safety awareness, undoubtedly contributes to the incidence, especially when small children are accompanied only by their older siblings on the way to school, a not uncommon sight on our roads. Although less common than pedestrian collisions, childhood passenger-related trauma was associated with a higher mortality rate. On impact, unrestrained children are propelled within or ejected from the vehicle, resulting in multiple body compartment injuries. A recent amendment to the National Transport Act enforceable in April 2015 stipulates that all infants under 3 years of age must be restrained in suitable car seats and all children must wear conventional seat belts. Unfortunately this does not apply to public transport, and until the law changes children in minibus taxis or buses remain at high risk for propulsion within, or ejection from, a vehicle. Of equal concern is the transportation of unrestrained passengers in the cargo area of light delivery vehicles. In a report by Howlett et al.,[20] one-third of these were children and virtually all were ejected upon impact. Injuries to the head, spine and extremities predominated, 21% of patients died and one in ten survivors was permanently disabled, a finding commensurate with our own data. Compared with previous publications in SA,[3,4] little has changed with respect to mechanism of injury and outcome; of pedestrians or passengers with severe traumatic brain injury, more than half die.

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