L. N. Purcell1, A. N. Yohann1, R. N. Maine1, T. N. Reid1, C. Mabedi2, A. Charles1 1University Of North Carolina At Chapel Hill,General Surgery,Chapel Hill, NC, USA 2Kamuzu Central Hospital,General Surgery,Lilongwe, LILONGWE, Malawi
Introduction: Trauma is a leading cause of morbidity and mortality, particularly in those 15 to 45 years old. Over 90% of trauma mortality occurs in low- and middle-income countries (LMICs), especially in sub-Saharan Africa. Head injury is the main driver of trauma mortality, specifically in the pre-hospital setting. For patients presenting with torso injury, mortality is potentially preventable if bleeding, particularly from solid organ injury, is controlled expeditiously. We therefore sought to determine the risk of mortality in trauma patients requiring laparotomy in Malawi.
Methods: This is a retrospective analysis of prospectively collected data at Kamuzu Central Hospital from 2008 – 2017 of admitted patients with torso trauma. Data variables include basic demographics, injury severity and characteristics, surgical intervention, and mortality outcome. Bivariate analysis was performed for covariates based on exploratory laparotomy status. A Poisson regression analysis was performed to estimate risk of mortality after trauma laparotomy controlling for pertinent covariates (injury severity, night time and weekend penetration, injury mechanism, time from injury to presentation).
Results: Over the study period, there were 120,573 trauma patients. Of the 20,522 (17%) patients admitted, 6,474 (31.6%) had torso trauma. Of these, 341 (5.3%) had exploratory laparotomies. Exploratory laparotomy had a male and blunt injury mechanism preponderance of 73.3% and 92.8%, respectively. The crude mortality for patient undergoing exploratory laparotomy versus non-operative management was 9.5% and 6.6 %, respectively. There was an 6.8% overall mortality for torso trauma. Following Poisson regression analysis, the incidence risk ratio for mortality following exploratory laparotomy after controlling for covariates was 3.74 (CI 2.06 -6.78, p <0.001).
Conclusion: After adjusting for injury severity, there is a greater than three-fold increased risk of mortality following trauma exploratory laparotomy. This may be attributable to limited availability of allogenic blood transfusion, inadequate perioperative resuscitation, in-hospital delays to operative intervention including limited access to the operating room, and delays in providers’ decision to perform operative intervention. Trauma protocols are imperative in low-resource settings to optimize timely and appropriate operative management of torso trauma.