Pattern and outcome of abdominal injuries in Kenyatta National Hospital (KNH)

Abstract

Eighty consecutive admissions of patients with abdominal injuries were recruited into this prospective study conducted over a period of three and half months between November 2004 and mid-February 2005. It involved patients in the adult general surgical wards only. There were 74 males and 6 females giving a male to female ratio of 12.3: I. The age ranged from 15 years to 56 years with a mean of 28.2 years. Majority of the patients (53.8%) were in the third decade of life. Fifty-three patients had penetrating while 27 had blunt abdominal injuries. The common causes of penetrating abdominal injuries were stab wounds (64.2%), gunshot wounds (32.1 %) and arrow wound (3.7%). Road Traffic Accidents (44.4%), assault (37.0%) and faJJ from heights (14.8%) were the leading causes of blunt abdominal injury. Overall, stab wounds, gunshot wounds (GSWs) and Road Traffic Accidents (RTAs) are the three top causes of abdominal injuries. Fifty-two patients (65%) had isolated abdominal injuries while the remaining 28 had associated extra-abdominal injuries. Seven of these had more than one extra-abdominal injury. Blunt abdominal injuries had a higher tendency to have associated extra-abdominal injuries. The injured extra-abdominal parts included the chest, limbs, head and pelvis. The duration prior to presentation to hospital depended on the degree of injury. Severe injuries presented early and vice-versa. The shortest duration was one hour and the longest one week. Sixty patients (75%) presented within the first six hours of injury. The type of injury did not determine the duration prior to presentation to hospital. As of the time of admission, 80% of the patients had normal vital signs. Out of 16 patients admitted with abnormal vital signs, I I had penetrating abdominal injury. Eighty percent of the blunt abdominal injuries with abnormal vital signs died. Less than 40% (36.4%) of the penetrating abdominal injuries with abnormal vital signs died, showing a better interventional outcome in the penetrating than blunt abdominal injuries. Patients were managed according to decisions made by the attending firms (wards SA, SB and SD). Fifty-six patients (70%) were operated on while 24 were subjected to conservative management. The modes of management and success of interventions varied from firm to firm.

Of the operated, 6 had initially been on conservative management (five blunt and one penetrating), showing a 20% change in the mode of management. Nine patients of the 56 operated on had negative laparotomies, giving a 16. I% rate of negative laparotomies. Eighty percent of the initially conserved patients with blunt injuries had positive findings on laparotomy. The waiting period before surgery for those primarily operated on ranged from half an hour to twenty hours and was depended on the degree of injury and state of patient rather than type of injury. For the initially conserved patients, blunt abdominal injuries took almost three times the penetrating injury waiting time before surgery could be performed. This would suggest greater dilemma in the management of the stable patients with blunt abdominal injury as to when to change instituted mode of treatment. There was correlation between duration prior to surgery and complications as well as deaths. Ten patients developed complications, grvmg a 12.5% rate of complications. The complications included sepsis, rebleed, enterocutaneous fistula and gas gangrene of anterior abdominal wall. Ninety percent of the patients who had complications had undergone surgery. Eight patients (10%) were admitted to the Intensive Care Unit (ICU). Surgery had been performed in all of them. While there was no difference between type of injury and need for ICU admission, the mortality rate was higher in blunt than in penetrating abdominal injuries (75% vs 50%). The overall mortality for patients with abdominal injury admitted to ICU was 62.5%. Twenty-three patients (fifteen penetrating and eight blunt) had blood transfusion. Twenty-one of these patients had laparotomy performed, yielding 19 positive and 2 negative laparotomies. Operative interventions was a strong reason for blood transfusion even in those with negative laparotomies. The 2 negative laparotomy patients who were transfused had a pre-existing anaemia that required transfusion after surgery. Ten patients (six blunt and four penetrating) succumbed to their injuries, making the mortality rate in abdominal injuries to be 12.5%. The correlates for mortality were long periods of conservative management in patients not showing improvement, associated extra-abdominal injuries, duration prior to admission, duration prior to surgery, admission to ICU and need for blood transfusion.

Majority of the patients (32) stayed up to five days. Within ten days, 88.6% of the patients had been discharged. The duration of stay depended on whether or not there were associated extra-abdominal injuries and presence or absence of complications. On the whole, the average duration of stay for abdominal injuries was 6.4 days with no significant difference between the type of injury and duration of stay for the simple, isolated injuries. For the abdominal mjunes with resultant complications, blunt injuries stayed almost twice as long as the penetrating injuries.