|Year : 2019 | Volume
| Issue : 1 | Page : 4-8
Surgical emergency deaths in a teaching hospital in lagos, Nigeria
OI Akinmokun1, MO Afolayan2, OA Ojo3
1 Department of Surgery, College of Medicine, , University of Lagos; Department of Orthopaedics, Lagos University Teaching Hospital; Department of Accident and Emergency, University of Lagos, Lagos, Nigeria
2 Department of Surgery, College of Medicine, University of Lagos; Department of Accident and Emergency, Lagos University Teaching Hospital, Lagos, Nigeria
3 Department of Surgery, College of Medicine, University of Lagos; Department of Surgery, Lagos University Teaching Hospital, Nigeria
|Date of Web Publication||26-Jul-2019|
Dr. O I Akinmokun
Department of Accident and Emergency, Lagos University Teaching Hospital, Idi-Araba, Lagos
Source of Support: None, Conflict of Interest: None
Introduction: Surgical emergency is a medical condition for which immediate or urgent surgical intervention is required. This includes acute trauma and other life- or limb-threatening conditions that may cause a loss of life or permanent deformity if surgical interventions are not applied immediately. The accident and emergency (A and E) room is the first point of call for patients with such surgical emergencies. This study is an audit of surgical emergency deaths in the A and E of the Lagos University Teaching Hospital (LUTH). Methodology: This was a retrospective study. It involved analysis of the records of patients who were attended to at the A and E room of LUTH, Idi-Araba, Lagos state. The period of study was 12 months. Data obtained were analysed using Microsoft Excel 2010 (Microsoft Corporation, Redmond, Washington, USA). Results: The crude mortality rate was 8.3%. The overall male:female ratio was 2:1. The average age at death for both sexes was 46.5 ± 17.5 years. The age ranged from 6 to 87 years. Trauma was the cause of death in 99 cases (52.4%), with a male:female ratio of 5.2:1. Traumatic brain injury was the largest contributor of death overall, with a male:female ratio of 6.6:1. The average age of females who died following trauma was 6 years younger than that of the males. More patients involved in trauma died within 24 h of presentation. The overall average age at death for trauma-related deaths was 38.9 ± 17.2 years. However, the overall average age at death for malignancy-related causes was 53.9 ± 13.5 years. The male:female ratio for malignancy as a cause of death was 1:2.3. More deaths occurred within ages 20 and 39 years, accounting for almost half (46.8%) of the total deaths. Breast carcinoma was the major (45.3%) cause of death among the malignancy-related causes of death, with all but one case occurring in women. Conclusion: Mortality at the surgical department of A and E is still high compared to centres of other Western countries. The general populace needs orientation to reduce risk factors for trauma, especially brain injury. The government also needs to improve facilities available at the trauma centre.
Keywords: Accident, death rate, emergency, emergency room, mortality, surgical deaths
|How to cite this article:|
Akinmokun O I, Afolayan M O, Ojo O A. Surgical emergency deaths in a teaching hospital in lagos, Nigeria. Niger J Orthop Trauma 2019;18:4-8
| Introduction|| |
Surgical emergency is a medical condition for which immediate or urgent surgical intervention is required. This includes acute trauma and other life- or limb-threatening conditions that may cause a loss of life or permanent deformity if surgical interventions are not applied immediately. The accident and emergency (A and E) room is the first point of call for patients with such surgical emergencies. Emergency care consists of three components i.e., the care in the community or at the accident scene (in case of trauma), the care during transportation and care received on arrival at the receiving health facility. The earlier two components constitute pre-hospital care, which has been documented to be lacking in our environment except a semblance in some parts of the country. Although the pre-hospital care was not the focus of this study, its absence may contribute to deaths of patients in emergency room as their physiological reserve may have been overwhelmed at the time of presentation at the emergency room, such that interventions applied may not yield desired effects in saving their lives. Most patients with surgical emergency in our environment rarely receive any form of pre-hospital care prior to their presentation at the emergency room, or few might have received suboptimal care at the peripheral centre before presentation, which indeed might be a form of delay rather than being a helpful intervention for such patients.,
Severe emergency surgical patients may often present at the emergency room either in a conscious or unconscious state, and sometimes in respiratory distress, shock, dehydration or in other conditions that would require resuscitation. Such patients need to be resuscitated and stabilised before the required surgical intervention can be performed. Mortality can occur during this period. This study is, therefore, an audit of surgical emergency deaths in the A and E of the Lagos University Teaching Hospital (LUTH). LUTH is a major referral centre and the biggest trauma centre in Lagos state. It is a 760-bedded hospital with two emergency rooms the A and E room and the Children Emergency room. The A and E is divided into different sections namely medical, surgical, obstetric and gynaecological emergencies. The surgery section attends to all surgical emergencies including children who sustained injuries following trauma. Lagos state is the commercial city in Nigeria with a population of 9,113,605 (based on the 2006 Census). LUTH is located within Surulere local government area (LGA) and also borders Mushin LGA. Both the LGAs have a combined population of 1,134,722 (based on the 2006 Census).
| Methodology|| |
This was a retrospective study. It involved analysis of the records of patients who were attended to at the A and E room of the LUTH, Idi-Araba, Lagos state. The period of study was 12 months, between May 2016 and May 2017. The data from the month of July 2016 were excluded due to an industrial action by hospital staffs. The data reviewed were extracted from all records available, including patients' attendance and admission register, mortality record book, nurses' report books and death certificate booklet. All pre-hospital deaths were excluded. The data of patients who died and were certified dead within the A and E department were extracted. Data of patients who died at the surgery section were, thereafter, retrieved and analysed. Patients with gynaecological emergencies were excluded. Data retrieved included age, sex, initial and final diagnosis, cause of death and length of stay. Postmortem records from the morbid anatomy department were retrieved and reviewed to confirm the cause of death in patients who died within hours of presentation or those in whom investigations were not concluded before their deaths (Coroner's cases). Limitation encountered in this study was incomplete record as a result of improper storage of registers and case notes. Data obtained were analysed using Microsoft Excel 2010 (Microsoft Corporation, Redmond, Washington, USA). Results were presented in descriptive and tabular forms. P < 0.05 was considered statistically significant.
| Results|| |
The total number of patients seen with surgical emergency within the 12-month period was 2281. The total number of deaths recorded during this period was 189. The crude mortality rate was 8.3%. The male:female ratio was 2:1. The average age at death for both sexes was 46.5 ± 17.5 years, with a median age of 46 years. The average age at death for males was 46.8 ± 17.8 years, whereas that of females was 45.9 ± 16.9 years. The age ranged from 6 years to 87 years.
Trauma accounted for deaths in 99 cases (52.4%), followed by malignancy (28%) and intestinal obstruction (5.6%). Perforated viscus with peritonitis accounted for 3.2% of deaths. Acute pancreatitis and obstructive jaundice also caused deaths [Table 1]. The average length of stay before death for all patients was 2.53 ± 2.03 days. The length of stay ranged from 15 min to 15 days. Thirty-one percent (31%) of the patients died within 24 h of presentation. Fifty-eight percent (58%) of the patients that died within 24 h of presentation were involved in trauma, and 52% of the total patients that died within 48 h were patients with injuries. A trauma patient has a 1.4 chance of dying within 24 h of presentation in the emergency room compared to others.
The overall average age at death for trauma-related deaths was 38.9 ± 17.2 years; the average age at death for males was 40.3 ± 15.8 years, whereas that of females was 34.1 ± 21.4 years. The highest number of deaths was recorded within 30–39 years' age group (30%) [Figure 1]. Death from traumatic brain injury represented 84.8% of the trauma-related causes of deaths [Figure 2]. Severe brain injury accounted for 83.3% of deaths from traumatic brain injury. Based on the mechanisms that caused the injuries that led to death, road crashes was the leading cause accounting for 42.4% of all trauma-related deaths. This was followed by falls (6.1%) and assaults (5.1%). Majority were undocumented (40%) [Figure 3].
Although the overall male:female ratio for all causes of death was 2:1, the male:female ratio for death following trauma was 5.2:1, and when death due to traumatic brain injury only was analysed, the male:female ratio increased to 6.6:1.
The overall average age at death for malignancy-related causes was 53.9 ± 13.5 years; the average age of males at death was 59.1 ± 16.0 years and that of females was 51.9 ± 11.9 years, with an age range of 29–87 years. The male:female ratio for malignancy as a cause of death was 1:2.3, which is in contrast to the overall male:female ratio of 2:1. Death from breast carcinoma was leading (45.2%) among the malignancy-related causes of death. It accounted for 62% of deaths among females who died of malignancy. Carcinoma of the prostate is the leading cause of death (25%) among males who died of malignancy. All patients who died of malignancy presented with metastasis [Table 2].
| Discussion|| |
The leading cause of death in the surgical emergency room was trauma. It accounted for 52.4% of all deaths recorded in this study. Road crash was the leading mechanism of trauma that caused most deaths. Similar studies have also shown the prevalence of trauma as a major cause of death in our environment and road traffic accidents as the mechanism causing most deaths among the trauma-related deaths.,, Nantulya and Reich opined that injury and deaths from road crashes are major public health problems in developing countries. The burden of road traffic injuries remains very high in Africa, and it should be tackled. The highest burden of injuries and fatalities occurring from road crashes is borne by poor people in developing countries as pedestrians and passengers in buses, minibuses and motorcycles. Policies aiming at prevention should be promulgated and enforced. Educating the populace on the need to obey the traffic rules and punishing those that contravene such laws will help to stem the tides of this neglected epidemic and burden.
Deaths following trauma occurred more within the productive (working) age group as seen in this study. The highest number of deaths was recorded within the ages of 20 and 49 years, accounting for 61.7% of deaths from trauma. This corroborates the previous similar studies.,, This period (Between 20 and 49 years) is the most active years for economic reasons. People within this age group are highly mobile, are risk takers and often participate in activities that are quite daring. It is, therefore, not surprising that they can be exposed to trauma easily, which may be severe enough to cause mortality. It was, however, noted that females died at an age that was 6 years younger than that of males.
Traumatic brain injury remained the most common cause of death for all surgical emergency room deaths. Majority of these injuries were sustained from road crashes. This trend was seen in other studies also.,,, Most (83.3%) of the patients who died following traumatic brain injury presented with severe head injury. Patients with severe head injuries require urgent endotracheal intubation, intensive care admission and mechanical ventilators. Although prognosis is poor in this group of patients, limited availability of bed spaces at the intensive care unit and lack of mechanical ventilators may also contribute to several deaths recorded in these patients. Expanding and equipping the present intensive care facility to cater for more injured patients will help ameliorate the death rate of patients with severe head injury. The citizens also should be educated on the need to inculcate actions that can prevent road crashes and other forms of trauma. Previous studies also have shown that trauma-related deaths occurred more in males. This corroborated our finding in this study, with a male:female ratio of 5.2:1, but within the subset of patients who died of traumatic brain injuries, the male:female ratio was 6.6:1. Male gender should be targeted deliberately, especially with educative and health-related programmes that should be designed to effect a change that will enable them to adopt preventive methods toward traumatic brain injury.
Malignancy was the second-most common cause of death, with more deaths in females than males, at a ratio of 1:2.3. The average age at death in females who died from malignancy was 8 years younger than that for males. The male:female ratio in our study is similar to the finding from a study by Akinde et al. Breast cancer was the leading cause of death amongst deaths caused by malignancy in this study. This corroborated the finding documented by Akinde et al. in their study. It, however, differs from the report of the World Health Organization's Global Burden of Disease Report where breast cancer was second to carcinoma of the cervix as the cause of death in Africa. Gynaecological causes of death were excluded from this study, which may be responsible for this discrepancy. Carcinoma of the prostate was the leading cause of death due to malignancy in this study as already noted in the Global Burden of Disease Report, where it was stated to be the leading cause of death in African men. Unfortunately, all patients who died from malignancy presented with metastasis. Early detection remains the best way to prevent deaths due to cancers. The populace should be educated properly on ways to avoid late detection of malignancy.
| Conclusion|| |
Deaths from trauma remained high. Our mortality rate is still high compared to centres in developed countries due to various factors. Severe head injury was the highest contributor to death in the surgical emergency room. Lack of adequate facility to cater for this group of injured patients will continue to lead to high mortality rate. The government needs to improve the facilities available. The populace should also be educated on the prevention of road crashes and other risks that can predispose one to trauma, especially brain injury. Early detection is important in the prevention of deaths from malignancy.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]