Burden of Chest trauma, Perspective of Nepal and SAARC

(South Asia) Region Way forward for rib fixation

surgery in the region

Dr. Ram Prasad Shrestha, MD, MS, FICS, FCSS

Dr. Tej Dawadi, MS

Date: March 19th, 2016

The South Asia • The South Asian Association for

Regional Cooperation (SAARC), a contiguous block of countries Established in 1985

• Initially seven countries — Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan and Sri Lanka.

• In 2006 extended by including Afghanistan as an eighth member.

• China and Myanmar have also applied for the status of full members of SAARC

Population of The South Asia Country Population

1 Bangladesh 152,518 2 Bhutan 697,000

3 India 1,210,193,422 4 Maldives 396,334 5 Nepal 26,620,080 6 Pakistan 180,440,000

7 Sri Lanka 20,277,597

8 Afghanistan 29,159,000

Total 1,626,000,000

Injury related mortality in south Asia Pattern of injury Frequency (%) RTA 18 Self inflicted 15 Fires 11 Falls 7 Violence 7 drowning 6 poisoning 6 War 1 Other unintentional 29

Source: WHO, Geneva, Global Burden of Disease Study (2004 update)

Road traffic death in SA

Country Estimated road traffic death rate / 100,000 pop.

Bangladesh 12.6

Bhutan 14.4

India 16.8

Maldives 18.3

Nepal 15.1

Sri Lanka 13.5

Spectrum of Chest trauma in Nepal and SA

TRAUMA / CHEST TRAUMA

• Trauma : * 3rd leading cause of death * 9% of total mortality Jha N, Agrawal CS. Epidemiological study of road traffic accident: A study from eastern Nepal. WHO Regional Health Forum. 2004; 8:15–22

Chest Trauma • 15% of surgical trauma cases 1

• Common in males * 80 : 20%2

* 73 : 27%3 1) Spectrum of surgical trauma and associated head injuries at a university hospital in eastern NepalA Bajracharya, A Agrawal, BR Yam, CS Agrawal, and Owen Lewis. J Neurosci Rural Pract. 2010 Jan-Jun; 1(1): 2–8. 2) Analysis of Blunt Chest Trauma Cases Requiring Admission in a Tertiary Care Level Hospital of Nepal. Robin Man Karmacharya, Hemanta Batajoo, Sumita Pradhan, Yagya Ratna Shakya, Bibhushan Shrestha. International Journal of Health Sciences and Research (IJHSR) 3) Profile of thoracic injury at College of Medical Sciences Teaching Hospital D Chapagain,1 D Jayapal Reddy,2 S Shah,3 K G Shrestha.3 Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-1

TRAUMA / CHEST TRAUMA Topographical variation

1) Profile of thoracic injury at College of Medical Sciences Teaching Hospital D Chapagain,1 D Jayapal Reddy,2 S Shah,3 K G Shrestha.3 Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-1, 30-39 2) Analysis of Blunt Chest Trauma Cases Requiring Admission in a Tertiary Care Level Hospital of Nepal. Robin Man Karmacharya, Hemanta Batajoo, Sumita Pradhan, Yagya Ratna Shakya, Bibhushan Shrestha. International Journal of Health Sciences and Research (IJHSR)

Mode of injury

1. Terai: RTA1

2. Hill: Fall from height2

Eastern Nepal experience, a study in 1848 patients

parameters frequency

Hemothorax 16.2%

Pneumothorax 8.1%

# Rib alone 51.1%

# Rib with Hemothorax 5.8%

Flail chest 3.4%

Title: Spectrum of surgical trauma and associated head injuries at a university hospital in eastern Nepal Author: A Bajracharya, A Agrawal, BR Yam, CS Agrawal, and Owen Lewis. Published: J Neurosci Rural Pract. 2010 Jan-Jun; 1(1): 2–8.

Experience in Mid Terai region of Nepal: a study in 100 thoracic injury cases

parameters Frequency Rib # 83% Hemothorax 57% Pneumothorax 33% Flail chest 9%

Title: Profile of thoracic injury at College of Medical Sciences Teaching Hospital, Bharatpur, Chitawan ,Nepal Author: D Chapagain,1. D Jayapal Reddy, 2. S Shah, 3. K G Shrestha. Published : Journal of College of Medical Sciences-Nepal, 2013, Vol-9,No-1, 30-39

Spectrum of chest trauma

Title: Analysis of Blunt Chest Trauma Cases Requiring Admission in a Tertiary Care Level Hospital of Nepal. Author: Robin Man Karmacharya, Hemanta Batajoo, Sumita Pradhan, Yagya Ratna Shakya, Bibhushan Shrestha. Published: International Journal of Health Sciences and Research (IJHSR)

Experience from Central India A study of Total # of trauma patient patients 1,408 total # of Chest injury 402 (29%)

Title: Pattern of chest injuries in fatal vehicular accidents in central india (at PGIMS, Rohtak)

Author: Dr. P Murkey, Dr. N Nagrale, Dr. B Tirpude, Dr. P Wankhade, Dr. S Patond The Internet Journal of Surgery. 2008 Volume 18 Number 1.

Parameter frequency Multiple rib # 52.2% Two Rib # 15.1% Single rib # 9.9% Pneumo / Hemothorax 12.4% Flail chest 7.7%

Experience from India: University College of Medical Sciences and Guru Teg Bahadur

Hospital, Delhi, India Total 105 patients of chest injuries

Title: Experiences with chest trauma: Where do we stand today Author: M. Mohta, P. Kumar, A. Mohta*, R. Bhardwaj, A. Tyagi, A. K. Sethi Published: Indian J Crit Care Med January-March 2006 Vol 10 Issue 1

Parameters frequency Fracture ribs 46.6%

Pneumothorax 46.6% Haemothorax 42%

Subcutaneous emphysema 42% Hemo-pneumothorax 34.2%

Flail Chest 13.3%

A Pakistan experience Total chest trauma cases 143

• Blunt Injury 87.4 % • Penetrating injury 12.6% • Rib # 74% • Mgt. Thoracostomy 45% • Ventilator support 11.8%

Title: Thoracic trauma: presentation and management outcome. Author: Saaiq M, Shah SA Coll Physians Surg Pak.2008 Apr;18(4):230-3. doi: 04.2008/JCPSP.230233.

A Taiwan experience • A prospective study of 1333 patients admitted to

the Department of Thoracic surgery • 6% of all trauma comprises Thoracic Trauma • 36.3% requiring ICU treatment • But accounts for up to 50% of trauma related

death • 1.5% is the flail chest rate Factors associated with ICU admission in patients with traumatic thoracic injury Journal of International Medical research: 2013 41: 1310 Author: Frank Cheau-Feng Lin et al

Commonalities

• Chest trauma are in increasing trend • In Hill areas causative factors are fall • RTA are in plain and urban areas • Male preponderance • Prevalence are seen from 20 – 40 years of age

Current status in management Supportive care Analgesics O2 + Ventilators Tube Thoracostomy Thoracotomy

Pain

Respiratory support

Surgery

The management of Pain

• Oral analgesics- NSAIDS, • IV analgesics • Inter-coastal Nerve root block • Epidurals analgesia

Interventional treatment • ICU admitted – 46% - significantly correlated with mortality (p<0.05) • Ventilator support – 11% • Tube thoracostomy – 45% • Thoracotomy – 4% • Flail chest - 9% - only O2 – 3% - ventilator with IPPV – 6% Title: Profile of thoracic injury at College of Medical Sciences Teaching Hospital Author: D Chapagain,1 D Jayapal Reddy,2 S Shah,3 K G Shrestha.3 Published: Journal of College of Medical Sciences-Nepal, 2013, Vol-9, No-1

Rib fixation surgery

• Around 2004-5 AD, wiring used to be done at TUTH, Nepal • Left out due to wire breakage and migration problems

At MMTH Rib Fixation surgery The initial experience

Case 1- Kanchhi Tamang

Case 1- Kanchhi Tamang

Case 2- Saraswoti Neupane

The team

FUTURE OF RIB SURGERY IN NEPAL (and in South Asia)

• Number of patients with chest trauma are growing • Till now, by and large, non-surgical management • Long hospital stay and ventilator dependency • High Morbidity and Mortality rate • Initial experience in MMTH ( in south asia) is highly

encouraging • Recent meet of SAARC Surgical care society in Dhaka and

personal discussion (Dr. Shrestha) with the regional surgeons found to be encouraged and excited in adopting the technology in the region

• It is a needed and viable option of treatment in Nepal and in the region

Consideration for technology transfer in the region

• Workshop • Seminar • Training

• Availability • Marketing

• Manufacturing

• From own pocket • Insurance

• Subsidy

Expertise

Implants and instruments

Cost of Surgery

3 Aspects to be considered:

RPS