Chapter 9Common surgical problems

Trauma

Case study: Hamid

14 year old boy was involved in the accident with a car

What are the stages in the management of Hamid?

Stages in the management of a sick child (Ref. Chart 1, p. xxii)

1. Triage

2. Emergency treatment

3. History and examination

4. Laboratory investigations, if required

5. Main diagnosis and other diagnoses

6. Treatment

7. Supportive care

8. Monitoring

9. Discharge planning

10. Follow-up

What emergency (danger) and priority (important) signs have you

noticed?

Pulse: 148/min, RR: 50/min with intercostal recession and reduced right sided chest movement,

BP 85 systolic,capillary refill: 3 seconds

Triage

Emergency signs (Ref. p. 2, 6)

• Obstructed breathing• Severe respiratory distress• Central cyanosis• Signs of shock• Coma• Convulsions• Severe dehydration

Priority signs (Ref. p. 6)• Tiny baby• Temperature• Trauma• Pallor• Poisoning• Pain (severe)• Respiratory distress• Restless, irritable, lethargic • Referral• Malnutrition• Oedema of both feet• Burns

What emergency treatment does Hamid need?

Emergency treatment

• Airway management?

• Oxygen?

• Intravenous fluids?

• Anticonvulsants?

• Immediate investigations?

Emergency treatment (continued)

□ How do you treat respiratory distress? Give oxygen (Ref. Chart 5, p. 11)

Manage airway*

*Neck trauma was excluded by clinical examination and cervical spine x-ray

Make sure child is warm

Emergency treatment (continued)

□ How do you treat signs of shock? Stop any bleeding Give IV fluids (Ref. Chart 7, p. 13)

– Insert an IV line (and draw blood for immediate investigations such as: haemoglobin, cross-match, blood sugar)

– Attach Ringer's lactate or normal saline – make sure the infusion is running well

– Infuse 20ml/kg as rapidly as possible– Reassess child after appropriate volume has run– Measure the pulse and breathing rate at start

and every 5-10 minutes

Emergency treatment (continued)

Insert a wide bore intercostal catheter into right chest (Ref. p. 348) and repeat chest x-ray to see if pneumothorax is drained

Immobilise the left leg (Ref. p. 277)

Give emergency treatment until the patient is stable

History

Hamid was the passenger on the back of the motorcycle. The estimated speed was 50 km/h. He was thrown clear of the car and slid along the road for some distance before hitting a building by the side of the road. There was momentary loss of consciousness.

He was placed in the back of another motor vehicle and driven to the local hospital.

On arrival he was alert but distressed. There was obvious deformity to his left leg. There were abrasions all down his back and left side. He was complaining of pain in the chest and left thigh.

Examination

Vital signs: pulse: 148/min, RR: 50/min, BP 85 systolic, capillary refill: 3 seconds

Chest: airway patent, no stridor; intercostal recession and reduced right sided chest movement, tender right clavicle

Cardiovascular: regular, no apex beat displacement

Cervical spine: non tender

Abdomen: soft and non tender

Back: non tender

Limbs: externally rotated left leg, swollen thigh

• List possible causes of the illness

• Main diagnosis

• Secondary diagnoses

• Use references to confirm

Differential diagnoses

Possible diagnoses

• Concussion

• Pneumothorax

• Neck trauma

• Leg fracture

• Pelvis fracture

• Internal injuries

• Internal bleeding

– AVPU (Ref. p. 18)

A alert

V responds to voice

P Responds to pain

U unconscious

– Pupil size and light reaction: normal

– Reacts appropriate to speech and questions

Further examination based on possible diagnoses

What investigations are required?

Investigations

•Cervical spine x-ray

•Chest x-ray

•Pelvis x-ray

•Left femur x-ray

•Full blood examination: haemoglobin, haematocrit, cross-match

Chest x-ray

Femur

DiagnosisSummary of findings:

• Examination: severe respiratory distress, signs of shock, but alert, pupil size and reaction normal

• X-Ray shows:

1. Pneumothorax (right side)

2. Fractured distal femur

(Pelvis normal)

• Abrasions

• Possible abdominal trauma

Multi-trauma

Treatment

Give emergency treatment until the patient is stable

□ Pneumothorax Keep the intercostal catheter until the air is

drained

□ Fractured distal femur

Consider referral for review by a surgeon experienced in paediatric surgery (Ref. p. 275-279)

□ Abrasions Clean the skin and avoid an infection

□ Possible abdominal trauma Observe the child and look for signs of peritonitis (Ref. p. 281-282)

What supportive care and monitoring are required?

Supportive care

•Pain control (Ref. p. 306)

•In dwelling urinary catheter

•Blood transfusion is not necessary in this case as shock resolved with clear fluid and drainage of pneumothorax, and haemoglobin: 9g/dl (Ref. p. 308)

•Nutrition when abdominal injury is excluded and Hamid is stable (Ref. p. 302-303)

What monitoring is required?

Monitoring

Nurses should monitor frequently the child's state of :

Consciousness

Pulse

RR

Pupil size

• Use a Monitoring chart (Ref. p. 320, 413)

• Medical review twice daily

• Reassess neurological state (AVPU score)

• Re-check haemoglobin

• Daily chest x-rays

Monitoring• Monitoring for signs of for each of the injuries:

–Improvement

–Complications

–Failure of treatment

• Frequent observations of:

–Pulse, SpO2 if available

–Chest tube water level swinging

–Check sensation, motor power, pulses and capillary return in left leg and foot

–Abdominal tenderness

Follow-up

• Review of fracture healing

• Physiotherapy

- and give simple suggestions to the mother for passive exercises

Summary

• Hamid is a 14 year old boy who was involved in a multi-trauma. He sustained a pneumothorax, fractured femur and abrasions. He had mild concussion only.

• No abdominal complications occurred.