Professional Documents
Culture Documents
A Brit in Rural SA.. The Foreword ................................................................................................... 3 Authors............................................................................................................................................ 4 Acronyms ........................................................................................................................................ 5 Ngwelezana Hospital....................................................................................................................... 6 Trauma Centre Hierarchies ............................................................................................................. 7 Rural Hospitals in SA ....................................................................................................................... 7 How to read this book and so forth.. .............................................................................................. 8 A pyrexial 14 year old with abdominal pain ................................................................................... 9 A pyrexial 14 year old with abdominal pain in OT ........................................................................ 12 A simple epigastric stab wound? .................................................................................................. 15 A tachypnoeic polytrauma case .................................................................................................... 18 Abdominal pain in a heavy smoker ............................................................................................... 22 Male with dysuria and subsequent scrotal insult ......................................................................... 26 Anterior stab wound to the neck .................................................................................................. 28 An old gunshot to the chest .......................................................................................................... 31 Urinary retention in an 8 year old boy ......................................................................................... 34 Man with a facial swelling............................................................................................................. 36 Post chest stab pain ...................................................................................................................... 38 A left sided red tap........................................................................................................................ 41 Haematuria after blunt abdominal trauma .................................................................................. 44 Delayed presentation post MVA ................................................................................................... 46 Patient with a wrist laceration ...................................................................................................... 48 Snake bite and black ..................................................................................................................... 50 Snake bite aftermath .................................................................................................................... 53 Painful left foot in a diabetic......................................................................................................... 55 An odd number of gunshot wounds ............................................................................................. 58 An odd number of gunshot wounds in theatre ............................................................................ 61 Abdominal distension in a 71 year old male................................................................................. 64 Patient involved in tractor trauma ............................................................................................... 67 Another stab chest ........................................................................................................................ 69 Patient with multiple leg lacerations post MVA ........................................................................... 71 Patient in a hot situation .............................................................................................................. 74 A community assault..................................................................................................................... 78 Tractor traction ............................................................................................................................. 80 Gunshot injury to the thigh........................................................................................................... 83 A directed kick............................................................................................................................... 85 Managing a kidnapped patient ..................................................................................................... 87 Neck Exploration ........................................................................................................................... 91 Patients in a house fire ................................................................................................................. 93 Another patient with abdominal distension ................................................................................. 96 A patient with head trauma ........................................................................................................ 100
An odd gunshot neck .................................................................................................................. 102 Appendix ............................................................................................................................................. 106 Burns Early Directed Goal Therapy ............................................................................................. 106 Burns Admission Criteria............................................................................................................. 108 Burns - Wallace Rule of Nines ..................................................................................................... 109 Trauma Assessment Form........................................................................................................... 110 Ngwelezana Hospital Trauma Referral Sheet ............................................................................. 114
Abeyna
Authors
Compiled, written and edited by Abeyna L C Jones Internal Review Mahesh Naidoo Iain Thirsk Case Contributors Samuel Kent Crush and snake bite cases Natasha Naidoo Burns case Photograph Contributors Andr Steiner Madsen CT head, neck gunshot wound, AXR with bullet Rob Conway facial abscess Hand-drawn lllustrations Summy Bola
Acknowledgements Servaise de Kock Supporting the start of the project Darryl Wood Ngwelezana Hospital Early Goal Directed Burns Guidelines Africa Health Placements for all their support! Tom Mendes da Costa For the inspiration! Waiting for the orthopaedic version! Ngwelezana Hospital Surgical Department
Acronyms
AAA abdominal aortic aneurysm ABG arterial blood gas ARDS acute respiratory distress syndrome ATLS Advanced Trauma Life Support ACLS Acute Cardiac Life Support ARVs Antiretroviral Drugs AP - Anteroposterior BiPAP Biphasic Postive Airway Pressure BP blood pressure CPAP Continuous Positive Airway Pressure Cr Creatinine CT Computerised Topography CVP central venous pressure DSTC Definitive Surgical Trauma Care FAST Focused abdominal sonography test GCS Glasgow Coma Scale Hb Haemoglobin HIV Human immunodeficiency virus ICD chest drain IVP Intravenous Pyelogram K - Potassium LFTs liver function tests LODOX low dosage digital x-ray scanning MVA motor vehicle accident Neut - neutrophils NG nasogastric OT operating theatre RIF right iliac fossa SIRS systemic inflammatory response syndrome TB tuberculosis TBSA total body surface area U&Es Urea and electrolytes WCC white cell count XR - x-ray
Ngwelezana Hospital
Ngwelezana Hospital is a 554 bedded hospital located in coastal Kwazulu Natal, which provides Level 2 trauma care and district, regional and tertiary multidisciplinary healthcare to a population of up to 3 million. Approximately 22 peripheral hospitals refer acute and elective patients to the hospital, which are then, if necessary, referred to hospitals in Durban for further specialist care.
Trauma and emergency services comprise of a specialist Resuscitation Unit in the Emergency Department, 24 hour access to Theatres, Anaesthetists, Trauma and Orthopaedic specialists, a CT scanner, Ultrasound and Radiology services. MRI is also available during working hours. The surgical department comprise of a mix of locally and foreign trained surgeons from intern to Consultant level.
Level
1 major trauma centre
Types of hospitals
University Teaching Hospitals
3 community hospital
Rural hospitals
Clinics
This structure is similar for all other non-trauma specialties. In reality, the quality of care healthcare facilities can provide, are variable; largely dependent on current availability of resources and staffing. The referral systems can potentially destruct when a higher-level centre is unable to provide care for a patient from a lower level healthcare facility requiring definitive treatment. Poor communication between these facilities can potentially result in a breakdown of trust, lack of morale and compromise of patient care.
Rural Hospitals in SA
Rural hospitals in South Africa play a hugely important role in primary and secondary level care. Unfortunately, they are often plagued by difficulties with regards to acquiring and retaining a suitably qualified workforce whilst being able to provide appropriate training to develop their broad range of procedural and knowledge base; frequently required to manage community demands effectively. The recruitment of foreign healthcare workers to rural hospitals and the
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creation of community service; a mandatory year for all healthcare professionals to be allocated to select hospitals, is a temporary solution to address staffing levels.
Further Reading
Hardcastle, T. et.al. (2011) Guidelines for the assessment of trauma centres for South Africa. S Afr Med J 2011;101:189-194.
Reid SJ, Chabikuli N, Jaques PH, Fehrsen GS. The procedural skills of rural hospital doctors S Afr Med J. 1999 Jul;89(7):769-74.
Couper ID. Recruiting foreign doctors to South Africa: difficulties and dilemmas. Rural Remote Health. 2003 JanJun;3(1):195. Epub 2003 Jun 10.
5. What are your differential diagnoses? 6. Her HIV rapid test is noted to be reactive. Would you wait for her CD4 count before proceeding towards a laparotomy?
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Learning Points: Treatment of the septic patient should always commence with fluid resuscitation and broad spectrum antibiotics. Review your local sepsis guidelines! Remember that abdominal sepsis can lead to ileus presenting with obstructive symptoms. A good history will direct you towards the correct diagnosis.
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1. You will need to gain consent for the operation. Who will you seek this from?
3. It is 2:30am. When would be the best time to perform the procedure? Are antibiotics indicated?
4. What other pre-operative arrangements do you need to make for this patient?
5. You perform a midline laparotomy, and discover widespread peritonitis and plenty of pus, secondary to a perforated appendix. You perform an appendicectomy and wash out the abdomen with warmed normal saline solution. What are your current options?
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In most cases of a dirty abdomen (i.e enteral or purulent contamination causing widespread peritonitis), we prefer to leave the abdomen open in view for a semi-elective closure within the next 48 hours in which they can be stabilised and resuscitated further in a high care facility. We use an op-site sandwich mechanism (show diagram). These patients are usually left on the ventilator, hence the availability of a high care facility with ventilatory support is essential. Other options include primary closure of the rectus sheath with or without skin closure. We find there is a high risk of wound infection and post-operative ileus in these patients, hence close post-operative monitoring is essential. Learning Points Plan for post operative care before you operate Op-site sandwich or Bogota bag is a reasonable option when there is widespread contamination and you feel that the patient will require a relook in the next few days. Further Reading
Health Professionals Council of South Africa. (2007) Seeking Patients Informed Consent The Ethical Considerations (Second Edition) http://www.hpcsa.co.za/downloads/conduct_ethics/rules/seeking_patients_informed_consent_ethical_considera tion.pdf Accessed December 2011 Van Ruler et. Al (2007) JAMA. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA. Aug 22;298(8):865-72.
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3. He undergoes a laparotomy for a stomach laceration, which is closed primarily and is sent to the ward. Two days later he becomes progressively tachycardic and pyrexial. His abdomen is moderately distended and tender throughout. He has a few coarse crepitations at the bases of his lungs. His repeat bloods show an Hb of 8.8, WCC 20 with normal U&Es. What are the possibilities and how would you proceed?
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Learning Points A negative FAST scan performed for a penetrating wound does not exclude significant injuries. All trauma operations should be performed in a centre with appropriately trained trauma surgeons and supporting high care facilities. If this is not immediately possible, the patient should be stabilised (ie intra-abdominal packing for massive haemorrhage) and transferred at the earliest opportunity. Further reading
Ng A, Trauma Ultrasonography (2001), Trauma.Org Website http://www.trauma.org/archive/radiology/FASTfast.html Accessed December 2011 Chapter 1 Initial Assessment and Management. ATLS Advanced Trauma Life Support for Doctors (8th Ed.) (2008) American College of Surgeons
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2. On examination of his breathing, you notice he has a respiratory rate of 40, with saturations of 84% on air. He has subcutaneous emphysema of his right anterior hemithorax with dull percussion notes at the bases bilaterally. He also has an odd sucking chest wall movement with see-sawing of his abdomen. What are the clinical possibilities and how would you treat them?
3. You have treated the patient appropriately and his oxygenation has improved to 93% on a non-rebreathe mask providing 100% oxygen. You order an ABG with the following results. What does it show? pH 7.28 pO2 12.6kPa pCO2 -7.5kPa HCO3 24.5 BE 4
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2. On examination of his breathing, you notice he has a respiratory rate of 40, with saturations of 84% on air. He has subcutaneous emphysema of his right anterior hemithorax with dull percussion notes at the bases bilaterally. He also has an odd sucking chest wall movement with see-sawing of his abdomen. What are the clinical possibilities and how would you treat them? Clinical suspicion for a tension pneumothorax should be high, hence the treatment of 2 nd intercostal space needle thoracocentesis with subsequent chest drain should be considered. Subcutaneous emphysema on the chest wall indicates a likely pneumothorax with a possible concomitant haemothorax, hence waiting for a CXR to confirm these suspicions before the procedure is not always necessary, especially in an unstable patient. The unusual chest wall movement is likely due to a flail chest segment. Flail chest occurs when >2 ribs are broken in 2 or more places, leaving a chest wall segment which moves paradoxically (in-drawing of the chest on inspiration and vice versa), subsequently increasing the work of respiration. The size of the flail chest varies dependent on the number of ribs involved and can potentially involve the sternum and the opposite hemithorax. 3. You have treated the patient appropriately and his oxygenation has improved to 93% on a non-rebreathe mask providing 100% oxygen. You order an ABG with the following results. What does it show? pH 7.28 pO2 12.6kPa pCO2 -8kPa HCO3 24.5 BE 4 The ABG shows a type 2 respiratory failure with respiratory acidosis. Although the pO2 is within normal limits, one should remember that this value is for people breathing an fiO2 of 0.21 (room air). This patient is on 100% oxygen, so you would expect a much higher pO2 in a normally functioning lung. 4. What further investigations should the patient have? The patient is too unstable to transfer to the radiology department, hence requesting a portable CXR is adequate at this time. It can be used to ensure the chest drains are in place, the amount of residual haemopneumothoraces, and also any rib fractures which sometimes can be difficult to identify. 5. What investigation is this and what does it show? These are images of an axial and coronal CT chest on the lung window setting. The axial image demonstrates right sided subcutaneous emphysema with a moderate right sided and very small left sided pneumothorax. There are significant lung contusions mainly involving the left lung on this slice. The coronal view of the same patient showing the right and left main bronchi and aforementioned lung contusions.
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6. How and where should this patient be managed? Due to the extent of his injuries illustrated by the pulmonary contusions and his deteriorating respiratory acidosis, the patient is likely to require airway intubation and mechanical ventilation in the form of BiPAP. Discussion with a high care unit dedicated to Trauma is essential for the management of this patient, as he is also at high risk of developing a pneumonia +/- ARDS. In patients who are more stable with less severe underlying pulmonary contusions, tailored oxygen administration and CPAP may be adequate in combination with intravenous fluid resuscitation and analgesia in the form of a pleural block, epidural or systemic opiates. Learning Points The presence of flail chest points towards the severity of the underlying lung contusions caused by high energy impact forces. This condition may subsequently result in respiratory failure. These patients can deteriorate quickly, hence transfer to the nearest Trauma centre where ventilator support is available is essential.
Further Reading
Rib Fractures and Chest Trauma (2004) Trauma.Org http://www.trauma.org/archive/thoracic/CHESTflail.html. Accessed December 2011
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4. His blood results: Hb 14.3 WCC 12 Plt 246 Cr 133 Urea 10 Na 133 K 3.5 LFTs Amylase LDH Normal 983 1006
What is the likely diagnosis and how would you manage this patient?
5. Further imaging was arranged. What imaging is this and what does it show?
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1. What initial investigations would you order for this patient? During resuscitation of this patient you would order FBC, U&Es, LFTs, Calcium, Magnesium, Phosphate and amylase. An erect CXR is important to exclude pneumoperitoneum as a result of a viscus perforation and identify any concomitant thoracic pathology. Cardiac pathology cannot be excluded, therefore an ECG is also paramount. If available, a venous or arterial blood gas may be of benefit for guidance of fluid resuscitation and predicting necessity for high care. 2. What is your differential diagnosis? Acute gastritis, perforated peptic ulcer disease/gastric carcinoma, acute coronary syndrome, acute pancreatitis, AAA, pneumonia 3. What is this image and what does it show? This is a PA film of an erect CXR. The main questionable abnormality is the appearance of two diaphragmatic markings separated by air. The air fluid level of the gastric bubble has a shadow where you would expect to see a relatively linear demarcation between fluid and air. These discreet signs may lead you to consider the possibility of pneumoperitoneum.
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4. His blood results: Hb 14.3 WCC 12 Plt 246 Cr 133 Urea 10 Na 133 K 3.5 LFTs Amylase LDH Normal 983 1006
What is the likely diagnosis and how would you manage this patient? With a raised amylase of 983, acute pancreatitis should be considered as one of the primary diagnoses. Amylase in acute pancreatitis should usually be 3 times the normal value. However remember that there are several other causes of hyperamylasaemia which should be placed into clinical context; salivary disease (ie. parotitis), hepatorenal failure (decreased clearance), intestinal disease (ie. visceral perforation, inflammatory diseases, mesenteric infarction), ovarian pathology (ie. ruptured ovarian cysts), trauma, acidosis and ectopic amylase production. LDH is a non-specific marker of tissue degradation. It can be raised in numerous pathologies including MI, haemolysis, empyema, pneumocystis jiroveci pneumonia. It is also used in Glasgow Scoring for acute pancreatitis. Despite a raised amylase, if there is any doubt as to the diagnosis, further imaging should be considered. 5. Further imaging was arranged. What imaging is this and what does it show? This is an axial CT scan in the arterial phase. It shows free fluid around the liver. In order to clearly identify free air on a CT scan, you should use the lung view window and inspect around the level of the umbilicus, superiorly. On the lung view image, free air can be clearly seen. The septation can easily be mistaken for valvulae conniventes in bowel, when in fact it is the falciform ligament. There is a pocket of air seen clearly on the lung view around in the stomach, which is the site of perforation of a gastric ulcer on the lesser curvature.
What happened next.. The patient had 2 litres of free fluid of gastric contents in the abdomen which was thoroughly washed out. The ulcer was biopsied, and a naso-jejunal tube secured by holter was inserted to provide nutrition in the immediate post-op period. An omental patch was secured over the perforation and the abdomen was closed. The patient was sent to the ward post-operatively however developed complications of a wound dehiscence from a wound infection, bowel evisceration and subsequent nosocomial pneumonia from which he demised.
Learning Points If the diagnosis is doubtful and the patient is stable, organise further definitive imaging at the nearest convenience. There are a multitude of causes for hyperamylasaemia; dont get caught out by taking a thorough history from the patient.
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2. What is the likely aetiology? 3. What would your initial and definitive management be? 4. Would you expect testicular involvement? 5. You have instituted your initial and definitive management successfully. What further intervention do you think he may require?
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1. What does this picture show? What is the diagnosis? This picture shows Fournieres gangrene of the scrotum. It has partial involvement of the perineum and superficial inguinal regions bilaterally. 2. What is the likely aetiology? Fournieres gangrene is the result of a synergistic infection of anaerobic (Bacteroides, Clostridium) and aerobic (ie. E. Coli, enterococcus) bacteria. It usually occurs secondary to localised skin trauma or a perianal or urinary tract infection. Watch out of the characteristic putrid smell! 3. What would your initial and definitive management be? It is important to ensure the patient is fluid resuscitated as necessary, bloods and blood cultures should be sent and the patient should be administered broad spectrum antibiotics such as Augmentin and Gentamicin. He then requires total debridement and exploration of the wound. The key to debridement is to cut down to bleeding tissue. If its not bleeding, its dead! 4. Would you expect testicular involvement? The blood supply of the scrotal skin is largely from the internal pudendal artery which is a branch of the internal iliac artery, whereas the testicular arteries originate from the abdominal aorta around the level of the renal arteries. The lymphatic drainage follows similar patterns (superficial inguinal for the scrotum, and para-aortic for the testicles), hence it is uncommon for testicular involvement unless direct spread has occurred. 5. You have instituted your initial and definitive management successfully. What further intervention do you think he may require? There will be loss of a large surface area of skin and perhaps some soft tissue, hence will likely need a skin graft. Split skin grafting may be a temporary option in the rural setting, but for the best cosmetic options, it should be referred to a Plastic Surgery specialty.
Learning Points Institute broad spectrum antibiotics and resuscitation early in these patients. Dont wait for them to become shocked! Testicular involvement is rare, yet it is essential to counsel and consent the patient for a possibility of orchidectomy. Discuss cosmetic options with Plastic Surgery Further Reading Reynard et al. Oxford Handbook of Urology (2005), OUP Oxford, Oxford
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1. How would you categorise the location of the stab wound and which category would this stab be in? 2. Why may he have subcutaneous emphysema?
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1. How would you categorise the location of the stab wound and which category would this stab be in? Zone 1 Anatomical Location Between the jugulo-sternal notch / clavicles, to the level of the cricoid cartilage Between the cricoid cartilage and the angle of the mandible Above the angle of the mandible to the skull base At risk structures Great vessels of the thorax, lung apices, common carotids, jugular veins, trachea, oesophagus, C-spine, spinal cord and vessels Carotids, trachea, larynx, pharynx, jugular, C-spine and spinal cord Carotids, jugular veins, parotid gland, CN IX-XII, vertebral bodies
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This stab wound is either just below or at the level of the, which would categorise it as a Zone 1 stab wound. 2. Why may he have subcutaneous emphysema? He may have sustained an injury to a structure containing air (ie. Larynx, hypopharynx, lung, oesophagus). 3. What further investigations are necessary? He requires an erect CXR to exclude a haemopneumothorax which may require a chest drain. An FBC is necessary to exclude acute anaemia secondary to a concealed vascular injury. A gastrograffin swallow should be considered in a rural setting to exclude
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oesophageal injury, but even in these situations, small injuries could potentially be missed. Upper GI endoscopy is an option, however small lacerations can easily be missed. All stable patients with Zone 1 injuries should ideally have a CT angiogram to exclude vascular injuries. U&Es will be required in the elective setting as IV contrast is excreted via the renal system may already be impaired on a background of pre-existing disease. In an emergency, one may argue against waiting for these results if the condition is time sensitive.
Learning Points Penetrating neck injuries can involve plenty of important structures. Zone categorisation enables you to identify which ones are at risk. Zone 2 vascular injuries can be excluded by Doppler ultrasonography with trained personnel, otherwise Zone 1 and 3 vascular injuries need to be excluded using CT angiography in stable patients at the nearest convenience
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1. What signs would you look for if you were concerned about a vascular injury? How could you further categorise these? 2. The patient has a few signs of vascular injury as you have described above. What further investigations would you organise in this situation. Would you change your management if he presented acutely with evidence of ongoing haemorrhage? 3. What is the likely diagnosis in this case? 4. What would be your management options in this case? 5. Where is the likely location of the bullet?
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1. What signs would you look for if you were concerned about a vascular injury? How could you further categorise these? These can be placed into two categories; Hard Signs Visible haemorrhage Palpable or visible pulsation Bruit and/or thrill Signs of distal ischaemia Expanding haematoma Soft Signs Anatomical location of a vessel at site of injury Distal decrease or absence of pulsation Neurological pathology distal to site of injury Bony injury
2. The patient has a few signs of vascular injury as you have described above. What further investigations would you organise in this situation? Would you change your management if he presented acutely with evidence of ongoing haemorrhage? This patient has a large pulsatile left supraclavicular mass with a bruit on auscultation. He has a relatively decreased pulsation in the left arm compared to the right, but no signs of distal neurological abnormality. In this outpatient setting it would be important to organise a CT angiogram to determine which vessels are involve and the extent of the injury. This information would be used to plan management options. An ultrasound Doppler is also a fairly rapid and cheap way to evaluate the extent of the injury in a rural setting but is operator dependent. If he was actively bleeding, you would try to avoid the donut of death (CT scanner) and go straight for a left subclavian artery exploration. 3. What is the likely diagnosis in this case? Pseudoaneurysm of the subclavian artery. The vein can also be involved. 4. What would be your management options in this case? In this elective setting, if left alone there is potential for aneurysmal rupture, distal embolus and upper limb ischaemia. Other options include a subclavian artery exploration using a supra and infraclavicular approach without cutting the clavicle. Always consent the patient and prepare for the possibility of a reverse saphenous vein graft. Interventional radiologists may be keen to attempt to embolise or coil the artery in available centers. Ensure you have an adequate amount of blood cross match ready on standby!
Learning Points Do not put unstable patients into the donut of death Prepare the patient for possibility of reverse saphenous venous grafting. Send these patients to the nearest vascular or trauma centre as soon as possible.
1. What is your diagnosis? 2. What is the aetiology of this condition? 3. What are the complications if this condition is left untreated? 4. What are your management options?
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2. What is the aetiology of this condition? Paraphimosis occurs when the foreskin has been pulled back and trapped behind the glans of the penis. It can occur as the result of urethral instrumentation, examination or cleaning, secondary to an erection or sexual intercourse. 3. What are the complications? The constrictive band leads to swelling of the foreskin and secondary swelling of the glans itself, sometimes associated with ulceration of the skin (sometimes confused with an infective process). This process can potentially lead to distal ischaemia of the penis and/or urinary retention, hence is a urological emergency. 4. What are the management options? If the patient has signs and symptoms of acute urinary tract obstruction, it is important to attempt to relieve this immediately. The patient should be cannulated and given some IV analgesia in the form of an opiate and/or paracetamol if available. Attempt to manually reduce the paraphimosis in casualty should be the first option. A dorsal penile block using 5-10mls of 1-2% lignocaine (dependent on age and weight) should be administered. This can also be combined with a dose of 0.25-5% bupivacaine (Marcaine) for a long-lasting effect. Marcaine solutions containing adrenaline are contraindicated. Hold the foreskin with both hands at the level of the constriction band and gently but firmly apply persistent traction in attempt to reduce the swelling. It can take quite a few minutes to achieve success. If the patient is unlikely to tolerate this procedure, or if it fails, a dorsal slit or full circumcision is a final option.
Learning Points Paraphimosis is a urological emergency and should be treated as soon as possible If successfully reduced, the patient should be counselled as to its cause. An elective circumcision is an option but not mandatory.
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1. What are the potential aetiologies for this face abscess? Dental abscess oral cavity shoud be inspected if possible. Orthopantogram should be performed and a dentist opinion sought TB cold abscess Idiopathic 2. What factors would you want to consider whilst planning this operation? This patient has a large abscess cavity with possibility of communication with the airway and subsequent risk of aspiration. A lateral soft tissue neck XR may show tracheal identation or compression if there is a risk of airway compromise. Discuss this patient with the anaesthetist as he may require post-op ventilation and regular airway toilet for a period of time until the cavity has completely drained. The site of incision is important. Ensure that regions containing certain facial nerves are avoided ie. the marginal mandibular nerve. A pus swab should also be taken and this result should be followed up. The patient should also be screened for HIV and Diabetes which are common causes for being Immunocompromised in the Zululand population.
Learning Points Predicting operative risks will help you plan post-operative care and avoid potential surgical catastrophes
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On examination he has equal air entry bilaterally with good chest expansion. Saturations are 98% on air with a respiratory rate of 22 breaths per minute. The rest of the observations are within normal limits. 1. What are the possibilities for the cause of his chest pain?
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4. You decide to take this patient to theatre. What position would you place him, what are the possible complications and what post-operative procedure would you perform?
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1. What are the possibilities for the cause of his chest pain? As he only had primary suturing performed at the clinic, they may have missed several acute pathologies; pneumothorax (tension or simple!), haemothorax, associated rib fractures and possible lung contusions. It is also important not to forget pulmonary embolus as a cause for chest pain post trauma. Cardiac injury is always a possibility, hence an ultrasound of the heart to exclude a haemopericardium should be organised at the nearest convenience. 2. What investigation would you order primarily? An erect CXR 3. What do these CXRs show? This CXR shows a knife blade located in the lateral right hemithorax. There is no obvious associated haemopneumothorax visible on these films. The mediastinum appears normal. 4. You decide to take this patient to theatre. What position would you place him, what are the possible complications and what post-operative procedure would you perform? It is safer to remove this blade under anaesthetic due to its size and the presence of serrated edges which may cause further bleeding. In the event of any complications occurring the patient should be positioned in the left lateral position in preparation for a posterolateral thoracotomy.
What happened next.. The knife was successfully removed by extending the wound incision inferolaterally by a few centimetres, and dissecting down to the knife handle. The knife blade was then removed with pliers. A chest drain was inserted post-operatively to monitor for secondary bleeding and to drain the chest cavity. He was discharged home a few days later after removal of the drain without complications
Learning Points All patients with thoracic injuries should have a plain film chest XR regardless how well the patient looks. Removing foreign bodies from the thorax is potentially very dangerous due to the proximity of several vascular structures, therefore it is advised to do this under controlled conditions in the operating theatre. Always prepare for the worst case scenario!
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1. Describe what the CXR shows. 2. Describe where you would insert a chest drain and how you would perform the procedure. 3. In the subsequent hour he drains another 300mls of blood. What concerns do you have? 4. What would be your management options?
Answers
1. Describe what the CXR shows. The CXR shows a large left sided haemopneumothorax nicely delineated with an air-fluid level at the top 2. Describe where you would insert a chest drain and how you would perform the procedure. In trauma situations, a large bore chest drain (approximately 32G) should be inserted in the triangle of safety which is bordered by the anterior border of latissimus dorsi, the lateral border of pectoralis major, the inferior border is an invisible horizontal line at the level of the nipple or 5th intercostal space, and the superior border is the apex of the axilla.
The patient should be consented adequately for the procedure. Local anaesthetic should be infiltrated after a bleb in the skin just above the rib and then deeper into the soft tissues down to the parietal pleura. Aspiration and injection can be performed until either air or fluid from the pleural space is aspirated. Make an incision with a blade down to the subcutaneous fat large enough to admit the chest drain. Then use blunt dissection with forceps to separate muscle fibres and moderate amount of force until breach of the parietal pleura is achieved. Remember to perform this procedure just superior to the rib as the intercostal neurovascular bundles run inferiorly. Perform a finger sweep to break down any adhesions and to ensure the cavity is free. Grip the proximal end of the chest drain with forceps and
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clamp the distal end. Insert the drain, usually superiorly for pneumothoraces and inferiorly for haemothoraces. Suture the drain to the skin either using a non-absorbable suture, then connect it to an underwater chest drainage system. If a large amount of haemothorax is anticipated, it is advised to use heparinsed saline in the bottle in the event it may need to be re-transfused if there is a massive haemorrhage. 3. In the subsequent hour he drains another 300mls of blood. What concerns do you have? Patient may have a significant vascular injury. There is also a possibility that you may have inadvertently inserted your drain into the heart (a well documented complication!), however this would be very obvious on initial insertion of the chest drain. 4. What would be your management options? If the patient is relatively stable, you should order blood for cross match and consider a CT angiogram to determine the site of the vascular injury. The patient should be continuously monitored in a high care setting. If the patient continues to bleed >200ml per hour from the drain, and/or becomes haemodynamically unstable, it would be prudent to perform a thoracotomy.
Learning Points Indications for thoracotomy include a chest drain output of 200 ml per hour or more for 3-4 hours and/or an initial drainage of 750mls or more. Insert heparinised saline into your chest drain bottle in the event you may need to autotransfuse your patient if a massive haemothorax is anticipated. Further Reading
ATLS Advanced Trauma Life Support for Doctors (8th Ed.) (2008) American College of Surgeons
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3. Which other investigations could you arrange to image the rest of the renal tract? 4. What would be your management for the patient?
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1. What would your initial management of this patient be? 2. What definitive investigations would you order? 3. In the event of a splenic injury, what factors would you consider which may preclude surgery? 4. What should the patient be counselled about post splenectomy?
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1. What would your intial management of this patient be? Despite the delayed trauma presentation, initial management should follow the primary survey in accordance to ATLS guidelines. FBC, U&Es and a Type and Screen should always be taken during the primary survey to evaluate for blood loss and dehydration and prepare for transfusions requirements. A blood gas will give you the general metabolic status of the patient including a lactate. 2. What definitive investigations would you order? The impact of blunt abdominal trauma can leave a Pandoras box for many possibilities. Your differential diagnosis should include solid or hollow visceral injuries, including delayed haemorrhage. In an acute setting a FAST scan will identify the presence of free fluid in the abdomen but will not specify the source. Ultrasound if available will help identify solid visceral injuries quickly, however in this scenario, a contrast enhanced CT scan is perhaps the most specific. 3. In the event of a splenic injury, what factors would you consider which may preclude surgery? 1. Signs of ongoing haemorrhage despite transfusion transient or non responder 2. Worsening abdominal pain 3. Haemodynamically unstable patient 4. Evidence of an infected haematoma (if not amenable to percutaneous drainage) 4. What should the patient be counselled about post splenectomy? Trauma patients who have undergone splenectomy should be vaccinated against encapsulated organisms Streptococcus pneumonia, Haemophilus B, Neisseria mengitiditis. As the patient is likely to be immuncompromised as a result of the extent of trauma, it is safest to administer approximately after 2 weeks or thereafter. Some centres give the patient low dose Penicillin prophylaxis daily to be taken for the rest of their life. It is also reasonable to educate the patient that if they begin to feel ill, they should seek medical attention as soon as possible. Learning Points Free fluid seen in a Trauma patient, in the absence of solid visceral injury, requires an exploratory laparotomy. Some solid visceral injuries can be managed conservatively, however these patients need close monitoring.
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2. This patient is taken to theatre and the wound is explored. There appears to be a radial artery transection. What operative options do you have?
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1. How would you primarily assess and manage this patient? All trauma patients should be assessed as per ATLS protocol. Her bloods should involve an FBC, U&Es and Crossmatch. Signs of perfusion distal to the injury should be documented. Neurology should also be assessed and documented. An isolated vascular injury is very rare and is usually accompanied by nerve and tendon injuries. 2. This patient is taken to theatre and the wound is explored. There appears to be a radial artery transection. What operative options do you have? Your choices are dependent on the general clinical state of the patient, (ie whether you have time to be performing distal salvageable vascular repairs), and the presence of good collateral flow from the ulnar artery. If the latter is present, the radial artery can be tied off without consequences. If the ulnar artery is also injured, an intra-operative decision should be made to determine which vessel could be repaired with a good outcome.
3. Who else should be present during the procedure? Orthopaedic / Hand surgeons. There will be a high likelihood of associated flexor tendon and/or nerve injuries.
Learning Points It is essential from a clinical and legal standpoint to document neurovascular status of the patient on admission Restoration of hand function requires multidisciplinary input, which continues after surgery.
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What type of venom is most likely in this case? There are three major classes of snake venom- cytotoxic, neurotoxic and haemotoxic. The most likely type of venom in this case is cytotoxic venom. Snakes Puff Adder Spitting Cobra Stiletto Snake Mamba Cobra Berg Adder Presentation Painful progressive swelling Paraesthesia Hypersalivation Hyperhidrosis Complications Blistering and subsequent necrosis requiring debridement Early muscle weakness affecting small muscles (eyes, speech, swallowing) Respiratory muscle compromise Headache Fainting Convulsions Deranged clotting screen
Cytotoxic
Neurotoxic
Haemotoxic
2. How will you decide if you need antivenom? Antivenom is a purified immunoglobin derived from horses who are repeatedly envenomated with a number of different snakes venoms. A monovalent antivenom is available for haemotoxic venoms. Indications for use in cytotoxic bites include swelling to the knee or elbow in 4 hours, or of the entire limb in 8 hours. With neurotoxic symptoms, or haemotoxicity with active bleeding antivenom should also be used. Therefore antivenom is indicated in this case. Antivenom shoud be administered with extreme caution as it will often cause a major hypersensitivity reaction or anaphylaxis. Therefore it is only given in a patient who is in a fully monitored bed, after intravenous hydrocortisone, chlorpheniramine and adrenaline have been administered. This regime is thought to reduce systemic hypersensitivity response to antivenom. 3. What late complications should you be vigilant for? Late complications of snake bite include haemotoxicity, which may accompany cytotoxic bites. Monitoring of INR and APTT should be carried out. Compartment syndrome secondary to tissue swelling rarely occurs and is usually related to the use of a tourniquet. Necrosis of tissue surrounding a cytotoxic bite will require debridement to prevent secondary infection.
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Learning Points Antivenom should only be given after discussion with a Consultant experienced in the management of snake bites and in a high care facility, due to the huge potential morbidity associated with its administration. Majority of patients do not see or cannot correctly identify the snake, hence continuous observation with regular monitoring of the level of oedema is recommended. Further Reading
Wood D, Webb C, DeMeyer J. 2009. Severe snakebites in northern KwaZulu-Natal: treatment modalities and outcomes. South African Medical Journal Vol 99 (11)
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1. From the description what pathological process is occurring? 2. The patient is taken to theatre and the wound is debrided as shown. What further management do you think this patient requires?
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1. From the description what pathological process is occurring? Skin is very tolerant to ischaemia, hence when it starts to necrose, it is a sinister sign that the involved tissues beneath it are already dead! The snake bite likely cytotoxic in nature, has resulted in tissue necrosis ; a brilliant culture medium resulting superimposed infection. This patient requires urgent debridement. 2. The patient is taken to theatre and the wound is debrided as shown. What further management do you think this patient requires? The flexor tendon sheath of the index finger has been involved, potentially compromising its function. The wound was extended proximally further down the dorsal forearm due to degloving of the subcutaneous tissues illustrating the extent of the bite. Loose closure of the skin proximally and application of a vacuum dressing on the hand for a few days will help to maintain relative sterility and encourage tissue granulation. There are several options for further management, which should be discussed in a multidisciplinary setting involving a Hand or Plastic Surgeon and a Hand Therapist. What happened next.. After several days of vacuum dressing, the wound was re-assessed. The index finger was amputated due to non-functioning of the flexor tendon. A split skin graft was applied with good results and the patient was discharged home with regular input from the occupational therapist.
Learning Points
It may take several days for a snake bite injury to demarcate, hence should be monitored on the ward with anti-inflammatories and elevation. Adequate debridement to viable tissues should be performed. Further management, especially if it involves the hand, should be multi-disciplinary and led by a hand, plastics or orthopaedic specialist. Surgery is only the first step of treatment. Hand exercises should be encouraged to maintain good hand function.
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1. What is the diagnosis? 2. What definitive management would this lady require? 3. What further pre-operative information would you require about this lady in order to ensure she is optimised for theatre? 4. What important issues should this lady be counselled about before her operation?
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2. What definitive management may this lady require? In a rural environment, once sepsis has become as extensive as illustrated, the most definitive option in our experience, is to perform a below knee amputation. Our experience from managing these high-risk patients with a trial of initial debridement results in on-going sepsis, morbidity and subsequent requirement for amputation, as the extent of tissue necrosis and infection is usually greater than anticipated. The degree and distribution of limb oedema may give clues as to the extent of infection in the tissues. Studies show that two stage operations for wet gangrene of the limb are the preferable option due to a brief initial operation in order to eliminate the source of sepsis, followed by further resuscitation using IV fluids and antibiotics according to local policy. Once the systemic inflammatory response has stabilised, the surgeon can plan for closure of the stump. 3. What further pre-operative information would you require about this lady in order to ensure she is optimised for theatre? Blood glucose level in diabetics. A sliding scale is likely to be required Arterial blood gas It is common to see a patient in ketoacidosis. Patients may be severely acidotic on presentation, and a lactate is a good marker for fluid resuscitation. FBC and Type & Screen or Crossmatch There may be requirement for pre or intraoperative blood transfusion if the patient is anaemic. Assume the patient may lose 2 units of blood and plan appropriately. CXR and ECG for anaesthetic workup. Pre-operative anaesthetic review
4. What important issues should this lady be counselled about before her operation? Loss of a limb can be very distressing for most patients, and we have found that many will want to go home and discuss with their family before consenting. They should be informed about the possibility of two operations, further risk of wound infection and possibility for requiring a higher level of amputation (ie. Above knee (AKA)) if the stump continues to dehisce. In some patients it is relatively easy to predict whether they may need an AKA, (ie previous AKA, fixed knee contractures, sepsis extending through to proximal tibia, clinically poor vascularity) and this should be offered during the consent if there is a high chance it may be required. Presence of palpable pulses may give additional information when making this decision however it is neither a sensitive nor
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specific due to variability in detection amongst clinicians. Handheld dopplers may be useful in this situation. Post-operative physiotherapy is an important role in ensuring these patients function and mobilise well before and after discharge. Co-operation and compliance is essential as these patients can potentially lead a near-normal life with the appropriate walking adjuncts or prostheses.
Learning Points Patients with lower limb sepsis are likely to require a brief period of optimisation in the form of fluid resuscitation and blood glucose control before definitive amputation. Broad spectrum antibiotics should be administered as early as possible.
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1. What are the immediate concerning issues regarding this patient? 2. How would you categorise her response to resuscitation? 3. What is the significance of having a 3 identifiable gunshot wounds? 4. If she was haemodynamically stable what further investigations could you arrange? 5. Before you take her to theatre, what other things should you arrange?
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1. What are the immediate concerning issues regarding this patient? She is displaying signs of grade 3 haemorrhagic shock implying a blood loss of at least 1.5 litres. Injuries sustained could be anything from solid viscus, mesenteric or vascular injuries. She needs an urgent laparotomy. She is also severely hypothermic, hence requires active warming in the form of blankets, bair huggers and warmed fluids. Hypothermia predisposes to coagulopathy which is counter-productive in a trauma patient with active haemorrhage. 2. How would you categorise her response to resuscitation? She would be categorised as a non-responder. See table below; Description After a fluid challenge of at least 2l, BP and pulse and/or CVP normalises and stays at the same level. Transient responder After a fluid challenge of at least 2l, haemodynamic observations improve to normal limits and then subsequently begin to deteriorate. Patient may either be underfilled or experiencing ongoing blood loss. Non-responder Despite fluid resuscitation, haemodynamic observations remain poor or continue to deteriorate
3. What is the significance of having 3 identifiable gunshot wounds? Clinicians become obsessed with which wound was an exit or entrance, which, in an acute setting is of minimal importance. Having an odd number of wounds implies that either one bullet is retained in the body or another exit or entrance wound has been missed. 4. If she was haemodynamically stable what further investigations could you arrange? A LODOX scan if available, is a quick imaging modality appropriate for trauma to assess for fractures and foreign bodies throughout the entirety of the body. Markers are usually placed at the site of gunshot wounds to aid determining the likely path of gunshot tracks and associated predicting injuries. A FAST scan may be used to identify the presence of free fluid, however in this scenario, a negative FAST scan will not change your management as the patient is haemodynamically unstable and enteric injuries cannot be excluded. If the patient was not haemodynamically stable, performing imaging will waste precious time spent in theatre. DSTC guidelines suggest a patient should aim to be in the emergency room for not more than 1 hour. 5. Before you take her to theatre, what other things should you arrange? This patient is likely to need high care post-operatively, so this should be arranged preoperatively if time is available.
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Learning Points Re-evaluate the patient at regular intervals. If they are not responding to your resuscitation attempts, you need to find the source. Do not forget to address hypothermia during resuscitation in your air-conditioned Resuscitation Unit. Bullet wounds come in multiples of two, unless one is retained somewhere in the body.
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1. What would be your approach to the procedure? As per DSTC and Top Knife guidelines (see Further Reading below). Enter the abdomen via a large midline laparotomy incision in no more than 3 sweeps of the blade. Pack each quadrant of the abdomen with large abdominal swabs to address the large amount of haemoperitoneum. Scoop out any obvious clots. Subsequently assess injury by systematic approach. Remove the swabs in order starting in the area where there is the least amount of blood and assess each quadrant. Inspect the bowel and its mesentery from duodenojejunal (DJ) flexure to rectum. Bladder and other pelvic structures can be inspected at this point. Stomach should be inspected anterior and posteriorly by opening the lesser sac, at which time you should inspect the pancreas. The second part of the duodenum may be visualised without mobilisation, however inspection of its entirety is difficult without performing a Kochers manoeuvre. 2. Your findings include a bleeding liver wound, transverse colon and four jejunal holes in close proximity and a non-expansile central retroperitoneal haematoma. What factors would you take into consideration before you proceed? The decision making process should direct you towards damage control or definitive care mode. Definitive care should be reserved for patients who are haemodynamically stable, not inotrope dependent and are requiring near normal respiratory support. In other circumstances, your main goal is to limit contamination and arrest ongoing haemorrhage. Repair of injuries can be performed at a later date once the patient has caught up on blood, fluids and the systemic insult of trauma resulting in a generalised inflammatory response. In this scenario, this patient has several injuries that need addressing, which if treated definitively, will take longer than an hour, which is the guideline for damage control trauma laparotomy. Depending on the extent of the multiple holes in the jejunum, they may be debrided and sutured if small, or tied/stapled off if large and requiring resection and anastomosis at a later date. One may attempt a deep liver suture to arrest a bleeding liver wound, otherwise it is advised to pack it. Central retroperitoneal haematomas should be explored as they are likely to be vascular injuries. If you are comfortable with repairing vascular injuries and it is actively bleeding, exploration and repair should be attempted, otherwise pack and leave until the most capable surgeon is available. 3. You complete the operation and have decided to perform an opsite sandwich. What is that and how is it made? It is a temporising measure for patients in which a definitive operation is required in the next few days. It consists of a couple abdominal swabs partially wrapped in Opsite. The swab is placed on the bowel and tucked beneath the sheath. A feeding tube is placed
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through a larger rubber drain with small holes. This is connected to suction and a further opsite is placed ontop of the skin creating a vacuum for drainage.
4. When should the patient be taken back to theatre? At the nearest convenient time once the patient has received adequate goal directed resuscitation and met endpoint requirements. 5. The ICU doctor calls you a few hours later to say the patient has had 2litres of blood drained from the abdomen opsite sandwich. She is concerned about ongoing haemorrhage. What should you do? Assess the patient carefully. Although ongoing haemorrhage is a possibility, coagulopathy and disseminated intravascular coagulation is a common cause for ongoing blood loss related to trauma. Assess how much blood has gone in and out of the patient. Have they caught up on the initial loss of fluids? Are any other sites bleeding, ie. Central lines, catheter sites and urine? What are the platelets and clotting profile? Ensure that all deficiencies are replaced at an appropriate rate remembering the need for replacing clotting factors and platelets according to your departments massive transfusion protocol. Learning Points 1. Trauma laparotomies should be performed systematically 2. The blood bank is an important adjunct to resuscitation. Do not hurry your patient back to theatre after you have already turned off the tap as they still may be under-resuscitated. Coagulopathy is a well documented complication of SIRS secondary to trauma. Further Reading
Boffard K, Manual of Definitive Surgical Trauma Care Second Edition (2007), Hodder Arnold Publications, Hirschberg A, Mattox K, Top Knife The Art and Craft of Trauma Surgery (2005), tfm Publishing Ltd, UK
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1. What is your differential diagnosis? 2. What are the likely causes in a patient of this age group? 3. What further investigations may be appropriate in this setting to determine a definitive diagnosis?
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4. A repeat imaging was performed on the casualty LODOX scanner as there was a technical problem in the radiology department. What is the likely diagnosis and what features of this AXR is pathognomic to the condition?
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What is your differential diagnosis? The erect AXR shows features of large bowel obstruction; grossly dilated large bowel shadows in the peripheries with a few identifiable haustrae. This patient must have a competent ileocaecal valve as there is no evidence of small bowel dilatation on this image. What are the likely causes in a patient of this age group? Colonic malignancy Sigmoid volvulus Stricture due to diverticular disease, malignancy or chronic inflammatory process Incarcerated or strangulated hernia Ogilvies syndrome What further investigations may be appropriate in a casualty setting to determine a definitive diagnosis? Repeat departmental XRay the sacrum is not fully visualised. [adequacy of AXR] Rigid sigmoidoscopy site of obstruction, biopsy, deflation of possibly volvulus and insertion of flatus tube Arterial blood gas Repeat imaging was performed on the casualty LODOX scanner as there was a technical problem in the radiology department. What is the likely diagnosis and what features of this Xray is pathognomic to the condition? Sigmoid Volvulus Coffee bean sign, originating from the left iliac fossa Learning Points Large redundant sigmoid colons with narrow based mesenteries are a recipe for volvulus and are relatively common in Zululand. Patients with a complete volvulus may not appear to be very sick as the ischaemic metabolites are isolated from systemic blood flow in the volved segment. Be aware that they may deteriorate significantly intraoperatively and require a high care facility postoperatively.
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1. What are the indications for peforming an eFAST scan? 2. Which eFAST view is this and what does it show?
3. Approximately how much free fluid is required to be present in the abdomen in order for it to be reliably detected? 4. How sensitive is the FAST scan for determining need for laparotomy in penetrating compared to blunt trauma? 5. This patient stabilises to a pulse of 110 and BP of 120/70 after resuscitation with crystalloid and blood transfusions. What is your next management plan?
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What are the indications for peforming an FAST scan? For haemodynamically unstable patients where the cause is undetermined Patients requiring transfer from a rural /district hospital with polytrauma Intoxicated trauma patients who require re-examination Patients with multiple wounds, penetrating trauma or unclear trajectory Any patient with whom there is concern
Which FAST view is this and what does it show? This view demonstrates Morrisons pouch which is the right upper abdominal view between the liver and the kidney most easily viewed between the 8th and the 11th intercostal space. The fluid visible (black area) between the liver and the kidney indicates a positive FAST scan. Approximately how much free fluid is required to be present in the abdomen in order for it to be reliably detected? Identification of free fluid is operator dependent, however with good views approximately as little as 200mls can be identified. How sensitive is the FAST scan for determining need for laparotomy in penetrating compared to blunt trauma? FAST scans can determine the presence of haemoperitoneum after significant blunt abdominal trauma. The cause is usually due to a solid organ injury, most commonly the spleen or liver. This investigation can be reliably repeated and can lead the clinician to determine whether a CT or laparotomy would be indicated. There is limited use and sensitivity of a FAST scan for penetrating injuries in determining the need for laparotomy as bowel injuries may not result in visible free fluid on ultrasound. This patient stabilises to a pulse of 110 and BP of 120/70 after resuscitation with crystalloid and blood transfusions. What is your next management plan? Once stabilised the patients open fracture should be washed out and reduced if possible in the emergency unit, then redressed. He then warrants a full body CT with oral, IV and if indicated, bladder contrast to determine the extent of the injuries. If no other significant injuries are noted, Orthopaedic intervention should be sought and the patient should be monitored in a high care or specialist trauma unit. Learning Points FAST scan is quick, easily reproducible and non-invasive method to identify free fluid in the abdomen in a trauma patient, however it is non-specific and operator dependent. Further Reading
Reardon R, Focused Assessment with Sonography in Trauma http://www.sonoguide.com/FAST.html Accessed December 2011
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1. What are your possible concerns about this patient? Unless an accurate description of the weapon and depth of penetration is available, it is difficult to ascertain the distance of possible penetration and in which direction. Here is where surface anatomy is extremely useful! In this case the patient may have sustained a lung parenchymal, pleural or intra-abdominal injury. 2. Blood results are normal. Would you discharge the patient from casualty? Despite normal blood results it is wise to have a high suspicion for concomitant injuries, hence admitting for observation or for arranging further imaging is advised if the patient is co-operative. Alternatively the patient can be discharged with advice that if any further pain develops, he should return immediately. The consequences of penetrating injury may not be apparent early on. 3. The casualty senior states she is concerned that he may have sustained a penetrating. diaphragmatic injury. How could you investigate this? Gold standard method of investigation would be a diagnostic laparoscopy or thoracoscopy, which is less invasive than laparotomy or thoracotomy. It is very difficult to identify small penetrating injuries of the diaphragm using conventional modes of imaging (CT, U/S, MRI).
Learning Points 1. A normal CXR does not exclude a diaphragmatic injury. Gold standard is diagnostic laparoscopy. 2. Always prepare for insertion of a chest drain intra-operatively.
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1. What type of injury does this picture illustrate? 2. What is the pathophysiology of this type of injury? 3. What general management options are available to you? 4. Where should this patient be managed post-operatively?
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5. The abdominal injury was explored and found to be entering the retroperitoneum. Which hollow viscus organs in the abdomen are particularly susceptible to shearing forces?
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Learning Points Always take into account the mechanism of injury when evaluating a patient. A relatively innocuous wound can lead to devastation if a degloving injury is missed.
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1. What should your primary management of this patient be? 2. Approximately what is the percentage and likely depth of the burn?
3. Do you know of any formulas to calculate the fluid requirement of this patient?
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4. What dressings are these shown below? What are the benefits of their use?
5. What further management issues should you consider for this patient?
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What should your primary management of this patient be? According to ATLS principles; Identify life threatening injuries Ensure no signs of inhalation injury (commonly associated with flame burns) o Face or neck burns o Singeing of the eyebrows and nasal vibrissae o Carbon deposits and acute inflammatory changes in the oropharynx o Carbonaceous sputum o Hoarseness o History of impaired mentation and or confinement in a burning environment o Explosion with burns to head and torso o Carboxyhemoglobin level greater than 10 % in patient who was involved in a fire Stop the burning process o Cover burned surface with water if time of injury <2hrs o Cover with an occlusive dressing (cling wrap) to prevent evaporation and cooling o Maintain core temp around 37 degrees o Use of a burnshield for cooling, if available Iv access and IV fluids Bloods: o full blood count and haematocrit o U&Es, T&S and/or Cross Match , LFT (albumin) What is the approximate percentage and likely depth of the burn? The calculation of burns should be as per percentage total body surface area (%TBSA) involvement according to diagrams for a child over the weight of 10kg (see appendix). The approximate percentage for this patient would be 15%. Wallace rules of 9 are used for adults. Burns depth as described are likely to be partial thickness identifiable by blanching on palpation. View the appendix for more information on determining burn depth. The depth can be variable throughout. Do you know of any formulas to calculate the fluid requirement of this patient? How much would you give this boy? Parklands formula is used to calculate the fluid requirements in a patient as follows; 4 x %TBSA x weight (kg) = total mls
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First half should be given within the first 8 hours of the burn, the rest given in the next 16 hours. This patient requires; 4 x 15 x 22 = 1320ml Therefore he should be given 660ml within 8 hours of the burn. It is now 4 hours since the burn so he should be given 330ml stat followed by the next 330ml in the next 4 hours. The final 660ml should be given at a continuous rate within the next 16 hours. View the appendix for calculation guidance. We use ringers lactate for resuscitation, which is isotonic, and has a relatively lower sodium content compared to normal saline. Other options include 5% dextrose with 0.45% Saline (if used, monitor HGT regularly) for maintenance in children, and plasmolyte solutions. What dressings are these shown below? What are the benefits of their use? Acticoat is silver impregnated polyethelene mesh with antimicrobial barrier properties. It can be used for 2-3 days on partial, full thickness and recently debrided open wounds. It is also suitable for donor and graft sites. Jelonet is a cotton weave impregnated with white paraffin, used to apply directly to open wounds, which is then covered by another dressing type (ie. gauze). It has no antimicrobial properties. What further management issues should you consider for this patient? In our practice, any patient with a total body surface area burn of 12% or more, should be admitted to high care for further monitoring and fluid resuscitation. These patients are at high risk of several morbidities including hypovolaemic shock, hypothermia, anaemia, malnutrition and sepsis. All patients are provided with an NG feeding tube to encourage enteral feeding as early as possible. A urinary catheter is inserted to monitor fluid output and to give indication of optimal resuscitation. Learning Points Every hospital should have a goal directed burns management protocol in order to ensure patients with significant burn injuries are managed appropriately. This should be a multidisciplinary approach. See Appendix for further burns sheet
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A community assault
A 22 year old man is brought to casualty by the police twenty four hours after he was beaten by his community. They used sjamboks (heavy whips) to beat him and he reports that he fell to the ground. He now complains of pains throughout his body, worst in his right arm and over his back. He is walking normally and reports that he did not lose consciousness during the attack. HR is 95, BP 120/75, RR 18. Examination reveals widespread bruising with tram lines on his back and decreased range of movement and diffuse swelling over his right forearm. He also has an undisplaced ulnar fracture which is managed in a back slab and orthopaedic opinion sought. The nursing staff perform a urine dipstick which shows 4+ blood with a pH of 6. 1. What is the underlying diagnosis and what single laboratory test can you request, which will confirm this? 1. What is the appropriate treatment? 2. His blood results: Hb 13.5 WCC 8 Plt 436 Cr 195 Urea 13 Na 135 K 5.1 LFTs Normal Amy 120 CK 10,650
What is the major complication of this condition, and how would you best manage it?
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A community assault
1. What is the underlying diagnosis and single laboratory test can you request which will confirm this? Crush syndrome is caused by the breakdown of muscle and soft tissues with release of creatinine kinase (CK) and other muscle proteins. This is evidenced by myoglobinuria and injuries consistent with crush syndrome (widespread bruising, entrapment, circumferential burns). It can be confirmed by testing for serum CK levels, where levels greater than 5000 are pathognomic. This patient has also suffered a classical defence fracture of the right forearm. 2. What is the appropriate treatment? Treatment must be initiated early, with the aim of establishing a diuresis, which allows renal excretion of the excess serum proteins and prevents blockage of the renal glomeruli. 0.9% NaCl is started at 500mls/hour, and a urinary catheter placed to measure urine output. If urine output is poor after 3 to 4 litres of intravenous fluid, mannitol may be trialled, and if oliguria persists then furosemide boluses become necessary. Bicarbonate can also be used to alkalinise the pH of urine, which allows excretion of higher concentrations of muscle proteins. Treatment is successful when urine is normal with no myoglobinuria and renal function is normalised. 3. What is the major complication of this condition and how would you best manage it? Renal failure is the main complication of crush syndrome which is identified by poor urine output despite adequate fluid therapy and use of diuretics. Adjuncts to diagnosis include CVP, serum urea and creatinine, the presence of peripheral oedema and raised jugular venous pressure, and finally evidence of pulmonary oedema. If this occurs the only recourse is to dialysis, which is usually effective in improving renal function. Early aggressive fluid therapy is paramount in the treatment of crush syndrome, because delayed presentation or inadequate fluid resuscitation makes renal failure more likely. Defence fractures are commonly missed in crush syndrome, and other injuries related to the initial trauma should be carefully sought out and managed. Learning Points Crush syndrome is under-diagnosed, hence have a low threshold of suspicion in patients suffering from assault, blunt trauma or history of prolonged immobility. Monitoring microscopic haematuria on urine dipstick for crush syndrome is not sensitive, especially in a population where there are several common pre-morbid causes ie, bilharzia, diabetes, hypertension etc.
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Tractor traction
A 11 year old male fell under a tractor and was dragged along the ground for a short period. On admission to the resuscitation unit he was assessed as follows; A patent. Talking in sentences B Decreased air entry bilaterally. Saturations 79% on air. RR 30 C pulse 130 BP: 105/90 cool peripheries D GCS 15/15 1. What would your primary management be? 2. The patient is stabilised by the casualty team. His abdomen is generally tender. What would your next step be?
3. What are your management options?
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Tractor traction
Answers
1. What would your primary management be? Your treatment should be according to ATLS protocol. Cervical spine should always be assessed and should not be cleared if a patient is in collar and blocks until adequate imaging has been arranged and/or a C-spine injury has been clinically excluded by an experienced health professional. He is noteably hypoxic with evidence of haemorrhage which will require O2 delivery and likely crossmatch for blood transfusion. He also requires a urinary catheter, and a formal logroll with assessment of PR tone. 2. The patient is stabilised by yourself and the trauma team. His abdomen is generally tender. What would your next step be? The patient requires trauma series Xrays CXR, Pelvis, Lateral, AP and open mouth cervical spine. If an abdominal injury is suspsected, there are several options available to diagnose a significant intra-abdominal injury in a trauma setting: Procedure FAST Pros Cheap and quick Easily accessible Reproducible No radiation dose High sensitivity and specificity Reproducible Cons Operator dependent Not quantitative either positive or negative Not diagnostic for type of free fluid or injury sustained Named donut of death for a reason Dependent on accessibility Expensive Radiation dose to patient Invasive Time consuming (awaiting results) Not diagnostic to injury sustained if haemoperitoneum Operator dependent Not always easily accessible in a trauma environment
Computerised Topography
Ultrasound
3. What are your management options? Children who are relatively stable with intra-abdominal solid organ injuries identified on CT, should be managed conservatively and actively monitored in a high care facility. Indication for laparotomy includes non or transient response to resuscitation, requirement for massive transfusion and evidence of ongoing concealed haemorrhage, evidence of significant abdominal compartment syndrome.
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Learning Points b. Up to 95% of children with blunt abdominal trauma can be managed conservatively in appropriate trauma centres, however it is important to acknowledge that the abdomen is the most common site for unrecognised fatal injuries in children who have suffered trauma. c. Familiarise yourself with the normal vital signs and fluid resuscitation protocols for children. They tend to have a considerably good cardiovascular reserve, hence may not display obvious signs of shock until they are peri-arrest. d. Transfer of a paediatric trauma patient to a specialist paediatric trauma centre, if available, is highly recommended. Further Reading
Saxena A (2011). Paediatric Abdominal Trauma. http://emedicine.medscape.com/article/1984811-overview Accessed December 2011 Alterman D (2011) Considerations in Paediatric Trauma http://emedicine.medscape.com/article/435031overview#a1 Accessed December 2011
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1. What factors into your checklist for the preparation of a vascular injury exploration? 2. What does the following picture show? What are the landmarks for this?
3. Why is it performed? 4. A vascular injury to the femoral artery is repaired and the patient progresses well on the ward with an increasingly warm and mobile foot! What are your options for closure of this wound?
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Answers
1. What factors into your checklist for the preparation of a vascular injury exploration? FBC, U&Es, Crossmatch 2 units on standby. Consent form also for the possibility of requiring saphenous vein harvesting for grafting and amputation of the limb if the leg is not viable 2. What does the following picture show? What are the landmarks for this? This is an example of lower limb fasciotomies. On the lateral side an incision is made anterolaterally approximately 2 cms anterior to the fibular shaft, and should be of adequate length to open up the lateral and anterior compartments. Care should be taken not to damage the common peroneal nerve which winds around the neck of the fibula. The medial incision opens the superficial and deep compartments with a single longtitudinal incision posterior to the posteromedial border of the tibia. The soleus should be detached from the posterior tibia in order to open up the deep compartment. The fascia is incised allowing decompression of the 4 leg compartments and inspection of the muscle. Diathermy may be used to stimulate the muscle fibres to determine the presence of contraction. 3. Why is it performed? Primarily to assess limb viability if there is any doubt. If deemed viable, one can proceed to a vascular exploration and repair. Revascularisation of an acutely ischaemic limb can have several problematic sequelae including oedema, crush syndrome resulting in renal failure and failure to revascularise resulting in ongoing ischaemia and necrosis. Fasciotomies allow for direct inspection and monitoring of the limb (remember skin changes in ischaemia occur much later than that of other tissues) and compartmental release protective against the development of compartment syndrome in swelling. 4. A vascular injury to the femoral artery is repaired and the patient progresses well on the ward with an increasingly warm and mobile foot! What are your options for closure of this wound? o Primary closure. Usually possible on one side and very difficult on the other. o Skin grafting for areas which cannot be closed by suturing due to tension o Secondary closure allow the wound to granulate. Grafting however would be preferable to protect against wound infections and fluid losses. Learning Points 1. Always consider a fasciotomy before you commence your lower limb vascular exploration and repair
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A directed kick
A 35 year old male was kicked in the suprapubic region by a foe. He subsequently was unable to urinate and began to complain of abdominal pain. On admission to casualty, observations were within normal limits. Abdomen was generally quite tender with no signs of peritonism. A catheter was introduced with some difficulty, revealing an output of frank haematuria which subsequently began to clear to a ros colour. 1. What methods could you use to diagnose a bladder injury? 2. What is this investigation? What are the limitations of the first image?
3. What do these images show? 4. How would you manage this patient?
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A directed kick
1. What methods could you use to diagnose a bladder injury? Cystogram CT cystogram useful if other intra-abdominal injuries suspected. 2. What is this investigation? What are the limitations of the first image? This is a cystogram; performed by inserting 250mls of urograffin via the urinary catheter into the bladder. The catheter was clamped and an erect AXR was taken. The catheter clamp was subsequently released and a post void film was taken. Limitations include the clamp is obscuring part of the image and the radiograph is focused only on the pelvis rather than the entire abdomen. 3. What does it show? The retention film shows a flame shaped bladder with contrast apparent between bowel loops. The post void film shows some contrast remaining in the bladder, however contrast is visible throughout the abdomen. This film shows an intraperitoneal bladder rupture. 4. Can this patient be managed conservatively? Intraperitoneal bladder rupture requires a laparotomy and repair of the bladder injury. Urine within in the peritoneum acts as an irritant and eventually leads to secondary peritonitis. Visualisation of intact vesico-ureteric junctions need to be documented. The bladder is closed in two layers using an absorbable suture. A urinary catheter is left in the bladder to allow time for healing of the injury under low pressure. A cystourethrogram should be performed before the catheter is removed to ensure there are no further leaks. This can be done after about 2 weeks of continuous drainage. Learning Points A cystogram can easily and quickly be performed in a casualty setting to diagnose bladder injuries. Intraperitoneal bladder injuries require a formal laparotomy and repair.
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4. a. What investigation is this? b. What are the labelled structures? c. What injury can be seen?
5. Considering this patient has been raped. What other investigations and treatment should be instigated?
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c. What injury can be seen? The right internal jugular vein (IJV) appears to have a filling defect. This may represent a thrombus at the site of injury. There is also some evidence of air in the soft tissues local to this.
5. Considering this patient has been raped, what other investigations and treatment should be instigated? Rape kits for victims should be available in your hospital and should be performed by a health professional trained in conducting the procedure. A variety of swabs are taken from the victims body including other evidence such as clothes. Post-exposure prophylaxis for HIV should be available for the patient as soon as the event occurs with subsequent HIV testing of the patient Learning Points CT angiograms can be used to diagnosed vascular injuries of the neck. IJV injuries, if they are no longer actively bleeding, can be managed conservatively, however should be observed for a period of time. Concealed haemorrhage in the trauma patient can occur in several body cavities, hence a formal ATLS assessment to identify potential sites. In the stable and/or unconscious trauma patient, a full body CT may be arranged. Further Reading
Inaba K et al. 2006 The nonoperative management of penetrating internal jugular vein injury. J Vasc Surg. Jan;43(1):77-80. Information of Rape Kits. DNA Project SA. http://dnaproject.co.za/crime-scenes/rape Accessed December 2011
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Neck Exploration
The concerning Zone 1 neck wound was found not to be actively bleeding and sutured up in casualty. She was intubated after it was diagnosed she had also developed a pneumonia and continued ventilation in intensive care. A few days later she suffered spontaneous bleeding at that site which was controlled by pressure by the one of the ICU nurses. She was subsequently taken to OT for an exploration. 1. What incision should be made? 2. What strategy should be adopted in order to find the IJV and control the bleeding? 3. There is a lateral injury of the IJV and the external jugular vein. What are your options? 4. If the external carotid artery was severely injured, would this be safe to ligate if repair was not possible?
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Neck Exploration
Answers
The concerning Zone 1 neck wound was found not to be actively bleeding and sutured up in casualty. She was intubated after it was diagnosed she had also developed a pneumonia and continued ventilation in intensive care. A few days later she suffered spontaneous bleeding at that site which was controlled by pressure by the one of the ICU nurses. She was subsequently taken to OT for an exploration. 1. What incision should be made? An incision should be made along the anterior border of the sternal head of the sternocleidomastoid (SCM) from the jugulosternal notch to the mastoid. Dissection through the platysma and lateral retraction of the SCM should open up the path to the IJV. 2. What strategy should be adopted in order to find the IJV and control the bleeding? Dissection through the platysma and lateral retraction of the SCM should open up the path to the IJV. Try to avoid entering the haematoma itself as the anatomy will have become distorted and it will be extremely easy to get lost. The key is finding the normal anatomy and gaining distal and proximal control. 3. There is a lateral injury of the IJV and the external jugular vein (EJV). What are your options? Both veins can be safely ligated. Attempt at repair of the IJV should only be sought if the patient is haemodynamically stable, and the surgeon is confident in his technical skills. 4. If the external carotid artery was severely injured, would this be safe to ligate if repair was not possible? The external carotid artery provides blood supply to the face and has plentiful anastomoses between the both sides, hence ligation would be reasonable without significant consequences. What happened This patient was not actively bleeding in the resuscitation unit hence the decision was made not to explore the injury, however she was intubated due to a low GCS and respiratory problems thought secondary to shock and a lower respiratory tract infection. Whilst being monitored in ICU, she started spontaneously bleeding from the wound whilst being washed by a nurse, hence was rushed straight to theatre. A complete external jugular and lateral internal jugular vein was identified. The IJV injury was very close to the clavicle, and due to difficulties controlling the bleeding, it was eventually ligated. She was sent back to ICU, however subsequently died of multi-organ failure. She never regained consciousness despite stopping sedation, which was thought to be due to hypoxic brain injury secondary to prolonged shock after the initial assault.
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1. What are your general concerns with the type of burn sustained?
2. Having assessed the burn the dermis appears have a leathery appearance. On palpation the child appears to be in no pain. What type of burn is this and what further management may you consider?
3. Does this patient meet any of the admission criteria for burns patients?
4. The patients mother who was also involved in the house fire was brought into hospital. She has sustained 80% flame burns to her body with facial involvement. Her observations are as follows; pulse 140, BP 85 / 60, temperature 35 degrees, GCS of 8. What general management options are available for her
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Answers
1. What are your general concerns with the type of burn sustained? Despite the patient appearing clinically well, his airway should be regularly assessed and monitored as an inpatient due to concerns regarding inhalational injuries which may potentially require intubation due to upper airway oedema and/or irritation from carbon deposits. Have a high suspicion of 3rd degree / full thickness burns in any patient that has been exposed to flame or hot candle wax injuries. The candle wax should be removed to assess the wound and to remove a potential source of ongoing heat. 2. Having assessed the burn the dermis appears have a leathery appearance. On palpation the child appears to be in no pain. What type of burn is this and what further management may you consider? This patient has sustained a full thickness burn. He will require debridement under general anaesthesia until healthy bleeding tissue is exposed. Subsequent skin grafting should be performed to cover this area, reduce the risk of localised sepsis and to encourage wound healing. If this burn was circumferential, an escharotomy should be considered. 3. Does this patient meet any of the admission criteria for burns patients? The admission criteria specific to this patients management includes the following Full thickness burns of greater than 5% TBSA in any age group. Risk of inhalational injury These are only guidelines, and should be managed based on individual patient factors. 4. The patients mother who was also involved in the house fire was brought into hospital. She has sustained 80% flame burns to her body with facial involvement. Her observations are as follows; pulse 140, BP 85 / 60, temperature 35 degrees, GCS of 8. What is her general probability of outcome? Patients with severe burn injuries of a high %TBSA in our experience have a very low survival rate. The Baux score may be used to predict probability of death (age + %TBSA) which can also be combined with evidence of inhalational injury using the revised method (+ 17), but there have been no studies to determine whether this can be extrapolated to the general Zululand population where TB, HIV and other significant comorbidities are endemic. Patients should be discussed as early as possible with the nearest specialist burns or trauma unit. Initial treatment should still follow ATLS principles until a definitive decision has been made. Learning Points Even candle wax can be an ongoing source of burn, hence it is imperative to remove it and assess the underlying damage to the skin beneath it. Debride burns until it reaches healthy bleeding tissue. These patients should be Cross matched in preparation for this procedure as they can potentially lose a lot of blood. Adrenaline soaked gauze (1mg in 500mls normal saline) or Burns solution ; a
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subcutaneously infiltrated mix of 100mg bupivicaine, 2mg adrenaline and 1l normal saline, can reduce the amount of bleeding. Further Reading
Osler T, Glance LG, Hosmer DW. 2010 Simplified estimates of the probability of death after burn injuries: extending and updating the Baux score. J Trauma Mar; 68 (3): 690-7 Stander M, Wallis L 2011. The Emergency Management and Treatment of Severe Burns. Emergency Medicine Int. 2011:161375. Epub 2011 Sep
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3. Another investigation was organized, what is it and what does it show? The image is of a different patient.
4. The patients symptoms settle after resuscitation and he is transferred to the ward. What further investigation could you organize to investigate the possible aetiology to his symptoms? 5. The patient was diagnosed with TB abdomen. What are the possible reasons for developing these symptoms? 6. The patient is subsequently discharged from hospital. What further advice would you give him with regards to his TB treatment?
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Answers
1. What would your primary management plan be aimed at? Fluid resuscitation of the patient and decompression using a nasogastric tube. 2. What is this image and what does it show? This is an erect AXR with multiple air fluid levels indicating several fluid filled loops of bowel which you may see in small bowel obstruction. There is barely any identifiable gas in he colon on this image as it is collapsed. 3. Another investigation was organized, what is it and what does it show? This is a Gastrografin Follow Through with dilated small bowel loops (>3cm diameter) and contrast in the stomach, duodenum and some of the small bowel. Initially the patient ingests 80ml of gastrografin and subsequent films are taken at 2, 4 and 6 hours to determine whether the contrast reaches the caecum. In the normal bowel, transit of gastrografin to the caecum should take 2-4 hours. Depending on surgeons preference, if contrast does not reach the caecum within a reasonable time period (sometimes up to 24 hours), surgical intervention may be required. Gastrografin is a hyperosmolar substance with possible therapeutic properties; a study has found it significantly reduces the need for surgery in patients with bowel obstruction after conservative treatment has failed 1. 4. The patients symptoms settle after resuscitation and he is transferred to the ward. What further investigation could you organize to investigate the possible aetiology to his symptoms? CT abdomen with IV and oral contrast will assist in determining the site and cause of obstruction. 5. The patient was diagnosed with TB abdomen. What are the possible reasons for developing these symptoms? TB abdomen can cause mechanical and functional bowel obstruction, and may result in localised intestinal perforations, which are usually associated with poor outcomes. TB treatment may result in bowel scarring and strictures once the lesions begin to resolve which may lead to a presentation of bowel obstruction. The terminal ileum is a commonly affected region. 6. The patient is subsequently discharged from hospital. What further advice would you give him with regards to his TB treatment? This patient is likely to require an extended period of TB treatment as he has extrapulmonary disease. This is likely to be from 9 12 months in total. Follow-up should be organized at his local TB clinic.
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Learning Points
TB abdomen may present acute or chronically, mimicking most gastrointestinal diseases. Have a high suspicion is patients with a previous or current history of TB. Medical treatment is the key to treatment. Surgical intervention should be reserved for patients who are likely to survive surgery and where conservative treatment has failed.
Further Reading
1. Choi, Chu, Law (2002) Therapeutic Value of Gastrografin in Adhesive Small Bowel Obstruction After Unsuccessful Conservative Treatment: A Prospective Randomized Trial. Annals of Surgery. 236(1) Sharma, Bhatia (2004) Abdominal Tuberculosis Review Article. Indian J Med Res 120, October 2004, pp 305-315 Heller et. al (2010) Abdominal tuberculosis: sonographic diagnosis and treatment response in HIV-positive adults in rural South Africa Int J Infect Dis. 2010 September; 14(6)
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The casualty doctor calls you for advice. 1. What features of the history are concerning? 2. What further investigations would you request? 3. Where should this patient be managed whilst waiting for results? 4. What is the following image and what does it show?
5. What is the cause of this type of injury? 6. What is your treatment plan?
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Answers
1. What features of the history are concerning? Despite the lucid period, the patient has started to develop signs of meningeal or dural irritation; severe unremitting headache, vomiting and fluctuating GCS. 2. What further investigations would you request? A basic set of bloods including a FBC, U&Es and also a clotting screen The patient will also need an urgent CT head organized to exclude a significant head injury. 3. Where should this patient be managed whilst waiting for results? The patient should be monitored in a resuscitation unit or area which is exposed where there will be a nominated health professional to perform and document neuro observations at regular intervals. 4. What is the following image and what does it show? This is an axial slice of a plain CT head. The image illustrates a large left sided extradural haematoma. The diagnostic features include a well defined concavity where the dura is being compressed externally. There is also evidence of midline shift and partial compression of the left ventricle with some blood in the midline sulcus. 5. What is the cause of this type of injury? This type of injury is usually caused by direct trauma to the middle meningeal artery which runs behind the pterion which marks the junction between the parietal, greater wing of the sphenoid, frontal and temporal bone. This area is particularly thin, hence forces are transmitted to the artery, which ruptures and causes an extradural haematoma. 6. What is your treatment plan? This patient will require an urgent decompressive craniotomy and evacuation of the haematoma. You should discuss this patient with the neurosurgical doctors at the earliest opportunity, as a continually expanding haematoma will lead to the patient coning resulting in brain stem death. A drop in GCS below 8 will likely require the patient to be intubated in order to protect their airway, hence any transport plans should include appropriate personnel with airway skills. Learning Points Familiarise yourself with the clinical indications for performing a CT head in adults and children. If in any doubt, discuss with your senior or neurosurgical doctor. (see appendix) If a CT is not required, or the patients CT was normal and clinically well, they should be monitored for 24-48 hours post injury by a responsible adult and given a head injury advice card. Not all patients need to be admitted into hospital.
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1. How would you primarily manage this patient? 2. Which zone is the injury in? 3. What would be your concerns about this injury and what imaging would request?
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4. The location of the bullet could not be found on skull, neck or chest XR, hence further imaging was organized. What does this image show and where is the likely location of the bullet considering his abdominal examination was normal?
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Answers
1. How would you primarily manage this patient? All trauma patients require primary survey evaluation as per ATLS protocol 2. Which zone is the injury in? This injury is at the border of Zone 1 and 2, therefore a high suspicion of injury for all structures in those areas should be maintained. 3. What would be your concerns about this injury and what initial imaging should you request? Despite the patient appearing clinically well, he may have sustained injuries that may not be clinically apparent at an early stage. There is also only one bullet wound, hence the bullet must still be retained in the body. Its location must be determined. Trauma series (CXR, C-spine lat and AP and Pelvis X-Rays) should be performed initially if a LODOX scanner is unavailable. Ultrasound Doppler of the neck if trained personnel are available, can be useful to identify Zone 2 vascular injuries. A gastrograffin swallow should be performed to exclude oesophageal injury, hence the patient should remain nil by mouth. CT angiogram of the neck and chest if available using oral contrast will be of diagnostic value for occult injuries. 4. The location of the bullet could not be found on skull, neck or chest XR, hence further imaging was organized. What does this image show and where is the likely location of the bullet considering his abdominal examination was normal? This is an AXR that was taken after a gastrograffin swallow which was performed to identify any oesophageal injuries. The bullet appears to be located just right of the L4 vertebral body. Having apparently crossed the midline in a clinically stable patient it is unlikely it is intraperitoneal. 5. What would be your management plan for this patient?
This patient requires further definitive investigation in the form of a CT abdomen with IV contrast. A DPL or Ultrasound would also be useful to determine the presence of free fluid, however would not necessarily identify the likely track of the bullet.
What happened next.. CT of the neck, chest and abdomen identified a high oesophageal injury and the bullet which was lodged in the patients right common iliac artery. On re-examination of the patient, he appeared to have no palpable pulses of his right lower limb. The patient had sustained a bullet embolus which had entered in the aortic arch and travelled through the
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systemic system until the vascular diameter was less than that of the bullet. The patient underwent a neck exploration and oesophageal repair. A bullet embolectomy via laparotomy was also performed. The patient underwent an uneventful post-operative course. Learning Points All trauma patients require formal primary and secondary survey, otherwise occult injuries can easily be missed. An odd number of bullet holes should ring alarm bells. Bullet emboli are very rare and occur due to low velocity gunshot injuries. It is likely the bullet entered the aortic arch and subsequently resealed preventing ongoing haemorrhage which would have likely killed the patient before he reached casualty. Further Reading
Symbas, Harlaftis (1977) Bullet emboli in the pulmonary and systemic arteries. Ann Surg. March; 185(3): 318320
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Appendix
Burns Early Directed Goal Therapy
Admission criteria to high dependence area: 1. 15-40% BSA 2. Inhalational burns INITIAL ASSESSMENT goal < 1hr Time of burn; type of burn (H2O, Flame, Electrical, Chemical) % BSA Thickness Inhalation Injury Special areas (hands, feet, genitals, face) A. B. ? Inhalation C.
AIRWAY ASSESSMENT and TREATMENT Assess nasal hair singing/ carbon sputum/ inflamed pharynx Stridor, Wheezing, Persistent coughing, RR > 30, O2 Sats < 90% RA Arterial Blood Gas (RA) PaO2 < 60mmHg, A-a grad > 10, CO level> 20mmHg,PaO2/FiO2 < 200mmHg; Lactate > 5 Early Intubation & Ventilation Refer ICU 100% humidified O2 Heparin 5000u/3ml + NAC 3ml nebs 4 hrly Adrenaline nebs 4 hrly (monitor heart rate & BP) Regular suctioning of ETT
RESUSCITATION goal < 1 hr 2X large bore IV lines Ultrasound (USS) assessment of IVC CVP monitor Urine Catheter Burn < 24 hrs - Crystalloids as per Parklands Formula* Burn > 24 hrs - Crystalloid fluid bolus with strict CVP and urine output monitoring Naso-gastric Tube Early escharotomy for compartment syndrome in full thickness burns
WORKUP goal < 4 hrs FBC, U&E, LFT (albumin) Glucose ECG if electrical burn CXR Tetanus Toxoid s/c Analgesia** Type and screen Sucralfate or H2 antagonist (e.g. ranitidine) Wound cover with non adhesive dressing clingwrap or Burnshield
GOALS
FLUID INPUT Crystalloid bolus as above CVP 10 cm H2O IVC USS o < 50% collapse o 2cm diam. adults Maintenance fluids (4:2:1ml/kg/hr) T/fuse RBC if: o Hb , 8g/dl
NUTRITION NGT feeding *****within 6 hrs (30kCal/hr titrated up to 80Kcal/hr) Glucose sliding scale goal 4-10mmol/l
VENTILATION CXR repeat after 24 hrs ABG monitoring 12 hrly PaO2 > 60mmhg SaO2 > 90% PaCo2 35-55mmHg A-a grad < 10-20mmHg PaO2/FiO2 > 200 mmHg Endobronchial washout/ lavage prn Ventilator settings ****
WOUND CARE Initial debridement within 48 hrs *** SSG and excision surgery
(ED DISCHARGE 48hrs) Septic screen (B/C, Urine MC&S, Tracheal Aspirate, ESR/CRP, CXR Blood Tests (FBC, U&E, Albumin, Glucose) Monitoring (CVP, Urine Output, ABG, Lactate) Nutrition full feeds
DEFINITIVE BURNS CARE GOAL 48 HRS POST ADMISSION Dedicated burns centre/ ward ICU
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* Parklands Formula: 4 x % BSA x 10ml/kg o the volume infused over the first 8 hrs o the volume infused over the next 16 hrs ** Analgesia Paracetamol (10mg/kg children) 6 hrly Valoron drops (age + 1 drop) PO stat Ketamine stat (ideal for sedation and analgesia during workup) o 2-3mg/kg IMI in children for initial workup and debridement o 1mg/kg IVI o Consent and monitoring (Sats, BP,P, ECG) required Morphine 1-2 mg/kg IV **** Initial ventilator settings: Tidal Volume 6-8ml/kg I:E ratio 1:1 (severe type 1 resp. failure) 1:3 (bronchospasm) PEEP 8cmH2O increase by 2.5cmH2O until target PaO2 FiO2 100% initially decrease to 40-60% Flow rate 40-100 l/min ***** Enteral Nutrition Consult dietician
Blood transfusion Transfuse (minimum 2 units RBC) only in those patients requiring extensive debridement with potential for blood loss
References: 1. Mlkak R. Suman O. Herndon D. Respiratory Management of Inhalation Injury. Burns. 2007; 33: 2-13
Kind permission for reproduction by D. Wood, from EMU Guidelines at Ngwelezana Hospital 2011.
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15% TBSA burns Inhalation Carbon Monoxide Inhalation Electrical burns Significant Comorbidities Other injuries 5% Full Thickness Facial burns Hand Burns Feet burns Burns across joints Circumferential burns Perineal burns Septic burn
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0 10 3 2
1 9 3 3
5 7 4 3
10 6 5 3
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Referral Hospital__________________________ History of Injury Time of Injury ___:____ Date of Injury ___/____/____
__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Allergies: _______________________________________ Past Medical History _______________________________________________ _______________________________________________ _______________________________________________ Last Meal Time: _________________ what?____________ Recent alcohol intake? Y/N Summary Box (To be completed prior to transfer from Resus Bay / Casualty) Diagnosis : 1. ______________________________ 2. _________________________________ 3. _______________________________ 4. ________________________________ Pregnant? Yes / No Medications ________________________________ ________________________________ ________________________________ Appears inebriated? Y/N
Clinical Status:
Investigations Pending: Destination: RU
Stable
CT Theatre
Transient Responder
XR ICU U/S FAST LODOX Home
Non responder
Ward ____
Consultant: ___________________
Description
Patent Obstructed Intubated C-spine collar? Y / N Sats - ___% on fiO2 _____ RR _____ breaths pm Trachea ______________
Intervention
Breath sounds: ___________________________ Percussion notes: ___________________________ C - Circulation HR ____ BP ___/____ Peripheries warm cool shut down Cannula size(s): ________ Site(s): _______________ IV fluid(s): __________________ GCS E: M: V: = /15 Pupils: Temperature: Glucose level:
Venous Line insertion(s) Size Site
IV fluid: _____________________
D - Disability
GI System
Urinary System
NG in situ? Y/N PR: Catheter? Y/N Blood at urethral meatus? Y/N Colour of urine: __________
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Intervention / Plan
Pelvis
Upper Limbs
Lower Limbs
Investigations
Bloods Sent: FBC U&Es LFTs Urine: beta hcg +ve? Y/N Imaging Results LODOX amylase T&S Xmatch _____ units Clotting Blood gas results (write or stick here)
FAST Scan
Departmental/Other XR
CT Scan
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C-spine:
Time: ___:___ Date:_____/______/______ B Breathing Sats: ____ on fiO2____% RR: _______ Chest exam:
C Circulation HR - ___ BP ___/___ Peripheries ________ Fluid input ________mls of _____________ Urine Output ____________________
ICD Output L = _____mls R = _____mls D Disability GCS E: M: V: = /15 Pupils: Temp: HGT:
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Hospital Admission Date: _____/_______/____ Hospital Admission Time:_____:_______ Mechanism of Injury: Stab History of Injury Gunshot MVA PVA Blunt Trauma Other ___________________ Date of Injury ___/____/____
Management received
Discussed and accepted by: Name of NGW MO: _______________ Speciality: ___________ Time: ____:____ Date: ___/___/___
/15
Cannula size(s): ________ Site(s): _______________ IV fluid(s): __________________ Additional Documents sent: Blood Results: Y / N Expected destination: Resus Unit Casualty Doctor: ________________________
*ALL PATIENTS TRAUMA PATIENTS SHOULD BE CANNULATED (>18G) AND HAVE A URINARY CATHETER PRIOR TO TRANSFER AS A MINIMUM*
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YES
NO
Head injury with low or fluctuating GCS Depressed/open skull fracture Head injury with history of LOC, vomiting, amnesia, seizures Head injury in the elderly >60 or the young <5
YES
NO
Trauma patient >2/7 post injury with signs of sepsis, or >2 systems failure
YES
NO
Still unsure?