28 year old motorbike rider presents to the accident service following a RTA. He was not wearing a helmet.

His GCS is 11 and you notice a depressed skull

fracture. There were no other external injuries.
What is the most likely diagnosis?

Intra-cranial Hemorrhage

EDH1:333 SDH SAH

Acute SDH1:334
• Classically due to damage to middle • Due to severe head injury
meningeal artery • Rupture of bridging cortical veins
• Injury at the temporal region • Underlying brain damage is much
more severe than in EDH2:156
• Mortality 50% - 100%
Chronic SDH
• Older age group: > 50 years
• Cerebral atrophy, alcoholism,
coagulation disorder
• Trivial head injury 2/52 to 6/12
earlier
• Presents with confusion, headache,
vomiting, hemiparesis, urine
incontinence, fluctuating level of
consciousness
• Rupture of berry aneurysm
• Trauma
• Worst headache the patient has
ever experienced
o Often descried as a "blow
to the head"
• Neck stiffness
• Nausea and vomiting

Clinical Features
Due To Increased ICP Due To Cranial Fossa/Basal Skull Fractures
• Reduced GCS: Glasgow coma scale1:333 • Anterior cranial fossa
• Ipsilateral pupil dilation o Blood/CSF from nose
• Contralateral hemiparesis: Both due to uncal herniation o Black eye (Bilateral periorbital haematoma): Raccoon eyes
• Cushing’s triad: Due to tonsillar herniation and compression of the o Subconjunctival haemorrhage
medullary respiratory and vasomotor centres1:328 • Middle cranial fossa
o Bradycardia o CSF Ottorrhea
o Hypertension o Tinnitus
o Irregular breathing o Vestibulo-cochlear nerve damage1:332 :Hearing loss1:333
• Irregular respirations/ Cheyne-Stokes breathing: Cycles of slowly o Facial nerve palsy1:332
diminishing respiration, leading to apnoea, followed by progressively o Haemotympanum1:332 or bleeding from the ear
increasing respiration and hyperventilation4:544 • Posterior cranial fossa
• Papilloedema o Battle’s sign
• VI nerve palsy
What is the key clinical feature of EDH?

Clinical Surgery

The patient is stable following ATLS protocol. What is the next step in Treatment
1:334-336
managing this patient?

Investigations To prevent secondary brain injury

• X-ray skull • Reduce ICP 1:336

• NCCT scan Indications1:330 o Prop up 15 degrees

o Within 1 hour o Raising the head end of bed and loosening the collar can improve
§ GCS < 13 at any stage since the injury venous drainage
§ GCS < 15 (13, 14) 2 hours after admission
o Hypertonic saline 5ml/kg
§ Suspected open/depressed skull fracture
§ Any sign of basal skull fractures o Controlled hyperventilation
§ Post traumatic seizure, epilepsy • Correct
§ More than one episode of vomiting o Hyperthermia1:336
o Within 8 hours o Hypoglycemia1:331
§ Post traumatic amnesia (PTA) > 30mins o Electrolyte imbalances especially hyponatraemia1:335: Causes
§ Age > 65 years
seizures1:337
§ Dangerous mechanism of injury (RTA, fall from a height)
§ Coagulopathy • Avoid fluid overload: Will aggravate head injury
• Surgery
Possible NCCT scan findings1:334-335
EDH • Immediate craniotomy and evacuation
• Lens shape/biconvex hyperdense lesion = EDH
• Crescent shape (High density) = Acute SDH • Immediate craniotomy/ craniectomy and
Acute SDH evacuation
• Diffuse hypodensity overlying the brain surface = Chronic SDH
• High density in sulci and cisterns: SAH • Conservative management
Traumatic SAH
• If there is any of these also look for intraventricular extension of
haemorrhage, cerebral oedema and midline shift
Types of Brain Injury1:328

Primary Secondary
Injury occurs at time of trauma
• Contusion1:336 • Cerebral oedema
• Laceration • Brain shift
• Concussion1:330
• Haemorrhage
• Diffuse axonal injury1:336

Clinical Surgery

A 36 year old cab driver fell asleep during a late night journey to the Katunayake airport and collided with a lamp post. He was not wearing a seatbelt and ended
up with his chest impacting against the steering wheel. He is conscious and rational, but is dyspnoeic. No other external injuries.
On further examination…

Clinical Features1:367-368
• Reduced chest expansion 19:97
• Reduced chest expansion • Beck’s triad19:101 • Pain on cough19:108 and deep
• Reduced breath sounds • Reduced breath sounds o Muffled heart sounds breathing
• Increased resonance • Dull on percussion o Engorged neck veins • Impair ventilation → Atelectasis →
• Dilated neck veins • Tracheal deviation to opposite side o Hypotention Pneumonia19:108
• Tracheal deviation to opposite side • Tachypnoea, dyspnoea • Kussmaul’s sign19:101
• Tachypnoea, dyspnoea • Tachycardia o Elevated JVP during
• Tachycardia19:97 • Hypotension inspiration
• Cyanosis • Tachycardia
• Use of accessory muscles • Cyanosis
• Hypotension19:97

What is the diagnosis? What is the diagnosis? What is the diagnosis?

What is the diagnosis?

Tension Pneumothorax
• Collection of air in the pleural
space through a 'one-way valve'
• Causes
o Blunt
§ Tear of lung tissue
§ Bronchial tear19:105
o Penetrating trauma
Introduction1:367-368
Haemothorax Cardiac Tamponade Rib Fracture and Flail Chest
• Blood collection in pleural space • Most commonly due to • Rib fracture19:108
• Damage to the intercostals penetrating trauma o Lacerate lung parenchyma:
vessels 20:649
• Presence of fluid under tension in Pneumothorax
o Smaller ones are usually the pericardial cavity o Lacerate IC vessels:
venous • Reduced venous return and Haemothorax
§ Self limiting reduced CO o 10-12th ribs: Splenic/hepatic
o Massive bleeds are arterial • Cardiothoracic emergency injury
(eg: from internal • Flail chest
mammary arteries) o At least 3 or more ribs fractured
§ More likely to in two or more places as a
require surgery segment
o Paradoxical movement: The
flail segment moves in during
inspiration
o +/- Underlying lung contusion
o High risk of haemothorax and
pneumothorax
Clinical Surgery

What is the next step in managing these conditions?

Investigations1:366-368

Tension Pneumothorax Haemothorax Cardiac Tamponade Rib Fracture and Flail Chest
• Chest X-ray • Chest X-ray • FAST scan • Chest X-ray
o Radiolucent/black o Homogenously radio- o Fluid in pericardial sac o 3 or more rib fracture
(But this is a clinical diagnosis and opaque/white • Chest x-ray • CT
never wait for radiological o Need minimum 400-500 ml o Enlarged heart shadow
confirmation) blood to see20:651 • ECG
o Small waves

Treatment1:367-368

Tension Pneumothorax
• If haemodynamically unstable
o Needle thoracostomy (14-
16G) 2nd IC space in the
mid-clavicular line
o Followed by IC tube
Haemothorax
• IC tube chest drain
• Correction of hypovolaemic shock
• Indications for thoracotomy
o > 1500 ml of blood at the
time of IC tube insertion
o > 200ml blood/hour for 3-4
hours after insertion of IC
tube
Cardiac Tamponade19:102 Rib Fracture and Flail Chest
Temporarily • Analgesia
• Immediate needle • High flow O2
pericardiocentesis • Careful fluid management19:99
• Frusemide
Definitive treatment • Regular ABG
• Pericardiotomy via thoracotomy or • Artificial ventilation
sternotomy1:368 o If risk of respiratory failure

What are the borders of the safe triangle? Why is careful fluid management and frusemide important in the
management of rib fractures and flail chest?2:99

Clinical Surgery

Pulmonary Contusion1:370-371
Myocardial Contusion1:370
Traumatic Rupture of Diaphragm1:370
Traumatic Rupture of Aorta1:366,369
Subcutaneous Emphysema1:370
Other Thoracic Injuries
• Usually associated with a flail segment or fractured ribs
• ‘White out’ Chest X-ray
• ABG
• Can present up to 48 hours later with worsening hypoxaemia and haemoptysis
• May be hidden injury
• V/Q mismatch
• Suspected in sternal fractures: Blunt chest trauma
• Monitor ECG: Higher risk of developing sudden arrhythmias
• Very little evidence that enzyme level estimation has any place in diagnosis (eg: Troponin level)
• Usually caused by compressive force applied to abdomen and pelvis
• Bowel loops in the chest
• Usually on the left side19:107
• Common causes: Automobile collision, fall from a great height
• Usually at the junction of arch and descending aorta (Aorta is relatively fixed just distal to the origin of left
subclavian artery)
• Wide mediastinum on chest X-ray
• Suspect in hard bone fractures
o 1st and 2nd ribs
o Scapula
o Sternum
o Bilateral clavicular fractures
o Thoracic spine
• Air leak from IC tube
• Ruptured oesophagus
• Ruptured trachea/main bronchus
• Subcutaneous air can be felt around the chest in the presence of a pneumothorax1:383
Clinical Surgery

52 year old man has fallen from a height of 10 feet and landed on a rock. The impaction has mainly been to his abdomen. You are the first contact doctor.

What is the next step?

Introduction
• Abdominal trauma is often underestimated or not detected
• High morbidity and mortality
• Causes19:125
o Blunt (90%)
§ RTA
§ Seat belt
o Penetrating injury
§ Low velocity: Knives
§ High velocity: Bullets

Clinical Features19:127-129

• Abdominal pain • Signs of peritoneal irritation (from blood or bowel contents)

• Obvious abdominal injuries o Tenderness
o Bruising § The most frequent and reliable sign of abdominal injury
o Abrasions o Guarding
o Lacerations o Rigidity
o Bleeding • Shoulder tip pain
• Lower chest trauma19:108 o Due to diaphragmatic irritation
o Spleen/ liver injury o On the left side: Kehr’s sign
• Seat-belt bruising § Splenic rupture
o Concomitant fractures of T12/L1
• DRE
o Lumbar spine fractures19:126
o High association with bowel perforation (especially with lap belts) o Blood on the finger: GIT bleeding
• Distension
o Not reliable1:372
o 2L of intraperitoneal fluid increases abdominal girth by only 1.9cm

Clinical Surgery

Investigations
1:372-373

• Erect chest X-ray

• Pelvic X-ray
• FAST (Focused Abdominal Sonogram for Trauma)
• CECT abdomen
• DPL (Diagnostic Peritoneal Lavage)
• Laparoscopy

Treatment

Initial Definitive19:133-134
• NBM Exploratory Laparotomy
• NG tube19:129 • Haemodynamically unstable patients
• Resuscitation • Penetrating trauma
• Analgesia o Gunshot wounds below the nipple
o Stab wounds
§ If protruding viscera, signs peritoneal irritation
§ Vs. If not: Local wound exploration and serial physical examination over 24 hours, DPL,
laparoscopy
• Blunt trauma
o If signs of peritoneal irritation or positive FAST

• If examination and FAST is equivocal: CECT scan abdomen

Clinical Surgery

Pelvic Fracture Urological Injuries

• Can be suspected by ecchymosis over the iliac wings, pubis, labia or • Haematuria is common1:377
scrotum19:17 • Causes
• The key indicators are unequal leg lengths, and pain or crepitus on o Penetrating urological injury
palpation or gentle compression of the pelvis. If positive, the examination § Need surgical exploration
should not be repeated. 20:639 o Blunt injury
• Pelvic haematomas are typically left alone if they are not expanding
• External fixation to reduce bleeding / pelvic binder1:378 • Due to lower rib fractures
• Extra-peritoneal rupture of the bladder is associated with pelvic Renal Injury 1:375
• CECT
fractures1:376 • Non-operative management if patient is stable
• Intra-peritoneal rupture
o Due to direct blow to a full bladder
o Surgery
Bladder • Extra-peritoneal rupture
Injury1:376 o Due to pelvic fracture
o Non-operative
o A cystogram is performed to assess the
injury1:375
• Associated pelvic fracture19:135
o Posterior urethral injury (Membranous
urethra)
• Falling astride19:135
o Anterior urethral injury (Bulbar urethra)
• Blood at the urethral meatus1:377
• Haematoma in the scrotum / perineum19:12
• High riding prostate on DRE1:378
Urethral Injury • Investigations19:128
o Ascending (retrograde) urethrogram
• Treatment
o IV antibiotics
o Analgesics
o Supra-pubic catheterization
o No urethral catheterization19:12
o Complete tear: Surgery
o Partial tear: Non-operative

Clinical Surgery