Dr.

Mohammed Al-Shahary
Trauma/surgery
Trauma patient evaluation;
Examination and history are important documents for management and medicolegal
procedures. Complications of the injury must be reported throughly in the history.
Trauma types;
I) Penetrating; limited course of injury (within tract)
II) Blunt; unknown spectrum of damage (falling, crashing…) major problem in evaluation.
III) Combined; the worst.
Personal history
Chief complaint;
You must mention; post what?
Road traffic accident, falling from height (and you must mention the height), post fall
down, post gun shot, post air strike, post fighting, post boxing … Full down; minor
trauma/event with significant fracture/trauma result → Put in mind pathological bone.
The title (mechanism) of the trauma → to exhibit the spectrum of injuries. Then you
mention the timing of the trauma by hours not by days, especially in emergency. The
patient came to you (1st admission) after 3 days he came to you )‫ ;(جالك مباشرة‬post 72
hours to the trauma. Or if he was hospitalized before coming to you
)‫( (جالك من مستشفى ثاني اذكر المدة المستغرقة ألول إسعاف له‬3 hours prior to first
hospitalization/arrival to hospital)
Chief complaint;
1)Title of the injury.
2)Timing of the injury and any emergency admission (by hours).
A pt came after 2 hours from injury; still depends on the injury type but we can say that
he is still within early period away from complications (good time for intervention).
However, if he came after 10 – 12 hours he will come with complications like sepsis
and multi-organ dysfunction.
A pt came with limb vascular injury, timing is important due to the risk of developing
ischemic lesion; the limbs can withstand the injury for about 6 – 8 hours particularly
without collaterals.
 Admission of limb injury after 12 hours; severe infection, necrotizing fasciitis and gas
gangrene so you have to perform debridement of tissues and muscles and other
procedures to manage the complications (you are dealing with complications rather than
trauma).
Thus, time of trauma is important;
Early presentation means less complications → good management & good outcome.
Late presentation means more complications → bad outcome.
History of present illness;
Mechanism of trauma (why we ask about it?)
injury ‫ أو‬trauma‫ أنواع من الـ‬4 ‫ مثالً بعد قصف جوي توجد عندنا‬، trauma‫هنا الزم نعرف نفرق بين أنواع ال‬
:mechanisms
1. Pressure (blast) injury
The (wave) is sometimes enough to kill you! due to the significant trauma it causes by
pressure before the shrapnel.
Evaluation;
By ear drum; if ruptured, the patient should be admitted for observation at least for
48 hours even he has no any sort of injury. Due to the fact some manifestations of
trauma may appear later. Important example is lung contusion. The wave may cause
significant internal injury/damage.
lung contusion→ acute respiratory distress syndrome, hypoxia and may need
intubation.
Investigations only are not enough to evaluate;
1) Some injuries like lung contusion don’t appear in CT before 48 – 72 hours.
Thus, lung contusion should be suspected from the mechanism of trauma, not by
investigations. (it leads to hypoxia & hypercapnia & can cause respiratory distress
syndrome).
2) CT -as an example- is usually done in response to a pain at any site, and not all traumatic
injuries are pain associated.

2. Blunt trauma; due to the wave, you may be thrown for a distance then crash on a surface
(blunt trauma).
3. Penetrating trauma; shrapnel injury.
4. Chemical and inhalation trauma.
So you should evaluate and take the details regarding mechanism of trauma and the
presence of associated trauma to determine the following management step and to
expect the spectrum of injury/damage.
Ex;
Post RTA; a patient who was crashed and got thrown for a distance then fell on a surface
(you must know the surface) is different from the one who crashed only.
‫ يطيرك ويسقطك‬...‫ زفلت‬،‫ نيسة‬،‫ وفي حادث يطيرك يسقطك على حديدة‬،‫في حادث يكتفي بالصدمة األولى‬
.‫ويجزع فوقك متر! كلها حاالت مختلفة يعبر عنها المريض بكلمة واحدة (حادث!) لذا مهم تاخذ التفاصيل كاملة‬

Put in mind risk factors like age; an old man was on height had a CVA and fell down
from that height!
Put in mind the associated trauma; a man was on the roof received a gunshot so he fell
down
localized ‫يجولك أهله خايفين من الرصاصة يشكولك عليها بدون ما يذكرولك إنه سقط تروح مركز على الـ‬
.‫ والمريض عنده نزيف داخلي‬injury

Ex for writing; patient post road traffic accident, as the patient was walking on the street
and a car hit him in the right side and he immediately fell down beside the event.
Or ….. a car hit him in the right side and he got thrown for a distant then fell on a hard
object.
Or … the patient was exposed to a gun shot while he was on the 2nd floor, after which
he fell down.
Note; In the history, ‘‫ ’دع المريض يسرد ما يشاء‬while telling you the mechanism, you are
supposed to write what he says as he says. No matter how the over concern of the patient
was, medically, over estimation of lesions is better than low estimation. Medicolegally,
your examination is the reference of evaluation; you don’t have to mention details like
the inlet and the outlet, type of lesion‫إلخ‬...‫ قطعي‬،‫( جرح طعني‬they legally cause troubles!).
It is enough to examine the injury; site, size, depth/floor and complications if present…

Symptoms and signs after the accident;

The body is divided into parts; head & neck, chest, extremities, abdomen, & back.
According to the affected part symptoms are detected. If the patient lost his
consciousness in the accident and doesn’t remember symptoms to tell you, you mention
that “the patient lost his consciousness during the accident for about …. minutes/hours,
after which he awaked spontaneously in the hospital complaining……..” ‫نسجل األعراض‬
‫ “ اللي بايبدأ المريض بذكرها أول ما يصحى‬the patient immediately he started complaining
of….” Ex; vascular; pain, muscle, bones, vascular, neural… the significant whole mark
is the pain “ patient complains of pain involving the right thigh. Site, onset, course,
duration, nature/character, aggravating and relieving factors, radiation, associated
symptoms; bleeding, fracture, swelling, deformity, limitation of movement,
neurological symptoms.
..‫ ومنه روح لباقي األعراض‬pain ‫تسهيالً لك أبدأ من الـ‬
Vascular injury in the limb→ bleeding; whether it is significant, whether the trauma is
significant or not. Is it accompanied with a neurological deficit?
Symptoms of limb trauma;
Pain.
Swelling; fracture, muscular hematoma, bleeding significant – subcutaneous or
aneurism, bone dislocation/deformity.
Deformity; bone dislocation, displaced fracture.
Limitation of movement; either due to neural injury or due to the pain.
Wound (if present)
Bleeding; vascular injury whether major or minor vessels (whether it stopped
spontaneously or required bandage).
Motor or sensory deficit.
Ex;
The patient is post road traffic accident, about three hours before arrival to the hospital.
The patient immediately after the trauma complained of pain involving his right lower
limb mainly at the thigh. The pain started immediately after the trauma, it was sever and
dull aching in nature involving the whole lower limb but more at the thigh, it was
progressive in course, localized at the lower limb not radiating, aggravated by the
movement with no relieving factors, associated with swelling involving the distal part
of the thigh and the knee joint. There was a deformity as the patient said ‫رجلي اعتطفت‬
)‫ )يادكتور‬the patient cannot move his limb (significant trauma and pain, or nerve injury).
The patient said that he cannot feel his foot, also he said that he has a wound at the
lower part of the thigh medially, this wound was of significant bleeding, he couldn’t
stop this bleeding unless he did bandage with ‫سماطه‬.
:‫إذاً اسأل المريض وخذ تفاصيل‬
‫؟‬pain, swelling, deformity ‫هل كان في‬
ً
‫ (مبدأيا تميزه من‬nerve injury ‫بسبب األلم واال‬limitation‫؟ وهل هذا الـ‬limitation of movement ‫في‬
.)‫أصابع رجله من عدمها واالحساس‬/‫قدرة المصاب على تحريك رجله‬
‫قدرت تحرك رجلك؟ أصابع رجلك؟‬
!‫ ماحسيت برجلي خذه وال حسيت بشي‬.‫ ماقدرت أحركها‬-
‫كم في معك نزيف؟ كيف وقف؟‬
...‫ وقف لحاله‬/‫ ربطوه بالسماطه‬-
‫ كل كلمة توجه تفكيرك‬.‫ حصل‬and it means a significant event ‫كل كلمة يقولها لك المريض لها أهميتها‬
dislocation, ‫ تفكر بـ‬deformity ‫ قالك‬، hematoma, fracture‫ تفكر بـ‬swelling ‫ قالك‬.‫نحو عرض معين‬
‫ قالك‬،vascular/nerve injury ‫ معناه احتمالية حصول‬displaced fracture ‫ و الـ‬displaced fracture
‫‪ significant bleeding‬ماوقفوه إال بالسماطه تروح محضر دم و تفهم إن المريض يمكن داخل ‪ ،shock‬قالك‬
‫رجلي خذت تفهم احتمالية إصابة ال‪ nerve‬وتركز على ال‪nerve evaluation during your examination‬‬
‫وتروح تفهم المرافق قبل إجراء أي تدخل إن المريض عنده إصابة في ‪ nerve‬ومش قادر يحرك رجله وتوريه‬
‫بعينه عشان ما يتعبك بعد العملية (من حق المريض وكذلك المرافق يعرف حالة مريضه بحيث مايتهمك)‪ .‬كذلك في‬
‫حالة العظم الخارج عن موضعه الزم تستدعي طبيب األوعية الدموية تقيموا الحالة للمريض والمرافق‪.‬‬

‫‪Pain assessment (according to score). The threshold of pain tolerance differs from a‬‬
‫‪person to another so it is not precise when you use expressions like severe.‬‬

‫;‪Back trauma‬‬
‫ماحصل لك؟‬
‫وهللا يادكتور صدمتني السيارة وبعدها يادكتور حسيت بألم شديد في سفال ظهري (ويبكي من شدة األلم)‪...‬‬
‫(أوصفه مثل الموضح سابقاً) ‪Back pain‬‬
‫في ناس يبدأ األلم معاهم متأخر‪ ،‬يكون بالبداية مش حاسس بشي واأللم يبدأ بعد فترة وذا ‪ .good‬لكن واحد يجيك‬
‫من البداية بألم شديد تبدأ تفكر‪:‬‬
‫‪Spinal cord injury‬‬
‫أسأله‪:‬‬
‫األلم ‪localized‬؟‬
‫يقولك "أيوه" تتوقع إن األمور كويسة ألن األعصاب ماتأثرت‪.‬‬
‫يقولك "ال األلم بينزل الرجلي بيمسكني القاع رجلي بالذات في اليمين‪ "..‬هنا تتوقع إن في ‪compression on‬‬
‫‪ nerve root‬والوضع خطير ال‪ way of transport‬قبل ما تروح للـ ‪ CT‬و ‪ MRI‬تسأل‪:‬‬
‫"بعد الحادث يادكتور حصل لي ألم شديد في ظهري ورجلي ماعد حسيت بها وعزك هللا البراز فلت والبول فلت"‬
‫هنا تبدأ تشرح للمرافق إن مريضه مصاب بالعصب وتهتم بالـ‪ way of transport‬ما تنقل المريض إال على سطح‬
‫صلب ‪ .hard flat object‬بعض األمراض يقولولك "بعد الصدمة حسيت بألم في ظهري و بخذه في رجلي‬
‫ماوصلوني المستشفى إال وقد البراز فلت والبول فلت ورجلي ماعد أحسهاش‪ "...‬هنا تعرف إن الـ ‪way of‬‬
‫‪ transmission‬كانت غلط‪.‬‬
‫إذاً بعد سؤال المريض تصيغ النقاط المهمة بالنسبة للـ‪:back‬‬
‫)بعد الصدمة مباشرة( ‪The patient also complained of lower back pain. This pain was sudden‬‬
‫‪) in onset, progressive in course, localized in the lower‬خالل دقائق إلى ساعات( ‪in onset/acute‬‬
‫‪part of the back, not radiating, no history of incontinence of urine or stool.‬‬
‫لكن مريض وصلك وقد ال بول بتشمه والبراز قد فلت سألت المريض قالك إنه يفلت عليه هنا تفهم تأكيد حصول‬
‫اإلصابة‪ ..‬يبقى لك الـ ‪ CT‬و الـ ‪ MRI‬كـ ‪ documentation‬لل‪ symptoms‬اللي شفتها فقط‪.‬‬
‫‪Back pain in this case differs from the back pain of the abdominal aorta dissection in‬‬
‫;‪this‬‬
‫‪In case of aortic dissection, the patient comes to you in (shock) and (pale). The back‬‬
‫‪pain is associated with severe abdominal pain.‬‬
‫ألن ال‪dissection‬يسلخ الـ ‪ intima‬من الـ‪ tunica media‬مع الـ‪ branches‬حقها وبالتالي الـ‪blood supply‬‬
‫اللي يخرج من الـ‪ aorta‬يتغلق فيجيك المريض بالم مثل حق الـ‪ .mesenteric ischemia‬ولو كان الـ‪dissection‬‬
lower limb ‫ ولو كان تحت احتمال يجيك بـ‬.CVA ‫ أو‬MI‫ ممكن يجيك المريض بـ‬thoracic aorta‫في الـ‬
.ischemia
Abdominal trauma;
‫إيش حصل معك؟‬
..‫حادث في البطن بعدها جالي ألم شديد‬/‫حصل لي طلق ناري‬
‫وين بدا األلم؟‬
‫) وبطني انتفخ وحصل نزيف من فتحة الجرح وخرجت‬diffuse( ‫) وبعدين انتشر في بطني كله‬localized(‫بدأ هنا‬
)‫ (إذا تكلم مريضك إذا ال اسأله‬...‫األمعاء وحاجة مثل الدهن خرجت وطرشت دم مرة‬
‫؟‬vomiting ‫حصل لك‬
‫انتفخ بطنك؟‬
‫تبرزت دم؟‬
‫طرشت دم؟‬
(in case of penetrating injury( ‫األمعاء خرجت من مكان اإلصابة؟‬
Also the patient complains of abdominal pain that started at the right
hypochondrium/upper abdominal pain/para umbilical then become generalized all over
the abdomen associated with abdominal distension. The patient stated that he has a
bleeding from the site of trauma, stool discharge from the site of trauma, bowel
eviscerated from the site of trauma (bowel evisceration indicates significant trauma
penetrating the peritoneum).
management‫ من الجرح اللي مافتحش فيه عشان الـ‬peritoneum ‫يفرق عندي بالطوارئ الجرح اللي فتح فيه الـ‬
‫أروح تحت التخدير الموضعي مدخل صبعي في فتحة الجرح أشوف هو مفتوح أو ال بالذات طعنة الخنجر ألنها‬
.‫أحيانا ً ماتكون عميقة كفاية‬
‫ ألن المريض‬investigator & translator ‫ تكون حققت فيه كونك‬scientific ‫الهستوري حقك دايما ً أبنيه بشكل‬
.(investigate( ‫) والباقي كله يشتي منك سؤال‬translate it) ‫بيجيك يذكرلك أكثر ما هو مركز عليه‬

Chest trauma
Chest pain (right/left/upper/lower/bilateral).
Dyspnea
Hemoptysis (strikes of blood/equals a cup of blood or half a bottle; significant)

The patient complains of chest pain bilateral more in the right side. He has dyspnea and
cough; the cough is dry / associated with blood (hemoptysis) about half liter. (serious
trauma)

Neck trauma
According to structures;
Trachea injury; difficulty breathing, stridor.
Vascular injury; swelling (expanding swelling; due to pressure)
..‫يجيك يقولك اسعفوني وكان معي ورمه صغيرة ما وصلت للمستفى إال وقدها كبيرة‬
Swelling of neck can be hematoma or air (surgical emphysema; opened esophagus/
trachea)
)significance; ‫الورم هذا زاد واال ثابت؟ (زاد‬
Head trauma (will be received by the neurosurgeon)

The patient lost his consciousness for about 10 minutes as said by the patient during
which the patient was transferred to hospital then he awaked and started to complain
…, …., ….

Way of transport;
‫كيف انتقل ولوين انتقل؟‬
‫أصحابه؟ لفوه بسماطة؟ شلوه فوق دباب؟ متر؟ سيارة إسعاف؟‬/‫بإيش نقلوه؟ نقله طبيب‬
The patient transferred to the hospital by his relatives/witnesses/ambulance/his friends
using their car. The patient arrived to Al-Kuwait hospital where they did for
him…,…,… then shifted to Al- Thawra hospital because of that
They reported a vascular injury and they asked for a vascular surgeon who was not
available.
They asked for ICU bed and there was no an ICU bed (here you the case is significant)
By patient request.
I don’t have the cause of transport/ The patient doesn’t know the cause of transport.
‫ لكن لو االثنين‬for more evaluation ‫من مستشفى أدنى لمستشفى أعلى ممكن تقول‬transport‫إذا كان الـ‬
.‫ سبب ما أدخله قبل ما أعرفه‬/ ‫المستشفيات من نفس المستوى اعرف إن في مشكلة‬

Procedures done in hospital

The patient was received in the ER and shifted to the OT; they did for him
laparotomy/chest tube/fixation.
The significant indicated procedures; like chest tube, back-slap, … don’t mention CBC,
IV fluid, ceftriaxone, …
‫ أثناء نقل المريض بنشر التاير وجلسوا نص ساعة يصلحوه (تم إسعاف‬:‫ال تقلب الهستوري قصة غزيرة التفاصيل‬
bad transport ‫…( أي حاجة غير سيارة اإلسعاف اعتبرها‬،‫ سيارة‬،‫ على طقم‬.........‫المريض في وقت مقداره‬
.‫واحتمل اإلصابات اللي ممكن سببتها أو فاقمتها ظروف النقل‬

Postoperative complications;
chief complain, HOPI, way of transmission, hospital ‫جتلك حالة بعد خمسة أيام أخذت هستوري‬
procedures,
The patient transferred from …. hospital to …. hospital by …. and they did for him
laparotomy about 5 days ago now the patient is shifted to …. hospital because of …. .
The patient is five days post laparotomy with no complications, passing stool with no
fever (‫)معناه األمور طيبة‬ ‫لكن يجيلك واحد‬
The patient presented 5 days postoperative. He has abdominal distension, vomiting, not
passing flatus/stool, he has a wound infection, stool/pus/bleeding coming out from the
wound, he has bleeding from the site of trauma, he cannot move his limb, … (means
you are dealing with complications).
‫هنا تشرح للمرافق حالة مريضه ويحق لك تقبل المريض أو ترفضه (إذا تحول لك من منطقة صحية أدنى مستوى‬
‫ إذا تحولك من منطقة مماثلة في المستوى‬،‫ممكن تقبله‬
Better medicolegally to return him to the hospital he came from, unless that hospital
officially requested your help.
.‫والتنسى تعرف سبب تحويل المريض العندك‬

Examination of trauma

‫ لو واجهت‬.wound examination‫اللي نحنا متعودين عليه كاامل أروح أركز على ال‬examination‫بعد الـ‬
‫بسبب األلم مثالً حق المريض اكتفي بذكر الخطوة وذكر سبب‬percussion‫صعوبة في بعض الحاجات مثل الـ‬
.‫عدم قيامك بها‬

‫بيجي العندك مريض مجبس تفحصه كيف؟‬

Ex/ the abdomen is covered with dressing (the site)
(the state of dressing ‫ )قبل ما تفتحه‬clean/dirty (no pus/discharge), smell (bad smell),
wet/dry (dirty dry; old dressing discharge, dirty wet; new dressing discharge)
.‫)لكن في عملك أكيد الزم تفتح‬shall I expose the wound?( ‫هنا لو أنت تمتحن تسأل‬

‫ أحيانا ً يكون في شظية صغيرة مش حاسس بها‬،‫ الزم تعريه كامل‬trauma‫يوصلك مريض بالذات مريض الـ‬
‫ ال تستحي تعري المريض وتفحصه كامل سواء‬.abscess ‫ و‬necrotizing fasciitis ‫ماتدري إال وقد حصل‬
‫ دم في المنطقة أو غيره نظف بنورمال سالين‬،‫ أو غيره ألنه ياما مصايب تحصل ألنهم ماشافوش كويس‬genitalia
.‫وافحص‬

Wound examination (by inspection)

There is wound involving the medial side of the right thigh. This wound is about 3x4
centimeters, the vessels are exposed, the bone is exposed, the nerve is exposed… (soft
tissue is exposed). There is dust, dirt…
There is a stitched wound with signs of inflammation in the form of redness, there is
pus discharge, stool coming out.
‫متى أقول الجرح يحتاج مجارحة؟‬
One of the indications of dressing;
If the dressing is wet, dirty, presence of discharge.