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Dr. Hiwa Omer Ahmed
Assistant Professor in General
(‘a living problem
is better than a
dead “cert”’ )

Grey Turner
• The indications for admission include:
• (1) All patients liable to shock (that is all burns
over 10%).
• (2) Any patient who has burnt his face, eyes,
hands, feet or perineum, whatever the size of his
burn. ALWAYS admit a child with a burnt hand
• (3) All patients who have inhaled smoke. If
possible, refer all these patients
• 4. Electrical and Chemical burn
• 5. cold burn
• 6. pregnant ladies
HEAD injury
• A head injured patient should be referred to
hospital if any of the following is present:
Impaired consciousness (GCS (15/15) at any
time since injury
– Amnesia for the incident or subsequent events
– Neurological symptoms, e.g.
• severe and persistent headache
• nausea and vomiting
• irritability or altered behaviour
• seizure
– Clinical evidence of a skull fracture (e.g. CSF leak,
periorbital haematoma)
– Significant extracranial injuries
– A mechanism of injury suggesting:
• a high energy injury (e.g. road traffic accident, fall from
• possible penetrating brain injury
• possible non-accidental injury (in a child)
– Continuing uncertainty about the
diagnosis after first assessment
– Medical comorbidity (e.g. anticoagulant use,
alcohol abuse)
Indication of skull x ray
• History of ^ ICP
• Features of ^ ICP
• Suspected # skull
• Penetrating wounds of head
• HVM wounds of head
• Severe facial-maxillary injuries
• Unconscious patient with trauma
• Deteriorating patient
• CT remains the investigation for the
diagnosis and management of many
central nervous system diseases.
• MRI is superior in the posterior fossa and
parasellar region and for the assessment
in multiple sclerosis, epilepsy and
• CT is superior to MRI in the assessment of
head injury.
• Indications for CT imaging, CT
Angiography, and CT venography include
CT Scan in Head Injuries
Selection of adults for CT Scan
• Urgent Scan if any of the following (results
within 1 hour)
– GCS <13 when first assessed or GCS<15 two
hours after injury
– Suspected open or depressed skull fracture
– Signs of base of skull fracture**
– Post-traumatic seizure
– Focal neurological deficit
– >1 episode of vomiting
– Coagulopathy + any amnesia or LOC since injury
• A CT scan is also recommended (within 8
hours of injury) if there is either:
– More than 30 minutes of amnesia of events
before impact
– Or any amnesia or LOC since injury if
• Aged ≥65 years
• Coagulopathy or on warfarin
• Dangerous mechanism of injury
– RTA as pedestrian
– RTA - ejected from car
– Fall > 1m or >5 stairs
Selection of children (under 16
years) for CT Scan
• Urgent scan if any of the following:
– Witnessed loss of consciousness >5 minutes
– Amnesia (antegrate or retrograde) >5 minutes
– Abnormal drowsiness
– ≥3 Discrete episodes of vomiting
– Post-traumatic seizure (no PMH epilepsy)
– GCS <14 in emergency room
(Pediatric GCS<15 if aged <1)
– Suspected open or depressed skull fracture or
tense fontanels
– Signs of base of skull fracture**
– Focal neurological deficit
– Aged <1 - bruise, swelling or laceration on
head >5cm
• Dangerous mechanism of injury (high
speed RTA, fall from >3m, high speed
Indication of anti-tetanus
• Every simple wound in patient not
immunized in the previous 5 years
Give ATS

• Every laceration or maceration or deep

wounds in patient not immunized in
the previous 5 years
Give ATS & Toxoid
Indications for snake
• G 1; 1-2 AMPULES
• G2 ; 2-3
• G3 ; 5-15
Not need admission
and sent home
Advice for the person taking a
patient home from the A&E
• [Name] ........................... has suffered a head
injury, but does not need to be admitted to a
hospital ward. We have examined the patient,
and believe that the injury is not serious. Very
rarely complications can develop as a result of
the injury, so please watch the patient closely
over the next day or so and rouse gently every
couple of hours, and follow this advice:
– Do not leave the patient alone in the
– Make sure that there is a nearby
telephone, and that the patient stays
within easy reach of medical help.
– Symptoms to look out for:
• Is it difficult to wake the patient up?
• Is the patient very confused?
• Does the patient complain of a very
severe headache?
• Has the patient:
– vomited?
– had any fits?
– lost consciousness?
– complained of weakness or numbness in an arm or a
– complained about not seeing normally?
– had any watery fluid coming out of their ear or nose?

• If the answer to any of these questions is

'Yes' or you are worried about anything
else, you should telephone the Accident
and Emergency Department on:
Acute abdominal pain
• represents 1% of hospital admissions and 6% of
emergency visits
1. These cases cause a burden on the hospital and
physician especially the nonspecific abdominal
pain, which is defined as acute abdominal pain
of less than 7 days‘ duration, and for which there
is no diagnosis after examination and baseline
2. Challenging as it is, a careful history-taking,
thorough evaluation of symptoms, head-to-toe
physical examination, and judicious use of
laboratory tests can simplify the evaluation of
this complaint.
However, some cases still remain confusing after
all diagnostic tools have been utilized.
An option that is taken is "wait and see" by
hospitalizing the patient and performing
frequent examinations when they have non-typical
The predictive value of this method was estimated
between 68-92%.
This method may pose undue risk upon the patient
from complications such as peritonitis,
hemorrhage, or infertility. However, if active
measures are taken, laparotomy may be
performed unnecessarily.
So Laparoscopy indicated:
• Laparoscopic finding Number of patient
• Appendicitis 73
• Pelvic inflammatory disease 14
• Significant ovarian cysts 7
• Endometriosis 3
• Ectopic pregnancy 2
• Meckel’s diverticulitis 1
Surgery is indicated in
simple goitre if:
• There is clinical or radiological evidence of
• Substernal goitres: are best removed
surgically, as biopsy is difficult and clinical
observation without frequent CT or MRI
scans is impossible
• The goitre continues to grow
• Cosmetic reasons if large or unsightly.
• Indications for thyroidectomy are
1.Patient preference, e.g. fear of radio-iodine
2.Children (radio-iodine or prolonged drug treatment
remain an option)
3.Pregnancy (medical treatment is usually preferred)
4.Large goitre (particularly multinodular goiter, with local
compressive symptoms)
5.Severe reaction to anti-thyroid drugs (but radio-iodine
remains an option)
6.Severe ophthalmopathy (medical therapy remains an
7.Suspicious nodule plus hyperthyroidism (perform fine
needle aspiration cytology first)
8.Complex situations, e.g. poor compliance with anti-
thyroid drugs and radio-iodine is refused.
Thyroid nodules
• Indications for surgery :
1.Malignant or suspicious fine needle aspiration cytology
2.Larger nodule with repeated non-diagnostic fine needle aspiration
3.Continued growth of nodule after fluid removal and thyroid hormone
4.Symptomatic nodules (pain or pressure)
5.Continued patient anxiety
6.Some clinicians recommend surgical removal of all nodules of
diameter over 4 cm
7.Hot nodules: a hyperthyroid hot nodule should be treated with radio-
iodine or surgery. Surgical thyroid lobectomy is effective and safe
therapy for hot nodules, and the risk of hypothyroidism after a
hemithyroidectomy is low.
Urinary catheter
Urethral catheterization is
contraindicated in
• the presence of traumatic injury to the lower urinary tract
(eg, urethral tear).
• This condition may be suspected in male patients with a
pelvic or straddle-type injury.
• Signs that increase suspicion for injury are a
1.high-riding or boggy prostate
2. perineal hematoma
3. blood at the meatus.
When any of these findings are present in the setting of
concerning trauma, a retrograde urethrogram should be
performed to rule out a ureteral tear prior to placing a
catheter into the bladder
Chest tube
1. Postoperative
2. Prophylactic
3. (pneumothorax)
4. (hemothorax)
5. (pneumothorax or hemothorax)
6. lung abscesses or pus in the
chest (empyema).
NG tube
• to drain gastric contents
• assessment of GI bleeding
• obtain a specimen of the gastric contents
decompress the stomach
• Administration of radiographic contrast to
the GI tract
• Administration of medication
• drainage and/or lavage in drug overdosage or
• In trauma settings, NG tubes can be used to aid
in the prevention of vomiting and aspiration
• MANAGEMENT of GI bleeding.
• NG tubes can also be used for enteral feeding
• Comatose patients have the potential of vomiting
during a NG insertion procedure, thus require
protection of the airway prior to placing a NG
• GASTRIC Irrigation before operation
• Absolute contraindications
– Severe midface trauma
– Recent nasal surgery
• Relative contraindications
– Coagulation abnormality
– Esophageal varices or stricture
– Recent banding or cautery of esophageal
– Alkaline ingestion
The indications for central lines
1.Measurement of CVP
2. Central venous access devices (CVADs) are used to
deliver larger volumes of irritating solutions, such as
antibiotics, blood products, parenteral nutrition media,
and sclerosing chemotherapeutic agents.
3.If patients need prolonged IV access, a CVAD is
preferred to a peripheral IV line.
4.Central access is also indicated when peripheral access
cannot be achieved; however, in an emergency situation,
an intraosseous needle is probably the primary choice
according to Pediatric Advanced Life Support (PALS)
Peripheral intravenous central
Although the lines are placed peripherally, usually
in the antecubital or superficial saphenous vein,
the distal tip remains in a large central vein.
• PICC lines are indicated in children who require
intermediate-term IV access for prolonged home
or hospital therapy, such as those with human
immunodeficiency virus (HIV) infection, cystic
fibrosis, osteomylitis, meningitis, or cancer.
• The success of introducing the PICC line is
greater if attempts at inserting noncentral
peripheral lines are limited. Therefore, PICC
placement should be attempted as soon as the
need for intermediate-term access is apparent.
Umbilical artery catheters and
umbilical vein catheters

• Useful in the first few days of life.

• The umbilical vein can be used for access
during the first 5-7 days but is rarely used
beyond 7 days.
• Both and UACs and UVCs can be used:
UAC is used for blood pressure
monitoring, and UVC is used for central
venous pressure monitoring.
• Emergent venous access, when attempts
to gain access by the peripheral or
percutaneous routes have failed.
• Coagulopathy or bleeding diathesis
• Vein thrombosis
• Overlying cellulitis
• Clean nil
• Clean contaminated periop.
• Contaminated periop.
• Dirty therap.

• Clean wounds in the following groups must

receive perioperative antibiotics;
• Cancer
• Immunodefiecent
• have foreign bodies
• With DM and Coagulopathy

• Antithyroid day before OP
• beta blockers in toxic goiter 7-10day post-
• Contraceptive 3 weeks pre OP in
1.operations on pelvis
2.operations on lower limb
3.using of tourniquet
• Oral antidiabetics day before OP and
replaced by soluble Insulin
• Don’t give steroid in acute head injury
• Don’t give opiate in biliary disease and
• Don’t give opiate in head injury
• Don’t give analgesia in undiagnosed acute
abdomen before decision
• Don’t suture wounds (except facial and
scalp) after 6 hours from the injury
• Don’t give heparin I.M.
• Don't give PP I.V.
• Don’t give blood unless indicated
• Don’t give antibiotics unless indicated
• Don’t give K+ unless there is normal urine
output ( 30-50ml/ hr )
• Don’t forget that 15-20 of all suspected acute
appendicitis there is normal appendix, and this
well accepted scientifically
• Don’t forget to give antispasmolytics in biliary
disease and surgery
• Don’t forget to search for features of
hypocalcemia in scorpian stings
• Don’t forget to ask every patient about allergy to
any drug, contrast or anasthetic agents
• Don’t forget to remove any torniquet within 45
• Don’t forget that 50% of surgical diseases
not need surgery
• Don’t forget to mark with skin pencil the
side of OP in double organs in the body
• Don’t forget to sign informed consent and
sign by your patient
• Don’t forget that adult patients are free not
to any treatment ,drug, investigations
,imaging or OP
• Don’t forget that every inpatient / day
costs 380 $
The indications for
thoracotomy following
blunt thoracic trauma
• are the following:
1. 50—1000 ml of blood at the time of initial
drainage is common and may need no further
action, but greater volumes, especially if the
blood is fresh, require intervention;
2. continued brisk bleeding (>100 mI/15 minutes)
from the intercostal drains indicates a serious
breach of the lung parenchyma and urgent
exploration is required;
3. continued bleeding of >200 ml/hour for 3 or
more hours may require thoracotomy under
controlled conditions;
4. rupture of the bronchus, aorta, oesophagus or
5. cardiac tamponade (if needle aspiration is
1.ulcer resist treatment for 5 years
2.Complicated PU as;
• Perforation
• Bleeding
• Obstruction
• Suspicion of malignancy
Priority in surgical lists
• Child first
• Major OP first
• Co-morbidity first
• Clean first
universal precautions for HIV &
• wearing either safety spectacles or a face
• a gown which provides waterproof
protection to the sur-geon’s anterior trunk
and arms.
• boots rather than open-toed shoes should
be worn to improve protection to the feet
should something sharp be dropped.
• wearing two pairs of gloves: it is usually
more comfortable if the larger-sized glove
is worn on the inside next to the skin and a
half-size, smaller glove is worn as the
outer second layer
• carry out the procedure in an orderly
• Surgical assistants should be kept to a
minimum and should be instructed not to
move while the operation is proceeding.
• The operation should proceed in a slow and methodical
manner with meticulous attention to haemostasis, taking
care to avoid unexpected rapid bleeding which changes
the tempo of the procedure and increases the risk of
inadvertent injury to the operators
• No sharp instruments or scalpels should be passed
across the operative field from hand to hand. All
instruments are passed from the scrub nurse to the
surgeon and back to the scrub nurse in a dish

high risk patients are:

• homosexual lifestyle;
• a history of intravenous drug abuse;
• a history of haemophilia treated with factor VIII;
• residents of sub-Saharan Africa;
• the partners of the above, higher risk groups.
0n exposure what to injury what to
do ?
• immediately clean the contaminated area by washing
under running water.
• postexposure prophylaxis to HIV should be started within
1 hour of the injury where possible
• zidovudine 250 mg twice daily, lamivudine 150 mg twice
daily and indinavir 800 mg three times daily for I month.
• The surgeon should then be given hepatitis prophylaxis
• A baseline HIV test should be carried out immediately
since seroconversion will not have occurred immediately
after injury.
• The HIV test should then be repeat-ed approximately 12
weeks after contamination to determine whether
seroconversion has occurred.
component steps
• Primary survey — identify what is killing
the patient
• Resuscitation — treat what is killing the
•Secondary survey — proceed to identify all
other injuries
• Definitive care — develop a definitive
management plan
Elements of the
primary survey
• Airway with cervical spine control
• Breathing and ventilation
• Circulation with control of haemorrhage
• Dysfunction of the central nervous system
• Exposure in a controlled environment
1.Stable vital signs
2.Up to Mild pain & nausea
3.Could move alone and walk
4.Could dress him self
5.Not needs parentral drugs
6. There are some one to take care of him at
7.Not far more than 60 minutes drive
8. Could take orally