1. science
2. medicine
3. surgery

The abdomen
The urinary bladder; the male urethra (Chapter 9.1)
Retention of urine
Presentation:
Acute retention: failure to pass urine, with pain.
Chronic retention of urine: pseudo-incontinence, overflow incontinence, often with
kidneys dilatation and renal failure.
Causes:
Prostate enlargement: benign prostate hypertrophy (adenoma), cancer, prostatitis.
Urethral stricture.
Severe pelvic trauma with urethral rupture.
Neurological cause.
Methods for draining urine:
Urethral catherization
Suprapubic catheterization
Cystostomy.
Urethral catheterization
The most commonly used, but to be avoided in case of prostatitis, rupture of urethra,
recurrent urethral stenosis.
Always use a Foley catheter of reasonable calibre (not less than CH 16), smaller
catheters are more difficult to insert into the bladder. In case of difficulties, and only if you
are experienced, you can use an introducer (risk of trauma and bleeding).
Wash hands. Don sterile gloves.
Clean the urethral meatus with povidone-iodine or chlorhexidine. Place a fenestrated
towel over the penis.
Technique
Clean again with gloves.
Connect catheter to bag straight away.
Lubricate the catheter with sterile K-Y jelly or Lidocain jelly.
The left hand holds up the penis under slight traction, the right hand inserts the
catheter slowly and continuously. Issue of urine confirms introduction into the bladder but it
is wise to insert the catheter fully (so as not to risk inflating the balloon in the posterior
urethra).
Inflate the balloon with sterile water and withdraw the catheter to pull the balloon
against the bladder neck.
Monitoring
Maintain a sufficient urine output to avoid blockage of the catheter.
Avoid opening the closed system and any lavage that may cause infection. The high
urine output will ensure the system is clean.
The same catheter can stay for several weeks if necessary.
No routine antibiotics unless there is fever caused by UTI, even if the urine analysis
shows evidence of UTI.
127
Suprapubic catheterization (see procedure)
To be preferred because it is cleaner and less traumatic. It allows easy reestablioshment of normal urination when re-established.
Compulsory in case of: prostatitis, traumatic rupture of urethra, recurrent urethral
stenosis, failure of urethral catheterization.
To be avoided in case of: known bladder tumour.
Monitoring
The only disadvantage is the small size of the drain, maintain a high urine output.
No routine antibiotics.
Cystostomy
Surgical drainage of the bladder when urethral and suprapubic catheterization have failed
(rare)
Anaesthesia
General or spinal. Local is possible, with 1% Lidocain.
Position
Supine. Drapes allowing a midline infra-umbilical incision. Povidone iodine painting.
Technique
Short suprapubic midline incision. Incise the fascia at the top of the incision, where
it is easier to find.
Avoid dissection. Insert a self-retaining retractor or two small retractors.
Push up the peritoneum.
Insert two traction stitches with big bites on either side of the anterior aspect of the
bladder. In case of doubt, aspirate to make sure this is the bladder
Stab with the knife between the two stitches and grasp the bladder edges with two
Allis forceps. Palpate inside the bladder for tumour or stone.
Insert a large Pezzer catheter (CH 16 or bigger) and close the bladder with 2/0 Vicryl
around the catheter.
Close the fascia.
Interrupted sutures on the skin on either side of the Pezzer catheter.
Fix the catheter to the skin with a strong stitch (braided 0 for example).
Dressing and sterile bag attached to the catheter.
128
Suprapubic catheterization procedure
Equipment
-
Povidone iodine
Sterile gauze swabs
1 table towel
1 sterile fenestrated towel
1 sterile gallipot
1 suturing set
1 pair of sterile surgical gloves
1 IM needle (green) and / or 1 spinal needle
1 suprapubic catheter placement kit
1% lidocaine without adrenalin
20 cc syringe (one)
n° 0 non-absorbable suture material (one)
bottle for urine analysis
129
1-
Mark the aspiration spot 2 finger-breadths above the symphisis pubis.
2-
Don surgical gloves
3-
Paint with Povidone iodine
130
4-
5-
Drape with sterile towel
Inject the LA (1% Lidocaine without adrenalin) with the IM needles or the spinal
needle ( according to the patient’s size)
Insert the needle at a right angle until urine is aspirated. Do not insert catheter if there is no
urine.
131
6-
Wait for LA to act
7-
Place the catheter into the trocard (don’t go beyond the tip)
8-
Make a short incision with n°11 knife (insert the blade fully)
9-
Insert trocard at a right angle until urine comes out
132
10-
Insert catheter into bladder as far as possible
11-
Withdraw the introducer (trocard)
12-
Fix catheter to the skin
133
13-
Save urine for routine urinalysis
14-
Connect to urine bag.
15-
Apply a sterile dressing, avoiding kinking of the catheter.
134
The abdomen
Phimosis – Paraphimosis (Chapter 11.4)
Phimosis (failure to retract the foreskin or prepuce) has two possible complications:
Paraphimosis which is the result of failure to pull the foreskin cover the glans (in case of
loose phimosis). Oedema develops at the level of obstruction (under the glans penis) and it
becomes impossible to cover the glans again. Oedema makes obstruction even worse and may
lead to glans necrosis. It is an emergency.
Infection, with pus formation under the foreskin. Infection often subsides with simple bath
but may require emergency intervention. Antibiotics are not required except in rare cases of
extensive penile infection associated with fever.
Two possible procedures:
Circumcision (removal of the foreskin); may also be performed for religious or ritual
reasons.
Dorsal slit, very easy, makes it easier to pull back the foreskin without removing it.
Both can be done under local anaesthesia but circumcision is more comfortable under general
or spinal anaesthesia; local anaesthesia changes the contours of the foreskin and may increase
bleeding.
Equipment
-
Fenestrated sterile towel.
One pair of gloves for surgeon and assistant.
Instrument set with:
knife
needle-holder
non-toothed dissecting forceps
scissors
2 small forceps
-
Suture material: ideally 3/0 Vicryl (or Chromic).
1 – Dorsal slit: slide the scissors under the dorsal part of the prepuce (to avoid the artery of
the frenulum), between glans and foreskin. Cut. Most often there is no bleeding and suturing
of the mucocutaneous layer with quick resorption material is enough (2/0 Chromic).
135
2 – Circumcision must be done carefully
- Paint penis and glans after retraction with disinfectant.(B)
- Bring the foreskin back over the glans and pull slightly on it.
- Cut the skin over the glans with scissors, while the assistant pulls back the penile skin
©.
- Make a circumferential incision of the mucosa about ½ cm from the corona (going
back slightly at the ventral part).(E)
- Ligate and cut the artery of the frenulum with 3/0 Vicryl on the ventral aspect of the
corona (G); control bleeding carefully, the only complication being haematoma.
- Cut redundant skin and mucosa, until the previous incision of the mucosa is met.
- Check bleeding.
- Approximate the cut edges with interrupted suture (Vicryl 3/0), without twisting. Use
loose interrupted suture, it must not be water-tight.
- Tied-over dressing or no dressing at all (F).
No postoperative care is necessary, the only risk is haematoma within next few hours.
Infection is very rare.
Paraphimosis: always try manual reduction by compression, then return the foreskin over
the glans. If successful, oedema will subside within a few hours. Otherwise, release the
obstructing ring with diathermy with or without dorsal split. Interval circumcision is
recommended.
Infection: if there is no fever and infection is limited to the foreskin, try bath with a
disinfectant solution. Otherwise, make an urgent dorsal slit. Interval circumcision is
recommended
136
The abdomen
The perineum; perianal area (Chapter 9.2)
Clinical examination
Anal fissure
Diagnosed on history (acute pain during defecation and for half an hour following it) and on
examination (little crack on the posterior side of the anal margin, sometimes hidden behind a
sentinel skin tag). But examination may be painful and must be repeated under anaesthesia. If
a medical diet for soft stools does not succeed, a simple anal stretching under general
anaesthesia, gradually with two or three fingers, may be enough. In case of recurrence, or
residual chronic fissure, refer him for more radical surgery (excision and sphincterotomy or
sphincteroplasty).
137
Prolapsed haemorrhoids
Try to reduce, give PO metronidazole, and surgery later.
Acute thombosed piles
Signs: Acute pain with bluish, tender, fixed anal swelling, making sitting or defecation
painful.
Treatment:
If there is one or two localized thrombosed haemorrhoids, make an incision under general or
large local anaesthesia on top of the pile and dislodge the clot without leaving anything
behind (use a curette).
If there is numerous thrombosed haemorrhoids, with circular oedematous prolapse, don’t try
multiple thrombectomy or radical haemorrhoidectomy. Sooth the patient with warm bathes
and pain killers. Refer him in case of failure.
Notes
• Due to acute local pain, it may be difficult to distinguish between anal fissure, internal
pile thrombosis and early anorectal abscess. In these cases, an examination under general
anaesthesia is necessary.
• The elective radical operation for uncomplicated piles is not that easy. There is no
emergency, so refer the patient for it.
Prolapsed haemorrhoids (top), thrombosed heamorrhoids (bottom)
138
Anorectal abscess; fistula-in-ano
Surgery has two goals:
1. Relieve the patient’s symptoms and stop the infection process.
2. Look for a fistula between the abscess and the anorectal canal. The cause of the
abscess is a primary infection inside the anal canal, on the “pectinate” line or ”dentate”
line, spreading secondarily through the anal (or rectal) wall up to the subcutaneous
space; there it may burst spontaneously unless it is treated surgically.
3. Treat the fistula only if a track is present and if you are sure it is a superficial
(infrasphincteric) fistula.
Clinical signs and indication for surgery
Acute, throbbing pain severe enough to keep the patient awake, fever, local tense swelling
with or without fluctuation are sufficient. Rectal examination is usually impossible without
anaesthesia because of the pain.
Always operate under general (or spinal) anaesthesia, in lithotomy position.
Start by examining the anorectal canal
Insert one then two fingers without dilating the anus. Look for pus discharge revealing the
internal orifice of the fistula. Put one or two retractors in the anus (or better: an anal bivalve
retractor) and have a look around all over the pectinate line. If the internal orifice can’t be
located with these manoeuvres, puncture the top of the abscess up to its centre and aspirate
pus to confirm the collection and its site, and to order a culture. Keeping the needle steady,
inject 10 cc of air or blue colouring while looking for bubbles or blue drops at the internal
orifice of the fistula. Whatever you find go to the next step:
Incise and explore the abscess
Use the routine technique (see above).
Keep especially in mind two possible extensions of the abscess:
1. Up through the levator ani muscle, up to the infraperitoneal space (collar-stud abscess)
2. Back, up to the midline and even through it up to the opposite side (horseshoe abscess)
3. Inwards: going back the blue coloured track of the fistula, and exploring that track with
your finger then, quite gently, with a smooth curve instrument, searching for an opening
into the anal canal. Caution! Do not insist with that instrument, you risk perforating the
anal mucosa and creating a second fistula (while ignoring the first one!). If you don’t find
easily the track, give up!
Drainage and postoperative care
• If there is no fistula, treat as in general case. Tell the patient he may suffer again from a
new abscess or a chronic fistula (refer).
• If there is a fistula, assess it by passing a probe through it and palpating the tissue over
that instrument. If that tissue is thin (less than 5 mm) and does not contract when applying
electro-diathermy, you can divide it, laying open the fistula. If the tissue is thicker, assume
it contains the anal sphincter, just incise the skin and the anal mucosa between the internal
orifice of the fistula and the incision, and replace the director by one thick non-absorbable
ligature, loosely tied around the sphincter.
Later (but not before two weeks) you or a proctologist will have to replace that thread by
an elastic band slightly tightened every week, cutting through the sphincter gradually.
139
140
The abdomen
The scrotum (Chapter 9.3)
Hydrocele; epididymo-orchitis; testicular torsion
Hydrocele (fluid around the testis)
Common, the only treatment is surgical; it is not painful or dangerous, so surgery should be offered
only when the patient is troubled by the volume of the scrotum.
The surgical treatment is easy but most be done carefully to avoid the one postoperative
complication: scrotal haematoma, which may be bigger than the initial hydrocele.
The diagnosis is clinical and easy in the face of:
Large, regular scrotum,
irreducible,
testis cannot be palpated.
In children the cause is patency of the processus vaginalis, which can be associated with a congenital
hernia.
In case of doubt:
US scanning will easily show the hydrocele as a fluid-filled mass with the testis on one side.
Needle aspiration will draw a straw-colour fluid (like urine) but should be avoided because
of the risk of infection.
Differential diagnosis:
Scrotal hernia, which is softer, reducible (at least partially), the testis is palpable.
Elephantiasis, where the skin is thick, infiltrated, sometimes even card-board-like (cannot be
pinched between two fingers).
Two surgical techniques (adults):
Eversion of the tunica vaginalis (Jaboulay’s procedure), the safest. To be preferred to:
Resection and placation of the tunic vaginalis (Lord’s procedure), preferred in case of thick
wall.
Two complications :
Intra-operative: injury to the cord.
Post-operative: scrotal haematoma.
Anaesthesia
Spinal anaesthesia is best.
Or general anaesthesia.
Installation
Patient supine.
Skin preparation must include the penis (not alway easy when the hydrocele is very big) and
the lower aspect of the scrotum (which must be lifted by the assistant with a sponge-holding forceps
during skin preparation until the towel has been placed underneath).
Prepare a narrow field (the penis can be covered) with 2-4 towels.
When the hydrocele is large, prepare for suction.
141
Transverse incision over the anterior aspect of the scrotum, with the assistant stretching the
skin with his hands.
Dissect layer by layer until the bluish layer of tunica vaginalis has been reached, trying not to
enter it.
Remove the fluid with a small stab incision of the tunica vaginalis, then grasp the edges with
two tissue forceps (the assistant must release its tension then!).
The fluid is typically straw colour but may be turbid, sometimes even brown when the wall is
thick. Once the hydrocele fluid has been removed, bring out the testis after enlarging the tunica
opening. Check the testis.
Jaboulay’s operation = eversion of tunica vaginalis
First choice but possible only when the tunica is soft.
The idea is to evert the tunica vaginalis and resuture it behind the testis, with interrupted 3/0
absorbable (chromic) stitches.
Two precautions:
- identify and protect the cord,
- do not strangulate the cord or leave a gap leading to recurrence.
Always check for bleeding and add if necessary small figure-of-eight 3/0 Vicryl stitches.
Drainage
Not compulsory if there is no bleeding at all.
More often when tunica has been resected the risk of bleeding is higher. Insert a corrugated
drain through a stab incision at the lowest spot; fix it with a large non absorbable stitch
Closure
Do not remove skin, even for a large hydrocele.
The subcutaneous layer is closed with a continuous 2/0 absorbable suture taking big bites of
all the layers. The skin is closed.
In any case (even if there is a drain), apply a criss-cross dressing i.e.:
- several gauze swabs over the operated scrotum,
- compressive dressing with Elastoplaster: two strips going from the iliac crest up to below the
opposite thigh after crossing under tension over the scrotum.
- remove the dressing the same evening or the following day (if tight it may prevent
micturation).
Postoperative period
Usually uneventful, mobilization as soon as the effect of spinal anaesthesia is over.
If there is a drain, mobilize it the following day, and remove it by the 3rd or 4th day.
Sutures removal on day 8 or 10.
In case of haematoma, wait for spontaneous absorption if not too large. Otherwise it must be
evacuated surgically.
The patient can be discharged on the 2nd day if there is no problem.
Avoid this operation in children: identification and closure of the sac may be difficult. Refer.
142
Epididymo-orchitis
Bacterial infection of the epididymis of prostate origin. The infection goes along the vas deferens
from the prostate to the epididymis.
The prostate infection may go un-noticed but there may be a history of:
recent unexplained fever,
burning micturation
recent frequency.
The clinical diagnosis is easy most of the time:
unilateral scrotal swelling,
inflammation,
often with high fever > 39°C (except when antibiotics were taken blindly)
physical examination is not very reliable, as tenderness and oedema prevent palpation of the
epididymis.
The only possible mistake is to miss a testicular torsion, therefore, in the absence of signs of
infection, any scrotal pain requires surgical exploration because it is better to explore a scrotum unnecessarily than risk loosing the testicle.
Urine analysis when available.
Antibiotics target the most common agent, Escherichia Coli. The treatment must last 3 weeks to
treat both epididymitis and prostatitis. Teat according to national protocols for STDs.
Avoid penicillin / ampicillin – Augmentin and β lactamines poorly active on Gram (-) germs.
Aminoside injections may be used.
Progress is slow and even though the fever ususally subside within 2-3 days, it may take 3-4 weeks
for the clinical findings to go back to normal. There may be residual nodules, without significance.
Cause:
recent instrumental manoeuvre: bougies or catheter,
to be investigated in case of recurrence: mostly urethral stricture seen on cystoscopy or
retrograde urethro-cystogramme or IVP,
often unidentified.
Special cases:
TB epididymitis: mild pain, no fever, but significant changes to the epididymis without signs of
infection. The diagnosis is based on identification of AAFBs in urine; when possible, an IVP should
be done looking for infection of the upper urinary tract because ‘TB goes down the urine stream, and
goes up the sperm stream’ the kidney infection always precedes the epididymal infection.
Subacute epididymitis, difficult to diagnose and treat, either because the cause is intra-cellular
germs (Chlamydiae), or because antibiotics have already been given.
143
Testicular torsion
A misnomer: the cord gets twisted, not the testicle!
It is an emergency that cannot suffer any delay, as the testis can get gangrenous within a few hours.
The history is usually typical:
At any age, but more common in children and young men (10- 30 years).
Severe, acute, sudden scrotal pain, without causing factor and no infection (no fever, no
burning micturation, no urethral discharge).
Clinical examination is often un-necessary (the diagnosis is obvious) and impossible (severe
tenderness). Just check that inguinal lymph nodes are not enlarged.
Sometimes there can be doubt after testicular trauma, epididymo-orchitis complicating a missed
prostatitis, or a scrotal abscess.
Therefore, any acute testicular pain without infection must lead to surgical exploration.
It is better to operate un-necessarily for an atypical epididymitis than to miss an atypical torsion.
144
Surgical technique
Surgery is quick and easy.
Short general anaesthesia to be preferred to spinal anaesthesia.
Installation:
- Supine, paint penis and scrotum with disinfectant.
- Drape scrotum only with 2-4 towels.
Incision:
- Scrotal, horizontal.
- On opening the tunica vaginalis, you may encounter clear (in case of torsion or
infection) or bloody fluid (in case of trauma).
Procedure:
- Bring out the testis.
- If the epididymis is swollen and inflammed with a normal looking testicle, this is
epididymitis put the testis back and close. Give antibiotics (2nd generation Quinolones for 3 weeks
or Bactrim).
- If the testicle is bluish, ischaemic and the cord is twisted one or more times, it is
indeed torsion. Then:
Detwist the cord.
Allow the testis to go back to its normal colour (with warm saline).
Fix the testis to the septum with 3 non-absorbable stitches (e.g. 4/0
Prolene) taking testis and septum (in normal position!).
Subcutaneous layer with 2/0 Chromic or 3/0 Vicryl.
Skin closure with interrupted 3/0 Vicryl (or non absorbable or skin clips).
- If the testis is black, obviously gangrenous or doesn’t go back to normal after
detorsion, it must be removed (the patient should have been informed of the possibility before-hand):
Separate the structures of the cord carefully.
Put a double ligature on each of the two cord structures with a ‘large’
ligature (n° 0 Vicryl or Chromic without needle).
Cut the cord and remove the testis.
Subcutaneous layer with 3/0 Vicryl or Chromic without drain.
Skin closure with interrupted 3/0 Vicryl or Chromic (or non absorbable or
skin clips).
Postoperative period
Haematoma is rare.
Remove skin sutures after 8 – 10 days.
If there was torsion, plan orchidopexy of the opposite testis next month.
Key points
Careful haemostasis for hydrocele operations.
Symptoms of testicular torsion are typical.
Explore the scrotum urgently in any suspicion of testicular torsion.
145
146
TRAUMATOLOGY AND ORTHOPAEDICS
147
148
Traumatology and Orthopaedics
Principles of Primary Trauma Care
A, B, C, D, E
Procedures
Chest injuries
Head injuries
149
150
Traumatology and Orthopaedics
Principles of Primary Trauma Care (16.2)
Primary Survey: A, B, C, D, E
A: Airway
B: Breathing
C: Circulation
D: Disability
E: Exposure
Secondary Survey: head to toe examination.
Head: Scalp, eyes, ears, mouth
Neck: Tenderness, tracheal deviation, JVD
Chest: Breath sounds, tenderness, crepitus, dullness, hyper-resonance
Abdomen: Tenderness, masses, distention
Pelvis: Instability, blood at meatus
Extremities: Pulses, neurologic exam, fractures
151
Airway
Is the airway free?
If the patient is talking, the airway is free.
If breathing is noisy or absent, use the following measures in that order:
-Extend the neck and lift the jaw forwards.
-Suck out the mouth.
-Remove pieces of vomit or foreign bodies with your finger.
-Insert an oropharyngeal airway.
-Intubate the trachea (if you know the technique), especially if the patient is
unconscious.
-Create a surgical airway through the cricothyroid membrane (see procedure)
Breathing (ventilation)
The airway being clear or cleared, is the patient breathing?
Look at the chest movements. Auscultate the chest for air entry. If it is normal, give
oxygen.
Otherwise, ventilate the patient with Ambu-bag and oxygen.
152
Circulation
Positioning the patient
Tilt the patient head down if possible or raise the legs so that most of the blood will go
to the most important organ, the brain, which is very sensitive to ischaemia.
Controlling external bleeding
If there is obvious severe external bleeding, start by applying firm pressure on the
bleeding part with your gloved fist and a pack and keep pressing as long as it is bleeding.
Raise a bleeding limb; this will lower the venous pressure and reduce the bleeding.
Applying a tourniquet to a limb is permitted as long as the patient can go to theatre
immediately. This is not recommended for first aid at the scene of an accident, pressure is
prefered because of the ischaemic complications of tourniquet.
Is the heart beating?
If there is no heart sounds on auscultation and no carotid pulse, start cardiopulmonary
resuscitation:
Continue to support ventilation and give oxygen.
Start external cardiac massage (see technique in skills practice).
Give 1 mg of adrenalin IV, repeat if necessary.
Emergency IV access
In case of hypovolaemic shock, the most common type of shock in surgical practice, it
is essential to get urgent IV access because the body response to hypovolaemia is by
vasoconstriction; the veins will rapidly get collapsed and become very difficult to cannulate.
Peripheral vein cannulation
You need a secure, reliable IV access.
If available, use the biggest cannula you think you will be able to insert. Draw blood
immediately for blood grouping if it is a case of haemorrhagic shock: you will save time and
will not have to find another vein to draw the blood. Send it to the laboratory for urgent blood
grouping and request blood at the same time (at least 2 units for an adult).
Secure your cannula well. Splint the arm of children or restless patients, they may have
no other usable vein and you don't want to lose it.
If possible put up 2 IV lines which offer more security in case one of them is pulled
out or get tissued.
153
External jugular vein cannulation
This is an easily accessible vein, which can be used in shocked patients whose
peripheral veins are collapsed or in children with difficult veins.
Tilt the patient head down and ask someone to press on the root of the neck just above
the clavicle to make the vein more visible. Connect a syringe to the cannula to aspirate the
blood because it can be under negative pressure.
The disadvantage of this site is that the rate of infusion varies with the position of the
head. You may have to keep the head turned to the other side to allow good flow.
Central vein cannulation
In desperate cases, even if you don't have central catheters, you can try to cannulate the
femoral vein or the subclavian vein with a large IV cannula.
Cutdown
Cutdown to the long saphenous vein or one of the superficial veins of the cubital fossa
can also be very useful in difficult situations.
Note on laboratory tests: haematocrit is not a useful emergency test in case of acute
haemorrhage as red cells are lost in equal proportion to plasma and the haematocrit is initially
normal. Only after compensation by fluid shift from the intracellular compartment will it be
lowered.
Infusion fluids
Give IV crystalloids (eg normal saline) as fast as it will go.
In case of haemorrhagic shock, give blood as soon as it is available if indicated.
Keep the patient warm.
Monitor the patient's response
You are looking for a reversal of the signs of shock: extremities must warm up,
consciousness must improve, ventilation rate must decrease, BP must pick up, pulse must
slow down, and urine must be passed: the urine output should be at least 0.5 ml/kg/hour.
If he is not responding to fluid replacement, suspect a missed injury. Re-examine him.
154
155
Chest trauma
Look:
- rate and depth of the breathing
- paradoxical movement (flail chest)
- distension of intercostal spaces (tension pneumothorax)
- cyanosis
- bruises or wounds (don’t forget to look at the back).
Feel:
- tenderness
- crepitus (rib fracture)
Surgical emphysema (air in the soft tissues)
- surgical emphysema
.
Percuss:
Dullness (haemothorax) or tympanism (pneumothorax).
Listen:
Reduced or absent air entry, suggesting pneumothorax, haemothorax, or lung collapse.
156
Also examine the abdomen because of the frequent association of rib fractures with
splenic (left side) or hepatic (right side) injuries.
X-rays, when available are useful may must not delay emergency measures (needle
insertion for a tension pneumothorax, insertion of a chest tube).
The majority of patients with thoracic trauma can be managed by simple manoeuvres
and do not require surgical treatment.
Simple pneumothorax: air in the pleural cavity
The affected side is hyper-resonnant on percussion and air entry is reduced.
On X-Ray: the lung markings do not reach the edge of the thoracic cage.
Chest drainage is indicated when:
- there is dyspnoea;
- the apex of the lung is about 3 cm below the top of the pleural cavity;
- the patient is going to need general anaesthesia for another injury: ventilation can
convert a simple pneumothorax into a tension pneumothorax.
Open pneumothorax or ‘sucking’ chest wounds
Air is sucked into the pleural cavity every time the patient breathes. As a first aid,
occlude the wound immediately with any available dressing or a plastic sheet. Then insert an
intercostal chest drain and proceed to close the wound, if possible under local anaesthesia:
wound toilet, debridement if necessary; then close pleura, muscle and skin; check that there is
no air leak.
157
Tension pneumothorax: air under tension in the pleural cavity.
Develops when air enters the pleural space but cannot leave. The consequence is
progressively increasing intrathoracic pressure in the affected side resulting in mediastinal
shift. The patient becomes short of breath and hypoxic. There is severe chest pain, increasing
dyspnoea and sometimes cyanosis; the chest is hyper-resonant with poor respiratory
movements and absent breathing sounds. The trachea and the apex beat are deviated to the
other side. Don’t wait for X-Rays! This is a real life-threatening emergency and immediate
treatment is required.
Urgent needle decompression is required prior to the insertion of a chest tube. The
trachea may be displaced (late sign) and is pushed away from the midline by the air under
tension.
Emergency treatment: insert a large needle in the 2nd intercostal space in the midclavicular line to let the air out of the pleura. This will considerably improve his breathing and
you can then insert a chest drain as usual.
Haemothorax: blood in the pleural cavity.
Hypovolaemic shock and respiratory distress may be present. There is chest pain,
dullness to percussion and reduced breath sounds on the affected side. X-Ray, when available,
shows a diffuse opacity but may be difficult to interpret.
If you are in doubt, do a needle aspiration of the chest before draining the chest. In fresh,
closed haemothorax, you can use the blood for autotransfusion by collecting it into a bloodcollecting bag. The complication of undrained haemothorax is clotting of the blood,
preventing the lung from re-expanding, and very difficult to treat.
Rib fractures
The ribs spontaneously become stable within 10-15 days. Pain control is important to
allow easier ventilation. Nothing else is necessary.
Flail chest: two or more ribs fractured at two different sites
The unstable segment moves separately and in the opposite direction from the rest of
thoracic cage during the respiratory cycle (‘paradoxical breathing’). Severe respiratory distress
may ensue.
158
Pulmonary contusion
A potentially life threatening condition. The onset of symptoms may be slow and
progress over 24 hours post-injury. It is likely to occur in cases of high speed accidents, falls
from great heights and injuries by high-velocity bullets or missiles.
Symptoms and signs include: dyspnoea (shortness of breath), hypoxia, tachycardia,
rare or absent breath sounds, rib fractures, cyanosis.
Oxygen therapy is essential.
Key points
Check all trauma patients for chest injury.
Take emergency measures if X-Ray is not available or is delayed.
Deflate a tension pneumothorax urgently by needle insertion.
Have a chest drainage set always ready to drain any significant pneumothorax or
haemothorax.
159
160
Traumatology and orthopaedics
Procedures (Chapter 16.3)
Chest drainage; cricothyroidotomy; diagnostic peritoneal lavage
Chest drainage
Indications
Pneumothorax (see above).
Haemothorax.
Haemopneumothorax.
Acute empyema.
Technique
Always have a chest drain set ready in your hospital. The method commonly used is
the underwater-seal chest drainage.
If you have no special chest drain, use any large sterile tube such as a gastric tube or a
large rubber tube on the sides of which you will have cut holes, and lead the tubing under the
surface of the water. Make an incision under local anaesthesia in the 4th intercostal space
(nipple level in a male patient), at the upper border of a rib, anteriorly to the midaxillary line
(fig 1 and 2).
Fig 1
Fig 2
161
Enlarge the opening with forceps (fig 3-4), insert the tube (fig 5) and fix it to the chest wall
(fig 6); insert a purse-string suture for easier removal later (not shown)
Fig 3
Fig 5
Fig 4
Fig 6
Connect to under-water system bottle (fig 7)
Fig 7
Important points
- do not puncture the lung by forceful use of the trocard
- secure the drain well, as accidental removal may have serious consequences
- get a control X-Ray after insertion
- monitor the drain frequently: presence of the tube tip in the chest cavity is indicated
by the swinging of the fluid level.
The water in the bottle prevents air from coming up into the pleura.
162
Cricothyroidotomy
A cricothyroidotomy is a surgical airway, which can be necessary in case of obstruction.
Severe hypoxia from obstruction of the airways can occur in case of:
• Head injury in unconscious patients
• Severe neck injury with laryngeal trauma
• Face injury.
• Burn injury to the face or the respiratory tract
• During the postoperative care of patients after neck surgery.
It is usually easy to detect the obstruction of the upper airway. The patient cannot have free
breathing or no breathing at all. He becomes cyanosed.
It is an extreme emergency, therefore:
• Have the various steps clear in your mind;
• all the equipment:
o tracheostomy set
o cannula
o oxygene
o suction apparatus
must be always kept in the same place, at hand, ready for use; everybody in the Operating
Theatre must know about the equipment, which ahs to be checked and sterilized at least
once a month.
Surgical setup
Except in cases of trauma or compression, when you have the possibility of inserting a
tracheal tube without wasting time, you may try it.
You may also immediately insert a large-bore needle or cannula into the trachea below the
cricoïd cartilage; this can improve temporarily the
patient and give him some air while you get ready for
crocothyroidotomy
The procedure is quick and simple.
Local anaesthesia, when necessary, may be given.
A pillow is placed under the shoulders, head and neck
are extended (fig 1).
Give oxygen through mask until the last seconds.
Have suction ready.
163
Surgical technique
Stand on the patient’s right side.
Feel for the thyroïd cartilage with your right index, then maintain it between left thumb and
middle finger placed on either side of the cartilage.
Remove the index and incise the skin and the subcutaneous layer until the space between the
thyroïd and cricoïd cartilages. The incision can be transverse or vertical midline and should
not be too long (fig 2). Place the tip of your index in the incision to prevent bleeding (fig 3).
Fig 2
ig3
Incise transversely the membrane until air comes out: take the tracheal dilator (if you do not
have, any short, curved forceps will do). Open it and extend the opening (fig 4). Do not
dissect.
Fig 4
164
Insert the cannula in horizontal position, at a right angle to the trachea. Push it and rotate it
downward (Fig 5). Push again along the curvature of the cannula and insert it fully.
Fig 5
When inserting the cannula, breathing sounds must be heard. If not, it means that it is not in
the proper place, may be in the subcutaneous layer in front of the trachea; take it out and try
again.
Suck out secretions and blood clots with a soft tube. Fix a tape around the neck (Fig 6). Suck
out again.
As soon as possible give O2 to the patient through the new airway.
Fig 6
Follow- up: intensive care is mandatory to prevent complications
Oxygen as needed. Humidify the air if possible. A wet gauze may be placed over the
tube.
Avoid obstruction of the cannula. Suck out secretions on a regular basis but not too
often, using sterile material.
According to the cause, the patient may have to be referred if safe to do so.
Difficulties:
In a life-threatening emergency, even when you have no cannula, any tube can do.
The size of the cannula is the same as his little finger.
The incision must be short, not much longer than the size of the tube.
165
Diagnostic peritoneal lavage (DPL)
This is a safe and valuable technique in abdominal trauma when positive; but a negative result
doesn’t rule out a visceral injury.
Contraindications:
• Pregnancy
• Previous abdominal surgery (because of possible adhesions)
• When the result will not influence your management.
Technique
Make sure bladder and stomach is empty. If in doubt, insert a catheter.
Infiltrate the abdominal wall and the peritoneum below the umbilicus with a local
anaesthetic (with adrenaline if available, to reduce abdominal wall bleeding) (Fig. 1). Make
a 2.5 cm midline incision below the umbilicus (Figure 2).
Fig 1
Fig 2
166
Lift up the fascia with two stay sutures and make a 3–5 mm incision through the fascia
(Figure 3).
Gently introduce a large catheter on an introducer into the peritoneum and push the
catheter into the pelvis (Figure 4). You also can use a cannula, a soft probe, or a gastric
tube. Spontaneous reflux or gross aspiration of blood or intestinal liquid is sufficient to
make a decision.
Fig 3
Fig 4
Fig 5
Fig 6
If there is no fluid reflux, infuse 1 litre of saline rapidly through the catheter (Fig 5).
Attach the catheter to a closed container and place it on the floor (Fig 6). About 100 ml of
fluid should flow back into the container.
Interpretation
When laboratory examination is available, ask for a red and white cells count and microscopic
examination for bacterias. More than 100,000 red cells per ml indicate abdominal bleeding; if
white cells are greater than 500 / ml, consider there is a damaged organ. Presence of bacterias
is a sign of intestinal perforation and of the need for a laparotomy. When laboratory
examination is not available, check the clarity of the fluid. If you cannot read “newsprint”
through the red-stained fluid, there is a haemoperitoneum; if the fluid is cloudy due to
presence of material, it is likely that there is a bowel injury and therefore laparotomy is
indicated.
167
168
Traumatology and orthopaedics
Head injuries (Chapter 16.2)
On admission apply the ABC primary trauma survey.
Get history of the trauma.
Admit when criteria for 24-hour admission and observation are present.
Specific examination and management
Initial and repeated assessment of the level of consciousness by the Glasgow Coma Scale
(GCS) is essential
Glasgow Coma Scale
Eyes opening
4
3
2
1
Spontaneously
To speech
To pain
None
Best verbal response
5
4
3
2
1
Orientated
Confused
Inappropriate words
Incomprehensible sounds
None
Best motor response
6
5
4
3
2
1
Obeys command
Localises pain
Withdraws to pain
Flexes to pain
Extends to pain
None
Minimum score: 3 / 15
Maximum score: 15 / 15
Patients with GCS below 8 are generally considered to have severe head injuries.
Many patients will recover with attentive supportive care.
169
For all severe head injuries, also assess:
Size and reactivity of pupils
Motricity of limbs
Presence of blood or clear fluid (CSF) coming from ears or nose (suggest basal skull fracture).
X- Rays (when available):
- X-Ray the cervical spine for all significant head injuries.
- AP, lateral right, left and special views of the skull are useful in some cases (see
criteria for skull radiology in annex).
Neurological assessment
Secondary brain injury means that symptoms not present when the patient arrived appear
after a few hours or days.
The “free interval” after head injury
I initial loss of consciousness
II conscious state
III deterioration or coma
- Deterioration of level of consciousness.
- Pupil dilation on the side of injury; controlateral motor weakness.
The association of deterioration of level of consciousness and new neurological signs means
haematoma (fig1-2 and photo) and is characteristic of a space-occupying lesion such as
extradural haematoma, and is an indication for emergency surgery: burr-holes, craniectomy,
release of haematoma.
170
When neurological symptoms are present from presentation, it is difficult to say whether the
cause is primary brain injury or secondary brain injury such as haematoma (which may be
associated with brain injury).
In your circumstances, we advise transfer whenever possible.
The wound
When the wound is significant, with bone fragments and hair inside, do a thorough wound
toilet, remove obviously damaged or prolapsed brain matter and close the wound (if possible
the dura, otherwise only the skin).
Give chloramphenicol + penicillin.
General management
Prevent hypoxia and hypovolaemia but do not overload.
No 5% dextrose.
No steroids!
Nurse in lateral position because of the risk of aspiration.
Seizure prophylaxis in all severe head injuries (phenobarbitone). Treat seizures with IV
diazepam.
In case of CSF leak through ear or nose, nasal bleeding, ear bleeding, open skull fracture:
antibiotics are mandatory to avoid meningeal infection: chloramphenicol + penicillin.
Key points
ABC of acute rauma care
Assess GCS, pupils and motricity on arrival.
Prevent gastric fluid aspiration, hypoxia, hypovolaemia, seizures.
No steroids.
No 5% dextrose
Re-assess frequently.
171
Fig 1: left extradural haematoma; right: subdural haematoma
Above: ‘jelly’ of an extradural haematoma
172
Fig 2: intracerebral haematoma
Criteria for skull radiology in head injury
History of loss of consciousness
Scalp laceration or contusion
Palpable depression
Suspicion of compound fracture
Criteria for 24-hour admission and observation after head injury
History of loss of consciousness
Alteration of level of consciousness (GCS 14 or lower)
Fracture on skull X-Ray
Any abnormal neurological sign
Seizures
CSF leakage for ear or nose
Bleeding from ear or nose
No responsible adult to take charge of the patient
173
174
Traumatology and Orthopaedics
Fractures and dislocations
175
Traumatology and orthopaedics
General principles of fractures and
dislocations
Definitions;
principles of treatment;
open fractures;
conservative management;
complications
Fractures general principles. 2006
1
Definitions
• Fracture: broken bone; may be complete or
incomplete.
• Sprain: ligament injury without loss of contact
of the joint surfaces.
• Dislocation: complete rupture of all the
ligaments with loss of contact between the
joint surfaces.
• Union: incomplete repair.
• Consolidation: complete repair.
2
Approach to orthopaedic trauma patient
ABCDE of acute trauma management
Timing and mechanism of injury.
Look (deformity, swelling, wound)
Feel getly for tenderness, deformity
Move very gently for tenderness,
restriction of movements.
Look for complications.
Immobilize and get X-Rays (when
available
3
X-Rays in orthopaedic trauma
(when available)
Anteroposterior and lateral views.
• Centered on the suspected area.
• Must show the whole bone and the joints
proximal and distal to it.
• Type of fracture, quality of bone,
displacement.
• When in doubt, X-Ray opposite (normal)
side in children.
4
176
Fracture mechanisms
• Direct trauma
Usually transverse fractures with soft tissues
injury.
• Indirect trauma, twisting injury
Spiroid or oblique fractures (short or long)
• Pathological fractures
Minimal trauma, occuring on infected or tumoural
bone
5
How to describe a fracture
• Bone, and part of bone involved (shaft,
distal, epiphysis)
• Open or closed.
• Complete or incomplete.
• Displaced or not displaced.
• Type of fracture: transverse, oblique, spiral,
comminuted.
• Articular, partial articular or extraarticular.
6
Transverse fracture (left); wedge fracture (right)
•
7
Spiral fracture
Rotational displacement (left); segmental fracture (right)
8
177
Comminuted fracture
Direct trauma.
A wound is common.
Soft tissues injury to
muscles, vessels,
nerves
9
Articular fractures
Metaphysis and epiphysis fractures
Complications: restriction of mobility, early or delayed
osteo-arthritis, algodystrophy, non union
10
Fracture displacements
Sideways shift
Shift with overlap
Rotation
11
Impacted fractures
Stable fractures.
Conservative treatment with no need for manipulation.
Examples: Colles’ fracture, femoral or humeral neck fracture
(below), spine (right)
12
178
Principles of treatment of fractures and
dislocations
Reduce (when necessary)
Hold until it unites (using one of different
methods).
Exercise (muscle activity and early
weightbearing).
13
Conservative treatment
• The most common management.
• When manipulation is necessary, it must be
done early, under anaesthesia and correct
alignment must be obtained with contact of
the 2/3 bone surface. Rotation must be
corrected.
• Stabilisation by POP cast or traction.
• If reduction is not obtained, refer.
14
Surgical treatment
Compulsory for open fractures.
But not to be used in your circumstances for
closed fractures.
15
179
Open fractures
• Fractures with a wound communicating
with the fracture.
• The major risk is infection.
• The risk is greater in contaminated
wounds and with delay since injury.
• After 6 hours, consider the fracture as
infected.
16
Open fractures: classification
Grade 1: small wound with clear cut edges, no contusion of soft
tissues.
Grade 2: wound is more than 1 cm with no skin flap,
not much soft tissue damage.
Grade 3: extensive damage to skin and soft tissues with
contamination of the wound.
Grade 1
Grade 2
Grade 3
17
Principles of open fractures management
• Urgent wound toilet under anaesthesia.
• Bone stabilization by traction, cast, or
external fixation.
• Tetanus prophylaxis.
• Start antibiotics early and continue for a
minimum one week.
18
Wound toilet for open fractures
• Irrigate with at least 3 litres of boiled water.
• Excise skin edges minimally.
• Check muscle 4 C’s: colour, consistency,
contractility, capacity to bleed and excise dead
mucle.
• Leave cut nerve undisturbed.
• Leave cut tendon ends alone: suture only if
totally clean.
• Only remove small and completely detached
bone fragments.
• Look for and remove any foreign bodies.
• Reduce the fracture.
19
180
Wound closure for open fractures
• Only grade 1 open fractures with very small,
very clean wouinds and seen early may be
closed primarily. Immobilize with a cast with
a window or a plaster back-slab.
• Delayed primary closure must be used for all
other injuries, apply a large American dressing
on the opened wound, plan DPC after 3-4 days
under anaesthesia. Apply a cast with windom, a
back-slab or traction as appropriate.
20
Options for immobilization of open fractures
• Circular Plaster of Paris cast with
window.
• POP backslab.
• Or skeletal traction.
21
Grade 2 open fracture of the distal leg suitable
for calcaneal traction
(here treated by external fixation)
22
Grade 3 open fractures may require
amputation
Immediately: major
injuries, irreversible
ischaemia, limb
beyond repair (right)
Later: infected bone,
gangrene, painful limb
that will never
be useful.
23
181
Sprains
Clinically:
Pain
Swelling
Inability to use the limb.
Principles of management:
Elastic bandage for 10 days.
Analgesics and NSAIDs.
24
Ligamental ruptures
Clinically:
Haemarthrosis (knee, ankle)
Deformity.
Principles of management:
Immobilize in a cast, or a backslab in case
of major swelling.
Partial weightbearing with crutches.
Analgesics and NSAIDs.
Physiotherapy later.
25
Dislocations
Clinical diagnosis is often possible
when seen early.
Reduce early under anaesthesia and
immobilize.
Analgesics and NSAIDs.
26
182
Conservative management of fractures
(17.1)
When necessary, manipulate the fracture early or
after oedema has subsided, under anaesthesia, and
apply cast
Fractures general principles. 2006
27
Protect the skin with cotton; include joints
proximal and distal to the fracture;
immobilize in position of function.
Here a back-slab
28
Here a circular cast
29
Always split a circular cast to
prevent limb compression and compartment syndrome
30
183
Special plaster casts
Walking cast
31
Complications of POP casts
• Compartment syndrom
• Deep vein thrombosis
• Fat embolism
• Skin problems
• Secondary
displacement
32
Skin problems
No tight casts, protect the skin with
enough cotton and keep the cast dry.
33
Secondary displacement under cast
Control X-Rays; gypsotomy correction is possible
•
Get a control X-Ray
after gypsotomy
•
Complete the cast if
the control is
satisfactory
•
New control X-Ray on
Day 8 and D 15
34
184
Compartment syndrom: caution!
Always elevate the limb
Don’t stretch circular plasters
Check movements, skin temperature after applying a
35
cast
Detect compartment syndrom
(leading to Volkman’s syndrom)
• Severe
pain is the first symptom.
• Neurological signs in fingers
and in the whole fore-arm.
• Vascular signs (oedema)
36
Prevent this!
Fixed deformity
• Flexed wrist
• Extended MP joints
• Flexed IPP
37
Treatment of compartment syndrome:
Remove the cast and all bandages immediately.
Urgent fasciotomy may be necessary.
38
Photo J. Chouteau
185
Tractions: different types
10% of body
weight
Trans-tibial pin (adults)
Skin traction (children)
39
Pin tractions
• Pin
insertion under LA or ketamine
just posterior to the upper tibial
tuberosity.
•Daily checks: pin site, position of limb,
isometric exercises and mobility of other
joints.
•Position: greater trochanter, midpatella and big toe must be aligned.
40
The 4 stages of fracture healing
• Tissue
destruction and haematoma
formation
• Inflammation and cellular proliferation
• Consolidation
• Remodelling
41
Clinical guide to union and
consolidation of fractures
• Union is incomplete repair: slight tenderness, the
bone moves in one piece, attempted angulation is
painful; it is not safe to subject the unprotected
bone to stress.
• Consolidation is complete repair: fracture site is
not tender, no movement can be obtained,
attempted angulation is painless; further protection
is unnecessary.
42
186
Duration of immobilization of common fractures in days
Bone
Adults
Children under 10 years
Clavicle
21
21
Neck of humerus
15
15
Shaft of humerus
60
60
Supracondylar elbow
45
45
Radius and ulna
90
45
Distal radius
45
30
Scaphoid
45
45
Metacarpals
30
21
Phalanx
30
21
Neck of femur
90
60
Shaft of femur
90
60
Tibia and fibula
90
60
Ankle
60
60
Metatarsals
15
15
187
43
Complications of fractures
(18.8)
44
General complications
Hypovolaemic shock (femur fracture,
polytrauma)
Infection, gas gangrene (wide
debridement, crystalline penicillin)
Tetanus (prevent by wound toilet and
tetanus toxoid for any wound, even
minor).
Deep vein thrombosis.
Fat embolism
45
Deep vein thrombosis
Due to bed rest, hypotension, lack of mobility,
trauma.
Calf pain on dorsal flexion of the foot; slightly
raise temperature; limb swelling; groin pain in
caseof pelvic DVT.
Life-threatening complication: pulmonary
embolism: tachycardia, low BP,polypnoea,
chest pain.
Prevent by early mobilization and physiotherapy.
Treat by aspirin.
Late complications: chronic limb swelling, skin
problems.
46
Fat embolism
Rare but serious.
Shock, mental confusion, spots on the skin (petechies),
fundoscopic examination.
Supportive treatment with oxygen.
47
188
Local complications
Vascular injury
Compartment syndrom (see other lecture)
Bone infection
Skin necrosis: blisters, necrosis, plaster
pressure sores.
48
Vascular injury
Always examine distal pulses.
Reduce displaced fractures and
dislocations early!
49
Bone infection (open fractures)
Acute osteomyelitis
Prevention by wound toilet.
Treat agressively !
May lead to chronic infection,
even more difficult to treat
50
Skin complications: blisters, necrosis, plaster sores
When the skin is necrosed, the bone becomes exposed,
51
with risk of infection.
189
Late complications
Avascular necrosis (compromised blood
supply, neck of femur fractures)
Delayed union, non-union
Malunion
Nerve compression and entrapment
Joint instability, stiffness, osteoarthritis
52
Delayed union; non-union
Pain on walking
Local signs of inflammation: tenderness.
Pain and movement on mobilizing the limb.
Fracture line still visible on X-rays, very little
callus formation.
• Delayed union: continue with conservative
management.
• Refer nonunion for possible surgery.
•
•
•
•
53
Nonunion: atrophic (left),
hypertrophic (right)
54
Malunion
Malunion of distal right tibia
190
55
Regional orthopaedics
Upper extremity injuries: shoulder, arm,
elbow, fore-arm, wrist
(18.1)
1
Clavicular fracture
Tenderness with or without abnormal
mobility
X-Ray confirmation not compulsory
Triangular bandage or sling
for 5-6 weeks; no surgery.
2
Fall on outstretched
hand; the patient cannot touch his chest;
typical deformity, easy diagnosis:
humeral head anterior, prominent
acromion, glenoid cavity feels empty,
arm abducted and externally rotated.
3
Anterior shoulder dislocation
The humeral head is not in front of the scapula but in the
antero-lower position
X-Ray may show a fracture of the greater tuberosity or
head of humerus (arrow).
191
4
Early complications of shoulder dislocation
Axillary nerve palsy (sensory loss at the shoulder)
- Brachial plexus injury.
5
Treatment of dislocated shoulder
Urgent manipulation
Traction on the arm with or
without anaesthesia if
recent, with counterpressure in the axilla.
Collar and cuff for 3 weeks;
avoid external rotation.
6
When not displaced, keep in a bandage in
neutral position (no rotation)
7
Fracture of the glenoid cavity of the scapula
(here with humerus dislocation)
8
192
9
Extracapsular shoulder fractures
Fractures of neck of humerus
Greater tuberosity fracture
10
Articular shoulder fractures
Non-displaced
displaced
very displaced
fracture +
dislocation
11
Conservative treatment of shoulder fractures
Manipulation under anaesthesia and stabilisation
!"!#$
Sling or bandage for 6-8 weeks
The major complication is shoulder stiffness.
12
193
Humerus shaft fractures
.
13
Humeral shaft fracture
Look for radial nerve injury +++
(sensation, wrist drop)
Keep the patient’s arm in a sling
for 6 - 8 weeks.
The weight of the fore-arm will reduce
the fracture.
14
Fractures of the distal humerus
Metaphysis fractures
Lateral condyle fractures
Articular fractures
15
Medial condyle fractures
Treatment of olecranon fractures
Non-displaced fractures: splint the
elbow at 90 degrees flexion.
Displaced fractures: splint the elbow
in extension.
16
194
Elbow posterolateral dislocation
Fall on outstretched
hand.
Inability to move the
elbow.
Prominent olecranon
posteriorly.
17
Elbow dislocation
Complications:
Brachial artery compresion
Ischaemia
Radial or ulnar nerve compression
Check sensation, motion.
Associated fractures: coronoid, medial
epicondyle, lateral epicondyle.
18
Elbow dislocation
Manipulation under anaesthesia, elbow
flexed 90°, posterior counter-traction
on arm,
anterior traction on forearm
POP 21 days + physiotherapy.
19
195
Fore-arm fractures
in adults
Always complete, most of
the time, radius and ulna
are broken.
When only one bone is
broken, look for a
dislocation of the
extremity of the other
bone
- isolated fracture of ulna
Æ possibility of
dislocation of the radial
head.
- Isolated fracture of
radius Æ watch for
dislocation of distal
radio-ulnar joint
20
Incomplete radius and ulna fracture
Plaster cast for 2 months
21
Displaced fracture of radius and ulna: traction,
disimpaction, angulation and recovery of initial length
with good bone contact.
22
Complications of radius and ulna fractures
- Open fractures
- Non-reducible fracture
- Compartment syndrom
- Non-union
- Secondary displacement.
23
196
Colles’ fracture
• Elderly, fall on the extended wrist
• Compression + significant extension
• Fracture of distal radius 2.5 cm above the
joint; typical deformity.
24
Non-displaced Colles’ fractures: cast 6 weeks.
Displaced fractures: manipulation under anaesthesia
25
Position of the wrist joint after reduction
of Colles’ fracture
• Flexion + ulnar deviation
• Control X-Ray
• Plaster cast for 6 weeks.
26
Main complication of Colles’ fracture:
malunion
27
197
Traumatology and
orthopaedics
The hand
(18.2)
28
Sensory areas of the wrist and the hand
Palmar aspect
Dorsal aspect
Radial nerve (green), median nerve (red), ulnar nerve
(purple), medial cutaneus brachialis nerve (brown),
musculocutaneous nerve (yellow).
29
Scaphoid fractures
Often minimally displaced
Plaster cast immobilizing
the thumb 2 months
30
Carpal dislocation (lunate); risk of necrosis
31
198
Benett’s fracture-dislocation
Proximal fracture of 1st metacarpal bone, extends into the
joint, unstable; conservative treatment with the thumb in
abduction for 6 weeks
32
Carpo-metacarpal dislocation: urgent reduction
and plaster cast for 6 weeks.
33
Documents J. Chouteau
Examples of phalangeal fractures
The 1st phalanx is often displaced in extension (left):
reduce it in flexion;
oblique proximal phalangeal fracture (right)
34
Malunion of fractures may cause
deformity and disability
35
199
Management of open hand injuries
Clinical examination:
- Sensation of each finger
- Motion of each phalanx.
- When in doubt, surgical exploration in OR under LA
or GA.
If a joint is open, wound toilet under anaesthesia
. Tendons may be difficult to identify in large palmar
wound with many tendons injured Æ thorough
exploration of the wound.
. Flexor tendons often retract Æ large incisions are
necessary to find the proximal end of the tendon(s).
. Splint wrist and fingers in correct position to relax
sutures of tendons ‘position of safety of the hand’.
36
Flexor tendon sheaths
37
Tendon avulsions
Direct suture
Pull out procedure
38
Complications of hand trauma
• Osteomyelitis
• Arthritis
• Tendon sheath
infection (may spread
to the whole hand)
39
200
Traumatology and orthopaedics
Injuries of the lower extremity
(18.4)
40
Dislocation of the hip
Pain and limb shortening; typical position:
anterior dislocation (left), posterior dislocation (right)
41
Dislocation of the hip
Anterior dislocation
(left) posterior dislocation (right)
Possible complications of posterior dislocations:
Iliac bone fracture; partial fracture of femoral head; posterior
circumflex artery injury (risk of femoral head avascular necrosis);
sciatic nerve injury.
42
Manipulation for dislocated hip
• Under GA or spinal anaesthesia.
• Place the patient on the floor.
• Pull on the flexed thigh, an assistant maintaining
the patient on the floor.
43
201
Femoral neck fractures
• Common in elderly people after simple fall.
• The blood supply to the femoral head may be disrupted, leading to
avascular necrosis.
• Clinically there is hip pain, inability to bear weight.
• Usually, but not always, shortness and external rotation.
X-Ray confirmation and fracture type:
– Intracapsular
– Intertrochanteric (extracapsular)
– Subtrochanteric (extracapsular)
Management:
• Non-displaced or impacted fractures: bed-rest or early ambulation
if possible.
• Displaced fractures, when internal fixation is not available,
traction for 2 months by femoral or tibia pin with 10% of patient’s
body weight.
44
Femoral shaft fractures
Major trauma, often with associated injuries.
Blood loss within the limb 1-2 litres; risk of haemorrhagic
shock.
Treat by trans-tibial traction.
Trans-tibial pin
Trans-femoral pin
1/7 of body
weight
Skin traction (children)
45
Distal femoral fractures
•
•
•
•
Condylar, supra-condylar.
Reduce early when displaced.
Aspirate the joint.
Traction for 2 months.
Patellar fractures
• Often very displaced because of the quadriceps muscle traction on the
proximal part of the bone.
• Involves the joint and requires perfect reduction
• When the quadriceps mechanism is intact, the patient can extend his
knee: plaster cast with knee in full extension for 45 days, weight
bearing possible.
• When the quadriceps mechanism is not intact: refer for surgical
repair; if not possible, cast 4-6 weeks. Weight bearing possible.
46
Patella fracture
Pins and metal wiring
202
47
Knee ligament injuries: management
Minor injuries
- Short term immobilisation, pain killers, early rehabilitation
Major injuries
- Plaster cast for 45 days with knee
20° flexed and without weight bearing
- The lateral, medial and sometimes PCL
heal
- The anterior cruciate never heals
spontaneously: rehabilitation
or surgery
(young and active people)
- Rehabilitation is essential.
48
Knee dislocation
Posterior,
Posterior, anterior,
anterior, medial or lateral
All the ligaments are ruptured.
ruptured.
Major vascular risk to popliteal vessels:
vessels: always check pulses
before and after reduction
Reduction is URGENT
49
Patellar dislocation
Trauma in valgus-flexion-lateral rotation
Lateral dislocation; partial fractures may be associated.
Reduce without anaesthesia when seen
early. Aspirate the knee.
Immobilisation in extension in a plaster cast for 45 days
Weight bearing possible; rehabilitation
Recurrence and chronic instability are possible.
50
Muscle trauma
Contusions, stretches, ruptures.
• Partial rupture: sudden pain, patient can walk, recovery in 4-6
weeks
• Complete rupture: quadriceps is the most common.
• Complete rupture requires surgical repair.
51
203
Tibiofibular fractures
When tibia and fibula are fractured, they are
usually displaced (here transverse fracture).
.
•
52
Check the skin carefully (commonly breached) and distal
pulses for vascular complications.
Closed reduction and long leg plaster cast for 3 months,
knee 20° flexed, ankle 90° dorsiflexed.
•
53
Wedge tibia fracture (left); left spiral fracture (right)
Control X-Rays are normally immediately and on a regular basis.
No weight bearing for 45 days.
54
Upper tibia metaphysis fracture direct
trauma; common
soft tissue injury to skin, muscle, vessels, nerves. Calcaneus traction is
an option.
Consolidation takes 3 months.
Convert cast to short leg
after 2 months.
55
204
Ankle sprains and dislocation
Minor sprain Æ little stretch of ligament without instability
Major sprain Æ rupture of ligament(s) with instability
The most common ankle sprain is the lateral type.
Trauma in varus with immediate severe pain
and large lateral swelling.
Management:
Minor sprains Æ strapping for 3 weeks
Major sprain Æ Plaster cast for 1 month
In major injuries Æ suture of ligaments
Importance of rehabilitation to prevent
recurrence
Usually good outcome
Ankle ligaments
56
Ankle dislocations
Severe trauma.
Medial, posterior, anterior, lateral displacement.
Skin problems, tendon,
blood vessels and nerve
injuries are common.
Urgent reduction
+/- suture of ligaments
Plaster cast 6 weeks.
Outcome may be poor.
Here medial dislocation
57
Articular ankle fractures
• Isolated fractures of distal fibula (stable): walking cast for
3 weeks.
• Non displaced fractures: plaster cast with the ankle at 90° of
dorsal flexion for 45 days. No weight bearing. Immediate control
X-Ray, then after 15 days, 1 month and after cast removal.
• Displaced fractures of medial and lateral malleolus
(unstable): early closed reduction under anaesthesia and plaster
cast in the same position and for the same duration. 6 weeks non
weight bearing.
58
Calcaneus
Calcaneus fracture
fracture
Major foot swelling.
Wait for swelling to subside.
Then plaster cast 2 months with a
window under the heel.
Early weightbearing on the
forefoot.
59
205
Talus fracture (right)
Partial or complete
fracture; joint often
involved.
Reduction and plaster
cast 45 days without
weightbearing, X-Ray
control every 15 days.
Metatarsal fractures:
Plaster cast for one
month without weight
bearing.
60
Rupture of Achille’s tendon
Often sport trauma; partial or
complete rupture. Inability to plantar
flex; visible gap.Conservative
treatment for high rupture. Surgery
when seen after 8 days, in lower
ruptures or in sportsmen. Surgical
suture and plaster cast for 6 weeks,
including 3 weeks in equinus.
61
206
Traumatology and orthopaedics
Fractures of the pelvis (Chapter 18.3)
ABC Trauma Survey.
Look for signs of shock (not uncommon), scrotal haematoma, blood in urine or at the urethral
meatus (below), blood in the rectum.
An AP X-Ray view of the pelvis is usually sufficient. Check:
•
•
•
•
Disruption of the ring
Sacro-iliac joints
Shenton’s line (here broken)
Sacral fractures
Ask for further views if indicated.
207
Fractures without disruption of the pelvic ring (Shenton’s line)
Avulsions
Often sports injuries, may involve the anterosuperior iliac spine, the antero-inferior
iliac spine, or the ischial tuberosity. Most avulsions can be treated conservatively by rest and
analgesics and heal within 3 months.
Iliac bone fractures
Usually resulting from a direct compressive force. Muscle attachments minimize the
displacement and bleeding.
Treat by bed rest until the patient is comfortable enough to be mobilised. Gradual
protected weightbearing.
Pubic and ischial rami fractures
Fracture of a single ramus is uncommon, usually both rami are broken following a fall,
often in the elderly.
X-ray is important to exclude an impacted fracture of the femoral neck.
Rest and progressive mobilization and weightbearing.
Coccyx fractures
Usually caused by direct blow. Symptomatic management.
Sacrum fractures
Usually direct trauma.
Neurological complications may occur (with urinary retention).
If the rectum is breached, there is a serious risk of contamination of the retroperitoneal
space and fracture site (it is an opened fracture).
Conservative treatment (bed rest).
208
Fractures with disruption of the pelvic ring
Fractures of the 4 pubic rami
Anteroposterior compression fractures (a)
Lateral compression injuries (b)
Vertical fractures (c)
‘Open book’ fractures’ (c)may be immobilized by a bed-sheet passed round the back and
closed with a safety-pin
Fracture of the acetabulum
Usually in young people after violent trauma (not just a fall). Acetabular injuries range from
simple avulsion of the periphery of the acetabulum to burst of the hip socket with fractures of
the anterior and posterior columns.
The femoral head is usually dislocated. After reduction, there is often poor fit between the
femoral head and the acetabulum.
Conservative treatment.
209
Complications of pelvic fractures
Vascular
The chief causes of death in pelvic fractures, especially severe ones.
Tear of pelvic vein may cause haemorrhagic shock. Patients may require blood transfusions.
Urinary tract complications
Intraperitoneal bladder rupture:
Trauma on a full bladder.
Urine not passed.
Lower abdominal pain, then rigidity due to peritonitis.
Blood and no urine on catheterization.
Open the lower abdomen and repair the bladder in 2 layers of chromic catgut; keep Foley
catheter for 10 days.
In extra-peritoneal bladder rupture, drainage of the bladder will allow the laceration to
heal.
Urethral injury:
Retention of urine.
Perineal pain.
Blood at the urethral meatus
Scrotal haematoma.
A high riding or ‘floating’ prostate on PR examination.
No urethral catheter! Insert a suprapubic catheter to divert the urine for 6 weeks. This may
be difficult in case of large pelvic haematoma. Later, refer to a urologist for repair of the
urethra.
Rectal injury
Some require a defunctioning colostomy.
Key points
Pelvic fractures may cause haemorrhagic shock.
No urethral catheter if there blood at the urethral meatus, scrotal haematoma,
or obvious pelvic fracture, insert a suprapubic catheter.
Most pelvic fractures can be managed by bed rest and/or traction.
210
Traumatology and orthopaedics
Spine injuries (Chapter 18.5)
ABC of trauma
‘Primum non nocere’: first do not harm.
The management of spinal injuries in your circumstances aims at:
1: Not making things worse by unskilled manipulation or movements.
Immobilize the injured part until a fracture has been ruled out.
2- Prevent complications and promote recovery of patients with incomplete spinal cord
injuries.
3- Prevent complications and promote rehabilitation of patients with complete spinal cord
injuries.
211
Neurological assessment
Sensory examination (see dermatomes diagram)
Sharp-dull discrimination is examined and marked with a skin marker from the
anaesthetic areas to the areas where sensation is maintained. The level of dermatome
sensation still present suggests the level of possible spinal cord injury.
Motor impairment
Grading
Grade 0: No contraction
1: slight contraction, no motion
2: Complete range of motion with gravity removed
3: “ “
“
“
against gravity with some resistance applied.
4: Normal or nearly normal
Muscles involved
- Above C4: Respiratory muscles paralysis. No survival in usual conditions.
- Under C5: Abduction of shoulders, flexion of elbows are present
C6: Extension of wrist and thumb
C7: Flexion of wrist, extension of fingers
C8: flexion of fingers
T1: Interossei muscles
L3: Adduction of thighs
L4: Extension of the knee; dorsiflexion of the ankle
L5: Active extension of the great toe
S1: Plantar flexion of the ankle.
Rectal examination: (sacral roots); an intact rectal tone suggests that spinal cord injury is
only partial with a much better chance of neurological recovery. An absent voluntary
rectal tone, after spinal cord shock has resolved, or priapism, indicates a complete cord
injury with no chance of recovery distal to the cord lesion.
Spinal shock
It is the absence of all spinal reflex activity below the level of cord injury that usually
persists for 24 hours after injury.
212
X-Rays
Lateral view, A.P. View, oblique and special views.
Denis’ 3-column concept of spinal stability
When 2 out of the 3 columns are disrupted, the spine is considered unstable.
213
214
Cervical spine injuries
The exact mechanism of the injury gives information about the resulting fracture.
Common causes of cervical spine injury are driving without seat belts, falls from height,
penetrating injuries.
Radiographic examination of the cervical spine
Cervical spine
What to check on X-Rays :
•
•
•
•
•
•
•
C1 to T1 must be seen
Alignment - trace out 4 lines
Pre-vertebral soft-tissue shadow
Atlanto-dens interval =3mm
Open-mouth view for C1 &C2 fractures
AP view for facet dislocations
Swimmer view may be helpful
Subluxation and ligament instability of the cervical spine
If the fracture fragments or the spine segments are likely to get displaced before healing
occurs, the fracture is said unstable. A fracture which is acutely unstable at the time of the
injury may become stable, three months later, after bone healing.
Burst fractures
Odontoid fractures (3 types); immobilize by halo brace, plaster cast or traction.
Locked facet dislocation: dislocation of the facets joints may be unilateral or bilateral.
Reduce by cervical tong traction. A cervical collar may be sufficient for
immobilization.
215
Fractures of the thoracolumbar spine
In elderly people with osteoporosis, compression fractures (b) are common and stable.
Fractures with compression of the anterior part of the vertebra limited to 50 % are stable.
Treatment is symptomatic.
If the height of the anterior vertebral body is reduced by more than 50 % (d), the fracture is
unstable and may require more intensive treatment.
Burst fractures (a) are also unstable.
Fracture dislocations (c) are common in this region. It is a crucial area for stability and
surgery may be necessary.
Thoracic & lumbar spine
What to look for
•
•
•
•
•
Loss of Vertebral body height
Displacement of posterior body
Angulation of spinous processes
On AP films look for : Widening of interpedicular distance
CT is best for upper thoracic spine
Here: loss of vertebral height
216
Indications for referral
- In theory, unstable fractures with incomplete spinal cord injuries (nothing can be done
for complete spinal cord injuries) require surgery, but transport may make matters worse.
- A neurologically normal patient with a fracture able to heal by immobilization must be
treated conservatively.
Nursing, bedsore prevention, urinary rehabilitation, neurological assessment are essential
in all cases.
Natural history of lower limbs paralysis
Compression of the spinal cord will give first a flaccid paralysis and then a spastic one;
spastic palsy allows walking with crutches and equipment.
Roots compression results in a flaccid permanent palsy. Walking is impossible if the spinal
lesion is bilateral and complete.
Urinary and rectal paralysis needs special rehabilitation and care.
217
218
Peripheral nerve injuries
Clinical test for peripheral nerve injuries:
Axillary nerve injury
Cannot abduct the shoulder (deltoid weakness), small sensory loss
Testing for median nerve injury
(a) Ask patient to clench the fist: index is pointing
(b) Wasting of opponens of thumb
(c) Sensory loss
Testing for radial nerve injury
219
(b) Inability to extend the wrist: drop wrist
(c) inability to extend the fingers at the knucke joints
(d) wasting of extensor muscles
(e) sensory loss
Testing for ulnar nerve injury
Motor: weakness of abductor pollicis compensated by flexor pollicis longus
Sensory loss.
Testing for sciatic nerve injury
220
(b): inability to dorsiflex the ankle joint: foot drop
Sensory loss in:
(c): complete sciatic nerve injury; (d) lateral popliteal nerve; (e) tibial nerve; (f) deep peroneal
nerve
Femoral nerve:
Quadriceps action is lacking.
Sensory loss anterior thigh.
221
222
223
Traumatology and orthopaedics
Congenital and developmental
problems: club-foot (19.1)
1
• The normal foot at birth is often in talus
• Malformation (fixed deformity) is different
from malposition (reducible deformity)
• Check where is the deformity, whether it is
reducible or not, what is the participation of the
hind foot ?
• Full examination (neurological +++)
• Are there other deformities (toes +++)
• Family history of malformations or diseases.
2
Movements of the ankle and foot joints
Pronation (left), supination (centre), dorsal flexion (right)
3
Congenital talipes equinovarus (CTEV)
‘club-foot’
• It is a fixed deformity of the whole foot with abnormal
bones (talus and calcaneus +++).
• 1 / 1000 births.
• There are club foot families (genetic factors? ).
• Commonly associated deformities: hip and spine.
4
224
Deformity
5
Clinical diagnosis:
Fore-foot is in supination and equinus;
heel in varus; sole turned medially.
The medial edge of the sole is hollow, its
lateral edge convex.
There is retraction of the joint capsules,
ligaments and muscles
(tibialis posterior, flexor digitorum,
gastrocnemius).
6
Urgent management at birth:
Physiotherapy twice a day with manipulations, stimulations and plaster splints
between sessions OR corrective plaster casts changed every week to correct
varus, adduction and supination.
Equinus will be corrected last.
If this method fails, surgery at the age of one year.
Whatever the method, physiotherapy must continue until 3 years with plaster
splints at night and proper shoe-ware.
7
8
225
Good result of conservative treatment (70%)
9
Results:
- 30% will need surgery at the age of 1 year.
- Even with good treatment recurrences do
happen.
- Possible complications:
. Fixed bone deformity
. Short foot
. Walking difficulties.
LONG FOLLOW UP
is needed
10
Late complications
11
12
226
Infection of bones and joints
(19.3)
13
Acute osteomyelitis
Epidemiology
It may be blood-borne, spread from a nearby
infection (tooth,urinary tract,skin,chest), or
may start in an open fracture.
It is more common in children and in long bone
metaphysis (femur, tibia, humerus).
The knee is the most common site.
Staphylococcus aureus is the most common
germ (60%)
14
Acute bloodblood-borne osteomyelitis
CHILD
ADULT
Knee, Hip, Shoulder
Femur, Spine, Foot
15
Symptoms
History of a recent infection in another site
High grade fever: 39° - 40°, chills
Severe, localized pain (knee ++)
Soft tissue swelling
The area feels warm to touch.
16
227
X - Ray
Early signs are minimal: swelling of
soft tissues.
After a few days: lysis in the
metaphyseal region: periosteal elevation
with new bone formation.
After a couple of weeks: sequestrum
formation.
17
X - Ray after a few days
Don’t wait for this!
18
Treatment
The only hope of cure is an emergency
treatment +++
Debridement of contaminated bone
Two IV antibiotics for 6 weeks
Then one antibiotic PO for 6 months
If possible, regular X-Ray controls
(every month)
High risk of recurrence
19
Case N°1
15-year old male
Acute osteomyelitis
following an open finger
fracture
Bone sclerosis and
periosteal elevation
20
228
Case N°2
Acute osteomyelitis of distal femur
Good progress with surgical treatment
and appropriate antibiotics.
But recurrence is common.
21
Case N°3
Acute osteomyelitis of radius
Good progress after agressive surgical treatment
22
Complications of acute osteomyelitis
General complications
Septicaemia
Spread to other sites: heart, lung,
brain, liver.
23
Complications of acute osteomyelitis
Local complications
Diffusion to the bone shaft
Acute arthritis: partial, then
complete joint destruction
Chronic osteomyelitis.
24
229
Case
N°1
Chronic
osteomyelitis
Symptoms
After a long history of osteomyelitis.
22-year old
male
Infection from bone to skin:
Partial,
a sinus forms through the skin with
then
total joint
spontaneous pus discharge
destruction
or after pressure around the area.
29
25
Case N°2
17-year old
male
Pain, fever,
hot arm,
swelling after
sport
Day 15
Case N°3
Spine osteomyelitis
27
Complete destruction of the disc, partial bone destruction
230
Day 20:
Shaft diffusion
Day 45:
Sequestrum and
recurvatum
26
Chronic osteomyelitis : Clinical aspect
Chronic sinus
Pus
Skin
inflammation
30
Chronic osteomyelitis: radiological aspect
Periosteal
destruction
Sequestrum
31
Chronic osteomyelitis: treatment
Antibiotics cannot reach the bone in a
sufficient concentration.
Repeated debridement : removal of necrotic
bone, foreign bodies, necrotic soft tissue.
The best indication is presence of a
sequestrum for sequestrectomy.
Time consuming and expensive:
therefore transfer
If transfer is not possible, amputation is
sometimes necessary after a long hsitory.
231
32
232
Acute pyogenic arthritis
33
Acute pyogenic arthritis
Epidemiology
Often blood-borne infection.
More common in children < 3 yrs old.
More common in hip and knee.
The risk is major joint cartigage
Damage.
34
Acute pyogenic arthritis
Symptoms
Fever, chills
Search for a portal of entry
Pain +++: walking is difficult or impossible
Every movement of the joint is difficult.
Swelling of the joint and warm skin on
palpation.
35
Acute pyogenic arthritis
X-Ray
Initially normal
Sometimes shows enlarged
joint space because of joint
abscess
36
233
Acute pyogenic arthritis
Treatment
Urgent +++.
Start immediately IV antibiotics.
In the OR, within 12 hours,
under full aseptic conditions :
Joint aspiration for pus.
Irrigation of the large joints (hip, knee)
Immobilize the joint by cast or traction.
37
Acute pyogenic arthritis
Complications
Destruction of the joint
arthritis
early osteo-
Joint fusion
Shortening
walking difficulties
38
Acute pyogenic arthritis
Complications : Case N°1
• Female, 2 Yrs
• Early treatment
Sinuses
Osteomyelitis
39
Acute pyogenic arthritis
Complications: late cases
Case N°2:
femoral head
necrosis
234
Case N°3: dislocation of
the hip
40
RESUSCITATION AND ANAESTHESIA
235
Resuscitation and anaesthesia
Shock and resuscitation of critically ill patients (Chapter 13.1)
1- Definition
Shock is a failure of the cardiovascular system to meet the demands of the body, causing
hypoperfusion of the tissues.
2- Symptoms and signs of shock
In established shock, the patient is pale, cold, thirsty, cyanosed, sweating, anxious,
hyperventilating with a low blood pressure, a rapid and feeble pulse and low urine output.
For treatment to be effective, shock must be recognized early when not all those signs and
symptoms are present. In particular, the fall in blood pressure occurs late, after at least one litre of
blood or plasma has been lost. A rising pulse rate is an earlier and more reliable sign.
3- Shock management
The treatment will be more efficient if done by several people: call for help.
Refer to the ‘ABCDE’ assessment of acute trauma (‘Trauma module’).
Monitor the patient's response
If he is not responding to fluid replacement, suspect a missed injury. Re-examine him.
When to abandon unsuccessful resuscitation?
After 15 minutes of unsuccessful CPR or after 15 minutes of fixed dilated pupils, you can
stop the resuscitation.
236
Identify the cause of shock
The patient having been resuscitated, you can now look for the cause of the shock if this
was not obvious from the start. This requires clinical examination, especially in cases of trauma
where the obvious injury (head injury or peripheral injury) may not be the cause of the shock.
Head injuries in particular do not cause shock.
Hypovolaemia
It is the most common cause of shock in surgical patients. It includes:
- Haemorrhagic shock in which the bleeding can be:
- external and obvious (femoral artery injury, heavy PV bleeding);
- or internal and hidden (ruptured ectopic pregnancy, ruptured spleen, etc...).
Estimating blood loss (see diagram).
- Dehydration (loss of extracellular fluid) e.g. vomiting and accumulation of intestinal
fluid in cases of intestinal obstruction.
- Severe burns (loss of plasma).
Other causes of shock:
- Neurogenic shock and vasovagal attack. One example is cases of abortions with
placenta stuck in the cervix or curettage performed without anaesthesia, because of a response to
cervix stimulation.
- Septic shock (often hyperdynamic with warm extremities) is difficult to diagnose and
manage. Give fluids, IV antibiotics and treat the cause (e.g. peritonitis, septic abortion).
- Anaphylactic shock.
- Cardiogenic shock: myocardial contusion or cardiac tamponade (rare).
Once the cause has been identified, initiate the specific management of the cause, e.g.
urgent laparotomy.However the patient must be in a reasonably stable condition before
anaesthesia is given, otherwise this will decompensate the condition further because he is only
maintaining his blood pressure by severe vasoconstriction.
237
Complications of shock
They are due to prolonged ischaemia of vital organs.
Acute renal failure due to prolonged hypovolaemia and kidney ischaemia.
Adult respiratory distress syndrom (ARDS), often fatal even with the best critical care
provided in sophisticated hospitals.
Hepatic failure.
Brain damage due to prolonged hypoxia.
Disseminated intravascular coagulation (DIC).
Myocardial infarction.
Intestinal infarction.
Key points
Identify shock early and treat it energetically.
Care for the airway, ventilation and circulation in that order.
Monitor the patient's response and reassess frequently.
Look for the cause, do a head to toe examination in case of trauma.
Don't operate on a shocked patient without resuscitation.
238
Resuscitation and anaesthesia
Blood Transfusion (Chapter 13.2)
General principles
Blood transfusion is a life-saving procedure in surgical patients when properly indicated;
however, strict safety procedures must be followed to avoid fatal complications.
Blood has usually been donated by a related or unrelated blood donor. Under current
conditions, the absolute safety of this blood cannot be guaranteed and indications for blood
transfusion must be kept to the strict minimum.
Indications/contraindications
Because of the multiple complications including transmission of HIV, the risk of which
cannot be completely eliminated, blood transfusion is indicated only for saving the life of the
patient, i.e. a patient in haemorrhagic shock who cannot be resuscitated by blood substitutes.
A blood transfusion that is not absolutely indicated is absolutely contraindicated.
This includes chronic anaemia which is well tolerated, even at very low rates of
haemoglobin or haematocrit and acute haemorrhage within certain limits. For example a fit adult,
such as a mother having a caesarean section, can tolerate a blood loss of up to 1 litre or even a
litre and a half, before you need to give her blood.
But when an adult needs blood, he needs at least two units. The transfusion of a single
unit is useless.
On the other hand children can easily bleed to death during relatively minor operations or
injuries because of their smaller circulating volume.
Laboratory results (haemoglobin rate, haematocrit) are never a justification for blood
transfusion as it is the clinical state of the patient that must justify the indication.
239
Complications
Transmission of HIV
This has become a major problem because of the high prevalence of HIV in the general
population and therefore in the blood donors, the fact that there is no cure and that the disease is
always fatal.
To keep the risk of transmission to the minimum all blood donors, however urgent the
case, must be screened by one of the quick tests available. However, tests have a variable
sensitivity and may also give some false negatives. There is a 'window' of about 3 months after
contamination by the virus during which a person is infected and can transmit the virus but will
test negative.
Therefore tested blood is never absolutely safe and for more protection of recipients the
indications of transfusion must be kept to the minimum.
Transmission of hepatitis (B and C) and other diseases such as syphilis, malaria,
cytomegalovirus, bacteria.
Transfusion reactions
Major transfusion reactions
They cause haemolysis, are potentially fatal and are usually due to incompatibility in the
ABO system; they are the result of a mistake, either in the grouping of the donor or recipient, the
labelling of the blood unit, or the control of the blood before transfusion. They are therefore
avoidable. They occur early in the course of the transfusion with feeling of unease, headache,
lumbar pain followed by a state of shock with rigors. In a patient under anaesthesia the first
symptoms will be absent and there will be an otherwise unexplained state of shock.If the patient
survives, later there will be oliguria, dark urine followed by jaundice.
Minor transfusion reactions
They are due to incompatibility in other blood group systems which are not checked in
basic laboratories, or to high agglutinins titre in the donated blood. Fortunately, they are seldom
fatal.
Febrile allergic reactions
They are due to the presence of pyrogenic substances in the blood.
Circulatory overload
It is a hazard especially in children, elderly patients or patients with heart failure. Causes
acute heart failure with pulmonary oedema.
Clotting problems
This happens with massive transfusions of stored blood which is deficient in unstable
clotting factors and platelets.
Other complications
Hypothermia, when large amounts of cold blood are transfused, hyperkalaemia.
240
Alternatives to transfusion of donated blood
-Plasma expanders (Haemacel, Gelafundin, Gelafusin, Dextran)
These are solutions of macromolecules (colloids) which remain in the intravascular
compartment of the body; they are expensive and no longer recommended in shock.
-Emergency autotransfusion
In this method, blood for the peritoneal cavity is collected and immediately transfused to the
patient.
Indications: ruptured ectopic pregnancy; rupture of the spleen or the liver.
Contraindications: when the blood is obviously infected (offensive smell) ; chronic
ectopic pregnancy ; splenic rupture by open trauma or with concomitant gut injury.
Equipment (to keep ready in theatre in case of emergency): a few blood collecting bags,
already containing citrate (anticoagulant); a metallic funnel that can be bought in a shop and
sterilized; a medium-size sterilized gallipot.
Procedure
As soon as the abdomen is opened collect escaping blood in the gallipot. Pour it through a
filter made of 2 or 3 thicknesses of gauze placed over the funnel, and collect it in a blood tacking
set. Then pass it to the anaesthetist for immediate transfusion. You can collect a few blood units
in this way and save the need for transfusion of donated blood.
Advantages: The patient can be transfused immediately. You are giving the patient's own
blood, so there is no problem of compatibility or transmission of diseases.
Key points
Absolute safety of donated blood cannot be guaranteed.
Blood transfusion has numerous complications.
If a blood transfusion is not absolutely indicated, it is absolutely contraindicated.
Only the clinical state of the patient is an indication.
To an adult give two units or none.
Use alternatives to transfusion of donated blood.
241
242
Resuscitation and anaesthesia
Fluids and electrolytes (Chapter 13.3)
Causes of dehydration in the surgical patient:
- Vomiting (acute abdomens, intestinal obstructions, peritonitis).
- Accumulation of fluids in the bowel (intestinal obstruction or ileus) or in the peritoneal
cavity (peritonitis).
- High fever.
- Uncompensated losses through drains, stomas or fistulae.
Assessing the severity of dehydration
If you operate on a dehydrated patient before correcting at least part of the deficit, there is
a real risk of death on the table or soon after the operation. Always assess the state of hydration
before taking a patient to theatre.
- Mild dehydration (5% of the body weight)
These are patients whose history indicates that they must be dehydrated but who do not
yet show any signs of it, e.g. patients who have had no fluids for 24 hours, or have been
vomiting.
- Moderate dehydration (8% of the body weight).
Clinically these patients have a dry mouth, sunken eyes, moderate reduction of their skin
elasticity. An infant may have a depressed fontanella.
- Severe dehydration (10% or more of the body weight)
They have a very dry mouth, severely sunken eyes, and greatly reduced skin elasticity. An
adult may be confused and a child delirious, comatose or shocked. The hands are cold and the
blood pressure is low.
Intravenous access
Peripheral vein cannulation
If the patient is in poor condition, undergoing a major operation or likely to require IV
fluids or IV antibiotics for a few days, you need to have a secure reliable IV access (with an IV
cannula) for both the anaesthesia and the postoperative period.
Especially if the patient is shocked or requires IV fluids at a high rate, choose the biggest
cannula you can find and secure it well. Critical patients may require 2 IV lines which offer
more security in case one of them is pulled out or gets tissued.
You can also use:
- External jugular vein cannulation;
- Central vein cannulation;
- Cutdown.
243
Correction of dehydration
Amount of fluid required
This depends on the severity of the dehydration estimated as above, and the patient's body
weight. Weigh the patient if you can, otherwise estimate his weight. This is particularly important
in children who can easily be under or over hydrated. See chart.
Example for a 60 kgs patient:
-Mild dehydration (5%): 3 litres deficit.
-Moderate dehydration (8%): 4.8 litres deficit.
-Severe dehydration (10% or more): 6 litres deficit.
Rate of correction
Severely dehydrated patients are often rehydrated too slowly. Correct dehydration
quickly: give half the fluid needs in the first hour and the other half in the next 4 hours.
Type of fluids required
A surgically dehydrated patient has lost more water than sodium and chloride. He will
also have lost potassium.
Give him the first half of the deficit as Ringer's lactate (or 0.9% saline) and the second
half as alternate bottles of Ringer's lactate (or saline) and 5% dextrose.
Add 10 mmol of KCl to each 500 mls of fluid after the first two.
Monitoring the response to IV fluid treatment
Monitor the pulse, blood pressure, skin turgor and urine output.
Insert a urinary catheter early and discard any urine present in the bladder at the time of
catheterization. Start recording the urine output from that time.
The pulse should decrease, the blood pressure increase, the skin turgor go back to normal,
and the urine output should be 1 ml/kg/h at least.
Only if you rehydrate them energetically like this, can you operate on surgically
dehydrated patients without risk within 4 hours of admission.
Intraoperative fluids requirements
Continue to correct any preoperative deficit not been completely corrected.
Patients undergoing laparotomy lose water all the time that their abdomen is open. Give
them 15 ml/kg of fluid during the first hour, 8 ml/kg/hour after that.
Compensate for fluid sucked during the operation (e.g. peritonitis) as measured in the
suction machine and for blood loss.
244
Fluid and electrolytes requirements in the postoperative period
You have to provide the normal requirements, replace any deficit that has not been
replaced before or during surgery and compensate any abnormal losses.
Basal requirements
Water: 35-40 mls/kg/24h ; for an adult 2500 mls/24 h ; in a hot climate 3000 mls.
Sodium: 1 mmol/kg/24h
Potassium: 1 mmol/kg/24h
Energy: 35 Kcal/kg/24h
Nitrogen, vitamins and trace elements: these are not available in isolated hospitals.
Abnormal losses
- NG suction and vomiting.
- Sweat and perspiration especially in a hot climate or in case of high fever.Give 250
mls extra fluids for each °C of temperature above 37°C.
- Diarrhoea.
- Other losses (through drains, stomas, fistulae)
Intravenous fluids
- 5% Dextrose
It is isotonic and contains 50 g of dextrose/litre.
Provides water and little energy (200 calories/litre) and no electrolytes.
If you want to give more energy to a patient who is unable to eat for a long time, you will
have to use or prepare more concentrated solutions by adding the appropriate amount of
hypertonic dextrose to 5% solutions. These hypertonic solutions thrombose the veins.
- 0.9% (normal) saline
It is isotonic and contains water 154 mmol/l of sodium and 154 mmol/l of chloride, which
is approximately the same concentration as in the extracellular fluid.
- Ringer's lactate (Hartman's solution)
It is isotonic and the best solution to replace water and electrolytes losses in case of
surgical dehydration.
It contains:
- 131 mmol of sodium
- 5 mmol of potassium
- 29 mmol of bicarbonate (as lactate)
- 0.9% saline in 5% dextrose (dextrose normal saline or DNS)
It contains 5O g of dextrose, 154 mmol of sodium and 154 mmol of chloride per litre.
It is hypertonic (osmolarity 585.5 mosm/litre while plasma osmolarity is 298 mosm/l)
and is not recommended in routine use.
245
Examples of fluid regimens in surgical patients
- Fit patient undergoing a non abdominal operation (including hernias repairs)
This patient will be able to drink a few hours after his operation. There is no need to give
him IV fluids after that. The drip can be discontinued as soon as he has recovered from the
anaesthetic.
- Fit patient undergoing an elective laparotomy
He will require IV fluids for a few days to cover his basal requirements until his bowel
sounds reappear and he can drink.Then his IV intake should be reduced until he can drink enough
to cover his needs.
Example 1 (60 kg adult who has had an elective laparotomy) : 2.5-3 litres of IV fluids in
the form of one l litre of Ringer's lactate followed by 2 litres of 5% dextrose.Avoid saline in the
first 2 postoperative days because of the metabolic response to surgery with salt and water
retention.You can give it if you have no Ringer's lactate.
- Patient undergoing an emergency laparotomy for intestinal obstruction
You must compensate his deficit before and during the operation.He may still have some
deficit at the end of the surgery which will have to be compensated.He needs to have his basal
requirements covered plus any abnormal losses.
Example 2: a 60 kg adult who has had a laparotomy for detorsion of sigmoid
volvulus.Urine output in the first 24 hours : 1200 mls, indicating that his deficit has been well
corrected.Drainage through the nasogastric tube in the first 24 hours : 600 mls.
Maintenance needs can be covered by 1 litre of Ringer's lactate (or saline) and 2 litres of
5% dextrose.
If he is passing urine, add 10 mmol of potassium to each litre of solution.
Don't give potassium if he is not passing urine.
Abnormal losses: 600 mls. Replace this by an equal quantity of normal saline and for each
500 ml of aspirate add 20 mmol of potassium to the patient's intravenous fluids.
Example 3: a 30 kg child who has had a laparotomy for peritonitis due to perforated
typhoid perforation. Temperature: 39°C, drainage through the nasogastric tube : 400 mls.
Maintenance needs can be covered by 30 x 40 mls = 1200 mls given as 400mls of
Ringer's lactate (or saline) and 800 mls of 5% dextrose.
Add 250 mls of 5% dextrose to compensate his abnormal losses through the skin and
400mls of saline to compensate his abnormal losses through nasogastric suction.
Total: (400+400) = 800 mls of Ringer's (or saline) and (800+250)= 1 litre of 5% dextrose.
246
Starting oral fluids
Intravenous infusion fluids are expensive and require good nursing supervision.They
should not be given unnecessarily.
If a patient has no nasogastric tube, give him sips of water the day after the operation,
then increase gradually.
If a patient has a nasogastric tube, start oral fluids as soon as his stomach is empty, his
bowel sounds have returned, and he has passed flatus. Reduce his IV fluids as you give him
fluids by mouth and discontinue them when he is taking a sufficient amount orally.
Nursing care
Postoperative patients and all patients on IV fluids for more than 24 hours should have a
fluid balance chart stating:
- intake: intravenous and oral.
- output: urine, gastric fluid (suction or vomiting), drainage, output through fistulae or
stomas, diarrhoea.
Prescribe the infusions in the column on the left. Ask the nurses to enter the bottles on the
'intake' column only when they are finished. Every day in the morning calculate the intake and
output of the previous day. The nursing staff will be more likely to fill these charts if they
understand how important they are and if you take the records into consideration. Use them for
serious patients.
Urine and gastric fluid collecting bags must not be emptied or changed by the relatives
because output must be recorded on the patient's chart. The output must be measured and
recorded at a fixed time in the day, preferably early in the morning so that fluids for the following
day can be accurately prescribed.
Nurses should be aware of the rate of infusion to be given and not just replace one bottle
by another when it is empty. Patients, especially children, can be dangerously under or over
loaded if this is not applied.
For children,write on the infusion bottle the time it should start and finish, and the rate of
infusion. Remove the excess fluid from the bottle before the drip is started; like this they will not
receive more than necessary.
Key points
Assess all patients for fluid deficit.
Get reliable IV access and correct deficit quickly.
Correct deficit preoperatively.
Postoperatively provide normal requirements, deficit and abnormal losses.
247
248
Resuscitation and anaesthesia
Pre-operative care (Chapter 14.1)
(Especially emergency laparotomy)
Pre-operative preparation
Careful preoperative preparation is essential except in case of extreme emergency. A
good preparation will prevent many complications during and after surgery.
In any case make sure he (the relatives in case of a child) understands and accepts the
operation, its risks and its possible consequences (e.g. colostomy, hysterectomy…). This is called
‘informed consent’.
First check the patient’s clinical signs
- Inspection: look at the patient, watch any facial expression of pain, how he is
breathing, the respiratory rate and its type (deep or superficial, abdominal wall
movement), the coloration of conjunctiva, mucosa and nails, sweating, shivering.
- Palpation: temperature of skin and nose, abdominal wall, signs of dehydratation,
tongue and skin; capillary refill.
- Auscultation: heart and abdominal sounds.
Vital signs
- Temperature: fever or hypothermia
- Pulse: tachycardia, bradycardia.
- Blood pressure: hypo or hypertension
- Urine output.
- Pulse oxymetry.
We recommend that all patients who need emergency laparotomy should be prepared in the
Recovery Room.
The ‘four tubes’` rule
Reliable IV line: One or two reliable IV lines are essential to rehydrate the patient. If
necessary treat shock with epinephrine only if there is no response to fluid challenge. Start
antibiotics if necessary.
Gastric tube: a nasogastric tube is routinely inserted to assure an empty stomach
especially in case of intestinal obstruction, vomiting, for any operation involving the gastrointestinal tract, or when you are not sure that the stomach is empty (as may often be the case in an
emergency operation). There is a risk of aspiration of stomach contents into the airway.
Urinary catheter: to monitor the urine output and to protect the bladder (lower abdominal
or pelvic surgery, caesarean-section). It should be inserted under strict aseptic conditions and any
urine present in the bladder discarded to start monitoring urine output.
Concentrated urine is also an indication of dehydration.
Tracheal tube (in theatre by anaesthetists).
249
In the operating theatre, before surgery
Position the patient supine, both arms resting on arm-boards for the anaesthesia team. If
the diagnosis is unclear, take the chance of the relaxation caused by anaesthesia to deeply reexamine the abdomen and look for masses.
Wash the patient’s back in case of a spinal anaesthesia.
Once the patient is under anaesthesia, wash the abdomen with soap and water. Then
prepare the skin generously with a strong antiseptic (povidone iodine preferred), starting
from the site of incision and extending from the nipples to below the groins and to both
flanks on the sides. Remember that you may have to extend the incision you originally
planned.
Draping must expose the whole of the anterior abdominal wall, from xiphoid process to
pubis.
Check suction and diathermy.
During surgery
Intravenous infusion must be continued. Urine output, pulse oxymetry, blood pressure, pulse and
skin coloration will be watched by the anaesthetist. Communication between anaesthesia and
surgical team is essential.
Take into account all intra-operative fluid losses, including fluid sucked out from the abdomen,
fluid sucked out of the stomach, long exposure of the bowels to air, urine output, bleeding.
The surgeon should check the correct position of the gastric tube.
Key points
Assess and resuscitate carefully patients before emergency laparomy.
4 tubes: IV, gastric, urinary, tracheal.
250
Resuscitation and anaesthesia
Postoperative care (Chapter 14.2)
The surgeon’s or Health Officer’s responsibility does not end when the patient leaves the OT. It
continues until the patient has been discharged.
Transfer of the patient from OT to recovery room
This must be coordinated by the anaesthetist who looks after the head and ensure the
safety of all drips, drains and catheters.
A minimum of 2 additional people are needed to help.
Criteria for the patient to leave the OT (for the anaesthetists)
•
•
•
•
•
•
•
the patient is awake
the patient can move but is not very agitated
his breathing is calm and regular
oxymetry is above 90% on air; if no oxymetry, the extremities are well coloured and
warm, the capillary refill is good
blood pressure and pulse are close to the pre-operative values
the drains, drips and catheters are not blocked
the book of the patient is completed and the anaesthesia card correctly filled
Post-operative patient’s position
As a rule, all patients who have had a general anaesthesia must be nursed in recovery position,
on the stretcher and in the bed of recovery room:
On the side, semi prone, with the legs and knees semi flexed.
This is to prevent respiratory obstruction by the tongue falling backwards and to reduce the
risk of inhalation in case of vomiting.
Exceptions: patients with large plaster casts, traction for fractures, multiple drains…it’s difficult
to put the patient on the side so he may to remain on his back with the head turned on the side
and additional supervision; also, in case of breathing difficulties, a semi-sitting position is better
to improve breathing.
251
In recovery room
The patient must never be left alone, and the barriers of the bed raised.
Check vital signs again: blood pressure, pulse, oxygen saturaation or extremities…
Check IV drips, drains, catheters…
Oral and written handover to the nurse in charge:
• which kind of operation has been done
• condition of the patient
• how often to check vital signs
• drip rates
• medications: antibiotics, analgesics…
• when to call in case of problem.
Immediate postoperative care
• monitoring vital signs : frequency and duration will depend on the operation and the
patient’s condition.
• correct amount of fluids IV : the best guide to adequate fluid replacement is the
urine output and concentration.
• medications: - pain relief: paracetamol ( 1g TID ), diclofenac ( 75mg TID)
- antibiotics as necessary.
• oxygen therapy if necessary after major surgery
• checking for bleeding
• attending to general nursing care and comfort of the patient.
When can the patient start drinking?
• After a minor operation: when he is fully conscious and has no nausea.
• After a major operation not involving the abdominal cavity ( orthopaedic for example):
usually after 12-24 h.
• caesarean section : 12 hours after surgery.
• After a laparotomy for GI surgery: usually only after the patient has passed gas or there
evidence of peristaltism.
When to start a solid diet
The next day if bowel movements are confirmed.
When to remove the nasogastric tube?
If output is less than 100 mls, and when flatus have been passed. Sometimes the postoperative
ileus may be prolonged, in which case gastric suction must continue (vomiting, no flatus,
abdominal distension).
When to mobilize the patient?
As soon as he/she is comfortable to do so, encourage leg movements in bed and ambulation as
soon as possible, as well as deep chest exercises.
252
Resuscitation and anaesthesia
Principles of Anaesthesia for surgeons (Chapter 14.3)
An-aesthesia means ‘without pain’.
It is a reversible condition witch allows a surgical operation.
A surgical operation requires:
Analgesia with or without unconsciousness, with or without muscle relaxation.
There are different types of anaesthesia
In general anaesthesia: the patient is unconscious, breathing alone or assisted by the
anaesthetist.
In local anaesthesia: the patient is conscious. There are 3 types:
Regional anaesthesia, spinal and epidural anaesthesia.
Blocks: scalenic, lumbar, troncular, ulnar, sciatic.
Local anaesthesia, skin.
Local and general anaesthetics can be used to treat the postoperative pain.
There is no such thing as minor anaesthesia.
When a patient needs surgery, the anaesthetist shares responsibility for the patient. He
must check all the parameters to ensure the patients safety from the preoperative period to the
exit from the recovery room. His work is not confined to the operating room.
253
General anaesthesia
Achieves absence of pain, unconsciousness, and sometimes muscle relaxation for
abdominal surgery.
To control pain, the anaesthetist uses opioids such as pethidine, or ketamine which is
sufficient for superficial surgery.
To make the patient sleep, hypnotics are given such as Ketamine, diazepam, thiopentone.
He can use also gas such as halothane.
For muscle relaxation two cases are possible:
Intubation needs Suxamethonium. This depolarisant muscle relaxant has a
short action and causes rapid spontaneous breathing. At the beginning of
his action, it stimulates the nerve (fasciculations) and a deep block is
realized.
Abdominal surgery needs long-acting drugs such as Tracrium, with no
depolarisation effect.
Ventilation during general anaesthesia can be spontaneous or assisted. In case of long
surgery or full stomach, intubation may be required.
When you are ready to cut, he must ask the anaesthetist’s permission to start. And when
the end of operation approaches, alert the anaesthetist.
For children, induction can be achieved by IM injection of Ketamine+/-diazepam without
IV line. For a very young patient gas induction is often necessary.
When you have finished the procedure, the anaesthetist awakes the patient. When
all parameters of recovery are right, he goes with the patient in the recovery room. He
orders infusions, analgesics in writing.
General anaesthesia risks include:
Asphyxia due to:
airway obstruction: aspiration, tongue drop, laryngal or bronchospasm,
respiration arrest: muscle relaxant, morphinomimetic, pneumothorax…
Circulation failure due to:
Septic shock, hemorrhagic, anaphylactic, infarctus
deshydratation, third sector in digestive occlusion, large burns.
254
Regional anaesthesia
Spinal and epidural anaesthesia give a block of nervous center.
1 - Spinal anaesthesia
The spinal needle is introduced between L3 and L4 vertebrae into the
subarachnoid space. This space is chosen because the spinal cord finishes at L2
level. When the needle is in correct position cerebrospinal liquid appears. A small
volume of hyperbaric lidocaine or Bupivacaine is injected slowly. The block is
complete motility and sensitivity. If the patient is positioned on the side, the spinal
anaesthesia can be lateralized.
Risks: Cardiovascular Collapse, bradycardia, respiratory cardiac arrest if
the block increases to the thoracic and cervical nervous centre, meningitis,
headache, urinary block permanent paralysis by local nervous poisoning or
compressive hematoma.
2 – Epidural
An epidural causes a block of the nerves where they cross the dura mater.
It is not widely practised in Ethiopia.
Regional blocks
1 – Plexus block
2 – Troncular block.
255
Local Anaesthesia
Advantages
- practical and easy
- cheap
- safe
- no need for admission
- done by the surgeon himself.
Disadvantages
- may fail
- not possible if tissues are infected
- complications are rare but can happen
- requires patient's cooperation; not for young children, anxious or restless patients.
Maximum safe doses
per body weight
for an adult
ml of 1% solution
Without adrenaline
3 mg/kg
200 mg
20 ml
With adrenaline *
6 mg/kg
400 mg
40 ml
* Adrenaline added to a local anaesthetic causes vasoconstriction and delays absorption of the
anaesthetic.The maximum safe dose of solutions with adrenaline is higher.
A 1% solution contains 10 mg/ml = 1 g/100 ml
Contra-indications
- No cooperation from the patient
- When you would need to use doses above the safe dose.
- Local infection.
- Hypersensitivity.
Contra-indications to the use of adrenaline in local anaesthesia solutions: extremities.
- Fingers and toes.
- Nose.
- Penis.
Precautions
- Give a diazepam premedication if the procedure is more than a minor one.
- Tell the patient what you are going to do.
- Aspirate to check that you are not in a blood vessel.
- Wait for 10-15 minutes.
256
Complications
Usually occurs when safe doses have been exceeded or in case of intravenous injection.
- Neurological complications
Anxiety,pins and needles, twitches, fits, loss of
consciousness.
- Cardiovascular complications
Tachycardia, cardiac arythmia, cardiac arrest.
Neurological symptoms occur before cardiovascular symptoms and are a warning.
- Hypersensitivity (allergy)
What to do in case of complications?
Be ready: have equipment ready for ventilation and resuscitation.
Give IV diazepam slowly.
Put up an IV drip for venous access.
Local anaesthetics can also be used for:
- Surface anaesthesia (lignocaine jelly or spray).
- Spinal anaesthesia.
- Nerve blocks
- Infiltration anaesthesia can also be combined with
spinal or general anaesthesia.
Key points
There is no such thing as ‘minor anaesthesia’
Cooperation and communication between surgeon and anaesthestist is essential.
Properly used,local anaesthesia is safe , easy and very useful for minor procedures.
Do not exceed 20 ml of 1% plain solution of lidocaine for an adult.
Complications of local anaesthesia are neurological and cardiovascular.
257
258