Accident & emergency surgery
Trauma is the study of medical problems associated with physical injury and centers upon the deleterious effects of kinetic energy on the human frame. Mechanism + Patient = Injury. Accidents are the fourth leading cause of death at all ages and the leading cause of death among persons between the ages of 1 and 37 years mainly males. 15–30% of the deaths due to trauma can be prevented.■ Forces that can lead to injury : Mechanical: involved in most injuries. Thermal Chemical Ionizing radiation
■ Types of injuryBluntPenetratingBlastCrushThermal injury
■ Blunt injury A direct mechanism : when the damage occurs at or close to the site of impact. An indirect mechanism : when the damage occurs at a distant site after transmission of that force.The most common cause of blunt trauma is the motor vehicle.■ Factors related to motor vehicles injuries : Mass Speed : 10% increase in impact speed translates into a 40% rise in the case fatality risk for occupants (both restrained and unrestrained). Wearing seatbelts : reduce the risk of death or serious injury for front-seat occupants by approximately 45% , but causes fourfold increase in thoracic trauma and eightfold increase in intra-abdominal trauma. Ejection from a vehicle is associated with a significantly greater incidence of severe injury.
Motorcyclists Experience a death rate 35 times greater than the occupants of cars. Helmets reduce the risk of fatal head injury by about one-third and reduce the risk of facial injury by two thirds.
■ Penetrating injuryA low-velocity projectile behaves more or less like a stabbing injury. The kinetic energy of stab wounds is low, and death occurs only if a critical organ such as the heart or a major blood vessel is injured.
The high-velocity bullet causes motion of the tissue particles away from their original position produces a cavity. Two types of cavity are produced: (1) permanent cavity – one that remains after the initial impact (2) temporary cavity – one that lasts for milliseconds, and may no longer be apparent during the physical examination of the wounded. This temporary cavitation can extend well beyond the boundaries of the apparent . It is large and draws in foreign materials .The treating surgeon must perform an adequate exploration and, if appropriate, a more radical wound excision than would otherwise be used.
■ Blast injury Bursting of bombs ruptures their casing and imparts a high velocity to the fragments. This is accompanied by a blast pressure wave with mass movement of air, which result in severe devastating injury to the tissues. Injury patterns ranging from injury to the ear, lungs, heart, traumatic amputation to total body disruption. Heavy contamination of the soft-tissue wounds with dirt, clothing and secondary missiles such as wood, and other materials from the environment. It is imperative that wounds should be left open and delayed primary closure performed ( One cannot be sure of complete wound excision) .
■ Crush injury Occurs when the body or part of it is subjected to a high degree of force or pressure, usually after being squeezed between two heavy or immobile objects. Causes lacerations, fractures, bleeding, bruising, compartment syndrome and crush syndrome. Crushing of muscle mass sequesters fluid, so reducing the effective intravascular volume, which results in renal vasoconstriction and ischemia, with release of myoglobin and vasoactive mediators into the circulation. Myoglobin is precipitated in the tubules, leading to tubular obstruction.
■ Basic types of trauma• Serious and life-threatening injury• Significant trauma requiring treatment but not immediately life threatening.
Trimodal distribution of deaths from trauma with regard to time (Described by Trunkey in the 1980s).
• Immediate – death within the first few minutes, unsalvageable patients, 50% of all deaths. Devastating brain, heart or major vessel injury. • Early – within the first few hours, represents 30% of all deaths, often death from torso trauma. Life threatening injuries (LTI) requiring urgent attention. Deaths occur as a result of hypovolaemia and haemorrhage (external or internal into one or more of the major body cavities (abdomen, chest, pelvis). Many of these deaths may be preventable.• Late – death within days / weeks , represents 20% of all deaths, resulting from the complications of initial injuries like sepsis or multiple organ failure.
Preparation• Pre-hospital phase – there must be good coordination and communication pathways set up prior to transfer of the injuredfrom the scene of injury. • In-hospital phase – a resuscitation area should be available and secured. Equipment in this area should be checked daily and placed where it is immediately accessible. Warmed intravenous crystalloid solutions should be prepared and ready for immediate attachment on arrival. The laboratory team should be warned that blood may be urgently needed. Techniques such as ‘damage control resuscitation’ and ‘damage control surgery’ have dramatically improved survival.
DAMAGE CONTROLMinimizing surgery until the physiological derangement can be corrected with two goals:• Stopping any active surgical bleeding.• Controlling any contamination.The operation is then suspended and the abdomen temporarilyclosed. The patient’s resuscitation continues in the intensive careunit. Once the physiology has been corrected, the patient is returned to the operating theatre for definitive surgery.
■ Triage• The sorting of patients, with the most severely injured patients being treated first.• The sorting of injuries, so that the most compelling threats to life, e.g. bleeding sites, receive priority.Three essential phases:Pre-hospital triage – in order to despatch ambulance and pre-hospital care resources.At the scene of trauma.On arrival at the receiving hospital.
■ Triage situation Multiple casualties: The number and severity of injuries do not exceed the ability of the facility to render care. Priority is given to the life-threatening injuries followed by those with polytrauma.Mass casualties: The number and severity of the injuries exceed the capability and facilities available to the staff. In this situation, those with the greatest chance of survival and the least expenditure of time, equipment and supplies are prioritised
Assessment and management of the multiply ( seriously) injured patients MIP The term ‘initial assessment’ applies particularly to the elements of primary survey, resuscitation, secondary survey, monitoring/reassessment and specific investigations. The term ‘definitive care’ relates to specific treatment (operative or non-operative) aimed at establishing the optimal conditions for the healing of specific injuries.
■ The Advanced (Basic)Trauma Life Support (ATLS, BTLS) A standardised protocol of management of MIP and the cornerstone of advanced resuscitation.It was created initially in the American College of Surgeons in 1977 and rapidly taken up globally.
The principles include:• Primary survey and early assessment. • Simultaneous aggressive resuscitation. • Secondary survey with full exam: front to back and top to toe.• Transfer to a definitive site of care.•The philosophy also includes the concept of triage.
Primary survey and early assessment Includes early triage to identify treatment priorities. Based on the rapid assessment and recognition of LTI with resuscitation of the patient's vital functions with simultaneous treatment of LTI. History must be obtained as soon as possible and must include the nature of accident. Constitutes the ABC of trauma care.
A: Airway maintenance with cervical spine control B: Breathing and ventilation C: Circulation D: Disability (neurological status) E: Exposure
Ensure a patent airway while protecting the cervical spine. Airway obstruction produces altered level of consciousness, noisy breathing with undetectable expired air. Consider all MIPs have a cervical spine injury until proved otherwise. Stabilize the neck by fitting a rigid collar and tape the forehead to the sides of the trolley.
Oropharynx - tongue (fallen back), or teeth, dental plates, foreign body, blood and vomit. Head- altered level of consciousness after head injury, alcohol and drug. Maxillofacial injuries- fracture of maxilla or mandible. Neck- laryngeal injury.
Clear airway initially by chin lift or jaw thrust maneuvers and using a gloved two finger sweep and suction to remove the obstructing cause. May need oropharyngeal or nasopharyngeal airway, cricothyroidotomy or tracheostomy may be needed in cases of crush injuries of the larynx, cricotracheal separation, or perforation / laceration of the trachea.
Patient with inadequate ventilation (hypoxia) may be distressed, irritable and cyanosed. A patent airway does not ensure adequate ventilation. Inspection of chest wall may reveal respiratory rate and depth, bruising, clothing imprint, open wounds, and unequal movement due to flail segment.
Palpation and auscultation may demonstrate surgical emphysema, tension pneumothorax and / or haemothorax, cardiac tamponade. Pulse oximeter gives an indication of the adequacy of perfusion and arterial oxygen saturation. Giving 100% oxygen (high concentration oxygen 6-8 liters / minute) to every patient through a mask or by intubation if necessary.
Airway obstruction Tension pneumothorax Large (massive) haemothorax Sucking chest wound (open pneumothorax) Flail segment (and underlying lung contusion) Major disruption of the tracheo-bronchial tree Cardiac tamponade
Delay for radiological confirmation may be fatal. A simple pneumothorax may be converted to a tension pneumothorax when a patient is ventilated and in this situation a chest drain should be inserted prophylactically prior to commencing ventilation. It should be treated initially by a large bore needle decompression of the pleural cavity at the second intercostal space in the mid clavicular line, followed by intercostal chest tube.
It should be treated with insertion of intercostal tube in the fifth intercostals space in the mid axillary line. Intrapleural hemorrhage exceeding 1200 to 1500 ml in the first 15 min after the insertion of a thoracostomy tube or continuing at a rate of 100 to 200 ml / h mandates a thoracotomy.
Occurs when ribs are fractured in at least two places. It can be recognized when the flail segment falls during inspiration as the rest of the chest rises (Paradoxical movement). It is always associated with significant pulmonary contusion resulting in hypoxia. If respiratory failure supervenes despite oxygen therapy and adequate analgesia (preferably epidural or intercostal blockade), then ventilation is required.
It needs immediate covering and sealing. This should be followed by pleural drainage and the wound can be sutured. Thoracotomy may be needed when the patient's condition has been stabilized.
These injuries have a very poor prognosis. The condition is diagnosed most often by the presence of pneumomediastinum, pneumopericardium or air below the deep cervical fascia of the neck. Minor tears may sometimes be managed conservatively. Major tears need immediate endotracheal or endobronchial intubation and thoracotomy.
It is suspected if there are muffled heart sounds, low arterial pressure and distended neck veins. It should be diagnosed early and treated by pericardiocentesis while monitoring ECG.
In a MIP blood loss is the commonest cause of diminished conscious level. External, severe haemorrhage should be identified and controlled by direct manual pressure or applying dressing. Tourniquets should not be used to prevent bleeding from a limb as they occlude collateral circulation causing tissue destruction (tourniquet is used only in bleeding amputated limb). Penetrating wounds should be identified and explored by a surgeon.
A rapid assessment of the neurological state can be made by seeing if the patient is speaking, by looking at the pupils and assessing the level of consciousness. A simple mnemonic is AVPU
A Alert V Vocal stimuli response P Painful stimuli response U Unresponsive
The Glasgow coma score (GCS) is more comprehensive but is often left until the secondary survey. Mild : GCS 14 – 15 Moderate : GCS 9 – 13 Severe : GCS 8 or below.Fully undress the patient to allow a thorough examination, but keep the patient warm (with caution).
It should be done while the primary survey is being conducted. It needs to be vigorous with shock treatment and to manage any LTI as they are discovered.
Oxygenate with 100% oxygen. Insert two cannulas (14 gauge) in the antecubital fossae and cross match blood. Infuse 2 liters of Hartmann's solution rapidly, blood transfusion. Send blood samples for full blood count, urea, electrolytes and glucose. Record vital signs (pulse, blood pressure , respiration, and temperature). Pulse oximetry. Electrocardiogram monitor. Urinary catheter (unless contraindicated). Nasogastric tube (unless contraindicated). Arrange x ray films: lateral cervical spine, chest and pelvis.
It must be made after the patient has been resuscitated and stabilized. It entails a detailed head to toe and front to back examination to identify all injuries. A full history should be obtained from the patient if possible or from the ambulance crew or relatives.
Persistent hypotension and the presence of fluid on a surgeon-performed abdominal ultrasound or more than 10 to 20 ml blood on a diagnostic peritoneal tap indicates that a laparotomy should be performed. Compression of the iliac wings causing a grinding sound in the comatose patient or eliciting a complaint of pain in the awake patient suggests that a Malgaigne's pelvic fracture is present. Such a patient should undergo application of an external fixator in the emergency center or operating room or transfer to the angiography suite for therapeutic embolization of bleeding pelvic vessels.