Common surgical problems Trauma

Chapter 9

Case study: Hamid

14 year old boy was involved in the accident with a car

What are the stages in the management of Hamid?

Stages in the management of a sick child

1. Triage

(Ref. Chart 1, p. xxii)

Emergency treatment, if required

2.
3. 4. 5. 6. 7.

History and examination

Laboratory investigations, if required

Differential diagnoses
Main diagnosis

Treatment Supportive care Monitoring Plan discharge

Follow-up, if required

What emergency (danger) and priority (important) signs have you noticed?

Pulse: 148/min, RR: 50/min with intercostal recession and reduced right sided chest movement, BP 85 systolic, capillary refill: 3 seconds

Triage
Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns

What emergency treatment does Hamid need?

Emergency treatment
Airway management? Oxygen? Intravenous fluids? Anticonvulsants?

Immediate investigations?

Emergency treatment (continued)

How do you treat respiratory distress?
Give oxygen (Ref. Chart 5, p. 11)
Manage airway*
*Neck trauma was excluded by clinical examination and cervical spine x-ray

Make sure child is warm

Emergency treatment (continued)

How do you treat signs of shock?
Stop any bleeding Give IV fluids (Ref. Chart 7, p. 13) Insert an IV line (and draw blood for immediate investigations such as: haemoglobin, cross-match, blood sugar) Attach Ringer's lactate or normal saline make sure the infusion is running well Infuse 20ml/kg as rapidly as possible Reassess child after appropriate volume has run Measure the pulse and breathing rate at start and every 5-10 minutes

Emergency treatment (continued)

Insert a wide bore intercostal catheter into right chest (Ref. p. 348) and repeat chest x-ray to see if pneumothorax is drained Immobilise the left leg (Ref. p. 277)

Give emergency treatment until the patient is stable

History
Hamid was the passenger on the back of the motorcycle. The estimated speed was 50 km/h. He was thrown clear of the car and slid along the road for some distance before hitting a building by the side of the road. There was momentary loss of consciousness.
He was placed in the back of another motor vehicle and driven to the local hospital. On arrival he was alert but distressed. There was obvious deformity to his left leg. There were abrasions all down his back and left side. He was complaining of pain in the chest and left thigh.

Examination
Vital signs: pulse: 148/min, RR: 50/min, BP 85 systolic, capillary refill: 3 seconds

Chest: airway patent, no stridor; intercostal recession and reduced right sided chest movement, tender right clavicle Cardiovascular: regular, no apex beat displacement
Cervical spine: non tender Abdomen: soft and non tender

Back: non tender

Limbs: externally rotated left leg, swollen thigh

Differential diagnoses
List possible causes of the illness Main diagnosis Secondary diagnoses Use references to confirm

Possible diagnoses
Concussion Pneumothorax Neck trauma Leg fracture Pelvis fracture

Internal injuries
Internal bleeding

Further examination based on possible diagnoses

AVPU (Ref. p. 18) A alert
V responds to voice P Responds to pain U unconscious

Pupil size and light reaction: normal Reacts appropriate to speech and questions

What investigations are required?

Investigations
Cervical spine x-ray Chest x-ray Pelvis x-ray

Left femur x-ray

Full blood examination: haemoglobin, haematocrit, cross-match

Chest x-ray

Femur

Diagnosis
Summary of findings: Examination: severe respiratory distress, signs of shock, but alert, pupil size and reaction normal X-Ray shows: 1. Pneumothorax (right side) 2. Fractured distal femur

(Pelvis normal)
Abrasions Possible abdominal trauma

Multi-trauma

Treatment
Give emergency treatment until the patient is stable

Pneumothorax
Keep the intercostal catheter until the air is drained

Fractured distal femur

Consider referral for review by a surgeon experienced in paediatric surgery (Ref. p. 275-279)

Abrasions
Clean the skin and avoid an infection

Possible abdominal trauma

Observe the child and look for signs of peritonitis (Ref. p. 281-282)

What supportive care and monitoring are required?

Supportive care
Pain control (Ref. p. 306) In dwelling urinary catheter Blood transfusion is not necessary in this case as shock resolved with clear fluid and drainage of pneumothorax, and haemoglobin: 9g/dl (Ref. p. 308)

Nutrition when abdominal injury is excluded and Hamid is stable (Ref. p. 302-303)

What monitoring is required?

Monitoring
Nurses should monitor frequently the child's state of : Consciousness Pulse RR

Pupil size
Use a Monitoring chart (Ref. p. 320, 413) Medical review twice daily

Reassess neurological state (AVPU score)

Re-check haemoglobin Daily chest x-rays

Monitoring
Monitoring for signs of for each of the injuries:

Improvement
Complications Failure of treatment Frequent observations of: Pulse, SpO2 if available

Chest tube water level swinging

Check sensation, motor power, pulses and capillary return in left leg and foot

Abdominal tenderness

Follow-up
Review of fracture healing Physiotherapy
- and give simple suggestions to the mother for passive exercises

Summary
Hamid is a 14 year old boy who was involved in a multi-trauma. He sustained a pneumothorax, fractured femur and abrasions. He had mild concussion only. No abdominal complications occurred.