1. Chapter 9 Common surgical problems Trauma

2. Case study: Hamid 14 year old boy was involved in the accident with a car

3. What are the stages in the management of Hamid?

4. Stages in the management of a sick child (Ref. Chart 1, p. xxii) 1.Triage 2.Emergency treatment 3.History and examination 4.Laboratory investigations, if required 5.Main diagnosis and other diagnoses 6.Treatment 7.Supportive care 8.Monitoring 9.Discharge planning 10.Follow-up

5. 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

6. 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

7. What emergency treatment does Hamid need?

8. Emergency treatment Airway management? Oxygen? Intravenous fluids? Anticonvulsants? Immediate investigations?

9. 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

10. 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

11. 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)

12. Give emergency treatment until the patient is stable

13. 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.

14. 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

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

16. Possible diagnoses Concussion Pneumothorax Neck trauma Leg fracture Pelvis fracture Internal injuries Internal bleeding

17. –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 Further examination based on possible diagnoses

18. What investigations are required?

19. Investigations Cervical spine x-ray Chest x-ray Pelvis x-ray Left femur x-ray Full blood examination: haemoglobin, haematocrit, cross-match

20. Chest x-ray

21. Femur

22. 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

23. 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)

24. What supportive care and monitoring are required?

25. 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)

26. What monitoring is required?

27. 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

28. Monitoring Monitoring for signs of for each of the injuries: –Improvement –Complications –Failure of treatment Frequent observations of: –Pulse, SpO 2 if available –Chest tube water level swinging –Check sensation, motor power, pulses and capillary return in left leg and foot –Abdominal tenderness

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

30. 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.