1. Chapter 9 Common surgical problems Trauma

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

3. Brief History of Accident Passenger on the back of the motorcycle. Hit by a car, slid along the road for some distance before hitting a post on the side of the road. There was brief loss of consciousness. Wearing a helmet. He was placed in the back of another motor vehicle and driven to the hospital. On arrival he was alert but in severe distress. Complaining of pain in the chest and left thigh.

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 and priority signs have you noticed? In Trauma this is called the Primary Survey 1.Brief history 2.Assessment of ABC A: no stridor or obstruction B: RR: 50/min with intercostal recession and no right sided chest movement, SpO 2 88%, cyanosed C: BP 85 systolic, HR 148, capillary refill: 4 seconds, cold limbs

6. Triage Emergency signs (Ref. p. 2) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Signs Severe dehydration

7. Triage Emergency signs (Ref. p. 2) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Signs Severe dehydration

8. What emergency treatment does Hamid need?

9. Emergency treatment Treat problems with ABC Airway OK, c-spine stabilisation B Oxygen Needle thoracostomy R chest for urgent decompression (Ref p. 349) C Intravenous line and bolus fluid: 20ml/kg Hartmanns or 0.9% NaCl Then do initial x-rays (chest, lateral c-spine, pelvis)

10. Chest x-ray

11. Emergency treatment (continued) B x-ray confirms tension pnerumothorax Insert intercostal catheter (Ref p.349) C Stop any external bleeding –Reassess child after appropriate IV fluid has run –Measure the pulse and breathing rate at start and every 5-10 minutes

12. Further history Hamid was the passenger on the back of the motorcycle, driven by his father. The estimated speed of the bike was 50 km/h. A car hit the bike on the left side, and Hamid slid along the road before hitting a post on the side of the road. He was wearing a helmet, but only shorts and a t-shirt. There was brief loss of consciousness, but he could talk to his father until help arrived. He was placed in the back of another motor vehicle and driven to the hospital. On the way to the hospital he started to have difficulty breathing. On arrival he was alert but distressed. He was complaining of pain in the chest and left thigh.

13. Examination: Secondary Survey (“head to toe examination”) First: Reassess vital signs after Emergency Treatment A: airway OK B: RR: 40/min, right chest good air entry, SpO 2 95% C: BP 105 systolic, capillary refill: 2 seconds, pulse volume good, heart sounds audible, no apex beat displacement Cervical spine: not tender, no swelling, moving limbs Abdomen: soft and non tender, no distension Rolled with spinal precautions: Back: abrasions Limbs: externally rotated left leg, swollen thigh, foot pulses present

14. Investigations Chest x-ray – repeat after chest drain Cervical spine x-ray - normal Pelvis x-ray - normal Left femur x-ray → Haemoglobin, cross-match

15. Femur

16. Treatment □ Fractured distal femur  Stabilise then refer to a surgeon (Ref. p. 275- 279) □ Abrasions  Clean the skin and avoid an infection □ Possible abdominal trauma  Observe the child and look for signs of peritonitis, review by surgeon (Ref. p. 275)

17. What supportive care and monitoring are required?

18. Supportive care Pain control (Ref. p. 275) In-dwelling urinary catheter Blood transfusion not necessary as shock resolved with IV fluid and drainage of the tension pneumothorax, and haemoglobin 9g/dl (Ref. p. 276) Nutrition when abdominal injury is excluded and Hamid is stable (Ref. p. 271-273)

19. Monitoring Frequent observations of: –Pulse, signs of respiratory distress, SpO 2 –Chest tube water level swinging, follow-up chest x- ray, decision on timing of removal –Check sensation, motor power, pulses and capillary return in left leg and foot –Abdominal tenderness

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

21. Summary Hamid is a 14 year old boy who was involved in a multi-trauma. He sustained a tension pneumothorax, fractured femur and abrasions. He had mild concussion only. Primary Survey (brief history ABC) → Emergency treatment, Secondary survey → injury treatment, monitoring, supportive care, discharge planning & follow-up