1. Chapter 9 Common surgical problems Stabilisation of Trauma

2. 14 year old boy was involved in the accident with a car
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 leg.

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

5. What emergency and priority signs have you noticed?
In Trauma this is called the Primary Survey
Brief history
Assessment of ABC
A: no stridor or obstruction
B: RR: 50/min with intercostal recession and no right sided chest movement, SpO2 88%, cyanosed
C: BP 85 / 40, 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 pneumothorax
Insert intercostal catheter (Ref p.349)
C Stop any external bleeding
Reassess 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, SpO2 95% on oxygen
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 □ Abrasions
 Stabilise in a splint then urgent referral to a surgeon (Ref. p )
□ 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. 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 )
Strict infection control. Risk of nosocomial infection: from where?
Abrasions
Intercostal catheter
Urinary catheter
Intravenous drip

18. Monitoring Frequent observations of:
Pulse, signs of respiratory distress, SpO2
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
Check for signs of infection in IV drip sites, etc

19. Follow-up
Review of fracture healing
Physiotherapy and rehabilitation

20. 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 no head injury.
Primary Survey (brief history ABC) → Emergency treatment, Secondary survey → injury treatment, monitoring, supportive care, discharge planning & follow-up