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Primary Surgery Vol.2 – Trauma |  |
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Primary Surgery Vol.2 – Trauma | |
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This is a summary of what follows—be systematic and examine the patient in an orderly way. (1) Clear his airway and maintain it. (2) Deal with any obvious chest injury. (3) Control any external haemorrhage. (4) Assess his circulatory state and correct it. (5) Note his level of consciousness and assess injury to his head (including testing his reflexes and examining his pupils). (6) Examine his abdomen and pelvis; look for fractures of his pelvis. Look for signs of internal bleeding. Note the state of his bladder. (7) Look for wounds and fractures of of his limbs. (8) Look for signs of injury to his spine.
cut away the parts trapping him with great care. Move him carefully as in Section 64.3 to avoid injury to his spine. Keep him lying flat.
Ask your ambulance driver to call you and let you see a seriously injured patient in the ambulance before he is moved. If he is not obviously alive, feel his carotid pulse, and listen for heart sounds with a stethoscope. If these are absent, and there is any evidence that they have only stopped in the last few minutes, attempt cardiopulmonary resuscitation as in A 3.5. Your task will be easier if you have three helpers, one to perform mouth–to–mouth ventilation, another to perform external cardiac massage, and a third to fetch help.
If the patient is unconscious, can you rouse him by pressing one of his supraorbital notches firmly with your nail?
This is a summary of the methods in Chapter 52. You may need any of the methods in Fig. 52–1. (1) Clear any vomit or foreign bodies from the patient’s mouth. Sweep your finger deeply into his mouth and pharynx. Suck out his pharynx. (2) Move his head and neck into the position in which he breathes best (A 4.2). (3) Make sure that his head is slightly dependent so that blood and secretions can drain. Unless particular injuries make it impractical, he will probably be best in the recovery position, if he is not already in it. (4) Insert an oropharyngeal airway if he is unconscious and will tolerate it.
If the patient Is sufficiently unconscious after a head injury for you to insert a tracheal tube, insert one. As soon as his level of consciousness improves, he will make spontaneous efforts to remove it.
If his airway is obstructed and intubation is impossible, as with a severe maxillary injury in an adult, you can do a cricothyroid puncture with a needle, or a tracheostomy. In a child you will have to do a tracheostomy.
If he is not breathing adequately after the above measures, either ventilate him with a self inflating bag (A 10.3), or mouth–to–mouth (A 3.5). Give him oxygen. Think of the possibility of a pneumothorax (65.5) or a flail chest (65.6). Feel for deviation of his trachea, and for the position of his apex beat.
![\includegraphics[scale=0.22]{/home/kumasi/Desktop/primsurg-tex/vol-2/fig/51-2.eps}](images/img-0006.png)
to the horizonal. You can support his chest with a pillow, but don’t let it interfere with his breathing. His head is extended to provide a free airway. His uppermost arm is flexed in front of his trunk with his hand under his jaw to provide additional support. His lower arm is behind his back. To prevent him rolling over, you can flex his upper or his under leg, depending on his injury, while the other leg remains extended. He will be more stable with his under leg flexed. If he is on a stretcher for any length of time, don’t let it press on his common peroneal nerve and cause foot drop. From the Field Surgery Pocket Book with the kind permission of Guy Blackburn. Do this as in Section 55.1. You will probably find firm pressure on the wound most useful.
If a knife, dagger, arrow, or spear is still in the patient’s body, l eave it there until he reaches the theatre. If you remove it he may bleed severely.
A patient may need treatment for an open chest wound (65.7), a tension pneumothorax (65.5), a haemothorax (65.4), or a flail chest (65.6).
Assess this by the methods in Section 53.2. If a patient is severely shocked, can you feel a pulse? Record its rate and his blood pressure. Set up an intravenous line by one of the methods in A 15.2. If he is in severe hypovolaemic shock and you are sufficiently skilled, the best method is to use a large bore catheter threaded into the great vessels of his upper trunk by the methods in A 19.2. Start by giving him a litre of Ringer’s lactate or 0.9% saline.
If he is severely shocked and you are sufficiently skilled, set up a CVP (central venous pressure) line, as in A 19.2. This requires the insertion of a fairly wide bore catheter into a central vein or into his superior vena cava.
Continue the treatment of shock as in Section 53.2.
CAUTION ! Take blood for cross matching. If possible, take the sample before the patient’s veins collapse, and before you give him a colloid such as dextran, which may interfere with cross matching. At the same time take blood for measuring his haemoglobin or haematocrit.
![\includegraphics[scale=0.23]{/home/kumasi/Desktop/primsurg-tex/vol-2/fig/51-4.eps}](images/img-0008.png)
Take a brief history now and complete it later. Exactly what happened at the accident? First question any witnesses, then the patient himself. How did his body have to withstand the trauma of the accident? If you can find this out, you will know better what injuries to expect. For example, if he was hit by a car, expect 3 injuries, one from the bonnet, one from the bumper and another from the road.
If he is conscious ask him where his pain is? Does he have abdominal pain? This is always important (66.1). Has he passed urine since the accident? (68.1)
Don’t forget his ordinary medical history. Perhaps he has a history of mental illness, or is taking drugs, such as insulin, steroids, or anticonvulsants.
How does he respond when you press his supraorbital margin firmly with your thumb nail?
![\includegraphics[scale=0.42]{/home/kumasi/Desktop/primsurg-tex/vol-2/fig/51-3.eps}](images/img-0009.png)
Paralysis is easily missed, so don’t forget a quick test to exclude quadriplegia, paraplegia, or a brachial plexus injury.
If he is conscious, ask him to move his arms and legs. If his legs are working, he has no serious spinal cord injury. Or, pinch one of his legs, and see if he complains.
If he is unconscious, check his pattern of breathing.
The following things suggest a spinal injury: (1) An accident in which there was violent movement of his neck, especially if he also has head or face wounds. (2) Severe occipital, shoulder, or arm pain. (3) Weakness or numbness in his arms or legs.
Don’t move him until you have evaluated his injury. You caNnot immediately exclude an injury to his spinal cord, so assume he has one and move him lying flat and without flexing or extending his spine as in Section 64.3.
Cervical cord injuries can come on insidiously, so don’t allow him to stand or sit up.
Clean the blood from his face, and note if it is coming from his nose or ears. If necessary, cut away his blood stained clothing. His history and immediate signs and symptoms will tell you what to expect, so look elsewhere for the detailed history and examination of his major injuries, such as those to his head (63.1), spine (64.3), thorax (65.1), abdomen (66.1), and pelvis (76.1).
Feel his limbs gently through his clothes. If there seems to be an injury underneath, you may have to cut them away along the seams. Compress his chest from front to back to test for fractured ribs (65.1).
On each side, feel the whole length of all his subcutaneous bones, the margins of his orbits, his clavicles, his olecranons, the subcutaneous borders of his ulnae, his patellae, and his tibiae.
CAUTION ! (1) Don’t forget to look for blood at the tip of his urethra (68.1). (2) Observe and record all bruises. If these bear the imprint of his clothing, the injury underneath them is likely to be severe. (3) Carefully turn him onto his side and examine his back. Deformity and bruising here may indicate an injured spine (64-6). (4) If he has any limb injuries, make sure that he has no injured tendons (55.11), nerves (55.8), or vessels (55.2) in his wrists, fingers, ankles, or feet.
Remove any large pieces of clothing or foreign bodies which come away easily. Cover any wounds or open fractures and do the rest of the exploration in the theatre (54.1).
Check the peripheral pulses of all his four limbs, especially the circulation peripheral to any limb injuries, particularly if he has supracondylar fractures of his humerus or femur. If a limb is cold and blue, a peripheral pulse is absent, or the capillary return to his nail beds is slow, you may need to reduce a fracture or dislocation urgently. CAUTION ! A delay of only 4 hours in restoring the circulation to a li mb can cause muscle necrosis (70.4).
Restore a patient’s respiration and circulation before you give him an analgesic. If you expect internal injuries, avoid morphine until you have planned a course of action. If he has severe multiple injuries, pain is not so much of a problem.
If a patient is merely restless, this probably indicates progressive bleeding rather than severe pain. He probably does not need morphine.
If he is in pain, give him small doses of intravenous morphine or pethidine. See also Section A 8.7. Dilute 10 mg of morphine in 10 ml of saline and give him fractions of 1 ml at a time intravenously until you have relieved his pain.
CAUTION ! (1) Don’t give him an intramuscular narcotic until you have excluded head and abdominal injuries, because they will confuse the diagnosis. You can give him small intravenous doses before you are certain of his diagnosis. If he has a head injury, he only needs morphine if he is conscious and has other injuries. (2) If he has a severe injury, such as a dislocated hip, he needs morphine—analgesic tablets are not enough!
If a patient has a severe abdominal or chest injury, or a low haemoglobin, give him oxygen. Otherwise it is unlikely to be useful.
Defer these until you have resuscitated the patient. If films are scarce, don’t X-ray the obvious. Where possible, try to do all X-rays in one trip. Wheel him to the theatre on a trolley with a radio–translucent top, so that he can be X-rayed on it with the minimum of movement. Splint limb fractures before he goes. This will minimize blood loss, and make positioning easier.
Take a chest X-ray and a supine view of the patient’s abdomen. Where posible, take the chest X-ray in the erect position. But beware-this is dangerous if he is shocked. If he is critically injured, X-ray only his major lesions initially. If you suspect a foreign body, X-ray the wound. If he has multiple injuries and needs an anaesthetic, X-ray him to exclude pneumothoraces, which would make anaesthesia dangerous.
CAUTION ! If you suspect a chest injury, but cannot confirm it clinically, X-ray him again in 48 hours. Lack of clinical signs does not exclude a haemothorax or pneumothorax of considerable size.
Before treating any peripheral fracture, make quite sure he has no proximal dislocation. If in doubt, X-ray him.
If you suspect an injury to his cervical spine, accompany him to the X-ray department yourself to supervise the way he is moved.
Complete these, record even negative findings, and make a management plan for the patient. If his consciousness is impaired, start a head injury chart. Prescribe all drugs and fluids. If there are many casualties, use Fig. 51-8.
If possible, ask if he is allergic to any drugs, particularly antibiotics.
![\includegraphics[scale=0.29]{/home/kumasi/Desktop/primsurg-tex/vol-2/fig/51-5.eps}](images/img-0010.png)
Don’t forget this, see Section 54.11.
Examine him again later after you have attended to his more obvious injuries. As he recovers, expect to find more injuries. Although you may have saved his life from a severe head injury, a finger fracture which you missed may trouble him ever after. A brachial plexus injury (71.3) is easily missed at the time of the accident.
A severely injured child is in special danger, particularly from thoracic injuries, because: (1) His blood volume is small, with the result that a correspondingly small loss can be fatal. So replace any blood he loses, even if it is only a little. (2) His air passages are small and are easily blocked.
If a patient is shocked, he will probably be thirsty. Don’t give him any fluids by mouth, including tea, even in minor injuries, because he may need a general anaesthetic. But, if you don’t have enough intravenous fluids, and he is not going to be operated on for some hours, an oral electrolyte fluid (58.5) can be life–saving, especially if you have many casualties to treat at the same time. Prevent a patient’s relatives from giving him food or fluids when they should not.
A patient’s stomach may be full and he may regurgitate its contents. So if he is drowsy or unconscious, or has severe injuries to his chest or abdomen, pass a nasogastric tube. This does not remove the risk of vomiting, perhaps with fatal results, but it does reduce its pro- bability.
Intense catabolism occurs some days after a severe injury. This is proportional to its severity, is worse if the injury is infected, and is especially important in severe burns, so see Section 58.11.
A patient may have been injured soon after his last meal. His stomach will empty very slowly. So, if he needs an anaesthetic, be safe, and use local anaesthesia when you can. If you have to give him a general anaesthetic, take the necessary precautions for anaesthetizing a patient with a full stomach (A 16.5).
If you are operating on a patient with multiple injuries, take the opportunity to insert traction tongs or Steinmann pins while he is in the theatre. Where possible, try to care for all his injuries at the same time.
(1) Never refer or evacuate a patient with an insecure airway—secure it first. (2) Even if a patient is not shocked, he must have a secure intravenous line—travel often causes shock in an injured patient.
Read on for the general methods for injuries of a patient’s: eyes (60.1), face (61.1), maxillofacial region (62.1), head (63.1), spine (64.1), chest (65.1), abdomen (66.1), kidneys (67.1), urinary tract, (68.1) or hand (75.1). Refer also to methods for specific injuries.
If a patient has lost consciousness after an injury, care for him as a head injury.
If he is severely injured, dead, or dying, talk to the relatives yourself, don’t leave this task to the nurses. If possible, give them the opportunity to talk to him.
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Primary Surgery Vol.2 – Trauma | |
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