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Chapter 9
Common surgical problems
Trauma
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
(Ref. Chart 1, p. xxii)
1.
Triage
•
2.
History and examination
•
3.
Emergency treatment, if required
Laboratory investigations, if required
Differential diagnoses
•
Main diagnosis
4.
Treatment
5.
Supportive care
6.
Monitoring
7.
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.