Surgery Online

Surgery and Surgical Procedure

Management in hospital

Reception in hospital

Planning and preparation

Accident departments dealing with the injured must have purpose-built and well-equipped resuscitation rooms. Medical staff should ideally be trained in a trauma system — ATLS provides an ideal framework within which to work and certification will soon be compulsory in the UK. Certification is already compulsory in North America. Nursing and other professional staff should also be trained within the system. Another advantage of a structured approach relates to equip­ment and layout. Working within a system removes debate concerning intravenous fluid type and amounts, techniques and investigations to be performed, and the summoning of appropriate specialists. Agreement in these areas is laid down in advance and allows medical teams to work within a com­mon language and sequence.

The trauma team

While a suitably trained doctor can successfully assess and resuscitate an injured patient while working to a system, it is obvious that a team approach is more efficient and is quicker. This is the vertical (alone) versus the horizontal (team) argument. Dr Peter Driscoll in Salford has shown clearly the benefits of a team in improving outcome. The team should initially comprise four doctors, five nurses and a radiographer. Roles should be paired and tasks allocated on a pre­agreed basis. To avoid chaos, there should be no more than six people physically attending to the patient at any one time. Others should stand back until called to perform specific tasks such as vascular access, radiographic assessment or assisting in log rolling. The team should have a leader responsible for co-ordination and at least one member should be a trained general surgeon. Injury is a surgical disease and surgical consultation is required throughout.

Controversy once surrounded the mobilisation of the trauma team, with accusations of inappropriate call-out resulting in time wasted from clinics and operating lists. This has now been resolved by widespread acceptance of traumateam call-out criteria. Agreed factors indicating high risk of 7multiple injuries and justifying trauma team mobilisation are (after Champion):

• penetrating injury to the chest, abdomen, head, neck or groin;

• two or more proximal long bone fractures;

• flail chest and pulmonary contusion;

• evidence of high-energy impact:

—  falls of 2 m (6 feet) or more;

—    changes in velocity in an road traffic accident of 32 km/hour (20 miles/hour) or more estimated from outward deformity of car;

—    rearward displacement of front axle;

—    sideward intrusion of 35 cm or more on the patient’s side of the car;

—    ejection of the patient;

—    rollover;

—  death of another person in the same car;

—    pedestrian hit at more than 32 km/hour.

Initial assessment and resuscitation

The objectives in this phase are to seek and manage immediately life-threatening conditions. In ATLS language this is the ‘primary survey and resuscitation’, following an ABCDE sequence in every circumstance. The description that follows holds good for vertical (alone) or horizontal (team) management. The only radiographs permitted during this phase are:

• cross-table lateral cervical spine;

• antero-posterior supine chest X-ray;

• antero-posterior plain pelvic film.

A— Airway management and cervical spine control

Injury to the cervical spine is assumed in the presence of injury above the clavicle, loss or alteration of conscious level, involvement in high-speed collisions or where there is a his­tory of neck pain. Airway assessment and management is performed with the cervical spine immobilised in the neutral position by manual in-line immobilisation or by a well-fitting neck brace, sandbags and forehead tape. Many injured patients arrive in the accident department with neck protection already in situ. In a conscious patient, speaking in a normal voice, the airway is patent and the brain is being adequately perfused. If the patient does not reply to a simple question, the airway is opened and dealt with as described for prehospital personnel. If there is any doubt concerning the integrity of the airway, skilled anaesthetic help should be summoned if not already present as part of an attending trauma team. All injured patients require supplemental oxygen at 15 litres/minute via a mask with a rebreathing bag.

B— Breathing and ventilation

The neck and chest are exposed. Examination involves inspec­tion, palpation, percussion and auscultation. The examination starts in the neck with inspection for wounds, condition of neck veins, wounds and evidence of tracheal injury. The respiratory rate is counted and recorded, with the time noted. Chest symmetry and respiratory effort are assessed. Wounds and bruising are noted. Palpation, particularly to include the sides and back (without spinal movement), is performed gently followed by percussion and auscultation. A dull percus­sion note and absent breath sounds over a hemithorax in the presence of shock are indicative of massive haemothorax. The objective is to hunt out and treat the six life threatening thoracic conditions listed below

Immediately life-threatening thoracic conditions

• Airway obstruction (dealt with under ‘A)

• Tension pneumothorax

• Massive pneumothorax (> 1500 ml blood in a hemithorax)

• Open pneumothorax (sucking wound’)

• Flail segment with pulmonary contusion

• Cardiac tamponade (almost always penetrating injury)

Tension pneumothorax requires immediate needle thoracocentesis in the second intercostal space in the midclavicular line on the affected side, followed by tube thoracostomy through the fifth intercostal space just anterior to the midaxillary line. Massive haemothorax is a combined breath­ing (B) and circulation (C) problem with death likely from hypovolaemic shock and impaired ventilation. Management is therefore by vigorous support of the circulation followed by tube thoracostomy. Open pneumothorax is managed by sealing the wound with a dressing secured on three sides followed by tube thoracostomy. Following insertion of the tube, the dressing is sealed on the fourth side. Flail segment with underlying contusion (always present) requires consul­tation with anaesthetic colleagues as endotracheal intubation and mechanical ventilation may be required to maintain adequate arterial oxygen saturation. Diagnosis of cardiac tamponade requires a high index of suspicion, particularly if a penetrating wound is noted medial to the nipples anteriorly or medial to the scapulae posteriorly. Needle pericardiocentesis may be life-saving in the short term; thoracotomy and repair are required for definitive management.

C— Circulation and haemorrhage control

This begins with assessment for signs of shock. Tachycardia in a cold patient indicates shock. Equally, shock associated with injury is hypovolaemic until ruled out. Causes of shock are listed below.

Causes of shock following injury

•     Hypovolaemic — haemorrhagic (most common)

•   Cardiogenic or pump failure (cardiac tamponade, tension pneumo­thorax or myocardial contusion)

•      Neurogenic (often combined with hypovolaemic shock and masked)

• Septic (a late event > 24 hours and associated with missed faecal spillage)

An early attempt should be made to assess the degree of blood loss. Blood loss may be external and obvious, or internal and covert, or combinations of both. External bleeding sites are dealt with by direct pressure at this stage. A hunt must be undertaken for signs of covert bleeding. Bleeding in the chest will have been noted already. The abdomen and pelvis must be rapidly assessed for signs of injury. A good aidemémoire is ‘blood on the floor and four more’:

•  blood on floor or enviornment , including clothing.

• blood inthe chest (dull percussion note);

• abdomen (wounds, abrasions, tenderness but may be silent);

• pelvis (usually associated with obvious pelvic disruption);

• limbs (should be obvious).

The presence of shock demands the presence of a surgeon, appropriate to the region injured if this is obvious. Whereas intravenous fluid administration has a vital role, the emphasis must be on stopping the bleeding by surgical means. Vascular access for resuscitation is by cannulation of peripheral veins

— if this fails, venous cut-down at the ankle or elbow is recommended. Once a cannula is in position, 20 ml of blood should be withdrawn for group, type or full cross-match depending on the degree of urgency. Central access will be required later for monitoring but is not a good route for initial resuscitation owing to slow flow rates, technical difficulty and uncertainty concerning position of the catheter

tip. There is revival of interest in interosseous access for adults. It is too early to comment on its utility for general use. Its place is well established for children under the age of 6 years and should be resorted to without hesitation if peripheral access fails on two attempts. Special paediatric interosseous needles are available commercially.

In adults, 1—2 litres of warmed Hartmann’s (Ringer’s) solution is recommended as an initial fluid challenge. The initial volume in children is calculated according to weight and is by convention 20 mI/kg body weight. This bolus may be repeated once.

The patient should now be reassessed. The three responses that may be seen are given below.

Responses to initial fluid challenge

•      Immediate and sustained return to normal vital signs

• Transient response with later deterioration

• No improvement

Immediate responders are likely to have less than 20 per cent blood loss and bleeding will have ceased spontaneously or by direct pressure — an open fracture of tibia, for example. Transient responders may have intra-abdominal or thoracic bleeding, and surgical intervention will be required. Non-responders are bleeding actively, usually in a body cavity, or shock is nonhaemorrhagic in nature. Hypovolaemic patients have lost over 40 per cent of their blood volume, demanding immediate surgical intervention. Continuing intravenous fluid administration may actually be detrimental.

D— Dysfunction of the central nervous system

The AVPU and pupillary assessment carried out by pre­hospital personnel is repeated. In addition, a rapid assessment of motor and sensory function is performed looking only for gross and obvious signs. A more detailed assessment will be carried out during the secondary survey (see later).

E— Exposure and environment

Any remaining clothing should now be removed. The environment must be considered. If too cold, hypothermia will ensue. Blankets or air heaters should be used if available.

Critical decisions

The response of the injured patient to the primary survey and resuscitation phase will influence decision making. A patient in whom no life-threatening condition was found, or one whose condition responded well and in a sustained way, is now fit for a full secondary assessment which may be carried out in the resuscitation room or in a ward area following admission. Some patients will have failed to respond and require immediate removal to the operating theatre. Exam­ples include disruptive pelvic injury, major liver laceration or injuries to multiple body systems requiring immediate con­trol of blood loss — these are relatively rare. Initial surgery in this instance is part of the primary survey and a secondary survey, although deferred, must not be forgotten. Good note-keeping and records are vital. A significant number of patients will respond transiently and is best taken to a critical care environment where more advanced resuscitation techniques and assessments are possible. Such patients will require surgery but it is usually possible to investigate and plan in advance. Examples include splenic laceration, bowel injury, diaphragmatic disruption, or multiple fractures and soft-tissue wounds. In summary, the patient may be taken to the ward, critical care unit or to theatre.

Secondary survey

This phase comprises a head-to-toe examination of the undressed and stable patient. It is lengthy and includes a detailed history if this is feasible. The examination may be conducted in any order. The description here starts with the head and works distally. At this time check that vital signs monitoring devices are in situ. These should include a pulse oximeter and an oesophageal or a rectal thermometer. During this phase detailed radiographic procedures including computerised tomography (CT) and dye studies may be performed. Patients should be stable and can therefore travel safely for CT, ultrasound or even magnetic resonance imaging (MRI) investigations if these are indicated.

Head and Glasgow Coma Scale (GCS)

A thorough check is undertaken for signs of external injury such as bruising, laceration or bony deformity. Depressed skull fractures may or may not he palpable.

At this stage, the patient’s conscious level is determined by applying the GCS, which measures eye opening, best verbal response and best motor response. The use of this coding system is detailed fully in Chapter 35 on ‘Cranium and head injury’. Neurological deterioration may indicate a haemorrhagic space-occupying lesion or rising intracranial pressure, or it may be due to hypoxia and hypoperfusion. Hypercarbia and hypoxia are the commonest causes of the preventable ‘second injury’ in head-injured patients. Hypotension in a head-injured adult should lead to a further search for evidence of blood loss elsewhere.

The nostrils and external auditory meatus are examined for rhinorrhoea or otorrhoea. Cerebrospinal fluid from these orifices mixed with blood produces a double ring if dropped on a hospital sheet or pillowcase.

Face

Maxillofacial injuries are discussed in Chapter 38. In summary, the eyes are checked for foreign bodies, perforation, subconjunctival haemorrhage, visual acuity, and pupillary and corneal reflexes. The mandible is checked for fracture and stability. Maxillary stability is also assessed — fractures of the middle third of the face may be displaced with risk to the airway, either immediately or late as a result of expanding haematoma. The mouth is checked again for broken teeth, loose dentures and foreign bodies. Check also for retropharnygeal haematoma. This may be associated with previously undetected cervical spine injury.

Neck

Look for subcutaneous emphysema. Palpate (gently) the cervical spine. A lateral radiograph showing all seven cervical vertebrae and the upper border of the first thoracic is essential in all multisystem injury patients. Particular care should be taken not to miss lesions at Cl, C2 and C7 levels

— fractures and dislocations at these levels are notoriously unstable. Downward traction on the arms while the film is being taken will enhance the demonstration of the lower cervical and Ti vertebrae. In some cases a ‘swimmer~ s view may be necessary — see also Chapter 33 on the spine.

Thorax

Start by repeating the steps on thoracic assessment performed in the primary survey. The search is now for potentially life-threatening and less serious injuries. These are listed below. Remember, penetrating and blunt injury below the nipples (male patient) raises the likelihood of injury to intra-abdomi­nal structures, in particular the liver, spleen, stomach and transverse colon. Simple haemothorax and pneumothorax may be picked up on an anteroposterior (AP) supine chest radiograph. Tube thoracostomy will suffice in most instances. Check also for the integrity of diaphragm, particularly on the left.

Secondary survey — potentially life-threatening injuries

•  Pulmonary contusion

•  Myocardial contusion

• Aortic tear

•  Diaphragmatic tear

•   Oesophageal tear

•  Tracheobronchial tear

Abdomen

The secondary survey is the phase of ‘fingers and tubes’ in every orifice. This particularly applies to the abdomen. Nasogastric and urinary catheters are inserted for diagnostic and assessment purposes. The abdomen is now fully examined in the usual way. A rectal examination and inspection of the per­ineum is mandatory. At this time please read the relevant sec­tions on specific injuries in Chapters 50—61 inclusive. Wounds should be covered with sterile dressings or towels. Eviscerated bowel should be covered in warm wet packs and must not be returned to the peritoneum at this stage. Assessment of the abdomen in cases of penetrating trauma is relatively easy. In most instances the abdomen will need to he explored. In some large centres, protocols may permit local exploration of stab wounds in stable patients. Difficulty arises in cases of blunt injury, all the more when multiple injuries are present or where the conscious level is altered. Diagnostic peritoneal lavage, ultrasound examination or, in some specialist centres, laparoscopy may be required to detect covert intra-abdominal injury. The retroperitoneum is notoriously silent. All of the foregoing remarks refer to stable patients. Any deterioration should lead to consideration of rapid surgical exploration.

Pelvis

The pelvis is gently compressed and distracted manually to check for pain enhancement and pelvic stability. If not already to hand, an AP radiograph of the pelvic ring should be obtained. Blood at the urinary meatus may indicate urethral injury. If injury is suspected, get expert help. If not available, do not catheterise; instead, place a suprapubic catheter.

Spinal in juries

Tests are made for peripheral sensory and motor defects. In spinal injuries with unstable fractures, further neurological damage can be caused by moving the patient inappropriately. Full examination will require the patient to be log rolled when sufficient personnel are present. At least five people are needed. The team leader should control the neck and co­ordinate. Three others are needed to effect rolling the torso and limbs, and a doctor to examine the back and perineum. A rectal examination is performed if not done before. In large urban centres, severely injured patients may he transported to hospital on a long spine board. Removal from the board on to a hospital trolley requires the same care as for a log roll.

Extremities

The limbs should be fully assessed for evidence of injury. This should include a complete neurovascular examination. Appropriate radiographs may be obtained at this stage.

Drug administration

As part of the early management of the injured patient, con­sideration should be given to administration of analgesics. Opiates are best, given in small intravenous increments. Anti­biotics and tetanus prophylaxis may also be appropriate.

Definitive care plan

A position should now have been reached where a daily management and definitive plan is initiated. Patients with multiple injuries may require the attention of a number of specialists. A decision on ‘ownership’ must be made but with arrangements for all involved to have access. The patient should not ‘fall between two stools’, without anyone in overall charge. The most appropriate person to take primary responsibility in such cases is usually the general or orthopaedic surgeon.

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April 12, 2009 - Posted by | Accident and emergency | , , ,

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