Funded under USAID Cooperative Agreement No. 663-A-00-00-0358-00.

Produced in collaboration with the Ethiopia Public Health Training Initiative, The Carter

Center, the Ethiopia Ministry of Health, and the Ethiopia Ministry of Education.

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Limited permission is granted free of charge to print or photocopy all pages of this publication for educational, not-for-profit use by health care workers, students or faculty. All copies must retain all author credits and copyright notices included in the original document. Under no circumstances is it permissible to sell or distribute on a commercial basis, or to claim authorship of, copies of material reproduced from this publication.

©2004 by Mensur Osman, Zeki Abdurahman, Gashaw Messele, Yemane Ayele, Abraham Deneke, Asrat Sime, Tariku Gelda M.D, Misgina Fisseha, Abera A. Gobeze, Mekdim Tadesse, Yimaj Abdulwahib

All rights reserved. Except as expressly provided above, no part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission of the author or authors.

This material is intended for educational use only by practicing health care workers or

students and faculty in a health care field.

ACKNOWLEDGMENT

The team of authors form the departments of surgery of varies university would like to thank and express their deep rooted gratitude to The Carter Center (EPHTI) for its initiation and drive to prepare this teaching material.

The team would like to thank the administration of university of Gondar University, Jimma University, Alemaya University and Debub University for extending support to authors whenever it was needed.

The authors are particularly grateful to Dr. Berhanu Kotisso associate professor and Dr. Girmaye Tamirat Asst. professor of surgery in a Addis Ababa University for their highly professional input that shaped this teaching material for the benefit of health science students.

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Table of Contents
Acknowledgment	i
Table of Contents	ii
Chapter One: Shock	1
Introduction	1
Classification	1
Patho Physiology of Shock	2
Management of Shock	3
Complications of Shock	4
Chapter Two: Fluid and Electolytes	5
Introduction	5
Normal Distribution of Body Fluids	5
Disturbances of Fluid and Electrolytes	7
Acid – Base Balance	12
Review Questions	15
References	16
Chapter Three: Blood Transfusion	17
Indications for Blood Transfusion	17
Compatibility Tests	17
Component Therapy	18
Review Questions	21
References	22
Chapter Four: Pre-Operative and Post-Operative Care	23
Introduction	23
General Consideration	23
Assessment and Minimization of Surgical Risks	24
Post-Operative Care, Complications and Their Treatment	26
Post Operative Intestinal Obstruction	31
Hematoma, Abscess and Seromas	33
Review Questions	34
References	35
Chapter Five: Aseptic and Antisepic Techniques	36
Introduction	36
Choice of Antiseptic	37
Review Questions	41
References	42
Chapter Six: Suture Materials and Suturing	43
Types of Suture Materials	43
Suturing Techniques	44

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Chapter Seven: Wounds- Wound Healing and Care	47
Introduction	47
Wound Healing	47
Wound Assessment and Classification	49
Wound Management	50
Crush and Avulsion Wounds	53
Wound Complications	55
Review Questions	57
Key To the Review Questions	59
References	60
Chapter Eight: Surgical Infections	61
Introduction	61
Classification	62
Pathogenesis	62
Specific Types of Infections	64
Review Questions	73
Key To the Review Questions	75
References	76
Chapter Nine: Trauma	77
Introduction	77
Treatment Priorities	78
Road Traffic Accidents	79
Firearm Injuries	80
BURN INJURIES	81
Review Questions	84
References	85
Head and Spinal Injuries	86
Head Injury	86
Brain Injuries	87
Spinal Cord Injuries	90
Review Questions	92
References	93
Chapter Ten: Orthopedic Surgery	94
Introduction	94
Infections of Bones and Joints	94
Fractures	97
Dislocations	102
Amputations	103
Review Questions	105
References	106
Chapter Eleven: Anesthesia	107
Pre-Anesthetic Patient Evaluation and Preparation	107

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Cardiopulmonary Resuscitation	111
Systemic (General) Anesthesia	115
Regional Anesthesia	118
Review Questions	124
References	125
SYSTEMIC SURGERY
Chapter One: The Thyroid Gland	126
Thyroid Enlargement: Goiter	126
Neoplasms of the Thyroid	130
Review Questions	132
References	133
Chapter Two: The Breast	134
Introduction	134
Anatomy	134
Breast Lumps	135
Carcinoma of the Breast	137
Review Questions	140
References	141
Chapter Three: The Chest	142
Introduction	142
Upper Airway Obstruction	142
Tracheostomy	143
Chest Injuries	146
Pneumothorax	149
Hemothorax	149
Tube Thoracostomy (Chest Tube)	150
Empyema and Lung Abscess	152
Lung Abscess	154
Review Questions	156
References	157
Chapter Four: Gastrointestinal Tract	158
Introduction	158
Upper Gastrointestinal Bleeding	159
Colorectal Tumors	164
Common Perianal Conditions	166
Anal Fissure (Fissure in ANO)	170
Hemorrhoids (Piles)	171
References	175
Acute Abdomen	176
Intestinal Obstruction	177
Sigmoid Volvulus	179

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Appendicitis	180
Peritonitis	183
Hepato Biliary Diseases	185
Hydatid Cyst of the Liver	187
Diseases of Gall Bladder and Biliary Tree	189
Obstructive Jaundice	193
Review Questions	197
Abdominal Wall Hernias	198
Introduction	198
Risk Factors for Abdominal Wall Hernia Development	199
Specific Types of Hernia	200
Review Questions	204
References	205
Stomach and Duodenum	206
Introduction	206
Peptic Ulcer Disease	206
Gastric Cancer	211
Review Questions	213
DYSPHAGIA	214
Introduction	214
Dysphagia	214
Carcinoma of the Esophagus	215
Review Questions	218
References	219
Chapter Five: Urology	220
Introduction	220
Urinary Symptoms and Investigations of Urinary Tract Problems	220
Acute Renal Failure (Anuria/Oliguria)	222
Disorder of the Kidneys and Ureters	223
Urinary Tract Infection	224
Renal Tuberculosis	226
Urinary Bladder	230
Bladder Cancer	231
Benign Prostatic Hyperplasia	231
The Urethra and Penis	233
Urethral Stricture	234
Review Questions	238
References	239

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CHAPTER ONE

SHOCK

Learning Objectives

At the end of this chapter, each student should be able to:

•State the clinical definition of shock

•List the chief characteristics and causes of all types of shock

•Describe the clinical symptoms and signs that are indicative of shock

•List the immediate treatment measures to prevent complications

Introduction

Shock is a life-threatening condition which occurs when the circulatory system fails to deliver oxygen and nutrients to the body tissues and becomes unable to remove waste products from the body. It is a descriptive term based on the symptoms and signs secondary to one or more of a wide range of problems. If not recognized and corrected as early as possible, shock may rapidly progress to an irreversible state with subsequent multi-organ failure and death.

DEFINITION

Shock is defined as a pathological state causing inadequate oxygen delivery to the peripheral tissues and resulting in lactic acidosis, cellular hypoxia and disruption of normal metabolic condition.

CLASSIFICATION

Shock is generally classified into three major categories:

1.Hypovolemic shock

2.Cardiogenic shock

3.Distributive shock

Distributive shock is further subdivided into three subgroups:

a.Septic shock

b.Neurogenic shock

c.Anaphylactic shock

Hypovolemic shock is present when marked reduction in oxygen delivery results from diminished cardiac output secondary to inadequate vascular volume. In general, it results from loss of fluid from circulation, either directly or indirectly.

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e.g. ▪ Hemorrhage

ƒLoss of plasma due to burns

ƒLoss of water and electrolytes in diarrhea

ƒThird space loss (Internal fluid shift into inflammatory exudates in the peritoneum, such as in pancreatitis.)

Cardiogenic shock is present when there is severe reduction in oxygen delivery secondary to impaired cardiac function. Usually it is due to myocardial infarction or pericardial tamponade.

Septic Shock (vasogenic shock) develops as a result of the systemic effect of infection. It is the result of a septicemia with endotoxin and exotoxin release by gram-negative and gram-positive bacteria. Despite normal or increased cardiac output and oxygen delivery, cellular oxygen consumption is less than normal due to impaired extraction as a result of impaired metabolism.

Neurogenic shock results primarily from the disruption of the sympathetic nervous system which may be due to pain or loss of sympathetic tone, as in spinal cord injuries.

PATHO PHYSIOLOGY OF SHOCK

Shock stimulates a physiologic response. This circulatory response to hypotension is to conserve perfusion to the vital organs (heart and brain) at the expense of other tissues. Progressive vasoconstriction of skin, splanchnic and renal vessels leads to renal cortical necrosis and acute renal failure. If not corrected in time, shock leads to organ failure and sets up a vicious circle with hypoxia and acidosis.

CLINICAL FEATURES

The clinical presentation varies according to the cause. But in general patients with hypotension and reduced tissue perfusion presents with:

ƒTachycardia

ƒFeeble pulse

ƒNarrow pulse pressure

ƒCold extremities (except septic shock)

ƒSweating, anxiety

ƒBreathlessness / Hyperventilation

ƒConfusion leading to unconscious state

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Summary: Clinical features of hypovolemic shock in adults with estimated volume loss.

Estimated blood loss	750-1500ml	1500ml-2000ml	>2000 ml
Blood pressure	Normal	Reduced	Severely Reduced
Pulse rate	>100/min	>120/m	>140/m
			very feeble
Capillary refill	Slow	Slow	Undetectable
Respiratory rate	20-30/m	30-40/m	>35/m
Urinary flow rate	20-30/hr	10-20/hr	0-10/hr
(Normal: 30-60 ml/hr or 0.5-
1ml/kg/hr)
Mental state(CNS)	Anxious	confused	Lethargic, comatose

MANAGEMENT OF SHOCK

Treatment is aimed at restoring oxygen delivery to the cells of vital organs as rapidly as

possible. The management depends on the cause and type of shock.

General Management

•Monitor the airway, breathing and circulation as first priority

•Stop bleeding

•Fluid resuscitation, preferably crystalloids

•Head down position

•Treat the cause

•Transfusion of compatible blood if indicated

•Oxygen and other supportive measures like inotropic agents

•Monitoring of resuscitation effectiveness: e.g. determine hourly urine output, blood pressure and pulse rate

Specific Management

Hypovolemic Shock: The goal of treatment is to restore vascular volume. This is effected by:

ƒGeneral approach as above

ƒFluid and blood replacement

ƒOxygen support etc.

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Septic Shock

ƒInitial management as above

ƒAppropriate antibiotics especially for gram-negative microorganisms

ƒInotropic support such as adrenaline and dopamine

ƒSurgical eradication of the infection focus

Cardiogenic shock

ƒInitial management as above

ƒInotropes

ƒTreat the causes

ƒEtc.

Neurogenic shock

ƒInitial management as above

ƒPain relief

ƒTreat the causes, give supportive measures like inotropic support

COMPLICATIONS OF SHOCK

The main complications of severe shock include:

1.Shock lung (ARDS)

2.Acute renal failure

3.Gastrointestinal ulceration

4.Disseminated intravascular clotting

5.Multiorgan failure

6.Death

Therefore, a patient in shock requires immediate emergency treatment. Early diagnosis and immediate correction of shock prevents permanent organ damage and death.

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CHAPTER TWO

FLUID AND ELECTOLYTES

Learning Objective

At the end of this chapter, the learner should know:

•The anatomy and physiology of body fluids and electrolytes

•The common fluid and electrolyte changes, their causes and management

•The common acid base imbalances and their treatment

Introduction

Knowledge about fluid electrolyte and acid base changes and their management is basic to the care of the surgical patient. Many disease processes result in changes that could result in rapid deterioration of the patient and death. Anyone caring for surgical patients should have a basic knowledge of fluid, electrolyte, acid and base disturbances, as well as their causes and their management.

DEFINITIONS

Moles or millimoles: number of particles present per unit volume

Equivalents or milliequivalents: number of electric charges per unit volume.

Osmoles or milliosmoles: number of osmotically active particles or ions per unit volume.

A mole of a substance is the molecular weight of that substance in grams. An equivalent of an ion is its atomic weight expressed in grams divided by the valence. In case of univalent ions, one milliequivalent (meq) is the same as one millimole. In case of divalent ions such as calcium or magnesium, one mole equals two meq. When the osmotic pressure of a solution is considered, it is more descriptive to use units of osmole or milliosmole.

These units refer to the actual number of osmotically active particles present in solution but they are not dependent on the chemical combining capacities of the substances. Thus, a millimole of sodium chloride which dissociated into sodium and chloride contributes 2 milliosmole.

NORMAL DISTRIBUTION OF BODY FLUIDS

Total body water

The total body water constitutes 50 – 85% of total body weight depending on age and lean body mass (muscle mass). In regard to this, 55% - 60% of body weight for a 70 Kg young

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man is water. Females have lower body water (45 –60%) because of the high fat content of their body. The total body water in neonates is 80%-85%, which is higher than in adults.

Total body water is further divided into two:

1.Intracellular fluid, comprising 2/3 of total body water

2.Extra cellular fluid, comprising 1/3 of total body water. The extra cellular fluid is sub divided into Intravascular (plasma) comprising 2/3 of extra cellular fluid and Interstitial which comprises 1/3 of extra cellular fluid.

N.B. Physiologically all compartments of body water are interdependent.

CHEMICAL COMPOSITION OF BODY FLUID COMPARTMENTS

CATIONS		ANIONS			CATIONS		ANIONS			CATIONS	ANIONS
154meq/l		154 meq/L			200 meq/L		200 meq/L			154meq/l	154 meq/L
		103			NA+ 144		CL	114		K+ 150	HPO4=
NA + 142		HC3-	27				HCO3- 30				So4= 150
		SO4-	3				SO4- 3
		PO4-					PO4-			Mg ++ 40	HCOc3- 10
k+	4	ORGANIC			K+		Organic
ca ++	5	ACID	5		Ca++ 3		Acid	5		Na+	Protein 40
Mg ++	3	Protein 16			Mg ++		protein	1
Plasma					Intracellular fluid					Interstitial fluid
AVERAGE DAILY WATER EXCHANGE
Out put			Urine:			1500 ml
			Insensible loss:			1000 ml (up to 1700 in hot climate)
			Stool:			200 ml
			Total:			2700-3400ml
Intake			Endogenous:			200 ml (from oxidation of ingested food.)
Net requirement:						2500-3200

N.B: A minimum urinary output of approximately 400 ml in 24 hours is required to excrete the end products of metabolism.

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Clinical feature

Depends on the severity of fluid loss

Moderate (5-10%): sleepiness, orthostatic hypotension

Severe (more than 15%): signs of hypotension, stupor or coma, sunken eye balls, dry oral mucosa and tongue, poor skin turgor and decrease in body temperature.

Treatment

Placement of extra cellular loss with fluid of similar composition:

Blood loss: Replace with Ringer’s Lactate, Normal Saline or Blood, if needed

Extra cellular fluid: Replace with Ringer’s Lactate, Normal Saline

Rate of fluid replacement

The Rate depends on the degree of dehydration. It should be fast until the vital signs are corrected and adequate urine output is achieved. One liter over 30 minutes to one hour can be given for severe dehydration.

Monitoring

The general condition and the vital signs of the patient should be followed. The urine out put should be monitored hourly.

Auscultate the chest to follow overload especially in children and the elderly.

Volume Excess

Extra cellular fluid volume excess is generally iatrogenic or secondary to renal insufficiency, cirrhosis, or congestive heart failure.

Clinical feature

Subcutaneous edema, basilar rales on chest auscultation, distention of peripheral veins, and functional murmurs may be detected. Children, the elderly, patients with cardiac or renal problems are at increased risk of dangers of fluid replacement.

Treatment

ƒStop IV fluids (Fluid restriction)

ƒDiuretics: e.g. frusemide

DISTURBANCE IN ELECTROLYTES

Even though there can be disturbance in any of the electrolytes, the most commonly encountered ones are discussed here.

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Sodium (Na+)

•It is the most abundant caution of the extra cellular fluid

•After trauma and surgery, there is a period of shut down of sodium excretion for up to 48 hours. During this period, it may not be advisable to administer large quantities of isotonic saline.

•The concentration of serum sodium is not related to the volume status of extra- cellular fluid. A severe volume deficit may exist with a normal low or high serum level.

•Daily requirement of sodium is one millimol/kg. The excretion of sodium by the kidneys is under the control of aldosterone.

Sodium depletion (Hyponatremia): Na+ less than 130 milliequivalent/liter

Hyponatremia can be associated with

1.Volume depletion, sodium and water depletion. Most frequent cause of sodium and water depletion in surgery is small intestinal obstruction. Duodenal, Biliary, pancreatic and high intestinal fistula are also causes of hyponatremia.

2.Water intoxication with excess volume and edema, over-prescribing of intravenous 5% D/W and colorectal washouts with plain water

Clinical feature

It can present with signs and symptoms of either fluid excess or fluid overload depending on the primary cause.

Laboratory:

Serum sodium and other electrolytes, hematocrit drops

Treatment

Ringer’s Lactate or Normal Saline In cases of volume depletion.

Fluid restriction and sodium sparing diuretics In case of fluid excess.

Sodium Excess (Hypernatremia): Na+ more than 145 mmol

Causes

ƒExcessive water loss in burns or sweating, insensible losses through the lungs.

ƒExcess amount of 0.9% saline solution is given IV during the early operative period where there is some degree of retention of sodium.

Clinical feature

Depending on the cause it can be of fluid excess or fluid deficit.

Treatment

5% D/W can be infused slowly

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Potassium (K+)

Potassium is the most abundant intracellular cation. 98% of potassium is found intracellular with ¾ of the total body potassium in skeletal muscles. The average daily requirement is 1 mmol/kg.

Potassium depletion (Hypokalemia): K + less than 3.5 millimol

Causes

1.Loss in gastrointestinal secretions such as vomiting in GOO or diarrhea

2.Movement of potassium into cells e.g. in alkalosis

3.Prolonged administration of potassium free parenteral fluids with continued obligatory renal loss of potassium

4.Excessive renal excretion – e.g. Diuretic use.

Clinical features

Most patients are asymptomatic. Clinical symptoms and signs such as listlessness, slurred speech, muscular hypotonia, and depressed reflexes are presenting features. Abdominal distention results due to paralytic ileus.

Treatment

ƒOral potassium in the form of milk, meat extracts, fruit juices, honey and KCl tablets

ƒ40 mmol KCl IV added to 1 liter of fluid run over 6 -8 hours. Never directly IV.

ƒCorrect the underlying cause

N.B.:- Administration should be properly controlled, the level of potassium should be checked daily and the urine out put must be adequate.

Potassium Excess (Hyperkalemia): K + more than 5 mmol

Significant quantity of intracellular potassium is released into the extra cellular space in response to severe injury, surgery, acidosis and a catabolic state. A significant rise in serum potassium concentration may occur in these states in the presence of oliguric or anuric renal failure. A renal insufficiency with hypoaldosteronism can cause hyperkalemia.

Clinical features

Nausea, vomiting, intermittent intestinal colic and diarrhea are the presenting pictures. Cardiovascular signs are apparent on ECG with high peaked T waves, widened QRS complex and depressed ST segment. Disappearance of T waves, heart block and cardiac arrest may develop with increasing levels of potassium.

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Treatment

Measures to reduce K+ level:

ƒAdministration of bicarbonate and glucose with insulin. 10 to 20 units of regular insulin and 25 to 50 g of glucose can be used.

ƒ10 ml of 10% calcium gluconate to suppress the myocardial effect

ƒEnteral administration of cation exchange resign (Kayexalate).

ƒDialysis

ƒAvoid exogenous potassium

Calcium (Ca++)

Normal serum level is 8.5 to 10 .5 mg/dl. An increase in pH causes a fall in the ionized proportion of calcium. Calcium imbalance is not frequently encountered.

Hypocalcaemia (serum level below 8mg/dl)

Common causes include:

Hypoparathyroidism after thyroid surgery

Acute pancreatitis

Massive soft tissue infection (necrotizing fascitis) and

Pancreatic and small bowel fistulas

Clinical feature

Latent hypocalcemia: Positive Chovestek’s and Trousseu’s sign.

Symptomatic: Numbness and tingling, hyperactive tendon reflexes, muscle and abdominal cramp, tetany with carpopedal spasm and convulsions.

Treatment

IV Calcium gluconate (10ml of 10% solution over 10 minute) or calcium chloride. Calcium lactate may be given orally with or without Vitamin D.

Hypercalcaemia (serum calcium over10.5mg/dl)

Hypercalcaemia occurs with hyperparathyroidism, Vitamin D intoxication, cancer and prolonged immobilization. It is uncommon in surgical patients.

Clinical feature

Most are asymptomatic. Symptoms can include fatigue, lassitude, weakness of varying degree, anorexia, nausea and vomiting. Other symptoms include severe headaches, pain in the back and extremities, thirst, polydypsia and polyuria.

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Treatment

A serum level of calcium of 15 mg/dl or higher requires emergency treatment.

ƒVigorous volume repletion with salt solutions.

ƒOral or IV inorganic phosphate or mithramycin.

ACID – BASE BALABCE

Normally, the blood pH lies within the range of 7.36-7.44. The control of this tight balance is accomplished by:

•Blood buffer:- which includes the bicarbonate and carbonic acid, phosphates ,serum proteins and meth-hemoglobin( play a greatest role from the blood buffers)

•The lung:- excretes acid(CO2 )

•Kidney :- the ultimate organ to maintain imbalance to near normal by its capacity to excrete both acid and base.

Alkalosis (accumulation of Base or loss of acid)

Metabolic Alkalosis

Causes

•Loss of acid from the stomach by repeated vomiting or aspiration

•Excessive ingestion of absorbable alkali

•Hypokalemic alkalosis in patients with pyloric stenosis: potassium loss due to repeated vomiting.

Clinical Features

•Cheyne-stokes respiration with periods of apnea

•Tetany sometime occurs.

Treatment

•Repletion of volume + potassium (check urine output )

•Use of 0.1 N or 0.2 N HCl is also effective in treatment of resistant metabolic alkalosis.

Respiratory Alkalosis (PCO2 below the normal range of 31 – 42 mmHg)

Causes

Most common cause is excessive pulmonary ventilation by anesthetized patients in surgical practice. It can also be caused by hyperventilation due to severe pain, hyper pyrexia and high altitude.

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Clinical Features

The dangers of a severe respiratory alkalosis are those related to potassium depletion and include the development of ventricular arrhythmias and fibrillation.

Treatment

Can be corrected by breathing into a plastic bag, or insufflation of carbon dioxide.

Acidosis (accumulation of acid or loss of base)

Metabolic Acidosis

Causes

Increase in fixed acids due to:

•Anaerobic tissue metabolism (shock, infection, tissue injury)

•Retention of metabolites in renal insufficiency

•Formation of ketone bodies in diabetes or starvation

Loss of bases in:

ƒChronic diarrhea, gastro colic or high intestinal fistula, excess intestinal aspiration

Clinical Features

Besides signs and symptoms of the primary etiology like shock and infection, rapid, deep, noisy breathing is found. The urine becomes strongly acidic.

Treatment

ƒTissue hypoxia should be treated by reperfusion

ƒSodium bicarbonate can be given where bases have been lost or where the degree of acidosis is so severe that myocardial function is compromised.

Respiratory Acidosis

Causes

Impaired alveolar ventilation due to:

-Airway obstruction

-Thoracic and upper abdominal incisions, abdominal distention in ileus

-Pulmonary diseases (pneumonia, atelectasis especially post operative

-Inadequate ventilation of the anesthetized patient

Clinical Features

Restlessness, hypertension and tachycardia may indicate inadequate ventilation with hypercapnia.

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Treatment

ƒMust focus on relieving the primary cause.

ƒRelieving airway obstruction, adequate analgesia, and draining pleural effusion are some of the definitive measures.

ƒIntubation and mechanical ventilation may be used in severe cases.

ACID BASE BALANCE SUMMARY

Type of
Acid-Base
Disorder	Defect			Common Causes		Compensation
Respiratory	Retention of			Respiratory center		Renal
acidosis	CO2			depression: morphine,		Retention of bicarbonate,
	(Decreased			CNS injury,		excretion of acid salts,
	alveolar			Pulmonary disease:		increased ammonia
	ventilation)			emphysema, pneumonia		formation
						Chloride shift into red cells
Respiratory	Excessive			Hyperventilation:		Renal
alkalosis	loss of CO2			Emotional		Excretion of bicarbonate,
	(increased			Severe pain		decreased excretion of acid
	alveolar			Assisted ventilation		slats decreased ammonia
	ventilation)			Encephalitis		formation
Metabolic	Retention of			Diabetes,		Pulmonary (rapid)
acidosis	fixed acids or			Azotemia,		Increased rate and depth of
	Loss of base			Lactic acid accumulation,		breathing
	bicarbonate			Starvation.		Renal (slow)
				Diarrhea,		As in respiratory acidosis
				Small-bowel fistula
Metabolic	Loss	of	fixed	Vomiting		Pulmonary (rapid)
alkalosis	acids			Gastric suction		Decrease rate and depth of
	Gain	of	base	(pyloric obstruction)		breathing
	bicarbonate			Excessive	bicarbonate	Renal (slow)
	Potassium			intake		As in respiratory alkalosis
	depletion			Diuretics

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Review Questions

1.What types of acids base balance and electrolyte changes will a patient with GOO have? Which kind of fluid will you use for resuscitation?

2.What is the role of the kidney in electrolyte and acid -base balance?

3.What are the buffer systems of the body? Which is the most rapid one?

4.Outline treatment of a patient with metabolic acidosis

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References

1.Bialy & Love – Short Practice of Surgery, 23rd edition

2.Schwartz, Principles of Surgery, 7th edition, short pimple year of surgery

3.Harrison’s Principles of Internal Medicine, 14th edition

4.General Surgery at the District Hospital, WHO 1998.

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CHAPTER THREE

BLOOD TRANSFUSION

Learning objectives

After reading this chapter students should be able to:

1.Identify indications for blood transfusion

2.Mention types of blood component therapy

3.Know blood transfusion reactions and their preventions

Definition

Blood transfusion is the procedure of introducing the blood of a donor, or pre-donated blood by a recipient into the recipient’s bloodstream.

Indications for blood transfusion

The need for blood transfusion in patients with acute hemorrhage is based on

•The volume lost

•The rate of bleeding

•The hemodynamic status of the patient; hematocrit may be normal if determined.

•A patient with acute blood loss of more than 2000ml certainly requires replacement of blood. It must be remembered that crystalloid infusions should be provided while the blood compound is obtained.

For patients with chronic blood loss or chronic anemia replacement of blood (RBC) should be based on the hematocrite level. The optimal hematocrite is considered to be in the range of 30%. But patients with chronic anemia (e.g. renal failure) seem to tolerate hematocrite as low as 18%-20%. Symptomatic patients exhibiting air hunger, dizziness, significant tachycardia or cardiac failure should, of course, be transfused.

Component therapy is indicated when specific factor deficiencies are demonstrated. For instance, factor VIII concentrates is the preferred mode of therapy for classic hemophilia.

Compatibility tests

If administrated blood is incompatible with the patients own blood, life threatening reactions may result. Blood banks routinely test for incompatibilities of the ABO and RH systems. Cross matches allow for detection of rare antibodies (e.g. kell, duffy, kidd) that are not detected in ABO and RH tests. Group-A contains anti-B antibodies, Group-B contains anti-A antibodies, Group-O contains anti-A and anti B antibodies. AB-group can receive any blood.

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Blood prepared after a full typing and cross match can be transfused safely in 99.95% cases. In some instances when fully cross- matched compatible blood is depleted or unavailable; type specific or O negative blood should be given. Type O Rh negative blood can be transfused without lysine the recipients blood.. Irregular recipient antibodies cannot be detected and extra vascular hemolysis can also occur. Overall, O negative blood, if randomly transfused, has a serologic safety of about 99.8%.

Component therapy

Treatment of specific hematologic abnormality often requires only a single component of whole blood. For example, factor VIII for classic hemophilic or platelet transfusion for patients with bone marrow suppression. Blood banks reduce the whole blood received from donors to a variety of components. The available products include whole blood, red blood cells, white blood cells, platelet concentrates and plasma in several forms.

Cellular component

Whole blood

This is collected in citrate phosphate dextrose- adenine solution (CPDA-) and contains 450 ml of whole blood and approximately 60ml of anticoagulant preservative. When it is used within 24 hours it is considered fresh, whole blood and after this time it is referred to as stored. Whole blood has a shelf life of 35 days. In acute massive hemorrhage transfusion with one unit of whole blood raises the recipient’s hematocrite by 3%.

Packed RBC

These are the remains after the plasma has been separated from whole blood. One unit raises the recipient’s hematocrite by 3%. Packed RBC may be warmed to a temperature not exceeding 370 c before transfusion. The storage life of red blood cells is 35 days.

Platelet concentrate

Platelets are separated from one unit of blood and suspended in a small volume of the original plasma. Depending on this technique, platelets may be stored for 3-7 days. One unit of platelet concentrate contains about 5.5×1010 platelets and increases the platelet count by 5000/ml. For a patient with platelet count below 25,000/mm3, 6-8 units are usually given. Platelet concentrate must be administered through a special platelet filter.

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Plasma components

Fresh frozen plasma

This is anti-coagulated plasma separated from a person’s blood and frozen within 6 hours of the time of collection. It may be stored up to 1 year. It contains all clotting factors and also provides proteins for volume expansion.

Cryoprecipitate

This is a protein fraction removed from a unit of fresh frozen plasma that is thawed at 40c. This white precipitate is then removed and frozen. It has a shelf life of about 1 year. It contains factor VIII, fibrinogen and factor XIII. It is used for the treatment of:

ƒclassic hemophilia,

ƒcertain consumptive coagupathies such as DIC or

ƒOther clotting abnormalities with specific therapy commonly not available.

Albumin

This is a plasma component used for oncotic support and plasma expansion. Its disadvantages are rapid excretion as well as expense.

Plasma protein fraction

Similar to albumin but contains additional protein molecules.

Complications and risks of blood transfusion

Hemolytic transfusion reactions

Intravascular hemolytic transfusion reactions; are potentially life threatening reactions that can occur by blood transfusion. They are almost always due to incompatibility of the ABO system involving the donor red blood cells and recipient plasma. These reactions are very rare occurring in 1 out of 15,000 -20,000 transfusions.

Pathophysiology

During hemolytic transfusion reaction all donor cells hemolyze, leading to hemoglobinemia, hemoglobinuria and renal failure. These reactions also activate the complement system with subsequent release of vasoacative amines causing hypotension. Complement activation also initiates the clotting mechanism which can produce intravascular thrombosis, DIC and hemorrhage

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Clinical manifestation: Patient often experiences fever, chills and dyspnea.

Treatment

ƒStop transfusion immediately

ƒAdministration of fluids and diuresis with mannitol or frusemide

ƒTransfused blood with patients blood sample should be sent for analysis

ƒSodium bicarbonate may prevent precipitation of hemoglobin in the renal tubules

ƒSteroids may ameliorate the immunologic consequences.

Transfusion reactions from mismatches involving the Rh system or minor antibodies usually induce extravascular hemolysis, since these reactions occur slowly, serious complications do not often develop.

Non-hemolytic transfusion reaction

Non-hemolytic reaction may occur after transfusions.

Febrile reaction: occurs in 0.5% -1% of all transfusions and is usually treated with antipyretic drugs.

Allergic reaction: occurs in 2-3% of all transfusion and manifests by urticaria and rashes. Antihistamins, steroids or epinephrine as indicated can accomplish treatment.

Transmission of disease: With the exception of albumin and PPF, the use of all blood products carries risk of transmitting infectious diseases. These include:

•hepatitis

•malaria

•Epstein- bar virus, cytomegalovirus, brucellosis, trypansomiasis and other diseases potentially transmitted by blood transfusions

Of great concern these days is the risk of transmission of the HIV virus. It is required to screen the donated blood using enzyme- linked immunosorbent assay (ELISA).

Other complications: Complications that can occur with massive transfusion include

•Citrate toxicity

•Acidosis

•Hyperkalemia

N.B:- As blood transfusion is accompanied by various complications mentioned above, the

decision to transfuse should only be made when it is believed to be life saving.

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Review Questions

1.What factors determine the need for blood transfusion in patients with chronic blood loss or chronic anemia?

2.Enumerate the routine compatibility tests performed in blood banks.

3.List the cellular components of blood with their specific importance.

4.Outline the management principle of patients with hemolytic transfusion reaction.

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References

1.Bailey and Loves: Short Practice of Surgery 22nd, ed.

2.Hardy’s Textbook of Surgery

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CHAPTER FOUR

PRE-OPERATIVE AND POS-TOPERATIVE CARE

Learning objectives

At the end of this chapter, students are expected to

•Be familiar with pre and post-operative care and complications

•Identify factors which make patients high risk for surgery

•Differentiate postoperative complications

•Manage common post operative complications

Introduction

In the management of patients with surgical procedures, the overall outcome of the operation mainly depends on the pre-operative diagnosis and the surgical procedure. But in addition to this, the patient’s pre-operative situation should be well evaluated so as to make the patient able to withstand the stress of surgery. Factors which make the patient high risk for surgery should be controlled as much as possible. Also, the patients’ postoperative course highly depends on the postoperative care given, and anticipation with early diagnosis and management of postoperative complications.

General consideration

Preoperative evaluation should include a general medical and surgical history, a complete physical examination and laboratory tests. The most important laboratory tests are:

•Complete blood count

•Blood typing and Rh-factor determination

•Urinalysis

•Chest x-ray

Further laboratory tests should be performed only when indicated by the patients’ medical condition or by the type of surgery to be performed.

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Assessment and Minimization of Surgical Risks

Cardiovascular System

Cardiac problems

The preoperative period is associated with significant cardiovascular stress. Patients with heart disease should be considered high-risk surgical candidates and must be fully evaluated.

•Patients with symptoms of previously undiagnosed heart disease (E.g. chest pain, dyspnea, pretibial edema or orthopnea)

•Recent history of congestive heart failure

•Recent myocardial infarction

•Severe hypertension

•Varicose vein and deep venous thrombosis

Such patients should be evaluated with the assistance of medical or cardiology consultation. The perioperative monitoring, induction, and maintenance techniques of anesthesia, and post – operative care can be tailored to the specific cardiovascular diseases.

Pulmonary system

The following respiratory tract problems make patients high risk for surgery;

•Upper airway infections

•Pulmonary infections

•Chronic obstructive pulmonary diseases: chronic bronchitis, emphysema, asthma

Elective surgery should be postponed if acute upper or lower respiratory tract infection is present. Pulmonary infections also predispose to postoperative bronchitis and pneumonia. If emergency surgery is necessary in the presence of respiratory tract infection, regional anesthesia should be used if possible and aggressive measures should be taken to avoid postoperative atelectasis or pneumonia.

Renal system

Renal function should be appraised

•If there is a history of kidney disease, diabetes mellitus and hypertension

•If the patient is over 60 years of age

•If the routine urinalysis reveals proteinuria, casts or red cells

It may be necessary to further evaluate renal function by measuring creatinine clearance, blood urea nitrogen and plasma electrolyte determination.

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Rheumatologic system

Anemia

Anemia affects the oxygen carrying capacity of the blood, which can complicate the stress of surgery. Anemia in pre-operative patients is of iron deficiency type caused by inadequate diet, chronic blood loss or chronic disease. Care must be taken to differentiate iron deficiency anemia from other anemias. Iron deficiency anemia is the only type of anemia in which stained iron deposit cannot be identified in the bone marrow. Megaloblastic, hemolytic and aplastic anemia usually are easily differentiated from iron deficiency anemia on the basis of history and simple laboratory examinations. Patients with iron deficiency anemia respond to oral or parenteral iron therapy. In emergency or urgent cases, a preoperative blood transfusion preferably with packed red cells may be given.

Thrombocytopenia

The normal platelet count ranges from 150,000 to 350,000/ml. In the patient with thrombocytopenia but normal capillary function, platelet deficiency begins to manifest itself clinically as the count falls below 100,000/ml. typical manifestations include

•Petechia

•Epistaxis in both sexes and

•Menorhagia in females of reproductive age

•Uncontrolled bleeding which could be intra or post-operative.

Treatment - treat the underlying cause and support with platelet transfusions and clotting factors as necessary.

Endocrine system

Diabetes mellitus

Diabetics with poor control are especially susceptible to post-operative sepsis. Preoperative consultation with an internist may be considered to ensure control of diabetes before, during and after surgery.

In type - II patients, avoid hypoglycemia by closely monitoring blood sugar on the day of surgery, and possibly by not using the longer acting oral hypoglycemic agents -2 days before operation. Insulin dependent diabetics with good control should be given half of their total morning dose as regular insulin on the morning of surgery. This is preceded or immediately followed by 5% dextrose solution intravenously to prevent hypoglycemia. Regular insulin should then be given every 6 hrs based on plasma glucose level. Chronic medical conditions associated with diabetes may also complicate the preoperative period, e.g. Hypertension,

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myocardial ischemia which may be silent. These patients should have an extended cardiac work up and receive metoclopromide as well as a non particulate antacid before surgery.

Thyroid disease

Elective surgery should be postponed when thyroid function is suspected of being either excessive or inadequate. In Hyperthyroidism, The patient should be rendered euthyroid before surgery if possible. This may take up to 2 months with anti-thyroid medications.

In hypothyroidism, thyroxin should be started before surgery if possible. In all cases, treatment should be started with a very low dose of thyroid replacement to avoid sudden and large workload on the myocardium. The usual tests of thyroid function include T3, T4, and TSH levels.

In addition to the above discussed factors, there are issues which might need special consideration in preoperative patients. The diagnosis of early pregnancy must be considered in the decision to do elective major surgery in reproductive age female.

History of serious reactions or sickness after injections, oral administration or other uses of substances like narcotics, anesthetics, analgesics, sedatives, antitoxins or antisera should be sought.

The patients’ general hydration status should be assessed and made optimal. Nutritional status of the patient also needs evaluation and correction.

After all this, prior to the operation, it is important to have an empty stomach because full stomach can result in reflux of gastric contents and aspiration pneumonitis. In elective surgery, patients should not eat or drink anything after midnight on the day before surgery.

Post-operative care, complications and their Treatment

Post-operative care

Post-operative care is care given to patients after an operation in order to minimize post operative complications. Early detection and treatment of post operative complications is possible if there is optimal care. Some of the care is given to all post operative patients, while the rest are specific to the type of operation. Routine cares include:

Immediate care:

a.Vital sign checking

b.Chest auscultation

c.Input and output monitoring

d.Checking for bladder and abdominal distention

e.Potent analgesics for pain relief

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On subsequent post-operative days:

a. Oral intake can be started

b. Patients encouraged to ambulate

In the following sessions, we will focus on common postoperative complications.

Cardiovascular complications

Shock

Postoperative efficiency of circulation depends on blood volume, cardiac function, neurovascular tone and adrenal secretions. Shock, or failure of the circulation, may follow:

ƒExcessive blood loss

ƒEscape of vascular fluid into the extra vascular compartments (“third spacing”)

ƒMarked peripheral vasodilatations

ƒSepsis

ƒAdrenocortical failure

ƒPain or emotional stress

ƒAirway obstruction

Treatment includes

ƒArresting hemorrhage

ƒRestore fluid and electrolyte balance

ƒCorrect cardiac dysfunction

ƒEstablish adequate ventilation

ƒMaintain vital organ function and avert adrenal cortical failure

ƒControl pain and relief apprehension

ƒBlood transfusion if required.

Thrombophlebitis

Superficial thrombophlebitis

It is usually recognized within the first few days after operation.

Clinical features

A segment of superficial saphenous vein becomes inflamed manifested by:

ƒRedness

ƒLocalized heat

ƒSwelling

ƒTenderness

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Treatment includes

ƒWarm moist packs

ƒElevation of the extremity

ƒAnalgesics

Anticoagulants are rarely indicated when only superficial veins are involved.

Thrombophlebitis of the deep veins

Occurs most often in the calf but may also occur in the thigh or pelvis.

Clinical features

It may be asymptomatic or there may be dull ache or frank pain in the affected leg or calf. The area may be tender and spasm felt in the same area. Examination may reveal slight swelling of the calf. Dorsiflexion of the foot may elicit pain in the calf (Homan’s sign). Major complication is pulmonary embolism.

Treatment

•Elevation of the limbs

•Application of full leg gradient pressure elastic hose

•Anticoagulants

Prevention: Early ambulation

Pulmonary embolism

Pre-disposing factors

ƒPelvic surgery

ƒSepsis

ƒObesity

ƒMalignancy and

ƒHistory of pulmonary embolism or deep vein thrombosis

It usually occurs around the seventh to tenth post-operative day. The diagnosis should be suspected if cardiac or pulmonary symptoms occur abruptly.

Clinical features

Patients with large emboli develop chest pain; severe dyspnea, cyanosis, tachycardia, hypotension or shock, restlessness and anxiety. In small emboli, the diagnosis is suggested by the sudden onset of pleuritic chest pain sometimes in association with blood-streaked sputum, and dry cough may develop. Physical examination may elicit pleural friction rub, but in many cases there are no classical diagnostic signs.

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Investigation

Chest X-ray- findings are pulmonary opacity in the periphery of the affected lung which is triangular in shape with the base on pleural surface, enlargement of pulmonary artery, small pleural effusion and elevated diaphragm. ECG may show characteristic changes.

Treatment

ƒCardiopulmonary resuscitation measures

ƒTreatment of acid-base abnormality

ƒTreatment of shock. Immediate therapy with heparin is indicated even in the absence of a definitive diagnosis.

Pulmonary Complications

About 30% of deaths that occur within six weeks after operation are due to pulmonary complication. Atelectasis, pneumonia, pulmonary embolism and respiratory distress syndrome from aspiration or sepsis, fluid overload or infection are the most common pulmonary complications.

Atelectasis

Definition

Atelectasis is a pulmonary complication of early postoperative period. It is a condition characterized by areas of airway collapse distal to an occlusion.

Predisposing factors

Include chronic bronchitis, asthma, smoking and respiratory infection. Inadequate immediate postoperative deep breathing and delayed ambulation also increase the risk.

Clinical features

ƒFever in the immediate post operative period

ƒIncreased pulse and respiratory rate

ƒCyanosis

ƒShortness of breath

ƒDull percussion note with absent breath sounds

Investigation

X-ray findings include patchy opacity and evidence of mediastinal shift towards the atelectatic lung.

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Prevention and treatment

ƒEncourage to stop smoking

ƒTreat chronic lung diseases

ƒPostpone elective surgery in presence of respiratory tract infections

ƒPost operatively, encourage sitting, early ambulation and breathing exercise while administering analgesics

ƒIntensive chest physical therapy

ƒSupplemental oxygen

Pneumonia and aspiration pneumonitis

Pneumonia may follow atelectasis or aspiration of vomits or other fluids. Preexisting bronchitis also predisposes to this complication.

Clinical features

ƒFever in the first few postoperative days

ƒRespiratory difficulty

ƒCough becomes productive

ƒPhysical examination may reveal evidence of pulmonary consolidation

Investigation

Chest-x-ray may show diffuse patchy infiltrates or lobar consolidation.

Prevention and treatment

Chance of pulmonary aspiration can be minimized by

-Fasting

-Naso-gastric tube decompression

If aspiration of gastric content occurs; an endotracheal tube should be placed and the air way suctioned and lavaged.

Treatment of pneumonia includes:

ƒDeep breathing and coughing

ƒChange position frequently to encourage expectoration

ƒBroad spectrum antibiotics therapy should be instituted and revised as indicated by subsequent sputum culture and sensitivity

Gastrointestinal complication

Paralytic Ileus

It is a functional intestinal obstruction usually noted within the first 48-72 hours

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Clinical features

ƒAbdominal distention

ƒAbsent bowel sounds

ƒGeneralized tympanicity on percussion

Investigation

ƒPlain x-ray-generalized dilatation and gaseous distention of the bowel loops

Treatment

ƒNGT decompression

ƒFluid and electrolyte balance

Post operative intestinal obstruction

Causes

ƒPeritonitis

ƒPeritoneal irritation

ƒFibrinous adhesion

Clinical features

ƒManifests between the 5th and 6th postoperative day

ƒSignificant and protracted vomiting

ƒCrampy abdominal pain

ƒFocal typmpanicity of the abdomen on percussion

ƒExaggerated bowel sounds

Investigation

Plain film of the abdomen usually reveals distension of a portion of small bowel with air fluid levels.

Treatment

Vigorous hydration and careful electrolyte monitoring is needed. This often results in re- alignments of the bowel loops and relief of the obstruction. Patient should be kept NOP and NGT inserted for decompression. If the obstruction doesn’t respond within 48-72 hours, re- operation is necessary.

URINARY TRACT COMPLICATIONS

Urinary retention

Urinary retention can follow pelvic operations and when spinal anesthesia is used. Inability of the patient to void is often due to pain caused by using the voluntary muscles to start the

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urinary stream. The patient should be encouraged to get out of bed. Bladder drainage by means of a urethral catheter should be instituted.

Urinary tract infection

Predisposing factors

ƒPre-existing contamination of the urinary tract

ƒCatheterization

Clinical presentation

•Fever

•Suprapubic or flank tenderness

•Nausea and vomiting

Investigation

-Urine analysis (pus or bacteria will be seen in the urinary sediments)

Treatment

ƒIncrease hydration

ƒEncourage activity.

ƒAfter urine specimen is obtained for culture, appropriate antibiotic therapy should be instituted

Wound complications

Wound infections

Pre disposing factors

ƒAge

ƒGeneral health

ƒNutritional status

ƒPersonal hygiene habits

ƒMalignancy

ƒPoor surgical technique

Diagnosis: clinical

ƒFever during the 4th to 5th day

ƒRedness or indurations at operation site

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Treatment

ƒSutures should be removed

ƒThe wound should be explored and cultured

ƒAmple drainage should be established together with local wound care

ƒAppropriate antibiotics if systemic manifestations like fever are persistent.

Hematoma, Abscess and Seromas

These may occur either in the pelvis or under the fascia of abdominal rectus muscle. They are suspected during falling of hematocrite in association with low-grade fever. Small hematoma or seroma often resolve spontaneously, but some can become infected. Ultrasonography is an excellent adjunct to physical examination. Drainage of infected hematoma should be accomplished extraperitoneally.

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Review Questions

1.What are the important components of preoperative patient evaluation?

2.List important laboratory investigations which need to be done in almost all pre-operative patients despite the specific diagnosis.

3.What are the risks of untreated respiratory tract infection in surgery?

4.Why is diabetes mellitus considered to be pre operative risk?

5.About post-operative shock

a)List the causes, what is the commonest cause?

b)What are the clinical manifestations?.

c)What are the important measures to be taken to combat shock?

6.What is the most common cause of fever in the immediate postoperative period ?

7.Outline the care for an infected post-operative wound.

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References

1.Bailey and Loves: Short practice of Surgery, 22nd ed.

2.Hardy’s Textbook of Surgery

3.Current Textbook of Obstetrics and Gynecology, 8th ed.

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CHAPTER FIVE

ASEPTIC AND ANTISEPIC TECHNIQUES

Learning Objectives

After reading this chapter, the student should know

1.The definition of the different terms used in asepsis and antisepsis

2.The properties of the most frequently used antiseptics and their use in surgical and traumatic wounds.

3.How choose the most suitable antiseptics for his/her institution

Introduction

The most serious outcome (important factor) of impaired wound healing is infection. Antiseptics and aseptic techniques are used in an attempt to prevent contamination to an acceptable level making the wound less receptive to bacterial growth. It should be noted, however, that the corner stones in decreasing wound infection are: gentle tissue handling, sharp dissection, good homeostasis, and accurate apposition of wound edge without tension. Proper wound debridement (wound excision) is vital in post traumatic wounds to prevent infection.

Therefore, knowledge of aseptic and antiseptic techniques is very important for the medical practitioner, be it in the ward, minor/major operation theaters or in the emergency out patient department: this knowledge can help prevent infection, unnecessary morbidity and some times mortality of patients.

DEFINITIONS

Aseptic technique: the prevention of microbial contamination of tissues and sterile materials by excluding, removing or killing microorganisms

Disinfection: involves the killing or removal of sufficient microbes to render an inanimate object safe for its intended purpose

Antiseptics: Chemicals which can be applied to living tissues to kill or inhibit the growth of microbes.

Cross infection: the transfer of microbes in hospitalized patients to other patients.

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Auto infection: infection caused by organisms already colonizing the patient’s body or in septic lesions.

CHOICE OF ANTISEPTIC

The ideal antiseptic will have the following four properties

a.The spectrum of activity would be broad

b.It would be resistant to inactivation by organic materials, such as blood & feces

c.There would be no toxicity or allergic reaction, and the antiseptic should be non – staining

d.It would be inexpensive.

USE OF ANTISEPTICS AND ASEPTIC TECHNIQUES

Prevention of infection in surgical wounds

For prevention of infection in surgical wounds one has to identify the sources and routes of infection. The source of infection in surgical wounds can be:

•The patient

•Staff (a healthy carrier, incubating an infectious disease or with overt clinical illness)

•The operation room

•Occasionally instruments.

The routes of infection are

•Personal contact: patient -to- patient, patient -to- staff, staff -to-patient

•Airborne

Ward and OPD

Patient:-

Common organisms in the absence of infection are gram-positives like

Staphylococcus and streptococcus found on the skin resisting dryness. Gram- negatives are not resistant and are not common causes in clean wounds.

Preventative Measures

•Short hospital stay preoperatively

•Shower a day before surgery

•Treatment of any infectious site before surgery

•Aseptic methods with sterile equipment for all procedures.

•Special preparations e.g. bowel preparation for colonic surgery

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Staff:-

Preventative Measures to be taken

•Skin disinfection between contact with patients by detergent (soap and water) in the wards or OPD and use of antiseptic in intensive care and neonatal units.

•Treatment for identified carriers and full blown cases e.g. boils

•Prophylactic antibiotics when indicated

Operating Theater

Most bacteria infecting surgical incisions are implanted during the operation. Therefore strict asepsis has to be maintained.

Staff

ƒWear clean clothes, shoes or covers, mask and cap or hood beyond the green line

ƒScrubbing up of all operating team before each operation for at least 5 minutes with an antiseptic soap or detergent. To prevent skin damage, brushes should be used

only to clean under the nails. Finally, dry with sterile towel and apply 70% alcohol or Povidone iodine if available.

ƒPut on sterile gloves and gowns in an aseptic manner

Patient

•Shave hair immediately before surgery

•Clean the operation field with antiseptic containing:

-Chlorohexidin and 2.5% Iodine for adults

-70% alcohol for children

-Podovine Iodine for all ages if available

•Finally, cover with sterile drapes.

Operating Room

There are few bacteria in the air of an empty theatre but every individual liberates about 10,000 organisms per minute into the air. Therefore, to decrease airborne infections, keep the number of personnel reduced to a minimum. Unnecessary movement should also be discouraged.

There should be adequate ventilation for most procedures. If there is no system to provide this, windows should be open to allow ingress of fresh outside air and escape of anesthetic gases.

Keep all doors closed except as needed for passage of equipment and personnel.

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Clean operating rooms between operations. At regular intervals, conduct a more thorough cleaning by mopping the floor and washing the walls with detergents.

Instruments

All instruments and garments to be used in surgical procedures must be sterile and this is attained by sterilization.

Sterilization: - is a process by which inanimate objects are made free of all microorganisms. Widely used methods of sterilization in a hospital are.

Autoclaving: - This is the preferred method of sterilization. It uses steam at a pressure of 750 mmHg above atmospheric pressure and temperature of 1200 C for 15-30 minutes. The steam is helpful for penetration even into spores. Appropriate indicators must be used each time to show that the sterilization is accomplished.

Dry heat:-

This is a poor alternative but suitable for metal instruments. It uses a temperature of 1700C for two hours.

N.B. Boiling is an unreliable means of sterilization and it is not recommended.

APPENDIX: properties of commonly used antiseptics

Alcohols (e.g. ethyl, isopropyl): -

Broad spectrum, rapid action, moderately expensive, most active against bacteria at 70% concentration

Chlorhexidine:-

Good activity against staphylococci and streptococci, moderate activity against gram- negative bacteria, persistent action, moderately expensive, non-toxic, unpleasant taste

Iodine (lugols solution):-

Broad spectrum, cheap, stains, hypersensitive

Povidone iodine:-

Broad spectrum, moderately expensive, some hypersensitivity, rapid inactivation by blood

Hexachlorophane:-

Slow, but cumulative action against staphylococci and streptococci, systemic toxicity for neonates, moderately expensive

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Triclosan:-

Similar activity but less toxic than hexachlorophene

Chlorine (chlorinated lime and Boric acid (Easol):-

Broad spectrum, locally toxic, expensive

Dilute sodium hypochlorite solution:-

Broad spectrum, cheap, locally toxic

Quaternary ammonium compounds :-( e.g. cetrimide in benzalkonium chloride) Poor gram-negative activity, readily contaminated, detergent, cheap, non-toxic.

Noxythiolin:-

Releases formaldehyde in contact with tissues, broad spectrum, expensive, weak and slowly bactericidal

Alcohol plus chlorhexidne

Alcohol plus povidon iodine useful mixtures

Chlorhexidine plus cetrimide

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Review Questions

1.Using your knowledge of the properties of the different antiseptics which one would you choose for your heath center?

2.Which antiseptics do you recommend for preoperative skin preparation for adults? What about for children?

3.What is the most important measure you would take for a patient who comes to the emergency room with a contaminated wound?

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References

1.General Surgery at the District hospital: WHO 1998.

2.Mark Farrington, Infection and the Surgery, Surgery, The medicine group (UK) ltd, 1988

42

CHAPTER SIX

SUTURE MATERIALS AND SUTURING

Definition

Suture is a thread like material used to close surgical wounds and unite two edges of cut tissue.

Types of Suture Materials

Suture materials can generally be classified as absorbable and non absorbable.

Absorbable:

This is a type of suture material that gets absorbed by the tissue.

E.g. Catgut (natural or biologic type)

Vicryl (Synthetic)

Non absorbable:

This is a type of suture material that remains unabsorbed by the tissue. E.g. Silk (natural or biologic type)

Nylon (Synthetic)

SELECTION OF SUTURE MATERIALS

Different surgical stitches are used in various types of tissues for different purposes. Important factors considered when selecting suture material for surgery include:

•Type and site of the operation

•Healing characteristics of the tissue involved

•Properties of the suture and needle

•Security of knots

•Behavior of the material in presence of infection

•Suture size (The commonest surgical suture size is between 4/0 and 1)

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SUTURING TECHNIQUES

The basic principles of suturing technique include:

1.Inserting the needle at right angle and gently advance through the tissue

2.Avoiding tension

3.Size and interval between bites are dependent on the tissue thickness and type of tissue to be sutured

FORMS OF SUTURING TECHNIQUES

Important types of suturing techniques commonly used include:

•Simple interrupted

•Continuous simple

•Vertical and horizontal mattress

•Subcuticular stitches

Figure 1: Simple Interrupted Sutures
Figure 1a	Figure 1b

Figure 1c

Figure 1d

Useful Tips:

•Insert the needle carefully at right angles to the tissue edges. Advance through, gently avoiding shearing force.

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•For long wounds being closed with interrupted sutures, it is advisable to start in the middle and to keep on halving the wound.

•Tie a careful reef knot and lay to one side of the wound.

•Cut suture end about 0.5cm long to allow length for grasping during removal.

•When removing sutures, cut flush with the tissue surface so that the exposed length of the suture, which is potentially infected, does not have to pass through the tissues.

Figure 2: Continuous Sutures

Useful Tips:

•Place a single suture and ligate but only cut the short end of the suture.

•Continue to place sutures along the length of the wound keeping tension through an assistant following by holding the suture at the same tension as it is when handed.

•Take care and avoid too much tension.

•Secure the suture at the end by an additional reef knot.

Figure 3: Mattress Sutures

Fig 3 a: Horizontal

Fig 3 b: Vertical

Mattress sutures may be either vertical or horizontal. They may be useful for ensuring either eversion or inversion of a wound edge.

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Figure 4: Subcuticular Sutures

This technique may be used with absorbable or non-absorbable sutures. For non-absorbable sutures, the ends may be secured by means of beads etc. For absorbable sutures, the ends may be secured by means of buried knots.

Small bites of the subcuticular tissues on alternate sides of the wound are taken and then pulled carefully together.

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CHAPTER SEVEN

WOUNDS-WOUND HEALING AND CARE

Learning Objectives

At the end of this chapter, each student will be able to:

•Define a wound clearly

•Understand the types of wounds

•Understand managing wounds according to type

•Understand the process of healing.

Introduction

Successful wound management with rapid and complete healing and minimal complication depends on understanding the basic principles of assessment, bacteriology and application of the general principles of wound care.

The primary goal of wound management is to aid the natural body process to produce optimal functional and cosmetic result. This requires an understanding of the basic principles of wound care and the process of healing. Failure to do this may result in delay of healing and unwanted secondary complications which may be distressing to the physician, patient and family and may lead to greater economic loss.

DEFINITION

Wound is defined as a break in the normal continuity of a tissue. It is caused by a transfer of any form of energy into the body which can be either to an externally visible structure like the skin or deeper structures like muscles, tendons or internal organs.

WOUND HEALING

Wound healing is a complex biologic process of restoring normal tissue continuity. There are integrated sequences of events leading to cellular proliferation and remodeling. under normal conditions it starts immediately following the event of wounding and passes through basic mechanisms with the following four phases in all wounds.

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Phases of healing

1-Coagulation phase:

This is the first phase of healing which is induced immediately following injury. It is characterized by vaso-constriction, clot formation and release of platelets and other substances necessary for healing and help as a bridge between the two edges.

2- Inflammatory phase:

This phase takes place from time of wounding up to three days. It is characterized by classical inflammatory response, vasodilatation and pouring out of fluids, migration of inflammatory cells and leukocytes and rapid epithelial growth.

3- Proliferate Phase:

This phase, also known as phase of fibroplasia, starts around the 3rd day of injury and stays for about three weeks. This is a phase during which important events occur for healing of the wound. It is characterized by fibroblast, epithelial and endothelial proliferation, Collagen synthesis, and ground substance and blood vessel production.

4- Maturation phase:

Also known as phase of remodeling, this takes the longest period which may extend for up to one year. Equilibrium between protein synthesis and degradation occurs during this phase with cross linking of collagen bundles leading to slow and continuous increase in tissue strength of the wound to return to normal.

Clinical types of healing

Traditionally, wound healing can be classified into three clinical types: Healing by first, second and third intention.

Healing by first intention:

This is a type of healing of clean wound closed primarily to approximate the ends. Healing takes place by epithelialization and leaves minimal scar.

Healing by Second intention:

This occurs in wide, contaminated wounds, which are not primarily closed. Healing takes place by granulation tissue formation, tissue contraction and epithelialization.

Healing by third intention:

This occurs in wounds which are left open initially for various reasons and closed later (delayed primary closure)

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Factors affecting healing

Healing of a wound can be affected by various conditions. The following are examples of factors which down grade a healing process.

Local factors

•Ischemia and decreased oxygen tension

•Presence of foreign bodies

•Closure under tension

•Infection

•Irradiation…

Systemic factors

•Systemic diseases like diabetes, cirrhosis, renal failure, malignancy…

•Poor nutritional State (hypo proteinemia vitamin and mineral deficiency)

•Decreased resistance due to immune suppression, chronic infection

•Drug therapy like steroids, cytotoxic agents

WOUND ASSESSMENT AND CLASSIFICATION

Assessment of wounds

For proper wound management, adequate assessment, based on relevant history and physical examination is important. In the history, one has to answer the following principal questions:

•How the wound was caused and what caused it? (Mechanism of injury)

•When did the wounding happen? (Time)

•Where was it caused? (Place and circumstances)

•Patient's past and current medical and vaccination/immunization history that may influence wound healing

Careful physical examination is important to assess the integrity and function of the structures. General inspection and specific tests have to be done to assess the following conditions:

•Extent of skin loss

•Degree of circulation

•Damage to nerves, tendons, bone and other structures (deep under) the skin

•The degree of contamination

•Presence of foreign body and tissue necrosis

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Classification of wounds

Once wound is carefully assessed, it is necessary to classify into a specific type in order to plan a proper management scheme. There are many approaches of classifying wounds. However, wounds can generally be grouped into two categories.

Closed wounds: These are wound types, which have an intact epithelial surface, and skin cover not completely breeched.

Example: Contusion, Bruise, Hematoma

Open wounds: These are wounds caused by injury which leads to a complete breakt of the epithelial protective surface.

Example: Abrasion, Laceration, Puncture, Missile injuries, Bites…

The following method is the traditional surgical wound classification scheme that was introduced in 1964. This method classifies wounds according to the likelihood or rate of wound infection.

Clean: Non-traumatic, non-infected wound, no break in sterility technique, the respiratory, gastrointestinal or genitourinary tracts not entered.

Clean-contaminated: Minor break in technique, oropharynx entered, gastrointestinal or respiratory tracts entered without significant spillage, genitourinary or biliary tracts entered in absence of infected urine or bile.

Contaminated: Fresh traumatic wounds, major break in sterility, gross spillage from gastrointestinal tract, and entrance of genitourinary or biliary tracts in the presence of infected urine or bile

Dirty and Infected: Acute bacterial inflammation without pus, wound with heavy contamination and evidence of infection, transection of “clean” tissue for the purpose of surgical access for collection of pus, traumatic wound with retained devitalized tissue, foreign bodies, fecal contamination, and/or delayed treatment, or from dirty sources

WOUND MANAGEMENT

GENERAL

In managing wounds, care should be taken not to overlook life threatening conditions by concentrating on less important wounds. If other serious conditions exist, which endanger the patient’s life, the wound should be covered with sterile gauze and priorities attended to.

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Therefore, the patient requires thorough examination before instituting wound management. The following priority has to be set and followed.

•Stabilize the patient and correct all life threatening conditions, like airway obstruction and bleeding.

•Take quick general history on the incident.

•Do gross physical examination to assess associated injuries.

•Assess the wound or soft tissue injury in detail.

•Plan and institute treatment according to the goal and specific wound type.

•Follow up, re-inspect the wound and assess the outcome of your management after a day or two.

Treatment of the wound begins following initial assessment. The initial care of all wounds is generally governed by several principles. However, the goal in all cases is to establish a good environment to assist wound healing and prevent infection. Proper wound care includes the following measures:

•Adequate hemostasis locally to stop bleeding.

•Adequate irrigation to reduce bacterial load and foreign particles.

•Careful debridement to remove all dead tissues and non-vascularized fragments.

• Careful decision on whether to close or leave the wound open for later closure.

•Supplementing with antibiotics and tetanus prophylaxis as required.

•Improving host response by correcting systemic diseases.

Regarding primary wound closure, each condition must be individualized. However, general guidelines that can be followed are:

•Clean wounds should be closed primarily

•Clean-contaminated wounds can be primarily closed if they can be converted, into clean wounds

•Untidy, contaminated wounds which cannot be converted to tidy wounds should not be closed primarily

•All missile wounds, animal and human bites should never be primarily closed unless strongly indicated

Primary closure

Primary closure is effective in wounds presenting within 6-8 hours and can accurately be debrided. This is usual in civilian practice.

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Delayed primary closure

Is done for traumatic or contaminated wounds to avoid the risk of wound sepsis. It is done within 3 days of initial treatment.

Secondary closure

This is usually done in 3-7 days of initial treatment. It is effected in contaminated or traumatic wounds. It provides a reliable drainage and opportunity for repeated inspection and debridement as necessary.

SPECIFIC WOUND MANAGEMENT

As mentioned earlier, the management of specific wound types should be individualized. This is mainly governed by local wound factors. The common wound types and their specific management is listed below.

Bruises

These wounds are very superficial. There is no specific management needed except local compress and analgesics if pain is severe.

Hematoma

This is a collection of extravasated blood in the soft tissues.

Management:

-It usually gets absorbed spontaneously and should be left

-Local compress to alleviate pain

-Aseptic evacuation or aspiration only if very large (expanding) or over a cosmetic area or leading to compression of vital structures.

Abrasion

An abrasion is rubbing or scraping of skin or mucous membrane. It may affect only a part or full layer of skin. Dirt particles can be imbedded into the skin defect.

Management:

-Cleanse using scrubbing brushes

-Use antiseptic or lean tap water and soap

-Analgesic

Punctures

These may be compound wounds which involve deeper structures. They require careful management.

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Management:

-Evaluate the depth of damage

-Remove pricking or other foreign bodies

-Excise damaged tissue

-Cover with antibiotics

-Tetanus prophylaxis

Lacerations

These are open wounds caused by an object moving across the skin, commonly by sharp and thin objects which slice with minimal energy, like a knife, or glass, but can also be due to high-energy impact. Their management should be as follows.

Management:

-Careful inspection

-Adequate cleansing

-Closure, if feasible, under appropriate anesthesia

-Proper wound debridement if needed

-Appropriate antibiotic prophylaxis

-Tetanus Prophylaxis

-Analgesics as needed

Crush and avulsion wounds

These are compound complicated wounds. They are usually associated with systemic involvement and have more extensive damage than may appear. Manage these conditions as follows.

Management:

-Correct associated life threatening conditions

-Proper wound debridement

-Early skin cover if possible or late graft, wound left open if contaminated

-Appropriate antibiotics

-Tetanus Prophylaxis

-Analgesics as needed

Missile injuries

These are type of wounds which are compound and complicated. There is excessive tissue damage and high degree of contamination. They usually present with severe life threatening conditions and should be carefully managed.

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Management:

-Correct life threatening conditions to stabilize the patient’s vital functions

-Careful wound inspection

-Careful wound debridement

-Adequate effective antibiotics

-Tetanus Prophylaxis and analgesics as needed

-Avoid primary closure of the wound

BITES

Bites can be caused by humans or other animals. The wounds can be puncture or laceration and are contaminated. Management of common bites is discussed below.

Human bites

These are relatively rare but more heavily contaminated than those of most animalss due to polymicrobial nature including anaerobic organisms as a normal oral flora. Management should include the following aspects.

-Careful wound inspection

-Take culture from wound site

-Thorough scrubbing and liberal irrigation with saline or plain water

-Adequate debridement

-Leave wound open except early face and head wounds

-Do not suture severed tendons and nerves primarily

-Broad-spectrum antibiotics, later to be changed to specific antibiotics according to culture result

-Tetanus Prophylaxis

-Wound observation

Dog bites

Peculiar to dog bites is that infected animals can transmit the rabies virus from the saliva which leads to rabies, a deadly disease. To avoid this complication the animal must be kept for observation for at least 10 days. These wounds should be urgently and carefully managed as follows.

Local management:

-Vigorous irrigation and repeated swabbing and flushing with soap and water or antiseptics

-Local anti-rabies serum infiltration under the wound if available

-Leave wound open

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Systemic management:

-Post exposure anti rabies prophylaxis (1ml, IM) on the 1st, 3rd, 7th, 14th and 28th day of bite.

-Tetanus prophylaxis

-Antibiotics

Snake Bites

Poisonous snakes cause severe local and systemic effects due to highly active substances in their venom. Immediate aggressive measures should be taken to limit the affects. Management should include:

First aid measures:

-Local wound irrigation

-Apply pressure bandage proximally to avoid or reduce venom spread with caution on the blood supply

-Immobilize the limb to minimize venom absorption

-Transport patient immediately to nearby hospital

Hospital Measures:

-Identify the species

-Conduct necessary laboratory investigations like hemoglobin, renal function...

-Anti-venom injection, if available

-Supportive care for severe conditions

-Rest

-IV-infusions to combat shock

-Antibiotics

-Blood transfusion

-Tetanus Prophylaxis

-Surgery, if local complications

-Wound excision

-Fasciotomy for compartment syndrome

WOUND COMPLICATIONS

Handled and managed improperly, wounds can result in variants from normal healing and become complicated, causing local systemic complications.

Local: Local complications may manifest as one or more of the following conditions-

-Hematoma

-Seroma

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-Infection

-Dehiscence

-Granuloma formation

-Scar formation

-Contracture leading to loss of joint function etc

Systemic:

-Death may occur if un controlled sepsis or hemorrhage

-Systemic manifestations of hemorrhagic shock due to massive bleeding

-Bacteremia and sepsis from a source of locally infected wound

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Review Questions

1.Which of the following is important in assessing a wound to manage it properly?

A)Duration of injury

B)The circumstance of wounding

C)The mechanism of injury

D)Local appearance of the wound

E)All of the above

2.Which of the following wounds can be categorized as “clean”?

A)Bullet wound of one hour duration

B)Human bite of 30 minutes duration

C)Glass laceration of five hours duration

D)Crush injury of the leg following car accident

E)None of the above

3.A proper wound care includes all measures except

A)Removing all devitalized tissue

B)Removing foreign bodies impregnated to the wound

C)Wound inspection following primary management

D)Inadequate hemostasis of a bleeding artery

E)Decision to close a wound primarily

4.Which of the following wounds should never be primarily closed?

A)Forearm laceration from a knife

B)Dog bite to the calf of one hour duration

C)Blast wound to the thigh of two hours duration

D)Stick wound to the scalp of four hours

E)B and C are correct

5.Which of the following wounds requires no surgical procedure?

A)Gas gangrene

B)Bruise

C)Abscess

D)Lacerations

E)Pyomyositis

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6.In a contaminated wound left open to heal without closure, healing is effected by

A)First intention

B)Second intention

C)Third intention

D)Purely by epithelialization

E)All of the above

7.Which of the following factors is unlikely to affect the healing of a wound?

A)Presence of foreign body

B)Systemic illness

C)Sex of the patient

D)Poor patient nutritional state

E)Presence of infection

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Key to the Review Questions

1.E

2.C

3.D

4.E

5.B

6.C

7.C

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References:

1.Wound care: First edition, 1986 William M. Cocke, Jr.

Raleigh R. White Dennis J. Lynch Charles N. Verheyden

2.Wound care: First edition, 1985 Stephen Westaby

3.Campbell’s operative orthopedics: Ninth edition S. Terry Canale

4.Principles of Surgery, 1999 Schwartz

5.Bailey and Love’s Short Practice of Surgery, 22nd edition.

6.Surgical care at the District Hospital: 2003 World Health Organization

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CHAPTER EIGHT

SURGICAL INFECTIONS

Learning Objectives

At the end of this chapter, each student will be able to:

-Define a surgical infection clearly

-Have a clear understanding on the pathogenesis of surgical infections

-Understand and define the common types of surgical infections

-Understand the management of surgical infection according to its type

-Identify types of surgical infections that require emergency procedure

Introduction

Surgical infection encompasses a wide pathologic aspect. It can be defined broadly as an infection related to or complicating a surgical therapy and requiring surgical management.

Many infections occupy a non-vascularized space of tissue, thus are likely to respond to non-surgical treatments. These types of infection therefore definitely require surgery as a primary or definitive therapeutic approach.

Examples of such infections, which definitely need surgery, can be:

-Gas gangrene

-Abscess

-Appendicitis...

On the other hand, any infection that is related to surgical therapy but that may not definitely require surgery is also categorized as a surgical infection.

Examples:

-Urinary tract infections after catheterization for surgical purpose

-Pulmonary complications following intubation for surgery

-Tracheotomy site infection

All wounds that follow operative procedure or incision are also grouped as surgical infections.

Example:

Post-operative wound infection

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CLASSIFICATION

Surgical infections can be classified in relation to specific conditions. According to temporal relation to surgery, surgical infections are grouped into three types.

Ante/pre operative infections:

These infections happen before a surgical procedure. The time of initial infection may or may not be known.

Example:

-Accidents

-Appendicitis

-Boils

-Carbuncle

-Pyomyositis…

Operative infections:

These are types of surgical infections that happen during a surgical procedure. It can occur either due to contamination of the site or poor tissue handling technique.

Postoperative infections:

These infections occur after a surgical procedure. The contamination is usually from the patient’s source.

Example:

-Surgical wound infections

-Urinary and respiratory tract infections

PATHOGENESIS

There are certain elements or factors present for a surgical infection to occur. These include:

-An infectious agent

-A susceptible host

-Favorable external factors or local condition with closed, less or non-per fused space.

An infection becomes overt only when the equilibrium between the bacterial and host factors becomes disturbed.

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Infectious agents:

Surgical infections are caused by various types of microorganisms either separately or in combination (poly microbial). The common organisms in decreasing order are:-

1- Aerobic bacteria

-Staphylococcus aureus

-Streptococci

-Klebsiella

-E. coli…

2- Anaerobic bacteria

-Bacteroids

-Peptostreptococci

-Clostridia…

3- Fungi

-Histoplasma

-Candida

-Nocardia and actinomycetes…

4- Parasites

-Entameba hystolytica causing amebic liver abscess

-Echinococcus causing hydatid cyst…

The organisms get access through skin breaks, operative wounds, tubes, and catheters…They lead to overt infection by various mechanisms, which commonly include tissue invasion, local damage and toxin production. Later, the organisms or their toxins impose more danger by systemic spread.

Host Susceptibility:

Reduced immune host defense predisposes to surgical infections. Conditions affecting the specific and non-specific immunity and systemic diseases that suppress the immune response, like diabetes mellitus, TB and AIDS can reduce the body's immune defense, thus increasing the susceptibility to infection.

Local and external factors:

Closed spaces, usually with poor vascularization, are areas susceptible to infection. Favorable situations under such condition contributing to infection include:-

-Poor perfusion of blood and oxygen

-Presence of dead tissue

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-Presence of foreign bodies

-Closure under tension etc.

External factors like a break in the sterility technique also contribute to the development of surgical infection.

DIAGNOSIS

Once an infection develops, it can be diagnosed by the clinical manifestation and supportive laboratory investigation:-

Clinical manifestation: Patients with overt surgical infection may present with the following symptoms and signs:

Symptoms and signs of local inflammation such as hotness, redness, edema/swelling, local pain and loss of function

Non-Specific symptoms like fever, chills, tachycardia, etc.

Constitutional symptoms: Fatigue, low-grade fever, etc.

Laboratory investigations:

WBC count: usually elevated

Staining and culture of discharges and fluids can be diagnostic Blood culture: Especially if there is bacterermia will be positive

Biopsy: Histologic inspection of tissues can also be diagnostic of infection of various structures

Imaging studies like X-ray and ultrasound can be diagnostic.

SPECIFIC TYPES OF INFECTIONS

Common surgical infections are discussed below separately.

Post-Operative Wound Infection

This is contamination of a surgical wound during or after a surgical procedure. The infection is usually confined superficially to the subcutaneous tissue. If it extends below the fascia, it is considered a deep infection.

Source of infection:

The source of contamination in more than 80% cases is the patient (endogenous). Organisms may come from the patient’s skin or transected viscus. In about 20% of cases, the source is from the environment, operating staff or unsterile surgical equipment (exogenous).

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Clinical findings:

The infection usually becomes evident on the 5th-7th postoperative day. The following clinical features may accompany the infection.

-Fever

-Wound pain

-Wound edema and induration

-Local hotness and tenderness

-Wound/stitch abscess

-Serous discharge

-Crepitation occasionally

Management:

-Remove stitches to allow drainage

-Local wound care

-Antibiotics only if systemic manifestations or signs of local spread accompany.

Abscess

An abscess is a localized collection of pus. It contains necrotic tissue and suppuration from damage by the bacteria, and white blood cells. It is surrounded by area of inflamed tissue due to the body’s response to limit the infection.

Etiology:

Pyogenic organisms, predominantly staphylococci are the leading causes. These organisms lead to tissue necrosis and pus formation.

Clinical features:

Patients with an abscess anywhere in the body may present with the following findings.

-Clinical features of inflammation when superficial (Heat, pain, edema, redness and loss of function)

-Local fluctuation if superficially located.

-Spontaneous discharge and sinus formation

-Systemic manifestations like fever, sweating, tachycardia

-Chronicity especially in granulomatous infection like mycobacteria,

Treatment:

-Primary treatment is drainage of the abscess by making incision

-Debridement and curettage to break all septations and loculations

-Delayed primary or secondary closure is preferred

-Antibiotics should not be given until systemic symptoms or signs of spread occur

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Cellulitis

Cellulitis is an inflammation of the subcutaneous tissue characterized by invasion without definite localization. Thin exudate spreads through the cleavage planes of tissue spaces. It usually involves the extremities and identifiable portal of entry is detectable.

Etiology: The most common etiologic organisms are

-Beta hemolytic streptococci

-Staphylococci

-Clostridium perfringens

Clinical Features: There is usually an identifiable portal of entry which can be a surgical wound, puncture site, skin ulcer or dermatitis. Other features include:

-Local signs of inflammation, which may be very intense

-Poorly defined brown-red edema

-Blebs and bullae in severe cases; tissue destruction and ulceration may follow

-Central necrosis and suppuration may occur late in some complicated cases

-Systemic signs of bacteremia and toxemia due to spread and toxin release

Management:

-Rest to limit spread of infection and pain

-Elevation of the involved limb

-Hot, wet pack

-High dose broad spectrum antibiotics IV

Impetigo

This is a skin infection characterized by a series of intraepithelial abscesses which present as multiple small pustules coalescing together. Later these pustules form lesions with erosion and crust formation. The disease is contagious in nature.

Etiology: The causative agents are streptococci and staphylococci.

Clinical Pictures:

-Series of small intra epithelial abscesses , multiple

-Bullous lesions

-Skin erosion and

-Crust formation.

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Management:

-Local care

-Careful washing with antiseptic soap

-Local antibiotic ointments like neomycin if available

-Systemic antibiotics like cloxacilline only in resistant cases

Furuncle (Boil)

Furuncle is an acute infection of hair follicles with Para follicular inflammation. It commonly occurs over the axillae, back of the neck and buttocks. Poor hygiene, immune suppressive diseases and irritation are known contributing factors.

Etiology:

The causative agents are staphylococci aureus.

Clinical feature:

-There is an intense local irritation of acute onset

-Painful firm, reddish, round swelling initially, which later becomes fluctuant

-Suppuration and central necrosis occurs later

-The condition subsides and is self-limited to recur in multiple lesions (chronicity)

Treatment:

•It may subside spontaneously without suppuration (Blind boil)

•Incision /Excision if complicated

•Antibiotics

Carbuncle

Carbuncle is an infective gangrene of subcutaneous tissue which commonly occurs in patients with diabetes and other immune suppressive conditions. It is commonly found over the nape of the neck.

Etiology: It is caused by staphylococcus aureus.

Clinical Feature:

•Formed by multiple furuncles

•Pain

•Erythema

•Induration

•Progressive suppuration of thick pus

•Tissue loss with shallow and deep ulcer surrounded by smaller areas of necrosis

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Treatment:

•Adequate systemic antibiotics in early stages

•Aggressive debridement

•Local wound care

•Detect and treat predisposing factors like diabetes mellitus

Pyomyositis

Pyomyositis is an acute bacterial infection of skeletal muscles with accumulation of pus in the intra-muscular area. It usually occurs in the lower limbs and trunk spontaneously or following penetrating wounds, vascular insufficiency, trauma or injection. Poor nutrition, immune deficiency, hot climate and intense muscle activity are highly associated factors.

Etiology: The most common causative agent is Staphylococcus aureus. Streptococci can also be detected in acute form.

Clinical Features: It usually has sub-acute onset and can present with

•Localized muscle pain and swelling, late tenderness

•Induration, erythema and heat

•Muscle necrosis due to pressure

•Fever and other systemic manifestations later after some days

Treatment:

•Immediate intravenous antibiotics before surgery

•Surgical drainage of all abscess

•Excision of all necrotic muscles

•Supportive care

Madura Foot

This is a chronic granulomatous disease commonly affecting the foot with extensive granulation tissue formation and bone destruction. The disease is common in the tropics and occurs through a prick in barefoot walkers in 90% of cases.

Etiology: The causative microorganisms for this infection are various fungi or actinomycetes found in road dust.

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Clinical Manifestation:

•Firm, painless, pale nodule appears initially followed by others

•Vesicles surrounding the nodules which later burst and form sinuses

•Watery discharge, which may contain granules appearing yellow, red or black color

•Flattening of the convexity of inner foot

•Deep spread to bones subcutaneous plane leading to secondary infection.

Treatment:

•Sulphonamides and Dapson (prolonged course)

•Broad spectrum antibiotics for secondary infection

•Amputation if severe and disfiguring infection

Necrotizing fasciitis

This is an acute invasive infection of the subcutaneous tissue and fascia characterized by vascular thrombosis, which leads to tissue necrosis. The skin is secondarily affected. It is idiopathic in origin but minor wounds, ulcers and surgical wounds are believed to be initiating factors. The condition is described as "Meleney’s synergistic gangrene" if it occurs over the abdominal wall and “Fournier’s gangrene “if in the scrotum and perineal area.

Bacteriology:

Mixed pathogens of the following microorganisms are usually cultured.

•Streptococci

•Staphylococci

•Gram negative bacteria

•Anaerobes and

•Clostridia

Clinical Features:

•Sudden onset of localized pain

•Rapidly spreading inflammation

•Spread along chemic fascial planes

•Hemorrhagic bulla and edema

•Skin devascularization

•+/- Crepitations

•+/- Muscle necrosis

•Systemic signs of toxemia

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Management:

•Broad spectrum combined antibiotics

•Gentamycin or Ceftriaxone for coverage of aerobic organisms and

•Cloxacilline or chloramphenicol or Metronidazole for coverage of anaerobic organisms

•Circulatory support with intravenous fluid as much as required and transfusion of cross matched blood when necessary

•Surgery soon as possible. The following surgical procedures may be required:

-Debridement and excision of all dead tissue

-Multiple incisions for drainage

-Repeated wound inspection

-Skin graft may be needed later if extensive skin involved.

CLOSTRIDIAL INFECTIONS

Tetanus

Tetanus is a non-invasive infection caused by anaerobic micro-organisms which requires favorable wounds like abortions, lacerations, injections, open fractures, burns, deep contused wounds with dead tissues and foreign body... It can practically be eliminated by tetanus vaccine immunization if properly initiated and maintained.

Etiology:

Clostridium tetani, a gram-positive rod found in soil and manure is the causative agent. It require anaerobic environment for growth, invasion and elaboration of toxin, tetano-spasmin for its dramatic virulence.

Clinical Features:

-Can be latent with healed and forgotten wounds

-Local or generalized weakness

-Stiffness or cramping pain on the back, neck and abdomen

-Difficult of chewing and swallowing

-Tonic muscles spasms

-Sardonic smile as evidence of onset of tonic spasm

-Severe pain and opisothonus due to reflex convulsion of all muscles

-Progressive difficulty of respiration

-Fever, tachycardia, cyanosis

-Respiratory failure and death due to repeated cyanotic convulsive attacks.

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Treatment:

-Meticulous surgical excision of the wound regardless of immunization state to eliminate the bacterial infection and the dead contaminated tissue

-Isolation, quietness and comfort

-Sedation with chlorpromazine up to 200mg IM/day barbiturates or diazepam 50mgIV under close followup and observation for central signs of drug over dose

-Antibiotics: crystalline penicillin is the drug of choice for parenteral medication. Tetracycline can be an alternative antibiotic for oral therapy.

-Intensive nursing care

-Naso-gastric tube for feeding to maintain protein balance

-Immunization

-Respiratory support and consider tracheostomy if spasms becomes frequent leading to cyanosis

-Human antitetanus globulin if available to neutralize circulating toxin

-Active immunization with 0.5 ml of tetanus toxoid if the patient is not immunized or the wound is tetanus prone

Prevention:

Prevention of clinical tetanus depends on adequate immunization of the population and careful surgical management of all traumatic wounds, even those which appear to be minor. Patients with grossly contaminated wounds and no or unclear history of immunization should receive an intramuscular antitoxin therapy. Active immunization with tetanus toxoid should also be started.

Gas Gangrene

Gas gangrene is another clostridia associated with soft tissue infection (Clostridial myonecrosis). It is a rare but devastating infection characterized by muscle necrosis and systemic toxicity due to the elaboration and release of toxins. It usually follows wounding with trauma or surgery and requires factors contributing to tissue hypoxia like foreign bodies, vascular insufficiency or occurs as a complication of amputation.

Etiology:

Clostridium perfringens is responsible for over 80% of cases. More than one species can be isolated or polymicrobial infection with other microorganisms can occur.

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Clinical features:

It is characterized by fulminant local and systemic manifestations. Patients may appear normal at early state. Clinical features include:

-Sudden and persistent severe pain at wound site.

-Localized tense edema, pallor and tenderness

-Gas noted on palpation or radiographs

-Progressive brownish discoloration of skin and hemorrhagic bullae formation

-Dirty brown discharge with offensive, sweetish odor

-Severe systemic manifestations including fever, tachycardia, hemolytic anemia, hypotension, renal failure and finally death

-Gram’s stain from the discharge can be diagnostic

Management:

•Surgery is most important component

•Extensive, wide excision of involved muscles

•Amputation of an extremity may be needed.

•Antibiotics: high dose penicillin is the preferred drug

•Supportive measures including

-Intravenous infusions

-Blood transfusions

-Close monitoring and follow up

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Review Questions

1.Which of the following is not categorized as “surgical infection”?

A)Urinary tract infection after catheterization for Prostatectomy

B)Abscess formation following injection on the thigh

C)Wound abscess following excision of big lipoma on the back

D)Lung atelectasis following intubation for laparotomy

E)None of the above

2.Which of the following is a requirement for a surgical infection to occur?

A)Virulent microorganism

B)A tissue of decreased or no blood supply

C)A decrease in the immune response of a patient

D)All of the above

E)None of the above

3.Which of the following are the most common microorganisms of surgical infection?

A)Viruses

B)Staphylococcus species

C)Clostridia

D)Candida

E)Entoameba

4.Which of these clinical states may indicate a presence of surgical infection?

A)Fever

B)Loss of function of body part

C)Local hyperemia

D)Tachycardia

E)All of the above

5.Which investigation can be helpful for diagnosing a surgical infection?

A)Gram’s stain from a discharge if there is any

B)Blood culture

C)WBC count

D)Tissue biopsy

E)All of the above

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6.The correct way of managing a patient with an abscess is

A)Start with effective antibiotics and send home

B)Drainage and no antibiotics if no systemic signs

C)Apply local ointments for aiding the abscess to burst

D)Give effective antibiotics and analgesics

E)All except B

7.In a patient with gas gangrene

A)Little circulatory support is needed

B)Surgical removal of gangrenous tissue is the primary management

C)Penicillin is the preferred antibiotic

D)B and C are correct

E)Systemic signs are not commonly seen

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Key to the Review Questions

1.E

2.D

3.B

4.E

5.E

6.B

7.D

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References:

1.Surgical infections: First edition, 1995; Donald E. Fry

2.Wound care: First edition, 1985; Stephen Westaby

3.Principles of Surgery: seventh ed., 1999; Schwartz

4.Bailey and Love’s short practice of surgery, 22nd edition.

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CHAPTER NINE

TRAUMA

Learning Objectives

After reading this chapter, the student should be able to:

ƒIdentify the various types of trauma; understand their epidemiology, predisposing factors and methods of their prevention.

ƒLearn the general approach and treatment priorities of a trauma victim.

ƒLearn the specific management of missile injuries and burn.

Introduction

Trauma is one of the leading causes of mortality, morbidity and disability worldwide. In developing countries, the magnitude of the problem has been increasing consuming more and more of the meager health resources of these nations. Moreover, trauma mostly affects people in their productive years of life, hence the high economic and social burden to society.

The causes of trauma are various and their relative incidence varies in different populations. Deaths due to trauma tend to occur in three patterns:

1.Immediate death (50%)

•Occur in the first few minutes after the accident

•Are due to extensive and lethal injuries to the brain, heart & major blood vessels

2.Early deaths (30%)

•Occur in the first few hours

•Are due to the collections and bleedings in the chest and abdomen, extensive fractures and increased intracranial pressure

•Early resuscitation, diagnosis and appropriate management can prevent these deaths.

3.Late deaths (20%)

•Occur days or weeks after the injury

•Are due to sepsis and organ failure

•May be decreased by early resuscitation and appropriate treatment

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DEFINITION

Trauma is tissue damage, which occurs due to transfer of different forms of energy either intentionally or unintentionally.

Types of Trauma: Trauma can be classified according to the:

I- Cause: Homicidal injuries

Road traffic accident and falls

Industrial accidents, burn, etc.

II- Mechanism: A/ Blunt Injury: Caused by acceleration, deceleration, rotational or shearing force

B/ Penetrating Injury: Caused by a direct breach by penetrating object

E.g. Bullet injury, stab injury

TREATMENT PRIORITIES

Management of trauma requires adherence to an established order of priorities like the advanced trauma life support (ATLS) protocol developed by the American College of Surgeons. The ATLS generally consists of a primary survey and resuscitation followed by a secondary survey and definitive management.

I- The primary survey and resuscitation

This part of management comprises a quick evaluation of the patient to detect immediately life threatening situations and institution of measures to correct them. It has the following components:

A- Air way: Assess the patency of air way. In a trauma victim, it may be compromised by the back fallen tongue, broken tooth, vomitus, blood etc. If the air way is compromised, use suctioning, jaw trust, positioning, oropharyngeal tube or endotracheal tube to open it, taking care of the cervical spine.

B- Breathing: Assess adequacy of breathing. It may be compromised by pneumothorax, hemothorax or multiple rib fractures causing flail chest.

C- Circulation: Assess the circulatory volume. Look for external hemorrhage and arrest it by pressure, bandaging or tourniquet if the other methods fail. Tachycardia, hypotension, pallor may mean bleeding into the body cavities or from an obvious external wound. Open a wide bore

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IV line, take blood sample for cross match and start resuscitation with Normal saline or Ringer’s lactate.

D- Do a quick neurologic examination to assess consciousness. Use the Glasgow coma scale (GCS) to determine the level. Look for any Neurological deficit or lateralizing sign.

E- Expose (undress) the patient fully for examination not to miss serious injuries.

II- Secondary survey and definitive management

This is done after the life threatening conditions have been evaluated and resuscitative measures are instituted. It includes the following aspects:

A- Take History: The informant may be the injured patient, relatives, police or ambulance personnel. The history should include:

•Time of injury,

•Mechanism of injury,

•Amount of bleeding,

•Loss of consciousness,

•Any intervention performed or drugs given should be asked for.

B- Do a proper and systematic examination of all body systems.

C- Make necessary investigations such as hematocrite, cross-match, urinalysis, X-ray, ultrasound, etc. However, never send a patient with unstable vital signs for investigation or referral before resuscitation.

D- Institute the appropriate specific treatment like laparotomy for possible abdominal organ injury, POP cast for tibio-fibular fracture.

ROAD TRAFFIC ACCIDENTS (RTA)

Road traffic accident is the leading cause of trauma deaths in industrialized nations and many developing countries. Several factors contribute to the high magnitude. These include poor condition and design of roads, traffic mix (sharing of road by vehicles of different speeds and pedestrians), poor condition of the vehicles and poor traffic rule enforcement.

The incidence of this serious problem can be reduced by improving the public awareness and the quality of training given to the drivers and strict enforcement of traffic rules. Moreover, improving the design and quality of the roads and regular checkup of vehicle fitness would help alleviate the problem.

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Injuries are caused by sudden acceleration e.g. a pedestrian hit by car or decelerations causing the passenger to collide with the interior of car, other passengers or be ejected out of the car. There are certain patterns of injury in RTA .The presence of one of the following injuries should alert to the possible presence of the other:

ƒHead and cervical spine injury

ƒLower rib fractures and spleen or liver injuries

ƒPelvic fracture and urinary tract injury etc

Certain factors indicate that a RTA victim has a high risk of serious and multiple injuries. These include:

•Presence of flail chest

•Roll over

•Death of another person in the car

FIREARM INJURIES

In civilian practice, these injuries are mostly due to homicidal violence, although accidental injuries also occur. In many developing countries like Ethiopia, the magnitude of the problem is big due to high distribution of firearms among civilians who have little or no knowledge on safe handling and usage. It is made worse by the presence of large number of land mines, which are remnants of repeated wars and conflicts in these poor nations.

Generally, missile injuries may be caused by bullets from pistols, rifles, machine guns or fragments from exploded grenades and mines. The degree of injury sustained depends on the amount of energy transferred from the missile to the patient as formulated below.

E=½mv2 (E = energy transferred, m = mass of the missile, v = velocity of the missile)

Thus, the speed and weight of the missile are the determinant factors. The extensive tissue injury with the high degree of contamination creates a perfect medium for life threatening infection to occur.

Missile injuries are classified into:

I- Low- velocity missile injuries

•Comprise missiles fired from hand guns (<400m/s)

•Injury is limited to the path of the bullet.

II- High velocity missile injuries

•Comprise bullets fired from rifles, machine guns and blast fragments (>1000m/s)

•Cause a small entrance and a larger exit wounds

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•Tissue damage occurs in the surrounding tissue as well, due to the temporary cavitation effect

•Foreign bodies, dirt and clothing materials are sucked deep in the wound due to the vacuum effect

Management of missile injuries

The most important factor in the management of missile injuries and prevention of serious infection is appropriate wound debridement. Wound debridement consists of:

ƒExcision of all dead tissue, e.g., dead muscle

ƒRemoval of all dirt, foreign bodies and free bone fragments

ƒThorough irrigation of wound with copious amount of saline

ƒThe debrided wound should be left open for closure later

N.B: Never close missile wounds primarily, not even the very trivial looking ones! All patients with missile injuries should receive broad spectrum antibiotics and tetanus prophylaxis.

BURN INJURIES

Burn is a coagulation necrosis of tissue due to thermal or chemical injury. It is mostly seen in developing countries where there is overcrowding, poor housing designs and wide spread usage of open fire for cooking. Women and children are affected most as majority of the burns occur at home. Types of burns, according to the mechanism, include:

•Flame burn

•Scalding

•Chemical burn

•Electrical burn, etc.

The severity of a burn injury is a function of the burn depth (degree) and the extent or percentage of the body surface that is burned. Determining the percentage of burn surface is important to calculate the amount of fluid requirement while determination of burn depth is important for burn wound management.

Classification of Burn according to depth (degree)

1- First degree burn: It involves the epidermis only and manifests with erythema.

2- Second degree (partial thickness) burn: This involves part of dermis. It manifests with blisters, edema, moist surface and pain at the affected site.

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3- Third degree (full thickness) burn: Involves complete burn of the dermis. The burned skin looks charred, white or grayish and the surface is pain free.

The extent or percentage of burn is determined by the “rule of nine” in which the body surface is divided into eleven parts each constituting 9% of the total (fig.). In children, the size of the hand may be used to estimate the burn surface, which is approximately 1%.

Management of a burn victim

General management:

Like all trauma patients, adhere to ATLS system.

•Airway obstruction may occur rapidly after inhalation injury or delayed for 24-48 hours. Endotracheal intubation or tracheotomy may be needed in patients with burns involving the air way.

•Major burn (> 20% body surface area) needs fluid resuscitation. Open IV line with wide bore cannula and infuse saline containing IV fluid (Ringer’s lactate if available)

-The amount of IV fluid needed for the first 24 hours is calculated as a product of percent of the burned surface area and the body weight in kilograms added to the daily maintenance (%BSA X Wt.) + daily maintenance. Half of the calculated volume is given in the first 8 hours and the remaining half over the next 16 hours from the time of burn.

-Volume and rate of fluid administration should be valid according to the vital signs and urine output, hence the need to catheterize the patient. The optimal urine output is 30-50ml /hr in adults and 1ml/kg/hr in children

Criteria for admission

•Adults > 20% BSA burn

•Children > 10% BSA burn

•Burns involving the face, hands, feet and genitalia

•Suspicion of inhalation injury

•Chemical and electrical burns

Burn wound management: There are several methods of managing a burn wound. The choice depends on the degree, size and site of the burn, and availability of facilities and expertise.

1- The exposure method: The burn wound is cleaned by antiseptic agents and left exposed to air. It is used for burns of the face and burns of large surface area.

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2- The occlusive method: A thick dressing after cleaning with antiseptics covers the burn wound. It is used mostly for outpatient treatment of small burns.

3- The plastic bag method: The burned part is wrapped in a transparent plastic bag. It is used for burns of hands and feet.

4- The saline method: The burn wound is intermittently irrigated with half strength saline solution. This is used for large surface deep burns.

5- Early excision and skin grafting: This needs skill of grafting and transfusion facilities. It is used for deep burns.

Emergency escharotomy and fasciotomy should be done for deep circumferential burns of limbs, neck or trunk.

Analgesia: Most burn patients are in severe pain. Therefore, analgesic doses of IV narcotics regularly to control the pain should be stressed as part of the management.

Prevention of Infection: Burn patients have impaired resistance against infection. Most deaths occur due to pneumonia and wound sepsis. Prophylactic antibiotics (penicillin) are given for severe burns but, routine administration has no value. Topical antimicrobials e.g. 1% silver sulfadiazine are helpful for deep 2nd and 3rd degree burns.

Nutrition: Naso-gastric tube should be inserted after admission for patients with more than 25% burn and those who have nausea and vomiting. Enteral feeding should be resumed as soon as possible.

Burn patients are in catabolic state and tend to lose weight very fast, thus special attention to their diet is important. The daily calorie required is 20 Kcal/Kg + 70 Kcal/%burn. Daily protein requirement for burn patients is 1 gm/kg + 3 gm/%burn.

Prophylaxis against tetanus: Tetanus prophylaxis should be supplemented as burn is potentially infected wound.

Prevention of contractures and rehabilitation: Patients should constantly be urged and made to move all joints. Failure to do this results in contractures, which may be very disabling, unsightly and difficult to treat.

Prevention

The magnitude of burn injuries can be reduced by keeping the high risks, like children and epileptics, away from open fire or boiling pots and enforcing strict safety precautions in working places like factories etc.

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Review Questions

1- A 20 year old man was brought in unconscious after car accident. Describe how you would proceed managing him.

2- What are the predisposing factors for road traffic accidents and describe the methods of prevention.

3- What does wound debridement mean?

4- How would you manage a 24 year-old housewife who was brought in eight hours after sustaining a 30% flame burn to her chest, arms, and face?

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Reference

1.Schwatz Text Book of Surgery, 1999.

2.Baily and Love’s Short Practice of Surgery, 22nd edition.

3.Primary surgery, Vol. 2 .Maurice Kings and Peter Bewes, 1987.

4.WHO. Investing in health research and development: Report of the ad-Hoc committee on health research relating to future intervention options. Geneva, 1996

5.Murray CJ, Lopez A. The global burden of disease, Vol. 1, WHO & World Bank.

6.Mensur O. et-al. Magnitude and Pattern of Injuries in North Gondar.

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HEAD AND SPINAL INJURIES

Learning objectives

At the end of this chapter students are expected to:

•Identity types of head injuries

•List the effects of head injury

•Outline assessment of patients with head or spinal injury

•Plan for management of patients with head injury

•Outline evaluation and management of spinal injuries

HEAD INJURY

Head injury is one of the most common causes for attending emergency departments. Craniocerebral trauma is consequently a source of major disability and huge financial and psychological burden. Trauma to the cranium can be either blunt or penetrating and involve the scalp, the skull or the brain. These injuries can take many forms.

Scalp Injury

Scalp lacerations are common and can result in severe hemorrhage if not controlled. Scalp lacerations can be sutured after ruling out possible associated skull or brain injuries.

Skull Injury

Different clinical forms of skull injury may follow trauma to the skull. These include:

Simple Linear Fracture

This is a line of fracture which usually marks of severe forces of injury. No specific neurological management is required.

Depressed skull fracture

This type of fracture is usually a result of blunt trauma. It could be either open or closed. The open type of fracture (compound depressed fracture) has a high risk of infection so that it should be handled as an emergency. The depressed fragments may lacerate the dura and brain tissue.

Treatment

oDebride and irrigate contaminated wounds o Full course of intravenous antibiotics

o Elevation if indicated: deeper than the thickness of the skull in adults or if there is any neurologic complication

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Fracture of the base of skull

Basal skull fractures can occur at different sites (anterior, middle or posterior fossa)

They often result in CSF leak. Anterior fossa fractures present with subconjuctival hematoma, anosmia, epistaxis and CSF rhinorrhoea. Middle fossa fracture presents with CSF rhinorrhea or otorrhea, heamotympanum and bruising behind the ear.

Brain injuries

Mechanisms of brain injury

Abrupt deceleration of a moving head results in minor injury at site of impact (coup injury) or contusion of the brain opposite the point of impact (contra coup injury). From clinical point of view, brain injuries could be primary (occurring at the time of impact) or secondary (develops subsequently).

Primary brain injury

Cerebral concussion

This is a clinical diagnosis characterized by temporary dysfunction. It is most severe immediately after injury and resolves after variable period of time. It is often accompanied by loss of consciousness and amnesia for the moment is common. Post-concussion syndrome which consists of headache, irritability, depression and lassitude may be seen as late manifestations.

Cerebral contusion and Laceration

Pia and arachnoid tearing and intracerebral bleeding characterize these conditions. It usually produces focal neurologic deficits that persist for more than 24 hours. Blood brain barrier defects and cerebral edema are common. Contusions may resolve spontaneously or persist.

Secondary brain injuries

Secondary brain injuries are effects which develop secondary to subsequent anatomical and physiological derangements. The role of the health worker is to early detect and manage these.

Intracranial hematomas

A.Extradural hematoma: This condition usually follows temporal bone fracture with tearing of middle meningeal artery leading to hematoma collection. Patients may present in coma after a lucid interval. Urgent evacuation of the hematoma is required.

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B.Acute Sudbural hematoma: This state is the most common intracranial mass lesion following head injury. Mostly, it results from tearing of bridging veins. The lesion is rapidly evolving and early evacuation is mandatory.

C.Chronic subdural hematoma: This is most common in infants and adults over 60 years of age. Patients usually present with progressive neurological deficit more than 2 weeks after the trauma.

D.Intracerebral hematoma: Intracerebral hematoma results from areas of contusion coalescing into contusion hematoma.

Cerebral swelling (Brain edema)

This results from vascular engorgement, due to loss of auto regulation and increased extra and intracellular fluid. If not corrected early, it results in cerebral ischemia.

Infections

Compound depressed fractures or basal skull fractures can lead to meningitis or cerebral abscess.

Patient assessment

In unconscious head injury patient, primary survey followed by resuscitation, if any impairment, should be the initial approach. Air way, breathing and circulation should be secured. This has to be followed by secondary survey and definitive management.

History

Points to determine in the history are:

ƒPeriod of loss of consciousness

ƒPeriod of post traumatic amnesia

ƒCause and circumstance of the injury

ƒPresence of headache and vomiting.

ƒPresence of seizures.

Physical examination

Then Patients will be examined for evidences of injury

ƒAssess level of consciousness (Glasgow coma scale )

ƒPupillary response

ƒComplete neurologic examination, look for lateralizing signs.

ƒLook for evidences of basal skull fracture

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Based on Glasgow coma scale, patients can be classified as severe, moderate or mild. These have significant contribution on subsequent management decision and outcome.

Table 1: Glasgow coma scale.

Eye opening		Best motor response		Verbal response
		Obeys	6
		Localizes	5	Oriented	5
Spontaneous	4	Withdraws	4	Confused	4
To speech	3	Abnormal flexion	3	Inappropriate words	3
To pain	2	Extension	2	Incomprehensible sound	2
Nil	1	Nil	1	Nil	1

Investigation

•Chest X-ray is mandatory in unconscious polytrauma patients to rule out hemothorax or pneumothorax

•Film of cervical spines in unconscious patients

•Skull X-ray when fracture is suspected

•CT- Scan helps to visualize hematoma contusions and edemas if indicated

Management

ABC

After ensuring adequate oxygen and blood flow to the patient’s body, treatment of intracranial hypertension follows. This can be done through:

•Controlled hyperventilation

•Diuretics or

•Hyper-osmotic agents

The role of surgery in head injury is to remove mass lesions and to prevent the delayed development of infection by treating open head injuries. Any hematoma found should be rapidly evacuated; otherwise it can lead to deterioration of the patient’s status due to brain compression.

Compound depressed skull fracture requires immediate operation to prevent intracranial infection. Fractures are debrided and bone fragments washed in antibiotic solutions and immediately replaced. Elevation is done if indicated.

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Intracranial hypertension must also be controlled in postoperative period. Post-operative control of amount of fluid (not to be given more than 2/3 of the daily requirement), electrolytes, positioning in 20-30 degree elevation of the bed and management convulsion and of late sequel of head injury should be accomplished.

SPINAL CORD INJURIES

INTRODUCTION

The spinal cord terminates at the caudal end of first lumbar vertebrae. Loose nerve roots of cauda equina fill the lumbar spinal canal. Fracture and dislocation of the 24 movable vertebrae can occur at any level. Displaced bone fragments and inter-vertebral disks may herniate to the spinal cord causing compression, commonly seen in cervical and thoraco lumbar region.

Most spinal injuries result in immediate and total paralysis. But there could also be incomplete injuries. Among incomplete injuries, the following ones are commonly seen.

i.Brown-sequard Syndrome: Ipsilateral paresis and contra-lateral loss of pain and temperature sensation. Vibration and position sensations are diminished on ipsilateral side.

ii.Anterior spinal cord syndrome: Paralysis occurs below the level of the lesion with loss of temperature, touch and pain sensation.

iii.Central cord syndrome: hand and upper extremities are affected with sparing of lower extremities.

Both complete and incomplete injuries of the spinal cord can result in neurogenic bladder. Immediately after injury, spinal shock ensues in which bladder reflex does not develop. Catheterized drainage is essential in this state. There could be a finding of flaccid paralysis, depressed deep tendon reflex and sensory level.

Patient assessment

Early detection of spinal injury will prevent further injury to the cord. During assessment and resuscitation, the spine must be carefully immobilized. Multiple injuries, seat belt markings and neurologic findings should alert the possibility of spinal injury. Examination should include:

•Secure the airway, breathing and circulation (ABC rule of trauma management)

•Local examination: Sign of bruise, swelling, echymosis, pain and tenderness at any site of spine could be secondary to fracture dislocation or disc herniation

•Sensory examination: Assess for any loss of sensation and its level

•Motor examination: Check for weakness of muscle power and tendon reflexes

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Investigation

After complete physical examination, x-rays should be taken. In conscious patients biplanar x-rays of the symptomatic part of spine are adequate. In cervical spines, unstable injuries are easily overlooked in lateral and A-P films. One option is to have real-time flexion and extension x- rays.

Treatment

•IV resuscitation should be started in patients with spinal shock.

•Majority of simple compression fractures heal without consequences. It is treated symptomatically initially with rest, then with splinting and mobilization as necessary.

•Adequate immobilization is mandatory in unstable cervical injuries. Further neurologic damage is prevented by suitable immobilization.

•If there is deterioration of neurological function after initial assessment, surgery should be considered to stabilize the spine and to decompress the spinal cord and nerve roots. Careful transfer to appropriate centers is therefore important.

•High dose steroids may improve recovery after spinal cord injuries.

•Bladder care.

•Bed sore prevention by bed care and frequent position changes.

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Review Questions

1.Discuss the basic mechanisms of brain injury in head injury patients

2.List the secondary brain injuries following head injury

3.A patient comes to you after sustaining a road traffic accident. On physical examination, there are no evidences of external injury. When you assess his level of consciousness, he opens his eyes when pinched, withdraws from pain and he is confused.

a)What is his Glasgow coma scale?

b)What further history and physical examination do you require?

c)List the investigation you order

d)Suggest your management plan

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References

1.Bailey and Loves, Short Practice of Surgery.22nd edition

2.Hardy’s Textbook of Surgery

4. Primary Surgery, Trauma.

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CHAPTER TEN

ORTHOPEDIC SURGERY

Learning Objective

After reading this chapter, the students should be able to:

•Understand the etiology, pathology and clinical presentation of bone and joint infections.

•Learn the mechanism, classification and healing of fractures and dislocations.

•Learn the general steps and the various modalities of fracture treatment and their complications.

•Learn about amputations, their indications and complications.

Introduction

Orthopedics deals with disorders of the musculoskeletal system. Although the musculoskeletal system can be affected by several conditions like congenital, metabolic or neoplastic diseases, traumatic and infectious disorders are the most important ones in developing countries.

INFECTIONS OF BONES AND JOINTS

ACUTE OSTEOMYELITIS

Acute osteomyelitis is an acute bacterial infection of the bone and its medullary cavity. It commonly affects children, boys more than girls.

Etiology

•Staphylococcus aureus is the agent in 80% of cases

•Gram negative rods and Staphylococcus in neonates

•H. Influenza is seen in children under 5 years of age

•History of trauma is common and may predispose children to osteomyelitis

Pathology

Bacteria reach the bone mostly via the hematogenous route. Infection begins in the metaphysis of a long bone and spreads through the cortex and medullary cavity causing thrombosis to vessels and bone infarction. Pus collects under the periosteum peeling it off the cortex.

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Diagnosis

•	History of	-	Pain, which is gradually increasing in severity
		-	Fever, Toxicity
		- Failure to use the involved limb
•	Physical Examination	-	Localized bony tenderness (most important)
		- Adjacent joint may contain effusion
•	Lab. Investigation	-	Leucocytosis and raised ESR
		-	Positive blood culture

- X-ray changes of bone: late to develop (10-15 days) and is thus not helpful for diagnosis of acute osteomyelitis.

Treatment

Antibiotics

•IV antibiotic should be started empirically after taking blood sample for culture

•Choice of antibiotics depends on the age:

-Neonates:- Penicillinase resistant penicillins + Aminoglycosides

E.g. Cloxacillin + Gentamycine

-Children under 5 years:- Penicillinase resistant penicillins + Anti H.influenzae E.g. Cloxacillin + Chloramphenicol

-Patients above 5 years:- Penicllinase resistant penicillin

E.g. Cloxacillin

The duration of antibiotic treatment is 6 weeks. IV route is changed to oral after fever and leucocytosis have disappeared (about 7-14 days).

Surgery: Surgery to drain abscess is recommended if fever and pain fail to subside after 48 hours of IV antibiotic treatment or if there is evidence of pus collection.

Analgesics and splinting: Analgesics and splinting of the limb in functional position using POP casts or skin traction reduces pain in the acute phase.

CHRONIC OSTEOMYELITIS

Chronic osteomyelitis usually follows a delay or inappropriate treatment of an acute stage osteomyelitis. It may also follow direct infection of bone in compound fracture.

Pathology: The dead bone (sequester) lies in an abscess cavity surrounded by a newly formed bone (Involcrum) under the elevated periosteum.

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Diagnosis: The usual presentation is periods of quiescence and acute exacerbation of persistently discharging sinus. There may be skin hyper pigmentation around the sinus and palpable bone thickening. X-ray may show sequester, abscess cavity, involucrum or diffuse sclerosis.

Treatment

Antibiotics: Used for acute exacerbation and perioperate for about six weeks.

Surgery: Surgery is done to remove a dead bone (sequesterectomy) or to eliminate an abscess cavity (saucerization). Conservative treatment is considered in a patient with minimal discharge and no obvious sequestrum or bone cavity. Amputation may be considered for extensive bone involvement and heavy discharge or frequent flare-ups which incapacitate the patient.

SEPTIC ARTHRITIS

Definition: Septic arthritis is an acute bacterial infection of joints.

Etiology: It varies in different age groups and is similar to that of acute osteomyelitis. Neisseria gonorrhea should be considered in the sexually active age group.

Pathology: The hip and knee joints are the commonly affected joints. Bacteria may reach the joint via the blood, local extension of osteomyelitis or directly in penetrating wounds of the joint. The pus formed in the joint is chondrolytic and destroys the joint cartilage if not evacuated.

Diagnosis:

History: The usual presenting symptoms are joint pain, swelling and fever.

Physical examination: The joint becomes swollen with effusion, tender and warm. The range of active and passive movement also gets severely limited.

Lab: Joint fluid analysis reveals opaque yellow to green fluid with

•High cell count (mostly>100,000/mm3, with >90% PMN).

•Decreased glucose level (50 mg/dl lower than blood)

•Culture is often positive.

Treatment

Start with IV antibiotics. Do joint aspiration repeatedly under aseptic condition. If frank pus is found, drain it by making arthrotomy. Immobilize the affected joint in functional position until inflammation subsides and physiotherapy to prevent joint stiffness.

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Complications

Early: Destruction of articular cartilage, dislocation, epiphyseal necrosis.

Late: Secondary osteomyelitis, joint stiffness and ankylosis

TUBERCULOUS ARTHRITIS

Tuberculosis of bones and joints is mostly due to hematogenous spread from a pulmonary focus. The intervertebral discs, the hip and knee joints are the most frequently affected.

Pathology

-Necrosis and granulation tissue formation in the synovium

-Destruction of sub chondral bone and articular cartilage

-Fibrous fusion (ankylosis) of the joint

Diagnosis

History: Insidious onset of dull aching pain, weight loss, anorexia, low grade fever

Examination:	- Muscular atrophy of affected limb
	- Joint swelling and warmth of overlying skin
	- Joint effusion
	- Limitation of joint movement
Laboratory:	- Raised ESR
	- Joint fluid analysis reveals turbid joint fluid with increased
	leukocyte count (predominantly mononuclear)
	- Acid-fast stain may reveal AFB.
X-ray:	- Joint space narrowing
	- Sub chondral bone destruction
	- Periarticular osteoporosis

Open biopsy of the joint is done if diagnosis is still in doubt.

Treatment

-Anti-TB drug treatment

-Splint joint in functional position to avoid contracture

FRACTURES

Definition: A fracture is a structural breech in the normal continuity of bone.

Mechanism of injury
1- Tubular bone:	- Direct violence to the bone
	- Indirectly due to twisting or angulation
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2- Cancellous bone:	- may be fractured by compression
	E.g. Clash fracture of vertebral body or by traction
	E.g. Transverse fracture of the patella

Bone Healing

oProgresses through the phase of hematoma, cellular proliferation, callus formation and remodeling

oGenerally takes longer than soft tissue healing

oIn general, a long bone takes 6-12 weeks to heal in an adult and 3-6 weeks in children. o Several factors, both local and systemic, affect fracture healing

•Local factors: - Degree of soft tissue injury

-Pattern and site of fracture

-Presence of Infection

-Adequacy of reduction

-Adequacy of immobilization

•Systemic factors: like debilitating diseases and immunosuppressive drugs impair healing.

Classification

-Fractures may be classified in several ways. the most important clinical classification is:

-Closed vs open (compound) fracture

Diagnosis
Clinical:	-	History of trauma
	- Pain, swelling, inability to use the injured body part
	- Tenderness, swelling and bruising
	-	Deformity, abnormal movement (sure signs of fracture)

X-ray: A suspected fractured bone should be x-rayed.

-X-ray should be taken in at least two planes (AP and lateral)

-Should always include the joints proximal and distal to the fracture

-Look in the X-ray for:

ƒPresence of fracture

ƒThe part of bone fractured

ƒThe pattern of the fracture which can be transverse, comminuted, oblique, spiral, segmental.

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ƒPresence and type of displacement which can be lateral shift, angulation, rotation, overlap, distraction

ƒQuality of bone: check for:

•Osteoporosis

•Pathological fracture, etc

Management of a patient with fracture

A)GENERAL TREATMENT

-Like any trauma patient, follow the ATLS system. Associated life threatening injuries may be missed if evaluation of the patient is not systematic.

-Always assess the status of distal circulation and neurological function.

-Administer anti pain and splint all fractures before sending the patient for x-ray or referring.

B)Local treatment of the fracture:-

I-Reduction

•Means bringing the fractured bone to normal or near normal anatomic position. This is needed only for displaced fractures

•Age and function of the patient are important in considering the goals of reduction

•Reduction may be done in various ways:

1- Using gravity E.g. Humeral shaft fracture

2- Closed reduction by:

A- Manipulation	e.g.	Colle’s fracture
B- Traction	e.g.	Femoral shaft fracture

3- Open (Operative) reduction: Used when other methods are not possible, have failed or a perfect anatomic reduction is needed.

E.g. displaced intra articular fractures.

II- Immobilization

The purpose of immobilization is to:

ƒprevent re displacement of a reduced fracture

ƒdecrease movement at the site of fracture and prevent further soft tissue injury

ƒrelieve pain

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Methods of Immobilization

1- Plaster of Paris (POP) cast

-Is the safest and cheapest method of immobilization

-Immobilization should always include the two adjacent joints

-Joints should be immobilized in a functional position

-Complications include joint stiffness and compartment syndrome.

2- Traction

A)Using gravity: e.g. U-slab for humeral shaft fracture

B)Skin traction: A method of applying traction using bandage, usually used in children and temporarily in adults. The maximum weight that can be applied is 2kg.

C)Skeletal traction: Traction applied via a pin inserted into the bone distal to the fracture. E.g. Tibial pin traction for femoral fracture

3- External fixation

-This is a method of fixing the fracture by metal pins passed through the bone above and below the fracture and connected to a metal frame.

-It is mostly used in compound fractures as it combines good access for wound care with immobilization

4- Internal fixation

-Internal fixation is a method of operative fixation of fractures by plates, nails, screws, pins and wires

-The rigid fixation allows patients to get out of bed early

-It’s employed when operative reduction has been done for any of the reasons mentioned before.

-It’s also indicated in poly traumatized patients whose confinement in bed if treated otherwise results in high morbidity and mortality.

-Infection is the main complication and may result in chronic osteomyelitis

-It also needs expertise and orthopedic surgical facilities.

III- Rehabilitation

-Preserving muscle and joint function both during and after treatment is an essential component of fracture treatment for a good result.

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Compound (open) fractures

Open (compound) fracture

-This is a fracture in which the fracture hematoma communicates with skin or mucous membrane.

-Infection is the most feared complication of compound fractures and may cause delayed healing, non union, sepsis or even death.

-It is a surgical emergency

Principles of management:

-Early wound debridement and thorough irrigation with saline

-Antibiotics: Broad spectrum e.g. Penicillin + Aminoglycoside should be given IV at least for 48 hrs.

-Tetanus prophylaxis

-Rigid immobilization with access to the wound e.g. external fixation

-Delayed wound closure!

N.B: Never close a compound fracture immediately in an attempt to convert it to a closed one. You’ll cause a severe anaerobic infection!

Complications of Fractures

I- Soft tissue Injuries

-Arteries, Nerves and Viscera may be injured

II- Compartment syndrome

•Is a dangerously increased pressure within the enclosed fascial compartments of extremities, especially forearm and leg.

•The high compartmental pressure causes Ischemia and necrosis of soft tissues in the compartment.

•It may be aggravated by application of tight bandages or circular POP casts on a freshly injured limb.

•Severe pain, especially with passive flexion of fingers is the earliest indicator.

•Paresthesia, Paralysis, Pallor or Pulselessness may develop later,

•Early diagnosis and complete splitting of a tight bandage or circular POP cast may resolve the situation.

•Fasciotomy is done if the above measures have failed.

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III- Infection

-Usually complicates open fractures

-Chronic osteomyelitis may be the result.

-Adequate debridement is the most critical factor in preventing infection.

IV- Bone healing abnormalities

1- Delayed Union

-Failure of a fracture to heal in the expected time period. 2- Non union

-Total failure of the fracture to heal with formation of a false joint between the fractured ends (pseudoarthrosis)

3- Malunion

-Healing occurs with deformity 4- Avascular necrosis

-Necrosis of part of the fractured bone occurs due to disruption of its vascular supply. E.g. Femoral head.

V- Joint complications

•Joint stiffness

•Secondary Hemarthrosis

•osteoarthritis

VI- Systemic complications

•Usually follow polytrauma and major long bone fracture

•Include ARDS and fat embolism syndrome

DISLOCATIONS

A dislocation is a total disruption of joint with no remaining contact between the articular surfaces.

A subluxation is partial joint disruption with partial remaining but abnormal contact of articular surfaces.

Types of Dislocation

1- Traumatic dislocations

-This is a type of dislocation caused by trauma. A force strong enough to disrupt the joint capsule and other supporting ligamentous structures dislocates a previously normal joint.

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2- Pathological /Spontaneous dislocation

-This is a type of dislocation which occurs when a pathological condition in the joint causes abnormality in the structural integrity of the joint.

E.g. Septic hip dislocation

3- Recurrent dislocation

-This is a dislocation which repeatedly occurs after trivial injuries due to weakening of the supportive joint structures

4- Congenital dislocation

-A type of dislocation which is present congenitally since birth. E.g. Congenital hip dislocation

Diagnosis

-The limb assumes an abnormally fixed position with loss of normal range of movement in the affected joint.

-Associated soft tissue injuries should be looked for:

E.g. Popliteal artery in knee dislocation Sciatic nerve in posterior hip dislocation

-X-ray in various planes and views confirms diagnosis

Management

•Early reduction of the dislocation

•Immobilizing the joint to allow time for the supporting structures of the joint to heal

•Rehabilitation of the joint

AMPUTATIONS

An amputation is removal or excision of part or whole of a limb.

Indications

1- Dead limb (Gangrene)

-Due to: - Atherosclerosis

-Embolism

-Major arterial injury

-Diabetic gangrene…

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2- Deadly limb

-Life threatening infection (e.g. Gas gangrene) or malignancies which can’t be controlled by other local measures

3- Dead loss

-Severe soft tissue injury especially associated with major nerve injury, which may occur in compound fractures.

Level of amputation

The choice for the level of amputation depends on:

-Age

-The nature and extent of the pathology e.g. Neoplasm, trauma

-The vascularity of tissues

-Presence of infection

-Status of the joints

-Access to the various types of prostheses

Generally, the most distal level that will heal and still provide a functional stump is selected.

-In the upper limb, attempt should be made to conserve every possible inch.

-In the lower limb, the most important factor is to try and conserve the knee joint whenever possible.

Amputations performed in the face of infection should be left open for a later closure.

Complications of amputation

-Edema

-Hematoma

-Secondary and reactionary hemorrhage

-Infection

-Ischemic necrosis

-Flexion contracture

-Chronic pain-psychogenic, neuromas, etc.

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Review Questions

1.Describe the pathogenesis of acute osteomyelitis.

2.A 25 year old man presents with severe pain and swelling of his right knee joint of two days duration. Discuss his management.

3.Describe the management of a patient with compound fracture.

4.What is compartment syndrome? Describe its clinical manifestation and management.

5.List the indications for amputation.

6.What are the factors considered in deciding the level of an amputation?

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Reference

1.Review of orthopedics. Mark D. Miller, 1992.

2.Sabiston Text Book of Surgery, 1997.

3.Schwartz Text Book of Surgery,1999

4.Bailey and Love’s Short Practice of Surgery.

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CHAPTER ELEVEN

ANESTHESIA

Learning Objective

After reading this chapter, the student should be able to:

ƒGet basic information and understanding about the proper pre-anesthetic preparation of a patient before surgery,

ƒGet basic knowledge on different types of anesthesia with their characteristics.

ƒGet basic knowledge about the steps in the assessment and management of a patient with cardio-respiratory arrest, needing cardiopulmonary resuscitation.

PRE-ANESTHETIC PATIENT EVALUATION AND PREPARATION

INTRODUCTION

The purpose of pre anesthetic assessment is to present the patient for surgery in the best possible condition. Pre anesthetic assessment and preparation should include:

oMedical History

oRelevant physical examination

oChecking the results of tests or investigation

oCorrect or improve any medical conditions before surgery o Prescribing any drugs for pre-medication (if needed)

o Explaining to the patient the procedure of anesthesia

History

oDiagnosis and planned surgery

oActual medical and surgical history

Respiratory system: Ask if there is history of shortness of breath, cough, sputum production and wheezing

Cardiovascular system: Check if there is history of:

oAngina/previous myocardial infarction, current orthopnea, ankle swelling

Past medical history: Such as bleeding disorders, hypertension, asthma, seizures, psychiatric disorders, previous anesthesia and any problem related to anesthesia

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Drug therapy: History of intake of drugs like:

-Anti-diabetics

-Anticoagulants

-Steroids

-Anti-hypertensive

Additional history on:

ƒExcessive alcohol intake, smoking and allergies to drugs

ƒPregnancy

ƒDental status (loose teeth)

ƒFasting

Physical Examination

Respiratory System

Check for cyanosis, finger clubbing, pattern and frequency of breathing, position of trachea, presence of added sounds on auscultation and their localization.

Cardiovascular system

Check the pulse rate, rhythm and character; blood pressure (raised or lowering of the blood pressure), peripheral dependent edema, apex beat, extra heart sounds.

State of nutrition and hydration

Assess the body weight and height (BMI) and state of hydration.

Skin color

Check for pallor, cyanosis, jaundice (suspect liver disease which needs some attention during anesthesia), and hyper-pigmentation.

Psychological status of the patient

This will influence the choice between regional and general anesthesia and also to give pre- medication.

CNS: Should be assessed for level of consciousness and neurological deficit

The airway:

Assess for difficulty of the airway maintenance and laryngoscopy, anatomical problems like receding lower jaw, protruding teeth; pathological problem like difficulty in opening jaw or neck-extension, tumors, inflammation or burn-contractions on the neck

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Ease of venous cannulation: Finally, check for the ease of venous access

Investigations: There are routine investigations prior to any surgery which requires anesthesia. This depends on the facilities and the condition of patient and type of surgery. Special investigations should be ordered according to the condition of the patient.

District Hospital: (Where the facilities are restricted)

•Hemoglobin

•Urine analysis

Referral Hospital:

•Hemoglobin and full blood count

•Urine analysis

•Blood Urea Nitrogen/Creatinine

•Serum electrolytes

•Electrocardiogram (age over 40 years)

Correct or improve any medical conditions before surgery (preoperative care) In case of elective surgery

Fluid imbalance: The volume of circulating fluid should be corrected.

Electrolyte imbalance: Correct, especially sodium and potassium imbalance.

Smoking: Smoking should be given up at least three days preoperatively because of the increased risk of bronchial exudation and the bronchospasm.

Dental treatment should be carried out if necessary before any major surgery.

Anemia: A value below 10 g/dl should be corrected.

Cardiovascular diseases: A period of 6 months should be allowed after an attack of myocardial infarction. Cardiac failure must be treated for achieving a maximum compensation. Arrhythmias must not be too severe to interfere with patient’s cardiac output and hypertension should be treated properly.

Respiratory disease: Acute respiratory disease is contraindication for elective general anesthesia. Asthma must be treated with appropriate bronco-dilators until the chest is clear to auscultation.

Metabolic diseases: Diabetes mellitus must be controlled. After severe case of infective hepatitis, operation is best postponed for a minimum of 6 months. Thyroid disorders (both hyper and hypothyroidism) must be corrected.

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In case of emergency surgery: Patients presenting for emergency surgery face additional problems to those with elective surgery. These include full stomach with high risk of aspiration and hypovolemia due to blood or fluid loss which has to be replaced as fast as possible. Measures which should be taken in case of full stomach include:

-Postpone surgery for at least 4 hours.

-Empty the stomach using Naso-Gastric Tube of largest possible size.

-Magnesium tricilicate to reduce the pH of the gastric content.

-Especial “Crash induction” can be employed in the case of general anesthesia.

Crash induction:

This is a procedure used to prevent aspiration when full stomach is suspected.

¾First preoxygenate the patient and give induction agent to make sleep.

¾An assistant apply pressure on the cricoids just below the thyroid cartilage to occlude the esophagus.

¾Then, muscle relaxant given

¾The pressure will be removed when the endotracheal tube is in the trachea and the balloon is inflated

N.B.: In case of a life-threatening emergency, there is no contraindication for general anesthesia!

Measures before leaving the ward to the theater

-Food and drink with held for 6 hours

-Lipstick removed, nails cleaned, etc.

-Dentures, artificial limbs and eyes removed

-Bladder emptied

-Premedication given

Premedication

Definition: Premedication is administration of drugs before surgery.

Purposes:

-To alleviate anxiety and fear with sedatives (Diazepam)

-To reduce secretions especially salivary and bronchial (Atropine)

-To prevent undesirable reflexes, e.g. bradycardia (Atropine)

-To facilitate induction and reduce the dose of anesthetic used

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Commonly used drugs:

¾Diazepam 10 mg

¾Atropine 0.01 mg/kg IV / 0.02 mg/kg IM (ideally 30 min prior surgery)

Route of administration:

-Oral with small amount of water

-Intramuscular (for children)

-Intravenous injection:

-Pre medication has not been given earlier in the ward

-In patients who have already intravenous infusion running

-In shocked patients

-In a patient who has a bleeding tendency

CARDIOPULMONARY RESUSCITATION (CPR)

Definition: Cardiopulmonary resuscitation is the attempt to restor the vital functions of the body, which are the respiration and the circulation.

ABC of Cardiopulmonary Resuscitation

A = Assessment and Airway

B = Breathing

C = Circulation

D = Drugs

A. Assessment: Assess the patient for response by

ƒgently shaking the shoulders

ƒshouting, “are you all right?”

If the patient responds by moving or answering, leave him/her in the position in which they were found (assuming there is no further danger) and look for any obvious injuries or causes for collapse (Diabetic, intoxication, etc).

If there is any suspicion of a neck injury, protect the cervical spine by manual immobilization. Provide first aid for any injuries present and carefully reassess the patient at the regular interval.

If the patient does not respond, shout for help.

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Fig. 1: Opening the Airway

By tilting the head back, open the airway by lifting the tongue off the fall by lifting the chin. Inspect the posterior pharyngeal wall. Remove any obvious obstruction from the mouth including loose denture.

Fig. 1: Opening the airway.	Top: Airway obstruction produced by tongue and epiglottis
	Bottom: Relief by head tilt –chin lift

B. Breathing:

¾Look, listen and feel for breathing (Fig. 2).

¾Look for chest movement.

¾Listen at the mouth for breathing sounds.

¾Feel for expired air with your cheek.

¾Look, listen and feel for up to 10 seconds before deciding whether breathing is present or absent.

Fig. 2: Determining breathlessness

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If the patient is breathing:

¾Turn the person into the recovery position (lateral position) unless you would aggravate any injuries (cervical spine injuries).

¾Observe him/her closely checking that uninterrupted breathing continues and pulse is present.

If the patient is not breathing:

¾Turn the patient into supine position and give two breaths of expired air ventilation (mouth to mouth breathing) (Fig. 3) then check the circulation.

¾Expired air ventilation provides oxygen concentration of 16%, which is adequate to oxygenate the collapsed patient in the initial phase.

Fig. 3: Rescue breathing: Mouth to mouth breathing

C. Circulation (Fig. 4)

¾Check the carotid pulse just lateral to the laryngeal prominence. Major pulses like the carotid or femoral pulses are more reliable in an emergency than peripheral pulses.

¾Feel up to 10 seconds before deciding about the presence or absence of pulse.

¾Look for any other signs of circulation (movement, swallowing, etc).

Fig. 4: Determining pulselessness. Locate the larynx while maintaining the head-tilt position (left). Slide the fingers into the groove between the trachea and the muscles at the side of the neck where the carotid pulse can be felt (right).

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If pulse is present:

¾Continue ventilation giving 10 breaths per minute.

¾Reassess for signs of continuing circulation every minute, taking no more than 10 seconds to do so on each occasion.

¾If signs of a spontaneous respiratory effort appear, stop and reassess ABC again.

If there are no signs of circulation, this is a cardiac arrest.

¾Start external chest compression (Fig. 5).

¾Give 15 chest compressions.

¾Reopen the airway and give a further 2 breathes of expired air ventilation.

¾External chest compression provides only 20% of normal cardiac out put.

Fig. 5: External chest compression.

Left: Locating the correct hand position on the lower half of the sternum

Right: Proper position of the rescuer with shoulder directly over the victim’s sternum and elbows locked

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Advantages of General Anesthesia

•It can be given quickly

•It makes the patient’s whole body insensitive to pain

•It makes the patient unconscious

A general anesthesia may cause both respiratory and cardio-vascular complications, which will require intervention. To fight against the complications, one should:

¾Keep a vein open before anesthesia

¾Have to prepare equipments for securing air way and possible ventilation.

Steps of general anesthesia

¾Premedication

¾Induction

¾Maintenance

¾Recovery

Premedication

Premedication can be started in the ward and /or in the OR before surgery.

Induction of Anesthesia

Induction of anesthesia is to make the patient unconscious. Before giving the drugs to make the patient sleep you should let him/her breathe 100% oxygen, which will be used as a reserve during the time of intubation. Induction can be performed:

•With intravenous anesthetic agents: Ketamine + Atropine or Thiopentone

•With inhalation agent (e.g. Halothane)

After the patient is induced, the anesthesia can be continued with intubation or with out (mask ventilation or spontaneous breathing).

Endo tracheal intubation:

It is a technique of passing an endotracheal tube into the trachea of the patient for securing the airway, and to make easier ventilation. For Intubation the patient should be adequately relaxed with inhalation agent or muscle relaxant. The relaxant used for intubation is Suxamethonium, which has fast onset of action and short effect.

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Equipment necessary for intubation and resuscitation:

•Face mask

•Self inflating bag (Ambo)

•Oropharyngeal air way (different sizes)

•Suction machine with suction tip

•Laryngoscope with different blade sizes

•Endotracheal tubes

Maintenance of Anesthesia: The anesthesia can be maintained with:

•inhalation agent (halothane or ether ± muscle relaxant

•inhalation agent + ketamine ± muscle relaxant

•intermittent Ketamine or Ketamine drip ± muscle relaxant

•Muscle relaxants for maintenance which usually are long-acting ones (e.g. Pancuronium, Vecuronium).

Monitoring: During anesthesia it is important to do strict monitoring of heart beat, blood pressure, respiration, temperature, fluid balance and urine output.

The carrier gas for volatile anesthetic agent can be atmospheric air or oxygen from compressed source depending on the type of Anesthesia machine in use.

Recovery and Extubation:

During recovery phase the patient recovers from:

•Inhalation agents by exhalation and/or metabolism

•Ketamine by excretion and metabolism

•Muscle relaxants by excretion and/or metabolism and/or reversal with neostigmine

Before extubation

•Be sure that the patient is breathing adequately (reversed from relaxant)

•Suck oropharyngeal secretion

•Deflate the cuff (which is used for adults) and remove the endotracheal tube

Transportation and immediate postoperative care:

•Transport in the recovery position

•Check and observe closely the pulse rate, blood pressure, respiratory rate, urine output hourly, any abnormal and continuing blood loss and presence of pain.

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Ketamine Anesthesia

Ketamine can make the patient unconscious with good analgesic effect. Because of these reasons it can be used alone for short procedures and surgery, which does not require relaxation and intubation.

Dose and route of administration:

ƒ	Intramuscular:	5-10 mg/kg
ƒ	Intravenous:	1-2 mg/kg

The effect of one single dose lasts for about 15 min. A dose of 0.5 mg/kg can be repeated intravenously for maintenance. IM-maintenance is not recommended.

•Diazepam 5-10 mg should be given for adults to prevent bad dreams of Ketamine.

•Atropine 0.01mg/kg IV or 0.02 mg/kg IM should be given as premedication to decrease intra-bronchial secretion, which is increased by Ketamine.

REGIONAL ANESTHESIA

Before performing conduction block, full facilities for resuscitation should be available.

Toxicity of local anesthetics

All local anesthetic drugs are potentially toxic due to:

•Allergic reactions

•Systemic toxicity due to accidental intravascular injection or overdose

ƒCNS-Toxicity:

ƒDrowsiness

This presents with unconsciousness, which progresses to convulsion, cardiovascular toxicity, hypotension and cardiac dysrhythmia.

Treatment of systemic toxicity

•The best treatment of systemic toxicity is prevention by meticulous attention to technique and recognition of intravascular injection.

•Oxygen must be administered at the first sign of toxicity.

•Control seizure with Diazepam or Thiopental.

Commonly used local anesthetic drugs

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Lidocaine (Xylocaine) 1%, 2% or 5% with or without Adrenaline in dose of:

With Adrenaline:

7 mg/kg

Without Adrenaline: 3 mg/kg

•Bupivacaine (Carbosthesin, Marcain) 0.25%, 0.5%, 0.75% without Adrenaline Maximum dose: 2 mg/kg

Adding Adrenaline to Lidocaine has two useful effects:

•Allows larger dose of Lidocaine without toxic effect, by causing vasoconstriction which reduces the rate of absorption of the drug.

•As the rate of absorption of local anesthetic drug is slow, the duration of anesthesia increases.

•Never use local anesthetic drugs with adrenaline in areas supplied with end arteries e.g.

o For finger block o At the ear lobe

o For circumcision (on penis)

Contraindications to conduction anesthesia

oTrue allergy to local anesthetic drugs

oInfection at the intended site of injection

oSystemic treatment of the patient with anti coagulant drugs

Types of conduction blocks

A) Spinal Anesthesia

Definition: Spinal anesthesia is a conduction block of nerve roots achieved by injecting a small volume of concentrated local anesthetic solution into the subarachnoidal space through the lumbar puncture. The level of lumbar puncture is at the interspaces between the 3rd and 4th lumbar vertebrae. The procedure should be performed with strict aseptic technique.

Drugs used

oHeavy or isobaric 0.5% Bupivacaine, duration of anesthesia 2-3 hours o Heavy 5% Lidocaine, duration of anesthesia 90 minutes

Indications

Spinal anesthesia is appropriate for procedures involving below the level of umbilicus like in the lower extremities, hip, perineum, lower abdomen, lumbar spine.

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Contraindications:

Complications for spinal anesthesia include:

oPatient refusal

oPatient with uncorrected hypovolemia o Local infection

o Bleeding tendency

o Raised intracranial pressure

Procedure of spinal anesthesia

•Choose the lumbar interspace below the 2nd lumbar vertebrae (usually the 3rd or the 4th interspace) (Fig. 6 + 7).

•Clean and drape.

•Do the lumbar puncture (Fig. 8 top left).

•When the cerebro-spinal fluid starts to drip on removal of the stylet from the spinal needle, (Fig. 8 top right) slowly inject a local anesthetic solution 2 - 3 ml 0.5% Bupivacaine (Fig.8). Turn the patient to a supine position with pillow under the head in the case of heavy (hyperbaric) local anesthetic drug.

Complications of spinal anesthesia and measures to take

•Drop in blood pressure-due to high spinal block

-Give Oxygen - Make faster the drip if that does not help.

-Give smaller dose of ephedrine starting with 5mg and bolus, usually, 1-2. If prolonged effect is required give 25-50 mg IM.

•Bradycardia

-Give Atropine 0.01 mg/kg IV

•Total spinal block with anesthesia and paralysis of the whole body

-Intubate and ventilate

-Treat Hypotension

•Post spinal headache

-Bed rest

-Hydration

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Fig. 6: Lateral positioning of the patient and selecting the lumbar interspace

Fig. 7: Sitting position of the patient and selecting the lumbar interspace

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Fig. 8: Technique of Spinal Anesthesia

B) Nerve block

Definition: Nerve block is injection of a solution of local analgesic drug near the nerve or nerves supplying the area to be operated on. The commonly used local anesthetic drug is Lidocaine with concentration of 1-2%.

Commonly performed nerve blocks:

oDigital nerve block

oAxillary block of the brachial plexus o Wrist-block

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C) Field block

Field block is injection of local analgesic so as to create a zone of analgesia around the operative field. It can be used for:

oRepair of an inguinal hernia o Caesarean section

o Circumcision

D)Infiltration

Infiltration is direct injection of drugs into the area to be incised and between bone ends in fractures. Lidocaine 0.5% is adequate for simple infiltration.

E) Topical anesthesia

This can be performed simply by applying 4% lidocaine to the mucus membrane, for minor surgery and instrumentation of:

oNose o Mouth o Eye

o Pharynx and larynx o Urethral procedures

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Review Questions

1.A 60 year old male patient presents to Emergency OPD with persistent vomiting, abdominal distension and failure to pass flatus and feces. After evaluation by the surgeon, it is decided to take him to the operating theater.

What preoperative preparation should be performed before surgery?

2.35 year old man with wt of 60 kg comes for inguinal herniorrhaphy which is planned to be done under local anesthesia.

a)What is the maximum volume of 1% Lidocaine (with Adrenaline) you can give?

b)Immediately after injection of Lidocaine, the patient tries to say something to you, subsequently he fails to communicate and the pulse is getting weak. What are your immediate measures?

3.A 17 year old girl is brought to the Emergency department with polytrauma after a car accident. At arrival her BP is not recordable, she is unconscious and cyanotic. How do you manage this patient?

4.You receive a patient from the OR, who had major surgery. How do you follow this patient in the immediate post-operative period?

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References

1.PG Barash, BF Calla, RK Stoepting: Clinical anesthesia. Lippincott Company, Philadelphia, 1989.

2.L Bartholomeusz: Safe Anesthesia: A Training manual, where facilities are limited. 2nd ed., Victoria, Australia, 1996.

3.GB Bushman, NJH Davies, JN Cashman: Lee’s Synopsis of Anesthesia. 12th edition, Butterworth Heinemann, 1999.

4.Adult Basic life support. JAMA, October 28, Vol. 268, No. 16, 1992, pp. 2184 – 97.

5.CA Graham, D Scollon, J McGowan, M. WG Gordon: Resuscitation 1: Basic life support. British Journal of Hospital Medicine, Vol. 56, No 2/3, 1997.

6.Dobson: Anesthesia at the District Hospital. World Health Organization, Geneva, 1988.

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SYSTEMIC SURGERY

CHAPTER ONE

THE THYROID GLAND

Learning objective

After reading this chapter students are expected to:

1.List common causes of thyroid enlargement

2.Know course and treatment of simple goiter

3.Identify clinical manifestation of hyper and hypothyroidism

4.Enumerate types of thyroid carcinomas

5.Outline management options for thyroid carcinomas

Thyroid Enlargement: Goiter

Goiter refers to a generalized enlargement of the thyroid gland which is normally impalpable.

Classification of thyroid swelling

1.Simple goiter (euthyroid)

•Diffuse hyper plastic

•(Multinodular)

2.Toxic

•Diffuse (Grave’s disease)

•Nodular

•Toxic adenoma

3.Neoplastic

•Benign

•Malignant

4.Inflammatory

•Autoimmune (chronic lymphocyte thyroiditis, Hashimoto’s disease)

•Infectious

•Acute (bacterial thyroiditis, viral,)

•Chronic (tuberculous, syphilitic)

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Simple Goiter

Patho-physiology: Simple Goiter is enlargement of the thyroid gland as a result of stimulation of the thyroid gland by high levels of circulating thyroid stimulating hormone. This high level of TSH might be due to dietary deficiency of iodine as in endemic goiter. Defective hormone synthesis also cause goiter and it accounts for many sporadic goiters. It has stages of development. All stages of simple goiter are far more common in females.

Diffuse hyper-plastic goiter: Persistent stimulation by TSH causes diffuse hyperplasia of the thyroid gland. The goiter is soft, diffuse and may become large enough to cause discomfort. In endemic goiter, it usually occurs at puberty when metabolic demands are high, this is reversible if stimulations cease. But, it tends to recur later at times of stress such as pregnancy. As a result of fluctuating stimulation of the thyroid gland, areas of active lobule and inactive lobules will develop. Active lobules become more vascular and hyperplasic until hemorrhage occurs causing necrosis. These necrotic lobules coalesce to form nodules filled with either iodine free colloid or inactive follicles. This the nodular stage of simple goiter. Nodular goiter can be solitary or multinodular. The nodules can be colloid when filled with colloid or cellular. Secondary changes like cystic degeneration, hemorrhage and calcification occur at late stages.

Diagnosis

Clinical presentation:

Discrete swelling in one lobe with no palpable abnormality else where is called solitary (isolated) nodule. And if there is abnormality else where in the gland it is termed dominant nodule.

Nodules are palpable and usually visible. They are smooth, firm and not hard. The Goiter is painless and freely moves with swallowing and usually patients are euthyroid.

Investigation

ƒThyroid function test (T3, T4, TSH) is necessary to exclude hyper or hypothyroidism.

ƒChest or thoracic inlet x-rays may show calcification, tracheal deviation and compression.

ƒEstimation of thyroid antibody titers to exclude auto-immune thyroiditis.

Complications

•Tracheal obstruction can occur due to gross lateral displacement or compression.

•Secondary thyrotoxicosis may develop after long standing cases.

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•Carcinoma: malignant changes of the follicular layer might develop in simple goiter.

Prevention and treatment

Prevention

In endemic areas the incidence of goiter can be significantly reduced by the introduction of iodized salt. In early stages, a hyper-plastic goiter may regress if thyroxin is given in a dose of 0.1mg daily for few months. The nodular stages of simple goiter are irreversible. But most of the patients are asymptomatic and do not require operation.

Operation might be indicated

•On cosmetic grounds

•Tracheal compression and

•When malignancy cannot be excluded

The options of surgical treatment are

•Near total thyroidectomy

•Subtotal thyroidectomy

Toxic goiters

Thyrotoxicosis - is a condition in which there is increased metabolic rate due to high level of circulating thyroid hormone. It is about eight times more commonly seen in females than males.

Clinical features

The most significant symptoms are

•Loss of weight in spite of good appetite,

•A recent preference of cold

•Palpitation.

•Tiredness

•Emotional liability.

The most important clinical signs of thyrotoxicosis commonly seen are

•excitability of the patient,

•the presence of goiter,

•hot and moist palms,

•exophthalmus in primary type

•tachycardia with cardiac arrhythmia

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•Weakness of the proximal limb muscles

•The goiter in primary thyrotoxicosis (Grave’s disease) is diffuse and vascular, it may be large or small, firm or soft and bruit may be present. Whereas in secondary thyrotoxicosis the goiter is nodular.

Diffuse toxic goiter: Primary toxic goiter or Grave’s disease is a diffuse vascular goiter appearing at the same time as symptoms of hyperthyroidism. It usually occurs in younger women and frequently associated with eye signs. The hypertrophy and hyperplasia are due to abnormal thyroid stimulating antibodies

Toxic nodular goiter: A simple nodular goiter is present for a long time before the hyperthyroidism, and hence termed secondary thyrotoxicosis. It is usually seen in middle aged or elderly people and less frequently associated with eye signs. In many cases of toxic nodular goiter, the nodules are inactive and it is the intermediate thyroid tissue that is involved in hyper secretion.

Toxic nodule: This is a solitary hyperactive nodule which may be part of a generalized nodularity or a true toxic adenoma. It is autonomous and its hypertrophy and hyperplasia are not due to thyroid stimulating antibodies. Because TSH secretion is suppressed by the high level of circulating thyroid hormones, the normal thyroid tissue surrounding the nodule is suppressed and inactive.

Diagnosis of thyrotoxicosis

•Most cases are easily diagnosed by the clinical picture.

•The thyroid functional status can be determined by estimation of serum thyroxin hormones and TSH.

•Isotope scanning is used to investigate discrete thyroid swelling. This helps to determine the functional activity relative to the surrounding gland according to isotope uptake.

Treatment of thyrotoxicosis

Treatment of thyrotoxicosis includes specific and non-specific measures. The specific measures are

•the use of antithyroid drugs

•surgery

•radioiodine

The nonspecific measures which include rest and sedation are not commonly recommended.

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Anti thyroid Drugs:

Antithyroid drugs are used to resume the patient to a euthyroid state and to maintain this for a prolonged period. But it should be clear that antithyroid drugs cannot cure a toxic nodule since the overactive thyroid tissue is autonomous and recurrence of the hyperthyroidism is certain when the drug is discontinued.

Surgery:

Surgery cures thyrotoxicosis by reducing the mass of overactive tissue below critical mass. Preoperatively, the patient must be prepared with antithyroid drugs so that the patient becomes euthyroid. The preferred procedure is subtotal thyroidectomy.

Post-operative complications

•Hemorrhage - a tension hematoma may develop deep to the cervical fascia – which is potentially life threatening

•Respiratory obstruction - can occur due to laryngeal edema or secondary to tension hematoma.

•Recurrent laryngeal nerve paralysis may be unilateral or bilateral and could be transient or permanent.

•Thyroid insufficiency. This is insidious and usually occurs after 2 years.

•Parathyroid insufficiency - is due to removal of parathyroid gland and usually seen in immediate post operative period.

•Thyrotoxic crisis (storm) - is an acute exacerbation of hyperthyroidism. It occurs if a thyrotoxic patient has been inadequately prepared for thyroidectomy.

•Wound infection - a subcutaneous or deep cervical abscess may occur rarely and necessitates drainage.

Neoplasms of the thyroid

Classification of thyroid neoplasm

Benign: follicular adenoma

Malignant: Primary - Follicular epithelial: follicular, papillary, anaplastic

-Para follicular epithelium: medullary

-Lymphoid cells: lymphoma

Secondary

-Metastatic

-Local infiltrations

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Benign tumors

Follicular adenomas present as clinically solitary nodules and the distinction between a follicular carcinoma and an adenoma can only be made by histological examination. Treatment of follicular adenoma is by wide excision preferably lobectomy.

Malignant Tumors

Clinical feature: The commonest presenting symptom is

•thyroid swelling

•Enlarged cervical lymph node may be the presentation of papillary carcinomas.

•Recurrent laryngeal nerve paralysis may be a presenting feature on locally advanced disease.

•Anaplastic growths are usually hard, irregular or infiltrating.

Diagnosis

Differentiated cancers: Diagnosis largely depends on

•history

•physical examination

•investigations: Thyroid function tests(T3,T4,TSH), fine needle aspiration, anti- body assays, and radio isotope scanning

Treatment: Treatment of differentiated thyroid carcinoma principally is surgery.

Prognosis: Prognosis is influenced by histological type, age, extra thyroid spread, and size of tumor. With regard to age, males of more than 40 years of age and females over 50 years have worse prognosis. Distant metastatic disease has worse prognosis.

Undifferentiated (anaplastic) Carcinoma

This occurs mainly in elderly woman. Local infiltration is an early feature of these tumors with spread by lymphatics and blood stream. They are extremely lethal tumors with death occurring in most cases within months. Many lesions present in advanced stages with tracheal obstruction and require urgent tracheal decompression. Radiotherapy should be given in all cases and may provide a worth while period of palliation.

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