Examination (cid:142)(cid:3) ABC (airway, breathing, circulation) (cid:142)(cid:3) Coexisti ng injuries (cervical spine, pelvis) (cid:142)(cid:3) Skin (large wounds, degloving, crushi ng) (cid:142)(cid:3) Compartment syndrome (cid:142)(cid:3) Vascular compromise (cid:142)(ci d:3) Nerve injury (cid:142)(cid:3) X-ray (comminution, segmental fractures, air in tissue). LOWER LIMB TRAUMA1 795 Classification The classification formulated by Gustillo is the most widely used and useful when discussing an injury. (cid:142)(cid:3) Grade I Low energy Skin opening of \211 1cm Quite clean Mostly from inside to outside Minimal musc le contusion Simple transverse or oblique fractures Moderate injury Laceration more than >1 cm long Moderate crushing component Simple transverse or oblique fractures with minimal com minution High energy Extensive soft tissue damage including muscle, skin, neurovascular str uctures Adequate bone coverage Extensive soft tissue injury with periosteal stripping and b one exposure Vascular injury requiring repair (cid:142)(cid:3) Grade II (cid:142)(cid:3) Grade III (cid:142)(cid:3) IIIA (cid:142)(cid:3) IIIB (cid:142)(cid:3) IIIC Preoperative management (cid:142)(cid:3) ABC (cid:142)(cid:3) Wound Bacteriology swab, teta nus prophylaxis. (cid:142)(cid:3) Antibiotics Broad spectrum but consider adding penicillin (against clostridia). (cid:142)(cid:3) Plan An initial one should be made at this stage. Initial surgical management (cid:142)(cid:3) Skin extension should be longitudinal (less li kely to compromise subsequent flaps). All devitalised tissue must be removed but it may be possible to harvest skin grafts from degloved areas. (cid:142)(cid:3) Muscle can be difficult to accurately assess as it is very sensitive to tr auma. Obviously dead muscle should be removed but a further inspection at 48 hours may be n eeded. (cid:142)(cid:3) Fasciotomies must be adequate and decompress all compartments (in lower limb; anterior, peroneal, posterior, and deep). (cid:142)(cid:3) Closure should not be attempted if there is any suggestion of skin tension \200\224subsequent oedema will only worsen this. Reconstruction (see Table 17.3) Using the reconstructive ladder the 3 methods are (cid:142) (cid:3) Skin grafting (cid:142)(cid:3) Local flaps (cid:142)(cid:3) Free flaps. CHAPTER 17 Principles of plastic surgery 796 Skin grafts These must be applied only if there is a vascularised bed with no infec- tion. If the bed is not vascularised then the next step up the reconstruc- tive ladder is a local flap, either skin (fasciocutaneous) or muscle. Fasciocutaneous flaps These may be based on the medial or lateral aspects of the leg and ei ther proximally or distally based. Muscle flaps (cid:142)(cid:3) Proximal third Medial or lateral bellies of gastrocnemius. (c id:142)(cid:3) Middle third Anterior compartment muscles or soleus. Free flaps These are very flexible and can be applied to almost any situation. They may be either muscle \200\224latissimus dorsi, rectus abdominis, gracilis or skin \200\224antero-l ateral thigh. LOWER LIMB TRAUMA1 797 Table 17.3 Summary of treatment options for lower limb trauma Region of defect Flap (cid:142)(cid:3) Gastrocnemius (cid:142)(cid:3) Proximal fasciocutaneous (cid:142)(cid:3) F ree flap (cid:142)(cid:3) Soleus (cid:142)(cid:3) Anterior compartment muscles (cid:142)(ci d:3) Proximal fasciocutaneous (cid:142)(cid:3) Free flap (cid:142)(cid:3) Distally based fa sciocutaneous (cid:142)(cid:3) Free flap (cid:142)(cid:3) Distally based fasciocutaneous (c id:142)(cid:3) Free flap (cid:142)(cid:3) Proximal third (cid:142)(cid:3) Middle third (cid:142)(cid:3) Distal third (cid:142)(cid:3) Ankle CHAPTER 17 Principles of plastic surgery 798 Neoplasia Basal cell carcinoma Basal cell carcinoma (BCC) is the most common skin tumor enc oun- tered in practice and is almost entirely, but not exclusively, confined to white cauca sian individuals. Etiology (cid:142)(cid:3) Sun exposure (cid:142)(cid:3) Scars (cid:142)(cid:3) Irradiation (cid:142)(cid:3) Genetic syndromes \200\224Gorlin \200\231s syndrome (cid:142)(cid:3) Autosomal dominant (chromosome 9q) (cid:142)(cid:3) Palmar pits (cid:142)( cid:3) Jaw cysts (cid:142)(cid:3) Parafalcine calcification. Xeroderma pigmentosa Presentation (cid:142)(cid:3) Nodulo-ulcerative (cid:142)(cid:3) Cysti c (cid:142)(cid:3) Morphoeic (cid:142)(cid:3) Superficial (cid:142)(cid:3) Pigmented. Treat ment (cid:142)(cid:3) Curettage (cid:142)(cid:3) Cryotherapy (cid:142)(cid:3) Radiation (ci d:142)(cid:3) Surgery (cid:142)(cid:3) Conventional (cid:142)(cid:3) Moh \200\231s microsur gery Squamous cell cancer Squamous cell cancer (SCC) is the second most common skin malignancy. Classified into: (cid:142)(cid:3) Well differentiated through to poorly differentiated. (ci d:142)(cid:3) Kerato acanthoma \200\224difficult to differentiate even pathologically and i s considered a form of well differentiated SCC. It is self limiting. Etiology (cid:142)(cid:3) Sun exposure (cid:142)(cid:3) Human papilloma virus (cid:142)(cid :3) Exogenous carcinogens (cid:142)(cid:3) Tobacco/pipe smoking (cid:142)(cid:3) Petrochemical exposure (cid:142)(cid :3) Radiation (cid:142)(cid:3) Genetic syndromes \200\224xeroderma pigmentosa (cid:142)(cid:3) Marjolin \200\231s ulcer NEOPLASIA1 799 Treatment (cid:142)(cid:3) Surgical excision with adequate margins is the treatment of choi ce (cid:142)(cid:3) Lymph node dissection should be considered in poorly differentiated or large cancers or if clinically enlarged lymph nodes (cid:142)(cid:3) Radiation therapy has been advocated in small cancers in anatomically impo rtant areas such as eyelids or in cases to control and palliate. Melanoma Melanoma is classified by description. Essentially all melanomas present pathologi cally as the same, but they are described by appearance (cid:142)(cid:3) Superficial spread ing (cid:142)(cid:3) Nodular (cid:142)(cid:3) Lentigo maligna (cid:142)(cid:3) Acral lentig inous (cid:142)(cid:3) Amelanotic and unclassifiable. Etiology (cid:142)(cid:3) Sunlight (c id:142)(cid:3) Genetic (cid:142)(cid:3) Pre-existing naevus. Staging (cid:142)(cid:3) Micro staging (cid:142)(cid:3) Breslow \200\224based on depth in millimeters (cid:142)(cid:3) Clarke \200 \231s level \200\223 I \200\224within epidermis \200\223 II \200\224within papillary dermis \200\223 III \200\224within reticular dermis \200\223 IV \200\224fills reticular dermis \200\223 V \200\224into subcutaneous fat (cid:142)(cid:3) AJCC classification 2002 Treatment (cid:142)(cid:3) Surgical (cid:142)(cid:3) Primary excision (cid:142)(cid:3) Marg ins (cid:142)(cid:3) Less than 1mm Breslow depth \200\2241cm margin (cid:142)(cid:3) Greater th an 1mm Breslow depth \200\2242cm margin Sentinel node WHO recognize sentinel node as being the standard of care in mela- noma great er than 1mm Breslow depth. In the UK it is still not accepted that sentinel node is the acc epted standard of care. Prognosis: lymph node status is the most important factor in assess ing prognosis. The AJCC Classification groups different aspects of melanoma, such as: (cid: 142)(cid:3) Breslow depth (cid:142)(cid:3) Ulceration (cid:142)(cid:3) Mitoses per high pow er field (cid:142)(cid:3) Sentinel node positivity (cid:142)(cid:3) Number of nodes positiv e, and gives a prognostic figure. CHAPTER 17 Principles of plastic surgery 800 The risk of recurrence may be stated approximately as: Breslow 1mm Breslow 2mm Breslow 3mm Breslow 4mm Breslow 5mm or greater 10% risk of recurrence 20% risk of recurrence 30% risk of recurrence 40 % risk of recurrenc e 50% risk of recurrence. Pressure sores Pressure sores (bedsores and decubitus ulcers) are areas of tissue loss resu lting from pressure. These areas are usually, but not exclusively, over bony prominences. Etiology (cid:142)(cid:3) Intrinsic factors (cid:142)(cid:3) Paraplegia (cid:142)(cid:3) An emia (cid:142)(cid:3) Infection (cid:142)(cid:3) Nutrition (cid:142)(cid:3) General medical conditions such as diabetes etc. (cid:142)(cid:3) Extrinsic factors (cid:142)(cid:3) Shear (cid:142)(cid:3) Friction (cid:142)(cid:3) Moisture (cid:142)(cid:3) Pressure. Classification (cid:142)(cid:3) Grade I \200\224superficial redness and blistering (cid:142 )(cid:3) Grade II \200\224Partial thickness loss (cid:142)(cid:3) Grade III \200\224Full th ickness skin loss (cid:142)(cid:3) Grade IV \200\224Deep to and including bone/periosteum. Treatment (cid:142)(cid:3) Systemic (cid:142)(cid:3) Nutrition (cid:142)(cid:3) Correct anemia (cid:142)(cid:3) Treat infection (cid:142)(cid:3) Local (cid:142)(cid:3) Conservative (cid:142)(cid:3) Relief of pressure (cid:142)(cid:3) Dressing s (cid:142)(cid:3) Catheterise (cid:142)(cid:3) Surgical treatment (Fig. 17.12) (cid:142)(cid:3) Debridement (cid:142)(cid:3) Resection of bony prominences (cid:142)(cid:3 ) Resurfacing of defect (cid:142)(cid:3) Design large flaps (cid:142)(cid:3) Muscle flaps i f necessary NEOPLASIA1 801 (A) (B) (C) Fig. 17.12 Pressure sores Reproduced with permission from Mccarthy JG (1990) Plastic surger y, p3820. Elsevier CHAPTER 17 Principles of plastic surgery 802 The breasts Breast cancer reconstruction It is not in the remit of this chapter to discuss diagnosis and management of breast cancer, rather to focus on post cancer reconstruction. I t is important, however, to comment on the approach of a clinician when confronted with a w oman (or man) in the out patient setting immediately after diagnosis. The patient should ha ve a frank and open discussion concerning reconstruction before definitive surgical treatme nt is per- formed. It should be in a no pressure situation with all the relevant personnel present \200\224patient and partner/family (if she wishes), nurse specialist, surgeon, and oncologist. It is the opinion of some clinicians that immediate reconstruction should not be offered. I t is principally the decision of the patient after she has weighed all options. Immediate, even delayed, reconstruction is not for every woman, but it beholds us all to give as much information prior to surgery. Reconstruction can be simply divided into expander based reconstruc- tion and autologous ti ssue transfer. This latter may be divided into pedicled transfers and free tissue transfers . Tissue expander reconstruction Insertion of a tissue expander under the skin of the chest w all is a simple and \200\230one-stop \200\231 method of reconstruction. Not without compli cations, insertion of an expander partially filled with Silicone gel and partially with sal ine (Becker), this method allows a breast mound to be made with no additional scars elsewhe re on the body. After insertion of the Becker, expansion can be performed immediately on the operating tabl e, or can be performed in out-patients after a period of one to two weeks post op. When the final volume is achieved, further expansion should continue up to a point where 25 \200 \22350% over expansion is achieved, this will allow for contraction post expansion (up to 2 5%) as well as allow a normal ptosis to develop. Insertion of an expander and then a second operation to insert a permanent silicone prosthesis is an acceptable option. Contraindications for tissue expansion: Absolute contraindications (cid:142)(cid:3) Do not place expander adjacent to obvious or suspected malignancy (cid:142)(cid:3) Do not place in an area of known infection Relative contraindications (cid:142)(cid:3) Poorly vascularised tissue (cid:142)(cid:3) Chemotherapy (cid:142)(cid:3) Previously irradiated skin (cid:142) (cid:3) Psychological problems. Autologous breast reconstruction Use of the patient \200\231s own tissues, with or without a prosthesis or expander, is increasing in popularity. THE BREASTS1 803 Pedicled autologous transfers (cid:142)(cid:3) Latissimus dorsi (cid:142)(cid:3) Based on the thoracodorsal artery or branches to serratus, the latissimus dorsi can be transferred with skin as a pedicled flap or a peforator flap with o r without a prosthesis. (cid:142)(cid:3) The \200\230extended \200\231 latissimus dorsi flap transfers a larger am ount of skin and fat with the muscle thus obviating the need for a prosthesis. (cid:142)(cid:3) streetcar (cid:142)(cid:3) Although not as reliable as a free streetcar, the pedicled streetcar is st ill a viable option for some cases of reconstruction. (cid:142)(cid:3) Transfer should ideally be as a delayed flap when the deep inferior epigas tric pedicle is ligated one week prior to the flap being raised and transferred on its supe rior epigastric pedicle. Free tissue transfer (cid:142)(cid:3) streetcar \200\224pedicle: deep inferior epigastric ( cid:142)(cid:3) DIEP \200\224deep inferior epigastric perforator (cid:142)(cid:3) SGAP \200 \224superior gluteal artery perforator flap (cid:142)(cid:3) TDAP \200\224thoraco-dorsal ar tery perforator flap. Esthetic Augmentation Breast augmentation is the procedure where the breast is enlarged usi ng autologous or alloplastic material. Prostheses may be saline filled or Silicone gel fill ed although the most common way is still using Silicone gel prostheses. Incisions (cid:142) (cid:3) Inframammary (cid:142)(cid:3) Periareola (cid:142)(cid:3) Axillary. Position of imp lant can be subglandular or subpectoral. Complications (most common) (cid:142)(cid:3) Infec tion (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Asymmetry (cid:142)(cid:3) Nipple sensory c hange (cid:142)(cid:3) Capsular contracture. Reduction Breast reduction is for women with g igantomastia. Essentially for women with cupsize DD or larger with associated symptoms of s houlder notch- ing from the bra, painful neck, rashes under the breasts, and occasionally b racahial plexus traction symptoms in the upper limb. It has been shown that if the BMI is > 30, complications post operatively are higher. There are a variety of techniques for reduct ion: (cid:142)(cid:3) Inferior pedicle (cid:142)(cid:3) Superolateral pedicle (cid:142)(cid :3) Superomedial pedicle. CHAPTER 17 Principles of plastic surgery 804 There are an equal number of varieties of skin incisions: (cid:142)(cid:3) Inverted \200 \230T \200\231 (cid:142)(cid:3) Single vertical scar (cid:142)(cid:3) Single horizontal sca r (cid:142)(cid:3) Regnault \200\230B \200\231 Complications (most common) (cid:142)(cid:3 ) Asymmetry (cid:142)(cid:3) Bleeding (cid:142)(cid:3) Infection (cid:142)(cid:3) Scarring (cid:142)(cid:3) Nipple sensory loss/hyperaesthesia (cid:142)(cid:3) Nipple necrosis. Masto pexy If the patient has ptosis of the breast but does not wish augmentation, or if skin tig htening is required along with augmentation, the skin can be tightened around the breast vo lume. Common incisions use breast reduction techniques without removal of breast volume. This page intentionally left blank CHAPTER 17 Principles of plastic surgery 806 Burns Children and persons over 75 years of age are more susceptible to burns of all kinds. Burns can be classified into: (cid:142)(cid:3) Thermal (cid:142)(cid:3) Chemical (cid:142)(cid:3) Electrical (cid:142)(ci d:3) Radiation. Causes (cid:142)(cid:3) Flammable liquids (cid:142)(cid:3) Space heaters (cid:142)(cid:3) E lectrical (cid:142)(cid:3) Outside fires (cid:142)(cid:3) House fires (cid:142)(cid:3) Self -inflicted. Burn prevention A strategy for burn prevention should include: (cid:142)(cid:3) Adequate an d reliable data collection (cid:142)(cid:3) Recognition of a particular mechanism of injury on which preventative action can be focused (cid:142)(cid:3) Devising means of prevention (cid:142)(cid:3) Implementing these measures (cid:142)(cid:3) Assessing the effects (cid:142)(cid:3) Making improvements to the device o r to its application as necessary. Depth of burn injury First aid Remove the patient from the immediate vicinity and danger, b ut it is important to not endanger the rescuer. Exposure 1. Stop burning process. 2. Cool area with water/wet dressings for 20min, but do n ot make patient hypothermic (patient may be in an external environment). It is impor- tant to realize that normal homeostatic mechanisms for temperature regulation are deranged by bu rns. 3. Remove clothing from affected area but do not peel off clothing stuck to the skin. 4. Cover wound \200\230Cling movie \200\231 type of dressing is the best. 5. Antibiotics a. Antibiotics have no place in the management of burn injury unless there is microbiological proof of invasive infection. b. Scald injuries in children are susceptible to infection by streptoco- ccus sp. There is a belief that children \200\231s scald injuries should be treated prophyl actically with penicillin (or erythromycin for penicillin allergy). Table 17.4 Classification and clinical appearance of thermal injury of different depth Depth of burn Usual history Appearance Blister formation Sensation Results Superficial Sunburn Red, bloated Absent Painful Heals in 7 days Partial thickness Superficial dermal Scalds of limited duration Red or pink with a capillary return Present Painful Heals in 14 days Deep dermal Scalds of long duration Contact with high temperature Red without capillary return Absent Wet or waxy surface Painless Heals in months Full thickness Contact with high temperatue Chemicals Electrical injury Charred black-brown or white, dry, throm- bosed vessels Absent Painless Granulates B U R N S 1 8 0 7 CHAPTER 17 Principles of plastic surgery 808 Assessment of area of burn and possible inhalation injury 1. History a. Explosion in confined space. b. Smoke inhalation. c. Consider electrical injury entry an d exit wound as well as cardiac involvement. d. Chemical injury \200\224acid/alkali. e. Burn may be secondary to: i. Stroke. ii. MI. iii. Seizure. iv. Non-accidental injury (child abuse). 2. Assess area of burn a. Wallace \200\231s rule of nines. (Fig. 17.13) b. Lund and Browder Chart for estimating t he size of a burn as a percentage of body surface area (see Fig.17.14). Airway and breathing 1. Smoke inhalation a . Confined space b. Confusion, agitation c. Burns to face d. Singeing of eyebrows or nasal hair e. Soot in the sputum f. Burning within the mouth g. Hoarseness or stridor. Circulation 1. Burns involving >15% TBSA will require circulatory support \200\224set up two large bore intravenous cannulas. 2. Choice of fluids \200\224in the A&E department the choice of fluid is secon- dary to the need for urgent and adequate fluid replacement. Any fluid is adequate so long as it contai ns sodium in a concentration between 130 and 150mmol/l. 3. Fluid resuscitation a. Oral fluids i. <10% TBSA in children or <15% TBSA in adults 1. Dioralyte or Dextrolyte 2. Moyer \200\231s solution a. 4g NaCl/L and 1.5g NaHCO3. b. intravenouis fluids i. Crystalloid a. 4ml/kg/% burn TBSA b. 50% in first 8 hours c. 25% in next 8 hours d. 25% in next 8 hours e. Routine daily maintenance fluids need to be added to the regime. ii. Colloid a. Muir and Barclay \200\224First 36 hours divided into 4, 4, 4, 6, 6, 12 hour periods. For mula for replacement of fluid in each period: total % area of burn (cid:190) weight (kg). BURNS1 809 9% Front 18% Back 18% 9% 9% 1% 18% 18% Fig. 17.13 Wallace \200\231s rule of nines CHAPTER 17 Principles of plastic surgery 810 Burns surgery Early surgery 1. Immediate \200\224escharotomies. 2. Early excision and graft ing. a. Tangential excision. b. Mesh grafts. c. Consider fascial excision. Late surgery 1. Functional \200\224scar excision and release. a. Skin grafting. i. split thickness. ii. full thickness. b. Z-plasties. c. Flaps. i. Local. ii. Free flaps. 2. Cosmetic. a. Facial surgery. i. nose. ii. eyelids. iii. lips. b. Trunk \200\224breast reconstruction. BURNS1 811 CHART FOR ESTIMATING SEVERITY OF BURN WOUND NAME__________WARD________NUMBER______DATE____ AGE__________ADMISSION WEIGHT_________ LUND AND BROWDER CHARTS IGNORE SIMPLE ERYTHEMA A 1 A 1 Partial thickness loss (PTL) Full thickness loss (FTL) 2 2 2 2 13 13 11 2 11 2 11 2 11 2 % 11 2 11 2 11 2 11 2 REGION HEAD NECK ANT.TRUNK POST.TRUNK RIGHT ARM LEFT ARM BUTTOCKS GENITALIA RIGHT LEG LEFT LEG TOTAL BURN PTL FTL 2 21 21 2 1 B B B B CC CC 4 13 13 4 4 13 13 4 RELATIVE PERCENTAGE OF BODY SURFACE AREA AFFECTED BY GROWTH AREA A = OF HEAD B = OF ONE THIGH C = OF ONE LEG AGE 0 1 9 2 2 5 6 4 2 10 5 4 3 15 4 4 3 ADULT 3 4 3 8 3 2 Fig. 17.14 Lund and Browder chart This page intentionally left blank Chapter 18 813 Trauma surgery D. Southward and T. Friesem Introduction 814 Needle cricothyroidotomy 816 Surgical cricothy roidotomy 820 Needle thoracocentesis 822 Intercostal drain insertion 824 Venous cutdown 826 Diagnostic peritoneal lavage (DPL) 828 DPL, ultrasound, CT, or laparotomy 830 CHAPTER 18 Trauma surgery 814 Introduction There are very few surgical procedures that are required in the acute resuscit ative phase of trauma management. The priority in trauma man- agement follows the ATLS fo rmat of Airway, Breathing, Circulation. The procedures that may be required in trauma are o utlined in that priority. Surgical airway procedures (cid:142)(cid:3) Needle cricothyroidotomy (cid:142)(cid:3) Surgi cal cricothyroidotomy. Procedures for breathing problems (cid:142)(cid:3) Needle thoracocentesis (cid:142)(cid:3) Intercostal drain insertion. Circulatory procedures (cid:142)(cid:3) Venous cutdown (cid:142)(cid:3) Diagnostic peritone al lavage. This page intentionally left blank CHAPTER 18 Trauma surgery 816 Needle cricothyroidotomy This technique is an emergency technique to oxygenate a patient. I t does not provide \200\230ventilation \200\231 and is time-limited due to accumulation of carbon dioxide. Indication (cid:142)(cid:3) Inability to intubate (cid:142)(cid:3) Airway burns (cid:142)(c id:3) Facial trauma (cid:142)(cid:3) Laryngeal fracture (cid:142)(cid:3) Emergency need for oxygenation, where non-surgical airway maneuvers have failed or are not available. Contraindications Use with caution if complete airway obstruction is present. Reduce flow r ates if there is complete obstruction. Position Supine. Neck maintained in neutral position with manual in-line immobili- sation. Equipment (cid:142)(cid:3) 14 gauge cannula (16 \200\22318 in children) (cid:142)(cid:3) 10 ml syringe (cid:142)(cid:3) Oxygen tubing either connected to a three way tap or with a hol e cut in the side of the tubing (cid:142)(cid:3) Oxygen supply with high pressure flow (cid:142)(cid:3) Cannula dressing. Preparation (cid:142)(cid:3) Clean skin of neck with appropriate antiseptic (cid:142)(cid:3 ) Ensure all equipment available and connects together. Anesthetic This is a procedure on a patient in extremis. Anesthetic is not usually required . Procedure (cid:142)(cid:3) Identify the cricothyroid membrane; find the thyroid cartilage a nd palpate in a caudal direction. The next rigid structure is the cricoid cartilage. The crico -thyroid membrane is between the two cartilages (Fig. 18.1). (cid:142)(cid:3) Stabilize the trachea with thumb and index finger of one hand. (cid:142)(c id:3) Attach a 14 gauge cannula to a 10ml syringe. (cid:142)(cid:3) Puncture skin with the cannula in a central position directly over the cricothyroid membrane. (cid:142)(cid:3) Direct the needle caudally at 45 while aspirating on the syringe. (cid:1 42)(cid:3) Puncture the crico-thyroid membrane, at this point air will be aspirated as the needle enters the trachea. NEEDLE CRICOTHYROIDOTOMY1 817 Puncture site Cricoid cartilage Thyroid cartilage Cricothyroid membrane Fig. 18.1 Needle cricothyroidotomy CHAPTER 18 Trauma surgery 818 (cid:142)(cid:3) While stabilizing the needle, advance the catheter, then remove the needle. Reaspirate to ensure that the catheter has not been advanced against the posterior tracheal wall. (cid:142)(cid:3) Attach the oxygen tubing over the luer lock of the catheter. (cid:142)(cid :3) Occlude the aperture in the tubing (or three way tap) for one second and release for 4 seconds whilst observing for lung inflation. Exhalation occurs passively during the four se conds off. (cid:142)(cid:3) Secure the cannula in place with dressing or sutures. Complications (cid:142)(cid:3) Inadequate ventilation leading to hypoxia (cid:142)(cid:3) H ypercarbia due to prolonged use of this technique (cid:142)(cid:3) Aspiration of blood (cid :142)(cid:3) Damage to posterior structures \200\224posterior tracheal wall, esophagus (cid :142)(cid:3) Subcutaneous emphysema (cid:142)(cid:3) Barotrauma to lung from high pressure insufflation. Be watchful to ensure the chest wall falls between inflations, if not you must reduce the flow rate to all ow the chest to \200\230exhale \200\231 before the next insufflation. This page intentionally left blank CHAPTER 18 Trauma surgery 820 Surgical cricothyroidotomy This is an emergency technique to provide a definitive airway. I t allows oxygenation, ventilation, and airway toilet to be performed. It is the surgical ai rway of choice in trauma because it is easier, quicker, and has less risks of bleeding than a tracheostomy. It is also more convenient in a patient immobilized in a semi-rigid collar . Percutaneous tracheostomy is not an acceptable alternative, as the neck needs to be hyper extended to perform this procedure. Indication (cid:142)(cid:3) Inability to intubate and definitive airway required (cid:142)( cid:3) Airway burns (cid:142)(cid:3) Facial trauma (cid:142)(cid:3) Laryngeal fracture. Contraindications Children under the age of 12 years. Position Supine. Neck maintained in neutral with manual in-line immobilization. Equipment (cid:142)(cid:3) Scalpel with number 10 blade (cid:142)(cid:3) Skin cleansing flu id (cid:142)(cid:3) Working suction equipment (cid:142)(cid:3) Tracheal dilator (or artery forceps) (cid:142)(cid:3) 5.0, 6.0 tracheostomy tube (cid:142)(cid:3) 10ml syringe (cid:142 )(cid:3) Endotracheal tube catheter mount (cid:142)(cid:3) Fittings to ventilate and delive r oxygen. Preparation (cid:142)(cid:3) Clean skin of neck with appropriate antiseptic solution. (cid: 142)(cid:3) Ensure all equipment available and connects together. (cid:142)(cid:3) Apply ma nual in-line immobilization and remove collar, sandbags and tape. Anesthetic If there is time and the patient is conscious local anesthetic using ligno- cain e with adrenaline should be used. Local infiltration of the skin and subcutaneous tissues s hould be performed. If the situation requires immediate action in an unconscious patient no anesthetic should b e used. Remember needle cricothyroidotomy may be used as an interim measure to buy time whi le preparing for this procedure. Procedure (cid:142)(cid:3) Stabilize the thyroid cartilage with the left hand. (cid:142)(ci d:3) Maintain stabilization of the trachea until the airway is established. SURGICAL CRICOTHYROIDOTOMY1 821 (cid:142)(cid:3) Make a 1cm skin incision transversely over the crico-thyroid membrane. (cid:142)(cid:3) Deepen your incision down through the membrane. (cid:142)(cid:3) Insert th e scalpel handle into the incision and rotate 90 to open the cricothyroidotomy. (cid:142)(cid:3) Intubate the trachea with a cuffed tracheostomy tube (or endotracheal tube if no tracheostomy tube available). (cid:142)(cid:3) Inflate the cuff, attach the tube to oxygen and a ventilating device, and ventilate the patient. (cid:142)(cid:3) Check for correct placement; check chest movements are symmetrical, listen for breath sounds and verify using capnograph if available. (cid:142)(cid:3) Secure the tube with tapes. You may now reapply the semi-rigid collar, san dbags and tape. Complications Immediate (cid:142)(cid:3) Aspiration of blood (cid:142)(cid:3) Malposition. Creation of a false passage into the tissues. Damage to posterior structures \200\224posterior tracheal wall (cid:142)(cid:3) Laceration of trachea or esophagus (cid:142)(cid:3) Hemorrhage or haematom a formation (cid:142)(cid:3) Subcutaneous emphysema (cid:142)(cid:3) Mediastinal emphysema. Delayed (cid:142)(cid:3) Local infection (cid:142)(cid:3) Subglottic stenosis (cid:142)(ci d:3) Laryngeal stenosis (cid:142)(cid:3) Vocal cord injury. CHAPTER 18 Trauma surgery 822 Needle thoracocentesis Once the primary survey has been completed for Airway and interven- tions performed as required the primary survey continues with \200\230Breath- ing \200\231 and the management of respiratory disorders. Most patients can be managed without the need for surgical intervention. However in the primary survey needle thoracocentesis and/or int ercostal drain insertion may be required for a patient in respiratory distress. Following the primary survey most chest injuries are managed without the need for thoracoto my and can be managed conservatively or with the insertion of an intercostal drain. Needle thoracocentesis, is an emergency technique to decompress a clinically suspected tens ion pneumothorax as a resuscitative procedure prior to chest drain insertion. High flow oxy gen should be administered concurrently via an oxygen mask with reservoir bag. Indication Suspected tension pneumothorax. Position Supine. If not cleared the neck should be maintained in neutral with collar, sandb ags and tape (or equivalent) or manual in-line immobilization. Equipment (cid:142)(cid:3) 14 gauge cannula (cid:142)(cid:3) 10ml syringe (cid:142)(cid:3) Cannula dressing. Anesthetic Anesthetic is not usually required. Procedure (cid:142)(cid:3) Identify the appropriate side of the tension pneumothorax \200 \224side away from tracheal deviation, hyper-resonant, absent breath sounds. (cid:142)(cid:3) Identify the 2nd intercostal space in the mid-clavicular line. (cid:142)(c id:3) Clean skin with appropriate antiseptic (e.g. steret). (cid:142)(cid:3) Insert the nee dle at right angles to the chest wall through the chest wall. Pass the needle just superior to the upper border of the 3rd rib. (cid:142)(cid:3) Remove the hub from the cannula and l isten for a hiss of air escaping under pressure from the tension pneumothorax. (cid:142)(cid:3) Remove the needle and advance the cannula to its hilt. (cid:142)(cid:3) Se cure the cannula in place with dressing or sutures. (cid:142)(cid:3) Prepare for chest drai n insertion. Complications (cid:142)(cid:3) Local haematoma (cid:142)(cid:3) If there is no tension pneu mothorax; creation of pneumothorax (cid:142)(cid:3) Direct lung injury. This page intentionally left blank CHAPTER 18 Trauma surgery 824 Intercostal drain insertion Indication (cid:142)(cid:3) As part of primary survey intervent ion in immediately life threatening chest conditions (cid:142)(cid:3) Tension pneumothorax (cid:142)(cid:3) Open pneumothorax (cid:142)(cid:3) M assive haemothorax (cid:142)(cid:3) Flail chest (cid:142)(cid:3) As part of ongoing treatme nt for other chest injury (cid:142)(cid:3) Haemothorax (cid:142)(cid:3) Pneumothorax (cid:1 42)(cid:3) Suspected severe lung injury and requiring transfer or general anesthetic. Position (cid:142)(cid:3) Supine. If not cleared the neck should be maintained in neutral w ith collar, sandbags and tape (or equivalent) or manual in-line immobilization. (cid:142)(cid:3) Arm abducted with hand behind head. Equipment (cid:142)(cid:3) Large intercostal drain with trocar removed (cid:142)(cid:3) Und erwater seal and tubing or Heimlich valve (cid:142)(cid:3) Local anesthetic (cid:142)(cid:3 ) Needles and syringe for administration of local anesthetic (cid:142)(cid:3) Size 10 scalp el (cid:142)(cid:3) Large artery forceps (cid:142)(cid:3) Suture material \200\224heavy gua ge non-absorbable suture (Nylon) (cid:142)(cid:3) Gauze dressing pads (cid:142)(cid:3) Adhe sive dressing to secure drain and dressing (cid:142)(cid:3) Appropriate antiseptic solution for skin cleansing. Preparation (cid:142)(cid:3) Clean skin of chest (cid:142)(cid:3) Ensure all equipment avai lable and connects together (cid:142)(cid:3) Fill drain bottle to fill line. Anesthetic Local infiltration of lignocaine in conscious patients. Anesthetic to skin and s ubcutaneous tissue, including periosteum and pleura. Anesthetized patients do not require l ocal anesthetics. Procedure (cid:142)(cid:3) Position the patient. (cid:142)(cid:3) Identify the 5th intercos tal space anterior to the mid-axillary line. (cid:142)(cid:3) Local infiltration with ligno caine, infiltrate the skin and deep to the 6th rib. Infiltrate around the rib and into the 5th space. Infiltrate the pleura. (cid:142)(cid:3) Clean area with appropriate skin prep. (cid:142)(cid:3) Make 2 \200\2233cm skin incision parallel to ribs in 5th intercostal space. INTERCOSTAL DRAIN INSERTION1 825 (cid:142)(cid:3) Dissect down to pleura using blunt dissection with artery forceps. (cid:14 2)(cid:3) Puncture pleura with artery forceps and enlarge the opening by spreading forceps within wound. (cid:142)(cid:3) Explore the wound with finger and pass it through the pleura into the chest cavity. Check for any adhesions or abdominal contents within the cavity. (cid:142)(cid:3) Guide the drain using the artery forceps to avoid any structures within the thoracic cavity. (cid:142)(cid:3) Attach to underwater drain or Heimlich valve. (cid:142)(cid:3) Secure in p lace using horizontal mattress suture and drain sutures. (cid:142)(cid:3) Apply dressing an d secure drainage tube. (cid:142)(cid:3) Check tube position with a chest X-ray. (cid:142)( cid:3) Reassess the patient. Complications (cid:142)(cid:3) Malposition of tube \200\224ext ra-thoracic, drain in thoracic cavity but drainage hole extra-thoracic (cid:142)(cid:3) Local infection (cid:142)(cid:3) Blockage of drain (cid:142)(cid:3) Subcut aneous emphysema (cid:142)(cid:3) Infection; wound, empyema (cid:142)(cid:3) Blockage of dr ain; kinking of tubing, clogging with solid debris, clotted blood, inappropriate clamping (cid:142)(cid:3) Damage to intra-thoracic or abdominal viscera (cid:142)(cid:3) Damage to n euro-vascular bundle under 5th rib. CHAPTER 18 Trauma surgery 826 Venous cutdown This technique is a surgical emergency technique to establish venous access when peripheral access is unobtainable. Any superficial vein can be used; the most common c hoices are the long saphenous vein at the ankle and the basilic vein in the ante-cubital fo ssa. This section will describe the procedure for the long saphenous vein. Indication Venou s access when peripheral route not available. Contraindications (cid:142)(cid:3) Previous h arvesting of long saphenous vein for arterial bypass procedure. (cid:142)(cid:3) Trauma to limb proximal to vein. Position Supine. If not cleared the neck should be maintained in neutral with collar, sandbags and tape (or equivalent) or manual in -line immobilization. Leg rotated laterally. Equipment (cid:142)(cid:3) Lignocaine (cid:142 )(cid:3) Syringe and needles for administration of local anesthetic (cid:142)(cid:3) 14 gau ge cannula (cid:142)(cid:3) IV fluids with giving set (cid:142)(cid:3) Sutures. Preparation Clean skin with appropriate antiseptic. Anesthetic Local infiltration with lignocaine. Pro cedure (cid:142)(cid:3) Identify the anatomical landmarks for the long saphenous vein. (cid :142)(cid:3) 2cm proximal and posterior to medial malleolus (cid:142)(cid:3) Infiltrate wit h local anesthetic (cid:142)(cid:3) 2cm transverse incision at identified site (cid:142)(ci d:3) Blunt dissection with artery forceps down to vein and behind vein (cid:142)(cid:3) Pas s two ties behind vein (cid:142)(cid:3) Tie one tie as distal as possible and use this to s ecure vein (cid:142)(cid:3) Pass second tie proximally (cid:142)(cid:3) Make a small transv erse venotomy. Dilate the venotomy with the tip of the artery forceps and pass the cannula into the vein lumen (cid:142)(cid:3) Secure the cannula in place using the proximal tie (cid:142)(cid:3) Attach IV tubing, close the wound and dress the wound. Complications (cid:142)(cid:3) Damage to v ein and/or surrounding structures (especially nerve) (cid:142)(cid:3) Extravasation (cid:14 2)(cid:3) Local infection (cid:142)(cid:3) Cellulitis (cid:142)(cid:3) Thrombo-phlebitis (c id:142)(cid:3) Venous thrombosis. This page intentionally left blank CHAPTER 18 Trauma surgery 828 Diagnostic peritoneal lavage This procedure provides a rapid sensitive assessment for intra peritoneal blood. It should be performed by the surgeon responsible for managing the patien t as it prevents accurate further assessment by clinical examina- tion or ultrasound scanni ng. Indication In the haeodynamically abnormal patient: (cid:142)(cid:3) Change in level of con sciousness (unreliable clinical examination) (cid:142)(cid:3) Change in normal sensation (s pinal cord injury) (cid:142)(cid:3) Injury to neighboring structures (rib, pelvis). Patient away from regular clinical assessment for a long time (in theater for limb/other non-abdom inal procedure, or transfer to other provider including X-ray). If a patient is not stable haemodynamically they should not be trans- ferred to the imaging department. Contraindications (cid:142)(cid:3) Patient requires laparotomy (cid:142)(cid:3) Relative co ntraindications include technical problems such as the possibility of adhesions or an obese patient (cid:142)(cid:3) Ultrasound may be considered and will be discussed later. Position Supine. If not cleared the neck should be maintained in neutral with collar, sandb ags and tape (or equivalent) or manual in-line immobilization. Equipment (cid:142)(cid:3) Lignocaine with adrenaline (cid:142)(cid:3) Syringe and needles for administration of local anesthetic (cid:142)(cid:3) Peritoneal dialysis catheter (cid:1 42)(cid:3) Minor procedures tray including small haemostats, small skin retractors. (cid:142)(cid:3) Antiseptic skin preparation fluid. (cid:142)(cid:3) 1 liter warmed Hartman n \200\231s solution (cid:142)(cid:3) IV giving set (cid:142)(cid:3) Urinary catheterisatio n equipment (cid:142)(cid:3) NG tube. Preparation (cid:142)(cid:3) Decompress the stomach with oro-gastric tube (cid:142)(cid:3) Insert urinary catheter to ensure bladder is empty (cid:142)(cid:3) Clean skin. Include who le of abdomen. Anesthetic Local infiltration with lignocaine in the midline over site of procedure. DIAGNOSTIC PERITONEAL LAVAGE1 829 Procedure (cid:142)(cid:3) Identify the operative area \200\2241/3rd distance from umbilicu s to symphysis pubis. (cid:142)(cid:3) Infiltrate the local anesthetic. (cid:142)(cid:3) Vertical incision throug h the skin and subcutaneous tissue. This should be a bloodless field down to the linea alba. (cid:142)(cid:3) Lift the fascia with the haemostats and incise the peritoneum. (cid:142)(c id:3) Insert a peritoneal dialysis catheter into the peritoneum, and advance it down to the pelvis gently. (cid:142)(cid:3) Aspirate from the dialysis catheter with a syringe. If gross blood is aspirated the test is positive. (cid:142)(cid:3) If blood is not aspirated attach the catheter to 1 liter of warmed Hartmann \200\231s solution, and instill 10ml/kg into the abdominal cavity, via an IV givin g set. (cid:142)(cid:3) Gently agitate the abdomen to distribute the fluid instilled. (cid:142)(ci d:3) Allow the fluid to remain for 5 \200\22310min then drain by lowering the IV bag to the floor. Drainage by siphoning. The IV bag should be vented to allow easy flow. (cid:142)(cid:3) Analyze the fluid in the pathology laboratory \200\224inform the hematolog y department that the sample is DPL fluid. (cid:142)(cid:3) A positive result is represented by RBC \211 100 000 per mm3 or WBC \211 500 per mm3. Any food or fecal material is also indicative of the need for laparotomy. NB A negative lav age does not rule out retroperitoneal injury.