Primary Health Care

SURGERY
For Primary Health Care Workers in PNG

Jerzy Kuzma
MD, Senior Surgeon, Modilon General Hospital Lecturer, Divine Word University

Divine Word University Press Madang

ACKNOWLEDGEMENT
Several people have helped in production of this book. I am particularly grateful to Dr Billy Selve for revision of the whole text. I am also indebted to Dr Dide Gertrude who wrote the chapter about anaesthesia and to Prof. Garry Philips who revised the chapter. Additionally I would like to recognize HEO Tutor Mr Bob Simon for revising the text and valuable practical advice. In preparation of this book I have also received help on rehabilitation issues from Mr Michel Dunkeire. A great deal of the practical advice contained in the book is based on surgeons in PNG, and I wish to acknowledge the indirect input of all my surgical colleagues. Additionally, I would like to recognize those behind the scene who had done editorial work. I should like to thank Ms Iwona Kolodziejczyk for editorial work and word processing assistance.

To All Readers
I shall be very grateful if you could please share with me your critical comments on the content of this book. Please send them to me to the following email address: [email protected]. Your comments will be taken into a consideration in the process of revision of the book and preparation of the next edition. Thank you Jerzy Kuzma. M.D.

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PREFACE
The development of evidence based medicine brought about numerous changes in surgical practice and this calls for a substantial revision of existing manuals in line with the current trend in surgery optimal to Papua New Guinea (PNG) Over eighty per cent of PNG populations live in rural and remote areas with access only to Primary Health Care. The objective of this book is two fold; (i) to up-date the surgical knowledge as a reference guide for Health Extension Officers (HEO) and nurses, and other health workers providing surgical services in the rural areas, (ii) provide a modern, updated; yet simplified surgical guide. The material is based on the surgical experiences of the author and other surgeons and Health Extension Officers in PNG. The book is problem-based oriented with appropriate practical advice on the management of most common surgical problems experienced by primary health workers. It is simplified and adapted to the rural setting where surgical procedures are done by a HEO, nurse or a Community Health worker (CHW). Although the book contains descriptions and illustrations on basic procedures, it in no way can substitute practical experience requiring hands on experience. Trauma remains the leading cause of death and disability in the first four decades of life and thus it has significant impact on public health. It is my hope that this book will improve the care of trauma patients. The book has included the latest advances in early trauma management. A system of Triage is described to indicate patients requiring referral for specialized care in provincial hospitals. The main focus is on curative surgical services but appropriate disease prevention and health promotion is emphasized. The purpose of the book is to make surgical skills relevant to the rural and remote areas and hopefully will greatly assist those with surgical problems in PNG.

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TABLE OF CONTENT
Acknowledgement-------------------------------------------------------------------i Preface---------------------------------------------------------------------------------ii Table of Content----------------------------------------------------------------------iii Glossary of Abbreviations----------------------------------------------------------v

1.0 Trauma---------------------------------------------------- -----------------1
1.1 Resuscitation and First Aid-------------------------------------------------------1 1.2 Head Injury--------------------------------------------------------------------------5 1.3 Neck Injury--------------------------------------------------------------------------10 1.4 Chest Injury-------------------------------------------------------------------------10 1.5 Abdominal Injury-------------------------------------------------------------------15 1.6 Spinal Injury------------------------------------------------------------------------17 2.0 Shock------------------------------------------------------------------------------21 2.1 Types of Shock---------------------------------------------------------------------21 2.2 The venous cut-down--------------------------------------------------------------26 2.3 Intraosseous puncture--------------------------------------------------------------28

3.0 Wounds----------------------------------------------------------------------------29 4.0 Burns------------------------------------------------------------------------------39 5.0 Principles of Fractures and Dislocations----------------------------------------49
5.1 Classification and Pattern of Fractures------------------------------------------49 5.2 Diagnosis of Fracture--------------------------------------------------------------51 5.3 General Management of Fractures-----------------------------------------------52 5.4 Management of Common Fractures --------------------------------------------61 5.4.1 Fractures of Shoulder and Humerus--------------------------------------61 5.4.2 Fractures of the Forearm Bones-------------------------------------------63 5.4.3 Fractures of the Wrist and Hand-------------------------------------------65 5.4.4 Fractures of the Pelvis and Hip--------------------------------------------66 5.4.5 Fractures of the Thigh and Knee------------------------------------------67 5.4.6 Fractures of the Lower Leg and Ankle-----------------------------------68 5.4.7 Fractures of the Foot--------------------------------------------------------69 5.5 Dislocations-------------------------------------------------------------------------69

6.0 Surgical Infections--------------------------------------------------------------------77
6.1 Abscesses----------------------------------------------------------------------------77 6.2 Head Infections --------------------------------------------------------------------82 6.3 Boil-----------------------------------------------------------------------------------84 6.4 An Acute Limb---------------------------------------------------------------------86 6.5 Ulcers--------------------------------------------------------------------------------87

7.0 Acute Abdomen------------------------------------------------------------------92
7.1 Clinical Presentation---------------------------------------------------------------92 7.2 Peritonitis----------------------------------------------------------------------------95

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7.3 Intestinal Obstruction--------------------------------------------------------------95 7.4 Gastrointestinal Bleeding ---------------------------------------------------------96 7.5 Some Common Causes of Acute Abdomen-------------------------------------97

8.0 Anal Pain--------------------------------------------------------------------------102 9.0 Congenital Abnormalities and Surgical Referral------------------------------104 10.0 Diseases of Bones and Joins------------------------------------------------------112
10.1 Osteomyelitis----------------------------------------------------------------------112 10.2 Septic Arthritis--------------------------------------------------------------------114 10.3 Back Pain--------------------------------------------------------------------------117

11.0 Tuberculosis--------------------------------------------------------------------------119
11.1 Tuberculous Lymphadenitis ----------------------------------------------------119 11.2 Lymph Gland Biopsy-------------------------------------------------------------120 11.3 Tuberculous Arthritis-------------------------------------------------------------121

12.0 Tumour---------------------------------------------------------------------------123
12.1 Benign Tumours ------------------------------------------------------------------123 12.2 Malignant Tumours---------------------------------------------------------------125 12.3 Cancer Management at Primary Care Level ---------------------------------133

13.0 Genito-Urinary Tract Diseases ----------------------------------------------136 14.0 Diseases of the Ear, Nose and Throat ------------------------------------------146 15.0 Eye Diseases -------------------------------------------------------------------151 16.0 Antiseptics and Antibiotics in Surgery--------------------------------------153
16.1 Antiseptics-------------------------------------------------------------------------153 16.2 Antibiotics-------------------------------------------------------------------------157

17.0 Anaesthesia for Health Extension Officers --------------------------------161
17.1 Pre-Anaesthetic Evaluation -----------------------------------------------------161 17.2 Local Anaesthetic Techniques Agents -----------------------------------------165 17.3 Intravenous Anaesthetic Agents ------------------------------------------------167 17.4 Opioid Analgesics ----------------------------------------------------------------170

18.0 Emerging Diseases in Surgery -----------------------------------------------173 19.0 Health Worker Ethics ---------------------------------------------------------176 References ----------------------------------------------------------------------------177 Index------------------------------------------------------------------------------------------179

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GLOSARY OF ABBREVIATIONS
AIDS bd BP BPH BSA CNS CPR CVS GCS GIT GUS Hb HBV HCV HIV H/O I&D IDC I.V. Lt. O/E ORS PEV PR Rt. PTB RR S.C.I. STI TB tds T.I.D. QID UTI Acquired Immune Deficiency Syndrome twice a day/ every 12 hours blood pressure benign prostate hyperplasia burned surface area central nervous system cardio pulmonary resuscitation cardio-vascular system Glasgow Coma Scale gastro-intestinal system genito-urinary system haemoglobin Hepatitis B Virus Hepatitis C Virus Human Immunodeficiency Virus history of incision and drainage indwelling catheter intravenous injection left on examination oral rehydratation solution pes equino-varus per rectum right pulmonary tuberculosis respiratory rate subcutaneous injection sexually transmitted infection tuberculosis three times a day/ every 8 hours three times a day/ every 8 hours four times a day/ every 6 hours urinary tract infection

1.0 TRAUMA 1.1 RESUSCITATION AND FIRST AID

W

hat would be the first step to take if a severely injured patient is rushed to your health centre? vi

A sound knowledge and skills in the proper order of rescue action can effectively rescue and save lives.

Primary survey (The first assessment)
The initial step is to make brisk assessment of patient’s general condition, excluding all major life-threatening injuries. Brisk assessment means that it does not take you more than one minute per patient. This process constitutes the ABCDEs of primary trauma management. During the primary survey you recognize life-threatening conditions and institute management at the same time!

A - Airway maintenance with cervical spine protection
• • • • In an unconscious patient the airway may become blocked by vomitus, blood or most commonly the tongue falling back and blocking the airway. If a patient is able to talk well usually the airway is not in immediate danger. Check for foreign bodies in the mouth and remove them. Inspect for facial bone fractures that can obstruct the airway. If the patient is not talking, has stridor or is unconscious with a Glasgow Comma Scale (GCS) of less then 9, (see page 7), or has no purposeful motor responses (not able to localize pain) – intubate or at the very least insert an oral airway. Initially a chin lift and/or jaw trust will improve airway patency. The cervical spine extension, rotation or flexion is forbidden until cervical spine injury is excluded.

• •

Airways blocked by tongue falling backward

Pull jaw forward; do not extend the neck

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With jaw pulled forward the airway is unblocked.

To secure airway patency oropharyngeal airway can be inserted.

If there is a need, remove foreign body with your finger.

Figure 1.1-1 Maintaining Airway

B - Breathing and ventilation
• • Check if a patient is breathing; if not, start artificial ventilation. The best method is to intubate the patient and use the reservoir bag for ventilation. If this is not possible then (i) use fascial mask to ventilate lungs using breathing bag; or (ii) use mouth to mask or mouth-to-mouth ventilation. In mouth-to-mouth resuscitation the patient’s nostril should be occluded between the forefinger and the thumb. In infants – mouth to both mouth and nose ventilation should be given. Recommended adult artificial respiration rate is 15 breaths per minute (1 per 4 seconds). Inspection - expose the patient’s chest to assess chest’s wall expansion or detect any damage to the chest (flail chest, open chest wound or trachea deviation). Auscultation – check breath sounds symmetry– reduced breath sounds on one side of the chest would indicate either air (pneumothorax) or blood (hemothorax) between the lung and the chest wall. viii

• •

•

Percussion - dull note on one side of the chest indicate hemothorax, while hyperresonant note indicate pneumothorax (air in the chest cavity).

If you diagnose tension pneumothorax (reduced breath sounds and hyperresonant note on one side of the chest with circulatory and respiratory failure) - insert a wide-bore needle into the 2nd inter-costal space in the mid-clavicular line (see Fig. 1.1-2).

a)

b)

c)

Figure 1.1-2 Emergency treatment of tension pneumothorax (pre-hospital stage)

• • •

The needle insertion location: 2nd intercostal space in mid-clavicular line. Use wide-bore needle or I.V. cannula inserting it just above the 3rd rib. Insert the needle through finger of latex glove. This works as a one way valve, allowing air out and stops air entering the pleural cavity.

C - Circulation with hemorrhage control
Hemorrhage is the predominant cause of post-traumatic death and therefore rapid assessment of the hemodynamic status is essential. • The important elements of clinical observation are: o level of consciousness o skin colour o pulse (check carotid or femoral artery) – rapid and thready pulse is a sign of hypovolemia.

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• •

Stop any sites of profuse external bleeding by applying pressure dressing and elevating the limb. Establish two large-bore I.V. cannulas and infuse rapidly Normal Saline or Hartman’s solution (adults 2 litres fast, initial bolus for children - 20 ml/kg). Do not infuse Dextrose solution, it is not a plasma expender.

D - Disability (neurological evaluation)
Check for spinal injury (see Spinal Injury, chapter 1.6) Asses the level of consciousness using AVPU It is more appropriate in the rapid assessment of trauma patients AVPU (simple mnemonic scale to asses the state of consciousness) A Alert V Response to Vocal stimuli P Response to Pain stimuli U Unresponsive to all stimuli You can use also Glasgow Coma Scale (see page 6) to describe the level of consciousness.

E - Exposure/Environmental control
If you are at the site of the accident, always make sure that you are safe and then move the patient away from danger if any. When assessing the patient, ensure that the patient is reclothed (prevent hypothermia) after completely undress patient and inspect for injuries. Always maintain in line immobilization.

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1.2 HEAD INJURY

I

n Papua New Guinea head injury is one of the common injuries and accounts for 60% of deaths from trauma. It is of paramount importance to know that first hour of head injury is called "gold hour" and early intervention will alleviate a lot of long lasting sequale. Prompt and proper action in the first hour after injury is the most effective in combating brain oedema and secondary brain injury thus saving patient’s life. Primary brain injury is caused by trauma while secondary brain injuries are usually due to hypoxia and hypovolemia notably systolic blood pressure (BP) less then 90mmHg. Likewise in all serious injuries, managing a patient with head injury should begin with primary survey (ABCDE) (see Resuscitation and First Aid, chapter 1.1) and secondary surveys. The best transport for unconscious casualties with head injury is in lateral safe position (recovery position) (see Fig. 1.2-1) but always remember that the cervical spine is immobilized in a rigid collar. In secondary survey of patients with head injury the following information should be looked for:

History
Obtain information on the: mechanism and time of the injury, vomiting, posttraumatic amnesia, convulsions (fits), and blood/ fluid discharge from either the ear or the nose.

Examination
1. The assessment of level of consciousness is the most important observation to record after any head injury. The most commonly in use is the Glasgow Coma Scale (see Tab.1.2.1). 2. The observation of the pupils - normally the pupils are equal and become smaller in reaction to light. Any difference in the pupils’ diameter and a unilateral loss of reaction to light indicates intracranial injury (hematoma). 3. Vitals: blood pressure (BP), respiratory rate (RR), pulse rate (PR); dropping pulse rate below 60/min accompanied by increasing blood pressure, or dropping respiratory rate is very suggestive of a gradual build up of intracranial pressure caused by brain swelling or an intracranial hematoma. Sometimes pulse rate may increase due to other injuries leading to internal bleeding (e.g. ruptured spleen). 4. Limbs paresis - lateralized extremity weakness or a weaker motor responses on one side is suggestive of intracranial hematoma; 5. Cranial nerve paresis - dropping eyelid or paresis of one side of the face may suggest intracranial injury.

Indications for the referral of patients with head injury
1. Altered level of consciousness (unconscious, restless, aggressive, confused) 2. Conscious with no neurological abnormalities but with a history of a. Posttraumatic amnesia (loss of memory); if transport is very difficult and the patient is improving within 24 hours, referral is not necessary

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2. 3. 4. 5.

b. Vomiting; if the patient is improving, referral is not necesary c. Convulsions d. Severe headache e. Clinically diagnosed open, depressed or basal skull fracture, penetrating head injuries Lateralizing signs - unilateral limb or facial muscle weakness or paralysis Double vision or blurred vision, unilateral papillary dilatation Deterioration of vitals (dropping pulse rate or respiratory rate, and/or raising blood pressure) Blood or cerebro-spinal fluid leaking from the ear or the nose

Table 1.2-1 The Glasgow Coma Scale

Response Eye opening (E) Spontaneous To speech To pain None Oriented (know name, place) Confused Inappropriate (single recognizable words) Incomprehensible (ground and groans, no words) None (flaccid) Obeying commands Localizing pain Withdrawal (pulls away from painful stimuli) Abnormal flexion Extension None

Score 4 3 2 1 5 4 3 2 1 6 5 4 3 2 1

Best verbal response (V)

Best motor response (M)

Based on Glasgow Coma Scale, patients are classified as having • Severe head injury GCS <9 • Moderate head injury GCS 9 – 12 • Minor (mild) head injury GCS 13 - 15 GCS of 8 and less is the generally accepted definition of coma. Patients should improve GCS in time as they recover. On the contrary if any patient shows no improvement on the GCS he/she should be watched carefully. Any deterioration in the GCS is serious – indicates deterioration in the patient’s condition

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and warrants urgent referral. If no signs of improvement of consciousness level within 24 hours, refer urgently. Frequent and stringent observations of patient’s consciousness using GCS, pupil’s dilation and pulse rate should be taken for 24 hours after head injury. If the state of consciousness is remains unaltered, the observations should continue.

Management of the unconscious patient after head injury at the Health Centre level.
1. Follow ABCDE resuscitation steps. 2. Apply cervical collar or other protection to the cervical spine 3. Make sure that the airway is clear at all times and aspiration of stomach content to the lungs is prevented by transport an unconscious patient in lateral safe position (recovery position), (see Fig. 1.2-1). Insertion of an oropharyngeal airway may be helpful. 4. Improve ventilation by giving oxygen (initially 12 litres per minute later 3-4 litres/ min) through a nasal drain or mask - adequate oxygenation prevents secondary brain damage; a patient with GCS of 8 and less require intubation. 5. Treat hypotension (drop of BP below 90mmHg) with intravenous (I.V.) fluids because hypotension is compromising brain perfusion and may lead to secondary brain damage and as a consequent, to twofold increase of mortality (give best dextrose saline or normal saline or Hartman’s solution; do not give 5% glucose!). 6. Elevate head to improve venous drainage from the head. 7. If transport is not immediately available insert IDC and record diuresis.

Figure 1.2-1 Recovery position

SCALP INJURY Scalp wounds bleeds a lot because of a very rich network of blood supply to the scalp tissues. Children rarely develop hemorrhagic shock from scalp wound bleeding. SCALP LACERATION Scalp laceration is the commonest type of the scalp wound. The treatment of the laceration should only proceed after the completion of primary and secondary survey as described above. xiii

Treatment
Shave wide the area around the laceration; Prepare the skin with povidone iodine or other antiseptic solution; Drape the area; Infiltrate skin with local anaesthetic, such as 0.5 – 1% Lignocaine with Adrenaline. If you do not have Lignocaine with Adrenaline, use plain Lignocaine. • If there is profuse bleeding, ask your assistant to press with the fingers on both sides of the wound to control bleeding; • Irrigate the wound thoroughly by pouring a lot of fluid using normal saline or Hartman’s solution, or cooled boiled water; • Excise ragged skin margins with scalpel or scissors removing all dirt or debris and non-viable tissues to prevent infection. • Check the skull by palpation of the bottom of the wound to rule out fractures; • Suture the wound; sometimes undermining of the scalp on both sides of the wound can release tension and thus facilitate closing; • Give tetanus toxoid (0.5ml s. c.); if no records of previous tetanus immunization is available, the injection of tetanus toxoid should be repeated after 4 weeks; • Scalp sutures usually can be removed after 4-6 days. • For bigger lacerations a short course of antibiotic can be given, but there is no strong evidence that it prevents infection. More important in preventing infection is appropriate surgical management of the wound. Scalp avulsion or head skin defect larger than 3 cm in diameter should be referred to a surgeon. It is generally recommended that hematoma between the skull and skin (scalp hematoma) should not be aspirated because of risk of infection. OPENED SKULL FRACTURE 1. If transport is readily available apply sterile dressing, give patrenteral (I.V. or I.M.) antibiotic (amoxicillin or benzyl penicillin (Crystalline), or chloramphenicol) and refer to hospital; 2. If transport is not possible within 6 hours • Follow all treatment principles as described above for scalp lacerations • Give antibiotic I.V. or I.M. (amoxicillin or benzyl penicillin (Crystalline), or chloramphenicol) • Refer to the hospital as soon as possible • Continue head injury observation • • • •

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CLOSED FRACTURE OF THE SKULL Depressed skull fractures can be palpated and ensure that this is done during clinical examination. After resuscitation following steps as described in 1.1; refer all depressed skull fractures. BASAL SKULL FRACTURE Periorbital ecchymosis (raccoon eyes), retroaricular ecchymosis, or cerebro-spinal fluid (CSF) leakage from the nose or ear can indicate basal skull fracture. As soon as a basal skull fracture is suspected, patients with CSF leakage must be instructed not to blow their nose. Basal fracture may tear the brain’s coverings and cause severe meningitis therefore these patients require early referral. In about 10% of patients with head injury it is associated with cervical spine injury. Always remember to check patients with head injury for pain in the neck. If injury to the cervical spine is suspected, immobilize with a soft collar and also ensuring that provisory immobilization is applied for patient’s transportation. In all basal skull fractures, do not plug the ear but apply a light dressing, or do not insert a nasogastric tube through the nose because it can enter cranial cavity and damage the brain through basal fracture. PENETRATING HEAD WOUNDS Penetrating injuries such as pellet wound require urgent referral to a surgical unit after resuscitation (see figure 1.1-1). Clean the wound and cover with sterile dressing. Give antibiotics (I.V. or I.M.) amoxicillin or chloramphenicol and continue head injury observation. INTRACRANIAL HEMATOMA As a consequence to head trauma, patients can develop intracranial hematoma. The main indicators of this condition are; deteriorating of level of consciousness, unilateral dilatation of pupil, unilateral weakness to the limbs, decrease in pulse rate (below 60/min) and an increase in blood pressure. Any patients with suspected of intracranial hematoma requires urgent referral. Patients have a better chance of survival if stabilized and referred early. Management of a patient with deteriorating conscious is as for an unconscious one (see page 7).

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1.3 NECK INJURY

B

LUNT NECK INJURY can cause swelling of larynx and result in airway obstruction. This injury requires immediate referral. If there is severe respiratory distress and stridor, promptly restore airway this can be a life-saving buy means of an emergency cricothyroidotomy or intubation. In children insertion of a large-bore needle into the trachea would suffice to sustain ventilation Subcutaneous emphysema (air felt under the skin) can be caused by tracheal laceration SHARP NECK INJURY Sharp neck injury may damage large vessels leading to torrential bleeding. Packing the wound with gauze and applying manual pressure over the dressing during transport to hospital can save the patient. Insert two large-bore needles or cannula and start fluid resuscitation (see page 3-4).

1.4 CHEST INJURY

M

ortality as a result of thoracic trauma is about 10% and a large proportion of these deaths is preventable. When taking history, information about the mechanism of injury and the force used should be elicited. This will assist greatly in determining the extent of the injury and the potential sequela. In all chest injury start management with primary survey. It is anticipated that during primary survey life-threatening thoracic injuries will be recognized and treated.

A.

Airway

If there is stridor and inability to talk, it indicates the airway obstruction. The management generally consists of endotracheal intubation. If inserting an oral airway or endotracheal tube is unsuccessful, attempt to re-establish an adequate airway or possibly another safe option - in emergency - is needle cricothyroidotomy (particularly in children). A wide-bore 12-guge needle or cannula should be inserted through the cricothyroid membrane just below thyroid cartilage in the midline. (See Figure 1.4-1)

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Figure 1.4-1 Needle cricothyroidotomy

If placing a definite airway is not possible in the interim - jet insufflation of the airway can oxygenate patients adequately for 30-45 minutes. Jet insufflation technique is performed by placing a large-calibre plastic cannula 12to 14-gauge (16- to 18-gauge in children), through the cricothyroid membrane into the trachea below obstruction. The cannula is then connected to oxygen at 15litres/minute with either Y-connector or a side hole cut in tube. Insufflation is achieved by closing one end of Y-connector with finger or side hole for 1 second and 4 seconds off. If there is complete glottis obstruction it is safer to use low oxygen flow rates - 5 to7 litres per minute.

B.

Breathing

Increased respiratory rate and cyanosis indicates hypoxia (lack of oxygen) and at his stage you should consider the following serious thoracic injuries: TENSION PNEUMOTHORAX Tension pneumothorax develops when air leaks either from lung or chest wall in a ‘one-way-valve’ type of action - air enters the chest cavity but cannot escape outside leading to unilateral lung collapse. This result in gradual intrathoracic pressure builds up followed by blocking venous return to the heart that can result in death if not alleviated early enough.

Diagnosis
Diagnosis of tension pneumothorax can be made confidently on clinical diagnosis. The main signs and symptoms are listed below. • Chest pain • Air hunger with respiratory distress • Tachycardia (rapid pulse rate) and hypotension • Tracheal deviation • Unilateral absence or reduction of breath sounds (on the affected side) • Reduced or no chest expansion on the affected side • Unilateral percussion hyper resonance (on the affected side) • Distension of neck veins (absent in hemorrhagic shock) • Cyanosis (late)

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Management
Immediately decompress tension pneumothorax by inserting a large-bore needle into the 2nd intercostals space above the rib in mid-clavicular line on the affected site (half way between the clavicle and the nipple). If available the best for this purpose is a soft I.V. cannula. The cannula/needle should be connected to a finger of latex glove (see Fig.1.1-1) or to a drain, using an I.V. line, with the distal end placed under water (underwater seal drain). Definite treatment will require chest tube insertion and proper underwater seal drainage in hospital. OPEN PNEUMOTHORAX Open pneumothorax is described also as “sucking chest wound”. This is caused by a larger defect in the chest wall leading to open pneumothorax.

Management
• • • • Apply the sterile occlusive dressing overlapping the wound’s edges Tape the dressing from 3 sides with adhesive plaster to provide a flutter-valve effect. This will allows air to exit but prevents it from entering pleuaral cavity Avoid tapping on four sides because it can cause tension pneumothorax. Definite management will require surgical intervention in hospital.

FLAIL CHEST Multiple fractures involving more than 2 ribs usually are associated with severe lung injury or pulmonary contusion. Chest wall instability alone does not cause hypoxia; however severe lung contusion associated with pain restricting chest movement contribute to hypoxia.

Diagnosis
Diagnosis is made primarily on observation of paradoxical movement of chest wall. Asymmetrical respiratory motion on palpation and fractured ribs crepitation can aid diagnosis.

Management
• • • • • Effective analgesia (start with panadol and codeine; if required, give Pethidine 1mg/kg I.M ; Chest strapping can improve breathing and reduce hypoxia; Always be beware of overloading the patient with fluid because it can deteriorate the patients clinical condition; If there is respiratory distress (air hunger), give oxygen; Refer urgently, best in a sitting position.

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C. Circulation
Observe the colour of the skin and mucosa. Check the pulse for rate, rhythm and amplitude. MASSIVE HEMOTHORAX By definition, massive hemothorax is a rapid accumulation of more than 1500 ml of blood in the chest cavity. The common causes are both from blunt or penetrating trauma.

Diagnosis
• • • • The clinical characteristics of hemorrhagic shock (see Hemorrhagic shock, chapter 2) Absence of breath sounds on the affected side Reduction or no chest expansion on the affected side. Dullness to percussion on the affected side

Management
  Start fluid resuscitation with Normal Saline or Hartman’s solution (see C step, chapter 1.1) Urgently refer the patient to hospital

CARDIAC TAMPONADE Cardiac tamponade is defined as blood collection in the pericardial sac enclosing the heart. The most common cause in PNG is infectious but it can be caused by a penetrating injury.

Diagnosis
• • • • increased pulse rate distended cervical veins dropped blood pressure muffled (diminished) heart sounds (HS)

Management
Refer immediately to hospital.

SIMPLE PNEUMOTHORAX Simple pneumothorax results from air entering the pleural cavity (see Fig.1.4-2). It is caused by blunt injury such as lung rupture or a penetrating injury

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Figure 1.4-2 Pneumothorax

Diagnosis
• • • Diminished breath sounds on the affected side; Hyperresonant percussion on the affected side; In simple pneumothorax without other injuries the patient is stable hemodynamically, while in tension pneumothorax - hemodynamic instability develops).

Management
It requires the referral to hospital. If a patient with pneumothorax in respiratory distress, manage as tension pneumothorax. If severe chest pain, give Pethidine (1mg/kg I.M.) If transport not immediately available, give antibiotic – penicillin (crystalline) or amoxicillin (I.V. or I.M.). The best for the transport of a patient with chest injury is a sitting position. SUMMARY OF FIRST AID IN CHEST INJURY 1. Tension Pneumothorax (insert a wide bore needle 2nd interspace, the midclavicular line; it should be connected with glove finger, or drain under water); 2. Opened chest wound – paraffin gauze dressing sealed from three sides; 3. Flail chest - elastic plaster on paradoxically moving wall; 4. Strong pain killers (Panadol, Codeine, even Morphine 5 mg S.C. or Pethidine 1mg/kg I.M.); 5. Oxygen therapy; 6. If there is respiratory distress or asymmetry of breath sounds refer urgently to hospital; 7. Sitting position is the best method for transporting a patient with chest injury.

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1.5 ABDOMINAL INJURY
A bdominal injury can be classified into blunt or penetrating injury. After primary survey, secondary survey will follow highlighting the following points.

Diagnosis
History – Find our about the mechanism of injury, symptoms such as vomiting, characteristic of pain and bowels motion Examination – • Inspection – Look for wounds, and abdominal distension; • Palpation – Elicit if any tenderness, rebound tenderness, percussion tenderness, rigidity or guarding; • Auscultation – listen for the absence of bowel sounds; • Percussion - shifting dullness on percussion indicate the presence of intraabdominal fluid (blood); • Vital signs – the signs of hemorrhagic shock such as increased pulse rate and dropping blood pressure. PENETRATING WOUND TO THE ABDOMEN

Management
• • • • Apply sterile dressing and refer to hospital; Nil by mouth; If bowels are protruding from the abdomen – apply wet saline dressing; give antibiotic I.V (amoxicillin or chloramphenicol) [see dosage under Antibiotics, chapter 16.2]; If patient is unstable hemodynamically - connect I.V. line, start fluid resuscitation, and transport urgently to the hospital.

BLUNT ABDOMINAL TRAUMA 1. If there are signs of internal bleeding (pale, tachycardia and dropping blood pressure) • Start on I.V. fluid resuscitation (for adults give fast 2 litres of normal saline or Hartman’s solution, for children give a bolus of 20ml/kg); • Give pethidine (1mg/kg I.M. or 0.5mg/kg I.V.); • Organize urgent transport to hospital, but ensure that the patients is moved carefully in order to avoid disturbing clots around the ruptured spleen; • Hemoglobin (Hb) drops progressively after few hours due to hemodilution so in early hours assessment of Hemoglobin is not a real indicator of the patient’s hemoglobin status. • Nil by mouth (fasting) xxi

•

If low blood pressure for longer than 1 hour, insert IDC and record diuresis.

2. If you elicit rebound tenderness or percussion tenderness - it generally indicate perforated guts or peritoneum irritated by blood in the abdominal cavity. • Give I.V. antibiotic (amoxicillin or chloramphenicol) • Start I.V. fluid resuscitation (see above) • Refer urgently to hospital • Nil by mouth (fasting) 3. If a patient sustained perineal, pelvis or lower abdominal trauma or there is frank blood in urine, or is unable to pass urine, transport to hospital. 4. If patients with lower abdominal or pelvic trauma are not able to pass urine or are bleeding from the urethra, do not attempt inserting urinary catheter (IDC). If the bladder is distended decompress it by suprapubic aspiration (see Fig.13.0-2). An inexperienced health worker attempting to insert an indwelling catheter in partial urethral injury cases carries the risk of causing further damage and introducing infection. 5. If a patient sustained blunt injury to the loin (e.g. after a kick) and has swollen and tender loin with hematuria (blood in urine), it indicate kidney injury. ]

Management of blunt loin injury
• • Monitor pulse rate and blood pressure in order to detect early signs of hemodynamic instability and start I.V fluid resuscitation and transport to hospital; If the patient condition is stable you can manage at the Health Center o Rest the patient in bed; o Give antibiotics (cotrimazole or amoxicillin); o Give pethidine to control pain; o Collect fresh urine specimens and observe for bleeding - usually in few hours the bleeding will decrease; o Do not insert IDC in order to avoid infection; o If there is increasing flank swelling or fever, refer to hospital.

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1.6 SPINAL INJURY

S

pinal injury requires careful assessment and proper management in order to avoid further damage to the injured spine when moving a patient. All unconscious patients should be managed as spinal injury cases until proven otherwise.

Diagnosis
• • • • Initiate the rapid assessment ABCDEs of primary survey. On history taking - ask for mechanism of injury, localization of pain, urine control and leg movements. Severe pain in the spine suggests spinal injury. On physical examination - check for limb movements and sensation; loss of sensation and movement indicates spinal injury. Examine the spine for disfiguration (angulation), tenderness over the spine on palpation - remember to keep in-line position and when inspecting the spine, log-roll the patient! ‘Log-roll” is defined as turning a suspected spinal injury patient in such a way that all segments of the body are rotated at the same time with no spinal movements. High cervical spine injury results in respiratory failure and priapism (chronic penile erection). If the patient cannot lift up his/her head assume cervical spine injury.

• •

Early Management of paralysed patient • Fall of blood pressure resulting from cervical spine injury requires fast I.V. fluid (normal saline) resuscitation; • Any patient early after spinal injury should be referred; ensure that the patient is kept in the ‘in-line’ position when transporting to hospital. • If there is urinary retention, insertion of urinary catheter (IDC).

Early Management of spine injury
Any patient with multi-organ injury, and unconscious, or with blunt injury above the clavicles must be treated as with cervical spine injury until it is excluded by Xrays. Any deformity along the spine, pain or tenderness and loss of movement or sensation in the limbs indicates spinal injury. The most important points in ensuring that not further damage is caused to the spinal injured patient outlined below. • Do not allow neck extension, flexion or rotation on resuscitation. • Always remember to protect cervical spine during manoeuvres connected with airways management. Minimising cervical spine injury can be done by the application of either a semi-rigid cervical collar or keeping the ‘in-line’ (neutral) position of the head during intubation.

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• •

• •

The proper technique of moving the patient is to have at least 4 helpers trained in moving patient with spine injury. The most experienced worker should exert moderate traction on the head. (See Figure 1.6-1). Before transporting patients, remember to immobilize the head in a collar. In the event that proper collar is unavailable, improvised immobilization can be done either by placing the head between two pillows (to prevent rolling during transport) or by strapping the patient’s head to the stretcher. Sometimes a thin pillow can be gently positioned between the head and shoulders but ensure that the neck is not flexed to avoid damage to the spinal cord (see Figure 1.6-2). Fall of blood pressure is treated by fast I.V. fluid instillation. Gentle transport to hospital.

Figure 1.6-1 Lifting the casualty with spinal injury

A - Exerting gentle traction and head support with both hands during transport B - Two sandbags on both sides of the neck and a small one rolled under the neck C - Temporary collar made from rolled towel
Figure 1.6-2 Improvised support for an injured cervical spine

Late management of patients with spinal injuries
Management of patents after spinal injury includes: 1. Prevention of further spinal cord injury; 2. Prevention of pressure sores (bedsores);

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3. 4. 5. 6.

Prevention of chest infections; Prevention of urinary infections; Prevention of constipation. Rehabilitation

1. Prevention of further spinal injury While moving a patient with spinal injury, the patient must be kept in the ‘in line’ position. Sitting is forbidden or at least for a few weeks (usually no less than 6 weeks) until the injury has stabilized. 2. Prevention of pressure sores In developing countries most of the paralysed patients develop pressure sores. Although annual cost of the care of pressure sores is not available, the economic burden is clearly immense. Pressure sores develop due to continuous pressure depriving blood supply to the tissues lying between the bones and the surface that the patient is resting on (e.g. mattress) resulting in necrosis. In order to prevent pressure sores: • Health workers have to train and empower the family to shift the patient’s position two hourly day and night; and that means shifting the patient from the back to one side, then to another side, then to back again. Lying on the abdomen is also acceptable. • Avoid the local collection of moisture and skin laceration around the pressure areas. This means that the bed must be changed whenever it is wet. • Avoid excessive use of soap to clean the patient, because the alkali in the soap will lead to epidermal swelling and maceration, and is known to remove protective fatty acids on the skin. • Gentle massage is helpful. Avoid vigorous rubbing because it can cause shearing injury with loss of the skin elasticity, resulting in cracking; 3. Prevention of urinary infection Urinary track infection (UTI) is the commonest cause of death in paralysed patients with spinal injury. In order to avoid UTI the IDC must be maintained 2 to 3 weeks after trauma to empty the urinary bladder. The IDC should not be too thick, 16 for an adult male Ch and 18 Ch for woman is the preferred size. If the IDC is too thick it will block glands discharging to urethra and predisposing to infection. Approximately 3 weeks from the time of injury the patient should be trained to perform self-catheterization. In order to achieve this you need a Nelaton drain (plastic straight drain) size 16 Ch for females, a mirror; and a plastic container to wash the drain. The drain can be soaked in bleach solution then washed with boiled water. If bleach is not available, use water (warm boiled) and soap to cleaning the catheter. The technique is very demanding and requires commitment and cooperation from the patient, but when performed correctly and regularly it is the best way to prevent urinary track infection. xxv

4. Prevention of chest infections Any patient lying flat in bed for long time is not breathing adequately. This condition leads to the collapse of some air sacs, fluid then accumulate in the lungs resulting in infection. This is known as hypostatic pneumonia. This condition is preventable if patient’s position is altered regularly and instruction is given on breathing exercises. 5. Prevention of constipation It is recognized that bed rest predispose to constipation and to avoid this, bowel motion should be maintained mainly by a high-fibre diet containing lots of fruits, vegetables, greens; and 1 to 2 tea spoons of pawpaw seeds can work as laxative. If additional laxative is required Coloxyl 1-2 tablets is supplemented at night. 6. Rehabilitation Rehabilitation is an important aspect of the paralysed that are generally handicapped and less consideration is given to them after the acute phase of their treatment in the resource poor nations of the world. The objective really is to stabilize the patient and making sure that the patient fits back into the society. All joints in the paralysed limb should be put through the full range of movement to prevent contractures developing. Special attention should be given to dorsal flexion of the ankle preventing Achilles tendon contracture. It is natural for a paraplegic patient to develop depression and see no purpose in life. In such circumstances medical team or other organization skilled in this can play an important role in boosting patient’s spirit. The paraplegic needs a lot of encouragement to cooperate in rehabilitation in order to become as independent as possible. Even more, they must be made to feel that they are contributing to the society they live in.

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2.0 SHOCK
D efinition: Shock is a severe haemodynamic disturbance characterized by failure of the circulatory system to maintain adequate perfusion of vital organs leading to deprivation of oxygen (hypoxia) and in adequate nutrients (starvation). Shock develops when one or more of three main circulatory components are impaired: 1. Decreased volume of circulating blood (hypovolemic, hematogenic) 2. Reduced effectiveness of heart pump (cardiogenic) 3. Reduced peripheral resistance with vessels dilatation (neurogenic, anaphylactic)

2.1 TYPES OF SHOCK Types of shock according to the cause:
♦ ♦ ♦ ♦ ♦ Hypovolemic shock (commonly due to hemorrhage or severe dehydration) Septic shock due to infection Neurogenic shock (classic hypotension but no tachycardia) Anaphylactic (allergic) shock (reaction to drugs) Cardiogenic shock (caused by heart failure)

HYPOVOLEMIC SHOCK Hypovolemic shock results from insufficient intravascular volume to maintain adequate cardiac output. The inadequate filling of the vascular system results in dropping of blood pressure and insufficient organ tissue perfusion. This can be caused by external or internal bleeding (hemorrhage), or severe dehydration (burns, bowel obstruction, diarrhoea, trauma etc.) The normal blood volume for an adult is 7% of body weight (70ml/kg), for a child 89%.

Diagnosis
1. 2. 3. 4. 5. 6. Weak (dizziness or fainting on standing position); Skin – pale, cold and clammy (cold sweating); Peripheral parts of the extremities – cold; Pulse – rapid and weak (thready); an early sign; Blood pressure low; a late sign; Signs of multi-organ failure : (very late signs) • altered consciousness (restless or sluggish response, disoriented, or unconscious - in the more advanced stage); • respiratory distress (respiratory rate >25/min, air hunger); • decreased urine output;

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•

paralytic ileus (abdominal distension and no bowel sounds).

Multi-organ failure is a late presentation of shock due to insufficient perfusion of the vital organs. For instance, poor blood perfusion of the brain leads to the deterioration of its function manifesting as agitation, disorientation, confusion and even loss of consciousness. Any injured patient who is cool and has rapid pulse rate is in shock until proven otherwise. Tachycardia is defined as pulse rate of –>160/min in an infant [under 1 year]; >140 in a preschool child; > 120 in children of age group 6 – 15 years; and >100 in adults.
Table 2.1-1 Estimated fluid and blood losses based on clinical presentation

Blood loss (ml)* Blood loss (% of blood volume) Pulse rate Blood pressure – systolic (mmHg) Pulse pressure Respiratory rate Urine output (ml/hr) Mental status

Class I <750 <15%

Class II 750-1500 15-30%

Class III 1500-2000 30-40%

Class IV >2000 >40%

<100 normal

>100 normal

>120 60-80

>140 40-60

Normal or increased 14-20 >30 Slightly anxious crystalloid

Decreased 20-30 20-30 Mildly anxious

Decreased 30-40 5-15 Anxious, confused

Decreased >35 negligible Confused lethargic Comatose

Fluid replacement*

crystalloid

Crystalloid and Crystalloid and blood blood

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*for an average 70kg adult; ** Apply “3:1 rule” “3:1 rule” provides rough guidelines for the amount of crystalloid required to replace blood loss and means that for each 1 millilitre of blood loss should be replaced with 3 ml of crystalloid fluid (e.g. Normal Saline).

Treatment
1. Follow ABC steps for resuscitation (see Chapter 1.1 Resuscitation and First Aid). 2. Stop any external hemorrhage by pressure dressing or other methods (see Resuscitation and First Aid, chapter 1.1) 3. Establish two I.V. accesses with large-bore needles and give 2 litres of Normal Saline fast (20ml/kg in children); you can repeat this bolus but only once. The rate of fluid replacement can be reduced when the skin becomes warm again, veins are visible and the pulse rate drops back to around 100/min (in adults). If after two boluses of Normal Saline the patient is not stabilizing, internal bleeding is possible and patients should be referred immediately to hospital. 4. If there is air hunger – give oxygen 2-4 litres /minute. 5. If in pain – give Pethidine – the normal dosage is 0.5mg/kg, I.V. (slowly over 5 minutes); after 15 minutes, if still in pain, repeat 0.5mg/kg I.V.; if systolic blood pressure is below 90 mmHg reduce Pethidine dose to 0.5mg/kg. It is important to note that because of poor tissues’ perfusion analgesics administered intramuscularly will not be taken up well into circulation and the drug action is unpredictable. 6. Keep all shock patients warm (cover with blanket, if needed). 7. Record regularly pulse rate, respiratory rate, blood pressure and the Glasgow Coma Scale (see Tab. 1.2-1). 8. Insert a urinary catheter (IDC) and monitor urine output. Adequate urine output is the best indicator of sufficient rehydratation of a patient (See Table 2.1-1). Normal diuresis is 0.5mL/kg/h for adults (in an average adult 30 ml/h), children under 1 year of age – 2ml/kg/h, others paediatric patients 1ml/kg/h 9. The stomach and large bowels are often paralysed in-patients with shock; normal food intake must be stopped. An overfilled stomach will result in vomiting posing aspiration risk, especially in the comatose patients. In patients with suspected internal bleeding or acute abdomen, fasting is obligatory as a pre operative preparation for possible operation. 10. Give antibiotic I.V. amoxicillin or benzyl penicillin (Crystalline) (see dosage 16.2). 11. After completing the above points refer to hospital. CARDIAC SHOCK Cardial shock is caused by heart failure or the mechanics of the heart not being able to provide the required cardiac output to supply nutrients to the tissues of the vital organs. This can be due to a reduction in the force of contraction or not having the right rate (bradycardia) or very fast rhythm (arrhythmia)

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Do note that severe hypoxia and shock can be caused by massive hemolysis (red cells break down). Some of the common causes of hemolysis can be congenital or acquired as in haemolytic disease, severe malaria or massive electric burns. Destruction of the red blood cell depletes the oxygen carrying capacity to the vital organs resulting in shock. ANAPHYLACTIC SHOCK Anaphylactic shock (allergic) is caused by allergic reaction most commonly to some drugs but can be due to any foreign substances introduced to body. The body reacts to these foreign substances by releasing chemicals causing the dilatation of vessels and spasm of the smooth muscles of the airways restricting air flow. The treatment of choice is Adrenaline Subcutaneous (S.I.C.) or I.V., fluid resuscitation, and Hydrocortisone (I.V.). In patients with airways obstruction give a potent bronchodilator such as Vaporized Salbutamol.
Table 2.1-2 Classification of shock according to severity

Symptoms /signs Consciousness level Pulse Rate Blood Pressure Capillary Refill Urine Output normal

Mild

Moderate mild alterations 120-140/min 80-100/40-60 mmHg >1.5-2 sec 0.6-0.8 ml/kg/hour

Severe disoriented >140/min <80mmHg No refill <0.3 ml/kg/hour

<110 (120)/min insignificant drop or normal Normal (1-1.5 sec) 1 ml/kg/hour

SEPTIC SHOCK Sepsis can be secondary to inflammatory factors, bacterial toxins and hyperthermia leading to severe impairment of the peripheral circulation, resulting in septic shock and consequently multi-organ failure. The pathological changes following septic shock are: reduced tissue and organs perfusion resulting in tissue hypoxia and starvation, increased endothelial permeability leading to fluid leaking from vessels to interstitial space, and toxins – impairing myocardial contractility and leading to heart failure.

Diagnostic criteria for septic shock:
I

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A drop in blood pressure < 90/50 or average BP <70 for more than 30 min; Average Blood pressure (average BP) is counted as follows: systolic BP + diastolic BP divided by 2. For example; the average of BP of 90/50 is
BP = 90 + 50 2

that is 70 mmHg.

II Presenting with 3 out of 6 of multi-organ dysfunctions signs 1. Diuresis <30ml/hour (kidneys failure) 2. Deteriorating conscience (Central Nervous System impairment) 3. RR >25/min (lungs dysfunction) 4. PR >120/min (heart failure) 5. Paralytic ileus (guts paralysis) III There are symptoms of infection 1. Abscess 2. Temperature >38.5 degree Centigrade 3. Chills In 80% of septic shock cases it is caused by the endotoxins of Gram-negative bacteria Source: wounds, burns, infections of genital track, digestive tract, uterine, and respiratory system Contributing factors: decreased resistance - diabetes, old age, cancer, liver cirrhosis, and immunosuppression.

Stages
I hyperkinetic (hyper-compensation) 'hot'; patient’s blood pressure is normal or even increased II hypokinetic ‘cold’; patient’s blood pressure is dropping and peripherals becoming cold

Management
1. Symptomatic (General points are as for hypovolemic shock – see above); 2. Eradicate the source of sepsis; o Drain an abscess by surgery o Debride a necrotic wound o Give antibiotic I.V. chloramphenicol or amoxicillin with gentamycin (see dosage under Antibiotics, chapter 16.2) o Refer to hospital.

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2.2 THE VENOUS CUT-DOWN
I ndication The term ‘cut down’ means exposure and insertion of a cannula into the vein. Cut downs are indicated only as a last resort in situation where access to the vein is urgently needed and when other ways (venopuncture) to access the veins has failed.

Site
The commonest site is the long saphenous vein (distal segment) located just anterior to medial malleolus at the ankle.

Equipment
• • • • If you do not have prepared cut down pack you need a sterile scalpel, three pairs of artery forceps (best curved and small), small scissors, needle holder and dissecting forceps. Set of intravenous cannula (for adults the smallest size nasogastric tube for babies can be used). The largest possible cannula should be inserted. Ties (2/0 or 3/0 chromic catgut and 3/0 black silk for the skin suturing) Local anaesthetic, such as 1% Lignocaine with a syringe and needles.

Besides the equipment, you must have good light and a capable assistant
Figure 2.2-1 Technique of venous cut-down

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1. Have an assistant hold the child’s leg firmly. 2. Clean the skin around the ankle with iodine and drape it. 3. Infiltrate the area with 1% Lignocaine (plain or with adrenaline) over the long saphenous vein which lies anterior and just proximal to the medial malleolus. 4. In children apply tourniquet in a way that it occludes only the veins but not the arteries then check the tibial arterial pulse behind the medial malleolus. Apply a tourniquet before the cut down site to engorge and making it easier to detect the vein. 5. Make a small transverse skin incision (2 – 3 cm long) over the vein. Use scalpel only to cut the skin. Do not cut deeper than the skin. 6. Separate the tissues advancing deeper with a pair of artery forceps to expose the long saphenous vein, which can lie deep. There is often a small superficial vein that may mislead you. The long saphenous vein is a relatively large structure. 7. Pass an artery forceps under the vein and place distal loop of chromic catgut thread (3/0) under the vein. Tied it and place artery forceps across the ends of the loop to apply traction. Place another loop at the proximal end (top) of vein and clamp artery forceps at the ends without tying the loop (see picture 1 above). 8. With a small, sharp pair of scissors, make a small V-shaped incision on the anterior part of the vein’s wall. Beware not to cut through the whole vein (see picture No 2 above). 9. Have the assistant exert gentle traction on the lower loop (distal) in order to hold the vein open so that you can use very fine forceps (see No 3 picture above) or insert the blunt end of a curved suture needle (see No 4 picture above) as a guide for the cannula. 10. Select the largest cannula to fit into the vein. The shorter the cannula the more rapid will be the flow of fluid – about 15 cm long is often what is needed. When inserting the cannula make sure it enters smoothly without stripping the intima (shearing the wall). It is good to connect and open the drip while threading the cannula up the vein to assist with the treading and prevent from sharing the wall. 11. Now tie the upper loop firmly around the cannula. 12. Initially the flow may be poor so for few minutes leave the drip running at full speed. 13. Suture the cannula in with a silk stitch through the skin just below the wound. 14. Suture the skin with silk or nylon and apply a firm dressing to stop bleeding. 15. In children splint the leg securely.

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2.3 INTRAOSSEOUS PUNCTURE

I

n patients with advanced shock or very severe dehydratation, in particular a small child, when attempt at venopuncture is not successful and venous cutdown is not possible, intra-osseous puncture can provide for fluid administration and thus save the life. 1. The procedure is restricted only to emergencies in children less the 6 years of age and must be discontinued as soon as venous access is obtained. 2. Position the patient in supine with the knee flexed to 30°. 3. Note that the best puncture site is on the anteromedial surface of proximal tibia. Cleanse the skin with iodine around a wide area and drape. 4. If patient is conscious infiltrate the area with local anesthetic (1% Lignocaine). 5. Introduce large-bore needle (e.g. bone marrow aspiration needle). 6. Begin the needle boring movement at 90° then change to 45°. 7. When you advanced needle and is free of resistance it is in the bone canal and aspirate with the needle to confirm. If you obtain bone marrow (looks like blood), start your fluid therapy. 8. Apply sterile dressing and secure the needle with intraosseous tube.

Figure 2.3-1 Intraosseous puncture

Delay in treatment of shock results in irreversible changes in organs and death. Therefore intensive therapy for shock has to be instituted as soon as possible.

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3.0 WOUNDS

A
•

wound is by definition a loss of continuity of the skin or mucus due to injury. The skin cannot regenerate and it is healing by scarring. Wounds are amongst the commonest surgical problems encountered.

Local factors influencing wound healing
Foreign material (dust, soil, stitches, drains) as well as necrotic tissue left in the wound predispose to infection and prolonged wound healing. In order to prevent wound infection you should: o Perform meticulous washing out of the wound to remove dust, clots and detached pieces of tissue and debris that when left in the wound as a media for bacterial colonization and growth; o In order to remove all dead tissues from the wound, excise crushed and lacerated wounds margins and perform meticulous debridement. o Stitches applied inside the wound should be as thin as possible; Hematoma predisposes to wound infection, and delays wound healing. This is best prevented by meticulous hemostasis through; o Ligation of a vessel without entrapping surrounding tissue; o Applying drainage if oozing from the wound persists; o Prevent the formation of dead space by suturing the wound in layers and apply vacuum drains. In dead space tissue fluid and blood accumulates increasing the risk of infection. Excessive tension may impair circulation at wound margin increasing the chance for wound infection and break down at the suture site. The correct judgement on bringing the skin edges together adequately to stop bleeding and avoid excess tension, which cuts off circulation, is a matter of practical experience. Immobilization promotes wound healing. If the wound is located at the joint area immobilize the affected limb.

•

•

•

Wounds - First aid
First aiders must protect themselves by wearing gloves from diseases that spread through the contact with blood and other body fluids. It is also advantageous to wear an apron or some protective clothing when attending to wounds. The main aims of first aid are to: • Control bleeding • Protect wound from infection The management of the wound and its prognosis is dependent on its severity therefore the first you need to do is to decide whether the wound is minor or major.

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MINOR WOUNDS 1. Wash the skin around the wound with antiseptic solution. 2. Clean the wound thoroughly with soap and gauze soaked in sterile water or cooled boiled water, or under running tap-water. 3. Apply a non-stick sterile or clean dressing. MAJOR WOUNDS 1. Follow ABC of resuscitation. 2. Control bleeding by (See also External Bleeding Control, chapter 1.1) a. Applying pressure dressing; b. Elevating the affected limb; c. Placing another pad on top and firmly bandage in place if the wound is still bleeding; d. Applying manual local pressure to the wound if it still continuous to bleeds (always wear gloves); e. Refer to a medical officer to control bleeding points. 2. Cleaning the wound thoroughly with soap and gauze, soaked with sterile water, cooled boiled water or tap-water. 3. Then swab the skin around the wound with an antiseptic (e.g. iodine) 4. Applying a sterile or clean dressing. 5. Give parenteral (I.V. or I.M.) antibiotic – amoxicillin or benzyl penicillin. 6. Refer to a medical officer.

Classification of the wounds according to the type of injury
1. Incised - sustained as a result of a cut by a sharp object such as a knife or a broken glass. The incised wound is characterized by smooth edges and minimal tissue damage. When injury time is less than 6 hours or with antibiotics up to 12 hours, the incised wound can be closed by primary suture. 2. Lacerated - due to blunt objects tearing tissue. They have ragged edges and contain fragments of devitalized tissue. The devitalized tissue (margin excision) are trimmed away before the wound is closed by primary suturing (<6 hours from injury). 3. Crushed and devitalized – wounds results from injuries such as gunshot and car accidents. It is very often impossible to distinguish between a viable and a nonviable tissue. In such a case primary suture if applied under tension can increase the area of ischemia and enlarge necrotic area. All dead muscles and devitalized tissues provide an ideal environment anaerobic bacterial growth and the development of gas gangrene. For this reason all non-viable tissues must be trimmed away and observed before any suturing. The management of this type of wound include:

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• • • •

Thorough debridement usually under general anesthesia (Ketamine); Leaving the wound open - primary suturing is contraindicated; Checking dressing daily for the appearance of dead tissues which may require debridement again; When clean, beefy red granulation appears close the wound by secondary suture, split skin graft or skin plasty.

4. Punctured wounds (similar stab or penetrated) Punctured wounds most frequently develop infective complications such as abscess, phlegmona, cellulitis and necrotizing fasciitis. For this reason the old surgical rule is mandatory, that is; all punctured wound must be extended (opened + drained) in order to prevent devastating infection. All punctured wound must be opened and drained to prevent severe infection 5. Complicated wounds – is associated with injury to the deeper body structures such as bones, joints, tendons, nerves, vessels and internal organs. The wound must be washed and dressed and the patient commenced on a broad-spectrum antibiotic, tetanus prophylaxis and referred to a surgeon.

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Figure 3.0-1 Types of wound

The Practical Technique of wound management
1. Follow the ABC principles of first aid. 2. Examine the wound: a. Inspect; b. Look for any deep structures destroyed by the injury; c. Check tendon function (see Tendon injury, Figures 3.0-4, 3.0-5); d. Check sensory innervations of the limbs; e. Always check pulse distally to the wound. 3. Apply anaesthesia – usually local infiltration or block anesthesia is sufficient. Sedate the patient with pethidine 0.5mg per kilogram body weight given slowly I.V. 4. Wash the wound and surrounding area thoroughly with a lot of water and soap. The best is saline, cooled boiled water or clean tap water). 5. Cleanse the skin around the wound with antiseptic (iodine, povidone iodine, chlorhexidine etc.). Note – avoid antiseptic contact with the wound. 6. Shave the skin around the wound if necessary. 7. Remove all non-viable tissues by margins excision or debridement. 8. Re-examine the wound for any deeper organs injuries. 9. Do primary suture of the wound primarily within 6 hours from the injury or 12 hours if an antibiotic was given. 10. For patients with larger and contaminated or compound wounds start on antibiotics amoxicillin or benzyl penicillin + metronidazol or chloramphenicol (see dosage under Antibiotics, chapter 16.2). 11. Prevention of tetanus. Tetanus is a severe disease with a high mortality rate. It is caused by bacteria developing more commonly in dirty, deep and infected wound but sometimes can develop in a clean looking wound. Prophylaxis of tetanus includes: • Adequate wound toilet (debridement); • Antitoxin – Tetanus Toxoid (Te Tox) o If patient has been immunized with triple antigen or Tetanus Toxoid within the last 10 years, give one injection of Tetanus Toxoid 0.5 ml subcutaneously stat. o If no documentation of recent tetanus immunization - give 0.5 ml Tetanus Toxoid and repeat the same dose after 4 weeks. • In the management of wounds posing a high risk of tetanus infection, e.g. crushed injuries, deep and penetrating wounds, add benzyl penicillin (Crystalline) injection (see dosage under Antibiotics, chapter 16.2). • In case of high risk wounds (crushed or deep penetrating wound) antiserum can be given – Human Tetanus Immune Globulin (HTIG). This is passive protection against tetanus. It must be noted that Tetanus Toxoid is not a cure for acute tetanus. It only activates the body to produce antibodies against any future infection. The

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mainstay of treatment is the management of the wound including: i/ adequate cleaning, ii/ exposing punctured wound and closed chambers, iii/ removing all dead and non viable tissues. 12. The injured limb must be elevated, rested or splinted for few days. As soon as pain is alleviated patient is advised on starting gentle exercises to prevent joint stiffness. 13. Pain relief: splinting aids pain reduction; if additional analgesics are needed give Panadol and/or pethidine 1 mg/kg of body weight, I.M. every 6 hours. Remember that patients transferred to hospital should have I.V. line connected, antibiotic administered intravenously and kept nil by mouth (fasting).

Figure 3.0-2 Surgical toilet (debridement) of a wound

A – Excise 1-2 mm wide of skin margin, B – Excised ragged edges of fascia, C – Excise dead muscles (non-viable muscle have greyish colour and are not bleeding), D - Pack the wound with gauze, but no suturing.

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Figure 3.0-3 Washing and suturing a wound

A – After anaesthesizing the wound pour plenty of water while washing it. If the skin is dirty, use soap wash and brush the nails. B – Pouring water on the wound is better than soaking in the bowl. C - Vertical mattress sutures results in excellent fitting of wound’s edges. D – A needle passes deep enough at right angle to the skin. The suture should enter the skin at 90°. Ensure that there is no dead space where discharge can accumulate.

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E - When the skin edges are approximated, do not apply too much tension on the suture. F G – Evert the wounds edge to take a good bite of tissue. H – Do not place sutures too superficial. I – Blood trapped in dead space is predisposing to wound infection. SUTURE TECHNIQUE • Lie the patient down in good light. • Anaesthetize the patient adhering to asepsis: o Gently wash the skin around the wound with antiseptic (iodine or Savlon) and make sure that the antiseptic does not go to the wound; o Apply local anesthetic – 0.5 - 1% Lignocaine; raise a weal with anaesthetic and inject through this all around targeted for anaesthesia, and wait few minutes. Make sure that your needle in not in a blood vessel and before injection always aspirate. A safe method is to gently withdraw your needle while injecting. o If the wound is very large or complicated and may require a lot of time, then it is safer to use Ketamine. • Always pour plenty of clean water on the wound. The best method is to wash a wound with normal saline or cooled boiled water. If these are none available use clean tap water. If the skin is dirty use soap to wash it and brush the nails. • Debride the wound thoroughly, excise all necrotic tissue and wash again the wound. • Suture the wound but without a lot of tension. If perceive excessive tension, it sometimes can be released by undermining the wound’s edges. Always make sure that there is no ’dead space’. If needed, apply sutures in layers. • For deeper layers use absorbable stitch (catgut or chromic catgut); for skin suturing the best is monofilament thread such as nylon. If nylon is not available silk can be used.

Management of complicated wounds
TENDONS INJURY In tendon injuries both incomplete and complete one require repair. It is well known that early repair gives better functional results than the delayed. Distant results depend on excellent surgical technique therefore for tendon suturing, refer to surgical unit. In order to diagnose tendon injury in the hand; • You must first identify the injured ends of the tendon in the wound; • Check for flexion and extension separately in each of the fingers; and extension and abduction in the thumb. If any of these movements are either absent or weak, it suggests tendon injury.

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Figure 3.0-4 Flexor tendon injury

Note in this illustration that the ring finger is not in flexion indicating injury to its flexor.

‘swan neck’ finger
Figure 3.0-5 Extensors injury to fingers

‘mallet finger’

NERVES INJURY – The best way to assess nerve injury is by doing sensory tests on specific areas. In the hand make quick pricking test on the pulp of the thumb (for radial nerve), on the index pulp (for medial nerve), on the small finger pulp (for ulnar nerve) with a needle for pain sensation. If the wound is clean and the injury is less than 6 hours - primary repair will have better results. If the patient cannot reach the hospital within 6 hours, manage the wound according to general rules as described above and after the wound has healed refer for evaluation at the hospital. VESSELS INJURY – In any blood vessel injury apply, pressure dressing, elevate the limbs, as an exception, when a large artery is bleeding manual pressure directly on the wound can temporarily stop bleeding. The application of tourniquets is forbidden because of other complications. One exception where a tourniquet is allowed is traumatic amputation. BONES INJURY – See Management of open fractures in Chapter 5.3.

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In general for all bone injuries never close skin over bone fracture (exception in head and face). After cleaning well, apply sterile dressing and immobilization and give antibiotics before referring to a hospital. ABDOMINAL WOUNDS – apply sterile dressing, give antibiotic and sent to the hospital for wound exploration (see Abdominal Injury, chapter 1.5). CHEST WOUND - opened sucking chest wall wound requires application of watertight dressing (see, Chest Injury, chapter 1.4). The wounds penetrating to the area of large vessels (head, chest, abdomen, and neck) and containing still object e.g. knife, spear, wire; it is better to leave the removal of the object with a surgeon, because immediately after removal of the object the patient might develop severe bleeding. Note: More serious complications occur when a health worker forgets to think rationally and check for damaged deep structures than from technical shortcomings in wound management.

The healing process of the wound is classified into 3 categories: 1. First intention – is ideal and rapid healing without infection. This can be achieved by accurately joining wound edges by sutures or by adhesive tape. 2. Second intention - occurs when the wound edges are not brought together or there is infection and the wound breaks open. Healing by granulation is slower process and it produces larger scar and scars may result in contractures. 3. Third intention (delayed closure) for an infected wound or a wound located in an area with poor circulation, it is safer to leave the wound open for 4-5 days. When infection has settled and there is good granulation, secondary stitch can be applied.

Repair of the wound
1. Primary closure or immediate suture can be applied to: • A clean wound • A wound not older than 24 hours from injury If the wound involves only the skin and subcutaneous tissue close it with nylon or silk. If the wound involves deeper layers, use catgut or other absorbable stitch. Always remember to prevent “dead space’ formation. Contraindications of primary suture are: • wounds older than 24 hours from the time of injury; • dirty wound;

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• • • •

wounds caused by animal or human bite; wounds in the proximity of anus; open fracture ( a wound over the fractured bone, except open skull or facial bone fracture); deep stab wounds.

2. Delayed primary suture If you are not able to suture a wound immediately, it should be dressed and if the wound looks clean after 48 hours it can be sutured. This method is called delayed primary suture. If the wound is dirty with non-viable tissue it should be treated as an ulcer (see Ulcers, chapter 6.5). 3. Secondary closure After 48 hours some wounds can be closed by undermining the edges and secondary suturing, or by skin grafting.

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4.0 BURNS

B

urns is a common cause of trauma in PNG. Stringent adherence to basic rules in burns management should reduce mortality both in its early and late complications. A burn is defined as the destruction of tissue by dry heat whereas scald is by moist heat such as boiling water or steam.

Burns disease – pathophysiology
1. The shock phase lasts usually for 1-2 days; it is referred to as ‘white bleeding'. During this phase massive loss of serum through the burned skin may lead to hypovolemic shock. The hypovolemia results in reduced kidney perfusion with blockage of renal canaliculi leading to acute renal failure. 2. The mobilization of swelling begins about 3rd day from the time of the burn injury. In this phase, patients can present with multi-organ failure – lungs injury, kidney failure or sepsis. (see, Septic Shock, chapter 2.1). 3. The third phase is called recovery (anabolic) phase where the healing process resumes. In management of burnt patients, it is important to count the percentage of the skin affected. For that purpose the rule of nines (see Figure 4.0-2) and the rule of sevenths specifically in children can be used. (see Figure 4.0-1)

Figure 4.0-1 Rule of sevenths (for children under 3 years)

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Table 4.0-1 Rule of seventh for children under 3 years

Body Surface Area Head and neck Trunk and groin Both arms Both legs

0 – 3 years 18% 32% 20% 30%

Over 3 years 12% 38% 20% 30%

Another useful guide is based on the fact that the palm (excluding fingers) of the patient’s hand represents approximately 1% of the patient body surface area (BSA).

Figure 4.0-2 Rule of nines.

Rule of nines or sevenths are practical guides to asses the extent of the burn and consequently helps to determine fluid replacement. Patients (especially children) with burns are at the risk of developing shock. xlvi

Children with > 10% BSA, adults with burns >15% BSA both in1st and 2nd degree. Children < 3 years of age with >5% BSA require fluid resuscitation. Classification of burns according to the depth of injury 1 (first degree) - erythema, pain, absence of blisters 2A (partial superficial) 2B (partial deep) 3 (full-thickness) - blisters (scalds) takes about 2 weeks to heal - burns to the bottom of sweat glands; the prick test is felt as a sharp pain - the burn would is painless, the pin prick test produce no pain and is felt as pressure sensation, with the skin dark, leathery or waxy white, and is usually dry

The estimation of depth of the burn wound is an important guide to treatment. Superficial burns (1st degree and 2A partial superficial) will heal from the islands of epithelium (remaining deep in the glands) in 2 weeks. Deep burns however will require tangential excision and early skin grafting (3-14 days from the time of injury) to speed the healing process and prevent scaring.

FIRST AID Early management of burnt patient A
Airway In burnt patients always exclude thermal injury to airway. Signs suggesting the likelihood of inhalation injury: 1. Facial burns 2. Burns or black spots around the nostrils and mouth 3. History of confinement in a burning room for over 5 minutes 4. Carbonaceous sputum 5. Carbon deposits or burns in oropharynx 6. Explosions with burns to head and torso 7. Full thickness burns of neck or chest 8. Hoarseness, rasping cough and stridor The presence of any of the above findings suggests inhalation injury and immediate transportation to a hospital is vital. Note that the clinical manifestation of inhalation injury may not manifest in the first 24 hours. Immediate intubation is required if there is cyanosis, stridor or respiratory rate (RR) >35/min.

B

Stop the burning process Any burning clothes should be removed. If burning substance is in a form of dry powder is still on the skin, brush it away before washing. Other burning chemical

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substances should be washed copiously with water. Neutralizing agents have little or no advantage over water wash out. It is important to note that in this situation, you must always recognize the potential danger surrounding you and your patients and respond by isolation from that dangerous situation or hazard so that there is no further harm to both yourself and your patient. In this situation you must apply DR ABC, that is, danger and response before airways and cervical spine. C Early fluid replacement

SET UP A GOOD I.V. LINE AND GIVE FLUIDS ACCORDING TO Parklands rule (for the first 24 hours) Adults Children 4ml x weight in kg x surface area of burn 3 ml/kg x weight in kg x surface area of burn

Give half of calculated amount based on the above formula in the first 8 hours then the remaining half in the next 16 hours. Note that the first 24 hours begins at the time when the burn was sustained. In children, burns of more than 10% of body surface area (BSA) require I.V. fluid replacement. Fluids used in resuscitation should be Hartmann’s solution or normal saline. In children use Hartman’s solution or Normal Saline only in the first eight hours and later changing to 4.3% dextrose in 0.18% normal saline. Any resuscitation formula provides a working guideline only as an estimate of fluid needed. The onus is on you to perform intermittent judgement based on the urine output. Fluids should be infused at such a rate to produce at least; (i) 2ml of urine per kilogram body weight per hour for infants (under 1 year), (ii) 1ml/kg/hour for children weighting less than 30 kg; and (iii) 30-50ml of urine per hour for adult (0.5 ml/kg/hour). If urine output is below these values then fluid intake should be increased. Therefore, any burns of over 20% body surface must have an indwelling catheter (IDC) inserted to measure urine output and monitor fluid replacement. If fluids is not replaced immediately, burned patient can die from hypovolemic shock. Always start fluid replacement at the Health Centre and keep it maintained stringently during the transfer and bring along with the patient his fluid balance chart. Give Oral Rehydration Solution (ORS) in burns of less than 10% in children, less than 20% in adults, less than 15% for patients over 50 years old. The dose for adult is 400ml of ORS every three (3) hours.

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Undertake the following (if possible): 1. Analgesics: administer pethidine 1mg/kg every 4-6 hours I.M. or 0.5mg/kg I.V. (give slowly I.V. over 5 minutes); 2. Gently cover the burned area with clean gauze or clean linen. Do not break blisters or apply antiseptics except silver sulfadiazine cream. 3. Prophylactic antibiotics are not indicated early, later if infection supervenes, start with benzyl penicillin (crystalline) or amoxicillin (see dosage under Antibiotics, chapter 16.2). 4. Insert a gastric tube if the patient experience nausea or is vomiting, has abdominal distension, or if the burns involve more than 20% of body surface area. 5. Tetanus prophylaxis – give 0.5 ml of tetanus toxoid subcutaneously. 6. Nurse the patient under a mosquito net. 7. Keep the patient warm during transfer to hospital. 8. If the patient is not nauseated, give oral fluids. When scars ultimately form, round ones on the chest, neck or the limbs, they can shrink impairing breathing or circulation. This is best relieved by escharotomy (longitudinal incisions in the scar) and this procedure should be performed in a hospital. The commonest cause of death in burns is septic shock. The second cause of death in burns is hypovolemic shock leading to kidney failure. To prevent septic shock ⇒ Apply sterile dressing, with saline or silver sulfadiazine cream; ⇒ Perform tangential excision of necrotic skin when the patient recovered from shock (2-7 days from the injury) and cover the wound with split skin graft (SSG); ⇒ Institute early oral feeding (as soon as nausea has ceased).

Methods of local treatment of burns
1. Exposure method – open method is recommended for the first degree burns, and second degree partial superficial burns (2A, scalds) and full thickness burns. It is a very convenient method for facial burns. 2. Saline method – you can use normal saline or half strength saline (0.45%) being less painful than normal saline to the burned skin. You can produce 0.45% saline by mixing 1 volume of normal saline with 1 volume of sterile or only boiled water. Cover the burn area with a thin layer of gauze and ensure that it is kept wet all the time. 3. Closed occlusive method – apply a thick layer of dressing usually with silver sulfadiazine cream. This method is more expensive because it requires a lot of silver sulfadiazine cream and sterile dressing materials.

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Local treatment for less serious burns
1. Clean the burned area gently with normal saline or chlorchexidine and choose one of the above described method to deal with the burnt area; 2. Gently cover the burn with a) clean linen (larger areas) or b) dry dressing or c) saline dressing; 3. Do not apply any antiseptic except silver sulfadiazine cream; 4. Do not break or remove blisters; 5. When dressing burned fingers/toes remember to wrap fingers separately to prevent stacking fingers together; 6. Ensure that dressing near the joints should ideally be in an extended posture to avoid flexion contractures. Inappropriate treatment of deep burns and burns over the joints is leading to contractures and severe disability.

Prevention of contractures
1. Prevent infection from turning partial to full thickness necrosis. 2. Refer as early as possible all 2B (partial thickness deep), 3rd (full thickness) degree burns and burns over the joints to hospital for skin grafting. Healed burn wound over a joint by granulation forms a lot of scarring and leads to contractures. 3. Maintain proper position of joints by early splinting or traction. Generally keep the limb in the opposite position to the potential contracture posture. For instance, the wrist should be in slight dorsal flexion and the knee, and elbow at the extension. 4. Immobilization is safe and will cause no joint stiffness when applied for a period less than 3 weeks in adults and less than 6 weeks in children. 5. After early grafting, and ensuring that the graft has taken and is stable, implement early rehabilitation through passive and active exercises. Contractures can be operated by a specialist surgeon but preventing contractures is better and easier than correcting contractures.

Criteria for the transfer of a patient with burns to hospital
1. Deep burns (partial deep and full-thickness) of face, neck, hand, feet, genitalia and over joints; 2. Burns grater than 10% of the total body surface (BSA) in patients under 10 and over 50 years of age; 3. Burns greater than 20% BSA in adult patients; 4. Full-thickness burns greater than 5% BSA; l

5. Significant electrical burns including lightning injury (to prevent acute renal failure, encourage urine output to >100ml/kg/hour); 6. Significant chemical burns; 7. Inhalation injury; 8. Burns with associated medical condition (e.g. diabetes) or pregnancy, or other trauma; 9. Burnt larger area requiring skin grafting; 10. If a patient is an epileptic give phenobarbitone to control fitting. SKIN GRAFTING PROCEDURE

Indications
• Ulceration larger than one Kina coin caused by o burns or o traumatic skin defect (wound) or o tropical ulcer (at the stage of ‘young’, beefy red granulation) ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦

Equipment
Syringe, needles, 1 % Lignocaine with Adrenaline Antiseptic solution (Savlon or iodine) Drapes, cotton wool, gauze - plain and combine, crepe or gauze bandages Normal Saline in a bowl Scalpel handle and blade No 22 Two wooden blocks Vaseline gauze Scissors Plain and toothed forceps Safety razor (modified) Sutures – chromic catgut 2/0 or 3/0

GENERAL TECHNIQUE FOR SPLIT SKIN GRAFTING The best donor site is anterior and lateral aspect of the upper thigh.  Shave if it is hairy.  Wash the skin with antiseptic solution.  If available use sterile gowns and gloves; if gowns not available sterile gloves will suffice.  Drape the area.  Rub the donor site with paraffin gauze.

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Figure 4.0-3 Local anaesthesia for skin grafting

A – Use 1% Lignocaine (best with Adrenaline) and dilute it in proportion 1:1 with Normal Saline to obtain 0.5% Lignocaine solution. Make wheals at the edge of the graft area.

B – Infiltrate the donor area through wheals

C – Flat raised area ready for taking a split skin graft. If it rises like a plateau, it will be easier to cut. Wait 5 minutes for anaesthesia to work.

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Figure 4.0-4 Taking split skin graft (SSG) with a scalpel

Select a large size scalpel blade with straight blade (No 22). Rub the donor site with paraffin gauze. An assistant stretches the skin between hands or using 2 wooden sterile blocks. Lay the scalpel on the patient’s skin at 5 to 15° (almost parallel with the skin). Then with to and fro movements move the knife forwards cutting the skin graft

Figure 4.0-5 Grafting with a razor blade

You can cut a narrow sheet graft with half the blade of a safety razor. Preparation and cutting at the angle as above.

Figure 4.0-6 Grafting with a modified safety razor

File away the central lug. Make a shim (distancing piece) by grounding away the edge of blade or using needle No 20 or 22). The distancing piece increases the width of the throat of the razor to accommodate graft sheet.

Never leave the graft uninspected for longer than 3 days.

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If the grafted wound site smells, dressings can be changed earlier than the optimal time. If the grafting is over the joints, the limb should be immobilized until graft takes. This dressing basically should be left undisturbed for 2 -3 days unless a hematoma is suspected.
Figure 4.0-7 Applying and removing a dressing.

A–1 Split skin graft A-2 Vaseline (paraffin) gauze A-3 Balls or pads of cotton wool (or plain gauze) soaked in normal saline or Acriflavine A-4 Dry gauze (plain or combine) A-5 Dry cotton wool A-6 Crepe bandage

B Pulling in the direction as illustrated will not detach the graft C Removing in the wrong way may strip the graft from the wound.

THE TIEOVER METHOD OF GRAFT DRESSING This dressing method is indicated for small grafts over the parts where holding dressing securely would be difficult.
Figure 4.0-8 Tieover dressing of skin graft

A Skin defect B The wound covered with a graft being sutured from within outwards. C Trim away excess graft. Cover the graft with paraffin gauze and tie over a ball of cotton wool soaked is normal saline. D Cotton wool tied over. You can remove it after 5 – 7 days for SSG.

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The donor area should be covered with paraffin gauze and combine, bandaged and left for 7 to 10 days without changing dressing. The area for grafting usually needs scraping away of the surface layer to prepare better bed for a graft. After scraping an assistant applies pressure to stop bleeding. If area is oozing the graft should be meshed with a scalpel.

5.0 PRINCIPLES OF FRACTURES AND DISLOCATIONS

A bony fracture is defined as a loss of continuity in a bone substance.

5.1 CLASSIFICATION AND PATTERN OF FRACTURES
C lassifications of fractures, according to their aetiology: • • • • • fractures caused by sudden injury; direct mechanism – direct stress e.g. a stick hits the forearm; indirect mechanism – forces applied at some distance from the fracture side; for instance fracture of the clavicle in a fall on the shoulder; fatigue (stress) fractures - stress repeated to a bone may result in fracture, e.g. fracture of the second metatarsal bone occurring in army recruits; pathological - occurs in a bone weakened by a disease, e.g. tumour, osteomyelitis; it is often caused by very small or trivial force.

CLOSED AND OPENED (COMPOUND) FRACTURES In an open fracture there is a wound in continuity with the fracture. The distinction between closed and opened fractures is important, because the opened fractures carry the risk of becoming infected. In addition external blood loss in opened fracture can be associated with significant blood loss leading to hemorrhagic shock. The pattern of fractures indicates ♦ the mechanism of fracture, for instance, a spiral fracture has been caused by a twisting force ♦ the stability of the fragments, e.g. a reduced transverse fracture is less likely to become redisplaced than an oblique fracture

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Green-stick fractures (subperiosteal) are characteristic among children, whose bones are resilient like the green twigs of a young tree; “bendable but not friable”.

Figure 5.1-1 Patterns of fractures

HEALING OF FRACTURES Healing of a fracture is influenced by factors such as the rigidity of fixation (perfect immobilization), closeness of bone fragments, and interposition of soft tissues, blood supply to bone fragments, inadequate bony alignment and presence of infection. The time taken to unite fractures depends on, the type of bone and its age. In young children union is usually rapid, bridging callus is seen on radiographs within 2 weeks and consolidation 4 to 6 weeks. It is slower in adults, in favourable conditions the optimal time required for consolidation of fractured bone is about 3 months, but may extends up to 5 months.

Figure 5.1-2 Remodeling of fractured bone in a child

Note not fully corrected a joint surface.

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5.2 DIAGNOSIS OF FRACTURES
H istory - the following points may prove helpful: 1. 2. 3. 4. 5. What was the patient doing at the time of incident? (sport, car driving etc.) What was the nature (mechanism) of the incident? (a kick, a stick, a fall etc.) What was the magnitude of applied forces? Where is pain located? Any loss of activity bodily function? (e.g. a patient unable to walk after injury must arouse suspicion of fracture)

Physical examination
1. Inspection • asymmetry of contour (deformity, angulation); • asymmetry of posture (position) e.g. external rotation of limb in fractured femoral neck; • local swelling, haematoma, bruising, grazing; • laceration - always check exactly skin for the presence of any wound related to the fracture. 2. Palpation (gentle) • local tenderness - tender spot over trauma is not characteristic of fracture; • the important feature distinguishing fracture from soft tissue injury is that palpation at any segment of the bone will elicit the pain over the fracture site; • sharp edges at the fractured bone ends; • crepitus - when the bone fractured ends are moved; • abnormal mobility. The exclusion of the last two signs at palpation is recommended once a diagnosis is established because of unnecessary pain to the patient. Always check distal pulse, capillary return, and sensomotor function of the distal part of the limb (see Peripheral Nerve Injury, chapter 3) The majority of fractures can be diagnosed or suspected from the clinical examination, while in others radiographic confirmation is required.

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5.3 GENERAL MANAGEMENT OF FRACTURES
A ims 1. The attainment of sound bony union without deformity. 2. The prompt restoration of function (rehabilitation).

First aid
1. All injured patients need assessments of all systems to exclude life-threatening injuries that may require immediate attention (see ABC of primary trauma management, chapter 1.1). Remember to stop bleeding from a compound fracture by application of firm (pressure) dressing on an immobilized limb. 2. Always examine pulse (radial, ulnar, dorsal foot and posterior tibial arteries); absence of pulse on injured limb suggests arterial injury and requires urgent transfer to hospital. 3. Check for evidence of nerve injury (see Diagnosis of peripheral nerve injury, chapter 3). 4. Ensure that all fractures are immobilized before transportation - this can be achieved by a temporary splint (corrugated cardboard, piece of plank, bamboos stick, by bandaging to other part of the body (finger, leg, and arm to chest). The immobilization should include two adjacent joints to the fracture. 5. Correct the deformity - if the deformity is huge, the viability of the overlying skin can be endangered and to prevent this apply moderate traction followed by immobilization. 6. Transport to the hospital – consider it as an emergency if an artery has been injured and limb is ischemic (blue or white, swollen, capillary refill is prolonged over 2 seconds and lack of peripheral pulse as in supracondylar fracture). You have only a few hours to decide on how to save the limb - ischemia over 6 hours can result in necrosis. Do take note that blood loss caused by some fractures can lead to hemorrhagic shock. For instance, pelvis fracture can cause blood loss up to 2-3 l, while femoral shaft fracture - up to 1.5 litres. This is considered as hidden blood loss and very often overlooked by a clinician hence the importance of vital observations within the first 24 hours of injury.

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Management of open fractures
The open or compound fractures demand emergency treatment, because the longer the delay in wound debridement and definite immobilization the greater the risk of bone infection. 1. Primary care of the wound in a limb with fracture a. wash well normal saline or warm boiled water, b. cover with a sterile dressing, if there is blood oozing apply a compression dressing, c. Generally skin wound on the limb with fracture should never be sutured soon after the injury. The suturing ideally is delayed as secondary closure possibly after 4-5 days if and when you are clear that infection has ceased, but most often suturing may not be necessary. 2. Give tetanus toxoid. If a patient has a record of previous tetanus immunization in the last 10 years administer only a booster dosage (0.5 ml tetanus toxoid). If the patient has no record of previous immunization a standard dosage repeated after 4 weeks is recommended. 3. Commence on broad spectrum antibiotic, (parenterally I.V. /I.M.) e.g. chloramphenicol or Cloxacillin/ Flucloxacillin (see dosage under Antibiotics, chapter 16.2). 4. Temporarily immobilize the fracture along with two adjacent joints. 5. Refer to a surgeon. All compound fractures should be referred to hospital as a matter of priority.

Management of uncomplicated closed fractures
There are three fundamental principles of fractures treatment • Reduction (if necessary) • Immobilization (maintaining reduced position) • Preservation and restoration of function (physiotherapy) If there is no adequate bony alignment, one of three form of reduction can be applied ⇒ Closed manipulation ⇒ Opened operative reduction ⇒ Traction. The rule is that earlier close reduction has a greater chance of success.

Methods of immobilization
♦ ♦ ♦ ♦ ♦ Traction (skin, skeletal) Bandaging, strapping (e.g. strapping a fractured finger to its neighbour) Plaster of Paris (POP) fixation – by full cast or a splint Open Reduction and Internal fixation (ORIF) (plate, wire, screw, pin) External fixation (EF)

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In general after 3 to 4 months from the time of fracture if there is no signs of bone union (bone is mobile and painful at fracture site) there is delayed union so the patient must be referred to a surgeon. If the bone presents clinical features of non-union (movements at the fracture site with little or no pain) after 6 months from the injury in most cases there is need for operation.

Clinical tests of bone union
1. NO movement - absence of mobility between the bone fragments; 2. NO pain - lack of tenderness on palpation or tapping over the fracture site; 3. Absence of pain when angulation forces are applied at the fracture site. If clinical tests raise doubts radiological confirmation of union is required.

Figure 5.3-1 Clove hitch

Rotate both sides forward and apply to the wrist. Then tie the ends behind the neck to complete collar and cuff.

Figure 5.3-2 The application of the collar and cuff sling.

The application of the arm sling
If you do not have an original triangular bandage you can cut a piece of linen, not less than 100 cm square, diagonally into two pieces.

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Figure 5.3-3 The arm sling application

1. Fold the lower corner of the triangular bandage (corner A) up over the injured shoulder

2. Tie corner A to corner B at the back of the patient’s neck.

3. Twist and tie the remaining corner of the triangular bandage at the patient’s elbow (corner C) or fold neatly and pin it with safety pin.

Figure 5.3-4 Skin traction

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APPLICATION OF SKIN TRACTION Equipment
Elastoplast or extension plaster, tincture of benzoin solution, a square piece of wood with a hole in the centre, sand bags or bottles of I.V. fluids, a rope, wooden blocks to elevate the foot of the bed.

Technique
• • • • • • • • • • Shave the lateral and medial aspects of the leg if required. If you have an elastoplast, skip the third point. Paint the medial and lateral aspect of the leg with tincture of benzoin. Place a piece of wood with a hole in the centre on the sticky side of elastoplast/ extension plaster. Apply extension plaster/ elastoplast with the wood starting from the medial aspect of mid thigh down the leg to the lateral aspect. Make sure the wood is placed symmetrically in front of the foot. Bandage the plaster with a gauze or crepe bandage. You can apply also adhesive plaster or narrower strips of elastoplast. Put a rope through the hole in the wood and apply the weight (sandbag or I.V. fluid bottle). The weight should be about 10% of the body weight. The traction should be applied below the fracture site. Elevate the foot of the bed. Encourage the patient to quadriceps exercises as well as gentle ankle movement.

PLASTER OF PARIS TECHNIQUE
Plaster of Paris (POP) is used to immobilize most fractures that either require emergency splinting or immobilization after reduction. POP applied using proper technique will avoid plaster complications. The precautionary measures early after a fracture is to apply padded backslab and elevate the injured limb to allow for swelling to subside. Apply the POP cast only after the swelling has subsided. The dangers of applying POP too early are:  immediately after the plastering the cast will become too tight due to the progressing swelling causing intense pain, pressure necrosis and venous obstruction may occur;  after the swelling subsides within the cast there will be space created between the limb and the cast resulting in defective immobilization of the fracture.

POP EQUIPEMENT
Apart from the equipment shown below the following items are needed: • Bucket or large dish with warm water (in warm water POP sets faster) • Mechintose (plastic sheet) lxii

• •

Crepe or cotton bandages Triangular bandage
Figure 5.3-5 Plaster equipment

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Figure 5.3-6 Plaster technique

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1. Padding with plaster wool: • if you do not have cotton plaster wool, a roll of ordinary cotton wool can be used; cut it into strips 10-20 cm wide and split it into thin layers, then roll it and apply on the limb; you can use also few layers of toilet paper as padding. • Make sure that you apply the wool smoothly without wrinkles, which can lead to pressure sores under the cast. • Pressure areas (skin lying directly over protruding bones, e.g. malleolus) should be padded carefully with wool. 2. Dip the plaster in the water. Wait until the bubbles stop appearing. 3. Squeeze the plaster and roll gently to remove excess water. 4. Apply plaster backslab held with crepe (or cotton) bandage. 5. You can complete plaster when the swelling has settled. 6. If a full cast is applied as in an acute stage, then the patient should be (i) observed for 2 days in a Health Center with the limb elevated or (ii) instructed to elevate the limb at home but must return immediately if there is swelling and pain.

Care of POP (cast)
 If there is pain and/or swelling of the fingers or toes, elevate the limb.  If there is no improvement in 1-2 hours, you have to split the cast longitudinally to relieve pressure; proper splitting include cutting of all layers up to the skin.  If there is no further improvement to the limb circulation and pain continue to persist, immediately transport to the hospital. Operation may be needed. COMPARTMENT SYNDROME One of the biggest problems caused by a tight POP is compartment syndrome. This syndrome does not necessary imply that the health worker applying POP had made technical error or applied the POP too tight. It is often due to limb swelling as a result of the injury itself, infection or impaired blood supply. The compartment syndrome results as groups of muscles enclosed within fascia envelope become swollen and the pressure in the fascial compartment is raised to a point whereby small arteries and veins are compressed and the blood supply to the muscles and nerves cut off. A vicious circle is set up, as the muscles become ischemic; it in turn results in further swelling and more pressure. Ischemic injury to muscles tissue produces excruciating pain. If the fascia is not opened to relieve pressure, the nerve and muscle will become necrotic within 6 hours. An example of the compartment syndrome is the Volkmann's ischemic contracture involving the forearm. Never ignore when a patient complains of pain under POP

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Clinical picture of compartment syndrome
1. 2. 3. 4. 5. Severe pain Swelling of the limb Whitish or blue fingers/toes Capillary refill (return) >2 sec Passive extension of fingers is especially painful and restricted (the characteristic feature) 6. No peripheral pulse, but it is often present.

Treatment of compartment syndrome
The first step • All splints, plasters and bandages potentially capable of causing obstruction to the circulation must be removed, in case of a fracture well padded splint is substituted. • If there is a dislocation of the elbow or the knee, it must be reduced without delay. • If the above mentioned measures do not bring about good circulation, the patient must be referred urgently to a hospital for an operation. REHABILITATION Rehabilitation is essential in order to improve results of the treatment of fractures. It is very often disregarded. The rehabilitation begins as soon as you start to manage a fracture. It aims to preserve function and restore it to normal when the fractured ends are united. The mainstay of this fracture management phase is to encourage and empower the patient to do specific active exercises in the recovery phase. The types and intensity of the exercises is very much dependent on the nature of the fracture and should be progressive towards returning to normal activity. The exercise starts while a limb is immobilized in a plaster, through early static contractions of muscles without moving a joint.

The most common pitfalls in fractures management
1. Prolong immobilization especially in elderly can cause joint stiffness and irreversible loss of function. 2. Incorrect immobilization Adjacent joints are not adequately immobilized; The cast being too loose does not provide rigid immobilization; Unnecessary immobilization of joints (e.g. the finger joints in Colles’ fracture); Wrong positioning over the fracture site. 3. POP applied on a grossly swollen limb can either lead to compartment syndrome or a loose POP after swelling subsides). 4. Missed fracture (e.g. naviculare or hair-line fracture). 5. Missed adjacent joint dislocation (e.g. Monteggia’s or Galeazzi’s fracture dislocation).

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6. Inadequate or no instructions to the patient about the signs of a tight POP - can produce permanent serious disability. 7. Failure to instruct and motivate a patient to take part in the rehabilitation program. This can lead to joint stiffness and irreversible loss of function.

5.4 MANAGEMENT OF COMMON FRACTURES 5.4.1 FRACTURES OF SHOULDER AND HUMERUS CLAVICLE (collar bone)
Most common mechanism for a fracture of the clavicle is a fall onto a shoulder.

Diagnosis
The clinical presentation of a clavicle fracture is often obvious because of deformity; but sometimes you will encounter only a tender swelling without palpable deformity to indicate clavicle fracture.

Treatment
The treatment does not require a POP; you only need to apply support for the arm in a simple sling to relieve pain. The sling should be worn for 2-3 weeks for children and up to 4 week in adults. X-rays are not necessary. Refer to hospitals only open fractures and if pain persists beyond 3 months.

Rehabilitation
As soon as the sharp pain subsides the patient should be encouraged to do active shoulder exercises.

HUMERUS
1. Fracture of proximal part of humerus Fracture of the humerus is usually caused by a fall onto that limb. It is an old person’s injury.

Diagnosis
There is usually a lot of swelling and bruising around the shoulder, and pain on palpation and movement. It is always advisable to confirm diagnosis by an X-ray.

Treatment
In the elderly if there is displacement it is generally ignored, while more attention is placed on the restoration of shoulder function. The sling is applied for 2-3 weeks and can be further supported by bandaging the arm to the chest (a body bandage) for a week.

Rehabilitation
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At the start of the treatment program commence on fingers, wrist and elbow exercises. The shoulder exercises may be deferred for 2-3 weeks until the pain subsides. By that time the fragments are generally adhered to each other by granulation tissue and you should gradually commence on shoulder exercises, even with little pain. It will not retard union. Take the arm from the sling and allow it to hang, and then swing the arm in moderate circles motion and gradually increasing it as the stiffness subsides.

2. Shaft of the humerus
Fractures of the shaft of the humerus generally results from direct hit (transverse) or from an indirect twisting forces.

Diagnosis
Observing a floppy arm and abnormal mobility are the undisputed signs of a fractured shaft of the humerus. A known complication of this fracture is radial nerve injury resulting in ‘wrist-drop’ and this should always be considered when suspecting a fracture. In uncomplicated closed fractures, recovery is over 6 – 8 months. X-ray is generally recommended to assess whether or not there is any displacement of fractured fragments.

Treatment
The standard management method is application of U-slab, starting on the medial side of the axillary fold and bringing it round the elbow up to the shoulder. The slab is supported with a wet cotton bandage. As the slab sets, any slight angulation may be corrected. Thereafter, the arm must be supported in a sling. In some cases where there is unacceptable displacement, reduction under general anaesthesia is needed.

Rehabilitation
Active fingers, wrist and elbow exercises start at the time of the immobilization of the arm. Then rotate the arm in circular motions (pendulum exercises) and gradually increasing it as pain subsides. If the fracture becomes ‘sticky’ (usually after about 5 weeks) is a good indication that union has occurred and more active exercises is required.

3. Supracondylar fracture of the humerus
Supracondylar fracture of the humerus is one of the most common fractures in childhood; typically the injury occurs through a fall on an outstretched arm.

Diagnosis
There is tenderness, marked swelling around the elbow joint and a characteristic deformity with distal fragment displaced backwards and tilted backwards. The olecranon and epicondyls equilateral triangular relationship is unaffected. Radiography is mandatory.

Treatment

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In every case circulation in the affected arm must be assessed (the character of the radial pulse, and pallor, coldness, capillary refill, severe pain, weakness or paralysis of forearm muscles). If there are signs of impaired circulation, an immediate referral is mandatory. In most cases closed reduction is necessary under general anaesthesia. While awaiting referral, putting the arm up in skin traction is recommended. A collar and cuff is sufficient if displacement is acceptable. Ensure that after every manipulation, always check again the radial pulse; if not palpable, it is an indication that the elbow is too flexed.
Figure 5.4.1-1 Supracondylar fracture can damage the brachial artery resulting in ischemia of the forearm and hand.

5.4.2 FRACTURES OF THE FOREARM BONES Classification
• • • • • • fractures of olecranon fractures of coronoid process fractures of head of radius fracture of upper third of ulna with dislocation of head of radius (Monteggia fracture) fractures of shafts ulna and/or radius fracture of lower end of radius (e.g. Colles’s fracture)

Fractures around the elbow and forearm bones require radiological assessment and more complex treatment therefore any patient with one of these fracture must be referred to a hospital. COLLES’ FRACTURE It is one of the commonest fractures in women over forty. The mechanism of injury is a fall on an outstretched hand.

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Diagnosis
Rarely palpation along the radial bone will reveal any displacement. Typically the lower (distal) fragment is displaced and tilted backwards (dorsally) and laterally (radially). The appearance of the forearm with the dorsum facing upward resembles a dinner fork hence the term “dinner-fork’ deformity. In case of severe swelling or detected displacement X-ray is necessary.

Treatment
If there is minimal displacement, a plaster slab applied to the radial side of the forearm will suffice. If displacement is major with a lot of angulation, closed reduction must be done under anaesthesia and immobilized in a below elbow plaster application. The hand should be elevated for first few days after the procedure. In case of undisplaced Colles’ fractures for adults and in children immobilization POP can be removed after 3-4 weeks, while after reduction in adults it should retain for 5-6 weeks. Occasionally if a close reduction fails to reduce the gross displacement an open reduction is needed. Therefore in any Colles fracture with gross displacement and wrist swelling refer to hospital.

Rehabilitation
After applying the plaster, the patient must be advised to carry out active exercises with his fingers, elbow and shoulder, and encouraged to use the hand freely in daily activities.
Figure 5.4.2-1 Method of reduction of Colles’ fracture

A - After anaesthetising with Ketamine apply strong traction along the forearm bones for 1 – 2 minutes.

B - Repeat the mechanism of fracture pushing dorsally on the fracture with both thumbs (increase angulation).

C - With the thumb push the distal fragment while pulling the hand and

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flexing ventrally.

5.4.3 FRACTURES OF THE WRIST AND HAND
Gross swelling, deformity and tenderness detected within the wrist after an injury should be referred for X-ray.

Figure 5.4.3-1 The best position (Position of function) for immobilization of the fingers

The best functional recovery after hand immobilization was noted when metacarpophalangeal joints were held in about 70° flexion and the interphalangeal joints held almost fully extended. THUMB AND THE FIRST METACARPAL BONE The thumb functionally opposes the other phalanges and is the most important finger regarding hand function. Generally, fractures of the thumb and the first metacarpal bone should be referred to a surgeon.

METACARPAL BONES AND PHALANGES A fall on a hand or a blow on the knuckles during a fight commonly causes fractures to metacarpal bones.

Treatment
Metacarpo-phalangeal and phalangeal fractures can be considered to be stable if angulation does not exceed 10°. If the angulation of the neck of the 5th metacarpal does not exceed 45° or there is no rotational deformity it can be accepted without correction. Undisplaced fracture with acceptable apposition of fracture ends will heal even without immobilization. Sometimes dorsal slab for 3 weeks can reduce initial pain. For fractured fingers, a simple method of immobilization is to strap the injured finger to its neighbour with 2 strips of adhesive plaster (a garter splint or “buddy splint”, see Figure 5.4.3-2).

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Grossly displaced fractures, unstable, overlapping or causing rotational deformity in fingers require referral. Sometimes a displaced phalangeal fracture can be reduced after local ring block and or digital block at the base of the digits with plain Lignocaine (without adrenaline) and strapped gently to the adjacent finger with adhesive plaster for 3 weeks.
Figure 5.4.3-2 A garter splint for fractured phalanges.

Note that strapping is not placed across the joints so that fingers can exercise.

Rehabilitation
Finger movements and active use of the hand must be encouraged from the beginning. Avoid over-treatment and immobilization should not exceed 3 weeks (there are few exceptions).

5.4.4 FRACTURES OF THE PELVIS AND HIP Pelvis
Fractures of the pelvis commonly result from a motor vehicle injury or a fall from a tree.

Diagnosis
Pelvic fracture should be suspected when there is difficulty in walking after an injury. Clinically there will be pain on symphysis on palpation or/and on side-to-side compression (sprung like open or close a book). If the hip joint movement is painful we can suspect fracture involving the joint. X-ray is recommended to confirm your diagnosis.

Treatment
Most common complications of pelvic fractures that need urgent attention are blood loss (1.5 – 2.5 litres) and damage to the urethra or bladder. Always give at least 1.5 litres on normal saline to adults and 20ml/ kg in children. If patient has a low blood pressure and a rapid pulse rate continue fluid resuscitation.

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If patient is bleeding from the urethra or cannot pass urine you must not insert urethral catheter IDC! If the bladder is grossly distended you can make bladder puncture to aspirate urine from the bladder, and refer the patient urgently to hospital. Contusions around the pelvis and pelvic fractures assessed by X-ray as stable one should be treated by bed rest for 2-3 weeks until pain settles.

Rehabilitation
As soon as pain settles encourage early mobilization.

HIP
Injuries around the hip should be referred for X-ray. If a hip dislocation is suspected it requires urgent radiological confirmation and reduction.

5.4.5 FRACTURES OF THE THIGH AND KNEE

FEMUR Diagnosis
Inability to walk, tender swelling, deformation (angulation) and abnormal mobility are clinical features of femoral fracture. X-ray completes the diagnosis.

Treatment
A patient with femoral fracture can loose up to 1.5 litre of blood and occasionally requires fluid resuscitation. This type of blood loss is concealed so it is important to always check pulse on the dorsal foot artery and continue the general vital signs observations. Children under 5 years are ideally treated by Gallows traction (see Fig.5.4.5-1) generally counting number of weeks of traction by adding one week to age in years. In Gallows traction the buttocks must be slightly lifted off the bed. This method can be easily applied at the Health Centers. Older children are treated by skin traction. The methods for treating adults with this type of fracture vary depending on type of fracture and available resources. It is recommended that older children and adults be transferred to hospital.

Rehabilitation
Static contractures of quadriceps should begin as soon as pain settles (usually after a week). Also knee and foot and toes exercises are important to preserve joints function.

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Figure 5.4.5-1 Gallows traction. Child’s buttocks are elevated above the bed (arrow)

KNEE
Fractures around the knee joint require referral. First aid consists of checking circulation in the leg and transporting the patient immobilized. If there is no pulse on the dorsal foot artery referral has to be urgent.

5.4.6 FRACTURES OF THE LOWER LEG AND ANKLE

TIBIA Diagnosis
It is usually based on clinical features such as pain over the fracture, angulation or abnormal mobility.

Treatment
For small children, without significant displacement of bony fragments, long leg plaster for about 4 weeks is the usual treatment. If plaster is not available it is safe to allow the child walk on one leg with crutches. Management of tibial fractures in adults varies depending on fracture type and available resources. Opened fractures of tibia should be managed following basic rules for the management of open fractures (see Management of opened fractures, chapter 5.3). It is better to refer all adults with tibial fracture to hospital unless you sure there is no displacement of tibia; it may be treated in a long-leg walking plaster for 5 weeks. If the leg is still painful refer to a surgeon.

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Fracture of fibula alone is rare and requires X-ray to exclude tibial involvement. If the ankle is intact no special treatment is required. Below knee walking plaster can be applied for 3 weeks to relieve pain.

ANKLE FRACTURES
The simplest and commonest ankle injury is sprain. Careful palpation over the bones will reveal that they are intact. Sprains are treated with ice packs, a firm bandage and with crutches until pain has subsided. If there is a small swelling with bony tenderness confined only to one side, it is safer to apply a below knee walking plaster for about 4 weeks. If there is gross swelling on both sides of the ankle, it can indicate fracture with subluxation in the ankle joint, and the patient should be referred to a surgeon.

5.4.7 FRACTURS OF THE FOOT
Fracture of the calcaneus (heel) sustained from a fall should be referred to a surgeon. Metatarsal bone fractures are common resulting from contact with falling objects. Immobilization is not essential for union, but can be applied for 3 weeks to relieve pain. Fractures of the toes do not require immobilization.

5.5 DISLOCATIONS

D

islocation is a complete loss of congruity between the articulating surfaces of a joint, or simply the articulating surfaces of the bones in the joint are displaced relative to one another. For instance in shoulder dislocation the head of the humerus losses all contact with glenoid fossa (socket) or a ball dislodged from its socket. Subluxation is a partial loss of bone contact in a join.

Normal joint

Subluxation

Dislocation

Figure 5.5-1 Subluxation and dislocation

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Diagnosis
• Disfiguration of the joint contour • Restriction of movement • Characteristic position (e.g. hip - flexed and externally rotated) • Swollen, tender joint Diagnosis is usually obvious, but in some cases when there is gross swelling, the bony landmarks are obscured and the dislocation can easily be overlooked. Any delay in the diagnosis and reduction will deteriorate the prognosis. Two main complications of dislocations are obstructing artery blood supply or nerve damage resulting in avascular necrosis of one of bone ends, and recurrent dislocations. Recurrent dislocations (e.g. recurrent shoulder dislocation) may require operation. Sprain is an incomplete tear of ligaments responsible for the stability of the joint.

DISLOCATION OF THE JAW
It can happen if a patient opens the jaw to laugh or yawn, or being hit at the jaw at the moment when the mouth is open.

Diagnosis
The mouth of a patient with dislocated jaw remains half opened and lower jaw is displaced forward. On palpation you can feel a small depression over dislocated jaw joint or the temporo-mandibular joint (TMJ). If the dislocation is unilateral, the mandible deviates away from the midline.

Treatment
Dislocation of the jaw (mandible) should be reduced as fast as possible. Late dislocations are difficult or impossible to reduce. If it is not reduced the patient will live permanently with half-open mouth.
It is easy when done early • Most patients do not need anaesthesia; if needed give pethidine or diazepam (Valium) • Sit the patient on a chair, hold the mandible with thumbs over premolar teeth • Press the premolar downwards and at the same time press under the chin upward and backwards • Re-dislocation can happen if the patient opens mouth wide. To prevent it bandage jaw

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for three days.
Figure 5.5-2 Method of reduction of a dislocated jaw

DISLOCATION OF ACROMIO-CLAVICULAR JOINT
Dislocation of the acromio – clavicular (AC) joint is a common sport injury sustained in a fall landing on a shoulder.

Diagnosis
Careful palpation in comparison with the opposite side will show that the injured clavicle has a step downwards from the outer end of the clavicle. In most cases there is only partial tear of ligaments with subluxation. Tenderness is usually local, on the acromio-clavicular joint.

Treatment
Incomplete injury is treated by a sling worn for 2 weeks. When the step from the outer end of the clavicle is high (larger than 1 cm) refer to a surgeon. It can be pushed back by a pad strapped firmly with Elastoplast.

Rehabilitation
Early active shoulder exercise is encouraged.

DISLOCATION OF THE STERNO-CLAVICULAR JOINT
It is recognized when tender step is felt at the sterno-clavicular joint following the injury. Dislocation of the sterno-clavicular joint is treated in similar way to the dislocation of acromio-clavicular joint (see above).

DISLOCATION OF THE SHOULDER
It is the commonest dislocation caused by a fall on an outstretched hand or an impact directly onto a shoulder. Posterior dislocation may be result after an electric shock. There are two main types of shoulder dislocations: anterior (common) and posterior (rare).

Diagnosis
Pain in the affected shoulder and deformity demonstrated by a flattened area below the acromion (anterior prominence) and humeral head felt below the clavicle (in anterior dislocation). The patient cannot lift up his arm or put it in front of the chest. It is obvious when you observe both shoulders – the smooth roundness or curvature is absent in a dislocated shoulder.

Treatment
The dislocation must be reduced as soon as possible. Give pethidine 50mg I.V. slowly (over 5 minutes) in adults and 0.5mg/kg in children. This is generally sufficient to perform reduction, but sometimes ketamine may be required.

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ANTERIOR DISLOCATION
The standard method of reduction is Kocher’s manoeuvre (see Figure 5.5-3). It is applied in the steps as follows: ♦ The anesthetized patient is laid in a supine position. ♦ With the elbow flexed to the right angle apply a steady traction in line of the upper arm. ♦ Rotate the arm laterally. ♦ Then adduct the arm so that the elbow comes across the chest. ♦ Now internally rotate the shoulder carrying the patient’s hand to the opposite shoulder. ♦ The shoulder often reduces with the clunking sensation. ♦ If the reduction fails you can repeat with counter-traction in axilla applied with folded bed sheet by one assistant and the another assistant manually push of humeral head backwards in the last stage of the manoeuvre.

Figure 5.5-3 Kocher’s method of reduction of anterior shoulder dislocation

The alternative technique (Hippocrates method) is simpler and now generally preferred. The description of this method is as follows: ♦ Apply counter-traction in axilla either by an assistant pulling a bed sheet or by the surgeon’s stocking foot. Make sure that the surgeon’s heel is pressing more against the chest than against the axilla to prevent nerve injury! ♦ Apply firm and steady traction along the arm in the semi-abducted position. ♦ At the same time the second assistant is pushing the humeral head backwards by direct pressure. ♦ The stocking heel acts as a fulcrum when the arm is gently adducted. ♦ Felt click and ability to passively abduct the arm indicates reduction, however radiological confirmation is advisable. After reduction external rotation should be prevented by a sling for two weeks. lxxviii

Figure 5.5-4 Hippocratic method of reduction of dislocated shoulder

Rehabilitation
As soon as pain subsides active movement should be encouraged.

DISLOCATION OF ELBOW
It is usually caused by a fall onto the outstretched hand. Most common is posterior form of dislocation (ulna and radius are displaced backwards).

Diagnosis
The olecranon process is displaced backwards, elbow is swollen, flexed, restricted and painful elbow movement; the extension of the elbow is impossible. To distinguish between supracondylar fracture and posterior elbow dislocation you have to check the equilateral triangle between humeral condyles and olecranon. The triangle is undisturbed in supracondylar fracture, while in this dislocation it is distorted. X-ray is recommended to confirm diagnosis and to rule out associated fractures. Furthermore, the dislocated elbow is shaped like the hill with the olecranon process displaced backwards carrying with it the triceps tendon.

Treatment
When diagnosis is not sure refer to hospital. If you are certain that the elbow is dislocated and if waiting time for the transport is long, reduce it as soon as possible and refer for X-ray. • With around elbow injuries always check the pulse on radial artery and capillary refill. • Reduce under anaesthesia. Give pethidine 0.5mg/kg I.V. slowly (or Ketamine). • An assistant pulls steadily on the forearm in moderate flexion. • An operator grasps the arm just above the elbow to apply counter-traction

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• • •

At the same time the operator applies direct pressure behind the olecranon process Usually successful reduction is felt as a click but it should be confirmed by radiographic examination. Apply a plaster back slab with the elbow in 90° flexion for 3 weeks maximum (no longer).

Figure 5.5-5 Reduction of dislocated elbow A – An assistant exerting traction for 1-2 minutes then slowly flexing the elbow; while you at the same time grab the arm above the elbow and with your thumbs behind the olecranon push it strongly forward

B – This method may work even without
anaesthesia if the dislocation is fresh; put a pillow over the top of the chair’s back; an assistant pulls down while you push forward with your thumbs on the olecranon

Rehabilitation
The elbow injury is particularly prone to stiffness and in order to avoid it immobilization should not exceed 3 weeks followed by active exercises to bring gradual improvement in mobility. Passive exercise in elbow have to be is not recommended because it can cause ossification of soft tissues around the joint.

DISLOCATIONS OF THE METACARPO-PHALANGEAL AND INTERPHALANGEAL JOINTS
Most of these dislocations are caused by hyperextension.

Treatment
Ring anesthesia (see Anaesthesia, chapter 18) around the finger or metacarpal bone with 1-2% plain Lignocaine (no adrenaline!). Reduction is achieved by pulling the finger while applying direct pressure over the base of displaced phalanx. Immobilization is not required, but reduction should be confirmed on X-ray. When reduction is not achieved operation is required to restore function.

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HIP DISLOCATION
The dislocation of the hip most commonly occurs as a result of dashboard injury in a motor accident where the flexed knee strikes against frontal parts of the car.

Diagnosis
Any movements of the hip are painful; extension is impossible, and a typical leg position as illustrated in Figure 5.5-6.
Figure 5.5-6 Typical position of leg with posterior hip dislocation

The hip is slightly flexed, adducted and internally rotated, the leg appears short.

Treatment
The dislocation is best managed in hospital but if waiting time for the transport is long, you can reduce it in health center. It should be reduced under general anaesthesia as soon as possible because delayed reduction increases the incidence of femoral head necrosis.

Figure 5.5-7 Method of reduction of posterior hip dislocation

Reduction of posterior dislocation of the hip
     The patient requires general anaesthesia, pethidine or ketamine. The patient is placed preferably on the floor or a low table. The assistant keeps the pelvis from lifting. The operator flexes patient’s hip and knee. The operator then pulls forcefully upwards simultaneously rotates the hip laterally.

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   

Successful reduction usually occurs with a ‘clunk’ and the position and length of the affected leg returns to normal position. If the hip re-dislocates easily, a fracture of the socket is very likely. Refer the patient to hospital. Radiological examination should confirm reduction as well as rule out acetabular fractures. If reduction fails refer urgently to hospital.

Rehabilitation
A common practice is to apply skin traction for 2 weeks with gradual exercises for the knee and hip. Then patient is allowed to walk with crutches without weight bearing before 4 weeks.

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6.0 SURGICAL INFECTIONS
I nflammation All injured tissues release chemical substances, which are responsible for inflammatory reaction. These chemical substances are called inflammatory mediators and are responsible for local and general changes in the body physiology. Locally, they cause dilatation of small vessels (capillaries) and leakage of plasma through injured vessels walls into the interstitial space leading to swelling. Clinically, acute inflammation manifests with varying degree of the following features: • Heat (caused by increased blood flow) • Redness (caused by increased blood flow) • Pain (caused by inflammatory mediators and swelling) • Swelling (caused by plasma leakage to the space between cells) • Loss of function (caused by pain and swelling) Inflammatory mediators that are released to the circulating blood can affect all body organs causing general inflammatory reaction. For instance, fever is a result of general body response to inflammation. Many bacteria also produce toxins that are impairing function of body organs. If the inflamed area is extensive and proper treatment is delayed, the circulating level of inflammatory mediators and toxins in the blood will increase resulting in damage to crucial body organs, such as heart, kidneys, lungs and brain, and consequently death. Therefore prompt and proper treatment of the inflammatory process is of vital importance. Injury to the tissue can be caused by microbial infections, chemical agents (e.g. acids) and physical factors (e.g. heat or mechanical injury).

6.1 ABSCESSES

A

bscess is defined as a well-localized collection of pus. It usually presents with all features of inflammation, such as heat, swelling, redness, pain and often loss of function. General reactions to an abscess include fever, headache, and weakness. A good indication of pus collection is a fluctuant swelling. If you have diagnostic doubts you can always aspirate with a wide bore needle (No 18). This however is not conclusive; pus can be present even if you fail to aspirate it. Often in a deep-seated abscess, a well-pronounced fluctuant area may not be obvious but the patient will manifest with clinical features of inflammation as described. In this case it is advisable to chart the patient’s temperature graphically. A swinging temperature is very suggestive and the patient should be referred to a hospital.

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General treatment for abscesses includes:
• • • • • • Where there is pus let it out Incise and drain (I&D) - under block anaesthesia or under Ketamine (see Anaesthesia, chapter 17). If there is excess bleeding/oozing from the incision site, the wound should be packed with a gauze soaked with normal saline and I.V. fluids (normal saline) if necessary, be administered. At the beginning, change saline dressing daily. Remove the drain when the discharge stops or is minimal. Immobilize the affected limb by a splint and elevate it to reduce swelling. Antibiotics are usually not needed. Give antibiotic if: o Deep abscess or signs the infection is spreading – increasing swelling and erythema, cellulitis, lymphangitis and lymphadenitis; o If the abscess is located on the hands, foots or around the upper lip; o High risk patients, such as a patient with compromised immune system or metabolic defect (e.g. diabetic, AIDS, malnourished, old people); o Breast abscess at early stage of mastitis without fluctuation; o Signs of sepsis (high fever, severe condition, toxemia); o If there is sign of sepsis give antibiotics I.V./I.M. for 1 -2 days then oral; o chloramphenicol 500mg to 1g QID [not indicated for pregnant mothers]; o Or cloxacillin 500 mg QID with Probenecid 1 gram BD and Flagyl (metronidazol) 500mg TDS; o If the above are not available give Amoxil with Flagyl or Erythromycin (see dosage under Antibiotics, chapter 16.2); if Flagyl is not available give Tinidazole; Give painkiller for initial period (Panadol/ paracetamol or aspirin).

•

If no improvement after 5 days of treatment • transfer to medical officer • think about diabetes (see Diabetes mellitus, chapter 18) • think about osteomyelitis (see Osteomyelitis, chapter 10.1)
Figure 6.1-1 Technique of abscess incision and drainage (I&D)

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The common mistake is not making the incision large enough. THE COMMONEST TYPES OF ABSCESSES MASTITIS Mastitis is the early stage of breast inflammation. The skin will show features of cellulitis. A short history of breast pain in a breast feeding mother differentiates acute mastitis from chronic mastitis in tuberculosis (TB) and an inflammatory form of breast cancer. Etiology: In two third of cases of mastitis and or breast abscess affects mothers shortly after delivery. Cleansing the baby’s mouth with a swab cause micro-injuries, which are prone to getting colonized by the bacteria Staphylococcus aureus. When the bacteria present in infant saliva come in contact with cracked nipples it may initiate mastitis. The milk stasis in the breast provides a good breeding ground for the bacteria to multiply causing inflammation and ultimately ending with pus collection.

Treatment:
• • Apply warm soaks to the area. Administer antibiotic (Flucloxacillin 500mg QID or Amoxicillin 500mg 8 hourly; both can be combined with Probenecid 1 tab BD; note that chloramphenicol is generally contraindicated in pregnant and breast feeding mothers). Apply breast support. Advice mothers to continue breast feeding on the affected and healthy side. Complete emptying of the affected breast prevents the spread of infection. An alternative is to empty infected breast of its milk by expressing with hands and feed a baby only with the healthy breast;

• •

BREAST ABSCESS If the infection does not resolve in 48 hours with the above treatment or if there is fluctuation, the breast should be incised and drained. The usual incision is done in a radial direction over the affected segment. However, a surgeon can chose a lxxxv

circumaleolar incision because of better cosmetic results. If antibiotics are used for an undrained abscess, a type of chronic abscess called "antibioma" may form, which takes many weeks to heal. Chronic abscess usually results from inadequate drainage and its hard induration is difficult to differentiate from cancer or TB (needs biopsy). LUDWIG'S ANGINA Ludwig’s angina is a bacterial inflammation of the submandibular area with a localized abscess. The source of infection can be suppuration of cervical lymph nodes or a decayed tooth. The mandible is fixed by swelling and mouth floor induration. It is a dangerous infection because it can obstruct the airways. A high-pitched inspiratory and expiratory breathing noise (stridor) is the manifesting upcoming airway obstruction.

Figure 6.1-2 Ludwig’s angina

Note swollen chin and tongue

Treatment
• If the patient’s breathing is not obstructed, give antibiotic – if high fever, start I.V. or I.M. for 24 – 48 hours; if improved and swelling reduced can continue oral antibiotic, o Benzyl penicillin (Crystalline) + metronidazol; o Or Amoxil + metronidazol; o Or chloramphenicol I.V. (see dosage under Antibiotics, chapter 16.2). If no improvement after 24 hours or if swelling increases, or if signs of airway obstruction (stridor, high respiratory rate) present, give I.V. antibiotics and refer immediately to a medical officer at the hospital. It is a surgical emergency. Incision and drainage is required and sometimes tracheostomy may be needed.

• •

PERIANAL ABSCESS

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Etiology: 60% of anorectal abscesses are caused by Gram-negative bacteria, in 90% the abscess commences as an infection of anal gland. Other causes can be injury or extension of a cutaneous boil.

Treatment
• • • Evacuating the pus by incision and drainage (I&D) as soon as possible. Antibiotic cover: o amoxicillin + metronidazol: o or chloramphenicol (see dosage under Antibiotics, chapter 16.2). Half of anorectal abscesses potentially can produce anal fistula, which needs referral for surgical treatment.

Axillary (or other localization) of suppurative adenitis with pus collection requires antibiotic and pus drainage (see general treatment of abscess above). If few recurrences occur, surgical consultation is warranted.
Figure 6.1-3 Incision of perianal abscess

A - A cruciate incision B - Insert your finger to
break down all loculi C - Trim the edges; the wound is left to granulate

AMOEBIC LIVER ABSCESS
Amoebic Liver abscess is caused by a gut protozoa or amoeba called Entamoeba histolytica. The parasite gains access to the human body through faecal oral contamination by ingesting the amoebic cyst. The amoeba in the gut then enters the liver via the portal vein and lives by ingestion of the liver cells and forming the abscess. If untreated, it will suppurate to through the skin, lungs or other sites.

Clinical picture
Symptoms: • pain - in the right upper abdominal quadrant, sometimes refers to the right shoulder and scapula; • fever; • cough (caused by irritation of pleura). Signs: • intercostals tenderness (over the abscess); lxxxvii

• • • •

tender and often enlarged liver; palpated mass in the right upper abdominal quadrant; chest: dullness, reduced breath sounds on the right side, rales; jaundice (rare).

Treatment: • drug of choice is metronidazol 1000 mg BD orally or (800mg TDS) for 14 days; • add chloramphenicol (see dosage under Antibiotics, chapter 16.2) for 14 days; • If no improvement after 5 days (still high fever, swelling increasing or general condition deteriorating) refer to hospital where ultrasound-guided aspiration can be performed.

6.2 HAND INFECTIONS
I t is important to know anatomy of the hand to avoid cutting important structures. Often there is no area of fluctuation to localize an abscess. When pain prevents a patient from sleeping, it is the indication for immediate incision and drainage. PARONYCHIA Paronychia is a term used for nail-fold infection. It is an infection around a nail.

Treatment
 under digital block (see Anaesthesia, chapter 17) with 2% plain Lignocaine (no adrenaline) incise the skin superficially along the lateral side of the nail; followed by a proper incision over the area of maximal swelling and tenderness;  administer antibiotic: o Chloramphenicol; o or Amoxil + Metronidazol (see dosage under Antibiotics, chapter 16.2);  other measures (see General treatment for abscesses, chapter 6.1). Chronic paronychia affects women with prolonged exposure to water and impaired defence system. It is often caused by fungal infection.

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Figure 6.2-1 Incisions of hand infections

A – incision of paronychia; B – incision of pulp abscess; C - sites of possible incisions on the hand, note the median nerve motor branch to the thumb that must not be injured; D – lateral finger incision for infected tendon sheath, incise dorsally to the tips of finger creases, this prevents injury to digital nerve which lies ventrally to the tips PULP SPACE INFECTION Pulp space infection (felon, whitlow) is finger pulp abscess. If a patient with hand infection cannot sleep because of pain, it indicates pus collection requiring immediate drainage. If not drained early, infection may advance deeper causing osteomyelitis.

Treatment:
• Incision o Apply digital block (2% plain Lignocaine without adrenaline) or Ketamine (see Anaesthesia, chapter 17). o Incise superficially over the point of maximum tenderness. Incision should be precise, cutting only the skin. Cutting the deeper layers with a scalpel can damage important structures to the finger. o Then a pair of small forceps or other blunt instrument (e.g. blunt tip scissors) to widen the opening and enter the abscess. The cavity is gently explored to help the evacuation of pus. Drains are generally contraindicated, but if the pus is undermining a large area, contra incision on the opposite side of the affected finger may be beneficial with placement of a small rubber drain (made from a strip of a rubber glove). The drain can be removed after few days when discharge is reduced. The hand should be elevated and movement commenced as early as the pain allows; this prevents finger stiffness. lxxxix

•

•

•

Other measures (see General treatment for abscesses, chapter 6.1).

Fig. 6.2-2 Incision for hand abscesses

When an abscess is already fluctuating at a point at the surface the incision must be directly over the centre of the abscess. WEB SPACE INFECTION (collar-stud abscess) Typically infection begins beneath palmar calluses, but often more swelling is seen on dorsal side than on the palmar site where the abscess is. Incise over the point of maximum tenderness. You can insert a small rubber drain (made from a glove). Other measures of treatment are applicable as for general treatment of abscesses (see General treatment for abscesses, chapter 6.1). SUPPURATIVE TENDOSYNOVITIS Suppurative tendosynovitis is purulent infection of tendon sheath. Four cardinal signs of suppurative tendosynovitis are: 1. tenderness over the involved tendon sheath (flexor); 2. rigid position of the affected finger in flexion; 3. severe pain on attempts to extend the affected fingers; 4. swelling.

Treatment
• • Give antibiotic (see General treatment of abscesses, chapter 6.1). Refer to a surgical unit. Surgical treatment must be fast to prevent irreparable damage to the finger.

INJECTION ABSCESS

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It is usually located on the buttock and treatment follows general treatment rules for abscesses (see General treatment of abscesses, chapter 6.1).

6.3 BOIL
B OIL (furuncle) A furuncle is an abscess of the hair follicle. It is often an implication of low hygiene and impaired immunity. It contains a small amount of pus in most cases discharging spontaneously, thus not requiring a surgical incision. Pain is usually significant with a tender swelling around a hair follicle. The abscess resolves well with the application of warm soaks to accelerate spontaneous opening. Antibiotic is indicated only if local treatment fails. NOTE • Never squeeze any boil especially on the face. • Boils on the face require a special care; at this location the boils can become a route form which infection is disseminated into the head and cause severe complications; therefore treat with 2 antibiotics (chloramphenicol and cloxacillin/amoxicillin) (see dosage under Antibiotics, chapter 16.2). • If the patient is not improving and swelling, temperature and pain not subsiding, refer to a medical officer. • Recurrent boils – think about impaired immunity (diabetes mellitus, malnourishment, overwork, AIDS). • Multiple boils in different areas require antibiotic and check for diabetes.

CARBUNCLES
Multiple boils compacted in a small area occurring usually at the nape of the neck are collectively called carbuncle. It is a typical infection in the dirty, malnourished or diabetic patients.

Treatment
• • • • Antibiotic administered at an early stage can prevent skin necrosis (see General treatment of abscesses, Chapter 6.1). If skin necrosis develops, it is very likely for the skin to separate spontaneously. If the slough takes a long time to separate you can excise the carbuncle (necrotic area) and dress it with normal saline. If there is a bare area larger than a one kina coin, cover it with a split skin graft as soon as there is a beefy red and clean granulation tissue. Be sure to test the patient’s urine for sugar.

CELLULITIS
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Cellulitis is described as bacterial infection of the subcutaneous tissue usually with little or no pus collection. The typical presentation is redness, heat and swelling, with the tenderness confined to the superficial soft tissue. Accompanying regional lymph nodes can be swollen and tender. An atypical case of cellulitis can be mistaken for osteomyelitis. In children it is safer to not diagnose initially cellulitis, always diagnose osteomyelitis and treat as such until excluded by an X ray after eleven days. The differential diagnosis includes osteomyelitis (see osteomyelitis, chapter 10.1), septic arthritis (see septic arthritis, chapter 10.2), and pyomyositis (below).

Treatment:
• • • • • Apply warm soaks to the area; Elevate and rest the affected limb; Give chloramphenicol for seven days (see dosage under Antibiotics, chapter 16.2); Incise and drain when pus develops (fluctuation); If no improvement after 5 days: o Refer to a medical officer; o Think about osteomyelitis (see osteomyelitis, chapter 10.1); o Rule out diabetes (test sugar in urine).

PYOMYOSITIS
Pyomyositis - is a disease characterized by abscess formation in one of the patient’s muscles. It affects young people between the ages of 5 and 25 predominantly in tropical countries. The muscles most commonly affected are the large muscles on the tights, buttocks, shoulders, back and abdominal wall.

Clinical presentation
• • • • General toxaemia (very ill, drowsy, high fever); The characteristic feature is that maximal tenderness is localized well over the affected one muscle or the group of muscles; Swollen and shining skin over the affected muscle; Fluctuation may not be present if pus collection is deep.

Differential diagnosis
 Osteomyelitis - in pyomyositis swelling is localized to the affected muscle, while in osteomyelitis the swelling surrounds the affected part of the limb (see osteomyelitis, chapter 10.1);  Septic arthritis (see septic arthritis, chapter 10.2);  Cellulites (see above);  If there is swelling in the upper abdomen, think about amoebic liver abscess, perinephric abscess, or acute abdomen;

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 If there is swelling in the groin think about psoas muscle abscess (‘cold’ TB abscess, strangulated hernia).

Treatment:

♦ Incise and drain (see Figure 6.1-1); ♦ Drain may be sawn to the skin to prevent accidental removal; ♦ When significant bleeding, the cavity can be packed with gauze; remove packing after 48 hours; if it bleeds again, repack it; ♦ The drain can be removed when drainage stops; ♦ Antibiotic (see General treatment for abscesses, chapter 6.1).

6.4 AN ACUTE LIMB
A n acute limb is a useful clinical term as a guide to conducting proper differential diagnosis for a child presenting with sudden onset of pain, swelling and limited movement in the affected limb. Based on experiences in the developing countries where improper differential diagnosis of the acute limb and delays in proper treatment has had catastrophic effect –children developing osteomyelitis resulting in bone necrosis. In osteomyelitis, clots formed from infective bacteria block the small bone canaliculi comprising of a rich network of blood supply. The damage or occlusion to the blood supply will results in bone necrosis. The early diagnosis and treatment of osteomyelitis prevents bone necrosis. Taking these statements into consideration, it is a safe and wise option to treat initially all acute limbs as osteomyelitis until a proper differential diagnosis is established or osteomyelitis is excluded. Learned from experience is the fact that an improper differential diagnosis of the acute limb and delayed adequate treatment has a catastrophic effect in osteomyelitis causing bone necrosis. It is cost effective and more humane to treat initially all cellulitis in children as osteomyelitis than to diagnose cellulitis and spend more money treating chronic osteomyelitis.

Differential diagnosis:
• • • Cellulites blisters with necrotic skin changes later (see Cellulitis, chapter 6.2); Pyomyositis tender swelling usually confined to one muscular compartment (see Pyomyositis, chapter 6.2); Osteomyelitis tenderness around the affected bone (see Osteomyelitis, chapter 10.1); particularly missing early diagnosis and proper treatment (antibiotic I.V. and drainage within 48 hours from the onset) may result in irreparable damage to the affected bone;

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• • •

Septic arthritis - maximal inflammatory changes and tenderness over the joint, tender swelling over joint, painful joint movement (see Septic arthritis, chapter 10.2); Incomplete fracture - minimal swelling, tender ‘loco’ fracture; Bone tumour (more chronic onset, pain increases at night, X-ray).

6.5 ULCERS

A

n ulcer is any breach in the epithelial surface resulting from either loss of skin or mucous membrane. Ulcers are especially common in the lower limbs and have a number of different aetiologies. Ulcers can be classified into acute and chronic or as non-specific, specific (TB or syphilitic), and malignant. In PNG there are five common ulcers. TROPICAL ULCER They are the most common type of ulcers seen in the tropic. Most characteristic clinical feature is its localization on the leg between the knee and ankle, usually on the anterior aspect. The causative micro-organisms are Vincent’s and fusiform bacteria (both are penicillin-sensitive). Tropical ulcers develop through three stages: Stage One: A pustule or small infected cuts (often from sharp grasses). Stage two: It develops rapidly for several weeks. A bloody discharge covers the necrotic skin floor and the surrounding skin is swollen and tender as in cellulites. The ulcer presents with a raised, thickened and slightly undermined edge. After about a month it starts healing or goes to third stage of non-specific chronic ulcer. Stage three: Chronic ulcer lasting for 10 or 20 years may develop into skin cancer (squamous cell carcinoma).

Treatment
• • • • At the early stage of tropical ulcer, amoxicillin may be given for 5 days (see dosage under Antibiotics, chapter 16.2). Necrotic skin can be separated faster by surgical debridement or encouraged to separate spontaneously by the use of saline dressings. When the wound develops clean granulation (pink) tissue and if the size of skin defect is greater than a Kina coin – about 3 cm in diameter, consider split skin grafting. If the ulcer is small, dress it with paraffin gauze; After skin grafting give amoxicillin for five days (see dosage under Antibiotics, chapter 16.2) and advice patient to stay in bed for 7 days. Early walking can cause graft failure. xciv

•

Chronic leg ulcers should be referred for specialist consultation at a surgical clinic.

MYCOBACTERIUM ULCERANS ULCER (MBU, Buruli ulcer) The number of cases is increasing worldwide, especially in the African countries affected by AIDS. In PNG it is regularly reported in the Sandaun, Oro, Western, and Central, and less commonly in other provinces. The causative bacteria live in the salivary glands of tiny water insects inhabiting shallow still waters. After the insect bites, the organism penetrates into subcutaneous tissue where it multiplies and produces a toxin causing massive tissue necrosis.

Clinical presentation
• • Early it presents as a pimple or papule, then it forms abscess which breaks spontaneously; The characteristic features of the MBU ulcer are o Painless ulcer; o Markedly undermined edge; o Central part can be covered with a white slough or granulation; o It may occur anywhere in the skin; o It can be confirmed by scrapping from granulation under the undermined edge from which AFB can be found. The techniques of staining differ slightly from the AFB for Tuberculosis.

Treatment
 Curette away all the granulation tissue taking special care to debride properly the under surface of the undermined skin;  Excise only bloodless free edge of the ulcer;  The wound should then be dresses and firmly bandaged;  After few days the undermined skin usually sticks to the underlying tissue and the centre is ready for grafting;  If there is a large skin defect over the joints it should be referred to a surgical unit; if the area for grafting is small, your grafting can be performed in a Health Center. If grafting fails, curettage and grafting has to be repeated.  If the ulcer is near the joints, proper splinting and early exercises is recommended.

MALIGNANT ULCERS (Majorin ulcer) Majorin ulcer develops in post-burn scar or chronic tropical ulcer of more than 10 years. It is a slow growing skin cancer and after a long time period can have metastases to lymph nodes. The characteristic clinical appearance of a malignant ulcer is a raised edge or at the late stage, a raised granulation tissue all over the ulceration area. When

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you suspect malignant ulcer, refer the patient for biopsy and surgical treatment. If confirmed Majorin ulcer, the patient will require amputation. TROPHIC ULCERS (planatar ulcer) [trophe in Greek is nutrition] Impairment to tissue nutrition is caused by ischemia and impaired nerve supply. The common causes of nerve damage in the feet are diabetes, leprosy, and other neurological disorders. In the anaesthetized feet repeated injury is caused by recurrent crushing of the soft tissue between the skin and the bone and subsequently ulcer develops. These ulcers are generally painless.

Treatment
A. Acute ulcers (hot ulcers) – characterized by swollen, warm and sometimes painful foot: • Rest and elevate the foot; • If there is cellulitis of the surrounding skin or signs of infection (fever) give antibiotic (see Cellulitis, chapter 6.2). B. Chronic or cold ulcer • Soak daily to soften the hard skin; • Scrape or cut off regularly the excess callus; • When the discharge stops and ulcer is clean. At this point you can apply a well moulded, lightly padded, below-knee walking cast for 6 weeks; • If there is no healing after the cast, trim the hard callus again and reapply cast for another 3 weeks; • When you remove cast, warn patient about consequences of early excessive walking, which can result in dislocation, fracture (because of weakened bones) or neuropathic foot. Advice the patient to gradually increasing the intensity of the walking exercises such that normal activity is resumed in 10 days. • Always wear suitable footwear which should protect the foot, to prevent the ulcer from recurring.

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Prevention of ulcers in an anaesthetized foot
Anaesthetized foot simply means that the foot has lost all modalities of pain sensation, a body protective mechanism to injury. For this reason alone it is important to protect the foot from all potential injuries. This is commonly seen in Diabetes, Leprosy and other neuropathic disorders. ⇒ Wearing footwear to prevent the feet from injury. No barefoot walking should be allowed; footwear should be supplied to prevent foot injury or ulcer formation, sport shoes or adjustable sandals padded with microcellular rubber would be suitable. ⇒ Inspect your feet daily to treat any damage regardless of how small it may be. ⇒ Any so-called “hot spot” must be treated seriously by resting the limb. ⇒ Any infected wound (even a small one) should be dressed, rested, give antibiotic (see Antibiotics for cellulites in chapter 16.2) and if there is no improvement in 2 days referred to medical officer. ⇒ If patients with chronic plantar ulcer are not on leprosy treatment, check for the other signs of leprosy, take biopsies and do skin scraping.

YAWS Yaws are more common among children and young people (5 - 15 years). The causative bacterium is present in the discharge from the yaws ulcers.

Clinical presentation
• • • • • • • • Skin ulcer with raised edges, reddish brown appearance with yellow crust; It is localized typically on the leg, sometimes on face or buttocks, Healing is slow and takes months

Treatment
Give a single dose of long-acing penicillin – Benzathine Penicillin 2,400,000 units I.M.; Treat all household contacts even if they have no symptoms; For those allergic to penicillin, give Doxycycline 100 mg bd for 7 days Apply a wet dressings; If ulcer with granulation is larger than 1 Kina coin, consider skin grafting.

SINUSES A sinus is a blind track leading from the skin or mucosa into deeper tissues that may or may not discharge fluid. It is not a specific disease per se but describes multiplicity of conditions that have canals that links a disease process with the outside exiting through the skin. The commonest causes of sinuses are: ♦ Foreign body (wood, material, even surgical stitch); ♦ Osteomyelitis (refer to hospital); xcvii

♦ Tuberculous lymphadenitis (it is a frequent cause of sinus on the neck); biopsy should be done to confirm diagnosis; ♦ Old inadequately drained abscess; enlarge opening and curette the abscess; ♦ Actinomycosis is caused by a Gram-positive bacillus that lives in the mouth as a harmless microbe. Carious teeth and trauma predisposes to the development of actinomycosis. It presents clinically as a hard induration with sinuses discharging pus with yellow particles called ‘sulphur granules’.

Treatment
Antibiotic of choice is Benzyl penicillin 4-mega units daily given until signs of disease have disappeared. Alternatively Doxycycline 100 mg bd can be given.

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7.0 ACUTE ABDOMEN

T

he crucial skill is the ability to discern if the patient with acute abdominal pain really has acute abdomen and to come to a provisional diagnosis through accurate differential diagnosis. What is the most important practical aspect of abdominal emergencies is the early diagnosis and treatment and that alone has been a major factor in reducing mortality. There are few cardinal symptoms and signs signalling abdominal emergency: 1. Abdominal pain 2. Persistent vomiting 3. Diarrhoea or constipation 4. Abdominal tenderness 5. Abdominal rigidity

7.1 CLINICAL PRESENTATION
H istory taking A detailed and history is essential in order to avoid serious mistakes. In female patients you must include a gynaecological history with question about last normal menstruation, contraceptives and vaginal discharge. 1. Abdominal Pain Acute abdominal pain is one of the most common symptoms among patients with surgical abdominal conditions. • All severe abdominal pain lasting more than 6 hours should be suspected of potential abdominal emergency. • Establish whether the pain is still present, becoming worse, or subsiding. If pain is persistent or is becoming worse, transfer immediately to hospital. • Intermittent colicky pain is characteristic of obstruction of tube organs (e.g. intestine). • Colicky flank pain radiating to the groin or thigh is typical for renal colic and is excruciating. This pain responds well to antispasmodics such as Buscopan. • Constant pain indicates organ inflammation and permanent pain of sudden onset is associated with hollow organs perforation (e.g. peptic ulcer perforation). • Pain in the right upper quadrant radiating to the back and to the right shoulder blade probably originates from gall bladder or bile tracts. • Central umbilical colic is usually intestinal. 2. Vomiting • Clear vomit (no bile content) may indicate gastric outlet obstruction. • Dark green, or feculent, or foul-smelling vomits often indicate a distal bowel obstruction. xcix

• •

Coffee ground appearance or bloody vomiting indicates bleeding from the upper part of gastro-intestinal system. Vomiting is a non-specific sign of many other diseases and not specific to acute abdominal diseases.

3. Diarrhoea and Constipation Diarrhoea is most commonly caused by gastro-enterocolitis, but rarely is it a symptom in acute abdomen. Red jelly (currant) diarrhoea indicates intussusception. Acute appendicitis or pelvic abscesses rarely cause diarrhoea. Constipation is a result of paralytic ileus occurring in most acute abdominal diseases. Constipation is also an important symptom of mechanical bowel obstruction.

Clinical examination
   Asses the general condition - look for signs of dehydration, shock, sepsis and anemia. Fast pulse rate usually indicates decreased blood volume from dehydratation, sepsis or bleeding. Increased respiratory rate is a non-specific sign and can indicate shock. It is also seen in pulmonary disease, severe anemia or advanced metabolic changes (metabolic acidosis) in acute abdomen. Fever is not a characteristic feature of acute abdomen. Patients with acute abdomen can have normal or raised temperature. Malaria in tropics is a common cause of fever and sometimes can mimic acute abdomen. Always treat for malaria or check blood slide for malaria in all patients with fever.





Abdominal examination

• Inspection If there is an abdominal scar, bowel obstruction due to adhesions must to be considered. The common causes of abdominal distension are distended bowels, stomach, urinary bladder, ascites (fluid), tumour or pregnancy. An asymmetrical swelling is very suggestive of a tumour. • Auscultation should last for at least 3 minutes. Auscultation is useful only in bowel obstruction where increased, high-pitched (metallic) sounds are signs of mechanical bowel obstruction. Increased bowel sounds occur also in gastro-enteritis. Absence of bowel sounds is typical for peritonitis, but is not specific for acute abdomen. It can be caused by extra-abdominal diseases. • Percussion Shifting dullness can help in differentiation between gaseous bowel distension and free peritoneal fluid. • Palpation

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Ask patient to cough before palpation of abdomen. Localized cough tenderness is an important sign of peritoneal inflammation. Superficial gentle palpation should begin far from the area of maximal tenderness. Elicited rebound tenderness is a sign of peritonitis. Symmetrically placed both hands can detect unilateral muscle guarding. Board-hard abdomen is a sign of diffuse peritonitis. Deep palpation serves to detect enlarged organs and tumours. It is not recommended in patients with peritonitis because of pain aggravation. All women with signs of acute lower abdominal pain should undergo bimanual gynaecological examination. Failure to examine the groins can lead to a misdiagnosis of a strangulated hernia. Examination of male external sexual organs can detect testicular torsion or an infection (epididymo-orchitis), often with scrotal pain radiating to lower abdomen. Localized rigidity accompanying localized tenderness is the most reliable sign of peritoneal inflammation. Majority of abdominal surgical emergencies (acute abdomen) can be classified into three groups: • Peritonitis • Bowel obstruction • Bleeding

General management of acute abdomen
♦ ♦ ♦ ♦ ♦ ♦ If a patient is dehydrated – give I.V. fluid (Normal Saline or Hartman’s solution) Give I.V. antibiotic chloramphenicol (see dosage under Antibiotics, chapter 16.2). Arrange urgent transfer to hospital. Fast the patient (Nil by mouth) in preparation for urgent operation. Give Pethidine 1mg/kg I.M. (or slowly half of this Dosage I.V.). There is a common but wrong believe that narcotics such as morphine or pethidine cannot be given to a patient with acute abdominal pain. This is not true, scientific studies indicated the opposite. ♦ Normal doses of pethidine do not interfere with diagnosis and assist a lot in palpation to feel abdominal masses by reducing pain and rigidity.

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7.2 PERITONITIS

I
•

t is the most common form of secondary peritonitis caused by inflammation of an abdominal organ, such as appendix, gall bladder, intestines or pelvic inflammatory disease. Rarely does the spread of bacteria from distant places develop in the peritoneum by blood e.g. tuberculosis (chronic peritonitis) or pneumococcal infection.

Clinical presentation
Severe and constant abdominal pain, made worse by coughing, breathing and moving. • Vomiting may accompany pain. • Abdominal tenderness, rebound tenderness, and cough with tenderness. • Guarding and rigidity is common (can be absent in pelvic inflammation). • Rapid pulse, but temperature changes are variable; it can be subnormal or increased. • Absence of bowel sounds (may be present at the beginning of peritonitis). When tenderness and guarding are localized it is referred to as localized peritonitis but if it is generalized it is classified as diffuse or generalized peritonitis.

Management
See General management of acute abdomen, chapter 7.1.

7.3 INTESTINAL OBSTRUCTION

I

ntestinal (bowel) obstruction is defined as blockage of the intestine at any level with acute o chronic presentation.

Classification of the causes of intestinal obstruction
 Intraluminal - the blockage is inside the lumen, e.g. impacted faeces, foreign bodies, a mass of tangled ascaris worms, gall stone, flatulance etc.;  Intramural - lesion in the intestinal wall, e.g. tumour, post-inflammatory strictures caused by TB , pigbel, typhoid ulceration;  Extraluminal - pressing on the intestine from outside; e.g. post-operative adhesions, strangulated hernia and tumour of adjacent organs.

Clinical presentation
• • • • • Pain Abdominal distension Vomiting Constipation Late: signs of dehydratation, rapid pulse, rapid respiratory rate cii

Pain usually starts as colic pain. Initially it is poorly localized, later becoming more permanent and localized. Colic is caused by periodic contractures of the intestinal muscles attempting to push the contents through obstructed segment, whereas the constant pain experienced is caused by progressing inflammation and peritonitis. Distension is caused by secretion and accumulation of alimentary fluids in the intestine content above the obstruction. The higher the obstructed segment the minimal is the distensions or may even be absent. Vomiting occurs when intestine peristaltic waves being unable to push the intestinal content down returns it backwards (retrograde) into the stomach and is emptied by vomiting. Constipation is the inability to pass stools. It is important sign of bowel obstruction; however remember that when obstruction is high a patient can still be passing bowels content for 2-3 days.

Management
• • • • Refer to the general management of acute abdomen (chapter 7.1). A patient with bowel obstruction is usually severely dehydrated: adults would requires 2 litres of Normal Saline I.V. fast then continue I.V infusion until urine output is between 1 and 2 ml/kg/hour. Place a naso-gastric tube in the stomach and patient should be fasted (nil by mouth). Transfer immediately to hospital.

7.4 GASTROINTESTINAL BLEEDING
T his can be divided into upper and lower gastrointestinal bleeding. UPPER GASTROINTESTINAL BLEEDING Severe bleeding may be due to: • Peptic ulcer (duodenal or gastric); • Gastric erosions often caused by anti inflammatory analgesics such as Aspirin, and Indocid; • Oesophageal varices (in cirrhotic liver); • Cancer; • Others.

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Clinically upper gastro- intestinal bleeding manifests as coffee ground or bloody vomits, or/and melena – black stools. Chronic bleeding leads to anaemia, while severe acute bleeding may result in haemorrhagic shock.

Management
     Connect I.V. line and start fluid resuscitation; for an adult give fast Normal Saline 2 litres 20mls/kg in children; Insert a naso-gastric tube to control bleeding; Sedate patient by giving pethidine (1mg/kg I.M.); if blood pressure drops below 90 mmHg, do not give pethidine or morphine; Can give antacids, e.g. Gastrogel; Transfer to hospital.

LOWER GASTRO-INTESTINAL BLEEDING It is characterized by passing large amount of blood in stools. Severe bleeding may be caused by • Intussusception (in children) • Amoebic colitis • Typhoid • Tumour (cancer or polyp) • Others

Management
The management is similar to the upper gastro-intestinal bleeding except for antacids – it is not required. .

7.5 SOME COMMON CAUES OF ACUTE ABDOMEN
A CUTE APPENDICITIS Appendicitis is a common cause of abdominal emergency and is noted with increased frequency in PNG. The presentation of appendicitis is not always classical and therefore a high index of suspicion is necessary. It affects any age group but is most common in adolescence and young adult. Generally it occurs from obstruction of the appendiceal lumen by lymphoid hyperplasia caused by inflammation or an impacted fecalith.

Clinical Presentation
History. Classic history is that pain starts in the periumbilical or epigastric area, and then migrates to right lower quadrant. Nausea and vomiting often occur after the onset of pain. Constipation is typical, but diarrhoea is common in children. Presentation is

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more likely to be atypical in the very young, very old and pregnant patients. Always suspect appendicitis in any patient with abdominal pain.

Physical examination Low-grade temperature is common (below 38 degrees C). High temperature is not common unless perforation has occurred. Abdominal examination should reveal right lower quadrant pain, possibly with rebound tenderness or guarding. Psoas sign (pain on active elevation of the legs) may be present as well as the obturator sign (pain on internal and external rotation of the hip. A late manifestation is an ill-defined fixed and tender mass (appendix mass) can be felt. If treated early, before rupture the prognosis is very good. However if the appendix ruptures, it will lead to generalized peritonitis increasing chance of death ten times followed by increasing number of serious complications. In a strong adult, the omentum as a natural protection will wall off the inflamed appendix forming appendicular mass. Since children have underdeveloped omentum they are at a much grater risk of spreading infection from the ruptured appendix all over the abdominal cavity. The differential diagnosis includes mainly gynaecological diseases (pelvic inflammatory disease, ectopic pregnancy), gastro-enteritis, right sided pyelonephritis and mesenteric adenitis. In spite of diagnostic development in the best world centres about 20% of cases operated for appendicitis turn out to be something else. However, in order to prevent the consequences of missed appendicitis and perforation, high level of suspicions must always be maintained.

Management
• • • • • Keep the patient fasting (nil by mouth); If dehydrated give I.V. fluids; Give antibiotic, chloramphenicol I.V. (see dosage under Antibiotics, chapter 16.2); Refer to hospital or observe doubtful cases overnight; A patient with appendicular mass can be treated as follows: o In a strong adult give chloramphenicol 1g, I.V./I.M. for first few days then change to oral for up to 10 days; o Bed rest; o Light diet; o Observation for few days in a Heath Centre or a Hospital; o If there is deterioration of vital signs, spiking temperature continues, or abdominal pain increase refer to hospital; o Children or old patients, or an adult in serious condition with an appendicular mass should be referred to hospital.

PIGBEL (Enteritis necroticans) cv

Prior to the introduction of pigbel vaccine, pigbel was commonest cause of death in children in the highlands of PNG. Presently, there are still isolated cases observed in the highlands. It is caused by toxins produced by the bacteria Clostridium perfringens type C.

Clinical Presentation
• • • • • • It usually affects children after ten years of age; Severe abdominal pain (starting up to five days from eating a high protein meal, usually pig meat); Often accompanied with abdominal distension; Black-flecked vomit; Mild, sometimes bloody diarrhoea; Toxic – looks sick with fast pulse (in severe cases).

Differential diagnosis includes gastro-enteritis (a lot of diarrhoea and little of pain), bowel obstruction, and peritonitis.

Management
♦ ♦ ♦ ♦ ♦ I.V. fluid rehydration; Give Benzyl penicillin (crystalline) and chloramphenicol I.V. or I.M.; Albendazol orally once then nil by mouth; Insert nasogastric tube and leave on free drainage; If child gets sicker or no improvement within 2 days refer to a surgeon.

The acute abdomen in the course of tropical diseases
A variety of bacterial and parasitic diseases are known to cause acute abdomen. TYPHOID FEVER Peritonitis can develop in the course of typhoid fever due to perforation of small bowel. If peritoneal signs develop in the course of typhoid start fluid resuscitation, continue chloramphenicol and refer urgently to hospital. AMOEBIASIS Amoebic colitis typically manifests as left abdominal pain with tenderness over left colon associated with diarrhoea (sometimes bloody). Rarely can perforation of colon or rupture of liver abscess produce peritonitis. If signs of peritonitis develop, start with fluid resuscitation, give chloramphenicol and refer urgently. MALARIA Malaria rarely can it mimic acute abdomen with symptoms of vomiting, abdominal pain, diarrhoea and very tender upper abdomen). To confirm malaria each patient with high temperature must have a blood slide done.

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MENINGITIS Occasionally a child with meningitis is referred with an acute abdomen. If you take your time and examine the patient systematically you can avoid this mistake when you check neck stiffness a sign of meningeal irritation in children with fever. PERFORATION OF PEPTIC ULCER

Clinical Presentation
• • • • Sudden onset of generalized abdominal pain. A patient can be in shock, with a rapid pulse. On abdominal examination there is board-rigidity. The abdomen does not move on inspiration.

Management
♦ I.V. fluid for rehydration; ♦ Pethidine (1mg/kg I.M.); ♦ Give antibiotic preferably chloramphenicol I.V. (see dosage under Antibiotics, chapter 16.2); ♦ Insert a nasogastric tube and leave on free drainage; nil by mouth; ♦ Refer urgently to hospital. STRANGULATED HERNIA An abdominal hernia is a protrusion of intra-abdominal organs or contents of the abdomen through an opening or a weakness in the abdominal wall. The most common is the inguinal hernia which can be direct (above the inguinal ligament or indirect below the inguinal ligament through the inguinal canal. If it can be easily reduced back into the abdomen, it is referred to as a reducible hernia and if it cannot be reduced, and non-tender we are dealing with an irreducible (incarcerated) hernia. When a hernia cannot be reduced and becomes tender, it is called strangulated hernia. Any inguinal hernia that is not reduced can easily become strangulated and lead to bowel obstruction if the content of the hernial sac is bowel. If left untreated, the blood vessels become obstructed resulting in intestinal necrosis.

Clinical Presentation
• • Tender irreducible abdominal bulging; Clinical picture or presentation of bowel obstruction (abdominal pain, vomiting, constipation and abdominal distension).

Management

♦ I.V. fluid infusion; ♦ Antibiotic chloramphenicol I.V./I.M. (see dosage under Antibiotics, chapter 16.2); ♦ Pethidine 1mg/kg I.M. cvii

♦ Up to 6 hours from the onset of pain and 20 minutes after pethidine injection, gentle attempt can be made to push the protruding hernia back into the abdominal cavity. If you succeed to reduce hernia and achieve pain relief, you can wait over night with referral. Often tilting the patient’s bed head down assist with the reduction of the oedema and assist with the manual reduction of the hernia. ♦ If reduction fails, refer urgently to hospital.

Gynaecological diseases causing acute abdomen
ACUTE PID (Pelvic Inflammatory Disease) Various micro-organisms contracted through sexual contacts cause Acute Pelvic Inflammatory Disease. It is a common disease affecting women in reproductive age.

Clinical Presentation
• • • • • Gradual onset of lower abdominal pain, often with a history of previous lower abdominal pain; High fever; Lower abdominal tenderness, often with guarding; On vaginal examination – very tender fornices and uterine tenderness when tilting the cervix; There is generally pussy vaginal discharge.

Treatment
 In less severe cases give Amoxicillin 2g oral stat + Probenecid 1g oral stat + Augmentin/Amoxyclav 2 tabs +Azitromycin 1g oral stat + Tinidazole 1g bd for 3 days. If the above drugs are not available, see Standard Treatment Book for Adults for alternatives. In severe cases with a palpable mass, peritonitis, or persisting fever refer to hospital.

 

RUPTURED ECTOPIC PREGNANCY To rule out ectopic pregnancy, always remember to ask the patients about her last period. Bear in mind that a normal menstrual history does not necessarily exclude ectopic pregnancy; however missing a menstrual period should raise suspicion of an ectopic pregnancy. A urine test for pregnancy, if available, will be very useful.

Clinical presentation
• • • • History of missing period; Sudden lower abdominal pain or previous colic pain in one side of lower abdomen; sometimes pain is referred to the shoulder; Signs of internal bleeding (painful abdomen + signs of hemorrhagic shock); PV examination can often reveal drops of blood and very tender cervix; cviii

•

Sometimes anaemia with tender one side of lower abdomen or mass felt may be the only clinical presentation.

Management
 Start I.V. fluid resuscitation (Normal Saline or Hartman’s solution);  Refer urgently to hospital.

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8.0 ANAL PAIN

A NAL FISSURE An anal fissure is a crack in the anus most commonly as a result of constipation. The patient presents with a history of pain on defecation and sometimes few drops of the blood on the stool surface. Inspection of the anus will reveal linear tear at posterior aspect of the anal mucosa often associated with the skin tag (sentinel pile). Although less common, fissure may presents as a painless non-healing wound that bleeds intermittently. Physical examination by gentle traction on the buttocks will show the anus sufficiently to reveal the fissure. Treatment of underlying constipation with sitz-bath and high fibre diet is sometimes sufficient in healing the fissure. In persistent fissure refer to a surgeon for further treatment. Topical agents or operation usually cures the condition. In the non-healing fissure a biopsy should be taken to rule out underlying disease such as TB or cancer). PERI-ANAL ABSCESS Peri-rectal abscess and fistula is most commonly connected with cryptoglandular infection at the ano-rectal junction. Affected patient complains of fever, severe throbbing pain around anus, constipation and urine retention. It presents as tender, swollen sometimes with fluctuation area in the vicinity of anus. Treatment comprises early incision and drainage even without fluctuation (see Figure 6.1-3) with antibiotic. If the abscess is not drained surgically or spontaneously, the infection can spread rapidly causing extensive tissue loss or even life-threatening sepsis. About 50 % of peri-anal abscesses are complicated by chronic anal fistula. ANAL FISTULA The infection generally starts in the rectal crypts and spread outside forming a fistula through the skin. Very rarely systemic disease such as TB or cancer can cause perianal fistulae and therefore tissue biopsy should be taken for histopathology. Treatment is operative. PILONIDAL SINUS It presents as a sinus or abscess between the buttocks. It affects hairy people and good hygiene will prevent its occurrence. Treatment is surgical HAEMORRHOIDS (Piles) External haemorrhoids may become thrombosed, leading to acute and severe anal pain. On examination a purplish, swollen, tense and tender perianal subcutaneous lump is easily visible. In thrombosed external haemorrhoids, excisions within 48 hours from the onset gives immediate relieve of pain.

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Internal haemorrhoids are felt only on rectal examination as protruding mucosa. They are usually painless, but can cause bleeding or may prolapse. They are classified as follows First-degree - bleeds Second-degree - bleeds and prolapses but reduces spontaneously Third-degree - bleeds prolapses but require manual reduction Fourth-degree - bleeds, incarcerate, and cannot be reduced First and second-degree usually need only medical treatment. These include high fibre diet and changing daily routine by adding more exercises. Third and fourth-degree, as well as complications such as bleeding, pain, necrosis, and mucous discharge require surgical treatment. RECTAL PROLAPSE Rectal prolapse is not uncommon among children. However in children it is a selflimiting condition. Two predisposing factors constipation and diarrhoea are associated with straining at stool. An important cause of rectal prolapse encountered in the rural and remote regions is massive Trichuris trichiura (threadworm) infection. Amongst the rare causes are paralysis of the anal sphincter (e.g. meningocele), malnutrition, and previous anorectoplasty. In differential diagnosis consider a rectal polyp, the head of intussusception, and external haemorrhoids.

Treatment
Regulation of diarrhoea or constipation continued for several weeks can eliminate the problem. When prolapse is failing to return after defecation strapping of the buttocks together can be helpful. For persistent prolapse operation can cure the problem. In patients with threadworm infection commence on Albendazol.

CANCER OF THE RECTUM Rectal cancer constitutes about 30% of all colorectal cancers.

Clinical presentation
• Rectal bleeding • Alteration of bowel habit (constipation, diarrhoea) • Narrow stools (pencil-shaped stools) • Pelvic or sacral pain (late) • Rectal exam will usually reveal tumour or infiltrated ulceration. Treatment is surgical so refer a patient to a surgeon. Sacrococcygeal tumour (Tumour in the sacral area)) in a neonate requires early operation because further delays will increase the chance for malignant transformation.

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9.0 CONGENITAL ABNORMALITIES AND SURGICAL REFERRAL

U rgent congenital abnormalities The aetiology of congenital abnormalities is complex; some are inherited while others are caused by diseases or drugs in early pregnancy. Various congenital abnormalities require correction at different stages of the child’s growth. It is important to be familiar with the deformities and be able to differentiate between those that require an urgent transfer and the others that can wait.

A. Intestinal malformations
All of the following abnormalities require urgent referral to a surgeon. Manage all of patients with the following congenital intestinal malformations as for bowel obstruction before transferring the baby. 1. Insert naso-gastric tube 2. Give oxygen (2 litres/ min) 3. Start on I.V. fluids 4. Keep the baby warm 1. IMPERFORATE ANUS This condition should be detected by routine examination of anus during neonatal ward rounds. Its presentation varies from a small opening inside the vagina or in the midline underneath the base of penis to a complete occlusion of the anal opening. The baby should be treated as a bowel obstruction patient and transferred to a surgeon within 48 hours. 2. INTESTINAL OBSTRUCTION It has various causes and develops at different periods of time from the time of birth.

Clinical presentation
• • • • Abdominal distension increasing gradually, but the absence of it does not exclude a high obstruction; Vomiting - increasing amount, changing content from light to dark green, and late faecal vomiting (can be absent in high obstruction); Little or no faeces; Visible peristalsis. Treat as a bowel obstruction (see above) and transfer urgently to a surgeon.

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3. CONGENITAL PYLORIC STENOSIS (obstruction) It is four times more common in male than female.

Clinical presentation
• Vomiting o The baby vomits feeds but no bile (nonbilious, white vomits); o It starts vomiting usually between 3 and 6 weeks of age. o The vomiting is forceful and described as ‘projectile’. • The stomach is distended after the feeding and sometimes peristaltic can be visible before vomiting. • Sometimes an olive shape nodule can be palpated in the right upper abdominal quadrant. Start treating as a bowel obstruction and refer to a surgeon for operation. 4. HIRSCHPRUNG DISEASE It is caused by lack of the nerve supply to some segments of large bowel and rectum resulting in segmental bowel constriction and thus obstruction.

Clinical presentation
• Intestinal obstruction (acute form) - Failure to pass meconium within the first 24 hours of life; - Abdominal distension; - Vomiting. • Severe constipation (chronic form) If in an acute presentation, treat as intestinal obstruction and refer urgently to a surgeon. 5. ABDOMINAL WALL DEFECTS Gastroschisis is a condition where the intestine herniates through a small defect in the abdominal wall lateral to umbilicus; they are not covered by a sac. Omphalocele (exomphalos) the intestine herniates through the umbilicus and is covered only by amniotic membrane fused with peritoneum. In both conditions wrap the eventrated (prolapsing) intestine with sterile dressing soaked with Normal Saline then cover the dressing with an opened plastic bag from the Normal Saline pack. Treat as intestinal obstruction and refer immediately to a surgeon. Umbilical hernia presents as umbilical bulging covered by skin. Most umbilical hernias close by the end of the first year. If it does not, do not be alarmed; refer for operation when the child is 5 years old.

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6. DIAPHRAGMATIC HERNIA Diaphragmatic hernia is a serious condition in which abdominal content (stomach and intestines) herniates into the left chest pressing on the lungs leading to a severe respiratory distress.

Clinical presentation
• • • • Respiratory distress (poor Apgar scores, frequent respiratory rate, chest retractions, cyanosis); On auscultation bowel sounds may be present on the left chest; Breath sounds can be diminished on both sides but usually more reduced on the affected side; Heart sounds may be hared more on the right side.

Treat as intestinal obstruction (see above) and refer urgently to a surgeon. The child should be kept in an upright position – supine or head down posture my make breathing more difficult.

B. Respiratory malformations
Respiratory malformations are caused by various pathologies. Sometimes large neck tumours or cysts (cystic hygroma) may cause respiratory obstruction. This group of malformations presents with respiratory difficulties especially on feeding. When a child has noisy breathing, transfer to hospital urgently.

Non-urgent congenital abnormalities
CLEFT (HARE) LIP AND CLEFT PALATE Cleft (hare) lip and palate are the most common congenital abnormalities and may occur either together or separately. All these children need thorough paediatric assessment to exclude other associated abnormalities. If the cleft is incomplete and the mother is not able to breast feed, she should resort to spoon-feeding. The lip is ready for repair when the baby is about 5 kg (5-6 months); the palate is best repaired at the age of about 12 -15 months. HYDROCEPHALUS Congenital hydrocephalus is due to the obstruction of the cerebrospinal fluid filling up the ventricles and grossly enlarging the cranial cavity. Clinical presentation: large head with bulging fontanelle, separated skull suture lines and prominent forehead, relatively small face with sunken eyes. The child is often irritable and may vomit. Because in PNG up to 60 per cent of hydrocephalus is associated with TB, give first a TB treatment trial. After four week trial of TB

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treatment, measure the head circumference. If the circumference is increasing more than 1.2 cm per month, refer the patient to a surgeon for possible operation. MENINGOCOELE Meningocoele is a congenital deformity consisting of a herniation of the intracranial structures from the cranial cavity. Myelomeningocele is a herniation of spinal neural structures along the spine.

Clinical presentation
It presents as a bulging in the midline of the head and can occur between eyes, on top of the head, in the occipital area and in the lumbar region. The bulge increases in size when the baby cries. Refer to a surgeon when convenient. SUBGALLEAL CYST (Odeka’s cyst) It presents as a soft egg-shaped swelling over the anterior fontanelle. The condition is common in many developing countries. It can be excised when baby is over 1 year old. SACROCOCCYGEAL TERATOMA The sacrococcygeal teratoma starts initially as a benign tumour, which in short time may become malignant. Therefore delaying the operations or an incomplete excision can worsen the outcome. It presents as a tumour in the sacrococcygeal area but rarely may grow inside the pelvis and can be palpated as a tumour in lower abdomen, sometimes associated with constipation or urinary retention. INGUINAL HERNIA Inguinal hernia presents as swelling above the inguinal ligament sometimes descending to the scrotum. If it is easily reducible, operation can wait until baby is 1-2 years old. If strangulations occur (see Hernia strangulation, chapter 7.5), refer immediately to a surgeon. HYDROCELE Hydrocele is recognized when there is a painless swelling in one side of the scrotum with well-defined upper border and transillumination is present. If it does not disappear in 12 months, it can be corrected by operation. UNDESCENDED TESTIS Undescended testis is diagnosed when testis cannot be pulled to the bottom of the scrotum. It should be corrected surgically by 1 year of age. TORTICOLLIS (wreck neck) Torticollis is a characteristic posture, with the face rotated away from the affected side and the head tilted towards the ipsilateral shoulder. It can be a congenital lesion resulting from fibrosis and shortening of sternocleidomastoid muscle or acquired through an infection or trauma).

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Early recognition and prompt physiotherapy (strapping in a correct position) corrects 80 to 90% of this deformity. The remaining cases require surgical transection of the muscle.

CONGENITAL CLUB FOOT (talipes, PEV)
The club foot is turned inwards and is in plantar flexion. The abnormality can affect one or both legs.

Figure 9.0-1 Clubfoot

Diagnosis
Characteristic position with plantar flexion and inversion is often natural to infants. The criterion for diagnosis is the inability to make full dorsiflexion and eversion (in infant under 1 year old the little toe should touch the skin).

Treatment
Ideally treatment should begin within 1 week after birth. Primary management is conservative treatment: • Apply firm manual pressure to overcorrect the deformity (dorsiflexion at least up to 90° and eversion); try to obtain normal or close to normal position of the foot • No anaesthesia is required. • Then maintain the correction with Strapping or Padded plaster; • If after 4-5 month of such treatment the clubfeet are not corrected, refer for operation. • Early after the birth the child with clubfoot should be referred to a surgeon for assessment of extent of the deformity and advice on how to manage the patient.

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Method 1 It is the safest method and giving good results for mild deformities when parents are cooperative. Perform regularly four times a day manual manipulation on the clubfoot trying to place it in normal position as in Figure 9.0-2

Figure 9.0-2 Manual manipulation for talipes equino-varus

Method 2 This method can cause impairment of leg circulation, but if properly applied and supervised, it is pretty safe.

Figure 9.0-3 Strapping for talipes

• • • • • • •

• •

You can use Elastoplast Put pieces of cotton wool over child’s knee, over lateral malleolus and on the dorsal aspect of the foot A - Apply the first piece of strapping trying to place the foot in normal position; when this piece of strapping is firmly affixed, the foot should be in normal position. B – The second piece of strapping is applied. Put the third piece of strapping around the neck transversally; it will keep the two long pieces in place. Instead of Elastoplast you can use zinc oxide strapping; but before applying zinc oxide strapping you have to paint the skin with tincture of benzoin to make it sticky. Count the toes and check if they are pink and warm; if they become blue and cold it means that strapping has impaired blood supply. This can cause foot necrosis so remove the strapping and reapply them more loosely. Instruct parents on this basic observation in case this happens again. Elevate legs on pillow for few days Change strapping every 2 weeks

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•

When baby is 4 months and talipes are not yet corrected, refer to a surgeon for check up.

Method 3 This method carries the highest risk for serious complications, even for leg necrosis. Therefore whenever possible a child with talipes should be referred to a surgeon or physiotherapist to apply this plaster. It should be learned practically during residency in hospital. POP for talipes • Plaster for talipes is the alternative method, however more difficult technically. • No need for anaesthesia. • Apply a thin layer of cotton wool padding which should be cut narrow, around 2.5 cm wide, in order to avoid wrinkling. • Apply first the part of plaster below knee; use narrow around 2.5 cm wide POP rolls; if you don’t have narrow POP, you can cut them with a scalpel. • When the plaster is setting, manipulate the foot into the normal position. • If the tension does not allow you an adequate normal position, do not press too hard. • Do not press with single fingers on a setting POP because creating a depressed area can result in pressure sores. • When the plaster over the foot is set, apply the above knee part of cast. • The plaster must go to the thigh (above knee) with the knee flexed at 90; otherwise the child will be able to remove it. • All toes must be seen as pink and warm. • If they become blue and cold, cut all cast along to the skin. • Elevate legs for few days on a pillow. • Instruct parents about the signs of a tight plaster. If the child cries excessively or they notice blue and cold fingers they must go immediately to Health Center in order for the POP to be cut or soak and remove the POP. • Change plaster every 2-3 weeks at the same time repeating the manual manipulation. In the very remote areas POP can be changed every 4 weeks.

Figure 9.0-4 The cast for talipes equinovarus

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EXTRA DIGITS OR WEBBING BETWEEN FINGERS AND TOES They can be repaired in preschool period (4-6 years old). It is better to repair early before the child advances in the grades, in the hope that others do not ridicule the child in the school. CONGENITAL DISLOCATION OF THE HIP It is a rare condition in PNG. You can suspect congenital hip dysplasia (dislocation) when a baby has asymmetrical buttock creases. On examination restricted abduction in the affected hip can be noted. To check abduction flex the hips and push both legs laterally until they lay fat. If undetected early, in late presentation a child may be seen limping with a shorter leg. Refer to a paediatrician for further assessment. If a child with a limp does not improving after few weeks, the child should be send to a surgeon for further investigation. BOW LEGS AND KNOCK KNEES Most of bow legs will recover spontaneously. Refer to a paediatrician for further assessment and exclusion of rickets.

It is of paramount importance that all health workers in the rural and remote locations take time to examine all newborn babies at the health centre before they are discharged. By doing so, a lot of congenital problems, and other neonatal conditions will be detected early and either treated or referred to specialists for further advise.

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10.0 DISEASES OF BONES AND JOINTS

10.1 OSTEOMYELITIS
O steomyelitis is a serious pyogenic infection of bone. There are two main types of osteomyelitis: 1. hematogenous in which bacteria reach the bone through blood stream, affecting commonly children; 2. a micro-organism is infecting the bone through continuity from the wound as in a opened fracture or a bone operation The bones commonly affected are femur, tibia and humerus.

Pathophysiology
As the infection sets, the inflammatory process forms pus under the periosteum detaching it from the bone, cutting off the blood supply coming from periosteum. In developed osteomyelitis, clots formed from bacteria blocks the small bone canals, through which bone is supplied with blood. The damage to blood supply results in bone necrosis. Part of necrotic or dead bone is called sequestrum. In osteomyelitis early diagnosis and treatment prevents bone necrosis.

Fig. 10.1-1 The natural evolution of osteomyelitis

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Clinical presentation
Signs • Fever • Tenderness over the affected bone, usually near the end of the bone • Swelling • Warmer overlying skin • Limitation of movement or limping Symptoms • Sadden onset of pain - severe, unremitting, waking at night • Malaise • Vomiting • History of infection, trauma The early diagnosis and aggressive treatment of osteomyelitis prevents bone necrosis and further complications!

Differential diagnosis See a child with 'an acute limb', chapter 6.4 Treatment of acute osteomyelitis
Effective treatment should start as soon as possible 1. Antibiotic – for at least 6 weeks • Start giving antibiotic parenterally (I.V. or I.M.) then if temperature normalizes, follow orally; • Initially Flucloxacillin (Cloxacillin) (250 mg/kg per day divided into 4 doses); • If Flucloxacillin is not available – give chloramphenicol or erythromycin (see dosage under Antibiotics, chapter 16.2). 2. Accurate monitoring of temperature. 3. If there is no drop of temperature after 36 hours of antibiotic therapy the patient requires an operation. Refer to hospital. 4. All bony exploration should be left to a surgeon at hospital. 5. The affected limb requires rest ( apply backslab) and later in case of proven bone destruction on X-ray, supporting POP is applied to prevent pathological fracture. Often to keep the child in bed, skin traction is a good option. It take approximately 11 days to see any periosteal elevation on a X-ray to confirm your diagnosis

Chronic osteomyelitis
It is characterized by a sequestrum formation and presence of chronic purulent discharge over skin fistula (sinus). Acute flare-up subsides on antibiotics and rest. Abscess should be drained and in some cases a major operation is indicated to remove the sequestrum.

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10.2 SEPTIC ARTHRITIS (PYOGENIC/ INFECTIVE/ SUPPURATIVE ARTHRITIS)
P athology The bacteria that cause septic arthritis can reach the joint through three routes: blood, penetrating wound or from expanding osteomyelitis (children under 6 years of age).

Clinical presentation
• • • • • • Acute onset (or subacute) with fever and joint pain Swelling of the joint Warmed and sometimes reddened skin over the joint Restricted painful joint movements Aspiration of the joint may yield cloudy serous fluid or pus Present primary focus of infection, such as boil or penetrating wound adjacent to the affected joint

Differential diagnosis:
• • • Tuberculous arthritis - more chronic course, culture, X-ray, (see Tuberculous arthritis, chapter 11.3); Gouty arthritis - often affects the big toe’s joints, increased uric acid in serum; Acute osteomyelitis (see Osteomyelitis, chapter 10.1).

Treatment
Effective and prompt treatment is crucial for the preservation of the affected joint function. • Flucloxacillin (cloxacillin), if flucloxacillin not available - chloramphenicol or erythromycin. For the first few days better give antibiotic I.V. or I.M.; the antibiotic should be continued for a minimum of four (4) weeks (see dosage under Antibiotics, chapter 16.2); • Rest the joint by applying plaster splint or skin traction (for knee or hip). • If pus is aspirated from the joint, it may require arthrotomy (opening of the joint). In this case the patient should be referred. • Treat the primary focus of infection (boil or penetrating wound adjacent to the joint). • Aspirin or paracetamol can be given to reduce pain. • Refer to surgical unit if o deep joints e.g. hip are affected; it often requires operative opening (arthrotomy); o if there is no improvement after 5 days of treatment.

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The prognosis in septic arthritis depends on prompt treatment and the severity of the infection. It varies from an intact joint to complete joint stiffness (ankylosis). TROPICAL ARTHRITIS

Clinical presentation
• • • • • Affects usually young men Warm painful one or more joints Rarely fever On aspiration – cloudy greenish fluid Some of patients will recover in few weeks while others will develop chronic arthritis

Management
• Because septic arthritis cannot be ruled out give antibiotics. Tropical arthritis is thought to be caused by Chlamydia and therefore give chloramphenicol or doxycycline for 3 weeks (see dosage under Antibiotics, chapter 16.2).

BURSITIS
A bursa is a thin bag found usually in the proximity of joints where one structure slides over the other. Bursitis is an inflammation of a bursa caused by either by mechanical irritation or infection. OLECRANON BURSITIS It is commonly caused by mechanical irritation (‘students elbow’). It is situated between the point of the elbow (the olecranon process) and the skin. If the skin over the enlarged bursa is red, aspiration should detect the presence of pus.

Treatment
• • • • Initial treatment consists of rest and anti-inflammatory drugs (aspirin). Ice packs can be helpful. If there is pus present - drainage and antibiotic is required. If there is no improvement or recurrent bursitis refer to hospital for operation.

PRE-PATELLAR BURSITIS It presents as swelling in front of patella sometimes tender on palpation. An irritating mechanical factor could be working on the knees (‘housemaid’s knees’).

Treatment
• • • If fluid aspirated is clear, avoid constant mechanical irritation is in some cases is sufficient. If swelling recurs – refer to a surgeon. If the skin over the enlarged bursa is red, warm and pus is aspirated, drainage is required complemented with a course of antibiotic. cxxiii

LATERAL MALLEOLAR BURSITIS Prolonged sitting on the ground with crossed legs causes lateral malleolar bursitis. If the bursa is inflamed, symptomatic operative treatment is possible. HIPSTONE The hipstone is nothing but a chronically inflamed bursa, often calcified, over the trochanter of femoral bone. It is commonly seen among elderly women is the highlands. The hipstone is clinically presents as a hard tender lump over the trochanter. The patient should be referred to a medical officer for excision. INGROWING TOE NAIL Ingrowing toe-nail is unusual in barefoot people. The common site for the ingrowing toe-nail is the great toe. It is cased by either cutting the nail too short or wearing uncomfortable shoes. If there is mild inflammation along the medial side of the nail conservative treatment is sufficient. Twice a day pieces of cotton wool soaked in iodine (or clove oil) is tucked under the corner of the nail to separate it from the skin. In chronic cases refer to a medical officer. Wedge excision of ingrowing toe-nail ♦ Wash with antiseptic solution, drape it ♦ Make ring anaesthesia and of digital block with 1 or 2% Lignocaine (without adrenaline) (see Anaesthesia, chapter 17.2) ♦ Further steps described by Fig. 10.2.
Figure 10.2-1 A wedge excision for ingrowing toe-nail

A - Excise margin of toenail with the side of nail bed B – Excise a wedge of soft tissues (the nail fold) C – You can apply 1 or 2 stitches through the nail and soft tissues

GANGLION Ganglion is a cystic collection of thick, jelly-like fluid, which accumulates around tendons near the joints. The commonest localization is on the back of the wrist. On examination it presents as firm, round, mobile and not tender lump.

Treatment

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A ganglion is harmless and if asymptomatic it can be left alone. If patient insists on excision it should be referred to a surgeon. Sometimes pushing strong on the ganglion can break its capsule and disperse it, but it is only temporarily and will recur.

10.3 BACK PAIN
D ifferential diagnosis 1. SCIATICA Sciatica is characterized by acute back pain radiating to one of lower limbs. The pain is often triggered by lifting in such a posture that exerts a lot of strain on the back. Coughing can aggravate the pain. The two main causes of sciatica are prolapsed lumbar disc and spinal tumour. On inspection there is no visible spinal deformity. The best way to diagnose sciatica is through the straight leg raising test. This test is performed by raising the leg with the knee straight up to 90°. The test is positive if back pain prevents full elevation of the leg (see Figure 10.3-1).

Figure 10.3-1 The straight leg raising test.

Treatment
• • • • Provide rest for the lumbar spine by rest in bed. Commence the patient on panadol, or aspirin. Apply ice or hot packs to the lumbar spine. If there is no improvement after 4-6 weeks, refer to a medical officer.

2. SPONDYLOARTHROSIS Spondyloarthrosis is connected with ageing process and wearing out of the spinal joints. Trauma to the back can predispose to spondyloarthrosis. Back pain is worse on rising from a sitting position and can be aggravated by prolonged sitting or standing. Tilting the trunk backwards can also aggravate back pain.

Treatment
• During acute exacerbations of pain - bed rest with analgesics (panadol, aspirin).

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• •

In chronic pain, active exercises strengthening spinal extensors, buttock and abdominal muscles is recommended (swimming). Referral to a medical officer for a thorough check up is advisable.

3. TRAUMA TO LUMBAR SPINE A patient with recent trauma to spine requires referral. Previous spinal injury predispose to spondyloarthrosis and chronic back pain (see also Spinal injury, chapter 1.6). 4. TB OF SPINE (Pott’s disease) Any visible angular deformation or swelling of the spine must be referred for X-ray, investigated and treated for TB if suspected (see Tuberculous arthritis, chapter 11.3). 5. EXTRINSIC CAUSES OF BACK PAIN To exclude extrinsic cases of back pain the investigation should include: the abdomen, pelvis (rectal and or vaginal examination and lower limbs. Any patient with limping should be referred in order to establish the cause of limping

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11.0 TUBERCULOSIS

T

uberculosis is one of the commonest infections worldwide. It is now the second cause of hospital admissions in PNG. Pulmonary tuberculosis is the commonest form of TB presentation, but with poor infection control and the emergence of HIV epidemic there is a notable increase in extra-pulmonary TB.

11.1 TUBECULOUS LYMPHADENITIS

TB

lymphadenitis is the common form of extra-pulmonary TB. TB bacillus (Mycobacterium tuberculi) reaches the cervical glands through the lymphatic tissue in the throat.

Clinical presentation
Commonly affects neck glands in children, but other lymph nodes can be affected.

Clinical features
Tuberculous lymph nodes (LN) can be grouped in four stages Stage I rubbery enlarged LN, at first mobile but later fixed to deep tissue by periadenitis Stage II Stage III Stage IV • • LN matted together, fixed to the skin caseation leads to a fluctuant mass (abscess), a purplish discoloration of overlying skin tuberculous ulcers-sinus formation

Management
Enlarged cervical glands, which are not very characteristic for TB (low TB score) should be treated with antibiotic for 10 days (amoxicillin or chloramphenicol); If no reduction in size after 4 weeks of antibiotics a trial of anti-TB treatment can be given for 4 weeks. If there is no improvement, refer for lymph node biopsy.

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11.2 LYMPH GLAND (NODE) BIOPSY
E quipment • • • • • • • • • • • Syringe, needles, 1% Lignocaine Scalpel Small artery forceps (5 pairs) Dissecting forceps Scissors Needle holder, suture needles (cutting edge and round body), Nylon or Silk (2/0 or 3/0) and catgut (2/0 or 3/0) Swabs and dishes, cotton wool, gauze plain and combine 10% Formalin in a small bottle Adhesive plaster Plastic bag (from a store) Drapes

Technique

♦ For excision choose an enlarged gland, which is close to the surface and possibly not stuck to the other glands and far from a major blood vessel. ♦ Make sure (look and feel) that there are no blood vessels in the area of your incision. Inject the local anaesthesia (1% Lignocaine) and after waiting few minutes make incision (rather transverse) with a scalpel – only skin deep - over the gland. ♦ If you see larger vessels try to clamp with an artery forceps before dissecting them and tie them with 2/0 or 3/0 catgut. Then using curved small or larger dissecting artery forceps (or curved scissors) separate the gland from the surrounding tissue. Free the gland by opening the dissecting instrument. The technique is similar to the excision of a sebaceous cyst (see Fig. 12.1-1; B,C,D,E). ♦ Suture the skin with nylon or silk ♦ Cut the gland open; when you see it soft, rotten and having yellowish patches – looks like cheese - (caseation foci), you can start TB treatment. If there is no caseation, put the specimen into the bottle with 10% formalin and send to your provincial hospital for histopathological confirmation.

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11.3 TUBERCULOUS ARTHRITIS

T
• • • • • •

here is no joint that is immune to tuberculosis arthritis but the joints most commonly affected are: The inter-vertebral joints of the thoracic and lumbar spine Hip Knee

Clinical features
Affects mostly children and young adults; History of past contact with TB patient; It develops progressively over weeks while septic arthritis with acute joint pain within hours or days; Pain, swelling and impairment of function of the affected joint; On examination the overlying skin is warm, there is synovial thickening, painful restriction of movement and a “cold” abscess or sinus is often present; The aspirated joint fluid is little cloudy.

Treatment
♦ Refer to hospital for final diagnosis and treatment ♦ Anti-tuberculous drugs - intensive phase =A ♦ If there is severe bone destruction the affected joint needs rest TUBERCULOUS SPONDILITIS (Pott’s disease) Tuberculosis of thoracic and lumbar vertebrae is the commonest form of skeletal tuberculosis.

Clinical features
• • • • • • Pain in the back Stiffness of the back Visible deformity of the back (angular kyphosis/ gibbus) Localized swelling (abscess) Weakness of the legs Urine retention

Treatment

♦ Refer to hospital for confirmation ♦ Anti-tuberculous drugs continued uninterruptedly for at least 9 months ♦ The back is left unsupported

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ABDOMINAL TUBERCULOSIS

Clinical presentation
• • • • • • • • Slow onset Vague abdominal pain Fever and night sweats Loss of weight, fatigue Ascites (shifting dullness) Often palpation reveal a transverse solid mass of rolled up omentum thickened by TB with infiltration or mass in right iliac fossa TB rarely present as acute peritonitis (acute abdomen) Sometimes may present with symptoms of bowel obstruction

Management
♦ Refer to hospital ♦ Anti-tuberculous drugs continued uninterruptedly for at least 9 months. TUBERCULOUS PERICARDITIS TB can affect the heart sac called the pericardium leading to fluid collection and impairing heart function. There are two possibilities associated with TB pericarditis; a cardiac tamponade or a constrictive pericarditis.

Clinical presentation
• • • • • • History of TB or TB contact Left side chest pain Shortness of breath Distended neck veins Swollen legs and sacral area BP is low and heat sounds are hard to hear (diminished) Transfer urgently to hospital

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12.0 TUMOURS

T

umour in Latin means ‘swelling’. Tumours can be classified into benign and malignant. Benign tumours are more localized and do not spread to distant sites. They are usually surrounded by a fibrous capsule, which make their excision easier. If the tumours are not very large, and does not cause much trouble they can be left alone. However, keep in mind that some of the benign tumours can transform into malignant ones. Malignant tumours invade surrounding tissues and destroying them, spreading to distant sites (metastases) and causing generalized spread of this malignancy leading to death. Cancers are malignant tumours. Surgery remains the most effective treatment for the majority of malignant tumours. Before the tumour spreads from its primary growth, wide surgical resection has good prognosis. Therefore early diagnosis and treatment of cancer patient gives a good chance for cure. Before any major resection, a biopsy must to be done to confirm its malignancy status.

12.1 BENIGN TUMOURS
D ERMOID CYSTS A dermoid cyst is a congenital condition caused by burying of the skin epidermis, which continue to grow filling the cyst cavity with a greasy white substance. They are commonly located near the external end of the eyebrow; however they can by located medially to the eye or near the anterior fontanelle. Sometimes they erode the bone and become attached to the dura and therefore an experienced surgeon should do the excision.

SEBACEOUS CYST
The sebaceous cyst develops as a result of blockage of a grease duct. They are located usually on the head or the face and are more common in dark skin than the white. They are spherical in shape and careful examination often reveals a small pit on its surface. Treatment is excision with the capsule under local anaesthesia (1% Lignocaine).

Excising a sebaceous cyst
• • • • Shave if necessary, wash with antiseptic Apply local anaesthesia Drape Excise (see Figure 12.1-1)

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Figure 12.1-1 Excising a sebaceous cyst

A – Excise an ellipse of skin over the cyst B – Insert curved scissors and define the plane of dissection C – By opening the scissors isolate the cyst D – Excise it E – Suture the wound without leaving an empty space

LIPOMA
It is a benign tumour originating from the fat cells. It has a soft consistency and can occur anywhere in the body. Complete excision is a treatment. Technique of excision is similar to sebaceous cyst excision (see above).

FIBROMA
Fibroma is a benign tumour outgrowth from the connective tissue. It may occur anywhere in the body - has firm consistency and a smooth surface. Tumour should be excised in total and sent for histopathology.

GOITRE AND TUMOURS OF THE THYROID GLAND
The term goitre is used to describe a benign enlargement of the thyroid gland due to iodine deficiency; other tumours (cyst, benign or cancer) of the thyroid gland can also occur. Large goitre can compress trachea and esophageus. Each patient with goitre or any suspicious growth in the anterior neck region should be referred to a medical officer. If there is a suggestion of a tracheal obstruction (respiratory distress, stridor) immediate transfer to hospital is required.

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SALIVARY CYST
Salivary cyst results from blockage of the salivary gland. The clinical presentation is a painless, cystic swelling under the tongue or under the jaw. Refer to surgeon for excision.

JAW TUMOURS
The majority of the jaw tumours have a dental origin. They affect predominantly the young people, presenting with a swelling and loose teeth over swelling. If left for a long time can become malignant. Always refer all jaw tumours to a surgeon.

PYOGENIC GRANULOMA
Pyogenic granuloma is a common benign skin growth after a minor trauma. It appears as a reddish nodule, often pedunculated and grows rapidly to sizes varying from 0.5 to 2 cm. It occurs most commonly on the head, fingers and toes. Treatment is excision. Neonates often develop a variant of pyogenic granuloma on the umbilicus after the umbilical chord separates from the abdomen. In this condition, the granuloma is easily treated by direct application with copper sulphate crystals.

12.2 MALIGNANT TUMOURS

M

alignant tumours or cancer is a worldwide problem. It kills about 3 million people per year in the developing countries. In PNG cancers are the 5 th cause of surgical admissions to hospitals. Many of these tumours are curable, provided they are diagnosed early. Late diagnosis of malignant tumours have poor prognosis. Therefore, all health workers should be familiar with the clinical presentation of the most common types of malignant tumours and refer them early to a surgeon. A lot of tumours require a biopsy for confirmation by histopathology before proceeding on with any operations. Although there are different methods and approached to treating cancers, surgery remains the mainstay treatment for most of cancers.

Causes of cancer
There are a number of factors known to increasing the risk of getting cancers and those that are well documented in medical literature are: 1. Smoking has been correlated to about thirty types of cancers; the strongest was in lung, mouth and laryngeal cancers. 2. Cervical cancer – is caused by papilloma virus and spreads as a sexually transmitted disease. Therefore the more sexual partners one has, the greater the risk of developing cervical cancer. Sexually active women must be encouraged to cxxxiii

3. 4. 5. 6. 7. 8.

do routine Pap smear to identify precancerous changes in the cervix and effect immediate treatment. The same virus is also responsible for cancer of the penis. Betel nut chewing is a known causative factor for mouth cancer. Low fibre diet is related to the increase of colon cancer in western countries. Chronic foot ulcers and old burn scars can transform into malignant skin cancer. Excess exposure to the sun increase risk for melanoma (malignant skin cancer) and other skin cancers. Those with white skin are more at risk of developing melanomas and skin cancers. Radiation is known risk factor for many cancers particularly leukaemia. Alfatoxins are produced by fungi growing on food (e.g. moulded peanuts or corn). Increased intake of alfatoxins in moulded food is associated with hepatoma (liver cancer), oesophageal and stomach cancers.

The most common cancers in PNG
MOUTH CANCER
Predisposing factors are betel nut chewing and smoking.

Clinical presentation

⇒ Sore on mouth mucosa or on the tongue not healing after course of antibiotic ⇒ Growth inside the mouth ⇒ Enlarged, palpable cervical lymph nodes A patient presenting with any of the above changes, not resolving after a course of amoxicillin and metronidazol (see dosage under Antibiotics, chapter 16.2), should be referred to a surgeon for biopsy and surgical excision. If the patient is diagnosed early, surgery can cure the cancer hence the importance of promoting prevention, early diagnosis, and referral to a surgeon.

BURKITT’S LYMPHOMA
Burkitt’s lymphoma is a tumour, affecting mostly children between 5 and 9 years of age. It is common in some parts of Africa and PNG and presents as a swelling of the upper or lower jaws, with unilateral protrusion of the eye (proptosis), and rarely as a pelvic or abdominal mass. Refer early to either a paediatrician or a surgeon to confirmation of diagnosis. In some cases it can be cured by chemotherapy.

BREAST CANCER
A large study in US revealed that estrogens (female hormones) given to postmenopausal women to strengthen their bones increase the risk of breast cancer.

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There is also familial predisposition to breast cancer and pregnancy play a protective role against this cancer. Childless women have a greater risk of getting breast cancer.

Clinical presentation
• • • • • • • • Small or large breast tumour or lump; ‘Peau de orange’ changes on the skin (orange skin appearance); Inverted or retracted nipple; Discharge from one or more breast ducts (especially bloody discharge); Chronic swelling; Enlarged axillary lymph nodes; Chronic inflammatory changes around areola (eczema, scales and redness); Inflammatory carcinoma presents with swollen, warm and tender breast.

A woman presenting with any of the above signs must be referred to a surgeon for further assessment, a biopsy for histology and surgical treatment. Early stages of breast cancer can be cured by surgery, whereas in advanced stages after the disease has spread and surgery will not be able to cure it. Operation is usually followed by hormonotherapy (Tamoxifen 20-40 mg daily, for life). There is a need for awareness and health education on the prevention of breast cancers through (a) primary prevention based on eating a lot of fresh vegetables and fruits, (b) secondary prevention includes breast self-examination, which should be promoted during village visits. Every patient with breast lump should be referred to hospital for biopsy or every breast lump must be treated as ‘breast cancer’ until excluded by histopathology.

SKIN CANCER
Skin cancer is more common in white skin people caused by ultraviolet radiation from the sun. It is located in the areas exposed to the sunlight, such as the head, neck and hands. In PNG, the majority of skin cancers arise from chronic scars from burns or trauma, or growths in chronic ulcerations.

Clinical presentation
♦ Chronic ulceration with raised areas, initially at the edges, then over the whole ulceration; ♦ Asymmetrical, irregular skin nodules; ♦ Long lasting red spot with occasional areas of erosion and bleeding. In general, skin cancer is a slowly growing cancer, invading surrounding structures making surgical excision more difficult. Refer all patients suspected of skin cancer early to a surgeon.

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SKIN BIOPSY

Figure 12.2-1 Technique of skin biopsy

Equipment
Equipment needed (see Lymph gland biopsy, Chapter 11.2)

Treatment
• • • • Clean the skin with antiseptic, drape and anaesthetize with 1% Lignocaine, Cut a piece of tissue for biopsy with a scalpel and toothed forceps, Put the sample into a bottle with 10% formalin, Bleeding is usually well controlled by pressure dressing however; sometimes the wound requires suturing to arrest bleeders.

MELANOMA
It is a common cancer amongst the white skin people. In the dark skin people it more commonly occur in the unpigmented areas, such as the palm, sole of the foot, under the nails and on the whites of the eyes (sclera).

Clinical presentation
• Mole (black spot) that is changing colour • Irregular black nodule • Irregular border in a dark lesion • Any changes in colour, size, bleeding etc of congenital nevus (black lesion) Any suspicious lesion should be sent without delay to a surgeon for excision. Any suspicious black spots (mole) should be sent to a surgeon for biopsy – excision. For this type of lesion biopsy is done by excision of the whole lesion with adequate (wide) margin.

LIVER CANCER (hepatoma)
Hepatoma or hepatocellular carcinoma is one of the most common cancers in PNG and is seen to be associated with hepatitis B infection. Studies in some regions of

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PNG have indicated a very high prevalence of Hepatitis B and vaccination will greatly reduce prevalence of this cancer. Other known risk factors are alfatoxins produced by fungi in moulded food (e.g. moulded peanut).

Clinical presentation
• • • • • • Malaise Non-specific chronic epigastric pain Abdominal tumour in the right upper quadrant Jaundice Abdominal distension (due to ascites, late sign) Loss of weight (late sign)

Treatment
Usually the patient presents late with the tumour at an inoperable stage, allowing only for symptomatic treatment. In selected cases, especially in the young patients, partial liver resection can be considered.

OESOPHAGEAL CANCER
Cancer of the oesophagus is a relatively common cancer in PNG. Smoking and excess drinking of alcohol are known risk factors. It is a very aggressive cancer with early metastases. The prognosis is poor.

Clinical presentation
♦ Difficulties in swallowing food (dysphagia); increasing in severity and usually not lasting longer than one year ♦ Chest or upper abdominal pain ♦ Excess saliva production ♦ Weight loss (late) ♦ Anaemia (late)

Treatment
Usually patients are diagnosed at a late stage or present to the centre with dysphagia – a symptom of advance stage of the cancer. Rarely for a young patient with early stage of disease can radical operation be considered. As a palliative measure – to give more comfort to the patient in swallowing, an oesophageal jejunum anastomosis can be done but this is dependent very much on the location and the extent of the tumour. Refer all dysphagia patients suspected of oesophageal carcinoma to a surgeon.

COLO-RECTAL CANCER

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Colo-rectal cancer is a common cancer in western countries and is increasing in PNG. Epidemiological studies suggest an association between diet rich in animal fat and colorectal cancer. High fibre and low animal fat diet is recommended as prevention against this cancer.

Clinical presentation
• • • • • • • Blood in stools Constipation or chronic constipation alternating with diarrhoea Painful defecation (tenesmus) Pencil-shaped stools Anaemia Weight loss Bowel obstruction (see chapter 7.1)

Remember that every patient with a history of blood in stool must have a rectal examination. Digital examination of the rectum can diagnose 50% of all large bowel cancers. Patient with bloody diarrhoea should be treated for dysentery but be told to come back if rectal bleeding recurs. Refer to hospital for confirmation of the diagnosis followed by appropriate treatment. An operation performed at early stage of the cancer is often curative.

CANCER OF ANUS
Anal cancer can present as a chronic ulcer or a growth in anus. Note that some chronic anal ulcers can be caused by infections such as amoebiasis or donovaniasis. Therefore give a two-week course of chloramphenicol and metronidazole (see dosage under Antibiotics, chapter 16.2). If there is no ulcer healing after antibiotics, refer to a surgeon for biopsy and operation if warranted.

STOMACH (GASTRIC) CANCER
Stomach cancer is a common cancer of gastrointestinal tract.

Clinical presentation
♦ ♦ ♦ ♦ ♦ ♦ ♦ Chronic upper abdominal pain Loss of appetite Loss of weight Anaemia Vomiting Blood in vomits or in stools (black stools – melena) Upper abdominal tumour

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Refer to hospital for further investigation and possible operation.

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URINARY TRACT CANCERS
Renal or urinary bladder tumours are rare. If diagnosed early, they can be treated successfully.

Clinical presentation
♦ ♦ ♦ ♦ Blood in urine (hematuria) Abdominal flank or lumbar area pain Abdominal tumour Dysuria (pain on urination) Remember that each patient with blood in urine should be referred to a surgeon for further investigation. Operation at early stage may be curative.

PROSTATE CANCER
The risk of cancer of the prostate increases with age. It generally begins, as a benign prostatic enlargement being far more common than cancer.

Clinical presentation
• • • • Dysuria (pain on passing urine) Frequency Urine retention Backache caused by metastases to the spinal bones and pelvis

Rectal digital examination reveals firm irregular prostatic enlargement. Refer to a surgeon to confirm diagnosis and institute further treatment.

CARCINOMA OF PENIS
Circumcision soon after birth and stringent hygiene of the foreskin can prevent penile carcinoma.

Clinical presentation
• • • Foul bloody discharge Fungating growth or non-healing erosion Enlarged inguinal lymph nodes (metastases to lymph nodes)

To rule out amebiasis of penis, treat it for 2 weeks with metronidazole (see dosage under Antibiotics, chapter 16.2). If lesion persists refer to a surgeon.

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LUNG CANCER
Lung cancer is on an increase in almost all countries. Mortality from lung cancer is 15 times higher in smokers than in non-smokers.

Clinical presentation
• • • • • Chronic cough Blood in sputum Loss of weight Recurrent pneumonia Chest pain

The clinical picture of lung cancer may be similar to pulmonary tuberculosis (PTB). Therefore if AFB is negative (i.e. no Tuberculous bacilli in sputum) the patient should have a chest X-ray to differentiate between the two. In less advanced tumours operation is possible.

INTRACRANIAL TUMOURS
Intracranial tumours affect usually young people.

Clinical presentation:
∗ ∗ Early localizing neurological signs (loss of acuity of vision, defects in vision, hydrocephalus, anorexia and poor coordination of movements); Symptoms of raised intracranial pressure (morning headache, vomiting and nausea and impaired consciousness).

Unless the diagnosis and operation are made early, there is little chance of long survival. Refer to a medical officer.

ABDOMINAL TUMOURS IN CHILDHOOD
The commonest abdominal "masses" in childhood are liver, faeces in the colon and a full bladder. Neuroblastoma and kidney tumours constitute half of all malignant abdominal tumours in children. When you palpate an abdominal mass refer to a medical officer.

BONE TUMOURS
Bone tumours can be divided into benign (more common) or malignant.

Clinical presentation

♦ A firm to hard swelling at the site of lesion ♦ Limb pain increasing at night ♦ Warmer over the overlying skin (due to increased vascularity of tumour)

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♦ Sometimes local tenderness ♦ Pathological fracture Refer to a surgeon for confirmation of diagnosis by biopsy. Treatment may require either a local bone resection or an amputation of the limb.

12.3 CANCER MANAGEMENT AT PRIMARY CARE LEVEL
E arly cancer detection and prevention Early diagnosis of cancer is a major determinant of the prognosis. In order to improve early detection of cancer, at the primary care level, all health workers must have broaden their knowledge about early signs and symptoms of cancers. Furthermore, primary care health workers should be actively involved in health promotion to increase awareness and knowledge about cancer, its presentation and prevention.

Treatment continuation
Some patients are given chemotherapy to continue under the supervision of Health Center staff. The commonly used cytotoxic drug in PNG is Methotrexate. It however produces only temporal help for mouth cancer patients by containing and limiting its spread. It is a very toxic drug and can kill when overdosed. It is therefore very important that instruction are written clearly should be followed precisely. Patients on chemotherapy should have their blood checked regularly. Tamoxifen is another drug that is known to slow down the growth of breast cancer.

Detection of cancer recurrence
Patients, who have had a surgical excision of a tumour or have had other cancer treatment, require: ⇒ Regular follow up. The recurrence may present as enlargement of regional lymph nodes or growth on the scar. ⇒ Primary care workers can detect cancer recurrence early and refer to a medical officer. Sometimes recurrence is treatable.

Terminal care
Terminal care is a specialized care for any patient with a diagnosed incurable disease. After a terminal patient is counselled on his condition and told of about death and life expectancy, it is a health worker duty to comfort and provide satisfactory relief of suffering. Most of these patients present late - the terminal stage of cancers suffering of pain. After knowing that a terminal patient is going to die, far too often the patient is neglected at a time of their maximum despair needing more comfort then ever.

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Health staffs have to have change heart and attitude towards such patients. It is good to refer a terminal patient to medical officers to confirm the diagnosis and decide upon best palliative treatment. Whenever possible the diagnosis should be confirmed by biopsy to rule out treatable disease that can mimic cancers. What looks like penile cancer or anal cancer may simply be a case of amebiasis or “malignant ascites” may in fact be abdominal tuberculosis. In some of these patients, palliative surgery can be performed to relieve suffering. For instance, the most humane thing to do to a patient to illustrate palliative management is to (a) amputate the painful limb with fungating tumour to effectively deal with pain and the offensive smell; (b) bypassing the obstructed segment of the bowel will stop vomiting and pain, (c) removing ovaries in a breast cancer patient can slow down the cancer progress. In other cases chemotherapy can be helpful, e.g. Methotrexate can cause long lasting remissions of mouth cancer. CONTROLLING CANCER PAIN Pain sensation can be modified by patient’s psychological, spiritual and social status. Emotional states such as anxiety, depression and fear of death can worsen the symptoms of pain. Therefore, drugs such as chlorpromazine, promazine and diazepam help a lot with anxiety and reducing pain. These drugs are called adjuvant and must be combined with the known potent painkillers such as codeine phosphate, morphine or pethidine. In cancer patient pain management, it is advisable to follow WHO’s three-step ladder approach. WHO’s three-step ladder consists of 1. A non-opioid (aspirin or paracetamol) [home care] 2. A mild opioid (codeine) [home care] 3. A strong opioid (morphine) [hospital]

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3 Strong opioid
+ Non-opioid

2 Mild opioid
+ Non-opioid

+ Adjuvant
If pain persists

+ Adjuvant

1 Non-opioid
+ Adjuvant

If pain persists

At each step adjuvant drugs are combined. Remember to manage constipation, which is the side effect of codeine and morphine by prescribing Coloxyl, Senokot or pawpaw seeds (1-2 spoons daily). It is important to give drugs before their pain starts again; give them every 4-6 hours by the clock. Do not give drugs ‘as required’ (p.r.n.) because doing these you need much bigger dose of painkillers to stop pain. If pain persists you can increase doses to maximum before moving to the next step. Preferably give drugs by mouth.

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Third step - when the pain intensified and morphine is required, the patient must be hospitalised

Adjuvants
Chloropromazine 10 to 25 mg 4-6 hourly; no more than 100 mg daily Promazine 10 to 25 mg 4-6 hourly, but no more than 100 mg daily Non-opioid: Aspirin 250 to 1000 mg every 4 – 6 hours. The maximum daily dose is 4g. Paracetamol 500 to 1000 mg every 4 – 6 hours; maximum daily dose is 4 g. Weak opioids: Codeine phosphate 30 to 90 mg every 4 – 6 hours, with paracetamol or aspirin. Strong opioids: Morphine 5 to 10 mg every 4 hours orally The doses as described are for an average adult, for children check dosage in the Children standard treatment book. Finally, one must always respect the wishes of a dying patient with dignity. In most cases the patient would prefer to die in his house surrounded by family members, friends and relatives. Therefore, always discuss with the family, as the terminally ill approaches death the preferred option where the last moment will be spent.

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13.0 GENITO-URINARY TRACT DISEASES

U RINE RETENTION Urinary retention is defined as inability to pass urine with retention of urine in the bladder.

Causes
1. In children: urinary infections, infections in organs adjacent to urinary tract (e.g. groin abscess), neuro-muscular disorders, dysfunctional valves of posterior urethra, urethral stricture, bladder neck stricture, hematoma in vagina, severe phimosis, urethral diverticulum. 2. In adults: • Prostate enlargement, such as Benign Prostatic Hyperplasia (BPH) or cancer of prostate • Urethral stricture o Post-traumatic (fractured pelvis) o Post-infectious, e.g. gonorrhoea or other infections • Neurological causes - spinal injury, spinal tumour, myelitis, after operations in pelvis • Drugs - narcotics, anticholinergic (e.g. Buscopan) • Pelvic tumours • Psychological disorders Sometimes when the bladder is overfilled, urine dribbles from the urethra without control. The patient complaints range from mild discomfort to severe pain in lower abdomen. Urinary retention extending over a long period of time leads to infection and sepsis. On examination a distended bladder can be palpated. Inspection of the external sexual organs and rectal examination can aid in finding a cause of urinary retention.

Management
⇒ Drain urine by inserting a urinary catheter (IDC). If the IDC meets resistance withdraw the catheter. If you see blood on the tip of the catheter do not attempt further catheterisation. You might be creating 'false route’ in prostate. If a Foleys catheter cannot pass, you can try a small feeding tube. In a male patient it can be fixed by strips of adhesive plaster placed along the penis. Remember to reduce foreskin to prevent paraphimosis. In a female patient it can be affixed to the labia. ⇒ If not able to pass any size catheter, do a suprapubic puncture of distended bladder with wide-board needle (gauge 14) or I.V. cannula to drain urine and relieve pressure (see the technique of insertion below). ⇒ If the patient is septic give I.V. fluids and antibiotics (amoxicillin). ⇒ The patient should be referred to a hospital for final diagnosis and management. cxlvi

Figure 13.0-1 Inserting urinary catheter (IDC)

•

•

•

Wash perineum and penis with 1% chlorhexidine Apply 2% Lignocaine gel to urethra; wait 5 minutes If this is not available skip this point.(A) In one hand pull the penis to straighten the urethra (B)

•

•

With the other hand, using sterile gloves or sterile forceps insert covered with sterile jelly IDC When IDC is in the bladder, fill the balloon with sterile water (or saline) connect a collecting bag.

Figure 13.0-2 Suprapubic puncture

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Indication
In acute urinary obstruction, with fully distended bladder, easily palpated above the pubis. If the bladder is not distended and a patient not passing urine, it can be a bladder rupture (if there is a history of trauma) or kidney failure.

Equipment
• • • • • • • • Bowl with antiseptic solution (iodine, chlorhexidine or Savlon) 1% Lignocaine with syringe and needles Cotton wool Kidney dish Window drape A pair of forceps for washing the skin Gloves (if sterile gloves not available, non-sterile one could be used) I.V. cannula (gauge 14 or 16) or wide-bore needle with syringe (the needle should be long (e.g. spinal) because short can slip out of bladder when it contracts.

Technique
1. 2. 3. 4. 5. 6. Palpate the lower abdomen to make sure that the bladder is distended. Wash the supra-pubic area with antiseptic solution. Drape the area. Inject local anaesthetic (1% Lignocaine) about 2 – 3 cm above the symphysis pubis in the midline and wait for few minutes. Insert an I.V. cannula or needle 2 – 3 cm above the pubis bone and push it backwards and slightly downwards into the distended bladder. It is better to use cannula and drain urine in few portions. To prevent fainting of the patient due to rapid decrease of intra-bladder pressure (vagal reflex) drainage should be done in few portions - 300-400 ml each. This fractional draining prevents also bleeding from the bladder mucosa caused by quick bladder decompression. If a cannula is not available drain with a needle as much as possible and withdraw the needle. After draining urine, you can try again catheterisation with IDC.

7. 8.

HEMATURIA (blood in urine) The best simple way to diagnose blood in urine is to examine the urine specimen under a microscope because there are chemical compounds and hemoglobin pigment from massive hemolysis can imitate hematuria. Blood in the urine specimen collected; (a) early stream is usually caused by the diseases of urethra; (b) in last stream - by bladder pathology; and (d) hematuria cxlviii

present throughout all micturition streams can be caused by a pathology localized at any segment of urinary tract. Hematuria accompanied by pain can be caused by cystitis (bladder infection) or descending of calculi, whereas painless hematuria is often early sign of neoplasm of urinary tract.

Most common causes of hematuria are:
• • • • • • Tumours (commonest cause for 40-60 of age males) Infections Benign prostate hypertrophy (for males over 60) Calculus Injuries Rare: TB, reflux, ureteric varices, allergy, acute appendicitis, foreign bodies, clotting disorders, some drugs.

Because infections account for around one third of all hematuria it is justified to treat the first episode of hematuria with antibiotic, provided that no other abnormalities were found on clinical examination. Selected antibiotic should include antibiotics sensitive to Gram-negative bacteria such as cotrimazole, or amoxicillin, or doxycycline (see dosage under Antibiotics, chapter 16.2). Patients with the second episode of hematuria must be sent to the hospital for a final diagnosis. Delayed diagnosis of a urinary tract cancer can ruin patient's chance for cure by early intervention.

URINARY STONES (CALCULI)
KIDNEY AND URETERIC STONE Kidney and ureteric stone can cause pain when passing down the urinary tract and consequently blocking urine passage. If there is chronic loin pain it can be caused by persisting infection.

Clinical presentation

♦ Renal/ureteric colic characterized by loin colic pain radiating dawn to the groin or testis. ♦ Nausea or vomiting, sweating and agitation can accompany the attack or the pain of renal colic. ♦ Sometimes chronic urine obstruction and infection manifests as chronic loin pain (backache) and recurrent dysuria. ♦ Occasionally hematuria (blood in urine) can occur.

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RENAL COLIC The commonest cause of renal colic is a stone (calculus).

Management
• • Painkillers: Panadol 1g oral or per rectum and Buscopan 1 amp I.M (or oral 2 tablets); if no alleviation in pain add Pethidine 50-75mg (1mg/kg) I.M. then refer for further diagnosis. It acute renal pain accompanied by fever and sepsis, it is a surgical emergency. o Connect I.V. infusion; o Give antibiotic amoxicillin 1g tds I.V. or gentamycin 7mg/kg daily for 7 days I.M. or chloramphenicol 500mg to 1g I.V./I.M.QID or 7 days; o Pethidine 1mg/kg I.M.; o Transfer to hospital. Chronic renal pain requires further diagnosis in the hospital. Advise the patient that the best prophylaxis against urinary stones formation is drinking a lot of fluids.

• •

BLADDER STONE It is a relatively frequent problem in PNG.

Clinical presentation
∗ ∗ ∗ Dysuria, frequency Occasionally hematuria Intermittent urinary obstruction is the most characteristic symptom. A patient reports a sudden stop in the urine flow, which releases after changing position or shaking pelvis.

Management
Refer to hospital for operative removal of the stone. INFECTION IN LOWER PART OF URINARY TRACT (UTI, cystitis, urethritis) Urinary tract infection (UTI) is few times more common among females than males, which is believed to be the anatomical difference - female shorter urethra predisposing to ascending migration of bacteria to the bladder. In male it is mostly due to sexually transmitted diseases.

Clinical picture
♦ ♦ ♦ ♦ Dysuria (pain on passing urine or burning pain along the urethra) Increased frequency (even every 10 minutes) The urge to urinate , dribbling urine Cloudy urine or rarely blood in urine

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♦ ♦ ♦ ♦

Purulent discharge from the urethra (commonly caused by gonorrhoea) Lower abdominal pain/discomfort, sacral or perineal pain Males occasionally have swollen tender testes (orchitis) If infection ascends to the upper part of urinary tract affecting the kidneys (pyelonephritis), fever with chills can occur; loin area will be tender on palpation.

Often lower urinary tract infection (UTI) is caused by sexually transmitted infection (STI). Urinary tract infection in small children can often be difficult to diagnose, it often presents as abdominal pain, with fever and vomiting. Recurrent symptoms of urinary tract infection are usually caused by an underlying pathology and require further diagnosis in hospital.

Management
• • In children treat with amoxicillin or cotrimazole for one week (see dosage under Antibiotics, chapter 16.2). Males with dysuria and frequency treat for STI’s both partners o amoxicillin 2g oral stat + Probenecid 1g oral stat + Augmentin 2 tablets stat + azitromycin 1g oral stat; o Alternative treatment is amoxicillin 3g oral stat + Probenecid 1g oral stat + doxycycline 100 mg bd for 10 days. Females with dysuria you can treat as above for STI’s or give cotrimazole 480 - 2 tablets bd for one week. If a patient has loin pain, dysuria, fever and tender loin areas diagnose pyelonephritis and start treatment with cotrimazole 480 2 tablets bd for 7 days. If a patient with pyelonephritis (upper urinary tract infection) is severely sick or fails to improve after 2 days of treatment, change antibiotics and refer to hospital; a patient with urine obstruction may need urgent operation o gentamycin 1st day 7mg/kg daily (but no more than 240mg); followed by 5mg/kg daily for 7 days; o Or chloramphenicol 500mg QID for 7 days. Encourage the patient to drink a lot of fluids to wash out the urinary tract. Patients with upper urinary tract infection should be referred to hospital for further investigation.

• • •

• •

ACUTE SCROTUM Acute scrotum comprises a group of conditions, which are associated with painful enlargement of the scrotum with both acute and subacute onset. • Firstly strangulated scrotal hernia has to be ruled out; in hernia - swelling extends upwards to the groin, and clinical picture of bowel obstruction can develop (see Intestinal obstruction, chapter 7.3).

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•

• •

Torsion of testis is the commonest cause for acute scrotum in childhood and adolescent (commonest at 10-20 years of age), sudden onset with testicular and lower abdominal pain, tender testis, thickening of funiculus spermaticus which can easily be palpated, the epididymis can be palpated anterior to testis (anatomical position is posterior to the testis). If in doubts, the final diagnosis is made on operation, early (<6-8 hours) diagnosis and operation can salvage the testis. Therefore if torsion is suspected, refer urgently to a surgeon. Torsion of one of testicular appendages, sometimes palpated as a small tender lump, if doubts – refer to a surgeon. Acute epididymo-orchitis;

Common causative factors are chlamydia or Gram-negative bacteria. It can be contracted through sexual route.

Clinical picture of acute epididymo-orchitis
      Painful swelling of half of the scrotum; Scrotal skin can be reddish and thickened; Urethral discharge with burning pain in urethra (dysuria); Pain can radiate to Right lower abdomen; Fever; Elevation of scrotum will reduce pain in epididymo-orchitis, if it has no effect on the pain it indicates testicular torsion (Prehn's sign).

Management of acute epididymo-orchitis

√ The clinical picture can mimic torsion, so if in doubts refer to a surgeon. √ Treat for gonorrhoea (amoxicillin 2g oral stat + Probenecid 1g oral stat + Augmentin 2 tab stat + doxycycline for 10 days (for chlamydia and G-negative bacteria; or alternatively can give chloramphenicol 500 mg QID for 2 weeks. √ For relieving pain: Indocid 1-2 tab tds; or Aspirin 2 tab (600mg) tds or Panadol 1g bd; also elevation of scrotum alleviates pain. √ Chronic epididymitis especially with a discharging fistula is highly suggestive of TB epididymitis. In this case refer for biopsy. UNDESCENDED TESTIS (cryptorchidism) You have to discern undescended from retractile testes. A retractile testis can lie in superficial inguinal pouch but can be easily made to reach scrotal bottom. The undescended testis is common condition in paediatric surgery, however is seen rarely in surgical units because most probably it went undiagnosed by primary health workers. The diagnosis of undescended testis is made on the clinical ground showing usually only one testis in the scrotum. Often the missing testis can be palpated in the inguinal canal but it cannot be pulled down to the scrotum. In some instances the testis may be atrophic and or lies in the abdomen and cannot be palpated. clii

If early diagnosis is made, surgical treatment is best before 1 year of age in order to avoid complications. Cryptochidism increases the risk of testicular tumour by 35 times. Also the potential for the production of spermatic cells is impaired severely when the undescended testis in not placed by in the scrotum. Therefore, early repair (best before the end of 1 year) is important to preserve fertility and control tumour development. Do note that if only one testis is undescended, the one scrotal testis is adequate to spermatogenesis and fertility. PHIMOSIS Phimosis is the stenosis of the preputial (foreskin) orifice. The prepuce is lightly adherent to the glans in the first year of life, but it may stay adherent until 3-4 years and it should not be forcibly separated. Management of phimosis is circumcision.
Figure 13.0-3 Circumcision

1. Wash the area with antiseptic solution and drape. 2. Two small artery forceps are clamped at the upper and lower margins of the prepuce (see Figure 13.0-3 Picture 1). If there are adhesions between the glans and prepuce, separate them using small artery forceps. 3. Apply gentle traction to the prepuce then using a pair of scissors cut the external layer of the prepuce skin at the level of the tip of the glans (see Figure 13.0-3 Picture 2). 4. The superficial layer of the prepuce retracts towards the corona, leaving the internal layer of the prepuce skin still stretched over the glans. Now slit the internal layer of the prepuce with scissors in the mid-dorsal line to about 1 cm distally of the corona. Then the internal layer of prepuce is trimmed around 1 cm distal from corona. Take care not to remove too much internal layer close to the frenulum (posterior part of the glans) (see Figure 13.0-3 Picture 3). Clean out the remaining smegma. 5. Ligate bleeding vessels with fine catgut then suture the two layers together with catgut (see Figure 13.0-3 Picture 4).

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6. Dress the wound with the paraffin gauze or antibiotic ointment. Wing it with plain gauze and secure it with adhesive plaster.

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PARAPHIMOSIS Paraphimosis describes condition when narrowed preputial orifice is trapped behind the glans causing gross swelling.

Management
    Give Pethidine 1mg/kg I.M. or 0.5mg/kg I.V. Sit at the bedside and draw the foreskin upwards, and squeeze the penis with your hand for few minutes to reduce swelling. Then place your thumbs on the glans and slowly roll the foreskin forward with the remaining fingers (see Figure 13.0-4 Picture 1). If reduction is not possible due to pain or long delay o Inject 10 ml of 2% Lignocaine (without adrenaline!) around the base of the penis or give Ketamine (see Anaesthesia for HEO); o Find the obstructing band; make a small slit on the narrowest ring on the back of penis until the foreskin can be reduced (see Figure 13.0-4 Picture 2); o Do not cut too deep because it can cause severe bleeding.

The final treatment consists of dorsal split or circumcision.

Figure 13.0-4 Paraphimosis, dorsal slit

BALANITIS It is acute or chronic inflammation of the foreskin and glans. It is often the manifestation of diabetes mellitus.

Treatment
Treatment includes correction of the underlying causes and circumcision. Balanitis can be an initial manifestation of diabetes or AIDS. DONOVANIASIS Donovaniasis presents as bright red painful ulceration of penis with enlarged soft and painful lymphatic glands in the groins. In case of painless ulceration, check for syphilis and other sexually transmitted infections

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Management
   Azitromycin 500mg daily for 7 days or 1g weekly for 4 weeks, or chloramphenicol 500mg QID until ulcer heals, at least 21 days, or doxycycline 100mg daily until ulcer heals, at least 21 days.

Amoebic balanitis is seen in young men in PNG. It presents as a necrotic ulcerations with greyish granulation, sometimes with small areas of skin necrosis. The condition is painful and smelly. It can mimic cancer of the penis.

Management
  Give metronidazole 600-800mg tds for at least 5 days. If amoebiasis is the underline cause, there will be improvement seen in 48 hours. If the is no response the lesion may be caused by cancer; refer to hospital.

HYPOSPADIASIS Hypospadiasis is one of the commonest congenital abnormalities of penis where the urethra is open at the ventral aspect of penis and proximally to the normal site. It can be repaired by one- or two- stage repair using the skin of the prepuce. Therefore, in this condition circumcision is contraindicated. EPISPADIASIS Epispadiasis is the condition in which the urethra opens on the dorsal aspect and at the base of penis. HYDROCELE Hydrocele manifests as painless swelling of one-side of the scrotum caused by collection of fluid. Congenital hydrocele is the result of a retained connection with peritoneum during in utero development, which normally should have closed by the end of first year. Therefore the operation before that time is not recommended. Secondary hydrocele can be caused by scrotal infections, trauma or tumour. Rarely can hydrocele mask the existence of a testicular tumour. It is common in areas in PNG where Lymphatic Filariasis is common. The adult filarial worm can either block lymphatic drainage or damage the lymphatic vessels leading to fluid collection. Diagnosis is made on palpation: hydrocele has clearly demarcated upper border on palpation whereas in scrotal hernia the swelling has continuity with the groin. Transillumination can be seen and in doubts aspirating of clear fluid can substantiate the diagnosis. Hydrocele fluid can be aspirated as a temporary measure. A patient above 1 year old should be referred for elective operation.

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14.0 DISEASES OF THE EAR, NOSE AND THROAT

A cute earache Otitis media is the commonest course of acute earache.

Clinical picture
√ √ √ √ earache fever O/E tenders the area in front of ear canal on otoscopy, the eardrum can be red, congested and bulging

Treatment
♦ Give amoxicillin oral for 5 days (see dosage under Antibiotics, chapter 16.2). ♦ If there is fever, treat for malaria with antimalarial drug.

Indication for transfer to hospital
1. 2. 3. 4. No improvement after two-day course of antibiotic. Facial palsy (one side of the face paralysed). Positive meningeal signs. Post-auricular swelling and/or tenderness over mastoid process indicating acute mastoiditis.

If you diagnose acute mastoiditis, start the patient on antibiotics (I.V. or I.M.) chloramphenicol or cloxacillin (flucloxacillin) and refer urgently. Mastoiditis can lead to severe complications such as brain abscess or meningitis; therefore urgently refer to hospital.

CHRONIC EAR DISCHARGE This is a common problem especially in the rural and remote highlands regions of PNG, and the recurrence of it is due to inadequate management of acute otitis media. It can be caused by: • Chronic otitis media • Fungal external otitis (swimmers ear) • Eczema • Foreign body

Management

♣ Check on otoscopy to rule out the presence of foreign body in the ear canal. ♣ Dry the discharging ear using the toilet paper spear method described in Paediatrics for HEO in PNG. clvii

♣ Put 1 - 2 drops of boric acid to the ear. ♣ Perforation of the drum and chronic ear discharge can be repaired sometimes by specialized operation. ♣ If tender swelling develops behind the ear over the mastoid (mastoiditis) refer to hospital. While waiting for transfer start on antibiotic – chloramphenicol I.M. (see dosage under Antibiotics, chapter 16.2) Antibiotics will not be effective if administered without adequate cleanliness of the ear canal, free of discharge. The best approach is to teach and empower the mothers the proper techniques of using toilet paper to clean the ears as frequently as possible.

OTITIS EXTERNA This is infection of the canal between eardrum and outside. It is common amongst swimmers. The ear is painful, itchy and moving of the external ear will cause pain. Otoscopic examination will show a reddish ear canal, sometimes with erosions, scales and discharging. A contact with the external auditory meatus may result in bleeding.

Treatment
⇒ Clean the canal gently with cotton wrapped around a fine stick. ⇒ Put 1 – 2 drops of boric acid with glycerine or if not available few drops of diluted vinegar. ⇒ If there is fever, or likelihood of a secondary infection start on a broad-spectrum antibiotics, preferable amoxicillin or cotrimazole.

WAX BLOCKING THE EAR CANAL Every normal ear naturally produces wax. Sometimes wax can form a plug blocking the auditory canal and the patient complains of deafness. Otoscopy will confirm wax plug.

Management
The management is very much dependent on the quality of the wax impacted in the auditory canal. If it is dry and the tympanic membrane is not visible it is advisable to start by softening the wax using glycerine or coconut oil or even cooking oil. Re examine the ear after about 3 days. If there is a waxy plug near the ear opening use a small pair of artery forceps to remove it then proceed with the steps as outlined below; ♦ Take a large syringe (50 ml) and prepare warm water at body temperature. Do NOT use cold water; it can cause vertigo (dizziness). ♦ Pull the ear upwards and backwards and syringe the ear canal. Ask if the patient feels dizzy every time you syringe the ear. Stop if there is dizziness. ♦ Repeat otoscopy to assess the completeness of cleaning. clviii

♦ If you failed to remove the plug after few washings install into the ear few drops of glycerine or cooking oil to soften the plug and repeat syringing next day.

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PARATONSILLAR ABSCESS 'QUINSY'

Clinical picture
• • • • • Fever, throat ache, O/E bulging one of the tonsils Difficulties in swallowing and breathing

Treatment
Give antibiotic [penicillin (crystalline) or amoxicillin] Transfer urgently for possible incision

LUDWIG'S ANGINA Ludwig’s angina presents as an induration and swelling of the mouth floor. The basic lesion is cellulitis or abscess situated between muscles behind the mandible.

Clinical picture
∗ ∗ ∗ ∗ ∗ ∗ Fever Painful, firm swelling in submandibular area The mandible is fixed with the mouth half opened and saliva dribbles (intubation can be impossible) Inability to protrude the tongue Swallowing may be difficult or impossible Airway constriction producing stridor and breathing difficulties

It is surgical emergency! The patient can die from strangulation by the tongue displaced posteriorly.

Treatment

♣ High dose of benzyl penicillin (crystalline 2-3 mega units 6 hourly) with Flagyl (metronidazole) and gentamycin, or chloramphenicol with high dose of amoxicillin is the recommended antibiotics (see dosages under Antibiotics, chapter 16.2). ♣ Refer urgently for incision and drainage

EPISTAXIS Epistaxis is defined as all bleeding from the nose, out of the nasal passage. It can be spontaneous or caused by trauma. The commonest bleeding points are located in the front of the nose in the nasal passage.

Management
• To stop the bleeding, squeeze the nostrils together for 5 minutes. clx

• •

• • • •

If the bleeding stops, advice the patient not to swim, dive or blow his nose. If the above method fails, pack the nose with gauze (anterior nasal tamponade). Often soaking the gauze pack moistened with adrenaline will facilitate vasoconstriction of the bleeders. For soaking gauze, dilute 1 ampullae of adrenaline with 10-20 ml of water or normal saline. If these measures has not controlled bleeding, insert through the nostril a well lubricated Foley catheter, then blow the balloon, draw it forward and pack gauze around it. Give amoxicillin (see dosage under Antibiotics, chapter 16.2). Refer recurrent nose bleeding. If failed to control bleeding and severe bleeding continues, insert I.V. cannula and start on fluid resuscitation then refer the patient.

FOREIGN BODIES Foreign bodies in the nose First sign could be purulent or bloody discharge from one nostril Examination with otoscopy or gentle probing will reveal it.

Management
∇ ∇ ∇ ∇ ∇ Put swab soaked with 2% Lignocaine with adrenaline into the nose. For a child you may need general anaesthesia with ketamine. First try to remove it with suction (cut the end of the suction catheter). Then try to remove it with a hook made of a bend paper clip (see Fig. 14.0-1). If these fail refer to a medical officer.

Foreign bodies in the throat A foreign body can by inhaled or swallowed. After spraying the throat with local anaesthetic (10% Lignocaine) check with spatula in good light and with laryngoscope. In case where10% solution is not available, you can use 2% Lignocaine. If foreign body is seen it can be removed with forceps. If a foreign body is inhaled or swallowed, transfer to hospital.

Emergency treatment
If patient is choking grasp his tongue with a piece of gauze, pull it out and with the finger try to hook out the foreign body. If that has not helped try the following manoeuvre: Stand behind the patient, place your hands in front of patient’s lower chest and compress forcefully while at the same time exert lateral compression on the chest with the your arms. If the patient cannot breath, insert a wide-bore needle or scalpel through his/her cricoid membrane, just below the thyroid cartilage to create a new airway (see Figure 1.4-1). Refer urgently to hospital. clxi

Foreign bodies in the ear Children often insert objects such as stones, beds and beans into the ear canal. History of foreign body insertion is often missed. Confirm the diagnosis with otoscopy.

Management
• • • Removal, especially in children should be performed under general anaesthesia (ketamine). Attempt to syringe the foreign body in similar way to removing earplug. If this fails try with a small hook made of a bent paper clip. Beware not to push it too far (it can perforate the eardrum) [see Figure 14.0-1 below). After the removal, put antibiotic drops or iodine.
Figure 14.0-1 Removal of ear foreign body A – Paper clip;

B – Paper clip unfolded; C – Bend the end over forming a hook. D – Lie a patient down, sedate (pethidine) or give ketamine for a child; an assistant holds the patient’s head firmly; using an auriscope with large speculum, insert gently the hook along the auricular canal.

E – The hook passes the foreign body; be gentle not to damage the eardrum or push the foreign body deeper.

F - Twist the hook so that it lies behind the foreign body. G – Pull out the foreign body; check in auriscope if the canal is clean.

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If there is an insect in the ear, instil a few drops of oil into the ear to kill it, and then try to syringe it out.

15.0 EYE DISEASES

E YE INJURIES

Blunt eye injury
The classical 'black eye' usually results from a peri-orbital hematoma. Delayed appearance of peri-orbital ecchymosis indicates fracture of the roof of the orbit or basal skull fracture. RUPTURE OF THE SCLERA

Clinical picture
∗ ∗ ∗ Decreased vision Soft eye Perforation seen most commonly on the junction of cornea and sclera

Management:
If a rupture or penetrating injury of the eyeball is suspected • Apply chloramphenicol antibiotic eye ointment. • Protect the eye with a firm eye pad dressing • Give antibiotic I.V. or I.M. (chloramphenicol) • Refer the patient as an emergency to an eye or surgical specialist

Penetrating eye injury
PERFORATION OF THE CORNEA

Clinical picture

∇ If there is collapse of the eye (soft eye) do not press hard on the injured eye because it can push the eye content out! ∇ Distorted pupil ∇ Hyphema (blood in anterior chamber of the eye) ∇ Prolapse of the eye content

Treatment

⇒ Do not wipe away the clots because they may be mixed with prolapsed eye content. ⇒ Cover the eye with dressing applying antibiotic eye ointment in the eye. ⇒ Give parenteral antibiotic (chloramphenicol I.V. or I.M.). ⇒ Refer urgently to hospital. clxiii

Perforated eye injury can lead to inflammation of the uninjured eye with subsequent blindness. Removal of a badly injured eye within 10 days from the injury can prevent sympathetic ophthalmia. CHEMICAL BURNS TO THE EYE Emergency treatment of lime burns requires copious irrigation with clean water. Putting patient's head under the water with the eyes open can satisfactory wash out chemicals. It is important to apply the eye wash for not less then 15 minutes.

Management
    Put anaesthetic drops (1 or 2% Lignocaine) Apply chloramphenicol eye ointment and apply eye pad for 24 hours. Review the patient the next day and reassess and reapply eye pad. If there is suspicion of secondary infection, refer for further management.

FOREIGN BODIES

Management
• • Examine the eye in a good light. If the examination is painful or foreign body identified, anaesthetize the eye with o 2 drops of amethocaine, repeat after 5 minutes o or 2 drops of 2%Lignocaine, repeat after 5 minutes o children may need ketamine for anaesthesia. For foreign body removal the patient is placed in lying position, while a health worker is sited. Using a needle preferably 16 G or pointed paper held flat against the cornea, you can easily remove most of impacted foreign bodies. A small black piece of iris often comes through if there is a laceration. Do not mistake it for blood clots. If the foreign body cannot be removed, refer to a medical officer with antibiotic ointment in the eye and a firm eye pad.

• • • •

CATARACT This condition occurs mostly in the elderly (senile cataract) and affects usually both eyes. Rarely it may occur in the newborn or may be caused by trauma. Traumatic cataract is usually unilateral. The lens is milky white instead of being clear and as a result the pupils look white instead of black. If the cataract is causing difficulties in walking or affecting normal life, the patient should be referred to an eye specialist for operation. SQUINT Squint is a condition in which each eye looks in different direction and devoid of synchronised movements. It is usually congenital but rarely can be caused by trauma. If the eye that is not in line is not adjusted early, it can loose function. It is therefore, important that a child with a squint is referred early to an eye specialist for operation. clxiv

16.0 ANTISEPTICS AND ANTIBIOTICS IN SURGERY

16.1 ANTISEPTICS
A CRIFLAVINE It is a bacteriostatic antiseptic specifically good for gram-positive bacteria. It can be used for treatment of infected sores and wounds until they become clean. Prolonged use slows healing of the wounds and ulcers. It is not recommended in clean wounds or lacerations. CHLORCHEXIDINE (Hibitane) 0.5% alcoholic solution 0.1% aqueous solution

Advantages:
 Wide range of antibacterial activity, effective against gram negative and positive bacteria.  Aqueous solutions at this concentration free of toxicity to healing tissues.

Disadvantages:
• • • It does not kill Pseudomonas and some gram-negative bacteria invading old wounds and ulcerations. Ineffective against bacterial spores, viruses and fungi. May cause skin irritation.

Recommendations:
Limited use for wound cleansing. It is not advised to use it for wounds for more than 7 days because it slows down healing. Iodine or soap inactivates chlorhexidine so do not use them together.

CRYSTAL VIOLET (Gentian violet)

Advantages:

♦ It is cheap agent. ♦ Effective against some gram-positive bacteria and Candida.

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Disadvantages:
• • Antimicrobial activity is eliminated by wound discharge. In animal study shows carcinogenic properties

Recommendations:
It can be used for skin excoriations and primary skin infections; basically it is not recommended in wound care.

HYDROGEN PEROXIDE (3 - 6%)

Advantages:
⇒ Effective cleaner for dirty open wounds. ⇒ Debriding agent.

Disadvantages:
• • Not recommended in dressing because it can damage new tissue and delaying healing. Limited antibacterial property.

HYPOCHLORITES (e.g. Eusol, Milton)

Advantages:
♣ Wide antibacterial spectrum; ♣ Useful for instruments disinfection and cleaning.

Disadvantages:
• They are not longer recommended in wound care because they are toxic to healing tissues and significantly delays healing process.

IODINE (or Povidone iodine, Betadine)

Advantages:

♣ It is the best antiseptic used for skin preparation. It can be diluted with alcohol but diluting with water can deteriorate its antiseptic properties. Therefore for skin preparation - do not dilute povidone iodine with water! ♣ It has a wide antimicrobial spectrum (effective against bacteria, viruses, fungi, and spores).

Disadvantages:

♠ It does not penetrate deep into tissues. ♠ It damages tissue and slows down the process of healing. Diluted iodine with water or normal saline can be used for washing contaminated wounds. ♠ It can cause allergic reactions. clxvi

Recommendations:
It is used in skin preparation and for initial decontamination of traumatic wounds. It is not recommended for granulating wounds or wound irrigation. It is contraindicated in premature babies. SAVLON (Cetrimide + Chlorchexidine)

Advantages:
♦ Antiseptic against gram positive and some gram negative bacteria. ♦ Detergent (washing agent).

Disadvantages:
• • • • Toxic to granulating tissue. Deactivated by pus and organic material. May cause skin allergy. May be contaminated by pseudomonas bacteria.

Recommendations:
It is useful for cleaning dirty contaminated wounds e.g. grease and gravel; but should not be used on clean wounds or for dressing wounds. It is also used for hand washing, disinfecting instruments and surface cleaning. GLUTARALDEHYDE (Cidex) It is used as a 2% solution. It has wide antimicrobial spectrum and disinfects in 10 minutes but to kill spores, it needs 10 hours. It is very potent irritant, so keep it away from the skin. MERCUROCHROME Mercurochrome is a very weak antiseptic and is toxic to tissue. Therefore it is not recommended in wound care. BLEACH Bleach is a cheap and high-level disinfectant in inactivating bacteria, viruses, fungi and some spores. It also kills HIV and Hepatitis B viruses. Contaminated instruments or linen should be soaked for 20 minutes. Bleach corrodes metals so soaking over a long period of time is not recommended. Always rinse thoroughly with clean fresh water before storing or sterilizing Bleach solutions should be stored in a glass or plastic containers and the solution replaced daily because the solution looses its activity over time and when exposed to sunlight. clxvii

For disinfection the recommended strength is 0.5% solution. Bleach powder (from Medical Stores) One (1) part of bleach powder to nine (9) parts of water [mix well] Commercial household bleach solution (e.g. Snow White, Pacific, King, and Zixo) One (1) part of bleach to (6) six parts of water [1:6] When mixed well, both preparations will give 0.5% solution.

Figure 16.1-2 Preparation of bleach solution for disinfection.

Disinfection
• • • Skin Any alcoholic solution (70% alcohol) is good, but iodine is the best. Chlorchexidine in spirit is also a good disinfectant. Wounds Nothing will replace detailed washing and brushing with soap with plenty of boiled water (or Normal Saline). Sometimes diluted iodine with water can be used. Instruments, suture materials and drains. The following agents are effective against HIV and HBV (Hepatitis B virus) – soaking not shorter than 10 minutes: o 2% glutaraldehyde (the best); o 5% formalin in 70% alcohol;

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o 0.5% bleach (20 minutes).

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16.2 ANTIBIOTICS
A ntibiotics have two uses in surgery: - to treat existing infection - to prevent postoperative infection It must be reiterated that adhering to proper surgical procedures is more effective in preventing surgical wound infection than prophylactic antibiotic (see Wound management, chapter 3). The abuse of prophylactic antibiotics will encourage resistance to the commonly used drugs. Use of topical (local) antibiotics is not generally recommended Topical antimicrobials have not been proved to have any direct effect on wound healing but rather induce resistance and can often produce allergic reactions. Apart from all the topical preparations available in Health centres, only silver sulfadiazine should be used in the care of burn wounds. In order to avoiding superimposed infection where antibiotics may be required stick to the following surgical techniques: • Aseptic routine in an operating room. • Thorough wound washing, toilet and irrigation of the wound with Normal Saline is an important component of infection control and prevention. The removal of necrotic tissue, loose debris and clots removes the source of food for bacterial growth in the wound. • Removing or minimizing all foreign bodies left in the wound by o removing excessive clots, necrotic tissues; o stitches – use the smallest as possible; o gentle tissue handling will produce minimal amount of necrotic tissue; o ligate only the vessels where possible, ligation of vessels with surrounding tissue will leave a large necrotic pedicle; o ensuring that there is no dead spaces in the wound. • Close contaminated wounds, by delayed primary closure.

Principles of antibiotic treatment
• Antibiotics are expensive and can cause side effects. Therefore give antibiotics only when a patient will benefit from it. Remember that the mainstay treatment for subcutaneous abscess is incision and drainage. Antibiotic given to a physically fit patient in simple abscess is not warranted, it does not improve the results. If abscess is causing sepsis or is affecting a patient with weakened defence system (e.g. diabetic) or is occurring in the foot, hand or around upper lip, proper surgical management should be complemented with antibiotic.

•

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• • • • • • • •

Allergic reactions to antibiotic, such as skin rash, shortness of breath even anaphylactic shock are common side effects. Therefore always ask about history of allergy before giving an antibiotic. Notice that a patient allergic to penicillin should not be given antibiotics from in the penicillin group, such as Amoxicillin, Cloxacillin and Augmentin. Do not put topical antibiotic into a patient’s wound because they slow dawn healing, while their efficacy in preventing wound infection has not been proven scientifically. Generally start with a narrow-spectrum antibiotic, you expect the bacteria to be sensitive to, e.g. for urinary tract infection start with amoxicillin, if it does not work after 2-3 days change to chloramphenicol or gentamycin. Gentamycin, cephalosporin and quinolones should be the last choice in antibiotic therapy and should be basically restricted to hospital use. In any form of sepsis, antibiotics are beneficial, but they are not a substitute for an operation if needed. Proper doses (not too low) and duration of antibiotic (not too long) prevents the development of bacterial resistance. Prolonged use of antibiotic in low doses, less than the therapeutic requirement is associated with bacterial resistance.

AMOXICILLIN (Amoxil) 25 – 50mg/kg/dose I.V./I.M./oral; adults 500mg 8 hourly oral or 500mg to 1g 6 -8 hourly I.V./I.M. AUGMENTIN Augmentin is a combination of amoxicillin and clavulonic acid used against ampicillin resistant bacteria. In PNG it is mostly used to treat male urethral discharge and pelvic inflammatory disease in women (with other antibiotics, such as Amoxil and Azitromycin). It can be used for treatment of staphylococcal infections causing septic arthritis or osteomyelitis. AZITROMYCIN It is used to treat male urethral discharge, donovanosis and pelvic inflammatory disease. BENZYL PENICILLIN (Crystalline) Vial 1000 000 units (add 2 ml sterile water). Severe infections 4 hourly, moderate infections 6 hourly I.V./I.M. It is cheap and a pretty safe antibiotic. The main side effect is allergic reactions. It works well for gram positive bacteria and some anaerobes.

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CHLORAMPHENICOL In children - 25mg/kg body weight, but no more than 500mg per dose 6 hourly (QID) I.V./I.M./Oral; Adults 500mg to 1g QID I.V./I.M./Oral. It is a cheap but effective wide spectrum antibiotic covering gram-positive, gramnegative and anaerobes. It penetrates well to bones, joints, meninges and other organs. It is good for sepsis, peritonitis, meningitis, septic arthritis and osteomyelitis. CLOXACILLIN (Flucloxacillin) 25 – 50mg/kg per dose; 6 hourly I.V./I.M./Oral; Adults 500mg to 1g 6 hourly (QID) I.V./I.M./Oral. It works well against staphylococcus aureus responsible for osteomyelitis, septic arthritis and abscesses. COTRIMAZOLE (Septrin, Bactrim) [Trimetoprim 80mg + Sulfamethoxazole 400mg]; Trimetoprim 1.5 – 3 mg/kg BD Oral; Adults 2 tablets BD Oral; It is indicated for lower urinary tract infection in women and children. DOXYCYCLINE It has wide spectrum covering gram-negative and gram-positive bacteria. It should not be given to children under 15 years of age and to pregnant mothers. It is a good substitute antibiotic in the penicillin allergic patient. Adults: 1 tablet (100mg) BD. ERYTHROMYCIN 10 mg/kg per dose 6 hourly (QID), Oral; Adults 250 mg BD Oral; It works for gram-positive and anaerobes. GENTAMYCIN It is given in single daily dose. Adults and older children: 7 mg/kg day 1, then 5 mg/kg daily in one dose I.V./I.M. Neonate: 1st 5 mg/kg then 2.5 mg/kg daily; It works mostly against gram-negative bacteria. For abdominal sepsis, it should be combined with metronidazol (Flagyl). It is also good for urinary sepsis if cotrimazole or amoxicillin are not working. METRONIDAZOLE (Flagyl) Tab 200mg or 250mg; 7.5 mg/kg every 8 hours, any route (I.V./Oral/PR); Adults: 2 tabs TID [maximal 600-800mg TID]; per rectum adults 1g TID; I.V. 400500mg 8 hourly; It is very cheap and effective drug against anaerobes and amebiasis. It is recommended for abscesses and abdominal or pelvic sepsis.

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Suggested antibiotic therapy for surgical infections
CELLULITIS requires short debridement and 3-5 days of penicillin, or amoxicillin, or cloxacillin NECROTIZING FASCIITIS - radical debridement + penicillin group (crystalline) with metronidazole PYOMYOSITIS – incision and drainage + penicillin group + metronidazole All ABSCESSES require incision and drainage + antibiotic, if • Deep abscess; • Abscess on hands, foots or around the upper lip; • High risk patients, such as a patient with immune system defect (e.g. diabetic, AIDS, malnourished, old people); • Breast abscess at early stage; • Abdominal sepsis. In an abscess there is usually mixed infection with gram-positive, gram-negative and anaerobes. For this reason wide spectrum antibiotic cover should be administered (benzyl penicillin or amoxicillin + metronidazol; or chloramphenicol + metronidazol) UROLOGICAL SEPSIS It is caused mostly by gram-negative bacteria. If the condition of the patient is satisfactory give amoxicillin or cotrimazole. If the condition does not improve in 2-3 days add gentamycin to amoxicillin or switch to chloramphenicol. OSTEOMYELITIS OR SEPTIC ARTHRITIS Osteomyelitis or septic arthritis is caused mostly by gram-positive staphylococcus aureus. Give: Cloxacillin or chloramphenicol parenterally (I.V. or I.M.) for 5 days then follow on with one of these antibiotics orally for up to 4 weeks. LIVER ABSCESS Liver abscess is usually caused by amoebiasis – give metronidazol 600 – 800 mg TID for 10 days and Chloramphenicol for 2 weeks. In some clinical situations antibiotic doses have to be adjusted. Therefore refer the following patients: ⇒ Known liver or renal failure; ⇒ Allergic to penicillin (you can give erythromycin or chloramphenicol) ; ⇒ Newborn and over 60 years of age; ⇒ Pregnant mothers;

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⇒ Fever lasting over 7 days in spite of antimalarials and antibiotics.

17.0 ANAESTHESIA FOR HEALTH EXTENSION OFFICERS
By Dide Gertrude INTRODUCTION

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he administration of anaesthesia is an overwhelming responsibility, if performed by an inexperienced person. However, in order to administer any form of anaesthetic SAFELY, several important factors must be considered. These include availability of oxygen, means of oxygen delivery, a working suction machine with its accessories and intravenous access. Basic knowledge of Cardio Pulmonary Resuscitation (CPR) is a vital component of anaesthesia as well as basic knowledge of local anaesthetics, ketamine, opioids analgesics and diazepam. This chapter will be describing how to use local anaesthetics, ketamine and sedation safely. Other forms of anaesthesia MUST only be administered by an ATO, ASO, anaesthetic registrar or SMO.

17.1 PRE-ANAESTHETIC EVALUATION

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efore administering any anaesthetic, it is very important to establish whether the patient is fit for anaesthesia or not. A thorough history and examination of the respiratory and cardiovascular systems must be done. History should note the presence of any respiratory or cardiovascular diseases or infections, current drug treatment, smoking and alcohol consumption habits in adults, previous anaesthetics problems, allergies and finally, but not the least, what was the last oral intake and when was it taken. The neurological status of the patient must also be examined if the patient has any neurological complaints. Other systems should be checked if indicated. Premedication The aim of premedication is to • Relieve anxiety, • Provide analgesia, • Reduce secretions in the airways, • Acid secretion and content of stomach. It is therefore, not really necessary to give premedication unless the patient needs it.

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PREPARATION BEFORE ANY ANAESTHETIC PROCEEDURE Before any anaesthetic procedure, check that oxygen is available with means of administering it when it is required. Basic apparatuses are nasal specks, or clear plastic face mask (also known as Hudson mask), a Guedel airway and an ambu-bag. Check the suction machine and set it up ready for use. Check that adrenaline is available. Check that intravenous fluids, such as normal saline or Hartmann’s solution and intravenous catheters are available. Check that the blood pressure cuff is available and is functioning. Identify the patient to ensure that it is the correct patient. Check that the patient's chest and abdomen are not restricted by the patient's attire, if need be, remove all tight clothing around the patient's chest and abdomen and cover with a clean loose sheet. Lay the patient flat on the bed; insert a good intravenous catheter or scalp vein needle and secure it well with adhesive tape. Monitoring of patient's pulse and blood pressure is of paramount importance. Check the patient's blood pressure and pulse and record them before administration of the anaesthetic. It is very important to check these two vital signs especially before administering ketamine. LOCAL ANAESTHETICS Local anaesthetics are bases. They belong to two groups of chemical compounds, esters and amides. Esters are not in wide use anymore because of the dangerous adverse reactions. Lignocaine (Lidocaine, Xylocaine) is the safest and cheapest amide local anaesthetic agent. Other members of the amide type of local anaesthetics are bupivacaine, cinchocaine and ropivacaine which have more serious side effects and are used by anaesthetists only.

Lignocaine Physical properties
Lignocaine is produced as plain lignocaine or lignocaine with adrenaline. It comes in solutions containing different percentages of lignocaine such as 0.5% 1%, 1.5% or 2%, etc. Antimicrobial preservatives are added to multi-dose vials. The percentages represent the concentration of lignocaine per millilitre of solution. For example, a 1% lignocaine vial contains 1.0gm, or1000mg of lignocaine per 100ml, and therefore100mg per 10ml or 10mg of lignocaine per ml. Therefore, a 20ml vial of 1% lignocaine contains a total of 200mg. A 2% lignocaine vial will contain 20mg per ml, etc.

Mechanism of action
Lignocaine acts by blocking the propagation of action potential (nerve electric impulse) along the nerve by direct interaction with receptors on the Na + channels, inhibiting the entry of sodium ions into the cell. Other factors that affect the action of lignocaine include the pH of the tissue and addition of adrenaline. Injection of lignocaine directly into or around an abscess does not work because this tissue is acidic and local anaesthetics are weak bases. Combination of acid and base produces a neutral substance. Addition of adrenaline to lignocaine causes vasoconstriction of clxxv

the blood vessels at the site of injection and surrounding tissues. This slows the absorption of lignocaine into the blood stream and thus increasing the duration of action of the lignocaine. Lignocaine containing adrenaline MUST not be injected into areas with end arteries - these areas are the penis, the toes, the fingers, and the ear lobe.

Duration of action
The duration of action depends on the concentration of lignocaine used and addition of adrenaline.
Table 17-1 Duration of action and Dosage of lignocaine.

Anaesthetic technique Infiltration

Anaesthetic Plain lignocaine Lignocaine with adrenaline

Concentration (%) 0.5 - 1.0 0.5 - 1.0

Dosage range mls; (50 kg patient ) 1 - 20 1 - 35

Duration of action ( hours ) 0.5 - 2.0 1 - 3

Maximum Dosages of lignocaine: Plain lignocaine Lignocaine with adrenaline 3 – 4 mg/kg 7 mg/kg

Lignocaine with adrenaline MUST not be used in nerve blocks of the penis, digits and ear lobe, because they become gangrenous.

Toxicity of lignocaine
ALLERGIC REACTIONS True allergic reactions are very rare. Patients with history of hypersensitivity may react to methyl paraben, the preservative added to some lignocaine solutions. These may manifest as local or generalized erythema, urticaria, oedema, bronchoconstriction, hypotension, or cardiovascular collapse.

Treatment
Treatment is symptomatic and supportive. Intravenous phenergan 0.5 - 1.0 ml will control the local manifestations. Adrenaline 0.5 - 1.0 ml subcutaneously should be given if patient develops hypotension, bronchoconstriction and cardiovascular clxxvi

collapse. Intravenous normal saline should be given fast and patient should be given oxygen, with airway protected and transferred immediately to the nearest hospital. TOXIC REACTIONS Local toxicity is very rare. Systemic toxicity usually results from accidental injection or overdose. Accidental intravenous injection can be prevented by taking care to aspirate before injection, and injecting small volumes slowly and aspirating between each of the small volumes. Systemic toxicity affects the central nervous system and cardiovascular system. CNS TOXICITY It manifests as light-headedness, tinnitus, metallic taste, visual disturbance, and numbness of lips and tongue. These may progress to muscle twitching, loss of consciousness, grand mal seizure and coma. CNS toxicity is exacerbated by carbon dioxide retention, hypoxia and acidosis.

Treatment
• • • Give oxygen. If patient has fits or convulsions, give intravenous diazepam (0.2 -1.0ml); slow! If the patient is breathing well, turn the patient onto his/her side in the coma (recovery) position. If not breathing use ambu-bag.

CARDIOVASCULAR TOXICITY Cardiovascular toxicity is manifested by severe hypotension, tachycardia and cardiac arrhythmias, which eventually lead to circulatory collapse.

Treatment

♦ Give oxygen and intravenous normal saline infusion or gelafundin or haemacel to maintain haemodynamic stability. ♦ Transfer the patient to the nearest hospital if intra-venous fluid therapy does not improve or maintain haemodynamic stability.

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17.2 LOCAL ANAESTHETIC TECHNIQUES

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he choice of local anaesthetic technique depends very much on the site of injury as well as the factors discussed already. Local infiltration blocks, digital nerve blocks or ring blocks and penile blocks are simple blocks to perform. Always aspirate for blood before injecting, to avoid intravascular injection. LOCAL INFILTRATION Plain lignocaine should be used on the ear lobe, fingers and toes, and in penile blocks. For lacerations or lumps, on sites other than those mentioned above, lignocaine with adrenaline is preferable to prevent excessive blood loss. • A 22 -24 gauge needle is inserted at one end of the laceration or lump subcutaneously, and 1 -2 mls of the calculated lignocaine is injected. Use 0.5% Lignocaine. If large volumes are needed, dilute with equal amount of normal saline to 0.25%. • Then as the needle is advanced, aspirations are done before more lignocaine is injected • After the skin has been anaesthetized the needle can be advanced deeper. • The procedure is repeated as for the subcutaneous injection. The calculated total dose required for the patient should NOT be exceeded.

DIGITAL NERVE BLOCK

Dorsal and ventral digital nerves

Figure 17.2-1 Digital nerve block

• •

Using a 10.0ml syringe, take 4 -6mls of 1.0% plain lignocaine. Then with a 24 - 26 gauge hypodermic needle attached to the syringe; insert the needle at the medial surface of the base of the affected finger or toe on the back of the hand or foot. Inject 2 -3mls of the plain Lignocaine near the periosteum. clxxviii

• •

Repeat the above step. Insert the needle at the lateral surface of the affected digit and inject 2 - 3mls of the plain Lignocaine. Wait for 5 -10 minutes before performing the surgery.

Complication
Nerve injury. If the patient complains of an “electric shock “down the finger, move the needle tip before injecting. RING BLOCK
Figure 17.2-2 Ring block

A ring block can be performed by • inserting a 23 -24 gauge needle at the base of the digit, • then inject 2 -3mls of 0.5 -1.0% plain lignocaine and • then advance the needle in a fan shape on either side of the digit, aspirating before injecting the lignocaine. (This block can also be done on the penis but using larger volume of 5 - 15mls of plain lignocaine).

PENILE BLOCK
Figure 17.2-3 Penile block

Dorsal penile nerve

•

• •

•

15.0mls of a 0.5 - 1.0% plain lignocaine is injected via a 24 gauge needle in adults. The volume is less for children according to the dose required. The needle is inserted at the base of the penis and 2 5mls are injected. Then the needle is advanced 2 - 4cm lateral to the base on both sides, injecting 2 5mls on each side. This is adequate to perform minor surgery on the penis.

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•

Remember to aspirate for blood before every injection.

Another technique is to block the dorsal nerve of the penis. • A 24 gauge needle is inserted 2cm lateral to the base of the penis, first on one side and then on the other. - 5mls of plain lignocaine is injected. • Then it is inserted again 2cm lateral to the base of the penis on the opposite side. Another 2 - 5mls of plain lignocaine is injected.

Complications
Intravascular injection can be avoided by careful aspiration before injection each time the needle is moved. Injection of large volumes of local anaesthetic can compress or obstruct blood flow to the penis and cause ischaemia.

17.3 INTRAVENOUS ANAESTHETIC AGENTS
K ETAMINE Ketamine is a very useful anaesthetic agent with both anaesthetic and analgesic properties. It is commonly prepared and produced in 10ml vials, but is also packed in 2.0ml ampoules. In PNG, there's only 10.0ml vials. The 10.0ml vial contains 500 milligrams, with each millilitre containing 50.0 milligrams. It can be administered intravenously or intramuscularly.

Uses
Ketamine is used mainly in anaesthesia as an anaesthetic agent for surgery. Because of its bronchodilatory effects it can be used in the treatment of severe asthma.

Dosage
Intramuscular Intravenous 5.0 - 10.0mg/kg 2.0mg/kg 1.0mg/kg initial bolus dose repeated doses

These repeated doses can be given after 15 - 20 minutes, if the surgery is prolonged more than 30 minutes. Care must be taken to establish intravenous access after I.M. injection. The patient is anaesthetized within 5 minutes following intramuscular injection and within 30 - 60 seconds following intravenous injection. Its effect lasts 15 - 30 minutes.

For treatment of severe asthma
Initial bolus dose - 0.5 - 1.0mg/kg i.v.. Check for any improvement in air-entry and wheezing or rhonchi. Consult a medical officer if patient does not improve.

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It is metabolized by the liver, and therefore, should be used with caution in patients with liver disease.

Pharmacodynamics (ketamine's effects on the body)
CNS EFFECTS Ketamine produces a "dissociative" state accompanied by amnesia and loss of consciousness. It increases cerebral blood flow, thus increasing intracranial pressure and cerebral metabolic rate. CVS EFFECTS Ketamine indirectly increases heart rate and systemic blood pressure by stimulating catecholamine secretion. However, if administered to patients in hypovolemic shock, spinal shock and those patients who are already stressed with increased catecholamines in circulation, ketamine may cause myocardial depression. RESPIRATORY EFFECTS Ketamine very often causes a transient period of apnoea. It causes mild respiratory depression, reduction in tidal volume and respiratory rate. Ketamine indirectly produces bronchodilatation by stimulating catecholamine release. Laryngeal reflexes are maintained. CONTRAINDICATIONS Due to its increased sympathetic activity Ketamine should not be administered to patients with hypertension, tachycardia, head injuries, space-occupying lesions and un-controlled diabetes with very high blood glucose levels. ADVERSE EFFECTS • Increased oral secretions. • Emotional disturbances. The patient can become restless and agitated during the anaesthetic or may have delusions and hallucinations (bad dreams). These can sometimes be very nasty. Premedication with diazepam helps reduce these unwanted side-effects. • Muscle tone is increased. Ketamine often produces focal muscle twitches. Fracture reduction may be difficult if skeletal muscle tone is increased. Diazepam premedication helps to prevent this. • Ketamine increases eye movements, nystagmus, diplopia and increased intra-ocular pressure. Therefore, it should not be used in closed eye surgery or patients known to have raised intra-ocular pressure. DIAZEPAM Diazepam belongs to the family of benzodiazepines. Other members of benzodiazepines include midazolam, and lorazepam. These drugs are used for sedation or as adjuncts to general anaesthesia. Diazepam is a greenish yellow oily liquid solution packed in amber glass ampoules. It comes in 2.0ml ampoules clxxxi

containing 10.0 milligrams, with each millilitre containing 5.0 milligrams. There are 10.0mg tablets also available.

Metabolism
Diazepam is metabolized in the liver. The duration of action of diazepam is 20 hours. An active metabolite is produced during its metabolism which is responsible for its actions for more than 72 hours or longer. In the elderly and patients with liver disease, the duration may be longer; therefore smaller doses may be required.

Dosage
Oral premedication in adults - 5.0 - 10.0mg, 1 - 2 hours prior to anaesthesia. ` Intravenous 0.3 - 0.4mg/kg; Incremental intravenous dose in adults is 2.5 - 5.0mg.

Pharmacodynamics
CNS EFFECTS Diazepam produces amnesia, anticonvulsant, hypnosis, muscle relaxation and sedation. Peak effect occurs after 4 - 8 minutes following intravenous administration. CVS EFFECTS: Diazepam causes a mild systemic vasodilatation and reduction in cardiac output. RESPIRATORY EFFECTS With the usual sedative doses diazepam produces a mild decrease in respiratory rate and tidal volume. Respiratory depression may be marked, if administered with a narcotic, in patients with lung disease, or in debilitated patients. Caution !! Advise your patient not to drive, swim, sit near the fire alone or drink alcohol for the next 3 days after administering diazepam to them. ADVERSE EFFECTS • • Phlebitis Intravenous injection of diazepam causes venous irritation and pain along the distribution of the vein. Therefore, always dilute the drug with sterile water or normal saline before giving it. • • Epileptic fits in patients on sodium valproate (anti-convulsant), if they are given diazepam. • • Congenital birth defects have been found in babies of women who had taken diazepam during pregnancy. These babies may be born with cleft lips and palates. • •When administered to mothers during labour, diazepam crosses the placenta and can cause CNS depression in the newborn baby.

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17.4 OPIOID ANALGESICS
P ETHIDINE and MORPHINE Pethidine and morphine are the most commonly used opioid analgesics. Morphine is prepared as suppositories, powder, tablets and injection while pethidine comes in injection only. Both are very strong analgesics.

Mechanism of Action
The central nervous system contains opioid receptors in the brain and the spinal cord which participate in transmission and perception of pain. These receptors also play a role in the behaviour of the patient in relation to the pain experience. Opioids such as pethidine and morphine bind to these receptors and block the transmission of pain, simultaneously elevating the patient's mood, affecting their behaviour. The intensity of pain is reduced and the patient feels comfortable.

Metabolism and Excretion
Morphine and pethidine are metabolised in the liver and chiefly excreted by the kidneys. Metabolism of morphine produces a by-product, which is just as active as morphine. In patients with renal failure, this metabolite can accumulate and may lead to prolonged and more pronounced analgesia. The metabolite of pethidine is quite toxic and can accumulate in patients with reduced renal function or those receiving very high doses of pethidine. In very high concentration, this metabolite can cause seizures, especially in children. Morphine is the best drug to use when repeated doses are required, as in cancer pain.

Dosages and Duration of action
Pethidine is available as injection only and can be administered intramuscularly or intravenously. The analgesic effect peaks in 2 hours and by 4 hours this effect is diminished after intramuscular injection.

Dosage
For intramuscular injection 0.5 - 1.0mg/kg; For intravenous injection 0.2 - 0.5mg/kg; This dose can be repeated every 15 - 20 minutes until the patient is pain free and comfortable. Morphine peaks in its action within 1 hour of administration and lasts for 5 - 6 hours. It is more potent than pethidine (this means a smaller dose of morphine will give the same analgesic effect of a larger dose of pethidine). 10mg of Morphine is equivalent to 100mg of Pethidine.

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Dosage
For oral, subcutaneous and intramuscular administration For intravenous injection 0.05 - 0.2mg/kg 0.03 - 0.15mg/kg

REMEMBER!! 1) NEVER give intramuscular morphine or pethidine to anybody in shock or unconscious. 2) ALWAYS monitor the patient's level of consciousness, pulse, blood pressure and respiration EVERY 15 minutes when administering INTRAVENOUS opioids.

Pharmacodynamics
Generally, both pethidine and morphine have the same CNS effects; however, there are some differences in other organ systems that will be mentioned. CNS EFFECTS: • The central nervous system is depressed, thus the respiratory and vasomotor center are depressed. As a result, respiration may be depressed and vasodilatation may occur in the peripheral vascular bed leading to mild venous stasis and reduction in venous return to the heart and eventually reduction in systemic blood pressure. • Opioids stimulate the medullary chemoreceptor trigger zone (vomiting center), causing nausea and vomiting in susceptible individuals. • Analgesia and sedation • Euphoria • Pupillary constriction (myosis) CVS EFFECTS Pethidine tends to increase heart rate and blood pressure in haemodynamically stable subjects but will decrease both in the unstable patient. Morphine on the other hand, will reduce heart rate and blood pressure in the compromised patient which may also be secondary to histamine release. RESPIRATORY SYSTEM EFFECTS Morphine causes bronchoconstriction as a result of its tendency to release histamine; therefore, it should be avoided in asthmatics and patients with history of allergies. Pethidine does not posses histamine releasing properties and so has been the opioid of choice for patients with histories of allergies. GIT EFFECTS Both pethidine and morphine affect the gastrointestinal motility and delay gastric emptying time. They increase intestinal tone and biliary tract tone causing intestinal and biliary spasm. Patients suffering from intestinal or biliary colic are worse when given morphine. Constipation is a common side effect of opioids.

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GUS EFFECTS Renal blood flow is reduced as a result of the CNS depressant effect, thereby, decreasing renal function. Ureteric colic is increased in the patients with ureteric calculi. Bladder sphincter tone is increased and so there is urinary retention. Administration of morphine and pethidine during labour may prolong labour. ENDOCRINE EFFECTS Histamine release causes not only bronchoconstriction but pruritis and urticaria. This is more common with morphine than pethidine. TOXICITY AND UNDESIRED EFFECTS 1. Tolerance. Patients develop tolerance to the opioid at the start of treatment, but don't usually show the signs until after 2 - 3 weeks of frequent treatment with therapeutic doses. The patient requires higher doses of the opioid each time to relieve his or her pain. 2. Physical dependence. With constant regular high doses of opioids, over a long period of time the patient can develop tolerance and physical dependence. Ceasing the opioid will trigger a withdrawal state where the patient can present with the following signs and symptoms - lacrimation, yawning, rhinorrhea, chills, gooseflesh, hyperventilation, hyperthermia, mydriasis (dilated pupils), muscle aches, vomiting, diarrhoea, anxiety and hostility. Administration of an opioid at this stage will suppress the symptoms. 3. Psychological dependence. This occurs in people who take opioids for the euphoric state they experience with the drugs. It rarely occurs in individuals who are in pain. To prevent tolerance, physical and psychological dependence small doses of opioids should be given at longer intervals in combination with other non-opioid analgesics such as paracetamol, indomethacin or aspirin in the treatment of pain.

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18.0 EMERGING DISEASES IN SURGERY

A CQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) Human immunodeficiency virus (HIV) infection has become a worldwide pandemic. The risk of surgeons becoming infected by HIV, hepatitis C virus (HCV) or hepatitis B virus (HBV) has changed local polices on infection control regarding protection against viral infections. Needle stick injury during surgery carries a transmission risk of about 0.3 per cent for HIV, about 3 per cent for HCV and around 30 per cent for HBV. HIV retrovirus is attacks and destroys the T-killer lymphocytes (type of white cells) causing deterioration of the immune function. Weakened defence system making an individual infected with HIV more prone to opportunistic infections, such as oral thrush (candidiasis), TB, other rare viral and parasitic infections. The tumours associated with HIV infection belong to the lymphomas, Kaposi sarcoma, and the mouth and anal cancers.

Universal precautions against HIV and Hepatitis include:
As a standard precautionary measure to treat all patients as if infected with HIV: • Hand washing is the single most important procedure for prevention of hospital acquired infection. Skin that is intact without abrasions or cuts is a natural defence barrier against infections. Any skin defects e.g. cuts less than 48 hours old, moist areas of dermatitis, ulcers should be covered with a waterproof dressing before commencing duty. • Health workers with any break in the skin or a weeping skin lesion should refrain from contact with any patient or the handling of patients’ care equipment until the skin is healed. • All blood and body fluids must be considered contagious and should not be allowed to come in contact with skin and mucous membranes. • Gloves should be used when there is likely to be in contact with blood or a body fluids or material contaminated with blood items such as soiled linen. • Masks and eye-wear should be worn where splattering of blood is likely e.g. orthopaedic surgery or dental procedures. • Gowns/aprons should be worn where splashing of blood is likely (childbirth, surgery etc.) • Sharp instruments should not be passed to or from surgeons to assistants. Such instruments should be placed on a kidney dish. • Ensure that all instruments are passed with the eye contact to avoid ’stick’ injury. • Do not bend, break or recap disposable needles. They should be disposed of immediately after use with their attached syringe into a thick puncture resistant cardboard, plastic, glass, or metal disposal container called SHARPS BOX. All Health Care Workers must ensure that uncapped needles after use are not left lying around, as a potential source of injury to fellow workers.

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•

Other used disposable sharp objects should also be placed in the containers as described above. The full containers should be carefully sealed for burning or buried in sanitary landfills. • Protective footwear e.g. gumboots should be worn during obstetric and surgical procedures. • When suturing, a needle holder and forceps should be used. • Newborn babies should be resuscitated with plastic or mechanical devices. Avoid mouth to mouth resuscitation in the delivery suite or emergency room. Resuscitation bags should be available. There is no scientific reason for healthy person to be excused from providing care to person infected with HIV. First aid in the event of a needlestick or other lacerating injury: After exposure to HIV (needle injury or other skin injury having contact with infected blood of the sero-positive patient) • Wash the wound off with soap or 1% hypochlorite; soak with iodine. • Squeeze the cut or even puncture to encourage bleeding. • Report to supervisor and Provincial Disease Control Officer who will do a series of blood tests. • Pre- and post-test counselling is standard practice. • Anti-HIV drug can be considered. • UK guidelines1 recommend administration within 1 hour (acceptable up to 72 hours) o Zidovudine - 1000mg daily for 4-6 weeks (confers about 80% of protection); o It is possible to administer combination therapy; o Protection is not absolute, while side effects are common. • Rest 3-6 months, refrain from blood donation, practice safe sex. HEPATITIS B VIRUS INFECTION (HBV) Hepatitis B viral infection is a common infection in PNG where an estimated one third of population are infected. HBV virus is transmitted through contact with blood, (e.g. blood transfusion, tattooing, needle stick injury) or body fluids; via sexual route or through contact with the infected with open sores. In case of needle stick injury from HBV sero-positive patient ♠ Follow the first three points regarding needle stick injury infected with HIV. ♠ Give HBV immunoglobin within 24 hours and start vaccination with boosters at one and eight months.
1

Department of Health. HIV post-exposure prophylaxis: guidelines from the UK Chief Medical Officers’ Expert Advisory group on AIDS. 2000: 1-34.

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♠ It is better to prevent infection by getting immunized against the HBV infection.

DIABETES IN SURGERY Diabetes mellitus is a very common disease in western societies, but its prevalence is increasing in PNG. In total it affects 6% of world population. In PNG, the commonly affected ethnic groups are the Tolais, Bouganvillians and Papuans. It is commonly type 2 diabetes (not insulin dependent) seen, particularly in overweight adults from costal areas. Diabetes is a disease in which blood sugar is elevated while cells are starving because of the lack of insulin which is required to move the sugar into the cells. Diabetics are often diagnosed in surgical ward or as they present to the hospital for other reasons. Therefore patients with the following clinical presentation should be checked for diabetes (blood sugar level - BSL) with a multistix or more convenient urine for sugar with a glucostix. ⇒ Foot infection or foot sepsis ⇒ Chronic foot ulcer ⇒ Multiple, recurrent abscesses (boils) ⇒ Balanitis (infection of the glans of penis) ⇒ Acute abdomen in ketoacidosis (vomiting, abdominal pain, tender abdomen) DIABETIC FOOT Diabetes is a leading cause of leg amputations and digital amputation. Advanced diabetes affects the nerves and the circulation in the feet resulting in the legs losing sensation and becoming more prone to traumatic injuries.

Treatment
• • Infection or chronic ulcer in the foot should be checked for blood sugar level, especially if the patient is overweight and over 30 years old. A known diabetic patient with foot infection or ulcer should be o commenced on wide spectrum antibiotics, such as penicillin + flagyl or amoxicillin + flagyl or cloxacillin + flagyl or chloramphenicol; o referred to a surgeon. All wet necrosis in the foot of a diabetic patient required immediate debridement.

• • • • •

Prophylactic of diabetic foot
Instruct all diabetics that any slightest trauma to the foot can result in severe infection and even foot amputation. Diabetics with anaesthetized foot should be protected with well-fitted shoes; diabetics should never walk barefooted! Daily self-examination allows early detection and treatment of any foot injury The skin of diabetic foot is generally dry and cracks easily therefore a cream (or oil) should be used to moisten the dry skin.

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•

Loosing weight, avoiding stress, good diet and plenty of exercises will help to bring the sugar level down. A well-controlled sugar level prevents foot infection and other complication of diabetes.

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19.0 HEALTH WORKER ETHICS

A

Medical worker has two cardinal moral duties – to protect life and health on one hand, and to respect human dignity on the other with the rights to make decisions about their personal life. Those involved in health care should always put patients’ benefits as a priority and providing the care that is entrusted upon them as professional health worker with dignity, ensuring equality irrespective of line, race and religion. INFORMED CONSENT As a gesture of respect for patients’ life and autonomy they have right to be properly informed about all advantages and disadvantages of the planned procedure. The health worker must find time to dialogue with the patient and reply to questions asked. The person obtaining consent should be the health worker who is tasked to carryout the procedure. The information about a procedure should include: • Why a surgical procedure should be done? • How does it correct the disease? • What is the prognosis (outcome)? • What is the risk of complications and death? • What are the consequences of no treatment? The best way to make sure the patient understand our explanation is to ask him/her to repeat it in his own words. CONFIDENTIALITY Health workers have a duty to respect patient’s right to confidentiality. It means that information obtained during treatment must not be revealed to anyone else. This rule, respect patients’ right to privacy, and enhance a sense of trust with health professionals. RESPONSIBILITY TO IMPROVE PROFESSIONAL QUALIFICATIONS As a part of the duty to protect life and health of the human race, the health workers have a responsibility to improve professional knowledge and skills through the selflearning process.

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REFERENCES
Adams, G.L, Boies, L.R., Paparella, M.M. (1978). Fundamentals of otolaryngology. London: Saunders Company. Adams, J.C., Hamblen, D. L. (1999). Outline of Fractures. London: Churchill Livingstone. Adams, J.C., Hamblen, D. L. (2001). Outline of Orthopedics. London: Churchill Livingstone American College of Surgeon. (1999). Advanced Trauma Life Support for Doctors (ATLS) (6th ed.). New York: American College of Surgeon. Ashcraft, K.W., Murphy, J.P., Sharp, R.J., et al. (2000). Pediatric surgery (3rd ed.). Philadelphia: Saunders Company. Condon, L.M., Nyhus, R.E. (1995). Manual of Surgical Therapeutics (8th ed.). London: Little, Brown and Company. Cook, J., Sankarah, B., Wasunna, A. E. O. (1988). General surgery of the district hospital. Geneva: WHO. Department of Health. (2000). HIV post-exposure prophylaxis: guidelines from the UK Chief Medical Officers’ Expert Advisory group on AIDS. UK. Galbraith, J. E. K. (1979). Basic eye surgery. A manual for surgeons in developing countries. London: Churchill Livingstone. Gill, J. K., Vincent, A. L., Greene, J. N., et al. (2002). Amoebic liver abscess. Infections in Medicine, 18 (12), 548-553. Hoppenfeld, S. (1976). Physical Examination of the Spine and Extremities. New York: Prentice-Hall, Inc. Huckstep, R. L. (1995). A simple guide to Trauma (5th ed.). London: Churchill Livingstone. Katzung, B. G. (2001). Basic and Clinical Pharmacology. (8th ed.). USA: Lange Medical Books McGraw Hill. King, M., Bewes, P., Cairns, J., Thornton, J., et al. (1993). Primary surgery (Vol. 1 & 2). Oxford: Medical Publications. 1 Morgan, G. E., Mikhail, M. S., Murray, M. J., Larson, C. P. (2002). Clinical Anaesthesiology (3rd ed.). USA: Lange Medical Books McGraw Hill. cxci

2 Norton, J. A., Bollinger, R. R., Chang, A. E., et al. (2000). Surgery. Basic science and clinical evidence. New York: Springer. Rosenfeld, J. V., Watters, D. A. K. (2000). Neurosurgery in the Tropics. London: Macmillan Education LTD. Russel, R.C.G., Williams, N.S., Bulstrode, C.J.K. ( 2000). Bailey and Love’s Short practice of surgery. (23rd ed.). London: Arnold. 3 Scott, D. B. (1989). Introduction to Regional Anaesthesia. USA: Appleton and Lange Mediglobe.

St John Ambulance. (2001). Australian First Aid ,Manual of St John Ambulance. Watters, D. A. K., Wilson, I. H., Leaver, R. J., (2004). A. Care for the critically ill patent in the tropics (2nd ed.). Malaysia: Macmillan Education.

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INDEX A
Abdominal injury · xxi abdominal wound · xxi blunt abdominal injury · xxi Abscess · amoebic · lxxxvii boil · xci breast · lxxxv carbuncle · xci general treatment · lxxxiii incision and drainage · lxxxiv Ludwig's angina · lxxxvi mastitis · lxxxv paronychia · lxxxviii perianal · lxxxvi pulp space · lxxxix suppurative tendosynovitis · xc Acquired Immunodeficiency Syndrome · clxxxvi needle injury · clxxxvi Acute abdomen · xcix abdominal pain · xcix amoebiasis · cvi diagnosis · xcix general managmement · ci malaria · cvi meningitis · cvii pelvic inflammatory disease · cviii peptic ulcer perforation · cvii ruptured ectopic pregnancy · cviii strangulated hernia · cvii typhoid fever · cvi vomiting · xcix Acute limb · xciii Acute scrotum · cli Anaesthesia · clxxiv digital nerve block · clxxviii lignocaine · clxxv local infiltration · clxxviii penile block · clxxix diazepam · clxxxi ketamine · clxxx pethidine · clxxxiii Antibiotics · clxx abscesses · clxxiii amoxicillin · clxxi azitromycin · clxxi cellulitis · clxxiii chloramphenicol · clxxi clotrimazole · clxxii cloxacillin · clxxii crystalline · clxxi doxycycline · clxxii erytromycin · clxxii gentamycin · clxxii liver abscess · clxxiii metronidazole · clxxii osteomyelitis · clxxiii urological sepsis · clxxiii augmentin · clxxi treatment principles · clxx

Antiseptics · clxv acriflavine · clxv chlochexidine · clxv crystal violet · clxv hydrogen peroxide · clxvi hypochlorites · clxvi iodine · clxvi bleach · clxvii savlon · clxvii Antiseptics · glutaraldehyde · clxvii Anus · anal fissure · cx anal fistula · cx anal pain differential diagnosis · cx haemorrhoids · cx Appendicitis · civ Arthritis · differential diagnosis · cxxii septic · cxxii tropical · cxxiii

B
Back pain · cxxv Balanitis · clv Burkitt's lymphoma · cxxxiv Burns · xlv early managment · xlvii local treatment · xlix percentage of skin affected · xlv transfer criteria · l Bursitis · cxxiii

C
Cancers · cxxxiv anal · cxxxviii breast · cxxxiv colo-rectal · cxxxvii liver · cxxxvi lung · cxl mouth cancers · cxxxiv oesophagus · cxxxvii pain control · cxliii penis · cxl primary care level · cxlii prostate · cxl skin · cxxxv stomach · cxxxviii terminal care · cxlii urinary tract · cxxxix Cellulitis · xci Chest injury · xvi, xx Chest injury · cardiac tamponade · xix chest wound · viii, xviii, xx first aid · xx flail chest · xviii hemothorax · xix Circumcision · cliii Congenital abnormalities · cxii abdominal wall defects · cxiii bow legs · cxix

cxciii

club foot · cxvi dislocation of the hip · cxix extra digits · cxix hare lip · cxiv Hirschprung disease · cxiii hydrocele · cxv hydrocephalus · cxiv inguinal hernia · cxv pyloric stenosis · cxii subgalleal cyst · cxv undescended testis · cxv wreck neck · cxv imperforate anus · cxii

G H

supracondylar fracture · lxviii test of bone union · lx tibia · lxxiv, lxxv wrist and hand · lxxi

Gastro-intestinal bleeding · ciii Glasgow Coma Scale · vi, x, xi, xii Head injury · xi, xii, xiii, xv Hematuria · cxlviii Hernia · diaphragmatic · cxiv hip stone · cxxiv Hydrocele · clvi Hypospadiasis · clvi

D
Dermoid cyst · cxxxi diabetes mellitus · clxxxviii Diabetes mellitus · diabetic foot · clxxxviii Dislocations · acromio-clavicular joint · lxxvii diagnosis · lxxv elbow · lxxix hand joints · lxxx hip · lxxxi jaw · lxxvi shoulder · lxxvii dysuria · cl

I
inflammation · lxxxiii Ingrowing toe nail · cxxiv Intestinal obstruction · cii diagnosis · cii management · ciii Intraosseous puncture · xxxiv

L

E
Ear · foreign body · clxii Ear discharge · clvii Earache · clvii Epispadiasis · clvi Epistaxis · clx Eye · clxiii blunt injury · clxiii foreign body · clxiv penetrating injury · clxiii cataract · clxiv

lignocaine · clxxv Lignocaine · dose · clxxvi toxic reactions · clxxvi Ludwig's angina · clx Lymph node biopsy · cxxviii

M
Mastoiditis · clvii Melanoma · cxxxvi

N O

Neck injury · xvi Osteomyelitis · cxx Osteyomyelitis · differential diagnosis · cxxi treatment · cxxi Otitis externa · clviii Otitis media · clvii

F
Fractures · lv applicaton of arm sling · lx classification · lv clavicle · lxvii collar and cuff · lx Colles' fracture · lxix compartment syndrome · lxv diagnosis · lvii femur · lxxiii first aid · lviii foot · lxxv forearm · lxix Gallow's traction · lxxiv hip · lxxiii humerus · lxvii knee · lxxiv opened fractures · lix pelvis · lxxii POP technique · lxii skin traction · lxi

P
Paraphimosis · cliv Perianal abscess · cx Peritonitis · cii Phimosis · cliii Pigbel · cvi Pneumothorax · viii, ix, xvii, xviii, xix, xx tension pneumothorax · ix, xx Pressure sores · xxv Pyloric stenosis · cxiii Pyomyositis · xcii

R

Rectal cancer · cxi Rectal prolapse · cxi Renal colic · cxlix Resuscitation · vi

cxciv

airway maintenance · vii artificial ventilation · viii primary survey · vii

inserting urinary catheter · cxlvii

V
Venous cut-down · xxxii

S
Scalp laceration · xiii treatment · xiv sebaceous cyst · cxxxi sexually transmitted diseases · cli Shock · xxvii septic shock · xxx types · xxvii anaphylactic shock · xxx cardiac shock · xxix estimation of fluid or blood loss · xxviii Sinus · xcvii Skin biopsy · cxxxv Skull fracture · depressed skull fracture · xv open skull fracture · xiv Skull fractures · xv Spinal injury · xxiii Stone · cxlix bladder · cl kidney and ureteric · cxlix

W
Wax plug · clviii wound · classification · xxxvi crushed wounds · xxxvi Wound · xv, xviii, xxi, xxxv, xxxviii, xlix, li, xcvii Wound · punctured · xxxvii factors influencing healing · xxxv first aid · xxxv management · xxxviii suture technique · xli

Y
Yaws · xcvii

T

Tendon injury · xli Tetanus · prevention · xxxviii Tonsillar abscess · clix Tuberculosis · cxxvii abdominal tuberculosis · cxxix tuberculous arthritis · cxxix tuberculous lymphadenitis · cxxvii tuberculous pericarditis · cxxx tuberculous spondilitis · cxxix Tumours · cxxxi abdominal · cxli bone · cxli fibroma · cxxxii intracranial · cxli jaw · cxxxiii malignant · cxxxiii pyogenic granuloma · cxxxiii salivary cyst · cxxxiii thyroid gland · cxxxii lipoma · cxxxii

U

Ulcers · xciv malignant ulcer · xcv Myobacterium ulcerans ulcer · xcv trophic ulcer · xcvi trophic ulcer, prevention · xcvi tropical ulcer · xciv yaws · xcvii undescended testis · clii urethritis · cl Urinary tract infection · cl Urine retention · cxlvi causes · cxlvi

cxcv

cxcvi