Compartment syndrome

Compartment syndrome - is increased tissue pressure within a tight fascial compartment, resulting in tissue ischemia.
- commonly occurs in the anterior lower leg.

Pathology:
- compartment syndrome is the self progressive cascade of events, begin with tissue edema that usually occur following injury.
- when edema occur in anterior or posterior fascial compartment, there is limit room for tissues expansion and compartment/interstitial  pressure increase.
- when compartment pressure exceeded 20 mmHg, tissue perfusion decrease or cease.
- because 20 mmHg is very low than arterial blood pressure, cellular flow can be occluded before pulse loss.
- as a result of occluded blood flow tissues ischemia develop and further worsening edema in a vicious cycle.

Aetiology:
Common cause of compartment syndrome include,
- fractures
- severe contusion
- rarely spiders and snakes bites

Symptoms :
- the early symptom are the progressive pain, worse in leg muscles stretching.
- later symptoms of ischemia are "5 P's" which includes ,

• Pain
• Paresthesias 
• Paralysis 
• Pallor 
• Pulselessness

Diagnosis:

- measure compartment pressure ( normal is <_ 20mmHg ) by using wick catheter.

Treatment:

- for <40 mmHg raised compartment  pressure, Antipain drugs, elevation and spilnting  can be done. 

- for >40 mmHg increased  compartment pressure, immediate fasciotomy is done to relieve pressure. 

- in some cases pulselessness or pallor develop, indicating necrosis. Amputation is needed in cases of necrosis. 

Complications:

- necrosis 

- infection 

- amputation 

- rhabdomyolysis. 

Thanks 

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Gastroschisis

-Gastroschisis is the protrusion or extrusion of abdominal viscera through a defect in the abdominal wall, usually in the right side of umbilical cord insertion. 

- Gastroschisis is one of congenital disorder occur due to defect in anterior abdominal wall closure, allowing protrusion of the viscera.

- More common in males than females babies.

- The anomaly results from incomplete closure of lateral fold during the fourth weeks of development.

- In gastroschisis there is no membrane covering the intestine, as a result edema and erythematus of intestine occur due to a long inflammation of intestine following directly exposure to amniotic fluid. 

- Other common congenital defect seen in gastroschisis is gut malrotation, and other congenital birth defect are rarely seen.

- During delivery, exposed abdominal viscera should be covered with sterile saline soaked, followed by effective sterile dressing to prevent evaporation.

- Baby should be kept in a sterile bowel bag, contain warm saline to prevent evaporation and maintain sterility. 

- Baby is evaluated for other anomalies before surgery.

- The primary closure of abdominal defect is done when is possible, because the abdominal cavity may be small to accommodate the whole viscera. 

- In case were whole visceral can not be returned inside, it should be covering by silicon pouch in which as time, it reduced in size and abdominal cavity will increasing in size. 

 Thanks,      

                               MWANDA, MD.

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Head trauma/injury

HEAD TRAUMA/INJURY:

Introduction.

 -Head injuries is the common problem seen at Emergency department.

-Many patient with severe brain injury died before reaching the hospital. 90% of prehospital trauma-related deaths involving brain injuries. 

- 75% of patients with brain injuries are categorized as having Minor brain injuries, 15% are moderate and 10% are severe brain injuries. 

- 1,700,000 cases of traumatic brain injuries are annual reported in USA, including 52,000 deaths due to traumatic brain injuries.

- survivors from TBI are left with neuropyschological impairment.

Notes

The primary goal of treatment the patients with head injuries is to prevent secondary brain injury.

- Oxygenation and maintenance of blood pressure to provide enough brain perfusion, are very important ways to prevent secondary brain injury.

- To identifying a mass lesion require surgical evacuation is critical and CT scan of the head should performed early as possible.

Risk group
- male age 15-24 years
-young children 6 months to 2 years
- primary school aged student
-elderly

Etiology/causes
 -motor vehicle accidents- 50%
-falls- 21%
-violence/assaults- 12%
-sports injuries- 10%
-others-7%

Anatomy review
- cranial anatomy include scalp, skull, meninges, brain, ventricular system and intracranial compartments.
 

 Scalp
- due to several blood supply of the scalp, lacerations can result in a major blood loss, shock, and even death especial in children.

Skull
- injury of the brain occur when the brain move with acceleration and deceleration of the skull because the skull base is regular.
- the anterior fossa contain the frontal lobes, while middle fossa houses the temporal lobe
- the posterior fossa contain cerebellum and lower portion of brain stem.


Meninges
-the meninges cover the brain and consist of three layers; the dura mater, arachnoid mater and Pia mater. Dura matter split to form major venous drainage of the brain.
- superior sagittal sinus drains into the transverse sinus and sigmoid sinuses.
-lacerations of this major sinuses can result into a massive hemorrhage.
-epidural space contain meningeal arteries, overlying skull fracture can lacerate these arteries and cause an epidural hematoma.
-middle meningeal artery located in temporal fossa is commonly injured  during head trauma.
-expanding hematoma from arteries in this location can result in rapid deterioration and death. Most epidural hematoma, is an emergency and require evaluation by neurosurgeon as soon as possible.
-veins travel from brain surface to the sinuses may tear during brain injury and lead to the subdural hematoma.
-subarachnoid contain cerebral spinal fluid (CSF). The hemorrhage into this space, is frequently seen during brain contusion or injuries to the major blood vessels at the base of brain.


Brain
-major parts are cerebrum, brain stem, and cerebellum. Cerebrum consist of right and left hemispheres
- left hemispheres is a language centers
-frontal lobe control executive function, emotions,motor function and dominant side, control expression of speech.
- the parietal lobe direct sensory function and spatial orientation
- the occipital lobe is responsible for vision and the temporal lobe responsible for regulation of memory function.
- brain stem involve mid-brain, pons, and medulla. Mid brain and pons control state of alertness, while medulla is the vital center for cardiovascular and respiratory system.
- thus the small lesion in the brain stem is associated with severe neurological deficits.


Ventricular system
- system filled with cerebral spinal fluid (CSF) and aqueducts within the brain.
- the presences of blood in the CSF, will impair CSF reabsoption and results in increase intracranial pressure
- mass lesion like hematoma can result in a shifting of ventricles that can be easily identified in the CT scan of the brain.



Intracranial compartments
- tough meningeal partitions separate the brain into regions. The tentorium cerebelli divide the intracranial cavity into the supratentorial and infratentorial compartments.
- midbrain pass through an opening called the tentorial hiatus or notch
- occulomotor nerve run along edge of tentorium and may become compressed against it during temporal lobe herniation.
-compression of these superficial fibers during herniation causes pupillary dilation due to unopposed sympathetic activity, often referred as "blown pupil". Because the parasympathetic fibers that constrict the pupil lie on the surface of the third cranial nerve.
-The part of the brain which usually herniates is the medial part of temporal lobe, known as the uncus, which may result the compression of corticospinal tract in the brain.


Notes
-Ipsilateral pupillary dilation associated with contralateral hemiparesis is the classical sign of uncal herniation.

Blood supply to the brain
- Brain use 20% of total body oxygen and receive 15% of cardiac output. It can also consumer large amount of the glucose and thiamine and it ca not store non of this substance.
- brain receive large amount blood supply from Carotid arteries which supply most of cerebrum and through vertebral arteries  which supply cerebellum and brain stem.


Normal Homeostasis
- blood flow to the brain should be maintained at constant level. Autoregulation of blood flow to the brain is done in three ways

• pressure- alteration of diameter of blood vessel to maintain SBP of 50 to 160 mm Hg
• Viscosity- occur as a result of changes in blood vessels diameter 
• metabolic- brain vasculacture respond quickly to hypoxia which a potent vasodilator and paCO2.

- Brain trauma can impair this autoregulation which in turn, result into hypotension and ischemia which responsible for secondary brain damage.

Physiology
-physiological process involve in head trauma include, intracranial pressure, the Monro-Kellie Doctrine and Cerebral blood flow (CBF).

Intracranial pressure (ICP)
- increased intracranial pressure, can reduce cerebral perfusion and causing ischemia. Normal intracranial pressure is ~ 10mmHg and ICP > 20mmHg are associated with poor outcome.
-As a compensatory mechanism the body produce  Cushing triad which involve:-

• Bradycardia
• hypertension
• irregular breathing 

Monro-Kellie Doctrine
- it explain the concept related to ICP, and its stated that; the volume of intracranial contents must remain constant, because the cranium is rigid, non-expansible container.
- at some point/begin, venous blood, CSF, may be squeezed out of the container, providing a degree of pressure buffering ( displacement).
- when the displacement of CSF and intravascular blood has been attained, ICP rapidly begin to raise up.


Cerebral blood flow (CBF)
- Traumatic brain injury severe enough to cause coma, may results in a marked reduction in CBF during the first hour after injury.
- secondary injury occur due to hypotension, hypoxia, hypercapnia,hypoxemia, and iatrogenic hypocapnia.
- not easy to measure CBF and clinically, cerebral perfusion pressure is used (CPP).

• CPP= ICP-MAP
• MAP= 2/3 DBP + 1/3 SPP

Classification of Head injuries
1. according to severity-using Glasgow coma scale

• minor    13 - 15 GCS
• moderate 9 - 12 GCS
• Severe     3-   8  GCS

2. according to morphology

• Skull fractures-vault -linear vs stellate, depressed/nondepressed, open/closed

                                  -basilar-with/without CSF leak, with/without seventh cranial nerve palsy

• Intracranial lesion- focal- epidural, subdural, intracranial hematoma/lesions

                                                 - diffuse- concussion, multiple contusion, hypoxi/ischemic injury and                                                        axonal injury.
3. according mechanism of injury

• blunt- closed
• penetrating- open

- Basilar skull fracture require CT scan for diagnosis. The clinical presentation of basilar skull fracture include periorbital ecchymosis ( raccoon eyes), retroauricular ecchymosis ( Battle sign).

- CSF leakage from the nose or ears and seventh and eight cranial nerves dysfuction may other signs for basilar skull fracture.
- CSF suspected tests include blood clotting delayed, halo sign ( Ring sign),  does not crush on drying and positive to dextrostick.

Note
- in basilar skull fracture, do not pack ears, not sucking fluid, not instrument the nose, allow drain, and gives antibiotics for prophylactic.
- open skull fracture should be managed like evisceration and protecting exposed tissue with moist, clean dressing.  

Intracranial lesions
1. Epidural hematoma
- blood collect between the skull and dura, usually caused by tear of middle meningeal artery.
- it associated with increased ICP, unconsciousness followed by lucid interval, headache, nausea vomiting,  hemiparesis, hemiplegia, unequal pupils( dilated on side of clot) and cushing triad.




Subdural hematoma
- more common types and it occurs between dura mater and arachnoid mater.
- usually develop following a tear of bridging veins between cortex and dura. This type of hematoma is also associated with increase ICP, but usually of slow onset. These symptoms are of same as epidural hematoma.

Intracranial hematoma
- occur following brain laceration and bleeding into brain develop. Associated with increased ICP, neuro deficit ( depending on the part of brain affected).

Assessment of brain injuries

1.Glasgow Coma Scale (GCS)

-severity of brain injury is scored using GCS and it was pointed out in the area classification of brain injuries.




2. AVPU scale
    A= Alert
    V= Respond to verbal stimuli
     P= Respond to pain stimuli
     U= Unresponsive

3.  Respiratory pattern
- cheyne stoke due to diffuse injury to cerebral hemispheres
- central neurological hyperventilation due to mid-brain injury
- apneustic due to pons injury

4.  eyes- unequal pupil dilation- pointed out before in this presentation

5. vital signs- cushing triad ( Hypertension, bradycardia and irregular respiratory patterns) due raise in ICP.

Management of head injuries
- Part of management involve ABCDs

A. Airway
-open, consider cervical spine injury
-jaw thrust with cervical spine control, clear airway, intubate the patient as needed, but avoid nasal intubation.
- spinal motion restriction

B. Breathing
- give 100% of oxygen, hyperventilate at 20 and 24 breaths per minute if GCS is less than 8, presences of neurological deterioration and evidence herniation.
- hyperventilation will decreased paCO2, vasoconstrication and decreased ICP, but it may increase risk of decrease cerebral blood flow, decrease perfusion of tissue, and increase edema.

C. Circulation
-  the role is to maintain adequate BP and brain perfusion by use IV fluids
- gives  RL/NS if BP is normal or elevated
- gives RL/NS bolus titrated to BP ~ 90 mm Hg in case decreased blood pressure.

D. Drugs
- dexamethasone- decreases cerebral edema but effect delayed
- mannitol - decrease cerebral edema but it may cause hypovolemia or worsen intracranial hemorrhage.
- furosemide- decrease cerebral edema, but may cause hypovolaemia
- diazepam- given in patient with seizures, but it may mask level of consciousness, depressed respiration and worsen hypotension.
- glucose- gives  hypoglycemic patient 



Investigations
- CT scan of brain
- skull  X-ray
- MRI
- Cerebral angiography in case of vascular injury
- ventriculography


Basic neurosurgical procedures 
- external ventricular Drainage- ventriculostomy
- exploratory or woodpeker surgery - exploratory burr holes
- Craniotomy/ craniectomy



Thanks  
                                                MWANDA MD!

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Ectopic pregnancy

                                                        ECTOPIC PREGNANCY
Ectopic pregnancy is the implantation of pregnancy outside of uterine  cavity. The common areas where ectopic pregnancy occur include fallopian tube,uterine interstitium, cervix, ovary, abdominal cavity, pelvic cavity etc. The most common site of ectopic pregnancy implantation is fallopian tube followed by uterine interstitium.
Epidemiology
- incidence is 2/100 of diagnosed pregnancies and its increase with maternal age.
- recurrence risk is about 10 to 25% from the first ectopic pregnancy.
- 5% of ectopic pregnancies occur when intrauterine device (IUD) is in place.

Risk factors
- higher maternal age
- pelvic inflammatory disease (P.I.D)
- post tubal surgery
- past history of ectopic pregnancy
- cigarette smoking
- history abortion
- assisted reproductive techniques

Symptoms and signs
-pelvic pain-common presentation
-vaginal bleeding
-severe pain followed by syncope/shock is sign of rupture ectopic pregnancy.
-small uterus compared to dates
-cervical motion tenderness may be present.

Diagnosis
- clinically is diagnosed in any reproduction age women with history of amenorrhea, pelvic, vaginal bleeding, unexplained syncope or hemorrhagic shock.
- physical examination like per abdomen examination may support the diagnosis.
- definitive diagnosis include urine test for

•  beta human chorionic gonadotropin -sensitive for 99% of pregnancy test include ectopic. If beta-hCG is < 5 mIU/ml, ectopic pregnancy is excluded. Absences of gestation sac with beta-hCG, are strongly suggest ectopic pregnancy.
• ultrasonography -ultrasound detect uterine gestation sac, ectopic pregnancy is unlikely when uterine gestation sac is seen, but care should be taken in case of abdominal ectopic pregnancy, because it may look the same in ultrasound. absence of uterine gestation are likely to be ectopic pregnancy. mixed masses (contain cyst and solids)  may be seen.

Treatment

•   surgical treatment- laparascopic (for hemodynamically stable) or open surgical resection (especially for unstable patient).
• medical treatment- 50mg/meter square single dose of methotrexate is given IM , in case of unruptured ectopic pregnancy, with not fetus heart rate, and with < 5000 mIU/ml of beta-hCG level. beta-hCG test are repeated after 4 and 7 days and when it doesn't fall, a second dose of methotrexate or surgery is needed.

Prognosis
- untreated ectopic pregnancy is fatal and maternal death is rare if treatment occur before rupture
- results in 10% of pregnancy maternal related death.
- 50% of fetuses are alive during surgery but only few reported to survive.

Complications
- ruptured into peritoneal cavity
- intra peritoneal abscess
- bleeding
-shock
-lithopedion/stone baby
-maternal death

    

                Thanks!



                             by MWANDA MD.
  

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Surgical suture techniques

Suture techniques:

-All suturing techniques aim at bring wound edges together without gaps or tension. Interval between suture bites should be equal in length and proportion to size of tissues brought together.
-Minimal size and necessary amount of suture needed to close the wound should be used, because suture are foreign body.

types of suture materials.

• Non-absorbable - usually used when possible. Braided suture are not ideal for contaminated wound.
• Absorbable suture- commonly used when the patient are not able to return or during suturing internal structures or used in children for whom suture removal may difficult. This type of suture loses tensile strength within 60 days.

Common Practical suture Techniques:

• interrupted sutures- commonly used to repair lacerated wound and used in wound with  minimal skin tension. Bites are equal in volume and all good eversion of wound edges. Non-absorbable suture is used when possible. 
• continuous/running sutures- not time consume during suturing, few knots tied and less material used. Complication of this techniques include poor cosmetic result compared to other options and epidermal skin cell growing along suture track.
• continuous subcuticular sutures- excellent cosmetic result and useful in wound with strong skin tension especially in patient prone to keloid formation.
• mattress sutures- more complex and there time consuming. Its provide the relief of wound tension and provide precise wound edge apposition. Vertical and Horizontal are the two types of mattress suturing techniques.
• purse string sutures- done in a circular pattern that draws tissue together in a path of suture. Used particularly around the drain sites.

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Colostomy

                              Colostomy
Ostomy- is an opening from the lumen of the out of the abdominal wall.
- it can either be done in upper part of the gut ( gastrostomy, jejunostomy) for purpose of feeding or in the lower part,  for the purpose of let the contents of gut out ( relieve obstruction).

Colostomy - is an opening of the colon to the abdominal wall for the purpose of emptying the gut.

Types of colostomy.
A).  According to anatomical site
       - Gastrostomy
       - jejunostomy
       - caecostomy
       - ileostomy
       - ascending colostomy
       - Transverse colostomy
       - other part of colon colostomy
B).  According to the way the stoma is.                  raised.
       1. Loop - is the most common, easy to.                perform, is closed extra peritoneally.

       2. Double Barrel - is type of colostomy.                 modified by stitching the last few.                   centimeters of its limbs inside the                   abdomen.

       3. Spectacle - is one in which limbs.                    separate by a small bridge of skin.                  Used when the patient need a.                          colostomy for a long time. Closed.                    intra peritoneally.
       4. Hartmanns/Permanent/Terminal/End            - form the end of the gut after.                           excision of rectum.  The distal loop of             the bowel is closed and left back into.             the abdomen.
       5. Mucus fistula colostomy - distal                        opening of the distal loop.

C).  According to the purpose
       1. Temporary
       2. Permanent

Indications
1. Feeding
2. Relieve of bowel obstruction /diversion of faeces in:-
- congenital bowel anomalies like hirschprungs disease, congenital anorectal malformations.
- trauma of the colon,  or anorectal Canal
- crohns diseases
- facilitate cure of fistula
- colorectal carcinoma
- others

Caecostomy
- done patients with caecal injury and caecal distal injury,  distal obstruction or when the patient is too sick for colostomy.
- one of disadvantages of caecal colostomy is divert little faecal materials unless large tube is placed. Also it has the risk to risk peritoneum during construction.

Transverse colostomy
- done in case of left side injury,  left side carcinoma,  or congenital anorectal malformation.

Sigmoid colostomy
-  alternative to transverse colostomy,  used in case sigmoid or rectum obstruction like in case of sigmoid volvulus.

Complications of colostomy
-prolapse
-retraction
-necrosis of distal end
-stomal stenosis
-stomal bleeding
-colostomy diarrhea secondary to infection.

Care of colostomy
1. Apply of colostomy bags
2. Avoid gas forming food
3. Irrigation of end colostomy
4. Medication to slow intestinal function during social occasion.

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Amputation

Amputation -refers to surgical removal of the whole or parts of a leg/foot or an  arm/hand.
Types of amputation:

• Minor amputation 
• Major amputation 

Minor amputation - only a toe, finger, part of the foot or part of the hand is removed.
Major amputation - is the one where part of the leg or arm is removed. Below knee amputation (BKA), above the amputation (AKA), above the elbow (AEA),  below the elbow amputation (BEA)  or through elbow amputation are the good examples of this type.

Indications :
1. Congenital limb deficiency - when the limb is grossly deformed and useless.
2. Vascular insufficient - in case of ischemic necrosis of the limb,  diabetic foot ulcer, peripheral vascular diseases and acute inflammation and thrombosis of the arteries and veins in smoker,  severe trauma beyond the repair and other many.
3. Chronic osteomylitis
4. Tumor- malignant
5.Trauma- crush injuries to the limbs

The goal of amputation is to preserve all possible length especially in the upper limbs depends on the level of pathology.

This rule may not apply much in lower limb,  but at least the knee should be saved if possible for functional advantage.

- During amputation of leg,  anterior margin of the tibia is often beveled,  enough tissues with a good blood supply to it is provided by a longer posterior flap.

- Below knee amputation should not be longer than 20cm, because it may interfere with healing process.

Types of Flaps.
1. Fish mouth - commonly used when amputation above the knee.
2. Long posterior flap - commonly used when amputation below the knee.

Procedure.
- arteries should be tied individual, and nerves should be at higher level as possible.
- enough soft tissues but not excessive amounts should be remain to covered the area.
- cut nerves should be away from pressure area and from scar to avoid neuromas symptoms When pressure is applied.
-the bone cut should be at high level and sharp margin should be cut.

Complications.:
-pressure sores
-infection of the wound
-failure of the wound to heal
-contractures of the knee or hip joint
-deep venous thrombosis in the leg
-phantom limb pain.

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Different between Benign And Malignant skin lesion

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Diabetic foot

                                                               Diabetic Foot:
Introduction

• From the time of insulin discovery, important observation was made by Joslin, who reported that, a large population of patients diagnosed to have diabetic mellitus, will develop foot ulceration or gangrene.
• Diabetic foot result from the way health provider look on the patients and the way patients look after themselves.
• Although this complication is the mostly feared by patient with diabetic, it is easly preventable through education and care.
• major complication from diabetic foot are lower limbs amputation.

What is Diabetic foot?

-Diabetic foot- are lesions occurring in people with diabetic mellitus, which range from superficial skin ulcer, infection of the ulcer to chronic bone infection/osteomylitis. 

-Diabetic foot can present in different ways, but the most important clinical presentation are foot ulcer.

- Diabetic Foot ulcer are sores in the feet occur in people with diabetic mellitus.

Epidemiology

-prevalance varying from place to place- in Europe is < 1%, but in Africa is around 11%, Tanzania is around 16% .

- diabetic foot in vast majority is associated with lower limbs amputation. About 28% to 51% of patient underwent first amputation, need second amputation within period of 5 years.

- mortality rate after amputation range from 39% to 68% after the lower limbs.

Risk factor for diabetic foot ulcer

• peripheral neuropathy
• peripheral arterial occlusive disease
• poor glycemic control
• obesity
• foot deformity 
• immune suppression 
• past history of ulcer/ amputation

Pathogenesis of diabetic foot ulcer

- for simple understand, its been divided into three parts

• Neuropathy-  is the disorder of nerve outside of brain and spinal cord, result from damage of peripheral nerve. Occur in 80% of all patients with diabetic foot ulcer. It can affect both sensory, motor and autonomic pathways. 

                  -motor neuropthay- affecting motor fibres/nerves to intrinsic muscles leading to atrophy                                                   from areas with increased pressure or friction from bones prominence.

                  

                  - autonomic neuropathy- lead to dermal/skin denervation of the affected area, which                                                                    results into reduced sweating, dry skin and eventually lead to the                                                            formation of fissure. It can also results into loss of sympathetic                                                              tone , which results into thickness of capillary basement                                                                          membrane, and loss of postural vasoconstriction, arterial-venous                                                            shunt and increased blood flow, predisposing to trivial skin                                                                    ulcer formation.

                - sensory neuropathy- vibration, temparature, and pain sensation is lost. Loss of awareness                                                      of pressure injury or trauma, can lead to unnoticed ulcer and                                                                  infections. 

• Diabetic foot angiopathy- peripheral arterial occlusive disease, is very common problem in diabetic patient. Diabetic foot angiopathy has been divide into microangiopathy and macroangiopathy. Occlusion of arterial, prevent oxygen, white blood cell and nutrients from reaching ulcer. This in turn affect the physiological process of wound healing.
• Immunopathy- immune cells function, chemotaxis ,phagocytosis and killing capability is loss.

Prevention of diabetic foot ulcer

• education and better health care.
• glycemic control to reduce neuropathy and maintain immune fuction
• patient self care, regular nail check, therapeutic shoes use, protecting self from lower extremities injury.
• regular assessment of  every diabetic patient limbs, early and proper management ulcer.

Management

- the management of diabetic foot ulcer involve three parts;

• removal of callus
• eradication of infections
• reduction of weight bearing forces often require bed rest with leg raised.

Danger signs: urgent treatment needed

- Redness and swelling of a foot that even when neuropathic causes

some discomfort and pain; this often indicates a developing abscess,

and urgent surgery may be needed to save the leg

- Cellulitis, discolouration, and crepitus (gas in soft tissues)

- Pink, painful, pulseless foot even without gangrene indicates critical

ischaemia that needs urgent arterial investigation followed by

surgical intervention whenever possible.

                                  BY MWANDA MD.

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Abdominal incision.

1. Right Subcostal Incision (Kocher’s) incision- indicated for biliary tract surgery especially for cholecystectomy.

2. Midline incision- are particularly indicated in diagnostic laparotomy, as they allow wide access to most of the abdominal cavity.

3. McBurney incision / Gridiron's incision- classically indicated or used for appendectomy.

 4. Battle incision-  used when dealing with acute appendicitis and other right lower quadrant pathology. 

5. Lanz incision - is more transverse than gridiron incision, and it can be used to access the appendix.

6. Paramedian incision- originally used to access much of the lateral viscera, such as the kidneys, the spleen, and the adrenal glands.

7. Transverse incision- was originally used for Cesarean section.

8. Rutherford-Morrison Incision- used for right and left sided colonic resection, caecostomy or sigmoid colostomy.

9. Pfannenstiel Incision- Used frequently by gynecologist and urologist for access to pelvic organ, bladder, prostate and for c- section. 

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Burns

burns is a wound  in which there is  coagulative necrosis of  the tissues. The following are the types of burns:-
    1). Ordinary burns- usually caused by dry heat with fire, open flame, hot metal, bomb injury, or   aeroplane crush etc.
    2). Scalds burns- are caused by moist heat like hot liquid or steam.
    3). Electric burns- result as result higher or lower electrical voltage contact.
    4). Chemical burns- caused by either strong base or strong acid
    5). Radiation burns- occurs usually due to X-ray or radium

Pathology of burns:- for better understand pathology of burns are divided into the following form
    a). local changes
    b). systemic changes
  
Local changes are further subdivide into:-
 1. Severity 2. The extent of burns 3. Vascular changes and 4.Infection.

1.SEVERITY OF BURNS.
The severity of the burn are subdivided into three degree or grades depend on depth of tissue damage/necrosis.
  -first degree is the one inwhich there only area of hyperaemic on the skin plus slightly oedema of the epidermis.

-second degree is the one in which entire area of the epidermis thickness is destroyed and vesicles are formed by dermis and epidermis. The hall mark of this type of burn is vesiculation.

-third degree is the one in which there is destruction of both epidermis and dermis depth thickness. In this form of burn , there irreversible destruction of dermis appendages and epithelial include sensory nerves end. Skin grafting become an important management to cover area of burns.

Another classification of severity of burns include-

a). partial thickness burn- is the one in which superficial part of skin involve the epidermis and partly part of dermis has bee destroyed, but sweat glands and enough epithelial remain intact which enable regeneration of destroyed skin.

b). full thickness burns- occur when the entire depths thickness of both dermis and epidermis has been destroyed. Epithelial layers and sweat glands has been destroyed and so no possible regeneration of the damaged area.

2.EXTENT OF BURNS:
The extent of burns is clinically estimated by using the rule of nines. The length and widths of the burn is expressed in percentage of the total body surface area. Usually used on second and third degree burns. To understand the rule of nines for adults and pediatric patients check the image below.
 



3. VASCULAR CHANGES.
Its of very important in the burns area. There is main two changes observed
 a). dilation of small vessels- due to direct  injury of blood vessel walls and through the release of histamine. This increase blood flow to the affected area without stasis as in case of the inflammation. 
 b). capillary permeability- is greatly increased.  plasma rich in protein released continously in large amount. Exudate collect in blister or form a dry crust to protect the wound.

4. INFECTION.
In case of first degree, the skin is intact and act as barrier to infection. In case of second or third degree of burns, the skin is destroyed and therefore, the burns wound is like to be infected from virulent organism.

SYSTEMIC CHANGES.
The following changes are observed -
1). shock 2). biochemical changes 3). changes in blood.

1.SHOCK- is one of  most important outcome of the burns. Different types of shock related to burns has observed, but the mostly important is oligaemic shock which is reported to cause death related to burns i most of the people.

a). oligaemic shock- follow damage of blood vessel walls as a result of  burns, there an increase of capillary permeability, which allow loss of fluid and proteins from intra-vascular to exra-vascullar compartment. Due to excessive loss of fluid, the blood become very concentrated and interfere with oxygen transport to the tissue and hence shock may develop.

b). neurogenic shock- occur likely due to severe pain 
c). cardiogenic shock- occur following a decreased in cardiac output due to marked peripheral vascular resistance, later due a decreased blood volume, and increased in viscosity due to increased in haematocrit and aggregation of RBC , white cells, and platelets.
d). bacteremic shock- occur following infection and toxic released on the burn area which are then absorbed into the body.

2. BIOCHEMICAL CHANGES-
     a). electrolyte imbalance- lower sodium and lower chloride, high potassium level in blood.
     b). hypoproteinaemia- occur following greatly loss of plasma proteins.
     c). hyperglycemia- are likely to develop in burns.
     d). rise in urea and creatinine due to acute kidney damage by burns.

3. CHANGES IN BLOOD.
     a). rise in Hb level following outpouring of serum.
     b). increase in number of RBC due to outpouring of serum.
     c). blood sludging due to aggulitation of RBC intravascularity.
     d). falling in eosinophic count within the first 12 hours which begin to rise after 24 hours.




TREATMENTS:
 1.Treatment of shock- the treatment of burn shock include the following method
        a). Sedation- sedatives and anti-pain is always required in burns victim. Usually morphine 1/4th or less is injected iv in order to avoid depression of cardiopulmonary function. Barbiturate is preferred  for children patients.
        b). fluid resuscitation- iv fluid should be given early for patients with 15% or more burns total body surface area  and 10% burns body area for children should be given fluid resuscitation.  When the burns involve more than 20% of full thickness  or 40% of partially thickness.
       c). maintenance of airway- victim of burns usually develop sign and symptoms of hypoxia like tachypnoea, respiratory arrest and coma. Patient should be given 100% oxygen with ventilator support.


GENERAL TREATMENT:-Include the following
1). Escharotomy and fasciotomy, 2). Tetanus prophylaxis, 3). Antibiotics, 4). Nutritional support, 5). Gastric decompression and 6. Treatment of G.I. complication.

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Incomplete miscarriage

Incomplete miscarriage is the type of abortion where the entire products of conception are not expelled out completely instead some part are remained inside the uterus.
This is the commonest type of miscarriage in hospitalized cases with miscarriage complications.

clinical features:-
- history of expulsion of the mass per vagina
-lower abdominal persist
-vaginal bleeding persist
-uterus small than gestation age
-cervix os remain partly open
-ultrasound reveal some product of conception within the uterine cavity.

complication:-
-sepsis/infection
-profuse/severe bleeding/anemia
-placental polyp

management:-
a). surgical methods- higher complications
- make the patient stable through resuscitation
-dilation and evacuation in early abortion under analgesic or general anesthesia.
-uterine evacuation in late abortion to remove the remain products under general anesthesia.

b). medical method-less complications
-misoprostol 200 micro-grams is used vaginally every four hours.

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complete miscarriage

Complete miscarriage is the type of abortion in which product of conception are already expelled out from the uterine cavity.

The patient may present with the history of expulsion/extraction of fleshy mass from the uterus per vaginal followed by;
1). reduced in abdominal pain
2). vaginal bleeding become reduced or absent
3). uterine become small than gestation age
4).  cervical os is closed and bleeding is less or absent
5). ultrasound examination reveal empty uterus.

management 
1. if ultrasound show the remained conception products, evacuation of uterine curratage should be done.
2. for Rh-negative mothers  50 or 100 micro-grams anti-D should be give intramuscularly within the period of 72 hours following abortion.

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Inevitable miscarriage

Inevitable abortion is the type of miscarriage in which the changes has progress to the extent that pregnancy can not be continuous in any means.  The following are clinical symptoms in which the patient with inevitable miscarriage may present  with:-
                                         -increased vaginal bleeding
                                         -the pain the lower abdomen become worse and aggressive
                                         -speculum examination reveal the dilated internal os of the cervix
                                         - +/- rupture of membrane
                                         - products of conception may be seen coming out through the internal os.

Note that if the threatened abortion can not managed properly it become inevitable abortion.

The management of inevitable abortion focus on
 1. increase the process of extraction of products of conception from the maternal womb and
 2. maintain sterility of the abortion to prevent sepsis/infection.

Depend on excessive blood loss and the condition of the patient we have two ways management
   a). general management - the blood loss is corrected by inter-venous fluids and blood transfusion.

   b). active management- before 12 weeks -dilation of cervix and evacuation followed by curettage of the uterine cavity and
-after 12 weeks - uterine contraction is accelerated by oxytocin drip ( 10units in 500ml of normal saline ).

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Threatened Abortion

Threatened abortion- is the type of miscarriage where the process of abortion has started but not worse to the extent that pregnancy can not be maintained if emergence clinical intervention has been done. In this type of abortion recovery can be possible.

       Clinical symptoms
-Before coming up with the diagnosis of threatened abortion, history and confirmatory test should be done to make sure, the patient is a pregnant in-order to rule out other obstetrics and gynecology conditions. Therefore the patient should a pregnant who present with the following symptoms:-
               -slightly bleeding per vagina
               -mild back or lower abdominal pain
              
-Speculum examination and per vagina examination (reveal the closed cervix) should be done to rule out ectopic pregnancy, molar pregnancy, cervical ectopy, fibroid and carcinoma.

-Basic investigations like hemoglobin level, blood group and cross match and hematocrits level should be done soon as possible. Urine test for viability of pregnancy may be unreliable, because it may be positive even several days after fetus death. Ultrasound is very important because it can be used to observe fetal cardiac movement, fetal movement and other  parameters.

 
      Treatments
 -the patient should be in bed/rest for few days until symptoms are no longer present.
 -sexual intercourse should be avoided because it may provoke symptoms and make the  condition     worse.
 -anti-pain drugs should be given to relief pain and diazepam may added.

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Spontaneous abortion ( Miscarriage)

                                               

Abortion is the extraction or expulsion of the embryo or fetus weighing 500g or less from its mother before it can survive alone. This 500g is usually attained by the fetus around 22 weeks of gestation. The products of abortion is called abortus. 

The incidence of abortion may be difficult to find out but according to current study is about 10-20% of all clinical pregnancies end in abortion and another 10% are induced illegally. 75% of all abortion occur before the 16 weeks of gestation .

Abortion has been classified into several subgroups. The main one is spontaneous abortion or miscarriage (occur naturally) and the other one induced abortion (initiated artificially). Spontaneous abortion is of clinical important and is the one will be explained here.

Spontaneous abortion has been subdivided into several groups which are threatened, inevitable, complete, incomplete, missed and septic abortion. Each type will be explained in details separately in the following post.

The etiology/causes of spontaneous abortion is complex and difficult to find out. The following factor are important and with the positive association:-


     Genetics-About 50% of all early spontaneous abortion occur due to chromosomes abnormalities in the conceptus. This include autosomal trisomy is the commonest one for about 50% and the commonest triosomy is 16 (30%).  polyploidy 22% (presences of three or more haploid  number of chromosomes) has been reported and the commonest one is triploidy. Other are monosomy and structural chromosomes rearrangement has been reported to cause miscarriage.

     Endocrine and metabolic factors- deficient in progesterone hormone or poor uterine response to the progesterone is the cause. conditions like hypothyroidism or hyperthyroidism has association with abortion. Poorly or uncontrolled diabetic mellitus has been linked to result in miscarriage.   

 
     Anatomical abnormalities- cervical and uterine factors like cervical incompetence, congenital malformation of the uterus has been associated with pregnancies lose especially during the second trimester. Condition like uterine fibroid and uterine adhesion has positive effect on pregnancy loss because of reduced uterine volume, interfere with implantation, placentation and fetus growth. 

    Infections- infections such as viral infections ( rubella, cytomegalo and even HIV infection), bacterial infections ( chlamydia, syphilis, and others ), parasitic infections ( malaria, and toxoplasma) are hardly result in abortion before 20 weeks of gestation because of effective thickness of placental barrier.


   Immunologic disorders- autoimmune disorder like antinuclear antibodies can cause miscarriage usually in the second trimester. Alloimmune disease may result into fetal rejection by maternal antibodies and hence miscarriage occur.Antifetal antibodies in case Rhesus isoimmunization where  by the mother is rhesus negative and the fetus is rhesus positive can usually cause spontaneous abortion.

   Other factors- maternal medical illness like cyanotic heart disease and hemoglobinopathy has been associated with early pregnancy loss. Premature rupture of membrane, cigarette smoking and alcohol used during pregnancy has increase the incidence of miscarriage.


  Unexplained etiology- around 40-60% of all miscarriage cases has no know etiology despite all of the above explained factors. However the risk of miscarriage increase with maternal age. More than 20% of all pregnancies diagnosed using urine pregnancy test, are lost before the clinical diagnosed. 




                 DR MWANDA.

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Third stage of labor

Third stage of labor.

The third stage of labor begin after delivery of the fetus and end with delivery of the placenta and its membrane. The average time for this stage is about 15 minutes. The separation of placenta from the uterus occur due uterine contraction which results into reduced in uterine surface area of the placental site following delivery due to uterine retraction. This stage is managed according to WHO protocol of third stage of labor management.

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Second stage of labor

Second stage of labor.

The second stage of labor begin from a full dilation of cervix and end with delivery of the fetus. Approximately time of this stage is 2 hours during the first pregnancy and 30 minutes in the following pregnancy. This stage is manifested with increase in frequency of uterine contractions and bearing down effort which result in delivery of the fetus.

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First stage of labor

first stage of labor


First stage of labor begin from the onset of true labor pain and end with the full dilation of the cervix. The approximately time is 12 hours during the first pregnancy and 6 hours in following pregnancy. Dilation of cervix up to 3cm is called a latent phase and dilation of cervix to 10cm is called active phase of first labor.
 This stage is clinically accompanied  with progressive uterine contractions, cervical dilation and rupture of membrane. Maternal and fetus remain normal in this stage except during uterine contractions, where fetus heart rate will be reduced physiologically.
 At this stage, no much intervention done rather than let nature takes its own place. Women should be encouraged, given support, make them stable psychologically and in some areas anti pain  is given in the course of labor. 

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Gonorrhea infection; symptoms,signs,diagnosis, treatment and prevention.

GONORRHEA:

 

Gonorrhea remains still as an important health problem especially in developing countries because of poor level of knowledge on Sexually transmitted infections ( STIs). Gonorrhea is caused by organism known as Neisseria gonorrhoeae. When a person become infected , it takes about 3-7 days for this bacteria organism to multiply and increase in number.

Usually this organism, enter the body through the epithelium layers covering genitalia and urinary system. The primary site of infections are urethra, cervix and glands like bartholin and skene`s gland. The organism may only affect lower genitalia tract and produce infections of cervix (cervicitis) , infection of the urethra (urethritis) and glands. Oral cavity, pharynx, anus, rectum and conjunctiva are the other common sites in the body infected with this organism.

About 15% of untreated cervicitis, gonorrhea infection may spreads by ascend and produces infections of the pelvic known as pelvic inflammatory diseases (PID). Sometimes in few patients, the infections may infect the blood ( septicemia) and results into infections of several joints in the body. The gonorrhea infection can also spreads along the sperms to infect upper genitalia organs like uterus, Fallopian tubes and sometimes ovaries. Infection of uterus and Fallopian tube is common. Neisseria gonorrhoeae is usually manifest with others sexual transmitted infection especially Syphilis and chlamydial infections.

    clinical features.

About half of people with gonorrhea, do not show any symptoms of the disease and are the one responsible in a higher percentage for transmission of this disease to uninfected people. The symptoms depend on the part of genital or urinary tract infected. The commonest symptoms are :

           -painful or difficult urination

           -foul smell vaginal discharge

           -pain on one side of vagina and swelling of the labia due to infection of Bartholin gland.

           -pain during or after sexual intercourse 

signs:

          -labia infected and look inflamed.

          - mixture of mucus and pus vaginal discharge is the common sign

           - cervix examination may reveal infection of the cervix. 

Other organs like liver and joints may also affected by gonorrhea especially when the infection infect blood (septicemia) and spread to distant area of the body. In case of septicemia symptoms like fever, generalized joint pains, pain along the level of stomach (epigastric pain) due to infection of liver and skin rashes may occur.

 complications:

The following are common complications of gonorrhea infection, if left untreated or poorly treated;

       - it may result in a chronic pelvic pain

       - infertility is the common complication

       -difficult or painful sexual intercourse

       -abscess of  genitalia gland especially bartholin gland

       - implantation   of the pregnancy outside of uterine cavity( womb).

  Diagnosis

Gonorrhea can be diagnosed clinically from above symptom and signs, but others sexual transmitted infection like Chlamydia can present almost the same as gonorrhea infection. Therefore, the definitive diagnosis of gonorrhea, can be done using Nucleic acid amplification test of the urine or genitalia discharge. Culture of urine or discharge from the genitalia can be done to isolated Neisseria gonorrhoeae organism and drugs sensivity can also be done. 

Treatment

   The common drugs recommend for the treatment of acute gonorrhea infection are the ceftriaxone 250mg IM  plus azithromycin 1gm  once orally and doxycline 100 mg orally every twelve hours for 7 days.

Prevention

  -definitive therapy should be give and the patient should be followed by health provide until cured.

  - both partners should be treated in the same time in order to avoid reinfection from untreated partner.  

     

                                 thanks.

 by

   DR MWANDA. 

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