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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