Surgical Skills

Basic Emergency and Surgical Skills
Prepared by
Dr. Mohamed Alasmar MB.Bch MRCS Vascular surgery trainee in Kasr Al Ainy hospitals, Cairo university. General surgery resident, Ahmad Maher Teaching Hospital. ATLS Coordinator, American college of surgeons. ATLS Instructor, American college of surgeons. Basic Emergency and Surgical Skills instructor, KasrAlainy Hospitals, Faculty of medicine Cairo university. Basic Surgical Skills instructor, MEDC training center. M.Sc. candidate, faculty of medicine, Cairo university.
Revised by Dr. Doaa Mansor, MB.Bch MSc MD MRCS

General surgery lecturer, KasrAlainy hospitals Cairo university ATLS instructor candidate, , American college of surgeons Basic Emergency and Surgical Skills instructor, KasrAlainy Hospitals, Faculty of medicine Cairo University.
Designed by Dr. Yosra Saeed Abd El-mawla MB.Bch House Officer Cairo University
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SURGICAL SKILLS
WOUND MANAGEMENT HANDLING INSTRUMENTS SUTURING TECHNIQUES SUTURES & NEEDLES LOCAL ANAESTHETIC TECHNIQUES
WOUND MANAGEMENT REMEMBER Simple wounds may be not simple at all Good surgeons know how to operate, Better surgeons when to operate, and the Best when NOT to operate. PLAN Assessment Preparation Procedure After-Care
PLAN
Preparation Procedure After-care
Dressing Medications (antibiotics - analgesics - others) Immunizations (tetanus rabies vaccine) Suture removal
Assessment
General
Regional
Consent (options - complications) Prepare your stuff (dressing instruments - ..) Anesthesia (local regional - general) Wound cleaning (tap water saline - antiseptic) Skin preparation (shaving - disinfection) Draping Wound examination: DONT close upon: F.B. , Hematoma, Edema & potentially infected ( after 12 hours delayed 1ry closure ) Positioning Lighting Ask & Examine Loss of consciousness Vomiting Persistent headache Blurring of vision Inspection, palpation, percussion and auscultation NECK Inspection, palpation, percussion and auscultation
Introduce yourself Ask about patients name and age Mode of trauma Co-morbidities Vital signs (esp. the pulse and conscious level )
Head
You may need to You may need to order Consult CT scan Neurosurgeon
Chest
Chest x-ray
Cardio-thoracic surgeon
Abdomen
Abdominal U/S Chest x-ray X-ray
General surgeon Orthopedics, plastic surgeon or vascular surgeon
Extremities Look, feel, move and special tests Bone, joints, muscles and tendons, nerves and blood vessels.
HANDLING INSTRUMENTS
General rules Surgical instruments are usually held by your 5 fingers for better control For example the needle holder, heamostat and scissors There are several methods for handling tools. One classic method is described here and we recommend to use this method as a trainee then you can modify and change your method according your experience and your senior. Scissors
The tips of the scissors should be used for dissection and division of structures.
When using instruments with finger loop handles, it is important to use the correct grip as shown in the image on the left. 5

Forceps
Toothed forceps are useful for atraumatic tissue handling as only a small area of tissue is held in the jaws. Tissue must be handled very gently to avoid unwanted damage used usually to handel skin or fascia
Atraumatic non-tooth forceps spread the force of the grip over a larger area and are used when handling delicate tissue such as bowel or vessels. Needle holder
After opening the suture pack, the needle is presented ready for mounting in the needle holder. Grasp the needle with the tip of the needle holder, two thirds along the shaft from the needle tip. When removing the suture from the pack, it is often useful to use your little finger to take up the slack in the suture. 6

It is important that the needle is grasped at the tip of the jaws of the needle holder.
The needle can either be held two thirds away from the tip and perpendicular to the needle holder or, when using a half curved needle, it can be held half way along the shaft at a slight angle as demonstrated. Use forceps to manipulate the needle in the holder.
When grasping the needle, only one click is required on the ratchet. Putting too much force on the handles will damage the hinged area of the needle holder.
Finally, it is important that the needle is not handled at the tip or the swaged area.
SUTURING TECHNIQUES
Interrupted Suturing Small toothed forceps, such as the Addison forceps shown here, should be used to grasp the skin edges during suturing. Forceps with teeth provide a secure grasp with minimal pressure, thereby avoiding crushing of the skin edge. The forceps should be held in the first three fingers as one would hold a pen, using the first three fingers. The needle holder should be held in a way that is comfortable and affords maximum control. Most surgeons grasp the needle holder by partially inserting the thumb and ring finger into the loops of the handle. Note that the index finger provides additional control and stability.
This illustrates the same grasp, but with the hand pronated. Supination and pronation are required to manipulate the curved needles used in surgery.

As a rule, the needle should be grasped two thirds along the shaft from the needle tip or at its center or perhaps 50-60% back from the pointed end. The needle should be grasped 1-2 mm from the tip of the needle holder.
One should avoid grasping the suture material or the distal end of the needle with the needle holder, since this will damage the suture.
Placement of the 1st suture is begun by grasping and slightly everting the skin edge. The right hand is rotated into pronation so that the needle will pierce the skin at a 90o angle. Note that the trailing suture is placed away from the surgeon to avoid tangling.
The needle is driven through the full thickness of the skin by rotating the needle holder (supinating). By keeping the shaft of the needle perpendicular to the skin surface at all times, one takes advantage of the needle's curvature in traversing the skin as atraumatically as possible.

Pronation in the previous step makes it possible to complete passage of the needle with a smooth, natural supination which rotates the needle upwards and away from the surgeon. Again, this minimizes trauma to the tissues.
Here the needle is being regrasped in preparation for passage through the opposite skin edge. This was traditionally done by grasping the needle with the non-dominant hand. However, given the risks of HIV and hepatitis, it is probably advisable to train yourself to use the forceps for this instead of fingers. The skin edge closest to the surgeon has been grasped and everted slightly, while the right hand is pronated to the needle and position it for passage through the skin.
Again, the right hand is supinated in order to rotate the needle through the full thickness of the skin, keeping the shaft at a right angle to the skin surface.
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After releasing the needle, the right hand is pronated before the needle is regrasped...
... and the right hand is then supinated in order to rotate the needle through the skin atraumatically.
The suture material is drawn through the skin, leaving 2-3 cm. protruding from the far skin surface. The forceps are then dropped or "palmed" so the left hand can grasp the long end in preparation for an instrument tie. Note that the needle holder is positioned between the strands over the wound. The long strand is being wrapped around the needle holder to form the loop for the first throw of a square knot (to perform surgeon knot wrap the long strand around the needle holder twice).
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The needle holder is then rotated away from the surgeon to grasp the short end of the suture.
The short end is grasped and drawn back through the loop toward the surgeon.
The throw is tightened...
... creating a flat throw which will be tightened just enough to approximate the skin edges. Remember: approximate; do not strangulate.
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The second throw of the square knot is initiated with the needle holder pointed to the left as the long strand is wrapped around it by bringing the long strand toward the surgeon.
The needle holder is then rotated toward the surgeon to retrieve the short end, ...
... and the short end is drawn through the loop that has been created, pulling it away from the surgeon.
The second throw is then brought down and tightened securely against the first throw.
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With a braided material, such as silk, a third throw (replicating the first) would be placed to secure the knot. If a slippery monofilament material, such as nylon, were being used, one would place 5 or 6 throws of alternating construction in order to minimize the likelihood of knot slippage. The suture will then be cut leaving 3-4 mm tails. The next suture will then be placed about 4 mm away from the first one. The distance between stitches will depend on how easily the wound edges can be approximated and how much tension or motion is likely to be exerted across the wound during healing. For example, a wound on a flexion surface, such as a knuckle, might require closer sutures than a wound in the scalp. Ensure that the knots are sitting at the side of the wound and not directly above the incision site
Vertical Mattress Sutures
The vertical mattress is used when we wish to evert the skin edges of a wound.
Path of the vertical mattress stitch:

The vertical mattress stitch consists of "farfar" and "near-near" components. The "farfar" component is similar to the two bites for a simple interrupted stitch. These are about 4 mm from the wound edge. The "nearnear" components are bites that are taken very close to the wound edge, and these are
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The first "far" bite is just like the beginning of a simple interrupted stitch - about 4 mm from the wound edge.
The second far bite is being placed in the proximal wound edge, and the needle emerges about 4 mm from the wound edge.
The first "near-near" component is placed by reversing the placement of the needle in the needle holder and "backhanding" the needle so that the bite is taken away from the surgeon.
The first "near" bite has been taken, and the needle holder is about to regrasp the needle to complete the bite.
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The needle has been regrasped, and now the second "near" bite is being taken on the wound edge furthest away from the surgeon.
Both the short and long strands emerge from the skin surface furthest away from the surgeon, and the needle holder is being positioned to begin an instrument tie.
The first loop of the square knot is formed by wrapping the long strand around the needle holder...
... and the short strand is grasped and pulled back through the loop toward the surgeon, bringing the throw down just tight enough to approximate the wound edges. After second and third throws are added to secure the knot, the next stitch will be placed about 4-5 mm to the right of the first stitch.
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Horizontal Mattress Sutures This is a less commonly used method of everting the wound edge and redistributing tension and is occasionally used, for example, on the back of the hand. In this instance the suture is passed the normal distance away from the skin edge on either side. The needle is then turned round for a reverse pass and re-inserted a short distance from where it emerged on that side of the wound to then emerge a short distance from the original insertion point as shown. An instrument tie with four throws is then performed.
This is called a horizontal mattress because the suture line is parallel to the wounds horizon, as it were. It is important to take up the slack of the suture before the second pass to avoid too much friction within the suture line causing trauma to the skin and the exit points of the suture.
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Continuous Suturing The first bite is placed at one end of the incision, inserting the needle at 90 degrees to the tissue surface and roughly 5mm from the wound edge. After forming a knot using an instrument tie, the tail of suture is trimmed. The assistant then holds the bight of suture under tension whilst further continuous sutures are placed to close the incision. It is important to pass the needle perpendicular to the wound and this will result in the external portion of the sutures lying diagonally. At the end of the suture line, a reef knot can be formed between the bight and residual loop of suture.
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Subcuticular Sutures The aim of this technique is to close a wound in such a way that no suture is visible on the skin surface. An absorbable, undyed suture material is used for increased cosmesis. The first bite is made deep and passed superficial. Starting the bite on the opposite edge superficially, it is then passed deep. A reef knot is tied with just three throws to keep the suture material in the wound to a minimum. The tail should be divided as close to the knot as possible. The long length of suture must now be passed from deep to superficial at the apex of the incision. Working from the apex, small bites are placed just deep to the dermal layer. The entry point of a bite is placed directly opposite the exit point of the previous bite. The suture is pulled along the line of the incision to close the wound edges. Once the other end of the wound is reached, the sutures will be quite superficial and it will not be possible to place a deep knot. A superficial knot at this point will erode through the skin surface and produce a small stitch abscess, reducing overall cosmesis. Thus to complete this closure, the needle is re-inserted at the apex and driven through the tissues to emerge distal to the wound. A Z-shaped suture is placed, passing the needle back into the skin close to the previous exit point and driving it perpendicular to the incision. To complete the Z suture, the needle is again inserted at the previous exit point and driven perpendicular to the wound. The suture is then divided flush with the skin surface, leaving the wound closed with no visible suture.
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Basic Emergency and Surgical Skills Basic principles

Insert the needle at right angles to the tissue and gently advance through the tissue avoiding shearing forces. As a rough rule of thumb, the distance from the edge of the wound should correspond to the thickness of the tissue and successive sutures should be placed at twice this distance apart, i.e. approximately double the depth of the tissue sutured.
All sutures should be placed at right angles to the line of the wound at the same distance from the wound edge and the same distance apart in order for tension to be equal down the wound length. For long wounds being closed with interrupted sutures, it is often advisable to start in the middle and to keep on halving the wound. No suture should be tied under too much tension or the subsequent oedema of the wound may cause the sutures to cut out or to develop ischaemia of the wound edge and delayed healing. In most cases it is advisable to only go through one edge of the tissues at a time but, if the edges lie in very close proximity and accuracy can be ensured, it is permissible to go through both edges at the same time. For elliptical wounds following lesion excision, the edges of the wound may be undermined to help closure. However, the length of the wound will need to be approximately three times the width of the wound if closure is to be safe and not under too much tension. Skin hooks may be useful to display the wound.
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Basic Emergency and Surgical Skills Removing a suture

When removing a suture, it is important to remember that the section of suture that has been sitting on the skin surface is potentially infected. This section should not therefore be passed through the tissues as the suture is removed. The suture is divided just below the knot, and the tail pulled so that the external part of the suture does not pass through the tissues.
Suggested Removal Times for Interrupted Skin Sutures

Area Face Neck Scalp Upper extremity Trunk Extensor surface hands Lower extremity Removal time (days) 3 to 5 5 to 8 7 to 9 8 to 14 10 to 14 14 14 to 28
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SUTURES & NEEDLES

Sutures
An ideal suture would be : Easy to tie/secure Give very little tissue reaction / not be allergenic Maintain their tensile strength for the period required for them to hold the tissue together while it heals
Nowadays, the vast majority of suture material is synthetic. They can be divided into 2 types (braided versus monofilament sutures), within 2 groups (non-absorbable & absorbable) Each type maintains its own properties, which are related to its:
Memory: the degree that the suture tries to stay in its original shape. Memory can lead to a difficulty with tying a knot as the suture will unravel as it tries to return to its original shape (eg from the suture packet). This is more of a problem with larger monofilament sutures. Tensile Strength: The amount of force required to snap a suture is related to its tensile strength, which diminishes with time, i.e. the suture will become weaker over a variable amount of time, depending on the suture. The tensile strength is usually measured as how long it takes for the suture to have half its original strength, for example the 50% tensile strength of polyglactin (eg vicryl) is 18 days.
Each suture type has its own advantages: Braided sutures have the advantage of: Tying more securely. Have less memory than monofilament. Less risk of the suture fracturing when handled with a forceps. Monofilament sutures have the advantage of: Less tissue reaction. Less incidence of microabscess formation in the tissue. Absorbable sutures have the advantage of: Not being required to be removed. Are not present after wound healing has been achieved.
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As can be seen, different suture types may be used in different situations. For example, most surgeons will close the skin layer by using either a subcuticular absorbable suture, or an interrupted monofilament suture. For a continuous suture, most prefer a monofilament suture, which slides through the tissues easier, and reduces the chances of the tissue bunching. For areas where wound healing takes longer, it is important to use a suture that has a longer 50% tensile strength and absorption rate eg polydiaxone may be used to close the linea alba in abdominal wound closure. Sutures vary in size, depending on the job that is required of them. They are sized using the USP (United States Pharmacopoeia). Some examples of sizes and diameters are shown below:
6/0 = 0.07 mm 4/0 = 0.15 mm 3/0 = 00.2 mm 2/0 = 0.3 mm 0 = 0.35 mm 1 = 0.4 mm 2 = 0.5 mm Some examples of sutures are shown below:
Monofilament
Non-absorbable
Polypropylene (Prolene)
Braded
Non-absorbable
Silk
Absorbable
Chromic Catgut
Absorbable
Polyglactin (Vicryl)
Some tensile strengths and absorption times are shown below, giving an indication as to what situation you may wish to use certain sutures:
Polyglactin (vicryl) Coated polyglactin (vicryl rapide) Polydiaxone (PDS) Polyglycolic acid (Dexon II) 50% Tensile Strength 18 days 6 days 28 days 16 days Absorption Time 28 days 10 days 180 days 60-90 days
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Needles Needles may vary in size, and type. The shape of the needle is determined by the access to the tissue that requires to be sutured. Normally the tighter the operative space is, the greater the curvature of the needle is that is required. The basic shapes used are: , 3/8, , 5/8 Circle, J shape compound curved needle (used to close the sheath in laparoscopic ports) Previously a straight needle was available for closing skin in a subcuticular fashion, but this is no longer used as they are more prone to needle stick injuries
Surgical eyeless needles are manufactured in a wide range of types, shapes, lengths and thicknesses.
The choice of needle to be used depends on several factors such as:

The requirements of the procedure; The nature of the tissue being sutured; The accessibility of the operative area; The gauge of suture material being used; and The surgeon's preference.
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Regardless of use, however, all surgical needles have three basic components: the tip, the body and the swage. The various components of a needle are shown in the diagram below:
o The tip depends on the needle type. o The body of the needle usually has a flattened section where the needle can be grasped by the needle holder. In addition some needles have longitudinal ribs on the surface which reduce rotational movement and ensure that the needle is held securely in the jaws of the needle holder. o If the needle does not have a flattened section, it should be grasped at a point approximately one-third of the needle length from the butt. o The swage of an eyeless needle has either a drilled hole or a channel at the end of the needle for insertion of the suture material. This area is then closed around the needle in the swaging process.
The commonest types of needle are:

Conventional cutting Reverse Cutting Round Bodied
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Cutting needles are used when tough or dense tissue needs to be sutured eg the skin. A conventional cutting needle has a triangular cross section with the apex of the triangle on the inside of the needle curvature:
A reverse cutting needle is again triangular in cross section, with the apex of the triangle on the outside of the needle curvature this improves the intrinsic strength of the needle, making it less susceptible to bending.
A round bodied needle is designed to separate the tissue, rather than to cut them. After the needle has passed through the tissue, the tissue closes around the suture, making it particularly useful in intestinal and cardiovascular suturing. A tapercut needle incorporates a cutting tip of a needle with a round body, to lessen the trauma to the tissue after the initial cut has been made. Nowadays, we can also use a blunt taperpoint needle (eg Ethiguard), where the tip of the needle is tapered to a blunt end this can be used to cut through fascia (eg the linea alba in abdominal closure), but cannot cut through skin, thereby reducing significantly the chance of an accidental needle stick injury.
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LOCAL ANAESTHETIC TECHNIQUES

Which Local Anaesthetic Should I Use ? Local anaesthetics (LA) prevent depolarisation of neurons and are effective only in their ionised state they can only cross neuronal membranes in the unionized state. It then becomes ionized and effective. Since the solutions used are ionised, the efficacy is dependent on the buffering effect of tissue. The pH is low in inflammatory conditions (eg around an abscess) and in normal mucous membranes, which occasionally leads to difficulty in obtaining anaesthetic effects. Adrenaline (1 in 200 000): is sometimes used in combination with LAs for its vasoconstriction effect. This decreases the systemic absorption of the LA from the site of injection, helping to decrease the risk of toxicity and prolong the duration of action.
It is important to avoid:
Accidental intravasular injection with adrenaline. This can lead to tachycardia, hypertension, ectopics, and even circulatory failure. It can be treated by counter injection of a -blocker. Use of adrenaline if the operation is on an organ supplied by an end artery; e.g. the digits (fingers/ toes), penis, nose, external ear. Patients with; thyrotoxicosis, hypertension, and those on MAOI and Tricyclic antidepressants. Injectable anaesthetics are metabolised in the liver (prilocaine is additionally metabolised extrahepatically, particularly in the lung). vasodilators. They are generally
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Basic Emergency and Surgical Skills Lignocaine hydrochloride (xylocaine)

Lignocaine comes in different concentrations - 0.5%, 1%, 2%, plain or with adrenaline 1:200000 It has a rapid onset (about 3 minutes) but is relatively short-acting (60-90 minutes). The dose of lignocaine required (for a 70 kg man) is: 3 mg/kg body weight = 21 mls of 1% solution 7 mg/kg if used with adrenaline (1:200000) = 25 ml of 1% solution + adrenaline
A rough rule of 3 with lignocaine is that it

Takes 3 minutes to work Has a maximum dose of 3 mg/kg (plain) Lasts for about 3 hours
Bupivacaine (marcain/ marcaine)

Bupivicaine comes in 2 concentrations- 0.25%, and 0.5% It has a slower onset of action than lignocaine but is longer acting up to about 6 hours. The maximum dose 2 mg/kg (= 28 ml of 0.5% solution in a 70 kg man)
EMLA cream - Eutectic Mixture of Local Anaesthetics- (2-10 gm)

This is an emulsion of the base form of lignocaine and prilocaine that can be absorbed by the skin. It is very useful in children. It is applied on the skin and must be covered with occlusive dressing one hour before venepuncture or injection of local anaesthetic.
NB. The correct dose of any LA is the smallest dose required to produce the desired analgesia. Infiltration LA is quick but not instantaneous, so give it time to work.
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Toxicity of Local Anaesthetic This is related to factors influencing the level of the drug in the circulation, use of adrenaline, and patient condition. Toxicity can occur not only with over dosage, but also with normal dosage if the drug is injected into a vein or artery, or if the patient suffers from serious liver disease. Higher concentrations are more toxic than lower ones. (i.e. 1 ml of 2% solution is more toxic than 2 ml of 1% solution). Infiltration of very vascular areas (without iv injection) can lead to peak levels sufficient to cause toxicity. It is important to reduce chances of this happening by careful injection and aspiration (to exclude intra-arterial or intravenous injection) every 5 ml of LA used.
Potential Problems with the use of LA include: 1st TO APPEAR : Circumoral numbness
Central Nervous System: Stimulatory effects predominate over depressive effects, but both occur. Excitatory effects include tremors, restless, tinnitus, headaches, blurred vision, nausea, and clonic convulsions. These can be treated by giving oxygen, and IV diazepam, where required. Inhibitory effects include respiratory and cardiac arrest, which might occur rapidly and without warning. Cardiovascular: Conduction problems: e.g. increased conduction time and refractory period of heart muscles (decreased heart rate, heart block and decreased cardiac output). Vasodilatation, which in addition to the direct action on the heart and autonomic ganglion blockade, can lead to severe hypotension and cardiovascular collapse. Local complications: Necrosis and gangrene if adrenaline is injected into an organ with an end-artery. Faulty aseptic technique or injection into infected area can lead to abscess formation.
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Allergy: A careful history is important, and if in doubt do intra-dermal sensitivity testing. In general terms the amide derived drugs cause little in the way of allergic response, but the ester derived LAs (e.g. procaine) contain PABA (para-amino benzoic acid) which can be allergenic in susceptible individuals.
Treatment of Toxicity

Call for help Simple ABC ensure clear airway Give 100% oxygen (support breathing with an ambu bag if required) Control CNS problems , e.g. convulsions, with midazolam/diazepam iv if required CPR if cardiac arrest intralipid may be of use in LA associated cardiac arrest
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EXAMINATION OF AN INJURED PATIENT

PRIMARY AND SECONDARY SURVEY OF INJURED PATIENTS TRANSFER ABDOMINAL TRAUMA HEAD TRAUMA TRAUMA OF EXTREMITIES UROLOGICAL TRAUMA BURN
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Examination of an injured patient

PRIMARY SURVEY OF INJURED PATIENTS Simple Combined Assessment (history, examination) and Management. A B C D E
Airway
You may need the help of Anesthetist
Clear airway
Protect airway
Cervical spine control
Oxygen mask
Manually, Suction or Chin lift or jaw thrust
Oropharyngeal airway, Nasopharyngeal airway, Tracheal intubation, Cricothyroidectomy
Backboard and rigid collar Manual inline immobilization
High flow O2
You may need the help of cardiothoracic surgeon
Breathing Assessment
Inspection Respiratory rate, Movement, Chest expansion, Accessory muscles of respiration, Cyanosis, Tracheal shift, Jugular venous distension and Open chest wound Subcutaneous emphysema and Flail segment Upper airway sounds and Lower airway sounds Hyper-resonance and Dullness
Management of the 5 killers

Tension Needle decompression pneumothorax Cardiac tamponade Flail chest Massive hemothorax Needle pericardiocentesis Intubation and positive pressure ventilation Chest tube Thoracotomy if indicated
Palpation Auscultation Percussion 32
Open Occlusive dressing pneumothorax Chest tube


You may need the help of General surgeon
Circulation Assessment
Symptoms and signs of shock: Blood on floor and 5 more.. Chest Abdomen Pelvis Extremities Retroperitoneal
Management
Control bleeding Insert 2 large caliber peripheral IV line Blood sampling for: Typing, Cross-matching, Haemoglobin and haematocrit, Pregnancy test (females), ABGs and Blood chemistry Ringer's lactate (warm 2 liters) Blood transfusion
Disability
You may need the help of neurosurgeon
GCS
Examination of pupil
Exposure and environment
Remove all clothes
Logrolling
Warmth
DRE
Mini radiological assessment and adjuncts

AP chest, AP pelvis and any other indicated X rays (e.g Cervical spine) or CT scan done after resuscitation. Pulse oximeter, Foley's catheter, FAST/DPL, ECG, ABGs and Gastric tube. 33
SECONDARY SURVEY Mini history

AMPLE Allergies, Medications, Past medical history/Pregnancy, Last meal time and Events of injury Complete head to toe examination Complete neurological examination (dermatomes and myotomes) Now it is your chance to transfer the patient or to consult other specialties like vascular surgery, urology or plastic surgery. Role of investigation in diagnosis of a traumatized patient
You may very well operate without investigation If investigation is urgent and not to delay operation Resuscitate first Be ready to resuscitate during investigation
TRANSFER
Transfer Principles
Know institutional capabilities. Be prepared and anticipate patient needs. Do no further harm. Identify patients whose needs exceed local resources. Perform only essential procedures. Establish direct communication between referring and receiving doctors. Transport to closest, appropriate facility. Use most appropriate mode of transport.
When should I transport the patient?

Transfer after life-threatening problems are managed. Transfer after disabling injuries are stabilized. Transfer after arrangements are made. Transfer before performing unnecessary tests and procedures. AVOID DELAY
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Basic Emergency and Surgical Skills ABCDEs interpretation of Chest X-ray:

Airways Breathing Circulation and cardiac shadwo Diaphragm Edges And Soft tissues
Supine anteroposeterior radiograph normal chest with ABCDEs interpretation
of Opaque left haemothorax with evidence of contralateral shift of the mediastinum.
ABCDEs interpretation of Pelvis X-ray:

Alignment Bones Cartilage Soft tissues
Radiograph of supine pelvis showing ABCDEs interpretation
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ABDOMINAL TRAUMA
Assessment Evidence of trauma Evidence of hypovolaemia Trauma to solid abdominal organ e.g. liver or spleen Trauma to hollow abdominal organ e.g. intestine
History of trauma, Bruises, Open wound, Tenderness, London's sign, Evisceration or Associated injuries May be present Mental state (Anxiety) Vital signs BP (Normal then Orthostatic hypotension then Hypotension) Pulse rate increased Respiratory rate increased Hypothermia Skin Pallor Coldness Urine output CVP Inspection Distension, Decreased movement and Cough tenderness Palpation Tenderness, Rigidity, Rebound tenderness and Tender DRE Percussion Tenderness and Fluid Auscultation Loss of intestinal sounds Cullen sign, Gray turner sign, Blue No scrotum or Kehr's sign Shifting dullness No No Percussion Obliterated liver dullness
Evidence of peritoneal irritation and ileus
Evidence of bleeding Evidence of free fluid Evidence of air
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Indications of laparotomy
Blunt Trauma
Hemodynamically abnormal with suspected abdominal injury (DPL /FAST) Free air Diaphragmatic rupture Peritonitis Positive CT
Penetrating Trauma
Hemodynamically abnormal Peritonitis Evisceration Positive DPL, FAST, or CT
CT scan of a 26-year-old man after a motor vehicle crash shows a significant amount of intra-abdominal bleeding.
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HEAD TRAUMA
ABC Cervical spine and cervical neck collar Examination of other sites to exclude other injuries Chest Abdomen Neurological examination Disturbed level of consciousness (GCS) Pupils Dermatomes and Myotomes Cranial nerves examination, Eyes, Nose and ear and Crepitus Examination of the scalp Swelling or Wound CT scan Consult neurosurgeon early Eye opening Verbal responsiveness Motor response Glasgow coma scale
Spontaneous To verbal command To pain None 4 3 2 1 Oriented Confused Inappropriate words Incomprehensible sounds None 5 4 3 2 1 Obeys Localizes Withdraws (pain) Flexion (pain) Extension (pain) None 6 5 4 3 2 1
Clinical manifestations of transtentorial herniation Compressed Structure Clinical Manifestations

Cranial nerve III Ipsilateral mydriasis Midbrain physiologic functional Decerebrate rigidity transaction Reticular formation Coma Ipsilateral cerebral peduncle Contralateral hemiparesis Contralateral cerebral peduncle Ipsilateral hemiparesis (false localizing sign) Cerebral aqueduct (of Sylvius) Headache and vomiting due to acute hydrocephalus Posterior cerebral artery Contralateral hemianopsia (false localizing sign)1 1This sign is a consequence of herniation and does not indicate the localization of the primary process; in this sense, the sign falsely localizes the primary lesion. 38
Basic Emergency and Surgical Skills Indication of CT scan in minor traumatic brain injury (MTBI)
Witnessed loss of consciousness Definite amnesia Witnessed disorientation in patient with GCS of 13 to 15 And any one of the following: High Risk GCS score still < 15 two hours after injury Neurologic deficit Open skull fracture Sign of basal skull fracture Extremes of age Moderate Risk Dangerous mechanism Retrograde amnesia >30 minutes in duration Severe headache Vomiting > 2 episodes
Obtaining CT scans or skull films should not delay transfer of the patient
Extradural haematoma and a subtle subdural haematoma (left), subdural haematoma (middle left), diffuse axonal injury (middle right), and combination injuries (right)
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Basic Emergency and Surgical Skills Indication of admission, Referral or Neurosurgeon consultation:
No CT scanner available Abnormal CT scan All penetrating head injury History of prolonged loss of consciousness Deterioration of level of consciousness Moderate to sever headache Significant alcohol/drug intoxication Skull fracture CSF leak: rhinorrhea or otorrhea Significant associated injuries No reliable companion at home Abnormal GCS <15 Focal neurological deficite
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TRAUMA OF EXTREMITIES
Fractures and dislocation
Examination
Look (inspection) Skin Ecchymosis Edema Shape Swelling Deformity Postural alternation Feel (palpation) Skin Tenderness Edema Shape Swelling (as any swelling) Deformity Examination of sensory and motor innervations Examination of peripheral circulation Move Loss of function Abnormal mobility Crepitus Measure
Radiological diagnosis
Plain X-ray 2 views 2 joints 2 limbs 2 injuries 2 occasions Above and below In children To exclude common association As in scaphoid fracture
CT MRI Bone scan
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Arterial trauma
Evidence of trauma Evidence of hypovolaemia Local examination Hard signs

External arterial bleeding Loss of distal pulse Classic manifestations of acute ischemia 6P's o Pain, Paralysis or paresis, Parasthesia, Pallor, Pulselessness and Poikilothermia Pulsating or expanding haematoma Palpable thrill Audible bruit
Soft signs
Small or moderate size haematoma Proximity of penetrating wound to a major vascular structure Nerve injury History of prehospital haemorrhage Presentation with shock
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UROLOGICAL TRAUMA
Differences between different types of trauma to the urinary bladder and the urethra
Extraperitoneal Intraperitoneal urinary blabber urinary bladder rupture rupture Sever trauma A blow or kick to Shock lower abdomen in Pelvic fracture presence of a full bladder Desire Full bladder Boggy swelling in suprapubic area No desire No full bladder Free fluid in peritoneal cavity with peritonism No Prostate in normal position Urine or not Blood Normal Leakage of contrast outside the bladder Injury of posterior Injury of urethra anterior urethra (intrapelvic) (extrapelvic) Sever trauma Falling Astride Shock hard object Pelvic fracture Kick to perineum Perineal haematoma Desire Desire Full bladder Full bladder deep in extraIf patient tries to peritoneal space void To superficial like peritoneal poch extraperitoneal rupture of bladder Drops of blood at external meatus Prostate in higher position Contraindicated Show the site of extravasation
History of trauma
Urine retention Urine extravasation
Bleeding perurethra DRE Passage of catheter Ascending Urethrography Ascending cystography
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BURN
First-aid
Combat fire and approach safely. Burnet part should be immersed in cold water (tap water). Chemical should be washed off. Hot and damaged clothes removed.
Assessment and resuscitation ABC of (of ATLS) o Consider direct thermal or inhalation injury. o Establish and maintain patent airway early and consider early ET intubation. o Oxygenate and ventilate. o Obtain ABGs and CO levels. Cannulea placed in big veins in area of unburned skin Assess : Size (role of nine) and Depth (partial(superficial and deep dermal) or complete thickness)
Fluid replacement
o 4 mL warmed balanced crystalloid solution / kg / %BSA in first 24 hours (global only) o Administer in first 8 hours o Administer in next 16 hours o Base calculations on time from injury o Monitor heart rate and urinary output Tetanus status Narcotic analgesia Antibiotics Wound care Flow sheet documentation
Management of Chemical Burns Flush with copious amounts of water for 20 30 minutes
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Basic Emergency and Surgical Skills Transfer (or admission to burn unit) Criteria for Second-Degree and ThirdDegree Burns
> 10% BSA in ages < 10 and > 50 years. 20% BSA (all ages). Unique areas (any size burn). Face, Eyes, Ears, Hands, Feet, Genitalia, Perineum and Major joints. Third-degree burns > 5% BSA (all ages). Electrical and chemical burns. Inhalation injury. Preexisting illnesses, associated injuries. Children. Special situations.
45
References
References
Prof. Dr. Hussien Khairy lectures ATLS course, American college of surgeons Intercollegiate Basic Surgical Skills Course, ROYAL COLLEGE OF SURGEONS OF EDINBURGH
Internet Resources
The New England Journal of Medicine website
http://www.nejm.org/doi/full/10.1056/NEJMvcm050183 http://www.nejm.org/doi/full/10.1056/NEJMvcm054648 http://www.nejm.org/doi/full/10.1056/NEJMvcm0706671 http://www.nejm.org/doi/full/10.1056/NEJMvcm0706789
Oxford Medical School channel on YouTube
http://youtu.be/PIma3MgjKlM http://youtu.be/cqObyDYfuy4 http://youtu.be/LcdLqfdIkFc
UConn Health Center website
http://fitsweb.uchc.edu/student/selectives/Luzietti/suturing101.htm
MEDKAAU website
http://www.medkaau.com/bssc/Unit%201/Intercollegiate%20Basic%20surgical%20skills%20course.htm
The American Academy of Family Physicians website
http://www.aafp.org/afp/2008/1015/p945.html
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Basic Emergency and Surgical Skills

Revised by Dr. Doaa Mansor, MB.Bch MSc MD MRCS

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

Abdominal U/S Chest x-ray X-ray

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General surgeon Orthopedics, plastic surgeon or vascular surgeon

Basic Emergency and Surgical Skills

Basic Emergency and Surgical Skills

Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

The throw is tightened...

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

Vertical Mattress Sutures

Path of the vertical mattress stitch:

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills Basic principles

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Basic Emergency and Surgical Skills Removing a suture

Suggested Removal Times for Interrupted Skin Sutures

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Basic Emergency and Surgical Skills

SUTURES & NEEDLES

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Basic Emergency and Surgical Skills

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Basic Emergency and Surgical Skills

The choice of needle to be used depends on several factors such as:

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Basic Emergency and Surgical Skills

The commonest types of needle are:

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