Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Fundamentals of Surgical Practice
The Surgical Patient
Approach to the surgical patient
The paediatric patient
Surgical Techniques
Tissue Handling
Suture and suture technique
Prophylaxis
Basic Surgical Procedures
Wound management
Specific lacerations and wounds
Burns
Foreign bodies
Cellulitis and abscess
Excision and biopsies
Cellulitis and Abscess
 


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SPECIFIC SITES

Cellulitis of the face

Cellulitis following a facial wound carries the risk of cavernous-sinus thrombosis. Monitor the patient closely during antibiotic treatment for signs of increasing facial oedema. Keep the patient in hospital, if necessary. Explain to the patient not to squeeze or manipulate infected foci on the face, even if small. To prevent cavernous-sinus thrombosis, administer heparin by continuous intravenous infusion.

Ocular infection

Panophthalmitis is a complication of a neglected penetrating injury of the eye. When efforts to save the eye have failed and the eye is useless, consider evisceration or enucleation. If possible, refer to an ophthalmologist.

Enucleation of the eye is the surgical removal of the entire globe and requires an ophthalmologist. Evisceration is the surgical removal of the content of the globe and does not require a specialist. This procedure involves excision of the anterior globe and curetting of is contents. If necessary, consider evisceration for uncontrolled panophthalmitis. The eviscerated globe is packed open and treated as an abscess cavity. After healing, refer the patient for a prosthesis.

Ear infection

Middle ear infection presents with chronic drainage of pus from the external meatus. Clean the ear, place a cotton wick and apply a gauze dressing. Continue the administration of antibiotics and give analgesics as needed. Keep the auditory canal dry and change the dressing when necessary.

Acute mastoiditis is usually a complication of acute otitis media. The patient complains of fever and pain in the affected ear, with disturbed hearing. There may be a discharge from the ear. Characteristically there is a tender swelling in the mastoid area, which pushes the pinna forward and out. Definitive treatment is exposure of the mastoid air cells by a qualified surgeon. When this is not possible, initial treatment is to relieve immediate pain with an incision and drainage of the abscess down to the periosteum.

Technique

1
Using a general or local anaesthetic, make a curved incision over the most fluctuant part of the abscess or, if not obvious, at 1.5 cm behind the pinna. Deepen the incision to the periosteum or until pus is found.
2
Take a sample for bacteriological examination and establish free drainage. Apply petroleum gauze or a small latex drain and dress the area with gauze.
3
Continue the administration of antibiotics and analgesics, and change dressings as necessary.
4 Remove the drain after 24–48 hours.

Dental abscess

Treat dental pain initially by cleaning the painful socket or cavity and then packing it with cotton wool soaked in oil of cloves or a paste of oil of cloves and zinc oxide.

Tooth extraction is the best way to drain an apical abscess when there are no facilities for root canal treatment. Remove a tooth if it cannot be preserved, is loose and tender, or causes uncontrollable pain.

Explain the procedure to the patient and obtain permission to remove the tooth. Dental forceps are designed to fit the shape of the teeth including their roots. The inexperienced operator will find it simpler to rely on one pair of universal forceps for the upper jaw and one for the lower (Figure 5.32).
The upper molars have three roots, two buccal and one palatal, whereas the lower molars have two, one medial and one distal. The upper first premolars have two roots side by side, one buccal and one palatal. All the other teeth are single-rooted.

Figure 5.32
Figure 5.32



Use local infiltration analgesia for extraction of all but the lower molars, which may require a mandibular nerve block. Occasionally, general anaesthesia is appropriate.

Technique

1
Seat the patient in a chair with a high back to support the head. After the patient has rinsed the mouth, swab the gum with 70% ethanol. Insert a 25-gauge, 25 mm needle at the junction of the mucoperiosteum of the gum and the cheek, parallel to the axis of the tooth (Figure 5.33).

Advance the needle 0.5 to 1 cm, level with the apex of the tooth, just above the periosteum. The bevel of the needle should face the tooth. Infiltrate the tissues with 1 ml of 1% lidocaine with adrenaline (epinephrine) and repeat the procedure on the other side of the tooth. Confirm the onset of numbness before handling the tooth.
Figure 5.33
  Figure 5.33
2
If you are right-handed, stand behind and to the right of the patient when extracting lower right molar or premolar teeth. Face the patient, to the patient’s right, when working on all other teeth. Separate the gum from the tooth with a straight elevator. While supporting the alveolus with your thumb and finger of your other hand, apply the forceps to either side of the crown, parallel with the long axis of the root. Position the palatal or lingual blade first. Push the blades of the forceps up or down the periodontal membrane on either side of the tooth, depending on which jaw you are working on (Figure 5.34). Successful extraction occurs if you drive the blades of the forceps as far along the periodontal membrane as possible.
Firmly grip the root of the tooth with the forceps and loosen the tooth with gentle rocking movements from buccal to lingual or palatal side. If the tooth does not begin to move, loosen the forceps, push them deeper, and repeat the rocking movements. Avoid excessive lateral force on a tooth, as this can lead to its fracture.
Figure 5.34
  Figure 5.34
3
Carefully inspect the extracted tooth to confirm its complete removal. A broken root is best removed by loosening the tissue between the root and the bone with a curved elevator. After the tooth has been completely removed, squeeze the sides of the socket together for a minute or two and place a dental roll over the socket. Instruct the patient to bite on it for a short while. After the patient has rinsed the mouth, inspect the cavity for bleeding. Arrest profuse bleeding that will not stop, even when pressure is applied, with mattress sutures of absorbable suture across the cavity.

4 Warn the patient not to rinse the mouth again for the first 24 hours or the blood clot may be washed out, leaving a dry socket. Have the patient rinse the mouth frequently with saline during the next few days. Analgesia may be needed. Warn the patient against exploring the cavity with a finger. If gross dental sepsis occurs, administer penicillin for 48 hours and consider giving tetanus toxoid.


Throat and neck abscesses

Non-emergency operations on the throat, including tonsillectomy, should be performed only by qualified surgeons.

Incision and drainage of peritonsillar abscess

Peritonsillar abscess (quinsy) is a complication of acute tonsillitis. The patient develops progressive pain in the throat which radiates to the ear. The neck is rigid, and there is fever, dysarthria, dysphagia, drooling, trismus, foul breath and lymphadenopathy. Local swelling causes the anterior tonsillar pillar to bulge and displaces the soft palate and uvula. The overlying mucosa is inflamed, sometimes with a small spot discharging pus. The differential diagnosis includes diphtheria or mononucleosis.

Technique

1
Administer antibiotics and analgesics and place the patient in a sitting position with the head supported. Spray the region of the abscess with 2–4% lidocaine. A local anaesthetic is safer than general anaesthesia because of the potential for aspiration with general anaesthetic.

2
Retract the tongue with a large tongue depressor or have an assistant hold it out between a gauze-covered finger and thumb. Perform a preliminary needle aspiration (Figure 5.35) and then incise the most prominent part of the swelling near the anterior pillar (Figure 5.36). Introduce the point of a pair of artery forceps or sinus forceps into the incision, and open the jaws of the forceps to improve drainage (Figure 5.37). Aspirate the cavity with suction and lavage it with saline.
Figure 5.35
  Figure 5.35
Figure 5.36
  Figure 5.36
Figure 5.37
  Figure 5.37

Instruct the patient to gargle with warm salt water several times a day for about 5 days. Continue antibiotics for one week and give analgesics as necessary.

Retropharyngeal abscess

Retropharyngeal abscesses occur in children and may compromise the airway. They result from infection of the adenoids or the nasopharynx and must be differentiated from cellulitis. The child cannot eat, has a voice change, is irritable and has croup and fever. The neck is rigid and breathing is noisy. In the early stages of the abscess the pharynx may look normal but, with progression, swelling appears in the back of the pharynx.

A lateral X-ray reveals widening of the retropharyngeal space. The differential diagnosis includes tuberculosis. Obtain a white-cell count and differential, determine the erythrocyte sedimentation rate and test the skin reaction to tuberculin (Mantoux test). Administer antibiotics and analgesics. Treat a patient with tuberculosis with specific antituberculous medication.

Spray the back of the throat with local anaesthetic. While an assistant steadies the patient’s head, retract the tongue with a depressor. Incise the summit of the bulge vertically. Introduce the tip of an artery forceps and open the jaws to facilitate drainage. Remove the pus with suction. Instruct the patient to gargle regularly with warm salt water. Administer antibiotics and analgesics.

Acute abscess of the neck


Deep abscesses in the neck arise in lymph nodes. Differentiate abscesses from lymphadenopathy. Examine the patient’s mouth and throat, particularly the tonsils and teeth to identify a primary focus. If the abscess is acute and clearly pointing, perform a simple incision and drainage. In children, treat an abscess of the neck by repeated aspiration. For small, superficial abscesses, aspirate the cavity using a syringe with a wide-bore needle.

Perform incision and drainage under general anaesthesia for large abscess cavities. Because of the complexity of the neck, surgical intervention requires a qualified surgeon with adequate support. Place the incision in a skin crease centred over the most prominent or fluctuant part of the abscess. Spread the wound edges with a pair of sinus or artery forceps to facilitate drainage. Take a sample of pus for bacteriological tests, including an examination for tuberculosis. Remove necrotic tissue, but avoid undue probing or dissection. Insert a soft latex drain. Remove the drain after 24–48 hours. Hold gauze dressings in place with tape.

Mastitis and breast abscess

Breast infections, common during lactation, are most often caused by penicillin resistant staphylococcus aureus. The bacteria gain entrance through a cracked nipple causing mastitis (breast cellulitis) which may progress to abscess formation. The features of a breast abscess are pain, tender swelling and fever. The skin becomes shiny and tight but, in the early stages, fluctuation is unusual. Failure of mastitis to respond to antibiotics suggests abscess formation even in the absence of fluctuation. When in doubt about the diagnosis, perform a needle aspiration to confirm the presence of pus.

The differential diagnosis of mastitis includes the rare but aggressive inflammatory carcinoma of the breast. Patients present with an advanced abscess in which the overlying skin has broken down and the pus is discharging. If the woman is not lactating, a neglected carcinoma should not be excluded.

Successful drainage of a breast abscess requires adequate anaesthesia; ketamine, a wide field block or a general anaesthetic. Prepare the skin with antiseptic and drape the area. Make a radial incision over the most prominent part of the abscess or the site of the needle aspiration (Figure 5.38).

Figure 5.38
Figure 5.38


Introduce the tip of a pair of artery forceps or a pair of scissors to widen the opening and allow the pus to escape (Figure 5.39). Extend the incision if necessary. Obtain cultures for bacteria, fungus and tuberculosis. Break down all loculi with a finger to result in a single cavity (Figure 5.40). Irrigate the cavity with saline and then either pack with damp saline gauze or insert a latex drain through the wound (Figure 5.41).

Figure 5.39
Figure 5.39

Figure 5.40
Figure 5.40

Figure 5.41
Figure 5.41


Dress the wound with gauze. Give analgesics as required, but antibiotic treatment is unnecessary unless there is cellulitis. Change dressings as necessary, and remove the drain when the discharge is minimal.

Have the patient continue breastfeeding, unless she is HIV positive. The child may feed from both breasts but, if this is too painful for the mother, she may express the milk from the affected breast.

Thoracic empyema
Thoracic empyema is the presence of pus in the pleural cavity. It can complicate lung, mediastinal or chest-wall infections and injuries. Rarely the source is a liver abscess. The infection results from mixed flora including staphylococci, streptococci, coliform bacteria, tuberculosis.

An empyema is either acute or chronic. It can invade adjacent tissues or cause abscesses to form in other organs.


Characteristic features are chest pain, fever and an irritating, dry cough. The affected area is dull to percussion, with an absence of, or markedly reduced, breath sounds. Diagnostic aids include a chest X-ray, white cell count, haemoglobin and urinalysis. A chest X-ray shows evidence of fluid in the pleural cavity, often with features of the underlying disease.

Needle aspiration of the chest is diagnostic. Examine the pus for the infecting organisms. Small acute empyema should be treated by repeated aspiration. Treat a moderate or large collection by placement of a chest tube attached to an underwater seal (see Unit 16: Acute Trauma Management). Indications for underwater seal chest drainage at the district hospital are pneumothorax, haemothorax, haemopneumothorax and acute empyema.

Give systemic antibiotics (do not instil them into the pleural cavity) and analgesics. If there is evidence of loculation or failure of lung expansion, refer the patient.

Patients with chronic empyema present with minimal signs and symptoms. Features include finger clubbing, mild chest discomfort and cough. Patients are generally in poor health and may have chronic sepsis, including metastatic abscesses, and malnutrition. The inflamed pleura is thickened and loculated and it is not possible to drain the pleural cavity adequately using underwater seal intercostal drainage. Refer for specialized surgical care.

Pyomyositis

Pyomyositis is an intramuscular abscess occurring in the large muscles of the limbs and trunk, most commonly in adolescent males. It presents with tender, painful muscles and fever. It is usually single but can occur in multiple distantly separated muscle groups. Staphylococcus aureus is the causative organism in over 90% of immune competent patients. Blood cultures are often negative and leukocytosis may be absent. In immune compromised patients, including those who are HIV positive or diabetic, gram negative and fungal pyomyositis may occur.

Aspiration of pus with a large bore needle (14 or 16 gauge) is diagnostic. Treat with incision and drainage. Leave a latex drain in place at least 48 hours.

Infections of the hand

Staphylococci are the organisms commonly responsible for acute infections of the hand. An early infection may resolve with antibiotics alone but incision and drainage are usually needed. Antibiotics should be given until sepsis is controlled.

Patients present with a history of throbbing pain, warm, tender swelling, a flexion deformity of the finger and pain on movement. Confirm the abscess with needle aspiration. Obtain an X-ray of the hand to determine if there is bone involvement and perform a Gram stain on the pus.
Give general or regional anaesthesia and proceed with incision and drainage. Make an adequate, but not extensive, incision along a skin crease at the site of maximum tenderness and swelling (Figure 5.42).

Figure 5.42
Figure 5.42


Aspirate or irrigate away all pus. Open up deeper loculi with artery forceps and insert a latex drain. Obtain a culture. Dress the wound loosely with dry gauze, administer antibiotics and elevate the hand.

Marked swelling on the dorsum of the hand is often due to lymphoedema, which does not require drainage. Infection of the nail bed may necessitate excision of a portion of the nail for effective drainage of pus.

Treat paronychia of the middle finger with an incision over the involved area (Figure 5.43) or excise a portion of the nail (Figure 5.44).

Figure 5.43
Figure 5.43


Figure 5.44
Figure 5.44


Treat finger tip abscesses with a “hockey stick” incision (Figure 5.45).

Figure 5.46
Figure 5.45


Treat acute septic contracture of an involved digit with antibiotics and prompt surgical drainage of the flexor tendon sheath through incisions along the lateral or medial borders of the fingers, preferably the junctional area between the palmar and dorsal skin (Figure 5.46). Infection of the tendon sheaths of the thumb or little finger may spread to the radial or ulnar bursa, respectively (Figure 5.47), necessitating drainage by short, transverse incisions in the distal palmar crease and/or at the base of the palm.

Figure 5.46
Figure 5.46


Figure 5.47
Figure 5.47


Infections of fascial palmar spaces result from extensions of infections of a web-space or a tendon sheath. Drain the affected fascial space through skin incisions directly over the area of maximum swelling and tenderness. Open deeper parts of the abscess with forceps. In general, place incisions for drainage along creases of the palm, along the lateral or medial borders of the fingers, or along the ulnar or radial borders of the forearm (Figure 5.48).

Figure 5.48
Figure 5.48


Splint the hand in position of function. Encourage active exercises as soon as possible. Give antibiotics and analgesics and remove the drain in 24–48 hours.

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