Surgery and Healing in the Developing World - Dartmouth-Hitchcock
Surgery and Healing in the Developing World - Dartmouth-Hitchcock Surgery and Healing in the Developing World - Dartmouth-Hitchcock
Abscesses and Other Infections Treated by Surgery Figure 6. Sardonic smile of tetanus. 365 Gas Gangrene This deadly infection, caused by the obligate anaerobe Clostridium perfringens, causes a rapidly progressive necrosis of muscle tissue and release of toxins. The only hope for cure is immediate complete excision of all involved muscles, often requiring amputation of limbs. Pyomyositis Pyomyositis is bacterial infection with abscess-formation in one or more muscles, especially the larger muscles. It is uncommon in wealthy communities and relatively common in poor tropical countries. Signs include swelling, pain, tenderness and redness over the muscle(s) with fever and loss of function. Usually the bacteria are sensitive to penicillin. Treatment involves intra-venous penicillin or cloxacillin followed by wide incision and drainage, packing the wound open or inserting large drains. If the patient does not recover following this treatment and becomes more septic, examine for undrained abscesses and change to clindamycin plus gentamicin, if available, or chloramphenicol. Osteomyelitis Osteomyelitis is far more common in poorer than in affluent communities. Early diagnosis and immediate treatment are the ideal but this is seldom achieved in most parts of the world. Thus, many patients present with chronic osteomyelitis manifested by sequestra and sinuses and they face long-term or permanent disability. 35 Therefore early diagnosis and treatment are imperative. Diagnosis of osteomyelitis usually starts with a sick child who is limping or unable to use the affected limb. There may not be redness in the earliest and most treatable stage. However, there is tenderness and usually swelling over the affected part of the bone. Any child with a fever and a painful limb should be suspected of suffering from osteomyelitis and urgent diagnostic drilling of the bone should be done. Treatment of early osteomyelitis is early exposure and drilling of the cortex in several sites with a 2mm drill bit (Fig. 7). Only this will reveal the early infection by pus extruding from one or more drill sites. Children under age one often have an associated septic arthritis which must also be drained. At any age, osteomyelitis of the upper end of the femur tends to be associated with pus in the hip joint which needs to be drained. If osteomyelitis is confirmed, the wound is packed open and antibiotics started. As soon as a culture is obtained, start cloxacillin or oral chloramphenicol and, if necessary, change to a more appropriate antibiotic based on the culture sensitivities. Antibiotics should be
35 366 Surgery and Healing in the Developing World Figure 7. Drilling cortex of bone to diagnose and drain acute osteomyelitis. continued for 3 weeks or longer if pus continues to drain. Management of later stages of osteomyelitis requires experience in exploring and unroofing the sequestrum within the encasing involucrum (Figs. 8A, B). Breast Acute Breast Abscess Breast abscesses appear in two typical manners: acute abscesses, which usually occur during lactation, and more chronic or recurrent abscesses. During lactation, a cracked nipple may lead to breast infection usually due to Staphylococcus. If detected within a day or two, antibiotics and breast pumping may clear the infection. Figure 8A. Chronic osteomyelitis with involucrum encasing dead sequestrum. Figure 8B. Chronic sinus and swelling in the same little girl.
- Page 330 and 331: Metabolic Maladaptation 315 Biologi
- Page 332 and 333: Metabolic Maladaptation 317 from io
- Page 334 and 335: Metabolic Maladaptation 319 25. Lon
- Page 336 and 337: CHAPTER 1 CHAPTER 30 Nutrition and
- Page 338 and 339: Nutrition and Development in Africa
- Page 340 and 341: CHAPTER 1 CHAPTER 31 Uterine Ruptur
- Page 342 and 343: Uterine Ruptures in Rural Zaire Tab
- Page 344 and 345: Uterine Ruptures in Rural Zaire 329
- Page 346 and 347: CHAPTER 1 CHAPTER 32 Vesicovaginal
- Page 348 and 349: Vesicovaginal Fistula in Democratic
- Page 350 and 351: CHAPTER 1 CHAPTER 33 Ophthalmology
- Page 352 and 353: Ophthalmology Figure 2. Refractive
- Page 354 and 355: Ophthalmology Figure 4. A tonometer
- Page 356 and 357: Ophthalmology 341 ml of 40 mg/ml IV
- Page 358 and 359: Ophthalmology Figure 6. Axis determ
- Page 360 and 361: Ophthalmology 345 thalmic set prepa
- Page 362 and 363: Ophthalmology 347 Procedures Region
- Page 364 and 365: Accommodating Deficits in Material
- Page 366 and 367: Accommodating Deficits in Material
- Page 368 and 369: Accommodating Deficits in Material
- Page 370 and 371: Accommodating Deficits in Material
- Page 372 and 373: Accommodating Deficits in Material
- Page 374 and 375: Abscesses and Other Infections Trea
- Page 376 and 377: Abscesses and Other Infections Trea
- Page 378 and 379: Abscesses and Other Infections Trea
- Page 382 and 383: Abscesses and Other Infections Trea
- Page 384 and 385: Abscesses and Other Infections Trea
- Page 386 and 387: Abscesses and Other Infections Trea
- Page 388 and 389: Abscesses and Other Infections Trea
- Page 390 and 391: Abscesses and Other Infections Trea
- Page 392 and 393: Abscesses and Other Infections Trea
- Page 394 and 395: CHAPTER 1 CHAPTER 36 Surgical Train
- Page 396 and 397: Surgical Training of Nurses for Rur
- Page 398 and 399: Surgical Training of Nurses for Rur
- Page 400 and 401: Surgical Training of Nurses for Rur
- Page 402 and 403: Training of Medical Assitants in Mo
- Page 404 and 405: CHAPTER 1 CHAPTER 38 Training Surge
- Page 406 and 407: Training Surgeons in the Developing
- Page 408 and 409: Training Surgeons in the Developing
- Page 410 and 411: Training Surgeons in the Developing
- Page 412 and 413: Training Surgeons in the Developing
- Page 414 and 415: Training Surgeons in the Developing
- Page 416 and 417: Training Surgeons in the Developing
- Page 418 and 419: Training Surgeons in the Developing
- Page 420 and 421: Mobile Surgery Figure 1. 405 of tec
- Page 422 and 423: Mobile Surgery Figure 3. 407 Childr
- Page 424 and 425: Mobile Surgery 409 We have realized
- Page 426 and 427: CHAPTER 1 CHAPTER 40 Public Health
- Page 428 and 429: Public Health Problems on Burma Fro
Abscesses <strong>and</strong> O<strong>the</strong>r Infections Treated by <strong>Surgery</strong><br />
Figure 6. Sardonic smile of tetanus.<br />
365<br />
Gas Gangrene<br />
This deadly <strong>in</strong>fection, caused by <strong>the</strong> obligate anaerobe Clostridium perfr<strong>in</strong>gens,<br />
causes a rapidly progressive necrosis of muscle tissue <strong>and</strong> release of tox<strong>in</strong>s. The only<br />
hope for cure is immediate complete excision of all <strong>in</strong>volved muscles, often requir<strong>in</strong>g<br />
amputation of limbs.<br />
Pyomyositis<br />
Pyomyositis is bacterial <strong>in</strong>fection with abscess-formation <strong>in</strong> one or more muscles,<br />
especially <strong>the</strong> larger muscles. It is uncommon <strong>in</strong> wealthy communities <strong>and</strong> relatively<br />
common <strong>in</strong> poor tropical countries. Signs <strong>in</strong>clude swell<strong>in</strong>g, pa<strong>in</strong>, tenderness <strong>and</strong><br />
redness over <strong>the</strong> muscle(s) with fever <strong>and</strong> loss of function. Usually <strong>the</strong> bacteria are<br />
sensitive to penicill<strong>in</strong>. Treatment <strong>in</strong>volves <strong>in</strong>tra-venous penicill<strong>in</strong> or cloxacill<strong>in</strong> followed<br />
by wide <strong>in</strong>cision <strong>and</strong> dra<strong>in</strong>age, pack<strong>in</strong>g <strong>the</strong> wound open or <strong>in</strong>sert<strong>in</strong>g large<br />
dra<strong>in</strong>s. If <strong>the</strong> patient does not recover follow<strong>in</strong>g this treatment <strong>and</strong> becomes more<br />
septic, exam<strong>in</strong>e for undra<strong>in</strong>ed abscesses <strong>and</strong> change to cl<strong>in</strong>damyc<strong>in</strong> plus gentamic<strong>in</strong>,<br />
if available, or chloramphenicol.<br />
Osteomyelitis<br />
Osteomyelitis is far more common <strong>in</strong> poorer than <strong>in</strong> affluent communities. Early<br />
diagnosis <strong>and</strong> immediate treatment are <strong>the</strong> ideal but this is seldom achieved <strong>in</strong> most<br />
parts of <strong>the</strong> world. Thus, many patients present with chronic osteomyelitis manifested<br />
by sequestra <strong>and</strong> s<strong>in</strong>uses <strong>and</strong> <strong>the</strong>y face long-term or permanent disability.<br />
35<br />
Therefore early diagnosis <strong>and</strong> treatment are imperative. Diagnosis of osteomyelitis<br />
usually starts with a sick child who is limp<strong>in</strong>g or unable to use <strong>the</strong> affected limb.<br />
There may not be redness <strong>in</strong> <strong>the</strong> earliest <strong>and</strong> most treatable stage. However, <strong>the</strong>re is<br />
tenderness <strong>and</strong> usually swell<strong>in</strong>g over <strong>the</strong> affected part of <strong>the</strong> bone. Any child with a<br />
fever <strong>and</strong> a pa<strong>in</strong>ful limb should be suspected of suffer<strong>in</strong>g from osteomyelitis <strong>and</strong><br />
urgent diagnostic drill<strong>in</strong>g of <strong>the</strong> bone should be done. Treatment of early osteomyelitis<br />
is early exposure <strong>and</strong> drill<strong>in</strong>g of <strong>the</strong> cortex <strong>in</strong> several sites with a 2mm drill bit<br />
(Fig. 7). Only this will reveal <strong>the</strong> early <strong>in</strong>fection by pus extrud<strong>in</strong>g from one or more<br />
drill sites. Children under age one often have an associated septic arthritis which<br />
must also be dra<strong>in</strong>ed. At any age, osteomyelitis of <strong>the</strong> upper end of <strong>the</strong> femur tends<br />
to be associated with pus <strong>in</strong> <strong>the</strong> hip jo<strong>in</strong>t which needs to be dra<strong>in</strong>ed. If osteomyelitis<br />
is confirmed, <strong>the</strong> wound is packed open <strong>and</strong> antibiotics started. As soon as a culture<br />
is obta<strong>in</strong>ed, start cloxacill<strong>in</strong> or oral chloramphenicol <strong>and</strong>, if necessary, change to a<br />
more appropriate antibiotic based on <strong>the</strong> culture sensitivities. Antibiotics should be