Introduction to Paediatric Surgery

Question 1

what are Physiological Indices in Children?

Answer 1

Wt (kg ) = 2 x (Age +4)

Blood Volume (mls) = 80ml/kg

Urine output = 1ml/kg/hour

Insensible fluid loss = 20ml/kg/day

Systolic BP (mm Hg) = 80 + (2 x Age)

Question 2

vital signs in children - what is the trend?

Answer 2

Babies have high RR, HR and low BP

and vice versa as age increases

Question 3

what are the big differences when dealing with children compared to adults?

Answer 3

communication

signs (Child can be very unwell with minimal signs)

disease processes

physiological parameters

expectations (If 2 and come in unwell, you are not expected to die and this adds to the stress)

STRESS

Question 4

what is used for Pain Management in children?

Answer 4

paracetamol - 20mg/kg 4-6 hly

ibuprofen - 10mg/kg 8 hly

(weak opiod) (Codeine not recommended <12 yrs)

Strong opiod (morphine)

Question 5

Fluid management - what is used for resuscitation and maintenance

Answer 5

Resuscitation - 20ml/kg bolus 0.9% Sodium Chloride (1/4 of circulating volume)

Maintenance - 0.9% NaCl/ 5% Dextrose +/- KCl

• 4ml/kg 1st 10kg
• 2ml/kg 2nd 10 kg
• 1mlkg every kg thereafter

10 yrs = 2 x (10+4) = 28kg = 40+20+8 = 68mls/hr

Question 6

what are the sentinal signs in a child?

These are really important in children, imply something significant going on

Answer 6

FEED REFUSAL

BILE VOMITS - Bile vomiting is green (not yellow), implies obstruction and should always be taken seriously

COLOUR - Grey is bad, blue is bad, pink is good, but grey implies poor skin prefusion

TONE - Sick baby will be a floppy baby, also if hyper rigid then something going on

TEMPERATURE - Pyrexia is a problem but hypothermia may even be a bigger problem as means you arnt perfusing your peripheral circulation adequately

Question 7

Case Presentation:

10 year old boy

2 day history of abdominal pain

vomited x 2

pain was initially periumbilical

now in RIF

temp 37.8, flushed

tender RIF with guarding

what is the diagnosis

Answer 7

appendicitis

Classical history of appendicitis

Question 8

Basis of management:

what decision does a GP make and what decision does a surgeon make?

Answer 8

GP / ED decision? - does this child need a surgical opinion?

Surgical decision? - does this child need an operation?

Question 9

what do you want to find out in the history?

Answer 9

pain - “closer to umbilicus, less chance of pathology”, colic vs constant (wonstant worse as implies peritonitis), movement (car trip)

vomiting - increases significance, bile important (bile is green not yellow!)

diarrhoea - retro-ileal/retro-colic, tenesmus in pelvic appendix (feeling of incomplete emptiness)

anorexia

previous episodes - lessens chances of surgical diagnosis

menstrual history

Question 10

what should be done on examination and how should it be carried out?

Answer 10

distraction techniques essential

general appearance important

temperature (Low grade temp in appendicitis)

“guarding and rebound” – don’t do this

Question 11

what investigations should be done?

Answer 11

Urine - all…

FBC - only if diagnostic doubt

Electrolytes - only if sick / very dry

X-rays - rarely

Question 12

Diagnoses - what should you think about when diagnosing appendicitis?

Answer 12

Is it appendicitis?

• unusual <4 years
• can be difficult diagnosis
• 20% admissions

“clues” to having apendicitis:

• moderate temperature, vomiting
• looks unwell

Question 13

what are the symptoms to look out for in apendicitis?

Answer 13

Murphy’s Triad - pain, vomiting, fever

tenderness over Mc Burney’s point (1/3 of the way between the umbilicus and the ASIS)

complications - abscess, mass, peritonitis

Question 14

how do you manage apendicitis?

Answer 14

analgesia - not a problem, shouldn’t be with held, oral paracetamol best option

Surgery

Medical management doesn’t work…COVID tested….

Question 15

Case:

10 year old boy

2 day history of abdominal pain

not Vomited

pain was initially periumbilical

now in LIF, was in RIF

temp 36.8,

tender suprapubically no guarding

what is his diagnosis?

Answer 15

NSAP - Non Specific Abdominal Pain

Question 16

what are the features of NSAP - Non Specific Abdominal Pain?

Answer 16

short duration

central

constant

not made worse by movement

no GI disturbance

no temperature

site & severity of tenderness vary

no vomiting

Question 17

Commonest cause of abdominal pain

who does NSAP occur in?

Answer 17

girls > boys

45% admissions

often recurrent

can mimic an early appendicitis

do we miss pathology with this label? - risk of missing appendicitis 0.2%

Question 18

what are some differential diagnosis of NSAP?

Answer 18

mesenteric adenitis (big swollen glands in abdomen) - high temperature, URTI often, not “unwell”

pneumonia - clue “sicker than abdominal signs”, usually Right Lower Lobe

Question 19

case:

3 day old baby presents with bile vomiting - “fairy liquid” green

Investigation – upper GI contrast study ASAP….

what is the diagnosis and management?

Answer 19

diagnosis - MALROTATION and VOLVULUS (twisted and lost blood supply)

Management – Laparotomy ASAP

Question 20

case:

nine-month baby

3 day history of viral illness then intermittent COLIC and DYING SPELLS

bilious vomiting

bloody mucous PR (redcurrant jelly stool)

on admission – 4 seconds capillary refill

what is the diagnosis?

Answer 20

Intussusception (specific to children)

Intussusception (in-tuh-suh-SEP-shun) is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This telescoping action often blocks food or fluid from passing through. Intussusception also cuts off the blood supply to the part of the intestine that’s affected

Question 21

what investigations and management would you do for intussusception

Answer 21

Investigations - USS abdomen

“target sign” – bowel slid inside other

Management

pneumostatic reduction (air enema)

laparotomy

Question 22

Case:

8 month baby

umbilical swelling

present from about 4 days old

worse with crying

easily reducible

Answer 22

Diagnosis: Umbilical hernia

Question 23

who do Umbilical hernia occur in, how are they managed?

Answer 23

1 : 6 children

spontaneous closure by 4 years is rule

complications rare

repair if - complications, relative (persistance>4yrs, large defect, aesthetic)

Common in children, Almost always get better

important to distinguish from paraumbilical hernia (hernia above umbilicus)

Question 24

what are 2 abdominal wall defects?

Answer 24

Gastroschisis…..

Exomphalos…..

Question 25

what is Gastroschisis? its management? and survival?

Answer 25

abdominal wall defect - gut eviscerated and exposed, 10% associated atresia

management - delayed closure, TPN

survival - 90%+, short gut

Gastroschisis is a birth defect in which the baby’s intestines extend outside of the abdomen through a hole next to the belly button. The size of the hole is variable, and other organs including the stomach and liver may also occur outside the baby’s body

Question 26

what is Exomphalos, its associated anomalies and its management?

Answer 26

umbilical defect with covered viscera

associated anomalies:

• 25% cardiac
• 25% chromosomal - Trisomy13, 18, 21
• 15% renal, neurological
• Beckwith-Weideman syndrome

management - primary / delayed closure

outcome: post natal mortality - 25% (Mortality worse due to being associated with severe abnormalities)

Exomphalos is a weakness of the baby’s abdominal wall where the umbilical cord joins it. This weakness allows the abdominal contents, mainly the bowel and the liver to protrude outside the abdominal cavity where they are contained in a loose sac that surrounds the umbilical cord