Introduction to Paediatric Surgery COPY Flashcards
what are Physiological Indices in Children?
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)
vital signs in children - what is the trend?
Babies have high RR, HR and low BP
and vice versa as age increases
what are the big differences when dealing with children compared to adults?
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
what is used for Pain Management in children?
paracetamol - 20mg/kg 4-6 hly
ibuprofen - 10mg/kg 8 hly
(weak opiod) (Codeine not recommended <12 yrs)
Strong opiod (morphine)
Fluid management - what is used for resuscitation and maintenance
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
what are the sentinal signs in a child?
These are really important in children, imply something significant going on
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
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
appendicitis
Classical history of appendicitis
Basis of management:
what decision does a GP make and what decision does a surgeon make?
GP / ED decision? - does this child need a surgical opinion?
Surgical decision? - does this child need an operation?
what do you want to find out in the history?
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
what should be done on examination and how should it be carried out?
distraction techniques essential
general appearance important
temperature (Low grade temp in appendicitis)
“guarding and rebound” – don’t do this
what investigations should be done?
Urine - all…
FBC - only if diagnostic doubt
Electrolytes - only if sick / very dry
X-rays - rarely
Diagnoses - what should you think about when diagnosing appendicitis?
Is it appendicitis?
- unusual <4 years
- can be difficult diagnosis
- 20% admissions
“clues” to having apendicitis:
- moderate temperature, vomiting
- looks unwell
what are the symptoms to look out for in apendicitis?
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
how do you manage apendicitis?
analgesia - not a problem, shouldn’t be with held, oral paracetamol best option
Surgery
Medical management doesn’t work…COVID tested….
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?
NSAP - Non Specific Abdominal Pain
what are the features of NSAP - Non Specific Abdominal Pain?
short duration
central
constant
not made worse by movement
no GI disturbance
no temperature
site & severity of tenderness vary
no vomiting
Commonest cause of abdominal pain
who does NSAP occur in?
girls > boys
45% admissions
often recurrent
can mimic an early appendicitis
do we miss pathology with this label? - risk of missing appendicitis 0.2%
what are some differential diagnosis of NSAP?
mesenteric adenitis (big swollen glands in abdomen) - high temperature, URTI often, not “unwell”
pneumonia - clue “sicker than abdominal signs”, usually Right Lower Lobe
case:
3 day old baby presents with bile vomiting - “fairy liquid” green
Investigation – upper GI contrast study ASAP….
what is the diagnosis and management?
diagnosis - MALROTATION and VOLVULUS (twisted and lost blood supply)
Management – Laparotomy ASAP
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?
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
what investigations and management would you do for intussusception
Investigations - USS abdomen
“target sign” – bowel slid inside other
Management
pneumostatic reduction (air enema)
laparotomy
Case:
8 month baby
umbilical swelling
present from about 4 days old
worse with crying
easily reducible
Diagnosis: Umbilical hernia
who do Umbilical hernia occur in, how are they managed?
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)
what are 2 abdominal wall defects?
Gastroschisis…..
Exomphalos…..
what is Gastroschisis? its management? and survival?
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
what is Exomphalos, its associated anomalies and its management?
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
