Paed Surgery

Question 1

How would you determine the avg weight of a child if you don’t have time to weigh them?

Answer 1

2 x (age +4)

E.g. 10yr old:
2 x (10 + 4) = 28 kg

Question 2

How do you determine blood volume, urine output and insensible fluid loss in kids?

Answer 2

Blood volume = 80ml/kg
UO = 1ml/kg/hr
Insensible fluid loss = 20ml/kg/day

Question 3

How do we determine the systolic BP of kids?

Answer 3

80 + (2 x age)

E.g. 9yr old:
80 + (2 x 9) = 98

Question 4

How do we manage pain in kids?

Answer 4

Follow the WHO pain ladder:

1) PM
2) Ibuprofen
3) Weak opiod (but codeine not recommended <12yrs)
4) Strong opioid e.g. morphine

Question 5

What would we give kids as resuscitation fluids?

Answer 5

20ml/Kg bolus of 0.9% NaCl (saline) over 10 mins

Question 6

What do we give kids as maintenance fluids?

Calculate how much the drip rate would be in a 10 yo

Answer 6

4ml/Kg (1st 10Kgs)
2ml/Kg (2nd 10kgs)
1ml/Kg (thereafter)
Of 0.9% NaCL & 5% dextrose +/- KCl

E.g. 10yr old = 28kgs
(4 x 10) + (2x10) + (1 x 8) = 68ml/hr

Question 7

List 5 red flag/sentinel signs of a surgical problem in kids? [5]

Answer 7

• Feed Refusal
• Bile vomits (green)
• Colour (worse grey)
• Tone (floppy)
• Temp (hypothermia > hyperthermia)

Question 8

What is the speed-bump pain? [2]

Answer 8

Abdo pain gets way worse on sudden movement e.g. going over speedbumps (indicates peritonitis)

Question 9

What tests can be used to determine the source of a child’s abdo pain? [4] Whats difference between investigations in child vs adult?

Answer 9

Urinalysis (For all of them)
FBC (only if dx doubt)
U&E (if very sick or dry cos cannulas)
X-ray (only necessary if you suspect bowel obstruction)

Question 10

Appendicitis
Epidemiology [1]
Symptoms [4]
Investigations [4]

Answer 10

Ep: 10-20y/o (rare <4y/o)

 Moderate temperature, unwell
Murphy’s triad of pain: pain (speed bump pain), vomiting, fever
 Tenesmus in pelvic appendix because colon pus-filled but can have diarrhea
 Anorexia

Ix: FBC (neutrophilic leucocytosis), CRP, urinalysis

Question 11

Appendicitis
Signs upon examination [1]
Mx for simple [2] vs perforated appendicitis [2]

Answer 11

Sign: tenderness over McBurney’s point
Management:
- Analgesia for both
• Simple appendicitis: Laparoscopic appendectomy, prophylactic METRONIDAZOLE and CEFUROXIME
• Perforated appendicitis: copious abdo lavage and appendectomy

Question 12

Non-specific Abdo Pain (NSAP) is a positive diagnosis for when we can’t find a pathological reason for abdo pain. What are it’s features? [6]

Answer 12

Short
Central
Constant and recurrent
Not affected by movement
No GIT disturbance, no temp
Site/severity changes

Question 13

What is Mesenteric Adenitis [2]
Sxs [3]
Mx [1]

Answer 13

Mesenteric lymphadenopathy following recent URTI

Sxs: generalised abdo discomfort without localised pain and tenderness, high fever

Management not required but appendectomy if dx doubt

Question 14

How can pneumonia present with abdo pain? [2]

Answer 14

Now and then a Right LL pneumonia comes with abdo pain

The clue is they’re very sick but have limited abdo signs

Question 15

What is a malrotation? [2]

Answer 15

Bowel fails to undergo the 270* rotation during pregnancy so it can become twisted/obstructed very easily (aka volvulus)

Question 16

How would a malrotation present? [4]

Answer 16

Asypmptomatic until a volvulus develops:

• bilious vomiting (pathognomic)
• abdo pain (inconsolable state)
• tachycardia with hypertension due to pain, then hypotension
• 3-7 days of life

Question 17

How do we investigate and manage a malrotation with volvulus? [2]

Answer 17

o Ix: upper GI contrast study stat

o Mx: urgent laparotomy and Ladd procedure

Question 18

What is an intussusception? [1]
Commonest parts of bowl that are involved [1]
Crucial part of history [1]

Answer 18

One big part of bowel has slid further inside another (telescoping) causing bowel obstruction
Mostly terminal ileum into colon
Leads to waves of colic which triggers vagal responses leading to dying spells - white floppy and not breathing

Question 19

How does an intussusception present? [5]

Answer 19

Usually viral illness followed by:

• Intermittent colic and dying spells
• Bilious vomiting
• Slow cap refill
• Bloody mucous PR, red currant jelly stools
• sausage shaped mass in RUQ

Question 20

How do we confirm [1] and treat an intussusception [2]?

Answer 20

Abdo US - target sign

Pneumostatic reduction (Aka air enema) under radiological visualization, if that fails a laparotomy

Question 21

What are Gastroschisis and exomphalos

Answer 21

Gastroschisis = Abdominal wall defect – gut eviscerated and exposed

Exomphalos = Like gastroschisis but covered with viscera

Question 22

What’s worse gastroshisis or exomphalos?

Answer 22

Gastroschisis has a good prognosis

Exomphalos has a bad one but not directly, it’s because of ass abnormalities e.g. cardiac, chromosomal, renal & neuro

Question 23

How do we treat Gastroschisis & exomphalos? [2]

Answer 23

Surgical closure (primary or delayed)

And TPN

Question 24

What makes an umbilical hernia more likely? [4]

Answer 24

LBW
Trisomy 21
Hypothyroid
Mucopolysaccharidoses

Question 25

What is an epigastric hernia? [2]

Answer 25

Defect in linea alba sup to umbilicus –> protrusion of peritoneal fat

Question 26

When would we repair an umbilical or epigastric hernia?

Answer 26

Umbilical hernias:
- Usually self-resolve, but if large or symptomatic perform elective repair at 2-3 years of age. If small and asymptomatic peform elective repair at 4-5 years of age.

Epigastric we tend not to, it’s largely hidden by natural fat as you age and preferable to a large scar

Question 27

Inguinal hernia 
Ax [1]
Symptoms [3]
Signs [3]
Sequelae [1]

Answer 27

Ax: patent processus vaginalis

Symptoms: Intermittent swelling in groin/scrotum on crying/straining, irritable, vomiting

Sign: visible on raising intra-abdominal pressure eg cough, irreducible lump in groin/scrotum, firm and tender

Risk of bowel strangulation, damage to testis

Question 28

Inguinal hernia management [3]

Answer 28

Reduce first with opioid analgesia, sustained gentle compression
Delay surgery for 24-48h to allow resolution of edema
Emergency surgery