Paed Surgery Flashcards
How would you determine the avg weight of a child if you don’t have time to weigh them?
2 x (age +4)
E.g. 10yr old: 2 x (10 + 4) = 28 kg
How do you determine blood volume, urine output and insensible fluid loss in kids?
Blood volume = 80ml/kg
UO = 1ml/kg/hr
Insensible fluid loss = 20ml/kg/day
How do we determine the systolic BP of kids?
80 + (2 x age)
E.g. 9yr old:
80 + (2 x 9) = 98
How do we manage pain in kids?
Follow the WHO pain ladder:
1) PM
2) Ibuprofen
3) Weak opiod (but codeine not recommended <12yrs)
4) Strong opioid e.g. morphine
What would we give kids as resuscitation fluids?
20ml/Kg bolus of 0.9% NaCl (saline) over 10 mins
What do we give kids as maintenance fluids?
Calculate how much the drip rate would be in a 10 yo
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
List 5 red flag/sentinel signs of a surgical problem in kids? [5]
- Feed Refusal
- Bile vomits (green)
- Colour (worse grey)
- Tone (floppy)
- Temp (hypothermia > hyperthermia)
What is the speed-bump pain? [2]
Abdo pain gets way worse on sudden movement e.g. going over speedbumps (indicates peritonitis)
What tests can be used to determine the source of a child’s abdo pain? [4] Whats difference between investigations in child vs adult?
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)
Appendicitis
Epidemiology [1]
Symptoms [4]
Investigations [4]
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
Appendicitis
Signs upon examination [1]
Mx for simple [2] vs perforated appendicitis [2]
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
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]
Short Central Constant and recurrent Not affected by movement No GIT disturbance, no temp Site/severity changes
What is Mesenteric Adenitis [2]
Sxs [3]
Mx [1]
Mesenteric lymphadenopathy following recent URTI
Sxs: generalised abdo discomfort without localised pain and tenderness, high fever
Management not required but appendectomy if dx doubt
How can pneumonia present with abdo pain? [2]
Now and then a Right LL pneumonia comes with abdo pain
The clue is they’re very sick but have limited abdo signs
What is a malrotation? [2]
Bowel fails to undergo the 270* rotation during pregnancy so it can become twisted/obstructed very easily (aka volvulus)
How would a malrotation present? [4]
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
How do we investigate and manage a malrotation with volvulus? [2]
o Ix: upper GI contrast study stat
o Mx: urgent laparotomy and Ladd procedure
What is an intussusception? [1]
Commonest parts of bowl that are involved [1]
Crucial part of history [1]
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
How does an intussusception present? [5]
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
How do we confirm [1] and treat an intussusception [2]?
Abdo US - target sign
Pneumostatic reduction (Aka air enema) under radiological visualization, if that fails a laparotomy
What are Gastroschisis and exomphalos
Gastroschisis = Abdominal wall defect – gut eviscerated and exposed
Exomphalos = Like gastroschisis but covered with viscera
What’s worse gastroshisis or exomphalos?
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
How do we treat Gastroschisis & exomphalos? [2]
Surgical closure (primary or delayed)
And TPN
What makes an umbilical hernia more likely? [4]
LBW
Trisomy 21
Hypothyroid
Mucopolysaccharidoses
What is an epigastric hernia? [2]
Defect in linea alba sup to umbilicus –> protrusion of peritoneal fat
When would we repair an umbilical or epigastric hernia?
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
Inguinal hernia Ax [1] Symptoms [3] Signs [3] Sequelae [1]
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
Inguinal hernia management [3]
Reduce first with opioid analgesia, sustained gentle compression
Delay surgery for 24-48h to allow resolution of edema
Emergency surgery
