paediatric surgery Flashcards
physiological indices in children
weight (kg) = 2 x age (+4)
blood vol (mls) = 80ml/kg
UO = 1ml/kg/hr
insensible fluid loss = 20ml/kg/day
systolic BP (mmHg) = 80 + (2x age)
vital signs in children
- babies = high RR, high HR, low BP
- as you get older, trends reverse
pain barrier in children
much more difficult for a child to get analgesia straight away
- children should get analgesia as soon as they are sore
- follow WHO pain ladder
- paracetamol 20mg/kg 4-6hrly
- ibuprofen 10mg/kg 8hrly
- weak opioid - codeine not recommended <12yrs (resp depression, rapid metabolises, may not be effective)
- strong opioid
fluid management in children - resuscitation
20ml/kg bolus 0.9% sodium chloride
fluid management in children - maintenance
0.9% Nacl + 5% dextrose +/- KCl
4ml/kg 1st 10kg
2ml/kg 2nd 10kg
1ml/kg every kg thereafter
what are the sentinel signs in children
imply there is something significant going on
- feed refusal
- bile vomits (green) - implies obstruction
- colour - grey = poor skin perfusion
- tone - floppy/rigid
- temp - pyrexia, hypothermia - inadequate peripheral circulation
basis of management of abdo pain
GP/ED decision - does this child need a surgical opinion
surgical decision - does the child need surgery
abdo pain in children - hx
- closer to umbilicus - tends to be related to mid-gut pain → less likely to be pathological
- colic vs constant - constant implies peritonitis
- pain on movement - implies peritonitis
- vomiting
- increases significance - more likely to be an issue if pain + vomiting
- bile is important
- diarrhoea
- retro-ileal/retro-colic appendix
- tenesmus in pelvic appendix
- anorexia
- previous episodes - lessens chances of surgical diagnosis
- menstrual hx
examining a child
- distraction techniques
- general appearance important
- temp
- guarding and rebound tenderness - avoid in children (very uncomfortable) - percussion is sufficient
investigations for abdo pain
urine - everyone
FBC - only if diagnostic doubt
electrolytes - only if sick/very dry
X-rays - rarely (unless obstruction), unlikely to alter management
when is it appendicitis in children
unusual <4y/o
can be difficult to diagnose
20% admissions
clues: moderate temp, vomiting, looks unwell
features of appendicitis
Murphy’s triad: pain, vomiting, fever
tenderness over McBurney’s point (⅓ of the way between umbilicus and iliac spine)
complications of appendicitis
abscess
mass
peritonitis
management of appendicits
analgesia - don’t withhold, oral paracetamol best option
surgery
features of non-specific abdo pain (NSAP)
short duration
central
constant
not made worse by movement
no GI disturbance
no temp
site and severity of tenderness vary
→ can mimic an early appendicitis (BUT risk of missing appendicitis 0.2%)
how common is NSAP
F > M
45% admissions
often recurrent
safe and usually not underlying pathology
DDx for NSAP
mesenteric adenitis - high temp, often URTI, not unwell
pneumonia - sicker than abdo signs, usually R lower lobe, high WCC, high temp
what does bile vomit indicate until proven otherwise
malrotation and volvulus
needs urgent diagnosis
what is malrotation and volvulus
malrotation - abnormal arrangement of intestines
volvulus - intestines have twisted and lost blood supply
management of malrotation and volvulus
laparotomy to salvage bowel before it dies
what does this hx suggest a diagnosis of:
9mth old baby
3/7 hx of viral illness then intermittent colic and dying spells
bilious vomiting
bloody mucus PR
4s CRT
intusussception
what are dying spells and what causes them
child is crying and then goes completely floppy and pale
don’t breathe for 10-15s then start crying again
- wave of abdo colic → vagal response → breath holding and floppiness
investigations for intusussception
USS abdo
- target sign
management of intusussception
requires urgent intervention to prevent ischaemia
pneumostatic reduction (air enema) - X-ray guided, generally successful
laparotomy
