Paediatrics Flashcards
Inguinal hernia mx in infant
Surgery over next few days
Neonate with decreased air entry on the left side of his chest and a displaced apex beat. Abdominal examination demonstrates a scaphoid abdomen
Congenital diaphragmatic hernia
Neonate with episodes of choking, cyanosis, hx of polyhyradminos
Oesophageal atresia
Mx of oesophageal atresia
Replogle tube which can be used to remove the oesophageal secretions, pending surgery.
Movement limited in SUFE
Internal rotation
Cherry red lesion, rectal bleeding
Juvenile polyp
Hyhpospadius symtoms
Urethra opens on ventral side of penis
Def of foreskin there
Skin tethering to hypoplastic urethra
Splayed columns of spongiosum tissue distal to the meatus
10% crytporchidism
Mx of hypospadias
Urethroplasty
Penile reconstruction
May not be needed in very distal disease
Usual diagnosis with meconium ileus and mx
Majority have cystic fibrosis
Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs
Mx of biliary atresia
Kasai at 8w
Roux-en Y portojejunostomy
45% who have kasai will require a transplantation
Overall survival 80%
Which is an ectopic teste
Canalicular or superficial inguinal pouch
Superficial inguinal pouch
Canalicular- between internal and external ring
Associated conditions and features with oesophageal atresia
Polyhydraminos
Imperforate anus
Absent gastric fluid on US
Sporadic risk
Distal fistula most common
Mx of NEC
Treatment is with total gut rest and TPN, babies with perforations will require laparotomy
Factors favouring septic arthritis
WCC > 12
ESR >40
Inability to weight bear
Fever >38.5
Swollen, erythematous umbilicus with septic neonate
Omphalaitis
Risk of portal pyaemia, and portal vein thrombosis
Mass above hyoid, multiloculated, heterogeneous
Dermoid cyst
Recurrent infections, slow loss of vision, Multiple x-rays show brittle bones with no differentiation between the cortex and the medulla
Osteopetrosis
No vas deferens, with recurrent chest infections
Cystic fibrosis
Sperm harvesting
Baby with undescended testicles mx
Review at 6-8w
Then 3m
Then will need referral to surgeon before 6m
Orchidopexy at 6- 18 months of age.
he operation usually consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch.
Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage or two stage procedure depends upon the exact location.
After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.
Maintenance fluids in children
First 10kg- 100ml
Next 10- 50ml
After- 20ml/kg
E.g 21kg
1000+500+20= 1520ml/day
Maintenance fluid in neonates
From birth to day 1: 50-60 ml/kg/day.
Day 2: 70-80 ml/kg/day.
Day 3: 80-100 ml/kg/day.
Day 4: 100-120 ml/kg/day.
Days 5-8: 120-150 ml/kg/day.
Buckle vs greenstick fracture
Greenstick- unilateral cortisol breach only
Buckle - incomplete cortical disruption- resulting in periosteal haematoma only
Choanal atresia
Congenital disorder in which the nasal choanae, (i.e., paired openings that connect the nasal cavity with the nasopharynx), are occluded by soft tissue
episodes of cyanosis are usually worst during feeding. Improvement may be seen when the baby cries as the oropharyngeal airway is used.
Ix after bilious vomitting
Upper GI contrast study
Contrast should be seen to exit the stomach and the location of the DJ flexure is noted (it lies to the left of the midline). If this is not the case, or the study is inconclusive, a laparotomy is performed.
Mx of uncomplicated umbilical hernia
After 3 years of age
Ix if perches disease does not show on X ray
MRI
Painful bright red defecation
Anal fissure
Breech presentation with Barlow and ortolani normal, what next
Hip USS
Cause of unilateral cleft lip
Incomplete fusion of nasolabial muscle ring
Ix for DDH
Initially no obvious change on plain films and USS gives best resolution until 3 months of age. On plain films Shentons line should form a smooth arc
Painful area at umbilicus, with clear yellow fluid draining
Patent urachus
Billious vomiting, DJ flexure is displaced to the right - what mx
Malrotation
Ladds procedure- Laparotomy and division of adhesional bands
Umbilicus providing diffuse foul smelling brown fluid with granulation tissue
Peristent vitello intestinal ducts
Small bowel content to umbilicus
meant to obliterate at 5w when yolk sac no longer required for nutrition
Features of Rickets
Failure to thrive
Bowing
Large head
Deformity of chest walll- thickening of costochondral junction (rickettary rosary)
Transverse sulcus in the chest caused by the pull of the diaphragm (Harrison’s sulcus).
X- Rays show widening and cupping of the epiphysis of the long bones, most readily apparent in the wrist.
A 3 day old baby develops dyspneoa. A chest x-ray is performed and shows a radio-opaque shadow with an air-fluid level in the chest
Bronchogenic cyst
Foregut-derived cystic malformations of the respiratory tract
Ix and tx of bronchogenic cyst
Many cases are diagnosed on antenatal ultrasound. Others may be detected on conventional chest radiography as a midline spherical mass or cystic structure. Once the diagnosis is suspected a CT scan should be performed.
Mx- thorascopic resection after 6w
Mx of FB in external auditory meatus not easily removed
Removal under GA in next operative list
Smooth mass anterior triangle, near mandible
Brachial cyst
Derived from second brachial cleft
Delayed meconium ix
Full thickness rectal biopsy
Mx of Hirschsprungs
Washout
Definitive surgery
Projective non billions vomiting
Pyloric stenosis
Ix and mx of pyloric stenosis
Hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
Diagnosis is most commonly made by ultrasound or test feed
Management is with Ramstedt pyloromyotomy
Single palmar crease and prominent epicanthic folds of the eyes, with projectile vomiting
Duodenal atresia
Fluids for replacement of high output ileostomy
0.9% NaCL with K added
Do not give glucose/Na outside neonates
Testes that come out in bath but otherwise aren’t there and mx
Retractile testes
If the examining clinician notes the testis to return rapidly into the inguinal canal when released then surgery is probably indicated.
Impalpable testes in scrotum or inguinal region 13m
Laparoscopy
US not very useful
Jaundice ix
Present <24hrs- haemolytic anaemia, sepsis
Measure direct(conjugated) serum BR + blood film
2d-2w can be normal- physiological, breastfeeding, breastmilk jaundice
Transcutaneous BR + blood film
> 2w- can be normal or biliary atresia
Direct and indirect serum BR
prolonged physiological jaundice or breast milk jaundice will cause a rise in unconjugated bilirubin, whereas those with obstructive liver disease will have a rise in conjugated bilirubin)
VACTERL sx
Vertebral, Ano-rectal, Cardiac, Tracheo-oesophageal, Renal and Radial limb anomalies
Intolerant of feeds, pan systolic murmur, forearms not developed properly
Pellet lodged in liver, patient is well mx?
Do not operate and review several weeks later
Airgun pellets (and glass) lodged in the soft tissues are usually notoriously difficult to localise and extract
Gastroschisis vs omphalocele
Gastroschisis: Isolated abnormality, bowel lies outside abdominal wall through defect located to right of umbilicus.
Other anomalies rare- intestinal atresia in 10%
Exomphalos:
Central umbilical
Peritoneal sac
Other anomalies present- heart
most common abdominal emergency in children under 1 year of age?
Intussesception
Mx of NEC
NG decompression
Laparotomy should be undertaken in patients do not who progress despite conservative management or in whom compelling indications for surgery exist (eg free air).
Exophalmus and diaphragmatic hernia, now has biliary stained vomit
Intestinal malrotation
Feature of talipes equinovarus
Adducted and inverted calcaneus
Wedge shaped head of talus and distal calcaneal articular surface
Severe Tibio-talar plantar flexion
Medial Talar neck inclination
Displacement of the cuboid and navicular (medially)
Bilateral in 50%
Features of perthes disease
Hyperactivity
Short
Hip pain- may be reared to knee
5-12
Bilateral in 20%
Cause of expanding head in NAI
Hydrocephalus
Ix of SUFE
Hip X ray
If suspicious of Perthes and nothing from 2 x ray what next
Hip MRI
Scaphoid abdomen and hypoxic at birth dx
Bochdalek hernia- Associated with pulmonary hypoplasia
Poor prognosis
Morgani- have little effect on lungs
Incision for laparotomy in children
Transverse supra umbilical abdominal
Where does spinal cord end in neonates
L3
Young girl, facial oedema, distended abdo, fever low Bp
Nephrotic syndrome now SBP
Patient had open abdo surgery, now erythema of wound and distention what ix
USS
Mx of ileo-ileal intussescpetion
Laparotomy
Tetralolgy of Fallot
VSD
RVH
Right ventricular tract obstruction- Pul Stenosis
Overriding aorta
Right to left shunt
Conditions causing intusseption
Peyers patches inflammed
CF
Meckels
Mucosal polyps
Calculating fluid bolus
kg x 10
10 if arrest
Presentation of biliary atresia
Jaundice in infants > 14 days in term infants (>21 days in pre term infants)
Pale stool, yellow urine (colourless in babies)
Associated with cardiac malformations, polysplenia, situs inversus
Ix of biliary atresia
Conjugated bilirubin (prolonged physiological jaundice or breast milk jaundice will cause a rise in unconjugated bilirubin, whereas those with obstructive liver disease will have a rise in conjugated bilirubin)
Ultrasound of the liver (excludes extrahepatic causes, in biliary atresia infant may have tiny or invisible gallbladder)
Hepato-iminodiacetic acid radionuclide scan (good uptake but no excretion usually seen)
Ix of duodenal atresia
AXR shows ‘double bubble sign, contrast study may confirm
Features of NEC
Premature
Second week of life
Dilated bowel loops on AXR, pneumatosis and portal venous air
Types of cleft palate
The primary palate consists of all anatomical structures anterior to the incisive foramen.
The secondary palate lies more posteriorly and is sub divided into the hard and soft palate.
Cleft palate occurs as a result of non fusion of the two palatine shelves.
What are those with cryptorchidism more likely to develop
Seminoma
Intrabominal teste mx
Laparoscopy and mobilised
> 2 yrs non descended teste mx
After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.
Tx of inguinal hernia in children
Inguinal herniotomy - cut open then tie off patent TV
In females offer bilateral As common
The younger the child the higher the risks of strangulation and most neonatal inguinal hernias are repaired on the next available list.
Ix of malrotation
Bowel viability depends of mesentery containing MSA
Abdominal ultrasound scan to determine the relationship between the superior mesenteric artery and vein (normally SMA lies to the left of the SMV).
This test is complemented with an upper GI contrast series and this aims to establish that the DJ flexure is correctly sited to the left of the vertebral bodies
What happens in malrotation
Malrotation occurs when the rotational process described is incomplete. Typically the duodenal loop lies to the left of the caecum and therefore lacks 90 o of its 270o rotation. It becomes fixed in this position with peritoneal attachments (Ladds bands).
Formation of cystic hygroma
Cystic hygroma result from occlusion of lymphatic channels
Infantile haemangioma features
Grow rapidly initially and then will often spontaneously regress
Plain x-rays will show a mass lesion, usually containing calcified phlebolith
Dermoid features
Derived from pleuripotent stem cells and are located in the midline
Most commonly in a suprahyoid location
They have heterogeneous appearances on imaging and contain variable amounts of calcium and fat
Where does Wilms tumour mets to
Lung
Toddler fracture
Oblique tibial fracture in infants
Plastic deformity
Stress on bone resulting in deformity without cortical disruption
Bends
Central abdominal pain and URTI, dx and mx
Mesenteric adeninitis - conservative
Post op care of inguinal hernia
Most cases are performed as day cases, neonates and premature infants are kept in hospital overnight as there is a recognised increased risk of post operative apnoea.
Features of Congenital talipes equinovarus.
Equinus of the hindfoot
Adduction and varus of the midfoot
High arch
Mx of Congenital talipes equinovarus.
Conservative first, the Ponseti method is best described and gives comparable results to surgery. It consists of serial casting to mold the foot into correct shape. Following casting around 90% will require a Achilles tenotomy. This is then followed by a phase of walking braces to maintain the correction.
Surgical correction is reserved for those cases that fail to respond to conservative measures. The procedures involve multiple tenotomies and lengthening procedures. In patients who fail to respond surgically an Ilizarov frame reconstruction may be attempted and gives good results.
Grade of VUR
1- reflux into ureter no dilation
2- renal pelvis no dilation
3- mild dilation od ureter, renal pelvis and calyces
4- dilatation with moderate ureteral tortuosity
5- gross dilation dn with ureteral tortuosity
Ladd procedure steps
Usually rotates 270 Anticlockwise
DJ normally to left
This doesn’t occur
Urgent laparotomy
Rotate volvulus anticlockwise
Return small bowel to right and caecum and colon to left and perform appendectomy
Most common cause of obstruction in paeds
Intusseption
What conditions are associated with intussusception
Haemangiomas, lymphomas, HSP, Haemophilia
Urinary pH in pyloric stenosis
Low
Locations of hypospadias
70% glandular
20% scrotal
10% penile
Pneumatosis intestianlis and postral venous gas
Severe NEC
Dose of IO vs IV
Same
Mx of rectal prolapse
Conservative
When should NAC be given
If above treatment line or delayed presentation >8 hrs
Child with congenital hypothyroid and what hernia
Umbilical
Positive Barlow test, when to US hip
4-6w
Normal urine output under 2
> 2ml/kg/hr
Pass meconium, bilious aspirates, not opened bowel since, distended small bowel
Small bowel atresia
Most common cause of intussepetion
Hypertrophic peyeres
Purpose of brown fat in children and location
Thermogenesis
Scpaulas, mediastinum, kidneys, adrenal
Feeding neonates post major bowel surgery
Often can’t tolerate gastric feeds
Parenteral nutrition
Condition associated with myelomenignocele
Hydrocephalus
Hypothermia effects
Decreased platelet activity
Increased anaesthetic duration
Acidosis due to resp Depression
Tumour of all 3 cell layers
Teratoma
Dose of IV morphine
0.1mg/kg
Most common ectopic teste location
Superficial inguinal pouch
If failed IV 2x
IO in tibia
Hormones levels post surgery
Catecholamines evaluated immediately
Cortisol- stays high for shorter period than adults <24hrs
Term vs pre term IV fluid requirements
Pre term required more <26 80-150ml/kg
Term- 60-80 per day
When should meconium be passed
By 48hrs
Persistent bilious vomiting after birth
Duodenal atresia
Most common cause of delayed passage of meconium and Ix
CF
Guthrie test- spot test
Sweat chloride - 2-5x more Cl
Na in pyloric stenosis
Low
What is CO most dependent on in paeds
HR
Edwards
Trisomy 18
Heart defect
Omphalocele
Oesophageal atresia
Microcepahly
Cleft lip
Paracetamol dose for <50kg
15mg/kg per dose
Important mechanism in heat conservation in newborns
Noradrenergic symp stimulation
Glucose and lactate in hypothermia
Glucose decrease lactate increase- anaerobic
Main cause of heat loss in surgery
Radiation
Rostral vs caudal
Rostral - nose
Caudal- posterior head
Mx of malrotation with regards to amount of viable bowel
If <50cm- untwist, return- perform second look lap
> 50cm- excise ischaemic bowel
