Part 35 Flashcards
Anatomy of a pediatric airway vs adult
Child is funnel shaped narrowing at the bottom, adult is cylinder shaped
Normal amount of blood donated in 1 unit
500mL
Children are more prone to blood loss resulting in a dangerous situation because….
….they have much less volume to begin with (400ml in neonate compared to 355ml in the average coke can) therefore losing an amount of volume puts them at higher class of shock than an adult
The most common disease in children
Trauma - high risk population for accidents
Waddell’s triad and what does it often occur with?
- contralateral head injury
- splenic fracture
- left femur fracture
-often in children struck by a car where they go on the hood and then are thrown off onto the ground when the driver brakes
Seatbelt sign
Bruising across the abdomen in children injured by a seatbelt, can see injuries to the small bowel, pancreas, colon, mesentary, and back ligament tearing
The narrowest spot in the GI pathway is the…
…LES
Strong acids tend to injure via ___ if ingested, strong alkaline agents tend to injure via ___
perforation of the stomach, liquefactive necrosis in the esophagus all the way down
Most common surgical disease of the newborn
Necrotizing enterocolitis (NEC) - infection and death of bowel tissue most common in premature infants of unknown etiology
Malrotation with volvulus definition
Surgically emergent procedure in children where the intestine becomes twisted and does not make turns as it should resulting in potential necrosis, may manifest as bilous vomiting
Intestinal atresia definition
Missing unformed blocked intestine most common in the ileum, results in swelling of the proximal bowel and shrinking of the distal bowel resulting in bilous vomiting, abdominal distension and failure to pass meiconium, has 5 subtypes
Pyloric stenosis definition, diagnosis, and treatment options (1)
Often presents with projectile NONbilous vomiting, can be visualized on ultrasound, treated with hydration and pylormyotomy
Intusussception definition, diagnosis/treatment (same)
Often presents as colicky pain without relief by comfort and frequently passing currant jelly stools, contrast enema (or surgery if can’t be treated)
Hirschprung’s disease definition
Absence of ganglion cells on distal bowel (must bipsy) that results in inability to dilate and inability to pass meconium, requires resection of aganglionic bowel
Characteristic x ray finding of duodenal atresia
Double bubble finding
What is the most common cancer in children?
Leukemia
What is the most common extracranial tumor in pediatric patients?
Neuroblastoma - often grow on the adrenal gland
2nd most common childhood abdominal malignancy
Wilms tumor
Ovarian teratomas
Childhood or teenage tumors that can be malignant 5-10% of time often as a suprapubic mass, 1/3 cause acute abdominal pain due to torsion of ovary (you can see teeth sometimes on x ray or hair upon removal)
Sacrococcygeal teratoma
Large exophytic soft tissue mass in the region of the sacral area that grows before birth and needs surgical excision, typically has good outcomes at preserving musculature and anal function
Hemorrhoids symptoms (5)
- pain (external)
- thrombosis
- skin tags
- bleeding (internal)
- prolapse
Hemorrhoids treatment options (7)
- bulking agents
- stool softeners
- anal canal suppositories
- creams
- promote hemorrhoid fixation to rectal wall to improve prolapse
- banding, sclerotherapy, electrodessication
- surgery
What grade of hemorrhoids require surgical approach?
Grade 3 unresponsive to nonsurgical approaches or grade 4 or those with combined internal and external components
Surgical therapy options for hemorrhoids (3)
- excisional hemorrhoidectomy
- circular stapling
- transanal hemorrhoidal dearterialization
Anal fissure definiton
Tear in anoderm between anal verge and dentate line, most common in posterior midline, often heal within 2-4 weeks, etiology due to tight internal anal sphincter
Anal fissure common presentation (3)
- pain during defecation that feels like passing broken glass that relieves an hour or so after passing
- bright red blood
- presence of sentinel pile (chronic ones - see heaped up skin on outside of fissure implying it has been chronic)
Anal fissure treatment options (5)
- avoid constipation (bulking agents)
- topical anesthetic agents
- diltiazem paste
- nitroglycerine paste (relaxes smooth muscle in the internal anal sphincter)
- botox injections
- anal dilatation in chronic
- lateral internal sphincterotomy (females need to go lateral opposed to anterior posterior because of vagina compromise)***
Anal fistula definition
Tracct with internal opening at level of dentate line and external opening somewhere in skin outside anal verge
Anal fistula presentation
Intermittent or persistent drainage from perianal opening, may have been preceding abscess, suspeect if perianal abscess recurs in same space
Fistulas surgical therapy general considerations (3)
- will not heal spontaneously
- must identify internal opening
- do not operate on a patient with crohn’s
Goodsall’s rule*****
Draw a line transversely across the anus, anything posterior to that will see tracts that are curved into the dentate line, while those anterior will see tracts that are directly straight into the dentate line unless it is 3cm or greater, in which case it will arc to the posterior midline in a curved fashion and then reach the dentate line posteriorally
Fistula surgical options (2)
- fistulectomy (pass probe along course of canal, entire canal laid open, tract curetted and granulation tissue removed
- seton placement (thin silicone string placed into the fistula tract allows it to drain and heal)
4 types of pneumothorax
- spontaneous (blebs which are weak areas cause it to occur often in thin tall males or immunocompromised)
- traumatic (closed from something like a rib fx or open from penetrating)
- iatrogenic (PEEP or thoracocentesis)
- tension (complete collapse and displacement of mediastinum to opposite side)
Pneumothorax can potentially cause what type of nonshockable cardiac arrest?
Pulseless electrical activity
Chest tube insertion procedure
- obtain consent
- position patient in lateral decubitus or reclined
- incision into the 4-5th intercostal space at mid anterior line
- insert chest tube
- attach bottle to tube so atmospheric air is not drawn into the lung
Video assisted thoracoscopy applications (4)
- spontaneous pneumo
- pleural effusions
- lobectomy
- tissue biopsy
Pleurodesis definition
Inflammation of plura that will lead to scarring, can be brought on by mechanical scraping (least inflammatory), chemical tox or dextrose (more irritating to pleura), or talc powder (most inflammatory to pleura)
Postop management of chest tube
-can be removed when CXR stable on water seal and drainage <150-200cc/24 hours
What phase of the respiratory cycle should a chest tube be removed?
Maximum inhalation
Heimlich valve
Device that attaches to end of chest tube that allows for air to only flow out (1 way valve) so any time they take a breath if there is any air in the pleural space it will come out, can allow for patient to discharge from hospital as long as attach well and make sure it doesn’t come detached
Preop eval for cardiovascular disease options (7)
- cardiac catheterization (inject dye to detect degree of stenosis)
- TEE (transesophageal echo to look at heart valves and ejection fraction)
- PFT (lung complications and severity)
- carotid doppler (detect stenosis)
- CXR (baseline, aortic calcification, COPD presence)
- lab tests (CBC, coags, complete metabolic panel, urinalysis, A1c, thyroid studies)
- CT scan
Indications for surgery in CAD (3)
- left main >50% presence
- length of stenosis
- vessels involved (2+)
Conduit selection of coronary artery bypass grafting
- internal mammary artery (most often left)
- saphenous vein (cannot be varicose, have to put in the right way so valves aren’t blocking!)
- radial artery (allen test it first!)
Cardiopulmonary bypass definition, what are some cons of it (3)?
A machine that removes venous blood, takes over function of heart, oxygenates blood, taking over function of lungs, and then returns arterial blood, while providing cardioplegia (high K+ solution that stops the heart from beating), “bloodless” procedure making it easy space to work with
- microemboli
- increased post op neurological event
- temporary cognitive delay (pump brain)
Causes of aortic stenosis (3)
- age
- bicuspid aortic valve (anatomic)
- rheumatic fever
Mechanical valve vs bioprostetic valve
Mechanical lasts forever and thus is good for younger patients but bad for noncompliant as requires anticoag with coumadin and and coumadin only**, vs tissue from animals and lasts 10-15 years so better for elderly and those who are not compliant, does not require any anticoag
TAVR Replacement
Currently approved for moderate to high risk patients with aortic stenosis involving temporarily pacemaking heart to stop it and then placement of a new valve in the place of the old one and expansion via balloon catheterization, risk of leak or heart block in future as these artificial valves can expand over time
Aortic surgery for ascending aortic aneurysm indications (3)
- measures >5cm
- dissection
- rapidly enlarging or co-occurring pathology
Post op care in cardiac surgery patients (4)
- Return to ICU for first 24 hours when most unstable for hemodynamic monitoring
- insertion of swan ganz catheter for monitoring
- intubation temporarily and wean off soon as tolerated
- chest tube and monitoring for hemothorax or tamponade
Intraaortic balloon pump
Indicated in a patient in cardiogenic shock pre or post op that inflates during diastole and contracts during systole to help improve ejection fraction, coronary perfusion, decreases afterload
ECMO
Extracorporeal membrane oxygenation that is indicated for failure of cardiac and or pulmonary system, VA is used to pull out venous blood, oxygenate it, and return it, VV pulls it out the blood of the venous system, oxygenates it, and returns it to the venous system as the heart is pumping well on its own
Associated factors with inguinal herniation (5)
- family history
- straining of stool
- obesity
- connective tissue disorder
- ascites
Scarpa’s fascia
Most superficial layer of the anterior lower abdominal wall seen initially during hernia repair
2 nerves that run thru the inguinal canal
- Ilioinguinal nerve
- Genitofemoral nerve
The ___ runs thru the male inguinal canal, the ___ runs thru the female
spermatic cord, round ligament
Hesselbach’s triangle components
Lateral - inferior epigastric vessels
Medial - lateral border of rectus abdominus
Inferior - inguinal ligament
Floor - internal oblique and transversus abdominus
Inguinal hernia signs and symptoms (3)
- vague discomfort
- pain
- bulge
During palpation of a hernia, indirect (abdomoinal contents going thru inguinal canal) is felt on the ___ of the finger while direct (abdominal contents going thru abdominal wall) is felt on the ___, often done while the patient valsalvas (turn head and cough)
tip, side
Inguinal hernia complications (4)
- Incarcerations (trapped herniated tissue but not ischemic)
- strangulation (ischemia - elevated wbc, nausea, acutely ill)
- bowel obstruction
- recurrence of hernia
Inguinal hernia therapy
Surgery - elective is less risk in all cases than emergency!
Inguinal hernia surgical complications (5)
- bleeding
- loss of testicle
- ileoinguinal nerve entrapment syndrome
- hematoma/seroma
- vas deferens injury
NAVEL acronym in the femoral triangle (lateral to medial)
Nerve artery vein lymphatics
Spigelian hernia
Located at the junction of the semilunar line and the semicircular line at the lateral border of the rectus muscle just below the umbilicus
Diastasis recti vs epigastric hernia
Easily mistaken for each other, diastasis recti is widening of abdomen muscles (thinning linea alba) often after pregnancy but preservation of the fascia while epigastric hernia will often continue to grow in size and has the potential to strangulate
How is GERD diagnosed? (4)
- clinical presentation and relief of symptoms with PPI or H2 blockers
- barium swallow and x ray
- upper endoscopy (EGD)
- esophageal manometry (measure LES strength)
When is surgery indicated for GERD? (3)
- incomplete relief with medical management
- development of barretts esophagus
- recurrent episodes
Primary surgery for GERD
Fundoplication surgery (almost always laproscopically)
Fundoplication procedure (and its 2 types)
Surgical procedure in which portion of stomach (fundus) is used to wrap around the LES to prevent reflux of gastric acid and fluid into esophagus to treat GERD,fairly quick with rapid recovery and minimal hospital times, either complete wrap around LES (nissen fundoplication) or partial (toupet fundoplication), has been shown excellent results and resolve damage to esophagus
Ataxia definition
a loss of full control of body movements often resulting in imbalance or being off gait, some patients may describe the sensation as dizziness
“Worst headache of my life…” is often the description of a…
…Subarachnoid hemorrhage typically from aneurysm rupture
Neuromuscular disease definition and most common symptom
- Disease that affects function of muscles due to problems with the nerves and muscles
- Most common symptom is muscle weakness (not general weakness but physical muscle weakness)
Myasthenia gravis
Most common neuromuscular transmission disorder, typically acquired by immunological abnormality but sometimes genetic, disorder of post synaptic neuromuscular junction
Pathophysiology of myasthenia gravis
- Post synaptic muscle membrane becomes distorted and simplified (loses its normal folded shape)
- This prevents Ach from binding to its receptors properly at the muscle end plate (alongside autoantibodies attaching to the membrane)
Myasthenia gravis most common onset age in women vs men
Women in 2nd to 3rd decade of life, men in 7th to 8th
Thymus-myasthenia gravis relationship
Many patients with myasthenia gravis have an enlarged thymus (not diagnostic, just a trend - can see enlaraged thymus for a variety of reasons), often triggers and maintains the production of antibodies that block the acetycholine
Myasthenia gravis presentation and 2 co-occurring symptoms in some cases
Fluctuating fatigable specific muscle weakness that worsens with activity and improves with rest, often worsening as the day progresses, with prolonged muscle use, with hot temps, stress, or infection. Most often begins with weakness of eye muscles, difficulty swallowing, or slurred speech with initial transient symptoms that gets worst within 1 year
-2/3 also have co-occurring ocular disturbances such as ptosis or ocular muscle weakness OR 1/6 have oropharyngeal muscle weakness (difficulty swallowing or talking)
Bulbar area of brain
Cerebellum, medulla, and pons including CN IX, X, XI, and XII
2 types of myasthenia gravis
- occular
- generalized
Myasthenia gravis diagnostic tests (5)
- Aceycholine receptor antibodies (80% of the time diagnostic)
- if negative then check muscle specific receptor tyrosine kinase (MuSK)
- Tensilon (edrophonium) test that blocks breakdown of Ach
- EMG:electromyogram to assess nerve and msucle function
- Ice pack test, cold decreases breakdown of Ach at the neuromusclar junction resulting in decreased ptosis
Myasthenia gravis treatment options (5), are any curative?
- Pyridostigmine (mestinon) that increases Ach available
- Immunotherapeutic agents such as prednisone or cyclosporine
- Plasmapheresis (replace antibody containing plasma with antibody free plasma)
- IV immunoglobulin
- Thymectomy
-(NONE of these are curative, only helpful)
Amyotrophic lateral sclerosis (ALS) AKA Lou Gehrig’s disease
Progressive incurable disease that affects nerve cells of the brain and spinal cord causing loss of muscle control resulting in muscle weakness, disability, and death with a median survival of 3 years
ALS epidemiology
Slight male predominance for sporadic cases, ALS is sporadic in 90-95% of cases, inherited in 5-10% of patients, increased risk suggested in laborers or military
ALS pathophysiology
Nerve cells that control volutnary muscle movements are affected, motor neurons gradually deteriorate and therefore are unable to send signals to muscles, theorized to be due to a complex interaction between environmental and genetic factors
ALS clinical findings in upper motor neurons and lower (3 in each)
Upper motor neuron findings (slow speech, jaw jerk, spasticity)
Lower motor neuron findings (atrophy, fasciculations, weakness)
ALS presentstion
Most common presentation in 80% is asymmetric limb weakness, 20% have onset in the bulbar segment resulting in dysarthria and dysphagia
Dysarthria definition
Weakness of muscles used for speech resulting in slowed or slurred speech
ALS signs and symptoms (7)
- Difficulty walking
- Tripping
- Weakness in hands, legs, and feet (foot drop)
- slurred speech or trouble swallowing
- muscle cramps
- inappropriate crying, yawning, laughing
- cognitive or behavioral changes
ALS often starts in the ____ and spreads to ____.
Does it cause pain? What system is not affected?
hands/feet/limbs, chewing/swallowing/speaking, does not cause pain in any stage, sensation and bladder control typically not affected
ALS diagnostic criteria (3)
- Upper and lower motor signs
- progressive clinical course
- lack of other etiology
ALS diagnostic tests (3)
- EMG
- Nerve conduction study
- MRI
ALS prognosis
Time from symptoms onset to typical diagnosis is 14 months, mean survival is 30 months, 30% survival 5 years after diagnosis, significant variability in rate of progression and requires palliative care from onset
ALS treatment options (4)
- Riluzole (rilutek) oral increases life expectancy 3-6 months
- Edaravone (radicava) IV infusion
- Meds to manage symptoms
- Therapies such as physical, occupational, nutritional, etc
ALS management
Encouraged to have a pre-determined plan before loss of functionality such as respiratory failure or nutritional failure to determine what they will do
Muscular dystrophy
Group of diseases that cause progressive weakness and loss of muscle mass, has no cure but meds and therapies can manage symptoms with signs and symptoms beginning at diff ages and diff muscle groups, often due to abnormal genes interfering with production of proteins to form healthy muscle
Signs/symptoms of muscular dystrophy (1)
-Main one is progressive muscle weakness
Duchenne muscular dystrophy (etiology and presentation)
Most common form of musclular dystrophy that is X linked recessive (more common in boys)
Often seen in 2nd year of life with early clumsiness walking
Gower’s maneuver
Refers to a common finding in duchenne muscular dystrophy where a patient has to place 1 hand on knee to assume upright position because of ilitibial bands and heel cords become tight
Duchenne muscular dystrophy progression (3)
- By 5-6 stair climbing becomes labored
- 6-7 frequently falls
- 8-10 cease to be able to climb stairs or stand from floor often requiring wheel chair
Cardiac, growth, and orthopedic complications from duchenne muscular dystropy
- primary dilated cardiomyopathy and conduction abnormalities resulting in degeneration and fibrosis
- short stature and growth delay
- fractures from frequent falling
Duchenne muscular dystrophy pathophysiology
Caused by mutation of gene that encodes dystrophin that helps keep muscles intact (protein localized to inner surface of sarcolemma of muscle fiber) affecting proximal muscles first then distal
Duchenne muscular dystrophy visual inspection findings
Thick lower leg muscles due to fat not muscle, thin weak thighs especially in front, weak muscles in front of leg cause foot drop and tiptoe contractures, belly sticks out due to weak muscles, shoulders and arms held back when walking
Duchenne muscular dystrophy diagnosis (4)
- DNA studies looking for deletion of dystrophin gene, 30% of patients are negative then
- muscle biopsy is required to establish absence of dystrophin
- Serum CPK levels markedly elevated
- EMG sees myopathic changes
Duchenne muscular dystrophy treatment (4)
- PT to keep joints loose as possible and maintain ligament laxity
- night splints and braces can delay progression
- surgery such as reconstruction or tendon release
- prednisolone
Duchenne muscular dystrophy prognosis
-16-18 predisposed to fatal pulmonary infections, affected children die from respiratory failure or cardiomyopathy that is resistant to treatment, or aspiration and acute gastric dilation
Becker muscular dystrophy differences from Duchenne
Signs and symptoms similar to duchenne but tends to develop more slowly in teens and be more mild perhaps not occurring until mid 20’s or later
Cerebral palsy
Group of disorders that affects muscle tone or posture and movement, can range in severity, caused by damage (such as lack of oxygen) to immature brain as it develops most often before birth, most common motor disability in childhood (4/1000) signs and symptoms appear during infancy or preschool years
Cerebral palsy causes prenatal (3) and natal (3) and what % does prenatal vs natal be seen as the cause
Prenatal: (70%), infection, anoxia, toxicity
Natal: (5-10%), anoxia, traumatic delivery, metabolic dz
Cerebral palsy risk factors (4)
- alcohol consumption
- prematurity
- intrauterine growth restriction or infection
- antepartum hemorrhage
4 origin types of cerebral palsy and what determines it
- spastic
- dyskinetic
- ataxic
- mixed
-Based on what part of brain has damage
Cerebral palsy signs and symptoms
-vary but all have problems with movement and posture, some may have intellectual disability, visual or hearing defect, etc.
Different types of cerebral palsy and what they mean (6)
- monoplegic (1 extremity)
- paraplegic (2 lower extremities)
- Hemiplegic (1 side upper and lower extremities)
- Triplegic (3 extremities)
- Quadraplegic (4 extremities)
- Diplegic (symmetrical left and right either upper or lower extremities)
Cerebral palsy diagnosis
-Clinical based on risk factors around birth, ruling out other etiologies, and relying on developmental milestones
Cerebral palsy treatment (3)
- physical therapy
- occupational therapy
- pharmacologic intervention to reduce symptoms that impair muscle coordination and control
Myasthenia gravis lifestyle modifications (2)
- Avoid overexertion
- Eat foods high in potassium to help maintain muscle strength
Fasciculation
Small, local, involunary muscle twitch
Cerebral palsy diagnostic studies (3)
Performed by ruling out other etiologies via
-MRI
-Cranial ultrasound
EEG
