Pediatric Surgical Emergencies Flashcards
Intussusception
etiology
location & pathogenesis
symptoms
Etiology
- telescoping of the bowel in kids: MC in those 6-26 months of life
- not likely in kids over 5 years old
- lead point: point in which the intussecption occurs
location: most common: illeoceccal junction (from small to large, so the small telescopts into the large bowel) = emerg. surg.
(if its small-small or large-large: can resolve on own without intervention)
pathogenesis
- 75% unknown why
- viral bug, baterial, meckel diverticulum
- in kids over 6= most common cause is lymphoma!!
Symptoms
- sudden onset colicky abd pain: in 15-2o min variables
- come and go : kids will pull knees to chest or bedn over in pain
- vomiting may occur with the pain
- stool: blood and mucus: “current jelly”
Intusucception
diagnosis
treatment
Diagnosis
- on PE: can be normal with no abd tenderness or distention
- letahrgic, episotic consciousness if severe
- RLQ: schaphoid (flat = empty)
- palpable sausage shaped masses in the righ mid/upper abd
Imaging
- abd xray = nondiagnostic but will exclude any perforations
- on AXR: “target sign/fried egg”
- CT: can be found incidental
- abdomenal US is gold standard : 100% sensitive for dx. : see target sign, bulls-eye or coiled spring
Treatment
- Enema: dx. and tx.
cannot barium enema if bowel perforation/stragulation
AIR ENEMA IS METHOD OF CHOICE under fluroscopy
Surgery: if unstable, peritonitis, perforation or nonsurgical doenst work
Pyleoric Stenosis
etiology
symptoms
Pyloric Stenosis
- MC indications of surgery in infants
- often in those 3-5 weeks of life, rare after 12 weeks
- an abnormal thickening of the antrapyloric muscles around the pylorsis, thus decreased ability to pass contents from the stomach to the SI
- unknown etiology: potential link to postnatal expsoure to erythromycin! or uncoordinated ontractions
Symptoms
- initially: vomiting small amoutns of food after feeds, overtime = weight loss
- projectile, nonbilious vomiting occuring after feeds (can be coffee ground emesis)
- they are super hungry, nursing vigourously
Signs
- of dehydartion, weight loss
- “OLIVE”: oval mass palpable on deep palpation in teh RUQ: shows hypertrophy of the pylorus
- gastric perstalsis visable left-right
Pyloric Stenosis
diagnosis (labs and imaging)
treatment
Diagnosis: Labs
- hypocloremic hypokalemic metabolic alkalosis (base excess)
- look at BUN and Cr for AKI
- increased Hgb/hct hemoconcentrationg since theyre dehydrated
Imaging
- US is imaging test of choice : wall thickening of pylorus more thant 3.7 mm & channel length of 17mm+
- can do barium upper GI: if the US is nondiagnostic
- see filling issues
Treatment
- Stabilize: correct the electrolyte derrangements and dehydration prior to surgery
- Surgery: myotomy of the pylorus
findings may remain for awhile; but they will get better over time!
Hernias
physiology of decent of testis
symptoms of hernias
incarerated v stragulated
Physiology
- testes decent: preceed by the tunica vaginalis – if this remains open; then abdomenal contents can protrude through the sac
- this remaining open also can allow for lfuid to flow: communication hydrocele
indirect hernia: through the inguinal canal is most common type in kids lateral to the epigastric vessels
Symptoms of Inguinal Hernias
- painless, inguinal swelling
- fulless in the area, associated with swelling or long periods of standing
- a full, firm globular swelling
Incarcerated = stuck in the wall and wont retract on its own
- when the tissue or loop of bowel protrudes through the canal, and cnanot retract
Stragulated = when it gets stuck and also starts to lose blood flow
Hernias in kids
manual reduction
Manual Reduction of an Inguinal hernia
- contraindicated if it incarcerated > 12 hours or if there are bloody stools
how its done
- infant sedated
- manual reduction
- or trendelenburhg and ice
Umbilical Hernia
extrusion through the abd. wall at the umbilicus due to a defect
- common in full term, AA babies
- usually resolve spontaneously
- risk of incarceration
treatement
- surgery if it is incarerated or happening after the age of 4
hernias
diagnosis tools and treatment options
Diagnosis
- clinically
- ultrasound to evaluate blood flow for stragulation eval.
Treatment
- if reducable: can elect for outpt. surgery to fix defect
- if nonreducable, stragualted or incarcerated: urgent surger
Testicular Torsion
etiology
symptoms and signs
Etiology
- 10x higher risk on those with undecended testicles
- a twisting of the testicle on the spermatic cord: compromising and cutting off blood flow
- ischemia can lead to necrosis of the testis very quickly! 9within 12 hours, so nned to dx. and treat within 4-6hr.)
- can be assocaited with trauma
- see a “bell clapper” deformity: of like a horizontal shapped testicle
Symptoms
- swollen, firm tender testicle
- overlying redness
- high lying testicl, thats trasnverse is size
- negative cremasteric reflex
- negative prhen’s sign : when you elevate testicle, pain relief (+) = epidydmysis
Testicular Torision
Diagnosis
Treatment
Diagnosis
- if high index of suspicious: immediate urologic consult !!!
- can do testicular US with doppler
- can do UA for infection
Treament
- manual detorsion : extremely painfun, analgesics/sedation needed
- “open book method: 540 degree rotation
- Surgical detorison: definitive management after manual detorsion
- if non-viable testis: gonna need to do orchiectomy
Necrotizing Enterocolitis
etiology
Etiology
- the MC emergency in peds GI of newborns!!
- those who are premis, LBW and NICU
- ischemic necrosis of the intestinal mucosa
- sever inflammation and invasion of enteris gas producing organsims
- the gas dissects into the bowel wall and portal system casuing necrosis
- high morbiditiy
Risk Factors
- premature babies
- those hwo have concentrated formulas
- those with pre-exsiting intestinal issues: CHD, sepsis, etc.
Symptoms
- sudden cahnge in feeding tolerance
- abd distention, redness, cerpitus, induration
- these babies are SUPER SUPER SICK
- bilious vomiting
- bloody stools + diarrhea
- apena, respiratory failure
- temperature instabiity, hypotensions septic shock
- can progress to bacteremia
NEC
diagnosis
Treatment
Diagnosis
abd. xray: see “intramural gas”, pneumotosis intestinalis, bowel perforation and sentiel bowl loops
Guiac + stool (blood)
labs: anemia, thrombocytpenia, DIC
Treatment
supportive medical management
- abx., decompression, parenteral nutrtion, fluids, support
- treat the sepsis and decompress the gas build up
Surgical intervention
- if clincally deteriorating
- perforation or irreversible necrosis; resection
NEC
Complications
Complications
Acute
- sepsis, meningitis, peritonisits
- abcess formation
- DIC, hypotention, shock
- respiratory failure, hypoglycemia, metabolic acidosis
mortality is high = in NICU babies
1/2 of those who survive: long term issues
- growth, neurodevelopment or GI disorders
Appendicitis
Etiology
classic symptoms
signs on exam
Etiology
- inflammation of the appendix (with or without infection)
- most common cause of emergent abd. surgery in kids
- peak incidence at 15 years olf
- high risk of appendicitis with perforation in those younger udner 2 years old
Classic Symptoms
- abdomenial pain = initally perumbilical/vauge: overtime localizing to the RLQ
- vomiting: which followsthe onset +/- constipation/diarrhea
- fever
- younger kids will be more atypical in presentation
- get a bood h&P: about timing/location of pain, timing of vomiting, no watning to eat/drink, last stool, pmhx.
Signs on Exam
- McBurney’s Point: the point tnederness localization of appendicitis, 1/2 way between teh ASIS and the umbilicus
- Rosuvig’s sign: pain within the RLQ when the LLQ is palpable : indicates periotoneal pain & indirect tenderness
- Psoas sign: when the right hip is extended passively;there is right sided pain in the lwoer quadrant (indicates a retrocecal appendix)
- obturator sign: when the knee and hip are flexed, the knee is externall rotated and produces pain in the RLQ: showing appendix inflammed and irritating muscles
Appendicitis
Diagnosis
labs and iaging
Diagnosis - Labs
- elevated WBC: but rarely over 15,000
- elevated CRP
- ANC can be high
- UA should be done & pregnancy test (rule or ectopic)
Diagnosis- Imaging
- US good test especitally in kids
- MRI- can be preferred over CT if the US is not diagnsotic
- CT can be done too if US cannot be done
- AXR: when you need to evaluate for a perforation (air)
US findings
- noncompressile tube in the RLQ
- wall thickness > 2mm
- overall diameter > 6mm
- calcified appedicolth
CT Findings
- wall thickness > 2mm
- enlargemetn of the appendix
- fluid,abcess
- thickening, fat stranding
