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Appendix > Pediatrics > Flashcards

Pediatrics Flashcards

1
Q

Earliest indicator of shock in a child after trauma is?

A

tachycardia

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2
Q

In a pediatric trauma pt who is hypotensive and tachycardic what fluids do we give?

A

bolus of 20 cc/kg of crystalloid should be given x2

if that fails 10 cc/kg of pRBCs

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3
Q

How do we calculate maintenance fluids for an infant?

A

4 cc/kg for first 10 kg

2cc/kg for next 11-20 kg

1 cc/kg for each additional kg

(ex: 26 kg kid as maintenance fluids; (4 x 10) + (2x10) + (1x6) = 66

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4
Q

The most common cause of neck mass in children is?

A

lymphadenopathy

can be seen midline or laterally

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5
Q

What is a thyrglossal duct cyst?

A

thyroid descends down into normal anatomic position

residual thyroid tissue that remains after normal descent, usually found in neck midline is a thyroglossal duct cyst

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6
Q

In pts with thyrloglossal duct cysts, we usually need to a nuclear scan to confirm what?

A

if pt has normal thyroid tissue

sometimes a pts midline ectopic thyroid tissue can be mistaken for a thyroglossal duct cyst, and that’s all the thyroid tissue they have

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7
Q

Tx for thyrglossal duct cysts?

A

if cyst presents w/abscess; incision and drainage, abx

once inflammation resolved–> resection of cyst, with tract, and central portion of hyoid bone, and resection of foramen cecum

SISTRUNK procedure

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8
Q

What is a cystic hygroma?

A

lymphatic malformation

occurs due to obstructed lymph vessels

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9
Q

Cystic hygromas; lymphatic malforations, tend to occur where?

A

posterior neck triangle

axilla, groin, mediastinum

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10
Q

The presence of a lateral neck mass in infancy, in association with head rotation to opposite side indicates what?

A

congenital torticollis

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11
Q

What causes congenital torticollis?

A

fibrosis of SCM

Tx–> PT w/passive stretches

rarely–> surgery with SCM transection

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12
Q

What’s a Bochdalek hernia?

A

congenital diaphragmatic hernia

postero-lateral

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13
Q

This is a congenital diaphragmatic defect that is postero-lateral:

A

Bochdalek henria

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14
Q

Congenital diaphragmatic hernias are more common on Left or Right?

A

LEFT

Bochdaleks

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15
Q

What happens in pts with congenital diaphragmatic hernias?

A

bowel contents in chest shift mediastinum to opposite site, air exchange in contralateral lung is fucked

pulmonary htn develops; fetal circulation persists (you get R–>L shunting)

lung on affected side becomes hypoplastic; useless

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16
Q

Tx for CDH?

A

mechanical ventilation–>low, gentle settings (pCO2 in 50-60 range are accepted)

inhaled NO used to improve oxygenation

ECMO

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17
Q

How is a CDH repaired?

A

thoracic or abdominal approach

open vs laparoscopic

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18
Q

What is pulmonary sequestration?

A

a mass of lung tissue, usually in LLL

occurs without the usual connections to the tracheo-bronchial tree or pulmonary artery

but it has a systemic blood supply from aorta

***can be extralobar vs intralobar

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19
Q

Whats difference between extralobar vs intralobar sequestration?

A

extralobar–> small area of non-aerated lung separate from main lung, with a systemic blood supply, usually above left diaphragm

intrlaobar–> usually occurs within parenchyma of LLL, with no major connection to tracheobronchial tree

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20
Q

Most common object aspirated is?

A

peanuts

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21
Q

Most common anatomic location for a foreign body is?

A

R-mainstem bronchus or RLL

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22
Q

What type of bronchoscope should be used in trying to obtain aspirated foreign objects from airways?

A

rigid

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23
Q

Most common foreign body in the esophagus?

A

small coin

followed by small toy

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24
Q

In terms of objects getting stuck in the esophagus, what 3 locations do they usually get stuck at?

A

cricopharyngeus

aortic arch

GE junction

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25
Q

What three parts of the esophagus have a normal anatomic narrowing and objects can sometimes get stuck?

A

circopharyngeus

aortic arch area

GE junction

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26
Q

What are the 5 types of esophageal atresia and TEF?

A

A– > isolated esophageal atresia (10%)

B–> EA, with proximal TEF

C–> EA, with distal TEF (85%)

D–> EA, with TEF between distal and proximal parts of esophagus and trachea

E–> TEF without EA (H-type)

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27
Q

What is the most common TEF?

A

type C (85% of cases)

EA with distal TEF (distal esophagus connected to trachea)

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28
Q

Congenital anomalies assc with TEF?

A

VACTERRL; vertebral anomalies, anorectal, cardiac defects, TEF, renal

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29
Q

Most commonly used options for esophageal substitutions are?

A

R,L, T-colon

or stomach

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30
Q

What is a Morgnagni CHD?

A

antero-medial defect

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31
Q

Who gets pyloric stenosis more? M/F?

A

Males 5;1

**first born male infants at highest risk

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32
Q

Pyloric stenosis is most common during what age?

A

3-6 weeks

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33
Q

Metabolic derangement seen in pyloric stenosis?

A

hypochloremic, hypokalemic, metabolic alkalosis

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34
Q

US can diagnose pyloric stenosis, what do you need to see on US?

A

channel length >16 mm

pyloric thickness >4 mm

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35
Q

Tx for pyloric stenosis?

A

not a surgical emergency

correct electrolyte derangements

Fredet-Ramstedt pyloromyotomy

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36
Q

How is a pyloromyotomy done for pyloric stenosis?

A

open (RUQ or supraumbilical incision) vs laparoscopic

splitting of the pyloric muscle while leaving the submucosa intact

incision is from pyloric vein of mayo to gastric antrum (1-2 cm long)

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37
Q

Complications of pyloromyotomy?

A

perforation
incomplete myotomy
bleeding

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38
Q

Cardinal symptom of intestinal obstruction in the newborn is?

A

bilious vomiting

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39
Q

In all cases of suspected intestinal obstruction, what imaging do we get?

A

xrays to check for air fluid levels

infant bowel does not have haustra or plica circulares, difficult to differentiate large vs SB

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40
Q

In infants with duodenal obstruction, why is the emesis bilious?

A

usually obstruction is past the ampulla of vater in most cases

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41
Q

Classic xray seen in infants suspected of having duodenal atresia?

A

double bubble sign

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42
Q

1/3 of pts with duodenal obstruction/atresia have what assc syndrome?

A

down’s

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43
Q

Surgical tx of duodenal atresia/obstruction?

A

duodenoduodenostomy

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44
Q

During normal embryological development, the midgut expands out of abdominal cavity into the umbilical cord, returns back into the belly and does a 270 counterclockwise rotation around what structure?

A

SMA

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45
Q

Surgical procedure for malrotation?

A

Ladds procedure

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46
Q

What’s the Ladd band procedure for malrotation?

A

bands between cecum and abd wall removed

bands between duodenum and terminal ileum removed

appendix removed to avoid confusion later in life

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47
Q

Why is an appendectomy performed during a Ladds procedure of volvulus?

A

after detorsion and cutting of adhesive bands to free up the small intestine and cecum, the small intestine is on the RLQ, and the cecum is on the left side of abdomen

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48
Q

What is meconium ileus>

A

infants with CF (CFTR gene mutation **AR) have pancreatic enzyme deficiencies and abnormal Cl secretions

produce a viscous, water-poor meconium

this highly viscous meconium can become impacted in ileum –> high grade obstruction

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49
Q

What do we see on xray of baby with suspected meconium ileus?

A

ground-glass opacities

small bubbles of gas get trapped in meconium in terminal ileus

**air fluid levels don’t form, bc the meconium is so viscous, thick

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50
Q

How do pts with meconium ileus present?

A

abdominal distention

bilious emesis

failure to pass meconium

**these are seen in first 24-48 hrs of life

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51
Q

Meconium ileus can be simple vs complicated, whats the difference

A

complicated–> intestinal perforation

simple–> dilated SB loops with absent air fluid levels, ground-glass opacities seen

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52
Q

Initial diagnostic study of choice for meconium ileus?

A

contrast enema using gastrograffin

gastrograffin is hypertonic, can aid in meconium evacuation (***Just make to hydrate the kids)

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53
Q

What will a contrast enema study in suspected meconium ileus show?

A

micro-colon with soap bubble sign in RLQ

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54
Q

If contrast enema not successful for simple meconium ileus what do we do?

A

surgery–> enterotomy made in small bowel, N-acetylcysteine with warm saline injected into bowel lumen to help remove meconium from bowel mucosa *breaks up disulfide bonds)

enterotomy then closed

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55
Q

Most important risk factor for development of NEC?

A

prematurity

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56
Q

What are some hallmark features of NEC?

A

abdominal distention/tenderness

feeding intolerance

blood in stool

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57
Q

NEC commonly affects what part of colon?

A

terminal ileum

colon

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58
Q

What do we see on abdominal xray of kid with suspected NEC?

A

pneumatosis intestinalis

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59
Q

How do we manage NEC?

A

NGT decompression
IV abx
IVF
blood/plts transfusions

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60
Q

When do we operate on pts with NEC?

A

presence of intestinal perforation on xray

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61
Q

Surgical principles in tackling NEC?

A

resect all nonviable segments of bowel

create a stoma

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62
Q

Most common cause of short gut syndrome in kids?

A

NEC

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63
Q

In pts with NEC, who undergo surgical procedures, what is a common side effects?

A

20% develop strictures

contrast enema is mandatory before re-establishing GI continuity

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64
Q

Pts with NEC, who require intestinal resections are at risk of developing what?

A

short gut syndrome

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65
Q

Leading cause of intestinal obstruction in young kids?

A

intussusception; segment of intestine becomes drawn into the lumen of a proximal segment of bowel

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66
Q

Where does intussuception usually occur?

A

begins in terminal ileum and progresses through the colon

67
Q

Cause of intussusception?

A

hypertrophied peyer’s patches in terminal ileum from a previous infection act as a lead point

68
Q

What do we see with stool in suspected intussuspcetion?

A

currant jelly stools (blood stools)

69
Q

Tx for intussusception?

A

if child does not have peritonitis; radiographic reduction is attempted

70
Q

Preferred method for diagnosis/treatment of intussuseption?

A

air enema

**if unsuccessful the first time, repeat air enema in 2-3 hrs

71
Q

Sx treatment for intussusception?

A

RLQ incision made

bowel is slowly milked out

appendectomy done due to vascular compromise of appendix

72
Q

Whats the rate of recurrence of intussusception regardless if it was treated radiographyically or surgically?

A

5-10%

73
Q

If you perform a diagnostic laparoscopy on a child who you suspect has appendicitis, but the appendix appears normal when you enter the abdomen, what do you do?

A

take the appendix

74
Q

MOst common complication after an appendectomy is?

A

SSI

75
Q

What is a Meckel’s?

A

remnant of ophalomesenteric (vitelline) duct

76
Q

Where do we normally find Meckel’s diverticula

A

2 ft from ileo-cecal valve

on anti-mesenteric border of SB

77
Q

Why do we see bleeding with Meckel’s?

A

can have ectopic gastric mucosa

can cause ileal ulcers

78
Q

What two types of tissue do we see in a Meckels?

A

pancreatic and gastric mucosa

79
Q

Rule of 2s for Meckels?

A

2% incidence
within 2 ft of ileo-cecal valve
2 inches long
symptomatic by age 2

80
Q

Is a Meckel’s diverticulum a true diverticulum?

A

yes

encompasses all tissue layers

81
Q

Most common symptom with a Meckels?

A

massive lower GI bleed, painless

82
Q

Test used to diagnose a Meckels?

A

pertechnetate Meckels scan looking for gastric mucosa

83
Q

Surgical tx for a Meckels?

A

if base is narrow and no mass at base noted, wedge resection with closure of ileum noted

if inflammation or perforation present, SB resection with end-to-end SB anastomosis

84
Q

What causes Hirshchripungs dx?

A

abscence of ganglion cells in Auerbach’s plexus

and hypertrophy of associated nerve trunks

85
Q

What causes Hirschurpgs dx?

A

failure of neural crest cells to migration to distal colon

86
Q

How is definitive dx of Hirschprungs dx made?

A

rectal bx

87
Q

What are the three surgical procedures used for Hirschrpungs dx?

A

Swenson procedure–>aganglionic rectum is dissected in the pelvis and removed down to the anus

ganglionic colon then anastomosed to anus via perineal approach

Duhamel procedure–> ganglionic colon is anastomosed to anus via posterior approach

Soave procedure–> rectal mucosa is stripped off from the muscular sleeve and ganglionic colon is brought down thru this channel to anus

88
Q

What gene associated with Hirschprung dx?

A

ret proto-oncogene

89
Q

What is omaphelocele?

A

congenital abdominal wall defect

herniation of abdominal contents contained within peritoneum and amniotic membrane

90
Q

This is protrusion of abdominal contents thru the umbilical ring with a covering over the intestines:

A

omphalocele

91
Q

With gastroschisis there is no covering over the abdominal organs as they protrude, do they protrude to the right or left of umbilicus?

A

almost always to the RIGHT (at site of obliterated umbilical vein)

92
Q

Associated anomalies noted with omphalocele?

A

Beckwith-Wiedmann syndrome; macroglossia, gigantism, and umbilical defect

pentology of Cantrell; omphalocele, anterior diaphragmatic hernia, sternal cleft, ectopia cordis, cardiac defects

93
Q

Incidence of inguinal hernias?

A

10;1 male

more common on right side

usually due to failure of processus vaginalis to close

94
Q

What do we do with pediatric umbilical hernias?

A

most resolve on own

wait till 5 yrs

95
Q

In terms of biliary atresia, who is affected more?

A

asian babies
winter months
higher in females

96
Q

What is NEC-totalis?

A

fulminant, rapidly progressive form of NEC

causes gangrene and necrosis of 75% of bowel

you have 25% or less viable intestines

**occurs in about 20% of pts with NEC

97
Q

Virtually all survivors of NEC-totalis develop short gut syndrome and will require lifelong TPN, and be pre-disposed to what?

A

liver problems, cholestasis

98
Q

Jaundice in new born?

A

physiologic

presents 2-3 days after birth, resolves in 5-7 days

babies have a lot of blood, and immature conjugation machinery (glucuronyl transferase)

jaundice beyond 2 weeks is considered pathologic

99
Q

What is biliary atresia?

A

fibroproliferative obliteration of biliary tree

progresses to hepatic fibrosis, cirrhosis and liver failure

100
Q

How do infants with biliary atresia present?

A

jaundiced at birth

pale-gray appearing stools

progress to failure to thrive

liver failure, portal htn

101
Q

How do we diagnose biliary atresia?

A

bilirubin levels
look for TORCHES infection
US; usually see absent GB, (10% of cases you have a GB present)

never see intra hepatic dilated ducts

102
Q

What are the 5 types of choledochal cysts?

A

type 1–> fusiform dilation of CBD (most common)
type 2–> isolated diverticulum protruding from wall of CBD

type 3–> cysts arise from the intra-duodenal portion of CBD

Type 4A–> many dilations of intra-extra hepatic bile ducts

Type 4B–> many dilations of only extra-hepatic bile ducts

Type 5–> multiple dilations of intra-hepatic ducts

103
Q

Cause of choledochal cysts?

A

long common biliary and pancreatic channel

reflux of enzymes into biliary channel and weakening of wall

104
Q

Tx for choledochola cysts?

A

complete cyst removal; followed by biliary enteric reconstruction

105
Q

What is prune belly syndrome?

A 
lax abdominal musculature
b/l undescended testes (remain sterile after orchiopexy due to retrograde ejac)
distended bladder (dilated ureters)

*AKA eagle barrett syndrome

106
Q

What do we worry about with undescended testis?

A

risk of malignancy

107
Q

1st and 2nd leading causing of death in pediatric population?

A

1st–> trauma

2nd–> cancer

108
Q

Most common primary malignant tumor of kidneys in children?

A

Wilms tumor

97% are sproadic, occur without any genetic or risk factor

109
Q

What’s a Wilm’s tumor?

A

most common primary malignant tumor of kidneys in children

most diagnosed between 1-5 yrs (3 yrs avg)

110
Q

How is Wilms tumor found?

A

usually as an asymptomatic mass in child’s flank

111
Q

What syndrome is Wilms tumor associated with?

A

WAGR syndrome + Beckwith-Wiedmann

wilms
aniridia
GU probelms
mental retardation

112
Q

What mutations cause WAGR syndrome?

A

abscence of WT1 gene and PAX6 gene

113
Q

BEfore operating on Wilm’s tumor what is done first?

A

CT a/p/c to look for mets, identify mass better, and look at other kidney

114
Q

Stages of Wilm’s tumor;

A

1–> confined to the kidney and completely excised

2–> extends beyond kidney but is completely excised , margins are clean, tumor was biopsied, local spillage of tumor confined to flank

3–> tumor confined to the abdomen, positive nodes, peritoneal implants, tumor not resectable because close to vital structures

4–> hematogenous mets

5—> b/l renal involvement

115
Q

Do pts with Wilm’s tumor get chemo?

A

yes, for stage 1 they get a short course

for stage 4-5 they get a more intensive course

for stage 4 Wilm’s, cure rate 80%

116
Q

Third most common pediatric malignancy?

A

neuroblastoma

117
Q

Peak age of neuroblastoma?

A

2 yrs

118
Q

Neuroblastomas arise from where?

A

neural crest cells

119
Q

Where do neuroblastomas normally originate?

A

adrenals
posterior mediastinum
neck
pelvis

120
Q

Some sxs of neuroblastomas?

A

proptosis and periorbital ecchymoses from retrobulbar mets

muscle weakness and sensory changes from spinal cord compression

diarrhea from VIPomas and paraneoplastic shit

121
Q

WHat hormone markers help in diagnosis of neuroblastomas?

A

neuroblastomas derive from SNS

catecholamines and their metabolites will be produced in excess

you see increased levels of VMA and VHA, catecholamine metabolites

122
Q

Most common liver lesion in kids?

A

hemangioma

123
Q

Most common liver cancer in kids?

A

hepatoblastoma followed by HCC

124
Q

Pectus excavatum is more common than carinatum and is associated with what syndromes?

A

congenital heart dx, MV prolapse
Ehlers-Danlos
marfans

125
Q

Opsoclonus-myoclonus syndrome assc with what childhood can?

A

neuroblastoma

antibodies cross react with cerebellar tissue

126
Q

Why do pts with neuroblastoma tend to have htn and tachycardia?

A

its a tumor from SNS

catecholamines are released

127
Q

How much blood do we give a child in hypovolemic shock?

A

10 cc/kg

128
Q

How much crystalloids do we give a child in trauma setting

A

20 cc/kg

129
Q

Utility of FAST in pediatric trauma?

A

not routinely as reliable

130
Q

Signs of non-accidental CNS trauma in kids?

A

retinal hemorrhages

intracranial hemorrhage without signs of external trauma

fractures of different stages of healing

131
Q

After an appendectomy how long does it usually take for an abscess to form?

A

about 7 days

132
Q

Primary reason for excision of thyroglossal duct cysts?

A

malignant potential

recurrent infections

133
Q

In new borns why should choledochal cysts be removed?

A

risk of cholangitis

risk of malignant transformation

134
Q

You suspect meconium ileus in a pt with abdominal distention, he is peritoneal and you take him to OR, why don’t you resect intestines?

A

bowel resection in a new born leaves them at risk for short gut syndrome

**surgery for meconium ileus–> make an enterotomy and use irrigation, there is no need for colostomy

135
Q

MOst common abnormality associated with gastroschisis is?

A

intestinal atresia

chromosomal abnormalities and congenital heart dx more assc with omphalocele

136
Q

In pts with congenital diaphragmatic hernias, what happens to their vessels?

A

can get pulmonary hypoplasia and pulmonary htn

137
Q

You have a child with an undescended testis, and you can palpate it, what do you do?

A

laparoscopy

US not recommended due to poor sensitivity

138
Q

Laproscopic vs open hernia repair in kids:

A

have similar recurrence rates
similar post-op length of stay
laparoscopic not less painful

**Laparoscopic can help visualize for femoral hernias while done routinely for inguinal hernias

139
Q

When doing an open inguinal hernia repair, what nerve can be injured when opening the externl oblique aponeurosis?

A

ilioinguinal n

140
Q

In trauma, handlebar injuries in kids assc with what injuries?

A

duodenal hematomas

pancreatic injuries

141
Q

Male children with cystic fibrosis may have abscence of b/l what?

A

vas deferens

**usually seen during routine inguinal hernia repairs and should prompt looking for CF

142
Q

Female children with sliding inguinal hernias have what organ trapped in hernia sac?

A

fallopian tube

143
Q

Most H type EA fistulas are located at level of thoracic inlet, how do you access it?

A

right cervicotomy

144
Q

Amyand hernia assc with?

A

appendix

145
Q

Littre’s hernia assc with?

A

Meckel’s

146
Q

4 different types of jejuno-ileal atresias?

A

1–> intact bowel wall and mesentery with a mucosal atresia

2-» blind ends separated by a fibrous cord

3a–> V-shaped mesenteric gap

3b–> large mesenteric gap

4–>multiple atresias

147
Q

What is a poor prognostic factor for neuroblastoma?

A

MYCN amplification > 10 copies

148
Q

Simple meconium ileus is treated with?

A

contrast enema as first line

aggressive fluids are given b/c gastrograffin will cause an osmotic diuresis

149
Q

Most common cause of intussusception in a 2 year old is?

A

Meckels

followed by intestinal polyps and duplications

150
Q

Pt has pyloric stenosis, underwent pyloromyotomy, is having persistent vomiting a week later, now what?

A

needs re-exploration

some nausea vomiting post-op is normal, but should resolve after 3-4 days

151
Q

Gold standard for pectus excavatum?

A

Nuss bar

152
Q

In someone suspected of hypertrophic pyloric stenosis, what do we see on US?

A

pyloric channel 16 mm or greater is usually seen

153
Q

How long do you wait for an umbilical hernia to resolve on its own before you repair it?

A

> 4 yrs old

154
Q

In EA, if we have an esophageal gap, how do we close the gap?

A

delayed primary repair is preferred if gap is less than 2 vertebral bodies long

if gap is larger, traction sutures are placed

for very large gaps, esophageal replacement with colon or jejunum can be done

155
Q

Most common malignant neoplasm found in a Meckels?

A

carcinoid

0.5–5% chance of finding malignancy in Meckels

156
Q

For choledochal cysts, first imaging modality ordered is?

A

US

then MRCP

157
Q

Why dont we operate on pts with pyloric stenosis right away ?

A

need to correct their hypochloremic, hypokalemic, metabolic alkalosis first

they can develop apnea if not corrected and receive general anesthesia

158
Q

How do we manage a type 1 choledochal cyst?

A

primary cyst excision

w/Roux-en-Y hepaticojejunostomy

159
Q

What are type I and type IV branchial cleft cysts?

A

type 1–> superficial to SCM

type 4–> deep to carotid sheath

160
Q

Things assc with jejunoileal atresia;

A

bilious emesis
distended abd
polyhydramnios

161
Q

What is Poland syndrome?

A

congenital abscence of pec major m (sometimes pec minor, chest wall, ribs)

in females, assc w/abscence of breast tissue on affected side (amastia)

162
Q

MOst common intra-abdominal solid tumor in children?

A

neuroblastoma

liver is most common site of mets

(histology: small round blue cells with rosette histology)

163
Q

What is the kasai procedure used for?

A

for pt w/biliary atresia

roux-en-y hepatic protoenterostomy

**entire extrahepatic biliary tree is excised, roux limb is connected to liver plate

164
Q

MOst common location for an undescended testis is?

A

superficial inguinal ring

next is superficial inguinal pouch

last is the inguinal canal

Appendix (39 decks)

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