Surgery Flashcards
(32 cards)
what is the immediate management of acute appendicitis?
IV access, bloods- FBC, CRP, IV fluids (20mls/kg Saline), urine dip, analgesia (paracetamol + IV Morphine if req), consider NGT if vomitting, consider Abx (DEF if septic but otherwise can mask appendicitis symptoms), call surgeons.
What are the possible abdo presentations of acute appendicitis?
1) RIF tenderness, guarding, redbound tenderness (anterior peritoneum inflamed)
2) RIF deep vague tenderness, may guard, may have mass. Children may limp due to irritation of psoas major. commonly perf;
3) vague suprapubic tenderness with no guarding. PR tenderness/ mass. may have urinary/ bowel symptoms due to irritation of these. commonly perf.
what is intusspection? What age does it typically present? What are the clinical features?
Where a portion of bowel (ileocaecal most common) prolapses “telescopes” into a segment of bowel immediately distal to it resulting in venous obstruction of drainage from the bowel, oedema (bowel becomes stuck in this position), necrosis + perf result if arterial supply is compromised. Will cause sepsis, shock + death if not quickly dealt with.
Typically presents in infants 3-18 months (5-10 PEAK).
Features: colicky abdo pain (bouts of crying), flexing of legs, fever, lethargy (possib hypotonia)/ irritable, vomitting (bilious/not), pallor, palpable abdo mass (RUQ/ Epigastrium), red currant jelly stool (late).
In kids mostly idiopathic but in older kids- viral infection, polyps, tumour, Meckel’s Diverticulum, HSP, Peyer’s patch hypertrophy.
What is mesenteric adenitis? What are the complications arising from it?
Inflammation of mesenteric LN,
Can result in intusspection
What is the workup of children presenting with what is thought to be intusspection? What might be your findings on XR?
Hx + ABCE + Examination, IV access- bloods FBC, U+E (dehyd + AKI), Blood Gas- lactate, Group + save, give IV bolus (20mls/kg Saline), Analgesia.
Abdo XR findings- dilated bowel loops, mass in RUQ,
US- target sign: single hypoechoic ring with a hyperechoic centre.
First line if not shocked, no perf, no peritonitis is air enema reduction using large bore catheter. If this fails or child is not a candidate for enema- open surgical reduction.
For Fluid resus, what is the estimated weight of a child below 9 and above 9? WHat is the average blood volume? What is the standard fluid bolus for a child?
<9 2 x (age + 4)
>9 3 x age
80ml/kg
20ml/kg 0.9% saline
How do you calculate maintenance fluids required for a child- what is the formula? what is the maintenance fluid of choice? What about fluid for a dehydrated child?
100ml/kg/day for first 10kg for 4ml/kg/hr
50ml/kg/day for next 10kg for 2ml/kg/hr
20ml/kg/day for additional kg for 1ml/kg/hr
0.9% saline + 5% dextrose
Dehydration– give 0.9% saline.
What is the appropriate resus for blood loss in children?
0.9% saline if you cannot get Oneg blood immediately.
10ml/kg of blood usually delivered bc risk of dislodging blood clot if too much more given. May need to get introssesous access if arresting and cant gain IV.
what are the clinical features of gastroschisis?
abdominal wall congenital abn usually to R of umbilical cord, abdo contents herniate into sac without covering. Usually small intestines but can also be colon, stomach + ovaries. often occurs in isolation of other abnormalities. More common in young moms. Immediate management- IV fluids, IV Abx, Bag lower half for temp control + reduce infection risk. surgical repair req. risk of dehydration + protein loss.
what are the clinical features of exomphalos?
the contents of the abdomen herniate into the umbilical cord and are covered by a thin membrane- peritoneum + amnion. It is commonly associated with other genetic abnormalities e.g. Trisomy 13, 15, 18, Turner’s. In add to genetic testing, kids often have an echo due to common cardiac abnormalities.
Immediate management- IV fluids, IV abx, allow skin to grow over defect. small defects may be conservatively managed.
what is a diaphragmatic hernia? What are its consequences?
Mostly identified antenatally. Due to the incomplete formation of the diaphragm, the thoracic and abdo cavities are not separated and therefore the lung buds are unable to develop normally. This usually occurs on the L of the body and can involve any viscera herniating through.
Immediate management- intubate without bag + mask to prevent inflating the stomach and worsening the Resp Distress. After 2 days, lateral thoracotomy/ abdo approach. ADD EMBRYOL
what condition should you think about in a newborn who is vomitting immediately after feeds and presents with Resp distress? How is it managed?
Oesophageal atresia (oesophagus ends in blind-ended pouch) often associated with tracheoesophageal fistula. vomitting after eating/ excessive salivation due to nowhere for these things to go except back out the mouth. Resp distress results quickly if the fistula exists due to the stomach enlarging and pushing onto and compressing the lungs. If its just atresia, the two ends of the oesophagus are reconnected via R lateral thoracotomy or if fistula is present this is most pressing issue to address before the atresia.
what is the ddx for neonatal bowel obstruction?
- failed gut canalisation- duodenal atresia
- ischaemic involution- small bowel atresia second to thrombo-embolism, volvulus, intusspection
- functional obstruction- NEC, Hirschprung’s, Meconium Ileus
- failed gut development- oesophageal atresia
what are the causes of bilious vomitting?
intussception (sometimes) duodenal atresia (distal portion) bowel obstruction (but not always present so shouldn't rule out obstruction due to its absence!) malrotation sepsis volvulus
what is duodenal atresia? how is it manageD?
narrowing of the lumen or atretic parts of the duodenum that sometimes results in bile vomitting (if distal segment of duodenum affected). managed via resuscitation of child and intervening to remove atretic section and restore bowel continuity.
what is small bowel atresia? What is its aetiology? how is it managed?
Vascular incident in utero resulting in ischaemic involution of the small bowel- narrowing/obliteration of lumen (usually ileum) due to thrombo-embolism, volvulus, intussception. Managed via resuscitation of child, removal atretic section + if not possible to reconnect, to create stoma. might require TPN if too much bowel removed.
what is a common cause of intestinal obstruction in premature infants? how is it managed?
necrotising enterocolitis. it results from a combo of an immature gut, vascular factors + poss infection resulting in mucosal injury or necrosis + perforation.
early recognition, triple antibiotic therapy and not to feed the child, sometimes NG decompression. if perf/ stenosis they require surgery to remove necrosed section or form a stoma.
how is meconium ileus managed?
washout or if complication occurs e.g. volvulus laparotomy is required
investigate cause of thickened stool
what are some signs of bowel obstruction in neonates?
abdo distension but not reliable
bilious vommiting
what is your ddx for scrotal pain?
testicular torsion, torted hydatid of margagni, torted epididymal cyst, epididymo-orchitis, idiopathic scrotal oedema.
what is testicular torsion? how is it managed?
more common to the L testicle, the spermatic cord twists occluding the testicular blood vessels and will affect the viability unless promptly untwisted via surgical intervention within 4 hours.
what is torted hydatid of margagni? how is it managed?
small embryological remnant at the upper pole of the testis. it presents similarly to testicular torsion. The pain is usually less severe and of a longer duration than a torted testis. Occasionally the torted hydatid may be palpable or visible as a ‘blue dot’ in the scrotum
MANAGEMENT
what is a torted epididymal cyst?
This is a smooth, small fluid filled swelling that slowly develops in the epididymis. They are often painless, but the affected testis sometimes ache or feel heavy
MANAGEMENT
what is epididymo-orchitis? How Is it managed?
inflammation of the epididymis and/or testis. It is usually due to infection, most commonly from a urinary tract infection or a sexually transmitted infection. A course of antibiotics will usually clear the infection and it resolves without complication.
