Surgery Flashcards
How do you estimate the weight (kg) in children from age
<1 = (Months x 0.5) +4 1-5 = 2x (Age+4) = THIS ONE >5 = 7 + (Age x 3)
What is the average blood volume in children /kg and why is it important
80ml / kg
If you weight 1kg and lose 2ml then lost 1/4 of volume
What should the urine output in a child be
0.5-1ml / kg / hour
Urine output falls as you get older
What is your insensible fluid loss in children
20ml / kg / day
What is your estimated systolic BP
80 + (2x age)
What are vital sign trends in children and average values
When do you do CPR in a child
Babies breath a lot faster (30-40) and HR a lot faster (110-160)
Babies have much lower BP (70-90)
As you get older this changes and becomes more similar to adult
Sats <92% = oxygen
When do you start CPR on baby
If HR <60 or not breathing properly
Brady <100
What is the pain barrier in children
Children have to communicate pain to teacher / parent / doctor
What should you do if child is in pain
Give analgesia
Not gonna miss Dx
How do you manage pain in children
WHO Pain Ladder
What is the WHO pain ladder
Paracetamol - big dose 4-6hr 15-20mg/kg (calpol age so don’t use)
Ibuprofen - regular 8hr 10mg/kg
Weak opiod
Strong opiod - morphine
What is not recommended in <12
Codeine - prodrug for morphine
Absence of enzyme for metabolising or rapid metaboliser so no effect or overdose
What should you use instead of codeine
Morphine
What do you give as resuscitation fluid
20ml /kg bolus 0.9% NaCl (saline)
What do you give for maintenance fluid
0.9% saline
5% dextrose
+- KCL
What volume of fluid do you give in children
4ml / kg in 1st 10kg
2ml / kg in 2nd 10kg
1ml / kg thereafter
or 100ml / kg for first 10kg
then 50ml / kg
then 20 ml / kg
In 24h period
What are the sentinel signs that children are very unwell
Feed refusal Decreased urine Bile vomit - green Colour - grey Tone Temperature - hypothermic = very sick, hyper = infection
What is green bile vomit suggestive off
Bowel obstruction
What is important in the history of abdominal pain
Colic - dysfunctional gut
Constant - peritoneal irritation
Movement - car?
What does speed bump pain indicate
Peritonitis
Movement irritates peritoneum
What increases the signficance of abdominal pain / RED FLAG
<5 or >14 NOCTURNAL - Almost always organic cause Persistent vomiting - especially green bile so ask colour Severe chronic diarrhoea Fever Anorexia Painful micturition Rectal bleed Weight loss Dysphagia Abdominal tenderness / distension / mass / HSM Fever. /rash / joint pain Signs of unwell child / vitals off
What does diarrhoea suggest
Inflammation of the appendix Irritating the colon
What is tenesmus
Feeling like you want to go to the toilet after emptying
What does anorexia suggest
Septic infection so lose appetite
Hungry children = less likely to be surgical
What does previous history suggest
Lessens chance of surgery
What is important to ask in abdominal pain
Menstrual history
How do you investigate abdominal pain
Vital signs Examination - Abdo - Hernia - Testis for hernia Urine dip - everyone as could be UTI Pregnancy test Glucose for DKA
Bloods - not always helpful, better to observe but would do if red flags
FBC - if diagnostic doubt / worried (may show anaemia)
CRP / ESR
Electrolytes if very sick / dry
Surgical opinion
Imaging
X-Ray - rare / bowel obstruction (only if surgeon requests for specific reason e.g. toxic megacolon)
USS = useful in paeds
CT if trauma
What is the triad of appendicitis
Pain - central abdominal radiate to RIF Guarding and rebound Vomiting = not continuous Moderate fever - if high more likely mesenteric Anorexia Look unwell Tachy
How do you diagnose appendicitis
Active observation
When is appendicitis unusual in
<4 but greater risk of perforation
Where is the tenderness in appendicitis
McBurney’s point
1/3 way between ASIS + umbilicus
Roving - pressing LLQ increases pain in RLQ
What are the complications of appendicitis
Abscess
Peritonitis after perforation
How do you manage appendicitis
Analgesia - Paracetamol best option
Fluid
Ax
Laparoscopic removal
What are the symptoms of non specific abdominal pain
What is it associated with
Short duration Central Constant Not worse by movement No GIT disturbance / vomiting No temperature Normal energy levels Site and severity of tenderness vary Often recurrent Can mimic early appendicitis - active observation Examination normal Responds to distraction
Can do bloods, calprotectin, coeliac screen to reassure parents
Must ensure growth and development normal
FODMAP can help
Associated with
- Abdo migraine
- IBS
- High achieving / OCD personality
What is mesenteric adenitis
Viral illness Abdominal pain due to inflamed LN in mesentery High temperature URTI history often Not unwell If tummy is soft then fine
Why can pneumonia cause abdominal pain
Pleural irritation referred Very unwell - tachy, CRP, breathing No abdominal signs - soft tummy Global killer of children in <5 Typically lower R lobe
How does UTI present in child
Abdo pain
VOMTING
Always dip urine
What are rare but important causes of abdominal pain
Malrotation Pyloric stenosis Intussusception Meckels diverticulum Hernia + torsion
What is the typical story of malrotation and what does it lead too
Baby born fine 3 days starts vomiting bile Unwell Can occur in any age Often high caecum Can cause volvulus and obstruction
What is a new baby vomiting bile suggestive off
Malrotation until proven otherwise
How do you Dx malrotation
Upper GI contrast study ASAP
USS
How do you Rx malrotation
Laparatomy URGENTLY
What is the story of intussusception
History of viral illness Intermittent colic and dying spell (floppy not breathing for 10s) due to big vagal response after wave of colic Pull up legs and scream / cry Bile vomiting - not always bile Frequent loose stools Distension Toxic + unwell child + dehydration Prolonged cap refill Bloody mucous PR Mass in RIF Often no fever
DDX
- Sepsis
- Gastroenteritis but immense frequency / distension / lack of fever
What age group is intussecpition common in
6-12 months
Very unusual outside
What is intussception
Bowel slides into another bit of bowel (terminal ileum into caecum)
Cause obstruction, perforation and necrosis
How do you Dx intussception
USS abdomen
Target sgin
May do bloods but not necessary
How do you treat intussception
Pneumostatic reduction - air enema
Put a line in because need access in case go into shock / bowel perforation
Laparotomy if signs of peritonitis or air enema doesn’t work
URGENT
What is gastroschisis
Abdominal wall defect
Gut eviscerated and exposed at birth
How do you Rx gastroschisis
Urgent Surgery
TPN
Risk of short gut
What is associated with gastroschisis
Bowel atresia
Short bowel - very rare
VSD
Cleft palate
What is exomphalos
Umbilical defect but covered with viscera
Poor prognosis due to associations
What is associated with exomphalos
Cardiac abnormality - VSD
Chromosomal - trisomy, 13,18,21
Beckwith-Weideman syndrome
How do you Rx exomphalos
Gradual surgery
What is Beckwith-Weideman
Exomphalos Hypoinsulinaemia Atrophic tongue Macrosomia Increased risk of ALL / nephroblastoma
What is Hirschprung’s
Absence of ganglion cells in colon causing intestinal obstruction in neonates
Myenteric plexus is part of the enteric nervous system responsible for stimulating peristalsis
When is Hirschprungs more common
FH
Down syndrome
NF
MEN II
How does it present
No stool passed in 24 hours
Vomit bile
Constipation, distension, vomiting, poor weight gain and FTT if older children
Can get overflow
When is it usually picked up
First 48 hours as don’t pass stool
How do you Dx
Rectal biopsy
X-Ray shows dilated bowl with air fluid level
How do you treat
Wash out = 1st line whilst waiting for biopsy
Anorectal pull through
Resection of aganglionic part
How does oesophageal atresia present
Choking Cyanotic spells Following aspiration Polyhydramnios as can't reabsorb fluid VATER association
How does duodenal atresia present
Billous voimt
How does biliary atresia present
Jaundice >14 days
What does biliary atresia require
Urgent Kasai
If a child fails to pass stool what do you think of
Constipation Hirschprung Meconium ileus Bowel atresia Imperforate anus
What is meconium ileus
Small bowel obstruction due to meconium
Common in CF (90%)
How does it present
Distension
Tender abdomen
Billous vomit
How do you Dx
PR contrast
X-ray = dilation, no fluid
How do you Rx
Surgery to remove plugs
What is Meckel’s diverticulum
Congenital diverticulum of small intestine
2% population
2 inches long
2 feet from ileo-caecal valve
What are the symptoms of Meckels diverticulum
Abdo pain mimicking early appendicitis Rectal bleeding - most common cause of rectal bleed in child Offensive stool Obstruction - vomiting Volvulus Intussception Unstable
When do you present
Usually age <2 like appendicitis
How do you Rx
Surgical removal
What is an umbilical hernia
Common self-limiting weak spot
Points to ceiling on increased pressure
What are RF for umbilical hernia
Down's LBW Premature Hypothyroid Storage disorder
When do you refer
Age 2
When do you Rx
If not closed by age 5
If large / cosmetic as risk of incarceration
What is paraumbilical hernia
Defect in linea alba
Points to feet on increased pressure
How do you Rx
DOesn’t close itself so surgery
What is epigastric hernia
Defect in linea alba causing protrusion of pre-peritoneal fat
How do you Rx
Don’t need to
Cosmesis only
What is a diaphragmatic hernia
Herniation of bowel into chest
If contains liver = poor prognosis
How is it Dx
Usually picked up at 20 week USS as seen bowel in chest
What does it caus
Pulmonary hypoplasia Pulmonary hypertension Resp distress at birth Cyanosis Absent heart sound as displaced to R Tinking bowel sounds Scaphoid chest
What does X-ray show
Loops of bowel in chest
How do you treat
NG tube tube to keep air out of gut
Intubate
ECMO
Surgery
What are risks
Recurrence
Occur in sibling
What should you do if child has hernia waiting for surgery
Advise of signs of obstruction or stragulation
Vomit
Pain
Unable to push hernia back
What do you examine if child presents with abdominal pain
Abdomen - Signs of peritonitis - guarding / rebound - Mass - Hernia ENT / chest / testis/ hernia Temperature PR not routine
How do you treat abdominal pain
ABCDE
Analgesia
AX
Consider NG / catheter
What do you asking history
SOCRATES Dysuria? N+V Amount of vomit - Bile or blood Appetite Can they tolerate fluid Bowels - last movement / consistency / blood / mucous Menstrual Hx Previous Hx
