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Surgery Flashcards

1
Q

How do you estimate the weight (kg) in children from age

A 
<1 = (Months x 0.5) +4
1-5 = 2x (Age+4) = THIS ONE 
>5 = 7 + (Age x 3)
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2
Q

What is the average blood volume in children /kg and why is it important

A

80ml / kg

If you weight 1kg and lose 2ml then lost 1/4 of volume

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3
Q

What should the urine output in a child be

A

0.5-1ml / kg / hour

Urine output falls as you get older

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4
Q

What is your insensible fluid loss in children

A

20ml / kg / day

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5
Q

What is your estimated systolic BP

A

80 + (2x age)

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6
Q

What are vital sign trends in children and average values

When do you do CPR in a child

A

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

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7
Q

When do you start CPR on baby

A

If HR <60 or not breathing properly

Brady <100

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8
Q

What is the pain barrier in children

A

Children have to communicate pain to teacher / parent / doctor

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9
Q

What should you do if child is in pain

A

Give analgesia

Not gonna miss Dx

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10
Q

How do you manage pain in children

A

WHO Pain Ladder

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11
Q

What is the WHO pain ladder

A

Paracetamol - big dose 4-6hr 15-20mg/kg (calpol age so don’t use)
Ibuprofen - regular 8hr 10mg/kg
Weak opiod
Strong opiod - morphine

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12
Q

What is not recommended in <12

A

Codeine - prodrug for morphine

Absence of enzyme for metabolising or rapid metaboliser so no effect or overdose

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13
Q

What should you use instead of codeine

A

Morphine

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14
Q

What do you give as resuscitation fluid

A

20ml /kg bolus 0.9% NaCl (saline)

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15
Q

What do you give for maintenance fluid

A

0.9% saline
5% dextrose
+- KCL

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16
Q

What volume of fluid do you give in children

A

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

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17
Q

What are the sentinel signs that children are very unwell

A 
Feed refusal
Decreased urine 
Bile vomit - green 
Colour - grey
Tone
Temperature - hypothermic = very sick, hyper = infection
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18
Q

What is green bile vomit suggestive off

A

Bowel obstruction

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19
Q

What is important in the history of abdominal pain

A

Colic - dysfunctional gut
Constant - peritoneal irritation
Movement - car?

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20
Q

What does speed bump pain indicate

A

Peritonitis

Movement irritates peritoneum

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21
Q

What increases the signficance of abdominal pain / RED FLAG

A 
<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
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22
Q

What does diarrhoea suggest

A

Inflammation of the appendix Irritating the colon

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23
Q

What is tenesmus

A

Feeling like you want to go to the toilet after emptying

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24
Q

What does anorexia suggest

A

Septic infection so lose appetite

Hungry children = less likely to be surgical

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25
What does previous history suggest
Lessens chance of surgery
26
What is important to ask in abdominal pain
Menstrual history
27
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
28
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 ```
29
How do you diagnose appendicitis
Active observation
30
When is appendicitis unusual in
<4 but greater risk of perforation
31
Where is the tenderness in appendicitis
McBurney's point 1/3 way between ASIS + umbilicus Roving - pressing LLQ increases pain in RLQ
32
What are the complications of appendicitis
Abscess | Peritonitis after perforation
33
How do you manage appendicitis
Analgesia - Paracetamol best option Fluid Ax Laparoscopic removal
34
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
35
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 ```
36
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 ```
37
How does UTI present in child
Abdo pain VOMTING Always dip urine
38
What are rare but important causes of abdominal pain
``` Malrotation Pyloric stenosis Intussusception Meckels diverticulum Hernia + torsion ```
39
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 ```
40
What is a new baby vomiting bile suggestive off
Malrotation until proven otherwise
41
How do you Dx malrotation
Upper GI contrast study ASAP | USS
42
How do you Rx malrotation
Laparatomy URGENTLY
43
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
44
What age group is intussecpition common in
6-12 months | Very unusual outside
45
What is intussception
Bowel slides into another bit of bowel (terminal ileum into caecum) Cause obstruction, perforation and necrosis
46
How do you Dx intussception
USS abdomen Target sgin May do bloods but not necessary
47
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
48
What is gastroschisis
Abdominal wall defect | Gut eviscerated and exposed at birth
49
How do you Rx gastroschisis
Urgent Surgery TPN Risk of short gut
50
What is associated with gastroschisis
Bowel atresia Short bowel - very rare VSD Cleft palate
51
What is exomphalos
Umbilical defect but covered with viscera | Poor prognosis due to associations
52
What is associated with exomphalos
Cardiac abnormality - VSD Chromosomal - trisomy, 13,18,21 Beckwith-Weideman syndrome
53
How do you Rx exomphalos
Gradual surgery
54
What is Beckwith-Weideman
``` Exomphalos Hypoinsulinaemia Atrophic tongue Macrosomia Increased risk of ALL / nephroblastoma ```
55
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
56
When is Hirschprungs more common
FH Down syndrome NF MEN II
57
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
58
When is it usually picked up
First 48 hours as don't pass stool
59
How do you Dx
Rectal biopsy | X-Ray shows dilated bowl with air fluid level
60
How do you treat
Wash out = 1st line whilst waiting for biopsy Anorectal pull through Resection of aganglionic part
61
How does oesophageal atresia present
``` Choking Cyanotic spells Following aspiration Polyhydramnios as can't reabsorb fluid VATER association ```
62
How does duodenal atresia present
Billous voimt
63
How does biliary atresia present
Jaundice >14 days
64
What does biliary atresia require
Urgent Kasai
65
If a child fails to pass stool what do you think of
``` Constipation Hirschprung Meconium ileus Bowel atresia Imperforate anus ```
66
What is meconium ileus
Small bowel obstruction due to meconium | Common in CF (90%)
67
How does it present
Distension Tender abdomen Billous vomit
68
How do you Dx
PR contrast | X-ray = dilation, no fluid
69
How do you Rx
Surgery to remove plugs
70
What is Meckel's diverticulum
Congenital diverticulum of small intestine 2% population 2 inches long 2 feet from ileo-caecal valve
71
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 ```
72
When do you present
Usually age <2 like appendicitis
73
How do you Rx
Surgical removal
74
What is an umbilical hernia
Common self-limiting weak spot | Points to ceiling on increased pressure
75
What are RF for umbilical hernia
``` Down's LBW Premature Hypothyroid Storage disorder ```
76
When do you refer
Age 2
77
When do you Rx
If not closed by age 5 | If large / cosmetic as risk of incarceration
78
What is paraumbilical hernia
Defect in linea alba | Points to feet on increased pressure
79
How do you Rx
DOesn't close itself so surgery
80
What is epigastric hernia
Defect in linea alba causing protrusion of pre-peritoneal fat
81
How do you Rx
Don't need to | Cosmesis only
82
What is a diaphragmatic hernia
Herniation of bowel into chest | If contains liver = poor prognosis
83
How is it Dx
Usually picked up at 20 week USS as seen bowel in chest
84
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 ```
85
What does X-ray show
Loops of bowel in chest
86
How do you treat
NG tube tube to keep air out of gut Intubate ECMO Surgery
87
What are risks
Recurrence | Occur in sibling
88
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
89
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 ```
90
How do you treat abdominal pain
ABCDE Analgesia AX Consider NG / catheter
91
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 ```

Paediatrics (35 decks)

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