Surgery (Gsx, optho, ent) Flashcards
Pyloric stenosis gas
hypochloremic hypokalemic metabolic alkalosis
common electrolyte derrangement in bowel obstruction
hypokaleia due to isotonic intravascular fluid depletion
Umbilical hernia management
no need to do surgery until school age (4-6 yrs)
if incarcerated, reduce and then repair soon
if strangulated, reduce in OR and then repair
It is recommended to repair any umbilical hernias with the defect of 1.5 cm or more in children over the age of 2 years because of minimal chance of spontaneous closure
Inguinal hernia management
refer asap - repair once stable but asap
US criteria for appendicitis
wall thickness ≥6 mm, luminal distention, lack of compressibility, a complex mass in the RLQ, or an appendicolith.
Omphalocele vs gastroschisis
Omphalocele
- awful
- sac around the abdominal contents because contents herniate into base of the cord
- often has associated anomalies (ex Beckwith Wiedeman, T13, T18, T21)
- bad baby, good gut
Gastroschisis
- typically smaller defect
- no membrane over the organs
- often isolated
- good baby, bad gut
Testicular torsion presentation
pain often is sudden in onset and may be associated with exercise or minor genital trauma, can see associated N/V, scrotum is often swollen, cremasteric reflex is often absent and the position (lie) of the testis is abnormal, and the testis position often is high in the scrotum
Epididymitis presentation
unilateral scrotal swelling and tenderness, erythema, often accompanied by a hydrocele and palpable swelling of the epididymis, associated with the history of urethral discharge
Diagnosis of testicular torsion
doppler US
Diagnostic test for Hirschsprung
Deep rectal biopsy (rectal suction biopsy)
Needs to be no closer than 2 cm above dentate line
Positive: aganglionosis
can also do contrast enemaa (only 70% sensitive)
Diagnostic test for diaphragm eventration
Dynamic US or diaphragm fluoroscopy (needs to be dynamic)
Timing for undescended testes surgery
6mo to 1 yr
bilious emesis in neonate
malrotation with volvulus
15 yr old sexually active male with 24 hrs low grade fever, dysuria, scrotal swelling and pain. Pyuria, microscopic hematuria. Treatment for the presumed diagnosis?
Epididymitis
STI
treat pt and partners with abx
Right sided vs left sided varicocele
right sided varicocele is concerning and should investigate for abdominal mass
left sided is likely due to SMA blocking the left renal vein
dull ache standing with bag of worms
Tubo ovarian abscess management
Ceftriaxone + doxycycline + metronidazole
Management of umbilical granuloma
Granulation tissue is treated by cauterization with silver nitrate, repeated at intervals of several days until the base is dry.
delayed umbilical cord separation
think leukocyte adhesion defect
normally separates within 1-2 weeks
Meckels diverticulum
Rule of 2’s:
2% of population
~2 feet from ileocecal valve
2 inches long
Presents in patients <2 50% of the time
“2 types of tissue” - usually contain ectopic mucosa
most common location for intuss
ileal colonic
Surgery indications for intuss
Indication for surgical reduction= refractory shock, suspected bowel necrosis or perforation, peritonitis, and multiple recurrences (suspected lead point)
2 year old girl with painless bright red blood per rectum. What test will best reveal diagnosis?
Meckel’s scan
Accounts for 50% of all lower GI bleeds in children younger than 2 yr of age
Painless rectal bleeding (peptic ulceration due to ectopic gastric tissue) Most are asymptomatic.
May cause perforation or peritonitis (like appendicitis). May be lead point for intussusception
Management G tube granulation tissue (CPS)
Ensure tube is secured to skin
Remove dressing
Apply warm saline compresses 3–4 times daily
If saline compresses are not effective and tissue is large, moist and friable, consider applying silver nitrate every 2–3 days until it resolves. Protect surrounding skin with a barrier cream before applying silver nitrate to avoid burning normal skin (1,15)
For balloon devices, ensure balloon is intact and appropriately inflated
age to start visual screening
3-5 yrs
Child with photophobia, squinting and tearing. Rt pupil bigger than left. Watery discharge and conjunctival injection of Rt eye. They are afebrile. Normal pupillary response and EOM but cornea is cloudy. What is the most likely diagnosis:
Glaucoma
pupil bigger
cornea opaque
blepharospasm (squinting)
Adenovirus ketatoconjunctivitis
pseudomembranse
foreign body sensation
looks like viral conjunctivitis
No specific medical therapy is available to decrease the symptoms or shorten the course of the disease. Emphasis must be placed on prevention of spread of the disease.
Optic neuritis presentation
Unilateral or bilateral visual loss over hours to days
Bilateral ON is more common in younger children and is often associated with a preceding viral infection
Unilateral ON can also be followed in time by bilateral involvement
Abnormal colour vision, visual field loss, sometimes RAPD
Risk factors for glaucoma
previous cataract surgery (lens surgery can cause blockage of fluid causing increased IOP)
when to refer AOM for ear tubes
- persistent bilateral OME with hearing loss x 3 mo
- recurrent AOM with middle ear effusion
others:
- at risk children
- complications of AOM
- OME > 3 mo with other problems (behaviour, school, vestibular)
Problem for contact lens wearers
Bacterial keratitis
most common cause of hearing loss
genetic
most common acquired/congenital hearing loss
CMV
hearing loss (SNHL), white forelock, heterochromic eyes
waardenburg syndrome
- autosomal dominant
- hirsprungs
who should have hearing screening
everyone - universal hearing screening
hearing screen techniques
otoacoustic emmission (level 1, misses hearing loss between 20-30dB)
automated auditory
brainstem response (AABR) (level 2, do this if at risk for hearing loss. ex CMV, VLBW)
rhinitis treatment
first line management is nasal steroids (best treatment) ex. fluticasone
can also avoid allergens and try antihistamines
AOM CPS statement pearls
No watch and wait approach if:
- perforated
- temp >/= 39
- <6mo
- systemically unwell
- symptoms >48hr
6mo - 2yr high dose x 10 days
>2 yr x 5 days
if perforated, drops + 10 days oral
indications for tympanostomy tubes
severe pain
complicated AOM (ex. mastoiditis)
failed 2 courses abx for AOM
unilateral OME x 3 months
hearing imairment
recurrent AOM 3 in 6 mo or 4 in 12 mo)
tube ottorhea
topical abx drops + steroid drops
if chronic > 6 weeks, culture and treat accordingly
mastoiditis
clinical diagnosis
recommend CT temporal bone with contrast to confirm
CT with contrast to look for intracranial complication s
IV antibiotics CTX +/- vanco
myringotomy
need hearing screen after treatment
CN complications 6 (lateral rectus) and 7 (facial nerve)
sinusitis
> 10 days persistent nasal draininage plus either severe symptoms, purulent discharge x 3 days, or worsening symptoms such as fever
sinus aspirate not practical
imaging not helpful
abx:
- amoxil 45mg/kg/d
- 2nd: amox-clav
7 - 10 days
tonsillectomy indications for recurrent strep
> 7 episodes in 1 yr
5 episodes/yr x 2 yr
3 episodes/yr x 3 yr
order of sinus development
ethmoid and maxillary present at birth
ethmoid pneumatized at birth
maxillary at 4yo
sphenoid by 5yo
frontal 7-8yo
RPA pearls
typically age 3-4
won’t look up, pain, drooling
lateral neck xr: widened pre-vertebral space (more than ½ at C2 or full vertebrae at C6/7)
IV abx
bacterial tracheitis pearls
will describe it as toxic appearing croup, not improving with epi neb, may have cough
usually young age <6yr
XR: candle dripping, narrow trachea
clinical dx
IV antibiotics, intubate
epiglottitis
2-12 yr,unimmunized
classically h flu
rapid onset, toxic, sniffing position (head extended, looking up), drooling, no cough/no resp sx
XR thumb print sign
IV abx, intubate
PTA
teenager
sore throat, hot potato voice, trismus (wont open mouth), deviated uvula, head may be tilted
no XR findings. clinical dx
drainage, abx
congenital neck cyst
thyroglossal: midline, moves with tongue
Branchial: border SCM, most common, non-tender and mobile
Ultrasound
abx if infected
dental caries bacteria
strep mutans
first dentist appt
within 6 mo of erruption of first tooth and no later than one year of age
conjunctivitis viral vs bacterial
purulent - bacterial - polysporin eye drops
watery/mucoid - viral
*if contact lens wearer, think pseudomonas
neonatal conjunctivitis
first day - chemical
first week - gonorrohea
*if mom + for gonorrhea, swab baby even if asx and give 1 dose IV/IM ctx until culture back
*no longer routine use of erythromycin prophylaxis
*IV abx + topical erythro
3 weeks - chlamydia
*only swab if symptomatic
*if positive, po erythro x 2 weeks
blurry vision/pain with foreign body sensation in contact lens wearer
bacterial keratitis
infection of the cornea
optho consult urgent
bactericidal abx for pseudomonas coverage (ex. tobramycin)
pseudomembranes
adenoviral keratoconjunctivitis
self limited but very contagious
dendritic lesions with fluorescein stain
HSV keratitis
po or topical antivirals
dont use topical steroids
uveitis management
if anterior (red eye, iris adhesions, irregular pupil, decreased vision) - can tx with topical steroids
if posterior (no signs of erythema, just decreased vision) - systemic steroids
eye finding in MS
optic neuritis
uni or bilateral vision loss over hours to days
amblyopia
functional reduction in vision due to abnormal vision development early in life
can be due to strabusmus, refractive error, or deprivation
strabismus
can be seen in babies
if persistent past 4 mo should be referred
dacrocystitis treatment
IV antibiotics
1 yr old with brown –> beige iris, large pupil, big eyes
glaucoma
corneal clouding, photophobia, blepharitis (twitching), tearing
due to icnreased IOP
risk after cataract surgeryc
congenital cataracts
clouding of the lens (pupil) only
associated with TORCH infxn (ex. rubella), galactossemia, trisomy 13, Alport’s, diabetes
removal by 8 weeks of age
ROP screening cut offs
<31 weeks or </= 1250 g
start at 31 weeks or 4 weeks of age, whichever is later
cherry red spots
tay sachs
indications for tympanostomy tubes
o Severe, refractory pain
o Hyperpyrexia
o Complications (facial paralysis, mastoiditis, labyrinthitis, CNS infection)
o Immune disorder
o Third line therapy for patients that have failed 2 courses of abx
o Unilateral OME with THREE months of effusion with vestibular, behavioral issues or poor school performance
o Recurrent AOM (3 in 6 mo, 4 in 12mo)
o Bilateral OME with persistence of THREE months
