Surgery: pediatrics Flashcards
consent is a legal issue: what specific situations can kids seek care without parental consent? what type of intervention NEEDS an adults signature
substance abuse, contraception and pregnancy, psychiatric problems
BUT Operative intervention needs an adult’s signature
what is “assent”?
Consideration of child’s input
considers…
Child’s developmental state
Child’s understanding of disease process
what are the most common conditions that warrant pediatric surgery?
Pyloric Stenosis Meckel Diverticulum Intussusception Appendicitis Splenic injury
Resuscitation for kids includes what? what might you need for severe hypovolemia?
20 mL/kg bolus of isotonic fluid
Normal saline or lactated ringer’s (rare)
*May need additional boluses for severe hypovolemia
two ways we remove intravascular fluid?
Diuresis and Dialysis
goal of mgmt for fluid management
make the pt euvolemic
not hypo or hypervolemic or fluid in the wrong place
fluid management: maintenance
Often 5% dextrose in 0.45% saline with 20 miliequivalents of potassium
“D5 ½ NS w/ 20 mEq K+”
4-2-1 rule
fluid mgmt: 4-2-1 rule
4 mL/kg/hr for each of the first 10 kg weight
2 mL/kg/hr for each kg from 10-20 kg
example: A 12.5 kg infant would need 40 + 5 = 45 mL/hr
1 mL/kg/hr for each kg above 20 kg
example: A 45 kg child would need 40 + 20 + 25 = 85 mL/hr
Most common cause of emesis (projectile vomiting) in infancy
pyloric stenosis
on physical exam: you palpate an olive shaped- mass in the abdomen (with projectile vomitting)
pyloric stenosis
what is the major danger with pyloric stenosis?
metabolic alkalosis (barfing all acid of the stomach)
- you have basic blood and acidic urine
so balance them!
what is the basic pathophys of pyloric stenosis?
Delayed hypertrophy, hyperplasia of pyloric circular muscles
Not present at birth, it develops
extensive PE of pyloric stenosis may show what signs ? (4)
- Progressive non-billious emesis : Undigested milk ( coffee-ground with gastritis) , diarrhea
- Dehydrated/malnourished : Increased appetite/thirst , Jaundice
- sunken fontanelles (if its progressed)
- “olive” felt in abdomen
txt of pyloric stenosis?
resuscitation
- can’t do surgery until they are electrodynamically stable
- need bicarb < 30
what procedure can help pyloric stenosis?
NG decompression
surgery for pyloric stenosis?
Pyloromyotomy
Open or laparoscopic
Divide hypertrophic muscular layer but not mucosa
presentation of meckel’s diverticulum ?
often asymptomatic- incidental finding
- PE usually shows normal
Most common congential GI abnormality
meckel’s diverticulum
what is the “rule of 2s “ for meckel’s diverticulum?
“Rule of 2”
~2% population, 2 inches long, 2 cm in diameter, 2 feet from IC valve, can have 2 types of heterotopic mucosa, often presents by 2 years old
txt for meckel’s diverticulum
Resect if symptomatic or causing pathology
–> Open and laparoscopic approaches (resection)
Leading cause of obstruction before 2 years old
Intussusception
Dx of Meckel’s Divertculum
Technetium-99 pertechnetate scan (aka a Meckel’s Scan)
- Ectopic gastric parietal cells
what is intussusception? what is the usual cause?
Usually idiopathic
Bowel “telescopes” in on itself
presentation of intussusception ?
Severe intermittent pain with periods of complete relief
Blood and mucus in stool
May or may not have vomiting
Pain is cramping
* some infants demonstrate no signs of pain
what is the “dance sign” on Xray indicative of?
intussusception
2 ways to Dx of intussusception?
Ultrasound: Target or “Donut” sign
Air or Contrast enema (can Dx and Txt with this)
intussusception txt (3)
- Fluid resuscitation: Multiple attempts at reduction with enema if stable
- Small bowel – small bowel will often spontaneously resolve
- Operate for peritonitis or persistent obstruction
Manually reduce intussusception
appendicitis presentation
Decreased appetite
Periumbilical pain that migrates to the RLQ
Laying very still, Felt every bump on the ride to hospital
appendicitis: often will rupture in ___ - ___ hrs after onset of symptoms
24-36 hrs
what are these indicative of?
Rovsing Sign – referred pain to RLQ
Psoas and obturator signs
appendicitis
Dx of appendicitis ?
MOSTLY a clinical Dx but CT is helpful to confirm
appendicitis txt
Laparoscopic appendectomy
what is stump appendicitis?
the interval repeated inflammation of remaining residual appendiceal tissue after an appendectomy.
PE of splenic injury
- abd pain/discomfort
- pale
- tachy
- hypotension (late finding)
Dx of splenic injury
CT scan
txt of splenic injury
- MOST can be done with supportive care
- if operation is needed you can try to repair spleen with angioembolization
- splenectomy and provide vaccines to avoid OPSI
(OPSI)
Overwhelming Post-splenectomy Sepsis -Fairly rare, but more common in children -Very severe once developed Sepsis, meningitis Encapsulated organisms
