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
what are the 5 most common conditions that warrant pediatric surgery? (KNOW)
Pyloric Stenosis Meckel Diverticulum Intussusception Appendicitis Splenic injury
Resuscitation for kids includes what? what might you need for severe hypovolemia? are oral fluids ok? KNOW
20 mL/kg bolus of isotonic fluid: Normal saline or lactated ringer’s (rare)
*May need additional boluses for severe hypovolemia
oral fluids OK for mild 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 KNOW
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 KNOW
- 4 mL/kg/hr for each of the first 10 kg weight
- 2 mL/kg/hr for each kg from 10-20 kg
- 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 (KNOW)
pyloric stenosis
on physical exam: you palpate an olive shaped- mass in the abdomen (with projectile vomitting) KNOW
pyloric stenosis
what is the major danger with pyloric stenosis? KNOW
Hypochloremic hypokalemic metabolic alkalosis
- you have basic blood and acidic urine
so balance them!
RESUSCITATE immediately
what is the basic pathophys of pyloric stenosis?
Delayed hypertrophy, hyperplasia of pyloric circular muscles
Not present at birth, it develops
presentation of pyloric stenosis? (4) KNOW
- Progressive non-billious emesis : Undigested milk, can be coffee-ground with gastritis, diarrhea
- Dehydrated/malnourished : Increased appetite/thirst , Jaundice
- sunken fontanelles (if its progressed)
- “olive” felt in abdomen
txt of pyloric stenosis? KNOW
resuscitation (normal Na, Cl, bicarb <30) FIRST
- can’t do surgery until they are electrodynamically stable
- need bicarb < 30
surgery for pyloric stenosis? KNOW
Pyloromyotomy- divide hypertrophic muscular layer but not mucosa
** and then start re-feeding program
presentation of meckel’s diverticulum ? KNOW
often asymptomatic- incidental finding
- PE usually shows normal
what is the most common congenital GI abnormality? KNOW
meckel’s diverticulum
what is the “rule of 2s “ for meckel’s diverticulum? KNOW
“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 KNOW
Resect if symptomatic or causing pathology
–> Open and laparoscopic approaches (resection)
Leading cause of obstruction before 2 years old KNOW
Intussusception
how do you diagnose Meckel’s Divertculum? KNOW
Technetium-99 pertechnetate scan (aka a Meckel’s Scan)
- Ectopic gastric parietal cells
what is intussusception? what is the usual cause?
Bowel “telescopes” in on itself and can cause ischemia; usually idiopathic
presentation of intussusception ? KNOW
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? KNOW
intussusception (RLQ empty)
2 ways to Dx of intussusception? KNOW
Ultrasound: Target or “Donut” sign
Air or Contrast enema (can Dx and Txt with this- mainly ileocolic)
intussusception txt (2), when would you operate? KNOW
- Fluid resuscitation
2). Multiple attempts at reduction with enema if stable
*small bowel will often spontaneously resolve - Operate for peritonitis or persistent obstruction
(Manually reduce intussusception)
appendicitis presentation KNOW
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 ? KNOW
MOSTLY a clinical Dx but CT is helpful to confirm
appendicitis txt KNOW
Laparoscopic appendectomy
what is stump appendicitis? KNOW
the interval repeated inflammation of remaining residual appendiceal tissue after an appendectomy.
PE of splenic injury KNOW
- severe abd pain/discomfort
- pale
- tachy
- hypotension (late finding)
Dx of splenic injury KNOW
CT scan (first) or FAST/US exam controversial in kids *monitor Hb levels
txt of splenic injury KNOW
- 90% of grades I-IV 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
body weight fluid % for kids
total body water volume = 60% body weight
Intracellular = 40%
Extracellular = 20% (interstitial = 80%, plasma = 20%)
how to diagnose pyloric stenosis? KNOW
abdominal US should be used first (also alkalotic labs)
peak age of appendicitis? KNOW
11-12
appendicitis pathophys KNOW (7)
Luminal obstruction- (Lymphatic tissue, Fecalith, Parasites) Stasis Infection Ischemia Necrosis Perforation Abscess / phlegmon
some sequelae for appendicitis? (4)
stump appendicitis
wound infection
post-op ileus
post-op abscess (consult IR for drain)
Initial management of splenic injury KNOW
Airway Breathing Circulation Disability Exposure
Grades of splenic injury KNOW
1 = laceration <1cm, subcapsular hematoma <10% 2 = laceration 1-3 cm, subcapsular hematoma 10-50% 3 = laceration >3cm, SH >50% OR ruptured SH 4 = segmental or hilar vascular injury and devascularization of >25% of spleen 5 = hilar injury and shattered spleen
post-splenectomy vaccines (3)
Streptococcus pneumonia
Haemophilus influenzaetype b
Nisseria meningitides
