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Paediatrics > Surgery > Flashcards

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
Q

What does previous history suggest

A

Lessens chance of surgery

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26
Q

What is important to ask in abdominal pain

A

Menstrual history

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27
Q

How do you investigate abdominal pain

A 
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

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28
Q

What is the triad of appendicitis

A 
Pain - central abdominal radiate to RIF
Guarding and rebound 
Vomiting = not continuous 
Moderate fever - if high more likely mesenteric 
Anorexia 
Look unwell
Tachy
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29
Q

How do you diagnose appendicitis

A

Active observation

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30
Q

When is appendicitis unusual in

A

<4 but greater risk of perforation

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31
Q

Where is the tenderness in appendicitis

A

McBurney’s point
1/3 way between ASIS + umbilicus
Roving - pressing LLQ increases pain in RLQ

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32
Q

What are the complications of appendicitis

A

Abscess

Peritonitis after perforation

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33
Q

How do you manage appendicitis

A

Analgesia - Paracetamol best option
Fluid
Ax
Laparoscopic removal

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34
Q

What are the symptoms of non specific abdominal pain

What is it associated with

A 
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
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35
Q

What is mesenteric adenitis

A 
Viral illness 
Abdominal pain due to inflamed LN in mesentery 
High temperature 
URTI history often
Not unwell 
If tummy is soft then fine
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36
Q

Why can pneumonia cause abdominal pain

A 
Pleural irritation referred 
Very unwell - tachy, CRP, breathing 
No abdominal signs - soft tummy 
Global killer of children in <5
Typically lower R lobe
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37
Q

How does UTI present in child

A

Abdo pain
VOMTING
Always dip urine

38
Q

What are rare but important causes of abdominal pain

A 
Malrotation
Pyloric stenosis 
Intussusception 
Meckels diverticulum 
Hernia + torsion
39
Q

What is the typical story of malrotation and what does it lead too

A 
Baby born fine 
3 days starts vomiting bile 
Unwell 
Can occur in any age 
Often high caecum 
Can cause volvulus and obstruction
40
Q

What is a new baby vomiting bile suggestive off

A

Malrotation until proven otherwise

41
Q

How do you Dx malrotation

A

Upper GI contrast study ASAP

USS

42
Q

How do you Rx malrotation

A

Laparatomy URGENTLY

43
Q

What is the story of intussusception

A 
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
Q

What age group is intussecpition common in

A

6-12 months

Very unusual outside

45
Q

What is intussception

A

Bowel slides into another bit of bowel (terminal ileum into caecum)
Cause obstruction, perforation and necrosis

46
Q

How do you Dx intussception

A

USS abdomen
Target sgin
May do bloods but not necessary

47
Q

How do you treat intussception

A

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
Q

What is gastroschisis

A

Abdominal wall defect

Gut eviscerated and exposed at birth

49
Q

How do you Rx gastroschisis

A

Urgent Surgery
TPN
Risk of short gut

50
Q

What is associated with gastroschisis

A

Bowel atresia
Short bowel - very rare
VSD
Cleft palate

51
Q

What is exomphalos

A

Umbilical defect but covered with viscera

Poor prognosis due to associations

52
Q

What is associated with exomphalos

A

Cardiac abnormality - VSD
Chromosomal - trisomy, 13,18,21
Beckwith-Weideman syndrome

53
Q

How do you Rx exomphalos

A

Gradual surgery

54
Q

What is Beckwith-Weideman

A 
Exomphalos 
Hypoinsulinaemia
Atrophic tongue 
Macrosomia
Increased risk of ALL / nephroblastoma
55
Q

What is Hirschprung’s

A

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
Q

When is Hirschprungs more common

A

FH
Down syndrome
NF
MEN II

57
Q

How does it present

A

No stool passed in 24 hours
Vomit bile
Constipation, distension, vomiting, poor weight gain and FTT if older children
Can get overflow

58
Q

When is it usually picked up

A

First 48 hours as don’t pass stool

59
Q

How do you Dx

A

Rectal biopsy

X-Ray shows dilated bowl with air fluid level

60
Q

How do you treat

A

Wash out = 1st line whilst waiting for biopsy
Anorectal pull through
Resection of aganglionic part

61
Q

How does oesophageal atresia present

A 
Choking
Cyanotic spells
Following aspiration 
Polyhydramnios as can't reabsorb fluid 
VATER association
62
Q

How does duodenal atresia present

A

Billous voimt

63
Q

How does biliary atresia present

A

Jaundice >14 days

64
Q

What does biliary atresia require

A

Urgent Kasai

65
Q

If a child fails to pass stool what do you think of

A 
Constipation
Hirschprung
Meconium ileus
Bowel atresia 
Imperforate anus
66
Q

What is meconium ileus

A

Small bowel obstruction due to meconium

Common in CF (90%)

67
Q

How does it present

A

Distension
Tender abdomen
Billous vomit

68
Q

How do you Dx

A

PR contrast

X-ray = dilation, no fluid

69
Q

How do you Rx

A

Surgery to remove plugs

70
Q

What is Meckel’s diverticulum

A

Congenital diverticulum of small intestine
2% population
2 inches long
2 feet from ileo-caecal valve

71
Q

What are the symptoms of Meckels diverticulum

A 
Abdo pain mimicking early appendicitis
Rectal bleeding - most common cause of rectal bleed in child 
Offensive stool
Obstruction - vomiting 
Volvulus
Intussception 
Unstable
72
Q

When do you present

A

Usually age <2 like appendicitis

73
Q

How do you Rx

A

Surgical removal

74
Q

What is an umbilical hernia

A

Common self-limiting weak spot

Points to ceiling on increased pressure

75
Q

What are RF for umbilical hernia

A 
Down's 
LBW
Premature
Hypothyroid
Storage disorder
76
Q

When do you refer

A

Age 2

77
Q

When do you Rx

A

If not closed by age 5

If large / cosmetic as risk of incarceration

78
Q

What is paraumbilical hernia

A

Defect in linea alba

Points to feet on increased pressure

79
Q

How do you Rx

A

DOesn’t close itself so surgery

80
Q

What is epigastric hernia

A

Defect in linea alba causing protrusion of pre-peritoneal fat

81
Q

How do you Rx

A

Don’t need to

Cosmesis only

82
Q

What is a diaphragmatic hernia

A

Herniation of bowel into chest

If contains liver = poor prognosis

83
Q

How is it Dx

A

Usually picked up at 20 week USS as seen bowel in chest

84
Q

What does it caus

A 
Pulmonary hypoplasia
Pulmonary hypertension
Resp distress at birth
Cyanosis
Absent heart sound as displaced to R
Tinking bowel sounds
Scaphoid chest
85
Q

What does X-ray show

A

Loops of bowel in chest

86
Q

How do you treat

A

NG tube tube to keep air out of gut
Intubate
ECMO
Surgery

87
Q

What are risks

A

Recurrence

Occur in sibling

88
Q

What should you do if child has hernia waiting for surgery

A

Advise of signs of obstruction or stragulation
Vomit
Pain
Unable to push hernia back

89
Q

What do you examine if child presents with abdominal pain

A 
Abdomen
- Signs of peritonitis - guarding / rebound
- Mass
- Hernia 
ENT / chest / testis/ hernia
Temperature 
PR not routine
90
Q

How do you treat abdominal pain

A

ABCDE
Analgesia
AX
Consider NG / catheter

91
Q

What do you asking history

A 
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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