PAEDIATRICS SURGICAL EMERGENCIES LECTURE_055634.docx

**PAEDIATRICS SURGICAL EMERGENCIES** ONAH,S.K OUTLINE -definition/overview -classifications -general management principles -conclusion DEFINITION/OVERVIEW \- Any disease/disorder/health challenge requiring urgent surgical intervention (open or endoscopic) to prevent mortality and or limit mo...

**PAEDIATRICS SURGICAL EMERGENCIES** ONAH,S.K OUTLINE -definition/overview -classifications -general management principles -conclusion DEFINITION/OVERVIEW \- Any disease/disorder/health challenge requiring urgent surgical intervention (open or endoscopic) to prevent mortality and or limit morbidity. \- Essentially in the turf of paediatric surgery, but should not escape the paediatricians' knowledge scope \- Should be within the diagnostic sensitivity and acuity of any child health specialist \- The input of the paediatrician essential and vital in the overall management of such cases CLASSIFICATIONS \- Could be based on anatomical regions, age range, systems involved, unique sub-specialties etc ANATOMICAL REGIONS \- Head and neck -thorax/chest \- abdominal -limbs AGE RANGES \- Neonatal \- Infantile \- toddler \- Preschool \- School age \- Pre-adolescent -Adolescent SYSTEMS \- Digestive -Central nervous -cardiovascular -respiratory \- musculoskeletal -Etc SUB-SPECIALTIES \- General surgical/abdominal \- Urological -Orthopaedic \- Ocular \- Otorhinolaryngological -Paediatric trauma -Etc. Etc. **ABDOMINAL - ACUTE ABDOMEN** \- Often referred to as a sudden, severe abdominal pain requiring urgent intervention \- Vast, very confounding condition \- confounding owing to children's limited communication and descriptive abilities, poor pain localization capacity \- pathologies may range from inflammatory to non inflammatory -Presenting features depend on nature of pathology and the specific organs involved \- Unravelling the condition would require detailed history, painstaking clinical examination and focused investigations \- very often, a paediatrician's nightmare PRESENTATION Pain..... \- often poorly localized, but could be a pointer to the pathology/diagnosis \*Epigastric.....oesophagitis, pancreatitis, gastritis, billiary tract disorders \*Flank pain...renal disorders \*Shifting from central to right....appendicitis \* Radiation to left shoulder...gall bladder disorders, subdiaphrgmatic abscess Intermittent/colicky...intestinal obstruction \*Diffuse cramps with loose stools....dysentary, inflammatory bowel disease \*Constant, boring, stabbing pain worse on lying down....acute pancreatitis VOMITING/BOWEL FUNCTION \*projectile.....GOO \*billous...........obstruction below 2^nd^ part of duodenum \*Haematemesis.....portal hypertension, bleeding peptic ulcer, Mallowry weis tears \*Melena....gastritis, oesophagitis, peptic ulcer, portal hypertension \*constipation.......intestinal obstruction EXAMINATION FOCUS/FINDINGS \*IPPA \*Always remember to start palpation away from pain locus/loci \*Should be meticulous and pedantic -localized fullness...mass -generalized fullness..intestinal obstruction -movement with respiration or not -hernial orifices -Rovsing's sign...appendicitis -Murphy's sign.....acute cholecystitis -rigidity........peritonitis -loss of liver dullness....situs invertus, pneumoperitoneum Remember that extra-abdominal conditions can equally present as acute abdomen: \*CCF....tender hepatomegally, ascitis \*Septicaemia...abdominal distension, billous vomiting, jaundice \*DKA...severe abdominal pain \*Basal pneumonea GENERAL MANAGEMENT PRINCIPLES: \* Proper history/examination \*focused investigations...to diagnose/determine morbidity spectrum, prepare treatment -abdominal ultrasound -abdominal xray Abdominal CT -electrolytes -FBC -RBS -Urinalysis \*Treatment -rest the gut/stop feeding in some cases \_nasogastric intubation -fluid and electrolyte correction -antibiotics -surgery **UROLOGICAL EMERGENCIES** \- Renal injuries...blunt abdominal injuries, flank contusions -bladder injuries/bladder rupture...esp if full -urethral injuries...meatal blood discharge -acute scrotum...torsion of testes\*\*\*, epididymo-orchitis, testicular tumour, hernia -paraphimosis,phimosis -penile zipper entrapment Testicular torsion...red, swollen, tender hemiscrotum......arguably the only true emergency in this domain....operation is crucial Management......cognate/focused **PAEDIATRIC TRAUMA** One of the leading causes of death post-infancy.....accidents eg RTA CATEGORIZATION: 1. Extent.....multiple/focal 2. Nature.....penetrating /blunt 3. Severity.....mild/moderate/severe Multiple trauma...refers to apparent injuries of at least two body areas MANAGEMENT PROTOCOL: \*Triage...a process of patient assessment, treatment prioritization and determination of appropriate treatment location. It is important to obtain details of the accident and probable mechanism of injuries. Caregivers must be informed about the exercise to enlist their understanding and cooperation. \*Primary survey.....ABC -Airway...ensure neck is stabilized, chin lift jaw thrust manoeuvre often enough, semi-prone position preferable, oropharyngeal airway could be used -Breathing...major trauma cases to receive supplemental oxygen, pulse oximetry, flail chest, tension pneumothorax to be promptly recognized, assessment of gastric dilatation, other ventilatory assistance could be needed -Circulation -Consciousness score...Glasgow, AVPU HEAD TRAUMA -Leading cause of death amongst paediatric trauma -subdivided into penetrating/non-penetrating..also further classified on severity scale \- pointers...skull fractures,unconsciousness, agonal breathing, Cheyne Stokes -management...ABC, admission,investigations/brain imaging, supplemental oxygen, anticonvulsants, judicious sedative use, antibiotics, surgery, regular monitoring **OCULAR EMERGENCIES** -Recognition and need for prompt referral very important -torchlight, opthalmoscope, magnifying glass, some emergency drugs like topical lignocaine to be handy \- pointers..discharge, redness, hyphaema, corneal opacity, watering, proptosis -foreign body...conjuctival FB should be gently removed, intraocular to be referred \- glaucoma, penetrating injuries\*\*\*.....referral.....acute glaucoma not common in children \- Endophthalmitis/panophthalmitis.....antibiotics..referral for possible enucleation -other ocular emergencies..orbital cellulitis...medical managent often enough **OTORHINOLARYNGOLOGICAL EMERGENCIES** -ASOM -Otitis Externa...antibiotics, analgesics, icthymol glycerine packing -Mastoid abscess...pain behind the ear, foul smelling ear discharge..could be a complication of ASOM. -Stridor: \_Epistaxis: Foreign bodies LUDWIG'S ANGINA -life threatening infection of the sublingual, submental and submandibular spaces...sometimes follows odontogenic infections, floor mouth laceration, salivary gland infection -presents with pancervical brawny induration/fever/malaise/excessive salivation, difficulty swallowing -treatment..I&D,antibiotics, analgesics..sometimes tracheostomy DENTOALVEOLAR ABSCESS..may require I&D in addition to antibiotics/analgesics **ORTHOPAEDIC EMERGENCIES** -Could be traumatic or non-traumatic -Traumatic -fractures(accidental and non accidental) -Stress fractures...proximal tibia most commonly involved...results from buckling due to failure to withstand repetitive non-violent loads...sometimes related to sports medicine -Non-traumatic -Acute osteomyelitis -septic arthritis Above conditions may just present with loss(pseudoparalysis) or limited movement of involved limbs..esp in neonates. Necessary investigations....FBC, blood culture, CRP(better than ESR), joint ultrasound, Xrays. Treatment....arthrotomy(septic arthritis), long course parenteral antibiotics -Slipped capital femoral epiphyses **CONCLUSION** -Surgical emergencies are not uncommon in children -They are as varied as they are unique -Place of conservative management exists even for supposedly surgical cases -Index of suspicion including for non accidental injuries should always be high -Proper and thorough physical examination under a good light source very important -Collaborative management with paediatricians, paediatric nurse etc found to give better outcome -Counselling always crucial