Management Priorities in Pediatric Surgical Emergencies I have no information to disclose.
Lesli Taylor, M.D. 08/02/2010 Management Priorities in Pediatric Surgical Emergencies I have no information to disclose. Lesli Taylor, M.D. Professor and Chief Division of Pediatric Surgery East Tennessee State University Sunday, August 1, 2010 26th Annual Southwest Virginia Pediatric Conference Pediatric Surgical Emergencies Thank you for your referrals over the past 5 years! I have enjoyed talking with you, and caring for your patients. CASE SCENARIOS 1. Ruptured appendicitis 2. Irreducible intussusception 3. Incarcerated inguinal hernia 4. Malrotation and midgut volvulus 5. Delayed diagnosis of pyloric stenosis 6. MRSA Buttock Abscess Patient age and gender can help make the diagnosis More common in boys Appendicitis 3:2 Intussusception 3:2 Inguinal hernia 7:1 Pyloric stenosis 4:1 Peak age of presentation 8-12 years 3-9 months 0 12 months 0-12 3-8 weeks Equal incidence Malrotation 1:1 MRSA Abscess 1:1 <1 year 12-24 months Ruptured Appendix 1 Lesli Taylor, M.D. 08/02/2010 Ruptured appendicitis in an 10 year old boy Ruptured appendicitis in an 10 year old boy An 10 year old school boy felt nauseated and lost his appetite on Friday morning at school. He developed peri-umbilical pain at lunch. He was seen by the school nurse and sent home with presumed gastroenteritis. That evening, he vomited his dinner. He slept poorly through the night and vomited his breakfast the next morning. The pain was now lower in his abdomen and more to the right. He continued to eat poorly that weekend with little oral intake, but on Sunday evening, he felt better. However, on Monday morning he had a temperature to 101. 101 He walked bent over like an old man. He hesitated to cough. He is evaluated by you at this point, 54 hours after the onset of symptoms. Localized Right Lower Quadrant Pain at McBurney’s Point Ruptured appendicitis in an 10 year old boy What are your management priorities? When should surgery be done? Why did he feel better on Sunday night? Ruptured appendicitis in an 10 year old boy Management priorities: Labs (Imaging) Intravenous fluid Antibiotics Analgesia Urgent exploration - 1-2 hours Ruptured appendicitis in an 10 year old boy History to elicit: Onset of pain Duration of pain Migration of pain Exacerbating factors Ameliorating maneuvers Home medications 2 Lesli Taylor, M.D. 08/02/2010 Ruptured appendicitis in an 10 year old boy Ruptured appendicitis Signs on physical exam: Right lower quadrant tenderness Rebound tenderness Rovsing’s sign Guarding/peritonitis Psoas/obdurator sign (Rectal mass or tenderness) 10 Presenting signs based on stage Stage Simple Suppurative Gangrenous Perforated Abscessed Duration> 36 hrs 4% 13% Diffuse Tenderness 8% 18% 92% 92% 100% 100% 100% 20% 3 Lesli Taylor, M.D. 08/02/2010 Presenting signs based on stage Stage Simple Suppurative Gangrenous Perforated Abscessed Temperature > 38 8% 21% Leucocytosis >13,000 rare 13% 83% 83% 93% 100% 100% 100% Differential diagnosis Onset of pain Diarrhea Rebound tenderness Rectal tenderness Gastroenteritis Appendicitis After vomiting Frequent High volume Usually absent Usually absent Before vomiting Infrequent Low volume Usually present Usually present Constipation is now the most common diagnosis in children with lower abdominal pain in my population if it is not appendicitis. Spectrum of Stages of Appendicitis Simple (focal inflammation) Suppurative Gangrenous Perforated Localized peritonitis – older children Diffuse peritonitis – younger children Abscessed Fecalith, appendicalith Early Acute Appencicitis Tip Fecalith Cecum 4 Lesli Taylor, M.D. 08/02/2010 Early Appendicitis 15 hours of symptoms Necrotic, gangrenous, unruptured appendicitis Cecum Tip Ruptured appendicitis with extruded fecalith Urgency of exploration Unruptured - Surgical Emergency Ruptured - Medical Emergency - resuscitation Dehydration Vomiting Fever Peritonitis Septic Shock Intussusception Intussusception 5 Lesli Taylor, M.D. 08/02/2010 Irreducible intussusception in a six month old boy Irreducible intussusception in a six month old boy A chubby, healthy 6 month old boy was noted by his mother to have intermittent, severe, but brief episodes of crampy abdominal pain that caused him to draw up his legs. legs These cramps persisted for 24 hours with no other symptoms except for spitting up of a formula feed once. He passed no stools. The next day he was extremely lethargic, but arousable. He went for 6 hours without a wet diaper. He is evaluated by you at this point, 32 hours after the onset of symptoms. A contrast enema confirms intussusception, but no contrast can be refluxed past the ileo-cecal ileo cecal valve. valve Irreducible intussusception in a six month old boy What are your management priorities? When is surgery indicated? 6 Lesli Taylor, M.D. Intussusception Symptoms and Signs 08/02/2010 Currant Jelly Stool Mucous Blood Episodic, severe, crampy abdominal pain Abdominal fullness Vomiting Lethargy out of proportion to dehydration Currant jelly stool Sloughed Mucosa Irreducible intussusception in a six month old boy Management priorities: Before contrast enema Surgical evaluation Intravenous fluid Analgesia during reduction Air outlining intussusception in transverse colon on KUB Diagnostic and therapeutic air or barium enema at institution with pediatric surgical expertise Barium outlining intussusception in transverse colon Bowel perforation during air or barium enema requires emergency surgery. 7 Lesli Taylor, M.D. 08/02/2010 Irreducible intussusception in a six month old boy Intussusception in ascending colon Surgical indications - urgent: Peritonitis on presentation Perforation during enema reduction Irreducible intussusception Suspicion of ileo-ileo intussusception Appendix Manual Reduction Colon Reduced Intussusception Ileo-cecectomy for irreducible intussusception 8 Lesli Taylor, M.D. 08/02/2010 Incarcerated inguinal hernia in a four week old boy Incarcerated Hernia Incarcerated Inguinal Hernia A 4 week old, term boy was evaluated at 3 weeks of age for a soft swelling in his right groin. This was a reducible right inguinal hernia. An elective repair was scheduled for one week later. However, the night before surgery, the infant became fussy and refused his feeds. Incarcerated inguinal hernia in a four week old boy He became inconsolable and when the mother checked his diaper, she noted a firm, tender mass in his right scrotum. On the way to see you for evaluation, evaluation the infant vomited stomach contents. Incarcerated inguinal hernia in a four week old boy What are the management priorities for this child? Intestine Peritoneum When is surgery indicated? Obliterated Processus Vaginalis g Tunica Vaginalis Indirect inguinal hernia 9 Lesli Taylor, M.D. 08/02/2010 Incarcerated inguinal hernia in a four week old boy Umbilical Hernia Side of inguinal hernia Right 60% Left 30% Bilateral 10% Indirect Inguinal Hernia Left Indirect Inguinal Scrotal Hernia Patient B Taylor Patient B Patient C 10 Lesli Taylor, M.D. 08/02/2010 Umbilical Hernia Right indirect inguinal hernia Patient C, reduced Polaroid photo taken at home Taylor Taylor Bowel obstruction from incarcerated inguinal hernia Bowel obstruction from incarcerated inguinal hernia Two step reduction technique 1. Decompress the air from the bowel 2. Reduce the bowel loop No ice packs! Warm room Trendelenburg Conscious Sedation Bowel gas in right scrotum 11 Lesli Taylor, M.D. 08/02/2010 Incarcerated inguinal hernia in a four week old boy Repair inguinal hernia electively shortly after diagnosis to avoid incarceration. I put the patient on the operating room schedule within one week of my documenting the hernia. hernia What Questions Do You Have? For incarcerated hernia, admit after reduction with conscious sedation and repair the next day. Malrotation and midgut volvulus in an 8 week old girl Malrotation a o a o and a d Midgut dgu Volvulus o u us Malrotation and midgut volvulus in an 8 week old girl A term female infant fed well for the first 8 weeks of life. After a routine feed, she vomited green material. She passed a normal stool 3 hours later. At the next feed, she vomited a large amount of green material at the initiation of the feed. She was evaluated at an outside hospital. An upper GI study showed malrotation. Midgut volvulus She was transferred for your evaluation. She vomited 30 cc of green material spontaneously en route to the hospital. On exam, her abdomen is soft and non-tender. non tender (Emergency!) 12 Lesli Taylor, M.D. 08/02/2010 Malrotation and midgut volvulus in an 8 week old girl What are your management priorities? When is surgery indicated? Malrotation and midgut volvulus in an 8 week old girl Bilious emesis in an infant is malrotation and possible volvulus until proven otherwise. (The pediatric surgeon’s mantra.) Malrotation and Midgut Volvulus 90% of patients present in the first year of life 25% from 1 month to 12 months of life 25% in the first 1 1- 4 weeks of life 50% in the first 7 days of life 10% present later in life Early volvulus Upper GI shows malrotation *Absent ligament of Treitz *Small bowel loops to right of midline 13 Lesli Taylor, M.D. 08/02/2010 Late volvulus Disastrous gut loss Patient A Non-specific plain film Patient A Midgut volvulus on contrast upper GI 14 Lesli Taylor, M.D. 08/02/2010 Causes of duodenal obstruction and green vomiting in malrotation and volvulus 1. Ladd’s Bands: Adhesive bands from cecum to right upper quadrant which cross over and obstruct duodenum. Anatomy of Malrotation Ladd’s Bands 2. Midgut volvulus with cecum and distal ileum wrapping around duodenum and superior mesenteric artery. Crisis of Volvulus Ladd’s Bands Cecum A double bubble with no distal air is duodenal atresia, which does not require emergency surgery. A double bubble with distal air is malrotation with midgut volvulus and is a surgical emergency. 15 Lesli Taylor, M.D. 08/02/2010 Dr. William Ladd Ladd’s procedure for midgut volvulus Boston Children Children’s s Hospital Ladd’s procedure for midgut volvulus Duodenum Duodenum Ladd’s Bands Ladd’s procedure for midgut volvulus Completed p Ladd’s procedure for midgut volvulus with appendectomy 16 Lesli Taylor, M.D. 08/02/2010 Mid Gut Volvulus Mid Gut Volvulus Ladd’s procedure awaiting appendectomy Malrotation and Midgut Volvulus Emergency Ladd’s procedure for malrotation or midgut volvulus, within 30-60 minutes. Appendix Pyloric Stenosis Delayed diagnosis of pyloric stenosis in a 4 week old boy A four week old, first born, white male infant fed well for the first 3 weeks of life. He then had intermittent spitting of formula, which gradually began to occur at every feed. feed He was seen by a local pediatrician and was diagnosed with formula intolerance. A soy formula was prescribed. The vomiting persisted and occurred at every feed and became more forceful with the passage of time. 17 Lesli Taylor, M.D. 08/02/2010 Delayed diagnosis of pyloric stenosis in a 4 week old boy Delayed diagnosis of pyloric stenosis in a 4 week old boy Two days later, Alimentum formula was prescribed. On re-evaluation by the pediatrician one day later, gastro-esophageal reflux was diagnosed and recommendations were made for smaller, more frequent feeds, rice cereal in the feeds and upright positioning. The vomiting continued and increased in forcefulness. Two days later, the infant child is brought to you for a second opinion. He has not had a wet diaper or tears in 8 hours. Delayed diagnosis of pyloric stenosis in a 4 week old boy What are your management priorities? When is surgery indicated? What is paradoxical aciduria? Delayed diagnosis of pyloric stenosis in a 4 week old boy Management priorities: Nothing by mouth IV hydration/resuscitation Electrolyte repletion Naso-gastric tube is not indicated Pyloric Stenosis Stomach Duodenum Operate when fluid and electrolytes are replete, usually within 24 hours of presentation. 18 Lesli Taylor, M.D. 08/02/2010 Stomach Stomach Completed pyloromyotomy Paradoxical aciduria in gastric outlet obstruction Hypokalemic, hypochloremic metabolic alkalosis Losses: Hydrogen and chloride ions are lost in the vomitus. Urine should be alkaline due to acid losses in the vomitus. Paradoxical aciduria in gastric outlet obstruction Paradoxical aciduria in gastric outlet obstruction Hypokalemic, hypochloremic metabolic alkalosis Hypokalemic, hypochloremic metabolic alkalosis Compensation: There is renal re-absorption of sodium to address the volume losses. losses There is potassium loss in the urine in exchange for the sodium. Bicarbonate is re-absorbed from the urine with the sodium. This increases the metabolic alkalosis. Compensation: When potassium is severely depleted from losses in the vomitus and the urine urine, hydrogen ion becomes the positive ion lost in the urine. This causes paradoxical ACIDURIA. 19 Lesli Taylor, M.D. 08/02/2010 MRSA Buttock Abscess in an 18 month old girl MRSA Buttock Abscess The mother of an 18 month old girl bought a cheaper brand of diapers, and child developed a diaper rash. On the outer aspect of child’s buttock, mother noted a ‘spider spider bite bite’.. This worsened, becoming red, swollen and tender with a necrotic center. Mother is 21 years old and has a red spot on her new tattoo. Grandmother works at a hospital. This is a fictitious composite scenario. MRSA Abscess in an 18 month old girl MRSA Abscess in an 18 month old girl What are your management priorities? When should surgery be done? MRSA Abscess in an 18 month old girl MRSA Abscess in an 18 month old girl – final scar 20 Lesli Taylor, M.D. 08/02/2010 MRSA Abscess MRSA Abscess MRSA small abscess and cellulitis treated without drainage MRSA Abscess leading to osteomyelitis of left femur MRSA Abscess MRSA Abscess 21 Lesli Taylor, M.D. 08/02/2010 MRSA Abscess MRSA Abscess of right labia MRSA Abscess MRSA abscess sequential abscess MRSA abscess MRSA burrows between the fat and the fascia Patient A Patient A 22 Lesli Taylor, M.D. MRSA Abscess 08/02/2010 MRSA Abscess MRSA Abscess 23 Lesli Taylor, M.D. 08/02/2010 MRSA Abscess of left axilla in teenager arm Total surgical procedures 658 / 647 / 844 / 636 (2785) MRSA Abscess of left forearm 2005 2006 1 2 3 4 5 6 7 July 2010 Abscesses Drained Date 7/1 7/3 7/3 7/8 7/8 7/12 7/14 7/16 7/19 7/21 7/22 Age 5m 10m 4m 11m 9y 8y 2y 14y 18m 12m 18m Gender female female male female male male female male female female female Location thigh buttock buttock buttock buttock shin buttock substernal/finger thigh buttock buttock Micro MRSA MRSA MRSA MRSA MRSA MRSA MRSA sys sensitive MRSA MRSA MRSA Inguinal hernia Pyloric stenosis Appendectomy Circumcision Abscess Venous catheter Umbilical hernia 75 63 48 44 27 26 24 2006 2007 79 40 70 58 58 49 40 2007 2008 90 42 57 45 148 38 49 2008 2009 82 32 59 63 93 23 40 July 2010 Abscesses Drained Date 7/23 7/24 7/24 7/25 7/25 7/25 7/26 7/27 7/28 7/30 Age 25m 16m 13.5m 8y 9y 8y 12y 19m 3y 18m Gender male male male female female male female female female female Location thigh buttock thigh shin and lymph nodes 8, various sizes calf mid face buttock buttock buttock Micro MRSA MRSA MRSA MRSA MRSA MRSA MRSA MRSA Sensitive in lab 24 Lesli Taylor, M.D. 08/02/2010 July 2010 Abscesses Drained Total July cases July abscesses 72 21 (29%) 13/21 = 62% female MRSA Abscess Management Pediatricians - Keep child NPO as soon as you suspect the diagnosis! We start IV antibiotics as soon as child arrives in hospital: Bactrim, vancomycin, clindamycin Drain in operating room as soon as NPO status allows – 6-8 hours NPO required Clorhexidine baths in hospital Mupirocin ointment to nares and anus Treat the whole family! MRSA Abscess Management Treat the whole family! Clorhexidine/antibiotic soap baths for all family members Mupirocin ointment to nares of all family members Bleach the bathtub, toilet seat, counter tops Clorox wipes and Lysol are not effective against MRSA! The end of the talk, the beginning of the discussion--- Thanks to Sheila Lyons for PowerPoint assistance. 25
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