兒童非創(chuàng)傷性手術(shù)急癥

1、Eb1,小組教學(xué)(一),兒童非創(chuàng)傷性手術(shù)急癥,Eb2,個(gè)案討論一,一個(gè)四天大女嬰,家長(zhǎng)主訴持續(xù)腹脹及血便,兩次配方餵食皆不吃,持續(xù)睡覺(jué).出生史方面則因母親有妊娠毒血癥而提早於34週大時(shí)剖腹生產(chǎn),出生體重3200公克,並順利於三天後出院.在家每三小時(shí)餵食配方奶60-100CC.,Eb3,初級(jí)評(píng)估(1/2),PATAppearance: Lethargic, poorly responsiveWork of breathing: Eff

2、ortless tachypnea (Compensated for metabolic acidosis) Circulation: Delayed capillary refill, cool, pallor, mottled extrimities, rapid pulse, poor skin turgor, abdominal wall erythema,Eb4,初級(jí)評(píng)估(2/2),Vital sign HR 180bp

3、m, RR 45/min, BP: 60/40 mmHg, BT 37.8C, BW 3010gmA: OpenB: Tachypnea, grunting, breath sounds clearC: Color pale, skin warm and dry, tachycardia, brachial pulse decreasedD: Tone decreasedE: No sign of injur

4、y, no rash,Eb5,重要病史,S: Bloody stool and abdominal distentionA: No allergies, formulafedM: NoneP: Born premature,C/S due to maternal preeclampiaL: Just prior to arrival but vomitedE: No feeding

5、 since 6 hours ago,Eb6,詳細(xì)理學(xué)檢查,Head, neck, lung, and heart examination are normal except for tachycardia ABD: distended, bowel sound: hypoactiveSkin:mildly shiny and erythematouosFemoral pulse(+)Capillary refill : de

6、layed,Eb7,診斷工具-Plain film,Eb8,檢驗(yàn)工具,WBC 12000/mm3, Hb 12.0, PLT 78000mm3, S/L/M=90/3/4ABG: PH=7.25 PCO2 34 PO2 65 HCO3 14 , BE=-8Glucose 70, Na 135 k 4.3Stool examination: OB(++),Eb9,最後診斷,Hollow organ p

7、erforation with septic shock R/O Necrotizing Enterocoltis,Eb10,NEC典型發(fā)現(xiàn),Metabolic acidosisNeutropeniaThrombocytopeniaPneumatosis intestinalisIntrahepatic portal venous gasPneumoperitoneum,Eb11,急診處置,ABCs( Endo siz

8、e 3.5-4.0,IV N/S 60cc)OG for decompressionBlood culture Antibiotics(AMP+GM+Metronadazole)NPOEarly PEDS consultationAdmission,Eb12,個(gè)案討論二,兩足歲男生由救護(hù)車送抵急診室,媽媽主訴發(fā)現(xiàn)小孩尿布上有很多紅色血便,不久前也曾有解血絲便經(jīng)驗(yàn),因?yàn)闊o(wú)疼痛癥狀而且自行緩解.持續(xù)兒科門診追蹤.大便形態(tài)上並無(wú)黏

9、液,病人無(wú)發(fā)燒,餵食情況良好,無(wú)嘔吐癥狀.,Eb13,初級(jí)評(píng)估(1/2),PAT:Appearance: alert and fearlyWork of breath: non-laboredCirculation:pale conjunctivae and mucous membraneVital signs:HR 140, RR 24, BP 100/60, T 37°

10、C Wt 15 kg,Eb14,初級(jí)評(píng)估(2/2),A: Open, no stridorB: Non-labored, breath sounds clearC: Pale conjunctivae and mucous membrane, skin warm and dry, tachycardia, brachial pulse strongD: Tone normalE: No sign

11、of injury, no rash,Eb15,重要病史,S: large mount of bloody stool A: No allergies, formulafedM: NoneP: Born full-term NSVD, history of break bloody stoolL: Just prior to arrivalE: Normal feeding,Eb16,詳細(xì)理學(xué)檢查

12、,Normal except :Head and Neck: pale conjunctivae and mucous membraneHeart: tachycardia with soft 2/6 systolic ejection murmur at the LLSBAnus: Stool is grossly bloody. No evidence of fissure, trauma, or tags,Eb17,急診處置

13、,ABCs : O2 with maskFluid resuscitation:IV with N/S 300CCOG or NG tube for saline lavageCBC-DC, PT/aPTT, type and crossmatchCorrect anemia: pRBC 150cc if indicated,Eb18,初步診斷,Painless rectal bleeding , cause?,Eb19,無(wú)痛性

14、血便之鑑別診斷,Meckel diverticulumIntestinal polypIntestinal duplicationsIntestinal hemangiomaArteriovenous malformationCoagulopathyPUDInflammatory bowel disease,Eb20,診斷工具,A Tc-99m pertechnetate scanExploratory laparoto

15、myLaparoscopyEsphagogastroduodenoscopyColonoscopy,Eb21,Tc-99m pertechnetate scan,The diagnosis of Meckel’s diverti-culum can be obtained by a technetium-99m scintiscan. The radioactivity can be seen in the stomach an

16、d bladder, and the diverticulum is seen in the mid-abdomen.,Eb22,Technetium-99m scan shows ectopic gastric mucosa,,Small intestineMeckel’s diverticulum,Eb23,結(jié)論,優(yōu)先定位出血位置:上消化道或下消化道有出血性腸阻塞或腹膜炎癥狀者皆應(yīng)緊急會(huì)診外科手術(shù)前應(yīng)先解決低血容及貧血問(wèn)題,E

17、b24,個(gè)案討論三,13 歲男生凌晨四點(diǎn)鐘右側(cè)陰囊突然疼痛,由父母帶到急診室,有嘔心感覺(jué).過(guò)去身體健康且喜歡足球運(yùn)動(dòng).前一天在學(xué)?；顒?dòng)一切正常,但過(guò)去右側(cè)陰囊曾有多次短暫疼痛,不過(guò)皆立即緩解,這次疼痛難耐,右側(cè)陰囊水腫而且有厲害壓痛,右側(cè)睪丸位置較平日高,右側(cè)Cremaster reflexs 消失,移動(dòng)身體陰囊就疼痛.,Eb25,,,Eb26,初級(jí)評(píng)估(1/2),PAT:Appearance: alert and embarrass

18、edWork of breath: Normal Circulation:Normal Vital signs:HR 98, RR 14/min, BP 100/60, T 37°C,Eb27,初級(jí)評(píng)估(2/2),ABCDE: normal except right side scrotal swelling , upper riding testis and severe tenderness,Eb28,重要病史及詳

19、細(xì)理學(xué)檢查,--Sudden onset of left scrotal pain --He has had several brief, less intense but similar episodes in the past.--A tender, swollen right hemiscrotum and the testis appears to ride higher i

20、n the scrotum,Eb29,Impression,right testicular torsion,Eb30,診斷工具,Technetium-99m radionuclide scan shows “cold spot” on affected side.Color Doppler ultrasonography shows decreased or absent flow to affected side.,Eb31,都卜

21、勒超音波檢查,Eb32,,,Eb33,Eb34,Eb35,鑑別診斷,Torsion of the appendix testis or appendix epididymisEpididymitisOrchitisIncarcerated inguinal herniaScrotal traumaHydroceleVaricoceleHenoch-Schonlein purpuraScrotal cellulitisK

22、awasaki diseaseTesticular tumor,Eb36,torsion of appendix or epididymitis,Eb37,急診處置,Anagesia with an IV narcoticsManual detorsion (open book)Obtain immediate surgical consultation,Eb38,結(jié)論,睪丸扭轉(zhuǎn)是真正手術(shù)急癥治療方法為去扭轉(zhuǎn)手術(shù)或睪丸固定術(shù)檢

23、查用於臨床經(jīng)驗(yàn)無(wú)法判斷個(gè)案,但不可因此延遲外科會(huì)診,Eb39,個(gè)案討論四,9個(gè)月大男嬰,一直睡覺(jué),早上吐兩次,嘔吐物並無(wú)黃綠色或血絲,不過(guò)大便有黏液.,Eb40,初級(jí)評(píng)估(1/2),PAT Appearance: lethargic Work of breath: Normal Circularion: NormalVital signs RR 20/min, PR 120bpm, BT: 37.5C BW:9

24、 kgw,Eb41,初級(jí)評(píng)估(2/2),A: Open, no stridorB: Non-labored, breath sounds clearC: Normal D: Tone normalE: No sign of injury, no rash,Eb42,重要病史,S: mucous stool(+) A: No allergies, formulafedM: NoneP: Born full-t

25、erm NSVDL: 3 hours agoE: No trauma history was told,Eb43,詳細(xì)理學(xué)檢查,HEENT: no active lesion Chest: clear BSHeart: Tachycardia without murmur ABD:normal Genital: normal Neuro: Pupil size: 4/4 mm and reactive,Eb44,初步診斷

26、,Altered mental status R/O enterocolitis,Eb45,診斷工具(1/2),Normal electrolyte and glucose levelNormal urine analysis Negative urine toxicology screenNormal blood gas analysis CBC-DC showed a leukocytosis without left s

27、hift and a normal Hb and Hct.Brain CT is normal,Eb46,檢查過(guò)程中又嘔吐及解便如下….,Eb47,診斷,Bloody stool R/O Intussusception,Eb48,診斷工具(2/2),Soft tissue mass, target sign, crescent sign on plain radiographTarget sign by sonography

28、An air contrast enemaA barium contrast enema,Eb49,Plain film,Eb50,Plain film,Eb51,鑑別診斷,IntussusceptonMeckel’s diverticulumIncarcerated inguinal herniaNonaccidental traumaGastroenteritisCow’s milk or soy protein al

29、lergy or other benign process.,Eb52,急診處置,Fluid resuscitationStop oral intakeConsult pediatric surgery earlyObtain appropriate radiographic studies,Eb53,結(jié)論,幼兒腹痛嘔吐皆應(yīng)將腸套疊列入鑑別診斷正常 X光檢查結(jié)果並不能排除腸套疊診斷,所以進(jìn)一步檢查如air/ barium ene

30、ma 或ultrasonography是必要的嬰兒腸套疊可以用持續(xù)嗜睡來(lái)表現(xiàn),Eb54,個(gè)案討論五,三個(gè)月大男嬰,過(guò)去12小時(shí)躁動(dòng)不安,哭鬧,不肯進(jìn)食,右側(cè)陰囊腫脹,由父母送到急診室求助.過(guò)去洗澡沒(méi)有過(guò)陰囊腫脹,而此陰囊腫脹部份可以透光.右側(cè)睪丸摸不著,左半側(cè)陰囊則正常,小孩狂哭,媽媽也含淚不斷,急問(wèn)”醫(yī)師,能不能快幫忙?”,Eb55,診斷為何?,是陰囊水腫(hydrocele)?是疝氣(hernia)?,Eb56,臨床表徵:你的線

31、索,若是疝氣第一次伴隨癥狀發(fā)現(xiàn)癥狀:躁動(dòng),哭鬧,疼痛,困難餵食單側(cè)若是陰囊水腫多自出生就有無(wú)癥狀雙側(cè),Eb57,所以高度懷疑. . . . .,Incacerated hernia,Eb58,急診處置(1/2),Further attempt at reduction by an experienced surgeon are warranted.IV and Cardiac and pulse oximetry mon

32、itorsFentanyl 1mcg/kg IVPlaced in Trendlenburg position for manual reduction,Eb59,急診處置(2/2),If manual reduction is successful, elective repair can be performed within the next 12-36hrs when swelling has decreased .The

33、 infant who undergo successful manual reduction of an incarcerated inguinal hernia should not be discharged? admission for observation due to the risk of ischemia of the loop of intestine.,Eb60,兒童鼠蹊部疝氣徵象,Early, nonincarc

34、erated :Appearance: Normal behaviorWork of breathing: NormalCirculation: Normal Late,incarcerated:Appearacne: Fussy, irritable, in pain, vomiting; if dehydrated, lethargicWork of breathing: If dehydrated, effortles

35、s tachypnea(Compensated metabolic acidosis)Circulation: If dehydrated, delayed capillary refill, cool, pallor, poor skin trugor, mottled extrimities.,Eb61,其他臨床表現(xiàn),Poor feedingAbdominal distensionPain(Crying, irritabili

36、ty)Lack of bowel movementSwelling in groin area that becomes firm and tender.,Eb62,鑑別診斷,Inguinal herniaCryptochid testisHydroceleVaricoceleRetractile testisTorsion of testisTraumaLymphadenitisTumor,Eb63,結(jié)論,兒童鼠蹊