儿童非创伤性手术急症课件

小組教學(一) 兒童非創傷性手術急症 Eb1 個案討論一 n一個四天大女嬰,家長主訴持續腹 脹及血便,兩次配方餵食皆不吃,持 續睡覺.出生史方面則因母親有妊 娠毒血症而提早於34週大時剖腹生 產,出生體重3200公克,並順利於三 天後出院.在家每三小時餵食配方 奶60-100CC. 2 初級評估(1/2) PAT nAppearance: Lethargic, poorly responsive nWork of breathing: Effortless tachypnea (Compensated for metabolic acidosis) nCirculation: Delayed capillary refill, cool, pallor, mottled extrimities, rapid pulse, poor skin turgor, abdominal wall erythema 3 初級評估(2/2) Vital sign HR 180bpm, RR 45/min, BP: 60/40 mmHg, BT 37.8C, BW 3010gm A: Open B: Tachypnea, grunting, breath sounds clear C: Color pale, skin warm and dry, tachycardia, brachial pulse decreased D: Tone decreased E: No sign of injury, no rash 4 重要病史 nS: Bloody stool and abdominal distention nA: No allergies, formulafed nM: None nP: Born premature,C/S due to maternal preeclampia nL: Just prior to arrival but vomited nE: No feeding since 6 hours ago 5 詳細理學檢查 nHead, neck, lung, and heart examination are normal except for tachycardia nABD: distended, bowel sound: hypoactive nSkin:mildly shiny and erythematouos nFemoral pulse(+) nCapillary refill : delayed 6 診斷工具-Plain film 7 檢驗工具 nWBC 12000/mm3, Hb 12.0, PLT 78000mm3, S/L/M=90/3/4 nABG: PH=7.25 PCO2 34 PO2 65 HCO3 14 , BE=-8 nGlucose 70, Na 135 k 4.3 nStool examination: OB(+) 8 最後診斷 nHollow organ perforation with septic shock R/O Necrotizing Enterocoltis 9 NEC典型發現 nMetabolic acidosis nNeutropenia nThrombocytopenia nPneumatosis intestinalis nIntrahepatic portal venous gas nPneumoperitoneum 10 急診處置 nABCs( Endo size 3.5-4.0,IV N/S 60cc) nOG for decompression nBlood culture nAntibiotics(AMP+GM+Metronadazole) nNPO nEarly PEDS consultation nAdmission 11 個案討論二 n兩足歲男生由救護車送抵急診室,媽媽主 訴發現小孩尿布上有很多紅色血便,不久 前也曾有解血絲便經驗,因為無疼痛症狀 而且自行緩解.持續兒科門診追蹤.大便 形態上並無黏液,病人無發燒,餵食情況 良好,無嘔吐症狀. 12 初級評估(1/2) PAT: Appearance: alert and fearly Work of breath: non-labored Circulation:pale conjunctivae and mucous membrane nVital signs: nHR 140, RR 24, BP 100/60, T 37C Wt 15 kg 13 初級評估(2/2) A: Open, no stridor B: Non-labored, breath sounds clear C: Pale conjunctivae and mucous membrane, skin warm and dry, tachycardia, brachial pulse strong D: Tone normal E: No sign of injury, no rash 14 重要病史 nS: large mount of bloody stool nA: No allergies, formulafed nM: None nP: Born full-term NSVD, history of break bloody stool nL: Just prior to arrival nE: Normal feeding 15 詳細理學檢查 Normal except : nHead and Neck: pale conjunctivae and mucous membrane nHeart: tachycardia with soft 2/6 systolic ejection murmur at the LLSB nAnus: Stool is grossly bloody. No evidence of fissure, trauma, or tags 16 急診處置 nABCs : O2 with mask nFluid resuscitation:IV with N/S 300CC nOG or NG tube for saline lavage nCBC-DC, PT/aPTT, type and crossmatch nCorrect anemia: pRBC 150cc if indicated 17 初步診斷 nPainless rectal bleeding , cause? 18 無痛性血便之鑑別診斷 nMeckel diverticulum nIntestinal polyp nIntestinal duplications nIntestinal hemangioma nArteriovenous malformation nCoagulopathy nPUD nInflammatory bowel disease 19 診斷工具 nA Tc-99m pertechnetate scan nExploratory laparotomy nLaparoscopy nEsphagogastroduodenoscopy nColonoscopy 20 Tc-99m pertechnetate scan nThe diagnosis of Meckels diverti- culum can be obtained by a technetium-99m scintiscan. nThe radioactivity can be seen in the stomach and bladder, and the diverticulum is seen in the mid- abdomen. 21 Technetium-99m scan shows ectopic gastric mucosa 1. Small intestine 2. Meckels diverticulum 22 結論 n優先定位出血位置:上消化道或 下消化道 n有出血性腸阻塞或腹膜炎症狀者 皆應緊急會診外科 n手術前應先解決低血容及貧血問 題 23 個案討論三 n13 歲男生凌晨四點鐘右側陰囊突然疼痛 ,由父母帶到急診室,有嘔心感覺.過去身 體健康且喜歡足球運動.前一天在學校活 動一切正常,但過去右側陰囊曾有多次短 暫疼痛,不過皆立即緩解,這次疼痛難耐, 右側陰囊水腫而且有厲害壓痛,右側睪丸 位置較平日高,右側Cremaster reflexs 消失,移動身體陰囊就疼痛. 24 25 初級評估(1/2) PAT: Appearance: alert and embarrassed Work of breath: Normal Circulation:Normal Vital signs: nHR 98, RR 14/min, BP 100/60, T 37C 26 初級評估(2/2) nABCDE: normal except right side scrotal swelling , upper riding testis and severe tenderness 27 重要病史及詳細理學檢查 n-Sudden onset of left scrotal pain -He has had several brief, less intense but similar episodes in the past. n-A tender, swollen right hemiscrotum and the testis appears to ride higher in the scrotum 28 Impression nright testicular torsion 29 診斷工具 nTechnetium-99m radionuclide scan shows “cold spot” on affected side. nColor Doppler ultrasonography shows decreased or absent flow to affected side. 30 都卜勒超音波檢查 R Testis L testis 31 32 33 34 鑑別診斷 nTorsion of the appendix testis or appendix epididymis nEpididymitis nOrchitis nIncarcerated inguinal hernia nScrotal trauma nHydrocele nVaricocele nHenoch-Schonlein purpura nScrotal cellulitis nKawasaki disease nTesticular tumor 35 torsion of appendix or epididymitis Blue dot sign 36 急診處置 nAnagesia with an IV narcotics nManual detorsion (open book) nObtain immediate surgical consultation 37 結論 n睪丸扭轉是真正手術急症 n治療方法為去扭轉手術或睪丸固 定術 n檢查用於臨床經驗無法判斷個案 ,但不可因此延遲外科會診 38 個案討論四 n9個月大男嬰,一直睡覺,早上吐 兩次,嘔吐物並無黃綠色或血絲, 不過大便有黏液. 39 初級評估(1/2) PAT Appearance: lethargic Work of breath: Normal Circularion: Normal Vital signs RR 20/min, PR 120bpm, BT: 37.5C BW:9 kgw 40 初級評估(2/2) A: Open, no stridor B: Non-labored, breath sounds clear C: Normal D: Tone normal E: No sign of injury, no rash 41 重要病史 nS: mucous stool(+) nA: No allergies, formulafed nM: None nP: Born full-term NSVD nL: 3 hours ago nE: No trauma history was told 42 詳細理學檢查 nHEENT: no active lesion nChest: clear BS nHeart: Tachycardia without murmur nABD:normal nGenital: normal nNeuro: Pupil size: 4/4 mm and reactive 43 初步診斷 nAltered mental status nR/O enterocolitis 44 診斷工具(1/2) nNormal electrolyte and glucose level nNormal urine analysis nNegative urine toxicology screen nNormal blood gas analysis nCBC-DC showed a leukocytosis without left shift and a normal Hb and Hct. nBrain CT is normal 45 檢查過程中又嘔吐及解便如下 . 46 診斷 nBloody stool R/O Intussusception 47 診斷工具(2/2) nSoft tissue mass, target sign, crescent sign on plain radiograph nTarget sign by sonography nAn air contrast enema nA barium contrast enema 48 Plain film Case ACase B 49 Plain film Case A Case B 50 鑑別診斷 nIntussuscepton nMeckels diverticulum nIncarcerated inguinal hernia nNonaccidental trauma nGastroenteritis nCows milk or soy protein allergy or other benign process. 51 急診處置 nFluid resuscitation nStop oral intake nConsult pediatric surgery early nObtain appropriate radiographic studies 52 結論 n幼兒腹痛嘔吐皆應將腸套疊列入鑑 別診斷 n正常 X光檢查結果並不能排除腸套 疊診斷,所以進一步檢查如air/ barium enema 或ultrasonography 是必要的 n嬰兒腸套疊可以用持續嗜睡來表現 53 個案討論五 n三個月大男嬰,過去12小時躁動不安,哭 鬧,不肯進食,右側陰囊腫脹,由父母送到 急診室求助.過去洗澡沒有過陰囊腫脹, 而此陰囊腫脹部份可以透光.右側睪丸摸 不著,左半側陰囊則正常,小孩狂哭,媽媽 也含淚不斷,急問”醫師,能不能快幫忙 ?” 54 診斷為何? n是陰囊水腫(hydrocele)? n是疝氣(hernia)? 55 臨床表徵:你的線索 若是疝氣 n第一次伴隨症狀發現 n症狀:躁動,哭鬧,疼痛,困難餵食 n單側 若是陰囊水腫 n多自出生就有 n無症狀 n雙側 56 所以高度懷疑. . . . . Incacerated hernia 57 急診處置(1/2) nFurther attempt at reduction by an experienced surgeon are warranted. nIV and Cardiac and pulse oximetry monitors nFentanyl 1mcg/kg IV nPlaced in Trendlenburg position for manual reduction 58 急診處置(2/2) nIf manual reduction is successful, elective repair can be performed within the next 12 -36hrs when swelling has decreased . nThe 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 int