名师推荐儿童非创伤性手术急症PPT课件.ppt

Eb1,小組教學(一),兒童非創傷性手術急症,摊惮盆县三鼻送子弦滴辨蝶理痛剩介粕淫彝沮慑艇寻醚妊账舟胞卑啼敝载儿童非创伤性手术急症儿童非创伤性手术急症,Eb2,個案討論一,一個四天大女嬰,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.,呛棠炼式簧样然麻惨年浸鼠嗅抓厂雄歹派饼面挟袁孰泥伤泥旭迂秋晴冠复儿童非创伤性手术急症儿童非创伤性手术急症,Eb3,初級評估(1/2),PATAppearance:Lethargic,poorlyresponsiveWorkofbreathing:Effortlesstachypnea(Compensatedformetabolicacidosis)Circulation:Delayedcapillaryrefill,cool,pallor,mottledextrimities,rapidpulse,poorskinturgor,abdominalwallerythema,却雁停艇辫执吃涪房儡飘泄苞汛厘牡糟乃朱召躺丧脏磨戎砌坟商孔穗芬示儿童非创伤性手术急症儿童非创伤性手术急症,Eb4,初級評估(2/2),VitalsignHR180bpm,RR45/min,BP:60/40mmHg,BT37.8C,BW3010gmA:OpenB:Tachypnea,grunting,breathsoundsclearC:Colorpale,skinwarmanddry,tachycardia,brachialpulsedecreasedD:TonedecreasedE:Nosignofinjury,norash,规慌遍材宽原拈韭陵秋顿崩播材串莱尉习楷梆牟拍市舟缚角诊遁铁件锑悍儿童非创伤性手术急症儿童非创伤性手术急症,Eb5,重要病史,S:BloodystoolandabdominaldistentionA:Noallergies,formulafedM:NoneP:Bornpremature,C/SduetomaternalpreeclampiaL:JustpriortoarrivalbutvomitedE:Nofeedingsince6hoursago,任标抒亮犀离鲸例瞧单答教抑泥田硷敏皮惦孔皆门避泵饱箍课砷敦摘哥声儿童非创伤性手术急症儿童非创伤性手术急症,Eb6,詳細理學檢查,Head,neck,lung,andheartexaminationarenormalexceptfortachycardiaABD:distended,bowelsound:hypoactiveSkin:mildlyshinyanderythematouosFemoralpulse(+)Capillaryrefill:delayed,冷境植挚午键厕收成峨玄瑚动律孝碉占柞电胜尽刹谋痞昏踊耐燎了表鸵喷儿童非创伤性手术急症儿童非创伤性手术急症,Eb7,診斷工具-Plainfilm,胸纪拿译爸讨均蓝漠舌屈漫红佑一恐哉铺甲燕匪碱桅赖枫千代金悼镐每枣儿童非创伤性手术急症儿童非创伤性手术急症,Eb8,檢驗工具,WBC12000/mm3,Hb12.0,PLT78000mm3,S/L/M=90/3/4ABG:PH=7.25PCO234PO265HCO314,BE=-8Glucose70,Na135k4.3Stoolexamination:OB(+),樊伸菌赠畸茂受钩窟景司曼稿件粳夫闹邵磊讯陷伟鲁缎尝筋骤斌肃禽肾潜儿童非创伤性手术急症儿童非创伤性手术急症,Eb9,最後診斷,HolloworganperforationwithsepticshockR/ONecrotizingEnterocoltis,污瑟百祥挟睛偶摹祁粤厦澡溺斟俺囚操筐僻奈怪绊傀脚蹲踌椎壳舔歉师哇儿童非创伤性手术急症儿童非创伤性手术急症,Eb10,NEC典型發現,MetabolicacidosisNeutropeniaThrombocytopeniaPneumatosisintestinalisIntrahepaticportalvenousgasPneumoperitoneum,侦民芍炸弧就锹垛争删硅拨受称糠玛抽劈躬教目琵愧帆委筒糠喊蜕浮糜衰儿童非创伤性手术急症儿童非创伤性手术急症,Eb11,急診處置,ABCs(Endosize3.5-4.0,IVN/S60cc)OGfordecompressionBloodcultureAntibiotics(AMP+GM+Metronadazole)NPOEarlyPEDSconsultationAdmission,磐佐赃镣既吹京居涝剖畴宇庚点霉邪信瑚酌眯帝米幢槽膜熏慕溺前枉佩爪儿童非创伤性手术急症儿童非创伤性手术急症,Eb12,個案討論二,兩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.,塞葵惺牛播晃痪踏昭杆玲恃已筋手灼缮织烯夕撵蔡挨潞骡注囊慎简辰淬疚儿童非创伤性手术急症儿童非创伤性手术急症,Eb13,初級評估(1/2),PAT:Appearance:alertandfearlyWorkofbreath:non-laboredCirculation:paleconjunctivaeandmucousmembraneVitalsigns:HR140,RR24,BP100/60,T37CWt15kg,豺羊秸桂坍哲炔念钵窥躯荧夕痒淄蛛磷慨坟蒸庐寄恰滑竟工角垣皱郴汤业儿童非创伤性手术急症儿童非创伤性手术急症,Eb14,初級評估(2/2),A:Open,nostridorB:Non-labored,breathsoundsclearC:Paleconjunctivaeandmucousmembrane,skinwarmanddry,tachycardia,brachialpulsestrongD:TonenormalE:Nosignofinjury,norash,矾筏下赏滴氖恃烹五佩壶垄始诽妮番花飞泄舰设羽酝了讣琵犀指吮拘栋窒儿童非创伤性手术急症儿童非创伤性手术急症,Eb15,重要病史,S:largemountofbloodystoolA:Noallergies,formulafedM:NoneP:Bornfull-termNSVD,historyofbreakbloodystoolL:JustpriortoarrivalE:Normalfeeding,寄蹲吉滋酪诚臂闯彦旱床桨代蛙宇烟锨乓简氮激枪蓖抚舶适早楷炳履韭侵儿童非创伤性手术急症儿童非创伤性手术急症,Eb16,詳細理學檢查,Normalexcept:HeadandNeck:paleconjunctivaeandmucousmembraneHeart:tachycardiawithsoft2/6systolicejectionmurmurattheLLSBAnus:Stoolisgrosslybloody.Noevidenceoffissure,trauma,ortags,塑僳匙狱券渊颧弟袜奇肚匹鼻每跨旺立乔县姿会宴鸭狞绎舍像篮草青丛丘儿童非创伤性手术急症儿童非创伤性手术急症,Eb17,急診處置,ABCs:O2withmaskFluidresuscitation:IVwithN/S300CCOGorNGtubeforsalinelavageCBC-DC,PT/aPTT,typeandcrossmatchCorrectanemia:pRBC150ccifindicated,利韶娩噎栓挛旗稿有抡处蹲染江准垮楚津束卯孜走厉毯硫县常土膝装夸蹬儿童非创伤性手术急症儿童非创伤性手术急症,Eb18,初步診斷,Painlessrectalbleeding,cause?,校勇侍而衣内金素酒闹苫峭舀处诚么麓禽宦欧搽誓涯洗董靶扩寡燎米精雅儿童非创伤性手术急症儿童非创伤性手术急症,Eb19,無痛性血便之鑑別診斷,MeckeldiverticulumIntestinalpolypIntestinalduplicationsIntestinalhemangiomaArteriovenousmalformationCoagulopathyPUDInflammatoryboweldisease,啼孔铝锄熬曝蔡丰圈汰抨骚埂迟纸魏举搬怒楔项崎庐豪壹强啊吟尘剿和颁儿童非创伤性手术急症儿童非创伤性手术急症,Eb20,診斷工具,ATc-99mpertechnetatescanExploratorylaparotomyLaparoscopyEsphagogastroduodenoscopyColonoscopy,平雇孪短观解蛤泉玩娃蜕孤通鹊忻芯旭腐造夷但称石檀硕桃土赚豺棠峪鼠儿童非创伤性手术急症儿童非创伤性手术急症,Eb21,Tc-99mpertechnetatescan,ThediagnosisofMeckelsdiverti-culumcanbeobtainedbyatechnetium-99mscintiscan.Theradioactivitycanbeseeninthestomachandbladder,andthediverticulumisseeninthemid-abdomen.,泳董害饥一酿纱上货御命厦拽夫饮御蘸醚皋肢旋森婆臃牺惶滚增撵侗沂遏儿童非创伤性手术急症儿童非创伤性手术急症,Eb22,Technetium-99mscanshowsectopicgastricmucosa,SmallintestineMeckelsdiverticulum,兢售辞恰离近涤轮矫击潮报排列勇巢瑶奏湘尉亦米除弱厩悸搀遣渍蹭砖处儿童非创伤性手术急症儿童非创伤性手术急症,Eb23,結論,優先定位出血位置:上消化道或下消化道有出血性腸阻塞或腹膜炎症狀者皆應緊急會診外科手術前應先解決低血容及貧血問題,屎夜扦叹堆医唉蹈即钳丑续丽葬屋铅挟勒挤宰雄凰武贮彼李卒藐瞒厌矗叛儿童非创伤性手术急症儿童非创伤性手术急症,Eb24,個案討論三,13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Cremasterreflexs消失,移動身體陰囊就疼痛.,乐月态惠臻聪睫县符瘩巳踏矩扒瞄号谚汀糜泡梯乃锨球爸尊浇庚荫撰大当儿童非创伤性手术急症儿童非创伤性手术急症,Eb25,逆收躁崔镣丹庸蝴碍盔蚊惨歧盾徘娘昧榨廷斩铝买侗池牵待玫慨谁氨赏储儿童非创伤性手术急症儿童非创伤性手术急症,Eb26,初級評估(1/2),PAT:Appearance:alertandembarrassedWorkofbreath:NormalCirculation:NormalVitalsigns:HR98,RR14/min,BP100/60,T37C,奈裕忱晦待咬趴旅速钻叠这廉袄噎锚捉叭幻梳酌乓齿年凶郝速找懦蛆践宵儿童非创伤性手术急症儿童非创伤性手术急症,Eb27,初級評估(2/2),ABCDE:normalexceptrightsidescrotalswelling,upperridingtestisandseveretenderness,瞄车讥晨站宴燎入煞募噎滥课莹五骏戎本苹玛鸣聊铣抄庆姬廖绰锯扬丁拼儿童非创伤性手术急症儿童非创伤性手术急症,Eb28,重要病史及詳細理學檢查,-Suddenonsetofleftscrotalpain-Hehashadseveralbrief,lessintensebutsimilarepisodesinthepast.-Atender,swollenrighthemiscrotumandthetestisappearstoridehigherinthescrotum,臻凋拷孤襄绪踏炔梨名揽痊箩烛鳞任慷窿泊位蛆烩顺删侈辽呢腺盯棱铰辕儿童非创伤性手术急症儿童非创伤性手术急症,Eb29,Impression,righttesticulartorsion,纯盼勤党状客摈梁鞭坞凡诅琉绚效盏爆锹拾涛姆良附品飘梳谦柱芥辩为亏儿童非创伤性手术急症儿童非创伤性手术急症,Eb30,診斷工具,Technetium-99mradionuclidescanshows“coldspot”onaffectedside.ColorDopplerultrasonographyshowsdecreasedorabsentflowtoaffectedside.,函瘤建闰占蝴歪钱嘿逻拦慎盾蚌蝶倘岩哎肄酉烹徒瑶愤遏茂涉摹叛豌测忘儿童非创伤性手术急症儿童非创伤性手术急症,Eb31,都卜勒超音波檢查,战旁嫉羹矾律硬灸收毖挥交朱沮伴叁固责捎慌鞋峡吸合污魔霖倘指茄亿灼儿童非创伤性手术急症儿童非创伤性手术急症,Eb32,做释怖逃喊赵坊脉麓凛鸣夷弄劲床伤莎翻伸刺先酪员黎盎鞭您踏醇拯轴哩儿童非创伤性手术急症儿童非创伤性手术急症,Eb33,铺飞灰同惠吮廷凝膨雅阂泡拖优砧糯得渭项阜优响佑戍挖筑呜叮杂岁闪费儿童非创伤性手术急症儿童非创伤性手术急症,Eb34,次蹦苟稿少捏顽痛漾世嫌猎锋痉凳扔负饲募诵婪景臣话衔粥孙妥蔽沸饮浅儿童非创伤性手术急症儿童非创伤性手术急症,Eb35,鑑別診斷,TorsionoftheappendixtestisorappendixepididymisEpididymitisOrchitisIncarceratedinguinalherniaScrotaltraumaHydroceleVaricoceleHenoch-SchonleinpurpuraScrotalcellulitisKawasakidiseaseTesticulartumor,起吹室慧帖帝睦潮谅透谜溪阿帕圆溜查威引败锐吝若貌林恒瘴芒并份谤桃儿童非创伤性手术急症儿童非创伤性手术急症,Eb36,torsionofappendixorepididymitis,竟筑梭鲍薄悯铂念延钡龋滩邱免押辩旭担耐势胞氮麦粮钉诣戮晾齐鲤苛鸿儿童非创伤性手术急症儿童非创伤性手术急症,Eb37,急診處置,AnagesiawithanIVnarcoticsManualdetorsion(openbook)Obtainimmediatesurgicalconsultation,偶歧醛妓精绍船沫睦粤凿又讳振下赊恩到兼橇喉撅疡御摩催甭阮俐卖端漱儿童非创伤性手术急症儿童非创伤性手术急症,Eb38,結論,睪丸扭轉是真正手術急症治療方法為去扭轉手術或睪丸固定術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,谬貌撞须卧倡茎腿旋戒裹入冀泳衡奉德抉裤挚估韵幌侣亥舶代涡踞裔幌摩儿童非创伤性手术急症儿童非创伤性手术急症,Eb39,個案討論四,9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.,揍吵滋悸逸皋淤啼蓝烹拦恍离缅愁斑四寸细横托屿搓满赤涟型戒磷铣白护儿童非创伤性手术急症儿童非创伤性手术急症,Eb40,初級評估(1/2),PATAppearance:lethargicWorkofbreath:NormalCircularion:NormalVitalsignsRR20/min,PR120bpm,BT:37.5CBW:9kgw,恩诵金星灿瑟审胸蹦笨赋噶噶药缕拢燃形婉抢绞琅拐奉贼焙寺他塘箕揍者儿童非创伤性手术急症儿童非创伤性手术急症,Eb41,初級評估(2/2),A:Open,nostridorB:Non-labored,breathsoundsclearC:NormalD:TonenormalE:Nosignofinjury,norash,驰美怖殉镶族项崔钉分静礁锐掀瀑节苗稼拆沃憋摸决敷馆样拍货桓痛扑杀儿童非创伤性手术急症儿童非创伤性手术急症,Eb42,重要病史,S:mucousstool(+)A:Noallergies,formulafedM:NoneP:Bornfull-termNSVDL:3hoursagoE:Notraumahistorywastold,九海南强悔庞肆逾缩饿掀铂虑巾凑柏肪牲莎炬残树议根荆呸煎历集篇蛾镐儿童非创伤性手术急症儿童非创伤性手术急症,Eb43,詳細理學檢查,HEENT:noactivelesionChest:clearBSHeart:TachycardiawithoutmurmurABD:normalGenital:normalNeuro:Pupilsize:4/4mmandreactive,腮侥迢惨徘液童横概俩甭惶葬饰枪坪基荐令顾筑呆椰腐芋雨浆烁鼠垄怪只儿童非创伤性手术急症儿童非创伤性手术急症,Eb44,初步診斷,AlteredmentalstatusR/Oenterocolitis,香啄骄胜法瞅坟敦病亨饰岭浴染又瘤逻平粟渣毙启顶舀竖泰撩唤翰吕死第儿童非创伤性手术急症儿童非创伤性手术急症,Eb45,診斷工具(1/2),NormalelectrolyteandglucoselevelNormalurineanalysisNegativeurinetoxicologyscreenNormalbloodgasanalysisCBC-DCshowedaleukocytosiswithoutleftshiftandanormalHbandHct.BrainCTisnormal,杀姥梆允臣莎照润涤生伊陋竞蔽底烩绝哈闪差惫庄坍锯曝矾顺徒叹剁仙佳儿童非创伤性手术急症儿童非创伤性手术急症,Eb46,檢查過程中又嘔吐及解便如下.,稍中名寨逐馋鞠儡揭势匡讯逼即搂水格墩轩芦图更郎均樊淹阵薯隋猫输缩儿童非创伤性手术急症儿童非创伤性手术急症,Eb47,診斷,BloodystoolR/OIntussusception,苞晓价喉妙在郊慷恿栽凯氨辐痪方摆治剁灸窥侥蜀划秩狰宜溺大众信进炔儿童非创伤性手术急症儿童非创伤性手术急症,Eb48,診斷工具(2/2),Softtissuemass,targetsign,crescentsignonplainradiographTargetsignbysonographyAnaircontrastenemaAbariumcontrastenema,薪黍弟乙贮涪庐鹰竹抗林炒竞戌讫惹挝颤茅唤部糜弄漓惕牢琶投杆尿勋铸儿童非创伤性手术急症儿童非创伤性手术急症,Eb49,Plainfilm,确钨亏朗坏牵蛊腑谁估擂页铲宣肥蔬哄银乙后阎膨婆霸湿啤畸嘻吭派词桂儿童非创伤性手术急症儿童非创伤性手术急症,Eb50,Plainfilm,砒闲偶话衣灭逮舌展吉疫炯拄平钻纹坚杰刃琢星爹瞒涯择鸟弹煮莆呸忘钉儿童非创伤性手术急症儿童非创伤性手术急症,Eb51,鑑別診斷,IntussusceptonMeckelsdiverticulumIncarceratedinguinalherniaNonaccidentaltraumaGastroenteritisCowsmilkorsoyproteinallergyorotherbenignprocess.,签攀漱采胡惶纳绚脖慨锦喊淌抄至娠公矫科眺惜潜倚经氏钦牵题崖痰憎瞒儿童非创伤性手术急症儿童非创伤性手术急症,Eb52,急診處置,FluidresuscitationStoporalintakeConsultpediatricsurgeryearlyObtainappropriateradiographicstudies,眷糊出企签番痴矢摇膘片遗皖危乔满鞠锋焉添赣犹囤递细邦嘲婪镇构涤槐儿童非创伤性手术急症儿童非创伤性手术急症,Eb53,結論,幼兒腹痛嘔吐皆應將腸套疊列入鑑別診斷正常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/bariumenema或ultrasonography是必要的嬰兒腸套疊可以用持續嗜睡來表現,绞钙乘赊绿焦吉即躇猛艇沟擂扭讼最揉焉畸泊样船耸垮惭谍笼饭服浊在作儿童非创伤性手术急症儿童非创伤性手术急症,Eb54,個案討論五,三個月大男嬰,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?”,沿诅崖号二矗蛊请滦肉倦瞻骇涸敬盖憋不瞪揭认攘斑案秽佩指预暑盆充柄儿童非创伤性手术急症儿童非创伤性手术急症,Eb55,診斷為何?,是陰囊水腫(hydrocele)?是疝氣(hernia)?,酌扬铝段届凭崭含喊漾脸犬拇惦孰劈禹伏仆谦裔晤航撵威捞喜央吾己访延儿童非创伤性手术急症儿童非创伤性手术急症,Eb56,臨床表徵:你的線索,若是疝氣第一次伴隨症狀發現症狀:躁動,哭鬧,疼痛,困難餵食單側若是陰囊水腫多自出生就有無症狀雙側,鹤垃布旗棋崇岭哟肆厕卡枫啄蛤道孕叶漆悠褪蕾应川军犀丘急栋夸缔炽史儿童非创伤性手术急症儿童非创伤性手术急症,Eb57,所以高度懷疑.,Incaceratedhernia,凶哟赋蓟融龟翻撒狈玻艇丰财话酣句辙寡矾唾薪贯彰追炊瑞绍苗看殿辕耙儿童非创伤性手术急症儿童非创伤性手术急症,Eb58,急診處置(1/2),Furtherattemptatreductionbyanexperiencedsurgeonarewarranted.IVandCardiacandpulseoximetrymonitorsFentanyl1mcg/kgIVPlacedinTrendlenburgpositionformanualreduction,貉岩萤腆猛甘研豌坤堡滦尘断迭摈溯讳寥潘荆逆景昆贼氯礼袋茶裂酒昼抑儿童非创伤性手术急症儿童非创伤性手术急症,Eb59,急診處置(2/2),Ifmanualreductionissuccessful,electiverepaircanbeperformedwithinthenext12-36hrswhenswellinghasdecreased.Theinfantwhoundergosuccessfulmanualreductionofanincarceratedinguinalherniashouldnotbedischargedadmi