1. Pediatric Surgery
Mark Perna
1/5/2010

2. Disclaimer Competitive 2 year surgical fellowship in 55minutes
Obviously gross overview

3. Pediatric Trauma Increased Risk for Head Trauma and Burns
HR and RR are best signs of shock (not BP)
Solid Organ Injury can most often nonoperatively
Bone non brittle
Set up for contusions
Nonaccidental Trauma
Duty to report

4. Pediatric Trauma Seat Belt Sign and Abd Pain
Small Bowel Injury
Handle Bar Injury and abd pain
Pancreatic Injury
Handle Bar Injury with profuse vomiting
Duodenal Hematoma

5. General Concepts Differences in Vital Signs
Prone to hypothermia and hypoglycemia
Fluid Bolus - 20 ml/kg (times 2)
Transfusion- 10ml/kg

6. Most appropriate vitals for 3 day newborn
HR SBP RR Sat

7. General Concept Nutritional Requirements Protein Requirements
Neonates kcal/kg
Children kcal/kg
Adolescents 30-60kcal/kg
Adults 25 kcal/kg
Protein Requirements
Neonates 2-3 g/kg
Infants 1-5 –2 g/kg
Children g/kg

8. General Concepts Urine Output Fluids Management Neonates 2 cc/kg/hr
Infants 1.5 cc/kg/hr
Children 1 cc/kg/hr
Adult 0.5 cc/kg/hr
Fluids Management
4 cc/kg/hr (for first 10kg)
2 cc/kg/hr (for second 10 kg)
1 cc/kg/hr (for remaining weight)

9. General Concepts- Radiology
U/S often the most helpful study
Abdomen
Cost
Low Risk
Xray and Contrasted xrays CT
MRI

10. PICU
SIMV ventilatory support
FIO2
Oscillatory Vent
Jet Vent
ECMO

11. Neck – High Yield Cervical Lymphadenopathy Thyroglossal Ducts Cyst
Most likely viral
Tender versus Nontender
Unresolving think of more rare causes
Cat-Scratch, TB, Lymphoma
Thyroglossal Ducts Cyst
Midline
From the foramen cecum
Sistrunk procedure
Brachial Cleft Cyst
Off midline
2nd cleft most common
Excision

12. Thoracic - High Yield Bronchogenic Cysts Congential Lobar Emphysema-
Failure of development bronchus cartilage
Congential cystic adenoid malformation
Alveolar structure not developed, but does communicate with airway
Pulmonary Sequestration
Lung tissue with systemic arterial supply
Intralobar – Venous drainage to pulm circ
Extralobar- Venous drainage to systemic circ
Anterior Mediastenal Mass
Thymoma, Teratoma, Terrible Lymphoma, Thyroid

13. Tracheoesophageal Fistula

14. What syndrome is associated with TE fistula
Vertebral
Anal
Cardiac
TE fistula
Renal
Limb dysplasia

15. Vomiting Nonbilious Projectile Bloody Bilious GERD Allergies
Pyloric Stenosis
Bloody
UG Bleed
Bilious
Broad Differential
Always abnormal, Generally Serious
Quick Elevation

16. Pediatric Bowel Obstructions -
Pyloric Stenosis
3 in 1000, generally male, first born
Projectile Vomiting, Nonbilious
Palpable Olive
US diagnosis
Tx??
Fredet-Ramstedt pyloromyotomy

17. Electrolytes
Na K CL CO2 Urine pH

18. Pediatric Bowel Obstructions
Duodenal Atresia
Failure of Recannulization of bowel
“Double Bubble”
Associated with Down’s and VACTERL Tx
Doudeno-doudneostomy

19. Pediatric Bowel Obstructions
Intestinal Atresia
Intrauterine vascular accident
Polyhydramnios Tx
Tapered jejunoplasty
Short Gut Syndrome

20. Pediatric Bowel Obstructions
Malrotation (Common) Always on Boards!!
Bilious vomiting, Abd distention, acidosis
Obstruction from Ladd’s band across the duodenum or Midgut volvulus
Tx-
Counterclockwise reduction of midgut volvulus
Lysis of Ladd’s Bands
Appendectomy

21. Pediatric Bowel Obstructions
Meconium Ileus
Inspissated meconium
90% will have CF. Get Sweat Test!!
“soap bubble” appearance
Tx- Nonoperative first
Gastrograffin enemas (Meglumine Diatrizoate)
Ileostomy, resection

22. Pediatric Bowel Obstructions
Meconium Plug Syndrome
Stool balls in the rectum
Almost never operative Tx
Time
Enema

23. Pediatric Bowel Obstructions
Hirshbrung’s
Absence in parasympathetic ganglion cell in distal colon
Dx with Suction Rectal Biopsy
Toxic enterocolitis Tx
Sauve
Swenson
Duhamel

24. Pediatric Bowel Obstructions
Intussusception
Telescoping of bowel
Currant jelly stools
Lead point usually not identified in kids
Dx US or Barium enema Tx
Barium enema
Air enema
Exploratory Lap and Reduction

25. Pediatric Bowel Obstructions
Imperforate Anus
High versus Low
US can diagnose
Associated abnormalities

26. Abdominal Wall Defects
Umbilical hernia
Common
AF children
Most close on there own
Don’t mistake for diastasis rectus
Omphalocele
Covered in a sac of chorium, Wharton’s jelly, peritoneum
Associated abnormalities
Gastroschisis
Bare bowel and abdominal contents
No congenital defects work up necessary
Cover and keep warm
Hypothermia, Bowel Bag, Reduce in OR

27. What GI abnormality seen with gastroschisis
Small Bowel Atresias
11% of the time

28. What is Cantrell syndrome?
Omphalocele
Diagphramatic hernia
Pericardial Defect
Cardiac Defects
Sternal Defects

29. NEC Most common pediatric surgery emergency
Low flow state = Bowel ischemia
Distention, bloody stools, perforation, sespis
Follow Serial Abx Xray Na
Platelets
CO2
Temps
Tx- Laparotomy versus abdominal drain

30. Inguinal Hernia versus Hydrocele
Common
More common in prematurity with high risk of incarceration
Anatomic Location
Medial versus Lateral
Congential versus Aquired Tx
High Ligation of Sac
Laproscopic Repair

31. What test does a child need with bilateral direct hernia repair?
Sweat Chloride Test

32. Jaundice Cholestatic Jaundice Biliary Atresia Choledochal Cyst
Portoenterostomy
Choledochal Cyst
Type I- Fusiform Enlargement
Type 2- Diverticular-like
Type 3- Distal Common Duct
Type 4- Extra and Intrahepatic Dilation
Type 5- Intrahepatic (Caroli Disease)

33. Solid Abdominal Tumors
Wilms tumor
Most common intraabd tumor
Staging
Group I - Limited to kidney, completely excised
Group II- Extends past kidney, completely excised
Group III- Extends past kidney, not excised
Group IV- Hematogenous metastasis
Group V- Bilateral tumors

34. Solid Abdominal Tumors
Neuroblastoma
Neuro crest cells
Most common solid organ tumor
Staging
Stage I- Tumor limited to organ of origin
Stage II- Regional spread, not across midline
Stage III- Tumor extending across midline
Stage IV- Distant Metastasis