PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "surgery"

PEM Questions

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A 3 week old female infant presents with a palpable inguinal mass of 2 hours duration. The dad states he noticed it while changing her diaper. He has seen it before while bathing her, but by the end of the bath it had disappeared. She is otherwise well, feeding and growing well, not vomiting, and is afebrile. She appears comfortable. The mass is nontender, and there is no overlying redness or discoloration. 

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You are seeing a 3 year old ex-premature infant who has a ventriculoperitoneal shunt in place. The patient presents with fever to 38.3, cough, and runny nose. There is no headache, vomiting, or altered mental status. The shunt was placed initially while in the NICU, and revised 4 months ago. 

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 4 week old infant with non-bilious forceful vomiting x 3 days. [yop_poll id="176"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 day old infant born term without complications brought to the ED because the parent noted a streak of bright red blood in the diaper. The baby is formula feeding well, not lethargic, has no fever, and has had a few non-bilious spit-up episodes. Physical exam shows mild abdominal distension; no anal fissure seen. [yop_poll id="175"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 year old boy with abdominal pain. He was seen last night with a few hours of periumbilical abdominal pain. Work-up at that time showed a CBC with WBC 10.2, 55% neutrophils, UA negative, RLQ ultrasound appendix not visualized. He was discharged home with return precautions and instructions to follow-up with his pediatrician. He returns 15 hours later with continued constant right mid-abdomen pain, anorexia, nausea, a few episodes of non-bilious vomiting, and temperature of 37.8. [yop_poll id="123"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="113"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="107"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="95"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 11 year old girl was sitting with lap belt only in the back seat of a minivan involved in a motor vehicle accident where her car was rear-ended. She has a “seat belt sign,” or ecchymosis over her lower abdomen. Her CT abdomen with contrast is normal, but she continues to have tenderness to palpation. However, she states she is hungry. [yop_poll id="48"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 13 year old girl presents with sudden onset sharp RLQ pain radiating toward her groin, along with nausea and vomiting once, non-bloody, non-bilious. [yop_poll id="40"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy comes is brought in to the ED at 2am for severe retrosternal chest pain that awoke him from sleep. He was well prior to going to bed at 11:30pm, and denies fever, cough, radiation of the pain, vomiting, trauma, foreign body ingestion. He has a past medical history of appendectomy 8 months prior, acne for which he takes an oral antibiotic and uses a topical cream daily, and mild intermittent asthma for which he uses an inhaler once or twice a year "when the weather changes." He is a straight A student applying to colleges currently. His physical examination is normal, as is a CXR and ECG. What is the probable cause of his chest pain? [yop_poll id="28"]
A 12yo boy with ALL, recent induction chemotherapy 2 weeks ago, presents to the ED with fever, RLQ abdominal pain, 2 episodes of watery diarrhea with streaks of blood, nausea but no vomiting. Denies ill contacts. On exam, temperature 38.4, HR 110, RR 24, BP 95/60. Alert, no nuchal rigidity, lungs clear to auscultation, heart RRR, abdomen mildly distended, RLQ tenderness, no rebound, decreased bowel sounds. Labs show an absolute neutrophil count of 100. KUB findings are similar to as shown here: pneumatosis The most appropriate next step would be: A. Consult surgeon for appendectomy B. Admit for IV antibiotics directed at treating infectious diarrhea C. Admit for empiric IV antibiotics to cover for fever and neutropenia D. Admit for broad spectrum antibiotics, make NPO, consult with surgeon, consider GCSF, for neutropenic enterocolitis E. Consult gastroenterologist for endoscopy to confirm pseudomembranous colitis

Controversies

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Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other!

You're seeing a child with CT-confirmed uncomplicated appendicitis. The child has had symptoms for 12 hours, and pain is well controlled with medications. You've given IV antibiotics. You're informed by utilization review that the child is not approved to stay at your hospital and must be transferred according to the insurance plan; the transfer will take 4-8 hours to coordinate.

[poll id="64"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! A recent randomized controlled trial by the CODA collaborative found a 10-day course of antibiotics to be non-inferior to appendectomy in adult, with 30-day health status as the primary outcome. By 90 days of follow-up, 29% of the antibiotics group had undergone appendectomy. Complications were more common in the antibiotics group, but not in the subgroup with no appendicolith. If you were seeing a young healthy male with acute appendicitis of short duration, afebrile, normal labs, no appendicolith, mild pain, tolerating oral intake, would you consider treating with antibiotics only? [poll id="53"]

Tips and Tricks

Hairtourniquet Wikimedia James Heilman Hair_Tourniquet_after Photos before & after release from Wikimedia Commons Hair tourniquets (and sometimes thread tourniquets) can occur on toes (most common), fingers, and more rarely the penis, clitoris, or uvula. Peak occurrence is at age 2-6 months, corresponding with maternal postpartum hair loss. Edema may progress to vascular compromise; ischemia and autoamputation have occurred. Tips for removal:
  • Magnifying loupes can be helpful
  • Consider topical anesthesia with EMLA or viscous lidocaine (avoid LET w/epinephrine so as to not confuse discoloration due to the tourniquet vs due to temporary epinephrine effect)
  • If definitely a hair, depilatory cream (eg Nair) can be applied for 3-10 minutes on unbroken skin; repeat once if not successful (the product can irritate skin, however)
  • AliEM describes use of a cutting needle to get under the hair and cut it https://www.aliem.com/2012/06/trick-of-trade-hair-tourniquet-release/
  • If the hair is too deep / not visualized, the cutting needle can still be used to lift the tissue and constricting band, and a scalpel then used to cut the hair and superficial layer of tissue
  • Severe tourniquets may require perpendicular cuts to the bone, best done at 3:00 and 9:00 positions
  • Look for improvement in swelling and color with release. If the hair cut deeply, it may be difficult to see if release is complete. At least one author has studied ultrasound for identification https://www.ncbi.nlm.nih.gov/pubmed/29341258.
  • Consult a urologist for deep penile tourniquets
  • Consider child abuse, particularly with genitalia involvement

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