Surgical teaching Ms Sarah Condron - PowerPoint Presentation

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Surgical teaching

Ms Sarah Condron

Paediatric surgeon

Northern Hospital

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Things to be covered

Abdominal pain short stay pathway

Assessing:

scrotal pain

Abdominal pain

5-14 years

Girls

Under 5

parents

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Calling consultants

For admissions

For discharges

To take someone to theatre

To

organise

imaging other than plain

xray

When you don’t know what to do

If there is concern about a child incl. MET call

After the ward round to provide up dates

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Abdominal pain short stay pathway

Improve patient hospital experience

Improve emergency flow

To be seen by AGSU registrar within 2 hours of admission

Abdominal pain is surgical admission unless VERY good reason not to be

Patients shouldn’t be discharged without discussion consultant

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Patients from the Austin

Northern has a policy to accept patients from the

austin

Appropriate patients - >2 years , common paediatric surgical problems,

eg

abdominal pain, scrotal pain

etc

Excluded

patietns

are those that are <2

yrs

, unwell, significant co-morbidity, significant past medical or surgical history

Patient is admitted to the

childrens

ward and needs medical review within 2 hours of leaving

austin

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Review of paediatric surgical patients

3 consultants, 1

paed

surg

rmo

Review of patients may be needed by covering RMOs, weekend RMOs

etc

Registrar support for emergencies/ new admission is through AGSU, for inpatients is through surgical 2 registrar

Weekend coverage by - ?vascular registrar

Oncall

paed

surgeon available 24 hours, 7 days

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Assessment and treatment children

Scrotal pain

DDX:

Testicular torsion

Torsion testicular appendage

Testicular trauma

Idiopathic scrotal

oedema

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Testicular torsion

Testicular torsion is time critical, if it is being considered the only course of action is to arrange surgical exploration

Testicular torsion is more likely in post pubertal boys and in the first three months of life, but can occur at any age

Testicular torsion may present with abdominal pain and or vomiting

if the scrotum isn’t examined then it WILL BE MISSED AND THE TESTIS WILL DIE

They may have - sudden onset severe unilateral scrotal pain associated with nausea, on examination a very tender

hemiscrotum

, high riding testis with transverse lie, tender scrotal cord, erythema on affected scrotum, hydrocele

Appropriate course of action: call the surgeon, arrange theatre

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Torsion testicular appendage

more common in

peripubertal

boys due to swelling of remnants in response to circulating hormones

may present with sudden or gradual onset scrotal pain, on examination there may be a tender

hemiscrotum

, erythema on affected side of scrotum, hydrocele

the child may be able to pinpoint the upper pole of the testis as the site of maximal tenderness

there may be a visible black dot

this is a self limiting, non-dangerous presentation, however the danger is missing a testicular torsion. Clinically the child will have pain for between 24 hours and a week. They may get increasing pain, redness and swelling. These children should be explored if there is any doubt over the diagnosis - a scrotal exploration is not a major undertaking, and if you decide not to explore them and they lose the testis it is your fault. Discuss with the surgeon of the day!!

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Testicular trauma

occasionally boys suffer testicular injury from cricket balls

etc

(more likely in post pubertal boys)

these boys need an ultrasound to assess testis capsule. If the testis is intact then they are managed with rest, simple analgesia and follow-up ultrasound

If the testis capsule is ruptured then they need scrotal exploration to repair it

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Idiopathic scrotal oedema

affects

prepubertal

boys

unknown cause

history of redness, swelling, itching in the scrotum

on examination the scrotum is

oedematous

, there is pinkish

discolouration

of the skin, the erythema is not limited to the

hemiscrotum

, may cross the midline and will frequently posteriorly on the perineum, or anteriorly up the inguinal region

the testis are often hard to find/ feel because of the swollen scrotal skin, but if identified are not tender

this condition is self-limiting, treat with simple analgesia, some treat with anti-histamines and

antibiotics

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Ultrasounds for scrotal pain

Testicular torsion if worried about a rupture,

If

they’vr

previously had an exploration and are representing with pain

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Why not US for torsion?

Time critical

Testes are too small to get accurate picture of blood flow

Study of 25 lost testes

–

16 had ‘blood flow’ on ultrasound

Non-therapeutic

Misdiagnoses

torted

appendage as epididymitis

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Abdominal pain

Ddx

:

Appendicitis

Opvarian

pathology

Non-surgical pathology incl. mesenteric adenitis

Meckel’s

diverticulum

Cholecystitis

Pancreatitis

Foreign

nodies

Inflammatory bowel disease

Pneumonia

Mnon

-medical pathology

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5-14 year olds abdominal pain

Most presentations will be non-surgical pathology

Appendicitis also common

How to assess children?

Same as adults but remember they are scared

–

build rapport first

–

schools, siblings, friends, sport,

tv

, music

etc

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History and examination

Length, progress, associated symptoms, hungry, moving without

paion

, hurting to void?

Do they look sick??

A

bdominal findings? The scrotum? Lymphadenopathy?

May be obvious they need an operation

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Investigations

If its more difficult, FBE, CUE, CRTP may help

If very early in

hx

(<24

hrs

),

I

x may be normal even if appendicitis

Admission for observation very useful

US can be helpful

–

but rarely in first 24 hours

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Admission plans

Children admitted with abdominal pain for observation need to be charted for

REGULAR

simple analgesia

NOT for antibiotics

Fasting status depending on your clinical

judgement

–

YES if you think they are going to need an operation

Antibiotics are

oly

used once a decision has been made to take them to theatre and they are going on ETBS, and it has been discussed with the consultant

IV hydration may help them feel better

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5- 14 year olds

Children of this age are usually quite sensible. they look sick if they are sick, they look better when they are better.

Talk to the child when you are examining them, they will be scared and if you look comfortable and distract them by asking them about siblings school, sports

etc

then you will be able to get a better examination of their abdomen

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Girls

Especially teenagers can be hard to assess

Secondary gains from abdominal pain

Try very hard to avoid unnecessary surgery

What to do?

assessment with history and examination as for any other presentation

investigate as appropriate,

eg

bloods including

bHCG

consider ultrasound more often in girls to look for ovarian pathology

treat them on their merits

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Under 5 year olds

Appendicitis much less frequent than older children

Hard to diagnose, no classical symptoms or signs

Children under 5 with appendicitis frequently just look sick. They frequently get central abdominal pain,

diarrhoea

, and fevers. There is often a delay to diagnosis because of the lack of normal signs.

What to do?

Remember that the 4 year old with abdominal pain, and the completely soft abdomen that can run around the room may have appendicitis

Use investigations, FBE, CRP, CUE; give them analgesia, rehydrate them, reassess them, talk to a consultant

its ok for them to be admitted for observation, better to be under surgical team than

medical

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Parents

Difference to adult surgery

Will be worried, scared, defensive

Can give you a lot of information and will need to give you permission to examine their child

As well as working out what you are doing, you need to explain it to the parent

Please talk to the consultants!

Eg

: “I think your daughter has appendicitis and needs antibiotics and surgery. I will discuss this with my consultant and let you know what the plan is.”

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Finally

We want you to assess patients, have an idea as to what is happening and to have a plan. We are responsible for the patient so we need to know about them, and we need to approve the plan. Don’t start irreversible course of action without discussion.

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References

The acute pediatric scrotum: Presentation, differential diagnosis and management,

Vasdev

, Chadwick, Thomas;

Curr

Urology 2012 Sep; 6(2):57-61

Scrotal exploration for acute scrotal pain: A 10 year experience in two tertiary referral paediatric units;

Nason

,

Tareen

,

McLoughlin

, McDowell,

Cianci

and

Mortell

; Scandinavian Journal of Urology Volume 47, 2013

iss

5

Acutely painful scrotum: Tips, traps, tricks and truths; McBride, Patel; Journal of

paediatrics

and child health/

Vol

53, Issue 11

Clinical review The management of acute testicular pain in children and adolescents BMJ 2015; 350