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Surgical teaching

Surgical teaching. Ms Sarah Condron Paediatric surgeon Northern Hospital. Things to be covered. Abdominal pain short stay pathway Assessing: scrotal pain Abdominal pain 5-14 years Girls Under 5 parents. Calling consultants. For admissions For discharges To take someone to theatre

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Surgical teaching

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  1. Surgical teaching Ms Sarah Condron Paediatric surgeon Northern Hospital

  2. Things to be covered • Abdominal pain short stay pathway • Assessing: • scrotal pain • Abdominal pain • 5-14 years • Girls • Under 5 • parents

  3. 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

  4. 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

  5. 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

  6. Review of paediatric surgical patients • 3 consultants, 1 paedsurgrmo • 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 • Oncallpaed surgeon available 24 hours, 7 days

  7. Assessment and treatment children • Scrotal pain • DDX: • Testicular torsion • Torsion testicular appendage • Testicular trauma • Idiopathic scrotal oedema

  8. 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

  9. 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!!

  10. 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

  11. 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

  12. Ultrasounds for scrotal pain • Testicular torsion if worried about a rupture, • If they’vr previously had an exploration and are representing with pain

  13. 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

  14. 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

  15. 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

  16. History and examination • Length, progress, associated symptoms, hungry, moving without paion, hurting to void? • Do they look sick?? • Abdominal findings? The scrotum? Lymphadenopathy? • May be obvious they need an operation

  17. Investigations • If its more difficult, FBE, CUE, CRTP may help • If very early in hx (<24 hrs), Ix may be normal even if appendicitis • Admission for observation very useful • US can be helpful – but rarely in first 24 hours

  18. 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

  19. 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

  20. 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

  21. 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

  22. 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.”

  23. 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.

  24. 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

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