1、Eb1,小組教學(xué)(一),兒童非創(chuàng)傷性手術(shù)急癥,Eb2,個(gè)案討論一,一個(gè)四天大女嬰,家長主訴持續(xù)腹脹及血便,兩次配方餵食皆不吃,持續(xù)睡覺.出生史方面則因母親有妊娠毒血癥而提早於34週大時(shí)剖腹生產(chǎn),出生體重3200公克,並順利於三天後出院.在家每三小時(shí)餵食配方奶60-100CC.,Eb3,初級評估(1/2),PAT Appearance: Lethargic, poorly responsive Work of breathing: Effortless tachypnea (Compensated for metabolic acidosis) Circulation: Delayed capi

2、llary refill, cool, pallor, mottled extrimities, rapid pulse, poor skin turgor, abdominal wall erythema,Eb4,初級評估(2/2),Vital sign HR 180bpm, RR 45/min, BP: 60/40 mmHg, BT 37.8C, BW 3010gm A: Open B: Tachypnea, grunting, breath sounds clear C: Color pale, skin warm and dry, tachycardia, brachial pulse

3、 decreased D: Tone decreased E: No sign of injury, no rash,Eb5,重要病史,S: Bloody stool and abdominal distention A: No allergies, formulafed M: None P: Born premature,C/S due to maternal preeclampia L: Just prior to arrival but vomited E: No feeding since 6 hours ago,Eb6,詳細(xì)理學(xué)檢查,Head, neck, lung, and hea

4、rt examination are normal except for tachycardia ABD: distended, bowel sound: hypoactive Skin:mildly shiny and erythematouos Femoral pulse(+) Capillary refill : delayed,Eb7,診斷工具-Plain film,Eb8,檢驗(yàn)工具,WBC 12000/mm3, Hb 12.0, PLT 78000mm3, S/L/M=90/3/4 ABG: PH=7.25 PCO2 34 PO2 65 HCO3 14 , BE=-8 Glucose

5、 70, Na 135 k 4.3 Stool examination: OB(+),Eb9,最後診斷,Hollow organ perforation with septic shock R/O Necrotizing Enterocoltis,Eb10,NEC典型發(fā)現(xiàn),Metabolic acidosis Neutropenia Thrombocytopenia Pneumatosis intestinalis Intrahepatic portal venous gas Pneumoperitoneum,Eb11,急診處置,ABCs( Endo size 3.5-4.0,IV N/S 6

6、0cc) OG for decompression Blood culture Antibiotics(AMP+GM+Metronadazole) NPO Early PEDS consultation Admission,Eb12,個(gè)案討論二,兩足歲男生由救護(hù)車送抵急診室,媽媽主訴發(fā)現(xiàn)小孩尿布上有很多紅色血便,不久前也曾有解血絲便經(jīng)驗(yàn),因?yàn)闊o疼痛癥狀而且自行緩解.持續(xù)兒科門診追蹤.大便形態(tài)上並無黏液,病人無發(fā)燒,餵食情況良好,無嘔吐癥狀.,Eb13,初級評估(1/2),PAT: Appearance: alert and fearly Work of breath: non-labored

7、Circulation:pale conjunctivae and mucous membrane Vital signs: HR 140, RR 24, BP 100/60, T 37C Wt 15 kg,Eb14,初級評估(2/2),A: Open, no stridor B: Non-labored, breath sounds clear C: Pale conjunctivae and mucous membrane, skin warm and dry, tachycardia, brachial pulse strong D: Tone normal E: No sign of

8、injury, no rash,Eb15,重要病史,S: large mount of bloody stool A: No allergies, formulafed M: None P: Born full-term NSVD, history of break bloody stool L: Just prior to arrival E: Normal feeding,Eb16,詳細(xì)理學(xué)檢查,Normal except : Head and Neck: pale conjunctivae and mucous membrane Heart: tachycardia with soft

9、2/6 systolic ejection murmur at the LLSB Anus: Stool is grossly bloody. No evidence of fissure, trauma, or tags,Eb17,急診處置,ABCs : O2 with mask Fluid resuscitation:IV with N/S 300CC OG or NG tube for saline lavage CBC-DC, PT/aPTT, type and crossmatch Correct anemia: pRBC 150cc if indicated,Eb18,初步診斷,P

10、ainless rectal bleeding , cause?,Eb19,無痛性血便之鑑別診斷,Meckel diverticulum Intestinal polyp Intestinal duplications Intestinal hemangioma Arteriovenous malformation Coagulopathy PUD Inflammatory bowel disease,Eb20,診斷工具,A Tc-99m pertechnetate scan Exploratory laparotomy Laparoscopy Esphagogastroduodenoscop

11、y Colonoscopy,Eb21,Tc-99m pertechnetate scan,The diagnosis of Meckels diverti-culum can be obtained by a technetium-99m scintiscan. The radioactivity can be seen in the stomach and bladder, and the diverticulum is seen in the mid-abdomen.,Eb22,Technetium-99m scan shows ectopic gastric mucosa,Small i

12、ntestine Meckels diverticulum,Eb23,結(jié)論,優(yōu)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癥狀者皆應(yīng)緊急會(huì)診外科 手術(shù)前應(yīng)先解決低血容及貧血問題,Eb24,個(gè)案討論三,13 歲男生凌晨四點(diǎn)鐘右側(cè)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(yùn)動(dòng).前一天在學(xué)校活動(dòng)一切正常,但過去右側(cè)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(cè)陰囊水腫而且有厲害壓痛,右側(cè)睪丸位置較平日高,右側(cè)Cremaster reflexs 消失,移動(dòng)身體陰囊就疼痛.,Eb25,Eb26,初級評估(1/2),PAT: Appearance: aler

13、t and embarrassed Work of breath: Normal Circulation:Normal Vital signs: HR 98, RR 14/min, BP 100/60, T 37C,Eb27,初級評估(2/2),ABCDE: normal except right side scrotal swelling , upper riding testis and severe tenderness,Eb28,重要病史及詳細(xì)理學(xué)檢查,-Sudden onset of left scrotal pain -He has had several brief, less

14、intense but similar episodes in the past. -A tender, swollen right hemiscrotum and the testis appears to ride higher in the scrotum,Eb29,Impression,right testicular torsion,Eb30,診斷工具,Technetium-99m radionuclide scan shows “cold spot” on affected side. Color Doppler ultrasonography shows decreased or

15、 absent flow to affected side.,Eb31,都卜勒超音波檢查,Eb32,Eb33,Eb34,Eb35,鑑別診斷,Torsion of the appendix testis or appendix epididymis Epididymitis Orchitis Incarcerated inguinal hernia Scrotal trauma Hydrocele Varicocele Henoch-Schonlein purpura Scrotal cellulitis Kawasaki disease Testicular tumor,Eb36,torsio

16、n of appendix or epididymitis,Eb37,急診處置,Anagesia with an IV narcotics Manual detorsion (open book) Obtain immediate surgical consultation,Eb38,結(jié)論,睪丸扭轉(zhuǎn)是真正手術(shù)急癥 治療方法為去扭轉(zhuǎn)手術(shù)或睪丸固定術(shù) 檢查用於臨床經(jīng)驗(yàn)無法判斷個(gè)案,但不可因此延遲外科會(huì)診,Eb39,個(gè)案討論四,9個(gè)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.,Eb40,初級評估(1/2),PAT Appearance: lethargic Work of

17、 breath: Normal Circularion: Normal Vital signs RR 20/min, PR 120bpm, BT: 37.5C BW:9 kgw,Eb41,初級評估(2/2),A: Open, no stridor B: Non-labored, breath sounds clear C: Normal D: Tone normal E: No sign of injury, no rash,Eb42,重要病史,S: mucous stool(+) A: No allergies, formulafed M: None P: Born full-term NS

18、VD L: 3 hours ago E: No trauma history was told,Eb43,詳細(xì)理學(xué)檢查,HEENT: no active lesion Chest: clear BS Heart: Tachycardia without murmur ABD:normal Genital: normal Neuro: Pupil size: 4/4 mm and reactive,Eb44,初步診斷,Altered mental status R/O enterocolitis,Eb45,診斷工具(1/2),Normal electrolyte and glucose leve

19、l Normal urine analysis Negative urine toxicology screen Normal blood gas analysis CBC-DC showed a leukocytosis without left shift and a normal Hb and Hct. Brain CT is normal,Eb46,檢查過程中又嘔吐及解便如下.,Eb47,診斷,Bloody stool R/O Intussusception,Eb48,診斷工具(2/2),Soft tissue mass, target sign, crescent sign on p

20、lain radiograph Target sign by sonography An air contrast enema A barium contrast enema,Eb49,Plain film,Eb50,Plain film,Eb51,鑑別診斷,Intussuscepton Meckels diverticulum Incarcerated inguinal hernia Nonaccidental trauma Gastroenteritis Cows milk or soy protein allergy or other benign process.,Eb52,急診處置,

21、Fluid resuscitation Stop oral intake Consult pediatric surgery early Obtain appropriate radiographic studies,Eb53,結(jié)論,幼兒腹痛嘔吐皆應(yīng)將腸套疊列入鑑別診斷 正常 X光檢查結(jié)果並不能排除腸套疊診斷,所以進(jìn)一步檢查如air/ barium enema 或ultrasonography是必要的 嬰兒腸套疊可以用持續(xù)嗜睡來表現(xiàn),Eb54,個(gè)案討論五,三個(gè)月大男嬰,過去12小時(shí)躁動(dòng)不安,哭鬧,不肯進(jìn)食,右側(cè)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

22、側(cè)睪丸摸不著,左半側(cè)陰囊則正常,小孩狂哭,媽媽也含淚不斷,急問”醫(yī)師,能不能快幫忙?”,Eb55,診斷為何?,是陰囊水腫(hydrocele)? 是疝氣(hernia)?,Eb56,臨床表徵:你的線索,若是疝氣 第一次伴隨癥狀發(fā)現(xiàn) 癥狀:躁動(dòng),哭鬧,疼痛,困難餵食 單側(cè) 若是陰囊水腫 多自出生就有 無癥狀 雙側(cè),Eb57,所以高度懷疑. . . . .,Incacerated hernia,Eb58,急診處置(1/2),Further attempt at reduction by an experienced surgeon are warranted. IV and Cardiac and

23、 pulse oximetry monitors Fentanyl 1mcg/kg IV Placed in Trendlenburg position for manual reduction,Eb59,急診處置(2/2),If manual reduction is successful, elective repair can be performed within the next 12-36hrs when swelling has decreased . The infant who undergo successful manual reduction of an incarcerated inguinal hernia should not be discharged admission for observation due to the risk of ischemia of the loop of