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1、小組教學(一)兒童非創傷性手術急症1個案討論一n一個四天大女嬰,家長主訴持續腹脹及血便,兩次配方餵食皆不吃,持續睡覺.出生史方面則因母親有妊娠毒血症而提早於34週大時剖腹生產,出生體重3200公克,並順利於三天後出院.在家每三小時餵食配方奶60-100CC.2初級評估(1/2)PATnAppearance:Lethargic,poorly responsivenWork of breathing:Effortless tachypnea(Compensated for metabolic acidosis)nCirculation:Delayed capillary refill,cool,p
2、allor,mottled extrimities,rapid pulse,poor skin turgor,abdominal wall erythema3初級評估(2/2)Vital sign HR 180bpm,RR 45/min,BP:60/40 mmHg,BT 37.8C,BW 3010gmA:OpenB:Tachypnea,grunting,breath sounds clearC:Color pale,skin warm and dry,tachycardia,brachial pulse decreasedD:Tone decreasedE:No sign of injury,
3、no rash4重要病史nS:Bloody stool and abdominal distentionnA:No allergies,formulafednM:NonenP:Born premature,C/S due to maternal preeclampianL:Just prior to arrival but vomitednE:No feeding since 6 hours ago5詳細理學檢查nHead,neck,lung,and heart examination are normal except for tachycardia nABD:distended,bowel
4、 sound:hypoactivenSkin:mildly shiny and erythematouosnFemoral pulse(+)nCapillary refill:delayed6診斷工具-Plain film7檢驗工具nWBC 12000/mm3,Hb 12.0,PLT 78000mm3,S/L/M=90/3/4nABG:PH=7.25 PCO2 34 PO2 65 HCO3 14,BE=-8nStool examination:OB(+)8最後診斷 nHollow organ perforation with septic shock R/O Necrotizing Enter
5、ocoltis 9NEC典型發現nMetabolic acidosisnNeutropenianThrombocytopenianPneumatosis intestinalisnIntrahepatic portal venous gasnPneumoperitoneum10急診處置 nABCs(Endo size 3.5-4.0,IV N/S 60cc)nOG for decompressionnBlood culture nAntibiotics(AMP+GM+Metronadazole)nNPOnEarly PEDS consultationnAdmission11個案討論二n兩足歲男
6、生由救護車送抵急診室,媽媽主訴發現小孩尿布上有很多紅色血便,不久前也曾有解血絲便經驗,因為無疼痛症狀而且自行緩解.持續兒科門診追蹤.大便形態上並無黏液,病人無發燒,餵食情況良好,無嘔吐症狀.12初級評估(1/2)PAT:Appearance:alert and fearlyWork of breath:non-laboredCirculation:pale conjunctivae and mucous membranenVital signs:nHR 140,RR 24,BP 100/60,T 37C Wt 15 kg13初級評估(2/2)A:Open,no stridorB:Non-lab
7、ored,breath sounds clearC:Pale conjunctivae and mucous membrane,skin warm and dry,tachycardia,brachial pulse strongD:Tone normalE:No sign of injury,no rash14重要病史nS:large mount of bloody stool nA:No allergies,formulafednM:NonenP:Born full-term NSVD,history of break bloody stoolnL:Just prior to arriva
8、lnE:Normal feeding15詳細理學檢查Normal except:nHead and Neck:pale conjunctivae and mucous membranenHeart:tachycardia with soft 2/6 systolic ejection murmur at the LLSBnAnus:Stool is grossly bloody.No evidence of fissure,trauma,or tags16急診處置nABCs:O2 with masknFluid resuscitation:IV with N/S 300CCnOG or NG
9、tube for saline lavagenCBC-DC,PT/aPTT,type and crossmatchnCorrect anemia:pRBC 150cc if indicated17初步診斷nPainless rectal bleeding,cause?18無痛性血便之鑑別診斷nMeckel diverticulumnIntestinal polypnIntestinal duplicationsnIntestinal hemangiomanArteriovenous malformationnCoagulopathynPUDnInflammatory bowel disease
10、19診斷工具nA Tc-99m pertechnetate scannExploratory laparotomynLaparoscopynEsphagogastroduodenoscopynColonoscopy20Tc-99m pertechnetate scannThe diagnosis of Meckels diverti-culum can be obtained by a technetium-99m scintiscan.nThe radioactivity can be seen in the stomach and bladder,and the diverticulum
11、is seen in the mid-abdomen.21Technetium-99m scan shows ectopic gastric mucosa1.Small intestine2.Meckels diverticulum22 結論n優先定位出血位置:上消化道或下消化道n有出血性腸阻塞或腹膜炎症狀者皆應緊急會診外科n手術前應先解決低血容及貧血問題23個案討論三n13 歲男生凌晨四點鐘右側陰囊突然疼痛,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動.前一天在學校活動一切正常,但過去右側陰囊曾有多次短暫疼痛,不過皆立即緩解,這次疼痛難耐,右側陰囊水腫而且有厲害壓痛,右側睪丸位置
12、較平日高,右側Cremaster reflexs 消失,移動身體陰囊就疼痛.2425初級評估(1/2)PAT:Appearance:alert and embarrassedWork of breath:Normal Circulation:Normal Vital signs:nHR 98,RR 14/min,BP 100/60,T 37C26初級評估(2/2)nABCDE:normal except right side scrotal swelling,upper riding testis and severe tenderness27重要病史及詳細理學檢查n-Sudden onset
13、 of left scrotal pain -He has had several brief,less intense but similar episodes in the past.n-A tender,swollen right hemiscrotum and the testis appears to ride higher in the scrotum28Impression nright testicular torsion29診斷工具nTechnetium-99m radionuclide scan shows“cold spot”on affected side.nColor
14、 Doppler ultrasonography shows decreased or absent flow to affected side.30 都卜勒超音波檢查都卜勒超音波檢查R TestisL testis31323334鑑別診斷nTorsion of the appendix testis or appendix epididymisnEpididymitisnOrchitisnIncarcerated inguinal hernianScrotal traumanHydrocelenVaricocelenHenoch-Schonlein purpuranScrotal cellu
15、litisnKawasaki diseasenTesticular tumor 35torsion of appendix or epididymitisBlue dot sign36急診處置nAnagesia with an IV narcoticsnManual detorsion(open book)nObtain immediate surgical consultation37結論n睪丸扭轉是真正手術急症n治療方法為去扭轉手術或睪丸固定術n檢查用於臨床經驗無法判斷個案,但不可因此延遲外科會診38個案討論四n9個月大男嬰,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.3
16、9初級評估(1/2)PAT Appearance:lethargic Work of breath:Normal Circularion:NormalVital signs BW:9 kgw40初級評估(2/2)A:Open,no stridorB:Non-labored,breath sounds clearC:Normal D:Tone normalE:No sign of injury,no rash41重要病史nS:mucous stool(+)nA:No allergies,formulafednM:NonenP:Born full-term NSVDnL:3 hours agonE
17、:No trauma history was told42詳細理學檢查nHEENT:no active lesion nChest:clear BSnHeart:Tachycardia without murmur nABD:normal nGenital:normal nNeuro:Pupil size:4/4 mm and reactive 43初步診斷nAltered mental status nR/O enterocolitis 44診斷工具(1/2)nNormal electrolyte and glucose levelnNormal urine analysis nNegati
18、ve urine toxicology screennNormal blood gas analysis nCBC-DC showed a leukocytosis without left shift and a normal Hb and Hct.nBrain CT is normal 45檢查過程中又嘔吐及解便如下.46診斷nBloody stool R/O Intussusception47診斷工具(2/2)nSoft tissue mass,target sign,crescent sign on plain radiographnTarget sign by sonographyn
19、An air contrast enemanA barium contrast enema48Plain filmCase ACase B49Plain filmCase ACase B50鑑別診斷nIntussusceptonnMeckels diverticulumnIncarcerated inguinal hernianNonaccidental traumanGastroenteritisnCows milk or soy protein allergy or other benign process.51急診處置nFluid resuscitationnStop oral inta
20、kenConsult pediatric surgery earlynObtain appropriate radiographic studies52結論n幼兒腹痛嘔吐皆應將腸套疊列入鑑別診斷n正常 X光檢查結果並不能排除腸套疊診斷,所以進一步檢查如air/barium enema 或ultrasonography是必要的n嬰兒腸套疊可以用持續嗜睡來表現53個案討論五n三個月大男嬰,過去12小時躁動不安,哭鬧,不肯進食,右側陰囊腫脹,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.右側睪丸摸不著,左半側陰囊則正常,小孩狂哭,媽媽也含淚不斷,急問”醫師,能不能快幫忙?”
21、54診斷為何?n是陰囊水腫(hydrocele)?n是疝氣(hernia)?55臨床表徵:你的線索若是疝氣若是疝氣n第一次伴隨症狀發現n症狀:躁動,哭鬧,疼痛,困難餵食n單側若是陰囊水腫若是陰囊水腫n多自出生就有n無症狀n雙側56所以高度懷疑.Incacerated hernia57急診處置(1/2)nFurther attempt at reduction by an experienced surgeon are warranted.nIV and Cardiac and pulse oximetry monitorsnFentanyl 1mcg/kg IVnPlaced in Trend
22、lenburg position for manual reduction58急診處置(2/2)nIf manual reduction is successful,elective repair can be performed within the next 12-36hrs when swelling has decreased.nThe infant who undergo successful manual reduction of an incarcerated inguinal hernia should not be discharged admission for obser
23、vation due to the risk of ischemia of the loop of intestine.59兒童鼠蹊部疝氣徵象Early,nonincarcerated:nAppearance:Normal behaviornWork of breathing:NormalnCirculation:Normal Late,incarcerated:nAppearacne:Fussy,irritable,in pain,vomiting;if dehydrated,lethargicnWork of breathing:If dehydrated,effortless tachy
24、pnea(Compensated metabolic acidosis)nCirculation:If dehydrated,delayed capillary refill,cool,pallor,poor skin trugor,mottled extrimities.60其他臨床表現nPoor feedingnAbdominal distensionnPain(Crying,irritability)nLack of bowel movementnSwelling in groin area that becomes firm and tender.61鑑別診斷nInguinal hernianCryptochid testisnHydrocelenVaricocelenRetractile testisnTorsion of testisnTraumanLymphadenitisnTumor62結論n兒童鼠蹊部疝氣多無法自行痊癒n不論疝氣或陰囊水腫皆具透光性,病史對鑑別很有幫助n對於箝閉性鼠蹊部疝氣,手技復位(manual reduction)仍是可以嘗試的63