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1、Eb1,小組教學(一),兒童非創傷性手術急症,Eb2,個案討論一,一個四天大女嬰,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.,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,詳細理學檢查,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典型發現,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,個案討論二,兩足歲男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.,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,詳細理學檢查,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,結論,優先定位出血位置:上消化道或下消化道 有出血性腸阻塞或腹膜炎症狀者皆應緊急會診外科 手術前應先解決低血容及貧血問題,Eb24,個案討論三,13 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,右側睪丸位置較平日高,右側Cremaster reflexs 消失,移動身體陰囊就疼痛.,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,重要病史及詳細理學檢查,-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,結論,睪丸扭轉是真正手術急症 治療方法為去扭轉手術或睪丸固定術 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,Eb39,個案討論四,9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.,Eb40,初級評估(1/2),PAT Appearance: lethargic Work of 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 nor
