Category Archives: Surgical


Children are small adults, when it comes to trauma!

Mortality jumps when airway management instituted more than 45 mins after 999 call. (NICE) Mortality actually rare with isolated head (7%) and abdominal (20%) trauma. But jumps to 50% for multiple sites.

Beware head impact apnoea.

Collars not required as part of immobilisation in children. Cx spine trauma v rare. Manual in line stabilisation best if necessary. Extrication maybe?

Triage tool highlights who needs to go to trauma centre eg mangled limbs, penetrating or open trauma, mechanisms eg ejection from vehicle.  But always clinical judgement.

If “hot critical” then decide on transfer to tertiary centre within 8 minutes. Airway, catastrophic haemorrhage and move.

C-ABC is catastrophic haemorrhage first.

Access above and below diaphragm if possible. Blood first line if bleeding. 10ml/kg aliquots. 1:1:1 packed cells, FFP and platelets as able.

Tranexamic acid dose 15ml/kg (same as paracetamol!). See major haemorrhage protocol. No role for permissive hypotension in children.

Avoid over resuscitation with crystalloid.

Pelvic binder problematic if moves. Fixes greater trochanters and public symphysis.

AVPU – but specify pain response!

Head injury: 3% saline preferred. Aim for high MAP, with inotropes if necessary. GGC has guideline. Adrenaline preferred.

Agitated kid – persevere with getting them into scanner without anaesthetic! In Wishaw, induction best in theatre but would then need to go in lift!  Limited expertise with waking them up! Discuss with Scotstar, maybe move, maybe tube.

Log roll 90% out, 20% in? Conrad 2012

Traumatic cardiac arrest: in adults, evidence for aggressive treatment of reversible causes. Consensus is for bundle of simultaneous interventions (not all necessary for every case), prioritised ahead of CPR!

  • Haemorrhage control
  • ETT or equivalent
  • Bilat finger thoracostomies
  • Rapid volume replacement with warmed blood NOT thoracotomy or inotropes. Persistent low ETCO2 is poor prognostic sign.

Even if death declared out of hospital, should be admitted for after care.

NAI audit – 5.2% rate of suspected child abuse. 75% under 1 yr. Often major trauma, often severe brain injury.

Major Incident

Workload should be spread out. Over 12 should go to adults (unless lots of adults too). Walking wounded to non trauma centres. Try not to separate children from injured parents – who worst affected?


Still routine practice in many parts of the world, including the USA. Last figures I can find suggest 56% of US boys circumcised, with higher rates among non-Hispanic white boys, which is down from previous decades.

The Royal Dutch Medical Association declared in 2010 that male circumcision as routine practice or for religious reasons is medically unjustified and therefore an abuse of the rights of the child.

In 2013 the Children’s ombudsmen of the Nordic countries proposed a ban. In Sweden it is illegal in the first 2 months of life, following a death from complications in 2001 (an attempt at an outright ban was watered down).

In the UK there have been legal cases where parents have disagreed on their son having the procedure.

Trials in Africa suggested that circumcision might help prevent spread of HIV (38-66% reduced risk). South African president Jacob Zuma made a point of getting circumcised, to encourage others.

Risks are low in neonates cf adults.

Muslim and Jewish cultures see it as part of cultural identity, of course.

Psoas abscess

Insidious, no specific signs/symptoms so often delayed diagnosis. Pain in region of lower back or hip, fever. Often 10+ days later that becomes more obvious.

Usually caused by haematogenous spread, but may be due to local suppuration.

Blood tests are not very helpful!  WCC/CRP/ESR non-specifically high.  CK is rarely raised!  Blood cultures often positive.

MRI is investigation of choice as ultrasound is only 60% sensitive.

Rx IV antibiotics for min 5/7 then complete 3-6/52 oral.  Large abscesses will require surgical drainage (open or ultrasound guided).  No reported sequelae but can be complicated by iliac thrombophlebitis followed by pulmonary emboli (akin to Lemierre’s disease).


Classic history in less than 60% of cases! Retrocaecal in 15% so hip pain (psoas irritation), flank or right upper quadrant pain/symptoms. A deep appendix tip can give rectal pain especially on defaecation, plus diarrhoea, dysuria!

Under 6 with 48+hr symptoms are likely to have appendicitis.

Periumbilical pain due to T10 innervation, then localises to RIF as serosa involved. But can be suprapubic if appendix lies medially, or flank pain if lateral.

Vomiting at start unusual except retrocaecal, tends to start later.

Fever low grade or absent.

Under 5 can just present with diffuse pain and peritonitis as omentum under developed, so fails to contain. Higher risk of delayed diagnosis, perforation.

To check for psoas irritation, hyperextend hip (lie on side). For obturator, flex hip and internally rotate.

Speed bump sign good positive predictive sign!


WCC/CRP poor sens/spec especially in first 24hrs.

USS – hyperechoic mesenteric fat, fluid collection, local dilated loop suspicious if appendix cannot be seen. 90-95% sens/spec.

Orbital cellulitis

Potentially serious infection of the eye.

Chandler classification describes the potential sequence of events:

  • Preseptal (periorbital) cellulitis, in other words, anterior to the eye. Usually caused by skin organisms entering via superficial trauma
  • Orbital cellulitis – surrounding the eye
  • Subperiosteal orbital abscess – penetration into bone of orbit
  • Orbital abscess
  • Cavernous sinus thrombosis

In older children, more likely to start with sinusitis, then eroding through into orbit. Differentiating between these types is difficult without imaging.

Different organisms cf skin commensals of preseptal cellulitis eg Haemophilus, streptococci including pneumococcus, anaerobes.

Often no organism is obtained, which adds to the difficulty of giving evidence based guidance. Multiple bugs not uncommon. Hence a variety of different guidelines, generally of poor quality.

In a large US review of 220 children and young adults, 98% were investigated by CT. High rate of steroid use – previous studies have suggested better outcomes, but no obvious benefit in terms of treatment success here. Various antibiotic regimens, various durations. More treatment failures if treated for more than 3 weeks but these will be the most severe/complex cases.


Jointly managed by ophthalmology, ENT and paediatrics. Ophthalmology are best at performing eye movement assessment, but it is ENT who tend to do any surgery (usually endoscopic sinus surgery).

Red flags:

  • Severe proptosis,
  • worsening visual acuity,
  • elevated intraocular pressure,
  • colour indiscrimination,
  • intracranial involvement,
  • inability to perform a reliable serial ophthalmologic examination,
  • poor response to a trial of intravenous antibiotics for 24 to 48 hours

These are indications for surgery.

The size of any subperiosteal abscess on CT is a new prognostic factor: diameter >10mm and volumes ≥500mm3 (although volume measurements not routinely reported) are thought typically to require immediate surgical intervention, with the remainder going to surgery only in the event of clinical deterioration, lack of clinical improvement after 48 hours of antibiotics, or worsening abscess on imaging.

Treatment duration – most people would agree to IV treatment until clear improvement, followed by oral antibiotics for a total of 14 days.

Hereditary haemorrhagic telangiectasia

=Osler-Weber-Rendu disease.

Autosomal dominant with high penetrance. 

Not a problem in early life.  Usually presents with recurrent nose bleeds.  Red spots on lips, tongue and fingertips, not so obvious in young children. But potential for GI and pulmonary haemorrhage, pulmonary/liver/brain AVMs.  Migraine common.

Iron deficiency a problem, of course!

Screening for AVMs done from age 16. Annual full blood count. Beware nasogastric interventions!

Post operative ENT complications

Post adenoidectomy

Trickling blood behind uvula or hanging clot are reasons for re-exploration.

Post tonsillectomy

Secondary haemorrhage typically at 5-7 days.  Beware constant swallowing! White slough normal. Yellow (with pain) might mean infection so Corsodyl or peroxide gargles, 3-6x daily, possibly antibiotics.

History of bleeding but clear fossae – assess general condition and exclude bleeding disorder (family history), safety net.

If small clot, observe to see if enlarging. Every 15 mins or more if still spitting/swallowing. IV access and fast. Sit up.

Active bleeding needs anaesthetist for airway management, crossmatch too. Tonsil tray – adrenaline solution soaked swab applied to bleeding spot with Magill’s forceps until reaches theatre. Ice packs for back of neck. Post exploration NG tube to keep stomach empty.

Tranexamic acid, DDAVP? Eg vWD

Acute pancreatitis

Incidence increasing, approaching that of adults!? INSPPIRE international study. 


Amylase 3x upper limit, radiology positive. 

Cullen’s and Grey Turner signs (umbilical and flank bruising respectively).

Amylase level not prognostic. False positive liver/renal impairment, GI inflammation.  False negative in 10%, esp drug induced!

Lipase more specific, only done in Huddersfield?! Stays high for longer.

Low calcium, high glucose seen.

Diagnosis mostly clinical. USS usually sensitive, else CT – more for complications (focal or diffuse enlargement, heterogeneous enhancement, irregular or shaggy outline, oedema of surrounding fat).

AXR may show sentinel loop, free gas (loss of psoas shadow). CXR for effusion.



  • idiopathic (25% in children)
  • gall stones
  • ethanol
  • trauma
  • steroids – and other drugs, esp anti-epileptics, immunosuppressants eg azathioprine, cancer drugs.
  • mumps (even without parotitis), malignancy
  • autoimmune
  • scorpion sting!

But misses IBD, sepsis, Mycoplasma (early or late), genetic causes! 


Prognosis good in children. Scoring systems in adults eg Modified Glasgow-Imrie not applicable, various paediatric versions, of debatable value. 

Fluid resuscitation then 1.5-2x maintenance requirements (not much evidence – don’t be afraid of positive balance! Keep urine output at 1ml/kg/hr), analgesia, early enteral nutrition if possible (to avoid bacterial translocation) else parenteral.

Antibiotics only for suspected sepsis.

Surgery eg necrosectomy. 

1/3 acute recurrent (defined as recurrence after full recovery). Often anatomical problems. Chronic associated with genetic disorders, metabolic, autoimmune.

ERCP for anatomical causes. Pancreatic enzymes. Non opiate pain management eg tricyclics. 

[NASPGHAN 2018 Guidelines]

Pyloric Stenosis

Pylorus is the name of the outflow tract of the stomach, the muscle in the wall controls how quickly the stomach empties.

For some reason, this muscle can become hypertrophied in the first month or two of life, to the point that the baby begins to vomit with feeds, become dehydrated and lose weight. Remains hungry of course, which may not be the case with some of the differentials.

The vomit is non-bilious of course, as the obstruction is above the bile duct.

4 male:1 female. Less common in black/Asian groups. Maternal history is more significant than paternal! NB Associated with TOF, other abnormalities. Associated with erythromycin use in infancy, particularly in first 14 days of life.

1st week to 5 months, but usually after 3 weeks. Only 6% present within 14 days of life – increasing proportion over time? (Even before US available) More likely to have family history?

Preterm babies make up only 3% of cases, and symptoms/signs tend to be less dramatic. Unclear whether USS criteria (below) are valid for preterms. [Arch Peds Adol Med 1996]


Peristalsis may be visible through abdominal wall. Olive shaped mass (2 cm diameter) felt RUQ just lateral to midline, under liver (sit on left side), after vomit.

When well established vomiting, hypochloraemic, hypokalaemic alkalosis characteristic (but not 100% specific).

On ultrasound scan, muscle thickness more than 3mm, transverse pyloric diameter more than 14mm (length similarly) – ie 3.14 (Pi, the mathematical constant)! [radiopaedia]

Differential diagnosis = reflux, sepsis, cow’s milk intolerance, other surgical condition eg malrotation, raised intracranial pressure, Congenital Adrenal Hyperplasia, biochemical imbalance eg renal tubular acidosis, inborn error of metabolism etc.


Surgical pyloromyotomy (Ramstedt’s)- usually laparascopic. Quite a minor procedure, since the muscle is incised and then left to heal without any need to enter bowel itself or repair anything.

Penis problems

The foreskin cannot, and should not, be retracted in newborn babies.  It should gradually begin to separate in the first few years of life.

Recurrent balanitis leads to scarring around the meatus, so that you cannot see the slit opening of the penis itself.  In this case, the foreskin will balloon on passing urine (a minor degree of this can still be seen in children without scarring.

Can try application of topical steroid creams: 0.05% betamethasone cream should be used twice daily for 2 to 4 weeks.  Gently retract foreskin without causing any discomfort and apply a thick layer of cream to the tightest part of the foreskin.  Steroid creams of higher potency may be tried if this fails.

Circumcision if significant phimosis and steroid creams fail.

Smegma pearls

Retained smegma can accumulate into substantial but painless lumps down the shaft of the penis.  Can be ignored.

Balanitis Xerotica Obliterans

A form of lichen sclerosus affecting the tip of the penis, causing white, crinkly thickening.