Category Archives: Surgical

Accidental Adrenaline self-injection

Allergy, Emergency medicine, General paediatrics, Surgical

eg with Epipen or Emerade.

Causes vasoconstriction with potential for gangrene.

Try:

  • warm water immersion
  • local nitroglycerin paste
  • subcut infiltration with a mixture of 1.5mg of phentolamine, 1mL of 2% lidocaine (at site and along course of digital arteries)

[advised by National Poisons Information Service]

n=365 adrenaline injections to hand, 213 to digit.  No cases with clinically apparent systemic effects, only a few patients had ischemia. No patient was admitted or had surgery. [Annals of Emergency Medicine. 56(3):270-4, 2010 Sep. PMID: 20346537]

Central serous chorioretinopathy

Allergy, General paediatrics, Surgical

Central serous chorioretinopathy (CSCR) = accumulation of subretinal fluid at the posterior pole of the fundus, ultimately leading to retinal detachment. Typically affects one eye only.  Vision becomes blurry and distorted, with objects often appearing smaller in the affected eye. May also cause difficulty with bright lights and contrast sensitivity.

Mechanism unknown, but associated with use of systemic corticosteroids, pregnancy, and Cushing’s syndrome.  Recently also been described after local corticosteroids including inhaled, intranasal, topical and periocular (!). Rare though.

Although blurred vision is a symptom of CSCR, it can be a side effect of periocular steroid treatment, as well as a symptom of whatever underlying eye condition is present (if any).

MHRA therefore says you should inform patients they should report any vision problems or disturbances.

[MHRA]

Idiopathic intracranial hypertension

General paediatrics, Neurology, Surgical

Previously “Benign” Intracranial Hypertension but not entirely benign…

Intracranial hypertension but with normal CSF, and no ventriculomegaly. Presents with usual symptoms of early morning headache, effortless vomiting. VI nerve palsy may be seen, rarely II/IV. Papilloedema is often the first clue.

No sex differential prepubertally, not associated with obesity (contrary to popular belief).

Normal CSF opening pressure is 7.5cm of water <2yr, 13.5 <5yr, 20 over 5yr. Lumbar puncture is therapeutic; 2 step tap procedure is usually used if opening pressure is over 30cm. NB General anaesthetic can give false pos result! Secondary causes include drugs, endocrine conditions.

Since repeated LP is unpleasant, medical therapy can be considered. Topiramate is probably equivalent to the more usual acetazolamide (a diuretic). Steroids should be used for malignant hypertension (ie where there is rapid progression). Any of these treatments may result in a low pressure headache.

Surgical options include Optic nerve sheath fenestration, lumbar-peritoneal shunt.

Posterior urethral valves

General paediatrics, Renal, Surgical

1 in 5000 births.  Mostly failure of Wolffian duct development, rarely failure of urethral canalisation.

2/3 detected antenatally, with distended bladder. If missed, then present with urinary tract infection, abnormal voiding (dribble rather than fountain!) else incontinence (if toilet trained, of course).

Later detrusor failure, tubular dysfunction, renal failure.

Lymphoedema

General paediatrics, Surgical

In adults, usually after surgery or radiotherapy.  But can be primary, appearing in childhood (but not necessarily in early childhood).  Secondary causes include Klippel-Tranaunay, Noonans, Turners, other venous malformation.

The incidence of primary lymphoedema is approximately 1 in 6,000 births. Approximately 10 children are born each year with primary lymphoedema in Scotland.

Lymphoedema, particularly if not well controlled, “carries significant human, personal, financial and societal costs”. Apart from cosmetic issues, pain is often a significant problem (underestimated), plus risk of cellulitis.  Inadequate treatment increases risk of complications:

  • fibrosis,
  • papillomatosis (warty growths consisting of dilated lymphatics and fibrous tissue)
  • lymphorrhoea (leakage of lymph fluid through the skin),
  • functional limitations
  • psychological morbidity, social isolation and limitation of life choices, including employment opportunities

So early diagnosis and control important.

Examination

Deep pressure for at least 30 seconds! If pits, then lymphatics ok.

Positive Stemmer sign= the inability to pick up a fold of skin at the base of the second toe, indicating thickening of the skin. This is useful in differentiating lymphoedema from other forms of oedema. [http://www.woundsinternational.com/ Journal of Lymphoedema, 2009, Vol 4, No 2]

Investigations

Consider secondary causes, as above.

Consider LFTs, thyroid function (impaired lymphatic drainage seen in hypothyroidism, hence oedema and even effusions).

Imaging to assess venous blood flow eg USS with dopplers.

MRI can show hypertrophy of fat, as in lipoedema (see below), or other tissues (viz Klippel Trenaunay).

Lymphoscintigraphy is gold standard but not readily available.

Differential is Lipoedema – almost exclusively females, presents at or after puberty, symmetrical lower limb enlargement.  Often a history of easy bruising and tenderness in the affected limbs. Lymphoedema can later develop as a secondary complication.

Further advice from http://www.thebls.com/patients/index.php?bls_user=9f0a85c93b84f4e36a2629f6d17c38e7

Patient support from http://www.lymphoedema.org/

[SMASAC Short Life Working Group on Lymphoedema – Lymphoedema Care in Scotland, Achieving Equity and Quality, 2013]

 

Head injury

Child protection, General paediatrics, Neurology, Surgical

In minor head injury (definition?!), statistically significant correlation between intracranial haemorrhage and:

  • skull fracture
  • focal neurology
  • history of loss of consciousness
  • GCS abnormality (difficult to gauge in preverbal children…)

Headache and vomiting were not found to be predictive and there was great variability in the predictive ability of seizures. (meta-analysis, ArchDisChild 2004;89)

SIGN 110 suggests immediate CT for:

  • GCS less than 14
  • high speed mechanism
  • witnessed loss of consciousness for more than 5 minutes
  • Suspicion of open or depressed skull fracture
  • Any sign of basal skull fracture
  • Tense fontanelle
  • Focal neurological deficit

Otherwise, early (ie within 8 hours) CT should be considered if:

  • bruise/swelling/laceration >5cm on head
  • post-traumatic seizure without epilepsy (and not reflex anoxic)
  • amnesia (antero- or retrograde) >5 minutes
  • suspicion of NAI
  • Significant fall
  • 3+ discrete episodes of vomiting
  • abnormal drowsiness
  • GCS other than 15 in under 1yr old, assessed by experienced provider

If suspicion of NAI, extra rule applies – CT should be done “as soon as child is stable” (and ideally within 24 hrs) if under 1 yr, or neuro signs (incl haemorrhagic retinopathy).

Any loss of consciousness should be assessed, but interestingly retrograde amnesia has to be for >30 minutes to warrant assessment, whereas NICE would do immediate CT! Otherwise 2+ vomits, severe and persistent headache, coagulopathy, difficulties with assessment or social situation, or any other indication for CT.

Admit if any indications for CT, although it also says discharge can be considered if social situation suitable!

NICE head injury (2017) guidelines

similar criteria, but suggests immediate CT for more. Change in practice from admit and watch (Royal College of Surgeons guidelines) to diagnose and decide. Leads to far fewer skull XRs, a lot more CTs and maybe half as many admissions. Some centres have seen cost savings due to earlier discharge.

CT within 1 hour for:

  • age over 1 year, GCS<14 on initial assessment;
  • age under 1 yr; GCS<15 on initial assessment.
  • GCS<15 at 2 hours after injury.
  • age under 1yr plus bruise, swelling or 5cm laceration.
  • Suspicion of NAI.
  • Loss of consciousness >5min (witnessed).
  • Post-traumatic seizure without epilepsy.
  • Abnormal drowsiness.
  • Suspected open or depressed skull fracture, or tense fontanelle.
  • Any sign of basal skull fracture – haemotympanum, panda eyes, CSF leak from ears/nose, Battle’s sign.
  • Focal deficit.

Plus CT within 1 hour if MORE than 1 of the following:

  • Witnessed loss of consciousness more than 5 minutes
  • Abnormal drowsiness
  • 3+ discrete episodes of vomiting
  • Dangerous mechanism eg high speed road traffic accident, fall >3m, high speed projectile
  • Amnesia (retro or antegrade) >5 min

If only 1 of the above, then observe minimum 4 hours – go to CT if during that time:

  • GCS <15
  • Further vomiting
  • Episode of abnormal drowsiness

In children under 10yr, CT for spine should be avoided (risk to thyroid) unless severe head injury (eg GCS<=8), strong suspicion despite plain films, or inadequate plain films. Over 10yr, CT is investigation of choice if:

  • GCS<13 (so 1 point less than for head).
  • intubated.
  • inadequate plain films.
  • Continued suspicion.
  • Needing multi-region scan anyway!

Neuroscience centres are expected to be able to perform initial management of multiple injuries in children. Local guidelines for transfer should be drawn up – there are benefits for being in a neurosurgical centre even if surgery is not required.

Kids with a fracture are not as prone to intracranial lesions as adults, at the same time they are more likely to have intracranial lesion without a fracture!

Note increased risk of malignancy with CT.  So observe for 4 hours if persistent vomiting, review by senior clinician to decide further observation rather than CT. Involve parents in decision [BMJ 2019;365:l1875]

Management

No good RCTs! Avoid secondary brain injury – 1 episode hypotension post head injury triples mortality. Cerebral blood flow is low in first 24hr, peaks at 48hr. Depends on temperature, seizures, pain/anxiety.

Glasgow Coma Score (GCS) 9-12 is moderate, <=8 is severe (equivalent to P or U in AVPU score) and is indication for ventilation to protect airway as reflexes potentially unreliable.

Diffuse axonal injury progresses over 24+ hrs, difficult to see on scan.

Consider external drain/ventriculostomy for intracranial haemorrhage. ?Remove contused brain ?Decompressive craniectomy

Neuroprotective strategy:

  • Head up 30deg, straight
  • Maintain pCO2 at 35-40mmHg
  • Cool if febrile (awaiting data on role of hypothermia). Paralyse to avoid shivering. Paralysis will make seizures difficult to recognise: role for prophylactic anti-epileptics?
  • Analgesia
  • (steroids not helpful)
  • CVP&arterial BP monitoring, ensure adequate perfusion pressure
  • ICP monitoring if neuro signs, GCS <9, post decompression. Bolt gives data but does not allow CSF drainage. ICP takes 7-10 days to settle

For RICP, 3% NaCl 3-5ml/kg bolus – Keep osmo <310mmol/l.

For induction, thiopentone is traditionally used. Ketamine theoretically increases ICP but no real evidence. Adding fentanyl smooths cardiovascular response to procedure.

CT@72h is prognostic.

Shaken Baby: lethargy, vomiting, apnoeas, seizures (40-80%), opisthotonus, irritability. See NAI.

Otitis media with effusion (OME)

General paediatrics, Surgical

Consider if:

  • hearing impairment
  • indistinct speech or speech delay
  • behavioural problems
  • repeated ear infections or pain
  • recurrent URTI or nasal obstruction

Important to check there is no other cause of hearing impairment.  Usually sufficient to monitor for 3/12.

Surgery only if bilateral and persistent, with impaired hearing or else significant impairment of learning or behaviour.

Nice guidance CG60, 2008

Testes

General paediatrics, Surgical

Bilateral impalpable testes at birth are associated with complex endocrine disorders and prune belly syndrome, so should be investigated within 2 weeks.

Warm hands and room will help find a testis, of course. Can the testis be manipulated into the scrotum? In that case retractile, not undescended.

A testis can be undescended but palpable eg in the inguinal canal. If retractile, then needs no intervention.

For suspected unilateral undescended testis, re-examine at 6–8 weeks, and again at 4–5 months of age, if needed. If the testis remains undescended, refer to paediatric surgery to consider surgery.

Rarely non retractile testis found later in childhood – “ascending testis” – ?cord shortening.  Usually age 8-10, not so urgent as initial development already complete. Seems to be more likely if retractile in the first place – family should keep an eye on them!

If not palpable then may be intraabdominal, absent, small (dysplastic, but in the right place) or else ectopic. Imaging is not sensitive so often diagnostic laparascopy is required. Ectopic testes are found in the perineum or femoral triangle, they are usually normal and orchidopexy is straightforward.

An undescended testis is seen in 5% of term infants but less than 2% of 1yr olds. It is theorized that part of the reason for poor descent is that they are fundamentally abnormal. If left for more than 4yrs then histological abnormalities often seen so generally repaired/removed between 1 and 4 yrs of age. Commonly associated with inguinal hernia, in which case fixed earlier with the hernia.

After surgery, advise self examination as increased risk of testicular cancer.

[NICE CKS]

Scalds and burns

General paediatrics, Sociology, Surgical

Study of accidental scalds/burns in 1215 children, looking predominantly at issues of prevention:

72% were <5 years, peak prevalence in 1-year-olds.

Commonest scald agent <5 years was a cup/mug of hot beverage (someone else’s, obviously).

Scalds affected the front of the body in almost all (96%): predominantly to the face, arms and upper trunk in <5-year-olds, compatible with pulling on an adult’s arm. Older children had scalds to the lower trunk, legs and hands.

Contact burns (<5 years) were mostly from touching hot items in the home, esp hair straighteners, irons and oven hobs.

Many contact burns in older children happen outdoors.

67% of all contact burns affected the hands.

 

Arch Dis Child doi:10.1136/archdischild-2013-304991  A M Kemp, S Jones, Z Lawson, S A Maguire