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1、Eb1,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.,Eb2,初級評估(1/2),PAT Appearance: Lethargic, poorly responsive Work of breathing: Effortless tachypnea (Compensated for metabolic acidosis) Circulation: Delayed capillary refill, cool, pal
2、lor, mottled extrimities, rapid pulse, poor skin turgor, abdominal wall erythema,Eb3,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 decreased D: Tone decr
3、eased E: No sign of injury, no rash,Eb4,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,Eb5,詳細理學檢查,Head, neck, lung, and heart examination are norm
4、al except for tachycardia ABD: distended, bowel sound: hypoactive Skin:mildly shiny and erythematouos Femoral pulse(+) Capillary refill : delayed,Eb6,診斷工具-Plain film,Eb7,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 70, Na 135 k 4.3 Stool
5、 examination: OB(+),Eb8,最後診斷,Hollow organ perforation with septic shock R/O Necrotizing Enterocoltis,Eb9,NEC典型發現,Metabolic acidosis Neutropenia Thrombocytopenia Pneumatosis intestinalis Intrahepatic portal venous gas Pneumoperitoneum,Eb10,急診處置,ABCs( Endo size 3.5-4.0,IV N/S 60cc) OG for decompressio
6、n Blood culture Antibiotics(AMP+GM+Metronadazole) NPO Early PEDS consultation Admission,Eb11,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.,Eb12,初級評估(1/2),PAT: Appearance: alert and fearly Work of breath: non-labored Circulation:pale conjunc
7、tivae and mucous membrane Vital signs: HR 140, RR 24, BP 100/60, T 37C Wt 15 kg,Eb13,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 injury, no rash,Eb14,重要病
8、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,Eb15,詳細理學檢查,Normal except : Head and Neck: pale conjunctivae and mucous membrane Heart: tachycardia with soft 2/6 systolic ejection mu
9、rmur at the LLSB Anus: Stool is grossly bloody. No evidence of fissure, trauma, or tags,Eb16,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,Eb17,初步診斷,Painless rectal bleeding
10、, cause?,Eb18,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,Eb19,診斷工具,A Tc-99m pertechnetate scan Exploratory laparotomy Laparoscopy Esphagogastroduodenoscopy Colonoscopy,Eb20,Tc-99
11、m 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.,Eb21,Technetium-99m scan shows ectopic gastric mucosa,Small intestine Meckels diverti
12、culum,Eb22,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,Eb23,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.,Eb24,Eb25,初級評估(1/2),PAT: Appearance: alert and embarrassed Work o
13、f breath: Normal Circulation:Normal Vital signs: HR 98, RR 14/min, BP 100/60, T 37C,Eb26,初級評估(2/2),ABCDE: normal except right side scrotal swelling , upper riding testis and severe tenderness,Eb27,重要病史及詳細理學檢查,-Sudden onset of left scrotal pain -He has had several brief, less intense but similar epis
14、odes in the past. -A tender, swollen right hemiscrotum and the testis appears to ride higher in the scrotum,Eb28,Impression,right testicular torsion,Eb29,診斷工具,Technetium-99m radionuclide scan shows “cold spot” on affected side. Color Doppler ultrasonography shows decreased or absent flow to affected
15、 side.,Eb30,都卜勒超音波檢查,Eb31,Eb32,Eb33,Eb34,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,Eb35,torsion of appendix or epididy
16、mitis,Eb36,急診處置,Anagesia with an IV narcotics Manual detorsion (open book) Obtain immediate surgical consultation,Eb37,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,Eb38,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.,Eb39,初級評估(1/2),PAT Appearance: lethargic Work of breath: Normal Circular
17、ion: Normal Vital signs RR 20/min, PR 120bpm, BT: 37.5C BW:9 kgw,Eb40,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,Eb41,重要病史,S: mucous stool(+) A: No allergies, formulafed M: None P: Born full-term NSVD L: 3 hours ago E: No
18、trauma history was told,Eb42,詳細理學檢查,HEENT: no active lesion Chest: clear BS Heart: Tachycardia without murmur ABD:normal Genital: normal Neuro: Pupil size: 4/4 mm and reactive,Eb43,初步診斷,Altered mental status R/O enterocolitis,Eb44,診斷工具(1/2),Normal electrolyte and glucose level Normal urine analysis
19、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,Eb45,檢查過程中又嘔吐及解便如下.,Eb46,診斷,Bloody stool R/O Intussusception,Eb47,診斷工具(2/2),Soft tissue mass, target sign, crescent sign on plain radiograph Target s
20、ign by sonography An air contrast enema A barium contrast enema,Eb48,Plain film,Eb49,Plain film,Eb50,鑑別診斷,Intussuscepton Meckels diverticulum Incarcerated inguinal hernia Nonaccidental trauma Gastroenteritis Cows milk or soy protein allergy or other benign process.,Eb51,急診處置,Fluid resuscitation Stop
21、 oral intake Consult pediatric surgery early Obtain appropriate radiographic studies,Eb52,結論,幼兒腹痛嘔吐皆應將腸套疊列入鑑別診斷 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 嬰兒腸套疊可以用持續嗜睡來表現,Eb53,個案討論五,三個月大男嬰,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
22、含淚不斷,急問”醫師,能不能快幫忙?”,Eb54,診斷為何?,是陰囊水腫(hydrocele)? 是疝氣(hernia)?,Eb55,臨床表徵:你的線索,若是疝氣 第一次伴隨症狀發現 症狀:躁動,哭鬧,疼痛,困難餵食 單側 若是陰囊水腫 多自出生就有 無症狀 雙側,Eb56,所以高度懷疑. . . . .,Incacerated hernia,Eb57,急診處置(1/2),Further attempt at reduction by an experienced surgeon are warranted. IV and Cardiac and pulse oximetry monitors
23、 Fentanyl 1mcg/kg IV Placed in Trendlenburg position for manual reduction,Eb58,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 sh
24、ould not be discharged admission for observation due to the risk of ischemia of the loop of intestine.,Eb59,兒童鼠蹊部疝氣徵象,Early, nonincarcerated : Appearance: Normal behavior Work of breathing: Normal Circulation: Normal Late,incarcerated: Appearacne: Fussy, irritable, in pain, vomiting; if dehydrated,
25、lethargic Work of breathing: If dehydrated, effortless tachypnea(Compensated metabolic acidosis) Circulation: If dehydrated, delayed capillary refill, cool, pallor, poor skin trugor, mottled extrimities.,Eb60,其他臨床表現,Poor feeding Abdominal distension Pain(Crying, irritability) Lack of bowel movement Swelling in groin area that becomes firm and tender.,Eb61,鑑別診斷,Inguinal hernia Cryptochid testis Hydrocele Varicocele Retractile testis Torsion of testis Trauma Lymphadenitis Tumor,Eb62,結論,兒童鼠蹊部疝氣多無法自行痊癒 不論疝氣或陰囊水腫皆具透光性,病史對鑑別很有幫助 對於箝閉性鼠蹊部疝氣,手技復位(manual reduction)仍是可以嘗試的,