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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),PATAppearance:Lethargic,poorly responsiveWork of breathing:Effortless tachypnea(Compensated for metabolic acidosis)Circulation:Delayed capillary refill,cool,pallor,mottle
2、d 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 3010gmA:OpenB:Tachypnea,grunting,breath sounds clearC:Color pale,skin warm and dry,tachycardia,brachial pulse decreasedD:Tone decreasedE:No sign of injury,no rash
3、,Eb4,重要病史,S:Bloody stool and abdominal distentionA:No allergies,formulafedM:NoneP:Born premature,C/S due to maternal preeclampiaL:Just prior to arrival but vomitedE:No feeding since 6 hours ago,Eb5,詳細理學檢查,Head,neck,lung,and heart examination are normal except for tachycardia ABD:distended,bowel soun
4、d:hypoactiveSkin:mildly shiny and erythematouosFemoral 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=90/3/4ABG:PH=7.25 PCO2 34 PO2 65 HCO3 14,BE=-8Glucose 70,Na 135 k 4.3Stool examination:OB(+),Eb8,最後診斷,Hollow organ perforation with septic sho
5、ck R/O Necrotizing Enterocoltis,Eb9,NEC典型發現,Metabolic acidosisNeutropeniaThrombocytopeniaPneumatosis intestinalisIntrahepatic portal venous gasPneumoperitoneum,Eb10,急診處置,ABCs(Endo size 3.5-4.0,IV N/S 60cc)OG for decompressionBlood culture Antibiotics(AMP+GM+Metronadazole)NPOEarly PEDS consultationAd
6、mission,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 fearlyWork of breath:non-laboredCirculation:pale conjunctivae and mucous membraneVital signs:HR 140,RR 24,BP 100/60,T 37C Wt 15 kg,Eb13,初級評估(
7、2/2),A:Open,no stridorB:Non-labored,breath sounds clearC:Pale conjunctivae and mucous membrane,skin warm and dry,tachycardia,brachial pulse strongD:Tone normalE:No sign of injury,no rash,Eb14,重要病史,S:large mount of bloody stool A:No allergies,formulafedM:NoneP:Born full-term NSVD,history of break blo
8、ody stoolL:Just prior to arrivalE:Normal feeding,Eb15,詳細理學檢查,Normal except:Head and Neck:pale conjunctivae and mucous membraneHeart:tachycardia with soft 2/6 systolic ejection murmur at the LLSBAnus:Stool is grossly bloody.No evidence of fissure,trauma,or tags,Eb16,急診處置,ABCs:O2 with maskFluid resusc
9、itation:IV with N/S 300CCOG or NG tube for saline lavageCBC-DC,PT/aPTT,type and crossmatchCorrect anemia:pRBC 150cc if indicated,Eb17,初步診斷,Painless rectal bleeding,cause?,Eb18,無痛性血便之鑑別診斷,Meckel diverticulumIntestinal polypIntestinal duplicationsIntestinal hemangiomaArteriovenous malformationCoagulop
10、athyPUDInflammatory bowel disease,Eb19,診斷工具,A Tc-99m pertechnetate scanExploratory laparotomyLaparoscopyEsphagogastroduodenoscopyColonoscopy,Eb20,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 stoma
11、ch and bladder,and the diverticulum is seen in the mid-abdomen.,Eb21,Technetium-99m scan shows ectopic gastric mucosa,Small intestineMeckels diverticulum,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
12、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 embarrassedWork of 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 te
13、stis 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 episodes 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
14、-99m radionuclide scan shows“cold spot”on affected side.Color Doppler ultrasonography shows decreased or absent flow to affected 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 epididymisEpididymitisOrchitisIncarcerated inguinal herniaScrotal traumaHydroceleVa
15、ricoceleHenoch-Schonlein purpuraScrotal cellulitisKawasaki diseaseTesticular tumor,Eb35,torsion of appendix or epididymitis,Eb36,急診處置,Anagesia with an IV narcoticsManual 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
16、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 Circularion:NormalVital signs RR 20/min,PR 120bpm,BT:37.5C BW:9 kgw,Eb40,初級評估(2/2),A:Open,no stridorB:Non-labored,breath sounds clearC:Normal D:Tone normalE:No sign of injury,no rash,Eb41,重要病史,S:mu
17、cous stool(+)A:No allergies,formulafedM:NoneP:Born full-term NSVDL:3 hours agoE:No trauma history was told,Eb42,詳細理學檢查,HEENT:no active lesion Chest:clear BSHeart: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 enterocoliti
18、s,Eb44,診斷工具(1/2),Normal electrolyte and glucose levelNormal urine analysis Negative urine toxicology screenNormal 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),
19、Soft tissue mass,target sign,crescent sign on plain radiographTarget sign by sonographyAn air contrast enemaA barium contrast enema,Eb48,Plain film,Eb49,Plain film,Eb50,鑑別診斷,IntussusceptonMeckels diverticulumIncarcerated inguinal herniaNonaccidental traumaGastroenteritisCows milk or soy protein alle
20、rgy or other benign process.,Eb51,急診處置,Fluid resuscitationStop oral intakeConsult pediatric surgery earlyObtain 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
21、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?”,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
22、 and Cardiac and pulse oximetry monitorsFentanyl 1mcg/kg IVPlaced 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
23、 an incarcerated inguinal hernia should 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 behaviorWork of breathing:NormalCirculation:Normal Late,incarcerated:Appearacne:Fussy,irritable,in pain,vom
24、iting;if dehydrated,lethargicWork 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 feedingAbdominal distensionPain(Crying,irritability)Lack of bowel movementSwelling in groin area that becomes firm and tender.,Eb61,鑑別診斷,Inguinal herniaCryptochid testisHydroceleVaricoceleRetractile testisTorsion of testisTraumaLymphadenitisTumor,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,
