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ACUTE ABDOMEN IN CHILDREN

can be defined as the set of signs and symptoms that demonstrate the alteration of intra-abdominal organs and reflect different pathologies.

Its special features
* acute suffering of Structures, This requires a quick resolution of the problem
* Rapid progression of symptoms
* may endanger the patient's life

* Classification

ö ö Medical Surgical

Medical Acute Abdomen (AAM), we refer to this when the structures that are affected are susceptible to medical treatment (oral or parenteral), ie resolution and treatment is from the medical point of view, includes general measures, any treatment that will put the patient by oral or rectal etc. Nothing that

Surgical acute abdomen (AAQ), any set of signs and symptoms from the cavity intraabdominal and whose decision or whose treatment for improving survival is imminently or surgical, there is no other resolution. This medical treatment is also important (medicines, intravenous tto) but if the problem is not resolved surgical patient's life may be endangered.

Surgical Clinic Acute Abdomen

ö PAIN, cardinal symptom, as assessed through Dr. ALICIA all semiological characteristics if the pain is colicky, dull and continuous, if its intensity is increasing or sharply and has strong intensity, if you have radiation, whether calm or no drug (usually AAQ pain does not subside with any medical treatment can improve relatively), this is very important to do the interview because can guide us to a presumptive diagnosis.

or Vomiting, its characteristics, if they are eating, bilious or fecaloid as we talk about different diseases depending on the group treasury, if post-feeding or not has nothing to see.

ö FEVER, we can refer to an infectious process or changes to the digestive tract that may be accompanying the other symptoms.

ö NO EVACUATION or decrease of the same and we see when we face a case of intestinal obstruction

ö Bloating , and the presence or otherwise of this is independent of whether or not an intestinal obstruction
All this clinic will vary depending on the organ affected and causal agent that is causing the problem, the time evolution and age group (this is very important because it may indicate the presence of certain types of diseases)

Diagnosis

ö Clinic, is fundamentally a good history, a good reason for questioning consultation and the actual disease may give us a large percentage of presumptive diagnosis without the need for other data, all based on a good interview with the parent or representative and we're talking about pediatric patients that we can offer good information. Ö


Laboratory Hematology Complete (hemoglobin, leukocytes Hematocrocrito and its differential)
-electrolytes, if the Px is presenting vomiting
-Bilirubin directly or indirectly dependent on the clinical Px, if jaundice or no coagulation
-Times
-Urea Liver Enzymes
-creatinine

ö Radiological Diagnostic Methods:
-plain abdominal X-ray , referring to an anteroposterior radiograph of the abdomen with the Px standing (not lying as it is not assessable) This allows us to see the distribution of air in the abdomen

- Intestinal Transit, is a study Dynamic radiology, which gives Px is radiopaque contrast orally and in making the Rx at different times we will evaluate how you diseminadose contrast to rule out or make a diagnosis of obstructive picture. Gives us information on upper gastrointestinal tract (esophagus, stomach, small intestine)

- barium enema, is also a contrast study, but the contrast is applied rectally. Information gives us the lower digestive tract (large intestine)

- Ultrasound is very useful because it is inexpensive, easy to perform, does not have any kind of disease the patient (as opposed to earlier by the administration of contrast)

- TAC, three-dimensional type we use when we want to show structures in greater detail. AGE


AAQ

-RN

AAQI Necrotizing enterocolitis, here is more characteristic

AAQO: Congenital Malformations: Atresia Intestinal Megacolon, Congenital Ano - Rectal, hypertrophic pyloric stenosis, meconium ileus

AAQT: Obstetric Trauma

-INFANT

AAQI Necrotizing enterocolitis

AAQO intussusception, Inguinal Hernia stuck

AAQT: Direct trauma

-PRESCHOOL

AAQI: Appendicitis

AAQO : Inguinal Hernia stuck, ascaris intestinal obstruction, NO ascariasis may obstruct

AAQT: Direct trauma

-SCHOOL

AAQI: Appendicitis

AAQO: intestinal obstruction by Ascaris

AAQT: Direct Trauma

NOTE:
* inguinal hernia by itself causes no obstruction AAQ has to be complicated or stuck
* When it comes ascaris intestinal obstruction due to ascariasis is very different because the latter may be present without obstruction and its treatment is a physician, while Ascaris obstruction is surgical medicines that we give in each case are different.
* does not mean that a preschooler has no place intussusception but what is more common for the age group. It is very rare in preschool and one school lot weirder, with intussusception but if you have seen, but when it comes within the Dx approaches we will go by more often, however when we get a infant first thing we think of intussusception.
Another cause is included for all ages, AAQ obstruction are tumors at any age can cause an intestinal blockage, what happens is that its frequency is now very low, but must be taken into account.

Obstructive Acute Abdomen is divided into:

-Mechanical, eg intussusception
-Functional and Neurological Megacolon eg RN In all causes are congenital or metabolic
-Paralytic

ACUTE ABDOMEN POST - TRAUMATIC

is a series of signs and symptoms from the abdominal cavity and has a history of abdominal trauma level.
So are all the signs and symptoms arising from the abdominal cavity are produced by trauma, whether direct or indirect.

* AA rankings Posttraumatic

AA ö ö Traumatic nonpenetrating AA


Traumatic penetrating Traumatic Penetrating AA: when the injury caused by trauma, irrespective of the object that has been direct contact with the abdomen, compromises the whole abdominal wall, including peritoneum (which is what I'm going to differentiate the non-penetrating), ie, I have committed the skin, subcutaneous tissue, fascia, muscle and peritoneum . At that time we talk about AA traumatic penetrating because they committed all layers of the abdominal wall to the parietal peritoneum comes
This can be classified into
Complicated. Complicated No


Nonpenetrating Traumatic AA: is one that does not involve the peritoneum, but may involve the skin, subcutaneous tissue, NO penetrates the Parietal Peritoneum Eg. With a knife make it a wound in the abdomen, abdominal wall, and bleeding and get it examined and if there is a wound, a discontinuity at the level of the abdominal wall and realize that involve the skin and subcutaneous tissue, but inside there for nothing else, this is a non-penetrating injury.
Depends on whether injured or not any viscera, as it can be AAPNPenetrante but endangers the viscera can be divided into
traumatismoEsta Complicated.
not complicated.

* Epidemiology
-represent 5% of injuries among children admitted to trauma units.
-14% mortality rate have AA disorder.
-The highest percentage is given by motor vehicle trauma or because the child comes in or be run over.
-falls, direct blows and child abuse, post-traumatic common cause of AA.
"Unfortunately, every year you go see that all the issues of insecurity, increased penetrating type injuries by firearms, stab, which before was not so much.


* most frequently injured organs
ö
First, the spleen, is a structure that is suspended and has a fold that suspends him back into the peritoneal cavity but is very labile, and is a friable body and any direct trauma the person has abdominal level may suffer an injury, breakage or any damage is structure. Then ö

the liver, although that is protected in part by the rib cage, is an organ frequently suffer trauma because it is a body high volume and some of it is in the anterior abdominal wall.

or kidney, but not intraperiotoneal but retroperitoneal organ, but we will include it as part and giving us the clinic is projected as a problem of abdominal organs is one of the most frequently injured.

or pancreas, which are injured less frequently because it is a body type and is protected by retroperitoneal organs that lie ahead of him, however if you are injured is very serious injuries.

or the intestinal tract, are in last place because they are the least injured, because is a hollow organ that receive direct trauma, certain opportunities may dampen shocks and avoid injury as such. However, when there are weapons or injured by gunshot, is one of the major structures involved. Remember also that the thin bowel loops are a mobile structure and to trauma, their mobility can contribute to that damage is not as severe.

The viscera are injured more Solid organ and the least injured are the hollow viscera.

* Clinical Picture

ö Obviously the first thing to investigate is the BACKGROUND OF THE ACCIDENT, it is important to ask how was the fall of the patient, as was the blow in that area received it, figuring that with the parents or the person bringing the child. Ö

Let's examine quickly the patient's hemodynamic status, heart rate, blood pressure, pulse and capillary refill, all that to show at first what the patient's hemodynamic status, if we are suspecting that the patient has a serious injury where there is massive bleeding us signs of more severe hypotension or hypovolemic shock.

ö If signs of hypovolemic shock, extremely low pressure, tachycardia, pallor important, altered level of consciousness of the patient in a few minutes, all these signs we must take into account.

ö If there is direct injury ABDOMINAL WALL This is important from the standpoint of physical examination, obviously if there is an injury, an injury or a continuum and if we are faced with a patient with a wound as noted above, examine the wound, before, after washing, place the gloves and do hemostasis, we must see whether the injury involves only the skin or subcutaneous tissue goes in, or is contaminated, we are playing, we to see if the finger progresses inward.

ö

We also need to evaluate the rest of the system, the body, if there are injuries. INJURIES, FRACTURES IN OTHER AREAS OF THE BODY, to consider the patient and not as an abdominal injury but as a polytrauma Px in Most cases are treated as such.

ö And assessing whether abdominal pain is generalized PRODUCT OR REFERRED TO IN OTHER AREAS OF INJURY. Whenever there is trauma or a trauma patient, or receives a direct blow, we must assess whether the pain is the px has abdominal or extra-abdominal. For example, if there comes a px a child who had an accident, saying that it hurts where it hurts, but there may be abdominal pain for a hip Fx, where Fx is a hip produces abdominal pain and separate type makes a big bruising of the abdominal wall and often confused with an abdominal type of problem and it is a hip Fx. To this we must study well and do think that imaging studies may be a fracture at this level or injury elsewhere in the body. Ö

paralytic ileus may occur as a reflex, or defense of the intestinal loop to the trauma, paralyze its peristalsis, this happens during the first hours after trauma.

* Diagnostics Posttraumatic AA First

ö detailed history, where we will find the history of the accident he had, where we will find someone who can tell how the accident occurred. Ö

We will perform a good physical exam to check for lesions in other parts of the body or only a problem of abdominal. Pulse, temperature, blood pressure, heart rate.

or laboratory tests, which we ask a patient posttraumatic
-hemoglobin and hematocrit, to guide us if there is a problem because remember that active bleeding in children is the problem of hydration and dehydration very frequent then we have to consider also this, because if the child is dehydrated, the hematocrit is not altered, not hemoconcentrado. Normally when we have a patient with abdominal trauma have to request a review Serial hemoglobin and hematocrit, to the extent that the Px This more or less affected we will ask for a greater or lesser interval of time. Usually one calls Hg and Hct every 2, 3 or 4 hours that will be checking if there is a problem or an injury to a viscus with a major bleeding than other common signs and symptoms, the Hg and Hct will help us because if the low-Hg in 2 hours 1 gr. something is happening and if in the third as low as one gram is any bleeding that is causing lower Hg.

Then in the laboratory the most important thing is to Hg and Hct.
-Another laboratory we can ask when abdominal trauma are amylases, thinking that there is a problem at the pancreas, initially not going to give some positive amylases in blood but in urine.
or later, we make RADIOLOGY chest and abdomen, as many times as a trauma patient may have a problem chest and abdominal level because we ask for, ideally, plain abdominal request with the patient standing, depending on same conditions will be placed in this position is ideal, but open to hacérsela projections lying. We want to see, or we're going to find? That has been a perforation of a hollow viscera that Rx is expressed as a Pneumoperitoneum, at the time of trauma and there is a hollow organ breaks through that structure will air out and will be open cavity that is going to visualize in a Rx and a pneumoperitoneum, this is an indication for surgery without ecuanon. Then pneumoperitoneum equals viscera perforation. We can also display a total opacity of the abdomen that does not draw the small bowel, and that when there is a product of free fluid in the cavity, we are talking about a trauma where there may be bleeding of a structure of some viscera and that will give a total opacity in the abdomen. Those are the most important things we'll see if we can find no lines or preperitoneal or display the lines of the psoas, when not displayed either means that there is an air or free fluid in the cavity and I are producing this opacity .

ö The study can not provide more information in the case of AA is the ULTRASONOGRAPHY traumatic or sonography, is a relatively easy study to do not have any mobility, it is easily transported because there are laptops in skilled hands and we will to give a lot of information, we can see if there is injury one of the solid organs like the spleen, liver, kidney etc., also whether there is cavity free fluid or collections Alguita bleeding in the abdomen. And within the instruments in an area of \u200b\u200bShock this is one of the methods Dx should not miss.

or CT / COIL, likewise, because it goes through its different sections, we see that there are at intra-abdominal injury or if there is fluid or air in the cavity. These two studies today have become more important in a polytrauma px. Ö

paracentesis, abdominal puncture is done when we doubt whether there is bleeding in adults is widely used but Pediatric almost no, because today we Dx methods are not as aggressive as ecosonografla and TAC, but obviously we sometimes find ourselves at a point where we can not count any of them and we have to make an abdominal puncture see if you have abnormal air or fluid in the cavity, to try to remove it, can be urine that the bladder has ruptured. The puncture will be done using as guide points in adults: the iliac spines of one side or the other drawing an imaginary line to the umbilicus, and can puncture the outer half, or one or two inches below the umbilicus, but in the Infants School to do in the imaginary line line and this is done only in adults because children and here is a stationary member that is the blind while the children are mobile. I will put a needle, a trocar or Yelco, the size depends on the age of Px, and I hope to see if fluid comes out, if air comes out and if nothing comes out.

that does not leave anything does not mean that there is no abdominal trauma, it might be small the injury, or simply did not fall where I should have fallen, it may be that when I came I fell into a glass and I'm taking the blood and not bleeding, and differentiate because the blood does not clot is accumulated. When you puncture we have the possibility of complication of perforation of a viscus, we must be careful, so today is more widely used ultrasound or CT scan, and also the Dx is not reliable if I aspire not to get any liquid does not mean that does not have an injury.

PERITONEAL WASHING ö Another method, very common in adults, it is followed by abdominal puncture if positive or if I have doubt. Through the same hole, I will introduce a catheter, trocar or Yelco, which will instill solution I've put in a drainage system and I'm putting a lot of liquid to enter the abdominal cavity, after has entered the fluid, gravity, I put that same system below the level where the patient to return. And let's see what kind of content back, if it is clear, or if it is dark with blood and will be positive. Remember that everything in pediatrics I fence to give the patient by mouth, vein or straight or whatever has a dose, then I will use a dose of 20 to 25 cc / kg body weight for children weighing 5 kg I will multiply by 20 cc and that total is what I put for washing. Be careful because the setting of a large amount of fluid in the abdominal cavity will cause organ damage, damage to the circulation. For that there is a dose, which is the amount of liquid that I will introduce. This is a Dx very invasive method. Today almost never performed because there are other methods (ultrasound and CT scan)

ö DISPOSAL urography, dynamic Rx is a study which uses intravenous contrast (water soluble) will give us Visualization renal function, the Excretion of that kidney, as soon as the dye is injected, the kidney is concentrated and begins to eliminate. Then it will take a number of different time Rx for how this contrast will be removed at the time of renal injury, such as hematuria, in the study that I should point out is the elimination urography, to see if the damage is a level of kidneys o a nivel de uréter, ya que esta me va a dar información de riñón, uréteres y vejiga porque aquí se va acumular.

Manejo del Px con Traumatismo Abdominal

ö Lo primero que vamos hacer es ver si el paciente está respirando, tener una Vía Aérea Permeable.

ö Debemos tomar una Vía Central O Periférica, lo ideal es una vía central por si hay necesidad de colocarle líquido parenteral tenemos que asegurarnos de tener una buena vía central o periférica para pasar hemoderivados, solución. Se dan líquidos de acuerdo a su peso. En pediatría se realiza más la Flebotomía.

ö Colocar SIEMPRE una Sonda Nasogátrica, es una condición sin ecuanon (nunca duden en colocarla NO va a pasar nada si lo hacen), pero OjO NO SIEMPRE UNA Sonda Vesical, cuando a ustedes le llega un paciente con un traumatismo abdominal siempre se le debe colocar sonda nasogátrica, porque ella independientemente de que haya o no una lesión intrabdominal les va a ayudar a descomprimir el tubo digestivo, además que si hay alguna lesión del estoma o de asas intestinales altas, vamos a ver a través de la sonda ese daño, la salida de sangre. Siempre colocar sonda nasogátrica porque me va a aliviar la distensión de asas y me va a evitar la distensión abdominal. Siempre que haya un traumatismo abdominal injury but is not any structure in, it will cause bloating because it handles for the gut, is a means of reacting the body and paralyzes the intestine and begins to build up happen in the air, and that begins to thaw intestinal loops and gives us an abdominal strain, so we must always place a nasogastric tube. Now, with the Foley catheter must be careful with children, if the patient is conscious and conditions we see that urine voluntarily and can measure and quantify this diuresis, no problem, although it is bloody indeed obey, even if hematuria, no matter, the child is urinating, because the problem is that if we have an injury at the lower abdomen, urethra can be compromised, and if I injured the urethra and bladder catheter placed at risk is made more serious because an injury could have been easy to correct by itself or with a simple surgical treatment and I introduce the probe compounds the problem, then we must be careful with the catheters. If the patient arrives with a distended bladder and I have doubts whether the patient has an injury to the urethra, we performed a suprapubic tap, 2 or 3 cm above the pubic symphysis. Ö

In most cases we make a conservative management, the patient enters the emergency area and we began to observe, and as long as hemodynamically stable, we observe it and study it, you do your lab tests, Hg and Hct serial, sonography, CT, his Rx, etc., will give us chance to observe and that is the appropriate behavior in a patient with abdominal trauma , but whenever hemodynamically stable.

serial Hg and Hct as mentioned earlier.

Parenteral or placement of liquid is needed, also according to patient weight parenteral solution we will tell you, and you more or less know as hydration of children and obviously a child who is with abdominal trauma and have more years dose will be greater by weight.

The placement of the blood also has a dose, when we put total blood erythrocyte concentrate, derived platelets, plasma, etc., We must place it at a dose of 10-15 cc / kg as a medical treatment if the patient needs to be carried flag because we assume that there is an injury to a viscus with important bleeding will be higher dose, 20 cc / kg as a surgical treatment, but that I have to have a central or peripheral, generally central line or phlebotomy. If these methods are not feasible can be done in the latter case through the intraosseous route, through the bone, the tibia at the tibial tuberosity of it about 2 or 3 cm below I will drill a large Yelka to fall into the bone marrow and hydrate the patient there, allow maximum 24 hours, with easy access and with it we can prevent the Px die of hypovolemic shock. Ö

Vital Signs Strict rating DECIDE TO CHANGE BEHAVIOR THERAPY, the patient under observation where we're monitoring your heart rate, BP, pulse, et., At the time that there is a variation on one of these signs, Our behavior will change.

ö Finally, exploratory laparotomy, to the extent that the patient did not improve or that there are clear signs that there is an abdominal problem hypovolemic shock, there are signs of active bleeding, we take an exploratory laparotomy. We open the abdomen to explore it, I'm going to open because that structure is not damaged, when I do exploratory laparotomy, a surgical exploration of the abdomen, I open the anterior abdominal wall to reach the peritoneal cavity and I will explore all all organs and structures that are inside to verify where the damage. When I have a patient with acute appendicitis, laparotomy also do, but does not explore, because I open the abdomen and also examine, when I have a patient with an intestinal blockage, but I also do not exploratory laparotomy. The Explorer is used when I have to open the abdominal wall to reach the cavity to see which of the structures is what is giving me the symptoms. And that's all I have to do when nothing else has worked for me when none of the studies has helped me when handling it and given to the patient, conservative, and I have not served the patient's clinical conditions have not improved, then do exploratory laparotomy.

Indications For Laparotomy Explorer:

acute deterioration of Vital signs after entering the patient. Where patients can enter and immediately he can come with signs of hypovolemic shock, blood pressure across the floor, tachycardia, rapid pulse, pale skin or mucosa important acute deterioration of vital signs, that's an indication to be taken to immediately flag, of course, the patient should have a central or peripheral to be able to laparotomy and know what the structure is damaged. Peritoneal penetration

stab wound or gunshot, without ecuanon what we talked about non-penetrating and penetrating injuries. Penetrating injury, peritoneal penetration is an indication absolute lead the patient to laparotomy, once I see the wound, examined it and realized at once because I put the finger with the glove or with the probe or the wound is so large that the patient is eviscerated, I have not to do anything just to take a central line and take the patient to the flag.


Evidence of a hollow viscera perforation, pneumoperitoneum translated as (open air in the peritoneal cavity)

persistent bleeding with haemodynamic instability, replace fluids through a good central line put him intravenous fluids at appropriate doses and even if be ye patient blood and hemodynamic instability persists, Vital signs are unstable.

transfusion requirement greater than half the estimated blood volume or in excess of 40 cc / kg of body weight, ie position and put blood and the patient does not improve, or I exceeded 40 cc / kg and the patient not obviously improved and there is persistent bleeding, hemodynamic instability, deterioration of vital signs, is a patient who required laparotomy because it does not get better.

Blogalaxia Tags: acute abdomen + + + in + pediatric acute appendicitis acute abdomen + medical + acute abdomen pediatric hernia + + stuck + necrotizing enterocolitis intestinal intussusception +