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On the basis of the NCEPOD findings, it is uncommon to perform an operation on a child between the hours of midnight and 9am unless ‘life or limb’ is at risk. Consequently most conditions can be optimally managed through the night with adequate resuscitation, analgesia and, if necessary, gastric decompression (NG tube).
It is impossible to admit all surgical referrals. Clinical decisions need to be made regarding the significance of a patient’s condition. Cases where suspicion of surgical pathology is low can be allowed home with advice to return if new symptoms / signs develop (e.g. non specific abdominal pain). Some minor cases (e.g. abscess, minor laceration) can be assessed and allowed home to return fasted (location for review to be arranged with on-call surgical team).
There are certain exceptions where the history, or a pre-existing condition, suggests a significant risk of major surgical pathology developing with only minimal change in clinical signs. These patients should be referred for admission and may have pre-emptive treatment or definitive investigation, even out of hours (e.g. bilious vomiting in a baby, previous history of Hirschsprung’s Disease with GI upset. It is impossible to exhaustively list all of these types of cases, but some are discussed in the text below.
Abdominal pain (? Appendicitis).
In older children, the positive predictive value of bilious (green) vomiting for having surgical pathology is less significant than it is in neonates and infants. However, in the absence of a history of multiple previous episodes of non-bilious vomiting which then became bilious, or if there are other features of concern, such as a previous history of abdominal surgery, abdominal distension or abnormal haemodynamics, older children with bilious vomiting should be discussed with the surgical registrar on-call.
The situation in neonates and young infants is very different. In these age groups, bilious vomiting should be viewed as a sign of intestinal obstruction until proven otherwise.
The archetypal time-critical condition presenting with bilious vomiting in this age group is midgut volvulus, which occurs when an abnormally rotated midgut twists on its narrow pedicle, leading to progressive ischaemia and necrosis of the bowel. Midgut volvulus usually presents in the first 6 months of life (but can present at any age). For this reason, bilious vomiting in neonates and young infants almost always warrants immediate surgical review and investigation (normally an upper GI contrast study, in the absence of another obvious cause).
Suspected / possible Intussusception
Incidence is 1.6 - 4 cases per 1000 live births. With M:F 3:1. In >4 years of age M:F 8:1. 2/3rds of cases present before 1st birthday with Peak incidence aged 5-10 months. Event can often be preceded by URTI.
Once the possibility of a diagnosis of intussusception has been raised, patients usually undergo an urgent ultrasound scan. A supine abdominal film may assist in changing the index of suspicion but cannot categorically exclude this diagnosis.
Blunt abdominal trauma (including handlebar related injuries).
More than 90% of blunt abdominal trauma in children does not require a laparotomy. The management is largely conservative and involves identifying the injury, providing supportive measures and initial bed rest in an appropriate clinical setting. Once the child has been assessed, inform the surgical registrar. In some scenarios, it would be beneficial to notify the surgical team prior to the child’s arrival in hospital, so that they can be in attendance in resus when the child arrives. The patient should have peripheral intravenous access sited, and bloods for FBC, U&E, LFT, amylase, VBG and G+S. Check urinalysis for blood. Appropriate imaging should be discussed and organised following discussion / review by the surgical registrar. Consider other injuries and discuss with appropriate teams.
Possible Adhesional Intestinal obstruction
If a child has had a previous intra-abdominal operation and they present with bilious vomiting and abdominal distension, it is likely that they have adhesional bowel obstruction (caused by the strands of scar tissue in the abdomen kinking or obstructing the bowel). Adhesional intestinal obstruction can occur without prior intra-abdominal surgery. Most will require admission for observation with around half of children ultimately coming to surgery. Establishing good management early will make the child feel better and optimise the chance of conservative resolution.
Post-operative wound problems
May or may not require admission. Assess - if evidence of infection treat with antibiotics. Collections may require drainage. Arrange for surgical review as required.
Post – operative surgical presentation
Should be seen by operating specialist team. If clinically unstable then initial stabilisation will be by the ED team in discussion with the operating specialist team.
Lacerations referred overnight with no significant associated injury and controlled bleeding can be asked to attend, fasted the following morning. Lacerations with tissue loss, and those sited on the limbs (especially hands and feet) and face, will require discussion with orthopaedics and plastic surgery respectively.
If the patient is not septic, these can be reviewed in the morning. If an abscess is referred overnight and is clinically well, the child can be asked to attend, fasted the following morning (location for review to be arranged with the on-call surgical team). Abscesses on limbs (especially hands and feet) will require discussion with Plastic Surgery or Orthopaedics.
Pilonidal or breast abscesses may require input from adult surgical services however the primary point of referral for this patient cohort from RHC ED will remain the on-call paediatric surgical registrar.
Pyloric stenosis is the most common cause of intestinal obstruction in infancy. It occurs secondary to hypertrophy and hyperplasia of the muscular layers of the pylorus, causing a functional gastric outlet obstruction. Incidence is 2-4 per 1000 live births, with peak age of presentation between 2 – 6 weeks of life. Approximately 95% of cases are diagnosed in those aged 3-12 weeks. History is of forceful non-bilious vomiting (“projectile”) typically with specific pattern of progressively projectile vomiting.
If clinical concerns about possible pyloric stenosis, then ensure that the following management steps are followed:
History of Hirschsprungs’ Disease
Hirschsprung’s Disease is a relatively uncommon condition where the innervation of the distal colon is abnormal. This can affect a varying length of bowel which leads to a wide spectrum of disease and clinical presentation. Almost all cases are prone to an aggressive form of gastroenteritis (Hirschsprung’s enterocolitis) and the risk of this persists, even following corrective surgery. The risk is higher in complex cases and those with associated anomalies or syndromes, such as Down syndrome. Over time these episodes become less frequent and severe, but should always be considered when there is a history of Hirschsprung’s disease.
All patients with PMHx of Hirschsprungs’ disease presenting with GI disturbance should be discussed with the surgical on-call team.
Children usually present with a subtle change in stooling (usually loose stools which can be offensive), distension and anorexia / vomiting - symptoms that in other children can be very safely managed at home. However, in the fulminant form of Hirschsprung’s enterocolitis these benign symptoms/ signs can progress in a matter of hours to septic shock and collapse. At present we have no investigation to predict who will follow a benign vs. fulminant course. Management is primarily with IV fluids, IV antibiotics and urgent bowel decompression, usually by rectal washouts. Prompt intervention on presentation may prevent rapid decline and speed recovery and discharge.
Around 1% of surgical circumcisions will bleed. The bleeding can be very significant and even life threatening. Bleeding rates from community circumcisions are unknown, but probably higher. Community circumcisions are primarily carried out for religious reasons in the Muslim community, often using a plastibell (the plastibell is a plastic ring which fits over the glans - a tie is then placed over this to stop bleeding and then the foreskin is cut away. Eventually the plastibell should fall off).
After assessment likely outcomes are:
This is where the foreskin is unable to return to its natural position having been retracted. The longer the foreskin is retracted, the more it swells up and the less the chance of a successful reduction. However, the vast majority can be put back with a simple technique:
Acute Scrotum? Torsion
A presentation where a child has acute pain in the scrotum with tenderness. It is often associated with swelling and erythema.
The differential diagnosis is extensive but, with a few exceptions, making the diagnosis clinically or with simple investigations is not possible and the default position should be to surgically explore (medico legally it is difficult to defend missing a torsion). As the time limit for successful recovery of a torsion is <6 hours these should be referred to the surgical registrar immediately.
Exceptions are as follows:
Once diagnostic experience increases, you may become more comfortable assessing and considering some of the exceptions. However, the default position must always remain referral and assessment by surgical registrar.
Post OP hypospadias
The majority of hypospadias surgery is performed as a daycase procedure with the children being cared for at home by their parents with telephone advice from CNS Urology available during office hours. Many of the Children have a catheter inserted to drain their urine, this can be a urethral foley catheter, a suprapubic catheter or a dripping stent which empties directly into the nappy. The penis either has a dressing supporting it or is covered in glue. Some children have no catheter inserted and the wound is covered in dermabond. This dermabond lifts like a scab after 5 or 6 days to reveal the underlying repair.
Listed below are some common post operative problems with their management.
Surgical or CNS urology review is required if the simple measures above are not improving the situation. Surgical review is definitely required where there is excessive pain, penile swelling, temperature and or urinary retention.
Red foreskin (balanitis)
A common complaint is a red painful foreskin that causes pain on urinating.
Last reviewed: 01 October 2019
Next review: 31 October 2021
Author(s): Mr Timothy Bradnock (Consultant Paediatric Surgeon, RHCG) and Ms Boma Lee (Consultant Paediatric Surgeon, RHCG) – on behalf of Paediatric Surgical and Urological services)
Co-Author(s): Correspondence author: Dr Steve Foster (Consultant in Paediatric Emergency Medicine, RHCG ED)