Wound care
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,-Wound cleansing - irrigation which reduces bacterial contamination and
prevents subsequent infection; tap water and sterile normal saline can be
used for irrigation; use a large syringe to provide force; remove all foreign
debris to decrease infection risk and prevent skin tattooing; chlorhexidine
or povidine-iodine solution may be used to clean the skin around the
wound but not the wound itself; hydrogen peroxide and alcohol are not
recommended
-Bites - animal and child - tetanus booster and rabies prophylaxis, analgesia
or anesthesia, debride tissue and remove foreign matter, using NS, irrigate
the wound, 3-5 day course of antibiotics for all human and cat bites
(Augmentin), bites involving the hand and foot should be allowed to drain,
bite wounds more than 8-12 hours old should not be sutured
-Refer children with severe bites; surgery consult if there is nerve, tendon,
or ligament injury
-Report dog and animal bites to animal control
-Puncture wounds - pain control, cleanse with antiseptic solution, irrigate,
ensure no foreign objects, imaging studies; refer if one, growth cartilage, or
a joint space; cover with a bandage and let it heal with secondary intention
without any repair; if simple - no antibiotics
-Abrasions - scrub with soap or antibacterial cleanser; small can be left
OTA or have a small bandage; larger abrasions heal quicker if moist; cover
large abrasions or ones of the hands, feet, and areas overlying joints;
antibiotic ointment may be applied especially to elbows and knees, instruct
them to wash at least every 24 hours and reapply dressing and ointment
until a dry scab forms; tetanus shot if the wound is significant or if the child
has not received a tetanus immunization within 5 years
-Lacerations - repair with staples, sutures, glue or tape; face, hands, or
genital areas need a specialist like an orthopedic surgeon or a plastic
surgeon; make a decision whether to close the wound, anesthesia, do not
shave hair because it increases infection, clip hair; wound cleansing
(above), wound exploration - for foreign objects, deep tissue layer damage,
injury to nerve or blood vessel or joint, wound debridement; wound
closure, dressing, immunization, antibiotics - not indicated if clean wound;
may be helpful in contaminated wound; suture and staple removal
-Avulsions - control bleeding with pressure an elevation; absorbent clean
dressing to hold pressure; stitches if deep; can reattach skin if there is still
skin attached to the wound and it is healthy; skin graft
-Augmentin - human bite
-Dog - don't close and irrigate
,Inguinal hernia
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-A scrotal or inguinal swelling (or both) that results in bulging of abdominal
contents through a weakness in the abdominal wall
-Presentation - swelling in inguinal area, scrotal area or both; hernia is
reducible on distal end, child is fussy and has a distended abdomen if the
hernia is incarcerated; silk glove sign - a sensation of two surfaces rubbing
against each other while one palpates the spermatic cord as it crosses the
pubic tubercle
-If a child is seen with a hernia, an attempt should be made to reduce it,
and the child should be referred to a surgeon or urologist for repair within
1-2 weeks; these do not resolve spontaneously
-Premature infants should have it repaired prior to discharge
-If not easily reduced, painful, hard, tender, or red mass is present - refer
immediately
-If reduction is difficult and ischemia is ongoing, hospitalization and
surgical repair within 24-48 hours
-Teaching - if surgery is deferred, parents must be aware of the signs and
symptoms of incarceration (tenderness, redness, crying, nausea, vomiting,
abdominal distention) and be cautioned to seek immediate evaluation by a
health care provider should they occur
Vomiting and cyclic vomiting
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, -Vomiting - the forceful emptying of gastric contents coordinated by the
medullary vomiting center and/or the chemoreceptor trigger in the brain
-Cyclic vomiting - uncommon, idiopathic disorder that is characterized by
recurrent, sudden-onset attacks of repeated retching and vomiting that are
separated by symptom-free intervals of weeks to months
-Accompanying symptoms include pallor, listlessness, appetite loss,
nausea, diarrhea, abdominal pain, fever, dizziness, headache, and
photophobia
-May be associated with migraine headaches and abdominal migraines
-Diagnostics - electrolytes including HCO3, upper GI radiographs to
exclude malrotation, abdominal US in refractory cases
-A diagnosis of exclusion
-Management - Prophylaxis during the well phase and acute and
supportive measures during the vomiting and recovery phase; prophylactic
medications - cyproheptadine in 5 year olds and younger & amitriptyline in
older than 5 years; in acute phase replace fluids and calories, relaxation,
exercise, keep a journal, recognize triggers, avoid trigger doods, carbs for
high energy demand times, zofran, PPIs
-Referral with red flag symptoms or doesnt respond to treatment -
worsening episodes, abnormal neuro exam, abdominal signs like
abdominal tenderness or pain or hematemesis
Wilms tumor
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-Aka nephroblastoma
-A primary malignant renal tumor
-Presentation - may be asymptomatic; nonpainful abdominal mass,
occasional abdominal pain, malaise, fever, loss of appetite, vomiting, blood
in urine; HTN, associated congenital anomalies - aniridia, hemihypertrophy,
GU anomalies
-A unilateral smooth, firm, abdominal mass
-Diagnosis - CBC, UA for anemia and hematuria; CT of abdomen - to see
presence and function of other kidney, evidence of bilateral involvement,
lymph node or liver involvement; abdominal and pelvic US - to see if tumor
is intrarenal; chest x-ray, CT of chest to r/o metastasis
-Diagnostic workup is the initial urgent priority, with referral to a pediatric
cancer center for treatment; surgery removes the affected kidney and
Give this one a try later!
,-Wound cleansing - irrigation which reduces bacterial contamination and
prevents subsequent infection; tap water and sterile normal saline can be
used for irrigation; use a large syringe to provide force; remove all foreign
debris to decrease infection risk and prevent skin tattooing; chlorhexidine
or povidine-iodine solution may be used to clean the skin around the
wound but not the wound itself; hydrogen peroxide and alcohol are not
recommended
-Bites - animal and child - tetanus booster and rabies prophylaxis, analgesia
or anesthesia, debride tissue and remove foreign matter, using NS, irrigate
the wound, 3-5 day course of antibiotics for all human and cat bites
(Augmentin), bites involving the hand and foot should be allowed to drain,
bite wounds more than 8-12 hours old should not be sutured
-Refer children with severe bites; surgery consult if there is nerve, tendon,
or ligament injury
-Report dog and animal bites to animal control
-Puncture wounds - pain control, cleanse with antiseptic solution, irrigate,
ensure no foreign objects, imaging studies; refer if one, growth cartilage, or
a joint space; cover with a bandage and let it heal with secondary intention
without any repair; if simple - no antibiotics
-Abrasions - scrub with soap or antibacterial cleanser; small can be left
OTA or have a small bandage; larger abrasions heal quicker if moist; cover
large abrasions or ones of the hands, feet, and areas overlying joints;
antibiotic ointment may be applied especially to elbows and knees, instruct
them to wash at least every 24 hours and reapply dressing and ointment
until a dry scab forms; tetanus shot if the wound is significant or if the child
has not received a tetanus immunization within 5 years
-Lacerations - repair with staples, sutures, glue or tape; face, hands, or
genital areas need a specialist like an orthopedic surgeon or a plastic
surgeon; make a decision whether to close the wound, anesthesia, do not
shave hair because it increases infection, clip hair; wound cleansing
(above), wound exploration - for foreign objects, deep tissue layer damage,
injury to nerve or blood vessel or joint, wound debridement; wound
closure, dressing, immunization, antibiotics - not indicated if clean wound;
may be helpful in contaminated wound; suture and staple removal
-Avulsions - control bleeding with pressure an elevation; absorbent clean
dressing to hold pressure; stitches if deep; can reattach skin if there is still
skin attached to the wound and it is healthy; skin graft
-Augmentin - human bite
-Dog - don't close and irrigate
,Inguinal hernia
Give this one a try later!
-A scrotal or inguinal swelling (or both) that results in bulging of abdominal
contents through a weakness in the abdominal wall
-Presentation - swelling in inguinal area, scrotal area or both; hernia is
reducible on distal end, child is fussy and has a distended abdomen if the
hernia is incarcerated; silk glove sign - a sensation of two surfaces rubbing
against each other while one palpates the spermatic cord as it crosses the
pubic tubercle
-If a child is seen with a hernia, an attempt should be made to reduce it,
and the child should be referred to a surgeon or urologist for repair within
1-2 weeks; these do not resolve spontaneously
-Premature infants should have it repaired prior to discharge
-If not easily reduced, painful, hard, tender, or red mass is present - refer
immediately
-If reduction is difficult and ischemia is ongoing, hospitalization and
surgical repair within 24-48 hours
-Teaching - if surgery is deferred, parents must be aware of the signs and
symptoms of incarceration (tenderness, redness, crying, nausea, vomiting,
abdominal distention) and be cautioned to seek immediate evaluation by a
health care provider should they occur
Vomiting and cyclic vomiting
Give this one a try later!
, -Vomiting - the forceful emptying of gastric contents coordinated by the
medullary vomiting center and/or the chemoreceptor trigger in the brain
-Cyclic vomiting - uncommon, idiopathic disorder that is characterized by
recurrent, sudden-onset attacks of repeated retching and vomiting that are
separated by symptom-free intervals of weeks to months
-Accompanying symptoms include pallor, listlessness, appetite loss,
nausea, diarrhea, abdominal pain, fever, dizziness, headache, and
photophobia
-May be associated with migraine headaches and abdominal migraines
-Diagnostics - electrolytes including HCO3, upper GI radiographs to
exclude malrotation, abdominal US in refractory cases
-A diagnosis of exclusion
-Management - Prophylaxis during the well phase and acute and
supportive measures during the vomiting and recovery phase; prophylactic
medications - cyproheptadine in 5 year olds and younger & amitriptyline in
older than 5 years; in acute phase replace fluids and calories, relaxation,
exercise, keep a journal, recognize triggers, avoid trigger doods, carbs for
high energy demand times, zofran, PPIs
-Referral with red flag symptoms or doesnt respond to treatment -
worsening episodes, abnormal neuro exam, abdominal signs like
abdominal tenderness or pain or hematemesis
Wilms tumor
Give this one a try later!
-Aka nephroblastoma
-A primary malignant renal tumor
-Presentation - may be asymptomatic; nonpainful abdominal mass,
occasional abdominal pain, malaise, fever, loss of appetite, vomiting, blood
in urine; HTN, associated congenital anomalies - aniridia, hemihypertrophy,
GU anomalies
-A unilateral smooth, firm, abdominal mass
-Diagnosis - CBC, UA for anemia and hematuria; CT of abdomen - to see
presence and function of other kidney, evidence of bilateral involvement,
lymph node or liver involvement; abdominal and pelvic US - to see if tumor
is intrarenal; chest x-ray, CT of chest to r/o metastasis
-Diagnostic workup is the initial urgent priority, with referral to a pediatric
cancer center for treatment; surgery removes the affected kidney and
