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Pediatric GU and Endo Emergencies

Pediatric GU and Endo Emergencies. S. McPherson Dec 11, 2003 . What are some causes of painless scrotal/testicular selling?. Hydrocele Testicular tumor HSP Varicocele Inguinal hernia Idiopathic scrotal edema. How do you diagnose a hyrdocele?. Enlarged scrotum Fluid may transilluminate

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Pediatric GU and Endo Emergencies

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  1. Pediatric GU and Endo Emergencies S. McPherson Dec 11, 2003

  2. What are some causes of painless scrotal/testicular selling? • Hydrocele • Testicular tumor • HSP • Varicocele • Inguinal hernia • Idiopathic scrotal edema

  3. How do you diagnose a hyrdocele? • Enlarged scrotum • Fluid may transilluminate • Not painful • No palpable mass • Usually right sided • May need an ultrasound to to differentiate cause of hydrocele • Arrange outpatient follow-up

  4. How can you differentiate btn a hydrocele and an inguinal hernia? • History of straining causes swelling • Hernia may have bowel sounds on auscultation • Hernias can be felt at the internal inguinal ring and hydroceles cannot

  5. How do varicoceles present? • Usually > 10 yrs old • Usually painless unilateral selling • Worse when standing • “bag of worms” • What might lead you to believe there is something sinister causing the varicocele? • Right sided • Acute onset of left sided • When might they need surgical correction? • Pain • Bilateral • Decreased spermatogenesis • Testicular hypotrophy

  6. What are some painful causes of scrotal/testicular swelling? • Torsion • Epididymitis • Torsion of the testicular appendage • Incarcerated hernia • Testicular rupture • Hemorrage into testicular tumor

  7. How does testicular torsion present? • Acute scrotal pain • Scrotal swelling • Negative cremasteric reflex (may be present if early or incomplete torsion) • Abnormal position of testicle (retracted may have transverse lie) • Swollen testicle • Nausea, vomiting, fever, abdo pain

  8. What should you do if you strongly suspect a torsion? • Surgical consult ASAP • If any appreciable delay can try manual reduction • How do you manually reduce a torsion? • Provide adequate analgesia/sedation • Rotate testis from medial to lateral until completely untwisted

  9. What is the role of ultrasound? • Used in early and equivicle cases to help confirm the diagnosis • If strongly suspicious of torsion after Hx/Px you shouldn’t delay surgical consultation to get an U/S • Sensitivity 82-86%, specificity ~ 100% PEMR Mar 2003

  10. Why is time so important in the treatment of torsion? • Success rates post detorsion • < 4 hr 96% • 4-8 hr 93% • 8-12 hr 80% • 12-24 hr 40% • > 24 hrs < 10% Ann Surg. 1984;200:664-73

  11. How can you differentiate testicular torsion from torsion of the appendage? • Age for appendage torsion usually 7-12 • Early pain may be localized to upper pole with remainder of testis nontender • Early may see blue dot sign • U/S shows normal or increased blood flow to testis

  12. What is the treatment for appendage torsion? • Analgesia • Anti-inflammatories • Rest • Should resolve in 2-12 days

  13. How do you make the diagnosis of epididymitis? • Rarely seen in prepubertal boys • Onset of swelling and pain usually more gradual than with torsion • Most will have cremasteric reflex • Early on can often localize pain to epididymis • May have + Prehn’s sign (relief of pain with elevation of scrotum) • May have dysuria, frequency, fever, pyruria • U/S increased blood flow to testis

  14. How do you manage epididymitis? • Urinalysis, test for chlamydia and gonorrhoeae • Analgesia, sitz baths, elevation of scrotum • Antibiotics: • Nonsexually acquired: TMP/SMX x 10d • Sexually acquired: 125 mg Ceftriaxone IM and Doxy 100 bid for 10 days • All prepubertal and epididymitis with a UTI should be investigated for structural abnormality with U/S and VCUG

  15. What are causes of penile pain and or swelling? • Balanitis/balanoposthitis • Paraphimosis • Phimosis • Penile tourniquet syndrome • Insect bite • Generalized edematous states

  16. What is balanitis and how do you treat it? • Inflammation of the glans +/- foreskin • Causes: • Infection • Chemical irritation • Trauma • Contact dermatitis • Treatment: • Adequate hygiene • Sitz baths • 1st generation cephalosporin for 5-7 d if cellulitis

  17. What is paraphimosis? • Inability to reduce the foreskin over the glans • Can cause a tourniquet like effect • May get infected • How can you fix it? • Put ice water in a glove over the glans for 5 min then circumferential compression of penis from glans to base, hopefully foreskin will slip over • Manual reduction “turn sock inside out” • Circumcision or dorsal slit if all else fails

  18. How do UTI’s present in kids? • Neonates: poor feeding, vomiting, jaundice, irritability, lethargy, sepsis • Infant: fever, vomiting, diarrhea, symptoms as above • Children: fever, dysuria, abdo pain, hematuria, cloudy foul urine, incontinence, eneuresis, frequency, hesitancy

  19. What is the incidence of UTI’s in febrile kids? • Neonates: 4.6% • < 1yrs 5.3% • 2.5% boys • 8.8% girls • Recurrence rate 18-26% in the first year (recurrence decreases with age) Emerg Med Clin Aug 2001

  20. When should you work up a UTI? • All neonates with fever, and signs/symptoms listed earlier • Febrile girls < 2 yrs without another obvious source • Febrile boys < 6 month without an obvious source • Children with signs and symptoms suggesting a UTI

  21. How should you get the urine specimen? • < 2-3 month: cath or suprapubic aspiration • < 2-3 year: cath or suprapubic aspiration is best. Can do a bag specimen but if at all positive on microscopy will need a cath or aspirate to confrim • > 2-3 yr: clean catch mid-stream Emerg Med clinic Aug 2001

  22. How do you do a suprapubic aspiration? • Local anesthesia • Perpendicularly insert 21 or 25 gauge needle one finger breadth above the pubic symphysis • Aspirate out urine

  23. How good is the urinalysis?

  24. How do you treat a UTI? • < 3 months: admit with iv amp and gent • > 3 months and febrile: • Conservative: outpatient iv antibiotics (2-3rd gen cephalosporin) until afebrile • Less conservative: one dose parenteral antibiotics (gent or ceftriaxone) followed by 10-14 days of oral • 10-14 days oral • Uncomplicated cystitis • 7-14 days oral (TMP/SMX, Cephalexin, amoxicillin, cefixime, nitrofurantoin); 7d if > 2yrs old

  25. What follow-up should you arrange? • If febrile should be seen in 24-48 hr • Arrange for pediatrician or family MD to work up for structural abnormality • All 2m-2y with first UTI should have VCUG and U/S Pediatrics.1999;103:834-853 • Some advocate all boys with first UTI regardless of age and girls < 5yrs

  26. How do children in DKA present? • Initial presentation of 20-40% of new IDDM • May have Hx of polayuria/polydipsia before decompensation • Nausea, vomiting, abdo pain, increased listlessness • , altered LOC, Coma (< 10%) • Signs of dehydration, Kussmaul resps, ketone smell of breath, abdo tenderness • Elevated serum glucose, ketones in urine, pH < 7.3, HCO3< 15

  27. How do you manage a child in DKA? • Fluids: • 20ml/kg NS over first hour (bolus if in shock) • Replace rest of fluid deficit over 24-48 hr • Assume dehydration is 10% of body weight • Lytes: • Watch K+, pt will be deplete even if initial labs normal • Replce K+ after initial fluid rescussitaiton and pt has urinated and follow lytes q4h • Insulin: • Infusion 0.1U/kg/hr, don’t bolus • Follow chemstrip q1h

  28. What about HCO3? • Not recommended in DKA • May increase risk of cerebral edema

  29. How is cerebral edema diagnosed and what is the risk? • Occurs in ~ 1% of all DKA • Responsible for 50-60% of diabetes related death • Mortality rate up to 90% • Onset within 24 hr of treatment • Irritability, disoriented, confused, lethargy, focal neuro findings, fixed dilated pupils, resp arrest • CT evidence or cerebral edema

  30. What are the risk factors for cerebral edema? • NEJM. 2001;344(4):264-69 • 61 pt with cerebral edema compared to random controls and matched controls • RISKS: • High initial BUN (RR 1.8 for every increase in 9mg/dL) • Low initial PCO2 (RR2.7 for every decrease in 7.8 mmHg) • Treatment with HCO3 (RR4.2) • J of Pediatrics. 2002;141:793-7 • Used the same 61 kids above • RISKS: • High initial BUN • Greater neurologic depression at time of dx • Intubation with hyperventillation

  31. What is CAH? • Inborn errors of steroid synthesis • How does it present? • Acute salt-wasting crisis • 2-5 weeks after birth • Poor feeding, poor weight gain, lethargy, irritability, vomiting, potentially shocky and acidotic • Ambiguous genitalia

  32. What should you do if you suspect an acute salt wasting crisis? • Get lytes, glucose and cap gas • Usually have high K+ and low Na+ • May have normal or low glucose • Blood for adrenal steroid profile (before hydrocortisone given) • Fluid bolus 20ml/kg NS • Correct hypoglycemia • 2mg/kg hydrocortisone

  33. Hypoglycemia….what should you know • How to treat • 0.5-1g/kg iv bolus • Neonates D10 • Children D25 • Adolescent D50 • Then 6-8mg/kg/min • Think about what caused it

  34. Causes of hypoglycemia • Neonatal: infant of diabetic mother, prematurity, hypothermia, systemic illness, adrenal hemorrhage, maternal meds • Endocrine: hyperinsulinism, hypopit, adrenal deficiency, hypothyroid • Inborn errors of metabolism: carbohydrate disorders, amino acid disorders • Toxic: salicylates, ETOH, oral hypoglycemics, insulin, propanolol • GI: fasting, malabsorption, liver failure, malnutrition

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