儿童非创伤性手术急症.pptVIP

小組教學(一) 兒童非創傷性手術急症 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. 初級評估(1/2) PAT Appearance: Lethargic, poorly responsive Work of breathing: Effortless tachypnea (Compensated for metabolic acidosis) Circulation: Delayed capillary refill, cool, pallor, mottled extrimities, rapid pulse, poor skin turgor, abdominal wall erythema 初級評估(2/2) Vital sign HR 180bpm, RR 45/min, BP: 60/40 mmHg, BT 37.8C, BW 3010gm A: Open B: Tachypnea, grunting, breath sounds clear C: Color pale, skin warm and dry, tachycardia, brachial pulse decreased D: Tone decreased E: No sign of injury, no rash 重要病史 S: Bloody stool and abdominal distention A: No allergies, formulafed M: None P: Born premature,C/S due to maternal preeclampia L: Just prior to arrival but vomited E: No feeding since 6 hours ago 詳細理學檢查 Head, neck, lung, and heart examination are normal except for tachycardia ABD: distended, bowel sound: hypoactive Skin:mildly shiny and erythematouos Femoral pulse(+) Capillary refill : delayed 診斷工具-Plain film 檢驗工具 WBC 12000/mm3, Hb 12.0, PLT 78000mm3, S/L/M=90/3/4 ABG: PH=7.25 PCO2 34 PO2 65 HCO3 14 , BE=-8 Glucose 70, Na 135 k 4.3 Stool examination: OB(++) 最後診斷 Hollow organ perforation with septic shock R/O Necrotizing Enterocoltis NEC典型發現 Metabolic acidosis Neutropenia Thrombocytopenia Pneumatosis intestinalis Intrahepatic portal venous gas Pneumoperitoneum 急診處置 ABCs( Endo size 3.5-4.0,IV N/S 60cc) OG for decompression Blood culture Antibiotics(AMP+GM+Metronadazole) NPO Early PEDS consultation Admission 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. 初級評估(1/2) PAT: Appearance: alert and fearly Work of breath: non-labored Circulation:pale conjunctivae and mucous membrane Vital signs: HR 140, RR 24, BP 100/60, T 37°C Wt 15 kg 初級評估(2/2) A: Open, no stridor B: Non-labored, breath