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Seen you. Yeah, good afternoon, sir. Yeah, good afternoon. Yes. Thank you again for agreeing to teach us. Um We've all been looking forward to this session. I'll just inform the group that we've started. So, um I hope more people would join, but I was going to waste your time. You can start. All right. All right. Thank you. So I would um mute and turn on my video now, so not to interrupt. All right. So let me share the slide. All right. Am I audible? And am I uh the slides being seen? Um answer those questions, sir. What I said, uh Can you hear me? And uh is the slide visible? Oh, yes. I said yes to both questions. I can hear you and I can see. Yeah. Yeah. Yeah, thanks. All right, good afternoon uh colleagues. Uh today I will be discussing the management of common emergencies in pediatric surgery. Uh I online Cash eye on me. So we just take it through the following uh outline and uh as much as we can, we will try and finish this. So, um we, we will be looking at this from two aspects. But first, let's uh, look at what emergencies are. These are sudden unexpected events that put the health of a child at risk. And, uh, when talking in terms of pediatric stroke surgery, uh, the emergency falls into one of these four or a combination of those four groups, they, it could be an obstruction, an ischemic event, it could be perforation or bleeding, whatever emergency you can think of in a surgery, generally speaking, will be one of these four. Now, uh it's not as though this is mutually, these uh items are mutually exclusive. Uh Each 1 may interact with the other or each 1 may lead to the other one. Uh For instance, a child with an obstructed hernia can have it strong leads. That is the uh blood supply to the testis or to the intestine that is uh herniating could be compromised. That is ischemia and uh with time and the passage of time, such a bar that is uh ischemic can pay for it and they can also be bleeding from the free ends of the vessels. So I've described all four from a single uh pathology. So they are not mutually exclusive boards. One can actually identify these as the basis for surgical emergency. This does not uh remove the importance of other things that comes to play. For instance, in obstruction. In addition, the child or whoever it is keeps on vomiting and in the process of vomiting, there is dehydration, dehydration is strictly speaking, not a surgical emergency, it is a medical emergency, but a surgeon has to confront uh dehydration in the process of managing obstruction and even other things such as ischemia and perforation. So there may be an overlap of these categories. But the most important thing is the fact that emergencies uh puts the health of a child at risk and that if there is not uh an urgent and appropriate intervention, there may be a loss of life or organ failure. So, the purpose of I uh of attending to emergency is to prevent this loss. And uh I want to look at the categories in the in first way that I have mentioned, I mentioned that uh it could be looked upon as uh four events here. You will see that there are three events that is intestinal or an obstruction, uh perforation or a vascular accident in which the ischemia and bleeding are both arms of the vascular accident. And again, one could look at uh emergencies in Children in terms of whether uh it is congenital, which is something that is common with Children such as a child having uh mal rotation with or without vou los. And then for Children that are presenting much earlier, uh it may be from a child that has uh intestinal atresia or an exposed bowel. We uh which is the the risk of uh perforation, uh strangulation and pa takes precedence and then there's also infective one and the vascular origin. So these are all categories of uh these emergencies that one can take a look at. That's good. So, um in terms of the age, one can look at the different presentation, one could present in the neonatal life uh with several things. Uh notably of which I, I have uh hy lipid NRI he SIA uh which will be talking about LA down there is also and then you can also, you can walk and also have to go work. Hello? Oh, so am I being hurt? Um Yes, you are. Yes, you are. We can hear you. Ok, good. All right. All right, good. So, uh, things that can occur especially in early childhood, not exclusive to early childhood. Anyway, includes corrosive or catic ingestion and uh foreign body ingestion or aspiration, uh uh o of uh occurrence of test to and then other trauma related injuries. Uh Other possible presentation are things that we've discussed earlier in the other two previous slides, intestinal obstruction, peritonitis or perforation ischemia. Uh There could also be area obstruction or bleeding uh from any. Oh Emma. Yeah, I see in pediatric surgery. And uh therefore the first priority is resuscitation because uh for each child, the starts by giving small warnings and uh, when they come with those symptoms, one needs to uh prioritize uh the resuscitation of such a child. And the first thing to take care of is the hemodynamic stability by that. I mean, uh, the cardiovascular status. Uh patient must have adequate circulating volume which is able to carry the second part, which is oxygen, which is able to carry oxygen around the body. So there should be adequate oxygenation. So, uh hemodynamic stability is typically achieved with uh IV fluid repletion. If there is need to transfuse uh because of anemia, one needs to uh transfuse and for oxygenation once one has checked and uh the oxygenation is not adequate enough. Uh 1 may need to uh give supplemental oxygen and then one is to give analgesia to make the child comfortable. And then also to be able to know the adequacy of the resuscitative efforts by way of uh reducing uh vital signs like pulse rate, which normalizes after one has resuscitated adequately and taking care of a pain and then one needs to monitor adequately. That is by repeat examination, one needs to repeat examination, uh skin to go uh pulse rate. These are all things that one needs to continually monitor and check to see if it is adequate enough. So as to go back to resuscitate if need be and then uh in many emergencies, nasogastric tube may be necessary as well as ureter catheter is not in all. But these two are also very important in monitoring. Nasogastric tube. Uh mainly uh in case of suspected uh gastrointestinal bleeding. Uh 1 may need to pass a nasogastric tube which will help monitor what is coming out the effluent if it remains bloody, one can uh expect that the bleeding is still ongoing. Uh And in terms of the urethra, in terms of the urethral uh one, we need to monitor the perfusion states of uh now the other mhm is diagnosis, which is like as usual. So we I deliberately did not say anything about that because what we are focusing on is with respect to all emergencies, not all emergencies will require those uh the the primary survey. And uh in fact, those ones are usually for trauma, which is a subset in this. And that's the reason why we are using this format. Now, after one has made a definitive diagnosis through the tripod of uh history, physical finding and appropriate investigations, uh One would need to take the definitive care which includes uh removing the course uh where in case uh a patient has perforation with peritonitis. The cost is the source of the peritonitis. So the first thing is to achieve a source control and then reestablish the bowel integrity that is reestablish anatomy. And then again, you prevent recurrence of such things. And then in the postoperative care, one is to watch to make sure that one pays attention to feeds and fluids. In other words, we need to make sure that the patient gets uh before they are able to feed the adequate food for each day, which can be calculated based on uh the uh 4211 rule or the 150 20 rule. So these are things that matter, that one needs to do. So you need to replete fluid, you need to give maintenance and also you need to take care of calories. And that's the reason why one needs to give adequate calories per day, which typically uh one would depend on the weight of the child. Usually we use a 10% dextrose in ac line in 1/5 strength C line. That's typically what we do here uh in my own center. But again, uh one needs also to take care of feeds that as soon as the child is able to, one needs to start the child on feeds. Uh because it's very important that once the gods is functioning, please use it. It has a lot of advantage, prevent bacterial translocation. Uh also helps in maintaining the uh health of the intestinal uh mucosa. Notably the uh the epithelia, the epithelial layer, it maintains the integrity of that one. And then in the postoperative period, one needs to pay attention to analgesia. Analgesia is very important and one cannot overemphasize uh the importance of analgesia, for instance, in patients that have oper abdominal and thoracic s uh analgesia is very important to help them to breathe. And this will prevent them from having uh postoperative atelectasis because a child that is in pain will not want to breathe. And this put them at risk of that at the leg disease, which can progress to give the child uh pneumonia. So these are all things that one needs to do. And then if there is need one needs to place on antibiotic and appropriate organ support. For instance, uh for someone that has uh uh say um cardiovascular collapse or that has a shock one, we need to give uh inotropic to support until the heart can restart its function. Or even uh for those with uh acute kidney injury uh during the immediate postoperative period or maybe preoperative, one is to support the renal system when we need to do hemodialysis, uh to support the child until the renal system can uh start functioning back. Even the oxygen that we give to uh patient is very, very important in the postoperative period. And ideally all patients uh that are postoperative should get uh supplemental oxygen to support in the immediate postoperative period. Now, more importantly, after uh the acute phase of emergency has gone off, uh patient has adequate postoperative care. One we need to give nutritional support and if there is need, we need to continually support uh the organs that are fledging and then uh such patients will require followup. Uh Now let's look at uh specific pieces uh that one would need. Mhm One me uh to manage especially the commons in June, right? Yeah, I can. The first one we'll be talking about is esophageal atresia. And uh this is uh a condition in which there is discontinuity in the doctor. Sorry. I'm so sorry to interrupt. So we can see this. Sorry. Ok, we can see it now. Thank you so much. Yes, we can see it now. Can you still see it? All right. Yes, I can. Yes, you can. So thank you. Uh Good. You're welcome. So, um esophageal atresia is something that one sees, not so common, but the problem with it is that uh when one does not take care urgently, uh the likelihood of death is is more. So, esophageal atresia usually presents typically present in the NITA period. And uh uh they usually are classified into vi types. And that's the reason why I put that usually there because there are obviously some of the spec as classified by grows in the 1953. You can, can you see the slide here. So is the top most of this question. Uh The classification that we can see here includes that of gross votes and uh la which are all important. But the one that uh is most widely used, especially by pediatric. So uh is the gross classification of 1953. And uh the first type is gross type A which is uh the pure AIA has a proximal atresia and a dis uh or is that usually it's long gap, have a uh a, a presentation that is typical. And then uh for grows type B is the one that has a proximal fistula with the distal at SIA and we can see the fistula here, fistula connection to the trachea and then the uh esophagus is without a fistula. So, uh this he uh, is not so common. It's just occurs in 1%. You can see the incidence on the second line. And uh this type is actually very rare to see in living patient. Maybe in autopsy, one will find it because anything that the child gets fed with, go get fed with goes directly into the lungs and uh can choke the child and then, then uh grows type C which is the most common. 86%. I've seen. Most of these, I've only ever seen one or type A are the two most common. So DC is the most common, which is a proximal Ayia with a distal trays, phia fistula and then a growth type D which in which there are separate fistula from both the proximal and distal art segment. And then a type E in which there is a fistula between the and the a, a continuous esophagus and the trachea. And then the gross type F which is uh esophageal stenosis. So, typically, uh such a patient will with uh 14 and choking of feeds. So that's what they would typically present with whichever uh type uh we are talking about even uh with gross type E and F, both of them will still present with uh fro and choking on feeds. Uh However, the rest of the nasogastric tube at about 10 centimeter from the tip of the nostril occurs only with the gross type a and gross type C as uh we have seen earlier uh with a growth type d that has a separate fistula. Uh 1 may not necessarily find uh 1 may end up passing the nasogastric tube into the uh trachea inadvertently either through the fistula or uh through the uh larynx. So, one needs also to consider the fact that uh they may have uh associated anomalies. So, one needs to, when uh doing the clinical evaluation, one needs to evaluate for this. Uh especially notable is the vector anomaly cal. Uh in terms of vertebra, anorectal malformation, vertebra anomalies such as ami vertebra, uh vertebra, agenesis, uh spina bifida, whatever and then uh cardiac uh uh cardiac anomalies uh in which uh it could be patent docs, um atrial septal defect and the likes and then the tracheoesophageal fistula like we mentioned, then they may also have uh renal anomalies or radial anomalies. It could not, it's not mutually exclusive, both could coexist there, coexist there and the L is for limb, they could also have limb deformity. In addition. So, uh when such a patient presents, the first thing that won do is to pass a tube. And uh this tube is a double lumen tube that is able to vent uh dis suction in pressure into the atmosphere at the same time as you are. So it because the typical problem that one will have when you have, when you pass a nasogastric tube into a whole viscose is the fact that the whole viscose tends to collapse. And then in the process of collapse, uh it's as it collapses, the mucosa gets into the or to each. Uh uh uh yeah, the suction domain makes it such that the outer domain houses the fluid that is being suctioned, which is saliva of the patient. And then the inner tube is the one that now suctions it. But with space in between that is connected to the atmosphere, uh this allows uh adequate venting of the uh tube and it will not catch mucosa. So you can suction continuously through a low pressure function. Uh And that way the child will be dry, the child will not have choking, the child will have even as the child swallows the saliva, one is able to suction all of the saliva through the proxima pouch. And then one, we also need uh to uh in evaluate further, which is to take a baby gram with a tube in situ that tube will have uh typically the tube, we have a uh a radio pic line on it. Now, there is a uh there is an adaptation that is being used in Ilori. Uh It is called an A ICU. That's er it was designed by Professor Abdur Ra Man. Uh It's uh uses two tubes that one can make using a five French fitting tube and placing it in a 10 frame feeding tube. So one cannot pass that and then one will be suctioning on the five frame which will prevent uh the uh 10, the mucosa from prolapsing on the 10 frame feeding tube because it has the opportunity of venting through it. Uh It's a bit difficult to describe here, but uh you should be able to find something about it if you uh check online the Aris tube a rise. Uh So wont now, please. So the slides keep going. Yes, it keeps popping up and off. So I don't know if there's anything. Ok. So we can see it now and after it goes off, wait coming up, let me uh uh let me if so. Um uh uh uh um I see it now. Yes, we can. Yes, I can. All right, you can see it now. Yes. Yes, thank you. So, uh one would need to do, yes, one will be able to see the distal extent of the pouch. In addition, the baby gram will also help us to be able to classify what type of esophageal atresia it is whether it's a gross type C if it's a growths type c, which is the most common, one would also see that there is a within the power within the bowel of the child. So that confirms that there is a com uh uh a communication between the uh trachea and the uh gastrointestinal tract, the distal gastrointestinal tract through the pro uh the distal pouch, as we can see here. So this is what I was describing. So if there is no connection with this one, then the only way I can get into the gastrointestinal tract is through the dis a uh distal esophagus that is connected to the trachea. So one would also need an echocardiogram to be able to identify if there is any associated congenital heart defects and would need a hemogram, electro and creatinine and then to group and cross match as indicated. And then after adequate evaluation of the patient, one needs to classify the child based on the operative risk. There are three main uh means of classification and uh these three are developed in sequence is not only three, there are still other uh classification uh prognostic uh indices, but these are the commonest. One. the oldest, one of them is the water testing. What testing is based on uh weight on the bat weight of the child, a bat weight of 2.5 uh kilograms or 2500 g. And then whether or not the child has a pneumonia. And then the third criteria is associated uh congenital major congenital anomalies. So those are the basis for classification and one can see all three classes based on what is in here. I didn't put speeds here but speeds is based on uh bad weight, the bad weight in the case of speeds is on 1.5 or 1500 g. And uh part of the reasons why speed uh based on 1.5 is because of the improvement with time on a neonatal intensive K. That's the reason why uh 1.5 has a, serves as the one that can be in speech classification uh or speech class one. And then uh there is also uh apart from er but weight, the second uh criteria in speeds is that of a major congenital heart defect. So those are the two main classification, uh main uh criteria for class fine in speeds. Whereas in the Montreal classification is mainly based on whether there is a ventilator dependence in the beginning of at the uh at admission. So if they don't have any or if it is minor or uh if there is uh if there is non, no dependence on ventilator, then uh it can belong to class one. And if there is no major anomalies, one can have them in class one. So those are the two criterias for classifying them. And then for those that are ventilator dependent but no other uh anomalies, they can still be classified as one. Whereas those that have ventilator dependence with or without uh uh major with, with or without uh major anomalies. But if they have a life threatening anomalies, they are automatically class two. So once one has classified, one can determine what's uh management, one would do four, class one and two or class A and B one can still do a primary eso esophagostomy for such a child. Uh And uh this is uh something that is very important is because what is being done for the child is a major procedure that uh one can only do on very healthy infants. So one can do a primary esopha esophagostomy for fits Children with a gross type c esophageal atresia. However, for those that have uh uh a grows type A, for instance, it's usually a long gap. Uh anomaly you can see here the defect is quite wide. But for such a patients, one would need to do an esophageal replacement and the replacement typically could be with the uh colonic interposition. One could also do a gastric pullup but in the interim, uh so that the child will be able to grow so that uh they can bear the major surgeries that will be done. The first thing to do for them is to put them on a cervical esophagus toy that is bringing out the esophagus through the neck so that saliva will be able to rule out. And then one can also give them sham feeding. Then in addition, such patients will have a gastrostomy, gastrostomy. So a tube gastrostomy two week, they can be feeding and then while feeding them simultaneously, one also give them sho uh WW will give them sham feeding which will help them to also maintain the soling reflex. And also in those patients that have growth type C, one can do uh the procedure if they are watering uh three, if they are watering three, uh what c or uh speeds, class three or Montreal class three, these are categories that 1 may need to do a breech for that is uh the uh cervical is of a toy and then a a and uh and then a gastrostomy or feeding, feeding gastrostomy. And then later on, one can do eso replacement. So that is that uh with uh the phage atresia, uh I won't talk much about uh the management later on. Now, the second uh issue that we'll be talking about in is the my got my rotation with volvulus. And this is a problem with the rotation and fixation of the myth go and is a potential source of intestinal loss, especially if the baby develops vvs. Uh uh typically, uh it's a cause as a result of a problem with embryology development in uter development in which the, during the second week, the God is still it. Well, by the fourth week of development, the God is just a straight tube that is supplied by the superior mesenteric artery that the mid God uh then later on, uh as development goes on, there is rapid elongation of the mid God which causes the physiologic herniation. And during this, in initial, a lot of develops and goes out of the, yeah, and goes out of the in abdominal cavity into the, uh, hello. Thank you. So, it seems there is a problem. Ok. Hello. All right. Let me just continue if there is no problem. Uh So what happens is that during the sixth week to the 10th week, uh, the bowel starts returning back into the abdominal cavity and by the end of the 10th, uh, by 16th week, uh, the bow would have returned in the process of returning the duodenum goes through a rotation around to the right of the uh superior mesenteric artery. It starts the rotation from that side uh in a 270 degrees rotation. And then the placement is such that the duo Jejuna junction which is fixed, which is the fixed point will be in the left upper quadrant. Whereas the ilia junction which is also the fixed portion uh or the relatively fixed portion of the uh mid God is going to be uh in the is going to be in the right Iliac area such that the uh axis is wide. Now, in the case of Matic or known rotation, as the case may be the gap between the two mobile parts, which is the s are the two fixed part, the si and the dual junction is so narrow and then the axis is now prone to twisting, which is what causes it to be prone to vvs. In addition, the lad band which crosses the Sico, uh which uh comes from the Sico to the liver is seen to cross and plaster over the duodenum, which can cause obstruction and therefore, uh such a child we with uh below vomiting, uh they generally, the abdomen is generally skiffle and then they have poor growth, especially if they don't have immediate problem. If there is a VLO, they may have v uh blood MS uh or even blood in the stool and they can have vascular collapse with abdominal distension. And then the anterior abdominal wall may have edema. Maybe the and the management is mainly uh resuscitation investigation should not be a thing that will delay intervention in the case of uh a child with belo vomiting. Any child, child with vilo vomiting is suspected to have malrotation with vvs on until proven otherwise. So, the most important thing is to rapidly resus the patient to render hemodynamically stable. Do the baseline investigation, especially the hemogram, uh electrolytes, ure and creatinine as well as uh getting uh blood for this surgery. And then such a patient will benefit from uh maybe an investigation such as a plain radiograph. The thing to make diagnosis with is is typically, especially if the patient is hemodynamically stable, is an upper G I series. Uh Here we see an upper G I series. This is a four year old boy that has a recurrence, abdo uh abdominal pain and povid pain. And you can see here, this is after about four hours and look and see here that the small boil is essentially on one side and then we have not even started see the large bo field because of the sloop. Uh, that is that? So, uh, the treatment essentially is the last procedure, last procedure is described by, uh, LA and, er, William LA. And er, the steps include uh evi of the bowel derotation if there is any VV loss and then release of the Lad band. Once one has released the land band, uh, one would, uh, want to widen the mesenteric base. This is done by uh dividing the an Cial leaflet of the mes and then bluntly teasing away so that the mesentery is widened, especially the base of the mesentery, one widens it so that, that narrow axis is widened and then it's less prone to uh Vu Lo and then once one has done that, uh, one needs to also do an invasion appendectomy, invasion appendectomy. In this, the reason for invasion is because we don't want to convert a clean wound into a clean contaminated wound because by breaching by doing a conventional appendectomy, one will have to breach the lumen, but this is done by placing a posting at the base of the sco, then deas the vermiform appendix and then using a lacri to push it from the tip of the appendix into the sco because you have de vais it, it will eventually, uh, slough off because it will get infected. But by putting a post string at the base and you are pushing it into the CCO it is slough off inside the intestine and the uh the wound will not be in any way contaminated. So once one is done with this, the next thing is to return the bowel fests the large bowel to the left and then the small boil to the right, such that one will have uh the bowel that is in the position of non rotation and then the patient is OK. So the other possibility, the other emergency, especially in the neonatal presentation uh is an erectile malformation which is uh an absent uh or abnormally sided anal opening, opening of the gastrointestinal tract. Uh This is as a result of um problem with uh the secretion of the gastrointestinal and the regal tract. So what's uh the child, the pathology that the child has is uh intestinal obstruction and they have a wide spectrum when we are talking about an erectile malformation. Uh Sorry, I didn't uh remember to put up a classification for it. But the most important thing is that it is an intestinal obstruction. So how do we take care of this? The first thing is to pass a nasogastric tube, pass the urethra catheter monitor urine output the nasogastric tube, of course, is for decompression. Similarly, in the uh patients with malrotation and VVE Los with or without VVE Los. So one is to pass nasogastric tube and then uh you know, uh give IV fluid uh do order investigation. You need also to investigate against other associated anomalies such as the Midline syndromes like uh oies that is uh on follow is on imperforate enos. Sorry, we don't use imperforate enos. Again, we use anal malformation but for the purpose of this, it is uh inos and this one is the ex C exstrophy specifically. Sorry, I I didn't bring a picture of these bos never mind. And then this one is spinal defects or spinal dysraphism. And then uh anorectal malformation of course, is associated with uh uh vector anomaly like uh esophageal SIA and many other things. So once you have passed a tube, you've placed on new pump uh aura and then you give IV fluid, you investigate appropriately uh cross the lateral radiograph which uh you can see here which shows that one can see the distal yeah pouch. This is typically done after at least 24 hours after delivery. This mm to allow it. Mm. And then what will see height of the pouch then and from that aspect within at the lift the oh uh dim oh That one can find or at the very least a uh this is a um Matua. No, this is a uh retrograde uh study with mur phase. And one can see here this is the rectum high, this is for the same patient. The rectum is high up there. And then one can see the fistula with the bladder neck. So this is a rectal blood and neck fistula in the case of these patients. So, what we need to investigate, uh, do an echocardiogram because they have, they commonly have uh anorectal. In addition to an erectile malformation, they have congenital heart defect. But again, this especially in case of emergency, if it's delayed, one does not necessarily need to do it for a colostomy. So in addition, one need to now make a decision based on uh the information that one has for those with er, a high anomaly such as rectal bladder, neck fistula that we have seen earlier. One would want to do a staged procedure which is uh it didn't a colostomy, uh a and the colostomy uh after the colostomy sagittal anor rectos and then after adequately dilating the new inos, which typically is any time from about six weeks post, the PSAP, one can do a colostomy takedown for such a child. Uh There are some subsets of uh Children that can have a primary anoplasty or a primary PAP or a primary Antero sagittal and rectos. Uh This subset of Children are those with a low anomaly and in the hands of a, an experienced surgeon. But for many surgeons, they prefer to do a colostomy first, a protective choles colostomy, then later do a PAP after the child has grown older. So even the uh P A or stop. Mm the ASAP is an study done. All right. You too. Mm plasty. Whereas the primary angioplasty it's too long. So that is what is done. So this can also be early or delayed for those that have a fistula with the exterior one can do a dilatation. So that's once the child is decompressing the gastrointestinal tract adequately through the uh fistula. One can now go on to allow the child to grow. Typically by the time the child is six months old, one can now do the uh PS A or ASAP as the case may be uh infantile hypertrophic pyloric stenosis is uh uh something is a disease of infants. Um Well, there are neon needs that do have it and it starts typically in the Unita life but in our environment here, many of them we present uh after the end of the Unita life and a lot of parents have been known to associate it with some local uh old wife deals and that's makes some babies so needlessly. So this is a, a relative common acquired uh emergency. And uh it's one in 300 to 900 live bats. It's more in male infants, 4 to 1, uh maybe as small as, as high as 6 to 1, but typically it fourth one in many literatures. And then it starts typically in the third week of life and then it may even stay up till the eighth week of life. And the presentation is typically with a projectile known below vomiting. Uh, the child is typically eager to feed immediately after the M ESIs. So the child continues to feed and, uh, is eager to feed. The child is hungry. The child feeds a lot, but the child vomits almost immediately. And uh, typically when you ask the parent, the parent will be able to confirm that even what the child vomits is, more than all that the child has fed with has been fed with, especially those that are formula feeding. Uh So the uh patient who presents with severe dehydration and they are usually acidotic. And when one examines such a patient, uh there will be people who live in the right upper quadrant. Uh these patients uh usually uh to be able to palpate the child, one needs, one can ask the mother to breastfeed the child and uh with the sojourn on the to the left of the child as the child is being breastfed, one can now palpate. In addition, one can place the uh you typically you use your left hand to palpate. So the right hand can be used to the spine of the child so that you can palpate against the other hand. And then you'll be able to feel it in the right upper quadrant, the ole mass, it's a oblong kind of, one needs to pass a nasogastric tube for uh aspirating whatever is there. Again, the nasogastric tube will also be useful in an investigation, which I will describe later on. But the first thing is to use it for decompression. Then after the compression, one needs to also uh replace the fluid. One needs to rehydrate. Typically you rehydrate using uh intravenous nomo, you rehydrate with nomo line and then uh subsequently you're not placed on maintenance fluid uh which typically is a half strength cell line or, or 5% half strength cell line, that's the typical maintenance treat for uh IHPS. And then uh you give the child uh with uh one third to two thirds maintenance in addition to the maintenance. So uh 5/3 maintenance, that's what the child can go with. And in every 500 mils of uh the uh maintenance with one adds a 20 millimeter of uh injection uh KCO. So uh one needs to investigate the child appropriately and the electrolyte and creatinine one will find uh the child has hypokalemia, hyponatremia, hypochloremia, metabolic acidosis. And uh the bicarbonate typically is as acidotic. So it would be quite low because of the metabolic acidosis. Uh Of course, we all should know about the Paradoxic aciduria, which may not be found, especially if it has not stayed long enough. So, an ultrasound should be undertaken. Uh One of the things that uh ultrasound will help make diagnosis uh and what one will find is an elongated and thickened pylos. In addition, one can also instill normal cell line through the nasogastric tube at the time of ultrasound, which will help to show uh to demonstrate the Pylorus beta. So the priority of management, as I have said is the resuscitation in which one needs to rehydrate and then correct the electrolyte derangement. And the definitive care is ramps pyloromyotomy. What is done with ramps P myotomy is that three right upper quadrant incision. Uh One will uh deliver the pylorus into the wound. One can do this by identifying the uh omentum. You cannot use the omentum to pull the stomach and then trace the stomach towards the pylorus and then you cannot deliver the pylorus into the wound using a a back cock forceps. And once the pylorus is delivered into the wound, one examines and confirms the diagnosis, they make an incision longitudinally starting from the uh the the pyloric antrum starting from the dis stop with most parts where the pyloric antron ends, you make the incision up to the point of the vein of me. So after making the incision, one would now uh further do a blown dissection either using the blunt end of the uh backpacker handle to further open it or one can use the uh co part of the artery forceps to spread it further or a pyloric. This can also be done uh using laparoscopy. So child can typically start feeding within six hours after the procedure. And uh uh typically the child is started on a glucose containing food. You can use 5% extra water or you can use a specific food, which is uh known as ple light. You can use Pedia light, you can feed the child with Pedro light. And once the child is tolerating, you can graduate for the uh until the child is able to tolerate. Well, orally, typically they are discharged within 1 to 2 days postoperative once they are tolerating or uh, so Children can vomit a bit more uh after the even after the surgery. But that's not to worry, one can still reassure the parents that the MS will stop. Sorry, I may have to move faster now. So in interception is the telescopic invagination of part of the bowel into an adjacent bowel. And it is the commonest cause of uh intestinal obstruction in infants and toddlers. Uh Typically these are Children three months to three years and they have below vomiting. Uh colleagues, which by that, I mean, they cry episodically and they do aic movement of the lower limbs like they are kicking or riding a bicycle and then uh they pass a bloody moko to which is typically uh described as a chore. Je to and the babies are typically well fed and they will have dehydration on presentation. They will be tachy. And then when we see them in discomfort intermittently, when one examines the abdomen, uh there may be distension uh with a palpable mass. And then uh when one examines the rectum, there may be a bloody mucoid too. Abdominal abdominal ultrasound scan will typically con confirm the diagnosis occasionally, even when one does the digital rectal examination? 1 may be able to palpate an inception that is about to prolapse through the anus. So uh once an abdominal pelvic ultrasound scan has confirmed it, one needs to resuscitate the patient. Typically, that is not done only after the ultrasound. One should resuscitate the patient first before ultrasound is done. Then uh at ultrasound, uh one will find a target sign on the transverse section uh or transverse view and a pseudo kidney sign uh on a on the longitudinal view. Uh and then uh one would need a full blood count, electrolyte and creatinine and then to group and see a unit of blood. Uh in case one needs surgery. So after patient is adequately resuscitated by freedom electrolyte repletion, then one passes tu also and then monitor the urine output through a rac and inhaling catheter as well as placed on antibiotics because of possible bacterial translocation. Uh One can uh take care. The standard of care is by an er reduction. The enema could be by a or barium and you monitor that using fluoroscopy. Again, it could also be by C line. When using cell line, one can use an ultrasound scan to monitor the progress of the reduction. If there is failure of uh reduction by of the enema by enema, then one would need to do an operative reduction. And typically this is what you find when doing operative reduction, you will note here that you have a dilated pro you have dilated proximal bowel, which you can see these are small bowel and then seven and then 6 p.m. So what one does is to start from distally and start milking it. Oral, what milking it towards the oral direction, it we from the inner what direction until it is totally milk. What one needs to avoid is to pull the barrow from this end. You don't pull from the end uh where the uh small bowel is coming from. Rather you mu it from distally or what and then you need to intermittently warm the bowel such that uh by applying a warm pack such that the edema reduces and gives you the chances of uh success without needing an intestinal resection and anastomosis. Uh Other pathology that I would want to talk about is what happens in a later childhood and in adolescent, uh which is acute appendicitis, which is the inflammation of the vermiform appendix. It's caused typically by the blockage of the lumen, either by fruit seed worms or tumor. Again, it could also be caused by lymphoid uh hyperplasia. So, when the lymphoid follicles within the wall of the appendix is hyper hyperplasia, has hyperplasia. This will reduce uh the drainage of the appendix and causes that obstruction. Again, it could be a feli, an inspissated uh cal matter that is blocking the lumen of the appendix. So, uh typically the patient will present with a right lower abdominal pain, anorexia, which are the most common uh symptoms, anorexia is almost invariably uh seen in acute appendicitis. And then they may also have nausea with vomiting. The vomiting is typically once except if it is complicated. Then again, some Children that feed from psychological, uh despite the anorexia, they still try to feed such Children will still vomit occasionally, they may have diarrhea, especially for pelvic appendi. That is irritating the rectum. So they may have diarrhea. And then if it is irritating the bladder, they may have frequency and dysuria, then uh once appendix is not complicated, they typically have low grade fever. So when you examine, one will find a low grade pyrexia. The we usually have right, lower abdominal tenderness is described as a point tenderness which is found over the mag bones point. And then one we have other signs and uh we need to investigate such a child. Uh WBC will show uh leukocytosis and then ultrasound will show a non comm appendix, a tubular blind ending, non uh compressible uh structure. Uh and it is a Peristatic, then one will find it is seven millimeters thick. One can also find uh felis within the lumen and then there may be increased peri appendi fluid, which if it has uh a high level uh mobile internal echoes, one would be thinking of a complicated appendicitis either uh appendiceal abscess or that uh it's ruptured. So one needs to place on IV fluid analgesic. And then the standard for of care is an open a, uh, is an appendectomy which can be done either open or laparoscopically. Occasionally when it's complicated. Some believe that one should do uh, a non operative treatment that is place the child on near power, uh measure the with uh the or mark the area in which the mass recite place on IV, fluid analgesics and antibiotics. And then observe over please to ensure if the mass is reducing or not, if the pain is not worsening, if there is no fever. So these are done uh in the ocean sharing regimen. But otherwise some believe that once she does go straight and do an appendectomy and that's uh if the base of the sico is inflamed as well, it's better to just take out the sico and appendix and then do a primary anastomosis of the terminal ileum with the ascending colon. Now, uh sorry, I won't be talking about uh Typhoid intestinal perforation, which should not be a common disease and a bit about it. Uh Typhoid intestinal perforation, the most important thing in making diagnosis is that fever precedes the generalized abdominal pain. And then when one examines them, they typically have uh they are generally sick patients febrile and they are toxic looking that is they look sick as though they want to die. Uh the abdomen is usually distended. And then there is uh severe tenderness. Uh when one does a tap on the um cause there is uh excruciating pain that is elicited or if the child coughs, the chart feels a severe pain, which is a way to demonstrate uh a rebound tenderness. One does not actually need to be demonstrate a rebound tenderness. And then uh one can also find on digital rectal examination, it tender uh anterior rectal wall. Uh So for such a patient, one will resuscitate by doing intravenous fluid repletion and electrolytes replacement. And then one will transfuse those that need transfusion as well as give uh blood, give blood when uh Children need it for a fully resuscitated patient that is making adequate urine. One will do uh a toy under uh general anesthesia and then uh identify the point of uh perforation, then do a source control by either simply closing it or resecting a segment that is diseased. If this segment is diseased, one needs to resect a segment, especially those with multiple perforation. When perforation is close to the ileal junction, when we need to take out the sim and then do a an uh ileo ascending colon anastomosis. And then we'll continue the patient on nasogastric uh suction or nasogastric intubation until patient uh is uh stable and then uh start oral intake with such patient. Bio intestinal perforation is actually quite much in our environment and it should not be as much as we are having it. Now, let's go on to the last one, which is a testicular portion and it's commons in the early things. Uh it also occurs in the neonatal life and even uh prenatally. But that type is the extra vagina, which happens uh in about 4% that's 4% of all testicular to and those uh Children that are found in that one is not an emergency mind you because typically what you find is after this has already happened. So they have extra vagina. The meaning is that uh the cord is twisted with the the en entire Hello, everyone. Apologies for the break in the um the the session. Um It seems that am mean is having some trouble with his network. We will be back shortly. Uh We're almost at the end of this session. So please just bear with us. Thank you. So sorry about that. I, I think the network must have acted up. I have to change both my network and uh the browser. Am I audible now? Yes, you are. Welcome back, sir. So sorry about that. So, uh from what I understand, it's the test to that uh we, we, I was totally lost from. So I'll start from there. Um Sorry, just a minute, sorry, just a minute. I'll be back on. OK. All right. So I believe we were able to hear where I was talking, talking about acute appendicitis. The uh the testis is horizontal line and makes it prone to rotating around it like the clapper inside a belt. And uh this deformity is usually bilateral. Again, trauma to the testis can uh be a predisposing factor. So typically, the patient presents with a sudden onset of uh testicular pain. There is also, there may also be ipsilateral pain to the groin in the ipil pain in the groin. And then the patient may also have a lower abdominal pain. Uh The child will typically be restless. We have a high ridding test is that lies horizontally and uh usually one will find a cremasteric reflex absent and pre sign is negative pre sign I described as a uh uh the pre sign, positive, pre pre sign is seen in acute epididymo in which when you elevate the testis, there is relief. But when there is no lie, when you lift up the testis towards where the code is, then friend sign is negative. And you assume that the patient has testicular sion, there is a need for urgent scrotal exploration. Again, 1 may even be able to palpate the cord and find that it is nothing but uh the patients usually have pain. So one needs to uh give pain relief while waiting to get the chart to theater. But getting the chat to thea is the priority. No investigation should delay the child from getting to the theater. And the priority is to make sure that where it will take you, you get the child to theta within six hours. And what is done is that one de thoughts the test is like one, what one does is to do it like opening the book in a book. So for the right test is one, does it in a clockwise fashion uh sorry, in a counter clockwise fashion. Whereas for the left, you do it in a clockwise fashion. That's what you do for the left is clockwise fashion. For the right, it is counter clockwise. And after achieving the, the to when we do oy, of both the side that uh had to and the side that didn't have to. Now, there are certain scenarios that 1 may encounter when doing a critical exploration for to number 11, we find that the test is, is dusky and may look as if it is not viable. And the thing to do with this is to warm it. And after woman, one needs to uh look at it again. The testes should have a setting shein, it should be shining and then it should also be pink. It or at least uh it, it's not going to be really pink, it's going to be pale. And then when you incise on it, you should see uh pumped bleeding. So if any of these things are absent, especially if what is coming out is just uh dark blood that is pouring out, then one knows that such a test is, has gone to renos, especially if it looks as if it has liquefied. So what we need to do uh orchidectomy in such a case, so as to prevent uh sympathetic o opathy. So this is what is done for testicular abortion. So in uh by uh to conclude, I'll say this uh emergencies are quite diverse and uh they are potentially fetal to individual organs or even to the patients himself. And one is to prioritize resuscitation and careful attention to patients response to the kid. So as to ensure that the patient is fit enough for the intervention, uh timely intervention, uh after hemodynamic stability is uh achieved, we ensure a good outcome of care. Thank you very much for listening. Uh You can also consult these textbooks uh for uh for the information. Thank. Thank you very much once again. Um Thank you so much that we can see the slides for the book. Yeah. Am I still audible? Yes, you are. But we can see the slides for the textbooks you mentioned. I just, I just uh I just finished or you didn't see at all I just look at. OK. OK. Um All right. Um We have three questions. Um So the first question um I would, I don't, can you see the chat box? Yes, I can see the chat chat box. Let me go through them. Um So the first question is from Doctor Adi um who ask about clinical uh what's the clinic? What are your clinical priorities. Um posts stabilization after surgery in A I with congenital uh disease who are single ventricle and add a ventricular assist assist device in it. Ok. Well, uh for that, uh it's not within the scope of uh what we are doing. What we are actually looking at is a pediatric surgery. And by pediatric surgery, we are looking at the core pediatric surgeries specialty, not uh pediatric cardiac surgery, that's within the domain of cardiothoracic surgery. So we won't go into that. Ok, sir, he also asked about um are antibiotic resistance uh are with antibiotic resistant, limited in febrile uti s among Children, especially in countries where you can buy over the counter antibiotics. Oh, that's more of a medical thing. You can't limit it in those kind of patients. Uh because already uh that is compromised. The cost of uh problem is because in a country like us, you can buy antibiotics without prescription. That's what you are asking about. And uh febrile urinary tract infections among Children. One can't really limit it. Are you getting me? This is also a medical question and the focus of our discussion is surgical. So strictly speaking, we are talking about pediatric surgical emergencies. Really sorry about that. But this is more of a medical thing. So this is more of a routine about regulation to be able to achieve uh this one would need regulation and that's what's uh can help in the case. Uh or in the scenario that he has asked. Um OK, thanks. Just going quickly to the last question, does steroids such as dexamethasone play any role in reduction of intussusception um by enema? Uh Well, it's, I haven't come across that typically. What we do, what we do is we use warm Saline. What about news? Especially when you use uh food enema, uh or liquid enema, it has to be warm, the warm will help uh improve the circulation. And then in the uh by so doing, it is also going to help in allowing the edema to resolve faster. So that's the mechanism by which it happens. And uh most time, more time than not uh the enema gets uh if it is effective in reducing intussusception. So use a steroid like dexamethasone. Uh Again, dexamethasone is going to take you a while before its action happens, especially in reducing the edema. I think there are two new messages. Um Well, those are all questions though. Yes. Um Thank you so much uh for this session today. Thank you. Thank you um for everyone. Thank you so much for being so patient. Uh There are feedback forms that you can fill so you can access the certificates. Thank you again, Doctor Shammi for this session. The catch of contents will be uploaded on the Me O platform so we can all have access to it later. Thank you so much, sir. Thank you. Thank you for having me. Um OK, so we've come to the end of this session. I would end this session now. Thank you everyone for attending. Please fill the feedback forms uh so you can get your certificate. Thank you so much.