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Good afternoon everyone. Am I audible? Can I know him? Hello, everyone. Please let me know if you can you hear me? Ok. Um Someone has confirmed an audible. Good afternoon, everyone. Welcome to today's session where we'll be discussing management of common emergencies in pediatric surgery. Doctors has kindly agreed um, to teach us this topic today. He also taught us a couple of weeks ago on the principles of previously surgical care. The ca content is available on the meal for those that are interested. I will be handing over for instance, so we can keep up. Uh, hopefully more people will join and uh, just to add one more thing, we'll take questions and comments at the end of the session. Thank you, everyone for joining us. Um, just give me a minute. I would add doctor Sh into the station. Um, we can't hear you, so I think you're muted. All right. Good afternoon. Good afternoon, sir. Sorry to be back in here. You just have to be with me but you. Yes. 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've just informed the group that we've started. So um I hope more people would join, but sure is not to waste your time. We can start. All right. All right. Thank you. So, um mute and channel my video now, so I'm 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 Yes, both 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 that. Ok. 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 ICI. 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 these 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 uh pediatric surgery, uh the emergencies falls into one of these four or a combination of those four groups. They, it could be an uh obstruction, an ischemic event, it could be perforation or bleeding, whatever emergency you can think of in the surgery, generally speaking, will be any 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 uh passage of time, such a bowel that is uh ischemic can pass it and they can also be bleeding from the free ends of the vessels. So I've described all from a single uh pathology. So they are not mutually exclusive, but 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 will 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 uh of attending to emergency is to prevent this loss. And uh one could 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 uh 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 uh a child having uh malrotation with or without vvs. 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 with uh which is that the risk of uh perforation, uh strangulation and per takes precedence. And then there is 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 have uh high lipid in red D ee esophagal atresia and which we'll be talking about lay down there is also and then you can also, you can walk and also have the Hello. Oh, so am I being hurt? Uh, yes, you are, sir. 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. Anyways includes corrosive or caustic ingestion and, uh, foreign body ingestion or aspirate, uh, uh, of, uh, occurrence of pilar torsion 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 ische. Uh There could also be area obstruction or bleeding uh from any. Oh I imagine. Yeah, in pediatric surgery. And uh therefore, the first priority is resuscitation because uh for each child, they start 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 toggle 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 urethral catheter. It 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 urethral catheter, in terms of the uh one we need to monitor the state of now, the other part mm is diagnosis which is like aesthesia. So V I deliberately did not say anything about that because what we are focusing on is with respect to all emergencies, not all emergencies. We 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 appropriate investigations, uh one would need to take the definitive care, which includes uh removing the cost, 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 fluid for each day, which can be calculated based on uh the uh 4 to 11 rule, all the 150 20 rule. So these are things that matter that one needs to do. So you need to repeat 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 uh 10% dextrose in uh Saline in 1/5 strength saline. 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, prevents 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 upper abdominal and thoracic. So, 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 ale 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 inotropics 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. One, 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. 1 may need to give nutritional support and if there is need, we need to continually support uh the organs that are flag and then uh such patients will require follow up. Uh Now let's look at uh specific cases. Uh that one would need two one me uh to manage especially the commons in two. Dr Yeah, here, the first one we'll be talking about is is fragile atresia. And uh this is uh a condition in which there is discontinuity in the doctor. I'm so sorry to interrupt. So we can see this slide. Sorry about. Yes, I can see it. Ok. We can see it now. Thank you so much. All right. 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 neonatal period. And uh uh they usually are classified into varying types. And that's the reason why I put that usually there because there are obviously some of the spectrum as classified by gross in the 1953. You can, can you see the slide here. So is the top most of this class. 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 surgeon uh is the gross classification of 1953. And uh the first type is gross type A which is uh the pure atresia has a proximal atresia. A, these are usually it's long have a uh a, a presentation that is typical. And then uh for gross type B is the one that has a proximal fistula with a distal atresia. And you can see the fistula here, fistula connection to the trachea. And then the uh fal esophagus is without a fistula. So uh this side uh is not so common. It's just a occurs in 1%. You can see the incidence on the second line. And uh this type is actually very weird to see in living patient, maybe in autopsy, one will find it because anything that the child gets fed, it go get fed with goes directly into the lungs and uh can choke the child. And then uh gross type C which is the most common. 86%. I've seen most of these, I've only ever seen one or type a, the two most common. So DC is the most common, which is a proximal aphasia with a distal trachys, agia fistula. And then a gross type D which in which there are separate fistula from both the proximal and the distal arthritic 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 present with uh 14 and choking of feets. 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 floating and choking on feet. Uh However, the arrest of the nasogastric tube at about 10 centimeter from the tip of the nostril are caused only with the gross type A and gross type C as uh we have seen earlier uh with uh gross 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 a clinical evaluation, one needs to evaluate for this. Uh especially notable is the vector anomaly ve uh in terms of vertebral and ectal malformation, vertebra, normally such as a vertebra, uh vertebra, agenesis, uh spina bifida, whatever. And then uh cardiac uh uh cardiac anomalies uh in which uh it could be patent ductus, arteriosus, 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 is not mutually exclusive. Both could coexist 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 one does is to pass a reparable tube. And uh this tube is a double lumen lumen tube that is able to vent uh dissection in pressure into the atmosphere at the same time as you are. So, because the typical problem that one will have when you ha when you pass a nasogastric tube into a hollow viscus is the fact that the hollow viscus tends to collapse and then in the process of collapse, uh it's as it collapses, the mucosa gets talk into the orifice two each, uh the suction lumen makes it such that the outer lumen 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 proximal pouch. And then only we also need uh to uh Eva evaluate further, which is to take a baby gram with a tube institute. That tube will have uh typically the repo good tube. We have a uh a radio pe line on it. Now there is a uh there is an adaptation that is being used in the lower. Uh it is called an you. That's uh it was designed by Professor Abdurrahman. Uh it's uh uses two tubes that one can make using a five French feeding tube and placing it in a 10 frame feeding tube. So one can now pass that and then one will be suctioning on the five range which would prevent uh the uh the mucosa from pros on the 10 frame feeding to 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 arise tube ari se. Uh So one can now please. The slides keep going. Yes, it keeps popping up and off. So I don't know if there's anything. Ok. So you can see it now, then after it goes off, wait coming on here. Let me uh let me see if 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 would 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 gross type C, which is the most common, one would also see that there is air within the power within the bowel of the child. So that confirms that there is a uh uh a communication between the uh trachea and the uh gastrointestinal tract. The distal gastrointestinal tract through the 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 air can get into the gastrointestinal tract is through the distal 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 who needs to classify the child based on the operative risk. There are three main uh 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 thing. Water thing 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 uh pneumonia. And then the third criteria is associated uh congenital major congenital abnormalities. So those are the basis for classification and one can see all three classes based on what is in here. I didn't put Spitz here but Spitz is based on uh bat weight. The bat weight in the case of spit is on 1.5 or 1500 g. And uh part of the reasons why speed uh based it on 1.5 is because of the improvement with time on a neonatal intensive care. That's the reason why uh 1.5 has, it serves as the one that can be in speech classification uh or speech class one. And then uh there is also uh apart from uh but with 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 classify in speeds. Whereas in the Montreal classification is mainly based on whether there is a ventilator dependence in the beginning of uh 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 no, 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 v little 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 uh life threatening anomalies, they are automatically class two. So once one has classified, one cannot determine what's uh management, one would do four, class one and two or class A and B1 can still do a primary eop 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 esophagoesophagostomy for fit Children with a gross type c esophageal atresia. However, for those that have uh uh it gross type A, for instance, it's usually a long gap. Uh anomaly you can see here, the defect is quite wide for such a patient. 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 pull up but in the interim, uh so that the child will be able to grow so that uh they can bear the major surgeries that we don't. The first thing to do for them is to put them on a cervical esophagostomy that is bringing out the esophagus through the neck. So that saliva will be able to drool out. And then one can also give them sham feeding. Then in addition, such patients, we have a gastrostomy, gastrostomy. So acute gastrostomy two, which they can be feeding and then while feeding them simultaneously, one also give them uh give them sham feeding which will help them to also maintain the cling reflex. And also in those patients that have growth type C, one can do uh the procedure if they are water stain uh three, if they are water stain three, uh what does see or uh speeds, class three or Montreal class three. These are categories that 1 may need to do a bridge for that is uh the uh se is to me and then a a and uh and then a gastrostomy for feeding a feeding gastrostomy and then later on, one cannot do esophageal replacement So that is that uh with uh esophageal 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 mid, got my rotation with Volos. And this is a problem with the rotation and fixation of the mid goat and is a potential source of intestinal loss, especially if the baby develops vov loss. Uh uh Typically uh it's occurs as a result of uh problem with embryology development in development in which the, during the second week the gut is still it. Well, by the fourth week of development, the gut is just a straight tube that is supplied by the superior mesenteric artery that is the mid got. Uh then later on uh as development goes on, there is rapid elongation of the mid go which causes the physiologic hernia. And during this mission, a lot of bo develops and goes out of the OK, and goes out of the in abdominal cavity into the uh Hello. Yeah. So it seems there is a problem. I see. 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 bowel would have returned in the process of returning the doom 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 junction which is fixed, which is a fixed point would be in the left upper quadrant. Whereas the iosal junction which is also the fixed portion uh or the relatively fixed portion of the uh mid goat 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 non rotation, as the case may be the gap between the two mobile parts, which is the s uh the two fixed part, the S and the, the, the junction is so narrow and then the axis is now prone to twisting, which is what causes it to be prone to volvulus. In addition, the la band which crosses the cecum uh which uh comes from the cecum to the liver is seen to cross and plaster over the bone, which can cause obstruction. And therefore, uh such a child we present 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 VV loss, they may have uh blood E MSs 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 S 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 Bloss, vomiting. Any child with V lost vomiting is suspected to have malrotation with VV loss until proven otherwise. So the most important thing is to rapidly resuscitate the patient to render hemodynamically stable. Do the baseline investigation, especially the hemogram, uh electrolytes, urea and creatinine as well as uh getting uh blood for the 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 gi series. Uh Here we see an upper gi series. This is a four year old boy that has a recurrent abdo uh abdominal pain and pain. And one can see here, this is after about four hours and one can see here that the small bowel is essentially on one side. And then we have not even started seeing the large bowel field because of the sloop. Uh that is that. So, uh the treatment essentially is the last procedure. Last procedure is described by uh lot and uh, William la and uh the steps include uh ration of the bowel derotation if there is any volve loss and then release of the lap band. Once one has released the L band, uh one would uh want to widen the mesenteric base. This is done by uh dividing the anterior leaflet of the mesentery 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 v loss. 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 post string at the base of the cecum, then devascularize the vermiform appendix and then using a lacryma to push it from the tip of the appendix into the sequon because you have this vascularized, 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 s it will slow 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 first, the large bowel to the left and then the small bowel to the right. Such that when we have uh the bowel that is in a position of non rotation and then the patient is OK. So the other possib, the other emergency, especially in the neonatal presentation uh is an rectal malformation which is uh an absence uh or abnormally sighted anal opening, opening of the gastrointestinal tract. Uh This is as a result of um problem with uh the separation of the gastrointestinal, the urogenital 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 urethral catheter, monitor urine output the nasogastric tube, of course is for decompression. Similarly, in uh uh patients with mild rotation and uh VV loss with or without VV loss. So, one is to pass nasogastric tube and then uh you now uh give IV free uh do other investigation. You need also to investigate against other associated anomalies such as the Midline syndromes like uh O I ES that is uh un follows you or is imperforate inos sorry, we don't use imperforate anus. Again, we use anorectal malformation but for the purpose of this, it is uh imperfect inos and this one is the clinical extrophy, clinical extrophy specifically. Sorry, II, didn't bring a picture of this but never mind. And then this one is spinal defect or spinal dystrophy. And then uh anorectal malformation, of course, is associated with uh uh vector anomaly like uh esophagal rezia and many other things. So once you are past N GT, you've placed on new pump uh oral and then you give IV fruit, you investigate appropriately uh cross lateral radiograph which uh you can see here, which shows that one can see the distal pouch. This is typically done after at least 24 hours after delivery. This mm to allow it mm. And then we see heights of the pouch is then and it is from that aspect within at the the oh uh do you to that one can find all at the very least a uh di um no, this a uh retrograde uh study with mating phase. And one can see here this rectum high update. 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 bladder 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 anorectal formation, they have congenital heart defect. But again, this especially in case of emergency, if it's delaying, one does not necessarily need to do it for a colostomy. So in addition, we need to now make a decision based on uh the information that one has for those with uh 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 start a colostomy. Uh And the uh after the colostomy, Sagitta anorectoplasty and then after adequately diluting the new inos, which typically is anytime from about six weeks post, the P SA one can do a colostomy takedown for such a child. Uh There are some subset of uh Children that can have a primary anoplasty or a primary Pisa or a primary anterial sagittal anorectoplasty. Uh This subset of Children are those with a low anomaly and in the hands of a unexperienced surgeon. But for many surgeons, they prefer to do a colostomy first, a protective colostomy, then later do ap up after the child has grown older. So even the uh P SA or a stop. Yeah, the ASAP is an interior study done. All right. Do bye plasty, whereas the primary anoplasty is 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 AP or ASAP as the case may be uh infantile hypertrophic pyloric stenosis is that, uh, something is a disease of infants. Mm. Well, there are units that do have it and it starts typically in the unit life. But in our environment here, many of them we present, uh, after the end of the neonatal life and a lot of parents have been known to associate it with some local, uh, old wife tas and that's, uh, makes some babies so far, needlessly. So, this is uh a relatively 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's fourth one in many literatures. And then it starts typically in the third week of life and then it may even stay up until the eighth week of life. And the presentation is typically with a projectile non below vomiting. Uh, the child is typically eager to feed immediately after the MS. 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 patient will present with severe dehydration and they are usually acidotic. And when one examines such patient, uh there will be a palpable 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 surgeon 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 olive mass, it's uh oblong kind of ma one is 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 uh describe later on. But the first thing is to use it for decompression. Then after the compression, one needs to also uh replete the fluid. One is to rehydrate. Typically, you rehydrate using uh intravenous, normal saline, you rehydrate with normal saline and then uh subsequently you not place on maintenance free, uh which typically is a half strengths line or, or 5% half strengths line. That's a typical maintenance rate for uh IHP S. 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 meals of uh the maintenance fee, one adds a 20 millimoles of uh injection. Uh KC O. 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 a acidotic. So it would be quite low because of the metabolic acidosis. Uh Of course, we all should know about uh 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 pyros. In addition, one can also instill normal saline through the nasogastric tube at the time of ultrasound, which will help to show uh to demonstrate the Pyro's 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 Ramstad plum myotomy. What is done with Rams pyro myotomy is that through right, upper quadrant incision. Uh One will uh deliver the pyros into the wound. One can do this uh by identifying the uh omentum, you cannot use the omentum to pull the stomach and then trace the stomach towards the pyros and then you cannot deliver the pylos into the wound, using a a back cock forceps. And once the pyros is delivered into the wound, wound examines and confirms the diagnosis, then make an incision longitudinally, starting from the uh the the pyloric antrum, starting from the distal most part where the pyloric antrum ends, you make the incision up to the point of the vein of mayo. So after making the incision, one would now uh further do a blunt dissection, either using the blunt end of the uh ba packer handle to further open it or one can use the uh c part of the artery forceps to spread it further or a pyloric spread. 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% dextrose water or you can use a specific food which is uh known as pedo light. You can use pedo light, you can feed the child with pedo light. And once the child is tolerating, you can graduate further uh until the child is able to tolerate well, orally. Typically, they are discharged within 1 to 2 days, postoperative once they are tolerating oral, 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 MSs will stop. Sorry. I may have to move faster now. So interception is the telescopic invagination of part of the bowel into an adjacent bowel. And uh it's 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 a rhythmic movement of the lower limbs like they are kicking or riding a bicycle. And then uh they pass a bloody mucoid to which is typically uh described as a Korea jelly to and the babies are typically well fed and they will have dehydration on presentation, they will be tachy and then 1 may 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 interception that is about to collapse 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, electro 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 free and electrolyte repletion, they won't pass this G tube also and then monitor the urine output through a urethra and inhaling catheter as well as place on antibiotics because of possible bacterial translocation. Uh One can uh take care. The standard of care is by an NMR reduction. The er could be by a or barium and you monitor that using fluoroscopy. Again, it could also be by saline. When using saline, 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 proximal, you have dilated proximal which you can see these are small bowel and then seven and then to 6 p.m. So what one does is to start from distally and start milking it or outward milking it towards the oral direction, away from the, in our what direction until it is totally milk. What one needs to avoid is to pull the barrel from this end, you don't pull from the end uh where the uh small bowel is coming from, rather you milk it from or award 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 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 the obstruction. Again, it could be a fecal, an ins uh fecal matter that is blocking the lumen of the appendix. So, uh typically the patient presents with the 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 appendix 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, when we find a low grade pyrexia, they, we usually have right lower abdominal tenderness. It is described as a point tenderness which is found over the mab points and then 1 may have other signs and uh we need to investigate such a child. Uh W BC will show uh leukocytosis and then ultrasound will show a noncompressible appendix, a tubular blind ending, non uh compressible uh structure. Uh and it is aperistaltic. Then one will find it is seven millimeters. Th one can also find uh fid within the lumen and then there may be increased periappendiceal 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 free and a just it. 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 or uh measure the width uh uh the uh or mark the area in which the mass recite place on IV fluid analgesics and antibiotics. And then observe over these 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 uh if the base of the cecum is inflamed as well, it's better to just take out the cecum 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. B 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 uh 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 the tap on the lycos, there is uh excruciating pain that is elicited or if the child coughs, the child feels a severe pain, which is a way to demonstrate uh a rebound tenderness. One does not necessarily need to demonstrate a rebound tenderness. And then uh one can also find on digital rectal examination, a tender uh anterior rectal wall. Uh So for such a patient, one will be sued by doing intravenous free 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 laparotomy under 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 the segment is diseased when we need to resect a segment, especially those with multiple perforation. When perforation is close to the I junction, one, we need to take out the cum and then do a an ileo ascending colon anastomosis. And then one continue the patient on nasogastric uh suction or nasogastric intubation on to your patient uh is uh stable and then uh start oral intake with such patients. 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 its commonest in the s 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 testiculo 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 court is twisted with the the entire Hello everyone, apologies for the break in the um the the session. Um It seems that pa 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 so sorry about that. II think the network must have acted up. I had to change with my network and the the browser. Am I audible now? Yes, you are. Welcome back, sir. So, sorry about that. So, uh from what I understand is the clock to that uh we, we, I was totally lost from, so I'll start from there. Um Sorry, just a minute. Yeah, sorry. Just a minute. I'll be back on. OK. All right. So I believe we were able to hear it when I was talking about acute appendicitis. The uh the test is 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 ipsilateral 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 riding test is that lies horizontally. And uh usually when we find uh 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 epididymorchitis. In which when you elevate the testis, there is relief. But when there is no relief, when you lift up the testis towards where the cord is, then friend sign is negative. And you assume that the patient has testicular torsion, there is a need for urgent scrotal exploration. Again, we may even be able to palpate the cord and find that it is nothing but uh the patients we usually have pain. So one needs to uh give pain relief while waiting to get the child to theater. But getting the child to theater is the priority. No investigation should delay the child from getting to the theater. And the priority is to make sure that whatever it will take you, you get the child to within six hours. And what is done is that one? They thought the test is like one, what one does is to do it like opening the book, opening a book. So for the right testis one does it in a clockwise fashion uh sorry, in a counterclockwise 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 torsion one we do, OK. Do of both the side that uh had torsion and the side that didn't have torsion. Now, there are certain scenarios that 1 may encounter when doing is ru exploration for torsion. Number 11, we find that the testis is dusky and may look as if it is not viable and the thing to do with this is to war it. And after warming one needs to uh look at it again, the testis should have a setting shin, 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 punctate 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 as gone gangrenous, 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 oath. So this is what is done for testicular torsion. So in uh by uh to conclude, I'll say these uh emergencies are quite diverse and uh they are potentially fatal to individual organs or even to the patient himself. And one is to prioritize resuscitation and care for 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 further information. Thank you very much once again. Um Thank you so much that we can see these slides for these books. 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. Ok. Ok. Um All right. Uh um We have three questions. Um So the first question, um I would, I don't, can you say the chat box? Yes, I can see the chat chat box. Let me go through them. Um So the first question is from doctor Ay, um who asks about clinical uh what's the clinic? What are your clinical priorities? Um Post stabilization after surgery in a child with congenital heart disease, who are single ventricle and add a ventricular assist assist device inserted? 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 how antibiotic resistance, uh how is 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 cause 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 thing about regulation to be able to achieve uh this one would need regulation and that's what can help in the case uh or in the scenario that he has a. Um ok, thanks sir. Just going quickly to the last question, does steroids such as dexamethasone play any role in reduction of inception um by enema? Uh Well, it's I haven't come across that typically. What we do, what we do is we use one saline. What about food use? Especially when you use uh food enema, uh or liquid enema, it has to be warm, the worm 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 into suction. So use a steroid like dexamethasone. Uh Again, dexamethasone is going to take a while before its action happens, especially in reducing the edema. I think there are two new messages. Um Well, those are no questions though. OK. There are no questions, just comment. 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 certificate. Thank you again, Doctor Shaoi for this session. The catch up contents will be uploaded on the me a 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 the session. I would end this session now. Thank you everyone for attending. Please fill the feedback forms. Uh So you can get your certificates. Thank you so much.