Category Archives: For Emergency Departments

Inguinal hernias

For Emergency Departments, For General Practitioners, ,

with thanks to Dr Jemma Say for putting the following information together:

Inguinal Hernias

An indirect inguinal hernia is a protrusion of abdominal contents into the inguinoscrotal or labial canal via an open deep inguinal ring due to the failure of obliteration of the processus vaginalis.

 In fetal life the descent of the testis into the inguinal canal and scrotum is preceded by a small pouch of peritoneum; the processus vaginalis. After birth this peritoneal communication is obliterated, failure to do so results in either a hydrocele or hernia, depending on the degree of fusion.  

 Indirect hernias are more commonly seen in a paediatric population, as opposed to direct inguinal hernias in adult patients, where the musculature is weak and abdominal contents protrude through the wall of the inguinal canal.

Epidemiology

The incidence is 1-2%, occurring 9 times more commonly in males. The majority are found on the right (60%), 15% are bilateral, more commonly with a family history. Presentation is most frequently in infancy.

Increased Incidence

  • Preterm infants (10-30%)
  • Abdominal wall defects (e.g. prune belly syndrome)
  • Connective tissue disorders (e.g. Ehlers Danlos syndrome)
  • Chronic respiratory disease
  • Undescended testes
  • Increased intraabdominal pressure

 

The diagnosis is clinical, although USS can play a role in older children with indeterminate pain. Surgery is indicated for all paediatric patients with inguinal hernia.

The risks of not performing surgery include bowel incarceration or necrosis, and testicular or ovarian compromise and necrosis. This risk is greatest in early infancy; premature infants have an incarceration risk of up to 30%, and therefore often warrant treatment prior to discharge.  Some surgeons keep under close review for a few weeks post discharge so that these still very small babies put on a bit of weight before the operation.

If a patient presents with incarceration, an attempt at reduction should be made and urgent surgery is required, as the risk of reincarceration is as high as 15% if surgery is delayed more than 5 days.

Referral Pathway

All inguinal hernias should be referred, paediatric patients >1 year can be referred to Mr Brearley at Whipps Cross while those <1 should be referred to the Royal London Hospital. Surgery involves either open or laparoscopic techniques (tranperitoneal or preperitoneal approaches). The majority are performed as an outpatient with normal activity resuming within 48 hours.

References

IPEG guidelines for Inguinal Hernia and Hydrocele, Nov 2009. http://www.ipeg.org/education/guidelines/hernia.html

Ashcraft’s Paediatric Surgery, Holcomb G W, Murphy. J P

ABC of General Paediatric Surgery: Inguinal hernia, hydrocele and the undescended testis: BMJ 1996 312:564

Patient Information Leaflets

http://www.patient.co.uk/doctor/Inguinal-Hernias.htm

http://www.bch.nhs.uk/acrobat/PDF%20for%20Web/Inguinal%20Hernia%20Repair.pdf

Video information

Distinguishing indirect and direct inguinal hernia

http://www.youtube.com/watch?v=wAzXSqGybvE

Indirect inguinal hernia repair

http://www.medicalvideos.us/play.php?vid=1108

 

April 2011 ED version

For Emergency Departments, , ,

NICE has recently reviewed its guideline on depression in children and young people – an important diagnosis to be aware of when treating children in the ED.  We have also looked at the evidence around non-sedating antihistamines and found you a “how to do it” video on pulled elbows, and indeed one on umbilical hernia repair in an adult!  Umbilical hernias are common and benign, inguinal hernias may not be.  Read all about it here!

Anti-histamines for the hayfever season!

For Emergency Departments, For General Practitioners

April 2011’s editions of Paediatric Pearls are being published late because there has been a bit of pre-publication discussion about our paragraph on anti-histamines which needed checking up on!  The newsletters go out to all my colleagues for checking prior to publication and occasionally Amutha and I have to go back to the drawing board for one or two of the text boxes.  This month 2 of the text boxes have had to be re-done, the ones on cetirizine and umbilical hernias as the surgeon with an interest in paediatrics at Whipps had some suggested modifications for this latter one.  All goes to show that this site is not just a collection of my own random thoughts….  

The full abstract of the paper on cetirizine is reproduced below:

Drugs. 2004;64(5):523-61.

Cetirizine: a review of its use in allergic disorders.

Curran MP, Scott LJ, Perry CM.

 

Source

Adis International Limited, Auckland, New Zealand. demail@adis.co.nz

 

Abstract

Cetirizine is a selective, second-generation histamine H1 receptor antagonist, with a rapid onset, a long duration of activity and low potential for interaction with drugs metabolised by the hepatic cytochrome P450 system. Cetirizine was generally more effective than other H1 receptor antagonists at inhibiting histamine-induced wheal and flare responses. Cetirizine is an effective and well tolerated agent for the treatment of symptoms of seasonal allergic rhinitis (SAR), perennial allergic rhinitis (PAR) and chronic idiopathic urticaria (CIU) in adult, adolescent and paediatric patients. In adults with these allergic disorders, cetirizine was as effective as conventional dosages of ebastine (SAR, PAR, CIU), fexofenadine (SAR), loratadine (SAR, CIU) or mizolastine (SAR). This agent was significantly more effective, and with a more rapid onset of action, than loratadine in 2-day studies in environmental exposure units (SAR). In paediatric patients, cetirizine was as at least as effective as chlorphenamine (chlorpheniramine) [SAR], loratadine (SAR, PAR) and oxatomide (CIU) in the short term, and more effective than oxatomide and ketotifen (PAR) in the long term. Cetirizine was effective in reducing symptoms of allergic asthma in adults and reduced the relative risk of developing asthma in infants with atopic dermatitis sensitised to grass pollen or house dust mite allergens. It had a corticosteroid-sparing effect in infants with severe atopic dermatitis and was effective in ameliorating reactions to mosquito bites in adults. Cetirizine was well tolerated in adults, adolescents and paediatric patients with allergic disorders. In adult, adolescent and paediatric patients aged 2-11 years, the incidence of somnolence with cetirizine was dose related and was generally similar to that with other second-generation H1 receptor antagonists. Although, its sedative effect was greater than that of fexofenadine in some clinical trials and that of loratadine or fexofenadine in a postmarketing surveillance study. In infants aged 6-24 months, the tolerability profile of cetirizine was similar to that of placebo. Cetirizine did not have any adverse effects on cognitive function in adults, or cognitive function, behaviour or achievement of psychomotor milestones in paediatric patients. Cetirizine was not associated with cardiotoxicity. CONCLUSION: Cetirizine is well established in the treatment of symptoms of SAR, PAR or CIU. It demonstrated a corticosteroid-sparing effect and reduced the relative risk of developing asthma in sensitised infants with atopic dermatitis. Cetirizine was effective in the treatment of allergic cough and mosquito bites; however, its precise role in these indications has yet to be clearly established. On the basis of its favourable efficacy and tolerability profile and rapid onset of action, cetirizine provides an important option for the treatment of a wide range of allergic disorders.

Umbilical issues

For Emergency Departments, For General Practitioners, ,

This month we have covered umbilical granulomas and hernias as part of the feature on 6-8 week baby checks. Our surgeon with an interest in paediatrics is happy to see children from around 3 years of age if their umbilical hernia has not spontaneously resolved by then.  This topic is covered succintly, including a list of differential diagnoses, in an on-line Australian handbook of neonatal care. Inguinal hernias are a different matter altogether (they carry a far greater risk of becoming incarcerated) and one of the junior paediatricians is working on a “Pearl” about them for the May or June PP edition. 

There is not much evidence published on what to do with umbilical granulomas.   They occur when the inflammatory process at the umbilicus leads to excess granulation tissue preventing the raw area from developing new epithelial tissue.  One theory is that infection has a part to play.  I do nothing when asked about them in the Emergency Department but then I don’t follow up those patients so some GPs may feel that masterly inactivity is not enough!  They tend to take a few weeks to months to clear up.  There are references in the literature to fusidic acid, cool boiled water, salt, silver nitrate and reassurance.  Salt seems to be “in” at the moment.  All comments welcome!

ED version of Paediatric Pearls for March 2011

Child Protection, For Emergency Departments, , , ,

The March 2011 version is now published.  I have covered the new NICE guideline on food allergy and provided a link to the Allergy Academy which runs some really excellent course on all aspects of allergy in children, including one specifically for ED physicians.   There’s a bit on how to get foreign bodies out of noses and a text box on the paediatric early warning system or PEWS.  I have reminded you all that children under 18 months with a fracture need to be seen by a paediatrician before discharge for a safeguarding assessment.  This guideline comes from a new document put together by the NSPCC and the Welsh Child Protection group.  The pamphlet, downloadable here, describes when to suspect physical abuse in children with fractures and is useful reading for all ED practitioners.  Do leave comments below.

Snoring children

For Emergency Departments, For General Practitioners,

Amutha reviewed a paper from Brazil in February’s Paediatric Pearls on children who snore.  I thought it was the kind of problem that would go to GPs but she tells me that a lot of the ED juniors ask her about it as well so presumably parents are seeking information on the cause of their sleepless nights from a number of different sources.

 The paper which talks about obstructive sleep apnoea and the need for ENT referral is downloadable in full from http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1808-86942010000500003&lng=en&nrm=iso&tlng=en.  Braz J Otorhinolaryngol. 2010 Oct;76(5):552-6. 

The effects of sleep disturbed breathing during middle- to late-childhood is related to important aspects of behavioral functioning, especially inattention and learning difficulties, that may result in significant functional impairment at school.  Sleep. 2010 Nov 1;33(11):1447-56.  (http://www.ncbi.nlm.nih.gov/pubmed/21102986)

Viral rashes

For Emergency Departments, For General Practitioners,

You know when you are not quite sure what the name is of the rash that a child has but you know it is not an acute emergency? I often wish I had done Latin “A” level and could come up with something credible sounding on the spur of the moment. I sent yet another “viral exanthem” child to my dermatology colleagues yesterday because I hesitated for a second too long over a possible diagnosis and lost the confidence of the parent. So today I have been educating myself. Take a look at www.dermnetnz.org for some fantastic images and information on more types of enteroviruses than you could possibly imagine existed.  The site also has some self-directed learning modules on it.

There’s another site worth looking at, aimed at non-health professionals but with some quite useful photos on.  Have a look at http://www.skinsite.com/index_dermatology_diseases.htm.

New APLS guidelines are sort of here…

For Emergency Departments

The new ILCOR 2010 resuscitation guidelines are now being taught on all life support courses in the UK. We are allowed this year as a transition year as people get trained up. I have put together a Word document (Useful emergency paediatrics bits and pieces (2)) with all the updated APLS “WETFAG” policies and a table with normal paediatric observations as an aide memoire for those leading paediatric resuscitations or stabilising sick and injured children.

Unfortunately version 5.0 of the APLS manual is not going to be available in hard copy until later this year so there may be a bit of confusion about which guidelines to use. The only thing that will affect the care of the individual child is if the leader loses confidence so please, when the chips are down, use the guideline the leader is comfortable with.

APLS instructors have access to the new manual in draft form through their VLE login. Can I remind you that we all have to do some updated VLE sections and print out a certificate to say we’ve done that before instructing on any courses this year?