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The term “emergency” is subjective and therefore can be difficult to define, especially when considering all the complexities of caring for a sick child with a surgical problem. To the anxious parent, anything surgical may be an emergency. Healthcare providers often have differing perspectives on what is or is not an emergency. The topics in this chapter are all surgical issues that need intervention, most in a relatively short period of time. But some might be considered “urgencies” rather than true surgical emergencies. For example, most surgeons do not consider appendicitis and pyloric stenosis as true surgical emergencies. The infant with pyloric stenosis is often delayed hours, possibly even days, while undergoing the necessary fluid rehydration and resuscitation. Likewise, appendicitis can be temporized with IV antibiotics overnight and taken to the operating room the following morning. Conversely, malrotation with midgut volvulus and other causes of ischemic bowel are always surgical emergencies due to the impending irreversible effects of ongoing ischemia. Finally, there are many diagnoses that may fall over a wide spectrum of severity. Therefore, the clinical picture will often dictate the presence of an emergency more than the diagnosis. Many congenital and acquired pediatric surgical issues can progress to emergencies if the underlying problem has been present long enough. In a general sense, intervention for surgical emergencies and the less acute surgical urgencies fall into four categories: obstruction, ischemia, perforation, and bleeding.

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The first step in the evaluation and treatment of a patient with a possible surgical emergency is resuscitation. Fluid losses can be massive from bleeding and bowel obstructions, while enormous third spacing can occur from perforation and ischemia. Choice of fluid replacement depends on where the loss occurs but should be isotonic early in the resuscitation, using either lactated Ringer’s (LR) solution or normal saline (NS). For most fluid losses and conditions where acidosis is present, LR is a better selection. It is the fluid replacement of choice for trauma, and many surgical problems can be compared to a trauma situation. LR contains electrolytes much closer to physiological serum chemistries than NS and also contains lactate for buffering. The lactate in LR does not contribute to the acidosis; in fact, it has the opposite effect. The lactate is rapidly converted to bicarbonate by the first-pass effect of the liver and will improve a patient’s acidotic picture much more effectively than NS. Moreover, the pH of NS is acidic (5.0) and can worsen an underlying acidosis. Conversely, NS is a far better choice for upper GI fluid losses such as excessive emesis. Pyloric stenosis is the best example. In these patients, the emesis has progressed to such an extreme that a severe hypochloremic metabolic alkalosis results. The acidic nature and high chloride concentration (154 mEq/L) of NS make this fluid the ideal resuscitation fluid for upper GI losses.

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Once resuscitation has been initiated, diagnostic workup can begin. Age is a key factor in determining ...

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