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