Treatment And Disposition Of Suspected Appendicitis In The Pediatric Patient

Acute Appendicitis In Childhood Pitfalls

Risk Management Pitfalls:
1. “The US (which at our institution has a high sensitivity) is negative; therefore, we have adequately ruled out appendicitis.” Again, estimating the pre-test probability is critical in the evaluation of appendicitis in the child. The appendix can be poorly visualized in 30% of studies, the sensitivity is highly variable, and the examination is operator dependent. If the pre-test probability of appendicitis is moderate or high, then a CT scan should be obtained to further evaluate for appendicitis.

2. “Perforated appendicitis in children is most commonly the result of late presentation and will be obvious.” Most cases of perforated appendicitis are due to the delay in diagnosis or misdiagnosis, particularly in young children. Poorly defined symptoms and non-specific findings in a child, along with a good-intentioned parent to treat “stomach aches” can have some impact on delayed presentation; however despite presentation for medical evaluation, 57% to 67% of children under 5 years of age are still misdiagnosed.

3. “This 6-month-old child doesn’t have appendicitis. Children under the age of 2 rarely get appendicitis.” Although it is less common than in children 10 to 17 years of age, children < 3 years of age can account for 1 to 2 cases per 10,000 children per year in the U.S. Infants commonly have atypical symptoms such as cough, grunting, vomiting, and diarrhea. Perforation rates are nearly universal in this age group; therefore, the relative infrequency of appendicitis (with increased morbidity) in this age group should not forego its consideration on the differential diagnosis.

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Acute Appendicitis In Childhood Case Study

Case Study:
A young couple brings in their 18-month-old daughter who has been ill for the past 36 hours. They recount symptoms of fevers as high as 101.9°, vomiting, one episode of diarrhea, and abdominal pain. Other than intermittent bouts of fast breathing and “grunting” noises, she has not had cough or other cold symptoms. An older sibling recently had an upper respiratory infection, with no gastrointestinal symptoms. The child is otherwise in good health with up-to-date immunizations. She currently has a low-grade temperature of 100.4°, with otherwise age-appropriate vital signs. She is not tachypneic. You perform an examination on the tired but alert child and note a slightly distended abdomen and diffuse tenderness with guarding. The chest examination is clear to auscultation. You wonder how to further evaluate this child. Then you grab the order sheet and explain to the parents the tests you are ordering.

Case Study Conclusion:
You order a WBC and an ultrasound to further evaluate this child. She has a leukocytosis of 11,100/μl and the ultrasound reveals an easily visualized appendix, which has inflammation suspicious for appendicitis per the radiologist. You obtain a pediatric surgical consult to confirm. The surgeon agrees that she indeed likely has appendicitis and explains the next step of surgical intervention to the parents. You administer additional pain medications to keep the child comfortable while the child is prepared for her appendectomy.

Clinical Pathway: Evaluation Of Severe Traumatic Brain Injury

Severe Traumatic Brain Injury Key Points

Key Points:
1. Rapid identification of severe traumatic brain injury in the field should prompt rapid transport to a Level I trauma center if possible.

2. Assume concomitant cervical spine injury and use full spinal precautions throughout assesment and treatment.

3. Identify and treat other traumatic injuries simultaneously.

4. Avoid hypotension and hypoxemia.

5. Endotracheal intubation by EMS should only be performed when adequate airway or oxygenation is not otherwise possible.

6. Avoid prophylactic or inadvertent hyperventilation.

7. Resuscitation of shock should follow ATLS protocols, using saline and blood products when necessary.

8. Non-contrast CT scanning offers the most rapid delineation of brain injury.

9. Intracranial pressure monitoring should be obtained early, and appropriate cerebral perfusion pressures should be maintained.

10. Sedation with opiates, benzodiazepines, and low dose propofol should be used when intra¬cranial hypertension is present; care must be taken to treat resulting systemic hypotension.

Severe Traumatic Brain Injury Case Study

Case Study:
You have just started your shift and the charge nurse informs you that EMS has arrived with a 48-year-old man who was involved in a high-speed motorcycle collision. He was not wearing a helmet. He was initially awake and combative on-scene but became lethargic and unresponsive en route to the hospital. He was intubated by EMS prior to arrival. His pupils are unequal; the left is dilated and unreactive. His blood pressure is 136/78; heart rate is 88; oxygen saturation is 100%. He does not respond to verbal or painful stimuli. You suspect that the patient has a severe traumatic brain injury and realize that any hope for a meaningful recovery depends on your ability to mobilize resources, manage the intracranial pressure, and maintain the cerebral perfusion pressure.

Before you even have time to finalize your plan, the EMS radio comes alive. The paramedics are bringing a 78-year-old woman with a history of dementia from a nursing home. The report notes that she suffered a minor fall yesterday, was “lethargic” this morning, and the staff could not arouse her from her nap this afternoon. According to the paramedics, she has a hematoma on her forehead and is protecting her airway but responds only to painful stimuli by withdrawing. Her vital signs are “stable.” EMS is requesting to use RSI to intubate her prior to transport and you are considering the wisdom of their request.

Case Study Conclusion:
The blown pupil raised concern for uncal herniation and consequently you began to hyperventilate the patient and administered mannitol 0.5 gm / kg. Once the pupil normalized, the hyperventilation was discontinued and mechanical ventilation was initiated with a goal arte¬rial PaCO2 of 35 mm Hg. A continuous IV infusion of propofol was started for sedation and prevention of ICP elevation. The on-call neurosurgeon was contacted while the patient was quickly transported to radiology for a non-contrast CT scan of the head, which revealed a large left epidural hematoma. The patient was taken to the operating room for surgical evacuation and decompres¬sive craniotomy. He was subsequently transferred to the intensive care unit for recovery and close monitoring for vasospasm, edema, and secondary injury.

After a brief examination of the second patient, you noticed equal sized pupils with normal reactions to light. You found a right-sided hemiparesis and a positive Babinski’s reflex on the right toe. You identified the GCS as 7 and recommended orotracheal intubation. Using full spinal precautions and inline stabilization, you preoxy¬genated with 100% supplemental oxygen. An IV bolus of lidocaine and a defasciculating dose of vecuronium was given followed by successful rapid sequence intubation with etomidate and succinylcholine. A noncontrast head CT revealed a hyperdense subdural hemorrhage with mid¬line shift. After drainage of the venous hemorrhage, the patient was extubated and discharged back to the nursing home after 14 days without neurologic sequelae.

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Clinical Pathway For Management Of Acute Asthma

Acutely Life-Threatening Diagnoses That May Mimic Asthma

Acute Asthma In The Pediatric Emergency Department Case Study

Case Study:
An 8-year-old boy is brought into your emergency department in the middle of the night with dyspnea. His mother states he has wheezed in the past, but he has been doing well since starting inhaled fluticasone. He only requires a few puffs of an albuterol metered-dose inhaler 2 or 3 times per week for relief. He has recently experienced coughing and a runny nose. The patient’s mother also admits that their family just started using a woodburning stove. Tonight the patient developed increasing shortness of breath which could not be relieved by several puffs of albuterol. Otherwise, he is healthy. On examination, you notice that he is working hard to breathe with supraclavicular, intercostal, and subcostal retractions. On auscultation, his lungs have poor aeration without wheezing. He is breathing 48 times per minute, his heart rate is 140, and his O2 saturation is 90%. How aggressive should you be with his treatment? What therapies would best treat his shortness of breath? What diagnostic studies does he require?

Case Study Conclusion:
You rapidly identify this patient as having a severe asthma exacerbation and needing aggressive management. You start continuous albuterol and ipratropium and administer a dose of corticosteroid. The patient continues to have severe distress and appears anxious. You give subcutaneous epinephrine, place an IV, and administer magnesium and a normal saline bolus. You also ask his respiratory therapist to administer his aerosol medications via BiPAP, which results in improvement in his retractions and anxiety. Within 15 minutes, wheezing is audible in his lung fields. You reassess him frequently, and his respiratory rate decreases over the next hour, after which you transition him to aerosols via a simple mask, which he tolerates well. After 2 hours, he is able to speak in full sentences and perform a peak flow, which is 50% of expected. You are able to transition him from continuous albuterol aerosols to intermittent treatments every 2 hours, but his oxygen saturations remain 92% while on room air. You contact his primary care physician and admit him to the hospital for continued treatment of his acute asthma exacerbation. He remains in the hospital for 2 days, after which he is discharged on an increased dose of fluticasone as a daily controller medication.

Staging Of COPD Based On Post-Bronchodilator Spirometric Criteria