Pediatric emergency medicine trisk 937
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TABLE 116.2
PEDIATRIC APPENDICITIS SCORE
Clinical finding
Point
Anorexia
Nausea or emesis
Migration of pain
Fever >38°C
Pain with cough,
percussion, or
hopping
Right lower
quadrant
tenderness
White blood cell
count
>10,000/mm3
Absolute band
count
>7,500/mm3
Total
1
1
1
1
2
2
1
1
10
At this time, nonperforated pediatric appendicitis primarily is managed
surgically although there are ongoing trials of nonoperative treatment with
antibiotics for selective cases of early, uncomplicated appendicitis. The
preoperative preparation of a patient with acute appendicitis should include
electrolytes if the patient has been vomiting or has had poor fluid intake for more
than a few hours. IV fluids should be started with the goal of rapid intravascular
expansion and then correction of further fluid deficits. Protracted GI losses, as
with vomiting, may lead to potassium depletion. Initial fluids should include a
bolus of isotonic fluid (20 cc/kg), then changed to D5–0.5NS with 10 to 20
mEq/L of potassium. These fluids can then be altered, if necessary, once the
serum chemistries are known. Antibiotics should be administered as soon as the
appendicitis is confirmed by imaging or sooner if there are signs of critical illness
or peritonitis.
The emergency physician must keep in mind the many variations in the way
appendicitis can present. Patients with equivocal findings should be admitted for
monitoring and serial examinations or have imaging studies to demonstrate a
normal appendix. If the imaging studies are equivocal, the surgeon will decide to
operate or continue to monitor. Patients who have a typical history for
appendicitis but suddenly have diminished pain may actually have undergone
perforation of the appendix. Such patients should be observed for several hours
before declaring an improved condition. Even in the presence of negative imaging
studies, the emergency physician should arrange close follow-up for any patient
with abdominal pain. For those patients with progressive pain, significant pain
requiring narcotic medications, or persistent emesis, admission for further care
and subsequent evaluation might be necessary.
PERFORATED APPENDICITIS
Goals of Treatment
When a perforated appendicitis is suspected, surgical consultation should be
obtained promptly and adjusted for the stability of the patient. Early restoration of
intravascular volume, correction of electrolyte derangements, pain control, and
antibiotics are essential parts of early care. In collaboration with surgery
colleagues, decisions about which patients need immediate operative care versus
advanced imaging can be discussed. When an abscess is identified, the surgeons
will determine the need for a drainage procedure in addition to antibiotic therapy
prior to a delayed appendectomy. Short-term treatment outcomes include
clearance of the intraperitoneal infection while limiting the duration of
hospitalization and the need for repeated imaging or drainage procedures.
Clinical Considerations
Clinical Recognition
Ideally, once the diagnosis of appendicitis is considered, the patient will proceed
with an efficient evaluation to establish the diagnosis and then definitive care
before perforation. Unfortunately, some patients, particularly younger children,
may arrive for emergency care with an already perforated appendix because of a
delay in seeking treatment or in making the diagnosis. Although the time to
perforation is variable, the time prior to ED presentation is a more important
determinant of perforation than the time of evaluation in the ED. Once the
appendix has perforated, there may be signs of generalized, rather than localized,
peritonitis. In a young child, the omentum is thin and often incapable of walling
off the inflamed appendix. As a result, perforation leads to a more disseminated
infection. Although the mortality from appendicitis has decreased over the last
several decades, the incidence of perforation in children has remained the same.
Clinical Assessment
Within a few hours after perforation has occurred, the child begins to develop
increasing signs of peritonitis and toxicity. First, the lower abdomen and then the
entire abdomen become rigid with extreme tenderness. Bowel sounds are sparse
to absent. Other signs include pallor, dyspnea, grunting, significant tachycardia,
and higher fever (39° to 41°C [102.2° to 105.8°F]). Rarely, the patient may
develop septic shock from the overwhelming infection.
FIGURE 116.2 Appendicitis. Longitudinal (A ) and transverse (B ) images of the appendix
demonstrate thickening of the wall (arrows ) consistent with appendicitis. C, D : Longitudinal
images of two different patients with a dilated, inflamed appendix, with a thickened wall and
dilatation of the appendiceal lumen. E : Longitudinal image of an inflamed appendix containing
an echogenic appendicolith (arrows ). F : Longitudinal image demonstrates hyperemia within
an inflamed appendix consistent with appendicitis. (A–D, F, Reprinted with permission from
Kawamura D, Nolan T. Abdomen and Superficial Structures . 4th ed. Philadelphia, PA: Wolters
Kluwer Health; 2017.)
