Pediatric emergency medicine trisk 938
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FIGURE 116.3 Perforated appendicitis with abscess and fecalith. Ultrasonography of the pelvis
shows a complex mass (A ) with a fecalith (arrow ) producing characteristic acoustic shadowing
to the right of the bladder (B ).
Initially, the findings may be confused with those of pneumonia because the
extreme abdominal pain may cause rapid shallow respirations, grunting, and
decreased air entry to the lower lung fields. In young children, the findings may
also be confused with meningitis because of paradoxical irritability—any motion
of the child, even trying to comfort the child, may cause pain and irritability.
The laboratory findings in the child with perforated appendicitis often suggest
this diagnosis. The WBC count is significantly elevated, usually higher than
15,000/mm3, with a marked shift to left; leukopenia may be seen with perforation
when associated with overwhelming sepsis.
The radiologic evaluation of suspected perforated appendicitis should include
plain abdominal radiographs and either US, CT, or MRI. The plain film of the
abdomen may show free air or evidence of peritonitis. The US of the pelvis may
show a complex mass with or without a calcified fecalith or free fluid within the
abdominal cavity ( Fig. 116.3 ). CT is generally performed with IV and enteral
contrast to define the size and location of an associated abscess ( Fig. 116.4 ).
MRI is being used by some centers in cases of suspected periappendiceal abscess,
although once identified, US is generally used to track resolution or postsurgical
complications.
Management
Initially, therapy should be directed toward proper resuscitation with assessment
and management of the airway, breathing, and circulation. Extremely ill children
may require endotracheal intubation in cases of shock. Hypovolemia should be
rapidly corrected with normal saline or Ringer’s lactate solution. An initial bolus
of fluid starting at 20 to 60 mL/kg is given rapidly until vital signs are improved
and the patient produces urine. Vasopressor therapy should be considered for
patients who do not have sufficient response to 60 to 80 mL/kg of isotonic fluids.
Broad-spectrum antibiotics targeting bowel flora (gram-negative enterics as well
as anaerobes) should be given. Immediate surgical consultation is necessary.
Placement of a bladder catheter and central venous access with measurement of
central venous pressure may be necessary to monitor response to therapy. Once
the patient is more stable, the surgeons generally request advanced radiologic
imaging to guide next steps.
FIGURE 116.4 CT scan of perforated appendix with abscess.
Once the emergency provider is certain that the airway can be controlled and
the circulation is adequate, relief of pain can be accomplished by using narcotic
agents (e.g., morphine 0.1 mg/kg). The patient’s fever can usually be controlled
by antipyretics or a cooling blanket. In very ill children or those with ongoing
vomiting, a nasogastric tube should be placed to evacuate the contents of the
stomach and to drain ongoing gastric secretions.
Children with perforated appendicitis can deteriorate quickly. Therefore,
emergency resuscitation should be quickly followed by operative intervention in
extremely ill patients. For patients with a perforated appendicitis with minimal
systemic signs, abscesses may be treated with antibiotics and possibly drained
percutaneously by interventional radiology—with the expectation of a delayed
appendectomy.
ACUTE INTESTINAL OBSTRUCTION
Goals of Treatment
When intestinal obstruction is suspected, early surgical consultation should be
obtained. Signs of obstruction with shock or evidence of ischemic bowel is a
surgical emergency. Although diagnostic studies to identify the exact etiology of
obstruction are generally valuable to direct management, a fraction of cases need
emergent exploratory surgery to rescue the bowel and prevent further
deterioration of the patient.
CLINICAL PEARLS AND PITFALLS
Bilious emesis in a neonate should be considered a surgical
emergency
Although diagnostic studies are helpful to identify the cause of
obstruction, critically ill patients or those with evidence of ischemic
bowel may need exploratory surgery
Tachycardia, blood per rectum, and acidosis are potential indicators of
ischemic bowel
FIGURE 116.5 A: Small bowel obstruction. Numerous dilated small bowel loops occupy the
midabdomen and have a stepladder configuration. Minimal air is seen in the rectum. B: Same
patient as in (A ). The upright abdominal roentgenogram shows numerous dilated loops in the
small bowel with differential fluid levels in one loop indicating mechanical bowel obstruction.
Current Evidence
In any child with persistent emesis, especially with bilious emesis, acute intestinal
obstruction must be considered. If the obstruction is high in the intestinal tract,
the abdomen does not become distended; however, with lower intestinal
obstruction there is generalized distension and diffuse tenderness, usually without
signs of peritoneal irritation. Only if the bowel perforates or vascular
insufficiency occurs will signs of peritoneal irritation be present. If complete
obstruction persists, bowel habits may change, leading to complete obstipation of
both flatus and stool. All patients with suspected bowel obstruction should have
radiographs of the abdomen in supine and upright (or lateral decubitus) views. In
patients with acute mechanical bowel obstruction, multiple dilated loops are
usually seen. Fluid levels produced by the layering of air and intestinal contents
are seen in the upright or lateral decubitus radiographs ( Fig. 116.5 ).
Intussusception
CLINICAL PEARLS AND PITFALLS
