Pediatric emergency medicine trisk 2071 2071
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hypovolemia and restores circulating volume, but also improves local
perfusion within the pancreas. On arrival to the ED, IV fluids should be
started immediately, and the patient’s oral intake should be discontinued. Once
the acute shock episode is resolved, IV fluids should be administered at 1.5 to
2 times the maintenance rate for the first 24 hours. Crystalloids are the
preferred fluid, however there is a lack of data comparing normal saline and
lactated Ringer’s. Vital signs and urine output should be monitored frequently.
A crucial part of management is the treatment of abdominal pain. There is no
strong evidence regarding the choice of pharmacologic agent for pain control.
For mild to moderate pain, nonopiates may be useful, including NSAIDs. For
more severe pain, opiates may be utilized safely. Historically there was a
theoretical concern about sphincter of Oddi spasm with the use of various
opiates, however this has not been supported in the literature. The use of
anticholinergic or H2 -receptor antagonists to reduce gastric secretion is not
recommended in the initial management of patients.
Laboratory studies that should be performed in the ED in patients with
severe disease should include amylase, lipase, CBC count, electrolytes, BUN,
calcium, glucose, AST, ALT, bilirubin (direct and indirect), alkaline
phosphatase, serum gamma-glutamyltransferase (GGT), triglyceride, PT, and
PTT. A chest radiograph should be obtained and evaluated for pleural
effusion, interstitial pneumonic infiltrates, and basilar atelectasis. A flat and
upright abdominal radiograph can assist in evaluating for perforation, ascites,
and pancreatic calcifications. An abdominal ultrasound should be performed.
Antibiotics are not routinely indicated in the initial management of
pancreatitis; however, infection is very common with necrotizing pancreatitis
and is associated with morbidity and mortality. Pancreatic abscess or
superinfection should be considered if the patients present with fever and in
those cases, broad-spectrum antibiotic coverage is indicated. While medical
management is sufficient for most children with pancreatitis, surgical
consultation is indicated in cases of traumatic pancreatitis, necrosis, prolonged
or potentially superinfected pseudocysts, or biliary duct obstruction from
stones or anatomic abnormalities such as choledochal cysts.
Clinical Indications for Admission
All patients with acute pancreatitis should be admitted to the hospital. The
decision to admit to the ICU should be based on hemodynamic status and
concern for complications.
