Having recently attended a pediatric ER conference I learned about this protocol for r/o appy in peds.
Ultrasound followed by MRI if results are equivocal instead of CT. I had never heard of this, but I can see this starting to gain traction in the community. I'm curious about people's practices for imaging kids for r/o appy.
How many people are using MRI as a follow up exam for nondiagnostic ultrasounds? Are you experiencing any barriers to this protocol? What do you think?
http://pediatrics.aappublications.org/content/pediatrics/early/2014/02/25/peds.2013-2128.full.pdf
That was our practice in residency, but that was at one of the pediatric Meccas. There was a clear, written protocol that was agreed upon by Peds EM, Peds surgery and Peds Radiology, so never any push back at all. It went something like this:
High suspicion -> Call peds surgery straight away -> usually US -> if US non diagnostic, usually MRI, or if sedation not available (middle of night, for example) then sometimes CT, sometimes obs depending on labs, serial exams, etc.
Moderate suspicion -> US (but order MRI at the same time) -> if US non diagnostic, reassess, if clinically improved and labs all good (no high WBC count, etc) either DC with strict return instructions/mandatory return in 24 hours for re-eval, obs a little more or call surgery consult that would often recommend DC as above.
Low suspicion -> US -> if non diagnostic, reassess and either upgrade to MRI or downgrade to DC with return instructions.
I think the standard is going to vary significantly depending on the resources available. With the best possible set up (ready availability of MRIs, anesthesia available for sedation, skilled US techs, etc) I think its the best possible protocol from the patient's perspective. However, if resources are less available, then the standard may be US -> CT, or straight to CT, or US -> serial exams, or US -> transfer to peds center. The most important thing is to have institutional agreement on what to do, and to have your surgeons on board.
PS: I only clicked your link after I wrote up this post, and it turns out that this is the Mecca I was talking about. Oops.