Pediatric abdominal pain: CT, MRI, US ???

[RustedFox]

Don't you do inpatient work? Would you not hit up an appy with Zosyn or (insert institutionally preferred drug here)?

Your fault, too. Lolz.

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[VA Hopeful Dr]

Don't you do inpatient work? Would you not hit up an appy with Zosyn or (insert institutionally preferred drug here)?

Your fault, too. Lolz.

Good God no, I haven't professionally set foot in a hospital since residency.

I honestly do think that my PCP colleagues are much more responsible for c. diff than ED/inpatient folks are. There is a 4 doctor FP practice across the street and I bet they give out more broad spectrum antibiotics in a day than my wife's 60-bed hospital and 100-visit/day average ED does.

 

[gro2001]

Good God no, I haven't professionally set foot in a hospital since residency.

I honestly do think that my PCP colleagues are much more responsible for c. diff than ED/inpatient folks are. There is a 4 doctor FP practice across the street and I bet they give out more broad spectrum antibiotics in a day than my wife's 60-bed hospital and 100-visit/day average ED does.

Remember, the cardinal rule of EM is that any patient presenting to the ED must get at least one of the following:

1) Vanc and Zosyn
2) CT scan
3) Dilaudid
4) Consult

If they get more than 1, they get admitted.
If they get more than 2, they get admitted to ICU.

 

[MSmentor018]

Remember, the cardinal rule of EM is that any patient presenting to the ED must get at least one of the following:

1) Vanc and Zosyn
2) CT scan
3) Dilaudid
4) Consult

If they get more than 1, they get admitted.
If they get more than 2, they get admitted to ICU.

get all 4 and its' jackpot, bill for critical care time!

 

[gamerEMdoc]

Many years ago, a wise attending told me that if you ever get stuck on a case, just use the 3 C's to figure them out:
1. Get a consult
2. Get a CT
3. Get another CT with Contrast

In all seriousness, my general approach to the young thin person with possible appy is do my own bedside US. If I find one, the US tech probably will. If I don't, they usually don't. So if I find one, then I order an US. In every case where I found an appy on a kid myself, the US tech confirmed it. If negative, I usually don't waste my time getting an US by the tech and I jump to CT.

I learned how to do appy US myself by watching the US podcast videos on it. The first time I ever did one on a kid, it was positive. I couldn't believe it!

 

[gro2001]

Many years ago, a wise attending told me that if you ever get stuck on a case, just use the 3 C's to figure them out:
1. Get a consult
2. Get a CT
3. Get another CT with Contrast

In all seriousness, my general approach to the young thin person with possible appy is do my own bedside US. If I find one, the US tech probably will. If I don't, they usually don't. So if I find one, then I order an US. In every case where I found an appy on a kid myself, the US tech confirmed it. If negative, I usually don't waste my time getting an US by the tech and I jump to CT.

I learned how to do appy US myself by watching the US podcast videos on it. The first time I ever did one on a kid, it was positive. I couldn't believe it!

The very first (adult!) patient I ultrasounded on a shift in residency I (with the help of a senior resident) found an appe. Never happened again since.

 

[bravotwozero]

What do you guys think of using esr/Crp in these kids? If they both come back negative, how likely is the kid to have any kind of -itis?


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[MSmentor018]

What do you guys think of using esr/Crp in these kids? If they both come back negative, how likely is the kid to have any kind of -itis?


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I've often wondered that myself. I use to think crp >10 = something's brewing. but just heard EMRAP lecture and he said crp is crAp. so I dunno now.....

 

[gamerEMdoc]

What do you guys think of using esr/Crp in these kids? If they both come back negative, how likely is the kid to have any kind of -itis?


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I've never liked ordering a test that doesn't answer the question. There is no blood test that rules out appendicitis. There's no imaging test that rules out appendicitis either, but they come closer to bloodwork. Getting a CBC, CRP, or ESR on someone right lower quadrant pain and stopping there if negative makes no sense to me.

Now in conjunction with imaging that is negative, I do think you have a much lower posttest probability. A normal inflammatory marker plus a normal ultrasound certainly lowers the post test probability. But does a really change practice? If the white count is high, or CRP is high, and the ultrasound is normal or the CT is normal, what are you going to do differently? Will a surgeon take the kid to the OR with normal imaging?

And on the flipside, people over order these tests on every kid with generalized abdominal pain, which will cause them to then over order imaging because of false positives. Every kid with gastroenteritis is going to be getting ultrasound and CT's and MRIs.

We definitely have a tendency to over order tests. And it hurts us medical legally. Either someone has a surgical abdomen or they dont at that moment in time. Relying on insensitive, nonspecific tests only hurts you. Excellent return precautions, talking to patients, re-examinations, etc. that's what helps.

Why do I say it hurts you. Let me give you two scenarios, one with a normal white count one with an abnormal.

Scenario one: child comes in with vague Abd pain and vomiting. You put an IV in to hydrate the child, and get a white count for some reason. The white blood cell count is normal. You assume he has gastroenteritis, send the kids home to follow up with his PCP in two days if not better. He returned three days later with a ruptured appendicitis. The white count only hurt you because it provided false reassurance. You can say it doesn't, and maybe it really doesn't, but it sure will look that way on the stand. If I was a lawyer first question I ask would be, "Dr. you know that a normal white blood cell count can occur in 20% of appendicitis right". To which you would answer yes. The lawyer with and ask why you would send a child home with a 20% of appy. You would say that you didn't think the child had an appy based on your exam. And this is where you'd be stuck. Because the next question the lawyer would ask is why you would order the white blood cell count if you didnt think an appy was possible. If you didn't think the disease existed, why did you order the lab. By looking for an abnormal white count, you were looking for a disease that in reality you didnt think exists in the first place, but instead it really just looks after the fact like you got false reassurance.

Scenario 2: child comes in with vague Abd pain and vomiting. You put an IV in to hydrate the child, and get a white count for some reason. The white blood cell count is high, but the child looks much better with the IV fluids so you just send him home with the same plan as above. Same bad outcome occurs. Now this looks even worse. You ordered a study screening for something, had a positive screening, and did nothing about it.

A much much better approach is a good physical exam, documenting that there are no physical signs of appy AT THAT MOMENT IN TIME but documenting good discussion with parents about early appy, good return precautions like return to ED in 8 to 12 hours for a re-exam instead of 2 to 3 days with your PCP. This will save you time, as you wont be testing kids with unnecessary bloodwork that wont change your management, and is a good safe approach to the problem.

That's in the kid with with more generalized pain or vomiting. In kids with actual right lower quadrant tenderness, I get imaging. Even if the imaging is negative, if they have a good enough exam I get a surgical consult.

 

[dchristismi]

Having had my appendix out (laparoscopically) as an attending, I am quite glad that I had the surgery. Once I woke up, I immediately felt better. Granted, my appendix had been to medical school and read the textbook, but I would NOT had wanted to stay in the hospital and be loaded up with more than 1 dose of the obligatory Zosyn.

I've caught a couple pedi appys with US, but it's iffy at best at my hospital. And in residency, I diagnosed the medicine chief's pregnant wife with an appy with US. I figure I used up all my US mojo right there. I am a fan of the US + recheck in 12 hours and not scanning unless I absolutely have to. The physical exam and documenting it well, are more important than in a lot of other things.

Also, if a kid can do "the worm" up the stretcher, the incidence of appendicitis approaches zero. (Granted n=1, but it was hilarious.)

 

[gamerEMdoc]

The physical exam and documenting it well, are more important than in a lot of other things.

So true

 

[Aesculapius]

Unfortunately, I feel that unless you are in a pediatric hospital, the chance of a sonographer consistently and unambiguously catching a pediatric appy (which then a surgeon has to accept for the admission) are very low. That being said, if I don't really believe the kid has an appendicitis, I will often get the ultrasound, and if it is negative, have a discussion with the family about observation with close follow up and strict return precautions vs. doing the CT, and document as such. Most of the time, they opt to go home. Even CT isn't a panacea, by the way: on my last shift, I had a case where I did a CT with contrast on a kid that I didn't really think had appendicitis, which got resulted as appendix not visualized, but no secondary findings, whom I sent home, and then came back the next day, had US suspicious for appendicitis but not definitive, and then CT that did show a non-perforated appendicitis.

 

[gro2001]

I've never liked ordering a test that doesn't answer the question. There is no blood test that rules out appendicitis. There's no imaging test that rules out appendicitis either, but they come closer to bloodwork. Getting a CBC, CRP, or ESR on someone right lower quadrant pain and stopping there if negative makes no sense to me.

Now in conjunction with imaging that is negative, I do think you have a much lower posttest probability. A normal inflammatory marker plus a normal ultrasound certainly lowers the post test probability. But does a really change practice? If the white count is high, or CRP is high, and the ultrasound is normal or the CT is normal, what are you going to do differently? Will a surgeon take the kid to the OR with normal imaging?

And on the flipside, people over order these tests on every kid with generalized abdominal pain, which will cause them to then over order imaging because of false positives. Every kid with gastroenteritis is going to be getting ultrasound and CT's and MRIs.

We definitely have a tendency to over order tests. And it hurts us medical legally. Either someone has a surgical abdomen or they dont at that moment in time. Relying on insensitive, nonspecific tests only hurts you. Excellent return precautions, talking to patients, re-examinations, etc. that's what helps.

Why do I say it hurts you. Let me give you two scenarios, one with a normal white count one with an abnormal.

Scenario one: child comes in with vague Abd pain and vomiting. You put an IV in to hydrate the child, and get a white count for some reason. The white blood cell count is normal. You assume he has gastroenteritis, send the kids home to follow up with his PCP in two days if not better. He returned three days later with a ruptured appendicitis. The white count only hurt you because it provided false reassurance. You can say it doesn't, and maybe it really doesn't, but it sure will look that way on the stand. If I was a lawyer first question I ask would be, "Dr. you know that a normal white blood cell count can occur in 20% of appendicitis right". To which you would answer yes. The lawyer with and ask why you would send a child home with a 20% of appy. You would say that you didn't think the child had an appy based on your exam. And this is where you'd be stuck. Because the next question the lawyer would ask is why you would order the white blood cell count if you didnt think an appy was possible. If you didn't think the disease existed, why did you order the lab. By looking for an abnormal white count, you were looking for a disease that in reality you didnt think exists in the first place, but instead it really just looks after the fact like you got false reassurance.

Scenario 2: child comes in with vague Abd pain and vomiting. You put an IV in to hydrate the child, and get a white count for some reason. The white blood cell count is high, but the child looks much better with the IV fluids so you just send him home with the same plan as above. Same bad outcome occurs. Now this looks even worse. You ordered a study screening for something, had a positive screening, and did nothing about it.

A much much better approach is a good physical exam, documenting that there are no physical signs of appy AT THAT MOMENT IN TIME but documenting good discussion with parents about early appy, good return precautions like return to ED in 8 to 12 hours for a re-exam instead of 2 to 3 days with your PCP. This will save you time, as you wont be testing kids with unnecessary bloodwork that wont change your management, and is a good safe approach to the problem.

That's in the kid with with more generalized pain or vomiting. In kids with actual right lower quadrant tenderness, I get imaging. Even if the imaging is negative, if they have a good enough exam I get a surgical consult.

I used to think this way too, but then I realized that I was overthinking it. If a bad outcome occurs, the lawyers will get their pound of flesh with or without a misleading test.

If you got the CBC, WBC was high, and you sent them home: "Why didn't you believe the WBC count? Don't you know its a sign of disease?"
If you got the CBC, WBC was low, and you sent them home: "Why did you believe the WBC? Don't you know its doesn't rule out disease?"
If you didn't get the CBC and you sent them home: "Why didn't you at least get the CBC? You might have seen a huge white count and ordered more testing."

The same logic can be applied to the use of any screening test for any disease process (d-dimer, ECG, CXR, etc). If a bad outcome happens, they will find a way to screw you. After all, their logic doesn't have to make medical sense, it just has to make sense to other lawyers and lay people.

Now I figure that I won't try to out lawyer the lawyers. If I think a test will be useful, I get it. If it won't be useful, I don't get it. If I do everything perfectly and a bad outcome happens, they can always bring Peter Rosen to testify against me anyway.