Pediatric fever w/ vomiting - your protocol?

[pinipig523]

Pediatric fever w/ abd pain and n/v but no diarrhea.

1. IF + DIARRHEA, then I'm more comfortable calling it a viral gastro, po challenge and f/up with pcp in am. Usually my work up is zofran odt here, po challenge, and UA to r/o UTI if the child is young enough to display GI sx moreso than dysuria sx. Sometimes I order a flu swab if there is congestion because kids usually present w/ GI sx rather than pure respiratory sx. Sometimes I order a KUB.

2. IF NO DIARRHEA, then I'm less comfortable calling it a viral gastro. Then usually I check UA and flu as above - if normal then I may proceed with blood tests (CBC and CRP). If these are positive then I may have to head towards imaging which I usually prefer US first before CTap.... I usually transfer at this point.

What do you guys do? I know that viral gastro is the most common mis-dx of appendicitis... and I just don't want to make that blanket mistake.

I'm not even sure if I can trust my exam in grade school kids (6yo-9yo).... I know that a good percentage will have no RLQ pain and only present w/ fever and vomiting.

I do see that if the child can't keep fluids down, then it's an easy move to stick the kid, get labs and give ivf and try po challenging again 30 min down the road.

But if the kid has some vague pain in the belly, fever and vomiting (no bile or blood)... do you guys end up sticking them for labs to make sure there isn't an appy that you're missing?

Thanks!

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[Rendar5]

Not sure why you don't trust your physical exam skills in a 6-9yo. they can feel pain just fine if you push on McBurney's point. I think that's a little more sensitive and specific than a WBC which we're trained to ignore. Now a 2 and under? little more difficult. But remember, kids are easier to admit than adults for serial exams. and they should still cry if you push on their abdomen and it's actually tender. If you've got a completely nontender nondistended abdomen, and there's a fever and vomiting (not post-tussive), as long as they're over 3months, I may not even stick them. I give them a single zofran, and then PO challenge them with tylenol and pedialyte/pedialyte pop. If they're not better, I just admit. If they're better with normal v/s (fever doesn't count, HR and RR do), I send them home to f/u with their doctor the next day with distinct instructions to return if they get any worse.

 

[xaelia]

There is no terribly sensitive or specific blood work regarding r/o appendicitis. I make my decisions on imaging based solely on history and exam.

For younger kids with less reliable exams, it's far easier to talk me into an abdominal ultrasound and an observation admission. Older kids get to eat and jump around. And the parents get a "maybe it's early appendicitis! see you soon if he's still sick!" talk.

 

[coachB]

Don't forget about "non-abdominal" causes like a lower lobe pneumonia.

 

[edgesofsanity]

What do you guys do? I know that viral gastro is the most common mis-dx of appendicitis... and I just don't want to make that blanket mistake.

If you don't want to make that mistake, it's pretty easy to avoid - never diagnose someone with viral gastroenteritis. There are ICD 9 codes for nausea, vomiting, and diarrhea; so use those instead.

If what you mean is you're worried about sending home a missed appendicitis, don't worry - if you work long enough in this business, you probably will. This is why having a good discharge/return talk, instruction set, and documentation of both of those 2 in your chart are so very important.

 

[UnderwaterDoc]

That's just how we are trained here. We had a recent Grand Rounds from the pediatric surgeons, and they stated that they also make imaging decisions based solely on history and physical exam findings. When we call them they never care what the lab work shows, and they are always very receptive for observation admissions . I have been having the "is maybe appendicitis" talk a lot lately. Most parents are very receptive to the idea and do not want to scan their kids unnecessarily.

 

[xaelia]

It boils back down to "zero miss" vs. "minimal harm" medicine. There's no incentive in the system to practice "minimal harm", but I sleep better at night despite missing the occasional case knowing I saved hundreds of thousands dollars to the system and prevented the harms of medical radiation and interventions secondary to false positives. It also helps I sleep in Texas.

If you listen to any expert speak regarding medicolegal liability issues, they'll tell you the recurrent theme is a communication breakdown between the providers and the patient/parents. Spending a couple minutes just sitting and talking (read: listening) to parents will save your ass more in the end than ordering more tests. And the sitting part is important.

 

[la gringa]

don't forget to check for strep in the over 2ish/under 10 set.

 

[Arcan57]

Pediatric belly pain is concerning but except in the very young it should be managed like most other belly pain. Obtaining a U/S or CT scan or even labs on every kid that comes in with a fever and abdominal pain is going to waste tons of resources and still won't prevent missed appys entirely (we had two school age kids with nl WBCs and neg CT scans bounce back with appys in the last month). The vast majority of pedi abdominal pain is going to have associated URI symptoms and needs a good physical exam (including GU), emesis control, at least a couple of serial abdominal exams, and good discharge instructions. Would add on a UA for under age 2 routinely if female, and would usually do more testing in the under-2 set in general.

If the parents look completely unreliable or your spidey sense is going off then a further work-up is reasonable but I wouldn't feel like you were mandated to get any particular tests in the setting of good PO intake and serial negative exams.

 

[xaelia]

don't forget to check for strep in the over 2ish/under 10 set.

...if you still think finding and treating strep serves an important public health function.

http://www.epmonthly.com/columns/in-my-opinion/antibiotics-for-strep-do-more-harm-than-good/
http://www.epmonthly.com/columns/in-my-opinion/antibiotics-for-strep-addressing-readers-concerns/

 

[GeneralVeers]

If belly obviously non-tender:

Zofran, Tylenol. 20 minutes later they get a PO challenge. If they tolerate PO they are out the door with the "return if not better in 12 hours" speech.

Seriously, if I worked up every kid under 2 with vomiting and fever, we'd be holding an entire department of kids for no reason.

 

[Arcan57]

...if you still think finding and treating strep serves an important public health function.

http://www.epmonthly.com/columns/in-my-opinion/antibiotics-for-strep-do-more-harm-than-good/
http://www.epmonthly.com/columns/in-my-opinion/antibiotics-for-strep-addressing-readers-concerns/

If a positive strep is what's necessary to keep you from applying unnecessary radiation to a pediatric belly, then go for it.

 

[GeneralVeers]

If a positive strep is what's necessary to keep you from applying unnecessary radiation to a pediatric belly, then go for it.

I generally don't look for it, due to the reasons stated. The same goes for Influenza. Yep the kid's got the flu. So what? As long as they can drink fluids and don't appear toxic they are going home.

I'm always astonished by EPs ordering tests that don't really matter or change clinical course, but in the process they hold patients for hours at a time in the ED waiting for results.

I understand that some EPs are OCD and "need to know" an answer, but if the answer is irrelevant, why bother?

 

[zinjanthropus]

I also test for strep in these as it helps avoid potential radiation/admission if positive and so often presents with belly pain, fever, vomiting in little people. The recent who cares about strep discussions/Newman stuff focuses to singularly on one set of important outcomes but ignores other reasons why we sometimes do tests or look for diagnoses

 

[UnderwaterDoc]

...if you still think finding and treating strep serves an important public health function.

http://www.epmonthly.com/columns/in-my-opinion/antibiotics-for-strep-do-more-harm-than-good/
http://www.epmonthly.com/columns/in-my-opinion/antibiotics-for-strep-addressing-readers-concerns/

I quote these every time I don't want to check a child for strep, but our pediatric-trained PediEM folks are still not convinced, all evidence to the contrary.

 

[UnderwaterDoc]

I also test for strep in these as it helps avoid potential radiation/admission if positive and so often presents with belly pain, fever, vomiting in little people. The recent who cares about strep discussions/Newman stuff focuses to singularly on one set of important outcomes but ignores other reasons why we sometimes do tests or look for diagnoses

So in that same vein. I recently had an 2-month old who presented febrile, with no clear source. UA was dirty so we treated and admitted. Inpatient peds wanted spinal tap but we said no because the chance of co-meningitis is much less than 1%, and child appeared very well/nontoxic/tolerating PO etc.

The inpatient peds folks reflexively tapped the kid, and wouldn't you know the kiddo had a raging meningitis with G+ in the CSF. Granted treatment was the same (we gave rocephin IV for the UTI) but still. It's always the ones you argue about...

 

[GeneralVeers]

So in that same vein. I recently had an 2-month old who presented febrile, with no clear source. UA was dirty so we treated and admitted. Inpatient peds wanted spinal tap but we said no because the chance of co-meningitis is much less than 1%, and child appeared very well/nontoxic/tolerating PO etc.

The inpatient peds folks reflexively tapped the kid, and wouldn't you know the kiddo had a raging meningitis with G+ in the CSF. Granted treatment was the same (we gave rocephin IV for the UTI) but still. It's always the ones you argue about...

As long as you are going to admit the kid, and treat for meningitis, it doesn't matter whether or not you do a tap. I generally leave that decision up to the admitting doc, unless there's clear evidence of Meningitis. Certainly wouldn't send home a 2 month with fever.

 

[dotcb]

Rocephin would not be the treatment of a gram positive meningitis, unless you meant that the gram stain was positive for gram negative organisms.

So in that same vein. I recently had an 2-month old who presented febrile, with no clear source. UA was dirty so we treated and admitted. Inpatient peds wanted spinal tap but we said no because the chance of co-meningitis is much less than 1%, and child appeared very well/nontoxic/tolerating PO etc.

The inpatient peds folks reflexively tapped the kid, and wouldn't you know the kiddo had a raging meningitis with G+ in the CSF. Granted treatment was the same (we gave rocephin IV for the UTI) but still. It's always the ones you argue about...

 

[la gringa]

If a positive strep is what's necessary to keep you from applying unnecessary radiation to a pediatric belly, then go for it.

precisely... it's an explanation for the fever. whether you treat it is up to you, but i don't think it's "standard of care" just yet to not treat strep (especially in kids!).

i also push Bicillin for strep to ensure compliance and minimize developing resistance.

 

[pinipig523]

Thanks a lot guys.... another helpful thread.

Learned and re-emphasized by knowledge base:
1. Above 2 yo = physical exam is a good marker
2. PO tolerance is a good marker
3. Close f/up is key, emphasize that it "could" be apply, come back if po intolerant, worse, etc
4. Look for associated signs that could point to viral syndrome (URI, recent contacts, diarrhea)... if more possibly viral, then zofran, po challenge and look for playful child on reeval.
5. If fever + vomit (ensure it is not pathologic i.e. no blood or bile), trust the physical exam in someone >2-3yo. If the exam is not concerning and the child is po tolerant, then close follow up.

Btw, in our residency, we had never really used CRP. Do you guys use CRP in your decision making process in patients with appendicitis? I've been searching the literature and though you still miss some w/ neg WBC elevation and neg CRP, the risk is pretty darn low especially if you have no neutrophilic predominance in addition to neg WBC and neg CRP. Just wanted some thoughts, thanks!

This forum is so helpful for someone who just left the mother base... it's tough when you don't have your trusted attendings around you anymore.

 

[deleted109597]

precisely... it's an explanation for the fever. whether you treat it is up to you, but i don't think it's "standard of care" just yet to not treat strep (especially in kids!).

i also push Bicillin for strep to ensure compliance and minimize developing resistance.

So if they're strep negative you don't have an explanation for the fever?
What about the reflex culture. I mean, that's inexpensive and not resource intensive at all, right?

Greg Henry said

We’ve always said that the standard of care is what a similarly-trained physician would do under similar circumstances, and not the ideal, not the retrospective evaluation.

If enough people start doing it, it becomes the standard of care. If people would stop agreeing to "deal" with states with ****ty malpractice laws, you could practice like you ought to, not like you worry about someone looking over your shoulder.

Resistance? For group A strep? 100% sensitive to penicillins. All of them.
If people would stop treating everything with a ****ing zpak then we wouldn't have macrolide resistance.

 

[Daiphon]

Thanks a lot guys.... another helpful thread.

Btw, in our residency, we had never really used CRP. Do you guys use CRP in your decision making process in patients with appendicitis? I've been searching the literature and though you still miss some w/ neg WBC elevation and neg CRP, the risk is pretty darn low especially if you have no neutrophilic predominance in addition to neg WBC and neg CRP. Just wanted some thoughts, thanks!

This forum is so helpful for someone who just left the mother base... it's tough when you don't have your trusted attendings around you anymore.

I don't use CRP to make dispo decisions; my framework is in line with above - looks good, soft belly = zofran/APAP/popsicle & home if tolerates, f/u within 24h w/ PMD. Otherwise, admit...

Now, my peds surgeons use CRP to decide if the pt should come to their service or gen peds with them on consult. Doesn't change a thing from my decision making process.

As for not being in the "mother base" - you can always call. I field 3-4 calls a month from my new grads looking for guidance. It's part of our job. d=)

Cheers!
-t

Sent from my DROID BIONIC using Tapatalk

 

[la gringa]

my "mother ship" is so different than the shops in which i've practiced that i'm not sure they'd be of any help! i have ready access to colleagues and consultants as i work in a multi-hospital group, all in the same hospital system.

our pedi surgeons like CRP too. i usually order ESR and CRP on r/o appy to help them on the other end in case of transfer.

i've been doing fewer streps lately - i almost never do in adults - symptoms only. kiddos there's the parent factor...

 

[Socrates25]

Disclaimer -- pediatrician here

IMHO a good physical exam without any labs will pick up the vast majority of appendicitis cases.

Some of you guys seem to be very skeptical of your physical exam skills on kids, and I have to ask why? If you have a child who is calm, then your abdominal exam should be pretty damn reliable in detecting appendicitis. I know its difficult with fussy kids who dont want you near them, but there's lots of things you can do to mitigate that effect. My belief is that if you can have a kid who is calm and will let you press on their belly then that's all you really need -- noting if the pain is only at McBurney's point or if they have rebound is not very helpful in peds IMHO.

The main issue is that a GOOD physical exam takes some time, you cant walk into a screaming 2 year old's room and expect to get a good abdominal physical exam in 60 seconds. You often have to touch the kid's belly, wait for him to calm down after a few minutes, and then try again later when he's more acclimated to you being in the room with him, preferably being held by mom/dad, preferably while you are trying to play with him/hold a toy/give some candy or whatever to take his focus/attention off of you.

I recommend getting a good visual toy with lots of lights/colors/sounds that will help distract the toddlers. Have him sit in the mom's lap, let him reach out for the toy and in most cases you can reach over feel his belly while he's distracted -- if he really has appendicitis he will tell you. Of course there will be kids who are freaked out enough they wont take the bait but I think that's effective for a sizable majority of kids.

Another effective strategy if the kid absolutely wont be calm when you touch him, even after trying distraction/bribing attempts is to let the mom/dad feel on his belly for you. I've seen kids that screamed bloody murder when I touch their belly, but if you have the mom put her hand with moderate pressure they are smiling/laughing. That kid does NOT have appendicitis, and I dont have to actually put my hands on the belly to tell that. Use the parents as a surrogate physical exam, that can help immensely.

Doing a good PE on a 6-9 year old should not be an issue at all. I think the hardest group is 12 months to 3 years but after that its not too bad.

 

[Socrates25]

As long as you are going to admit the kid, and treat for meningitis, it doesn't matter whether or not you do a tap. I generally leave that decision up to the admitting doc, unless there's clear evidence of Meningitis. Certainly wouldn't send home a 2 month with fever.

I agree the ER doesnt need to do the tap, although I think the admitting peds should do one.

Also, I would say that a well appearing 2 month old with fever can go home as long as they can get PCP follow-up the next day. But I would definitely have a very low threshold for admitting.

 

[Socrates25]

That's just how we are trained here. We had a recent Grand Rounds from the pediatric surgeons, and they stated that they also make imaging decisions based solely on history and physical exam findings. When we call them they never care what the lab work shows, and they are always very receptive for observation admissions . I have been having the "is maybe appendicitis" talk a lot lately. Most parents are very receptive to the idea and do not want to scan their kids unnecessarily.

You probably meant that they are very receptive for observation admissions to the general peds team

I know, you guys dont care who admits them, as long as somebody takes them out of your ER

 

[Rendar5]

lol that's why I like my local peds hospital ambulance crew. they take em right out for me. as long as it goes to someone

 

[Socrates25]

I'm not even sure if I can trust my exam in grade school kids (6yo-9yo).... I know that a good percentage will have no RLQ pain and only present w/ fever and vomiting.

You should absolutely trust your physical exam findings in this age group. They might not have specific RLQ pain but the vast majority of the time they should have some kind of abdominal pain on exam, it wont be the classic adult findings, but there will be something there that perks your ears up.

If you miss a case of appendicitis in this age group because of a normal physical exam, then I'd say you'd be just as likely to miss it with labs and imaging too.

 

[Birdstrike]

If belly obviously non-tender:

Zofran, Tylenol. 20 minutes later they get a PO challenge. If they tolerate PO they are out the door with the "return if not better in 12 hours" speech.

Seriously, if I worked up every kid under 2 with vomiting and fever, we'd be holding an entire department of kids for no reason.

Pretty much this.

The best advice I was ever given on how to learn how to work up kids, was this:

Have some kids.

Probably the best "test" in this situation is time. Make the symptoms better like Veers says, and you won't be able to hold a well kid back. They'll be so bored, and irritated at being in the ED, driving the parents crazy, asking for food, asking for their video game, asking to play games on the parents iPhone/iPad, that the parents will be begging for discharge and you'll have your diagnosis.

If I CT'd my kids every time they said their stomachs hurt, I'd be living under a mushroom cloud. One minute they're dying, the next minute, they want ice cream and they're wacking their sibling over the head with a toy, making a scene.

Remember, the appendix isn't going to explode in the next 5 minutes.

For the non-toxic kid with belly pain, get them feeling better and watch them for a little bit.

One of 3 things will happen: either A) they'll get better, B) get worse, or C)stay the same.

If it's A, you are done.
If it's B, you know what to do (order your favorite tests.)
If it's C, wait 5 minutes and it'll flip to either A or B.

 

[RustedFox]

Pretty much this.

The best advice I was ever given on how to learn how to work up kids, was this:

Have some kids.

Maaaan. I try and stand with my genitals in front of the portable x-ray as often as possible. Sometimes, I ask them just to push the button when there's no film there anyways.

 

[Birdstrike]

Maaaan. I try and stand with my genitals in front of the portable x-ray as often as possible. Sometimes, I ask them just to push the button when there's no film there anyways.

 

[Old_Mil]

I don't use CRP to make dispo decisions; my framework is in line with above - looks good, soft belly = zofran/APAP/popsicle & home if tolerates, f/u within 24h w/ PMD. Otherwise, admit...

Now, my peds surgeons use CRP to decide if the pt should come to their service or gen peds with them on consult. Doesn't change a thing from my decision making process.

As for not being in the "mother base" - you can always call. I field 3-4 calls a month from my new grads looking for guidance. It's part of our job. d=)

Cheers!
-t

Sent from my DROID BIONIC using Tapatalk

I like crp in the adult population but my understanding is that its sensitivity in ruling out an appy increases with advancing age and so it may not be as useful in young kids.

 

[Socrates25]

I like crp in the adult population but my understanding is that its sensitivity in ruling out an appy increases with advancing age and so it may not be as useful in young kids.

Anecdotally most peds surgeons I know really like CRPs in kids, but I'm not sure if there's any real evidence to support that.

 

[UnderwaterDoc]

I agree the ER doesnt need to do the tap, although I think the admitting peds should do one.

Also, I would say that a well appearing 2 month old with fever can go home as long as they can get PCP follow-up the next day. But I would definitely have a very low threshold for admitting.

Actually no, peds surg admits their own patients at our hospital.

 

[Socrates25]

Actually no, peds surg admits their own patients at our hospital.

I have no doubt, I was being somewhat facetious. Some places have very supportive peds surgery attendings who are willing to take these kids. However many places I have been at have the classic surgery mindset of "admit to someone else and I will consult if needed" stuff.

 

[dchristismi]

I tend to agree - the exam, done correctly, gives you a ton of info. I tend to be playful with kids (amazing how quickly a peek-a-boo game behind a curtain gets them smiling. I crawl on my knees to get to their level. Make them walk. Make them jump.

The youngest appy I've picked up on was 2. The kicker was that he wouldn't stand upright - he leaned forward. I did the same exact thing when my own appy went south. (Mine read the textbook, though!)

Don't forget the testicles! I had a torsion case where the 12 year old swore his testicles were fine. I looked, and they most certainly were not. He was so embarassed, he flat out lied to me. When I asked if it "normally looked like that" (Red, tender), he shrugged his shoulders and said "I guess." I then told him that there was no way it was normally like that, and he knew it. I am just so thankful I looked on my first trip in the room when his belly exam was startlingly benign, rather than believe him. Testicle was a goner, but I'm glad I was able to know that it wasn't a delay in catching it.

 

[UnderwaterDoc]

Rocephin would not be the treatment of a gram positive meningitis, unless you meant that the gram stain was positive for gram negative organisms.

AFAIK Rocephin and Vancomycin is first line for meningitis in the 2 month old age group, as you can find in the 2013 EMRA antibiotic guide. We would have added vanco to the rocephin had we known about the meningitis.

 

[la gringa]

I tend to agree - the exam, done correctly, gives you a ton of info. I tend to be playful with kids (amazing how quickly a peek-a-boo game behind a curtain gets them smiling. I crawl on my knees to get to their level. Make them walk. Make them jump.

The youngest appy I've picked up on was 2. The kicker was that he wouldn't stand upright - he leaned forward. I did the same exact thing when my own appy went south. (Mine read the textbook, though!)

Don't forget the testicles! I had a torsion case where the 12 year old swore his testicles were fine. I looked, and they most certainly were not. He was so embarassed, he flat out lied to me. When I asked if it "normally looked like that" (Red, tender), he shrugged his shoulders and said "I guess." I then told him that there was no way it was normally like that, and he knew it. I am just so thankful I looked on my first trip in the room when his belly exam was startlingly benign, rather than believe him. Testicle was a goner, but I'm glad I was able to know that it wasn't a delay in catching it.

great point.

and amen to being sometimes painfully patient and doing serial exams on kids. nurses will sometimes grouse that they're there over the magical 3 hr mark that the admins want...but i'm not rushing out a kiddo w/ belly pain. they don't manipulate and you WILL have more info after tylenol/zofran/bolus/labs are done and working.

every kid i've had w/ a confirmed appy had a DEAD ON exam. one 16 y/o girl had such an exam and it turned out to be a cyst... only "kids" i'll scan (rarely) are older teen girls if they're not sexually active and U/S shows nothing.

 

[Mighty Mouse]

i find most of my kids are motrin, zofran, popsicle and out.

but....good exam and good history taking are paramount. anorexia (lack of appetite) is a big deal to me. if the kid is old enough to speak, i ask him what his/her favorite food is. normally they're like, pizza! or mac and cheese! and then i say, if i had the best pepperoni pizza right now, would you want it? if they say yes, i'm a lot less concerned. if i have a kid who is like, there's no way i'd eat a pizza right now, then i suddenly get a lot more interested.

in addition, on some of the younger kids (2ish) i make it a game. i get them up, we run around the room, i ask them to jump and touch my hand, anything i can think of to see if they're peritoneal or not.

and absolutely, every time....look at the genitals!!!!!

also....i find that a kid who is screaming and crying and won't let you near you is going to be just fine most of the time. i worry about the kids who are too sick to care when you touch them, poke them with IVs, etc. those are the ones that you need to be afraid of.