Abdominal Pain in Pediatric Emergency

Causes of abdominal pain in childhood Abdominal pain is one of the more common reasons for parents to bring their child to the Emergency Department. While many diagnoses traverse all age groups, some are more age specific (Table 1).

Assessment of abdominal pain

The assessment of the child with acute abdominal pain depends on a good history and careful examination. The nature of the pain itself must be carefully elicited, including its characteristics, relieving and precipitating factors. Truly severe colicky pain suggests an obstruction of the gastrointestinal, genitourinary or hepatobiliary tract. Pain can be referred from elsewhere such as the testes and the lungs. Associated features must also be elicited such as gynecological symptoms in adolescent girls. A full and careful but sensitive examination must follow. If acute activity precipitates pain, it suggests peritonitis. Acute serious problems need rapid combined surgical and medical assessment and management. The algorithm (Table 1) may be used as a guide to the systematic consideration of various categories of causes of acute abdominal pain. Typical features of some important causes of acute abdominal pain in children are described in the following table (Table 2).

Notes:

• Acute appendicitis must be considered in any child with severe abdominal pain, aggravated by movement such as walking, or a bumpy car ride. The child is often flushed, with a tachycardia and a mildly elevated temperature. In the very young child, in whom the risk of perforation is higher, the presenting symptoms are less specific. The diagnosis is clinical—no laboratory or radiological tests are required, although there is usually an elevated white cell count.

• The peak age for intussusception is 6–12 months. The child may present in shock. Plain anterior chest X-ray may show signs of bowel obstruction, with decreased gas in the right colon. The diagnosis is confirmed by air insufflation or barium enema, with reduction usually possible by the same means (unless there are signs of peritonitis, which increase the risk of perforation).

• Mid-gut volvulus is commonest in the newborn period, but can occur in later childhood. Predisposing factors include malrotation and abnormal mesentery.

• Vomiting is rarely due to constipation.

• Some children suffer recurrent non-specific abdominal pain, with no organic cause identifiable. Constipation is often an important contributing factor. Psychogenic factors (e.g. family, school issues) need to be considered. These children should be referred for general pediatric assessment.

• Some less common diagnoses need to be considered in patients with certain underlying chronic illnesses. Hirschsprung disease can be complicated by enterocolitis, with sudden painful abdominal distension and bloody diarrhea. These patients can become rapidly unwell with dehydration, electrolyte disturbances, and systemic toxicity, and are at risk of colonic perforation. Primary bacterial peritonitis can occur in children with nephrotic syndrome, splenectomy and those with VP shunts.

Table 1.  Causes of abdominal pain by age

Table 2. Assessment of abdominal pain in pediatric

Management

An algorithm for abdominal pain management is given in Table 1.

Intravenous access should be established. The electrolytes should be measured in a child who appears dehydrated and blood and stool cultures obtained if the child is potentially septic. The patient should be given and fasted until a surgical opinion has been sought. In addition, a nasogastric tube will be needed if there is bowel obstruction.

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Meningitis in Pediatric Emergency

The presentation of a child with meningitis varies with age. Infants with meningitis frequently present with non-specific signs and symptoms such as fever, irritability, lethargy, poor feeding and vomiting. The fontanelle may or may not be full. Older children may complain of headache or photophobia. Neck stiffness may be present (although this is not a reliable sign in young children). A purpuric rash is suggestive of meningococcal septicemia. It is important to examine for spinal and cranial abnormalities such as dermal sinuses, which may have predisposed the child to meningitis.

Note: This guideline is not for use in children with spinal abnormalities or ventriculoperitoneal shunts where the neurosurgical team should be consulted.

Assessment

Assess airway, breathing and circulation. Monitor pulse, blood pressure, respiratory rate, oxygen saturation and consciousness. Insert intravenous line and take blood for glucose, FBC and blood cultures and U&Es, meningococcal PCR, and CRP (C-reactive protein). Do nose and throat swabs, as occasionally the organism is isolated from these. If the clinical diagnosis is meningitis and there are contraindications for a lumbar puncture give intravenous antibiotics without delay.

Lumbar puncture (LP)

An LP is used to confirm the diagnosis of bacterial meningitis and to identify the organism and its antibiotic sensitivities. In some cases it should be postponed because of the risk of coning. There are contraindications to performing an LP, including:

• Coma—Glasgow Coma Scale (GCS) <13 or rapid deterioration in conscious state or absent or non-purposeful responses to painful stimuli (squeeze earlobe hard for up to 1 minute. Children should localise response and seek a parent)

• Focal neurological signs

• Papilledema

• Cardiovascular compromise

• Evidence of coagulopathy.

If any of these signs are present the patient is in danger of coning, and management in Intensive Care is usually required. Notify a PICU immediately (for retrieval or transfer), perform blood cultures, commence antibiotics.

Remember cerebrospinal fluid (CSF) findings in early bacterial meningitis may mimic a viral pattern or even be normal (see Table 6.1). In a traumatic tap, allow 1 white blood cell for every 500 red blood cells, and 0.01 gl−1 of protein for every 1000 red cells. Request culture and analysis for bacterial antigens (this is non-urgent as it does not change immediate management and there is no need for it to be performed out of hours).

Management

a. Admission to a PICU

Admission to PICU should be discussed with the consultant in the following circumstances:

Meningitis: Factors requiring consultant opinion

•Age less than 2 years

•Coma

•Cardiovascular compromise

•Intractable seizures

•Hyponatremia

b. Antibiotics

In a child aged over 2 months the usual organisms causing bacterial meningitis are Streptococcus pneumoniae, Neisseria meningitidis and Hemophilus influenzae type b (HiB—uncommon after the age of 6 and the incidence is reduced following HiB vaccination).

Empirical treatment consists of cefotaxime (50 m g/kg weight per dose up to a maximum of 3 g, 6 hourly) given prior to determination of the organism responsible and its sensitivities. Chloramphenicol may be used in children with a type 1 hypersensitivity to cephalosporins. You may need to consider the addition of vancomycin if pneumococcus is suspected in an area of high incidence of penicillin-resistant pneumococcus.

Continue empirical treatment until cultures are known to be negative or an organism and its sensitivity pattern are known. A positive culture result with sensitivities should lead to narrower spectrum treatment.

In a child aged under 2 months, the organisms to consider in this age group include group B streptococcus, Escherichia coli and other Gram negative organisms, Listeria monocytogenes, Streptococcus pneumoniae, Neisseria meningitidis and Hemophilus influenzae type b.

Initial therapy is with i.v. benzylpenicillin (50mg/kg weight per dose, 6 hourly), and i.v. cefotaxime (50 mg/kg weight per dose, 6 hourly), and i.v. gentamicin (dose according to age). Ongoing therapy is modified according to culture and sensitivity results. Consult local guidelines.

Treatment in meningjtis with positive cultures with sensitivities

• Neisseria meningitidis—give i.v. benzylpenicillin 50 mg/kg weight per dose up to a maximum of 3 g, 4 hourly for 7 days (in penicillinsensitive cases)
• Streptococcus pneumoniae—give i.v. benzylpenicillin 50 mg kg−1 per dose up to a maximum of 3 g, 4 hourly for minimum of 10 days (in penicillinsensitive cases)
• Hemophilus influenzae—give i.v. cefotaxime 50 mg/kg weight  per dose up to a maximum of 3 g, 6 hourly for 7–10 days, or i.v. amoxycillin 50 mg/kg weight  per
• dose 4 hourly for 7–10 days (depending on sensitivities)
• Other—if an organism is not isolated, but significant CSF pleocytosis is present, a minimum of 7 days treatment with i.v. cefotaxime is recommended.

c. Fluid management

Careful fluid management is important in the treatment of meningitis as many children have increased antidiuretic hormone (ADH) secretion. The degree to which fluid should be restricted varies considerably from patient to patient depending primarily on their clinical state.

Shock should be corrected with 20 ml/kg weight of normal saline. A patient who is not in shock and whose serum sodium is within the normal range should be given 50% of maintenance fluid requirements as initial management. If the serum sodium is less than 135 mmol/l give 25–50% of maintenance requirements. The serum sodium should be repeated every 6–12 hours for the first 48 hours and the total fluid intake altered accordingly. If the serum sodium is less than 135 mmol/l, reduce the fluid intake.

d. General measures

• Neurological observations including blood pressure should be performed every 15 minutes for the first 2 hours and then at intervals determined by the child’s conscious state.

• Weight and head circumference should be monitored on a daily basis.

• Control seizures.

• Early consultation with intensive care unit is necessary for any child who is experiencing a deterioration in conscious state, hemodynamic instability or seizures.

• Electrolytes should be checked every 6–12 hours until the serum sodium is normal.

• Ensure adequate analgesia (e.g. paracetamol) for children in the recovery phase who may have significant headache.

• The role of steroids is still controversial and we have opted generally not to use them, although they may be indicated in Hemophilus meningitis.

Isolation

Children with meningococcal disease require isolation until they have had 24 hours treatment. Other children with meningitis can be nursed on the open ward.

Fever persisting for more than 7 days

This may be due to nosocomial infection, subdural effusion or other foci of suppuration. Uncommon causes include inadequately treated meningitis, a parameningeal focus or drugs.

Contact chemoprophylaxis

Practice differs in different countries. Below is one regime used in Australia. It is important that prophylaxis be given early to both the index case and contacts as follows:

• Index Case and all household contacts if household includes other children under 4 years of age who are not fully immunized.

 Index Case and all household contacts in households with any infants under 12 months of age, regardless of immunization status.

• Index Case and all household contacts in households with a child 1–5 years of age who is inadequately immunized.

• Index Case and all room contacts including staff in a child-care group if Index Case attends over 18 hours per week and any contacts under 2 years of age who are inadequately immunized. (NB. Inadequately immunized children should also be immunized.)

• Index Case (if treated only with penicillin) and all intimate, household or day-care contacts who have been exposed to the Index Case within 10 days of onset.

• Any person who gave mouth-to-mouth resuscitation to the Index Case.

Australian contact chemoprophylaxis regimen

• Hemophilis influenzae type b—give rifampicin 20 mg/kg weight orally as a single daily dose to a maximum 600 mg) for 4 days. For infants <1 month give rifampicin 10 mg/kg weight  orally daily for 4 days. In pregnancy or contraindication to rifampicin give ceftriaxone 125 mg/kg weight  i.m. (<12 years) or 250 mg/kg weight  i.m. (>12 years) as a single dose.
• Neisseria meningitidis—give either: rifampicin 10 mg/kg weight  orally 12 hourly up to a maximum 600 mg for 2 days. For infants <1 month give rifampicin 5 mg/kg weight  orally 12 hourly for 2 days. In pregnancy or contraindication to rifampicin give ceftriaxone 125 mg/kg weight  i.m. (<12 years) or 250mg/kg weight  i.m. (>12 years) as a single dose. or ciprofloxacin 500 mg orally as a single dose.
• Streptococcus pneumoniae—there are no increased risks to contacts, so no antibiotic required.
• Rifampicin may cause orange-red discoloration of tears, urine and contact lenses, skin rashes and itching, and gastrointestinal disturbance. It negates the effect of the oral contraceptive pill and should not be used in pregnancy or severe liver disease.

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Headaches in Pediatric emergency

Headache is a common symptom in children, affecting 80–90% by the age of 15. The common causes are systemic illness with fever, local ENT problems, migraine and tension headache. Meningitis, raised intracranial pressure (ICP), e.g. from tumors, and subarachnoid hemorrhage (SAH) are much rarer causes but these need to be considered. Any headaches that wake a child from sleeping or that are associated with focal signs such as a hemiplegia require investigation as an inpatient

Assessment

History

It is useful to classify headache as acute or recurrent. The following list gives the causes and key features to help make a diagnosis, based on careful history and examination:

Acute

• Systemic: fever and general illness (e.g. ’flu, pneumonia, septicemia)

• Local sinusitis, dental caries, otitis media

• Trauma: head injury

• Meningitis: reduced conscious level, toxicity, photophobia, neck stiffness

• SAH: sudden onset, severe occipital pain; possible reduced conscious level, neck stiffness

Recurrent

• Migraine: aura, nausea, vomiting, pallor, family history

• Tension: throbbing pain (involving neck muscles) at end of day

• Behavioral: family/social/school problems (may be difficult to identify)

• Raised ICP: morning headaches ± vomiting, worse with coughing/sneezing/bending

• Progressively worsening raised ICP: personality or behavioral changes, focal neurological symptoms

• Benign intracranial hypertension, systemic hypertension, uremia, recurrent hypoglycemia, recurrent seizures, lead or CO poisoning.

It may be useful to make out a possible family headache patterns diagram to help identify the nature of the headache.

Examination

As part of the examination it is important to document the following:

• ABC: blood pressure, heart rate

• General: toxic, unwell, temperature, rash

• Neurology: conscious level, fundi, visual fields, cerebellar signs, neurocutaneous stigmata, neck stiffness, cranial bruits

• Local causes: cervical lymphadenopathy, teeth, sinus, ears

• Growth and puberty: head growth, height, weight, growth velocity, pubertal status.

Investigations

In the acute situation, the two most important questions to answer are:

• Does the child need an urgent computerised tomography (CT) scan of the head? and

• Should a lumbar puncture (LP) be performed? In making the decision, you should consider the following factors:

• If the child has altered state of consciousness, focal neurological signs, raised blood pressure or papilledema, consider management of raised ICP and CT scan of head. Discuss this with senior medical staff.

• Consider LP (in the absence of the contraindications) if you are concerned about meningitis or SAH. You may need to do a CT scan first (discuss with consultant).

• If there are no symptoms and signs suggesting raised ICP/SAH/ meningitis and the story is suggestive of migraine, then treat symptomatically (see below).

• If other causes are suspected, do the appropriate investigations (e.g. septic screen, urea, carboxyhemoglobin or lead level [wrist X-rays], blood sugar profile).

Management

If there is a specific diagnosis such as meningitis, SAH, tumor, systemic infection or local infection, then treat as appropriate. Most recurrent headaches can be managed by a pediatrician and do not need to be referred to a neurologist.

Abort attack

Avoid opiates. Initially try simple oral analgesics such as paracetamol (20 mg/kg weight stat then 15 mg/kg weight per dose every 4 hours, to a maximum of 4g per day) or codeine (1 mg/kg weight per dose every 4 hours) or NSAID (ibuprofen 2.5–10 mg/kg weight per dose 6–8 hourly). For adolescents give 1 g of aspirin, 1 g of paracetamol, 10 mg of metoclopramide. Some, but not all, pediatricians use intravenous anti-emetics in severe vomiting. For example, if vomiting is a prominent feature in children over 10 years give slow i.v. prochlorperazine

(0.1–0.2 mg/kg weight).

Prophylaxis

Refer to a local doctor or general pediatric outpatient clinic for long-term management. Consider beta blockers, pizotifen or calcium channel blockers. Non-pharmacological interventions (e.g. avoidance of triggers, relaxation) often play an important role in prevention. Consider getting the child or parents to make a headache diary.

Headache patterns

It may be a good idea with the use of the chart below to explore the pattern of the child’s headaches .

• Acute recurrent includes migraine (common, classical, complicated).

• Chronic non-progressive includes tension (stress related); muscle contraction; anxiety; depression; somatisation headaches.

• Chronic progressive includes headaches from tumor; benign intracranial hypertension; brain abscess; hydrocephalus.

• Acute on chronic non-progressive includes tension headache with coexistent migraine.

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Febrile Convulsions

A simple febrile convulsion is a brief (<15 min) generalized convulsion in a febrile (>38°C) child aged between 6 months and 6 years, with no previous afebrile seizures, no progressive neurological condition and no central nervous system infection. Febrile convulsions are common, and occur in 3% of healthy children between the ages of 6 months and 6 years. They are usually associated with a simple viral infection. The onset of the convulsion may be sudden with little evidence of preceding illness. The convulsion may be terrifying for the parents to observe—they frequently believe that their child is dying and may attempt CPR or other resuscitative measures. Febrile convulsions are benign, with minimal morbidity and essentially no mortality. Most febrile convulsions are brief and do not require any specific treatment. The initial management of the convulsion is described in the afebrile seizure section.

After the convulsion

A septic work-up including lumbar puncture is mandatory in children under 6 months of age; by definition a febrile convulsion should not be diagnosed in a child under 6 months. Lumbar puncture should be very strongly considered in those aged 6–12 months. Possible clinical scenarios and management include those shown in Box 6.2. Most children with simple febrile convulsions who have recovered sufficiently do not need to be admitted to hospital If a patient is discharged home following a febrile convulsion, it is important to give the family advice regarding fever control and what to do in the event of a future convulsion. Verbal advice should be reinforced with written advice. Follow up during the next 24 hours is advisable to assess the progress of the child’s illness and to allow parents the opportunity for further discussion.

Possible clinical scenarios and management following febrile convulsions

Repeated convulsions during the same illness occur in about 10–15% of children. The child should be reassessed in hospital. There are usually no serious implications; however, a period of observation might be required to clarify the progress of the illness.

Fever control

Clothing should be minimal—a nappy alone or light outer layer depending on ambient temperature. Tepid sponging, baths and fans are ineffective in lowering core temperature, and are not recommended. Paracetamol has not been shown to reduce the risk of further febrile convulsions. It may be used for pain or discomfort or as an antipyretic associated with febrile illnesses such as otitis media. The parents should understand the reasons for its use and be discouraged from trying to get their child’s fever down.

Long-term issues

Recurrence rate depends on the age of the child—the younger the child at the time of the initial convulsion, the greater the risk of a further febrile convulsion. Epilepsy. Risk of future afebrile convulsions is increased by a family history of epilepsy, any neurodevelopmental problem or complex, very prolonged or focal febrile convulsions. 

Risk of afebrile convulsions following a febrile convulsion

• No risk factors: 1% risk of future epilepsy, similar to the general population

• 1 risk factor: 2% increased risk

• More than 1 risk factor: 10% increased risk

Anticonvulsant treatment. Children who have recurrent prolonged convulsions (which are rare) may benefit from having a rectal diazepam kit available at home, which their parents can administer if a convulsion does not cease spontaneously within 5 minutes. Long-term anticonvulsants are not indicated except in rare situations with frequent recurrences. It may be appropriate to offer a review appointment with a general pediatrician.

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Convulsions in Pediatric Emergency

Afebrile convulsions and status epilepticus

Most convulsions are brief and do not require any specific treatment Convulsions may be generalized and tonic-clonic in nature but can also be focal. Generalized convulsive status epilepticus (CSE) is currently defined as a convulsion lasting 30 minutes or more or when successive convulsions occur so frequently that the patient does not recover consciousness between convulsions. Tonic-clonic status occurs in up to 5% of patients with primary epilepsy and about 5% of children with febrile seizures may present with CSE.

Management of the convulsion

The primary assessment should be as for any seriously ill child. A structured approach to the primary survey is particularly important; if a problem is found during the initial ABCDE assessment then immediate treatment and resuscitation should occur,remembering to treat the treatable as you progress through the primary survey. In a fitting child never forget to check the glucose and treat hypoglycemia appropriately. If a convulsion occurs, position the child in a semiprone position to minimise the chance of aspiration. If necessary and possible, clear the airway with gentle suction and give oxygen via the facemask.

If the convulsion continues for more than 10 minutes then follow the flow chart in pict below.

Give high-flow oxygen via facemask, monitor oxygen saturation and test the glucose level. A short acting benzodiazepine should then be administered. The nature and dose of the drug will depend on whether intravenous access had been obtained and on departmental guidelines. Some antiepileptics such as paraldehyde are used in some countries but not others.

Convulsions management and treatment in Pediatric Emergency

a. If venous access or intraosseous access has been obtained

The following drugs can be given in sequence if fitting continues:

• Lorazepam 0.1 mg/kg weight i.v. or intra-osseous (i.o) can be given and repeated after 10 minutes if necessary. This is currently the drug of choice in the latest Advanced Pediatric Life Support Guidelines in the UK, USA and Australia. Diazepam 0.25 mg/kg weight or midazolam 0.15mg/kg weight are alternatives to lorazepam. They can be repeated after 5 minutes if seizures continue. The child needs to be monitored carefully for respiratory depression.

• Paraldehyde 0.4 ml/kg weight per rectum (p.r.) is given 10 minutes after the benzodiazepines if necessary, but is not available in Australia.

• Phenytoin 18 mg/kg weight i.v. or i.o. as a loading dose in normal saline over 30 minutes can then be given with ECG monitoring. If the child is already on phenytoin, then i.v. phenobarbitone 15–20 mg/kg weight can be used over 10 minutes. In neonates, phenobarbitone is often used as the drug of choice.

• If fitting still continues, seek senior anesthetic and medical advice and assistance. The child may require rapid sequence induction and intubation with thiopentone 4 mg/kg weight i.v. or i.o. Muscle relaxants should not be used long term.

b. If venous access has not been obtained

• Diazepam 0.25–0.5 mg/kg weight rectally or midazolam 0.15 mg/kg weight i.v. can be given.

• After 10 minutes, give paraldehyde 0.4 ml/kg weight p.r. (0.4ml of paraldehyde plus 0.4 ml of olive oil=0.8 ml/kg weight of prepared solution), but this is not a choice in Australia.

• Seek medical assistance as above for vascular access and RSI.

Notes

Non-convulsive status may occur. It manifests as decreased conscious state with or without motor accompaniments. It may occur particularly in the Lennox-Gastaut syndrome, or in other children with developmental delay. Pyridoxine-dependent seizures should be considered in any infant under 18 months with recurrent or refractory afebrile seizures. A clinical trial of pyridoxine 100 mg i.v. is warranted. If it is going to be effective it will work within 10–60 minutes. If it is not effective in 10 minutes begin other standard anticonvulsants as above.

After the convulsion

First seizures, even if unprovoked, rarely require continuous anticonvulsant medication. Discuss with the Registrar or a Consultant. Parents should be warned that all children or adolescents who have had seizures should be supervised when bathing, swimming, or riding a bicycle on the road, and that children should avoid tree-climbing. Parents should be advised of first-aid measures should the seizure recur. In some centres, children with their first afebrile seizure are referred to the general pediatric outpatient clinic for follow up. If the child has not fully recovered, or there are concerns about the underlying etiology, he or she should be admitted to hospital.

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