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A 7 yo boy presents to the ED with right sided abdominal pain, vomiting and decreased appetite x 2 days. ROS negative for diarrhea or rash. On exam, patient with rebound tenderness and gaurding.
T38.4 C, HR 115, bp 88/50
Appendicitis
Incarcerated inguinal hernia
Testicular Torsion
Meckels Diverticulum
Constipation
Gastroenteritis
Foreign body
Volvulus
Peak age onset is 12 yo, unusual in kids < 2 yo
Temporary relief of pain followed by fever, rebound and gaurding may be indicative of rupture
positive Rovsing sign (pain in RLQ w/left sided palpation)
positive Iliopsoas sign (RLQ pain w/hip extension
Non compressible appendix > 6mm in diameter is diagnostic
Perforated appendix may be compressible with free fluid visualized
If not visualized on ultrasound, obtain CT scan
Features include thickened wall > 2mm
Morphine 0.05 mg/kg, max 5 mg/dose for moderate to severe pain
Ceftriaxone 75 mg/kg
Metronidazole 30 mg/kg
Labs: CBCdiff, BMP, UA, CRP, upreg
Fluids fluids fluids and +/- pressors for hemodynamically unstable patient
A 15 yo female is presents to the emergency department with left sided abdominal pain and groin pain x 2 days. She denies fever or recent changes in stool pattern, but does complain of nausea and 4 episodes of vomiting. Pain is sharp, crampy. Denies medicatons.
Vitals: AF, HR 95, bp 119/77.
Physical exam with tender palpable mass in LLQ, but no rebound tenderness or guarding.
Ovarian Torsion
Ectopic Pregnancy
Ruptured Ovarian Cyst
Kidney Stone
Teratoma
Constipation
Complete or partial rotation of the ovary on its ligamentous supports
Risk factors include ovarian mass or cyst , especially is cysts > 5 cm in diameter
Patients may have palpable adenexal mass
Hemmoraghic infarction and necrosis 2/2 to vascular compromise can occur within hours
Diagnosis w/ultrasound or CT Scan
Treatment is rapid surgical detorsion, within 8 hours
Support hemodynamics with fluid resuscitation
Obtain CBC diff, CMP, type and screen, consider STI Testing, upreg
Adequate pain control with IV analgesics
Ectopic Pregnancy
Similar presentation with lower qaudrant pain
May have palpable adenexal mass
If suspected obtain upreg, serum beta HCG, CBC, type and screen
Stat IV access with fluid resuscitation
Beta HCG >2000 should be able to visualize prenancy on ultrasound
Phased Array probe with indicator pointing to patients head
Place probe right above pubic symphsis
Identify bladder and fan to either side
A 6 yo male with autism is brought to the emegency department with acute onset vomiting that began 2 hours ago. Emesis initially NB, but now blood tinged. Patient lives with grandmother who reports that patient appears more sleepy. On exam patient arousable with painful stimuli, pupils equal and reactive, epigastric tenderess without rebound/gaurding, hypoactive bowel sounds. Vitals: AF, HR 110, RR 36, bp 100/60
Ingestion
Peptic Ulcer
Gastroenteritis
Volvulus
Obstruction
Pancreatitis
Support ABCs
Stat VBG
Lab work up generally broad: CBCdiff, BMP, Mg, phos, EKG, Utox, serum tylenol, serum salicylate, serum alcohol
XR can be helpful with radiopaque pills
CHIPES (Calcium carbonate, Heavy metal - lead, Iron, Phenothiazines, Enteric coated pills, Sustained release preparations)
Most common GI decontamination
Used in about 5% of ingestions
Most benefit if adminstered within 1 hour of ingestion
Risk of aspiration is biggest contraindication, especially with altered or depressed mental status
Contradicated in alcohol ingestion
Whole bowel irrigation considered when extended release of toxin is anticipated. Requires a large amount of electrolyte solution (miralax) in the stomach. Contraindicated with airway compromise, ileus, bowel obstruction.
Ipecac no longer in use with ingestions
Gastric lavage ideal for very recent ingestion <1 hour of potentially lethal substance
An 8 yo male presents to the emergency department after a motor vehicle accident. Patient was restrained, vehicle traveling 40 mph. On physical exam, patient with abdominal tenderness and epigastric bruising.
GCS 12, Vitals AF, HR 115, RR 30, 100/50
Evaluates pericardium and three potential spaces for fluid collection
Phased array probe, great for deep structures
Start between rib space 8-11 with probe marker to patients head
Slide transducer caudally until liver edge and kidney pole visualized
Free fluid (black) will most likely collect in Morrison's pouch, a potential space between liver and kidney
Inspects splenorenal recess
Similar positioning of probe and downward sliding motion as RUQ
Hemorrhagic Shock
Spleen and liver most commonly injured organs
Can present with abdominal ecchymosis --> seatbelt sign
Obtain labs CBC, lipase, LFTs and preform FAST exam on any patient with suspected internal injury