The Approach and the differential

Praneel KumarBundaberg Hospital Emergency Department

● Sneak a peak – wealth of information simply by observing the child from the door way

● Detailed history – parents and kids are poor historian

● Fear of 'stethoscope' and white coat● Unique presentation

• Child's level – kneel or sit near the child as opposed to standing over the child

• Distract with toys• Use parent-- let mum do the abdominal

exam• Peritoneal signs – bounce the baby • Take off diaper• Rectal exam – only if indicated -generally

not helpful

● Remember Extra- abdominal cause – full examination

● VITAL SIGNS ARE VITAL -Don't memorize – have a reference card

● Importance of observation – in Dem or in the ward

● Most kids are going home● Kids live longer to face the

consequences of radiation● Surgical disease turn bad quickly

● In terms of the age of the child● Surgical Emergencies of

Abdopelvic/non surgical GI disease and Extra-abdominal

● 1/3 kids -appendix ruptures before operation

● Classical presentation of appendicitis is seen less often in peads compared to adults – eg loss of appetite

● WBC-- neither sensitive nor specific

● Pain meds or anti emetic do not delay diagnosis

● Rectal exam- not helpful

● Ultrasound -- Investigation of choice

● 2nd most common cause of abdominal emergency

● 3months to 6years ( peak – 5-9 months of age )

● 90% are ileocolic and idiopathic in nature

● Red current jelly stool and palpable mass – not common

● Fecal occult blood positive more common -rectal exam to test fecal occult blood

● Ultrasound -investigation of choice

● Infant with bilious vomiting – volvulus until proven otherwise

● Abdomen usually soft and non tender until strangulation of the bowel has developed – distended and tender

● Investigation of choice –xray and ultrasound

● Time is bowel

● Take the diaper off – most common is inguinal hernia

● Get the surgeons involve early

● Acute Gastroenteritis● Constipation● Functional abdominal pain or non

specific abdominal pain

Which of 2 diagnosis are found on emergency discharge records most frequently for missed pediatric abdominal catastrophies in court cases??

● 1.Gastroenteritis● 2. Constipation

● Pneumonia● Group A beta hemolytic streptococal

pharyngitis

● Recheck and document exam before discharge

● Good discharge instruction are key-- movie analogy

● Follow up –revisit or phone follow up