Pediatric emergency medicine trisk 2690 2690

FIGURE 98.1 Chest radiograph demonstrating a large, homogeneous anterior mediastinal mass.
Patient presented with persistent cough and progressive orthopnea.

Management
Diagnostic workup in the ED should always include a chest radiograph, including a
lateral view, to help establish the location of the mass. Chest CT scan should only be
performed in a patient who can comfortably lie supine. CT contrast should not be
given without verifying adequate renal function since TLS can occur. Laboratory
evaluations should include CBC to assess for evidence of marrow replacement and
to identify circulating blasts. Metabolic screening for possible TLS should be
performed. Patients with symptoms from an AMM must be admitted to a center with
pediatric oncology expertise and may require critical care. If an effusion is drained
in the ED for relief of symptoms, a fluid sample should be sent to pathology for
cytology if malignancy is suspected. In general, patients who are not experiencing
respiratory or hemodynamic compromise by an effusion should not have fluid
drained for diagnostic purposes while in the ED.