Pediatric emergency medicine trisk 2699 2699

opsoclonus myoclonus. This latter is a paraneoplastic syndrome characterized by
“dancing eyes and dancing feet” and is associated with a favorable cancer prognosis
but a poor neurocognitive outcome. Neuroblastoma can secrete catecholamines that
cause hypertension and vasoactive intestinal peptide (VIP) that causes secretory
diarrhea. Subcutaneous nodules can occur.
Clinical Assessment
Initial assessment of a child with possible neuroblastoma should include an
assessment of the patient’s airway, breathing, and circulation, followed by a
complete history and physical examination that focuses on the potential signs and
symptoms above. Given the risk of cord compression from a retromediastinal or
retroperitoneal tumor, all patients should have a thorough neurologic examination
including percussing the vertebral bodies, with emergent imaging should neurologic
deficits be detected. The patient’s blood pressure should be measured and carefully
matched against norms for age. Signs and symptoms of pain should also be explored
to localize potential tumor masses and pain should be treated as needed.
Laboratory evaluation should include CBC, liver function testing, renal function
testing (BUN and creatinine), and urine catecholamines. If neuroblastoma is
suspected and the disease burden is high, TLS may develop (see “Leukemia”
section). If the CBC shows evidence of marrow replacement, platelet and packed red
blood cell transfusions may be needed (see Table 98.7 ). A plain film of the chest or
abdomen may be useful for detecting calcifications. Abdominal ultrasound may help
define the location of a mass and its relationship to other structures. CT scans should
include the suspected site of the primary tumor, the surrounding lymph node groups,
and the liver (a common site of metastasis).
Management
If a thorough evaluation and initial management finds no life-threatening or organthreatening problems, no uncontrolled pain, and no evidence of severe systemic
illness, discharge to the care of a pediatric oncologist may be possible. Otherwise
admission is recommended.

TUMORS OF THE KIDNEY
Goals of Treatment

The most critical decision making and care in the ED is the differentiation of
emergent from nonemergent. Stable patients with newly diagnosed kidney tumors
can be managed as outpatients with close subspecialty follow-up.
CLINICAL PEARL AND PITFALLS