Pediatric emergency medicine trisk 3746 3746

The emergency physician must keep in mind the many variations in the way
appendicitis can present. Patients with equivocal findings should be admitted for
monitoring and serial examinations or have imaging studies to demonstrate a
normal appendix. If the imaging studies are equivocal, the surgeon will decide to
operate or continue to monitor. Patients who have a typical history for
appendicitis but suddenly have diminished pain may actually have undergone
perforation of the appendix. Such patients should be observed for several hours
before declaring an improved condition. Even in the presence of negative imaging
studies, the emergency physician should arrange close follow-up for any patient
with abdominal pain. For those patients with progressive pain, significant pain
requiring narcotic medications, or persistent emesis, admission for further care
and subsequent evaluation might be necessary.

PERFORATED APPENDICITIS
Goals of Treatment
When a perforated appendicitis is suspected, surgical consultation should be
obtained promptly and adjusted for the stability of the patient. Early restoration of
intravascular volume, correction of electrolyte derangements, pain control, and
antibiotics are essential parts of early care. In collaboration with surgery
colleagues, decisions about which patients need immediate operative care versus
advanced imaging can be discussed. When an abscess is identified, the surgeons
will determine the need for a drainage procedure in addition to antibiotic therapy
prior to a delayed appendectomy. Short-term treatment outcomes include
clearance of the intraperitoneal infection while limiting the duration of
hospitalization and the need for repeated imaging or drainage procedures.

Clinical Considerations
Clinical Recognition
Ideally, once the diagnosis of appendicitis is considered, the patient will proceed
with an efficient evaluation to establish the diagnosis and then definitive care
before perforation. Unfortunately, some patients, particularly younger children,

may arrive for emergency care with an already perforated appendix because of a
delay in seeking treatment or in making the diagnosis. Although the time to
perforation is variable, the time prior to ED presentation is a more important
determinant of perforation than the time of evaluation in the ED. Once the
appendix has perforated, there may be signs of generalized, rather than localized,
peritonitis. In a young child, the omentum is thin and often incapable of walling