A Standardized Diagnostic Pathway for Suspected Appendicitis in Children Reduces Unnecessary Imaging.

Ultrasound (US) for the diagnosis of acute appendicitis is often nondiagnostic, and additional imaging is required. A standardized approach may reduce unnecessary imaging. Methods: We retrospectively analyzed all patients who had imaging for appendicitis in our emergency department in 2017 and evaluated patient characteristics associated with nondiagnostic US. Using these results, we developed a pediatric appendicitis score (PAS)-based imaging pathway and compared imaging trends prepathway and postpathway implementation. Results: A total of 971 patients received imaging for suspected appendicitis prepathway in 2017. Female sex, obesity, and low/intermediate PAS were significantly associated with nondiagnostic US, but not magnetic resonance imaging (MRI) (P < 0.0001). Nearly one-third of patients received multiple imaging studies (US followed by MRI/computed tomography). As low/intermediate PAS was most strongly associated with a nondiagnostic US on multivariate analysis, we developed a PAS-based imaging stewardship pathway to eliminate imaging in low-PAS patients and reduce the number of patients with an intermediate PAS who received multiple imaging studies by obtaining an MRI as the first-line study. After implementation, only 22 low-PAS patients received imaging (compared with 238 preimplementation), and the proportion of intermediate-PAS patients receiving multiple imaging studies decreased from 31.4% to 13% (P < 0.0001). The cost of imaging per 100 patients increased from $24,255 to $31,082. Conclusion: A PAS-based imaging stewardship pathway reduces unnecessary imaging for suspected appendicitis.

Does the Role of A Rapid Triage Provider Improve Pain Control in an Academic Pediatric Emergency Department?

Pediatric pain control in the emergency department (ED) remains problematic. This quantifiable metric may be positively affected by the utilization of a rapid triage provider (RTP). This is a retrospective case control study of pediatric patients requiring either ketorelac intravenous (IV) or morphine IV for painful conditions. Patients in the control group were managed according to standard nursing-driven triage process. Patients in the RTP group were seen by the standard triage team as well as by the RTP.We identified 114 patients who required IV pain medications. The mean time from arrival to pain medication administration for the RTP group as compared with the control group was 47 and 64 minutes (P = 0.02). Similarly, the mean time from arrival to IV pain medication order placement was 15 and 43 minutes (P < 0.01). An RTP improves pain control in the pediatric ED via more efficient order placement and IV pain medication administration.

Female Adolescent Presenting With Abdominal Pain: Accidental Wire Bristle Ingestion Leading to Colonic Perforation.

INTRODUCTION: Abdominal pain in female adolescents is a common presentation to both the emergency department and the outpatient pediatric clinic. The broad differential diagnosis for abdominal pain requires a high index of suspicion to make an accurate diagnosis of foreign body ingestion as the etiology. Foreign body ingestion occurs in all age groups, but sequelae of gastrointestinal tract perforation in children are rare. Treatment for perforation requires consultation of the pediatric general surgeon. Clinicians should take care to not overlook subtle imaging findings or dietary/exposure history, even in the context of a patient with known history of abdominal pain. CASE REPORT/TECHNIQUE DESCRIPTION: We report the accidental ingestion of a wire bristle from a grill cleaning brush by a female adolescent. The patient, previously treated and seen for constipation and irritable bowel syndrome in the outpatient gastroenterology clinic, was referred to the emergency department after identification of a foreign body on abdominal radiography. Emergency department physicians discovered the history of grilling and consumption of grilled food, facilitating diagnosis of a wire bristle as the foreign body. The metallic foreign body had migrated to the colon, where it perforated and lodged into the abdominal wall, causing acute, focal symptoms. Observation in the hospital with pain control and infection management allowed for elective laparoscopy. The surgical team removed the object with minimal morbidity and avoided laparotomy. DISCUSSION: Reports of unintended ingestion of wire bristles have been increasingly reported in the literature; however, most focus on injury to the upper airway or upper digestive tract and subsequent endoscopic or laryngoscopic removal. Most reports detail injury in adult patients, pediatric case reports with digestive tract injury are uncommon, and foreign body removal after lower digestive tract injury in children from a wire bristle has not been reported. We caution pediatric emergency medicine and ambulatory providers to consider such an ingestion and perforation in the differential diagnosis of acute-onset, focal, and localizable abdominal pain in children.