Clinical Flowchart for the Diagnosis of Appendicitis in Pediatric Patients September 10, 2019


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Appendicitis is the most common condition in children requiring emergency abdominal surgery. Delayed or missed diagnosis in young children is common and is associated with increased rates of perforation. Although several scoring systems have been developed, there is still no consensus on clinical, laboratory, and imaging criteria for diagnosing appendicitis.

The dangers associated with misdiagnosis, delay, and perforation make quick and accurate diagnosis of appendicitis essential. This flowchart provides guidance for the management of children with appendicitis

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Clinical Pathway for the Diagnosis of Appendicitis in Pediatric Patients

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What’s Your Diagnosis? 11-year-old boy with acute abdominal pain August 29, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 5 comments

But before we begin, check out if you got last month’s case right, about the 8-year-old boy presenting to the ED after falling at a local playground. Click here to check out the answer!

Case Presentation: an 11-year-old boy with acute abdominal pain

An 11-year-old previously healthy boy presents to the ED on a busy Saturday evening. He has acute abdominal pain that started 18 hours ago as diffuse periumbilical abdominal pain. Within the last 3 hours or so, the pain migrated to the right lower quadrant and worsened in severity. The child says the bumps on the car ride to the hospital were painful, and hopping up and down makes the pain worse. He says it seems to be a bit better when he lies still and does not move. Oral ibuprofen has not really helped the pain. The patient has not eaten a meal all day and has vomited 3 times today. On presentation, he has a temperature of 38.3°C (101°F). He is fully immunized and does not have any upper respiratory symptoms. He has never had similar pain in the past and has no history of previous
abdominal surgeries. He has a normal genitourinary examination. He has obvious discomfort with palpation of his abdomen with maximum tenderness in the right lower quadrant. He exhibits guarding and rebound tenderness.

His mother asks you whether this could be appendicitis, and whether he will need surgery. You begin to think…

Is this appendicitis? What else could it be? How will you definitively determine the diagnosis? What laboratory evaluation and imaging tests should you order? It is now 2:00 AM. If the patient definitely has appendicitis, does he need an emergent appendectomy or can it wait?

Case Conclusion

You sent a CBC and CRP for the 11-year-old boy with abdominal pain and vomiting. The WBC count and CRP were both elevated. An appendix ultrasound showed a dilated, noncompressible appendix with mesenteric fat stranding and appendiceal wall hyperemia, and you diagnosed the boy with appendicitis. The on-call pediatric surgeon was contacted and asked that you start antibiotics and admit the patient for appendectomy in the morning.

Review the issue to find out more recommendations.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

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Test Your Knowledge Management of Patients With Complications of Bariatric Surgery August 22, 2019


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As bariatric procedures have become more common, more of these patients present to the emergency department postoperatively. The most common complaints in these patients are abdominal pain, nausea, and vomiting.

Did you get it right? Click here to find out!

The correct answer: A.


Check out the issue on Emergency Department Management of Patients With Complications of Bariatric Surgery to brush up on the subject. Plus earn CME for this topic by purchasing this issue.

Clinical Pathway for Emergency Department Management of Patients With Bariatric Surgery Complications August 14, 2019


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As bariatric procedures have become more common, more of these patients present to the emergency department postoperatively.

The most common complaints in these patients are abdominal pain, nausea, and vomiting, though each of the surgical procedures will present with specific complications, and management will vary according to the surgical procedure performed. Computed tomography is often the primary imaging modality, though it has it limits, and plain film imaging is appropriate in some cases.

This clinical pathway will help you improve care in the management of patients with bariatric surgery complications. Download now.

Clinical Pathway for Emergency Department Management of Patients With Bariatric Surgery Complications

Get access to more pathways with an individual or group subscription. Visit www.ebmedicine.net/EMPinfo to find out more!

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Test Your Knowledge on Assessing Abdominal Pain July 17, 2019


Posted by Andy Jagoda, MD in: Brain Tease , 1 comment so far

Patients with abdominal pain are common in the ED, but you need a strategy for quickly identifying patients who are at high risk for life-threatening causes of pain.

The management of abdominal pain has changed significantly in the past 20 years, with increasing emphasis on identifying patients who are at high risk for occult pathology and worse outcomes. Test your knowledge of the most common causes of sudden-onset abdominal pain.

Did you get it right? Click here to find out!

The correct answer: A.

Check out the issue on Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy to brush up on the subject. Plus earn CME for this topic by purchasing this issue.

From the author of the very first issue of Emergency Medicine Practice June 24, 2019


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Stephen Colucciello, MD, FACEP
Professor of Emergency Medicine, University of North Carolina School of Medicine-Charlotte Campus,
Charlotte, NC

When we first published Emergency Medicine Practice 20 years ago, emergency clinicians were becoming skeptical of established dogma, which was often based on an “expert” who defined best practices; otherwise known as “eminence-based” medicine. For example, abdominal pain patients were never to get opioids, oral contrast should always be used for abdominal CT scans and the rectal exam was essential in the abdominal pain workup.

Instead of blindly accepting such “textbook facts”, we created Emergency Medicine Practice to advance an evidence-based approach. Evidence-based medicine depends upon the best available evidence, while incorporating personal experience and individual patient values. The size and quality of the study, the research methodology, and the reproducibility of results matters in assessing practice validity.

For Emergency Medicine Practice’s 20th anniversary, we turn back to our roots and revisit and revive our very first issue on abdominal pain. I understand from EB Medicine that hundreds – if not thousands – of emergency clinicians have said this course has aided them in their training and practice in the 20 years since its publication. The editors tell me it is oft-referenced even to this day.

Abdominal pain is one of the complaints seen most frequently in the ED, and the degree of pathology runs from the mundane to catastrophic. Unfortunately, the severity of illness is easily overlooked, especially in the elderly and immunosuppressed. Identifying the high-risk patient is crucial to avoiding a life-threatening diagnostic mistake.

There are many changes in best practices for assessing patients with abdominal pain compared to 20 years ago. Bedside ultrasound by the emergency provider is certainly revolutionizing ED practice. Radiation-reduction strategies are also becoming more commonplace. MRI is a growing modality, especially in pregnant women with suspected appendicitis. In the past two decades, we have learned that oral contrast provides no additional benefit to IV contrast in abdominal CT scans (with some exceptions). We also have seen a dramatic decrease in abdominal plain films and a corresponding increase in abdominal CT scans, especially in the elderly.

In the end, all the thinking, research, peer reviewing, and thought-provoking discussions that go into each issue of Emergency Medicine Practice are to ensure that every topic makes a difference in your diagnostic or treatment routine. I would be honored if you change your daily practice after reading this new edition of “Assessing Abdominal Pain In Adults.”

Sincerely,
Stephen Colucciello MD

Click here to read the updated version of our inaugural issue prepared specifically for our 20th anniversary this June!

For two decades, we have helped emergency medicine clinicians like you, who are committed to lifelong learning, providing excellent patient care, and saving lives, with the resources and information you need to do the things that you do best. Tap here to take advantage of the 20th anniversary sale!

It’s our way of saying thank you for helping us reach this significant landmark in our company’s history, which is your history, too. Here’s to 20 more!

Clinical Pathway for Patients Aged < 50 Years With Abdominal Pain June 7, 2019


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The management of abdominal pain has changed significantly in the past 20 years, with increasing emphasis on identifying patients who are at high risk for occult pathology and worse outcomes. With abdominal pain still the most common chief complaint seen in the emergency department, a new look at the evolution of assessment strategies is in order.

After an extensive workup, patients with severe pain may prove to have gastroenteritis, while those with a seemingly benign belly are hiding a surgical catastrophe.

This clinical pathway will help you improve care in the management of patients with abdominal pain and recognize a surgical abdomen. Download now.

Clinical Pathway for Patients Aged < 50 Years With Abdominal Pain

Get access to more pathways with an individual or group subscription. Visit www.ebmedicine.net/EMPinfo to find out more!

Need more information?
Click here to review the issue!

68-year-old woman presents with severe abdominal pain May 31, 2019


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Case Recap:
As you begin your shift, a 68-year-old woman presents with severe abdominal pain. She requires 4 mg of morphine before you can even talk to her. Surprisingly, her abdomen is soft, and not particularly tender. She is tachycardic to the 120s, and her pulse feels irregular. Her blood pressure is 100/50 mm Hg. It seems strange that her pain is so incongruent with her exam, and you wonder: What is the best imaging study to help clarify things?

Case Conclusion:
You recognized that she needed pain control and fluids along with a full sepsis workup, including lactate, ECG, CT abdominal angiography, and an almost-certain surgical consult. Her ECG showed atrial fibrillation, and the CT angio confirmed the diagnosis. She was emergently taken to the OR, where a dead bowel segment was resected and she had a surprisingly good recovery, thanks to your rapid mobilization of specialty care.

Did you get it right?

Brush up on most recent best practices in evaluating patients with abdominal pain in the ED with our 20th anniversary Emergency Medicine Practice issue, Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy.

P.S. Emergency Medicine Practice celebrates its 20th anniversary this month! Click here to check out our story, our plans and our great anniversary sale!

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Trauma Awareness Month Is Almost Here – Test Your Knowledge with Genitourinary Trauma Question April 18, 2019


Posted by Andy Jagoda, MD in: Brain Tease , add a comment

A patient suffering blunt abdominal trauma complains of suprapubic pain and has gross hematuria. Initial CT of the abdomen and pelvis with IV contrast is normal. Do yo know the answer?

For trauma patients in the ED, life- and limb-threatening injuries take priority, but renal and genitourinary injury can have long-term consequences for patients, including chronic kidney disease, erectile dysfunction, incontinence, and other serious problems.


Did you get it right? Click here to find out!

The correct answer: A.

Check out the issue on Emergency Management of Renal and Genitourinary Trauma: Best Practices Update to brush up on the subject.Plus earn CME for this topic by purchasing this issue.