A Systematic Approach to Management of Abdominal Pain in Preverbal and Nonverbal Children in the Emergency Department (Pain Management CME and Pharmacology CME)

A healthy 14-month-old girl presents with increased fussiness...

• The mother says she was up all night due to her daughter screaming every hour from the other room.
• During your physical examination, you note a well-appearing child and a concerned, attentive mother. While you talk with the mother, the child is happily playing on a cell phone but winces intermittently throughout your discussion. You pay attention to the girl’s facial expressions while taking her vital signs, then you have the mother bounce her on her lap and subsequently lay her on the stretcher flat while she reassures her. On palpation, you appreciate a nonsurgical abdomen, with an overall benign examination. The girl has dry mucous membranes and good skin turgor.
• You ask about the patient’s eating and voiding habits, and the mother says the child has had dark, sticky stools, attributed to eating spinach.
• You wonder what further assessment is needed for this patient...

A healthy 3-year-old boy presents with fever and vomiting...

• His father is concerned because of difficulties controlling fevers at home for the last 2 days. There are no reported upper respiratory symptoms. The boy’s maximum temperature of 38.1°C was treated with acetaminophen 2 hours prior to arrival.
• The patient is being held by his father, whose shirt has yellow vomitus on it. When approached, the patient makes direct eye contact, watches while you examine him, and does not cry when separated from his father to be placed on the examination table; instead, he has a flat affect. The abdominal examination is significant for rebound tenderness in the right lower quadrant and guarding throughout. You appreciate wincing when you palpate the right lower quadrant; the boy tries to grab your hands away and tucks his legs upwards.
• In addition to ordering basic laboratory studies, ultrasound, and intravenous crystalloid fluids, you contact the on-call surgery resident because you are concerned for potential acute appendicitis. They share your concern and agree to see your patient but ask you to withhold pain medication since it will “interfere with examinations.”
• You begin to think about the best way to manage this patient’s condition, including his pain…

The triage nurse alerts you of an 8-year-old boy with nonverbal autism who was brought in by his mother for concerns of dark, “stinky” urine and lower abdominal pain...

• The child is visibly agitated, and the nurse is struggling to take his blood pressure and place him on pulse oximetry. You notice heavy foot traffic outside the patient’s room, which is causing him to become more agitated. You advise the nurse to hold off momentarily, close the door, and dim the lights. You sit in a chair facing the patient and mother, introduce yourself, and engage in light conversation. The mother then pulls you aside to say that her son has had bad experiences in the past with hospitals, particularly in the emergency department and with IV placement. You ask her for additional information, including the patient’s sensory preferences, and she tells you that he likes to wear his earmuffs and watch his favorite TV show while the cuff is inflating and the pulse oximeter is on. She asks if the oximeter could be taken off between readings, if continuous monitoring is not required. She also mentions that they have used a “numbing cream” in the past when obtaining IV access, so the boy does not feel the stick, and asks you if you could do that if an IV is needed.
• On examination, you notice a slight tachycardia of 115 beats/min, potentially due to the recent stimulation from the blood pressure cuff and noise, and you decide to monitor it. When you remeasure the patient’s heart rate, it is 102 beats/min. The HEENT, cardiopulmonary, and abdominal examinations are grossly benign, other than a mild grimace when you palpate the boy’s suprapubic area.
• You consider how to best treat this patient’s agitation and pain while maintaining the integrity of patient and parent rapport…