Current Practice and Pitfalls of Select Biomarkers in the Emergency Care of Children -
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Publication Date: March 2022 (Volume 19, Number 3)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. CME expires 03/01/2025.

Author

Landon A. Jones, MD

Associate Professor; Program Director, Pediatric Emergency Medicine Fellowship, Makenna David Pediatric Emergency Center; Department of Emergency Medicine & Pediatrics, University of Kentucky, Lexington, KY

Peer Reviewers

Kate Dorney, MD, MSHPEd

Instructor in Pediatrics and Emergency Medicine, Harvard Medical School; Attending Physician, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA

Jay D. Fisher, MD, FAAP, FACEP

Associate Professor of Emergency Medicine; Program Director, Pediatric Emergency Medicine Fellowship, Kirk Kerkorian School of Medicine at UNLV; Medical Director, Pediatric Emergency Services, UMC Children’s Hospital, Las Vegas, NV

Abstract

Specific biomarker levels can help differentiate children who require emergent medical interventions, such as procedures, surgeries, or antibiotics, from those who may not. Appropriate application of biomarkers after a thorough history and physical examination can potentially improve cost-effective management by minimizing unnecessary procedures and tests without sacrificing patient safety. This issue reviews the literature regarding 4 biomarkers: lactate, C-reactive protein, ferritin, and procalcitonin. Evidence-based recommendations are made for the clinical evaluation of bacterial meningitis, common infections, and appendicitis.

Case Presentations

CASE 1

A 10-year-old boy is brought in for stomach pain that started last night…

The boy’s mom says he has been complaining of “tummy pain” since before he went to bed last night, and he has been walking “hunched over.” The boy tells you that the pain started at his belly button and has now moved down into his lower abdomen. When you question him, he says that he is hungry, and he denies nausea.
On examination, the boy does not have a fever, and his vital signs are stable. The boy is lying comfortably on the bed. His heart and lung examinations are normal. His abdomen is mildly tender between the umbilicus and right lower quadrant but not specifically at McBurney’s point. There is no rebound or guarding. He has a positive obturator sign and negative psoas and Rovsing signs. The genitourinary examination is benign.
As you walk away, you think: Does this patient have acute appendicitis? What additional blood tests might change suspicion for acute appendicitis? If an ultrasound is inconclusive, is a CT of the abdomen warranted?

CASE 2

A full-term 65-day-old girl is brought in for fever…

The girl had a measured fever at home of 38.5°C. She has no significant past medical history. The mother denies the infant having difficulty breathing or malodorous urine. The girl has not received her 2-month immunizations yet. She is eating well and has no diarrhea.
On examination, the girl's fontanelle is soft and nonbulging, and her neurologic examination is normal. Her lungs are clear, without tachypnea. Her abdomen is soft. You order bloodwork and go on to see the next patient.
While awaiting the results, you think: Does this patient have a bacterial infection? Are there blood tests that can change your suspicion for a serious bacterial infection or meningitis? Does a lumbar puncture need to be performed?

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