1 / 36

Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof (not the classic tale)

Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof (not the classic tale). Joe Nemeth MD CCFP (EM) Department of Emergency Medicine Montreal Children’s Hospital Montreal General Hospital MUHC. QUALITY OF A PRESENTATION. 1. Novel but not Interesting 2. Interesting but not Novel

salena
Télécharger la présentation

Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof (not the classic tale)

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Pediatric Abdominal Pain: Making Sense of Crap or Lack Thereof(not the classic tale) Joe Nemeth MD CCFP (EM) Department of Emergency Medicine Montreal Children’s Hospital Montreal General Hospital MUHC

  2. QUALITY OF A PRESENTATION • 1. Novel but not Interesting • 2. Interesting but not Novel • 3. Both • 4. Neither

  3. Case 1 (You are the attending) • 7 male, diarrhea, fever x 2 days • vs:wnl, looks well • abd: soft, +/-diffuse tenderness, no peritoneal sign • Bloods, urine: non contributory • Dg: Gastro?enteritis

  4. Case 1 cont’d • Presents again next day, same symptoms • exam: no change • no bloods drawn • seen by Gen Surg. • D/C with Gastroenteritis

  5. Case 1 cont’d • Presents 3rd time, abd pain increased • rebound • OR:perforated appendix

  6. Case 2 (You are the attending) • 24 months, male, crying, “bloated” • no v/d, last bm 2 days ago • vs: wnl, happy, looks well • abd:no mass, nontender, +BS • Abd. Series: stool+++ • Dg: Constipation

  7. Case 2 cont’d • Presents next day lethargic • pale, not responding, tachypneic • protuberant abd • 7.10/30/5 • OR:intussusception

  8. Which of 2 diagnosis are found on emergency discharge records most frequently for missed pediatric abdominal catastrophies in court cases? Gastroenteritis Constipation

  9. GOoooooooooooooaL • Brazil 2 Germany 0 (my prediction)

  10. GOALS • Distinguish between benign and sinister causes of non-traumatic A/P • Which labs to order/not to order? • Which imaging modalities to order/not to order? • How to dispose of the patient…..I mean disposition of the patient?

  11. EPIDEMIOLOGY • #1.Minor Trauma 20-40% • #2.URTI 8-20% • etc • #5. Non-traumatic abdominal pain 2-5%

  12. WHAT’S IN COMMON? • Patient 1: 1/52, lethagic • Patient 2: 8/12 m, irritable, po, bilious vomiting, red current jelly stools • Patient 3: 4/52 f, crying episodes x hours x 2 weeks, legs drawn up, “passing ++gas”, otherwise well baby

  13. KIDS: VERBAL vs. NON-VERBAL • Differences? • Similarities?

  14. PRESENTATION:THE SPECTRUM • stoic denies pain fear of further medical attention • histrionic exaggerates pain

  15. WHAT ’S IN COMMON? • fever nyd • irritability nyd • lethargy nyd • vomiting/diarrhea nyd

  16. 1/3 of kids presenting with Abdominal Pain get no specific diagnosis!!! (not good)

  17. DICTUM • All kids of non-verbal age presenting with DIAGNOSIS NYD should be considered to have abdominal pathology.until proven otherwise.

  18. BENIGN CAUSES OF A/P (how long is this lecture again?) • Everything that’s not part of the next slide

  19. SINISTER CAUSES OF A/P • Obstruction • Perforation • Inflammation • (Metabolic)

  20. OBSTRUCTION: SYMPTOMS • persistent (bilious,feculent) vomiting • no stool/gas per rectum (not an absolute!) • po (P.S.!!) • poorly localized A/P

  21. OBSTRUCTION:SIGNS • ALWAYS START WITH THE VITAL SIGNS!!!!

  22. OBSTRUCTION: SIGNS • Inconsolable?/lethargic?/absolutely well? • hernias? • check out the asshole?

  23. TAKE HOME MESSAGE • rely on history • very few physical findings (50% normal abd. exam)

  24. DIFFERENTIAL DIAGNOSIS • Infants: #1.ing. hernia, #2 intussusception

  25. OBSTRUCTION:INVESTIGATION • +/-abd series (prior rectal exam?) • upper gi/lower gi study • CT?

  26. PERFORATION:SYMPTOMS • irritability?/lethargy?/not well • sudden onset severe abd……….

  27. PERFORATION:SIGNS • Vital signs!!!!!!!!!!!!

  28. PERFORATION:SIGNS • not moving/legs drawn up • rebound (what is it?)

  29. PERFORATION:INVESTIGATIONS • abd. series • CT

  30. INFLAMMATION:SYMPTOMS • Irritable?/lethargic?/not bad(Perforation rate <2 82-92%) • limping/”PID shuffle”?

  31. APPENDICITIS • Classical presentation 50-60% • RLQ pain 90-95% • n/v/anorexia 65% • mean temp @ presentation 37.6C • WBC < 10000, no left shift <10% • WBC normal in first 24hrs 80% • Serial WBC or CRP measurementsuseless • ? triple test for NPV (WBC<9000, CRP<0.6mg%, nph <75%)

  32. APPENDICITIS SCORE • RLQ 2/10 anorexia 1/10 fever 1/10 good story 1/10 • WBC 2/10 n/v 1/10 left shift 1/10 rebound 1/10 • 9-10/10OR • 7-8/10imaging • <6/10consider other Dg

  33. INVESTIGATION • abd. Series • U/S vs. CT

  34. ANALGESIA • not a license to snow them • titration is the key

  35. AT SIGN OVER….(ANYTHING MISSING?) • 11 girl • A/P x 2 days, periumbilical • vomitted once, no “poop” • exam unremarkable • u/a NEG, cbc unremarkable • waited long enough, “wants to go home”

  36. TAKE HOME ANDBRING TO WORK MESSAGE • HISTORY!!!! • IF IN DOUBT RE-EXAMINE • IF STILL UNSURE RE-EXAMINE LATER • GASTROENTERITIS (Dg of exclusion)

More Related