NASXXX10.1177/1942602X16654172NASN School NurseNASN School Nurse 654172research-article2016

Ask the E.R. Pediatrician School Nurses on the Front Lines of Medicine An Adolescent Female Student with Severe Robert P. Olympia, MD Jodi Brady, MD

Abdominal pain is a common chief Philadelphia, PA on the topic of pediatric degrees Fahrenheit (38 degrees Celsius). complaint encountered by school emergencies and sports-related What should you do? nurses. This article explains the emergencies in the school-based setting. etiology of abdominal pain in children Final Exams Aren’t the Only and adolescents, describes the office What Is the Purpose of the Things That Give Students assessment, and delineates life- “School Nurses on the Front Abdominal Pain threatening conditions associated with Lines of Medicine” Series? Abdominal pain is a common reason severe abdominal pain that may prompt The “School Nurses on the Front Lines why students present to their school the school nurse to transfer the student to of Medicine” series will present cases nurse. It is also a very common chief a local emergency department. reflecting emergencies commonly complaint for children and adolescents encountered in the school setting, presenting to emergency departments Keywords: abdominal pain; focusing on an evidence-based approach (Smith & Fox, 2016) and urgent care ; ovarian torsion to the initial management, stabilization, centers in the United States (Wilkinson, and disposition of the ill or injured child. Olympia, Dunnick, & Brady, 2016) and Topics to be covered in this series will the most common reason that children Who Is the Emergency Room include children presenting with a chief are referred immediately from urgent (ER) Pediatrician? complaint of fever, // care centers to the closest emergency Dr. Robert P. Olympia is a pediatric dehydration, shortness of breath, severe department (Olympia, Wilkinson, emergency medicine physician with allergic reaction, lacerations/abrasions, Dunnick, Dougherty, & Zauner, in press). almost 20 years of experience, currently sprains/strains/contusions, head injury/ working in an emergency department in headaches, heat-related illness, acute It Is Always , Unless the Sweetest Place on Earth (Hershey, mental status changes, seizures, cardiac It Is Something Else PA). His research interests include arrest, chest pain, fainting, abdominal Over my 20-year career, the most emergency and disaster preparedness for pain, and extremity fractures. common identifiable cause of abdominal children in the setting of schools and pain is constipation. But there are so school-based athletics as well as sports- Case many other causes for abdominal pain in related illness and injuries. He has A 13-year-old female student with no children and adolescents. It is the presented his research both regionally significant past medical history comes to responsibility of the medical professional and nationally and has lectured on a your office complaining of severe to assess the child for minor conditions variety of topics pertaining to pediatric abdominal pain since last evening. She (constipation; musculoskeletal causes; emergency medicine, such as fever and describes the abdominal pain as sharp, infections, such as pharyngitis, infectious diseases, trauma, sport-related constant, and localized to her right side. pneumonia, gastroenteritis, and urinary injuries, and disaster preparedness. More She tells you that she feels “sick to her tract infections) or serious, life- recently, he was invited to speak at the stomach” and thinks she is going to threatening ones (appendicitis, ectopic NASN 47th Annual Conference in vomit. You check her temperature: 100.4 pregnancy, ovarian or testicular torsion,

DOI: 10.1177/1942602X16654172 For reprints and permission queries visit SAGE’s Web site, http://www.sagepub.com/journalsPermissions.nav. © 2016 The Author(s) September 2016 | NASN School Nurse 271 ). When I think of a due to diaphragmatic urinating, or frequent urination may child or adolescent presenting with irritation or significant coughing may be associated with a urinary tract abdominal pain, in an effort to construct lead to musculoskeletal spasm or infection (, or infection a limited but thorough differential strain of the abdominal musculature), of the kidney; bladder or urethral diagnosis, I ask myself these initial gastroenteritis, or urinary tract infections). Blood with urination may questions: infections (including kidney and be associated with abdominal or bladder infections). Major infections pelvic trauma, intra-abdominal tumors 1. How long has the child had his or her that may lead to abdominal pain (such as Wilms tumor), urinary tract abdominal pain? Children who have include appendicitis, , infection, or kidney stones. surgical or life-threatening causes for hepatitis, intra-abdominal abscesses, 8. Think out of the box? For males, their abdominal pain usually present and tubo-ovarian abscesses always ask about testicular pain and within 24-36 hr of initial discomfort. (secondary to pelvic inflammatory swelling. Most boys will admit to Typically, chronic abdominal pain, disease in sexually active females). abdominal pain instead of testicular associated with less emergent Septic shock may lead to pain. Testicular torsion, a twisting of conditions, can be managed in the hypoperfusion of major organs, the bundle that holds each testicle child’s primary care physician’s office. including the gastrointestinal tract, within the scrotum, leading to 2. What is the abdominal pain like? leading to severe pain from vascular reduced blood flow, ischemia, and Where did the abdominal pain start, ischemia. testicular injury, is a true urologic where is it now, and does the pain go 5. Is there vomiting, and if yes, what is emergency where time to diagnosis anywhere else (radiation of pain)? the color of the vomit? Although minor and treatment is critical. An What is the quality of pain: sharp or conditions, such gastroenteritis or incarcerated or strangulated inguinal dull? Does the pain come and go, or is urinary tract infections, may present , presenting with groin or it constant? What makes the pain worse with abdominal pain and vomiting, scrotal swelling, severe lower or better (body positioning, movement, surgical conditions (appendicitis, abdominal pain, and / eating or drinking, coughing, or bowel ischemia/obstruction, vomiting, requires immediate vomiting)? For example, intermittent testicular/ovarian torsion, ectopic recognition and treatment. For and sharp, right upper quadrant or pregnancy) may present with females, consider menstrual cramps, epigastric pain that may radiate to the persistent and forceful vomiting, or ovarian cysts/torsion, endometriosis, right shoulder or back, and be vomit that is bilious (dark green in and pregnancy. For both males and exacerbated by eating a fatty meal color, indicative of obstruction of the females, consider eating disorders that could be associated with gall stones? bowel) or bloody (due to injury of may present with abdominal pain, 3. Has there been recent trauma to the the blood vessels that line the internal vomiting/diarrhea/constipation, child’s chest and/or abdomen? lining of the stomach or bowel). weight fluctuations, and body Abdominal discomfort may be 6. Are there bowel movement symptoms? dysmorphia. secondary to minor musculoskeletal Hard pellet-like stool or large stool, injury (too many sit-ups during gym straining when the child stools, or Other important questions are related class, dodgeball to the abdomen, new infrequent stool may be indicative of to past medical and surgical history, weightlifting regimen during a sport constipation (although children who medication and allergies, and social season) or more significant injuries are constipated may have a lack of history. (lower rib fractures; pulmonary any of these symptoms). Profusely contusions; intra-abdominal organ watery stool is consistent with an Past Medical History contusions or lacerations, such as infectious gastroenteritis, whereas Exacerbation or poorly controlled those involving the kidneys, , loose, mushy, or slimy stool may be chronic medical conditions, such as spleen, pancreas, resulting in internal consistent with surgical conditions, inflammatory bowel disease (Crohn’s bleeding; injury to the bowel, such as appendicitis or bowel disease or ulcerative colitis), resulting in obstruction and/or rectal ischemia. Bloody stool may be gastroesophageal reflux or gastritis, bleeding) (Holmes et al., 2013). infectious (viral, bacterial, parasitic) in constipation, diabetes, cystic fibrosis, or 4. Is there a fever? Fever may indicate an nature or related to surgical sickle cell disease, may present with infection. Minor infections that may conditions (lack of oxygen to the severe abdominal pain, as well as other lead to abdominal pain include bowel wall) or anatomical conditions systemic symptoms. A recent bacterial or pharyngitis (due to mesenteric (inflammatory bowel disease, viral illness may lead to slowing of adenitis or enlargement of lymph intestinal polyps, hemorrhoids, rectal bowel peristalsis, resulting in abdominal nodes in the abdominal cavity), fissures). pain and distention, vomiting, or pneumonia (lower lobe infections 7. Are there urinary symptoms? Burning constipation-type symptoms may lead to referred pain to the or discomfort with urination, difficulty (postinfectious gastroparesis).

272 NASN School Nurse | September 2016 Past Surgical History Previous abdominal surgery may lead Table 1. Diagramming a Differential Diagnosis: Abdominal Pain in a to intra-abdominal adhesions, resulting in Student bowel obstruction or ischemia. Medications Common, nonemergent causes of abdominal pain Certain medications, such as antibiotics, • Constipation may result in abdominal pain, vomiting, • Musculoskeletal (strains or contusions) or diarrhea. The intentional or accidental ingestion of medications, such as • Pharyngitis acetaminophen, iron, or salicylates, may • Pneumonia result in gastrointestinal symptoms. Significant usage of caffeine or energy • Gastroenteritis drinks may be associated with abdominal • Urinary tract infections pain. • Gallstones Allergies Any allergic reaction, due to ingested, • Kidney stones inhaled, or contact exposures, may • Menstrual cramps present with gastrointestinal symptoms (abdominal pain or cramping, vomiting • Ovarian cysts or diarrhea) as well as skin and mucous • Stress-related membrane changes, respiratory symptoms, and cardiovascular effects. Serious or life-threatening causes of abdominal pain Social History • Appendicitis Adolescent males and females should • Pancreatitis be asked about their sexual history and • Hepatitis exposure to sexually transmitted infections. For a male, urethritis and • Intra-abdominal abscesses epididymitis may present with abdominal • pain, urinary symptoms, or urethral discharge. For a female, consider ectopic • Pelvic inflammatory disease pregnancy, pelvic inflammatory disease • Tubo-ovarian abscess (lower abdominal pain +/– fever or vaginal discharge), tubo-ovarian abscess • Ovarian or testicular torsion (lower right or left quadrant abdominal • Bowel obstruction pain +/– vaginal discharge), or Fitz-Hugh- Curtis (ascending perihepatitis, associated • Bowel infarction (secondary to shock) with right flank pain). Furthermore, • Incarcerated or strangulated inguinal hernia psychologic or social stressors may present with varying somatic complaints, • Ingestion or overdose including abdominal pain. • Severe allergic reaction A list of common and serious or life-threatening conditions that may result • Intra-abdominal organ contusions or lacerations (trauma) in a student presenting to the nurse’s office with abdominal pain is found in Table 1. examination, concentrating on the dehydration, infection, or overdose. A You’ve Obtained a Good History following: fast respiratory rate may be associated and Developed a Thorough with pneumonia, dehydration, or Differential Diagnosis. What Do 1. What are his or her vital signs? A fever overdose. A low blood pressure may You Do Next? may be associated with an infection be associated with septic shock or The next step in your assessment or overdose. A fast heart rate may be severe dehydration. And always should include a focused physical associated with fever, pain, obtain a pain score (I personally like

September 2016 | NASN School Nurse 273 a scale from 1 to 10, where 1 is no pain and 10 is severe pain) to follow Table 2. Report Card: Who Should You Send to the ER When They improvements or worsening of pain. Present With Abdominal Pain? 2. What is his or her positioning? A student who is laying on a bed and • Severe abdominal pain associated with inability to walk or do 10 jumping jacks not wanting to change positions, or a student who is either writhing in pain • Abdominal examination shows an extremely hard/rigid, tender, or distended or screams when you try to move him abdomen or her, may be indicative of an “acute • Severe dehydration (altered mental status, dizziness, fainting spells, pale or abdomen” (surgical etiology of the mottled skin, sunken eyes, dry lips or tongue, cool extremities, thready or abdominal pain). A student who is bounding pulses, or prolonged capillary refill) able to ambulate in your office, or • Persistent, bilious, or bloody vomiting even better, perform 10 jumping jacks is unlikely to have an “acute • Profusely bloody diarrhea abdomen.” • Blood in urine with severe abdominal pain (possible kidney stones) 3. What is his or her mental status? Is he or she alert and oriented? Is he or she • Altered mental status (possible hypoperfusion from severe dehydration or septic following commands? Etiologies of shock) abdominal pain, such as severe • Evidence of respiratory distress (possible pneumonia or acute asthma) dehydration or septic shock, may lead to altered mental status. • Presence of petechiae or purpura (possible septic shock) 4. Is he or she in respiratory distress? • Suspicion of ingestion or overdose Does he or she speak in full sentences, or is he or she out of • Suspicion of allergic reaction breath? Does he or she have noisy • Recent history of chest, abdominal, or pelvic trauma labored breathing, with grunting, nasal flaring, intercostal retractions, or • Possibility of pregnancy abdominal breathing? Does he or she • Testicular pain or swelling have cyanosis, especially of the face and lips, or trunk? Do you hear good breath sounds, crackles, rales, or wheezes? Pneumonia and acute asthma may lead to abdominal pain, quadrants (right and left upper how the student looks (see Table 2). from either persistent coughing or quadrants, epigastric, right and left Because a few of the conditions that irritation of the diaphragm (leading to flanks, periumbilical, right and left present with abdominal pain require referred abdominal pain). lower quadrants, suprapubic). Is surgical intervention, please keep the 5. Are there signs of dehydration, namely there tenderness? Is there guarding student NPO (nothing by mouth) until he pale or mottled skin, sunken eyes, dry (patient’s muscles tense up when you or she is evaluated in the ER. lips or tongue, cool extremities, push down)? Is there rebound The Plot Thickens thready or bounding pulses, or tenderness (minimal pain when you prolonged capillary refill (greater than push down, but significant pain Your student is sent directly to the ER 3 seconds)? Students who have severe when you let go)? Abdominal because of her severe abdominal pain. abdominal pain typically present with guarding and rebound tenderness are On arrival, I observe the student to have significant dehydration, from either a often associated with an “acute tachycardia (heart rate of 140 beats per loss of appetite or vomiting/diarrhea. abdomen,” a life-threatening, minute) and tachypnea (respiratory rate 6. Does he or she have a petechial (small, intra-abdominal infection, or ischemia of 30 breaths per minute) with a normal pinpoint, purple lesions on the skin of the bowels. blood pressure. She is laying in the bed, that do not blanch) or purpuric writhing in pain, and cannot seem to (bruises) rash? Septic shock and get comfortable. She has localized pain Who Needs to be Sent Directly vasculitis (inflammation of the lining to her right lower quadrant with to the ER From Your Office of blood vessels) may result in both abdominal guarding and rebound When They Present With petechial/purpuric rashes and severe tenderness. An IV is placed, a normal Abdominal Pain? abdominal pain. saline bolus and morphine is 7. Is his or her abdomen distended? Is it Direct referrals to the ER should be administered, blood work is collected rigid like a board? Palpate the nine based on your office assessment and (including complete blood count,

274 NASN School Nurse | September 2016 Table 3. Report Card: Appendicitis—What You Need to Know?

Age Any

Abdominal pain Generalized and dull, eventually leading to sharp, constant, right lower quadrant pain over the next 24–36 hours; pain exacerbated by ambulation or movement

Associated symptoms Fever, nausea/vomiting, loss of appetite, and loose/mushy stools

Diagnosis Clinical (rigid abdomen, right lower quadrant abdominal pain with rebound tenderness, abdominal guarding, and/or Rovsing’s sign), although laboratory and radiologic tests used to confirm the diagnosis

Treatment Surgical intervention with intravenous antibiotics

Complications secondary to a ruptured appendix, abscess, adhesions/obstruction, sepsis, and death

Table 4. Report Card: Ovarian Torsion—What You Need to Know?

Ages Commonly in females less than 20 years

Associated symptoms Classically, the abdominal pain is intense, described as dull or sharp, constant or intermittent, and may be associated with nausea and vomiting

Diagnosis Either pelvic ultrasound or MRI of the pelvis, demonstrating an enlarged ovary with peripheral follicles

Treatment Surgical intervention

Complications Ischemia and necrosis of the ovary, resulting in loss of the ovary, as well as peritonitis

electrolytes, and liver function tests), Associated symptoms include fever, than 20 years. The twisting of the ovary and urine chemstick is performed nausea/vomiting, loss of appetite, and may be secondary to an or (pregnancy test is negative, and there is loose/mushy stools. Diagnosis is clinical malignancy, although the etiology of the no evidence of blood or white blood (rigid abdomen, right lower quadrant torsion is often not determined. cells in the urine). My differential abdominal pain with rebound tenderness, Classically, the abdominal pain is intense, diagnosis includes appendicitis and abdominal guarding, and/or Rovsing’s described as dull or sharp, constant or ovarian torsion. I order an MRI of her sign, which is referred pain to the right intermittent, and may be associated with abdomen and pelvis to help me make lower quadrant when the left lower nausea and vomiting. Diagnosis is made the diagnosis (Kulaylat et al., 2015). quadrant to pushed), although laboratory by either pelvic ultrasound or MRI of the tests (elevated white blood cell count, pelvis, demonstrating an enlarged ovary Wrapping Up: Appendicitis elevated sedimentation rate, elevated with peripheral follicles. Treatment is Versus Ovarian Torsion c-reactive protein) and radiologic tests surgical. If not diagnosed and treated Both appendicitis (see Table 3) and (ultrasound, CT scan, or MRI of the expeditiously, complications include ovarian torsion (see Table 4) are abdomen and pelvis) are used to confirm ischemia and necrosis of the ovary, conditions that require immediate the diagnosis. Treatment is surgical with resulting in loss of the ovary, as well as assessment and surgical treatment. concomitant intravenous antibiotics peritonitis (Samuel-Kalow & Mollen, Appendicitis can occur at any age. administered. If not diagnosed and treated 2015). Typically, the abdominal pain starts as expeditiously, complications include Other conditions that require generalized and dull, eventually leading peritonitis secondary to a ruptured immediate assessment and treatment to sharp, constant, right lower quadrant appendix, abscess, adhesions/obstruction, include bowel obstruction (see Table 5), pain over the next 24–36 hours. The pain sepsis, and death (Craig & Dalton, 2016). testicular torsion (see Table 6), ectopic is usually exacerbated by ambulation or Ovarian torsion is relatively rare, and pregnancy (see Table 7), and pelvic movement (cannot do 10 jumping jacks). most often occurs in women younger inflammatory disease (see Table 8).

September 2016 | NASN School Nurse 275 Table 5. Report Card: Bowel Obstruction—What You Need to Know?

Age Any

Abdominal pain Generalized, dull or sharp, and intermittent

Associated symptoms , nausea, often bilious and repetitive vomiting, decreased bowel movements

Diagnosis An x-ray of the abdomen may show “air-fluid levels” consistent with an obstruction of the bowels

Treatment Bowel rest (nothing by mouth) and intravenous fluids, bowel decompression with a gastric tube, and at times surgical intervention

Complications Severe dehydration, bowel perforation, peritonitis, abscess, sepsis, and death

Table 6. Report Card: Testicular Torsion—What You Need to know?

Age Often during puberty but any age (related to trauma or infection)

Abdominal pain Lower suprapubic abdominal or scrotal pain, may be referred to right or left lower quadrant or flank; pain is often constant, dull, and exacerbated by movement

Associated symptoms Nausea/vomiting, pain or difficulty with urination, swelling of the hemiscrotum and testicle, pain on palpation of the testicle, absent Cremasteric reflex (no movement of the testicle into the scrotum when the inner thigh is stroked)

Diagnosis Ultrasound of the testicle demonstrating no blood flow

Treatment Surgical intervention (detorsion)

Complications Ischemia and necrosis of the testicle, resulting in loss of the testicle

Table 7. Report Card: Ectopic Pregnancy—What You Need to Know?

Age Adolescent females

Abdominal pain Often lower abdominal pain, dull or sharp, constant, pain exacerbated by ambulation or movement

Associated symptoms Associated symptoms: other signs of pregnancy, nausea/vomiting, loss of appetite, possibly vaginal bleeding

Diagnosis Confirmation of pregnancy (urine and/or blood test), transvaginal ultrasound

Treatment Medical or surgical intervention

Complications Life-threatening bleeding, peritonitis secondary to a ruptured ectopic, adhesions/obstruction, sepsis, and death

Case Resolution consulted, and the student was taken to Contact Dr. Olympia the operating room. An operative The MRI of the pelvis demonstrated a detorsion was performed. No If you have a clinical question, send your normal appendix but an enlarged right malignancy, ischemia, or necrosis was question to Dr. Olympia (rolympia@hmc. ovary with peripheral follicles, resulting determined to be associated with the psu.edu). Questions will be selected and in a diagnosis of right ovarian torsion. torsion. She recovered well and is now a discussed as part of the “School Nurses on Gynecology surgery was immediately nursing student at a local university. the Front Lines of Medicine” series. ■

276 NASN School Nurse | September 2016 Table 8. Report Card: Pelvic Inflammatory Disease—What You Need to Know?

Age Adolescent females

Abdominal pain Lower abdominal pain with possible referral to the flanks, constant and dull

Associated symptoms Fever, nausea/vomiting, vaginal discharge or bleeding, urinary symptoms (increased frequency, pain, blood in urine), difficulty ambulating

Diagnosis Pelvic exam demonstrating cervical motion and/or adnexal tenderness, positive cultures consistent with a sexually transmitted infection

Treatment Antibiotics (outpatient or inpatient)

Complications Infertility, tubo-ovarian abscess (diagnosed by ultrasound), peritonitis, sepsis, and death

References Smith, J., & Fox, S. M. (2016). Pediatric abdominal pain: An emergency medicine Craig, S., & Dalton, S. (2016). Diagnosing Jodi Brady, MD perspective. Emergency Medical Clinics of Assistant Professor appendicitis: What works, what does not and North America, 34, 341-361. where to go from here? Journal of Pediatrics Division of Adolescent Medicine and Child Health, 52, 168-173. Wilkinson, R., Olympia, R. P., Dunnick, J., & Brady, J. (2016). Pediatric care provided Department of Pediatrics Holmes, J. F., Lillis, K., Monroe, D., Borgialli, at urgent care centers in the United States: Penn State Hershey Children’s Hospital, D., Kerrey, B. T., Mahajan, P., et al. (2013). Compliance with recommendations Hershey, PA Identifying children at very low risk of for emergency preparedness. Pediatric Jodi is a pediatrician practicing at clinically important blunt abdominal Emergency Care, 32, 77-81. injuries. Annals of Emergency Medicine, 62, the Penn State Hershey Children’s 107-116. Hospital. She is board certified in Kulaylat, A. N., Moore, M. M., Engbrecht, B. W., Robert P. Olympia, MD both pediatrics and adolescent Brian, J. M., Khaku, A., Hollenbeak, C. S., Attending pediatric emergency medicine medicine, and her clinical and et al. (2015). An implemented MRI program physician research interests include adolescent to eliminate radiation from the evaluation of Penn State Hershey Medical Center gynecology, eating disorders, and pediatric appendicitis. Journal of Pediatric Hershey, PA sports medicine. Surgery, 50, 1359-1363. Robert is a physician boarded in Olympia, R. P., Wilkinson, R., Dunnick, J., Dougherty, B., & Zauner, D. (in press). both pediatrics and pediatric Correspondence should be sent to: Pediatric referrals to the emergency emergency medicine with over 19 Robert P. Olympia, MD, Department department from urgent care centers. years of clinical experience. His of Emergency Medicine, Penn State Pediatric Emergency Care. research interests include emergency Hershey Medical Center, 500 Samuel-Kalow, M., & Mollen, C. (2015). Acute and disaster preparedness for University Drive, P.O. Box 850, in the adolescent: A case report. children in the setting of schools Hershey, PA 17033-0850, rolympia@ Clinical Pediatric Emergency Care, 16, and school-based athletics. hmc.psu.edu. 119-124.

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