Clinical Guideline ! This guideline should not replace clinical judgment. Suspected appendicitis Pediatric Emergency Medicine

Consider alternative dx: Exclude: Pain control and antiemetics PRN • Ovarian/testicular torsion If toxic, hemodynamically assess risk of appendicitis: • PID unstable or rigid abdomen. Maximal tenderness in RLQ and/or • Ectopic pregnancy Treat per sepsis guideline constellation of anorexia, vomiting, fever, • Pyelonephritis and place emergent peds migration of pain • Intussusception surgery consult. • Obstruction • Meckels • Hepatitis/pancreatitis Risk factors absent/minimal Risk factors present • Viral process

Low risk Moderate/high risk • Consider alternative dx Re-exam concerning for appy • NPO • PO challenge • UA/UPT, CBC w/diff, CRP • Reassess • RLQ ultrasound • Consider pelvic u/s, r/o torsion Re-exam reassuring against appy

Obs CDU vs home with close PCP f/u

The Pediatric Appendicitis Score Positive RLQ u/s Indeterminant Negative RLQ u/s Score Item (point) • Consult peds surg RLQ u/s • Consider • Ceftriaxone (50 mg/ • Consider peds alternative dx Anorexia 1 kg, max 2000 mg) surg consult • PO challenge Nausea or vomiting 1 + metronidazole (30 • Admit obs vs • Reassess mg/kg, max 1,500 fast MRI or CT • Obs CDU vs home Migration of pain 1 mg), IV stat x 1 with PCP f/u Fever >38°C (100.5°F) 1 • NS bolus and MIVF

Pain with cough, percussion 2 or hopping Right lower quadrant 2 tenderness White blood cell count 1 >10,000 cells/microL Neutrophils plus band forms 1 >7,500 cells/microL Low risk <4, Moderate/high risk ≥4 Total 10 points C: Centigrade; F: Fahrenheit Data from: Samuel, M. Pediatric appendicitis score. J Prediatr Surg 2002; 37:877.

chrichmond.org For questions concerning this guideline, contact: Last updated: May 2020 [email protected] Next expected update: May 2023

Suspected Appendicitis Guideline Executive Summary

Children’s Hospital of Richmond at VCU Pediatric Suspected Appendicitis Workgroup Pediatric Emergency Medicine Owner: Jonathan Silverman, MD, MPH Pediatric Radiology: Joo Cho, MD Pediatric Surgery Owner: Laura Boomer, MD Pediatric Emergency Nursing: Kelly Strickler, RN Pediatric Emergency Medicine: Judy Barto, MD

Approved (May 2020) Pediatric Emergency Medicine Quality Committee: CHoR Clinical Guidelines Committee: Rashida Woods, MD Jonathan Silverman, MD, MPH Chief of Pediatric Emergency Medicine: Ashlie Tseng, MD Frank Petruzella, MD, MS CHoR Quality Committee: Chief of Pediatric Surgery: José Muñoz, MD Charles Bagwell, MD Dory Walczak, MS, RN, NE-BC, CPHQ

Chief of Pediatric Radiology: Jacqueline Urbine, MD

References Duke E, Kalb B, Arif-Tiwari H, Daye ZJ, Gilbertson-Dahdal D, Keim SM, Martin DR. A Systematic Review and Meta-Analysis of Diagnostic Performance of MRI for Evaluation of Acute Appendicitis. AJR Am J Roentgenol. 2016 Mar;206(3):508-17. Krishnamoorthi R, Ramarajan N, Wang NE, Newman B, Rubesova E, Mueller CM, Barth RA. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology. 2011 Apr;259(1):231-9. Epub 2011 Jan 28. Right lower quadrant pain - suspected appendictis. Variant 4: Fever, leukocytosis, possible appendicitis, atypical presentation in children (younger than age 14). ACR Appropriateness Criteria. American College of Radiology (ACR), 2013. http://www.acr.org/~/media/ACR/ Documents/AppCriteria/Diagnostic/RightLowerQuadrantPainSuspectedAppendicitis.pdf Zúñiga RV, Arribas JL, Montes SP, Fernandez MN, Abad CG, Martin LG, González-Sagrado M. Application of Pediatric Appendicitis Score on the emergency department of a secondary level hospital. Pediatr Emerg Care. 2012 Jun;28(6):489-92.

Citation Title: Pediatric ED Suspected Appendicitis Guideline

Authors: Children’s Hospital of Richmond at VCU Jonathan Silverman, MD, MPH Joo Cho, MD Laura Boomer, MD Kelly Strickler, RN Judy Barto, MD

Date: May 2020

Retrieval website: http://www.chrichmond.org/clinical-guideline-suspected-appendicitis

Example: Children’s Hospital of Richmond at VCU, Silverman J, Boomer L, Barto J, Cho J, Strickler K. Pediatric ED Suspected Appendicitis Guideline. Available from: http://www.chrichmond.org/clinical-guideline-suspected-appendicitis

chrichmond.org

For questions concerning this guideline, contact: Last updated: May 2020 [email protected] Next expected update: May 2023