A Lange Medical Book Pediatrics on call - part 1 pptx

Callahan, MD Clinical Associate Professor of Pediatrics Vice Dean for Academic Affairs Jefferson Medical College of Thomas Jefferson University Philadelphia, Pennsylvania Kathleen Kilroy

A Lange Medical Book

PEDIATRICS

ON CALL

Edited by

Charles A Pohl, MD

Clinical Associate Professor of Pediatrics

Associate Dean for Student Affairs and Career CounselingJefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

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To the girls in my life especially Emma and Annie

and

To Donald R Pohl, MD, my pediatrician and dad Thanks for all of your love and support!

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Associate Editors xi

Contributors xiii

Preface xxiii

Common Abbreviations and Acronyms xxv

I On Call Problems 1 Abdominal Distention .1

2 Abdominal Pain 6

3 Acidosis 13

4 Airway Devices .18

5 Alkalosis .23

6 Altered Mental Status .26

7 Anaphylactic Reaction 34

8 Anemia .39

9 Apnea and Apparent Life-Threatening Event .44

10 Back Pain .48

11 Bradycardia .51

12 Cardiopulmonary Arrest .56

13 Chest Pain 61

14 Child Abuse: Physical .69

15 Child Abuse: Sexual .74

16 Coagulapathy .80

17 Coma 84

18 Constipation .89

19 Cough .92

20 Cyanosis .96

21 Diarrhea .102

22 Dysuria .110

23 Epistaxis .115

24 Eye Discharge (Conjunctivitis) and Swelling .120

25 Failure to Thrive 124

26 Feeding Problems .128

27 Fever .131

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vi CONTENTS

28 Fever of Unknown Origin 139

29 Foreign Body: Gastrointestinal Tract .143

30 Foreign Body: Respiratory Tract .147

31 Gastrointestinal Bleeding: Lower Tract .150

32 Gastrointestinal Bleeding: Upper Tract .155

33 Headache .160

34 Heart Murmurs and Heart Sound Abnormalities .166

35 Hematuria .172

36 Hemoptysis .177

37 Hyperbilirubinemia, Direct (Conjugated) .180

38 Hyperbilirubinemia, Indirect (Unconjugated) .185

39 Hypercalcemia .189

40 Hyperglycemia .194

41 Hyperkalemia .196

42 Hypermagnesemia .201

43 Hypernatremia .203

44 Hyperphosphatemia .209

45 Hypertension .213

46 Hypocalcemia .218

47 Hypoglycemia .223

48 Hypokalemia .226

49 Hypomagnesemia .229

50 Hyponatremia .232

51 Hypophosphatemia .236

52 Hypotension .240

53 Hypothermia .245

54 Hypotonia .248

55 Inability to Void (Urinary Retention) 252

56 Increased Intracranial Pressure .255

57 Intravenous Access Problems .260

58 Irritability .262

59 Joint Swelling .268

60 Leg Pain .271

61 Lethargy .276

62 Leukocytosis .282

63 Leukopenia and Neutropenia .287

64 Limp .291

65 Macrocephaly .295

66 Metabolic Diseases .299

67 Nasogastric Tube Management 305

68 Neck Swelling and Masses .309

69 Nutrition in the Pediatric Patient .316

70 Pain Management .320

71 Pharyngitis .325

72 Phlebitis 330

73 Pneumothorax 332

74 Poisoning and Overdoses .337

75 Polyuria .350

76 Proteinuria 353

77 Rectal Prolapse 357

78 Renal Failure, Acute .360

79 Respiratory Distress .369

80 Scrotal Swelling 374

81 Sedation and Analgesia .377

82 Seizures, Febrile .384

83 Seizures, Nonfebrile .387

84 Stridor .393

85 Syncope .396

86 Tachycardia .401

87 Thrombocytopenia .408

88 Transfusion Reaction 412

89 Trauma and Injuries 415

90 Urinary Incontinence .421

91 Urinary Tract Infections .423

92 Vaginal Bleeding .429

93 Vaginal Discharge .432

94 Vomiting .435

95 Wheezing .441

II Laboratory Tests and Their Interpretation .449

III Bedside Procedures .488

1 Arterial Line Placement 488

2 Arterial Puncture .490

3 Bladder Catheterization 491

4 Chest Tube Insertion .492

5 Cricothyrotomy .495

6 Endotracheal Intubation (Oral and Nasal) .497

7 Gastrointestinal Tube Insertion .500

8 Gynecologic Evaluation 503

9 Heelstick (Capillary Blood Sampling) .505

10 Intraosseous Cannulation .505

11 Knee Arthrocentesis .507

12 Lumbar Puncture 509

13 Paracentesis .511

14 Percutaneous Central Venous Catheterization .513

viii CONTENTS

15 Percutaneous Venous Catheterization .517

16 Skin Biopsy .519

17 Splinting .520

18 Thoracentesis .527

19 Tympanocentesis .529

20 Umbilical Vein Catheterization 530

21 Venipuncture (Phlebotomy) .532

22 Wound Care and Suturing 533

IV Fluids and Electrolytes .542

1 Maintenance Fluids and Electrolytes .542

2 Deficit Replacement .544

V Blood Component Therapy .547

1 Blood Components and Their Uses in Pediatrics .547 2 Transfusion Reactions .547

VI Ventilator Management .551

1 Indications for Ventilatory Support 551

2 Ventilation Options and Classification .553

3 Ventilator Setup .555

4 Modification of Ventilator Settings .560

5 Special Modes of Ventilation .564

6 Equations .565

VII Preoperative Management .567

1 Preoperative Assessment .567

2 Postoperative Care .578

VIII Commonly Used Medications .580

1 Classes of Generic Drugs, Minerals, and Vitamins .580 2 Generic Drugs: Indications, Actions, Dosage, Supplied, and Notes .594

3 Minerals: Indications/Effects, RDA/Dosage, Signs/ Symptoms of Deficiency and Toxicity, and Notes .740 4 Vitamins: Indications/Effects, RDA/Dosage, Signs/ Symptoms of Deficiency and Toxicity, and Notes .745

5 Tables .750

Appendices 757

A Blood Cell Indices: Age-Specific .758

B Blood Pressure Measurement Percentiles (Girls and Boys): Age Specific 759

C Body Surface Area .759

D Childhood Immunization Schedule .759

E Denver Developmental Assessment .762

F Glasgow Coma Scale .765

G Growth Charts (Girls and Boys) .766

H Heart Rates: Age Specific .768

I SBE Prophylaxis .768

J Specimen Tubes for Phlebotomy 770

K Temperature Conversion .770

L Tetanus Prophylaxis .771

M Weight Conversion .773

Index 775 Commonly Used Pediatric Resuscitation

Drugs and Algorithms Inside Front

and Back Covers

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Associate Editors

Clara A Callahan, MD

Clinical Associate Professor of Pediatrics

Vice Dean for Academic Affairs

Jefferson Medical College of Thomas Jefferson University Philadelphia, Pennsylvania

Kathleen Kilroy Bradford, MD

Assistant Professor of Pediatrics

University of North Carolina School of Medicine

Chapel Hill, North Carolina

xi

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Sheeja K Abraham, MD

Assistant Professor of Pediatrics

Division of Pediatric Gastroenterology

Jefferson Medical College of Thomas Jefferson University

Philadelphia, Pennsylvania

Ellen Arch, MD

Staff Physician/Clinical Geneticist

Alfred I duPont Hospital for Children

Wilmington, Delaware

Magdy William Attia, MD

Associate Professor of Pediatrics

Jefferson Medical College of Thomas Jefferson University

Philadelphia, Pennsylvania

Jeanne Marie Baffa, MD

Clinical Associate Professor of Pediatrics

Jefferson Medical College of Thomas Jefferson University

Pediatric Cardiologist

The Nemours Cardiac Center

Alfred I duPont Hospital for Children

Wilmington, Delaware

Mara L Becker, MD

Pediatric Rheumatology Fellow

Alfred I duPont Hospital for Children

Wilmington, Delaware

Caroline D Boyd, MD

Pediatric Critical Care Fellow

Alfred I duPont Hospital for Children

Wilmington, Delaware

xiii

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xiv CONTRIBUTORS

Kathleen Kilroy Bradford, MD

Assistant Professor of Pediatrics

University of North Carolina School of Medicine

Chapel Hill, North Carolina

B Randall Brenn, MD

Assistant Professor of Anesthesiology and Pediatrics

Jefferson Medical College of Thomas Jefferson UniversitySenior Staff Anesthesiologist

Alfred I duPont Hospital for Children

Staff Attending Anesthesiologist

Department of Anesthesiology and Critical Care MedicineChildren’s Hospital of Philadelphia

Philadelphia, Pennsylvania

Michael P Carboni, MD

Clinical Assistant Professor

Division of Pediatric Cardiology

Duke University Medical Center

Durham, North Carolina

Aaron S Chidekel, MD

Assistant Professor of Pediatrics

Jefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

Maria Childers, MD

Assistant Professor of Pediatrics

Jefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

Esther K Chung, MD, MPH

Assistant Professor of Pediatrics

Jefferson Medical College of Thomas Jefferson UniversityPediatrician

Alfred I duPont Hospital for Children

Philadelphia, Pennsylvania

Sandra Como-Fluehr, MSN, RN, APRN, BC

Pain Management Nurse Specialist

Department of Anesthesiology and Critical Care MedicineAlfred I duPont Hospital for Children

Wilmington, Delaware

Deborah M Consolini, MD

Assistant Professor of Pediatrics

Jefferson Medical College of Thomas Jefferson UniversityPediatrician

Alfred I duPont Hospital for Children

Wilmington, Delaware

Steven P Cook, MD, FACS, FAAP, FRSM

Clinical Assistant Professor

Department of Otolaryngology/Head and Neck Surgery

Jefferson Medical College of Thomas Jefferson UniversityChief, Division of Pediatric Otolaryngology

Alfred I duPont Hospital for Children

Wilmington, Delaware

Andrew T Costarino, Jr., MD

Professor of Anesthesiology and Chairman of Pediatrics

Jefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

Chief, Division of Pediatric Nephrology

Alfred I duPont Hospital for Children

Wilmington, Delaware

Director, Children at Risk Evaluation (CARE) Program

Alfred I duPont Hospital for Children

Wilmington, Delaware

Ellen S Deutsch, MD, FACS, FAAP

Associate Professor of Otolaryngology and Pediatrics

Alfred I duPont Hospital for Children

Wilmington, Delaware

Joan S Dipalma, MD

Attending Physician

Division of Pediatric Gastroenterology

Alfred I duPont Hospital for Children

Wilmington, Delaware

Maureen F Edelson, MD

Medical Director of Blood Bank

Department of Laboratory Medicine

Alfred I duPont Hospital for Children

Wilmington, Delaware

Gary A Emmett, MD, FAAP

Clinical Associate Professor of Pediatrics

Director of General Pediatrics

Jefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

T Ernesto Figueroa, MD, FAAP, FACS

Chief, Division of Pediatric Urology

Alfred I duPont Hospital for Children

Wilmington, Delaware

Christopher N Frantz, MD

Chief, Division of Hematology/Oncology

Alfred I duPont Hospital for Children

Wilmington, Delaware

Chief, Division of Neurology

Alfred I duPont Hospital for Children

Wilmington, Delaware

Gregory C Griffin, MD

Attending Physician

Division of Pediatric Hematology/Oncology

Alfred I duPont Hospital for Children

Division of Emergency Medicine

Alfred I duPont Hospital for Children

Medical Director of Pulmonary Function Laboratory

Alfred I duPont Hospital for Children

Division of Emergency Medicine

Alfred I duPont Hospital for Children

Wilmington, Delaware

Kelly R Leite, DO

Assistant Professor of Pediatrics

Assistant Director, Pediatric Residency Program

Penn State College of Medicine

Hershey, Pennsylvania

James Jeffrey Malatack, MD

Director of Diagnostic Referral Service

Pediatric Medical Liver Transplantation Program

Alfred I duPont Hospital for Children

Wilmington, Delaware

Keith J Mann, MD

Associate Director, Pediatric Residency Program

Alfred I duPont Hospital for Children

Wilmington, Delaware

Stephen J McGeady, MD

Associate Professor of Pediatrics

Division of Allergy, Asthma, and Immunology

Jefferson Medical College of Thomas Jefferson UniversityChief, Division of Pediatric Allergy, Asthma, and ImmunologyAlfred I duPont Hospital for Children

Wilmington, Delaware

Charles P McKay, MD

Director, Bone and Mineral Program

Division of Pediatric Nephrology

Alfred I duPont Hospital for Children

Wilmington, Delaware

Robin E Miller, MD

Attending Physician

Division of Pediatric Hematology/Oncology

Alfred I duPont Hospital for Children

Wilmington, Delaware

Linda Muir, MD

Pediatric Gastroenterologist

Sacred Heart Medical Center

Providence Physician Services

Chief, Division of Pulmonology

Director, Cystic Fibrosis Program

Alfred I duPont Hospital for Children

Wilmington, Delaware

xx CONTRIBUTORS

Scott Penfil, MD

Director, Pediatric Critical Care Training Program

Alfred I duPont Hospital for Children

Wilmington, Delaware

Melanie Pitone, MD, FAAP

Attending Physician

Division of Pediatric Emergency Medicine

Alfred I duPont Hospital for Children

Wilmington, Delaware

Charles A Pohl, MD

Clinical Associate Professor of Pediatrics

Associate Dean for Student Affairs and Career CounselingJefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

Amanda Pratt, MD

Assistant Professor

Division of Pediatric Emergency Medicine

University of Medicine and Dentistry of New Jersey—RobertWood Johnson Medical School

New Brunswick, New Jersey

Erin Preston, MD

Instructor of Pediatrics

Jefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

James S Reilly, MD, MS, FACS

Professor of Otolaryngology and Pediatrics

Jefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

Steven B Ritz, MD

Attending Cardiologist

The Nemours Cardiac Center

Alfred I duPont Hospital for Children

Wilmington, Delaware

Marianne Ruby, MD, FACOG

Clinical Instructor

Division of Reproductive Endocrinology

Jefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

Jean M Russell, RN, BSN, CRNI

IV Therapy Coordinator

Department of Nursing

Alfred I duPont Hospital for Children

Wilmington, Delaware

Richard J Scarfone, MD, FAAP

Associate Professor of Pediatrics

University of Pennsylvania School of Medicine

Philadelphia, Pennsylvania

Steven M Selbst, MD

Professor of Pediatrics and Vice Chair for Education

Jefferson Medical College of Thomas Jefferson UniversityPediatric Residency Program Director

Alfred I duPont Hospital for Children

Wilmington, Delaware

Glenn Stryjewski, MD, MPH

Department of Anesthesia and Critical Care

St Christopher’s Hospital for Children

Philadelphia, Pennsylvania

Shamim Tejani, PharmD

Clinical Pharmacy Coordinator

Alfred I duPont Hospital for Children

Wilmington, Delaware

Andrew W Walter, MS, MD

Associate Professor of Pediatrics

Division of Pediatric Hematology/Oncology

Jefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

xxii CONTRIBUTORS

Rhonda S Walter, MD

Acting Chief, Division of Developmental Medicine

Alfred I duPont Hospital for Children

Clinical Assistant Professor

Division of Allergy and Immunology

Jefferson Medical College of Thomas Jefferson UniversityPhiladelphia, Pennsylvania

I am grateful to be able to bring you the first edition of Pediatrics On Call.

The “on-call” series of which this book is a part is based on a concept

applied by Tricia Gomella, MD, in her book, Neonatology: Basic Management, On Call Problems, Diseases, and Drugs The books in this

series reflect how clinicians typically approach and manage patients; that

is, patients usually present with a specific complaint or problem, whichnecessitates an evaluation and action rather than a specific diagnosis

Pediatrics On Callis designed to aid the practitioner and serve as a learningresource to housestaff and students, enabling them to better understandmedical conditions in children and provide the necessary tools to initiatethe evaluation and care of these young patients

It would be remiss not to acknowledge those who have made this bookpossible The staff at McGraw-Hill, especially Janet Foltin and DonnaFrassetto, have been supportive and patient All three associate editors,Drs Callahan, Gartner, and Bradford, have devoted significant effort aswell as endless attention to detail to ensure academic integrity The con-tributors have provided medical expertise and insight while giving up valu-able personal time And finally I must acknowledge and thank our pediatricpatients, who have been our teachers through the years

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Common Abbreviations

and Acronyms

/: per

< : less than, younger than

> : more than, older than

≥ : more than or equal to

≤ : less than or equal to

ABG: arterial blood gas

ABPA: allergic bronchopulmonary

ADH: antidiuretic hormone

ADP: adenosine diphosphate

AG: anion gap

AIDS: acquired immunodeficiency

syndrome

ALT: alanine aminotransferase

ALTE: apparent life-threatening

event

AM: morning

AME: apparent mineralocorticoid

excess

ANA: antinuclear antibody

ANC: absolute neutrophil count

AP: anteroposterior

APIGN: acute postinfectiousglomerulonephritisAPRV: airway pressure releaseventilation

APTT: activated partial plastin time

thrombo-ARDS: acute respiratory distresssyndrome

ARF: acute rheumatic fever;

acute renal failureAST: aspartate aminotransferaseATN: acute tubular necrosisATP: adenosine triphosphateAV: atrioventricular

β-HCG: beta human chorionicgonadotropin

BiPAP: bilevel positive airwaypressure

BM: bowel movementBP: blood pressureBUN: blood urea nitrogenCa: calcium

CaO2: arterial oxygen contentcap: capsule

CBC: complete blood countCF: cystic fibrosis

CHF: congestive heart failureCl: chloride

CMV: cytomegalovirusCNS: central nervous systemCOX-2: cyclooxegenase-2CPAP: continuous positive airwaypressure

The following are common abbreviations used in medical records and inthis edition

xxv

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xxvi COMMON ABBREVIATIONS AND ACRONYMS

CVA: costovertebral angle

CVP: central venous pressure

E coli: Escherichia coli

EBV: Epstein-Barr virus

ECFV: extracellular fluid volume

EMS: emergency medical services

ENT: ear, nose, throat

EPAP: expiratory positive airway

FEM G: fractional excretion

of magnesiumFHH: familial hypocalciurichypercalcemia

FiO2: fraction of inspired oxygenFSGS: focal segmentalglomerulosclerosisFTT: failure to thriveFUO: fever of unknown originFWLS: fever without localizingsigns

g: gramGABHS: group A β-hemolyticstreptococcus

GCS: Glasgow Coma ScaleG-CSF: granulocyte colony-stimulating factorGERD: gastroesophageal refluxdisease

GFR: glomerular filtration rateGGTP: gamma-glutamyltranspeptidaseGI: gastrointestinalGM-CSF: granulocyte-macrophage colony-stimulating factorG6PD: glucose-6-phosphatedehydrogenase

GRA: glucocorticoid remediablealdosteronism

GU: genitourinaryh: hour

H: hydrogenHCG: human chorionicgonadotropinHCl: hydrochloric acidHCO3: bicarbonateHct: hematocritHEENT: head, eyes, ears, nose,and throat

HFOV: high-frequency oscillatoryventilation

Hgb: hemoglobinHIDA: hepato-iminodiacetic acid

HIPAA: Health Insurance

Portability and Accountability

HUS: hemolytic uremic syndrome

IBD: inflammatory bowel disease

ICP: intracranial pressure

ICU: intensive care unit

I:E ratio: inspiratory-to-expiratory

ISI: international sensitivity index

ITP: idiopathic thrombocytopenic

purpura

IU: International Unit

IUGR: intrauterine growth retarded

KUB: [X-ray examination of]

kidneys, ureters, and bladder

MAOI: monoamine oxidaseinhibitor

MAP: mean arterial pressuremax: maximum

MBS: modified barium swallowMCD: minimal change diseasemcg: microgram

mcL: microliterMCL: midclavicular lineMCV: mean corpuscular volumeMDI: metered dose inhalerMg: magnesium

mg: milligrammin: minutemL: millilitermm: millimeter

mm Hg: millimeters of mercurymmol: millimole

mo: monthmOsm: milliosmoleMRA: magnetic resonanceangiography

MRCP: magnetic resonancecholangiopancreatographyMRI: magnetic resonanceimaging

MSUD: maple syrup urine ease

dis-Na: sodiumNC: nasopharyngeal carcinomaNG: nasogastric

NGU: nongonoccoccal urethritis

NH4Cl: ammonium chlorideNICU: neonatal intensivecare unit

NIF: negative inspiratory forceNP: nasopharyngeal

NPO: nothing by mouth

(nulla per os)

NS: normal salineNSAIDs: nonsteroidal anti-inflammatory drugsOI: oxygenation indexO&P: ova and parasitesOS: intraosseous

COMMON ABBREVIATIONS AND ACRONYMS xxvii

xxviii COMMON ABBREVIATIONS AND ACRONYMS

OSAS: obstructive sleep apnea

PDA: patent ductus arteriosus

PEEP: positive end-expiratory

pressure

P/F ratio: PaO2-to-FiO2ratio

PFIC: progressive familial

intrahepatic cholestasis

pg: picogram

PICU: pediatric intensive care unit

PID: pelvic inflammatory disease

PIP: positive inspiratory pressure

PMN: polymorphonuclear

neutrophil

PO: by mouth (per os)

PPD: purified protein derivative

PPI: protein pump inhibitor

ppm: parts per million

PR: by rectum (per rectum)

prn: as often as needed (pro

q15min: every 15 minutes

RAP: recurrent abdominal pain

RBC: red blood cell

RDW: red blood cell distributionwidth index

RE: retinol equivalentRMSF: Rocky Mountain spottedfever

RPR: rapid plasmin reagin (test)RR: respiration rate

RSV: respiratory syncytial virusRTA: renal tubular acidosiss: second

SCFE: slipped capital femoralepiphyses

SCIWORA: spinal cord injurywithout radiographic abnor-mality

SGA: small for gestational ageSIADH: syndrome of inappropri-ate secretion of antidiuretichormone

SIDS: sudden infant deathsyndrome

SIMV: synchronized intermittentmandatory ventilationSLE: systemic lupuserythematosus

sp gr: specific gravitySPECT: single-photon emissioncomputed tomography

SpO2: functional oxygen tion; pulse oximetrySQ: subcutaneousSSRIs: selective serotoninreuptake inhibitorsSTD: sexually transmitteddisease

satura-SVT: supraventriculartachycardia

T1/2: half-life

T3: triiodothyronine

T4: thyroxinetab: tabletTAR: thrombocytopenia—absentradius

tbsp: tablespoonTIBC: total iron-binding capacityTMP-SMX: trimethoprim-sulfamethoxazole

TORCH: toxoplasmosis, other

(congenital syphilis and

viruses), rubella,

cytomegalovirus, and herpes

simplex virus

TPN: total parenteral nutrition

TRALI: transfusion-related acute

living injury

tsp: teaspoon

UDP: uridine diphosphate

UTI: urinary tract infection

UV: ultraviolet

VC: vital capacity

VCUG: voiding cystourethrogram

V/Q: ventilation-perfusionVSD: ventricular septal defectVT: ventricular tachycardia

VT: tidal volumeVUR: vesicoureteral refluxvWD: von Willebrand diseasevWF: von Willebrand factorWBC: white blood cellwk: week

wt: weightw/w: weight; percent weightXLH: X-linked hypophosphatemic(rickets)

y: year

COMMON ABBREVIATIONS AND ACRONYMS xxix

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I. On Call Problems

1 ABDOMINAL DISTENTION

I Problem.An 8-month-old boy is brought to the pediatrician because

of abdominal distention

II Immediate Questions

A What are the vital signs?Because infants are diaphragmaticbreathers, distention may impair respiratory function and causetachypnea Massive distention can compromise cardiac output,resulting in hypotension and tachycardia Fever suggests infec-tion, such as peritonitis or pneumonia, which can cause distentionfrom adynamic ileus

B Is abdomen usually distended?Abdominal distention resultingfrom obesity and fecal retention occurs gradually, whereas thatfrom intestinal obstruction is more rapid

obstruction and inflammatory conditions are accompanied bypain Distention that develops more slowly may be painless

D Has there been any vomiting?Vomiting, particularly bilious orfeculent, is a frequent sign of intestinal obstruction

E When was the most recent bowel movement? What is patient’s usual bowel pattern?Complete obstruction and ady-namic ileus are usually associated with lack of bowel movements.Constipation is associated with infrequent or difficult passage ofstool

F Has patient previously been well?Organomegaly, tumors, andascites often occur in chronically ill children who have diminishedactivity, failure to thrive, and fever

G Does patient void normally? Is there any diminution in urine output?Distention may occur from hydronephrosis, obstructedbladder, polycystic kidney, or urinary ascites Intestinal obstruc-tion and ascites frequently produce hypovolemia

H If an adolescent girl, has patient had regular periods?Giantovarian cysts and pregnancy may cause abdominal distention

III Differential Diagnosis.Distention may be caused by obesity, gaswithin or outside the GI tract, ascites, feces, a large mass, and, in

adolescent females, pregnancy As a mnemonic remember the 6 F’s:

F at, Flatus, Fluid, Feces, Fearsome-sized masses, and Fetus.

A Obesity.Strikingly increased incidence in United States; however,the abdomen in infants and children may be normally protuberantuntil puberty

B Gas

1

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intussus-2 Adynamic (paralytic) ileus.Intestine dilates from

accumulat-ed gas and fluid when there is diminishaccumulat-ed peristaltic activity.Seen with infectious or inflammatory conditions of theabdomen (eg, necrotizing enterocolitis), systemic infections(eg, UTIs, pneumonia), hypokalemia, and following surgicalmanipulation of intra-abdominal organs

3 Pneumoperitoneum.Abdomen can distend from free air orsequestered fluid accompanying peritonitis

a Causes in neonates.Necrotizing enterocolitis, neous gastric perforation

sponta-b Causes in older children.Perforated peptic ulcer, Meckeldiverticulum

4 Excessive air in GI tract.Infants and children may swallowlarge quantities of air with feeding or crying

C Ascites.Nonpurulent fluid in peritoneal cavity May be serous,chylous, urinary, biliary, or bloody

1 Serous.From increased splanchnic capillary hydrostatic

pres-sure, and decreased plasma oncotic pressure Causes:

Hepatobiliary (cirrhosis, biliary atresia, other causes of portalhypertension), cardiac (congestive heart failure, constrictivepericarditis), or peritoneal (infectious, from tuberculosis or bac-teria producing peritonitis; intra-abdominal tumors)

2 Chylous.From congenital malformation of lymphatic channels,lymphatic obstruction due to abdominal or mediastinal masses,

or traumatic disruption

3 Urinary.From fluid retention in renal failure, decreased plasmaprotein with nephrotic syndrome, and direct extravasation ofurine with obstructive uropathy

4 Biliary.From perforated gallbladder or common bile duct

5 Bloody.From trauma

D Constipation.Most often functional; may also be mechanical(from an anteriorly displaced anus), neurologic (with defects ofthe spinal cord), metabolic (associated with hypokalemia andhypothyroidism), or a result of Hirschsprung disease

E Masses.May represent enlarged organ (liver, spleen, kidney,bladder), tumor (neuroblastoma, Wilms tumor, hepatoblastoma,ovarian tumors), or cyst (ovarian, omphalomesenteric, mesenteric)

F Pregnancy.In adolescent girls

IV Database

1.ABDOMINAL DISTENTION 3

A Physical Exam Key Points

1 Vital signs.Tachypnea suggests respiratory compromise,

where-as hypotension and tachycardia are where-associated with poor venousreturn or hypovolemia Fever may occur with infectious processes

diaphragm Auscultate for pneumonia

3 Abdomen

a Inspection.A protuberant abdomen from obesity is formly rounded, with the umbilicus buried An evertedumbilicus indicates increased intra-abdominal pressure.Distention from ascites is most marked in the hypogastricarea when upright; flanks bulge when supine When ascites

uni-is severe, skin uni-is shiny, with prominent veins Duni-istentioncaused by abdominal masses may be asymmetric Diastasisrectus (midline protrusion from xiphoid to umbilicus) is anormal variant

b Auscultation. Bowel sounds are high pitched in earlyobstruction, diminished with adynamic ileus and peritonitis

c Percussion.Differentiate air (tympany) from fluid and solidstructures (dull) Free intra-abdominal air causes loss ofnormal dullness on percussion of the liver Free fluid pro-duces shifting dullness, percussible in the flanks whenpatient is supine and moving to dependent side when inlateral decubitus position

d Palpation.Abdomen may be rigid from peritonitis or tensefrom ascites Note location, size, consistency, and movability

of masses (retroperitoneal masses do not move with ration) Stool can often be identified by its deformability Afluid wave from ascites is demonstrated by tapping the flankwith the right hand and receiving an impulse with the lefthand on the opposite flank while an assistant presses down-ward along the midline

respi-4 Rectal exam.Check for imperforate anus and fecal impaction.Tenderness may imply peritonitis Functional obstruction fromHirschsprung disease may be explosively decompressed

5 Hernias.Assess groin and umbilicus

6 Intake and output.Check for fluid retention or dehydration

B Laboratory Data

1 CBC.Leukocytosis or left shift suggests infection; anemia may

be associated with intra-abdominal bleeding

2 Serum electrolytes, BUN, creatinine, liver function tests.

Hypokalemia can cause an ileus Elevated bilirubin andtransaminases can identify hepatic disease Elevated BUN andcreatinine indicate renal failure

3 ABGs.Respiratory acidosis implies hypoventilation from tention Metabolic acidosis accompanies intestinal ischemia(eg, with severe necrotizing enterocolitis)

dis-4 I:ON CALL PROBLEMS

TABLE I–1 IDENTIFICATION OF ASCITIC FLUID

Fluid Color Characteristics

Serous

Transudate Clear yellow Sp gr < 1.020, protein < 2.5 g/dL, serum:ascites

albumen > 1.1 Exudate Turbid Sp gr > 1.020, protein > 3 g/dL serum:ascites albu-

men < 1.1, elevated leukocyte count Chyle Milky white a Triglycerides < 1000 mg/dL, leukocytes 1000–5000

cells/mm 3 , 70–90% lymphocytes Urine Clear yellow Creatinine 5–10 mg/dL

Bile Green, golden yellow Bilirubin 100–400 mg/mL

Pus Purulent Many leukocytes, bacteria on Gram stain and culture

a Clear yellow in neonates who have never been fed.

4 Paracentesis.If ascites is present, insert butterfly needle inleft lower quadrant and aspirate Fluid is readily identified asserous, chyle, urine, bile, or pus (Table I–1) Serous fluid may

be transudate (from increased hydrostatic pressure) or date (from inflammatory process)

exu-5 ␤-HCG Measure in any patient who may be pregnant.

C Radiographic and Other Studies

1 Chest and abdominal x-rays.Chest x-ray may show limitedlung volumes from increased intra-abdominal pressure orpneumonia as a cause of ileus Upright chest x-ray is the bestview for detecting pneumoperitoneum Abdominal x-rays willdemonstrate intestinal obstruction, fecal retention, and ady-namic ileus A mass is suggested by a paucity of intestinalloops in a particular area; ascites is seen as generalizedhaziness

2 GI contrast x-rays.May be indicated if there is evidence ofobstruction

3 Ultrasonography.Can characterize abdominal masses and isvery sensitive in detecting fluid; can also differentiate free fluid,loculated fluid, and fluid in a cyst

4 CT scan.Provides excellent anatomic detail of enlarged abdominal organs and other masses

intra-V Plan.If respiration or perfusion is impaired, provide urgent tation Perform intubation with positive pressure ventilation and give

resusci-IV fluid therapy if needed, even while diagnostic workup is carriedout Specific treatment depends on cause of distention

A Obstruction.Insert NG tube to suction, usually followed by gery Exceptions include meconium ileus, meconium plug, andintussusception, which may be treated successfully with contrastenemas Hirschsprung disease may be managed with decom-pressive enemas until surgery is performed

sur-B Adynamic ileus.Usually temporary; treat underlying cause

1.ABDOMINAL DISTENTION 5

administer IV fluids and antibiotics while preparing patient forsurgery

D Ascites.Aspirate only if there is respiratory compromise or pain,because this measure is only temporary (fluid will reaccumulate)

If fluid is removed too rapidly, hypovolemia and hypotension mayresult

1 Serous. Salt and fluid restriction, diuretics, and rarely, ifintractable, peritoneovenous shunting Definitive management

of transudative and exudative ascites requires treatment

of underlying condition (cirrhosis, constrictive pericarditis,peritonitis)

2 Biliary.Surgical drainage and alleviation of biliary obstruction

3 Urinary.Decompression and drainage of obstruction

4 Chylous.Reduce flow through obstructed or perforated phatic channels by withholding oral intake with TPN initially,then implement low-fat diet enhanced with medium-chaintriglycerides Surgery if no response

lym-E Constipation. Rectal irrigations followed by comprehensivebowel management program If Hirschsprung disease is suspected,order barium enema and rectal biopsy to confirm

F Masses.Enlarged intra-abdominal organs are treated by ing underlying condition Urinary obstruction is decompressed.Abnormal masses are resected

manag-VI Problem Case Diagnosis.The 8-month-old boy with abdominal tention had a history of delayed passage of meconium and infre-quent bowel movements He presented with respiratory distress andpoor perfusion and had a massively distended, tympanitic abdomen.Rectal exam yielded an explosive output of stool and gas withdecompression Contrast enema and rectal biopsy confirmedHirschsprung disease

dis-VII Teaching Pearl: Question.Why do infants who are born with genital obstruction of the intestine usually have no significantabdominal distention at the time of birth?

con-VIII Teaching Pearl: Answer.Before birth, the GI tract does not containair; thus, even with complete obstruction distention is rare Over24–48 hours, distention develops as air is swallowed, with thedegree of distention being proportional to how far down in the intes-tine the obstruction is located If an infant’s abdomen is distended atbirth, consider something other than simple mechanical obstruction(ie, meconium peritonitis or intra-abdominal fluid)

REFERENCES

Fischer AC Ascites In Mattei P, ed Surgical Directives: Pediatric Surgery Lippincott

Williams & Wilkins, 2003:505–510.

Jordan MR, Ziai M Abdominal masses In Ziai M, ed Bedside Pediatrics Little

II Immediate Questions

A How old is patient?Many conditions that cause abdominal painare age specific Necrotizing enterocolitis only occurs in earlyinfancy, midgut volvulus is most common in the first year, intus-susception is seen mostly in toddlers, appendicitis is rare in thenewborn and increases in frequency through adolescence, andmany gynecologic disorders are seen only in girls after puberty

B Where is the pain located?Gastroenteritis and most types offunctional abdominal pain are centrally located; pain of appendici-tis begins centrally and then migrates to the right lower quadrant;gallbladder and hepatic pain occurs in the right upper quadrantand may radiate to the back or right shoulder; pain from the stom-ach, duodenum, and pancreas occurs in the epigastrium; painfrom the small intestine is central; pain from the large intestineoccurs in the hypogastrium; pain from the spleen is felt in the leftupper quadrant and may radiate to the left shoulder; pain fromthe kidneys or ureters is often felt in the flank and may radiate to thegroin; and pain from the ovaries or fallopian tubes occurs in theipsilateral lower quadrant

C What is the quality of the pain?Visceral pain, produced by tention of a hollow organ or stretching of the capsule of a solidorgan, is colicky and dull (eg, intestinal obstruction, early appen-dicitis, ureteral calculus, hepatitis) Parietal pain involves inflam-mation of the peritoneum and is sharp, well localized, andexacerbated by movement (eg, appendicitis in its later stages,necrotic intestine, perforated viscus)

dis-D Duration of pain?Gastroenteritis and mesenteric adenitis startgradually and plateau over hours Appendicitis starts graduallyand classically increases in severity until perforation occurs.Urinary calculi, ovarian torsion, and ruptured ovarian cyst aresudden in onset and severe from the outset Pain of intussuscep-tion is intermittent over hours and sometimes days Functionalpain is most frequently chronic

E Has patient had this pain before?Functional abdominal pain ismost likely to be recurrent However, volvulus and even appen-dicitis may be self-limited on several occasions and then recurwith full-blown manifestations

2.ABDOMINAL PAIN 7

F Are there associated GI symptoms?Individuals with significantintra-abdominal pathology are rarely hungry Nausea, vomiting,and a change in bowel habits often accompany GI conditions such

as gastroenteritis, appendicitis, and intestinal obstruction Biliousvomiting is indicative of obstruction and possibly volvulus.Vomiting preceding pain is most characteristic of gastroenteritis.Copious diarrhea is typical with enteric infections, and severe con-stipation itself can be the cause of the pain

G Urinary symptoms?UTIs are associated with dysuria, frequency,and urgency; calculi may produce dysuria and hematuria

H Symptoms from other organ systems?Abdominal pain in dren is frequently a manifestation of extra-abdominal disease (eg,pharyngitis, otitis, pneumonia) Intussusception frequently follows

K Fever?With appendicitis, there is typically afebrile or low-gradefever until perforation; with viral conditions and peritonitis, temper-ature may be highly elevated

L Chronic systemic illnesses?Children with sickle cell diseasemay have abdominal pain from a crisis; those with diabetes canhave abdominal pain associated with ketoacidosis Leukemiamay produce typhlitis during periods of severe leukopenia.Inflammatory bowel disease can cause abdominal pain duringperiods of exacerbation

III Differential Diagnosis.Because both acute and chronic abdominalpain are extremely common in children, the challenge is to identifythe relatively few patients with significant medical and surgical ill-nesses that require treatment In a survey of children with acuteabdominal pain in the emergency department, 86% had self-limiteddisease and only 1% required surgical intervention Diagnostic prob-abilities are age dependent

A Patients Older Than 3 Years of Age

1 Appendicitis.The most common cause of abdominal pain thatrequires surgery in children older than age 2 years; prototype

of the so-called acute abdomen Early diagnosis is most tant, because perforation may occur 36–48 hours after onset

impor-2 Mesenteric lymphadenitis.Usually a diagnosis of exclusionwhen no other cause is found or a normal appendix is seenduring exploration for presumptive appendicitis Considered to

be viral in origin Pain is more generalized, with fewer toneal signs than in appendicitis Leukocyte count usually isnormal

5 Intestinal obstruction. Causes in older children includeMeckel diverticulum that twists or telescopes, and adhesionsfrom previous surgery.

6 Constipation.Frequent cause of acute or recurrent pain inchildren Usually functional but may be due to Hirschsprungdisease, an anteriorly displaced anus, defects of the spinalcord, or metabolic abnormalities (ie, hypokalemia, hypothy-roidism)

7 Inflammatory bowel disease.Ulcerative colitis or Crohn ease is frequently accompanied by pain; either condition mayalso give rise to toxic megacolon Crohn disease may appear

dis-as acute ileitis (10% of cdis-ases) and have a presentation similar

to appendicitis

8 Typhlitis.Occurs in immunosuppressed patients (eg, leukemia)when leukocytes < 1000/mm3 Involves terminal ileum and rightcolon and is probably infectious

9 Biliary colic, cholecystitis.Gallstones are most common inadolescent girls; may also occur in children with hemolytic ane-mias and those who have received long-standing TPN

10 UTI.Cystitis is usually associated with dysuria, frequency, andurgency; pyelonephritis with fever and flank tenderness

11 Urinary calculus.May produce excruciating “writhing” pain inflank or abdomen as well as hematuria

12 Ovarian cyst.Rare before puberty May produce pain when itbleeds, ruptures, or twists Torsion is a surgical emergency

13 PID.Salpingitis or tuboovarian abscess is common amongadolescent girls

14 Mittelschmerz.Ovulatory bleeding can cause peritoneal tation; occurs midway in cycle

irri-15 Ectopic pregnancy.

16 Primary peritonitis.May occur in normal children (especiallygirls 2–6 years of age) but is more common in patients withnephrotic syndrome or cirrhosis, or after splenectomy Bacterialinfection; probably hematogenous source

17 Other systemic illnesses.Abdominal pain may accompanyother acute and chronic conditions (eg, lower lobe pneumonia,hepatitis, Henoch-Schönlein purpura, hemolytic uremic syn-drome, sickle cell disease, porphyria, diabetes)

18 Recurrent abdominal pain (RAP).Occurs in 10% of children.Most cases are functional (ie, no structural or biochemical

asso-a Possible mechanisms Increased gastric acid, intestinalhyperactivity, spasm of abdominal wall muscles.

b Irritable bowel syndrome.This form of RAP occurs inolder children and adolescents and is characterized bypain with diarrhea or constipation Pain is often relieved bydefecation

B Patients Younger Than 3 Years of Age

1 Necrotizing enterocolitis. Inflammatory condition of theintestine Occurs almost exclusively in premature infants andcan progress to necrosis and perforation

2 Colic. Recurrent inconsolable crying during the first 3–4months in infants who are otherwise healthy Occurs mostly atnight Episodes are characterized by knees drawn up to theabdomen

3 Midgut volvulus.Associated with intestinal malrotation Mayoccur at any age but is most common during first year Patientmay present initially with bilious vomiting; early recognition iscrucial to prevent intestinal necrosis

4 Intussusception.Telescoping of one portion of the intestineinto another, usually ileocolic Most common in children aged

6 months to 2 years Usually idiopathic (ie, no pathologic leadpoint)

IV Database

A Physical Exam Key Points.Most patients can be diagnosed ically, without need for sophisticated tests Critical question is:Does patient require urgent surgery or can more leisurely evalua-tion take place? It is controversial whether analgesics will maskthe findings of abdominal disease Many surgeons maintain theycannot adequately assess patients who have received narcotics,although recent studies suggest otherwise A compromise may be

clin-to administer a single dose of analgesia if it is decided clin-to observepatient and then reassess when medication wears off If surgery

is definitely planned, pain relief may be provided

1 General appearance.Note overall appearance, how patientmoves about, and whether he or she “looks sick.” Writhing withintermittent crying and drawing the knees up suggests colickypain; lying still in fetal position is more indicative of peritonitis

2 Vital signs.Children with nonperforated appendicitis rarelyhave a high fever; significant fever suggests a viral syndrome

or peritonitis