Emergency Department Clinical Pathway for Evaluation/Treatment
of Children with Suspected Appendicitis
- Reassuring H&P
- Able to tolerate PO
- Alternative diagnosis probable
- Labs as indicated
- Treat as clinically indicated
- Discharge, follow-up
- FLOC/RN Team Assessment
- History & Physical Examination
- Review
Appendicitis: High Probability
Classic features of appendicitis
Classic features of appendicitis
Appendicitis: Equivocal
Some features of appendicitis
Some features of appendicitis
Males, Pre-Pubertal Females
- Consider Laboratory Studies
- CBC, CRP, UA POC, BMP
- IVF, analgesia as indicated
Post-Pubertal Females
- Consider Laboratory Studies
- CBC, CRP, BMP, serum HCG, UA POC
- NPO, IVF, analgesia as indicated
- Instruct child not to urinate
- Consider STI testing
- Obtain Laboratory Studies
- CBC, CRP, UA POC, BMP
- Urine HCG as clinically indicated
- NPO, IVF, analgesia as indicated
- Obtain RLQ Ultrasound
- For weight >100 kg, MRI Appy instead
- Consider US Pelvis with Doppler for post-pubertal females,
- but do not delay RLQ US
Appendicitis
Appendix not Seen
Appendix Normal
- Consult General Surgery
- IV Antibiotics
- Restore intravascular volume
- NS bolus, maintenance fluids
Disposition
OR/PACU
Admit
Most children with non-perforated appendicitis don't require admission following surgery and go home same day
Secondary Signs
No Secondary Signs
- Reassess PE, PO challenge
- Consider alternative diagnosis
- Further evaluation as indicated
MRI Appendix
Positive
- Concern for ovarian pathology continue with bladder filling and add US Pelvis with Doppler
Disposition
Discharge
Instructions for f/u in 24 hrs
if symptoms progress
if symptoms progress
Admit
As indicated
Pre-Operative Antibiotics for All Children with Appendicitis
Healthy, Non-allergic Children
Ceftriaxone + Metronidazole
Cephalosporin Allergy
Ciprofloxacin + Metronidazole
Ill-appearing, Immunocompromised, or Recent Hospitalization > 4 days
Piperacillin-tazobactam
Consult ID