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
Appendicitis: High Probability
Classic features of appendicitis
Appendicitis: Equivocal
Some features of appendicitis
Males, Pre-Pubertal Females
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
  • Consider alternative diagnoses
  • Review lab results
  • Review PAS, pARC  
  • Consider MR based on risk
  • Consider US Pelvis with Doppler
  • Surgical Consult as indicated
  • 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
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