TABLE 116.2 PEDIATRIC APPENDICITIS SCORE Clinical finding Point Anorexia Nausea or emesis Migration of pain Fever >38°C Pain with cough, percussion, or hopping Right lower quadrant tenderness White blood cell count >10,000/mm3 Absolute band count >7,500/mm3 Total 1 1 2 1 10 At this time, nonperforated pediatric appendicitis primarily is managed surgically although there are ongoing trials of nonoperative treatment with antibiotics for selective cases of early, uncomplicated appendicitis The preoperative preparation of a patient with acute appendicitis should include electrolytes if the patient has been vomiting or has had poor fluid intake for more than a few hours IV fluids should be started with the goal of rapid intravascular expansion and then correction of further fluid deficits Protracted GI losses, as with vomiting, may lead to potassium depletion Initial fluids should include a bolus of isotonic fluid (20 cc/kg), then changed to D5–0.5NS with 10 to 20 mEq/L of potassium These fluids can then be altered, if necessary, once the serum chemistries are known Antibiotics should be administered as soon as the appendicitis is confirmed by imaging or sooner if there are signs of critical illness or peritonitis The emergency physician must keep in mind the many variations in the way appendicitis can present Patients with equivocal findings should be admitted for monitoring and serial examinations or have imaging studies to demonstrate a normal appendix If the imaging studies are equivocal, the surgeon will decide to operate or continue to monitor Patients who have a typical history for appendicitis but suddenly have diminished pain may actually have undergone perforation of the appendix Such patients should be observed for several hours before declaring an improved condition Even in the presence of negative imaging studies, the emergency physician should arrange close follow-up for any patient with abdominal pain For those patients with progressive pain, significant pain requiring narcotic medications, or persistent emesis, admission for further care and subsequent evaluation might be necessary PERFORATED APPENDICITIS Goals of Treatment When a perforated appendicitis is suspected, surgical consultation should be obtained promptly and adjusted for the stability of the patient Early restoration of intravascular volume, correction of electrolyte derangements, pain control, and antibiotics are essential parts of early care In collaboration with surgery colleagues, decisions about which patients need immediate operative care versus advanced imaging can be discussed When an abscess is identified, the surgeons will determine the need for a drainage procedure in addition to antibiotic therapy prior to a delayed appendectomy Short-term treatment outcomes include clearance of the intraperitoneal infection while limiting the duration of hospitalization and the need for repeated imaging or drainage procedures Clinical Considerations Clinical Recognition Ideally, once the diagnosis of appendicitis is considered, the patient will proceed with an efficient evaluation to establish the diagnosis and then definitive care before perforation Unfortunately, some patients, particularly younger children, may arrive for emergency care with an already perforated appendix because of a delay in seeking treatment or in making the diagnosis Although the time to perforation is variable, the time prior to ED presentation is a more important determinant of perforation than the time of evaluation in the ED Once the appendix has perforated, there may be signs of generalized, rather than localized, peritonitis In a young child, the omentum is thin and often incapable of walling off the inflamed appendix As a result, perforation leads to a more disseminated infection Although the mortality from appendicitis has decreased over the last several decades, the incidence of perforation in children has remained the same Clinical Assessment Within a few hours after perforation has occurred, the child begins to develop increasing signs of peritonitis and toxicity First, the lower abdomen and then the entire abdomen become rigid with extreme tenderness Bowel sounds are sparse to absent Other signs include pallor, dyspnea, grunting, significant tachycardia, and higher fever (39° to 41°C [102.2° to 105.8°F]) Rarely, the patient may develop septic shock from the overwhelming infection FIGURE 116.2 Appendicitis Longitudinal (A ) and transverse (B ) images of the appendix demonstrate thickening of the wall (arrows ) consistent with appendicitis C, D : Longitudinal images of two different patients with a dilated, inflamed appendix, with a thickened wall and dilatation of the appendiceal lumen E : Longitudinal image of an inflamed appendix containing an echogenic appendicolith (arrows ) F : Longitudinal image demonstrates hyperemia within an inflamed appendix consistent with appendicitis (A–D, F, Reprinted with permission from Kawamura D, Nolan T Abdomen and Superficial Structures 4th ed Philadelphia, PA: Wolters Kluwer Health; 2017.) ...The emergency physician must keep in mind the many variations in the way appendicitis can present Patients... hours before declaring an improved condition Even in the presence of negative imaging studies, the emergency physician should arrange close follow-up for any patient with abdominal pain For those... before perforation Unfortunately, some patients, particularly younger children, may arrive for emergency care with an already perforated appendix because of a delay in seeking treatment or in