Tia Dickson, RN, BSN

Primary Children's Hospital

Acute abdominal pain is a common cause for EMS calls. We see abdominal complaints hourly in the ER at Primary Children's Hospital. These cases can be frustrating for EMS providers as the generic complaint can have many causes. Some are no big deal; while others can be life threatening and time sensitive. The pediatric patient adds another challenge because they may not be great historians and their exam can be difficult to interpret.

Since there is no way to know what is really going on in the abdomen while in the field, treatment of abdominal pain is typically the same for each call. Follow your local protocols. Oxygen should be administered when appropriate and an IV should be established if it’s in your scope of practice. Treat the pain with pharmacological and non-pharmacological methods, and monitor the patient’s heart rhythm as abdominal pain can sometimes indicate cardiac problems. Administer Zofran if the patient is feeling nauseous. Routinely check vital signs and monitor for shock.

A basic understanding of abdominal anatomy, as well as the conditions that can result in abdominal pain will help you in caring for these children.

Joyce Soprano, MD

Medical Director, Emergency Department, Primary Children’s Hospital

Professor of Pediatrics, University of Utah School of Medicine

Abdominal pain is one of the most common complaints in children and often prompts urgent evaluation either in the office or emergency setting. The differential diagnosis is broad, but most causes of abdominal pain in children are mild and/or non-surgical, such as constipation, gastroenteritis, or an intercurrent illness such as urinary tract infection, pharyngitis, or viral syndrome. However, there are severe and/or life-threatening causes of abdominal pain in children that must be identified.

A careful history is critical in determining the cause of abdominal pain in children. Important features of the history include: patient’s age and gender; history of trauma; prior surgeries or congenital conditions; presence of fever, vomiting, or diarrhea; and characteristics of pain.

The character of the pain can be helpful in determining the etiology. Visceral pain is typically poorly localized or diffuse. Often the child will localize the pain to the periumbilical area. This is common in early appendicitis, intussusception, and gastroenteritis. In contrast, conditions that cause peritoneal irritation typically cause localized pain and increased pain with movement. This is common in advanced appendicitis and peritonitis.

A complete physical examination is essential in children with abdominal pain, with particular attention to signs of shock that may occur from blood or fluid loss, ischemic bowel, or sepsis. Fever suggests an infectious process. Pneumonia or metabolic acidosis may cause tachypnea. Bruising, including in areas other than the abdomen, may suggest trauma including child abuse. While the abdominal examination in young children can be challenging, attempts should be made to determine whether there is distension, tenderness, guarding, or a palpable mass.

Trauma – Solid and hollow organ injuries may occur from motor vehicle collisions, auto-pedestrian accidents, falls, sports injuries, and child abuse. In children two years of age or older with blunt torso trauma, any reported abdominal pain is associated with a 13% risk of intraabdominal injury. Isolated injury to the spleen is the most common solid organ injury, while small bowel injury, especially to the jejunum or ileum, is the most frequent hollow viscus injury. Clinical signs may include abdominal bruising (including seat belt sign or handle bar bruising), distension, tenderness, as well as vital sign instability. A seat belt sign is strongly associated with significant intraabdominal injury, including hollow viscus injuries.

Acute Appendicitis – Appendicitis is the most common indication for emergent abdominal surgery in childhood. It can be one of the most difficult diagnoses to make, especially in the young child who has a difficult time describing their pain. It presents most frequently in the second decade of life, and is more common in boys. The classic presentation of appendicitis is periumbilical abdominal pain that migrates to the right lower quadrant; associated peritoneal signs such as rebound tenderness; nausea, vomiting, and anorexia; and fever developing 24-48 hours after the onset of pain. That being said, there may be lack of migration of pain and lack of rebound tenderness in half of the patients. The most consistent clinical examination finding is localized tenderness in the right lower quadrant. The risk of perforation is related to age, with 50-100% of neonates and children younger than age five presenting with perforation.

Intussusception – Intussusception, the invagination of a part of the intestine into itself, is the most common cause of acute intestinal obstruction in infants. It typically occurs in children ages two months to two years, although can be seen in older children. It is more common in males. While the most common location is ileocolic, it can propagate through the colon as far as the rectum. The most common presentation is sudden onset of severe episodic colicky abdominal pain with inconsolable crying and drawing up of the legs. Other symptoms include bilious or non-bilious emesis, bloody or currant jelly appearing stool, and lethargy occurring between episodes of pain. The latter is more common in the younger patients. A sausage shaped mass may be felt in the right mid-abdomen. Intussusception may be preceded by viral gastroenteritis or URI symptoms in one third of the cases.

Malrotation with Midgut Volvulus – This is one of the most serious causes of acute abdominal pain and vomiting in infants. Malrotation of the bowel is a congenital condition associated with abnormal fixation of the mesentery resulting in a tendency to twist and obstruct at the points of abnormal fixation. Complete volvulus of the bowel for more than an hour or two can totally obstruct blood supply to the bowel leading to complete necrosis of the involved segment. The entire small bowel and ascending colon can be lost. One third to one half of children with malrotation present with volvulus in the first month of life. Common symptoms include: constant pain, bilious or non-bilious vomiting in 90% of patients, abdominal distension; and tenderness, peritonitis, and shock. Older children may present with chronic episodic vomiting and abdominal pain over weeks to years.

Hirschsprung Disease – Hirschsprung disease results from the absence of parasympathetic ganglion cells between the circular and longitudinal muscle layers of the colon, resulting in spasm and abnormal motility for that segment of bowel. Children can have complete obstruction or chronic constipation. There is a male predominance of up to four times. While most patients are diagnosed during the neonatal period with delayed passage of meconium, abdominal distention and bilious emesis, up to 10% of patient are diagnosed after the age of three.

There are many common causes of abdominal pain in children that are not life-threatening. Constipation causes colicky abdominal pain that can be quite severe. Typically, there is a history of infrequent stooling, retentive behaviors, fecal incontinence, and painful defecation. You can often palpate a stool mass in the lower abdomen and/or rectum. Gastrointestinal infections, both viral and bacterial, may cause severe cramping pain, with or without non-bilious vomiting, fever, and diarrhea. Urinary tract infections typically present with abdominal pain and fever, with or without vomiting, in children younger than the age of five. Streptococcal pharyngitis often causes abdominal pain and fever. Some children will even experience a sore throat, and often the pharyngitis is non-exudative. Pneumonia, especially in the lower lobes, may cause abdominal pain, fever, and vomiting. While many children will have cough, tachypnea, and abnormal breath sounds, abdominal pain can be the only presenting symptom.

While the list of less common causes of abdominal pain in children is long, there are a few other diagnoses worth mentioning. Testicular and ovarian torsion both may present with abdominal pain and vomiting, and are surgical emergencies. Testicular torsion presents with a tender, swollen testicle that may be elevated and lying horizontally, with an absent cremasteric reflex. Since the abdominal pain may be referred from the scrotum, all males with abdominal pain must have a genitourinary examination performed. Ovarian torsion typically develops as a result of an ovarian mass or cyst. Pain is severe and colicky, though may be intermittent. While ovarian torsion is more common in postmenarchal females, it can occur at any age. Henoch-Schonlein purpura is a vasculitis that affects small vessels. Typically, patients present with a classic rash of palpable purpura in the lower extremities and buttock. Involvement of the small vessels of the intestines can result in abdominal pain which may be from ileo-ileal intussusception. Finally, diabetic ketoacidosis (DKA) can present with abdominal pain and vomiting, along with the other common signs of polyuria, polyphagia, weight loss, and Kussmaul breathing.

References:

1. Aboagye J, et al. Age at presentation of common pediatric surgical conditions: Reexamining dogma. J Pediatr Surg. 2014 Jun;49(6):995-9.

2. Adelgais KM, et al. Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr. 2014 Dec;165(6):1230-1235.e5.

3. Colvin JM, et al. The presentation of appendicitis in preadolescent children. Pediatr Emerg Care. 2007 Dec;23(12):849-55.

4. D’Agostino J. Common abdominal emergencies in children. Emerg Med Clin North Am. 2002;20(1):139.

5. Loening-Baucke V, et al. Constipation as a cause of acute abdominal pain in children. J Pediatr 2007;151:666.

6. Lutz N, et al. Incidence and clinical significance of abdominal wall bruising in restrained children involved in motor vehicle crashes. J Pediatr Surg. 2004;39(6):972.

7. Mandeville K, et al. Intussusception: clinical presentations and imaging characteristics. Pediatr Emerg Care. 2012 Sep;28(9):842-4.

8. Reynolds SL. Diagnosing abdominal pain in a pediatric emergency department. Pediatr Emerg Care. 1992;8(3):126.

9. Rothrock SG, Pagane J. Acute appendicitis in children: emergency diagnosis and management. Ann Emerg Med. 2000;36(1):39.

We have a new program manager!

Mark Herrera, NRP, FP-C

markherrera@utah.gov

”Hi. My name is Mark Herrera and I am the new EMSC Program Manager. I have been employed with the state of Utah since 2019. Before coming to state employment, I worked full time as a paramedic in a rural community for 10 years. I am excited to fill this position as EMSC Program Manager as I have a passion for emergency medicine. More specifically, on improving the quality of emergency care for children.”

Safe Haven, what does it mean for you?

Utah Newborn Safe Haven team has developed a training specific to the law and how it works with EMS. When EMS is called to a scene, or may be approached at a station with the newborn, or may be assisting a mother with delivery who expresses her wishes to surrender the child. we encourage you all to check it out!

The Handtevy App Purchase is almost complete

How Does my agency get this app for free?

EMSC sent out a letter to all EMS agency leadership detailing our plan to distribute the Handtevy Mobile app throughout the state. The letter requested a response. It is not too late! Our timeline for implementation is early 2021. Encourage your agency leadership to respond. Contact our program manager MarkHerrera@utah.gov if you need another copy of the letter.

Want more information?

• Our January 11 PETOS topic was Handtevy. Those in attendance had an opportunity to use the demo and practice with the app.
• In September 2020, Dr. Peter Antevy and EMSC held a virtual demo to introduce the app. Follow this link https://register.gotowebinar.com/recording/4248070236387080459

Utah RSV and pediatric flu cases plummet to unprecedented levels

Two diseases that normally result in many pediatric hospitalizations have been almost nonexistent this winter. Primary Children’s Hospital caregivers had been concerned that a winter respiratory syncytial virus (RSV) and flu surge on top of COVID-19 cases could stretch hospital resources to the brink. Instead, there have been enough resources to treat children with COVID-19 and its related serious complication, multi-system inflammatory syndrome in children (MIS-C).
The safety measures people are taking during the COVID-19 pandemic can explain some, but not all, of the anomaly, says Andrew Pavia, MD, chief of pediatric infectious disease at University of Utah Health and director of epidemiology at Primary Children’s Hospital. One theory for the flu is that there were so few cases during the Southern Hemisphere winter, and travel restrictions were in place, so the flu couldn’t really carry over from that region of the world. RSV, on the other hand, is “somewhat more perplexing,” he says.
“One thing seems to be clear from the experience of the winter of 2020–2021; We can decrease the impact of influenza on infants and children with better handwashing, mask use, and limiting their exposure to others,” Dr. Pavia says. “Whether and how we’ll change our winter behavior enough in the future to reduce the impact of RSV and flu is yet another mystery.”

People 16 years or older with any of the following medical conditions are now eligible for the COVID-19 vaccine:

• Asplenia including splenectomy or a spleen dysfunction
• Body Mass Index (BMI) of 40 or higher (this is also called Class III or severe obesity)
• Chronic heart disease (not hypertension) including chronic heart failure, ischaemic heart disease, and severe valve or congenital heart disease
• Chronic liver disease including chronic hepatitis B or C, alcohol-related liver disease, primary biliary cirrhosis, or primary sclerosing cholangitis or hemochromatosis
• Cancer diagnosed within the last 5 years that began in the blood, bone marrow, or cells in the immune system. This type of cancer is called hematologic cancer (such as leukemia, lymphoma, and multiple myeloma).
• Cancer diagnosed within the last 1 year that didn’t begin in the blood or bone marrow. This type of cancer is called non-hematologic cancer (excluding basal and squamous cell cancer diagnoses).
• Immunocompromised state (weakened immune system) from blood, bone marrow, or organ transplant; HIV; long-term use of corticosteroids; or other medicines that weaken the immune system
• Neurologic conditions that impair respiratory function, including cerebral palsy, Down syndrome, epilepsy, motor neuron disease, multiple sclerosis, myasthenia gravis, Parkinson’s disease, progressive cerebellar disease, and quadriplegia or hemiplegia
• Receiving dialysis for severe kidney disease
• Receiving immunosuppression therapy
• Sickle cell disease
• Severe chronic respiratory disease (other than asthma) including severe chronic obstructive pulmonary disease, fibrosing lung disease, bronchiectasis, or cystic fibrosis
• Solid organ transplant recipient
• Stage 4 or stage 5 chronic kidney disease
• Stroke and dementia (Alzheimer’s, vascular, or frontotemporal)
• Uncontrolled diabetes with an A1c of 9% or higher

The vaccine for younger kids

Vaccine studies on children's ages 12-17 should finish by the end of June. They will then submit results to the Food and Drug Administration (FDA) which may approve the vaccines for teens by fall for distribution in late 2021 per Dr. Andrew Pavia, chief of pediatric infectious disease at University of Utah Health. Nationally, Dr. Anthony Fauci predicted a sooner time frame of late spring or summer. Currently there are no trials underway for children 0-11 years.

Covid-19 Trackers

Johns Hopkins Global tracker (desktop)

Johns Hopkins Global tracker (mobile)

Utah Department of Health

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the following address tdickson@utah.gov.

Contact PCH EMS Liasion Lynsey Cooper at Lynsey.Cooper@imail.org

If you are a pediatric advocate within your agency, we need you. Please contact our program manager, Mark Herrera (markherrera@utah.gov) to find out how you can help.

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($18.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth