CHICAGO — In these days of evidence-based medicine, the art of the medical profession may sometimes get lost in the science. But keeping a few simple tricks up one's sleeve can often save valuable time for children with acute problems, Dr. Robert A. Wiebe said at a meeting sponsored by the American College of Emergency Physicians.
Appendicitis
Dr. Wiebe, director of emergency services at Children's Medical Center in Dallas, gave an example of acute appendicitis: painful, potentially life threatening, and yet often vague in its presentation. “Looking at the current perforation rate, we are not doing a good job at identifying these kids early.”
Despite the availability and the evidence supporting computed tomography and ultrasound for diagnosing this condition, he advocates a simpler approach.
Watching a patient's eyes during physical examination can reveal a great deal, said Dr. Wiebe, professor of pediatrics in the division of pediatric emergency medicine at University of Texas Southwestern Medical Center at Dallas. He cited an 18-year-old journal article that changed his approach when he first read it (BMJ 1988;297:837). The authors noted that among patients found to have appendicitis, only 4% closed their eyes on physical examination, compared with 33% who did not have appendicitis. “Voluntary guarding occurs when the patient sees the doctor's hand near a tender area,” Dr. Wiebe explained. In contrast, “a patient aware that there is no pain may consciously or unconsciously close [his or her] eyes during the exam.”
Sudden movements also offer valuable insight in cases of suspected appendicitis, he added. “Pain with sudden movement has good specificity for this.” Asking the patient and parents about pain on the car ride to the hospital is one way to assess this. In addition, asking the patient to reach up and do a “high five” or to hop off the examining table is another way. According to the American Pediatric Surgical Association, “holding a hand above the child's head and challenging him or her to jump and touch is irresistible to most children except those in whom pain is produced,” he noted.
Bacterial Meningitis
Pain on movement also is a telltale sign in infants with suspected bacterial meningitis, he said. “It's not unusual to go quite some time, maybe even through an entire residency program, before seeing a case of bacterial meningitis these days,” he said. “When a case comes in, it's hard to recognize, and unfortunately it will likely be in a younger child who has not yet been immunized.”
He advocates the “bounce test”—bouncing the infant fairly vigorously on one's knee—as a good screening tool. Children with bacterial meningitis will cry and arch their backs to protect the sensory nerve while you are bouncing them. “For viral meningitis, this is less reliable,” he said. “This test has high sensitivity and very low specificity.”
Retropharyngeal Abscess
“Bolte's sign” is another simple, fast screen—this time for retropharyngeal abscess, said Dr. Wiebe. First described in 2003, it is based on the simple fact that “kids won't look up when their retropharyngeal space is filled with pus” (Pediatrics 2003;111:1394–8). The study of 64 patients, median age 36 months, found that 45% demonstrated limited neck extension on physical examination, 36.5% had torticollis, 12.5% had limited neck flexion, 1.5% had stridor, and 1.5% had wheezing. “Think [retropharyngeal abscess] when a child will not fully extend his neck to look up,” he advised.
Hypertrophic Pyloric Stenosis
He recommends removing the baby's shirt and feeding between 2 and 4 ounces of Pedialyte while keeping one hand on the baby's abdomen. “The baby will usually stop feeding and look very calm for a short period before you see the reverse peristaltic wave and projectile vomiting,” he said. Immediately after the vomiting, the abdominal wall relaxes and the pylorus remains in spasm, making it easy to palpate.
Most surgeons will usually require an ultrasound confirmation. However, starting with this approach usually saves some time. “We have been diagnosing infants earlier. It is usually a 4-week diagnosis rather than a 6-week one.”?