What is the sex?
IV antibiotics for a minimum of 72 hours
Reassessment
≥ Post-Op day #3
Meet discharge criteria?
Daily reassessment
Continue IV antibiotics daily reassessment until failure after post-op day #7
Abnormal serum WBC?
BMI > 85th percentile?
High risk for appendicitis pediatric patients still may benefit from imaging
Clinical assessment of the likelihood of appendicitis (PAS/AS or labs not required). Clinical prediction scores for appendicitis are equivalent to an experienced (surgical or ED) physician's clinical impression.
Recent antibiotics?
Treat appropriately
Surgery consultation
Treat appropriately
Contact a surgical specialist. If excluded for pregnancy, consider MRI appy.
Severe pain?
What is the sex?
Severe penicillin or cephalosporin allergy?
Septic or immunocompromised?
Urinalysis, urine pregnancy and gonorrhea/chlamydia testing and pelvic exam in appropriate menstrual age females
For patients > 9 months
Continued clinical concern for appendicitis?
Meets discharge criteria?
Perforation, gangrene, abscess or supperative/purulent findings?
Discharge
Meets discharge criteria?
Discharge, follow up with PMD within 24 hours
Patients with perforated appendicitis or abscesses DO NOT need different antibiotics from uncomplicated appendicitis.
Pediatric Appendicitis Score (PAS) | Alvarado Score (AS) | ||||
Nausea/Vomiting | 1 | 1 | |||
Anorexia | 1 | 1 | |||
Fever | 1 | Temperature ≥ 37.3 C (99.1 F) | 1 | ||
RLQ tenderness | 2 | 2 | |||
Migration of pain to RLQ | 1 | 1 | |||
Cough, percussion or hopping tenderness | 2 | Rebound tenderness | 1 | ||
Leucocytosis (WBC > 10k) | 1 | 2 | |||
Neutrophilia (ANC > 7,500) | 1 | 1 |
Uncomplicated appendicitis
Contraindications to ketorolac
White blood cell count (WBC)
Absolute neutrophil count (ANC)
C-reactive protein (CRP)
Procalcitonin
Urinalysis
Complicated appendicitis
Daily reassessment
Discharge, follow up with PMD within 24 hours
Discharge criteria
Non-diagnostic US with no secondary signs of appendicitis
Operating room
Discharge criteria
1 or more sign of poor hydration:
IV morphine, intranasal fentanyl or intranasal ketamine
Operating room