Abdominal Pain: To Be Seen Or Not To Be Seen. Andrew Hertz, MD Medical Director, Rainbow Call Center March 2015

Transcription

1 Abdominal Pain: To Be Seen Or Not To Be Seen Andrew Hertz, MD Medical Director, Rainbow Call Center March

2 Disclaimer I receive royalties from the American Academy of Pediatrics for the book I authored, Pediatric Nurse Telephone Triage. Views expressed are mine, inherent with my experience and biases.

3 Objectives 1. Identify key considerations in the evaluation of children with abdominal pain and/or vomiting. 2. Identify circumstances for which children with abdominal pain and vomiting should be seen urgently or emergently. 3. Identify reasons for over referral for urgent evaluation for children with abdominal pain and vomiting. 3

4 Agenda Abdominal pain overview Chart audit lessons learned Vomiting overview 4

5 2014 Top Guidelines 5

6 Top Referral Guidelines (911, Go to ED, Call PCP, See in 4) 6

7 What is Over Referral?

8 Third Level Triage = Send In All guidelines avg % Abdominal Pain (male and female) Guideline Disposition Percentage 2013 Go to ED See in 4 Total Abdominal Pain (all) 19.63% 15.32% 34.95% Guideline Disposition Percentage 2012 Go to ED See in 4 Total Abdominal Pain (all) 20.26% 15.44% 35.78% 8

9 What is Appropriate? Pediatric Call Center ED / Call PCP Now See 4 Hr Total A 46.7% 14.5% 61.2% B 42.8% 11.7% 54.5% C 37.7% 14.2% 51.9% D 19.6% 15.3% 34.9% What is Under Referral? 9

10 Why so high?

11 Causes of Abdominal Pain Organ System Illness Usual Associated Signs and Symptoms Gastrointestinal Gastroenteritis Vomiting, diarrhea or both are predominant symptom, vomiting is non-bilious Appendicitis Pain begins central, becomes localized to right lower quadrant, loss of appetite, pain worse with any movement Constipation Infrequent, painful bowel movements Intusussusception Intermittent severe pain, may be associated with mental status change, may have bloody stool Hepatitis Pain, vomiting, dark urine, scleral jaundice Pancreatitis Severe pain, radiates through body, vomiting, worse with anything PO Malrotation, Recurrent bilious emesis, persistent pain, though Volvulus Gastritis, Esophagitis Henoch- Schönlein Purpura Trauma can be intermittent Vague upper abdominal pain, waxes and wanes with food (may be better or worse with eating depending on location of irritation) Non-localized abdominal pain, rash usually on back of legs and buttocks (purpuric) History of trauma 11

12 Causes of Abdominal Pain Urinary Tract Cystitis and Pyelonephritis Kidney Stones Lower abdominal pain, flank or back pain, urinary symptoms (dysuria, frequency, incontinence) Severe constant or intermittent pain, radiates from back down into groin, may have gross blood in urine Lungs Pneumonia Often with cough, but not necessarily Female Reproductive Pelvic Inflammatory Dz Worse pain with walking or movement, fever, recent menses Ovarian Cyst Localized to one side Ovarian Torsion Localized to one side Dysmenorrhea Cramping, associated with menses onset Ectopic Localized to one side, persistent pain Pregnancy Pharynx Strep Pharyngitis Sore throat Ingestions History of ingestion iron pills, prenatal vitamins, lead paint chips, foreign body, other Functional / No identifiable cause, may be recurrent at Psychogenic / specific time of day, physical location, or Anxiety situation 12

13 Review of Calls 120 charts reviewed (60 male, 60 female) 113 completed (omitted over 18, double guideline, wrong guideline) 54 Male 59 Female Average age 7.7 years 13

14 Dispositions 14

15 Dispositions 15

16 Review of Calls See in % Go to ED Now % TOTAL % Over referral per documentation - See in % Over referral per documentation - Go to ED % TOTAL % All 5 because pain was not constant per documentation 1 - sounds weak to triager, 1 not c/w intussecption Of note - 2 sent to ED w/appropriate documentation on 1st day of z-max (age 3 and 11 yrs.) 16

17 ED Now: Reason for Dispo 17

18 See in 4: Reason for Dispo 18

19 Why so High - Rainbow? Pattern Severity Intussusception worry Appendicitis worry Medications Bias 19

20 Bias We all have it Wellness bias Illness bias Learn to ignore it Rely on your wonderful nursing assessment skills 20

21 Pain Severity Mild (1-4) no interference with activity Easy to console Eating, drinking, sleeping, active Moderate (5-7) interferes with activity or awakens Wants to be held, comforted Interferes with sleep, not playing Severe (8-10)- unable to do activity, prefers not to move Holds abdomen, doesn t want to walk, walks bent over 21

22 Intermittent Pattern Comes and goes, resolves between episodes (but after vomiting or cramping the abdominal muscles may be sore, ask about activity between, walking etc.) If pain drops down to mild between episodes consider intermittent Constant Constant is constant, does not resolve or improve to mild. Interferes with activities (can be constant mild, but that should be managed in the office always) 22

23 Intussusception Telescoping of one part of intestine into another Most under 2 yrs (can be up to 6 yrs) Hallmark is intermittent sx 23

24 Intussusception Intermittent severe pain (resolves between) Can be associated with intermittent mental status change (lethargy), but rare Usually with vomiting early on No watery diarrhea (may have bloody BM) Can have severe consequences with intestinal necrosis 24

25 Azithromycin Abdominal pain is a relatively common side effect Seen in 1.9 7% of adults and 1.2 4% of children Dose dependent (first day is twice the dose) Some 1 and 3 day dosing regimens exist 25

26 Appendicitis Begins as mild, vague, periumbilical pain Pain moves to RLQ as it intensifies May develop fever and vomiting Prefers not to move Peritoneal signs pain worse with movement and jumping 26

27 Appendicitis vs Gastroenteritis Sign or Symptom Appendicitis Gastroenteritis Fever Possible, later Variable Periumibilical pain Early Common Localized, RLQ, pain Present Absent Vomiting Possible, later Variable, if occurs early in illness, then improves Diarrhea Absent Present Pattern Constant, progressive Intermittent, colicy Others with illness None Possible 27

28 Reassuring Signs/Symptoms No fever No vomiting Generalized periumbilical pain (non-specific) Intermittent Mild pain Normal to mildly reduced activity Eating 28

29 Concerning Signs/Symptoms Severe localized abdominal pain, esp RLQ Persistent pain for more than 2 hours, worsening pain Refusal to walk, pain worsens with movement Loss of appetite Fever Persistent vomiting associated with decreased urination (especially if the emesis is bilious - green) Blood in stool Rash, especially if on legs and/or buttocks 29

30 Study 3 months later Abdominal Pain ED / Call PCP Now See in 4 Total July - December % 15.3% 34.9% Intervention in January 2014 Feb-March % 13.8% 25.5% % Change -40% -10% -27% What next? 30

31 Vomiting Dispo Variability Vomiting w/diarrhea ED / Call PCP Now See 4 Hr Total A 20.0% 4.8% 24.8% B 27.6% 10.0% 37.6% C 13.5% 7.0% 20.5% D 8.7% 5.6% 14.3% Vomitting w/o Diarrhea ED / Call PCP Now See 4 Hr Total A 18.0% 4.9% 22.9% B 23.7% 6.8% 30.5% C 14.8% 6.3% 21.1% D 8.0% 6.2% 14.2% 31

32 Vomiting The forceful expulsion of gastric (sometimes small intestine) contents through the mouth accompanied by vigorous contraction of the abdominal muscles. 32

33 Common Causes of Vomiting CNS Pharynx Inner Ear Upper GI Intracranial pressure - bleed, infection, tumor, hydrocephalus Trauma - Concussion Migraine Gag reflex gagging, post-tussive, strep throat, self-induced Vestibular motion sickness, viral infection Reflux disease, peptic ulcer disease GI Obstruction Pyloric stenosis, volvulus, intussusception Intestinal Metabolic Renal Gyn Infection - viral, bacterial, parasitic, toxin (food poisoning) Appendicitis, Food allergy/intolerance Drugs, Metabolic abnormalities DKA, inborn errors of metabolism UTI, Stones Pregnancy, ovarian, menses 33

34 What is NOT Vomiting Spitting Post-tussive emesis (not really) Coughing up phlegm What is a vomiting episode Each series not each heave PLUS Don t worry about a single episode 34

35 Vomiting vs Spitting Spitting Care free Food color No discomfort (usually) Vomiting Forceful, abd muscles, disconcerting Food color, yellow, green, red Uncomfortable 35

36 Vomiting Red Flags Hydration Activity mental status Head Trauma Green bile Red blood Constant abdominal pain 36

37 What is Diarrhea More frequent than baseline More loose than baseline Usually 3 or more a day NOT one loose watery stool 37

38 Diarrhea Red Flags Dehydration Blood Constant abdominal pain 38

39 Glad I could help, call back anytime!

40 Thank You!