Baracco R et al. Pediatric Hypertensive Emergencies. Curr Hypertens Rep. 2014; 16:456.

Belsha CW. Pediatric Hypertension in the Emergency Department. Ann Emerg Med. 2008; 51(3):21-24.

Chandar J et al. Hypertensive crisis in children. Pediatr Nephrol. 2012; 27:741-751.

Dionne JM et al. Hypertension Canada’s 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension. Canadian J Cardiol. 2017; 33:577-585

*Flynn JT, Kaelber DC, Baker-Smith CM, et al; SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017; 140(3):e20171904

Gilhotra Y et al. Blood pressure measurements on children in the emergency department. Emergency Medicine Australasia. 2006; 18:148-154.

Lurbe E et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016; 34:1-35.

Patel NH et al. Evaluation and management of pediatric hypertensive crises: hypertensive urgency and hypertensive emergencies. Open Access Emergency Medicine. 2012; 4:85-92.

Yang WC et al. Clinical Analysis of Hypertension in Children Admitted to the Emergency Department. Pediatr Neonatol. 2010; 1:44-51.

Adapted from: Constantine E. Hypertension. In: Textbook of Pediatric Emergency Medicine, 6th Ed. Fleischer GR, Ludwig S, Henretig FM (Eds). Lippincott, Williams & Wilkins, Philadelphia. 2010; p315.

This post and podcast are dedicated to Manpreet 'Manny' Singh for his collegiality, collaboration, and overall awesomeness. 

[Details in Audio]

This post and podcast are dedicated to Henry Goldstein, B.Pharm, MBBS for his tireless dedication to all things #FOAMed, #FOAMped, and #MedEd.  You are awesome.  Make sure to visit Don't Forget the Bubbles!

References

Cohen GM, Albertini LW. Colic. Pediatr Rev. 2012; 33(7):332-3.

Friedman SB et al. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009; 123(3):841-8

Herman M, Le A. The crying infant. Emerg Med Clin North Am. 2007 Nov;25(4):1137-59.

Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics. 1991; 88 (3): 450-5.

Prentiss KA, Dorfman DH. Pediatric Opthalmology in the Emergency Department. Emerg. Med. Clin. N. Am. 2008; 26: 181-198.

Shope TR, Rieg TS, Kathiria NN. Corneal abrasions in young infants. Pediatrics. 2010 Mar;125(3):e565-9. Epub 2010 Feb 8.

This post and podcast are dedicated to Mads Astvad for sharing his enthusiasm, clinical excellence, and #FOAMed warrior spirit.

Tak, min ven!  #SMACConia #Vikingeblod

There is none.  The presentation varies so much, we need a rule to live by:

Unilateral pelvic pain in a girl is ovarian torsion until proven otherwise.  This includes the cases in which you are concerned about appendicitis.  They both can be fake-outs.

Often the pain is severe and abrupt, but trying to tease this out is often not fruitful.

Here are the often-reported signs and symptoms associated with ovarian torsion:

Stabbing pain, 70%

Nausea and vomiting, 70%

Sudden, sharp pain in the lower abdomen, 59%

Pain radiating to the back, flank, or groin, 51%

Peritoneal signs, 3%

Fever, less than 2%

And of course…no pain on presentation…30%...intermittent torsion.

1. Structurally abnormal ovary (including cysts) that causes the ovary to flop over and twist on its vascular axis
2. Hypermobile ovary with vigorous movement twists on its vascular pedicle and cuts off blood supply

1. The enlarged hyper or hypoechoic ovary from generalized edema
2. Peripherally displaced follicles with hyperechoic central stroma – this is called the string of pearls sign, because the stroma is edematous, leaving the follicles to stand out
3. A midline ovary – if the ovary magically makes it to midline, something is up
4. Free fluid in the pelvis – this is seen in the vast majority of cases

As far as Doppler flow goes, you may see one of several scenarios:

1. Little or no venous flow – this is very common, as we talked about, because the low pressure venous system is the first to take a hit in torsion
2. Totally absent arterial flow – this is not as common, but totally diagnostic
3. There may be no flow in diastole, or the flow may even be reversed. Rememver the red and blue of dopple does not correspond to arterial and venous.  Doppler is a vector.  Red is fluid coming towards the probe, blue is programmed to present flow away from the probe.  If you have just one or the other, then by definition there is a problem with the vascular circuit.

Other things you may see on ultrasound include focal tenderness with the probe, or the whirlpool sign – this is a twisted vascular pedicle.  

In children, is there an ovarian size (volume) that rules out torsion?”

In the Journal of Pediatric Radiology, Servaes et al catalogued the ultrasound findings in children with surgically confirmed torsion over a 12 year period.  In this case series of 41 patients, the median age was 11.  The age range was one month old to 21 years of age.  They found that in torsed ovaries, the ovarian volume was 12 x that compared to the normal, non-torsed contralateral ovary.

That is to say, in this case series all torsed ovaries were larger than the normal contralateral ovary.

Sudden unilateral lower abdominal or pelvic pain in a female? Think torsion.

Have a low threshold for investigation.

Know the performance characteristics of ultrasound findings and involve a gynecologist early.

This post and podcast are dedicated to Stephanie Doniger, MD for her enthusiasm, spirit, and expertise in #MedEd #FOAMed #FOAMped #POCUS 

Abe M, Sarihan H. Oophoropexy in children with ovarian torsion. Eur. J. Pediatr. Surg. 2004;14:168.

Aziz D, Davis V, Allen L, Langer J. Ovarian torsion in children: Is oophorectomy necessary? J. Pediatr. Surg. 2004;39:750-3.

Bristow RE, Nugent AC, Zahurak ML, et al. Impact of surgeon specialty on ovarian-conserving surgery in young females with an adnexal mass. J. Adolesc. Health 2006;39:411.

Chang YJ, Yan DC, Kong MS, et al. Adnexal torsion in children. Pediatr. Emerg. Care. 2008;24:534-7.

Conforti A, Giorlandino C, Bagolan P. Fetal ovarian cysts management and ovarian prognosis: a report of 82 cases. J. Pediatr. Surg. 2009;44:868; author reply 868-9.

Guthrie BD, Adler MD, Powell EC. Incidence and trends of pediatric ovarian torsion hospitalizations in the United States, 2000-2006. Pediatrics 2010;125:532-8. Epub 2010 Feb 1.

Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann. Emerg. Med. 2001;38:156-9.

Huang TY, Lau BH, Lin LW, Wang TL, Chong CF, Chen CC. Ovarian cyst torsion in a toddler. Am. J. Emerg. Med. 2009;27:632, e1-3.

Hurh PJ, Meyer JS, Shaaban A. Ultrasound of a torsed ovary: characteristic gray-scale appearance despite normal arterial and venous flow on Doppler. Pediatr. Radiol. 2002;32:586-8. Epub 2002 May 25.

Kokoska E, Keller M, Weber T. Acute ovarian torsion in children. Am. J. Surg. 2000;180:462-5.

Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion – a 15-year review. J. Pediatr. Surg. 2009;44:1212-6; discussion 1217.

Chmitt ER et al. Twist and Shout! Pediatric Ovarian Torsion Clinical Update and Case Discussion. Pediatr Emerg Care. 2013; 29(4):518-523.

Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS. Sonographic findings of ovarian torsion in children. Pediatr. Radiol. 2007;37:446-51. Epub 2007 Mar 15.

Valsky DV. Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet. Gynecol. 2010;36:630-4.

Normally metabolized into codeine-6-glucuronide (50-70%) and norcodeine (10-15%).  Codeine, codeine-6-glucuronide, and norcodeine have low affinity for the μ (mu) receptor.

However, the most active metabolite of codeine is morphine with 200x the affinity for the mu receptor as the codeine derivates.  The problem is, people vary in its metabolism from 0-15% of codeine is metabolized to morphine.

Ok, codeine is lame at best, unpredictable at worst.

True.  Unless you are hiding a genetic time bomb.

You're an ultra-rapid metabolizer.

Some people have multiple extra copies of the DNA sequence for the CYP2D6 enzyme.  Ultra rapid metabolizers funnel a huge proportion of their codeine into morphine metabolism, resulting in a bolus of morphine, ending in apnea.

This combination is no better than placebo -- all of the risks, with no proven benefit.  This combination is notoriously abused -- as purple drank or sizzurp.  The rapper Pimp C died of this.

Speaking of cough syrups...

The AAP recommends no cough and cold preparations in children under age 6.  They have not been adequately studied in young children, and are not recommended for treating the common cold.

What then?  You gotta give me something, doctor!

Ok, Honey!

In a study in the Archives of Pediatric and Adolescent Medicine, Dr Paul and colleagues published: Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents.  They compared a buckwheat honey, honey-flavored dextromethorphan (DM) and no treatment 30 min before bed for children with upper respiratory tract infections.

Of the three, honey, dextromethorphan, and no treatment – honey scored the best for symptom improvement and cough frequency.

Over age 1?  Cough and cold?  Honey.  There is no concern about accidental overdose, parents are doing something with a proven effect, and compliance is pretty much 100% -- and Grandma approves.

No proven benefit over placebo.  Also widely abused, in pill form ("Skittles") and/or liquid form mixed in alcoholic beverage ("robotripping").

Allow the child to speak for himself whenever possible. After acknowledging the parent’s input, perhaps try “I want to make sure I understand how the pain is for you. Tell me more.”

Engage parents and communicate the plan to them. Elicit their expectations, and give them of preview of what to expect in the ED.

Opioids are meant for pain caused by acute tissue injury, for the briefest period of time feasible. Older school-aged children and adolescents are increasingly at risk for opioid dependence and addiction.

Give detailed advice on how to manage pain at home. Set expectations. Let them know you understand and will help them through your good advice that will carry them through this difficult time. Patients and families often just need a plan. Map it out clearly.

And...

Just say no to: codeine, promethazine with codeine, and dextramethorphan.

Dhaliwal G, Hsu D. Tramadol Ultra Rapid Metabolizers at Risk for Respiratory Depression. Pain Physician. 2016; 19(2):E361.

European Medicines Agency. Restriction on the use of codeine for pain relief in children—CMDh endorses PRAC recommendation [press release]. June 28, 2013.

FDA. Most Young Children With a Cough or Cold Don't Need Medicine.

Hartling L et al. How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review. Pain Res Manag. 2016; 2016: 5346819.

Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet. 2004;43(13):879-923.

Jin J. Risks of Codeine and Tramadol in Children. JAMA. 2017 Oct 17;318(15):1514. doi: 10.1001/jama.2017.13534.

Kelly LE et al. More Codeine Fatalities After Tonsillectomy in North American Children. Pediatrics. 2012; 129(5).

Kirchheiner J, Schmidt H, Tzvetkov M, et al. Pharmacokinetics of codeine and its metabolite morphine in ultra-rapid metabolizers due to CYP2D6 duplication. Pharmacogenomics J. 2007;7(4):257–265

Orliaguet G et al. A Case of Respiratory Depression in a Child With Ultrarapid CYP2D6 Metabolism After Tramadol. Pediatrics. 2015; 135(3).

Poonai N. Analgesia for children in acute pain in the post-codeine era. Curr Pediatr Rev. 2017 Aug 28. doi: 10.2174/157339631366617082911563.1.

This post and podcast are dedicated to Bryan Hayes, PharmD for his practical approach to pharmacologic conundrums and to David Juurlink, MD, PhD for his steadfast dedication to patient safety and clinician education.  Check out Bryan's helpful blog and clinical resource, PharmERToxGuy.  Check out David anywhere one utters the word Tra-ma-dol.

Dayan PS et al. Association of Traumatic Brain Injuries with Vomiting in Children with Blunt Head Trauma. Ann Emerg Med. 2014; 63(6):657-665.

Dayan PS et al. Headache in Traumatic Brain Injuries from Blunt Head Trauma. Pediatrics. 2015; 135(3):504-512.

Horeczko T, Kuppermann N. To scan or not to scan: pediatric minor head trauma in your office, clinic or emergency department. Contemporary Pediatrics. 2012;29(8):40-47.

Kupperman et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-70.

Lee LK et al. Isolated Loss of Consciousness in Children with Minor Blunt Head Trauma. JAMA Pediatr. 2014; 168(9):837-843.

Magana JN, Kuppermann N. The PECARN TBI Rules Do Not Apply To Abusive Head Trauma. Acad Emerg Med. 2017; 24(3)382-384.

Rogers AJ et al. Children with Arachnoid Cysts who Sustain Blunt Head Trauma: Injury Mechanisms and Outcomes. Acad Emerg Med. 2016; 23:358-361.

This post and podcast are dedicated to Kevin Klauer, DO, EJD, FACEP for his dedication to education, and for his unique balance of safety and keeping it real.  Thank you.

For intractable epilepsy; sends retrograde signal up corona radiata

Also may be used in: depression, bulimia, Alzheimer, narcolepsy, addiction, and others

Used to infuse basal rate of drug, usually baclofen for spasticity, but pump may contain morphine, bupivicaine, clonidine.  Also used for severe MS, stroke, TBI, chronic pain.  Verify the medication and identify the toxidrome if symptomatic.

May be left ventricular assist, right ventricular assist, or biventricular assist device.

Elliott RE, Rodgers SD, Bassani L et al. Vagus nerve stimulation for children with treatment-resistant epilepsy: a consecutive series of 141 cases. J Neurosurg Pediatrics. 2011; 7:491-500.

Groves DA, Brown VJ. Vagal nerve stimulation: a review of its applications and potential mechanisms that mediate its clinical effects. Neuroscience and Biobehavioral Reviews. 2005; 29: 493–500.

Panebianco M, Rigby A,Weston J,Marson AG. Vagus nerve stimulation for partial seizures. Cochrane Database of Systematic Reviews. 2015; 4, Art. No.: CD002896.

Ruffoli R,  Giorgi FS, Pizzanelli C et al. The chemical neuroanatomy of vagus nerve stimulation. Journal of Chemical Neuroanatomy; 2011; 42: 288–296.

Borowski A, Littleton AG, Borkhuu B et al. Complications of Intrathecal Baclofen Pump Therapy in Pediatric Patients. J Pediatr Orthop. 2010; 30:76–81.

Ghosh D, Mainali G, Khera J, Luciano M.  Complications of Intrathecal Baclofen Pumps in Children: Experience from a Tertiary Care Center. Pediatr Neurosurg. 2013; 49:138–144.

Yang TF, Wang JC, Chiu JW et al. Ultrasound-guided refilling of an intrathecal baclofen pump—a case report. Childs Nerv Syst. 2013; 29:347–349.

Yeh RN, Nypaver MM, Deegan TJ, Ayyangar R. Baclofen Toxicity in an 8-year-old with an Intrathecal Baclofen Pump. J Emerg Med. 2004; 26(4): 163–167.

Blume ED, Naftel DC, Bastardi HJ et al. for the Pediatric Heart Transplant Study Investigators. Outcomes of Children Bridged to Heart Transplantation With Ventricular Assist Devices: A Multi-Institutional Study. Circulation. 2006; 113: 2313-2319.

Colón JE, Laborde ME, Nossaman BD. Case Report: Left Ventricular Assist Device in a 12 Year Old Child as a Bridge to Heart Transplantation. Section of Congenital Cardiac Anesthesia, Ochsner Medical Center, New Orleans, Louisiana. 2012.

Fan Y, Weng YG, Huebler M et al. Predictors of In-Hospital Mortality in Children After Long-Term Ventricular Assist Device Insertion. J Amer Coll Cardiol. 2011; 58(11):1183–90

Fraser CD,  Jaquiss RDB, Rosenthal DN et al. Prospective Trial of a Pediatric Ventricular Assist Device. N Engl J Med. 2012;367:532-41.

Gazit AZ, Gandhi SK, Canter CC. Mechanical Circulatory Support of the Critically Ill Child Awaiting Heart Transplantation. Current Cardiology Reviews. 2010; 6: 46-53.

VanderPluym CJ, Fynn-Thompson F, Blume ED.  Ventricular Assist Devices in Children Progress With an Orphan Device Application. Circulation. 2014;129:1530-1537.

This post and podcast are dedicated to Joe Bellezzo, MD, FACEP and Zack Shinar, MD, FACEP for bringing us all up to speed.  Listen to their fantastic ED ECMO podcast here.

PEMplaybook.org

One of our largest responsibilities in the Emergency Department is sorting out benign from surgical or medical causes of abdominal pain.  Morbidity and mortality varies by age and condition.  

Essentials:

• Typically presents in 1st week of life (case reports to 6 months in chronically ill children)
• Extend suspicion longer in NICU graduates
• Up to 10% of all cases of necrotizing enterocolitis are in full-term children
• Pathophysiology is unknown, but likely a translocation of bacteria

Diagnosis:

• Feeding intolerance, abdominal distention
• Abdominal XR: pneumatosis intestinalis

Management:

• IV access, NG tube, broad-spectrum antibiotics, surgery consult, ICU admission

Essentials:

• Bilious vomiting (80-100%) in the 1st month; especially in the 1st week
• May look well initially, then rapidly present in shock
• Ladd’s bands: abnormally high tethering of cecum to abdominal wall; peristalsis, volvulus, ischemia

Diagnosis:

• History of bilious emesis is sufficient to involve surgeons
• Upper GI series: corkscrew appearance
• US (if ordered) may show abnormal orientation of and/or flow to superior mesenteric artery and vein

Management:

• Stat surgical consult
• IV access, resuscitation, NG tube to decompress (bowel wall perfusion at risk, distention worsens)

Essentials:

• Problem in migration of neural crest cells
• Aganglionic colon (80% rectosigmoid; 15-20% proximal to sigmoid; 5% total colonic aganglionosis) colon (known as short-segment disease)
• Poor to no peristalsis: constipation, perforation, and/or sepsis

Diagnosis:

• May be diagnosed early as “failure to pass meconium in 1st 48 hours”
• In ED, presents as either bowel obstruction or enterocolitis
• Contrast enema
• Beware of the toxic megacolon (vomiting, distention, sepsis)

Management:

• Resuscitation, antibiotics, NG tube decompression, surgical consultation; stable patients may need rectal biopsy for confirmation
• Staged surgery (abdominoperineal pull-through with diverting colostomy, subsequent anastomosis) versus one-stage repair.

Essentials:

• Hypertrophy of pyloric sphincter; genetic, environmental, exposure factorsString Sign in Pyloric Stenosis.

Diagnosis:

• Hungry, hungry, not-so-hippos; they want to eat all of the time, but cannot keep things down
• Poor weight gain (less than 20-30 g/day)
• US: “π–loric stenosis” (3.14); pylorus dimensions > 3 mm x 14 mm
• UGI: “string sign”

Management:

• Trial of medical treatment with oral atropine via NGT (muscarinic effects decrease pyloric tone)
• Ramstedt pyloromyotomy (definitive)

Essentials:

• Majority (90%) ileocolic; no pathological lead point
• Small minority (4%) ileoileocolic due to lead point: Meckel’s diverticulum, polyp, Peyer’s patches, Henoch-Schönlein purpura (intestinal hematoma)

Diagnosis:

• Ultrasound sensitivity and specificity near 100% in experienced hands
• Abdominal XR may show non-specific signs; used mainly to screen for perforation before reduction

Management:

• Hydrostatic enema: contrast (barium or water-soluble contrast with fluoroscopy) or saline (with ultrasound)
• Air-contrast enema: air or carbon dioxide (with either fluoroscopy or ultrasound); higher risk for perforation than hydrostatic (1% risk), but generally safer than perforation from contrast
• Consider involving surgical service early (precaution before reduction)
• Traditional disposition is admission; controversial: home discharge from ED

Essentials:

• Appendicitis occurs in all ages, but rarer in infants. Infants do not have fecalith; rather they have some other anatomic or congenital condition. 
• More common in school-aged children (5-12 years) and adolescents
• Younger children present atypically, more likely to have perforated when diagnosed.

Diagnosis:

• Non-specific signs and symptoms
• Often have abdominal pain first; vomiting comes later
• Location/orientation of appendix varies
• Appendicitis scores vary in their performance
• Respect fever and abdominal pain

Management:

• Traditional: surgical
• On the horizon: identification of low-risk children who may benefit from trial of antibiotics
• If perforated, interval appendectomy (IV antibiotics via PICC for 4-6 weeks, then surgery)

Essentials:

• Same pathophysiology and epidemiology as adults: “ABC” – adhesions, “bulges” (hernias), and cancer.

Diagnosis:

• Obstruction is a sign of another condition. Look for cause of obstruction: surgical versus medical
• Abdominal XR in low pre-test probability
• CT abdomen/pelvis for moderate-to-high risk; confirmation and/or surgical planning

Management:

• Treat underlying cause
• NG tube to low intermittent wall suction
• Admission, fluid management, serial examinations

• Consider surgical pathology early in encounter
• Resuscitate while you investigate
• Have a low threshold for imaging and/or consultation, especially in preverbal children

Selected References

Necrotizing Enterocolitis

Neu J, Walker A. Necrotizing Enterocolitis. N Eng J Med. 2011; 364(3):255-264.

Niño DF et al. Necrotizing enterocolitis: new insights into pathogenesis and mechanisms. Nature. 2016; 13:590-600.

Walsh MC et al. Necrotizing Enterocolitis: A Practitioner’s Perspective. Pediatr Rev. 1988; 9(7):219-226.

Malrotation with Midgut Volvulus

Applegate KE. Intestinal Malrotation in Children: A Problem-Solving Approach to the Upper Gastrointestinal Series. Radiographics. 2006; 26:1485-1500.

Kapfer SA, Rappold JF. Intestinal Malrotation – Not Just the Pediatric Surgeon’s Problem. J Am Coll Surg. 2004; 199(4):628-635.

Lee HC et al. Intestinal Malrotation and Catastrophic Volvulus in Infancy. J Emerg Med. 2012; 43(1):49-51.

Martin V, Shaw-Smith C. Review of genetic factors in intestinal malrotation. Pediatr Surg Int. 2010; 26:769-781.

Nehra D, Goldstein AM. Intestinal malrotation: Varied clinical presentation from infancy through adulthood. Surgery. 2010; 149(3):386-391.

Hirschprung Disease

Amiel J, Sproat-Emison E, Garcia-Barcelo M, et al. Hirschsprung disease, associated syndromes and genetics: a review. J Med Genet 2008; 45:1.

Arshad A, Powell C, Tighe MP. Hirschsprung's disease. BMJ 2012; 345:e5521.

Aworanti OM, McDowell DT, Martin IM, Quinn F. Does Functional Outcome Improve with Time Postsurgery for Hirschsprung Disease? Eur J Pediatr Surg 2016; 26:192.

Clark DA. Times of first void and first stool in 500 newborns. Pediatrics 1977; 60:457.

Dasgupta R, Langer JC. Evaluation and management of persistent problems after surgery for Hirschsprung disease in a child. J Pediatr Gastroenterol Nutr 2008; 46:13.

De Lorijn F, Reitsma JB, Voskuijl WP, et al. Diagnosis of Hirschsprung's disease: a prospective, comparative accuracy study of common tests. J Pediatr 2005; 146:787.

Doig CM. Hirschsprung's disease and mimicking conditions. Dig Dis 1994; 12:106.

Khan AR, Vujanic GM, Huddart S. The constipated child: how likely is Hirschsprung's disease? Pediatr Surg Int 2003; 19:439.

Singh SJ, Croaker GD, Manglick P, et al. Hirschsprung's disease: the Australian Paediatric Surveillance Unit's experience. Pediatr Surg Int 2003; 19:247.

Suita S, Taguchi T, Ieiri S, Nakatsuji T. Hirschsprung's disease in Japan: analysis of 3852 patients based on a nationwide survey in 30 years. J Pediatr Surg 2005; 40:197.

Sulkowski JP, Cooper JN, Congeni A, et al. Single-stage versus multi-stage pull-through for Hirschsprung's disease: practice trends and outcomes in infants. J Pediatr Surg 2014; 49:1619.

Pyloric Stenosis

Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pedaitr Surg. 2007; 16:27-33.

Dias SC et al. Hypertrophic pyloric stenosis: tips and tricks for ultrasound diagnosis. Insights Imaging. 2012; 3:247-250.

Kawahara H et al. Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the olive? J Pediatr Surg. 2005; 40:1848-1851.

Mack HC. Adult Hypertrophic Pyloric Stenosis. Arch Inter Med. 1959; 104:78-83.

Meissner PE et al. Conservative treatment of infantile hypertrophic pyloric stenosis with intravenous atropine sulfate does not replace pyloromyotomy. Pediatr Surg Int. 2006; 22:1021-1024.

Mercer AE, Phillips R. Can a conservative approach to the treatment of hypertrophic pyloric stenosis with atropine be considered a real alternative to pyloromyotomy? Arch Dis Child. 2013; 95(6): 474-477.

Pandya S, Heiss K, Pyloric Stenosis in Pediatric Surgery.Surg Clin N Am. 2012; 92:527-39.

Peters B et al. Advances in infantile hypertrophic pyloric stenosis. Expert Rev Gastroenterol Hepatol. 2014; 8(5):533-541.

Intussusception

Apelt N et al. Laparoscopic treatment of intussusception in children: A systematic review. J Pediatr Surg. 2013; 48:1789-1793.

Applegate KE. Intussusception in Children: Imaging Choices. Semin Roentgenol. 2008; 15-21.

Bartocci M et al. Intussusception in childhood: role of sonography on diagnosis and treatment. J Ultrasound. 2015; 18 Gilmore AW et al. Management of childhood intussusception after reductiion by enema. Am J Emerg Med. 2011; 29:1136-1140.:205-211.

Chien M et al. Management of the child after enema-reduced intussusception: hospital or home? J Emerg Med. 2013; 44(1):53-57.

Cochran AA et al. Intussusception in traditional pediatric, nontraditional pediatric, and adult patients. Am J Emerg Med. 2011; 523-527.

Loukas M et al. Intussusception: An Anatomical Perspective With Review of the Literature. Clin Anatomy. 2011; 24: 552-561.

Mendez D et al. The diagnostic accuracy of an abdominal radiograph with signs and symptoms of intussusception. Am J Emerg Med. 2012; 30:426-431.

Whitehouse et al. Is it safe to discharge intussusception patients after successful hydrostatic reduction? J Pediatr Surg. 2010; 45:1182-1186.

Appendicitis

Amin P, Chang D. Management of Complicated Appendicitis in the Pediatrc Population: When Surgery Doesn’t Cut it. Semin Intervent Radiol. 2012; 29:231-236

Blakely ML et al. Early vs Interval Appendectomy for Children With Perforated Appendicitis. Arch Surg. 2011; 146(6):660-665.

Bundy DG et al. Does This Child Have Appendicitis? JAMA. 2007; 298(4):438-451.

Cohen B et al. The non-diagnostic ultrasound in appendicitis: is a non-visualized appendix the same as a negative study? J Pediatr Surg. 2015 Jun;50(6):923-7

Herliczek TW et al. Utility of MRI After Inconclusive Ultrasound in Pediatric Patients with Suspected Appendicitis. AJT. 2013; 200:969-973.

Janitz et al. Ultrasound Evaluation for Appendicitis. J Am Osteopath Coll Radiol. 2016; 5(1):5-12.

Kanona H et al. Stump Appendicitis: A Review. Int J Surg. 2012; 10:4255-428.

Kao LS et al. Antibiotics vs Appendectomy for Uncomplicated Acute Appendicitis. Evid Based Rev Surg. 2013;216(3):501-505.

Petroianu A. Diagnosis of acute appendicitis. Int J Surg. 2012; 10:115-119.

Mazeh H et al. Tip appendicitis: clinical implications and management. Amer J Surg. 2009; 197:211-215.

Puig S et al. Imaging of Appendicitis in Children and Adolescents. Semin Roentgenol. 2008; 22-28.

Schizas AMP, Williams AB. Management of complex appendicitis. Surgery. 2010; 28(11):544-548.

Shogilev DJ et al. Diagnosing Appendicitis: Evidence-Based Review. West J Emerg Med. 2014; 15(4):859-871.

Wray CJ et al. Acute Appendicitis: Controversies in Diagnosis and Management. Current Problems in Surgery. 2013; 50:54-86

Intestinal Obstruction

Babl FE et al. Does nebulized lidocaine reduce the pain and distress of nasogastric tube insertion in young children? A randomized, double-blind, placebo-controlled trial. Pediatrics. 2009 Jun;123(6):1548-55

Chinn WM, Zavala DC, Ambre J. Plasma levels of lidocaine following nebulized aerosol administration. Chest 1977;71(3):346-8.

Cullen L et al. Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial. Ann Emerg Med. 2004 Aug;44(2):131-7.

Gangopadhyay AN, Wardhan H. Intestinal obstruction in children in India. Pediatr Surg Int. 1989; 4:84-87.

Hajivassiliou CA. Intestinal Obstruction in Neonatal/Pediatric Surgery. Semin Pediatr Surg. 2003; 12(4):241-253.

Hazra NK et al. Acute Intestinal Obstruction in children: Experience in a Tertiary Care Hospital. Am J Pub Health Res. 2015; 3(5):53-56.

Kuo YW et al. Reducing the pain of nasogastric tube intubation with nebulized and atomized lidocaine: a systematic review and meta-analysis. J Pain Symptom Manage. 2010 Oct;40(4):613-20.  .

Pediatric Surgery

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Louie JP. Essential Diagnosis of Abdominal Emergencies in the First Year of Life. Emerg Med Clin N Am. 2007; 25:1009-1040.

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Pepper VK et al. Diagnosis and Management of Pediatric Appendicitis, Intussusception, and Meckel Diverticulum. Surg Clin N Am. 2012

This post and podcast are dedicated to Mr Ross Fisher for his passion and spirit of collaboration in all things #FOAMed.  Thank you, sir!

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