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AAP National Conference: ED docs to present challenging cases of children with acute pain :

October 22, 2016

An 11-year-old boy has had a headache for a week. He had some minor head trauma playing soccer. The headache got a little better, but for the past few nights he has had severe pain.

His pediatrician wants to see him, but the child then develops diarrhea and his family thinks he has a virus. So they don’t bring him in.

A few days later, the boy wakes up at 2 a.m. screaming in pain and vomits once. So the family brings him to the office.

On exam, his vital signs are normal. He has mild clonus, difficulty doing finger-to-nose testing and difficulty with tandem gait. He prefers to be in a dark room.

Would you be worried about migraine, stress-related headache, meningitis, a mass lesion or bleed in the head from trauma? Would you schedule a neurology appointment, do a blood test or spinal tap, give him some pain medication and recheck him in a couple of days, get a skull X-ray, or send him to the emergency department for a CT scan?

“I don’t think this is a straightforward case. I think this is a little confusing,” said Steven Selbst, M.D., FAAP, professor of pediatrics and pediatric residency program director at Sidney Kimmel Medical College at Thomas Jefferson University, Nemours/Alfred I. duPont Hospital for Children in Delaware.

Dr. Selbst and John Loiselle, M.D., FAAP, will take pediatricians through cases like this during a session titled “Evaluation of Patients with Acute Headache, Chest Pain, or Abdominal Pain (S2058),” which will be presented from 8:30-10 a.m. Sunday in Room 3018 of Moscone West.

After each case, attendees will be asked to think about what their next steps would be. Dr. Selbst and Dr. Loiselle, chief of emergency medicine at Nemours/Alfred I. duPont Hospital for Children, then will discuss options and what they would do. The boy with persistent headache was one of Dr. Selbst’s patients and may be among the cases discussed during the session.

“A lot of these cases are not straightforward, but that’s life. We’re not trying to trick anybody,” said Dr. Selbst, a member of the AAP Section on Emergency Medicine.

One of the challenges with perplexing cases is to do enough testing so you don’t miss an important diagnosis without doing too much.

“We don’t want to do a spinal tap on every patient, but some kids need a spinal tap,” Dr. Selbst said. “You don’t want to do a CAT scan unnecessarily — not just for the cost but for the radiation — but some patients need an emergency CAT scan.”

Dr. Selbst and Dr. Loiselle will review subtle findings that may indicate a child needs an extensive workup.

“Abdominal pain is very common, headache is very common and chest pain is very common,” Dr. Selbst said. “Which are the kids to worry about, why do we worry and then what should we do about them?”

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