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No.
I try and keep it simple, especially as I am starting to feel US to Rule IN Appendicitis is becoming more and more of a losing battle...
If I have a strong clinical suspicion, I call Peds Surgery and admit..
If I feel the history and exam are equivocal, I utilize a CBC and CRP, along with RLQ pain and fever...hydrate them up, and re exam after labs are back and bolus is done, and make decision to call surgery and admit or home to return if they get worse.
I will discuss with Peds Surgery prior to giving antibiotics for sure, but will give abx if I feel it is an obvious case.
I have not utilized an appendicitis score in a while, but certainly invite itand would be open to instituting one that keeps it simple and makes sense and backed by data.
This works for me quite well.
Chow,
Todd Z


Dr. Todd Zimmerman

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-----Original Message-----
From: christian Rocholl <[log in to unmask]>
To: PED-EM-L <[log in to unmask]>
Sent: Wed, Aug 9, 2017 5:35 pm
Subject: WBC counts for appy workup

I am interested to know, if you routinely use a WBC count to determine if you would perform an US to look for appendicitis. Many times I perform a RLQ US based on clinical suspicion and thus I don't perform a CBC on many children before imaging. I usually order a CBC if I think a child has enough pain to warrant IV fluids and medication but in these cases I will admit that I typically order the CBC with the US. We have US available 24/7 and I think that anecdotally our technicians are pretty good. We rarely, almost never, do CT before US but if US is equivocal and suspicion is high then will proceed to CT. I work at a hospital that is part of a larger system where other hospitals (without 24/7 Pediatric EM) are doing appendicitis scoring on all abdominal pain. Obviously not everyone has high enough suspicion of appendicitis to warrant a score and I would assume that many patients with abdominal pain are discharged without a work up. However, the healthcare system can not compare data of appendicitis outcome comparing pre diagnosis low, moderate, and high suspicion cases because the providers at my hospital are not completing a pediatric appendicitis score. A CBC is required for the score to be completed in the EMR and thus for it to be retrievable in a report without a chart review. 
It has been questioned whether our process adds cost and I am in the process of obtaining cost for US compared to lab. I take into consideration that we rarely perform blood work without an IV on children and I am sure this can be questioned but we try not to "poke" a child for a CBC only to return and "poke" for an IV. Our turn around time for US is vey good. And also this may be questionable but I feel that US for appy is very operator dependent and the process has helped in that our rates of US where the appendix can not be visualized has improved. I know this previous sentence is not a justification for US on children but I would also say that we have many patients referred to our hospital with inconclusive or borderline measurements of an appendix where an US at our hospital sometimes provides clarity. 

Thank You for your thoughts

Christian Rocholl MD

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For more information, send mail to [log in to unmask] with the message: info PED-EM-L
The URL for the PED-EM-L Web Page is:
                 http://listserv.brown.edu/ped-em-l.html