Updated December, 2010 Pediatric Call Protocols PYLORIC STENOSIS: In most cases, the ER requests an ultrasound examination which is performed by the technologist. In those instances when patients arrive at MUSC with outside imaging, the imaging studies should be made available to the radiology residents and subsequently the pediatric radiology attendings by downloading onto the Web 1000 server. The radiologists will review the imaging for adequacy and determine if further imaging is required. If it is determined that further imaging is appropriate, the sonographer will perform the ultrasound. However, we agreed that although the diagnosis of pyloric stenosis is urgent it does not constitute a medical emergency and therefore, in those instances when there is no tech available, the ultrasound examination can wait until first thing in the a.m. If there are extenuating circumstances and the examination cannot wait, the clinical residents and faculty should make the radiology resident and pediatric radiology attending aware of the situation, so that an alternative plan can be developed. APPENDICITIS Protocol for CT scans of the abdomen/pelvis performed for the clinical concern of Acute appendicitis in children: High Pelvis with Coronal Reconstructions @ 2 mm IV Contrast in all patients < 10 yo - Oral Contrast 10 or older - No oral Contrast necessary In those cases where the history is prolonged and there is a concern for ruptured appendicitis and abscess formation, oral and/or rectal contrast should be given. If there is a question about whether or not to give Oral contrast, contact the pediatric attending, prior to the study. SEPTIC HIP//SEPTIC JOINT After multiple meetings with colleagues in the pediatric ED, ICU, orthopedic surgery, and children's hospital administration, we have developed the following multidisciplinary algorithmic approach to the evaluation of possible septic hips. Please use the Synovial Fluid Kit, which contains appropriate sterilization materials and tubes for submission. The KITS may be located in the pediatric ED physician workspace in the cabinets adjacent to ED protocol binders. 1) The orthopaedic surgeons and/or ER physicians will perform the clinical evaluation and determine the need for US evaluation and possible diagnostic tap. 2) US examination of the hip will be performed under the direction of the radiology resident and pediatric radiologist on call. 3) If an effusion is demonstrated and the patient meets criteria of labs and history suggestive of septic arthritis, an ultrasound-guided arthrocentesis is to be performed. 4) Access to the on-call radiologist who will do this procedure will be through the Pediatric Radiology attending on call. A benchmark ideal will be established of 2 hours from time of ultrasound results to time of arthrocentesis. Need for sedation and adequate fasting time may modify this interval. A weekly call schedule inclusive of pediatric radiologists and adult radiologists who are comfortable performing the ultrasound-guided arthrocentesis will be established. For those weeks that Dr. Hill and Dr. Rao are on weekend call, they will provide backup during the preceding weekdays. 5) Joint aspiration should be performed sterilely. Chloraprep swabsticks should be used for skin disinfection, 30 seconds contact with 30 seconds drying. Alcohol pads should be used to sterilize specimen containers, 60 seconds drying time. USE MATERIALS IN PEDIATRIC SYNOVIAL FLUID KIT. The kit is stored in the ED physician cabinets that are adjacent to protocol books. 6) The following tests should be ordered on the synovial fluid specimen: a) Aerobic Bacterial culture a. Yellow cap bottle b. Clean bottle cover with alcohol before inoculation c. Minimum requirement= 0.5 ml, preferred = 2-4 ml b) Anaerobic Bacterial culture a. Purple cap bottle b. Clean bottle cover with alcohol before inoculation c. Minimum requirement=2 ml c) Gram stain a. Sterile tube b. Remove cover, inoculate directly into tube without touching sides of tube c. Minimum requirement = 0.5 ml d) Cell count and differential a. Lavender tube b. Minimum requirement = 0.5ml, preferred = 2ml, acceptable = 1ml c. Tube should be swabbed with alcohol before inoculation (60 seconds drying time) e) Kingella PCR if CHILD UNDER 4 a. Sterile tube b. Remove cover, inoculate direrectly into tube without touching sides of tube c. Minimum requirement = 0.5 ml d. PCR will not be performed if gram stain shows gram positive organisms 7) Patient labels should be applied to all synovial fluid specimen containers. Each label should be dated and timed by physician. 8) Synovial fluid specimens should be walked directly to the lab by a member of the ED team. 9) Pediatric ED and/or ICU attending physicians can provide sedation in their respective units for the arthrocentesis. NPO status and the risks/benefits of sedation will need to be assessed for all patients. 10) Once fluid is obtained for culture and gram stain, antibiotics may be administered if indicated while awaiting operative intervention. 11) Pediatric orthopedics will be responsible for operative management once the diagnosis of septic hip is confirmed by arthrocentesis.