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Abstract. Objective: To evaluate the effects of intravenous morphine on pain reduction, physical examination, and diagnostic accuracy in children with acute abdominal pain. Methods: A randomized, double-blind, placebo-controlled clinical trial was conducted at an emergency department of a tertiary care children's hospital. Children aged 5-18 years with abdominal pain of Յ5 days' duration, pain score Ն5 on a 0-10 visual analog scale, and need for surgical evaluation were eligible. Following the initial assessment, patients were randomized to receive either 0.1 mg/kg morphine or an equal volume of saline. The pediatric emergency medicine physician and surgical consultant independently recorded the areas of tenderness to palpation and percussion, and their diagnoses before the study medication and 15 to 30 minutes later. Results: Sixty patients were enrolled, and 29 received morphine and 31 received saline. The demographic characteristics between the two groups were similar. The median reduction of pain score between the two study groups was 2 (95% CI = 1 to 4; p = 0.002). There was no significant change in the areas of tenderness in both study groups. Children with surgical conditions had persistent tenderness to palpation and/or percussion. There was no significant change in the diagnostic accuracy between the study groups and between the physician groups. All patients requiring laparotomy were identified and no significant complication was noted in the morphine group. Conclusions: Intravenous morphine provides significant pain reduction to children with acute abdominal pain without adversely affecting the examination, and morphine does not affect the ability to identify children with surgical conditions. Key words: analgesia; acute abdominal pain; children; pediatrics. ACADEMIC EMERGENCY MEDICINE 2002; 9: 281-287 F OR decades, analgesia was withheld from patients with acute abdominal pain in the fear of masking symptoms, changing physical findings, and ultimately delaying diagnosis and definitive surgical intervention.1,2 This non-evidence-based teaching/practice was challenged recently by several studies that demonstrated effectiveness of opioids in providing pain relief to adult patients with acute abdominal pain without adverse effects or delay in diagnosis.3-7 These findings have led to the recommendation for judicious use of analgesia 8,9 Furthermore, the Agency for Healthcare Research and Quality (AHRQ) concluded that appropriate use of analgesics in patients with acute abdominal pain effectively decreases pain and does not interfere with diagnosis or treatment.10 However, application of this recommendation in children with acute abdominal pain has not been studied to date. Our study objective was to examine the effect of intravenous morphine on pain reduction, physical examination, and diagnostic accuracy in children with acute abdominal pain. METHODSStudy Design. A randomized, double-blind, placebo-controlled clinical trial was conducted to evaluate the effects of intravenous morphine on pain reduction, ...

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The medical records of 43 hemodynamically stable children with elevated serum transaminase levels (aspartate aminotransferase [AST] and alanine aminotransferase [ALT]) who underwent abdominal computed tomographic (CT) scan for blunt abdominal trauma were reviewed. Nineteen patients (44.2%) had AST levels >450 IU/L and ALT levels >250 IU/L, and 17 of these 19 patients had hepatic injury identified on abdominal CT scan. Of the 43 patients, 25 (58.1%) had AST and ALT levels of less than 450 IU/L and 250 IU/L, respectively, and none of these patients had evidence of hepatic injury on CT scan. Elevated serum transaminase levels (AST >450 IU/L and ALT >250 IU/L) identified all of the patients with hepatic injury visible on abdominal CT scan. The sensitivity and specificity of elevated serum transaminase levels were 100% and 92.3%, respectively, for predicting hepatic injury. It is recommended that hemodynamically stable pediatric patients with blunt abdominal trauma and AST levels >450 IU/L and/or ALT levels >250 IU/L undergo abdominal CT scan to determine the presence and extent of hepatic injury. Children with serum transaminase levels below these values are at decreased risk of liver injury.

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OBJECTIVES: Accuracy of pyuria for urinary tract infection (UTI) varies with urine concentration. Our objective of this study was to determine the optimal white blood cell (WBC) cutoff for UTI in young children at different urine concentrations as measured by urine specific gravity. METHODS:Retrospective cross-sectional study of children ,24 months of age evaluated in the emergency department for suspected UTI with paired urinalysis and urine culture during a 6year period. The primary outcome was positive urine culture result as described in the American Academy of Pediatrics clinical practice guideline culture thresholds. Test characteristics for microscopic pyuria cut points and positive leukocyte esterase (LE) were calculated across 3 urine specific gravity groups: low ,1.011, moderate 1.011 to 1.020, and high .1.020.RESULTS: Of the total 24 171 patients analyzed, urine culture result was positive in 2003 (8.3%). Urine was obtained by transurethral in-and-out catheterization in 97.9%. Optimal WBC cutoffs per high-power field (HPF) were 3 (positive likelihood ratio [LR1] 10.5; negative likelihood ratio [LR2] 0.12) at low, 6 (LR1 12; LR2 0.14) at moderate, and 8 (LR1 11.1; LR2 0.35) at high urine concentrations. Likelihood ratios for small positive LE from low to high urine concentrations (LR1 25.2, LR2 0.12; LR1 33.1, LR2 0.15; LR1 37.6, LR2 0.41) remained excellent.CONCLUSIONS: Optimal pyuria cut point in predicting positive urine culture results changes with urine concentration in young children. Pyuria thresholds of 3 WBCs per HPF at low urine concentrations whereas 8 WBCs per HPF at high urine concentrations have optimal predictive value for UTI. Positive LE is a strong predictor of UTI regardless of urine concentration.WHAT'S KNOWN ON THIS SUBJECT: The accuracy of pyuria for urinary tract infection varies with urine concentration in children. Previously, optimal diagnostic white blood cells (WBCs) per high-power field (HPF) cutoffs for pyuria have been established at 2 different urine concentrations.WHAT THIS STUDY ADDS: With this study, we identify optimal WBCs per HPF cut points for pyuria at 3 different urine concentrations. WBCs per HPF cutoffs of 3 at low, 6 at medium, and 8 at high urine concentrations should be used to improve pyuria accuracy for urinary tract infection in young children.