Objectives: Suggestive radiographic studies with nonvisualization of the appendix can present a challenge to clinicians in the evaluation of pediatric abdominal pain. The primary objective of this study was to quantify the accuracy of magnetic resonance imaging (MRI) and of ultrasound (US) in the setting of nonvisualization of the appendix. Secondary objectives reported include sensitivity of MRI and US overall and correlation between MRI and US for diagnosis of appendicitis.Methods: Records of pediatric emergency department patients aged 3 to 21 years undergoing MRI and/ or US for the evaluation of appendicitis were retrospectively reviewed. Radiographs were categorized as a normal appendix, neither demonstrating the appendix nor demonstrating abnormalities consistent with appendicitis; equivocal, not demonstrating the appendix but showing evidence of appendicitis; demonstrating an abnormal appendix consistent with appendicitis; or demonstrating an alternate pathology. The reading was compared with the final diagnosis for accuracy.Results: Of the 589 patients included, 146 had appendicitis. Diagnostic accuracy for studies with a nonvisualized appendix without secondary signs of appendicitis was 100% for MRI and 91.4% (95% CI = 87.3% to 94.2%) for US. Diagnostic accuracy for studies with a nonvisualized appendix with secondary signs of appendicitis was 50% (95% CI = 2.5% to 97.5%) for MRI and 38.9% (95% CI = 18.2% to 64.5%) for US. Appendicitis was ultimately diagnosed in 8.6% of patients with an otherwise negative right lower quadrant (RLQ) US that failed to directly identify the appendix. There was a moderate correlation between US and MRI (q = 0.573, p = 0.0001) when all studies were considered.Conclusions: Magnetic resonance imaging without secondary signs of appendicitis is effective in excluding appendicitis regardless of whether the appendix is directly visualized, while otherwise negative RLQ US that fail to identify the appendix are less useful. Secondary signs of appendicitis without visualization of the appendix were not helpful regardless of radiographic modality. Results of MRI and US correlated moderately well.ACADEMIC EMERGENCY MEDICINE 2016;23:179-185

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investigated pediatric blunt head injury with mild traumatic brain injury (TBI), most discussing the utility of head computed tomography (CT). This was specifically addressed in the Pediatric Emergency Care Applied Research Network (PECARN) study. The goal of this investigation was to look at patients who did not require CT imaging after blunt head injury, and compare the length of stay (LOS) in the ED of patients who received CT imaging versus those who did not.Methods: This is a retrospective review of pediatric patients presenting to the ED of three urban community hospitals with head injuries. Excluded were cases of alcohol intoxication, motor vehicle collisions, and assault victims. Data was extracted including age, sex, detailed history, detailed physical findings, CT scan results, and ED LOS. Presence of PECARN criteria were abstracted. The data was stratified by PECARN criteria and CT scan and tested using Student-t, Chi Square, or Fisher test as appropriate. Significance was set with an alpha of 0.05 (two-tailed). Statistical calculations were performed using SPSS 22.0 (IBM, Inc., Chicago, Illinois, 2012).Results: Between June 1, 2013 and December 31, 2013, 13,118 pediatric patients were evaluated. There were 323 (2.5%) head injuries and 271 patients (2.1%) met inclusion/exclusion criteria. The mean age was 7.5 years (SD: 4.6) with 68.6% male. At least one of the PECARN criteria was met by 21.4% (58/271); while 78.6% (213/ 271) had no PECARN criteria. Patients without PECARN-criteria did not have CT scans in 98.1% of cases while patients with PECARN were not scanned in 44.8% (P<.001) Overall 36 CT scans were done (13.3%). There were five positive CT scans, all in PECARN positive patients (8.6%): three subdural hematoma, one epidural hematoma, and one sinus fracture with pneumocephalus. PECARN negative patients without CT scans had mean length of stay (LOS) of 94.1 minutes versus an increase to 170.2 minutes for the four PECARN-negative patients who did have CT done (Diff: 77.9, 95% CI: 35.1, 120.8, P<.001) Excluding CT-positve patients, CT scanning in PECARN-positive patients also increased ED LOS by 73.4 minutes (95% CI: 30.0, 116.9, P¼.001. Of the 58 PECARN-positive patients, 38 (14.0%) patients had one criteria, 11 (4.1%) had two criteria and 9 (3.3%) had three criteria. The most frequent criteria reported was severe headache (8.9%) followed by severe mechanism of injury (5.9%), altered mental status (5.5%), loss of consciousness (4.8%), emesis (3.7%), GCS<14 (2.6%), and basal skull signs (0.7%) Of the five positive CT scans, one patient had only one PECARN criteria while four patients had two criteria.Conclusion: In this study, 21.4% had at least one PECARN criteria. Patients without any PECARN criteria were not scanned 98.1% of the time. Patients without any PECARN criteria were scanned 1.9% of the time. These patients had an increased LOS by 77.9 minutes. Positive CT scans were found in 8.6% of PECARN-positive patients and none of the PECARN-negative patients.

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