Emergency Department Clinical Pathway for Evaluation/Treatment
of Children with Suspected Appendicitis

  • Reassuring H&P
  • Able to tolerate PO
  • Alternative diagnosis probable
  • Labs as indicated
  • Treat as clinically indicated
  • Discharge, follow-up
Appendicitis: High Probability
Classic features of appendicitis
Appendicitis: Equivocal
Some features of appendicitis
Males, Pre-Pubertal Females
Post-Pubertal Females
  • Consider Laboratory Studies
    • CBC, CRP, BMP, serum HCG, UA POC
  • NPO, IVF, analgesia as indicated
  • Instruct patient not to urinate
  • Consider STI testing
  • Obtain Laboratory Studies
    • Urine HCG as clinically indicated
  • NPO, IVF, analgesia as indicated
  • Obtain RLQ Ultrasound
  • For weight >100 kg, MRI Appy instead
  • Consider US Pelvis with Doppler for post-pubertal females,
    • but do not delay RLQ US
Appendix not Seen
Appendix Normal
  • Consult General Surgery
  • IV Antibiotics
  • Restore intravascular volume
    • NS bolus, maintenance fluids
  • Directly to OR vs
  • Admit General Surgery
Secondary Signs
No Secondary Signs
  • Reassess PE, PO challenge
  • Consider alternative diagnosis
  • Further evaluation as indicated
MRI Appendix
  • Consider alternative diagnoses
  • Review lab results
  • Review PAS, pARC  
  • Consider MR based on risk
  • Consider US Pelvis with Doppler
  • Surgical Consult as indicated
  • Concern for ovarian pathology continue with bladder filling and add US Pelvis with Doppler
Instructions for f/u in 24 hrs
if symptoms progress
As indicated

Pre-Operative Antibiotics for All Patients with Appendicitis

Healthy, Non- Allergic Patients
   Ceftriaxone + Metronidazole

Cephalosporin Allergy
   Ciprofloxacin + Metronidazole

Ill-appearing, Immunocompromised, or Recent Hospitalization > 4 days
   Consult ID

Posted: October 2006
Revised: December 2021
Authors: J. Lavelle, MD; J. Collins, MD; S. Kaplan, MD; B. Ku, MD; C. Jacobstein, MD; M. Mittal, MD; M. Joffe, MD; J. Zorc, MD; M. Nance, MD;