Pediatric Appendicitis Score (PAS)

• For patients who are not low risk, next steps include NPO status, IV fluids, analgesia, and imaging or surgical consultation.
• In real life practice, imaging is often obtained simultaneously with labs for the evaluation of appendicitis.
• The PAS can help to determine whether further imaging is needed in cases of an equivocal ultrasound, for example. However a “low risk” score does not completely rule out appendicitis. 
• Use caution in evaluating for appendicitis in younger age groups (age <5 years), as their ability to articulate their symptoms and their overall clinical presentation may vary greatly.

Low Risk PAS (<4)

• Low likelihood of acute appendicitis, imaging may not be warranted.
• The score has a higher negative predictive value (95%) when patients do not have right lower quadrant pain, do not have pain with walking, jumping, or coughing, and have an ANC < 6,750.
• Consider other causes of acute abdominal pain.

Equivocal PAS (4-6)

• Imaging can be helpful for this subgroup of patients.
• Typically, ultrasound is the first study of choice for pediatric patients to reduce the risk of radiation exposure.
• When not available, or if other imaging results are equivocal, cross sectional imaging such as CT abdomen/pelvis with IV contrast can be considered.
• Consider surgical consultation for patients with equivocal scores and imaging where the appendix cannot be visualized.

High Risk PAS (>6)

• Consider surgical consultation prior to or alongside imaging studies for these patients.
• Imaging may still be pursued, but patients should only undergo ultrasound prior to a surgical consult.

• Acute appendicitis can cause severe illness and sepsis. In cases of unstable patients with suspected sepsis, regardless of cause, empiric antibiotic and fluid resuscitation should not be delayed in order to obtain imaging studies or diagnostic tests. 
• Patients in the low risk group according to the PAS do not have zero risk. In other words, a low risk score does not completely rule out the diagnosis of acute appendicitis. Use clinical discretion if imaging or surgical consultation may aid in diagnosis.
• Other diagnoses such as mesenteric adenitis or ovarian torsion may present similarly to acute appendicitis. The PAS should be used in conjunction with clinical assessment to aid in determining further evaluation or consultation for suspected pediatric appendicitis.