A lumbar puncture (LP) is a common procedure that every emergency physician must master. Pediatric LPs can be challenging for even the most experienced clinician due to small anatomy, difficulty with patient cooperation, and lack of frequency performed. A successful procedure is defined by obtaining cerebrospinal fluid and/or performing a non-traumatic lumbar puncture. There are multiple variables that lead to a successful pediatric lumbar puncture including provider experience, use of anesthesia, and patient positioning. Success rates for pediatric lumbar punctures are variable, with a large range from 34%-75%.1
A 10-year old girl presents with progressively worsening right lower quadrant pain for the last 2 days. She reports having chills and feeling warm. Her review of systems is negative for nausea, vomiting, diarrhea, or urinary symptoms. Her abdominal exam is unremarkable except for some diffuse, mild tenderness with deep palpation in bilateral lower quadrants. Labs: WBC 9 x 10^9/L. Because of radiation exposure concerns, you order an abdominal ultrasound as the initial imaging modality to evaluate for appendicitis. The radiologist’s reading was: “Unable to visualize the appendix.” Now, what do you do?