opsoclonus myoclonus This latter is a paraneoplastic syndrome characterized by “dancing eyes and dancing feet” and is associated with a favorable cancer prognosis but a poor neurocognitive outcome Neuroblastoma can secrete catecholamines that cause hypertension and vasoactive intestinal peptide (VIP) that causes secretory diarrhea Subcutaneous nodules can occur Clinical Assessment Initial assessment of a child with possible neuroblastoma should include an assessment of the patient’s airway, breathing, and circulation, followed by a complete history and physical examination that focuses on the potential signs and symptoms above Given the risk of cord compression from a retromediastinal or retroperitoneal tumor, all patients should have a thorough neurologic examination including percussing the vertebral bodies, with emergent imaging should neurologic deficits be detected The patient’s blood pressure should be measured and carefully matched against norms for age Signs and symptoms of pain should also be explored to localize potential tumor masses and pain should be treated as needed Laboratory evaluation should include CBC, liver function testing, renal function testing (BUN and creatinine), and urine catecholamines If neuroblastoma is suspected and the disease burden is high, TLS may develop (see “Leukemia” section) If the CBC shows evidence of marrow replacement, platelet and packed red blood cell transfusions may be needed (see Table 98.7 ) A plain film of the chest or abdomen may be useful for detecting calcifications Abdominal ultrasound may help define the location of a mass and its relationship to other structures CT scans should include the suspected site of the primary tumor, the surrounding lymph node groups, and the liver (a common site of metastasis) Management If a thorough evaluation and initial management finds no life-threatening or organthreatening problems, no uncontrolled pain, and no evidence of severe systemic illness, discharge to the care of a pediatric oncologist may be possible Otherwise admission is recommended TUMORS OF THE KIDNEY Goals of Treatment The most critical decision making and care in the ED is the differentiation of emergent from nonemergent Stable patients with newly diagnosed kidney tumors can be managed as outpatients with close subspecialty follow-up CLINICAL PEARL AND PITFALLS