PEM Source

Your source for all things Pediatric Emergency Medicine

Tips and Tricks

There are several techniques for removing a ring that is stuck on a patient’s finger, starting with the simplest – using ring cutters to cut it off. However, if the patient doesn’t want the ring destroyed, the string technique has been advocated, where a string is wrapped around the finger to compress the edema, then passed under the ring and unwound for removal. An oxygen mask strap works well for this purpose because of its elasticity and flatness; check out this AliEM trick of the trade post https://www.aliem.com/2012/08/trick-of-trade-ring-removal-using/. Also, this site provides a nice overview of the numerous methods https://aneskey.com/ring-removal/. Remember that tungsten and ceramic rings are usually hard to cut, but easy to break using vice or locking pliers.
Hyperemesis due to cannabis use is on the rise, particularly in areas with marijuana legalization. While classically it is seen in chronic, daily users, affected patients sometimes have been using cannabis for less than a year, and may be using it as infrequently as once a week. Patients present with bouts of severe nausea, vomiting, and abdominal pain. A classic symptom is relief with hot showers (due to activation of the TRPV1 receptors). Symptom relief in the ED involves fluid rehydration and ondansetron (although this often no longer works for the patient after multiple bouts). There are also many reports of successful resolution of acute symptoms with benzodiazepines, haloperidol, and topical capsaicin. Curative treatment involves convincing the patient to stop cannabis use. Therein lies the tip, which I just learned from a colleague – a good way to help the patient understand is to tell them they suffer from an “allergy” to marijuana– while some people may be able to use marijuana chronically, they cannot, as it will cause these symptoms. Cessation of cannabis use can result in symptom relief as soon as 12-24 hours but sometimes not for as long as 3 weeks. So let them know how long that “allergic reaction” can continue!
Improve success of vagal maneuvers for patients in simple SVT by adding the "REVERT" maneuver: the patient performs valsalva maneuver in a semi-recumbent position, then the practitioner immediately puts the patient into a supine position with legs passively raised at a 45 degree angle. This maneuver improved conversion to NSR at 1 minute from 17% to 43%, for a NNT of 3.8. A simple way to have a patient perform a valsalva maneuver is to blow on the tip of a 10cc syringe hard enough to move the plunger. For an excellent discussion of the trial and a video of the maneuver see http://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/ REVERT for SVT
It's July, so good time to review the basics. For pediatric resuscitations of any type, the mnemonic ABCDEFG is great - Airway, Breathing, Circulation, Don't Ever Forget Glucose. Children have lower reserves and become hypoglycemic more easily than adults when stressed. This mnemonic also came from a fantastic quick review of pediatric congenital heart disease presentations from the awesome folks at emergencymedicinecases.com
Disclosure: I have no ties whatsoever to GoodRx When prescribing a medication to a patient who may need to pay out of pocket, use the GoodRx app or website to compare the prices at local pharmacies nearby, and sometimes, to find coupons that patients can use. This article explains how GoodRx makes money and why it exists.
Staying with the topic of urine... investigators at University of Pittsburgh have derived and validated a UTI risk calculator for patients aged 2-23 months. The calculator (UTICalc) is linked from the On Shift page of PEMsource under the heading Neonatal / Infant, and can be found at https://uticalc.pitt.edu/ The study by Shaikh et al was published online on April 16, 2018 at JAMA pediatrics here. Some highlights: derived on consecutive 2-23mo old febrile patients evaluated in ED for UTI, 542 with UTI and 1144 matched controls without UTI. Validated on a dataset of 380 patients, 30 with UTI. Investigators estimate sensitivity of UTICalc at 95-100% and state that use of the calculator results in approximately 10 patients tested for every 1 UTI found; UTICalc outperformed the current AAP algorithm in both of these outcomes. Users can also enter urinalysis dip, micro, and gram stain results to obtain post-test probabilities. Investigators suggest testing when pre-test probability is 2% or higher, and treating when post-test probability is 5% or higher. Further validation is warranted, but UTICalc may be useful in shared decision making with parents to give a ballpark risk estimate.
Nothing slows down the ED flow like waiting for the urine flow of an infant or toddler. Whether or not to screen for UTI with a clean catch urine vs obtain a catheterized specimen will be left for another discussion, but here are some of the latest techniques described for obtaining clean catch specimens. (For all, clean genital area thoroughly first) "CCU" procedure, first described by Herreros Fernandez et al, Arch Dis Child 2013;98:27, 80 infants aged < 30 days. Patient held under armpits with legs dangling in upright position. Suprapubic area gently tapped at 100 taps/minute x 30 seconds, followed by light circular massage of the lower back x 30 seconds. Repeat these maneuvers until urine collected. Successful in 86% of the infants with median time to collection 45 seconds. Labrosse et al, Pediatrics 2016;138(3):320160573 studied this CCU method with the addition of another person flexing the hips of female children, 126 infants < 6 months old. CCU method successful in providing urine sample within 300 seconds in 49%, median time 45 seconds. More successful in < 3 months old than 3-6 months old. "Quick-Wee" method, Kaufman et al, BMJ 2017;357:j1341, 354 infants aged 1-12mos With patient supine, suprapubic skin was rubbed with gauze soaked in cold saline. 31% voided within 5 minutes using Quick-Wee vs. 12% in the standard collection group. Finally, Naimer in Pediatr Emerg Care 2017;33:446 describes cutting a slit in an infant's diaper to push the urine collection bag through when obtaining a bag urine. This both helps to secure the bag and allows parents and nurses to see when the specimen has been obtained.
A quick rule of thumb for estimating whether the QTc is normal is to look for it to be half the preceding RR interval (see figure below from ECG Interpretation). However, note that this rule of thumb is not accurate at heart rates < 62 bpm. Also, it is conservative at heart rates > 66 bpm. An excellent thorough explanation can be found at Dr. Smith's ECG blog here. For heart rates < 62 bpm, Dr. Smith suggests using QT < 40% of the preceding RR as rule of thumb. Also, be careful - computer calculated QTc are often incorrect - may need to get those calipers out! (or just count little boxes - each one is 0.04 sec, or 40msec). The most common formula used to correct QT is the Bazett formula QTc = QT / sqrt(RR), although this formula produces false positives at high heart rates. Here is a calculator at MedCalc that will do the math for you! QT half RR ecg-interpretation.blogspot.com
Your local hospital cafeteria can be a useful resource in managing your PED patients:
  1. Sugar liberally applied to the edema of a paraphimosis or rectal prolapse may help decrease swelling and improve reduction efforts
  2. A mayonnaise packet provides useful lubricant for removing a tight ring
  3. Tannins from a tea bag (particularly black tea) can help clotting with post dental extraction bleeding (place a moistened tea bag in the socket and have the patient apply pressure by biting down)
  4. A packet of sugar + 10 mL sterile water = make your own sucrose solution for treatment of pain associated with procedures in infants
Know of any more? Comment below!
Having trouble with bag valve mask ventilation? Don't forget to use adjunctive airways - nasopharyngeal for conscious patients, oropharyngeal for unconscious. Reuben Strayer's great video here advocates placing 2 nasal airways and an oral airway, then bagging over those, for the difficult to bag patient. You can also place an ETT adaptor (pull the adaptor off the tube) into a nasal airway and bag the nasal airway directly - see more information here. Don't forget, nasal airways are measured from the nostril to the tragus of the ear, and oral airways are measured from the center of the mouth to the angle of the jaw.
The SAMPLE mnemonic is typically used to remember the important brief history needed for trauma patients: Symptoms, Allergies, Meds, Past medical history, Last meal, and Events leading up to the trauma. Think of the mnemonic as SAMPLE-PT and add in Pregnancy (history, testing) and Tetanus status. Also, ABCDE is used to recall Airway, Breathing, Circulation, Disability, Exposure in managing trauma patients. Keep going in the alphabet and add on FAST, Gastric tube (NG or OG) and Glucose check, Hemoglobins (serial), IV (two large-bore).
Having trouble finding the ICD-10 code in your electronic medical record? Do a Google search "ICD 10" + whatever diagnosis you're looking for. For example, searching "ICD 10 parent concern" turns up "Z 71.1 Person with feared complaint in whom no diagnosis is made." Here's another useful one "R 68.11 Excessive crying of infant (baby)." Hope everyone has a Happy Thanksgiving, and no one feels the need to use "Z 63.1 Problems in relationships with in-laws."
Use the PATCH mnemonic to remember transdermal medications Child with unusual symptoms, potential toxidrome? Look all over their body for a medication patch. Many are transparent or look like bandaids. P   Pain (fentanyl, lidocaine) A   Anti-cholinergic (scopolamine) T   Tobacco (nicotine) C   Clonidine H   Hormones (estrogen, testosterone)
Some tips and tricks for examining children's throats:
  1. Don't do it until after you've gotten your lung, heart, and abdomen exam - once you make them cry, it's game over
  2. A helpful position for young children is to sit on the parent's lap facing the parent, legs straddling the parent. Then, have the parent lean the child back so he/she is laying supine on the parent's knees with the head hanging back (the dentist chair view)
  3. Older children can be asked to pant like a dog, scream, or sing "ah ah ah ah ah" opera-style
  4. Sometimes if you do the ear exam first, the child will yell and then you can see the throat
Placing topical anesthetic (EMLA, LMX4) on skin abscesses may result in spontaneous drainage, precluding need for incision. If topical anesthetic doesn't result in spontaneous drainage, it at least provides some skin anesthesia prior to local anesthetic injection for incision and drainage procedure. In one published retrospective study, 26 of 110 patients with the topical anesthetic LMX4 placed had spontaneous drainage, 3 of whom required no further intervention: https://www.ncbi.nlm.nih.gov/pubmed/21129885
Thanks to Tim Horeczko pemplaybook.org for tube-tape-tap mnemonic Peds Sizing  
What do you do if you have a patient with a tooth avulsion and no commercial periodontal dressing? You can use the flexible thin metal nasal bridge on an N95 mask and glue the reimplanted avulsed tooth to an adjacent tooth using 2-octocyanoacrylate skin adhesive (made for laceration repair). N95 maskN95 mask, Amazon.com See this discussed in an Aliem.com trick of the trade See more on tooth avulsion management from NCEMI Common Simple Emergencies
We all know the importance of lining up the two sides of a laceration that goes through the vermillion border of a lip laceration. Injecting lidocaine or swelling from the trauma itself can make this difficult. Use a skin marker to outline the the vermillion border on each side, making this easier. Vermillion border closing the gap This photo comes from this great tutorial on Closing the Gap For lip lacerations requiring repair beyond simple alignment, consult a plastic surgeon. Here is an interesting discussion on Plastic Surgery Key
The Katz extractor is a great tool for removing nasal foreign bodies, as shown on the video here (I have no financial interests in this product). But, if you don't have one available, get a Fogarty cardiac embolectomy catheter from the O.R., and this will do nicely as well. For many many tips and tricks on removing foreign bodies in the head and neck, go to PEMplaybook
A young girl comes in c/o dysuria and the urine is stone cold normal. What else can explain her symptoms? (BTW, you must do a GU exam at this point). Adhesions (labial) Bubble bath (and other soaps, irritants) Candida (particularly if recently on antibiotics, or at risk for new onset diabetes) Detergent (harsh laundry detergent, new tight clothing / underwear) Enterobius (aka pinworms) Foreign body (typically toilet paper) Gonorrhea & chlamydia (in sexually active or sexually abused) Hygiene, poor (teach girls to wipe front to back, consider having them sit on toilet backwards to urinate, especially if they are overweight/obese, to encourage complete voiding and keep urine from collecting in vagina) Irritation (masturbation is a common normal behavior in preschoolers)
Easily remember the approximate Oxygen-Hemoglobin dissociation curve as follows: PaO2 40 corresponds to SaO2 70% PaO2 50 corresponds to SaO2 80% PaO2 60 corresponds to SaO2 90% This rule along with a lot of other handy RT knowledge can be found here Read more about PaO2 vs SaO2 at airwayjedi.com here
For minor procedures in the PED, analgesia, anxiolysis, and distraction are the most important therapies to promote cooperation and procedural success. See our algorithm for procedural pain here. But sometimes, even with all of those, physical restraint is needed. Most PEM practitioners know how to wrap a child up using a simple bedsheet folded lengthwise twice, and then wrapped over one arm, behind the back, and over the other arm, and then around the child as seen here. Another technique if you have a pillowcase is to put both arms behind the child into a pillowcase and then lay the child down onto the pillowcase, thus restraining the arms (see picture below). (This technique was published under the colorful name "Superhero Cape Burrito" here). Finally, a c-collar can be useful to immobilize the head for face and scalp laceration repairs. pillowcase-restraint
Mucosal atomizer devices improve administration of intranasal medications. Intranasal fentanyl 1.5 mcg/kg is a great way to give stronger pain medication (eg for fractures) without placing an IV. Intranasal midazolam 0.2 mg/kg (use concentrated 5mg/mL form to keep total volume < 1mL per nostril) can be used to treat active seizures when no IV access is yet obtained, or as an anxiolytic for procedures. Intranasal naloxone at a standard dose of 4 mg is being provided to opiate addicts to use in case of overdose. A commercial device is available, but currently some lots are being recalled (check here for recalled lots), or you may simply not have one in stock. Here's how to make an improvised atomizer courtesy of Faisal Alghamdi of KFMC Riyadh. Hook up a 3 way stopcock with the lever turned so that all 3 ports are open to 1) a 14 or 16 gauge angiocath, 2) a syringe with the medication you wish to deliver, and 3) oxygen tubing. Hook the other end of the oxygen tubing up to oxygen and turn up to 5-10 L/min. Place the angiocath in the nostril and gently & slowly depress the plunger of the medication. See picture and video below. img_1123 Click here to see a video and compare to commercial device here
You're seeing a 5 day old with a fever of 39. Attempts to get IV access have been unsuccessful. The child is alert and not toxic appearing, but you'd like to get empiric antibiotics started within the first hour of evaluation. What are your options other than drilling with an IO or embarking on a potentially long sweaty frustrating attempt at a central line in a neonate? An ultrasound-guided peripheral line is one possibility if you have the skills. Another vascular access method to keep in mind is the umbilical venous line - the umbilical vein can stay patent up to 7-10 days of life! Soak the dry cord in saline soaked gauze to soften it, use a scalpel to cut straight across at 1-2cm from the base, look for the single large vein, insert a pre-flushed catheter with gentle pressure into the vein while pulling back on a syringe until you see a flash of blood. For more info: https://blogs.brown.edu/emergency-medicine-residency/emergent-umbilical-venous-catheter-uvc-placement/ The "Fast-cath" technique advocates using a 14 gauge angiocath http://www.emsworld.com/article/10852257/paramedic-umbilical-vein-catheterization-for-newborns Find resources for born out of asepsis babies on our algorithms page, including how to make umbilical venous catheter mini kits to keep in your ED. http://pemsource.org/algorithms/boa-newly-born/
Use a glass test tube or specimen tube to press on a rash to see if it blanches - remember, petechiae and purpura don't blanch. You can also use a glass test tube as a mini-anoscope to blanch surrounding mucosa and assist in identifying anal fissures in infants. (Anal fissures are one of the many possible causes of GI bleeding in children - check out pemplaybook.org's latest podcast on GI bleeding) glass_test-focus-none-width-800 (From https://www.meningitisnow.org/meningitis-explained/signs-and-symptoms/glass-test/)  
Check out these cuties that CHOC PED physician and former Harbor PEM fellow Seth Brindis makes! See below for step-by-step instructions and more ideas for toys to make with medical supplies. Tongue Depressor Puppets Here are instructions put together by Seth, and a video of them in action. And here are some more ideas for toys to make in the PED (thanks to former Harbor PEM fellow Casey Buitenhuys for the glowstick idea): make-your-own-toys
What can you do if your patient is maxed out on ondansetron but still feels nauseated? A recent study in Annals EM found a positive treatment effect of deeply inhaling from a standard isopropyl alcohol pad held 2.5 cm from the patient's nose. Patients inhaled for 60 seconds at 0, 2, and 4 minutes (stopping if nausea resolved), and nausea was rated up to time 10 minutes. (Caveat: this study enrolled only adults). A 2012 Cochrane review also found isopropyl alcohol inhalation beneficial, although less so than standard antiemetic medications. Also, anecdotally, for dehydrated patients, rehydration and resolution of ketosis is thought to improve nausea and vomiting. For the grammar police out there, clarification of nauseated vs nauseous can be found here
Measure your fingernails to see which is closest to 1cm - now you will always have a 1cm "ruler" with which to measure lesions, lacerations, discolorations, etc. Measure nail  
Use a sterile saline respiratory ampule: wet the fluorescein strip with the saline, squeeze out half of the saline, then suck the yellow fluorescein liquid back up into the ampule. Now you can use the ampule as an eyedropper. For uncooperative kids, lay them supine and squeeze the liquid into the medial corner of the closed eye - when they open their eyes it will run into the eye. Respiratory Ampules (Amazon.com) For additional methods, see AliEM's great tricks of the trade post at: https://www.aliem.com/2015/tricks-of-the-trade-fluorescein-eye/
Cut a narrow caliber ETT short to create a semi-rigid suction catheter for foreign body removal of the nose or ears.  (From EM News September 2009, Tricks of the Trade: An Improvised, Semi-Rigid, Nasal/Aural Suction Catheter, by Timothy McGuirk DO)
For a forhead laceration, place gauze over patient's eye and hairline, cut a hole in center of a large tegaderm, peel and stick with the laceration positioned in the middle of the hole. Now you can use tissue adhesive to close the laceration without worrying about the adhesive running into the patient's eye, hair, or down the face.
Explain to parents - colds are called colds because viruses thrive in cold temperatures, so fevers are the body's natural way to fight off the cold
Use a laryngoscope upside down as a tongue blade, or use a self-lighting pelvic exam speculum (remove top half of the speculum)

PEM Questions

(Click the link to comment and to vote - voting not working through email, sorry!) A 5yo girl comes in for chest pain for 6 hours and is noted to have a heart rate of 250 that is not varying. Review of the electronic medical record reveals a history of WPW. Mom says she has not had an episode of fast heart rate since age 3 weeks when she was first diagnosed. She is not on any medications. She is awake and alert, and her blood pressure is 85/45. SVT WPW 1 [yop_poll id="67"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 16 year old obese teen with no previous history of diabetes who presents with recent viral URI symptoms and increasing altered mental status over the last 8 hours. Her temperature is 37.9, heart rate 140, resp rate 22, and BP 90/35.  Blood glucose is 950, Na 130, K 3.4, and urine negative for ketones. The teen is confused and has a GCS of 13. [yop_poll id="66"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 16 year old football player is brought in with severe right knee pain after being hit from the front. He states that he thought his knee was displaced initially, but now it looks back in place. He has no obvious deformity or effusion on observation, and no ecchymosis. Instability testing is difficult due to the patient’s pain. Radiographs are negative for fracture or dislocation. Dorsalis pedis pulses are palpable and normal bilaterally. [yop_poll id="65"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old child has a flat lesion of the entire left forehead and upper eyelid the color of light red wine that has been present since birth. The family has presented to the ED because they are concerned that the child has right sided weakness.   sturge-weber-1 https://mindfulmema.wordpress.com/tag/sturge-weber/ [yop_poll id="64"]  
(Click the link to comment and to vote - voting not working through email, sorry!)   Match the classic serum electrolyte / acid-base findings with the pediatric condition: 1) hypochloremic hypokalemic metabolic alkalosis 2) hyponatremic hyperkalemic metabolic acidosis 3) hyponatremic normokalemic metabolic acidosis 4) hypercalcemic metabolic alkalosis A) DKA B) pyloric stenosis C) milk alkali syndrome D) congenital adrenal hyperplasia [yop_poll id="63"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 6yo girl presents with palpable purpura of both legs for 2 days. She has not had any fever and is well appearing. Her labs, including CBC, electrolytes, BUN, Creatinine, and ESR are normal. She does not complain of any pain. Her vital signs are temperature 37.5 C, HR 90, RR 20, BP 90/45. She has no abdominal tenderness, vomiting, respiratory difficulty, joint pain or swelling, and her urination has been normal. Her stool guaiac is negative. [yop_poll id="62"]
(Click the link to comment and to vote - voting not working through email, sorry!) 14yo boy presents with LLQ abdominal pain and left hip pain for 5 days. He has not had any fever. He is an active baseball player and skinned his right knee the week before. On exam, he prefers to keep his left hip flexed at 90 degrees, walks with a limp and lordosis, and is most comfortable laying on his right side with his hips flexed. He has LLQ abdominal tenderness and has maximal pain with any attempt to extend or internally rotate his left hip. Genitourinary exam is normal. [yop_poll id="61"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17yo boy presents with a round lesion similar to that noted below, but on his penis, noted 1 hour after taking a dose of TMP-SMX that was prescribed to him for “stomach infection.” He had 2 episodes of non-bloody diarrhea 2 days ago and went to a clinic and received the prescription, which he was unable to fill until today. The diarrhea has actually improved. He has no fever. The rash is not painful or itchy. He mentions that he previously had a similar rash in the same place after taking the same drug a few years ago. Fixed drug eruptionWikimedia Commons Donald M. Pillsbury, M.D., and Clarence S. Livingood [yop_poll id="60"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="59"]
(Click the link to comment and to vote - voting not working through email, sorry!) A toddler is accidentally left in the car during summer. Luckily, a bystander sees her and calls 911. The car is broken into, and the patient is brought to the PED. She has a temperature of 105.9. [yop_poll id="58"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 4 year old child comes in 20 minutes after falling with avulsion of her left upper lateral incisor. The parents have brought the tooth in a tissue. The entire crown and root are present. There is no active bleeding from the socket. The remainder of her exam is normal; she is able to open her mouth widely without pain and has no bony tenderness over her facial bones or jaw. [yop_poll id="57"]
(Click the link to comment and to vote - voting not working through email, sorry!) 8yo girl with history of asthma presents with increased work of breathing x 1 day. She is alert but anxious appearing, tachypneic, has retractions and flaring, and her O2 sat is 88% on room air. She has poor air movement and few wheezes are heard. She is given two 5mg albuterol nebulized treatments and oral steroids. An initial venous blood gas had a pH of 7.45 and pCO2 of 34. A repeat blood gas shows a pH of 7.33 and pCO2 48, O2 sat on oxygen with 3rdnebulized albuterol is 91%; her mental status is unchanged [yop_poll id="56"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 9 month old baby is brought in with this problem, first noted a few hours prior. Hair tourniquet By James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], from Wikimedia Commons [yop_poll id="55"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 19yo woman who is 33 weeks pregnant presents with contractions every 2 minutes and thinks her water broke. She has no prenatal care records available, and was only recently diagnosed as pregnant at an outside clinic. On exam, she is 9cm dilated and +1 station. She is screaming with pain. [yop_poll id="54"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="53"]
(Click the link to comment and to vote - voting not working through email, sorry!) You design a study to compare a new antiviral to treat herpangina to placebo. During the trial, some of the parents stop giving their children the new drug because it tastes bad, and some (but fewer) parents stop giving their children the placebo because they forget to give it. During the analysis, you compare the outcomes based on the patients’ assignment to their original group. [yop_poll id="52"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 year old recently moved to the U.S. from Mexico with left sided chest pain for one day, and a fever to 38.2. Lung sounds are clear, the O2 sat is 100% on room air, and the CXR is negative. The ECG shows diffuse 1mm ST elevations and PR depression. The patient is well appearing with normal vital signs and hemodynamics. [yop_poll id="49"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 13 year old girl with heavy prolonged menses x 10 days who appears pale to her parents. She had menarche at age 11, and has had heavy irregular menses since then. She actually feels that her menses is slowing down and she is currently using 1-2 pads per day. She has never had any other bleeding. Her HR is 90, and BP 100/50. Her hemoglobin is 9 and her MCV is 65. [yop_poll id="50"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 month old comes in with diarrhea x 3 days, 5 times per day initially now 3 times per day, non-bloody, no fever, no vomiting. The patient was seen in the ED the day before, and had stool culture sent which was negative, C. difficile toxin which was positive, and stool WBC negative. [yop_poll id="51"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 11 year old girl was sitting with lap belt only in the back seat of a minivan involved in a motor vehicle accident where her car was rear-ended. She has a “seat belt sign,” or ecchymosis over her lower abdomen. Her CT abdomen with contrast is normal, but she continues to have tenderness to palpation. However, she states she is hungry. [yop_poll id="48"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing an 8 month old child with viral URI symptoms and pulling at the left ear. The child has not had any fever, is fully immunized, and is well appearing and playful. The right ear is translucent. The left ear is erythematous, with no bulging, perforation, or air-fluid level. Mobility is normal on pneumatic otoscopy. The child had one previous ear infection diagnosed at age 5 months. [yop_poll id="47"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 year old child with cochlear implants placed 8 months ago. The child has fever, headache, vomiting, altered mental status, and meningismus. The implant sites are well healed and show no signs of local infection. [yop_poll id="46"]
(Click the link to comment and to vote - voting not working through email, sorry!) D5 ¼ NS is no longer recommended for maintenance fluids in hospitalized young infants. Why not? [yop_poll id="45"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are caring for a 4 year old child struck by a car. The child has significant maxillofacial trauma, a large parietal hematoma, and a GCS score of 7. Attempts to intubate with direct and video laryngoscopy have been unsuccessful due to blood obscuring visualization of the airway, and you are only partially able to oxygenate and ventilate the child with bag-mask ventilation, with an O2 sat on 100% FiO2 of 80%. [yop_poll id="44"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2yo child is brought in after having taken some of Grandma’s “heart medicine.” Because the pills are kept in an unlabeled box and not their original container, the parents don’t know what the medication was. The child has sinus bradycardia with frequent PVC’s on the ECG, a blood glucose of 90; electrolytes on the i-stat are normal except for a slightly elevated potassium level. [yop_poll id="43"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 10 month old infant with history of constipation comes in with a 1cm dark red (but not dusky) painless mass extruding from the anus. The patient is afebrile, well appearing and playful, and the remainder of the exam is unremarkable. Rectal_Prolapse_Toddler_1 Wikimedia Commons, user BellaVuk [yop_poll id="42"]
(Click the link to comment and to vote - voting not working through email, sorry!) You design a trial comparing two different techniques for draining skin abscesses: standard I&D with packing vs. loop drainage. Your chosen outcome is the proportion of patients that require a second drainage procedure. You expect to enroll 100 patients in each group, and expect an average of 10% to require a second drainage procedure. [yop_poll id="41"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 13 year old girl presents with sudden onset sharp RLQ pain radiating toward her groin, along with nausea and vomiting once, non-bloody, non-bilious. [yop_poll id="40"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 4 year old with ventriculoperitoneal shunt revision 1 month ago, presents with headache and vomiting and increased sleepiness according to mom. The patient is well appearing and nontoxic, tolerating po’s in the ED, and has a normal funduscopic and neurologic exam. He got acetaminophen 2 hours ago and has no headache currently. [yop_poll id="39"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old is brought in because all of his fingernails and toenails are falling off, painlessly. On review of the ED electronic medical record, he was seen 6 weeks ago and diagnosed with a viral infection. What viral infection did he have? [yop_poll id="38"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 3 year old child sustains a cold water submersion injury. He is brought in with a core temperature of 30 degrees C, in ventricular fibrillation, and is successfully defibrillated and intubated. Rewarming is occurring by: removing wet clothes, forced air warming blanket, warmed IV fluids to 40-44C, warmed humidified oxygen at 42-46C. What rate and endpoint of rewarming is best? [yop_poll id="37"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 14 month old is brought in with lethargy and obtundation. The patient is breathing spontaneously and has stable vital signs. The parents admit that they were having a party with alcohol and recreational drugs present, and the toddler had been walking around. [yop_poll id="36"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old uncircumcised boy is brought in because his parents are concerned that they cannot retract his foreskin. On exam he has phimosis, but there are no signs of inflammation or swelling and no palpable scarring or fibrosis. The patient is asymptomatic and has experienced no ballooning, dysuria, incontinence, dribbling, or recurrent balanoposthitis or UTI. [yop_poll id="35"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 18 month old child has sustained an arm fracture. Per the parent, the 4 year old sibling was carrying the child and tripped. [yop_poll id="34"]
(Click the link to comment and to vote - voting not working through email, sorry!) Teardrop pupil www.jems.com A 2 year old toddler comes in from the playground crying and rubbing at his right eye. Exam is as above. [yop_poll id="33"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 15 year old girl is brought in by her uncle for a chief complaint of vaginal discharge (he explains that her parents are working and unable to bring her in). She has yellow vaginal discharge and cervical motion tenderness on exam. Her pelvic exam is otherwise unremarkable. She has a linear bruise on her neck, some circular marks on her right dorsal hand, and some linear hyperpigmented marks on her right volar wrist. She shrugs her shoulders when asked how these occurred. Her uncle states that she “does it to herself.” She avoids eye contact, is not very conversant, and her uncle answers most of her questions for her. She shakes her head “no” when asked about depression or suicidality. [yop_poll id="32"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old was bitten by the family cat superficially on his right index finger, 3 days ago. He presents now with redness, warmth, and pain over the volar aspect of his index finger. [yop_poll id="31"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy was scuba diving with his father. Soon after coming to surface, he began to experience symptoms of decompression illness, including joint pains, itchiness, ataxia, paresthesias, and confusion. He has been placed on 100% oxygen by non-rebreather and an IV has been placed and the plan is to transport him to a facility with a hyperbaric chamber. [yop_poll id="30"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8 day old male is brought in with bilateral breast enlargement. They seem slightly tender, but there is no redness, fluctuance, or fever. The parents have noted discharge of a milky substance. [yop_poll id="29"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy comes is brought in to the ED at 2am for severe retrosternal chest pain that awoke him from sleep. He was well prior to going to bed at 11:30pm, and denies fever, cough, radiation of the pain, vomiting, trauma, foreign body ingestion. He has a past medical history of appendectomy 8 months prior, acne for which he takes an oral antibiotic and uses a topical cream daily, and mild intermittent asthma for which he uses an inhaler once or twice a year "when the weather changes." He is a straight A student applying to colleges currently. His physical examination is normal, as is a CXR and ECG. What is the probable cause of his chest pain? [yop_poll id="28"]
(Click the link to comment and to vote - voting not working through email, sorry!) Put these causes of pediatric limp in order of what age they typically present, from youngest to oldest:
  1. Legg-Calve-Perthes disease
  2. Developmental dysplasia of the hip
  3. Slipped capital femoral epiphysis
  4. Nondisplaced hairline oblique fracture of the tibia w/o history of trauma
[yop_poll id="27"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following patients that sustained electrical injury requires further observation in the ED or admission (should not be discharged home now)? A) A toddler that bit on an electrical cord, has an oral commissure burn, but has normal labs and ECG and is tolerating po’s and has no active bleeding B) A 4 year old that put a fork into a European socket and sustained a small burn to the hand, is asymptomatic, has normal CK and ECG and soft compartments C) A teen who was running from law enforcement and was brought in with a retained taser dart, which has been subsequently removed, and who is currently asymptomatic D) A teen who touched a downed power line and sustained electrical shock, labs and ECG are normal and is currently asymptomatic [yop_poll id="26"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are triaging patients from a multi-casualty incident. The following patients are seen: Patient A: Approximately 2 years old, ambulatory, crying, large 8cm parietal hematoma, obvious right humeral deformity Patient B: Approximately 5 years old, unresponsive, apneic after airway positioning and 5 rescue breaths, weak palpable pulse Patient C: Approximately 3 years old, responsive to painful stimuli, breathing at 40 breaths per minute, very weak palpable pulse Patient D: Approximately 7 years old, unresponsive, breathing at 30 breaths per minute, weak palpable pulse [yop_poll id="25"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old child recently brought from a third world country with PMH of an unrepaired hole in the heart and mild cyanosis is brought in to the ED. The patient fed in the AM, then began to cry and became unconsolable, hyperpneic, and deeply cyanotic. On arrival, the patient has a temp of 37.6, HR 180, RR 60, BP unobtainable, O2 sat 40% on room air. [yop_poll id="24"]
(Click the link to comment and to vote - voting not working through email, sorry!) A previously healthy 5 year old boy with PMH of ADHD presents with 9 days of lethargy, fever, vomiting, diarrhea, and weight loss. He recently was diagnosed with strep pharyngitis and treated with amoxicillin for 3 days. His vital signs are: temp 39 C, HR 140, RR 24, BP 154/99, O2 sat 99% on room air. His exam is significant for agitation and restlessness, and tachycardia with bounding pulses and a hyperdynamic PMI. His mother feels that his anterior neck looks swollen. [yop_poll id="23"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 year old fully immunized patient with 2 weeks of new onset bedwetting, 3 days of cough and fever, and 2 days of increased work of breathing. Initial POC labs are significant for a blood sugar of 450 and a pH of 7.11, Na 130, K 3.4. You start a 20 cc/kg NS bolus and send a full set of labs. The patient is complaining of headache and is lethargic initially, becoming increasingly obtunded over the first half hour in the ED. [yop_poll id="22"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are evaluating the electrocardiogram of a 2 year old boy. The patient presented for fever and the ECG was inadvertently ordered on him instead of another patient. [yop_poll id="21"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 6 week old ex-30 4/7 weeks twin A male infant was seen at an outside clinic because his parents felt that his heart was beating faster than his twin sibling’s and was found to have a hemoglobin of 7.9 g/dL. The clinic referred him in to the ED for blood transfusion and hematology consultation. The heart rate is 165 bpm on the monitor, blood pressure is 74/40, cap refill is < 2 seconds, and color is pink. The remainder of his CBC is normal, and the patient is afebrile, feeding and growing well, and asymptomatic except for his heart rate. Reticulocyte count is 4.77%. [yop_poll id="20"]
(Click the link to comment and to vote - voting not working through email, sorry!) You receive word that the clinic is rushing over a patient with a genetic syndrome and respiratory distress. You have a few moments to look in the electronic chart of the patient and set up the resuscitation room. Which of the following syndromes would make you concerned for a potential difficult airway scenario? [yop_poll id="19"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8 year old boy presents after taking 3-4 of grandma’s pills about an hour prior. It is unknown what Grandma takes, but she has “chronic pain, a heart condition, high blood pressure, and sugar problems”. He is altered, but arousable to stimuli and answers questions. He says he took the pills because he was “curious.” His vital signs are: Temp 36.6, HR 49, RR 12, BP 80/40, O2 sat 98% on room air. Physical exam is significant only for miosis, bradycardia, and somewhat weak pulses. Bedside glucose is 100. [yop_poll id="18"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following is true about erythema multiforme major, Stevens-Johnson syndrome, and toxic epidermal necrolysis? [yop_poll id="17"]
(Click the link to comment and to vote - voting not working through email, sorry!) Several members of a family present to the cruise ship infirmary of an Alaskan cruise. They just ate a lunch consisting of tuna salad sandwiches. For breakfast they had a buffet of pancakes and waffles, and last night they ate a shellfish feast dinner which included raw oysters, crab, clams, scallops, and fish. For dessert they had ice cream. They have also been visiting the bar onboard. They are all experiencing abdominal cramping, nausea, vomiting, and frequent watery diarrhea. Some have low-grade fever and chills. Which meal most likely caused their symptoms? [yop_poll id="16"]
(Click the link to comment and to vote - voting not working through email, sorry!) You have sutured a 2cm forhead laceration on a 4yo boy using 6-0 nylon sutures. [yop_poll id="15"]
Impetigo http://diseasespictures.com/ What is the best treatment for this 3 year old patient’s rash? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="14"]
You are caring for a 6yo oncology patient presenting in septic shock. Although he is oxygenating and ventilating well at this time, you plan to intubate him to reduce his metabolic work. The most important pre- treatment before rapid sequence intubation (RSI) is: (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="13"]
A family obtained tuna from the local farmer’s market and prepared it for dinner. The children thought the fish tasted weird, peppery or metallic, but the parents did not, and told the children to stop complaining and eat dinner. Within 20 minutes of consumption, the children complain of headache, dizziness, pruritis, abdominal cramping, and nausea. They appear somewhat flushed in the face, neck, and chest. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="12"]
Which of the following cervical spine findings would you expect to be less common in a young child as compared to an adolescent or adult? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="11"]  
Jellyfish en.wikipedia.org (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="10"]
A 12yo girl presents to the ED in December with fever for 4 days, malaise, and pain in the right thigh gradually leading to her having difficulty walking. There is no history of trauma, although she did play a lot of basketball 1 week ago. She is alert and oriented. Physical exam of her leg is unremarkable except for diffuse pain. She has no rash nor joint swelling or erythema. Her vital signs are: temp 39.1, HR 165, RR 22, BP 85/44. Labs show an elevated WBC count with a bandemia, a BUN of 20 with a creatinine of 2.2, and mildly elevated transaminases with a bilirubin of 2.4. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="9"]
A 19yo man presents with his 3rd bout of unremitting nausea and vomiting. He has been admitted twice before and treated with ondansetron and IV fluids. He was noted to take frequent long showers while admitted. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="8"]
A 3 year old comes in after falling 3 feet from the top of a kiddie slide onto cement, hitting his head. His only +PECARN symptom is 2 episodes of vomiting in the 2 hours since the fall. The medical student seeing him states to you that he is PECARN+ and he has discussed CT with the parents. What is the approximate risk of clinically important traumatic brain injury in this patient? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="7"]
A 10yo girl comes home from a family vacation to Florida in June, where she swam in the ocean. She has an itchy rash in the area covered by her bathing suit that started soon after swimming in the ocean and is still present 3 days later. Seabathers   http://www.medicinenet.com (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="6"]
A 16yo girl presents to the ED with symptoms and rash consistent with varicella (chickenpox). She was never vaccinated, as a personal family choice. She also recently gave birth. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="5"]
A 19yo man presents with progressively worsening extremity numbness in a glove and stocking distribution and ataxia x 1 month. He has areflexia, weakness, and a wide-based gait on exam. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="4"]
NEW! Vote your answer and see what others voted for. Correct answer will be in Comments in a few days. A 14yo female soccer player comes to the ED complaining of bilateral knee pain x 1 month, right greater than left. She does not recall a specific traumatic injury or fall, nor of any knee swelling, popping, or locking. The pain is worse after soccer practice or a game, and after getting up from sitting for a prolonged period such as her 2-hour block classes. The pain is described as behind the knee cap. There is no knee effusion, and there is full active range of motion. She has been afebrile throughout the course. [yop_poll id="1"]
A 10yo boy obtained a pet rat from a commercial pet store. Upon returning home, his new pet promptly bit him. 5 days later, he has fever, chills, severe headache, polyarthralgias, and a maculopapular rash with some petechiae that developed after 2 days of fever. What organism is the most likely cause for the boy’s symptoms? A. Staphylococcus aureus B. Group A Streptococcus pyogenes C. Eikenella corrodens D. Rabies virus E. Streptobacillus moniliformus
A 16yo boy just returned from a vacation to the U.S. Virgin Islands. On the flight, he developed abdominal pain, nausea, vomiting, which he initially attributed to airsickness. He came straight from the airport to the ED, and now he also complains of lingual and circumoral paresthesias, painful paresthesias of his hands and feet, feeling as though his teeth feel “loose”, and generalized weakness. Another classic symptom of this entity is: A. Urticaria and flushing B. Tachycardia C. Profuse watery diarrhea D. Paralysis E. Temperature reversal Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
You are conducting a study to compare the efficacy of a new bronchodilator against standard albuterol therapy in patients with acute asthma exacerbations. To reduce the possibility of selection bias in your study, the key element in your study design is: A. Blinding study participants so that they do not know which treatment has been selected for them, and do not change their subjective assessment of improvement in asthma symptoms B. Enrolling sufficient numbers of study participants to ensure an accurate estimate of the difference in treatment effects C. Randomizing study participants to ensure that the two groups studied are equivalent in potential confounding factors D. Only enrolling study participants > 2 years old, to avoid selecting bronchiolitis patients instead of asthma patients Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
A 17yo boy comes in with complaint of inability to breathe from the right nares. He was seen 2 days ago by his PMD and prescribed amoxicillin for sinusitis, but is not improving. He denies placing any foreign body in his nose. He was in an altercation at school and was hit in the nose 4 days ago. Which of the following would be the most appropriate treatment of this patient’s condition? Septal hematoma http://rhinitis.hawkelibrary.com/album09/83_G A. Change antibiotics to amoxicillin-clavulanate B. Attempt removal of foreign body C. Incision and drainage and nasal packing D. Referral to otorhinolaryngologist for polyp removal Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
Which of the following wild animal exposures is the lowest risk for rabies?
  1. Skunk
  2. Coyote
  3. Raccoon
  4. Fox
  5. Rabbit
Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
A 36-week infant is born precipitously NSVD to a 17yo G2P1 mother in the ED after the mother presented with the chief complaint of intermittent abdominal pain. Apgars are 8 and 9 at 1 and 5 minutes, with -1 for color at both times and -1 for reflex irritability at 1 minute. The O2 sat in the left upper extremity is 82% at 5 minutes. The baby is crying intermittently, is not pale or plethoric, and is in no respiratory distress. Lung sounds are equal and clear bilaterally, and cardiac exam is normal. The next best intervention is: A. Intubate and mechanically ventilate B. Suction and apply 100% O2 C. Suction and apply nasal canula O2 at 5 L/min D. Transilluminate the chest to r/o pneumothorax E. Continue to observe the infant Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID Question of the Week, you can find it here
A 10yo girl is sitting lapbelted in the rear of an SUV that is involved in a rear-end collision at 40mph. She complains of abdominal pain, and has an ecchymosis from the lapbelt going across her lower abdomen. Of the following, which is the LEAST likely injury the patient may have: A. Small bowel injury B. Kidney injury C. Horizontal vertebral body fracture in lower spine D. Spinal cord injury Check back in a few days for my answer and others' comments Also if you're interested in the Peds ID question of the week, go here
A 7yo patient with peanut allergy at a rice krispy treat at a birthday party and discovered afterwards that it was made with peanut butter. She presents with hives, mild swelling of her lower lip and periorbital, and some faint wheezes. O2 sat is 99% on room air. Vital signs are temp 37.6, HR 120, RR 28, BP 90/60. What is your first priority treatment? A. Diphenhydramine 1.25 mg/kg IV B. Epinephrine 0.01 mg/kg of 1mg/mL solution IM C. Methylprednisolone 2 mg/kg IV D. Normal saline 20 cc/kg IV E. RSI and prophylactic intubation Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here
A 2 month old ex-30 week premie just discharged from the NICU comes in with respiratory distress and hypoxia. You determine that the patient needs to be intubated. The baby’s weight at discharge was 2.5 kg. What size ETT should you use? A. 2.5 uncuffed B. 3.0 uncuffed C. 3.0 cuffed D. 3.5 uncuffed E. 3.5 cuffed Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here
Of the following fractures, which is most concerning for non-accidental trauma? A. 18 month old brought in for refusing to walk, no history of any trauma or fall. Toddlerfx (source medscape) B. 18 month old brought in for refusing to walk, history of falling from a jungle gym approximately 3 feet off the ground. Cornerfx (source http://www.meddean.luc.edu/) C. Both are concerning for non-accidental trauma D. Neither are concerning for non-accidental trauma Check back in a few days for my answer and others' comments
You are seeing a 12yo child with right ear pain for 2 days. He has been swimming recently. On examination, he has pain when you pull on the pinna of the ear to straighten the canal, and the canal is swollen and full of purulent discharge. He is afebrile and has no previous history of ear infection. Which of the following is FALSE regarding the management of this patient? A. Systemic antibiotics play no role B. If the patient had a history of pressure equalization tubes, neomycin + polymyxin B + hydrocortisone (cortisporin) drops would be contraindicated C. The patient should be advised not to swim while undergoing treatment D. Pain can be treated with antipyrine + benzocaine (auralgan) drops E. Fluoroquinolone drops are the most commonly used antibiotic therapy
Which of the following is true about Clostridium difficile? A. It is the most common cause of antibiotic-associated diarrhea B. The treatment of choice for C. diff colitis is IV vancomycin C. Asymptomatic carriage in children < 1 year old is common D. A and B E. A and C
A 14yo boy presents with fever and chest pain for 2 days. The chest pain is pleuritic and worse with leaning back. On examination, lung sounds are clear bilaterally, heart is regular with no murmurs, but a friction rub is heard. Which of the following is true of this condition? A. Treatment of choice is NSAID therapy B. All patients must be admitted to the hospital on a cardiac monitor C. CXR is always abnormal D. Electrocardiogram most commonly shows ST elevation isolated to leads II, III, and aVF E. Pain is rarely referred to shoulder or back
A 5yo uncircumcised boy comes in because his parents are unable to retract the foreskin of his penis. They have not been able to retract it ever, but now note also that he is having ballooning of the foreskin when he urinates. On exam, the opening of the foreskin is very tight. Appropriate treatment includes: A. Forceful retraction of the foreskin to break any adhesions B. Topical steroid cream and close follow-up C. Topical estrogen cream and close follow-up D. Emergent consultation with a urologist for immediate circumcision E. Reassurance that the condition will resolve by age 10 years
A 20kg child sustains a 15% body surface area burn. The best answer for the rate of IV fluids that should be administered over the first 8 hours is: A. 60 cc/hr B. 75 cc/hr C. 120 cc/hr D. 135 cc/hr E. 150 cc/hr
What is the difference between Enhanced 911 and 911? A. With Enhanced 911, operators are able to give instructions on how to perform CPR in the field B. With Enhanced 911, EMS response times are under 10 minutes C. With Enhanced 911, ALS units are available, whereas with 911 only BLS units are available D. With Enhanced 911, the caller’s location and phone number is automatically transmitted to the operator E. With Enhanced 911, calls are routed by type to specific specialized call centers
A 6yo child is brought in after rescue from a housefire. He is unconscious, and has soot in his nares. You perform rapid sequence intubation. Vital signs are: Temp 37.5, HR 120, BP 68/40, O2 saturation 100%. You note a cherry red color to his skin. What is the antidote most indicated? A. Methylene blue B. 2-PAM C. Hydroxocobalamin D. Sodium bicarbonate E. Naloxone
A 12yo boy with ALL, recent induction chemotherapy 2 weeks ago, presents to the ED with fever, RLQ abdominal pain, 2 episodes of watery diarrhea with streaks of blood, nausea but no vomiting. Denies ill contacts. On exam, temperature 38.4, HR 110, RR 24, BP 95/60. Alert, no nuchal rigidity, lungs clear to auscultation, heart RRR, abdomen mildly distended, RLQ tenderness, no rebound, decreased bowel sounds. Labs show an absolute neutrophil count of 100. KUB findings are similar to as shown here: pneumatosis The most appropriate next step would be: A. Consult surgeon for appendectomy B. Admit for IV antibiotics directed at treating infectious diarrhea C. Admit for empiric IV antibiotics to cover for fever and neutropenia D. Admit for broad spectrum antibiotics, make NPO, consult with surgeon, consider GCSF, for neutropenic enterocolitis E. Consult gastroenterologist for endoscopy to confirm pseudomembranous colitis
According to the Belmont report, the 3 main ethical principles for conducting research involving human subjects are: A) Beneficence, nonmaleficence, justice B) Respect for persons, beneficence, justice C) Respect for persons, beneficence, nonmaleficence D) Beneficence, justice, informed consent E) Nonmaleficence, justice, informed consent
A 17yo boy presents with severe sore throat for two days, and fever to 39. He has difficulty swallowing due to pain. He has no cough, congestion, nor ill contacts. His immunizations are up to date. On examination, he is alert, has no respiratory distress or stridor. His oropharynx has 2+ tonsils which are somewhat red, no exudate, no vesicles, no peritonsillar swelling. He has tender cervical lymphadenopathy and is very tender on palpation of his anterior neck at the level of the hyoid bone. The most appropriate management is: A. Obtain lateral neck X-ray in the ED and consult ENT specialist B. Consult ENT specialist to intubate the patient in the O.R. C. Give dexamethasone and penicillin-benzathine and discharge home D. Recommend supportive care for a viral URI E. Obtain a CT scan to evaluate for deep neck infection
A 12yo boy with very high risk ALL, recent chemotherapy 4 days prior, presents to the ED with fever and lethargy. Temperature is 39C, HR 180, RR 24, BP 80/50.  The patient is lethargic, has no nuchal rigidity, lungs are clear to auscultation, heart is tachycardic but regular rate and rhythm, abdominal exam is benign, and there is no rash. Pulses are bounding, there is flash capillary refill, skin is warm and dry. After adequate fluid resuscitation, cultures, and empiric antibiotics, the patient remains hypotensive. The next best treatment is: A. Dopamine IV at 5 mcg/kg/min B. Epinephrine IV at 0.1 mcg/kg/min C. Norepinephrine IV at 0.1 mcg/kg/min D. Dobutamine IV at 5 mcg/kg/min E. Hydrocortisone 1 mg/kg IV
All of the following preclude expectant outpatient management in the case of an ingested button battery found by imaging to be in the stomach except: A. Co-ingestion of a magnet B. Child complains of abdominal pain C. Child has history of constipation D. Battery is > 15mm diameter and has been present > 4 days in a child < 6 years old E. N/A; ingested batteries should always be endoscopically removed
A 6yo boy is in the ED with his third episode of intussusception over the past year. Previous episodes presented with colicky abdominal pain and stool guaiac positive, and were successfully managed using barium enemas. He has been completely well between episodes. What imaging study is indicated to assess for the most common cause of a pathologic lead point? A. Complete ultrasound of the abdomen B. Computed tomography of the abdomen with oral and IV contrast C. Upper gastrointestinal study with small bowel follow-through D. Technetium-99m-pertechnetate scintigraphy E. Magnetic resonance imaging of the abdomen
Which of the following is true of EMT scopes of practice (EMT-B = EMT-Basic, EMT-I = EMT-Intermediate, EMT-P = Paramedic)?
  1. Only EMT-I and Paramedic level EMT’s can administer oxygen
  2. Training to become an EMT-B is usually 100-150 hours
  3. Training to become a Paramedic is an additional 250 hours of training
  4. IV therapy may be given by EMT-I and EMT-P
A. 1 and 3 B. 2 and 4 C. 1, 2, and 3 D. 4 only E. All of the above
A 10yo was a rear seat passenger in a high-speed MVA, belted only with a lapbelt, and had a hyperflexion injury mechanism during impact. The patient cannot move his legs, and does not have lower extremity sensation to light touch or temperature sensation, but does have intact proprioception and vibration sense. What is the injury?
  1. Anterior cord syndrome
  2. Brown-Sequard cord syndrome
  3. Central cord syndrome
  4. Chance fracture
17yo boy with long legs and arms, h/o scoliosis and mild pectus excavatum, hyperextensibility of the thumbs, presents with sudden onset ripping quality chest pain and feeling lightheaded. On exam, patient is anxious appearing, afebrile, HR 105, BP 98/45, RR 14, pulse ox 98% RA, alert, HEENT non-revealing, Lungs BCTA, Cor RRR with mid-systolic click followed by a late systolic murmur at the apex, Abd soft ND NT, Extremities and Skin non-contributory.  Of the following, which diagnostic study is the best choice? A) POC troponin B) Arterial blood gas C) Bedside ultrasound looking for lung sliding D) CT angiogram E) CT abdomen
For aeromedical transport, transport mode transitions from helicopter to fixed wing aircraft when the distance from base station to patient pick-up location exceeds how many miles? A) 70 miles B) 150 miles C) 200 miles D) Distance is not a factor
A child is brought in with a stab wound to the right neck just superior to the cricoid cartilage. What zone of the neck is this? What is the significance of the zones?
A 2 year old is brought in that has chewed on an electrical cord. He has a scab in the corner of his mouth and no active bleeding and is otherwise well appearing with no other trauma. What delayed complication can occur?
In a population of 1,000 people, 100 have a disease. A test is positive in 95 people with the disease and 100 people without the disease. What is the sensitivity, specificity, and positive predictive value of this test?

Conundrums

(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 3 year old with 2nd lifetime episode of SVT. The patient has no other prior PMH, was not on any medications, was healthy prior, and does not have WPW. After 2 doses of properly administered adenosine, the patient is still in SVT. She is alert, not toxic, has good perfusion, and is not hypotensive. [poll id="29"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 4 year old in status epilepticus. The patient is not on anti-epileptics at home. The patient has received benzodiazepines x 3 and fosphenytoin 20 mg/kg. Glucose and electrolytes are normal. The patient is afebrile. [poll id="28"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a patient with a simple small abscess and no or minimal overlying cellulitis, nontoxic and afebrile, immunizations up to date, no prior abscesses. After successful incision and drainage, what treatment would you give? [poll id="27"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! An 8yo patient with history of mild intermittent asthma comes in with an acute exacerbation that clears readily with 1 treatment of nebulized albuterol. The patient has had 2 similar ED visits in the last 3 months. The patient has an albuterol MDI for home use, but no spacer. The patient is not on any controller medications. The respiratory therapist has taught the patient/parents how to use the MDI properly with a spacer, and you are discharging the patient home. [poll id="26"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 4 year old with 1 day of limp and now, refusal to bear weight. He is afebrile. On exam, his hip is irritable to passive external and internal rotation. He holds his hip slightly externally rotated. His CBC WBC is 8,400 with 50% neutrophils, and his ESR is 20. His plain films are normal. He has reliable parents and an assigned pediatrician who can see him the next day. [poll id="25"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="24"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! For pediatric blunt trauma patients... [poll id="23"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! A repeat - since we are in the throes of influenza season right now, and this is a particularly controversial issue. Many emergency medicine FOAM bloggers have argued against the use of oseltamivir, such as here. But, the CDC continues to recommend it for high risk patients presenting with < 48 hours of symptoms, citing their reasoning here. To complicate things further, the "definition" of influenza-like illness basically includes nearly all kids seen in the ED in the wintertime - fever and cough or sore throat, and point-of-care tests are not very sensitive. [poll id="19"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Got this one from a recent EM physician facebook group post. You see a mother with symptoms of influenza. Her 3 day old asymptomatic full-term infant is tested and is POC influenza+. There is good follow-up and the patient is healthy, afebrile, feeding well, etc. [poll id="22"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 10 week old infant with a 38 degree fever of 6 hours duration. He has mild rhinorrhea as does Dad. He is otherwise well and feeding well. Point of care RSV and influenza are negative, and urine shows no pyuria or bacteriuria. Review of the chart shows mom was GBS+ and was treated with intrapartum penicillin as recommended. Baby was observed for 2 days in the nursery but not treated with antibiotics. [poll id="21"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="20"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="19"]
A 2 month old was seen in the ED 36 hours ago with a temperature of 39.2. The CBC had a WBC of 11.2 with 70% lymphocytes and no bandemia. Urinalysis was negative. The lab calls you to report that 1 of 2 blood culture bottles is growing gram positive cocci in clusters. You call the patient and the parent reports that he is doing well, is now thought to be afebrile (tactile, parents have not checked the temperature in 24 hours), and is feeding well. What do you do? (Click the link to comment and to vote - voting not working through email, sorry!) [poll id="18"]
You are about to incise and drain a relatively small simple abscess in a healthy child. (Click the link to comment and to vote - voting not working through email, sorry!) [poll id="17"]
Do you do a CT and LP on all complex febrile seizure patients? [poll id="16"]
What do you include in your GI cocktail for adolescents? [poll id="15"]
You are seeing a 4 year old with a deep cheek laceration with irregular margins, under some tension. The parents express concerns about scarring, and they are also concerned that their child will definitely not be able to stay still for repair or for suture removal. Plastic surgery is unavailable, and the parents are amenable to having you repair the laceration with procedural sedation. Forheadlac (Source: Closing the Gap https://lacerationrepair.com) [poll id="14"]
You are seeing a 5 year old with intermittent LLQ abdominal pain for a month. She is well appearing and has a benign abdominal exam. She is eating normally, not vomiting, and has no fever or diarrhea. The parents deny constipation or hard stools, but you suspect constipation is the diagnosis. [poll id="13"]
You are seeing a 6 week old ex-full term infant who is breastfeeding exclusively, having 6 wet diapers per day, 4 or more soft seedy stools per day, growing well, and no fever. Baby has been jaundiced since 1st week of life, and while it is not worse, parents come in because it is prolonged. Jaundice is to the level of the chest, and transcutaneous bili is 10. [poll id="12"]
It's RSV season and you're seeing a 30 day old ex-39 week infant with a runny nose. The resident has ordered a POC RSV, which is positive. The baby is afebrile, feeding well, and nontoxic. Do you admit the infant just for being RSV positive due to the risk of apnea in this age group? [poll id="11"]
You are seeing a 6 year old with a wet-sounding cough for 4 days and fever to 39 C for 3 days. You hear crackles in the right lower lobe; there is no wheezing. CXR shows no infiltrates. Do you diagnose a "clinical pneumonia" with false negative CXR and treat with antibiotics? [poll id="10"]
Vote! But for something other than President... You are seeing a 3mo old with clinical bronchiolitis who is otherwise well-appearing, tolerating po's, not in significant respiratory distress, afebrile, has good follow-up. At what O2 sat do you admit the patient for supplementary O2? The AAP says: aap-bronchiolitis-o2-sat [poll id="9"]
3 week old infant is brought in with fever of 38.5. The baby is well appearing and does not have any high risk factors in the birth history. You plan to get urine, blood, and CSF cultures and give empiric IV antibiotics. [poll id="8"]
You are seeing a 35 month old boy with fever and sore throat x 2 days. He has no cough or runny nose, but his sister also had fever and sore throat recently, and his mom has a cough. His temp is 38.5. He has no tonsillar exudate or palatal petechiae, and only tender cervical lymphadenopathy. He is otherwise well appearing, previously healthy, and is well hydrated. [poll id="6"]
Nearly 3 year old girl was eating nuts and had a coughing episode. 6 year old sibling told parents "she's choking on the nuts." In the ED, patient is completely asymptomatic, has a normal CXR and a 100% O2 sat on room air. [poll id="7"]
You are seeing a 15 month old female with 36 hours of fever, current temp in ED 38.9 rectal (last antipyretic 6 hours prior), no other symptoms, well-appearing, no past medical history. Which would you do? [poll id="5"]
How much work-up do you do in the well-appearing, term, feeding, 29-60 day old infant with low-grade fever (38-38.5) without source? What about the 61-89 day old? [poll id="2"]
You're seeing a febrile well-appearing 29-60 day old with clear lab evidence of UTI and benign CBC. Do you do an LP? Do you admit and do you give parenteral antibiotics? What about for a 61-90 day old?
When was the last time you saw a kid have a paradoxical reaction to a benzo and how did you treat it? a. Wait it out b. More benzos c. Flumazenil d. Haldol e. Something else???  Have heard precedex, ketamine, propofol all suggested. Click post to read and add comments
You're seeing a 10yo who weighs 40 kg for acute asthma exacerbation. Do you give decadron or prednisone? If you give decadron, do you give 0.6 mg/kg or a lower dose? What is your maximum dose of decadron for asthma? Click post to read and add comments [poll id="4"]

Oops! We detected that you are on mobile and in portrait mode.


Please turn your phone to landscape mode to view this website. If you are not on mobile, extend your browser window.