PEM Source

Your source for all things Pediatric Emergency Medicine

1-2-3 Lower Extremity IO Sites

The lower extremity IO placement sites from medial to lateral are 1-3cm above the medial malleolus at the distal tibia, 1-3cm below the tibial tuberosity on the flat anteromedial proximal tibia, and 1-3cm above the patella in the midline of… Continue Reading →

Question: Ortho

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 15-year old girl with pain in her right foot. She is moderately overweight, and joined a running club 1 month ago… Continue Reading →

Question: Ear FB

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Question: Paraphimosis

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 11-year-old uncircumcised boy whose foreskin became retracted over his glans penis, and then stuck (paraphimosis). It has been this way for… Continue Reading →

PEM Guides

The latest version of PEM Guides from Michael Mojica and the PEM division at NYU is out. PEM Guides is updated annually, and provides a great concise PEM reference. From the creators of PEM Guides: PEM Guides Version 11.0 (2024)… Continue Reading →

Question: Lightning

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 15-year-old male who was sitting in his backyard when he says he was struck by lightning. He had no loss of… Continue Reading →

Question: A&I

(Click the link to comment and to vote – voting not working through email, sorry!) Clinic staff rush over a 6-year-old child for management in the ED. The child had received a new IV chemotherapeutic agent and 5 minutes later… Continue Reading →

Customer Service

Just read a PED-EM-L post from Todd Z (in response to a questioner wanting to improve Press Ganey scores) that really resonated. Customer (parent) satisfaction is an important part of the ED visit, even if you are not beholden to… Continue Reading →

Question: Derm

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Question: ENT

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 2-month-old infant brought in by parents because they notice the center and mid-back of the tongue is black in color. The… Continue Reading →

Question: GI

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 13-month old toddler who presents with 1 day of lethargy and 2 episodes of vomiting. There is no fever or diarrhea…. Continue Reading →

Tox Bradycardia

The ABCDEFG of tox-caused bradycardia Alpha-2 agonists (e.g. clonidine) Beta-blocker Calcium channel blocker Digitalis ETOH Fentanyl and other opiates Gardening (pesticides with organophosphates)

Question: GI

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 2-year-old girl that had a PEG gastrostomy tube placed 1.5 years ago. The parents have noticed resistance when pushing in the… Continue Reading →

Question: Dx

(Click the link to comment and to vote – voting not working through email, sorry!) Three female high school basketball players and two male scorekeepers entered the school gym before all other students. Soon after entering, all 5 began to… Continue Reading →

Question: ARDS

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LAME cephalosporins

What organisms do Cephalosporins not cover? Remember LAME: Listeria, Atypicals, MRSA, and Enterococci

Question: Treatment

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 16-year-old boy who was walking home from school when he experienced sudden onset of intense dread, racing heartbeat, dizziness, difficulty breathing,… Continue Reading →

Question: Nosebleed

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 8-year-old boy for prolonged nosebleed last night and this morning. Last night it happened on the right nares, and this morning… Continue Reading →

Question: Pharm

(Click the link to comment and to vote – voting not working through email, sorry!) Which of the following otherwise well-appearing non-toxic patients with a low-grade fever from viral URI should NOT take ibuprofen?

Eye Drops per mL

Ever wonder how many doses you’re giving out when you prescribe a 10mL bottle of antibiotic eye drops? Or need to decide between prescribing a 3mL or 10mL bottle? The accepted conversion is 20 drops per mL (or 0.05mL per… Continue Reading →

Question: FEN

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Question: ENT/ID

(Click the link to comment and to vote – voting not working through email, sorry!) A previously-healthy 12-year old girl who was allowed to get a high cartilage ear piercing after much begging now comes in with evidence of infection… Continue Reading →

Question: Tox

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Question: Pharm

(Click the link to comment and to vote – voting not working through email, sorry!) Ketamine has been in the news lately, contributing to the death of actor Matthew Perry and playing a part in the recent successful prosecution of… Continue Reading →

Urgent Care Diagnoses

Tripledemic is here, and many a chief complaint will be, “he just won’t stop coughing” or “she has a fever.” PEMsource has a new Urgent Care section with tips, differential diagnoses, symptomatic treatments, dosing of common medications, and parent education aids, for… Continue Reading →

Question: ID

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Question: Submersion

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Question: ID

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Question: Toy Safety

(Click the link to comment and to vote – voting not working through email, sorry!) A childless uncle & aunt are picking up a last-minute holiday gift for their nephews and nieces. They desparately want to be thought of as… Continue Reading →

Time Management

Is one of your New Year’s Resolutions to manage your time better, get organized, and prioritize your goals so you can work to achieve them? PEMsource has a section of tips on time management – click the Wellness tab! (Because if… Continue Reading →

Question: GU

(Click the link to comment and to vote – voting not working through email, sorry!) Parents bring in their 18 month old uncircumcised son because of concern regarding a bump on his penis. He has no other symptoms and is… Continue Reading →

Question: ENT

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 10 year old boy with 3 days of submandibular swelling. On exam, he has a 2cm x 3cm tender swelling in… Continue Reading →

Question: Onc

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Question: ID

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New PEM Podcast

There’s a (relatively) new PEM podcast in town – Peds-Centered – which “provides leading-edge information and conversations with experts in the field of Pediatric Emergency Medicine and Urgent Care, and Pediatric Hospital Medicine.” And don’t forget all the other great… Continue Reading →

Question: Onc

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Question: Joint

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 12 year old boy with pain in his lower back and right buttock for 2 weeks. He is an active soccer… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 15 year old boy who was “jumped” by a group of boys at school today and hit in the head area…. Continue Reading →

Question: Endocrine

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 18 month old with 3 days of cough and congestion and 4 hours of tachypnea. On exam, she has diffuse scattered… Continue Reading →

ED Flow

Tripledemic is coming. Here are some tips for keeping your ED moving (please add more in the comments!) 1) Dispo is King. Often when many patients are waiting to be seen, it’s tempting to sign up for several more. But… Continue Reading →

Question: Metabolic

(Click the link to comment and to vote – voting not working through email, sorry!) A 20-month old child is brought in by ambulance for lethargy and altered mental status. You find out his grandmother has been administering frequent doses… Continue Reading →

Question: Dental

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 year old who was running in the house, tripped and fell, hitting his mouth on the coffee table. On exam,… Continue Reading →

Question: Back Pain

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Question: Syncope

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an adolescent who had a syncopal episode at school. It occurred 10 minutes after P.E. class had finished, when she was in… Continue Reading →

Question: Rash

(Click the link to comment and to vote – voting not working through email, sorry!) Parents bring in their 11 month old baby for a new-onset rash. The baby is unimmunized by parent choice. The baby had fever for the… Continue Reading →

Question: ENT

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 year old boy with unresolving right-sided ear infection. He was first seen 1 month ago and diagnosed with right AOM… Continue Reading →

Question: Syndromes

You are seeing a 6 year old girl who comes in for right leg pain after a ground level fall at the park. She is currently being worked up by her pediatrician for precocious puberty, including vaginal spotting and breast… Continue Reading →

Amazing Apps

Harbor-UCLA Emergency Medicine Residency grad and all around great educator Tom Fadial has made some highly useful apps that you absolutely need. The latest, Fractures, is a comprehensive library of fracture types along with radiograph images, pearls, a guide to… Continue Reading →

Question: Derm

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 14 month old who has a two irregularly oval yellow-tan lesions on his right upper arm, just under 1cm each. They… Continue Reading →

Question: Sports

(Click the link to comment and to vote – voting not working through email, sorry!) A father brings in his 11-year-old son for medial elbow pain. The boy is the star player (and often the starting pitcher) on his little… Continue Reading →

Question: leg pain

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 17-year-old boy with one day of right calf pain and swelling. The day before onset of his symptoms, he was helping… Continue Reading →

TinyTotsERDocs

Do you ever have a parent that has many many questions about how to handle minor illnesses and trauma but also a crazy busy PED with other patients requiring your attention? I once spent 30 minutes answering nervous first-time parents’… Continue Reading →

Question: febrile seizures

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 18-month-old brought in by ambulance for simple febrile seizure that lasted 2 minutes. You have determined the source of his fever… Continue Reading →

Question: fever + rash

(Click the link to comment and to vote – voting not working through email, sorry!)A You are seeing a 3-year-old boy with 2 days of fever to a maximum of 102.7 F, an urticarial rash (but no enanthem), and significant… Continue Reading →

Question: July 4th

(Click the link to comment and to vote – voting not working through email, sorry!) Happy Belated 4th of July!

Question: GI

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 10 month old female with profuse projectile vomiting and one episode of diarrheal stool over the last 2 hours. She is… Continue Reading →

Question: Pharm

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 6 year old with 1 ½ weeks of cough, nasal congestion, and malaise. Initially, he seemed to be improving a bit,… Continue Reading →

Covering UTI & Pneumonia

Picture this: you’re seeing a 3 year old girl with fever for 4 days, cough and runny nose (her parents estimate that since starting preschool she has had cough and runny nose 75% of the time). She has no evidence… Continue Reading →

Question: Eye Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 9 year old African-American child who was hit in the eye with a baseball. On exam there is visible blood layering… Continue Reading →

Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 17 year old girl that works in a pet store, where she is sometimes scratched by the animals there. She felt… Continue Reading →

Question: NAGMA

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 15 year old girl who presents with acute bilateral lower leg weakness / near-paralysis. She is found to be hypokalemic, which… Continue Reading →

Pediatric Exam

A successful pediatric physical exam is all about taking advantage of opportunities when they present themselves. Picture this: you enter the room and the child is draped over his/her parent’s shoulder, fast asleep. Consider taking a moment to whisper a… Continue Reading →

Question: Cough

Your next patient, actually your next 10 patients, are brought in by their parents because they have been coughing for 2 weeks. Match the characteristic of the cough with the appropriate treatment (you may use letters twice or not at… Continue Reading →

Question: Dental

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 17 year old male who had his left upper impacted wisdom tooth extracted 3 days ago. He comes in complaining of… Continue Reading →

Question: Back Pain

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 year old child with 3 weeks of gradually progressing low back pain, now impacting her ability or willingness to walk…. Continue Reading →

Question: Environmental

(Click the link to comment and to vote – voting not working through email, sorry!) You are working locum tenens in Breckenridge, Colorado, and see a 2 year old boy with irritability, vomiting, and poor appetite. He has no fever… Continue Reading →

Question: fever

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 8 year old girl with fever of unclear etiology for 7 days. She is well appearing. Exam reveals 1-2cm tender nodes… Continue Reading →

Question: Rash

(Click the link to comment and to vote – voting not working through email, sorry!) You are evaluating a 10 year old patient who had a bone marrow transplant 2 months ago. The patient is presenting with low-grade fever, a… Continue Reading →

Administering eye drops

For children who have difficulty allowing the caretaker to administer eye drops, have them lay flat and close their eyes. Place several drops in the medial corner of the eye – when they open their eye, the drops will seep… Continue Reading →

Question: hematuria

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Question: Ortho

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 16 year old basketball player who presents with pain and swelling over his dorsal PIP joint, and inability to extend at… Continue Reading →

Question: Wounds

(Click the link to comment and to vote – voting not working through email, sorry!) You are caring for a 20 kg child involved in an auto vs. bicycle accident who has several superficial lacerations requiring suturing. You calculated the… Continue Reading →

A Universal Sign for Help

A universal signal for help, first developed by the Canadian Women’s Association and then popularized on social media platforms, can be used by victims of human trafficking, domestic violence, and abuse, to surreptitiously ask for help escaping their assailant. See… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 15 year old who sustained significant facial trauma. He complains of decreased vision in his right eye. On exam you note… Continue Reading →

Question: submersion

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Question: ENT / ID

(Click the link to comment and to vote – voting not working through email, sorry!) During the recent “tri-demic” of influenza, RSV, and COVID disease, there was also a nationwide shortage of common oral liquid antibiotics used to treat otitis… Continue Reading →

Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!) COVID is on the rise again, with a more transmissible and immune-evading variant. Nirmatrelvir-ritonavir (brand name Paxlovid) is approved for children 12 years and older… Continue Reading →

Question: Cardiac

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Question: Endocrine

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 5 year old child with known adrenal insufficiency with fluid and pressor-resistant hypotension. You wish to give stress-dose steroids. 

COVID symptoms

The use and interpretation of rapid COVID-19 tests to reduce transmission is changing slightly with new variants and increased natural and vaccine-induced immunity in the population. A positive rapid test (even a very faint line) remains a good indicator of… Continue Reading →

Question: Cardiac

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Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) A teen living in a state where abortion is newly outlawed ingests something that she has read online is an abortifacient. She presents to the… Continue Reading →

Question: EMTALA

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Question: Christmas

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Eczema: “Skin Asthma”

Managing parent expectations is half of pediatric emergency medicine. When parents bring in kids with worsened eczema (either as a chief complaint or a side complaint), they are often frustrated that they used the prescribed cream, things got better, but… Continue Reading →

Question: Flu Shot

(Click the link to comment and to vote – voting not working through email, sorry!) We are currently experiencing a “tridemic” of influenza, RSV, and COVID-19.

Question: PALS

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Happy Thanksgiving!

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RSV Return to School

We are seeing unprecedented numbers of cases of RSV, and many of our patients are older school-age children. Ever wonder when those kids can return to school? RSV is contagious up to 8 days after symptom onset, so children can… Continue Reading →

Question: QI

(Click the link to comment and to vote – voting not working through email, sorry!) A PEM group is performing a quality improvement initiative to improve ED flow in the busy evening shift of their 12-bed PED. They implement a… Continue Reading →

Question: Menorrhagia

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 13 year old girl for menorrhagia. This is her second menses ever, and she has been having to change her pad… Continue Reading →

Question: Behavior

(Click the link to comment and to vote – voting not working through email, sorry!) You are evaluating a 15 year old girl brought in from a foster home for symptoms of psychosis. 

Question: Medicolegal

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Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 8 year old male with 3 days of progressively worsening redness, tenderness, and swelling of his right index finger proximal lateral… Continue Reading →

Lac Cheat Sheet

First, highly recommend Dr. Brian Lin’s site lacerationrepair.com (free) for all your wound management education and questions. Second, in a recent blog post, there was a review of an online laceration repair course, The Laceration Course (paid). Dr. Lin posted… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 6 year old child that was involved in a motor vehicle accident. He was belted in the rear left seat using… Continue Reading →

Question: Surgical

(Click the link to comment and to vote – voting not working through email, sorry!) A 3 week old female infant presents with a palpable inguinal mass of 2 hours duration. The dad states he noticed it while changing her… Continue Reading →

Question: Cardiology

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Question: Lice

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 18 month old girl with chief complaint of itchy scalp and rash at the nape of her neck just below her… Continue Reading →

LP Needles

The Royal Children’s Hospital of Melbourne has a great clinical guideline for pediatric lumbar puncture 22 gauge spinal needle can be used in all age groups. Use 1.5 inch length in < 2-3 year olds, 3.5 inch length in older… Continue Reading →

Question: EMS

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Question: Diagnosis

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 13 year old boy with vague complaints of malaise, nausea, morning headaches, loss of appetite, and intermittent abdominal pain. When he… Continue Reading →

Question: A&I

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 6 year old boy who sustained a bee sting. He presents with diffuse urticaria, wheezing and shortness of breath, and crampy… Continue Reading →

Question: EMS

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a critically ill 4 week old with bilious vomiting, abdominal distension, and shock. You have a high suspicion for volvulus. You have… Continue Reading →

Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!) It’s summertime, and you are seeing a 15 month old with fever and papulovesicular lesions on the palms, lateral borders of the feet and soles,… Continue Reading →

Eye Drop Colors

Following up on last month’s tips regarding antibiotic eye drops, it’s helpful to know that the color of the eye drop bottle cap tells you the medication class of the contents! Also, here is a great table giving a summary… Continue Reading →

Question: Fever

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a well-appearing 20 day old infant brought in for passing 4 stools instead of 6 today. The baby is full term, eating… Continue Reading →

Question: Cards

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 14 year old boy who presents with shortness of breath and chest pain while playing basketball. He has noticed it for… Continue Reading →

Antibiotic Eye Drops

When treating run of the mill bacterial conjunctivitis, I was taught to use erythromycin ointment for young infants that are not yet walking, and polytrim drops for older kids. The ointment is nice in that it sticks in the eyes… Continue Reading →

Question: Derm

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 8 year old boy with the pictured lesion. He has had it for 2 months; it is slowly growing, and occasionally… Continue Reading →

Question: Metabolic

(Click the link to comment and to vote – voting not working through email, sorry!) A 14-month old boy presents with altered mental status. He has had 2 days of vomiting and diarrhea, but no fever. He weighs 10 kg…. Continue Reading →

Question: Ortho

(Click the link to comment and to vote – voting not working through email, sorry!) A 20 month old boy is brought in by his mother for refusal to bear weight on the right leg. She was at work all… Continue Reading →

School Notes

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Environmental

(Click the link to comment and to vote – voting not working through email, sorry!) A 10 year boy was out hiking with his family, several feet ahead of everyone else. He heard a rattle, felt a sharp pain in… Continue Reading →

Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!) A 17yo boy presents with fever, myalgias, headaches, swollen cervical lymph nodes, and a maculopapular rash that became vesiculopustular on his face, torso, and extremities… Continue Reading →

ASK

Asking Saves Kids: Firearms are now the leading cause of death for U.S. children aged 1-19 years. While school mass shootings make headlines, suicides make up the majority of these deaths. Accidental shootings by curious children who access unsecured firearms… Continue Reading →

Question: neonate

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 day old infant with a new onset rash on the chest and abdomen. The baby was born full-term with no… Continue Reading →

Question: heme

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 16 month old toddler who is a very picky eater. He mostly eats 32 oz of whole milk per day, and… Continue Reading →

A rainbow of asthma meds

If your patient with asthma can only remember the color and shape of their inhaler, but not the name, have them look at this poster to identify their medications.

Question: Edema

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 4 year old boy who presents with a few weeks of periorbital edema and generalized fatigue. He occasionally complains of abdominal… Continue Reading →

Question: Rash

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 8 year old girl who was prescribed an oral cephalosporin antibiotic 1 week ago for rhinitis. She has 3 more days… Continue Reading →

Wait & Watch OM Rx

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: CF

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Pediatric throat exam Pt 2

Here is our prior post on getting that pediatric throat examined Another method for older children that can follow commands: ask them to try to touch their chin with their tongue (try it on yourself)

Question: STI in abuse

(Click the link to comment and to vote – voting not working through email, sorry!) A 6 month old female infant is referred in from PMD for concerns regarding the GU exam. Physical examinations at the 2 and 4 month… Continue Reading →

Question: fever + rash

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 10 month old infant with one day of fever, purpuric rash, and subcutaneous edema of bilateral extremities. He was seen in… Continue Reading →

Masks forever?

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Neuro

(Click the link to comment and to vote – voting not working through email, sorry!) Which of the following physical exam findings on a newborn’s sacrum does NOT mandate an MRI to rule out occult closed spinal dysraphism?

Question: Syndromes

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a patient with history of congenital sensorineural hearing loss. 

Nail bed lacs in 2022

Our approach to nail bed lacerations has evolved quite a bit over the last decade or two. The old teaching was that a significant subungual hematoma required removal of the nail to check for a nail bed laceration, and if… Continue Reading →

Question: Renal

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 17 year old boy with left flank pain, nausea, and vomiting. There has been no fever, dysuria, hematuria, or urinary frequency…. Continue Reading →

Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!) A seven day old neonate is brought in for a fever of 38.5 and lethargy. The baby had a home birth, and the parents have… Continue Reading →

Dex dosing in croup

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Oral

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 1 week old with the pictured oral lesions. 

Question: Neuro

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 12 year old child that presents with altered mental status, fever, and history of headache and vomiting before the decline in… Continue Reading →

Too much milk?

Iron deficiency anemia can be seen in toddlers that have switched to cow’s milk (typically at age 1 yr) from formula. If the child’s diet is nearly exclusively cow’s milk, a severe anemia can slowly develop due to iron deficiency… Continue Reading →

Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) Parents bring in a 3 year old child that drank a few sips of household bleach which had been stored by grandparents in an empty… Continue Reading →

Question: Urology

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 5 year old boy with abdominal pain. His parents say that he has not been eating solids, but has been taking… Continue Reading →

Miralax

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: COVID

(Click the link to comment and to vote – voting not working through email, sorry!) What are pediatric emergency physicians seeing more of when COVID prevalence rises?

Question: Ophtho

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 10 day old ex-full term infant with bilateral watery mucoid eye discharge, mild eyelid edema, and papillary conjunctivitis. You suspect chlamydial… Continue Reading →

Question: Resusc

(Click the link to comment and to vote – voting not working through email, sorry!) You are told that you will be receiving a 12 month old child in full arrest. CPR is in progress by the paramedics. Your EMS… Continue Reading →

Estimate NPA size

Classic teaching is to estimate the nasopharyngeal airway (NPA) size as the length from the patient’s nares to tragus of the ear, and the oropharyngeal airway (OPA) from the maxillary incisors to the angle of the mandible. However, a few… Continue Reading →

Question: Vomiting

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 19 year old male who has had several ED visits for abdominal pain, nausea and vomiting. He insists that he does… Continue Reading →

Question: Renal

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 7 year old boy who presents with dark coca-cola colored urine and puffy eyes. You suspect glomerulonephritis. Which of the following… Continue Reading →

COVID tests in the ED

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Urology

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 14 year old boy who presents with sudden onset of left scrotal pain and swelling, starting 4 hours prior to presentation…. Continue Reading →

Question: Neuro

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 8 year old boy brought in by ambulance for a first time unprovoked afebrile seizure. The seizure was generalized tonic-clonic and… Continue Reading →

BRUE Tips

These come from Joe Ravera – creator of great podcast PEM GEMS – the U in BRUE stands for unexplained. So if it’s explainable, it’s not a BRUE. For example, if the baby vomited after eating and then choked on… Continue Reading →

Question: Holiday Edition

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Question: Hypocalcemia

(Click the link to comment and to vote – voting not working through email, sorry!) Last week’s 10 day old patient presented with seizures and jitteriness due to hypocalcemia. In the ED, he has a peripheral 22 gauge IV placed. 

Teething and Fever

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Neonate

(Click the link to comment and to vote – voting not working through email, sorry!) A 10 day old presents with shaking of bilateral upper extremities and jitteriness. The patient was a term infant born NSVD with no complications. He… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 14 year old boy involved in a helmet vs helmet football injury. Which of the following is true regarding his evaluation… Continue Reading →

Penicillin “Allergy”

While up to 10% of patients may think they have an allergy to beta-lactam antibiotics, fewer than 1% have a true IgE-mediated hypersensitivity, with concomitant risk of anaphylaxis. However, even if a true allergy is confirmed, this does not mean… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) A 16 year old female involved in a motor vehicle accident is brought into your trauma bay; she is obviously gravid and states that she… Continue Reading →

Question: Jaundice

(Click the link to comment and to vote – voting not working through email, sorry!) You are evaluating a term neonate for hyperbilirubinemia. The baby was sent home at 36 hours of life with a bilirubin measurement of 7.0, and… Continue Reading →

Pediatric DL Blades

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Ortho

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 17 year old boy who fell while skateboarding and sustained an axial loading force to his right thumb. He is exquisitely… Continue Reading →

Question: NRP

(Click the link to comment and to vote – voting not working through email, sorry!) A 16 year old girl arrives to the ED by ambulance and promptly delivers a 34 weeks by dates neonate. The infant is unresponsive, apneic,… Continue Reading →

Rash follow-up

Here’s a great tip from one of our PEM fellow’s recent lectures. When a patient has cellulitis that’s being treated as an outpatient, we often outline the area of erythema with a pen so the parent can know if the… Continue Reading →

Question: Onc

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 year old whose parent noticed a lump in the neck while bathing her. You palpate posterior cervical node(s). 

Question: Resp

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a toddler with 2 days of cough, congestion, and low-grade fever, who now presents with a worsened barky cough. His vital signs… Continue Reading →

Forehead Fever

(Click the link to comment and to vote – voting not working through email, sorry!)Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding… Continue Reading →

Question: Neuro

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 9 year old boy who returned from a camping trip in Colorado 6 days ago. He had some vague complaints of… Continue Reading →

Question: Fever + Rash

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 year old ill-appearing child with high fever and rash. She initially started with tender erythema in her skin folds, progressing… Continue Reading →

Question: Airway

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Immunizations

Parent / guardian unsure of the child’s immunization history? Almost every state has an immunization registry, and EMRs are often configured to be able to access them – ask your institution’s IT person how if that’s possible. For a quick… Continue Reading →

Question: Fever + rash

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 year old girl who was discharged from the hospital a week ago. At that time, she presented with fever, intermittent… Continue Reading →

Question: Cardiology

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an 18 year old male who presents with palpitations. Electrocardiogram reveals atrial fibrillation with a rapid ventricular response rate at 145.

Transferring Appy

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: COVID Vacc

(Click the link to comment and to vote – voting not working through email, sorry!) Your ED is providing patients who are eligible and interested in receiving the COVID-19 vaccine the opportunity to receive the 1st dose of an mRNA vaccine… Continue Reading →

Question: HEENT

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 12 year-old with 2 weeks of nasal congestion, rhinorrhea, sneezing, and sore throat, especially in the mornings. She has had no… Continue Reading →

New Guidelines

You’ve probably heard… AAP Subcommittee on Febrile Infants came out with new guidelines. The algorithms have been posted on PEMsource algorithms page, and the fever table updated to reflect them. Also, the CDC came out with new guidelines regarding STI… Continue Reading →

Question: Rheum

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 16yo girl who has been followed by her primary physician and a rheumatologist for systemic lupus erythematosus since being diagnosed 1… Continue Reading →

Question: GU

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 5 year old girl who presents with dysuria and small amounts of blood in her underwear for 3 days. She has… Continue Reading →

LP for febrile 22-28 days?

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Question: Lac

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Question: Gyn

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Ear laceration

Dr. Rahul Patil describes using the suture packaging to create a sterile field / barrier in “Easy way of keeping hairs away while suturing ear lacerations” Indian J Plast Surg 2011;44(3):531

Question: Nursemaid’s

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Question: VP Shunt

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 year old ex-premature infant who has a ventriculoperitoneal shunt in place. The patient presents with fever to 38.3, cough, and… Continue Reading →

CT 1st afebrile seizure?

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 15 year old who took a handful of aspirin in a suicide attempt. The salicylate level at 3 hours post-ingestion is… Continue Reading →

Question: Lacs

(Click the link to comment and to vote – voting not working through email, sorry!) You are repairing a large laceration extending from the occipital scalp over the top of the head and onto the forehead of a 5 year… Continue Reading →

Question: GERD

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Peds Hypertension

Hypertensive urgencies and emergencies can be missed in kids when physicians are used to the elevated BP’s of adults with essential hypertension. Hypertension in children is defined relative to the 95th percentile for age & sex. BP > 90th percentile is elevated;… Continue Reading →

Question: Hypertension

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Question: Syndromes

(Click the link to comment and to vote – voting not working through email, sorry!) The pediatric genetics clinic is sending over a patient with respiratory distress. As you prepare for the patient’s arrival, you have a chance to look… Continue Reading →

Bag for UA?

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Rash

(Click the link to comment and to vote – voting not working through email, sorry!) A 6 year old boy presents with 2 days of nontender palpable purpura of bilateral lower extremities, accompanied by arthralgia of the left ankle. Vital… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing an adolescent who slammed her finger in a door and has a subungual hematoma. 

Abscess Loop Drainage

Treating abscesses by making two smaller incisions and placing a loop through them is becoming popular, preferred by many over traditional I&D. For a review of the technique: https://pemcincinnati.com/blog/loop-abscess/ Don’t have a vessel loop? You can use the cuff of any glove… Continue Reading →

Question: GU

(Click the link to comment and to vote – voting not working through email, sorry!) A 4-year old boy is brought in because of marked edema and pruritis of his penis and foreskin. His family is visiting on vacation and… Continue Reading →

Question: Utox

(Click the link to comment and to vote – voting not working through email, sorry!) As part of the work-up for abnormal behavior in a 3 year old, the qualitative urine drug screen comes back positive for a substance. 

Buckle Fractures

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: nephrolithiasis

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 15yo girl with a strong family history of nephrolithiasis who presents with colicky right flank pain, non-bloody non-bilious vomiting twice, and… Continue Reading →

Question: STD

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Ddx COVID-19

Of course, we’re going to test everyone for COVID, but this handy chart from National Jewish helps differentiate the common symptoms and course of COVID-19 with those of colds, influenza, and allergies

Question: Angioedema

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 7 year old patient with his third lifetime episode of angioedema. He has swelling around both eyes and his right upper… Continue Reading →

Question: Ortho

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a child who fell on an outstretched hand and sustained a radius fracture. 

Pediatric RSI

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 year old who sustained a 2cm laceration to the neck from a jagged edge on a piece of metal play… Continue Reading →

Question: Rash

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a previously healthy 9-month old boy brought in for rash. The child had 3 days of fever. He was seen yesterday evening… Continue Reading →

Question: Resp

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 4 month old infant with fever, nasal congestion, and cough for 2 days. The baby is a previously well ex-full term… Continue Reading →

PEM in your Pocket

Everyone knows it’s nearly impossible to memorize all the formulas and doses relative to pediatric emergency medicine. That’s why 2 pediatric emergency medicine physicians created http://pocketpem.com/ when they were PEM fellows. Log on for a plethora of PEM info; maybe even bookmark… Continue Reading →

Question: STD

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Question: Neuro

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Migraine Tx

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Ortho

(Click the link to comment and to vote – voting not working through email, sorry!) A teen who plays on the high school varsity basketball team comes in after jamming her finger during a game. She has a distal phalanx… Continue Reading →

Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 15yo patient with past psychiatric history who takes escitalopram (Lexapro) and quetiapine (Seroquel) for nausea and vomiting. You give the patient… Continue Reading →

What’s New UTI

A trio of recent publications on pediatric UTI offer some insights. First, Mattoo et al offer a review of UTI diagnosis and management in children. Nadeem et al studied the optimal WBC cutoffs for diagnosing UTI, balancing overdiagnosis/overtreatment with underdiagnosis/missed UTIs, based on the… Continue Reading →

Question: Stroke

(Click the link to comment and to vote – voting not working through email, sorry! You are seeing a 3 year old child with unrepaired Tetralogy of Fallot who presented with a generalized tonic-clonic seizure, and residual hemiparesis and speech… Continue Reading →

Question: Pharm

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BOA in the ED

(Click the link to comment and to vote – voting not working through email, sorry!) A full term infant born out of asepsis (BOA) at home is brought in by ambulance to your PED. No neonatologist or pediatrician is in… Continue Reading →

Question: hypoglycemia

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3yo girl brought in by ambulance after a new-onset seizure. The patient has no past medical history, but has been having… Continue Reading →

Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) A 15yo obese patient is brought in after admitting to taking an overdose of “a handful” of metformin as a suicide attempt. No other drugs… Continue Reading →

PEM Pods

Learn some pediatric emergency medicine while you drive, do dishes, fold laundry, etc. The best known PEM podcast is Tim Horeczko’s (Harbor-UCLA) PEM Playbook – whereby Tim coaches you through tons of great learning, methodical approaches to PEM problems, and… Continue Reading →

Question: SSTI

(Click the link to comment and to vote – voting not working through email, sorry!) You are caring for a 19 year old woman who is breastfeeding her 2 month old infant. She has a superficial 2cm breast abscess located… Continue Reading →

Question: regional block

(Click the link to comment and to vote – voting not working through email, sorry!) You are preparing to repair an upper lip laceration that crosses the vermillion border in a cooperative 15 year old girl who was bitten by… Continue Reading →

COVID home O2 sat

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Critical Care

(Click the link to comment and to vote – voting not working through email, sorry!) You are sedating a 16 year old boy with past medical history of spontaneously resolved VSD as an infant with ketamine for tube thoracostomy to… Continue Reading →

Question: Tox

A 16yo patient is brought in directly from a large “pharm” party with altered mental status, respiratory depression, and pinpoint pupils. You suspect opiate overdose and administer naloxone with improvement in spontaneous respirations. To your surprise, however, the qualitative urine… Continue Reading →

Question: ENT

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 year old child with acute onset draining right ear. The child has no fever and no history of recent swimming… Continue Reading →

Otitis Externa

When treating otitis externa, placement of an ear wick can help direct topical antibiotics into a swollen canal. If you don’t have a commercially sold ear wick, you can make one by cutting a small strip of merocel or even… Continue Reading →

Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) A toddler, visiting for the holidays, has been roaming his grandmother’s large backyard, nibbling on plants. 

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 2yo who was being carried by a teenager who fell through a glass sliding door. The toddler has a 1.5 inch… Continue Reading →

Corneal Abrasion Tx

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: GU

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 4 year old boy with PMH of two UTIs and frequent episodes of otitis media. He has dysuria, frequency, straining to… Continue Reading →

Question: BRUE

(Click the link to comment and to vote – voting not working through email, sorry!) Which child does not meet the criteria for a low-risk BRUE? (Assume for all patients the events are now resolved and resolved immediately after the… Continue Reading →

Volume of a Swallow

There is surprisingly sparse literature to help determine how much a child swallowed as part of a toxic ingestion. Most texts quote the work of Jones & Work in Am J Dis Child 1961, who studied 10 children aged 1.25-3.5… Continue Reading →

Question: ABCs

(Click the link to comment and to vote – voting not working through email, sorry!) You are managing a 1yo patient with submersion injury who has respiratory distress and falling O2 saturation. You begin bag-valve-mask ventilation as you prepare to… Continue Reading →

Question: Seizures

(Click the link to comment and to vote – voting not working through email, sorry!) EMS is bringing you a 10yo patient that has been actively seizing for 20 minutes. They are unable to obtain IV access.

Hypothermia as Harbinger

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Surgical

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 4 week old infant with non-bilious forceful vomiting x 3 days.

Question: Neonatal

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 5 day old infant born term without complications brought to the ED because the parent noted a streak of bright red… Continue Reading →

Quick antipyretic dosing

To calculate the mL of standard concentration ibuprofen (100 mg / 5 mL) or acetaminophen (160 mg / 5 mL) to give, take the child’s weight in kg and divide by 2. mL of ibuprofen or acetaminophen = child’s weight… Continue Reading →

Question: EMS

(Click the link to comment and to vote – voting not working through email, sorry!) Paramedics are caring for a toddler with respiratory distress in the field. They contact the base hospital and receive instruction to administer nebulized albuterol.

Question: Rash

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 13 month old with a rash for 3 days. It started as fluid-filled vesicles that grew, burst, and released clear-yellow non-purulent… Continue Reading →

Antibiotics for Appendicitis

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Metabolic

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 10 day old infant born via midwife-assisted water birth at home, brought in for lethargy and vomiting. Physical exam is significant… Continue Reading →

Question: Pancreatitis

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Question: Psych

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Radiology – normal by age

bonepit.com is a great website for learning radiology. Specifically go to their Normal for age page to see normal skeletal radiographs by age and gender!

Question: Migraines

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Question: Spider Bite

(Click the link to comment and to vote – voting not working through email, sorry!) An 8 year old boy caught a spider, placed it in a jar, and was showing it to his friend when he was bit on… Continue Reading →

Intractable vomiting

(Click the link to comment and to vote – voting not working through email, sorry!) Note: controversies are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also… Continue Reading →

Question: Diagnostics

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 3 year old child adopted from another country 6 months ago for abdominal pain. Since then, the child has had chronic… Continue Reading →

Question: Ophtho

GC & Chlamydia Treatment

To remember the difference in antibiotic regimens for chlamydia cervicitis / urethritis vs pelvic inflammatory disease, rap this in your head: Ceph 10 x 50 for GC is nifty; give Zith 1 gram for the chlam, but doxy 14 days… Continue Reading →

Question: Musculoskeletal

(Click the link to comment and to vote – voting not working through email, sorry!) An 11yo girl presents with 2 weeks of right knee pain and limp after falling off a bicycle. She has had no fever, rash, other… Continue Reading →

Question: Diagnosis

(Click the link to comment and to vote – voting not working through email, sorry!) A 2yo girl is brought in by ambulance after a seizure lasting 1 minute. She has had 2 days of fever, vomiting, and diarrhea. Her… Continue Reading →

Traumatic arthrotomy

(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… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) You are caring for a 9 year old boy involved in a motor vehicle accident. He has a seatbelt sign on his left neck and… Continue Reading →

Question: Endocrine

(Click the link to comment and to vote – voting not working through email, sorry!) You are caring for a 12 year old known diabetic who presents in diabetic ketoacidosis. Temperature is 37.5, HR 100, RR 24, BP 96/36, O2… Continue Reading →

Infographics

Visuals, infographics, algorithms, charts, mnemonics etc. are great ways to quickly review, to provide on-shift teaching, even to keep notes for board review. I organize mine in Evernote, which is easily searchable, but there are numerous other options. Cool graphics… Continue Reading →

Question: Inborn Error

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Question: Airway

(Click the link to comment and to vote – voting not working through email, sorry!) A 3 week old infant that is positive for RSV has had several prolonged episodes of apnea requiring BVM ventilation. The decision is made to… Continue Reading →

Fever work-up in COVID era

(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… Continue Reading →

Question: FEN

(Click the link to comment and to vote – voting not working through email, sorry!) An 18 month old with history of pseudohypoaldosteronism presents with a K+ level of 9.0 and peaked T waves with mild QRS widening on the… Continue Reading →

Question: Genetics

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a patient with Trisomy 21 in the ED.

Question: GU

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 2 year old boy with complaint of penile pain for 2 days. He is previously healthy, fully immunized, afebrile, and has… Continue Reading →

Tele SimBox

As many programs have moved to Zoom (or other virtual meeting space programs) conferences, don’t think that you have to give up Simulation! There are 7 amazing pediatric emergency medicine tele-sim cases (and likely more to come – instructions for… Continue Reading →

Question: PTSD

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Question: Medical

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 2 year old who is slowly improving from a bout of acute gastroenteritis manifested by fever, vomiting, diarrhea, and abdominal pain… Continue Reading →

When to work up for MIS-C

(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… Continue Reading →

Question: Eye

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 13 year old girl with 2 days of left eye redness and pain, and 1 day of fever. She recently got… Continue Reading →

Question: red toes

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 14 year old boy who hiked in the snow yesterday with inadequate warm clothes and footwear. He has developed swollen violaceous… Continue Reading →

Question: GI

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 2yo patient with 6 hours of intermittent episodes of apparent abdominal pain happening every 15-20 minutes, and non-bloody non-bilious vomiting. In… Continue Reading →

Med Ed resources

As patients and parents observe shelter-in-place recommendations, PED volumes are down nationwide. On slow shifts, we are all looking for opportunities and resources to educate ourselves and our trainees. MedEdGuru has a great resource catalog of educational offerings, and there’s… Continue Reading →

Question: Hematuria

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Question: Abuse

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LP for febrile infants with UTI

(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… Continue Reading →

Question: Kawasaki

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Question: ENT

(Click the link to comment and to vote – voting not working through email, sorry!) A 2yo child presents with a 1.5cm diameter erythematous tender fluctuant swelling in the right preauricular area. There is a small pinhole sized indentation in… Continue Reading →

Re-use of N95

Here’s a great way to store your N-95 for re-use, and here is a great article on N-95s and re-using them

Question: Pregnancy

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Question: OM

(Click the link to comment and to vote – voting not working through email, sorry!) Match the child with acute otitis media to appropriate therapy per AAP guidelines (all children well-appearing, non-toxic, no distress or indications of severe otalgia, symptomatic… Continue Reading →

Adults in PED

(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… Continue Reading →

Question: Cardiology

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Question: Abuse

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Hand exam: nerves

PEM Infographics (linked here) has many helpful infographics. One of my all-time favorites is how to use rock-paper-scissors-OK sign to test children’s peripheral nerves in the upper extremity / hand exam

Question: Respiratory

(Click the link to comment and to vote – voting not working through email, sorry!) An adolescent is brought in intoxicated with history of drinking large amounts of alcohol at a dorm party. He vomited multiple times at the scene… Continue Reading →

Question: Ortho

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On Shift PPE

(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… Continue Reading →

Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!)A recent JAMA article summarized China’s experience with 72,314 COVID-19 novel coronavirus cases (Wu & McGoogan, JAMA 2020 Feb 24 [Epub ahead of print]). Which of the… Continue Reading →

Question: GU

(Click the link to comment and to vote – voting not working through email, sorry!) An 8yo boy presents with dribbling urination and pain with urination. When he urinates he sees his foreskin balloon out. On exam, he has phimosis…. Continue Reading →

To cath or not

(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… Continue Reading →

Question: Rash

(Click the link to comment and to vote – voting not working through email, sorry!) A 12mo old child with immunizations up to date presents with fever and rash. Which of the following distributions is concerning for measles?

Question: ENT

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Stimson shoulder reduction

Busy ED and don’t have time for procedural sedation or prolonged anterior shoulder dislocation reduction techniques? Set ’em up in the Stimson technique position and forget ’em – check back in 20-30 minutes. AliEM posted this great tip for using… Continue Reading →

Question: CXR

(Click the link to comment and to vote – voting not working through email, sorry!) A 17yo girl presents with LUQ abdominal pain and vomiting x 2 days, and SOB x 1 day. Past medical history includes mild intermittent asthma,… Continue Reading →

Question: Heme

(Click the link to comment and to vote – voting not working through email, sorry!) Pediatric patients with sickle cell anemia have a higher susceptibility to becoming infected with which organism?

Question: OB

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To Tamiflu or Not

(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… Continue Reading →

Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!) An 8 year old boy comes in with 2 days of fever, chills, myalgias, headache, and a few episodes of non-bloody, non-bilious vomiting. He also… Continue Reading →

Question: RSI

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Large Bore IV

So many helpful tips and tricks can be found on twitter! Of course, for kids, adjust IV catheter size and amount of fluid infused.

Question: Cardiology

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Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) At a New Year’s Eve party several glasses of champagne are left lying around the house. The family’s 2yo toddler proceeds to drink some of… Continue Reading →

Status epilepticus

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… Continue Reading →

Question: fluids

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Question: Anemia

(Click the link to comment and to vote – voting not working through email, sorry!) An 18 month old toddler is brought in for decreased energy and “not acting right.” On exam, the child is noted to be pale, mildly… Continue Reading →

Estimate LMA size

From Haliloglu M, Bilgen S, Uzture N, Koner O. Simple method for determining the size of the ProSeal laryngeal mask airway in children: a prospective observational study. Braz J Anesthesiol 2017; 67(1):15-20. The child’s ear is a good estimate of… Continue Reading →

Question: Post-ictal

(Click the link to comment and to vote – voting not working through email, sorry!) EMS has brought in an 8 month old child who had a generalized tonic-clonic seizure at home. The child has a history of 2 prior… Continue Reading →

Question: Metabolic

(Click the link to comment and to vote – voting not working through email, sorry!) You are asked to evaluate a 3 day old male with severe lethargy and hypotonia. He is mildly tachypneic. He is afebrile. As part of… Continue Reading →

Question: Spasms

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 6 year old boy with a few days of episodes of crying and jaw clenching, decreased oral intake, and intermittent painful… Continue Reading →

Pelvic exam in the ED

(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… Continue Reading →

Question: RSI

(Click the link to comment and to vote – voting not working through email, sorry!) For which of the following pediatric patients is it most important to have the clinician with the most experience in advanced airway management and endotracheal… Continue Reading →

Question: Vape Lung

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Honey for cough

Respiratory virus season is here, and we all know that the FDA recommends against the use of OTC cough medications in children < 4 years old (due to too many adverse effects and lack of efficacy). Some studies have shown… Continue Reading →

Question: Abd Pain

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 10 year old boy with abdominal pain. He was seen last night with a few hours of periumbilical abdominal pain. Work-up… Continue Reading →

Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 2.5 month old baby who underwent a fever work-up yesterday and has been called back due to a positive blood culture… Continue Reading →

Penetrating Palate Injury

(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… Continue Reading →

Question: Foreign body

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Question: Respiratory

(Click the link to comment and to vote – voting not working through email, sorry!) Which of the following is/are true of bacterial tracheitis? Children presenting with bacterial tracheitis tend to be older than children presenting with viral croup Children… Continue Reading →

Blood on POC hCG test

Patient won’t or can’t urinate for point-of-care pregnancy test, and quantitative hCG will take too long? Put a couple drops of whole blood on the POC cassette. Read more on ALiEM here, and below  

Question: Ortho

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 17 year old who was playing basketball for his high school team this evening when he felt a sudden pop and… Continue Reading →

Question: ENT

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 16 year old boy with sore throat, worse on the left side, dysphagia, low-grade fever, difficulty fully opening jaw (trismus), and… Continue Reading →

Facial lacerations

(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… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) An 11 year old left-hand dominant boy is brought in after accidentally sustaining an injury from a paint injection gun while helping his father on… Continue Reading →

Question: Eye

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AliEM P3 PECARN App

You know PECARN has done some trial relevant to the patient you’re seeing; you just can’t remember the trial, or the results… You wonder if the inclusion/exclusion criteria matches your patient at all. The amazing P3 team at AliEM has… Continue Reading →

Question: Renal

(Click the link to comment and to vote – voting not working through email, sorry!) You have diagnosed a 14 year old boy with likely nephrolithiasis, as evidenced by his colicky flank pain, hematuria, and ultrasound showing mild hydronephrosis.

Question: Heme

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 12 year old girl with PMH of sickle cell disease complicated only by 2 lifetime hospitalizations for vasoocclusive pain crisis. She… Continue Reading →

Bilimeters

(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… Continue Reading →

Question: Surgical

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Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) A 13yo boy comes in by ambulance after a syncopal episode. He and his friends heard that vaping is dangerous, so they used a hookah… Continue Reading →

Hair Tourniquets

  Photos before & after release from Wikimedia Commons Hair tourniquets (and sometimes thread tourniquets) can occur on toes (most common), fingers, and more rarely the penis, clitoris, or uvula. Peak occurrence is at age 2-6 months, corresponding with maternal… Continue Reading →

Question: Neuro

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 15 month old who became angry about a toy being taken away, cried, turned blue in the face, passed out, and… Continue Reading →

Question: Jaundice

(Click the link to comment and to vote – voting not working through email, sorry!) A full term infant with no birth complications and no known risk factors for hyperbilirubinemia complications, discharged early at 36 hours of life, presents to… Continue Reading →

Question: Eye Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) A 16yo boy presents with chief complaint of a black “hole” in the center of his vision in his right eye 4 days after being… Continue Reading →

Abscesses

(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… Continue Reading →

Question: Renal

(Click the link to comment and to vote – voting not working through email, sorry!) An 8yo boy presents with a 1 month history of progressive periorbital and generalized facial swelling, worse in the morning. Urine dip is positive for… Continue Reading →

Question: Heme-Onc

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BRUE Duration

Part of the new AAP BRUE algorithm’s definition of low-risk BRUE (Brief Resolved Unexplained Event) is that the event duration was < 1 minute. I always ask the caretaker to walk me through what happened step by step, using “and then… Continue Reading →

Question: Neonatal

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Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 17yo boy with cough x 1 month. You prescribe Tessalon Perles (benzonatate). He has a 2yo sibling at home.

Unvaccinated w/febrile seizure

(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… Continue Reading →

Question: FBs

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Question: Red Eye

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Hot sauce capsaicin

With the rise in legality of cannabis products, ED (and even PED) clinicians are seeing a big rise in cannabis hyperemesis syndrome. Topical capsaicin 0.025-0.075% is a known reliever of symptoms, as outlined on AliEM here. But who stocks topical… Continue Reading →

Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 10 month old with symptoms consistent with varicella. The infant is well-appearing, has no complications, and is 3 days into her… Continue Reading →

Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a child with suspected methemoglobinemia from overuse of benzocaine teething gel. You plan to treat with methylene blue. Which of the following… Continue Reading →

Question: Nursemaid’s

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Obs after anaphylaxis

(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… Continue Reading →

Question: Ortho

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 10 year old boy active in club soccer who comes in complaining of intermittent posterior heel pain, particularly after soccer games…. Continue Reading →

Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a pair of 14 year old girls who took “Triple C” at a party. One is altered and the other is hallucinating…. Continue Reading →

Blind Stick

When resuscitating neonates vascular access is often a challenge. While IV and IO attempts are ongoing, the ability to obtain a small amount of blood for point-of-care testing of, for example, glucose, hemoglobin, electrolytes, and venous blood gas, can be… Continue Reading →

Question: Measles

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a child with fever and rash x 1 day. Cognizant that we are in the middle of a measles outbreak, which of… Continue Reading →

Question: Meckel’s

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Dog bites – Antibiotics?

(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… Continue Reading →

Question: Gallbladder

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Question: OB-Gyn

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Developmental Milestones

Here’s a quick and dirty method to recall developmental milestones See the zero 0 as the “o” in tone, as the eyes for gaze, and as the mouth for strong suck The word two (months) is a combination of track… Continue Reading →

Question: Adolescent

(Click the link to comment and to vote – voting not working through email, sorry!) A 14 year old girl is brought in by her parents because of concerns that she is “too thin.” The girl feels that she is… Continue Reading →

Question: Rash

(Click the link to comment and to vote – voting not working through email, sorry!) A 19 year old otherwise well-appearing man presents with 2 days of headache, anorexia, tactile fever (but afebrile in the ED), and 1 day of… Continue Reading →

Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) A toddler is brought in to the ED after it is suspected that he ate his uncle’s brownie containing cannabis.

CT for headache

(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… Continue Reading →

Question: Seizures

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 1yo child in status epilepticus (first time seizure). The child received 0.2 mg/kg intranasal midazolam in the field, 0.1 mg/kg IV… Continue Reading →

Question: Elbow Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) Which of the following elbow radiography findings can be normal in a 2 year old that fell on an outstretched arm and has decreased use… Continue Reading →

Interpreting the VBG

The Coach at PEMPlaybook.org has a great podcast on using the VBG in situations where we used to try to get an ABG (which was never fun to do in small children). From the podcast: the rule of 4’s: (note… Continue Reading →

Question: Impetigo

(Click the link to comment and to vote – voting not working through email, sorry!) Which of the following topical antibiotics has the least efficacy against impetigo? (see pictures of impetigo here and a short article here)

Question: Normals

(Click the link to comment and to vote – voting not working through email, sorry!) You are seeing a 4 week old brought in for vomiting with every feed. The vomitus is non-bilious, non-projectile, and non-bloody. The baby is making… Continue Reading →

Steroids for Hives

(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… Continue Reading →

Question: Airway

(Click the link to comment and to vote – voting not working through email, sorry!) For which of the following patients is a laryngeal mask airway (LMA) as a temporizing measure after failure of intubation contraindicated?

Question: Onychocryptosis

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Pediatric Ear Exams

My husband the internist likes to say that we peds MDs are pretending to see the TM, but I say the MDs for adults are pretending to hear diastolic murmurs. Kidding aside, you really can get good at seeing TMs… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) A 7 year old boy presents to the ED after falling off his bike and impacting his mouth against the handlebar and the ground. Bystanders… Continue Reading →

Question: Otitis Media

(Click the link to comment and to vote – voting not working through email, sorry!) About 70% of ear infections improve spontaneously. Which of the following patients is NOT a candidate for the “wait and watch” no-antibiotics option (for all… Continue Reading →

“BRUE” with Choking

(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… Continue Reading →

Question: Dislocation

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Question: Swelling

(Click the link to comment and to vote – voting not working through email, sorry!) A 10-year old child is brought in for swelling that developed 2 hours ago around the mouth as well as a sensation of difficulty swallowing… Continue Reading →

Intubating the Obese Patient

Two tips for intubating the obese patient: Position the patient: build a sizeable ramp to position the patient such that his/her ears are at the level of the sternal notch, and his/her face is parallel to the ceiling Position yourself: keep… Continue Reading →

Question: GI bleeding

(Click the link to comment and to vote – voting not working through email, sorry!) What is the most common cause of lower GI tract bleeding in young infants after anal fissure?

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) A child has a large galea aponeurotica laceration that is part of a scalp laceration. The provider sutured the scalp laceration but failed to close… Continue Reading →

Occult Bacteremia

(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… Continue Reading →

Question: Tox

(Click the link to comment and to vote – voting not working through email, sorry!) Regarding common Christmas holiday plants:

Question: Croup

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Estimating BSA of burns with patient’s palm

It is commonly taught that a patient’s palmar hand represents approximately 1% of his/her body surface area (BSA), a useful tool when estimating the BSA of burns. But does one use the palm including or excluding the fingers? Adult studies… Continue Reading →

Question: GI Bleed

(Click the link to comment and to vote – voting not working through email, sorry!) A 1 week old presents with multiple bouts of hematemesis. The baby was born full-term, no complication, has been breast-feeding normally, and is afebrile. The… Continue Reading →

Question: Trauma

(Click the link to comment and to vote – voting not working through email, sorry!) A new edition of ATLS (10th edition) was recently released. Which of the following is not a recommendation of the 10thedition of ATLS regarding the trauma… Continue Reading →

Question: Stats

(Click the link to comment and to vote – voting not working through email, sorry!) You are studying a new rapid flu test’s performance in your ED. Using PCR as a gold standard, you studied 100 kids at the peak… Continue Reading →

Cricoid Pressure

(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… Continue Reading →

Question: Dental

(Click the link to comment and to vote – voting not working through email, sorry!) A 19 year old man presents 4 hours after leaving his dentist office from wisdom tooth extraction. He has been having bleeding from the socket… Continue Reading →

Question: Shoulder dystocia

(Click the link to comment and to vote – voting not working through email, sorry!) A 17 year old G1P0 girl at 38 weeks gestation presents in active labor, crowning. OB has been called but is responding from home and… Continue Reading →

Early stylet removal for infant LP

Success rates in infant lumbar punctures may be declining as we do fewer and fewer (doing fewer is a good thing, except that we get less experience). One thing that can improve success is early stylet removal. The stylet is… Continue Reading →

Question: Neuro

(Click the link to comment and to vote – voting not working through email, sorry!) A 12 year old boy with a history of ADHD on Adderall comes in for acute onset weakness of his bilateral upper arms, particularly on… Continue Reading →

Question: ID

(Click the link to comment and to vote – voting not working through email, sorry!) A 5 year old girl presents with a 2 cm tender lump in her right armpit. It is not fluctuant and there is no overlying… Continue Reading →

Double Sequential Defibrillation

(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… Continue Reading →

Question: Study Design

(Click the link to comment and to vote – voting not working through email, sorry!) An investigator wishes to know whether PED patients seen with bloody diarrhea are prescribed antibiotics in the PED are more likely to develop hemolytic uremic… Continue Reading →

Question: STD

(Click the link to comment and to vote – voting not working through email, sorry!) A 19yo man was seen in the ED 2 weeks ago with a painless lesion to his penis. He is sexually active with men, has… Continue Reading →

Ring Removal

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… Continue Reading →

Question: Cardiac

(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…. Continue Reading →

Question: Diabetic patient

(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… Continue Reading →

Stable adenosine-refractory SVT

(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… Continue Reading →

Question: Ortho

(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… Continue Reading →

Question: Congenital condition

(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… Continue Reading →

Cannabis hyperemesis

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… Continue Reading →

Question: Labs

(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… Continue Reading →

Question: Rash

(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,… Continue Reading →

Question: Abd & hip pain

(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… Continue Reading →

Levetiracetam dosing for status

(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… Continue Reading →

Question: Rash

(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… Continue Reading →

Question: Cardiology

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REVERT for SVT

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… Continue Reading →

Question: Heat Stroke

(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… Continue Reading →

Question: Dental

(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… Continue Reading →

Antibiotics for abscess?

(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… Continue Reading →

Question: Asthma

(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… Continue Reading →

Question: Extremity

(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. By James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)… Continue Reading →

ABCDEFG

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… Continue Reading →

Question: OB

(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… Continue Reading →

Question: Heme

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Question: Study Design

(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… Continue Reading →

Inhaled steroids for asthma

(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… Continue Reading →

Question: Chest Pain

(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… Continue Reading →

Question: Menorrhagia

(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… Continue Reading →

GoodRx

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… Continue Reading →

Question: C diff

(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… Continue Reading →

Question: Trauma

(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… Continue Reading →

Hip pain in kids

(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… Continue Reading →

Question: ENT

(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,… Continue Reading →

Question: ID

(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… Continue Reading →

UTI Risk Calculator

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… Continue Reading →

Question: FEN

(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?

Question: Trauma

(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… Continue Reading →

Ibuprofen in infants

(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… Continue Reading →

Question: Tox

(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… Continue Reading →

Question: GI

(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…. Continue Reading →

Clean Catch Urine

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,… Continue Reading →

Question: Biostats

(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… Continue Reading →

Question: ovarian torsion

(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.

Hematuria in trauma

(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… Continue Reading →

Question: VP shunt

(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… Continue Reading →

Question: ID

(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… Continue Reading →

QTc as half the RR

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… Continue Reading →

Question: hypothermia

(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… Continue Reading →

Question: Tox

(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… Continue Reading →

Conundrum: Tamiflu?

(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… Continue Reading →

Question: GU

(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,… Continue Reading →

Question: NAT

(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.

Cafeteria run

Your local hospital cafeteria can be a useful resource in managing your PED patients: Sugar liberally applied to the edema of a paraphimosis or rectal prolapse may help decrease swelling and improve reduction efforts A mayonnaise packet provides useful lubricant… Continue Reading →

Question: Eye problem

(Click the link to comment and to vote – voting not working through email, sorry!) www.jems.com A 2 year old toddler comes in from the playground crying and rubbing at his right eye. Exam is as above.

Question: Adolescent Gyn

(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… Continue Reading →

Dispo for flu+ neonate

(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… Continue Reading →

Question: Ortho

(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,… Continue Reading →

Question: Transport

(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… Continue Reading →

Airway Adjuncts

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… Continue Reading →

Question: Neonate

(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… Continue Reading →

Question: Chest pain

(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… Continue Reading →

Question: Limp

(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: Legg-Calve-Perthes disease Developmental dysplasia of the hip… Continue Reading →

10 wk w/ fever & GBS+ mom

(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… Continue Reading →

Question: Environmental

(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… Continue Reading →

Question: Triage

(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,… Continue Reading →

Trauma SAMPLE-PT and ABCs

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… Continue Reading →

Question: Congenital heart disease

(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… Continue Reading →

Question: 5yo with tachycardia

(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… Continue Reading →

Magnesium for asthma

(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… Continue Reading →

Question: DKA

(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… Continue Reading →

Question: ECG in Peds

(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… Continue Reading →

ICD-10 codes

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… Continue Reading →

Question: Ex-premie

(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… Continue Reading →

Question: Syndromes

(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… Continue Reading →

Oseltamivir for influenza

(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… Continue Reading →

Question: Tox

(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… Continue Reading →

Question: Derm

(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?

Transdermal Medications

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… Continue Reading →

Question: Food poisoning

(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…. Continue Reading →

Question: Laceration

(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.

Follow-up blood cultures positive

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… Continue Reading →

Question: Rash

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!)

Question: Critical Care

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… Continue Reading →

Pediatric throat exam

Some tips and tricks for examining children’s throats: Don’t do it until after you’ve gotten your lung, heart, and abdomen exam – once you make them cry, it’s game over A helpful position for young children is to sit on… Continue Reading →

Question: Food illness

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… Continue Reading →

Question: Cervical Spine

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!)… Continue Reading →

Question: Environmental

 en.wikipedia.org (Click the link to comment and to vote – voting not working through email, sorry!)

Analgesia for abscess I&D

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!)

Question: ID

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… Continue Reading →

Question: Tox

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… Continue Reading →

Topical anesthetic for abscesses

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…. Continue Reading →

Question: Trauma

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… Continue Reading →

Question: Rash

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… Continue Reading →

Complex febrile seizures

Do you do a CT and LP on all complex febrile seizure patients?

Question: ID

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… Continue Reading →

Peds Sizing and Formulas

Thanks to Tim Horeczko pemplaybook.org for tube-tape-tap mnemonic Link to the latest version

Question: Tox

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… Continue Reading →

Question: MSK

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… Continue Reading →

Question: ID

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… Continue Reading →

Question: Tox

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… Continue Reading →

GI cocktail

What do you include in your GI cocktail for adolescents?

Question: Study design

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… Continue Reading →

Question: ENT

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… Continue Reading →

Tooth avulsion, no coe-pak

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… Continue Reading →

Question: Rabies

Which of the following wild animal exposures is the lowest risk for rabies? Skunk Coyote Raccoon Fox Rabbit Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here

Question: Neonatal

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… Continue Reading →

Question: Trauma

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… Continue Reading →

Facial lacerations

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… Continue Reading →

Question: Allergy

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… Continue Reading →

Question: Intubation

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… Continue Reading →

Lining up the vermillion border

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… Continue Reading →

Question: Fractures

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.  (source medscape) B. 18 month old brought in for refusing to walk, history… Continue Reading →

Question: ENT

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… Continue Reading →

Constipation in the ED

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… Continue Reading →

Question: C diff

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… Continue Reading →

Nasal foreign body removal balloon catheter

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… Continue Reading →

Question: chest pain

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… Continue Reading →

ABCs of dysuria w/o UTI

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… Continue Reading →

Hyperbili work-up @6wks

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… Continue Reading →

Question: GU

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… Continue Reading →

Question: Trauma

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… Continue Reading →

4-5-6 7-8-9 rule

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… Continue Reading →

Question: EMS

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… Continue Reading →

RSV Apnea Risk

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… Continue Reading →

Question: Toxicology

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… Continue Reading →

Restraining for procedures

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… Continue Reading →

Question: Oncology

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,… Continue Reading →

Clinical pneumonia

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… Continue Reading →

Question: research ethics

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,… Continue Reading →

Improvised mucosal atomizer device

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… Continue Reading →

Question: HEENT

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… Continue Reading →

Vascular access in first week of life

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… Continue Reading →

Discharge O2 sat for bronchiolitis

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… Continue Reading →

Question: Shock

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… Continue Reading →

Question: battery ingestion

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… Continue Reading →

Are they petechiae?

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… Continue Reading →

Bolus before infant LP

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… Continue Reading →

Question: GI

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… Continue Reading →

Tongue Depressor Puppets & More!

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. Here are instructions put together by Seth, and a video of… Continue Reading →

Pharyngitis in toddler

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… Continue Reading →

Isopropyl alcohol pad for nausea

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… Continue Reading →

Question: EMS

Which of the following is true of EMT scopes of practice (EMT-B = EMT-Basic, EMT-I = EMT-Intermediate, EMT-P = Paramedic)? Only EMT-I and Paramedic level EMT’s can administer oxygen Training to become an EMT-B is usually 100-150 hours Training to… Continue Reading →

Rule out airway foreign body

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… Continue Reading →

1cm “ruler”

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.  

Question: Trauma

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… Continue Reading →

Urinalysis in febrile young children

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?

Question: chest pain

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… Continue Reading →

Flourescein exam

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… Continue Reading →

Infant Fever Work-up

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?

Question: EMS

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

ETT as suction catheter for FB removal

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)

Question: Trauma

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?

Infant UTI – do you LP?

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?

Tegaderm for tissue adhesive

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… Continue Reading →

Benzo paradoxical reaction

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,… Continue Reading →

Question: Trauma

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… Continue Reading →

Combat fever phobia

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

Decadron for asthma?

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… Continue Reading →

Light source for peritonsillar abscess drainage

Use a laryngoscope upside down as a tongue blade, or use a self-lighting pelvic exam speculum (remove top half of the speculum)

Question: Stats

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?

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