PEM Source

Your source for all things Pediatric Emergency Medicine

Tips and Tricks

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

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 drop). For tips on administering eye drops see this prior post: https://pemsource.org/2023/03/17/administering-eye-drops/

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 common urgent non-emergent complaints, including cough & cold. Included is a dosing calculator that returns the exact mL of acetaminophen and ibuprofen for weight in kg. PEMsource also has a list of the common OTC children’s cough & cold medications. Note: the FDA just released a statement in September 2023 that phenylephrine, a common ingredient in OTC cold medications, is no better than placebo. Read more on that here.

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 you manage your time well, you’ll have more time for all the activities that contribute to wellness – mindfulness, hobbies, exercise, SLEEP.)

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 PEM podcasts out there, starting with the O.G. popular PEM Playbook from Tim Horeczko, great for deep dives, show notes, and clever mnemonics. If you have a shorter commute time, there's quicker tips and tricks from Joe Ravera at PEM GEMS. Listen to PEM Currents, a podcast from PEMBlog - bonus: each topic includes some references. Another bite-sized PEM podcast is PEM Rules, also featuring guests. For a more academic / expert commentary viewpoint CHOP's PEM Podcast hosted by Robert Belfer features guest experts. Finally, Pulse Check from Ruchika & Will covers non-clinical topics of interest to PEM providers.

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 nothing slows down the ED more than not having rooms available, so remember to make dispo rounds and get patients either sent home or admitted

2) Order stuff from triage – either assign someone to screen and order or empower your nurses to initiate certain orders

3) Before ordering anything, ask yourself, “Does the patient really need that?” Example: flu or RSV test when the answer wouldn’t change your other work-up or treatment

4) Identify the bottleneck. Sometimes, you are shorter on nurses than anything else, and if you really want to keep the ED flowing, doctors will have to pitch in and escort a patient to xray or hand the patient a urine collection cup

5) Buff up your EHR templates, auto-text, and other shortcuts to charting now. Do it on less busy overnight shifts. Do you find yourself typing the same medical decision-making for minor closed head injury where no CT was done over and over? Do it once, select, save as auto-text or dot-phrase, and repeat repeat repeat for all your commonly used text

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 choosing the appropriate splint, and recommended orthopedics follow-up. The Sutures app reviews the basics of suture materials and anesthetic dosing, and includes links to video walkthroughs of suture techniques from another one of our favorite sites, Closing the Gap. The apps are available on iOS and Android, and some also have web-based versions. Go to fadial.com to check them out!

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’ questions, and ultimately printed out the cover of “What to Expect the First Year” from a book-buying website and told them to go buy it. Well, you're in luck... two of our former PEM fellow trainees are posting guides and videos to answer common parent questions on TinyTotsERDocs – follow them on Facebook, Instagram, and YouTube, and check out their webpage where there will soon be courses that parents or other caretakers can take!

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 of otitis media, or strep throat; her lung exam is difficult because she is uncooperative, but she is not tachypneic, has no increased work of breathing, and her O2 sat is 97% on room air. A clean-catch urine shows 1+ leukocytes with 6-10 wbc/hpf on micro; urine culture has been sent. A chest x-ray shows some vague haziness along the right heart border; radiologist read will not be available until tomorrow. Both diagnoses of UTI and pneumonia are possible but not clear-cut. What antibiotic covers both situations? While high-dose amoxicillin and augmentin are first-line for community-acquired pneumonia (CAP) in < 5-year-olds, resistance by UTI bugs to these antibiotics is high. While cephalexin is often used to treat pediatric UTI, first-generation cephalosporins are not a good choice for CAP. Your best bet is a 2nd or 3rd generation cephalosporin such as cefixime, cefdinir, or cefibuten. (Cefuroxime is not available in suspension form in the USA).

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 brief introduction to the parent and mime that you are going to listen to their child’s lungs. In general, if a child is quiet when you are ready to start the exam, start by listening to the lungs and heart first. If the very sight of you upsets the child, try asking the parent to hold the child over their shoulder facing back to listen to the lungs. For the abdominal exam, unless the chief complaint requires a careful thorough abdominal (and GU in that case) exam, you can reach around to palpate as the parent holds the child in this position. You can also ask the parent to palpate (for tenderness) once the child calms down because you have walked across the room. Save the ENT exam for last. Start with the ear exam and if the child cries with his/her mouth wide open, take advantage to do a quick throat exam between ears! More pediatric exam tips can be found on AliEM here

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 in. If a caretaker is going to use this technique, be sure to prescribe extra volume of medication. This method is shown ~0.42 in this video, which is a useful video overall showing several techniques.

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 this article for an example.

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 infectivity. However, some COVID-19 symptoms are now seen early in the disease course before the rapid test is positive. These are symptoms produced by the body’s immune response (something we now have due to natural or vaccine-induced immunity) to the virus – symptoms such as nasal congestion and runny nose, fever, sore throat. Symptoms produced by the virus damaging body cells (loss of taste or smell, diarrhea, shortness of breath) come later. Thus, if someone begins having scratchy throat and runny nose, rapid tests negative, and assumes they “just have a cold,” they may unwittingly build to a higher viral load in the next few days (that would turn a rapid test positive) and infect others with COVID-19. This is the reasoning behind recommendations for repeat testing 48 hours after an initial negative in symptomatic patients and for doing throat + nasal swabs to increase test sensitivity. For more info: https://lemonadamedia.com/podcast/will-we-all-get-omicron-in-2022-with-david-agus/ and https://www.axios.com/2022/12/16/changing-thoughts-rapid-tests and follow Michael Mina @michaelmina_lab on Twitter.

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 now the rash is back. I like to explain that eczema is like “asthma of the skin,” and to expect “attacks” or “flares” just like asthmatics get, depending on environmental pollen counts, dry air, etc. When an asthmatic has a flare, they use their albuterol inhaler, and when someone with eczema has worsened rash, they ramp up their dry skin regimen and use steroid creams. Lately I’ve also been comparing hand-foot-mouth to “a virus in the chickenpox family” with similarities that it has to get better on its own, antibiotics don’t help, and it takes 7-10 days for the lesions to heal up.

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 return to school on the 9th day after symptoms started. However, young infants and immunosuppressed children may shed active virus for up to 4 weeks.

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 a pdf of a high yield laceration cheat sheet from that course. Below are some highlights...

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 (can use 2.5 inch length in 2-12 year olds if available)

20 drops of CSF = ~ 1 mL

AgeWeight (kg)Median spinal cord depthNeedle length (cm)Needle length (in)
Neonate / Infant1-50.9-1.7cm20.8
Toddler 12-18mo102.4cm31.2
4yo152.6cm3-41.2-1.6
6yo202.8cm41.6
9yo303.2cm41.6
12yo403.6cm52
14yo504cm5-62-2.4

Formulas to estimate median spinal cord depth (mm):

Neonates and infants: 2 (wt in kg) + 7 mm

Children: 0.4 (wt in kg) + 20 mm

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!

From https://www.ophthobasics.com/medications

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 better, but it can be annoying to have goopy eyes for an ambulatory toddler. This is a nice summary from an ophthalmologist / comedian. In particular, as he states, stay away from gentamicin and sulfas - they often cause eye irritation. It can be hard to differentiate viral from bacterial conjunctivitis, and in the spirit of "first do no harm," you don't want to worsen the symptoms of a viral conjunctivitis that was going to self-resolve anyways.

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 also contribute. It should be a standard part of our practice to assess access to firearms when seeing children who are depressed or suicidal, expressing homicidal thoughts, or are current victims of gun or gang violence. But if there’s time during the visit, it doesn’t hurt to run through an injury prevention checklist (helmets, carseat/seatbelt, unsecured firearms) with all our patients / parents. Find resources here 

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.

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)

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 present, painstaking suturing of the laceration with fine friable absorbable suture. Then, the nail plate or a substitute such as the foil from the suture packet needed to be placed in the nail fold to stent it open. Current state-of-the-art is much simpler! Simply trephinate significant subungual hematomas (e.g. > 50%, raising the nail, painful). If a nail bed laceration is to be repaired, tissue adhesive is an easier acceptable alternative to suturing. And there may not be a need to stent the nail fold unless there is direct injury to the nail fold itself. Check out this review from the experts.

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 and chronic subclinical GI blood loss. Toddlers should not drink > 20 oz milk / day; their diet must contain a variety of foods. Only severe cow's milk-associated anemia (Hgb < 5 g/dL) requires transfusion; otherwise diet modification and iron supplementation suffices. When transfusing hemodynamically stable patients who developed their anemia chronically, transfusion aliquots should be smaller and slower to avoid TACO (transfusion-associated circulatory overload). A good rule of thumb is: transfusion aliquot = Hemoglobin amount in mL/kg over 3-4 hours, so a child with a hemoglobin of 2.5 would receive 2.5 mL/kg PRBCs over 3-4 hours (instead of the typical pediatric transfusion aliquot of 10 mL/kg).

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 recent studies found that (nares to tragus minus 10mm) more accurately predicted the correct size NPA in children: Johnson et. al. and Nemeth et. al.

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 that vomit a bit, Joe says, "It's not a BRUE, it's a spew." And if the baby was defecating and strained and grunted and turned red in the face, "It's not a BRUE, it's a poo." Another important part of defining a low-risk BRUE is that it lasted < 1 minute. But terrified parents often report much longer times than the actual event. Some ways to better define the timing: 1) start a stopwatch (e.g. on your phone) and ask the parent to say Stop when they reach about how long it was, 2) ask the parent what he/she did - "I patted his back and he started crying" = < 1 minute, whereas "I ran to the neighbor's house, got a washcloth and put cold water on his face, then called 911, and then he started crying" is > 1 minute.

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 that the patient cannot receive any beta-lactam antibiotics. Whether or not there is likely to be cross-reactivity between the antibiotic to which the patient is allergic and another beta-lactam antibiotic depends on whether their structures share similar R side chains, as explained in this article. A handy can be kept on your mobile phone delineating which antibiotics cross react.

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 cellulitis spreads further. Another tip to follow the progression of rashes in general is to ask the parent to take a photo with their smart phone and bring it to the follow-up PMD or ED visit.

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 powerpoint on the immunizations that matter for ED care, check this out.

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 treatment. The summary wall poster can be found on the PEMsource On Shift tab. Some highlights: higher dose of ceftriaxone recommended for uncomplicated gonococcal infections, doxycycline only is 1st line for chlamydial infection (azithromycin no longer 1st line), and sex-specific dosing for trichomoniasis treatment. Also recommended IV regimen to treat PID is ceftriaxone + doxycycline + metronidazole; clindamycin & gentamicin now an alternate regimen.

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

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; Stage 1 hypertension is a BP from the 95th percentile to 95th + 12 mm Hg. Stage 2 hypertension is a BP > the 95th percentile + 12 mm Hg (or > 140/90 for > 13yo). Stage 1 and asymptomatic Stage 2 patients should be referred back to the PMD for confirmation of repeated elevated BPs and outpatient work-up. Hypertensive emergency is a Stage 2 patient with evidence of end-organ damage, e.g. seizure, stroke, altered mental status, papilledema, heart failure, or a BP > the 95th percentile + 30 mm Hg, even if asymptomatic. Charts can be used to determine the 90th and 95th percentile, but a rule of thumb is that 95 + 2 (age in yrs)/50 + 2 (age in yrs) = the 90th percentile, and 115 + 2 (age in yrs)/65 + 2 (age in yrs) = Stage 2 hypertension. (Source: MacNeill E. Pediatric Emergency Medicine Practice, March 2019)

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 – doesn’t need to be sterile as abscesses themselves aren’t! 

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

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 the page on your phone. PEMsource also has several quick references that can be printed out / laminated and attached to your badge, or added to the files on your phone – check out resuscitation formulas and sizingECGslabs, and medications.

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 specific gravity and found them to be: 3 WBC/hpf for spec grav < 1.011, 6 WBC/hpf for 1.011-1.020, and 8 WBC/hpf for spec grav > 1.020. And Liang et al reviewed 2144 PED visits in < 2yo and calculated likelihood ratios and posttest probabilities for various urinalysis findings. UTI prevalence was 9.2%, which the authors used as the pretest probability. Likelihood ratios for leukocytes were: 1+ 2.79. 2+ 7.53, 3+ 37.68. Nitrite positivity carried a LR of 25.35. WBC/hpf at 5-10 had a LR of 1.2 (95CI 0.7-2.04), 10-20 LR 1.82, 20-50 LR 11.18. Few bacteria had an LR of 1.46, moderate 6.05, many 14.04. 

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 useful mnemonics; the helpful show notes are a great bonus. If you just have 15-20 minutes, though, head over to Joe Ravera's (another Harbor-UCLA alum, now at University of Vermont) PEM GEMS for tips and tricks for taking care of children in the ED (as well as some so bad they're good puns). And, finally, the new kid on the block is from Robert A. Belfer and Children's Hospital of Philadelphia, PEM Podcast, offering insights into the latest clinical updates and innovations in Pediatric Emergency Medicine.

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 ribbon packing gauze (~15mm is a typical length). This video explains insertion. At least 6 drops of oto-antibiotics should be placed on the external end of the wick to prime it, and the patient should then be instructed to continue applying 2-4 drops to the external end of the wick 2-4x/day. The wick should be removed after 2-3 days. If insurance doesn’t cover otic fluoroquinolone drops, ophthalmic fluoroquinolone drops can be used in the ear (but vice versa is not true). If the canal is so swollen that it’s hard to get the ear wick in, use a small well tapered otoscope speculum to direct steroid otic drops into the canal first to decrease swelling.

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 years and found the average mL/swallow to be 4.6mL, or 0.33 mL/kg. To remember more easily, round up to 5mL, or one teaspoon, per swallow of a small child. Another study by Watson et al in Am J Emerg Med 1983, found that container opening size made a difference. Older children swallow 10-15mL per swallow, while teens and adults swallow 15-30mL. Some liquid substances highly toxic to toddlers in a teaspoon or less include: camphor (vaporub, tiger balm), methyl salicylate (oil of wintergreen), liquid nicotine (vaping solution), and selenium dioxide (gun bluing solution).
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 in kg divided by 2 Don't use for children > 40 kg for ibuprofen (as 20 mL = 400 mg is an appropriate maximum dose of ibuprofen) The math: Ibuprofen weight (kg) x 10 mg/kg x 5 mL/100mg = weight (kg) x 1/2 Acetaminophen weight (kg) x 15 mg/kg x 5mL/160mg = weight (kg ) x 0.47 0.47 is close enough to 1/2  
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!
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 BID is needed for PID
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 are often found by following some active educators on Twitter, but other resources include PEM Infographics and Grepmed
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 contributing are on the site), complete with facilitator guides, EMS run audio, and video of the patient and the patient's monitor on acepsim.com - use Zoom breakout rooms and multiple facilitators to have a virtual sim session. Here are several other tips for making your Zoom virtual conferences more interactive and engaging.
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 a handy "pediatric specific" checkbox below the filters as well! Open Pediatrics also has two great simulators (also linked from the PEMsource FOAM page): a Ventilator Simulator and a fun ED simulator (pick VS Peds for pediatric only patients) complete with interruptions and multiple roomed patients. Finally, PEMsource offers 100 PED Cases to go through, ordered in groups of 10 from neonates to teens, and PEM Playbook has an amazing array of podcasts with informative show notes
Here's a great way to store your N-95 for re-use
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 rock paper scissors ok
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 soft restraints to attach weights to the patient's wrist. If you don't have weights - each 1 Liter bag of NS including the bag is about 2.4 lbs; attach 2 to 4 bags for 5-10 lbs of weight. Stimson2017  Weight for Stimson (Stimson technique via Wikipedia)
So many helpful tips and tricks can be found on twitter! Of course, for kids, adjust IV catheter size and amount of fluid infused. Get a bigger IV
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 the LMA size. Ear LMA
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 honey to be something useful we can recommend to frustrated parents, but how exactly is it administered? Studies tested from 2.5mL to 10gm (5mL of honey = ~ 7gm). Pulling the results together, 5mL of honey can be mixed in any non-caffeinated drink, such as warm lemon water, herbal tea, or warm skim milk, and given at bedtime or up to TID. Giving it longer than 3 days had no added benefit. There is some evidence that dark honey is more effective. (Oduwole et al Cochrane Database Syst Rev 2018 Apr 10;4:CD007094).
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 Blood on ICON slide  
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 developed an app, available for iOS or Android, that summarizes the 140+ PECARN publications! The publications are organized into categories. Find out all about this awesome resource here
Hairtourniquet Wikimedia James Heilman Hair_Tourniquet_after 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 postpartum hair loss. Edema may progress to vascular compromise; ischemia and autoamputation have occurred. Tips for removal:
  • Magnifying loupes can be helpful
  • Consider topical anesthesia with EMLA or viscous lidocaine (avoid LET w/epinephrine so as to not confuse discoloration due to the tourniquet vs due to temporary epinephrine effect)
  • If definitely a hair, depilatory cream (eg Nair) can be applied for 3-10 minutes on unbroken skin; repeat once if not successful (the product can irritate skin, however)
  • AliEM describes use of a cutting needle to get under the hair and cut it https://www.aliem.com/2012/06/trick-of-trade-hair-tourniquet-release/
  • If the hair is too deep / not visualized, the cutting needle can still be used to lift the tissue and constricting band, and a scalpel then used to cut the hair and superficial layer of tissue
  • Severe tourniquets may require perpendicular cuts to the bone, best done at 3:00 and 9:00 positions
  • Look for improvement in swelling and color with release. If the hair cut deeply, it may be difficult to see if release is complete. At least one author has studied ultrasound for identification https://www.ncbi.nlm.nih.gov/pubmed/29341258.
  • Consult a urologist for deep penile tourniquets
  • Consider child abuse, particularly with genitalia involvement
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 what” prompting. I have had parents that told me the event lasted 2 minutes whose step-by-step description varied from “I picked her up, called for my husband to call 911, and blew in her face and she started coming around” (probably < 1 minute) to “I picked her up, ran to my neighbor’s house, she was still blue, we laid her on the couch, my neighbor gave mouth-to-mouth, and I called 911” (probably > 1 minute). Another trick I use is to say, “OK let’s say it starts when I say “now”, let me know when you think it stopped… now,” while timing with a stopwatch (available on your phone) – when your baby’s not breathing, 15 seconds can seem like 5 minutes; this helps get a more realistic estimate.
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 capsaicin cream in their ED? Turns out hot sauces can be used as outlined here. Hot sauces are graded in Scoville units, and the equivalent to capsaicin cream is a hot sauce with 4,000-12,000 Scoville units. Avoid hot sauces that go higher than that - they can burn the skin. Tabasco original red sauce has a Scoville rating of 2,500-5,000 units.
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 valuable. One method is the "blind stick", attempting to hit a venous plexus in the upper volar forearm blindly. Note: this method should only be used in emergent resuscitation conditions, as complications such as hematoma formation can occur. Blind Stick
Here's a quick and dirty method to recall developmental milestones Development 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 and coo At four, the baby finds things funny (laughs) and pushes up on forearms to roll At six, the baby sits and makes sounds Picture the number 9 in a standing position and making a pincer grasp The w in twelve is for words and walks At 2 years old, the child has 2-word sentences and runs on 2 legs
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 ABG values are always higher): VBG pH is 0.04 lower than ABG pH VBG pCO2 is 4 lower than ABG pCO2 VBG pO2 is approximately 40 lower than ABG pO2 The bottom line is that for most of our clinical concerns, we can use VBG to assess pH and pCO2, and O2 sat to assess oxygenation. VBG may be less reliable in shocky or hypercapneic patients (but end-tidal CO2 will be useful in hypercapneic patients). When do we really need an ABG? When we want to calculate the Aa gradient, looking for e.g. VQ mismatch, shunt, or a diffusion problem.
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 in kids - a useful skill since 60% of kids will have AOM by age 4 years. Tip 1: Positioning: my most successful position is with the child sitting on parent’s lap, turned 90 degrees to one side, legs held between the parent’s legs, parent restraining child with a “hug”. Rotate the child 180 degrees to face the other way to look at the other ear. Even though the below picture shows a child getting a shot, this is the basic positioning. Don’t let the child face forward, make sure they are turned to the side. Ear Exam PositionDHS Comforting Restraint for Immunizations 2001 Tip 2) Specula: Our ED has just two size specula – 2.75mm “pediatric” and 4.25mm “adult”. If the child is 1yo or more, start with the larger specula. You can always go down in size if it’s too big or you need to push through or around wax. Don't be afraid to push the speculum in a bit - it is tapered so you are unlikely to reach the tympanic membrane with the tip. Tip 3) Otoscope: Grasp the helix of the ear and pull posteriorly and slightly outwards. Brace the fingers of your otoscope hand against the patient’s cheek so you can move with the child if he moves. Angle the speculum anteriorly as you enter – a common pitfall of trainees is seeing only the canal because the TM is angled more anteriorly in a young child. The best visual I could find of this positioning is a screen grab from the video below: Ear Exam Position 2 Regarding the video, to examine the patient's left ear, I prefer to keep the otoscope in my right hand and bring my left hand up and over the ear to pull on the helix, rather than switch hands https://www.youtube.com/watch?v=FE0sot4OoAE    
Two tips for intubating the obese patient:
  1. 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
  2. Position yourself: keep your back straight, your left elbow in, and lift (don't crank). If you're having difficulty summoning enough muscle, try straightening your left arm at the elbow to make use of your stronger upper arm muscles, rather than just your forearm.
Two great resources: Obese Difficult Airway Airway Jedi Step by Step (scroll down to the "How you lift matters" section)
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 support that the palmar hand including fingers actually represents about 0.8% BSA. Despite this widespread teaching, there are surprisingly few pediatric studies. Pediatric studies support the palmar hand without fingers to = 0.5% BSA, and with fingers close to 1% BSA. What is considered pediatric for using this estimation method? One original study included children to age 13 years, and another to age 17 years; puberty may be a useful cutoff age. How well the palm estimates BSA may also vary by gender, race, and degree of obesity. Ref: Thom D, Burns 2017 Feb; 43(1):127-136.
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 kept in when entering the skin in order to avoid the very rare complication of intraspinal epidermoid tumors. However, once the needle is past the epidermis and dermis, such that a plug of skin tissue cannot be cored out by the hollow needle and deposited into the spinal canal, the stylet can be removed. Here are two excellent FOAMed discussions of this practice and the advantages: http://pemcincinnati.com/blog/wwdwwd-early-stylet-removal-lp/ and https://pedemmorsels.com/spinal-needle-stylet/
There are several techniques for removing a ring that is stuck on a patient’s finger, starting with the simplest – using ring cutters to cut it off. However, if the patient doesn’t want the ring destroyed, the string technique has been advocated, where a string is wrapped around the finger to compress the edema, then passed under the ring and unwound for removal. An oxygen mask strap works well for this purpose because of its elasticity and flatness; check out this AliEM trick of the trade post https://www.aliem.com/2012/08/trick-of-trade-ring-removal-using/. Also, this site provides a nice overview of the numerous methods https://aneskey.com/ring-removal/. Remember that tungsten and ceramic rings are usually hard to cut, but easy to break using vice or locking pliers.
Hyperemesis due to cannabis use is on the rise, particularly in areas with marijuana legalization. While classically it is seen in chronic, daily users, affected patients sometimes have been using cannabis for less than a year, and may be using it as infrequently as once a week. Patients present with bouts of severe nausea, vomiting, and abdominal pain. A classic symptom is relief with hot showers (due to activation of the TRPV1 receptors). Symptom relief in the ED involves fluid rehydration and ondansetron (although this often no longer works for the patient after multiple bouts). There are also many reports of successful resolution of acute symptoms with benzodiazepines, haloperidol, and topical capsaicin. Curative treatment involves convincing the patient to stop cannabis use. Therein lies the tip, which I just learned from a colleague – a good way to help the patient understand is to tell them they suffer from an “allergy” to marijuana– while some people may be able to use marijuana chronically, they cannot, as it will cause these symptoms. Cessation of cannabis use can result in symptom relief as soon as 12-24 hours but sometimes not for as long as 3 weeks. So let them know how long that “allergic reaction” can continue!
Improve success of vagal maneuvers for patients in simple SVT by adding the "REVERT" maneuver: the patient performs valsalva maneuver in a semi-recumbent position, then the practitioner immediately puts the patient into a supine position with legs passively raised at a 45 degree angle. This maneuver improved conversion to NSR at 1 minute from 17% to 43%, for a NNT of 3.8. A simple way to have a patient perform a valsalva maneuver is to blow on the tip of a 10cc syringe hard enough to move the plunger. For an excellent discussion of the trial and a video of the maneuver see http://rebelem.com/the-revert-trial-a-modified-valsalva-maneuver-to-convert-svt/ REVERT for SVT
It's July, so good time to review the basics. For pediatric resuscitations of any type, the mnemonic ABCDEFG is great - Airway, Breathing, Circulation, Don't Ever Forget Glucose. Children have lower reserves and become hypoglycemic more easily than adults when stressed. This mnemonic also came from a fantastic quick review of pediatric congenital heart disease presentations from the awesome folks at emergencymedicinecases.com
Disclosure: I have no ties whatsoever to GoodRx When prescribing a medication to a patient who may need to pay out of pocket, use the GoodRx app or website to compare the prices at local pharmacies nearby, and sometimes, to find coupons that patients can use. This article explains how GoodRx makes money and why it exists.
Staying with the topic of urine... investigators at University of Pittsburgh have derived and validated a UTI risk calculator for patients aged 2-23 months. The calculator (UTICalc) is linked from the On Shift page of PEMsource under the heading Neonatal / Infant, and can be found at https://uticalc.pitt.edu/ The study by Shaikh et al was published online on April 16, 2018 at JAMA pediatrics here. Some highlights: derived on consecutive 2-23mo old febrile patients evaluated in ED for UTI, 542 with UTI and 1144 matched controls without UTI. Validated on a dataset of 380 patients, 30 with UTI. Investigators estimate sensitivity of UTICalc at 95-100% and state that use of the calculator results in approximately 10 patients tested for every 1 UTI found; UTICalc outperformed the current AAP algorithm in both of these outcomes. Users can also enter urinalysis dip, micro, and gram stain results to obtain post-test probabilities. Investigators suggest testing when pre-test probability is 2% or higher, and treating when post-test probability is 5% or higher. Further validation is warranted, but UTICalc may be useful in shared decision making with parents to give a ballpark risk estimate.
Nothing slows down the ED flow like waiting for the urine flow of an infant or toddler. Whether or not to screen for UTI with a clean catch urine vs obtain a catheterized specimen will be left for another discussion, but here are some of the latest techniques described for obtaining clean catch specimens. (For all, clean genital area thoroughly first) "CCU" procedure, first described by Herreros Fernandez et al, Arch Dis Child 2013;98:27, 80 infants aged < 30 days. Patient held under armpits with legs dangling in upright position. Suprapubic area gently tapped at 100 taps/minute x 30 seconds, followed by light circular massage of the lower back x 30 seconds. Repeat these maneuvers until urine collected. Successful in 86% of the infants with median time to collection 45 seconds. Labrosse et al, Pediatrics 2016;138(3):320160573 studied this CCU method with the addition of another person flexing the hips of female children, 126 infants < 6 months old. CCU method successful in providing urine sample within 300 seconds in 49%, median time 45 seconds. More successful in < 3 months old than 3-6 months old. "Quick-Wee" method, Kaufman et al, BMJ 2017;357:j1341, 354 infants aged 1-12mos With patient supine, suprapubic skin was rubbed with gauze soaked in cold saline. 31% voided within 5 minutes using Quick-Wee vs. 12% in the standard collection group. Finally, Naimer in Pediatr Emerg Care 2017;33:446 describes cutting a slit in an infant's diaper to push the urine collection bag through when obtaining a bag urine. This both helps to secure the bag and allows parents and nurses to see when the specimen has been obtained.
A quick rule of thumb for estimating whether the QTc is normal is to look for it to be half the preceding RR interval (see figure below from ECG Interpretation). However, note that this rule of thumb is not accurate at heart rates < 62 bpm. Also, it is conservative at heart rates > 66 bpm. An excellent thorough explanation can be found at Dr. Smith's ECG blog here. For heart rates < 62 bpm, Dr. Smith suggests using QT < 40% of the preceding RR as rule of thumb. Also, be careful - computer calculated QTc are often incorrect - may need to get those calipers out! (or just count little boxes - each one is 0.04 sec, or 40msec). The most common formula used to correct QT is the Bazett formula QTc = QT / sqrt(RR), although this formula produces false positives at high heart rates. Here is a calculator at MedCalc that will do the math for you! QT half RR ecg-interpretation.blogspot.com
Your local hospital cafeteria can be a useful resource in managing your PED patients:
  1. Sugar liberally applied to the edema of a paraphimosis or rectal prolapse may help decrease swelling and improve reduction efforts
  2. A mayonnaise packet provides useful lubricant for removing a tight ring
  3. Tannins from a tea bag (particularly black tea) can help clotting with post dental extraction bleeding (place a moistened tea bag in the socket and have the patient apply pressure by biting down)
  4. A packet of sugar + 10 mL sterile water = make your own sucrose solution for treatment of pain associated with procedures in infants
Know of any more? Comment below!
Having trouble with bag valve mask ventilation? Don't forget to use adjunctive airways - nasopharyngeal for conscious patients, oropharyngeal for unconscious. Reuben Strayer's great video here advocates placing 2 nasal airways and an oral airway, then bagging over those, for the difficult to bag patient. You can also place an ETT adaptor (pull the adaptor off the tube) into a nasal airway and bag the nasal airway directly - see more information here. Don't forget, nasal airways are measured from the nostril to the tragus of the ear, and oral airways are measured from the center of the mouth to the angle of the jaw.
The SAMPLE mnemonic is typically used to remember the important brief history needed for trauma patients: Symptoms, Allergies, Meds, Past medical history, Last meal, and Events leading up to the trauma. Think of the mnemonic as SAMPLE-PT and add in Pregnancy (history, testing) and Tetanus status. Also, ABCDE is used to recall Airway, Breathing, Circulation, Disability, Exposure in managing trauma patients. Keep going in the alphabet and add on FAST, Gastric tube (NG or OG) and Glucose check, Hemoglobins (serial), IV (two large-bore).
Having trouble finding the ICD-10 code in your electronic medical record? Do a Google search "ICD 10" + whatever diagnosis you're looking for. For example, searching "ICD 10 parent concern" turns up "Z 71.1 Person with feared complaint in whom no diagnosis is made." Here's another useful one "R 68.11 Excessive crying of infant (baby)." Hope everyone has a Happy Thanksgiving, and no one feels the need to use "Z 63.1 Problems in relationships with in-laws."
Use the PATCH mnemonic to remember transdermal medications Child with unusual symptoms, potential toxidrome? Look all over their body for a medication patch. Many are transparent or look like bandaids. P   Pain (fentanyl, lidocaine) A   Anti-cholinergic (scopolamine) T   Tobacco (nicotine) C   Clonidine H   Hormones (estrogen, testosterone)
Some tips and tricks for examining children's throats:
  1. Don't do it until after you've gotten your lung, heart, and abdomen exam - once you make them cry, it's game over
  2. A helpful position for young children is to sit on the parent's lap facing the parent, legs straddling the parent. Then, have the parent lean the child back so he/she is laying supine on the parent's knees with the head hanging back (the dentist chair view)
  3. Older children can be asked to pant like a dog, scream, or sing "ah ah ah ah ah" opera-style
  4. Sometimes if you do the ear exam first, the child will yell and then you can see the throat
Placing topical anesthetic (EMLA, LMX4) on skin abscesses may result in spontaneous drainage, precluding need for incision. If topical anesthetic doesn't result in spontaneous drainage, it at least provides some skin anesthesia prior to local anesthetic injection for incision and drainage procedure. In one published retrospective study, 26 of 110 patients with the topical anesthetic LMX4 placed had spontaneous drainage, 3 of whom required no further intervention: https://www.ncbi.nlm.nih.gov/pubmed/21129885
Thanks to Tim Horeczko pemplaybook.org for tube-tape-tap mnemonic Peds Sizing  
What do you do if you have a patient with a tooth avulsion and no commercial periodontal dressing? You can use the flexible thin metal nasal bridge on an N95 mask and glue the reimplanted avulsed tooth to an adjacent tooth using 2-octocyanoacrylate skin adhesive (made for laceration repair). N95 maskN95 mask, Amazon.com See this discussed in an Aliem.com trick of the trade See more on tooth avulsion management from NCEMI Common Simple Emergencies
We all know the importance of lining up the two sides of a laceration that goes through the vermillion border of a lip laceration. Injecting lidocaine or swelling from the trauma itself can make this difficult. Use a skin marker to outline the the vermillion border on each side, making this easier. Vermillion border closing the gap This photo comes from this great tutorial on Closing the Gap For lip lacerations requiring repair beyond simple alignment, consult a plastic surgeon. Here is an interesting discussion on Plastic Surgery Key
The Katz extractor is a great tool for removing nasal foreign bodies, as shown on the video here (I have no financial interests in this product). But, if you don't have one available, get a Fogarty cardiac embolectomy catheter from the O.R., and this will do nicely as well. For many many tips and tricks on removing foreign bodies in the head and neck, go to PEMplaybook
A young girl comes in c/o dysuria and the urine is stone cold normal. What else can explain her symptoms? (BTW, you must do a GU exam at this point). Adhesions (labial) Bubble bath (and other soaps, irritants) Candida (particularly if recently on antibiotics, or at risk for new onset diabetes) Detergent (harsh laundry detergent, new tight clothing / underwear) Enterobius (aka pinworms) Foreign body (typically toilet paper) Gonorrhea & chlamydia (in sexually active or sexually abused) Hygiene, poor (teach girls to wipe front to back, consider having them sit on toilet backwards to urinate, especially if they are overweight/obese, to encourage complete voiding and keep urine from collecting in vagina) Irritation (masturbation is a common normal behavior in preschoolers)
Easily remember the approximate Oxygen-Hemoglobin dissociation curve as follows: PaO2 40 corresponds to SaO2 70% PaO2 50 corresponds to SaO2 80% PaO2 60 corresponds to SaO2 90% This rule along with a lot of other handy RT knowledge can be found here Read more about PaO2 vs SaO2 at airwayjedi.com here
For minor procedures in the PED, analgesia, anxiolysis, and distraction are the most important therapies to promote cooperation and procedural success. See our algorithm for procedural pain here. But sometimes, even with all of those, physical restraint is needed. Most PEM practitioners know how to wrap a child up using a simple bedsheet folded lengthwise twice, and then wrapped over one arm, behind the back, and over the other arm, and then around the child as seen here. Another technique if you have a pillowcase is to put both arms behind the child into a pillowcase and then lay the child down onto the pillowcase, thus restraining the arms (see picture below). (This technique was published under the colorful name "Superhero Cape Burrito" here). Finally, a c-collar can be useful to immobilize the head for face and scalp laceration repairs. pillowcase-restraint
Mucosal atomizer devices improve administration of intranasal medications. Intranasal fentanyl 1.5 mcg/kg is a great way to give stronger pain medication (eg for fractures) without placing an IV. Intranasal midazolam 0.2 mg/kg (use concentrated 5mg/mL form to keep total volume < 1mL per nostril) can be used to treat active seizures when no IV access is yet obtained, or as an anxiolytic for procedures. Intranasal naloxone at a standard dose of 4 mg is being provided to opiate addicts to use in case of overdose. A commercial device is available, but currently some lots are being recalled (check here for recalled lots), or you may simply not have one in stock. Here's how to make an improvised atomizer courtesy of Faisal Alghamdi of KFMC Riyadh. Hook up a 3 way stopcock with the lever turned so that all 3 ports are open to 1) a 14 or 16 gauge angiocath, 2) a syringe with the medication you wish to deliver, and 3) oxygen tubing. Hook the other end of the oxygen tubing up to oxygen and turn up to 5-10 L/min. Place the angiocath in the nostril and gently & slowly depress the plunger of the medication. See picture and video below. img_1123 Click here to see a video and compare to commercial device here
You're seeing a 5 day old with a fever of 39. Attempts to get IV access have been unsuccessful. The child is alert and not toxic appearing, but you'd like to get empiric antibiotics started within the first hour of evaluation. What are your options other than drilling with an IO or embarking on a potentially long sweaty frustrating attempt at a central line in a neonate? An ultrasound-guided peripheral line is one possibility if you have the skills. Another vascular access method to keep in mind is the umbilical venous line - the umbilical vein can stay patent up to 7-10 days of life! Soak the dry cord in saline soaked gauze to soften it, use a scalpel to cut straight across at 1-2cm from the base, look for the single large vein, insert a pre-flushed catheter with gentle pressure into the vein while pulling back on a syringe until you see a flash of blood. For more info: https://blogs.brown.edu/emergency-medicine-residency/emergent-umbilical-venous-catheter-uvc-placement/ The "Fast-cath" technique advocates using a 14 gauge angiocath http://www.emsworld.com/article/10852257/paramedic-umbilical-vein-catheterization-for-newborns Find resources for born out of asepsis babies on our algorithms page, including how to make umbilical venous catheter mini kits to keep in your ED. http://pemsource.org/algorithms/boa-newly-born/
Use a glass test tube or specimen tube to press on a rash to see if it blanches - remember, petechiae and purpura don't blanch. You can also use a glass test tube as a mini-anoscope to blanch surrounding mucosa and assist in identifying anal fissures in infants. (Anal fissures are one of the many possible causes of GI bleeding in children - check out pemplaybook.org's latest podcast on GI bleeding) glass_test-focus-none-width-800 (From https://www.meningitisnow.org/meningitis-explained/signs-and-symptoms/glass-test/)  
Check out these cuties that CHOC PED physician and former Harbor PEM fellow Seth Brindis makes! See below for step-by-step instructions and more ideas for toys to make with medical supplies. Tongue Depressor Puppets Here are instructions put together by Seth, and a video of them in action. And here are some more ideas for toys to make in the PED (thanks to former Harbor PEM fellow Casey Buitenhuys for the glowstick idea): make-your-own-toys
What can you do if your patient is maxed out on ondansetron but still feels nauseated? A recent study in Annals EM found a positive treatment effect of deeply inhaling from a standard isopropyl alcohol pad held 2.5 cm from the patient's nose. Patients inhaled for 60 seconds at 0, 2, and 4 minutes (stopping if nausea resolved), and nausea was rated up to time 10 minutes. (Caveat: this study enrolled only adults). A 2012 Cochrane review also found isopropyl alcohol inhalation beneficial, although less so than standard antiemetic medications. Also, anecdotally, for dehydrated patients, rehydration and resolution of ketosis is thought to improve nausea and vomiting. For the grammar police out there, clarification of nauseated vs nauseous can be found here
Measure your fingernails to see which is closest to 1cm - now you will always have a 1cm "ruler" with which to measure lesions, lacerations, discolorations, etc. Measure nail  
Use a sterile saline respiratory ampule: wet the fluorescein strip with the saline, squeeze out half of the saline, then suck the yellow fluorescein liquid back up into the ampule. Now you can use the ampule as an eyedropper. For uncooperative kids, lay them supine and squeeze the liquid into the medial corner of the closed eye - when they open their eyes it will run into the eye. Respiratory Ampules (Amazon.com) For additional methods, see AliEM's great tricks of the trade post at: https://www.aliem.com/2015/tricks-of-the-trade-fluorescein-eye/
Cut a narrow caliber ETT short to create a semi-rigid suction catheter for foreign body removal of the nose or ears.  (From EM News September 2009, Tricks of the Trade: An Improvised, Semi-Rigid, Nasal/Aural Suction Catheter, by Timothy McGuirk DO)
For a forhead laceration, place gauze over patient's eye and hairline, cut a hole in center of a large tegaderm, peel and stick with the laceration positioned in the middle of the hole. Now you can use tissue adhesive to close the laceration without worrying about the adhesive running into the patient's eye, hair, or down the face.
Explain to parents - colds are called colds because viruses thrive in cold temperatures, so fevers are the body's natural way to fight off the cold
Use a laryngoscope upside down as a tongue blade, or use a self-lighting pelvic exam speculum (remove top half of the speculum)

PEM Questions

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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, tingling in his fingertips, and trembling. His friend called 911 and he was brought in by ambulance. Although many of his symptoms have improved, he remains nervous-appearing and mildly tremulous. He denies any drug intake or intake of other substances, supplements. He does not recall thinking about anything stressful prior to his symptom onset. Vital signs are temp 37.6, HR 90, RR 20, BP 110/60, O2 sat 99% on room air. His physical and neurologic exams are normal.

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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 on the left nares. Dad is a nurse and held pressure until the bleeding stopped, and there is currently no bleeding. Exam shows temp 37.5, HR 90, RR 24, BP 94/56. Exam is negative for lymphadenopathy, hepatosplenomegaly, or pallor. There is a small amount of dried blood in the left nares. His parents did not notice any rash, but on exam with the patient undressed you notice a few petechiae on the ankles and across the lower abdomen. There are no purpura. Laboratory values are: WBC 10.3, diff 40% polys, 45% lymphs, 8% monos; Hgb 13, Hct 39, Platelets 1. Lytes, LFTs, BUN/Cr, are all normal. There are no inpatient beds available, so management will begin in the ED. 

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Which of the following otherwise well-appearing non-toxic patients with a low-grade fever from viral URI should NOT take ibuprofen?

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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 around the piercing site. There is a small amount of purulent discharge. The piercing has been removed.  The child is afebrile and nontoxic and there are no signs of infection spread such as mastoiditis, brain abscess, meningitis. You plan a trial of outpatient antibiotic therapy with close follow-up. 

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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 two paramedics for the death of Elijah McClain. 

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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 cool by the kids. The children range in age from 2 years to 13 years old. 

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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 afebrile. They first noticed it 3 days ago and it is unchanged. On exam there is a 3-4mm diameter pearl-like white mass under the prepuce (distal foreskin). It is not fluctuant or tender. The child is phimotic, and the foreskin can be retracted to visualize the meatus, but not fully retracted. 

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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 his right submandibular area. The parents report that the has had this twice before, each time treated with amoxicillin-clavulanate and resolved. He is afebrile.

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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 player. On exam, he has tenderness over his right sacroiliac joint. 

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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. He has a 3cm diameter tender ecchymotic area that is swollen and fluctuant on the auricle of his left ear, in the scaphoid fossa, which is the area between the helix and antihelix. 

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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 wheezes and mild intercostal retractions. Her vital signs are: temperature of 38.6, HR 160, RR 40, and O2 sat 94% on room air. As part of her fever work-up her urine is dipped, and while there are no signs of UTI, she has glucosuria. Her serum glucose is 160, and her lytes are Na-138, K-4.2, Cl-110, CO2-17. 

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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 of milk of magnesia to treat constipation. You suspect hypermagnesemia. 

[yop_poll id="316"]

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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, his two upper central incisors are pushed up into his gums. None of his teeth, including those two, are loose. There was bleeding initially, but it has stopped spontaneously. He has no apparent pain and is climbing all over the gurney.

[yop_poll id="315"]

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[yop_poll id="314"]

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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 the locker room changing out of her gym clothes. 

[yop_poll id="313"]

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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 last 3 days to a maximum of 104 F. Although he had fever, he was well-appearing and still eating normally and playful. But since the fever was persistent, they took him to a clinic yesterday and he was diagnosed with a throat infection and started on amoxicillin. He has received 2 doses. Today he awoke with a fine morbilliform blanching pink rash that started on the neck and trunk, then has spread to the face and extremities. It does not seem itchy and it does not involve the mucosa. The only other medication he has had was acetaminophen yesterday at 5pm. On exam, he is nontoxic and interactive. Vital signs: temp 98.9 F, HR 132, RR 28, O2 sat 99% on room air. ENT, chest, and abdomen exams are unremarkable. 

[yop_poll id="312"]

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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 and prescribed 10 days of amoxicillin. He returned after completing that course with ongoing pain, was diagnosed with persistent right AOM, and prescribed 10 days of augmentin. He has completed the augmentin and was feeling a little bit better for a few days before his symptoms returned and then became worse. He now also has a fever to 101. During the few days he felt better, he did go to a waterpark. On exam, his external auditory canal is swollen and red. Partial view of his tympanic membrane reveals it to be bright red and bulging. He indicates his entire ear when asked where it hurts, and he has swelling and redness and tenderness to palpation behind his ear as well. 

[yop_poll id="311"]

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 buds. On exam, her temp is 37.5, HR 90, RR 22, pulse ox 100% on room air. Her face appears asymmetric. Heart and lung exam is normal. Abdomen is soft, and you do not palpate any masses. Her right leg shows no swelling, obvious deformity, or neurovascular compromise, but she is tender to palpation along her anterior tibia. She has a large light brown irregularly shaped macule on her back. 

[yop_poll id="310"]

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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 have been present all his life and have grown slightly. Sometimes they seem to become acutely inflamed, and the boy has flushing and intense itching. 

[yop_poll id="309"]

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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 league team, and Dad is the coach. The team is in second place and there are just a few more games until playoffs. At first, the boy had medial elbow pain only at the end of the game, but lately his elbow hurts after the first throws, and he is not pitching as accurately as he had been before. On physical exam, he is tender at the medial epicondyle. On your preliminary read of the xray, there is no fracture, dislocation, and the expected ossification centers are all present. 

[yop_poll id="308"]

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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 with a kitchen remodel and tried to remove a support beam by kicking it multiple times. He continued to help, and it wasn’t until the next morning that he noticed his symptoms. He has no significant PMH. He has taken no medications. He has had no recent travel, illness, or other trauma. On exam, he is afebrile, HR 65, RR 18, BP 140/80, weight 135 kg, BMI 42. His right calf circumference measures 1.5 inches more than his left. His calf is not particularly tender to palpation, and there is no redness or warmth. His leg is not swollen above the knee. He has normal sensation distally and normal color. He is able to walk without a limp but has pain with walking. He has no pitting edema. 

[yop_poll id="307"]

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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 to be viral URI with acute otitis media. He has fully recovered, his temperature has normalized (from 40C) with antipyretic, and he is interactive and playful now. His neurologic exam is normal, and he has no significant past medical history. His parents are asking about whether this will happen again, whether he is at higher risk of epilepsy, and whether he will have any negative neurologic outcome.

[yop_poll id="306"]

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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 arthralgias. The individual urticarial lesions are not transient, but rather present for more than 24 hours. He is not toxic but appears miserable. He was diagnosed with acute otitis media 8 days ago and is on day 8 of a 10-day amoxicillin course. 

[yop_poll id="305"]

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Happy Belated 4th of July!

[yop_poll id="304"]

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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 ill-appearing and has signs of significant dehydration. While obtaining vascular access and rehydrating her, you obtain additional history and peruse her chart. She has had three prior similar but more mild episodes, all diagnosed as acute gastroenteritis, starting at age 7 months. This episode began ~90 minutes after the family had dinner. The family had peanut chicken curry over rice and a salad. The baby had rice and small pieces of chicken set aside before being mixed with the peanut curry sauce. The baby has a 3-year-old sister in preschool. She is asymptomatic. 

[yop_poll id="303"]

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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, but now for the last 2 days he has a fever and worsened cough, post-tussive and spontaneous vomiting, as well as a new sore throat and conjunctival injection. His vital signs are: temperature is 38.2, HR 110, RR 32, and pulse ox 96% on room air. On exam he is nontoxic but has some crackles heard bilaterally. Your plan is to treat him with azithromycin for community-acquired pneumonia, pseudoephedrine during the day and diphenhydramine at night for his nasal congestion, and ondansetron for his vomiting. 

[yop_poll id="301"]

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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 in the anterior chamber, filling approximately 50% of the anterior chamber. There is no evidence of an open globe injury. 

[yop_poll id="300"]

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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 fine that morning, but noted malaise and low-grade fever in the afternoon, and pain in her lower right shin. She presents to the ED with temp 38.5, HR 140, RR 20, BP 95/60. She has a 4cm x 4cm non-well demarcated area of red-purple discoloration on her lower right shin, with mild edema. On close inspection there are a few small bullae in the area of discoloration. On palpation of the area, it is warm, extremely, tender, and has crepitus. 

[yop_poll id="299"]

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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 led to her weakness and paralysis. She also has a hyperchloremic (non anion gap) metabolic acidosis. She was previously healthy and denies ingestion of any substances. She has not been having diarrhea. Her urine pH is 6.0. 

[yop_poll id="302"]

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 all). (Cannot answer on-line – jot down your answers and then check back for discussion).

  1. Dry cough worse at night and when out in the cold air
  2. Cough that sounds like a seal or dog barking
  3. Cough with an inspiration between each cough (staccato cough)
  4. Wet phlegmy cough accompanied by nasal congestion
  5. Paroxysms of cough with post-tussive vomiting
  1. Albuterol
  2. Amoxicillin
  3. Azithromycin
  4. Dark honey
  5. Dexamethasone

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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 unbearable pain despite taking ibuprofen and one oxycodone. He has had no fever. Exam is unrevealing – there is no swelling around the socket, no discharge, no foul odor. 

[yop_poll id="298"]

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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. There has been no trauma and no fever noted at home, although temperature is 37.8 in the ED. On exam she has loss of lumbar lordosis and tenderness to palpation of the lumbar spine. She has full passive range of motion without pain of the hips. She was seen by her PCP 3 days ago and CBC was normal, blood cultures negative to date. Today, CBC is still normal and ESR is 47. Plain radiograph shows narrowing of the L3/4 disc space. MRI is not available in your ED.

[yop_poll id="297"]

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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 or diarrhea and no one else in his family is affected. The family landed in the Denver airport the night before and drove to Breckenridge. The patient awoke this morning with these symptoms. 

[yop_poll id="296"]

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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 in her left axilla and left anterior cervical areas. She has a superficial healing scratch on her left forearm, and history reveals that she has been spending time at a cousin’s house with the cousin’s new kitten. She is also noted to have hepatomegaly 2cm below the right subcostal margin, and a palpable spleen tip. She has no petechiae or purpura. The remainder of her exam is noncontributory. 

[yop_poll id="295"]

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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 maculopapular rash on the nape of the neck, shoulders, palms, and soles as well as nausea, vomiting, and diarrhea. The patient owns a cat but is not involved in caring for it and does not have it sleep with him. 

[yop_poll id="294"]

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[yop_poll id="293"]

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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 the PIP joint. 

[yop_poll id="292"]

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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 maximum amount of 1% lidocaine with epinephrine that you can safely infiltrate for laceration repair. 

[yop_poll id="291"]

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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 proptosis, periorbital swelling, and relative afferent pupillary defect (aka Marcus-Gunn pupil) on the left. The intraocular pressure is measured at 45.

[yop_poll id="290"]

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[yop_poll id="289"]

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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 media. Which of the following antibiotics is recommended in the 2013 AAP guidelines as an alternative to amoxicillin to treat acute otitis media?

[yop_poll id="288"]

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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 AND weighing 40 kg or more in high-risk situations.

[yop_poll id="284"]

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[yop_poll id="286"]

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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. 

[yop_poll id="285"]

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[yop_poll id="287"]

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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 ED with nausea, vomiting, and abdominal pain. Her AST and ALT are elevated, and her acetaminophen level is zero. 

[yop_poll id="283"]

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[yop_poll id="282"]

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[yop_poll id="281"]

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We are currently experiencing a “tridemic” of influenza, RSV, and COVID-19.

[yop_poll id="280"]

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[yop_poll id="278"]

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[yop_poll id="279"]

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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 fast-track using three patient care rooms, one nurse, and one physician. They gather data after implementation but find that ED flow is not improved because of the loss of ¼ of their patient care rooms to the new fast track. They then adjust their initiative to using only two rooms and re-gather data. 

[yop_poll id="277"]

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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 every 2 hours for 7 days. Her physical exam is unremarkable except for some mild tachycardia and ongoing vaginal bleeding. She has not had any surgeries, but she does recall a nosebleed episode that lasted 15 minutes, and she does endorse easy bruising. She is not taking any medications and has no significant past medical history. There is no known family history of a bleeding disorder, and she has one older brother who is healthy. 

[yop_poll id="276"]

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You are evaluating a 15 year old girl brought in from a foster home for symptoms of psychosis. 

[yop_poll id="275"]

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[yop_poll id="274"]

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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 nail fold and adjacent skin. The central portion of the swollen area shows a small amount of subcutaneous purulent fluid. He is right-hand dominant, otherwise healthy, and is afebrile. He admits to having a habit of biting his fingernails.

[yop_poll id="273"]

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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 a regular adult seatbelt. He is alert and crying. His airway is open, there is no evidence of head trauma, trachea is midline, and chest rise is equal with no increased work of breathing. He is tender in the right upper quadrant of his abdomen and has a seatbelt sign across his mid-abdomen. He has no obvious extremity deformities. GCS is 14. His vital signs are HR 160, RR 30, BP 80/40, O2 sat 98% on 5L by face mask non-rebreather.

[yop_poll id="272"]

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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 diaper. He has seen it before while bathing her, but by the end of the bath it had disappeared. She is otherwise well, feeding and growing well, not vomiting, and is afebrile. She appears comfortable. The mass is nontender, and there is no overlying redness or discoloration. 

[yop_poll id="271"]

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[yop_poll id="270"]

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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 hairline. On examination, you note nits but do not see any live lice. The parents have not performed any treatments for lice. 

[yop_poll id="269"]

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[yop_poll id="268"]

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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 first stands up, he feels dizzy. His exam is notable for tachycardia and hyperpigmentation of his gingiva, lips, knuckles, and palmar creases.

[yop_poll id="267"]

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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 abdominal pain, nausea, and vomiting. There is no angioedema. His vital signs are: temperature 37.7 C, HR 140, RR 30, BP 76/36, pulse oximetry 92% on room air. 

[yop_poll id="266"]

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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 resuscitated the infant and improved hemodynamic stability but you are at an ED with no pediatric surgeon available and no PICU. The nearest children’s hospital with these capabilities is 100 miles away. There is a light rain but the road conditions are good and there is no traffic. 

[yop_poll id="265"]

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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, and buttocks, as well as vesicles in the posterior pharynx. 

[yop_poll id="264"]

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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 well, and there were no significant birth complications or maternal infections. Vital signs are rectal temperature 38.0 C, HR 140, RR 36, O2 sat 99% on room air. Physical exam is unremarkable except the right tympanic membrane is redder than the left. 

[yop_poll id="263"]

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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 the last few weeks, whenever he plays basketball. He has no significant past medical history, and he has not had a syncopal event. On exam, he has a 2/6 harsh systolic murmur best heard at the left lower sternal border. The murmur is louder with the Valsalva maneuver and softer when the patient goes from standing to squatting.

[yop_poll id="262"]

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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 bleeds when irritated. It is not tender and he has no fever.

[yop_poll id="261"]

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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. Bedside blood glucose measurement is 38 mg/dL. A 22 gauge peripheral IV is obtained in his right hand.

[yop_poll id="260"]

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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 day and the child went to the park with his father, but no known trauma occurred. He has had no fever, URI symptoms, or rash. He was born full-term and has no significant past medical history. Physical exam of his right leg is unremarkable. AP and lateral X-rays are as shown. 

[yop_poll id="259"]

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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 his leg, and may have seen a snake slither away into the underbrush. He is brought to the ED 40 minutes after the event. On exam, his vitals are normal, and he has a bite mark with 2 punctures on his right calf. There is no surrounding swelling or discoloration, and the compartments are soft. He complains of pain, but no paresthesias.

[yop_poll id="258"]

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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 including palms and soles. You are working in a small community ED. The triage nurse expresses concern for monkeypox. 

[yop_poll id="257"]

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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 complications and went home yesterday. Mom has been exclusively breastfeeding every 1-2 hours, and ate a bag of peanuts several hours before noticing the baby’s rash. The baby has no fever and is eating and urinating well. There is no history of maternal infections.

[yop_poll id="256"]

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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 a few finger foods. His parents feel that he looks pale – you check a hemoglobin and find that they are correct! It is 4.8 g/dL. He is active and playful, hemodynamically stable, and has no evidence of bleeding. He has no petechiae, purpura, hepatosplenomegaly, or mass, and the remainder of his blood counts (WBC, platelets) are normal. 

[yop_poll id="255"]

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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 pain. There has been no fever, rash, vomiting, diarrhea, or joint pains. His work-up shows proteinuria and a low serum albumin.

[yop_poll id="254"]

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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 until she finishes the course. Now she has developed an itchy urticarial-like rash, although it is more fixed than urticaria typically are (does not move around nor come and go). She also has some generalized mild arthralgias and a low-grade fever to 100.2 F. 

[yop_poll id="253"]

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[yop_poll id="252"]

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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 old visits were normal. There are findings of concern for an STI. 

[yop_poll id="251"]

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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 the ED one week ago for cough and congestion and diagnosed with a viral URI. At that time, COVID, influenza, and RSV were negative. On exam, his temp is 39.1. He has multiple, scattered, annular, sharply demarcated hemorrhagic plaques, mainly on his cheeks and bilateral extremities, lower > upper. He is otherwise well appearing and remainder of the physical exam is unremarkable. CBC including platelet count, CMP, coags, DIC panel, CRP, UA, and CSF were all normal.

[yop_poll id="250"]

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Which of the following physical exam findings on a newborn’s sacrum does NOT mandate an MRI to rule out occult closed spinal dysraphism?

[yop_poll id="249"]

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You are seeing a patient with history of congenital sensorineural hearing loss. 

[yop_poll id="248"]

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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. The pain did start after the patient drank a large caffeinated frappuccino and had a brisk diuresis. The patient reports similar pains in the past that self resolved, but never this severe. Urinalysis has 0-2 wbc, 0-2 rbc, no bacteria, and is nitrite negative. Suspecting nephrolithiasis, you obtain a renal US that shows severe left hydronephrosis but no evidence of stone. You then obtain a CT non-contrast that confirms no stone is present. 

[yop_poll id="247"]

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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 chosen a “lotus birth,” or umbilical nonseverance. The placenta remains attached to the newborn (carried around with the baby, often in a small bag), until it separates on its own, typically in 5-15 days. 

[yop_poll id="246"]

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You are seeing a 1 week old with the pictured oral lesions. 

[yop_poll id="245"]

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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 mental status. The patient has a seizure on arrival to the ED, which resolve with lorazepam IV. The CT scan shows evidence of a subdural fluid collection. The lumbar puncture results show a neutrophilic pleocytosis with an elevated protein. Gram stain is negative. 

[yop_poll id="244"]

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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 coke bottle. 

[yop_poll id="243"]

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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 in liquids all day, yet he has not urinated.

[yop_poll id="242"]

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What are pediatric emergency physicians seeing more of when COVID prevalence rises?

[yop_poll id="241"]

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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 conjunctivitis. What is the best management?

[yop_poll id="240"]

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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 agency does not have pre-hospital providers intubate children. Which of the following is true as you prepare your equipment and medications?

[yop_poll id="239"]

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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 not use cannabis at all.

[yop_poll id="238"]

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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 is NOT consistent with post-streptococcal glomerulonephritis (the most common cause of acute nephritis in children worldwide)?

[yop_poll id="237"]

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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. He has had a cold recently, but no fever. He fell off his bike yesterday but did not think he had any injuries beyond a scraped knee. Which of the following aspects of his presentation is not consistent with testicular torsion?

[yop_poll id="236"]

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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 lasted 3 minutes then self-resolved. The child is now back to baseline. A thorough history and physical exam has revealed no clear etiology for the seizure, and the neurologic exam is normal. The child was well prior to the seizure and has no significant past medical history. Blood glucose in the field was 98. The child is well-appearing and can easily obtain follow-up with his primary physician in a timely fashion. 

[yop_poll id="235"]

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[yop_poll id="234"]

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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. 

[yop_poll id="233"]

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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 is afebrile, HR 140, RR 50, and currently not having any abnormal movements. He has been feeding and urinating normally. His blood glucose is 120. Labs, EKG, head CT, and a CXR are performed – the CXR is shown here.

https://www.hawaii.edu/medicine/pediatrics/pemxray/v2c02.html
[yop_poll id="232"]

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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 and management in the ED in regards to his equipment?

[yop_poll id="231"]

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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 is 8 months pregnant.

[yop_poll id="230"]

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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 has returned at 72 hours of life due increased jaundice. 

[yop_poll id="229"]

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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 tender at the base of the thumb (carpometacarpal joint), and you note swelling as well. Which of the following injuries is least likely to be encountered based on this mechanism and exam?

[yop_poll id="228"]

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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, and you cannot palpate a pulse. After initial steps of drying, warming, and stimulating, the baby is still apneic with a heart rate < 100. You initiate positive pressure ventilation for 15 seconds but still do not hear the heart rate rising. Which of the following is not a part of the MR SOPA ventilation corrective steps recommended to try next?

[yop_poll id="227"]

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You are seeing a 3 year old whose parent noticed a lump in the neck while bathing her. You palpate posterior cervical node(s). 

[yop_poll id="226"]

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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 in the ED are temp 38.3 C, HR 110, RR 26, BP 80/40, O2 sat 96% on room air. He has stridor when crying but none at rest. He has no history concerning for foreign body aspiration. He is not happy to be in the ED but is not toxic appearing. He is fully immunized and has no significant past medical history. 

[yop_poll id="225"]

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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 paresthesias, myalgias, and general fatigue the night before. On waking this morning, he had significant bilateral lower extremity weakness and ataxia that rapidly worsened. He is afebrile. On exam, he has no patellar or Achilles deep tendon reflexes. 

[yop_poll id="224"]

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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 over the next 48 hours to diffuse erythema with flaccid desquamating bullae and yellow crusting around the eyes and mouth. Nikolsky sign is positive. There is no mucous membrane involvement. She was given ibuprofen at home after onset of the fever. 

[yop_poll id="223"]

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[yop_poll id="222"]

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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 polyarthralgias, and an evanescent salmon pink rash. She was diagnosed with new onset systemic juvenile idiopathic arthritis, treated with ibuprofen, and initially did well. She now presents with unremitting fever and rash, bruising, petechiae, gum bleeding, hepatosplenomegaly, and lethargy. Labs reveal elevated transaminases, ferritin, LDH, and triglycerides, but a low ESR.

[yop_poll id="221"]

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You are seeing an 18 year old male who presents with palpitations. Electrocardiogram reveals atrial fibrillation with a rapid ventricular response rate at 145.

[yop_poll id="220"]

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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 approved for age 12 years and older during the ED visit. 

[yop_poll id="219"]

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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 fever. On exam, her nasal turbinates are pale and boggy. She has a horizontal crease below the bridge of her nose and her lower eyelids are bluish and puffy.

[yop_poll id="218"]

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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 year ago. She is presenting with chest pain.

[yop_poll id="217"]

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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 no fever, urinary frequency, abdominal pain, or history of trauma or straddle injury. Her mother noted a swelling at her vaginal introitus and shows it to you. She has a red donut-like mass just above the vaginal introitus where you expect to see her urethra.

[yop_poll id="216"]

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[yop_poll id="215"]

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[yop_poll id="214"]

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[yop_poll id="213"]

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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 runny nose. There is no headache, vomiting, or altered mental status. The shunt was placed initially while in the NICU, and revised 4 months ago. 

[yop_poll id="212"]

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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 20 mg/dL. Toxicity generally begins at levels of 30 mg/dL and higher. You are certain there were no co-ingestants and the patient’s vital signs, physical exam, metabolic panel, and EKG are normal. 

[yop_poll id="211"]

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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 old 20 kg child. You have the parent and nurse place the child his head in a sink under tap water to irrigate the wound. You anesthetize the wound with a total of 14 mL of 1% lidocaine. You put on a surgical mask and nonsterile gloves. You use staples on the scalp, transitioning to 5-0 polyglactin irradiated suture for the forehead. 

[yop_poll id="210"]

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[yop_poll id="209"]

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[yop_poll id="208"]

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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 at the chart. 

[yop_poll id="207"]

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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 signs are temperature 37.6, HR 90, RR 20, BP 105/60. He has no nuchal rigidity. He has no significant past medical history. His CBC shows normal platelet count and PT/PTT are normal. 

[yop_poll id="206"]

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You are seeing an adolescent who slammed her finger in a door and has a subungual hematoma. 

[yop_poll id="205"]

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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 staying at a rental home. He spent most of the prior day playing outside, and he has several papules consistent with bug bites on his arms, legs, and back. He is afebrile and there is no redness or warmth to the edema. He is uncircumcised, and there is no tight constricting band noted. 

[yop_poll id="204"]

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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. 

[yop_poll id="203"]

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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 microscopic hematuria. Her UA results do not support a diagnosis of UTI or pyelonephritis. She is not sexually active. She was seen in the ED 6 months prior for RLQ abdominal pain and underwent a CT scan which was negative for appendicitis or any other pathology. She describes the current pain as different from the pain she had 6 months ago. After IV fluids, ketorolac, and morphine therapy her pain is improved.

[yop_poll id="202"]

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[yop_poll id="201"]

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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 lip, but none of his tongue or pharynx, and he is maintaining his airway. He has a history of multiple food allergies. Besides lack of urticaria or itching, which of the following findings supports hereditary bradykinin-mediated angioedema over allergic histamine-mediated angioedema as the underlying pathophysiology?

[yop_poll id="200"]

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You are seeing a child who fell on an outstretched hand and sustained a radius fracture. 

[yop_poll id="199"]

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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 equipment at a local park. 

[yop_poll id="198"]

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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 at an urgent care and diagnosed with otitis media and prescribed amoxicillin. He has never taken any antibiotics before. This morning, his fever was gone, but he developed a blanching pink maculopapular rash on the torso that spread to the extremities and face later in the afternoon. He does not seem to be itchy. He has been well appearing and eating normally throughout his illness. 

[yop_poll id="197"]

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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 infant with no past medical history, up to date on immunizations. He has been slightly less than usual but still having several wet diapers per day, and is still playful and interactive. On exam, his temperature is 38.4C, HR 135, RR 48, BP 80/40, and O2 sat 93% on room air. He has diffuse mild wheezes and minimal subcostal retractions, but no grunting, nasal flaring, stridor, cardiac murmur, hepatomegaly, or evidence of dehydration. There is no personal or family history of prior wheezing. His parents are able to return to the ED if necessary and can arrange follow-up with their pediatrician. 

[yop_poll id="196"]

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[yop_poll id="195"]

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[yop_poll id="194"]

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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 simple dislocation without fracture. 

[yop_poll id="193"]

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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 a dose of ondansetron (Zofran) and an IV fluid bolus, then discharge him home with a prescription for ondansetron. His parent gives him diphenhydramine (Benadryl) before bed to help him fall asleep. He becomes upset and overdoses on one of the medications in the home. 

[yop_poll id="192"]

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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 difficulty after waking up from the post-ictal phase. 

[yop_poll id="191"]

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[yop_poll id="190"]

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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 an acute viral gastroenteritis for the last 24 hours, as have several family members. She has had decreased oral intake, vomited 3 times non-bloody non-bilious, and had 3 episodes of watery non-bloody diarrhea. She is afebrile. She went to bed at 9:30pm, sleeping next to her parent, and the parent was awakened by her having a generalized tonic-clonic seizure at 6am. Per EMS, seizure had resolved on their arrival but she was lethargic; point-of-care blood glucose was 40 mg/dL in the field, and she was given 5 mL/kg of D10W IV with patient becoming more alert. In the ED, her urine dip is positive for ketones.

[yop_poll id="189"]

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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 were available to the patient and co-ingestion is not suspected. 

[yop_poll id="188"]

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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 on her inferior breast with minimal overlying cellulitis and no involvement of the nipple. She is nontoxic, afebrile, and not septic appearing. Which of the following ED management choices is most appropriate and most likely to result in rapid improvement?

[yop_poll id="187"]

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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 the family dog. In order to reduce distension of the tissues which may result in poor vermillion border alignment and poor cosmesis, you decide to use a regional block for anesthesia. 

[yop_poll id="186"]

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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 treat a spontaneous pneumothorax. Before the tube thoracostomy procedure can begin, the patient has a sudden episode of oxygen desaturation, lack of end-tidal CO2 waveform, and gurgling noises. It successfully resolves after a couple of minutes of bag-valve-mask ventilation, and the practitioners prepare to begin the procedure again. However, immediately thereafter the patient begins to cough up pink frothy secretions and to desaturate again, although the end-tidal CO2 waveform does not change this time. 

[yop_poll id="185"]

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 drug screen comes back negative for opiates. Which of the following drugs is the patient unlikely to have taken?

[yop_poll id="184"]

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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 or other risk factors for otitis externa. The child has a PMH of frequent otitis media, and pressure equalization (tympanostomy) tubes were placed at age 1 year. There have been no episodes of otitis media since then. As far as the parents know, the tubes are still in place, but they have not had any follow-up with an ENT. On exam, the left ear canal has a PE tube laying in the canal, which you remove; the tympanic membrane is translucent and mobile. The right canal is full of seropurulent drainage. You cannot see the tympanic membrane nor any PE tube. The canal itself is not swollen or red. 

[yop_poll id="183"]

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A toddler, visiting for the holidays, has been roaming his grandmother’s large backyard, nibbling on plants. 

[yop_poll id="182"]

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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 laceration of the right neck at the level of the thyroid cartilage. 

[yop_poll id="181"]

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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 void, a poor urinary stream, and large volumes of urine when he does void. He is circumcised and his external genitalia exam is normal.

[yop_poll id="180"]

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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 period of the event, there is no significant PMH, this is the first and only event, the child appears well in the ED)

[yop_poll id="179"]
(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 intubate the patient, using a 450mL self-inflating bag with oxygen at 10 L/minute, bagging at a rate of 20 breaths/minute. You note that the patient is not improving and there is poor chest rise, so you insert a correctly sized and placed nasopharyngeal airway. The patient is still not improving and has poor chest rise - after repositioning, which is the best intervention? [yop_poll id="178"]
(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. [yop_poll id="177"]
(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. [yop_poll id="176"]
(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 blood in the diaper. The baby is formula feeding well, not lethargic, has no fever, and has had a few non-bilious spit-up episodes. Physical exam shows mild abdominal distension; no anal fissure seen. [yop_poll id="175"]
(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. [yop_poll id="174"]
(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 fluid. It seems mildly itchy to the parent. The child has had a low-grade fever to 38.2 for one day and appears otherwise well. There is no past medical history and no ill contacts; immunizations are up to date. Bullous Impetigo Open access, Pereira LB - Anais brasileiros de dermatologia (2014 Mar-Apr) [yop_poll id="173"]
(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 for lethargy, jaundice, and fever to 38.5. He is exclusively breastfeeding. Labs include pH 7.34, ammonia 80, point of care glucose 80, urine trace ketones. [yop_poll id="172"]
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(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 the hand. Initially he had minimal pain but now, 1 hour later, has significant hand and arm pain and he has vomited a few times. On physical exam, the wound site is a blanched rounded patch with central punctum, and palpation of extremity reveals muscle rigidity when compared to the other side. [yop_poll id="168"]
(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 nasal congestion and cough as well as failure to thrive which was expected to improve with improved nutrition provided by the adoptive family but has not. The child is afebrile and there are no ill contacts. On exam, there are scant wheezes and O2 sat is 95% on room air. CXR shows hyperinflation. Chart review shows prior visits for respiratory illness, and an episode of rectal prolapse. When asked about the presence of constipation, the parents describe frequent smelly oily stools. [yop_poll id="167"]
[yop_poll id="166"]
(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 trauma. Vital signs are: temperature 37.5, HR 80, RR 16, BP 110/60. Her exam is normal except for: a 1/6 musical systolic ejection murmur at the LLSB, acanthosis nigricans, and gait with a noticeable limp. Her right knee has no effusion, deformity, erythema, or warmth appreciable. [yop_poll id="165"]
(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 temperature is 39.1, HR 202, BP 129/61. Despite antipyretics, calming down, and volume resuscitation, she remained febrile and tachycardic. On exam, a midline neck mass is palpable, and the mother gives a history of several months of sweating and poor weight gain. A lab test confirms her diagnosis. [yop_poll id="164"]
(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 you palpate subcutaneous emphysema of his upper chest. [yop_poll id="163"]
(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 sat 98% on room air. Labs show glucose 550, Na – 132, K – 2.8, pH 7.09. An initial bolus of normal saline 20 mL/kg has been given. [yop_poll id="162"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="161"]
(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 intubate the baby. It is a difficult intubation, although the tube is finally observed to pass through the cords on video laryngoscopy. A 3.5 uncuffed tube has been placed and taped at 12cm at the lip. After several positive pressure breaths on 100% FiO2, the pulse oximetry has fallen to 85% and fails to rise. The ETCO2 waveform is normal and reading 46 mm Hg. Heart rate is 170, BP is 62/30. On auscultation breath sounds are decreased on the left side. Trachea is midline. [yop_poll id="160"]
(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 electrocardiogram, and blood pressure of 70/40. [yop_poll id="159"]
(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. [yop_poll id="158"]
(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 not had this before. He has been able to urinate although he complains of pain with urination. There is no history of trauma to the area. He is uncircumcised. Exam shows the tip of the foreskin to be swollen and erythematous and tender to the touch. There is no discharge, evidence of trauma, discoloration of the penile shaft or perineum, nor inguinal lymphadenopathy. The testes are descended and nontender. [yop_poll id="157"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="156"]
(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 that started 5 days ago. The parent is concerned that he remains less active and appears pale. Vital signs are temperature 37.7, HR 135, RR 24, BP 110/60, O2 sat 99% on room air. Point of care hemoglobin is 6.5 g/dL. [yop_poll id="155"]
(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 a new kitten and had been having itchy eyes and nasal congestion for the last 2 weeks. Her temperature is 38.3, HR 90, RR 20, BP 110/60, O2 sat 99% on room air. She is alert, has no nuchal rigidity, and is not toxic appearing. She has left periorbital edema and erythema but her eye can be manually opened. She is PERRL, has no chemosis or proptosis, and has mild conjunctival injection but no discharge. Her extraocular movements are full, but she complains of pain with extraocular movements. Her vision is 20/20 on the right and 20/60 on the left. [yop_poll id="154"]
(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 papules and nodules on the toes of both feet. He states that the areas are itchy and sometimes have a burning sensation. Which of the following courses of action would be appropriate?
  1. Advise him to avoid further cold exposure and to use appropriate protective footwear
  2. Perform gentle rewarming in 37 to 39 degree Celsius water
  3. Perform a COVID-19 test
  4. Reassure him that this is a benign Raynaud phenomenon
[yop_poll id="153"]
(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 between episodes, the child appears well and is playful. There is no fever, diarrhea, or concern for toxic ingestion. The child has a history of constipation with hard stools and occasional skipped days with no stooling. There is no other significant past medical history. [yop_poll id="152"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="151"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="150"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="149"]
(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 the center. Which of the following is not appropriate management? [yop_poll id="148"]
(Click the link to comment and to vote – voting not working through email, sorry!) [yop_poll id="147"]
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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 for 1 day, and have not had recent antibiotics in the last 30 days):

Child A) 5mo old with bilateral otitis media, afebrile

Child B) 18mo old with unilateral otitis media, fever to 38.5, penicillin-allergic

Child C) 27mo old with bilateral otitis media and bilateral purulent conjunctivitis and fever to 39.1

Child D) 37mo old with unilateral otitis media, fever to 39.5, penicillin-allergic

  1. Oral analgesic
  2. Amoxicillin 90 mg/kg/day divided BID
  3. Amoxicillin-Clavulanate 90 mg/kg/day divided BID
  4. Cefdinir 14 mg/kg/day
[yop_poll id="146"]
(Click the link to comment and to vote – voting not working through email, sorry!) [yop_poll id="145"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="144"]
(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 and on arrival to the ED. Initial labs and CXR are normal except for an ETOH level of 390. He is protecting his airway, arousable with deep stimulation, and hemodynamically stable, so the decision is to observe him on a monitor while he slowly sobers up, and then reevaluate him for discharge. However, 2 hours later he is requiring 5L O2 by non-rebreather to maintain an O2 saturation of 97%. He does not show significant respiratory distress or apnea, and a venous blood gas does not reveal CO2 retention or significant acidosis. [yop_poll id="143"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="142"]
(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 following is true? [yop_poll id="141"]
(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. Per parents, they were previously able to retract his foreskin for hygiene purposes, but now they can’t. The patient is able to urinate and ultrasound shows no significant post-void residual. He is afebrile and urinalysis does not show evidence of UTI. [yop_poll id="140"]
(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? [yop_poll id="139"]
(Click the link to comment and to vote - voting not working through email, sorry!) Bullous Myringitis [yop_poll id="138"]
(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, treatment for community-acquired pneumonia one month ago, and an MVA 1 year ago – she received head CT that was negative and was admitted and observed overnight at that time. Her CXR is below. Diaphragmatic Hernia [yop_poll id="137"]
(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? [yop_poll id="136"]
(Click the link to comment and to vote - voting not working through email, sorry!)   [yop_poll id="135"]
(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 has a faint maculopapular rash beginning on his legs. It is influenza season. He has no past medical history. He was bitten 4 days ago by the class pet rat that the teacher bought from a commercial pet store the week before. He went hiking 3 days ago and to Disneyland 2 days ago. He has no drug allergies and takes no medications. [yop_poll id="134"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="133"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="132"]
(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 them. The parents sheepishly bring the somnolent child in to the ED, and the ethanol level is 120 mg/dL. [yop_poll id="131"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="130"]
(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 tachypneic, and has a flow murmur. She is afebrile. Her point of care hemoglobin is 3.2 g/dL, and additional history reveals that she is a very picky eater and drinks five 8-oz bottles of milk per day and takes in little else. A full CBC and iron studies are sent to the lab. [yop_poll id="129"]
(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 febrile seizures, starting at age 6 months, and is not on any long-term anticonvulsants. There is no other significant PMH. The child was given IM Ativan 1mg by EMS with resolution after 10 total minutes of seizure. Vital signs are temp 37.9, HR 160, RR 10, BP 72/42, O2 sat 90% room air, weight 7 kg, POC glucose 110. An IV is now in place. What is the MOST appropriate first intervention, assuming all can be instituted within the same amount of time? [yop_poll id="128"]
(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 your work-up, you evaluate him for inborn errors of metabolism. Which of the following is false about urea cycle disorder as a diagnosis for his findings? [yop_poll id="127"]
(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 muscle spasms causing him to arch his neck and back. He cannot control or stop the spasms, but is otherwise alert. He visited a cousin’s farm 6 days ago where he played with a goat, drank unpasteurized milk, sustained a small laceration to his scalp that was allowed to heal on its own, and had a tick on him that was pulled off by his mother that evening. He is unimmunized by parent choice. He has received no medications and has no PMH. His temperature is 38.2, HR 140, RR 20, BP 130/65. O2 sat 97% on room air. [yop_poll id="126"]
(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 intubation perform rapid sequence medication-assisted intubation? [yop_poll id="125"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="124"]
(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 at that time showed a CBC with WBC 10.2, 55% neutrophils, UA negative, RLQ ultrasound appendix not visualized. He was discharged home with return precautions and instructions to follow-up with his pediatrician. He returns 15 hours later with continued constant right mid-abdomen pain, anorexia, nausea, a few episodes of non-bilious vomiting, and temperature of 37.8. [yop_poll id="123"]
(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 growing gram positive cocci in clusters. The baby received the first set of immunizations at age 7 weeks. The baby is afebrile today and has been doing well and eating normally. The only treatments have been acetaminophen, last given 8 hours ago. [yop_poll id="122"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="121"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following is/are true of bacterial tracheitis?
  1. Children presenting with bacterial tracheitis tend to be older than children presenting with viral croup
  2. Children with bacterial tracheitis do not respond as well to racemic epinephrine and steroids as children with viral croup
  3. Children with bacterial tracheitis may have a “steeple sign” on xray
  4. Children with bacterial tracheitis most commonly have Strep pneumoniae infection
[yop_poll id="120"]
(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 immediate pain in his right Achilles tendon area. He is able to bear weight, but with pain. On exam, there is a palpable gap in his Achilles tendon, and you suspect a ruptured tendon. [yop_poll id="119"]
(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 muffled voice. You diagnose peritonsillar abscess and plan to perform a needle drainage procedure. [yop_poll id="118"]
(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 a project at home. The injury occurred 2 hours ago. On exam, he has a barely perceptible entrance puncture wound at the tip of his right index finger, no deformity or swelling, and a normal neurovascular exam. Radiographs are negative for fracture and his tetanus is up to date. [yop_poll id="117"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="116"]
(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. [yop_poll id="115"]
(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 presents with fever, cough, and increasing shortness of breath over the last 2 days. Her mother was recently diagnosed with influenza. CXR shows a right upper lobe infiltrate. Vital signs are: temperature 38.8, HR 130, RR 30, BP 110/60, O2 sat 96% on room air. Hemoglobin is 9 g/dL, which is the patient’s baseline. [yop_poll id="114"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="113"]
(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 to inhale flavored tobacco smoke. His HR is 94, BP 116/60, pulse ox 98% on room air. He complains of dizziness and headache. [yop_poll id="112"]
(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 then developed tonic-clonic activity for 15 seconds. The entire episode lasted 1-2 minutes. The child is playful, drinking from a bottle of juice, and back to baseline in the ED, with a normal physical exam and vital signs. He has never done this before. Which of the following test(s) is/are most indicated?
  1. Bedside glucose
  2. Electrocardiogram
  3. Point of care hemoglobin
  4. Non-contrast CT head
[yop_poll id="111"]
(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 the ED on day of life #4 with jaundice that just started on the day of presentation. Serum bilirubin is 15, all unconjugated. The baby is exclusively breastfed and having 4 wet diapers per day. [yop_poll id="110"]  
(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 hit by a baseball to the eye. He has periorbital ecchymosis but no evidence of orbital fracture. Visual acuity is 20/60 on right, 20/20 on left. He is PERRL, EOMI without pain, and has normal IOP and slit lamp exam. Fundoscopic shows a deep subretinal hemorrhage in his macular area with a small curvilinear yellow line visible. [yop_poll id="109"]
(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 proteinuria. You suspect nephrotic syndrome. [yop_poll id="108"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="107"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="106"]
(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. [yop_poll id="105"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="104"]
(Click the link to comment and to vote - voting not working through email, sorry!) Perilimbic redness [yop_poll id="103"]
(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 illness. Her mother is pregnant. [yop_poll id="102"]
(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 past medical history conditions makes methylene blue a contraindicated treatment? [yop_poll id="101"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="100"]
(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. He has pain at the posterior calcaneus, especially when the sides of the heel are squeezed. There is no history of trauma or fall. There are no other abnormal physical exam findings, and radiographs are normal. The patient is not limping and currently does not have pain at rest. [yop_poll id="99"]
(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. In addition, they are tachycardic. [yop_poll id="98"]
(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 the following reassures you that this is unlikely to be measles? [yop_poll id="97"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="96"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="95"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="94"]
(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 not too thin (and, if anything, is a little “chubby”), and that she eats plenty, but says she tries to eat “healthy.” Per her parents, she exercises 2 hours per day. Vital signs in the ED are: temperature 95.8 oral, HR 55, RR 18, BP 88/40. Her BMI is 15, and her weight is 73% of her ideal body weight. Her mental status is normal. Her capillary refill is < 2 seconds. An ECG is performed and is normal. [yop_poll id="93"]
(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 palpable purpura on bilateral lower legs. Which of the following is true? [yop_poll id="92"]
(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. [yop_poll id="91"]
(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 lorazepam in the ED, then 20 mg/kg fosphenytoin, 60 mg/kg levetiracetam, and 40 mg/kg valproate, with no cessation of seizures. The bedside glucose and i-stat Na and Ca are normal. Which vitamin might you try next? [yop_poll id="90"]
(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 of her elbow? [yop_poll id="89"]
(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) [yop_poll id="88"]
(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 5 wet diapers per day and weighs 10 lbs, and has gained 30 gm per day since regaining birth weight at 10 days of age. The baby is formula feeding, taking 5 ounces every 2-3 hours. [yop_poll id="87"]
(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? [yop_poll id="86"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="85"]
(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 reported to the parent that there was a tooth on the ground, and per paramedics the parent is on the way in and may or may not have the tooth. Exam reveals a grossly luxated tooth that is very loose, and two sockets of apparently missing teeth. [yop_poll id="84"]
(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 patients assume well appearing otherwise)? [yop_poll id="83"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="82"]
(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 and breathing. Vital signs are normal and she is not hypoxic nor stridorous, but she does have right sided perioral swelling as well as mucous membrane swelling. There is no discoloration. She has no urticaria, pruritis, nor hypotension. She had dental work on her right lower teeth the day prior, and had local anesthetic injection for that. She took one dose of acetaminophen the day prior and one dose 6 hours ago. Her stepfather gave her diphenhydramine 1 hour ago, but it hasn’t helped. The child denies trauma and says that she felt tingling in the area for 1 hour prior to the onset of swelling. [yop_poll id="81"]
(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? [yop_poll id="80"]
(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 the galea. [yop_poll id="79"]
(Click the link to comment and to vote - voting not working through email, sorry!) Regarding common Christmas holiday plants: [yop_poll id="78"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="77"]
(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 baby is nontoxic, has normal vital signs and perfusion, and has a normal physical examination. Point of care hemoglobin is 15 g/dL. [yop_poll id="76"]
(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 patient in shock? [yop_poll id="75"]
(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 of flu season, of whom 60 had influenza and 40 did not. Of the 60 who had influenza by PCR, 54 had a positive rapid flu test, and of the 40 who did not have influenza by PCR, 2 had a positive rapid flu test. [yop_poll id="74"]
(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 that will not stop for the last 2 hours. His dentist office is now closed and no one is answering the phone. He has no prior history of excessive bleeding and is not taking any medications. He is hemodynamically stable, and on exam you see a clot in the socket surrounded by a steady ooze of blood, which the patient spits out onto a napkin every minute or so. [yop_poll id="73"]
(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 won’t be there for 20 minutes. The head delivers, but the baby then has the “turtle sign” with fetal head retracting against the perineum. [yop_poll id="72"]
(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 the right side. He had a viral URI 1 week ago with fever, cough, congestion, sore throat, from which he had recovered. For the past week, he did not take the Adderall because he had been sick and “forgot” to resume. On physical exam, his right arm is flaccid and motionless at his side, and he is unable to use it at all. He is able to lift his left arm partly against gravity, but it is weak. He has a low-grade fever of 38, and mild neck stiffness. His mental status is normal. [yop_poll id="71"]
(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 redness. On history, she has a kitten, and did sustain scratches to her right hand from the kitten in the last few weeks. She had a small papule on her hand in an area of a scratch 1.5 weeks ago that mom thought was a bug bite. Parents are unsure if she has had any fevers. She is otherwise healthy and well appearing. [yop_poll id="70"]
(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 syndrome (HUS). Over a 10-year period, several cases of patients with HUS diagnosed after a PED visit for diarrhea are identified, and for each of these patients, 3 other patients seen in the PED for diarrhea that did not develop HUS matched for age, gender, duration of illness, and stool culture findings are identified. The two groups of subjects are compared regarding whether they received PED antibiotics or not. [yop_poll id="69"]
(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 had 2 recent partners, and “sometimes forgets” to use condoms. At that time testing for HIV, RPR, gonorrhea, and chlamydia urine NAT were performed at the time and he was treated empirically with IM bicillin for presumed chancre of syphilis and empiric IM ceftriaxone for gonorrhea. All of the labs were subsequently negative. He now returns with bilateral tender inflamed inguinal adenopathy. His penile lesion resolved after a few days. [yop_poll id="68"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5yo girl comes in for chest pain for 6 hours and is noted to have a heart rate of 250 that is not varying. Review of the electronic medical record reveals a history of WPW. Mom says she has not had an episode of fast heart rate since age 3 weeks when she was first diagnosed. She is not on any medications. She is awake and alert, and her blood pressure is 85/45. SVT WPW 1 [yop_poll id="67"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 16 year old obese teen with no previous history of diabetes who presents with recent viral URI symptoms and increasing altered mental status over the last 8 hours. Her temperature is 37.9, heart rate 140, resp rate 22, and BP 90/35.  Blood glucose is 950, Na 130, K 3.4, and urine negative for ketones. The teen is confused and has a GCS of 13. [yop_poll id="66"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 16 year old football player is brought in with severe right knee pain after being hit from the front. He states that he thought his knee was displaced initially, but now it looks back in place. He has no obvious deformity or effusion on observation, and no ecchymosis. Instability testing is difficult due to the patient’s pain. Radiographs are negative for fracture or dislocation. Dorsalis pedis pulses are palpable and normal bilaterally. [yop_poll id="65"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old child has a flat lesion of the entire left forehead and upper eyelid the color of light red wine that has been present since birth. The family has presented to the ED because they are concerned that the child has right sided weakness.   sturge-weber-1 https://mindfulmema.wordpress.com/tag/sturge-weber/ [yop_poll id="64"]  
(Click the link to comment and to vote - voting not working through email, sorry!)   Match the classic serum electrolyte / acid-base findings with the pediatric condition: 1) hypochloremic hypokalemic metabolic alkalosis 2) hyponatremic hyperkalemic metabolic acidosis 3) hyponatremic normokalemic metabolic acidosis 4) hypercalcemic metabolic alkalosis A) DKA B) pyloric stenosis C) milk alkali syndrome D) congenital adrenal hyperplasia [yop_poll id="63"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 6yo girl presents with palpable purpura of both legs for 2 days. She has not had any fever and is well appearing. Her labs, including CBC, electrolytes, BUN, Creatinine, and ESR are normal. She does not complain of any pain. Her vital signs are temperature 37.5 C, HR 90, RR 20, BP 90/45. She has no abdominal tenderness, vomiting, respiratory difficulty, joint pain or swelling, and her urination has been normal. Her stool guaiac is negative. [yop_poll id="62"]
(Click the link to comment and to vote - voting not working through email, sorry!) 14yo boy presents with LLQ abdominal pain and left hip pain for 5 days. He has not had any fever. He is an active baseball player and skinned his right knee the week before. On exam, he prefers to keep his left hip flexed at 90 degrees, walks with a limp and lordosis, and is most comfortable laying on his right side with his hips flexed. He has LLQ abdominal tenderness and has maximal pain with any attempt to extend or internally rotate his left hip. Genitourinary exam is normal. [yop_poll id="61"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17yo boy presents with a round lesion similar to that noted below, but on his penis, noted 1 hour after taking a dose of TMP-SMX that was prescribed to him for “stomach infection.” He had 2 episodes of non-bloody diarrhea 2 days ago and went to a clinic and received the prescription, which he was unable to fill until today. The diarrhea has actually improved. He has no fever. The rash is not painful or itchy. He mentions that he previously had a similar rash in the same place after taking the same drug a few years ago. Fixed drug eruptionWikimedia Commons Donald M. Pillsbury, M.D., and Clarence S. Livingood [yop_poll id="60"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="59"]
(Click the link to comment and to vote - voting not working through email, sorry!) A toddler is accidentally left in the car during summer. Luckily, a bystander sees her and calls 911. The car is broken into, and the patient is brought to the PED. She has a temperature of 105.9. [yop_poll id="58"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 4 year old child comes in 20 minutes after falling with avulsion of her left upper lateral incisor. The parents have brought the tooth in a tissue. The entire crown and root are present. There is no active bleeding from the socket. The remainder of her exam is normal; she is able to open her mouth widely without pain and has no bony tenderness over her facial bones or jaw. [yop_poll id="57"]
(Click the link to comment and to vote - voting not working through email, sorry!) 8yo girl with history of asthma presents with increased work of breathing x 1 day. She is alert but anxious appearing, tachypneic, has retractions and flaring, and her O2 sat is 88% on room air. She has poor air movement and few wheezes are heard. She is given two 5mg albuterol nebulized treatments and oral steroids. An initial venous blood gas had a pH of 7.45 and pCO2 of 34. A repeat blood gas shows a pH of 7.33 and pCO2 48, O2 sat on oxygen with 3rdnebulized albuterol is 91%; her mental status is unchanged [yop_poll id="56"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 9 month old baby is brought in with this problem, first noted a few hours prior. Hair tourniquet By James Heilman, MD [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], from Wikimedia Commons [yop_poll id="55"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 19yo woman who is 33 weeks pregnant presents with contractions every 2 minutes and thinks her water broke. She has no prenatal care records available, and was only recently diagnosed as pregnant at an outside clinic. On exam, she is 9cm dilated and +1 station. She is screaming with pain. [yop_poll id="54"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="53"]
(Click the link to comment and to vote - voting not working through email, sorry!) You design a study to compare a new antiviral to treat herpangina to placebo. During the trial, some of the parents stop giving their children the new drug because it tastes bad, and some (but fewer) parents stop giving their children the placebo because they forget to give it. During the analysis, you compare the outcomes based on the patients’ assignment to their original group. [yop_poll id="52"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 10 year old recently moved to the U.S. from Mexico with left sided chest pain for one day, and a fever to 38.2. Lung sounds are clear, the O2 sat is 100% on room air, and the CXR is negative. The ECG shows diffuse 1mm ST elevations and PR depression. The patient is well appearing with normal vital signs and hemodynamics. [yop_poll id="49"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 13 year old girl with heavy prolonged menses x 10 days who appears pale to her parents. She had menarche at age 11, and has had heavy irregular menses since then. She actually feels that her menses is slowing down and she is currently using 1-2 pads per day. She has never had any other bleeding. Her HR is 90, and BP 100/50. Her hemoglobin is 9 and her MCV is 65. [yop_poll id="50"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 month old comes in with diarrhea x 3 days, 5 times per day initially now 3 times per day, non-bloody, no fever, no vomiting. The patient was seen in the ED the day before, and had stool culture sent which was negative, C. difficile toxin which was positive, and stool WBC negative. [yop_poll id="51"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 11 year old girl was sitting with lap belt only in the back seat of a minivan involved in a motor vehicle accident where her car was rear-ended. She has a “seat belt sign,” or ecchymosis over her lower abdomen. Her CT abdomen with contrast is normal, but she continues to have tenderness to palpation. However, she states she is hungry. [yop_poll id="48"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing an 8 month old child with viral URI symptoms and pulling at the left ear. The child has not had any fever, is fully immunized, and is well appearing and playful. The right ear is translucent. The left ear is erythematous, with no bulging, perforation, or air-fluid level. Mobility is normal on pneumatic otoscopy. The child had one previous ear infection diagnosed at age 5 months. [yop_poll id="47"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 year old child with cochlear implants placed 8 months ago. The child has fever, headache, vomiting, altered mental status, and meningismus. The implant sites are well healed and show no signs of local infection. [yop_poll id="46"]
(Click the link to comment and to vote - voting not working through email, sorry!) D5 ¼ NS is no longer recommended for maintenance fluids in hospitalized young infants. Why not? [yop_poll id="45"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are caring for a 4 year old child struck by a car. The child has significant maxillofacial trauma, a large parietal hematoma, and a GCS score of 7. Attempts to intubate with direct and video laryngoscopy have been unsuccessful due to blood obscuring visualization of the airway, and you are only partially able to oxygenate and ventilate the child with bag-mask ventilation, with an O2 sat on 100% FiO2 of 80%. [yop_poll id="44"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2yo child is brought in after having taken some of Grandma’s “heart medicine.” Because the pills are kept in an unlabeled box and not their original container, the parents don’t know what the medication was. The child has sinus bradycardia with frequent PVC’s on the ECG, a blood glucose of 90; electrolytes on the i-stat are normal except for a slightly elevated potassium level. [yop_poll id="43"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 10 month old infant with history of constipation comes in with a 1cm dark red (but not dusky) painless mass extruding from the anus. The patient is afebrile, well appearing and playful, and the remainder of the exam is unremarkable. Rectal_Prolapse_Toddler_1 Wikimedia Commons, user BellaVuk [yop_poll id="42"]
(Click the link to comment and to vote - voting not working through email, sorry!) You design a trial comparing two different techniques for draining skin abscesses: standard I&D with packing vs. loop drainage. Your chosen outcome is the proportion of patients that require a second drainage procedure. You expect to enroll 100 patients in each group, and expect an average of 10% to require a second drainage procedure. [yop_poll id="41"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 13 year old girl presents with sudden onset sharp RLQ pain radiating toward her groin, along with nausea and vomiting once, non-bloody, non-bilious. [yop_poll id="40"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 4 year old with ventriculoperitoneal shunt revision 1 month ago, presents with headache and vomiting and increased sleepiness according to mom. The patient is well appearing and nontoxic, tolerating po’s in the ED, and has a normal funduscopic and neurologic exam. He got acetaminophen 2 hours ago and has no headache currently. [yop_poll id="39"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old is brought in because all of his fingernails and toenails are falling off, painlessly. On review of the ED electronic medical record, he was seen 6 weeks ago and diagnosed with a viral infection. What viral infection did he have? [yop_poll id="38"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 3 year old child sustains a cold water submersion injury. He is brought in with a core temperature of 30 degrees C, in ventricular fibrillation, and is successfully defibrillated and intubated. Rewarming is occurring by: removing wet clothes, forced air warming blanket, warmed IV fluids to 40-44C, warmed humidified oxygen at 42-46C. What rate and endpoint of rewarming is best? [yop_poll id="37"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 14 month old is brought in with lethargy and obtundation. The patient is breathing spontaneously and has stable vital signs. The parents admit that they were having a party with alcohol and recreational drugs present, and the toddler had been walking around. [yop_poll id="36"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old uncircumcised boy is brought in because his parents are concerned that they cannot retract his foreskin. On exam he has phimosis, but there are no signs of inflammation or swelling and no palpable scarring or fibrosis. The patient is asymptomatic and has experienced no ballooning, dysuria, incontinence, dribbling, or recurrent balanoposthitis or UTI. [yop_poll id="35"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 18 month old child has sustained an arm fracture. Per the parent, the 4 year old sibling was carrying the child and tripped. [yop_poll id="34"]
(Click the link to comment and to vote - voting not working through email, sorry!) Teardrop pupil www.jems.com A 2 year old toddler comes in from the playground crying and rubbing at his right eye. Exam is as above. [yop_poll id="33"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 15 year old girl is brought in by her uncle for a chief complaint of vaginal discharge (he explains that her parents are working and unable to bring her in). She has yellow vaginal discharge and cervical motion tenderness on exam. Her pelvic exam is otherwise unremarkable. She has a linear bruise on her neck, some circular marks on her right dorsal hand, and some linear hyperpigmented marks on her right volar wrist. She shrugs her shoulders when asked how these occurred. Her uncle states that she “does it to herself.” She avoids eye contact, is not very conversant, and her uncle answers most of her questions for her. She shakes her head “no” when asked about depression or suicidality. [yop_poll id="32"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old was bitten by the family cat superficially on his right index finger, 3 days ago. He presents now with redness, warmth, and pain over the volar aspect of his index finger. [yop_poll id="31"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy was scuba diving with his father. Soon after coming to surface, he began to experience symptoms of decompression illness, including joint pains, itchiness, ataxia, paresthesias, and confusion. He has been placed on 100% oxygen by non-rebreather and an IV has been placed and the plan is to transport him to a facility with a hyperbaric chamber. [yop_poll id="30"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8 day old male is brought in with bilateral breast enlargement. They seem slightly tender, but there is no redness, fluctuance, or fever. The parents have noted discharge of a milky substance. [yop_poll id="29"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17 year old boy comes is brought in to the ED at 2am for severe retrosternal chest pain that awoke him from sleep. He was well prior to going to bed at 11:30pm, and denies fever, cough, radiation of the pain, vomiting, trauma, foreign body ingestion. He has a past medical history of appendectomy 8 months prior, acne for which he takes an oral antibiotic and uses a topical cream daily, and mild intermittent asthma for which he uses an inhaler once or twice a year "when the weather changes." He is a straight A student applying to colleges currently. His physical examination is normal, as is a CXR and ECG. What is the probable cause of his chest pain? [yop_poll id="28"]
(Click the link to comment and to vote - voting not working through email, sorry!) Put these causes of pediatric limp in order of what age they typically present, from youngest to oldest:
  1. Legg-Calve-Perthes disease
  2. Developmental dysplasia of the hip
  3. Slipped capital femoral epiphysis
  4. Nondisplaced hairline oblique fracture of the tibia w/o history of trauma
[yop_poll id="27"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following patients that sustained electrical injury requires further observation in the ED or admission (should not be discharged home now)? A) A toddler that bit on an electrical cord, has an oral commissure burn, but has normal labs and ECG and is tolerating po’s and has no active bleeding B) A 4 year old that put a fork into a European socket and sustained a small burn to the hand, is asymptomatic, has normal CK and ECG and soft compartments C) A teen who was running from law enforcement and was brought in with a retained taser dart, which has been subsequently removed, and who is currently asymptomatic D) A teen who touched a downed power line and sustained electrical shock, labs and ECG are normal and is currently asymptomatic [yop_poll id="26"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are triaging patients from a multi-casualty incident. The following patients are seen: Patient A: Approximately 2 years old, ambulatory, crying, large 8cm parietal hematoma, obvious right humeral deformity Patient B: Approximately 5 years old, unresponsive, apneic after airway positioning and 5 rescue breaths, weak palpable pulse Patient C: Approximately 3 years old, responsive to painful stimuli, breathing at 40 breaths per minute, very weak palpable pulse Patient D: Approximately 7 years old, unresponsive, breathing at 30 breaths per minute, weak palpable pulse [yop_poll id="25"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 2 year old child recently brought from a third world country with PMH of an unrepaired hole in the heart and mild cyanosis is brought in to the ED. The patient fed in the AM, then began to cry and became unconsolable, hyperpneic, and deeply cyanotic. On arrival, the patient has a temp of 37.6, HR 180, RR 60, BP unobtainable, O2 sat 40% on room air. [yop_poll id="24"]
(Click the link to comment and to vote - voting not working through email, sorry!) A previously healthy 5 year old boy with PMH of ADHD presents with 9 days of lethargy, fever, vomiting, diarrhea, and weight loss. He recently was diagnosed with strep pharyngitis and treated with amoxicillin for 3 days. His vital signs are: temp 39 C, HR 140, RR 24, BP 154/99, O2 sat 99% on room air. His exam is significant for agitation and restlessness, and tachycardia with bounding pulses and a hyperdynamic PMI. His mother feels that his anterior neck looks swollen. [yop_poll id="23"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 5 year old fully immunized patient with 2 weeks of new onset bedwetting, 3 days of cough and fever, and 2 days of increased work of breathing. Initial POC labs are significant for a blood sugar of 450 and a pH of 7.11, Na 130, K 3.4. You start a 20 cc/kg NS bolus and send a full set of labs. The patient is complaining of headache and is lethargic initially, becoming increasingly obtunded over the first half hour in the ED. [yop_poll id="22"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are evaluating the electrocardiogram of a 2 year old boy. The patient presented for fever and the ECG was inadvertently ordered on him instead of another patient. [yop_poll id="21"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 6 week old ex-30 4/7 weeks twin A male infant was seen at an outside clinic because his parents felt that his heart was beating faster than his twin sibling’s and was found to have a hemoglobin of 7.9 g/dL. The clinic referred him in to the ED for blood transfusion and hematology consultation. The heart rate is 165 bpm on the monitor, blood pressure is 74/40, cap refill is < 2 seconds, and color is pink. The remainder of his CBC is normal, and the patient is afebrile, feeding and growing well, and asymptomatic except for his heart rate. Reticulocyte count is 4.77%. [yop_poll id="20"]
(Click the link to comment and to vote - voting not working through email, sorry!) You receive word that the clinic is rushing over a patient with a genetic syndrome and respiratory distress. You have a few moments to look in the electronic chart of the patient and set up the resuscitation room. Which of the following syndromes would make you concerned for a potential difficult airway scenario? [yop_poll id="19"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8 year old boy presents after taking 3-4 of grandma’s pills about an hour prior. It is unknown what Grandma takes, but she has “chronic pain, a heart condition, high blood pressure, and sugar problems”. He is altered, but arousable to stimuli and answers questions. He says he took the pills because he was “curious.” His vital signs are: Temp 36.6, HR 49, RR 12, BP 80/40, O2 sat 98% on room air. Physical exam is significant only for miosis, bradycardia, and somewhat weak pulses. Bedside glucose is 100. [yop_poll id="18"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following is true about erythema multiforme major, Stevens-Johnson syndrome, and toxic epidermal necrolysis? [yop_poll id="17"]
(Click the link to comment and to vote - voting not working through email, sorry!) Several members of a family present to the cruise ship infirmary of an Alaskan cruise. They just ate a lunch consisting of tuna salad sandwiches. For breakfast they had a buffet of pancakes and waffles, and last night they ate a shellfish feast dinner which included raw oysters, crab, clams, scallops, and fish. For dessert they had ice cream. They have also been visiting the bar onboard. They are all experiencing abdominal cramping, nausea, vomiting, and frequent watery diarrhea. Some have low-grade fever and chills. Which meal most likely caused their symptoms? [yop_poll id="16"]
(Click the link to comment and to vote - voting not working through email, sorry!) You have sutured a 2cm forhead laceration on a 4yo boy using 6-0 nylon sutures. [yop_poll id="15"]
Impetigo http://diseasespictures.com/ What is the best treatment for this 3 year old patient’s rash? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="14"]
You are caring for a 6yo oncology patient presenting in septic shock. Although he is oxygenating and ventilating well at this time, you plan to intubate him to reduce his metabolic work. The most important pre- treatment before rapid sequence intubation (RSI) is: (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="13"]
A family obtained tuna from the local farmer’s market and prepared it for dinner. The children thought the fish tasted weird, peppery or metallic, but the parents did not, and told the children to stop complaining and eat dinner. Within 20 minutes of consumption, the children complain of headache, dizziness, pruritis, abdominal cramping, and nausea. They appear somewhat flushed in the face, neck, and chest. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="12"]
Which of the following cervical spine findings would you expect to be less common in a young child as compared to an adolescent or adult? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="11"]  
Jellyfish en.wikipedia.org (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="10"]
A 12yo girl presents to the ED in December with fever for 4 days, malaise, and pain in the right thigh gradually leading to her having difficulty walking. There is no history of trauma, although she did play a lot of basketball 1 week ago. She is alert and oriented. Physical exam of her leg is unremarkable except for diffuse pain. She has no rash nor joint swelling or erythema. Her vital signs are: temp 39.1, HR 165, RR 22, BP 85/44. Labs show an elevated WBC count with a bandemia, a BUN of 20 with a creatinine of 2.2, and mildly elevated transaminases with a bilirubin of 2.4. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="9"]
A 19yo man presents with his 3rd bout of unremitting nausea and vomiting. He has been admitted twice before and treated with ondansetron and IV fluids. He was noted to take frequent long showers while admitted. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="8"]
A 3 year old comes in after falling 3 feet from the top of a kiddie slide onto cement, hitting his head. His only +PECARN symptom is 2 episodes of vomiting in the 2 hours since the fall. The medical student seeing him states to you that he is PECARN+ and he has discussed CT with the parents. What is the approximate risk of clinically important traumatic brain injury in this patient? (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="7"]
A 10yo girl comes home from a family vacation to Florida in June, where she swam in the ocean. She has an itchy rash in the area covered by her bathing suit that started soon after swimming in the ocean and is still present 3 days later. Seabathers   http://www.medicinenet.com (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="6"]
A 16yo girl presents to the ED with symptoms and rash consistent with varicella (chickenpox). She was never vaccinated, as a personal family choice. She also recently gave birth. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="5"]
A 19yo man presents with progressively worsening extremity numbness in a glove and stocking distribution and ataxia x 1 month. He has areflexia, weakness, and a wide-based gait on exam. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="4"]
NEW! Vote your answer and see what others voted for. Correct answer will be in Comments in a few days. A 14yo female soccer player comes to the ED complaining of bilateral knee pain x 1 month, right greater than left. She does not recall a specific traumatic injury or fall, nor of any knee swelling, popping, or locking. The pain is worse after soccer practice or a game, and after getting up from sitting for a prolonged period such as her 2-hour block classes. The pain is described as behind the knee cap. There is no knee effusion, and there is full active range of motion. She has been afebrile throughout the course. [yop_poll id="1"]
A 10yo boy obtained a pet rat from a commercial pet store. Upon returning home, his new pet promptly bit him. 5 days later, he has fever, chills, severe headache, polyarthralgias, and a maculopapular rash with some petechiae that developed after 2 days of fever. What organism is the most likely cause for the boy’s symptoms? A. Staphylococcus aureus B. Group A Streptococcus pyogenes C. Eikenella corrodens D. Rabies virus E. Streptobacillus moniliformus
A 16yo boy just returned from a vacation to the U.S. Virgin Islands. On the flight, he developed abdominal pain, nausea, vomiting, which he initially attributed to airsickness. He came straight from the airport to the ED, and now he also complains of lingual and circumoral paresthesias, painful paresthesias of his hands and feet, feeling as though his teeth feel “loose”, and generalized weakness. Another classic symptom of this entity is: A. Urticaria and flushing B. Tachycardia C. Profuse watery diarrhea D. Paralysis E. Temperature reversal Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
You are conducting a study to compare the efficacy of a new bronchodilator against standard albuterol therapy in patients with acute asthma exacerbations. To reduce the possibility of selection bias in your study, the key element in your study design is: A. Blinding study participants so that they do not know which treatment has been selected for them, and do not change their subjective assessment of improvement in asthma symptoms B. Enrolling sufficient numbers of study participants to ensure an accurate estimate of the difference in treatment effects C. Randomizing study participants to ensure that the two groups studied are equivalent in potential confounding factors D. Only enrolling study participants > 2 years old, to avoid selecting bronchiolitis patients instead of asthma patients Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
A 17yo boy comes in with complaint of inability to breathe from the right nares. He was seen 2 days ago by his PMD and prescribed amoxicillin for sinusitis, but is not improving. He denies placing any foreign body in his nose. He was in an altercation at school and was hit in the nose 4 days ago. Which of the following would be the most appropriate treatment of this patient’s condition? Septal hematoma http://rhinitis.hawkelibrary.com/album09/83_G A. Change antibiotics to amoxicillin-clavulanate B. Attempt removal of foreign body C. Incision and drainage and nasal packing D. Referral to otorhinolaryngologist for polyp removal Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
Which of the following wild animal exposures is the lowest risk for rabies?
  1. Skunk
  2. Coyote
  3. Raccoon
  4. Fox
  5. Rabbit
Also, if you’re interested in the Peds ID Antibiotics Question of the Week, you can find it here
A 36-week infant is born precipitously NSVD to a 17yo G2P1 mother in the ED after the mother presented with the chief complaint of intermittent abdominal pain. Apgars are 8 and 9 at 1 and 5 minutes, with -1 for color at both times and -1 for reflex irritability at 1 minute. The O2 sat in the left upper extremity is 82% at 5 minutes. The baby is crying intermittently, is not pale or plethoric, and is in no respiratory distress. Lung sounds are equal and clear bilaterally, and cardiac exam is normal. The next best intervention is: A. Intubate and mechanically ventilate B. Suction and apply 100% O2 C. Suction and apply nasal canula O2 at 5 L/min D. Transilluminate the chest to r/o pneumothorax E. Continue to observe the infant Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID Question of the Week, you can find it here
A 10yo girl is sitting lapbelted in the rear of an SUV that is involved in a rear-end collision at 40mph. She complains of abdominal pain, and has an ecchymosis from the lapbelt going across her lower abdomen. Of the following, which is the LEAST likely injury the patient may have: A. Small bowel injury B. Kidney injury C. Horizontal vertebral body fracture in lower spine D. Spinal cord injury Check back in a few days for my answer and others' comments Also if you're interested in the Peds ID question of the week, go here
A 7yo patient with peanut allergy at a rice krispy treat at a birthday party and discovered afterwards that it was made with peanut butter. She presents with hives, mild swelling of her lower lip and periorbital, and some faint wheezes. O2 sat is 99% on room air. Vital signs are temp 37.6, HR 120, RR 28, BP 90/60. What is your first priority treatment? A. Diphenhydramine 1.25 mg/kg IV B. Epinephrine 0.01 mg/kg of 1mg/mL solution IM C. Methylprednisolone 2 mg/kg IV D. Normal saline 20 cc/kg IV E. RSI and prophylactic intubation Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here
A 2 month old ex-30 week premie just discharged from the NICU comes in with respiratory distress and hypoxia. You determine that the patient needs to be intubated. The baby’s weight at discharge was 2.5 kg. What size ETT should you use? A. 2.5 uncuffed B. 3.0 uncuffed C. 3.0 cuffed D. 3.5 uncuffed E. 3.5 cuffed Check back in a few days for my answer and others' comments Also, if you're interested in the Peds ID question of the week, go here
Of the following fractures, which is most concerning for non-accidental trauma? A. 18 month old brought in for refusing to walk, no history of any trauma or fall. Toddlerfx (source medscape) B. 18 month old brought in for refusing to walk, history of falling from a jungle gym approximately 3 feet off the ground. Cornerfx (source http://www.meddean.luc.edu/) C. Both are concerning for non-accidental trauma D. Neither are concerning for non-accidental trauma Check back in a few days for my answer and others' comments
You are seeing a 12yo child with right ear pain for 2 days. He has been swimming recently. On examination, he has pain when you pull on the pinna of the ear to straighten the canal, and the canal is swollen and full of purulent discharge. He is afebrile and has no previous history of ear infection. Which of the following is FALSE regarding the management of this patient? A. Systemic antibiotics play no role B. If the patient had a history of pressure equalization tubes, neomycin + polymyxin B + hydrocortisone (cortisporin) drops would be contraindicated C. The patient should be advised not to swim while undergoing treatment D. Pain can be treated with antipyrine + benzocaine (auralgan) drops E. Fluoroquinolone drops are the most commonly used antibiotic therapy
Which of the following is true about Clostridium difficile? A. It is the most common cause of antibiotic-associated diarrhea B. The treatment of choice for C. diff colitis is IV vancomycin C. Asymptomatic carriage in children < 1 year old is common D. A and B E. A and C
A 14yo boy presents with fever and chest pain for 2 days. The chest pain is pleuritic and worse with leaning back. On examination, lung sounds are clear bilaterally, heart is regular with no murmurs, but a friction rub is heard. Which of the following is true of this condition? A. Treatment of choice is NSAID therapy B. All patients must be admitted to the hospital on a cardiac monitor C. CXR is always abnormal D. Electrocardiogram most commonly shows ST elevation isolated to leads II, III, and aVF E. Pain is rarely referred to shoulder or back
A 5yo uncircumcised boy comes in because his parents are unable to retract the foreskin of his penis. They have not been able to retract it ever, but now note also that he is having ballooning of the foreskin when he urinates. On exam, the opening of the foreskin is very tight. Appropriate treatment includes: A. Forceful retraction of the foreskin to break any adhesions B. Topical steroid cream and close follow-up C. Topical estrogen cream and close follow-up D. Emergent consultation with a urologist for immediate circumcision E. Reassurance that the condition will resolve by age 10 years
A 20kg child sustains a 15% body surface area burn. The best answer for the rate of IV fluids that should be administered over the first 8 hours is: A. 60 cc/hr B. 75 cc/hr C. 120 cc/hr D. 135 cc/hr E. 150 cc/hr
What is the difference between Enhanced 911 and 911? A. With Enhanced 911, operators are able to give instructions on how to perform CPR in the field B. With Enhanced 911, EMS response times are under 10 minutes C. With Enhanced 911, ALS units are available, whereas with 911 only BLS units are available D. With Enhanced 911, the caller’s location and phone number is automatically transmitted to the operator E. With Enhanced 911, calls are routed by type to specific specialized call centers
A 6yo child is brought in after rescue from a housefire. He is unconscious, and has soot in his nares. You perform rapid sequence intubation. Vital signs are: Temp 37.5, HR 120, BP 68/40, O2 saturation 100%. You note a cherry red color to his skin. What is the antidote most indicated? A. Methylene blue B. 2-PAM C. Hydroxocobalamin D. Sodium bicarbonate E. Naloxone
A 12yo boy with ALL, recent induction chemotherapy 2 weeks ago, presents to the ED with fever, RLQ abdominal pain, 2 episodes of watery diarrhea with streaks of blood, nausea but no vomiting. Denies ill contacts. On exam, temperature 38.4, HR 110, RR 24, BP 95/60. Alert, no nuchal rigidity, lungs clear to auscultation, heart RRR, abdomen mildly distended, RLQ tenderness, no rebound, decreased bowel sounds. Labs show an absolute neutrophil count of 100. KUB findings are similar to as shown here: pneumatosis The most appropriate next step would be: A. Consult surgeon for appendectomy B. Admit for IV antibiotics directed at treating infectious diarrhea C. Admit for empiric IV antibiotics to cover for fever and neutropenia D. Admit for broad spectrum antibiotics, make NPO, consult with surgeon, consider GCSF, for neutropenic enterocolitis E. Consult gastroenterologist for endoscopy to confirm pseudomembranous colitis
According to the Belmont report, the 3 main ethical principles for conducting research involving human subjects are: A) Beneficence, nonmaleficence, justice B) Respect for persons, beneficence, justice C) Respect for persons, beneficence, nonmaleficence D) Beneficence, justice, informed consent E) Nonmaleficence, justice, informed consent
A 17yo boy presents with severe sore throat for two days, and fever to 39. He has difficulty swallowing due to pain. He has no cough, congestion, nor ill contacts. His immunizations are up to date. On examination, he is alert, has no respiratory distress or stridor. His oropharynx has 2+ tonsils which are somewhat red, no exudate, no vesicles, no peritonsillar swelling. He has tender cervical lymphadenopathy and is very tender on palpation of his anterior neck at the level of the hyoid bone. The most appropriate management is: A. Obtain lateral neck X-ray in the ED and consult ENT specialist B. Consult ENT specialist to intubate the patient in the O.R. C. Give dexamethasone and penicillin-benzathine and discharge home D. Recommend supportive care for a viral URI E. Obtain a CT scan to evaluate for deep neck infection
A 12yo boy with very high risk ALL, recent chemotherapy 4 days prior, presents to the ED with fever and lethargy. Temperature is 39C, HR 180, RR 24, BP 80/50.  The patient is lethargic, has no nuchal rigidity, lungs are clear to auscultation, heart is tachycardic but regular rate and rhythm, abdominal exam is benign, and there is no rash. Pulses are bounding, there is flash capillary refill, skin is warm and dry. After adequate fluid resuscitation, cultures, and empiric antibiotics, the patient remains hypotensive. The next best treatment is: A. Dopamine IV at 5 mcg/kg/min B. Epinephrine IV at 0.1 mcg/kg/min C. Norepinephrine IV at 0.1 mcg/kg/min D. Dobutamine IV at 5 mcg/kg/min E. Hydrocortisone 1 mg/kg IV
All of the following preclude expectant outpatient management in the case of an ingested button battery found by imaging to be in the stomach except: A. Co-ingestion of a magnet B. Child complains of abdominal pain C. Child has history of constipation D. Battery is > 15mm diameter and has been present > 4 days in a child < 6 years old E. N/A; ingested batteries should always be endoscopically removed
A 6yo boy is in the ED with his third episode of intussusception over the past year. Previous episodes presented with colicky abdominal pain and stool guaiac positive, and were successfully managed using barium enemas. He has been completely well between episodes. What imaging study is indicated to assess for the most common cause of a pathologic lead point? A. Complete ultrasound of the abdomen B. Computed tomography of the abdomen with oral and IV contrast C. Upper gastrointestinal study with small bowel follow-through D. Technetium-99m-pertechnetate scintigraphy E. Magnetic resonance imaging of the abdomen
Which of the following is true of EMT scopes of practice (EMT-B = EMT-Basic, EMT-I = EMT-Intermediate, EMT-P = Paramedic)?
  1. Only EMT-I and Paramedic level EMT’s can administer oxygen
  2. Training to become an EMT-B is usually 100-150 hours
  3. Training to become a Paramedic is an additional 250 hours of training
  4. IV therapy may be given by EMT-I and EMT-P
A. 1 and 3 B. 2 and 4 C. 1, 2, and 3 D. 4 only E. All of the above
A 10yo was a rear seat passenger in a high-speed MVA, belted only with a lapbelt, and had a hyperflexion injury mechanism during impact. The patient cannot move his legs, and does not have lower extremity sensation to light touch or temperature sensation, but does have intact proprioception and vibration sense. What is the injury?
  1. Anterior cord syndrome
  2. Brown-Sequard cord syndrome
  3. Central cord syndrome
  4. Chance fracture
17yo boy with long legs and arms, h/o scoliosis and mild pectus excavatum, hyperextensibility of the thumbs, presents with sudden onset ripping quality chest pain and feeling lightheaded. On exam, patient is anxious appearing, afebrile, HR 105, BP 98/45, RR 14, pulse ox 98% RA, alert, HEENT non-revealing, Lungs BCTA, Cor RRR with mid-systolic click followed by a late systolic murmur at the apex, Abd soft ND NT, Extremities and Skin non-contributory.  Of the following, which diagnostic study is the best choice? A) POC troponin B) Arterial blood gas C) Bedside ultrasound looking for lung sliding D) CT angiogram E) CT abdomen
For aeromedical transport, transport mode transitions from helicopter to fixed wing aircraft when the distance from base station to patient pick-up location exceeds how many miles? A) 70 miles B) 150 miles C) 200 miles D) Distance is not a factor
A child is brought in with a stab wound to the right neck just superior to the cricoid cartilage. What zone of the neck is this? What is the significance of the zones?
A 2 year old is brought in that has chewed on an electrical cord. He has a scab in the corner of his mouth and no active bleeding and is otherwise well appearing with no other trauma. What delayed complication can occur?
In a population of 1,000 people, 100 have a disease. A test is positive in 95 people with the disease and 100 people without the disease. What is the sensitivity, specificity, and positive predictive value of this test?

Controversies

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You are seeing a 14 year old high school Freshman brought in for minor cold symptoms consisting of sporadic dry cough and nasal congestion. There is no fever, and the patient is negative for COVID, RSV, and influenza. The patient is well appearing and spends the majority of the visit on her mobile phone. The parent asks for a school note. What duration of time off from school do you typically give on the school note?

[poll id="74"]

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The AAP Otitis Media (OM) guidelines note that the majority of OM spontaneously resolves, with a number needed to treat (NNT) with antibiotics of 15-20 in low risk cases. Clinicians and parents can elect an "observation option" in select patients that are nontoxic, have temperature < 39 C, have had ear pain for < 48 hours, and have mild ear pain, and have no otorrhea; this applies to children aged 6-23 months with unilateral OM, and children > 24 months with bilateral OM. If symptoms persist for 48-72 hours, then antibiotics should be started.

[poll id="73"]

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If due to a combination of low rates due to public health measures, low risk due to vaccinations and treatments available, COVID is under control and poses no additional morbidity or mortality risk to you, your family, or your patients, and your hospital no longer requires masks for patients or physicians, would you still wear a mask for your PED shifts?

[poll id="72"]

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[poll id="70"]

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You are seeing a child who has been passing infrequent stools, and when the child does stool, the stools are hard.

[poll id="69"]

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How should ED's handle patients with mild URI symptoms who mostly want a COVID test?

[poll id="68"]

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[poll id="67"]

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[poll id="66"]

(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 your thought processes and the evidence behind your decisions. We can learn from each other!

You are seeing a 30 day old full term infant whose parents thought the baby felt warm, checked the temperature with an infrared mid-forehead thermometer, and it read 100.4. They did not give any antipyretics and came straight to the ED. The rectal temperature in the ED is 99. Mother received prenatal care, there were no complications, and she was GBS negative. There are no ill contacts and the baby is well-appearing and feeding normally.

[poll id="65"]

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You're seeing a child with CT-confirmed uncomplicated appendicitis. The child has had symptoms for 12 hours, and pain is well controlled with medications. You've given IV antibiotics. You're informed by utilization review that the child is not approved to stay at your hospital and must be transferred according to the insurance plan; the transfer will take 4-8 hours to coordinate.

[poll id="64"]

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The new AAP Subcommittee on the Febrile Infant guidelines for managing febrile 8-60 day olds gives the option to perform an LP for febrile 22-28 day olds only if inflammatory markers, if obtained, are abnormal (Temp > 38.5, Procalcitonin > 0.5 ng/mL, CRP > 20 mg/dL, ANC > 4500-5200). This is an option even for the infant with a + UA. If an LP is not performed, they do recommend admission to the hospital and treatment with parenteral antibiotics. This is a change from prior practice, where concerns about masking meningitis obviated administration of parenteral antibiotics without performing the LP. What are your thoughts?

[poll id="63"]

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You are seeing a child who has had a self-resolving 5 minute generalized tonic-clonic seizure for the first time. The patient is afebrile, previously healthy, and has a normal non-focal neurologic exam. There is no evidence on your evaluation of another cause for the seizure, such as meningitis or a toxicological cause. There is no associated headache or vomiting. Family history if non-contributory. MRI is unavailable from the ED.

[poll id="62"]

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[poll id="61"]

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[poll id="60"]

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[poll id="59"]

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[poll id="58"]

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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 house. The baby's venous blood gas shows a pH of 6.9, PCO2 80. The baby has inadequate respirations. Which do you decide to do?

[poll id="57"]

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You have diagnosed an 11 year old boy who has a PMH of mild intermittent asthma with COVID (he has been symptomatic with fever, vomiting, cough, and myalgias for 2 days). Currently, his RR is 20, SaO2 98% on room air, and his lungs are clear to auscultation. He has home albuterol MDI with spacer available. You discharge him with a portable pulse oximeter. For what persistent SaO2 would you tell the parent to bring him back to the ED?

[poll id="56"]

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[poll id="55"]

(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 your thought processes and the evidence behind your decisions. We can learn from each other! A 17mo old is brought in for rhinorrhea and mild cough. The patient is well-appearing, has no past medical history, is not on any medications, and is up to date on immunizations. Physical examination is normal. Vital signs are: temperature 35.8 rectal, heart rate 100, respiratory rate 24, blood pressure 85/42, pulse ox 100% on room air. The child is wearing a standard hospital gown and was brought in wearing appropriate clothing for the ambient mild outdoor weather. What would you do given the hypothermic rectal temperature? [poll id="54"]  
(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 your thought processes and the evidence behind your decisions. We can learn from each other! A recent randomized controlled trial by the CODA collaborative found a 10-day course of antibiotics to be non-inferior to appendectomy in adult, with 30-day health status as the primary outcome. By 90 days of follow-up, 29% of the antibiotics group had undergone appendectomy. Complications were more common in the antibiotics group, but not in the subgroup with no appendicolith. If you were seeing a young healthy male with acute appendicitis of short duration, afebrile, normal labs, no appendicolith, mild pain, tolerating oral intake, would you consider treating with antibiotics only? [poll id="53"]
(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 your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="52"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 9 year old with a knee laceration IMG_1416 [poll id="51"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Your emergency medicine colleague has a 7mo old, immunized, well-appearing, no PMH, with a fever of 40 C and no other symptoms. They have been scrupulously self-isolating, wiping down packages, etc. Your colleague has adhered to maximal PPE use including using N95s usually at work. No one around the child has been symptomatic. Your colleague asks what work-up you suggest in this era of COVID. [poll id="50"]
(Click the link to comment and to vote – voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 3yo child whose parents are essential workers and have recently tested positive for COVID-19. The child has had 3 days of fever, vomiting and diarrhea a few times per day with intermittent mild abdominal pain, and has a nonspecific blanching macular rash on the trunk and somewhat on the extremities. The child is well-appearing with good perfusion and hemodynamically stable, but is febrile in the ED. There are no respiratory symptoms, distress, nor hypoxia. [poll id="49"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="48"]
(Click the link to comment and to vote – voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! With the COVID-19 pandemic, PED volumes are low nationwide. A recent SAEM COVID-19 national grand rounds webinar suggested that PED's, to help out inundated adult ED's, might see adult patients up to age 35 years. I tried to pick the most common ages, but feel free to comment with specifics! [poll id="47"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Couldn't put every possibility, so pick the one closest to what you are doing. Also, your choice may depend on your hospital's recommendations and your PPE availability [poll id="46"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Parents bring a 15mo old non-black uncircumcised well-appearing fully immunized male with 3 hours of fever and no other symptoms. His temperature is 39 C. You find no clear source for the fever on exam. It is wintertime and his siblings all have URIs but this patient has no cough or congestion. He has not had any prior UTIs. Do you catheterize him for urine to rule out UTI? [poll id="45"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Reviving an old one since it's pretty relevant again. Added some commentary in the Comments section. [poll id="19"]
Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="44"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="43"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! A 7 year old boy presents after injuring his lateral soft palate with a straw. He is completely asymptomatic and exam other than what is shown is normal. Palate injury [poll id="42"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="41"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Bilimeters are devices that measure bilirubin transcutaneously (ie without drawing blood). They work by directing light into the neonate's skin and then measuring the intensity of specific wavelengths that return, and using this information to calculate bilirubin level. [poll id="40"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="39"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 15 month old brought in for simple febrile seizure lasting 2 minutes. The child is back to baseline and well appearing. The vital signs are temperature 40.4 C, HR 175, RR 30, BP 80/40. Exam reveals no source for infection. The child has no vaccinations at all by parent choice. [poll id="38"]  
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="37"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="36"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 4 year old child in significant distress due to a headache, which he has had for 2 days. It is bilateral, frontotemporal, not sudden onset, never had before. No associated fever, vomiting, neurologic abnormalities, relevant past medical history. Do you image? [poll id="35"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="34"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 29 day old afebrile former 35 weeker brought in by ambulance. The patient was given a few sips of "gripe water" for runny nose, appeared to choke and gasp for air, turned blue briefly, then recovered. The entire episode was about a minute. There was no tone change. The baby has no birth complications. The baby's vital signs and physical exam are normal in the ED, pulse ox is 100% on room air, RSV testing is negative. What would be your management? [poll id="33"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 14 month old whose parents have chosen not to vaccinate him. He has a fever of 39.2 for one day and no other symptoms. He is circumcised. He appears well and has no known ill contacts. His physical examination is unremarkable. [poll id="32"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! It's the day after Thanksgiving, and your patient just ate a bunch of leftovers before getting into an automobile accident. You are intubating, and hoping the patient doesn't aspirate during the procedure. A medical student asks whether he should apply cricoid pressure for you. [poll id="31"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 19 year old with a history of illicit drug use brought in with sudden onset cardiac arrest. He received bystander CPR immediately after the arrest, and is in a ventricular fibrillation rhythm that has persisted despite 5 shocks, epinephrine, and amiodarone following the ACLS algorithm. [poll id="30"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 3 year old with 2nd lifetime episode of SVT. The patient has no other prior PMH, was not on any medications, was healthy prior, and does not have WPW. After 2 doses of properly administered adenosine, the patient is still in SVT. She is alert, not toxic, has good perfusion, and is not hypotensive. [poll id="29"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 4 year old in status epilepticus. The patient is not on anti-epileptics at home. The patient has received benzodiazepines x 3 and fosphenytoin 20 mg/kg. Glucose and electrolytes are normal. The patient is afebrile. [poll id="28"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a patient with a simple small abscess and no or minimal overlying cellulitis, nontoxic and afebrile, immunizations up to date, no prior abscesses. After successful incision and drainage, what treatment would you give? [poll id="27"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! An 8yo patient with history of mild intermittent asthma comes in with an acute exacerbation that clears readily with 1 treatment of nebulized albuterol. The patient has had 2 similar ED visits in the last 3 months. The patient has an albuterol MDI for home use, but no spacer. The patient is not on any controller medications. The respiratory therapist has taught the patient/parents how to use the MDI properly with a spacer, and you are discharging the patient home. [poll id="26"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 4 year old with 1 day of limp and now, refusal to bear weight. He is afebrile. On exam, his hip is irritable to passive external and internal rotation. He holds his hip slightly externally rotated. His CBC WBC is 8,400 with 50% neutrophils, and his ESR is 20. His plain films are normal. He has reliable parents and an assigned pediatrician who can see him the next day. [poll id="25"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="24"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! For pediatric blunt trauma patients... [poll id="23"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! A repeat - since we are in the throes of influenza season right now, and this is a particularly controversial issue. Many emergency medicine FOAM bloggers have argued against the use of oseltamivir, such as here. But, the CDC continues to recommend it for high risk patients presenting with < 48 hours of symptoms, citing their reasoning here. To complicate things further, the "definition" of influenza-like illness basically includes nearly all kids seen in the ED in the wintertime - fever and cough or sore throat, and point-of-care tests are not very sensitive. [poll id="19"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! Got this one from a recent EM physician facebook group post. You see a mother with symptoms of influenza. Her 3 day old asymptomatic full-term infant is tested and is POC influenza+. There is good follow-up and the patient is healthy, afebrile, feeding well, etc. [poll id="22"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! You are seeing a 10 week old infant with a 38 degree fever of 6 hours duration. He has mild rhinorrhea as does Dad. He is otherwise well and feeding well. Point of care RSV and influenza are negative, and urine shows no pyuria or bacteriuria. Review of the chart shows mom was GBS+ and was treated with intrapartum penicillin as recommended. Baby was observed for 2 days in the nursery but not treated with antibiotics. [poll id="21"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="20"]
(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! [poll id="19"]
A 2 month old was seen in the ED 36 hours ago with a temperature of 39.2. The CBC had a WBC of 11.2 with 70% lymphocytes and no bandemia. Urinalysis was negative. The lab calls you to report that 1 of 2 blood culture bottles is growing gram positive cocci in clusters. You call the patient and the parent reports that he is doing well, is now thought to be afebrile (tactile, parents have not checked the temperature in 24 hours), and is feeding well. What do you do? (Click the link to comment and to vote - voting not working through email, sorry!) [poll id="18"]
You are about to incise and drain a relatively small simple abscess in a healthy child. (Click the link to comment and to vote - voting not working through email, sorry!) [poll id="17"]
Do you do a CT and LP on all complex febrile seizure patients? [poll id="16"]
What do you include in your GI cocktail for adolescents? [poll id="15"]
You are seeing a 4 year old with a deep cheek laceration with irregular margins, under some tension. The parents express concerns about scarring, and they are also concerned that their child will definitely not be able to stay still for repair or for suture removal. Plastic surgery is unavailable, and the parents are amenable to having you repair the laceration with procedural sedation. Forheadlac (Source: Closing the Gap https://lacerationrepair.com) [poll id="14"]
You are seeing a 5 year old with intermittent LLQ abdominal pain for a month. She is well appearing and has a benign abdominal exam. She is eating normally, not vomiting, and has no fever or diarrhea. The parents deny constipation or hard stools, but you suspect constipation is the diagnosis. [poll id="13"]
You are seeing a 6 week old ex-full term infant who is breastfeeding exclusively, having 6 wet diapers per day, 4 or more soft seedy stools per day, growing well, and no fever. Baby has been jaundiced since 1st week of life, and while it is not worse, parents come in because it is prolonged. Jaundice is to the level of the chest, and transcutaneous bili is 10. [poll id="12"]
It's RSV season and you're seeing a 30 day old ex-39 week infant with a runny nose. The resident has ordered a POC RSV, which is positive. The baby is afebrile, feeding well, and nontoxic. Do you admit the infant just for being RSV positive due to the risk of apnea in this age group? [poll id="11"]
You are seeing a 6 year old with a wet-sounding cough for 4 days and fever to 39 C for 3 days. You hear crackles in the right lower lobe; there is no wheezing. CXR shows no infiltrates. Do you diagnose a "clinical pneumonia" with false negative CXR and treat with antibiotics? [poll id="10"]
Vote! But for something other than President... You are seeing a 3mo old with clinical bronchiolitis who is otherwise well-appearing, tolerating po's, not in significant respiratory distress, afebrile, has good follow-up. At what O2 sat do you admit the patient for supplementary O2? The AAP says: aap-bronchiolitis-o2-sat [poll id="9"]
3 week old infant is brought in with fever of 38.5. The baby is well appearing and does not have any high risk factors in the birth history. You plan to get urine, blood, and CSF cultures and give empiric IV antibiotics. [poll id="8"]
You are seeing a 35 month old boy with fever and sore throat x 2 days. He has no cough or runny nose, but his sister also had fever and sore throat recently, and his mom has a cough. His temp is 38.5. He has no tonsillar exudate or palatal petechiae, and only tender cervical lymphadenopathy. He is otherwise well appearing, previously healthy, and is well hydrated. [poll id="6"]
Nearly 3 year old girl was eating nuts and had a coughing episode. 6 year old sibling told parents "she's choking on the nuts." In the ED, patient is completely asymptomatic, has a normal CXR and a 100% O2 sat on room air. [poll id="7"]
You are seeing a 15 month old female with 36 hours of fever, current temp in ED 38.9 rectal (last antipyretic 6 hours prior), no other symptoms, well-appearing, no past medical history. Which would you do? [poll id="5"]
How much work-up do you do in the well-appearing, term, feeding, 29-60 day old infant with low-grade fever (38-38.5) without source? What about the 61-89 day old? [poll id="2"]
You're seeing a febrile well-appearing 29-60 day old with clear lab evidence of UTI and benign CBC. Do you do an LP? Do you admit and do you give parenteral antibiotics? What about for a 61-90 day old?
When was the last time you saw a kid have a paradoxical reaction to a benzo and how did you treat it? a. Wait it out b. More benzos c. Flumazenil d. Haldol e. Something else???  Have heard precedex, ketamine, propofol all suggested. Click post to read and add comments
You're seeing a 10yo who weighs 40 kg for acute asthma exacerbation. Do you give decadron or prednisone? If you give decadron, do you give 0.6 mg/kg or a lower dose? What is your maximum dose of decadron for asthma? Click post to read and add comments [poll id="4"]

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