PEM Source

Your source for all things Pediatric Emergency Medicine

Tips and Tricks

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:

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 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: and 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 (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

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!


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: 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 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 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 - 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
  • 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
  • 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 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    
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: and
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 Also, this site provides a nice overview of the numerous methods 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 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
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 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
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:
Thanks to Tim Horeczko 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, See this discussed in an 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 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: The "Fast-cath" technique advocates using a 14 gauge angiocath 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.
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's latest podcast on GI bleeding) glass_test-focus-none-width-800 (From  
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 ( For additional methods, see AliEM's great tricks of the trade post at:
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)

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