PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "labs"

PEM Questions

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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. 

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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. 

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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. 

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(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"]
(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!) 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!) 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
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(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"]

Tips and Tricks

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. 

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  

Controversies

(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"]

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