PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "neonate"

PEM Questions

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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?

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

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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. 

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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
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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. 

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Tips and Tricks

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.

Controversies

(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.

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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!

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?

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