PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "procedures"

PEM Questions

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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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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. 

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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.

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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.

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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. 

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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?

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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. 

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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?

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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.

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

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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. 

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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?

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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. 

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(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!) 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"]
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(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!) 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!) You have sutured a 2cm forhead laceration on a 4yo boy using 6-0 nylon sutures. [yop_poll id="15"]
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 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

Tips and Tricks

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!

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

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.

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.

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

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! 

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

Controversies

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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!

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

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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!

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(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! [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! [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! 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 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"]
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"]
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"]
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"]

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