Season / Sit out Previous injury Other sports / activities Right or Left handed Team (school, club, or just for fun) Sanity Besides the usual how did it happen, where does it hurt, did you feel a pop, could you… Continue Reading →
Am I the only one that has trouble remembering inversion vs. eversion of the ankle? Just remember that the most common “rolling of the ankle injury” is inversion, i.e. that’s the most popular, or “in” version. The ankle sprain that… Continue Reading →
There are several online trackers that report one’s local geographic environmental risk for health-related hazards. Enter your zip code or check the map and find out your current status. Here are some to know about: Heat illness risk cdc.gov/heatrisk Pollen… Continue Reading →
The lower extremity IO placement sites from medial to lateral are 1-3cm above the medial malleolus at the distal tibia, 1-3cm below the tibial tuberosity on the flat anteromedial proximal tibia, and 1-3cm above the patella in the midline of… Continue Reading →
The latest version of PEM Guides from Michael Mojica and the PEM division at NYU is out. PEM Guides is updated annually, and provides a great concise PEM reference. From the creators of PEM Guides: PEM Guides Version 11.0 (2024)… Continue Reading →
Just read a PED-EM-L post from Todd Z (in response to a questioner wanting to improve Press Ganey scores) that really resonated. Customer (parent) satisfaction is an important part of the ED visit, even if you are not beholden to… Continue Reading →
The ABCDEFG of tox-caused bradycardia Alpha-2 agonists (e.g. clonidine) Beta-blocker Calcium channel blocker Digitalis ETOH Fentanyl and other opiates Gardening (pesticides with organophosphates)
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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’… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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! Also, here is a great table giving a summary… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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;… Continue Reading →
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… Continue Reading →
Of course, we’re going to test everyone for COVID, but this handy chart from National Jewish helps differentiate the common symptoms and course of COVID-19 with those of colds, influenza, and allergies
Everyone knows it’s nearly impossible to memorize all the formulas and doses relative to pediatric emergency medicine. That’s why 2 pediatric emergency medicine physicians created http://pocketpem.com/ when they were PEM fellows. Log on for a plethora of PEM info; maybe even bookmark… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
bonepit.com is a great website for learning radiology. Specifically go to their Normal for age page to see normal skeletal radiographs by age and gender!
To remember the difference in antibiotic regimens for chlamydia cervicitis / urethritis vs pelvic inflammatory disease, rap this in your head: Ceph 10 x 50 for GC is nifty; give Zith 1 gram for the chlam, but doxy 14 days… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
Here’s a quick and dirty method to recall developmental milestones 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… Continue Reading →
The Coach at PEMPlaybook.org has a great podcast on using the VBG in situations where we used to try to get an ABG (which was never fun to do in small children). From the podcast: the rule of 4’s: (note… Continue Reading →
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… Continue Reading →
Two tips for intubating the obese patient: 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 Position yourself: keep… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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,… Continue Reading →
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… Continue Reading →
Your local hospital cafeteria can be a useful resource in managing your PED patients: Sugar liberally applied to the edema of a paraphimosis or rectal prolapse may help decrease swelling and improve reduction efforts A mayonnaise packet provides useful lubricant… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
Some tips and tricks for examining children’s throats: Don’t do it until after you’ve gotten your lung, heart, and abdomen exam – once you make them cry, it’s game over A helpful position for young children is to sit on… Continue Reading →
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…. Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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… Continue Reading →
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. Here are instructions put together by Seth, and a video of… Continue Reading →
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… Continue Reading →
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.
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… Continue Reading →
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)
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