PEM Source

Your source for all things Pediatric Emergency Medicine

All posts with tag: "pharm"

Tips and Tricks

What organisms do Cephalosporins not cover? Remember LAME: Listeria, Atypicals, MRSA, and Enterococci

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: https://pemsource.org/2023/03/17/administering-eye-drops/

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.

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).

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.

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!

From https://www.ophthobasics.com/medications

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.

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.

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.

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  
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).
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.
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.
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)
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
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

PEM Questions

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You are seeing a 16-year-old boy who was walking home from school when he experienced sudden onset of intense dread, racing heartbeat, dizziness, difficulty breathing, tingling in his fingertips, and trembling. His friend called 911 and he was brought in by ambulance. Although many of his symptoms have improved, he remains nervous-appearing and mildly tremulous. He denies any drug intake or intake of other substances, supplements. He does not recall thinking about anything stressful prior to his symptom onset. Vital signs are temp 37.6, HR 90, RR 20, BP 110/60, O2 sat 99% on room air. His physical and neurologic exams are normal.

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Which of the following otherwise well-appearing non-toxic patients with a low-grade fever from viral URI should NOT take ibuprofen?

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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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A 20-month old child is brought in by ambulance for lethargy and altered mental status. You find out his grandmother has been administering frequent doses of milk of magnesia to treat constipation. You suspect hypermagnesemia. 

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Parents bring in their 11 month old baby for a new-onset rash. The baby is unimmunized by parent choice. The baby had fever for the last 3 days to a maximum of 104 F. Although he had fever, he was well-appearing and still eating normally and playful. But since the fever was persistent, they took him to a clinic yesterday and he was diagnosed with a throat infection and started on amoxicillin. He has received 2 doses. Today he awoke with a fine morbilliform blanching pink rash that started on the neck and trunk, then has spread to the face and extremities. It does not seem itchy and it does not involve the mucosa. The only other medication he has had was acetaminophen yesterday at 5pm. On exam, he is nontoxic and interactive. Vital signs: temp 98.9 F, HR 132, RR 28, O2 sat 99% on room air. ENT, chest, and abdomen exams are unremarkable. 

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You are seeing a 3-year-old boy with 2 days of fever to a maximum of 102.7 F, an urticarial rash (but no enanthem), and significant arthralgias. The individual urticarial lesions are not transient, but rather present for more than 24 hours. He is not toxic but appears miserable. He was diagnosed with acute otitis media 8 days ago and is on day 8 of a 10-day amoxicillin course. 

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You are seeing a 6 year old with 1 ½ weeks of cough, nasal congestion, and malaise. Initially, he seemed to be improving a bit, but now for the last 2 days he has a fever and worsened cough, post-tussive and spontaneous vomiting, as well as a new sore throat and conjunctival injection. His vital signs are: temperature is 38.2, HR 110, RR 32, and pulse ox 96% on room air. On exam he is nontoxic but has some crackles heard bilaterally. Your plan is to treat him with azithromycin for community-acquired pneumonia, pseudoephedrine during the day and diphenhydramine at night for his nasal congestion, and ondansetron for his vomiting. 

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Your next patient, actually your next 10 patients, are brought in by their parents because they have been coughing for 2 weeks. Match the characteristic of the cough with the appropriate treatment (you may use letters twice or not at all). (Cannot answer on-line – jot down your answers and then check back for discussion).

  1. Dry cough worse at night and when out in the cold air
  2. Cough that sounds like a seal or dog barking
  3. Cough with an inspiration between each cough (staccato cough)
  4. Wet phlegmy cough accompanied by nasal congestion
  5. Paroxysms of cough with post-tussive vomiting
  1. Albuterol
  2. Amoxicillin
  3. Azithromycin
  4. Dark honey
  5. Dexamethasone

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You are working locum tenens in Breckenridge, Colorado, and see a 2 year old boy with irritability, vomiting, and poor appetite. He has no fever or diarrhea and no one else in his family is affected. The family landed in the Denver airport the night before and drove to Breckenridge. The patient awoke this morning with these symptoms. 

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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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During the recent “tri-demic” of influenza, RSV, and COVID disease, there was also a nationwide shortage of common oral liquid antibiotics used to treat otitis media. Which of the following antibiotics is recommended in the 2013 AAP guidelines as an alternative to amoxicillin to treat acute otitis media?

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COVID is on the rise again, with a more transmissible and immune-evading variant. Nirmatrelvir-ritonavir (brand name Paxlovid) is approved for children 12 years and older AND weighing 40 kg or more in high-risk situations.

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You are seeing a 5 year old child with known adrenal insufficiency with fluid and pressor-resistant hypotension. You wish to give stress-dose steroids. 

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You are seeing an 18 month old girl with chief complaint of itchy scalp and rash at the nape of her neck just below her hairline. On examination, you note nits but do not see any live lice. The parents have not performed any treatments for lice. 

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A 14-month old boy presents with altered mental status. He has had 2 days of vomiting and diarrhea, but no fever. He weighs 10 kg. Bedside blood glucose measurement is 38 mg/dL. A 22 gauge peripheral IV is obtained in his right hand.

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You are seeing an 8 year old girl who was prescribed an oral cephalosporin antibiotic 1 week ago for rhinitis. She has 3 more days until she finishes the course. Now she has developed an itchy urticarial-like rash, although it is more fixed than urticaria typically are (does not move around nor come and go). She also has some generalized mild arthralgias and a low-grade fever to 100.2 F. 

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A seven day old neonate is brought in for a fever of 38.5 and lethargy. The baby had a home birth, and the parents have chosen a “lotus birth,” or umbilical nonseverance. The placenta remains attached to the newborn (carried around with the baby, often in a small bag), until it separates on its own, typically in 5-15 days. 

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You are seeing a 10 day old ex-full term infant with bilateral watery mucoid eye discharge, mild eyelid edema, and papillary conjunctivitis. You suspect chlamydial conjunctivitis. What is the best management?

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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 a 3 year old ill-appearing child with high fever and rash. She initially started with tender erythema in her skin folds, progressing over the next 48 hours to diffuse erythema with flaccid desquamating bullae and yellow crusting around the eyes and mouth. Nikolsky sign is positive. There is no mucous membrane involvement. She was given ibuprofen at home after onset of the fever. 

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You are seeing a previously healthy 9-month old boy brought in for rash. The child had 3 days of fever. He was seen yesterday evening at an urgent care and diagnosed with otitis media and prescribed amoxicillin. He has never taken any antibiotics before. This morning, his fever was gone, but he developed a blanching pink maculopapular rash on the torso that spread to the extremities and face later in the afternoon. He does not seem to be itchy. He has been well appearing and eating normally throughout his illness. 

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A 16yo patient is brought in directly from a large “pharm” party with altered mental status, respiratory depression, and pinpoint pupils. You suspect opiate overdose and administer naloxone with improvement in spontaneous respirations. To your surprise, however, the qualitative urine drug screen comes back negative for opiates. Which of the following drugs is the patient unlikely to have taken?

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You are seeing a 3 year old child with acute onset draining right ear. The child has no fever and no history of recent swimming or other risk factors for otitis externa. The child has a PMH of frequent otitis media, and pressure equalization (tympanostomy) tubes were placed at age 1 year. There have been no episodes of otitis media since then. As far as the parents know, the tubes are still in place, but they have not had any follow-up with an ENT. On exam, the left ear canal has a PE tube laying in the canal, which you remove; the tympanic membrane is translucent and mobile. The right canal is full of seropurulent drainage. You cannot see the tympanic membrane nor any PE tube. The canal itself is not swollen or red. 

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(Click the link to comment and to vote - voting not working through email, sorry!) EMS is bringing you a 10yo patient that has been actively seizing for 20 minutes. They are unable to obtain IV access. [yop_poll id="177"]
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Match the child with acute otitis media to appropriate therapy per AAP guidelines (all children well-appearing, non-toxic, no distress or indications of severe otalgia, symptomatic for 1 day, and have not had recent antibiotics in the last 30 days):

Child A) 5mo old with bilateral otitis media, afebrile

Child B) 18mo old with unilateral otitis media, fever to 38.5, penicillin-allergic

Child C) 27mo old with bilateral otitis media and bilateral purulent conjunctivitis and fever to 39.1

Child D) 37mo old with unilateral otitis media, fever to 39.5, penicillin-allergic

  1. Oral analgesic
  2. Amoxicillin 90 mg/kg/day divided BID
  3. Amoxicillin-Clavulanate 90 mg/kg/day divided BID
  4. Cefdinir 14 mg/kg/day
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(Click the link to comment and to vote - voting not working through email, sorry!) EMS has brought in an 8 month old child who had a generalized tonic-clonic seizure at home. The child has a history of 2 prior febrile seizures, starting at age 6 months, and is not on any long-term anticonvulsants. There is no other significant PMH. The child was given IM Ativan 1mg by EMS with resolution after 10 total minutes of seizure. Vital signs are temp 37.9, HR 160, RR 10, BP 72/42, O2 sat 90% room air, weight 7 kg, POC glucose 110. An IV is now in place. What is the MOST appropriate first intervention, assuming all can be instituted within the same amount of time? [yop_poll id="128"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 6 year old boy with a few days of episodes of crying and jaw clenching, decreased oral intake, and intermittent painful muscle spasms causing him to arch his neck and back. He cannot control or stop the spasms, but is otherwise alert. He visited a cousin’s farm 6 days ago where he played with a goat, drank unpasteurized milk, sustained a small laceration to his scalp that was allowed to heal on its own, and had a tick on him that was pulled off by his mother that evening. He is unimmunized by parent choice. He has received no medications and has no PMH. His temperature is 38.2, HR 140, RR 20, BP 130/65. O2 sat 97% on room air. [yop_poll id="126"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 17yo boy with cough x 1 month. You prescribe Tessalon Perles (benzonatate). He has a 2yo sibling at home. [yop_poll id="105"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a child with suspected methemoglobinemia from overuse of benzocaine teething gel. You plan to treat with methylene blue. Which of the following past medical history conditions makes methylene blue a contraindicated treatment? [yop_poll id="101"]
(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a pair of 14 year old girls who took “Triple C” at a party. One is altered and the other is hallucinating. In addition, they are tachycardic. [yop_poll id="98"]
(Click the link to comment and to vote - voting not working through email, sorry!) Which of the following topical antibiotics has the least efficacy against impetigo? (see pictures of impetigo here and a short article here) [yop_poll id="88"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="77"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old girl presents with a 2 cm tender lump in her right armpit. It is not fluctuant and there is no overlying redness. On history, she has a kitten, and did sustain scratches to her right hand from the kitten in the last few weeks. She had a small papule on her hand in an area of a scratch 1.5 weeks ago that mom thought was a bug bite. Parents are unsure if she has had any fevers. She is otherwise healthy and well appearing. [yop_poll id="70"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 19yo man was seen in the ED 2 weeks ago with a painless lesion to his penis. He is sexually active with men, has had 2 recent partners, and “sometimes forgets” to use condoms. At that time testing for HIV, RPR, gonorrhea, and chlamydia urine NAT were performed at the time and he was treated empirically with IM bicillin for presumed chancre of syphilis and empiric IM ceftriaxone for gonorrhea. All of the labs were subsequently negative. He now returns with bilateral tender inflamed inguinal adenopathy. His penile lesion resolved after a few days. [yop_poll id="68"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5yo girl comes in for chest pain for 6 hours and is noted to have a heart rate of 250 that is not varying. Review of the electronic medical record reveals a history of WPW. Mom says she has not had an episode of fast heart rate since age 3 weeks when she was first diagnosed. She is not on any medications. She is awake and alert, and her blood pressure is 85/45. SVT WPW 1 [yop_poll id="67"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 17yo boy presents with a round lesion similar to that noted below, but on his penis, noted 1 hour after taking a dose of TMP-SMX that was prescribed to him for “stomach infection.” He had 2 episodes of non-bloody diarrhea 2 days ago and went to a clinic and received the prescription, which he was unable to fill until today. The diarrhea has actually improved. He has no fever. The rash is not painful or itchy. He mentions that he previously had a similar rash in the same place after taking the same drug a few years ago. Fixed drug eruptionWikimedia Commons Donald M. Pillsbury, M.D., and Clarence S. Livingood [yop_poll id="60"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 month old comes in with diarrhea x 3 days, 5 times per day initially now 3 times per day, non-bloody, no fever, no vomiting. The patient was seen in the ED the day before, and had stool culture sent which was negative, C. difficile toxin which was positive, and stool WBC negative. [yop_poll id="51"]
(Click the link to comment and to vote - voting not working through email, sorry!) D5 ¼ NS is no longer recommended for maintenance fluids in hospitalized young infants. Why not? [yop_poll id="45"]
A 19yo man presents with his 3rd bout of unremitting nausea and vomiting. He has been admitted twice before and treated with ondansetron and IV fluids. He was noted to take frequent long showers while admitted. (Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="8"]
A 7yo patient with peanut allergy at a rice krispy treat at a birthday party and discovered afterwards that it was made with peanut butter. She presents with hives, mild swelling of her lower lip and periorbital, and some faint wheezes. O2 sat is 99% on room air. Vital signs are temp 37.6, HR 120, RR 28, BP 90/60. What is your first priority treatment? A. Diphenhydramine 1.25 mg/kg IV B. Epinephrine 0.01 mg/kg of 1mg/mL solution IM C. Methylprednisolone 2 mg/kg IV D. Normal saline 20 cc/kg IV E. RSI and prophylactic intubation 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

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!

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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!

You are seeing a child who has been passing infrequent stools, and when the child does stool, the stools are hard.

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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!

[poll id="59"]

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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!

[poll id="58"]

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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!

[poll id="55"]

(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! [poll id="52"]
(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! Reviving an old one since it's pretty relevant again. Added some commentary in the Comments section. [poll id="19"]
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="44"]
(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="36"]
(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="34"]
(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 in status epilepticus. The patient is not on anti-epileptics at home. The patient has received benzodiazepines x 3 and fosphenytoin 20 mg/kg. Glucose and electrolytes are normal. The patient is afebrile. [poll id="28"]
(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 patient with a simple small abscess and no or minimal overlying cellulitis, nontoxic and afebrile, immunizations up to date, no prior abscesses. After successful incision and drainage, what treatment would you give? [poll id="27"]
(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="24"]
(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! A repeat - since we are in the throes of influenza season right now, and this is a particularly controversial issue. Many emergency medicine FOAM bloggers have argued against the use of oseltamivir, such as here. But, the CDC continues to recommend it for high risk patients presenting with < 48 hours of symptoms, citing their reasoning here. To complicate things further, the "definition" of influenza-like illness basically includes nearly all kids seen in the ED in the wintertime - fever and cough or sore throat, and point-of-care tests are not very sensitive. [poll id="19"]
(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="19"]
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"]
What do you include in your GI cocktail for adolescents? [poll id="15"]

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