Pediatric Emergency Playbook

Guess or Process? Abductive Clinical Reasoning: a PEM Primer

List or Gist? Inductive Clinical Reasoning: a PEM Primer

Harpoon or Hook? Deductive Clinical Reasoning: a PEM Primer

Knee Pain

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Anaphylaxis

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Strep Throat

Does Your Patient Have Streptococcal Pharyngitis? No Problem -- I'll just Swab. Not So Fast... Fagan Nomogram for Likelihood Ratios 1. Decide on your pre-test probability of the disease (choose an approximate probability based on our assessment) 2. Use the likelihood ratio that correlates to your exam. 3. Draw a straight line frm your pre-test probability starting point, to the LR of the feauture/test, take it through to find your post-test probability 4. Use this new post-test probability to he...

Concussion

How do we make the diagnosis? What now? Concussion in Sport Group Guidelines Concussion Recognition Tool (for coaches, trainers on field) Child Sports Concussion Assessment Tool, 5th Ed. (Child SCAT); Ages 5-12 Sports Concussion Assessment Tool, 5th Ed. (SCAT5); Ages 13 and Up This post and podcast are dedicated to the great K Kay Moody, DO, MPH for her stalwart effort to care for both patient and doctor. Thank you for all that you do to help us to be our best and for promoting #FOAMed #FOAMped ...

EKG Killers: Part Two

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EKG Killers: Part One

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Hypertension in Children

References Baracco R et al. Pediatric Hypertensive Emergencies. Curr Hypertens Rep . 2014; 16:456. Belsha CW. Pediatric Hypertension in the Emergency Department. Ann Emerg Med . 2008; 51(3):21-24. Chandar J et al. Hypertensive crisis in children. Pediatr Nephrol. 2012; 27:741-751. Dionne JM et al. Hypertension Canada’s 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension. Canadian J Cardiol . 2017; 33:577-585 *Flynn JT, Kaelber DC, Baker-Smith CM, et...

The Fussy Infant

A Social Visit or Your Most Dangerous Presentation Tonight? [Details in Audio] This post and podcast are dedicated to Henry Goldstein, B.Pharm, MBBS for his tireless dedication to all things #FOAMed, #FOAMped, and #MedEd. You are awesome. Make sure to visit Don't Forget the Bubbles! References Cohen GM, Albertini LW. Colic. Pediatr Rev. 2012; 33(7):332-3. Friedman SB et al. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009; 123(3):841-8 Herman M,...

Airway Master Moves

You know how to intubate safely. You can recite all of the Ps backwards and forwards. Until you can't. Real-time trouble-shooting. [Details in Audio] This post and podcast are dedicated to Mads Astvad for sharing his enthusiasm, clinical excellence, and #FOAMed warrior spirit. Tak, min ven! #SMACConia #Vikingeblod...

Ovarian Torsion

Ovarian torsion is like the MI of the pelvis. Sometimes all it takes is a good story to investigate. When to worry, when to walk it off, and when to work it up: What is the typical presentation of ovarian torsion? There is none. The presentation varies so much, we need a rule to live by: Unilateral pelvic pain in a girl is ovarian torsion until proven otherwise. This includes the cases in which you are concerned about appendicitis. They both can be fake-outs. Often the pain is severe and abrupt,...

Just Say No To (These) Drugs

Dogma often dictates routine care. There are times when we have to attend to paradigm shifts. An easy way to save lives? Just say no to (these) drugs: Codeine Normally metabolized into codeine-6-glucuronide (50-70%) and norcodeine (10-15%). Codeine, codeine-6-glucuronide, and norcodeine have low affinity for the μ (mu) receptor. However, the most active metabolite of codeine is morphine with 200x the affinity for the mu receptor as the codeine derivates. The problem is, people vary in its metabo...

Blunt Head Trauma

Not all head trauma is minor. Not all minor head trauma is clinically significant. How can we sort out the overtly ok from the sneakily serious? Mnemonics for bedside risk stratification of minor pediatric blunt head trauma, based on PECARN studies: [Details in Audio] Blunt Head Trauma in Children < 2 years of Age Blunt Head Trauma in Children ≥ 2 years of Age Image Gently Campaign Medical Imaging Record (maintain like an immunization card) Brochure for Parents: Just in Time Education Selecte...

The Higher Tech Kid in the ED

Comfortable with G-tubes, tracheostomies, and VP shunts? Good. Get ready for the next level: Vagus Nerve Stimulators, Intrathecal Pumps, and Ventricular Assist Devices. Details in Audio: Vagus Nerve Stimulators For intractable epilepsy; sends retrograde signal up corona radiata Also may be used in: depression, bulimia, Alzheimer, narcolepsy, addiction, and others VNS magnets Are VNS safe in MRI? Are VNS safe in everyday life? Intrathecal Pumps Used to infuse basal rate of drug, usually baclofen ...

Vaccine Preventable Illness Part Two

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The Pediatric Surgical Abdomen

Abdominal pain is common; so are strongly held myths and legends about what is concerning, and what is not. One of our largest responsibilities in the Emergency Department is sorting out benign from surgical or medical causes of abdominal pain. Morbidity and mortality varies by age and condition. Abdominal Surgical Emergencies in Children: A Relative Timeline General Advice Neonate (birth to one month) Necrotizing Enterocolitis Pneumatosis Intestinalis. Essentials: Typically presents in 1st week...

Vaccine Preventable Illness Part One

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MI in Children

Myocardial infarction (MI) in children is uncommon, but underdiagnosed. This is due to two main factors: the etiologies are varied; and the presenting symptoms are “atypical”. We need a mental metal detector! Case examples Congenital Two main presentations of MI due to congenital lesions: novel and known . The novel presentation is at risk for underdiagnosis, due to its uncommonness and vague, atypical symptoms. There are usually some red flags with a careful H&P. The known presentation is a...

Neonatal Jaundice

Most newborns will have some jaundice. Most jaundice is benign. So, how can we sort through the various presentations and keep our newborns safe? Pathologic Jaundice When a baby is born with jaundice, it’s always bad. This is pathologic jaundice, and it’s almost always caught before the baby goes home. Think about ABO-incompatbility, G6PD deficiency, Crigler-Najjar, metabolic disturbances, and infections to name a few. Newborns are typically screened and managed. Physiologic Jaundice Physiologic...

Foreign Bodies in the Head and Neck

Children the world over are fascinated with what can possibly “fit” in their orifices. Diagnosis is often delayed. Anxiety abounds before and during evaluation and management. Most common objects :1,2 Food Coins Toys Insects Balls, marbles Balloons Magnets Crayon Hair accessories, bows Beads Pebbles Erasers Pen/marker caps Button batteries Plastic bags, packaging Non-pharmacologic techniques Set the scene and control the environment . Limit the number of people in the room, the noise level, and ...

Supraglottic Airways

When you give only after you're asked, you've waited too long. – John Mason First, learn to bag Place a towel roll under the scapulae to align oral, pharyngeal, and tracheal axes: Karsli C. Can J Anesth. 2015. Use airway adjuncts such as the oropharyngeal airway or a nasal trumpet. Use the two-hand ventilation technique whenever possible: (See Adventures in RSI for more) Supraglottic Airways : for difficult bag-valve-mask ventilation or a difficult airway (details in audio) LMA Classic Pros : Be...

Urine Trouble

When should you commit to getting urine? When can you wait? When should you forgo testing altogether? When do I get urine? Symptoms – either typical dysuria, urgency, frequency in a verbal child, or non-descript abdominal pain or vomiting in a well appearing child. Fever – but first look for an obvious alternative source, especially viral signs or symptoms. No obvious source? Risk stratify before “just getting a urine”. In a low risk child, with obviously very vigilant parents, who is well appea...

Pediatric Pain

N.B.: This month's show notes are a departure from the usual summary. Below is a reprint (with permission) of a soon-to-be released chapter, Horeczko T. "Acute Pain in Children". In Management of Pain and Procedural Sedation in Acute Care . Strayer R, Motov S, Nelson L (eds). 2017. Rather than the customary blog post summary, the full chapter (with links) is provided as a virtual reference. INTRODUCTION Pain is multifactorial : it is comprised of physical, psychological, emotional, cultural, and...

Bronchiolitis

"By the pricking of my thumbs, Something wheezing this way comes." -- Witches in Macbeth , with apologies to William Shakespeare "Bronchiolitis is like a pneumonia you can’t treat. We support, while the patient heals." -- Coach, still apologetic to the Bard The Who The U.S. definition is for children less than two years of age, while the European committee includes infants less than one year of age. This is important: toddlerhood brings with it other conditions that mimic bronchiolitis – the fir...

Pediatric Elbow Injuries

Johnny has fallen on an outstretched hand, and comes to you with a swollen, painful elbow. Position of comfort, analgesia, xrays, and now what? What am I seeing -- or not seeing -- here? First a refresher on radiographic anatomy of the elbow -- Images courtesy of Radioglypics (Open Access Radiology Education) . Used with permission. Now that we have our adult anatomy reviewed, let's go through the development of the elbow in a child. We are all born with primary ossification centers -- the basic...

GI Bleeding in Children

Blood in the vomit. Blood in the stool. Blood in the diaper. How far do I go in my investigation? What do I really have to worry about? The differential diagnosis of GI bleeding in children is broad . ( Here is the complete differential diagnosis ) In the ED, we can simplify by categorizing by age and appearance . Neonates GI bleeding in the neonate (less than one month of age) is serious until proven otherwise. Well appearing? If this in obvious anal fissure , then no further work-up is necessa...

Pediatric Headache: Some Relief for All

Seemingly vague, but potentially dangerous... common, but possibly with consequences... ...or maybe just plain frustrating. Let's talk risk stratification, diagnosis, and management. Primary or Secondary? We can make headache as easy or as complicated as we like, but let's break it down to what we need to know now, and what the parents need to know when they go home. Primary headaches: headaches with no sinister secondary cause – like tension or migraine – are of course diagnoses of exclusion (c...

Subcutaneous Rehydration

Have you ever been in any of these situations? ⇒ You have a stable child who just needs fluids, but no laboratory tests ⇒ You’ve tried PO hydration, to no avail, despite anti-emetics ⇒ You’re poking the stable, but dehydrated child repeatedly without success What now? Hypodermoclysis , otherwise known as subcutaneous rehydration . [Insert Player] Clysis comes from the same Greek word that “a flood” – hypodermoclysis refers to flooding the subcutaneous space with fluid, so that it can be absorbed...