PEM Pearls: Brief Resolved Unexplained Events (BRUE)

A 2-month old boy was brought in by his mother after an episode of the child’s face turning blue and a pause in breathing. Mom reports this lasted a few seconds. The mother was terrified, so she brought the baby to the ED.

Sometimes infants briefly stop breathing or go limp. How do we determine if an infant is low-risk for serious illness? Earlier last year, the American Academy of Pediatrics (AAP) released guidelines on the evaluation and management of Brief Resolved Unexplained Events (BRUE, replacing a 30-year old label “apparent life-threatening event” or ALTEs).1
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2017-10-26T14:33:24-07:00

PV Card: Algorithm for acute bronchiolitis management

baby-cough-canstockphoto5283520Bronchiolitis is a common lower respiratory tract infection in children less than 2 years old, and especially in those 3-6 months old. In a collaboration with the American Academy of Pediatrics’ (AAP) Section on Emergency Medicine Committee on Quality Transformation, we present a PV card summarizing the Section’s “Clinical Algorithm for Bronchiolitis in the Emergency Department Setting” (reproduced with permission).1 Dr. Shabnam Jain sums it up best in her expert peer review below: “In bronchiolitis, less is more.”
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2019-01-28T21:38:43-07:00

PEM Pearls: Perfecting your pediatric lumbar puncture using ultrasound

lp_collect-croppedA lumbar  puncture (LP) is a common procedure that every emergency physician must master. Pediatric LPs can be challenging for even the most experienced clinician due to small anatomy, difficulty with patient cooperation, and lack of frequency performed. A successful procedure is defined by obtaining cerebrospinal fluid and/or performing a non-traumatic lumbar puncture. There are multiple variables that lead to a successful pediatric lumbar puncture including provider experience, use of anesthesia, and patient positioning. Success rates for pediatric lumbar punctures are variable, with a large range from 34%-75%.1

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2017-10-26T14:33:32-07:00

Radiograph-Negative Lateral Ankle Injuries in Children: Occult Growth Plate Fracture or Sprain?

Lateral Ankle Injuries in ChildrenAn 7-year-old girl presents to your Emergency Department (ED) with an ankle inversion injury from while performing gymnastics. Plain films of her ankle show no fracture. It has been a long-held presumption that skeletally immature children with fracture-negative radiographs should be immobilized with a cast given the concern for an occult Salter-Harris 1 fracture. “Children do not get sprains” is a common teaching point. But a recent 2016 JAMA Pediatrics article challenges that premise in a prospective cohort study of 135 pediatric patients.1 Can these injuries be managed more like a sprain, utilizing a removable ankle brace?

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2017-02-15T08:36:58-07:00

PEM Pearls: This may hurt! How to manage pediatric anxiety in the ED

screaming child

Pain and anxiety in the emergency department (ED) are two of the most common things we see in children. Pediatric patients, whether first time visitors or those with chronic illnesses, can exhibit marked anxiety and fear when in the ED setting. Child development, parenting styles and prior medical experiences will  guide their reactions in these cases. Practitioners must have a unique set of tools to work with these children and understand the optimal methods for providing care, while decreasing some of these normal reactions to a stressful environment. The most important part of treating anxiety and fear in children is recognizing it early. While pharmacologic interventions can adequately treat pain and anxiety in children, there are quick and effective approaches to avoid these medicines in many cases. Below is a structured approach to assess and reduce anxiety during examination:

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2017-10-26T14:33:41-07:00

PEM Pearls: The nonvisualized appendix quandary on ultrasound

appendicitis imageA 10-year old girl presents with progressively worsening right lower quadrant pain for the last 2 days. She reports having chills and feeling warm. Her review of systems is negative for nausea, vomiting, diarrhea, or urinary symptoms. Her abdominal exam is unremarkable except for some diffuse, mild tenderness with deep palpation in bilateral lower quadrants. Labs: WBC 9 x 10^9/L. Because of radiation exposure concerns, you order an abdominal ultrasound as the initial imaging modality to evaluate for appendicitis. The radiologist’s reading was: “Unable to visualize the appendix.” Now, what do you do?

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PEM Pearls: Prolonged Fever in Pediatric Patients – When should you worry?

Prolonged Fever in Pediatric PatientsFebrile pediatric patients are ubiquitous in emergency departments (ED) around the country.  Parents agonize over the presence, height, and persistence of fever, despite the energy we invest in attempting to reassure them and minimize ‘fever phobia’. But when should we, as providers, also be worried? Very often in pediatric patients we are trying to distinguish self-limited viral infections from potentially harmful bacterial ones. In ill-appearing patients, it’s easy. We treat the patient aggressively as if their symptoms were attributable to a bacterial infection. The proper approach is more opaque with the relatively well-appearing febrile child. How do we pick out the bacterial infections in these cases?

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2017-10-26T14:33:56-07:00