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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2017-10-26T14:33:56-08:00

PEM Pearls: Hydrocortisone stress-dosing in adrenal insufficiency for children

Hydrocortisone stress-dosing in adrenal insufficiencyDuring your shifts in the pediatric ED, you may encounter a few patients with adrenal insufficiency or adrenal crisis. Some of the most common causes include those patients with Addison disease, pituitary hypothalamic pathology, and those patients on chronic steroids. When these patients get sick or sustain trauma, it is important to consider giving them a stress dose of hydrocortisone. Patients in adrenal insufficiency or crisis can present with dehydration, weakness, nausea, vomiting, confusion, lethargy, and severe hypotension refractory to vasopressors. 1–3

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PEM Pearls: Pediatric Concussions

pediatric concussions canstockphoto0691281A 9-year boy was hit in the head during a soccer game and was out for a few seconds. He regained consciousness quickly, but was repetitive for EMS. By the time the patient arrived at the ED, he was back to his normal self. Did this patient sustain a concussion? If so, what discharge instructions, anticipatory guidance, and resources do you have for your patient and his family? Here’s a quick 170-second animated video tutorial to sum up some thing for you.

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2017-10-26T14:34:13-08:00

AIR-Pro Series: Pediatrics (2016)

Below we have listed our selection of the 14 highest quality blog posts related to 5 advanced level questions on pediatric topics posed, curated, and approved for residency training by the AIR-Pro Series Board. The blogs relate to the following questions:

  1. Pediatric arrhythmias
  2. Procedural sedation in pediatrics
  3. The neonate in distress
  4. Toddlers with a limp
  5. Pediatric syncope

In this module, we have 10 AIR-Pro’s and 4 honorable mentions. To strive for comprehensiveness, we selected from a broad spectrum of blogs identified through FOAMSearch.net.

This module we also had two editorial board guests trained in Pediatric Emergency Medicine to increase the strength of our recommendations – Dr. Robert Cloutier and Dr. Jason Woods.

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PEM Pearls: Assessing Radiation Risk in Children Getting CT Imaging – Managing Risk and Making Medical Decisions

Radiation risk in children getting CT imaging The Case: A 5 year old girl presents to the ED with approximately 24 hours of suprapubic and RLQ abdominal pain. Vital signs are: Temp 38.2 C, HR 110, RR 19, BP 100/60, Oxygen Sat 100% on room air. She has vomited twice but has not had diarrhea. She had a history of constipation a year ago that has resolved and mother denies any urinary symptoms or history of UTI’s. The patient is quiet but nontoxic appearing. Your abdominal exam notes mild to moderate RLQ tenderness but no rebound and normal bowel sounds. You order a urinalysis, which is negative and a RLQ US which ‘does not visualize the appendix’. Your suspicion for possible appendicitis is still intermediate; however, now the patient states she is “a little hungry”. Should you order a CT of the abdomen and pelvis? Uuugh!

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2017-10-26T14:34:22-08:00

Child Whisperer Series: Making the Most of the Holidays in the ED

“Ugh I have to work Christmas Eve and Christmas day.”Child Whisperer Series: Making the Most of Holidays in the ED
“I hate not being with my family for the holidays.”
“Hanukkah won’t be the same this year if I can’t be with my Dad.”
“New Year’s Eve in the ED, sounds like a blast… said no one ever.”

These are just a few of the comments I have heard over the last few weeks leading up to the holidays. The last one is courtesy of myself. While I complain, deep down I know it’s not so bad. If you look hard enough I have found you can find the holiday spirit all over the Emergency Department. There are also easy tips and tricks to incorporate the spirit in the medicine and care that we provide to our patients.

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2016-12-25T16:38:05-08:00