Paucis Verbis: Fever without a source (29 days-3 months old)

In part 2 of this “Pediatric Fever Without a Source” Paucis Verbis cards, we now cover febrile infants aged 29 days to 3 months (PV card for birth-28 days). Note that there is no single correct answer in how to manage these patients. There can be a wide variation in practices, partly because of the slightly different criteria used by the 3 studies. The overarching principle is that “high risk” infants get admitted with IV ceftriaxone and “low risk” infants get discharged with close follow-up +/- a ceftriaxone IV or IM dose. The line between these two risk categories is the grey area.

Where I practice, we tend to follow a modified version of the Rochester criteria, where a lumbar puncture and antibiotics aren’t always required for this age group (unlike the Boston criteria).

PV Card: Pediatric Fever Without a Source (29 Days-3 Months)

Go to ALiEM (PV) Cards for more resources.

Keep a lookout for future PV cards which will address fevers without a source in pediatric patients aged 3 months-3 years old.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.

By Michelle Lin, MD|2021-12-21T13:34:31-08:00Feb 3, 2012|ALiEM Cards, Pediatrics|

Trick of the Trade: Difficult intubation — making lemonade out of lemons

In many cases of massive GI bleeding, airway control is essential. During endotracheal intubation, suction sometimes just isn’t adequate enough to allow to get a good view of the vocal cords. The pool of blood keeps re-accumulating faster than you can suction. You think you see an arytenoid, pointing you in the direction of the trachea, and so you slide the endotracheal tube in.

Unfortunately, when you bag the patient, you realize that you are in the esophagus.

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By Michelle Lin, MD|2016-11-11T18:51:16-08:00Jan 31, 2012|Tricks of the Trade|

Paucis Verbis: Pediatric fever without a source (Birth-28 days)

Pediatric patients commonly are brought to the Emergency Department for a fever without a source. Management of these patients depends on the patient’s age. Today’s PV card focuses on the youngest age group: Birth-to-28 days.

QUESTION to everyone:

Do you correct your age calculation for prematurity? Premature neonates are more at risk for SBI, but I’ve seen varying practices.

PV Card: Pediatric Fever Without a Source (Birth-28 Days Old)

Go to ALiEM (PV) Cards for more resources.

Keep a lookout for future PV cards which will address fevers without a source in pediatric patients aged 29 days-3 months and 3 months-3 years old.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.

By Michelle Lin, MD|2021-10-11T15:15:20-07:00Jan 27, 2012|ALiEM Cards, Pediatrics|

Trick of the Trade: Minimizing propofol injection pain

“Ow, that burnnnnssss… ow! ow! ow! … zzzzzz…

As many as 60% of patients report significant pain with the injection of IV propofol. Once a patient experiences pain, it’s too late to reverse it. Often all you can do is to tell them that the pain will subside in a few seconds. What can you do preemptively to minimize the pain of propofol injection?

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By Michelle Lin, MD|2019-01-28T22:23:58-08:00Jan 24, 2012|Tox & Medications, Tricks of the Trade|

Paucis Verbis: Antibiotics and open fractures

$Fx Tib Fib Open Irrigation open fractures antibiotics$

Open fractures come in all shapes and sizes. Sometimes fractures create only a small, innocuous-looking puncture through the skin. Other times they look grossly contaminated with organic material and have significant soft tissue injury. The major concern is wound infection. Prophylactic antibiotics are essential in the ED.

Typically antibiotics are first-generation cephalosporins. When do you start adding more coverage with high-dose penicillin or aminoglycosides?

Pearl

Once you have significant soft tissue injury, you are automatically have a Type III fracture and should add an aminoglycoside.

PV Card: Open Fractures and Antibiotics

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Reference

Hoff W, Bonadies J, Cachecho R, Dorlac W. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma. 2011;70(3):751-754. [PubMed]

By Michelle Lin, MD|2021-10-11T15:20:36-07:00Jan 20, 2012|ALiEM Cards, Orthopedic|

Trick of the Trade: Dental Avulsion and Subluxation

It’s a Friday evening shift in the “minor area” of your ED and a young woman who had imbibed a little too much alcohol comes in with an avulsion of her first left upper incisor after falling and striking her face against the ground. She’s crying because of the event but is otherwise unscathed. At this point it’s time to take care of the avulsion. What to do?

Trick of the Trade

Dermabond (2-octyl cyanoacrylate) and N95 Nasal Bridge Technique

Although originally described for dental avulsions, I have also used this technique to stabilize subluxations. This is temporizing fix until the patient can get to the dentist for a definitive repair. Below is a description of the technique.

Lightly rinse tooth with saline solution.
Rinse socket with 20-40 mL of saline solution and then pat dry with a surgical sponge.
Gently reimplant tooth into a satisfactory anatomic position.
Pat tooth dry and apply 2-octyl cyanoacrylate (2-OCA) to the mesial and distal edges of the tooth, thereby adhering it to the adjacent teeth. In this case of a left central incisor avulsion, “mesial” means right edge and “distal” means left edge in dental speak.
Use the pliable metal nasal bridge from an N95 respirator mask as a splint. Cut it to the appropriate size. Be sure to round the edges to avoid injury.
Secure the replanted tooth by applying 2-OCA to the inner aspect of the splint and buccal surface of the target and one/both adjacent teeth.
Hold the splint under pressure for about 1 minute.
Confirm stability.

In addition, remember to start the patient on prophylactic antibiotics. Penicillin is a reasonable choice. Keep a liquid diet and see a dentist, as soon as possible.

Warnings

Children: Avulsed primary teeth should not be replanted. Also ensure they will not be at aspiration risk.
Warn the patient that if they feel that the dental splint is loosening, simply remove it.

Special thanks to our amazing residents Dr. Mike Hickey for his assistance with the case report and Dr. Warren Cheung for providing one of the images.

Below are other images where we have successfully used this technique in our ED.

Reference

Rosenberg H, Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011 Apr;57(4):375–7.

By Hans Rosenberg, MD|2021-09-04T09:55:04-07:00Jan 17, 2012|Dental, Tricks of the Trade|

Paucis Verbis card: Interpretation of intraosseous blood

There is a growing number of normal volunteers who agree to get an intraosseous (IO) needle placed. Just search Intraosseous Needle on Youtube. Often you can draw blood out of the needle. How do you interpret the lab values? Are they the same as your peripheral blood draw? Should we even send the blood to the lab?

In a 2010 article in Archives of Pathology and Laboratory Medicine, peripheral IV blood from 10 volunteers was compared to blood drawn twice from a single IO line in the humerus. After discarding the first 2 mL of IO blood, the first IO sample was drawn (4 mL). Then a second IO sample was drawn (4 mL), which is equivalent to a sample with the first 6 mL discarded.

Interesting, not all IO labs correlated with IV labs. The good news is that a few critical ones do show correlation: creatitine, glucose, and hematocrit.

PV Card: Interpreting Labs from the IO Line

Adapted from [1]
Go to ALiEM (PV) Cards for more resources.

Thanks to Dr. Michael McGonigal at Trauma Professional’s Blog for posting about this.

Reference

Miller L, Philbeck T, Montez D, Spadaccini C. A new study of intraosseous blood for laboratory analysis. Arch Pathol Lab Med. 2010;134(9):1253-1260. [PubMed]

By Michelle Lin, MD|2021-10-11T15:23:29-07:00Jan 13, 2012|ALiEM Cards, Heme-Oncology|

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