Trick of the Trade: Topical anesthetic cream for cutaneous abscess drainage in children

AbscessDiagramAbscess drainage can be painful and time consuming in the ED. Can this article help? 1

Trick of the Trade

Apply a topical anesthetic cream on skin abscesses prior to incision and drainage (I and D).

In this press-released article in American Journal of Emergency Medicine, the authors found that application of a topical 4% lidocaine cream (LMX 4) was associated with spontaneous cutaneous abscess drainage in children.


Hot off the press: Clinical practice guideline for ketamine in the ED

Ketamine (475-10)

A 3 year old girl is brought into the ED with an abscess to her groin. Upon examination it is fluctuant and needs incision and drainage. Next door is a 5 year old boy, who fell off his bed and has an angulated radius fracture that needs reduction.

Hhhmmmm…how to manage these patients? Local anesthesia? Hematoma block? Nothing (aka brutacaine)? What about ketamine, that seems popular these days. IV? IM? With or without atropine? So many decisions!

Luckily you were surfing the internet one night and came across the 2011 clinical practice guideline on ketamine in the ED, which was just published.1


By |2017-02-28T09:43:19-08:00Mar 1, 2011|Pediatrics, Tox & Medications|

Tricks of the Trade: Nursemaid elbow reduction

We’ve all seen it before while working in the ED. A parent brings in their child because they pulled on their arm, and now the child is not using it. Parents are thoroughly convinced that the child’s arm is either broken or dislocated. We all recognize this as radial head subluxation or “nursemaid’s elbow” and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? What if nothing happens?

Is there an alternative technique to reducing a nursemaid elbow?


By |2016-11-15T22:02:31-08:00Jan 19, 2011|Orthopedic, Pediatrics, Tricks of the Trade|

Trick of the Trade: Laryngospasm notch maneuver


 smLacerationLipKetamine1What is the incidence of laryngospasm in pediatric patients receiving ketamine for procedural sedation in the ED?

Answer = 0.3%

A child with laryngospasm can be a scary thing to manage. There’s no way to predict whether a child is going to get it.

You can try the usual maneuvers including a jaw-thrust, positive pressure ventilation to try to open the vocal cords, and suctioning. If these don’t work, you might consider giving the patient a paralytic, such as succinylcholine, and performing an endotracheal intubation for worsening hypoxia. Before that, what non-invasive maneuver can you try first?



By |2016-11-11T19:00:18-08:00Dec 1, 2010|Pediatrics, Tricks of the Trade|

Paucis Verbis card: Algorithm for suspected pertussis in pediatrics


To treat for pertussis or not?

In the setting of the current pertussis epidemic in California, each kid with a cough sparks constant debate about whether to treat with azithromycin or not. Finally, thanks to my friends Dr. Andi Marmor and Dr. Shon Agarwal Jain (UCSF Pediatrics faculty), there’s a great algorithm to help you answer the question. I have found this algorithm extremely helpful.

You basically start by risk-stratifying by age and pertussis immunization status. For instance, if the patient is 6 months of age AND unimmunized), then follow the algorithm listed as “High Risk for Pertussis”.

PV Card: Suspected Pertussis in Pediatric Patients

Go to ALiEM (PV) Cards for more resources.

By |2021-10-17T09:28:20-07:00Oct 29, 2010|ALiEM Cards, Infectious Disease, Pediatrics|

Tricks of the trade: Intranasal fentanyl for pediatric patients


Pediatric patients often receive inadequate pain control in the setting of orthopedic injuries. Because the child experiences fear, anxiety, and pain with needles, practitioners often shy away from ordering IV or IM pain medications. Oral agents, while easier to administer, usually provide inadequate pain control.

Trick of the Trade

Intranasal (IN) fentanyl

Thanks to my friend Dr. Ron Dieckmann (Editor-in-Chief for PEMSoft, Chairman of Board for KidsCareEverywhere, and Pediatric Director for Valley Emergency Physicians) for his tip about intranasal fentanyl:

It is imperative that the drug be administered in a nebulized form using an atomizer device — one half the volume in each nostril. Attach a 1 cc syringe to the end of the atomizer to administer fentanyl intranasally.
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It is rapidly absorbed and provides excellent analgesia within minutes. It works just as well as IV morphine (1). If you just drop the liquid in the nose without using the atomizer, the child will swallow some of the drug, and onset and effect will be blunted significantly and titration is not possible.

The starting dose of 1.5 microgram/kg can be repeated in a dose of 0.5-1.5 microgram/kg IN in 5 minutes.  Be sure to use extreme caution in younger patients who are more susceptible to the respiratory depressant effects of all opiates; it has not been tested in children < 3 years of age at all, so I would not use in this age group. Put patients on a pulse oximeter. In the event that a child receives the drug and starts to desaturate, bag the patient, then just give naloxone 0.1 mg/kg/dose to a maximum of 2 mg intramuscularly, and the respiratory effects will be rapidly reversed.

Do you use intranasal fentanyl at your practice?

1. Borland M, Jacobs I, King B, O’Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007 Mar;49(3):335-40.


By |2016-11-11T19:00:24-08:00Oct 27, 2010|Pediatrics, Tricks of the Trade|

Paucis Verbis card: Pediatric weight-based reference (5-34 kg)


The foundation in any pediatric resuscitation is the length-based estimation of the patient’s lean body weight. Once determined, equipments and medications are sized and dosed, respectively, according to that weight. You can use electronic resources such as PEMSoft (Pediatric Emergency Medicine Software) or the more traditional paper-based Broselow tape.

If you have neither of these at your easy disposal, I thought I would create a multi-card reference which works best in electronic pdf form on your mobile device. Even if you DO have other available references, it’s still nice to have some redundant back-up sources just in case.

This data was collected by merging data from the Broselow tape and PEMSoft.

  • I created 30 individual cards for patients weighing between 5 kg and 34 kg.
  • I didn’t include whether endotracheal tubes should be cuffed or uncuffed. This is controversial currently. The traditional teaching is that patients younger than 8 years old should receive UNcuffed tubes.
  • D10W glucose should be given in patients younger than 1 year old. D25W glucose should be given for patients 1-2 years old. D50W glucose can be given to patients 2 years and older.
  • Please use these cards with caution. I’ve proof-read these cards multiple times, but there still may be some typos. Please let me know if you see any discrepancies.

PV Card: Pediatric Weight-Based Resuscitation Reference

Go to ALiEM (PV) Cards for more resources.


By |2021-10-17T09:30:51-07:00Oct 22, 2010|ALiEM Cards, Pediatrics|
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