AVOIDING COMMON ERRORS IN PEDIATRIC EMERGENCY MEDICINE

• THE CRASHING PATIENT 1
1 Overlooking the Basics and Focusing on Medications That Do Not Matter During Pediatric Codes 1
2 Placing Provider Comfort Over Family Presence . 2
3 Overlooking Opportunity to Help the Family by Saving Crucial Evidence . 4
4 Epinephrine 1:10 000 vs 1:1000: Are You Prepared to Make Sense of This? 5
• IMAGING 7
5 Do Not Scan Head Trauma Based on Your “Gut”—Use Evidence-Based Guidelines! . 7
6 Negative Scan—Positive Belly: Do Not Rely Solely on the CT Scan When Evaluating Children With Blunt Force Abdominal Trauma 8
7 Appreciate Practice Differences in the Approach to Pediatric Nontraumatic Abdominal Pain 10
8 Neuroimaging of Nontrauma Patients 11
9 To CT or Not to CT: Develop Good Imaging Strategy. 13
10 Know the Options: Imaging Modalities for Pediatric Neck Masses . 14
11 Advanced Imaging—MRI in Children . 16
12 Pediatric Lung POCUS: An Underutilized Tool for Pediatric Pneumonia 17
14 Cardiac POCUS: Be Able to Distinguish Pericardial Effusions From Their Mimics 20
15 Scan First, Irradiate Second: The Error in Jumping to Computed Tomography. 21
16 Skin and Soft Tissue Infections: Fifty Shades of Grayscale. 23
• ENVIRONMENTAL/TOXICOLOGY 25
17 Errors to Avoid: Overlooking Potential for Lung Injury in Children Who Appear Well. 25
18 Not Aggressively Treating the Hypothermic Drowning Victim . 26
19 Drowning Prevention—Missing the Opportunity to Teach: Prevention When the Near-Miss Events Happen 28
20 When Small Bites Matter: The Deadly Potential of a Pill 30
21 Activated Charcoal: Avoiding Worthless Usage of a Valuable Therapy 32
22 Underestimating the Damage a Simple Laundry Detergent Pod Can Cause 33
23 Not Having a Plan to Safely and Effectively Cool Critically Ill Patients With Heat Stroke 35
24 Cold Illness: Be Prepared to Use All the Tricks for Aggressive Rewarming . 36
25 Rabies, It Is More Than Bats: Know Your High-Risk Cases 38
26 Antivenom in Children Is Not Based on the Child’s Weight 39
• EAR NOSE THROAT 41
27 Otitis Externa: A Dive Into Swimmer’s Ear 41
28 Acute Otitis Media and Complications 42
29 Don’t Miss Hearing Loss—A Subtle Sign of Serious Pathology 43
30 Leaking the Information: Be Prepared to Manage Otorrhea 45
31 Punching Up the Management of External Ear Trauma 46
32 Do Not Miss Middle and Inner Ear Trauma: Not All Ear Drainage Is Infectious 48
33 Intranasal Foreign Bodies: Optimizing Chances of Successful Removal. 50
34 Blow by Blow on Nasal Trauma in Children . 51
35 Epistaxis: The Nose Knows How to Stop the Leak . 53
36 Orbital Fractures: Be Careful to Avoid Getting Trapped . 54
Amanda Price, MD
37 Not Using Absorbable Sutures for Children With Facial Lacerations 56
38 Overlooking the Benefits of Regional Anesthesia in Children 58
39 Using Color of Rhinorrhea As a Justification for Giving Antibiotics . 59
40 Basing Treatment of Strep Pharyngitis Solely on Centor Criteria. 60
41 Neck Pain and Fever Does Not Always Mean Meningitis. Think of RPA. Retropharyngeal Abscess. 62
42 Oropharyngeal Puncture? Do Not Forget That There Is a Big Blood Vessel to Worry About. . 63
43 Not Believing the Parent Who Believes the Child Choked on Something. 65
44 Do Not Treat Detergent Pods Like Any Other Type of Ingestion 66
45 Not Appreciating “Recurrent Croup” to Be a Clinical Sign of Anatomic Airway Anomalies . 68
46 Not Having a Strategy in Place to Manage the Patient With a Posttonsillectomy Hemorrhage . 69
47 Attempting to Close Every Intraoral Laceration. 71
48 Thinking Ludwig Angina Only Happens in Adults . 72
49 Overlooking Simple Strategies to Manage Pain Related to a Dry Socket 74
50 Dismissing Sialadenitis as a Simple Infection and Throwing Antibiotics at It 75
51 Do Not Forget About the Secondary Teeth While Managing a Primary Tooth Injury. 77
52 Focusing on Only the Teeth When There Is Dental Trauma 78
53 Not Thoroughly Evaluating Facial Fractures. 80
54 Put Down the Scalpel—A Thoughtful Approach to Neck Masses 81
55 Blunt Neck Trauma 83
56 Penetrating Neck Trauma . 84
57 Torticollis: Maybe a T wist but Hopefully Never a Shout 86
58 Atlantoaxial Rotatory Subluxation (AARS): When Children Truly Look Like Little Birds . 88
59 Managing Pediatric Eye Injuries: You Will Shoot Your Eye Out, Kid!. 90
60 Be Prepared to Manage Eye Lacerations . 92
61 Be Prepared to Care for the Other Pediatric Red Eye: Hyphema. 93
62 Pediatric Vision Loss 95
63 Be Prepared to Manage Eye Burns—Chemical, UV , Thermal . 97
64 Do Not Confuse Orbital Cellulitis With Preseptal Cellulitis 98
65 “Eye Spy” Abnormal Pupils: Be Aware That an Abnormal Pupillary
Exam Is Often a Sign of Underlying Problems . 100
66 Nasolacrimal Duct Disorders: More Than Just Tears . 102
Meghan Cain, MD
67 Conjunctivitis: A Sight for Sore Eyes . 103
• AIRWAY 105
68 Not Considering an Infant’s Airway as a “Difficult Airway” from the
Beginning 105
69 Not Knowing the Differences Between the Pediatric and Adult
Airways Can Lead to Failure to Intubate the Pediatric Airway . 106
70 Get Rid of Your Discomfort With Percutaneous Transtracheal Ventilation 108
71 Treating All Noisy Breathing as the Same. 110
72 Don’t Rush to Intubate an Infant After PGE1 Administration 112
73 Thinking Lack of Wheezing Is a Good Finding With Severe Asthma 113
74 Giving Albuterol to All Kids With Bronchiolitis 115
75 Treating Patients With Cystic Fibrosis and Pneumonia With Typical
Treatments for Community-Acquired Pneumonia . 116
76 Not Recognizing Risk Factors for PE in Children. 118
77 Overlooking the Concurrent Injuries in Children With Rib Fractures . . . . . . . . . 120
• CARDIOLOGY/DYSRHYTHMIA 122
78 Do Not Miss Undiagnosed Congenital Heart Disease: In Babies With Heart
Disease, Color Matters!. 122
79 Poor Feeding, Cough, and Fussiness? Common Complaints Deserve a
Comprehensive Workup for Pericarditis in the Postoperative Congenital
Heart Disease Patient 123
80 A Faint Chance of Danger—Do Not Assume Pediatric Syncope Is Just
Orthostasis Without Ruling Out These Diagnoses 125
81 Chest Pain: Do Not Let a Normal Examination Falsely Reassure You. 127
82 T achycardia: Don’t Assume T achycardia Is Just “Stranger Danger” 128
83 Secondary Signs of Endocarditis: Know Them by Heart 130
84 Viruses Can Be Real Heart Breakers—Do Not Let the Myocarditis
Patient Blend in With All the Respiratory Viral Illnesses 131
85 Remember That Very Little of Pediatric Hypertension Is Cardiac 133
86 Getting to the Heart of the Matter: Do Not Miss These Features of Pathologic
Murmurs . 134
87 Do Not Crash and Burn by Missing Kawasaki Disease 136
88 Pediatric Electrocardiogram Differences: Know Which Findings Are
Normal in Children and Which Ones Spell Trouble 137
89 Do Not Be Shocked! Know the Meaning of the First Three Letters of
a Pacemaker’s Code 139
• ABDOMEN 141
90 Be Aware of the Varied Presentation of Pediatric Appendicitis . 141
91 Pyloric Stenosis: Diagnosis the Stenosis Before It Becomes “Classic” . 142
92 The Inception of an Intussusception: Look for the Bowel Within
a Bowel Even if Symptoms Are Not “Classic” 144
93 GI bleed: Do Not Be fooled by bleeding imposters 145
94 The Hard Truth of Constipation—Do Not Miss the Potentially Serious Causes 147
95 Pediatric Diarrhea—Hydration Is the Most Important Factor in Treatment . 148
96 Dehydration and Electrolyte Problems: Do Not Start IV Fluids in Children Without a Trial of PO Fluids and Antiemetics 150
97 Why Is My Baby’s Poop White?: Do Not Forget to Check the Direct Bilirubin Level for Jaundiced Infants. 151
98 Lets Be Blunt—Do Not Underestimate the Importance of Serial Abdominal Examinations in Pediatric Blunt Abdominal Trauma 153
99 Oh Heavens…. HUS and Escherichia coli 0157:H7—Do Not Rush to Give Antibiotics to Children With Bloody Diarrhea 154
100 T wist of Fate: Do Not Ignore Bilious Emesis in a Baby 156
101 Let Your Light Shine!: Do Not Confuse a Hydrocele for a Hernia 157
102 Time Is Stoma: G-Tube Dislodgement Is a Time-Sensitive Emergency . 158
103 “Not Aggressively Treating Patients With Nephrotic Syndrome Presenting With Fever” . 160
• GENITOURINARY AND RENAL 162
104 Renal: Nephritis: “Not Having a Strategy to Evaluate Hematuria in a Child” 162
105 Overlooking Spontaneous Bacterial Peritonitis in Patients With Nephrotic Syndrome 163
106 “Urine” Trouble Now—Evidence to Approach Pediatric UTI 165
107 Funny Dermatologic Findings 166
108 Vaginitis in the Prepubertal Girl—A Not So Challenging Discharge Diagnosis . 168
109 GU Torsion (Male and Female) 169
110 Not Just Adults: Abnormal Uterine Bleeding and Teenage Menstrual Issues. 171
111 Straddle Injuries Management: Be Able to Distinguish Accident From Abuse 172
112 A Sticky Situation: Know How to Manage Labial Adhesions . 174
113 Always Look Under the Diaper: Congenital Abnormalities of the Genitourinary Tract 175
114 Always Check Under the Hood: Do Not Confuse Phimosis and Paraphimosis . 177
• DERMATOLOGY 179
115 Neonatal Rashes: Know the Bad From the Not So Bad 179
116 Be Prepared to Manage the Common Pediatric Rashes . 181
117 Be Prepared to Manage Common Pediatric Infectious Rashes . 183
118 The Fits and Starts of Atopic Dermatitis: Strategies to Adjusting Treatment 185
119 Be Prepared to Recognize and Manage the “Bad” Rashes . 186
120 Do Not Be Tricked Into Missing a Diagnosis of Henoch-Schönlein Purpura . 188
121 Be Prepared to Accurately Diagnose and Support Your Patients With Erythema Multiforme. 189
• ENDOCRINE 191
122 DKA: Being Overly Concerned About IV Fluids . 191
123 Allowing Hypoglycemia to Surprise You in the Pediatric Patient Presenting With Gastroenteritis . 192
124 Do Not Forget the Stress-Dose Steroid in Hypopituitarism! . 194125 Not Using Hydrocortisone for Treating Congenital Adrenal Hyperplasia (CAH) 196
126 Overlooking the Clinical Scenarios That Place a Child at Risk for SIADH. 197
127 Forgetting Thyrotoxicosis in Patients With Vague Complaints. 199
128 Not Considering Rickets as a Cause of New-Onset Seizures in Young Children . 200
• NEUROLOGY 203
129 Not So Simple, or Is It? Prepare to Care for Febrile Seizures in Children 203
130 Status Epilepticus: The Most Common Neurologic Emergency in Children 204
131 A Lower Threshold to Seize: Understand First-Time Seizure in Pediatric Patients . 206
132 Pediatric Headache 208
133 Pediatric Stroke Is Routinely Missed on Initial Presentation: Do Not Be Routine! 209
134 “Flaming Hot Pediatric Brains”—Anti-NMDA and Other Forms of Encephalitis 211
135 Pediatric Vertigo: Differentiating Life-Threatening From Benign Etiologies 213
136 Be Able to Scrutinize the Causes of Pediatric Ataxia . 214
137 Muscular Dystrophy . 216
138 Skull Fractures: When Do We Really Need to Know They Are There? .. . 218
139 When a River Does Not Run Through It—Prepare to Manage Pediatric Hydrocephalus 219
140 Be Prepared to Troubleshoot and Manage Shunts 221141 Be Prepared to Manage Pediatric Neurologic Technology . .. 222
• ORTHOPEDICS 225
142 Fingertip Injuries: Keep It SIMPLE, Do Not Forget to Check the Tendons, and Use Glue . 225
143 Supracondylar Fractures . 226
144 It Is Not Just a Sprain: Do Not Miss Cases of Slipped Capital Femoral Epiphysis and Idiopathic Osteonecrosis (Legg-Calve-Perth Disease) . 228
145 Big Problems in Little Bones: Do Not Miss Physeal Fractures . 229
146 Be Prepared for an Easy ED Fix: Subluxed Radial Head—The Nursemaid’s Elbow 231
147 Ankle Fracture—Triplane and Juvenile Tillaux Fracture 232
148 Pediatric Cervical Spine Trauma: The Biggest Pain in the Neck Would Be to Miss One 234
149 SCIWORA: Do You SCIWORA What I SCIWORA? . 235
150 Overuse Syndromes: When a Good Thing Has Gone Too Far 237
151 What to Know About Lumbago 238
• Infectious Disease 240
152 Everything At Once—Obtain Cultures Quickly But Do Not Delay Antibiotics for Fever in the First 28 Days 240
153 Risky Business: Know How to Approach the “What Ifs” in Neonatal Fever Risk Stratification 241
154 Fever 2 Months Old and Beyond . 243
156 It Is a Small World After All: Know the Differential for Fever, Diarrhea, and Rash in the Traveling Child . 246
157 Diagnose Outpatient Pediatric Pneumonia Clinically and Avoid the X-Ray . 247
158 I Thought It Was Just a Cold: Do Not Forget to Consider Sepsis . 249
159 Meningitis—Do Not Delay the Lumbar Puncture in Patients With High Suspicion for Bacterial Meningitis 250
160 Pertussis Infection in Infants and Children: Do Not Miss the Early Signs . 252
161 Bronchiolitis: Value Aggressive Airway Clearance Over Nebulizers, X-Rays, and Steroids in Bronchiolitis 253
162 Bad to the Bones—Do Not Let a Child Limp Out of the ED Without Considering Septic Joint 255
• HEMATOLOGY/ONCOLOGY 257
163 Tumor Lysis Syndrome 257
164 Do Not Get Caught Unaware: Recognizing NEW-ONSET CANCER 258
165 Sickle Cell Disease Is Not Just Anemia: Be Prepared for Complications Affecting All Organ Systems 260
166 Hemolytic Anemia: Think Before You Transfuse 262
167 Feeling Blue Despite O2?: Consider Methemoglobinemia . 264
168 Pediatric Neutropenia: Worth a Pause, but Not Always Panic 266
169 Fever and Neutropenia: Be Prepared When That Oncology Patient Arrives . 267
170 Hemophilia—Do Not Undertreat the Bad Bleeds 269
171 How Much Is Too Much: Spotting Abnormal Bleeding Disorders 270 ¦
• GENETICS/METABOLISM 273
172 Recognition and Management of Inborn Errors of Metabolism—The Needle in the Haystack . 273
173 Have No Fear; an Inborn Error of Metabolism Is Here! Managing Patients With Known Inborn Errors of Metabolism 275
174 Be Aware of Abnormal Newborn Screens . 277
• NEONATOLOGY 279
175 Umbilical Care: Do Not Confuse the Normal Granulation With the Purulence of Omphalitis 279
176 I Am So Hungry! Know the Right Questions to Ask About Feeding Difficulty in the Neonate . 280
177 Is It Supposed to Look That Way?: Know What Is Normal Postcircumcision So You Can Reassure Parents 282
178 Skin and Bones, or Normal Growth: Identifying Failure to Thrive . 284
• ALLERGY/IMMUNOLOGY 286
179 Anaphylaxis: It May Come as a Shock, but It Does Not Have to End in Tragedy… . 286
180 Primary Immunodeficiency: Know What to Expect When Cell Lines Go Awry 287
• COMMUNITY/LEGAL 290
181 Do Not Forget to Look for the Five W’s of Cutaneous Injuries . 290
182 Do Not Miss Abusive Head Trauma! . 291
183 Broken Bones in Broken Homes: When to Get a Skeletal Survey . 292184 Sentinel Moments, Sentinel Injuries: Know How to Recognize the Signs of Abuse . 294
185 Cannot Miss: Adolescent Sexual Assault 295
186 It Is Normal to Be Normal: Understand Unique Aspects of the Prepubescent Sexual Assault Examination 297
187 Treat the Patient, Not the Poison 298
188 The Minefield of Minor Consent: Be Sure That You Are Following Your State’s Legal Statutes . 300
• APPLIED PRACTICE 302
189 Evidence-Based Medicine: Have the Tools to Test Wisely . 302
190 My Baby Turned Blue: Changing the Terminology From ALTE to BRUE . 304
191 The Technological-Dependent Child. 306
192 Well-Child Care in the Emergency Department Setting: Looking for “Goldilocks Moments” by Doing Just the Right Amount. 308
• BEHAVIORAL HEALTH 310
193 Psych Outbursts, Pediatric Behavioral Management: Exhaust All Nonpharmacologic Measures Before Chemically or Physically Restraining a Child 310
194 Navigating the Complexity of Autism Spectrum Disorder in the Pediatric ED—Work With Caregivers to Individualize Care 311
• PHARMACY 313
195 Avoiding Common Errors in Pediatric Emergency Medicine: Sedation Adjuncts—Do Not Underestimate the Power of Distraction and Analgesia for Pediatric Procedures. 313
196 Wait, Are Pediatricians Secretly Mathematicians?: Do Not Forget That All Dosing in Children Is Weight-Based 314
197 May the Dose Be With You… Focus on Communication to Avoid the 10-fold Dosing Error 316
198 Just a T aste: Be Aware of Bad T asting Medicines That Kids May Refuse to T ake .. 317
Index 319

Conversational and easy to read, Avoiding Common Errors in Pediatric Emergency Medicine discusses 198 errors commonly made in the practice of pediatric emergency medicine and gives practical, easy-to-remember tips for avoiding these pitfalls. This unique manual offers brief, approachable, evidence-based chapters suitable for reading immediately before the start of a rotation, for quick reference on call, or daily for personal assessment and review.

• Covers nuanced topics specific to the care of children in the emergency setting, including treatment strategies, procedure competencies, distinct pathophysiology, and disease processes.
• Discusses the crashing patient, ultrasound and imaging, community and legal issues, applied practice, behavioral health, and medication/pharmacy topics.
• Summarizes each chapter with handy key points that present must-know information in an easy-access, bulleted format.
• Helps prevent clinical practice errors in the ED due to applying an adult management approach instead of a directed pediatric approach.
• Ideal for emergency medicine physicians, residents, and attendings; emergency nurse practitioners, PAs who practice in the ED, and pediatricians.

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