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Title: Emergence Reactions
Author: Seth Ball Keywords: Procedural sedation, medication side effects Reference Article: Wang Z, Wang X, Yang Y, He X, Jia W, Yao X, Sheng X, Jiao H. The effect of repeated maternal voice orientation on postoperative emergence agitation in children following tonsillectomy and adenoidectomy: A randomized controlled trial. J Clin Anesth. 2025 May 2;104:111851. doi: 10.1016/j.jclinane.2025.111851. Epub ahead of print. PMID: 40318514. |
Bottom Line: repeated maternal voice orienting a child to their surroundings can be an effective way to decrease the incidence and severity of emergence agitation in children after sedation. While this study was focused on children undergoing general anesthesia and overall had a much higher incidence of agitation compared to what is reported in procedural sedation literature, it is a safe and easy intervention that I think can be regularly implemented in our procedural sedation practices in the PED.
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Title: Antibiotic Hypersensitivity
Author: Ami Shah Keywords: Antibiotics, allergies, infectious disease Reference Article: Banerji A, Solensky R, Phillips EJ, Khan DA. Drug Allergy Practice Parameter Updates to Incorporate Into Your Clinical Practice. J Allergy Clin Immunol Pract. 2023 Feb;11(2):356-368.e5. doi: 10.1016/j.jaip.2022.12.002. Epub 2022 Dec 20. PMID: 36563781. |
Bottom Line: With a history of non-anaphylactic reaction to either cephalosporin or PCN, there is no need to consider cross-sensitivity or to hold off on the use of the other drug. In case of anaphylactic reactions, skin testing is recommended before the drug use.
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Title: Development of PNA after Negative CXR
Author: Seth Ball Keywords: Chest x-ray, pneumonia, infectious disease Reference Article: Hirsch AW, Wagner A, Lipsett SC, Monuteaux MC, Neuman MI. Risk of Subsequent Pneumonia After a Negative Chest Radiograph in the ED. Pediatrics. 2025 Apr 7:e2024069829. doi: 10.1542/peds.2024-069829. Epub ahead of print. PMID: 40189217. |
Bottom Line: Development of pneumonia after a negative chest xray is quite rare (0.27% based on this relatively large study). Watch out for specific findings such as tachypnea, hypoxemia, and signs of dehydration. I think this also highlights the importance of REALLY GOOD RETURN PRECAUTIONS. Tell parents to come back if their child develops X, Y or Z, "or if anything else changes that you're concerned about."
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Title: IV Fluids in DKA
Author: Seth Ball Keywords: Diabetes, DKA, IV fluids Reference Article: Agarwal A, Jayashree M, Nallasamy K, Dayal D, Attri SV. 0.9% Saline versus Ringer's lactate as initial fluid in children with diabetic ketoacidosis: a double-blind randomized controlled trial. BMJ Open Diabetes Res Care. 2025 Apr 7;13(2):e004623. doi: 10.1136/bmjdrc-2024-004623. PMID: 40194836 |
Bottom Line: In this smaller study out of India (generalizability?), pediatric patients presenting in DKA had faster resolution of DKA when Lactated Ringers was used as the initial fluid for resuscitation/rehydration compared to 0.9% NS.
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Title: Dextrose in IVF
Author: Seth Ball Keywords: gastroenteritis, vomiting, diarrhea, IV fluids, hypoglycemia Reference Article: Santamaria, Christina MD*; Péloquin, Fannie MD, FRCPC†; Mousseau, Sarah MD, FRCPC*; Gravel, Jocelyn MD, MSc, FRCPC*. Impact of the Amount of Intravenous Glucose Administration on Hospitalization for Acute Gastroenteritis in a Pediatric Emergency Department. Pediatric Emergency Care 41(3):p 176-182, March 2025 |
Bottom Line: in this retrospective cohort study, for every 100mg/kg increase of dextrose given in the patients' IVF rehydration, there was a decrease in the likelihood of hospitalization and return visit.
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Title: Testicular Torsion Scoring
Author: Seth Ball Keywords: Testicular Torsion, male GU Reference Article: Schultz-Swarthfigure CT, Kelly AM. UnTWISTing the BALS: A study of predictive accuracy of clinical scoring tools for testicular torsion identification in adults. Emerg Med Australas. 2025 Feb;37(1):e14479. doi: 10.1111/1742-6723.14479. Epub 2024 Aug 12. PMID: 39129651. |
Bottom Line: The TWIST score performed slightly better. A TWIST score ≥3 had a 92% sensitivity, and a score of 6-7 had 80% PPV. A BAL score ≥2 also had a sensitivity of 92% with a slightly lower specificity. The negative predictive value of each of these was 97% and 95%, respectively.
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Title: Management of Streptococcal Pharyngitis
Author: Sandra Horning Keywords: Group A strep, Pharyngitis, antibiotics Reference Articles: -Group A Streptococcal Tonsillopharyngitis in Children and Adolescents: Clinical Features and Diagnosis; UpToDate: January 2025 (Ellen R. Wald, MD) -Treatment and Prevention of Streptococcal Pharyngitis in adults and Children; UpToDate: January 2025 (Michael E. Pichichero, MD) -Accuracy and Precision of the Signs and Symptoms of Streptococcal Pharyngitis in Children: A Systematic Review; Shaikh N, Swaminathan N, Hooper EG, Journal of Pediatrics 2012; 160:487. |
Bottom Line: Recent discussions on Group A Streptococcus (GAS) treatment in children emphasize evidence-based indications for antibiotic use, including confirmed symptomatic cases in children over age 3, suspected or confirmed acute rheumatic fever, and symptomatic infants with household GAS contacts. Recommended first-line treatment is amoxicillin, with alternatives like azithromycin or clindamycin for those with allergies or resistance concerns.
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Title: Furosemide to Fill the Bladder in Suspected Ovarian Torsion
Author: Seth Ball Keywords: ovarian torsion, ultrasound Reference Article: Jersey C, Heggland A, Moote D, Brimacombe M, Chicaiza H. Furosemide use to expedite bladder filling in pediatric females with suspected ovarian torsion: A randomized controlled pilot study. Am J Emerg Med. 2025 Jan 31;90:205-209. doi: 10.1016/j.ajem.2025.01.082. Epub ahead of print. PMID: 39922106. |
Bottom Line: In this small pilot study, in pediatric patients presenting with concern for ovarian torsion, IV Lasix at 0.1mg/kg (max of 5mg) significantly decreased time to full bladder, time to completion of radiology-performed ultrasound, and time to official radiology read. Consider using this method next time you find yourself ordering fluids for the patient awaiting a full bladder for pelvic US.
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Title: Elbow DIslocations
Author: Seth Ball Keywords: elbow dislocation, reduction technique, musculoskeletal injury Reference Article:s -Gottlieb M. Managing Elbow Dislocations. Ann Emerg Med. 2022 Nov;80(5):460-464. doi: 10.1016/j.annemergmed.2022.04.029. Epub 2022 Jun 16. PMID: 35717272. -Journal Feed article summarizing the above article: How to Perform Seven Elbow Dislocation Reduction Techniques https://journalfeed.org/article-a-day/2022/how-to-perform-seven-elbow-dislocation-reduction-techniques/ |
Bottom Line: consider the hanging-arm technique for elbow dislocations. Note- I did not prone my most recent patient- once sedated with ketofol we sat him up straight and put his elbow over the bedrail hanging at 90 degrees and applied traction while flexing the hand back toward his body.
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Title: IV Ondansetron Effect on QT Interval
Author: Seth Ball Keywords: gastroenteritis, nausea and vomiting, EKG, QT prolongation Reference Article: Yürük Mısırlıoğlu H, Öztürk İnce E, Akkaş M. The effect of intravenous ondansetron on QT interval in the emergency department. Am J Emerg Med. 2024 Nov;85:7-12. doi: 10.1016/j.ajem.2024.08.011. Epub 2024 Aug 10. PMID: 39153265. |
Bottom Line: IV Ondansetron caused a rapid, brief and mild QT prolongation (average 8ms, peak effect at 5 min) in this large ADULT study.
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Title: 1st Generation Antihistamines and Seizures
Author: Rusty Walker Keywords: seizures, Antihistamines, medication side effects Reference Article: Kim JH, Ha EK, Han B, et al. First-Generation Antihistamines and Seizures in Young Children. JAMA Netw Open. 2024;7(8):e2429654. doi:10.1001/jamanetworkopen.2024.29654 |
Bottom Line: Kids who got prescriptions for 1st generation antihistamines had a 22% higher risk of seizures in this Korean Cohort study.
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Title: Post-Tonsillectomy Hemorrhage
Author: Seth Ball Keywords: Bleeding, hemorrhage, tonsillectomy, TXA Reference Articles: -Maksimoski M, McCauley M, Osoba M, Pirotte M, Liddy W. Treatment of Post-Tonsillectomy Hemorrhage With Nebulized Tranexamic Acid: Initial Investigation of a Novel Therapeutic Modality. Ann Otol Rhinol Laryngol. 2024 Aug;133(8):729-734. doi: 10.1177/00034894241254697. Epub 2024 May 27. PMID: 38801210. -Shin TJ, Hasnain F, Shay EO, Ye MJ, Matt BH, Elghouche AN. Treatment of post-tonsillectomy hemorrhage with nebulized tranexamic acid: A retrospective study. Int J Pediatr Otorhinolaryngol. 2023 Aug;171:111644. doi: 10.1016/j.ijporl.2023.111644. Epub 2023 Jul 6. PMID: 37423163. |
Bottom Line: Nebulized TXA (500mg-1g) for post-tonsillectomy hemorrhage can help prevent need for operative intervention and can decrease rates of rebleeding.
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Title: Laceration Repair
Author: Seth Ball Keywords: laceration repair, sutures, dermabond, steri-strips Reference Article: Barton MS, Chaumet MSG, Hayes J, Hennessy C, Lindsell C, Wormer BA, Kassis SA, Ciener D, Hanson H. A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatr Emerg Care. 2024 Oct 1;40(10):700-704. doi: 10.1097/PEC.0000000000003244. Epub 2024 Aug 2. PMID: 39141836; PMCID: PMC11560696. |
Bottom Line: in this small, randomized trial, Dermabond showed non-clinically signifcant improved outcomes compared to stitches and steri-strips in terms of pain, patient satisfaction and cosmetic results at 3 months as interpreted by parents for simple lacerations. Keep using dermabond for these simple lacs, and have this data in your back pocket to reassure parents when needed.
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Title: Lactated Ringers vs Normal Saline in Sickle Cell Crisis
Author: Rusty Walker Keywords: IV Fluids, sickle cell, vaso-occlusive crisis Reference Article: Alwang, A. K., Law, A. C., Klings, E. S., Cohen, R. T., & Bosch, N. A. (2024). Lactated Ringer vs Normal Saline Solution During Sickle Cell Vaso-Occlusive Episodes. JAMA Internal Medicine. |
Bottom Line: Multicenter cohort study in adults showed that Lactated Ringers is better than Normal saline in fluid management for sickle cell vaso-occlusive episodes.
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Title: UTI cutoffs
Author: Ami Shah Keywords: Urinary Tract Infections, UTI, urine culture Reference Article: Shaikh N, Lee S, Krumbeck JA, Kurs-Lasky M. Support for the Use of a New Cutoff to Define a Positive Urine Culture in Young Children. Pediatrics. 2023 Oct 1;152(4):e2023061931. doi: 10.1542/peds.2023-061931. PMID: 37691613; PMCID: PMC10914346. |
Bottom Line: Conventional culture remains an accurate method of diagnosing UTIs in young children; however, these data suggest that a cutoff of 10,000 CFU/mL provides the optimal balance between sensitivity and specificity for children undergoing bladder catheterization.
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Title: Teaching Kids CPR
Author: Seth Ball Keywords: CPR, bystander CPR, out-of-hospital cardiac arrest, outreach Reference Articles: -Schroeder DC, Semeraro F, Greif R, et al. KIDS SAVE LIVES: Basic Life Support Education for Schoolchildren: A Narrative Review and Scientific Statement From the International Liaison Committee on Resuscitation [published correction appears in Circulation. 2023 Jul 4;148(1):e1. doi: 10.1161/CIR.0000000000001166]. Circulation. 2023;147(24):1854-1868. doi:10.1161/CIR.0000000000001128. -Borovnik Lesjak V, Šorgo A, Strnad M. Retention of Knowledge and Skills After a Basic Life Support Course for Schoolchildren: A Prospective Study. Inquiry. 2022 Jan-Dec;59:469580221098755. doi: 10.1177/00469580221098755. PMID: 35652386; PMCID: PMC9168916. |
Bottom Line: CPR should be introduced to elementary school children and yearly or twice yearly training can aid in knowledge retention.
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Title: High Dose Magnesium in Severe Asthma
Author: Rusty Walker Keywords: asthma, Wheezing, magnesium Reference Article: Irazuzta, J. E., Paredes, F., Pavlicich, V., & Domínguez, S. L. (2016). High-Dose Magnesium Sulfate Infusion for Severe Asthma in the Emergency Department: Efficacy Study. Pediatric Critical Care Medicine, 17(2), e29–e33 |
Bottom Line: Small study in 2016 showed that high dose Mg (50mg/kg/hr over 4 hours) in the pED decreased admissions, upgrades, and healthcare costs for severe asthma exacerbations.
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Title: Femoral IO
Author: Seth Ball Keywords: Intraosseous line, IO insertion, resuscitation Reference Articles: -Zitek T, Antevy P, Garay S, Thorn M, Buckley E, Coyle C, Scheppke KA, Farcy DA. Evaluating the Success Rate of Distal Femur Intraosseous Access Attempts in Pediatric Patients in the Prehospital Setting: A Retrospective Analysis. Prehosp Emerg Care. 2024 Sep 4:1-8. doi: 10.1080/10903127.2024.2398185. Epub ahead of print. PMID: 39230342. -https://dontforgetthebubbles.com/intraosseous-access/ |
Bottom Line: This study showed the distal femur to be a good option for IO insertion, comparable in both success rates and complications when compared to the proximal tibia. Dont forget to consider distal femur as a location for IO insertion if distal tibia is unsuccessful or otherwise contraindicated.
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Title: Cushing Syndrome
Author: Ami Shah Keywords: Cushing Syndrome, hypertension Reference Article: Parish A, Cheung C, Ryabets-Lienhard A, Zamiara P, Kim MS. Cushing Syndrome in Childhood. Pediatr Rev. 2024 Jan 1;45(1):14-25. doi: 10.1542/pir.2022-005732. PMID: 38161162. |
Bottom Line: Consider Cushing Sydndrome in pediatric patients presenting with hypertension
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Title: C-Spine Injury in Children
Author: Rusty Walker Keywords: pediatric trauma, cervical spine injury, PECARN C-spine Reference Article: Leonard JC, Harding M, Cook LJ, Leonard JR, Adelgais KM, Ahmad FA, Browne LR, Burger RK, Chaudhari PP, Corwin DJ, Glomb NW, Lee LK, Owusu-Ansah S, Riney LC, Rogers AJ, Rubalcava DM, Sapien RE, Szadkowski MA, Tzimenatos L, Ward CE, Yen K, Kuppermann N. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. 2024 Jul;8(7):482-490. doi: 10.1016/S2352-4642(24)00104-4. Epub 2024 Jun 4. PMID: 38843852; PMCID: PMC11261431. |
Bottom Line: CSI in children remains uncommon but potentially devastating; however indiscriminate neck imaging after trauma unnecessarily exposes children to ionizing radiation. Hopefully this prediction rule will help to mitigate both risks. If they are in a bad way, scan them. If the exam is nuanced, start with an x-ray. If there is no risk, take off the collar.
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Title: Pneumonia and Wheezing
Author: Yaron Ivan Keywords: pneumonia, Wheezing Reference Article: Mathews B, Shah S, Cleveland RH, Lee EY, Bachur RG, Neuman MI. Clinical predictors of pneumonia among children with wheezing. Pediatrics. 2009 Jul;124(1):e29-36. doi: 10.1542/peds.2008-2062. PMID: 19564266. |
Bottom Line(s):
1. Among the “historical Features”, Fever was the only one that was statistically significant AND had a positive LR. - so asking the parents about fever is important. 2. Among the examination findings - Respiratory distress was useless (not statistically significant) but the higher temp clearly correlated with findings of Pneumonia on CXR. (Look at the P value and the value of the LR) 3. Triage oxygen sat also correlated with pneumonia (if the pt was less than 92% or 90%). Read more... |
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Title: Pediatric Appendicitis
Author: Seth Ball Keywords: appendicitis, ultrasound Reference Article: Pernía J, Cancho T, Segovia I, de Ponga P, Granda E, Velasco R. Predictive values of indirect ultrasound signs for low risk of acute appendicitis in paediatric patients without visualisation of the appendix on ultrasound. Emerg Med J. 2024 Jul 22;41(8):475-480. doi: 10.1136/emermed-2023-213466. PMID: 38729752. |
Bottom Line: even if the appendix is not visualized, US can be helpful in ruling out appendicitis in patients with an Alvarado score under 7, no free fluid, and no peri-appendiceal fat inflammation.
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Disclaimer: The information in this writing is the opinion of the authors and does not necessarily represent the official opinion of the University of Nevada- Las Vegas School of Medicine or the Department of Emergency Medicine at the University of Nevada-Las Vegas School of Medicine.
For Health Care Practitioners: This writing is provided only for medical education purposes. Although the authors have made every effort to provide the most up-to-date evidence-based medical information, this writing should not necessarily be considered the standard of care and may not reflect individual practices in other geographic locations.
For the Public: This writing is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Your physician or other qualified health care provider should be contacted with any questions you may have regarding a medical condition. Do not disregard professional medical advice or delay seeking it based on information from this writing. Relying on information provided in this writing is done at your own risk. In the event of a medical emergency, contact your physician or call 9-1-1 immediately.
For Health Care Practitioners: This writing is provided only for medical education purposes. Although the authors have made every effort to provide the most up-to-date evidence-based medical information, this writing should not necessarily be considered the standard of care and may not reflect individual practices in other geographic locations.
For the Public: This writing is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Your physician or other qualified health care provider should be contacted with any questions you may have regarding a medical condition. Do not disregard professional medical advice or delay seeking it based on information from this writing. Relying on information provided in this writing is done at your own risk. In the event of a medical emergency, contact your physician or call 9-1-1 immediately.
