Welcome

I struggled to find PEM resources for my CT3 year, despite the variety of excellent resources out there. I hope this website will help point you in the right direction. I'm not a PEM expert, but am following the guidance CEM have issued (in the form of a syllabus) to put together this page. This page is not endorsed by CEM, and any mistakes are mine.

Please comment with corrections, additions and further suggestions.

All the information here is collected from the internet, and it might be out of date or inaccurate, so please use your judgement and adhere to your hospital's protocols. If you do notice any errors or omissions please comment so we can put them right!

To navigate, decide whether you want to start with a PMP or a PAP. You can then select which PMP or PAP you want to look at. You will then be taken to the summary page for that PMP, with links expanded topic collections. If you know what topic you want to look at already, click on the link on the right hand side.

Wednesday, 17 July 2019

Purpura in Children

HSP
Vasculitis with arthralgia, abdo pain, and or renal involvement. Purpura occurs in all patients. The rash is distinctive. Urinalysis is needed - manage with analgesia. Consider steroids.

A first episode of HSP usually resolves within 4 weeks with the rash being the last symptom to go.
Joint pain usually resolves spontaneously within 72 hours and abdo pain in 24- 48 hours.
Uncomplicated abdominal pain usually resolves spontaneously within 24-48 hours

ITP
Covered on DFTB.

Petechial Rash 
The flow chart on this website is useful for highlighting when to investigate but this one is probably the best.
NICE say give ceftriaxone if:
  petechiae start to spread
  the rash becomes purpuric
  there are signs of bacterial meningitis
  there are signs of meningococcal septicaemia
  the child or young person appears ill to a healthcare professional
A non specific viral illness is the most likely cause of the rash.

References
https://www.rcemlearning.co.uk/foamed/7-pem-rashes/
https://dontforgetthebubbles.com/henoch-schonlein-purpura-steroids-helpful-preventing-nephropathy/
https://www.rch.org.au/clinicalguide/guideline_index/HenochSchonlein_Purpura/
http://www.clinicalguidelines.scot.nhs.uk/ggc-paediatric-guidelines/ggc-guidelines/emergency-medicine/non-blanching-rash-management-in-children/
https://dontforgetthebubbles.com/itp-idiopathic-thrombocytopenia-purpura/

Sunday, 14 July 2019

BRUE

A BRUE or an ALTE needs thorough history taking and examination.

It is defined as:

“an episode that is frightening to the observer and that is
characterized by some combination of apnea (central or obstructive), color
change (usually cyanotic or pallid, but occasionally erythematous or plethoric)
marked change in muscle tone (usually marked limpness), choking"

ie Apnoea, Looks Different, Tone different, Exhibits unconsciousness

If this occurs whilst the child is sleeping, it may be apnoea of infancy. The child may also have insomina, hypersomnia etc. History will be key!


Take a careful history. And if there are no high risk features, the child can probably go home.
References
https://pedemmorsels.com/brue/
http://dontforgetthebubbles.com/brue-is-the-new-black/ 
http://www.stemlynsblog.org/alte-brue/
http://foamcast.org/2016/05/04/episode-49-the-aap-brue-guidelines/
https://www.ncbi.nlm.nih.gov/pubmed/15499062
https://www.gosh.nhs.uk/conditions-and-treatments/conditions-we-treat/central-sleep-apnoea-syndrome-csa
http://sleepeducation.org/sleep-disorders-by-category/sleep-breathing-disorders/infant-sleep-apnea/overview-facts
https://www.rcemlearning.co.uk/foamed/pem-and-ex-prems/
https://www.rcemlearning.co.uk/reference/myocarditis/
https://www.rcemlearning.co.uk/modules/causes-and-management-of-myocarditis/

Self Harm in Children

From a medical point of view, it is worth remembering that especially in toddlers who have a low mass, one pill can kill. Especially:
- Cardiac drugs
- Antidiabetics
- Antidepressents
- Iron, vicks, pepto - bismul (contains salicylates)

From a mental health point of view - remember to complete all safeguarding paperwork, and encourage talking and communication.


Your thorough HEADSSS assessment will help make sure all important points are covered.

References
https://pemgeek.com/2016/10/27/one-pill-killers/
https://www.nice.org.uk/guidance/cg133/resources/selfharm-in-over-8s-longterm-management-pdf-35109508689349
https://www.nice.org.uk/guidance/cg16/resources/selfharm-in-over-8s-shortterm-management-and-prevention-of-recurrence-pdf-975268985029
https://www.health.gov.au/internet/publications/publishing.nsf/Content/triageqrg~triageqrg-mh
https://www.rcemlearning.co.uk/curriculum/paeds-acute/pap2/
https://www.rcemlearning.co.uk/modules/paediatric-toxicology-considerations/
https://youngminds.org.uk/find-help/for-parents/parents-guide-to-support-a-z/parents-guide-to-support-self-harm/
https://www.nspcc.org.uk/preventing-abuse/keeping-children-safe/self-harm/
https://www.rcemlearning.co.uk/foamed/the-3cs-of-paediatrics/

Kawasaki Disease

Medium sized artery vasculitis in children under five years old.
Unknown aetiology but possibly infection.
Higher risk in Asians, especially Japenese and Koreans.

Signs
or
In the absense of inflammation (high WCC or CRP) Kawasaki is unlikely.
Don't wait for fever >5 days to diagnose it though - it might be incomplete.

https://www.rcemlearning.co.uk/foamed/a-child-with-a-fever/
https://adc.bmj.com/content/99/1/74
https://www.paediatricfoam.com/2017/06/kawasaki-disease-pearls-and-pitfalls/?subscribe=success#blog_subscription-4
http://dontforgetthebubbles.com/kawasaki-disease-beware-the-incomplete/
http://rolobotrambles.com/notjustafever/
https://calgaryguide.ucalgary.ca/wp-content/uploads/image.php?img=2017/05/Kawasaki-Disease.jpg

Thursday, 6 July 2017

Nasal Foreign Body

Nasal foreign bodies are surprisingly common. The technique is not too dissimilar to that of removing auricular foreign bodies. In theory, they might be hidden behind a turbinate and tricky to see - and therefore tricky to remove.

1. Mother's Kiss
This works in 60% of cases. Occlude patent nostril. Get Mum to blow into the mouth. You can do this with a BVM if needed - but be careful the pressure isn't too high.

2. Suction
Like with FBs in the ear, gentle suction, can help. I guess glue could too - although I haven't seen any case reports of this.

3. Curved Needles
If you can't find one, as we can never find them in the ED, bend a green needle, and that should help!

4. Foley Catheter
Inflate baloon with 0.5 - 3ml water or air. Insert it behind the foreign body, and then pull. I've never tried this, but it seems to be really frequently used outside the UK!

References
http://journals.lww.com/em-news/blog/M2E/Pages/post.aspx?PostID=17
http://www.emdocs.net/ear-nose-throat-foreign-bodies/ 
https://wikem.org/wiki/Nasal_foreign_body 
http://pmj.bmj.com/content/76/898/484
http://epmonthly.com/article/how-to-remove-a-nasal-foreign-body-with-a-balloon-catheter/
https://lifeinthefastlane.com/nasal-foreign-bodies/
http://www.racgp.org.au/download/Documents/AFP/2013/May/201305handi.pdf 
http://emedicine.medscape.com/article/763767-overview?pa=kFsFTvrB8j%2FPtwK%2BOEAs61ub09VNBtvaAN6mPVwMp%2FDFndF9mwj4ym0rESwqOfDUa5AxknqcRm1Zi18mAza%2B0XnZ5j5IICuJuaa3Z%2BY2XGY%3D#a4

Ear Foreign Bodies

Extracting foreign bodies from the ear can be very painful, and it is easy to impact them where the auditory canal narrows. 75% of patients with ear foreign bodies are younger than eight.

To start with:
- Check if there's a tympanic membrane perforation. If you can't see whether there is or not, that makes things trickier.
- Position the patient comfortably and securely
- Consider anesthetising the ear - some lignocaine dripped in may well help. Blocks don't tend to be too helpful - if this fails, think about general anaesthesia or sedation.
- Check whether you should be removing this. ENT should help with button batteries, sharp objects, tightly wedged FBs, and FBs you can't remove after multiple attempts.
- When successfully removed, double check you've removed it. Consider prophylactic antibiotic drops.

Potential Methods: 
1. Forceps Removal
If the FB is "graspable" this can be useful.

2. Irrigation
This is especially useful if there is a live insect in the ear. The insect must be killed with alcohol, 2% lignocaine or mineral oil - but hopefully you can check there is no tympanic membrane perforation first. Once the insect is dead, suction might remove it more effectively than grasping or forceps as this can cause shedding. Until the insect is dead, remember it might try to fly towards the otoscope light - this can be uncomfortable for the patient!
Don't irrigate button batteries in the ear.
Don't irrigate organic matter that might swell, and get wedged.
Don't forget to use warm water - as the patient won't thank you if the water is cold, as it can cause vertigo and vomiting. If you're having trouble directing the irrigation, think about getting a cannula (needle out) connected to a syringe (that you can gently flush).

3. Modified Suction
We don't have microsuction like ENT do, but cutting a 12Fr suction catheter short, and then applying gentle suction, may help. Equally, cutting the soft tubing from a butterfly needle, and using that for suction may help.

4. Glue
A bit of wound glue on the end of a syringe or Q tip can adhere to the foreign body and pull it out. You're going to have to be pretty convinced you're going to get the Foreign Body out, and not just stick the FB further to the ear canal! If you do this, it might be worth putting an ear speculum on the foreign body, then guiding the glue in that way - it protects the rest of the ear canal. You really do need a compliant patient.

5. Magnets
A small magnet may help remove a magnetic foreign body.

References
https://www.aliem.com/2017/05/pem-search-rescue-ear-foreign-bodies/
http://www.bcmj.org/article/removal-ear-canal-foreign-bodies-children-what-can-go-wrong-and-when-refer
https://www.aliem.com/2011/06/trick-of-trade-mini-suction-device/
https://www.aliem.com/2015/08/trick-of-the-trade-ear-foreign-body-removal-with-modified-suction-setup/
http://www.emdocs.net/ear-nose-throat-foreign-bodies/ 
AFP
https://www.aliem.com/2014/10/trick-of-trade-insect-removal-from-the-ear/ 
https://www.aliem.com/2016/08/trick-of-trade-ear-irrigation/ 
https://www.aliem.com/2012/05/trick-of-trade-ear-foreign-body-2/ 
http://pedemmorsels.com/ear-foreign-body/
http://emj.bmj.com/content/17/2/91 
http://www.pemed.org/blog/2014/4/9/anyone-seen-my-corn-pediatric-foreign-bodies.html
http://emj.bmj.com/content/22/4/266
https://wikem.org/wiki/Ear_foreign_body 
http://emblog.mayo.edu/2017/04/04/stick-glue-and-cone-for-ear-foreign-bodies/
https://entsho.com/removing-foreign-bodies/

Thursday, 27 October 2016

Collapsed Neonates

Resuscitate
As per appropriate
Adrenaline 10mcg/kg

Prostin -  
    - 5 ng/kg/min if clinically well
    - 20 ng/kg/min if unstable or absent femoral pulses
    - 50-100 ng/kg/min if no response
Apnoea common: 1st hr of Rx, dose
Hypotension may occur with high dose

Prostin
- 5 ng/kg/min if clinically well
- 20 ng/kg/min if unstable or absent femoral pulses
- 50-100 ng/kg/min if no response
Apnoea common: 1st hr of Rx, dose

Hypotension may occur with high dose

Think about Causes
Infection
Group B strep, E Coli - PROM, maternal GBS, fever in labour
Herpes Simplex - GCS, coagulopathy, ALT, family cold sores
MRSA - Unresponsive 1st line antibiotics,+ contact

Cardiac
Coarctation aorta - Systolic arm/leg gradient > 20 mmHg
Hypoplastic Left heart - Poor pulses –may be pink= pulm. overcirculation
Transposition (TGA) - Preductal sats < post ductal sats
TAPVD (obstructed) - Shocked & cyanosed/CXR plethoric
SVT  - HR>220 despite fluid, f ixed HR, narrow QRS
Myocarditis - Cardiac failure, tachycardia, small QRS

Injury 
Intracranial bleed  - Focal neuro signs, fontanel le , retinal bleeds
Intrabdominal bleed - Unexplained anaemia, abdominal bruising

Cardiac

Metabolic
Vomiting, reduced GCS, hypoglycaemia
Stop the feeds. Give fluid and dextrose as highly likely to be fluid depleted

References
http://paediatricem.blogspot.co.uk/search/label/NLS
http://www.rcemlearning.co.uk/references/congenital-heart-disease/ 
http://www.rcemlearning.co.uk/modules/the-shocked-neonate/ 
http://www.rcemfoamed.co.uk/portfolio/metabolic-babies-in-the-ed-easy-as-1-2-3/