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All the information here is collected from the internet, and it might be out of date or inaccurate, so please use your judgement and adhere to your hospital's protocols.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.

Saturday 24 August 2019

Headaches in Children

Headaches need a good history in children - just like in adults! Unlike in adults, a head circumference is really important.
If the headache is in a <5 year old refer to paeds.

Brain Tumour
Headache for more than 2 weeks with any other symptoms should get imaged - preferably with an MRI, but if not available a contrast CT.

Similar to in adults.

Bacterial meningitis is an infection of the surface of the brain (meninges) by bacteria that have usually travelled there from mucosal surfaces via the bloodstream.

Meningococcal disease occurs as a result of a systemic bacterial infection by Neisseria meningitidis (meningococcus).


GI Bleeding in Children

As far as I can tell, GI bleeding seems to be similar to in adults.

There might be an intussusception.
There might be an anal fissure (common).
They might need an IO for access.

Other References

Ear Problems

Otitis Media
Any upper respiratory tract infection (often bacterial - strep) but may be viral can cause inflammation of the respiratory mucosa, with obstruction of the eustacian tube isthmus, with results in accumulation of middle ear secretions. This causes negative pressure which pulls viruses and bacteria into the middle ear.
This increases the pressure causing otalgia and a bulging TM - the most obvious sign.
75 - 80% resolve by 72 hours - most are better by 3 days.

It is frequently overdiagnosed.

Complications include hearing loss, recurrent otitis media, perforation, labyrinthitis, mastoiditis, facial palsy, meningitis, cerebral abscess and venous sinus thrombosis.

Treatment is mostly with time. Watch and wait antibiotics may be useful.
Amoxicillin is the first choice if antibiotics actually needed (bilateral infection, longer than 3 days, systemically poorly)

There may be an associated effusion (glue ear). Consider a hearing assessment especially if recurrent.

Otitis Externa
This is often caused by bacteria and fungi, and less commonly viruses. The ear canal is swollen and sore with discharge- like a pimple. If there's mucous there, the discharge is probably from AOM. Treat with drops - antiseptic (acetic acid) and antibiotic (ciprofloxacin or aminoglycoside if no TM rupture).

Malignant Otitis Externa
Very painful and often in the elderly. Caused by pseudomonas.

Foreign Bodies in the Ear
Read this RCEMLearning article.

Nose Trauma
Nose trauma is common in children. There is a belief that nasal septal haematomas are more common - look for a cherry red haematoma in the nose.


Friday 23 August 2019

Other Rashes

Chicken Pox
Often blistering and crusting.
Incubation 10-21days
Infectivity when symptoms start

Starts from the top and moves down. Often associated with conjunctival problems.
Incubation 7 - 21days
Infective - before symptoms to four days after appearance of rash
Rash - maculopapular, spreads head downwards
One of cough, conjunctivities or coryza
- Get Koplik's spots, red throat
- throat swab
- notify if suspicious
- off school until 5 days after rash
- need immunoflobulin if under 12months, immunocompromised or pregnant.
- MMR if unimmunised within 72hours of exposure
MMR side effects are in the 2nd week after immunisation - fever and rash.

Rubella or German Measles
It's benign and self eliminating.
- 2 week incubation
- headache, fever, lymphadenopathy
- infective 7 days efore, 7 days after onset of rash
- rash face down to feet
- fever, tender occipital and post auricular lymphadenopthy, arthralgia
- Forschheimer spots - pin-point red macules and petechiae, seen on soft palate and uvula
- Immuniglobulin G and M assays

Slapped Cheek / Parvovirus / Fifth Disease 

Scarlet Fever
Pastias lines in the flexural folds with circumoral pallor, and pharyngitis. Desquamation of hands, feet and groin. Rash has a sandpaper-link quality.
- 2-5 days incubation
- infective 5 days from antibiotics
- sore throat, headache, fever, lymphadenopathy, malaise, abdopain. Sandpaper-like rash
  Strawberry tongue, pastias lines, circumoral pallor, pharyngitis, desquamation of hands feet and groin.
- notify clinical suspicion
- off school 5 days after antibiotics (HPA)
- for grop A strep tonsillitis 24hours off after antibiotics.

The roseola rash often appears after the fever has settled.
Herpes virus
Fever + febrile illness
5-15days incubation
Respiratory illnesss, 3-5days fever, cervical lymphadenopathy
Rash from behind ears - blanching macules and papules surrounded by halos
Nagayama's spots- erythematous papules on the soft palate

Other References

Rashes in Children

Eczema and Seborrhoeic Dermatitis
Are essentially the same thing, and I think don't forgetthebubbles have it covered!

Bites and Infestations 
Lyme disease causes erythema migrans (pathognomic). If rash present treat - otherwise test. You can get a Jarisch-Herxheimer reaction  - normally self limiting. Don't give routine prophylactic antibiotics. Remove a tip with direct forceful pressure. 

Dog Bites
Probably OK for primary closure, and no routine prophylactic antibiotics. 
Human Bites
Prophylactic antibiotics - always. Don't close if over 24hours old. Remember tetanus and BBV prophylaxis.

The classic burrows may be difficult to see in children. May look a bit pustular - but always VERY itchy! Treat with permethrin.

Head Lice or Nits
Can you read this without itching?


Thursday 22 August 2019


Most of the tonsillitis syllabus has already been covered elsewhere.

Post Tonsillectomy Bleeding 
Tonsillitis - see adult notes 
     Great resource from DFTB
FB in the throat (aka choking)

Wednesday 17 July 2019

Purpura in Children

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

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.