SMH ER

Keeping Up To Date

Jo Miriam

Needle Decompression

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Case: A helmeted 13-yo-boy carrying a friend on his e-scooter ran into a pole and was pinned against the handle. He was brought in by his parents for chest pain from periphery to SMH. His CXR shows rib fractures and a tension hemopneumothorax. He is hypoxic and requires a decompression. What is the ideal location for needle decompression according to 2025 ATLS?

Discussion: 2025 ATLS recommends 2nd ICS at midclavicular line in peds and 4th/5th ICS anterior to midaxillary line in adults. Transition from peds to adult for placement site is considered based on chest wall thickness and patient size (around age 13). See latest EB article for a deeper dive.

Thoracostomy-Thoracotomy-PediatricDownload

Ear Rash

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Case: A 5 year-old boy presents with scaly plaques affecting both ears. They are itchy with crusty vesicular lesions. He is not responding to mupirocin. This happened last spring as well. 

Discussion: These lesions are Juvenile Spring Eruptions (JSE). They are caused by an immune response to UV radiation often in the spring, after the first significant sun exposure, more commonly in boys and young men who are more likely to have their ears exposed to sunlight. They can be treated with mineral-based SPF 30 sunscreens and nonsteroid anti-inflammatories i.e. protopic 0.1% oint BID until improved.  

PEM Articles of the Month- March 2026

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1) Does a well-appearing 10-day-old with a rectal temp of 38.4 °C in the ED always require an LP?

Discussion : The answer depends on whether you have access to procalcitonin! We currently perform LP, start ABx, and admit all febrile neonates. The first two articles inform us in a well-appearing febrile neonate with PCT ≤ 0.5 ng/mL, ANC ≤ 4000/μL and negative UA, LP and Abx could be deferred. Close observation while waiting for urine/blood C/S is required. In a series of 1537 patients, no neonates meeting low-risk criteria had meningitis. This is why access to PCT is something we should strive for in our PEDS ED.

Just the Facts Management of Febrile Infants 60 Days old and YoungerDownload
Prediction_of_Bacteremia_and_Bacterial_Meningitis_Among_Febrile_InfantsDownload

2) Do you need to perform LP in febrile infants 29-60 days of age who have a positive UA?

Discussion : For decades, we subjected these infants to LP, ABx, and hospitalization based on the assumption that a positive UA results in increased risk of meningitis. The third article is a large meta-analysis suggesting rate of concomitant meningitis in this population is low and LP should not be undertaken on the basis of a positive UA alone.

bacteria meningitis in 29-60 daysDownload

PEM Article of the Month- February 2026

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Emergency Department Management of Dehydration in Pediatric Patients

Dehydration in Pediatric PopulationDownload

Key Points:

  1. Zinc supplementation may lead to shorter duration and reduced severity of diarrheal illness. 
  2. ETCO2 can be used as a non-invasive adjunct for detection of metabolic acidosis in children with dehydration. 
  3. Balanced isotonic solutions such as Plasmalyte are preferred to avoid hyperchloremic metabolic acidosis. Its use in our department is limited due to IV compatibility concerns. 
  4. Dextrose should only be used after rehydration to assist with resolving ketosis. 

PEM Article of the Month- January 2026

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Influenza-Associated Acute Necrotizing Encephalopathy in US Children

Influenza associated acute necrotizing encephalopathy in US children (1)Download

Takeaway messages:

  • Influenza can cause acute necrotizing encephalitis (ANE).
  • This condition has high morbidity and mortality. 
  • Median age is 5 years and it is more common among those not flu-immunized.
  • ANE should be suspected in a child with ILI Sx’s presenting with altered LOC or seizures
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