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December 2022: Which is Best? Manual or Drill for IO Access in Neonates
Intraosseous (IO) vascular access use in children began in the 1940s, but the practice was abandoned when intravenous catheters were invented. A resurgence of interest in IO access began decades later, and the procedure was first added to the Pediatric Advanced Life Support guidelines in 1986. Intraosseous access has now become the preferred access method over central line placement and for peripheral IV access that takes longer than 30 seconds.Initially, manual intraosseous needles were used for neonatal resuscitations because they were the only tools available. Once we learned the skill, manual IO needles served their pu...
Source: M2E Too! Mellick's Multimedia EduBlog - November 30, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

November 2022: How to Kill Vampire Ticks Instantly
Yes, ticks are vampires. They need blood to progress from larva to nymph to adult and then for females to lay eggs. They can drink so much blood in one meal that they increase their weight several hundred times. Once engorged, they release their mouth attachments and fall off the host and progress to their next life stage.Ticks, depending on the species, can have up to three different hosts during a lifetime. Their complicated mouthparts—the hypostome, chelicera, and palp—allow the tick to attach and feed on animals and humans.The mouth of a tick. (Photo by the National Institutes of Health)Like most insects, ticks pro...
Source: M2E Too! Mellick's Multimedia EduBlog - October 31, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

October 2022: Baby Breathing Treatments—Are We Doing Them Wrong?
Children under 2 years of age who are wheezing may or may not have bronchiolitis syndrome. They could be experiencing the first wheezing episode of a young, aspiring asthma patient. Nevertheless, both conditions deserve treatment trials with a bronchodilator, yet there is significant concern in the literature that infants under 2 years old are less responsive to bronchodilator medications than older patients.This concern primarily stems from a perception of decreased responsiveness to medication in bronchiolitis patients. Truthfully, the vast majority of first-time wheezing episodes in children are associated with viral in...
Source: M2E Too! Mellick's Multimedia EduBlog - October 6, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

September 2022: The Torsed Testicle Traction Technique
I asked in my May blog whether immediate attempts at manual reduction of a testicular torsion should be the standard of care. Without a doubt, timely manual detorsion of a torsed testicle saves the organ from death. (Pediatr Emerg Care. 2019;35[12]:821; Pediatr Emerg Care. 2012;28[1]:80; https://bit.ly/3T9W0N0.)The detorsion procedure is sometimes quick and easy, but other times it is technically difficult and even unsuccessful. Unfortunately, many physicians are hesitant to attempt manual detorsion because they lack procedural confidence or have anxiety about worsening the torsion.Testicles torsed for a prolon...
Source: M2E Too! Mellick's Multimedia EduBlog - August 31, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Nihilistic AAP Bronchiolitis Guidelines
​Not only has the COVID-19 pandemic killed millions of people, but it has also caused disruptions in every imaginable aspect of our lives. One has been the seasonality of other diseases like influenza and respiratory syncytial virus infection. RSV infection is typically a winter disease, but here we are in the summer months and our pediatric emergency department is flooded with infants infected with RSV.I expressed concern about the 2014 American Academy of Pediatrics bronchiolitis guidelines three years ago. (EMN. 2019;41[1]:31; http://bit.ly/2TlwNj9.) Those comments have proven to have real-life clinical releva...
Source: M2E Too! Mellick's Multimedia EduBlog - August 5, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Parenteral Diarrhea: Medical Myth or Reality?
Researchers have described parenteral diarrhea's association with extraintestinal infections for more than a century, but the evidence is impressively limited, which perpetuates claims that it is a medical myth and not an actual clinical entity.But it matters that noninfectious diarrhea and vomiting are sometimes associated with bacterial infections such as acute urinary tract infections because this can create diagnostic confusion. Diarrhea and vomiting in a girl or woman with a febrile UTI could lead to a misdiagnosis of acute gastroenteritis. Febrile UTIs are often pyelonephritis, so missing the diagnosis has significan...
Source: M2E Too! Mellick's Multimedia EduBlog - July 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

A New and Better Option for Ventilating Children
​You know the scenario: Someone in your department identifies a need for managing a child who can't be intubated or oxygenated. He assembles a 14-gauge catheter, a 3.0 ET tube adapter, and maybe a 3 mL syringe with some oxygen tubing and a Y adaptor or some other variation. Then he stuffs everything in a plastic bag and hangs it on the resuscitation room wall. Months or years go by, and eventually someone throws out the makeshift kit without inquiring why the yellowed, dusty plastic bag with assorted odds and ends of equipment was hanging on the wall.The truth is that needle transtracheal jet ventilation is almost ne...
Source: M2E Too! Mellick's Multimedia EduBlog - June 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Should Immediate Manual Testicular Detorsion Become the Standard of Care?
​Testicular torsion is a highly time-sensitive event for a patient and the survival of his testicle. The clock is ticking the minute the retracting cremasteric muscle starts the spermatic cord twisting. Does that mean an immediate attempt at manual detorsion should become a standard of care?The technique for detorsion is straight forward and relatively simple. Detorsion is described as opening a book. The twisting or unraveling procedure for the patient's left testicle is counterclockwise and clockwise for the right testicle. Torsion events more commonly occur as an inward twisting of the testicles, and the treatment is ...
Source: M2E Too! Mellick's Multimedia EduBlog - May 2, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

The Mysteries of Patella Dislocations
​The patella, the largest sesamoid bone of the body, resides within the patellar tendon and gives the quadriceps muscle mechanical advantage during knee extension. It also protects the knee joint. The flat triangular-shaped patella with its apex pointed downward consists of dense trabecular bone covered with a thin compact lamina.The patella develops embryologically from six ossification centers that ultimately fuse around ages 4 to 6. The patellar tendon attaches to the patella inferiorly, and the vastus medialis and lateralis attach medially and laterally. The quadricep muscle attaches at the top and anterior aspects o...
Source: M2E Too! Mellick's Multimedia EduBlog - April 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Painless Nasogastric Tube Placement
​A 6-year-old boy presented with intermittent abdominal pain, nausea, and vomiting. Because his abdominal examination was unremarkable, the pain intermittent, and constipation a possibility, we provided an enema along with an abdominal pain workup but no radiographs. His pain improved, the abdominal labs were unremarkable, and the child tolerated an oral fluid challenge after treatment with ondansetron.The mother was advised at discharge to return if she became concerned about her child's condition. They did return a few hours later for increased vomiting and abdominal pain. A CT scan demonstrated multiple dilated loops ...
Source: M2E Too! Mellick's Multimedia EduBlog - March 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Our Canary in the Coal Mine: The Rapid Viral Testing Mini-Lab
​Like a beggar telling other beggars where to find bread, I have to talk about our pediatric emergency department mini-lab for rapid viral testing and its undeniable positive impact on our practice during the pandemic. We had begun discussions with Abbott Laboratories months before the COVID-19 pandemic about setting up rapid testing for flu, RSV, and strep. Hospital administration approved moving forward with the concept, but like most big endeavors, administrative delays and other distractions resulted in many months passing without much apparent movement on the contract. And then it happened: The COVID-19 pandemic...
Source: M2E Too! Mellick's Multimedia EduBlog - February 1, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Ring Removal Techniques and Challenges
​Unfortunately, rings sometimes need to be removed emergently. Other times, ring removal is more prudent than emergent, such as when further swelling may occur (i.e., after distal radius fracture), preoperatively, prior to MRI, and postmortem. Allergic reactions, anasarca, digital trauma, age-related changes, late pregnancy, and excessive weight gain are common causes of acute and chronic changes in finger circumference.Metal rings also need to be removed emergently when placed on the penis and scrotum for sexual purposes and become entrapped. Cutting is generally the first line of management for removal.Scores of anecdo...
Source: M2E Too! Mellick's Multimedia EduBlog - January 4, 2022 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Treating Supraventricular Tachycardia in Newborns
​Supraventricular tachycardia (SVT) occurs when conduction of electrical impulses travels along an accessory connection from the atrium to the ventricle (atrioventricular reentry tachycardias) or when conduction takes place within the atrioventricular node (atrioventricular node reentry tachycardia). SVT is technically defined as pulse rates that exceed 180 bpm in children and adolescents and 220 bpm in infants.Infantile-onset SVT classically presenting in the first month or two of life is the most common sustained arrhythmia with an incidence of one in 250 infants. SVT is not uncommon with congenital heart disease, but ...
Source: M2E Too! Mellick's Multimedia EduBlog - December 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Properly Naming the Sinusitis-Otitis-Conjunctivitis Syndrome
One of our nonphysician providers recently announced, “This kid has that double-sickening thing you talk about all the time." She was referring to the sudden worsening of signs and symptoms (e.g., onset of fever) in a patient who had had an upper respiratory tract infection for several days.The majority of links in a Google search for “double-sickening" are references for sinusitis, but new-onset pneumonia is another double-sickening event. The Infectious Diseases Society of America guidelines for sinusitis acknowledge double-sickening and concur that pneumonia can present similarly. I investigate for sinusit...
Source: M2E Too! Mellick's Multimedia EduBlog - November 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs

Pediatric COVID-19 and Multisystem Inflammatory Syndrome in Children
​Since the start of global pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), at least four waves have occurred as mutations and variant strains have developed. During the first waves, adults were the primary target, but the highly infectious delta variant has been infecting children and unvaccinated adults with a vengeance.On this go-round, the delta variant is predominately infecting children. I am seeing reports of high school football games being canceled, schools deciding to go virtual, and occasional reports of teachers dying of COVID. I have never seen anything like this pandemic ...
Source: M2E Too! Mellick's Multimedia EduBlog - October 1, 2021 Category: Emergency Medicine Tags: Blog Posts Source Type: blogs