pediatric emergency medicine

The Five Canons of Levitan - Difficult Airway Part 3

Canon - a general law, rule, principle, or criterion by which something is judged

No one has changed the face of how we approach difficult airway more than Rich Levitan, MD.  In this episode I review five of Rich's most important contributions to how we approach emergent intubations.  These are techniques you can take to the department tomorrow to improve your view, increase your success, and save your patient's life! 

Click here to follow Dr. Levitan on twitter.

Click here to follow Dr. Levitan on twitter.

Levitan's best bougie techniques (includes Shaka, Kiwi and Ducanto)!

Levitan's best bougie techniques (includes Shaka, Kiwi and Ducanto)!

Child Abuse

It is hard to put into words or even imagine the concept of someone intentionally hurting a child, but it happens more frequently than we'd like to believe.  In this episode, I had the privilege of discussing some of the cornerstone exam findings and history flags for occult abuse with Marci Donaruma-Kowh, MD a child abuse expert from the Baylor College of Medicine ~ Texas Children's Hospital.  This episode will change the lens you view your pediatric patients through; even with those who have what appears to be the most mundane of injuries.  Unfortunately, abuse is not always overt and Dr. Donaruma is an expert in identifying the subtleties of this diagnosis, nailing the perpetrator, and making sure they go away for a long-long time...

If you know of a child that is being abused call the police now.  If you would like to refer a case and you are in the Houston area please click here: Children's Assessment Center.

Asthma and the Vent

                                                              TOP  =  AUTO PEEP        BOTTOM  =  NORMAL FLOW

                                                              TOP  =  AUTO PEEP        BOTTOM  =  NORMAL FLOW

Set the Vent in SIMV at 7cc/kg and an I:E ratio of 1:4/1:5 and check a blood gas!
— Andrew Sloas, DO, RDMS, FAAEM

iTunes Link

Wow!  We've made it to the end of three episodes on asthma.  We've covered everything from diagnosis to treatment and everything in between.  We now know how to best educate our patients to empower them to treat their disease at home and prevent recitivism! 

Tune in this episode for the specifics on how to use a Peak Flow Meter, Bi-Pap, EtCO2 and of course how to set-up the ventilator in a way to maximize support and minimize chances of injury in your asthmatics. 

EM Crit - Infamous Awake Sedated Video

EM Crit - Dominating the Vent Part 1

EM Crit - Dominating the Vent Part 2

Asthma Andrews Style - What's the best oral steroid you ask?

What's the best oral steroid to treat acute asthma exacerbations you may ask? Well, we're here to answer that for you.  Please welcome Dr. Annie Andrews, MD, MSCR who has written all the articles you will find listed below on just that subject.  In this podcast we will prove that dexamethasone is not only the most cost effective steroid to prescribe in asthma exacerbations, decreases recidivism, and has the best compliance rates, but it tastes great too!

Andrews AL, Simpson AN. Dexamethasone may be a viable alternative to

prednisone/prednisolone for the treatment of acute asthma exacerbation in the

paediatric emergency department. Evid Based Med. 2014 Jun 10. pii:

ebmed-2014-110006. doi: 10.1136/eb-2014-110006. [Epub ahead of print] PubMed

PMID: 24919976.

Andrews AL, Wong KA, Heine D, Scott Russell W. A cost-effectiveness analysis

of dexamethasone versus prednisone in pediatric acute asthma exacerbations. Acad

Emerg Med. 2012 Aug;19(8):943-8. doi: 10.1111/j.1553-2712.2012.01418.x. Epub 2012

Jul 31. PubMed PMID: 22849379.

Andrews AL, Teufel RJ, 2nd, Basco WT, Jr., Simpson KN. A Cost-Effectiveness Analysis of Inhaled Corticosteroid Delivery for Children with Asthma in the Emergency Department. Journal of Pediatrics. 2012 Nov;161(5):903-907

Keeney GE, Gray MP, Morrison AK, Levas MN, Kessler EA, Hill GD, Gorelick MH, Jackson JL. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014 Mar;133(3):493-9. doi: 10.1542/peds.2013-2273. Epub 2014 Feb 10. Review. PubMed PMID: 24515516; PubMed Central PMCID: PMC3934336.

Podcast 25 ~ Asthma and Steroids

Anyone Seen My Corn? Pediatric Foreign Bodies


How many times have you seen a square object inserted into a round hole.....of an ear canal???  It's quite a quandary and can be the source of frustration for both you and the patient.  You may end up waiting two to three hours just to be able to sedate the little bugger because they have usually just choked down a cheese burger and fries (if your in Britain it may be bangers and mash, Australia a vegemite sandwich, Russia borscht, etc, etc) and then even after you have them sedated, you don't have the right tool to get the foreign body out because the right tool was never created… that is, until now!  Thanks to Dr. David DeLemos from the Texas Children's Pediatric Emergency Medicine program, we now have the solution to the round (or square) object in the ear canal. Let me be the first to introduce you to the "Derma-Q."  The Derma-Q is a contraption created from the plunger of a small syringe or a Q-tip, which has then been tipped (like a tribal dart) with a minute amount of Dermabond.  The Derma-Q provides the perfect rescue technique to get those tough foreign bodies out of almost any orifice. Also making her debut this month on the PEM ED Podcast, my wife, Dr. Holly Sparks will risk life, limb, and my ear canal by getting a cheap piece of plastic jewelry out of my EAC for your viewing pleasure.

Rich Levitan's Yellowstone Advanced Airway Critical Care Course

Cabo CME Course - Levitan, Weingart, Matt & Mike, Orman, and Sloas

Podcast 23 ~ DermaQ Pediatric Foreign Body

Thin Kids, Gallbladders Too


Now I've got your mind palatable to the fact that young thin kids can get cholecystitis too, lets figure out how to weed those kids out from the hundreds of gastroenteritis that you're still going to see each week.  On this episode we'll explore which labs and rads get you to the place you want to be.... not just a disposition, but the correct disposition.  Dr. Doug Fishman is back to get you on the right track to making the right diagnosis!

Podcast 21 ~ Pediatric Cholecystitis 2

Great Pedi Gallbladders of Fire

GB Kid 2.jpg

You may think that Miley Cyrus' on-stage theatrics was the most shocking thing to happen in 2013, but au contraire mon frère.  Hold on tight, because the most outrageous thing you've heard between stanzas of "Auld Lang Syn" is that kid's are getting gallbladder disease.  This is especially frequent in the good ole US of A where we have mid-morning cheese burgers for a snack.  Shocking I know.  In this episode Pediatric Gastroenterologist Dr. Doug Fishman, from the Texas Children's Hospital, is going to go through the In-N-Outs of pediatric cholecystitis.  Not that In-N-Out is in anyway responsible for pediatric gallstones...they make a tasty burger....try the double-meat animal's fantastic....

Thanks to Doug Fishman, MD.  Director, Gastrointestinal Endoscopy

Texas Children's Hospital

Associate Professor of Pediatrics

Please visit his website devoted to education and treatment of Celiac Disease below

Check out the Celiac Universe Here

Park that Shoulder in Place - Shoulder Reductions & One Hip


How many times have you been involved in an adult or pediatric shoulder reduction that you just can't relocate.  Very frustrating, but here's your solution: Dr. Jay Park has invented a method that allows you to reduce a shoulder without sedation (RNs love that) and without any pain to your patient (Press Ganey scores will rise faster than your salary).  Listen up, this defines cool!

Jay Park, MD

Contact Jay For Website Design:

Dr. Park is involved in numerous medical missions, if you would like to contact Dr. Park to see how you can get involved or make a donation email him at:

Shoulder Dislocation Video

Hip Dislocation Video

Levitan Airway

Contact (1-800-651-2363 ext. 1312) for enrollment.  


fax: 610-341-1866

2 - Red Eyes


Red eyes usually come in pairs and so do podcasts on the subject.  In part two of the red eye disorders we discuss the non-threatening maladies that can turn into eye threatening disorders if missed.  Sit back and relax and let dear ole' dad tell you one more time why it's going to be OK...If you listen to him.  Otherwise you may get spanked.  I'm serious he spanked me a lot for not listening.  Call CPS; there's still a chance for me....

Eye Show Notes

Dr. Shenoi's Emergency Preparedness Book

PEM ED Podcast iTunes Link

Podcast 18 ~ The Non-Threatening Red Eye

The Eyes Have It..... Or At Least The Red Eyes Do

Eye Threat.jpg

Harold Andrew Sloas Jr, DO, CAPT, USN-R is a board certified ophthalmologist (and my dad).  He had a competition with his son Harold Andrew Sloas III, DO, RDMS, FAAEM to see who could get get more letters behind their name. As it turns out none of those letters have any bearing on what we'll be talking about today. 

You're in for a real treat because I got to sit down with dear ole' dad and talk about some red eye disorders.  We explore all the threatening causes of the red eye on this podcast and move into the non-threatening red eye disorders on the next episode.  You need to know something about both so you can distinguish between the two.  Pull out your Kleenex and dry your eyes; you're going to need to see this. 

Eye Show Notes

iTunes Link

Podcast 17 ~ The Threatening Red Eye

Pediatric Concussion

knock out.jpg

I have had the opportunity to work with some truly amazing people in my life and Dr. Matt Bayes, sports medicine physician extraordinaire, is no exception.  Dr. Bayes is the only person I have known to successfully ask about a “code red” and somehow avoid receiving one.  Dr. Bayes now resides in St. Louis, Missouri (Bayes from The Lou) and has been part of the sports medicine team that delivers care to the St Louis Cardinals.   On this episode Dr. Bayes takes me through the intricacies of diagnosing and managing a pediatric concussion from the ER perspective. Hold on to your head because you’re about to get knocked out....Smokey


Kupperman N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160-1170.

William R. Mower, MD.  What Rules Should Guide Imaging Decisions in Injured Children?  Medscape.  Posted: 02/23/2010.

Evaluating Minor Head Injury - Sports Medicine Update

Pediatrics - Sports Related Concussions and Management

Pediatrics - Emergency Department Visits for Concussion in Young Athletes

Misconceptions Common With Pediatric Concussions

José Álvarez-Sabín, MD; Antoni Turon; Manuel Lozano-Sánchez; José Vázquez, MD; Agustí Codina, MD Delayed Posttraumatic Hemorrhage "Spät-Apoplexie"Stroke. 1995;26:1531-1535doi: 10.1161/01.STR.26.9.1531

SCAT 2 iPhone App

Dr Matt Bayes Contact Info:  

12855 North Forty Drive

Suite 380

St Louis, MO 63141

Ph: 314-434-7784

Fax: 314-434-4775

iTunes Link

Podcast 16 ~ Pediatric Concussion

Penis Talk ~ With Your Hosts Sloas and Stroup


 The finale in the Urology trilogy.  In this episode Dr. Sean Stroup, CDR, USN, MC and I wrap-it-up with a series of "down-there" complaints (down-there does not imply that this episode is about Australians with grievances) with the most sensitive of subjects to any male patient, penile complaints, worries about the willie, persevering about the pee pee, jargon about the junk, etc.  Hold on to your hats....

The Disclaimer hasn't changed: if you think jokes about "shrinkage" are funny than please listen to the podcast, but if you find those offensive then skip this episode and I wish you all the best in your attempt to make it through your career without encountering another penis...again....ever.

iTunes Link

Podcast 12 - Penis Talk ~ With Your Hosts Sloas and Stroup

Urology Part 2 ~ The Painless Scroti


"Amigo, the only thing in this world that gives orders is balls. Balls. You got that?" ~  Scarface 1983

Every man is attached to their nuts.  In this episode CDR Sean Stroup, MD USN and I continue to discuss non painful ballular complaints.  You make think your safe with a non-painful swollen scrotum, but oh contraire mon frere, you can lose a nut that way too.  A guy just can't get a break....

The Disclaimer from the last episode still applies: if you think jokes about old man balls are funny then please proceed to listen to this podcast, but if you find those offensive then skip this episode and look into non-urologic career paths.  However, if you do listen to this podcast then the ball you save could be your own....

iTunes Link

Podcast 11 - Urology Part 2 ~ The Painless Scroti

Urological Complaints Part 1 - The Painful Scrotum


"Rub your balls, squeeze your balls so you don't get cancer"  ~  Tom Green

Few things cause more pain for the patient and fear in the practitioner than scrotal discomfort in a child.  I sat down with my good friend and pee-pee doctor CDR Sean Stroup, MD USN at the National Naval Medical Center in sunny, beautiful, oh how I miss it: San Diego, to discuss painful ballular complaints.  Dr. Stroup is a fellowship trained urologist practicing on the west coast and sees a ton of children at the Naval Medical Center.  Disclaimer:  If you are offended by jokes about pee-pee, the scroti, or not wearing appropriate underwear than it is probably best to skip this episode.  No testicles were injured or neutered in the production of this podcast. 

iTunes Link

Podcast 10 - Urological Complaints Part 1: The Painful Scrotum

Ketofol & Shah

I had the privilege to sit down with one of Canada’s finest, Dr. Amit Shah, and discuss his blinded randomized prospective study concerning one of my favorite procedural medications: Ketofol.

This is the evidence based follow-up to my last (more opinion based) podcast on “Sedation and Ketofol.”  The chocolate in my peanut butter.......


Shah A, Mosdossy G, McLeod S, Lehnhar, Peddle M, Rieder M. A blinded randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425 33.e2. Epub 2010 Oct 13. PubMedPMID: 20947210

iTunes Link

Podcast 9 - Ketofol and Shah

Pediatric Airway - The Advanced Course

This is the second part of a two part series in pediatric airway management.  Here we focus on how to use the "Airway Algorithm" that we have created and how to manage the more difficult airways we encounter in the emergency department.  The "Airway Algorithm" is designed to be used in both adults and children. 

 Mac Friendly Airway Algorithm

iTunes Link

Reference: The Difficult Airway Course: Emergency™ ( and from Walls RM and Murphy MF: Manual of Emergency Airway Management, 4th Edition, Philadelphia, Lippincott, Williams and Wilkins, 2012.

Podcast 7 - Pediatric Airway The Advanced Course

Pediatric Airway 101

“Airway is the reason that many go into emergency medicine…”

-  Jaime McCarthy MD,  UT Health Sciences Center at Houston EM Director

One of the many things that we do better than anyone in the business is obtain the emergent airway.  Unlike our colleagues in other disciplines, we do not have the luxury of planning our airway approach on the golf course the evening before; we meet patients on their worst day.  Even though we would often prefer it, we do not have the option to reschedule our intubations. 

Smashed, bloody, distorted, edematous, airways secondary to trauma, anaphylaxis and GI bleeds are the things that we deal with routinely with nary a complaint or even a hither for a better look than what were given.  We often feel lucky to get any type of view that resembles normal laryngeal anatomy.  Personally, if I knew that I would need to be intubated today, that my airway would be bloody and edematous, and there was only time for one person to take a shot at placing the tube, then I would pray to God that the last face I see before the Roc and Etomidate push me asunder is the familiar grill of one of my EM colleagues.  Who better to bet all my chips on then someone who deals with the hardest airways on the face of the planet as part of their daily routine?  The general EM provider can not only get that airway, but is so relaxed about it that they will casually check on the patient in the next bed before and after the intubation.   That’s the confidence I’m looking for when it comes to the fast paced life and death world of emergency airway.

Whether it is pediatric or adult emergency medicine, the most important thing that we do as “emergentologists and resusitologists” is control the airway.   

iTunes Link

 Mac Friendly Airway Algorithm

Podcast 6 - Pediatric Airway 101

Clearing The Pediatric C-spine

Developing a good rule to clinically clear the pediatric cervical spine would be difficult.  Very few kids suffer injuries to that region of the body making it nearly impossible to create a well-powered decision instrument.  Like with many other attempts in pediatrics you would most likely end up with a guideline that would be fairly sensitive, but horribly specific. 


Lets say we abstracted and validated a pediatric c-spine rule that was 95% sensitive and 50% specific.  With a disease that occurs at an incidence of less than 0.1% (1/1000), by employing a decision instrument that is 95% sensitive you would reduce your patient's risk of missed injury to say 0.005% (1/20,000) .  Sounds great right?  Hold on though; there's more.  If that same rule is 50% specific (which most peds clinical rules are) 50% of the kids you applied your rule to will have false positives.  Therefore 500 of every 1000 patients you employ your decision instrument for would actually be subjected to further workup and needless radiation.


Does any of that sound familiar?  It's nearly identical to the use of D-Dimer in very low risk adults (probably better stated as no risk).  If you take a low to medium pre-test probability of disease (Wells Score of low-mod = 2-16% risk) and apply a D dimer (sensitivity > 95%) that comes back as a negative result (you now have reduced your 16% chance of having disease to less than 1% because 16% reduced 95% is 0.8%).  Well done!  You are done with the work-up and you have excluded disease.  If you apply the D-Dimer to a very low risk population (1-1000 to 1/10,000 depending on who you read) then you may further reduce your risk (I'm not sure how much lower you need to go to fell comfortable 1/1000 is pretty low), but just like in the example above, you will have subjected twice as many patients to needless CTA of their chests because your D-Dimer specificity was so poor (about the same 50% as above).  


Sorry, that's a lot of stats, but here's the take-home message. Your pediatric patient doesn't need a decision instrument as much as they need a good doctor.  Any injury with extremely low prevelence will most likely end up below the test threshold of creating and validating a decision instrument that you can rely on.  It is hard to get objective data in pre-verbal children, but it is easy to play with them, earn their trust and make a good clinical decision.  NEXUS gets you to 8 years of age, but then it's up to you to make a decision based on experience. 

 iTunes Link


 Podcast 5 - AVI Format (Larger Video Version)


Podcast 5 - Pediatric C Spine Clearance

An Easy LP Technique

If you downloaded the fist version of this (no intro music), delete it and re-downlad.  The audio is much better on the second version.

Practitioners have a love-hate relationship with this procedure.  Whether you embrace it or react to its’ necessity in the same manner you would when finding out you've just been cut-out out of your wealthiest relative’s will, the words “lumbar puncture” invoke emotion.  I would like to thank Dr. David Delemos for inventing this simple recipe for success. It is one of my favorite procedures and hopefully after hearing this podcast it will be one of yours as well.  

Check out the PDA friendly companion file below.

iTunes Link

Pediatric LP Show Notes

Podcast 4 - The Pediatric LP

Fever of Unknown Source - Part 2

In this episode we complete our discussion on “Fever Without a Source” in the 2-3 month old population and also cover the 3-month plus age group.  Again Dr. Andrea Cruz a subspecialist in emergency medicine and infectious disease at The Texas Children’s Hospital gives us some further insight into when and how to work these kids up.

Full disclosure: The author on two of the articles below is LCDR Sherry Rudinsky who is an old navy friend of mine.  We were interns together and then attended the same Naval Flight School class.  Dr. Carstairs is also an aquantaince; she was a resident when I was a Navy Surgical Intern.  I was stationed at the Naval Medical Center San Diego when they were collecting their data, but I had no part in this study.  They are simply dang good reads so check them out.

iTunes Link

Fever Algorithm

Fever Part 2 - MP3 Version


Reardon JM, Carstairs KL, Rudinsky SL, Simon LV, Riffenburgh RH, Tanen DA. Urinalysis is not reliable to detect a urinary tract infection in febrile infants presenting to the ED. Am J Emerg Med. 2009 Oct;27(8):930-2. PubMed PMID: 19857409.

Rudinsky SL, Carstairs KL, Reardon JM, Simon LV, Riffenburgh RH, Tanen DA. Serious bacterial infections in febrile infants in the post-pneumococcal conjugate vaccine era. Acad Emerg Med. 2009 Jul;16(7):585-90. Epub 2009 Jun 15. PubMed PMID: 19538500.\

Carstairs KL, Tanen DA, Johnson AS, Kailes SB, Riffenburgh RH. Pneumococcal bacteremia in febrile infants presenting to the emergency department before and after the introduction of the heptavalent pneumococcal vaccine. Ann Emerg Med. 2007 Jun;49(6):772-7. Epub 2007 Mar 6. PubMed PMID: 17337092.

Podcast 3 - Fever of Unknown Source Part Two