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

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

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

Fever of Unknown Source - Part 1

Just in time for the winter season.....

Have you seen a bunch of snot-nose kids with fever recently?  Do you want to put a needle in their back?  Better yet, do you not want to put a needle in their back, but feel really guilty about it?

I sat down with Texas Children’s very own Dr. Andrea Cruz who is triple boarded in pediatrics, pediatric emergency medicine and pediatric infectious disease to talk about fever without a source in neonates/infants and who really needs that LP.

There are so many pearls here that I am going to break  this into 2 podcasts.  Enjoy part one now and don’t forget to check out the link to my “fever without a source” algorithm link below.   

iTunes Link

Undifferentiated Hypotension and the Modified RUSH Exam

This is my simplistic take on hypotension (ie. shock) in pediatric patients.  All you need is an ultrasound, fluids and a basic understanding of the physiology.  

 iTunes Link

 Undifferentiated Hypotension Slide

 RUSH Slide




Podcast 1 - Und Hypotension & Mod RUSH

Introductions are in order....

Welcome to PEM ED Podcast.  Pediatric Emergency Medicine; an Educational and Directional Podcast for the general emergency medicine provider.  I hope you find this podcast informative and practice changing.  Please click on the link below and enjoy.

iTunes Link

Podcast 0 - Introductions are in order...