Musculoskeletal Chest Pain DDx

1. Trauma – ptx, hemothorax, contusions, fractures.

2. Costochondritis

3. Tietze’s Syndrome – similar to costochondritis but has associated swelling, redness and warmth at costochondral junction. Self limited inflammatory condition.

4. Slipping rib syndrome – occurs at false or floating ribs. Sharp, intermittent pain for several minutes and settles to a dull ache. “Hooking maneuver” to dx. Reach under lower costal margin and pull rib anteriorly. Will reproduce the pain and cause a clicking sensation.

5. Precordial catch syndrome – also known as Texidor’s twinge. Brief, sharp pain to L chest without radiation. Worsens with exercise or when resting in a slouched position.

6. If follows a dermatome consider herpes zoster. Pain may precede the skin lesions.

Pediatric Lymphadenitis Causes

Viruses, GAS, TB, S.Aureus, anaerobes, mycobacterium, actinomycetes, bartonella henselae. Always ask TB exposures and kitten exposures

Cyanotic Congenital Heart Disease Lesions

I Truncus Arteriosus

II Transposition of the Great Vessels

III Tricuspid Atresia

IV Tetralogy of Fallot

V Total Anomalous Pulmonary Venous Return

And also add: Critical AS, Critical Coarctation, Hypoplastic Left Heart Syndrome, Ebstein’s Anomaly and Pulmonary Atresia


I’m going to be starting what will hopefully be a very frequent daily posting of very short little daily pearls regarding all subjects within the field of pediatric emergency medicine. This is actually done with my own interests in mind as it will keep me focused on studying for my PEM boards. Nothing like a little motivation. The first post with PEM pearls will be in the next post. I hope you all enjoy and follow along.

Mac vs Miller blades in pediatric intubation

A common discussion point when deciding what equipment to use for a pediatric intubation. Anecdotally placing the tip of the miller blade in the vallecula is technically easier than lifting the epiglottis and will frequently provide a more than satisfactory view of the cords. This article agrees with this. See the abstract below.

Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children?

Elsa Varghese, Ratul Kundu
Paediatric Anaesthesia 2014 April 2


BACKGROUND: Both Miller and Macintosh blades are widely used for laryngoscopy in small children, though the Miller blade is more commonly recommended in pediatric anesthetic literature. The aim of this study was to compare laryngoscopic views and ease and success of intubation with Macintosh and Miller blades in small children under general anesthesia.

MATERIALS AND METHOD: One hundred and twenty children aged 1-24 months were randomized for laryngoscopy to be performed in a crossover manner with either the Miller or the Macintosh blade first, following induction of anesthesia and neuromuscular blockade. The tips of both the blades were placed at the vallecula. Intubation was performed following the second laryngoscopy. The glottic views with and without external laryngeal maneuver (ELM) and ease of intubation were observed.

RESULTS: Similar glottic views with both blades were observed in 52/120 (43%) children, a better view observed with the Miller blade in 35/120 (29%) children, and with the Macintosh blade in 33/120 (28%). Laryngoscopy was easy in 65/120 (54%) children with both the blades. Restricted laryngoscopy was noted in 55 children: in 27 children with both the blades, 15 with Miller, and 13 with Macintosh blade. Laryngoscopic view improved following ELM with both the blades.

CONCLUSION: In children aged 1-24 months, the Miller and the Macintosh blades provide similar laryngoscopic views and intubating conditions. When a restricted view is obtained, a change of blade may provide a better view. Placing the tip of the Miller blade in the vallecula provides satisfactory intubating conditions in this age group.

Ketamine and increased ICP

Interesting article just published in J of Crit Care regarding ketamine effects on ICP…..feel free to keep using ketamine freely. See abstract below.

The ketamine effect on intracranial pressure in nontraumatic neurological illness

Frederick A Zeiler, Jeanne Teitelbaum, Michael West, Lawrence M Gillman

Journal of Critical Care 2014 June 4

PURPOSE: The purpose of the study was to perform a systematic review of the literature on the use of ketamine in nontraumatic neurological illness and its effects on intracranial pressure (ICP).

MATERIALS AND METHODS: Articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to January 2014), and gray literature were searched. Two reviewers identified manuscripts on the administration of ketamine in nontraumatic neurological illness that recorded effects on ICP. The strength of evidence was adjudicated using the Oxford and Grading of Recommendation Assessment Development and Education (GRADE) methodology.

RESULTS: Our search produced a total of 179 citations. Sixteen articles, 15 manuscripts, and 1 meeting proceeding were included in the review. Across all studies, there were 127 adult and 87 pediatric patients described. Intracranial pressure did not increase in any of the adult studies reporting premedication during ketamine administration, with 2 studies reporting a decrease in ICP. No significant non-ICP-related adverse events from ketamine were recorded in any of the studies.

CONCLUSIONS: There exists Oxford level 2b, GRADE C evidence in adults and level 4, GRADE C in pediatrics to support that ketamine does not increase ICP in nontraumatic neurological illness when patients are sedated and ventilated, and in fact may lower it in selected cases.

Heroes, difficult airways, and Number Needed to Treat Reviews

First, to follow up last months post of Dr. Cliff Reid on “The Mind of the Resuscitationist” this month there is another fantastic lecture by Dr. Reid on “How to be a Hero.” Trust me, the lecture isn’t as egotistical as the title sounds. It is a humble, sweet and fantastic lecture with lots of great stories and tips on critical issues in resuscitation. It can be found here:

How to be a Hero

Here are two simple and amazingly efficient airway videos from the blog describing jet insufflation and a bougie guided cricothyroidotomy.

Jet Insufflation:

Bougie Guided Cricothyroidotomy

Also, the blog is one that will be getting added to the website list – not only for its creative name socmob = “standing on corner minding my own business.” If you do adult emergency medicine you’ll appreciate this title…

Found an interesting new blog this week titled “The Number Needed to Treat.” Its purpose, per the authors, is: “We are a group of physicians that have developed a framework and rating system to evaluate therapies based on their patient-important benefits and harms as well as a system to evaluate diagnostics by patient sign, symptom, lab test or study. ” Most of these reviews getting to the important details of Cochrane Reviews. Links below:

The Therapy (NNT) Reviews

The Diagnosis (LR) Reviews




Weekly Peds EM Update: PALS vids, a new website and a difficult airway algorithm

This week I came across on Academic Life in EM blog a series of 8 videos by Dr. Rahul Patwari  where he walks you through the 2010 PALS updated guidelines that were published in Circulation that year. Click the hyperlink below to see the videos. They will also be permanently available under the videos tab. They are quite amusing in that they are in cartoon format, but quite informative nonetheless. All vids are also available under the Videos/Pals tabs:

Academic Life in EM Dr. Patwari PALS Videos

Another new link with tons of great information I’ll be adding to the links page that I recommend you check out by Dr. Sean Fox at the Carolinas Medical Center is:

More on this in coming weeks, but here is a nicely summarized failed airway algorithm from the Difficult Airway Society (DAS) of the UK.

Peds Diff Airway Algorithm APA3-CICV-FINAL

And here is why this is important – a case report of a nightmare airway and what all can go wrong. It’s like reading a horror story. Granted its an adult patient, and in the OR, but the principles are the same:

Failed Airway Ewing – case report – KM




Weekly updates from around the web:

So, added to the journal articles are Canada and US status epilepticus management guidelines, also linked here:  Status Epil Guidelines Canada  &   US Status Seizure Guidelines.

In the tox section there is an interesting article on TCA overdose treated with intralipid: TCA OD Intralipid.

From around the web some interesting posts:

An interesting talk from John Kheir from the cardiac PICU at Boston’ Children’s Hospital talking at TEDMED. The talk begins with the story of a tragic PICU case and leads to Kheir explaining his obsession with figuring out how to administer oxygen microparticles intravenously. Fascinating stuff. Makes you wonder what we will be doing in resuscitations in 10 years:

From Annals of EM this month – the concept of DELAYED sequence intubation is now making its way into pediatrics. Something we’ve been doing in adult EM for some time now….From Weingart and Schneider a case report in full form is available in the airway journal articles tab. Here is a case summary at this link:

Pediatric DSI

This looks to be a super cool pediatric emergency medicine website that was just launched – LOTS of potential here:

Don’t Forget the Bubbles

Lastly, I think everyone should watch this lecture from Cliff Reid. He is the editor of the website (in the links page) and this is his lecture from the SMACC (Social Media and Critical Care) conference on “The mind of the resuscitationist: making things happen.” For anyone who is leading resuscitations, you should watch this lecture. Posted originally on

(Click on link and scroll to bottom of page to see video)

Cliff Reid:Making Things Happen


The doctor as the detective…

I just posted on the journal articles page a fun article by Rapezzi et al about how modern tools is killing of the art of medicine and the role of the physician as a diagnostician. I first read about this article when it was referenced on Food for thought…..

Click on the link below to read:

Medicine Detectives Article