UMEM Educational Pearls - By Ashley Strobel

Category: Pediatrics

Title: Happy New Year 2015

Keywords: intraosseous access, pediatrics (PubMed Search)

Posted: 1/3/2015 by Ashley Strobel, MD (Updated: 6/24/2024)
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Are you comfortable with Intraosseous Catheter Placement in Children during a code?  A pediatric code or child in distress is also distressing to care providers.  Your staff may not feel comfortable with IO access in children. Read on to be more comfortable with your options as IO access in children can be difficult, especially the chubby toddlers.  The basics for a patient in distress are "IV, O2, Monitor".  Access is vital to giving resuscitation medications.

Indications for IO access: Any child in whom IV access cannot readily be obtained, but is necessary.

All IOs are 15G for infusion equal to central vascular access.  

Different colors indicate different sizes:

  • Pink=15 mm
  • Blue=25 mm
  • Yellow=45 mm

Preferred sites:

  1. Proximal tibial (place a towel in popliteal fossa to bend the leg, pinch tibia and 1 finger width below the patella inferior and medial if you can’t palpate the tibial tuberosity)
  2. Distal tibia (proximal to medial malleolus by 1 finger width)—preferred in older children
  3. Proximal Humerus (internally rotate humerus and 1 finger width below surgical neck)
  4. Distal Femoral (1-2 finger widths superior to femoral epicondyles)

Kids-do NOT use the sternum or distal radius

The reference from NEJM has videos to review placement and different tools (manual, EZ IO, and autoinjector).

Show References

Emergency Physician Bedside Ultrasound for Appendicitis


To reduce length of stay, improve patient care, and reduce radiation exposure in young patients.


Start with pain medication so you get a better study. (Consider intranasal fentanyl for quicker pain relief and diagnostics in pediatrics.) Study results are also improved with a slim body habitus.

Place the patient supine

Use a high-frequency linear array transducer

Start at the point of maximal tenderness in the RLQ

Transverse and longitudinal planes "graded compression" to displace overlying bowel gas which usually has peristalsis (See Sivitz, et al article for images of "graded compression")

Appendix is usually anterior to the psoas muscle and iliac vein and artery as landmarks

Measure from outer wall to outer wall at the most inflamed portion of the appendix (usually distal end)


Positive study:

A non-compressible, blind-ending tubular structure in the longitudinal axis >6 mm without peristalsis (see second image above with 8.3 mm diameter measurement)

A target sign in the transverse view (see first image above)

Additional suggestive findings: appendiceal wall hyperemia with color Doppler, appendicoliths hyperechoic (white) foci with an anechoic (black) shadow, periappendiceal inflammation or free fluid

Negative study:

Non-visualization of the appendix with adequate graded compression exam in the absence of free fluid or inflammation.

Limitations for visualization and possible false negative result:

Retrocecal appendix and perforated appendix are difficult to visualize with US.


US has good specificity (93% in Sivitz et al article), but limited sensitivity (85% in Sivitz et al article), so trust your clinical judgement. You may need a MRI (pregnant/pediatrics) or CT as they have improved, but not perfect sensitivity.

Show References


1411081818_Appendicitis_Blind_End_Pouch_US.jpg (1,372 Kb)

1411081818_Target_Sign_US_Appendix.jpg (1,461 Kb)

Category: Pediatrics

Title: A young asthmatic with a bad day: Visual Diagnosis

Keywords: Macklin Phenomenon, asthma, pneumomediastinum (PubMed Search)

Posted: 9/22/2014 by Ashley Strobel, MD
Click here to contact Ashley Strobel, MD


16 yo M with pleuritic right upper chest pain that started today.  He is suffering from an asthma exacerbation currently in the setting of URI with cough.  He is afebrile, tachycardic to 140-150s, respiratory rate 20, and sats 98% on room air.  ECG was performed which incidentally diagnosed this patient WPW and he went for ablation as an outpatient.  His chest x-ray showed:

Besides a bad day, what do we call this chest x-ray finding?

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Show References


1409221530_IMG_5821.jpg (1,850 Kb)

Category: Pediatrics

Title: Visual Diagnosis Pediatrics: Case thanks to Ari Kestler MD (@KestlerMD) and Haney Mallemat MD (@CriticalCareNow)

Keywords: non-accidental trauma, clavicle fracture, neonate, pediatrics, abuse (PubMed Search)

Posted: 10/4/2014 by Ashley Strobel, MD (Emailed: 6/24/2024)
Click here to contact Ashley Strobel, MD


Q: What is wrong with this baby? And what Dx should you entertain?

Previously healthy 7d old presents after difficulty feeding, one episode of vomiting and now with intermittent apneic episodes.


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Show References


1410041359_Clavicle_Fracture.jpg (1,743 Kb)