I struggled to find PEM resources for my CT3 year, despite the variety of excellent resources out there. I hope this website will help point you in the right direction. I'm not a PEM expert, but am following the guidance CEM have issued (in the form of a syllabus) to put together this page. This page is not endorsed by CEM, and any mistakes are mine.

Please comment with corrections, additions and further suggestions.

All the information here is collected from the internet, and it might be out of date or inaccurate, so please use your judgement and adhere to your hospital's protocols. If you do notice any errors or omissions please comment so we can put them right!

To navigate, decide whether you want to start with a PMP or a PAP. You can then select which PMP or PAP you want to look at. You will then be taken to the summary page for that PMP, with links expanded topic collections. If you know what topic you want to look at already, click on the link on the right hand side.

Sunday, 7 February 2016

Long Bone Fractures - in Children

Femoral fractures are uncommon, as considerable force is often required. There is often a history of a fall with the leg twisted awkwardly. In children fractures are more common at the physis, and we need to know about the "SALTER" classification. There is a bimodal distribution of femoral fractures - they are common in 2 - 4 year olds, and adolescents. We should always consider child abuse and non accidental injury, especially if the fracture presents in a patient before walking age.

Radiology of Note
The distal femoral epiphyses are normally present from birth to 18 -20 years
The patella ossifies between 3 - 6 years

Support the leg with the hip and knee slightly flexed
Analgesia (intra-nasal very likely to be helpful)
Orthopaedic referral

Most sources agree that splinting should be carried out as soon as possible, although practically this can be difficult.
< 3months:           Pavlick harness
>3 months/ 16kg:  Gallows traction
> 16kg:                Thomas splint (skin traction)

I have written a presentation that says all this with pretty pictures.

Emergency Care of Minor Trauma in Children. Ffion Davies et al. 
ABC of Emergency Radiology

Friday, 12 June 2015

Auricular Haematoma

Drainage of an auricular haematoma is one of the "new" practical procedures that has popped up on our e-portfolio. This is difficult to get signed off because there are minimal resources on it, and it's not a skill I've ever seen performed in the ED. I'm not sure if it's because I'm missing them, and not looking hard enough for them, or if it quite simply isn't a procedure we do in the ED. I've seen ear lacs and swollen ears - I must be missing something.

What is An Auricular Haematoma?
An auricular haematoma is a collection of blood that forms between the cartilage and the perichondrium of the ear. It is most often caused by blunt trauma to the ear.

Initial Treatment
Needle aspiration is often recommended. This failed in 75% of cases - maybe because the needle itself introduces haematoma.

Incision and Drainage
Incise along an anatomic crease to avoid a scar. Use forceps to encourage all of the haematoma out. Put a drain in, and then a dressing for compression. Prophylactic antibiotics have no evidence.


Sickle Cell

Sickle cell disease is really common where I work and I've seen lots of different presentations. Our management seems a little different, and more rational, than some of the guidelines I've found on the internet - it was an interesting literature search.

Once again, the Calgary guide explains this better than I ever could.

The Calgary Guide
Glu --> Val substitution of the sixth amino acid of the beta-globin chain
Get HbS instead

Heterozygous: 45% HbS, 52% HbA, 2% HbA2, 1% HbF
  Sickle trait - increased renal cancer but no "disease"
Homozygous: 90% HbS, 8% HbF, 2%HbA2

HbS is less soluble so might precipitate. This means they become sickle shaped. Can be precipitated by dehydration, hypoxemia or acidosis.

Clinical Signs
Have you looked at the Calgary guide? It is a very under-rated resource.

A painful crisis is the most common presentation to the ED for sickle cell.  Vaso-occlusion causes many problems - priapism, splenic sequestration, dactylitis, splenic infarction, stroke, renal failure, necrosis of the femoral head, blockage of the lung vessels and painful crises. 

Painful crises are more common in the limbs and backs. The pain is normally throbbing, sharp or gnawing. 

- Splenic infarction means RBC not removed by the spleen leading to Howell-Jolly bodies on blood smear. 
- Aplastic crisis causes anaemia, pallor, tachycardia and a low reticulocyte count. 

- Extravascular haemolysis causes a normocytic anaemia. As the red blood cells breakdown, there can be jaundice, and increase in gallstone formation. There can be increased marrow production to compensate for haemolysis. 

Nocturnal Enuresis
Pulmonary Hypertension
Develops in 15-35% of children with SCD.

Acute Chest Syndrome
This is most common in children, especially at around age three. It presents with fever, chest pain, difficulty in breathing and shadows on CXR. 

Need to treat the pneumonia / infection and have urgent transfusion. Be careful as overhydration may lead to oedema and pulmonary vascular congestion. 

Splenic Sequestration
This is a major cause of mortality, especially in those less than five years old. Major causes a rapid drop of Hb, pallor, LUQ pain, splenomegaly. Minor is more gradual onset. 

Neurological Disease
Strokes are common - up to 25% of patients. They need urgent imaging, and urgent exchange transfusion.

This is often the presenting feature in children, and normally resolves in a few days. 

If there is any eye trauma, look carefully for a hyphema - it may not be obvious. Refer anyone who has protrusion of the eye, changes in visual acuity or loss of vision. 
Patients with sickle are risk of hyphema triggering acute narrow angle closure glaucoma. 

Two group and saves if transfusion likely - patients with sickle cell likely to have abnormal antigens. 
D-dimers are unhelpful as levels are usually elevated. 

CXR, ABG, LFTs (jaundice or abdo pain), reticulocytes, blood and urine cultures (if febrile), USS abdo, parvovirus B19 serology (Hb drop, low reticulocytes Transient red cell aplasia (TRCA) is caused by infection with parvovirus B19, which causes red cell production to halt for 3-7 days), brain imaging, limb x-rays, CRP. 

Consider serology for atypical respiratory organisms and urine for pneumococcal and legionella antigen. 
Look for mycoplasma infection - red cell agglutination on a stained blood film and cold agglutinins in serum.

Look for parvovirus B19 - erythema infectiosum or slapped cheeks, gloves and socks syndrome (painful erythema of hands and feet), arthropathy, aplastic crisis.

Oxygen - only if sats are low. 
Antibiotics - really consider antibiotics if CRP>25 - but not amoxicillin as it is so similar to pen v - consider co-amox or tax. Stop prophylactic antibiotics if starting regular treatment. Prophylactic penicillin should be used in children until five years old, unless they had a splenectomy or invasive pneumococcal infection. 

Transfusion - consider. If Jehovah's witness need transfusion, go ahead as per normal,  then contact legal department who arrange out of court hearing and you can normally transfuse them within an hour! And most parents are happy because they've done their bit. 

Hydroxycarbamide  (also known as hydroxyurea) - stop if febrile or low platelets as can cause cardiomyopathy and neutropenia. 
Hydroxyurea - more than three crisis in twelve years, or sickle cell-associated pain, or any infants older than nine months. 
Folic acid - 5mg OD
Hydrozine - 25mg BD PO for itching
Hydration - oral if tolerated

NICE Guidelines
- Treat as a medical emergency
- Analgesia within 30min
- Obs
- Offer opioid bolus for severe and moderate pain
- Do NOT give pethidine

- Offer patients PCA, and treat opiate side effects



Sunday, 7 June 2015

Dehydration - Pyloric Stenosis

I've probably missed something, but PAP7 seems very similar to dehydration in children. The new bit is pyloric stenosis, also known as hypertrophic pyloric stenosis, which we'll cover here.

There is hypertrophy and hyperplasia of the two muscular layers of the pylorus. This labels the gastric atrum. The pyloric canal becomes lengthened and the whole pylorus becomes thickened. The stomach may then become markedly dilated.

First-born white males
Northern European ancestry
Family history (7%)
Bottle feeding
Macrolide antibiotics for infants

Pyloric stenosis normally starts in the first 3 weeks of life.
Non-bilious vomiting or regurgitation - projectile in 70% of cases.
The infant is still hungry after feeding and may be jaundiced.
Signs of dehydration and malnutrition.
Firm,non-tender and mobile hard pylorus 1-2cm in the RUQ. Best palpated when vomited and calm. Happens in 60-80%.

Bloods:  Severe metabolic alkalosis with partial respiratory compensation

    Hyponatraemic, hypokalaemia --> or maybe higher because of dehydration
Alkaline Urine
AXR: Distended stomach with minimal distal intestinal bowel gas
USS:  Pylorus hypertrophy

NG Tube if vomiting
Fluid resuscitation
Correct electrolyte abnormalities
Nil by mouth
Surgeons for a pyloromyotomy - splitting muscle layer of the pylorus


http://broomedocs.com/2013/02/clinical-case-079-is-it-pyloric-stenosis/ may be useful - their server is still down so I haven't read it yet!

Friday, 5 June 2015

Functional Abdominal Pain

Functional abdominal pain is mentioned in the higher syllabus for abdominal pain, and not the core syllabus. It is common in children, and some resources suggest it has a non-organic cause in most cases - some don't. Either way, a cause is difficult to elucidate, with a cause identified in <10%. It is important to consider physical and psychological factors. Functional abdominal syndrome is abdominal pain for 25% of the time, with other symptoms.
Apley's law: the further a recurrent abdominal pain is from the umbilicus, the more likely it is to be organic.

40% of 7 year olds have at least one episode of abdominal pain, with peaks in incidence at 5 and 10 years old.

Recurrent pain:  more common in girls than boys
                           more common in children whose parents have GI problems

3 of more episodes of abdominal pain in three months, that affects daily activities. 
Pain not associated with eating, loss of daily functioning, no other disorder

There is no clear idea what causes recurrent abdominal pain. The biophysical model of disease suggests it's a response to biological factors, family and school interactions, family environment and critical life events. 
It is thought, by Rome III, there are three main categories of functional abdominal pain:
Duodenal Ulcers
Abdominal Migraine
Irritable Bowel Syndrome

Duodenal Ulcers or Functional Dyspepsia: 
Consider in epigastric pain that causes night time waking. Treat by giving PPIs. Test for and treat H Pylori. If symptoms do not respond, then get an endoscopy - if the endoscopy is normal, consider functional dyspepsia.

Irritable Bowel Syndrome
Intestinal dysmotility. Family history is common, and the infection may follow a GI infection. You normally get abdominal pain that is worse before defecation - and relieved by defacation. It can be helpeful to say to children that sometimes the insides of the intestine become so sensitive that some children can feel the food going round the bends. 
Peppermint oil may be helpful. 
Avoiding sorbitol can be helpful, and increasing intake of oats and linseed can help. 

Abdominal Migraine
Abdominal migraine is associated with travel sickness. This may be associated with a headache, but in some children the abdominal pain predominates. The pain is normally midline associated with vomiting and pallor. There is normally a history of migraine. 
Pizotifen may be helpful. 

Make sure you differentiate between serious and dangerous diagnoses. Serious is a disruption to schooling and life. Dangerous is life threatening. 

- Urine culture and microscopy
- FBC, ESR, CRP, LFTs, U&E, Coeliac
- Stool microsccopy 
- Abdominal USS to exclude gall stones and PUJ obstruction
- Pain and life event diary

Red Flags
Unexplained fever
Weight loss and poor growth
Joint problems, rashes
Pain causing waking, referred to back or shoulders
Urinary symptoms, perianal disease, PR blood 
Age under 5 



Wednesday, 3 June 2015

Foreign Bodies

Children often swallow things. The management pretty much depends on what they have swallowed, and whether they have symptoms or not. If the child is coughing, consider that they may have inhaled the foreign body instead - the inhaled FB can act as a ball-valve and air can enter but not leave.

The Object
Button batteries, objects >5mm and sharp, and razor blades are considered dangerous. Button batteries are toxic, and have a slow but deep action, and can also cause direct pressure necrosis. Their effects may be seen after they have been removed. Open safety pins might be dangerous - sharp objects have a 15 - 35% risk of perforation.

1. X-ray if likely to be radio-opaque or "dangerous".  Request a neck and chest x-ray- an abdomen is not needed, and irradiates the gonads un-necessarily.
Look at the x-ray carefully- common points that get stuck are:
- C6 is cricopharyngeal sling and upper oesophageal sphincter
- 15% get stuck in the midoesophagus where the aortic arch and carina push on the oesophagus.
- 15% get stuck in the lower oesophageal sphincter / oesophagogastric junction
Check carefully it is a coin and not a button battery. If you are not sure if the coin is in the oesophagus or not, do a lateral film. If the coin is in the oesophagus, it appears coronal. Tracheal objects appear in a sagittal orientation.

2. Dangerous Object - refer to surgeons where ever the object is. There is some debate about button batteries if they are below the diaphragm. Above the diaphragm - in the oesophagus, nose or throat, they need to come out ASAP.

3. Above diaphragm, symptomatic, - refer to the surgeons. Most (75%) objects impact in the upper oesophagus.
b. Mild or no symptoms - home, repeat x-ray 24 hours.

4. Below diaphragm
Reassure, return if symptoms develop

5. Asymptomatic, not seen - reassure and return if symptoms develop.
b. Symptomatic - refer to surgeons

There is no need to search the poo. It might take six weeks for the foreign body to come out.

Metal Detector
The metal detector can help prove whether a FB is above the diaphragm or not. They can confirm whether the coin has reached the stomach.


Tuesday, 2 June 2015


Constipation is common. DFTB has written some excellent pieces of work on this - I've written myself more of a summary using their resources, and some I've found from elsewhere. 

RomeIII Criteria: 
≤2 stools per week for a duration of 2 months if patient >2 years
                               for duration of 4 months if patient <2 years
or with evidence of overflow incontinence (no stool, then diarrhoea, then no stool, etc), 
or stools that clog toilet

Chronic: >8 weeks
Happens in 5 - 30%of the child population, progressing to chronic in > 1/3 of patients

<3 months, 2-3 stools/ day, 8.5 hours mouth to rectum time
<2 years, <2/ day, 16 hours mouth to rectum time

Reservoir Constipation
- Too busy to poo, scared to poo leads to reservoir constipation. Stools get larger and harder. Pass a large diameter stool every 1-2 weeks. It's painful to pass these.
The rectum stretches. The internal sphincter struggles leading to a numb, toneless rectum. Chronically, can lead to anal fissures, which are painful so poo-ing is avoided. The stool continues to become harder and more painful to pass.

Hirschprung's Disease
1/500 live births
Normally diagnosed in newborns. 
Get abdominal distension that is relieved by rectal stimulation, or enemas.

Cow's Milk: Tolerance may lead to constipation - should be investigated by a specialist before avoiding cow's milk. 

Weigh the child
Abdo exam
Perianal exam – appearance, position, patency, fissures
Scoliosis + Gait 
Skin overlying the spine – discoloured/sinus/hairy patch/central pit
Gluteal muscles – is there asymmetry?

Red Flag Features
Constipation from early infancy
Delay in meconium >48hrs
Ribbon stools
Abdo distension & vomiting
Abnormal appearance of anus including multiple anal fissures
Asymmetry/flattening of gluteals
Sacral agenesis, skin changes over spine
Skin changes overlying spine
Deformity of lower limbs – talipes
Abnormal neuromuscular signs

This is summarised so clearly on CYP that I haven't re-written it
- Get rid of old, dark, hard and smelly poo
- Continue treatment for 3 months. 
- Make going to the toilet fun