PEM Currents: The Pediatric Emergency Medicine Podcast

• BRUE: Brief Resolved Unexplained Events

  BRUE, Brief Resolved Unexplained Events, are a common and anxiety-provoking condition that presents to the Emergency Department. In this episode we explore the definition of BRUE, contrast it with ALTE, and walk through evidence-based approaches to risk stratification. We’ll explore the original AAP framework and two subsequent prediction models to see where the recommendations stand today. This is a classic example of scary event / well child that you will see in the Emergency Department. Learning Objectives By the end of this episode, you will be able to: Define BRUE and contrast it with the older concept of ALTE. Recognize evolving risk stratification criteria Apply evidence-based strategies for evaluation and counseling of infants with BRUE, including safe discharge decisions and the role of home monitoring. References Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: Executive summary. Pediatrics. 2016;137(5):e20160591. doi:10.1542/peds.2016-0591 Carroll AE, Bonkowsky JL. Acute events in infancy including brief resolved unexplained event (BRUE). In: McMillan JA, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025). Carroll AE, Bonkowsky JL. Use of home cardiorespiratory monitors in infants. In: McMillan JA, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025). Carroll AE, Bonkowsky JL. Sudden infant death syndrome: Risk factors and risk reduction strategies. In: McMillan JA, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025). Carroll AE. Patient education: Brief resolved unexplained event (BRUE) in babies (The Basics). In: UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025). Nama N, Neuman MI, Finkel MA, et al. Risk prediction after a brief resolved unexplained event. JAMA Pediatr. 2023;177(12):1263–1272. doi:10.1001/jamapediatrics.2023.4197 Nama N, Neuman MI, Finkel MA, et al. External validation of brief resolved unexplained events prediction rules for serious underlying diagnosis. JAMA Pediatr. 2024;178(4):398–407. doi:10.1001/jamapediatrics.2024.0114    

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• Penicillin Allergy?

  Is that penicillin or amoxicillin allergy real? Probably not. In this episode, we explore how to assess risk, talk to parents, and refer for delabeling. You’ll also learn what happens in the allergy clinic, why the label matters, and how to be a better antimicrobial steward. Learning Objectives Describe the mechanisms and clinical manifestations of immediate and delayed hypersensitivity reactions to penicillin, including diagnostic criteria and risk stratification tools such as the PEN-FAST score. Differentiate between low-, moderate-, and high-risk penicillin allergy histories in pediatric patients and identify appropriate candidates for direct oral challenge or allergy referral based on current evidence and guidelines. Formulate an evidence-based approach for evaluating and counseling families in the Emergency Department about reported penicillin allergies, including when to recommend outpatient referral for formal delabeling. Connect with Brad Sobolewski PEMBlog: PEMBlog.com Blue Sky: @bradsobo X (Twitter): @PEMTweets Instagram: Brad Sobolewski References Khan DA, Banerji A, Blumenthal KG, et al. Drug Allergy: A 2022 Practice Parameter Update. J Allergy Clin Immunol. 2022;150(6):1333-1393. doi:10.1016/j.jaci.2022.08.028 Moral L, Toral T, Muñoz C, et al. Direct Oral Challenge for Immediate and Non-Immediate Beta-Lactam Allergy in Children. Pediatr Allergy Immunol. 2024;35(3):e14096. doi:10.1111/pai.14096 Castells M, Khan DA, Phillips EJ. Penicillin Allergy. N Engl J Med. 2019;381(24):2338-2351. doi:10.1056/NEJMra1807761 Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and Management of Penicillin Allergy: A Review.JAMA. 2019;321(2):188–199. doi:10.1001/jama.2018.19283 Transcript Note: This transcript was partially completed with the use of the Descript AI and the Chat GPT 5 AI  Welcome to PEM Currents, the Pediatric Emergency Medicine podcast. As always, I'm your host, Brad Sobolewski, and today we are taking on a label that's misleading, persistent. Far too common penicillin allergy, it's often based on incomplete or inaccurate information, and it may end up limiting safe and effective treatment, especially for the kids that we see in the emergency department. I think you've all seen a patient where you're like. I don't think this kid's really allergic to amoxicillin, but what do you do about it? In this episode, we're gonna break down the evidence, walk through what actually happens during de labeling and dedicated allergy clinics. Highlight some validated tools like the pen FAST score, which I'd never heard of before. Preparing for this episode and discuss the current and future role of ED based penicillin allergy testing. Okay, so about 10% of patients carry a penicillin allergy label, but more than 90% are not truly allergic. And this label can be really problematic in kids. It limits first line treatment choices like amoxicillin, otitis media, or penicillin for strep throat, and instead. Kids get prescribed second line agents that are less effective, broader spectrum, maybe more toxic or poorly tolerated and associated with a higher risk of antimicrobial resistance. So it's not just an EMR checkbox, it's a label with some real clinical consequences. And it's one, we have a role in removing. And so let's understand what allergy really means. And most patients with a reported penicillin allergy, especially kids, aren't true allergies in the immunologic sense. Common misinterpretations include a delayed rash, a maculopapular, or viral exum, or benign, delayed hypersensitivity, side effects, nausea, vomiting, and diarrhea. And unverified childhood reactions that are undocumented and nonspecific. Most of these are not true allergies. Only a very small subset of patients actually have IgE mediated hypersensitivity, such as urticaria, angioedema, wheezing, and anaphylaxis. These are super rare, and even then they may resolve over time without treatment. If a parent or sibling has a history of a penicillin allergy, remember that patient might actually not be allergic, and that is certainly not a reason to label a child as allergic just because one of their first degree relatives has an allergy. So right now, in 2025, as I'm recording this episode, there are clinics like the Pats Clinic or the Penicillin Allergy Testing Services at Cincinnati Children's and in a lot of our peer institutions that are at the forefront of modern de labeling. Their approach reflects the standard of care as outlined by the. Quad ai or the American Academy of Allergy, asthma and Immunology and supported by large trials like Palace. And you know, you have a great trial if you have a great acronym. So here's what happens step by step. So first you stratify the risk. How likely is this to be a true allergy? And that's where a tool like the pen fast comes. And so pen fast scores, a decision rule developed to help assess the likelihood of a true penicillin allergy based on the patient's history. The pen in pen fast is whether or not the patient has a self-reported history of penicillin allergy. They get two points if the reaction occurred in the past five years. Two points if the reaction is anaphylaxis or angioedema. One point if the reaction required treatment, and one point if the reaction was not due to testing. And so you can get a total score of. Up to six points. If you have a score of less than three. This is a low risk patient and they can be eligible for direct oral challenge. A score greater than three means they're higher risk and they may require skin testing. First validation studies show that the PEN FFA score of less than three had a negative predictive value of 96.3%. Meaning a very, very low chance of a true allergy. And this tool has been studied more extensively in adults, but pediatric specific adaptations are emerging, and they do inform current allergy clinic protocols. But I would not use this score in the emergency department just to give a kid a dose of amoxicillin. So. For low risk patients, a pen fast score of less than three or equivalent clinical judgment clinics proceed with direct oral challenge with no skin testing required. The protocol is they administer one dose of oral amoxicillin and they observe for 62 120 minutes monitoring for signs of reaction Urticaria. Respiratory symptoms or GI upset. This approach is safe and effective. There was a trial called Palace back in 2022, which validated this in over 300 children. In adolescents. There were no serious events that occurred. De labeling was successful in greater than 95% of patients. And skin tested added no benefit in low risk patients. So if the child tolerates this dose, then you can remove that allergy immediately from the chart. Parents and primary care doctors will receive a summary letter noting that the challenge was successful and that there's new guidance. Children and families are told they can safely receive all penicillins going forward. And providers are encouraged to document this clearly in the allergy section of the EMR. So you're wondering, can we actually do this in the emergency department? Technically, yes, you can do what you want, but practically we're not quite there yet. So we'd need clearer risk stratification tools like the Pen fast, a safe place for monitoring, post challenge, clinical pathways and documentation support. You know, a clear way to update EMR allergy labels across the board and involvement or allergy or infectious disease oversight. But it's pretty enticing, right? See a kid you diagnose otitis media. You think that their penicillin allergy is wrong, you just give 'em a dose of amox and watch 'em for an hour. That seems like a pretty cool thing that we might be able to do. So some centers, especially in Canada and Australia, do have some protocols for ED or inpatient based de labeling, but they rely on that structured implementation. So until then, our role in the pediatric emergency department is to identify low risk patients, avoid over document. Unconfirmed reactions and refer to allergy ideally to a clinic like the pets. So who should be referred and good candidates Include a child with a rash only, especially one that's remote over a year ago. Isolated GI symptoms. Parents unsure of the details at all. No history of anaphylaxis wheezing her hives, and no recent serious cutaneous reactions. I would avoid referring and presume that this allergy is true. If they've had recent anaphylaxis, they've had something like Stevens Johnson syndrome dress, or toxic epidermolysis necrosis. Fortunately, those are very, very rare with penicillins and there's a need for penicillin during the ED visit without allergy backup. So even though we don't have an ED based protocol yet. De labeling amoxicillin or penicillin allergy can start with good questions in the emergency department. So here's one way to talk to patients and families. You can say, thanks for letting me know about the amoxicillin allergy. Can I ask you a few questions to better understand what happened? This is gonna help us decide the safest and most effective treatment for your child today, and then possibly go through a process to remove a label for this allergy that might not be accurate. You wanna ask good, open-ended questions. What exactly happened when your child took penicillin or amoxicillin? You know, look for rash, hives, swelling, trouble breathing, or anaphylaxis. Many families just say, allergic, when the reaction was just GI upset, diarrhea or vomiting, which is not an allergy. How old was your child when this happened? Reactions that occurred before age of three are more likely to be falsely attributed. How soon after taking the medicine did the reaction start? Less than one hour is an immediate reaction, but one hour to days later is delayed. Usually mild and probably not a true allergy. Did they have a fever, cold or virus at that time? Viral rashes are often misattributed to antibiotics, and we shouldn't be treating viruses with antibiotics anyway, so get good at looking at ears and know what you're seeing. And have they taken similar antibiotics since then? Like. Different penicillins, Augmentin, or cephalexin. So if they said that they were allergic to amoxicillin, but then somehow tolerated Augmentin. They're not allergic. If a patient had rash only, but no hive swelling or difficulty breathing, no reaction within the first hour. It occurred more than five years ago or before the kid was three. And especially if they tolerated beta-lactam antibiotics. Since then, they're a great candidate for de labeling and I would refer that kid to the allergy clinic. Generally, they can get them in pretty darn quick. Alright, we're gonna wrap up this episode. Most kids labeled penicillin allergic or amoxicillin allergic, or not actually allergic to the medication. There are some scores like pen fasts that are validated tools to assess risk and support de labeling. Direct oral challenge for most patients is safe, efficient, and increasingly the standard of care. There are allergy clinics like the Pats at Cincinnati Children's that can dela children in a single visit with oral challenges alone, needing no skin testing, and emergency departments can play a key role in identifying and referring these patients and possibly de labeling ourselves in the future. Well, that's all for this episode on Penicillin Allergy. I hope you learn something new, especially how to assess whether an allergy label is real, how to ask the right questions and when to refer to an allergy testing clinic. If you have feedback, send it my way. Email, comment on the blog, a message on social media. I always appreciate hearing from you all, and if you like this episode, please leave a review on your favorite podcast app. Really helps more people find the show and that's great 'cause I like to teach people stuff. Thanks for listening for PEM Currents, the Pediatric Emergency Medicine podcast. This has been Brad Sobolewski. See you next time.

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• The Limping Child

  Limping is a common complaint in pediatric emergency care, but the differential is broad and the stakes are high. In this episode, we walk through a detailed, age-based approach to the evaluation of the limping child. You’ll learn how to integrate the Kocher criteria, when imaging and labs are truly necessary, and how to avoid being misled by small joint effusions on ultrasound. We also highlight critical mimics like appendicitis, testicular torsion, and malignancy—and remind you why watching a child walk is one of the most valuable parts of the exam. Whether it’s transient synovitis, septic arthritis, or something much more concerning, this episode gives you the tools to manage pediatric limps with confidence. Learning Objectives Apply an age-based approach to the differential diagnosis of limping in children. Demonstrate diagnostic reasoning by integrating history, physical exam, imaging, and lab findings to prioritize urgent conditions like septic arthritis and SCFE. Appropriately select and interpret imaging and lab studies, including understanding the utility and limitations of ultrasound, MRI, and the Kocher criteria. Connect with Brad Sobolewski Mastodon: @[email protected] PEMBlog: PEMBlog.com Blue Sky: @bradsobo X (Twitter): @PEMTweets Instagram: Brad Sobolewski References Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999;81(12):1662-70. doi:10.2106/00004623-199912000-00002 UpToDate. Evaluation of limp in children. Accessed September 2025. UpToDate. Differential diagnosis of limp in children. Accessed September 2025. StatPearls. Antalgic Gait in Children. NCBI Bookshelf. Accessed September 2025. Pediatric Emergency Care. “Approach to Pediatric Limp.” Pediatrics in Review. 2024. Transcript Note: This transcript was partially completed with the use of the Descript AI and the Chat GPT 5 AI Welcome to PEM Currents, the Pediatric Emergency Medicine podcast. As always, I’m your host, Brad Sobolewski, and in this episode we’re gonna tackle the evaluation of a child presenting with limp. We’ll cover, age-based differential diagnosis. How to take a high yield history and do a detailed physical exam, imaging strategies, lab tests, and when to worry about systemic causes. We’ll also talk about the Kocher criteria for septic arthritis and how to use and not misuse ultrasound when you’re worried about a hip effusion. After listening to this episode, I hope you will all be able to apply an age based. Approach to the differential diagnosis of limp in children. Demonstrate diagnostic reasoning by integrating history, physical exam, imaging, and lab findings to prioritize urgent conditions like septic, arthritis, and scfe, and appropriately select and interpret imaging and lab studies, including understanding the utility and limitations of ultrasound MRI and the Kocher criteria. So let me start out by saying that a limp isn’t a diagnosis, it’s a symptom. It can result from pain, weakness, neurologic issues, or mechanical disruption. So think of limping as the pediatric equivalent of chest pain. In adults. It’s common, it’s broad, and it’s sometimes could be serious. And the key to a good workup is a thought. Age-based approached and kids under three think trauma and congenital conditions between three and 10 transient synovitis range Supreme and over 10 think SCFE and systemic disease. And your differential diagnosis always starts with history. So you gotta ask the family, when did the lymph start? Was it sudden or gradual? Is there a preceding viral illness or an injury? Is the limp worse in the morning? Does it get better with activity? Do the kid complain of pain or are they just favoring one leg? And then are there any systemic symptoms such as fever, rash, weight loss, fatigue, or joint swelling elsewhere? And you wanna find out whether or not the kid is actually bearing any weight at all. Have they had recent travel or known tick exposure? Are they potty trained and are they having accidents now? Have they had any prior episodes of joint swelling or limping like this in the past? And don’t forget a developmental history, especially in kids under preschool age. Most children begin to stand at nine to 12 months. Cruise at 10 to 12 months and walk independently by 12 to 15 months. A child who has never walked normally may have a neuromuscular or congenital problem. When you are evaluating limp, obviously you wanna watch the kid walk, get them outta the exam room if needed. First of all, your exam room is small. Kid may feel confined and they might be more willing to take some steps. If you have ’em out in the hallway, obviously have the caregiver nearby and a toy, a phone, some object of enticement. You wanna watch their stance phase, or they just avoiding bearing weight on one limb. When they’re standing the swing phase, do they hold that leg stiff? Does it bend normally? And are they in balance? Are they symmetric? And again, don’t just settle for a few steps. Try to get ’em walking at least 10 to 15 feet if possible, and if they’re refusing to walk in, the ED asks parents for a video. You wanna examine every joint head to toe, and even if the child only complains about one area, palpate every limb. I usually start distally so at the fingertips or toes and really systematically work my way up watching for any signs of pain, you check range of motion and observe resistance to movement log. Roll the hips externally and internally rotate them as well. See if you can feel an A fusion, you know, squeeze the calf to localize pain. And in a kid with limp, you always gotta check the feet too, right? Look for puncture wounds on the plantar surface. Splinters, ingrown, toenails, cellulitis, or even, you know, gravity dependent swelling or petechiae. And certainly your systemic exam should include the abdomen. You know, look for signs of appendicitis or sous irritation, testes for testicular torsion. And you wanna look at the skin diffusely to make sure there’s no petechiae, target shape, rashes, or bruising. Now for most kids with limp, I find that the history and physical exams sort of guide where you’re going, right? If they had a fall or an injury, well, you’re just looking at a kid who may have sprained or broken something, and you can really target towards imaging as your workup. You know, there’s some kids though that may benefit from labs and in general, they depend on the scenario. So if you see A C, B, C, well you’re gonna get leukocytosis, but C, B, C. In the context of limp is most useful when you’re considering a differential. So if you see blasts, well, you know you’ve got a new malignancy. If you have a general elevation of the white count and use it in context with the Kocher criteria, it could be more valuable. So A CBC alone is not gonna get you the cause it supports your differential. ESR and CRP are often ordered and they’re just general inflammatory labs. CRP rises and falls faster than ESR, and they co vary and either can be used in prediction rules. I’ll talk about that in a little bit if you think the kid’s bacteremic, yeah. Get a blood culture. If you’re in an endemic area and you’re considering Lyme on the differential, you can send off serology. And let’s be honest, a NA and rheumatoid factor are really only useful if there’s a chronic history and you can have about 15% of kids with a false positive a NA anyway, and they’re not really helpful in acute limp. So get them if rheumatology recommends them, but otherwise, they’re not really a useful part in the initial differential diagnosis. And again, I alluded to Lyme a moment ago, but if Lyme arthritis is your top diagnosis, especially with a known rash. You can start treatment while serologies are pending. That’s totally okay. So in conjunction with Labs, imaging is generally recommended in most kids with Limp, and I would say in most cases you start with plain films. Sometimes it’s easy, right? They hurt in one particular occasion. You take a picture, you see a fracture, but two views, the affected and unaffected side can be really helpful, especially in cases of SCFE or in subtle or perhaps occult toddler’s fracture. If you’re not sure where the problem is, you can’t isolate it on your exam or history. Consider imaging the entire leg. I mean, that’s when you’re looking at like the hip femur, knee tib fib, even the ankle and foot. It’s not that much radiation. Ultrasound is useful for seeing joint effusions, especially of the hip. It’s fast, generally painless and radiation free, but not all effusions are infected. Ultrasound is not part of the Kocher criteria. I’ll get back to that in a minute. And a normal ultrasound or an ultrasound without effusion doesn’t rule out septic arthritis. And then we’ve got MRI, which is definitely best for detecting osteomyelitis, discitis, and soft tissue abscesses. Among other diagnoses in kids under five, you’re probably gonna need to sedate them, which can delay diagnosis. So in general, you’re admitting those kids and then they can get a sedated MRI later the next day. But if radiology has it available and you’ve got the right protocol and the kids’ the right age, you can get it in the emergency department. But these are often more subtle situations. So if you’re really suspicious for septic arthritis, don’t wait around for an MRI contact ortho and tap that hip. And speaking of septic arthritis, let’s talk about the Kocher criteria. K-O-C-H-E-R. These are four classic criteria, and they are only validated for differentiating septic arthritis and transient synovitis of the hip. So you can’t use the labs and values of Kocher criteria in the knee or elbow, or another joint. It is only the hip. And the four classic criteria are fever greater than 38.5 Celsius, non-weight bearing on the affected side, ESR, greater than 40. Or CRP greater than two and white blood cell count greater than 12,000, and you use them in combination to predict the likelihood of septic arthritis of the hip. So if you have none of them, you have less than a 0.2% chance of septic arthritis. If you have one, you have 3%, two 40%. Three of them, 93% and all four, a 99 plus percent chance of having septic arthritis. So the more criteria that are positive, the higher the post-test probability of septic arthritis. And remember I mentioned this before, ultrasound isn’t part of that rule, so don’t let a small effusion sway you one way or the other. Septic arthritis is a clinical diagnosis supported by aspiration of the hip. Ultrasound can help, but a normal scan doesn’t clear the joint, so some orthopedists will recommend not getting an ultrasound on intermediate risk cases and just going straight to joint aspiration if the concern’s high. So if the kid’s worried they stay, don’t discharge a maybe septic joint. I think now’s a good time to come back to some of the common diagnoses that you’ll have on your differential, and I think an age-based schema makes sense here. In Kids Under three, you’re thinking toddlers fracture, septic, hip, developmental dysplasia of the hip, non-accidental trauma, leukemia and transient synovitis in kids three to 10 transient synovitis rules the day. Injuries and trauma. Hopefully you have a good history. Septic arthritis, juvenile idiopathic arthritis, and leg calf, Perth’s disease, and then kids older than 10, you’ll start to see scfe. So slipped capital, femoral epiphysis, stress fractures, osteomyelitis, overuse injuries, and yes, still unfortunately, malignancy leg, Ewing sarcoma. Thinking beyond the limb should remind you that systemic causes can lead to limp as well. Appendicitis can present as right hip pain or limp. Testicular torsion may cause abdominal pain and referred thigh pain. Leukemia obviously can present with limp, nighttime pain, and subtle systemic signs. Discitis may masquerade as refusal to walk or sit upright. And any malignancy can present subtly. You can see bruising, fatigue, pal anemia, or bony tenderness. So red flags for a child with limp, so you’re calling orthopedics, admitting or escalating. Your plan is when the kid is ill appearing toxic or febrile. Your labs obviously suggest inflammation or infection. You have septic, arthritis, osteomyelitis, or non-accidental trauma. At the top of your list, and you have diagnostic uncertainty on a child who isn’t improving. So you did a workup. It’s reassuring, and despite analgesia, reassurance and time, the kid still won’t walk well. Maybe that kid needs workup for osteomyelitis, so sometimes the best course of action is to admit them and get the MRI the next day. All right. Here’s some take home points on the child with limp. Limping is due to pain, weakness, mechanical or neurologic causes. Think broadly in terms of your differential history, physical exam and observation, or more valuable than a dozen labs. Age-based differential diagnoses guide you and help you tailor your exam and questions accordingly. So I think that’s a good schema to teach. Always start with plain films, especially if you suspect injury. The Kocher criteria are only valid for differentiating septic hip versus transient synovitis. Don’t use them in another joint. And septic arthritis is a clinical diagnosis, so if you’re worried and they have multiple factors, tap that joint. If you’re concerned about the kid and they’re still not walking, it’s okay to admit, and again, don’t forget to check the feet. I’ve seen many kids that have been limping because there’s a splinter in the bottom of the foot. You can save yourself a lot of time and money by just yanking that little splinter. Well, that’s all for this episode. I hope that this helps you evaluate limping kids with a bit more confidence, precision, efficiency, and ultimately lets you communicate rationale for testing and treatments better with families. If you’ve got ideas for other episodes, send them my way. If you wanna collaborate on making a podcast in the future, I’d love to do that as well. If you like this episode of this show in general, share it with your colleagues and. If you have the time, leave a comment on the blog or like rate review the podcast. It helps more people find it and more people learn. If you notice that input adds on this, I’m not making a dime. I just wanna teach people stuff. That’s all for this one, for PEM Currents, the Pediatric Emergency Medicine podcast. This has been Brad Sobolewski. See you next time.

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• Managing Pain in Sickle Cell Vaso-Occlusive Crises

  Vaso-occlusive pain episodes are the most common reason children and adolescents with sickle cell disease present to the Emergency Department. Prompt, protocol-driven management is essential starting with early administration of IV opioids, reassessment at 15–30 minute intervals, and judicious hydration. Understanding the patient’s typical pain pattern, opioid history, and psychosocial context can guide more effective care. This episode walks through the pathophysiology, clinical presentation, pharmacologic strategy, discharge criteria, and complications to watch for helping you provide evidence-based, compassionate care that improves outcomes. Learning Objectives Describe the pathophysiology of vaso-occlusive crises in children and adolescents with sickle cell disease and how it relates to clinical symptoms. Differentiate uncomplicated vaso-occlusive crises from other acute complications of sickle cell disease such as acute chest syndrome, splenic sequestration, and stroke. Implement evidence-based strategies for early and effective pain management in vaso-occlusive crises, including appropriate use of opioid analgesia, reassessment intervals, and disposition criteria. Connect with Brad Sobolewski PEMBlog: PEMBlog.com Blue Sky: @bradsobo X (Twitter): @PEMTweets Instagram: Brad Sobolewski Mastodon: @[email protected] References Kavanagh PL, Fasipe TA, Wun T. Sickle cell disease: a review. JAMA. 2022;328(1):57-68. doi:10.1001/jama.2022.10233 Yates AM, Aygun B, Nuss R, Rogers ZR. Health supervision for children and adolescents with sickle cell disease: clinical report. Pediatrics. 2024;154(2):e2024066842. doi:10.1542/peds.2024-066842 Bender MA, Carlberg K. Sickle Cell Disease. In: Adam MP, Everman DB, Mirzaa GM, et al, eds. GeneReviews®. University of Washington, Seattle; 1993–2024. Updated February 13, 2025. Available from: https://www.ncbi.nlm.nih.gov/books/NBK1377/ Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv. 2020;4(12):2656-2701. doi:10.1182/bloodadvances.2020001851 Brandow AM, Carroll CP, Creary SE. Acute vaso-occlusive pain management in sickle cell disease. In: Hoffman R, Benz EJ, Silberstein LE, Heslop HE, Weitz JI, Anastasi J, eds. UpToDate. UpToDate; 2024. Accessed July 2025. https://www.uptodate.com Glassberg JA, Strouse JJ. Evaluation of acute pain in sickle cell disease. In: Hoffman R, Benz EJ, Silberstein LE, Heslop HE, Weitz JI, Anastasi J, eds. UpToDate. UpToDate; 2024. Accessed July 2025. https://www.uptodate.com DeBaun MR, Quinn CT. Overview of the clinical manifestations of sickle cell disease. In: Hoffman R, Benz EJ, Silberstein LE, Heslop HE, Weitz JI, Anastasi J, eds. UpToDate. UpToDate; 2024. Accessed July 2025. https://www.uptodate.com McCavit TL. Overview of preventive outpatient care in sickle cell disease. In: Hoffman R, Benz EJ, Silberstein LE, Heslop HE, Weitz JI, Anastasi J, eds. UpToDate. UpToDate; 2024. Accessed July 2025. https://www.uptodate.com Transcript Note: This transcript was partially completed with the use of the Descript AI and the Chat GPT 4o AI Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. I’m your host, Brad Sobolewski. In this episode, we’re digging into a common but complex emergency department challenge: pain management for vaso-occlusive crises in children and adolescents with sickle cell disease. These episodes are painful—literally and figuratively. But with thoughtful, evidence-based care, we can make a big difference for our patients. Overview and Epidemiology Vaso-occlusive crises, or VOCs, are the most frequent cause of emergency visits and hospitalizations for individuals with sickle cell disease (SCD). They are responsible for more than 70 percent of ED visits among children with SCD and account for substantial healthcare utilization and missed school days. Most children with homozygous HbSS will experience their first painful episode before the age of 6. Recurrent VOCs are associated with higher risks of chronic pain, opioid use, and diminished quality of life. Why Do VOCs Happen? Sickle cell disease is caused by a point mutation in the beta-globin gene, leading to hemoglobin S. Under stress—such as infection, dehydration, or even cold exposure—red blood cells polymerize, sickle, and become rigid. These sickled cells obstruct capillaries and small vessels, leading to local tissue ischemia, inflammation, and pain. It’s not just about the blockage—the inflammatory cascade, endothelial damage, and cytokine release all contribute to the pain experience. What Does the Pain Feel Like? Ask kids and teens with sickle cell disease, and they’ll describe their pain as deep, throbbing, stabbing, or aching. It often feels bone-deep and can be relentless and exhausting. Many say it’s unlike any other pain—they may compare it to being “hit with a bat,” “bone being crushed,” or “something stuck inside my limbs trying to get out.” Common sites include: Long bones (femur, humerus) Lower back Chest (look out for acute chest syndrome) Abdomen Hands and feet (especially in younger children—think dactylitis) Clinical Presentation History Ask about typical pain patterns and how this episode compares to prior ones. Look for triggers: dehydration, weather changes, infection, stress. Document home medications, including opioid tolerance and response to prior ED treatments. Physical Exam Often nonspecific. Localized tenderness, guarding. May have fever if infection is present (but fever is not diagnostic of VOC). Look for signs of acute chest syndrome: tachypnea, hypoxia, chest pain. Vitals May show tachycardia from pain or dehydration. Febrile patients should be evaluated for sepsis or osteomyelitis. Pain scales Use age-appropriate tools: FLACC, Wong-Baker FACES, or numerical rating scales. Management: Treat Early, Treat Effectively Pain Medications Start early. Do not delay for labs. Aim for analgesia within 30–60 minutes of arrival. Mild pain (rare in ED): Acetaminophen or NSAIDs (e.g., ibuprofen, ketorolac). Moderate to severe pain: Opioids are first-line. Morphine IV: 0.1 mg/kg (max 10 mg) every 15–30 minutes as needed; consider PCA in admitted patients. Hydromorphone IV: 0.015 mg/kg if morphine does not work or if the patient has used it effectively in the past. Intranasal fentanyl: 1.5–2 mcg/kg as a bridge while waiting for IV access. Avoid codeine and meperidine due to poor efficacy and neurotoxicity risks. Reassess every 15–30 minutes until pain is controlled, then space doses out. Adjunctive Therapies Hydration: Lactated Ringer’s is associated with shorter hospital stays and lower readmission rates than normal saline. Avoid fluid overload; maintain euvolemia. Heat packs for local comfort. Distraction techniques, Child Life, music, games, screens. Anxiolytics may be considered for severe distress but use cautiously. Labs and Imaging Labs are not always needed if the child looks well and has an uncomplicated VOC. Follow local protocols. Consider: CBC and reticulocyte count: A low retic suggests aplastic crisis (often parvovirus B19). A high retic is appropriate in VOC, showing marrow response. Compare hemoglobin to baseline. BMP for renal function. LFTs or lipase if right upper quadrant pain. Chest x-ray if chest symptoms present. Blood cultures if febrile. Oxygen Only indicated if the patient is hypoxic. Transfusion Routine transfusion is not indicated for uncomplicated VOC. May be used in complications such as acute chest syndrome, stroke, or symptomatic anemia. Disposition: Discharge vs. Admission Discharge if: Pain is improved and manageable on oral medications. Tolerating oral intake. No concern for complications. Reliable follow-up and support available. Admit if: Persistent severe pain despite multiple IV doses. Need for frequent parenteral opioids. Acute chest syndrome, sepsis, or other complications. Poor outpatient support or unreliable follow-up. Complications to Watch For Acute chest syndrome: Chest pain, hypoxia, new infiltrate on chest x-ray. Splenic sequestration: Rapid hemoglobin drop, splenomegaly, signs of shock. Stroke: New neurologic deficits. Sepsis: Fever, tachycardia, especially in asplenic patients. Avascular necrosis: Recurrent or chronic hip or shoulder pain. Chronic pain: Increasing in frequency in adolescents and young adults. Prevention Hydroxyurea is the cornerstone of prevention. It increases fetal hemoglobin and reduces the frequency and severity of pain crises. It can be started as early as 9 months of age in children with HbSS or Sβ⁰-thalassemia. Other preventive strategies include: Staying hydrated. Avoiding extreme cold exposure. Keeping up with vaccines and penicillin prophylaxis. Addressing mental health and social stressors. Take-Home Points Treat pain promptly and aggressively. Do not wait on labs. Use IV opioids for moderate to severe pain and reassess often. Lactated Ringer’s may be preferred for IV hydration, but avoid overload. Labs and imaging should follow clinical appearance and local protocols. Reticulocyte count and hemoglobin trends are key. Disposition should be based on pain control, potential complications, and social support. Prevention matters—hydroxyurea and primary care follow-up reduce crises and admissions.

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• Penetrating Neck Injuries

  Penetrating neck injuries in children are rare—but when they happen, the stakes are high. In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, we explore the clinical pearls behind “no-zone” management, how to distinguish hard and soft signs, when to image versus operate, and why airway always comes first. Get ready for a focused, evidence-based deep dive into pediatric neck trauma. Learning Objectives Understand the shift from zone-based to “no-zone” management in pediatric penetrating neck injuries and describe the rationale behind this transition. Apply ATLS principles to the initial assessment and stabilization of children with penetrating neck injuries, including decisions regarding imaging and airway management. Evaluate clinical findings to determine the need for operative intervention versus observation in stable pediatric patients with soft versus hard signs of vascular or aerodigestive injury. Connect with Brad Sobolewski PEMBlog: PEMBlog.com Blue Sky: @bradsobo X (Twitter): @PEMTweets Instagram: Brad Sobolewski Mastodon: @[email protected] References Stone ME Jr, Christensen P, Craig S, Rosengart M. Management of penetrating neck injury in children: A review of the National Trauma Data Bank. Red Cross Annals. 2017;32(4):171–177. doi:10.1016/j.rcsann.2017.04.003 Callcut RA, Inaba K. Penetrating neck injuries: Initial evaluation and management. UpToDate. Waltham, MA: UpToDate Inc. [Accessed June 24, 2025]. Available from: https://www.uptodate.com Transcript Note: This transcript was partially completed with the use of the Descript AI and the Chat GPT 4o AI Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and in this episode we are diving into a high-stakes but fortunately rare topic in pediatric trauma — penetrating neck injuries. Now these injuries make up less than 1% of all pediatric trauma, but when they occur, they demand precision and vigilance in terms of diagnosis and management. As you know, the neck packs some vital organs, vessels, the airway, esophagus, and nerves into a tiny little area, so even a seemingly minor wound can injure multiple structures. Now you remember — way back when — where you learned about the zones of the neck, and this is the traditional teaching, which chopped the neck up into three zones. You’ve got Zone I, which is the area between the clavicle and cricoid. You’ve got the subclavian arteries and vein, the carotid, and the apices of the lungs. Zone II, the cricoid to the angle of the mandible — this includes the carotids, jugulars, the vagus nerve, the trachea, and the esophagus. And then you have Zone III, which is the angle of the mandible to the base of the skull — you’ve got the distal carotid, the vertebral artery, and cranial nerves IX through XII. Now, you may recall some teaching that you got in medical school or residency where the management was dictated by which zone was injured. And admittedly, a lot of this evidence is in adults, and more penetrating trauma is seen in adults as well. But now practice is leaning towards the “no zone” approach, where imaginary lines on the skin surface are not dictating management as much as presentation, symptoms, and deciding when to go to the OR versus using CT angiography. So let’s talk about mechanisms of injury for a minute. Toddlers can injure their neck when they fall with something in their mouth, like pencils or chopsticks. School-age kids may take a bike handlebar to the neck, or they’re trying to run or jump over a fence and they get impaled on that — that sounds painful. Adolescents, unfortunately, are subject to assaults, stabbings, and gunshot wounds, as well as clothesline-type injuries or other high-velocity injury where the neck is injured as they’re riding a bike. So low-velocity mechanisms dominate pediatric penetrating neck injuries. Force matters, because depth and tissue cavitation decide the overall injury pattern. In terms of assessing the patient with a penetrating neck injury, it all starts with the ABCs. Is the patient’s airway patent? Are they protecting and maintaining it? Look for signs such as hoarseness, stridor, aphonia (they can’t talk at all), a bubbling wound, or an expanding hematoma. For breathing, patients should be breathing comfortably with no distress. Look for any signs of asymmetry on chest rise, feeling of crepitus or subcutaneous air, or diminished breath sounds — obviously the latter two indicating a pneumothorax or even hemothorax. For circulation, if the wound is bleeding, apply direct pressure. Some surgeons will use a Foley balloon tamponade method if they need to stop bleeding before going to the operating room. Patients will need large bore IVs and fluids — and especially blood product resuscitation. Only immobilize the C-spine if a patient has neurologic deficits or a high injury mechanism. Think — somebody that was riding their bike and clotheslined the fence. Neck collars hide neck wounds and hamper airway management unless they’re strictly needed. You may have also heard of hard signs and soft signs in terms of the parlance of managing penetrating neck injury. In general, hard signs mean go to the operating room. Soft signs need a CT angiogram and observation. So here are some hard signs: • Active arterial bleeding — blood spurting out of the patient • Expanding or pulsatile hematoma • Airway compromise, stridor, or other signs • Air bubbling from the neck wound • Shock that is unresponsive to fluids • Any focal neurologic deficit Soft signs include: • Minor oozing • A small and stable hematoma • Mild dysphonia or dysphagia • Subcutaneous air without any respiratory distress • Mild voice changes • Just a little bit of hemoptysis A large pediatric series showed that 50 to 70% of children with hard signs did need operative repair. Most with only soft signs were managed safely with imaging and serial exams. So I alluded to this paradigm at the beginning of the episode — the “no zone” strategy. For stable children with no hard signs, CT angiography is the gold standard. It has a sensitivity of 95 to 99% for major vascular injury. You’re able to visualize the trachea, esophagus, spine, and any foreign bodies. Make sure you always get a chest X-ray as well, since penetrating neck injuries can injure the apices of the lungs or thoracic structures. Also, if the CTA is negative but you still have suspicion for injury to the aerodigestive tract, you can do a water-soluble contrast esophagram or flexible endoscopy. Plain films — yes, you can assess the C-spine and look for radiopaque foreign bodies, but again, if you truly have a child that is stable and has no hard signs, CTA is the gold standard. If you follow this, you can cut non-therapeutic neck explorations in half without missing any injuries. So this should be part of your protocol. If you do have a neck wound that you have to manage before the surgeons can get to it: direct pressure first. The Foley balloon tamponade method is where you take an 18 to 20 French catheter, place it into the wound, inflate the balloon with 10 to 15 milliliters of water, and then clamp it. I wouldn’t necessarily do this in a Level 1 trauma center — I have surgeons available — but it might be useful if you have to transport a kid quickly to a trauma center. Never, ever, ever pull an impaled object out of the neck in the emergency department. These should be removed in the operating room. Now, superficial injuries with the platysma intact get routine closure. Anything deeper deserves imaging. So here’s some pediatric-specific pearls, again, because these are really rare. Kids have a small airway, and soft tissues swell quickly, so there’s a low threshold for securing the airway. If you’re concerned about the airway, make a plan to do it right now. Kids have low blood volume and don’t tolerate hemorrhage as well. They’ll underreport pain, especially younger ones — so rely on the exam and parental observations. Definitely use Child Life to help keep them calm. And unfortunately, some neck wounds are self-inflicted, so make sure you address mental health concerns after the child is stabilized. Alright. So let’s bring it all home. What are some key take-home points? 1. Penetrating neck trauma is fortunately rare in kids — far less than 1% of all pediatric trauma — but still high-risk. 2. Males predominate. The younger the child, the higher the risk of aerodigestive injury. 3. Hard signs → go straight to the OR. 4. Soft signs → CT angiography and observation. 5. Hard vs soft signs reliably stratify risk. 6. CTA + chest X-ray is first-line in stable, hard-sign-negative children, which limits unnecessary surgical exploration. 7. Esophageal injuries are sneaky — you may need endoscopy or contrast studies if CTA is equivocal. 8. In terms of immediate management: airway beats everything. • People talk about the triple setup: RSI, extraglottic rescue, surgical airway kit. 9. Children with concerning but non-operative injuries need serial examinations — these are very powerful. • Observation is a test. Check neurovascular status every 2 to 4 hours for at least a day. 10. If there’s an impaled object — leave it, transport intact, and remove it in the OR. 11. If you’re working in the community or not at a Level 1 pediatric trauma center — focus on careful airway management and immediate transport. That’s all for this episode. I hope you found it useful — especially since these injuries are less common, but can be incredibly impactful. If you enjoyed the content, or want to hear something different about pediatric trauma, reach out and let me know — I’ll take an email, a comment on the blog, a social media message. And please — as my 13-year-old would encourage me to say — like, rate, and review. It helps other people find the podcast. I just want people to learn, basically. Share this episode and the podcast with the folks you work with — and not just physicians in the emergency department. I think we all deserve to learn about how we manage injuries in children. For PEM Currents: The Pediatric Emergency Medicine Podcast, this has been Brad Sobolewski. See you next time.

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