PEM Currents: The Pediatric Emergency Medicine Podcast

In children with septic shock, does the choice between balanced crystalloids and 0.9% saline actually matter? This episode reviews the composition and physiologic differences between commonly used crystalloids, summarizes the 2026 PRoMPT BOLUS trial, and discusses how its findings fit with the updated Surviving Sepsis Campaign pediatric guidelines. We also consider the trial’s limitations and what the results mean for fluid selection at the bedside. Learning Objectives By the end of this episode, listeners should be able to: Compare the composition and physiologic effects of 0.9% saline and balanced crystalloids used for pediatric fluid resuscitation. Summarize the design and major findings of the PRoMPT BOLUS trial. Describe important limitations of PRoMPT BOLUS when applying its results to children with septic shock. Apply current evidence and 2026 Surviving Sepsis Campaign recommendations when selecting crystalloid fluids for pediatric septic shock. References Weiss SL, Peters MJ, Oczkowski SJW, et al. Surviving Sepsis Campaign International Guidelines for the Management of Sepsis and Septic Shock in Children 2026. Pediatr Crit Care Med. 2026. Published April 1, 2026. Jointly issued by the Society of Critical Care Medicine and Infectious Diseases Society of America. Recommendation 24 suggests balanced/buffered crystalloids over 0.9% saline for children with septic shock requiring fluid boluses (conditional recommendation, very low certainty), while recognizing 0.9% saline as a suitable alternative and preferred in selected situations such as hyponatremia or concern for increased intracranial pressure. Balamuth F, Weiss SL, Long E, et al. Balanced Fluid or 0.9% Saline in Children Treated for Septic Shock. N Engl J Med. 2026. Published April 24, 2026. PRoMPT BOLUS was a large pragmatic randomized trial comparing balanced crystalloids with 0.9% saline in children treated for suspected septic shock and found no reduction in major adverse kidney events within 30 days with balanced fluids. Transcript This transcript was generated using Descript and subsequently reviewed and lightly edited for spelling, grammar, and clarity. Minor inaccuracies may remain, and the audio recording should be considered the definitive version of this content. Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and today we’re gonna talk about which fluid we should use when managing a septic pediatric patient. So when we resuscitate a child with septic shock, the major decision is usually not whether to give crystalloid, but which crystalloid to give. And for a long time, there’s been a gradual shift towards balanced fluids such as Lactated Ringer’s or Plasma-Lyte, largely because they are more physiologic and produce less hyperchloremia than normal saline. The question’s always been whether those biochemical differences actually translate into better clinical outcomes. That is the question that a study called PRoMPT BOLUS was designed to answer. So before getting into the trial, it’s worth briefly reviewing what these fluids actually contain. So normal saline is 0.9% sodium chloride. It contains one hundred and fifty-four milliequivalents per liter of sodium and a hundred and fifty-four milliequivalents per liter of chloride. The chloride concentration is substantially higher than plasma. Balanced crystalloids contain less chloride and have some other electrolytes and a buffer. Lactated Ringer’s contains approximately a hundred and thirty milliequivalents per liter of sodium, one hundred and nine of chloride, four of potassium, a small amount of calcium, and lactate as a buffer. Plasma-Lyte contains approximately one hundred and forty of sodium, ninety-eight of chloride, five of potassium, magnesium, and acetate and gluconate as buffers. The concern with normal saline is that the large chloride loads can produce hyperchloremic metabolic acidosis. There’s also been concern about adverse effects on renal blood flow and kidney function. Balanced fluids are designed to more closely approximate plasma composition, so the hypothesis has been that they might reduce kidney injury. That hypothesis has been supported by physiologic data and by some adult studies, although pediatric evidence before PRoMPT BOLUS was limited and inconsistent. The 2026 Surviving Sepsis Campaign Pediatric Guidelines recommend crystalloids over albumin for initial resuscitation and conditionally suggest balanced or buffered crystalloids over 0.9% saline in children with septic shock who require fluid boluses. Importantly, that recommendation is based on very low-certainty evidence. Balanced options again include Lactated Ringer’s, Hartmann’s solution, or Plasma-Lyte. If balanced fluids are not readily available, saline remains an acceptable alternative. Saline may also be preferable in some specific situations like significant hyponatremia or concern for increased intracranial pressure. For children in resource-abundant settings, the general approach is still ten to twenty mLs per kilo per bolus with reassessment after each bolus, potentially up to forty to sixty mLs per kilo in the first hour if perfusion remains abnormal and there are no signs of fluid overload. Now, PRoMPT BOLUS, the full name of which is the Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis, was an international randomized pragmatic trial designed to specifically compare the two fluid strategies in children with suspected septic shock. The final trial enrolled nine thousand and forty-one children from two months to younger than eighteen years across forty-seven emergency departments in five countries. Children were randomized to predominantly balanced crystalloid or predominantly 0.9% saline, and the assigned fluid strategy was used for bolus and maintenance crystalloid during the initial treatment period. The balanced fluid arm was not a single product. Depending on the site, children could get Lactated Ringer’s, Hartmann’s solution, or Plasma-Lyte. That’s important when interpreting the study. PRoMPT BOLUS was really testing a strategy of predominantly balanced crystalloid versus a strategy of predominantly saline use rather than comparing LR versus saline alone, though LR was the most commonly used one. The primary outcome was something called MAKE30, M-A-K-E thirty, or major adverse kidney events within thirty days. This was a composite outcome that included death, new renal replacement therapy, or persistent kidney dysfunction. That choice of outcome is useful because the biologic rationale for balanced fluids has always centered largely on kidney protection. The investigators were therefore asking whether the lower chloride exposure associated with balanced fluids translated into clinically meaningful renal benefit. So what was the result? Well, the spoiler is that the answer was no. So MAKE30 occurred in three point four percent of children receiving balanced fluids and three percent receiving saline. The relative risk was one point one with a ninety-five percent confidence interval from point eight eight to one point four. There were also no significant differences in death, new renal replacement therapy, persistent kidney dysfunction, or hospital-free days. In practical terms, balanced crystalloids did not improve the major patient-centered outcomes the trial was designed to measure. There were clear biochemical differences between the groups. Hyperchloremia occurred in thirty-one point four percent of children receiving balanced fluids compared with forty-nine percent with saline. Hypernatremia was also less common with balanced fluids, one point eight versus three point one percent. Hyperlactatemia was slightly more common in the balanced fluid group, nineteen point eight compared with sixteen point seven percent. So the fluids behaved differently in the ways that you would expect physiologically. Balanced crystalloids clearly reduced hyperchloremia, but that difference did not translate into fewer major kidney events, less dialysis, shorter hospitalization, or lower mortality. There are several limitations to this study worth keeping in mind. The first is that this was a broad emergency department population with suspected septic shock, not a study limited to children with the most severe forms of shock. Only a minority of patients required vasoactive medications, and overall mortality was low. The results are therefore most applicable to the typical child with suspected septic shock receiving early ED resuscitation. They do not completely answer whether fluid composition might matter more in a smaller subgroup of children receiving very large fluid volumes or prolonged resuscitation. The second limitation is that the event rate for MAKE30 was lower than expected. When the trial was designed, investigators anticipated an event rate of about six percent in the saline group. The observed rate was closer to three percent. That means there were fewer outcome events than anticipated, which reduced the ability to detect a very small treatment effect. So the trial makes a large benefit from balanced fluids unlikely, but it can’t exclude a small or subtle difference. A third limitation is that the balanced fluid group included several different solutions. Lactated Ringer’s, Plasma-Lyte, and Hartmann’s are all considered under the umbrella of balanced crystalloids, but they’re not chemically identical. The study therefore supports the broader conclusion that a balanced fluid strategy is not superior to saline for most children in this setting, rather than providing equivalence between any single specific balanced solution and saline, even though Lactated Ringer’s is used far and away most often. The trial was also intentionally pragmatic, which means that there was some crossover between fluid types. Adherence was defined as receiving at least seventy-five percent of crystalloid as the assigned fluid rather

Embedded earrings are a common pediatric emergency department presentation that can usually be managed quickly and safely without procedural sedation. This episode reviews why earrings become embedded, how to distinguish uncomplicated earlobe cases from higher-risk cartilage piercings, step-by-step removal techniques, pain control strategies, and appropriate wound care, antibiotics, and follow-up. Learning Objectives Recognize the evaluation and management of embedded earlobe earrings, including indications for local anesthesia, incision, and removal techniques. Differentiate uncomplicated earlobe piercings from cartilage piercings that require additional concern for perichondritis, Pseudomonas infection, and possible ENT consultation. Apply evidence-based post-procedure care, including appropriate wound management, antibiotic selection, and counseling to help prevent future embedded earrings. References Timm N, Iyer S. Embedded earrings in children. Pediatr Emerg Care. 2008;24(1):21-24. Muntz HR, Pa-C DJ, Asher BF. Embedded earrings: a complication of the ear-piercing gun. Int J Pediatr Otorhinolaryngol. 1990;19(1):73-76. Kim MM, Goldman RD. Ear-piercing complications in children and adolescents. Can Fam Physician. 2022;68(9):661-663. Transcript This transcript was generated using Descript and subsequently reviewed and lightly edited for spelling, grammar, and clarity. Minor inaccuracies may remain, and the audio recording should be considered the definitive version of this content. Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski. Today, we’re continuing our new series on minor procedures. These are the procedures we perform all the time in pediatric emergency departments. They’re not the subject of giant multicenter trials or big keynote lectures, but they are the procedures that families remember. If you make them quick, comfortable, and maybe even a little less scary, families and patients will remember that. And if the procedure turns into a wrestling match with three people trying to hold down a screaming child while you’re searching for an earring backing, they’re gonna remember that too. Today’s topic is embedded earrings. A kid walks into the emergency department holding one ear. The earlobe is swollen and red, and the parent says, “I can’t find their earring.” It didn’t disappear. The ear basically swallowed it, and the parents almost always feel bad. They think they did something wrong or they waited too long. Honestly, this happens all the time. The first one can be a little intimidating because the hardware isn’t always where you expect it to be, but after you’ve removed a few of these, you’ll realize they’re actually pretty straightforward. Most can be managed right in the emergency department or a well-resourced urgent care. One of the best studies on the topic actually came from Cincinnati Children’s. Tim and Iyer reviewed over 100 children who presented to our emergency department with embedded earrings over about a four-and-a-half-year period. The median age was eight years, and about 60% of the children were younger than 10. That fits with most of our clinical experience. Younger children are more likely to sleep on new piercings, play with their earrings, forget the aftercare instructions, or simply not notice that the backing has become too tight. Nearly 90% of embedded earrings involve the earlobe rather than the cartilage, and in about two-thirds of patients, it wasn’t the decorative front of the earring that got stuck, it was the posterior backing or clasp. That’s helpful because I, um, almost always start looking on the back of the ear, ‘cause usually they’ve taken off the front. About one-third of children had evidence of a localized infection when they presented. Usually, that meant tenderness, erythema, swelling, and maybe a little purulent drainage or crusting around the piercing. Doesn’t necessarily mean they need oral or systemic antibiotics, but it does mean they shouldn’t wait another week hoping the earring somehow works itself out. So why does this happen? It’s really a pressure injury. The backing gets tightened against the earlobe, either because it was applied too snugly when the ears were pierced or because the ear swells afterward and suddenly there’s no room for the tissue to expand. That constant pressure decreases blood flow, produces local inflammation, and eventually the skin begins to grow around the earring hardware. Kids speed the whole process along by twisting the earrings, playing with them, sleeping on them, bumping them during play, and not cleaning the piercing consistently while it’s healing. One thing that probably contributes as well is the spring-loaded ear piercing gun. These devices place the earring and immediately snap on the backing, and sometimes that backing ends up much tighter than it should be. If swelling develops over the next day or so, the backing can quickly become buried beneath the skin. It’s one of the reasons I generally recommend families avoid piercing guns and instead use a method that leaves just a little room for post-procedure swelling. When these patients show up in the emergency department, they almost always complain of pain, swelling, redness, and tenderness around the piercing site. Sometimes there’s drainage. Sometimes the parent says they can’t unscrew the backing anymore. Sometimes they tell you they can feel the earring in the earlobe, but you can’t actually see it. Now, I’ll get to the procedure technique in just a minute. But before I start talking about that, I do wanna separate earlobe piercings from cartilage piercing, ‘cause they’re really different problems. Once cartilage is involved, the stakes go up considerably. Cartilage has relatively poor blood supply, making it much more susceptible to perichondritis, chondritis, cartilage necrosis, and permanent cosmetic deformity. The bacteria may be different as well. We’ll come back to that later. For now, though, let’s stay with the earlobe because, frankly, that’s where almost all of these procedures occur. All right. Before you start any procedure, you wanna have everything ready. So I’ll have local anesthetic, so lidocaine or lidocaine with epi. Epi is totally fine in the earlobe. At least two mosquito hemostats, stuff to grab the earring, an 11 blade, gauze, saline, and a good light source. I think if there’s any chance I’ll need to make a small incision, I’ll prep the ear before I do anything with, uh, betadine or chlorhexidine. Once the ear starts bleeding a little or the child starts moving around, everything gets just a little harder to see and grab. Absolutely bring your child life specialist if you’ve got them and someone to hold, like a medic or a PCA. One of the interesting things about the Cincinnati study is that none of the 100 children required procedural sedation. None. And honestly, that fits with my experience. The overwhelming majority of these can be managed with local anesthesia alone. For the earlobe, I usually perform a small field block using one percent lidocaine with epinephrine, using a twenty-seven or thirty-gauge needle. Epi is perfectly safe in the earlobe and gives you a little hemostasis while you’re working. One thing I probably do differently from some people is I actually wait for the anesthetic to work a little longer. I don’t just block and immediately start. I’ll wait at least five minutes. Honestly, it’s usually closer to seven to ten minutes. During that time, I’m talking with the family, keeping child life involved, making sure all my equipment is ready, and just letting everybody settle down a bit. Those extra few minutes make the whole procedure a lot easier. And again, this is pediatrics, so never underestimate distraction. You’ve got videos, music, you know, stuffed animal, a toy. Parents should be there holding the child’s hand. You gotta coach the parents as well. And sometimes that’s really all you need, a good block and some distraction. Of course, some kids do need more. For an anxious child, you can use intranasal midazolam or oral midazolam. If your department has nitrous oxide, this is a great procedure for it because it’s usually pretty quick. You’re often treating anxiety more than pain. I have used ketamine a handful of times, and not because something went wrong, but just because you have an extremely anxious child, and you’re not gonna accomplish the procedure safely any other way. First, figure out what you can see and what you can feel. Sometimes both the decorative front and backing are still visible, but the ear is simply too swollen to separate them normally. Those are the easy ones. I’d grab each side with a mosquito hemostat, disengage the backing from the post, and remove the earring. More commonly, the backing is buried beneath the skin. The decorative front may still be attached, or the parents may have already removed it and left the backing sitting in the earlobe. I’ll gently compress the earlobe from the front while looking at the back. That pressure tents the skin enough to expose a few millimeters of metal through the original piercing hole, and that may be all that I need to grab the backing and remove it. If you still can’t see it, keep palpating. Usually, I can feel the hardware through the swollen tissue. Once you localize it, I’ll make a tiny incision on the back of the earlobe directly over it. And when I say tiny, I mean tiny, like a couple millimeters, just enough to expose the metal. But don’t be afraid of making that incision. It’s honestly usually the difference between wrestling with the earring for ten minutes and having it out within sixty seconds. From there, the rest is pretty straightforward. Whether the front is buried, the backing is buried, or neither side is visible, I gently spread the tissue with a mosquito hemostat until the hardware comes into view. Notice that I said spread, not dissect. You’re not hunti

Cyclospora is an uncommon but important cause of prolonged watery diarrhea in children, particularly during the summer months and during foodborne outbreaks. This episode reviews the epidemiology, clinical presentation, diagnostic pitfalls, treatment, and practical emergency department approach to recognizing and managing pediatric cyclosporiasis.   Learning Objectives Recognize the clinical features and epidemiology of Cyclospora cayetanensis infection in children, including when to suspect the diagnosis in patients with prolonged watery diarrhea. Select appropriate diagnostic testing for cyclosporiasis and identify the limitations of routine stool cultures, ova and parasite examinations, and gastrointestinal pathogen panels. Apply evidence-based treatment and supportive care for pediatric cyclospora infection, including appropriate antimicrobial therapy, hydration, and follow-up considerations. References Stobbe M. Outbreak of diarrhea-causing parasite grows to more than 1,000 cases. ABC News. Published July 8, 2026. Accessed July 10, 2026.   Bilung LM, Tahar AS, Yunos NE, et al. Detection of Cryptosporidium and Cyclospora oocysts from environmental water for drinking and recreational activities in Sarawak, Malaysia. Biomed Res Int. 2017;2017:4636420. doi:10.1155/2017/4636420.   Giangaspero A, Gasser RB. Human cyclosporiasis. Lancet Infect Dis. 2019;19(7):e226-e236. doi:10.1016/S1473-3099(18)30789-8.   Pyzocha N, Cuda A. Common intestinal parasites. Am Fam Physician. 2023;108(5):487-493.   Centers for Disease Control and Prevention. Clinical care of cyclosporiasis. Updated March 8, 2024. Accessed July 10, 2026.  Transcript This transcript was generated using Descript and subsequently reviewed and lightly edited for spelling, grammar, and clarity. Minor inaccuracies may remain, and the audio recording should be considered the definitive version of this content.   Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski. It’s July and a seven-year-old comes into your emergency department with 10 days of watery diarrhea. They were seen earlier in the week and told it was probably viral gastroenteritis. Maybe they got a prescription for ondansetron, maybe they didn’t. Stool cultures have already come back negative. Mom tells you, “Every time I think he’s finally getting better, the explosive diarrhea comes right back.” So what’s going on? Today we’re talking about Cyclospora. Honestly, it’s one of those organisms that most of us forget about until summer rolls around, or since medical school. We don’t diagnose it every week, and depending on where you practice, you may go years without seeing a case. But then an outbreak happens, and maybe just a handful of sporadic cases show up, and suddenly you’re reminded that not every child with prolonged diarrhea has viral gastroenteritis. Cyclospora cayetanensis is a coccidian protozoan that’s transmitted through contaminated food or water. In the United States, it’s most commonly associated with imported fresh produce, things like cilantro, basil, lettuce, salad mixes, and berries. Unlike bacterial food poisoning, everyone at the picnic usually isn’t sick, so it often presents as an isolated illness because the exposure happened days earlier and may have involved only one particular food item. Families are often trying to remember the one thing that they ate that made everybody sick. Honestly, sometimes it’s simply the salad they bought at the grocery store a week ago. One thing that’s helped me remember these organisms over the years is that they each sort of develop their own personality. You know, it’s often confused with Giardia and Cryptosporidium. So if the diarrhea is greasy, think Giardia. If it’s profuse, watery diarrhea after swimming, think Cryptosporidium. If it’s prolonged, watery diarrhea during the summer, think Cyclospora. Now, obviously there are exceptions, but I think that’s a pretty useful framework, especially when you’re seeing patients one after another in a busy ED. One of my favorite pearls about Cyclospora, and I think it’s probably the one fact that’s most worth remembering because it explains how it sort of works. Unlike Giardia or Cryptosporidium, the oocysts that are passed in stool aren’t immediately infectious. They actually have to spend days to weeks out in the environment before they mature enough to infect somebody else. So Cyclospora isn’t really spread by the kids sitting next to them at daycare. It’s spread by the salad they both ate last week. I think that’s a lot easier to remember than trying to memorize the organism’s life cycle. The incubation period averages about seven to 10 days, so by the time symptoms begin, families usually don’t remember exactly what their kid ate. They’re certainly not connecting today’s diarrhea with the salad they had a week ago. The diarrhea itself is usually watery, sometimes pretty high volume, sometimes even explosive. One thing that’s a little deceptive is that it tends to wax and wane. Parents will tell you, “Yesterday I thought we had finally turned the corner,” and today they’re right back where they started. Along with the diarrhea, you’ll often see abdominal cramping, bloating, nausea, fatigue, maybe even a low-grade fever, and if this has been going on for a while, some weight loss or poor weight gain. Most of these kids don’t walk in looking critically ill. They walk in because they’re still having diarrhea when everyone expected them to be over it. That’s really the patient where Cyclospora should come to mind. And of course, not every child with prolonged diarrhea has it. Giardia is still incredibly common, especially after untreated water exposure, camping, or daycare. Again, those kids have greasy, foul-smelling stools with bloating and flatulence. Cryptosporidium is the swimming pool organism. Those oocysts are remarkably resistant to chlorine, so swimming pools, splash pads, and water parks should all get your attention. Those patients usually have profuse watery diarrhea, but in otherwise healthy children, it tends to run its course over a couple weeks. Cyclospora is different because it just hangs around. That’s really what makes me think about it. It’s not necessarily how sick the kid is, it’s that they’re still sick when they should actually be getting better. So aside from when you’re in the middle of an outbreak, when should you actually suspect it? It’s really when a few things start lining up. The diarrhea has lasted more than a week. Maybe it got a little better and then came back. The kid has lost some weight or looks a little dehydrated. It’s summertime. The bacterial stool studies are negative. Maybe there’s a history of travel. Maybe there isn’t. Maybe there’s a history of eating fresh produce. Maybe there isn’t. At some point, you have to stop saying, “Eh, it’s probably still viral,” and start asking yourself whether you’re dealing with something else. One teaching point that’s worth repeating, partly because it shows up on board exams and partly because it explains the epidemiology, is that Cyclospora isn’t spread directly from person to person. Fresh stool isn’t immediately infectious because those oocysts still have to sporulate in the environment before they can infect the next person. So let’s say you’re thinking about Cyclospora. What do you actually order? A routine stool culture isn’t gonna help you. Even a routine ova and parasite examination may not be enough. That’s an easy mistake to make because a lot of us were taught persistent diarrhea, send culture and O&P or a stool molecular pathogen panel. Many labs don’t specifically look for Cyclospora unless you ask them to or order it specifically. So there’s gastrointestinal PCRs for it, but you have to order them separately. So you can actually get back a negative O&P and feel reassured when in reality no one’s really tested for Cyclospora. If your hospital has a multiplex GI PCR panel that includes it, that’s probably what you should order first. If you don’t, you probably have to order it separately. Another board pearl. So if you’re taking a board exam and they describe a child with prolonged watery diarrhea during the summer, maybe after eating fresh produce, and then they casually mention that the routine ova and parasite examination was negative, don’t let that throw you off. That’s actually the clue. The organism may still be there, the lab just wasn’t sent to look for it. If your lab is using microscopy, Cyclospora can be identified with a modified acid-fast stain. The oocysts are a little larger than Cryptosporidium, and one interesting feature is that they stain variably. Some stain bright red, while others hardly stain at all, giving them that classic ghost organism appearance, which I think is just, like, cool. And because oocyst shedding is intermittent, collecting two or three stool specimens over several days can improve the diagnostic yield if you still have a high index of suspicion. The good news is that once you make the diagnosis, treatment is actually pretty straightforward. Trimethoprim-sulfamethoxazole remains the treatment of choice. In adult-sized patients, that means trimethoprim one hundred and sixty milligrams plus sulfamethoxazole eight hundred milligrams, just one double-strength tablet, orally twice a day for seven to ten days. For kids greater than two months of age to eighteen years, it’s eight to ten milligrams per kilogram trimethoprim and forty to fifty milligrams per kilogram sulfamethoxazole per day orally in two divided doses for seven to ten days. Most children begin feeling noticeably better within twenty-four to forty-eight hours. Honestly, this can be a pretty satisfying infection to treat because families have often been searching for an answer for a week or two. They’ve been told it’s viral. They’ve been waiting for it to improve, and then you finally make the diagnosis within a day or two of starting the righ

Fishhook injuries are common, surprisingly nuanced, and honestly a little intimidating until you’ve removed a few. In this first episode of our Minor Procedures series, we’ll reel in the essentials of pediatric fishhook removal, helping you take the bait on four classic removal techniques, procedural planning, anesthesia strategies, and post-removal management. We’ll discuss when to pull back, when to advance, when not to get hooked on a single technique, and how to avoid turning a simple procedure into the one that got away. Along the way we’ll cover sedation, antibiotics, wound care, and practical pearls to help you land these cases with confidence. Learning Objectives Compare and select among the four major fishhook removal techniques based on hook characteristics, depth of penetration, and anatomic location. Apply evidence-based approaches to analgesia, anxiolysis, procedural sedation, and post-removal management for pediatric fishhook injuries. Identify situations requiring escalation of care, including ocular involvement, contaminated water exposure, tendon or joint involvement, and circumstances where routine management may not be sufficient. References Gammons MG, Jackson E. Fishhook removal. Am Fam Physician. 2001;63(11):2231-2236. Prats M, O'Connell M, Wellock A, Kman NE. Fishhook removal: case reports and a review of the literature. J Emerg Med. 2013;44(6):e375-e380. doi:10.1016/j.jemermed.2012.11.058 Doser C, Cooper WL, Ediger WM, et al. Fishhook injuries: a prospective evaluation. Am J Emerg Med. 1991;9(5):413-415. doi:10.1016/0735-6757(91)90204-w Transcript This episode used an AI-generated transcript created in Descript as an initial draft. The transcript was subsequently edited, expanded, and refined by the author with assistance from OpenAI’s ChatGPT (GPT-5.5). Final editorial decisions and content responsibility remain with the author. Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I'm your host, Brad Sobolewski, and today we're gonna start a new series on minor procedures. These are the types of procedures that we perform all the time in the emergency department. They're not the subject of multicenter trials or big keynote lectures, but these are the things that patients and families remember, and trust me, they will remember them whether you do them well or not. First up, fishhook removal. So I'm hoping to reel in some listeners with this one, and so hopefully you'll take the bait, and by the end of this episode you'll understand exactly what angle I'm coming from. And hopefully I'm just not trying to make a bass of myself. So anyway, fishhook removal sounds really simple until you actually start doing it. There's not just one technique. There are four classic approaches, and I'll talk about them all, and which one you choose depends on the hook, whether there's a barb, how deep it is, where it's located, your personal experience with different techniques. Fishhook injuries in children are usually minor and most commonly involve the hands and head, though I've seen them stuck in other body parts as well. Most can be managed in the emergency department or urgent care setting with local anesthesia and basic equipment Of course, if there's concern for tendon involvement, joint penetration, neurovascular compromise, if it's anywhere near the eyeball, you should stop and rethink your plan. You know, so ortho, if it's embedded deeply in a joint, um, anything that involves the eye itself isn't necessarily an emergency department procedure, and I'm not talking about the eyebrow, I'm talking about the globe. Fortunately, that's very rare, but that's definitely an ophthalmology conversation. And so before you even think about removing, you need to understand the hook. Is this a single hook or is this a treble hook? A treble hook is a type of fishing hook that has three individual hooks and barbs arranged in a triangular formation, and they're all fused to a single shank and eye. The eye is where the line gets tied to the hook. Is it freshwater or saltwater? How long has it been there? Is it an old rusty one that was sitting in your garage? Was it underwater for a few hours and then it got hooked in the skin? And honestly, how cooperative is the kid gonna be? Because unlike actual fishing, this is one of the procedures where patience beats blunt force. So the simplest technique is retrograde removal. This is exactly what families think you're gonna do before you walk in the room. You know, just pull it out the way it went in. But that's not how hooks are designed. They have the barb. They're designed to stay in the fish. So most of the hooks that I've removed are barbed hooks, and so you can't just back them out. If you try to pull a hook out the way it came in, it's gonna catch and tug on the tissue, it's gonna lead to more pain, bleeding and tissue distortion and not really gonna get you anywhere. So just pulling it out doesn't work, and family probably would have already tried that at home. The technique I end up using most often is advance and cut. And it kind of sounds wrong the first time you explain it to a family because your solution to removing the hook is to continue to advance the hook, but mechanically, this makes the most sense. So you advance the point of the hook through the skin until the barb exits completely, then use either really good trauma shears or heavy wire cutters to cut the hook in between the shank and the barb. If it's in a location where you have, uh, enough room, I like to hold a hemostat real close to the skin, grabbing the hook. Then I cut near the barb, get the pointy part out of the way, remove the hemostats, and then back it through the skin. This is considered the most reliable technique, and in most reviews it's described as being nearly universally successful, even for larger hooks. In children, I think this needs to be the go-to technique because success matters. You just gotta get it done on the, the first attempt. Kids don't tolerate multiple failed attempts very well. Um, obvious downside is that you create a second puncture wound, but in practice, that puncture is usually controlled and much less traumatic than repeated unsuccessful pulling. Depending on where the skin's at, you may actually need to put a little bit of tension or pressure against the skin to get that hook to poke through. Ultimately, this advance and cut method is the one that you should spend the most time learning and teaching to your trainees. The string yank technique is the one that often is seen at summer camps and on YouTube videos. You loop string or heavy suture or even fishing line around the bend of the hook, apply downward pressure to the shank to disengage the barb, and then pull quickly in line with the shaft of the hook. When it works, it yanks it out almost instantly. That's why the YouTube videos are popular. One second there's a fishhook in the finger, and the next there isn't. The advantage is that this can sometimes just be performed without anesthesia and can even be done at home. The disadvantage is obvious if you work with children. This requires cooperation. Younger kids, anxious kids, a treble hook, something that's deeply embedded, like this isn't gonna work all that well, and it's, again, less reliable with bigger and deeply embedded hooks. The last technique is needle cover. This one gets less attention. It seems elegant, but in practice it's actually pretty hard to do, especially in smaller kid parts. You insert an 18-gauge needle alongside the entry tract until the bevel of that needle covers the barb, and then pull both out together The advantage is that you avoid creating a second puncture wound, and you can minimize tissue trauma. The disadvantage is it's really complex technically. Maintaining alignment of both the hook and needle can be tricky because they sort of like roll and move around. And if you want to do this one, it's probably easier for smaller and medium-sized hook rather than larger embedded or treble hooks. And as you might imagine in the literature, there's not really any randomized trials comparing these techniques. Most of what we know comes from prospective observational studies, case series, procedural experience, and expert review. Advance and cut seems to have the broadest success across scenarios. String yank does earn some points for field use and avoiding local numbing. Needle cover is hard to do, but if the parent is absolutely adamant that you don't create a second hole, then that's probably your best option. And as with any procedure, you should probably be facile in multiple techniques in case the first one doesn't work. You don't just want to stand there and flounder. Anyway, most fishhook removals in children can be done with local anesthesia alone. One percent Lido with or without epi is usually enough. Depending on the location, you may need to do a digital block or a field block instead of just injecting directly around the hook because local infiltration itself can distort the anatomy and actually make removal harder. So that's why I like blocking the digit or doing a little bit of a field block around it. If you have time, a topical anesthetic before local infiltration can be a nice gesture. LMX or EMLA can be really helpful, especially for really anxious kids or kids who are escalating before you even start setting up. They take about forty to sixty minutes. About forty-five minutes is probably ideal. So if you can get that put on in triage, that's actually a, a great technique. So if you know you're going to inject to numb to get the fishhook out, and you need a little bit of extra time to get child life or other personnel in the room, by all means, put a topical anesthetic there. It only absorbs into the outer two millimeters, but it'll help with the poke, not necessarily the burning that happens once the lidocaine is in the tissue. And now that we've talked about pain, I think

Croup is a clinical syndrome of upper airway obstruction defined by barking cough, stridor, and hoarseness. Management hinges on severity assessment, universal corticosteroid use, and selective epinephrine. The key clinical task is distinguishing typical croup from high-risk mimics that require urgent airway intervention. Learning Objectives Differentiate croup from other causes of pediatric upper airway obstruction using key historical and physical exam features. Apply a severity-based approach to croup management, including appropriate use of corticosteroids and nebulized epinephrine. Recognize clinical features that suggest alternative or life-threatening diagnoses requiring escalation of care. References Cooke A, Conway S, Griffin L. Croup: Rapid Evidence Review. Am Fam Physician. 2026;113(3):254-258. Gates A, Johnson DW, Klassen TP. Glucocorticoids for Croup in Children. JAMA Pediatr. 2019;173(6):595-596. doi:10.1001/jamapediatrics.2019.0834 Bjornson CL, Klassen TP, Williamson J, et al. A Randomized Trial of a Single Dose of Oral Dexamethasone for Mild Croup. N Engl J Med. 2004;351(13):1306-1313. doi:10.1056/NEJMoa033534 Bjornson CL, Johnson DW. Croup. Lancet. 2008;371(9609):329-339. doi:10.1016/S0140-6736(08)60170-1 Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. Nebulized Epinephrine for Croup in Children. Cochrane Database Syst Rev. 2013;(10):CD006619. doi:10.1002/14651858.CD006619.pub3 Transcript This transcript was generated using Descript and subsequently reviewed and lightly edited for spelling, grammar, and clarity. Minor inaccuracies may remain, and the audio recording should be considered the definitive version of this content.  Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski. And today we’re gonna talk about croup. We’re gonna focus on diagnosis, severity based management, and how to differentiate it from scarier high risk conditions that may present similarly, but behave very differently. So croup is best understood as a clinical syndrome of upper airway obstruction caused by inflammation at the level of the larynx and subglottis. So in most cases this is viral laryngotracheitis, most commonly due to parainfluenza virus. But as you’d expect multiple viruses can cause it. The subglottis is the narrowest portion of the pediatric airway. So even small amounts of edema create large increases in airway resistance. So that’s why the clinical picture is so consistent. You’ve got inspiratory stridor, hoarseness, and that characteristic barking cough, which either sounds like a seal or a dog, and yes, of course, I know the difference between the two coughs because I was a biology major. This is primarily a disease of children between six months and three years of age with a peak incidence in the second year of life. It’s really, really common, like one and a half percent of all ED visits, maybe 350,000 visits a year, and 85% of these kids have mild disease. Hospitalization is rare. The range is variable, about two to 8% of cases, and return visits occur in about three to 5%. Fewer than 1% of children, a lot fewer, require intensive care or airway intervention. Honestly, most kids do really well. The ones who don’t can get sick very quickly, and that’s been my clinical experience. In the Northern Hemisphere, we see croup throughout the fall and winter, usually starting in around November and sort of tapering off by April. But that being said, I’ve seen croup-like symptoms every month of the year over the past couple of decades. Croup is absolutely a classic clinical diagnosis. A typical case begins with 12 to 48 hours of viral prodrome, you know, body aches, fever, congestion, cough, followed by often abrupt nighttime onset of barky cough and stridor. Symptoms fluctuate, and they’re generally worse with agitation and get better when the kid is calm. That variability is the key feature. So what you’ll have is a child who wakes up after sleeping for a few hours with a barky cough and then noisy stridor. This freaks parents out, and this is not hyperbole. There’s this little center in the back of your brain that’s like, please don’t stop breathing and die. So appropriately, they’re worried about the kid, they call emergency medical services, they bring them to the emergency department, and by and large, by the time they get there, the stridor has resolved. The kid is calm, and parents will say, I swear he looked a lot worse at home. Trust me, we believe you parents, this is what croup does. When I’m taking a history of croup, I get all of these details. Are there any sick contacts? If the parents are worried about a foreign body inhalation or ingestion, then I’m worried about a foreign body inhalation or ingestion. Listen to the lungs, inspect their airway. Always check the ears for concomitant otitis and I’ll feel their trachea. I’ll actually grab and hold the trachea and move it. Kids with croup really don’t have a painful trachea. Kids with bacterial tracheitis, aside from looking more toxic, actually have a lot of pain when they move their trachea. Testing for croup is generally unnecessary. Labs and viral studies do not change management, and imaging is really reserved for atypical presentations or when you’re considering an alternative diagnosis like a foreign body. If you do get an X-ray, what you’re looking for is the classic steeple sign on the AP view. It is seen in croup, but it’s not 100% sensitive nor specific. Once you’ve made the diagnosis of croup, it’s important to assess severity, and remember that I said that most kids are mild. So mild croup is defined by the absence of stridor at rest. So they may have some stridor when they’re upset or even a little bit of hoarseness or noise. It’s important to listen to many, many children with croup to get a sense of this. Moderate croup includes stridor at rest with mild to moderate retractions. So at rest means that the child is in a position of comfort. They’re calm with a parent, and they’ve generally been that way for about 10 to 15 minutes. Sometimes that’s how long it can take for the stridor to dissipate once you get the kid calm. Severe croup, which is fortunately rare, involves marked work of breathing, agitation, fatigue, need for oxygen, altered mental status, and this aligns with the Westley croup score. It formalizes stridor, retractions, air entry, cyanosis, and mental status. But really, in practice, most of us get very good at bedside assessment of croup. Management of croup starts with corticosteroids. This is one of the highest-yield interventions that we have in pediatric emergency medicine. Every child with croup should receive dexamethasone. Typically 0.6 milligram per kilogram as a single dose up to a maximum of 10 milligrams. Some places will use 0.15 milligram per kilogram. Locally, we often give the IV formulation orally. It’s 10 milligrams per mL. Tastes bad, but pairs reasonably well with apple juice. The oral suspension is 1 milligram per mL, tastes terrible, and pairs nicely with being spit on the ground by toddlers. The evidence behind dexamethasone is very robust. The main benefit is that it reduces return visits and hospital readmissions by about half, and those return visits include doctor’s offices and emergency departments. In a Cochrane review of 1,679 children, glucocorticoids reduce return visits or readmissions with a risk ratio of 0.52, so that translates to a number needed to treat of seven. I’ve certainly seen seven or more croup kids during one shift, so for every seven children treated with dexamethasone, one return visit is prevented. Symptom improvement begins within about two hours and lasts at least 24 hours, but maybe up to a couple of days. Hospital length of stay for kids that get steroids is reduced by an average of 15 hours as well. Serious adverse events are rare. It’s well tolerated, and other than the taste, kids do fine with it. And importantly, the benefit is consistent across all severities of croup, mild, moderate, and severe. So when you explain this to families who are very scared about their kids, but now their kid is looking better and you’re only giving them a single medicine, not doing any tests or X-rays or anything, I think you have to frame the medicine in terms of what it’s going to do for them over the next couple of days. So one way of explaining this to families would be to say something like this is a steroid called dexamethasone. It reduces the swelling in your child’s airway that’s causing the barky cough and noisy breathing. Most children start feeling better within a couple of hours, and the benefit lasts at least a full day, if not longer. Without this medicine, about one in five children need to come back because symptoms get worse again. You really get two bad days with croup in most cases. With this medicine, the risk of returning drops to about one in 10, so it cuts the chance of coming back in half. We can expect your child’s cough to start improving over the next day or two. Most children are feeling a lot better within 48 hours, though a little bit of hoarseness and cough can last for a week to about 10 days. So it’s possible that when your child goes to sleep later tonight, they may experience that barking cough and noisy breathing again. They’re almost certainly going to be upset. The steroid blunts enough of the swelling so that you are much more likely to have them free of distress and stridor, that noisy breathing, once you get them calm. So if they’re upset, get them calm, and if in about 10 minutes the stridor and noisy breathing get better, that’s the dexamethasone doing its job and you can safely stay home. For children with moderate or severe croup, we’re gonna use nebulized racemic epinephrine. It works fast by reducing airway edema by constricting inflamed blood vessels. You’ll see improvement in stridor and work of breathing often within 30 minutes. The effect is transient