Massive Hemorrhage Post-Tonsillectomy

The initial emergency medicine management of post-tonsillectomy bleeding


A ten year old boy presents with significant bleeding from his mouth and nose. He is learning forward, and although blood is rapidly pouring onto the stretcher, he is able to tell you his name. Two very anxious appearing parents are at the bedside, and are able to tell you that he had a routine tonsillectomy performed 5 days ago…

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Resuscitation of the crashing infant (pediatric resuscitation)

An approach the the initial resuscitation of the critically ill child


It is your last of 3 night shifts, but so far it has been great. You successfully resuscitated a woman with severe postpartum hemorrhage. You got ROSC on a young cardiac arrest patient, and just heard that he is awake and talking after having his LAD opened in the cath lab. You even managed to get the Cunningham technique to work on a dislocated shoulder for the first time in your career. Now, during a lull, you are joking with the nurses, and someone says the word “quiet”. The next minute, the triage nurses is running down the hallway with a limp, blue 3 week infant in her arms and 2 very scared parents in tow…

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Managing laryngospasm in the emergency department

How to manage laryngospasm

It has now been a full year since I started First10EM. Thank you to everyone who has helped me a long the way, and especially to everyone who has spent their time reading this blog. I never imagined that so many people would be interested in my emergency medicine education project. This is an updated version of the first ever post on


A feisty 3 year old tripped, cut her lip, and is now politely refusing your colleague’s attempts at suturing. You hear these polite refusals from across the department and wander over to offer your help with a procedural sedation. After moving to an appropriate room, going through the pre-sedation checklists, and tracking down all the folks that are required to be present, you give a dose of ketamine. Just as you are about to entertain the room with your latest cheesy joke, you hear a loud squeaking. You glance at the patient and recognize significant respiratory muscle contraction and stridor. A quick glance at the monitor shows a flat CO2 tracing. Oh no, laryngospasm…
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Neonatal (Newborn) Resuscitation 2015 update

A summary of the resuscitation of the newborn infant, updates with the 2015 ILCOR guidelines


Code pink in labour and delivery, and you are the only doctor in the hospital tonight…

(This is an update of a prior version of this post based on the newest 2015 ILCOR/AHA/ERC guidelines)

The biggest changes are:

  • We no longer intubate and suction for meconium. The resuscitation proceeds identically whether or not meconium is present
  • Heart rate is monitored using ECG leads, rather than the classic palpation of the umbilicus
  • CPAP is added as an option for laboured breathing or persistent cyanosis
  • The first 30 second assessment has been removed because it was unrealistic. The goal is to just get an initial assessment and initial maneuvers done in the first minute.

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Management of severe croup

A brief review of the management of the child with severe airway obstruction from croup in the emergency department


Another night shift in the emergency department and you are 25 minutes into the history of a patient with 17 chief complaints when your phone rings. “You are needed in resus 3”. Initially, it feels good to be called away for a ‘real emergency’. However, when you lay eyes on the little girl, you kick yourself for that thought. Her mother says she has had a mild cough and runny nose for a few days, but tonight she developed a very harsh, barking cough and noisy breathing. Now she is barely making noise at all. The one year old in front of you is using every accessory muscle she has, breathing at least 60 times a minute, and the monitor shows an oxygen saturation of 88%.

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VP shunt malfunction

A simplified approach to the initial assessment and management of sick patients with VP shunts in the emergency department


A 4 year old presented to the ED with a mild headache, nausea, and vomiting, and was triaged to the sub-acute area of the department. You are called to the room stat, as the child is now unresponsive with a HR of 55, a BP of 167/65, and a sat of 96% on room air. His mom mentions that he had a VP shunt placed when he was younger, but now has no medical problems. The closest neurosurgeon is 45 minutes away, if everything goes perfectly…

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Procedure: Umbilical Vein Catheterization

A review of umbilical vein catheterization


You find yourself leading a code pink in L&D, with no pediatricians to be found. You have already moved efficiently through the neonatal resuscitation algorithm, but despite clearing the airway, bagging, and chest compressions, the baby is still flat with a HR of 50. It is time for medications, but your experienced neonatal nurses have not been able to get a line. They look at you expectantly: “umbilical line, doc?”…

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