ABEM Peds EM common mistakes
ABEM Peds EM · Understand the traps and how to avoid them.
Applying adult weight-based dosing or fluid boluses to infants and young children without recalculating per kilogram, and stating a dose without a weight anchor.
Adult EM training ingrains fixed doses (1 g of a drug, 1 L bolus); under time pressure candidates reach for the memorized adult number instead of deriving from kg.
What to do instead
Before answering any dosing or fluid question, state the assumed weight (e.g., 10 kg for a 1-year-old, 20 kg for a 5-year-old) out loud, then compute the pediatric dose and volume from that anchor. For boluses, default to 10–20 mL/kg and titrate.
Treating a febrile infant under 3 months with a partial workup - skipping LP, urine culture, or empiric antibiotics after a reassuring appearance.
The well-appearing febrile neonate looks deceptively normal, and candidates anchor on 'looks good' rather than age-stratified risk.
What to do instead
Memorize the age bands: ≤28 days = full sepsis workup plus admission and IV antibiotics regardless of appearance; 29–90 days = risk-stratify with validated criteria but still obtain urine, blood, and CSF as indicated. State the age band explicitly before choosing management.
Missing non-accidental trauma because the stated mechanism is accepted at face value and a skeletal survey or retinal exam is not ordered.
Candidates focus on treating the visible injury and are uncomfortable raising abuse; the history 'fell off the couch' is plausible-sounding.
What to do instead
Screen mechanism against developmental milestones (a non-rolling infant cannot fall off a bed). For any injury in a pre-mobile infant, or bruising in a child under 4 months, order skeletal survey, retinal exam, and report per mandate.
Failing to recognize compensated shock in a child because the blood pressure is normal.
Candidates apply adult hypotension thresholds; children maintain BP until late decompensation via tachycardia and vasoconstriction.
What to do instead
Use tachycardia, prolonged capillary refill, mottling, and narrowed pulse pressure as shock markers. Treat shock on clinical grounds; do not wait for hypotension, which is a late and pre-arrest sign in children.
Choosing the wrong airway adjunct size or device for a pediatric patient (uncuffed tube sizing, blade choice, BVM) without a size-estimation method.
Adult habits and infrequent pediatric intubation; candidates misremember formulas or skip them.
What to do instead
Anchor on age-based formulas (uncuffed ETT ≈ age/4 + 4; cuffed ≈ age/4 + 3.5) and length-based tape. State the formula you used so the reasoning is visible.
Misreading pediatric ECG intervals and rate-dependent findings - calling sinus tachycardia SVT or missing a prolonged QT.
Normal pediatric rates and intervals vary widely by age; adult norms are over-applied.
What to do instead
Memorize age-specific rate ranges and QTc correction; distinguish sinus tach (variable rate, visible P waves, identifiable cause) from SVT (fixed fast rate, abrupt onset). Correct QT for rate before interpreting.
Under-dosing or omitting analgesia and anxiolysis in children out of fear of respiratory depression.
Opiophobia and the belief that children 'don't feel pain the same way'; candidates default to nothing or to a subtherapeutic dose.
What to do instead
Give weight-based analgesia (e.g., morphine 0.1 mg/kg IV, fentanyl 1–2 mcg/kg) with monitoring; treat pain as a vital sign. State dose, route, and monitoring plan together.
Anchoring on a single diagnosis and failing to consider the pediatric-specific differential for the chief complaint (e.g., calling all vomiting 'gastroenteritis' without considering intussusception, DKA, or increased ICP).
Pattern-matching to common adult or outpatient diagnoses; time pressure discourages a broad differential.
What to do instead
For each chief complaint, force a three-item 'can't-miss' list before committing (vomiting → intussusception, DKA, ICP; abdominal pain → appendicitis, intussusception, testicular torsion). Name the can't-miss diagnoses in the answer.
Ignoring caregiver-reported red flags or vital-sign trends and relying only on the child's appearance at the moment of exam.
A calm interval or sleeping child reads as 'well'; candidates discount history and trend data.
What to do instead
Integrate history, feeding/urine output, and serial vitals into the assessment. Explicitly state how the child looked before and after intervention rather than a single snapshot.
Failing to adjust for developmental stage in procedures and communication - e.g., not immobilizing appropriately, not using distraction, or misjudging what a child can comprehend by age.
Adult-focused training assumes cooperative patients; candidates overlook age-appropriate technique and family-centered care.
What to do instead
Pair every procedure answer with an age-appropriate comfort plan (distraction, caregiver presence, sedation when indicated) and state the developmental assumption (e.g., stranger anxiety at 8–18 months).