ABP Pediatric Emergency Medicine common mistakes
ABP Pediatric Emergency Medicine · Understand the traps and how to avoid them.
When asked for the next best step in a child with suspected septic shock, choosing a fluid bolus or antibiotic before recognizing that airway/breathing or hypoglycemia/electrolyte correction must come first in the stated scenario.
Candidates pattern-match 'sepsis = fluids + antibiotics' without anchoring to the ABCs and the specific clinical stem, so they skip the immediate life threat described.
What to do instead
Before answering any resuscitation item, write down the patient's ABC status from the stem and ask 'is there a reversible threat to airway, breathing, or glucose before the algorithm step?' Then select the option that addresses the earliest threat.
Failing to apply pediatric weight-based dosing and instead selecting an adult dose or a dose without weight adjustment for epinephrine, adenosine, defibrillation energy, or push-dose medications.
Adult-derived heuristics dominate recall, and candidates memorize drug names without the mg/kg or J/kg numbers, so they pick a plausible but wrong magnitude.
What to do instead
Build a one-page weight-based dosing card (epinephrine 0.01 mg/kg IV, 0.01 mg/kg of 1:10,000; adenosine 0.1 then 0.2 mg/kg; defibrillation 2 J/kg then 4 J/kg; fluid 10-20 mL/kg) and rehearse calculating doses for 5, 10, 20, 40 kg during study so the numbers are automatic.
Missing non-accidental trauma when the mechanism provided does not explain the injury, or when injuries are in different stages of healing, and instead selecting a workup focused only on treating the visible injury.
Candidates focus on the acute chief complaint and accept the caregiver's history at face value, and they under-weight the discordance between mechanism and injury pattern.
What to do instead
For every trauma stem, explicitly compare stated mechanism to injury pattern and age of child; if discordant, or if there are injuries of differing ages, bruising in non-mobile infants, or delayed presentation, choose the option that includes a full skeletal survey, retinal exam, and reporting to child protective services.
Choosing activated charcoal, ipecac, or gastric lavage as first-line management for a toxic ingestion instead of supportive care and the specific antidote when indicated.
Old teaching and memorized 'decontamination' steps persist, and candidates do not check the time-since-ingestion or contraindications (altered mental status, caustic ingestion, hydrocarbons).
What to do instead
For each tox item, first state the toxin, the toxidrome, and the antidote (e.g., naloxone for opioids, N-acetylcysteine for acetaminophen, sodium bicarbonate for salicylates/TCA, fomepizole for toxic alcohols); only then consider decontamination, and default to 'supportive care' when no antidote exists or the airway is unprotected.
Treating a febrile young infant with a full sepsis evaluation but selecting the wrong age-based threshold or omitting the lumbar puncture when the infant is in the 29-90 day or 0-28 day stratum described.
Candidates memorize 'fever workup' as one bundle and do not map the specific age band and appearance to the required tests and disposition (admit vs. observe vs. discharge).
What to do instead
Create a three-column table (0-28 days, 29-60 days, 61-90 days) listing required tests, empiric antibiotics, and disposition, and for every fever stem first assign the age band and ill/well appearance before choosing an option.
Under-treating or under-recognizing severe asthma/ bronchiolitis by choosing a single modality (e.g., albuterol alone) when the stem describes impending respiratory failure, or by giving routine antibiotics or chest radiographs for uncomplicated bronchiolitis.
Candidates equate 'wheezing' with 'asthma' and apply one treatment reflexively, missing severity markers (silent chest, rising PaCO2, fatigue) and the age-based distinction between bronchiolitis and asthma.
What to do instead
For every respiratory stem, grade severity first (mild/moderate/severe/impending failure) using work of breathing, air entry, mental status, and SpO2; then select the bundle for that grade (continuous albuterol + ipratropium + steroids + magnesium for severe asthma; supportive oxygen/hydration only for bronchiolitis), and avoid antibiotics or routine imaging unless focal findings or toxicity are described.
Missing a duct-dependent congenital heart lesion or an arrhythmia with hemodynamic compromise because the candidate attributes cyanosis or shock to sepsis or respiratory disease without considering hyperoxia testing or an ECG.
Neonatal collapse and cyanosis have overlapping presentations, and candidates anchor on the most common diagnosis rather than testing the alternative with a simple bedside maneuver.
What to do instead
For any neonate with cyanosis or shock, explicitly consider hyperoxia test (PaO2 response to 100% oxygen), pre/post-ductal saturations, and a 12-lead ECG; if the stem shows differential cyanosis, no improvement with oxygen, or a wide-complex rhythm with poor perfusion, choose the option that addresses the cardiac cause (prostaglandin E1 or synchronized cardioversion).
Failing to recognize and treat status epilepticus with timely benzodiazepine escalation, or choosing a workup (e.g., head CT, LP) before stopping the seizure in a child still seizing.
Candidates want to find the cause first and under-prioritize the time-dependent treatment clock, and they may under-dose benzodiazepines for fear of respiratory depression.
What to do instead
Memorize the status epilepticus timeline (benzodiazepine at 0-5 min, second benzodiazepine at 5-10 min, second-line load at 10-20 min) and for any item with ongoing seizure choose the option that gives an appropriately dosed benzodiazepine before any diagnostic imaging or lumbar puncture.
Discharging a child with abdominal pain or vomiting without considering surgical emergencies (intussusception, malrotation/volvulus, appendicitis, testicular torsion) when red flags are present, or choosing observation over imaging/surgical consultation.
Candidates anchor on gastroenteritis because it is common and the stem includes vomiting and diarrhea, and they discount bilious emesis, localized tenderness, or pain out of proportion.
What to do instead
For every vomiting or abdominal pain stem, screen for red flags (bilious emesis, blood in stool, localized or migratory pain, guarding, pain out of proportion, empty/scrotal asymmetry) and if any are present choose the option that obtains urgent imaging or surgical consultation rather than discharge or observation.
Failing to screen for and address suicidality or safe disposition in a adolescent with a behavioral or psychiatric chief complaint, or choosing a medical workup alone when the stem describes a suicide attempt or ingestion.
Candidates focus on the medical stabilization and under-recognize that psychiatric risk assessment, means restriction, and safe disposition are required before discharge.
What to do instead
For any behavioral health stem, always include a structured suicide risk assessment, collateral history, means restriction counseling, and a disposition plan (inpatient psychiatric evaluation or close follow-up) in the selected option, and treat medical stabilization and psychiatric safety as parallel, not sequential.
In quality-improvement and systems items, choosing a solution that is a single educational intervention or a policy memo rather than a systems-level change (checklist, forcing function, standardized order set, or measurement with feedback).
Candidates default to 'educate the staff' as the fix and do not distinguish individual from system causes in the scenario.
What to do instead
For QI/administration items, first identify whether the failure is knowledge, process, or system; if the stem describes a recurring error, choose the option that changes the system (standardized protocol, checklist, electronic order set, audit-and-feedback) and includes a measurable outcome, rather than one-time teaching.