Nondisabling stroke is where Emergency Medicine earns its keep. The threats are quieter, the windows are wider, and the misses—especially in younger and female patients—are more common. In this Part 2 or our 2-part podcast update on ED stroke management with Dr. Katie Lin and Dr. Walter Himmel we explore non-disabling strokes, where symptoms are mild enough that patients can continue daily activities if deficits persist. Yet, non-disabling does not mean benign. Nondisabling strokes occupy the same ischemic continuum as high risk TIAs and carry a substantial risk of early recurrent disabling stroke. In this EM Cases podcast we answer questions such as: Which patients with non-disabling stroke can safely be discharged from the ED with prompt follow-up and which require urgent investigation or admission? Which stroke mimics do we need to be on the look out for and how do we identify them at the bedside? How dangerous is thrombolysis in a patient with presumed stroke who turns out to be a stroke mimic? What are the key distinguishing features between a stroke and functional neurologic disorder? What are the most common causes of stroke in young people that we commonly miss? How does stroke etiology dictate the management pathway? What are the indications for carotid endarterectomy in patients with nondisabling stroke and what is the ideal timing of the endarterectomy? When is dual antiplatelet therapy vs single antiplatelet therapy vs anticoagulant therapy indicated? What is the best medication strategy for the patient on a DOAC for atrial fibrillation who presents to the ED with a nondisabling stroke? For patients not on a DOAC for atrial fibrillation who come in with a stroke, when is it safe to start anticoagulation? and many more…

Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Anton Helman, edited by Katie Lin, November, 2025

Cite this podcast as: Helman, A. Himmel, W. Lin, K. Nondisabling Strokes Recognition and Management. Emergency Medicine Cases. November, 2025. https://emergencymedicinecases.com/nondisabling-strokes-recognition-management. Accessed November 15, 2025

Nondisabling stroke accounts for a substantial proportion of ED cerebrovascular presentations. Although clinical deficits are mild, the 30-day risk of neurologic deterioration or disabling stroke is about 4-5%. ED priorities include precise phenotyping, urgent vascular imaging when indicated, early secondary prevention, and reliable short-interval follow-up. The key operational pivot is from “major/minor” toward disabling vs nondisabling—a distinction that determines whether to activate reperfusion pathways or pursue prevention-first pathways. Nondisabling stroke is where quiet presentations carry big stakes. Deficits may be subtle, windows feel wider, and the risk of being lulled into false reassurance is real—especially in younger patients and women.

Pitfall: a common pitfall is getting lulled into a false sense of reassurance for expedited workup when a patient presents with a nondisabling stroke. While nondisabling strokes do not require as rapid workup and treatment as disabling strokes, urgent workup and management should still be a priority.

As discussed in Part 1, The very first decision is whether the symptoms are disabling vs nondisabling, not whether the presentation is consistent with a “major vs minor” stroke. Disabling means the deficit(s)—if persisted—would compromise independence: language that prevents functional communication, dominant-hand motor weakness that prevents ADLs or work, gait failure, major visual field loss, or depressed consciousness. Nondisabling implies that, even if the deficit remained, independent living would still be possible (e.g., mild facial droop, subtle sensory change, small visual field cut that doesn’t affect reading/driving, mild dysarthria without aphasia). The classification determines tempo: disabling strokes get immediate CT and stroke-protocol CTA to consider reperfusion; nondisabling strokes still demand urgent prevention—non-contrast CT now to screen for intracranial hemorrahge, CTA soon thereafter—but the pathway is focused on stopping the next event.

Source: Dr. Katie Lin’s SYNAPSE: EM Neuro Essentials Course (www.SynapseCourse.com)

Emergency physicians miss approximately 1 in 10 strokes. Short term morbidity and mortality are 8 fold higher in missed strokes. Conversely, a similar proportion of “strokes” turn out to be mimics. Recognizing the difference is critical for avoiding both under- and overtreatment.

Functional presentations can mimic stroke. The key is inconsistency and distractibility.

Pitfall: Functional ≠ feigned. Up to 60% of patients with functional presentations have underlying organic disease—always rule out stroke first. Avoid diagnosing a “functional condition” in a patient without prior objective testing and/or neurologic consultation. Err on the side of stroke until proven otherwise. FND features do not exclude stroke.

Data show very low rates of hemorrhage (0–1%) when thrombolytics are given to stroke mimics as compared to the 3–5% seen in true strokes.
Thus, for disabling presentations, it’s safer to err on the side of treating as a potential true stroke when in doubt, including shared decision-making, informed consent when possible, and timely specialist consultation.

Strokes in the young are rare but can be devastating when missed. Approximately 13–18% of all strokes in North America occur in individuals under the age of 50. This proportion has increased over the past two decades. Younger patients are more likely to be labeled migraine, anxiety, or “functional”—particularly women—despite a vascular event. Etiologies also differ: dissection, PFO-related emboli, hypercoagulable states, and intracranial disease figure more prominently, yet we often default to “too young for stroke.”

Bottom line: Any sudden focal neurological deficit in a young person should be treated as a stroke until proven otherwise.

Non-disabling strokes and TIAs share pathophysiology, prognosis and treatments. The DOUBT study found that 13% of TIA presentations as short as 5 minutes in duration are subsequently found to have evidence of stroke lesions on MRI. 2-17% of patients with TIA or minor stroke suffer a subsequent disabling stroke within 90 days, most within 48 hours.

The ABCD2 score lacks sufficient sensitivity and specificity to reliably stratify short-term stroke risk after TIA, particularly for identifying patients at very low or very high risk. The score does not account for critical high-risk features such as ipsilateral large artery stenosis, atrial fibrillation, recurrent or crescendo TIAs, or imaging evidence of acute infarction, all of which substantially increase early stroke risk independent of ABCD2 score. As a result, patients with low ABCD2 scores may still harbor significant vascular pathology and face substantial risk, undermining the score’s utility for disposition or management decisions. Instead, current best practice focuses on clinical features to risk stratify patients. These are the features that predict a subsequent disabling stroke and mandate urgent imaging and treatment:

Persistent nondisabling deficits and resolved high-risk features share the same message: active cerebrovascular pathology with high risk for early subsequent stroke. A persistent deficit—even when “mild”—raises the pretest probability of a treatable lesion such as symptomatic carotid stenosis, intracranial atherosclerosis, or cervical artery dissection, and the opportunity for secondary prevention. Resolved high-risk features—true motor weakness (often described as heaviness), speech or language disturbance, major visual field loss, or depressed consciousness—suggest potentially high risk vascular territory at risk for susequent stroke from ongoing vascular pathology. Either scenario should trigger urgent head CT to exclude hemorrhage, early CTA head and neck to define the vasculature, and immediate antithrombotic decisions. The goal is to prevent the next stroke event, which is at highest risk within the first 48 hours to one week.

~¼ Large-artery atherosclerosis (carotid/intracranial):

~¼ Lacunar/small-vessel:

~¼ Other/cryptogenic (dissection, thrombophilia, hyperviscosity; higher in young):

Etiology is not an academic afterthought—it determines secondary prevention timelines, including both medications and interventional procedures. Large-artery atherosclerosis (carotid or intracranial) may require a surgical approach when symptomatic ICA stenosis is present; pre-op therapy is typically single antiplatelet, and the procedural window is early (after the first 48 hours, but ideally within the first couple of weeks). Lacunar or small-vessel disease typically requires an antiplatelet-based prevention strategy with aggressive risk-factor control; thrombolysis is reserved for disabling presentations within the treatment window. Cardioembolic sources (most commonly atrial fibrillation, but also structural heart disease) shift the plan toward oral anticoagulation once it is safe, so an ECG at the time of presentation and arrangements for rhythm monitoring and echocardiography matter even in nondisabling stroke or high risk TIA cases. Cervical artery dissection and other “cryptogenic/other” mechanisms are proportionally more common in younger patients; they necessitate CTA head/neck to confirm the diagnosis and typically lead to a short course of dual antiplatelets for TIA/nondisabling stroke presentations while awaiting confirmatory testing for underlying stroke etiology.

The appropriate acute imaging study in suspected ischemic stroke is a stroke-protocol CTA performed immediately, not a delayed “carotid stenosis” CTA intended for elective surgical planning. The stroke-protocol CTA provides time-sensitive information essential to emergency management: identifying the site of occlusion, assessing collateral circulation, and detecting stenosis or dissection that may alter acute therapeutic decisions.

A normal early CT or CTA does not exclude ischemic stroke. Lacunar infarcts, distal vessel occlusions, and small ischemic cores can be radiographically occult in the hyperacute phase. Clinicians should treat the clinical syndrome, and when imaging findings appear discordant with the patient’s presentation, pursue specialist advice rather than prematurely excluding the diagnosis.

Carotid and vertebral Doppler ultrasonography remain useful for secondary prevention and pre-operative assessment, but they do not substitute for CTA when available to inform real-time decisions in the ED.

Carotid endarterectomy remains one of the few surgical interventions in stroke care that meaningfully alters outcomes. Patients with symptomatic internal carotid artery stenosis of 70–99% derive the greatest absolute risk reduction in recurrent stroke with early CEA. Selected patients with 50–69% stenosis may also benefit, depending on plaque/composition/stability, comorbidities, and symptoms.

Timing is critical: CEA is typically deferred for the first 48 hours following ischemic stroke to avoid reperfusion injury in the “hot brain” phase, then performed as soon as safely feasible—ideally within 7–14 days of the index event. The benefit declines substantially with delay beyond two weeks.

Emergency clinician priorities:

Once intracranial hemorrhage is ruled out:

High-risk TIA and nondisabling stroke live on the same continuum and should be managed with the same urgency. Load antiplatelets in the ED and tailor the regimen to mechanism. Most patients without endarterectomy plans or atrial fibrillation benefit from a short course of dual antiplatelet therapy (DAPT)—typically  21 days—then de-escalation to monotherapy. Pragmatically, aspirin 160–325 mg loading then 81 mg daily combined with clopidogrel 300 mg loading then 75 mg daily is common; aspirin with ticagrelor 180 mg loading then 90 mg twice daily is a reasonable alternative. Benefit is front-loaded in the first three weeks; bleeding risk rises after, which is why DAPT is not continued indefinitely as a standard. Use single antiplatelet therapy if carotid surgery is anticipated, extend dual antiplatelet therapy when intracranial atherosclerosis is the culprit per local protocol, and/or transition to anticoagulation when cardioembolic sources such as atrial fibrillation are identified and it is safe to do so. For symptomatic cervical artery dissection with TIA or nondisabling stroke, treatment typically involves a short course of DAPT, while asymptomatic dissection commonly receives single-agent therapy for months in coordination with the stroke team.

Single antiplatelet medication options:

DAPT (short course ~21–28 days):

Etiology-specific nuances:

Cardioembolic sources (e.g., AF): oral anticoagulation for secondary prevention; initiation/timing individualized (consider infarct size, hemorrhagic risk, and neurology guidance) but typically within 4 days; the trend as of 2025 is to start a DOAC as soon as 24 hrs after the stroke initiation for smaller infarcts with low hemorrhagic transformation risk.

Smoking cessation, diabetes optimization, physical activity, and diet counselling—all should begin in the ED discharge summary or follow-up instructions.

Disposition decisions for patients presenting with acute nondisabling stroke should be individualized, guided by risk stratification and institutional resources. Admission to a specialized stroke unit is associated with improved outcomes even in nondisabling presentations and should be prioritized when high-risk features are present or reliable outpatient follow-up cannot be assured.

Hospital admission or observation is recommended for patients with any of the following:

Selected patients with nondisabling stroke can be discharged safely from the ED when all of the following are satisfied:

The post PODCAST: Nondisabling Stroke Recognition and Management first appeared on האיגוד הישראלי לרפואה דחופה.

Date: October 10, 2025

Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world’s leading researchers on pain management in the emergency department. 

Case: A 37-year-old man presents to the emergency department (ED) with severe right-sided flank pain.  The pain started about eight hours ago as a vague discomfort in his right flank, but it has gotten progressively worse and now is radiating to his groin. Patient reports nausea, an increased urge to urinate and noticing blood in his urine on one occasion. The patient denies prior medical or surgical history.

Upon ED arrival, his vital signs are normal. Physical examination revealed a stated age patient in distress due to severe right flank pain, prominent right-sided costovertebral angle tenderness, and absence of abdominal tenderness or guarding. While strongly considering renal colic in differential diagnosis and reaching for the bedside ultrasound, you are wondering if a single dose of a non-steroidal anti-inflammatory (NSAID) will be enough to relieve this patient’s pain, or should you add Magnesium or Lidocaine?

Background: Renal colic is a common and extremely painful emergency department (ED) complaint encountered in the ED that frequently recurs. The nonsteroidal anti-inflammatory drugs (NSAIDs) given intravenously or intramuscularly (IM) are frequently used as first-line therapy. However, about 30% of ED patients receiving NSAIDS require rescue analgesia in the form of opioids. Opioid use, though effective, is limited at times due to the potentially dangerous adverse effects. Thus, there might be a role for other non-opioid classes of drugs to be co-administered with NSAIDs for relief of renal colic.

Magnesium sulfate (MgSO₄) has been suggested as a possible treatment option. It may blunt ureteral smooth muscle spasm by antagonizing calcium influx in smooth muscle and by N‑methyl‑D‑aspartate (NMDA) receptor antagonism. These are mechanisms that can reduce visceral pain and augment other analgesics. Small ED trials and meta‑analyses suggest MgSO₄ can reduce pain scores and opioid use in renal colic, though the evidence base has been limited and heterogeneous [1].

Another suggested treatment modality for renal colic is intravenous lidocaine. We looked at this treatment on SGEM#202 and were unimpressed with the efficacy. Systemic lidocaine blocks voltage‑gated sodium channels and appears to modulate central sensitization and visceral pain pathways. In ED populations, systematic reviews indicate IV lidocaine offers variable analgesia with a mixed signal for benefit, and renal colic–specific RCTs suggest it may be inferior to ketorolac and best considered (if at all) as part of a multimodal strategy rather than as monotherapy [2].

Reference: Toumia M, Sassi S, Dhaoui R, et al. Magnesium Sulfate Versus Lidocaine as an Adjunct for Renal Colic in the Emergency Department: A Randomized, Double-Blind Controlled Trial. Ann Emerg Med 2024

Authors’ Conclusions: “Adding intravenous MgSO4, but not lidocaine, to IM diclofenac offered superior pain relief but at levels below accepted thresholds for clinical importance.” 

Quality Checklist for Randomized Clinical Trials:

Results: They screened 1,321 patients and included 840 who were randomized (280 per arm). The mean age is in the mid 40s with a fairly even male/female split. The mean baseline NRS ~8.5–8.7. Ultrasound showed stones in ~20% and pyelocaliceal dilation in over one-third of patients.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We would have tweaked the conclusion to say: Adding intravenous MgSO₄, but not lidocaine, to IM diclofenac MAY offer superior pain relief, but at levels below accepted thresholds for clinical importance.

Case Resolution: You proceeded with administration of 10mg of IV Ketorolac as a single agent, and upon assessment of the patient at 20 minutes, the patient verbalized significant pain relief without experiencing any adverse effects. Urinalysis is positive for blood, while complete blood count, complete metabolic panel, and the remainder of the urinalysis are normal.  A non-contrast CT scan reveals a 4 mm non-obstructing stone in the right distal ureter.

Dr. Sergey Motov

Clinical Application: Intravenous adjunctive MgSO₄ does not seem to provide clinically meaningful pain relief in patients with renal colic but leads to frequent development of facial flashing. This precludes if from routine use in the ED for patients with renal colic. Similarly, IV lidocaine combined with parenteral NSAIDs does not provide clinically meaningful pain relief in patients with renal colic, and the evidence doesn’t support its use at this time.

What Do I Tell the Patient?  It looks like you have classic kidney‑stone pain. I will order an IV analgesic called ketorolac that should reduce your pain and make you more comfortable. However, if you are still in pain in 15-20 minutes after receiving this medication, I will proceed with ordering intravenous morphine.

Keener Kontest: Last week’s winner was Dr. Steven Steltz from NZ. He knew it was called Cable Beach in Broome, Western Australia, because it was the site where an undersea telegraph cable came ashore in 1889, connecting Australia to the rest of the world via Java.

Listen to the SGEM podcast this week to hear the trivia question. If you know the answer, send an email to [email protected] with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

Other SGEM Episodes:

References: 

The post PODCAST:Smooth Muscle Relaxator – But does Magnesium Work for Renal Colic? first appeared on האיגוד הישראלי לרפואה דחופה.

Massive hemorrhage is one of the most time-critical, high-stakes scenarios in Emergency Medicine. Every minute matters. Every decision counts. But more blood is not always better—what saves lives is systematic, team-based, goal-directed care. In this update to the 7 T’s of Massive Hemorrhage Protocols with Dr. Jeannie Callum and Dr. Andrew Petrosoniak, we explore the most current, evidence-informed strategies for bleeding patients, from polytrauma to obstetrical, drawing on the latest clinical trial data, provincial MHP 2.0 rollouts, and real-world experience. We answer the questions: What is the evidence based alternative to FFP in EDs where FFP is not readily available? How accurate are decision scores in helping decide the trigger for MHP activation? Why is testing fibrinogen levels and giving fibrinogen concentrates so important in massive hemorrhage? How should we tailor our MHP to the GI bleed patient? To the obstetrical patient? and many more….

Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Matthew McArther, edited by Anton Helman August, 2025

Cite this podcast as: Helman, A. Callum, J. Petrosoniak, A. Massive Hemorrhage Protocols 2.0 – Update on the 7 Ts. Emergency Medicine Cases. August, 2025. https://emergencymedicinecases.com/massive-hemorrhage-protocols-2-0/. Accessed August 5, 2025

Determining when to activate MHP can be challenging. Overactivating MHP can cause harm by clogging up hospital resources as well as adverse sequelae from overtreatment. But even small delays in transfusing critically bleeding patients is associated with increased mortality. Rather than calling an MHP immediately based on EMS report or on arrival in the ED, our experts suggest a critical administration threshold approach to MHP.

In general, the literature suggests there is little downside to giving a 2-3 units of RBCs up front, so have RBCs ready for any patient who has hypotension in the field with a concerning mechanism, or any other suspicion of hemorrhagic shock. Once the patient arrives and you begin your primary survey, have a low threshold to administer those first 1-3 units if you are still concerned for hemorrhagic shock. In trauma, this strategy aligns with observational evidence that early red cell transfusion improves outcomes while minimizing premature plasma exposure.

Predicting upfront which bleeding patients will go on to need massive transfusion is challenging. Even our best clinical scoring tools are only 60-80% accurate. Trauma scores such as the Assessment of Blood Consumption (ABC), Shock Index, Revised Assessment of Bleeding and Transfusion score (RABT) and Resuscitation Intensity (RI) have been used to predict need for MHP. However, their sensitivity and specificity are modest. Instead, seeing how a patient responds after those first few units during the initial resuscitation will be most useful for you to decide when to activate MHP.

MHP Mnemonic: “Easy as ABC After 3”

It is useful to conceptualize the MHP as a “full court press” for patients with massive hemorrhage, designed to:

Dr. Andrew Petrosoniak proposes a two-step decision-making model: first, administer two or three units of uncrossmatched red cells to the bleeding patient. Then, reassess. This “ABC after 3” rule—standing for “Activate MHP, Balance products, Consider calcium and concentrates (fibrinogen)”—anchors the transition point between supportive transfusion and full protocol activation. If, after three RBCs, the patient remains unstable, coagulopathic, or is likely to require operative or angiographic intervention, then activation is warranted.

Ask three questions after 3 units RBCs (the “ABC after 3” rule):

Most of the evidence around MHP activation is in trauma. But not all bleeding patients share the same physiology: what about other causes of hemorrhagic shock?

Importantly, bleeding patients differ in fundamental ways depending on etiology. Trauma-induced coagulopathy occurs in approximately 25% of trauma patients and arises from complex endothelial dysfunction and fibrinolysis. In contrast, gastrointestinal bleeds—particularly variceal bleeds—typically involve a paradoxical mix of hypercoagulability and active bleeding. Postpartum hemorrhage, on the other hand, is most often caused by uterine atony, with hypofibrinogenemia as a late and ominous sign.

Accordingly, thresholds for MHP activation must be tailored. In trauma, early red cells followed by reassessment offers a reasonable approach. In GI bleeding, full activation is rarely needed, with only 5% of patients requiring more than red cells alone, and FFP may even be harmful. In contrast, obstetric hemorrhage demands a low threshold for activation. With blood flow to the gravid uterus at term reaching 1.5L/min, complete exsanguination can occur in minutes. Thus, any signs of instability in postpartum patients should prompt immediate protocol initiation.

These patients have very different physiology than bleeding trauma patients and rarely need MHP activation. A combination of crystalloid volume resuscitation and red cell transfusions to a hemoglobin target of 70-80mg/dL should be adequate for the vast majority of patients with variceal bleeds (Baveno VII consensus guidelines). Activating consultants early for endoscopic management is key. Giving plasma, as in MHP protocols, could increase portal venous pressures and increase bleeding.

Pitfall: Do not trust the INR in cirrhotic patients. These patients have alterations in both pro-thrombotic and anti-thrombotic protein synthesis, so they may have an overall pro-thrombotic state despite having an elevated INR. Focus your management on resuscitation, decreasing portal pressures, and hemorrhage source control, rather than trying to correct coagulopathy. TXA has been shown to increase thrombotic complications in these patients with no mortality benefit (HALT-IT trial).

Because of the high uterine blood flow of 1.5L/min of pregnancy, these patients have the potential to exsanguinate rapidly. Have a very low threshold to activate MHP for any post partum hemorrhage (PPH) patient who is showing signs of hemorrhagic shock in order to mobilize blood products quickly. Rapid source control of uterine atony, with medications and operative management if needed, is critical for these patients.

The first “T,” trigger, remains perhaps the most critical. Without timely activation of the MHP, the rest of the pathway simply doesn’t unfold. Traditionally, we’ve relied on a mix of gestalt, shock index, and trauma scores like ABC or REBT to guide activation. But the latest thinking encourages a more pragmatic, flexible approach.

Ratio-based Resuscitation

2:1 ratio of RBC to FFP is recommended by our experts which corresponds with multiple consensus guidelines. PROPER trial did not show a benefit of 1:1 compared to 2:1.

If FFP is unavailable, after the first 4 units of RBCs, give 2000 units of PCC and 4g of fibrinogen in lieu of FFP. You can repeat this once after the second pack of 4 RBCs.

Don’t overuse O negative – it’s a very limited resource. Women under 45 of childbearing potential should get O negative Kell negative blood. Everyone else gets O positive.

MHPs require seamless collaboration between emergency, surgical, nursing, transfusion, and laboratory services. High-performance teams emphasize clear role allocation, defined hemodynamic goals, and shared mental models.

Delegating transfusion logistics to two team members operating a rapid infuser is another high-yield move. Once MHP is activated, the transfusion sequence can be semi-automated: start with four units of RBCs, then alternate between RBC and FFP to approach a 2:1 ratio, with the team leader monitoring for signs of over- or under-transfusion. Regular check-ins—every 30 minutes or after each pack—allow for reassessment and recalibration. Shared situational awareness is critical. Reminders like “pause the transfusion if systolic >140 or <70” empower the team to speak up and support dynamic decision-making.

Despite its importance, lab testing is often overlooked in the midst of resuscitation. Yet timely, repeated laboratory data are essential for guiding goal-directed therapy. Trauma-induced coagulopathy can occur due to the release of natural heparins and tPA from damaged endothelial cells. Clinical signs of trauma-induced coagulopathy include excessive oozing from IV sites as well as mucosal bleeding.

Serial labs should be repeated every hour or after every 4 units of red cells, whichever comes first. Anchoring lab draws to clinical actions—such as after each MHP pack—makes this easier to remember.

Labs at baseline and minimum q60min (or after every pack/4 units):

A PTT should be included at baseline but only repeated if elevated or if the patient is on heparin or dabigatran.

 Pitfall: Forgetting fibrinogen. It’s important and often missed.

In Small Centers:

No fibrinogen testing? For hospitals lacking fibrinogen testing, empirical administration  of fibrinogen concentrates 4 g IV is recommended after two MHP packs in patients with ongoing bleeding.

The importance of fibrinogen and calcium

Among all these tests, fibrinogen is one of the most crucial—and the most frequently missed. Hypofibrinogenemia is a strong predictor of transfusion need and poor outcomes, particularly in obstetric and liver disease–associated bleeding. A declining fibrinogen level is a key indicator of worsening coagulopathy, and replacement must be timely and targeted. Calcium levels must also be vigilantly monitored, as hypocalcemia reduces cardiac contractility and interferes with coagulation factor activity. In cirrhotic patients with variceal bleeds, fibrinogen remains important. While their INRs may appear deranged, many are in a tenuous hemostatic balance. However, if fibrinogen is critically low, even expert endoscopists will struggle to achieve source control of bleeding.

CRASH-2 study showed that TXA has a time-sensitive mortality benefit if given in the 1st hour, so remember to give it ASAP for trauma patients with severe bleeding. Give the entire 2g upfront as a bolus- no need for an infusion as described in earlier protocols.

Tranexamic acid (TXA) is one of the few medications in hemorrhage resuscitation that has been shown to confer a mortality benefit—when used correctly. For trauma patients, their is an associated reduced mortality benefit with a 2-gram dose given within the first hour of injury. The key is speed. Delayed administration beyond 3 hours confers no benefit and may cause harm. In the chaos of resuscitation, having a timekeeper or checklist item reminding the team to administer TXA early is crucial. In prehospital settings, a 1 g dose by EMS can be followed by an additional 1 g in the ED.

In postpartum hemorrhage, our experts recommend 1 gram as soon as bleeding begins, followed by a second gram if bleeding persists after 30–60 minutes. This is supported by the WOMAN trial and WHO guidelines.

However, in gastrointestinal bleeding, TXA is no longer recommended. The HALT-IT trial demonstrated no mortality benefit and an increased rate of thromboembolic events in patients who received TXA. This underscores the importance of tailoring adjunctive therapy to the bleeding context.

Caution is advised in patients with recent thromboembolic disease (<3 months), although anticoagulated patients may still benefit from TXA given the overriding risk of hemorrhagic death.

Hypothermia is one-third of the deadly trauma triad, yet it’s often overlooked in the early stages of care. Hypothermia exacerbates coagulopathy by impairing platelet function and fibrinogen polymerization. Every 1°C drop is associated with a 20% increase in transfusion needs. There is also a potential psychologic benefit to our patients: patients who are kept warmer in the trauma bay often feel safer during their resuscitation.

A systems-based approach is needed. Warm IV fluids, forced-air warming, and heated resuscitation rooms should be standard. Temperature monitoring should begin immediately upon arrival, as anesthesia and operating room teams do routinely.

Tips to avoid hypothermia in trauma patients:

Target a temperature of 37 degrees celsius.

The initial 1-2 hours of the resuscitation is guided by hemodynamics and the overall clinical impression rather than lab parameters. The ongoing resuscitation is then guided by lab testing.

Pitfall: The treatment dose of fibrinogen is 4g which will increase the serum fibrinogen by approximately 1g/L. A common pitfall is to underdose fibrinogen.

Recommendations for platelet transfusion are based on expert opinion without RCT-level evidence of benefit. Studies in multiple patient populations (ICH on antiplatelet, dengue patients, neonatal patients) show a signal for harm with platelet transfusion, so be cautious to not over-transfuse platelets even in bleeding patients.

In the context of MHP, our experts recommend using a platelet treatment threshold of 50 × 10⁹/L, and increase to 100 × 10⁹/L if significant brain or spinal cord injury.

Transfusion decisions during massive hemorrhage must evolve from fixed-ratio empiricism to goal-directed, personalized care. While initial resuscitation can follow predefined ratios, once lab results are available, therapy should be adjusted based on specific targets.

For hemoglobin, a threshold of 70–90 g/L is adequate post-stabilization, according to a large cluster-randomized Japanese trial. During early resuscitation, however, red cells are given to maintain perfusion rather than based on hemoglobin levels.

Fibrinogen should be maintained above 1.5–2.0 g/L. If replacement is required, fibrinogen concentrate is preferred over cryoprecipitate where available. Unfortunately, underdosing is common; less than four grams is often ineffective. A full four-gram dose increases fibrinogen by approximately 1 g/L.

INR should be kept below 1.8, although this threshold is based on consensus rather than high-level evidence. Calcium (ionized) should be monitored and maintained above 1.15 mmol/L. A major trial in progress (CAVALIER) may soon provide more clarity on prehospital calcium administration.

There is growing interest in viscoelastic assays (TEG/ROTEM) for fine-tuned coagulation guidance. While the ITACTIC trial did not show mortality benefit in trauma, widespread adoption is limited by cost, complexity, and clinician unfamiliarity. Cardiac surgery data suggest these tools improve outcomes when used in experienced hands.

Deciding when to terminate an MHP is as important as when to initiate. The risks of over-transfusion include volume overload, alloimmunization, and product wastage. Therefore, the protocol should not run on autopilot.

Continuously Assess the Need for Ongoing MHP

Automate: reassess the need for MHP every 30 minutes or after every pack.

Use protocolized prompts: e.g., blood bank asks if MHP can be discontinued after 1 hour of inactivity.

Post-MHP, continue 4–6 hours of vigilant monitoring:

Development of antibodies is a real risk, so make sure the patient knows about what they have received and is informed of subsequent risks. For every unit there is 1/13 chance of making antibodies, but these are usually fleeting. Women of childbearing potential who received MHP should undergo a group and screen q3months. They should go into any future pregnancy aware of the increased risk of complication, as antibody-related transfusion complications can profoundly impact pregnancies.

In resource-limited settings where fresh frozen plasma (FFP) is unavailable, a validated alternative approach is to administer 2000 IU of prothrombin complex concentrate (PCC) along with 4 grams of fibrinogen concentrates. This replacement strategy has been shown to be safe and effective, was validated in the FIRST2 trial, and aligns with European guidelines.

PCC 2000 IU + fibrinogen concentrates 4 g per four units of RBCs

These centers typically deliver two such packs (PCC + fibrinogen) alongside RBCs before transferring the patient. Even without lab capacity to measure fibrinogen, empirical dosing in this context is justified and often lifesaving.

The MHP must also be modified for anticoagulated patients. Rapid identification is crucial, particularly in elderly patients presenting with trauma or GI bleeding.

For patients taking warfarin, administer 2000 IU of PCC along with vitamin K. For direct oral anticoagulants (DOACs), the same 2000 IU dose of PCC is given initially, and a second 2000 IU may be administered after one hour if bleeding continues. This simplified approach reduces delay and aligns with recent expert consensus.

MHP 2.0 emphasizes clinical judgment, early red cells, goal-directed therapy, and avoidance of over-activation. The 7 T’s remain our framework, but we now understand that:

Massive hemorrhage protocols have evolved. What began as a reactionary, one-size-fits-all approach has matured into a tailored, systematic framework grounded in physiology, evidence, and team dynamics. The 7 T’s offer a cognitive scaffold, but MHP 2.0 demands clinical judgment, humility, and leadership. As practice evolves, focus must shift from fixed-ratio empiricism to goal-directed transfusion guided by physiology, laboratory data, and systems-level readiness.

The post PODCAST: Massive Hemorrhage Protocols 2.0 – Update on the 7 TsMassive Hemorrhage Protocols 2.0 – Update on the 7 Ts first appeared on האיגוד הישראלי לרפואה דחופה.

Angioedema = localized swelling of mucous membranes and subcutaneous tissues due to increased vascular permeability.

Triggers increased vascular permeability → fluid shifts into tissues.

The post PODCAST: Angioedema first appeared on האיגוד הישראלי לרפואה דחופה.

We’re back with another episode of Push Dose Pearls with ED Clinical Pharacist, Haley Burhans! In this episode, we break down the essentials of managing agitation in the ED—starting with why you should avoid diphenhydramine in the elderly and benzodiazepines in the 3 D’s: drunk, delirium, and dementia. We discuss how to quickly assess the cause, choose the right medication, and decide between IM and IV routes. And Haley offers some key safety tips and considerations for special populations, including kids and the elderly. 

Was this episode helpful? What other medications would you like to learn more about? Hit us up on social media @empulsepodcast or at ucdavisem.com

Hosts:

Dr. Julia Magaña, Professor of Pediatric Emergency Medicine at UC Davis

Dr. Sarah Medeiros, Professor of Emergency Medicine at UC Davis

Guests:

Haley Burhans, PharmD, Emergency Medicine Clinical Pharmacist at UC Davis

Resources:

ACEP’s New Clinical Policy on Severe Agitation. By Molly E.W. Thiessen, MD, FACEP | on February 12, 2024

Pediatric Education and Advocacy Kit (PEAK): Agitation

Hoffmann JA, Pergjika A, Konicek CE, Reynolds SL. Pharmacologic Management of Acute Agitation in Youth in the Emergency Department. Pediatr Emerg Care. 2021 Aug 1;37(8):417-422. doi: 10.1097/PEC.0000000000002510. PMID: 34397677; PMCID: PMC8383287.

Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418. doi: 10.5811/westjem.2019.1.41344. Epub 2019 Feb 19. Erratum in: West J Emerg Med. 2019 May;20(3):537. doi: 10.5811/westjem.2019.4.43550. Erratum in: West J Emerg Med. 2019 Jul;20(4):688-689. doi: 10.5811/westjem.2019.4.44160. PMID: 30881565; PMCID: PMC6404720..

****

The post PODCAST: Acute Agitation first appeared on האיגוד הישראלי לרפואה דחופה.

Matthew MacArthur on the role of occipital nerve block for the treatment of headache (1:32)

Ian Chernoff on the role of POCUS in patients with pulmonary embolism (10:25)

Hans Rosenberg on identification and management of myelopathy in the ED (29:13)

Shawn Segeren on the importance of the recorder during resuscitations (35:27)

Brit Long on incidental neutropenia (39:20)

Kylie Booth on Emergency Medicine peer programs (49:50

Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Brandon Ng, Brit Long, Mathew MacArthur, edited by Anton Helman, June, 2025

Cite this podcast as: Helman, A. MacArthur, M. Chernoff, I. Rosenberg, H. Segeren, S. Long, B. Booth, K. EM Quick Hits 65 – Occipital Nerve Block, PoCUS in Pulmonary Embolism, Myelopathy, Team Resuscitation, Incidental Neutropenia, Peer Programs. Emergency Medicine Cases. June, 2025. https://emergencymedicinecases.com/em-quick-hits-june-2025/. Accessed June 15, 2025.

Source: Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010 Apr;7(2):197-203

A single injection can halt the dysregulated pain signaling and provide sustained headache relief even after the anesthetic wears off.

Evidence for occipital nerve blocks for headache

1. Systematic review in 2023 of Nerve Blocks for Occipital Headaches (Evans et al)

2. Systematic review in 2024 of Occipital Nerve Block for Chronic Migraine (Mustafa et al)

Bottom Line: Occipital nerve block is safe, fast, and often effective with proper landmarking. Consider its use for occipital neuralgia and as a second-line treatment for occipital migraines/headaches refractory to standard ED therapy.

This is a companion podcast segment to our 2-part podcast on Management of Pulmonary Embolism: Management of Intermediate Risk PE, and Management of High Risk PE

POCUS may offer high-yield prognostic information for intermediate-risk PE patients with CT, as well as diagnostic information for high-risk PE patients who are too unstable for CT.

All basic PoCUS views have findings that support the diagnosis of RV strain in PE:

Advanced Signs:

Approach:

Pitfalls:

Bottom Line: In intermediate risk PE, PoCUS may help risk stratify. In high-risk or crashing patients PoCUS can be diagnostic and guide immediate reperfusion decisions.

Myelopathy = spinal cord dysfunction from compressive or non-compressive causes.

Key Clinical Clues: 

Workup of suspected myelopathy

ED management of suspected myelopathy

Bottom Line: Upper motor neuron signs with dermatomal sensory loss should raise suspicion for myelopathy. MRI is an essential diagnostic tool and patients may require whole spine imaging. Rapid recognition and referral to neurosurgery or neurology are critical for preventing irreversible deficits.

Tips for Resuscitation Team Leaders

Bottom Line: The recorder is not passive—when empowered and involved, they can elevate team performance and patient safety.

1) Clinical status of the patient and the suspected cause based on history and exam and

2) Laboratory testing with CBC and ANC, differential, other cell lines, and peripheral smear.

* Most commonly associated with neutropenia

Peer programs provide support for emergency providers to consult a trusted EM colleague before, during or after a shift.

The Ontario Health Peer-to-Peer Program is a an example of a peer program with a 24/7 support line for Ontario ED physicians to speak with a trusted colleague in real time for assistance or advice.

The service is especially valuable for smaller centers where physicians are working under single coverage environments where a physician colleague is not available.

Outcomes of the program include reported impact on physician wellness, increased rural locum uptake due to availability of peer support, and improved patient preparedness for transfer.

Bottom Line: EM peer programs are a model of compassionate, horizontal support to build sustainable EM practice—especially in rural and solo-coverage environments.

More about Ontario Peer to Peer Program

For more information and advice on setting up a peer program where you work, contact Dr. Kylie Booth at [email protected]

None of the authors have any conflicts of interest to declare

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The post PODCAST: EM Quick Hits 65 Occipital Nerve Block, PoCUS in Pulmonary Embolism, Myelopathy, Team Resuscitation, Incidental Neutropenia, Peer Programs first appeared on האיגוד הישראלי לרפואה דחופה.

Reference:  St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025

Date: March 19, 2025

Dr. Camille Wu

Guest Skeptic: Dr. Camille Wu is a paediatric surgeon based at Sydney Children’s Hospital where she is the Head of Department. She is also on the Training Committee of Paediatric Surgery for Australia and New Zealand.

Case: A 10-year-old boy presents to the emergency department (ED) with his parents. He started having abdominal pain yesterday and did not want to eat. Today, his abdominal pain worsened, and he developed a fever. On examination, he looks uncomfortable and is tender to palpation in the right lower quadrant. You tell the parents that his examination is concerning for appendicitis. You order an ultrasound that demonstrates a dilated and non-compressible appendix. You consult the surgery team and both of you come to speak with the family. His parents tell you, “His sister was diagnosed with appendicitis during the Covid pandemic. At that time, she was admitted to the hospital but just treated with antibiotics. She was able to go home and has done well since that time. Do you think he needs surgery, or can he be treated with antibiotics as well?”

Background: Acute appendicitis is one of the most common pediatric surgical complaints that we encounter in the ED. Traditionally, appendicectomy has been the gold standard for treatment, based on its effectiveness in preventing complications such as perforation, abscess formation, and peritonitis​. This is typically done laparoscopically through a few small incisions.

The concept of non-operative treatment of appendicitis (NOTA) with antibiotics has gained interest over the past decade. This has been supported by growing evidence suggesting that some cases of uncomplicated appendicitis may resolve without surgery​.

We have covered NOTA before on the SGEM that included some meta-analyses, randomized controlled trials, and observational studies.

The results have been mixed. Some of these studies have suggested that antibiotic therapy is non-inferior to surgical management while other studies have suggested antibiotic therapy did not meet criteria for non-inferiority compared to appendectomy. Most of these studies were conducted in the adult population with fewer studies conducted in children. The question remains:

To cut or not to cut?

Reference:  St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025

Authors’ Conclusions: Based on cumulative failure rates and a 20% non-inferiority margin, antibiotic management of non-perforated appendicitis was inferior to appendicectomy.

Quality Checklist for Randomized Clinical Trials:

Results: They recruited 936 patients from 11 children’s hospitals in Canada, the US, Finland, Sweden, and Singapore. 459 were assigned to the appendicectomy group and 477 were assigned to the antibiotic group.

Primary Outcome:

34% of the patients in the antibiotic group had treatment failure compared to 7% of the appendicectomy group. That was a difference of 26.7% (90%CI 22.4-30.9). Most treatment failure in the appendicectomy group was due to negative pathology.

In the antibiotic group, 72 (47%) met definition of treatment failure during the first admission.

Secondary Outcomes: 

Neither of the groups had deaths or serious adverse events.

The relative risk of having an adverse event related to the antibiotic treatment compared to the appendicectomy was 4.3 (95% CI 2.1-8.7). Most of these adverse events were classified as Gastrointestinal Distress.

Median length of stay was 1.0 day (IQR 0.76-1.68) for the appendicectomy group compared to 1.25 days (IQR 0.92-2.09) for the antibiotic group. The patients from the antibiotic group spent more time in the hospital during the 12 month follow up period 1.6 days (IQR 1.0-2.6) compared to 1.0 days (IQR 0.75-1.7).

The antibiotic group was able to return to normal activity and school faster than the appendicectomy group. They also did not require pain medications compared to the appendectomy Approximately three-quarters (73%) of the families surveyed from both groups reported being satisfied with their treatment.

Diagnosis of Appendicitis

In previous studies, the way a diagnosis of appendicitis is made has varied. Some studies have included imaging findings on CT scan or ultrasound. Some studies have included lab tests.

This study included patients with a diagnosis of simple, non-perforated appendicitis. They excluded those with suspicion of perforated appendicitis. How was this diagnosis made? We went back to the trial protocol on ClinicalTrials.gov to find some more details. It appears that all children with suspected acute non-perforated appendicitis were assessed by the on-call surgeon. The diagnosis could be made based on clinical suspicion with or without ultrasound imaging.

What is the gold standard for diagnosing appendicitis? We would imagine that surgical pathology consistent with the diagnosis is best but also recognize that is does not make any sense to remove the appendix of every child in the study.

Camille does not rely on imaging. However, often by the time she’s called to see the patient in ED, they’ve already had an ultrasound. Sometimes it’s helpful, sometimes it’s unnecessary, and sometimes it’s distracting. One of the common annoying scenarios is the finding of a mildly thickened 7mm appendix in a child who does have right inferior quadrant tenderness with no other signs of appendicitis, and parents are expecting an operation as the ultrasound says “appendicitis’ and the referring hospital has told them that’s why they were getting transferred. Many of these kids have a viral illness, causing lymphoid tissue in the wall of the appendix to hypertrophy, thereby enlarging the appendix.

Treat the patient, not the test or image finding.

Tests are an adjunct to clinical evaluation. They help us to confirm our diagnosis. How sure does a surgeon need to be to take a patient to theatre? How sure does an ED doctor need to be to call their surgeon to review? Seems like the threshold is different for different specialties, different hospitals, different practitioners, and different countries!

Selection Bias

Of the patients screened for eligibility in the study, 90% were excluded. Of those excluded, ~40% were excluded due to perforated appendicitis or suspected perforation, and the other 60% were excluded because they either declined to participate or “other reasons.”

Suspected perforation seems fairly subjective. I asked Camille to comment on how she clinically distinguishes between perforated or non-perforated appendicitis and the accuracy of making that determination based solely on physical exam.

The other group that was excluded were those who declined to participate or had other reasons. It would have been nice to know what those reasons were. A previous study found that a common reason parents declined to participate was they wanted to choose their treatment arm. Authors acknowledge this in the discussion section that they weren’t able to track the reasons for refusal or declined consents due to lack of funding.

Finally, another group that was excluded was pregnant patients, but pregnant people can get appendicitis too.

Appendicectomy Group vs. Antibiotic Group

There were two groups in this study, one group had surgery while the other received antibiotics. The patients in the antibiotic group received a minimum of 12 hours of IV antibiotics and were discharged if they were tolerating regular diet, pain was controlled, and vital signs were stable. If the patients in this group were not getting better, they could opt for another day of antibiotics or go for appendicectomy.  The surgical group was scheduled for appendicectomy in the next available slot. While these patients were waiting for the operating room, they also received IV antibiotics. The paper does not go into detail as to how long these patients who were in the surgery group waited. Previous research has demonstrated that it is fairly safe to delay surgery for appendicitis for 12 to 24 hours after presentation.

It is possible that these two group received similar treatment.  An antibiotic group  patient might have been on antibiotics for 1-2 days before changed over to getting an operation. An appendicectomy arm patient might be waiting 24-36 hours before getting their operation. Their study protocol specifies that the antibiotic group would have appendectomy by 48 hours if there was no clinical improvement. The surgery group would receive an appendectomy within 18 hours of randomization. We read both the paper and supplementary appendix to see if this actually occurred but couldn’t find any more information. And yes, a paper about appendicitis also has an appendix.

Additionally, the antibiotics given to patients may have varied. The authors write that the choice of antibiotic was dependent on the local centre. The variation in antibiotic regimen may also add some confounding but does help with generalizability. There is no consensus about the best antibiotic regimen for non-operative treatment of appendicitis.

Loss to Follow Up

The proportion of loss to follow up differed between the two groups. There was more data missing from the appendicectomy group compared to the antibiotic group (14% vs 5%). This may lead to attrition bias and over-estimate the treatment effect.

It is unclear why there was a higher proportion that were lost to follow up in the appendicectomy group. Is this because the patients who underwent appendicectomy did great and did not feel the need to follow up? Alternatively, did they not do as well? We don’t know.

Having more patients lost to follow up in the appendicectomy group may also lead to overestimating the difference in treatment failure between the two groups. The authors did perform a sensitivity analysis assuming event rates were the same in the missing data as the complete data without a change in their conclusions.

Non-inferiority Margin

The non-inferiority trial format is particularly relevant in this context, as it assesses whether antibiotic therapy is “not significantly worse” than surgery in terms of efficacy and safety.

This study had a proposed non-inferiority margin of 20%. This was decided as a compromise between patients and families and surgeons. Nonetheless, it is quite generous. Despite this margin that was set, this study still demonstrated that for appendicitis was inferior.

Different families and patients and surgeons probably have differing thresholds for how much risk of complications they are willing to tolerate.

The other question that we need to ask is what aspect of treatment is non-inferior? The primary outcome was treatment failure, but there were other aspects in the secondary outcomes that were also patient-oriented outcomes such as a faster return to school and activity, and less pain medication requirement in the antibiotic group. Those aspects may be more important to the family and patient. We saw very similar satisfaction rates between the two groups.

Although “appendicitis” is the one entity, it affects individuals in different ways, so that in patient-centered care, one size does not fit all.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion but think there is more research to be done to investigate if there is a subset of low-risk patients who may do well with non-operative treatment.

Case Resolution: You and the surgical team engage in shared decision-making with the family and patient. You discuss the potential harms and benefits of operative versus non-operative management. The family expresses their desire to try and avoid surgery and the patient is admitted to the hospital for observation on IV antibiotics.

Clinical Application: 

Tune in to the podcast to hear how this paper changed or didn’t change Dr. Wu’s practice and her personal experience with non-operative treatment for appendicitis.

What do I tell my patient/family?

Thank you for your question. There have been many people studying whether we need to do surgery for appendicitis or if we can treat it with antibiotics. The results have been mixed. Let’s talk about the potential harms and benefits of each choice. If you decide that you want to try to avoid surgery, we can have your child stay in the hospital on IV antibiotics and observe him. If he gets better, we can send him home with oral antibiotics. If he gets worse or does not improve, we can revisit the discussion about performing surgery.

References

The post PODCAST: Cuts like a Knife or Antibiotics for Pediatric Appendicitis first appeared on האיגוד הישראלי לרפואה דחופה.

Welcome to Part 1 of our two-part podcast series on Adult Asthma Exacerbations. Given this past summers’ increase in the number and size of forest fires leading to increased asthma presentations to the ED, we are joined by Dr. Leeor Sommer from North York General Hospital and Dr. Sameer Mal, an ED-Intensivist and Transport Physician from London, Ontario to discuss the most important aspects of ED asthma care. Together, we’ll explore a systematic approach to managing patients presenting to the ED with asthma exacerbations. Our discussion will emphasize the critical role of a thorough history and physical examination in effectively stratifying patient risk and guiding treatment/disposition decisions. Additionally, we’ll examine the importance of providing comprehensive discharge medications and instructions to mitigate both mortality and morbidity associated with asthma exacerbations. We answer questions such as: which patients, if any, require peak expiratory flow measurements in the ED? Why is it so important to add steroid MDI therapy to oral steroid therapy in patients being discharged from the ED after an asthma exacerbation? What are the most predictive variables to risk stratify patients with asthma exacerbations to help guide treatment and disposition? and many more. Stay tuned for Part 2, where we’ll delve deep into the management of the crashing asthmatic.

Welcome to Part 1 of our two-part podcast series on Adult Asthma Exacerbations. Given this past summers’ increase in the number and size of forest fires leading to increased asthma presentations to the ED, we are joined by Dr. Leeor Sommer from North York General Hospital and Dr. Sameer Mal, an ED-Intensivist and Transport Physician from London, Ontario to discuss the most important aspects of ED asthma care. Together, we’ll explore a systematic approach to managing patients presenting to the ED with asthma exacerbations. Our discussion will emphasize the critical role of a thorough history and physical examination in effectively stratifying patient risk and guiding treatment/disposition decisions. Additionally, we’ll examine the importance of providing comprehensive discharge medications and instructions to mitigate both mortality and morbidity associated with asthma exacerbations. We answer questions such as: which patients, if any, require peak expiratory flow measurements in the ED? Why is it so important to add steroid MDI therapy to oral steroid therapy in patients being discharged from the ED after an asthma exacerbation? What are the most predictive variables to risk stratify patients with asthma exacerbations to help guide treatment and disposition? and many more. Stay tuned for Part 2, where we’ll delve deep into the management of the crashing asthmatic.

Cite this podcast as: Helman, A. Mal, S. Sommer, L. Episode 192 Asthma Management Strategies for Improved Prognosis – A Stepwise Approach. Emergency Medicine Cases. March, 2024. https://emergencymedicinecases.com/emergency-asthma-management-strategies. Accessed May 18, 2025

Go to part 2 of this 2-part podcast on adult asthma exacerbations

“Not all that wheezes is asthma, and asthma does not always present with a wheeze.”

While the diagnosis of asthma is often straightforward, especially in patients with a history of exacerbations and repeat ED visits, it is crucial to consider several other conditions in patients presenting to the ED with wheezing, including:

In cases where wheezing is absent, particularly in patients suspected of having an asthma exacerbation, be mindful that patients may exhibit a silent chest—a sign of a severe/life-threatening exacerbation where patients are unable to generate sufficient airflow to produce an audible wheeze.

Utilize adjuncts such as PoCUS and chest X-ray to help refine your differential diagnosis in conjunction with a thorough history and physical examination. Guard against diagnostic premature closure that might lead you to exclusively consider asthma upon hearing the term ‘wheeze’.

Effective risk stratification of patients presenting to the ED with asthma exacerbations, grounded in a comprehensive assessment of their medical history and physical examination findings, is pivotal in directing appropriate management and disposition decisions. Patients exhibiting a greater number of the following risk factors are at heightened risk for experiencing a severe exacerbation and having poor outcomes.

Most predictive variables on history:

Other risk factors to consider:

The efficacy of peak expiratory flow (PEF) monitoring in the ED for improving outcomes remains uncertain. While some guidelines advocate for incorporating PEF measurements, aiming for >60-80% of personal best (or predicted) in their discharge algorithms, the American College of Emergency Physicians (ACEP) conducted a comprehensive review of the literature and concluded that PEF monitoring in the ED does not improve outcomes, predict the need for hospitalization, or reduce mortality in adults with asthma exacerbations.

According to our experts, the decision to utilize PEF monitoring should be tailored to each patient and regarded as one factor among many in the clinical assessment to inform disposition decisions.

A brief overview of how to use a Peak Flow Meter and information on PEF use for at-home monitoring of asthma.

*While steroids onset of action is traditionally thought to be delayed there is evidence to suggest that when given within the first hour of presentation there are improved outcomes compared to after 1 hour. It has been proposed that steroids may have a synergistic effect with B-agonists and epinephrine which may explain why improved outcomes are seen when steroids are given early, despite the traditionally thinking that the onset is delayed by several hours.

*When ever possible, re-assess these patients frequently (q15-20 minutes) especially patients in whom you have concern for a severe exacerbation.

There has been a significant shift in clinical practice favoring the use of Metered-Dose Inhalers (MDIs) over nebulizers for ED asthma treatment, primarily driven by concerns around aerosolization during the COVID pandemic. More drug is delivered to the alveoli with MDIs compared to nebulizers. Moreover, the question of potential medication wastage into the environment when utilizing nebulizers as opposed to MDIs with a spacer device has also been raised.

An additional benefit to employing MDIs in the ED is that it provides an opportunity for patients to receive instruction on proper inhalation techniques, equipping them for successful self-management upon discharge. However, it is essential to recognize that MDIs may pose a higher labor burden on nursing staff or RTs if patients require assistance with administration. In scenarios where patients are too unwell to self-administer with an MDI, a nebulizer may offer a more practical and effective treatment option.

Adequate time should spent providing good discharge instruction and appropriate discharge medications to patients with asthma exacerbations, as there is evidence that such care improves outcomes. This is one of the most important aspects of care in the ED that is too often overlooked in our busy EDs.

Discharge Criteria (note that ED PEF measurements have not been shown to improve outcomes when used alone, but can be considered to help with disposition decisions along with other criteria):

Discharge Medications

*Pitfall: Observational data shows clearly that ED physicians seldom prescribe inhaled corticosteroid at ED discharge. Inhaled steroids used as a controller therapy improve lung function and symptom control, reduce airway inflammation, the risk of exacerbation, the need for repeat ED visits, and the total exposure to systemic steroids. Steroid inhalers should routinely be prescribed even when oral steroids are also prescribed.

Inhaler Technique

Ensure patients have a spacer; have a team member, or you walk them through proper inhaler technique prior to discharge. Provide resources for patients to access if they need a refresher (video on correct MDI technique)

Return to Care Instructions

Patients should follow-up with their primary care team or respirologist within a few days after discharge for re-assessment following an asthma exacerbation. Patients should be advised to return to care urgently via EMS if they experience any of the following:

Identification of Triggers

Encourage patients to identify and avoid or mitigate possible triggers for their asthma (i.e. pets, allergens, exercise, medications, smoking/ irritants, or workplace exposures).

Asthma Action Plan

There is good evidence to suggest that asthma action plans improve patient outcomes, yet these are seldom provided to patients from the ED. Patients should routinely be encouraged to fill in an Asthma Action Plan (see below) which can help them to identify worsening symptoms, plan for up titrating home therapies as well as recognize when to come into hospital for further management.

Asthma Action Plan pdf: https://asthma.ca/wp-content/uploads/2020/06/Asthma-Action-Plan_optimized.pdf

By following this simple 5 step approach to asthma exacerbations in the ED outline here, being careful to consider the differential diagnosis and understand that “not all the wheezes is asthma and that asthma does not always wheeze”, taking a history that elicits risk factors for severe exacerbations requiring aggressive treatment, accurately categorizing patients based on physical exam findings, administering appropriate medications guided by these categories and ensuring adequate discharge instructions, education, prescriptions and follow up, you will very likely improve the outcomes of your patients who present to the ED with asthma exacerbations.

Go to part 2 of this 2-part podcast on adult asthma exacerbations

Cite this podcast as: Helman, A. Mal, S. Sommer, L. Episode 192 Asthma Management Strategies for Improved Prognosis – A Stepwise Approach. Emergency Medicine Cases. March, 2024. https://emergencymedicinecases.com/emergency-asthma-management-strategies. Accessed May 18, 2025

Go to part 2 of this 2-part podcast on adult asthma exacerbations

“Not all that wheezes is asthma, and asthma does not always present with a wheeze.”

While the diagnosis of asthma is often straightforward, especially in patients with a history of exacerbations and repeat ED visits, it is crucial to consider several other conditions in patients presenting to the ED with wheezing, including:

In cases where wheezing is absent, particularly in patients suspected of having an asthma exacerbation, be mindful that patients may exhibit a silent chest—a sign of a severe/life-threatening exacerbation where patients are unable to generate sufficient airflow to produce an audible wheeze.

Utilize adjuncts such as PoCUS and chest X-ray to help refine your differential diagnosis in conjunction with a thorough history and physical examination. Guard against diagnostic premature closure that might lead you to exclusively consider asthma upon hearing the term ‘wheeze’.

Effective risk stratification of patients presenting to the ED with asthma exacerbations, grounded in a comprehensive assessment of their medical history and physical examination findings, is pivotal in directing appropriate management and disposition decisions. Patients exhibiting a greater number of the following risk factors are at heightened risk for experiencing a severe exacerbation and having poor outcomes.

Most predictive variables on history:

Other risk factors to consider:

The efficacy of peak expiratory flow (PEF) monitoring in the ED for improving outcomes remains uncertain. While some guidelines advocate for incorporating PEF measurements, aiming for >60-80% of personal best (or predicted) in their discharge algorithms, the American College of Emergency Physicians (ACEP) conducted a comprehensive review of the literature and concluded that PEF monitoring in the ED does not improve outcomes, predict the need for hospitalization, or reduce mortality in adults with asthma exacerbations.

According to our experts, the decision to utilize PEF monitoring should be tailored to each patient and regarded as one factor among many in the clinical assessment to inform disposition decisions.

A brief overview of how to use a Peak Flow Meter and information on PEF use for at-home monitoring of asthma.

*While steroids onset of action is traditionally thought to be delayed there is evidence to suggest that when given within the first hour of presentation there are improved outcomes compared to after 1 hour. It has been proposed that steroids may have a synergistic effect with B-agonists and epinephrine which may explain why improved outcomes are seen when steroids are given early, despite the traditionally thinking that the onset is delayed by several hours.

*When ever possible, re-assess these patients frequently (q15-20 minutes) especially patients in whom you have concern for a severe exacerbation.

There has been a significant shift in clinical practice favoring the use of Metered-Dose Inhalers (MDIs) over nebulizers for ED asthma treatment, primarily driven by concerns around aerosolization during the COVID pandemic. More drug is delivered to the alveoli with MDIs compared to nebulizers. Moreover, the question of potential medication wastage into the environment when utilizing nebulizers as opposed to MDIs with a spacer device has also been raised.

An additional benefit to employing MDIs in the ED is that it provides an opportunity for patients to receive instruction on proper inhalation techniques, equipping them for successful self-management upon discharge. However, it is essential to recognize that MDIs may pose a higher labor burden on nursing staff or RTs if patients require assistance with administration. In scenarios where patients are too unwell to self-administer with an MDI, a nebulizer may offer a more practical and effective treatment option.

Adequate time should spent providing good discharge instruction and appropriate discharge medications to patients with asthma exacerbations, as there is evidence that such care improves outcomes. This is one of the most important aspects of care in the ED that is too often overlooked in our busy EDs.

Discharge Criteria (note that ED PEF measurements have not been shown to improve outcomes when used alone, but can be considered to help with disposition decisions along with other criteria):

Discharge Medications

*Pitfall: Observational data shows clearly that ED physicians seldom prescribe inhaled corticosteroid at ED discharge. Inhaled steroids used as a controller therapy improve lung function and symptom control, reduce airway inflammation, the risk of exacerbation, the need for repeat ED visits, and the total exposure to systemic steroids. Steroid inhalers should routinely be prescribed even when oral steroids are also prescribed.

Inhaler Technique

Ensure patients have a spacer; have a team member, or you walk them through proper inhaler technique prior to discharge. Provide resources for patients to access if they need a refresher (video on correct MDI technique)

Return to Care Instructions

Patients should follow-up with their primary care team or respirologist within a few days after discharge for re-assessment following an asthma exacerbation. Patients should be advised to return to care urgently via EMS if they experience any of the following:

Identification of Triggers

Encourage patients to identify and avoid or mitigate possible triggers for their asthma (i.e. pets, allergens, exercise, medications, smoking/ irritants, or workplace exposures).

Asthma Action Plan

There is good evidence to suggest that asthma action plans improve patient outcomes, yet these are seldom provided to patients from the ED. Patients should routinely be encouraged to fill in an Asthma Action Plan (see below) which can help them to identify worsening symptoms, plan for up titrating home therapies as well as recognize when to come into hospital for further management.

Asthma Action Plan pdf: https://asthma.ca/wp-content/uploads/2020/06/Asthma-Action-Plan_optimized.pdf

By following this simple 5 step approach to asthma exacerbations in the ED outline here, being careful to consider the differential diagnosis and understand that “not all the wheezes is asthma and that asthma does not always wheeze”, taking a history that elicits risk factors for severe exacerbations requiring aggressive treatment, accurately categorizing patients based on physical exam findings, administering appropriate medications guided by these categories and ensuring adequate discharge instructions, education, prescriptions and follow up, you will very likely improve the outcomes of your patients who present to the ED with asthma exacerbations.

Go to part 2 of this 2-part podcast on adult asthma exacerbations

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Reference: Muldowney et al. A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting. Ann Emerg Med. 2025

Date: April 24, 2025

Guest Skeptic: Dr. Howie Mell received his Medical Doctorate (MD) from the University of Illinois at Chicago, College of Medicine at Rockford. Prior to that, he received a Master of Public Health (MPH) degree emphasizing Environmental and Occupational Health from the University of Illinois at Chicago, School of Public Health, while serving as a firefighter/paramedic in the Chicago suburbs. He completed his residency in emergency medicine at the Mayo Graduate School of Medicine, Rochester, Minnesota. Dr. Mell is board-certified by the American Board of Emergency Medicine in both Emergency Medicine (EM) and Emergency Medical Services (EMS) Medicine. He is a Fellow of the American College of Emergency Physicians (FACEP). Dr. Mell serves as an Ambassador Emergency Physician for Vituity (formerly CEP-America), and he is currently assigned to Schneck Medical Center in Seymour, Indiana (John Cougar Mellencamp’s “Small Town”).

Case: You’re an experienced paramedic working a busy night shift in an urban EMS system. Dispatch sends you to a call for a 35-year-old male found acting erratically in a public park. Upon arrival, you find him disoriented, agitated, and combative. Bystanders report that he has been using methamphetamine and alcohol.

The patient is uncooperative, making verbal de-escalation ineffective. Physical restraint is needed for transport. Your EMS protocol allows for pharmacologic sedation with either midazolam (1 to 5 mg IV/IM, repeat every 2 to 5 minutes as needed) or ketamine (5 mg/kg IM, max 500 mg).

The patient is tachycardic (HR 122 bpm), hypertensive (BP 156/96 mmHg), and has a Glasgow Coma Scale (GCS) score of 12. You need to act quickly for scene safety and the patient’s well-being.

Background: Acutely agitated patients in the pre-hospital setting present a unique challenge for emergency medical services (EMS). Agitation can stem from various underlying conditions, including psychiatric disorders, substance intoxication, metabolic disturbances, traumatic brain injury, or postictal states​. If not managed appropriately, severe agitation can escalate, leading to self-harm, harm to others, or interference with necessary medical care.

Initial management emphasizes verbal de-escalation techniques, which should always be attempted first. However, when these strategies fail, pharmacologic sedation may be necessary to ensure the safety of both the patient and pre-hospital providers. The choice of sedative agent is a critical decision. The paramedic must balance the need for rapid sedation with the risk of adverse effects, including respiratory depression and cardiovascular instability​.

Benzodiazepines, such as midazolam, have historically been used for pre-hospital sedation due to their anxiolytic and muscle-relaxant properties. However, their use is associated with risks such as respiratory depression and paradoxical agitation. In recent years, ketamine has gained popularity due to its rapid onset, potent dissociative properties, and preservation of airway reflexes​. Despite its advantages, ketamine is not without concerns, including the potential for emergence reactions, increased blood pressure, and the need for airway management in some cases.

Current guidelines lack consensus on the optimal pharmacologic approach, leading to significant variation in practice across EMS systems. The ongoing debate surrounding the best sedation strategy highlights the need for robust clinical research to guide evidence-based practice. A newly published study aims to address this knowledge gap by comparing ketamine and midazolam in the out-of-hospital setting, shedding light on their relative efficacy and safety.

Reference: Muldowney et al. A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting. Ann Emerg Med. 2025

Authors’ Conclusions: “In this cohort study of patients with acute behavioral disturbance, emergent airway support and other outcomes did not differ following out-of-hospital treatment with midazolam or ketamine.”​

Quality Checklist for Observational Study:

Results: 376 patients with acute behavioural disturbances were included in the study. The median age was 35 years, 78% were male, and the most common cause of agitation was substance use (51%).

1) Retrospective Design: A major limitation of the retrospective study design is its reliance on existing records, which can introduce selection bias, information bias, and confounding. Unlike prospective studies, where variables can be controlled and standardized in real time, retrospective studies depend on previously collected data, which may be incomplete, inconsistent, or inaccurately documented. A prospective or randomized design would be stronger.

2) Selection Bias: This type of bias occurs when the study population is not representative of the broader patient population due to systematic differences in how participants are included or excluded. In this retrospective EMS study, selection bias could arise if certain patients with acute agitation were not documented or excluded due to incomplete records, leading to an overrepresentation of cases where sedation outcomes were more favourable or easier to track.

3) Information Bias. This occurs when inaccuracies in data collection, which can lead to systematic errors in measuring exposures or outcomes. In this retrospective EMS study, information bias could arise from inconsistent documentation of key variables, such as the exact dose and route of sedative administration, the severity of agitation, or the criteria used for initiating airway management. Suppose some EMS providers were more meticulous in documenting adverse events, while others underreported complications like transient hypoxia or delayed sedation onset. In that case, the study might underestimate or overestimate the true risks associated with ketamine or midazolam.

4) Confounders: This is a limitation of observational studies. Confounding variables are factors that are associated with both the intervention (midazolam vs ketamine) and the outcome (need for airway management), potentially distorting the true relationship between them. In this EMS study, patient characteristics such as underlying medical conditions (e.g., COPD, obesity, or intoxication level), severity of agitation, or additional sedative medications administered could have influenced airway management independently of whether ketamine or midazolam was used. If, for example, ketamine was more frequently given to severely agitated patients who were already at higher risk for airway compromise, this could make ketamine appear riskier than it is. Conversely, if midazolam was preferentially used in patients with known respiratory conditions, providers might have been more cautious, leading to fewer airway interventions. Without randomization or robust statistical adjustments, these confounders could obscure true differences between the medications and limit the study’s validity​.

5) Generalizability: The external validity of this study depends on how well its findings apply to other EMS systems, patient populations, and clinical settings. Since the study was conducted in an urban EMS system, its results may not translate directly to rural or suburban settings, where transport times, provider training, and access to advanced airway management differ.

Additionally, variability in EMS protocols, such as differences in sedation dosing, monitoring practices, or local guidelines, could limit the applicability of these findings to regions with different pre-hospital care standards. The patient population also plays a role—if the study included a higher proportion of substance-related agitation, the results may not fully reflect outcomes in psychiatric agitation or postictal states.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.

Case Resolution: You administer intramuscular ketamine, and the patient becomes much calmer. His vital signs are stable, maintains spontaneous respirations with no signs of airway compromise and is safely transported to the ED.

Clinical Application: Given the comparable safety profiles, your decision should weigh speed of onset, route of administration, and context (i.e. it all depends).

What Do I Tell the Patient? When we found you, you were very agitated and possibly at risk of hurting yourself or others. For your safety and ours, we had to give you medication to calm you down. We used a sedative that works quickly and is commonly used in emergencies like yours. Thankfully, you didn’t need a breathing tube, and everything went smoothly.

Keener Kontest: Last week’s winner was Dr. Steven Steltz from New Zealand. He knew the first computer that stored a program in its memory was the Manchester Baby, also known as the Small-Scale Experimental Machine (SSEM). It was developed at the University of Manchester in England and ran its first program on June 21, 1948.

Listen to the SGEM podcast for this week’s question. If you know, then send an email to [email protected] with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode.

Other FOAMed on Agitation:

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Reference: Leonard JC et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. June 2024.

Date: Oct 15, 2024

Dr. Tabitha Cheng

Guest Skeptic: Dr. Tabitha Cheng is a Southern California native and board-certified emergency medicine physician and completed an EMS fellowship as well. The learning didn’t end because she then completed another fellowship in pediatric emergency medicine at Harbor UCLA.

Case: An 8-year-old girl is brought in by EMS after a car accident. She was seat belted, sitting in the backseat of the family’s car when they were hit from the side by another vehicle that ran a red light. The airbags deployed, and the car spun a few times. When EMS arrived on the scene, they found both parents unconscious and the girl appeared slightly dazed and confused.

EMS places her in a cervical collar and brings her to the emergency department (ED). On your examination, you see she is scared but answering questions appropriately. She does have some abrasions from her seatbelt and complains of pain around her ankle. The rest of her exam is unremarkable.

After your evaluation, you are informed that her grandmother has arrived to be with the girl as her other family members are being treated. She looks at the contraption on the girl’s neck and asks you, “Is she okay? Is something wrong with her neck? Does she need an X-ray or CT scan?”

Background: Pediatric cervical spine (c-spine) injuries are uncommon (1-3% of blunt trauma). These injuries typically result from blunt trauma caused by motor vehicle accidents, falls, sports injuries, or physical abuse. Although C-spine injuries represent a small fraction of pediatric trauma cases, their potential severity makes accurate and timely diagnosis critical.

Younger kids tend to have big lollipop heads which makes them more prone to injury in the upper cervical spine compared to adults (their fulcrum is higher).

It is also sometimes difficult to get a scared child to give an accurate history or cooperate with an exam. Many of us use CT or X-rays to help detect cervical spine injuries in this population.

Clinicians working in EDs must strike a balance between ensuring they do not miss these rare but serious injuries and avoiding unnecessary imaging, particularly computed tomography (CT), which exposes children to ionizing radiation. Given the sensitivity of developing tissues to radiation, especially in younger children, avoiding unnecessary imaging is a high priority in pediatric care.

Traditional diagnostic approaches often lead to the overuse of imaging tools, like CT scans and X-rays, even in low-risk children. This has prompted a movement toward more refined, evidence-based methods for identifying pediatric C-spine injuries, particularly through the development of clinical decision rules (CDRs). CDRs are designed to assist clinicians in making more accurate decisions about when imaging is truly necessary by identifying key clinical predictors of serious injuries.

The Pediatric Emergency Care Applied Research Network (PECARN) has been instrumental in developing one of the most widely recognized CDRs for pediatric C-spine injuries. Based on large, multicenter studies, this tool identifies critical risk factors that signal the need for imaging, such as altered mental status, focal neurological deficits, and certain mechanisms of injury. The PECARN rule, validated in clinical settings, has demonstrated high sensitivity in detecting C-spine injuries, while also reducing unnecessary imaging.

There are multiple CDRs for identifying pediatric c-spine injuries besides PECARN. The SGEM recently covered the Cochrane systematic review on pediatric CDRs on SGEM #441.

Dr. Julie Leonard

Reference: Leonard JC et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. June 2024.

Guest Authors

Dr. Caleb Ward

Dr. Caleb Ward is a pediatric emergency medicine attending and Associate Professor of Pediatrics and Emergency Medicine at Children’s National Hospital and The George Washington School of Medicine and Health Sciences in Washington, DC. He is the principal investigator for EMSC State Partnership in Washington, DC and is also involved in various multi-center EMS studies with the Pediatric Emergency Care Applied Research Network (PECARN).

Dr. Julie Leonard is a pediatric emergency medicine attending and Associate Division Chief for Research at Nationwide Children’s Hospital. She’s also a Professor of Pediatrics at the Ohio State University College of Medicine. Dr. Leonard serves as the Principal I investigator of the Great Lakes Atlantic Emergency Medical Services for Children Research Node of PECARN.

Authors’ Conclusions: “Incorporated into a clinical algorithm ,the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the ED and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community EDs.”

Quality Checklist for Clinical Decision Tools:

Results: The cohort consisted of 22,430 children. To put this into perspective, the Cochrane review that we critically appraised included 5 studies and only had 21,379 children. There were 11,857 included in the derivation cohort and 10,573 included in the validation cohort. Around 2% had confirmed cervical spine injuries.

The new prediction rule had a 94.3% sensitivity, 60.4% specificity, 99.9% negative predictive value, and 0.09 negative likelihood ratio.

Tune in to the podcast to hear the authors answer our questions.

Follow Up

Some of the children in this study did not undergo any imaging. You report that in these cases, the guardians were contacted by phone to see whether they had a C-spine injury. This could lead to verification bias where not all patients received the gold standard imaging, potentially affecting specificity​​.

What proportion of children did not have imaging? Out of the ones you had to contact for phone follow-up, what percent were lost to follow-up? How do you think this may impact your results?

Who Completes the Clinical Decision Rule

This study was performed at academic centers with a mix of pediatric emergency medicine, trauma surgery, and prehospital teams. You report that you looked back at the children with c-spine injuries that were missed by the prediction rule and noted that there was a risk factor recorded in the medical record or case report form which would have improved the test characteristics of the rule.

Could you comment on the interrater reliability of people completing the clinical decision rule? Ideally, who do you think should be the one completing it (EMS, EM, surgery, or a mix)?

Moderate Risk Patients

In the moderate risk criteria, the CDR recommends an X-ray.

What kind of X-ray should be gotten? Lateral neck, 2 view, 3 view, any of the above with flexion and extension?

Assuming that the X-ray ends up being normal, but the child is having persistent neck pain, what would you do?

Prehospital Application

This CDR was designed for implementation in the ED.

Do you think there’s a potential application of risk stratification for the prehospital environment? 

Child Abuse

The study included 1,327 (5.9%) children with the mechanism of injury as “suspected child abuse.” You performed a separate analysis after these patients were removed that showed similar test characteristics.

Can you comment on the application of this CDR specifically in this vulnerable population?

Bonus Question: Implementation

The study found that had the prediction rule been in place, the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%).

A limitation of this study was that it was conducted at academic children’s hospitals.

Do you think you would see the same impact when implemented more generally?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion.

Case Resolution: After you assess the child, you do not note anything remarkable in her primary survey. Her secondary survey is only notable for a small abrasion on her forehead and shoulder. You ask someone to hold her head still as you prepare to examine her neck. You tell her very clearly, “I am going to ask you if you are having any pain around the area that I am touching. Do not nod or shake your head. Just answer yes and no.” After noting that she does not have any tenderness to palpation of her neck and testing the range of motion of her neck, you clinically clear her C-collar and avoid additional imaging.

 Clinically Application: The new PECARN CDR for cervical spine trauma in children can help guide imaging decisions. Remember, we refer to these as clinical decision “tools” rather than rules. Considering all three pillars of evidence-based medicine, the scientific literature, clinical judgement, and patient/family values and preferences.

What Do I Tell the Patient’s Grandmother?

 I understand that you are worried about your granddaughter. We examined her closely. She is acting appropriately and answering questions. She is not having any pain when she moves her neck or when we touch her neck. We try to balance the possible harms and benefits when thinking about whether we need to do X-rays or CT scans on children because we want to minimize radiation exposure. Based on her reassuring exam, I have low suspicion that she has a serious injury to her neck.

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