Case Presentation - האיגוד הישראלי לרפואה דחופה

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.

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

FacebookXLinkedInInstagramEmail

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.

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.

The post PODCAST: Send me on my way…without Cervical Spine Imaging first appeared on האיגוד הישראלי לרפואה דחופה.

0:00 – Introduction

0:41 – Overview

1:10 – Types of Necrotizing Fasciitis

2:21 – Pathophysiology & Risk Factors

3:16 – Clinical Presentation

4:06 – Diagnosis

5:37 – Treatment

7:09 – Prognosis and Recovery

7:37 – Take Home points

Early Signs & Symptoms

Late-Stage Signs

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

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the December 2024 Emergency Medicine Practice article, Diagnosis and Management of Acute Mesenteric Ischemia in the Emergency Department

Emergency Medicine Residents, get your free subscription by writing [email protected]

Sam Ashoo, MD, FACEP,  is board certified in emergency medicine and clinical informatics. He serves as EB Medicine’s editor-in-chief of interactive clinical pathways and FOAMEd blog, and host of EB Medicine’s EMplify podcast. Follow him below for more…

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

Reference: Sanchez-Pinto, L.N., et al. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024​​.

Guest Skeptic: Prof. Damian Roland is a Consultant at the University of Leicester NHS Trust and Honorary Professor for the University of Leicester’s SAPPHIRE group. He specializes in Paediatric Emergency Medicine and is a passionate believer and advocate of FOAMed. Damian is also part of the Don’t Forget the Bubbles Team.

Dr. Damian Roland

Case: A 3-year-old boy arrives at the emergency department (ED) with a high fever, rapid breathing, and lethargy. His parents state that he has had a fever and cough for the past three days. He tested positive for influenza two days ago but seems to be getting worse. On exam, he has crackles in his right lung field. His pulse oximeter reads 88% on room air. His heart rate is elevated. He looks sleepy but is clinging to his parents. A medical trainee you are working with asks, “He looks really sick. Is this pneumonia or could this be sepsis?”

Background: Pediatric sepsis is a major global health concern, causing an estimated 3.3 million deaths annually. The 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria were established based on expert consensus and used for diagnosis. However, they’ve been criticized for low specificity and not being adaptable across different resource settings​​.

The SGEM has covered sepsis multiple times:

Today we’re covering the newest criteria, the Phoenix Criteria, for the diagnosis of pediatric sepsis and septic shock. It is more evidence-based and incorporates data from high and low-resource settings.

Reference: Sanchez-Pinto, L.N., et al. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024​​.

Dr. Elizabeth Alpern

Guest Authors: Dr. Elizabeth Alpern is a Professor of Emergency Medicine and Chief of Emergency Medicine at Lurie Children’s Hospital of Chicago and Vice Chair of Pediatrics at Northwestern University Feinberg School of Medicine. She’s also a clinical epidemiologist and expert in large databases including the PECARN registry.

Dr. Halden Scott is an Associate Professor of Pediatrics at the University of Colorado School of Medicine and an attending physician at Children’s Hospital Colorado

where she also serves as Director of Research. Her research interest includes the diagnosis and treatment of sepsis across the emergency care continuum.

Authors’ Conclusions: “The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.”

Quality Checklist for Clinical Decision Tools:

Results: They collected data from over three million emergency departments, inpatient, and intensive care unit encounters from ten health systems in the United States, Colombia, Bangladesh, China, and Kenya.

Dr. Halden Scott

Five sites in the United States (higher-resource settings) and two sites in Bangladesh and Colombia (low-resource settings) were included in the derivation.

One site from the United States, China, and Kenya were included in the validation.

There are four main systems included in the Phoenix Sepsis Score: respiratory, cardiovascular, coagulation, and neurologic. They recommended that sepsis should be considered for any child with suspected infection and score of at least 2 points.

“Septic shock” was identified by at least 1 point in the cardiovascular component.

Children with suspected infection in the first 24 hours of presentation had in-hospital mortality of 0.7% in higher-resource settings and 3.6% in lower-resource settings.

Children with sepsis had a mortality of 7.1% in higher resource settings and 28.5% in lower resource settings.

Children with septic shock had a mortality of 10.8% in higher resource settings and 33.5% in lower resource settings.

The Phoenix score had a higher positive predictive value (PPV) and higher or comparable sensitivity for in-hospital mortality and early death or ECMO compared to the IPSCC definition.

Tune into the podcast to hear the authors’ responses to our questions.

Scoring Tool Development

 This was a huge effort amongst a multidisciplinary group. The team reviewed many organ dysfunction scoring systems. They were run through multiple models (stacked regression, LASSO, logistic regression). The team voted through a modified Delphi process on thresholds for the score.

With such a large team and so many processes, were there any big areas of agreement or disagreement?

Chosen Criteria

The final Phoenix score focuses on four organ systems: respiratory, cardiovascular, coagulation, and neurologic. Some criteria are lab criteria which certain centers may not have or may not be able to get results in a timely fashion. We’re probably not calculating PaO2/SpO2: FiO2 ratios in the emergency department. Data on the use of lactate seems mixed. Inter-rater reliability of GCS scores can be quite variable.

How did you choose which components under each organ system to include? Some may also argue that the thresholds for lactate or GCS are also pretty lenient.

“Suspected Infection”

The inclusion of patients based on “suspicion” of sepsis might lead to selection bias, affecting generalizability.

“Suspected infection” was defined as the receipt of systemic antimicrobials or antimicrobial testing. This still creates quite a degree of subjectivity and possible variation amongst providers. Any tips about dealing with this?

Generalizability

This study used data from many institutions across the world. They had an international sample that included both high and low-resource settings. They also included children with complex healthcare needs. All of these things make the results more generalizable.

There was some missing data from one of the lower-resourced sites, and the higher-resourced sites were all tertiary children’s hospitals. When you undertake the next iteration of this project, are there plans to recruit from an even wider array of sites including more community hospitals in higher-resourced settings?

NOT a Screening Tool

An accompanying paper states:

“The Phoenix criteria for sepsis and septic shock were intended to identify life-threatening organ dysfunction due to infection in children. They were NOT designed for screening children at risk for developing sepsis or early identification of children with suspected sepsis.”

Set the record straight for us:

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

Case Resolution: You tell the trainee that the patient looks very ill. You suspect the possibility of a superimposed bacterial pneumonia in the setting of influenza, but his sleepiness is concerning for possible sepsis. He is initially placed on BiPAP and receives empiric antibiotics, but his mental status continues to decline. He is intubated and transferred to the intensive care unit for further care.

Clinical Application:

Tune in to hear how the Phoenix criteria can be applied in the emergency department setting.

What Do I Tell My Student: This patient looks very sick. It may be pneumonia, but his ill-appearance and sleepiness make me concerned that he may also be septic. There are new criteria for sepsis and septic shock in children based on the Phoenix Sepsis Score, but it should not be used for screening. He is sick enough that we should be aggressive and treat him for presumed sepsis.

Reference: Sanchez-Pinto, L.N., et al. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024​​.

Guest Skeptic: Prof. Damian Roland is a Consultant at the University of Leicester NHS Trust and Honorary Professor for the University of Leicester’s SAPPHIRE group. He specializes in Paediatric Emergency Medicine and is a passionate believer and advocate of FOAMed. Damian is also part of the Don’t Forget the Bubbles Team.

Dr. Damian Roland

Case: A 3-year-old boy arrives at the emergency department (ED) with a high fever, rapid breathing, and lethargy. His parents state that he has had a fever and cough for the past three days. He tested positive for influenza two days ago but seems to be getting worse. On exam, he has crackles in his right lung field. His pulse oximeter reads 88% on room air. His heart rate is elevated. He looks sleepy but is clinging to his parents. A medical trainee you are working with asks, “He looks really sick. Is this pneumonia or could this be sepsis?”

Background: Pediatric sepsis is a major global health concern, causing an estimated 3.3 million deaths annually. The 2005 International Pediatric Sepsis Consensus Conference (IPSCC) criteria were established based on expert consensus and used for diagnosis. However, they’ve been criticized for low specificity and not being adaptable across different resource settings​​.

The SGEM has covered sepsis multiple times:

Today we’re covering the newest criteria, the Phoenix Criteria, for the diagnosis of pediatric sepsis and septic shock. It is more evidence-based and incorporates data from high and low-resource settings.

Reference: Sanchez-Pinto, L.N., et al. Development and Validation of the Phoenix Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024​​.

Dr. Elizabeth Alpern

Guest Authors: Dr. Elizabeth Alpern is a Professor of Emergency Medicine and Chief of Emergency Medicine at Lurie Children’s Hospital of Chicago and Vice Chair of Pediatrics at Northwestern University Feinberg School of Medicine. She’s also a clinical epidemiologist and expert in large databases including the PECARN registry.

Dr. Halden Scott is an Associate Professor of Pediatrics at the University of Colorado School of Medicine and an attending physician at Children’s Hospital Colorado

where she also serves as Director of Research. Her research interest includes the diagnosis and treatment of sepsis across the emergency care continuum.

Authors’ Conclusions: “The novel Phoenix sepsis criteria, which were derived and validated using data from higher- and lower-resource settings, had improved performance for the diagnosis of pediatric sepsis and septic shock compared with the existing IPSCC criteria.”

Quality Checklist for Clinical Decision Tools:

Results: They collected data from over three million emergency departments, inpatient, and intensive care unit encounters from ten health systems in the United States, Colombia, Bangladesh, China, and Kenya.

Dr. Halden Scott

Five sites in the United States (higher-resource settings) and two sites in Bangladesh and Colombia (low-resource settings) were included in the derivation.

One site from the United States, China, and Kenya were included in the validation.

There are four main systems included in the Phoenix Sepsis Score: respiratory, cardiovascular, coagulation, and neurologic. They recommended that sepsis should be considered for any child with suspected infection and score of at least 2 points.

“Septic shock” was identified by at least 1 point in the cardiovascular component.

Children with suspected infection in the first 24 hours of presentation had in-hospital mortality of 0.7% in higher-resource settings and 3.6% in lower-resource settings.

Children with sepsis had a mortality of 7.1% in higher resource settings and 28.5% in lower resource settings.

Children with septic shock had a mortality of 10.8% in higher resource settings and 33.5% in lower resource settings.

The Phoenix score had a higher positive predictive value (PPV) and higher or comparable sensitivity for in-hospital mortality and early death or ECMO compared to the IPSCC definition.

Tune into the podcast to hear the authors’ responses to our questions.

Scoring Tool Development

 This was a huge effort amongst a multidisciplinary group. The team reviewed many organ dysfunction scoring systems. They were run through multiple models (stacked regression, LASSO, logistic regression). The team voted through a modified Delphi process on thresholds for the score.

With such a large team and so many processes, were there any big areas of agreement or disagreement?

Chosen Criteria

The final Phoenix score focuses on four organ systems: respiratory, cardiovascular, coagulation, and neurologic. Some criteria are lab criteria which certain centers may not have or may not be able to get results in a timely fashion. We’re probably not calculating PaO2/SpO2: FiO2 ratios in the emergency department. Data on the use of lactate seems mixed. Inter-rater reliability of GCS scores can be quite variable.

How did you choose which components under each organ system to include? Some may also argue that the thresholds for lactate or GCS are also pretty lenient.

“Suspected Infection”

The inclusion of patients based on “suspicion” of sepsis might lead to selection bias, affecting generalizability.

“Suspected infection” was defined as the receipt of systemic antimicrobials or antimicrobial testing. This still creates quite a degree of subjectivity and possible variation amongst providers. Any tips about dealing with this?

Generalizability

This study used data from many institutions across the world. They had an international sample that included both high and low-resource settings. They also included children with complex healthcare needs. All of these things make the results more generalizable.

There was some missing data from one of the lower-resourced sites, and the higher-resourced sites were all tertiary children’s hospitals. When you undertake the next iteration of this project, are there plans to recruit from an even wider array of sites including more community hospitals in higher-resourced settings?

NOT a Screening Tool

An accompanying paper states:

“The Phoenix criteria for sepsis and septic shock were intended to identify life-threatening organ dysfunction due to infection in children. They were NOT designed for screening children at risk for developing sepsis or early identification of children with suspected sepsis.”

Set the record straight for us:

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

Case Resolution: You tell the trainee that the patient looks very ill. You suspect the possibility of a superimposed bacterial pneumonia in the setting of influenza, but his sleepiness is concerning for possible sepsis. He is initially placed on BiPAP and receives empiric antibiotics, but his mental status continues to decline. He is intubated and transferred to the intensive care unit for further care.

Clinical Application:

Tune in to hear how the Phoenix criteria can be applied in the emergency department setting.

What Do I Tell My Student: This patient looks very sick. It may be pneumonia, but his ill-appearance and sleepiness make me concerned that he may also be septic. There are new criteria for sepsis and septic shock in children based on the Phoenix Sepsis Score, but it should not be used for screening. He is sick enough that we should be aggressive and treat him for presumed sepsis.

The post PODCAST: Criteria for Sepsis first appeared on האיגוד הישראלי לרפואה דחופה.

You are working at Clerkship General when you hear an EMS call on the base command radio. “Clerkship General. We are bringing you a minimally responsive 79 year-old female found lying on the floor inside her apartment. ETA 5 minutes”

Initial Vitals:

HR: 143

BP: 160/105

Temp: 106.3F

RR: 22

O2: 99% Room Air

Critical Actions:

Initial Vitals:

HR: 143

BP: 160/105

Temp: 106.3F

RR: 22

O2: 99% Room Air

Critical Actions:

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

Reference: Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. February 2023

Date: January 24, 2024

Guest Skeptic: Dr. Rupinder Sahsi is a fellow EBM enthusiast with academic appointments at McMaster University and Wright State University who works as an emergency physician in Kitchener-Waterloo, Ontario, Canada. He is also an assistant medical director for EMS at the Centre for Paramedic Education and Research in Hamilton, Ontario, Canada.

Case: You are an advanced care paramedic dispatched to the scene of a 53-year-old female with chest pain. She developed retrosternal chest discomfort shortly after she came in from using her snowblower. You provide her with two tablets of ASA to chew while your partner acquires an ECG, which ultimately shows clear ST elevation in the inferior leads and some ST changes in V1-V2 that make you wonder if your patient is having an acute myocardial infarction (MI) with right-sided ventricular involvement (RVI). Your patient rates their pain as an 8/10 and looks visibly uncomfortable. Do you give nitroglycerin?

Background: You have likely heard the caution to avoid nitrates in acute myocardial infarctions that have right ventricular involvement. What is that based upon? As is often the case, when you go back to the primary literature, you discover we are standing on pillars of salt and sand. The evidence for this recommendation is a single observational study of 40 patients published in 1989 [1].

Yet, the findings in those 40 patients went on to be the evidence commonly cited by the American Heart Association (AHA) [2] and the European Society of Cardiology (ESC) [3] in their recommendation against the use of nitrates in acute MIs if there is right ventricular involvement.

The pathophysiologic rationale was that nitrates would cause vasodilation and thus reduce RV preload, decreasing left end diastolic volume, and ultimately resulting in clinically important hypotension. Many times, pathophysiology has been used to explain something in medicine only to be discovered later that the body is much more complicated than we thought.

That 40-patient study by Ferguson et al did show a statistically significant increased likelihood of hypotension in RVMI patients who received nitrates, but to me, the study design was just plain weird.

I was not surprised by this information. Fanaroff et al looked at the ACC/AHA guidelines from 2008-2018 [4]. They found 26 guidelines with 2,930 recommendations. Only 9% were Level A while 50% were Level B and 41% were Level C.

Compare that previously mentioned 40-patient study to the 2016 Canadian study by Robichaud et al which was 22 times larger (n=1,004) than the Ferguson study [5]. It looked at the administration of a standardized amount of nitroglycerin in MI patients with various vascular territories involved. It shows no statistical difference in adverse events between patients with and without RVMI – a relative risk of 1.02 (95% CI: 0.49 to 2.15) p-value = 0.95.

Reference: Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. February 2023.

Authors’ Conclusions: “This review suggests that the [American Heart Association] and [European Society of Cardiology] contraindications [stating that nitrates are contraindicated in RV MI] are not supported by evidence. Key limitations include all studies having concomitant inferior and RVMI, no evaluation of beneficial effects in any of the studies, and very low certainty of evidence. As adverse events such as hypotension are transient and easily managed, nitrates are a reasonable treatment modality to consider during RVMI on current evidence.”

Quality Checklist for Therapeutic Systematic Reviews:

Results: Their search produced five studies that met the inclusion criteria. Only two of the studies used nitroglycerin 400 μg sublingual as their treatment and could be meta-analyzed. One was a small study of 46 patients done in the UK with 19 RVMI [6]. The other was a larger Canadian study of 1,004 patients yet it only contained 86 patients with RVMI in the cohort [5].

1. Pathophysiology: When we get our medical education, we’re expected to consolidate large amounts of information in a very short amount of time. Naturally, that deprives us of the opportunity to critically examine every single assumption we’re given. Such is the case for this dogmatic admonition against nitrate administration in patients who might be experiencing a right ventricular MI. I remember getting that drilled into my head in residency. There’s this fear that nitrates will decrease their preload to an already impaired right ventricle, which goes on to reduce the patient’s LV end-diastolic volume, which itself leads to hypotension and malperfusion.

Sometimes this warning gets extended to patients who show signs of inferior ischemia on a 12-lead ECG because that /might/ involve the RV (which is where posterior leads would be nice). So, paramedics and emergency physicians see inferior ST ischemia on an ECG and get unnecessarily freaked out about giving nitrates.

Just because something makes pathophysiologic sense does not mean it always turns out to be true when tested.

2. Pillars of Salt and Sand: The SRMA authors point out that the “don’t give nitrates in RVMI patients” recommendation seems to stem from a study of 40 patients by Ferguson et al in 1989 [1]. It took a retrospective look at 20 patients with inferior MI and hypotension after getting nitrates, and 20 patients with inferior MI who weren’t hypotensive after receiving nitrate therapy. 15/20 patients in the first (hypotension) group had electrocardiographic evidence of RV involvement. Only 2/20 patients in the non-hypotension group had electrocardiographic evidence of RV involvement. As is often the case, when you go back to the primary literature that informs guideline recommendations you discover it’s not high-level evidence.

3. Best Paper: Of the papers included in the systematic review, arguably the most compelling is the larger one from Robichaud et al (n=1,004) [5]. It looked specifically at the administration of 400ug of sublingual nitroglycerin in MI patients who were categorized as inferior MI, inferior + RVMI, inferior + other, and MI’s involving only non-inferior/RVMI territories. What it showed was that there was no increased risk to any of those subgroups when given nitrates. Oddly enough, nitrate administration appeared to be safest in patients experiencing an isolated inferior MI.

When the Robichaud et al data was analyzed to look specifically at RVMI vs non-RVMI, the relative risk was 1.02 (not statistically different). Furthermore, the discussion in the SRMA points out that the definition of hypotension – a systolic BP of < 90 – doesn’t consider that the hypotension is often transient and easily managed, and as such unlikely to be clinically meaningful in the first place.

4. The Other Paper: McConnell et al 2017 is the other study meta-analyzed in this systematic review [6]. When I went to look it up, I discovered it was an abstract presented at a conference. The SRMA authors were able to contact the study team, get the original study data, and incorporate that into their meta-analysis.

I’m not entirely sure why the McConnell paper weighed so heavily in the final analysis when it had such a small sample size (n=46). It’s a function of weighted relative risk calculation in a random effects model. I give more psychological weight to the Robichaud paper, but McConnell’s findings are congruent.

5. Benefits: None of the studies included in the SRMA looked at the benefits of nitrate administration (analgesia and reduced sympathetic activation) balanced against the risks of transient hypotension. That is only looking at one side of the coin. We know that any intervention will have potential benefits and potential harms. It’s difficult to know the clinical impact when only considering one aspect of a treatment. We do know that nitrate administration doesn’t appreciably affect morbidity/mortality in acute MI, but its provision still has some potential benefits worth considering.

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

Case Resolution: The patient is clearly in discomfort, and nitroglycerin may help to ease their symptoms. Though you recognize the historical call for caution when administering nitrates to a patient with suspected RVMI, the best evidence says that doing so is no more dangerous than giving it to any other MI patient. Hypotension is a possibility regardless of the cardiac territory involved, though usually transient and easily managed, so you make sure to start an IV line before giving that first dose.

Dr. Rupinder Sahsi

Clinical Application: The overall level of evidence as assessed by GRADE criteria is very low. The authors recommend that the AHA and European guidelines be revised from contraindicating nitrates in RVMI to permitting them with a more appropriate degree of caution. We echo that position as a reasonable step in the right direction.

What Do I Tell My Patient? This nitroglycerin spray might help to ease some of your chest discomfort, but there’s always the risk that it could drop your blood pressure too. We’ll watch your vital signs on the monitor, and we have this IV set up in case your blood pressure drops too low.

I would also tell my EMS partner if their BP pressure drops do what Bobby McFerrin says, “it will soon pass, whatever it is. Don’t worry…be happy” 

Keener Kontest: Last week’s winner was….no winner. The question was, who first described using a mechanical device to provide artificial ventilation to a human? The answer from Dr. Chris Root was Alexander Monro of Scotland who recommended fitting a wooden pipe to the nostril of the patient and blowing into it with a pair of bellows.

Listen to the SGEM podcast to hear this week’s keener question. The first correct answer will receive a cool skeptical prize.

References:

The post PODCAAST: Don’t Worry, Be Happy – The Safety of Nitroglycerin Administration in RVMI first appeared on האיגוד הישראלי לרפואה דחופה.