Face mask ventilation is one of those skills that can easily be overlooked. It's often seen as the simple bit of airway management — something that sits below the glamour of videolaryngoscopy, fibre-optics and endotracheal intubation. But the reality is that excellent face mask ventilation is one of the most important airway skills we have.

In this episode, we take a deep dive into bag-valve-mask ventilation and airway adjuncts, exploring why this is far more than just putting a mask on a face and squeezing a bag. We discuss when facemask ventilation is indicated, how to identify patients who may be difficult to ventilate, and the practical steps that can dramatically improve success rates.

We cover positioning, airway opening manoeuvres, mask seal techniques, the role of airway adjuncts and how to recognise whether your ventilations are actually working. We also look at troubleshooting common problems, the evidence comparing bag-mask ventilation with supraglottic airways and endotracheal intubation, and how to decide when it's time to move to another airway strategy.

Whether you're working in the emergency department, prehospital environment or critical care, this episode is packed with practical tips, cognitive aids and evidence-based advice to help you deliver facemask ventilation with confidence and excellence.

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon. Rob & James

The post PODCAST: Face mask ventilation is one of those skills that can easily be overlooked. first appeared on האיגוד הישראלי לרפואה דחופה.

Japanese Airway Study: Kubo A, Kunitatsu K, Nakashima T, Horitani R, Kajimoto Y, Inoue S, Hironishi M. Association between endotracheal intubation and outcomes of nonshockable out-of-hospital cardiac arrest in Japan. BMC Emerg Med. 2025 Sep 24;25(1):185. doi: 10.1186/s12873-025-01341-6. PMID: 40993541; PMCID: PMC12462024.

The post PODCAST: Association between endotracheal intubation and outcomes of nonshockable out-of-hospital cardiac arrest in Japan first appeared on האיגוד הישראלי לרפואה דחופה.

Reference: . Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child & Adolescent Health. July 2025

Dr. Kammeron Brissett

Guest Skeptic: Dr. Kammeron Brissett is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. She completed her pediatrics residency and a chief year at Rainbow Babies and Children’s Hospital in Cleveland, Ohio. Her interests include injury prevention, social determinants of health, and advocacy.

Case: A 7-year-old boy with a peanut allergy presents to the emergency department (ED) after eating a cookie at a birthday party. Shortly afterwards, he developed hives and wheezing. His parents gave him an epinephrine auto-injector to improve his symptoms. In the ED, he feels much better. His vital signs are normal, and his lungs are clear. He has no other gastrointestinal or cardiovascular symptoms. The parents tell you, “Unfortunately, we’ve been through this before. It’s not the first time he has accidentally eaten something that may have had some peanuts in it. Last time, we sat in the ED for a few hours before going home. It’s been a long day. Can we just go home now?”

Background:  Anaphylaxis is a serious, potentially life-threatening systemic allergic reaction with a fast onset. It is a clinical diagnosis that should be considered when:

Early recognition and treatment with intramuscular epinephrine is crucial.

Sometimes, even after initial symptom improvement with IM epinephrine, anaphylaxis symptoms can recur even without exposure to the known trigger. This is called a biphasic reaction and can happen up to 72 hours later.

The SGEM discussed anaphylaxis and biphasic reactions 13 years ago on SGEM#57. The bottom line was that prolonged observation is likely unnecessary in patients whose symptoms resolve with therapy in the ED. Biphasic reactions are rare and can occur anywhere from 10 minutes up to 6 days. We already have problems with boarding and overcrowding. We can’t keep all patients with anaphylaxis for 6 days. So, when can we send them home?

Traditionally, ED observation after anaphylaxis has been around 4 to 6 hours to monitor for biphasic reactions. The Resuscitation Council UK recommends a risk-stratified approach: A patient can be discharged after 2 hours when there’s a good response to a single dose of epinephrine, the symptoms have resolved, the child and family has another epinephrine autoinjector and knows how to use it, and has adequate supervision after discharge. They recommend at least 6 hours of observation if two IM doses of epinephrine were needed or there was a prior biphasic reaction. Finally, they recommend at least 12 hours observation if there was severe respiratory compromise, >2 doses of epinephrine, ongoing allergen absorption, late-night presentation/limited access to care, or difficult access to emergency services.

The National Institute for Care and Health Excellence (NICE) is even a bit more conservative, recommending any child under age of 16 with suspected anaphylaxis be admitted. What about in the US?

In the United States, the 2023 AAAAI/ACAAI Joint Task Force Practice Parameter (JTFPP) emphasizes individualized, risk-based observation and shared decision-making, noting that risk for biphasic reactions is higher with more severe initial reactions and when >1 dose of epinephrine is required. It also highlights that patients with a prompt, complete, and durable response to epinephrine may not always require activation of EMS or prolonged monitoring, underscoring tailored disposition planning.

Reference: . Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child & Adolescent Health. July 2025

Authors’ Conclusions: “A 2-h observation period is probably safe for most children who present to an emergency department with an acute allergic reaction requiring epinephrine. A 4-h observation period might be enough for patients with cardiovascular involvement who appear well.”

 Quality Checklist for Observational Study:

Results: They included 5,641 eligible children with a median age of 7.9 years, with slightly more males (56%). 4956 (88%) fulfilled the National Institute of Allergy and Infectious Diseases and Food Allergy and Anaphylaxis Network criteria for anaphylaxis.

In that group, 1.5% met criteria for biphasic anaphylaxis and 10.7% had persistent anaphylaxis.

4.7% received repeat epi after 2 hours from initial dose. 1.9% received repeat epi dose after 4 hours.

Patients with cardiovascular involvement had higher rates of biphasic anaphylaxis.

Among all patients, 5% received a repeat dose of epinephrine after 115 minutes. There were differences in patients with or without respiratory or cardiovascular involvement.

Primary Outcome: In the entire cohort, 4.7% received epi 2 hours after the initial dose, 1.9% received epi after 4 hours, 1.1% received epi after 6 hours, and 0.8% received epi after 8 hours. 

Secondary Outcomes: 

Diagnosis of Anaphylaxis

 We mentioned that anaphylaxis is a clinical diagnosis, but it’s not always clear-cut. In this retrospective review, the authors used ICD-10 codes and chart reviews to determine whether patients experienced anaphylaxis. They included patients who were treated with intramuscular, subcutaneous, or intravenous epinephrine. Potential biases include selection bias, information bias, and misclassification bias.

Not all the patients included in this study actually met criteria for anaphylaxis, which is acknowledged by the authors. Anaphylaxis Practice Guideline update in 2023 states, “treatment with epinephrine or clinical response to epinephrine should also not be used as a surrogate marker to establish a diagnosis of anaphylaxis because there are many cases in which patients receive epinephrine for milder reactions.” Some of these patients were included because authors reported that “the administration of epinephrine might have mitigated reaction progression.”

Appendix Table 3, which examines interrater reliability for agreement on anaphylaxis identification, reports kappa values ranging from 0.68 to 0.76, indicating substantial agreement but not perfect agreement.

Repeat Epinephrine

 The primary outcome for this study was the time from first to last administration of epinephrine. We must be careful and state that this is not the equivalent of a biphasic reaction.

The decision to administer a repeat dose of epinephrine is also not always clear-cut. It is pragmatic. The clinician may have decided to administer another dose of epinephrine despite the patient not meeting the exact definition of anaphylaxis or a biphasic reaction. Epinephrine may have been administered because the child exhibited concerning signs or symptoms.

For example, if a child was being observed in the ED after experiencing anaphylaxis and receiving that first dose of epi started saying that his throat was feeling weird again, we wouldn’t fault the clinician for choosing to give a second dose of epinephrine, but we just wouldn’t know if the child really needed it.

Confounding

 Any observational study is at risk of confounding. One example we can see is if we look at Figure 3, it appears that the pre-emergency administration of epinephrine is a factor that increases the odds of repeat administration of epinephrine.

This is somewhat counterintuitive, as early recognition of anaphylaxis and administration of epinephrine should be beneficial. Instead, this may indicate disease severity. Sicker children received epinephrine in the pre-emergency setting.

We can also see something similar with steroid use in the emergency department associated with an increased odds of repeat epinephrine. I do not routinely give corticosteroids for anaphylaxis, given that the likelihood of benefit is low or uncertain. In this study, it may be more indicative of a patient who had a more severe reaction.

 Risk of Repeat Epinephrine

 The study team a priori defined the observation threshold at which the cumulative incidence of repeat epinephrine dosing increased by < 2% with each 1-hour increase in observation time. It’s not clear where this 2% came from.

The paper reports that this “was deemed clinically acceptable because it represented the optimal balance between prolonged observation with limited benefit and the likelihood of biphasic reaction occurring after discharge.”

Who decided this? Was it the authors? Was there any input from patients and families? Ultimately, individual clinicians and patients/families may have differing risk thresholds.

Bounce Backs for Biphasic Anaphylaxis

 Assuming a patient who is discharged from the ED for anaphylaxis with an epinephrine autoinjector returns after a biphasic reaction. Is that necessarily a failure, or should it reflect negatively on the discharging clinician?

A significant part of our work in the ED is to provide anticipatory guidance and discuss signs and symptoms that would prompt the patient to return to the ED for care. It can be argued that a patient returning to the ED after discharge for a biphasic anaphylactic reaction who self-administered an epinephrine autoinjector is a good thing. This indicates that our anticipatory guidance was effective and well delivered.

Comment on the Authors’ Conclusion Compared to the SGEM’s Conclusion: In general, we agree that most pediatric patients likely do not require prolonged observation in the ED after being treated for anaphylaxis. However, the risk tolerance for a biphasic reaction may vary among patients, families, and clinicians.

Case Resolution: The 7-year-old boy improved rapidly after a single dose of IM epinephrine. During his time in the ED, he has no difficulty breathing or changes in hemodynamics. After discussion with the family, you recognize that they are familiar with signs and symptoms of anaphylaxis and know how to administer IM epinephrine auto-injector. You also confirm that the family has another epinephrine auto-injector at home and send them with a prescription for two new auto-injectors. Afterwards, you send them home.

Clinical Application: There is limited high-quality evidence on observation times for anaphylaxis. Specifically, there is no evidence that any particular observation period is superior, as biphasic reactions may occur up to 72 hours after the initial event. Institutional guidelines may vary. Remember the pillars of evidence-based medicine. Consider your clinical judgement and the patient or family’s values and preferences. Prior to discharge, ensure the patient feels better, that families and patients are aware of the signs and symptoms of anaphylaxis and biphasic reactions, and that they have another epinephrine autoinjector at home.

What Do I Tell the Patient/Family?

Sorry that this happened to your son. It’s great that he seems to be feeling better. It sounds like you have found yourself in this situation before. There’s no set amount of time we must observe him in the emergency department. Let’s briefly go over what symptoms to look out for at home and make sure that you can get another epinephrine autoinjector before you leave the ED.

The post PODCAST: Home Where I Wanted to Go After Anaphylaxis first appeared on האיגוד הישראלי לרפואה דחופה.

Welcome to the Rebel Core Content Blog, where we delve into crucial knowledge for emergency medicine. Today, we share insightful tips from PEM specialist Dr. Elise Perelman, shedding light on respiratory challenges in infants, toddlers, and young children during the viral season. Understanding that most cases involve typical viruses, we aim to equip you with diagnostic pearls to identify more serious pathologies.

Pearl #1: Look at Your Patient

Begin exams from the doorway. Observing patterns such as accessory muscle usage can reveal a patient’s respiratory effort. Specify whether the work of breathing occurs during inspiration, expiration, or both. Inspiratory work indicates difficulty getting air in, while expiratory work suggests trouble pushing air out. Silent tachypnea may point to other issues, like acidemia or pneumothorax.

Pearl #2: Localize the Sound

Breathing noises signal varied respiratory issues. Stridor, often heard on inspiration, results from obstructions above the thoracic inlet. Conversely, wheezing, generally linked to exhalation, indicates obstructions in the lower airways. Watch for signs like ‘silent chest’—a dangerous, severe obstruction, and distinguish grunting as a bodily mechanism to prevent alveolar collapse. Correctly identifying the sound assists in determining the appropriate intervention.

Once a sound is localized, treatments vary. We explore Soder from nasal congestion, typically needing supportive care and suctioning. Stridor from conditions like croup is eased with interventions to reduce airway swelling, such as steroids or inhaled epinephrine. Conversely, wheezing in infants is often due to bronchiolitis—not bronchospasms—and over-treatment is to be avoided. Supportive measures including suction, hydration, and oxygen are preferred unless improvement warrants bronchodilators.

In severe cases of asthma or bronchiolitis, where standard at-home treatments fail, immediate adjunct therapies like intramuscular epinephrine become essential. Administering this quickly can alleviate obstruction when inhalants aren’t effective due to low air movement.

When recognizing Zebras—uncommon cases overshadowed by routine diagnoses—remain vigilant for histories or presentations that don’t conform. Conditions like pneumonia, bacterial tracheitis, and even myocarditis may mimic more common issues.

As attending physicians, our role extends beyond conventional treatment—it’s about discerning the atypical from the typical. Dr. Perelman urges continual reassessment, emphasizing reliance on observational skills as much as technological aid. Keeping keen on respiratory nuances ensures we catch those outlier cases, paving the way for adept medical care despite the overwhelming prevalence of viral infections.

The post PODCAST: Pediatric Respiratory Emergencies: Beyond Viral Season first appeared on האיגוד הישראלי לרפואה דחופה.

Try Alex (chatbot in right lower corner of the website)

Published on September 1, 2025

Written by Vivian Lei

Mindful Intubation

How does this change my practice?

Source

The post PODCAST: Airway Management in TBI or Ischemia 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.

Dr. Harish Kinni, a triple-board-certified emergency medicine and critical care physician and assistant professor at the Mayo Clinic, provides an overview of the fundamentals of ventilator care for emergency department professionals. We will review key modes that we should know, the variables to set, how to adjust them for your patient’s needs, and provide troubleshooting tips and tricks for when things suddenly go awry. This is sure to be one of the most helpful chapters of Always on EM, but don’t let it take your breath away!

CONTACTS

X – @AlwaysOnEM; @VenkBellamkonda

YouTube – @AlwaysOnEM; @VenkBellamkonda

Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch

Email – [email protected]

REFERENCES & LINKS

The post PODCAST: Airway to Heaven- A Primer on Mechanical Ventilation for Emergency Providers first appeared on האיגוד הישראלי לרפואה דחופה.

Jonathan H. Kim, MD, MSc1; Austin J. Rim, MD1; James T. Miller, MS1; et al

Question  What is the contemporary incidence of cardiac arrest and death among marathon and half-marathon runners in the US?

Findings  In this case series and cohort study from the Race Associated Cardiac Event Registry, the incidence of cardiac arrest during marathons and half-marathons has remained relatively stable since 2010, compared with 2000-2009. The risk of dying from cardiac arrest during long-distance running races has decreased by approximately 50% compared with 2000-2009.

Meaning  Effective emergency action planning during marathons and half-marathons, inclusive of immediate access to defibrillation, has likely led to significant improvements in cardiac arrest outcomes, equivalent to settings with publicly accessible automated external defibrillators.

Importance  More than 29 million participants completed marathons and half-marathons in the US between 2010-2023, approximately 3 times the number from 2000-2009. Contemporary long-distance race-related cardiac arrest incidence and outcomes are unknown.

Objective  To determine the incidence and outcomes of cardiac arrests during US marathons and half-marathons between 2010-2023 from a record of race finishers and a comprehensive review of cases from media reports, direct contact with race directors, USA Track & Field claims, and interviews with survivors or next of kin.

Design, Setting, and Participants  Observational case series from the Race Associated Cardiac Event Registry; cohort data from US marathon and half-marathon runners from January 1, 2010, to December 31, 2023. Case profiles were reviewed to determine etiology and factors associated with survival. Incidence and etiology data were compared with historical reference standards (2000-2009).

Exposure  Recreational long-distance running (marathon and half-marathon distance).

Main Outcomes  Incidence proportions of sudden cardiac arrest and death.

Results  Among 29 311 597 race finishers, 176 cardiac arrests (127 men, 19 women, 30 sex unknown) occurred during US long-distance running races. Compared with 2000-2009, cardiac arrest incidence remained unchanged (incidence rate, 0.54 per 100 000 participants [95% CI, 0.41-0.70] vs 0.60 per 100 000 [95% CI, 0.52-0.70], respectively). However, there were significant declines in cardiac death incidence (0.20 per 100 000 [95% CI, 0.15-0.26] vs 0.39 per 100 000 [95% CI, 0.28-0.52]) and case fatality rate (34% vs 71%). Cardiac arrests remained more common among men (1.12 per 100 000 [95% CI, 0.95-1.32]) than women (0.19 per 100 000 [95% CI, 0.13-0.27]) and during the marathon (1.04 per 100 000 [95% CI, 0.82-1.32]), compared with the half-marathon (0.47 per 100 000 [95% CI, 0.38-0.57]). Among runners for which a definitive cause of cardiac arrest could be determined (n = 67/128 [52%]), coronary artery disease rather than hypertrophic cardiomyopathy was the most common etiology. Decreased cardiopulmonary resuscitation time and an initial ventricular tachyarrhythmia rhythm were associated with survival.

Conclusions and Relevance  Despite increased participation in US long distance running races, cardiac arrest incidence remains stable. There has been a marked decline in cardiac arrest mortality, and coronary artery disease was the most common etiology among cases with sufficient cause-related data. Effective emergency action planning with immediate access to defibrillation may explain the improvement in survival.

related articles icon 

Related

Millions of people participate in long-distance running, particularly marathons and half-marathons, annually.1 While the health benefits of regular exercise are well established,2 long-distance running can cause significant cardiovascular stress, potentially increasing the risk of cardiac arrest in individuals with underlying heart conditions.3 This concern is particularly notable as the number of middle-aged and elderly runners—a population at higher average cardiovascular risk than younger runners—continues to rise.4 Understanding the incidence, causes, and outcomes of cardiac arrest in long-distance runners is crucial for informing risk, identifying prevention strategies, and optimizing race-day medical preparedness.

In this issue of JAMA, Kim et al5 report on a comprehensive prospective observational study that investigated the incidence and outcomes of cardiac arrest during marathons and half-marathons in the US between 2010 and 2023. Their study provides valuable insights into the incidence, risk factors, etiologies, and survival trends associated with cardiac arrest in long-distance runners.

The researchers used data from the Race Associated Cardiac Event Registry (RACER), a prospective registry of marathon and half-marathon runners in the US.1 A targeted, multistep algorithm was used to identify cases of cardiac arrest through media reports, direct contact with race directors, and USA Track & Field claims data. This systematic approach minimized the risk of underreporting and ensured a more accurate representation of cardiac arrest incidence. A similar approach was used in an earlier report using RACER data, allowing for comparisons over time.1

A total of 176 cardiac arrest cases were identified among 29 311 597 race finishers between 2010 and 2023. The incidence of cardiac arrest remained relatively stable over this period compared with the previous decade (2000-2009), with an incidence proportion of 0.54 per 100 000 participants. However, the study revealed a significant decline in cardiac arrest mortality from 2010-2023 compared with 2000-2009 (34% vs 71%, P < .001).1,5 The study also highlighted key demographic factors associated with higher cardiac arrest incidence. Men were found to be at a higher risk than women, with an incidence rate of 1.12 per 100 000 compared with 0.19 per 100 000 in women. Marathons were associated with a higher incidence proportion of cardiac arrest, compared with half-marathons (1.04 per 100 000 vs 0.47 per 100 000).

Coronary artery disease was identified as the most common cause of cardiac arrest, accounting for 40% of cases. This finding contrasts with earlier studies that identified hypertrophic cardiomyopathy as the predominant cause.1 The authors suggest that the shift in etiology may be due to improved case ascertainment methods and a potential bias in previous studies toward identifying hypertrophic cardiomyopathy cases. It is also possible that diagnosis and treatment of hypertrophic cardiomyopathy has improved to the point that it now accounts for only a small minority of cardiac arrest cases in marathon runners.

The strengths of the study include its large sample size, comprehensive case identification methods, and detailed analysis of clinical profiles that may help identify individuals at the highest risk for cardiac arrest during long-distance running. The study also has limitations. Race finishing times were used as surrogates for race participants, which may have resulted in some participants being counted more than once. This would have the potential effect to underestimate cardiac arrest risk slightly. There is no reason to believe this limitation would have differed in the prior RACER analysis; thus, relative comparisons between periods are likely still valid. The study was unable to ascertain the cause of cardiac arrest in approximately 50% of cases, which may limit the accuracy of the etiologic findings.

Despite these limitations, the study has important clinical implications. The decline in cardiac arrest mortality likely underscores the importance of effective emergency action planning during races, including immediate access to defibrillation. Rapid access to prehospital automated external defibrillators has been associated with a favorable survival and neurologic outcome in distance runners who experience a cardiac arrest.6 The findings of the study also may reinforce the importance of primary cardiac prevention in older runners, particularly men, who are at higher risk of coronary artery disease. This is in line with some lines of thinking that would support use of low-dose aspirin before races to prevent cardiovascular events, including cardiac arrest, in patients with an increased estimated atherosclerotic risk.7

This study provides valuable insights into the incidence, causes, and outcomes of cardiac arrest during long-distance running races. While the overall incidence of cardiac arrest has remained stable, the significant decline in mortality highlights the positive impact of improved medical preparedness for races. The study’s findings emphasize the need for continued efforts to enhance primary and secondary prevention strategies for runners, ensuring the safety of participants in long-distance running events.

The post JAMA: Cardiac Arrest During Long-Distance Running Races first appeared on האיגוד הישראלי לרפואה דחופה.