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This episode reviews the basics of cervical spine clearance in adult blunt trauma patients including

References at FOAMcast.org

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In this episode of the Rebel Core Content podcast, Swami provides crucial tips on using tourniquets. Highlighting the significance of these life and limb-saving devices, the discussion focuses on the optimal placement of tourniquets, emphasizing placing them 2-3 inches (5-6 cm) above the bleeding source and avoiding joints. Swami also advises on the correct way to tighten the tourniquet using the Velcro strap first, followed by minimal use of the windless. The importance of noting the application time to avoid prolonged arterial flow interruption is also discussed. The episode concludes with a reminder to visit the podcast’s website for more valuable content.

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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

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

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

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

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

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

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

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

MHP Mnemonic: “Easy as ABC After 3”

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

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

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

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

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

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

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

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

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

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

Ratio-based Resuscitation

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

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

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

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

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

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

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

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

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

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

In Small Centers:

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

The importance of fibrinogen and calcium

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

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

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

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

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

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

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

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

Tips to avoid hypothermia in trauma patients:

Target a temperature of 37 degrees celsius.

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

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

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

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

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

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

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

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

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

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

Continuously Assess the Need for Ongoing MHP

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

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

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

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

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

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

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

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

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

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

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

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Penetrating neck injuries in children are rare—but when they happen, the stakes are high. In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, we explore the clinical pearls behind “no-zone” management, how to distinguish hard and soft signs, when to image versus operate, and why airway always comes first. Get ready for a focused, evidence-based deep dive into pediatric neck trauma.

Stone ME Jr, Christensen P, Craig S, Rosengart M. Management of penetrating neck injury in children: A review of the National Trauma Data Bank. Red Cross Annals. 2017;32(4):171–177. doi:10.1016/j.rcsann.2017.04.003

Callcut RA, Inaba K. Penetrating neck injuries: Initial evaluation and management. UpToDate. Waltham, MA: UpToDate Inc. [Accessed June 24, 2025]. Available from: https://www.uptodate.com

Note: This transcript was partially completed with the use of the Descript AI and the Chat GPT 4o AI

Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and in this episode we are diving into a high-stakes but fortunately rare topic in pediatric trauma — penetrating neck injuries. Now these injuries make up less than 1% of all pediatric trauma, but when they occur, they demand precision and vigilance in terms of diagnosis and management.

As you know, the neck packs some vital organs, vessels, the airway, esophagus, and nerves into a tiny little area, so even a seemingly minor wound can injure multiple structures.

Now you remember — way back when — where you learned about the zones of the neck, and this is the traditional teaching, which chopped the neck up into three zones.

You’ve got Zone I, which is the area between the clavicle and cricoid. You’ve got the subclavian arteries and vein, the carotid, and the apices of the lungs.

Now, you may recall some teaching that you got in medical school or residency where the management was dictated by which zone was injured. And admittedly, a lot of this evidence is in adults, and more penetrating trauma is seen in adults as well.

But now practice is leaning towards the “no zone” approach, where imaginary lines on the skin surface are not dictating management as much as presentation, symptoms, and deciding when to go to the OR versus using CT angiography.

So let’s talk about mechanisms of injury for a minute.

Toddlers can injure their neck when they fall with something in their mouth, like pencils or chopsticks.

So low-velocity mechanisms dominate pediatric penetrating neck injuries. Force matters, because depth and tissue cavitation decide the overall injury pattern.

In terms of assessing the patient with a penetrating neck injury, it all starts with the ABCs.

Is the patient’s airway patent? Are they protecting and maintaining it?

For breathing, patients should be breathing comfortably with no distress.

For circulation, if the wound is bleeding, apply direct pressure. Some surgeons will use a Foley balloon tamponade method if they need to stop bleeding before going to the operating room.

Patients will need large bore IVs and fluids — and especially blood product resuscitation.

Only immobilize the C-spine if a patient has neurologic deficits or a high injury mechanism.

You may have also heard of hard signs and soft signs in terms of the parlance of managing penetrating neck injury.

In general, hard signs mean go to the operating room.

So here are some hard signs:

Soft signs include:

A large pediatric series showed that 50 to 70% of children with hard signs did need operative repair.

So I alluded to this paradigm at the beginning of the episode — the “no zone” strategy.

For stable children with no hard signs, CT angiography is the gold standard.

Make sure you always get a chest X-ray as well, since penetrating neck injuries can injure the apices of the lungs or thoracic structures.

Also, if the CTA is negative but you still have suspicion for injury to the aerodigestive tract, you can do a water-soluble contrast esophagram or flexible endoscopy.

Plain films — yes, you can assess the C-spine and look for radiopaque foreign bodies, but again, if you truly have a child that is stable and has no hard signs, CTA is the gold standard.

If you follow this, you can cut non-therapeutic neck explorations in half without missing any injuries.

If you do have a neck wound that you have to manage before the surgeons can get to it: direct pressure first.

The Foley balloon tamponade method is where you take an 18 to 20 French catheter, place it into the wound, inflate the balloon with 10 to 15 milliliters of water, and then clamp it.

I wouldn’t necessarily do this in a Level 1 trauma center — I have surgeons available — but it might be useful if you have to transport a kid quickly to a trauma center.

Never, ever, ever pull an impaled object out of the neck in the emergency department.

Now, superficial injuries with the platysma intact get routine closure.

So here’s some pediatric-specific pearls, again, because these are really rare.

Kids have a small airway, and soft tissues swell quickly, so there’s a low threshold for securing the airway.

Kids have low blood volume and don’t tolerate hemorrhage as well.

And unfortunately, some neck wounds are self-inflicted, so make sure you address mental health concerns after the child is stabilized.

Alright. So let’s bring it all home. What are some key take-home points?

That’s all for this episode. I hope you found it useful — especially since these injuries are less common, but can be incredibly impactful.

If you enjoyed the content, or want to hear something different about pediatric trauma, reach out and let me know — I’ll take an email, a comment on the blog, a social media message.

And please — as my 13-year-old would encourage me to say — like, rate, and review.

Share this episode and the podcast with the folks you work with — and not just physicians in the emergency department. I think we all deserve to learn about how we manage injuries in children.

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Hypoglycemia can be subtle—or dangerously obvious—and knowing when and how to treat it is critical. In her first episode as our new Push Dose Pearls expert, Emergency Medicine Clinical Pharmacist, Haley Burhans, joins us to break it down. We discuss glucose thresholds by age, when to draw critical labs, and how to choose the right treatment—whether it’s oral glucose, IV dextrose, or IM or intranasal glucagon. From neonates to older adults, Haley delivers practical, evidence-based pearls to help you manage low blood sugar safely and effectively in the ED.

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

Hosts:

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

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

Guests:

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

Resources:

Gandhi K. Approach to hypoglycemia in infants and children. Transl Pediatr. 2017 Oct;6(4):408-420. doi: 10.21037/tp.2017.10.05. PMID: 29184821; PMCID: PMC5682370.

Rickels MR, Ruedy KJ, Foster NC, Piché CA, Dulude H, Sherr JL, Tamborlane WV, Bethin KE, DiMeglio LA, Wadwa RP, Ahmann AJ, Haller MJ, Nathan BM, Marcovina SM, Rampakakis E, Meng L, Beck RW; T1D Exchange Intranasal Glucagon Investigators. Intranasal Glucagon for Treatment of Insulin-Induced Hypoglycemia in Adults With Type 1 Diabetes: A Randomized Crossover Noninferiority Study. Diabetes Care. 2016 Feb;39(2):264-70. doi: 10.2337/dc15-1498. Epub 2015 Dec 17. PMID: 26681725; PMCID: PMC4722945..

MD Calc GIR (Glucose Infusion Rate) Calculator

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

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

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

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

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

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

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

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

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

Most predictive variables on history:

Other risk factors to consider:

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

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

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

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

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

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

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

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

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

Discharge Medications

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

Inhaler Technique

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

Return to Care Instructions

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

Identification of Triggers

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

Asthma Action Plan

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

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

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

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

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

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

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

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

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

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

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

Most predictive variables on history:

Other risk factors to consider:

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

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

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

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

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

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

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

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

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

Discharge Medications

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

Inhaler Technique

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

Return to Care Instructions

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

Identification of Triggers

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

Asthma Action Plan

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

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

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

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

The post PODCAST: Adult Asthma Management Strategies For Improved Prognosis – A Stepwise Approach first appeared on האיגוד הישראלי לרפואה דחופה.

00:37 – Overview of Smoke Inhalation Injury

00:55 – Three Key Pathophysiologic Processes

01:41 – Physical Exam Findings to Watch For

02:12 – Airway Management and Early Intervention

03:23 – Carbon Monoxide Toxicity

04:24 – Workup and Initial Treatment of CO Poisoning

06:14 – Cyanide Toxicity

07:19 – Treatment Options for Cyanide Poisoning

09:12 – Take-Home Points and Clinical Pearls

The post PODCAST: Smoke Inhalation Injury 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.

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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.