כירורגיה - האיגוד הישראלי לרפואה דחופה

Date: June 12, 2026

Guest Skeptic: Mr. Ross Fisher. Ross is a paediatric surgeon, presentation guru (P-Cubed), and long-time friend of the SGEM.

Reference: Talan et al. Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. June 2026

Case: A 29-year-old healthy man presents to the emergency department (ED) with 18 hours of abdominal pain that began around the umbilicus and migrated to the right lower quadrant. He has anorexia, nausea, a temperature of 38.1°C, and focal right lower quadrant (RLQ) tenderness without diffuse peritonitis. The white blood cell (WBC) count is 13,500/µL. CT abdomen/pelvis shows an 8-mm inflamed appendix with periappendiceal fat stranding but no abscess, phlegmon, perforation, mass, or appendicolith. He is hemodynamically stable, not immunocompromised, has no history of inflammatory bowel disease (IBD), can return to the ED if worse, and asks whether he really needs surgery tonight.

Background: Appendicitis is one of those diagnoses we don’t want to miss. It’s common, it can be sneaky, and the classic textbook presentation only shows up around half the time. That means labs and scores can help, but they often can’t rule out appendicitis. In 2026, imaging (especially CT scans) is still doing much of the heavy lifting.

For more than a century, appendicitis was taught as a surgical emergency: diagnose it, call surgery, and remove the appendix before it ruptures. This new narrative review challenges that mental model. It argues that modern imaging can identify uncomplicated appendicitis, that perforated and nonperforated appendicitis may be biologically different entities, and that short delays to surgery in uncomplicated disease do not appear to increase perforation risk. This new narrative review notes that the American College of Surgeons (ACS) has endorsed antibiotics as a safe alternative for selected patients while continuing to endorse appendectomy.

The SGEM has followed this topic for years, and our interpretation of the literature has evolved as the evidence has changed (see list of other SGEM episodes at the end of this blog post). In 2015, the SGEM emphasized diagnostic uncertainty and concern that failed antibiotics could increase morbidity; in 2017, the pediatric conclusion was that NOTA was “not ready for prime time.” By 2019, we were more open to antibiotics in selected patients, using shared decision-making and acknowledging that nonoperative care may be better than we thought, though it may (or may not) come with a small absolute increase in complications.

So, the question is no longer whether to cut or not to cut. The ED question is: who is safe for an antibiotic-first pathway, who needs the surgeon now, and who can reliably come back if things go sideways? This is a classic preference-sensitive decision: surgery is highly definitive, while antibiotics may reduce pain, disability, and time away from school or work, but with a meaningful recurrence/appendectomy risk. This review by Talan et al explicitly places emergency physicians in the shared decision-making role for selected uncomplicated appendicitis patients.

This matters because appendicitis sits right at the intersection of emergency medicine, surgery, radiology, antibiotics, patient values, and system capacity. Some patients want the most definitive treatment. Others want to avoid surgery if it’s safe to do so. Our job is not to sell one option. Our job in the emergency department is to explain the trade-offs.

Reference: Talan et al. Nonoperative Treatment of Appendicitis and Implications for Emergency Department Management: A Narrative Review. Ann Emerg Med. June 2026

Authors’ Conclusions: “Nonoperative treatment of uncomplicated appendicitis will be increasingly considered as experience and confidence grows among physicians and as awareness grows among patients in this new treatment option. Emergency physicians are being asked about nonoperative treatment of uncomplicated appendicitis and have an important role now to inform patients of their treatment options and expected associated outcomes, and an emerging role in expanding access to safe and cost-effective care for patients with appendicitis, including those who can be managed by nonoperative treatment of uncomplicated appendicitis as outpatients.”

Quality Checklist for Systematic Reviews: (Yes/No/Unsure)

Results: The review focused on four major comparative trials: APPAC, CODA, MPSC, and APPY. Together, they included more than 2,000 adults and more than 2,000 children. The review did not provide a pooled table of sex, race, baseline pain duration, comorbidities, or socioeconomic demographics.

The ED discharge data came mainly from CODA. In a CODA sub-analysis, 335 of 726 antibiotic-treated adults, 46%, were discharged from the ED after longer-acting parenteral antibiotics, observation, oral tolerance, stable status, and pain control. Serious adverse events over 7 days were uncommon: 0.9 per 100 outpatients vs 1.3 per 100 inpatients. ED discharge was associated with fewer appendectomies and about one day less disability, without a significant increase in first-week ED return visits.

Summary of the Four RCTs:

1. Narrative Review: This was not a systematic review, and that matters. No PRISMA diagram, no duplicate screening, no formal risk-of-bias assessment, and no pooled estimate. That does not make it useless, and we should not judge it against a formal SRMA. It just means we should treat it for what it is, an expert narrative synthesis, not the final word.

Open Label

2. Open-Label: The included RCTs were not masked and vulnerable to performance, detection, and preference bias. You really can’t blind antibiotics vs surgery. But when outcomes include pain, disability, and the decision to operate, lack of blinding can push things around. Some failures may have been true clinical deterioration. Others may have been surgeon, patient, or system discomfort with waiting.

3. Uncomplicated Appendicitis: ED clinicians must exclude abscess, phlegmon, perforation, tumour, diffuse peritonitis, pregnancy, immunocompromise, and other higher-risk conditions. Yet appendicitis diagnosis itself is imperfect: classic symptoms occur in only about half of patients, labs and clinical prediction rules are insufficient to rule in or rule out disease, ultrasound is operator-dependent, and CT can still produce false positives and negative appendectomies. This means the evidence applies best to carefully selected, stable, imaging-confirmed uncomplicated cases, not to all RLQ pain or all appendicitis.

Heterogeneity

4. Heterogeneity: The RCTs differed by age group, randomization method, inclusion of appendicolith, antibiotic regimen, inpatient versus outpatient management, thresholds for surgery, primary outcome definitions, and noninferiority margins. A one-year appendectomy rate is not the same as patient-important success if a patient’s goal is avoiding an operation today, reducing pain, minimizing time off work, or avoiding recurrence of anxiety. Without a formal meta-analysis, there is no pooled I², no forest plot, and no systematic exploration of heterogeneity.

5. Rare & Long-Term Outcomes: These outcomes remain uncertain. Missed appendiceal cancer is uncommon, but the review reports cancer in 5 of 1,033 CODA-qualifying antibiotic-treated adults at 2 years, with a median diagnosis at 3 months and all stage 1. That is reassuring but not definitive for older adults or those with atypical imaging. Pediatric outpatient data remain sparse, and cost-effectiveness depends heavily on the health system, discharge model, return visits, recurrent symptoms, and whether recurrences are treated with antibiotics or surgery. The review is promising for ED pathways, but the evidence is not equally mature for children, patients with appendicolith, older adults, rural sites without surgical backup, or patients with unreliable follow-up.

Compare the Authors’ Conclusion Compared with the SGEM Conclusion: The authors seem more optimistic about an expanded ED role. They argue that nonoperative treatment is a safe alternative for selected uncomplicated appendicitis patients, that ED discharge/outpatient care is feasible in many adults, and that emergency physicians should be prepared to initiate shared decision-making and outpatient pathways.

We are more cautious due to the strength of the evidence, diagnostic uncertainty, patient selection, the possibility of increased perforation/complications with failed nonoperative care, and the importance of shared decision-making (SDM).

Case Resolution: The patient’s CT shows uncomplicated appendicitis without appendicolith. Surgery is consulted. After discussing appendectomy versus antibiotics, he says avoiding surgery today is very important because he has no paid sick leave, but he is comfortable returning if getting worse. He receives intravenous (IV) ceftriaxone plus metronidazole, analgesia, and antiemetics. After several hours, he is afebrile, pain is improved, he tolerates oral intake, and he remains hemodynamically stable. He is discharged with oral antibiotics to complete a 7- to 10-day total course, written instructions to return immediately if worse, and follow-up within 24 to 48 hours.

Clinical Application: This review should not make ED clinicians offer antibiotics to every patient with appendicitis. It should prompt EDs to create local pathways with surgery, radiology, pharmacy, and follow-up systems. Candidates should have localized uncomplicated appendicitis, no diffuse peritonitis, no abscess/phlegmon/perforation/tumour, no severe sepsis, no pregnancy, no major immunocompromise, no inflammatory bowel disease, and ideally no appendicolith unless the higher failure risk is explicitly discussed. Outpatient management should be reserved for patients who improve, tolerate oral intake, have controlled pain, can access antibiotics, and can reliably return.

What Do I Tell the Patient? You have appendicitis, but the CT scan suggests it is the uncomplicated kind. There are two reasonable options. Surgery is the most definitive option. It removes the appendix, so this problem is very unlikely to come back, but it means an operation, anesthesia, incisions, and recovery time. Antibiotics may let you avoid surgery today. In the large studies, most people improved at first, and about 2 out of 3 avoided surgery for at least a year. The trade-off is that about one out of three still needs surgery within a year, and the risk is higher if there is a stone in the appendix. There is not one right answer for everyone. Let’s talk about what matters most to you, and you can decide with the surgery team.

Keener Kontest: Last week’s winner was our friend, Dr. Steven Stelts from New Zealand. He knew the 2024 international consensus report defines diabetic ketoacidosis (DKA) by the presence of all three of these features:

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

Other SGEM Episodes:

The post PODCAST: When you go your way, and I Go Mine – Surgery or Antibiotics for Acute Appendicitis. first appeared on האיגוד הישראלי לרפואה דחופה.

Administration of blood products in the field prior to hospital arrival

Aimed at patients in hemorrhagic shock

Traditional US prehospital resuscitation relied on crystalloid

ED and trauma care now prioritize early blood

Hemorrhage occurs before hospital arrival

Delays to definitive hemorrhage control are common

Earlier blood may improve survival

ATLS and trauma paradigms emphasize blood over fluid

National organizations support prehospital blood when feasible

EMS already manages high risk, time sensitive interventions

Data are mixed and evolving

COMBAT: no benefit

PAMPer: mortality benefit

RePHILL: no clear benefit

Signal toward benefit when transport time exceeds ~20 minutes

Urban systems still experience long delays due to traffic and geography

LA County median time to in hospital transfusion ~35 minutes

~2 years of planning before launch

Pilot began April 1

Partnerships:

LA County Fire

Compton Fire

Local trauma centers

San Diego Blood Bank

14 units of blood circulating in the field

Blood rotated back 14 days before expiration

Ultimately used at Harbor UCLA

Continuous temperature and safety monitoring

Focused rollout

Trauma related hemorrhagic shock

Postpartum hemorrhage

Physiologic criteria:

SBP < 70

Or HR > 110 with SBP < 90

Shock index ≥ 1.2

Witnessed traumatic cardiac arrest

Products:

One unit whole blood preferred

Two units PRBCs if whole blood unavailable

~28 patients transfused at time of discussion

Evaluating:

Indications

Protocol adherence

Time to transfusion

Early outcomes

Too early for outcome conclusions

Multiple active programs:

Riverside (Corona Fire)

LA County

Ventura County

Additional programs planned:

Sacramento

San Bernardino

Programs meet monthly as CalDROP

Focus on shared learning and operational optimization

Trauma surgeon concerns about blood supply

Need for system wide buy in

Community engagement

Patients who may decline transfusion

Women of childbearing age and alloimmunization risk

Risk of HDFN is extremely low

Clear communication with receiving hospitals is essential

Rapid national expansion expected

Greatest benefit likely where transport delays exist

Prehospital Blood Transfusion Coalition active nationally

Major unresolved issue: reimbursement

Currently funded largely by fire departments

Sustainability depends on policy and payment reform

Hemorrhagic shock is best treated with blood, not crystalloid

Prehospital transfusion may benefit patients with prolonged transport times

Implementation requires strong partnerships with blood banks and trauma centers

Early data are promising, but patient selection remains critical

National collaboration is key to sustainability and future growth

The post PODCAST: Prehospital Blood Transfusion 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: Gibbons et al. The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study. AEM February 2024.

Date: February 28, 2024

Guest Skeptic: Dr. Neil Dasgupta is an emergency medicine physician and ED intensivist from Long Island, NY.  He is the Vice Chair of the Emergency Department at Nassau University Medical Center in East Meadow, NY, the safety net hospital for Nassau County.

Case: A 59-year-old man walks into your community emergency department (ED) complaining of chest pain. It is described as a ripping sensation that radiates to his back. His vital signs are all normal and the ECG done at triage does not show an occlusive myocardial infarction. The chest x-ray is unremarkable, and his troponin is not elevated. You suspect an acute aortic dissection (AoD). However, your CT scanner is offline for two hours of scheduled maintenance. He will need to be transferred to the tertiary care center which is 35 minutes away by ground EMS if it is a dissection. Your Spidey senses are tingling, and you don’t want to wait for the CT scanner to be back online to make the diagnosis. Arrangements are made for him to be transferred stat to the tertiary hospital while he is still stable. You wonder if a quick POCUS examination looking for three sonographic findings while waiting for the paramedics could help determine the likelihood of this being an AoD.

Background: We recently covered acute aortic syndrome (AAS) on SGEM#430. AAS has been called the lethal triad and includes aortic dissection (AD), intramural hematoma (IMH), and penetrating aortic ulcer [1]. It is a rare but deadly condition that can present in atypical ways leading to delays in diagnosis and an associated increase in mortality.

This episode is going to focus on acute aortic dissection (AoD) which is classified into two major types according to the Stanford classification system: Type A and Type B. This system is based on the location of the tear and helps guide treatment strategies.

Type A dissections Involves the ascending aorta and may extend into the descending aorta. It’s more common and more dangerous than Type B, as it can lead to serious complications like rupture into the pericardial space leading to cardiac tamponade, aortic valve insufficiency, or myocardial infarction. Symptoms may include more severe chest pain radiating to the back, loss of consciousness, or symptoms of stroke if the blood supply to the brain is affected. Type A AoDs generally require an emergent trip to the operating room as soon as they are identified to reduce the likelihood of a terrible outcome.

Type B dissections occur in the descending aorta only, after it has passed the arteries that supply blood to the arms and head. They are less common than Type A and usually less immediately life-threatening, but still serious and potentially fatal if not treated properly. Symptoms can include sudden onset of pain in the back or abdomen, depending on the exact location and extent of the dissection. The pain is often described as tearing or ripping.

Speed is important in making the diagnosis of an AoD due to the associated increase in mortality with delays [2,3]. We know from last week that clinical decision tools (CDTs) are not ready for prime time. This is consistent with the American College of Emergency Physicians (ACEP) which does not recommend the routine use of clinical decision rules in suspected cases of AoD [4].

Reference: Gibbons et al. The sonographic protocol for the emergent evaluation of aortic dissections (SPEED protocol): A multicenter, prospective, observational study. AEM February 2024.

Dr. Ryan Gibbons

This is the first SGEMHOP of 2024. I’m pleased to introduce Dr. Ryan Gibbons. He is a proud graduate of the Lewis Katz School of Medicine (LKSOM) at Temple University where he completed his Emergency Medicine (EM) residency, serving as chief resident, followed by an Advanced Emergency Medicine Ultrasonography (AEMUS) fellowship at Temple as well. Currently, Dr. Gibbons is an Associate Professor of EM, AEMUS fellowship director, and the Director of Ultrasound in Undergraduate Medical Education (UME). 

Authors’ Conclusions: “The SPEED protocol has an overall sensitivity of 93.2% for AoD.”

Quality Checklist for Observational Study:

Results: Over the ten years, 1,314 patients were approached and agreed to be enrolled in the study. The median age was 59 years with 49% being female. There were 21 (1.5%) Stanford type A and 23 (1.8%) Stanford type B dissections diagnosed. Of the 44 (3.3%) cases diagnosed, 41 of them (93.2%) had at least one finding present on POCUS.

Listen to the SGEM podcast to hear Ryan answer our five nerdy questions.

1. Convenience Sample: These were not consecutive patients but rather a convenience sample of patients with suspected AoD. How did patients ultimately make it into the study, and what biases could this have introduced into the sample?

2. Ultrasonographers: These scans were done by PGY1 – PGY3 emergency medicine residents. They received a four-hour introductory course taught by our emergency ultrasound faculty. In addition, each resident completed a three-week emergency ultrasound rotation during their internship. They did not receive any additional formal training before participating in the study except for the standard bedside teaching throughout their residency. Do you think this can be extrapolated to an attending physician in a non-academic, community or rural setting?

3. Lack of Masking: Physicians performing the scan were not masked. They also had access to laboratory results (d-dimer) and plain film imaging. How do you think that could have biased the results?

4. Prevalence Higher: Your prevalence of 3.5% was high compared to previously published data [5.6]. This too suggests some selection bias. What other biases could this suggest?

5. Prevalence Sill Low: The 3.5% is still a small number even if it is larger than other published data. This small number of cases results in a wide 95% confidence interval around the point estimate for the diagnostic accuracy metrics. What impact do you think this may have had on your results?

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusions but would have added that there was a wide confidence interval around the reported 93.2% sensitivity.

Case Resolution: The vascular surgeon says to get on the road and don’t wait for the CT scanner to be up and running. Speed is of the essence, and they will be standing by on arrival to assess the patient. The patient arrives alive, and you transfer care to the vascular team. When you get back to the community hospital you find out the CTA shows a Stanford Type B aortic dissection, and the vascular team is discussing the next steps with the patient and their family.

Dr. Neil Dasgupta

Clinical Application: This is an interesting study but would need to be replicated in other clinical settings to see if it could be a fast and accurate way to diagnose AoD.

What Do I Tell the Patient? It looks like the large blood vessel coming off your heart has a tear. This is a serious and potentially deadly condition. We need to get you to the city hospital ASAP. The ambulance is on the way and the vascular surgeons are waiting for you to arrive.

Keener Kontest: Last week’s winner was David Bowden. He knew St. John’s Wort has some evidence for efficacy in the treatment of mild to moderate depression

Listen to the podcast to hear the question for this episode. If you think you know the answer, send an email to [email protected].  The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on POCUS for diagnosing AoD? Tweet your comments using #SGEMHOP. What questions do you have for Ryan and his team? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

References:

The post PODCAST: SPEED, GIVE ME WHAT I NEED – TO DIAGNOSE ACUTE AORTIC DISSECTIONS first appeared on האיגוד הישראלי לרפואה דחופה.