מתמחים - האיגוד הישראלי לרפואה דחופה

Date: January 3, 2026 

Reference: Shroyer et al. Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: Physicians vs. AI (Queen of Hearts by PMcardio). Am J Emerg Med. 2025 Nov.

Guest Skeptic: Dr. Amal Mattu has been on the faculty at the University of Maryland since 1996. He has developed an academic niche in emergency cardiology and electrocardiography, and he also enjoys teaching and writing on other topics, including emergency geriatrics, faculty development, and risk management. Amal is currently a tenured professor and Vice Chair of Emergency Medicine at the University of Maryland School of Medicine, and a Distinguished Professor of the University of Maryland-Baltimore.

Case: A 58-year-old man with diabetes and hypertension arrives at the emergency department (ED) 30 minutes after the sudden onset of substernal chest pressure radiating to the left arm, now improved to 3/10. His vital signs are BP 146/88, HR 92, RR 18, O2 sat 98% on room air. The initial 12-lead ECG shows RBBB with left anterior fascicular block and subtle anterior ST‑depression with proportionally tall, broad T waves in V2 to V4. This is an appearance that can be seen with Hyper-Acute T Wave Occlusive Myocardial Infarction (HATW‑OMI) or an ST-Elevated Myocardial Infarction (STEMI)‑mimic in conduction disease. A debate ensues between emergency medicine and cardiology on whether to activate the cath lab now or get troponins plus serial ECGs?

Background: Emergency physicians need to be experts at interpreting ECGs. For decades, we’ve been taught STEMI criteria, only to learn repeatedly that important exceptions exist (posterior OMI, de Winter, hyperacute T waves, modified Sgarbossa in LBBB, etc.). Those exceptions have evolved into two distinct categories. There are the STEMI‑equivalents (OMI without classic ST‑elevation) and STEMI‑mimics (ST‑elevation without OMI). That expanding exception list increases diagnostic complexity and uncertainty. This is the area where artificial intelligence (AI), utilizing computer vision and machine learning, could provide a benefit.

ECG-specific AI models now aim squarely at this problem. The study we are reviewing today evaluated the Queen of Hearts (QoH) AI. It is a deep neural network trained to detect occlusive myocardial infarction (OMI) on 12-lead ECGs. The model is described as “91% accurate” in prior work and is undergoing FDA review as of March 24, 2025, but whether it outperforms practicing clinicians on the hardest cases (STEMI‑equivalents and mimics) remained unclear.

ECG diagnostic accuracy is important in emergency medicine because misclassification cuts both ways. Missed OMI delays reperfusion, while overcalls send patients and teams to the cath lab unnecessarily, putting patients at risk and using up valuable resources. A diagnostic aid that catches true positive OMIs while reducing false activations could improve outcomes and team throughput.

Reference: Shroyer et al. Accuracy of cath lab activation decisions for STEMI-equivalent and mimic ECGs: Physicians vs. AI (Queen of Hearts by PMcardio). Am J Emerg Med. 2025 Nov.

Authors’ Conclusions: “Physicians frequently misinterpret STEMI-equivalent and STEMI-mimic ECGs, potentially impacting CLA decisions. QoH AI demonstrated superior accuracy, suggesting a potential to reduce missed OMIs and unnecessary catheterization laboratory activations. Prospective studies are needed to validate these findings in clinical practice.” 

Quality Checklist for a Diagnostic Study:

Results: They recruited 95 physicians to interpret the ECGs. There were 53 EM physicians and 42 cardiologists (23 general, 15 interventional, 4 EP electrophysiology). Experience: EPs 7 years (IQR 3 to 15) vs cardiologists 15 years (IQR 9.2 to 21).

The most frequently misclassified by humans were LBBB (±OMI), transient STEMI, HATW‑OMI, and de Winter. QoH AI missed LBBB‑OMI and LV aneurysm. RBBB + fascicular block and HATW‑OMI produced the largest EP-cardiologist disagreement.

1) Spectrum Bias: The investigators intentionally selected “ambiguous” STEMI‑equivalent and STEMI‑mimic ECGs and fixed the OMI prevalence at 50% for the reader study. That design improves efficiency in comparing readers and the AI, but it does not reflect the spectrum or prevalence we see in day-to-day ED practice and therefore threatens external validity. In diagnostic accuracy research, spectrum bias occurs when the distribution of disease/non-disease, disease severity, or look-alikes in the sample differs from that in the clinical population in which the test will be used. It can change sensitivity and specificity in either direction. Selecting borderline cases may deflate both compared with routine practice, and it will certainly distort PPV/NPV because predictive values are prevalence‑dependent. The authors acknowledge this by noting the 50% OMI prevalence and the deliberate use of ambiguous ECGs “may not accurately reflect predictive values observed in real-world settings.”

2) Differential Verification & Imperfect Gold Standard: Not every patient had the same reference standard. While most OMI determinations used angiography, some mimic cases without angiography were adjudicated by serial troponins, echocardiography, and clinical follow-up. Using different reference standards in different subgroups constitutes differential verification (double gold‑standard) bias and can bias sensitivity and specificity up or down, depending on whether the disease can resolve or only become detectable over time. In addition, any composite or clinical adjudication process is an imperfect gold standard, which can either inflate or deflate the index test’s performance depending on how errors correlate across tests. The authors explicitly note these issues in their discussion.

3) Incorporation/Review Bias: The paper reports that cardiologists performing angiography were not masked to the ECG. When the result of (or information from) the index test helps determine the reference diagnosis, that is incorporation (review) bias. This typically inflates both sensitivity and specificity of the index test because the gold standard classification is partially “contaminated” by the test under study. In this context, seeing a concerning ECG may tilt the invasive assessment and adjudication toward “culprit” lesion labelling or influence borderline calls, making ECG-based classification look better than it truly is.

4) Unit‑of‑analysis & Precision Limitations: This was a reader study with 95 clinicians classifying the same small set of 18 ECGs. Even with appropriate statistics, the small number of cases means performance estimates can be fragile, and the 95% confidence intervals reflect that imprecision. To their credit, the authors modelled accuracy with multi-level robust variance to account for clustering (multiple readers rating the same cases), but the design still limits precision and generalizability across the full morphology spectrum of each category. The authors themselves state that “one representative ECG per type…cannot represent all ST‑T variants”, and that asking physicians to read far more than 18 tracings was impractical. This imprecision concerns should raise our skeptical radar, and we should factor this into our study interpretation.

5) External Validity: The study is single-center and uses an online survey without the interruptions, time pressure, serial ECGs, bedside echo, or troponin trends that influence ED decision‑making. The authors explicitly caution that the controlled survey conditions do not replicate real clinical environments and could over- or under-estimate real-world accuracy. AI performance can also be domain‑dependent (ECG device/process, patient mix). Showing “simulation” superiority does not guarantee clinical utility until confirmed in prospective practice studies. This is a limitation known in the diagnostic literature (including the AI diagnostic literature) that emphasizes the potential difference between an artificial scenario and prospective bedside clinical application. In other words, until it is released into the wild involving other hospitals and workflows, we don’t know if it will have a net positive patient-oriented outcome (POO) of benefit.

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

Case Resolution: Given the concerning RBBB + LAFB with anterior repolarization changes and ongoing symptoms, we activate the cath lab. If available, an AI read supporting OMI would reinforce the call. If it disagreed, we would not delay for the algorithm. In the lab, the patient is found to have a proximal LAD culprit and undergoes PCI.

Dr. Amal Mattu

Clinical Application: The most significant finding that immediately makes me doubt the utility of the study is the chart that shows sensitivity and specificity. Even without all of the nerdy details, it is obvious that a 65% sensitivity for picking up OMIs (or my long-preferred term: acute coronary occlusion, ACO) is not possible. Any emerg phys or cardiologist who is missing 35% of ACOs is going to be fired, sued many times over, and driven out of medicine! Without reading any of the paper, as soon as I see that chart, I know it can’t be right unless the clinicians at his institution are incompetent.

No one has discussed the costs associated with integrating AI systems into all those ECG machines.

This QoH AI system is not ready for implementation in clinical practice outside a research study. The use of AI has the potential to augment clinical decision-making, but it is not currently done on autopilot without a human-in-the-loop.

What Do I Tell the Patient? Your ECG shows changes that could mean a blocked heart artery. We think the best course of action is to take you to the cath lab now to restore blood flow if needed. We also use a computer tool to double-check ECGs. It supports our concern, but it doesn’t replace us as doctors. The goal is to act fast and safely to get you the care you need.

Keener Kontest: Last week’s winner was Dr. Steven Stelts from Auckland, NZ. He knew the enzyme inhibited by etomidate to decrease cortisol and aldosterone is 11-beta-hydoxylase.

The post PODCAST: Playing with the Queen of Hearts – AI, Is It Very Smart (for ECG Interpretation)? first appeared on האיגוד הישראלי לרפואה דחופה.

Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below.

The post PODCAST: Meningitis 2.0 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.

Reference: Aronson PL, et al. Prediction Rule to Identify Febrile Infants 61–90 Days at Low Risk for Invasive Bacterial Infections. Pediatrics. September 2025

Date: January 6, 2026

Dr. Jillian Nickerson

Guest Skeptic: Dr. Jillian Nickerson is a pediatric emergency medicine attending at Children’s National Hospital and Assistant Professor of Pediatrics and Emergency Medicine at The George Washington University School of Medicine and Health Sciences in Washington, DC. Prior to completing her PEM fellowship, she completed an emergency medicine residency at Mount Sinai in New York. Now she is also the associate program director for the pediatric emergency medicine fellowship program at Children’s National Hospital.

Background:

Fever is a common complaint that we encounter in the emergency department. In general, we want to be careful in our counseling and our practice not to perpetuate many of the myths and misconceptions that contribute to fever phobia.

But there are certain populations where fever does get us a bit worried. When infants present with fever, we have to think about evaluating for other sources of infection such as bacteremia or meningitis, termed invasive bacterial infections (IBI). Fortunately, the prevalence of IBI tends to be low, but missing one could lead to significant morbidity or mortality. How do we determine whom to test and what tests to perform?

We’ve covered multiple clinical decision rules for risk-stratifying febrile infants before on the SGEM:

Some of these clinical decision rules like Step by Step can be applied to infants up to 90 days. Others like the 2021 American Academy of Pediatrics (AAP) clinical practice guideline and the Pediatric Emergency Care Applied Research Network (PECARN) clinical decision rule, only include infants up to 60 days.

Reference: Aronson PL, et al. Prediction Rule to Identify Febrile Infants 61–90 Days at Low Risk for Invasive Bacterial Infections. Pediatrics. September 2025

Dr. Nathan Kuppermann

Dr. Paul Aronson

Authors: Dr. Paul Aronson is a pediatric emergency medicine attending and Professor of Pediatrics and Emergency Medicine at Yale School of Medicine. He is the Deputy Director of the Pediatric Residency Program and leads the Research Track.

Dr. Nathan Kuppermann is executive vice president, chief academic officer of Children’s National Hospital and director of the Children’s National Research Institute. He also serves as chair of the Department of Pediatrics and associate dean of Pediatric Academic Affairs at the George Washington University School of Medicine and Health Sciences. Dr. Kuppermann is a pediatric emergency medicine physician, clinical epidemiologist and leader in emergency medical services for children.

Authors’ Conclusions: We derived two accurate clinical prediction rules to identify febrile infants 61–90 days at low risk for invasive bacterial infections when urine and blood testing are obtained. Prospective validation is needed.

Quality Checklist for Clinical Decision Rules:

Results: They included 4,952 infants. The median age was 72 days, and 54% male. Median maximum qualifying temperature was 38.7°C. Urinalysis was positive in 18%, LP/CSF testing was performed in 10%, antibiotics were given in 26%, and 34% were hospitalized. Approximately 100 (2%) tested positive for IBI with 95 cases of bacteremia and 5 cases of bacterial meningitis. A little bit over half (57%) with bacteremia also had UTI.

Of those infants 1207 (24%) had procalcitonin and absolute neutrophil count (ANC) measured. That group had 27 with IBIs with 2 being bacterial meningitis.  Low risk predictors:

This decision rule missed 14 infants with IBIs (13 with bacteremia and one with Group B Strep meningitis).

There was a second decision rule that included procalcitonin ≤0.24 ng/mL and ANC  ≤10,710 cells/mm3. The derivation sensitivity was 100% but dropped to 85.2% on cross-validation. The specificity was around 65-68%. NPV ranged from 99.5-100%, Negative likelihood ratio was 0.22.

Tune in to the podcast to hear Drs. Aronson and Kuppermann answer our nerdy questions.

Selection Bias

This secondary analysis included only febrile infants aged 61-90 days who underwent both urine and blood testing. A total of 20,211 infants in that age range had fevers, but only 30% of them had urine and blood cultures obtained. It’s also mentioned that the included infants had higher maximum qualifying temperatures, more assigned ESI triage level 2, and received parenteral antibiotics or were hospitalized. It’s possible that these infants may have been deemed sicker than those who did not undergo testing. The study was unable to capture the clinical decision-making that determined which infants underwent testing and which did not.

How do you think this selection bias could impact your results?

Overfitting the Data

 The PCT and ANC rule showed perfect sensitivity in derivation but lower sensitivity on cross-validation (4 false negatives). This is a pattern that may represent model instability especially when dealing with uncommon outcomes. Increasing model complexity can improve apparent performance in the derivation set but worsen performance in validation because of overfitting.

What steps did you take to try to limit overfitting and what changes if any do you anticipate in making to this CDR for external validation?

The “Original” PECARN

 Although this new clinical decision rule has a high NPV, we must also recognize the limitation that the prevalence of IBI is low. As disease prevalence decreases, NPV increases. The study team did look at this with the “original” PECARN rule’s rounded cutoffs of procalcitonin ≤0.5 and ANC ≤4000 without urinalysis. The sensitivity was 100% (95% CI 87.2-100) and specificity was 49.7% (95% CI 46.8-52.6). This was in the supplemental section.

While we’re waiting for external validation of this new clinical decision rule, why not use the tried-and-true existing clinical decision rule? One less thing with new cutoffs for inflammatory markers to remember right?

90 Days and Beyond!

 The clinical decision rule in this study, if and when externally validated, would apply to infants up to 90 days. What about beyond that? There’s quite a bit of variation in practice when it comes to workup for infants 2-6 months presenting with fever to the emergency department.

How do you approach the workup of infants over 90 days? 

Prematurity

Many of the existing clinical decision rules exclude infants born prematurely. In reality, we also encounter these patients in the ED.

How do you approach the workup of a febrile premature infant? 

Bonus Question: Respiratory Virus Testing

You report that you were unable to assess the results of respiratory viral testing as a predictor because of missing data, but we do know that febrile infants with viral infections do seem to have lower prevalence of IBI compared to those without.

In your clinical practice, how do you manage infants with viral symptoms? Is there a role for obtaining a respiratory viral PCR test?

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

Case Resolution: You acknowledge the parents’ concern and explain to them that their daughter’s age makes the approach to testing a little bit different compared to if she were still a really young infant. While there is still some risk of urinary tract infection, which is most common, and bacteremia, the risk of bacterial meningitis is lower.

You explain that you’d recommend at least checking the urine and engage in shared-decision-making about whether to pursue blood tests.

Clinical Application: Tune in to hear the response from Drs. Aronson and Kuppermann

Is this clinical prediction tool ready for us even without external validation?

What do you do if the infant does NOT meet low risk criteria based on this tool?

What Do I Tell the Patient? I’m sorry your daughter has a fever. Based on her age, we approach how we work-up a fever a little bit differently in comparison to if she were younger. We can check her urine for signs of a urinary tract infection. This is the most common bacterial infection in this age group. We could also obtain blood tests to determine whether bacteria are present in her blood. Her risk of infection, including bacterial meningitis, is lower given her age.

I would recommend at least checking her urine. Let’s talk more about doing the blood tests.

The post PODCAST: Here it Goes Again – Another Clinical Decision Rule for Febrile Infants 61-90 Days first appeared on האיגוד הישראלי לרפואה דחופה.

Non-invasive ventilation (NIV) refers to respiratory support provided without endotracheal intubation. The most common modalities include continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and high-flow nasal cannula (HFNC). These therapies aim to improve oxygenation, reduce the work of breathing, and potentially prevent invasive mechanical ventilation.

The post PODCAST: Demystifying Non-Invasive Ventilation & HiFlow first appeared on האיגוד הישראלי לרפואה דחופה.

We discuss the diagnosis and management of SCAPE in the ED.

Hosts:

Download Leave a Comment Tags: Acute Pulmonary Edema, Critical Care

Course Highlights:

Click Here to Register and Begin Module 1 The Clinical Case

Differential Diagnosis for the Hypoxic/Tachypneic Patient

What is SCAPE?Sympathetic Crashing Acute Pulmonary Edema (SCAPE) is characterized by a sudden, massive sympathetic surge leading to intense vasoconstriction and a precipitous rise in afterload.

Bedside Diagnosis: POCUS vs. CXRPOCUS is the gold standard for rapid bedside diagnosis.

Management Strategy 1. NIPPV (CPAP or BiPAP)Start NIPPV immediately to reduce preload/afterload and recruit alveoli.

2. High-Dose NitroglycerinThe goal is to drop SBP to < 140–160 mmHg within minutes.

3. Refractory HypertensionIf SBP remains > 160 mmHg despite NIPPV and aggressive NTG, add a second vasodilator:

Troubleshooting & Pitfalls The “Mask Intolerant” PatientHypoxia is the primary driver of agitation. NIPPV is the best sedative. * Pharmacology: If needed, use small doses of benzodiazepines (Midazolam 0.5–1 mg IV).

The Role of DiureticsIn SCAPE, diuretics are not first-line.

Disposition

Take-Home Points

The post PODCAST: Sympathetic Crashing Acute Pulmonary Edema (SCAPE) first appeared on האיגוד הישראלי לרפואה דחופה.

Mike Weinstock on medmal cases: upper back pain (1:29)

Andrew Petrosoniak on traumatic pneumothorax and hemothorax decision making (27:55)

Justin Morgenstern on brain injury guidelines: risk stratification for neurosurgical consult, imaging and admission (38:23)

Andrew Tagg on management of post-circumcision bleeding  (47:32)

Hans Rosenberg & Ariel Hendin on evaluation and management of CT contrast allergy  (50:30)

Shawn Seregren on emotional contagion in resuscitation teams  (59:30)

Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Anton Helman, January, 2026

Cite this podcast as: Helman, Petrosoniak, A. Morgenstern, J. Tagg, A. Rosenberg, H. Hendin, A. Seregren, S. EM Quick Hits 70 – MedMal Case Upper Back Pain, Traumatic Pneumothorax/Hemothorax Decision Making, Risk Stratification of ICH for Consultation, Post-Circumcision Bleeds, IV Contrast Allergy, Emotional Contagion. Emergency Medicine Cases. January, 2026. https://emergencymedicinecases.com/em-quick-hits-70-jan-2026/. Accessed January 14, 2026.

This is Part 1 of a 2-part EM Quick Hits series on traumatic pneumothorax/hemothorax

This determines urgency, imaging, and tube selection for traumatic pneumothorax.

Peri-arrest or unstable patients with suspected traumatic pneumothorax: Immediate decompression is required—often before imaging. Finger thoracostomy followed by large-bore surgical chest tube placement prioritizes speed, reliability, and maximal drainage.

Stable patients allow for nuance. Imaging-based thresholds for traumatic pneumothorax help guide decisions:

Chest X-ray: pneumothorax >38 mm or >20% hemithorax

CT chest: pneumothorax >35 mm (largest lung-to-chest-wall distance)

For hemothorax, CT is preferred as size is difficult to quantify on ultrasound and chest X-ray; roughly 300 mL or pleural thickness >1.5 cm is a practical cutoff for drainage.

Stable patients generally benefit from CT imaging, which improves diagnostic certainty and decision-making.

*These thresholds apply primarily to patients without hemothorax and without significant oxygen requirements.

*Decisions should integrate imaging findings with respiratory status and work of breathing.

Evidence supports pigtail catheters for stable patients with traumatic pneumothorax and hemothorax, with similar outcomes to large-bore tubes. However, large-bore surgical tubes remain preferred in unstable patients, those with suspected pleural adhesions, significant subcutaneous emphysema, or complex injury patterns.

The AAST Brain Injury Guidelines (BIG 1–3) stratify traumatic intracranial hemorrhage by clinical risk and bleed characteristics to reduce unnecessary neurosurgery consults, repeat CTs and admissions while maintaining patient safety. Risk assignment is based on neurologic exam, intoxication status, anticoagulation, and bleed characteristics.

BIG 1 (low risk): small, simple bleeds, perfect neuro exam, no intoxication, no anticoagulants → in the study there were no neurosurgical interventions and very low rates of progression, but the data are still limited and confidence intervals wide.

BIG 2 (moderate risk): normal exam but larger bleeds or higher‑risk features → admit, repeat exam and CT; neurosurgical consultation is not mandatory up front, as neurosurgery interventions were 0% in this group despite ~7% radiographic progression.

BIG 3 (high risk): any neuro abnormality, anticoagulation/antiplatelet use (including aspirin), or larger/more complex bleeds → neurosurgery consult, admission and repeat CT; this group had high rates of clinical deterioration, progression and neurosurgical intervention.

Pragmatic approach:

BIG 1 (low risk): consider observation + reassessment; discharge only if your local system supports it and follow-up is reliable.

BIG 2 (moderate risk): admission often reasonable; consider repeat imaging selectively (progression isn’t zero).

BIG 3 (high risk): neurosurgical consult + admission + repeat imaging.

First10EM deeper dive into AAST Brain Injury Guidelines

Modern iodinated and gadolinium contrast agents are remarkably safe. Contrast agents used after 2000 are significantly safer than older formulations.

True contrast hypersensitivity is rare, most “contrast allergies” are misclassified, and routine steroid premedication should be abandoned.

How common are true allergic reactions?

Shellfish or iodine allergies are not contrast allergies.

Many “contrast allergies” represent physiologic or non-allergic reactions.

Longstanding steroid premedication protocols persist despite weak, outdated evidence derived from older high-osmolar contrast agents. Contemporary data show:

Contrast switching

Which antihistamines are best for treatment of true mild IV contrast allergy?

Poor documentation is the biggest barrier to safe imaging—always record the exact contrast agent, reaction type (immediate vs delayed), severity, treatment required, and outcome.

Bottom line: switch contrast agents, document accurately, and stop reflex steroid premedication.

Resuscitations are not emotionally neutral environments. Emotional contagion describes how tone, pace, and affect spread unconsciously through teams, shaping the emotional climate of the room. The emotional tone of a resuscitation is strongly influenced by the team leader. Leaders often underestimate how their tone affects team performance. A rushed or sharp tone amplifies anxiety, cognitive overload, and error. Calm, firm leadership steadies performance—even when decisions are complex or stakes are high. Simple, trainable behaviors help regulate the room:

Importantly, leadership is shared. Nurses, recorders, and respiratory therapists can actively dampen rising tension with neutral phrasing and steady updates. Leadership skills require deliberate practice, often recognized after simulation.

Bottom line: emotional regulation is not “soft skills”—it is a patient safety intervention.

The post PODCAST: EM Quick Hits 70 MedMal Cases Upper Back Pain, Traumatic Pneumothorax/Hemothorax Decision Making, Risk Stratification of ICH for Consultation, Post-Circumcision Bleeds, IV Contrast Allergy, Emotional Contagion first appeared on האיגוד הישראלי לרפואה דחופה.

Date: January 5, 2026

Reference: Robblee et al. 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache 2025 Dec

Happy New Year, SGEMers! What better way to start 2026 than with an SGEM Xtra about migraine headaches? We were originally scheduled to record this episode in December, but circumstances changed.

This is another SGEM Xtra and not the typical structured critical appraisal with a checklist. It will be a conversation about what we should be doing and should stop doing when treating migraine patients in the ED based on the new American Headache Society (AHS) guidelines. However, you will find a standard SGEM nerdy critical appraisal at the end of this blog post.

Migraine is one of the most common causes of headache visits to the ED, representing ~¼ of the 3.5 million annual headache-related visits in the US. Despite prior guidelines, ED practice is still all over the map, and patients sometimes leave without much relief. The AHS has just released the 2025 guideline update on parenteral pharmacotherapies and nerve blocks for adult ED migraine. To help us understand these new guidelines, we are joined by two neurologists who literally wrote the guidelines.

Dr. Jennifer Robblee

Dr. Jennifer Robblee (lead guideline author) is a Board‑certified neurologist and headache specialist at Barrow Neurological Institute in Phoenix. Her practice focuses on refractory migraine and status migrainosus. She trained at the University of Toronto (MD, neurology residency, MSc) and completed a headache fellowship at the Mayo Clinic Scottsdale.

Jennifer is the third eurologist to be on the SGEM. We’ve had Dr. Jeff Saver and Dr. Ravi Garg discuss thrombolytics and stroke. This will be an example that not all of neurology and emergency medicine intersect over stroke care.

Dr. Serena Orr

Dr. Serena Orr (senior guideline author) is a pediatric neurologist, headache subspecialist, and director of the pediatric headache program at Alberta Children’s Hospital in Calgary. Serena has a strong interest in acute treatment of migraine, tech‑based treatment solutions, and psychosocial factors affecting migraine in kids and teens.

The AHS guideline committee uses a 5-year update cycle for guidelines. Since 2016, 26 new RCTs and 20 injectable treatments, including nerve blocks (GONB, SONB, SPG) and eptinezumab.  Unfortunately, ED migraine outcomes are still not great. Only ~37% of ED patients achieve headache freedom at discharge.

These new guidelines were trying to answer two questions.

Listen to the SGEM podcast to hear Jennier and Serena discuss the top five things emergency physicians should know about the 2025 migraine guidelines.

1. Prochlorperazine IV & Greater Occipital Nerve Blocks (GONB) Are Now Level A “Must Offer”

2. Hydromorphone Is Level A “Must NOT Offer”

3. The Level B Recommendations: 

4. Nerve Blocks Are Mainstream

5. Big Evidence Gaps

No meta‑analyses were possible because of significant heterogeneity in methods and outcomes. Additional ED-specific outcomes, such as pain relief at 1 hour. Asking about patient-oriented outcomes (POO) such as “Would you want this treatment again on your next ED visit?” Need ED‑specific data on eptinezumab (currently Level U for general ED use despite strong outpatient data).

The goal here is not to dunk on the guideline; there are limitations to any study.  This is just a nerdy conversation about how the next cycle could be improved. Listen to the SGEM Xtra podcast to hear Jennifer and Serena respond.

Limitation 1: Risk of Bias Tool & Study Quality Nuances

Limitation 2: External Validity – Not All RCTs Were ED RCTs

Limitation 3: Active Comparators of Unclear Significance

Limitation 4: No Meta‑Analyses; Reliance on Narrative Synthesis

Limitation 5: Broader Biases – Publication, Selection, and the ED Reality

Reference: Robblee et al. 2025 guideline update to acute treatment of migraine for adults in the emergency department: The American Headache Society evidence assessment of parenteral pharmacotherapies. Headache 2025 Dec

Background: Migraine is one of the most common reasons people roll into the ED with a headache, and it’s not just “a bad headache.” It’s a chronic neurologic disorder that affects over a billion people globally and is consistently among the top causes of years lived with disability, especially in young and middle-aged adults [1.2].  In the ED specifically, migraine accounts for about one‑quarter of the ~3.5 million headache-related visits per year in the US. That’s a lot of stretchers tied up with photophobic patients in dark rooms.

Clinically, migraine is defined by the International Classification of Headache Disorders (ICHD‑3). Typical attacks last 4 to 72 hours and are moderate to severe, often unilateral, pulsating, and worsened by routine physical activity. They’re commonly accompanied by nausea and/or vomiting and photophobia/phonophobia [3]. Migraine without aura is the most common type; migraine with aura adds transient focal neurologic symptoms (usually visual) that precede or accompany the headache. Diagnosis in the ED is clinical: apply ICHD‑3 criteria, look for a typical migraine phenotype, and screen for red flags (fever, meningeal signs, focal deficits, thunderclap onset, immunocompromise, anticoagulation, etc.) to rule out secondary causes.

Outside the ED, acute migraine treatment usually starts with oral NSAIDs or acetaminophen, triptans, and newer agents like gepants or ditans, often combined with antiemetics. Preventive therapy (beta‑blockers, topiramate, CGRP monoclonal antibodies) targets attack frequency and disability, not the single ED visit [4,5].  In the ED, however, patients usually present with moderate–severe attacks that have failed home therapy and can’t tolerate oral meds, so parenteral therapies (IV/IM/SC drugs and nerve blocks) dominate practice. Historically, ED care has been all over the map, with substantial opioid use and only about 37% of patients leaving headache‑free in one large study. This is the gap the new American Headache Society (AHS) guideline is trying to address.

Authors’ Conclusions: “Prochlorperazine IV and GONB must be offered to eligible adults presenting to the ED with a migraine attack for treatment of headache requiring parenteral therapy (level A – must offer) in those without contraindications, while hydromorphone IV must not be offered (level A – must not offer). Treatments that should be offered when appropriate (level B – should offer) include dexketoprofen IV, ketorolac IV, metoclopramide IV, sumatriptan SC, and SONB. Chlorpromazine IV, dexamethasone IV, and valproate IV may be offered (level C – may offer). Paracetamol IV may not be offered (level C – should not offer). Eptinezumab should be offered (level B) only for patients matching the clinical trial population but is rated level U – no recommendation for an ED-­ specific population. Additional evidence is needed for caffeine, granisetron, ibuprofen, ketamine, lidocaine, normal saline, propofol, and SPG blocks, all currently rated level U – no recommendation.”

Quality Checklist for Guidelines (Yes/No/Unsure)

The guideline uses the AAN/AHS scheme for communicating the strength of recommendations:

Level A – Must Offer & Must NOT Offer

Level B – Should offer / Should NOT offer

References:

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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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Roy Perlis, MD, MSc1; Yulin Hswen, ScD, MPH2

In this episode of JAMA+ AI Conversations, we review the past year in AI and health, and talk about what we hope to see this coming year. We discuss our favorite articles and what they might mean for the future of medicine.

This interview is part of a series in which JAMA Network editors and expert guests explore issues surrounding the rapidly evolving intersection of AI and medicine.

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