נירולוגיה - האיגוד הישראלי לרפואה דחופה

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May 24PODCAST: Pediatric Agitation: Assessment and Management
“This learning material is sourced from Emergency Medicine Cases and has been published here with permission as per Creative Commons copyright.”
Pediatric agitation in the Emergency Department is one of those presentations that can escalate quickly and leave even experienced clinicians feeling on edge. It is high-risk, resource-intensive, and often unfolds in an already overstimulating environment where small missteps can make things worse. At the same time, agitation is not a diagnosis, it is a clinical presentation that may reflect anything from psychiatric illness to delirium, intoxication, trauma, or simply a child overwhelmed by the ED itself. So how do we approach these patients in a way that is safe, systematic, and effective?
In this episode with guest experts, Dr. Susan Duffy and Dr. Thomas Chun, we tackle the questions that come up at the bedside: How do we rapidly distinguish mild, moderate, and severe agitation in a way that actually changes what we do next? Which patients are most likely to escalate, and how can we intervene early to prevent that? When should we be worried about a medical or toxicologic cause rather than assuming this is “behavioural”? What does effective verbal de-escalation actually look like in a busy ED, and why does it so often fail? When is a “code white” for emergency security measures truly indicated, and how do we avoid turning it into an escalation trigger? How should we be thinking about medications: what to choose, when to give them, and how to avoid over-sedation? And once the patient is finally calm, how do we make sure we aren’t missing the underlying diagnosis? and many more…
Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul
Written Summary and blog post by Sara Brade, edited by Anton Helman April 2026
Cite this podcast as: Helman, A. Duffy, S. Chun, T. Ep 217 Pediatric Agitation: Assessment and Management. Emergency Medicine Cases. April 2026. https://emergencymedicinecases.com/pediatric-agitation-assessment-and-management. Accessed May 24, 2026
Résumés EM Cases
Classifying pediatric agitation in the ED as mild, moderate, or severe
The first task is to determine whether the agitation is mild, moderate, or severe, because this classification drives almost everything that follows: where the patient is placed, who needs to be involved, how closely the patient must be observed, whether urgent intervention is required, and what pharmacologic options are appropriate. Our experts emphasize that this categorization is not merely descriptive: it’s operational. It creates a shared mental model for the team so everyone can share the same level of concern and the same urgency of response.
In practical terms:
Mild agitation: patient is anxious, restless, or oppositional but remains redirectable and able to engage with staff. These patients are appropriate for standard ED spaces with early environmental modification.
Moderate agitation: patient demonstrates escalating behavior, is intermittently unsafe, or has limited ability to engage. These patients require closer observation, early team involvement, and proactive planning for escalation.
Severe agitation: patient poses an imminent risk to self or others, is not redirectable, or is actively violent. These patients require immediate safety interventions, including possible security involvement and pharmacologic management.
There are clinical tools such as the Aggressive Behaviour Assessment Risk Tool (ABRAT) and the Brief Rating of Aggression by Children and Adolescents (BRACHA) to guide assessment; however, our experts emphasize that clinical judgement is paramount in these cases.
Anticipating agitation: Early identification of pediatric patients at high risk of agitation in the ED
Our best tool for managing pediatric agitation in the ED is prevention. This starts at triage. Even when a child appears calm on first encounter, the team should identify red flags that suggest a higher likelihood of escalation during the ED visit.
The most predictive factor is a prior history of aggression. This is particularly important when the child has presented because of aggression at home, school, or in the community, even if they appear settled on arrival. Other important risk factors include:
Adolescence
Male sex
Known psychiatric or behavioural diagnoses
Current or prior substance use
Neurodevelopmental disorders such as autism spectrum disorder or developmental delay
History of trauma, abuse, or neglect
These factors influence how patients perceive the ED environment as they may be sensitive to noise, authority figures, unpredictability, and loss of control. Identification of these risk factors should trigger preventative communication and environmental modification strategies.
Using a trauma-informed approach to prevent pediatric agitation in the ED
Children with agitation often have prior experiences that affect how they respond to the ED. A trauma-informed approach means recognizing that what may look like “bad behaviour” can actually represent fear, loss of control, sensory overload, or a learned protective response.
Key early prevention interventions include:
Place patient in a low-stimulation environment (quiet room, minimal traffic)
Avoid crowded waiting areas
Ask who the patient wants present (or not present)
Offer food, drink, and comfort items
Maintain a calm, non-confrontational approach
Set expectations early (including wait times)
If repeat visits, ask about and offer interventions that have been previously helpful
Pearl: Do not ignore these patients. Lack of engagement and long waits increase agitation. Regular team check-ins reduce escalation risk.
Initial stabilization of the agitated pediatric patient: simultaneous safety assessment and evaluation for medical causes
Once agitation is present, the clinician’s job is not simply to calm the child down. The more important task is to determine whether this is primarily a psychiatric or behavioral presentation, or whether there is an underlying medical cause that requires urgent treatment.
Red flags that suggest a medical or toxicological cause of agitation include:
Delirium or acute confusional state
Head trauma or other injury
Hypoxia
Hypoglycemia
DKA or metabolic derangement
Infection
Intoxication or withdrawal
Other acute medical illness
Some EDs choose critical care or high-observation areas for severely agitated pediatric patients because they are often undifferentiated and may require urgent medical assessment and monitoring.
Verbal de-escalation is the central intervention in pediatric agitation
Verbal de-escalation is a structured and team-based intervention that begins the moment the patient enters the ED and should continue throughout the entire encounter.
The foundational elements of de-escalation include:
Stay calm and regulate your own emotional response
Use one designated lead communicator
Give the patient physical space
Avoid provocative language or confrontational postures
Use simple, direct, concise language
Be realistic and honest about limits
Focus the conversation on safety
Offer choices whenever possible
Useful de-escalation language includes:
“How can we help you feel safe?”
“We want you to feel safe, and we need everyone here to be safe.”
“When you do that, it makes us worried about safety.”
“You have a choice — we can try this by mouth or by injection.”
“What helps when you feel like this?”
When to activate a “code white” for the agitated pediatric patient in the ED
Calling a “code white” or emergency security response is one of the most consequential decisions in agitation management. This response should be reserved for cases with concern for imminent harm to self or others. It is not a response to mere non-compliance, verbal hostility, or frustration if the patient is still redirectable and not yet physically threatening.
Indications for calling a “code white”/emergency security response include:
Imminent physical threat to staff
Imminent risk of self-harm
Severe agitation that is no longer responsive to de-escalation
Need for multiple trained personnel to maintain safety
If staff are becoming increasingly concerned for safety, it is better to communicate calmly and transparently: “We’re worried about safety. We want to avoid restraints. How can we work together to keep everyone safe?” That keeps the focus on collaboration and preserves the possibility of de-escalation even as staff prepare for escalation.
Pitfall: Calling a “code white”/emergency security response is a safety response, not a disciplinary tactic. The most important pitfall is using a code white as a threat. “If you don’t cooperate, we’ll call security and hold you down” is counterproductive and often escalates the situation further. A code white should never be framed as punishment or coercion.
Use of restraints in pediatric agitation is a last resort
If physical restraint becomes necessary, it should be used only as a last resort, for the shortest possible duration, and almost always as a bridge to calming medication.
Important safety principles of physical restraints:
Constant observation is essential
Restraint use should follow institutional policy and time limits
Restraints usually go hand in hand with medication
Staff should be trained in safe restraint technique
Prolonged restraint should be avoided whenever possible
Some pediatric centers also use structured papoose-style restraints for selected neurodevelopmental patients, or specially designed chair restraints in behavioural settings.
Pitfall: A common pitfall is prolonged and/or inappropriate use of physical restraints. Restraints are not treatment. They are a temporary safety measure while definitive calming measures take effect. The overarching principle is to use the least harmful method that safely contains the patient, and discontinue it as soon as possible.
Pharmacologic management of the agitated pediatric patient
When medications are needed, the goal is to calm the patient, not over-sedate them. The ideal medication choice depends on the likely cause of agitation, the urgency of the situation, the patient’s age and co-morbidities, prior medication response, and practical issues such as route and onset of action.
Key principles of medication management of the agitate pediatric patient in the ED:
Continue verbal de-escalation while planning medications
Offer oral medication first if feasible
Avoid trying to place an IV in a severely agitated child
Know the onset and peak effect of the medication you choose
Make a safe plan while waiting for the medication to work
For the undifferentiated severely agitated child, a second-generation antipsychotic such as olanzapine is our experts’ go-to agent, with some clinicians using a combination of olanzapine and lorazepam depending on the situation. There are no robust RCTs to guide calming medication choices for pediatric agitation. A truly undifferentiated patient is uncommon; usually, some information about psychiatric history, developmental condition, substance exposure, or prior medication response can be obtained and should guide medication choice.
The oral route is preferred when possible, IM is used when danger is imminent, and IV is rarely needed.
Pearl: Even highly agitated children sometimes accept oral medication if it is presented as a meaningful choice. A child who seems to be heading toward IM treatment may still say, “I’ll take the oral medication.” That moment of choice can preserve dignity and reduce the need for force.

Preventing re-escalation: ongoing environmental management in pediatric agitation
After the patient has settled, the work is not done. The ED remains a high-risk environment for re-escalation. Our experts emphasize that ongoing management of the room and the care process is one of the most important determinants of whether the patient stays calm.
Helpful ongoing strategies include:
Keep the room low-stimulation
Limit nonessential staff traffic
Remove potentially dangerous objects
Offer food and hydration
Provide distraction with music, videos, games, or cards
Use child life experts, caregivers, sitters, or observers constructively
Revisit what the child says helps them feel safe
Give regular updates so the patient does not feel forgotten
Other practical examples include: using guided imagery, weighted blankets, sensory tools, headphones, puzzles, and comfort items; allowing a preferred caregiver to remain present; and even maintaining a dedicated “autism closet” or activity closet to improve environmental support.
Revisiting the differential diagnosis in pediatric agitation
Once initial safety is restored, the clinician should return to the underlying cause. The adult EM Cases approach is especially helpful here: after calming medications take effect, clinicians should actively pursue immediate life threats and the diagnosis beneath the agitation.
Reassess for:
Delirium
Intoxication or withdrawal
Trauma
CNS pathology
Metabolic derangement
Infection
Primary psychiatric illness
Developmental or sensory contributors
Children with developmental disorders, autism, acute psychosis, intoxication, or trauma-related dysregulation may all look superficially “agitated,” but their optimal management differs. The more clearly the clinician identifies the driver, the safer and more effective the care becomes.
Take-home points for management of pediatric agitation
Start by classifying pediatric agitation as mild, moderate, or severe, because severity determines the management.
Anticipate agitation early at triage by identifying prior aggression, trauma, neurodevelopmental conditions, substance use, and other risk factors.
Prevent escalation with a trauma-informed approach, low-stimulation environment, clear expectations, and attention to the child’s preferences and triggers.
Use verbal de-escalation early and continuously, with one calm communicator focusing on safety, empathy, and choice.
Reserve “code white”/emergency security response and physical restraints for imminent danger, never as threats or substitutes for thoughtful care.
Choose medications based on likely etiology, prior response, and the goal of calming rather than over-sedating.
Once the patient is calmer, identify and treat the underlying cause of agitation.
References

Expand to view reference list
The post PODCAST: Pediatric Agitation: Assessment and Management first appeared on האיגוד הישראלי לרפואה דחופה.
1 hr 23 min
January 11PODCAST: Hit Me with Your Best Block – 2025 AHS ED Migraine Guidelines
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.
Which injectable meds are effective in adults with migraine in the ED?
Are nerve blocks effective in adults with migraine in the ED?
Top 5 things ED should know about the 2025 AHS Migraine Guidelines
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”
IV prochlorperazine and greater occipital nerve blocks (GONB) are Level A – must offer or adults presenting to the ED with a migraine attack requiring parenteral therapy (if no contraindications).
Questions:
This is a big upgrade from 2016. Why did prochlorperazine and GONB earn Level A status in 2025?
Practically, what does that look like in an ED order set? Are you imagining that everyone gets prochlorperazine?
For the EM docs who have not been performing occipital nerve blocks, how steep is the learning curve?
2. Hydromorphone Is Level A “Must NOT Offer”
Hydromorphone IV: Level A – Must NOT offer for migraine in the ED.
Questions:
Let’s talk about opioids. Hydromorphone is now ‘must NOT offer’, what tipped the scale to Level A harm/no benefit?
“Must NOT offer” seems like a strong statement (thou shalt not), is there not a potential clinical situation where an opioid still should be offered?
How do we balance real‑world pressures, patient expectations, throughput, Press Ganey scores with an anti‑opioid, evidence‑based stance? It’s going to impact ED docs and not neurologists.
3. The Level B Recommendations:
Level B – “Should offer” for headache requiring parenteral therapy (Dexketoprofen IV, ketorolac IV, metoclopramide IV, subcutaneous sumatriptan, and supraorbital nerve blocks [SONB]).
Dexamethasone IV remains Level B “should offer” for recurrence prevention from the 2016 guidance.
Questions:
If Level A is your starting lineup, who’s on the bench as your Level B ‘should offer’ options, and when do you pull them in?
Is there a preferred sequence – dopamine antagonist first, then NSAID, then triptan, or is it more patient‑specific?
How should ED clinicians think about dexamethasone? Is it still a routine add‑on, or more selective?
4. Nerve Blocks Are Mainstream
GONB: Level A – Must offer.
SONB: Level B – May/should offer when GONB is insufficient or not possible.
Questions:
For a busy ED, how realistic is it to integrate occipital and supraorbital nerve blocks into standard migraine care?
What’s the pragmatic advice on training?
Can EM doctors become competent with blocks via bedside teaching and FOAMed resources>
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).
Questions:
If you had unlimited funding for one ED migraine randomized control trial, what would you test, and what outcome would you choose?
You recommended a 1‑hour endpoint for ED trials. How does that change how we design and interpret future studies?
I love the idea of the patient-centred outcome: ‘Would you want this again?’ How do we make sure future trials include that kind of measure?
Five Limitations of the AHS Migraine Guideline
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
Question: “You explicitly say that some ‘class I’ RCTs had small sample sizes or weird time points that made you less confident. From an EBM standpoint, how did you reconcile the AAN RoB categories with what we’d call imprecision and indirectness in GRADE?”
Limitation 2: External Validity – Not All RCTs Were ED RCTs
Question: “Many of the trials you had to work with weren’t actually done in ED settings – eptinezumab and SPG blocks being two examples. How worried should we be about extrapolating outpatient data into the ED, where patients are often later in the attack, more distressed, and maybe have different comorbidities?”
Limitation 3: Active Comparators of Unclear Significance
Question: “You call out trials that compare against ‘iffy’ active controls (valproate, dexamethasone, etc). In EBM terms, this muddies the signal. If you beat a weak comparator, is your drug actually good? How did you handle that when grading evidence and crafting recommendations?”
Limitation 4: No Meta‑Analyses; Reliance on Narrative Synthesis
Question: “From a methodological point of view, the fact that you couldn’t meta‑analyze anything limits precision and makes it hard to quantify effect sizes. How should EM clinicians interpret Level A or B recommendations that rest on narrative synthesis instead of pooled estimates?”
Limitation 5: Broader Biases – Publication, Selection, and the ED Reality
Question: “Zooming way out, every guideline sits on top of the published RCT iceberg. How much do you worry about publication bias, selection bias, and the fact that ED patients we see at 3 am rarely look like the trial population?”
Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.
Critical Appraisal
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.
Clinical Question: In adults presenting to the ED with an acute migraine attack requiring parenteral therapy, which injectable medications and nerve blocks improve pain and related outcomes, and which should be avoided?
Population: Adults (>18 years) with an ICHD-diagnosed migraine who presented to the ED with a migraine attack. The update includes 26 new randomized controlled trials (RCTs) with 3019 additional participants, added to the 2016 evidence base. Most trials enrolled adults with moderate–to–severe migraine, often with previous migraine history; some nerve‑block and biologic trials included more selected or outpatient populations, which becomes a limitation later.
Exclusions: Children, non‑ED settings, non‑parenteral interventions or comparators, nonmigraine headaches, non‑RCTs, and non‑English trials.
Interventions:
Medications: Dopamine antagonists (prochlorperazine IV, chlorpromazine IV, metoclopramide IV, haloperidol IV/IM, and droperidol IM), NSAIDs and related (ketorolac IV, dexketoprofen IV, diclofenac IM, IV aspirin, dipyrone IV, and ibuprofen IV), Antiepileptic (valproate IV), Corticosteroid (dexamethasone IV), Antihistamine (diphenhydramine IV – mainly for akathisia prevention and as an active comparator), Opioids (hydromorphone IV, morphine IV, meperidine IV, nalbuphine IV, tramadol IV), Other agents (magnesium IV, caffeine IV, granisetron IV, ketamine IV, lidocaine IV, paracetamol/ acetaminophen IV, normal saline IV, propofol IV, dihydroergotamine IV/SC, octreotide IV/SC, ergotamine SC, lysine clonixinate IV, trimethobenzamide IM and biologic (eptinezumab IV).
Nerve Blocks: Greater occipital nerve block (GONB), supraorbital nerve block (SONB) and sphenopalatine ganglion (SPG) blocks. These are delivered with local anesthetics like lidocaine or bupivacaine in various doses and volumes.
Comparison: Placebo parenteral injections (saline or sham blocks) or active parenteral comparators (another ED migraine drug or a ess well‑supported agents like IV valproate or dexamethasone used as controls). Non‑parenteral comparators (oral agents) were explicitly excluded.
Outcomes: Each trial had to report pain outcomes within 6 hours of administration.
Primary Outcomes: Change in headache intensity on a numerical rating scale (NRS) or VAS at an early time point (often 1–2 hours). Proportion of patients achieving “headache freedom”or at least 50% reduction in pain by a specified time (often discharge/2 hours). Need for rescue medication in the ED
Secondary Outcomes: Headache recurrence after discharge (24 to 48 hours). Functional outcomes (ability to resume normal activity). Patient‑reported satisfaction or willingness to receive the same treatment again. Adverse events (akathisia, dystonia, hypotension, sedation, local anesthetic toxicity)
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)
Study population included or focused on those in the emergency department? Yes
Explicit and sensible process used to identify, select and combine evidence? Yes
Quality of the evidence explicitly assessed using a validated instrument? Yes
Explicit and sensible process used to weigh the relative value of different outcomes? Unsure
Guideline thoughtfully balances desirable and undesirable effects? Yes
Guideline accounts for important recent developments? Yes
Guideline has been peer‑reviewed and tested? Yes/No
Practical, actionable and clinically important recommendations are made?
Yes
Guideline authors’ conflicts of interest fully reported, transparent and unlikely to sway recommendations? Unsure
The guideline uses the AAN/AHS scheme for communicating the strength of recommendations:
Level A – Must / Must NOT offer
Level B – Should / Should NOT offer
Level C – May / May NOT offer
Level U – No recommendation
Key Recommendations:
Level A – Must Offer & Must NOT Offer
Must offer (Level A):
Prochlorperazine IV for adults with migraine attacks in the ED requiring parenteral therapy, without contraindications.
Greater occipital nerve block (GONB) with local anesthetic as an effective acute treatment in ED patients with migraine.
Must NOT offer (Level A):
Hydromorphone IV is judged likely ineffective and potentially harmful, and therefore recommended against for migraine-related pain relief.
Level B – Should offer / Should NOT offer
Should offer (Level B – positive): For adults with migraine in the ED requiring parenteral therapy, when clinically appropriate (Dexketoprofen IV, Ketorolac IV, Metoclopramide IV, Sumatriptan SC and Supraorbital nerve block)
Should offer (Level B – special case): Eptinezumab IV (100 mg) should be offered only to patients who closely match the outpatient clinical trial population; for general ED use it is rated Level U (no recommendation) because ED‑specific evidence is lacking.
Should NOT offer (Level B negative): No new designations at Level B negative beyond existing opioids, being strongly discouraged overall. The clearest negative recommendation is hydromorphone at Level A, which must not be offered.
Five Limitations that Threaten the Validity of the Guidelines:
Heterogeneity: Although the authors planned meta-analyses when ≥2 class I/II studies with comparable methods were available, they appropriately did not perform any meta-analyses because no intervention met the prespecified criteria for pooling. This means the evidence synthesis is entirely narrative, relying on qualitative judgment rather than quantitative pooling. Guidelines based on narrative synthesis are inherently more fragile than those built on robust, transparent meta-analyses where possible.
Use of Active Comparators with Uncertain Efficacy: Several RCTs used active controls such as IV valproate or dexamethasone. These are agents whose own efficacy is not strongly established in this setting and could be considered a “strawman”. The guideline explicitly flags this as a limitation, noting that “active controls of unclear significance” complicate interpretation, and that it can be unclear whether similar outcomes indicate both treatments are good or neither is effective. Trials using inadequately validated comparators risk biocreep and make effect sizes difficult to interpret. These comparator issues propagate up into guideline grading and can threaten the internal validity of some recommendations.
Limited ED‑Specific Data: The guideline includes evidence from non-ED populations for some interventions, notably eptinezumab IV and commercial SPG block kits, and appropriately downgrades or withholds ED-specific recommendations. From a validity standpoint, importing outpatient/chronic data into an ED acute‑care guideline raises concerns about indirectness (PICO mismatch), a key downgrade domain in systems like GRADE. This weakens the strength and applicability of those specific recommendations to ED patients.
Conflict of Interest & Potential Editorial Influence: The guideline authors fully disclose substantial relationships with industry (honoraria, advisory roles, research funding, and equity positions). While transparency is great and consistent with IOM standards, both the IOM and later methodological reviews stress that trustworthy guidelines should minimize and manage conflicts, particularly among chairs and voting members, given evidence that financial ties can shift recommendations toward more favourable or aggressive treatment. The paper notes reliance on AAN/AHS procedures and consensus when evidence was limited, which is precisely where COI‑related bias can creep in (choice of thresholds, downgrading vs not, enthusiasm for newer agents). We don’t have evidence that bias occurred, the degree of industry involvement should make us more skeptical of the recommendations.
Patient Values & Preferences: Multiple widely used guideline-development standards explicitly recommend involving patients/public (IOM, WHO, AGREE II, NICE and GIN). Knowing what patients want is one of the three pillars of evidence-based medicine (EBM). These guidelines did not involve any patient input during their development. It would be great if, in the next guideline, the AHS could find a way to engage with patients and ensure their preferences and values are known.
SGEM Bottom Line: For adults with acute migraine in the ED, intravenous prochlorperazine and greater occipital nerve blocks are now “must‑offer” treatments, opioids (especially hydromorphone) and IV acetaminophen should be avoided, and many other parenteral agents remain either “should offer,” “may offer,” or “no recommendation” based on a heterogeneous but systematically appraised evidence base.
References:
Dong L, Dong W, Jin Y, Jiang Y, Li Z, Yu D. The Global Burden of Migraine: A 30-Year Trend Review and Future Projections by Age, Sex, Country, and Region. Pain Ther. 2025 Feb;14(1):297-315. doi: 10.1007/s40122-024-00690-7. Epub 2024 Dec 11. PMID: 39661241; PMCID: PMC11751287.
GBD 2023 Headache Collaborators. Global, regional, and national burden of headache disorders, 1990-2023: a systematic analysis for the Global Burden of Disease Study 2023. Lancet Neurol. 2025 Dec;24(12):1005-1015. doi: 10.1016/S1474-4422(25)00402-8. PMID: 41240916; PMCID: PMC12612381.
HIS Classification of ICHD-3: https://ichd-3.org/1-migraine/1-1-migraine-without-aura/ Accessed December 5, 2025
Pescador Ruschel MA, De Jesus O. Migraine Headache. [Updated 2024 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560787/
Medscape. Chawla et al. Migraine Headache. https://emedicine.medscape.com/article/1142556-overview?form=fpf Accessed
The post PODCAST: Hit Me with Your Best Block – 2025 AHS ED Migraine Guidelines first appeared on האיגוד הישראלי לרפואה דחופה.
1 hr 13 min
July 26, 2025 PODCAST: Acute Agitation
We’re back with another episode of Push Dose Pearls with ED Clinical Pharacist, Haley Burhans! In this episode, we break down the essentials of managing agitation in the ED—starting with why you should avoid diphenhydramine in the elderly and benzodiazepines in the 3 D’s: drunk, delirium, and dementia. We discuss how to quickly assess the cause, choose the right medication, and decide between IM and IV routes. And Haley offers some key safety tips and considerations for special populations, including kids and the elderly.
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:
ACEP’s New Clinical Policy on Severe Agitation. By Molly E.W. Thiessen, MD, FACEP | on February 12, 2024
Pediatric Education and Advocacy Kit (PEAK): Agitation
Hoffmann JA, Pergjika A, Konicek CE, Reynolds SL. Pharmacologic Management of Acute Agitation in Youth in the Emergency Department. Pediatr Emerg Care. 2021 Aug 1;37(8):417-422. doi: 10.1097/PEC.0000000000002510. PMID: 34397677; PMCID: PMC8383287.
Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med. 2019 Mar;20(2):409-418. doi: 10.5811/westjem.2019.1.41344. Epub 2019 Feb 19. Erratum in: West J Emerg Med. 2019 May;20(3):537. doi: 10.5811/westjem.2019.4.43550. Erratum in: West J Emerg Med. 2019 Jul;20(4):688-689. doi: 10.5811/westjem.2019.4.44160. PMID: 30881565; PMCID: PMC6404720..
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21 min
May 20, 2025PODCAST: Parkinson’s, Myasthenia Gravis, and MS in the ED
In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the May 2025 Emergency Medicine Practice article, Emergency Department Management of Patients With Complications of Chronic Neurologic Disease: Parkinson Disease, Myasthenia Gravis, and Multiple Sclerosis
Parkinson’s Disease
Importance of maintaining medication schedule for Parkinson’s patients
Strategies for ensuring patients receive their medications promptly
Overview of Carbidopa Levodopa’s mechanism of action
Myasthenia Gravis
Description of the disease mechanism
Importance of assessing respiratory function
Diagnostic alternatives like the negative inspiratory force test and counting test
Discussion on appropriate emergency department actions and treatments including steroids, plasmapheresis, and IVIG
Multiple Sclerosis
Description of the disease mechanism
Description of the typical patient demographic
Discussion on the varied presentation of MS
Treatment strategies including high-dose steroids and Baclofen
Emergency Medicine Residents, get your free subscription by writing [email protected]
Sam Ashoo, MD
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: Parkinson’s, Myasthenia Gravis, and MS in the ED first appeared on האיגוד הישראלי לרפואה דחופה.
43 min
May 01, 2025PODCAST: Did You Ever Have To Make Up Your Mind – Midazolam or Ketamine for Acute Agitation in the Pre-Hospital Setting
Reference: Muldowney et al. A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting. Ann Emerg Med. 2025
Date: April 24, 2025
Guest Skeptic: Dr. Howie Mell received his Medical Doctorate (MD) from the University of Illinois at Chicago, College of Medicine at Rockford. Prior to that, he received a Master of Public Health (MPH) degree emphasizing Environmental and Occupational Health from the University of Illinois at Chicago, School of Public Health, while serving as a firefighter/paramedic in the Chicago suburbs. He completed his residency in emergency medicine at the Mayo Graduate School of Medicine, Rochester, Minnesota. Dr. Mell is board-certified by the American Board of Emergency Medicine in both Emergency Medicine (EM) and Emergency Medical Services (EMS) Medicine. He is a Fellow of the American College of Emergency Physicians (FACEP). Dr. Mell serves as an Ambassador Emergency Physician for Vituity (formerly CEP-America), and he is currently assigned to Schneck Medical Center in Seymour, Indiana (John Cougar Mellencamp’s “Small Town”).
Case: You’re an experienced paramedic working a busy night shift in an urban EMS system. Dispatch sends you to a call for a 35-year-old male found acting erratically in a public park. Upon arrival, you find him disoriented, agitated, and combative. Bystanders report that he has been using methamphetamine and alcohol.
The patient is uncooperative, making verbal de-escalation ineffective. Physical restraint is needed for transport. Your EMS protocol allows for pharmacologic sedation with either midazolam (1 to 5 mg IV/IM, repeat every 2 to 5 minutes as needed) or ketamine (5 mg/kg IM, max 500 mg).
The patient is tachycardic (HR 122 bpm), hypertensive (BP 156/96 mmHg), and has a Glasgow Coma Scale (GCS) score of 12. You need to act quickly for scene safety and the patient’s well-being.
Background: Acutely agitated patients in the pre-hospital setting present a unique challenge for emergency medical services (EMS). Agitation can stem from various underlying conditions, including psychiatric disorders, substance intoxication, metabolic disturbances, traumatic brain injury, or postictal states. If not managed appropriately, severe agitation can escalate, leading to self-harm, harm to others, or interference with necessary medical care.
Initial management emphasizes verbal de-escalation techniques, which should always be attempted first. However, when these strategies fail, pharmacologic sedation may be necessary to ensure the safety of both the patient and pre-hospital providers. The choice of sedative agent is a critical decision. The paramedic must balance the need for rapid sedation with the risk of adverse effects, including respiratory depression and cardiovascular instability.
Benzodiazepines, such as midazolam, have historically been used for pre-hospital sedation due to their anxiolytic and muscle-relaxant properties. However, their use is associated with risks such as respiratory depression and paradoxical agitation. In recent years, ketamine has gained popularity due to its rapid onset, potent dissociative properties, and preservation of airway reflexes. Despite its advantages, ketamine is not without concerns, including the potential for emergence reactions, increased blood pressure, and the need for airway management in some cases.
Current guidelines lack consensus on the optimal pharmacologic approach, leading to significant variation in practice across EMS systems. The ongoing debate surrounding the best sedation strategy highlights the need for robust clinical research to guide evidence-based practice. A newly published study aims to address this knowledge gap by comparing ketamine and midazolam in the out-of-hospital setting, shedding light on their relative efficacy and safety.
Clinical Question: In prehospital patients requiring pharmacologic sedation for acute behavioural disturbance, does ketamine or midazolam result in a lower need for emergent airway support?
Reference: Muldowney et al. A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting. Ann Emerg Med. 2025
Population: Patients with acute behavioural disturbances treated by an urban EMS system between 2017 and 2021.
Exclusion: Patients simultaneously administered both drugs
Exposure: Administration of midazolam
Comparison: Administration of ketamine
Outcome:
Primary Outcome: The need for emergent airway support, defined as endotracheal intubation or supraglottic airway insertion.
Secondary Outcomes: ED intubation rates and overall mortality.
Type of Study: Retrospective cohort study
Authors’ Conclusions: “In this cohort study of patients with acute behavioral disturbance, emergent airway support and other outcomes did not differ following out-of-hospital treatment with midazolam or ketamine.”
Quality Checklist for Observational Study:
Did the study address a clearly focused issue? Yes
Did the authors use an appropriate method? Yes
Was the cohort recruited in an acceptable way? Unsure
Was the exposure accurately measured? Yes
Was the outcome accurately measured? Yes
Were all important confounding factors identified? No
Was follow-up complete enough? Yes
How precise are the results? The confidence intervals suggest uncertainty, indicating a need for a larger study population.
Do you believe the results? Yes
Can the results be applied to the local population? Yes
Do the results fit with other available evidence? Yes
Who funded the study? This project did not receive any external funding.
Did the authors declare conflicts of interest? All authors report no relevant conflicts of interest.
Results: 376 patients with acute behavioural disturbances were included in the study. The median age was 35 years, 78% were male, and the most common cause of agitation was substance use (51%).
Key Result: There was no statistical difference between agitated patients who required advanced airway management and were treated with midazolam vs ketamine.
Primary Outcome: Advanced airway management was required in 12% of midazolam patients vs. 11% of ketamine patients (difference: 0.5%, 95% CI: -6% to 7%). Adjusted odds ratio (aOR) for airway management: 1.02 (95% CI: 0.44 to 2.38), suggesting no significant difference.
Secondary Outcomes:
No statistical difference in ED intubation rates (14% vs. 11%)
No statistical difference in mortality (2% vs. 1%)
1) Retrospective Design: A major limitation of the retrospective study design is its reliance on existing records, which can introduce selection bias, information bias, and confounding. Unlike prospective studies, where variables can be controlled and standardized in real time, retrospective studies depend on previously collected data, which may be incomplete, inconsistent, or inaccurately documented. A prospective or randomized design would be stronger.
2) Selection Bias: This type of bias occurs when the study population is not representative of the broader patient population due to systematic differences in how participants are included or excluded. In this retrospective EMS study, selection bias could arise if certain patients with acute agitation were not documented or excluded due to incomplete records, leading to an overrepresentation of cases where sedation outcomes were more favourable or easier to track.
3) Information Bias. This occurs when inaccuracies in data collection, which can lead to systematic errors in measuring exposures or outcomes. In this retrospective EMS study, information bias could arise from inconsistent documentation of key variables, such as the exact dose and route of sedative administration, the severity of agitation, or the criteria used for initiating airway management. Suppose some EMS providers were more meticulous in documenting adverse events, while others underreported complications like transient hypoxia or delayed sedation onset. In that case, the study might underestimate or overestimate the true risks associated with ketamine or midazolam.
4) Confounders: This is a limitation of observational studies. Confounding variables are factors that are associated with both the intervention (midazolam vs ketamine) and the outcome (need for airway management), potentially distorting the true relationship between them. In this EMS study, patient characteristics such as underlying medical conditions (e.g., COPD, obesity, or intoxication level), severity of agitation, or additional sedative medications administered could have influenced airway management independently of whether ketamine or midazolam was used. If, for example, ketamine was more frequently given to severely agitated patients who were already at higher risk for airway compromise, this could make ketamine appear riskier than it is. Conversely, if midazolam was preferentially used in patients with known respiratory conditions, providers might have been more cautious, leading to fewer airway interventions. Without randomization or robust statistical adjustments, these confounders could obscure true differences between the medications and limit the study’s validity.
5) Generalizability: The external validity of this study depends on how well its findings apply to other EMS systems, patient populations, and clinical settings. Since the study was conducted in an urban EMS system, its results may not translate directly to rural or suburban settings, where transport times, provider training, and access to advanced airway management differ.
Additionally, variability in EMS protocols, such as differences in sedation dosing, monitoring practices, or local guidelines, could limit the applicability of these findings to regions with different pre-hospital care standards. The patient population also plays a role—if the study included a higher proportion of substance-related agitation, the results may not fully reflect outcomes in psychiatric agitation or postictal states.
Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with the authors’ conclusions.
SGEM Bottom Line: Both midazolam and ketamine seem like reasonable choices in managing agitated patients in the pre-hospital setting, depending on clinical context and provider preference.
Case Resolution: You administer intramuscular ketamine, and the patient becomes much calmer. His vital signs are stable, maintains spontaneous respirations with no signs of airway compromise and is safely transported to the ED.
Clinical Application: Given the comparable safety profiles, your decision should weigh speed of onset, route of administration, and context (i.e. it all depends).
What Do I Tell the Patient? When we found you, you were very agitated and possibly at risk of hurting yourself or others. For your safety and ours, we had to give you medication to calm you down. We used a sedative that works quickly and is commonly used in emergencies like yours. Thankfully, you didn’t need a breathing tube, and everything went smoothly.
Keener Kontest: Last week’s winner was Dr. Steven Steltz from New Zealand. He knew the first computer that stored a program in its memory was the Manchester Baby, also known as the Small-Scale Experimental Machine (SSEM). It was developed at the University of Manchester in England and ran its first program on June 21, 1948.
Listen to the SGEM podcast for this week’s question. If you know, then send an email to [email protected] with “keener” in the subject line. The first correct answer will receive a shoutout on the next episode.
Other FOAMed on Agitation:
SGEM#45: Vitamin H (Haloperidol for Psychosis)
SGEM#218: Excited Delirium Syndrome
SGEM#328: I Can’t Fight This Med Any Longer – Droperidol for Acute Agitation
SGEM Xtra: I’m So Excited – But Don’t Call It Excited Delirium
The post PODCAST: Did You Ever Have To Make Up Your Mind – Midazolam or Ketamine for Acute Agitation in the Pre-Hospital Setting first appeared on האיגוד הישראלי לרפואה דחופה.
54 min

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