PEM CHATT

24 | Tick Paralysis: Easy to treat but easy to miss with Toni Dobson, DNP, FNP-C, ENP-C

⏱️ Runtime: about 13 minutes

📝 Episode Summary In this conference-series episode, Toni steps into the role of both host and guest to share her AAENP presentation on tick paralysis. It's a rare neurologic presentation in the emergency department and one that ED clinicians often miss. Toni explains why: she had it on her differential, searched the patient for a tick and still missed it.

The episode covers how tick paralysis develops and who's most at risk. Toni walks through a pediatric case of acute-onset ataxia, builds a differential and shows how to tell tick paralysis from Guillain-Barré syndrome (GBS). She also shares a practical ED algorithm that starts with a thorough skin exam.

LINK to algorithm: https://drive.google.com/file/d/1Ld-3mh1m89_dVaFo82CtCS-oqQa3xll7/view?usp=sharing

⏰ Timestamps

00:00 Intro

00:18 Welcome and the AAENP conference series

00:39 Why tick paralysis, and why it gets missed

01:24 What tick paralysis is: the tick, the toxin and the timeline

02:25 Ascending paralysis, mortality and treatment

02:59 Who's at risk

03:23 Why ED clinicians miss it

04:15 The case: a 3-year-old with acute ataxia

05:53 Building the differential

07:19 Tick paralysis vs. GBS

09:31 The ED algorithm 10:14 The skin exam and the flea comb

11:00 After the tick is removed: observe, then discharge or admit

11:32 When symptoms don't improve

12:13 Take-home points

13:05 Disclaimer

⚖️ Disclaimer Any opinions expressed on today's podcast are solely those of the speaker and do not reflect the opinions or policies of any employer or hospital system. In many states, advanced practice providers work collaboratively with physicians. Always consult your physician leader when appropriate. Any cases discussed on this podcast have been de-identified, and details have been changed or omitted to protect patient privacy. Some cases may also represent composites of our clinical experiences, and any resemblance to a specific individual beyond the educational context is unintentional. This podcast was designed for medical education purposes only. Its speakers have made every effort to provide the most current and evidence-based information. However, that should never replace one's own effort to validate current evidence-based practice before implementing a plan of care. Any pathway or algorithm that we may have discussed may not reflect those of your healthcare system. Please be aware that there may be changes based on your geographic location or current employer site. This podcast was not designed in any way to provide medical advice or treatment plans for patients and their families. If you have a medical concern or an emergency, please be seen by a local medical provider or call nine one one for assistance.

23 | Delivering Difficult News with Cory Edgar, DMSc, PA-C

Host: Toni Dobson

Delivering bad news is not a "soft skill" — it is a core clinical skill that can be learned, practiced, and improved. In this episode, Toni sits down with Corey Edgar to walk through the SPIKES protocol, a structured framework for difficult conversations. Corey breaks down each step with practical ED examples, explains why the warning shot and the pause matter so much, and reminds us that bad news is not only cancer or death. Anything that changes a patient's or family's anticipated future counts — which means most of us deliver bad news on every shift.

🔑 Key Takeaways

⏰ Timestamps

⚖️ Disclaimer

Any opinions expressed on today's podcast are solely those of the speaker and do not reflect the opinions or policies of any employer or hospital system. In many states, advanced practice providers work collaboratively with physicians. Always consult your physician leader when appropriate. Any cases discussed on this podcast have been de-identified, and details have been changed or omitted to protect patient privacy. Some cases may also represent composites of our clinical experiences, and any resemblance to a specific individual beyond the educational context is unintentional.

This podcast was designed for medical education purposes only. Its speakers have made every effort to provide the most current and evidence-based information. However, that should never replace one's own effort to validate current evidence-based practice before implementing a plan of care. Any pathway or algorithm that we may have discussed may not reflect those of your healthcare system. Please be aware that there may be changes based on your geographic location or current employer site. This podcast was not designed in any way to provide medical advice or treatment plans for patients and their families. If you have a medical concern or an emergency, please be seen by a local medical provider or call 911 for assistance.

📍 Special Adult EM Edition, Live from the AAENP Conference in Nashville, Tennessee

🎧 Host: Toni Dobson

In this special adult emergency medicine edition of PEM CHATT, Toni talks with Brandy Ganatra at the AAENP conference about SCAPE, or sympathetic crashing acute pulmonary edema. This is the patient many of us learned to call "flash pulmonary edema." Brandy covers the pathophysiology behind the newer name, how to recognize these patients quickly, why high-dose nitroglycerin is the mainstay of treatment, and why early, aggressive management in the ED can turn a crashing patient around in minutes.

SCAPE is sympathetic crashing acute pulmonary edema, the presentation many clinicians know as "flash pulmonary edema."

The term is fairly new. Cardiology often calls it acute decompensated heart failure, but critical care and ED literature increasingly use "SCAPE."

The name points to the pathophysiology, and the pathophysiology points to the treatment. Think bigger than "the lungs are full of fluid."

A sympathetic surge causes marked peripheral vasoconstriction and a sharp rise in systemic vascular resistance (SVR), which is the afterload the left ventricle has to pump against.

The core need is afterload reduction.

Extremely tachypneic and tachycardic

Profoundly hypertensive

Hypoxic and tripoding, with severe respiratory distress

Pink, frothy sputum from acute pulmonary congestion

Onset is sudden. "It happens in an instant."

Common history: heart failure or hypertension, sometimes with missed medications

💊 Nitroglycerin is the mainstay of therapy.

Lower doses mostly cause venous dilation, which is why nitro is used for angina and ischemia.

SCAPE calls for high doses. Brandy starts IV nitro at 100 mcg/min and may titrate up to 400 mcg/min.

One sublingual nitro tablet is roughly equal to 80 mcg/min, which puts the IV dosing in perspective. "It's not as scary as we think."

Nitro has a short half-life (about 2–5 minutes). Titrate down instead of turning the drip on and off.

😮‍💨 Support breathing at the same time. Use non-invasive ventilation (CPAP/BiPAP) for the high work of breathing, with the goal of avoiding intubation.

🔀 Do things in parallel, not one at a time. We like our ABCs, but here several interventions need to start together.

📋 A practical sequence:

Give sublingual nitroglycerin.

While you do that, set up non-invasive ventilation.

While you do that, prepare to start IV nitroglycerin, then titrate.

With timely afterload reduction, restored cardiac output, and breathing support, these patients can turn around in 15–20 minutes. 🔄

👀 Recognize it early, monitor closely, and treat aggressively. Timing and the right management are critical.

🤝 Teamwork is essential.

🚫 Don't get stuck on diagnostics. Don't wait for a chest X-ray to confirm it. Put the POCUS probe on 🔍 and look for volume overload.

💪 Act quickly and with confidence. Current literature supports high-dose nitroglycerin as safe and effective in the ED.

[00:00] Intro: special adult EM edition from the AAENP conference

[00:18] Meet guest Brandy Ganatra

[00:39] What is SCAPE, and why the new name?

[01:28] How bedside management has changed: getting comfortable with high-dose nitro

[02:41] Recognition: what these patients look like

[03:17] Nitroglycerin dosing: low vs. high dose, starting at 100 mcg/min

[04:00] Nitro safety: short half-life, and sublingual compared with IV

[04:50] Turning patients around in 15–20 minutes

[05:12] Take-home points: teamwork, POCUS, and acting with confidence

[05:44] Closing and disclaimer

Any opinions expressed on today's podcast are solely those of the speaker and do not reflect the opinions or policies of any employer or hospital system.

In many states, advanced practice providers work collaboratively with physicians. One should always be careful to consult with their physician leader when appropriate.

Any cases discussed on this podcast have been de-identified, and details have been changed or omitted to protect patient privacy. Some cases may also represent composites of our clinical experiences, and any resemblance to a specific individual beyond the educational context is unintentional.

This podcast was designed for medical education purposes only. Its speakers have made every effort to provide the most current and evidence-based information. However, that should never replace one's own effort to validate current evidence-based practice before implementing a plan of care. Any pathway or algorithm that we may discuss may not reflect those of your healthcare system. Please be aware that there may be changes based on your geographic location or current employer site.

This podcast was not designed in any way to provide medical advice or treatment plans for patients and their families. If you have a medical concern or an emergency, please be seen by a local medical provider or call 911 for assistance.

21 | Submersion Injuries with Dr. Sarah Lazarus

In this episode of PEM CHATT, host Toni Dobson is joined by pediatric emergency physician Dr. Sarah Lazarus to break down the critical topic of pediatric drowning and submersion injuries. Together, they explore real-world clinical scenarios, debunk common myths, and provide practical guidance for both clinicians and caregivers.

Drowning remains one of the leading causes of death in children, particularly ages 1–4, and even non-fatal events can result in devastating long-term consequences. This episode emphasizes both clinical management and prevention strategies—highlighting how quickly these events occur and how often they happen despite close supervision.

🔑 Key Takeaways

⚠️ Clinical Pearls

🧠 Myth Busting

“Dry drowning” isn’t real.

🛟 Prevention Insights

Resources and references:

Timeline

00:00 Welcome to PEM CHATT

00:19 Why Drowning Matters

01:12 Meet Dr. Sarah Lazarus

02:14 Bread Pudding is my favorite

03:34 Drowning Terminology

04:38 Who Is Most at Risk

06:08 Silent Drowning Explained

09:15 Systemic Effects Checklist

11:03 Fresh vs Salt vs Cold

11:46 Three Patient Categories

12:36 Case One Asymptomatic Kid

14:12 Avoiding Unneeded X-Rays

16:12 Case Two Symptomatic Infant

18:40 Imaging and Labs Strategy

18:58 When to Skip Antibiotics

20:02 Arrest Scenario Walkthrough

20:30 Resuscitation Priorities And ECMO

21:54 When Resuscitation Is Futile

22:40 C-Spine Immobilization Debate

23:24 Drowning CPR Starts with Breaths

25:29 Injury Prevention Work and Stats

27:14 Layers of Drowning Prevention

30:01 Dry Drowning Myth Busting

33:16 Key Pearls and Closing

In this “Rewind” episode, Toni sits down with retired pediatrician Dr. Margaret “Meg” Wang, who trained and practiced through the pre-vaccine and early-vaccine eras of pediatrics, including the 1989–1990 measles epidemic in New York City. Together, they walk us through what pediatrics looked like before Hib, pneumococcal, varicella, and rotavirus vaccines and what we might face again as vaccination rates fall and herd immunity wanes.

You’ll hear vivid, frontline stories of:

Clinically, Toni and Dr. Wang dig into:

🔑 Key Takeaways:

📌 Call to Action:

Hit play, then share this episode with a colleague, resident, or trainee who has never seen these diseases and thinks of measles or chickenpox as “mild.” Their future patients are counting on it. 💉🧠

Fever Management in Children 3-36 Months: An Evidence-Based Approach

Join host Toni Dobson and guest Andrea Perkins, PA-C, as they dive deep into the evidence-based management of fever in otherwise healthy children aged 3-36 months. This comprehensive episode covers everything from basic fever physiology to algorithmic approaches for both vaccinated and unvaccinated children.

Key Topics Covered:

Defining fever and understanding the pathophysiology

The critical difference between fever and hyperthermia

Vaccination status and risk stratification

Comprehensive physical exam pearls

Evidence-based algorithms for immunized vs. unimmunized children

UTI risk assessment and when to obtain urine samples

Laboratory workup guidelines based on vaccination status

Fever management strategies and parent education

Addressing fever phobia in families

Resources:

UTI Calculator: www.uticalc.com

UpToDate management guidelines: UpToDate Link

Andrea's algorithm: Link to Algorithm

Next Episode: Dr. Margaret Wang joins us to discuss the return of vaccine-preventable illnesses and how we can prepare.

📺YouTube: https://www.youtube.com/@PEMChatt

🟢Spotify: https://open.spotify.com/show/6oaYDeq5AXIZGxBvEIxaTs

🍎 Apple Podcasts: https://podcasts.apple.com/us/podcast/pem-chatt/id1806882767

In this episode of PEM CHATT, the focus is on febrile neonates, the first part of a two-part series on pediatric fever management. Host Toni speaks with Dr. Lindsay McHale, a pediatric emergency medicine physician, to discuss how historical protocols for managing febrile neonates have evolved with advances in vaccines, PCR testing, and maternal surveillance. The discussion covers the 2021 AAP guidelines for managing febrile neonates, the essential components of a fever workup, interpretation of test results, and the nuances of decision-making across neonatal age groups. Practical insights on performing lumbar punctures, antibiotic selection, and interpreting potentially confounding results, such as bloody CSF taps, are shared, along with real-life case examples that illustrate the complexities involved. The conversation aims to equip clinicians with an evidence-based approach to improve patient outcomes in various clinical settings.

#PEM #NP #APP #PA #pediatrics #emergencymedicine #emergencynursepractitioner #fellowship #medicaleducation #podcast #children #nursepractitioner #clinicalpharmacists #febrileneonate #sickbabies #lumbarpuncture

00:00 Introduction to Febrile Neonates

00:57 Historical Management of Febrile Neonates

01:25 Advancements in Medicine and New Guidelines

02:23 Introducing Dr. Lindsay McHale

03:56 Defining Febrile Neonates

04:54 Managing Febrile Neonates in the ER

05:51 Cold Babies and Controversies

07:45 Treating Fever in Neonates

09:06 Inclusion and Exclusion Criteria for Febrile Neonate Protocol

10:27 Why Neonates Are High-Risk

11:40 Code 60: Rapid Response for Febrile Neonates

12:30 Hypothetical Case Study: Febrile Neonate

14:24 Parental Concerns and Communication

19:57 Detailed Workup and Testing

23:27 Antibiotic Choices for Neonates

25:13 Dosing Nuances in Neonatal Antibiotics

26:49 Tips for Performing Lumbar Punctures

30:25 Interpreting Test Results in Neonates

32:46 AAP Sepsis Protocol for Neonates

40:06 Managing Febrile Infants: Case Studies

44:18 Conclusion and Next Episode Preview

LINKS:

AAP Guideline https://publications.aap.org/pediatrics/article/148/2/e2021052228/179783/Evaluation-and-Management-of-Well-Appearing?autologincheck=redirected

CHOP Algorithm

https://www.chop.edu/clinical-pathway/febrile-infant-emergent-evaluation-clinical-pathway

THE MISFITS

 https://drive.google.com/file/d/1gpUsQOxMlbuqI-6hBDcZEF5ckpJWhWWb/view?usp=sharing

🩺 Essential Medications in Pediatric Emergency Medicine - In-Depth Discussion with Clinical Pharmacists, Mager Raker and Morgan Padron 💊

In this episode of PEM CHATT 🎙️, host Toni Dobson is joined by clinical pharmacists Maggie and Morgan to delve into the key medications used in pediatric emergency medicine 🏥. They cover a wide range of topics, from proper medication dosing and pain control 💉 to antiemetics for nausea 😷, asthma management 🫁, and safe sedation practices 😴. The discussion also includes practical tips for advanced practice providers working in both community hospitals and pediatric-focused facilities 👩‍⚕️👨‍⚕️. Listeners will gain insights into common pitfalls in pediatric prescribing 🚫, the importance of proper dosing ⚖️, and strategies to effectively use medications like Tylenol, ibuprofen, Zofran, morphine, fentanyl, Decadron, and others 💊. The episode aims to enhance the confidence and skills of healthcare providers in caring for young patients 👶👧🧒. The show concludes with a look ahead to the next episode, which will focus on the febrile neonate workup 🍼.

00:00 Introduction to Pediatric Emergency Medicine

00:42 Meet the Hosts and Guests

02:08 Common Pitfalls in Pediatric Prescribing

03:51 Basics of Antipyretics: Tylenol and Ibuprofen

10:03 Anti-Emetic Medications: Zofran and Alternatives

21:19 Pain Control Strategies in Pediatric ER

26:42 Pediatric Dosing and Medication Caps

28:06 Fentanyl: Usage and Administration

29:26 Intranasal Medication Techniques

31:30 Pain Management in Pediatric Emergencies

34:58 Enemas for Constipation Relief

40:00 Asthma Management in Pediatric Patients

48:18 Sedation Techniques in Pediatric Care

52:00 Conclusion and Final Thoughts

🎉 In this special 1-year anniversary episode of PEM CHATT, host Toni Dobson reflects on the podcast’s growth and welcomes guest Dayna Jaynstein, PA, to discuss the critical topic of maternal mortality. Together, they explore why the U.S. has the highest maternal mortality rate among developed countries, highlight the unique risks for Black and Native women, and introduce ACOG’s new initiative to help non-OB providers recognize and manage OB emergencies. The episode covers key warning signs, the importance of asking about current pregnancy status and delivery within the last year, and practical algorithms for managing cardiovascular and hypertensive emergencies in pregnant and postpartum women. Listeners are encouraged to use these resources, advocate for patients, and share knowledge to help prevent maternal deaths.

Link to ACOG website with algorithms: ACOG.org/obemergencies

⏰ Timeline:

0:00 – Welcome & 1-year anniversary celebration

2:00 – Podcast journey & gratitude to listeners

5:00 – Guest introduction: Dana Jane Dean, PA

7:00 – Maternal mortality stats & disparities

10:00 – ACOG’s new initiative explained

15:00 – Key questions for providers & identifying at-risk patients

20:00 – Cardiovascular emergencies in pregnancy

25:00 – Hypertensive emergencies & management tips

30:00 – Eclampsia, preeclampsia, and medication guidance

35:00 – Family-centered care & advocating for moms

40:00 – Resources, final thoughts, and next episode preview

In this episode of 🎤PEM CHATT, host Toni Dobson is joined by pediatric clinical pharmacists 💊Maggie Raker and 💊Morgan Padron for an in-depth discussion on antibiotic use in the pediatric emergency department. The conversation highlights the unique and invaluable role clinical pharmacists play in patient care, from assisting with medication selection and dosing to providing real-time support during traumas and codes. Maggie and Morgan share their backgrounds and offer practical insights into the collaborative approach between pharmacists, providers, and nurses.

The episode dives into evidence-based strategies for treating common pediatric infections 🦠, including ear infections, UTIs, pneumonia, animal bites, cellulitis, and more. Listeners will learn about first-line therapies, dosing nuances, and the importance of selecting targeted antibiotics. The team also shares helpful resources and tips for staying current with best practices. This episode is a must-listen for anyone seeking to deepen their understanding of pediatric antibiotics and the importance of clinical pharmacy collaboration in emergency medicine.

Resources Mentioned:

Part two of this series with Maggie and Morgan will cover other common medications in the pediatric ER (coming December 2025).

Next month: 🤰🏻Special episode on OB emergencies for the one-year anniversary of PEM CHATT.

Thank you for listening to PEM CHATT! 🫶🏽

Disclaimer: The content in this podcast is for educational purposes only and does not constitute medical advice. Always consult your local guidelines and collaborate with your physician leader as appropriate.