Amna Karabegovic on a case of pediatric altered LOA and neurocritical care review (2:09)

Anand Swaminathan on management of pulmonary hypertension and RV failure (24:32)

Brit Long on cytokine release syndrome (30:44)

Andrew Tagg on management of pediatric distal radius fractures (39:31)

Jesse McLaren on ECG interpretation for the bradycardic patient (46:05)

Sara Gray & Katie Lin on Coaching the EM Mind Part 2: stress management and optimizing safety on shift (52:55)

Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Sara Brade, edited by Anton Helman, July, 2026

Cite this podcast as: Helman, A. Lin, K. Karabegovic, A. Swaminathan, A. Long, B. Tagg, A. McLaren, J. Gray, S. EM Quick Hits 72 – EMC²: Peds Neurocritical Care, Pulmonary Hypertension, Cytokine Release Syndrome, Peds Wrist Fracture, Bradycardia ECG Interpretation, Coaching the EM Mind Part 2 Emergency Medicine Cases. July, 2026. https://emergencymedicinecases.com/em-quick-hits-72-july-2026/ ‎. Accessed August 16, 2026.

In the crashing child suspected of neurologic catastrophy, focus on the essential neurologic exam: eyes/pupils, verbal response and motor response.

AVPU—Alert, responds to Voice, responds to Pain, Unresponsive—can provide a fast common language when calculating an exact GCS is impractical, and correlates well with GCS.

Patients with acute pulmonary hypertension—from a large pulmonary embolism or decompensated chronic pulmonary arterial hypertension—can deteriorate rapidly when right-ventricular preload falls or RV afterload rises. The immediate goal is to improve oxygenation and ventilation while avoiding interventions that precipitate RV collapse.

EM Cases Crit Cases 7 – Pulmonary Hypertension – A Fine Balance

Cytokine Release Syndrome (CRS) is a severe systemic inflammatory response caused by a rapid surge of cytokines. It is increasingly encountered after chimeric antigen receptor T-cell therapy and may range from a mild influenza-like illness to shock, hypoxic respiratory failure and multiorgan dysfunction. Other triggers include: monoclonal antibodies, haploidentical donor stem cell transplantation, and nonprotein cancer drugs.

CAR T-cell therapy uses genetically modified T cells to attack malignant cells and it is used to treat cancers like ALL, CLL, and multiple myeloma. Examples include:

Consider CRS when a patient within two weeks of CAR T-cell therapy has a fever of at least 38°C that is not better explained by another cause, together with constitutional symptoms, hypotension or hypoxia. There is no single diagnostic ED laboratory or imaging test. Evaluate simultaneously for sepsis, tumour lysis syndrome, pulmonary embolism, heart failure and treatment-related organ injury.

ED management of CRS

Bottom line: A recent CAR T-cell infusion (within last 2 weeks) plus otherwise unexplained fever, hypotension or hypoxia should immediately raise CRS. Resuscitate, cover possible infection and involve the oncology/cellular-therapy team early—specific therapy is time-sensitive.

A completely displaced pediatric wrist looks alarming and traditionally prompts reduction under sedation or general anesthesia, sometimes with fixation. The CRAFFT trial asked whether immediate anatomic correction improves outcomes that matter to children and families—or whether casting alone allows sufficient remodeling.

The paper: Perry DC, Zimmermann A, Achten J, et al. Non-surgical casting versus surgical reduction for children with severely displaced distal radial fractures (the CRAFFT Study): a multicentre, randomised, controlled non-inferiority trial and economic evaluation. The Lancet. Published online April 8, 2026.

PICO:

Population: 750 children aged 4–10 years with severely displaced distal radial fractures across 49 UK hospitals; 44% had completely off-ended fractures. Intervention: casting without purposeful manipulation, general anesthesia or procedural sedation. Comparison: surgical (closed or open) reduction under general anesthesia or conscious sedation, with fixation permitted at the surgeon’s discretion. Primary outcome: parent-reported PROMIS upper-extremity function at three months. The prespecified non-inferiority margin was −2.5 points.

Results:

Limitations and application:

Bottom line: For most children aged 4–10 years with a severely displaced distal radius fracture, an intact neurovascular exam and no skin threat, a cast-first strategy is a reasonable default—even when the X-ray looks dramatic. Treat the child’s function and safety, not the radiograph alone.

ACLS is designed to stabilize primary electrical bradyarrhythmias, but many ED patients are bradycardic because of a secondary, reversible process. The rhythm strip tells you what the rate and rhythm are; the history, vital signs and full 12-lead ECG may tell you why.

B – BRASH syndrome and hyperkalemia: Think renal dysfunction, AV-nodal blockers, shock and hyperkalemia. Hyperkalemic bradycardia may be sinus or junctional and may show PR prolongation, QRS widening, axis change or peaked T waves. Atropine and pacing may fail; treat suspected hyperkalemia promptly, including empiric calcium when the clinical and ECG picture fits.

R – Reduced vital signs: Check the complete set: oxygen saturation, glucose and temperature. Hypoxia and hypoglycemia require immediate correction. Hypothermia may produce bradycardia, shivering artifact, prolonged intervals and prominent J waves.

A – Acute coronary occlusion: The left circumflex perfuses the SA node as well as the lateral and posterior territories, while the RCA perfuses the SA and AV nodes as well as the inferior and posterior territories. In a patient with ischemic symptoms and bradycardia, look for signs of inferior, lateral or posterior occlusion: inferior ST elevation or hyperacute T waves, reciprocal change in aVL, or anterior ST depression reciprocal to posterior injury.

D – Drugs: Consider beta-blockers, calcium-channel blockers, digoxin, opioids and medication accumulation from renal failure. Management may require antidotal or supportive therapy, withholding the culprit drug and allowing clearance. Digoxin may produce a shortened QT interval and scooped ST depression, but most drug causes are identified primarily by history.

I – Intracranial pressure (raised) or infection: Raised ICP is primarily a clinical diagnosis, although diffuse deep T-wave inversion and QT prolongation may occur. Lyme carditis may cause high-grade or complete AV block and is a reversible reason to avoid an unnecessary permanent pacemaker.

Bottom line: Stabilize the unstable patient, but do not stop at atropine, epinephrine or pacing. Ask why the patient is bradycardic and use the 12-lead ECG most actively when hyperkalemia or acute coronary occlusion is plausible.

For examples of the BRADI mnemonic, ECG Cases 58.

Emergency medicine exposes clinicians to recurring high-stress situations, from critically ill patients and overcrowded departments to challenging interactions with patients, families and colleagues. Stress cannot—and should not—be eliminated entirely. A moderate level of stress can improve energy, focus and performance, while excessive stress can produce panic, cognitive overload and impaired decision-making. The goal is to recognize when stress is moving outside the optimal performance zone and develop practical strategies that can be used before, during and after challenging encounters.

Clinicians may not immediately recognize that they have entered a state of cognitive or emotional overload. Warning signs include:

Colleagues and family members may recognize these changes before the clinician does. Treat these observations as an opportunity to pause and reassess rather than as criticism.

When time permits:

The most important principle is to avoid adding more emotion to the interaction.

Practical strategies include:

The objective is not necessarily to agree with the other person. It is to lower the emotional temperature enough to return to productive problem-solving.

Use progressively assertive safety-escalation language:

This structure allows concerns to be raised respectfully while ensuring that escalating danger is communicated clearly.

The effects of a stressful resuscitation may continue long after the event is over. Immediate recovery strategies include:

Some events—including physical assault or an exceptionally distressing clinical event—may leave a clinician temporarily unable to provide safe care. Departments should have clear processes for obtaining coverage and stepping away when necessary.

Deep dive on pre-shift strategies: Episode 134 Shift Preparation: Pre-gaming with Rob Orman

Stress management should not be treated solely as an individual responsibility. Emergency departments should consider:

Bottom line: Stress-management skills are most useful when they are practised before they are urgently needed. Develop brief techniques through regular practice—breathing, grounding, positive self-talk and safety-escalation language—and use them regularly until they become automatic. Pause, reset and reframe before, during and after stressful encounters. A few deliberate seconds can improve emotional regulation, team communication, clinical performance and safety for both clinicians and patients.

The post PODCAST: EM Quick Hits 72 EMC²: Peds Neurocritical Care, Pulmonary Hypertension, Cytokine Release Syndrome, Peds Wrist Fracture, Bradycardia ECG Interpretation, Coaching the EM Mind Part 2 first appeared on האיגוד הישראלי לרפואה דחופה.

Written by Alex Clark

Spoon Feed

Sparky likes lidocaine

This target trial emulation utilized the Resuscitation Outcomes Consortium Cardiac Epistry to compare lidocaine (n=987) with amiodarone (n=1464) in adults with atraumatic, shockable OHCA refractory to at least three defibrillation attempts. Because the study used cases from 2011–2015, when ACLS guidelines recommended amiodarone as first-line, investigators used inverse probability weighting and doubly robust regression to reduce treatment-selection bias. Lidocaine was associated with higher rates of ROSC at ED arrival (41.0% vs. 34.6%; absolute difference 6.43%; 95%CI 2.6–10.3%) but not with significantly improved survival to hospital discharge (26.2% vs. 23.5%; absolute difference 2.78%; 95%CI–0.6 to 6.2%) or favorable neurologic outcome (17.7% vs. 16.2%; absolute difference 1.5%; 95%CI–1.5 to 4.5%). Although appropriately cautious in their interpretation, the authors suggest the upper bounds of the confidence intervals leave open the possibility for clinically meaningful benefit of lidocaine. While the target trial emulation strengthens causal inference compared to traditional observational analyses, the study still has severe limitations when it comes to drawing any conclusions of superiority, including the older registry data with potentially outdated practices, the inability to assess timing of antiarrhythmic administration, and the potential for residual confounding.

How does this change my practice?

Source

The post PODCAST: ​Which Is Better? Amiodarone vs. Lidocaine for OHCA first appeared on האיגוד הישראלי לרפואה דחופה.

July 11, 2026 by Scott Weingart, MD FCCM

The RUSH Exam has grown up. Originally conceptualized in 2006 as a rapid medical surrogate to the trauma FAST exam, the classic protocol was built to find immediate life threats in 30 seconds or less. But hemodynamics in non-crashing patients require more thought and time. Enter RUSH 2.0—the iRUSH (Interface-Informed RUSH) exam.

Inspired by the recent interface model of hemodynamics, this updated protocol transforms the RUSH exam from a tool reserved solely for crashing patients into a standardized bedside map for comprehensive hemodynamic assessment and shock phenotyping.

Huge thanks to Sara Crager for peer review and so many contributions that made this a better work!!!

If your patient is actively spiraling, you don't have time for complex physiology. You need the CRUSH (Crashing RUSH) exam. This is a hyper-abbreviated screening protocol designed to be executed in under 30 seconds:

If the patient is not circling the drain, you have time to do a more comprehensive and thoughtful evaluation

[] CRUSH Exam

[] LVOT VTI

[] Measurement of Tricuspid Regurg Jet Peak Velocity (TRV)

[RVSP=4(TRV)2 +  RAP ] ~ PASP

Korbin Haycock writes:

As long as you've included both TAPSE and Tricuspid regurge velocities, I'd like to point out a few low hanging fruits to add to the raw data points. TAPSE is a decent surrogate of the RV's EF which itself is a rough approximation of RV-PA coupling (interface 4). However, an RV can fail or uncouple from the PA because of different reasons and at different loading conditions. Some examples would be an acute decompensation of chronic PHTN, a PE, or a RV infarct. So when you see a TAPSE that is low, consider it in context of the sPAP and it will give you a good clue as to the mechanism of the uncoupled 4th interface.

For examples: low TAPSE with sPAP > 65-70 is probalby decompensated prexisting PHTN; low TAPSE with sPAP elevated but < 65 is likely to be a PE; low TAPSE with normal sPAP is a good chance of being a RV infarct. There's some “ins and outs and what have yous” here, but in general the princple holds true.

Along these lines, in stable PH patients the ratio of TAPSE and sPAP has been shown to be a good surrogate of invasively meausred RV-PA uncoupling, with ratios >0.31 being normal coupling. In acutely decompensated patients I don't think the cut off of 0.31 has been investigated (becuase its probably impossible to conduct such a study), but I have many examples I saved/archived where 4th interface uncoupled patients do have lower TAPSE/sPAP ratios and that when the uncoupling is addressed the ratio dramatically increases.

A small tip I would give for the Tricuspid regurge measurers out there is you might as well trace a VTI of the TR jet instead of just getting a peak velocity. The reason is it only take a couple more seconds and the machine will spit out at you a peak pressure gradient AND a mean pressure gradient, so you get sPAP and mPAP essentially for free. Doing the TR VTI for a mPAP is additionally useful if you happen to be someone who is doing dPAP (and mPAP) estimates from the PR jet. If the TR VTI mPAP estimate is close to the PR mPAP estimate this is a great validation and cross check that the PR Doppler insonation angle and TR Doppler angles are both pretty good and the estimated values of sPAP, mPAP, and dPAP are thus likely valid.

Since you have included LVOT VTI in the iRUSH, some may want to push themselves to get a RVOT VTI as well. There are loads and loads of data to be gleaned from a RVOT VTI if you know what to look for, but a submassive/massive PE can be very reliably be recognized from certain RVOT Doppler patterns.

The post PODCAST: You are here: Home / EMCrit / EMCrit 429 – RUSH 2.0 – The I-RUSH and CRUSH Exams EMCrit 429 – RUSH 2.0 – The I-RUSH and CRUSH Exams first appeared on האיגוד הישראלי לרפואה דחופה.

On the July episode of the Annals of Emergency Medicine podcast, Ryan and Rory discuss social vulnerability in EMS recognition, ED social care approaches, pediatric prehospital readiness, and much more.

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When another person is upset or angry, our instinct can be to help them lower their emotional temperature by saying something like, "Just calm down," or, "Relax," or, "Take a breath," or, "Look at the facts." However, saying those things when the other person is in the heat of the moment can have the reverse effect from what we were hoping for.

The reason is simple: People who do not feel heard are not ready to hear solutions.

In this episode, we explore the communication strategy of valence matching, why it works at both a psychological and neurological level, and how it can transform interactions with patients, colleagues, consultants, and loved ones. Finally, we show how a few seconds of emotional attunement can save minutes, or even hours, of unnecessary conflict.

💡 Get Rob's Book

Supranormal: A Field Guide for the Impossible Job.

Tools, mindsets, and communication techniques so you don't get eaten alive by a job you're good at.

The post PODCAST: Why Saying "Calm Down" Never Works (and what does) first appeared on האיגוד הישראלי לרפואה דחופה.

Date: June 12, 2026

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

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

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

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

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

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

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

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

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

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

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

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

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

Summary of the Four RCTs:

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

Open Label

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

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

Heterogeneity

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

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

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

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

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

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

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

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

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

Other SGEM Episodes:

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

Face mask ventilation is one of those skills that can easily be overlooked. It's often seen as the simple bit of airway management — something that sits below the glamour of videolaryngoscopy, fibre-optics and endotracheal intubation. But the reality is that excellent face mask ventilation is one of the most important airway skills we have.

In this episode, we take a deep dive into bag-valve-mask ventilation and airway adjuncts, exploring why this is far more than just putting a mask on a face and squeezing a bag. We discuss when facemask ventilation is indicated, how to identify patients who may be difficult to ventilate, and the practical steps that can dramatically improve success rates.

We cover positioning, airway opening manoeuvres, mask seal techniques, the role of airway adjuncts and how to recognise whether your ventilations are actually working. We also look at troubleshooting common problems, the evidence comparing bag-mask ventilation with supraglottic airways and endotracheal intubation, and how to decide when it's time to move to another airway strategy.

Whether you're working in the emergency department, prehospital environment or critical care, this episode is packed with practical tips, cognitive aids and evidence-based advice to help you deliver facemask ventilation with confidence and excellence.

Once again we'd love to hear any thoughts or feedback either on the website or via X @TheResusRoom!

Simon. Rob & James

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Pulmonary embolism ECG findings are one of the most commonly tested Emergency Medicine board topics — and one of the easiest places to get tricked. Let's quickly cover what is the right answer on boards, and how in real life there is an even better option.

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Recorded live at the ACEP Leadership and Advocacy Conference, this episode of ACEP Frontline features a timely conversation with Dr. Sean Michael, Chief Medical Officer for Centers for Medicare & Medicaid Services. As emergency departments across the country continue to face unprecedented crowding, prolonged boarding, staffing strain, and access challenges, Dr. Michael joins us to discuss how CMS is viewing the crisis and what potential policy “levers” may help address the growing nationwide problem. From hospital throughput and inpatient capacity to quality measures and accountability, we explore how federal policy could influence meaningful change for patients, physicians, hospitals, and the emergency care system as a whole.

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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

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:

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.

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:

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.

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:

Pearl: Do not ignore these patients. Lack of engagement and long waits increase agitation. Regular team check-ins reduce escalation risk.

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:

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 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:

Useful de-escalation language includes:

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:

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.

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:

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.

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:

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.

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:

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.

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:

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.

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