spoon feed

In this episode, Sam Ashoo, MD and T.R. Eckler, MD discuss the February 2026 Emergency Medicine Practice article, Emergency Department Diagnosis and Management of Acute Coronary Occlusion

00:00 – Introduction & Welcome

01:21 – Episode Overview: Acute Coronary Occlusion

02:06 – Why This Topic Matters: Statistics & New Guidelines

03:35 – Nomenclature: ACO vs STEMI/NSTEMI

06:15 – Differential Diagnosis for STEMI

07:41 – Pre-Hospital Care & EMS Role

11:37 – Patient History & Presenting Symptoms

12:28 – Physical Examination Findings

14:54 – EKG: The Most Important Test

17:00 – STEMI Definition & Criteria

20:32 – STEMI Equivalents: Scarbosa Criteria

22:40 – Smith Modified Scarbosa Criteria

24:10 – Hyperacute T Waves

25:30 – Posterior STEMI

28:40 – De Winter Sign

29:38 – Non-STEMI EKG Findings

31:30 – AVR ST Elevation

32:47 – Wellens Syndrome

33:54 – Reciprocal ST Segment Changes

36:15 – Inferior MI Patterns

37:54 – Laboratory Testing

39:51 – Imaging: Chest X-Ray & Echocardiography

42:25 – Supplemental Oxygen: What the Evidence Shows

44:50 – Analgesia & Pain Management

46:35 – Pharmacotherapy: Aspirin & Antiplatelet Agents

49:18 – Reperfusion Therapies & Thrombolytics

53:05 – Cardiac Arrest in STEMI Patients

53:55 – Closing Remarks & CME Information

The post PODCAST: Acute Coronary Occlusion first appeared on האיגוד הישראלי לרפואה דחופה.

Reference: . Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child & Adolescent Health. July 2025

Dr. Kammeron Brissett

Guest Skeptic: Dr. Kammeron Brissett is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. She completed her pediatrics residency and a chief year at Rainbow Babies and Children’s Hospital in Cleveland, Ohio. Her interests include injury prevention, social determinants of health, and advocacy.

Case: A 7-year-old boy with a peanut allergy presents to the emergency department (ED) after eating a cookie at a birthday party. Shortly afterwards, he developed hives and wheezing. His parents gave him an epinephrine auto-injector to improve his symptoms. In the ED, he feels much better. His vital signs are normal, and his lungs are clear. He has no other gastrointestinal or cardiovascular symptoms. The parents tell you, “Unfortunately, we’ve been through this before. It’s not the first time he has accidentally eaten something that may have had some peanuts in it. Last time, we sat in the ED for a few hours before going home. It’s been a long day. Can we just go home now?”

Background:  Anaphylaxis is a serious, potentially life-threatening systemic allergic reaction with a fast onset. It is a clinical diagnosis that should be considered when:

Early recognition and treatment with intramuscular epinephrine is crucial.

Sometimes, even after initial symptom improvement with IM epinephrine, anaphylaxis symptoms can recur even without exposure to the known trigger. This is called a biphasic reaction and can happen up to 72 hours later.

The SGEM discussed anaphylaxis and biphasic reactions 13 years ago on SGEM#57. The bottom line was that prolonged observation is likely unnecessary in patients whose symptoms resolve with therapy in the ED. Biphasic reactions are rare and can occur anywhere from 10 minutes up to 6 days. We already have problems with boarding and overcrowding. We can’t keep all patients with anaphylaxis for 6 days. So, when can we send them home?

Traditionally, ED observation after anaphylaxis has been around 4 to 6 hours to monitor for biphasic reactions. The Resuscitation Council UK recommends a risk-stratified approach: A patient can be discharged after 2 hours when there’s a good response to a single dose of epinephrine, the symptoms have resolved, the child and family has another epinephrine autoinjector and knows how to use it, and has adequate supervision after discharge. They recommend at least 6 hours of observation if two IM doses of epinephrine were needed or there was a prior biphasic reaction. Finally, they recommend at least 12 hours observation if there was severe respiratory compromise, >2 doses of epinephrine, ongoing allergen absorption, late-night presentation/limited access to care, or difficult access to emergency services.

The National Institute for Care and Health Excellence (NICE) is even a bit more conservative, recommending any child under age of 16 with suspected anaphylaxis be admitted. What about in the US?

In the United States, the 2023 AAAAI/ACAAI Joint Task Force Practice Parameter (JTFPP) emphasizes individualized, risk-based observation and shared decision-making, noting that risk for biphasic reactions is higher with more severe initial reactions and when >1 dose of epinephrine is required. It also highlights that patients with a prompt, complete, and durable response to epinephrine may not always require activation of EMS or prolonged monitoring, underscoring tailored disposition planning.

Reference: . Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child & Adolescent Health. July 2025

Authors’ Conclusions: “A 2-h observation period is probably safe for most children who present to an emergency department with an acute allergic reaction requiring epinephrine. A 4-h observation period might be enough for patients with cardiovascular involvement who appear well.”

 Quality Checklist for Observational Study:

Results: They included 5,641 eligible children with a median age of 7.9 years, with slightly more males (56%). 4956 (88%) fulfilled the National Institute of Allergy and Infectious Diseases and Food Allergy and Anaphylaxis Network criteria for anaphylaxis.

In that group, 1.5% met criteria for biphasic anaphylaxis and 10.7% had persistent anaphylaxis.

4.7% received repeat epi after 2 hours from initial dose. 1.9% received repeat epi dose after 4 hours.

Patients with cardiovascular involvement had higher rates of biphasic anaphylaxis.

Among all patients, 5% received a repeat dose of epinephrine after 115 minutes. There were differences in patients with or without respiratory or cardiovascular involvement.

Primary Outcome: In the entire cohort, 4.7% received epi 2 hours after the initial dose, 1.9% received epi after 4 hours, 1.1% received epi after 6 hours, and 0.8% received epi after 8 hours. 

Secondary Outcomes: 

Diagnosis of Anaphylaxis

 We mentioned that anaphylaxis is a clinical diagnosis, but it’s not always clear-cut. In this retrospective review, the authors used ICD-10 codes and chart reviews to determine whether patients experienced anaphylaxis. They included patients who were treated with intramuscular, subcutaneous, or intravenous epinephrine. Potential biases include selection bias, information bias, and misclassification bias.

Not all the patients included in this study actually met criteria for anaphylaxis, which is acknowledged by the authors. Anaphylaxis Practice Guideline update in 2023 states, “treatment with epinephrine or clinical response to epinephrine should also not be used as a surrogate marker to establish a diagnosis of anaphylaxis because there are many cases in which patients receive epinephrine for milder reactions.” Some of these patients were included because authors reported that “the administration of epinephrine might have mitigated reaction progression.”

Appendix Table 3, which examines interrater reliability for agreement on anaphylaxis identification, reports kappa values ranging from 0.68 to 0.76, indicating substantial agreement but not perfect agreement.

Repeat Epinephrine

 The primary outcome for this study was the time from first to last administration of epinephrine. We must be careful and state that this is not the equivalent of a biphasic reaction.

The decision to administer a repeat dose of epinephrine is also not always clear-cut. It is pragmatic. The clinician may have decided to administer another dose of epinephrine despite the patient not meeting the exact definition of anaphylaxis or a biphasic reaction. Epinephrine may have been administered because the child exhibited concerning signs or symptoms.

For example, if a child was being observed in the ED after experiencing anaphylaxis and receiving that first dose of epi started saying that his throat was feeling weird again, we wouldn’t fault the clinician for choosing to give a second dose of epinephrine, but we just wouldn’t know if the child really needed it.

Confounding

 Any observational study is at risk of confounding. One example we can see is if we look at Figure 3, it appears that the pre-emergency administration of epinephrine is a factor that increases the odds of repeat administration of epinephrine.

This is somewhat counterintuitive, as early recognition of anaphylaxis and administration of epinephrine should be beneficial. Instead, this may indicate disease severity. Sicker children received epinephrine in the pre-emergency setting.

We can also see something similar with steroid use in the emergency department associated with an increased odds of repeat epinephrine. I do not routinely give corticosteroids for anaphylaxis, given that the likelihood of benefit is low or uncertain. In this study, it may be more indicative of a patient who had a more severe reaction.

 Risk of Repeat Epinephrine

 The study team a priori defined the observation threshold at which the cumulative incidence of repeat epinephrine dosing increased by < 2% with each 1-hour increase in observation time. It’s not clear where this 2% came from.

The paper reports that this “was deemed clinically acceptable because it represented the optimal balance between prolonged observation with limited benefit and the likelihood of biphasic reaction occurring after discharge.”

Who decided this? Was it the authors? Was there any input from patients and families? Ultimately, individual clinicians and patients/families may have differing risk thresholds.

Bounce Backs for Biphasic Anaphylaxis

 Assuming a patient who is discharged from the ED for anaphylaxis with an epinephrine autoinjector returns after a biphasic reaction. Is that necessarily a failure, or should it reflect negatively on the discharging clinician?

A significant part of our work in the ED is to provide anticipatory guidance and discuss signs and symptoms that would prompt the patient to return to the ED for care. It can be argued that a patient returning to the ED after discharge for a biphasic anaphylactic reaction who self-administered an epinephrine autoinjector is a good thing. This indicates that our anticipatory guidance was effective and well delivered.

Comment on the Authors’ Conclusion Compared to the SGEM’s Conclusion: In general, we agree that most pediatric patients likely do not require prolonged observation in the ED after being treated for anaphylaxis. However, the risk tolerance for a biphasic reaction may vary among patients, families, and clinicians.

Case Resolution: The 7-year-old boy improved rapidly after a single dose of IM epinephrine. During his time in the ED, he has no difficulty breathing or changes in hemodynamics. After discussion with the family, you recognize that they are familiar with signs and symptoms of anaphylaxis and know how to administer IM epinephrine auto-injector. You also confirm that the family has another epinephrine auto-injector at home and send them with a prescription for two new auto-injectors. Afterwards, you send them home.

Clinical Application: There is limited high-quality evidence on observation times for anaphylaxis. Specifically, there is no evidence that any particular observation period is superior, as biphasic reactions may occur up to 72 hours after the initial event. Institutional guidelines may vary. Remember the pillars of evidence-based medicine. Consider your clinical judgement and the patient or family’s values and preferences. Prior to discharge, ensure the patient feels better, that families and patients are aware of the signs and symptoms of anaphylaxis and biphasic reactions, and that they have another epinephrine autoinjector at home.

What Do I Tell the Patient/Family?

Sorry that this happened to your son. It’s great that he seems to be feeling better. It sounds like you have found yourself in this situation before. There’s no set amount of time we must observe him in the emergency department. Let’s briefly go over what symptoms to look out for at home and make sure that you can get another epinephrine autoinjector before you leave the ED.

The post PODCAST: Home Where I Wanted to Go After Anaphylaxis first appeared on האיגוד הישראלי לרפואה דחופה.

“Should we be giving blood transfusions to patients with traumatic cardiac arrest?” EMJ editor Prof. Richard Body and associate editor Dr. Sarah Edwards talk through some original research on the value of blood transfusions in this difficult situation. Next is the new UNCORKED study from the Trainee Emergency Research Network (TERN), with some sobering statistics on the prevalence of emergency care carried out in non-standard treatment places across the UK. Then we move to a world of high-pressure injuries, often caused by industrial spraying equipment, where things on the surface aren’t quite as they seem. The last paper returns to the theme of cardiac arrests, examining the predictive value of end-tidal CO2 usage.

Read the highlights: Primary survey:

The EMJ podcast is hosted by:

Prof. Richard Body, EMJ Editor-in-Chief, University of Manchester, UK (@richardbody)

You can subscribe to the EMJ podcast on all podcast platforms to get the latest podcast every month. If you enjoy our podcast, please consider leaving us a review or a comment on the EMJ Podcast Apple (https://apple.co/4bfcMU0) or Spotify (https://spoti.fi/3ufutSL) page.

The post EMJ Podcast: Solving corridor care, and return of spontaneous circulation : Primary Survey February 2026 first appeared on האיגוד הישראלי לרפואה דחופה.

Date: January 3, 2026 

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

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

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

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

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

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

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

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

Quality Checklist for a Diagnostic Study:

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

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

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

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

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

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

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

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

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

Dr. Amal Mattu

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

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

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

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

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

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

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

The post PODCAST: Meningitis 2.0 first appeared on האיגוד הישראלי לרפואה דחופה.

Administration of blood products in the field prior to hospital arrival

Aimed at patients in hemorrhagic shock

Traditional US prehospital resuscitation relied on crystalloid

ED and trauma care now prioritize early blood

Hemorrhage occurs before hospital arrival

Delays to definitive hemorrhage control are common

Earlier blood may improve survival

ATLS and trauma paradigms emphasize blood over fluid

National organizations support prehospital blood when feasible

EMS already manages high risk, time sensitive interventions

Data are mixed and evolving

COMBAT: no benefit

PAMPer: mortality benefit

RePHILL: no clear benefit

Signal toward benefit when transport time exceeds ~20 minutes

Urban systems still experience long delays due to traffic and geography

LA County median time to in hospital transfusion ~35 minutes

~2 years of planning before launch

Pilot began April 1

Partnerships:

LA County Fire

Compton Fire

Local trauma centers

San Diego Blood Bank

14 units of blood circulating in the field

Blood rotated back 14 days before expiration

Ultimately used at Harbor UCLA

Continuous temperature and safety monitoring

Focused rollout

Trauma related hemorrhagic shock

Postpartum hemorrhage

Physiologic criteria:

SBP < 70

Or HR > 110 with SBP < 90

Shock index ≥ 1.2

Witnessed traumatic cardiac arrest

Products:

One unit whole blood preferred

Two units PRBCs if whole blood unavailable

~28 patients transfused at time of discussion

Evaluating:

Indications

Protocol adherence

Time to transfusion

Early outcomes

Too early for outcome conclusions

Multiple active programs:

Riverside (Corona Fire)

LA County

Ventura County

Additional programs planned:

Sacramento

San Bernardino

Programs meet monthly as CalDROP

Focus on shared learning and operational optimization

Trauma surgeon concerns about blood supply

Need for system wide buy in

Community engagement

Patients who may decline transfusion

Women of childbearing age and alloimmunization risk

Risk of HDFN is extremely low

Clear communication with receiving hospitals is essential

Rapid national expansion expected

Greatest benefit likely where transport delays exist

Prehospital Blood Transfusion Coalition active nationally

Major unresolved issue: reimbursement

Currently funded largely by fire departments

Sustainability depends on policy and payment reform

Hemorrhagic shock is best treated with blood, not crystalloid

Prehospital transfusion may benefit patients with prolonged transport times

Implementation requires strong partnerships with blood banks and trauma centers

Early data are promising, but patient selection remains critical

National collaboration is key to sustainability and future growth

The post PODCAST: Prehospital Blood Transfusion first appeared on האיגוד הישראלי לרפואה דחופה.

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

Date: January 6, 2026

Dr. Jillian Nickerson

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

Background:

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

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

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

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

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

Dr. Nathan Kuppermann

Dr. Paul Aronson

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

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

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

Quality Checklist for Clinical Decision Rules:

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

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

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

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

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

Selection Bias

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

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

Overfitting the Data

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

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

The “Original” PECARN

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

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

90 Days and Beyond!

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

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

Prematurity

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

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

Bonus Question: Respiratory Virus Testing

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hosts:

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

Course Highlights:

Click Here to Register and Begin Module 1 The Clinical Case

Differential Diagnosis for the Hypoxic/Tachypneic Patient

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

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

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

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

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

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

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

Disposition

Take-Home Points

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

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

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

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

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

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

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

Podcast production, editing and sound design by Anton Helman

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Pragmatic approach:

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

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

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

First10EM deeper dive into AAST Brain Injury Guidelines

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

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

How common are true allergic reactions?

Shellfish or iodine allergies are not contrast allergies.

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

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

Contrast switching

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

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

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

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

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

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

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