summary - האיגוד הישראלי לרפואה דחופה

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.

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.

The post PODCAST: July 2026 Annals of Emergency Medicine by Annals of Emergency Medicine first appeared on האיגוד הישראלי לרפואה דחופה.

Kate Lazier on a case of fever without a source (1:13)

Andrew Petrosoniak on chest tubes in trauma part 2 (15:59)

Adrianna Roweon the challenges of recognition and management of medetomidine withdrawal (28:49)

Justin Morgensternon why the PECARN c-spine rule may be dangerous (36:19)

Zach Cantor on paramedic handover done right (48:45)

Sara Gray & Katie Lin on coaching the em mind part 1: physiology – sleep, nutrition and exercise (59:16)

Podcast production, editing and sound design by Anton Helman

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

Cite this podcast as: Helman, A. Lin, K. Lazier, K. Petrosoniak, A. Morgenstern J. Cantor, Z. Gray, S. EM Quick Hits 71 – EMC²: Fever Without a Source, Coaching the EM Mind Part 1, Traumatic Pneumothorax Part 2, PECARN C-spine Rule, Medetomidine Withdrawal, EMS Handover. March, 2026. https://emergencymedicinecases.com/em-quick-hits-march-2026/. Accessed March 11, 2026.

High-risk infectious diagnoses to consider

Inflammatory diagnoses

Giant cell arteritis and other vasculitites

Malignancy

Leukemia / blast crisis

Toxicologic / endocrine diagnoses

West Nile Virus pearls

Fever of Unknown Origin (as apposed to Fever Without a Source)

If you haven’t already, listen to Part 1 first where Dr. Petrosoniak talks about the following…

Needle Decompression in the ED for traumatic pneumothorax

Physiology-First Approach to Traumatic Pneumothorax

Medetomidine, a veterinary sedative and potent non-selective alpha-2 adrenergic agonist pharmacologically similar to clonidine and dexmedetomidine, has increasingly been identified as an adulterant in the unregulated opioid supply and is now emerging as an important cause of withdrawal syndromes presenting to emergency departments.

Acute toxicity from alpha-2 agonists typically produces sedation and sinus bradycardia, and although naloxone may reverse concomitant opioid-induced respiratory depression, it does not reverse sedation related to alpha-2 agonists or benzodiazepines that may also be present in contaminated drug supplies.

The more challenging clinical presentation is medetomidine withdrawal…

Key features:

Complications reported:

Patients using unregulated drugs with:

The goal of medetomidine withdrawal treatment is to restore alpha-2 agonism

Clonidine

Dexmedetomidine infusion

Use antidopaminergic agents

Note that ondansetron is often ineffective.

A recent multicenter study derived and validated a pediatric c-spine decision rule for children with blunt trauma presenting to trauma centers, identifying several high-risk clinical features associated with a substantially increased likelihood of cervical spine injury.

High-risk findings include:

Additional intermediate-risk features include:

Despite the methodological riggor of the study, the resulting rule demonstrates only moderate sensitivity, raising concern that a clinically meaningful proportion of injuries could be missed, while the positive predictive value remains extremely low given the rarity of cervical spine injury even in high-risk trauma populations.

Importantly, the rule was derived in pediatric trauma center cohorts with far higher baseline imaging rates than most emergency departments, and has not yet undergone adequate external validation, comparison with clinician judgment, or implementation studies assessing its real-world impact on imaging practices.

In the opinion of our guest expert, routine application of the rule outside highly selected trauma settings may paradoxically increase cervical spine imaging, potentially exposing large numbers of children to unnecessary radiation without improving diagnostic accuracy.

Communication during prehospital-to-emergency department handover represents a critical but frequently under-recognized patient safety intervention, with observational studies demonstrating substantial information loss during transitions of care.

Research suggests that a significant proportion of key clinical information is either omitted or not retained during handover, with frequent interruptions, parallel conversations, and premature patient transfer contributing to incomplete communication and potential downstream impacts on patient care.

Evidence consistently demonstrates that handovers are most effective when they are brief, structured, and delivered before patient transfer, allowing receiving teams to focus attention on the information being communicated.

The IMIST-AMBO framework provides a standardized structure for handover:

IMIST

AMBO

Bottom Line -> Better EMS handover → fewer interruptions, clearer communication, improved patient care.

Emergency medicine places clinicians in a uniquely demanding cognitive and physiologic environment characterized by shift work, sleep disruption, high cognitive load, and repeated exposure to emotionally stressful situations. Over time, these stressors can degrade both clinical performance and personal wellbeing, making deliberate attention to physiologic needs an essential component of professional sustainability.

Emergency medicine practice exposes clinicians to sustained physiologic and psychological stressors, particularly related to shift work, which is associated with increased risk of metabolic syndrome, cardiovascular disease, malignancy, and mental health disorders.

In addition to long-term health risks, sleep disruption from rotating shift schedules impairs cognitive performance, concentration, reaction time, and clinical decision-making, with fatigue-related motor vehicle collisions representing an additional hazard during post-shift commutes.

Strategies to mitigate these effects include:

Early indicators of declining resilience often emerge in four physiologic domains: sleep, physical conditioning, nutrition, and stress regulation. Warning signs may include falling asleep during commutes or routine activities, progressive deterioration in physical fitness or health metrics, irregular or inadequate nutrition during shifts, and increasing feelings of overwhelm, irritability, or dread before work. Importantly, these changes often develop gradually and may be more readily recognized by colleagues or family members before clinicians recognize them themselves.

Several evidence-informed scheduling principles may help mitigate these effects. Whenever feasible, schedules should incorporate flexibility that allows clinicians to align shifts with their chronotype, recognizing that individuals naturally differ in their sleep–wake preferences.

Because sleep disruption is unavoidable in emergency medicine, clinicians benefit from intentionally optimizing sleep environments and routines. Practical measures include maintaining a dark, cool, and quiet sleeping environment, using blackout blinds, eye masks, earplugs, and white-noise devices when necessary. Strategic pre-shift napping before night shifts, minimizing caffeine intake in the hours preceding sleep, and limiting exposure to bright light before planned sleep periods may also improve sleep quality. Developing consistent routines around sleep—even when schedules vary—can significantly improve restorative sleep over time.

Episode 207 Deep dive into sleep strategies for shift workers

Regular physical activity plays a critical role in maintaining both physical and cognitive resilience. Exercise has been shown to improve attention, memory, mood regulation, and stress tolerance, while also reducing long-term risks of cardiovascular disease and dementia. Even modest and consistent exercise routines—such as brief daily workouts or incorporating activity into existing routines—can yield meaningful physiologic and psychological benefits. Importantly, sustainable habits often begin with small, achievable goals rather than ambitious but unsustainable lifestyle changes.

Nutrition is an often overlooked determinant of physician performance, yet it plays a critical role in maintaining cognitive function, metabolic health, and circadian stability, all of which are challenged by shift work. Irregular schedules and busy clinical environments frequently lead emergency physicians to skip meals or rely on highly processed foods, which can produce fluctuations in blood glucose that contribute to fatigue, irritability, and impaired concentration.

Bottom Line – > Ultimately, maintaining personal physiologic health should be viewed not as optional self-care but as a professional responsibility essential for sustaining high-quality emergency care over the course of a long career.

The post PODCAST: EM Quick Hits 71 EMC²: Fever Without a Source, Coaching the EM Mind Part 1, Traumatic Pneumothorax Part 2, PECARN C-spine Rule, Medetomidine Withdrawal, EMS Handover 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.

Deborah Schonfeld on pediatric urinary retention & acute transverse myelitis (01:27)

Jesse McLaren on Occlusion MI Diagnosis (24:44)

Matthew McArthur on post-dural puncture headache (31:34)

Joseph Yasmeh on Med Mal Cases: clenched fist injury (42:42)

Brit Long on IV thrombolysis for minor strokes (59:27)

Victoria Myers & Lauren Westafer on mentorship and what it means to be a physician leader (1:11:34)

Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Brandon Ng, edited by Anton Helman, December, 2025

Cite this podcast as: Helman, A. Schonfeld, D. McLaren, J. McArther, M. Yasmeh, J. Long, B. Myers, V. Westafer, L. EM Quick Hits 69 – Pediatric Urinary Retention & Acute Transverse Myelitis, Post-Dural Puncture Headache, Med Mal Cases: Clenched Fist Injury, IV Thrombolysis for Minor Stroke, EM Leadership Spotlight #4. Emergency Medicine Cases. December, 2025. https://emergencymedicinecases.com/em-quick-hits-month-year/. Accessed December 3, 2025.

Inability to void at least 12 hours, no urine output for 12 hours, greater volume of urine in the bladder expected for age, or palpable bladder distension.

Bottom line: Urinary retention may present variably in pediatric patients. In pediatric patients with otherwise unexplained urinary retention, consider neurogenic causes of urinary retention in patients.

Bottom line: ECG represents only one aspect of the clinical picture. Do not interpret ECGs using STEMI criteria alone. Consider POCUS to enhance diagnosis of OMI.

Deeper Dive and practice ECGs: ECG Cases 57 Art of Occlusion MI Part 5 – Clinical-ECG-POCUS Triptych

Register for Dr. McLaren’s HEARTS ECG Course to master your ECG interpretation skills.

Consider post-dural puncture headache in any patient with new positional headache that occurs within five days of a dural puncture.

This case involves an young adult male who presents with an injured hand that occurred when “messing around with some friends” when a brick “fell directly onto the back of his left hand”. The case highlights the importance of spotting the disconnect between the patient’s story and the presenting wound.

Clenched Fist Injury (Fight Bite) = consider in any laceration over the dorsal aspect of MCP or PIP joints, usually in the dominant hand.

Pathophysiology of clenched fist injury (fight bite)

Red-flag exam: Pain with passive finger motion = deep infection (infectious tenosynovitis/septic arthritis) until proven otherwise.

Investigations for suspected clenched fist injury (fight bite)

Critical Error #1: During wound care (including anesthetizing, irrigation and exploration), the tendon sheath was “frayed”, but the wound was closed with sutures.

Critical Error #2: Cefazolin/cephalexin were given for the skin and soft tissue injury.

Critical Error #3: Patient was discharged with a splint and told to follow-up with a plastic surgeon in several days.

Additional considerations: An accurate diagnosis and reasonable plan may fail if the patient can’t access treatment.

Bottom line: Trust the injury pattern not the story, injury over the knuckles of young person = clenched fist injury until proven otherwise. For bite wounds: irrigate thoroughly, do not suture primarily, splint hand in position of function, follow-up within 24-48 hours, and preferred antibiotic is amoxicillin-clavulanate. Acknowledge and address barriers of care to help ensure that patient gets the treatment you prescribe.

*This case was obtained from Dr. Mike Weinstock’s EM Boucebacks series of closed legal cases

To address an EM Caser’s concern about the questionable evidence for IV thrombolysis in patients who present within 4.5 hours of symptom onset with a minor stroke (defined as NIHSS ≤5) but their stroke is deemed disabling, we asked Brit Long for an evidence-based deep dive…

Current Guidelines

Literature on IVT in disabling strokes:

·       NINDS II (1995): n = 333, 12% benefit with IVT in 3 hours.

·       ECASS III (2008): n = 821, 8% benefit with IVT in 3-4.5 hours.

Literature on IVT in non-disabling stroke:

Optimizing practice:

Bottom line: Evidence overall suggests that risk of IVT may outweigh benefits in patients with minor stroke, however for disabling minor strokes, IVT should be offered. Consider legal implications of not giving IVT in disabling minor strokes. Reference your local institutional protocols on IVT for stroke.

For further listening on referenced EMCases episodes and Dr. Katie Lin’s take on the evidence for thrombolysis is disabling minor stroke in the comments sections: Ep 208 Paradigm Shift in Ischemic Stroke Management Part 1: Disabling Strokes and Ep 209 Nondisabling Stroke Recognition and Management.

The post PODCAST: EM Quick Hits Pediatric Urinary Retention & Acute Transverse Myelitis, Post-Dural Puncture Headache, Med Mal Cases: Clenched Fist Injury, IV Thrombolysis for Minor Stroke, EM Leadership Spotlight #4 first appeared on האיגוד הישראלי לרפואה דחופה.

Date: June 2, 2025

Dr. Andrew Tagg

Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder and website lead of Don’t Forget the Bubbles.

This is another SGEM Xtra that talks about what we can learn about being physicians from certain pop culture (TV and Movies). Past episodes include:

The SGEM will return with a structured critical appraisal of a recent publication. We will continue to strive to reduce the Knowledge Translation (KT) window from over ten years to less than one year, leveraging the power of social media.

Share:

Dr. Wm. Ken Milne Emergency Medicine Physician Researcher/EBM Skeptic

The post PODCAST: Your Mission, Should You Choose to Accept It – To Be an EM Doc first appeared on האיגוד הישראלי לרפואה דחופה.

In this episode, Sam Ashoo, MD interviews Rob Orman, MD about ways to manage the trauma inflicted by the ER.

For more about Rob Orman and physician coaching: https://roborman.com/

Sam Ashoo, MD, FACEP,  is board certified in emergency medicine and clinical informatics. He serves as EB Medicine’s editor-in-chief of interactive clinical pathways and FOAMEd blog, and host of EB Medicine’s EMplify podcast. Follow him below for more…

The post PODCAST: Strategies for Keeping Trauma at Bay with Rob Orman, MD first appeared on האיגוד הישראלי לרפואה דחופה.

Phase One: CNS

Phase Two: Cardiopulmonary

Phase Three: Renal

Diagnosis:

Treatment:

The post PODCAST : summary EM clerkship CNS, Cardiopulmonary, Renal Diagnosis: first appeared on האיגוד הישראלי לרפואה דחופה.

Stephen Freedman on pediatric bloody diarrhea, S-TEC and hemolytic uremic syndrome (1:06)

Justin Morgenstern on the evidence for IM epinephrine in out of hospital cardiac arrest (27:04)

Matthew McArther on recognition and ED management of dengue fever (33:56)

Andrew Petrosoniak on imaging decision making in trauma in older patients (47:20)

Brit Long & Michael Gotlieb on recognition and management of TTP (59:10)

Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Brandon Ng, edited by Anton Helman, March, 2025

Cite this podcast as: Helman, A. Freedman, S. Morgenstern, J. McArther, M. Petrosoniak, A. Long, B. Gotlieb, M. EM Quick Hits 63 – S-TEC and HUS, IM Epinephrine in OHCA, Dengue, Geriatric Trauma Imaging, TTP. Emergency Medicine Cases. March, 2025. https://emergencymedicinecases.com/em-quick-hits-march-2025/. Accessed March 12, 2025.

Consider obtaining a stool specimen or rectal swab in the ED for PCR testing (not culture) to detect S-TEC, Salmonella, Shigella, and Campylobacter.

Which children with bloody diarrhea require bloodwork? Most children with blood in stool do not require blood work. Indications for bloodwork include:

When to suspect S-TEC?

Children generally do not require stool O&P for acute diarrhea but should be considered for chronic abdominal pain, chronic diarrhea, or failure to thrive.

When to test for C.difficile? There is a high carriage rate of C. diff (up to ~50% in children under 2 years old). Consider C. diff testing only in children with risk factors such as recent antibiotic use or hospitalization, or as a second line test on follow up if bloody diarrhea persists that is not noted to be from another bacterial etiology.

Why is it important to recognize S-TEC?

A complication of S-TEC infection is Hemolytic Uremic Syndrome (HUS), caused by Shiga toxin accumulation in the kidney which leads to the HUS triad: acute kidney injury, hemolysis, and thrombocytopenia.

How to risk stratify a positive STEC result:

How to manage high risk patients with confirmed S-TEC?

Bottom line: Obtain early stool testing to identify children who present with bloody diarrhea for STEC, as some are at high risk of developing complications such as HUS. Children with STEC and their hydration status should be closely monitored.

The Paper: Early intramuscular adrenaline administration is associated with improved survival from out-of-hospital cardiac arrest by Palatinus et al. Resuscitation 2024.

This before-and-after study suggests 5mg IM epinephrine may improve survival when given while IV access is being secured during an out of hospital cardiac arrest.

P: Adult patients with out-of-hospital cardiac arrest at a single-center urban setting

I (After): Single dose 5mg IM epinephrine prior IV/IO access in patient between November 2019 and May 2024

C (Before): Standard EMS ACLS protocol without IM epinephrine in patients between January 2010 and October 2019

O: Time to epi administration: 4.3 min in IM epi group, 7.8 min in standard protocol group. Survival to hospital admission: 37% in IM epi group, 32% in standard protocol group. Hospital survival: 11% in IM epi group, 7% in standard protocol group. Favourable neurological status at hospital discharge: 10% in IM epi group, 6% in standard protocol group

Limitations of this study:

Bottom line: There is insufficient evidence for early administration of IM epinephrine compared to standard ACLS protocols to improve outcomes in out of hospital cardiac arrest.

Background: Dengue is a mosquito-borne flavivirus (related to Zika and West Nile) which transmits between humans by mosquitos and is endemic to many countries in tropical and subtropical regions. It has been an increasing public health concern due to increasing outbreaks over the last decade. All 4 types of Dengue cause acute infections in humans but are not known to cause chronic infections.

75% of dengue infections are asymptomatic. However, 2-5% of dengue can progress to severe dengue.

There are 3 phases of dengue:

The updated WHO classification system for dengue includes dengue, dengue with warning signs, or severe dengue. Consider the diagnosis of dengue in patients coming from an endemic area who have fever and any 2 of: aches, rash, nausea, vomiting, leukopenia, and positive tourniquet test.

Warning signs for severe dengue:

Severe dengue = shock, clinically significant bleeding, or severe organ impairment

There are no specific therapies or vaccines for Dengue. Management is primarily supportive:

Bottom line: Dengue is self-limiting in most cases but can be life-threatening in 2-5% of patients. Management of dengue is primarily supportive with oral or IV fluid resuscitation.

Falls in the older patient can result in significant injuries despite seemingly minor mechanisms.

CT imaging considerations:

The Eastern Association for the Surgery of Trauma (EAST) developed an imaging decision algorithm for the evaluation of blunt trauma patients > 65 although it has not received external validation. They recommend:

Thrombotic thrombocytopenic purpura (TTP) is a rare but important disorder as it is associated with a mortality rate of 4-30%, even with early recognition and treatment.

In TTP, enzyme ADAMTS13 (responsible for cleaving large von Willebrand factor (vWF) becomes dysfunctional, resulting in large vWF multimers which accumulates in platelets, form clots, and destroys RBCs, leading to thrombocytopenia and hemolysis.

The classic pentad is seen in less than 7% of patients with TTP, and many of these findings can be transient:

Lab work for TTP

A PLASMIC Score ≥5 has a 99% sensitivity and 57% specificity for TTP (incorporates elements including platelet count, hemolysis, active cancer, solid organ or stem cell transplant, low MCV, INR <1.5, Cr <2mg/dL).

Management of TTP:

Bottom line: Patients with TTP may not present with all elements of the classic pentad. Early identification and therapy can significantly improve mortality. The PLASMIC score can be used to assist in identifying patients with TTP.

The post PODCAST: EM Quick Hits 63 S-TEC and HUS, IM Epinephrine in OHCA, Dengue, Geriatric Trauma Imaging, TTP first appeared on האיגוד הישראלי לרפואה דחופה.