In this episode of the Rebel Core Content podcast, Swami provides crucial tips on using tourniquets. Highlighting the significance of these life and limb-saving devices, the discussion focuses on the optimal placement of tourniquets, emphasizing placing them 2-3 inches (5-6 cm) above the bleeding source and avoiding joints. Swami also advises on the correct way to tighten the tourniquet using the Velcro strap first, followed by minimal use of the windless. The importance of noting the application time to avoid prolonged arterial flow interruption is also discussed. The episode concludes with a reminder to visit the podcast’s website for more valuable content.

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Limping is a common complaint in pediatric emergency care, but the differential is broad and the stakes are high. In this episode, we walk through a detailed, age-based approach to the evaluation of the limping child. You’ll learn how to integrate the Kocher criteria, when imaging and labs are truly necessary, and how to avoid being misled by small joint effusions on ultrasound. We also highlight critical mimics like appendicitis, testicular torsion, and malignancy—and remind you why watching a child walk is one of the most valuable parts of the exam. Whether it’s transient synovitis, septic arthritis, or something much more concerning, this episode gives you the tools to manage pediatric limps with confidence.

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Try Alex (chatbot in right lower corner of the website)

Published on September 1, 2025

Written by Vivian Lei

Mindful Intubation

How does this change my practice?

Source

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Massive hemorrhage is one of the most time-critical, high-stakes scenarios in Emergency Medicine. Every minute matters. Every decision counts. But more blood is not always better—what saves lives is systematic, team-based, goal-directed care. In this update to the 7 T’s of Massive Hemorrhage Protocols with Dr. Jeannie Callum and Dr. Andrew Petrosoniak, we explore the most current, evidence-informed strategies for bleeding patients, from polytrauma to obstetrical, drawing on the latest clinical trial data, provincial MHP 2.0 rollouts, and real-world experience. We answer the questions: What is the evidence based alternative to FFP in EDs where FFP is not readily available? How accurate are decision scores in helping decide the trigger for MHP activation? Why is testing fibrinogen levels and giving fibrinogen concentrates so important in massive hemorrhage? How should we tailor our MHP to the GI bleed patient? To the obstetrical patient? and many more….

Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Matthew McArther, edited by Anton Helman August, 2025

Cite this podcast as: Helman, A. Callum, J. Petrosoniak, A. Massive Hemorrhage Protocols 2.0 – Update on the 7 Ts. Emergency Medicine Cases. August, 2025. https://emergencymedicinecases.com/massive-hemorrhage-protocols-2-0/. Accessed August 5, 2025

Determining when to activate MHP can be challenging. Overactivating MHP can cause harm by clogging up hospital resources as well as adverse sequelae from overtreatment. But even small delays in transfusing critically bleeding patients is associated with increased mortality. Rather than calling an MHP immediately based on EMS report or on arrival in the ED, our experts suggest a critical administration threshold approach to MHP.

In general, the literature suggests there is little downside to giving a 2-3 units of RBCs up front, so have RBCs ready for any patient who has hypotension in the field with a concerning mechanism, or any other suspicion of hemorrhagic shock. Once the patient arrives and you begin your primary survey, have a low threshold to administer those first 1-3 units if you are still concerned for hemorrhagic shock. In trauma, this strategy aligns with observational evidence that early red cell transfusion improves outcomes while minimizing premature plasma exposure.

Predicting upfront which bleeding patients will go on to need massive transfusion is challenging. Even our best clinical scoring tools are only 60-80% accurate. Trauma scores such as the Assessment of Blood Consumption (ABC), Shock Index, Revised Assessment of Bleeding and Transfusion score (RABT) and Resuscitation Intensity (RI) have been used to predict need for MHP. However, their sensitivity and specificity are modest. Instead, seeing how a patient responds after those first few units during the initial resuscitation will be most useful for you to decide when to activate MHP.

MHP Mnemonic: “Easy as ABC After 3”

It is useful to conceptualize the MHP as a “full court press” for patients with massive hemorrhage, designed to:

Dr. Andrew Petrosoniak proposes a two-step decision-making model: first, administer two or three units of uncrossmatched red cells to the bleeding patient. Then, reassess. This “ABC after 3” rule—standing for “Activate MHP, Balance products, Consider calcium and concentrates (fibrinogen)”—anchors the transition point between supportive transfusion and full protocol activation. If, after three RBCs, the patient remains unstable, coagulopathic, or is likely to require operative or angiographic intervention, then activation is warranted.

Ask three questions after 3 units RBCs (the “ABC after 3” rule):

Most of the evidence around MHP activation is in trauma. But not all bleeding patients share the same physiology: what about other causes of hemorrhagic shock?

Importantly, bleeding patients differ in fundamental ways depending on etiology. Trauma-induced coagulopathy occurs in approximately 25% of trauma patients and arises from complex endothelial dysfunction and fibrinolysis. In contrast, gastrointestinal bleeds—particularly variceal bleeds—typically involve a paradoxical mix of hypercoagulability and active bleeding. Postpartum hemorrhage, on the other hand, is most often caused by uterine atony, with hypofibrinogenemia as a late and ominous sign.

Accordingly, thresholds for MHP activation must be tailored. In trauma, early red cells followed by reassessment offers a reasonable approach. In GI bleeding, full activation is rarely needed, with only 5% of patients requiring more than red cells alone, and FFP may even be harmful. In contrast, obstetric hemorrhage demands a low threshold for activation. With blood flow to the gravid uterus at term reaching 1.5L/min, complete exsanguination can occur in minutes. Thus, any signs of instability in postpartum patients should prompt immediate protocol initiation.

These patients have very different physiology than bleeding trauma patients and rarely need MHP activation. A combination of crystalloid volume resuscitation and red cell transfusions to a hemoglobin target of 70-80mg/dL should be adequate for the vast majority of patients with variceal bleeds (Baveno VII consensus guidelines). Activating consultants early for endoscopic management is key. Giving plasma, as in MHP protocols, could increase portal venous pressures and increase bleeding.

Pitfall: Do not trust the INR in cirrhotic patients. These patients have alterations in both pro-thrombotic and anti-thrombotic protein synthesis, so they may have an overall pro-thrombotic state despite having an elevated INR. Focus your management on resuscitation, decreasing portal pressures, and hemorrhage source control, rather than trying to correct coagulopathy. TXA has been shown to increase thrombotic complications in these patients with no mortality benefit (HALT-IT trial).

Because of the high uterine blood flow of 1.5L/min of pregnancy, these patients have the potential to exsanguinate rapidly. Have a very low threshold to activate MHP for any post partum hemorrhage (PPH) patient who is showing signs of hemorrhagic shock in order to mobilize blood products quickly. Rapid source control of uterine atony, with medications and operative management if needed, is critical for these patients.

The first “T,” trigger, remains perhaps the most critical. Without timely activation of the MHP, the rest of the pathway simply doesn’t unfold. Traditionally, we’ve relied on a mix of gestalt, shock index, and trauma scores like ABC or REBT to guide activation. But the latest thinking encourages a more pragmatic, flexible approach.

Ratio-based Resuscitation

2:1 ratio of RBC to FFP is recommended by our experts which corresponds with multiple consensus guidelines. PROPER trial did not show a benefit of 1:1 compared to 2:1.

If FFP is unavailable, after the first 4 units of RBCs, give 2000 units of PCC and 4g of fibrinogen in lieu of FFP. You can repeat this once after the second pack of 4 RBCs.

Don’t overuse O negative – it’s a very limited resource. Women under 45 of childbearing potential should get O negative Kell negative blood. Everyone else gets O positive.

MHPs require seamless collaboration between emergency, surgical, nursing, transfusion, and laboratory services. High-performance teams emphasize clear role allocation, defined hemodynamic goals, and shared mental models.

Delegating transfusion logistics to two team members operating a rapid infuser is another high-yield move. Once MHP is activated, the transfusion sequence can be semi-automated: start with four units of RBCs, then alternate between RBC and FFP to approach a 2:1 ratio, with the team leader monitoring for signs of over- or under-transfusion. Regular check-ins—every 30 minutes or after each pack—allow for reassessment and recalibration. Shared situational awareness is critical. Reminders like “pause the transfusion if systolic >140 or <70” empower the team to speak up and support dynamic decision-making.

Despite its importance, lab testing is often overlooked in the midst of resuscitation. Yet timely, repeated laboratory data are essential for guiding goal-directed therapy. Trauma-induced coagulopathy can occur due to the release of natural heparins and tPA from damaged endothelial cells. Clinical signs of trauma-induced coagulopathy include excessive oozing from IV sites as well as mucosal bleeding.

Serial labs should be repeated every hour or after every 4 units of red cells, whichever comes first. Anchoring lab draws to clinical actions—such as after each MHP pack—makes this easier to remember.

Labs at baseline and minimum q60min (or after every pack/4 units):

A PTT should be included at baseline but only repeated if elevated or if the patient is on heparin or dabigatran.

 Pitfall: Forgetting fibrinogen. It’s important and often missed.

In Small Centers:

No fibrinogen testing? For hospitals lacking fibrinogen testing, empirical administration  of fibrinogen concentrates 4 g IV is recommended after two MHP packs in patients with ongoing bleeding.

The importance of fibrinogen and calcium

Among all these tests, fibrinogen is one of the most crucial—and the most frequently missed. Hypofibrinogenemia is a strong predictor of transfusion need and poor outcomes, particularly in obstetric and liver disease–associated bleeding. A declining fibrinogen level is a key indicator of worsening coagulopathy, and replacement must be timely and targeted. Calcium levels must also be vigilantly monitored, as hypocalcemia reduces cardiac contractility and interferes with coagulation factor activity. In cirrhotic patients with variceal bleeds, fibrinogen remains important. While their INRs may appear deranged, many are in a tenuous hemostatic balance. However, if fibrinogen is critically low, even expert endoscopists will struggle to achieve source control of bleeding.

CRASH-2 study showed that TXA has a time-sensitive mortality benefit if given in the 1st hour, so remember to give it ASAP for trauma patients with severe bleeding. Give the entire 2g upfront as a bolus- no need for an infusion as described in earlier protocols.

Tranexamic acid (TXA) is one of the few medications in hemorrhage resuscitation that has been shown to confer a mortality benefit—when used correctly. For trauma patients, their is an associated reduced mortality benefit with a 2-gram dose given within the first hour of injury. The key is speed. Delayed administration beyond 3 hours confers no benefit and may cause harm. In the chaos of resuscitation, having a timekeeper or checklist item reminding the team to administer TXA early is crucial. In prehospital settings, a 1 g dose by EMS can be followed by an additional 1 g in the ED.

In postpartum hemorrhage, our experts recommend 1 gram as soon as bleeding begins, followed by a second gram if bleeding persists after 30–60 minutes. This is supported by the WOMAN trial and WHO guidelines.

However, in gastrointestinal bleeding, TXA is no longer recommended. The HALT-IT trial demonstrated no mortality benefit and an increased rate of thromboembolic events in patients who received TXA. This underscores the importance of tailoring adjunctive therapy to the bleeding context.

Caution is advised in patients with recent thromboembolic disease (<3 months), although anticoagulated patients may still benefit from TXA given the overriding risk of hemorrhagic death.

Hypothermia is one-third of the deadly trauma triad, yet it’s often overlooked in the early stages of care. Hypothermia exacerbates coagulopathy by impairing platelet function and fibrinogen polymerization. Every 1°C drop is associated with a 20% increase in transfusion needs. There is also a potential psychologic benefit to our patients: patients who are kept warmer in the trauma bay often feel safer during their resuscitation.

A systems-based approach is needed. Warm IV fluids, forced-air warming, and heated resuscitation rooms should be standard. Temperature monitoring should begin immediately upon arrival, as anesthesia and operating room teams do routinely.

Tips to avoid hypothermia in trauma patients:

Target a temperature of 37 degrees celsius.

The initial 1-2 hours of the resuscitation is guided by hemodynamics and the overall clinical impression rather than lab parameters. The ongoing resuscitation is then guided by lab testing.

Pitfall: The treatment dose of fibrinogen is 4g which will increase the serum fibrinogen by approximately 1g/L. A common pitfall is to underdose fibrinogen.

Recommendations for platelet transfusion are based on expert opinion without RCT-level evidence of benefit. Studies in multiple patient populations (ICH on antiplatelet, dengue patients, neonatal patients) show a signal for harm with platelet transfusion, so be cautious to not over-transfuse platelets even in bleeding patients.

In the context of MHP, our experts recommend using a platelet treatment threshold of 50 × 10⁹/L, and increase to 100 × 10⁹/L if significant brain or spinal cord injury.

Transfusion decisions during massive hemorrhage must evolve from fixed-ratio empiricism to goal-directed, personalized care. While initial resuscitation can follow predefined ratios, once lab results are available, therapy should be adjusted based on specific targets.

For hemoglobin, a threshold of 70–90 g/L is adequate post-stabilization, according to a large cluster-randomized Japanese trial. During early resuscitation, however, red cells are given to maintain perfusion rather than based on hemoglobin levels.

Fibrinogen should be maintained above 1.5–2.0 g/L. If replacement is required, fibrinogen concentrate is preferred over cryoprecipitate where available. Unfortunately, underdosing is common; less than four grams is often ineffective. A full four-gram dose increases fibrinogen by approximately 1 g/L.

INR should be kept below 1.8, although this threshold is based on consensus rather than high-level evidence. Calcium (ionized) should be monitored and maintained above 1.15 mmol/L. A major trial in progress (CAVALIER) may soon provide more clarity on prehospital calcium administration.

There is growing interest in viscoelastic assays (TEG/ROTEM) for fine-tuned coagulation guidance. While the ITACTIC trial did not show mortality benefit in trauma, widespread adoption is limited by cost, complexity, and clinician unfamiliarity. Cardiac surgery data suggest these tools improve outcomes when used in experienced hands.

Deciding when to terminate an MHP is as important as when to initiate. The risks of over-transfusion include volume overload, alloimmunization, and product wastage. Therefore, the protocol should not run on autopilot.

Continuously Assess the Need for Ongoing MHP

Automate: reassess the need for MHP every 30 minutes or after every pack.

Use protocolized prompts: e.g., blood bank asks if MHP can be discontinued after 1 hour of inactivity.

Post-MHP, continue 4–6 hours of vigilant monitoring:

Development of antibodies is a real risk, so make sure the patient knows about what they have received and is informed of subsequent risks. For every unit there is 1/13 chance of making antibodies, but these are usually fleeting. Women of childbearing potential who received MHP should undergo a group and screen q3months. They should go into any future pregnancy aware of the increased risk of complication, as antibody-related transfusion complications can profoundly impact pregnancies.

In resource-limited settings where fresh frozen plasma (FFP) is unavailable, a validated alternative approach is to administer 2000 IU of prothrombin complex concentrate (PCC) along with 4 grams of fibrinogen concentrates. This replacement strategy has been shown to be safe and effective, was validated in the FIRST2 trial, and aligns with European guidelines.

PCC 2000 IU + fibrinogen concentrates 4 g per four units of RBCs

These centers typically deliver two such packs (PCC + fibrinogen) alongside RBCs before transferring the patient. Even without lab capacity to measure fibrinogen, empirical dosing in this context is justified and often lifesaving.

The MHP must also be modified for anticoagulated patients. Rapid identification is crucial, particularly in elderly patients presenting with trauma or GI bleeding.

For patients taking warfarin, administer 2000 IU of PCC along with vitamin K. For direct oral anticoagulants (DOACs), the same 2000 IU dose of PCC is given initially, and a second 2000 IU may be administered after one hour if bleeding continues. This simplified approach reduces delay and aligns with recent expert consensus.

MHP 2.0 emphasizes clinical judgment, early red cells, goal-directed therapy, and avoidance of over-activation. The 7 T’s remain our framework, but we now understand that:

Massive hemorrhage protocols have evolved. What began as a reactionary, one-size-fits-all approach has matured into a tailored, systematic framework grounded in physiology, evidence, and team dynamics. The 7 T’s offer a cognitive scaffold, but MHP 2.0 demands clinical judgment, humility, and leadership. As practice evolves, focus must shift from fixed-ratio empiricism to goal-directed transfusion guided by physiology, laboratory data, and systems-level readiness.

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Penetrating neck injuries in children are rare—but when they happen, the stakes are high. In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, we explore the clinical pearls behind “no-zone” management, how to distinguish hard and soft signs, when to image versus operate, and why airway always comes first. Get ready for a focused, evidence-based deep dive into pediatric neck trauma.

Stone ME Jr, Christensen P, Craig S, Rosengart M. Management of penetrating neck injury in children: A review of the National Trauma Data Bank. Red Cross Annals. 2017;32(4):171–177. doi:10.1016/j.rcsann.2017.04.003

Callcut RA, Inaba K. Penetrating neck injuries: Initial evaluation and management. UpToDate. Waltham, MA: UpToDate Inc. [Accessed June 24, 2025]. Available from: https://www.uptodate.com

Note: This transcript was partially completed with the use of the Descript AI and the Chat GPT 4o AI

Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and in this episode we are diving into a high-stakes but fortunately rare topic in pediatric trauma — penetrating neck injuries. Now these injuries make up less than 1% of all pediatric trauma, but when they occur, they demand precision and vigilance in terms of diagnosis and management.

As you know, the neck packs some vital organs, vessels, the airway, esophagus, and nerves into a tiny little area, so even a seemingly minor wound can injure multiple structures.

Now you remember — way back when — where you learned about the zones of the neck, and this is the traditional teaching, which chopped the neck up into three zones.

You’ve got Zone I, which is the area between the clavicle and cricoid. You’ve got the subclavian arteries and vein, the carotid, and the apices of the lungs.

Now, you may recall some teaching that you got in medical school or residency where the management was dictated by which zone was injured. And admittedly, a lot of this evidence is in adults, and more penetrating trauma is seen in adults as well.

But now practice is leaning towards the “no zone” approach, where imaginary lines on the skin surface are not dictating management as much as presentation, symptoms, and deciding when to go to the OR versus using CT angiography.

So let’s talk about mechanisms of injury for a minute.

Toddlers can injure their neck when they fall with something in their mouth, like pencils or chopsticks.

So low-velocity mechanisms dominate pediatric penetrating neck injuries. Force matters, because depth and tissue cavitation decide the overall injury pattern.

In terms of assessing the patient with a penetrating neck injury, it all starts with the ABCs.

Is the patient’s airway patent? Are they protecting and maintaining it?

For breathing, patients should be breathing comfortably with no distress.

For circulation, if the wound is bleeding, apply direct pressure. Some surgeons will use a Foley balloon tamponade method if they need to stop bleeding before going to the operating room.

Patients will need large bore IVs and fluids — and especially blood product resuscitation.

Only immobilize the C-spine if a patient has neurologic deficits or a high injury mechanism.

You may have also heard of hard signs and soft signs in terms of the parlance of managing penetrating neck injury.

In general, hard signs mean go to the operating room.

So here are some hard signs:

Soft signs include:

A large pediatric series showed that 50 to 70% of children with hard signs did need operative repair.

So I alluded to this paradigm at the beginning of the episode — the “no zone” strategy.

For stable children with no hard signs, CT angiography is the gold standard.

Make sure you always get a chest X-ray as well, since penetrating neck injuries can injure the apices of the lungs or thoracic structures.

Also, if the CTA is negative but you still have suspicion for injury to the aerodigestive tract, you can do a water-soluble contrast esophagram or flexible endoscopy.

Plain films — yes, you can assess the C-spine and look for radiopaque foreign bodies, but again, if you truly have a child that is stable and has no hard signs, CTA is the gold standard.

If you follow this, you can cut non-therapeutic neck explorations in half without missing any injuries.

If you do have a neck wound that you have to manage before the surgeons can get to it: direct pressure first.

The Foley balloon tamponade method is where you take an 18 to 20 French catheter, place it into the wound, inflate the balloon with 10 to 15 milliliters of water, and then clamp it.

I wouldn’t necessarily do this in a Level 1 trauma center — I have surgeons available — but it might be useful if you have to transport a kid quickly to a trauma center.

Never, ever, ever pull an impaled object out of the neck in the emergency department.

Now, superficial injuries with the platysma intact get routine closure.

So here’s some pediatric-specific pearls, again, because these are really rare.

Kids have a small airway, and soft tissues swell quickly, so there’s a low threshold for securing the airway.

Kids have low blood volume and don’t tolerate hemorrhage as well.

And unfortunately, some neck wounds are self-inflicted, so make sure you address mental health concerns after the child is stabilized.

Alright. So let’s bring it all home. What are some key take-home points?

That’s all for this episode. I hope you found it useful — especially since these injuries are less common, but can be incredibly impactful.

If you enjoyed the content, or want to hear something different about pediatric trauma, reach out and let me know — I’ll take an email, a comment on the blog, a social media message.

And please — as my 13-year-old would encourage me to say — like, rate, and review.

Share this episode and the podcast with the folks you work with — and not just physicians in the emergency department. I think we all deserve to learn about how we manage injuries in children.

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Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025

Date: May 7, 2025

Dr. Sandi Angus

Guest Skeptic : Dr. Sandi Angus is a Paediatric and Adult Emergency Medicine Registrar in the Shrewsbury and Telford Hospital NHS Trust. She is passionate about paediatric EM, wellbeing and medical education.

Case: A ten-year-old boy presents to your emergency department (ED) after being involved in a motor vehicle collision at high speed. Emergency Medical Service (EMS) tells you that he was properly restrained. His parents were also in the vehicle and are currently being brought to the ED as well. He appeared a bit dazed initially, but he has had a Glasgow Coma Scale (GCS) score of 15 throughout transport. Your primary survey is unremarkable. He complains of some abdominal pain, although you note a soft abdomen on exam and no seatbelt sign. As you complete your secondary survey, he vomits once, which is non-bloody. A medical trainee working with says to you, “He says his stomach hurts and threw up. Do you think we need to CT scan his abdomen?”

Background: Intra-abdominal injury (IAI) in children is a significant concern for emergency physicians. This is particularly true in cases of blunt trauma. Although relatively uncommon compared to adults, IAIs in children can be life-threatening. We have to identify them early and manage them appropriately.

The organs most frequently injured include the spleen, liver, and kidneys, but any abdominal organ can be affected​. Diagnosing IAIs in pediatric patients poses a unique challenge. Children often present with subtle clinical findings, and the physical examination can be unreliable due to factors such as altered mental status, distracting injuries, or the child’s inability to articulate their symptoms​.

Imaging modalities like computed tomography (CT) are the gold standard for diagnosis, but CT use must be balanced against the risks of ionizing radiation. Traditionally, clinicians relied heavily on their clinical gestalt, but this approach can miss injuries or lead to unnecessary imaging. The risks of CT imaging are not inconsequential. Children are more radiosensitive than adults, and for each  abdominal or pelvic scan, the lifetime risks of cancer are 1 per 500 scans, irrespective of the age at exposure. However, this is actually very small compared with the background risk of developing cancer in a lifetime, which is 1 in 3, so if your scan is clinically justified, the benefit is likely to outweigh the potential harm [1].

To improve diagnostic accuracy and minimize unnecessary CT scans, clinical decision rules (CDRs) or “tools” have been developed. One such tool, the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rule for intra-abdominal injuries, identifies children at very low risk of clinically important IAIs, aiming to safely reduce CT utilization​ [2-3]. This rule was composed of seven variables, all of which could be collected on history and physical exam. There was no need for labs or imaging in this decision rule.

These seven variables were:

If all seven variables were negative, the child was at very low risk of having intra-abdominal injury requiring intervention and the decision rule recommended against a CT scan.

Despite the benefits of existing decision rules, the question remains how best to apply these tools when only one or two PECARN criteria are positive—a clinical gray zone not well characterized in earlier validation studies. Understanding the individual performance of PECARN rule components in predicting IAI is crucial for refining decision-making in pediatric trauma care.

Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025

Authors’ Conclusions: “Few children with blunt torso trauma and one or two PECARN predictor variables present have IAIAI. Those with GCS score <14, however, are at highest risk for IAI.”

Quality Checklist for Clinical Decision Rules:

Results: The original study included 7,542 children with blunt torso trauma across six emergency departments. Of those children, 2,986 (39.6%, 95% CI 38.5 to 40.7) had one or two PECARN positive variables. The median age was 9.8 years and slightly over half (56%) were male. CT scans were obtained in 1236 (41%) of the patients.

Primary Outcome: Of the 1,639 patients who had one variable positive, 21 (1.3%, 95% CI 0.8-2) had intra-abdominal injuries undergoing acute intervention. Of the 1347 who had two variables positive, 27 (2%, 95% CI 1.3-2.9) had intra-abdominal injuries undergoing acute intervention.

Secondary Outcome: Of those 2986 patients enrolled, 227 (7.6%, 95% CI 6.7-8.6) had intra-abdominal injuries.

They also broke it down by each individual variable and how many patients were diagnosed with intra-abdominal injury and intra-abdominal injury undergoing acute intervention. GCS≤14 was the most important individual predictor variable for intra-abdominal injury undergoing acute intervention.

Inclusion Criteria:

It’s important to review the inclusion criteria from the original study because we do not think this clinical decision rule should be applied indiscriminately to every child with abdominal trauma.

A large proportion of the children included in the original study had some pretty severe mechanisms of injury (32% from motor vehicle collisions, 19% were struck by a vehicle, and 13% due to fall from height. Be careful in applying this clinical decision tool to less severe mechanisms.

They excluded patients who had injury that occurred over 24 hours ago. Many of us may have encountered a patient in the emergency department who complains of belly pain from a blunt abdominal injury a day ago and were perhaps seen at an urgent care facility or tried to wait it out. Although they were not part of the patient population in this study, would it be inappropriate to use this clinical decision tool on those patients?

Partial Verification Bias:

In this secondary analysis, only around 40% of patients included had CT scans. What about those who did not?

In the original derivation study, there was one patient with a splenic laceration who returned after being discharged from the ED without imaging who underwent splenic artery embolization. It is possible that some of these patients who did not undergo CT scan still had intra-abdominal injuries that were missed.

This does highlight the primary outcome that they defined as IAI undergoing acute intervention. It is arguably more patient oriented, they missed some IAI but maybe it was not clinically significant. I’ve admitted low grade splenic or liver laceration to the hospital who were observed without any intervention except a repeat hemoglobin before being sent home.

Spectrum Bias:

Subpopulations with only 1–2 rule variables may not fully represent all blunt trauma presentations​. This study only looked at the risk of IAI if one or two variables were positive. Table 5 demonstrates the proportion of children with IAI with two positive variables. Be cautious in that some combinations of these two variables included very few patients.

What happens as you add more variables (>2), and does it matter which variables are positive?

They excluded 2,357 (31%) of patients in the original study because they had more than one positive variable. In that study, 203 children had intra-abdominal injuries undergoing acute interventions. We know there is a proportion of children who can have more variables present and still not have intra-abdominal injury requiring acute intervention.

It is also important to remember that not all variables are created equal. In this study, no patients with the positive single variable of: abdominal pain, vomiting, abnormal breath sounds, or abdominal tenderness had intra-abdominal injury undergoing acute intervention.

Comparison to Clinical Gestalt:

Our FOAMed friend, Dr. Justin Morgenstern, at First10EM thinks clinical decision rules are ruining medicine. Is this clinical decision rule too obvious? Would you be thinking about performing a CT scan if all seven predictor variables were negative without the decision rule? How does this compare to clinical gestalt?

There was another secondary analysis of the same original PECARN study that compared the decision rule with clinicians recorded suspicion of IAI (<1, 1-5, 6-10, 11-50, >50%). The CDR had higher sensitivity 97% compared to clinicians 82.8%, but the clinicians had higher specific 78.7% vs 42.5% [4].

A third of low-risk patients by clinical suspicion still got CT scans, so we see that suspicion for intraabdominal injury did not correlate with the ordering of CTs. We are unsure of the reasons why clinicians chose to obtain the CT even if the suspicion was low.

Adjunct Workup for Intra-abdominal Injury:

One of the strengths of this PECARN clinical decision tool is that all of these variables are things you get from the history and physical examination alone. But are there other things we can use to help risk-stratify children with blunt abdominal injury?

Blood tests, including hemoglobin, lipase, and liver enzymes? The evidence for the use of lab tests is mixed. Hemoglobin measurement is not particularly reliable in the setting of acute blood loss. The sensitivity, specificity, PPV, and NPV of these lab tests are quite variable.

The evidence for FAST is mixed as well [5-9]. It is dependent on operator skill. Unfortunately, a negative FAST scan in pediatrics does not necessarily mean that there’s no significant intra-abdominal injury, just as in adults. The specificity of it is better- so if you see free-fluid in the context of trauma and hemodynamic instability, it’s blood until proven otherwise. However, the sensitivity is poor – Children can still have abdominal injuries without free fluid, although it can be improved by doing serial scanning [10].  There’s still a lot of ongoing research on this topic.

And finally, there is the option of observation in the ED or hospital for serial exams as well.

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

Case Resolution: During the boy’s stay in the ED, you and the trainee assessed him multiple times. His reported abdominal pain seems to improve, and he does not have any further episodes of emesis. Your repeat examinations reassure you that the chances of him having a clinically significant intra-abdominal injury are low. His aunt arrives at the ED. You fill her in on the patient’s ED course, and she takes the patient home.

Clinical Application: The PECARN clinical decision tool can be used to risk-stratify children presenting with blunt intra-abdominal injury. If the child is negative for all seven variables, there is a very low chance of them having an intraabdominal injury that requires urgent intervention. Even if one or two of the variables are positive, this does not necessarily mean that the child needs to undergo a CT scan. Use this decision tool in conjunction with your clinical judgement.

What Do I Tell My Trainee? I’m glad you asked that question. There are several ways a child presenting with blunt intra-abdominal injury can be evaluated. Those include lab tests, ultrasound, CT scans, serial exams and observation. The PECARN clinical decision tool risk stratifies these children based on seven variables from the history and physical examination. Even if one or two of these variables are positive, this doesn’t mean we automatically need to put the child through the scanner. Let’s continue to re-evaluate him while he is under our care in the emergency department.

References:

The post PODCAST: Light Em Up Up Up (CT) or Not for Pediatric Blunt Abdominal Trauma? 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.

Reference: Cohen et al; SUSPECT study group. Can we avoid casting for suspected scaphoid fractures? A multicenter randomized controlled trial. J Orthop Traumatol. 2025

Date: May 1, 2025

Guest Skeptic: Dr. Matt Schmitz is an orthopedic surgeon specializing in Adolescent Sports Medicine and Young Adult Hip Preservation. He practices at the Rady Children’s Hospital in San Diego and is Professor of Orthopedics at UC San Diego.

Case: A 48-year-old woman presents to the emergency department (ED) with left wrist pain after slipping on a wet pavement while walking into work. It was a FOOSH injury (fall on out-stretched hand). She did not lose consciousness and was able to drive herself to the ED, but she reports increasing wrist pain with movement. She rates the pain as 6/10 and notes it’s worse with lifting or rotating the wrist. She denies numbness, weakness, or swelling of the fingers. No previous wrist fractures or injuries. On inspection, she has no obvious deformity and minimal swelling at the wrist. The examination reveals tenderness in the anatomical snuffbox and over the scaphoid tubercle. Her range of motion is decreased due to pain, especially with radial deviation and wrist extension. Sensation and cap refill intact; radial pulse present. Plain radiographs (PA, lateral, scaphoid view) show no fracture.

Background: Scaphoid fractures are a common injury seen in the ED but can represent a challenge to diagnose, even for experienced clinicians. The scaphoid injury is the most frequently fractured carpal bone, typically occurring after a fall onto an outstretched hand (FOOSH) in young, active individuals. The clinical dilemma arises when there is a high suspicion of fracture based on mechanism and physical exam (especially tenderness in the anatomical snuffbox), but the initial radiographs appear normal. An excellent SRMA on the history, physical exam, and imaging for scaphoid fractures was done by Carpenter et al AEM 2014.

On SGEM#420, we wanted to know what to do with a patient who presents with a FOOSH injury and has a normal x-ray. Specifically, are there clinical exam findings that can help rule in/rule out a scaphoid fracture? The bottom line was there was no single physical examination maneuver that could reliably rule out an occult scaphoid fracture.

Given this dilemma, ED physicians have erred on the side of caution. If a fracture is not radiographically visible, the patient is immobilized and referred for follow-up imaging in 10 to 14 days or orthopedic review. This conservative approach stems from the significant morbidity associated with missed scaphoid fractures, including non-union and avascular necrosis.

However, this “cast first, confirm later” philosophy has led to over-treatment in most cases. Studies estimate that only 10–20% of patients with clinical suspicion of a scaphoid fracture and normal initial X-rays have a fracture confirmed on follow-up imaging.

With this context, a new wave of research has emerged, questioning whether immediate casting is necessary or whether selective immobilization and early reassessment may be equally safe and more patient-centred. This ongoing debate challenges emergency physicians to balance the risks of under-treatment with the harms of unnecessary immobilization, time off work, and healthcare costs.

Reference: Cohen et al; SUSPECT study group. Can we avoid casting for suspected scaphoid fractures? A multicenter randomized controlled trial. J Orthop Traumatol. 2025

Authors’ Conclusions: “Casting for suspected scaphoid fractures but normal initial radiographs can be avoided because bandaging seems to be an alternative treatment option when patients are reevaluated after 2 weeks.”

Quality Checklist for Randomized Clinical Trials:

Results: There were 180 patients included in the trial (91 in the bandaging group and 89 in the casting group). The median age was 45 years, with slightly more women than men, and the most common mechanism of injury (32%) was a fall from standing.

1. Performance Bias: Neither patients nor clinicians were masked. This can introduce performance bias. This occurs when there are differences in the care provided to participants other than the intervention being studied, and those differences influence the outcomes. It often arises in trials where blinding is not possible, like in this trial. When participants and clinicians know which group a patient is in, they may unconsciously (or consciously) change how they deliver care, how closely they monitor patients, or how they report outcomes.

2. Detection Bias: This can occur when the assessment of outcomes is influenced by the knowledge of which intervention the participant received. When masking is not possible, it can lead to systematic differences in how outcomes are measured or interpreted between groups. The primary outcome in the trial was a patient-reported functional score (QDASH at 3 months), and secondary outcomes included additional subjective measures. These types of outcomes are especially vulnerable to detection bias when neither patients nor assessors are masked.

If patients in the bandaging group expected to do better (less restrictive, more natural recovery), they may overreport functional improvement. If assessors expect stiffness or complications in the casting group, they may unconsciously look harder for dysfunction. Even small differences in how outcomes are measured or reported can make a noninferiority trial appear more favourable to the experimental intervention (in this case, bandaging).

3. Follow-up Bias: Patients in the bandaging group had earlier clinical contact (day 3 vs. day 14). This seems logical but from a methodological standpoint, it can introduce some concerns. Being seen sooner could enhance patient education, reassurance, or counselling. This could influence subjective outcomes like satisfaction, function, and perceived improvement. This difference in care intensity could favour the intervention group, not because the treatment is better, but because patients were monitored more closely, and early issues were managed proactively. It would have been great if both cohorts were seen on day 3 to mitigate this potential bias.

4. Non-Inferiority: The authors set the non-inferiority margin using a log-transformed threshold for the primary outcome measure. This was the QDASH score at 3 months with a natural logarithm of the margin of noninferiority = 2.0.

A margin of ln (2.0) corresponds roughly to a doubling of the QDASH score, or about 10–15 points, depending on the baseline values. This margin reflects the maximum difference between the bandaging and casting groups that would still be considered clinically acceptable—i.e., not worse enough to matter to patients. The choice of this margin is one of the most subjective and impactful parts of a non-inferiority trial. It defines the threshold for what we’re willing to accept as “not meaningfully worse.” If it’s set too wide, a truly worse treatment could be accepted. If it’s too narrow, useful alternatives could be rejected.

The authors selected a non-inferiority margin of 7.5 points on the QuickDASH, based on 50% of the established MCID, which they cite from Vercelli et al. (2014) as 15.91 points. This is a reasonable and accepted method in non-inferiority trials; halving the MCID is a conservative way to set a threshold for “no meaningful harm.”

However, this MCID comes from patients undergoing physical therapy for upper-limb disorders, not necessarily those with acute wrist trauma (as in this RCT). MCIDs are population- and context-dependent, affected by baseline disability, comorbidities, culture (study done in the Netherlands i.e. external validity), and patient expectations. Halving the MCID is commonly done, but it is still somewhat arbitrary unless justified with stakeholder input or clinical reasoning. There’s no universal agreement that 50% is the “correct” threshold—some argue for 75%, while others prefer asking patients about what they value or would consider an unacceptable margin of harm.

5. Confidence Intervals: The adjusted difference in QDASH was 0.30 (95% CI: 0.02–0.62). That’s barely within the margin, and the lower bound (0.02) nearly touches the margin. This raises the possibility that a slightly different sample or method could have yielded a different conclusion.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: While the trial was well-conducted and pragmatic, some skepticism is warranted. However, the findings do present an option for a low-risk population, where clinical suspicion is high, but radiographs are normal, and follow-up is possible.

Case Resolution: The 48-year-old patient is placed in a removable wrist splint rather than a rigid cast. She is provided with detailed discharge instructions and scheduled for follow-up reassessment in 10–14 days. At follow-up, she had no signs of fracture progression or complications and returned to work without difficulty.

Dr. Matt Schmitz

Clinical Application: This study supports a more selective, less immobilization-heavy approach for managing patients with suspected scaphoid fractures and negative X-rays, especially in settings with reliable follow-up. It reinforces the shift toward minimizing overtreatment while still prioritizing safety and patient-centred care. EDs may consider updating protocols to offer wrist splinting and early re-evaluation rather than default casting. However, you also must consider the ability or willingness to follow up. Although we may overtreat occult scaphoid fractures, scaphoid non-union poses a real problem. Suppose you place someone in a bandage and they don’t come back in 2 weeks (as per the authors is the standard of care in the Netherlands). Do the 10% with a scaphoid fracture not come back until it’s an established non-union at 6 months, and thus have a much more invasive treatment rather than the potential for casting? In a universal healthcare system where you can get regular follow-up, and I don’t know the landscape in the Netherlands, but perhaps it is less litigious? The results need to be interpreted through the lens of external validity bias.

What Do I Tell the Patient? You have signs of a possible wrist fracture, but your X-rays today don’t show one. In the past, we would put almost everyone in a cast for a couple of weeks just in case. But newer evidence suggests that for many people, we can try a supportive bandage or splint instead, check again in 10–14 days, and only treat more aggressively if needed. This approach can be more comfortable, avoids unnecessary casting, and doesn’t increase the risk of long-term problems if you can come back for follow-up. But it is also critical that if you aren’t improving, you should return for a recheck.

Keener Kontest: Last week’s winner was a friend of the SGEM, Dr. Cindy Bitter. She knew that ketamine is a sedative used for acute agitation and a dissociative anesthetic also used in procedural sedation and rapid sequence intubation.

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

Reference:

The post PODCAST: Break on Through to the Other Side – Management of Clinical Scaphoid Fractures first appeared on האיגוד הישראלי לרפואה דחופה.

00:37 – Overview of Smoke Inhalation Injury

00:55 – Three Key Pathophysiologic Processes

01:41 – Physical Exam Findings to Watch For

02:12 – Airway Management and Early Intervention

03:23 – Carbon Monoxide Toxicity

04:24 – Workup and Initial Treatment of CO Poisoning

06:14 – Cyanide Toxicity

07:19 – Treatment Options for Cyanide Poisoning

09:12 – Take-Home Points and Clinical Pearls

The post PODCAST: Smoke Inhalation Injury first appeared on האיגוד הישראלי לרפואה דחופה.

Reference: Leonard JC et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. June 2024.

Date: Oct 15, 2024

Dr. Tabitha Cheng

Guest Skeptic: Dr. Tabitha Cheng is a Southern California native and board-certified emergency medicine physician and completed an EMS fellowship as well. The learning didn’t end because she then completed another fellowship in pediatric emergency medicine at Harbor UCLA.

Case: An 8-year-old girl is brought in by EMS after a car accident. She was seat belted, sitting in the backseat of the family’s car when they were hit from the side by another vehicle that ran a red light. The airbags deployed, and the car spun a few times. When EMS arrived on the scene, they found both parents unconscious and the girl appeared slightly dazed and confused.

EMS places her in a cervical collar and brings her to the emergency department (ED). On your examination, you see she is scared but answering questions appropriately. She does have some abrasions from her seatbelt and complains of pain around her ankle. The rest of her exam is unremarkable.

After your evaluation, you are informed that her grandmother has arrived to be with the girl as her other family members are being treated. She looks at the contraption on the girl’s neck and asks you, “Is she okay? Is something wrong with her neck? Does she need an X-ray or CT scan?”

Background: Pediatric cervical spine (c-spine) injuries are uncommon (1-3% of blunt trauma). These injuries typically result from blunt trauma caused by motor vehicle accidents, falls, sports injuries, or physical abuse. Although C-spine injuries represent a small fraction of pediatric trauma cases, their potential severity makes accurate and timely diagnosis critical.

Younger kids tend to have big lollipop heads which makes them more prone to injury in the upper cervical spine compared to adults (their fulcrum is higher).

It is also sometimes difficult to get a scared child to give an accurate history or cooperate with an exam. Many of us use CT or X-rays to help detect cervical spine injuries in this population.

Clinicians working in EDs must strike a balance between ensuring they do not miss these rare but serious injuries and avoiding unnecessary imaging, particularly computed tomography (CT), which exposes children to ionizing radiation. Given the sensitivity of developing tissues to radiation, especially in younger children, avoiding unnecessary imaging is a high priority in pediatric care.

Traditional diagnostic approaches often lead to the overuse of imaging tools, like CT scans and X-rays, even in low-risk children. This has prompted a movement toward more refined, evidence-based methods for identifying pediatric C-spine injuries, particularly through the development of clinical decision rules (CDRs). CDRs are designed to assist clinicians in making more accurate decisions about when imaging is truly necessary by identifying key clinical predictors of serious injuries.

The Pediatric Emergency Care Applied Research Network (PECARN) has been instrumental in developing one of the most widely recognized CDRs for pediatric C-spine injuries. Based on large, multicenter studies, this tool identifies critical risk factors that signal the need for imaging, such as altered mental status, focal neurological deficits, and certain mechanisms of injury. The PECARN rule, validated in clinical settings, has demonstrated high sensitivity in detecting C-spine injuries, while also reducing unnecessary imaging.

There are multiple CDRs for identifying pediatric c-spine injuries besides PECARN. The SGEM recently covered the Cochrane systematic review on pediatric CDRs on SGEM #441.

Dr. Julie Leonard

Reference: Leonard JC et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. June 2024.

Guest Authors

Dr. Caleb Ward

Dr. Caleb Ward is a pediatric emergency medicine attending and Associate Professor of Pediatrics and Emergency Medicine at Children’s National Hospital and The George Washington School of Medicine and Health Sciences in Washington, DC. He is the principal investigator for EMSC State Partnership in Washington, DC and is also involved in various multi-center EMS studies with the Pediatric Emergency Care Applied Research Network (PECARN).

Dr. Julie Leonard is a pediatric emergency medicine attending and Associate Division Chief for Research at Nationwide Children’s Hospital. She’s also a Professor of Pediatrics at the Ohio State University College of Medicine. Dr. Leonard serves as the Principal I investigator of the Great Lakes Atlantic Emergency Medical Services for Children Research Node of PECARN.

Authors’ Conclusions: “Incorporated into a clinical algorithm ,the cervical spine injury prediction rule showed strong potential for aiding clinicians in determining which children arriving in the emergency department after blunt trauma should undergo radiographic neck imaging for potential cervical spine injury. Implementation of the clinical algorithm could decrease use of unnecessary radiographic testing in the ED and eliminate high-risk radiation exposure. Future work should validate the prediction rule and care algorithm in more general settings such as community EDs.”

Quality Checklist for Clinical Decision Tools:

Results: The cohort consisted of 22,430 children. To put this into perspective, the Cochrane review that we critically appraised included 5 studies and only had 21,379 children. There were 11,857 included in the derivation cohort and 10,573 included in the validation cohort. Around 2% had confirmed cervical spine injuries.

The new prediction rule had a 94.3% sensitivity, 60.4% specificity, 99.9% negative predictive value, and 0.09 negative likelihood ratio.

Tune in to the podcast to hear the authors answer our questions.

Follow Up

Some of the children in this study did not undergo any imaging. You report that in these cases, the guardians were contacted by phone to see whether they had a C-spine injury. This could lead to verification bias where not all patients received the gold standard imaging, potentially affecting specificity​​.

What proportion of children did not have imaging? Out of the ones you had to contact for phone follow-up, what percent were lost to follow-up? How do you think this may impact your results?

Who Completes the Clinical Decision Rule

This study was performed at academic centers with a mix of pediatric emergency medicine, trauma surgery, and prehospital teams. You report that you looked back at the children with c-spine injuries that were missed by the prediction rule and noted that there was a risk factor recorded in the medical record or case report form which would have improved the test characteristics of the rule.

Could you comment on the interrater reliability of people completing the clinical decision rule? Ideally, who do you think should be the one completing it (EMS, EM, surgery, or a mix)?

Moderate Risk Patients

In the moderate risk criteria, the CDR recommends an X-ray.

What kind of X-ray should be gotten? Lateral neck, 2 view, 3 view, any of the above with flexion and extension?

Assuming that the X-ray ends up being normal, but the child is having persistent neck pain, what would you do?

Prehospital Application

This CDR was designed for implementation in the ED.

Do you think there’s a potential application of risk stratification for the prehospital environment? 

Child Abuse

The study included 1,327 (5.9%) children with the mechanism of injury as “suspected child abuse.” You performed a separate analysis after these patients were removed that showed similar test characteristics.

Can you comment on the application of this CDR specifically in this vulnerable population?

Bonus Question: Implementation

The study found that had the prediction rule been in place, the number of children having CT might have decreased from 3856 (17·2%) to 1549 (6·9%).

A limitation of this study was that it was conducted at academic children’s hospitals.

Do you think you would see the same impact when implemented more generally?

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

Case Resolution: After you assess the child, you do not note anything remarkable in her primary survey. Her secondary survey is only notable for a small abrasion on her forehead and shoulder. You ask someone to hold her head still as you prepare to examine her neck. You tell her very clearly, “I am going to ask you if you are having any pain around the area that I am touching. Do not nod or shake your head. Just answer yes and no.” After noting that she does not have any tenderness to palpation of her neck and testing the range of motion of her neck, you clinically clear her C-collar and avoid additional imaging.

 Clinically Application: The new PECARN CDR for cervical spine trauma in children can help guide imaging decisions. Remember, we refer to these as clinical decision “tools” rather than rules. Considering all three pillars of evidence-based medicine, the scientific literature, clinical judgement, and patient/family values and preferences.

What Do I Tell the Patient’s Grandmother?

 I understand that you are worried about your granddaughter. We examined her closely. She is acting appropriately and answering questions. She is not having any pain when she moves her neck or when we touch her neck. We try to balance the possible harms and benefits when thinking about whether we need to do X-rays or CT scans on children because we want to minimize radiation exposure. Based on her reassuring exam, I have low suspicion that she has a serious injury to her neck.

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