Topics in this EM Quick Hits podcast
Deborah Schonfeld on pediatric torticollis (02:33)
Anand Swaminathan on stable wide-complex tachycardia (28:24)
Andrew Petrosoniak on post-intubation neurocritical care considerations (33:45)
Justin Morgenstern on correcting hyponatremia (42:39)
Andrew Tagg on paronychia management (53:09)
Victoria Myers and Judith Tintinalli on Women in EM leaders series (1:00:00)

Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Brandon Ng, edited by Anton Helman, July, 2025
Cite this podcast as: Helman, A. Schonfeld, D. Swaminathan, A. Petrosoniak, A. Morgenstern, J. Tagg, A. Myers, V. Tintinalli, J. EM Quick Hits 66 – Pediatric Torticollis, Stable Stable Wide Complex Tachydysrhythmias, Post-intubation Neurocritical Care, Hyponatremia Correction Rates, Paronychia Management, Women in EM Leader Series with Judith Tintinalli  https://emergencymedicinecases.com/em-quick-hits-july-2025/. Accessed July 16, 2025.
Pediatric torticollis: Not just muscular injury

Broad Categories in the differential diagnosis of pediatric torticollis


Muscular (SCM/trapezius): Most common; typically resolves within a week.


Atlantoaxial Subluxation: C1/2 instability due to ligamentous or osseous abnormalities.


Infectious:

Viral URTI/Pharyngitis → Referred pain, muscle spasm
Retropharyngeal Abscess (typically ages 2–4): Limited neck extension, fever, dysphagia, drooling, stridor
Osteomyelitis/Discitis: Cervical spine tenderness
Lemierre Syndrome: IJ thrombophlebitis post-oropharyngeal infection → SCM or jugular tenderness/swelling



CNS Lesion (typically painless):

Up to 20% of posterior fossa tumors present with torticollis
* 50% of pediatric malignant brain tumors are located in the posterior fossa
Clinical red flags: headache, vomiting, gait changes, ataxia, focal neuro deficits



Atlantoaxial Subluxation
Risk Factors for Atlantoaxial Subluxation

Ligamentous injury (more common than fracture in children)
Congenital hypermobility: Trisomy 21/Down syndrome, Marfan's Syndrome, Juvenile Idiopathic Arthritis
Grisel Syndrome: Post head/neck surgery with local inflammation → ligament laxity

Physical exam pearl to distinguish atlatoaxial subluxation from muscular torticollis

Muscular torticollis: Head tilts toward spastic SCM
Subluxation: Tilts away from affected side

Imaging for suspected atlantoaxial subluxation


XR: Odontoid and lateral views; assess Atlantodental Interval (≤5 mm if <8 years) - use as screening in low pretest probability patients; be aware than sensitivity is poor


Source: Radiopaedia under the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported licence


CT: Gold standard when high suspicion or red flags present


Bottom Line

Most cases of torticollis self-limiting, due to SCM muscle spasm
Torticollis >1 week or with neurological findings → Image to rule out subluxation, infection, or CNS lesion

Expand to view reference...

Emergency departments operate in a state of near-constant crisis. Whether it's a hospital-wide IT system crash at 3:00 a.m., a mass casualty event, a string of high-acuity patients, or simply the daily grind of bed block and hallway stretchers, the ED is a crucible. Success depends not just on individual clinical acumen, but on how well we function as teams. Great teams don’t happen by accident — they are built, sustained, and led by people who understand that leadership is not a title, but a way of thinking and behaving. In this EM Cases podcast, we dive deep into what it means to be a leader in EM with three powerhouse voices in Canadian and U.S. EM: Dr. Carolyn Snider, Dr. Howard Ovens, and Dr. Thom Mayer. Whether you’re a veteran staff physician, charge nurse, a resident, or the person holding the door during a trauma code, you are a leader. In this podcast, we cover foundational principles, practical habits, and transformative insights that can make any member of an ED team a more effective, compassionate, and adaptive leader. Here, you’ll find tools, philosophy, and stories that just might transform how you think about your role in the ED to make your work more satisfying, make your teams work together better and improve patient outcomes...

Podcast production, sound design & editing by Anton Helman
Written Summary and blog post by Anton Helman June, 2025
Cite this podcast as: Helman, A. Snider, C. Ovens, H. Mayer, T. Leading from the Inside Out: Building Trust, Teams, and Purpose in Emergency Medicine. Emergency Medicine Cases. June, 2025 https://emergencymedicinecases.com/leadership-emergency-medicine. Accessed June 24, 2025
Résumés EM CasesWe Are All Leaders in Emergency Medicine
Emergency medicine is a team sport. Every team member, from the attending to the triage nurse to the registration clerk, plays a critical role in the delivery of care. And because EM is team-based, every team member has the capacity and responsibility to lead. This kind of leadership isn’t tied to hierarchy or titles. Instead, it starts with leading yourself: showing up prepared, rested, and present. It extends to leading your peers through support, communication, and shared responsibility. And it culminates in contributing to a culture where every person feels valued and empowered to do their best work. Leadership, in this sense, is not a future aspiration. It’s a current responsibility. Whether you’re leading a resuscitation or stepping up in a hallway conversation, you’re shaping the culture and flow of your ED. You’re leading.

“The leader you're looking for is you.” - Dr. Thom Mayer

Leadership Is Not a Title — It’s a Verb: Leadership vs Leading
There’s a big difference between leadership and leading. Leadership is something people talk about; leading is something you do. We all know the type — someone who wants the role, the office, the nameplate — but hasn’t inspired, empowered, or supported anyone around them. Leadership is often conceptualized as a role, a job title, or a position of authority. But leading is a verb. It’s what happens when someone steps up to take initiative, to inspire others, to ask the right question, or to admit a mistake. Leading is actionable, constant, and deeply personal. Emergency medicine is full of moments that call for leading: coordinating a code, de-escalating an agitated patient, advocating for a hallway patient who has waited hours,

Topics in this EM Quick Hits podcast
Matthew MacArthur on the role of occipital nerve block for the treatment of headache (1:32)
Ian Chernoff on the role of POCUS in patients with pulmonary embolism (10:25)
Hans Rosenberg on identification and management of myelopathy in the ED (29:13)
Shawn Segeren on the importance of the recorder during resuscitations (35:27)
Brit Long on incidental neutropenia (39:20)
Kylie Booth on Emergency Medicine peer programs (49:50)

Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Brandon Ng, Brit Long, Mathew MacArthur, edited by Anton Helman, June, 2025
Cite this podcast as: Helman, A. MacArthur, M. Chernoff, I. Rosenberg, H. Segeren, S. Long, B. Booth, K. EM Quick Hits 65 - Occipital Nerve Block, PoCUS in Pulmonary Embolism, Myelopathy, Team Resuscitation, Incidental Neutropenia, Peer Programs. Emergency Medicine Cases. June, 2025. https://emergencymedicinecases.com/em-quick-hits-june-2025/. Accessed June 3, 2025.
Indications, evidence, techniques and tips of occipital nerve block for headache management
Indications for occipital nerve block

* Suspected diagnosis of occipital neuralgia: Recurrent sharp stabbing headache with reproducible tenderness on percussion in the occipital nerve distribution.

* ICHD diagnostic criteria for occipital neuralgia includes symptom relief from nerve block.


* Other occipital headaches, including occipital migraines, cervicogenic headaches, cluster headaches.

* Consider occipital nerve block especially if patient fails first line treatments, and if headaches are predominantly occipital.



Source: Levin M. Nerve blocks in the treatment of headache. Neurotherapeutics. 2010 Apr;7(2):197-203
Occipital nerve block technique

* Medication: ~3cc of 2% lidocaine (± dexamethasone or bupivacaine).
* Landmarks:

* Palpate for the occipital protuberance and the mastoid process.
* Draw a linear line between the two landmarks = superior nuchal line of the occipital bone.
* Greater occipital nerve (GON) ≈ 1/3 from midline to mastoid process.
* Lesser occipital nerve (LON) ≈ 2/3 from midline to mastoid process.
* The GON & LON can also be landmarked using palpation or ultrasound to identify the occipital artery (the GON runs medially to artery), or by percussing along the superior nuchal line and injecting at the point of maximal tenderness.


* Injection:

* Use a small, 25–27G needle,
* Advance needle perpendicularly to periosteum, then withdraw slightly and aspirate.
* Inject ~1cc over nerve, and fan/reposition the needle to inject 1cc medial and 1cc lateral to the nerve.
* Always inject on or just above the superior nuchal line.



A single injection can halt the dysregulated pain signaling and provide sustained headache relief even after the anesthetic wears off.
Evidence for occipital nerve blocks for headache

Based on recent systematic reviews, the current RCT evidence for occipital nerve block shows statistically significant reductions in occipital headache intensity and frequency, both immediately and over the weeks that follow
Also no serious adverse events
However the evidence is limited by small sample sizes, with variations between different nerve block techniques (eg choice of ...

Our patient from part 1 of this 2-part podcast series on pulmonary embolism management is now tanking. Recall she is a 30-year-old female on oral contraceptive pill who was satting 68% on room air when EMS picked her up after 6 hours of shortness of breath and a syncopal episode. She had an initial ECG and PoCUS suggestive of right heart strain, was started on IV heparin and had a saddle embolus on CTPA.
This time, however, instead of just being admitted to the ICU, she comes back from the donut of truth satting 88% on a non-rebreather with a blood pressure of 70/40 and now she’s altered. She now has a high-risk pulmonary embolism. How is this going to change our management?
These are the sickest of the PE patients – about 5-10% of all PE cases, but with a high mortality rate of 30-40% at 30 days. All of these patients, unless there are absolute contraindications, should be considered for timely thrombolysis, which is guideline recommended despite the evidence for mortality benefit being fair at best. Just like in intermediate-risk patients, high-risk PE patients are a heterogenous group ranging from the patient with persistent systolic BP under 90 and otherwise looking not bad, to the cardiac arrest patient. There are many nuances in the management of these patients in oxygenation and airway management, hemodynamic support, acid/base management, thrombolysis, catheter-directed therapies that we dive into with our guest experts Dr. Lauren Westafer, Dr. Bourke Tillmann and Dr. Justin Morgenstern...

Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul
Written Summary and blog post by Sara Brade, edited by Anton Helman May, 2025
Cite this podcast as: Helman, A. Morgenstern, J. Tillmann B. Westafer, L. High Risk Pulmonary Embolism Management. Emergency Medicine Cases. May, 2025 https://emergencymedicinecases.com/high-risk-pulmonary-embolism-management. Accessed May 13, 2025
Résumés EM CasesPart 1 of this 2-part podcast is on Intermediate Risk PE Risk Stratification and Management

How does PE kill our patients? The Pulmonary Embolism Spiral of Death
In pulmonary embolism, there is a physical obstruction (ie. clot) decreasing the flow from RV to LV. The RV is a weak muscle to begin with and this obstruction increases the pressure the RV has to pump against. As the RV starts to fail, it dilates and becomes even weaker resulting in hypotension. In an undifferentiated patient, we’re likely to start by giving them fluids. But the RV is very sensitive to fluids and as we give more fluids to a patient in this state, this causes the RV to dilate further. The RV then becomes ischemic and bows into the LV. The LV now can’t fill well because the RV is in the way and because there is limited flow coming from the pulmonary vessels. This worsens systemic hypotension. Further, vasoconstriction in areas of the lungs obstructed by clot causes hypoxemia, and hypoxemia worsens myocardial perfusion. This cycle is how our high risk pulmonary embolism patients die from if we don’t intervene.
Image soure: EMCrit : https://emcrit.org/pulmcrit/eight-pearls-for-the-crashing-patient-with-massive-pe/
Defining high-risk Pulmonary Embolism
High-risk pulmonary embolism, previously called massive PE, includes patients with hemodynamic instability due to PE delineated by one of the following:

* Cardiac arrest

Topics in this EM Quick Hits podcast
Zafar Qasim & Andrew Petrosoniak on whole blood transfusion in trauma (1:32)
Justin Morgenstern on calcium pre-treatment to prevent diltiazem-induced hypotension (29:57)
Kiran Rikhraj on dynamic LV outflow tract obstruction (36:35)
Anand Swaminathan on resuscitative thoracotomy (42:35)
Andrew Tagg on uterine casts (48:22)
Jesse McLaren on scale & proportionality in occlusion MI ECG interpretation (53:38)

Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Brandon Ng, edited by Anton Helman, April, 2025
Cite this podcast as: Helman, A. Swaminathan, A. Qasim, Z, M. Petrosoniak, A. Rikhraj, K, Tagg, A. Morgenstern J. EM Quick Hits 64 Whole Blood Transfusions, Calcium Before Diltiazem in Afib, Thoracotomy Pearls, Uterine Casts, OMI Scale & Proportionality. Emergency Medicine Cases. April, 2025 https://emergencymedicinecases.com/em-quick-hits-month-year/. Accessed April 22, 2025.
Whole blood transfusions in trauma resuscitation: Better than component therapy?
Current Practice: Most centers use component therapy (RBCs, plasma, platelets) with a 1:1:1 ratio based on evidence from the PROPPR trial (Holcomb et al. 2015) rather than whole blood tranfusions. However, there is a recent shift in some U.S. centers towards adopting whole blood therapy in trauma resuscitation.
Benefits of whole blood transfusion therapy
(Typically refers to cold-stored low-titer O whole blood in civilian practices)

* Simplicity: Simpler to administer and logistically less complex than separate components, with universal compatibility and no need to balance component ratios.
* Evidence: Observational studies in military settings show improved early survival with warm fresh whole blood compared to component therapy (Gurney et al. 2020, Shackelford et al. 2021).
* Physiologic advantages: Provides higher hematocrit, platelet counts, and clotting factor content in a whole blood unit when compared to equivalent component therapy.
* Safety: May have fewer transfusion-related complications.

Arguments against using whole blood transfusions, challenges to implementation

* Limited RCT Evidence: Robust RCT evidence is lacking to support widespread adoption; data to support whole blood as superior to component therapy is primarily observational.
* Rh Sensitization Risk: Potential for alloimmunization in Rh- women of childbearing age receiving Rh+ whole blood, posing a risk for hemolytic disease of the newborn in future pregnancies.
* Logistics: Supply is very dependent on donor availability, which can fluctuate.
* Storage: Platelet function declines over time in stored whole blood. Solutions include rotating stock to high-usage centers or converting near-expiry units to component products.

Read more about massive hemorrhage protocols in Ep 152 “The 7 Ts of Massive Hemorrhage Protocols”
How Can Whole Blood be Used in a Massive Hemorrhage Protocol?

* Example protocol from Dr. Qasim: Patients who present with an ABC score ≥2 (e.g., penetrating trauma, hypotension, +FAST, tachycardia) receive up to 4 units of whole blood before switching to component therapy.
* Observational studies suggest earlier is better: every minute delay beyond 14 mins may worsen survival outcomes (Torres et ...

A 30-year-old woman rolls into your resuscitation bay looking very dyspneic on a non-rebreather, clammy with a heart rate of 135 bpm. She takes oral contraceptives, has had a sudden syncopal episode, and now lies in the stretcher struggling. Her blood pressure is 100/60 and she is hypothermic with a temp of 35.7°C. Her ECG and PoCUS suggest right heart strain. CTPA confirms a saddle pulmonary embolism (PE). But she’s not hypotensive… yet. So, what’s next? How do you predict which intermediate-risk patients will suddenly deteriorate? What role do biomarkers, imaging, and hemodynamics play in decision-making? Should she receive anticoagulation alone, or is thrombolysis warranted? When should you consider catheter-directed or surgical interventions? This case focuses us to think critically about risk stratification and early interventions in PE. Not all patients fit neatly into classification boxes, making clinical judgment crucial. Join Dr. Lauren Westafer, Dr. Justin Morgenstern, Dr. Bourke Tillman and Anton as they explore the key decision points, pitfalls, and lifesaving strategies for managing intermediate-risk PE in the ED...

Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul
Written Summary and blog post by Sara Brade, edited by Anton Helman April, 2025
Cite this podcast as: Helman, A. Morgenstern, J. Tillmann, B. Westafer, L. Intermediate Risk Pulmonary Embolism Risk Stratification, Management and Algorithm. Emergency Medicine Cases. Month, 2024. https://emergencymedicinecases.com/intermediate-risk-pulmonary-embolism-risk-stratification-management. Accessed April 1, 2025
Résumés EM CasesPulmonary embolism risk categories
PE severity exists on a spectrum, ranging from low-risk cases to cardiac arrest. Patients who fall in the intermediate-risk category are particularly challenging because they represent a heterogenous group with varying degrees of severity and risk for clinical deterioration.
The European Society of Cardiology (ESC) classifies PE severity into four categories:

Low-risk patients do not require oxygen, show no signs of RV dysfunction, and have normal biomarkers.
Intermediate-low risk patients have either elevated biomarkers OR RV dysfunction but not both.
Intermediate-high risk patients exhibit both elevated biomarkers AND RV dysfunction.
High-risk patients have prolonged hypotension (systolic BP <90 mmHg for at least 15 minutes), require pressor support, or cardiac arrest.

Source: https://doi.org/10.1161/CIRCINTERVENTIONS.116.00434
Mortality for intermediate-risk PE patients has been reported as high as 15% within the first 30 days. The challenge in the ED is identifying and treating those at the highest risk of deterioration before they progress to hemodynamic instability.
The pulmonary embolism death spiral: understanding how patients decompensates helps risk stratify them
In cases of clinically significant high risk and intermediate high risk pulmonary embolism, the clot is thought to increase pulmonary vascular resistance, forcing the right ventricle (RV) to work harder to pump blood forward. Since the RV is not structurally designed to handle increased afterload, it begins to dilate. This dilation leads to a vicious cycle where the RV's myocardial perfusion is compromised, further reducing its contractility.
As the obstruction worsens, blood return to the left ventricle (LV) is diminished, reducing cardiac output. The dilated RV also physically compresses the LV, worsening cardiac output even further. Additionally, hypoxia from pulmonary vasoconstriction exacerbates myocardial isc...

Topics in this EM Quick Hits podcast
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 11, 2025.
Pediatric bloody diarrhea: Shiga Toxin Producing E. Coli (S-TEC) and HUS
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:

* Hemodynamic instability
* S-TEC is high on your differential (bloodwork may be useful as baseline)
* Recent travel with bloody diarrhea and fever
* Close contact with S-TEC cases (~10% household transmission rate)

When to suspect S-TEC?

* Severe crampy abdominal pain
* >15-20 small frequent, mucousy, bloody stools per day
* Low grade fever
* Signs of microangiopathy (e.g. petechiae, jaundice)
* Endemic area




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.

* Shiga toxin 2 (STX2) is specifically associated with a 15-20% risk of HUS in children <5 years

* HUS development increases risk of dialysis to 50-60% within 1 week
* Differentiating between STX1 (<1% risk of HUS) and STX2 toxin can help risk-stratify patients



How to risk stratify a positive STEC result:

* Assume blood in stool to be STX2 producing STEC until proven otherwise (non-bloody STEC unlikely making Shiga toxin 2 and unlikely to cause HUS)
* Determine duration of diarrhea: HUS develops a median of 7 days after diarrhea onset

* Diarrhea >10 days = low risk of HUS


* Determining if toxin result is STX2+ (high risk)

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

* Manage dehydration aggressively (volume depletion is associated with adverse outcomes in H...

Eating disorders have the highest mortality rate of any psychiatric illness, yet they are frequently missed in the Emergency Department as they can be elusive. Only one in 246 patients who screen positive for an eating disorder at triage have a chief complaint suggesting it. These patients don’t always fit the stereotype—many appear “healthy", have normal BMIs, and/or present with vague GI, cardiac, or neurological symptoms. Missing the diagnosis has important consequences. The earlier an eating disorder is identified and the earlier that appropriate treatment is initiated the better the long term outcomes. In this episode, with the expertise of Dr. Samantha Martin and Dr. Jennifer Tomlin, we’ll break down the essential clinical clues, screening questions, red flags, and subtle exam findings that can help Emergency Physicians diagnose eating disorders early and initiate treatment to decrease mortality and long term morbidity in these young patients. Eating disorders need to be thought of as both a psychiatric condition and medical condition to optimize the pick up rate and appropriate management. Missing or mismanaging eating disorders in the ED means missing an opportunity to save a life and prevent long term morbidity...

Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul
Written Summary and blog post by Anton Helman February, 2025
Cite this podcast as: Helman, A. Tomlin, J. Martin, S. Episode 202 Eating Disorders: Common, Commonly Missed, Mismanaged and Misunderstood. Emergency Medicine Cases. February, 2025. https://emergencymedicinecases.com/eating-disorders. Accessed February 28, 2025
Résumés EM CasesA 16-year-old male presents to the ED with his mother with the chief complaint of intermittent abdominal pain and constipation for several weeks. There are no red flag symptoms for an underlying surgical cause and review of systems is otherwise unremarkable. Vital signs include a HR 50, BP 85/40 T 35.9. Blood work is ordered, and it shows a mildly low potassium at 3.2 mEq/L, a mildly low hemoglobin at 11g/dl and normal liver enzymes. The patient is discharged from the ED with the diagnosis of low-risk nonspecific abdominal pain with a recommendation to follow up with their primary care physician, and instructions to return for list of red flag symptoms. This case represents a miss of a potentially life-threatening diagnosis that Emergency Physicians have little knowledge of.
Eating disorders are common, often elusive, and can be deadly

* Eating disorders, which include anorexia nervosa, bulimia nervosa, binge eating disorder and Avoidant/restrictive food intake disorder (ARFID), are common with increasing prevalence, increasing visits to emergency departments, and have the highest mortality of any psychiatric illness.
* The lifetime prevalence rates of anorexia nervosa are as high as 4% among females and is increasing among males.
* In young females the mortality rate of eating disorders is estimated to be as high as 10%.
* In a recent study, after a 5-year follow-up the mortality rate of anore...

Topics in this EM Quick Hits podcast
Anand Swaminathan on optimizing RSI medication timing (1:08)
Brittany Ellis on ED boarding challenges in older patients and improving ED overcrowding and ED flow (7:30)
Dave Jerome on managing prolonged tourniquet application (30:21)
Nour Khatib and Phil Gillick on a rural peer support program case (39:20)
Jesse McLaren on ECG reciprocal changes in acute occlusion myocardial infarction: the mirror image (54:43)
Melody Ng on practical nutrition tips for shift workers (best of University of Toronto EM) (1:01:23)

Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Brandon Ng, edited by Anton Helman, January, 2025
Cite this podcast as: Helman, A. Swaminathan, A. Ellis, B. Jerome, D. Khatib, N. Gillick, P. McLaren, J. Ng. M. EM Quick Hits 62 - Optimizing RSI Medication Timing, ED Boarding of Older Patients, Prolonged Tourniquet Use, Rural Peer Support Programs, ECG Reciprocal Changes, Nutrition for Shift Workers. Emergency Medicine Cases. January, 2025. https://emergencymedicinecases.com/em-quick-hits-january-2025/. Accessed February 2, 2025.
Optimizing RSI Medication Timing

* Much of recent airway research relates to RSI preparation and tube delivery: Resuscitate prior to intubation, improve hemodynamics to decrease risk of peri-intubation hemodynamic collapse, improve oxygenation to increase safe apneic time, positioning, ramping, airway alignment, bed up, head elevated, and bougie first approach etc.
* Typical approach to RSI involves near simultaneous administration of induction and paralytic agents to rapidly result in ideal intubating condition. However, this approach often results in an induced but not paralyzed patient, causing difficulties with tube delivery as medication onset times differ:

* Succinylcholine: 45-60 seconds
* Rocuronium (1.2 mg/kg): ~60 seconds
* Etomidate: 30-40 seconds
* Ketamine: 30-45 seconds
* Propofol: 20-25 seconds


* As such, consider aiming for simultaneous onset rather than simultataneous administration of induction and paralytic agent.
* In studies by Driver et al. 2019 and Catoire et al. 2024, administering paralytic prior to induction agent is associated with lower first attempt intubation failure.

Bottom line => Consider administering paralytic first, then induction agent ~20-30 seconds later, ensuring simultaneous onset for optimal RSI while averting awake paralysis.
Expand to view reference list

* Driver BE, Klein LR, Prekker ME, Cole JB, Satpathy R, Kartha G, Robinson A, Miner JR, Reardon RF. Drug Order in Rapid Sequence Intubation. Acad Emerg Med. 2019 Sep;26(9):1014-1021. doi: 10.1111/acem.13723. Epub 2019 Mar 19. PMID: 30834639.
* Catoire P, Driver B, Prekker ME, Freund Y. Effect of administration sequence of induction agents on first-attempt failure during emergency intubation: A Bayesian analysis of a prospective cohort. Acad Emerg Med. 2024 Oct 18. doi: 10.1111/acem.15031. Epub ahead of print. PMID: 39425254.



ED Boarding for Older Patients
This segment is the first part of our series on The Best of The Internat...

In this Part 2 of our 2-part podcast series on How EM Experts Think with Dr. Reuben Strayer, Dr. Mike Betzner and Dr. Scott Weingart we dive deep into the nuances of practicing smarter, faster, and better in the ED. We answer questions like: How should we employ hypothetico-deductive reasoning in our daily practice of Emergency Medicine? How can we best streamline thorough data gathering for each case so that we don't miss key data points? How do the master EM clinicians perform an efficient and targeted history and physical exam? How can the concept of heuristic cycling help you avoid outdated or faulty thinking? How can we document our clinical encounter in a way that considers a differential diagnosis that prioritizes dangerous conditions and improve our thinking around cases? How can we use the 2-10% rule for pre-test probabilities and the concept of preferred error to guide our decision making for tests and treatments in the ED? What strategies can we use to avoid anchoring bias and keep your mind open to all possibilities? What’s the role of shared decision-making when navigating diagnostic uncertainty? How does understanding the vigilance pendulum help us assess our risk tolerance better? How can post-shift decision journaling, conducting pre-mortems and meditation improve our decision making and boost our emotional resilience on shift? and many more...

Podcast production, sound design & editing by Anton Helman
Written Summary and blog post by Rowan Helman and Anton Helman January, 2025
Cite this podcast as: Helman, A. Weingart, S. Betzner, M. Strayer, R. How EM Experts Think Part 2: Data Gathering, Diagnostic and Treatment Decision Making, Test Ordering and Interpretation, Documentation, Emotional Resilience. Emergency Medicine Cases. January, 2025. https://emergencymedicinecases.com/how-em-experts-think-part-2. Accessed February 2, 2025
Résumés EM CasesEpisode 200 How EM Experts Think Part 1: Strategies for Pre-Shift, Arrival Ritual, Staying Focused, Managing Interruptions, Cognitive Load & Negative Emotions, Resuscitation Mindset, Post-Resuscitation Recovery
History taking: How EM Experts Think
"We're not as concerned only about what the patient has. We're concerned about what the patient needs". -Reuben Strayer
Traditional approaches to history-taking taught in medical school usually by internal medicine, often fall short in the dynamic and unpredictable environment of the ED, and fail to address the patients immediate needs. Emergency Medicine works on a hypothetico-deductive methodology, using simultaneous inductive and deductive reasoning. It involves formulating a hypothesis to make predictions, comparing predictions to observations and determining if they are consistent and finally, confirming or falsifying the hypothesis. The cardinal skill in differential diagnosis generation for EM is being able to link symptoms and signs to a list of dangerous conditions that apply to the patient in front of you. Generating a list of dangerous conditions for all common presentations to the ED at home, and them having them easily accessible via documentation templates can help hone your diagnostic skills.
Data gathering
Preparation before entering the patient’s room is critical. Effective pre-history strategies include:

* Chart Review: Review triage vital signs, nursing notes, EMS run sheets,

Which elements of your current pre-shift preparation contribute most to your mental clarity and performance, and what new practices might further optimize your readiness? With interruptions shown to increase task errors and decision fatigue, how can you strike a balance between being approachable to colleagues and safeguarding your focus for patient care? When confronted with a particularly challenging or emotionally charged case, what strategies have you found most effective for maintaining professionalism and clear decision-making under pressure? How often do you debrief after high-stakes scenarios, and what impact has debriefing—whether formal or informal—had on your team’s learning, emotional recovery, and future preparedness? What strategies do you use to foster open communication and ensure all team members feel empowered to provide input during high-stakes situations? How do you mentally and emotionally shift from managing a critical resuscitation to treating lower-acuity patients without compromising your focus or energy? When faced with a complex case where diagnostic clarity is elusive, how do you prioritize your next steps while maintaining confidence in your decision-making process? How can apps, personalized workflows, or EMR tools be better utilized to minimize cognitive load and enhance clinical decision-making during shifts? These are just some of the questions we pose in this 2-part podcast series on How the Experts Think with Dr. Reuben Strayer, Dr. Scott Weingart and Dr. Mike Betzner...

Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul
Written Summary and blog post by Anton Helman December, 2024
Cite this podcast as: Helman, A. Weingart, S. Betzner, M. Strayer, R. Episode 200 How EM Experts Think: Pre-Shift Preparation and Arrival Ritual, Staying Focused on Shift, Managing Interruptions, Managing Cognitive Load, Handling Negative Emotions, Resuscitation Mindset and Execution, Post-Resuscitation Recovery. Emergency Medicine Cases. December, 2024. https://emergencymedicinecases.com/how-the-em-experts-think-part-1. Accessed February 2, 2025
Résumés EM CasesPre-Shift Preparation and Arrival Ritual
Effective preparation ensures you start your shift focused and ready. The chaos of the ED demands that clinicians arrive mentally and physically ready to handle high decision density, frequent interruptions, and unpredictable challenges. By developing pre-shift rituals, emergency providers can start shifts with clarity and confidence. Think of yourself as an elite athlete who requires both physical and mental training to maximize performance.
Key Tips:

* Mental and Physical Routines:

* Ride a bike or run to work or perform a quick exercise routine to clear the mind
* Take a cold shower to invigorate the body and mind
* Consume protein-rich foods to sustain energy levels
* Set up your workspace the same way each shift to reduce cognitive strain
* Arrive early to establish a flow without interruptions
* Establish a ritual to leave your personal issues at the door and mentally commit to the shift


* Mental Framing:

* Listen to medical podcasts or inspirational music during your commute to set a positive and engaged mindset
* Practice gratitude by reflecting on the privilege of being a physician
* Use positive self-talk to reinforce your readiness and confidence
* Visualize success and mentally rehearse procedures and challenging ...

Topics in this EM Quick Hits podcast
Ross Prager on TEE in cardiac arrest (1:05)
Justin Morgenstern on nebulized ketamine for analgesia in the ED (26:27)
Hans Rosenberg & Krishin Yadav on standardizing cellulitis management (32:48)
Matthew McArther on latest studies on subcutaneous insulin protocols in DKA (40:04)
Jennifer C. Tang on documenting differential diagnoses medicolegal tips (52:47)

Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Anton Helman, December, 2024
Cite this podcast as: Helman, A. Prager, R. Morgenstern, J. Rosenberg, H. Yadav, K. McArther, M. Tang, J. EM Quick Hits 61 - TEE in Cardiac Arrest, Nebulized Ketamine, Cellulitis Update, SQ Insulin for DKA, Medicolegal DDx Documentation Tips. Emergency Medicine Cases. December, 2024. https://emergencymedicinecases.com/em-quick-hits-decemeber-2024/. Accessed February 2, 2025.
Transesophageal Echo - TEE in Cardiac Arrest - Resuscitative TEE

* Rational for resuscitative TEE and TEE in cardiac arrest:

* Provides real-time feedback on the optimal location and quality of chest compressions in cardiac arrest (precise location of chest compressions with respect to cardiac anatomy can be observed and manipulated to optimize circulatory flow as compressions directly over the LV have been shown to be most effective); ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression (rather than LV compression), obstructing blood flow. Absence of aortic valve compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU.









* Minimizes chest compression interruptions in cardiac arrest
* Allows identification of reversible causes of cardiac arrest - identification of obstructive pathologies including tension pneumothorax, cardiac tamponade, deep vein thrombosis with RV dilation suggesting pulmonary embolism, as well as filling status suggesting hypovolemia, pericardial tamponade, intracardiac thrombus, fine ventricular fibrillation, and to characterize the type of cardiac activity such as cardiac standstill or pseudo-PEA
* Provides prognostic information in cardiac arrest - LVOT opening as identified by TEE during CPR was associated with successful resuscitation in retrospective study
* For operators who are already experienced at using POCUS, Resus-TEE skills can be acquired rapidly.
* Procedural guidance:

* placement of an intravenous temporary pacemaker
* placement of extracorporeal life support cannulae






* Risks of TEE in cardiac arrest

* The risks of TEE are generally related to sedation & airway management. Critically ill patients who undergo resus-TEE are already intubated and sedated, thus these risks are minimized. There are risks of esophageal trauma with insertion, however these are probably comparable to the risks of gastric tube placement.
* Major complications such as serious oropharyngeal trauma, esophageal perforation, and major bleeding are rare with incidence rates between 0.01% and 0.08%
* Unclear if placement of the TEE in an emergent scenario or use during electrical defibrillations and chest compressions increase risk of damage to the transducer.

In this EM Cases main episode podcast, we tackle the complexities of trauma airway management, including direct trauma to the airway. We discuss indications and timing of intubation, penetrating neck trauma, the head injured patient, the agitated patients and the soiled airway. The critical question is: when should we deviate from, delay or modify RSI, and how do we navigate the unique challenges presented by trauma airways and airway trauma? Dr. George Kovacs and Dr. Andrew Petrosoniak answer this and other questions such as: how should we re-sequence the trauma resuscitation depending on immediate life-threats? When is immediate vs delayed intubation recommended? How useful are the Zones of the neck in penetrating neck trauma? What is the optimal dosing of airway medications in the sick trauma patient? How should we modify our airway strategy for the severely head injured patient and/or agitated patient? When should we consider ketamine facilitated fiberoptic intubation in the trauma patient? and many more...

Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul
Written Summary and blog post by Sara Brade, edited by Anton Helman November, 2024
Cite this podcast as: Helman, A. Petrosoniak, A. Kovacs, G. Trauma Airway & Airway Trauma. Emergency Medicine Cases. November, 2024. https://emergencymedicinecases.com/trauma-airway. Accessed February 2, 2025
Résumés EM Cases





Case study: Penetrating neck trauma
Consider a 25-year-old woman who presents with a stab wound to the anterior neck. She arrives with a heart rate of 145, oxygen saturation at 90%, and audible gurgling sounds, indicating potential airway compromise. This is a high-stakes scenario where every decision, especially regarding airway management, could have life-altering consequences. The injury, located just off the midline in the anterior neck, immediately raises concerns about airway obstruction, major vascular injury, or both.
Re-sequencing the trauma airway: A paradigm shift
While working through the standard ATLS approach of A then B then C can be a helpful memory tool, our trauma resuscitations often require simultaneous assessment and management of all three or a total re-ordering of priorities. Some traumas may require a CAB approach or a CBA approach. Intubation is not always the first priority in trauma and, in fact, it may worsen outcomes if done prior to adequate resuscitation. Instead of focusing on letters, we should be focusing on identifying and managing the most immediate threat to life for each patient. Look for and immediately manage the following:

* Massive hemorrhage: For example, a spurting artery that needs immediate management/compression or an unstable pelvis that needs binding.
* Severe airway compromise:

* Dynamic airway: If you wait even minutes, you may miss the opportunity to secure an airway. For example, expanding neck hematoma.
* Critical hypoxia: Despite maximum noninvasive ventilation, O2 saturation is still <90%.


* Obstructive shock:

* Tension pneumothorax/ hemothorax: Consider bilateral finger thoracostomies/ chest tube before airway management.
* Cardiac tamponade: Very high-risk intubations, should likely be done in the OR if patient still has a BP. If cardiac arrest, consider thoracotomy if your resources allow.




The decision to intubate the trauma patient

Topics in this EM Quick Hits podcast
Kevin Wasko on post-tonsillectomy hemorrhage management (1:06)
Brit Long on assessment and management of post-CABG surgical incision infections (15:40)
Anand Swaminathan on evidence, pitfalls and tips on using Bougies (23:07)
Leah Flannigan on when to suspect vascular injury in patients with low energy mechanism pelvic fractures (31:05)
Andrew Petrosoniak on debriefing after cases: why, when and how (38:35)

Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Anton Helman, October, 2024
Cite this podcast as: Helman, A. Wasko, K. Long, B. Swaminathan, A. Flannigan, L. Petrosoniak, A. EM Quick Hits 60 - Post-Tonsillectomy Hemorrhage, Post-CABG Infections, Bougie Tips, Pelvic Fracture Bleeds, Debriefing: Why, When & How. Emergency Medicine Cases. October, 2024. https://emergencymedicinecases.com/em-quick-hits-october-2024/. Accessed February 2, 2025.
Post-Tonsillectomy Hemorrhage Management
Best of University of Toronto EM

* Primary vs. Secondary post-tonsillectomy hemorrhage:

* Primary post-tonsillectomy hemorrhages occur within the first 24 hours post-op, usually related to intraoperative factors like surgical technique or undiagnosed coagulopathies (e.g., von Willebrand disease). These bleeds are more likely in the immediate post-op period.
* Secondary post-tonsillectomy hemorrhages occur after 24 hours, typically around post-op days 5 to 7, but can occur up to 14 days. They are caused by the sloughing off of the fibrin clot, exposing underlying tissue, which can lead to ongoing oozing or trickling bleeding. These are more insidious and can escalate quickly into life-threatening hemorrhages.


* Key point:

* Even if the bleeding is minor, like a small trickle, it should be considered a potential herald bleed—a precursor to a larger, more dangerous bleed. In these cases, early ENT consultation is crucial as definitive source control is needed, especially if bleeding persists for several hours.


* Management approach (3-pronged):

* Resuscitation:

* Ensure the patient is sitting upright in a comfortable position to prevent aspiration and make visualization easier.
* Establish IV access and consider starting IV TXA 1-2g in adults, 15mg/kg in children if appropriate.


* Get help early:

* Contact ENT early, especially if you’re in a rural or resource-limited setting where transfer may be delayed.
* Arrange for transport to a tertiary care center if no ENT is available locally.


* Temporizing measures (until definitive management in the operating room):

* Direct pressure with gauze and topical medications: Use lidocaine spray for local analgesia, and gauze soaked in epinephrine and/or TXA
* Tranexamic Acid (TXA) options:

* Nebulized TXA: Consider while other preparations are made. It’s a low-risk, easy intervention.
* Topical TXA: Soak gauze in TXA and apply it directly to the bleeding site.
* IV TXA: 15 mg/kg in children or 1-2 grams in adults over 10 minutes.
* While evidence is limited, it is a reasonable adjunct in these cases, given the low risk of harm.






* Airway Management in the post-tonsillectomy bleed



* If the patient starts to aspirate blood, or if bleeding becomes severe enough to cause respirato...

There is a culture problem in medicine. 70% of us are disengaged, more than 50% contribute nothing to our departments and more than 15% actively work against a healthy culture in our departments. What makes an Emergency Department run like a well-oiled machine with staff that find meaning in their work and who are grateful for serving the public? There are individual skills; there are team skills; there is the admin, and then there is the oh-so-important culture which permeates all of these and can make them great or can drive them into the ground. The culture of an ED can make it or break it. In this EM Cases podcast Anton chats with Dr. Peter Brindley and Dr. Leon Byker who have a deep interest in the Culture of Medicine to explore what culture in medicine is, why culture is so important, and then drive home 10 strategies to improving the culture in our departments emphasizing the importance of human connection, empathy, open communication, and a willingness to learn from mistakes in creating a positive and fulfilling work environment, so that we love our work, we love our department, we love taking care of our patients and our patients have better outcomes...

Podcast production, sound design & editing by Anton Helman
Written Summary and blog post by Anton Helman October, 2024
Cite this podcast as: Helman, A. Byker, L. Brindley, P. Episode 198 Understanding and Improving Culture in Emergency Medicine: Key Insights. Emergency Medicine Cases. October, 2024. https://emergencymedicinecases.com/improving-culture-emergency-medicine. Accessed February 2, 2025
Résumés EM CasesWhat is culture in medicine?
Culture in medicine integrates values, beliefs, behaviors, and interpersonal dynamics. Gert Hofstede’s framework outlines five key indices to evaluate cultural health in organizations: power distance, individualism vs. collectivism, assertiveness, uncertainty avoidance, and long vs. short-term orientation. Understanding where your department stands on these scales can illuminate pathways for cultural improvement.
Hofstede’s 5 Dimensions of Culture

* Power differential – the degree of inequality that exists and is accepted between people with and without power
* Individualism vs collectivism – the strength of the ties that people have to others within their community

* High IVD – high value placed on people’s time and need for privacy and freedom, an enjoyment of challenges, and expectation of individual rewards for hard work – in these communities should encourage debate and expression of people’s ideas and don’t mix work life with social life too much
* Low IVD – emphasis on building skills and becoming a master of something, people work for intrinsic rewards, maintaining harmony among group members is important, wisdom is important, avoid giving negative feedback in public


* Uncertainty avoidance index – how well people can cope with anxiety
* Long vs short-term orientation
* Indulgence vs restraint

Why culture in medicine matters
The culture of an ED shapes every aspect of its operation, from teamwork to patient care. It is critical for fostering a supportive environment that allows medical professionals to thrive. Culture is often intensified in high-pressure situations typical of Emergency Medicine, making it imperative to assess and enhance cultural dynamics actively.
It can be a challenge to foster teamwork in a culture that often prioritizes individualism and status.

Topics in this EM Quick Hits podcast
Ian Chernoff on traumatic coronary artery dissection (1:05)
Anand Swaminathan on proper use of insulin in DKA and in hyperkalemia (15:50)
Brit Long & Hans Rosenberg on mesenteric ischemia pearls and pitfalls in diagnosis and management (21:47)
Dave Jerome on managing exercise-associated hyponatremia and heat illness (33:47)
Jesse McLaren on the Queen of Hearts AI model in helping identify occlusion MI on ECG (50:50)

Podcast production, editing and sound design by Anton Helman
Podcast written summary & blog post by Brandon Ng, edited by Anton Helman, September, 2024
Cite this podcast as: Helman, A. Chernoff, I. Swaminathan, A. Long, B. Rosenberg, H. Jerome, D. McLaren, J. EM Quick Hits 59 Traumatic Coronary Artery Dissection, Proper Use of Insulin, Mesenteric Ischemia, Exercise Associated Hyponatremia, AI for OMI. Emergency Medicine Cases. September, 2024. https://emergencymedicinecases.com/em-quick-hits-september-2024/. Accessed February 2, 2025.
Traumatic Coronary Artery Dissection - Best of University of Toronto EM

Traumatic coronary artery dissection is a rare, but often fatal injury that is challenging to diagnose and requires specific knowledge of it's clinical features. Clinical clues for traumatic coronary artery dissection include:

* History of blunt force chest trauma ranging from low to high energy mechanisms (direct blow to the chest, high speed motor vehicle crash)
* Possible delayed presentation by many hours to days to weeks
* Typical angina symptoms in young patient with no cardiac risk factors
* Wall motion abnormalities on cardiac PoCUS
* Elevated troponin
* ECG ischemic changes

Why is traumatic coronary artery dissection difficult to diagnose?

* Cardiac injuries ranging from contusions to dissections occur in 5-15% of blunt chest trauma; traumatic coronary artery dissection comprises a small proportion of these patients
* Symptoms may not present for days to weeks after inciting event
* May occur even with low energy mechanisms
* Most often occur in young patients who are not at risk for cardiac ischemia – 82% under age 45 and have been reported in as young as age 14
* Often overlooked due to low index of suspicion in the context of other concurrent traumatic injuries



Traumatic coronary artery dissection vs SCAD (Sontaneous Coronary Artery Dissection)

* There are some corollaries with SCAD and traumatic CAD in that both have historically been under-recognized;h owever, whereas SCAD has now belatedly been recognized as the leading cause of MI in women under age 50, traumatic CAD continues to be under appreciated





Workup of traumatic coronary artery dissection

* Patients complaining of chest pain after sustaining blunt chest trauma should undergo prompt cardiovascular workup
* Current Eastern Association for the Surgery of Trauma (EAST) guidelines propose an ECG as well as cardiac markers should be performed on any patient in which one suspects blunt cardiac injury; doing so appears practitioner dependent



A key pitfall in chest trauma is assuming that a borderline ECG and positive troponin is due only to cardiac contusion, which does not warrant activation of the cath lab.

We’d like to think that we’re getting better at identifying acute heart failure and making good disposition decisions. But the facts are, ED physicians are only about 80% accurate diagnosing acute heart failure, and 30-day mortality outcomes and readmission rates for acute heart failure have been about the same in North America for the last few decades – plus we often send home patients who should be admitted and admit patients who should be sent home. This is because there are many challenges for EM docs when it comes to acute heart failure. First, the diagnosis can be tough, and often is only made once the patient is admitted. There is no one clinical feature that is a slam dunk for the diagnosis, and even combinations of features are not great. There are many flavours of heart failure – diastolic, systolic, right-sided, left-sided, SCAPE, cardiogenic shock - just too complicate things further. Even if we’ve made an accurate diagnosis, the decision of whether to admit or send home can be challenging. We have risk stratification decision scales to help, but are they good enough? Are we using them appropriately? In this podcast, with the help of Dr. Doug Lee, cardiologist and researcher at Sunnybrook Hospital in Toronto and Dr. Clare Atzema, our go to EM Atrial fibrillation expert, an EM doc and researcher also from Sunnybrook Hospital, with a special appearance by Ian Chernoff on the role of PoCUS in the diagnosis and risk stratification of acute heart failure, we’ll dig into how to improve our diagnostic accuracy of acute heart failure in the ED and how to improve our disposition decision making so that just the right number of people are admitted and just the right number of people of sent home safely...

Podcast production, sound design & editing by Anton Helman
Written Summary and blog post by Ryan O'Reilly and Anton Helman August, 2024
Cite this podcast as: Helman, A. Episode 197 Acute Heart Failure Risk Stratification and Disposition. Emergency Medicine Cases. August, 2024. https://emergencymedicinecases.com/acute-heart-failure-risk-stratification-disposition. Accessed February 2, 2025
Résumés EM CasesAccuracy of initial evaluation findings in the diagnosis of acute heart failure 
Source: King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012 Jun 15;85(12):1161-8.
Value of NT-pro-BNP in risk stratification of acute heart failure remains controversial
Based on our in depth review of the world's literature in 2018 in this Journal Jam podcast, and as detailed on First10EM, BNP has limited, if any, value in risk stratification of acute heart failure in the ED. However, a subsequent study and guidelines suggest that NT-pro-BNP is highly accurate at the extremes (NT-pro-BMP <300 highly unlikely acute heart failure and NT-pro-BNP ≥5,000 highly likely acute heart failure). There remains an argument to be made that in patients who obviously do not have acute heart failure clinically or obviously do have heart failure clinically, a BNP is not going to shift your diagnostic certainty significantly, and for the intermediate cases where BNP would be most valuable, it is seldom discerning, and may be misleading.
Cardiology guidelines from Europe and Canada seem to have settled on NT-pro-BNP <300pg/ml as “rule-out” threshold, while implementing an age-adjusted “rule-in” threshold:

* Rule out  - <300
* Rule in ("consider admission")

* <50y - >450
* 50-75 - >900

Topics in this EM Quick Hits podcast
Megan Landes on providing HIV PEP and PrEP in the ED (1:05)
Justin Morgenstern and George Kovacs on evidence for pre-oxygenation with NIPPV before intubation in RSI (19:05)
Brit Long on recognition and management of blast crisis in the ED (41:31)
Leah Flanagan and Liam Loughrey on the rise of nitrous oxide toxicity (50:40)
Andrew Petrosoniak on the role of vasopressors in the hemorrhaging trauma patient (59:55)

Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Brandon Ng and Brit Long, edited by Anton Helman, July, 2024
Cite this podcast as: Helman, A. Morgenstern J. Landes, M. Kovacs, G. Long, B. Flanagan L. Loughrey, L. Petrosoniak, A. EM Quick Hits 58 - HIV PEP and PrEP, PREOXY Trial, Blast Crisis, Nitrous Oxide Poisoning, Vasopressors in Trauma. Emergency Medicine Cases. July, 2024. https://emergencymedicinecases.com/em-quick-hits-month-year/. Accessed February 2, 2025.
HIV Post-exposure prophylaxis (PEP) and pre-exposure prophylaxis (PrEP)
This is part 2 of our 2-part EM Quick Hits series on HIV. We suggest reviewing part 1 if you haven't already - Part 1 of this 2-part EM Quick Hits series on HIV

* PEP is an effective method for reducing the risk of transmission for persons who have been exposed to HIV. It needs to be given less than 72 hours from initial exposure to be maximally effective and is prescribed as a 28-day course of Anti-retroviral therapy (ART).
* PEP reduces the relative risk of a single exposure event to HIV by 80% (reduces risk of percutaneous exposure and mucocutaneous exposure to HIV positive blood to 0.3% and 0.09%, respectively).
* Note that every risk of exposure to HIV is relatively low, and PEP reduces that to an even more minuscule risk.

HIV post-exposure risk stratification and indications for post-exposure prophylaxis (PEP)?
1.Determine the source risk for transmissible HIV, which can be categorized into substantial, low but nonzero, and negligible/none:
Source: Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis by Tan et al. EMAJ 2017

* Concomitant STIs increase the risk of transmitting HIV through methods such as breaking down mucosal barriers and increasing inflammatory states.

2.Determine the type of transmission:
Source: Canadian guideline on HIV pre-exposure prophylaxis and nonoccupational postexposure prophylaxis by Tan et al. EMAJ 2017

* There is no good data on the risk of HIV transmission via mucocutaneous splash. Refer to your local occupational health policies.

Who should we advise to start PEP?

* Consider PEP if the source risk is in the substantial category and the type of exposure is high/moderate risk.
* PEP is not recommended if the source’s risk is negligible/none and the exposure type is low risk.


Indications for pre-exposure prophylaxis for HIV (PrEP)?

* PrEP is ARTs (e.g. Truvada®) on an ongoing basis due to expecting repeated high-risk exposures to HIV.
* There is a relative risk reduction of 44% and a NNT of <15.
* People who should consider taking PrEP include: sexually active adults who have ongoing exposure (e.g. ongoing condomless sex with known HIV exposure), patients with recent STI, and those presenting to ED for recurrent PEP.
* There are also current studies and ongoing evidence for adding doxyc...

In this EM Cases main episode podcast with Dr. Shannon MacPhee and Dr. Jeanette Comeau we discuss the recognition, risk stratification, decision tools, indications for lumbar puncture in the febrile pediatric patient, tips and trick on performing LPs in children, and ED management of pediatric meningitis including antibiotic choices and dexamethasone. We answer such questions as: what are the test characteristics of the various clinical features of meningitis across various ages? How does one differentiate between meningitis and retropharyngeal abscess on physical exam? How do the Canadian and American guidelines on work up of well-appearing febrile infants compare when to it comes to indications for lumbar puncture? Which patients with suspected meningitis require imaging prior to lumbar puncture? Which patients with febrile seizure require a workup for meningitis? How do we best interpret the various CSF tests to help distinguish between viral and bacterial meningitis? What are the indications and timing of administering dexamethasone in the pediatric patient with suspected meningitis? and many more....

Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul
Written Summary and blog post by Matthew McArthur, edited by Anton Helman July, 2024
Cite this podcast as: Helman, A. Comeau, J. MacPhee, S. Pediatric Meningitis Recognition, Workup and Management. Emergency Medicine Cases. July, 2024. https://emergencymedicinecases.com/pediatric-meningitis-recognition-workup-management. Accessed February 2, 2025
Résumés EM CasesWhile pediatric bacterial meningitis is rare, it is predicted to be on the rise due to decreasing vaccination use
Thanks in large part to vaccination programs, meningitis is a rare diagnosis. Its rarity and potential serious sequelae if untreated make it challenging but important to recognize when it occurs. The estimated incidence of bacterial meningitis is only 0.4/100,000 in adolescents but increases to 81/100,000 in neonates with a mortality rate of 20% in infants and 2% in older children. Most pediatric meningitis is caused by an enterovirus. The earlier the diagnosis of bacterial meningitis is made and the sooner treatment is initiated, the better the outcomes. One of the reasons we chose this topic is because there is a trend of decreasing use of childhood vaccinations in the last decade, which experts predict is likely to increase the rates of meningitis from vaccine preventable pathogens including Hemophilus Influenzae, Streptococcus Pneumoniae, Neisseria Meningiditis in the coming years. 
Understanding the pathophysiology of and knowing the risk factors for bacterial meningitis helps guide recognition and management
Sequence of steps leading to bacterial meningitis:

Bacterial colonization (most often respiratory tract/oropharynx - bacterial meningitis may be preceded by a viral infection which increase the likelihood of bacterial colonization)
Invasion of bloodstream (risk factors to consider in the pre-test probability of bacterial meningitis include: recent viral illness, smoking history, alcohol use disorder, immune suppression/immune deficiency, no or incomplete vaccinations against S pneumoniae, N meningitides, H influenza)
Survive intravascularly and interact with BBB to penetrate into subarachnoid space (main risk factors are duration and degree of bacteremia, antibiotics that penetrate the BBB are required - see below)
Relative lack of immunity within CSF space, bacterial proliferation and immune/inflammatory response (dexamethasone for inflammation - see below)

Topics in this EM Quick Hits podcast
Megan Landes on the importance of diagnosing HIV in the ED (1:10)
Jesse McLaren on the failed paradigm of STEMI criteria and ECG tips to identify acute coronary occlusion (22:33)
Anand Swaminathan on evidence for non-invasive airway management in the poisoned patient (29:25)
Brit Long and Hans Rosenberg on the identification, workup and management of spontaneous bacterial peritonitis (37:32)
Matt Poyner on the most lucrative side-gig, DIY investing (46:34)


Podcast production, editing and sound design by Anton Helman
Written summary & blog post by Shaila Gunn & Megan Landes, edited by Anton Helman
Cite this podcast as: Helman, A. Landes, M. McLaren, J. Swaminathan, A. Long, Rosenberg, H. B. Pointer, M.  EM Quick Hits 57 - HIV diagnosis, Failed Paradigm of STEMI Criteria, Poisoned Patient Airway Management, Spontaneous Bacterial Peritonitis, DIY Investments. Emergency Medicine Cases. June, 2024. https://emergencymedicinecases.com/em-quick-hits-june-2024/. Accessed February 2, 2025.
HIV diagnosis and why it's important in EM

HIV is a commonly missed diagnosis. 1 in 7 HIV+ Canadians are unaware of their diagnosis.
For many people at high risk for HIV, the ED is the only accessible place to get tested. An early diagnosis saves lives by initiating early treatment, thus preventing transmission of the infection by 96% (undetectable = untransmissible).
In whom should we consider testing for HIV in the ED?
1a) Major risk factor for HIV - persons who inject drugs (PWID), indigenous people, and people from endemic areas, suspect TB plus
1b) Clinical condition associated with HIV



* Acute retroviral syndrome: an influenza like illness that happens within the first month of seroconversion. Influenza like illness + risk factor = think HIV.
* Opportunistic infections: may include angular cheilitis, aphthous ulcers, oral candida, and hairy leukoplakia (from left to right in image below). The clues are in the mouth, so examine it! Be suspicious of unexpected weight loss and chronic diarrhea.



Opportunistic infections of the mouth in people with HIV, from left to right, angular cheilitis, aphthous ulcers, oral candida, and hairy leukoplakia



* AIDS defining illnesses: severe wasting, esophageal candida, and PCP/PJP pneumonia (may be identified by characteristic 'bag wing' bilateral pneumonia) are the most common. Also consider unusual CNS presentations including altered mental status, meningitis, and encephalitis.



2.Anyone who requests a test
3. Unexplained pancytopenia

* Other risk factors for HIV: People presenting with any STI,  people with multiple sexual partners and people with recurrent presentations for post-exposure prophylaxis (PEP).

=> Integrating IVDU and sexual history into your history for all adult patients presenting with a fever will improve your diagnostic pick up rate of HIV
Testing should be done through whatever means you have access to at your institution. This may include point of care testing, self-testing with oral swabs, or lab-based antigen-antibody tests. Note, if the test if negative and you have high suspicion, repeat testing in 1-3 months as false negatives are common early in the natural history of HIV.
Other illnesses to be aware of in HIV+ patients

* Immune reconstitution inflammatory syndrome: This is a paradoxical worsening of any pre-existing infectiou...