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In this episode, Sam Ashoo, MD and Dr. Dana Klavansky, MD discuss the March 2026 Emergency Medicine Practice article, Emergency Department Evaluation and Management of Severe Traumatic Brain Injury Introduction & Welcome (0:15) Guest Introduction (0:55) Epidemiology of Severe TBI (2:37) Pathophysiology: Primary vs. Secondary TBI (4:24) Types of Hemorrhage and Hematomas (5:25) Classification (7:31) Mild vs. Moderate vs. Severe TBI Impact Loading vs. Inertial […] The post PODCAST: Severe Traumatic Brain Injury witih Dr. Dana Klavansky first appeared on האיגוד הישראלי לרפואה דחופה.

Chris and Wade talk about sepsis. For EMT and AEMT classes, check out IdahoMedicalAcademy.com and use code "Summit" at checkout for 10% off. Welcome to the Basically EMT podcast! We are very excited to be able to bring this new content to all of you and hope that you find it as fun and as informative as we do. With so many outlets for media, it can be hard to find accurate, up-to-date, and digestible material. With basically EMS we hope to be your go to station to listen for basic EMS information. Listen as our highly knowledgeable guests talk about their experiences in the field and share their expertise.The post PODCAST: SEPSIS for EMS first appeared on האיגוד הישראלי לרפואה דחופה.

Japanese Airway Study: Kubo A, Kunitatsu K, Nakashima T, Horitani R, Kajimoto Y, Inoue S, Hironishi M. Association between endotracheal intubation and outcomes of nonshockable out-of-hospital cardiac arrest in Japan. BMC Emerg Med. 2025 Sep 24;25(1):185. doi: 10.1186/s12873-025-01341-6. PMID: 40993541; PMCID: PMC12462024.The post PODCAST: Association between endotracheal intubation and outcomes of nonshockable out-of-hospital cardiac arrest in Japan first appeared on האיגוד הישראלי לרפואה דחופה.

In January, OpenAI, developer of ChatGPT, launched ChatGPT Health, one of many patient-facing generative artificial intelligence (AI) tools in various stages of development.   (opens in new tab) In January, OpenAI, developer of ChatGPT, launched ChatGPT Health. OpenAI   From educating patients on women’s sexual health and hip replacement surgery to generating postoperative instructions and digitizing informed consent, the potential medical applications of generative AI tools for the public are vast. In general, their goal is to increase patients’ comprehension of complex medical information and, in the case of ChatGPT Health, provide personalized information based on individual users’ own data. In the not-too-distant future, some experts predict new AI technologies will be able to independently make decisions about patient care.   At their most sophisticated, though, these technologies should serve as a “clinician extender,” not a clinician replacer, said cardiologist Haider Warraich, MD, a program manager at the US government’s Advanced Research Projects Agency for Health (ARPA-H) who previously helped shape digital health and AI policy at the US Food and Drug Administration (FDA).   “I hate the term AI doctor,” Warraich said. “There’s a lot more to me than what these technologies can do.”   There’s more than one reason why using an AI chatbot for health advice is not the same as consulting a physician. Recent studies have raised questions about the accuracy of health information provided by chatbots, and physicians and consumers have expressed concerns over the sharing of personal medical data with large language models (LLMs) that aren’t covered by the Health Insurance Portability and Accountability Act (HIPAA).   ChatGPT Health failed to properly triage the most and the least serious cases in what might be the first study to assess the new tool’s performance, according to an accelerated preview of the article published in late February. The authors, who tested the chatbot using vignettes written by physicians, noted that under-triage of emergency conditions may delay or preclude lifesaving treatment, while over-triage of nonurgent presentations may increase health care utilization.   But LLMs hold promise as a way of expanding access to medical expertise or, at the very least, preparing patients to make the best use of visits with their physicians. “There’s a reason patients want to use these models,” said radiation oncologist Danielle Bitterman, MD, clinical lead for data science and AI at Mass General Brigham. “It’s so hard to access health care right now.”   ChatGPT vs ChatGPT Health   Of the 800 million users of ChatGPT each week, 1 in 4 seek health-related information, according to Nate Gross, MD, MBA, who leads health care strategy at OpenAI, which developed the chatbot.   “We said, ‘Hey, let’s build some differences to the product to make it a more contextually aware experience,’” as well as one with additional privacy and security connections, he recalled.   Users of “vanilla” ChatGPT, as Gross describes the forerunner of ChatGPT Health, can upload a physician’s note or copy laboratory results from their patient portal, he explained, but those bits of information lack context. “Just uploading a really short doctor’s note could be interpreted very differently if you’re age 20 or age 70.”   ChatGPT Health, on the other hand, invites users to upload all their personal health information, including laboratory test and imaging results as well as data collected by their Apple watch.   Although OpenAI consulted with hundreds of physicians from around the world to improve its models, ChatGPT Health is not designed to play doctor, Gross emphasized.   “We train our models specifically to guide patients to health care professionals for diagnosis and treatment,” he said. “We’re looking to give people information, not tell them if they’re sick, not tell them if they’re healthy. We’re a partner to the health care system in that regard.”   By late February, ChatGPT Health was not yet available to all comers; prospective users could add their name to a waitlist for using the chatbot. OpenAI declined to say how many people have used ChatGPT Health so far.   Privacy is one of users’ main concerns about ChatGPT Health and other LLMs that allow people to upload personal health information.   Elon Musk recently suggested in an X post that “[y]ou can just take a picture of your medical data or upload the file to get a second opinion from Grok,” an AI chatbot developed by his company, xAI.   Commenters were aghast at the idea. One decided to ask Grok’s opinion and posted its reply: “Grok is not HIPAA compliant, and we strongly advise against uploading sensitive medical data.”   Gross acknowledged that ChatGPT Health isn’t HIPAA compliant either. That’s not due to negligence, he pointed out, but because ChatGPT Health, like Grok, is not an entity covered by HIPAA, such as a physician or health insurance plan, or a business associate of a covered entity.   “They are not held to the same legal requirements that doctors and health care institutions are,” Bitterman said of the AI companies.   ChatGPT Health “is building on a lot of very proprivacy protections that ChatGPT already had, with additional layers of protection,” Gross said. “We wanted to set a really high bar.” For example, he noted, OpenAI will not include any ChatGPT Health conversations among the data it uses to train the LLM. And, he explained, as with ChatGPT, ChatGPT Health users can opt to make chats temporary, meaning they won’t appear in their history and ChatGPT Health won’t save them.   Even so, “those assurances may not be worth that much if companies get sold,” pointed out David Liebovitz, MD, codirector of the Institute for Artificial Intelligence in Medicine’s Center for Medical Education in Data Science and Digital Health at the Northwestern University Feinberg School of Medicine.   For now, he said, if patients asked him whether he thought they should try ChatGPT Health, he’d probably suggest “they could wait a little bit longer, when there could be more privacy-related tools.”   The Complete Picture?   Even if they want to, chatbot users—especially clinically challenging patients with long, complex medical histories—can’t always upload all their medical records, Bitterman pointed out.   “It’s very hard to ensure that you have all your medical records,” she said. “Those are the missing pieces that make clinical practice hard.”   Gross acknowledged that “our health care system is very fragmented.” But, he said, if patients forget to upload records from a particular physician or hospital, their physicians’ most recent notes likely will at least mention them.   Even patients who have all the relevant information may not paint a complete picture of their situation when interacting with LLMs, concluded research published in February.   The study, led by the Oxford Internet Institute in the UK, tested whether LLMs could help individuals without medical training identify underlying conditions and choose a course of action in 10 physician-drafted health scenarios. Researchers randomly assigned 1300 participants to receive assistance from 1 of 3 LLMs or, to serve as the control, a source of their choice, which was typically Google. The 3 LLMs were ChatGPT-4o, Meta’s Llama 3, and Command R+, which was developed by Cohere, a Canada-based company.   On average, when the scientists presented the vignettes directly to the LLMs, bypassing human interaction, the chatbots correctly identified the condition 95% of the time and the appropriate course of action 56% of the time.   But when study participants presented the vignettes to the same LLMs, the chatbots correctly identified relevant conditions only about a third of the time and the appropriate course of action less than 44% of the time. The LLMs performed no better than Google did in the control group.   “The limiting factor wasn’t just the model’s medical knowledge,” coauthor Rebecca Payne, MBBS, PhD, MPH, a general practitioner at the North Wales Medical School, Bangor University, said in an email. “It was the human-AI communication loop: people providing incomplete information, the model misinterpreting key details, and, importantly, people failing to carry forward a relevant diagnostic suggestion that the model did raise during the exchange.”   Whether using an LLM or Google, study participants “tended to underestimate the severity in the vignettes we tested,” Payne said. “That raises the risk that some users may feel falsely reassured or may delay seeking care.”   Payne’s findings didn’t surprise Bitterman. “With these chatbots, it’s incumbent on the user to know what they need to provide to the model to get the best information,” she said. “Having that kind of clinical nuance requires a lot of on-the-ground training,” not just the LLMs’ training on medical literature and textbooks.   The advice she gives to patients: “Don’t take immediate action just based on what you find online. We can discuss it together.”   Shorter and Simpler   The result could be deadly if, say, a chatbot mistakenly told a user that they didn’t need to go the emergency department because their chest pain was due to indigestion, not a heart attack.   That’s why Payne advises patients to use chatbots only for low-stakes support, such as explaining medical terms, preparing questions for a clinician, and summarizing what they’ve been told. “LLMs currently perform best as ‘assistants/secretaries’ that help organize known information rather than generate high-stakes clinical interpretations,” she said.   Physicians are working on a number of generative AI applications for more focused, lower-stake purposes.   For urologist Gio Cacciamani, MD, the diagnosis of a loved one with a serious disease unrelated to his specialty gave him a taste of what patients face when trying to decipher scientific information.   “When it comes to something outside my field, it’s very challenging to read,” said Cacciamani, director of the Artificial Intelligence Center for Surgical and Clinical Applications in Urology at USC’s Keck School of Medicine. “That situation opened my eyes.”   Cacciamani discovered 2 types of medical information online—either “extremely readable but not certified,” such as blog posts, or “peer-reviewed, certified, but not readable at all,” mainly publications in scientific journals.   Generative AI “has the potential to bridge long-standing gaps between certified medical knowledge and patient understanding,” Cacciamani and coauthors noted in a commentary published in February.   Using the retrieval-augmented generation, or RAG, technique, which trains the LLM with a medically verified knowledge base, he developed a new tool that can translate and summarize abstracts and full articles. More than 6000 people have turned to Pub2Post, and some medical journals are using it for their social media posts, Cacciamani said.   Antonio Forte, MD, a plastic surgeon at the Mayo Clinic in Jacksonville, Florida, used RAG to develop an LLM virtual assistant for postoperative instructions.   Patients often are discharged after surgery while still experiencing the residual effects of anesthesia or painkillers, making it difficult to remember postoperative instructions, Forte said. And, he added, they frequently misplace printouts of the information. “That’s why we thought, ‘What if we got patients the ability 24/7 to have access to high-quality, medically verified information?’”   Using simulated patient interactions, testing the virtual assistant demonstrated strong technical accuracy, safety, and clinical relevance, albeit at a relatively high 11th-grade reading level, Forte and his coauthors recently reported.   And Bitterman has tested the ability of ChatGPT-4o and Llama 3.2-8B to answer patients’ questions about clinical trials with the goal of simplifying informed consent forms. In a recent study, she and her coauthors found that ChatGPT-4o was significantly more reliable and safer that Llama 3.2-8B in answering these queries.   Federal Initiatives   In January, 2 federal agencies, both part of the US Department of Health and Human Services, launched initiatives focusing on digital health tools for patients with common, chronic conditions. One is designed to evaluate a regulatory pathway for digital health tools including LLMs, and the other aims to spur the development of an LLM for patients with heart failure.   The FDA, working with the Center for Medicare & Medicaid Innovation, announced the Technology-Enabled Meaningful Patient Outcomes (TEMPO) for Digital Health Devices Pilot.   According to the FDA, the voluntary pilot will evaluate a new enforcement approach “that supports digital health devices intended for use to improve patient outcomes in cardio-kidney-metabolic, musculoskeletal, and behavioral health conditions.”   The FDA has not yet authorized any LLM, Warraich said. Generative AI applications such as LLMs “present a unique challenge because of the potential for unforeseen, emergent consequences,” according to a Special Communication he coauthored in JAMA in 2024.   Today, Warraich is leading a new ARPA-H initiative whose goal is the development of new LLM systems that are ready for submission to the FDA within 2 years for authorization as medical devices. The Agentic AI-Enabled Cardiovascular Care Transformation (ADVOCATE) program “aims to transform advanced cardiovascular disease management with an agentic AI system that can provide 24/7 holistic clinical care.”   “I believe that as AI presents an opportunity to fundamentally transform what it means to be a clinician, a patient, and the relationship between them, cardiology will be at the tip of the spear…,” Warraich noted in an opinion piece published in February in the Journal of the American College of Cardiology.   The first use for technologies developed through ADVOCATE will be providing care for patients with congestive heart failure. If a patient is feeling short of breath, for example, the technology will decide if the patient should go to the emergency department and whether they might need a new prescription or a higher dose of a current medication, Warraich explained. Along with developing AI agents that can be trusted to make such changes autonomously, ADVOCATE will also support the creation of a supervisory AI “overseer” to monitor the safety and effectiveness of clinical AI agents after they’ve been deployed by health systems.   Given that ChatGPT is only 3 years old, the rapid development of new generative AI applications for patient use may seem like science fiction. As Bitterman said, “This is so far beyond what I would have predicted 5 years ago.”   Article Information Published Online: March 6, 2026. doi:10.1001/jama.2026.1122 Conflict of Interest Disclosures: Dr Bitterman reported serving as an associate editor of JCO Clinical Cancer Informatics, Annals of Oncology, and radiation oncology for HemOnc.org. She also reported receiving consulting fees from Inspire Exercise Medicine LLC and honoraria from Harvard Medical School, Med-IQ, and the National Comprehensive Cancer Network and serving as a scientific advisory board member for Blue Clay Health LLC and Mercurial AI. Dr Liebovitz reported receiving research grants from Children’s Hospital of Philadelphia, the FDA, Merck Sharp & Dohme, the National Institutes of Health, the National Science Foundation, and the University of Chicago. He also reported that he has an ownership or investment interest in CodeAccelerate, Dendritic Health AI, KYRAL Inc, and Optima Integrated Health Inc. Dr Cacciamani reported holding equity in EditorAIPro, of which Pub2Post is a product. Dr Forte reported that his research at Mayo has been funded by Dalio Philanthropies, the Gerstner Family Foundation, the Richard M. Schulze Family Foundation, and Schmidt Sciences and that he is a paid medical advisor for OpenEvidence. No other disclosures were reported. The post JAMA PODCAST: Are AI Tools Ready to Answer Patients’ Questions About Their Medical Care? first appeared on האיגוד הישראלי לרפואה דחופה.

Reference: . Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child &amp; Adolescent Health. July 2025 <img loading="lazy" decoding="async" class="size-thumbnail wp-image-18360" src="https://i0.wp.com/thesgem.com/wp-content/uploads/2026/01/Brissett-headshot.png?resize=150%2C150&amp;ssl=1" sizes="auto, (max-width: 150px) 100vw, 150px" srcset="https://i0.wp.com/thesgem.com/wp-content/uploads/2026/01/Brissett-headshot.png?resize=150%2C150&amp;ssl=1 150w, https://i0.wp.com/thesgem.com/wp-content/uploads/2026/01/Brissett-headshot.png?resize=440%2C440&amp;ssl=1 440w, https://i0.wp.com/thesgem.com/wp-content/uploads/2026/01/Brissett-headshot.png?zoom=2&amp;resize=150%2C150&amp;ssl=1 300w" alt="" width="150" height="150" data-recalc-dims="1" aria-describedby="caption-attachment-18360" data-attachment-id="18360" data-permalink="https://thesgem.com/2026/02/sgem504-home-where-i-wanted-to-go-after-anaphylaxis/brissett-headshot/" data-orig-file="https://i0.wp.com/thesgem.com/wp-content/uploads/2026/01/Brissett-headshot.png?fit=988%2C1268&amp;ssl=1" data-orig-size="988,1268" data-comments-opened="1" data-image-meta="{&quot;aperture&quot;:&quot;0&quot;,&quot;credit&quot;:&quot;&quot;,&quot;camera&quot;:&quot;&quot;,&quot;caption&quot;:&quot;&quot;,&quot;created_timestamp&quot;:&quot;0&quot;,&quot;copyright&quot;:&quot;&quot;,&quot;focal_length&quot;:&quot;0&quot;,&quot;iso&quot;:&quot;0&quot;,&quot;shutter_speed&quot;:&quot;0&quot;,&quot;title&quot;:&quot;&quot;,&quot;orientation&quot;:&quot;0&quot;}" data-image-title="Brissett headshot" data-image-description="" data-image-caption="&lt;p&gt;Dr. Kammeron Brissett&lt;/p&gt; " data-medium-file="https://i0.wp.com/thesgem.com/wp-content/uploads/2026/01/Brissett-headshot.png?fit=234%2C300&amp;ssl=1" data-large-file="https://i0.wp.com/thesgem.com/wp-content/uploads/2026/01/Brissett-headshot.png?fit=798%2C1024&amp;ssl=1" /> Dr. Kammeron Brissett Guest Skeptic: Dr. Kammeron Brissett is a pediatric emergency medicine fellow at Children’s National Hospital in Washington, DC. She completed her pediatrics residency and a chief year at Rainbow Babies and Children’s Hospital in Cleveland, Ohio. Her interests include injury prevention, social determinants of health, and advocacy. Case: A 7-year-old boy with a peanut allergy presents to the emergency department (ED) after eating a cookie at a birthday party. Shortly afterwards, he developed hives and wheezing. His parents gave him an epinephrine auto-injector to improve his symptoms. In the ED, he feels much better. His vital signs are normal, and his lungs are clear. He has no other gastrointestinal or cardiovascular symptoms. The parents tell you, “Unfortunately, we’ve been through this before. It’s not the first time he has accidentally eaten something that may have had some peanuts in it. Last time, we sat in the ED for a few hours before going home. It’s been a long day. Can we just go home now?” Background:  Anaphylaxis is a serious, potentially life-threatening systemic allergic reaction with a fast onset. It is a clinical diagnosis that should be considered when: Acute illness with skin/mucosal involvement and either respiratory compromise or reduced blood pressure/end-organ symptoms; or Two or more of the following occurring rapidly after exposure: skin/mucosal involvement, respiratory compromise, reduced blood pressure, or persistent gastrointestinal symptoms; or Reduced blood pressure after exposure to a known allergen for the patient. Early recognition and treatment with intramuscular epinephrine is crucial. Sometimes, even after initial symptom improvement with IM epinephrine, anaphylaxis symptoms can recur even without exposure to the known trigger. This is called a biphasic reaction and can happen up to 72 hours later. The SGEM discussed anaphylaxis and biphasic reactions 13 years ago on SGEM#57. The bottom line was that prolonged observation is likely unnecessary in patients whose symptoms resolve with therapy in the ED. Biphasic reactions are rare and can occur anywhere from 10 minutes up to 6 days. We already have problems with boarding and overcrowding. We can’t keep all patients with anaphylaxis for 6 days. So, when can we send them home? Traditionally, ED observation after anaphylaxis has been around 4 to 6 hours to monitor for biphasic reactions. The Resuscitation Council UK recommends a risk-stratified approach: A patient can be discharged after 2 hours when there’s a good response to a single dose of epinephrine, the symptoms have resolved, the child and family has another epinephrine autoinjector and knows how to use it, and has adequate supervision after discharge. They recommend at least 6 hours of observation if two IM doses of epinephrine were needed or there was a prior biphasic reaction. Finally, they recommend at least 12 hours observation if there was severe respiratory compromise, &gt;2 doses of epinephrine, ongoing allergen absorption, late-night presentation/limited access to care, or difficult access to emergency services. The National Institute for Care and Health Excellence (NICE) is even a bit more conservative, recommending any child under age of 16 with suspected anaphylaxis be admitted. What about in the US? In the United States, the 2023 AAAAI/ACAAI Joint Task Force Practice Parameter (JTFPP) emphasizes individualized, risk-based observation and shared decision-making, noting that risk for biphasic reactions is higher with more severe initial reactions and when &gt;1 dose of epinephrine is required. It also highlights that patients with a prompt, complete, and durable response to epinephrine may not always require activation of EMS or prolonged monitoring, underscoring tailored disposition planning.  Clinical Question: Among children treated with epinephrine for anaphylaxis, what is the timing and incidence of repeat epinephrine that could inform safe observation periods? Reference: . Timing of repeat epinephrine to inform paediatric anaphylaxis observation periods: a retrospective cohort study. Lancet Child &amp; Adolescent Health. July 2025 Population: Children 6 months to 17 years presenting to 31 EDs (30 US, 1 Canada) with an acute allergic reaction treated with epinephrine from 2016 to 2019. Excluded: Transfers from outside facilities, ED medication-induced reactions, missing pre-ED symptom documentation; comorbidities requiring tailored management Intervention: ED observation following the first epinephrine dose and need for additional epinephrine Comparison: Comparisons were made across severity strata (no respiratory/cardiovascular involvement vs respiratory involvement only vs cardiovascular involvement). Outcome: Primary Outcome: Time from first to last epinephrine dose (repeat epinephrine as a proxy for clinically significant ongoing/recurrent reaction). Secondary Outcomes: Biphasic anaphylaxis and non-anaphylaxis, persistent anaphylaxis and non-anaphylaxis, refractory anaphylaxis, other return-care outcomes Trial: Multicenter retrospective cohort Authors’ Conclusions: “A 2-h observation period is probably safe for most children who present to an emergency department with an acute allergic reaction requiring epinephrine. A 4-h observation period might be enough for patients with cardiovascular involvement who appear well.”  Quality Checklist for Observational Study: &nbsp; Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Unsure Was the outcome accurately measured to minimize bias?  Unsure Have the authors identified all-important confounding factors? Unsure Was the follow-up of subjects complete enough? Unsure How precise are the results? Unsure Do you believe the results? Yes Can the results be applied to the local population? Yes Do the results of this study fit with other available evidence? Yes Funding of the Study: National Center for Advancing Translational Sciences and The National Institute of Allergy and Infectious Diseases of the National Institutes of Health. The funders had no role in study design, data collection, data analysis, interpretation, or writing of paper. Two of the authors report receiving consultant fees. One is on the advisory board and gets stock options from biotech companies and royalty fees from the publisher. Results: They included 5,641 eligible children with a median age of 7.9 years, with slightly more males (56%). 4956 (88%) fulfilled the National Institute of Allergy and Infectious Diseases and Food Allergy and Anaphylaxis Network criteria for anaphylaxis. In that group, 1.5% met criteria for biphasic anaphylaxis and 10.7% had persistent anaphylaxis. 4.7% received repeat epi after 2 hours from initial dose. 1.9% received repeat epi dose after 4 hours. Patients with cardiovascular involvement had higher rates of biphasic anaphylaxis. Key Results: Around 95% of children can be safely discharged after 2 hours of observation without the need for additional epinephrine. Among all patients, 5% received a repeat dose of epinephrine after 115 minutes. There were differences in patients with or without respiratory or cardiovascular involvement. Primary Outcome: In the entire cohort, 4.7% received epi 2 hours after the initial dose, 1.9% received epi after 4 hours, 1.1% received epi after 6 hours, and 0.8% received epi after 8 hours.  Secondary Outcomes:  86 (1.5%) had biphasic anaphylaxis 236 (4.2%) had biphasic non-anaphylactic allergic reactions 605 (10.7%) had persistent anaphylaxis 1400 (24.8%) had persistent non-anaphylactic allergic reactions 118 (2.1%) had refractory anaphylaxis <img loading="lazy" decoding="async" class="aligncenter size-full wp-image-4170" src="https://i0.wp.com/thesgem.com/wp-content/uploads/2015/04/Screen-Shot-2015-04-25-at-3.11.12-PM.png?resize=889%2C162&amp;ssl=1" sizes="auto, (max-width: 889px) 100vw, 889px" srcset="https://i0.wp.com/thesgem.com/wp-content/uploads/2015/04/Screen-Shot-2015-04-25-at-3.11.12-PM.png?w=889&amp;ssl=1 889w, https://i0.wp.com/thesgem.com/wp-content/uploads/2015/04/Screen-Shot-2015-04-25-at-3.11.12-PM.png?resize=300%2C54&amp;ssl=1 300w" alt="" width="889" height="162" data-recalc-dims="1" data-attachment-id="4170" data-permalink="https://thesgem.com/2015/04/sgem117-diarrhea-hard-to-spell-easy-to-smell-and-easy-to-cause-with-iv-antibiotics/screen-shot-2015-04-25-at-3-11-12-pm/" data-orig-file="https://i0.wp.com/thesgem.com/wp-content/uploads/2015/04/Screen-Shot-2015-04-25-at-3.11.12-PM.png?fit=889%2C162&amp;ssl=1" data-orig-size="889,162" data-comments-opened="1" data-image-meta="{&quot;aperture&quot;:&quot;0&quot;,&quot;credit&quot;:&quot;&quot;,&quot;camera&quot;:&quot;&quot;,&quot;caption&quot;:&quot;&quot;,&quot;created_timestamp&quot;:&quot;0&quot;,&quot;copyright&quot;:&quot;&quot;,&quot;focal_length&quot;:&quot;0&quot;,&quot;iso&quot;:&quot;0&quot;,&quot;shutter_speed&quot;:&quot;0&quot;,&quot;title&quot;:&quot;&quot;,&quot;orientation&quot;:&quot;0&quot;}" data-image-title="Screen Shot 2015-04-25 at 3.11.12 PM" data-image-description="&lt;p&gt;talk nerdy&lt;/p&gt; " data-image-caption="" data-medium-file="https://i0.wp.com/thesgem.com/wp-content/uploads/2015/04/Screen-Shot-2015-04-25-at-3.11.12-PM.png?fit=300%2C54&amp;ssl=1" data-large-file="https://i0.wp.com/thesgem.com/wp-content/uploads/2015/04/Screen-Shot-2015-04-25-at-3.11.12-PM.png?fit=889%2C162&amp;ssl=1" /> Diagnosis of Anaphylaxis  We mentioned that anaphylaxis is a clinical diagnosis, but it’s not always clear-cut. In this retrospective review, the authors used ICD-10 codes and chart reviews to determine whether patients experienced anaphylaxis. They included patients who were treated with intramuscular, subcutaneous, or intravenous epinephrine. Potential biases include selection bias, information bias, and misclassification bias. Not all the patients included in this study actually met criteria for anaphylaxis, which is acknowledged by the authors. Anaphylaxis Practice Guideline update in 2023 states, “treatment with epinephrine or clinical response to epinephrine should also not be used as a surrogate marker to establish a diagnosis of anaphylaxis because there are many cases in which patients receive epinephrine for milder reactions.” Some of these patients were included because authors reported that “the administration of epinephrine might have mitigated reaction progression.” Appendix Table 3, which examines interrater reliability for agreement on anaphylaxis identification, reports kappa values ranging from 0.68 to 0.76, indicating substantial agreement but not perfect agreement. Repeat Epinephrine  The primary outcome for this study was the time from first to last administration of epinephrine. We must be careful and state that this is not the equivalent of a biphasic reaction. The decision to administer a repeat dose of epinephrine is also not always clear-cut. It is pragmatic. The clinician may have decided to administer another dose of epinephrine despite the patient not meeting the exact definition of anaphylaxis or a biphasic reaction. Epinephrine may have been administered because the child exhibited concerning signs or symptoms. For example, if a child was being observed in the ED after experiencing anaphylaxis and receiving that first dose of epi started saying that his throat was feeling weird again, we wouldn’t fault the clinician for choosing to give a second dose of epinephrine, but we just wouldn’t know if the child really needed it. Confounding  Any observational study is at risk of confounding. One example we can see is if we look at Figure 3, it appears that the pre-emergency administration of epinephrine is a factor that increases the odds of repeat administration of epinephrine. This is somewhat counterintuitive, as early recognition of anaphylaxis and administration of epinephrine should be beneficial. Instead, this may indicate disease severity. Sicker children received epinephrine in the pre-emergency setting. We can also see something similar with steroid use in the emergency department associated with an increased odds of repeat epinephrine. I do not routinely give corticosteroids for anaphylaxis, given that the likelihood of benefit is low or uncertain. In this study, it may be more indicative of a patient who had a more severe reaction.  Risk of Repeat Epinephrine  The study team a priori defined the observation threshold at which the cumulative incidence of repeat epinephrine dosing increased by &lt; 2% with each 1-hour increase in observation time. It’s not clear where this 2% came from. The paper reports that this “was deemed clinically acceptable because it represented the optimal balance between prolonged observation with limited benefit and the likelihood of biphasic reaction occurring after discharge.” Who decided this? Was it the authors? Was there any input from patients and families? Ultimately, individual clinicians and patients/families may have differing risk thresholds. Bounce Backs for Biphasic Anaphylaxis  Assuming a patient who is discharged from the ED for anaphylaxis with an epinephrine autoinjector returns after a biphasic reaction. Is that necessarily a failure, or should it reflect negatively on the discharging clinician? A significant part of our work in the ED is to provide anticipatory guidance and discuss signs and symptoms that would prompt the patient to return to the ED for care. It can be argued that a patient returning to the ED after discharge for a biphasic anaphylactic reaction who self-administered an epinephrine autoinjector is a good thing. This indicates that our anticipatory guidance was effective and well delivered. Comment on the Authors’ Conclusion Compared to the SGEM’s Conclusion: In general, we agree that most pediatric patients likely do not require prolonged observation in the ED after being treated for anaphylaxis. However, the risk tolerance for a biphasic reaction may vary among patients, families, and clinicians. SGEM Bottom Line: There is no high-quality evidence to support specific observation times in the ED after pediatric anaphylaxis. Engage in shared decision-making and consider your clinical judgement and the patient/family’s values. Case Resolution: The 7-year-old boy improved rapidly after a single dose of IM epinephrine. During his time in the ED, he has no difficulty breathing or changes in hemodynamics. After discussion with the family, you recognize that they are familiar with signs and symptoms of anaphylaxis and know how to administer IM epinephrine auto-injector. You also confirm that the family has another epinephrine auto-injector at home and send them with a prescription for two new auto-injectors. Afterwards, you send them home. Clinical Application: There is limited high-quality evidence on observation times for anaphylaxis. Specifically, there is no evidence that any particular observation period is superior, as biphasic reactions may occur up to 72 hours after the initial event. Institutional guidelines may vary. Remember the pillars of evidence-based medicine. Consider your clinical judgement and the patient or family’s values and preferences. Prior to discharge, ensure the patient feels better, that families and patients are aware of the signs and symptoms of anaphylaxis and biphasic reactions, and that they have another epinephrine autoinjector at home. What Do I Tell the Patient/Family? Sorry that this happened to your son. It’s great that he seems to be feeling better. It sounds like you have found yourself in this situation before. There’s no set amount of time we must observe him in the emergency department. Let’s briefly go over what symptoms to look out for at home and make sure that you can get another epinephrine autoinjector before you leave the ED. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.The post PODCAST: Home Where I Wanted to Go After Anaphylaxis first appeared on האיגוד הישראלי לרפואה דחופה.