2025

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SGEM#473: Did You Ever Have To Make Up Your Mind – Midazolam or Ketamine for Acute Agitation in the Pre-Hospital Setting

The Skeptics' Guide to EM

Reference: Muldowney et al. A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting. Ann Emerg Med. 2025 Date: April 24, 2025 Guest Skeptic: Dr. Howie Mell received his Medical Doctorate (MD) from the University of Illinois at Chicago, College of Medicine at Rockford. Prior to that, he received a Master of Public Health (MPH) degree emphasizing Environmental and Occupational Health from the University of Illinois at Chicago, School

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Post-Tonsillectomy Hemorrhage: A Three-Pronged Approach

ACEP Now

Its 4 a.m., and youre three hours from the nearest tertiary care center. A young woman, 13 days post-tonsillectomy, comes into your rural emergency department (ED) coughing up blood. On exam, you see bright red blood trickling down her left tonsillar fossa. Her vital signs are normal, except for a heart rate of 115 bpm. Its going to take time to get her to a tertiary center.

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Ambulance Deserts

International Journal of Paramedicine

The growing prevalence of ambulance deserts—geographic areas where residents live more than 25 minutes from the nearest ambulance station—poses a critical threat to health equity and public safety in the United States. Rooted in systemic underinvestment, workforce shortages, and fragmented policies, these deserts disproportionately affect rural and underserved communities, where response times can exceed 30 to 60 minutes during life-threatening emergencies.

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The Future of Autonomous EMS Delivery Systems

JEMS

JEMS Training JEMS Events Job Board EMS Product Center EMS Airway EMS Rig Podcasts Webcasts Subscribe Patient Care Emergency Medical Care Emergency Trauma Care Cardiac & Resuscitation Airway & Respiratory EMS Operations Flight Ambulance Operations Ground Ambulance Operations Rescue Operations EMS Equipment & Gear Mobile Integrated Health and Community Paramedicine Mental Health and Wellness EMS Training Paramedic Training EMT Training Admin/Leadership EMS Recruitment & Retention

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Torsade in a patient with left bundle branch block: is there a long QT? (And: Left Bundle Pacing).

Dr. Smith's ECG Blog

By Smith with comments from our electrophysiologist, Rehan Karim. (And of course Ken's comments at the bottom) An elderly obese woman with cardiomyopathy, Left bundle branch block, and chronic hypercapnea presented hypoxic with altered mental status. She was intubated. Bedside cardiac ultrasound showed moderately decreased LV function. CT of the chest showed no pulmonary embolism but bibasilar infiltrates.

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Trauma Stewardship: Caring for the Caregivers in EMS

The EMS Educator

How do EMS clincians process the trauma they witness dailyand how can they be better supported? In this episode of The EMS Educator podcast, hosts Rob Lawrence, Hilary Gates and Maia Dorsett explore the critical topic of trauma stewardship with guest Ronit Reguer, the first behavioral health coordinator for DC Fire and EMS. Together, they unpack the challenges of emotional resilience, the importance of proactive mental health care, and the cultural shifts shaping the future of first responder su

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JC: Do physician led prehospital teams improve outcomes?

St. Emlyn's

St.Emlyn's - Emergency Medicine #FOAMed This article explores the impact of physician-led interprofessional pre-hospital teams on survival and mortality outcomes for critically ill and injured patients. Drawing on a systematic review and meta-analysis, it examines the evidence, evaluates key benefits, and critically appraises the limitations. The discussion highlights the potential of this model to enhance pre-hospital emergency care while addressing challenges in implementation across dive

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Emergency Evidence Updates – May 2025

The Bottom Line

Skip to content Twitter Google+ Facebook Reddit RSS The Bottom Line A compendium of critical appraisals in Intensive Care Medicine research and related specialties Home About Us Summaries Intensive Care Medicine Emergency Medicine Peri-operative Medicine Blog News EBM Editorial Submit a review Wessex ICS You are here: Home Blog Emergency Evidence Updates – May 2025 Emergency Evidence Updates – May 2025 27 June 2025 Rebecca Howes Blog , Evidence-based Medicine Leave a comment Tweet Ra

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[Paramedic Chiefs of Canada] Tariffs and the Impacts to Paramedic Services

Paramedic Chiefs of Canada

PCC Members, As Canadians face the disruption and uncertainty of our countrys financial stability as a result of the trade war initiated earlier this week, we collectively have concerns impacting our personal situations as well as our professional role as leaders delivering critical health services to Canadians. With the true impact of the current and any future tariffs and counter-tariffs notyetclearly understood, what is certain is that the downstream effect will significantly challengeparamed

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ECG Pointers: A Dynamic Approach to Tachydysrhythmias Part 4

EMDocs

Authors: Lloyd Tannenbaum, MD (EM Attending Physician, Geisinger Wyoming Valley, PA); Mai Saber, DO (EM Attending Physician, Hackensack University Medical Center, NJ); Rachel Bridwell, MD (EM Attending Physician, Charlotte, NC) // Reviewer: Brit Long, MD (@long_brit) Hello and welcome back to ECG Pointers, a series designed to make you more confident in your ECG interpretations.

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Symptomatic Bradycardia: The Epinephrine Era Ends

Handtevy

It’s official: the 2025 ILCOR Pediatric Life Support guidelines have removed the recommendation to administer cardiac arrest dose epinephrine for symptomatic bradycardia in children. Hallelujah For years, the use of epinephrine in bradycardic pediatric patients receiving CPR has been embedded in resuscitation algorithms. But as many of you have long recognized, evidence—not tradition—should guide our protocols.

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Airway Considerations in Prehospital Cardiac Arrest

ACEP Now

Endotracheal intubation (ETI) has long been defined as the “gold standard” for airway management to secure the airway. It is historically the “definitive airway” and, in the setting of cardiac arrest, a successfully placed and confirmed endotracheal tube connected to a well-managed ventilator removes the bulk of airway and breathing concerns from the Basic Life Support (BLS)/ Advanced Cardiovascular Life Support (ACLS) algorithms.

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Integrating community paramedicine topics into degree-level paramedic education programs

International Journal of Paramedicine

Introduction: Community paramedicine programs address the needs of diverse and often underserved communities and individuals with varied social and chronic disease needs. Community paramedics have adopted knowledge, skills, and behaviours characteristic of primary healthcare professionals. Paramedics often lack access to higher education that enables autonomous practice alongside other health professionals.

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The Silent Struggle: Addressing the Mental Health Epidemic in EMS

JEMS

Let’s shed light on the mental health crisis among EMS providers, emphasizing the high rates of PTSD, depression, anxiety and suicide within the profession.

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When Every Second Counts

Pulsara

How Metropolitan EMS and Baptist Health Medical Center worked together to achieve a remarkable outcome for one stroke patient When a woman in Little Rock, Arkansas, began showing signs of a severe stroke on her birthday, what followed was a powerful example of how early recognition, coordinated teamwork, and real-time communication can lead to an extraordinary outcome.

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SAEM Clinical Images Series: Spontaneous Eye Luxation

ALiEM

A 55-year-old female presented with the complaint of my right eye popped out. Symptoms started approximately seven hours prior to arrival and progressive, severe pain eventually prompted her visit to the ED. This happened once 10 years ago, requiring reduction in the ED. The patient denied preceding trauma, rubbing her eyes/eye-lids, or any history of thyroid disease.

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Maintenance of Prehospital Anaesthesia in Trauma Patients: Variability in Practice

St. Emlyn's

St.Emlyn's - Emergency Medicine #FOAMed Explore the variability in maintaining prehospital anaesthesia for trauma patients in this comprehensive summary of a multinational survey. With insights into drug protocols, administration methods, and governance, the article highlights challenges and opportunities for standardisation in prehospital care.

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Toward a Better Understanding of “Availability”

High Performance EMS

Many agencies simply default units that are on duty with a general “available” status whenever they are not in some active phase of a specific response. The common impression is that this is an unproductive time embodying only the cost of preparedness. Increasing pressure on limited EMS resources suggests benefits to a more detailed appreciation of the precise nature of any unit or crew in this generic status.

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Protocol Change

Peter Canning

When I started as a paramedic in Hartford in January of 1995, I was given a 100-page protocol book to memorize. There were fewer than 50 protocols in the book, along with pages for 24 medications and 8 procedures. The book was approved by the two largest hospitals in Hartford. Looking through the book today, it is truly an antiquated. For instance, there was no protocol for stroke or STEMI.

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Episode 204: Necrotizing Fasciitis

Core EM

We discuss the recognition and treatment of necrotizing fasciitis. Hosts: Aurnee Rahman, MD Brian Gilberti, MD [link] Download Leave a Comment Tags: Critical Care , General Surgery Show Notes Table of Contents 0:00 – Introduction 0:41 – Overview 1:10 – Types of Necrotizing Fasciitis 2:21 – Pathophysiology & Risk Factors 3:16 – Clinical Presentation 4:06 – Diagnosis 5:37 – Treatment 7:09 – Prognosis and Recovery 7:37 – Take Home points Int

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Agitated with a head injury: Will Ketamine make it worse?

NAEMSP

Author : Katie Stuart MD; Washington University Emergency Medicine Residency Editors : Sarah Fabiano MD, FACEP, FAAEM & Michael DeFilippo DO You are a second-year emergency medicine resident physician doing a ride along with a helicopter-based EMS (HEMS) agency. You are dispatched to the scene of a golf cart versus tree. The air crew successfully identifies a safe landing place near where the ambulance is staged.

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All you need to know about Adrenaline

Don't Forget the Bubbles

You are working in the paediatric emergency department overnight, and the resus nurses are checking the emergency drugs during their daily checks. The department is quiet, and one of the newly qualified nurses asks you to explain why there are so many different concentrations of adrenaline and how they work. On his last shift, he noticed a different dose for croup vs. cardiac arrest.

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Case Report: Rapid Diagnosis of Acute Aortic Dissection with POCUS

ACEP Now

A 55-year-old woman with medical history of well-controlled hypertension and renal cell carcinoma, status post-partial nephrectomy, presented to the emergency department (ED) with sudden-onset, 10-out-of-10 chest pain and pressure. She arrived via emergency medical services and was noted to be hypotensive with several blood pressure readings in the 60s/40s mm Hg range en route.

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Strengthening EMS in Malawi

International Journal of Paramedicine

Background: Malawi has no country-wide emergency medical services, with prehospital care majorly provided by laypersons. Transport is typically provided by private car or taxi with less than 2% of emergency patients receiving transport by ambulance. Zomba Private Ambulances is currently the only private ambulance group operating in south-eastern Malawi.

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Unpacking CDC Guidelines on Masks, Vehicle Ventilation and Post-Exposure Protocols

JEMS

JEMS Training JEMS Events Job Board EMS Product Center EMS Airway EMS Rig Podcasts Webcasts Subscribe Patient Care Emergency Medical Care Emergency Trauma Care Cardiac & Resuscitation Airway & Respiratory EMS Operations Flight Ambulance Operations Ground Ambulance Operations Rescue Operations EMS Equipment & Gear Mobile Integrated Health and Community Paramedicine Mental Health and Wellness EMS Training Paramedic Training EMT Training Admin/Leadership EMS Recruitment & Retention

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emDOCs Podcast – Episode 122: Performing Under Pressure

EMDocs

Today on the emDOCs cast Brit Long interviews Zachary Aust on a performing under pressure. Episode 122: Performing Under Pressure Understanding Crisis Performance Myth of the “Clutch Performer” – debunked High pressure reduces performance Data shows we fall to the level of our training No one is immune— everyone is affected How Our Brain and Body Reacts Threat vs.

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SAEM Clinical Images Series: A Curious Case of Anisocoria

ALiEM

A 3-month-old male with no past medical history was brought to the emergency department for evaluation of newly asymmetric pupils. The infant appeared to be asymptomatic per parents, without any behavior changes or associated symptoms noted. The patients mother noticed her sons left pupil was dilated and unresponsive to light the morning of presentation.

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Hurricane Season Readiness: 10 Essential Steps for First Responders

Pulsara

The 2025 hurricane season has arrived, and emergency professionals are watching the forecasts closely. The National Oceanic and Atmospheric Administration (NOAA) predicts an above-normal Atlantic hurricane season this year with increased chances of severe storm activity. This is a serious concern for EMS, fire, and public safety agencies, especially in communities still recovering from the loss of life and property caused by Hurricanes Helene and Milton.

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Anaphylaxis in the ED: Epinephrine First, Questions Later

EM Board Bombs

-Case- A 31-year-old woman rushes into the ED with her lips swelling and a rapidly spreading rash. She was stung by a bee while jogging, and within minutes developed hives, throat tightness, and shortness of breath. On arrival, her vitals are notable for HR of 118 bpm, a BP 82/50 mmHg, and she’s wheezing audibly. She’s anxious, flushed, and says, “I feel like I can’t breathe.

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[Paramedic Chiefs of Canada] Impacts to Paramedic Services Amid Tariff Disputes

Paramedic Chiefs of Canada

PCC Members, Further to the bulletin issued on March 6, 2025 Member Messages regarding the impact of tariffs and counter-tariffs on equipment, supplies and services used to provide paramedic services across Canada, we want to provide an update on our advocacy activities and share resources to members as our messaging is expanding across government and the public.

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Episode 209: Blast Crisis

Core EM

We dive into the recognition and management of blast crisis. Hosts: Sadakat Chowdhury, MD Brian Gilberti, MD [link] Download Leave a Comment Tags: Hematology , Oncology Show Notes Topic Overview Blast crisis is an oncologic emergency, most commonly seen in chronic myeloid leukemia (CML). Defined by: >20% blasts in peripheral blood or bone marrow.

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Evidence Based Guidelines for Fatigue Risk Management in Emergency Medical Services

Irish College of Paramedics

Workplace fatigue is a common complaint among shift workers. Emergency Medical Services (EMS) personnel work shifts and deliver emergent health care to the acutely ill and injured on the roadside, in patients homes, and other environments. They must deliver this care while under significant time pressure and stress. Fatigue is a threat that is often overlooked by EMS leadership and personnel as just part of the job.

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The SWAST Feedback Project

Don't Forget the Bubbles

Building educational networks through case feedback: Delivering bespoke, on-demand prehospital paediatric emergency clinical case follow-up Prehospital clinicians in the UK—and globally—often report feeling anxious and underconfident when caring for paediatric patients. While there is widespread recognition that focused education is key to addressing this, there remains little agreement on the most effective way to deliver it.

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Toxin-Induced Hypotension Treatment Tips

ACEP Now

Acute toxic ingestions are a common reason for presentation to the emergency department (ED) and clinical scenarios range from benign accidental ingestions to large overdoses resulting in hemodynamic instability. A wide variety of toxins cause hemodynamic instability, from cardiotoxic medication to plant-based toxins, and even inhaled substances. 1 In the ED, the most important consideration in management of these toxicities involves decontamination, evaluating for airway protection, and managin

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A prehospital protocol for geriatric agitation

International Journal of Paramedicine

Approximately 10% of geriatric patients (adults over the age of 65) transported via ambulance will have a mental status altered from baseline, otherwise known as delirium. Many of these patients will be agitated, posing a management challenge for EMS practitioners. Existing protocols for delirium in the pre-hospital setting were designed for younger adults, who have different etiologies and different levels of tolerance for medications than most older adults.

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ESO 2025 EMS Index Reveals Decrease in Opioid Overdose Calls

JEMS

The eighth annual index adds metrics on obstetric emergencies, invasive airway confirmation and more.

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US Probe: Velocity Time Integral (VTI) in Sepsis Management

EMDocs

Author: Jude Luke (EM Resident Physician, NYU/Bellevue Hospital) and Jonathan Warren, MD (Clinical Ultrasound and EMS Fellow, Department of Emergency Medicine , Harbor-UCLA Medical Center) // Reviewed By: Steve Field, MD; Brit Long, MD (@long_brit) Case A 65-year-old female with a history of heart failure with reduced ejection fraction, type 2 diabetes, and hypertension presents to the emergency department (ED) with fever, altered mental status, and weakness.