PEM CHATT

🎙️ PEM CHATT Podcast: SCAPE (Sympathetic Crashing Acute Pulmonary Edema)
📍 Special Adult EM Edition, Live from the AAENP Conference in Nashville, Tennessee
🎧 Host: Toni Dobson🩺 Guest: Brandy Ganatra, an acute care/ICU nurse practitioner who now works in emergency medicine in Nebraska⏱️ Runtime: About 6 minutes
📝 Episode Summary
In this special adult emergency medicine edition of PEM CHATT, Toni talks with Brandy Ganatra at the AAENP conference about SCAPE, or sympathetic crashing acute pulmonary edema. This is the patient many of us learned to call "flash pulmonary edema." Brandy covers the pathophysiology behind the newer name, how to recognize these patients quickly, why high-dose nitroglycerin is the mainstay of treatment, and why early, aggressive management in the ED can turn a crashing patient around in minutes.
🔑 Key Takeaways
🫁 What Is SCAPE?
SCAPE is sympathetic crashing acute pulmonary edema, the presentation many clinicians know as "flash pulmonary edema."
The term is fairly new. Cardiology often calls it acute decompensated heart failure, but critical care and ED literature increasingly use "SCAPE."
The name points to the pathophysiology, and the pathophysiology points to the treatment. Think bigger than "the lungs are full of fluid."
⚡ The Pathophysiology
A sympathetic surge causes marked peripheral vasoconstriction and a sharp rise in systemic vascular resistance (SVR), which is the afterload the left ventricle has to pump against.
The core need is afterload reduction.
🚨 Recognition: What Does It Look Like?
Extremely tachypneic and tachycardic
Profoundly hypertensive
Hypoxic and tripoding, with severe respiratory distress
Pink, frothy sputum from acute pulmonary congestion
Onset is sudden. "It happens in an instant."
Common history: heart failure or hypertension, sometimes with missed medications
💊 Management: High-Dose Nitroglycerin + Non-Invasive Ventilation
💊 Nitroglycerin is the mainstay of therapy.
Lower doses mostly cause venous dilation, which is why nitro is used for angina and ischemia.
SCAPE calls for high doses. Brandy starts IV nitro at 100 mcg/min and may titrate up to 400 mcg/min.
One sublingual nitro tablet is roughly equal to 80 mcg/min, which puts the IV dosing in perspective. "It's not as scary as we think."
Nitro has a short half-life (about 2–5 minutes). Titrate down instead of turning the drip on and off.
😮‍💨 Support breathing at the same time. Use non-invasive ventilation (CPAP/BiPAP) for the high work of breathing, with the goal of avoiding intubation.
🔀 Do things in parallel, not one at a time. We like our ABCs, but here several interventions need to start together.
📋 A practical sequence:
Give sublingual nitroglycerin.
While you do that, set up non-invasive ventilation.
While you do that, prepare to start IV nitroglycerin, then titrate.
With timely afterload reduction, restored cardiac output, and breathing support, these patients can turn around in 15–20 minutes. 🔄
💎 Final Pearls
👀 Recognize it early, monitor closely, and treat aggressively. Timing and the right management are critical.
🤝 Teamwork is essential.
🚫 Don't get stuck on diagnostics. Don't wait for a chest X-ray to confirm it. Put the POCUS probe on 🔍 and look for volume overload.
💪 Act quickly and with confidence. Current literature supports high-dose nitroglycerin as safe and effective in the ED.
⏰ Episode Timestamps
[00:00] Intro: special adult EM edition from the AAENP conference
[00:18] Meet guest Brandy Ganatra
[00:39] What is SCAPE, and why the new name?
[01:28] How bedside management has changed: getting comfortable with high-dose nitro
[02:41] Recognition: what these patients look like
[03:17] Nitroglycerin dosing: low vs. high dose, starting at 100 mcg/min
[04:00] Nitro safety: short half-life, and sublingual compared with IV
[04:50] Turning patients around in 15–20 minutes
[05:12] Take-home points: teamwork, POCUS, and acting with confidence
[05:44] Closing and disclaimer
⚖️ Disclaimer
Any opinions expressed on today's podcast are solely those of the speaker and do not reflect the opinions or policies of any employer or hospital system.
In many states, advanced practice providers work collaboratively with physicians. One should always be careful to consult with their physician leader when appropriate.
Any cases discussed on this podcast have been de-identified, and details have been changed or omitted to protect patient privacy. Some cases may also represent composites of our clinical experiences, and any resemblance to a specific individual beyond the educational context is unintentional.
This podcast was designed for medical education purposes only. Its speakers have made every effort to provide the most current and evidence-based information. However, that should never replace one's own effort to validate current evidence-based practice before implementing a plan of care. Any pathway or algorithm that we may discuss may not reflect those of your healthcare system. Please be aware that there may be changes based on your geographic location or current employer site.
This podcast was not designed in any way to provide medical advice or treatment plans for patients and their families. If you have a medical concern or an emergency, please be seen by a local medical provider or call 911 for assistance.

21 | Submersion Injuries with Dr. Sarah Lazarus
In this episode of PEM CHATT, host Toni Dobson is joined by pediatric emergency physician Dr. Sarah Lazarus to break down the critical topic of pediatric drowning and submersion injuries. Together, they explore real-world clinical scenarios, debunk common myths, and provide practical guidance for both clinicians and caregivers.
Drowning remains one of the leading causes of death in children, particularly ages 1–4, and even non-fatal events can result in devastating long-term consequences. This episode emphasizes both clinical management and prevention strategies—highlighting how quickly these events occur and how often they happen despite close supervision.
 
🔑 Key Takeaways
Drowning is fast and silent
Often occurs in seconds with little to no splashing or noise
Terminology matters
“Dry drowning” and “secondary drowning” are outdated and misleading
Pathophysiology is respiratory
Water aspiration → surfactant washout → impaired gas exchange → hypoxia
Observation is critical
True aspiration events should be monitored for ~6 hours from the time of incident
Imaging isn’t always helpful
Chest X-rays can lead to unnecessary admissions without changing outcomes
Management is symptom-driven
Asymptomatic → observe
Symptomatic → oxygen support, VBG, imaging, admission
Cardiac arrest cases are severe
Focus on oxygenation, ventilation, rewarming, and consider ECMO early
Prevention requires layers
No single strategy (including swim lessons) is sufficient
⚠️ Clinical Pearls
Drowning is an evolving process, not a single moment event
Patients should be observed for 6 hours after the event
Symptoms appearing days later are NOT due to drowning
Pediatric arrests are often respiratory in origin → prioritize ventilation
Antibiotics and steroids are not routinely indicated
Most toddler submersion injuries do NOT require C-spine immobilization
🧠 Myth Busting
“Dry drowning” isn’t real.This term originated from outdated medical concepts but is no longer used. If a child had a true submersion injury, symptoms will present within 6 hours—not days later.
🛟 Prevention Insights
Use “arms reach, eyes reach” supervision
Perform a home swim test (can the child swim 2 pool lengths?)
Understand that:
Swim lessons ≠ drowning proof
Life jackets ≠ guaranteed safety
Drowning prevention requires multiple overlapping layers of safety
Resources and references:
Brenner’s article: https://pubmed.ncbi.nlm.nih.gov/19255386/
CHOA Algorithm: https://www.choa.org/-/media/Files/Childrens/medical-professionals/clinical-practice-guidelines/submersion-event-ed.pdf
NEJM Article: https://www.nejm.org/doi/full/10.1056/NEJMra1013317#figures_media
Timeline
00:00 Welcome to PEM CHATT
00:19 Why Drowning Matters
01:12 Meet Dr. Sarah Lazarus
02:14 Bread Pudding is my favorite
03:34 Drowning Terminology
04:38 Who Is Most at Risk
06:08 Silent Drowning Explained
09:15 Systemic Effects Checklist
11:03 Fresh vs Salt vs Cold
11:46 Three Patient Categories
12:36 Case One Asymptomatic Kid
14:12 Avoiding Unneeded X-Rays
16:12 Case Two Symptomatic Infant
18:40 Imaging and Labs Strategy
18:58 When to Skip Antibiotics
20:02 Arrest Scenario Walkthrough
20:30 Resuscitation Priorities And ECMO
21:54 When Resuscitation Is Futile
22:40 C-Spine Immobilization Debate
23:24 Drowning CPR Starts with Breaths
25:29 Injury Prevention Work and Stats
27:14 Layers of Drowning Prevention
30:01 Dry Drowning Myth Busting
33:16 Key Pearls and Closing
 
 

In this “Rewind” episode, Toni sits down with retired pediatrician Dr. Margaret “Meg” Wang, who trained and practiced through the pre-vaccine and early-vaccine eras of pediatrics, including the 1989–1990 measles epidemic in New York City. Together, they walk us through what pediatrics looked like before Hib, pneumococcal, varicella, and rotavirus vaccines and what we might face again as vaccination rates fall and herd immunity wanes.
You’ll hear vivid, frontline stories of:
Hib meningitis, occult bacteremia, and epiglottitis in infants and toddlers, when full sepsis workups (blood, urine, CSF, IV antibiotics, 72-hr admissions) were standard for many febrile children through 36 months of age.
“Old-school” periorbital and buccal cellulitis from Hib—bright red with a violaceous hue, toxic kids, high fevers, and automatic LP + admission.
Measles in an actual epidemic: the prodrome with the “three Cs” (cough, coryza, conjunctivitis), Koplik spots, and that classic confluent, head-to-toe rash, plus why measles is not a mild illness.
Varicella beyond the “nuisance rash”: super-itchy multi-stage lesions, serious skin infections, and a child who developed Staph aureus bacteremia and tricuspid valve endocarditis requiring open-heart surgery—all from chickenpox in an unvaccinated child.
Rotavirus winters: the green, watery, diaper-filling diarrhea, relentless fluid losses, metabolic acidosis, hypoglycemia in infants, and frequent admissions—versus the near-disappearance of severe rotavirus disease after the vaccine.
Clinically, Toni and Dr. Wang dig into:
How fever protocols for 0–36 month-olds have evolved from routine full sepsis workups to today’s more nuanced approach with viral testing and inflammatory markers like CRP and procalcitonin.
Bedside pattern recognition for epiglottitis (toxic, drooling, tripod positioning, chin thrust, neck extension) and why you never upset these kids or put a tongue blade in their mouth—just get them upright and straight to controlled intubation with anesthesia.
The role of parental gut instinct and why “this is not my kid” should always make you pause and reassess.
🔑 Key Takeaways:
Vaccines didn’t just reduce visit volumes; they completely changed inpatient and ED workflows, procedure rates (LPs!), and long-term morbidity (e.g., deafness after meningitis).
As coverage declines, we won’t just see “more fevers”—we’ll see sicker kids, more invasive procedures, more admissions, and more preventable complications.
Your vaccine counseling today is part of preventing tomorrow’s “Rewind” from becoming reality again.
📌 Call to Action:
Hit play, then share this episode with a colleague, resident, or trainee who has never seen these diseases and thinks of measles or chickenpox as “mild.” Their future patients are counting on it. 💉🧠

Fever Management in Children 3-36 Months: An Evidence-Based Approach
Join host Toni Dobson and guest Andrea Perkins, PA-C, as they dive deep into the evidence-based management of fever in otherwise healthy children aged 3-36 months. This comprehensive episode covers everything from basic fever physiology to algorithmic approaches for both vaccinated and unvaccinated children.
Key Topics Covered:
Defining fever and understanding the pathophysiology
The critical difference between fever and hyperthermia
Vaccination status and risk stratification
Comprehensive physical exam pearls
Evidence-based algorithms for immunized vs. unimmunized children
UTI risk assessment and when to obtain urine samples
Laboratory workup guidelines based on vaccination status
Fever management strategies and parent education
Addressing fever phobia in families
Resources:
UTI Calculator: www.uticalc.com
UpToDate management guidelines: UpToDate Link
Andrea's algorithm: Link to Algorithm
Next Episode: Dr. Margaret Wang joins us to discuss the return of vaccine-preventable illnesses and how we can prepare.
📺YouTube: https://www.youtube.com/@PEMChatt
🟢Spotify: https://open.spotify.com/show/6oaYDeq5AXIZGxBvEIxaTs
🍎 Apple Podcasts: https://podcasts.apple.com/us/podcast/pem-chatt/id1806882767

In this episode of PEM CHATT, the focus is on febrile neonates, the first part of a two-part series on pediatric fever management. Host Toni speaks with Dr. Lindsay McHale, a pediatric emergency medicine physician, to discuss how historical protocols for managing febrile neonates have evolved with advances in vaccines, PCR testing, and maternal surveillance. The discussion covers the 2021 AAP guidelines for managing febrile neonates, the essential components of a fever workup, interpretation of test results, and the nuances of decision-making across neonatal age groups. Practical insights on performing lumbar punctures, antibiotic selection, and interpreting potentially confounding results, such as bloody CSF taps, are shared, along with real-life case examples that illustrate the complexities involved. The conversation aims to equip clinicians with an evidence-based approach to improve patient outcomes in various clinical settings.
#PEM #NP #APP #PA #pediatrics #emergencymedicine #emergencynursepractitioner #fellowship #medicaleducation #podcast #children #nursepractitioner #clinicalpharmacists #febrileneonate #sickbabies #lumbarpuncture
00:00 Introduction to Febrile Neonates
00:57 Historical Management of Febrile Neonates
01:25 Advancements in Medicine and New Guidelines
02:23 Introducing Dr. Lindsay McHale
03:56 Defining Febrile Neonates
04:54 Managing Febrile Neonates in the ER
05:51 Cold Babies and Controversies
07:45 Treating Fever in Neonates
09:06 Inclusion and Exclusion Criteria for Febrile Neonate Protocol
10:27 Why Neonates Are High-Risk
11:40 Code 60: Rapid Response for Febrile Neonates
12:30 Hypothetical Case Study: Febrile Neonate
14:24 Parental Concerns and Communication
19:57 Detailed Workup and Testing
23:27 Antibiotic Choices for Neonates
25:13 Dosing Nuances in Neonatal Antibiotics
26:49 Tips for Performing Lumbar Punctures
30:25 Interpreting Test Results in Neonates
32:46 AAP Sepsis Protocol for Neonates
40:06 Managing Febrile Infants: Case Studies
44:18 Conclusion and Next Episode Preview
 
LINKS:
AAP Guideline https://publications.aap.org/pediatrics/article/148/2/e2021052228/179783/Evaluation-and-Management-of-Well-Appearing?autologincheck=redirected
CHOP Algorithm
https://www.chop.edu/clinical-pathway/febrile-infant-emergent-evaluation-clinical-pathway
THE MISFITS
 https://drive.google.com/file/d/1gpUsQOxMlbuqI-6hBDcZEF5ckpJWhWWb/view?usp=sharing

🩺 Essential Medications in Pediatric Emergency Medicine - In-Depth Discussion with Clinical Pharmacists, Mager Raker and Morgan Padron 💊
In this episode of PEM CHATT 🎙️, host Toni Dobson is joined by clinical pharmacists Maggie and Morgan to delve into the key medications used in pediatric emergency medicine 🏥. They cover a wide range of topics, from proper medication dosing and pain control 💉 to antiemetics for nausea 😷, asthma management 🫁, and safe sedation practices 😴. The discussion also includes practical tips for advanced practice providers working in both community hospitals and pediatric-focused facilities 👩‍⚕️👨‍⚕️. Listeners will gain insights into common pitfalls in pediatric prescribing 🚫, the importance of proper dosing ⚖️, and strategies to effectively use medications like Tylenol, ibuprofen, Zofran, morphine, fentanyl, Decadron, and others 💊. The episode aims to enhance the confidence and skills of healthcare providers in caring for young patients 👶👧🧒. The show concludes with a look ahead to the next episode, which will focus on the febrile neonate workup 🍼.
00:00 Introduction to Pediatric Emergency Medicine
00:42 Meet the Hosts and Guests
02:08 Common Pitfalls in Pediatric Prescribing
03:51 Basics of Antipyretics: Tylenol and Ibuprofen
10:03 Anti-Emetic Medications: Zofran and Alternatives
21:19 Pain Control Strategies in Pediatric ER
26:42 Pediatric Dosing and Medication Caps
28:06 Fentanyl: Usage and Administration
29:26 Intranasal Medication Techniques
31:30 Pain Management in Pediatric Emergencies
34:58 Enemas for Constipation Relief
40:00 Asthma Management in Pediatric Patients
48:18 Sedation Techniques in Pediatric Care
52:00 Conclusion and Final Thoughts

🎉 In this special 1-year anniversary episode of PEM CHATT, host Toni Dobson reflects on the podcast’s growth and welcomes guest Dayna Jaynstein, PA, to discuss the critical topic of maternal mortality. Together, they explore why the U.S. has the highest maternal mortality rate among developed countries, highlight the unique risks for Black and Native women, and introduce ACOG’s new initiative to help non-OB providers recognize and manage OB emergencies. The episode covers key warning signs, the importance of asking about current pregnancy status and delivery within the last year, and practical algorithms for managing cardiovascular and hypertensive emergencies in pregnant and postpartum women. Listeners are encouraged to use these resources, advocate for patients, and share knowledge to help prevent maternal deaths.
Link to ACOG website with algorithms: ACOG.org/obemergencies
⏰ Timeline:
0:00 – Welcome & 1-year anniversary celebration
2:00 – Podcast journey & gratitude to listeners
5:00 – Guest introduction: Dana Jane Dean, PA
7:00 – Maternal mortality stats & disparities
10:00 – ACOG’s new initiative explained
15:00 – Key questions for providers & identifying at-risk patients
20:00 – Cardiovascular emergencies in pregnancy
25:00 – Hypertensive emergencies & management tips
30:00 – Eclampsia, preeclampsia, and medication guidance
35:00 – Family-centered care & advocating for moms
40:00 – Resources, final thoughts, and next episode preview

In this episode of 🎤PEM CHATT, host Toni Dobson is joined by pediatric clinical pharmacists 💊Maggie Raker and 💊Morgan Padron for an in-depth discussion on antibiotic use in the pediatric emergency department. The conversation highlights the unique and invaluable role clinical pharmacists play in patient care, from assisting with medication selection and dosing to providing real-time support during traumas and codes. Maggie and Morgan share their backgrounds and offer practical insights into the collaborative approach between pharmacists, providers, and nurses.
The episode dives into evidence-based strategies for treating common pediatric infections 🦠, including ear infections, UTIs, pneumonia, animal bites, cellulitis, and more. Listeners will learn about first-line therapies, dosing nuances, and the importance of selecting targeted antibiotics. The team also shares helpful resources and tips for staying current with best practices. This episode is a must-listen for anyone seeking to deepen their understanding of pediatric antibiotics and the importance of clinical pharmacy collaboration in emergency medicine.
Resources Mentioned:
Maggie and Morgan’s antibiotic guide with ID man: https://drive.google.com/file/d/1ZLNEeUAXlG8hvX_rycAASB3PZ5x0GOuh/view?usp=sharing
Ninja Nerd’s YouTube lecture on antibiotics: https://www.youtube.com/watch?v=GGtwJ-SGXTA&t=7s
Sanford Guide, EMRA app, and UpToDate for antibiotic selection
Part two of this series with Maggie and Morgan will cover other common medications in the pediatric ER (coming December 2025).
Next month: 🤰🏻Special episode on OB emergencies for the one-year anniversary of PEM CHATT.
Thank you for listening to PEM CHATT! 🫶🏽
 
Disclaimer: The content in this podcast is for educational purposes only and does not constitute medical advice. Always consult your local guidelines and collaborate with your physician leader as appropriate.

In this episode of PEM CHATT, host Toni Dobson is joined by Dr. Sarah Sterner, a pediatric emergency medicine physician and medical director at Children's at Erlanger, to discuss chest pain in children. The discussion delves into the differences between pediatric and adult chest pain presentations, common causes, high-risk diagnoses, and appropriate workup strategies. The episode includes discussions on real-life case scenarios, covering conditions such as hypertrophic cardiomyopathy, myocarditis, pericarditis, pneumothorax, and more. Dr Sterner also discusses why it is important to admit children with persistent tachycardia. The importance of a systematic approach, thorough history-taking, and recognizing potential red flags in pediatric patients is highlighted.
WATCH on YouTube: https://www.youtube.com/@PEMChatt
00:00 Introduction to PEM CHATT
00:19 Understanding Pediatric Chest Pain
01:28 Introducing Dr. Sarah Sterner
03:22 Common Causes of Chest Pain in Children
04:05 Don't Miss Diagnoses
05:03 Approach to Pediatric Chest Pain Workup
06:31 Case Study: 14-Year-Old Male with Chest Pain
11:54 Case Study: 5-Year-Old Female with Chest Pain
22:23 Understanding Myocarditis
23:05 Pericarditis in Children
24:59 Pneumonia Management
25:56 Case Study: 9-Year-Old with Chest Pain
29:25 Case Study: 16-Year-Old with Pneumothorax
32:19 Case Study: 15-Year-Old with Pneumomediastinum
35:03 Rare but Serious: ACS and PE in Kids
39:58 Conclusion and Final Thoughts
 

Exploring Mental Models in Emergency Medicine with Dr. Dan France
In this episode of PEM CHATT, host Toni discusses the importance of mental models in emergency medicine with Dr. Dan France, a professor at Vanderbilt University. They examine how mental models influence decision-making, resilience, and teamwork in high-pressure medical settings. Dr. France shares his journey and explains how mental models have played a significant role in his career, providing practical examples from healthcare and personal experiences. Listeners are encouraged to reflect on their mental models to improve their clinical practice and patient interactions.
WATCH on YouTube: https://www.youtube.com/@PEMChatt
Apple Podcasts: https://podcasts.apple.com/us/podcast/pem-chatt/id1806882767
Spotify Podcasts: https://open.spotify.com/show/6oaYDeq5AXIZGxBvEIxaTs
#PEM #NP #APP #PA #pediatrics #emergencymedicine #emergencynurse practitioner #fellowship #medicaleducation #podcast #children #nursepractitioner #mentalmodels #criticalthinking #mentalevolution #pediatricemergencymedicine
 
00:00 Introduction to Mental Models in Emergency Medicine
02:00 Meet Dr. Dan France: A Pioneer in Patient Safety
04:32 Understanding Mental Models: A Deep Dive
06:57 Developing Mental Models: Influences and Examples
07:38 The Ladder of Inference: How We Form Beliefs
09:29 The Evolution of Mental Models: Adapting to Change
15:52 The Shadows of the Neanderthal: A Book Discussion
26:55 Personal Reflections on Mental Models
36:44 Personal Reflections on Palliative Care
38:09 Navigating Family Dynamics in Healthcare
40:07 Professional Growth and Conflict Resolution
43:32 Addressing Vaccine Hesitancy in the ER
51:50 The Importance of Mental Models in Medicine
53:36 Building a Culture of Safety and Reliability
59:25 Final Thoughts and Reflections
 
Link to Shadows of the Neanderthal on Amazon: https://www.amazon.com/Shadows-Neanderthal-Illuminating-Beliefs-Organizations/dp/1883823307