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ALiEM AIR Series | Non-ACS Cardiology Module (2026)

ALiEM AIR Certified seal and Non-ACS Cardiology 2026 module shield badge

Welcome to the AIR Non-ACS Cardiology Module! After carefully reviewing all relevant posts in the past 12 months from the top 50 sites of the Digital Impact Factor [1], the ALiEM AIR Team is proud to present the highest quality online content related to non-ACS cardiology emergencies in the Emergency Department. 9 blog posts met our standard of online excellence and were approved for residency training by the AIR Series Board. More specifically, we identified 6 AIR and 3 Honorable Mentions. We recommend programs give 5 hours of III credit for this module.

AIR Stamp of Approval and Honorable Mentions

In an effort to truly emphasize the highest quality posts, we have 2 subsets of recommended resources. The AIR stamp of approval is awarded only to posts scoring above a strict scoring cut-off of ≥30 points (out of 35 total), based on our scoring instrument. The other subset is for “Honorable Mention” posts. These posts have been flagged by and agreed upon by AIR Board members as worthwhile, accurate, unbiased, and appropriately referenced despite an average score.

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Highlighted Quality Posts: Non-ACS Cardiology 2025

SiteArticleAuthorDateLabel
EMCritSupraventricular TachycardiaDr. Josh FarkasJanuary 5, 2025AIR
EMCritRight Ventricular FailureDr. Josh FarkasMarch 21, 2025AIR
EMCritValvular Heart DiseaseDr. Josh FarkasJanuary 27, 2025AIR
EMCritAntiarrhythmicsDr. Josh FarkasJanuary 8, 2025AIR
EM CasesAcute heart failure risk stratification and dispositionDr. Anton HelmanAugust 19, 2025AIR
EMCritSCAPE (sympathetic crashing acute pulmonary edema)Dr. Josh FarkasJanuary 30, 2025AIR
RCEMlearningCardiogenic Pulmonary OedemaDr. Victoria HensonMay 30, 2025HM
EMCritAcute PericarditisDr. Josh FarkasSeptember 20, 2025HM
EMCritAcute Myocarditis and evaluation of newly discovered HFrEFDr. Josh FarkasOctober 1, 2024HM

(AIR = Approved Instructional Resource; HM = Honorable Mention)

If you have any questions or comments on the AIR series, or this AIR module, please contact us!

By |2026-04-29T12:00:25-07:00Apr 30, 2026|Approved Instructional Resources (AIR series), Cardiovascular|
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Who Gets Mistriaged? Disparities in Pediatric Behavioral Health ED Triage | A PECARN multicenter analysis

mistriaging of pediatric mental health conditions with ESI
A 14-year-old Hispanic girl presents to the Emergency Department with her mother for suicidal ideation after a conflict at home. The girl is quiet and cooperative. Her mother, who speaks primarily Spanish, is trying to explain the situation. The nurse assigns an ESI level 2, the same score given to nearly every child who walks through the door with a behavioral health complaint. But does that score accurately capture this patient’s needs?

A new multicenter PECARN study published this week in JAMA Network Open takes a close look at triage accuracy for pediatric behavioral health ED visits. The findings: mistriaging errors are common, and they are not equally distributed [1].

Hoffmann et al. analyzed 78,411 ED visits by children aged 5 to 17 with behavioral health chief concerns across 15 PECARN Registry EDs from 2021 to 2023 [1]. They classified each visit as appropriately triaged, overtriaged, or undertriaged using vital signs, Glasgow Coma Scale, pain scores, emergency medication use, resource utilization, and disposition. Of the 74,564 visits with complete data:

  • 57% were overtriaged
  • 34% were appropriately triaged
  • 8.5% were undertriaged

How ESI Handles Behavioral Health

The Emergency Severity Index (ESI) is used in over 90% of US EDs [2]. It sorts patients into 5 acuity levels. Level 1 is for patients needing lifesaving interventions. Level 2 is for high-risk situations, confused patients, or those in severe pain. Levels 3 through 5 are based on anticipated resource needs. In this study, 83.5% of all behavioral health visits were triaged as ESI level 2.

To assess triage accuracy, the authors compared each child’s assigned ESI level against what actually happened during their visit.

Overtriage

Overtriage means a child was assigned a higher acuity score than their clinical course supported. For a child assigned ESI level 2, overtriage was defined as meeting ALL of the following [1]:

  • Stable vital signs within 2 hours of arrival (heart rate and respiratory rate not high risk for age, SpO2 ≥93% or not recorded)
  • Pain score <7 (or not recorded)
  • GCS of 15 (or not recorded)
  • No emergency medications during the visit

In other words, the triage nurse predicted high acuity, but the visit didn’t bear that out.

Undertriage

Undertriage means the opposite: a child was assigned a lower acuity score than their clinical course warranted. For example, a child triaged as ESI level 4 (expected to need 1 resource) who ended up being admitted, needing emergency medications, or using multiple resources. The triage nurse underestimated how sick the child was or how much care they would need.

Undertriage Disproportionately Affects Minority Children and Spanish-Speaking Families

The most concerning equity finding was in undertriage.

After adjusting for clinical and visit characteristics, undertriage was significantly more likely for Hispanic children (AOR 1.46), non-Hispanic Black children (AOR 1.28), and children whose families preferred Spanish (AOR 1.31), all compared to non-Hispanic White and English-speaking patients [1]. The authors point to implicit clinician bias, systemic racism, and underutilization of professional interpreters as likely contributors.

The safety implications are real. Children whose acuity is underestimated may face longer waits, miss time-sensitive interventions, or leave the ED without being seen despite elevated risk.

Overtriage Was Common

More than half of all visits (57%) were overtriaged [1]. These children received a higher acuity triage score than their clinical course supported.

The strongest predictor was age. Children aged 5-9 had over 4-fold higher adjusted odds of overtriage compared to those aged 10-14 (AOR 4.43), possibly because younger children have a limited ability to communicate their symptoms and needs.

To a lesser degree, non-Hispanic Black children also had higher adjusted odds of overtriage compared to non-Hispanic White children (AOR 1.17). The authors cite research on adultification, the tendency to perceive Black youth as older or more threatening than they are, as a potential contributor. This means Black children in this study were more likely to be both undertriaged and overtriaged compared to White children. The errors are not unidirectional. They likely reflect different biases operating at different points in care.

Take Home Points

  1. The ESI has limited ability to differentiate pediatric behavioral health presentations. In this study, 83.5% of behavioral health visits were triaged as ESI level 2.
  2. UNDERTRIAGE was more likely for Hispanic children (AOR 1.46), non-Hispanic Black children (AOR 1.28), and Spanish-speaking families (AOR 1.31), raising concerns about missed acuity in these groups.
  3. OVERTRIAGE occurred in 57% of visits, driven most strongly by younger age (AOR 4.43 for ages 5 to 9) and to a lesser degree by non-Hispanic Black race (AOR 1.17).

References

  1. Hoffmann JA, Foster AA, Rojas CR, et al. Overtriage and undertriage of children presenting to the emergency department for behavioral health. JAMA Netw Open. 2026;9(3):e263042. Full text
  2. McHugh M, Tanabe P, McClelland M, Khare RK. More patients are triaged using the Emergency Severity Index than any other triage acuity system in the United States. Acad Emerg Med. 2012;19(1):106-109. doi:10.1111/j.1553-2712.2011.01240.x
By |2026-03-28T19:43:20-07:00Mar 28, 2026|Pediatrics, Psychiatry|
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Dump the Myths, Not the Milk: Medication and Imaging Considerations for Lactating Patients in the Emergency Department

lactation myths with medications and imaging
The challenges in lactation are often compounded by outdated beliefs held by clinicians.  Most of the medications we administer in the emergency department (ED) do not warrant any interruption in expression or feeding of breastmilk. Most imaging we perform in the ED is safe in the lactating patient and likewise does not need interruption. Let us convince you to trash the phrase, “Pump and Dump” in the ED.

Most medications commonly given in the ED are safe in lactation

Evidence suggests medication transfer through breast milk is frequently overestimated, with actual infant exposure typically minimal for most medications commonly prescribed in emergency settings [1]. The majority of medications administered in the ED are compatible with continued breastfeeding or pumping without interruption [2]. The practice of “pumping and dumping” is harmful to infants and lactating adults given the many benefits of lactation [3, 4]. It can cause irreparable disruptions in supply, increased parental burden and stress, and is not medically indicated except in very rare circumstances (chemotherapeutics for example) [3, 4]. When uncertainty exists regarding medication safety during lactation, clinicians should consult evidence-based resources such as LactMed or the LactRx app [iphone] to provide informed recommendations. A brief summary table is provided below for quick reference on some common medications.

Medication ClassSafe in LactationCautions in Lactation
Analgesia
  • Acetaminophen [5]
  • Ibuprofen [6]
  • Opioids in routine doses: Oxycodone [7], Morphine [8], Hydromorphone [9],  Fentanyl [10]
  • ⚠️ Caution in very high doses or prolonged infusions of opioids
  • Data on oxycodone shows no adverse effects attributed to oxycodone in maternal doses up to 60 mg/day (~90 MME/day) [11], which is well within the range of typical short-term ED prescribing for acute pain [12]
Sedative Hypnotics
  • Propofol [13]
  • Ketamine [14]
  • Midazolam [15]
  • Safe to feed when awake
  • ⚠️ Caution in infusions and higher doses of long-acting benzodiazepines
Paralytics
  • Succinylcholine [16]
  • Rocuronium [17]
  • Safe to feed when no longer paralyzed; likely safe to feed even on infusions
Opioid Use Disorder
  • Buprenorphine [18]
  • Methadone [19]
  • Recommended to continue feeding
Antibiotics
  • Penicillins [20]
  • Cephalosporins [20]
  • Macrolides [20]
  • Metronidazole [21]
  • Doxycycline (≤21 days) [22]
  • ⚠️ Trimethoprim-sulfamethoxazole (Avoid in premature, ill or jaundiced and those with G6PD) [23]
Anti-hypertensives
  • Labetalol [24]
  • Nifedipine [25]
  • Captopril, Enalapril, Benzapril (Lisinopril—less data) [26]
  • HCTZ [27]
  • Furosemide [28]
  • ⚠️ Diuretics may decrease milk supply if dehydrated
  • ❌ ARBs (Losartan) — No safety data and other alternatives are safe [26]
Antidepressants
  • Sertraline [29]
  • Paroxetine [30]
  • Fluoxetine [31]
  • Citalopram [32]
  • Do not stop an effective antidepressant because of lactation. Risk of depression relapse outweighs the small differences in milk transfer.
  • ⚠️ Bupropion (case reports of infant seizures without causal link) [33]
  • ❌ Doxepin (case reports of infant respiratory depression, hypotonia) [34]
Anticonvulsants
  • Carbamazepine [35]
  • Valproic acid [36]
  • Phenytoin [37]
  • Lamotrigine [38]
  • ⚠️ Levetiracetam (levels can be high, monitor for somnolence) [39]
  • ⚠️ Topiramate (case reports of infant somnolence) [40]
  • ❌ Phenobarbital (Avoid due to high infant exposure and sedation risk) [41]

Most Imaging Performed in the ED is Safe in Lactation

Radiation Exposure

Radiation exposure from diagnostic imaging we typically use in the ED (CT, x-ray) is minimal and there is no need to interrupt nursing/pumping [42].

IV contrast

Iodinated and gadolinium contrast agents are safe and do not require interruption of breastfeeding [43]. Read more in the American College of Radiology 2025 ACR Manual on Contrast Media (start at page 94).

In suspected pulmonary embolism (PE), CT pulmonary angiography (CTPA) is preferred over V/Q scan in lactating patients due to contrast safety (no breastfeeding interruption required), speed and availability, and high rates of indeterminate V/Q scans requiring subsequent CTPA [43, 44].

Exception: In the rare circumstance where contrast is contraindicated (such as anaphylaxis) and a radioactive tracer is indicated (V/Q scan with Tc-99m MAA), the radioactivity does warrant separation from both patient contact and milk for a period of time determined by the rate of decay of the specific agent [45]. Keep expressed milk stored appropriately until radioactivity has been able to decay then it’s safe to feed [46].

References (AMA Format)

  1. Nauwelaerts N, Macente J, Deferm N, Bonan RH, Huang MC, Van Neste M, et al. Generic workflow to predict medicine concentrations in human milk using physiologically-based pharmacokinetic (PBPK) modelling—a contribution from the ConcePTION project. Pharmaceutics. 2023;15(5):1469. doi:10.3390/pharmaceutics15051469
  2. Premer C, Caruso K. Safety profile of the most ordered medications for breastfeeding patients in the emergency department. Am J Emerg Med. 2024;80:1-7. doi:10.1016/j.ajem.2024.02.042
  3. Sachs HC; Committee On Drugs. The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics. 2013;132(3):e796-e809. doi:10.1542/peds.2013-1985
  4. Meek JY, Noble L; Section on Breastfeeding. Policy statement: breastfeeding and the use of human milk. Pediatrics. 2022;150(1):e2022057988. doi:10.1542/peds.2022-057988
  5. Acetaminophen. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  6. Ibuprofen. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  7. Oxycodone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  8. Morphine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  9. Hydromorphone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  10. Fentanyl. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  11. FDA drug label. Food and Drug Administration; 2024-2025.
  12. Zhu W, Chernew ME, Sherry TB, Maestas N. Initial opioid prescriptions among US commercially insured patients, 2012-2017. N Engl J Med. 2019;380(11):1043-1052. doi:10.1056/NEJMsa1807069
  13. Propofol. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  14. Ketamine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  15. Midazolam. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  16. Succinylcholine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  17. Rocuronium. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  18. Buprenorphine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  19. Methadone. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  20. Spencer JP, Thomas S, Trondsen Pawlowski RH. Medication safety in breastfeeding. Am Fam Physician. 2022;106(6):638-644.
  21. Metronidazole. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  22. Doxycycline. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  23. Trimethoprim-sulfamethoxazole. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  24. Labetalol. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  25. Nifedipine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  26. Park K. Management of women with acquired cardiovascular disease from pre-conception through pregnancy and postpartum: JACC Focus Seminar 3/5. J Am Coll Cardiol. 2021.
  27. Hydrochlorothiazide. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  28. Furosemide. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  29. Sertraline. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  30. Paroxetine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  31. Fluoxetine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  32. Citalopram. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  33. Bupropion. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  34. Doxepin. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  35. Carbamazepine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  36. Valproic acid. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  37. Phenytoin. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  38. Lamotrigine. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  39. Levetiracetam. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  40. Topiramate. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  41. Phenobarbital. In: Drugs and Lactation Database (LactMed®). National Institute of Child Health and Human Development; 2006.
  42. Naseri M, Shahsavan M, Salahshour F, et al. Effective dose for radiological procedures in an emergency department: a cross-sectional study. Radiat Prot Dosimetry. 2020;189(1):63-68. doi:10.1093/rpd/ncaa013
  43. ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast Media. American College of Radiology; 2025.
  44. Falster C, Hellfritzsch M, Gaist TA, et al. Comparison of international guideline recommendations for the diagnosis of pulmonary embolism. Lancet Haematol. 2023;10(11):e922-e935. doi:10.1016/S2352-3026(23)00181-3
  45. El-Sayed Y, Phillips Heine R, Wharton KR, eds. Guidelines for Diagnostic Imaging During Pregnancy and Lactation. American College of Obstetricians and Gynecologists; 2017.
  46. Leide-Svegborn S, Ahlgren L, Johansson L, Mattsson S. Excretion of radionuclides in human breast milk after nuclear medicine examinations: biokinetic and dosimetric data and recommendations on breastfeeding interruption. Eur J Nucl Med Mol Imaging. 2016;43(5):808-821. doi:10.1007/s00259-015-3286-0
By |2026-03-24T13:23:44-07:00Mar 26, 2026|Ob/Gyn, Radiology, Tox & Medications|
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SAEM Clinical Images Series: Painful Red Eye

The patient is a 60-year-old male with a history of insulin-dependent diabetes, hypertension, and hyperlipidemia who presents to the Emergency Department after one day of sudden onset right eye pain associated with nausea and vomiting. He notes progressively blurring vision and vision loss in his right eye since the onset of the pain. His wife noted redness of his sclera and urged him to go the emergency department. He can now only sense light and shadows with his right eye. He denies traumatic injury or any history of serious ophthalmological pathology. He wears corrective eyeglasses and does not use contacts. He has no other complaints at this time.

 

Vitals: BP 149/83; HR 107; R 17; T 98.9°F; O2 sat 100 on room air.

General: Appears to be in pain and uncomfortable.

HEENT: As shown. Extraocular movements are intact. The right pupil is fixed and dilated with a relative afferent pupillary defect. There is no sign of traumatic injury.

Neck: There are no carotid bruits auscultated.

Cardiovascular: Regular rate and rhythm, no murmur.

Neurologic: Normal other than the abnormal findings of the right eye.

Imaging: POCUS of the right eye is performed, image as shown.

Acute angle-closure glaucoma.

Ultrasound shows retinal detachment with subretinal hemorrhage and associated choroidal detachment.

Acute angle-closure glaucoma occurs due to a rapid increase in intraocular pressure (IOP) due to outflow obstruction of the aqueous humor. Patients with a shallower angle between the iris and the cornea in the anterior chamber are predisposed to this condition. This is characterized clinically by severe eye pain, headache, nausea, vomiting, blurred vision, and multicolored halos around lights. If left untreated, this can result in optic neuropathy and vision loss. The diagnosis of acute angle-closure glaucoma is confirmed with elevated intraocular pressure (IOP) measurements obtained via tonometry. Normal IOPs are between 10 and 21 mmHg. The pressure in this patient’s right eye was 47 mmHg. Slit-lamp microscope exam showed a shallow anterior chamber, corneal edema, fixed dilated pupil, and conjunctival injection around the limbus (ciliary flush). Uncommonly, retinal and choroidal detachment may cause secondary acute angle-closure glaucoma, as seen in this case. Treatment includes medical and surgical interventions to reduce IOP, address underlying causes, and manage associated pain and nausea.

Take-Home Points

  • Retinal detachments are seen as a “V”-shaped hyperechoic and freely moving membrane tethered to the optic disc on ultrasound.

  • Acute angle-closure glaucoma is an ocular emergency. Delays in treatment can result in optic neuropathy and permanent vision loss.

  • Stenberg RT, Nelson J, Rabinowitz J, Simon EL. Spontaneous Hyphema and Vitreous Hemorrhage Causing Secondary Glaucoma in a Patient on Apixaban. J Emerg Med. 2023;64(3):359-362. doi:10.1016/j.jemermed.2022.12.021
  • Jersey A, Perice L, Li N, Johnson J, Dulani T. Acute Angle-Closure Glaucoma Secondary to Vitreous Hemorrhage Diagnosed with the Aid of Point-of-Care Ultrasound. J Emerg Med. 2020 Dec;59(6):e235-e237. doi: 10.1016/j.jemermed.2020.08.015. Epub 2020 Sep 29. PMID: 33004244.
  • Chen SN, Ho CL, Ho JD, Guo YH, Chen TL, Chen PF. Acute angle-closure glaucoma resulting from spontaneous hemorrhagic retinal detachment in age-related macular degeneration: case reports and literature review. Jpn J Ophthalmol. 2001 May-Jun;45(3):270-5. doi: 10.1016/s0021-5155(00)00382-8. PMID: 11369377.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2025 SAEM Annual Meeting | Copyrighted by SAEM 2025 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.



By |2026-03-10T21:17:06-07:00Mar 20, 2026|Ophthalmology, SAEM Clinical Images|
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