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Core EM - Emergency Medicine Podcast

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Core EM - Emergency Medicine Podcast

Episode 212: Angioedema

Sat, 02 Aug 2025







Angioedema – Recognition and Management in the ED


Hosts:

Maria Mulligan-Buckmiller, MD

Brian Gilberti, MD









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Show Notes



Definition & Pathophysiology


Angioedema = localized swelling of mucous membranes and subcutaneous tissues due to increased vascular permeability.


Triggers increased vascular permeability → fluid shifts into tissues.



Etiologies



  • Histamine-mediated (anaphylaxis)

    • Associated with urticaria/hives, pruritus, and redness.

    • Triggered by allergens (foods, insect stings, medications).

    • Rapid onset (minutes to hours).



  • Bradykinin-mediated

    • Hereditary angioedema (HAE): C1 esterase inhibitor deficiency (autosomal dominant).

    • Acquired angioedema: Associated with B-cell lymphoma, autoimmune disease, MGUS.

    • Medication-induced: Most commonly ACE inhibitors; rarely ARBs.

    • Typically lacks urticaria and itching.

    • Gradual onset, can last days if untreated.



  • Idiopathic angioedema

    • Unknown cause; diagnosis of exclusion.





Clinical Presentations



  • Swelling

    • Asymmetric, non-pitting, usually non-painful.

    • May involve lips, tongue, face, extremities, GI tract.



  • Respiratory compromise

    • Upper airway swelling → stridor, dyspnea, sensation of throat closure.

    • Airway obstruction is the most feared complication.



  • Abdominal manifestations

Episode 211: Granulomatosis with Polyangiitis

Tue, 01 Jul 2025







Granulomatosis with Polyangiitis (GPA) – Recognition and Management in the ED


Hosts:

Phoebe Draper, MD

Brian Gilberti, MD









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Show Notes


Background



  • A vasculitis affecting small blood vessels causing inflammation and necrosis

  • Affects upper respiratory tract (sinusitis, otitis media, saddle nose deformity), lungs (nodules, alveolar hemorrhage), and kidneys (rapidly progressive glomerulonephritis)

  • Can lead to multi-organ failure, pulmonary hemorrhage, renal failure


Red Flag Symptoms:



  • Chronic sinus symptoms

  • Hemoptysis (especially bright red blood)

  • New pulmonary complaints

  • Renal dysfunction

  • Constitutional symptoms (fatigue, weight loss, fever)


Workup in the ED:



  • CBC, CMP for anemia and AKI

  • Urinalysis with microscopy (hematuria, RBC casts)

  • Chest imaging (CXR or CT for nodules, cavitary lesions)

  • ANCA testing (not immediately available but important diagnostically)


Management:



  • Stable patients: Outpatient workup, urgent rheumatology consult, prednisone 1 mg/kg/day

  • Unstable patients: High-dose IV steroids (methylprednisolone 1 g daily x3 days), consider plasma exchange, cyclophosphamide or rituximab initiation, ICU admission


Conditions that Mimic GPA:



  • Goodpasture syndrome (anti-GBM antibodies)

  • TB, fungal infections

  • Lung malignancy

  • Other vasculitides (EGPA, MPA, lupus)


Episode 210: Capacity Assessment

Mon, 02 Jun 2025







We discuss capacity assessment, patient autonomy, safety, and documentation.


Hosts:

Anne Levine, MD

Brian Gilberti, MD









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Show Notes


The Importance of Capacity Assessment



  • Arises frequently in the ED, even when not formally recognized

  • Carries both legal implications and ethical weight

  • Failure to appropriately assess capacity can result in:

    • Forced treatment without justification

    • Missed opportunities to respect autonomy

    • Increased risk of litigation and poor patient outcomes




Defining Capacity



  • Capacity is:

    • Decision-specific: varies based on the medical choice at hand

    • Time-specific: can fluctuate due to medical conditions, intoxication, delirium



  • Distinct from competency, which is a legal determination

  • Relies on a patient’s ability to:

    • Understand relevant information

    • Appreciate the consequences

    • Reason through options

    • Communicate a clear choice




Real-World ED Examples



  • Intoxicated patient with head trauma refusing CT

    • Unreliable neuro exam

    • Potentially time-sensitive intracranial injury



  • Elderly patient with sepsis refusing admission due to caregiving responsibilities

    • Balancing autonomy vs. beneficence



  • Patient with gangrenous diabetic foot refusing surgery

    • Demonstrates logic and consistency despite high-risk decision




The 4 Pillars of Capacity Assessment



  • Understanding

    • Can the patient explain:

    • Their condition

    • Recommended treatments

    • Risks and benefits

    • Alternatives and outcomes?



  • Sample prompts:

Episode 209: Blast Crisis

Thu, 01 May 2025







We dive into the recognition and management of blast crisis.


Hosts:

Sadakat Chowdhury, MD

Brian Gilberti, MD









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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.

    • May include extramedullary blast proliferation.



  • Without treatment, median survival is only 3–6 months.


Pathophysiology & Associated Conditions



  • Usually occurs in CML, but also in:

    • Myeloproliferative neoplasms (MPNs)

    • Myelodysplastic syndromes (MDS)



  • Transition from chronic to blast phase often reflects disease progression or treatment resistance.


Risk Factors



  • 10% of CML patients progress to blast crisis.

  • Risk increased in:

    • Patients refractory to tyrosine kinase inhibitors (e.g., imatinib).

    • Those with Philadelphia chromosome abnormalities.

    • WBC >100,000, which increases risk for leukostasis.




Clinical Presentation



  • Symptoms often stem from pancytopenia and leukostasis:

    • Anemia: fatigue, malaise.

    • Functional neutropenia: high WBC count, but increased infection/sepsis risk.

    • Thrombocytopenia: bleeding, bruising.



  • Leukostasis/hyperviscosity effects by system:

    • Neurologic: confusion, visual changes, stroke-like symptoms.

    • Cardiopulmonary: ARDS, myocardial injury.

    • Others: priapism, limb ischemia, bowel infarction.



Episode 208: Geriatric Emergency Medicine

Tue, 15 Apr 2025







We explore the expanding field of Geriatric Emergency Medicine.


Hosts:

Ula Hwang, MD

Brian Gilberti, MD









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Show Notes



Key Topics Discussed



  • Importance and impact of geriatric emergency departments.

  • Optimizing care strategies for geriatric patients in ED settings.

  • Practical approaches for non-geriatric-specific EDs.


Challenges in Geriatric Emergency Care



  • Geriatric patients often present with:

    • Multiple chronic conditions

    • Polypharmacy

    • Functional decline (mobility issues, cognitive impairments, social isolation)




Adapting Clinical Approach



  • Core objective remains acute issue diagnosis and treatment.

  • Additional considerations for geriatric patients:

    • Review and caution with medications to prevent adverse reactions.

    • Address functional limitations and cognitive impairments.

    • Emphasize safe discharge and care transitions to prevent unnecessary hospitalization.




Identifying High-Risk Geriatric Patients



  • Screening tools:

    • Identification of Seniors at Risk (ISAR)

    • Frailty screens



  • Alignment with the “Age-Friendly Health Systems” initiative focusing on:

    • Mentation

    • Mobility

    • Medications

    • Patient preferences (what matters most)

    • Mistreatment (elder abuse awareness)




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