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  • Episode 217: Prehospital Blood Transfusion

    Episode 217: Prehospital Blood Transfusion
    2026/01/01
    We discuss the shift to prehospital blood to treat shock sooner. Hosts: Nichole Bosson, MD, MPH, FACEP Avir Mitra, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Prehospital_Transfusion.mp3 Download Leave a Comment Tags: EMS, Prehospital Care, Trauma Show Notes Core EM Modular CME Course Maximize your commute with the new Core EM Modular CME Course, featuring the most essential content distilled from our top-rated podcast episodes. This course offers 12 audio-based modules packed with pearls! Information and link below. Course Highlights: Credit: 12.5 AMA PRA Category 1 Credits™Curriculum: Comprehensive coverage of Core Emergency Medicine, with 12 modules spanning from Critical Care to Pediatrics.Cost: Free for NYU Learners$250 for Non-NYU Learners Click Here to Register and Begin Module 1 What is prehospital blood transfusion Administration of blood products in the field prior to hospital arrival Aimed at patients in hemorrhagic shock Why this matters Traditional US prehospital resuscitation relied on crystalloid ED and trauma care now prioritize early blood Hemorrhage occurs before hospital arrival Delays to definitive hemorrhage control are common Earlier blood may improve survival Supporting rationale ATLS and trauma paradigms emphasize blood over fluid National organizations support prehospital blood when feasible EMS already manages high risk, time sensitive interventions Evidence overview Data are mixed and evolving COMBAT: no benefit PAMPer: mortality benefit RePHILL: no clear benefit Signal toward benefit when transport time exceeds ~20 minutes Urban systems still experience long delays due to traffic and geography LA County median time to in hospital transfusion ~35 minutes LA County program ~2 years of planning before launch Pilot began April 1 Partnerships: LA County Fire Compton Fire Local trauma centers San Diego Blood Bank 14 units of blood circulating in the field Blood rotated back 14 days before expiration Ultimately used at Harbor UCLA Continuous temperature and safety monitoring Indications used in LA County Focused rollout Trauma related hemorrhagic shock Postpartum hemorrhage Physiologic criteria: SBP < 70 Or HR > 110 with SBP < 90 Shock index ≥ 1.2 Witnessed traumatic cardiac arrest Products: One unit whole blood preferred Two units PRBCs if whole blood unavailable Early experience ~28 patients transfused at time of discussion Evaluating: Indications Protocol adherence Time to transfusion Early outcomes Too early for outcome conclusions California collaboration Multiple active programs: Riverside (Corona Fire) LA County Ventura County Additional programs planned: Sacramento San Bernardino Programs meet monthly as CalDROP Focus on shared learning and operational optimization Barriers and concerns Trauma surgeon concerns about blood supply Need for system wide buy in Community engagement Patients who may decline transfusion Women of childbearing age and alloimmunization risk Risk of HDFN is extremely low Clear communication with receiving hospitals is essential Future direction Rapid national expansion expected Greatest benefit likely where transport delays exist Prehospital Blood Transfusion Coalition active nationally Major unresolved issue: reimbursement Currently funded largely by fire departments Sustainability depends on policy and payment reform Take-Home Points Hemorrhagic shock is best treated with blood, not crystalloid Prehospital transfusion may benefit patients with prolonged transport times Implementation requires strong partnerships with blood banks and trauma centers Early data are promising, but patient selection remains critical National collaboration is key to sustainability and future growth Read More
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  • Episode 216: BRUE (Brief Resolved Unexplained Event)

    Episode 216: BRUE (Brief Resolved Unexplained Event)
    2025/12/01
    We review BRUEs (Brief Resolved Unexplained Events). Hosts: Ellen Duncan, MD, PhD Noumi Chowdhury, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/BRUE.mp3 Download Leave a Comment Tags: Pediatrics Show Notes What is a BRUE? BRUE stands for Brief Resolved Unexplained Event.It typically affects infants <1 year of age and is characterized by a sudden, brief, and now resolved episode of one or more of the following: Cyanosis or pallor Irregular, absent, or decreased breathing Marked change in tone (hypertonia or hypotonia) Altered level of responsiveness Crucial Caveat: BRUE is a diagnosis of exclusion. If the history and physical exam reveal a specific cause (e.g., reflux, seizure, infection), it is not a BRUE. Risk Stratification: Low Risk vs. High Risk Risk stratification is the most important step in management. While only 6-15% of cases meet strict “Low Risk” criteria, identifying these patients allows us to avoid unnecessary invasive testing. Low Risk Criteria To be considered Low Risk, the infant must meet ALL of the following: Age: > 60 days old Gestational Age: GA > 32 weeks (and Post-Conceptional Age > 45 weeks) Frequency: This is the first episode Duration: Lasted < 1 minute Intervention: No CPR performed by a trained professional Clinical Picture: Reassuring history and physical exam Management for Low Risk: Generally do not require extensive testing or admission. Prioritize safety education/anticipatory guidance. Ensure strict return precautions and close outpatient follow-up (within 24 hours). High Risk Criteria Any infant not meeting the low-risk criteria is automatically High Risk. Additional red flags include: Suspicion of child abuse History of toxin exposure Family history of sudden cardiac death Abnormal physical exam findings (trauma, neuro deficits) Management for High Risk: Requires a more thorough evaluation. Often requires hospital admission. Note: Serious underlying conditions are identified in approx. 4% of high-risk infants. Differential Diagnosis: “THE MISFITS” Mnemonic T – Trauma (Accidental or Non-accidental/Abuse) H – Heart (Congenital heart disease, dysrhythmias) E – Endocrine M – Metabolic (Inborn errors of metabolism) I – Infection (Sepsis, meningitis, pertussis, RSV) S – Seizures F – Formula (Reflux, allergy, aspiration) I – Intestinal Catastrophes (Volvulus, intussusception) T – Toxins (Medications, home exposures) S – Sepsis (Systemic infection) Workup & Diagnostics Step 1: Stabilization ABCs (Airway, Breathing, Circulation) Point-of-care Glucose Cardiorespiratory monitoring Step 2: Diagnostic Testing (For High Risk/Symptomatic Patients) Labs: VBG, CBC, Electrolytes. Imaging: CXR: Evaluate for infection and cardiothymic silhouette. EKG: Evaluate for QT prolongation or dysrhythmias. Neuro: Consider Head CT/MRI and EEG if there are concerns for trauma or seizures. Clinical Pearl: Only ~6% of diagnostic tests contribute meaningfully to the diagnosis. Be judicious—avoid “shotgunning” tests in low-risk patients. Prognosis & Outcomes Recurrence: Approximately 10% (lower than historical ALTE rates of 10-25%). Mortality: < 1%. Nearly always linked to an identifiable cause (abuse, metabolic disorder, severe infection). BRUE vs. SIDS: These are not the same. BRUE: Peaks < 2 months; occurs mostly during the day. SIDS: Peaks 2–4 months; occurs mostly midnight to 6:00 AM. Take-Home Points Diagnosis of Exclusion: You cannot call it a BRUE until you have ruled out obvious causes via history and physical. Strict Criteria: Stick strictly to the Low Risk criteria guidelines. If they miss even one (e.g., age < 60 days), they are High Risk. Education: For low-risk families, the most valuable intervention is reassurance, education, and arranging close follow-up. Systematic Approach: For high-risk infants, use a structured approach (like THE MISFITS) to ensure you don’t miss rare but reversible causes. Read More
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  • Episode 215: Marburg Virus and Global EM

    Episode 215: Marburg Virus and Global EM
    2025/11/01

    Lessons from Rwanda’s Marburg Virus Outbreak and Building Resilient Systems in Global EM.

    Hosts:
    Tsion Firew, MD
    Brian Gilberti, MD

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Marburg_Virus.mp3 Download Leave a Comment Tags: Global Health, Infectious Diseases Show Notes Context and the Rwanda Marburg Experience
    • The Threat: Marburg Virus Disease is from the same family as Ebola and has historically had a reported fatality rate as high as 90%.
    • The Outbreak (Sept. 2024): Rwanda declared an MVD outbreak. The initial cases involved a miner, his pregnant wife (who fell ill and died after having a baby), and the baby (who also died).
    • Healthcare Worker Impact: The wife was treated at an epicenter hospital. Eight HCWs were exposed to a nurse who was coding in the ICU; all eight developed symptoms, tested positive within a week, and four of them died.
    • The Turning Point: The outbreak happened in city referral hospitals where advanced medical interventions (dialysis, mechanical ventilation) were available.
      • Rapid Therapeutics Access: Within 10 days of identifying Marburg, novel therapies (experimental drugs and monoclonal antibodies) and an experimental vaccine were made available through diplomacy with the US government/CDC and agencies like WHO, Africa CDC, CEPI and more.
    • The Outcome: This coordinated effort—combini...
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  • Episode 214: Acute Pulmonary Embolism

    Episode 214: Acute Pulmonary Embolism
    2025/10/02

    We review the diagnosis, risk stratification, & management of acute pulmonary embolism in the ED.

    Hosts:
    Vivian Chiu, MD
    Brian Gilberti, MD

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Pulmonary_Embolism.mp3 Download One Comment Tags: Pulmonary Show Notes Core Concepts and Initial Approach
    • Definition: Obstruction of pulmonary arteries, usually from a DVT in the proximal lower extremity veins (iliac/femoral), but may be tumor, air, or fat emboli.
    • Incidence & Mortality: 300,000–370,000 cases/year in the USA, with 60,000–100,000 deaths annually.
    • Mantra: “Don’t anchor on the obvious. Always risk stratify and resuscitate with precision.”
    • Risk Factors: Broad, including older age, inherited thrombophilias, malignancy, recent surgery/trauma, travel, smoking, hormonal use, and pregnancy.
    Clinical Presentation and Risk Stratification
    • Presentation: Highly variable, showing up as anything from subtle shortness of breath to collapse.
    • Acute/Subacute: Dyspnea (most common), pleuritic chest pain, cough, hemoptysis, and syncope. Patients are likely tachycardic, tachypneic, hypoxemic on room air, and may have a low-grade fever.
    • Chronic: Can mimic acute symptoms or be totally asymptomatic.
    • Pulmonary Infarction Signs: Pleuritic pain, hemoptysis, and an effusion.
    • High-Risk Red Flags: Signs of hypotension (systolic blood pressure < 90 mmHg for over 15...
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  • Episode 213: Pneumothorax

    Episode 213: Pneumothorax
    2025/09/01

    We break down pneumothorax: risks, diagnosis, and management pearls.

    Hosts:
    Christopher Pham, MD
    Brian Gilberti, MD

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Pneumothorax.mp3 Download Leave a Comment Tags: Chest Trauma, Pulmonary, Trauma Show Notes Risk Factors for Pneumothorax
    • Secondary pneumothorax
      • Trauma: rib fractures, blunt chest trauma (as in the case).
      • Iatrogenic: central line placement, thoracentesis, pleural procedures.
    • Primary spontaneous pneumothorax
      • Young, tall, thin males (10–30 years).
      • Connective tissue disorders: Marfan, Ehlers-Danlos.
      • Underlying lung disease: COPD with bullae, interstitial lung disease, CF, TB, malignancy.
    • Technically, anyone is at risk.
    Symptoms & Differential Diagnosis
    • Typical PTX presentation: Dyspnea, chest pain, pleuritic discomfort.
    • Exam clues: unilateral decreased breath sounds, focal tenderness/crepitus.
    • Red flags (suggest tension PTX):
      • JVD
      • Tracheal deviation
      • Hypotension, shock physiology
      • Severe tachycardia, hypoxia
    • Differential diagnoses:
      • Pulmonary: asthma, COPD, pneumonia, pulmonary edema (SCAPE), ILD, infections.
      • Cardiac: ACS, CHF, pericarditis.
      • PE and other acute causes of dyspnea.
    Diagnostics
    • Bloodwork: limited role, except type & screen if intervention likely.
    • EKG: reasonable given chest pain/shortness of br...
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  • Episode 212: Angioedema

    Episode 212: Angioedema
    2025/08/02
    Angioedema – Recognition and Management in the ED Hosts: Maria Mulligan-Buckmiller, MD Brian Gilberti, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/Angioedema.mp3 Download Leave a Comment Tags: Airway 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 Bowel wall angioedema can mimic acute abdomen: Nausea, vomiting, diarrhea, severe pain, increased intra-abdominal pressure, possible ischemia. Key Differentiating Features Histamine-mediated: rapid onset, hives/itching, resolves quickly with epinephrine, antihistamines, and steroids.Bradykinin-mediated: slower onset, lacks urticaria, prolonged duration, less responsive to standard anaphylaxis medications. Diagnostic Approach in the ED Focus on airway (ABCs) and clinical assessment.Labs (e.g., C4 level) useful for downstream diagnosis (esp. HAE) but not for acute management.Imaging: only if symptoms suggest abdominal involvement or to rule out other causes. Treatment Strategies Airway protection is always priority: Early consideration of intubation if worsening obstruction or inability to manage secretions. Histamine-mediated (anaphylaxis): Epinephrine (IM), antihistamines, corticosteroids. Bradykinin-mediated: Epinephrine may be tried if unclear etiology (no significant harm, lifesaving if histamine-mediated).Targeted therapies: Icatibant: bradykinin receptor antagonist.Ecallantide: kallikrein inhibitor (less available).C1 esterase inhibitor concentrate: replenishes deficient protein.Fresh frozen plasma (FFP): contains C1 esterase inhibitor.Tranexamic acid (TXA): off-label, less evidence, considered if no other options. Complications to Watch For Airway compromise: rapid deterioration possible.Abdominal compartment syndrome from bowel edema (rare, surgical emergency). Take-Home Points Secure the airway if in doubt.Differentiate histamine-mediated vs bradykinin-mediated by presence/absence of hives/itching and speed of onset.Use epinephrine promptly if suspecting histamine-mediated angioedema or if uncertain.Consider bradykinin-targeted therapies for confirmed hereditary, acquired, or ACE-inhibitor–related angioedema.Recognize ACE inhibitors as the most frequent medication trigger; ARBs rarely cause it.Labs and imaging generally don’t change initial ED management but aid diagnosis for follow-up care. Read More
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  • Episode 211: Granulomatosis with Polyangiitis

    Episode 211: Granulomatosis with Polyangiitis
    2025/07/01

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

    Hosts:
    Phoebe Draper, MD
    Brian Gilberti, MD

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/GPA.mp3 Download One Comment Tags: Rheumatology 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)
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  • Episode 210: Capacity Assessment

    Episode 210: Capacity Assessment
    2025/06/02

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

    Hosts:
    Anne Levine, MD
    Brian Gilberti, MD

    https://media.blubrry.com/coreem/content.blubrry.com/coreem/Capacity_Assessment.mp3 Download One Comment 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:
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