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

Hosts:
Anne Levine, MD
Brian Gilberti, MD

• 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

• 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

• 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

• Understanding
  • Can the patient explain:
  • Their condition
  • Recommended treatments
  • Risks and benefits
  • Alternatives and outcomes?
• Sample prompts:

We dive into the recognition and management of blast crisis.

Hosts:
Sadakat Chowdhury, MD
Brian Gilberti, MD

• 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.

• 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.

• 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.

• 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.

We explore the expanding field of Geriatric Emergency Medicine.

Hosts:
Ula Hwang, MD
Brian Gilberti, MD

• Importance and impact of geriatric emergency departments.
• Optimizing care strategies for geriatric patients in ED settings.
• Practical approaches for non-geriatric-specific EDs.

• Geriatric patients often present with:
  • Multiple chronic conditions
  • Polypharmacy
  • Functional decline (mobility issues, cognitive impairments, social isolation)

• 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.

• 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)

We discuss the injuries sustained from smoke inhalation.

Hosts:
Sarah Fetterolf, MD
Brian Gilberti, MD

00:37 – Overview of Smoke Inhalation Injury

00:55 – Three Key Pathophysiologic Processes

01:41 – Physical Exam Findings to Watch For

02:12 – Airway Management and Early Intervention

03:23 – Carbon Monoxide Toxicity

04:24 – Workup and Initial Treatment of CO Poisoning

06:14 – Cyanide Toxicity

07:19 – Treatment Options for Cyanide Poisoning

09:12 – Take-Home Points and Clinical Pearls

• Thermal Injury:
  • Direct upper airway damage from heated air or steam.
  • Leads to swelling, inflammation, and possible airway obstruction.
• Chemical Irritation:
  • Causes bronchospasm, mucus plugging, and inflammation in the lower airways.
  • Increases capillary permeability, potentially causing pulmonary edema.
• Systemic Toxicity:
  • Primarily involves carbon monoxide and cyanide poisoning.

We discuss the evaluation of and treatment options for acute back pain.

Hosts:
Benjamin Friedman, MD
Brian Gilberti, MD

• Primary Goal: Distinguish benign musculoskeletal pain from serious pathology.
• Red Flags: Look for indicators of spinal infection, spinal bleed, or space-occupying lesions (e.g., tumors, large herniated discs).
• Assessment: A thorough history and neurological exam (strength testing, gait) is essential.
• Additional Tools: Use bedside ultrasound for post-void residual assessment in suspected cauda equina syndrome

• Routine Imaging: Generally not indicated for young, healthy patients without red flags.
• ACEP Recommendations: Avoid lumbar X-rays in patients under 50 without risk factors, as they do not change management and may increase costs and ED time.
• Advanced Imaging: Reserve MRI for patients with red flags, neurological deficits, or suspected cauda equina syndrome; CRP may be a part of your calculus when evaluating for infectious causes of back pain

• Evidence-Based First-Line:
  • NSAIDs offer modest benefit.

We discuss the impact of family presence during resuscitations.

Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD

• Historical Context: The conversation around allowing family members in the room during resuscitation events began gaining attention in 1987. Since then, the practice has been increasingly encouraged.
• Current Practices in Pediatrics:
  • Family presence during pediatric resuscitations remains inconsistent, with healthcare provider acceptance ranging from 15% to 85%.
  • Many subspecialists and consultants still request that families step out, often due to outdated concerns.
• Common Concerns & Myths:
  • Interference in resuscitation → Studies show minimal disruption.
  • Legal risks → No increased litigation risk has been demonstrated.
  • Family trauma → Research suggests that presence may help with grieving and reduce PTSD symptoms.

New England Journal of Medicine study on Family Presence During Cardiopulmonary Resuscitation (Jabre et al., 2013):

• In a randomized controlled trial of 570 relatives, PTSD-related symptoms were significantly higher in family members who were not...

We discuss the recognition and treatment of necrotizing fasciitis.

Hosts:
Aurnee Rahman, MD
Brian Gilberti, MD

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

• Necrotizing soft tissue infections can be easily missed in routine cases of soft tissue infection.
• High mortality and morbidity underscore the need for vigilance.

• A rapidly progressive, life-threatening infection of the deep soft tissues.
• Involves fascia and subcutaneous fat, causing fulminant tissue destruction.
• High mortality often due to delayed recognition and treatment.

• Type I (Polymicrobial)
  • Involves aerobic and anaerobic organisms (e.g., Bacteroides, Clostridium, Peptostreptococcus).

We sit down with one of our toxicologists to discuss acetaminophen toxicity.

Hosts:
Marlis Gnirke, MD
Brian Gilberti, MD

0:35 – Hidden acetaminophen toxicity in OTC products

3:24 – Pharmacokinetics and toxicokinetics

6:06 – Clinical Course

9:22 – The antidote – NAC

11:02 – The Rumack-Matthew Nomogram

17:36 – Treatment protocols

22:34 – Monitoring and Lab Work

23:23 – Considerations when treating pediatric patients

23:57 – IV APAP overdose, fomepizole

25:42 – Take Home Points

Acetaminophen vs. Tylenol:

• The importance of recognizing that acetaminophen is found in many products beyond Tylenol.
• Common medications containing acetaminophen, such as Excedrin, Fioricet, Percocet, Dayquil/Nyquil, and others.
• The risk of unintentional overdose due to combination products.

Prevalence of Acetaminophen Toxicity: