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Core EM - Emergency Medicine Podcast

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Core EM - Emergency Medicine Podcast

Episode 214: Acute Pulmonary Embolism

Thu, 02 Oct 2025







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


Hosts:

Vivian Chiu, MD

Brian Gilberti, MD









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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 minutes),

Episode 213: Pneumothorax

Mon, 01 Sep 2025







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


Hosts:

Christopher Pham, MD

Brian Gilberti, MD









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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 brea...

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:

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