We break down pneumothorax: risks, diagnosis, and management pearls.
Hosts:
Christopher Pham, MD
Brian Gilberti, MD
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 breath.
Episode 212: Angioedema
Sat, 02 Aug 2025Angioedema – Recognition and Management in the ED
Hosts:
Maria Mulligan-Buckmiller, MD
Brian Gilberti, MD
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 2025Granulomatosis with Polyangiitis (GPA) – Recognition and Management in the ED
Hosts:
Phoebe Draper, MD
Brian Gilberti, MD
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 2025We discuss capacity assessment, patient autonomy, safety, and documentation.
Hosts:
Anne Levine, MD
Brian Gilberti, MD
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 2025We dive into the recognition and management of blast crisis.
Hosts:
Sadakat Chowdhury, MD
Brian Gilberti, MD
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.
Send Message to Core EM - Emergency Medicine Podcast
Unverified Podcast
Is this your Podcast? Claim It!
Is this your Podcast? Claim It!