Core EM - Emergency Medicine Podcast

We review diagnosing and managing bacterial meningitis in the ED.

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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. 

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We discuss the diagnosis and management of SCAPE in the ED.

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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:

Sympathetic Crashing Acute Pulmonary Edema (SCAPE) is characterized by a sudden, massive sympathetic surge leading to intense vasoconstriction and a precipitous rise in afterload.

POCUS is the gold standard for rapid bedside diagnosis.

Start NIPPV immediately to reduce preload/afterload and recruit alveoli.

The goal is to drop SBP to < 140–160 mmHg within minutes.

If SBP remains > 160 mmHg despite NIPPV and aggressive NTG, add a second vasodilator:

Hypoxia is the primary driver of agitation. NIPPV is the best sedative. * Pharmacology: If needed, use small doses of benzodiazepines (Midazolam 0.5–1 mg IV).

In SCAPE, diuretics are not first-line.

We discuss the shift to prehospital blood to treat shock sooner.

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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:

Administration of blood products in the field prior to hospital arrival

Aimed at patients in hemorrhagic shock

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

ATLS and trauma paradigms emphasize blood over fluid

National organizations support prehospital blood when feasible

EMS already manages high risk, time sensitive interventions

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

~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

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

~28 patients transfused at time of discussion

Evaluating:

Indications

Protocol adherence

Time to transfusion

Early outcomes

Too early for outcome conclusions

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

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

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

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

We review BRUEs (Brief Resolved Unexplained Events).

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Cyanosis or pallor

Irregular, absent, or decreased breathing

Marked change in tone (hypertonia or hypotonia)

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.

Differential Diagnosis: “THE MISFITS” Mnemonic

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.

Clinical Pearl: Only ~6% of diagnostic tests contribute meaningfully to the diagnosis. Be judicious—avoid “shotgunning” tests in low-risk patients.

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.

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.

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

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

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

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Angioedema – Recognition and Management in the ED

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

Triggers increased vascular permeability → fluid shifts into tissues.

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

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

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Time Pressure

Communication Barriers

Ethical Dilemmas

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