Core EM - Emergency Medicine Podcast

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Core EM - Emergency Medicine Podcast episodes

May 01, 2025Episode 209: Blast Crisis
We dive into the recognition and management of blast crisis.
Hosts:
Sadakat Chowdhury, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Blast_Crisis.mp3
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Tags: Hematology, Oncology
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.
Rapid deterioration is common — early recognition is critical.
Diagnostic Workup
CBC with differential: assess blast % and cytopenias.
Peripheral smear and manual diff: confirm immature blasts.
CMP: screen for tumor lysis syndrome:
Elevated potassium, phosphate, uric acid.
Low calcium.
LDH & uric acid: markers of high cell turnover.
Coagulation studies (PT, PTT): assess for DIC.
Definitive tests (done inpatient): bone marrow biopsy, flow cytometry.
Emergency Department Management
Resuscitation & ABCs: oxygen, IV fluids, vitals monitoring.
Avoid aggressive transfusions:
Risk of hyperviscosity with PRBCs and platelets.
Initiate broad-spectrum antibiotics early:
High suspicion for sepsis in functionally neutropenic patients.
Consider antifungals for prolonged febrile neutropenia.
Cytoreduction strategies:
Hydroxyurea to lower WBCs quickly.
Tyrosine kinase inhibitors (TKIs).
High-dose chemotherapy.
Early consultation with hematology/oncology is essential.
Mutation testing may guide targeted therapy.
Prognosis
Without treatment: median survival ~3 months.
With treatment:
Potential survival >1 year.
Best outcomes in patients who enter a second chronic phase and undergo allogeneic stem cell transplant.
Ethical & Logistical Considerations
Treatment may involve aggressive interventions with serious side effects.
Important to assess:
Patient goals of care.
Capacity for informed consent.
Resource limitations:
Not all hospitals have oncology services.
Patients may require transfer over long distances.
Emphasize early, transparent discussions with patients and families.
Top 3 Take-Home Points
Recognize early: Look for cytopenias, leukostasis, and rapid clinical decline.
Resuscitate appropriately: Start antibiotics; be cautious with transfusions.
Call for help: Early hematology/oncology involvement is essential for definitive care.

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11 min
April 15, 2025Episode 208: Geriatric Emergency Medicine
We explore the expanding field of Geriatric Emergency Medicine.
Hosts:
Ula Hwang, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Geriatric_Emergency_Medicine.mp3
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Tags: Geriatric
Show Notes
Key Topics Discussed
Importance and impact of geriatric emergency departments.
Optimizing care strategies for geriatric patients in ED settings.
Practical approaches for non-geriatric-specific EDs.
Challenges in Geriatric Emergency Care
Geriatric patients often present with:
Multiple chronic conditions
Polypharmacy
Functional decline (mobility issues, cognitive impairments, social isolation)
Adapting Clinical Approach
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.
Identifying High-Risk Geriatric Patients
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)
Minimizing Hospital-Related Harms
Involvement of multidisciplinary teams:
Social workers and care managers for care transitions
Geriatric-certified pharmacists for medication review
Coordination with outpatient services post-discharge
Implementing Geriatric Care in All EDs
Basic geriatric care achievable even in resource-limited or rural EDs.
Level 3 Geriatric ED Accreditation can be achieved through:
Improved care transitions
Staff education enhancements
Age-friendly environments (comfort, nutrition, hydration)
Future of Geriatric Emergency Medicine
Vision: Universal integration of geriatric-focused care.
Goals:
Enhanced patient experience
Improved care transitions
Alignment of treatments with patient goals
Broader enhancement of emergency care quality for all patient populations

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10 min
April 02, 2025Episode 207: Smoke Inhalation Injury
We discuss the injuries sustained from smoke inhalation.
Hosts:
Sarah Fetterolf, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Smoke_Inhalation.mp3
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Tags: Environmental, Toxicology
Show Notes
Table of Contents
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
Physiological Effects of Smoke Inhalation:
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.
Clinical Signs and Symptoms:
Physical Exam:
Facial burns, singed nasal hairs
Hoarseness, stridor (upper airway swelling)
Carbonaceous sputum (lower airway edema)
Systemic Symptoms:
Headache, dizziness, nausea
Syncope, seizures, altered mental status
Airway Management Considerations:
Not every patient requires immediate intubation.
Intubation should be performed early if airway compromise is suspected, as swelling can rapidly progress.
Close airway monitoring recommended for all patients.
Carbon Monoxide Poisoning:
Common cause of death post-smoke inhalation (50–75% of fire-related injuries).
Hemoglobin affinity 250 times greater for CO than oxygen, impairing tissue oxygenation.
Diagnosis:
Carboxyhemoglobin level via VBG (ensure proper lab ordering).
Pulse oximetry unreliable; falsely high readings.
Treatment:
Immediate high-flow oxygen administration.
Consider hyperbaric oxygen therapy for severe cases to reduce delayed neurocognitive sequelae.
Cyanide Poisoning:
Blocks cytochrome oxidase in electron transport chain, halting aerobic ATP production.
Patients present critically ill; notable features include:
Elevated lactate levels (>8–10 mmol/L)
Arterialization of venous blood
Treatment:
First-line therapy: hydroxocobalamin (Cyanokit) binds cyanide forming vitamin B12 for renal excretion.
Alternative: Cyanide antidote kit (amyl nitrite, sodium nitrite, sodium thiosulfate); induces methemoglobinemia and requires monitoring.
Important note: hydroxocobalamin turns blood and urine bright red; draw labs beforehand.
Key Takeaways:
Assess for airway compromise and signs of inhalation injury early.
Maintain a high index of suspicion for CO and cyanide poisoning in smoke inhalation victims.
Immediate, aggressive oxygen therapy and early antidote administration can significantly impact outcomes.

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11 min
March 03, 2025Episode 206: Acute Back Pain
We discuss the evaluation of and treatment options for acute back pain.
Hosts:
Benjamin Friedman, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acute_Back_Pain.mp3
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Tags: Musculoskeletal, Orthopaedics
Show Notes
**Please fill out this quick survey to help us develop additional resources for our listeners: Core EM Survey**
Clinical Evaluation:
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
Imaging Guidelines:
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
Treatment Options:
Evidence-Based First-Line:
NSAIDs offer modest benefit.
Skeletal muscle relaxants can be used but require caution due to side effects.
Ineffective Therapies:
Acetaminophen shows no benefit for back pain.
Steroids are not recommended for non-radicular pain, with only limited benefit in sciatica.
Topical treatments, lidocaine patches, and opioids are not supported by evidence and may pose additional risks.
Alternative and Experimental Interventions:
Nerve Blocks: Current evidence is limited; more research is needed on trigger point injections and erector spinae plane blocks.
Severe Pain Management:
A single opioid dose (preferably codeine or oral morphine) may be considered to facilitate discharge when necessary.
Use diazepam sparingly for immediate mobilization.
Onsite physical therapy in the ED can be beneficial when available.
Preventing Chronic Pain:
Research Focus: Ongoing studies are evaluating whether duloxetine (Cymbalta) can prevent the transition from acute to chronic back pain.
Non-Pharmacologic Measures: Consider spinal mobilization, physical therapy, acupuncture, and cognitive behavioral therapy (CBT) as adjuncts in management.
Take-Home Points:
Most acute back pain is benign, but watch for red flags like IV drug use, anticoagulation, or neurological symptoms (e.g., weakness, bladder dysfunction) that may indicate serious conditions like spinal infections, bleeds, or cord compression.
Avoid unnecessary lumbar X-rays in young, healthy patients without red flags—MRI is preferred only for those with risk factors, neurological deficits, or suspected cauda equina syndrome.
Use NSAIDs and skeletal muscle relaxants for acute musculoskeletal back pain, as they offer modest benefits. Avoid opioids, acetaminophen, and steroids for non-radicular pain, as they lack evidence.
For severe, uncontrolled pain, consider a single opioid dose (e.g., codeine) or diazepam sparingly
Encourage patients to engage in non-pharmacologic therapies like yoga, massage, or cognitive behavioral therapy to aid recovery and prevent chronic pain.

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18 min
February 02, 2025Episode 205: Family Presence during Resuscitation
We discuss the impact of family presence during resuscitations.
Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Family_Presence_During_Resuscitation.mp3
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Tags: Critical Care, Pediatrics
Show Notes
Overview
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.
Evidence from the Literature
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 offered the opportunity to be present during resuscitation.
79% of relatives in the intervention group witnessed CPR compared to 43% in the control group.
Family members who did not witness CPR had a higher likelihood of PTSD symptoms (adjusted OR 1.7, p=0.004).
Anxiety and depression symptoms were also higher in those who did not witness CPR.
Impact on Medical Teams:
The study found no evidence that family presence affected resuscitation success rates, medical team stress levels, or led to legal consequences.
Health professionals’ concerns over interference were largely unfounded.
Guideline Support & Barriers to Implementation
Professional recommendations from pediatric societies support family presence during resuscitations.
Barriers include:
Lack of institutional policies ensuring family inclusion.
Lack of formal training for providers on how to support families during these critical moments.
Final Takeaways
Encouraging institutional policy changes and training providers is key to implementing family presence during codes.
Medical teams should challenge outdated practices and prioritize family-centered care in the emergency department.
Family-witnessed resuscitation does not increase stress, legal risk, or compromise medical care—but it can significantly improve bereavement outcomes.

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4 min
January 01, 2025Episode 204: Necrotizing Fasciitis
We discuss the recognition and treatment of necrotizing fasciitis.
Hosts:
Aurnee Rahman, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Necrotizing_Fasciitis.mp3
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Tags: Critical Care, General Surgery
Show Notes
Table of Contents
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
Introduction
Necrotizing soft tissue infections can be easily missed in routine cases of soft tissue infection.
High mortality and morbidity underscore the need for vigilance.
Definition
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.
Types of Necrotizing Fasciitis
Type I (Polymicrobial)
Involves aerobic and anaerobic organisms (e.g., Bacteroides, Clostridium, Peptostreptococcus).
Common in immunocompromised patients or those with comorbidities (e.g., diabetes, peripheral vascular disease).
Type II (Monomicrobial)
Often caused by Group A Streptococcus (Strep pyogenes) or Staphylococcus aureus.
Can occur in otherwise healthy individuals.
Vibrio vulnificus (associated with water exposure) is another example.
Fournier’s Gangrene (Subset)
Specific to perineal, genital, and perianal regions.
Common in diabetic patients.
Higher mortality, especially in females.
Pathophysiology
Spread Along Fascia
Poor blood supply in fascial planes allows infection to advance rapidly.
Tissue ischemia worsened by vascular thrombosis → rapid necrosis.
High-Risk Patients
Diabetes with vascular compromise.
Recent surgeries or trauma (introducing bacteria into deep tissue).
Immunosuppression (e.g., cirrhosis, malignancy, or immunosuppressive meds).
NSAID use may mask symptoms, delaying diagnosis.
Clinical Presentation
Early Signs & Symptoms
Severe Pain out of proportion to exam findings.
Erythema (often with indistinct borders).
Fever, Malaise (systemic signs of infection).
Rapid progression with possible color changes (red → purple).
Bullae Formation (fluid-filled blisters) and skin necrosis/gangrene.
Crepitus in polymicrobial cases (gas production in tissue).
Late-Stage Signs
Systemic toxicity: hypotension, multi-organ failure if untreated.
Diagnosis
Clinical Suspicion Is Key
Pain out of proportion, rapid progression, systemic signs.
The “finger test” (small incision to explore fascial planes).
Surgical Consultation
Early surgical exploration is often the definitive diagnostic step.
Lab Tests
LRINEC Score (CRP, WBC, Hemoglobin, Sodium, Creatinine, Glucose) to stratify risk.
Not definitive but can guide suspicion.
Imaging
CT scan may reveal gas in tissues, fascial edema, or muscle involvement.
Must not delay surgical intervention if clinical suspicion is high.
Treatment Principles
Immediate & Aggressive Surgical Debridement
Often multiple surgical procedures are required as necrosis progresses.
Debridement back to healthy tissue margins.
Empiric Broad-Spectrum Antibiotics
Cover gram-positive (including MRSA), gram-negative, and anaerobes.
Examples include:
Vancomycin or Linezolid (for MRSA).
Piperacillin-tazobactam or Carbapenems (for gram-negative & anaerobes).
Clindamycin (to inhibit bacterial toxin production).
Adjust based on culture results later.
Adjunct Therapies
Hyperbaric Oxygen Therapy (if available) for resistant cases.
Evidence is mixed; not universally accessible.
Supportive Care
Intensive monitoring, often in an ICU setting.
Fluid resuscitation & vasopressors for septic shock.
Prognosis & Disposition
High Mortality Rate
Influenced by infection site, patient’s baseline health, and speed of intervention.
Importance of Rapid Intervention
Early recognition, aggressive surgery, and antibiotics improve survival.
Long-Term Considerations
Patients may require extensive rehabilitation.
Reconstructive surgery often needed for tissue deficits.
Disposition
Operative management is mandatory; patients do not go home.
Critical care admission is typical for hemodynamic monitoring and support.
Five Key Take-Home Points
High Suspicion Saves Lives: Recognize severe pain out of proportion as a critical red flag.
Know Your NF Types & Risk Factors: Type I polymicrobial vs. Type II monomicrobial, plus subsets (Fournier’s).
Clinical Diagnosis Above All: LRINEC and imaging help, but timely surgical exploration is paramount.
Combined Surgical & Medical Therapy: Early debridement + broad-spectrum antibiotics (including toxin inhibition) is lifesaving.
Extended Recovery & Mortality Risks: High mortality if missed or delayed. Expect prolonged rehab and possible multiple surgeries.
Resources & Further Reading
LRINEC Score Calculator
EMCrit – Necrotizing Fasciitis

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10 min
December 02, 2024Episode 203: Acetaminophen Toxicity
We sit down with one of our toxicologists to discuss acetaminophen toxicity.
Hosts:
Marlis Gnirke, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Acetaminophen_Toxicity.mp3
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Tags: Toxicology
Podcast Video
Show Notes
Table of Contents
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:
Widespread availability and under-recognition contribute to its prevalence.
The potential for unintentional overdose when taking multiple medications containing acetaminophen.
Pharmacokinetics and Metabolism:
Normal metabolism pathways of acetaminophen and the role of glutathione.
Formation of the toxic metabolite NAPQI during overdose situations.
Saturation of safe metabolic pathways leading to hepatotoxicity.
Pathophysiology of Liver Injury:
How excessive NAPQI leads to hepatocyte death, especially in zone III of the liver.
The difference between therapeutic dosing and overdose metabolism.
Clinical Stages of Acetaminophen Toxicity:
Stage 1: Asymptomatic or nonspecific symptoms (first 24 hours).
Stage 2: Onset of hepatic injury (24-72 hours), elevated AST/ALT.
Stage 3: Maximum hepatotoxicity (72-96 hours), signs of liver failure.
Stage 4: Recovery phase, complete hepatic regeneration if survived.
Antidote – N-Acetylcysteine (NAC):
Mechanisms of NAC in replenishing glutathione and detoxifying NAPQI.
The importance of early administration, ideally within 8 hours post-ingestion.
NAC’s role even in late presenters and in fulminant hepatic failure.
The Rumack-Matthew Nomogram:
How to use the nomogram for acute overdoses to determine the need for NAC.
Limitations in chronic overdoses and late presentations.
Emphasis on obtaining accurate time of ingestion and acetaminophen levels.
Treatment Protocols:
Standard 21-hour IV NAC protocol and dosing specifics.
Managing anaphylactoid reactions associated with IV NAC.
Criteria for extending NAC therapy beyond 21 hours.
Monitoring and Laboratory Work:
Importance of trending AST/ALT, INR, creatinine, lactate, and phosphate.
Use of the King’s College Criteria for potential liver transplant evaluation.
Special Considerations:
Adjustments in pediatric patients regarding NAC dosing volumes.
Awareness of IV acetaminophen overdoses and their management.
Emerging discussions on the use of fomepizole in massive overdoses.
Take-Home Points:
Comprehensive Medication History: Always inquire about all medications taken to assess for potential acetaminophen exposure.
Early Recognition and Treatment: Due to often silent initial stages, maintain a high index of suspicion and measure acetaminophen levels promptly.
Understanding Metabolism and Toxicity: Recognize how overdose alters metabolism, leading to toxic NAPQI accumulation.
N-Acetylcysteine Efficacy: NAC is most effective when administered early but remains beneficial even in advanced stages.
Proper Use of the Nomogram: Utilize the Rumack-Matthew Nomogram appropriately for acute ingestions and consult toxicology when in doubt.
Monitoring and Continuing Care: Be vigilant in monitoring laboratory values and prepared to extend NAC therapy as needed.
Consultation and Resources: Engage with poison control centers and utilize available resources for complex cases.

Resources Mentioned
Rumack-Matthew Nomogram
Rumack-Matthew Nomogram, credit: MDCalc
King’s College Criteria
King’s College Criteria for Acetaminophen Toxicity
Use this tool to assess the need for liver transplant evaluation in cases of acetaminophen-induced hepatic failure. Includes criteria for pH, INR, creatinine, and more.
Poison Control Center (available 24/7 for consultation): 1-800-222-1222

References
Goldfrank’s Toxicologic Emergencies, 9th Edition was consulted for information on the pharmacokinetics and clinical presentation of acetaminophen toxicity.
For more details, see: Nelson, L. S., Howland, M. A., Lewin, N. A., Smith, S. W., Goldfrank, L. R., & Hoffman, R. S. (Eds.). (2011). Goldfrank’s toxicologic emergencies (9th ed.). McGraw-Hill Education.

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29 min
November 01, 2024Episode 202: Sexually Transmitted Infections 2.0
We review Sexually Transmitted Infections and pertinent updates in diagnosis and management.
Hosts:
Avir Mitra, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Sexually_Transmitted_Infections_2_0.mp3
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Tags: gynecology, Infectious Diseases, Urology
Show Notes
Table of Contents
(1:49) Chlamydia
(3:31) Gonorrhea
(4:50) PID
(6:14) Syphilis
(8:08) Neurosyphilis
(9:13) Tertiary Syphilis
(10:06) Trichomoniasis
(11:13) Herpes
(12:49) HIV
(14:10) PEP
(15:13) Mycoplasma Genitalium
(18:00) Take Home Points
Chlamydia:
Prevalence:
Most common STI.
High percentage of asymptomatic cases (40% to 96%).
Presentation:
Urethritis, cervicitis, pelvic inflammatory disease (PID), prostatitis, proctitis, pharyngitis, arthritis.
Importance of considering extra-genital sites (oral and rectal infections).
Testing:
Gold Standard: Nucleic Acid Amplification Test (NAAT) via PCR.
Sampling Sites:
Endocervical or urethral swabs preferred over urine samples due to higher sensitivity.
Triple-site testing (genital, rectal, pharyngeal) recommended for comprehensive detection.
Treatment Updates:
Previous Regimen: Azithromycin 1 g orally in a single dose.
Current First-Line Treatment: Doxycycline 100 mg orally twice daily for 7 days.
Alternatives:
Azithromycin remains an option for patients unlikely to adhere to a 7-day regimen or for pregnant patients.
Note: PID treatment differs and will be discussed separately.
Gonorrhea:
Presentation:
Similar to chlamydia; can be asymptomatic.
Symptoms include urethritis, cervicitis, PID, prostatitis, proctitis, pharyngitis.
Testing:
Gold Standard: NAAT.
Sampling Sites:
Endocervical swabs are more sensitive than urine samples.
Triple-site testing is crucial to avoid missing infections.
Treatment Updates:
Previous Regimen: Ceftriaxone 250 mg IM plus azithromycin 1 g orally.
Current Recommendation: Ceftriaxone 500 mg IM single dose.
Adjusted due to rising azithromycin resistance and updated pharmacokinetic data.
Co-Infection Considerations:
High rates of chlamydia and gonorrhea co-infection (20% to 40%).
CDC recommends empiric treatment for chlamydia when treating gonorrhea to prevent complications like PID and infertility.
Pelvic Inflammatory Disease (PID):
Etiology:
Not solely caused by chlamydia and gonorrhea; about 50% of cases involve other pathogens like bacterial vaginosis (BV) organisms and anaerobes.
Treatment Changes:
Expanded Coverage Regimen:
Ceftriaxone 500 mg IM once.
Doxycycline 100 mg orally twice daily for 14 days.
Metronidazole 500 mg orally twice daily for 14 days.
Inclusion of metronidazole addresses anaerobic bacteria contributing to PID.
Syphilis:
Stages and Presentation:
Primary Syphilis:
Painless chancre on genitals.
Treatment: Penicillin G 2.4 million units IM single dose.
Secondary Syphilis:
Rash (often diffuse), mucocutaneous lesions, nonspecific joint pain.
Treatment: Same as primary syphilis.
Latent Syphilis:
Asymptomatic phase; divided into early (<1 year) and late (>1 year).
Treatment for Late Latent:
Penicillin G 2.4 million units IM once weekly for 3 weeks.
Recommended when the timing of infection is unclear.
Neurosyphilis:
Can occur at any stage.
Symptoms include visual changes, severe headaches, neurological deficits.
Diagnosis: Requires lumbar puncture (LP) for confirmation.
Treatment: Admission for intravenous penicillin G.
Tertiary Syphilis:
Rare, advanced stage with severe manifestations (e.g., gummas, cardiovascular complications, neurological signs).
Treatment: Extended penicillin therapy similar to late latent syphilis.
Trichomoniasis:
Presentation:
Often asymptomatic.
In women: Vaginal discharge.
In men: Urethritis.
Testing:
Shift from wet mount microscopy to NAAT for improved detection.
Swab samples preferred over urine for higher sensitivity.
Treatment Updates:
Previous Regimen: Metronidazole 2 g orally in a single dose.
Current Recommendations:
Women: Metronidazole 500 mg orally twice daily for 7 days.
Men: Single 2 g dose remains acceptable.
Herpes Simplex Virus (HSV):
Types and Transmission:
HSV-1 and HSV-2: Both can cause oral and genital infections.
Increasing crossover between oral and genital sites.
Testing:
Serum IgG testing not useful for acute diagnosis due to widespread prior exposure.
Preferred Method: PCR testing from lesion swabs.
Clinical Tip: If the lesion is characteristic, clinicians may start treatment without waiting for test results.
Treatment:
Preferred Medication: Valacyclovir (Valtrex) for ease of dosing.
Dosage:
Initial episode: 1 g orally twice daily for 7 to 10 days.
Recurrence: 1 g daily for 5 days.
Alternative: Acyclovir for cost considerations.
Human Immunodeficiency Virus (HIV):
Testing Limitations:
Window Periods:
Fourth-generation tests have a window period of 2 to 4 weeks.
Negative results during this period may not rule out recent infection.
Acute HIV Infection:
Presents with flu-like symptoms: malaise, joint pains, fatigue.
Diagnosis Challenges:
Standard HIV tests may be negative during the window period.
Options:
Empiric treatment with follow-up testing.
Order an HIV viral load test (more sensitive but expensive and delayed results).
Post-Exposure Prophylaxis (PEP):
Timing: Initiate ideally within 72 hours of potential exposure.
Duration: 28-day regimen.
Pre-Treatment Testing:
Baseline HIV test to rule out existing infection.
Renal and hepatic function tests to monitor for medication side effects.
Follow-Up: Reassess renal/hepatic function in 2 weeks.
Mycoplasma genitalium:
Recognition:
Newly recognized STI by the CDC in 2021.
Causes cervicitis and urethritis.
Possible associations with PID and proctitis, but not definitively established.
Testing:
When to Test:
Only in patients with persistent symptoms after standard STI testing and treatment.
Not recommended for initial screening.
Method: NAAT.
Treatment:
Step 1: Doxycycline 100 mg orally twice daily for 7 days.
Step 2: Moxifloxacin 400 mg orally once daily for 7 days.
Addresses antibiotic resistance concerns and ensures comprehensive treatment.
General Management and Patient Counseling:
Partner Notification:
Encourage patients to inform sexual partners for testing and treatment.
Medication Adherence:
Emphasize the importance of completing the full course of prescribed medications.
Prevention Measures:
Discuss the use of barrier protection (e.g., condoms) to prevent transmission and reinfection.
Follow-Up Care:
Advise patients to return if symptoms persist, indicating possible infections like Mycoplasma genitalium.
Key Take-Home Points:
Chlamydia Treatment Update:
Doxycycline 100 mg orally twice daily for 7 days is now first-line treatment for cervical infections.
For epididymitis, extend doxycycline to 10 days.
Gonorrhea Treatment Update:
Treat with a single 500 mg IM dose of ceftriaxone.
PID Management Update:
Expanded antimicrobial coverage includes:
Ceftriaxone 500 mg IM once.
Doxycycline 100 mg orally twice daily for 14 days.
Metronidazole 500 mg orally twice daily for 14 days.
Mycoplasma genitalium Recognition:
Test in patients with persistent symptoms after standard treatment.
Treat with doxycycline followed by moxifloxacin.
HIV Testing and PEP:
Be aware of HIV test window periods; negative results may not rule out recent infection.
Consider HIV viral load testing if acute infection is suspected.
Initiate PEP within 72 hours for a 28-day course, ensuring clear discharge planning and patient support.

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20 min
October 01, 2024Episode 201: Migraines
We discuss migraines with one of the authorities in the field.
Hosts:
Benjamin Friedman, MD of Montefiore
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Migraines.mp3
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Tags: Neurology
Show Notes

Initial Approach to Diagnosing Migraines:
Differentiating between primary headaches (migraine, tension-type, cluster) and secondary causes (e.g., subarachnoid hemorrhage).
The importance of patient history and reevaluation after initial treatment.
Recognizing the unique presentation of cluster headaches and their management implications.
Effective Acute Migraine Treatments:
First-line treatments including anti-dopaminergic medications like metoclopramide (Reglan) and prochlorperazine (Compazine), and parenteral NSAIDs like ketorolac (Toradol).
The limited role of triptans in the ED due to side effects and less efficacy compared to anti-dopaminergics.
The use of nerve blocks (greater occipital nerve block and sphenopalatine ganglion block) as effective treatments without systemic side effects.
Treatments to Avoid or Use with Caution:
Diphenhydramine (Benadryl): Studies show it does not prevent akathisia from anti-dopaminergics nor improve migraine outcomes.
IV Fluids: Routine use is not supported unless the patient shows signs of dehydration.
Magnesium: Conflicting evidence with some studies showing no benefit or even harm.
Managing Refractory Migraines:
Second-line treatments including additional doses of metoclopramide combined with NSAIDs or dihydroergotamine (DHE).
Considering opioids as a last resort when other treatments fail.
The potential use of newer medications like lasmiditan and CGRP antagonists.
Preventing Recurrence of Migraines:
Administering a single dose of dexamethasone (4 mg IV) to reduce the risk of headache recurrence after discharge.
Prescribing NSAIDs or triptans upon discharge for outpatient management.
Recognizing and addressing chronic migraine, and initiating preventive therapies like propranolol when appropriate.
Key Takeaways
Differentiate Primary from Secondary Headaches and Reassess After Treatment:
Use patient history and reevaluation post-treatment to distinguish migraines from more serious conditions, reducing unnecessary imaging and procedures.
First-Line Treatments Are Effective:
Anti-dopaminergic medications and NSAIDs are the mainstay of acute migraine treatment in the ED.
Reserve opioids for cases unresponsive to multiple lines of treatment.
Avoid Unnecessary Interventions:
Diphenhydramine and routine IV fluids do not have proven benefits and can be excluded to streamline care.
Utilize Nerve Blocks for Refractory Cases:
Greater occipital nerve blocks and sphenopalatine ganglion blocks are effective alternatives for patients not responding to medication.
Prevent Recurrence with Dexamethasone and Outpatient Planning:
A single IV dose of dexamethasone can help prevent recurrence.
Provide prescriptions and consider preventive therapies to reduce future ED visits.

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22 min
September 02, 2024Episode 200: Immune Checkpoint Inhibitors
We discuss a new class of medications, Immune Checkpoint Inhibitors, and their side effects.
Hosts:
Avir Mitra, MD
Brian Gilberti, MD
https://media.blubrry.com/coreem/content.blubrry.com/coreem/Immune_Checkpoint_Inhibitors.mp3
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Tags: Oncology
Show Notes
Overview of Immune Checkpoint Inhibitors (ICIs)
ICIs are a relatively new class of oncologic drugs that have revolutionized cancer treatment.
Unlike chemotherapy, ICIs help the immune system develop memory against cancer cells and adapt as the cancer mutates.
Since their release in 2011, ICIs have expanded to 83 indications for 17 different cancers, with approximately 230,000 patients using them.
Mechanism of Action
Cancer cells can evade the immune system by binding to T cell receptors that downregulate the immune response.
ICIs work by blocking these receptors or ligands, preventing the downregulation and allowing T cells to proliferate and attack cancer cells.
Common ICIs
Risks and Toxicities of ICIs
ICIs can lead to autoimmune attacks on healthy cells due to immune system upregulation.
Immune-related adverse effects (irAEs) include colitis, pneumonitis, dermatitis, hepatitis, and endocrine issues (e.g., hypothyroid, hypocortisolemia, hypophysitis).
These toxicities can present as infections, making diagnosis challenging in the emergency room.
Management of ICI Toxicities in the ER
Diagnosis: Look for signs that mimic infections (e.g., cough and fever in pneumonitis).
Diagnostic Imaging in pneumonitis: If CXR is normal but suspicion is high, consider CT scans to differentiate conditions like pneumonitis from other issues such as malignancy-associated pleural effusion or acute pulmonary embolism.
Treatment: The primary treatment for irAEs is steroids (e.g., prednisone 1 mg/kg). Start steroids early and hold the ICI to manage symptoms effectively and increase the likelihood of resuming ICI therapy later.
Consider using antibiotics in combination with steroids if there is uncertainty about whether symptoms are due to infection or ICI toxicity.
Coordinate care with the patient’s oncologist if possible
Disposition Decisions
Patient disposition (admit vs. discharge) should depend on clinical presentation and severity.
Coordination with oncology is crucial; they are often comfortable with starting steroids even if there is a potential infection.
Patients can be discharged if symptoms are mild, but sicker patients with more complex presentations may require admission.
Take-Home Points
ICIs are a new class of cancer drugs that effectively target cancer cells but come with unique immune-related toxicities.
Diagnosing irAEs can be challenging due to symptom overlap with infections.
The cornerstone of treatment is early administration of steroids and temporarily holding the ICI.
Close collaboration with oncology teams is essential for optimal patient management.

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14 min