Core EM - Emergency Medicine Podcast

Show Notes

Core EM Modular CME Course

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:

• Credit: 12.5 AMA PRA Category 1 Credits™


• Curriculum: Comprehensive coverage of Core Emergency Medicine,  with 12 modules spanning from Critical Care to Pediatrics.


• Cost:
  
  
  
  • Free for NYU Learners
  
  
  • $250 for Non-NYU Learners
  
  
  
  

Click Here to Register and Begin Module 1

The Clinical Case

• Presentation: 60-year-old male with a history of HTN and asthma.


• EMS Findings: Severe respiratory distress, SpO₂ in the 60s on NRB, HR 120, BP 230/180.


• Exam: Diaphoretic, diffuse crackles, warm extremities, pitting edema, and significant fatigue/work of breathing.


• Pre-hospital meds: NRB, Duonebs, Dexamethasone, and IM Epinephrine (under the assumption of severe asthma/anaphylaxis).

Differential Diagnosis for the Hypoxic/Tachypneic Patient

• Pulmonary: Asthma/COPD, Pneumonia, ARDS, PE, Pneumothorax, Pulmonary Edema, ILD, Anaphylaxis.


• Cardiac: CHF, ACS, Tamponade.


• Systemic: Anemia, Acidosis.


• Neuro: Neuromuscular weakness.

What is SCAPE?

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

• Pathophysiology: Unlike HFrEF, these patients are often euvolemic or even hypovolemic. The primary issue is fluid maldistribution (fluid shifting from the vasculature into the lungs) due to extreme afterload.

Bedside Diagnosis: POCUS vs. CXR

POCUS is the gold standard for rapid bedside diagnosis.

• Lung Ultrasound: Look for diffuse B-lines (≥3 in ≥2 bilateral zones).


• Cardiac: Assess LV function and check for pericardial effusion.


• Why not CXR? A meta-analysis shows LUS has a sensitivity of ~88% and specificity of ~90%, whereas CXR sensitivity is only ~73%. Importantly, up to 20% of patients with decompensated HF will have a normal CXR.

Management Strategy

1. NIPPV (CPAP or BiPAP)

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

• Settings: CPAP 5–8 cm H₂O or BiPAP 10/5 cm H₂O. Escalate EPAP quickly but keep pressures to avoid gastric insufflation.


• Evidence: NIPPV reduces mortality (NNT 17) and intubation rates (NNT 13).

2. High-Dose Nitroglycerin

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

• No IV Access: 3–5 SL tabs (0.4 mg each) simultaneously.


• IV Bolus: 500–1000 mcg over 2 minutes.


• IV Infusion: Start at 100–200 mcg/min; titrate up rapidly (doses > 800 mcg/min may be required).


• Safety: ACEP policy supports high-dose NTG as both safe and effective for hypertensive HF. Use a dedicated line/short tubing to prevent adsorption issues.

3. Refractory Hypertension

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

• Clevidipine: Ultra-short-acting calcium channel blocker (titratable and rapid).


• Nicardipine: Effective alternative for rapid BP control.


• Enalaprilat: Consider if the above are unavailable.

Troubleshooting & Pitfalls

The “Mask Intolerant” Patient

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).

• AVOID Morphine: Data suggests higher rates of adverse events, invasive ventilation, and mortality. A 2022 RCT was halted early due to harm in the morphine arm (43% adverse events vs. 18% with midazolam).

The Role of Diuretics

In SCAPE, diuretics are not first-line.

• The problem is redistribution, not volume excess. Diuretics will not help in the first 15–30 minutes and may worsen kidney function in a (relatively) hypovolemic patient.


• Delay Diuretics until the patient is stabilized and clear systemic volume overload (edema, weight gain) is confirmed.

Disposition

• Admission: Typically requires CCU/ICU for ongoing NIPPV and titration of vasoactive infusions.


• Weaning: As BP normalizes and work of breathing improves, infusions and NIPPV can be gradually tapered.

Take-Home Points

1. Recognize SCAPE: Hyperacute dyspnea + severe HTN. Trust your POCUS (B-lines) over a “clear” CXR.


2. NIPPV Immediately: Don’t wait. It saves lives and prevents tubes.


3. High-Dose NTG: Use boluses to “catch up” to the sympathetic surge. Don’t fear the dose.


4. Avoid Morphine: Use small doses of benzos if the patient is struggling with the mask.


5. Lasix Later: Prioritize afterload reduction over diuresis in the hyperacute phase.

Show Notes

Core EM Modular CME Course

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:

• Credit: 12.5 AMA PRA Category 1 Credits™


• Curriculum: Comprehensive coverage of Core Emergency Medicine,  with 12 modules spanning from Critical Care to Pediatrics.


• Cost:
  
  
  
  • Free for NYU Learners
  
  
  • $250 for Non-NYU Learners
  
  
  
  

Click Here to Register and Begin Module 1

What is prehospital blood transfusion

• 
  

  Administration of blood products in the field prior to hospital arrival

  
  


• 
  

  Aimed at patients in hemorrhagic shock

  
  

Why this matters

• 
  

  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

  
  

Supporting rationale

• 
  

  ATLS and trauma paradigms emphasize blood over fluid

  
  


• 
  

  National organizations support prehospital blood when feasible

  
  


• 
  

  EMS already manages high risk, time sensitive interventions

  
  

Evidence overview

• 
  

  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

  
  

LA County program

• 
  

  ~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

  
  

Indications used in LA County

• 
  

  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

  
  

Early experience

• 
  

  ~28 patients transfused at time of discussion

  
  


• 
  

  Evaluating:

  
  
  
  
  • 
    

    Indications

    
    
  
  
  • 
    

    Protocol adherence

    
    
  
  
  • 
    

    Time to transfusion

    
    
  
  
  • 
    

    Early outcomes

    
    
  
  
  
  


• 
  

  Too early for outcome conclusions

  
  

California collaboration

• 
  

  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

  
  

Barriers and concerns

• 
  

  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

  
  

Future direction

• 
  

  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

  
  

Take-Home Points

• 
  

  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

  
  

Show Notes

What is a BRUE?

• BRUE stands for Brief Resolved Unexplained Event.


• It typically affects infants <1 year of age and is characterized by a sudden, brief, and now resolved episode of one or more of the following:
  
  
  
  • 
    

    Cyanosis or pallor

    
    
  
  
  • 
    

    Irregular, absent, or decreased breathing

    
    
  
  
  • 
    

    Marked change in tone (hypertonia or hypotonia)

    
    
  
  
  • Altered level of responsiveness
  
  
  
  

Risk Stratification: Low Risk vs. High Risk

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:

1. 
   

   Age: > 60 days old

   
   


2. 
   

   Gestational Age: GA > 32 weeks (and Post-Conceptional Age > 45 weeks)

   
   


3. 
   

   Frequency: This is the first episode

   
   


4. 
   

   Duration: Lasted < 1 minute

   
   


5. 
   

   Intervention: No CPR performed by a trained professional

   
   


6. 
   

   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.

  
  


• Note: Serious underlying conditions are identified in approx. 4% of high-risk infants.

Differential Diagnosis: “THE MISFITS” Mnemonic

• 
  
  T – Trauma (Accidental or Non-accidental/Abuse)
  
  


• 
  
  H – Heart (Congenital heart disease, dysrhythmias)
  
  


• 
  
  E – Endocrine
  
  


• 
  
  M – Metabolic (Inborn errors of metabolism)
  
  


• 
  
  I – Infection (Sepsis, meningitis, pertussis, RSV)
  
  


• 
  
  S – Seizures
  
  


• 
  
  F – Formula (Reflux, allergy, aspiration)
  
  


• 
  
  I – Intestinal Catastrophes (Volvulus, intussusception)
  
  


• 
  
  T – Toxins (Medications, home exposures)
  
  


• 
  
  S – Sepsis (Systemic infection)
  
  

Workup & Diagnostics

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.

    
    
  
  
  
  


• Neuro: Consider Head CT/MRI and EEG if there are concerns for trauma or seizures.

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

Prognosis & Outcomes

• 
  

  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.

    
    
  
  
  
  

Take-Home Points

1. 
   

   Diagnosis of Exclusion: You cannot call it a BRUE until you have ruled out obvious causes via history and physical.

   
   


2. 
   

   Strict Criteria: Stick strictly to the Low Risk criteria guidelines. If they miss even one (e.g., age < 60 days), they are High Risk.

   
   


3. 
   

   Education: For low-risk families, the most valuable intervention is reassurance, education, and arranging close follow-up.

   
   


4. 
   

   Systematic Approach: For high-risk infants, use a structured approach (like THE MISFITS) to ensure you don’t miss rare but reversible causes.

   
   

Show Notes

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), requirement of vasopressors, or signs of shock → activate PERT team immediately.


• Crucial Mimics: Think broadly; consider pneumonia, ACS, pneumothorax, heart failure exacerbation, and aortic dissection.

Workup & Diagnostics

• History/Scoring: Ask about prior clots, recent surgeries, hospitalizations, travel. Use Wells/PERC criteria to assess pretest probability.


• Labs:
  
  
  
  • D-dimer: A good test to rule out PE in a patient with low probability. If suspicion is high, proceed directly to imaging.
  
  
  • Troponin/BNP: Act as RV stress gauges. Elevated levels are associated with increased risk of a complicated clinical course (25-40%).
  
  
  • Lactate: Helpful in identifying patients in possible cardiogenic shock.
  
  
  • EKG: Most common finding is sinus tachycardia. Classic RV strain patterns (S₁Q₃T₃, T-wave changes/inversions) are nonspecific.
  
  
  
  


• Imaging:
  
  
  
  • CXR: Usually normal, but quick and essential to rule out other causes.
  
  
  • CTPA: The usual standard and gold standard for stable patients. High sensitivity (> 95%) and can detect RV enlargement/strain.
  
  
  • V/Q Scan: Option for patients with contraindications to contrast (e.g., severe contrast allergies).
  
  
  • POCUS (Point-of-Care Ultrasound): Useful adjunct for unstable patients.
    
    
    
    • Bedside Echo: Can show signs of RV strain (enlarged RV, McConnell sign).
    
    
    • Lower Extremity Ultrasound: Can identify a DVT in proximal leg veins.
    
    
    
    
  
  
  
  

Treatment & Management

• Resuscitation (Reviving the RV):
  
  
  
  • Oxygenation: Give supplementally as needed (nasal cannula, non-rebreather, high flow).
  
  
  • Intubation: Avoid if possible; positive pressure ventilation can worsen RV dysfunction.
  
  
  • Fluids: Be judicious; even the smallest amount can worsen RV overload.
  
  
  • Vasopressors: Norepinephrine is preferred as first-line for hypotension/shock.
  
  
  
  


• Anticoagulation (Start Immediately):
  
  
  
  • Initial choice is UFH or LMWH (Lovenox).
  
  
  • Lovenox is preferred for quicker time to therapeutic range, but is contraindicated in renal dysfunction, older age, or need for emergent procedures.
  
  
  • DOACs can be considered for stable, low-risk patients as an outpatient.
  
  
  
  

Escalation for High-Risk PE

• Systemic Thrombolytics: Consider for very sick patients with shock/cardiac arrest (e.g., Alteplase 100 mg over two hours or a bolus in cardiac arrest). High risk of intracranial hemorrhage; weigh risks versus benefits.


• PERT Activation: Engage multidisciplinary teams (usually including ICU, CT surgery, and interventional radiology).


• Interventions: Consult specialists for catheter-directed thrombolysis or suction embolectomy. Surgical embolectomy can also be considered.


• Bridge to Care: Activate the ECMO team early for unstable patients to buy valuable time.

Prognosis & Disposition

• Mortality: Low risk < 1%; intermediate 3-15%; high risk 25-65%.


• Complications: 3-4% of patients develop Chronic Thromboembolic Pulmonary Hypertension (CTEPH). Others may have long-term RV dysfunction and chronic shortness of breath.


• Recurrence: ∼ 30% chance in the next few weeks to months, if not treated correctly.


• Disposition:
  
  
  
  • ICU: All high-risk and some intermediate-high risk patients.
  
  
  • Regular Floor: Intermediate-low risk patients.
  
  
  • Outpatient Discharge: Low-risk patients can be sent home on anticoagulation. Use PSI or HESTIA scores to risk stratify suitability, typically starting a DOAC.
  
  
  
  


• Shared Decision-Making: Critical to ensure care is safe and consistent with the patient’s wishes.