204 episodes

Core EM is dedicated to bringing Emergency Providers all things core content Emergency Medicine. In the true spirit of Emergency Medicine our content is available to anyone, anywhere, anytime.

Core EM - Emergency Medicine Podcast Core EM

    • Health & Fitness
    • 4.3 • 32 Ratings

Core EM is dedicated to bringing Emergency Providers all things core content Emergency Medicine. In the true spirit of Emergency Medicine our content is available to anyone, anywhere, anytime.



    We discuss the approach to diagnosing and managing hypernatremia in the emergency department.


    Abigail Olinde, MD

    Brian Gilberti, MD



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    Tags: Electorlye

    Show Notes

    Episode Overview:

    * Introduction to Hypernatremia

    * Definition and basic concepts

    * Clinical presentation and risk factors

    * Diagnosis and management strategies

    * Special considerations and potential complications

    Definition and Pathophysiology:

    * Hypernatremia is defined as a serum sodium level over 145 mEq/L.

    * It can be acute or chronic, with chronic cases being more common.

    * Symptoms range from nausea and vomiting to altered mental status and coma.

    Causes of Hypernatremia based on urine studies:

    * Urine Osmolality > 700 mosmol/kg

    * Causes:

    * Extrarenal Water Losses: Dehydration due to sweating, fever, or respiratory losses

    * Unreplaced GI Losses: Vomiting, diarrhea

    * Unreplaced Insensible Losses: Burns, extensive skin diseases

    * Renal Water Losses with Intact AVP Response:

    * Diuretic phase of acute kidney injury

    * Recovery phase of acute tubular necrosis

    * Postobstructive diuresis

    * Urine Osmolality 300-600 mosmol/kg

    * Causes:

    * Osmotic Diuresis: High glucose (diabetes mellitus), mannitol, high urea

    * Partial AVP Deficiency: Incomplete central diabetes insipidus

    * Partial AVP Resistance: Nephrogenic diabetes insipidus

    * Urine Osmolality 100 mEq/L

    * Causes:

    * Sodium Overload: Ingestion of salt tablets, hypertonic saline administration

    * Salt Poisoning: Deliberate or accidental ingestion of large amounts of salt

    * Mixed or Variable Urine Sodium

    * Causes:

    * Diuretic Use: Loop diuretics, thiazides

    * Adrenal Insufficiency: Mineralocorticoid deficiency

    * Osmotic Diuresis with Renal Water Losses: High glucose, mannitol

    Risk Factors:

    * Patients with impaired thirst response or those unable to access water (e.g., altered or ventilated patients) are at higher risk.

    * Important to consider underlying conditions affecting thirst mechanisms.


    * Initial assessment includes history, physical examination, and laboratory tests.

    Episode 197: Acute Agitation

    Episode 197: Acute Agitation

    We discuss an approach to the acutely agitated patient and review medications commonly used.


    Jonathan Kobles, MD

    Brian Gilberti, MD



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    Tags: Agitation, psychiatry, Toxicology

    Show Notes


    •Definition and Scope: Agitation encompasses behaviors from restlessness to severe altered mental states. It’s a common emergency department presentation, often linked with acute medical or psychiatric emergencies.

    •Significance: Patients with agitation are at high risk for morbidity and mortality, necessitating prompt and effective management to prevent harm to themselves and healthcare providers.

    A Changing Paradigm in Describing Agitation

    •Terminology Shift: Move away from terms like ‘excited delirium’ due to their politicization and stigmatization. Focus on describing agitation by severity and underlying causes.

    Agitation as a Multifactorial Process

    •Complex Nature: Recognize agitation as a result of various factors, including medical, psychiatric, and environmental influences.

    Recognizing Agitation

    •Signs and Symptoms: Identify agitation early by monitoring for behaviors such as hostility, pacing, non-compliance, and verbal aggression.

    Initial Evaluation

    •Severity Assessment: Determine the severity of agitation and prioritize reversible causes and life-threatening conditions.

    •Diagnostic Steps: Perform vital signs check, blood glucose levels, ECG, and a targeted medical screening exam.

    Life Threats

    •Immediate Concerns: Identify and address immediate life threats such as hypoxia, hypoglycemia, trauma, and acute neurological emergencies.

    Forming a Differential Prior to Treatment

    •Prioritization: Severe agitation requires immediate treatment to facilitate further evaluation and reduce risk of harm.

    Physician/Staff Safety

    •Safety Measures: Ensure personal and team safety by maintaining a calm environment and preparing for potential violence.

    Multimodal Approach

    •Self-check In: Physicians should mentally prepare and approach the situation calmly to ensure effective management.

    •Verbal De-escalation: Use techniques focused on safety, therapeutic alliance, and patient autonomy to manage agitation non-pharmacologically.

    Medication Administration

    •Oral/Sublingual Medications: Consider oral medications for less severe cases to maintain patient autonomy and avoid invasive procedures.

    •IM or IV Medications: Use intramuscular or intravenous medications for rapid control in severe cases.

    Specific Medication Regimens

    •PO Regimens:

    •Medications: Antipsychotics like Zyprexa (olanzapine) 5-10 mg, benzodiazepines like Ativan (lorazepam) 1-2 mg.

    •Benefits: Empower patients with a sense of autonomy, avoid injection-related trauma.

    The Critically Ill Infant

    The Critically Ill Infant

    We discuss an approach to the critically ill infant.


    Ellen Duncan, MD, PhD

    Brian Gilberti, MD



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    Tags: Pediatrics

    Show Notes

    The Critically Ill Infant: THE MISFITS


    * ‘T’ in the mnemonic stands for trauma, which includes both accidental and intentional causes.

    * Considerations for Non-accidental Trauma:

    * Stresses the importance of considering non-accidental trauma, especially given that it may not always present with obvious external signs.

    * Anatomical Vulnerabilities:

    * Highlights specific anatomical considerations for infants who suffer from trauma:

    * Infants have proportionally larger heads, increasing their susceptibility to high cervical spine (c-spine) injuries.

    * Their liver and spleen are less protected, making abdominal injuries potentially more severe.


    * 5 T’s of Cyanotic Congenital Heart Disease: Introduces a mnemonic to help remember key right-sided ductal-dependent lesions:

    * Truncus Arteriosus: Single vessel serving as both pulmonary and systemic outflow tract.

    * Transposition of the Great Arteries: The pulmonary artery and aorta are switched, leading to improper circulation.

    * Tricuspid Atresia: Absence of the tricuspid valve, leading to inadequate development of the right ventricle and pulmonary circulation issues.

    * Tetralogy of Fallot: Comprises four defects—ventricular septal defect, pulmonary stenosis, right ventricular hypertrophy, and an overriding aorta.

    * Total Anomalous Pulmonary Venous Connection (TAPVC): Pulmonary veins do not connect to the left atrium but rather to the right heart or veins, causing oxygen-rich blood to mix with oxygen-poor blood.

    * Other Significant Conditions:

    * Ebstein’s Anomaly: Malformation of the tricuspid valve affecting right-sided heart function.

    * Pulmonary Atresia/Stenosis: Incomplete formation or narrowing of the pulmonary valve obstructs blood flow to the lungs.

    * Left-sided Ductal-Dependent Lesions:

    * Conditions such as aortic arch abnormalities (coarctation or interrupted arch), critical aortic stenosis, and hypoplastic left heart syndrome are highlighted. These generally present with less obvious cyanosis and more pallor.

    * Diagnostic and Management Considerations:

    * Routine prenatal ultrasounds detect most cases, but conditions like coarctation of the aorta and TAPVC might not be apparent until after birth when the ductus arteriosus closes.

    * Emphasizes the importance of a thorough physical exam: checking for murmurs, assessing hepatosplenomegaly, feeling for femoral pulses, measuring pre- and post-ductal saturations,



    We review Acute Respiratory Distress Syndrome


    Sadakat Chowdhury, MD

    Brian Gilberti, MD



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    Tags: Critical Care, Pulmonary

    Show Notes

    * Definition of ARDS:

    * Non-cardiogenic pulmonary edema characterized by acute respiratory failure.

    * Berlin criteria for diagnosis include acute onset within 7 days, bilateral pulmonary infiltrates on imaging, not fully explained by cardiac failure or fluid overload, and impaired oxygenation with PaO2/FiO2 ratio 5 cm H2O.

    * Severity based on oxygenation (Berlin criteria):

    * Mild: PaO2/FiO2 200-300 mmHg

    * Moderate: PaO2/FiO2 100-200 mmHg

    * Severe: PaO2/FiO2 100 mmHg

    * Epidemiology:

    * Occurs in up to 23% of mechanically ventilated patients.

    * Mortality rate of 30-40%, primarily due to multiorgan failure.

    * Differentiation from Cardiogenic Pulmonary Edema:

    * Chest CT shows diffuse edema and pleural effusion in cardiogenic edema; patchy edema, dense consolidation in ARDS.

    * Ultrasound may show diffuse B lines in cardiogenic edema; patchy B lines and normal A lines in ARDS.

    * Pathophysiology:

    * Exudative phase: Immune-mediated alveolar damage, pulmonary edema, cytokine release.

    * Proliferative phase: Reabsorption of edema fluid.

    * Fibrotic phase: Potential for prolonged ventilation.

    * Etiology:

    * Direct lung injury (pneumonia, toxins, aspiration, trauma, drowning) and indirect causes (sepsis, pancreatitis, transfusion reactions, certain drugs).

    * Diagnostics:

    * Comprehensive workup including imaging (chest X-ray, CT), laboratory tests (complete blood count, basic metabolic panel, blood gases), and specialized tests depending on suspected etiology.

    * Management Strategies:

    * Steroids: Beneficial in certain etiologies of ARDS, with specifics on dosing and duration.

    * Fluid Management: Conservative fluid strategy, diuresis guided by patient condition.

    * Ventilation: Non-invasive ventilation (NIV) preferred in specific cases; mechanical ventilation strategies to ensure lung-protective ventilation.

    * Proning: Used in severe ARDS to improve oxygenation.

    * Inhaled Vasodilators: Used for refractory hypoxemia and specific complications like right heart failure.

    * Extracorporeal Membrane Oxygenation (ECMO): Considered for severe ARDS as salvage therapy.

    * Supportive Care: Includes monitoring and management of complications, nutrition, and physical therapy.

    * Ventilation Specifics:

    * Tidal volume and pressure settings aim for lung-protective strategies to prevent ventilator-induced lung injury.

    * Permissive hypercapnia, plateau pressure, PEEP,

    Nitrous Oxide Toxicity

    Nitrous Oxide Toxicity

    We review Nitrous Oxide Toxicity: Symptoms, diagnosis, and treatment overview


    Stefanie Biondi, MD

    Brian Gilberti, MD



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    Tags: Toxicology

    Show Notes

    Patient Case Illustration

    * Hypothetical case: 21-year-old male with no previous medical history, experiencing a month of progressively worsening numbness, tingling, and weakness. Initially starting in his toes and spreading to his hips, and later involving his hands, the symptoms eventually escalated to the point of immobilization. Despite initially denying drug use, the patient admitted to using 40-60 canisters of nitrous oxide (whippets) every weekend for the last three months.

    Background and Recreational Use of Nitrous Oxide

    * Nitrous oxide, a colorless, odorless gas with anesthetic properties.

    * Synthesized in the 18th century.

    * Its initial medical purpose expanded into recreational use due to its euphoric effects.

    * Resurgence as a recreational drug during the COVID-19 lockdowns.

    * Accessibility and legal status.

    Public Misconceptions and Health Consequences

    * There are widespread misconceptions about nitrous oxide

    * Particularly the belief in its safety and lack of long-term health risks.

    * Contrary to popular belief, frequent use of nitrous oxide can lead to significant, sometimes irreversible, health issues.

    Neurological Examination and Diagnosis

    * Key components of the examination include assessing strength, sensation, cranial nerves, and proprioception, with specific abnormalities such as symmetrically decreased strength in a stocking-glove pattern, upgoing Babinski reflex, and positive Romberg sign being indicative of potential toxicity. 

    Physical Exam Findings: Upper vs Lower Motor Neuron Lesions

    Localize the Lesion- Differential Diagnoses for Extremity Weakness 

    Localize the Lesion- Differential Diagnoses for Extremity Weakness

    Localize the Lesion- Differential Diagnoses for Extremity Weakness

    MRI Findings and Subacute Combined Degeneration

    * The MRI displayed symmetric high signal intensity in the dorsal columns, a diagnostic feature identified as the inverted V sign or inverted rabbit ear sign.

    * Significance of the Inverted V Sign: This MRI sign is pathognomonic for subacute combined degeneration, indicating it is a distinct marker for this condition.

    * T2 Weighted Axial Images: The inverted V sign is observed in T2 weighted axial MRI images, which are used to evaluate the presence and extent of demyelination within the spinal cord.

    * Interpretation of Hyperintense Signals: Hyperintense signals on T2 weighted images generally indicate demyelination, where the protective myelin sheath around nerve fibers is damaged or destroyed.

    * Anatomical Location: The dorsal columns,

    Threatened Abortion

    Threatened Abortion

    We review threatened abortion and the complexities in its care.


    Stacey Frisch, MD

    Brian Gilberti, MD



    One Comment

    Tags: OBGYN

    Show Notes


    * Defined as vaginal bleeding during early pregnancy (before 20 weeks) with a closed cervical os, no passage of fetal tissue, and IUP on ultrasound

    * Occurs in 20-25% of all pregnancies.

    Initial Assessment and Management

    * Priority is to assess patient stability, establish good IV access, FAST may be helpful in identifying some ruptured ectopics early

    * Broad differential diagnosis is crucial to avoid mistaking conditions like ectopic pregnancy for other emergencies.

    * Importance of a detailed history and physical examination.

    Diagnostic Approach

    * Essential tests include HCG level, urinalysis, and possibly CBC + blood type/Rh status.

    * Rhogam’s use is well-supported in second and third trimester bleeding; however, data is less robust for first trimester bleeding in preventing sensitization

    * Importance of interpreting b-HCG with caution and understanding HCG discriminatory zones.

    * Use of ultrasound imaging, both bedside and formal, to assess the pregnancy’s status.

    Patient Counseling and Management

    * Open and honest communication about the prognosis of threatened abortion.

    * Addressing psychosocial aspects, including dispelling guilt and myths, and screening for intimate partner violence and mental health issues.

    * Recommendations against bedrest and certain activities

    * Lack of evidence supporting restrictions on sexual activity.

    * Standard pregnancy guidelines: avoiding smoking, alcohol, drug use, and starting prenatal vitamins.

    Follow-up and Precautions

    * Adopting a wait-and-see approach for stable patients, with scheduled follow-ups for ultrasounds and beta-HCG tests.

    * Educating patients on critical warning signs that require immediate medical attention.

    * Emphasizing the importance of returning to the hospital if experiencing significant bleeding or other severe symptoms.

    Take Home Points

    * Threatened Abortion is defined as Experiencing abdominal pain and/or vaginal bleeding during early pregnancy (before 20 weeks), characterized by a closed cervical os and no expulsion of fetal tissue. In these cases, it is important to assess patient stability promptly.

    * Keep your differential broad in these cases. The evaluation will in most cases involve a combination of labs and ultrasound imaging. 

    * Understand that the Rhogam certainly has a role in second and third trimester vaginal bleeding in the Rh-negative patient, and that there is a dearth of good data on its role in the first trimester – it will ultimately be a decision that is made by you, OBGYN, and the patient. 

Customer Reviews

4.3 out of 5
32 Ratings

32 Ratings

Dr. Kelbs ,

Fantastic, concise, the BEST!

I have listened to many EM podcasts as a CCFP-EM resident (as part of a rural program I drive 4 hours every week and listen to a lot!). This is by far the most useful, concise and informative podcast. Keep it up!!

Paul greet ,

EM Podcast

Great podcast! Love the focussed approach to core topics in EM and keeping the podcast to a digestible length. Is there any way that previous podcasts can be left uploaded to itunes?

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