Angioedema – Recognition and Management in the ED

Hosts:
Maria Mulligan-Buckmiller, MD
Brian Gilberti, MD

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

Triggers increased vascular permeability → fluid shifts into tissues.

• 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.

• 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

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

Hosts:
Phoebe Draper, MD
Brian Gilberti, MD

• 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

• Chronic sinus symptoms
• Hemoptysis (especially bright red blood)
• New pulmonary complaints
• Renal dysfunction
• Constitutional symptoms (fatigue, weight loss, fever)

• 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)

• 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

• Goodpasture syndrome (anti-GBM antibodies)
• TB, fungal infections
• Lung malignancy
• Other vasculitides (EGPA, MPA, lupus)

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

Hosts:
Anne Levine, MD
Brian Gilberti, MD

• 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

• 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

• 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

• Understanding
  • Can the patient explain:
  • Their condition
  • Recommended treatments
  • Risks and benefits
  • Alternatives and outcomes?
• Sample prompts:

We dive into the recognition and management of blast crisis.

Hosts:
Sadakat Chowdhury, MD
Brian Gilberti, MD

• 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.

• 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.

• 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.

• 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.

We explore the expanding field of Geriatric Emergency Medicine.

Hosts:
Ula Hwang, MD
Brian Gilberti, MD

• Importance and impact of geriatric emergency departments.
• Optimizing care strategies for geriatric patients in ED settings.
• Practical approaches for non-geriatric-specific EDs.

• Geriatric patients often present with:
  • Multiple chronic conditions
  • Polypharmacy
  • Functional decline (mobility issues, cognitive impairments, social isolation)

• 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.

• 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)

We discuss the injuries sustained from smoke inhalation.

Hosts:
Sarah Fetterolf, MD
Brian Gilberti, MD

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

• 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.

We discuss the evaluation of and treatment options for acute back pain.

Hosts:
Benjamin Friedman, MD
Brian Gilberti, MD

• 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

• 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

• Evidence-Based First-Line:
  • NSAIDs offer modest benefit.

We discuss the impact of family presence during resuscitations.

Hosts:
Ellen Duncan, MD, PhD
Brian Gilberti, MD

• 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.

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...