Core EM - Emergency Medicine Podcast

We review BRUEs (Brief Resolved Unexplained Events). Hosts: Ellen Duncan, MD, PhD Noumi Chowdhury, MD https://media.blubrry.com/coreem/content.blubrry.com/coreem/BRUE.mp3 Download Leave a Comment Tags: Pediatrics 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 Crucial Caveat: BRUE is a diagnosis of exclusion. If the history and physical exam reveal a specific cause (e.g., reflux, seizure, infection), it is not a BRUE. 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: 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. 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 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. Read More

Dr. Zayan Firou, an expert in emergency medicine from Rwanda, shares insights from the country's Marburg virus outbreak. He recounts how the initial cluster of cases highlighted the vulnerability of healthcare workers and led to tragic fatalities. Notably, rapid access to experimental therapies and vaccines significantly impacted the outbreak's outcome, reducing the fatality rate. Dr. Firou emphasizes the need for resilient healthcare systems, local production of vaccines, and the importance of equity in emergency care to prepare for future global threats.

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Dr. Maria Mulligan-Buckmiller, a rock star chief resident, shares her expertise on angioedema management in the emergency department. She dives into the different types of angioedema, highlighting the crucial distinctions between histamine and bradykinin-mediated responses. The podcast discusses clinical presentations, including upper airway swelling and abdominal symptoms. Mulligan-Buckmiller emphasizes the importance of timely interventions and effective airway management, as well as key treatments like Icatabant and C1 esterase inhibitors to address potential complications.

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In this discussion, Anne Levine, a former chief resident and now a simulation fellow, teams up with Brian Gilberti to delve into the complexities of capacity assessment in emergency departments. They highlight the balance between patient autonomy and the ethical need for safety. Real-world examples, like intoxicated patients and those facing serious health decisions, showcase the nuanced decision-making involved. The conversation also unpacks the vital pillars of capacity assessment and the legal ramifications of failing to properly evaluate a patient's decision-making capability.

Join Sadakat Chowdhury, an emergency medicine physician specializing in ARDS and trauma, as he uncovers the urgent complexities of blast crisis in chronic myeloid leukemia. Discover the critical symptoms stemming from pancytopenia and leukostasis, impacting multiple systems from neurological to cardiopulmonary. Chowdhury discusses key management strategies in emergency care and navigates the ethical dilemmas that arise, emphasizing the balance between aggressive treatment and patient autonomy. A must-listen for insights into this oncologic emergency!

Ula Hwang, a full professor at NYU and a trailblazer in geriatric emergency medicine, discusses the growing importance of specialized emergency care for older adults. She highlights the unique challenges faced by these patients, such as polypharmacy and functional decline. The conversation delves into essential screening tools to identify at-risk seniors and emphasizes customized care strategies. Ula also covers the need for multidisciplinary teams in emergency settings to ensure safe transitions and optimal outcomes for geriatric patients.

Smoke inhalation injuries can lead to serious complications, including airway obstruction from thermal injury. Key symptoms to watch for include facial burns and altered mental status. Carbon monoxide toxicity is a critical concern, requiring immediate oxygen treatment and potential hyperbaric therapy. Cyanide poisoning poses a lethal risk, affecting cellular respiration, but can be countered with hydroxocobalamin. Quick recognition and targeted interventions are crucial for effective management.