FOAMcastini 3 – All About the Pearls


In this tiny episode, Jeremy reviews his favorite pearl from each episode, loooking at episodes 4-14.  Why the repetition?  Well, it turns out we learn better when information is spaced in small aliquots over time (spaced repetition).

Episode 4 – Transfusions and Ingested Foreign Bodies.

  • Most common infection from blood transfusion – Parvovirus B19

Episode 5 – Psychiatry and Increased ICP.

  • If re-initiating medications in the emergency department, some need to be titrated up slowly, such as quetiapine (Seroquel) and risperidone.
  • Figure out why patients stopped taking their medications.

Episode 6 – Hepatic Emergencies.

  • INR peaks after about 24-36 h in acute liver failure
  • AST>3000 suggests toxic or ischemic injury
  • ALT OR AST>300: Alk phos is useful.

Episode 7 – Heart Failure.

  • Right Ventricle MI: ST elevation in lead III greater than lead II – you know what to do (cath lab).  ST elevation in II greater than III – think pericarditee (pericarditis).
  • Right sided leads: elevation in V4R most specific but elevation in V3R-6R are indicative of RVMI.

Episode 8 – Acid-Base and Hyponatremia.

  • Strong Ion Difference (SID), which is the difference between the sums of concentrations of the strong cations and strong ions (typically Sodium minus Chloride). Small SID = acidic (example SID of 0.9% NaCl = 0)

Episode 9 – Pregnancy Emergencies.

  • The discriminatory zone is out.  Get ultrasounds in pregnant patients, regardless of the quantitative beta-hCG. A certain beta-hCG level can not be used to rule in or rule out ectopic pregnancy or viable intrauterine pregnancy (IUP), get the ultrasound and ensure you identify the uterus.

Episode 10 – Pediatric GI Emergencies.

  • Jaundice in the first 24 hours is NOT normal and is bad.

Episode 11 – Ebola and Transmission Precautions.

  • Airborne precautions recommended for: Measles (rubeola), Varicella, Tuberculosis.  Ebola is not airborne, but often we treat it as such.

Episode 12 – Anaphylaxis and Angioedema.

  • Biphasic anaphylaxis is extremely rare and prolonged ED observation does not really help as these reactions can occur up to 6 days later.  Rosenalli recommend observation 2-4 hours.

Episode 13  Tricyclic Antidepressants and Sodium Channel Blockade.

  • Tricyclic antidepressants can cause a rightward axis, in addition to prolonged QRS on an ECG.  This can resolve with treatment with sodium bicarbonate.

Episode 14 – Hand.

  • Flexor TenosynovitisKanavel’s Cardinal Signs (look for words that start with “F”).
    • Pain on passive extension -happens early
    • Finger held in flexion – see above point..extension hurts!
    • Fusiform (uniform) swelling of finger – most common
    • Tenderness along flexor tendon sheath – happens later