Podcast Ep 6: Bupivacaine Toxicity, Iron Overdose, & More

“As to diseases, make a habit of two things — to help, or at least, to do no harm.”   ― Hippocrates

Welcome back to episode 6!

Last week’s episode included a new intro Rapid Review…let us know what you think of it. Should we continue it? Keep sending your thoughts to feedback@roshreview.com. This podcast is fluid, and we are open to making changes that would best suit our listeners’ learning styles.

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Let’s get started.

• Prophylaxis for Neisseria meningitidis should be offered to household members, school contacts in the prior 7 days, and those with direct exposure to the patient. The preferred antibiotic regimen is rifampin BID for two days.
• The most common cause of a bilateral Bell’s palsy is Lyme disease.
• The most common cause of maternal mortality during delivery is maternal hemorrhage, which can be caused by uterine atony, genital trauma, retained products, or, DIC.
• The most serious adverse reaction to ketamine is laryngospasm, which is treated with bag-valve-mask ventilation. Tthe most common adverse reaction is an emergence reaction.

Now to this week’s podcast.

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Question 1

Which of the following antidotes is paired with the correct poisoning?

A. Bupivacaine – Intralipid

B. Hydrofluoric acid – Sodium bicarbonate

C. Lorazepam – Fomepizole

D. Metformin – Octreotide

Teaching image

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Question 2

A 3-year-old girl presents to the ED with altered mental status. She was in her usual state of health until one day prior to presentation when she developed abdominal pain, vomiting, and bloody diarrhea after she was found with a bottle of vitamins from the family’s medicine cabinet. She transiently improved for a few hours then became increasingly lethargic. On arrival, she responds only to painful stimulus. Her blood pressure is 65/40 mm Hg and her heart rate is 160 beats per minute. She appears profoundly dehydrated. Her arterial blood gas demonstrates a metabolic acidosis. What is the most definitive therapy for this patient?

A. Activated charcoal

B. Deferoxamine

C. Sodium bicarbonate

D. Whole-bowel irrigation

Teaching image

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Question 3

You are the physician for a patient who is diagnosed with pancreatic adenocarcinoma. The oncologist makes a note of a positive Trousseau’s syndrome in the documentation. Which of the following is she referring to?

A. Nontender palpable gallbladder

B. Palpable left supraclavicular lymph node

C. Popliteal pain with abrupt ankle dorsiflexion

D. Tender migratory thrombophlebitis

Teaching image

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Question 4:

A 27-year-old woman presents with a painful rash on both of her legs. What is the most common cause of this condition?

A. Allergy

B. Drug hypersensitivity reaction

C. Herpes virus

D. Streptococcal infection

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Question 5

A 15-year-old G1P0 woman at 23 weeks presents with sharp, left lower quadrant abdominal pain for 1 hour. She has had an ultrasound confirming the presence of a single intrauterine pregnancy. The pain is severe and associated with nausea. Pelvic examination reveals tenderness of the left adnexa. The patient’s urinalysis is unremarkable. What test should be ordered to diagnose the patient?

A. Abdominal X-ray

B. CT scan of the abdomen and pelvis

C. Pelvic ultrasound

D. White blood cell count

Teaching image

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Question 6

Which of the following statements is true regarding the diagnosis of Epstein-Barr virus infection?

A. Guillain-Barre syndrome is a possible complication

B. Neutrophilia predominates

C. Splenomegaly occurs in 10% of patients

D. The virus is transmitted via respiratory droplets

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• Bupivacaine toxicity is treated with intralipid.
• Hydrofluoric acid is treated with calcium gluconate, either topically or intra-arterially.
• Benzodiazepine overdoses should be treated with flumazenil but use caution in those who use them chronically as reversal may precipitate seizures.
• Iron overdoses occur with ingestions of greater than 40 mg/kg. They should be treated with deferoxamine. For less significant overdoses, GI decontamination may be attempted. Charcoal is of no use here, as it does not bind Iron.
• The 5 stages of iron toxicity are GI irritation, recovery, shock and metabolic acidosis, fulminant hepatic failure, and bowel obstruction leading to scarring.
• Trousseau’s syndrome, a migratory thrombophlebitis, is associated with pancreatic cancer.
• Erythema nodosum is an inflammatory condition characterized by tender red-violet nodules under the skin. The most common cause is infection. Drugs can also cause erythema nodosum, with OCPs being the most common culprit.
• Erythema nodosum is treated with NSAIDs. Potassium iodine can be used in severe cases.
• Ovarian torsion is difficult to diagnose. It is commonly seen in women of childbearing age and more commonly occurs on the right, especially in ovaries with large cysts. Laparoscopy is the only way to definitively rule out the condition.
• EBV infection can lead to many neurologic complications such as encephalitis, meningitis, and Guillain-Barre Syndrome.
• EBV infection is associated with a profound lymphocytic predominance, with atypical lymphocytes seen on the peripheral smear.
• Splenomegaly is a common sequela of EBV infection, so remember to tell athletes to abstain from contact sports for up to 4 weeks after infection.

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That concludes episode 6. We’ll keep new episodes coming throughout the holiday season so make sure to set your favorite podcast player to download them automatically. Also, don’t forget to write a short review for Roshcast on iTunes when you have a minute.

If you’d like to start at episode 1 to hear more of our educational pearls, just follow this link back to Roshcast.

Until next time,
Jeff and Nachi

P.S. Dr. Rosh recently published an article to help residents preparing for the upcoming emergency medicine In-training Exam…you may find it useful to learn How to Increase Your Emergency Medicine In-Training Exam Score by 10 Points.