Getting started with FOAMed

Just a little note to state that I have collated a few resources for those looking to get started with both consuming and creating FOAMed. There’s a little link at the top right of the page.

I also recorded some talks recently for the RCEM FOAMed network on creating podcast type material. Hopefully they’re of some use:

01 – recording a solo podcast

Scott Weingart on getting started in FOAMed

Andy Neill’s Social Media Workshop


02 – recording a skype interview

03 – recording a screencast

Tasty Morsels of EM 055 – Paeds Cardiology: Murmurs

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Today we have some notes from a lecture by a paeds cardiologist at a recent national EM training day.

Murmurs in babies

  • mostly VSD and ASD
  • mostly picked up antenatally these days
  • TGA is the one often missed antenatally
  • poor feeding is the hallmark sign (as it seems to be of all bad things in neonates). If feeding alright then the murmur is unlikely to be a big problem
  • 92% of those with coarctation will have lost femoral pulses at 5 days (afraid I don’t have a reference for this). Which means some femoral pulses will be normal at discharge
  • less than a 20 mmhg difference between the upper and lower limbs is reassuring that there is no coarct
  • in his cardiology clinic they are trying to move away from echo for everyone (see the 2014 appropriate use guidelines for this)
  • recommended and the pediatric ECG stat app

Tasty Morsels of EM 050 – Rheumatoid arthritis

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure. Some of this morsel is straight advice from a local rheumatologist rather than strict EBM.

  • commonest presentation
    • middle aged female with multiple small joints
    • remember that if symptoms less than 6 weeks then it’s usually one of many viruses
  • there are formal diagnostic criteria
    • heavily weighted on number of joints involved and some of the tests
    • >6 weeks duration is on the criteria
  • 10% of healthy population has pos rheumatoid factor.
  • Swollen joint much more diagnostically useful than simple painful joint
  • anti CCP the big new test. Very specific test but not sensitive
  • Rheumatoid in general carries increased CV risk never mind the NSAID use

Treatment pearls

  • flare of known RA
    • steroids depomedrone 80mg IM or 40mg oral for a week
    • NSAIDs – remember naproxen is the only one with low CV risk
  • mouth ulcers on methotrexate?
    • change to nightly dose
    • double up on folic acid dose
  • abnormal LFT on methotrexate?
    • ALT is usually first to rise, if continuing to rise at 2 weeks consider stopping
  • abnormal FBC on methotrexate?
    • neuts <1.5 then stop drug.
    • it was suggested that MTX be held in all infections needing antibiotics even when WCC is normal
  • Long term steroids are rarely appropriate any more – if you find someone floating around on long term steroids from 15 yrs ago the they’ve probably been lost to follow up and it’s worth referring them again.



  • Excellent rheumatology lecture somewhere in the midlands of Ireland Spring 2015
  • Rosen’s 8th Chap 116

Featured Image: James Heliman MD, CC License, Wikipedia

Approach to the IDU in the ED from the CFN

[Featured Image: Creative Commons, danielleellis55 on Flickr.]

First off here’s a video I recorded for the CEM FOAMed network on “approach to the injecting drug user“. Be sure to subscribe on iTunes and check out the site. There’s a podcast feed and a blog feed, so be sure to get both.

CEM FOAMed widget

[Direct Download ]]


Injecting Drug User (IDUs) are frequent attenders at EDs for lots of reasons. While there is no doubt that there are a lot of social factors involved in these attendances, we can all too easily forget that these patients get really sick and often get left in the bottom of the queue of patients waiting to be seen. I think “the approach to the IDU” would make a great chapter for Rosen’s but it’s not in there yet. Harwood Nuss is the only one I’ve seen with a good chapter on it.

Complications of injection drug use

Hardwood-Nuss 5th edition p1398

I find this population of patients perhaps the most fascinating to treat. Generally ostracised by society in the way homeless people usually are.  Usually undertriaged at the front door (“just another junkie”) I frequently find them in the waiting room with fairly dramatic vital signs. Without doubt injection drug use is usually not compatible with a stable and productive lifestyle and low grade criminality abounds. Certain aspects of the doctor patient relationship can be challenging here but they aren’t always drug seeking the way we expect they are.

And if your waiting room is anything like mine by the time they’ve waited 12 hrs to be seen then they’ve usually gone into withdrawal and it’s easy to blame all their symptoms and abnormal vital signs on withdrawal (even though their symptoms and abnormal vital signs all occurred prior to their withdrawal…)

All this to say that we approach them with so many cognitive biases and good old fashioned prejudices that it’s no wonder we fail to diagnose lots of the really interesting illnesses they bring with them.

Soft tissue infections

  • Probably higher incidence of MRSA
  • Most tentanus and wound botulism these days is associated with IDU
  • Necrotising fascitis is a much higher risk
  • Pyomyositis is a nice complication


  • DVT
  • Arteriovenous malformations
  • Pseudo aneurysm
    • Here’s a quote “any mass over a vascular territory may actually be a pseudo aneurysm and should be approached with caution”
    • I know a number of people with great stories of enthusiastic junior surgeons incising and draining these with impressive and unexpected results
  • Associated abscess
  • All 4 of the above in the same leg as I saw once…
  • Those lovely cutaneous groin sinuses that descend to dear knows where.
  • Mycotic aneurysms, typically with infectious endocarditis


  • ‘Pocket shooting’: injecting into the supraclvaicular space in the hope of finding a vessel. Can result in pneumo, haemo, hydropneumo and the wonderfully titled pyopneumothorax
  • Dissolving tablets and injecting them can result in what I’ve heard called trash lung or talc lung. [Check out BroomeDocs podcast with @dreapadoirtas on this]
    • This can cause granulomas in the pulmonary and even retinal vasculature (in fact looking at the retinas for talc might be better CXR or pulmonary function tests)
    • Restrictive and obstructive dysfunction can occur. I suspect this is commoner than we suspect. I see a lot of IDUs with lowish sats and it gets blamed on something like COPD from smoking.
    • Chronic pulmonary hypertension can result


  • Osteomyelitis and septic arthritis can be local or haematogenous
  • Commonest is vertebral osteomyelitis usually lumbar which may have associated disc it is with or without the even more emergent spinal epidural abscess
    • Pain is often chronic (as has been in the cases I have seen)
    • Don’t expect fever (unless you’re the admitting doctor in which case it can’t possibly be vertebral osteo without a fever…)
  • Joint involvement is axial. Think sacroiliac, sternoclavicular, hip and pubic symphysis. (Mainly fibro cartilaginous joints if you’re into the anatomy of it all)
    • This is really important as no one will consider septic arthritis in someone with tender central chest pain.

Central nervous system

  • Meningitis both fungal and bacterial
  • Various sites for epidural abscesses
  • Brain abscesses
  • CNS aspergillosis
  • Cerebral murcomycosis (even when HIV negative)
    • Headache, fever, cranial and motor deficits
    • Apparently basal ganglia lesions on CT are the key

 Fungal endophthalmitis

  • Decreased acuity, eye pain
  • White vitreal exudate on fundoscopy

Blood Born Viruses

  • Hep C (almost ubiquitous amongst IDU. >80% in our population)
  • Hep B (up to 80% become seropositive over lifetime)
  • HIV (about 10% in our local population)


  • (lifetime incidence of 5%)
  • Classic signs are rare
  • Mainly right sided

Cotton fever

  • A brief, febrile episode following injection when the solution is filtered through cotton balls
  • No way to distinguish this in the ED from the other more serious occult causes of fever in the IDU

It might be easier is to think about common clinical presentations and then apply appropriate IDU pathologies

IDU with stroke

  • Brain abscess
  • Subdural empyema
  • Botulism
  • Mycotic aneurysms
  • Good old fashioned stroke

Groin pain

  • Abscess
  • AV fistula
  • DVT
  • Pseudo aneurysm
  • And I suppose it could be just a hernia

Chest pain

  • Pneumonia
  • PE (esp in groin injectors)
  • ACS (chronic inflammatory states like HIV lead to accelerated atherosclerosis. Never mind the cocaine use)
  • Sternal joint osteomyelitis


  • Brain abscess
  • Meningitis
  • SAH (remember all the cocaine use that goes with the heroin)
  • Complications of associated HIV
    • Toxoplasmosis
    • Lymphoma
  • And yes it could just be a migraine too i suppose…

 Back pain

  • Epidural abscess
  • Discitis
  • Vertebral osteomyelitis
  • And yes it could just be good old fashioned back pain too I suppose


  • Endocarditis
  • Meningitis
  • Osteomyelitis
  • Cotton fever
  • HIV related
  • TB (a lot of these guys are homeless and in Dublin anyhow there are reasonably high rates of TB amongst the homeless)
  • Haematological malignancy
  • And yes I suppose it could just be a flu or the dreaded ‘viral illness’

Shortness of breath

  • PE
  • Talcosis or trash lung
  • Chronic pulmonary hypertension
  • Pneumothorax from trying to inject a neck vein
  • Aspiration from their recent OD, GCS 3 episode
  • And yes I suppose it could be a good old fashioned chest infection too

Cellulitis in IDU

  • necrotising fasciitis
  • Pyomyositis
  • Subcutaneous abscess
  • And yes I suppose it could be a simple staph or strep cellulitis


References/FOAMed Resources:

  •  Nice EM News Post on the febrile IDU
  • Hardwood-Nuss 5th edition p1398
  • A paper from our place characterising our population

Recent controversies in sepsis

Below is a recent talk I prepared for a teaching meeting for the ICU and ED staff. Unfortunately I was still on my train when I was due to give it so here it is online instead.


  • Annane D. Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock. JAMA. 2013 Nov 6;310(17):1809.
  • Brown SGA. Fluid resuscitation for people with sepsis. BMJ (Clinical research ed). BMJ Publishing Group Ltd; 2014 Jul 22;349(jul22 16):g4611–1.
  • SMACC Podcast: Myburgh: Fluid Resuscitation: Which, When and How Much?
  • EMCrit Podcast: Marik: Fluids in Sepsis
  • EMCrit Podcast: Angus on Process
  • Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008 Jul;134(1):172-8. doi: 10.1378/chest.07-2331. Review. PubMedPMID: 18628220.
  • Marik PE. Iatrogenic salt water drowning and the hazards of a high central venous pressure. 2014 Jun 24;:1–9. [free pdf]
  • Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001 Nov 8;345(19):1368–77.
  • Jones AE, Shapiro NI, Trzeciak S, Arnold RC, Claremont HA, Kline JA. Lactate Clearance vs Central Venous Oxygen Saturation as Goals of Early Sepsis Therapy: A Randomized Clinical Trial. JAMA. 2010 Feb 24;303(8):739–46.
  • Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb SA, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee2012. Crit Care Med.2013 Feb;41(2):580-637. doi: 10.1097/CCM.0b013e31827e83af. PubMed PMID: 23353941.
  • The ProCESS Investigators. A Randomized Trial of Protocol-Based Care for Early Septic Shock. N Engl J Med. 2014 Mar 18;:140325070040003.
  • Kaukonen K-M, Bailey M, Suzuki S, Pilcher D, Bellomo R. Mortality Related to Severe Sepsis and Septic Shock Among Critically Ill Patients in Australia and New Zealand, 2000-2012. JAMA. American Medical Association; 2014 Apr 2;311(13):1308–16.
  • Marik PE. Early Management of Severe Sepsis. Chest. American College of Chest Physicians; 2014 Jun 1;145(6):1407–18.