SARS-CoV-2 literature review March 25 – April 1, 2020

Dear colleague,

Our weekly FOAMed Quiz is suspended until further notice. 

However, quite a large body of evidence is published weekly on COVID-19. Evidence that might help us and our patients get through the upcoming weeks to months.

These are the best FOAMed resources and most useful papers of the last 7 days.

Last weeks most useful FOAMed resources:

Clay Smith provides an overview on the evidence so far on Journal Feed (COVID-19 | Spoon-Feed Version). 

Justin Morgenstern covered some really useful papers on First10EMs COVID Research Roundup and published his take on the evidence behind antivirals (Antivirals for COVID19 – Not ready for clinical use)

EmDocs covered anti-inflammatory agents (Anti-Inflammatory Agents and Corticosteroids in COVID-19: What’s the Controversy?) and antivirals  (Antiviral Agents: What is their use in COVID-19?)

Salim Rezaie discussed NIV, awake proning and more on RebelEM  (COVID-19 Hypoxemia: A Better and Still Safe Way.)

EM cases provided another on the latest literature as well  (COVID-19 Updates)

Scott Weingard uploads a new podcast almost every other day about a range of critical care topics (EMCrit RACC Blog & Podcast)

Josh Farkas discusses how a risk stratification tool for COVID might look like (PulmCrit Theoretical Post – The COVID Severity Index (CSI 1.0)).

EM Ottawa covered the airway (Guidelines for Emergency Airway Management of COVID-19)

And taming the SRU is thinking of ways to make intubation safer (The Mother of Invention Meets the Little Red Hen – The “Nat Mat”).

The following papers deserve some additional attention or are not yet covered in the FOAM society.

Paper 1

Title: Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)
Author: Alhazzani, W.
Publication date: March 28, 2020
Journal: Intensive Care Medicine

A panel of 36 experts from 12 countries was formed. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU.

Results: Follow this link for a Table containing all Recommendations and statements

Link to paper: https://link.springer.com/article/10.1007/s00134-020-06022-5

FOAMed sources covering the guideline: 
First10EM: Surviving Sepsis Campaign COVID Guidelines
CanadiEM: Surviving Sepsis Campaign: COVID-19 Recommendations
RebelEML Surviving Sepsis Campaign Guidelines on the Management of Critically Ill Adults with COVID-19

Paper 2

Title: Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study
Author: To, K. K.
Publication date: March 25, 2020
Journal: The Lancet INfectious Diseases

Aim: To ascertain the serial respiratory viral load of SARS-CoV-2 in posterior oropharyngeal (deep throat) saliva samples from patients with COVID-19, and serum antibody responses.

Methods: This is a cohort study at two hospitals in Hong Kong. Serial viral load was ascertained by reverse transcriptase quantitative PCR (RT-qPCR). 

Results: 23 patients were included. Salivary viral load was highest during the first week after symptom onset and subsequently declined with time. In one patient, viral RNA was detected 25 days after symptom onset. Older age was correlated with higher viral load.

Conclusion: The high viral load on presentation suggests that SARS-CoV-2 can be transmitted easily, even when symptoms are relatively mild. 

Link to paper: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30196-1/fulltext

Paper 3

Title: Quantitative Detection and Viral Load Analysis of SARS-CoV-2 in Infected Patients
Author: Yu, F.
Publication date: March 28, 2020
Journal: Clinical Infectious Diseases

Aim: To explore the changes in viral load in different tissue samples and during disease progression with SARS-CoV-2- infected patients.

Methods:  127 patients were tested simultaneously by RT-PCR and ddPCR. 

Results: 76 COVID19 confirmed cases were included in the final analysis (77.6% mild). The average viral load in sputum was significantly higher than in throat swabs and nasal swabs. The viral load in the early and progressive stages were significantly higher than that in the recovery stage.

Conclusion: Sputum is a better indicator of viral replication in the body than throat and nasal swabs. The viral load of sputum samples tends to increase and then decrease during the course of the disease.

Link to paper: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa345/5812997

Paper 4

 

Title: Performance of VivaDiagTM COVID-19 IgM/IgG Rapid Test is inadequate for diagnosis of COVID-19 in acute patients referring to emergency room department
Author: Cassaniti, I.
Publication date: March 30, 2020
Journal: Journal of Medical Virology

Aim: To investigate the diagnostic Performance of VivaDiagTM COVID-19 IgM/IgG Rapid Test 

Methods: Pre-proof. The performance of VivaDiagTM COVID-19 IgM/IgG Rapid Test LFIA was tested in 50 patients at their first access at emergency room department with fever and respiratory syndrome (34 M/16 F; median age 61.50 range 33-97 years) in comparison with results of nasal swab molecular screening.

Results:  All 30 COVID-19 negative volunteers were negative for both IgG and IgM. No cross-reactivity was detected in the 10 subjects with previous coronaviruses infection. 38 patients were positive for COVID-19 by real time RT-PCR. Of these, only seven (18.4%) showed a positive or weak positive serology for IgM and/or IgG while the other 31/38 (81.6%) tested negative for the rapid serology assay.

Conclusion: VivaDiagTM COVID-19 IgM/IgG Rapid Test LFIA is not recommended for triage of patients with suspected COVID-19.

Link to paper: https://onlinelibrary.wiley.com/doi/abs/10.1002/jmv.25800

Paper 5

Title: Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method.
Author:  Soldatini, G.
Publication date: March 30, 2020
Journal: Journal of Ultrasound in Medicine

Aim:  The authors share their experience and propose a standardized approach in order to optimize the use of lung ultrasound in covid‐19 patients.

Link to paper: https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15285

Paper 6

Title: Life-threatening cardiac tamponade complicating myo-pericarditis in COVID-19
Author: Hua, A.
Publication date: March 30, 2020
Journal: European Heart Journal

Aim: This is the first reported case of COVID-19-associated cardiac tamponade.

Conclusion: Cardiac tamponade is an important differential to consider in a deteriorating patient with COVID-19.

Link to paper: https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa253/5813280

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SARS-CoV-2 literature review March 17-24 2020

Dear colleague,

Our weekly FOAMed Quiz is postponed until further notice.

However, quite a large body of evidence is published weekly on COVID-19. Evidence that might help us to help more patients in the upcoming weeks to months.

This is a selection of useful papers on SARS-CoV-2 published in the last 7 days.

Wishing you all the courage and strength to push forward…

Paper 1

Source: First10EM

Title: Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial.
Author: Gautret P,
Publication date: March 20, 2020
Journal: International Journal of Antimicrobial Agents.

Goal: This is an observational study of patients 12 years and older with documented COVID-19 admitted to a single hospital in France, with a control group from other hospitals around France.

Methods: Patients in the primary centre with rather mild disease were treated with hydroxychloroquine. Patients in the control centres did not. The authors originally enrolled 42 patients. However, 6 were excluded from the main site, mostly because of death or transfer to the ICU, while no patients were excluded from the controls.

Results: Viral clearance on day 6 occured in 70% of the treatment group and 13% of the controls (p=0.001)

Conclusion: Due to profound methodological flaws this paper does not provide any evidence for treatment of COVID-19 with hydroxychloroquine

Chloroquine for COVID: No good evidence yet

Paper 2

Title: The characteristics and clinical value of chest CT images of novel coronavirus pneumonia
Author: Zhao, X.
Publication date: March 19th, 2020
Journal: Clinical Radiology

Goal: This study was undertaken to retrospectively analyse the chest CT images of 80 PCR-confirmed COVID-19 patients at various hospitals in Anhui Province, China.

Conclusion: The chest CT of these patientis is typically characterised by bilateral groundglass lesions located in the subpleural area of the lung. Pleural effusions and mediastinal lymphadenopathy are rare.


Click image for link

Paper 3

Title: Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy
Author: Onder, G.
Publication date: March 23, 2020
Journal: JAMA

Goal: To explain the relatively high case fatality (CFR) rate in Italy compared to China and other countries

Conclusion: The relatively high CFR in Italy may be due to an older population, a difference in definition of SARS-CoV-2 related death compared to other coutries and a difference in testing strategies (less testing in Italy compared to China).


Click image for link

Paper 4

Title:  COVID-19 outbreak: less stethoscope, more ultrasound
Author: Buonsenso, D.
Publication date: March 20, 2020
Journal: The Lancet

Goal: A view on the use of portable ultrasound in these challenging times

Conclusion: The use of ultrasound is now essential in the safe management of the COVID-19 outbreaks, since it can allow the concomitant execution of clinical examination and lung imaging at the bedside by the same doctor.


Paper 5

Title:  Time Kinetics of Viral Clearance and Resolution of Symptoms in Novel Coronavirus Infection
Author: Chang, D.
Publication date: March 20, 2020
Journal: American Journal of Respiratory and Critical Care Medicine

Goal: To determine the time kinetics of viral clearance in reference to the resolution of symptoms in 16 patients treated in Beijing, China

Conclusion: Half (8/16) of the patient remained viral positive (a surrogate marker of shedding) even after the resolution of symptoms (median 2.5 days, range 1 to 8 days).


Click image for link

Paper 6

Title: Platelet‐to‐lymphocyte ratio is associated with prognosis in patients with Corona Virus Disease‐19
Author: Qu, R.
Publication date: March 17, 2020
Journal: Journal of Medical Virology

Goal: The platelet‐to‐lymphocyte ratio (PLR) is considered quite a good marker for overall badness (and mortality). If this holds true for SARS-CoV-2 patients is the main question in this paper.

Conclusion: The PLR, when measured at the peak of thrombocytosis, was significantly higher in patients with severe disease (from oxygen sat <94% and a respirtory rate of > 30 to respiratory failure) compared to patients with non-severe disease.
Only 30 patient were enrolled in this study.

Click image for link

Paper 7

Title:  Transmission potential and severity of COVID-19 in South Korea
Author: Shim, E.
Publication date: March 17, 2020
Journal International Journal of Infectious Diseases

Goal: To examine the growth rate of the outbreak, the authors aimed to present the first study to report the reproduction number of COVID-19 in South Korea.

Conclusion: The mean reproduction number of COVID-19 in Korea was estimated at 1.5. Futhermore, the crude case fatality rate is higher among males and increases with age.

Click image for link

Paper 8

Title: Covid-19: European drugs agency to review safety of ibuprofen
Author: Michael Day (journalist)
Publication date: March 23, 2020
Journal: BMJ

Goal: This newsflash is about the use of ibuprofen for symptoms relief in SARS-CoV-2 patients? The authors interviewed several specialists on this topic.

Conclusion: 1. There is no evidence relating specifically to people with covid-19. 2. Pending further research, a pragmatic and cautionary approach would be for the public to avoid these plausible harms.

Click image for link

Paper 9

Title:  Systematic review of COVID‐19 in children show milder cases and a better prognosis than adults
Author: Ludvigsson, J.
Publication date: March 23, 2020
Journal:Acta Pedeatrica

Goal: A systematic literature review was carried out to identify papers on COVID‐19, which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), using the Medline and EMBASE databases between 1 January and 18 March 2020.

Summary: This review identified 45 relevant studies on COVID-19 in children. The disease course in paediatric COVID-19 was milder than in adults, children had a better prognosis and deaths were extremely rare. Diagnostic findings have been similar to adults.

Click image for link
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Quiz 65, March 6th, 2020

Welcome to the 65th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Question 1

 

The Surviving Sepsis Campaign guidelines recommend blood cultures should be drawn before starting antimicrobial treatment. However, obtaining blood cultures prior to antibiotics may be challenging at times. Does administration of antibiotics really have an influence on the amount of positive blood cultures taken after administration of these antibiotics?

Recently, the FABLED Trial, was published in Annals of Internal Medicine to answer this question. 325 patients were included in the study. They obtained the sensitivity of blood cultures obtained before and within 120 minutes of initiation of antimicrobial treatment as their primary outcomes.

What did the authors find?

A: The percentage of positive blood cultures was significantly higher if obtained before the administration of antibiotics compared to blood cultures obtained after administration of antibiotics

B: The percentage of positive blood cultures was not statistically different if obtained before the administration of antibiotics compared to blood cultures obtained after administration of antibiotics

C: The percentage of positive blood cultures was significantly lower if obtained before the administration of antibiotics compared to blood cultures obtained after administration of antibiotics

The correct answer is A

Salim Rezaie from REBEL EM covered this paper this week.

This multicenter study was performed in 7 Emergency Departments (EDs) in North America. It is the first study to prospectively quantify the decrease in sensitivity of blood culture sensitivity from the time of antimicrobial initiation.

The percentage of positive blood cultures before administration of antibiotics was 31.4% compared to 19.4% after administration of antibiotics. This absolute difference of 12% (95% CI 5.4 to 18.6%) was statistically significant with a P-value of <0.001. The authors mentioned in their discussion that taking blood cultures after administration of antibiotics would lead to false-negative blood cultures to 1 in every 6.7 patients.

The clinical take home point is that drawing blood cultures after administration of antibiotic treatment reduces culture sensitivity which could affect downstream optimization of treatment as well as safe de-escalation of treatment.

The FABLED Trial: Blood Cultures 1st, Then Antibiotics in Sepsis

Source image: https://radiopaedia.org/

Question 2

A 50-year old male presents to your Emergency Department after being assaulted. His right orbita is swollen and shows a big hematoma. He mentions severe headache and does not remember exactly what happened. Physical examination shows tenderness of his upper orbital wall and zygoma. You are worried that he might have orbital fractures.

Which of the following statements is true about orbital wall fractures?

A: The superior and medial wall are the weakest and therefore most commonly fractured

B: A ‘’teardrop sign’’ on computed tomography (CT) indicates a fracture of the inferior orbital wall and should make you aware of possible entrapment of the inferior rectus muscle

C: Around 10% of patients with orbital fractures have concomitant ocular trauma

D: There is clear evidence to support oral antibiotics in orbital fractures

The correct answer is B

 

Jessica Tsao from Core EM covered orbital fractures this week. 

The orbita can be divided into four walls, made of multiple bones. The superior wall (frontal bone), lateral wall (zygome and sphenoid), inferior wall (zygoma and maxilla) and medial wall (ethmoid, including the lamina papyracea). The inferior and medial walls are the weakest and therefore most commonly fractured.

 

A study done in 2003 showed ocular trauma in ⅓ of patients with orbital wall fractures so therefore a thorough eye exam should always be done. Look for visual acuity, eye movements, teardrop pupil, enophtalmos or proptosis.

 

Although there is really poor evidence for routine use of antibiotics, they are routinely prescribed in patients with orbital fractures.

 

Orbital Blow-Out Fractures

Source image: www.pixabay.com

Question 3

Which of the following treatments for migraine is not supported by a proper amount of evidence?

A: Haloperidol

B: Metoclopramide

C: Dexamethasone 10mg to 25mg (to prevent headache recurrence)

D: Ketorolac or another NSAID

The correct answer is A

Taming the SRU covered the treatment of migraine this week. 

It seems the use of prochlorperazine and metoclopramide, ketorolac and dexamethasone are supported by evidence. The evidence of haloperidol however is very weak. 

Another treatment supported by evidence is the occipital nerve block. A recent meta-analysis  demonstrated reduction in headache severity, amount of headache days, and amount of medication consumed for headache in patients receiving occipital nerve blocks. 

Source image: www.emottowablog.com

Question 4

A 54 year old male is brought in by EMS after being found unconscious in a park. The outside temperature is -5 degrees Celsius (that is 23 degrees Fahrenheit). His core temperature turns out to be 27 ℃ (80 ℉). As you want to rewarm this patient, you doubt which method would be most effective. Put the following methods of rewarming in the correct order, starting with the least effective and finishing with the most effective method.

A: Bladder lavage, thoracic lavage, dialysis, VV-ECMO

B: Bladder lavage, dialysis, thoracic lavage, VV-ECMO

C: Thoracic lavage, dialysis, bladder lavage, VV-ECMO

D: Dialysis, Bladder lavage, VV-ECMO, thoracic lavage

The correct answer is A

EMOttawa covered the hypothermic patient last week.

It turns out bladder lavage is the least effective warming method (0.5-1 ℃ / hour), next is thoracic lavage (1-2 ℃ / hour, however the risks outweigh the benefits). Then dialysis (2-3 ℃ / hour and finally ECMO 4-10 ℃. 

 

Source image: www.pixabay.com

Question 5

Which of the following finding has the highest positive likelihood ratio for an elevated intracranial pressure (ICP > 20 mmHg)?

A: Midline shift >10 mm on CT

B: GCS score ≤8

C: Compression or absence of basal cisterns on CT

D: Any pupillary dilation

The correct answer is C

Clay Smith covered this recently published paper last week on Journal Feed.

This was a systematic review of 40 studies with 5,123 patients to determine the diagnostic accuracy of physical exam and imaging findings for the diagnosis of increased ICP, compared with a gold standard of invasive ICP monitoring. 

It turns out none of the examined features alone were very helpful at ruling in or out elevated ICP. Compression or absence of basal cisterns on CT had the highest positive likelihood ratio (2.20). Pupillary dilatation only had a positive likelihood ratio of 2.00 and a midline shift >10 mm on CT only had a positive likelihood ratio of 1.92. 

 

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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 64, February 28th, 2020

Welcome to the 64th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Question 1

Source image: https://www.aliem.com/

Ankle injuries are common in the Emergency Department. Which of the following statements is true about ankle x-rays?

A: A tibiofibular space >2 mm indicates a syndesmotic injury

B: The AP view should be used to asses the medial clear space

C: A Bohler’s angle <20 degrees suggest a calcaneus fracture

D: A gravity stress view should be considered in Weber A fractures to assess for syndesmotic involvement

The correct answer is C

This week’s post on ALIEM is about the approach to the traumatic ankle x-ray. 

The tibiofibular space is widened in syndesmotic injury, when > 6 mm suspect a syndesmotic injury. 

The medial clear space is assessed on the mortise view. This is the medial border of talus and lateral border of medial malleolus. When > 4 mm there might be syndesmotic injury. 

Another approach to assess for syndesmotic injury is the gravity stress view. To be considered in Weber B fractures. 

Bohler’s angle is measured on the lateral view. If < 20 degrees, a calcaneus fracture might be present. You could then consider ordering a calcaneus view, although CT has higher sensitivity and specificity for this fracture.

https://www.aliem.com/emrad-ankle/

Question 2

Source image: https://litfl.com/

You see a 70 year old patient with in the past medical history diabetes mellitus, hypertension and epilepsy. He presents with fever-like symptoms and an erythematous macular rash. There is mucosal and ocular involvement and the Nickolsky sign is positive. He has been taking penicillin recently.

Which of the following critical rashes do not have mucosal involvement?

A: Toxic Epidermal necrolysis (TEN )

B: Stevens-Johnson syndrome (SJS)

C: Staphylococcal scalded skin syndrome (SSSS)

D: Acute generalised exanthematous pustulosis (AGEP)

E: Pemphigus Vulgaris ( PV)

The correct answer is C

This week critical rashes were covered on emDocs.

Nickolsky sign is positive when lateral pressure on intact skin causes shedding of the epidermis. This sign can be seen in all of the above critical rashes. Mucosal involvement is common in TEN and SJS, and is less common, but can be seen in AGEP and PV. SSSS presents as erythematous painful skin with flaccid bullae and desquamation, but without mucosal involvement.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Mimics – Differential Diagnosis and Initial Management

Question 3

Which combination of vasopressor and mechanisms of action is correct?

A: Vasopressin – increase in systemic vascular resistance and increase in pulmonary vascular resistance

B: Milrinone – positive effect on inotropy and decrease in pulmonary vascular resistance

C: Dopamine, low dose – decrease in systemic vascular resistance and increase in pulmonary vascular resistance

D: Phenylephrine – decrease in systemic vascular resistance and increase in pulmonary vascular resistance

The correct answer is B

This week’s chapter of the internet book of critical care on emcrit is about vasopressors. The table below gives a summary of the most commonly used vasopressors and their mechanisms of action.

Vasopressors

Source image: https://emcrit.org/ibcc/pressors/
Source image: https://emergencymedicinecases.com

Question 4

Your 40 year old patient presents with acute chest pain. You find some ST-elevation (STE) in the precordial leads and you doubt whether you are looking at Benign Early Repolarization (BER) or an acute myocardial infarction (MI).

Which of the following findings may point you in the direction of MI?

A: Convex STE morphology

B: Concave STE morphology

C: Notching at the J point

D: Normal R wave progression

The correct answer is A

County EM covered Benign Early Repolarization Pattern vs. Anterior STEMI this week.

Convex STE morphology is highly specific for AMI, while STE at the J point with upward concavity is more typical for BER (but LAD occlusions can be seen with concave morphology).

Notching at the J point is typical for BER, as well as normal R wave progression (of course).

Benign Early Repolarization Pattern vs. Anterior STEMI

Question 5

Source image: https://first10em.com/

Your 34 year old patient presents with a linearly arranged itching rash over his trunk and arms 2 days after eating mushrooms. This presentation is typical for:

A: Type 1 (IgE mediated) hypersensitivity

B: Type 4 (T-cell mediated) hypersensitivity

C: Tinea corporis

D: Shiitake dermatitis

The correct answer is D First10EM covered shiitake dermatitis this week. ´Shiitake dermatitis is an intensely pruritic rash caused by a toxic reaction to lentinan, a component of shiitake mushrooms. It usually develops 1-3 days after eating raw or undercooked shiitake mushrooms.´ Type 1 hypersensitivity reactions occur earlier after exposure. Type 4 hypersensitivity can present 2 days after exposure, but as contact dermatitis. Tinea corporis has nothing to do with eating mushrooms.
Shiitake Dermatitis
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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 63, February 21th, 2020

Welcome to the 51th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Source image: www.emcrit.org

Question 1

Recently, the 65 Trial, was published in JAMA. 2463 critically ill patients with vasodilatory hypotension, aged 65 years and older, were randomized between usual care (MAP targets at the discretion of the treating ICU team, usually a MAP >65 mmHg) and permissive hypotension (MAP of 60-65 mmHg). The primary outcome was mortality at day 90.

What did the authors find?

A: Mortality at day 90 was significantly higher in the permissive hypotension group

B: Mortality at day 90 was not significantly different between both groups

C: Mortality at day 90 was significantly lower in the permissive hypotension group

The correct answer is B

Celia Bradford from The Bottom Line and Josh Farkas from PulmCrit covered this recently published paper this week.

The 65 Trial is a multi-center, unblinded RCT (in of course… 65 ICU’s, in the United Kingdom).

1221 patients were assigned to the intervention group (target op MAP between 60 and 65 mmHg) and 1242 patients were assigned to the control group (MAP targets were at the discretion of the treating ICU team).

The mean MAP was 66.7 mmHg in the intervention group and 72.6 mmHg in the control group.

Targeting a MAP of 60-65 mmHg resulted in the use of lower doses of vasopressors and allowed for faster weaning off these vasopressors (33 hours with permissive hypotension vs 38 hours with conventional therapy).

The primary endpoint, mortality at day 90, was 2.9% lower in the permissive hypotension group (41.0 vs 43.8 percent) but this small benefit was not statistically significant. Secondary endpoints showed no differences in renal function, ICU length of stay, ventilation and 90-day cognitive outcomes.

Keep in mind the mean MAP in the permissive hypotension group was higher than targeted. Furthermore, this was an unblinded trial.

It appears safe to target a MAP of 60-65mmHg in elderly patients with vasodilatory shock.

 

65 Trial

Source image: http://blog.clinicalmonster.com/

Question 2

Your 53-year old patient presents with shock. POCUS reveals this image.

You remember seeing your colleague struggle with pericardiocentesis and you really want to releaf this tamponade under ultrasound guidance. Which of the following approaches is best suited for ultrasound guided tamponade drainage?

A: Subxiphoid approach

B: Parasternal approach

C: Apical approach

The correct answer is B

CountyEM covered pericardiocentesis last week.

Of course there are more variables to take into account when choosing an approach for tamponade drainage than just the best way to visualise the needle. However, if you find a large quantity of effusion on every view, the parasternal approach might be the easiest. The pericardium is located most superficially and the angle of your needle accounts for better visualisation compared to an apical or subxiphoid approach. Keep in mind there is a risk of injury to the left internal mammary artery and pleura of your site of puncture is too lateral.

Question 3

Quite a lot of evidence has recently emerged regarding clinical pretest probability (CPTP) guided d-dimer cutoff in the diagnosis of pulmonary embolism. But how does CPTP guided d-dimer cutoff compare to age-adjusted d-dimer cutoff in the diagnosis of deep venous thrombosis according to this recently published paper 

A: CPTP guided d-dimer cutoff has superior diagnostic utility compared to age-adjusted d-dimer

B: CPTP guided d-dimer cutoff has similar diagnostic utility compared to age-adjusted d-dimer

C: CPTP guided d-dimer cutoff has inferior diagnostic utility compared to age-adjusted d-dimer

The correct answer is B

Clay Smith covered this paper last week.

It seems that both D-dimer interpretation strategies were associated with a high and similar NPV, and similar utility.

Sensitivity was 98.7% for CPTP guided cutoff and 98.0% for age-adjusted cutoff.

 

Source image: www.pixabay.com

Question 4

You commence high dose insulin (HDI) in a patient with combined calcium channel blocker (CCB) and beta blocker (BB) intoxication. Which of the following is true about the mechanism of action of HDI?

A: HDI acts as a strong vasoconstrictor

B: HDI is a specific antidote to CCB

C: HDI acts as a strong inotrope

The correct answer is C

The latest Tox and Hound post on EMcrit is about cardiotoxic overdoses.

It seems HDI has a couple of mechanisms of action. The most important one is inotropy by augmenting calcium mediated contractility in cardiovascular tissue and by increasing the availability of intracellular glucose to maximize ATP production in stressed myocardium. Insuline is a vasodilator, not a vasoconstrictor. There is no specific antidote voor CCBs.

 

 

https://emcrit.org/toxhound/hdi-vs-pressor/ 

Source image: www.pixabay.com

Question 5

You are at 35.000 feet, sitting in your airplane seat on your way to a well deserved holiday when suddenly: ‘’ Is there a medical professional on board?’’ You, as a well trained emergency physician, decide to volunteer.

Which of the following statements about In-Flight Medical Emergencies (IMEs) is true?

A: The most common reason for an IME is cardiac arrest

B: Every airplane should be equipped with an IV start kit, AED, oral airways, oxygen tank and a stethoscope

C: Physicians from the United States, Canada and Europa have a legal obligation to help when medical assistance is needed due to a IME

D: Airlines do not have medical ground support available

The correct answer is B

IMEs happen roughly once in every 604 flights and about 4% of IMEs require diversion to a nearby airport. The most common reason is syncope or pre-syncope (33-37%), followed by all kinds of complaints like GI symptoms, respiratory symptoms, seizures, allergic reactions and obstetric emergencies. Only 0.2-0.3% of IMEs are due to cardiac arrest.

There are minimal requirements for on board medical equipment and medications which includes basic supplies for assessment, airway/breathing, and intravenous access. Additional equipment and medications differ between airliners.

Physicians from the United States, Canada and England have no legal obligation to assist in an IME. But when they do, they are protected from liability by the Good Samaritan provision of the Aviation Medical Assistance Act. However, physicians from Australia and some European countries like ours (the Netherlands), do have a legal obligation to assist in an IME.

Every airline should be able to assist you with medical ground support during a significant IME.

 

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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 62, February 14th 2020

Welcome to the 62th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Question 1

Source image: litfl.com
 

Last week this paper was published in NEJM. 316 patients between 18 and 50 years old with moderate to large (> 32%) one-sided pneumothoraces were randomized to either conservative treatment or treatment with a 12 Fr pleural catheter. What did this paper show?

A: Conservative treatment was inferior compared to insertion of a pleural catheter for re-expansion at 8 weeks

B: Conservative treatment was superior compared to insertion of a pleural catheter for re-expansion at 8 weeks

C: Conservative treatment was non-inferior compared to insertion of a pleural catheter for re-expansion at 8 weeks

The correct answer is C

St. Emlyn’s covered this recently published paper. In our ED, patients with these large pneumothoraces always get a pleural catheter. This paper certainly opens up possibilities to study conservative management of pneumothoraces.

The primary outcome (reexpansion at 8 weeks) was met in 94.4 percent of patients in the conservative management group and 98.5 percent of patients in the non-conservative group. This was non-inferior according to the authors, who set the non-inferiority margin at 9 percentage points. As expected the conservative managed patients spend less time in the hospital (1.6 to 6.1 days), had less adverse events and a lower 1-year recurrence rate.

There are some methodological issues to mention. The non-inferiority margin of 9 percent seems a bit high. Furthermore there was a significant loss to follow up in both groups (23 in the non-consevative group and 37 in the conservative group). 15 percent of patients in the conservative group ended up getting an intervention after all and it seems 316 patients out of 2600 screened patients might suggest selection bias.

JC: Conservative management of pneumothoraces.

Question 2

For what kind of pediatric fracture should the Ogden classification be used?

A: Tillaux fractures

B: Greenstick fractures

C: Tibial Tubercle Fractures

D: Supracondylar fractures

The correct answer is C

AliEM covered tibial tubercle fractures last week.

The Ogen classification schema is similar to the Salter-Harris classification, but is used preferentially in the proximal tibia because of the presence of two ossification centers.

I: Fracture of the secondary ossification center
II: Fracture propagates proximal between primary and secondary ossification center
IV: Fracture crosses the primary ossification center
V: Fracture through the entire proximal primary ossification center
VI: Avulsion fracture of the patellar tendon from the secondary ossification center

Source image: https://musculoskeletalkey.com/

SplintER: Knee pain after the jump

Question 3

Which of the following is not part of the classic triad of Serotonin Syndrome?

A: Agitation, Confusion (Altered mental status)

B: Tachycardia, Fever and Flushing (Autonomic hyperactivity)

C: Lead pipe rigidity, hyporeflexia (Neuromuscular abnormality)

The correct answer is C

em3 covered serotonin syndrome this week.

Yes, the triad consists of Altered mental status, Autonomic hyperactivity and Neuromuscular abnormality. However, the neuromuscular abnormality you will find in serotonin syndrome is hyperreflexia and myoclonus.

Lead-pipe’ rigidity is found in Malignant Neuroleptic Syndrome.

Question 4

A 39-year old male presents with severe epigastric pain, nausea and several episodes of non-bloody, non bilious emesis. He describes the pain as sharp and it radiates to her back. On examination, he is tachycardic and tachypneic with abdominal tenderness. Lipase comes back markedly elevated.

Which of the following statements about acute pancreatitis is true?

A: The most common etiology is alcohol (up to 50%), followed by gallstones (20%), hypertriglyceridemia (5-10%), idiopathic (up to 20%), medications and some more rare causes

B: Diagnosis requires the following: characteristic abdominal pain AND a lipase or amylase >3 times the upper limit of normal AND characteristic findings on ultrasound (US) or computed tomography (CT)

C: Conditions, other than pancreatitis, like bowel obstruction, bowel ischemia, perforation, biliary disease and renal failure can not elevate lipase and amylase >3 times the normal limit

D: A triglyceride level of at least 500 mg/dL (typically >1000 mg/dL or 11.2 mM) suggests hypertriglyceridemia as the underlying etiology

The correct answer is D

Britt Long covered pancreatitis this week on EMdocs.

Pancreatitis is a common diagnosis in the Emergency Department. It is caused by numerous things but mostly by gallstones (up to 40%), alcohol (30%) or hypertriglyceridemia (5-10%).

Diagnosis requires 2 of the following: characteristic abdominal pain, lipase >3x the upper limit of normal, characteristic findings on US or CT. Besides pancreatitis, other conditions like bowel obstruction, bowel ischemia etc can also cause elevated levels of lipase, but normally won’t exceed levels 3 times the upper limit.

Treatment is mostly supportive. In case of hypovolemia, flu. Antibiotics are controversial and only warranted in patients with signs/sources of infection, necrosis, abscess and infected pseudocysts.

EM@3AM: Pancreatitis

Question 5

Your patient presents with fever of unknown origin. POCUS reveals a mitral valve vegetation. Which of the following statements about endocarditis is true?

A: Fever is present in about half of patients with endocarditis

B: Roth spots are an example of extracardiac manifestations of endocarditis and present as tender lesions which can be found on finger pulps and thenar/hypothenar eminences

C: Flank pain in a patient with endocarditis could be due to splenic or renal emboli and therefore abdominal imaging should be considered in these patients

D: Workup should include two proper sets of blood cultures

The correct answer is C.

Endocarditis was covered by Anand Swaminathan this week as part of the REBEL Core Cast.

Endocarditis is an infection of the endocardial surface of the heart, heart valves or both. Fever is present in 90% of patients whereas a new murmur is present in 50-80% of patients. Examples of extracardiac symptoms are: Osler nodes, Janeway lesions, splinter hemorrhages and Roth Spots which are emboli in the eye causing boat-shaped hemorrhages with pale centers.

Emboli can cause all sorts of complications in the lungs, spleen and kidneys. Splenic and renal emboli can cause flank pain.

Workup should include three sets of blood cultures.

REBEL Core Cast 27.0 – Endocarditis

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 61, February 7th, 2020

Welcome to the 61th FOAMed Quiz. 

Enjoy!

Eefje, Hüsna, Joep and Rick

Source image: www.pixabay.com


Question 1

A 50-year old male presents to your Emergency Department after incidental ingestion of windshield washer fluid he had stored in a Gatorade bottle, although you doubt this is really what happened. 30 Minutes after ingestion he felt dizzy, nauseated and sleepy. Physical examination shows a vomiting patient with normal vital signs as well as ataxia and dysarthria.

Which of the following statements about ingestion of this is true?

A: Windshield washer fluid typically contains hydrocarbons

B: An arterial blood gas will most likely show a normal osmolar gap and a metabolic acidosis

C: This patient should be treated with activated charcoal

D: This patient has an indication for treatment with fomepizole or ethanol

The correct answer is: D

Richard Byrne of EM Daily presented a case of windshield washer ingestion and recently toxic alcohol toxicity was covered on the Internet Book of Critital Care.

Windshield washer fluid often contains ethylene glycol and or methanol. An arterial blood gas will show a metabolic acidosis with an elevated anion gap and osmolar gap indicating the presence of unmeasured osmotically active solute.

Activated charcoal is not effective in treatment of toxic alcohol toxicity.

The enzyme alcohol dehydrogenase is responsible for metabolism of (on themselves not very toxic) alcohols into their toxic metabolites. Fomepizole and ethanol are inhibitors of alcohol dehydrogenase therefore reduce formation of toxic metabolites. Consider hemodialysis early on.

IBCC chapter & cast – Toxic Alcohols

 

Question 2

A 14-year old boy just arrived by ambulance after playing a rugby match. A sudden course correction was followed by a surge of severe pain in his knee. You see a hugely swollen knee with an obvious deformity on the lateral side.

The triage nurse thinks his patella is dislocated.

Which of the following statements about patella dislocation is true?

A: Most patella dislocations are due to direct contact like knee to knee strike in basketball or a helmet/head to knee in rugby

B: Lateral tenderness is common as the lateral patellofemoral ligament (LPFL) is ruptured in 94% of dislocations

C: Reduction of the dislocation should be done by flexing the hip, applying pressure to the lateral border of the patella in a medial direction while extending the knee

D: The older the patient the higher the rate of re-dislocation

The correct answer is C

Tadgh Moriarty covered acute patella dislocation this week in Don’t Forget the Bubbles.

Patella dislocations are caused by non-contact twisting injuries most of the time (66-82%) and cause medial tenderness of the knee due to rupture of the medial patellafemoral ligament (MPFL) in over 94% of dislocations.

Reduction of the dislocated patella should be done by flexing the hip while applying pressure to the lateral border of the patella in a medial direction while extending the knee. Post reduction management consists of immobilisation with a knee immobilizer and follow up with a orthopedic or trauma surgeon.

The younger the patient, the higher the change of re-dislocation: 60% for those 11-14 years old and 33% for those 15-18 years old.

Source image: www.pixabay.com

Question 3

A lot of controversies exist regarding the use of Oseltamivir in influenza (read the BMJ campaign here). It seems Oseltamivir does not have any effect on preventing secondary complications and mortality, but it might shorten symptom duration.

Luckily this paper was recently published in the Lancet. What does this paper show according to the authors?

A: Oseltamivir shortens duration of symptoms in patients with suspected influenza

B: Oseltamivir reduces X-ray confirmed pneumonia in patients with suspected influenza

C: Oseltamivir reduces use of acetaminophen or ibuprofen containing medicine in patients with suspected influenza

The correct answer is A, I think

Justin Morgenstern covered this paper last week in First10EM.

Conclusion of the authors: Oseltamivir shortens duration of symptoms in patients with suspected influenza.

However: there are evident methodological issues with this paper. The authors randomized some 3000 patients with suspected influenza to either ´usual care’ or ´usual care´ plus Oseltamivir, no placebo in the comparison group. This combined with the subjective primary outcome (patient-reported time to recovery, defined as having returned to usual daily activity and fever, headache, and muscle ache rated as minor or no problem in key subgroups) make a very high risk on bias.

Furthermore, it seems Oseltamivir had the same effect regardless of the subject having influenza or not (only half of the population tested influenza PCR positive). This suggests even more the entire reported difference is due to placebo effect.

Tamiflu doesn’t work

Source image: www.pixabay.com

Question 4

Your patient presents to the Emergency Department after an unknown substance was sprayed into her eyes.

Which of the following statements is true about caustic eye injuries?

A: Pain is a good indicator of degree of injury

B: Acids erode through the corneal epithelium and penetrate into the anterior chamber more easily than alkali do

C: Acidic injuries may initially look worse than an alkali burn but are often less severe

D: Hydrofluoric acid injury should be treated just like any acidic eye injury

The correct answer is C

Pain is not a good indicator of degree of injury, as alkali substances cause nerve damage. Alkali erode through the corneal epithelium and penetrate into the anterior chamber more easily than acids. Acidic injuries may initially look worse than an alkali burn but are often less severe. Hydrofluoric acid is an exception as it chelates calcium (and magnesium) ions and causes serious and deep injury with possible systemic toxicity. Treatment consists of irrigations and calcium, calcium and calcium (more on this another time). 

Source image: NTSP Manuel 2013 from www.tracheostomy.org.uk

Question 5

Your 45 year old patient comes in with dyspnoea and difficulty breathing through his permanent tracheostomy tube he had for years. He has increased work of breathing and you wonder if the tube is patent.

Which of the following would be adequate in this situation?

A: Do not remove the inner tube when obstruction is suspected

B: Passing a suction catheter via the tracheostomy is a safe way to assess whether or not the tube is patent

C: Passing a Gum Elastic Bougie (GEB) via the tracheostomy is a safe way to assess whether or not the tube is patent

D: Most laryngectomy stomas will have a tube in situ

The correct answer is B

The RCEM learning podcast covered tracheostomy issues this month.

Passing a suction catheter via the tracheostomy will establish whether or not the tube is patent and also allow therapeutic suction to be performed. Gum elastic bougies or similar introducers should be avoided at this stage because these stiffer devices are more likely to create a false passage if the tracheal tube tip is partially displaced.

Most laryngectomy stomas will NOT have a tube in situ. Try to find out early whether your patient still has a patent orotracheal route or not.

Have a read here and here. 

 

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This quiz was written by Eefje Verschuuren, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 60, January 31th, 2020

Welcome to the 60th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: http://www.ultrasoundpodcast.com
 

Ultrasound guided intravenous access is a procedure commonly performed in our ED. Success rates are pretty high, but dislodgement in case of cannulation of a deeper vein is a concern. Does the use of ultralong (6.35 cm) catheters for ultrasound guided peripheral intravenous access have benefit over the use of standard catheter (4.78 cm) in patients with difficult IV access?

A: No, use of ultralong catheters does not have any benefit over use of a standard catheter

B: Yes, use of ultralong catheters leads to a higher success rate on first attempt compared to use of a standard catheter

C: Yes, use of ultralong catheters leads to a decrease in minutes to completion compared to use of a standard catheter

D: Yes, use of ultralong catheters leads to an increase in survival time of the catheter compared to use of a standard catheter

The correct answer is D

This weeks journal club of St. Emlynsblog covered the following paper.

I guess it depends a bit on if you consider 6.35 cm (2.5 inch) ultralong (I wouldn’t). 

This is a randomised controlled trial comparing standard catheters for ultrasound guided intravenous access to ultralong catheters. The ultralong catheters survived on average 44 hours longer than the standard catheters. There was no difference in first attempt success, number of attempts and time to completion.

JC: Long lines for USS guided peripheral IVs. St Emlyn's

Question 2

 

Source image: https://litfl.com/

A 7-year-old child is seen at your emergency department with a temperature of 38.2℃, a little tachypnoe, oxygen saturation around the high 80s and some crackles on auscultation. The X-ray shows bilateral peribronchial shadowing. You piece her age and clinical picture together and consider Mycoplasma pneumonia.

Which of the following statements about acute Mycoplasma pneumoniae infection is true?

A: β-lactams should be the first-line antibiotic prescribed when a clinical diagnosis of M. pneumoniae pneumonia is made

B: Antibiotic therapy is always indicated for extra-pulmonary manifestations

C: 1/3 of children hospitalized with M. pneumoniae infection have a concurrent viral infection

D: M. pneumoniae has an incubation period of 3 days

The correct answer is C

Phoebe Williams covered acute M. pneumoniae infection this week in Don’t Forget the Bubbles.

M. pneumoniae infection can occur in children of all ages, with a median age of hospitalization with community-acquired pneumonia (CAP) due to M. pneumoniae of 7 years.
Codetection of viral pathogens (in 1/3 of children hospitalized with M. pneumoniae infection) is common.

M. pneumoniae is transmitted via infected respiratory droplets during close contact, with a long incubation period of up to 23 days.

Mycoplasma spp. lack a cell wall, so are intrinsically resistant to a number of our most common antibiotic classes (including β-lactams). Azithromycin should be the first-line antibiotic prescribed when a clinical diagnosis of M. pneumoniae pneumonia is made. Antibiotic therapy is generally only indicated for pulmonary disease, as extra-pulmonary manifestations tend to be immune-mediated.

The mire of mycoplasma

Question 3

Source image: pixabay.com

 

Which of the following therapies is not indicated in a hemodynamically unstable patient with calcium channel blocker (CCB) toxicity?

A: High‐dose insulin euglycaemic therapy (HIET)

B: Calcium intravenously

C: Catecholamine adrenergic receptor agonists

D: hemodialysis or hemofiltration

The correct answer is D

Scott Weingard recorded a podcast about a very interesting case of beta blocker (BB) and calcium channel blocker (CCB) poisoning.

Treatment of BB and CCB poisoning is more or less the same. Both can be lethal and both should be managed very carefully, even if the patient does not look ill to start with. Treatment generally consists of:

•Calcium
•HIET
•Inotropy and if needed vasoactive medication
•Methylene Blue (to be considered)
•Lipid emulsion therapy (to be considered)
•Glucagon (to be considered)

Because of their affinity to plasma proteins, high hepatic first pass, and a large volume of distribution, hemodialysis or hemofiltration are not effective.

EMCrit 264 – Case Discussion of Combined CCB and BB Overdose

Question 4

Your 65 year old patient presents to the ED with diarrhea since 4 days with some bloody stools. You wonder whether antibiotics might benefit recovery of your patient. Diarrhea caused by which of the following causative organisms does not respond to antibiotics?

A: Shiga Toxin producing E. Coli

B: Shigella

C: Campylobacter

The correct answer is A

EMdocs covered infectious diarrhea this week.

Shigella and Campylobacter may benefit from antimicrobials, whereas Shiga Toxin producing E. Coli (STEC) and most likely salmonella do not. When concern for Shiga Toxin producing organisms, distinguishing between Shiga toxin 1 and Shiga toxin 2 (which is more potent) is useful. Considering HUS in these cases is important

Infectious Diarrhea

Question 5

A 12-year old child, with a history of moderate Hemophilia, is seen at your emergency department with hemarthrosis of his/her right knee after falling down from a skateboard.

The three most common bleeding disorders in children are Hemophilia A, Hemophilia B and Von Willebrands.

Which of the following statements is true about this child and Hemophilia?

A: This child is most likely female

B: Patiënts with Hemophilia A have a deficiency of coagulation factor IV while patients with Hemophilia B have a deficiency of coagulation factor VIII

C: This child’s site of bleeding is the most common site of bleeding in Hemophilia patients

D: Patients with Hemophilia A need higher doses of replacement coagulation factors compared to patients with Hemophilia B

The correct answer is C

Brad Sobolewski from PEMblog covered the most common bleeding disorders in children this week.

This child is most likely male since Hemophilia is a X-linked recessive disease. Patients with Hemophilia A have a deficiency of coagulation factor VIII while patients with Hemophilia B have a deficiency of coagulation factor IV.

Hemophilia can be mild, moderate or severe. The most common type of bleeding is hemarthrosis of a joint like the knee but it can cause all kinds of bleeding complications ranging from minor bruises to heavy menorrhagia, muscle bleeds and even intracranial bleeds.

The first line of treatment in the ED is replacement of coagulation factors. Patients with Hemophilia B need higher doses than patients with Hemophilia A and depending on the kind of injury site and bleed type, further treatment and admission to the hospital could be necessary.

Factor First! Hemophilia management in the Emergency Department

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 59, January 24th, 2020

Welcome to the 59th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: www.thebottomline.org

Most certainly the most widely discussed study last week was the VITAMINS paper. Some two and a half years after the Marik report, this randomized controlled trial provides some real evidence about the golden cocktail of Hydrocortisone, Vitamin C, and Thiamine in septic ICU patients. What did the VITAMINS paper show?

A: Treatment with Hydrocortisone, Vitamin C, and Thiamine resulted in significantly more septic ICU patients off the ventilator and alive on day 7 after randomization compared to hydrocortisone only

B: Treatment with Hydrocortisone, Vitamin C, and Thiamine resulted in significantly less septic ICU patients off the ventilator and alive on day 7 after randomization compared to hydrocortisone only

C: Treatment with Hydrocortisone, Vitamin C, and Thiamine resulted in equal numbers of septic ICU patients off the ventilator and alive on day 7 after randomization compared to hydrocortisone only

The correct answer is C

The Bottom Line  , St. Emlyn’s,  Emergency Medicine Literature of Note  and others covered the VITAMINS trial this week. 

This is the first in a series of papers about Hydrocortisone, Vitamin C, and Thiamine (or HAT). This one shows no sign of benefit. However, it is a relatively small study (n = 216) and it has some weaknesses (eg. underpowered for mortality, thiamine levels not measured). More to come….

https://www.thebottomline.org.uk/summaries/icm/vitamins/

Question 2

Source image: https://litfl.com/

A sixty year old patient with no past medical history presents to your emergency department with nonspecific chest pain. His physical exam is normal. The ADD-RS (aortic dissection detection risk score) shows a low pretest probability for aortic dissection. You decide to perform focused cardiac ultrasound (FoCUS) to feel more secure about sending this patient home later on. 

What is the sensitivity of FoCUS for acute aortic syndromes with a low ADD-RS score?

A: Presence of direct symptoms (an intimal flap, intramural aortic haematoma or a penetrating aortic ulcer) on FoCUS has a sensitivity of 89 percent for acute aortic syndromes in patients with a low ADD-RS score

B: Presence of direct symptoms (an intimal flap, intramural aortic haematoma or a penetrating aortic ulcer) on FoCUS has a sensitivity of 70 percent for acute aortic syndromes in patients with a low ADD-RS score

C: Presence of direct symptoms or indirect symptoms (thoracic aorta dilatation, pericardial effusion and aortic valve regurgitation) has a sensitivity of 89 percent for acute aortic syndromes in patients with a low ADD-RS score

D: Presence of direct symptoms or indirect symptoms (thoracic aorta dilatation, pericardial effusion and aortic valve regurgitation) has a sensitivity of 70 percent for acute aortic syndromes in patients with a low ADD-RS score

The correct answer is C

This weeks Ultrasound G.E.L  podcast is about this paper published in 2019. This was a prespecified subanalysis of the ADvISED multicentre prospective study. It turns out sensitivity of PoCUS in a population with low pretest probability for acute aortic syndromes is quite fair if indirect signs like pericardial effusion and a dilated aortic root are considered to be a positive test. If only direct signs (visualize the intimal flap itself of detect an intramural hematoma) are considered to be positive, the sensitivity drops to about 45 percent.

Question 3

Source image: www.pixabay.com

Your 34 year old patient is in convulsive status epilepticus. 2 Doses of 5 mg Midazolam intravenously were administered without any effect. Your patient turns out to use Isoniazid (INH), Pyrazinamide and Rifampin. Which of the following should be your next step?

 A: Levetiracetam

 B: Fosphenytoin 

 C: Valproate 

 D: Pyridoxine

The correct answer is D

EmDOCs covered INH toxicity this week.

This seizure is most likely caused by INH (isonicotinylhydrazide). This is a hydrazide (like rocketfuel) and causes a functional pyridoxine deficiency. INH also inhibits the enzyme that converts the stimulatory neurotransmitter glutamate to GABA. Dosing of pyridoxine when an unknown amount of INH is ingested is 5 g IV and 70 mg/kg IV in pediatrics, repeated every 5-20 minutes.

Question 4

Source image: www.rebelem.com

You see a 54-year old patient with cirrhosis now complaining about progressive abdominal pain.

Which of the following statements about spontaneous bacterial peritonitis (SBP) is true?

A: If a patient has fever or abdominal pain/tenderness, empiric antibiotics should be given even if ascitic neutrophil count < 250 cells/mm3

B: The most common causative organisms are Pseudomonas aeruginosa and Bacteroides fragilis

C: The classic triad includes fever, abdominal pain and increasing ascites. Presence of all three components is common.

D: Serum blood tests (i.e. WBC, CRP, ESR) are helpful in making this diagnosis

The correct answer is A

RebelEM covered SBP this week.

If a patient has fever or abdominal pain/tenderness, empiric antibiotics should be given even if ascitic neutrophil count < 250 cells/mm3. The most common bacterial causes are E. Coli, S. Pneumoniae and Enterococci. The classic triad includes fever, abdominal pain and increasing ascites, but the presence of all three symptoms is rare. 

https://rebelem.com/spontaneous-bacterial-peritonitis-sbp/

Question 5

www.aliem.com

What percentage of patients over 60 years old have rotator cuff tears after a shoulder dislocation?

 A: 10 percent

 B: 30 percent

 C: 50 percent

 D: 80 percent

The correct answer is D

AliEM covered recurrent shoulder dislocations in their Splinter Series this week. 

35 Percent of patients over 40 years of age have concomitant rotator cuff tears with their shoulder dislocations. This number jumps to over 80 percent when patients with shoulder dislocations are over 60.

 

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 58, January 17th, 2020

Welcome to the 58th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://www.aliem.com. Case courtesy of Andrew Murphy, Radiopaedia.org

Which of the following suspected injuries of the hand and wrist can be a reason to perform a ‘’clenched fist view’’?

A: A hook of hamate fracture

B: Scapholunate dissociation

C: A Scaphoid Fracture

D: Perilunate or lunate dislocation

The correct answer is B

AliEM covered radiographic approach to the injured wrist this week.

A hook of hamate fracture can be seen most easily on a carpal tunnel view. 

A perilunate or lunate dissociation should be visible on normal AP and Lateral views. 

Scaphoid series might help you find a scaphoid fracture, which leaves a Scapholunate dissociation to be most easily found on a ‘’clenched fist view’’.

EMRad: Radiologic Approach to the Traumatic Wrist

Question 2

Source image: www.pixabay.com

An otherwise healthy 24-year-old female is brought to the emergency department by her roommate because of an altered mental status. They went to a party together. After she got home this morning she was acting strange and progressively became more somnolent. The roommate admits she and the patient taking 3,4-Methylenedioxymethamphetamine (MDMA) last night. Her sodium comes back 103 mEq/l.

Which of the following statements is true regarding the hyponatremia in this patient?

A: MDMA causes hyponatremia due to adrenal insufficiency and polydipsia

B: MDMA causes hyponatremia due to heart failure and polydipsia

C: MDMA causes hyponatremia due to hypothyroidism and polydipsia

D: MDMA causes hyponatremia due to Syndrome of Inappropriate ADH secretion (SIADH) and polydipsia

The correct answer is D

EmDocs covered the pearls and pitfalls of hyponatremia this week.

This patient most likely suffered acute hyponatremia after using MDMA at the party. Drugs like MDMA can be a trigger for SIADH.

Patients with acute onset hyponatremia are at risk for cerebral edema because intracellular osmolality suddenly exceeds extracellular osmolality. This causes water to move into the cells.

Current recommendations have defined correction should be no greater than 8 mEq/L in a 24-hour period and a total of 16 mE1/L in a 48-hour period.

 

Critical Hyponatremia: Pearls and Pitfalls

Question 3

Source image: www.pixabay.com

Febrile illnesses are the most common cause of presentation to acute pediatric medical services. Which of the following statements is true about fever in children?

A: Bacteria are killed more easily by antibiotics at higher core temperatures

B: Higher temperature indicates a more serious infection

C: Rigors are associated with an increased risk of bacterial infection in children

D: Fever should always be treated with antipyretics

The correct answer is A.

Don’t forget the bubbles covered fever last week. 

Fever is a beneficial response to an infection, with higher temperatures promoting the immune response and inhibiting the growth of pathogens. Furthermore, bacteria are killed more easily by antibiotics at higher temperatures.

There is little to no evidence that higher temperatures, fever that don’t respond to antipyretics, or rigors indicate an increased risk of a serious infection.

Since fever doesn’t cause any harm (unless exceeding 41°C (105.8°F), treating a fever is only necessary if the child is uncomfortable.

https://dontforgetthebubbles.com/hot-garbage-mythbusting-fever-children/

Question 4

This French retrospective, observational, multicenter study is about efficiency of thrombolysis in out of hospital cardiac arrest (OHCA) caused by pulmonary embolism (PE). The primary endpoint was 30-day survival. 328 patients with confirmed or suspected PE were included. What did the authors find?

A: Thirty-day survival was higher in the thrombolysis group than in the control group but good neurologic outcome was not significantly different

B: Thirty-day survival was higher in the thrombolysis group than in the control group and good neurologic outcome was significantly higher in patients receiving thrombolysis

C: Thirty-day survival was similar in the thrombolysis group and the control group and good neurologic outcome was not significantly different

D: Thirty-day survival was similar in the thrombolysis group but good neurologic outcome was significantly higher in patients receiving thrombolysis

The correct answer is A

Clay Smith covered this paper on JournalFeed last week.

The authors of the paper state: ‘‘Thirty-day survival was higher in the thrombolysis group than in the control group (16% vs 6%; P ¼ .005) but the good neurologic outcome was not significantly different (10% vs 5%; adjusted relative risk, 1.97; 95% CI, 0.70-5.56).’’

However, it is a bit unclear to me which patient were eventually considered having PE. ‘’PE was diagnosed on hospital admission by CT pulmonary angiography (CTPA) (definite PE) or echocardiogram (probable PE)’’. There is no mention of sonographic evaluation for deep venous thrombosis.

Question 5

Which of the following statements is true about the Greater Occipital Nerve Block (GONB)?

A: If palpation of the Greater Occipital Nerve (GON) reproduces headache pain or irritation, it should be avoided

B: The GONB can be used in the treatment of refractory migraine, cluster headache, occipital neuralgia, or cervicogenic headache

C: A GONB should not be performed bilaterally

D: The GON lies just lateral to the occipital artery

The correct answer is B

NUEM covered the GONB this week.

GONB has been used in the treatment of cervicogenic headache, cluster headache, and occipital neuralgia, with demonstrated efficacy in improving pain and reducing headache frequency.

If palpation of the GON reproduces headache pain or irritation, it may be a good target for GONB

A GONB can be performed bilaterally if needed and the GON lies just medial to the occipital artery.

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen