Quiz 70, June 5th, 2020

Welcome to the 70th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

    Source image: www.radiopaedia.org. Case courtesy of Dr. Henry Knipe

Question 1

A healthy 45 year old patient presents to your ED with a displaced humeral shaft fracture after a fall on the football pitch. According to this recently published Randomised Controlled Trial, does surgery lead to better functional outcome (Disabilities of Arm, Shoulder and Hand (DASH) score) compared to functional bracing ?

A: The functional outcome (DASH) at 12 months after injury was statistically better in the surgical intervention group

B: The functional outcome (DASH) at 12 months after injury was statistically better in the functional bracing

C: There was no statistically significant difference between the two groups

The correct answer is C

Anand Swaminathan covered the FISH RCT on RebelEM last week.

This rather small RCT (n = 82) revealed no significant difference in DASH scores at 12 months (12.0 for bracing vs 8.9 for surgery). This is in line with the 2017 Masunga trial.

However, non-union occurred in 11 out of 44 patients in the functional bracing group leading to significant cross-over.

The FISH RCT: Surgical vs Non-Surgical Management of Displaced Humeral Shaft Fractures

Question 2

The use of tranexamic acid (TXA) in the emergency department has been increasing in the last decade after CRASH-2 showed a reduction in all cause mortality in severely injured patients. CRASH-2 also reported no difference in vascular occlusive events (2 percent in the TXA group). However, TXA is still considered to be quite thrombogenic.

This recently published paper looked at 273 patients in a level 1 trauma centre receiving TXA. What did the authors find?

A: The rate of thromboembolic events was lower (1 percent) compared to the rate in the CRASH-2 cohort (2 percent)

B: The rate of thromboembolic events was equal to the rate in the CRASH-2 cohort (2 percent)

C: The rate of thromboembolic events was higher (6 percent) compared to the rate in the CRASH-2 cohort (2 percent)

The correct answer is C

Clay Smith covered this paper on Journal Feed.

This paper found a higher rate of thromboembolic events compared to the CRASH-2 cohort (6,6 percent compared to 2 percent). The mortality was about equal to the CRASH-2 cohort. Some differences to the CRASH-2 cohort were noted. Patients in this study received blood transfusions and surgery more often, were older, and there was a higher percentage of female patients than the CRASH-2 cohort. Interestingly only 61% received both boluses of TXA.

 

Source image: www.pixabay.com

Question 3

Low dose non contrast CT are increasingly performed in case of suspected renal colic. However, the effect these CT’s on patient oriented outcomes are uncertain (Ultrasonography Versus Computed Tomography for Suspected Nephrolithiasis).

According to this paper combining a systematic review and multidisciplinary consensus, which of the following patients should receive a CT?

A: A 35-y-old man with no history of kidney stones presents with an acute onset of flank pain during the last 3 h. He reports nausea with vomiting and has hematuria on urine dip. He has no abdominal tenderness. His pain is relieved after intravenous analgesics.

B: A 35-y-old man with 2 previous kidney stones that passed spontaneously presents with an acute onset of flank pain during the last 3 h. He reports nausea with vomiting and has hematuria on urine dip. He has no abdominal tenderness. His pain is relieved after intravenous analgesics. Ultrasonography is performed; there is hydronephrosis on the side with the pain, and a stone is not visualized.

C: A 75-y-old man with no history of kidney stones presents with an acute onset of flank pain during the last 3 h. He reports nausea with vomiting and has hematuria on urine dip. He has no abdominal tenderness. His pain is relieved after intravenous analgesics.

D: A 35-y-old woman who is 10 weeks pregnant with no history of kidney stones presents with an acute onset of right flank pain during the last 3 h. She reports nausea with vomiting and has hematuria on urine dip. She has no abdominal tenderness. Her pain is relieved after intravenous analgesics.

The correct answer is C

This week Justin Morgenstern discussed this paper on Imaging in Renal Colic on First10EM

According to this systematic review an alternative diagnosis is found on CT in 0-33 percent of cases and a clinically important diagnosis is found on CT in less than 5% of patients. The sensitivity of a formal ultrasound is reported to be between 3 and 98 percent, so that does not help us a lot. For POCUS, the authors report a pooled sensitivity of 70% and specificity of 75%.

In general it seems ultrasound will do in younger patients if pain is not relieved by analgesics. Older patients may benefit from CT because alternative diagnoses are more likely to show up and radiation is less of a concern.

A panel of 9 clinicians (emergency physicians, urologists, and radiologists) was used to determine the recommended imaging strategy. There was perfect consensus about the 75 years old patient requiring CT (patients A, B and D do not).

Imaging for renal colic

Source image: www.emcrit.org

Question 4

Your 62-year old female presents with severe chest pain, elevated troponin and dyspnea. Your views on bedside ultrasound are far from perfect, but you suspect some apical ballooning. Furthermore, 2 weeks ago your patient lost a relative. Both acute myocardial infarction (AMI) and Takotsubo cardiomyopathy (TC) are on your differential diagnosis.

Which of the following statements about findings that could help you differentiate between AMI and TC is true?

A: Presence of anterior ST-elevation makes TC unlikely

B: Hyperacute T-waves exclude TC

C: An elevated troponin makes TC unlikely

D: An elevated BNP is seen in 80 percent of TC patients

The correct answer is D

Josh Farkas from Emcit covered Takotsubo cardiomyopathy this week as part of the IBCC series. 

Takotsubo cardiomyopathy is present in 1-2% of patients who present with chest pain and troponin elevation. 

Although EKG cannot reliably differentiate Takotsubo cardiomyopathy from occlusive MI, there are some characteristic EKG features which are worth being aware of. ST elevation is usually most notable in V3-V6 in TC, but it has lower magnitude than is typically seen with an anterior occlusive MI. Hyperacute T-waves may be seen in Takotsubo cardiomyopathy. Troponin is elevated in 90% and BNP is elevated in 80% of cases of Takotsubo cardiomyopathy (however very non-specific).

 

 

Source image: www.aliem.com

Question 5

The lab calls you to alert you on a sodium of 112 mmol/L. 3 minutes later your patient is seizing. You order 100 cc of 3% sodium chloride, but your nurse tells you this can take a while. You do have 8,4 percent sodium bicarbonate in the crashcart.

Can you use sodium bicarbonate 8,4% instead of sodium chloride 3% to treat symptomatic hyponatremia?

A: Yes, 50 ml of sodiumbicarbonate 8.4% equals 100 ml of sodium chloride 3%

B: Yes, 500 ml of sodiumbicarbonate 8.4 % equals 100 ml of sodium chloride 3%

C: Yes, 5 ml of sodiumbicarbonate 8.4 % equals 10 ml of sodium chloride 3%

C: No, this is not a safe thing to do

The correct answer is A

Dr. Jonathan Hootman explains how to use sodium bicarbonate in symptomatic hyponatremia on Aliem this week.

We usually treat symptomatic hyponatremia with boluses of 100 to 150 ml sodium chloride 3%. However, sodium bicarbonate is a reasonable alternative. One ampule of sodium bicarbonate 8.4 % contains about the same amount of sodium as 100 ml sodium chloride 3% (50 mEq vs 51.3 mEq).

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 69, May 29th, 2020

Welcome to the 69th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.thebottomline.org.uk

Question 1

The ACTT-1 trial was covered by almost every FOAMed blog and podcast this week. This preliminary report concerning an RCT comparing Remdesivir to placebo for in COVID-19 patients was published earlier this week. 


Which of the following statements is true about this trial?


A: A clear mortality benefit was found in favour of the Remdesivir group


B: Time to recovery was shorter in favour of the Remdesivir group


C: The sickest patients seem to benefit most from Remdesivir therapy

The correct answer is B

This trial was covered by:

Justin Morgenstern on First10EM 

Fraser Magee on the Bottom Line 

Salim Rezaie on RebelEM 

Josh Farkas on EMcrit 

Rory Spiegel on EMcrit 

They all come to the same conclusion. Yes, the trial shows faster recovery in the not very ill COVID-19 patients (11 vs. 15 days). However there are some methodological concerns. The trial was stopped early (full outcomes available of 69% of the patients). The primary outcome was changed after data collection commenced (but before data analysis). A lot of data is not reported (including laboratory results).

 

Question 2

Quite some research has been published recently on the Canadian Syncope Risk Score (CSRS). It seems to have excellent diagnostic diagnostic accuracy for serious adverse events (SAE) (sensitivity of 99% if cutoff is -2 and sensitivity of 98% if cutoff is -1 on serious adverse events at 30 days) in syncope patients. NT-proBNP is found to have an independent association with mortality and SAE in patients with syncope. 

Does adding NT-pro-BNP to the CSRS improve its diagnostic accuracy? 

A: Yes, it does

B: No, it does not

C: it might

The correct answer is B

Clay Smith covered this paper last week on JournalFeed.

Of 1452 patients enrolled, 152 had 30-day SAEs. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them, but adding this value did not significantly improve prognostication.

Source image: www.pixabay.com

Question 3

Malaria continues to cause 230 million clinical infections and almost half a million deaths each year. Therefore it continues to caused a lot more deaths than COVID-19 (so far at least).

Which of the following statements about malaria is true?

A: A single negative blood film, or negative antigen test, does not completely exclude the diagnosis of malaria

B: A thick blood film is used to determine the Plasmodium species

C: Severe malaria only occurs secondary to Plasmodium falciparum infection

D: Artemether can cause severe hemolysis in patients with G6PD deficiency

The correct answer is A

Malaria was covered on Don´t forget the bubbles this week.

A single negative blood film, or negative antigen test, does not completely exclude the diagnosis of malaria . Some guidelines recommend 3 negative tests to exclude malaria in patients with a high pre-test probability.

A thick blood film is used to detect the presence of the parasites and the percentage of parasitised erythrocytes.

Severe malaria was previously considered only to occur secondary to P. falciparum, although there are increasing case reports of patients with P. vivax or P. knowlesi malaria presenting severely ill.

When prescribing primaquine you should definitely be aware of G6PD deficiency, as it can cause severe hemolysis.

Malaria

Source image: www.pixabay.com

Question 4

A 36 year old man with a history of severe alcohol abuses comes in with diaphoresis, tachycardia, hypertension and a tremor. He is clearly anxious and agitated. You expect he might be suffering from alcohol withdrawal and you consider different treatment options.

Which of the following statements about phenobarbital versus lorazepam for alcohol withdrawal is true?

A: Phenobarbital and benzodiazepines both target NMDA receptors in order to decrease withdrawal symptoms

B: Phenobarbital has a shorter length of action (i.e. half life) compared to lorazepam

C: Phenobarbital has low bioavailability when administered PO so it has to be given IV, whereas lorazepam can be administered IV, IM and PO

D: Phenobarbital dosing is more standardised compared to lorazepam dosing and is therefore more predictable and easier to titrate

The correct answer is D

Nuem covered treatment of alcohol withdrawal this week.

Alcohol withdrawal can be treated in multiple ways. Benzodiazepines are the current treatment of choice whereas phenobarbital was used as a first line treatment in the past although it seems to be making a comeback.

Both lorazepam and phenobarbital target GABA receptors to decrease excitatory tone. Phenobarbital does this more effectively since it does not rely on the presence of endogenous GABA hormone alone.

Both lorazepam and phenobarbital can be given IV, IM or PO. One benefit of phenobarbital is its longer half life of 80-120 hours compared to 14-20 hours for lorazepam.

The efficiency of lorazepam varies between different patients and drug levels. Therefore its effect is very hard to predict. The linear relationship between cumulative weight based dose and resulting plasma concentration of phenobarbital make it easier to achieve the right target dose and also easier to avoid levels in which toxicity may occur.

This subject was previously also discussed on Emcrit. 

Source image: www.tamingthesru.com

Question 5

You see a 64 year old female with a history of hypertension and diabetes. Her chief complaints are shortness of breath and a productive cough. She has a fever and an SpO2 of 82% on ambient air. She looks ill and she has diminished breath sounds on the right. You place her on a non-rebreather mask at 15 liters per minute. As part of your further work-up, you perform point-of-care ultrasound (POCUS). You suspect she has pneumonia.

Which of the following ultrasonographic signs are not typically found in case of pneumonia?

A: Shred sign

B: Localized B-lines

C: Subpleural fluid / pleural effusion

D: Lung point

E: Air bronchograms

F: Hepatization of the lung

The correct answer is D

POCUS for the diagnosis of pneumonia was covered by Taming the SRU this week.

The shred sign refers to a shredded deep border of the tissular image, as in connection with the aerated lung.

Localised B-lines and air bronchograms are typically seen in pneumonia. 

Hepatization of the lung refers to tissue-like appearance of the lung in which lung tissue loses its traditional artificial appearance and takes on an echo texture which is similar to liver tissue. 

A lung point is seen in pneumothorax. 

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This quiz was written by Eefje Verschuuren, NIcole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 68, May 22th, 2020

Welcome to the 68th FOAMed Quiz. 

Enjoy!

Eefje, Joep, Nicole and Rick

Source image: www.pixabay.com

Question 1

Your 45 year old patient is presented in cardiac arrest after an electrical injury on a construction site. Co-workers stated he passed out after a spark came from the fuse box of a residential building he was working on. This patient therefore most likely suffered an Alternating Current (AC) injury. A Direct Current (DC) injury is unlikely.

Which of the following statements about this case is true?

A: This type of electrical injury causes rhythmic muscle contractions and can induce tetany

B: The electrical injury most likely caused asystole immediately, ventricular fibrillation is unlikely

C: This electrical injury is most likely considered high voltage

D: This type of electrical injury tends to throw a victim with significant force

The correct answer is A

BrownEM covered electrical injury this week.

This patient suffered Alternating Current (AC) injury and the direction of flow of electrons alternates on a cyclical basis, like a metronome. The electricity we use in our houses is AC. Direct Current (DC) is found in circuits using batteries, railway tracts and lightning.

AC causes muscle contractions and is far more likely to cause ventricular arrhythmias than DC does. DC is more likely to ‘’throw’’ a patient. High voltage injury is considering electrical injury > 1000 Volts. These voltages are not typically found in our house.

Source image: www.pixabay.com

Question 2

A 3-year old boy is brought into the emergency department by EMS after being found unconscious during a house fire. Besides carbon monoxide poisoning, you guess the risk of cyanide poisoning is high.

Which of the following statements about the treatment of cyanide poisoning is true?

A: Sodium Thiosulfate helps to convert cyanide to thiocyanate, which is another harmful compound but readily metabolized in the liver

B: The preferred administration route of amyl nitrite is intravenously

C: Sodium nitrite is used to treat methemoglobinemia

D: Hydroxocobalamin complexes cyanide to form the not very toxic cyanocobalamin

The correct answer is D

Cyanide poisoning was covered by Elise Alves Graber from emDocs this week as part of the ToxCards series.

Toxicity is mainly due to inhibition of cytochrome oxidase in the electron transport which halts ATP production leading to acidosis and anaerobic metabolism despite an often oxygen rich environment.

Sodium Thiosulfate helps to convert cyanide to thiocyanate, which is a harmless compound eliminated in the urine.

Amyl nitrite is no longer used due to unpredictable effectiveness. It is highly volatile and used to be administered by inhalation.

Sodium nitrite causes methemoglobinemia. This helps because cyanide has a higher affinity for the ferric iron in methemoglobin than for cytochrome oxidase.

Indeed, hydroxocobalamin complexes cyanide to form the not very toxic cyanocobalamin.

ToxCard: Cyanide Toxicity and Treatment

Source image: www.first10em.com

Question 3

A 30 year old woman presents to your emergency department with ongoing seizures.

Which of the following non-intravenous options has the shortest duration from administration to seizure cessation according to this recently published paper?

A: Intranasal midazolam

B: Buccal midazolam

C: Intramuscular midazolam

D: Rectal diazepam

E: Sublingual lorazepam

The correct answer is C

Justin Morgenstern discussed this paper on First 10 EM this week.

The authors of this systematic review analysed data about different routes and medications for terminating status epilepticus. 20 RCT’s were included, of which most were unblinded and of low methodological quality.

Intramuscular midazolam was the fastest to terminate seizures (2.1 minutes), followed by intranasal midazolam (2.4 minutes). Rectal diazepam and buccal midazolam both needed around 4 minutes.

Is there any reason to use intranasal midazolam for seizures?

Question 4

A 40 year old man comes in with altered mental status, agitation, tachypnoea, tachycardia, hypertension, diffuse (lead-pipe) tremors and hyperthermia. His neighbor found him confused and states the patient uses drugs from his psychiatrist. Which of the following clinical findings may point you in the direction of Serotonin Syndrome (SS) and does not so much fit Malignant Neuroleptic Syndrome?

A: Hypertension

B: Hyperthermia

C: Tachypnoea

D: Tremor

The correct answer is D

SinaiEM covered Serotonin Syndrome this week.

The difference between SS and NMS is quite tricky sometimes. Especially when the causative agent is not known. Differences in clinical findings are often very subtle. Hypertension, Hyperthermia, Tachypnoea, Tachycardia and Altered mental status can fit both etiologies. However, tremor and increased muscle tone are more typically seen in SS, while diffuse rigidity is more typical for NMS. Furthermore, the onset of SS is a lot faster compared to the more gradual onset of NMS.

 

 

Question 5

A 13 year old boy presents to your emergency department with severe pain in his right ankle caused by an uncomfortable landing during a basketball game. The X-ray of his ankle shows a triplane ankle fracture.

Which of the following statements is true about triplane ankle fractures?

A: They mostly occur shortly after closure of the distal tibial physis

B: Since triplane ankle fractures are caused by rotational forces, proximal spiral fibula fractures and base of the 5th metatarsal fractures are relatively common concomitant fractures

C: Triplane ankle fractures always consist of three parts as the name suggests

D: The Arcuate sign on CT is typical for this type of fracture

The correct answer is B

Anna O’Leary covered triplane ankle fractures this week in Don’t Forget the Bubbles.

Triplane fractures are classically seen in 10-17 year olds and occur before complete closure of the distal tibial physis. Tillaux fractures are seen in a bit older patients within 1 year after complete distal tibia physeal closure.

Triplane fractures may be classified as 2 part, 3 part or 4 part fractures and additional CT imaging is often necessary to evaluate the amount of dislocation of the different fracture parts. The typical sign which can be seen on CT is the Mercedes sign (see picture above).

The Arcuate sign refers to an avulsion fracture of the head of the fibula at the insertion site of the arcuate ligament complex.

Triplane ankle fractures

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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 67, May 15th, 2020

Welcome to the 67th FOAMed Quiz. 

Enjoy!

 Eefje, Joep, Nicole and Rick

 

Question 1

While treating an eyelid laceration you accidentally glued the eyelids shut a couple of minutes ago. Which of the following compounds is recommended for removal of histoacryl tissue adhesive according to this recently published paper?

A: Acetone

B: Ciprofloxacin eye ointment

C: Polydexa ear/eye drops

The correct answer is C

Clay Smith covered this paper on Journal Feed last week.

Interestingly, Polydexa (neomycin, polymyxin B, and dexamethasone) eye drops were most effective in removal of tissue adhesive in a porcine model if the adhesive was not removed within 90 seconds. The authors soaked the adhesive in test compound, with removal attempted hourly by rubbing gently for 1 min before reapplication of test compound.

Acetone seems to be effective if the adhesive has just been applied, but at 90 seconds it is not effective anymore. Furthermore, it leads to skin lesions if prolonged use. 

Question 2

Source image: http://litfl.com

Which of the following statements is true about U-waves?

A: They can appear in the setting of hypomagnesemia

B: They are the usually the first electrophysiological sign of hypokalemia

C: They are not associated with significant electrolyte disturbances

D: Once visible they always signify serious underlying disease

The correct answer is A

Steve Smith covered hypokalemia this week on dr. Smit’s ECG blog.

U-waves also appear in case of hypomagnesemia. The first electrophysiological sign of hypokalemia is flattening of the T-wave. U-waves are associated with a number of significant underlying disease, but can also occasionally occur as normal variant.

 

Source image: www.pixabay.com

Question 3

A 30 year old female presents to your emergency department with a wide range of symptoms including numbness of the lips, tongue and hands, hot and cold temperature reversal, generalized weakness and red skin rash. She states she ate barracuda in a restaurant yesterday after which she had some mild nausea and loose stool. Which one of the following foodborne diseases fit the picture best?

A: Scombroid fish poisoning

B: Botulism

C: Tetraodon poisoning

D: Ciguatera fish poisoning

The correct answer is D.

CountyEM covered Ciguatera fish poisoning last week.

Scombroid occurs from eating fish high in histamine due to inappropriate storage or processing and does not cause neurological symptoms. Botulism could present in similar fashion, but typically causes no sensory deficits. Tetraodon poisoning causes these symptoms but the patient would have recalled eating puffer fish.

This syndrome is typical for ciguatera fish poisoning. Patients can present with dysesthesia, vomiting, diarrhea, and/or a red skin rash. Hot and cold temperature reversal, generalized weakness, blurred vision, photophobia and myalgias may also occur.

Source image: http://blog.clinicalmonster.com/2020/05/08/ciguatera-fish-poisoning-2/
Source image: www.pixabay.com

Question 4

A 10 year old girl presents to your emergency department with complaints of monocular loss of vision and light flashes on her left eye. Her visual acuity on her left eye is 20/70. Her history is unremarkable. You wonder if, however rare, this child could have retinal detachment.

What is NOT a risk factor for retinal detachment in children?

A: Trauma

B: Myopia

C: Hyperopia

D: Previous ocular surgery

The correct answer is C

Last week Pediatric EM Morsels covered retinal detachment in children.

Retinal detachment is rare in children, but can occur. It is more common in the age 9-13 years old. Known risk factors are trauma, surgery, myopia and congenital abnormalities. Most children will not present with the classic symptoms like floaters, light flashes or a dark curtain falling down and might have a more gradual evolution of the condition. Ocular and fundoscopic examination is important. Ultrasound has a high sensitivity and specificity for this diagnosis

Retinal Detachment

Source image: www.pixabay.com

Question 5

The use of steroids in COVID-19 remains highly controversial. This recent multi-center pre/post implementation study evaluated the effect of a protocol involving early steroid administration in confirmed COVID-19 patients with bilateral pulmonary infiltrates and hypoxemic respiratory failure.

Patients admitted between 3/12 – 3/19 (pre- implementation of steroids) were compared to patients admitted the following week 3/20 – 3/27 (post- inplementation of use of steroids).

What did the authors find?

A: Treatment with corticosteroids correlated with an increase in clinical deterioration (composite outcome including ICU admission if not already in the ICU, intubation, mortality)

B: Treatment with corticosteroids correlated with a reduction in clinical deterioration (composite outcome including ICU admission if not already in the ICU, intubation, mortality)

C: Treatment with corticosteroids did NOT correlate with a difference in clinical deterioration (composite outcome including ICU admission if not already in the ICU, intubation, mortality)

The correct answer is B

Josh Farkas covered this paper on PulmCrit this week.

Compared to patients in the pre-steroid protocol, a significantly lower percentage of patients in the post-steroid protocol died (13.6% vs 26.3%), was admitted to the ICU (27.3% vs 44.3%) or needed to be intubated (21.7% vs 36.6%). 

Up until now, corticosteroids are more widely accepted among intubated patients than among non-intubated patients. This study suggests that steroids might be useful if administered earlier in the disease course in order to avoid deterioration and intubation in COVID-19 patients.

Nevertheless, we need to be aware of the fact that this was a pre/post study and therefore causality cannot be proven. Subtle changes in management of COVID-19 patients could have occurred during the two weeks of the post-steroid protocol. A randomised controlled trial will therefore be needed.

PulmCrit – Before/after study of short-course steroid in COVID-19

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This quiz was written by Eefje Verschuuren, Joep Hermans and Nicole van Groningen

Reviewed and edited by Rick Thissen

Quiz 66, May 8th, 2020

Welcome to the 66th FOAMed Quiz. 

Slowly the Corona-crisis seems te be under control in our region (for now). Time for some good old FOAMed trivia. Did you read up on the latest?

Enjoy!

Eefje, Joep and Rick

Question 1

The next trial in the Vitamin C story has arrived. This trial (the HYVCTTSSS trial) is a single-center RCT evaluating the combination of hydrocortisone, vitamin C, and thiamine versus placebo for patients with sepsis or septic shock. What did the authors find?

A: There was statistically significant lower mortality in the intervention (hydrocortisone, vitamin C, and thiamine) group compared to the control group

B: There was statistically significant lower mortality in the control group compared to the intervention (hydrocortisone, vitamin C, and thiamine) group

C: The trial was stopped early because of safety (adverse events in the intervention group)

D: The trial was stopped early because of benefit (the study hypothesis is unexpectedly proven early)

The correct answer is C

Josh Farkas covered this trial on PulmCrit and Clay Smith devoted a journal feed post to this trial. 

Severe hypernatremia (>160meq/L) was more common in the treatment group, 13 vs. 3 in the control (p=0.005), leading to early termination of the study.  Whether this is justified remains debatable, as Josh Farkas explains in his post. The result is this trial was profoundly underpowered and it provides no meaningful information about the intervention (hydrocortisone, ascorbate, and thiamine.)

Question 2

Your patient presents after following a high speed motor vehicle collision. You suspect a posterior sternoclavicular dislocation. Which of the following X-ray views is the most likely to help you?

A: Clavicle series

B: Velpeau view

C: Modified Axillary view

D: ‘’Serendipity’’ view

The correct answer is D

AliEM posted on a radiologic approach to the traumatic shoulder this week.

A ‘’Serendipity view’’ can be obtained when there is suspicion for sternoclavicular dislocations. It is obtained at an angle where the displacement of the clavicle is better appreciated

A Velpeau view is useful if the patient has too much pain to obtain a true axillary view or if the patient re-dislocates the shoulder upon taking post-reduction films.

Serendipity View

Source image: radiopaedia.org

Velpeau View

Source image: www.orthobullets.com

Question 3

Source image: www.litfl.com

Your 45 year old patient presents with a wide complex tachycardia (WCT) of about 190/minute. The patient is hemodynamically stable. You are not sure if this is ventricular tachycardia or supraventricular tachycardia with aberrancy or pre-existing bundle branch block. Which of the following findings makes a ventricular tachycardia more likely?

A: Normal QRS-axis

B: Resemblance to any known form of conduction block

C: Relative “delay” in the initial QRS deflection

D: Dominant terminal R wave in aVR

The correct answer is C

Ken Grauer covered VT vs SVT on dr. Smith’s ECG blog this week.

A normal QRS does not make VT more likely, an extreme axis does. Resemblance to any known conduction block makes pre-existent bundle branch block more likely. A dominant initial R in aVR makes VT more likely (Vereckei Algorithm). A relative slow initial deflection makes a VT more likely.

When in doubt, just assume it as VT.

Source image: http://hqmeded-ecg.blogspot.com/ Click image for link to original post

Question 4

Source: radiopaedia.org

A 78 year old patient with diabetes, COPD and stage 2 chronic kidney disease presents to your ED with significant abdominal distension, as well as abdominal pain, nausea, and vomiting. There is no fever and she does not feel unwell. The patient is stable and does not have peritoneal signs on exam. Contrast abdominal CT shows colonic dilation involving the right and transverse colon with no evidence of mechanical obstructive cause. There are no signs of (impending) perforation. What would be your diagnosis?

A: Ischaemic colitis

B: Wilkie’s syndrome

C: Sigmoid volvulus

D: Ogilvie’s syndrome

The correct answer is D

Justin Morgenstern covered Ogilvie’s syndrome this week. 

Ogilvie’s syndrome or acute colonic pseudo-obstruction is a cause of abdominal pain typically seen in elderly patients with multiple chronic illnesses. The underlying pathophysiology is uncertain. Management is conservative unless there are signs of (impending) hollow viscus perforation.

Ischemic colitis and sigmoid volvulus would show on the CT. Wilkie’s syndrome is a rare cause of duodenal obstruction, caused by a low aortomesenteric angle resulting in vascular compression of the duodenum. 

Acute colonic pseudo-obstruction (Ogilvie’s syndrome)

Question 5

Source image: @matslumholdt on pixabay.com

Slightly longer IV-cannulas are increasingly used when ultrasound guidance is necessary for peripheral vascular access. This recently published paper is about standard 4.78-cm, 20-gauge ultrasonographically guided intravenous peripheral catheters versus 6.35-cm, 20-gauge ultrasonographically guided intravenous peripheral catheters in patients in the emergency department with self stated  difficult vascular access. The primary endpoint was duration of catheter survival. What did the authors find?

A: Catheter survival was increased with use of 6,35 cm catheters

B: Catheter survival was increased with use of 4,78 cm catheters

C: There was no difference in catheter survival between 6,35 and 4,78 cm catheters

The correct answer is A

The RCEM learning podcast of May 2020 covered this paper.

It seems, as expected, catheter survival is increased when longer catheters are used.  Especially when cannulating deeper veins a longer than standard catheter should be used. A minimum of 2,5 to 3 cm of the cannula should be located in the vein. Even with the 6,35 cm catheters (which are still not very long) the chance of dislodgement after placement is high if deeper veins are cannulated. Midlines are likely to be more useful in this case.

https://www.rcemlearning.co.uk/foamed/may-2020/#1588607334956-2c93064d-8474

rcemlearning.co.uk
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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen

SARS-CoV-2 literature review April 2 – April 10, 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.

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

Paper 1

Title: The use of high-flow nasal oxygen in COVID-19

Author: Lyons, C.

Publication date: April 4, 2020

Journal: Anaesthesia

 

Aim: Explaining why High-Flow Nasal Oxygen could well be an appropriate therapy for COVID-19. 

Conclusion: ‘’The COVID-19 pandemic has evoked an understandable sense of vulnerability in healthcare workers. Clinicians should remain open-minded that HFNO may be an appropriate therapy for many patients for whom tracheal intubation has not yet become a necessity but for whom low-flow nasal oxygen or facemask oxygen is not providing adequate respiratory support.’’


Link to paper: The use of high‐flow nasal oxygen in COVID‐19

Paper 2

Title: Prediction of Number of Cases of 2019 Novel Coronavirus (COVID-19) Using Social Media Search Index

Author: Qin, L.

Publication date: Apr 5, 2020

Journal: International Journal of Environmental Research and Public Health,

 

Aim: This study investigated the correlation between the number of new cases of COVID-19 and the search index for a popular social network in China

Methods: Social media search indexes (SMSI) for dry cough, fever, chest distress, coronavirus, and pneumonia to predict new suspected COVID-19 case numbers from 20 January 2020 to 9 February 2020. 

Results:  The new suspected COVID-19 case numbers correlated significantly with the lagged series of SMSI. SMSI could be detected 6–9 days earlier than new suspected cases of COVID-19.

Conclusion: SMSI could be an effective early predictor for the number of COVID-19 infections.

Link to paper: Prediction of Number of Cases of 2019 Novel Coronavirus (COVID-19) Using Social Media Search Index

Paper 3

Title: Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy

Author: Grasselli, G.

Publication date: April 6, 2020

Journal: JAMA

 

Aim: What are the baseline characteristics and outcomes of patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to intensive care units (ICUs) in Lombardy, Italy?

Methods / Results: Retrospective case series that involved 1591 critically ill patients 

The majority were older men, a large proportion required mechanical ventilation and high levels of PEEP, and ICU mortality was 26%.

Link to paper: Characteristics and Outcomes of Patients Infected With SARS-CoV-2 Admitted to ICUs in Italy 

Paper 4

Title: Pre-proof: A first Case of Meningitis/Encephalitis associated with SARS-Coronavirus-2

Author: Moriguchi, T.

Publication date: April 3, 2020

Journal: International Journal of Infectious Diseases

 

Aim: This is the first case of meningitis associated with SARS-CoV-2 who was brought in by ambulance.

Highlight: This patient had transient generalized seizures and obvious neck stiffness The specific SARS-CoV-2 RNA was not detected in the nasopharyngeal swab but was detected in a CSF.

Link to paper: A first Case of Meningitis/Encephalitis associated with SARS-Coronavirus-2

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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