Quiz 74, July 3th, 2020

Welcome to the 74th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick


Question 1

Your patient presents with a hemopneumothorax and 4 rib fractures after a motor vehicle collision. Your usual analgesics (including opioids and analgesic dose ketamine) are ineffective and you didn’t even perform the thoracocentesis yet. You consider a serratus anterior plane block.

Which of the following statements is true regarding this block?

A: It affects dermatomes C6-T3

B: Anticoagulation is not a contraindication

C: It is equally effective in providing analgesia to the posterior part and anterior part of the ribs

D: The anesthetic should always be injected just superficial the serratus anterior muscle, never deep to the muscle

The correct answer is B

CountyEM covered the serratus anterior plane block this week. 

This block is fairly easy to perform and can be beneficial in these painful patients with thoracic trauma. Anticoagulation is not a contraindication. The block affects dermatomes T2 to T9. The block may not be effective for posterior chest wall trauma as the block only covers lateral cutaneous branches of the long thoracic nerve. The block can be performed superficial to and deep to the serratus anterior muscle. 

Source image: Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 13211

Question 2

The PESIT trial caused some consternation a couple of years ago, stating one in every 6 patients with syncope in the ED has pulmonary embolism. Fortunately this was proven wrong by numerous studies. However, what does it mean when a patient with pulmonary embolism suffers syncope?

This recent meta-analysis evaluated the prognostic value of syncope on mortality in patients with pulmonary embolism (PE).

What did the authors find?

A: Patients with PE and syncope have an increased risk of short term mortality compared to patients with PE without syncope

B: Patients with PE and syncope have an equal risk of short term mortality compared to patients with PE without syncope

C: Patients with PE and syncope have a decreased risk of short term mortality compared to patients with PE without syncope

The correct answer is A.

Clay Smith covered this meta-analysis on Journal Feed this week.

This meta-analysis of 20 studies showed an increase of short-term mortality in patients with PE and syncope compared to patients with PE without syncope (OR 1.82, 95%CI 1.14 tot 2.90). 

Source image: www.pixabay.com

Question 3

The recently published LOCO2 trial (Liberal Oxygenation vs Conservative Oxygenation) recently compared liberal and conservative oxygen targets in patients with acute respiratory distress syndrome (ARDS) which had been intubated and mechanically ventilated for less than 12 hours.

Patients in the liberal oxygen (LO) group had a target PaO2 of 90-105 mmHg with a SpO2 of >96% while patients in the conservative oxygen (CO) group had a target PaO2 of 55-70 mmHg with a SpO2 of 88 to 92%.

The primary outcome was death from any cause at 28 days. Mortality in the ICU or at day 90 days was the most important secondary outcome.

What did the authors find?

A: Mortality from any cause at 28 days was significantly higher in the conservative oxygen group compared to the liberal oxygen group

B: Mortality from any cause at 28 days was significantly higher in the liberal oxygen group compared to the conservative oxygen group

C: Mortality at day 90 or in the ICU was significantly higher in the liberal oxygen group compared to the conservative oxygen group

D: Mortality at day 90 or in the ICU was significantly higher in the conservative oxygen group compared to the liberal oxygen group

The correct answer is D

The LOCO2 trial was covered by Leen Alblaihed on RebelEM this week.

This prospective multicenter study was conducted in 13 French ICU’s. A total of 205 patients were randomized. 

At day 28, no significant difference in mortality between the conservative oxygen and liberal oxygen group was found (34.3% vs 26.5%; 95% CI -4.8 to 20.6) while mortality in the ICU or at day 90 was significantly higher in the conservative oxygen group compared to the liberal oxygen group (44.4% vs 30.4%). 

The main take home point is that conservative oxygen therapy may worsen mortality in patients with ARDS compared to liberal therapy. According to the Oxygen-ICU, ICU-ROX and LOCO2 trials, both hyperoxia (SpO2 >97%) and hypoxemia (SpO2 <90%) should be avoided. 

The LOCO2 Trial: Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome

    

Source image: www.pixabay.com

Question 4

A 67 year old female presents to your emergency department with complaints of dysuria, right flank pain, fever and increased urinary frequency. She is febrile and shows tachycardia and tachypnoea. On physical examination she has right flank and suprapubic tenderness. Urinalysis shows positive nitrite and white blood cells. The patient is diagnosed with pyelonephritis.

Which of the following options is a correct management for this patient’s illness?

A: The patient can go home with oral antibiotics due to its mild presentation and acceptable vital signs for this diagnosis

B: The patient can go home with oral antibiotics despite fever and tachycardia

C: The patient needs to be admitted for intravenous antibiotics because she shows tachycardia and tachypnea

D: The patient needs to be admitted for intravenous antibiotics because all patients with acute pyelonephritis should be admitted for intravenous fluids and antibiotics

The correct answer is C.

EMDocs covered pyelonephritis this week.

The majority of the mild to moderately ill patients with acute pyelonephritis can be discharged home with oral antibiotics. Important for discharging will be the ability to tolerate oral intake and the absence of tachycardia, hypotension and tachypnea. The patients should have stable comorbidities, a reliable psychosocial situation and the ability to visit for outpatient follow-up. 

What if it’s not just cystitis? Disposition of pyelonephritis…

Source image: Case courtesy of Dr Haytham Bedier, Radiopaedia.org, rID: 56857

Question 5 

‘This radiographic abnormality on a knee x-ray represents an avulsion fracture of the proximal fibula and is associated with cruciate ligament injury (in about 90 percent of cases). It is caused by a direct blow with the tibia in external rotation or sudden hyperextension of the knee with the tibia internally rotated.’

What abnormality is described here?

A: The Segond fracture

B: Stieda fracture

C: The arcuate sign

D: The intercondylar eminence fracture

The correct answer is C

AliEM covered not to miss knee injuries this week. 

The arcuate sign is often a subtle finding on knee x-rays and represents an avulsion fracture of the proximal fibula at the site of insertion of the arcuate ligament complex. It is usually associated with cruciate ligament injury (~90% of cases). The Segond fracture is also strongly associated with ACL injury, but it is an avulsion fracture of the lateral tibial plateau. A Stieda fracture refers to a bony avulsion injury of the medial collateral ligament (MCL) at the medial femoral condyle.

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

Reviewed and edited by Rick Thissen

Quiz 73, June 26th, 2020

Welcome to the 73th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.rebelem.com

Question 1

This week the most widely discussed Randomized Controlled Trial (RCT) is about the use of dexamethasone in patients with COVID-19. 

Hospitalized patients with clinically suspected or laboratory confirmed COVID-19 received either usual care or usual care plus dexamethasone 6 mg daily (either orally or intravenously) for up to 10 days, or until discharge. The primary outcome was all cause mortality at 28 days.

What did the authors find?

A: All cause mortality at 28 days was higher in the dexamethasone group compared to the usual care group

B: All cause mortality at 28 days was not different between the groups

C: All cause mortality at 28 days was lower in the dexamethasone group compared to the usual care group

The correct answer is C

First10EM covered the pre-publication of The RECOVERY trial along with others like Emcrit,  REBEL EM, FOAMcast  and Broom Docs

This pragmatic, open-label, multi-centre RCT from 176 hospitals in the United Kingdom, randomized 2104 patients to the dexamethasone group and 4321 to the usual care group.

All cause mortality at 28-days was lower in the dexamethasone group compared to the usual care group (21.6% vs 24.6%; OR 0.83; 95% CI 0.74-0.92, P<0.01). The biggest benefit was among the sickest patients who needed oxygen and appeared to occur later in the disease course. Dexamethasone thereby reduced the duration of hospitalization.

These results seem very promising. Keep in mind that there is a possibility of selection bias and a lack of blinding. Furthermore this article hasn’t been peer reviewed yet.

Dexamethasone for COVID: The RECOVERY trial

Source image: www.pixabay.com

Question 2

The second widely discussed RCT this week is not about COVID-19. The HALT-IT trial is about Tranexamic Acid (TXA) versus Placebo in patients with acute gastrointestinal bleeding. The primary outcome was death due to bleeding at 5 days. Close to 6000 patients were randomised to both groups (12000 is total).

What did the authors find?

A: There was lower death due to bleeding at 5 days and lower all cause mortality at 28 days in the TXA group compared to the control group

B: There was no difference in death due to bleeding at 5 days and all cause mortality at 28 days between both groups

C: There was lower death due to bleeding at 5 days in the TXA group compared to the control group, but all cause mortality at 28 days was equal

D: There was lower all cause mortality at 28 days in the TXA group compared to the control group, but death due to bleeding at 5 days was equal

The correct answer is B

The HALT-IT trial was discussed on StEmlyns, First10EM  and the Resus Room podcast this week.

This is definitely a negative trial. There was no difference in death due to bleeding at 5 days and all cause mortality at 28 days between both groups. The authors did change the primary outcome from a patient centered outcome (all cause mortality at 28 days to death due to bleeding at 5 days) which does not make a lot of sense.

Keep in mind the subjects were not very sick on average and the time from symptom onset to inclusion was very long (22 hours on average). Both can impact the efficacy of TXA in gastrointestinal bleeds.

Image from the original open access paper on www.thelancet.com

JC: Halt! It’s not time for TXA! Or is it? HALT-IT results at St Emlyn’s

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 8935

Question 3

The Aortic Dissection Detection Risk Score (ADD-RS) is a useful tool for aortic dissection. Does adding a d-dimer with a cutoff of 500 ng/dL alter the diagnostic accuracy of this tool even further?

A: Adding a d-dimer to the ADD-RS increases sensitivity without decreasing specificity

B: Adding a d-dimer to the ADD-RS increases sensitivity, but decreases specificity

C: Adding a d-dimer to the ADD-RS does does alter its diagnostic accuracy

The correct answer is B

This recently published systematic review was covered on Journal Feed last week.

An ADD-RS with a cutoff of ≥ 1 was found to have a sensitivity of 94% on its own. Adding a d-dimer increases the sensitivity to 1 at the cost of lowering the specificity to 15%.

 

Source image: http://www.emdocs.net/

Question 4

Your 53 year old patient presents to your ED with a backache and fever. Even though there are no neurological deficits found on physical exam you suspect her of having an spinal epidural abscess. The patient reports having recovered from a skin infection recently.

Which of the following statements is true about spinal epidural abscesses (SEA)?

A: Neurological symptoms are found in most of the patients

B: CT with contrast is equally accurate in diagnosing SEA compared to MRI

C: Recent Soft Tissue Infection with bacteremia is an independent risk factor for SEA

D: The most common causative organism of SAE is E. coli

The correct answer is C

RebelEM covered spinal epidural abscesses this week.

Neurological symptoms are found in only 33 percent of patients with SEA. Gadolinium enhanced MRI is considered gold standard for diagnosis with a sensitivity of over 90 percent. The most common causative organism is Staphylococcus aureus.

Recent Soft Tissue Infection with bacteremia is associated with pyogenic spinal infection (OR 13.5).

Spinal Epidural Abscess (SEA)

Source image: www.pixabay.com

Question 5

A 30 year old female presents to the Emergency Department. She tells you that she took a substantial amount of aspirin about 5 hours ago because she wanted to end her life after a fight with her two best friends. Her complaints include a ringing sensation in her ears and mild nausea. She is tachycardic and tachypneic but appears well and non-toxic.

What will her arterial blood gas most likely look like?

A: A mixed respiratory alkalosis / metabolic acidosis with an elevated anion gap

B: A mixed respiratory acidosis / metabolic alkalosis with an elevated  anion gap

C: A mixed respiratory acidosis / metabolic alkalosis with a normal anion gap

D: A mixed respiratory alkalosis / metabolic acidosis with a normal  anion gap

The correct answer is A

Salicylate overdose was covered on emDocs this week.

Aspirin has a high overdose potential since it can be bought over the counter in different formulations. An overdose leads to activation of the medulla in the early stages, leading to hyperventilation causing a respiratory alkalosis.

In later stages, salicylates like aspirin cause inhibition of oxidative phosphorylation, increased renal bicarbonate excretion and lipolysis, leading to metabolic acidosis.

Finally, an increased anion gap can be found due to increased fatty acid metabolism leading to an increase in ketone bodies.

EM@3AM: Salicylate Overdose

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

Reviewed and edited by Rick Thissen

Quiz 72, June 19th, 2020

Welcome to the 72th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

A 50 year old male presents to your emergency department with the complaint of dizziness and nausea. You want to distinguish a peripheral from a central cause.

Which of the following findings make a central cause more likely?

A: A negative test of skew

B: Positive head impulse test (eyes make corrective saccade to fix on target)

C: A predominantly vertical nystagmus

D: A unidirectional nystagmus

The correct answer is C

This week’s post on EMdocs by Ava Pierce is about posterior circulation strokes and how to approach the patient with vertigo.

Almost half of the patients with a posterior circulation stroke present with dizziness. The HINTS (consisting of: 1. head impulse test, 2. nystagmus 3. test of skew) examination is helpful to distinguish central from peripheral causes. A positive head impulse test suggests peripheral pathology. Although most strokes present with a horizontal nystagmus, this is also often seen in peripheral vestibular disease. Vertical and bidirectional nystagmus suggest a central cause of vertigo.

Source image: www.radiopaedia.org

Question 2

This multicenter retrospective observational cohort study is about the safety and efficacy of prothrombin complex concentrates (PCCs) in adult patients with spontaneous or traumatic intracranial hemorrhage (ICH) using apixaban or rivaroxaban.

The primary outcome was the percentage of patients with excellent or good hemostasis defined as 0-20% and 20-35.0% increase of hematoma size respectively on follow-up CT of MRI within the first 24 hours. The primary safety outcome was the occurrence of thrombotic events (DVT, PE).

What did the authors find?

A: Excellent or good hemostasis was found in about 40% of patients

B: Excellent or good hemostasis was found in about 80% of patients

C: Thrombotic events were seen in 20% of patients

D: Thrombotic events were seen in only 1% of patients

The correct answer is B

Salim Rezaie from REBEL EM covered factor Xa inhibitor related ICH and PCCs this week.

Excellent or good hemostasis was found in 81.8% (95% CI 77.9 – 85.2) of patients whereas thrombotic events were only seen in 3.8% of patients.

Although this study is the largest multicenter, observational study to date to evaluate hemostatic efficacy and safety of PCC’s in patients on apixaban or rivaroxaban with ICH, it still has quite some limitations. Of course, the absence of a comparison group make any useful conclusion about the efficacy of PCC’s in these cases impossible.

In the future, randomised controlled trials are needed in order to evaluate the clinical efficacy of PCCs in patients on Xa inhibitors with ICH.

Factor Xa Inhibitor Related ICH & PCCs

Source image: www.emottowablog.com

 Question 3

Your otherwise healthy 19 year old patient presents with an AV-nodal Reentrant Tachycardia. The modified Valsalva manoeuvre is not effective. In your hospital the usual path is to try Adenosine first, but as you read up on your literature, you choose Diltiazem.

Which of the following is an advantage of diltiazem over adenosine?

A: Diltiazem has a shorter duration of action compared to adenosine

B: Diltiazem does not make patients feel like they are dying, like adenosine does

C: Diltiazem is not as likely to cause hypotension compared to adenosine

D: Diltiazem can be safely administered in patients in cardiogenic shock, while adenosine is not safe in these cases

The correct answer is B

EMOttawa covered a couple of treatment controversies on their blog this week. The first part is about adenosine vs diltiazem in terminating supraventricular tachycardia.

Diltiazem has a range of benefits over adenosine. The most important one is probably not causing the patient to feel like he or she is dying (like adenosine frequently does). It is a safe drug and at least equally effective for this indication compared to adenosine.

However, diltiazem is not harmless as it can cause hypotension. In cardiogenic shock, please use electrical cardioversion. 

Diltiazem for intravenous use is not globally available. Verapamil is a proper alternernative.

Source image: www.pixabay.com

Question 4

Headache is one of the most common complaints of patients in the Emergency Department (ED). This, randomized double blind, placebo controlled trial compared the administration of 2.5 mg IV haloperidol with placebo (0.9% NaCl) in patients with benign headaches. Their primary outcome was pain reduction at 60 minutes.

What did they authors find?

A: >50% pain reduction at 60 minutes was significantly more often seen in the haloperidol group compared to the control group

B: No differences were found in >50% pain reduction at 60 minutes after administration of haloperidol or placebo

C: >50% pain reduction at 60 minutes was significantly more often seen in the placebo group compared to the haloperidol group

The correct answer is A

Meghan Breed from Journal Feed covered this RCT this week.

58 patientes, aged 18-55 years, received haloperidol while 60 patients received placebo. Pain reduction of >50% at 60 minutes was seen in 63.8% of patients treated with haloperidol. Patients in the haloperidol group thereby reported an average reduction in visual analogue scale score (VAS) of 4.77 units compared to 1.87 units in the placebo group, 60 minutes after administration of either haloperidol or placebo.

This study suggests that the administration of haloperidol 2.5 mg IV could be useful in the treatment of benign headaches. Further research with larger studies are needed to confirm these results.

Question 5

Your 26 year old patient presents with some mild weakness of the lower limbs since 1 day. She also complaints about diplopia and an ‘unsteady walk’ starting about a week ago and getting worse. She does not feel ill and does not appear to be confused. Physical examination reveals symmetric areflexia without any sensory deficits. Her Cerebrospinal Fluid (CSF) shows elevated CSF protein and normal CSF White Blood Cell count.

Which of the following Guillain Barré Syndrome (GBS) types is most likely?

A: Miller Fisher Syndrome (MSF)

B: Acute inflammatory demyelinating polyneuropathy (AIDP)

C: Acute motor-sensory axonal neuropathy (AMSAN)

D: Bickerstaff encephalitis

The correct answer is A

BrownEM covered the variants of GBS this week. 

AMSAN would cause sensory deficits so is not very likely. AIDP is the most common form in the United States and Europe, representing approximately 85 to 90 percent of cases. However ophtalmoplegia and ataxia point us in the direction of either Miller Fisher Syndrome (MSF) or Brickerstaff encephalitis. Since this patient has no signs of encephalopathy, Brickerstaff encephalitis is unlikely, which leaves MSF as the most likely GBS type in this case. 

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

Reviewed and edited by Rick Thissen

Quiz 71, June 12th, 2020

Welcome to the 71th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

This week’s COVID-19 Randomised Controlled Trial (RCT) is about Ruxolitinib. Ruxolitinib blocks a shared signal transduction pathway which is used by several cytokine receptors (many immunomodulatory therapies only block one specific interleukin). 43 Severely ill but not yet intubated patients were enrolled and randomised to either Ruxolitinib or placebo (in this case Vitamin C).

What did the authors find?

A: Ruxolitinib did improve cytokine levels and C-reactive protein

B: Immunomodulation was found to delay viral clearance

C: A statistically significant reduction in mortality was found at day 28 in the treatment group

D: A statistically significant reduction in duration of invasive ventilation was found in the treatment group

The correct answer is A

Josh Farkas discusses this RCT this week on PulmCrit.

Yet another study that was terminated early. This time due to the simple fact that there were no more patients with COVID-19 in the Chinese center to enroll. A not statistically significant reduction in mortality (7.3 vs 14.3 percent) was found in favor of the treatment group. No difference was found in time to clinical improvement. However, cytokine levels and CRP were reduced in the treatment group indicating its ability to function rapidly as an immunomodulator. Ruxolitinib was not found to delay viral clearance.

PulmCrit Wee – Multicenter RCT evaluating ruxolitinib (a JAK inhibitor) for COVID-19

 

 

Question 2

Your 75 year old patient comes in with sudden onset vertigo and vomiting. Her vertigo is provoked by specific types of head movements and the episodes last for about 20 seconds. She has no other neurologic complaints. The Dix-Hallpike test shows a rotational nystagmus which disappears after 10 seconds.

You suspect Benign Paroxysmal Positional Vertigo (BPPV). The patient does not believe the Epley maneuver will be helpful as it just sounds silly and wants to know what the literature says. What do you tell your patient?

A: Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (83% vs 5%) for a NNT of 1.2

B: Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (56% vs 21%) for a NNT of 3

C: Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (61% vs 55%) for a NNT of 17

D: Compared to sham groups, Epley maneuver does not increase likelihood of symptom resolution

The correct answer is B

Clay Smith covered this review on the Epley Manoeuvre last week.

The paper reviews a cochrane review and another recent randomized trial set in 6 EDs.

Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (56% vs 21%).

Well, you can’t get around an NNT of 3.

Source image: www.aliem.com

Question 3

Your 75 year old patient tells you that he used some fresh herbs out of his garden to prepare dinner. Shortly after his meal he started to be dyspnoeic, the parsley out of his garden turned out to be Poison Hemlock.

Which of the following statements is true about Poison Hemlock?

A: It causes a cholinergic toxidrome

B: It causes a anticholinergic toxidrome

C: It causes a sympathomimetic toxidrome

D: It causes a sedative-hypnotic syndrome

The correct answer is C

This week Aliem posted about poison hemlock.

Poison hemlock is a plant that can be mistaken for parsley, wild carrots or sweet fennel.

Poison Hemlock contains multiple toxic agents of which the most important is coniine. Coniine causes primarily nicotinic effects (muscle fasciculations, weakness, paralysis, coma, seizures, tachycardia and hypertension) and secondary muscarinic symptoms (salivation, lacrimation, vomiting, diarrhea, wheezing, bradycardia, diaphoresis, and small pupils).

Treatment is usually supportive and intubation might be required. Muscarinic symptoms (bradycardia, bronchorrhea, or bronchospasm) can be treated with atropine.

ACMT Toxicology Visual Pearls: A Foraging Experience to Die For

Source image: www.pixabay.com

Question 4

Which of the following statements is true about pediatric ECGs?

A: The amplitude of the p-wave increases with age

B: The duration of the p-wave shortens with age

C: A right QRS axis is normal in children < 6 months

D: Inversion of T-waves a week after birth is concerning

 The correct answer is C

The very basics of pediatric ECG’s were covered at Don’t Forget the Bubbles last week.

The amplitude of the p-wave does not increase with age (should be < 3 mm). The duration of the p-wave lengthens a little with age. A right axis in young children is normal in the very young due to right ventricular dominance. After the first week of life T waves become inverted in V1-3.

Approaching the paediatric ECG

 

Source image: www.emottowablog.com

Question 5

Which of the following statements about the use of ultrasound in COVID-19 is true?

A: It is possible to differentiate a COVID-19 pneumonia from other viral pneumonia on ultrasound

B: B-lines are not typically seen in COVID-19 patients

C: Irregularity of the pleural line is typically seen in COVID-19 patients

D: Large pleural effusions are common in COVID-19

The correct answer is C

EMOttawa covered ultrasound in COVID-19 patients this week.

It is not possible to distinguish COVID-19 from other viral pneumonia on ultrasound (or any other imaging as far as I’m aware). B-lines, irregularity of the pleural line and subpleural consolidation are common findings. Lung sliding is typically present but can be absent in case of ARDS. Large pleural effusions are typically absent in COVID-19.

Protocol for lung ultrasound in COVID-19 patients

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

Reviewed and edited by Rick Thissen

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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