2018. QUIZ 3. WEEK 40

Question 1

In the recently published paper by Shah in The Lancet, a high-sensitive troponin assay (Hs-cTnI) in the workup of patients with suspected acute coronary syndrome led to:

A: significant degree of over-diagnosis and over-treatment

B: a decrease in the number of patients diagnosed with subsequent myocardial infarction or death

C: no difference in the number of patients undergoing coronary angiography

The correct answer is A

There was no difference detected in patient centered outcomes, but a reduction in length of stay in hospital sounds appealing.




Question 2

According to a study published in the October edition of annals of Emergency Medicine, which of the following agents provides the most effective sedation at 15 minutes in agitated emergency department patients?

A: Haloperidol 10mg IM
B: Olanzapine 10mg IM
C: Midazolam 5mg IM
D: Ziprasidone 20 mg IM

The correct answer is C

R.E.B.E.L.em posted about this paper a couple of months ago, when the e-pub became available.

The fantastic Resus Room’s papers of the month podcast discusses this paper as well.

Both basically come to the same conclusion: Yes, of these drugs midazolam seems to come out on top, but what about longer acting benzodiazepines like lorazepam and diazepam?

Read the paper here

Question 3

What agent should be used to treat a hemodynamically stable pregnant patient with pulmonary embolism?

B: Low Molecular Weight Heparin
C: Warfarin
D: Trombolytics

Question 4

For how long should you continue the agent chosen in question 3?

A: Stop at 38 weeks gestation
B: Stop after delivery
C: Continue 3 weeks post-partum
D: Continue 6 weeks post-partum

The correct answer to question 3 is B
The correct answer to question 4 is D

The only treatment options are LMWH and unfractioned heparin (LMWH’s are far more patient friendly), those agents do not cross the placenta. Warfarine crosses the placenta and is teratogenic and the effects of DOAC on the unborn are unknown. Lytics, well, that would be asking for a lot of trouble in a stable patient.

The pregnant patient with venous thrombo-embolic disease should be treated at least three months in total, and at least 6 weeks postpartum.

Canadiem has a great post about how to manage pregnant patients with pulmonary embolism as part of their blood and clot series.

Question 5

You treat a patient with severe sepsis. She has a metabolic acidosis due to high serum lactate (8,5 mmol/L). After 500 cc of normal saline you switch to Lactated Ringers, because you apply EBM and you believe in the conclusions of the SMART and SALT-ED trials. Then your very savvy nurse askes you: Hey doc! But.. we are giving this patient lactate, while he has a metabolic acidosis, this seems a bit illogical, not?

Does Intravenous Lactated Ringer’s Solution Raise Serum Lactate?

A: Yes, the nurse is right, switch back to normal saline
B: No, the nurse is wrong, continue lactated ringers infusion

The correct answer is B

Intravenous Lactated Ringer’s Solution does not raise Serum Lactate. Journal Feed discusses a paper about this topic. Although in this recent study they used healthy subjects, there is no evidence that administering LR might worsen lactic acidosis. Furthermore, the content of Ringer’s lactate is sodium lactate, not lactic acid. I would say we over-emphasize the clinical value of lactate in our work up, but that is another days discussion. 

Do some further reading here

That’s all for now. We hope to see you next week!

Eefje and Rick