2018. QUIZ 5. WEEK 42

Question 1

In a recent podcast of Emergency Medicine Cases, the management of patients with a GI bleed and a Left Ventricular Assist Device is discussed.

What is true about a patient with an LVAD?

A: You have to feel your patients pulse at the carotid, and never rely on oxygen saturation measured by peripheral probes

B: These patients have increased risk of bleeding due to the higher incidence of arteriovenous malformations

C: LVAD patients are afterload dependent

D: A mechanical hum over the pericardium is incredibly concerning

The correct answer is B

This excellent read gives a good recap about patients we do not see every day.

The LVAD gives a constant non pulsatile flow, so often your patient has no palpable pulse and no heart sounds.

Arteriovenous malformations are thought to arise from this absent pulsatile flow.

Furthermore, patients with an LVAD are on anticoagulant therapy and thrombocytopenia is common due to the shear force from the LVAD propeller (or impeller).

LVAD patients are preload dependent and in hypovolemia the negative pressure generated by the LVAD can cause left ventricle collapse.

You can hear the mechanical hum over the chest, which indicates tot the pump is working.

Question 2

What is true about synthetic cannabinoids?

A: Synthetic cannabinoids are potent cannabinoid antagonist

B: There is a distinct synthetic cannabinoid toxidrome and patient presentation does not vary a lot

C: The synthetic cannabinoids have the same binding affinity to the cannabinoid receptor as THC (as in old fashioned weed)

D: Cannabinoid receptor modulate the release of GABA, glutamate, dopamine and norepinephrine

The correct answer is D

Synthetic cannabinoids are agonist of the cannabinoid receptor (Surprise!). There is no specific toxidrome, the symptoms vary per case and drug. The synthetic drugs have more affinity for the receptor than THC.

Read the excellent post on synthetic cannabinoids of the Tox and the Hound here.

Also, do not forget the Dantastic Mr. Tox and Howard show about the exposure to brodifacoum through synthetic cannabinoid use.

Question 3

According to a recent systematic review and met-analysis of RCTs that compare the use of Coronary Computed Tomography Angiography (CCTA) to standard of care (SOC) in the workup of low risk patients with acute chest pain:

A: CCTA decreases the rate of invasive coronary angiography and revascularisation

B: Overall hospital length of stay was shorter with CCTA

C: There was higher all-cause mortality in the SOC group

D: All of the above

The correct answer is B

R.E.B.E.L. em breaks this recent met-analysis down.. literally. 

Yes, overall hospital length of stay was reduced, but there was an increase in invasive coronary angiography and revascularization without any patient oriented benefit.

Question 4

What is NOT true about Lemierres syndrome?

A: It is often preceded by a common oropharyngeal infection

B: It is an infectious thrombophlebitis of the internal jugular vein

C: Can cause septic emboli to the liver, lung, endocardium and lungs

D: The mortality rate approaches 50 %

The correct answer is D

The mortality rate nowadays is still about 15 percent (however it used to be 90%!).

EM in 5 gives a proper recap of this rare but disastrous disease.

Question 5

How will your patient with 2,4 dinotrophenol poisoning most likely present in your ED?

A: Hypothermic, bradycardic and hypotensive

B: Hypothermic, tachycardic and hypertensive

C: Hyperthermic, bradycardic and hypotensive

D: Hyperthermic, tachycardic and hypertensive

The correct answer is D

Fortunately, we have never seen a case like this.. and we hope we never will.

Critical Care Northampton describes this awful case of a 2,4 dinotrophenol poisoning. Scary shit!

(It appears the link to Critical Care Northampton is not working.. We will try to fix it but it seems the post disappeared)

Well, that’s all for now. We hope to see you next week!

Eefje and Rick

2 Replies to “2018. QUIZ 5. WEEK 42”

  1. Ha Eefje en Rick,

    M’n complimenten voor jullie site en quizzen! Wat een tof idee en goede uitvoering!! Kan ik me ergens opgeven zodat ik wekelijks een update (en nieuwe quiz) in m’n mailbox krijg?

    Martine Zwols (SEH-arts Zwolle)

    1. Ha Martine,

      Dank je wel voor de complimenten 🙂 Ik ben bezig met het maken van een inschijfformulier op de website. Ik verwacht dat ik deze morgen of in ieder geval het weekend op de website heb staan.

      Groetjes!

      Rick Thissen

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