2018. QUIZ 9. WEEK 46

Question 1

You see a 58 year old male patient presenting with fever, chest pain, hemoptysis, dyspnea, and a productive cough. Past history includes diabetes mellitus, IV drug use and chronic alcohol abuse. Your differential diagnosis includes lung abscess.

Which of the following statements is not true regarding this condition?

A: Putrid smell of the sputum is a common complaint in lung abscesses

B: Anaerobic bacteria are the most common causative organism of lung abscesses

C: Chest X-ray should ideally be performed in supine position

D: Blood cultures are rarely positive in anaerobic lung abscesses

Answer C is correct.

Anaerobes are the most common causative organisms although aerobic bacteria may cause lung abscess in immunocompromised patients as well. The chest X-ray should be performed in upright or lateral decubitus position to show air-fluid levels. Like all anaerobic bacteria, anaerobes causing lung abscesses are difficult to culture. And the putrid smell.. Well you recollect that one.

emDOCs published this great overview with a lot of pearls and pitfalls on lung abscesses.

Question 2

Which of the following combinations of an eponym of atraumatic ecchymosis and location on the body is correct?

A: Fox sign – ecchymosis in the flank

B: Stabler sign – inguinal / pubic ecchymosis

C: Grey Turner sign – ecchymosis at the upper leg

D: Cullen sign – scrotal ecchymosis

The correct answer is B.

The Stabler sign is described as an ecchymosis in the inguinal pubic region is seen in intra-abdominal hemorrhage. The first case report was about a patient with ruptured ectopic pregnancy.

Fox sign is located at the upper thigh. Grey Turner describes bruising in the flank associated with retroperitoneal bleeding.

Cullen sign is periumbilical ecchymosis associated with intra abdominal bleeding. Ecchymosis in the scrotum caused by a ruptured AAA is named after a good sir Bryant.

Life in the Fast Lane gives an overview of the eponymous signs associated with intra-abdominal and retroperitoneal hemorrhage.

Question 3

Which statement is true about pacemakers?

A: Failure to sense is a common reason for the absence of pacing

B: In a DDD programmed pacemaker, there is always an atrial and a ventricular spike seen in the ECG

C: We use a magnet when there is failure to pace in order to stop oversensing and stop inhibiting pacing

D: Failure to capture is often caused by hypokalemia

Answer C is correct.

This recent dr. Smith’s ECG blog post is all about pacemakers.

Failure to sense is NOT a reason for absence of pacing, it will result in inappropriate pacing. When there is failure to pace, this can be caused by oversensing. Due to oversensing, pacing is inappropriately inhibited.

A DDD programmed pacemaker has the capacity to sense and pace with atrial and ventricular leads on demand.

Failure to capture is most frequently caused by hyperkalemia, ischemia, drug toxicity or poor electrode contact.

Question 4

Patients with SCIWORA (Spinal Cord Injury Without Radiographic Abnormality):

A: Never have abnormalities on MRI

B: Often present with leg weakness greater than arm weakness

C: Never need surgery

D: Is most commonly caused by hyperextension trauma

The correct answer is D.

SCIWORA is most often defined as signs of acute traumatic myelopathy in the absence of spinal column findings on X-ray and CT. Up to 15 percent of the patient have abnormalities on MRI. Unstable ligamentous injury might be an indication for surgical intervention.

Arm weakness is often greater than leg weakness due to central cord syndrome when presenting with a ‘high’ lesion.

This grand rounds recap by Taming the SRU discusses this condition briefly. There are some other great PEARLS in this post as well.

Question 5

You treat a patient in cardiac arrest. After usual advanced cardiac life support the patient is still refractory ventricular fibrillation (RVF). Your amiodarone, lidocaine and esmolol don’t seem to do anything. You consider dual sequential defibrillation (DSD). Literature about this topic suggests

A: When performing DSD make sure the pads overlap

B: Good neurologic outcomes are reported in up to 35% of the patients treated with DSD

C: Literature suggests that in up to 54% of the patient with RVF, ROSC is achieved by DSD

The correct answer is C.

Although limited evidence is available and performing a randomized trial seems almost impossible due to the low incidence, it seems Dual Sequential Defibrillation is reasonable to try if nothing helps. Take in mind there is (of course) a huge publication bias regarding this subject. And make sure the pads do not overlap, you can kill both your defibrillators.

You will find an extended review of DSD on RebelEM here.

Thanks for joining us again!

Eefje and Rick, the FOAMed Quiz Crew

2 Replies to “2018. QUIZ 9. WEEK 46”

  1. Question 3 Which statement is true about pacemakers?

    Q3 states that answer B is the correct one, but you probably meant C
    C: We use a magnet when there is failure to pace in order to stop oversensing and stop inhibiting pacing

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