2018. QUIZ 4. WEEK 41

Question 1

You find a patient with wide complex tachycardia at a rate of 200 per minute in your ED. You doubt if it is Ventricular Tachycardia or a Supraventricular Tachycardia with Right Bundle Branch Block. Which statement is correct regarding the ”Bunny Ears” of the RSR complex?

A: A taller left bunny ear suggest presence of a VT and a taller right bunny ear suggests presence of a RBBB

B: A taller right bunny ear suggest presence of a VT and a taller left bunny ear suggests presence of a RBBB

C: The bunny ears will not help you to distinguish between a SVT with RBBB and VT

D: Bunny ears is a type of cactus

The correct answers are A and D

A taller left bunny ear suggest presence of a VT and a taller right bunny ear suggests presence of a RBBB.

EMdocs published a great post about diagnosing ventricular tachycardias

And well.. We learned it is a cactus as well

Some free advice: do not google Bunny Ears while at work 🙂

Question 2

The recently published LOMAGHI trial examined the role of magnesium as an addition to conventional rate control medication. Does intravenous Magnesium Sulfate appear to have a synergistic effect when combined with other AV nodal blockers resulting in improved rate control?

A: No, it doesn’t

B: Yes, and 9 grams of Magnesium Sulfate  was superior to 4,5 grams of Magnesium Sulfate

C: Yes, but there was no difference between 4,5 and 9 grams of Magnesium Sulfate

The correct answer is C

The addition of 4,5 grams Magnesium Sulfate to standard rate-control agents appears to improve therapeutic response rates. 9 grams of Magnesium Sulfate was not superior to 4,5 grams of Magnesium Sulfate.

R.E.B.E.L.EM and Taming the SRU discuss this paper in their recent posts.

And.. have a look at the paper yourself.

Question 3

When in the treatment of hypoglycaemia should you give octreotide iv?

A: Never

B: Persistent or recurrent hypoglycaemia after sulfonylurea exposure

C: Only after iv dextrose and steroids

D: Persistent hypoglycaemia and exogenous insulin

The correct answer is B

The latest EMcrit podcast gives a great overview of the symptoms, diagnosis and treatment of hypoglycaemia.

The indication for octreotide is primarily sulfonylurea intoxicaton. However, it might play has a role in non-sulphonylurea hypoglycemia to prevent rebound hypoglycaemia as well.

Question 4

Do small occult traumatic pneumothoraces (not seen on X-ray, seen on CT) initially need drainage?

A: Yes, always

B: No if spontaneously breathing, yes if ventilated

C: Probably never initially, but watch the patient carefully and tube when pneumothorax gets larger

The correct answer is C

The RCEM podcast (highly recommend!) discusses a 2017 paper by Walker about the Conservative Management in Traumatic Pneumothoraces.

Although it is an observational study (using TARN data), the results seem to empower the trend to reduce the number of thoracocenteses in traumatic pneumothoraces. 90% of the small pneumothoraces never needed an intervention and it didn’t matter if the patient was ventilated or not.

Question 5

Which statement is correct regarding the management op acute pulmonary embolism?

A: Standard Troponin is a valuable test to prognosticate patients with acute pulmonary embolism

B: In patients with acute pulmonary embolism, a HsTnT (High Sensitive Troponin T) smaller than 14 pg/mL means a complicated outcome is excluded

C: Absense of Right Ventricular enlargement on CT has a Negative Predictive Value of 99 percent for 30-day PE-related mortality

D: The prediction scores PESI (Pulmonary Embolism Severity Index) and sPESI (simplified Pulmonary Embolism Severity Index) identify the same number of patients with acute pulmonary embolism as low risk

The correct answer is C

The recently published British Thoracic Society Guideline for the initial outpatient management of pulmonary embolism gives answer to all these questions. And it is only 40 pages 🙂

Standard Troponin is useless in prognosticating patients with acute pulmonary embolism.

Patients with pulmonary embolism and a HsTnT of < 14 pg/mL still have 2% chance on an complicated outcome.

The prediction score PESI deems more patients low risk than the sPESI does.

The RCEM learning podcast discusses the earlier this year published BTS Guideline for the initial outpatient management of pulmonary embolism.

One more thing before you go.

It seems we (humans) didn’t learn a damn thing since this classic TV-show was recorded 30 years ago.

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

Eefje and Rick

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