2019. QUIZ 19. WEEK 04

Question 1

A concerned mother presents to your emergency department with her 6 year old son. Yesterday he fell and developed a scalp hematoma but initially he had no other symptoms. Today (24 hours after trauma) he vomited twice and seems a little bit fuzzy. When ordering a CT scan in children presenting > 24 hours , you should keep in mind that

A: A non frontal scalp hematoma is associated with clinical important traumatic brain injury

B: The PECARN rule can be used, for it is validated for presentation > 24 hours after injury

C: When presenting more than 24 hours after injury the chance of clinically important traumatic brain injury is negligible in children

D: Suspicion of depressed skull fracture does not increase the risk of TBI

The correct answer is A

Don’t forget the Bubbles discussed this relevant paper recently.

It seems a non frontal scalp hematoma and suspicion of a depressed skull fracture is associated with clinical important traumatic brain injury. It also seems children presenting more than 24 hours after injury are more likely to have traumatic brain injury than children presenting earlier. Furthermore PECARN and CATCH clinical decision rules specifically exclude children who present with a head injury more than 24 hours after the injury. CHALICE doesn’t specifically exclude this group, but there is no published data on this group of patients.

Delayed presentation of head injuries – should we be worried?

Question 2

Source: litfl.com/hypokalaemia-ecg-library/

Which of the following ECG abnormalities is typically caused by moderate to severe hypokalemia?

A: Shortened QT duration

B: Peaked T-waves

C: Large U-waves

D: Diffuse ST-elevation

The correct answer is C

Moderate to severe hypokalemia (<2.5 mmol/L) causes prominent U-waves. The QT duration can appear long because of merging of T and prominent U wave. Peaked T-waves are typical for hyperkalemia (and other relevant causes of course). ST-depression would be expected as well.

Steven Smith discusses ECG changes in hypokalemie in his latest post.

Question 3

Hydrogen peroxide is a household product that can easily be ingested accidentally, what is NOT true about hydrogen peroxide ingestion?

A: It can cause cerebral gas embolism

B: Hyperbaric oxygen therapy is sometimes indicated

C: Injury is caused by three mechanisms: corrosive injury, gas formation and acute demyelination

D: At room temperature this liquid is clear

The correct answer is C

At low concentrations (like in most household products) hydrogen peroxide ingestion normally causes only gastrointestinal symptoms due to corrosive injury. However, highly concentrated hydrogen peroxide is on the market and can cause complications due to gas formation and lipid peroxidation. Cerebral gas embolism can be caused by hydrogen peroxide ingestion. Demyelination does not occur. The liquid is clear and can easily be mistaken for water.

ACMT Toxicology Visual Pearls: Abnormal Brain Imaging

Question 4

Which statement is true about treatment of an obstructive pulmonary disease exacerbation?

A: Single dose oral dexamethasone might be almost as effective as a 5 day course of prednisone in an asthma exacerbation

B: Magnesium infusion is not beneficial in severe asthma exacerbation

C: Antibiotics are almost always indicated in COPD exacerbations

D: Amoxicillin is a good choice of antibiotic when an atypical bacteria is expected to cause exacerbation of COPD

The correct answer is A

Single dose dexamethasone might be almost as effective as a 5 day course of prednisone. Magnesium is effective in moderate to severe asthma exacerbations. Antibiotics are sometimes indicated in COPD exacerbation. ‘’There is evidence supporting the use of antibiotics in exacerbations when patients have clinical signs of a bacterial infection e.g., increased sputum purulence.’’(1)

1. Global Initiative for Chronic Obstructive Lung Disease, 2018 report (2018). https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-revised-20-Nov_WMS.pdf


Question 5

Your patient is found by your prehospital services on the side of the road. She is unresponsive. It is -5 ℃ outside (23 ℉ for those of us using a completely illogical system). Your can’t get a read on your thermometer. What is true about the diagnosis and management of severe hypothermia?

A: An Osborne wave is frequently seen in patients with a temperature between 32 and 35 ℃

B: The magnitude of an Osborne wave often correlates with the level of hypothermia and should improve as rewarming occurs

C: Temperature can be measured reliably using your ear thermometer in suspected hypothermia

D: In rewarming the patient, warm IV fluids are just as effective as ECMO

The correct answer is B

The Osborn wave is seen in moderate to severe hypothermia (<32 ℃) and the magnitude of an Osborne wave often correlates with the level of hypothermia and should improve as rewarming occurs. Temperature should be measured rectally. ECMO is the most effective rewarming option, but it is not widely available and should be used as a last resort.

SinaiEM covered this topic recently on their blog.

Thank you for joining us again. Hope to see you next week!

Eefje and Rick, the FOAMed Quiz crew