2019. QUIZ 20. WEEK 5

Question 1

Your patient is a healthy 35 year old man and he is bitten in his leg by a dog. There is a 5 cm wound which normally would need suturing. Which statement would be true about management of this patient:

A: Antibiotics are always indicated in dog bites

B: The wound has to be left open

C: There is a small risk of developing a fulminant sepsis

The correct answer is C

Justin Morgenstern discusses the evidence on antibiotics and suturing in mammalian bites. It seems there is simply no evidence for prophylactic antibiotics or leaving the wound open to prevent a wound infection. An exception is a wound on the hand, in which antibiotics are indicated.

A reason to still consider antibiotics in ‘’non-hand’’ mammalian bites is to prevent fulminant sepsis (like a Capnocytophaga sepsis). However rare, it can be fatal.


Question 2

Source image: Dr. Smith’s ECG Blog


Your otherwise healthy patient presents with palpitations. She is hemodynamically pretty stable with a pulse of 190, blood pressure of 110/60, a capillary refill of <2 sec and is mentating well. You wonder whether this is Ventricular Tachycardia (VT) or SupraVentricular Tachycardia (SVT) with aberrancy. Which of the following makes VT more likely?

A: Very rapid initial part of the QRS

B: A typical LBBB of RBBB

C: Extreme axis deviation (“northwest axis”)

D: A pulse of greater than 180 per minute

The correct answer is C

Steven Smith discusses the old VT versus SVT in his most recent blog.
In the hemodynamically unstable patient the underlying rhythm doesn’t really matter, for defibrillation is needed right away. It can be beneficial to know the underlying rhythm in stable patients. When the patient is stable you can try adenosine, it will terminate an SVT and it will have no effect on VT. Make sure the rhythm is regular though…

Question 3

In stroke management, the VAN tool is one of newer tools developed to predict cortical stroke (and select candidates for endovascular therapy). What does VAN stand for?

A: Vertigo, Aphasia, Neglect

B: Vision, Ataxia, Neglect

C: Vision, Aphasia, Neglect

D: Vertigo, Ataxia, Neglect

The correct answer is C

Anton Helman discusses stroke on EM cases.

The VAN tool has been shown in a pilot study to have a 100% sensitivity and 90% specificity for large vessel stroke.1 It is a lot easier to use than NIHSS.

1. Teleb, M. S., Hage, A. V., Carter, J., Jayaraman, M. V., & Mctaggart, R. A. (2016). Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: Pilot study and comparison with current clinical severity indices. Journal of NeuroInterventional Surgery, 9(2), 122-126. doi:10.1136/neurintsurg-2015-012131

Ep 120 ED Stroke Management in the Age of Endovascular Therapy

Question 4

Which statement is true about performing a Lumbar Puncture (LP)

A: A platelet counts < 50.000 is an absolute contraindication

B: An LP can be safely performed if there is concern for spinal epidural abscess

C: All patients with suspected meningitis need a CT of their brain before performing a LP

D: 90% of patient who experience post-procedural headache will affirm onset within 3 days of the procedure

The correct answer is D

Anthony DeVivo posted a nice practical update on Lumbar Punctures.

A platelet count of < 50.000 used to be an absolute contraindication. However, newer evidence suggests a platelet count of > 20.000 is safe. An LP should not be performed if a spinal epidural abscess is suspected. Selected patients need a CT before LP (like patients with seizures, immunocompromised patient etc.).

Question 5

There is a growing body of evidence supporting the use of exogenous nitric oxide in the treatment of submassive pulmonary embolism in order to support hemodynamics. Inhaled nitric oxide might be beneficial in pulmonary embolism because:

A: iNO causes dilation of pulmonary vasculature, thereby reducing the RV afterload

B: iNO causes referential constriction of capillaries in the best ventilated areas of the lung may decrease ventilation-perfusion matching

C: iNO causes peripheral vasoconstriction, increasing the systemic blood pressure

D: NO has anti-thrombin properties

The correct answer is A

Josh Farkas posted about the iNOPE trial, discussing the effect of inhaled NO in pulmonary embolism. It seems dilation of pulmonary vasculature, thereby reducing the RV afterload and avoiding decompensated RV failure is likely the primary mechanism of benefit.

Please read the post for further discussion of the paper.

PulmCrit- Inhaled NO for submassive PE: iNOPE or iYEP?

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

Eefje and Rick, the FOAMed Quiz crew