Question 1
A 78-year-old woman with a body weight of 63kg is brought into your ED with a massive pulmonary embolism (PE). She has a respiratory rate of 30/min, pulse oximetry of 86% on room air, a heart rate of 132/min and a blood pressure of 70/55. You consider alteplase because she is in shock.
What is true about low dose alteplase?
A: It is a safe treatment with a comparable efficacy as full dose alteplase, but it does not seem to lower the bleeding risk
B: It seems to have a similar efficacy and a significant lower bleeding risk than standard dose alteplase
C: It has a lower efficacy than full dose alteplase and it should not be used in clinical practice
The correct answer is B.
Although low dose alteplase seems to have a similar efficacy and a significant lower bleeding risk when compared to standard dose alteplase, it’s use is still controversial. The lower bleeding risk is especially seen in patients with a body weight <65kg. (Wang et al., Chest 2010)
Dr. Amit Shah talks about the controversy around the use of half dose alteplase in his latest podcast. He recommends to evaluate the effect of a standard dose of alteplase after 1 hour and skip the other half of alteplase if your patient is doing well.
Question 2
There is a growing body of literature supporting the use of Thiamine in patients with septic shock. According to this recently published paper, Thiamine intravenously in the first 24 hours of hospital admission:
A: Might reduce 28 day mortality, especially in female patients
B: Is only beneficial in patients that are actually thiamine deficient
C: Has no effect on lactate levels
D: Reduces 28 day mortality, especially in male patients
The correct answer is A
The bottom line discussed this paper recently. Patients who received thiamine in the first 24 hours in septic shock were retrospectively matched to patients who did not. Thiamine seems to have an effect on lactate clearance and reduces the 28 day mortality, especially in female patients. There was no difference in vasopressor use, ICU admission and ventilator free days. Thiamine levels were not measured, so it is not clear if the benefit is related to thiamine deficiency.
Keep in mind this is a retrospective observational study based on data derived from electronic medical records.
Woolum
Question 3
In CPR for Out of Hospital Cardiac Arrest (OHCA), the use of telephone guidance from trained dispatchers leads to:
A: Better compression depth
B: Better compression rate
C: Shorter no flow time
D: No difference
The correct answer is B
In OHCA, quality of CPR is important. Telephone guidance from dispatchers leads to an increased bystander participation. In this recently published paper in Resuscitation the authors found that compression rate is improved with the telephone guidance from dispatchers too. No difference was found in compression depth, no flow time or complete releases during CPR.
Dispatcher-Assisted Cardiopulmonary Resuscitation (DA-CPR)
Question 4
Ocular ultrasound is a fast and simple technique that helps to differentiate between various ophthalmologic emergencies.
For which diagnoses in ocular trauma is ultrasound a suitable diagnostic approach?
A: Globe rupture, retrobulbar hematoma, ocular foreign bodies
B: Lens detachment, globe rupture, retrobulbar hematoma
C: Lens detachment, retrobulbar hematoma, ocular foreign bodies
D: Lens detachment, globe rupture, ocular foreign bodies
The correct answer is C.
Lee Johnson (Core EM) wrote about ocular ultrasound in his latest blog.
Lens detachment, retrobulbar hematoma and ocular foreign bodies can be detected with ultrasound with a sensitivity of >80%. The sensitivity for retinal detachment and vitreous detachment are slightly lower. Do NOT perform ocular ultrasound in cases with a known or suspected globe rupture, since even mild ocular pressure can be potentially exacerbate damage. If you are concerned about a globe rupture in your patient, obtain a CT.
Ocular Ultrasound
Question 5
The prehospital services rush in with a 29 year old pregnant lady (estimated 34 weeks). The was involved in a motor vehicle collision and seems to be in profound shock. As the first sweat pearls appear on your forehead you place the patient in 30 degrees left lateral tilt. A recently published paper about pregnant patients (3th trimester) looked at the ideal lilt. What did the authors find?
A: A 30° left-lateral tilt position most consistently reduced inferior vena cava compression
B: A 15° left-lateral tilt position most consistently reduced inferior vena cava compression
C: A 30° right-lateral tilt position most consistently reduced inferior vena cava compression
D: A 15° right-lateral tilt position most consistently reduced inferior vena cava compression
The correct answer is A
Clay Smith discussed this article on Journal Feed.
In quite simple but rather brilliant paper, 13 3th trimester females were tilted in 15 and 30 degrees, left and right. Inferior Vena Cava volumes where measured by MRI. 70% (9/13) had the greatest IVC volume in the 30° left tilt position, however 23% (3/13) had the greatest IVC volume in the 30° right lateral tilt position.
This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet
