Quiz 36, May 24th 2019

Question 1

Are you using chest compressions in hemorrhage induced traumatic cardiac arrest? It doesn’t make a lot of sense to start compressions if the patient has no intravascular volume. Last week a paper was published comparing closed chest compression with and without fluid therapy (normal saline or whole blood). Importantly, it was an animal study using exsanguinating large pigs. What did the authors find?

A: Closed chest compressions alone may lead to Return of Spontaneous Circulation (ROSC)

B: Closed chest compressions and whole blood therapy led to increased rates of ROSC compared to whole blood therapy without chest compressions

C: Closed chest compressions and normal saline therapy led to increased rates of ROSC compared to normal saline therapy without chest compressions

D: Closed chest compressions and whole blood therapy led to reduced rates of ROSC compared to whole blood therapy without chest compressions

The correct answer is D

Simon Carley covered this paper on St.Emlyn’s last week.

It sure is an interesting paper. Pigs were divided in 5 groups, anaesthetised and exsanguinated. The pigs in group 1 received closed chest compressions only, in group 2 whole blood only, in group 3 normal saline only, in group 4 whole blood + closed chest compressions and in group 5 normal saline + closed chest compressions. Pigs only receiving chest compressions did not achieve ROSC. The only pigs achieving ROSC where the pigs treated with whole blood while chest compressions seem to reduce the rate of ROSC in the ‘’whole blood’’ group.

Of course this does not mean you should never initiate chest compression in trauma patients. These are small numbers and well, the subjects were pigs. However, if the cause of the cardiac arrest is definitely hemorrhage, it makes sense to withhold chest compressions and focus on restoring intravascular volume first.

JC: Should we use chest compressions in traumatic cardiac arrest? St Emlyn’s

Question 2

Which of the following is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP)?

A: Viscous perforation

B: Gastrointestinal bleeding

C: Post-ERCP pancreatitis (PEP)

D: Biliary infections (acute cholangitis and cholecystitis)

The correct answer is C

Tim Montrief covered post ERCP complications pretty extensively on emDOCs.

Acute pancreatitis is the most common complication of ERCP, with an estimated incidence between 3.5-9.7% and a mortality rate of 0.7%.

Complications of ERCP: ED presentations, evaluation, and management

Question 3

Source image: https://www.grepmed.com/

Which of the following statements about epiglottitis is NOT true?

A: Epiglottitis is most common in the adult population

B: A lateral neck X-ray might support the diagnosis of epiglottitis

C: Epiglottitis presents most commonly with the 3D’s: drooling, dysphagia and distress

D: Do not use supraglottic devices; they can aggravate the situation

The correct answer is C.

Anand Swaminathan covers epiglottitis in his latest podcast on RebelEM.

Despite of what we all learned in medical school, epiglottitis seldom presents with the classical triad of drooling, dysphagia and distress. Most commonly the patient presents with a painful throat, dysphagia and hoarseness without any obvious findings in the oropharynx on physical examination. Epiglottitis can, of course, lead to airway occlusion over a very short period of time, so be ready for a difficult airway. You should not use any supraglottic devices, or perform any oropharyngeal manipulations since they can aggravate the situation due to compression of the epiglottis.

Since the introduction of the Haemophilus influenza type B vaccin the child versus adult ratio changed from 2,6 to 1 to 0,3 to 1, with a mean age of 55 years. Risk factors include the immunocompromised patient, smoking and diabetes.

With a lateral (soft tissue) neck x-ray a typical ‘thumbprint’ sign can be seen in 90% of the cases.

REBEL Core Cast 11.0 – Epiglottitis

Question 4

Which of the following statements is true about Rhabdomyolysis?

A: Early on, Creatine Kinase (CK) levels might be normal or moderately elevated

B: CK levels correlate very well with the risk of acute kidney injury and dialysis

C: If treatment is indicated, starting with 300 ml per hours of crystalloid seems to be a reasonable approach, even if the patient has no urine output

D: A McMahon score of six or greater indicates risk of acute kidney injury or dialysis, suggesting a possible benefit from treatment

The correct answer is D

Josh Farkas covered rhabdomyolysis in his latest IBCC podcast.

CK levels often rise quite late in the course of the illness, while kidney injury might develop early on. Kidney injury is due to hypermyoglobinemia, not due to CK levels directly and CK levels correlate poorly with the risk of acute kidney injury and dialysis. The McMahon score is useful in patient with a CK between 1000 and 5000 U/L, as a McMahon score of 6 or greater means treatment is indicated.

Be careful with iv fluids, for patients can get volume overloaded quite easily. Start with 150 to 200 cc’s of crystalloids per hour and monitor urine output closely. If the patient is (or gets) anuric or not matching urine output to fluids given, stop administration of iv fluids.

IBCC chapter & cast: Rhabdomyolysis

Question 5

Defibrillation often causes delay in compressions during cardiopulmonary resuscitation, for everyone has to be clear from patient and bed before a shock is delivered. According to this recently published paper  do polyethylene drapes provide sufficient protection from defibrillator currents during hands-on defibrillation?

A: Yes, current leaks were well below accepted IEC safety standards

B: No, current leaks did not meet IEC safety standards

C: No, the shocks were perceptible

The correct answer is A

This interesting paper was discussed on Journal Feed last week.

Both mean and peak current leaks were well below accepted IEC safety standards. None of the shocks were perceptible.

This might be the future. Using these drapes (of same material gloves) sure would reduce compression pause during defibrillation.

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This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet.

Edited by Rick Thissen