Quiz 38, June 7th 2019

Question 1

Which cardiac arrhythmia is seen most often in patients with electrical injury?

A: Bundle branch blocks

B: QT prolongation

C: Atrial fibrillation

D: AV-blocks

The correct answer is C

Lorraine Lau and Anton Helman covered Electrical Injuries on EM cases this week.

Fortunately, cardiac complications from electrical injury are relatively uncommon with an overall incidence of 4-17%. Atrial fibrillation is the most common arrhythmia. Other ECG findings are bundle branch blocks, AV-blocks, QT prolongation, ST-changes, ventricular fibrillation and asystole. The fatal arrhythmias normally appear directly after the electrical trauma, with a VF more common after a trauma with alternating current and an asystole more common after injury with direct current. Cardiac monitoring is required in the first few hours for all high voltage (>1000V) injured patients, and for low voltage injured patients with symptoms (chest pain or syncope). Troponines are only indicated in patients with clinical presentation of cardiac ischemia and should not be obtained routinely.

Ep 125 Electrical Injuries – The Tip of the Iceberg

Question 2

How many days after tracheostomy can the trach be replaced safely without fiberoptic guidance?

A: > 3 days

B: > 4 days

C: > 7 days

D: > 10 days

The correct answer is C

REBELem covered tracheostomy emergencies this week.

It takes 7-10 days for the tract to become mature. It is not recommended to blindly replace the trach if 7 days old or less, because of the risk of creating a false tract.

REBEL Core Cast 12.0 – Tracheostomy Emergencies

Question 3

In a patient with superficial venous thrombosis, which of the following is NOT a risk factor for development of deep venous thrombosis or pulmonary embolism?

A: The clot is less than 3 cm from SaphenoFemoral junction

B: The clot is more than 5 cm in length

C: The clot is in a varicose vein

D: Male gender

The correct answer is C

Jacob Avila covered superficial venous thrombosis on emDOCs.

Risk factors for extension of Superficial Venous Thrombosis include: a clot > 5 cm; < 3 cm from the SaphenoFemoral Junction; male gender; clot in a non-varicose vein; severe symptoms (whatever they may be); involvement above the knee; history of thrombo-embolic disease; active cancer and recent surgery.

CORE EM: Superficial Venous Thrombosis (SVT)

Question 4

Source image: https://www.stemlynsblog.org/

Which of the following statements is true about fluid boluses?

A: The majority of fluid boluses lead to sustained clinical benefit in patient with septic shock

B: Fluid boluses always provide reliable information about the patient’s hemodynamics

C: The transient improvement in hemodynamics sometimes seen after crystalloid fluid bolus is probably caused by its low temperature

D: Increase in cardiac output always translate into an increase in oxygen delivery

The correct answer is C

Josh Faskas published ‘’Myth-busting the fluid bolus’’ on EMcrit this week.

Fluid boluses usually cause only a transient hemodynamic improvement and don’t necessarily provide reliable information about the patient’s hemodynamics. It appears it is hypothermia that triggers an endogenous sympathetic nervous system response leading to transient improvement of hemodynamics. An increase in cardiac output duo to a fluid bolus does not necessarily lead to an increase in oxygen delivery, because a fluid bolus leads to decrease of hemoglobin (and oxygen transport).

PulmCrit: Myth-busting the fluid bolus

Question 5

Source image: https://litfl.com/

What is the optimal puncture site for needle decompression in tension pneumothorax in children?

A: 2nd intercostal space midclavicular

B: 4th intercostal space anterior axillary line

The correct answer is B

The Resus Room discusses this paper in it’s papers of the month podcast of June. Although there is plenty of evidence in the adult literature, evidence regarding needle decompression in children is scarce.
This paper evaluates chest wall thickness and relation to vital structures on CT in children in three different age groups. The authors recommend the 4th intercostal space in the anterior axillary line as the primary site for needle decompression. Especially in children 0-5 year old the authors found vital structures like thymus and heart close to the 2nd intercostal space puncture site.

Papers of June 2019

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

Edited by Rick Thissen