Quiz 39, June 13th, 2019

Question 1

Source image: http://sinaiem.org/tis-the-season-summer-edition/

Which of the following statements is true about Hand Foot Mouth Disease (HFMD)?

A: The majority of HFMD cases last 3-4 days

B: Most cases of HFMD result in encephalitis, acute flaccid paralysis or aseptic meningitis

C: HFMD is caused by several species of the flavivirus genus

D: Herpangina is the mouth-only cousin of HFMD

The correct answer is D

SinaiEM covered Hand Foot Mouth Disease this week.

The majority of HFMD cases last 7-10 days. Most cases of HFMD are benign, self-limiting and treated with supportive care. HFMD and its mouth-only cousin, herpangina, are caused by several species of the Enterovirus genus.


Question 2

Source image: https://litfl.com/an-unusual-wrist-injury/

Your patient presents to your emergency department with a distal radio-ulnar joint (DRUJ) dislocation. Which of the following statements is true about DRUJ dislocations?

A: The mechanism of injury for isolated volar DRUJ dislocation is most commonly due to hyper- pronation of the forearm

B: Postero-anterior (PA) view will not show any abnormalities

C: Isolated DRUJ dislocation is pretty common

D: DRUJ dislocation is often associated with injury to surrounding structures

The correct answer is D

Dan Stevens and Mike Cadogan covered DRUJ dislocation on LITFL.

The mechanism for isolated volar DRUJ dislocation is most commonly due to hyper-supination of the forearm. Postero-anterior (PA) view will show increased overlap of radius and ulna. Isolated (i.e. with no associated fracture) DRUJ dislocation is very rare with dorsal dislocation thought to be more common than ulnar.

An unusual wrist injury

Question 3

Recently this Randomised Controlled Trial was published about Phenobarbital as a second line agent in status epilepticus in children. Phenobarbital was compared to Phenytoin after 2 doses of benzodiazepines. The primary outcome was termination of seizure activity. What did the authors found?

A: Phenobarbital was superior to Phenytoin in terminating the seizure

B: Phenobarbital equally effective compared to Phenytoin in terminating the seizure

C: Phenytoin was superior to Phenobarbital in terminating the seizure

The correct answer is A

Justin Morgenstern discusses this very interesting paper on first 10 EM. He suggests anaesthetics (Phenobarbital, Propofol) might be a better second line agent for status epilepticus because of high failure rates of current second line agents (Phenytoin, Levetiracetam) and therefore delay in termination seizure activity (and I agree).

In the Phenobarbital group 86% of children responded with seizure termination. In contrast, seizures where terminated in only 46% of children who received a single parenteral dose of Phenytoin (p = 0.0003). Also, Phenobarbital terminated status epilepticus significantly faster compared to Phenytoin (10 vs 28 minutes).

Keep in mind this is a non-blinded study and it was designed to look at seizure management in a resource limited setting.

Question 4

Source image: https://www.rcemlearning.co.uk/references/angioedema/

Your patient presents with swelling of the face and tongue as well as profound urticaria. You wonder if this reaction is bradykinin or histamine mediated. Which of the following statements is true?

A: Medication always causes a histamine mediated reaction

B: Presence of urticaria is suggestive of a histamine mediated reaction

C: Hereditary Angio Edema (HAE) causes a histamine mediated reaction

D: Acquired C1-INH deficiency causes a histamine mediated reaction

The correct answer is B

Brit Long covered angio-edema on EMdocs this week.

Medication can cause both a histamine and bradykinin (like ACE-inhibitors) mediated reaction. Presence of urticaria is indeed suggestive of a histamine mediated reaction. HAE and Acquired C1-INH deficiency cause a bradykinin mediated reaction. Bradykinin-mediated forms are usually longer-lasting, more severe, and tend to affect the upper airway.

emDocs Cases: Angioedema Evaluation and Management

Question 5


You see another two year old child in your emergency department with fever and a rash. She is not vaccinated and your differential diagnosis includes measles.

Which of the following statements is true about measles?

A: The mortality rate is 0.02 %

B: Transmission occurs only via direct contact

C: The vaccine is 87% effective after 2 shots

D: There is no animal reservoir

The correct Answer is: D

This weeks REBEL corecast is about measles.

Since vaccination rates are dropping, it is vital to know more about contagious infectious diseases like measles ( which was almost eliminated in the year 2000).
The vaccine is highly effective, (97 % after 2 shots). Because humans are the only host, (there is no animal reservoir) we keep this virus in circulation because of failure to vaccinate. Transmission occurs by airborne droplets, and the transmission rates are extremely high. The mortality rate is 0.2 %

REBEL Core Cast 13.0 – Measles

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

Edited by Rick Thissen