Quiz 40, June 21th, 2019

Question 1

Source image: https://litfl.com/ultrasound-case-097/

Which of the following syndromes is best described by: episodes of vessel inflammation due to blood clot (thrombophlebitis) which are recurrent or appearing in different locations over time (thrombophlebitis migrans)?

A: Lemierre’ s Syndrome

B: Trousseau’s Syndrome

C: Antiphospholipid Antibody Syndrome

The correct answer is B

LIFTL published this great ultrasound case  last week.

Lemierre’s Syndrome refers to infectious thrombophlebitis of the internal jugular vein.

Antiphospholipid Antibody Syndrome (ASP) can cause widely spread thrombosis, but in general causes no thrombophlebitis. Very rarely, some people who have APS develop many blood clots within weeks or months.

Trousseau’s Syndrome is characterised by thrombophlebitis migrans secondary to several types of cancer.

Ultrasound Case 097

Question 2

Which of the following statements is true about Serotinin Syndrome?

A: Compared to Malignant Neuroleptic Syndrome, the onset of symptoms is slow

B: Hypothermia is often present

C: Lack of clonus argues strongly against the diagnosis of serotonin syndrome

D: If a sedative is needed, benzodiazepines are superior to dexmedetomidine

The correct answer is C

The Internet Book of Critical Care covers Serotonin Syndrome this week.

Compared to Malignant Neuroleptic Syndrome, the onset of symptoms in Serotonin Syndrome is rather rapid. Hyperthermia is often seen. Lack of clonus argues strongly against the diagnosis of serotonin syndrome. However, serotonin syndrome can occur in the absence of clonus under certain circumstances. If a sedative is needed, dexmedetomidine is a good choice because it seems to treat the underlying pathophysiology (serotonin excess) as well (and benzodiazepines do not).

IBCC chapter & cast: Serotonin syndrome

Question 3

Source image: https://litfl.com

What is the sensitivity of ECG abnormalities for detecting severe hyperkalemia (K > 6,5)?

A: About 10 percent

B: About 30 percent

C: About 50 percent

D: About 70 percent

The correct answer is B

This recently published paper
was discussed on journal feed last week.

The authors let 8 attending physicians read 528 ECGs from end stage renal disease patients. 30% of these ECG’s belonged to patients with a potassium of > 6,5. The sensitivity for detecting severe hyperkalemia was only 29%. The specificity was 95%.

Keep in mind you cannot rule out severe hyperkalemia by just an ECG reading.

Question 4

Source image: https://litfl.com

A 40 year old patient presents with a regular, monomorphic, narrow complex tachycardia. Previous ECG’s show a Delta Wave and a short PR interval. She shows no signs of shock or ischemic discomfort. You tried Valsalva maneuver, but it failed. What is true about the management of this case?

A: Adenosine is contraindicated in this case

B: You treat her as any other patient with a small complex, regular tachycardia

C: If adenosine is given, there is no chance of inducing Ventricular Tachycardia

D: Adenosine never triggers atrial tachyarrhythmias

The correct answer is B

The treatment of tachycardia in Adult with WPW recommended by the American Heart Association is discussed by Paula Sneath on CanadiEM.

The first step in the treatment of AVRT in Wolff Parkinson White is vagal maneuvers. The second step they recommend is adenosine, but even in the abcence of Atrial Fibrillation induction of Atrial and Ventricular Tachy-arrhytmias is a concern so electrical cardioversion should be available. Synchronized cardioversion is recommended for acute treatment in hemodynamically unstable patients or when pharmacological therapy is ineffective or contraindicated. IV diltiazem and verapamil are good choices for hemodynamically stable AVRT if adenosine fails (or if the patient refuses adenosine because of the sensation of dying).

Sirens to Scrubs: Wolff-Parkinson-White Syndrome

Question 5

Source image: http://www.emdocs.net/

Thromboelastography (TEG) is a laboratory test to assess coagulation. It has been around for decades, but so far has not been widely available. It has some real benefits over our standard clotting test (aPTT, PT/INR, thrombocytes) as a guide for transfusion of FFP, thrombocytes and cryoprecipitate. Which of the following is NOT one of these benefits?

A: TEG examines both clot formation and fibrinolysis. Our standard tests only examine clot formation

B: TEG examines clot strength, our standard tests do not

C: TEG guided transfusion leads to fewer blood product transfusion in bleeding cirrhotic patients

D: Validated algorithms on TEG-guided transfusion are available

The correct answer is D

Josh Farkas covered new literature on TEG this week on Pulmcrit.

I can’t say I fully understand TEG, but the potential benefits make a lot of sense. One disadvantage of TEG is the number of transfusion algorithms that come with it and the absence of validation of these algorithms. I do recommend reading the post on Pulmcrit, for understanding this concept will at least help you understand the flaws of our current blood product transfusion strategies.

PulmCrit- TEG for cirrhotic coagulopathy: Time for clinical implementation?

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:

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

Edited by Rick Thissen