Quiz 41, August 2nd, 2019

After a short break (Holidays!) we are back. Thanks for joining us again!

The FOAMed Quiz Crew

Question 1

You admit a patient with Diabetic KetoAcidosis (DKA). Which of the following insulin strategies would be appropriate?

A: Start long acting insulin treatment after you stop the insulin drip

B: Stop the insulin drip when the anion gap is normal, even if the patient is still acidotic

C: Administer the home dose basal insulin at least two hours before you stop the drip

The correct answer is C

Josh Farkas covered the management of patients with DKA on the latest EMCRIT blog.

The blog includes a literature review on early administration of basal insulin and some pointers about the management of patients with DKA.

If you stop the insulin drip before you administer long acting insulin or when the patient is still acidotic, there is a risk on widening of the anion gap and cause rebound hyperglycemia. However, if you administer basal insulin at least two hours before you discontinue the drip, there is lower risk on sub-therapeutic insulin levels. When basal insulin is administered early in the course of the disease this time gap could be eliminated and the insulin drip can stop when the patient meets the criteria for discontinuation.

PulmCrit – Early basal insulin in DKA

Question 2

Source image: https://litfl.com/

Which of the following statements is true about the Pediatric ECG?

A: A Right Axis on ECG is abnormal in the first 6 months of life

B: The first months of life a short QTc can be found

C: A negative QRS complex in AVF is abnormal and can be seen with some cardiac malformations

D: T-wave inversion in anterior precordial leads is abnormal in a 3 year old child

The correct answer is C

Dr. Sean Fox covered the Pediatric ECG on emDocs this week.

Pediatric ECGs may make us less comfortable because of the infrequent encounters.

The initial right axis is because of a thicker RV and is caused by the high pulmonary pressure in utero. QTc is longer in the young. A negative QRS vector in AVF can be seen with some cardiac malformations like AtrioVentricular septal defect or single ventricle. T-wave inversions in anterior precordial leads are normal. They will usually turn upright in adolescence.

Pediatric ECG

Question 3

https://www.flexicare.com/

The management of bronchiolitis is quite simple, nothing really works except for oxygen, right? Which of the following statements is true about oxygen administration in bronchiolitis?

A: Infants with bronchiolitis and hypoxia should be started on 5L oxygen via nasal cannula

B: High Flow Nasal Cannula (HFNC) should only be started if there is deterioration after low flow (2L) oxygen via nasal cannula has been administered

C: There is plenty of evidence supporting the use of HFNC in order to reduce work of breathing in infants without hypoxia

D: There is plenty of evidence supporting the use of HFNC as an early treatment for bronchiolitis in Emergency Department

The correct answer is B

Don’t Forget The Bubbles covered HFNC and bronchiolitis this week.

Infants with bronchiolitis and hypoxia should be started on 2L oxygen via nasal cannula. HFNC should indeed only be started if there is deterioration after this has been administered. There is no evidence for using HFNC for work of breathing in infants with no hypoxia. There is no evidence for using HFNC as an early treatment for bronchiolitis in the emergency department.

https://dontforgetthebubbles.com/evidence-high-flow-bronchiolitis/

Question 4

This recently published paper is about budding taping versus plaster immobilization for uncomplicated neck of fifth metacarpal fractures (boxers fracture).

What did the authors find?

A: Buddy taping is equally effective compared to plaster immobilization in patients with an uncomplicated boxer’s fracture

B: Buddy taping is inferior to plaster immobilization in patients with an uncomplicated boxer’s fracture

C: Buddy taping is superior to plaster immobilization in patients with an uncomplicated boxer’s fracture

The correct answer is A

EMOttawa covered this paper last week.

It looks like buddy taping may be a reasonable treatment option for selected ED patients with an uncomplicated boxer’s fracture. Well, somewhere in the future…

Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial

Question 5

Source image: https://litfl.com/

Which of the following statements is correct about ECG abnormalities?

A: A Flipped T-wave in AVL might be an early sign of inferior STEMI

B: Wellens syndrome type B includes biphasic T waves in V1-V4

C: Isolated T wave inversion in III is usually an early sign of inferior STEMI

D: De Winters T waves are symmetric inverted T waves in V1-V4

The correct answer is A

This week’s Emergency Medicine Cases podcast is all about chest pain.

Some key ECG patterns and their significance are covered in this podcast. In Wellens syndrome type A, biphasic T waves in V1-V4 are seen and type B is characterized by deeply inverted T-waves in V1-V4.

This pattern is a sign of high grade LAD or Left main artery lesion. De Winter T-waves are an equivalent of anterior STEMI, and are tall, symmetric T-Wave in leads V1 – V4 with upsloping ST-Depression at J Point in leads V1 – V4 without ST elevation. Although an inverted T wave in lead III is nonspecific, it increases the risk of major cardiac events in patients with chest pain.

Ep 128 Low Risk Chest Pain and High Sensitivity Troponin – A Paradigm Shift

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

Edited by Rick Thissen

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