Quiz 42, 16th of August, 2019

Question 1

This trial published earlier this year
compared oral Ibuprofen at three single-dose regimens for treating acute pain in the emergency department. Which dose of ibuprofen was found to be most effective?

A: Doses of 400 mg, 600 mg and 800 mg were found to be equally effective

B: Doses 600 mg and 800 mg were found to be more effective than 400 mg

C: A dose of 800 mg was found to be more effective than 400 mg and 600 mg

The correct answer is A

The authors conclude: Ibuprofen has similar analgesic efficacy profiles at single oral dosing regimens of 400 mg, 600 mg and 800 mg for short-term treatment of moderate to severe acute pain in the ED.

REBEL EM covered this paper last week. Keep in mind the follow-up time was only 60 minutes and patients who already received opioids were excluded.

A Randomized Control Trial Comparing Oral Ibuprofen at Three Single-Dose Regimens for Treating Acute Pain in the ED

Question 2

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

Which of the following signs is NOT commonly seen on ultrasound in the case of an occult supracondylar humerus fracture in children?

A: Bulging or the posterior fat pad

B: Lipohemarthrosis

C: Cortical disruption

The correct answer is C

AliEM covered the diagnostic value of ultrasound in radiographically occult supracondylar humerus fractures in children.

Signs of potential occult fracture include a bulging posterior fat pad and lipohemarthrosis. It seems elbow ultrasound can assist in ruling out a supracondylar fracture because of it’s excellent sensitivity.

PEM Pearls: Ultrasound for Diagnosing Occult Supracondylar Fractures

Question 3

Source image: http://blog.clinicalmonster.com/2019/08/09/high-pressure-injection-injury/

Which of the following statements is true about the management of high pressure injection injuries in the Emergency Department?

A: Patients are often discharged home due to the benign initial appearance of the injury

B: Digital nerve blocks can be given safely

C: The most important prognostic factor is the result of microbiological culture

The correct answer is A

County EM covered this topic last week.

Diagnosis is often delayed and patients are often discharged home due to the benign initial appearance of the injury which later results in amputation of the affected digit or hand. Do NOT perform digital nerve blocks given the risk of increased compartment pressure at the fingers. The most important prognostic factor is aggressive debridement by a hand surgeon within the first six hours following injury.

ED Management of High-Pressure Injection Injury

Question 4

A 42 year old patient with a history of alcohol abuse presents to your emergency department after he ingested half a bottle of antifreeze. What is correct about this intoxication?

A: Antifreeze contains propylene glycol

B: Acetonemia is typically seen in this intoxication

C: Hypocalcemia is typically seen in this intoxication

D: Optic Nerve Toxicity is typically seen in this intoxication

The correct answer is C

This weeks blog on Taming the SRU is about toxic alcohols and covers the clinical presentation, diagnosis and management of this intoxication.

Antifreeze contains ethylene glycol and forms calcium oxalate crystals that can be seen with microscopic urine analysis. It can cause hypocalcemia, a wide QRS and prolonged QT.
Ingestion of methanol can cause blurred vision caused by optic nerve toxicity. Methanol is found in wiper fluid and paint. Isopropanolol is found in hand sanitizer and rubbing alcohol, and is broken down to acetone. Propylene glycol is used as a diluent for parenteral medications and can cause lactic acidosis. All of these toxic alcohols can cause CNS depression, GI symptoms and an increased osmol gap. For more about this topic you can read the following post.

Question 5

Source image: https://www.nuemblog.com/blog/pleural-effusions-101

What would probably be the best strategy to drain large pleural effusions keeping the risk of re-expansion pulmonary edema (REPE) in mind?

A: Limit initial fluid removal to 1,5 liters

B: Do not limit fluid removal, but stop the procedure when the patient is experiencing central chest discomfort

C: There are no limitations with regard to the drainage of large pleural effusions

The correct answer is B

Josh Farkas wrote about large volume pleural drainage in his latest blog. Although there is no data to support it, traditional guidelines recommend a maximal volume of fluid removal of 1,5L during thoracentesis to prevent re-expansion pulmonary edema (REPE). Josh explains why this is arbitrary, and why the risk of REPE is probably due to the baseline size of the effusion rather than the volume of fluid removed.

In a large cohort study with 9320 inpatients who underwent thoracentesis, the rate of REPE after removal of >1,5L fluid was very low (0,75%). Josh concluded that large pleural effusions can generally be drained entirely, although the procedure should be stopped if the patient experience vague central chest discomfort.

Using multiple small-volume thoracenteses is a misguided strategy, since this causes an overall increase in procedural complications (bleeding, infection, lung laceration).

PulmCrit- Large volume thora: Can we drain ‘em dry?

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

Reviewed and edited by Rick Thissen