Quiz 43, August 28th, 2019

Question 1

Which of the following statements is true about the use of epinephrine in anaphylaxis?

A: Intramuscular (IM) epinephrine takes 30 seconds to reach peak blood levels

B: A bolus of 50 micrograms epinephrine intravenous (IV) should be given to patients with mild anaphylaxis

C: For severe hypotension, start epinephrine (IV) infusion at 20 micrograms per minute until the mean arterial pressure increases over 65 mm

D: Maintenance epinephrine infusion (IV) rate should be titrated within a range of 20-50 micrograms per minute

The correct answer is C

Josh Farkas covered the benefits of IV epinephrine in the management of anaphylaxis this week.

His post is about patients who have pre-existing IV access and are being managed by a resuscitationist who is comfortable with the use of IV epinephrine. IV epinephrine has several potential advantages over IM epinephrine, including faster onset and greater titratability. An infusion of IV epinephrine provides greater control.

Patients in peri-arrest should get a bolus of 20-50 micrograms IV epinephrine. Patients with mild to moderate anaphylaxis should start on a loading epinephrine infusion at a rate of 20 micrograms per minute for 2 minutes. In case of severe hypotension, continue epinephrine at 20 micrograms per minute until the mean arterial pressure increases over 65 mm. Then the infusion rate should be dropped to 10 micrograms per minute and titrated to effect with a range of roughly 5-15 micrograms per minute. Begin weaning off epinephrine after 20-30 minutes of clinical improvement.

PulmCrit- How to use IV epinephrine for anaphylaxis

Question 2



Which of the following statements is true about SCUBA diving injuries?

A: The first symptoms of nitrogen narcosis can occur once descending past 10 meters (33ft)

B: Oxygen toxicity can occur without the use of enriched gas mixtures (O2 > 21%) or closed circuit rebreathers

C: A Non Rebreathing Mask is just as effective as hyperbaric therapy in treatment of barotrauma

D: Tooth fractures do occur due to barotrauma

The correct answer is D

Diving injuries were covered on NUEM this week.

The first symptoms of nitrogen narcosis occur once descending past 30 meters (99ft).

Oxygen toxicity occurs due to the use of enriched gas mixtures (O2 > 21%) or closed circuit rebreathers.

All cases of barotrauma should be treated with hyperbaric therapy (hyperbaric chamber) if available. If not, use 100% oxygen and place the patient in horizontal position.

An yes, tooth fractures do occur due to barotrauma.

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Question 3

Which of the following is NOT a side-effect of intravascular contrast used in CT-scanning?

A: Vasodilatation

B: Functional hypocalcemia

C: Osmotic diuresis

D: Change of urine color

The correct answer is D

Justin Morgenstern discusses why patients are more likely to die during a CT-scan (if so) and why iv contrast might cause this.

It turns out contrast has a lot more side effects than anaphylactoid reactions and the feeling of peeing in the pants (vasodilation). The contrast binds calcium, resulting in functional hypocalcemia and it causes osmotic diuresis (which might harm the sick patient later on).

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Question 4

Diagnosing Necrotising Fasciitis (NF) can be quite challenging. Fortunately The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) was developed to make our lives a bit easier. Which statement is correct about this risk score?

A: This score has excellent diagnostic utility

B: Use it, but with caution. Sensitivity is likely around 80 percent

C: It is absolutely rubbish. Please do not use this score

The correct answer is C

CountyEM covered necrotising fasciitis this week.

The original derivation study was retrospective observational. Validation studies showed poor sensitivity (around 50%) and specificity for the LRINEC score. It is not uncommon for fatal NF cases to have scores ≤ 2 (low risk).

Everything you ever wanted to know about Necrotizing Fasciitis

Question 5

Which of the following statements is true about colchicine poisoning?

A: Activated charcoal will not be effective in colchicine overdose

B: Most life threatening effects will occur within the first 12 hours after ingestion

C: There is no specific antidote

The correct answer is C

Life in the Fast Lane covered colchicine poisoning this week.

Clinical symptoms of colchicine poisoning include: Gastrointestinal symptoms, cardiovascular collapse, coagulopathy and acute renal failure. The most dangerous phase is 2 to 7 days after ingestion. Administer activated charcoal as soon as possible as any reduction in absorption may be lifesaving and no, there is no specific antidote.

Colchicine toxicity

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

Reviewed and edited by Rick Thissen