Quiz 44, September 12th 2019

Question 1

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

Your 7 year old patient has been in a motor vehicle accident. On physical examination he has normal vital signs, but you notice an area of bruising on the lower abdomen.

Which of the following statements is true about seat belt injury in children?

A: The risk on intra abdominal injury is higher than the risk of spinal injury

B: The most common site of intestinal injury is the duodenum

C: Seat belt sign without abdominal tenderness is not associated with an increased need for surgical intervention

D: Small mesenteric tears and perforation are the most common hollow viscus injury

The correct answer is D

Last weeks post on DFTB is about seat belt injuries. 

The seat belt sign is associated with an increased risk of intra abdominal and even higher risk of spinal injury. The most common intestinal injury are small mesenteric tears or perforation of the jejunum, followed by injury to the duodenum. A seat belt sign is associated with a higher requirement for surgical intervention, even in the absence of abdominal tenderness.

Seat Belt Injuries

Question 2

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

You see a 16 year old patient who has been complaining about abdominal pain, nausea and vomiting for the past 24 hours. He has been smoking marihuana regularly for the past year, and you think his symptoms might be caused by cannabinoid hyperemesis syndrome.

Which of the following is not effective in this condition?

A: Ondansetron

B: Capsaicin topical cream

C: Hot shower

The correct answer is A

Last week’s post on Pediatric EM Morsels covers Cannabinoid Hyperemesis Syndrome.

Cannabis consumption is very common. Cannabinoid Hyperemesis Syndrome causes cyclic nausea and vomiting. Symptom relief can be achieved by hot showers, topical capsaicin cream, and there have been some positive results with the use of haloperidol. Sadly, most anti-emetics (like ondansetron) are not effective.

Cannabinoid Hyperemesis Syndrome

Question 3

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

An 8-year-old female presents with pain on the lateral ankle. She is a dancer and she had no trauma in the past. The pain exists for 4 months and is worse while exercising. On X-ray you see a vertically oriented bone fragment of the base of MT 5. Your supervisor says it’s a MT5 apophysis. What is your diagnosis?

A: Osgood- Schlatter disease

B: Iselin disease

C: Kohler disease

The correct answer is B

Iselin disease is also called traction apophysitis at the base of the 5th metatarsal. The pain typically begins after activity. It is a stress reaction at the insertion apophysis from overpull of the peroneus tendon. Do not confuse this on imaging with a base of the 5th MT fracture, these are typically horizontally oriented.

Osgood-Schlatter disease is a common cause of knee pain caused by overuse in growing adults.

Kohler disease is childhood osteonecrosis of the navicular bone.

SplintER Series: Ankle and Foot Pain in a Child

Question 4

Which of the following is NOT part of the HINTS exam in order to differentiate between peripheral and central vertigo?

A: Test of Skew

B: Nystagmus observation

C: Dix-Hallpike Manoevre

D: Head Impulse Test

The correct answer is C

Taming the SRU covered the HINTS exam last week.

In the original study, a HINTS exam indicating peripheral etiology had a 100% sensitivity for ischemic stroke. However, a negative HINTS exam on its own should never prevent you from further examination. Furthermore, the HINTS exam hasn’t been validated for use by emergency physicians. Always keep pre-test probability in mind and be sure there is no additional focal neurological sign.

The HINTS test consists of: Head Impuls test, Nystagus and Test of Skew. Although Dix-Hallpike is not officially not part of this exam, it can be used to provoke nystagmus.


Question 5

In chemical sedation of the agitated patient, which of the following drugs has the fastest time of onset when given intramuscular?

A: Midazolam

B: Ketamine

C: Haloperidol

D: Droperidol

The correct answer is B

NUEM covered chemical sedation of the agitated patient this week.

This post contains an excellent infographic about the various drugs used to sedate agitated patients in the ED. It seems ketamine (5 mg/kg im) has the fastest time of onset.


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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