Quiz 50, November 14th, 2019

Welcome to the th FOAMed Quiz. 

This weeks Quiz is about Cardiogenic Shock, PSA and Testicles. 


Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Which of the following statements is correct regarding diagnosis and management of cardiogenic shock?

A: Dobutamine should almost always be first line treatment in cardiogenic shock

B: Patients in cardiogenic shock are not always hypotensive

C: Milrinone is easy titratable in the Emergency Department

D: Intra Aortic Balloon Pumps (IABPs) increase cardiac contractility

The correct answer is B

In the latest very interesting EMcrit podcast, Scott Weingard discusses cardiogenic shock with Jenelle Badulak.

Starting dobutamine without a vasopressor can cause vasodilatation and hypotension. Patients in cardiogenic shock are quite often normotensive. Milrinone is not easy to titrate, especially in patients with suspected kidney failure. And finally, AIBPs do not increase cardiac contractility directly.

EMCrit 259 – Cardiogenic Shock — The Next Level & Mechanical Circulatory Support with Jenelle Badulak

Question 2

Source image: www.nuemblog.com

NUEM covered the basics of Procedural Sedation and Analgesia (PSA) this week. Which of the following statements is true?

A: Third trimester pregnant patients do not have an increased chance of vomiting

B: Midazolam can safely be used  in pregnant patients

C: End tidal (Et) CO2 provides earlier detection of hypoventilation

D: Ketofol is clearly superior to Ketamine and Propofol alone

The correct answer is C

Yes, pregnant patients do have an increased risk of vomiting. This is one of the reasons PSA is rarely performed in the Emergency Department in pregnant patients (at least in our shop). Some benzodiazepines have been shown to be teratogenic, so midazolam should not be used. EtCO2 does provide earlier recognition of hypoventilation, although false positives occur (apnea on etCO2, but still breathing). Evidence is mixed on Ketofol. Although in theory lower doses of ketamine and propofol are necessary and chance of side effects smaller, you will have to deal with the side effects of 2 drugs instead of 1.

Click Image for link to source

Question 3

Which of the following statements is true about patellar sleeve fractures?

A: Injury to the proximal pole typically leads to avascular necrosis of the proximal portions

B: Patellar Sleeve Fractures are the most common type of patellar fractures in pediatric patients

C: Patellar sleeve fractures occur most often due to powerful contraction of the hamstrings while knee is extended

D: Patellar sleeve fractures are easily seen on conventional X-ray

The correct answer is B

Pediatric EM Morsels covered patellar sleeve fractures this week.

Blood supply to the immature patella comes from the distal pole and the anterior surface. Therefore, injury to the anterior or distal pole can lead to avascular necrosis of the proximal portions. Patellar sleeve fractures are quite often due to powerful contraction of the quadriceps while the knee is flexed. Patellar sleeve fractures are easily missed on conventional X-ray. MRI might be necessary for diagnosis. And indeed, a Patellar Sleeve Fracture is the most common type of patellar fracture in pediatric patients. Most fractures require open reduction and internal fixation.

Patellar Sleeve Fracture

Question 4

Source image: pixabay.com

An 18-year old male is seen in the emergency department with sudden onset severe pain in his right testicle. His pain increased over time and is now 9/10.

Which of the following is true about testicular torsion?

A: Testicular torsion is equally common in all age groups

B: At 4 hours after onset of symptoms, damage to the testicle is irreversible.

C: Absence of cremasteric reflex is the most sensitive and specific clinical finding in diagnosing testicular torsion

D: Isolated tenderness at the superior pole of the affected testicle is not a very specific sign for torsion

The correct answer is C

Testicular torsion was covered by CanadiEM this week.

Testicular torsion should be considered in every patient presenting with testicular pain although it is most prevalent in the pediatric population. Irreversible damage is more likely to be present if torsion consists for 8 hours or more. An absent cremasteric reflex is very sensitive and specific and can help to distinguish between testicular torsion and other conditions like epididymitis. Isolated tenderness at the superior pole of the affected testical is very specific for testicular torsion.

Testicular Torsion

Question 5

Source image: pixabay.com

In critically ill patients admitted to the hospital and receiving at least 48 hours of oxygen therapy, what would be the range of oxygen saturation associated with the lowest adjusted mortality according to this recently published paper?

A: 90-94%

B: 92-96%

C: 94-98%

D: 96-100%

The correct answer is C

JournalFeed  discussed this Singaporean paper last week.  

No big surprise in this recently published paper. Retrospective analyses were conducted of two electronic medical record databases: the eICU Collaborative Research Database (eICU-CRD) and the Medical Information Mart for Intensive Care III database (MIMIC). Nonlinear regression was used to analyze the association between median pulse oximetry-derived oxygen saturation (Spo2) and hospital mortality. The optimal range of Spo2 was 94% to 98% in both databases (total of > 35.000 patients).

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen