Quiz 51, November 21th, 2019

Welcome to the 51th FOAMed Quiz. 


Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: www.nuemblog.com

Your patient presents to the Emergency Care because of worsening binocular diplopia since yesterday. She does not complain of a headache and no fever is present. On physical examination you find bilateral ataxia and areflexia without hemiparesis. No additional abnormal findings are found. Which of the following diagnosis is the likely ?

A: Myasthenia Gravis

B: Claude Syndrome

C: Botulism

D: Miller Fisher variant of Guillain Barré Syndrome

The correct answer is D

NUEM covered diplopia this week.

Myasthenia Gravis can present with isolated diplopia, but one would not expect areflexia and ataxia. Often ptosis is present as well.
Claude syndrome is caused by a midbrain infarct and typically includes unilateral oculomotor or trochlear palsy with contralateral ataxia. One would not expect worsening of symptoms over time and bilateral ataxia.
Botulism should be considered, but does not cause areflexia until a muscle group is paralyzed.
This set of symptoms (diplopia, areflexia and ataxia) is typical for Miller Fisher variant of Guillain Barré syndrome.

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Source image: pixabay.com

Question 2

You see a 27 year old G4P2 female at 25 weeks of gestation at the emergency department (ED) with right upper quadrant abdominal pain and vomiting. While abdominal pain during pregnancy is an extremely common complaint, medical emergencies should be considered.

Which of the following statements is true about medical emergencies in pregnant women:

A: Risk factors for uterine rupture include blunt abdominal trauma, grand multiparity and prior cesarean sections or myomectomies

B: Diagnostic criteria of HELLP syndrome include: proteinuria, leukocytes >12, AST and ALT ≥ 2x the upper limit of normal and platelet counts <100,000 x 10⁹/L

C: The ‘’discriminatory zone’’ describes that there is a certain ß -hCG level above which the gestational sac associated with a normal intrauterine pregnancy should reliably be visible on ultrasound. In case of transvaginal ultrasound (TVUS) this has been set at >500 mlU/ml

D: Physical examination in women with Pelvic Inflammatory Disease (PID) typically reveals lower abdominal pain and cervical motion tenderness. Treatment of PID in pregnant and non-pregnant woman is the same

The correct answer is A.

EMdocs covered pathologic obstetric abdominal pain this week and provided some useful summaries of notable signs in these conditions.

Uterine rupture most commonly occurs at the site of prior uterine surgical manipulation such as scar sites of prior cesarean sections or myomectomies. It most commonly occurs during labour but it should also be considered in blunt abdominal trauma in pregnant woman.

HELLP syndrome is a severe form of preeclampsia and is associated with hemolysis, transaminitis and thrombocytopenia. It is often associated with hypertension and proteinuria but these elements are not necessary for the diagnosis.

The ß -hCG level in the ‘’discriminatory zone’’ has traditionally been set at >1500 mlU/ml for TVUS but recently the American College of Obstetrics and Gynecology set this value conservatively high at >3500 mlU/ml. If no intrauterine gestational sac is visible on TVUS, an ectopic pregnancy should be considered.

PID is an infection of the upper genital tract (uterus, endometrium, fallopian tubes and ovaries) in women and is mostly caused by sexually-transmitted infections such as Neisseria gonorrhea and Chlamydia trachomatis. Pregnant women are treated with a second generation, cephalosporin and azithromycin, since regimens using doxycycline should be avoided during pregnancy due to adverse fetal effects.

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Question 3

You treat a patient with septic shock. After fluid resuscitation, antibiotics and the start of norepinephrine at 5 microgram per minute your patient is not improving. According to this recently published study about the non-catecholaminergic vasopressor Selepressin you should:

A: Start selepressin at 3.5 ng/kg/min in addition to norepinephrine

B: Stop norepinephrine and start selepressin at 3.5 ng/kg/min

C: Start selepressin at 1.7 ng/kg/min in addition to norepinephrine

D: Not start selepressin

The correct answer is D

RebelEM covered this recently published paper last week.

This study addresses an important question about whether adding a second vasopressor with a different action mechanism has an effect on the outcome in refractory septic shock. The authors did not find any significant difference in primary outcomes as vasopressor and ventilator free days. However, the study did show some differences in secondary outcomes (norepinephrine requirement and urine output).

SEPSIS-ACT: Selepressin in Septic Shock

Question 4

Source image: https://emergencymedicinecases.com/

Your patient presents with suspected hook of Hamate fracture. Which of the following statements is true about this condition?

A: Patients may have decreased grip strength and can endorse numbness in the 2th and 3th fingers as the deep branch of the ulnar nerve lies under the hook of the hamate

B: Hook of hamate fractures almost always require open reduction internal fixation (ORIF)

C: Hook of hamate fractures can be managed conservatively with a short arm cast

D: Excision of the fractured portion of the hamate is never indicated

The correct answer is C

AliEM covered Hook of Hamate fractures this week.

Patients may have decreased grip strength and can endorse numbness in the 4th and 5th fingers as the deep branch of the ulnar nerve lies under the hook of the hamate. ORIF is possible but has little benefit. Excision of the fractured portion of the hamate is sometimes indicated. And yes, hook of Hamate fractures can be managed conservatively with a short arm cast.

SplintER Series: Pain in the Palm

Question 5

Source image: www.pixabay.com

A number of methods are used to estimate the weight of pediatric patients. Which of the following methods was most accurate according to this recently published paper?

A: Parent estimation

B: Broselow tape

C: The Mercy Method

D: The APLS formula

The correct answer is A

JournalFeed covered this paper last week.

Parent estimation was within 10% of actual weight 89% of the time and within 20% of actual weight 97% of the time. The Broselow tape came second and the APLS formula and the Mercy Method were less accurate. Bear in mind this study was conducted in Thailand.

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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