Quiz 52, november 29th, 2019

Welcome to the 52nd FOAMed Quiz. 


Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://first10em.com/

Drug reaction with eosinophilia and systemic symptoms, also known as DRESS syndrome, is a rare but severe condition which should be in the differential diagnosis of every sick patient presenting to the Emergency Department with a rash.

Which of the following is true about DRESS syndrome?

A: Symptoms generally occur within 72-hours after exposure to the drug

B: Carbamazepine is the drug most commonly associated with this condition

C: Diseases like Stevens-Johnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis and erythroderma are easy to discriminate from DRESS syndrome

D: As the name suggests, eosinophilia is present in at least 75% of patients with DRESS syndrome

The correct answer is B

Justin Morgenstern covered DRESS syndrome on First10EM.

Symptoms of DRESS syndrome generally appear within 2-6 weeks after starting the drug.

Carbamazepine is the drug most commonly associated with this condition and although leukocytosis is very common, eosinophilia is only present in 30% of patients.

There is no golden standard for diagnosis, it is based on a combination of diagnostic criteria. The most important takeaway from this post is to think about DRESS syndrome in patients with a rash with at least one systemic and one hematologic symptom.

DRESS syndrome – a rapid review

Question 2

You see a five year old patient with a dislocated distal radius fracture, and you want to provide analgesia. You wonder if you should give fentanyl or ketamine intranasal (IN). Recently the PRIME trial was published addressing this topic.

What did the results of this paper tell us?

A: IN fentanyl was superior to IN ketamine in providing analgesia

B: IN fentanyl was inferior to IN ketamine in providing analgesia

C: IN ketamine was non inferior to IN fentanyl in providing analgesia

D: IN ketamine leads to less adverse events compared to IN fentanyl

The correct answer is C

Simon Carley covered this paper on St. Emlyns last week.

This relatively small study ( 90 patients) is a randomized controlled trial designed to show non inferiority between IN fentanyl and IN ketamine for analgesia. The two treatments were similar in reducing pain score at 15, 30 en 60 minutes post administration. There were more adverse effect in the ketamine group, although they were minor.

JC: IN Fentanyl vs Ketamine for analgesia in PED. St Emlyn’s

Source image: pixabay.com

Question 3

Massive Transfusion Protocols (MTPs) differ between hospitals. The ratio PRBC to FFP to Platelets- ratio generally differs between 1:1:1 and 2:1:1. Which statement is true about the evidence behind this in trauma patients?

A: Evidence suggests a 2:1:1 ratio is superior to 1:1:1 ratio in reducing mortality at 30 days

B: Evidence suggests a 1:1:1 ratio is superior to 2:1:1 ratio in reducing mortality at 30 days

C: Evidence suggests a 2:1:1 ratio is superior to 1:1:1 ratio in decreasing death from exsanguination at 24 hours

D: Evidence suggests a 1:1:1 ratio is superior to 2:1:1 ratio in decreasing death from exsanguination at 24 hours

The correct answer is D

Last week this systematic review was discussed at The Trauma Professional’s Blog.

Most of the evidence comes from the PROPPR trial (2015)  which was broadly covered by lots of FOAMed blogs like RebelEM and EMNerd.

Massive Transfusion: What’s The Right Ratio?

Question 4

Source image: pixabay.com

A known cirrhotic patient comes in with hematemesis. He is hemodynamically unstable, you start with Packed Red Blood Cells (PRBCs) and prepare to intubate. Which of the following three additional treatment options has shown benefit in reducing mortality?

A: Octreotide

B: A Proton Pump Inhibitor (PPI)

C: Antibiotics (3rd generation cephalosporin)

The correct answer is C

RebelEM covered Decompensated Liver Disease last week in their latest Rebel Core Cast.

There is no proven benefit of octreotide or PPIs in these patients. However, administration of antibiotics (ceftriaxone) has shown benefit with an NNT for preventing one death of 22! Keep in mind this evidence comes from 12 trials of which only one was placebo controlled (the others were antibiotics vs no treatment).

REBEL Core Cast 22.0 – Decompensated Liver Disease

Question 5

In which type of hyponatremia is treatment with oral Urea indicated?

A: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

B: Cerebral Salt wasting

C: Primary polydipsia or malnutrition

D: Cortisol deficiency

The correct answer is A

Josh Farkas covered treatment of hyponatremia in SIADH with oral Urea this week. 

‘’Oral urea functions as an osmotic diuretic (an “aquaretic”).  Ingested urea will be completely excreted by the kidneys.  It is excreted along with water, so the ultimate effect is removal of water.’’’

PulmCrit- Controlled aquaresis: Management of hypervolemic or euvolemic hyponatremia with oral urea

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:

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

Reviewed and edited by Rick Thissen