Quiz 53, December 6th, 2019

Welcome to the 53th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://litfl.com/

Your 53-year-old female patient presents with an AV-nodal reentry tachycardia (AVNRT). She is hemodynamically stable with a pulse rate of 175/min and blood pressure of 118/90 mmHg. You want to give her adenosine.

Which of the following statements is true about the administration of adenosine?

A: Adenosine diluted with saline in a single syringe push seems to be at least non-inferior to the usual adenosine push followed by a rapid saline flush

B: Adenosine diluted with saline in a single syringe push seems to be inferior to the usual adenosine push followed by a rapid saline flush

C: Adenosine diluted with saline as a single syringe push seems to induce more adverse events in comparison to the usual adenosine push followed by a rapid saline flush

The correct answer is A

Clay Smith covered this trial about the single syringe method for the administration of adenosine on JournalFeed.

One of the challenges of giving adenosine is the very quick saline push needed after the adenosine push. A few seconds between the two administrations might make a difference for successful cardioversion. Diluted adenosine in one syringe (a sort of push and flush together) can make it a lot easier!

The results of this trial are promising: successful conversion to normal sinus rhythm (NSR) with the first dose of adenosine was higher in the single syringe group: 73.1% compared to 40.7% in the controlgroup. There were no adverse events reported in the single syringe group. Keep in mind that this was a small, unblinded pilot study.

Source image: https://journalfeed.org/

Question 2

We prescribe a lot of antiemetics in the Emergency Department (ED). After all, nausea and vomiting are pretty common complaints.

But how about the evidence? Justin Morgenstern covered this paper earlier this week on First10EM. Which of the following statements is correct regarding the efficacy of droperidol and ondansetron as an antiemetic in the ED?

A: This paper shows ondansetron is more effective than placebo in reducing nausea

B: This paper shows droperidol is more effective than placebo in reducing nausea

C: This paper shows droperidol and ondansetron are more effective than placebo in reducing nausea

D: This paper shows ondansetron, droperidol and placebo are equally effective in reducing nausea

The correct answer is D

This paper compared ondansetron, droperidol and placebo. Their primary outcome was an improvement of 8 mm of a visual analogue scale and was met in 75 (droperidol), 80 (ondansetron) and 76 percent (placebo). These differences were not statistically significant. However patients reported significantly higher rates of achieving desired effect when using droperidol (this was elicited from direct questioning—”The drug I received had the desired effect for me: Yes or No”). Furthermore, the authors enrolled 215 patients (unfortunately, this was only about half way to the calculated sample size of 378 patients). So, although this paper shows no clear benefit of droperidol and ondansetron, it is not a done deal.

Nausea and vomiting in the ED: Does nothing work?

Question 3

Source image: www.pixabay.com

Auwch, that hurts! Penile injuries are men’s worst nightmare. Examples include penile fracture, zipper injuries and penile strangulation.

Which of the following statements is true?

A: ‘’A zucchini deformity’’ is an often notable clinical sign in penile fractures

B: Urethral injuries are seen in 60-70% of penile fractures

C: The best way to separate an entrapped penis from a zipper is by using a wire cutter to cut the middle portion of the zipper that connects the two halves

D: In case of penile strangulation blood can be drained from the corpora cavernosa in a manner similar to draining a priapism to get underneath the constricting band

The correct answer is D

Jacob Stelter covered penile injuries this week on NUEM.

A penile fracture is a medical emergency in which the‘’eggplant deformity’’ refers to the clinical presentation of a fractured penis with swelling and detumescence of the penis, often with notable ecchymosis and deformity.

Penile fracture could lead to urethral injuries which occur in up to 38%. If suspected, a retrograde urethrogram or cystoscopy should be performed before a Foley catheter is inserted.

In case you see a patient with his penis trapped in a zipper, use a lubricant, this almost always works. If not, try using a wire cutter to cut the piece connecting the two halves of the zipper.

Finally, injuries resulting from penile strangulation are divided into five grades ranging from isolated penile edema in stage I all the way up to penile necrosis or amputation of the distal segment in grade 5.

Source image: https://www.nuemblog.com/

Question 4

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

A 4 years old patient presents to your department with colicky abdominal pain. The ultrasound image looks like the one above.

Which of the following statements is true regarding this diagnosis?

A: Surgery is indicated for all pediatric patients

B: Pneumatic or hydrostatic enema is preferred modality in pediatric patients

C: The male to female ratio is 1:5

D: Currant jelly stools are very common in these patients

The correct answer is B

AliEM covered intussusception this week in their ´´Ultrasound for the Win´´ series.

The male to female ratio is 3-8:1. While pneumatic or hydrostatic enema is preferred modality in pediatric patients, surgery is indicated in adults patients. Currant jelly stools are pretty rare.

Ultrasound for the Win! 3-year-old with abdominal pain #US4TW

Question 5

Which of the following statements is true about acute torsion of the appendix epididymis?

A: Torsion of the testicular appendages is dangerous

B: Diagnosis is made via color doppler ultrasound

C: Treatment includes surgical detorsion

D: Late torsion of the appendix testis or epididymis may present with a “blue dot sign”

The correct answer is B

BrownEM covered acute torsion of the appendix epididymis this week.

Torsion of the testicular appendages is not dangerous. Diagnosis is made via color doppler ultrasound. Treatment includes NSAIDs, scrotal support, and reassurance and early torsion of the appendix testis or epididymis may present with a “blue dot sign”.

Source image: http://brownemblog.com/

 

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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

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