Quiz 54, December 13th, 2019

Welcome to the 54th FOAMed Quiz. 


Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Early use of vasopressors is considered harmful in trauma patients and is not recommended by ATLS or other trauma courses. 

This year the AVERT trial was published. This randomized controlled trial is about the efficacy of low dose Arginine Vasopressin (AVP) versus placebo in patients with major trauma. What did the authors find?

A: AVP reduced mortality in this cohort

B: AVP reduced transfusion of blood products in this cohort

C: AVP reduced use of crystalloids in this cohort

D: AVP did not have any significant effect

The correct answer is B

This paper was covered on REBELem this week. 

In august 2019 the AVERT trial was published. As stated above, this is an RCT comparing low dose AVP versus placebo in 999 sick trauma patients (receiving at least 6 U of any blood product within 12 hours of injury). Participants received either placebo or AVP bolus (4 U) followed by an infusion to achieve a mean arterial pressure of 65 mmHg. 

Patient receiving AVP required significantly less blood products, but requirement of crystalloids and mortality were similar between groups. 

Keep in mind that 80 percent of the studied population sustained penetration injury, which is not very comparable to our shop.


Source image: www.emDOCs.net

Question 2

A 75 year old female with a history of diabetes mellitus presents with one day of abdominal pain with numerous loose, bloody bowel movements. She is hemodynamically and respiratory stable.
The abdominal exam shows significant left lower quadrant tenderness without guarding or rebound tenderness.

A diagnosis you don’t want to miss is Ischemic Colitis (IC).

Which of the following statements is true about this condition?

A: Symptoms usually include abdominal pain, severe rectal bleeding and vomiting

B: Patients are most often male, at least 40 years old and have a history of hypertension, vascular disease, chronic kidney disease and or diabetes mellitus

C: Bowel wall thickening, edema and thumbprinting on CT suggest IC. Colonic pneumatosis and portomesenteric venous gas indicate more severe disease

D: IC and mesenteric ischemia are two different names for the same condition.

The correct answer is C.

EMDocs covered the presentation, evaluation and management of IC this week.

Patients with IC most often present with abdominal pain (87%), subtile rectal bleeding (84%) and diarrhea (57%). Since these are non specific symptoms, up to 80% of cases are missed in the emergency department.

Patients are most often at least 50 years old, female and have a history of hypertension, vascular disease, chronic kidney disease and diabetes mellitus.

Although IC and mesenteric ischemia both occur in the setting of poor perfusion, acute mesenteric ischemia results in ischemia of the small bowel, most often due to occlusion of the superior mesenteric artery whereas ischemic colitis affects the colon in the distribution of the inferior mesenteric artery. Mesenteric ischemia also has a much higher mortality rate (60-80%) compared to ischemic colitis (10-15%).

Ischemic Colitis: ED Presentations, Evaluation, and Management

Source image: pixabay.com

Question 3

Although advanced cardiac life support (ACLS) protocols do not currently mandate the use of echocardiography, cardiac point-of-care ultrasound (POCUS) has become standard practice in many emergency departments during cardiopulmonary resuscitation (CPR).

Recently, the SHoC-ED2 trial has been published, which is about POCUS and ECG findings as predictors of cardiac arrest outcomes.

Which of the following is true about POCUS in the prediction of return of spontaneous circulation (ROSC) during CPR in non-shockable cardiac arrest?

A: Absence of cardiac activity on POCUS by itself has both high sensitivity and a high specificity for futility of CPR

B: In patients with asystole on ECG, the sensitivity of POCUS for futility of CPR is higher than in patients with electrical activity on ECG

C: ECG in combinations with POCUS performs well as reliable tests to identify patients likely to survive

The correct answer is B.

Simon Huang discussed the results of this trial on his blog at CanadiEM.

Absence of cardiac activity on POCUS alone has a high sensitivity (96%) but a low specificity (34%) for futility of CPR.

The combination of no cardiac activity on POCUS and an asystole on the ECG has a sensitivity of 98.2% for failure of ROSC, compared to 87% with no cardiac activity on POCUS and a PEA on the ECG.

Unfortunately, neither ECG nor POCUS alone or in combination performed well as reliable tests to identify patients likely to survive, with specificities maximizing at just over 50%.

SHoC-ED2: Ultrasound and ECG findings as predictors of cardiac arrest outcomes in the emergency department

Source: www.aliem.com

Question 4

A 66-year-old otherwise healthy female presents at your emergency department after being found unconscious on the floor. On arrival she is back to her baseline normal mental status, without complaints and with normal vital signs.  

Which of the following statements is true about syncope?

A: Unilateral tongue biting is more common in seizures compared to vasovagal syncope, whereas bilateral tongue biting is more characteristic for vasovagal syncope 

B: Several Clinical Decision Rules for syncope are reliable and externally validated

C: The rate of pulmonary embolism in syncope patients is most likely about 17 percent 

D: Routine use of laboratory tests in syncope are not recommended in ACEP guidelines

The correct answer is D.

Andrew Grock covered the work-up of syncope this week on AliEM.

He introduced a 3-step, evidence-based framework for the evaluation and work-up of syncope. Step 1: make sure it’s syncope, step 2: consider true syncope versus symptom syncope and step 3: assess the patient’s dysrhythmia risk.

Lateral tongue biting, especially bilateral, or postictal confusion is more characteristic for a seizure than for syncope. 

Not a single Clinical Decision Rule for syncope is externally validated so far, although the Canadian Syncope Rule looks promising.

17 Percent pulmonary embolism… well enough said about the PESIT trial. The rate of pulmonary embolism in patients presenting to the ED is most likely < 1 percent. 

And indeed, routine use of laboratory tests in syncope is not recommended in ACEP guidelines.

Question 5

In this recently published secondary analysis of patients from the Isotonic Solutions and Major Adverse Renal Events Trial (SMART), the authors compared balanced crystalloids (>90 % Lactated Ringer’s) and normal saline in sepsis patients admitted to the intensive care. 

What did this paper show?

A: In this cohort of very ill patients, the 30 day mortality was significantly lower in patients treated with balanced crystalloids

B: In this cohort of very ill patients, the 30 day mortality was significantly lower in patients treated with normal saline

C: There was no difference between the two groups

The correct answer is A.

RebelEM covered this secondary analysis of the SMART trial last week. 

1,641 Out of >15,000 patients were analyzed. A total of 217 patients (26.3%) in the balanced crystalloids group and 255 patients (31.2%) in the saline group experienced 30-day in-hospital mortality.

Probably one more piece of evidence toward the use of balanced crystalloid… to be continued.

SMART Trial Part 2: Secondary Analysis of Balanced Crystalloids vs Saline in Sepsis

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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