Quiz 55, December 20th, 2019

Welcome to the 55th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Source image: www.canadiem.org

Question 1

A 38-year old male presents to your emergency department (ED) with a red left eye. The symptoms started yesterday and are getting worse. He describes the feeling as something stuck in his eye. His past medical history contains allergies, asthma and genital herpes.

Which of the following statements is true about corneal disorders?

A: This patient could be suffering of Herpes simplex keratitis, a condition which is most often bilateral

B: Contact lens users are at increased risk for bacterial keratitis, but only if the lenses are worn overnight

C: If a patient has a painful eye with pain which is out of proportion, corneal abrasion is more likely than corneal laceration

D: A positive Seidel’s test indicates corneal laceration

The correct answer is D

Corneal disorders were covered by Hubert Yu from CanadiEM this week.

The differential diagnosis for corneal disorders in the Emergency Department contains corneal abrasion, foreign bodies, corneal laceration, superficial punctate keratitis, herpes simplex keratitis, herpes zoster ophthalmicus and bacterial keratitis.

Herpes simplex keratitis is almost always unilateral and is most likely a reactivation of latent HSV infection.

Lens users are at increased risk of bacterial keratitis, particularly when the keep them in overnight.

If you see a patient with pain out of proportion, think about corneal laceration.

The Seidel test is intended to detect the leak of aqueous fluid following globe penetration (and it looks pretty).

Approach to Corneal Disorders in the ED

Source image: www.pixabay.com

Question 2

A 61-year-old woman presents to your Emergency Department with severe hypertension (RR 240/130 mmHg) and grade 4 hypertensive retinopathy.

Which of the following statements about hypertensive emergency is true?

A: Headache is almost always indicates end-organ damage

B: In this patient you should target a systolic blood pressure (SBP) of 120mmHg in 2 hours

C: Hypertensive Urgencies should be managed in the Emergency Department

D: Stopping previously prescribed medication is the most common reason for hypertensive urgency

The correct answer is D

Clay Smith discussed the management of acute severe hypertension this week at JournalFeed.

Headache by itself is not diagnostic for end organ damage. Be sure no underlying disorder like Spontaneous Intracranial Hemorrhage, Stroke or Posterior reversible encephalopathy syndrome (PRES) is present.

Acute severe hypertension without acute target-organ damage is not associated with adverse short-term outcomes and can be safely managed in the ambulatory setting.

The target SBP depends on the type of end-organ damage. In case of grade 3 or 4 hypertensive retinopathy you should strive to decrease the SPB with 20-25% in a couple of hours. In case of more serious pathology the reduction in SBP should be faster and more rigorous (like 120 mmHg immediately in case of an Aortic Dissection).

Question 3

Which of the following statements is true about Vaping Associated Lung Injury (VALI) according to this recently published descriptive paper?

A: The causative agent of VALI is Tetrahydrocannabinol (THC)

B: It seems most patients with VALI have unilateral infiltrates on chest imaging

C: Glucocorticoids does not seem to improve respiratory symptoms

D: Vaping THC containing substance leads to a higher chance of developing VALI compared to vaping a non-THC containing substance.

The correct answer is D

RebelEM covered this paper about VALI this week.

The authors of this paper analyzed 53 case patients. The causative agent is still unknown, but vaping THC containing substance leads to a higher chance of developing VALI compared to vaping a non-THC containing substance. All case patients had bilateral infiltrates on chest imaging (which was part of the case definition) and 65% of patients who received systemic glucocorticoids had “documentation by the clinical team that respiratory improvement was due to the use of glucocorticoids.”

Vaping Associated Lung Injury (VALI)

Question 4

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

Which of the following statements is true about Nontraumatic Atlantoaxial Subluxation (Grisel Syndrome)?

A: It is most frequently associated with recent head, eyes, ears, nose, and throat (HEENT) infection or recent HEENT surgery

B: Adolescents are more predisposed to Grisel syndrome compared to young children

C: Cervical plain films with odontoid views are not helpful

D: Most cases require surgical management

The correct answer is A

Pediatric EM Morsels covered Nontraumatic Atlantoaxial Subluxation this week.

Nontraumatic Atlantoaxial Subluxation is most frequently associated with recent HEENT infection or recent HEENT surgery. Children are more predisposed to Grisel syndrome, likely due to greater ligamentous laxity in the cervical region. Cervical plain films with odontoid views can be a helpful screening tool and most cases are able to be managed without surgery.

Nontraumatic AtlantoAxial Subluxation in Children

Question 5

Source image: https://www.emergencymedicinekenya.org/

Which of the following statements is true about Monteggia fracture – dislocations in children?

A: The fracture is most often located at the distal to middle third of the ulna

B: Monteggia fracture-dislocations can occur with other more subtle ulna fractures such as greensticks and even plastic deformation fractures

C: Monteggia fracture-dislocations do not require reduction most of the time

D: Isolated midshaft ulna fractures are pretty common in children

The correct answer is B

Don’t Forget the Bubbles covered Monteggia fracture – dislocation this week.

The ulna fracture is most often at the proximal to middle third of the ulna. Monteggia fracture-dislocations can occur with other more subtle ulna fractures such as greensticks and even plastic deformation fractures. All Monteggia fracture-dislocations will require an urgent reduction of the radial head dislocation. Isolated midshaft ulna fractures are very rare in children, so when an ulna fracture is identified you must also get an x-ray of the wrist and elbow joints.

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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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