Quiz 56, January 3th, 2020

Welcome to the 56th FOAMed Quiz. 

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Enjoy the first quiz of 2020!

Kirsten, Eefje, Hüsna, Joep and Rick

Written by Joep Hermans. Post edited by Rick Thissen.

Question 1

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Nowadays peripheral vasopressor use is quite common in the Emergency Department. It seems to be pretty safe, but still includes some risks.

Which of the following statements is true about the safety of peripheral vasopressors according to 2 recently published observational studies?

A: The rate of extravasation is about 5 percent

B: Tissue necrosis or limb ischemia was present in over half of extravasation cases

C: All reported extravasation events in both papers were managed conservatively or with vasodilatory medications

The correct answer is C

REBELem covered this and this paper this week.

The extravasation rate was found to be below 2,6 percent and all 43 cases between these papers were managed conservatively without tissue necrosis or limb ischemia.

Peripheral vasopressor use seems to be really safe according to these papers, but keep in mind there are no randomized studies on this topic. All data comes from observational studies.

REBEL Cast Ep73: Are Peripheral Vasopressors Safe?

Question 2

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A 52-year-old male was hit by a car and suffered a tibia fracture. He has no other injuries but keeps complaining about severe pain, despite repeated doses of morphine.

Which statement about compartment syndrome (CS) is true?

A: Female patients above 50 years of age have the highest risk for developing CS

B: The anterior compartment of the lower leg is the most common location for CS to occur

C: Clinical findings such as excessive pain, pain which increases with passive stretching, paresthesia and paresis have a very high sensitivity for CS

D: Removal of external compressive devices, elevation of the extremity at risk and relocation of a displaced fracture may possible decrease pain sensation but will not reduce pressure inside the compartment at risk

The correct answer is B.

EMdocs covered the pearls and pitfalls of compartment syndrome this week as part of their EM Educator Series.

Compartment syndrome is most common in males <35 years of age since these patients have increased risk of high-energy injuries, stronger fascia and greater muscle bulk. It mostly occurs in the anterior compartment in the lower leg but it is also seen in the deep posterior compartment and in other limbs like the upper legs, underarms and hands/feet.

It is true that most seen clinical signs include excessive pain, pain which increases with passive stretching, paresthesia and paresis. These signs have a high specificity but a low sensitivity on their own, when all four are compared, sensitivity is much better (93%).

Finally, pressures inside compartments can certainly be lowered by removal of external compressive devices, elevation of the extremity and relocation of a displaced fracture. Each centimeter of elevation decreases pressure with 0.8 mmHg. However, treatment is fasciotomy.

Question 3

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Your patient presents with an acute first CarpoMetaCarpal (CMC) dislocation. Which of the following statements is true about this topic?

A: Isolated dislocations are uncommon and are usually associated with Bennett, Roland and carpal fractures

B: Thumb CMC dislocations are often caused by direct force into the webspace between the first and second digits

C: Closed reduction performed with traction in the Emergency Department is absolutely futile

D: Operative treatment is always indicated

The correct answer is A

AliEM covered CMC dislocations this week.

Indeed, isolated dislocations are uncommon.

´Thumb CMC dislocations are often caused by axial loading of the thumb in a flexed position, and less commonly, direct force into the webspace between the first and second digits.’

During initial treatment in the ED, CMC dislocations should be anesthetized with an intra-articular injection, and then closed reduction should be performed with traction. The joint is likely unstable after reduction.

There is debate over the optimal treatment strategy, and several studies have compared nonoperative and operative treatment.

SplintER Series: A Rare Cause of Traumatic Thumb Pain

Question 4

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Ah, the ever continuing discussion about the best anti-epileptic drug when benzodiazepines fail.

Recently the ESETT trial was published. This is a multicenter, randomized, blinded, trial of second line agents for the treatment of status epilepticus in the emergency department. What did the authors find?

A: Levetiracetam was superior in terminating seizure activity compared to Valproate and Fosphenytoin at 60 minutes after administration

B: Fosphenytoin was superior in terminating seizure activity compared to Valproate and Levetiracetam at 60 minutes after administration

C: No difference in effectiveness and safety was seen between the three drugs

D: Levetiracetam is safer compared to Valproate and Fosphenytoin

The correct answer is C

First10EM covered this trial last week (REBELem and EMcrit covered this trial as well).

It is the best evidence we have so far on second line agents for status epilepticus and it tells us: no agent is more effective compared to the others and no agent is clearly less safe compared to the others.

The effectiveness (termination of seizure activity at 60 minutes after administration without the need of additional medication) isn’t really that good to put it lightly.

Furthermore, letting patients seize for up to 1 hour after administration of second line agent without proceeding to the next step (sedation and intubation) is not acceptable.

The ESETT Trial: 2nd Line Medications in Status Epilepticus

Question 5

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Non-traumatic cardiac arrest (CA) is often associated with multiple pathologies. This retrospective study reviewed 100 whole body CT (WBCT) performed within 6 hours after Return Of Spontaneous Circulation (ROSC). What did the authors find?

A: Pneumothorax was present in about 5 percent of patients

B: Rib fractures were found in nearly 50 percent of patients

C: Pulmonary embolism was found in 10 percent of patients

D: No abdominal acute pathologies were found on these scans

The correct answer is C

The ever fantastic Resus Room paper of the month podcast covered this pretty interesting paper (January 2020)

The authors found a staggering amount of pathologies in 100 consecutive patients. These include pneumothorax in 26%, rib fractures in nearly 90%, pulmonary embolism in 10 percent of patients, acute pathology of the brain in 15 percent and acute pathology in the abdomen in 6% of cases (including splenic hematoma in 2 percent and bowel rupture in 1 percent) and so on…  It is not clear how many of these findings led to a different treatment. 

Well. We normally don’t perform WBCT after ROSC and we are not likely to start doing so, but these numbers are quite impressive. 

https://theresusroom.co.uk/papers-of-january-2020/

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