Welcome to the 57th FOAMed Quiz.
Enjoy!
Kirsten, Eefje, Hüsna, Joep and Rick
Question 1
Diplopia is pretty common in the Emergency Department (ED) and proves often to be quite a diagnostic dilemma.
Which of the following statements is true about diplopia?
A: A patient with mononuclear diplopia should be evaluated by a neurologist first
B: Rotational diplopia that worsens when looking down and towards the nose is caused by a cranial nerve IV (trochlear nerve) palsy
C: The most common oculomotor nerve palsy is palsy of the nervus oculomotorius (n. III)
D: Multidirectional horizontal and vertical diplopia, except on lateral gaze to the affected side and eyelid droop are symptoms of cranial nerve VI (abducens nerve) palsy
The correct answer is B.
Diplopia was covered by CanadiEM this week as part of their CRACKCast series.
Diplopia, the perception of double vision, is most often divided into monocular and binocular diplopia. Monocular diplopia is caused by a dysfunction in one eye whereas binocular diplopia is caused by misalignment of the visual axis and causes diplopia in both eyes. Patients with monocular diplopia should be evaluated by an ophthalmologist instead of a neurologist.
One important group causing binocular diplopia are cranial nerve palsies. Palsy of the nervus abducens is most common and causes diplopia when a patients looks to the side of the affected nerve.
Rotational diplopia that worsens when looking down and towards the nose is caused by a cranial nerve IV (trochlear nerve) palsy
Multidirectional horizontal and vertical diplopia, except on lateral gaze to the affected side and eyelid droop are symptoms of cranial nerve III palsy.
Question 2
This recently published paper compares elective intubation using direct laryngoscopy (DL) in supine position, DL in Bed Up Head Elevated (BUHE) position and video laryngoscopy (VL) in supine position. What did the authors find?
A: VL in supine position was superior to DL in BUHE position regarding obtained view of the glottis (POGO score)
B: DL in BUHE position was superior to VL in supine position regarding obtained view of the glottis (POGO score)
C: DL in BUHE position was non inferior to VL in supine position regarding obtained view of the glottis (POGO score)
D: DL in supine position was non inferior compared to VL in supine position and DL in BUHE position
The correct answer is C
RebelEM covered this paper last week.
It is a non-inferiority trial comparing VL in supine position and BUHE DL to DL in supine position. Because it was a non inferiority trial, we can not make a statement about superiority. DL in BUHE was non inferior to videolaryngoscopy. Intubation with video took 8 seconds longer than DL in BUHE. The authors did find both BUHE and videolaryngoscopy to give better views of the glottis compared to DL in supine position. This trial was conducted in a controlled and elective setting in the operating room though, so might not be applicable to our Emergency Department patients. Furthermore, the primary outcome is not patient centered. To me it is not clear why the authors chose not to include a group using VL in BUHE position.
Should Bed Up Head Elevated (BUHE) be the New Standard Position for RSI in the ED?
Question 3
It is a pretty busy shift and you have to intubate yet another patient. You position the patient bed up head elevated (BUHE). You visualise the glottis, but not completely and you want to use a Gum Elastic Bougie (GEB).
Which of the following is true about the effect of using a GEB on the first pass success (FPS) rate of intubation?
A: A GEB is most effective in Cormack-Lehane grade 1 views
B: A GEB is only effective in Cormack-Lehane grade 2 views
C: A GEB is most effective in Cormack-Lehane grade 3 views
D: A GEB is only effective using videolaryngoscopy
E: A GEB is only effective using direct laryngoscopy
The correct answer is C
George Kovacs shared an overview of the literature and his take on the bougie this week on EMcrit.
Use of a GEB does not lead to an increased first pass success rate in case of Cormack-Lehane grade 1 views, but it does result in better FPS when a Cormack-Lehane grade 2 or 3 view is found.
A GEB can improve FPS in both video and direct laryngoscopy. Keep in mind that not all blades used in videolaryngoscopy are suitable for using a bougie.
Of course the first pass success rate is a combination of many parameters other than the hardware used, including experience and skills of the physician.
https://emcrit.org/emcrit/bougie-lessons-from-the-literature/
Question 4
Your patient presents with hyperkalemia (potassium of 6,9 mmol/l) and ECG abnormalities. There are some caveats in treatment of hyperkalemia. Which of the following statements is true?
A: Treating hyperkalaemia with insulin will not cause blood glucose levels to fall if you co-administer dextrose
B: The effects of IV dextrose will wear off before those of insulin, so check blood glucose after 1-2 hours
C: Use 10% calcium gluconate unless you have a central line. Give 1 dose of 10ml
D: The duration of action of iv calcium is 3-4 hours
The correct answer is B
The BREACH covered two important caveats in the treatment of hyperkalemia this weeks.
Treating hyperkalemia with insulin will cause blood glucose levels to fall, even if you co-administer dextrose. The effects of IV dextrose will ideed wear off before those of insulin, so check blood glucose after 1-2 hours.
Use 10% calcium gluconate unless you have a central line. Give 3 sequential doses of 10ml until the ECG normalises (advice from the UK Renal Association). The duration of action is 30-60min, so be ready to repeat the dose if ECG changes reappear.
Hyperkalaemia: two problems with our current management
Question 5
Pacemaker complications are quite common and most of these complications can occur at any time after placement.
Which of the following statements is true about pacemaker complications?
A: The incidence of phlebitis or thrombophlebitis is 20-30%
B: ‘Pacemaker Syndrome’ involves tricuspid regurgitation due to damage to this valve during pacemaker insertion
C: Patients with pacemaker syndrome usually present with vague symptoms including fatigue and exercise intolerance
D: Pocket infection of the pacemaker site can be managed with oral antibiotics most of the time
The correct answer is C
Phlebitis and thrombophlebitis have a very high incidence of 30-50% in pacemaker patients. However, symptomatic presentations are rare because patients develop collateral blood flow.
Pacemaker syndrome arises from the contraction of the atria against closed tricuspid and mitral valves, resulting in high pulmonary pressures. Patients usually present with vague symptoms like fatigue, weakness and dizziness, but they can also present with syncope or congestive heart failure.
A pocket infection requires most often intravenous antibiotics and removal of the pacemaker. Keep in mind that a pocket infection equals endocarditis until proven otherwise.
This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans
Reviewed and edited by Rick Thissen
