Quiz 59, January 24th, 2020

Welcome to the 59th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: www.thebottomline.org

Most certainly the most widely discussed study last week was the VITAMINS paper. Some two and a half years after the Marik report, this randomized controlled trial provides some real evidence about the golden cocktail of Hydrocortisone, Vitamin C, and Thiamine in septic ICU patients. What did the VITAMINS paper show?

A: Treatment with Hydrocortisone, Vitamin C, and Thiamine resulted in significantly more septic ICU patients off the ventilator and alive on day 7 after randomization compared to hydrocortisone only

B: Treatment with Hydrocortisone, Vitamin C, and Thiamine resulted in significantly less septic ICU patients off the ventilator and alive on day 7 after randomization compared to hydrocortisone only

C: Treatment with Hydrocortisone, Vitamin C, and Thiamine resulted in equal numbers of septic ICU patients off the ventilator and alive on day 7 after randomization compared to hydrocortisone only

The correct answer is C

The Bottom Line  , St. Emlyn’s,  Emergency Medicine Literature of Note  and others covered the VITAMINS trial this week. 

This is the first in a series of papers about Hydrocortisone, Vitamin C, and Thiamine (or HAT). This one shows no sign of benefit. However, it is a relatively small study (n = 216) and it has some weaknesses (eg. underpowered for mortality, thiamine levels not measured). More to come….

https://www.thebottomline.org.uk/summaries/icm/vitamins/

Question 2

Source image: https://litfl.com/

A sixty year old patient with no past medical history presents to your emergency department with nonspecific chest pain. His physical exam is normal. The ADD-RS (aortic dissection detection risk score) shows a low pretest probability for aortic dissection. You decide to perform focused cardiac ultrasound (FoCUS) to feel more secure about sending this patient home later on. 

What is the sensitivity of FoCUS for acute aortic syndromes with a low ADD-RS score?

A: Presence of direct symptoms (an intimal flap, intramural aortic haematoma or a penetrating aortic ulcer) on FoCUS has a sensitivity of 89 percent for acute aortic syndromes in patients with a low ADD-RS score

B: Presence of direct symptoms (an intimal flap, intramural aortic haematoma or a penetrating aortic ulcer) on FoCUS has a sensitivity of 70 percent for acute aortic syndromes in patients with a low ADD-RS score

C: Presence of direct symptoms or indirect symptoms (thoracic aorta dilatation, pericardial effusion and aortic valve regurgitation) has a sensitivity of 89 percent for acute aortic syndromes in patients with a low ADD-RS score

D: Presence of direct symptoms or indirect symptoms (thoracic aorta dilatation, pericardial effusion and aortic valve regurgitation) has a sensitivity of 70 percent for acute aortic syndromes in patients with a low ADD-RS score

The correct answer is C

This weeks Ultrasound G.E.L  podcast is about this paper published in 2019. This was a prespecified subanalysis of the ADvISED multicentre prospective study. It turns out sensitivity of PoCUS in a population with low pretest probability for acute aortic syndromes is quite fair if indirect signs like pericardial effusion and a dilated aortic root are considered to be a positive test. If only direct signs (visualize the intimal flap itself of detect an intramural hematoma) are considered to be positive, the sensitivity drops to about 45 percent.

Question 3

Source image: www.pixabay.com

Your 34 year old patient is in convulsive status epilepticus. 2 Doses of 5 mg Midazolam intravenously were administered without any effect. Your patient turns out to use Isoniazid (INH), Pyrazinamide and Rifampin. Which of the following should be your next step?

 A: Levetiracetam

 B: Fosphenytoin 

 C: Valproate 

 D: Pyridoxine

The correct answer is D

EmDOCs covered INH toxicity this week.

This seizure is most likely caused by INH (isonicotinylhydrazide). This is a hydrazide (like rocketfuel) and causes a functional pyridoxine deficiency. INH also inhibits the enzyme that converts the stimulatory neurotransmitter glutamate to GABA. Dosing of pyridoxine when an unknown amount of INH is ingested is 5 g IV and 70 mg/kg IV in pediatrics, repeated every 5-20 minutes.

Question 4

Source image: www.rebelem.com

You see a 54-year old patient with cirrhosis now complaining about progressive abdominal pain.

Which of the following statements about spontaneous bacterial peritonitis (SBP) is true?

A: If a patient has fever or abdominal pain/tenderness, empiric antibiotics should be given even if ascitic neutrophil count < 250 cells/mm3

B: The most common causative organisms are Pseudomonas aeruginosa and Bacteroides fragilis

C: The classic triad includes fever, abdominal pain and increasing ascites. Presence of all three components is common.

D: Serum blood tests (i.e. WBC, CRP, ESR) are helpful in making this diagnosis

The correct answer is A

RebelEM covered SBP this week.

If a patient has fever or abdominal pain/tenderness, empiric antibiotics should be given even if ascitic neutrophil count < 250 cells/mm3. The most common bacterial causes are E. Coli, S. Pneumoniae and Enterococci. The classic triad includes fever, abdominal pain and increasing ascites, but the presence of all three symptoms is rare. 

https://rebelem.com/spontaneous-bacterial-peritonitis-sbp/

Question 5

www.aliem.com

What percentage of patients over 60 years old have rotator cuff tears after a shoulder dislocation?

 A: 10 percent

 B: 30 percent

 C: 50 percent

 D: 80 percent

The correct answer is D

AliEM covered recurrent shoulder dislocations in their Splinter Series this week. 

35 Percent of patients over 40 years of age have concomitant rotator cuff tears with their shoulder dislocations. This number jumps to over 80 percent when patients with shoulder dislocations are over 60.

 

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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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