Quiz 60, January 31th, 2020

Welcome to the 60th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: http://www.ultrasoundpodcast.com
 

Ultrasound guided intravenous access is a procedure commonly performed in our ED. Success rates are pretty high, but dislodgement in case of cannulation of a deeper vein is a concern. Does the use of ultralong (6.35 cm) catheters for ultrasound guided peripheral intravenous access have benefit over the use of standard catheter (4.78 cm) in patients with difficult IV access?

A: No, use of ultralong catheters does not have any benefit over use of a standard catheter

B: Yes, use of ultralong catheters leads to a higher success rate on first attempt compared to use of a standard catheter

C: Yes, use of ultralong catheters leads to a decrease in minutes to completion compared to use of a standard catheter

D: Yes, use of ultralong catheters leads to an increase in survival time of the catheter compared to use of a standard catheter

The correct answer is D

This weeks journal club of St. Emlynsblog covered the following paper.

I guess it depends a bit on if you consider 6.35 cm (2.5 inch) ultralong (I wouldn’t). 

This is a randomised controlled trial comparing standard catheters for ultrasound guided intravenous access to ultralong catheters. The ultralong catheters survived on average 44 hours longer than the standard catheters. There was no difference in first attempt success, number of attempts and time to completion.

JC: Long lines for USS guided peripheral IVs. St Emlyn's

Question 2

 

Source image: https://litfl.com/

A 7-year-old child is seen at your emergency department with a temperature of 38.2℃, a little tachypnoe, oxygen saturation around the high 80s and some crackles on auscultation. The X-ray shows bilateral peribronchial shadowing. You piece her age and clinical picture together and consider Mycoplasma pneumonia.

Which of the following statements about acute Mycoplasma pneumoniae infection is true?

A: β-lactams should be the first-line antibiotic prescribed when a clinical diagnosis of M. pneumoniae pneumonia is made

B: Antibiotic therapy is always indicated for extra-pulmonary manifestations

C: 1/3 of children hospitalized with M. pneumoniae infection have a concurrent viral infection

D: M. pneumoniae has an incubation period of 3 days

The correct answer is C

Phoebe Williams covered acute M. pneumoniae infection this week in Don’t Forget the Bubbles.

M. pneumoniae infection can occur in children of all ages, with a median age of hospitalization with community-acquired pneumonia (CAP) due to M. pneumoniae of 7 years.
Codetection of viral pathogens (in 1/3 of children hospitalized with M. pneumoniae infection) is common.

M. pneumoniae is transmitted via infected respiratory droplets during close contact, with a long incubation period of up to 23 days.

Mycoplasma spp. lack a cell wall, so are intrinsically resistant to a number of our most common antibiotic classes (including β-lactams). Azithromycin should be the first-line antibiotic prescribed when a clinical diagnosis of M. pneumoniae pneumonia is made. Antibiotic therapy is generally only indicated for pulmonary disease, as extra-pulmonary manifestations tend to be immune-mediated.

The mire of mycoplasma

Question 3

Source image: pixabay.com

 

Which of the following therapies is not indicated in a hemodynamically unstable patient with calcium channel blocker (CCB) toxicity?

A: High‐dose insulin euglycaemic therapy (HIET)

B: Calcium intravenously

C: Catecholamine adrenergic receptor agonists

D: hemodialysis or hemofiltration

The correct answer is D

Scott Weingard recorded a podcast about a very interesting case of beta blocker (BB) and calcium channel blocker (CCB) poisoning.

Treatment of BB and CCB poisoning is more or less the same. Both can be lethal and both should be managed very carefully, even if the patient does not look ill to start with. Treatment generally consists of:

•Calcium
•HIET
•Inotropy and if needed vasoactive medication
•Methylene Blue (to be considered)
•Lipid emulsion therapy (to be considered)
•Glucagon (to be considered)

Because of their affinity to plasma proteins, high hepatic first pass, and a large volume of distribution, hemodialysis or hemofiltration are not effective.

EMCrit 264 – Case Discussion of Combined CCB and BB Overdose

Question 4

Your 65 year old patient presents to the ED with diarrhea since 4 days with some bloody stools. You wonder whether antibiotics might benefit recovery of your patient. Diarrhea caused by which of the following causative organisms does not respond to antibiotics?

A: Shiga Toxin producing E. Coli

B: Shigella

C: Campylobacter

The correct answer is A

EMdocs covered infectious diarrhea this week.

Shigella and Campylobacter may benefit from antimicrobials, whereas Shiga Toxin producing E. Coli (STEC) and most likely salmonella do not. When concern for Shiga Toxin producing organisms, distinguishing between Shiga toxin 1 and Shiga toxin 2 (which is more potent) is useful. Considering HUS in these cases is important

Infectious Diarrhea

Question 5

A 12-year old child, with a history of moderate Hemophilia, is seen at your emergency department with hemarthrosis of his/her right knee after falling down from a skateboard.

The three most common bleeding disorders in children are Hemophilia A, Hemophilia B and Von Willebrands.

Which of the following statements is true about this child and Hemophilia?

A: This child is most likely female

B: Patiënts with Hemophilia A have a deficiency of coagulation factor IV while patients with Hemophilia B have a deficiency of coagulation factor VIII

C: This child’s site of bleeding is the most common site of bleeding in Hemophilia patients

D: Patients with Hemophilia A need higher doses of replacement coagulation factors compared to patients with Hemophilia B

The correct answer is C

Brad Sobolewski from PEMblog covered the most common bleeding disorders in children this week.

This child is most likely male since Hemophilia is a X-linked recessive disease. Patients with Hemophilia A have a deficiency of coagulation factor VIII while patients with Hemophilia B have a deficiency of coagulation factor IV.

Hemophilia can be mild, moderate or severe. The most common type of bleeding is hemarthrosis of a joint like the knee but it can cause all kinds of bleeding complications ranging from minor bruises to heavy menorrhagia, muscle bleeds and even intracranial bleeds.

The first line of treatment in the ED is replacement of coagulation factors. Patients with Hemophilia B need higher doses than patients with Hemophilia A and depending on the kind of injury site and bleed type, further treatment and admission to the hospital could be necessary.

Factor First! Hemophilia management in the Emergency Department

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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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