Welcome to the 61th FOAMed Quiz.
Enjoy!
Eefje, Hüsna, Joep and Rick
Question 1
A 50-year old male presents to your Emergency Department after incidental ingestion of windshield washer fluid he had stored in a Gatorade bottle, although you doubt this is really what happened. 30 Minutes after ingestion he felt dizzy, nauseated and sleepy. Physical examination shows a vomiting patient with normal vital signs as well as ataxia and dysarthria.
Which of the following statements about ingestion of this is true?
A: Windshield washer fluid typically contains hydrocarbons
B: An arterial blood gas will most likely show a normal osmolar gap and a metabolic acidosis
C: This patient should be treated with activated charcoal
D: This patient has an indication for treatment with fomepizole or ethanol
The correct answer is: D
Richard Byrne of EM Daily presented a case of windshield washer ingestion and recently toxic alcohol toxicity was covered on the Internet Book of Critital Care.
Windshield washer fluid often contains ethylene glycol and or methanol. An arterial blood gas will show a metabolic acidosis with an elevated anion gap and osmolar gap indicating the presence of unmeasured osmotically active solute.
Activated charcoal is not effective in treatment of toxic alcohol toxicity.
The enzyme alcohol dehydrogenase is responsible for metabolism of (on themselves not very toxic) alcohols into their toxic metabolites. Fomepizole and ethanol are inhibitors of alcohol dehydrogenase therefore reduce formation of toxic metabolites. Consider hemodialysis early on.
IBCC chapter & cast – Toxic Alcohols
Question 2
A 14-year old boy just arrived by ambulance after playing a rugby match. A sudden course correction was followed by a surge of severe pain in his knee. You see a hugely swollen knee with an obvious deformity on the lateral side.
The triage nurse thinks his patella is dislocated.
Which of the following statements about patella dislocation is true?
A: Most patella dislocations are due to direct contact like knee to knee strike in basketball or a helmet/head to knee in rugby
B: Lateral tenderness is common as the lateral patellofemoral ligament (LPFL) is ruptured in 94% of dislocations
C: Reduction of the dislocation should be done by flexing the hip, applying pressure to the lateral border of the patella in a medial direction while extending the knee
D: The older the patient the higher the rate of re-dislocation
The correct answer is C
Tadgh Moriarty covered acute patella dislocation this week in Don’t Forget the Bubbles.
Patella dislocations are caused by non-contact twisting injuries most of the time (66-82%) and cause medial tenderness of the knee due to rupture of the medial patellafemoral ligament (MPFL) in over 94% of dislocations.
Reduction of the dislocated patella should be done by flexing the hip while applying pressure to the lateral border of the patella in a medial direction while extending the knee. Post reduction management consists of immobilisation with a knee immobilizer and follow up with a orthopedic or trauma surgeon.
The younger the patient, the higher the change of re-dislocation: 60% for those 11-14 years old and 33% for those 15-18 years old.
Question 3
A lot of controversies exist regarding the use of Oseltamivir in influenza (read the BMJ campaign here). It seems Oseltamivir does not have any effect on preventing secondary complications and mortality, but it might shorten symptom duration.
Luckily this paper was recently published in the Lancet. What does this paper show according to the authors?
A: Oseltamivir shortens duration of symptoms in patients with suspected influenza
B: Oseltamivir reduces X-ray confirmed pneumonia in patients with suspected influenza
C: Oseltamivir reduces use of acetaminophen or ibuprofen containing medicine in patients with suspected influenza
The correct answer is A, I think
Justin Morgenstern covered this paper last week in First10EM.
Conclusion of the authors: Oseltamivir shortens duration of symptoms in patients with suspected influenza.
However: there are evident methodological issues with this paper. The authors randomized some 3000 patients with suspected influenza to either ´usual care’ or ´usual care´ plus Oseltamivir, no placebo in the comparison group. This combined with the subjective primary outcome (patient-reported time to recovery, defined as having returned to usual daily activity and fever, headache, and muscle ache rated as minor or no problem in key subgroups) make a very high risk on bias.
Furthermore, it seems Oseltamivir had the same effect regardless of the subject having influenza or not (only half of the population tested influenza PCR positive). This suggests even more the entire reported difference is due to placebo effect.
Tamiflu doesn’t work
Question 4
Your patient presents to the Emergency Department after an unknown substance was sprayed into her eyes.
Which of the following statements is true about caustic eye injuries?
A: Pain is a good indicator of degree of injury
B: Acids erode through the corneal epithelium and penetrate into the anterior chamber more easily than alkali do
C: Acidic injuries may initially look worse than an alkali burn but are often less severe
D: Hydrofluoric acid injury should be treated just like any acidic eye injury
The correct answer is C
Pain is not a good indicator of degree of injury, as alkali substances cause nerve damage. Alkali erode through the corneal epithelium and penetrate into the anterior chamber more easily than acids. Acidic injuries may initially look worse than an alkali burn but are often less severe. Hydrofluoric acid is an exception as it chelates calcium (and magnesium) ions and causes serious and deep injury with possible systemic toxicity. Treatment consists of irrigations and calcium, calcium and calcium (more on this another time).
Question 5
Your 45 year old patient comes in with dyspnoea and difficulty breathing through his permanent tracheostomy tube he had for years. He has increased work of breathing and you wonder if the tube is patent.
Which of the following would be adequate in this situation?
A: Do not remove the inner tube when obstruction is suspected
B: Passing a suction catheter via the tracheostomy is a safe way to assess whether or not the tube is patent
C: Passing a Gum Elastic Bougie (GEB) via the tracheostomy is a safe way to assess whether or not the tube is patent
D: Most laryngectomy stomas will have a tube in situ
The correct answer is B
The RCEM learning podcast covered tracheostomy issues this month.
Passing a suction catheter via the tracheostomy will establish whether or not the tube is patent and also allow therapeutic suction to be performed. Gum elastic bougies or similar introducers should be avoided at this stage because these stiffer devices are more likely to create a false passage if the tracheal tube tip is partially displaced.
Most laryngectomy stomas will NOT have a tube in situ. Try to find out early whether your patient still has a patent orotracheal route or not.
This quiz was written by Eefje Verschuuren, Hüsna Sahin and Joep Hermans
Reviewed and edited by Rick Thissen
