Quiz 62, February 14th 2020

Welcome to the 62th FOAMed Quiz. 


Eefje, Joep and Rick

Question 1

Source image: litfl.com

Last week this paper was published in NEJM. 316 patients between 18 and 50 years old with moderate to large (> 32%) one-sided pneumothoraces were randomized to either conservative treatment or treatment with a 12 Fr pleural catheter. What did this paper show?

A: Conservative treatment was inferior compared to insertion of a pleural catheter for re-expansion at 8 weeks

B: Conservative treatment was superior compared to insertion of a pleural catheter for re-expansion at 8 weeks

C: Conservative treatment was non-inferior compared to insertion of a pleural catheter for re-expansion at 8 weeks

The correct answer is C

St. Emlyn’s covered this recently published paper. In our ED, patients with these large pneumothoraces always get a pleural catheter. This paper certainly opens up possibilities to study conservative management of pneumothoraces.

The primary outcome (reexpansion at 8 weeks) was met in 94.4 percent of patients in the conservative management group and 98.5 percent of patients in the non-conservative group. This was non-inferior according to the authors, who set the non-inferiority margin at 9 percentage points. As expected the conservative managed patients spend less time in the hospital (1.6 to 6.1 days), had less adverse events and a lower 1-year recurrence rate.

There are some methodological issues to mention. The non-inferiority margin of 9 percent seems a bit high. Furthermore there was a significant loss to follow up in both groups (23 in the non-consevative group and 37 in the conservative group). 15 percent of patients in the conservative group ended up getting an intervention after all and it seems 316 patients out of 2600 screened patients might suggest selection bias.

JC: Conservative management of pneumothoraces.

Question 2

For what kind of pediatric fracture should the Ogden classification be used?

A: Tillaux fractures

B: Greenstick fractures

C: Tibial Tubercle Fractures

D: Supracondylar fractures

The correct answer is C

AliEM covered tibial tubercle fractures last week.

The Ogen classification schema is similar to the Salter-Harris classification, but is used preferentially in the proximal tibia because of the presence of two ossification centers.

I: Fracture of the secondary ossification center
II: Fracture propagates proximal between primary and secondary ossification center
IV: Fracture crosses the primary ossification center
V: Fracture through the entire proximal primary ossification center
VI: Avulsion fracture of the patellar tendon from the secondary ossification center

Source image: https://musculoskeletalkey.com/

SplintER: Knee pain after the jump

Question 3

Which of the following is not part of the classic triad of Serotonin Syndrome?

A: Agitation, Confusion (Altered mental status)

B: Tachycardia, Fever and Flushing (Autonomic hyperactivity)

C: Lead pipe rigidity, hyporeflexia (Neuromuscular abnormality)

The correct answer is C

em3 covered serotonin syndrome this week.

Yes, the triad consists of Altered mental status, Autonomic hyperactivity and Neuromuscular abnormality. However, the neuromuscular abnormality you will find in serotonin syndrome is hyperreflexia and myoclonus.

Lead-pipe’ rigidity is found in Malignant Neuroleptic Syndrome.

Question 4

A 39-year old male presents with severe epigastric pain, nausea and several episodes of non-bloody, non bilious emesis. He describes the pain as sharp and it radiates to her back. On examination, he is tachycardic and tachypneic with abdominal tenderness. Lipase comes back markedly elevated.

Which of the following statements about acute pancreatitis is true?

A: The most common etiology is alcohol (up to 50%), followed by gallstones (20%), hypertriglyceridemia (5-10%), idiopathic (up to 20%), medications and some more rare causes

B: Diagnosis requires the following: characteristic abdominal pain AND a lipase or amylase >3 times the upper limit of normal AND characteristic findings on ultrasound (US) or computed tomography (CT)

C: Conditions, other than pancreatitis, like bowel obstruction, bowel ischemia, perforation, biliary disease and renal failure can not elevate lipase and amylase >3 times the normal limit

D: A triglyceride level of at least 500 mg/dL (typically >1000 mg/dL or 11.2 mM) suggests hypertriglyceridemia as the underlying etiology

The correct answer is D

Britt Long covered pancreatitis this week on EMdocs.

Pancreatitis is a common diagnosis in the Emergency Department. It is caused by numerous things but mostly by gallstones (up to 40%), alcohol (30%) or hypertriglyceridemia (5-10%).

Diagnosis requires 2 of the following: characteristic abdominal pain, lipase >3x the upper limit of normal, characteristic findings on US or CT. Besides pancreatitis, other conditions like bowel obstruction, bowel ischemia etc can also cause elevated levels of lipase, but normally won’t exceed levels 3 times the upper limit.

Treatment is mostly supportive. In case of hypovolemia, flu. Antibiotics are controversial and only warranted in patients with signs/sources of infection, necrosis, abscess and infected pseudocysts.

EM@3AM: Pancreatitis

Question 5

Your patient presents with fever of unknown origin. POCUS reveals a mitral valve vegetation. Which of the following statements about endocarditis is true?

A: Fever is present in about half of patients with endocarditis

B: Roth spots are an example of extracardiac manifestations of endocarditis and present as tender lesions which can be found on finger pulps and thenar/hypothenar eminences

C: Flank pain in a patient with endocarditis could be due to splenic or renal emboli and therefore abdominal imaging should be considered in these patients

D: Workup should include two proper sets of blood cultures

The correct answer is C.

Endocarditis was covered by Anand Swaminathan this week as part of the REBEL Core Cast.

Endocarditis is an infection of the endocardial surface of the heart, heart valves or both. Fever is present in 90% of patients whereas a new murmur is present in 50-80% of patients. Examples of extracardiac symptoms are: Osler nodes, Janeway lesions, splinter hemorrhages and Roth Spots which are emboli in the eye causing boat-shaped hemorrhages with pale centers.

Emboli can cause all sorts of complications in the lungs, spleen and kidneys. Splenic and renal emboli can cause flank pain.

Workup should include three sets of blood cultures.

REBEL Core Cast 27.0 – Endocarditis

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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