Quiz 63, February 21th, 2020

Welcome to the 51th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Source image: www.emcrit.org

Question 1

Recently, the 65 Trial, was published in JAMA. 2463 critically ill patients with vasodilatory hypotension, aged 65 years and older, were randomized between usual care (MAP targets at the discretion of the treating ICU team, usually a MAP >65 mmHg) and permissive hypotension (MAP of 60-65 mmHg). The primary outcome was mortality at day 90.

What did the authors find?

A: Mortality at day 90 was significantly higher in the permissive hypotension group

B: Mortality at day 90 was not significantly different between both groups

C: Mortality at day 90 was significantly lower in the permissive hypotension group

The correct answer is B

Celia Bradford from The Bottom Line and Josh Farkas from PulmCrit covered this recently published paper this week.

The 65 Trial is a multi-center, unblinded RCT (in of course… 65 ICU’s, in the United Kingdom).

1221 patients were assigned to the intervention group (target op MAP between 60 and 65 mmHg) and 1242 patients were assigned to the control group (MAP targets were at the discretion of the treating ICU team).

The mean MAP was 66.7 mmHg in the intervention group and 72.6 mmHg in the control group.

Targeting a MAP of 60-65 mmHg resulted in the use of lower doses of vasopressors and allowed for faster weaning off these vasopressors (33 hours with permissive hypotension vs 38 hours with conventional therapy).

The primary endpoint, mortality at day 90, was 2.9% lower in the permissive hypotension group (41.0 vs 43.8 percent) but this small benefit was not statistically significant. Secondary endpoints showed no differences in renal function, ICU length of stay, ventilation and 90-day cognitive outcomes.

Keep in mind the mean MAP in the permissive hypotension group was higher than targeted. Furthermore, this was an unblinded trial.

It appears safe to target a MAP of 60-65mmHg in elderly patients with vasodilatory shock.

 

65 Trial

Source image: http://blog.clinicalmonster.com/

Question 2

Your 53-year old patient presents with shock. POCUS reveals this image.

You remember seeing your colleague struggle with pericardiocentesis and you really want to releaf this tamponade under ultrasound guidance. Which of the following approaches is best suited for ultrasound guided tamponade drainage?

A: Subxiphoid approach

B: Parasternal approach

C: Apical approach

The correct answer is B

CountyEM covered pericardiocentesis last week.

Of course there are more variables to take into account when choosing an approach for tamponade drainage than just the best way to visualise the needle. However, if you find a large quantity of effusion on every view, the parasternal approach might be the easiest. The pericardium is located most superficially and the angle of your needle accounts for better visualisation compared to an apical or subxiphoid approach. Keep in mind there is a risk of injury to the left internal mammary artery and pleura of your site of puncture is too lateral.

Question 3

Quite a lot of evidence has recently emerged regarding clinical pretest probability (CPTP) guided d-dimer cutoff in the diagnosis of pulmonary embolism. But how does CPTP guided d-dimer cutoff compare to age-adjusted d-dimer cutoff in the diagnosis of deep venous thrombosis according to this recently published paper 

A: CPTP guided d-dimer cutoff has superior diagnostic utility compared to age-adjusted d-dimer

B: CPTP guided d-dimer cutoff has similar diagnostic utility compared to age-adjusted d-dimer

C: CPTP guided d-dimer cutoff has inferior diagnostic utility compared to age-adjusted d-dimer

The correct answer is B

Clay Smith covered this paper last week.

It seems that both D-dimer interpretation strategies were associated with a high and similar NPV, and similar utility.

Sensitivity was 98.7% for CPTP guided cutoff and 98.0% for age-adjusted cutoff.

 

Source image: www.pixabay.com

Question 4

You commence high dose insulin (HDI) in a patient with combined calcium channel blocker (CCB) and beta blocker (BB) intoxication. Which of the following is true about the mechanism of action of HDI?

A: HDI acts as a strong vasoconstrictor

B: HDI is a specific antidote to CCB

C: HDI acts as a strong inotrope

The correct answer is C

The latest Tox and Hound post on EMcrit is about cardiotoxic overdoses.

It seems HDI has a couple of mechanisms of action. The most important one is inotropy by augmenting calcium mediated contractility in cardiovascular tissue and by increasing the availability of intracellular glucose to maximize ATP production in stressed myocardium. Insuline is a vasodilator, not a vasoconstrictor. There is no specific antidote voor CCBs.

 

 

https://emcrit.org/toxhound/hdi-vs-pressor/ 

Source image: www.pixabay.com

Question 5

You are at 35.000 feet, sitting in your airplane seat on your way to a well deserved holiday when suddenly: ‘’ Is there a medical professional on board?’’ You, as a well trained emergency physician, decide to volunteer.

Which of the following statements about In-Flight Medical Emergencies (IMEs) is true?

A: The most common reason for an IME is cardiac arrest

B: Every airplane should be equipped with an IV start kit, AED, oral airways, oxygen tank and a stethoscope

C: Physicians from the United States, Canada and Europa have a legal obligation to help when medical assistance is needed due to a IME

D: Airlines do not have medical ground support available

The correct answer is B

IMEs happen roughly once in every 604 flights and about 4% of IMEs require diversion to a nearby airport. The most common reason is syncope or pre-syncope (33-37%), followed by all kinds of complaints like GI symptoms, respiratory symptoms, seizures, allergic reactions and obstetric emergencies. Only 0.2-0.3% of IMEs are due to cardiac arrest.

There are minimal requirements for on board medical equipment and medications which includes basic supplies for assessment, airway/breathing, and intravenous access. Additional equipment and medications differ between airliners.

Physicians from the United States, Canada and England have no legal obligation to assist in an IME. But when they do, they are protected from liability by the Good Samaritan provision of the Aviation Medical Assistance Act. However, physicians from Australia and some European countries like ours (the Netherlands), do have a legal obligation to assist in an IME.

Every airline should be able to assist you with medical ground support during a significant IME.

 

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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen

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