Quiz 66, May 8th, 2020

Welcome to the 66th FOAMed Quiz. 

Slowly the Corona-crisis seems te be under control in our region (for now). Time for some good old FOAMed trivia. Did you read up on the latest?

Enjoy!

Eefje, Joep and Rick

Question 1

The next trial in the Vitamin C story has arrived. This trial (the HYVCTTSSS trial) is a single-center RCT evaluating the combination of hydrocortisone, vitamin C, and thiamine versus placebo for patients with sepsis or septic shock. What did the authors find?

A: There was statistically significant lower mortality in the intervention (hydrocortisone, vitamin C, and thiamine) group compared to the control group

B: There was statistically significant lower mortality in the control group compared to the intervention (hydrocortisone, vitamin C, and thiamine) group

C: The trial was stopped early because of safety (adverse events in the intervention group)

D: The trial was stopped early because of benefit (the study hypothesis is unexpectedly proven early)

The correct answer is C

Josh Farkas covered this trial on PulmCrit and Clay Smith devoted a journal feed post to this trial. 

Severe hypernatremia (>160meq/L) was more common in the treatment group, 13 vs. 3 in the control (p=0.005), leading to early termination of the study.  Whether this is justified remains debatable, as Josh Farkas explains in his post. The result is this trial was profoundly underpowered and it provides no meaningful information about the intervention (hydrocortisone, ascorbate, and thiamine.)

Question 2

Your patient presents after following a high speed motor vehicle collision. You suspect a posterior sternoclavicular dislocation. Which of the following X-ray views is the most likely to help you?

A: Clavicle series

B: Velpeau view

C: Modified Axillary view

D: ‘’Serendipity’’ view

The correct answer is D

AliEM posted on a radiologic approach to the traumatic shoulder this week.

A ‘’Serendipity view’’ can be obtained when there is suspicion for sternoclavicular dislocations. It is obtained at an angle where the displacement of the clavicle is better appreciated

A Velpeau view is useful if the patient has too much pain to obtain a true axillary view or if the patient re-dislocates the shoulder upon taking post-reduction films.

Serendipity View

Source image: radiopaedia.org

Velpeau View

Source image: www.orthobullets.com

Question 3

Source image: www.litfl.com

Your 45 year old patient presents with a wide complex tachycardia (WCT) of about 190/minute. The patient is hemodynamically stable. You are not sure if this is ventricular tachycardia or supraventricular tachycardia with aberrancy or pre-existing bundle branch block. Which of the following findings makes a ventricular tachycardia more likely?

A: Normal QRS-axis

B: Resemblance to any known form of conduction block

C: Relative “delay” in the initial QRS deflection

D: Dominant terminal R wave in aVR

The correct answer is C

Ken Grauer covered VT vs SVT on dr. Smith’s ECG blog this week.

A normal QRS does not make VT more likely, an extreme axis does. Resemblance to any known conduction block makes pre-existent bundle branch block more likely. A dominant initial R in aVR makes VT more likely (Vereckei Algorithm). A relative slow initial deflection makes a VT more likely.

When in doubt, just assume it as VT.

Source image: http://hqmeded-ecg.blogspot.com/ Click image for link to original post

Question 4

Source: radiopaedia.org

A 78 year old patient with diabetes, COPD and stage 2 chronic kidney disease presents to your ED with significant abdominal distension, as well as abdominal pain, nausea, and vomiting. There is no fever and she does not feel unwell. The patient is stable and does not have peritoneal signs on exam. Contrast abdominal CT shows colonic dilation involving the right and transverse colon with no evidence of mechanical obstructive cause. There are no signs of (impending) perforation. What would be your diagnosis?

A: Ischaemic colitis

B: Wilkie’s syndrome

C: Sigmoid volvulus

D: Ogilvie’s syndrome

The correct answer is D

Justin Morgenstern covered Ogilvie’s syndrome this week. 

Ogilvie’s syndrome or acute colonic pseudo-obstruction is a cause of abdominal pain typically seen in elderly patients with multiple chronic illnesses. The underlying pathophysiology is uncertain. Management is conservative unless there are signs of (impending) hollow viscus perforation.

Ischemic colitis and sigmoid volvulus would show on the CT. Wilkie’s syndrome is a rare cause of duodenal obstruction, caused by a low aortomesenteric angle resulting in vascular compression of the duodenum. 

Acute colonic pseudo-obstruction (Ogilvie’s syndrome)

Question 5

Source image: @matslumholdt on pixabay.com

Slightly longer IV-cannulas are increasingly used when ultrasound guidance is necessary for peripheral vascular access. This recently published paper is about standard 4.78-cm, 20-gauge ultrasonographically guided intravenous peripheral catheters versus 6.35-cm, 20-gauge ultrasonographically guided intravenous peripheral catheters in patients in the emergency department with self stated  difficult vascular access. The primary endpoint was duration of catheter survival. What did the authors find?

A: Catheter survival was increased with use of 6,35 cm catheters

B: Catheter survival was increased with use of 4,78 cm catheters

C: There was no difference in catheter survival between 6,35 and 4,78 cm catheters

The correct answer is A

The RCEM learning podcast of May 2020 covered this paper.

It seems, as expected, catheter survival is increased when longer catheters are used.  Especially when cannulating deeper veins a longer than standard catheter should be used. A minimum of 2,5 to 3 cm of the cannula should be located in the vein. Even with the 6,35 cm catheters (which are still not very long) the chance of dislodgement after placement is high if deeper veins are cannulated. Midlines are likely to be more useful in this case.

https://www.rcemlearning.co.uk/foamed/may-2020/#1588607334956-2c93064d-8474

rcemlearning.co.uk
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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen

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