Quiz 70, June 5th, 2020

Welcome to the 70th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

    Source image: www.radiopaedia.org. Case courtesy of Dr. Henry Knipe

Question 1

A healthy 45 year old patient presents to your ED with a displaced humeral shaft fracture after a fall on the football pitch. According to this recently published Randomised Controlled Trial, does surgery lead to better functional outcome (Disabilities of Arm, Shoulder and Hand (DASH) score) compared to functional bracing ?

A: The functional outcome (DASH) at 12 months after injury was statistically better in the surgical intervention group

B: The functional outcome (DASH) at 12 months after injury was statistically better in the functional bracing

C: There was no statistically significant difference between the two groups

The correct answer is C

Anand Swaminathan covered the FISH RCT on RebelEM last week.

This rather small RCT (n = 82) revealed no significant difference in DASH scores at 12 months (12.0 for bracing vs 8.9 for surgery). This is in line with the 2017 Masunga trial.

However, non-union occurred in 11 out of 44 patients in the functional bracing group leading to significant cross-over.

The FISH RCT: Surgical vs Non-Surgical Management of Displaced Humeral Shaft Fractures

Question 2

The use of tranexamic acid (TXA) in the emergency department has been increasing in the last decade after CRASH-2 showed a reduction in all cause mortality in severely injured patients. CRASH-2 also reported no difference in vascular occlusive events (2 percent in the TXA group). However, TXA is still considered to be quite thrombogenic.

This recently published paper looked at 273 patients in a level 1 trauma centre receiving TXA. What did the authors find?

A: The rate of thromboembolic events was lower (1 percent) compared to the rate in the CRASH-2 cohort (2 percent)

B: The rate of thromboembolic events was equal to the rate in the CRASH-2 cohort (2 percent)

C: The rate of thromboembolic events was higher (6 percent) compared to the rate in the CRASH-2 cohort (2 percent)

The correct answer is C

Clay Smith covered this paper on Journal Feed.

This paper found a higher rate of thromboembolic events compared to the CRASH-2 cohort (6,6 percent compared to 2 percent). The mortality was about equal to the CRASH-2 cohort. Some differences to the CRASH-2 cohort were noted. Patients in this study received blood transfusions and surgery more often, were older, and there was a higher percentage of female patients than the CRASH-2 cohort. Interestingly only 61% received both boluses of TXA.

 

Source image: www.pixabay.com

Question 3

Low dose non contrast CT are increasingly performed in case of suspected renal colic. However, the effect these CT’s on patient oriented outcomes are uncertain (Ultrasonography Versus Computed Tomography for Suspected Nephrolithiasis).

According to this paper combining a systematic review and multidisciplinary consensus, which of the following patients should receive a CT?

A: A 35-y-old man with no history of kidney stones presents with an acute onset of flank pain during the last 3 h. He reports nausea with vomiting and has hematuria on urine dip. He has no abdominal tenderness. His pain is relieved after intravenous analgesics.

B: A 35-y-old man with 2 previous kidney stones that passed spontaneously presents with an acute onset of flank pain during the last 3 h. He reports nausea with vomiting and has hematuria on urine dip. He has no abdominal tenderness. His pain is relieved after intravenous analgesics. Ultrasonography is performed; there is hydronephrosis on the side with the pain, and a stone is not visualized.

C: A 75-y-old man with no history of kidney stones presents with an acute onset of flank pain during the last 3 h. He reports nausea with vomiting and has hematuria on urine dip. He has no abdominal tenderness. His pain is relieved after intravenous analgesics.

D: A 35-y-old woman who is 10 weeks pregnant with no history of kidney stones presents with an acute onset of right flank pain during the last 3 h. She reports nausea with vomiting and has hematuria on urine dip. She has no abdominal tenderness. Her pain is relieved after intravenous analgesics.

The correct answer is C

This week Justin Morgenstern discussed this paper on Imaging in Renal Colic on First10EM

According to this systematic review an alternative diagnosis is found on CT in 0-33 percent of cases and a clinically important diagnosis is found on CT in less than 5% of patients. The sensitivity of a formal ultrasound is reported to be between 3 and 98 percent, so that does not help us a lot. For POCUS, the authors report a pooled sensitivity of 70% and specificity of 75%.

In general it seems ultrasound will do in younger patients if pain is not relieved by analgesics. Older patients may benefit from CT because alternative diagnoses are more likely to show up and radiation is less of a concern.

A panel of 9 clinicians (emergency physicians, urologists, and radiologists) was used to determine the recommended imaging strategy. There was perfect consensus about the 75 years old patient requiring CT (patients A, B and D do not).

Imaging for renal colic

Source image: www.emcrit.org

Question 4

Your 62-year old female presents with severe chest pain, elevated troponin and dyspnea. Your views on bedside ultrasound are far from perfect, but you suspect some apical ballooning. Furthermore, 2 weeks ago your patient lost a relative. Both acute myocardial infarction (AMI) and Takotsubo cardiomyopathy (TC) are on your differential diagnosis.

Which of the following statements about findings that could help you differentiate between AMI and TC is true?

A: Presence of anterior ST-elevation makes TC unlikely

B: Hyperacute T-waves exclude TC

C: An elevated troponin makes TC unlikely

D: An elevated BNP is seen in 80 percent of TC patients

The correct answer is D

Josh Farkas from Emcit covered Takotsubo cardiomyopathy this week as part of the IBCC series. 

Takotsubo cardiomyopathy is present in 1-2% of patients who present with chest pain and troponin elevation. 

Although EKG cannot reliably differentiate Takotsubo cardiomyopathy from occlusive MI, there are some characteristic EKG features which are worth being aware of. ST elevation is usually most notable in V3-V6 in TC, but it has lower magnitude than is typically seen with an anterior occlusive MI. Hyperacute T-waves may be seen in Takotsubo cardiomyopathy. Troponin is elevated in 90% and BNP is elevated in 80% of cases of Takotsubo cardiomyopathy (however very non-specific).

 

 

Source image: www.aliem.com

Question 5

The lab calls you to alert you on a sodium of 112 mmol/L. 3 minutes later your patient is seizing. You order 100 cc of 3% sodium chloride, but your nurse tells you this can take a while. You do have 8,4 percent sodium bicarbonate in the crashcart.

Can you use sodium bicarbonate 8,4% instead of sodium chloride 3% to treat symptomatic hyponatremia?

A: Yes, 50 ml of sodiumbicarbonate 8.4% equals 100 ml of sodium chloride 3%

B: Yes, 500 ml of sodiumbicarbonate 8.4 % equals 100 ml of sodium chloride 3%

C: Yes, 5 ml of sodiumbicarbonate 8.4 % equals 10 ml of sodium chloride 3%

C: No, this is not a safe thing to do

The correct answer is A

Dr. Jonathan Hootman explains how to use sodium bicarbonate in symptomatic hyponatremia on Aliem this week.

We usually treat symptomatic hyponatremia with boluses of 100 to 150 ml sodium chloride 3%. However, sodium bicarbonate is a reasonable alternative. One ampule of sodium bicarbonate 8.4 % contains about the same amount of sodium as 100 ml sodium chloride 3% (50 mEq vs 51.3 mEq).

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

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