Quiz 72, June 19th, 2020

Welcome to the 72th FOAMed Quiz. 


Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

A 50 year old male presents to your emergency department with the complaint of dizziness and nausea. You want to distinguish a peripheral from a central cause.

Which of the following findings make a central cause more likely?

A: A negative test of skew

B: Positive head impulse test (eyes make corrective saccade to fix on target)

C: A predominantly vertical nystagmus

D: A unidirectional nystagmus

The correct answer is C

This week’s post on EMdocs by Ava Pierce is about posterior circulation strokes and how to approach the patient with vertigo.

Almost half of the patients with a posterior circulation stroke present with dizziness. The HINTS (consisting of: 1. head impulse test, 2. nystagmus 3. test of skew) examination is helpful to distinguish central from peripheral causes. A positive head impulse test suggests peripheral pathology. Although most strokes present with a horizontal nystagmus, this is also often seen in peripheral vestibular disease. Vertical and bidirectional nystagmus suggest a central cause of vertigo.

Source image: www.radiopaedia.org

Question 2

This multicenter retrospective observational cohort study is about the safety and efficacy of prothrombin complex concentrates (PCCs) in adult patients with spontaneous or traumatic intracranial hemorrhage (ICH) using apixaban or rivaroxaban.

The primary outcome was the percentage of patients with excellent or good hemostasis defined as 0-20% and 20-35.0% increase of hematoma size respectively on follow-up CT of MRI within the first 24 hours. The primary safety outcome was the occurrence of thrombotic events (DVT, PE).

What did the authors find?

A: Excellent or good hemostasis was found in about 40% of patients

B: Excellent or good hemostasis was found in about 80% of patients

C: Thrombotic events were seen in 20% of patients

D: Thrombotic events were seen in only 1% of patients

The correct answer is B

Salim Rezaie from REBEL EM covered factor Xa inhibitor related ICH and PCCs this week.

Excellent or good hemostasis was found in 81.8% (95% CI 77.9 – 85.2) of patients whereas thrombotic events were only seen in 3.8% of patients.

Although this study is the largest multicenter, observational study to date to evaluate hemostatic efficacy and safety of PCC’s in patients on apixaban or rivaroxaban with ICH, it still has quite some limitations. Of course, the absence of a comparison group make any useful conclusion about the efficacy of PCC’s in these cases impossible.

In the future, randomised controlled trials are needed in order to evaluate the clinical efficacy of PCCs in patients on Xa inhibitors with ICH.

Factor Xa Inhibitor Related ICH & PCCs

Source image: www.emottowablog.com

 Question 3

Your otherwise healthy 19 year old patient presents with an AV-nodal Reentrant Tachycardia. The modified Valsalva manoeuvre is not effective. In your hospital the usual path is to try Adenosine first, but as you read up on your literature, you choose Diltiazem.

Which of the following is an advantage of diltiazem over adenosine?

A: Diltiazem has a shorter duration of action compared to adenosine

B: Diltiazem does not make patients feel like they are dying, like adenosine does

C: Diltiazem is not as likely to cause hypotension compared to adenosine

D: Diltiazem can be safely administered in patients in cardiogenic shock, while adenosine is not safe in these cases

The correct answer is B

EMOttawa covered a couple of treatment controversies on their blog this week. The first part is about adenosine vs diltiazem in terminating supraventricular tachycardia.

Diltiazem has a range of benefits over adenosine. The most important one is probably not causing the patient to feel like he or she is dying (like adenosine frequently does). It is a safe drug and at least equally effective for this indication compared to adenosine.

However, diltiazem is not harmless as it can cause hypotension. In cardiogenic shock, please use electrical cardioversion. 

Diltiazem for intravenous use is not globally available. Verapamil is a proper alternernative.

Source image: www.pixabay.com

Question 4

Headache is one of the most common complaints of patients in the Emergency Department (ED). This, randomized double blind, placebo controlled trial compared the administration of 2.5 mg IV haloperidol with placebo (0.9% NaCl) in patients with benign headaches. Their primary outcome was pain reduction at 60 minutes.

What did they authors find?

A: >50% pain reduction at 60 minutes was significantly more often seen in the haloperidol group compared to the control group

B: No differences were found in >50% pain reduction at 60 minutes after administration of haloperidol or placebo

C: >50% pain reduction at 60 minutes was significantly more often seen in the placebo group compared to the haloperidol group

The correct answer is A

Meghan Breed from Journal Feed covered this RCT this week.

58 patientes, aged 18-55 years, received haloperidol while 60 patients received placebo. Pain reduction of >50% at 60 minutes was seen in 63.8% of patients treated with haloperidol. Patients in the haloperidol group thereby reported an average reduction in visual analogue scale score (VAS) of 4.77 units compared to 1.87 units in the placebo group, 60 minutes after administration of either haloperidol or placebo.

This study suggests that the administration of haloperidol 2.5 mg IV could be useful in the treatment of benign headaches. Further research with larger studies are needed to confirm these results.

Question 5

Your 26 year old patient presents with some mild weakness of the lower limbs since 1 day. She also complaints about diplopia and an ‘unsteady walk’ starting about a week ago and getting worse. She does not feel ill and does not appear to be confused. Physical examination reveals symmetric areflexia without any sensory deficits. Her Cerebrospinal Fluid (CSF) shows elevated CSF protein and normal CSF White Blood Cell count.

Which of the following Guillain Barré Syndrome (GBS) types is most likely?

A: Miller Fisher Syndrome (MSF)

B: Acute inflammatory demyelinating polyneuropathy (AIDP)

C: Acute motor-sensory axonal neuropathy (AMSAN)

D: Bickerstaff encephalitis

The correct answer is A

BrownEM covered the variants of GBS this week. 

AMSAN would cause sensory deficits so is not very likely. AIDP is the most common form in the United States and Europe, representing approximately 85 to 90 percent of cases. However ophtalmoplegia and ataxia point us in the direction of either Miller Fisher Syndrome (MSF) or Brickerstaff encephalitis. Since this patient has no signs of encephalopathy, Brickerstaff encephalitis is unlikely, which leaves MSF as the most likely GBS type in this case. 

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

Reviewed and edited by Rick Thissen