Quiz 74, July 3th, 2020

Welcome to the 74th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick


Question 1

Your patient presents with a hemopneumothorax and 4 rib fractures after a motor vehicle collision. Your usual analgesics (including opioids and analgesic dose ketamine) are ineffective and you didn’t even perform the thoracocentesis yet. You consider a serratus anterior plane block.

Which of the following statements is true regarding this block?

A: It affects dermatomes C6-T3

B: Anticoagulation is not a contraindication

C: It is equally effective in providing analgesia to the posterior part and anterior part of the ribs

D: The anesthetic should always be injected just superficial the serratus anterior muscle, never deep to the muscle

The correct answer is B

CountyEM covered the serratus anterior plane block this week. 

This block is fairly easy to perform and can be beneficial in these painful patients with thoracic trauma. Anticoagulation is not a contraindication. The block affects dermatomes T2 to T9. The block may not be effective for posterior chest wall trauma as the block only covers lateral cutaneous branches of the long thoracic nerve. The block can be performed superficial to and deep to the serratus anterior muscle. 

Source image: Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 13211

Question 2

The PESIT trial caused some consternation a couple of years ago, stating one in every 6 patients with syncope in the ED has pulmonary embolism. Fortunately this was proven wrong by numerous studies. However, what does it mean when a patient with pulmonary embolism suffers syncope?

This recent meta-analysis evaluated the prognostic value of syncope on mortality in patients with pulmonary embolism (PE).

What did the authors find?

A: Patients with PE and syncope have an increased risk of short term mortality compared to patients with PE without syncope

B: Patients with PE and syncope have an equal risk of short term mortality compared to patients with PE without syncope

C: Patients with PE and syncope have a decreased risk of short term mortality compared to patients with PE without syncope

The correct answer is A.

Clay Smith covered this meta-analysis on Journal Feed this week.

This meta-analysis of 20 studies showed an increase of short-term mortality in patients with PE and syncope compared to patients with PE without syncope (OR 1.82, 95%CI 1.14 tot 2.90). 

Source image: www.pixabay.com

Question 3

The recently published LOCO2 trial (Liberal Oxygenation vs Conservative Oxygenation) recently compared liberal and conservative oxygen targets in patients with acute respiratory distress syndrome (ARDS) which had been intubated and mechanically ventilated for less than 12 hours.

Patients in the liberal oxygen (LO) group had a target PaO2 of 90-105 mmHg with a SpO2 of >96% while patients in the conservative oxygen (CO) group had a target PaO2 of 55-70 mmHg with a SpO2 of 88 to 92%.

The primary outcome was death from any cause at 28 days. Mortality in the ICU or at day 90 days was the most important secondary outcome.

What did the authors find?

A: Mortality from any cause at 28 days was significantly higher in the conservative oxygen group compared to the liberal oxygen group

B: Mortality from any cause at 28 days was significantly higher in the liberal oxygen group compared to the conservative oxygen group

C: Mortality at day 90 or in the ICU was significantly higher in the liberal oxygen group compared to the conservative oxygen group

D: Mortality at day 90 or in the ICU was significantly higher in the conservative oxygen group compared to the liberal oxygen group

The correct answer is D

The LOCO2 trial was covered by Leen Alblaihed on RebelEM this week.

This prospective multicenter study was conducted in 13 French ICU’s. A total of 205 patients were randomized. 

At day 28, no significant difference in mortality between the conservative oxygen and liberal oxygen group was found (34.3% vs 26.5%; 95% CI -4.8 to 20.6) while mortality in the ICU or at day 90 was significantly higher in the conservative oxygen group compared to the liberal oxygen group (44.4% vs 30.4%). 

The main take home point is that conservative oxygen therapy may worsen mortality in patients with ARDS compared to liberal therapy. According to the Oxygen-ICU, ICU-ROX and LOCO2 trials, both hyperoxia (SpO2 >97%) and hypoxemia (SpO2 <90%) should be avoided. 

The LOCO2 Trial: Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome

    

Source image: www.pixabay.com

Question 4

A 67 year old female presents to your emergency department with complaints of dysuria, right flank pain, fever and increased urinary frequency. She is febrile and shows tachycardia and tachypnoea. On physical examination she has right flank and suprapubic tenderness. Urinalysis shows positive nitrite and white blood cells. The patient is diagnosed with pyelonephritis.

Which of the following options is a correct management for this patient’s illness?

A: The patient can go home with oral antibiotics due to its mild presentation and acceptable vital signs for this diagnosis

B: The patient can go home with oral antibiotics despite fever and tachycardia

C: The patient needs to be admitted for intravenous antibiotics because she shows tachycardia and tachypnea

D: The patient needs to be admitted for intravenous antibiotics because all patients with acute pyelonephritis should be admitted for intravenous fluids and antibiotics

The correct answer is C.

EMDocs covered pyelonephritis this week.

The majority of the mild to moderately ill patients with acute pyelonephritis can be discharged home with oral antibiotics. Important for discharging will be the ability to tolerate oral intake and the absence of tachycardia, hypotension and tachypnea. The patients should have stable comorbidities, a reliable psychosocial situation and the ability to visit for outpatient follow-up. 

What if it’s not just cystitis? Disposition of pyelonephritis…

Source image: Case courtesy of Dr Haytham Bedier, Radiopaedia.org, rID: 56857

Question 5 

‘This radiographic abnormality on a knee x-ray represents an avulsion fracture of the proximal fibula and is associated with cruciate ligament injury (in about 90 percent of cases). It is caused by a direct blow with the tibia in external rotation or sudden hyperextension of the knee with the tibia internally rotated.’

What abnormality is described here?

A: The Segond fracture

B: Stieda fracture

C: The arcuate sign

D: The intercondylar eminence fracture

The correct answer is C

AliEM covered not to miss knee injuries this week. 

The arcuate sign is often a subtle finding on knee x-rays and represents an avulsion fracture of the proximal fibula at the site of insertion of the arcuate ligament complex. It is usually associated with cruciate ligament injury (~90% of cases). The Segond fracture is also strongly associated with ACL injury, but it is an avulsion fracture of the lateral tibial plateau. A Stieda fracture refers to a bony avulsion injury of the medial collateral ligament (MCL) at the medial femoral condyle.

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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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