Quiz 76, June 17th, 2020

Welcome to the 76th FOAMed Quiz. 


Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Your 27 year old patient comes in with status epilepticus. She had a first seizure one month ago without a clear cause and she is currently not on anti epileptic medications. Now she is seizing for 5 minutes already.

Which of the following statements is true about the management of status epilepticus?

A: Ketamine might play a role once conventional therapies are not effective

B: Evidence shows levetiracetam is more effective as a second line drug compared to valproic acid and phenytoin

C: The first dose of benzodiazepines should not be administered in the first 5 minutes of the seizure

D: The time frame in which neurolytic intubation should be performed in status epilepticus is one hour

The correct answer is A

EMottawa covered the management of status epilepticus this week. 

Ketamine might well be beneficial in status epilepticus as a fourth line treatment as the first to 3th line treatments focus on GABA receptors, while ketamine is a strong NMDA antagonist. Evidence so far is limited (case reports). 

There still is no answer to which drug is most effective as second line treatment. Choose wisely depending on potential effects and ease of administration. 

The first dose of benzodiazepines should be given within 5 minutes, as longer lasting seizures are more difficult to treat. 

The timeframe in which neurolytic intubations should be performed is definitely not 1 hour, but 20 minutes. However, especially when administration of the second line drug is delayed, 20 minutes go by quickly. 

The Status on Status: Management of Status Epilepticus

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 6079

Question 2

You see a 29 months old girl with a history of spina bifida. She has a ventriculoperitoneal (VP) shunt which was implanted in the first month of her life. She is now more lethargic than usual and vomited twice during triage. Her shunt was revised when she was just 18 months old. You think that her symptoms could be explained by a raised intracranial pressure due to a problem with her VP shunt.

Which of the following statements about VP shunt failure is true?

A: Distal occlusion of the VP shunt is more common than proximal occlusion of the VP shunt

B: VP shunt infections are most common during the first 6 months after implantation

C: Symptoms occur rapidly in case of a VP shunt fracture or VP shunt disconnection

D: Over-drainage by the VP shunt is not possible

The correct answer is B

VP shunts were covered by Angharad Griffiths from Don’t Forget the Bubbles this week.

A VP shunt is a medical device used to drain fluid via a pressure gradient, away from the brain for conditions of excessive cerebrospinal fluid (CSF). They drain according to the difference in pressure gradient between the ventricle and the tip of the distal catheter which is tunneled down into the abdomen inside the peritoneal cavity.

The most common cause of shunt malfunction is proximal occlusion and infections are mostly seen during the first 6 months after implantation.
Since CSF can still drain when the VP shunt fractures or disconnects, symptoms take time to evolve. 

Over-drainage leading to the ‘’slit ventricle syndrome’’ is rare but can occur.

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

Question 3

Your 38 year old patient has a progressive asymmetrical face since this morning. He is unable to move the right side of his mouth and he can’t shut his right eye. Further physical examination reveals no additional focal deficits.

You suspect Bell’s palsy.

Which of the following is not routinely part of treatment of Bells palsy?

A: Artificial tears

B: Steroids

C: Antivirals

The correct answer is C

CountyEM covered Bell’s palsy last week.

Difficulty fully closing the eyelids puts patients at risk for corneal abrasions, foreign bodies, and other ocular trauma. The eye should be protected and artificial tears should be started.

The evidence on steroids (prednisolone 60 to 80 mg daily) is quite clear as they have been shown to increase the chance of full recovery, particularly if started within 3 days of onset of symptoms.

The evidence on antivirals is far less convincing as you can read on the blog.


Question 4

In which of the following mood stabilizers is activated charcoal NOT effective in case of toxicity?

A: Valproic acid

B: Lithium

C: Carbamazepine

D: Haloperidol

The correct answer is B

NuEM posted a really useful summary about Lithium and Valproic acid last week

4 drugs quite commonly encountered in intentional overdose are Valproic acid, Lithium, Carbamazepine and Haloperidol.

Activated charcoal does not bind Lithium, so it is not useful in Lithium overdose. It should be considered in cases of Valproic acid, Carbamazepine and Haloperidol overdose. 


Question 5

Thromboelastography (TEG) (or the quite similar ROTEM) is commonly used to guide treatment in acute traumatic bleeding.

Not a lot of evidence exists about its efficacy in non-traumatic bleeding.

This paper published in January 2020 is about the use of TEG versus standard of care (SOC) in the treatment of cirrhotic patients with non-traumatic, non-variceal upper GI bleeding.

What did the authors find?

A: Compared to the SOC group, the patient in the TEG group required half the total volume of Fresh Frozen Plasma (FFP) transfused

B: Compared to the SOC group, the patient in the TEG group were more likely to require no transfusions

C: Compared to the SOC group, less serious transfusion reactions occurred in the TEG group

D: All of the above

The correct answer is D

EMdocs covered this single-center, randomized controlled trial last week.

96 Patients were enrolled in the study.

In the TEG-group the subjects received TEG-guided FFP (long r-time), platelets (small amplitude) and cryoprecipitate (small alpha angle). In the control group the patients received FFP when the INR was greater than 1.8 and/or received platelets when the platelet count was below 50× 109/L.

Compared to the SOC group, the TEG group required half the total volume of FFP transfused, were less likely to require transfusion of all three blood components (27% vs. 87%), and were more likely to require no transfusions (14% vs. 0%; P<0.02 for all comparisons). Serious transfusion reactions occurred significantly less often in the TEG group (31% vs. 75%).

Interestingly, this paper does not mention packet red blood cell use. Keep in mind this study excluded patients who were on antiplatelet and anticoagulation therapy, which are common in bleeding patients in the emergency department.

Thromboelastography for Hypocoagulable Patients with Non-Traumatic Bleeding

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

Reviewed and edited by Rick Thissen