Quiz 79, August 7th, 2020

Welcome to the 79th FOAMed Quiz. 


Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

The recently published GRECCO-19 trial is about the use of colchicine in hospitalized adult patients with SARS-CoV-2 infection, confirmed by PCR.

Patients in the intervention group received a loading dose of colchicine followed by a maintenance dose of 0.5 mg twice daily until hospital discharge or a maximum of 21 days. Patients in the control group received standard care.

The objective was to evaluate the effect of treatment with colchicine on cardiac and inflammatory biomarkers and clinical outcomes in patients hospitalized with coronavirus disease 2019 (COVID-19).

What did the authors find?

A: hsTnT and CRP levels were significantly lower and clinical deterioration occurred significantly less often in the intervention group compared to the control group

B: hsTnT and CRP levels were significantly higher and clinical deterioration occurred significantly more often in the intervention group compared to the control group

C: hsTnT and CRP levels were not statistically different while clinical deterioration occurred significantly less often in the intervention group compared to the control group

D: no differences were found between both groups for all the primary outcomes

The correct answer is C

The GRECCO-19 trial was covered by David Slessor from The Bottom Line this week. 

A total of 105 patients were included in this multicentre trial. 

This small study (n=105) demonstrates that colchicine may be effective in reducing the number of admitted patients with COVID-19 that deteriorate to the level of needing ICU admission. 

Although these results sound promising, we have to be aware of several limitations such as small number of subjects, even smaller absolute benefit numbers and wide confidence intervals. 


Question 2

Your 63-year old septic patient needs endotracheal intubation. Worried about hemodynamical deterioration you choose ketamine as the induction agent instead of etomidate.

According to this recently published paper, which intubation agent leads more often to post procedure hypotension?

A: Ketamine

B: Etomidate

C: There was no difference in post procedure hypotension

The correct answer is A

This recently published paper was discussed at JournalFeed this week.

It is a an observational cohort study of the prospective (US) National Emergency Airway Registry (NEAR) data set. 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Interestingly, postprocedure hypotension was higher is those intubated with ketamine compared to etomidate (74% vs. 50%).

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Question 3

Exclusion of Serious Bacterial Infections (SBI) in infants remains one of the biggest diagnostic challenges in the ED. Multiple risk stratification tools have been developed along the years, but none of them seem to be very accurate.

Quite recently the Pecarn Rule for Low Risk Febrile Infants (or Kuppermann criteria) was developed in order to exclude SBI. According to this rule, SBI can be excluded in infants between 29 and 60 days if:

– Urinalysis is negative

– Absolute Neutrophil Count <4,090/μL 

– Procalcitonin <1.71 ng/mL

What is the sensitivity of these criteria for SBI?

A: 76 %

B: 82 %

C: 91 %

D: 98 %

The correct answer is D

Justin Morgenstern covered this paper on First10EM.

The group included 1,821 febrile infants less than 60 days of age. The mean age was 36 days old and 42% were female. 9.3% were SBI positive with 7.7% from urinary tract infection alone.

The sensitivity was 97.7% and negative likelihood ratio of 0.04.

Keep in mind this risk score is not yet externally validated. While derived in infants aged 0-60 days, the authors recommend using this calculator only in infants aged 29-60 days.

To LP, or not to LP (the febrile infant): That is the question

Source image: www.emdocs.net

Question 4

 A healthy 5 year old boy presents to your ED after a fall on his right arm. The elbow is painful and slightly swollen. An X-ray is made to rule out a fracture.

For the assessment of the x-ray of the elbow you use the mnemonic CRITOE.

Which statement is true about CRITOE?

A: The C stands for capitellum and the R for the radial head and they appear simultaneously at the age of 3

B: The I stands for the internal epicondyle which starts to be visible at the age of 7

C: The T stands for the trochlea and is visible at the age of 7

 D: The O stands for the olecranon and the E for the external epicondyle and both appear at the age of 9

The correct answer is C.

This week EMDocs covered pediatric elbow injuries.

CRITOE stands for capitellum, radial head, internal epicondyle, trochlea, olecranon and external epicondyle. 

The first ossification is the Capitellum at the age of one. By the age of three the Radial head appears as a small balloon. The Internal epicondyle starts to ossify by the age of five and the Trochlea will be visible at the age of seven. By the age of nine the Olecranon of the ulna will appear. And finally at the age of eleven the external Epicondyle will appear.

Source image: www.pixabay.com

Question 5

Step one in the treatment of Hyperosmolar Hyperglymic State (HHS) will be volume resuscitation and insulin administration.

What changes in serum laboratory values can be seen after initial treatment?

A: Serum sodium, serum glucose and serum osmolality all decrease

B: Serum sodium decreases, serum glucose increases and serum osmolality decreases

C: Serum sodium increases, serum glucose decreases and serum osmolality increases

D: Serum sodium increases, serum glucose decreases and serum osmolality decreases

The correct answer is D.

Josh Farkas covered Hyperosmolar Hyperglycemic State in this week’s podcast on PULMCrit.

Due to the resuscitation with isotonic fluids serum sodium will increase. The tonicity will decrease despite the rising sodium. Serum glucose will fall due to the administration of insulin and fluids. Serum osmolality will decrease because it is affected by chloride and glucose.

IBCC chapter & cast – Hyperosmolar Hyperglycemic State

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

Reviewed and edited by Rick Thissen