Quiz 82, August 28th, 2020

Welcome to the 82th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Critically ill patients admitted to the intensive care unit (ICU) with acute kidney injury have a higher morbidity and mortality.

The authors of the STARRT-AKI study compared accelerated initiation of Renal Replacement Therapy (RRT) and standard strategy of RRT initiation to investigate if this would result in lower risk of death from any cause at 90 days.

What did the authors find?

A: In the accelerated strategy group a smaller percentage of the patients were dependent on RRT at 90 days

B: There is no significant difference in mortality between early RRT initiation and standard initiation

C: In the accelerated strategy group more serious adverse events were seen compared to the standard RRT initiation. 

The correct answer is B

This week Mark Ramzey covered the STARRT AKI trail on RebelEM.

A larger percentage of the patients in the accelerated strategy group were dependent on RRT at 90 days. The authors suggest longer exposure to RRT can compromise kidney recovery.

There was no difference in serious adverse events between the two strategies.

This is not the first study that shows no significant difference in mortality between early RRT and standard or delayed RRT.

STARRT-AKI Trial: Timing of Renal Replacement Therapy Initiation in Acute Kidney Injury

Source image: www.pixabay.com

Question 2

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (or PFAPA) is a pretty rare syndrome, yet it is still the most common periodic fever syndrome in children.

Which of the following statements is true about the management and prognosis of PFAPA?

A: A single dose of corticosteroids will rapidly resolve the PFAPA symptoms in about 90% of patients

B: Colchicine is the most effective treatment for active PFAPA

C: The prognosis is poor. This syndrome leads to long term sequelae very often

D: Episodes of PFAPA generally seize spontaneously 3-5 years after symptoms onset

The correct answer is A

First10EM covered PFAPA this week.

It is a disease of unknown etiology that is characterized by clock-work regular episodes of fever, aphthous stomatitis, pharyngitis, and cervical adenitis.

A single dose of corticosteroids will rapidly resolve the PFAPA symptoms in about 90% of patients.

Colchicine has been used prophylactically to reduce the number of attacks.

The prognosis is excellent. The syndrome does not induce any long term sequelae and is not associated with comorbidities. It generally resolves spontaneously 3-5 years after symptoms onset.

PFAPA: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome

Source image: www.nuemblog.com

Question 3

Lightning injuries are not often seen in the Emergency Department. The majority of subjects struck by lightning survive. However, 10% of injuries are fatal. Lightning (as any electrical current) follows the path of least resistance. 

What is the right order of conductivity of tissues, starting with the tissue with the best conductive properties? 

A: fat – muscle – nerve – skin – bone

B: bone – nerve – muscle – skin – fat

C: fat – muscle – skin – fat – nerve – bone

D: nerve – muscle – skin – fat – bone

The correct answer is D

NuEM covered lightning injuries last week. 

´´Lightning strikes can cause primarily neurologic injury, but the most common fatal complications are cardiac and respiratory arrest. This is due to the relative nature of conductivity of the various organs in the body, with lightning following the path of least resistance. The order of conductivity is: nerve > blood > muscle > skin > fat > bone ´´

Question 4

In infants with traumatic brain injury the challenge lies in finding those with clinically important brain injury (ciTBI) while limiting the use of radiation exposure from CT imaging.

The Infant Scalp Score (ISS) is a risk stratification tool for infants under 1 year of age with isolated scalp hematoma who are otherwise asymptomatic, well-appearing, but may still be getting head CTs when guided by existing clinical decision aids.

source image: journalfeed.org

This recently published paper is about the validation of the Infant Scalp Score (ISS) to stratify risk for traumatic brain injury in infants with isolated scalp hematoma.

What did the authors find?

A: Using a scalp score cutoff of ≥7 to obtain a cranial CT, no TBI and no ciTBI would be missed

B: Using a scalp score cutoff of ≥6 to obtain a cranial CT, no TBI and no ciTBI would be missed

C: Using a scalp score cutoff of ≥4 to obtain a cranial CT, no TBI and no ciTBI would be missed

The correct answer is C

This week JournalFeed covered the Infant Scalp Hematoma Score.

This easy to use risk stratification tool seems to be helpful in avoiding CT’s in the very young.

No infant with an ISH and an infant scalp score < 4 had TBI found on CT.

No infant with an ISH and an infant scalp score <5 had a ciTBI defined as death, need for neurosurgical intervention, intubation for at least 24 hours or hospitalization for two or more nights for TBI.

Source image: www.coreem.net

Question 5

Which of the following statements about a Maisonneuve fracture is true?

A: A Maisonneuve fracture should be suspected in all patients with fractures of the medial and / or posterior malleolus

B: Maisonneuve fractures are seen in 15% of all ankle fractures

C: A distal positive ‘’Squeeze test’’ suggests more severe injury to the tibiofibular syndesmosis than a more proximal positive ‘’Squeeze test’’

D: Weakness of ankle dorsiflexion, subtalar foot eversion and/or numbness along the lateral lower leg and dorsum of the foot should raise clinical suspicion for a Maisonneuve injury due to a damaged sural nerve

The correct answer is A

Maisonneuve fractures were covered by Jessica Tsao from CORE EM this week.

A Maisonneuve fracture is defined by the combination of a proximal fibula fracture and an unstable ankle joint injury. It involves an injury of the distal tibiofibular syndesmosis and/or fracture of the medial or posterior malleolus and it is seen in 5% of all ankle fractures.

The ‘’Squeeze test’’ is performed by giving compression on the tibia and fibula simultaneously and is considered positive when ankle or distal lower leg pain is felt. The more proximal the test is positive, the more severe the injury to the syndesmosis is and therefore the more likely a Maisonneuve fracture is.

The common peroneal nerve can be damaged in a Maisonneuve fracture since it courses over the fibular head.

Maisonneuve Fractures

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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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