Quiz 84, September 11th, 2020

Welcome to the 84th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Source image: https://rebelem.com/

 The CoDEX trial is another trial about dexamethasone as treatment of Covid.

Patients with moderate to severe ARDS (receiving mechanical ventilation within 48hrs of meeting criteria for moderate to severe ARDS (P/F ratio ≤200)) were randomised to either dexamethasone plus standard care (n=151) or standard care (n=148).

The primary outcome was ventilator free days during the first 28 days.

What was the effect of dexamethasone treatment on ventilator free days in this patient population?

A: Patients in the dexamethasone group had more ventilator free days during the first 28 days after enrollment

B: Patients in the standard care group had more ventilator free days during the first 28 days after enrollment

C: There was no difference in ventilator free days between patients in both groups

The correct answer is A

Salim Rezaie covered three recently published trials about corticosteroids and Covid last week.

This RCT showed a difference of ventilator free days of 2.6 in favor of the dexamethasone group (6.6 vs 4.0, p=0.04). The study was underpowered for secondary outcomes (mortality).

It’s Raining Steroids in COVID-19: REMAP-CAP, CoDEX, & CAPE COVID

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 7132

Question 2

You see a 25 year old patient with suspected first time anterior shoulder dislocation. You wonder if POCUS is reliable to confirm your suspicion to speed up reduction of the shoulder.

Which of the following is true about POCUS in shoulder dislocations according to this paper?

A: Sensitivity of POCUS for shoulder dislocations is 100 percent

B: Time to diagnosis using POCUS is equal compared to x-ray

C: Sensitivity of POCUS for non Hill Sachs fractures is 100 percent

The correct answer is A

This week’s ultrasound gel podcast is about this recently published paper about POCUS in shoulder dislocation.

A novel technique of posterior shoulder ultrasound showed perfect accuracy for diagnosing shoulder dislocation and reduction. For non Hill Sachs fractures the sensitivity of POCUS was 92 percent (including Hill Sachs and Bankart lesion the sensitivity dropped significantly). Time to diagnosis was almost twice as fast in the pocus group.

Source image: https://www.ultrasoundgel.org/

 

Question 3

In the ACTT-1 trial Remdesivir was not effective in the really sick (HFNC, NIV, IMV, and ECMO) and completely useless in patients that didn’t need O2. It seems the moderately ill might benefit from Remdesivir.

This paper, published last week, is about the effect of Remdesivir in just this patient group.

Patients with pulmonary infiltrates on X-ray and with room air oxygen saturation >94% were randomised to either a 10-day course of remdesivir, a 5-day course or remdesivir and standard care (no remdesivir). The primary outcome was clinical status on day 11 on a 7-point ordinal scale (ranging from death to discharged from hospital).

What did the result show?

A: Patients receiving 10 days Remdesivir had significantly better clinical status on day 11 compared to patients receiving standard care alone

B: Patients receiving 5 days Remdesivir had significantly better clinical status on day 11 compared to patients receiving standard care alone

C: Patients receiving 10 days Remdesivir had significantly better clinical status on day 11 compared to patients receiving 5 days Remdesivir

D: Patients receiving standard care alone had significantly better clinical status on day 11 compared to patients receiving standard care 10 days Remdesivir or 5 days Remdesivir

The correct answer is B

Salim Rezaie covered this paper on RebelEM last week.

596 patients were randomized to either a 10-day course of remdesivir, a 5-day course of remdesivir and standard care (no remdesivir).

Only the 5 day remdesivir group did significantly better than the standard care alone group (OR 1.65; 95% CI 1.09 – 2.48; p = 0.02). Interestingly, the 10 day remdesivir group did not statistically better (by far).

This is even more remarkable when considered the patient in the 10 day remdesivir group only used remdesivir for 6 days on average. This leaves the question whether the effect seen in the 5-day arm is just random chance.

Only 76% of patients completed therapy in the 5 days group and 38% in the 10 days group.

So, yet another paper with some major methodological issues leaving the question whether or not to embrace Remdesivir as an effective drug for Covid unanswered.

Remdesivir in Moderate COVID-19

Question 4

Your 34 year old patient presents with a pelvic fracture after a motor vehicle collision. Opioid and NSAIDs are inefficient for pain control. Your next step is low dose ketamine and you consider slow continuous infusion (SI) instead of iv push (IVP) to prevent the patient freaking out (like your last patient did).

This paper is about iv push versus slow continuous infusion of ketamine for analgesia. 48 patients were randomised to either IV push ketamine (0.3 mg/kg) or mixed in a 100cc NS bag and infused over 15 minutes.

What does the evidence say about iv push versus slow continuous infusion of ketamine for analgesia?

A: Patients were more likely to experience a feeling of unreality at any time in the IV push group compared to the slow infusion group

B: Patients in the slow infusion group had a higher degree of sedation compared to the slow infusion group at 5 minutes

C: Patients in the slow infusion group had larger a decrease in mean pain scores from baseline to 15 minutes compared to the slow infusion group at 5 minutes

The correct answer is A

Taming the SRU covered 3 quite important papers on ketamine last week. Among them this paper on ketamine iv push versus slow continuous infusion for analgesia.

Patients were more likely to experience a feeling of unreality at any time in the IV push group compared to the slow infusion group (91.7% vs 54.2%, p=0.008).

Patients in the IV push group had a higher degree of sedation compared to the slow infusion group (RASS -2 versus RASS 0, p=0.01).

Decrease in mean pain scores from baseline to 15 min was similar across groups: 5.2 ± 3.53 (95% CI 3.7–6.7) for IVP; 5.75 ± 3.48 (95% CI 4.3–7.2) for SI.

Question 5

Source image: https://pixabay.com/

Your 38 year old female patient comes in with a severe headache which is rapidly increasing over the past few days. She is overweight and her past medical history includes migraine and a pulmonary embolism. She tells you that this headache is different from previous episodes of migraine. Your differential diagnosis includes a cerebral venous sinus thrombosis.

Which of the following statements about diagnostic tools for cerebral venous sinus thrombosis is true?

A: A negative D-dimer excludes cerebral venous sinus thrombosis as a diagnosis

B: Lumbar puncture is part of the standard work-up in patients with suspected cerebral venous sinus thrombosis

C: CT-venogram and MRI-venography are both equally accurate in diagnosing a cerebral venous sinus thrombosis

The correct answer is C

Josh Farkas covered cerebral venous sinus thrombosis on the Internet Book of Critical Care this week.

Symptoms and chief complaints in patients with cerebral venous thrombosis are variable and non specific. They include headache, focal neurologic findings, seizure and encephalopathy.

The diagnosis is difficult and the sensitivity of D-dimer varies between 82-94%. The diagnosis can therefore not be excluded solely based on a D-dimer. Lumbar puncture is not indicated for this condition but may be performed as part of a broader evaluation to exclude infection. Imaging findings can be divided between direct (visualising the clot itself) and indirect signs (hemorrhage or edema as a consequence of the clot).

IBCC chapter & cast – Cerebral Venous Thrombosis

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

Reviewed and edited by Rick Thissen