Quiz 87, October 23th, 2020

Welcome to the 87th FOAMed Quiz. 

We’re back after a small break, enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Source image: coreem.net

A healthy 15 month old boy presents to your ED after suspicion of swallowing a button battery. The parents saw the boy playing with the remote control which he opened. The battery was nowhere to be found and parents think he may have swallowed the battery.

Which of the following statements is true about battery-related injuries?

A: Damage occurs hours after ingestion and not directly

B: For damage control until removal, no therapies are indicated

C: Complications after removal can present late (even after more than 9 days)

D: After removal of the battery no following therapy is necessary

The correct answer is C

This week Sean Fox covered Button Batteries in the Esophagus on PedEM Morsels.

Tissue damage is due to isothermal hydrolysis reaction and alkaline caustic exposure. When placed in a moist environment an electrical charge is generated. This electrical charge hydrolyses water generating hydroxide ions, which are leading to alkaline injury.

Tissue damage starts even within 2 hours. Damage continues after removing the battery and complications can present after 9 days up to even weeks later.

Removing the battery is imperative. Honey (children > 1 year) or sucralfate may reduce the severity of esophageal burns and improve patient outcomes. After removal a weak acid can reduce continued liquefaction necrosis.

Neutralize Button Battery in the Esophagus

Souce image: www.pixabay.com

Question 2

As the COVID pandemic reaches a second peak in our country, more data emerges on treatment options. Lopinavir – Ritonavir (Kaletra) has been regarded as a potentially useful drug, although evidence available so far does not show any benefit.

The RECOVERY trial is an overarching trial design that looks at different treatment options simultaneously. This paper is about the Lopinavir-Ritonavir (Kaletra) arm of the RECOVERY trial.

What does the trial show about the efficacy of Lopinavir-Ritonavir?

A: Lopinavir-Ritonavir reduced mortality at day 28

B: Lopinavir-Ritonavir reduced time to hospital discharge at day 28

C: Lopinavir-Ritonavir reduced progression to receipt of mechanical ventilation

D: Lopinavir-Ritonavir did not show any benefit 

The correct answer is D

The Lopinavir – Ritonavir arm of the RECOVERY trial was discussed at The Bottom Line last week.

1616 COVID patients admitted to hospital received Lopinavir-Ritonavir and 3424 patients were allocated usual care. Only 4% of the patients included were invasively mechanically ventilated.

Time to hospital discharge (median 11 days vs. 11 days), progression to receipt of mechanical ventilation (10% vs. 9%) and mortality at day 28 (22% vs. 22%) did not show any difference. 

RECOVERY: COVID-19 Kaletra

Source image: ww.pixabay.com

Question 3

A 16-year old male presents to your ED after ´twisting his right ankle’ on the football pitch. He cannot bear weight, but the ankle does not appear swollen. An X-ray is made (lateral view not shown here).

Source image: dontforgetthebubbles.com

Which of the following is the most likely diagnosis?

A: Tillaux fracture

B: Triplane fracture

Don’t Forget The Bubbles covered Tillaux fractures last week.

Both Tillaux fractures and Triplane fractures are considered transitional fractures, which occur in patients with partially closed growth plates.

In case of a Tillaux fracture, an avulsion of the distal tibia epiphysis by the tibiofibular ligament.

In case of a Triplane fracture, in addition to a epiphyseal fracture similar to the Tillaux fracture, the physis is separated in the axial plane and the metaphysis is fractured on the posterior aspect in the coronal plane.

Both fractures are caused by supination and external rotation of the foot. Patient with a Tillaux (average age is fracture tend to be a little older than patients with a triplane fracture (average age is 13 years).

The lack of a fracture through the coronal plane distinguishes this injury from that of a triplane fracture.

https://dontforgetthebubbles.com/tillaux-fractures/ 

Question 4

Source image: litfl.com

A 46-year old female patient presents to your emergency department with severe chest pain. She does not have a medical history, does not smoke and also never experienced this pain before.

Her ECG shows an anterior OMI while her troponines are not (yet) elevated. The cardiologist takes her to the cath lab and performs a coronary angiography which shows a spontaneous coronary arterial dissection (SCAD) of the left anterior descending (LAD) coronary artery.

Which of the following statements about SCAD is true?

A: Male gender is a known risk factor

B: Cardiac enzymes are rarely elevated

C: The left coronary artery (LAD) is most commonly affected

D: Treatment always includes PCI or CABG

The correct answer is C

Muhammad Durrani covered SCAD on REBELEM this week.

SCAD is defined as a non-traumatic and non-iatrogenic tear in the coronary arterial wall. It accounts for approximately 1-4% of ACS cases overall.

Women, especially <50 years old, are at highest risk. The diagnosis is difficult to make and patients may mistakenly be discharged due to their relatively young age and lack of cardiovascular risk factors. Cardiac enzymes are frequently elevated and the most commonly affected vessel is the LAD, followed by the left circumflex artery and RCA.

A conservative approach is recommended unless there is ongoing ischemia, hemodynamic instability, or left main dissection might need PCI or CABG.

Spontaneous Coronary Artery Dissection (SCAD)

Source image: www.emdocs.net

Question 5

Puncture wounds can be associated with complications such as soft tissue infections and deep abscesses.

Which of the following statements is true about puncture wounds?

A: Puncture wounds through a rubber sole have increased risk of pseudomonas infection and therefore osteomyelitis

B: The risk of an infection in puncture wounds is about 50% and 20% of these patients will develop osteomyelitis

C: Ultrasound has a low specificity and sensitivity for the detection of foreign bodies

The correct answer is A

EMDocs covered puncture wounds this week.

Pseudomonas infections are commonly seen when puncture injury occurs through rubber soles. Infection with Pseudomonas is the most common cause of osteomyelitis. In approximately 10% of the puncture wounds an infection is seen and 1-2% of patients will develop osteomyelitis.

Ultrasound can be used for the detection of foreign bodies and has a sensitivity of 87% and specificity of 97%. A benign course is seen in the majority of the puncture wounds if a foreign body is not retained. 

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

Reviewed and edited by Rick Thissen