Quiz 91, November 20th, 2020

Welcome to the 91th FOAMed Quiz. 

Nicole, Joep and Rick

Source image: www.first10em.com

Question 1

Idiopathic Intracranial Hypertension (IIH) is reguraly missed diagnosis with potentially devastating consequences.

Headache is the main symptom and papilledema is common. Patients can present with abducens nerve palsy, pulsatile tinnitus, dizziness, neck or back pain and confusion.

Which of the following patients is most at risk for IIH?

A: A 22 year old female with a body mass index (BMI) of 36

B: A 63 year old female with a BMI of 31

C: A 22 year old female with a BMI of 22

D: A 45 year old male with a BMI of 40

The correct answer is A

First10EM covered IHH this week.

The diagnosis of IIH is a tricky one. The headache is often nonspecific and can be confused with migraine.

Always keep this diagnosis in your mind when treating a female of childbearing age who is overweight.

Idiopathic Intracranial Hypertension: a rapid review

Source image: www.emottowablog.com

Question 2

The role of viscoelastic hemostatic assays (VHA) like TEG and ROTEM in trauma patients is not supported by a lot of evidence so far.

In this recently published study, trauma patients with activated major haemorrhage protocols were randomised to either VHA or Conventional Coagulation Tests (CCT) guided therapy.

The primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of ongoing massive transfusion.

What did the authors find?

A: VHA guided therapy resulted in a increase in patients alive and free of massive transfusion at 24 hours after injury compared to CCT guided therapy

B: CCT guided therapy resulted in a decrease in patients alive and free of massive transfusion at 24 hours after injury compared to VHA guided therapy

C: There was no difference between the two groups in number of patients alive and free of massive transfusion at 24 hours after injury

The correct answer is C

EMOttawa covered this paper last week.

There was no difference in patients alive and free of massive transfusion at 24 hours after injury between VHA- and CCT-augmented-major haemorrhage protocols (64 versus 67 percent). This may be due to the lower than expected rate of coagulopathy and therefore the study may have been underpowered.

There was a reduction in 28-day mortality in the VHA group in patients who also had severe TBI. However, this is probably a chance finding.

Source image: www.atsu.edu

Question 3

Which of the following bacteria is the most likely causative organism of menstrual toxic shock syndrome due to colonisation of tampons?

A: Streptococcus pyogenus

B: Staphylococcus aureus

C: Enterococcus faecium

D: Pseudomonas aeruginosa

The correct answer is B

Toxic Shock Syndrome (TSS) is covered on the Internet Book of Critical Care this week.

Toxic shock syndrome can either be caused by Streptococci of Staphylococci. The bacteria found to be the causative organism in menstrual related TTS is Staphylococcus aureus.

Question 4

In which of the following situations is administration of sodium bicarbonate most likely to be beneficial to the patient?

A: A patient with diabetic ketoacidosis (DKA) and a pH of 7.05

B: A patient with renal failure and a pH of 7.15

C: A patient with lactic acidosis and a pH of 7.10

D: A patient with Hyperchloremic Metabolic Acidosis and a pH of 7.31

The correct answer is B

NUEM covered sodium bicarbonate and the recently published BICAR-ICU trial last week.

In patients with DKA, please do not administer sodium bicarbonate unless the pH is well under 7.00. In lactic acidosis it seems sodium bicarbonate is not beneficial.

Patients with uremic acidosis are likely to benefit from sodium bicarbonate to cope with the inability of the kidney to excrete anions.

Patients with hyperchloremic acidosis might benefit from sodium bicarbonate, but not if the acidosis is very mild like in this case.

Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9644

Question 5

The discussion about antibiotics versus surgical management of appendicitis has been around for some years now.

Recently the CODA trial was published. The CODA trial is an RCT comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis. The primary outcome was 30-day health status (by questionnaire). Patients with signs of severe disease were excluded.

What did the authors find?

A: Antibiotics were inferior to appendectomy on the basis of results of a standard health-status measure

B: Antibiotics were superior to appendectomy on the basis of results of a standard health-status measure

C: Antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure

The correct answer is C

RebelEM covered this paper last week.

1552 adults underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy. Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores.

However, in the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Only 30% of eligible patients agreed to undergo randomization.This data was only from the first 90 days after randomisation, so long term adverse effects may be missed.

Interestingly, perforation was more common in the antibiotics group compared to the appendectomy group (32% vs 16%) when the analysis was limited to participants in either group who had undergone appendectomy. This difference was only seen in patients with an appendicolith (61% vs 24%).

REBEL Cast Ep 89: The CODA Trial – Antibiotics vs Appendectomy for Appendicitis

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This quiz was written by Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen