Quiz 93, December 4th, 2020

Welcome to the 93th FOAMed Quiz. 

Enjoy!

Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Morphine and low dose ketamine (0.25 to 0.5 mg/kg) are commonly used analgesics in the ED. A 2018 meta-analysis did not show any difference in effectiveness between the two.

Recently a new and larger meta-analysis was published. What did the authors find?

A: Morphine is superior to low dose Ketamine in pain control up to 60 minutes after administration

B: Low dose Ketamine is superior to Morphine in pain control up to 60 minutes after administration

C: No difference was found between Morphine and low dose Ketamine in pain control up to 60 minutes after administration

The correct answer is C

The paper was covered on JournalFeed this week.

A total of 1191 patients (morphine = 593, LDK = 598) were included.

The recently published, larger, meta-analysis did not show any difference in effectiveness between the two drugs in the first hour after administration. Beyond 60 minutes however, morphine may be more effective.

Furthermore, the rate of adverse effects (nausea, vomiting) were equal.

Source image: www.aliem.com

Question 2

Your 25 year old patient presents to the ED, three months after a punch to the left side of the head. He complains of intermittent blurry vision. His aching left eye gets worse with ocular movements and is associated with conjunctival injection. 

Due to the story, a high intraocular pressure and a mild proptosis in the left eye you decide for further imaging (CT-angiography). You see a dilatation of the left ophthalmic vein.

What is the most likely diagnosis?

A: Rupture of the opthalmic nerve

B: Carotid cavernous fistula

C: Frontal subdural hematoma

D: Orbital fracture

The correct answer is B

This week Aliem covered carotid cavernous fistula this week.

Carotid-cavernous fistulas present shortly after trauma and can become symptomatic until weeks after trauma.

Conventional angiography is the gold standard for this diagnosis and neurosurgery should be consulted. Treatment will be coil embolization of the carotid-cavernous fistula by interventional radiology.

Question 3

The Head Impulse test is part of the HINTS exam (along with Nystagmus and Test of Skew) used in patients with continuous vertigo to distinguish peripheral from central causes.

In this test, the patient is asked to maintain focus on your nose while gently moving the patient’s head to one side and then rapidly move the head back to the neutral position. The Head Impulse test can be abnormal or normal. In an abnormal test, a corrective saccade can be seen.

What does an abnormal Head Impulse test tell you?

A: It makes a central cause of vertigo more likely

B: It makes a peripheral cause of vertigo more likely

The correct answer is B

The HINTS exam was covered on JournalFeed this week.

An abnormal Head Impulse test makes a peripheral cause of vertigo more likely and is good news for your patient. Patients with a central cause of vertigo typically have a normal Head Impulse test. This test can only be used in continuous vertigo, so it is not to be used in patients with BPPV.

 

Source image: www.rebelem.com

Question 4

Magnesium Sulfate may have analgesic effects. Most likely this is due to its antagonism of NMDA receptors. Perioperative Magnesium decreases opioid use post-operatively (source).

This recently published paper is about Magnesium Sulfate (50 mg/kg iv with a maximum of 2 g) versus Morphine (0.1 mg/kg iv with a maximum of 5 mg) as monotherapy for renal colic. 80 Patients were randomised.

What did the authors find?

A: Magnesium Sulfate resulted in better pain scores at 20 minutes post administration compared to Morphine

B: Morphine resulted in better pain scores at 20 minutes post administration compared to Magnesium Sulfate

C: There was no difference in pain score at 20 minutes post administration between Morphine and Magnesium Sulfate

The correct answer is C

Salim Rezaie covered the paper last week on RebelEM.

In this small, single centre study, Magnesium Sulfate showed to be possible non-inferior to Morphine in renal colic at 20 minutes past administration. However, morphine showed to give faster pain relief. Magnesium Sulfate may help in reducing opioid use in renal colic.

Pain reduction was equal between both groups Magnesium (3.20: decrease by 4.68 from baseline) and Morphine (3.65: Decrease by 4.28 from baseline).

The effectiveness of these agents in conjunction with an NSAID was not evaluated.

Adjunctive Pain Management of Renal Colic and Migraines

Source image: www.dontforgetthebubbles.com

Question 5

What is the correct eponym for this fracture?

 A: Galeazzi

B: Monteggia

C: Essex-Lopresti

The correct answer is A

Galeazzi fracture-dislocation was covered on Don’t Forget The Bubbles this week.

I have seen countless mnemonics for Monteggia versus Galeazzi in the past years. Personally the best one that works for me is: just remember it.

An Essex-Lopresti fracture occurs due to the compressive force of trauma transmitted down the forearm leading to a radial head fracture, interruption of the interosseous membrane and dislocation of the distal radio-ulnar joint (DRU).

 

Source image: www.pixabay.com

Question 6

Your 40 year old male patient is admitted to a nearby psychiatric clinic. He comes in with diarrhoea and vomiting. The psychiatrist suspects lithium intoxication. He has been using lithium for some months now.

Which of the following is true about lithium intoxication?

A: Lithium plasma levels correlate quite well to severity of intoxication

B: Cardiac toxicity is the most pronounced feature of lithium intoxication

C: Renal replacement therapy is the mainstay of treatment for lithium toxicity

D: Activated charcoal is the mainstay of treatment for lithium toxicity

The correct answer is C

CountyEM covered multiple toxicology cases this week.

A lithium level can help confirm the diagnosis, but plasma levels can’t tell you how much is in the tissue compartments, particularly the central nervous system.

Cardiac toxicity of lithium might very well be a significant consequence of intoxication, but the evidence behind cardiac toxicity is very limited so far.

Activated charcoal does not bind well to lithium and has no role when lithium is the sole agent in the overdose.

And yes, renal replacement therapy is the mainstay of treatment for lithium toxicity (if severe enough).

 

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:

This quiz was written by Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen