Quiz 94, December 11th, 2020

Welcome to the 94th FOAMed Quiz. 

Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Corneal abrasions are common in the ED and usually heal spontaneously within 24 to 72 hours. Patients can experience a fierce pain. Tetracaine and other topical anesthetics have been avoided due to the concerns for poor wound healing and subsequent corneal ulceration, scarring or blindness. However evidence is limited.

This paper compared the home use of topical tetracaine 0.5% vs placebo for uncomplicated corneal abrasions. The primary outcome was the overall pain score measured at the 24-48 hour ED follow up examination.

What did the authors find?

A: The topical tetracaine group showed a lower median pain score and decreased use of hydrocodone compared to placebo

B: There is no difference in median pain score between topical tetracaine and placebo

C: The topical tetracaine group showed an increase in adverse events compared to the placebo group

The correct answer is A

This week Sam Parnell covered the treatment of uncomplicated corneal abrasions on SpoonFeed.

Topical tetracaine use was associated with lower median pain score (1/10 vs 8/10) and decreased use of hydrocodone tablets for breakthrough pain (median 1 vs 7) compared to placebo for the first 24-48 hours. No serious adverse events were reported, however this was a small group with numerous exclusion criteria. Therefore the overall safety is still unknown but topical tetracaine might be used safely with strict counselling and instructions.

Source image: www.pixabay.com

Question 2

Your 30 year old male patient was involved in a motor vehicle accident. He is in profound hemorrhagic shock. FAST shows free abdominal fluid. You initiate Massive Transfusion Protocol (MTP).

Which of the following statements is true about Massive Transfusion Protocols (MTP’s)?

A: A triple lumen central venous catheter is ideal for transfusing large amounts of packed red blood cells

B: Whenever possible, crystalloids should be avoided In hemorrhagic shock with ongoing bleeding

C: There is no place for fibrinogen supplementation in trauma-induced bleeding

D: A mild hypocalcemia due to the citrate in blood products can be accepted and suppletion is not necessary

The correct answer is B

This week Josh Farkas discusses the Massive Transfusion Protocols in EMCrit

In hemorrhagic shock with ongoing bleeding, crystalloid administration may dilute coagulation factors and erythrocyte concentration. Crystalloids should be avoided whenever possible.

Due to the length of the catheter and its relatively small diameter, central venous catheters can not handle rapid fluid administration.

Administration of fibrinogen should be initiated rather early. Recent guidelines for trauma-induced bleeding suggest targeting a fibrinogen level > 150-200mg/dL

If blood products are given rapidly, the citrate in blood products chelates calcium and will lead to hypocalcemia. Hypocalcemia can cause coagulopathy and therefore after each round of MTP you should also give 1 gram of IV calcium chloride or 3 grams of IV calcium gluconate.

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 12560

Question 3

Your 19-year old male patient comes in with a painful lateral clavicle on the left side.

The X-ray is shown above.

Which of the following statements about acromioclavicular joint (ACJ) injuries is true?

A: The first ligament to rupture in ACJ injuries is typically the coracoclavicular (CC) ligament, followed by the acromioclavicular (AC) ligament and coracoacromial (CA) ligament

B: A positive scarf test suggests an ACJ injury

C: The normal space between the clavicle and acromion on X-ray is <8mm

D: Management of Rockwood grades I-IV ACJ injuries is conservative whereas Rockwood grades V-VI require operative management

The correct answer is B

ACJ injuries were covered on Don’t Forget The Bubbles this week.

Injury to the ACJ means disruption of the AC ligaments with or without disruption of the CC ligament. ACJ injuries most often occur due to a direct blow or fall onto the superior or lateral part of the shoulder with the arm adducted.

The Scarf test is performed by compression on the affected shoulder while the patient’s hand on the affected side holds the contra-lateral side of the patient’s neck. If painful, it suggests an ACJ injury.

The normal space between the clavicle and the acromion is <5mm (or <2mm difference compared to the other side). Management of Rockwood Grades I-III is conservative while Rockwood Grades IV-VI need surgical management. Grade III ACJ injuries also need surgical intervention when non-operative management fails.

Question 4

The use of convalescent plasma therapy (CPT) in the treatment of COVID-19 increases despite a lack of supporting evidence from randomised studies.

This recently published paper comparesd CPT to placebo in hospitalized adult patients with severe COVID-19 pneumonia. It is a double-blind, placebo-controlled, multicenter, randomized controlled trial from Argentina and the first randomised study on this topic.

The primary outcome was clinical status 30 days after intervention, measured on a 6-point ordinal scale ranging from total recovery to death.

What did the authors find?

A: There was no difference in the distribution of clinical status at 30d after intervention

B: CPT was superior to placebo in the distribution of clinical status at 30d after intervention

C: Placebo was superior to CPT in the distribution of clinical status at 30d after intervention

The correct answer is A

RebelEM covered the paper  last week.

334 patients with severe COVID-19 pneumonia (SaO2 <93% on room air, P/F ratio <300mmHg or SOFA or mSOFA score ≥2 above baseline status) were randomised to either CPT (228 patients) or placebo (105 patients). The median time from onset of symptoms to enrollment was 8 days.

There was no difference in the distribution of clinical status at 30d after intervention. Furthermore, overall mortality was equal (11.0 vs 11.4 percent), ICU admissions (53.9 vs 60.0 percent or progression to invasive ventilatory support (26.8 vs 22.9 percent).

Keep in mind transfusion-associated cardiac overload (TACO) and transfusion-related acute lung injury (TRALI) could not be differentiated from COVID-19 progression in this trial.

COVID-19 Update: The PlasmAr Trial – Convalescent Plasma vs Placebo

Question 5

Source image: www.tamingthesru.com

Your 40 year old patient presents with urticaria, wheezing, hypotension and shock after injection of antibiotics.

The use of which of the following drugs is supported by evidence in this case?

A: Diphenhydramine or another antihistamine

B: Prednisolone or another glucocorticoid

C: Adrenalin (epinephrine)

D: Methylene blue

The correct answer is C

Taming the SRU covered the treatment of anaphylaxis this week.

There is no data so far that supports the use of glucocorticoids in anaphylaxis. The dreaded biphasic reaction sure seems quite rare and often not clinically significant.

Antihistamines may reduce cutaneous manifestations of anaphylaxis, but their benefit in systemic anaphylactic reactions is not supported by evidence.

Animal studies and case reports have indicated a possible role for IV methylene blue in anaphylactic shock refractory to epinephrine.

And well, adrenalin is the mainstay of management of anaphylaxis. It agonizes α1, β1, and β2 receptors and so increases peripheral vascular resistance and aids significantly in bronchodilation. Agonism of β2 receptors leads to decreased release of mast cells contents.

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This quiz was written by Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thisse