Quiz 97, January 8th, 2021

Welcome to the 97th FOAMed Quiz. 

Sophie, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

While the vaccinating campaign against COVID-19 finally started, research on treatment options is not slowing down. The previous BLAZE-1 trial on bamlanivimab showed no differences in patient centered outcomes as well as serious methodological flaws.

This recently published paper is about casirivimab/imdevimab (REGN-COV2) monoclonal antibody cocktail. The researchers compared a high (8.0 g) and low dose (2.5 g) of this cocktail to placebo in non-hospitalized patients over 18 years of age with a confirmed SARS-COV2 infection within 72 hours of randomization and symptom onset.

Viral load was one of the most important outcomes although no primary endpoint was selected a priori.

What did the authors find?

A: Viral load was significantly lower in the low-dose and high-dose REGN-COV2 groups compared to the placebo group at day 7

B: Viral load was not significantly different between both REGN-COV2 groups compared to the placebo group at day 7

C: Viral load was significantly higher in the low-dose and high-dose REGN-COV2 groups compared to the placebo group at day 7

The correct answer is A

Anand Swaminathan covered the paper last week on RebelEM.

A total of 275 patients (REGN-COV2 low dose: n=92, REGBN-COV2 high dose: n=90, placebo: n=93) underwent randomization from which 228 were analyzed. Antibody status prior to treatment was measured (45% with antibodies, 41 without antibodies and 14% with unknown antibody status).

The viral load was significantly lower in both REGN-COV2 groups in comparison to placebo at day 7 while clinical efficacy (change in medically attended visits) was not significantly different (3% vs 6%, -3% CI -16 to 9).

Even though these results might seem promising, we have to inperpret these results with a lot of caution due to numerous limitations such as the fact that no formal hypothesis testing was performed and the fact that the authors randomly mentioned positive outcomes while they downplayed a large number of negative findings. They thereby combined all medically attended visits ignoring the very obvious difference between for example a Telehealth visit and an admission to the hospital. Finally, this study was sponsored by Regeneron, a large pharmaceutical company.

No Evidence that REGN-COV2 (Regeneron) Antibody Cocktail Has Clinical Benefits

Source image: www.pixabay.com

Question 2

After an uncomplicated home delivery (39+1 weeks), the paramedics present to your ED a 1 hour old girl with hypoxia. There were no problems during the pregnancy. In the ED you see mask ventilation is difficult and oxygen is dropping again. You have to intubate the neonate.

Which of the following statements is true about Rapid Sequence Induction/Intubation (RSI) in neonates?

A: The use of both sedative and paralytic medication shows reduction of adverse events compared to sedation only

B: The use of sedative only shows a reduction in adverse events compared to using both sedative and paralytic medication

C: The use of paralytic medication only is good practice

D: No medication need to be given because neonates are to small, young and immature to perceive pain

The correct answer is A

This week Pediatric EM Morsels covered Neonatal Intubation and RSI.

Neonates have all the characteristics of a difficult airway. They have a challenging physiology with a low functional residual capacity and a high metabolic rate and oxygen consumption. First attempt success rate in the NICU is about 49%. Significantly fewer adverse events occur when both paralytics and sedative medication is used compared to either sedative alone or no medication. Despite the fact that they are small and young, neonates do feel pain. Not using any medication or paralytic only is just inhumane.

Neonatal Intubation and RSI

Source image: www.litfl.com

Question 3

Your 59 year old female patient has ongoing pain in her chest since yesterday. She denies dyspnoea. Her ECG is shown above. She was treated with aspirin, ticagrelor, and heparin. Troponin came back markedly elevated. Catheterization showed normal coronary arteries and POCUS revealed the following:

Source image: coreultrasound.com

What is the most likely diagnosis?

A: Occlusion Myocardial Infarction (OMI)

B: Myocarditis

C: Takotsubo cardiomyopathy

The correct answer is C

Brown EM covered takotsubo cardiomyopathy last week.

Takotsubo cardiomyopathy is an acute, transient stress-induced cardiomyopathy. The diagnosis of takotsubo can be quite challenging as it cannot be distinguished from OMI without coronary angiography. ST elevation and apical ballooning are typical for takotsubo. There is no consensus on diagnostic criteria for Takotsubo so far. Although most patients will have a complete recovery within a month, this disease is certainly not purely benign.

Question 4

A 23 year old male comes in with pain in his right foot after a jump from the second floor. He landed on both feet. The X-ray shows the following:

Source image: www.aliem.com

Which of the following injuries is associated with this fracture?

A: Vertebral fracture of the cervical spine

B: Vertebral fracture of the thoracic or lumbar spine

C: Fracture of the skull base

D: Dislocated shoulder

The correct answer is B

ALIEM covered fractures of the calcaneus last week.

‘’7-10% of calcaneal fractures are associated with a concomitant vertebral fracture, including compression or burst fractures, especially with high energy mechanisms such as a fall from height’’ 

SplintER Series: We’ve Got A Jumper

Source image: www.tamingthersu.com

Question 5

Your 54 year old patient presents to your emergency department with a painful right hand. He has been cleaning his car about 6 hours ago with ‘’some chemical stuff’’ and he thinks his glove might have been perforated. Initially he did not notice a burn, but since 2 hours ago the pain was increasing.

What chemical compound is most likely the cause of this injury?

A: Chloric acid

B: Sodium hydroxide

C: Hydrofluoric Acid

D: Ammonia

The correct answer is C

Taming the SRU covered hydrofluoric acid burns last week.

The chronology of this story is typical for hydrofluoric (HF) acid burns. High concentration (>60 percent) solutions will cause immediate symptoms, as lower concentrations tend to cause symptoms later on. This latent period causes delay in treatment.

Hydrofluoric acid is a calcium and magnesium scavenger, leading to local (and if the burn is large enough systemic) hypocalcemia and hypomagnesemia and therefore to extensive and deep necrosis. Treatment consists of decontamination, irrigation and calcium, calcium and calcium. Calcium should be applied topically and can be injected locally (subcutaneous), intravenously and even intra-arterial.

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This quiz was written by Sophie Nieuwendijk, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen