Quiz 99, January 22th, 2021

Welcome to the 99th FOAMed Quiz. 

Sophie, Nicole, Joep, Denise, Gijs and Rick

Source image: www.pixabay.com

Question 1

Your 27 year old patient comes in after a motor vehicle accident. She has respiratory failure (saturation 88 percent on non rebreather, breathing 48 times per minute) and has extensive rib fractures. She appears to be hemodynamically stable (for now). After bilateral finger thoracostomy you will have to intubatie her. By the way, she is pregnant (AD 26 weeks and 2 days).

Which of the following statements is true about emergency intubation of a pregnant patient?

A: Rocuronium should not be used because it easily passes the placenta

B: Succinylcholine should not be used because it easily passes the placenta

C: Etomidate is a good induction agent in this case

D: Thiopental is the only induction agent that can be used safely in this case

The correct answer is C

NUEM covered intubation of the pregnant patient this week.

Moral of the story: Use the medications you would typically use for the patient. All induction agents cross the placenta, but hypoxia, hypercarbia and acidosis are far more harmful to the fetus.

Paralytic agents are highly ionized and do not cross the placenta in significant amounts. Etomidate can be used in these cases.

 

Question 2

Soft tissue injuries due to retained foreign bodies are regularly seen in the Emergency Department. These sometimes radiolucent foreign bodies can not always be identified on conventional X-rays or computed tomography.

Ultrasonography has a high accuracy for detecting radiopaque foreign bodies. Each material has his own common sonographic signature.

The picture shown below shows a foreign body in a patient’s finger:

Source image: rebelem.com

This foreign body is most likely made of:

A: Glass

B: Wood

The correct answer is A

POCUS and Soft Tissue Foreign Bodies were covered on REBELEM this week.

The linear series of bright echogenic structures (reverberation artifacts) along the path of this foreign body are often seen in foreign bodies made out of glass.

Wooden foreign bodies have a more discrete acoustic shadow without artifacts.

POCUS and Soft Tissue Foreign Bodies

Source image: www.pixabay.com

Question 3

In Disseminated Intravascular Coagulation (DIC) there is widespread, uncontrolled clot formation in the microvascular as well as macrovascular system. Due to depletion of procoagulant proteins it can also cause hemorrhage.

DIC is a clinical diagnosis based on the presence of a constellation of laboratory abnormalities, the presence of an underlying disorder known to cause DIC and absence of a different explanation for the laboratory abnormalities.

Laboratory tests which can help diagnosing DIC include a complete blood count, PT/INR, APTT, fibrinogen and D-dimer.

Which of the following statements about laboratory tests in DIC is NOT true?

A. Thrombocytopenia is often the first laboratory abnormality to appear

B. Normal PT/INR and APTT occur in half of the patients with DIC

C. The majority of patients with DIC show low fibrinogen

D. A normal D-dimer essentially excludes DIC

The correct answer is C.

Disseminated intravascular coagulation (DIC) was covered by EMCRIT’s IBCC this week.

Low fibrinogen is seen in only 25% of patients with DIC. It supports the diagnosis of DIC, but usually isn’t seen. Remember fibrinogen is an acute phase protein, so sepsis-induced DIC may have normal or elevated levels of fibrinogen.

Source image: www.ntvt.nl

Question 4

The management of ACE-inhibitor induced angioedema can be challenging. No drugs are proven effective and it is not always obvious which patients need a secure airway.

In this retrospective study, investigators wanted to determine which patients have a higher risk and need for intubation.

What did the investigators find?

A: Isolated lip swelling was associated with an increase in risk for intubation

B: Intubation should only be performed within the first 6 hours of onset of angioedema symptoms

C: Anterior tongue swelling and vocal changes are associated with a high risk for intubation

D: Over 30 percent of patients presenting with ACE-inhibitor induced angioedema required intubation

The correct answer is C

This week Sam Parnell covered ACEi angioedema on Spoon Feed.

Isolated lip swelling was present in 54% of all patients and more common in patients that did not require intubation. These patients are usually at low risk for intubation but be aware of rapid symptom progression. Patients that required intubation were more likely to present within 6 hours of onset of angioedema symptoms. Rapid progression within the first 6 hours of onset and anterior tongue swelling, vocal changes, drooling and dyspnea are associated with intubation for ACEi associated angioedema.

 

Source image: www.pixabay.com

Question 5

Which of the following can potentially cause pancreatitis?

A: Soy beans

B: Lentils

C: Fava beans

D: Kidney beans

The correct answer is A

CountyEM covered soy bean induced pancreatitis this week.

Soy beans contain a component that is a known trypsin inhibitor. Trypsin inhibitors cause hypertrophy and hyperplasia of acinar cells (at least in rats) and are believed to cause pancreatitis in humans.

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

Reviewed and edited by Rick Thissen