Quiz 100, January 29th, 2021

Welcome to the 100th FOAMed Quiz!

 

Source image: www.emcrit.org

Question 1

Extracorporeal membrane oxygenation (ECMO) can improve survival after out of hospital cardiac arrest (OHCA). However, we can’t put them all on ECMO.

This recently published paper is about the use of ECMO in patients with refractory ventricular fibrillation (VF). 30 patients were randomised to either start of ECMO on the cath lab or standard ACLS with catheterisation after ROSC.

What did the authors find?

A: Survival to hospital discharge with a favourable neurologic outcome (modified Rankin score of  3 at 6 months) was higher in the ECMO group compared to the standard ACLS group

B: Survival to hospital discharge was higher in the ECMO group compared to the standard ACLS group, but a favourable neurologic outcome (modified Rankin score of  3 at 6 months) was equal in both groups

C: Survival to hospital discharge was equal in both groups

The correct answer is A

Micheal Wolf covered this paper on Journal Feed this week.

15 patients were randomised to each group. The mean age was just below 60 years in both groups. One patient in the ECMO group withdrew consent at day 3 after randomisation. In the ECMO group, 6 patients survived to hospital discharge. All had a modified Rankin score of  3 at 6 months after randomisation. 1 patient in the standard ACLS group survived to hospital discharge (however, with devastating neurology).

Source image: www.rebelem.com

Question 2

Awake proning may be beneficial in patients suffering from COVID-19. However, data to support this is scarce.

This recently published systematic review and meta-analysis of observational trials is about multiple small observational studies in which awake proning was compared to standard care in patients receiving oxygen therapy (conventional, NIV or HFNC). The outcomes included intubation rate and in-hospital mortality.

What did the authors find?

A: Both in-hospital intubation rate and in-hospital mortality were significantly higher in patients who underwent awake proning compared to patients who underwent standard care

B: The in hospital intubation rate and in hospital mortality rate were not statistically different between patients who underwent awake proning compared to patients who underwent standard care

C: Both in-hospital intubation rate and in-hospital mortality rate were significantly lower in patients who underwent awake proning compared to patients who underwent standard care

The correct answer is B

This systematic review and meta-analysis was covered on REBEL EM this week.

No significant differences were found for both primary endpoints. In-hospital intubation rates were 27% and 30% for patients who underwent awake proning and standard care respectively (p = 0.71). In-hospital mortality rates were not statistically different (11% in awake proning vs 22% in standard care, p = 0.10).

Keep in mind this systematic review and meta-analysis is a summation of small and methodologically flawed studies. However, this is all the evidence available so far.

COVID-19 Awake Proning – All Hype?

Source image: www.coreultrasound.com

Question 3

Your colleague pulled an emesis bag over a patient’s foot and filled it with water.

What is she doing?

A: Cooling the foot after a thermal burn

B: Trying to ultrasonographically determine the composition of her patient’s vomit (not sure why the patient put her foot in though)

C: Using the bag as an alternative to a water bath to ultrasonographically assess for effusion of the ankle joint

The correct answer is C

Jacob Avila mentioned this trick on his vodcast on core ultrasound.

This is actually pretty cool and something I will try soon. Quite often I cannot find a water bowl large enough to submerge the patient’s limb. This just might be the solution.

Source image: www.rebelem.com

Question 4

In wintertime a patient with severe hypothermia arrives at your emergency department. He was found in the snow and upon arriving has a core body temperature of 27,4°C. You immediately decide to rewarm the patient by using a Bair Hugger.

After how many hours do you reckon he reaches a core temperature of 37°C if you don’t use any other warming technique besides a Bair Hugger?

A: 2 h

B: 4 h

C: 6 h

D: 8 h

The correct answer is B

This week The Trauma Pro provided an updated compilation of the average rewarming rates of commonly used techniques.

Source image: Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 6136

Question 5

Glucocorticoids have been used in chronic subdural hematoma. However, there is limited evidence from multicenter, randomized trials to assess the effects of glucocorticoids on outcomes.
This recently published paper is about dexamethasone in patients with chronic subdural hematoma. 748 patients with chronic subdural hematoma were randomised to either 2 two week course of dexamethasone or placebo.

 What did the authors find?

A: A favourable neurologic outcome (modified Rankin scale score 0-3) at 6 months post randomisation was significantly more frequent in the dexamethasone group compared to the placebo group

B: A favourable neurologic outcome (modified Rankin scale score 0-3) at 6 months post randomisation was significantly more frequent in the placebo group compared to the dexamethasone group

C: The modified Rankin scale score at 6 months post randomisation did not differ significantly between the two groups

The correct answer is B

The Bottom Line covered this paper last week.

A favorable outcome was reported in 286 of 341 patients (83.9%) in the dexamethasone group and in 306 of 339 patients (90.3%) in the placebo group (P=0.01). However, recurrence of the subdural haematoma requiring repeat surgery was less likely in the dexamethasone group.

Anyway, it seems patients with chronic subdural hematoma should not be treated with dexamethasone.

Dex-CSDH

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen