Quiz 102, February 12th, 2021

Welcome to the 102th FOAMed Quiz.


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Question 1

An eight year old child presents to your ED with an acute asthma attack. After treatment with intravenous steroids and nebulised ipratropium and salbutamol, she shows no signs of improvement.

Your colleague suggests 
nebulised magnesium.

Based on recent research, what is the best response?

A: This must be a mistake. Nebulising magnesium has many side effects

B: In refractory acute asthma, nebulised magnesium decreases hospitalisation rate

C: Interesting suggestion, but the child will not really benefit from it

The correct answer is C

This week Don’t Forget The Bubbles discussed the use of nebulised magnesium sulphate in the management of acute asthma in children.

There is some evidence supporting the use of magnesium sulphate intravenously in refractory asthma. But little was known about the effects of inhaled magnesium.

DFTB covered this recently published paper. The authors randomized 816 children 2 to 17 years to either nebulized magnesium with placebo after completing 1 hour of initial treatment (steroids, salbutamol and ipratropium) . There was no significant decrease in the rate of hospitalization. Also no differences were found in secondary outcomes such as hospital revisits, oxygen use or respiratory rate. It did not lead to any serious adverse effects though.

Source image: www.emdocs.net

Question 2

As obesity is more and more common, so is the need for bariatric surgery. Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures. However, these procedures are not without risk.

Link the complications of RYGB to the most likely postoperative interval after RYGB:

A: marginal ulceration
B: anastomotic leak
C: internal herniation
D: stenosis

1: up to several weeks after surgery
2: several months after surgery
3: one year post-operative
4: any time post-operatively

The correct combinations are: B-1, D-2, A-3, C-4

This week, emDOCs addressed the complications of bariatric procedures and how to differentiate them in the emergency room.

Early complications are most likely bleeds or leaks of the anastomosis or staple line. Anastomotic stenosis (narrowing of the stoma <1cm) typically occur several weeks to months after the procedure.

Internal herniation is a devastating complication of RYGB. This condition can occur any time after surgery.

Always keep a broad differential. Because of the former obesity, these patients are still at risk of any disease linked to obesity.

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Question 3

Syncope is a commonly encountered complaint in the Emergency Department (ED). Identification of low risk patients is often challenging, leading to frequent hospital admission for rhythm observation.

In this systematic review, the researchers evaluated nine different syncope rules and their accuracy to detect patient with a high risk of any adverse event (such as death, myocardial infarction, stroke, or cardiac surgery).

The authors evaluated the San Francisco Syncope Rule (SFSR), Canadian Syncope Risk Score (CSRS), OESIL Score for Syncope, Risk stratification Of Syncope in the ED (ROSE), FAINT Score, Boston syncope, Syncope Risk Score, Canadian Syncope Arrhythmia Score and the Ottawa ECG rule.

Which of the risk scores was the most accurate?

A: San Francisco Syncope Rule (SFSR)

B: Canadian Syncope Risk Score (CSRS)

C: FAINT Score

D: OESIL Score for Syncope

The correct answer is B.

This week Clay Smith covered the Syncope Score Systematic Review on SpoonFeed.

The investigators included 17 studies and evaluated nine risk stratification scores. For all the syncope rules that have been externally validated, except the CSRS, the LR+ ranged from 1 to 2.5. This means they are pretty useless.

A CSRS of 4 or more was associated with a high likelihood of an adverse event and a CSRS of 0 or less was associated with a low likelihood of an adverse event.

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Question 4

The results of the RECOVERY trial on Tocilizumab in COVID-19 patients are available in pre-print. 2022 patients receiving oxygen or respiratory support were allocated to receive tocilizumab by intravenous infusion and were compared with 2094 patients randomly allocated to usual care alone.

What did the authors find?

A: Treatment with tocilizumab significantly reduced mortality

B: Treatment with tocilizumab had no effect on mortality

C: Treatment with tocilizumab significantly increased mortality

The correct answer is A

Simon Carley was the first one to cover the paper on St. Emlyns.

Keep in mind this is a pre-print.

In the studied population, 562 (14%) patients received invasive mechanical ventilation, 1686 (41%) received non-invasive respiratory support, and 1868 (45%) received no respiratory support other than oxygen.

596 (29%) of the 2022 patients allocated tocilizumab and 694 (33%) of the 2094 patients allocated to usual care died within 28 days (p=0·007).

Among patients not on invasive mechanical ventilation when entered into the trial, tocilizumab significantly reduced the chance of progressing to invasive mechanical ventilation or death from 38% to 33%.

JC: RECOVERY trial shows Tocilizumab effective for COVID19. St Emlyn’s

Source image: http://hqmeded-ecg.blogspot.com/

Question 5

Which of the following drugs causes ECG-changes resembling Salvador Dali’s moustache?

A: Amitriptyline

B: Isoprenaline

C: Procainamide

D: Digoxin

The correct answer is D.

Pendell Meyers covered ECG changes caused by digoxin this week on dr. Smith’s ECG blog.

‘’Digoxin in therapeutic levels causes downsloping ST depression with a characteristic “Salvador Dali sagging” appearance. Flattened, inverted, or biphasic T waves. Shortened QT interval.’’ 

Source image: hqmeded.com

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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