Quiz 103, February 19th, 2021

Welcome to the 103th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Your 68-year old patient comes in with septic shock. He is hypotensive, tachycardic, tachypnoeic and has a fever. His blood pressure normalises after initial resuscitation with iv fluids but he continues to be tachycardic with a heart rate of 140 bpm.

You wonder if it might be beneficial for this patient to add a beta blocker to his current treatment in order to moderate his hypersympathetic state.

This recently published systematic review and meta-analysis is about 7 trials in which patients in septic shock with persistent tachycardia, after adequate initial resuscitation, were randomised to either a short acting beta blocker (esmolol or landiolol) or placebo. The primary outcome was 28-day mortality.

What did the authors find?

A: 28-day mortality was significantly lower in patients who received a beta blocker compared to patients who received placebo

B: 28-day mortality was not statistically different in patients who received a beta blocker compared to patients who received placebo

C: 28-day mortality was significantly higher in patients who received a beta blocker compared to patients who received placebo

The correct answer is A

This recently published systematic review and meta-analysis was covered by Clay Smith on SpoonFeed this week.

A total of 7 RCT’s (613 patients) were included in this systematic review and 6 of these trials (572 patients) were eventually analysed. Mortality risk was reduced by 32% in patients who received a beta blocker vs placebo. The overall mortality rates were 36.7% and 54.9% in the esmolol/landiolol cohort and placebo group respectively (absolute risk reduction 18%, NNT 5.5). 

Heart rate was significantly lower in patients who received a beta blocker compared to patients who received placebo while the mean arterial pressure (MAP) was not statistically different between these two groups.

Although these results look encouraging, we have to take in mind that the studies were rather small and that there was a wide range of mortality across these centers (12-62% in the beta blocker group; 20-80% in the placebo group).

Source image: Case contributed by Dr Alexandra Stanislavsky, Radiopaedia.org

Question 2

The “empty cup” sign is a radiological image of a perilunate dislocation. The distal radius is the saucer and the tilted lunate is the cup.

In a normal situation, which bone would project above the lunate and be the “fill” of the cup?

A: Trapezium

B: Trapezoid

C: Capitate

D: Hamate

The correct answer is C.

This week, DFTB discussed carpal injuries in children.

In this case the apple, cup, saucer analogy, the capitate, lunate and radius, respectively, should be aligned.

Source image: www.pixabay.com

Question 3

Benign Paroxysmal Positional Vertigo (BPPV) is common in the ED. Displaced otoliths are located in the semicircular canals, causing brief episodes of dizziness.

Which of the following is most commonly affected?

A: Unilateral posterior canal

B: Unilateral horizontal canal

C: Bilateral posterior canals

D: Bilateral horizontal canals

The correct answer is A

AliEM covered BPPD and its treatment last week.

The affected canals are:
83%: Unilateral posterior canal
7% : Unilateral horizontal canal
6% Bilateral posterior canals
Rare: Anterior canal

The same maneuvers can be used to treat both posterior and anterior BPPV (Epley, Semont).

Tricks of Trade: Benign paroxysmal positional vertigo | Beyond the Basics

Source image: www.pixabay.com

Question 4

Diabetic ketoacidosis (DKA) is often encountered in the ED. Despite improved treatment in the last decades, mortality is still about 2 percent.

Euglycemic ketoacidosis is quite often missed leading to delayed treatment.

Which of the following drugs can cause euglycemic ketoacidosis?

A: Metformin

B: Liraglutide

C: Sitagliptine

D: Canagliflozine

The correct answer is D

The resus room covered DKA extensively in their podcast last week.

SGLT2 inhibitors are known to (although very rare) cause euglycemic ketoacidosis.

Liraglutide is a GLP1 agonist. Sitagliptin is a DPP4 inhibitor.

Diabetic Ketoacidosis

Source image: www.rebelem.com

Question 5

Although alteplase is registered as the first line agent of choice for iv thrombolysis in ischemic stroke, tenecteplase may have some benefits over alteplase. It is about half the price, it has greater fibrin specificity and has a longer half-life than alteplase.

Recent data has emerged regarding tenecteplase as an alternative to alteplase in ischemic stroke. This recently published systematic review and meta-analysis covers these papers.

What did the authors find?

A: Alteplase was associated with an increase in good or excellent functional outcome (modified Rankin Scale 0-2) compared to tenecteplase

B: There was no difference in good or excellent functional outcome (modified Rankin Scale 0-2) between the two drugs

C: Tenecteplase was associated with an increase in good or excellent functional outcome (modified Rankin Scale 0-2) compared to alteplase

The correct answer is B

RebelEM covered the paper last week.

8 trials were included (of which 6 randomised and 2 observational), covering data of 2031 patients. There was no difference in good or excellent functional outcome. However, tenecteplase showed higher rates of recanalization.

There are several studies using tenecteplase in ischemic stroke patients underway to be on the lookout for.

Tenecteplase may well be equally effective or even more effective as iv thrombolytic agent compared to alteplase.

Tenecteplase for Thrombolysis of AIS?

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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