Quiz 104, February 26th, 2021

Welcome to the 104th FOAMed Quiz.


Source image: www.rebelem.com

Question 1

Epistaxis can often be treated with local therapy and anterior nasal packing. Topical tranexamic acid (TXA) is quite often used for this indication. Evidence available so far supports the use of topical tranexamic acid, but the evidence is weak.

Recently, the first blinded RCT on this topic was published. The authors compared topical intranasal TXA to placebo in patients with persistent epistaxis

What did the investigators find?

A: Topical tranexamic acid was more effective compared to placebo in stopping the bleeding

B: Topical tranexamic acid was equally effective compared to placebo in stopping the bleeding

C: Topical tranexamic acid was less effective compared to placebo in stopping the bleeding

The correct answer is B

This paper was covered by StEmlyns, First10EM and FoamCast.

496 patients with epistaxis were randomized. All patients received a topical vasoconstrictor on emergency department arrival. If bleeding continued, the patient was included.

TXA (2 ml = 200 mg) was placed on a dental roll and left in the nose for 10 minutes. If necessary, this was repeated.

The primary outcome was the use of anterior nasal packing during the emergency department visit.

In the TXA group, 111 of 254 (43.7%) received nasal packing compared to 100 of the 242 (41.3%) in the placebo group. There were no statistically significant differences for any of the secondary outcomes either.

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 20287

Question 2

A 32 year old male patient attends your ED after twisting his right knee during a football game. The X-ray shows an avulsion fracture of the lateral tibial plateau. Also known as a Segond fracture.

A tear in which ligament is associated with this finding?

A: Lateral Collateral Ligament (LCL)

B: Medial Collateral Ligament (MCL)

C: Anterior Cruciate Ligament (ACL)

D: Posterior Cruciate Ligament (PCL)

The correct answer is C

NuEM discussed knee trauma this week.

Internal rotation and varus stress can lead occurrence of a Segond fracture. It is frequently associated with disruption of the ACL.

Source image: www.pixabay.com

Question 3

Your 35 year old patient presents to your ED in southern Florida with vomiting, hot and cold reversal (cold allodynia) and a headache. Performing a thorough medical history, you find she ate barracuda earlier tonight.

Which of the following is most likely the cause of your patient’s symptoms:

A: Scombroid poisoning

B: Tetrodotoxin poisoning

C: Ciguatera (ciguatoxin poisoning)

The correct answer is C

EMDocs covered seafood poisoning this week.

Scombroid is caused by the improper storage of dark-meat fish (and sometimes raw milk cheese), which results in the conversion of histidine to large quantities of histamine.

Tetrodotoxin is the neurotoxin of pufferfish.

Ciguatera fish poisoning is the most frequently reported seafood illness worldwide. The syndrome is caused by ingestion of reef finfish. It causes gastrointestinal symptoms, cold allodynia (hot-cold reversal), paresthesias (stocking-glove & peri-oral), headache, and dizziness. Some patients go on to develop cardiovascular complications including heart block, bradycardia, and hypotension.

Source image: www.rebelem.com

Question 4

The optimal dosage for ketamine to achieve adequate analgesia with as little side effect as possible is still up for debate.

This recently published paper is about 0.15 mg/kg intravenous (IV) versus 0.3 mg/kg intravenous ketamine in emergency department (ED) patients with acute pain. Patients were randomised to either dose. The primary endpoint was NRS pain score at 30 minutes.

What did the authors find?

A: 0.15 mg/kg IV ketamine was inferior to 0.3 mg/kg IV ketamine

B: 0.15 mg/kg IV ketamine was noninferior to 0.3 mg/kg IV ketamine

C: Both 0.15 mg/kg and 0.3 mg/kg IV ketamine were not effective at all

The correct answer is B

The paper was covered on JournalFeed last week.

49 patients were included in each group. The mean NRS score at 30 minutes was 4.7 (95% confidence interval [CI] = 3.8 to 5.5) in the low-dose group and 5.0 (95% CI = 4.2 to 5.8) in the high-dose group. Differences in the baseline NRS score were adjusted for.

0.15 mg/kg iv ketamine does not appear to be less effective compared to 0.30 mg/kg iv ketamine.

Source image: www.pixabay.com

Question 5

Patients with hypoxaemic respiratory failure are frequently encountered in the ED and ICU. Hypoxia is harmful of course, but hyperoxia is potentially harmful as well. The OXYGEN-ICU trial showed a mortality benefit in favour of conservative protocol for oxygen therapy versus conventional therapy. Subsequent RCT’s could not reproduce these results.

Another RCT on this topic was published recently. 2928 Patients with hypoxaemic respiratory failure were randomised to either a lower oxygen target group (PaO2 of 60mmHg) or a higher oxygen target group (PaO2 of 90mmHg). The primary outcome was 90-day all–cause mortality.

What did the authors find?

A: Patients in the low target oxygen group had a decreased mortality compared to patients in the high target oxygen group

B: Patients in the low target oxygen group had a increased mortality compared to patients in the high target oxygen group

C: There was no difference in mortality between the two groups

The correct answer is C

The Bottom Line covered the paper last week.

All–cause mortality was 42.9% and 42.4% in the low target oxygen group and the high target oxygen group respectively (p = 0.64). There were no differences in serious adverse events either.

A target PaO2 of 60mmHg for patients with hypoxaemic respiratory failure does not result in a mortality benefit compared to a target of 90 mmHg, but it does not lead to harm either.


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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