Quiz 105, March 5th, 2021

Welcome to the 105th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

A 54-year-old man with a history of intravenous drug abuse is referred for persistent neck pain which radiates to his left arm. He also complains of progressive hand weakness and a mild fever. You suspect him of a spinal epidural abscess (SEA).

What is the most appropriate next step?

A: Cervical X-ray and Lumbar Puncture

B: Spinal CT scan and surgical consultation for laminectomy

C: Start empirical intravenous antibiotics and order MRI

D: Start antibiotics and CT guided drainage

The correct answer is C

EMdocs discussed SEA this week.

SEA is an uncommon condition with often non-specific complaints. Less than 15% of the patients present themselves with the classical triad of; fever, neck / back pain and focal neurologic deficits.

SEA most often occurs in immunocompromised patients. Intravenous drug use and diabetes mellitus are significant risk factors for SEA.

Most of the SEA is caused by Staphylococcus aureus. Empirical antibiotics should not be delayed by imaging. The imaging modality of choice is MRI.

Source image: www.pixabay.com

Question 2

A 13-month old baby found a tablet of suboxone (buprenorphine/naloxone) and most likely ate it. The baby looked fine. Her mother calls your emergency department if she needs to worry. 

What should be the answer?

A: It depends on the dosing of the pills; if low dose (buprenorphine 2mg and naloxone 0.5mg), she does not need to worry. If high dose (buprenorphine 8mg and naloxone 2mg), she needs to come in with the toddler

B: The naloxone will counteract the buprenorphine, so this is not harmful.

C: She needs to come in with the baby. One pill can cause symptoms in babies and toddlers

The correct answer is C

Opioid intoxication was covered in PEM Currents toxicology podcast this week.

Suboxone is used in adults with opioid use disorder. These are sublingual pills. The added naloxone does not prevent opioid effects when taken orally, but prevents iv abuse of the suboxone pills.

One pill can cause severe symptoms in babies and toddlers. The Tmax is about 90 minutes.

Of course, this child should be thoroughly evaluated for child abuse as well.

Source image: slideplayer.com, published by Timothy Beasley

Question 3

Your 35 year old patient fell off his racing bike. He presents with an open fracture of his left lower leg. There appears to be no visible contamination and mild soft tissue damage.

Which Gustilo type matches the photo and description?

A: Type 1

B: Type 2

C: Type 3b

D: Type 4

The correct answer is B

Taming the SRU covered open fractures last week.

Grade II fractures have wounds between >1 cm and 10 cm and have mild soft tissue damage. Type 1 fractures are < 1 cm in size and type 3 fractures are more severe. Gustilo type 4 fractures do not exist.

Case courtesy of Dr David Cuete, Radiopaedia.org, rID: 22770

Question 4

It seems every other week a trial about tranexamic acid (TXA) is published. Last month, the ULTRA trial was published in the Lancet.

955 patients with CT confirmed subarachnoid hemorrhage (SAH) were randomised to receive either TXA (1 gram iv bolus and 1 gram every 8 hours) or usual care.

The primary outcome was a good neurologic outcome (modified Rankin Scale 3 or less) at 6 months.

What did the authors find?

A: More patients in the TXA group had a good neurologic outcome at 6 months compared to patients in the usual care group

B: Less patients in the TXA group had a good neurologic outcome at 6 months compared to patients in the usual care group

C: The rate of good neurologic outcome did not differ between the groups

The correct answer is C

First10EM covered the trial last week.

This is another negative trial on TXA.

A good neurologic outcome was found in 60% of the TXA group and 64% of the control group. All cause mortality was 27% in the TXA group and 24% in the usual care.

Keep in mind the researchers were not blinded and the mRS is a far from perfect tool to assess neurologic state. Nevertheless, TXA should not be used in SAH. 

TXA for SAH: Another swing and a miss for the wonder drug

Source image: www.pixabay.com

Question 5

Your 64 year old, otherwise healthy patient states he has hearing loss in his left ear since yesterday. He denies any other complaints.

Rinne’s test is positive on both sides.

Weber’s test lateralizes to the right.

Which of the following causes is most likely?

A: Otitis externa

B: Otitis media

C: Cholesteatoma

D: Sudden sensorineural hearing loss (SSNHL) (sudden deafness)

The correct answer is D

Don’t forget the bubbles covered Rinnes and Webers test last week.

Weber’s test lateralizes to the good side, indicating there is sensorineural hearing loss on the left side or conductive hearing loss in the right side.

Rinne’s test is positive (normal) on both sides, indicating there is no conductive hearing loss.

So, there is sensorineural (perceptive) hearing loss on the left side.

Otitis externa, otitis media and cholesteatoma cause conductive hearing loss. The only sensorineural hearing loss in this list is SSNHL (formerly sudden deafness).

Sudden sensorineural hearing loss (SSHL), commonly known as sudden deafness, occurs as an unexplained, rapid loss of hearing—usually in one ear—either at once or over several days. It should be considered a medical emergency.

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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