Quiz 107, March 19th

Welcome to the 107th FOAMed Quiz.


Question 1

Source image: pixabay.com

Your 37 year old patient presents with hypertension, flushing and a tremor. During physical exam she makes a confused impression and you notice a tremor. She has a bipolar disease and uses fluoxetine. You suspect serotonin syndrome in this patient.

Which of the following statements about serotonin syndrome is true?

A: The clinical triad of serotonin syndrome includes mental state changes, autonomic dysfunction and neuromuscular abnormalities

B: The clinical triad of serotonin syndrome includes ophthalmoplegia, ataxia and confusion

C: The clinical triad of serotonin syndrome includes retinopathy, encephalopathy and deafness

The correct answer is A.

This week EMDocs covered the Serotonin Syndrome.

The clinical triad of the Serotonin Syndrome consists of mental state changes (anxiety, agitation, delirium, seizure or coma), autonomic dysfunction (hypertension, hyperthermia, tachycardia, diaphoresis, flushing and mydriasis) and neuromuscular abnormalities (such as hyperreflexia, clonus, myoclonus, tremor, hypertonia/rigidity).

Wernicke encephalopathy is classically characterised by ophthalmoplegia, ataxia and confusion. If a patient presents with retinopathy, encephalopathy and deafness, Susac Syndrome is a possibility.

EM@3AM: Serotonin Syndrome

Question 2

Source image: www.ultrasoundcases.info/


A 42-year-old woman who recently had a few teeth extracted visits the emergency room. She has a fever and a sore neck. Ultrasound shows a non compressible internal jugular vein. After a CT you determine that she has septic thrombophlebitis of the internal jugular vein (Lemierre’s syndrome). You start antibiotics.

Which bacteria is the most common cause of Lemierre’s syndrome and should therefore definitely be covered?

A: Streptococcus pyogenes

B: Fusobacterium necrophorum

C: Staphylococcus aureus

D: Eikenella corrodens

The correct answer is B.

This week Lemierre’s syndrome was discussed by Taming the SRU.

The disease pathway typically begins with oropharyngeal infection leading to inflammation within the wall of the jugular vein, leading to infected thrombus within the lumen, leading to soft tissue inflammation, leading to persistent bacteremia and eventually septic emboli.

The most common (but not the only) causative pathogen is the anaerobe Fusobacterium necrophorum.

Question 3

Source image: pemcincinnati.com

An 8-year-old child has been hit in the face with a football. His nose is painful, but doesn’t look deviated. On inspection you see a swelling of the right nasal septum that occludes almost the entire nostril.

Which of the following is the correct management?

A: Ice packs for several hours and start xylometazoline

B: Emergent drainage of the hematoma

C: Consultation with ENT doctor within a week

D: X-rays of the nasal bones

The correct answer is B.

This week, PedEMmorsels discussed nasal septal hematomas in children.

About 15% of children with a nasal fracture will have a septal hematoma. Despite being an uncommon condition, it can have far-reaching consequences. A septal hematoma can lead to necrosis, which in the long term can lead to saddle nose deformity. It is therefore a clinical diagnosis requiring urgent surgical intervention.

Nasal Septal Hematoma in Children

Question 4

Source image: pixabay.com

In your emergency room, a middle-aged man with no relevant medical history presents with seizures. Family tells you that after swimming in a lake last week (on holiday in Florida), he became increasingly ill. He has a high fever and a headache. This morning he also started vomiting.

Which of the following exotic-sounding pathogens really exist?

A: Brain-eating amoeba

B: Liquor drinking bacteria

C: Nerve devouring parasite

D: Seizure worm

The correct answer is A.

NuEM covered various pathogens that can be acquired in, around or through water this week.

One of these is Naegleria fowleri. This is a protozoa, also known as the Brain-eating Amoeba. It occurs in warm fresh water. It reaches the brain through the olfactory nerve and causes acute hemorrhagic meningoencephalitis. It is rare but has a high fatality rate of almost 98%. Treatment includes miltefosine, an anti-leishmania drug.


Question 5

Source image: www.neurologyadvisor.com

With the emergence of endovascular treatment of acute ischemic stroke, the question arises which role systemic thrombolysis still has. Previous research shows the role of systemic thrombolysis in patients eligible for endovascular treatment is limited.

Last month, the DEVT trial was published.

In this trial, patients > 18 years of age presenting within 4.5 hours of ischemic stroke symptom onset, eligible for IV alteplase treatment and with cerebral vascular occlusion on CT angiography (CTA) or magnetic resonance angiography (MRA) of the intracranial internal carotid artery or middle cerebral artery (first segment) were randomised to either systemic thrombolysis and endovascular treatment (control) or endovascular treatment alone.

The primary outcome was the proportion of patients achieving a modified Rankin Scale (mRS) 0-2 assessed at 90 days after randomization.

What did the trial show?

A: The trial showed endovascular treatment alone to be superior to systemic thrombolysis and endovascular treatment in achieving a mRS of 0-2 at 90 days

B: The trial showed endovascular treatment alone to be inferior to systemic thrombolysis and endovascular treatment in achieving a mRS of 0-2 at 90 days

C: The trial showed endovascular treatment alone to be non-inferior to systemic thrombolysis and endovascular treatment in achieving a mRS of 0-2 at 90 days

The correct answer is C

RebelEM covered the DEVT trial last week.

235 patients were randomised to either standard care (systemic + endovascular treatment) or intervention (endovascular treatment only).

An mRS of 0-2 was achieved in 54.3% (endovascular alone) versus 46.6% (combination). The non-inferiority margin (-10%) was met. The study was stopped early due to pre-planned interim analysis that demonstrated non-inferiority.

Unfortunately, only 25% of the planned enrollment was completed.

There are additional ongoing trials that will add to the available evidence on this topic.

The DEVT + SKIP Trials: Does Systemic Thrombolysis Prior to Endovascular Treatment Improve Outcomes in Large Vessel Occlusion Strokes?

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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