Quiz 108, March 26th, 2021

Welcome to the 108th FOAMed Quiz.


Source image: https://pemplaybook.org/

Question 1

Your 7-year-old patient fell backwards on her outstretched left hand and is now complaining of pain in her elbow. You order an X-ray of her left elbow.

Which of the following statements about pediatric elbow X-ray is true?

A: The anterior humeral line should pass through the posterior third of the capitellum

B: A sail sign can indicate an occult supracondylar fracture

C: The capitellum is the last ossification centre to appear

D: An oblique view is useful when suspicion for a supracondylar fracture is high

The correct answer is B.

ALiEM covered the pediatric traumatic elbow X-ray in their EMRad series.

The anterior humeral line should pass through the middle third of the capitellum. An anterior humeral line passing through the anterior third of the capitellum can be normal, however, in children < 4 years of age.

A sail sign is an excessively prominent anterior fat pad and is (like a posterior fat pad) considered pathologic.

There are six ossification centers in the elbow. If one is missing or prematurely present you should consider a fracture. The mnemonic CRITOE is used for the order in which these ossification centers appear: capitellum – radial head – internal (medial) epicondyle – trochlea – olecranon – external (lateral) epicondyle.

Oblique views allow for better visualization of the radiocapitellar joint, medial epicondyle, radioulnar joint, and coronoid process.

EMRad: Radiologic Approach to the Pediatric Traumatic Elbow X-ray

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 20542

Question 2

A 44-year-old woman presents to the emergency department with persistent abdominal pain. The pain is located in the upper right quadrant. She states to have had similar symptoms before, but then they were self-limiting. POCUS reveals pericholecystic fluid and gallstones. The wall looks thickened.

Which of the following statements is true?

A: Wall thickness up to 5 mm is considered normal

B: Wall thickening and pericholecystic fluid are the most sensitive US findings in acute cholecystitis

C: The posterior wall may appear falsely thickened because of posterior acoustic enhancement

The correct answer is C.

This week ultrasound for suspected acute cholecystitis was discussed on NUEM blog.

POCUS by EM physicians has been shown to be very sensitive (82-91%) and specific (66-95%) for diagnosing biliary pathology.

The most sensitive US finding in acute cholecystitis is the presence of cholelithiasis in combination with the sonographic Murphy sign. Both gallbladder wall thickening (> 3 mm) and pericholecystic fluid are secondary findings.

Wall thickness is best measured on the anterior wall. Posterior gallbladder wall thickness is frequently more unreliable due to gallstones, intestinal loops or posterior acoustic enhancement.


Source image: www.pixabay.com

Question 3

The HEART Pathway consists of History, ECG, Age, Risk factors (HEAR) and serial troponins to identify those who most likely do not have ACS. So, to follow the pathway correctly, you need a troponin.

This recently published paper is about identification of very low-risk acute chest pain patients without troponin testing. The main goal was to measure the major adverse cardiac event (MACE) rate among patients with ≼1 HEAR scores and determine whether serial troponin testing is needed to achieve a miss rate <1%.

What do you think the authors found?

A: The HEAR score without troponin testing had a sensitivity of 81,8 percent for MACE at 30 days

B: The HEAR score without troponin testing had a sensitivity of 87,4 percent for MACE at 30 days

C: The HEAR score without troponin testing had a sensitivity of 97,8 percent for MACE at 30 days

D: The HEAR score without troponin testing had a sensitivity of 99,4 percent for MACE at 30 days

The correct answer is C

RebelEM covered the trial last week.

This was a preplanned secondary analysis of the HEART Pathway Implementation Trial.

447 patients had a HEAR score of ≤1.

The sensitivity was 97.8% for a HEAR score ≤1 without troponin and 99.4% for HEAR score ≤1 with troponin.

Risk stratifying algorithms without the need for biochemical tests sure are interesting. However, in this paper the sensitivity seems a tad low.

The HEAR Score: Does Very Low-Risk Acute Chest Pain Not Require Troponin Testing?

Source image: www.rcemlearning.co.uk

Question 4

Your 45 year old patient presents with abdominal pain which radiates to his back. His prior history of alcohol abuse and the high lipase in his blood make the diagnosis of pancreatitis.

This recently published review is about acute pancreatitis. The evidence of disease severity, fluid and nutrition management and risk reduction methods are summarised.

Which of the following statements is true about acute pancreatitis?

A: Gallstone disease and triglyceridemia are the two most common causes of acute pancreatitis

B: Cross sectional imaging (CT/MRI) are necessary for the definite diagnosis of acute pancreatitis

C: Enteral nutrition should be delayed at least 24 hours in pancreatitis

D: The BISAP score is the best and easiest score used for risk stratification in pancreatitis

The correct answer is D.

This week’s Spoon feed covered Acute Pancreatitis. 

The two most common causes of acute pancreatitis are gallstones (21-33%) and alcohol (16-27%). 

To diagnose acute pancreatitis 2 of the following criteria must be present: (1) Abdominal pain suggestive of pancreatitis, (2) serum amylase and/or lipase greater than 3 times the upper limit of normal, (3) cross sectional imaging (CT/MRI) findings consistent with acute pancreatitis. 

The APACHE II and Ranson score are cumbersome to calculate. The Bedside Index for Severity in Acute Pancreatitis (BISAP) score is based on 5 variables: BUN, impaired mental status, SIRS, age >60 years or radiographic evidence of pleural effusion within the first 24 hours of admission. This easy score gives an indication about mortality and the association of developing organ failure. 

Starting enteral nutrition within 24 hours of admission is favored because it decreases mortality and multi-organ failure. Use a low fat, soft diet.

Source image: www.rebelem.com

Question 5

The role of Point of Care Ultrasound in patients with Pulmonary Embolism (PE) remains controversial, especially in hemodynamically stable patients.

This paper is about cardiac ultrasound in suspected PE.

Which of the following findings on cardiac ultrasound was the most sensitive for PE according to the paper?

A: Tricuspid Annular Plane Systolic Excursion (TAPSE)

B: McConnell’s sign

C: Septal flattening

D: Right ventricular enlargement

The correct answer is A

BrownEM covered the paper last week.

In this study the sensitivity of focused cardiac ultrasound for pulmonary embolism in emergency department patients with abnormal vital signs was quite high. In patients with a heart rate of >110/min, the sensitivity was even 100%. However, the sensitivity quickly falls when the patient’s vitals signs are close to normal.

Of the cardiac ultrasonographic findings, TAPSE was the most accurate.

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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