Quiz 112, April 23th, 2021

Welcome to the 112th FOAMed Quiz.


Case courtesy of Dr Naqibullah Foladi, Radiopaedia.org, rID: 73139

Question 1

Direct needle decompression (ND) is known to be a possible lifesaving intervention in patients with tension pneumothorax. Current guidelines recommend different locations for this decompression. Preferred locations are the 2nd intercostal space midclavicular line (ICS2-MCL) and the 4th-5th intercostal space at the anterior axillary line (ICS4/5-AAL).

Chest wall thickness (CWT) of the patient and needle length both play a role in the success rate of ND.

The primary outcome in this study was the CWT at ICS2-MCL and ICS4/5-AAL in normal weight (BMI <25), overweight (BMI 25-30) and obese patients (BMI >30) using Point of Care Ultrasound (POCUS). Their secondary outcome was the hypothetical failure rates of ND for these locations, based on standard catheter lengths (45mm and 50mm).

What did the authors find concerning CWT for both locations in overweight and obese patients?

A: CWT in ICS2-MCL was significantly thinner than ICS4/5-AAL

B: CWT was not significantly different in ICS2-MCL compared to ICS4/5-AAL

C: CWT in ICS2-MCL was significantly thicker than ICS4/5-AAL

The correct answer is A.

This prospective, multicenter, observational study was covered by Benjamin Gerritsen on REBEL EM this week.

CWT in ICS2-MCL was significantly thinner than ICS4/5-AAL in both overweight (p<0.001) and obese patientes (p=0.016) but not in patients with a normal BMI.

Hypothetical failure rates for 45mm and 50mm catheters were 2.5% and 0.8% for ICS2-MCL and 6.2% and 2.5% for ICS4/5-AAL (p=0.016 and -=0.052 respectively).

The authors concluded that, in overweight and obese patients, ICS2-MCL is the preferred anatomical location for ND in tension pneumothorax compared to the ICS4/5-AAL when using standard large bore catheters (45mm and 50mm).

Optimal Needle Position for Decompression of Tension Pneumothorax

Source image: www.pixabay.com

Question 2

Your 62 year old patient comes in with gradually worsening mental status changes, lead-pipe rigidity, hyperthermia and tachycardia. She uses medication prescribed by her psychiater, but it remains unclear what medication exactly.

Your differential diagnosis includes neuroleptic malignant syndrome (NMS) and serotonin syndrome (SS).

Which of the following clinical features point in the direction of NMS instead of SS?

A: Mental status changes

B: Lead-pipe rigidity

C: Hyperthermia

D: Tachycardia

The correct answer is B.

NMS was covered on the Internet Book of Critical Care last week.

Both patients with NMS and patients with SS present typically with mental status changes, hyperthermia and tachycardia. However, NMS leads to lead-pipe rigidity, whereas SS typically causes clonus and hyperreflexia.

IBCC – Neuroleptic Malignant Syndrome (NMS)

Source image: www.emdocs.net

Question 3

The use of Droperidol was largely abandoned in 2001 due to concerns about QT-prolongation and Torsade de Pointes. However, recent data supports it’s safety and effectiveness in the treatment of acute agitation and nausea.

These two Australian papers (paper 1, paper 2) covered the safety of Droperidol. A total of 209 patients older than 65 years receiving 2.5, 5 or 10 mg intramuscularly for agitation control were followed. 9 adverse events were reported. What was the most common adverse event?

A: Hypoxia

B: Airway obstruction

C: QT-prolongation

D: Hypotension

The correct answer is D.

AliEM covered these papers (paper 1, paper 2) last week.

In these cohorts of elderly agitated patients, adverse events were rare. The most common adverse event was hypotension (6/9). No patients developed Torsades de Pointes. Droperidol appears to be both effective and safe in agitated adults ≥ 65 years of age for the treatment of agitation.

Droperidol for Agitation in Older Adults in the Emergency Department

Source image: www.intranasal.net

Question 4

The use of intranasal midazolam is pretty convenient in the convulsing patient. At least for emergency care providers. This recently published retrospective pre-hospital study assessed the effectiveness of intranasal midazolam (0,1 mg/kg) versus alternative routes of administration (IV, IM) in children ≤14 years with a seizure. The primary outcome was need for redosing.

What did the authors find?

A: Intranasal midazolam was associated with lower rates of redosing compared to intravenous or intramuscular midazolam

B: Intranasal midazolam was associated with equal rates of redosing compared to intravenous or intramuscular midazolam

C: Intranasal midazolam was associated with higher rates of redosing compared to intravenous or intramuscular midazolam

The correct answer is C.

JournalFeed covered the paper last week.

Redosing of midazolam occurred in 25% (116/461) of patients receiving intranasal midazolam initially compared to 14% (222/1573) of patients receiving alternative routes. It seems intranasal administration is (at least in this dosage) less effective compared to intravenous and intramuscular administration of midazolam in children with a seizure.

Case courtesy of David Puyó, Radiopaedia.org, rID: 22317

Question 5

Your 67 year old patient presents with a renal colic. CT shows a 0.7 cm stone in the right distal ureter. POCUS and CT show moderate hydronephrosis on the right side. In addition to analgesics, you decide to start tamsulosin (an alpha blocker).

Which of the following characteristics make tamsulosin more likely to be beneficial in this patient?

A: Hydronephrosis

B: Location of the stone in the proximal ureter

C: The size of the stone is > 5 mm

The correct answer is C.

Taming the SRU covered the treatment of renal colic this week.

The role of alpha blockers is up for debate in renal colic. Especially patients with a stone > 5 mm may benefit from an alpha blocker in terms of time to stone passage, episodes of pain, hospital admissions and surgical intervention. This effect is irrespective of stone location and the existence of hydronephrosis.

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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