Quiz 114, May 14th, 2021

Welcome to the 114th FOAMed Quiz.

Case courtesy of Dr Behrang Amini, Radiopaedia.org, rID: 3456

Question 1

A 2-year old is brought to the ER with severe abdominal pain. The pain is intermittent and is accompanied by vomiting and a bloody stool. You decide to perform an intussusception POCUS examination. Transverse sonography shows an alternating concentric pattern of echogenic and hypoechoic bands. This is called a “target sign”.

Which two of the following structures are seen as echogenic bands in a target sign?

A: Mucosa

B: Submucosa

C: Muscularis

D: Lymph node

The correct answers are A & C.

This week ALiEM discussed intussusception POCUS examination.

POCUS findings consistent with intussusception are a sandwich sign (or pseudo-kidney sign) in the longitudinal view and target sign (or donut sign) in the transverse view. There are few studies that have looked at POCUS for intussusception, but the existing studies have shown favorable test characteristics and a decreased length of ER stay with using POCUS.

PEM POCUS Series: Intussusception | Learn about it and test your skills on ALiEMU

Source image: www.pixabay.com

Question 2

The RECOVERY trial  showed a clear mortality benefit of dexamethasone in COVID-19 patients requiring oxygen therapy or mechanical ventilation. In contrast, methylprednisolone is the preferred anti-inflammation agent in other pulmonary diseases because of its direct effect on cell membrane associated proteins.

This recently published single centre retrospective study compared methylprednisolone (1mg/kg/day for > 3 days) to dexamethasone (6mg/day for > 7 days) and usual care (no steroid treatment) in adult patients who were admitted to the ICU for respiratory failure due to COVID-19.

What did the authors find?

A: Methylprednisolone had a mortality benefit over dexamethasone in patients on mechanical ventilation but no benefit in patients not requiring mechanical ventilation

B: Methylprednisolone had a mortality benefit over dexamethasone in patients on mechanical ventilation and in patients not requiring mechanical ventilation

C: Methylprednisolone had no mortality benefit over dexamethasone in patients on mechanical ventilation and in patients not requiring mechanical ventilation

D: Methylprednisolone had no mortality benefit over dexamethasone in patients on mechanical ventilation but was superior in patients not requiring mechanical ventilation

The correct answer is A.

This recent study was covered by Mark Ramzy on RebelEM this week.

This study addressed a clinically relevant and important question. External validity is limited since this study was single center and causation can not be determined since this was a retrospective study.

Switching from dexamethasone to methylprednisolone in a subgroup of patients on mechanical ventilation could be beneficial and should therefore be investigated in future studies.

Dexamethasone vs Methylprednisolone in ICU Patients with COVID19

Source image: www.pixabay.com

Question 3

A 38-year-old man is brought in by the EMS with acute chest pain. He is pale and diaphoretic. In his medical file you find that he is a frequent flyer in your emergency department. His visits are usually drug related. He has been known to use cocaine for several years.

What statement is true about cocaine related chest pain?

A: Beta blockers are absolutely contra-indicated in cocaine induced myocardial infarction

B: Cocaine induces tachycardia and thus higher oxygen demands by inhibition of M2-receptors

C: Patients with cocaine intoxication and clear ST elevations should undergo PCI immediately

D: Cocaine can cause myocardial or pulmonary infarction due to pro-thrombotic properties

The correct answer is D.

This week’s NUEM blog was about cocaine related chest pain. Acute coronary syndrome is caused by coronary vasospasm, higher oxygen demands by inhibiting the reuptake of norepinephrine and enhancing platelet aggregation. Chronic effects of cocaine further contribute to a higher risk of cardiovascular disease (especially acute coronary syndrome and aortic dissection) by accelerating atherogenesis, weakening of the aortic vessel wall and inducing left ventricular hypertrophy.

The mainstay of treatment is benzodiazepines which decrease adrenergic response. Beta-blockers are avoided by some physicians because of fear for unopposed alpha-stimulation. However, this is most likely only a theroretical risk.

Source image: LITFL.com

Question 4

Your 65 year old patient comes in with ongoing chest pain. The ECG shows STE in III, ST depression in any of leads V4 to 6, ST in lead V1 higher than ST in V2.

How is this pattern called?

A: De Winter’s pattern

B: Wellen’s pattern

C: Aslanger’s pattern

D: Brugada’s pattern

The correct answer is C

Dr. Smith’s ECG blog this week was about Aslanger’s pattern.

It is caused by a combination of inferior OMI and diffuse subendocardial ischemia. The subendocardial ischemia produces an ST depression vector toward leads II and V5 (with reciprocal STE in aVR) and cancels most of the STE caused by the inferior OMI results (except for lead III).

Source image: www.pixabay.com

Question 5

Sepsis is a common condition with a high mortality and morbidity. The first (blood) cultures are often taken in the emergency room. Whenever no microbiological pathogens are found, this is referred to as culture negative sepsis.

This systematic review and meta-analysis, consisting of 7 studies with a total of 22,655 patients, compared the overall mortality and clinically relevant secondary outcomes between culture-negative and culture-positive sepsis.

What conclusion did the authors draw?

A: There was no association between culture negativity or positivity and overall mortality. But culture-positive septic patients had a longer hospital stay and mechanical ventilation duration

B: Culture negativity was associated with higher mortality. It also resulted in an extended ventilation duration and a higher need for renal replacement therapy

C: Culture positivity was associated with higher mortality, but there was no significant difference in secondary clinically relevant outcomes

D: Culture-positive septic patients had longer ICU length of stay, but no significantly higher overall mortality compared to culture-negative patients

The correct answer is A.

The proportion of culture negativity is reported between 28 and 49% of all patients with sepsis. Culture positivity or negativity was not associated with a difference in mortality.

Culture-positive septic patients had comparable ICU length of stay, mechanical ventilation requirements and renal replacement requirements compared to culture-negative patients. However, the length of hospital stay and mechanical ventilation time of culture-positive septic patients were both longer than those of culture-negative patients.

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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