Quiz 116, May 28th, 2021

Welcome to the 116th FOAMed Quiz.


Question 1

Source image: dontforgetthebubbles.com

Your 12 year old patient presents to your ED after his gastrostomy tube has fallen out 30 minutes ago. He and his parents do not have a spare one. You decide to place a foley catheter through the tract to keep it open as soon as possible.

Which of the following is a contra-indication for placement of the foley catheter?

A: This is a primary tube, placed 3 weeks ago

B: There is minor bleeding from the tract

C: It concerns a gastro-jejunostomy tube

D: Never place a foley in the tract of a gastrostomy tube

The correct answer is A

Don’t forget the Bubbles covered feeding tube troubles last week.

If the tract is left empty it will close up in hours. Replace the tube if you can. Otherwise put a foley catheter in the tract and tape it to the skin.

In patients that had the gastrostomy placed less than 4 weeks ago, the tract has not matured yet and placing a catheter should be avoided. Between 4 and 6 weeks, placement of a catheter can be tried very carefully.

Question 2

Source image: ctscanmachines.blogspot.com

Your 67 year old patient presents to the emergency department with an altered level of consciousness. Her Glasgow Coma Scale is E1M4V1. Her husband tells you she has been complaining of progressive headaches, diplopia and vomiting for a couple of weeks. You suspect her of having elevated intracranial pressure due to a cerebral mass.

Elevated intracranial pressure (ICP) can occur due to mass lesions, cerebral edema (stroke, traumatic brain injury, metabolic disturbances) or obstruction of venous or cerebrospinal fluid outflow.

Which of the following statements about elevated intracranial pressure is true?

A: Lumbar puncture is safe when elevated ICP exists due to a mass lesion

B: Patients with elevated ICP should be hyperventilated to sustain a normal ICP (target PaCO2 20-25 mmHg)

C: Mannitol seems to be less effective in improving cerebral perfusion pressure compared to hypertonic saline

D: Hypothermia improves clinical outcomes

The correct answer is C.

Elevated intracranial pressure was discussed in EMcrit’s Internet Book of Critical Care this week.

Mannitol is frequently used to decrease ICP, but is increasingly replaced by hypertonic saline as a first line agent. Mannitol is nephrotoxic, causes volume depletion (and brain hypoperfusion) and can cause a rebound elevation in ICP. Hypertonic saline (3%) is a safer treatment option. Furthermore, Mannitol seems to be less effective in improving cerebral perfusion pressure compared to hypertonic saline

When performing a lumbar puncture you risk downward herniation of the brain if there is a mass lesion.

Hyperventilation causes cerebral vasoconstriction and thus lowers ICP, but also lowers cerebral perfusion pressure. Low-normal PaCO2 (35-40 mmHg) is a reasonable target.

Hypothermia lowers ICP, but also causes bradycardia and hypotension. There is no high-quality evidence to support its use.

Elevated intracranial pressure (ICP)

Question 3

Source image: www.endoskopiebilder.de/

What is the cause of a stercoral ulcer?

A: Ingestion of a button battery

B: Recent abdominal surgery

C: Fecal mass

D: Malignancies

The correct answer is C

EMdocs covered a case in which a patient died from a perforated stercoral ulcer in their medical malpractice series

As you know, constipation is not always benign. Hard stool can cause colonic wall ulceration (stercoral ulcer) which leads to stercoral perforation.

Medical Malpractice Insights: Bowel perforation due to stercoral ulcer

source image: pixabay.com

Question 4

Intravenous calcium is increasingly used in the bleeding trauma patient. However, it is not yet included in all major guidelines.

This recently published systematic review covered 3 cohort studies including 1213 trauma patients.

What did the authors find?

A: Higher mortality rates were observed in patients with hypocalcemia in all three studies compared to patients with normal serum calcium

B: Patients with hypocalcemia required less blood transfusion compared to patients with normal serum calcium

C: Patients with normal serum calcium had increased coagulopathy (defined as initial INR ⪖ 1,5) compared to patients with hypocalcemia

The correct answer is A

Calcium in the trauma patient was covered on St. Emlyns last week.

In general, hypocalcemia in the bleeding patient is a bad thing. It is associated with higher mortality. Furthermore, patients with hypocalcemia require more blood transfusion and hypocalcemia is associated with increased coagulopathy and clot strength.

Hypocalcaemia, Trauma and Major Transfusion. St Emlyn’s

Question 5

Source image: www.first-nature.com


Your 45 year old patient presents to your ED after eating mushrooms. He ate several different types and does not remember what they looked like exactly.

Which of the following symptoms points in the direction of a life threatening intoxication?

A: Gastrointestinal symptoms starting 20 minutes after ingestion

B: Gastrointestinal symptoms starting 8 hours after ingestion

The correct answer is B

Mushroom poisoning was covered on CountyEM last week.

Mushrooms that cause symptoms more than six hours after consumption are associated with serious and potentially lethal toxicity.

The Poisoned Mushroom Hunter

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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