Quiz 117, June 4th, 2021

Welcome to the 117th FOAMed Quiz.


Source image: www.emdocs.net

Question 1

A 48-year-old patient is brought in by the EMS after a motor vehicle collision. He complains of pain in his lower back. His vital signs are SpO2 97% on room air, RR 24/min, HR 124bpm, BP 97/72 mmHg and T 36.4 °C. On physical examination you notice bilateral normal breath sounds and his abdomen is non-tender without distention. FAST is negative. There are no bony deformities. No fractures are seen on the X-rays of his back.

You should have a high suspicion of bleeding in this patient, given his vital signs. You suspect a retroperitoneal bleeding source. Which of the following statements about retroperitoneal trauma is true?

A: Vascular injury in pelvic fractures is usually venous

B: The most common retroperitoneal source of bleeding is renal

C: Negative FAST combined with normal abdominal examination has a negative predictive value of 98% for retroperitoneal bleeding

D: Signs of retroperitoneal hemorrhage (Cullen’s, Turner’s, and Bryant’s sign) are usually present within one hour after trauma

The correct answer is A.

Retroperitoneal trauma was covered by emDocs this week. Retroperitoneal trauma is common; up to a third of polytrauma patients have retroperitoneal trauma. If your trauma patient is hemodynamically unstable, suspect retroperitoneal bleeding, especially if you can’t find another source.

The most common source of bleeding is due to pelvic fractures (use the pelvic binder!). Physical examination is usually normal. 

Source image: www.pixabay.com

Question 2

A 3 year old boy visits the emergency department (ED) with burns on both of his upper legs. He pulled a kettle of hot water from the kitchen table. The mother cooled the boy in the shower and rushed to the ED.

Which of the following statements is true about pediatric burns?

A: Children have a lower metabolic rate and their need for glucose and oxygen is lower compared to adult patients

B: Due to their smaller intravascular volume, children are more sensitive for fluid overload

C: Ice is an effective and safe cooling method

D: The threshold for starting fluid replacement in Total body surface area (TBSA) is higher for children than for adults

The correct answer is B

This week First10EM covered the Pediatric burns.

You should use cool running water for 20 minutes and never use ice This can lead to vasoconstriction and secondary tissue injury.

Fluid resuscitation should be considered for infants with a TBSA greater than 10%. In adults this threshold is generally 15%.

Keep in mind pediatric patients are vulnerable to fluid overload. This can be explained by the smaller intravascular volume per unit burned surface area.

Children have a higher metabolic rate and therefore have an increased fluid loss, oxygen and glucose demand.

Pediatric Burns: A Rapid Review

Source image: www.pixabay.com

Question 3

In patients defining themselves as either black or white, what can be said about the incidence of false normal pulse oximetry measurement (occult hypoxia) according to this paper?

A: The rate of occult hypoxia is equal in black and white patients

B: The rate of occult hypoxia is 3 times higher in black patients compared to white patients

D: The rate of occult hypoxia is 3 times higher in white patients compared to black patients

The correct answer is B.

JournalFeed discussed an article concerning racial bias in pulse oximetry this week.

The authors analyzed a total of 48,097 pairs of measures of oxygen saturation by pulse oximetry and arterial oxygen saturation in arterial blood gas. Black patients had nearly three times the frequency of occult hypoxemia compared to white patients.

Source image: www.pixabay.com

Question 4

Naloxon can be used in different ways in patients with suspected opioid intoxication. The most common route of administration is intravenous. It can also be nebulized.

Which of the following statements is true about nebulized naloxone?

A: This is especially useful in apneic patients

B: The correct dose is 0,2 mg in 3 ml of sodium chloride 0,9%

C: Patients do not get withdrawal symptoms when naloxone is nebulized

D: Patients can self-titrate and remove the nebulizer mask when responsive

The correct answer is D

This week ALIEM covered the utility of nebulized naloxone.

Most studies show a positive result using nebulized naloxone in patients with mildly decreased consciousness. Patients can experience withdrawal symptoms. They can remove the nebulizer mask and this can be seen as ‘self titrating’.

It should not be used as a therapy for apneic patients with suspected opioid intoxication.

Utility of Nebulized Naloxone

Source image: www.saem.org

Question 5

Your patient presents with ascending progressive symmetrical weakness. You want to distinguish Guillain Barré Syndrome (GBS) from tick paralysis and transverse myelitis. You perform a lumbar puncture.

Which of the following is typically elevated in cerebrospinal fluid (CSF) in GBS?

A: Leukocytes

B: Glucose

C: Protein

D: Erythrocytes

The correct answer is C.

EM Cases covered neuromuscular disease in their 2 part podcast series.

Elevated cerebrospinal fluid proteins are seen in GBS. However, during the initial phase of the disease course protein levels may be normal requiring a repeat lumbar puncture if GBS remains on the differential.

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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