Quiz 118, June 11th, 2021

Welcome to the 111th FOAMed Quiz.


Source image: https://www.eplabdigest.com/

Question 1

Your 63 year old patient is in profound shock. His capillary refill is 4 seconds, his heart rate is 120 / minute, blood pressure 86/40 mmHg and his hands and feet are cold. He states he took a handful of his antiarrhythmic drugs to end his life. His ECG is shown above.

Which of the following antiarrhythmics is most likely the cause?

A: Flecainide

B: Metoprolol

C: Verapamil

D: Digoxine

The correct answer is A.

EMDocs covered flecainide poisoning this week.

The ECG shows prolonged QRS interval and a large terminal R wave in aVR. These findings are suggestive of sodium channel blockade.

Class I antiarrhythmics rely on sodium channel blockade. Flecainide is the only class I antiarrhythmic in this list.

Question 2

Your 65 year old patient presents with right hemiparesis. His medical history reveals an increased risk of cardiovascular disease and hypertension. He uses acetylsalicylic acid and metoprolol. He shows no abnormal findings in A and B, but he has mild hypertension (170/90).

His CT-scan reveals the following:

Source image: https://consultqd.clevelandclinic.org/

Which of the following statements about the management of this patient is true?

A: Platelet transfusion is required because the patient uses antiplatelet therapy

B: Lowering the systolic blood pressure to below 140 mmHg is safe

C: The blood pressure should not be lowered

D: Seizure prophylaxis is recommended in this patient

The correct answer is B

County EM covered Spontaneous Intracranial Hemorrhage (SIH) this week.

To this date there is no evidence to support the use of seizure prophylaxis in patients with Spontaneous Intracranial Hemorrhage.

The PATCH trial showed that patients with ICH who are on antiplatelet agents have worse neurological outcomes at 3 months if they are treated with a platelet transfusion compared to standard care alone.

INTERACT2 and ATACH II trial showed at least no harm of lowering systolic blood pressure in patients with SIH to < 140 mmHg. Whether lowering the blood pressure to < 140 mmHg is beneficial to < 180 mmHg remains uncertain to this point.

Question 3

Which of the following odontoid fractures is considered the least stable?


Source image: https://radiologykey.com/spine-12/


Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 20305


Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org, rID: 12233

The correct answer is B.

AliEM covered odontoid fractures last week.

Answer A shows a type I odontoid fracture. This fracture is considered stable.

Answer B shows a type II odontoid fracture. This fracture is the most likely to require surgery. It has a high nonunion rate due to interruption of blood supply.

Answer C shows a type III odontoid fracture. It is a mechanically unstable injury, but has good prognosis for healing.

SplintER Series: The Tooth of the Cervical Spine

Source image: www.pixabay.com

Question 4

Your patient presents to the ED with tachycardia, hypertension, tachypnea and dystonia. He recovered completely during observation in the ED. His symptoms occurred for the fifth time this week and lasted about 30 minutes. He is admitted because of the suspicion of Paroxysmal Sympathetic Hyperactivity (PSH).

Which of the following pathologies is NOT a cause of Paroxysmal Sympathetic Hyperactivity?

A: Lithium intoxication

B: Traumatic Brain injury

C: Stroke

D: Cerebral Fat Embolism Syndrome

The correct answer is A

EMCrit covered Paroxysmal sympathetic Hyperactivity on their The Internet Book of Critical Care.

Paroxysmal Sympathetic Hyperactivity (PSH) causes recurrent episodes of dysregulated sympathetic activity, resulting from severe brain injury.

PSH typically occurs in the first two weeks after severe and diffuse brain injury. It usually resolves within a year.

Symptoms include tachycardia, hypertension, tachypnea, fever, diaphoresis and dystonia. They can last up to 30 minutes with a near complete resolution.

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8161

Question 5

Your 29 year old female patient presents to the ED with left sided abdominal pain, syncope and hypotension. She tells you she missed a couple of menses and all of a sudden she started vaginal bleeding this afternoon. You suspect ectopic pregnancy.

Which of the following statements is true about ectopic pregnancy?

A: Low serum B-HCG rules out an ectopic pregnancy

B: The absence of visible pregnancy on ultrasound rules out an ectopic pregnancy

C: Risk factors such as prior tubal surgery, ectopic pregnancy or previous PID are present in almost every patient with ectopic pregnancy

D: The triad, consisting of abdominal pain, missed menses and vaginal bleeding is not seen in a quarter of the patients

The correct answer is D

This week’s EMDocs covered Ectopic Pregnancy.

No hCG level or series of hCG levels can rule out ectopic pregnancy completely.

If no pregnancy is visible on ultrasound, an ectopic pregnancy can still be present. It may just be too early to visualize it.

Half of patients with ectopic pregnancy have no risk factors such as prior tubal surgery, ectopic pregnancy, previous PID, assisted fertility and smoking.

Abdominal pain (80-90%), missed menses 4-12 weeks after last menstrual period (75-90%) and vaginal bleeding (50-80%) is the classic triad and seen in 75% of the 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