Quiz 119, June 18th, 2021

Welcome to the 119th FOAMed Quiz.


Question 1

A 25-year-old male has fallen from his bike on his left side. He complains of left-sided chest pain and dyspnea. On physical examination, you hear decreased breath sounds on the left side. X-ray shows rib fractures of ribs 6-8 and a pneumothorax. You insert a chest tube.

Chest tube placement is frequently performed in the ED. Usually the course is not remarkable, but occasionally these tubes cause problems.

Which of the following actions to chest tube complications is correct?

A: Your chest tube is placed intrafissural. You don’t have to reposition the tube as long as it is draining blood and air

B: You suspect a clot is obstructing your tube. You can try to extract the clot by squeezing the tube with your entire hand (milking)

C: Your patient develops miosis, ptosis, anhidrosis and enophthalmos. This is a neurosurgical emergency

D: 500 cc’s of blood is evacuated immediately after placement. It continues to produce 80cc/hour. This patient should undergo emergency thoracotomy as you suspect a laceration of an intercostal artery

The correct answer is A.

County EM covered complications of chest tube placement.

In suspected obstructing clot, milking a chest tube can be dangerous due to high negative intrathoracic pressure. You can irrigate the tube with saline or insert an embolectomy catheter through the tube to resolve the obstructing clot.

Horner’s syndrome (miosis, ptosis, anhidrosis and enophthalmos) after tube placement is caused by direct pressure of the tube or hematoma. The first action is to pull the chest tube back 2-3 cm, and confirm placement. Most patients will fully recover.

Iatrogenic hematothorax is not an uncommon complication. According to ATLS, emergent surgical intervention should be performed if the evacuated volume exceeds 1500 cc or if the ongoing blood loss is greater than 150 cc per hour.

Source image: www.pixabay.com

Question 2

It is a congenital abnormality of the small intestine that is present in 2% of the population. 2% of these people will become symptomatic. It is 2 inches long. There can be 2 types of ectopic tissue in it: gastric and pancreatic. There is a 2:1 male preponderance.

Which of the following congenital intestinal abnormalities fits this description?

A: Duodenal atresia

B: Intestinal malrotation

C: Duodenal web

D: Meckel’s diverticulum

The correct answer is D.

Don’t forget the Bubbles covered Meckel’s diverticulum last week.

The rule of 2s is about the features of Meckel diverticulum (although the ranges are quite wide):

It usually becomes symptomatic (if at all) before the age of 2
It occur in 2% of the population
Meckel’s diverticulum is about 2 inches (5 cm) long
You can find a Meckel’s diverticulum 2 feet (60 cm) from the ileocecal valve
2 types of ectopic tissue are commonly present (gastric and pancreatic)
2% become symptomatic

Source image: www.epmonthly.com

Question 3

Urine drug screens are occasionally used in the ED in patients with unexplained changes in mental status. The interpretation of these tests is challenging, because of frequent false positive and false negative results.

Which of the following statements is true about urine drug screens?

A: Bupropion can cause a false positive result for amphetamines

B: Sertraline can cause a false positive result for benzodiazepines

C: Synthetic opioids (fentanyl, methadone, tramadol) are typically missed on the standard urine drug screen and require a specific immunoassay

D: All of the above are true

The correct answer is D.

This week’s emDocs toxcard is about urine drug screens.

The big take-home-message of this toxcard is to interpret urine drug screens with great caution. Be aware of the many false positive results and also of the high percentage of false negative screens.

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 35793

Question 4

Recently, this systematic review about the value of POCUS for patients with acute dyspnea was published. Two RCT’s and a prospective cohort study reported on use of POCUS and the rate of correct diagnosis and correct treatment within 4 hours.

What did the authors find?

A: Adding POCUS to standard care did not improve the rate of correct diagnosis and did not improve the rate of the correct treatment within 4 hours

B: Adding POCUS to standard care did not improve the rate of correct diagnosis, but led to an improvement in the rate of the correct treatment within 4 hours

C: Adding POCUS to standard care did improve the rate of correct diagnosis and the rate of the correct treatment within 4 hours

The correct answer is C

This week Graham van Schaik covered POCUS for acute dyspnea on JournalFeed.

In case of diagnostic uncertainty POCUS should be used for patients in acute dyspnea in addition to the standard diagnostic pathway in the ED or inpatient settings.

According to this paper, adding POCUS improved the rate of correct diagnosis at the 4 hours mark (88% vs 64%) and, even more important, the rate of appropriate treatment (78% vs 57%).

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 4425

Question 5

A 39 year old female patient presents to your ED with thunderclap headache and vomiting. She has had these headaches five times before over the past two weeks. These episodes lasted about 1-3 hours but now she does not seem to recover. The headache started directly after sneezing. You suspect a Subarachnoid Hemorrhage (SAH) or Reversible Cerebral Vasoconstriction Syndrome (RCVS).

Which of the following statements is true about RCVS?

A: RCVS has a mortality rate of about 40 percent

B: About a third of patients recover spontaneously

C: RVCS can lead to subarachnoid hemorrhage

D: CT without contrast is the gold standard diagnostic test for RVCS

The correct answer is C

This week Josh Farkas covers the Reversible Cerebral Vasoconstriction Syndrome.

RCVS causes severe headaches due to diffuse, multifocal vasospasm of intracranial arteries.

About 90% of patients will improve spontaneously, so conservative therapy is appropriate for nearly all patients.

Small convexity subarachnoid hemorrhages occur in about a third of patients.

Invasive angiography is the gold standard diagnostic test however it is safer and easier to obtain an CTA or MRA, because of the risk of provoking ischemia (9%).

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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