Quiz 120, June 25th, 2021

Welcome to the 120th FOAMed Quiz.


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Question 1

The 2021 European Resuscitation Council guidelines about newborn resuscitation (European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth) and the UK guideline (Newborn resuscitation and support of transition of infants at birth Guidelines | Resuscitation Council UK) include some changes from the previous guidelines.

According to these guidelines, at what time should the umbilical cord be clamped after the first cry?

A: Immediately

B: Within 30 seconds

C: Between 30 and 60 seconds

D: After at least 60 seconds

The correct answer is D

Don’t forget the Bubbles covered the new UK guideline on neonatal resuscitation last week.

Ideally, we should delay clamping the cord for sixty seconds after the first cry.

However, we should delay cord clamping only if we are able to appropriately support the infant when the transition is incomplete or poor.

Where delayed cord clamping is not possible consider cord milking in infants >28 weeks gestation.

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Question 2

Headache is a known complication after Lumbar Punture (LP). Which of the following actions is proven to reduce the risk of post LP headache according to this recently published paper ?

A: Using a lower intervertebral space

B: Using an atraumatic needle instead of a cutting needle

C: Advising the patient to drink 3 cups of caffeinated coffee per day for three days

D: Placing the patient in upright position instead of lateral decubitus position

The correct answer is B

Journalfeed covered this systematic review about post LP headache last week.

Factors that are associated with post-LP headache are female sex, lower BMI, younger age, and history of headache.

Atraumatic needles are definitely effective to reduce this complication and are not more difficult to use compared to cutting needles.

Lateral decubitus position and using a higher intervertebral space may reduce the risk, whereas IV fluids and caffeine do not reduce the risk on post LP headache.

Question 3

Last month, this article  about the treatment of acute basilar occlusion was published in the New England Journal of Medicine.

The authors included 300 patients with proven basilar artery occlusion on CTA or MRA and an NIHSS score of ≥ 10. These patients were randomly assigned to either endovascular therapy (154 patients) or standard therapy (146 patients). Primary outcome was favorable functional outcome, which was defined as having a modified Rankin score of 0-3 at 90 days post randomisation.

What did the authors find?

A: Patients treated with endovascular therapy had a higher rate of favorable functional outcome compared to patients treated with standard therapy

B: Patients treated with endovascular therapy had an equal rate of favorable functional outcome compared to patients treated with standard therapy

C: Patients treated with endovascular therapy had a lower rate of favorable functional outcome compared to patients treated with standard therapy

The correct answer is B.

RebelEM covered the paper last week.

The paper did not show benefit of endovascular therapy in basilar artery occlusion. A favorable functional outcome occurred in 68 of 154 patients (44.2%) in the endovascular group and 55 of 146 patients (37.7%) in the medical care group (confidence interval, 0.92 to 1.50).

However, there are some limitations. The sample size was small and no perfusion imaging was used (no information about salvageable tissue in patients receiving artra arterial therapy).


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Question 4

Your patient presents with altered mental status, visual disturbance and a headache. He also has marked hypertension and had a seizure on the way to your ED. You suspect this patient to have Posterior Reversible Encephalopathy Syndrome (PRES).

Which of the following diagnostic tools can help you to diagnose PRES?



C: Lumbar Puncture

The correct answer is A.

Josh Farkas covered PRES in The internet Book of Critical Care last week.

PRES is characterised by vasogenic edema which occurs predominantly in the posterior brain. The pathogenesis is largely unknown, but is likely partly due to failure of autoregulation in hypertension.

No single diagnostic test proves PRES and it is mostly a clinical diagnosis, but MRI typically shows vasogenic edema.

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Question 5

Your 65 year old patient presents with decreased vision, headache, severe eye pain and vomiting. You do not have the equipment to measure ocular pressure, but the affected eye appears rock hard on gentle palpation. You suspect the patient to have angle-closure glaucoma.

Which of the following is part of the acute management of this patient?

A: Do not give any analgesics, for this may lead to an increased ocular pressure

B: Make the patient sit upright

C: Intraocular Acetazolamide (Diamox) will lower the intraocular pressure

D: Timolol eye drops will lower the intraocular pressure

The correct answer is D

The RCEM podcast covered ophthalmic emergencies last week.

Acute angle-closure glaucoma is an emergency diagnosis and should be treated promptly. It is advised to place the patient in supine position and give analgesics as soon as possible.

Acetazolamide can be given intravenously and orally, but not ocular.

Timolol eye drops or a combination drug containing timolol (like Cosopt) is effective in order to lower intraocular pressure.

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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