Quiz 121, July 2nd , 2021

Welcome to the 121th FOAMed Quiz.


Question 1

Source image: www.stemlynsblog.org

In addition to Toculizumab and Dexamethasone, the REGN monoclonal antibodies combination (Casirivimab and Imdevimab) have shown to be beneficial in patients with COVID-19 according to this part of the RECOVERY trial.

However, the Casirivimab and Imdevimab combination was only associated with reduced mortality, increased speed of discharge and reduced progression to invasive mechanical ventilation or death in a subset of patients.

Which group of COVID-19 patients benefit from the Casirivimab and Imdevimab combination?

A: Patients on mechanical ventilation

B: Patients beyond the 10th day of their illness

C: Patients on oxygen therapy

D: Patients that were seronegative on randomisation

The correct answer is D

St Emlyns covered the RECOVERY trial about the Casirivimab and Imdevimab combination last week.

9785 patients were randomly allocated to receive usual care plus REGN antibody combination or usual care alone.

3153 (32%) of these patients were seronegative. In the primary efficacy population of seronegative patients, 396 (24%) of 1633 patients allocated to REGN antibody combination and 451 (30%) of 1520 patients allocated to usual care died within 28 days (p=0.0010). When combining the seropositive group with the seronegative patients, there was no longer a significant effect on 28-day mortality.

REGN monoclonal antibodies work in selected hospitalised COVID-19 patients. St Emlyn’s

Question 2

Source image: journals.lww.com

Your 65 year old patient presents to your ED with acute respiratory distress. She is tachypneic and her oxygen saturation is 92 percent without oxygen suppletion. She has tachycardia, capillary refill of 4 seconds, is diaphoretic and she has a blood pressure of 90/50 mmHg.

POCUS does not reveal any B-lines and lung sliding is present in all areas. You suspect this patient to have massive Pulmonary Embolism (PE). You get a parasternal short axis view of the base of the heart and you retrieve a pulse wave doppler image of the right ventricular outflow tract (RVOT). This image is shown above.

This POCUS finding makes a massive PE more likely.

How is this finding called?

A: McConnell’s sign

B: RVOT acceleration time

C: 60/60 sign

D: Early Systolic Notching

The correct answer is D.

The Ultrasound Gel podcast covered this paper about POCUS findings in PE.

277 patients of which 100 had massive or submassive PE were included. Early Systolic Notching was present in 92 percent of these patients (compared to only 2 percent in patients with subsegmental PE). This was superior to any other POCUS finding in suspected PE.

Source image: www.ultrasoundgel.org/

Question 3

Source image: radiopaedia.org/


Your 36-year-old patient is brought in by the EMS with head trauma after falling down the stairs. On arrival, his Glasgow Coma Scale was E1M3V2.

What statement about different types of traumatic brain injury is true?

A: Epidural hematoma is typically due to laceration of the anterior meningeal artery

B: An intraparenchymal hematoma with a volume of ≥20 ml is an indication for surgical drainage, regardless of location of the hematoma and midline shift

C: Traumatic subarachnoid hemorrhage (SAH) is typically located over the peripheral cerebral convexities, rather than the sylvian fissures and basal cisterns

D: Diffuse Axonal Injury (DAI) is usually associated with elevated intracranial pressure

The correct answer is C.

Traumatic brain injury was covered in this week’s Internet Book of Critical Care by EMcrit.

Epidural hematomas are typically due to laceration of the middle meningeal artery.

An intraparenchymal hematoma with a volume of ≥50 ml is a potential indication for surgical drainage; as well as a volume of ≥20 ml and located frontal or temporal with a midline shift of ≥ 5 mm and/or cisternal compression with GCS 6-8.

For traumatic subarachnoid hemorrhage, be careful not to miss primary aneurysmal hemorrhage which can lead to syncope and a fall.

DAI is usually not associated with elevated ICP.

Traumatic Brain Injury (TBI)

Question 4

Source image: https://saskblood.ca/

Postpartum hemorrhage (PPH) is an obstetric emergency. It is one of the most common causes of maternal mortality.

The causes of postpartum hemorrhage can be summarized by the four “T’s”.

Which of the following is not a part of the four T’s?

A: Trauma (rupture or lacerations)

B: Tension (hypertension)

C: Tone (uterine atony)

D: Tissue (retained placenta)

E: Thrombine (coagulopathies)

The correct answer is B.

JournalFeed covered this recently published paper about preparation, risk factors, identification and management of postpartum hemorrhage last week.

Postpartum hemorrhage can be defined by blood loss >500ml after vaginal delivery and > 1000ml after cesarean delivery.

The causes of postpartum hemorrhage can be summarized by the four “T’s”: tone (uterine atony), trauma (lacerations or uterine rupture), tissue (retained placenta or clots), and thrombin (clotting-factor deficiency). The most common cause is uterine atony (accounting for approximately 70% of cases).

Question 5


Source image: www.elmhurstfootdoc.com

Your patient presents with profound fever and severe pain with cramping in his calf for two days. The calf looks swollen and red and it feels warm. You suspect pyomyositis and you start empiric antibiotics.

Which of the following bacteria is most often the cause of pyomyositis?

A: Staphylococcus aureus

B: Mycobacterium tuberculosis

C: Fusobacterium necrophorum

D: Capnocytophaga canimorsus

The correct answer is A.

RebelEM covered pyomyositis last week.

Pyomyositis is a purulent infection of the skeletal muscles that arise from hematogenous spread.

The most common causative organism of pyomyositis is Staphylococcus aureus. Less common are Streptococci.

REBEL Core Cast 60.0 – Pyomyositis

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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