Quiz 124, August 6th, 2021

Welcome to the 124th FOAMed Quiz.


Source image: www.pixabay.com

Question 1

Listening to educational podcasts is becoming increasingly popular amongst emergency medicine staff. A lot of us listen while commuting by car.

However, the question remains if any of the information sticks when you’re on the road. This paper compared initial and delayed recall of a podcast while driving versus undistracted seated listening.

What conclusion did the authors draw?

A: Recall is better when listening to a podcast undistracted compared to while driving

B: Recall is better when listening to a podcast while driving compared to undistracted

C: Initial recall is better while listening undistracted but there is no difference in delayed recall

D: There is no difference in recall between the driving and undistracted cohort

The correct answer is D.

The RCEM podcast covered the paper last week.

This multicenter, randomized trial looked at initial (within 30 minutes after listening) and delayed (one month after listening) recall of a podcast by 100 postgraduate emergency medicine residents. They were divided into a cohort of listeners while seated undistracted and a cohort of listeners while driving a car.

There was no statistically significant difference between the driving and undistracted cohorts. 

Source image: www.litfl.com

Question 2

Your 40 year old patient needs intubation due to respiratory failure. She has a wide QRS on the ECG, but potassium results have not come back yet. You are in doubt between using succinylcholine and rocuronium.

Which of the following predisposing conditions do not increase the risk of clinically significant hyperkalemia when using succinylcholine?

A: Denervating, crush or burn injuries

B: Chronic dialysis

C: Rhabdomyolysis

D: Prolonged total body immobilization

The correct answer is B

This week AliEM covered succinylcholine and the risk of hyperkalemia.

Succinylcholine is preferably avoided in selected patients. Hyperkalemia can be caused by activation of acetylcholine receptors which leads to an influx of sodium and calcium and an efflux of potassium to the extracellular space.

Patients with a normal renal function have an average increase of potassium of 0.5mEq/L. Patients on chronic dialysis do not have an increased risk of developing clinically significant hyperkalemia. Succinylcholine should be avoided when ECG changes are present prior to administration, rhabdomyolysis, prolonged total body immobilization, denervating disease, inherited myopathies and crush or burn injuries after 72 hours.

Source image: https://static.wixstatic.com

Question 3

A 35 year old male patient presents to the ED with a swollen finger. He tells you that the swelling started 4-5 days ago after minor trauma to the fingertip. The problem is located on the finger pad, anterior and very distal of the finger. A picture is shown above.

 Would you expect all Kanavel’s cardinal signs to be positive in this patient?

A: Yes

B: No

The correct answer is B.

AliEM covered the swollen finger in their SplintER series last week.

Kanavel’s signs are used to differentiate between a felon and flexor tenosynovitis. These 4 make up Kanavel’s signs:

1. Exquisite tenderness over the course of the sheath, limited to the sheath.
2. Flexion of the finger.
3. Exquisite pain on extending the finger, most marked at the proximal end.
4. Fusiform swelling of the finger.

This patient most likely has a felon which is a subcutaneous abscess in the finger pulp and usually presents on the pad of the finger.

Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 71639

Question 4

Flail chest is most often defined as a fracture of 3 or more contiguous ribs in 2 or more locations.

Flail chest is not mentioned in the latest ATLS guidelines as life threatening thoracis injury anymore.

This study included 407 patients with rib fractures, of which 79 (19.4%) had flail chest. Patients with a flail chest were compared to patients with the same number of ribs fractured, but without a flail segment.

According to this paper, what difference does the presence of a flail chest make in patients with three to five rib fractures?

A: Patients with a flail chest had higher mortality compared to patients without a flail chest

B: Patients with a flail chest had longer need for intensive care compared to patients without a flail chest

C: Patients with a flail chest had longer need for hospitalisation compared to patients without a flail chest

D: Patients with a flail chest had higher incidence of pneumothorax compared to patients without a flail chest

The correct answer is D

The Resus Room podcast covered the paper this week.

When comparing patients with three to five rib fractures, there was no difference in length of intensive care and length of hospitalisation or mortality; however, there was a higher incidence of pneumothorax (24.6% vs 50.0%, p<0.05). When comparing patients with six or more rib fractures, no difference was found between patients with and without flail chest.

Source image: www.nysora.com

Question 5

Your 65 year old patient presents with a dislocated shoulder. He has obesity, major chronic cardiac ischemic disease and he ate 3 quarter pounders at a well known fast food restaurant about 45 minutes ago. Shoulder reduction techniques with intra-articular and intravenous anesthesia are not successful. You are not very keen on sedating this patient and you decide to perform an interscalene brachial plexus block (ISB).

Which of the following actions can be used to reduce the chance of phrenic nerve blockade when performing an ISB (2 correct answers)?

A: Decreasing local anesthetic volume

B: Increasing local anesthetic volume

C: Performing the ISB more caudad in the neck

D: Performing the ISB more cephalad in the neck

The correct answers are A and C.

CoreEM covered the interscalene brachial plexus block last week.

The ISB effectively numbs C5-C7 nerve distribution unilaterally. It can affect C8-T1 as well but not as reliably.

Phrenic nerve blockade is a well known complication and can induce respiratory problems.

Reducing the anesthetic volume and using a more caudad location reduce the chance of phrenic nerve blockade.

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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