Quiz 125, August 13th, 2021

Welcome to the 125th FOAMed Quiz.

 

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Question 1

A 28-year-old male felt a painful snap in his posterior left lower leg while playing basketball. Physical exam is suggestive of Achilles tendon rupture, but you are not certain.

You decide to perform a bedside ultrasound to confirm the diagnosis.

Which of the following statements is true about POCUS in Achilles tendon injury?

A: Minimal fluid surrounding the Achilles tendon is normal due to the synovial sheath

B: Most Achilles tendon ruptures occur at the calcaneal insertion

C: Anisotropy is a useful ultrasonographic artifact to confirm tendon tear

D: Plantaris tendon is usually found medial of the Achilles tendon

The correct answer is D.

This week ALiEM discussed Achilles tendon rupture.

The Achilles tendon is surrounded by paratenon, rather than a synovial sheath, therefore fluid is normally not seen on ultrasound. A tear rarely occurs at calcaneal insertion. Anisotropy can mimic a tendon rupture and can be used to identify the tendon (which shouldn’t be a problem in case of the Achilles tendon). The Plantaris tendon is found medial to the Achilles tendon. Keep in mind the Thompson test can be false negative if the Plantaris tendon is intact.

SplintER Series: My Foot Doesn’t Work Right

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Question 2

A patient is brought in unconcious after a suicide attempt. He was found hanging on a self made noose. He did not drop from height.

Which of the following is most likely the primary main pathologic mechanism?

A: Fracture of the upper cervical spine

B: Venous obstruction in the neck

C: Arterial damage in the neck

D: Airway compromise

The correct answer is B.

NUEM blog wrote about hanging injuries this week.

Loss of consciousness in hanging occurs most often due to obstruction of venous outflow from the brain and occurs in 15 seconds.

When the drop is greater than or equal to the height of the victim, there will almost always be cervical spine injury. Without a drop cervical injury is rare.

The rate of arterial damage is pretty uncommon as well.

Airway compromise plays less of a role in the immediate death of hanging.

Source image: www.nuemblog.com

Question 3

Which of the following findings on POCUS is suggestive of cardiac tamponade?

A: Right atrial diastolic collapse

B: A collapsed Inferior Vena Cava (IVC)

C: Right ventricular systolic collapse

D: Absence of a pericardial effusion

The correct answer is A.

Jacob Avila covered POCUS in cardiac tamponade on Core Ultrasound last week.

Right atrial or right ventricular diastolic collapse is highly suggestive for cardiac tamponade. Systolic collapse is normal. When in doubt whether the atrium or ventricle collapses during diastole or systole, slow down the clip and have a look at what the tricuspid and mitral valve are doing.

One would expect at least some amount of pericardial effusions and a wide IVC in case of tamponade.

 

Source image: rebelem.com

Question 4

Last week the BaSICS paper was published. This study was about normal saline (NS) versus balanced solution (Plasma-Lyte) in ICU patients. 10520 patients were randomised to receive either NS or balanced solution. The primary outcome was difference in all cause mortality at 90 days.

In 2018, the SMART  trial found a small but statistically significant difference in Major Kidney Events in favour of balanced solutions.

What did the BaSICS paper show?

A: Mortality was lower in the normal saline group compared to the balanced solution group

B: Mortality was lower in the balanced solution group compared to the normal saline group

C: Mortality was equal between the groups

The correct answer is C.

The Bottom Line and EMCrit covered the BaSICS trial last week.

In this extremely large, multi-centre trial 5290 ICU patients were randomised to the NS group and 5230 patients were randomised to the balanced solution group. Fluid that patients were randomised to was used for entire ICU stay. 26.4% in the balanced solution group died vs 27.2% in the NS group (p = 0.47).

The use of a balanced crystalloid compared to 0.9% sodium chloride did not reduce 90-day mortality.

There actually was another part of this study about fast fluid boluses versus slow infusion. No difference in mortality was found either.

BaSICS

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Question 5

You are evaluating your 9 year old patient for hearing loss. Weber test lateralizes to the right ear. Rinne’s test is positive on the left side and negative on the right side.

What is most likely the cause of this girls hearing loss?

A: Sensorineural hearing loss on the right side

B: Conductive hearing loss on the right side

C: Sensorineural hearing loss on the left side

D: Conductive hearing loss on the left side

The correct answer is B.

Don’t forget the Bubbles covered Weber’s and Rinne’s test last week.

Weber’s test lateralizes to the right ear, so there is either sensorineural hearing loss on the left side or conductive hearing loss on the right side.

Rinne’s test is positive (air conduction > bone conduction) on the left side and negative (air conduction < bone conduction) indicating there is a conductive problem on the right side or a sensorineural problem on the left side. However, a negative Rinne’s test is always abnormal, making conductive hearing loss on the right side most likely.

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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