Quiz 126, August 20th, 2021

Welcome to the 126th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

COVID-19 patients are at high risk for the development of venous thromboembolic disease.

Recently two randomised controlled trials were published in which the authors investigated the effectiveness and safety of therapeutic dose anticoagulation in critically ill patients (trial 1, n= 1098) and non critically ill patients (trial 2, n=2219) with COVID-19.

Patients were randomized to one of two arms (unfractionated or low molecular weight heparin):
Therapeutic Anticoagulation (TA): Full dose anticoagulation
Prophylactic Anticoagulation (PA): Prophylactic or intermediate dose anticoagulation

The primary outcome was organ support-free days (cardiovascular and respiratory) after 21 days.

What did the authors find about the use of therapeutic dose anticoagulation in COVID-19 patients?

A: Non-critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm. In critically ill patients, there was no difference

B: Critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm. In non-critically ill patients, there was no difference

C: Both critically ill and non-critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm

D: Neither critically ill nor non-critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm

The correct answer is A.

This week RebelEM covered the two trials (trial 1 and trial 2) about Anticoagulation in COVID-19 patients.

In non critically ill COVID-19 patients the use of therapeutic dose anticoagulation increased organ support-free days and survival to hospital discharge. These results were not found in critically ill COVID-19 patients.

The reason therapeutic coagulation seems beneficial in non-critically ill patients and not in critically ill patients is up for debate. However, one can imagine the antithrombotic and anti-inflammatory properties of therapeutic anticoagulation is most effective in early stages of the disease.

COVID-19 and Anticoagulation: Full Dose or Prophylactic Dose?

Source image: www.pixabay.com

Question 2

A 4 year old patient presents to the ED after possible ingestion of a coin. He is completely asymptomatic. His mother only found him playing with her wallet without actually seeing him swallow something.

You wonder whether a handheld metal detector might be sufficient to rule out the presence of a coin.

Which of the following is true about the sensitivity of a handheld metal detector for detection of ingested coins?

A: The sensitivity is low and a handheld metal detector is not useful for this indication

B: The sensitivity is about 85 percent. Combined with a low pretest probability this test is pretty accurate

C: The sensitivity is 99-100 percent. You can safely exclude the presence of a coin with this test

The correct answer is C.

EMDocs covered ingestion of metal foreign bodies last week.

It seems a handheld metal detector can be safely and reliably used as a screening tool in the process of detecting ingested coins.

A 2005 systematic review and a 2018 observational study showed the sensitivity of a handheld metal detector for detection of coins to be almost 100%. Keep in mind the sensitivity for other metal objects (long and sharp objects, lid of a can) is lower.

The metal detector might even be used to localize the coin.

EM@3AM: Beverage Tab Ingestion

Source image: www.nuemblog.com

Question 3

When exposed to cold, unprotected tissues can sustain frostbite injury. If digits sustain severe frostbite, this can result in amputation.

Which of the following has a role in the management of severe frostbite?

A: Tissue plasminogen activators (tPA)

B: Beta Blockers

C: Phenylephrine

D: Tranexamic acid

The correct answer is A.

This week NUEM blog covered frostbite injury.

Treatment consists of warming the affected tissue. Rewarming leads to a second mechanism of injury, a reperfusion injury resulting in patchy microvascular thrombosis and tissue death. To prevent the latter tPA can be administered. Evidence is limited, but intravenous and intra-arterial tPA seem to be effective in preventing loss of limbs.

Source image: www.orthobullets.com

Question 4

In acute compartment syndrome of the lower leg, which of the following compartments is most commonly affected?

A: Lateral compartment

B: Deep posterior compartment

C: Superficial posterior compartment

D: Anterior compartment

The correct answer is D.

Taming the SRU covered compartment syndrome last week.

The anterior compartment of the lower extremities is most commonly affected in acute compartment syndrome.

Source image: www.pixabay.com

Question 5

Complaints about waiting time are common in the ED. This recently published paper is about patients’ perception of their waiting time.

Which of the following is true according to the paper.

A: Most ED patients overestimate their waiting time

B: Most ED patients underestimate their waiting time

C: Most ED patients are accurate about their waiting time

The correct answer is A.

The paper was covered on first10EM this week.

Most patients overestimate their waiting time.

Justin Morgenstern adds an important note: ´´For the most part, we just blame the patients and call them dumb. Patients will complain that they have been waiting for 2 hours, and will be met with the response, “no, dummy, the computer says you have only been waiting 1.5 hours.” The key point is that the patient feels like they have been waiting 2 hours, and that is largely our fault. There are lots of ways that we could influence the perception of wait times, but we routinely fail.´´ 

Research Roundup (August 2021)

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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