Quiz 129, September 16th, 2021

Welcome to the 129th FOAMed Quiz.

Source image: www.pedemmorsels.com

Question 1

Your 4 year old patient comes in with a nail bed laceration.

Which of the following statements is true about the management of nail bed injuries?

A: Nail bed injuries with tuft fractures are considered open fractures and therefore antibiotics are indicated

B: Cyanoacrylates (glue) should not be used to repair the nail bed

C: Nail bed injuries occur in up to one quarter of fingertip injuries

D: Most nail bed lacerations do not need repair

The correct answer is C.

Pediatric EM Morsels covered nail bed injuries last week.

According to available literature, prophylactic antibiotics do not change the rate of infection or osteomyelitis.

Cyanoacrylates may be as effective as suturing for nail bed injury repairs in children.

Nail bed injuries occur in up to one quarter of fingertip injuries.

Significant nail bed lacerations should be repaired to avoid bad cosmesis.

Nail Bed Lacerations

Question 2

Your 64 year old patient is brought in by prehospital services. She was found unconscious at home and she was intubated. She had been complaining about dyspnoea for 2 days.

Her capnography waveform looks like this:

Which of the following mechanisms causes a waveform like this?

A: Circulatory arrest

B: Tube in the right main bronchus

C: Bronchospasm

D: Hypoventilation

The correct answer is C.

NuEM covered capnography waveforms last week.

A normal waveform looks like this:

Delayed exhalation causes the typical sawtooth slope often seen in airway obstruction and bronchospasms such as COPD or asthma exacerbation.

Source image: www.thebottomline.org.uk

Question 3

The recently published DOREMI trial is about Dobutamine versus Milrinone in cardiogenic shock.

192 patients with cardiogenic shock were randomised to receive either Dobutamine or Milrinone in this randomised controlled trial.

The primary outcome was a composite of in-hospital death, resuscitated cardiac arrest and other badness.

What did the authors find?

A: Dobutamine was superior to Milrinone in patients with cardiogenic shock

B: Milrinone was superior to Dobutamine in patients with cardiogenic shock

C: Milrinone and Dobutamine were equally effective in patients with cardiogenic shock

The correct answer is C

The Bottom Line covered the recently published paper last week.

There was no significant difference in the composite of in-hospital death, resuscitated cardiac arrest, receipt of cardiac transplant or mechanical support, non-fatal myocardial infarction, cerebrovascular event or renal replacement therapy (Milrinone: 49% vs Dobutamine: 54%).

Keep in mind the study was not powered to detect smaller differences in the composite outcome or individual components of the primary outcome.


Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 35793

Question 4

Differentiating acute heart failure from other causes of dyspnoea is often challenging. This recently published paper is about POCUS in dyspneic patients.

81 patients aged 50 years and older with shortness of breath from suspected acute heart failure or COPD were evaluated in this cohort study.

The classification performance of lung POCUS to diagnose acute heart failure as well as that of chest x-ray study was calculated.

What did the authors find?

A: Lung POCUS has a higher sensitivity for heart failure than chest x-ray

B: Chest x-ray has a higher sensitivity for heart failure than lung POCUS

C: Lung POCUS and chest X-ray have equal sensitivity for heart failure

The correct answer is A

Last week Journalfeed covered this recently published paper.

This small study showed POCUS has a sensitivity of 92.5% for identification of acute heart failure. Chest X-ray has a sensitivity of 63.6%.

This is in line with previous data.

The study has been limited by a small sample size and high prevalence of heart failure but it highlights the importance of early use of ultrasound in the undifferentiated dyspneic patient.

Source image: www.emcrit.org

Question 5

Suppletion of Antidiuretic hormone (ADH) has a wide variety of indications. 

For which of the following patients is ADH certainly NOT part of the management?

A: Patient of the Neuro-ICU with diabetes insipidus

B: Patient on Aspirin who sustained traumatic head injury

C: Patient with hyponatremia due to primary polydipsia

D: Patient with septic shock

E: Patient with central hypernatremia

The correct answer is C.

This week, Josh Farkas EMCrit posted his Cooper Conference talk about ADH on EMCrit.

Roughly, ADH can be used to prevent water loss (and thereby influence blood sodium levels), cause vasoconstriction and promote platelet aggregation (due to increase of platelet activating factor).

NeuroEMCrit – The Many Aliases and Uses of ADH by Casey Albin

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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