Quiz 131, October 8th, 2021

Welcome to the 131th FOAMed Quiz.


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Question 1

A 33 week pregnant patient comes in after a motor vehicle accident. Upon waiting for her arrival, you and your team prepare for the initial assessment.

Which of the following statements is true?

A: Due to higher arterial pO2 state in third trimester pregnancy, desaturation will appear late

B: A chest drain should be inserted at the 5th intercostal space in the anterior axillary line just like in non-pregnant patients

C: Foetal distress on CTG is an early sign of maternal hypovolemia and shock

D: You should add in the Kleihauer-Betke test  if you think the patient could be Rhesus positive (Rh+)

The correct answer is C.

This week St. Emlyn’s discussed trauma in pregnant patients.

A difficult airway should be anticipated due to relative airway oedema, reduced esophageal sphincter tone and delayed gastric emptying.

Because of reduced functional residual capacity, desaturation will be fast so pre-oxygenation is especially important.

Foetal distress on CTG (loss of beat to beat variability or any decelerations) are an early sign of maternal hypovolemia and shock.

Use the Kleihauer-Betke test if you think the patient could be Rhesus negative (Rh-).

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Question 2

A 37-year-old female is presented to the emergency department with headache, emesis and diplopia. There are no other signs of stroke. You remember that in rare cases an anterior communicating artery (ACOM) aneurysm may produce ophthalmologic symptoms in the form of 3rd nerve palsy.

Which clinical finding corresponds to 3rd nerve palsy?

A: Inability to move the eye down and inwards (look towards the nose)

B: Inability to move the eye outwards (look away from the nose)

C: Presence of ptosis and mydriasis

The correct answer is C.

This week First10EM discussed diplopia last week.

Cranial nerve 3 innervates all the ocular muscles except for the superior oblique (moving the eye down and inwards, CN4) and the lateral rectus muscle (abducting the eye, CN6). CN 3 lesions present with a pupil that is “down and out”, in combination with ptosis and mydriasis.

DON’T FORGET THE DOUBLE VISION (Diplopia rapid review)

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Question 3

This recently published paper is a secondary analysis of the National Emergency Airway Registry (NEAR) between 2016 and 2018. The authors evaluated first-pass success in about 19.000 trauma intubations.

What did the authors find?

A: Direct laryngoscopy had a higher first pass success rate compared to video laryngoscopy

B: Video laryngoscopy had a higher first pass success rate compared to direct laryngoscopy

C: Video laryngoscopy and direct laryngoscopy had similar first pass success rates

The correct answer is B.

The paper was covered on JournalFeed last week.

Video laryngoscopy had a 90% first-pass success rate compared to 79% for direct laryngoscopy.

Another piece of evidence supporting the use of video laryngoscopy in the ED.

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Question 4

The 2020 LoDoCo2 and 2019 COLCOT studies suggest that daily low dose colchicine in patients with chronic coronary disease or a myocardial infarction reduces the risk of future acute myocardial infarction or death from cardiovascular causes.

The COVERT trial was published last August. It is about the benefits of colchicine in the acute phase of myocardial infarction. Theoretically the anti-inflammatory properties of colchicine may decrease size of myocardial infarction. 192 patients with occlusion myocardial infarction were randomised to receive either colchicine (2 mg loading and 0,5 mg per day) or placebo.

The primary outcome was infarct size (IS) in grams.

What did the authors find?

A: The myocardial infarct size was largest in the colchicine group

B: The myocardial infarct size was largest in the placebo group

C: There was no difference between the groups

The correct answer is C.

The Bottom Line covered the COVERT trial last week.

At 5 days post randomisation, the infarct size did not differ between the colchicine and placebo groups with a mean of 26 versus 28.4 grams.

At 3 months follow-up, there was no significant difference in left ventricular remodeling between the colchicine and placebo groups.


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Question 5

Your patient presents with a methotrexate intoxication. A calculation error led to administration of a 10-fold dose of intravenous methotrexate.

Which of the following treatments should be initiated?

A: Folinic acid

B: Folic acid

C: Dexamethasone

D: Hydroxocobalamin

The correct answer is A.

Methotrexate intoxication was covered on EMDocs last week.

Folinic acid antagonizes the toxic effects of methotrexate on bone marrow. Folic acid will not suffice.

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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