Quiz 133, November 12th, 2021

Welcome to the 133th FOAMed Quiz.


Case courtesy of Dr Joachim Feger, Radiopaedia.org, rID: 72001

Question 1

In case of traumatic haemothorax, large bore chest tubes are often used. Chest tubes with a smaller diameter are often believed to be less effective for drainage and easier obstructed.

This recently published paper is about small (14 Fr) percutaneous catheter versus large (28-32 Fr) open chest tube for traumatic hemothorax. 119 not critically ill patients with hemothorax were randomised. The primary outcome was failure rate, defined as a retained haemothorax requiring a second intervention.

What did the authors find?

A: Failure rate was higher in the small percutaneous catheter group

B: Failure rate was higher in the large bore chest tube group

C: Failure rate was equal between the two groups

The correct answer is C.

The paper was covered on St. Emlyns this week.

The failure rate was similar between the two groups (11% in small catheter group vs. 13% in chest tubes). Patients in the percutaneous catheter group reported lower IPE (insertion perception experience) scores, meaning that percutaneous catheters are better tolerated.

They kept all drains on -20mmHg suction


JC: Can we use smaller pigtail drains in traumatic haemothorax?

Source image: www.pixabay.com

Question 2

Your patient presents with thunderclap headache (TCH). She also has ophthalmoplegia, decreased visual acuity, and change in mental status. She also has profound hypotension and her laboratory results show hyperkalemia and hyponatremia.

Which of the following causes of TCH explain the combination of these findings?

A: Pituitary apoplexy

B: Subarachnoid Hemorrhage

C: Posterior Reversible Encephalopathy Syndrome

D: Cervical artery dissection

The correct answer is A.

EMDocs covered thunderclap headache this week.

Pituitary apoplexy is caused by hemorrhage or infarction of the pituitary gland. It can manifest as acute headache, ophthalmoplegia, change in mental status and adrenal crisis. Diagnosis is often made by MRI.

emDOCs Podcast – Episode 40: Thunderclap Headache



Source image: www.huidziekten.nl

Question 3

In the recently published ADVANCE trial, patients with skin and soft tissue infections (SSTIs), who are normally often hospitalized to receive IV antibiotics, were directly discharged after being treated with a single dose of IV Dalbavancin (a novel second-generation lipoglycopeptide antibiotic belonging to the same class as vancomycin). This was a pre-intervention (usual care) versus postintervention (Dalvancin pathway) trial. 

What did the ADVANCE trial show comparing Dalbavancin outpatient treatment to usual care in SSTIs?

A: Dalbavancin use led to lower hospitalisation, but higher overall healthcare utilization

B: No difference was found in patient hospitalization rates or overall healthcare utilization

C: Dalbavancin was associated with significant reduction of initial hospitalization and decreased healthcare utilization

The correct answer is C.

This week Journalfeed.org discussed the ADVANCE trial.

This study suggests that a single dose of Dalbavacin in the ED, is an option for treating uncomplicated SSTIs that otherwise would have been admitted for IV antibiotics. Because Dalbavacin reaches steady state after 3 days and has a half-life of 8.5 days, it is ideal for outpatient management.

Keep in mind it is expensive, so cost efficiency should first be investigated. Furthermore, the local antimicrobial resistance might make these results less generalisable.

Source image: www.medscape.com

Question 4

We all remember the face helmets for CPAP during the beginning of the COVID pandemic in Italy. The helmets seem to be better tolerated than facemasks.

This recently published paper is about helmet continuous positive airway pressure (hCPAP) and facemask continuous positive airway pressure (fCPAP). 224 patients with respiratory insufficiency ( 80% cardiogenic pulm oedema vs 20% COPD. No COVID) were included and randomized in this Malaysian, noninferiority study. The primary outcome was change in respiratory rate.

What did the authors find?

A: hCPAP was non-inferior to fCPAP and resulted in greater comfort levels

B: hCPAP was inferior to fCPAP but resulted in greater comfort levels

C: hCPAP was inferior to fCPAP and did not result in greater comfort levels

The correct answer is A.

The paper was covered on the RCEM podcast last week.

Both techniques reduced respiratory rate equally. 

However, change inrespiratory rate is a weird and not patient centered primary outcome.

Source image: www.pixabay.com

Question 5

Your patient presents with profound hyperglycemia. Which of the following is consistent with hyperosmolar hyperglycemic state (HHS) and not with diabetic keto-acidosis (DKA)?

A: pH < 7.30

B: Serum osmolarity of 305 mOsm/L

C: Develops over days to weeks

D: Anion Gap > 12z

The correct answer is C

Taming the SRU covered HHS and DKA last week.

In general, DKA develops quite rapidly (hours to days), whereas HHS develops more slowly (days to weeks).

A pH of < 7.3, serum osmolarity of < 320 and a high anion gap are typically seen in DKA.

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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