Quiz 139, December 24th, 2021

Welcome to the last FOAMed Quiz of the year..



Source image: www.pixabay.com

Question 1

Your 25-year old patient comes in with high fever and mono-arthritis of the right knee. Aspiration of synovial fluid reveals pus. You suspect him of having bacterial arthritis.

He is known with sickle cell disease.

Which of the following pathogens is quite commonly a cause of bacterial arthritis in patients with sickle cell disease and is a rare cause of musculoskeletal infections in patients without sickle cell disease?

A: Staphylococcus aureus

B: Kingella species

C: Salmonella species

D: Klebsiella pneumoniae

The correct answer is C.

Pediatric hip pain was covered on NUEM last week.

Staphylococcus aureus is the most common pathogen in bacterial arthritis overall. Due to functional asplenia, patients with sickle cell disease are more susceptible to encapsulated bacteria and gram-negative bacteria, especially Salmonella.

Source image: www.pixabay.com

Question 2

Earlier this month, the HEP-COVID trial was published.

257 Hospitalized adult patients with COVID-19 with D-dimer levels more than 4 times the upper limit of normal or sepsis-induced coagulopathy score of 4 or greater were randomised to standard prophylactic or intermediate-dose LMWH or unfractionated heparin versus therapeutic-dose enoxaparin.

32.8% of these patients received ICU-level care.

The primary outcome was a composite of venous thromboembolism (VTE), arterial thromboembolism (ATE), or death from any cause within 30 days.

In which group did the authors find a benefit of therapeutic anticoagulation?

A: ICU patients

B: Non-ICU patients

C: Neither ICU nor non-ICU patients

The correct answer is B.

The paper was covered on Rebel-EM last week.


Therapeutic-dose LMWH reduced the incidence of the primary outcome (48.0% vs 30.1%; P = .007). This benefit is seen only among the 170 patients who are sick enough to be hospitalized but not sick enough to be managed in the ICU.

There was no statistically significant difference in major bleeding.

There was a trend toward mortality benefit in the therapeutic dose anticoagulation group, but the study was not powered to find a mortality benefit.

The HEP-COVID Trial: Therapeutic Anticoagulation in Non-Critically Ill COVID-19 Patients


Source image: www.aliem.com

Question 3

A 20 year old patient presents to the ED with diffuse abdominal pain and vomiting for a couple of days. He has no prior medical history. His abdomen reveals mild distention and diffuse tenderness to palpation. His laboratory results show a lactate of 4.9 and no signs of infection. Ultrasound is non conclusive. CT scan reveals Superior Mesenteric Artery (SMA) Syndrome (or Wilke’s syndrome).

Which of the following causes Superior Mesenteric Artery Syndrome?

A: A thrombus in the SMA

B: Dissection of the SMA

C: An increase in mesenteric fat surrounding the SMA, leading to compression of the artery

D: A decrease in mesenteric fat surrounding the SMA, leading to compression of the artery

The correct answer is D

ALiEM covered the Superior Mesenteric Artery Syndrome this week.

Superior Mesenteric Artery (SMA) syndrome is also called Wilke’s or Cast syndrome. A loss of mesenteric fat which normally surrounds the SMA, can lead to a steep angle between the aorta and SMA. Due to this angulation the duodenum can be compressed and can result in a partial or complete obstruction of the proximal duodenum.

The treatment includes gastric decompression and supportive care.

SAEM Clinical Image Series: I Have a Stomachache

Source image: www.tamingthersu.com

Question 4

 Your patient presents with a peritonsillar abscess. You treat your patient with drainage and antibiotics.

What does the evidence say about the addition of corticosteroids?

A: Evidence is clear, glucocorticoids are ineffective

B: Evidence is clear, glucocorticoids should be administered after drainage

C: Evidence is inconsistent, routine use of glucocorticoids can not yet be recommended

The correct answer is C.

Taming the SRU covered peritonsillar abscess last week.

Evidence is inconsistent. A few very small trials suggest benefit (less pain at 24 hours, faster recovery), but a larger retrospective paper did not reproduce these results.

Question 5

Which of the following ultrasound images suggests tamponade?







The correct answer is C.

CountyEM covered POCUS in cardiac tamponade last week.

It is often challenging to appreciate diastolic collapse in dynamic ultrasound images. M-mode can help. The anterior leaflet of the mitral valve is closest to the septum in diastole (at the point you measure e-point septal separation). If the anterior wall of the right ventricle moves further away from the probe during diastole, right ventricular collapse is very likely. This is visible on image C.

Ultrasonography of Cardiac Tamponade

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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