Quiz 140, January 7th, 2022

Welcome to the 140th FOAMed Quiz.


Question 1

The MR CLEAN-NO IV trial was published last november. It is another trial about the benefit of treatment with alteplase in patients who qualify for endovascular therapy.

539 adult ischemic stroke patients with an NIHSS of ≥2 that were eligible for endovascular treatment (EVT) and IV alteplase, within 4.5 hours after symptom onset, were included. They were randomised to usual care (alteplase plus EVT) or EVT alone. The primary outcome was functional outcome (modified Rankin scale at 90 days). The outcome was analyzed for superiority and then for noninferiority.

What did the authors find (two correct answers)?

A: EVT alone was superior to alteplase followed by EVT

B: EVT alone was not superior to alteplase followed by EVT

C: EVT alone was non-inferior to alteplase followed by EVT

D: EVT alone was not non-inferior to alteplase followed by EVT

The correct answers are B and D.

RebelEM covered the MR CLEAN-NO IV trial last week.

Patients in the EVT-alone group had a median mRS of 3. Patients in the Alteplase + EVT group had a median mRS of 2.

EVT alone was both not superior and non-inferior compared to EVT plus alteplase.

MR CLEAN-NO IV: Endovascular Treatment for Stroke Compared to Alteplase Followed by Endovascular Treatment: No Difference, But Also Not Not Worse

Question 2

Source image: healio.com

You see a 6-year-old boy in your emergency department who complains of a funny feeling in his chest. This started during his soccer training an hour ago. On 12-lead ECG, you see a narrow-complex tachycardia of 205bpm. His BP is 110/70 mmHg. He appears comfortable and is neither tachypneic nor diaphoretic. He has no history of structural heart disease.

Of the following options, which is the most appropriate?

A: You carefully examine the 12-lead ECG for signs that indicate the presence of a bypass tract as this is a contra-indication for giving adenosine

B: You give adenosine (with pads for electrical cardioversion standby) 0.1 mg/kg whether you have reasons to think about a bypass tract or not

C: You treat him with electrical cardioversion (0.5-2J/kg) because adenosine is contra-indicated in children under 8

D: You search for an underlying etiology as sepsis or a toxidrome, as a narrow-complex tachycardia in children is nearly always a secondary phenomenon and responds poorly to cardioversion (high recurrence rate) if the primary condition remains untreated

The correct answer is B.

EMDocs’ pediatric small talk was about narrow complex tachyarrhythmia this week.

Nearly all children under 1 and most children under 8 have a bypass tract which can cause AVRT. Presence of a bypass tract is not a contra-indication to use adenosine if resuscitative equipment is readily available (low risk of conversion into ventricular fibrillation). Electrical cardioversion with 0.5-2J/kg is indicated when the patient is unstable. When cardioversion (chemical or electrical) fails due to immediate recurrence of the SVT, search for an underlying etiology.

Pediatric Small Talk – The Rhythm Is Gonna Get Ya’: Age Based Approach to Pediatric Narrow Complex Tachydysrhythmia

Question 3

Source image: tamingthesru.com

What type of fracture is shown in this image?

A: Le Fort 1

B: Le Fort 2

C: Le Fort 3

D: Le Fort 4

The correct answer is B.

Taming the SRU covered facial trauma last week.

‘’Le Fort I fractures are transverse fractures that separate the maxilla from the pterygoid plate and nasal septum.

Le Fort II fractures are pyramidal fractures that extend into the orbital floor and inferior orbital rim separating the central maxilla and hard palate from the rest of the face.

Le Fort III fractures, also known as craniofacial disjunction, cause mobility of the entire face.’’

Question 4

Source image: www.mdpi.com

You suspect a high intracranial pressure in your patient. He is too unstable for CT-scanning right now and you perform ocular ultrasound.

To assess for elevated intracranial pressure, the optic nerve sheath diameter (ONSD) should be measured at a fixed distance from the rim of the globe.

How many millimeters behind the rim should the ONSD be measured?

A: 0 mm (at the rim)

B: 1 mm

C: 3 mm

D: 7 mm


The correct answer is C.

BrownEM covered ocular ultrasound this week.

The ONSD can be measured 3 mm behind the rim of the globe and its diameter should measure approximately 5 mm or less in healthy adults (although this cutoff is arbitrary).


Question 5

Source image: radiopaedia.org

You’ve ordered an AP chest x-ray for a 5 year old patient who you suspect of pneumonia. His parents are worried about radiation.

Everyone is exposed to a normal amount of background radiation during their life. For example the activity in Australia is 1.5mSv per year.

How many days of background radiation is equivalent to one AP chest x-ray for this patient living in Australia?

A: 3

B: 15

C: 89

D: 294

The correct answer is A.

This week Don’t Forget The Bubbles discussed ionizing imaging in children.

It is difficult to provide parents with clear information, because of the wide variety of contributing factors to the risk of ionizing radiation imaging. For chest x-rays the lifetime risk of radiation-induced cancers is considered to range from negligible to low.

However for CT scans in pediatric patients studies have shown a statistically significantly increased risk for malignant and non-malignant brain tumors.

Best to keep in mind: Is this test really needed and will it change the patient’s diagnosis or management?

How safe are CT scans in children?

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:

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