Quiz 141, January 14th, 2022

Welcome to the 141th FOAMed Quiz.


Source image: www.litfl.com

Question 1

The 2015 REVERT trial showed the modified Valsalva technique was more effective than standard Valsalva technique (without lifting the legs) as an early treatment for hemodynamically stable patients presenting with supraventricular tachycardia.

This recently published meta-analysis includes 4 studies (including the REVERT trial) about modified Valsalva versus standard Valsalva for cardioversion of stable supraventricular tachycardia in adults.

What did the review show?

A: The modified Valsalva technique is more effective than the standard Valsalva technique

B: The standard Valsalva technique is more effective than the modified Valsalva technique

C: Both techniques are equally effective

The correct answer is A.

The paper was covered on RebelEM last week.

The modified Valsalva technique was effective in 43.8% of cases, whereas the standard Valsalva technique was only effective in 16.0% of cases (NNT = 3.6).

To view a video about how to perform the modified Valsalva technique click here.

The Modified Valsalva Maneuver: Head Down, Legs Up

Source image: www.aliem.com

Question 2

What is the name of the set of criteria used to distinguish septic arthritis from transient synovitis in a child with an inflamed hip?

A: Sgarbossa criteria

B: Kocher criteria

C: Duke criteria

D: Hestia criteria

The correct answer is B.

PEMblog covered the Kocher criteria last week.

Hestia criteria are used to identify low-risk PE patients safe for outpatient treatment.

Duke criteria are for diagnosis of endocarditis.

Sgarbossa criteria are used to diagnose acute MI in patients with prior LBBB.

Question 3

Source image: pixabay.com

Your 20 year old patient presents after smoke inhalation. There was a fire in her living room and she couldn’t leave in time. She has no signs of inhalation injury, an oxygen saturation of 100% on a non rebreather mask but is severely tachypneic. Her heart rate is 130/min, blood pressure of 132/82 mmHg, cool extremities and a capillary refill time of 4 seconds. Her blood gas shows a pH of 7.14, bicarbonate of 14 mmol/L, lactate of 16 mmol/L and hypocarbia without hypoxia. Her carbon monoxide is 8%. Methemoglobin turns out to be 10%.

What is the most likely cause of these symptoms?

A: Carbon monoxide

B: Cyanide

C: Methemoglobinemia

D: Hydrazine

The correct answer is B.

Cyanide inhibits aerobic metabolism by binding to the binuclear heme center of cytochrome c oxidase (CcOX) in mitochondria.

High Anion Gap Metabolic Acidosis (AGMA), lactic >10 and normal pulse oximetry point in the direction of cyanide toxicity. A carbon mono-oxide level of 8% and a MetHB level of 10% are not likely to cause severe symptoms. Hydrazine (eg. rocket fuel) intoxication is very unlikely in this case.

Which of the following is not a treatment option in this case?

A: Methylene blue

B: Hydroxocobalamine

C: Amyl nitrite

D: Sodium thiosulfate

The correct answer is A.

CoreEM and PedEM Morsels covered cyanide toxicity last week.

In case of cyanide poisoning, hydroxocobalamine scavenges cyanide present in blood and forms cyanocobalamin (vitamin B12).

Amyl nitrite (inhalation) and sodium nitrite (intravenous) antagonize cyanide toxicity in part by oxidizing hemoglobin to methemoglobin, which then scavenges cyanide. Keep in mind iatrogenic methemoglobinemia can be dangerous, especially in case of co-intoxication with carbon monoxide.

Sodium thiosulfate acts as a sulfur donor in the conversion of cyanide to thiocyanate through rhodanese.

Methylene blue is used in case of methemoglobinemia.

Toxic Gas Exposure

Cyanide Poisoning in Children

Question 5

Sotrovimab is a monoclonal antibody that binds to a conserved epitope on the spike protein of SARS-CoV-2.

In the COMET-ICE trial 583 not severely ill adults in early stages of COVID-19 (≤5 days) with risk factors for progression of the disease were randomised to receive either Sotrovimab (500 mg IV over 1 hour) or placebo.

The primary outcome was hospitalisation for >24 hours or death from any cause up to 29 days after randomization.

What did the authors find?

A: Patients in the Sotrovimab group had a lower rate of hospitalisation compared to patients in the placebo group

B: Patients in the placebo group had a lower rate of hospitalisation compared to patients in the Sotrovimab group

C: The rate of hospitalisation was equal in both groups

The correct answer is A.

EMOttawa covered the COMET-ICE trial last week.

The primary outcome (hospitalisation for >24 hours or death from any cause) was met in 1 percent of cases in the Sotrovimab group and in 7 percent of cases in the placebo group. This was driven by the rate of hospitalisations, as only 1 patient in the entire study population died (placebo group).

It seems Sotrovimab is effective in preventing hospitalisation if administered early on to not (yet) severely ill COVID-19 patients with risk factors for disease progression.

Keep in mind this trial was funded by Vir Biotechnology and GlaxoSmithKline.

COMET-ICE Trial on Sotrovimab

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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