Quiz 144, February 11th

Welcome to the 144th FOAMed Quiz.


Question 1

Source image: http://brownemblog.com/

Which of the following techniques is most effective for reduction of a nursemaid’s elbow?

A: Hyperpronation of the lower arm

B: Supination of the lower arm and flexion of the elbow

C: Traction

The correct answer is A.

Radial head subluxation (RHS) was covered on NuEM last week.

Hyperpronation is associated with a higher rate of successful RHS reduction than supination and flexion. Traction is the injuries mechanism and is not considered a reduction technique.

Question 2

Patients on DOAC are at increased risk of major traumatic intracerebral bleeding compared to patients who don’t use anticoagulation. The risk of delayed bleeding after an initial negative CT of the brain may be a reason to admit patients and repeat a CT.

In our hospital, we generally dismiss asymptomatic patients on DOAC after mild traumatic brain injury (mTBI) and a negative CT, but in other places it seems to be practice to admit these patients and repeat a CT the following day.

In this Italian retrospective paper, 1426 patients on DOACs with mTBI were evaluated in the ED. 68.3% underwent a repeat CT after an initial negative CT and 24 hours of observation.

What was the rate of delayed intracerebral hemorrhage?

A: 35.4 percent of which 12.3 percent required neurosurgical intervention or died

B: 25.2 percent of which 8.4 percent required neurosurgical intervention or died

C: 8.6 percent of which 4.4 percent required neurosurgical intervention or died

D: 1.5 percent of which 0 percent required neurosurgical intervention or died

The correct answer is D.

The paper was covered on JournalFeed last week.

A total of 1426 patients taking DOACs were evaluated for an mTBI. Of these, 68.3% (916/1426) underwent a repeat CT after an initial negative CT and 24 h of observation, with a rate of delayed intracranial hemorrhage of 1.5% (14/916). None of the patients with delayed ICH at 24-h repeat CT required neurosurgery or died within 30 days.

Question 3

Source image: www.pixabay.com

Your 65 year old female patient comes in with altered mental status. She started using new medication from her psychiater yesterday.

She presents with abrupt altered mental status, hyperthermia (39.2 degrees Celsius), vomiting, myoclonus, tremor and mydriasis.

Which of the following diagnoses is most likely?

A: Neuroleptic Malignant Syndrome (NMS)

B: Serotonin Syndrome (SS)

C: Malignant Hyperthermia (MH)

The correct answer is B

Hyperthermic conditions in the psychiatric patient were covered on CanadiEM this week.

SS presents abrupt, whereas NMS has a more gradual onset. SS typically causes myoclonus, tremor and mydriasis, whereas NMS causes rigidity.

Malignant hyperthermia is typically caused by volatile anesthetic gasses or depolarizing muscle relaxants (succinylcholine).

Hyperthermic Conditions in the Psychiatric Patient

Question 4

Your patient presents to your ED 30 minutes after a suicide attempt by ingestion of a large amount of tablets. She does not appear ill and is alert.

In what case will activated charcoal not work?

A: Lithium intoxication

B: Tricyclic antidepressant intoxication

C: Barbiturate intoxication

D: Benzodiazepine intoxication

The correct answer is A.

SinaiEM covered activated charcoal last week.

Activated charcoal binds toxins preventing absorption, both initial or reabsorption via enterohepatic recirculation. It does not work well for electrolytes, alcohols and metals such as lithium.

Activated Charcoal in Brief

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This quiz was written by Sophie Nieuwendijk, Maartje van Iwaarden, Denise van Vossen, Gijs de Zeeuw and Nicole van Groningen

Reviewed and edited by Rick Thissen