Welcome to the 146th FOAMed Quiz.
Question 1
This recently published retrospective study is a head to head comparison of apixaban versus rivaroxaban in venous thromboembolism (VTE).
The primary effectiveness outcome was recurrent VTE, a composite of deep venous thrombosis and pulmonary embolism. The primary safety outcome was a composite of gastrointestinal and intracranial bleeding.
18.618 patients with VTE were included in both groups and median follow-up duration was a little over 100 days in both groups.
What did the authors find?
A: Apixaban was associated with a lower rate for recurrent VTE and a lower rate of gastro-intestional or intracranial bleeding compared to rivaroxaban
B: Apixaban was associated with a higher rate for recurrent VTE and a lower rate of gastro-intestional or intracranial bleeding compared to rivaroxaban
C: Apixaban was associated with a lower rate for recurrent VTE and a higher rate of gastro-intestional or intracranial bleeding compared to rivaroxaban
D: Apixaban was associated with a higher rate for recurrent VTE and a lower higher of gastro-intestional or intracranial bleeding compared to rivaroxaban
The correct answer is A.
This recently published paper was covered on JournalFeed last week.
An absolute reduction in probability of recurrent VTE and gastro-intestinal and intracranial bleeding was seen in favor of apixaban (recurrent VTE: 8.9 vs 11.4 events per 100 person-years. ICH and GI bleeds (7.2 vs 11.0 per 100 person-years).
Question 2
You are attempting reduction of a distal metacarpal 5 fracture and you decide to perform an ultrasound guided ulnar nerve block.
Which of the following statements is true about performing an ulnar nerve block.
A: The ulnar nerve always runs radially to the ulnar artery
B: You need at least 10 cc’s of local anesthetic
C: The nerve should only be surrounded by local anesthetic on its superficial side
D: The ulnar nerve is most easily anesthetized proximal of the lower arm as it runs alongside the ulnar artery more distally
The correct answer is D.
SinaiEM covered hand blocks last week.
The ulnar nerve runs on the ulnar (medial) side of the ulnar artery and at the proximal lower arm it is separated from the artery. 3-5 cc’s of local anesthetic should be sufficient and the goal is to surround the nerve entirely by local anesthetic (however it should still work a bit if not the entire nerve is surrounded).
Question 3
What is the most common ECG abnormality in patients with digoxin intoxication?
A: Atrial fibrillation
B: Any type of AV block
C: Ventricular tachycardia
D: Frequent Premature Ventricular Complex (PVC) including ventricular bigeminy and trigeminy
The correct answer is D.
Digoxin toxicity was covered on RebelEM this week.
Digoxin can cause a large variety of ECG abnormalities. The most common ECG abnormality is frequent PVCs.
Question 4
The dose of IV insulin for hyperkalemia is often adjusted in patients with renal disease.
This recently published single center retrospective study is about 5 vs 10 units of IV insulin in patients with moderate renal dysfunction (eGFR 15-59 mL/min/m2) and symptomatic hyperkalemia.
A total of 377 hyperkalemic patients with moderate renal dysfunction were included.
The primary outcome was the rate of hypoglycemia in each group. Secondary outcomes included rate of potassium-lowering effect and incidence of severe hypoglycemia.
What did the authors find?
A: There were less hypoglycemic events in the 5 units group. Serum potassium was equally lowered in both groups
B: There were less hypoglycemic events in the 5 units group and serum potassium was lowered more in the 10 units group
C: There was no difference in hypoglycemic events between both groups and serum potassium was equally lowered in both groups
D: There was no difference in hypoglycemic events between both groups and serum potassium was lowered more in the 10 units group
The correct answer is D.
This week, JournalFeed discussed Insulin dose for hyperkalemia treatment in patients with moderate renal dysfunction.
In this study hypoglycemia occurred in 6.5% of patients in the 5 units iv insulin group and 8.4% of patients in the 10 units group (p = 0.476). Serum potassium lowered significantly more in the 10 units group compared to the 5 units group (-0.9 mmol/L vs. -0.63 mmol/L, p = 0.001).
Question 5
Your patient comes in comatose with a carbon monoxide (CO) level of 50 percent.
Which of the following results in the shortest CO half life?
A: Non rebreather mask
B: Hyperbaric oxygen
C: High Flow Nasal Cannula (HFNC)
D: Intubation and ventilation with an FiO2 of 1.0
The correct answer is B.
Carbon monoxide intoxication (and ECG changes) was covered on dr. Smith’s ECG blog last week.
Although evidence is not clear about it’s exact benefits, hyperbaric oxygen therapy is indicated for patients with carbon monoxide poisoning at high risk of persistent neurological sequelae. Carbon monoxide half life is 90 minutes in an intubated patient with 100% FiO2 and only 23 minutes in at 3 atmospheres (and 100% oxygen).
This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Maartje van Iwaarden and Nicole van Groningen
Reviewed and edited by Rick Thissen
