Welcome to the 147th FOAMed Quiz.
Question 1
Pain control in patients with sickle cell disease (SCD) and vaso-occlusive crisis (VOC) is often challenging. High doses of opioids are often needed to achieve acceptable analgesia.
In this paper 278 adults with acute sickle VOC were randomized to receive a single dose of either ketamine or morphine, infused over 30 min.
The primary outcome was the mean difference in the numerical pain rating scale (NPRS) score over 2 hours.
What did the authors find?
A: Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2-h period and reduced the cumulative morphine dose in the ED compared to morphine alone
B: Early use of ketamine in adults with VOC did not result in a meaningful reduction in pain scores over a 2-h period and did not reduce the cumulative morphine dose in the ED compared to morphine alone
C: Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2-h period and did not reduce the cumulative morphine dose in the ED compared to morphine alone
The correct answer is A.
The paper was covered on BrownEM last week.
Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2-h period and reduced the cumulative morphine dose in the ED with no significant drug-related side effects in the ketamine-treated group.
Question 2
Your patient comes in with altered mental status, bradypnoeic and with miosis after ingesting quite a large amount of pills he uses ´for his stomach’.
Which of the following drugs is most likely the cause.
A: Metoclopramide
B: Ondansetron
C: Loperamide
The correct answer is C.
PEMCincinnati covered loperamide intoxication last week.
Loperamide is an over-the-counter μ-opioid receptor agonist which can be abused to get an opioid high. The required dosages are quite significant.
Metoclopramide can cause lethargy, bradypnoea and extrapyramidal symptoms, but no miosis.
Ondansetron can cause serotonin syndrome.
Loperamide abuse and misuse
Question 3
Atrial fibrillation (AF) is the most commonly encountered arrhythmia in the Emergency Department. Rate control is one of the treatment goals in permanent AF.
This recently published meta analysis is about IV Diltiazem versus IV Metoprolol for rate control in patients with AF and rapid ventricular rate (RVR).
Seventeen studies involving 1214 patients in nine RCTs were included.
What did the authors find?
A: Intravenous diltiazem has higher efficacy but an increase in adverse events compared to intravenous metoprolol
B: Intravenous diltiazem has higher efficacy and with no increase in adverse events compared to intravenous metoprolol
C: Intravenous diltiazem has lower efficacy and an increase in adverse events compared to intravenous metoprolol
The correct answer is B.
The paper was covered in JournalFeed last week.
Intravenous diltiazem was found to have higher efficacy, shorter onset time and no increase in adverse events compared to intravenous metoprolol.
Question 4
The effectiveness of andexanet alfa (AA) for reversal of oral factor Xa inhibitors (FXi) therapy remains uncertain.
In this retrospective cohort study, 44 adult patients with life-threatening traumatic or spontaneous intracranial bleeds in the setting of apixaban or rivaroxaban use were analysed. 28 of these patients received AA and 16 patients received 4F-PCC.
The primary outcome was ´stable´ head CT (no large increase in hematoma size) at 6 and 24 hours post-administration of AA or 4F-PCC.
What did the authors find?
A: Patients receiving AA had significantly more stable neuroimaging assessment at 24 hours compared to patients receiving 4F-PCC
B: Patients receiving 4F-PCC had significantly more stable neuroimaging assessment at 24 hours compared to patients receiving AA
C: There was no significant difference in the proportion of patients with stable neuroimaging at 24 hours assessment between the two groups
The correct answer is C.
This retrospective observational paper was covered on Rebel EM last week.
There was no statistically significant difference rate of stable neuroimaging at 24 hours between the two groups.
Keep in mind this paper has several methodological issues. The sample size is very small and the primary outcome is not patient centered. Furthermore there is major concern for selection bias and unbalanced baseline characteristics.
Andexanet Alfa Vs. Four-Factor PCC: Is Andexanet Alfa Worth The Hype?
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
