Welcome to the 150th FOAMed Quiz.
Question 1
In stroke patients that undergo successful intra-arterial thrombectomy of a large vessel occlusion, it is thought that microthrombi cause suboptimal neurological recovery.
In the recently published CHOICE trial, 121 patients undergoing successful intra-arterial thrombectomy of a large vessel occlusion were randomized to receive either additional intra-arterial alteplase (0.225 mg/kg) or intra-arterial placebo.
The primary outcome was proportion of patients achieving a modified Rankin Scale (mRS) of 0-1 at 90 days.
What did the authors find?
A: The proportion of patients achieving a mRS of 0-1 was higher in the intra-arterial alteplase group compared to the intra-arterial placebo group
B: The proportion of patients achieving a mRS of 0-1 was higher in the intra-arterial placebo group compared to the intra-arterial alteplase group
C: The proportion of patients achieving a mRS of 0-1 was equal in both groups
The correct answer is A.
Mechanical thrombectomy was covered on EMCrit last week.
The results of this trial are promising. Treatment with intra-arterial alteplase was associated with a score of 0 or 1 on the mRS at 90 days in 59.0% in the alteplase group and in 40.4% in the placebo group (P = .047).
There was no increase in intracranial hemorrhage in the intra-arterial alteplase group.
NeuroEMCrit – Time is Brain – Acute Ischemic Stroke Part 2: Mechanical Thrombectomy
Question 2
A known alcoholic is brought to your ER. Bystanders saw him drinking from a bottle, which did not appear to contain normal potable liquor. His level of consciousness is decreased. Lab results come back. You expected to find a high anion gap metabolic acidosis, but this is not the case.
Which toxic alcohol does not typically lead to high anion gap metabolic acidosis?
A: Methanol
B: Ethylene glycol
C: Propylene glycol
D: Isopropanol
The correct answer is D.
This week NUEMBlog discussed toxic alcohols.
Isopropanol, found in hand sanitizers, mouthwashes and disinfectants, is hepatically metabolized by alcohol dehydrogenase to acetone. There is no further metabolism, and because no acid byproducts are formed, isopropanol is the only toxic alcohol that does not cause an elevated anion gap acidosis.It does cause an osmol gap though.
Question 3
Pre-endoscopy administration of intravenous proton pump inhibitors (PPI) in patients with upper gastro-intestinal tract bleeding is common practice.
According to the Cochrane review on this topic, what is the rationale behind this practice?
A: It is associated with a benefit in mortality
B: It is associated with lower chance of rebleeding
C: It is associated with lower need for transfusion
D: It is associated with lower need for surgery
E: There is no evidence for any patient related benefit
The correct answer is E.
First10EM covered the evidence behind pre-endoscopy PPI administration quite extensively.
To put it shortly, there is no evidence for any patient related benefit of pre-endoscopy PPI administration.
There is moderate-certainty evidence that pre-endoscopy PPI treatment likely reduces the requirement for endoscopic haemostatic treatment at index endoscopy. However, this is not a patient centered outcome.
Question 4
Your patient presents with Sympathetic Crashing Acute Pulmonary Edema (SCAPE). She has profound tachypnea, hypoxia, a heart rate of 120 bpm, blood pressure of 210/110 mmHg and a capillary refill time of 4 seconds.
Which of the following treatment options is least likely to be beneficial in the acute phase?
A: Nitroglycerin (NTG)
B: Continuous Positive Airway Pressure (PEEP)
C: Loop diuretics
The correct answer is C.
Heart failure was covered on EMDocs last week.
The mainstay of SCAPE treatment is NTG and CPAP. There is insufficient evidence for diuretics like furosemide in acute SCAPE.
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
