Quiz 155, May 20, 2022

Welcome to the 155th FOAMed Quiz.


Source image: www.pixabay.com

Question 1

Your 65 year old patient comes in with tachypnea, profound tachycardia, diaphoresis, fever and confusion. She has been losing weight and is feeling restless for the last few months and last week she had influenza.

You suspect her of having thyrotoxic crisis.

Which of the following agents is not part of ED treatment of thyrotoxic crisis?

A: A beta blocker (propranolol)

B: A glucocorticosteroids (hydrocortisone)

C: A thioamides (propylthiouracil)

D: Acetylsalicylic acid (Aspirin)

The correct answer is D.

Thyrotoxic crisis was covered on EM Pills last week (in Italian).

Aspirin interacts with protein binding and might increase free T4 and T3 serum levels. It should be avoided in case of thyrotoxic crisis.

Source image: www.gezondheid.be

Question 2

Renal colic is a clinical diagnosis and imaging is often unnecessary. However, when in doubt, imaging can be helpful. The preferred initial imaging modality (CT, POCUS or formal ultrasound) is debatable.

In this 2014 paper, 2759 patients with suspected nephrolithiasis were randomized to undergo diagnostic ultrasonography performed by an emergency physician (POCUS), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT as initial imaging. The patients were only included if the treating physician decided imaging was necessary.

The primary outcomes included high-risk diagnoses with complications that could be related to missed or delayed diagnoses.

What did the authors find?

A: Patients in the POCUS group had a higher rate of complications that could be related to missed or delayed diagnoses compared to patients in the CT group. Patients in the radiology ultrasound group did not

B: Patients in both the POCUS group and the radiology ultrasound group had a higher rate of complications that could be related to missed or delayed diagnoses compared to patients in the CT group

C: The incidence of high-risk diagnoses with complications in the first 30 days did not vary according to imaging method

The correct answer is C.

The paper was covered on NUEM last week.

High-risk diagnoses with complications during the first 30 days after randomization occurred in only 11 patients with no significant difference according to study group.

However, 40.7% of the patients in the point-of-care ultrasonography group and 27.0% of the patients in the radiology ultrasonography group underwent subsequent CT in the emergency department. This did not result in a higher mean ED length of stay.

The sensitivity was 54% for point-of-care ultrasonography, 57% for radiology ultrasonography, and 88% for CT.

Source image: www.pixabay.com

Question 3

Alcohol consumption appears to be increasing and alcohol withdrawal syndrome (AWS) is quite frequently encountered in our ED.

Which of the following statements about the management of AWS is true?

A: IV midazolam is superior to IV lorazepam in treatment of AWS

B: IV benzodiazepine have higher effectiveness in treatment of AWS compared to IV phenobarbital

C: IV benzodiazepines have a favorable safety profile for treating alcohol withdrawal compared to IV phenobarbital

D: IV phenobarbital can cause persistent coma in patients with liver failure or hepatic encephalopathy

The correct answer is D.

Both EMDocs and Downeast EM covered alcohol withdrawal syndrome last week.

There is no clear evidence suggesting superiority of one benzodiazepine over another for AWS treatment and phenobarbital is most likely at least as effective as benzodiazepines. The safety profile of phenobarbital appears similar to that of benzodiazepines, but beware of patients with liver failure.

Source image: first10EM.com

Question 4

The prevalence of monkeypox is increasing. This viral zoonosis is endemic to central and western Africa, but is increasingly encountered throughout Europe and the US. 

Which of the following statements about monkeypox is true?

A: The first clinical features of the illness are skin lesions. There are no prodromes.

B: Monkeypox may look very similar to chickenpox

C: Monkeypox has a higher rate of transmission from human to human compared to smallpox

D: Smallpox vaccination does not provide protection against monkeypox

The correct answer is B.

Monkeypox was covered on first10EM last week.

Monkeypox may mimic chickenpox.

Prodromes include fever, malaise and headaches and typically last for 2 days.

Monkeypox has a lower transmission rate compared to smallpox and the smallpox vaccine actually provides some protection against monkeypox.

Smallpox vaccination appears to provide reasonable (approximately 85%) protection against monkeypox.


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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