Quiz 156, May 27, 2022

Welcome to the 156th FOAMed Quiz.


Question 1

Source image: pixabay.com

Your 3 year old patient comes in with a cough. There is no respiratory distress. Her mom is pretty sure she aspirated a peanut.

Which of the following statements about aspiration of a peanut is true?

A: In case of mild symptoms, there is no need to retrieve the peanut. It will dissolve by itself

B: In case of mild symptoms, the peanut should be retrieved within 48 hours

C: Even in case of mild symptoms, the peanut should be retrieved as soon as possible

The correct answer is C.

Don’t forget the Bubbles covered foreign object aspiration last week.

Peanuts should be retrieved as soon as possible. ‘’ lipophilic objects (like peanuts) can cause massive cytokine release and inflammation due to their fat content.’’

The hidden dangers of inhaled plastic toys

Question 2

Source image: http://brownemblog.com/

Diagnosing pyogenic flexor tenosynovitis can be challenging when the clinical picture is not obvious. The diagnostic value of laboratory testing is uncertain and plain X-ray and CT are not helpful. MRI can aid in diagnosing tenosynovitis but is not always available. In comes ultrasound…

In this 2018 paper 57 patients with suspected pyogenic flexor tenosynovitis (but not obvious, those were excluded) underwent ultrasound in addition to clinical examination (fluid within the tendon sheath). The gold standard was inter-operative findings or (whenever the patient did not get surgical intervention) the clinical course when treated with antibiotics only.

What did the authors find?

A: Ultrasound had both a high sensitivity and a high specificity

B: Ultrasound had a high sensitivity, but a low specificity

C: Ultrasound had a low sensitivity, but a high specificity

D: Ultrasound had both a low sensitivity and a low specificity

The correct answer is B.

AlieEM covered pyogenic flexor tenosynovitis last week.

In the 2018 paper, of 57 patients, 29 patients had a negative ultrasound and were treated with antibiotics only with good outcome. There was only 1 patient that turned out to have flexor tenosynovitis after all. Of the 27 patients that had a positive ultrasound, 10 patients did not have flexor tenosynovitis intra-operatively.

The sensitivity was 94% and the specificity only 65%.

SplintER Series: Point Tender

Question 3

Your 55 year old patient comes in with hypovolemic shock due to esophageal varices bleeding. You intubate and ask for a minnesota tube.

Which of the following is a Minnesota tube?


The correct answer is C (tough one)

This very helpful EMRap video was shared on UMEM last week.

A is a Linton tube and B is a Blakemore tube. The Missesota tube is the one with the many ports. It has a port for both balloons and for suction of gastric content as well as for esophageal content. For an explanation of the differences, watch the video.

Question 4

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Which of the following clinical signs fit the picture of heparin induced thrombocytopenia?

A: A fall in platelet of 20 percent

B: The platelet fall starts 1 days after start of heparin

C: New venous thrombosis

D: The patient 1 one day post surgery

The correct answer is C.

Critical Care Now covered heparin induced thrombocytopenia (HIT) last week.

A platelet fall of > 50 percent, platelet fall within 5-10 days of starting heparin, new thrombosis and no other cause of thrombocytopenia eg. no surgery) are typical for HIT.

4Ts versus 3Ls: heparin induced thrombocytopenia probability scoring

Question 5

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There are two generations of anticoagulant rodenticides: first generation include warfarin. Second generation rodenticides are also called superwarfarins and very long acting and potent.

Which of the following statements is true about management of superwarfarin intoxication in the emergency department?

A: Asymptomatic patients with a normal INR 12 hours post ingestion can be safely discharged and don’t need follow-up

B: Charcoal may be useful if administered in the first 1-2 hours after ingestion

C: Vitamin K should definitely be administered at presentation in the emergency department

D: If INR is normal at 48-72h after ingestion, toxicity still can’t be ruled out

The correct answer is B.

Anticoagulant rodenticide intoxication was covered on EMDocs last week.

Charcoal may be useful if administered to prevent absorption in the first 1-2 hours after ingestion.

Administration of vitamin K prior to detecting an elevated INR is debatable, as vitamin K1 may delay INR elevation and underestimate severity of exposure.

If INR is normal at 48-72 hrs, clinical toxicity can be safely ruled out with very rare exceptions.

emDOCs.net – Emergency Medicine EducationToxCard: Superwarfarins – emDOCs.net – Emergency Medicine Education

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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