Quiz 157, June 10th, 2022

Welcome to the 157th FOAMed Quiz.


Source image: www.litfl.com

Question 1

A patient is brought to your ED with nausea and palpitations after drinking tea from self picked garden plants. The ECG, as displayed, shows “sagging” ST segments and T waves taking on a typical appearance.

Which of the following plants was likely to be inside the tea?

A: Oleander

B: Monkshood

C: Yew

D: Foxglove

The correct answer is D.

AliEM discussed Foxglove intoxication this week.

The botanical name for foxglove is Digitalis purpurea. ECG changes are in line with digoxin intoxication.

Oleander is a poisonous plant with a non-digitalis cardiac glycoside effect. The Na+/K+ ATPase pump of the heart is affected, resulting in hyperkalaemia which might lead to matching ECG changes.

Both Monkshood and Yew contain alkaloids that disrupt impulse conduction in the heart by blocking sodium channels in the cell membrane, slowing depolarization, leading to bradycardia and cardiac arrest.

ACMT Toxicology Visual Pearl: Pretty (and Deadly) in Purple

Source image: https://thesgem.com

Question 2

There used to be a time every patient with pneumothorax, traumatic or not, received a large bore chest tube. Fortunately, nearly all patients with pneumothorax get a smaller percutaneous catheter nowadays.

Patients with hemothorax still routinely get a 28-32 Fr chest tube, for smaller tubes are thought to increase the risk of complications and retained hemothorax.

In this 2021 paper, patients with traumatic hemothorax or hemopneumothorax requiring drainage were randomized to receive a 14 Fr pigtail catheter or a 28–32 Fr large-bore chest tube.

The primary outcome was failure rate of the drainage catheter, defined as retained hemothorax requiring additional intervention including a second catheter, thrombolysis and video-assisted thoracoscopy surgery.

What did the authors find?

A: The failure rate of the drainage catheter was higher in the 28-32 Fr group

B: The failure rate of the drainage catheter was higher in the 14 Fr pigtail group

C: The failure rate of the drainage catheter did not differ between the two groups

The correct answer is C.

The paper was covered on RebelEM last week.

The failure rate was 11 percent in the pigtail group versus 13 percent in the 28-32 Fr chest tube group. This difference was not statistically significant.

Keep in mind this is a rather small RCT with some methodological flaws. Larger RCT’s are needed for change of practice.

Traumatic Hemothorax: Pigtail vs Chest Tube

Source image: www.litfl.com

Question 3

The patient behind this ECG presents with a certain type of hypertrophic cardiomyopathy (HCM).

In patients with what nationality is this type of HCM most frequently seen?

A: Mongolian

B: Japanese

C: Philippine

D: South Korean

The correct answer is B.

This ECG is typical for apical HCM. Apical HCM was covered on LITFL last week.

‘’This relatively uncommon form of HCM is seen most frequently in Japanese patients (13-25% of all HCM cases in Japan) and it is also known as Yamaguchi syndrome’’.

Apical hypertrophic cardiomyopathy (AHC)

Source image: www.henw.org

Question 4

Your patient presents with acute hearing loss.

The Weber test lateralizes to the right ear and the Rinne test is positive (normal) on both sides.

What does this patient most likely have?

A: Conductive hearing loss of the right ear

B: Conductive hearing loss of the left ear

C: Sensorineural hearing loss of the right ear

D: Sensorineural hearing loss of the left ear

The correct answer is D.

Taming the SRU covered tinnitus and auditory disturbances last week.

Weber test lateralizes to the right ear, so this patient either has conductive hearing loss on the right side or sensorineural hearing loss on the left side.

A positive Rinne on both sides means there is no conductive hearing loss, leaving sensorineural hearing loss on the left side as the most likely cause.

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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