Quiz 162, July 15, 2022

Welcome to the 162th FOAMed Quiz.


Question 1

source image: pixabay.com

The recently published SALSA trial was about the risk of overcorrection of symptomatic hyponatremia using hypertonic saline (3%) bolus versus slow continuous infusion. 178 patients with moderately severe to severe symptomatic hyponatremia were randomised to receive either a rapid intermittent bolus (RIB, 2 cc per kilogram, repeated if necessary) versus slow continuous infusion (SCI, 0,5 to 1 cc per kilogram per hour, adjusted if necessary).

Overcorrection was defined as an increase in serum sodium of 12 mmol/L in 24 hours or 18 mmol/L in 48 hours.

What did the authors find?

A: Overcorrection occurred significantly more in the RIB group compared to the SCI group

B: Overcorrection occurred significantly more in the SCI group compared to the RIB group

C: There was no significant difference in occurrence of overcorrection between the RIB group and SCI group

The correct answer is C.

emDOCs covered the SALSA trial last week.

In this randomized clinical trial, overcorrection occurred in 17.2% of patients in the RIB group and 24.2% in the SCI group (absolute risk difference, -6.9% [95% CI, -18.8% to 4.9%]; P = .26). Both RIB and SCI therapy strategies for treating symptomatic hyponatremia seem effective and safe.

The groups did not differ in terms of efficacy in increasing serum sodium concentrations nor improving symptoms. However, RIB, when compared with SCI, showed better efficacy in achieving target correction rate within 1 hour (intention-to-treat analysis: 32.2% vs 17.6% P = .02). Because of this RIB seems to be preferable in treating hyponatremia in the emergency department

52 in 52 – #2: The SALSA Trial

Question 2

Source image: emergencymedicinecases.com

We are most likely overdiagnosing pulmonary embolism and harming our patient with unnecessary anticoagulation. Whether to treat isolated subsegmental pulmonary embolism or not remains controversial.

In this recently published observational trial, 292 patients with isolated subsegmental pulmonary embolism who did not receive anticoagulation were included. Patients with active cancer or history of venous thromboembolism (VTE) were excluded.

The primary outcome was recurrent venous thromboembolism during the 90 day follow-up period.

What did the authors find?

A: The risk of recurrent VTE was 0%

B: The risk of recurrent VTE was 1%

C: The risk of recurrent VTE was 3%

The correct answer is C.

The paper was covered on first10EM last week.

In this cohort, the risk of recurrent VTE was 3%. There were a total of 8 patients with recurrent VTE. 4 were proximal PE’s and 4 were proximal DVT’s. This number seems a bit high to deny patients from anticoagulation.

What to do about subsegmental pulmonary embolism?

Question 3

Source image: http://hqmeded-ecg.blogspot.com/

The ECG above shows de Winter’s T- waves. There are hyperacute T waves with depressed ST takeoff or ST depression in leads V2-V4.

What are de Winter’s T-waves indicative of?

A: Occlusion on the RCA

B: Occlusion of the LAD

C: Occlusion of the Cx

D: Pericarditis

The correct answer is B.

This ECG was covered on dr. Smiths ECG blog last week.

The de Winter pattern is seen in about 2% of acute LAD occlusions and is often under recognized.

Question 4

Source image: EMDocs.com

The PEricapsular Nerve Group block (PENG-block) is used as an alternative (and likely more effective block) to nerve blocks like the femoral nerve block and the Fascia Iliaca Compartment Block in patients with proximal femur pathology.

In performing the PENG block, in what location should the local anesthetic be injected?

A: Deep to the psoas tendon

B: Just superficial to the anterior inferior iliac spine

C: Just superficial to the iliopubic eminence

D: Superficial to the iliopsoas muscle

The correct answer is A.

EM Pills covered the PENG block last week.

The local anesthetic should be injected in the iliopsoas recess deep to the psoas tendon.

PENG Block

Question 5

Source image: myblockbuddy.com

Which of the following statements about B-lines in ultrasonography is true?

A: B-lines are only seen in pulmonary ultrasound

B: B-lines in pulmonary ultrasound are typically seen in case of pneumothorax

C: B-lines are caused by adjacent fluid filled and air filled structures

D: B-lines typically fade with increasing depth

The correct answer is C.

Ultrasound artifacts are covered by Jacob Avila on Core ultrasound last week.

B-lines are often seen in pulmonary ultrasound, but can be present around the body as long as reverberation artifacts can be caused by adjacent fluid filled and air filled structures. These artifacts are not seen in pneumothorax and they typically don’t fade with increasing depth.

Ultrasound Artifacts, Part 2

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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