Quiz 177, January 26th, 2023

Welcome to the 177th FOAMed Quiz.


Question 1

Source image: www.freepik.com

Your patient comes in with vomiting and a distended, painful abdomen. 3 years ago he had an hemicolectomy because of Crohn’s disease, which has been stable ever since.

You suspect bowel obstruction.

Which of the following findings on POCUS is most sensitive for small bowel obstruction?

A: Fluid filled bowel with extra-luminal free air

B: Bowel wall thickening (> 3 mm)

C: Decreased peristalsis and retrograde peristalsis

D: Dilated loops of small bowel (diameter > 2.5 cm)

The correct answer is D.

Small bowel obstruction was covered on RebelEM last week.

Dilated loops of small bowel is the most sensitive and specific finding for small bowel obstruction. The other signs mentioned above can be found as well.

A normal lactate or plain X-ray does not rule out the diagnosis. POCUS has a high positive (9.5 (2.1 – 42.2)) and a low negative (0.04 (0.01 – 0.13)) likelyhood ratio. 

REBEL Core Cast 94.0 – SBO

Question 2

Your resident mentions your patient has a Insall-Salvati ratio of 1.4 on the X-ray.

What is she talking about?

A: A patient with suspected patellar tendon rupture

B: A patient with suspected achilles tendon rupture

C: A patient with suspected biceps tendon rupture

D: A patient with suspected supraspinatus muscle rupture

The correct answer is A.

AliEM covered the patellar tendon rupture last week.

The Insall-Salvati ratio or index is the ratio of the patella tendon length to the length of the patella on a 30° flexed lateral knee x-ray and is used to determine patellar height.

Source image: www.radiopaedia.org

SplintER Series: Patellar Tendon Rupture

Question 3

Source image: www.technopower.com.bd

Your patient presents in profound cardiogenic shock and respiratory insufficiency. He does not tolerate non-invasive ventilation and you put him on High Flow Nasal Cannula (HFNC) therapy.

Which of the following statements is true about HFNC in this patient?

A: HFNC will likely decrease his hypercarbia

B: HFNC is less well tolerated than non invasive ventilation

C: HFNC will provide some PEEP

D: HFNC can be administered to a maximum of 100 L/min

The correct answer is C

Cardiogenic shock was covered on EMDocs last week.

HFNC is a very useful tool in patients with respiratory insufficiency. Although its main goal is to optimize oxygenation by matching inspiratory flow rates and deliver humidified and warm oxygen with an adjustable FiO2, it also decreases hypercarbia slightly by providing a washout effect of the upper airway dead space.

It can deliver some PEEP (some say up to 7 cm H2O) and can provide up to 60 L/min flow.


Question 4

Which of the following medication delivery devices is worst for the environment?


Source image: www.pharmtech.com


Source image: BBC.co.uk


Source image: www.thehealthy.com
The correct answer is A. Don’t forget the Bubbles covered inhalers and sustainability last week. The hydrofluorocarbons (HFCs) used in metered dose inhaler (MDIs) are potent greenhouse gasses. ‘’Their effect on climate change is up to 3800 times more potent than carbon dioxide’’.
Inhalers and sustainability
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This quiz was written by Sophie Nieuwendijk, Denise van Vossen,  Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen