Quiz 179, February 10th, 2023

Welcome to the 179th FOAMed Quiz.

Question 1

A five year old girl who recently started with chemotherapy for acute lymphoblastic leukemia presents at the emergency department with acute kidney injury. Based on laboratory findings you suspect a tumor lysis syndrome.

Which of the following laboratory findings fits this diagnosis?

A: High potassium, high calcium

B: Low potassium, high LDH

C: High calcium, low creatinine

D: High potassium, low calcium

Reveal answer

The correct answer is D.

Tumor lysis syndrome was covered on DFTB last week.

It is defined by massive tumor cell lysis with the release of intracellular molecules, such as potassium, phosphate and uric acid. The phosphate binds to the calcium already in the blood, forming complexes and thus causing hypocalcemia. Tumor lysis syndrome often occurs after initiation of chemotherapy and mostly in patients with high-grade lymphomas, but it can also occur spontaneously and with other fast proliferating tumor types.

Ten oncology emergencies in kids

Question 2

What type of drug use is referred to when your patient talks about “nanging”?

A: Sipping GHB (gamma-hydroxybutyric acid)

B: Smoking crack (cocaine)

C: Inhalation of laughing gas (nitrous oxide)

D: Snorting speed

Reveal answer

The correct answer is C.

Don’t forget the bubbles covered the use and abuse of nitrous oxide.

The use of nitrous oxide to obtain a so-called “safe high” has increased over the past decade. The exact mechanism is poorly understood. Long term use of N2O can cause permanent damage to the nervous system.

Recreational nitrous oxide

Question 3

Can we swap neuromuscular blockers (NMB) for remifentanil in rapid sequence intubation (RSI)?

In this recently published paper, 1150 ED patients undergoing PSI were randomised to receive (next to a sedation) either a neuromuscular blocker (succinylcholine or rocuronium) or remifentanil (3-4mcg/kg). The aim of the study was to prove remifentanil non-inferior to neuromuscular blockers for rapid sequence induction.

The primary outcome was successful tracheal intubation on the first attempt without major complications.

What did the authors find?

A: Remifentanil was indeed non-inferior to neuromuscular blockers in rapid sequence induction

B: Remifentanil was not non-inferior to neuromuscular blockers in rapid sequence induction

C: Remifentanil was superior to neuromuscular blockers in rapid sequence induction

Reveal answer

The correct answer is B.

The paper was covered on St. Emlyns last week.

Tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (95% CI, –11.6% to –0.5%). Remifentanil was not non-inferior to neuromuscular blockers in rapid sequence induction.

This paper was covered by St. Emlyn’s this week. Keep in mind that a non-inferiority paper can never prove the intervention to be superior to a control. That takes a different kind of study approach.

JC: Keep on blocking in the free world. Remi vs. NMB for RSI. St Emlyn’s

Question 4

Abdominal compartment syndrome is defined by an intra abdominal pressure > 20 mm Hg with organ dysfunction.

The standard method for diagnosis is:

A: Intravesical pressure measurement, typically through a Foley catheter

B: CT abdomen

C: Intra and extra abdominal pressure measurement, typically by surgery

D: Point of care ultrasound (POCUS)

Reveal answer

The correct answer is A.

Abdominal compartment syndrome was discussed this week at emDOCs last week.

Measurement of intravesical pressure is the standard method for diagnosis of intra-abdominal hypertension. However, intragastric, intracolonic or inferior vena cava catheters can also be used.

Normal abdominal compartment pressure is 2-5 mmHg. This pressure is higher in critically ill patients, obese patients and pregnancy. Above 5 mm Hg we call it intra abdominal hypertension, at this point there is no organ dysfunction.