Quiz 182, March 3rd, 2023

Welcome to the 182th FOAMed Quiz.


Question 1

Source image: www.coreem.net

Major joint dislocations are a common problem in the emergency room and shoulder dislocations account for 50 percent of them. Most often we use analgesia before reduction, varying from procedural sedation and analgesia (PSA), intra-articular injection to nerve blocks.

In this systematic review and meta-analysis (based on 12 RCT’s, n = 630) the authors compared intravenous sedation (IV sedation, n total = 303) with intra-articular lidocaine (IAL, n total = 327) for dislocation reduction.

What did the authors find concerning the rate of successful reduction?

A: There was no significant difference in rate of successful reduction.

B: The rate of successful reduction was significantly higher in the IAL group compared to the IV sedation group.

C: The rate of successful reduction was significantly higher in the IV sedation group compared to the IAL group.

The correct answer is A.

The paper was covered by CanadiEM last week.

The successful reduction rate was 83.8% in the IAL group and 91.4% in the IV sedation group (RR 0.93, CI 0.86-1.01). There was also no difference in pain scores or ease of reduction.

However, patient satisfaction was significantly greater in the IV sedation group with decreased procedural time, suggesting the benefit of this approach in resource-appropriate settings.

Also, most of the included studies used a combination of opioids and a benzodiazepine as ‘’IV sedation’’ which is definitely not my go to choice of drugs.

CJEM Visual Abstract: Intra-articular lidocaine versus intravenous sedation for closed reduction of acute shoulder dislocation

Question 2

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The use of sodium bicarbonate in cardiac arrest remains controversial and routine use is not advised in current guidelines.

In this recently published cohort study, 1100 children with in hospital cardiac arrest (IHCA) were analyzed. 528 (48.0%) received sodium bicarbonate during CPR.

The primary outcome was survival to hospital discharge.

What did the authors find?

A: Sodium bicarbonate use was associated with lower rates of survival to hospital discharge

B: Sodium bicarbonate use was associated with higher rates of survival to hospital discharge

C: Sodium bicarbonate use was not associated with lower or higher rates of survival to hospital discharge

The correct answer is A.

The SGEM covered the paper last week.

Survival to hospital discharge was 42.2% in patients who received sodium bicarbonate and 73.3% in patients who did not receive sodium bicarbonate (aOR 0.7, 95% CI; 0.54-0.92).

Sodium bicarbonate use was also associated with lower survival to hospital discharge with favorable neurologic outcome rate .

SGEM#394: Say Bye Bye Bicarb for Pediatric In-Hospital Cardiac Arrest

Question 3

Source image: www.ucsfbenioffchildrens.org

Your patient has a two lead pacemaker which is set to DDD mode. What does the third D stand for?

A: Paces both atrium and ventricle

B: Senses both atrium and ventricle

C: Dual trigger of both atria and ventricular pacing in response to absence of intrinsic ventricular depolarization

D: Dual inhibition of both atria and ventricular pacing in response to intrinsic ventricular depolarization

The correct answer is D.

The first letter reveals which chamber gets paced. The second letter means which chamber is sensed and the third letter gives away the sensing response. That is, what the pacemaker does in response to a sensed intrinsic electrical activity. This can be triggered, inhibited, dual or none.

Question 4

Source image: www.ebay.nl

Methylene blue is widely prescribed as treatment for methemoglobinemia.

For which purpose is methylene blue also used?

A: CO intoxication

B: Refractory vasoplegic shock

C: Haemochromatosis

The correct answer is B

Methylene blue as an off-label treatment in refractory vasoplegic shock was covered by ALiEM.

By inhibiting the NO/cGMP pathway, the systemic vascular resistance increases. It can function as a vasopressor in patients with shock.

ACMT Toxicology Visual Pearl: Is the Silver Bullet for Refractory Vasoplegia Really Blue?

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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