Quiz 79, August 7th, 2020

Welcome to the 79th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

The recently published GRECCO-19 trial is about the use of colchicine in hospitalized adult patients with SARS-CoV-2 infection, confirmed by PCR.

Patients in the intervention group received a loading dose of colchicine followed by a maintenance dose of 0.5 mg twice daily until hospital discharge or a maximum of 21 days. Patients in the control group received standard care.

The objective was to evaluate the effect of treatment with colchicine on cardiac and inflammatory biomarkers and clinical outcomes in patients hospitalized with coronavirus disease 2019 (COVID-19).

What did the authors find?

A: hsTnT and CRP levels were significantly lower and clinical deterioration occurred significantly less often in the intervention group compared to the control group

B: hsTnT and CRP levels were significantly higher and clinical deterioration occurred significantly more often in the intervention group compared to the control group

C: hsTnT and CRP levels were not statistically different while clinical deterioration occurred significantly less often in the intervention group compared to the control group

D: no differences were found between both groups for all the primary outcomes

The correct answer is C

The GRECCO-19 trial was covered by David Slessor from The Bottom Line this week. 

A total of 105 patients were included in this multicentre trial. 

This small study (n=105) demonstrates that colchicine may be effective in reducing the number of admitted patients with COVID-19 that deteriorate to the level of needing ICU admission. 

Although these results sound promising, we have to be aware of several limitations such as small number of subjects, even smaller absolute benefit numbers and wide confidence intervals. 

GRECCO-19

Question 2

Your 63-year old septic patient needs endotracheal intubation. Worried about hemodynamical deterioration you choose ketamine as the induction agent instead of etomidate.

According to this recently published paper, which intubation agent leads more often to post procedure hypotension?

A: Ketamine

B: Etomidate

C: There was no difference in post procedure hypotension

The correct answer is A

This recently published paper was discussed at JournalFeed this week.

It is a an observational cohort study of the prospective (US) National Emergency Airway Registry (NEAR) data set. 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Interestingly, postprocedure hypotension was higher is those intubated with ketamine compared to etomidate (74% vs. 50%).

Source image: www.pixabay.com

Question 3

Exclusion of Serious Bacterial Infections (SBI) in infants remains one of the biggest diagnostic challenges in the ED. Multiple risk stratification tools have been developed along the years, but none of them seem to be very accurate.

Quite recently the Pecarn Rule for Low Risk Febrile Infants (or Kuppermann criteria) was developed in order to exclude SBI. According to this rule, SBI can be excluded in infants between 29 and 60 days if:

– Urinalysis is negative

– Absolute Neutrophil Count <4,090/μL 

– Procalcitonin <1.71 ng/mL

What is the sensitivity of these criteria for SBI?

A: 76 %

B: 82 %

C: 91 %

D: 98 %

The correct answer is D

Justin Morgenstern covered this paper on First10EM.

The group included 1,821 febrile infants less than 60 days of age. The mean age was 36 days old and 42% were female. 9.3% were SBI positive with 7.7% from urinary tract infection alone.

The sensitivity was 97.7% and negative likelihood ratio of 0.04.

Keep in mind this risk score is not yet externally validated. While derived in infants aged 0-60 days, the authors recommend using this calculator only in infants aged 29-60 days.

To LP, or not to LP (the febrile infant): That is the question

Source image: www.emdocs.net

Question 4

 A healthy 5 year old boy presents to your ED after a fall on his right arm. The elbow is painful and slightly swollen. An X-ray is made to rule out a fracture.

For the assessment of the x-ray of the elbow you use the mnemonic CRITOE.

Which statement is true about CRITOE?

A: The C stands for capitellum and the R for the radial head and they appear simultaneously at the age of 3

B: The I stands for the internal epicondyle which starts to be visible at the age of 7

C: The T stands for the trochlea and is visible at the age of 7

 D: The O stands for the olecranon and the E for the external epicondyle and both appear at the age of 9

The correct answer is C.

This week EMDocs covered pediatric elbow injuries.

CRITOE stands for capitellum, radial head, internal epicondyle, trochlea, olecranon and external epicondyle. 

The first ossification is the Capitellum at the age of one. By the age of three the Radial head appears as a small balloon. The Internal epicondyle starts to ossify by the age of five and the Trochlea will be visible at the age of seven. By the age of nine the Olecranon of the ulna will appear. And finally at the age of eleven the external Epicondyle will appear.

Source image: www.pixabay.com

Question 5

Step one in the treatment of Hyperosmolar Hyperglymic State (HHS) will be volume resuscitation and insulin administration.

What changes in serum laboratory values can be seen after initial treatment?

A: Serum sodium, serum glucose and serum osmolality all decrease

B: Serum sodium decreases, serum glucose increases and serum osmolality decreases

C: Serum sodium increases, serum glucose decreases and serum osmolality increases

D: Serum sodium increases, serum glucose decreases and serum osmolality decreases

The correct answer is D.

Josh Farkas covered Hyperosmolar Hyperglycemic State in this week’s podcast on PULMCrit.

Due to the resuscitation with isotonic fluids serum sodium will increase. The tonicity will decrease despite the rising sodium. Serum glucose will fall due to the administration of insulin and fluids. Serum osmolality will decrease because it is affected by chloride and glucose.

IBCC chapter & cast – Hyperosmolar Hyperglycemic State

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 78, July 31th, 2020

Welcome to the 78th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Tricuspid Annular Plane Systolic Excursion (TAPSE) is a quantitative measurement of the movement of the tricuspid annulus during the cardiac cycle and is quite often measured as a surrogate of right ventricular function.

Which of the following statements is true about TAPSE?

A: TAPSE is a multiple-plane measurement

B: TAPSE is very sensitive for pulmonary embolism in normotensive patients

C: Abnormal TAPSE measurement is only seen in pulmonary embolism

D: A TAPSE of less than 2 cm is considered abnormal

The correct answer is D

County EM covered TAPSE as a diagnostic parameter for pulmonary embolism this week.

TAPSE is a pretty easy one plane measurement in apical view.

Right ventricle dysfunction may still be present with normal TAPSE.

TAPSE is not sensitive or specific enough in normotensive patients, however it is more sensitive in patients with tachycardia.

Abnormal TAPSE measurement may be seen in other disease processes that cause RV strain, such as pulmonary hypertension, RV ischaemia, and congestive heart failure.

A TAPSE of less than 2 cm is considered abnormal.

Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 31240

 Question 2

Your 78 year old patient presents to the ED after a fall with her bicycle. She turns out to have 3 rib fractures. According to this paper  which of the following parameters is a useful predictor for length of stay (LOS) in the hospital?

A: Change in pain between day one and two

B: FEV1 on day one

C: Grip strength on day one

The correct answer is B

Sam Parnell covered this paper on JournalFeed.

It turns out FEV1 is a reliable predictor of LOS. The course of pain is not. Furthermore, pain did not correlate with spirometry values.

Spirometry as a adjunct test to decide which patients can be discharged sure sound interesting.

 

Source image: www.pixabay.com

Question 3

You see a forty year old male patient with gastritis. You consider prescribing a combination of an antacid and lidocaine.

What is the benefit of this cocktail compared to antacid monotherapy?

A: Faster pain relief

B: Better pain relief

C: Less adverse events

D: There is no benefit

The correct answer is D

This recently published randomised controlled trial compared antacid monotherapy versus antacid and lidocaine.

The authors included and randomised 89 patients. They found no statistical difference in pain scores between the groups. Patients did prefer the taste of the antacid monotherapy and there were more adverse events reported in the lidocaine group.

Don’t use lidocaine for epigastric pain

Question 4

Progressive weakness of extremities and diminished reflexes in the affected limbs are cornerstone features of Guillain-Barre Syndrome (GBS).

Which of the following features is inconsistent with GBS?

A: Relatively symmetric symptoms

B: Fever at onset of symptoms

C: Cranial nerve involvement

D: Autonomic dysfunction

The correct answer is B

Josh Farkas covered GBS on the internet book of critical care this week.

The usual presentation of this disease involves sensory disturbances, ascending flaccid paralysis and autonomic dysfunction. Cranial nerve involvement can be present, especially facial palsy. Although infection is involved as a trigger, fever is not typically present at onset of the disease.

Guillain Barre Syndrome (GBS)

Question 5

Source image: Pixabay.com

The prognosis of traumatic cardiac arrest is dismal. Which of the following parameters is associated with higher odds of survival according to this paper?

A: Bystander CPR

B: Prehospital intubation

C: Penetrating mechanism of injury

D: Use of prehospital or in-hospital epinephrine 

The correct answer is A

RebelEM covered this systematic review and meta-analysis on prognostic factors in traumatic cardiac arrest last week. 

A total of 53 studies involving 37,528 patients were included.

Male sex, penetrating mechanism of injury and head injury were not associated with a lower or higher survival rate. 

Presence of cardiac motion on ultrasound, shockable initial cardiac rhythm, witnessed arrest and bystander CPR had higher odds of survival. 

Use of prehospital or in-hospital epinephrine and prehospital intubation had lower odds of survival.

Traumatic Cardiac Arrest – Can we Find Prognostic Factors that Predict Survival?

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 76, June 17th, 2020

Welcome to the 76th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Your 27 year old patient comes in with status epilepticus. She had a first seizure one month ago without a clear cause and she is currently not on anti epileptic medications. Now she is seizing for 5 minutes already.

Which of the following statements is true about the management of status epilepticus?

A: Ketamine might play a role once conventional therapies are not effective

B: Evidence shows levetiracetam is more effective as a second line drug compared to valproic acid and phenytoin

C: The first dose of benzodiazepines should not be administered in the first 5 minutes of the seizure

D: The time frame in which neurolytic intubation should be performed in status epilepticus is one hour

The correct answer is A

EMottawa covered the management of status epilepticus this week. 

Ketamine might well be beneficial in status epilepticus as a fourth line treatment as the first to 3th line treatments focus on GABA receptors, while ketamine is a strong NMDA antagonist. Evidence so far is limited (case reports). 

There still is no answer to which drug is most effective as second line treatment. Choose wisely depending on potential effects and ease of administration. 

The first dose of benzodiazepines should be given within 5 minutes, as longer lasting seizures are more difficult to treat. 

The timeframe in which neurolytic intubations should be performed is definitely not 1 hour, but 20 minutes. However, especially when administration of the second line drug is delayed, 20 minutes go by quickly. 

The Status on Status: Management of Status Epilepticus

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 6079

Question 2

You see a 29 months old girl with a history of spina bifida. She has a ventriculoperitoneal (VP) shunt which was implanted in the first month of her life. She is now more lethargic than usual and vomited twice during triage. Her shunt was revised when she was just 18 months old. You think that her symptoms could be explained by a raised intracranial pressure due to a problem with her VP shunt.

Which of the following statements about VP shunt failure is true?

A: Distal occlusion of the VP shunt is more common than proximal occlusion of the VP shunt

B: VP shunt infections are most common during the first 6 months after implantation

C: Symptoms occur rapidly in case of a VP shunt fracture or VP shunt disconnection

D: Over-drainage by the VP shunt is not possible

The correct answer is B

VP shunts were covered by Angharad Griffiths from Don’t Forget the Bubbles this week.

A VP shunt is a medical device used to drain fluid via a pressure gradient, away from the brain for conditions of excessive cerebrospinal fluid (CSF). They drain according to the difference in pressure gradient between the ventricle and the tip of the distal catheter which is tunneled down into the abdomen inside the peritoneal cavity.

The most common cause of shunt malfunction is proximal occlusion and infections are mostly seen during the first 6 months after implantation.
Since CSF can still drain when the VP shunt fractures or disconnects, symptoms take time to evolve. 

Over-drainage leading to the ‘’slit ventricle syndrome’’ is rare but can occur.

Source image: http://blog.clinicalmonster.com/

Question 3

Your 38 year old patient has a progressive asymmetrical face since this morning. He is unable to move the right side of his mouth and he can’t shut his right eye. Further physical examination reveals no additional focal deficits.

You suspect Bell’s palsy.

Which of the following is not routinely part of treatment of Bells palsy?

A: Artificial tears

B: Steroids

C: Antivirals

The correct answer is C

CountyEM covered Bell’s palsy last week.

Difficulty fully closing the eyelids puts patients at risk for corneal abrasions, foreign bodies, and other ocular trauma. The eye should be protected and artificial tears should be started.

The evidence on steroids (prednisolone 60 to 80 mg daily) is quite clear as they have been shown to increase the chance of full recovery, particularly if started within 3 days of onset of symptoms.

The evidence on antivirals is far less convincing as you can read on the blog.

 

Question 4

In which of the following mood stabilizers is activated charcoal NOT effective in case of toxicity?

A: Valproic acid

B: Lithium

C: Carbamazepine

D: Haloperidol

The correct answer is B

NuEM posted a really useful summary about Lithium and Valproic acid last week

4 drugs quite commonly encountered in intentional overdose are Valproic acid, Lithium, Carbamazepine and Haloperidol.

Activated charcoal does not bind Lithium, so it is not useful in Lithium overdose. It should be considered in cases of Valproic acid, Carbamazepine and Haloperidol overdose. 

 

Question 5

Thromboelastography (TEG) (or the quite similar ROTEM) is commonly used to guide treatment in acute traumatic bleeding.

Not a lot of evidence exists about its efficacy in non-traumatic bleeding.

This paper published in January 2020 is about the use of TEG versus standard of care (SOC) in the treatment of cirrhotic patients with non-traumatic, non-variceal upper GI bleeding.

What did the authors find?

A: Compared to the SOC group, the patient in the TEG group required half the total volume of Fresh Frozen Plasma (FFP) transfused

B: Compared to the SOC group, the patient in the TEG group were more likely to require no transfusions

C: Compared to the SOC group, less serious transfusion reactions occurred in the TEG group

D: All of the above

The correct answer is D

EMdocs covered this single-center, randomized controlled trial last week.

96 Patients were enrolled in the study.

In the TEG-group the subjects received TEG-guided FFP (long r-time), platelets (small amplitude) and cryoprecipitate (small alpha angle). In the control group the patients received FFP when the INR was greater than 1.8 and/or received platelets when the platelet count was below 50× 109/L.

Compared to the SOC group, the TEG group required half the total volume of FFP transfused, were less likely to require transfusion of all three blood components (27% vs. 87%), and were more likely to require no transfusions (14% vs. 0%; P<0.02 for all comparisons). Serious transfusion reactions occurred significantly less often in the TEG group (31% vs. 75%).

Interestingly, this paper does not mention packet red blood cell use. Keep in mind this study excluded patients who were on antiplatelet and anticoagulation therapy, which are common in bleeding patients in the emergency department.

Thromboelastography for Hypocoagulable Patients with Non-Traumatic Bleeding

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 75, July 10th, 2020

Welcome to the 75th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Case courtesy of Dr Bahman Rasuli, Radiopaedia.org, rID: 74573

Question 1

This recently published cohort study examined associations between NSAID, COX-2-inhibitor (e.g. celecoxib) and opioid prescriptions and the rate of nonunion of long-bone fractures.

What did the authors find?

A: Exposure to selective COX-2-inhibitors was associated with an increased risk of nonunion of long-bone fractures

B: Exposure to NSAIDs was associated with an increased risk of nonunion of long-bone fractures

C: Exposure to none of the three medication groups increased the risk of nonunion of long-bone fractures

The correct answer is A

Clay Smith covered this paper on Journal Feed this week.

Exposure to selective COX-2 inhibitors was associated with a significant 84% (OR 1.84; 95% CI 1.38 to 2.46) increase in the odds of nonunion respectively compared to NSAIDs (OR 1.07; 95% CI 0.93 to 1.23). Use of opioids was also associated with a significant increase (69% (OR 1.69; 95% CI 1.53 to 1.86)).

Selective COX-2 inhibitors, as the name suggests, only inhibit COX-2 while NSAIDs have some COX-1 and COX2 inhibition. The important role of COX-2 in fracture healing, due to its role in the inflammatory response, could be the explanation for the difference that was found for nonunion in long-bone fractures between selective COX-2 inhibitors and NSAIDs.

It is unknown if the increased odds ratio for nonunion of long-bone fractures in patients with an opioid prescription could be explained by the fact that these patients probably had more severe injuries.

 

Question 2

Source: https://first10em.com/atrial-fibrillation/

The RAFF2 paper is about electrical versus pharmacological cardioversion of stable atrial fibrillation. 

Subjects in one group received procainamide first, followed by electrical cardioversion (ECV) if normal sinus rhythm was not achieved. Subjects in the other group received placebo first, followed by ECV if sinus rhythm was not achieved.

What did the authors find?

A: Conversion to normal sinus rhythm (NSR) was more often achieved in the procainamide + ECV group compared to the placebo + ECV group

B: Conversion to normal sinus rhythm (NSR) was more often achieved in the placebo + ECV group compared to the procainamide + ECV group

C: Conversion to normal sinus rhythm (NSR) was similar in the placebo + ECV group compared and the procainamide + ECV group

The correct answer is C

RebelEM covered this paper last week. It was published in the Lancet in Februari 2020.

396 Subjects were enrolled.

Both the drug-shock and shock-only strategy led to similar conversion rates (96 and 92 percent) and rates of discharge home (97 and 95 percent). 52% of patients in the drug-shock group converted after drug infusion only vs 9% in the shock only group.

RAFF2: Electrical vs Pharmacological Cardioversion for ED Patients with Acute Atrial Fibrillation

Question 3

Your 45-year old male patient comes in with severe chest pain and dyspnea. He has a history of sickle cell disease and you think he might be suffering from acute chest syndrome.

Which of the following statements about the treatment of acute chest syndrome is true?

A: The recommended oxygen saturation target is >88%

B: A state of hypervolemia should be obtained

C: Exchange transfusion is likely more effective than simple blood transfusion

D: NSAIDs can safely be used

The correct answer is C

Josh Farkas covered sickle cell acute chest syndrome this week on the IBCC podcast.

Acute chest syndrome can be described as a vaso-occlusive crisis which involves the lungs and is defined as a combination of a new opacity on chest X-ray with either fever and/or respiratory symptoms (e.g. cough, dyspnea or chest pain) in patients with sickle cell disease.

Adequate oxygenation is essential to decrease progressive sickling of erythrocytes. An oxygen saturation target of >92% or >95% is therefore commonly recommended.

Normovolemia should be obtained since hypovolemia could increase blood viscosity and thereby increase sickling. Hypervolemia potentially causes fluid overload since these patients could have acute lung injury, cardiac dysfunction and/or renal failure.

Exchange transfusion is likely more effective than simple transfusion because it allows for a rapid and dramatic reduction of sickle hemoglobin without increasing blood viscosity.

Analgesia with NSAIDs should be avoided in most patients since patients with severe acute chest syndrome are prone to develop renal failure.

IBCC chapter & cast – Sickle Cell Acute Chest Syndrome

Question 4

Cyclic vomiting syndrome in children is associated with an increased risk in adulthood on

A: Inflammatory bowel disease

B: Migraine

C: Hyperemesis gravidarum

D: Psoriasis

The correct answer is B

Cyclic vomiting syndrome is characterised by recurrent episodes of vomiting in a stereotypical pattern. It is a clinical diagnosis based on the history, and can only be made after several other causes are excluded. The pathogenesis is not understood, but there is an association with migraine in adulthood. Many children respond to anti migraine medication like sumatriptan.

Cyclic Vomiting Syndrome

Source image: www.ultrasoundgel.org

Question 5

Deep learning is a branch of artificial intelligence that holds a lot of promise for point-of-care ultrasound.

Investigators from this recent paper used a deep learning algorithm to label upper extremity structures such as veins, nerves, bones and tendons. They compared DL to expert POCUS users in order to define who can interpret the images most accurately.

What did the investigators find?

A. The DL algorithm proved to be more accurate in identifying 4 common structures compared to the POCUS experts

B. The DL algorithm had an equal accuracy in identifying 4 common structures compared to the POCUS experts

C. The DL algorithm proved to be less accurate in identifying 4 common structures compared to the POCUS experts

The correct answer is A

This week Michael Prats covered this study on the Ultrasound G.E.L. Podcast.

In the comparison of the deep learning algorithm to the POCUS experts, only one out of two POCUS experts beat the algorithm on identifying blood vessels. In the identification of 4 key anatomic structures (such as veins, nerves, bones and tendons) in transverse ultrasound images of the upper extremity the deep learning outperformed both POCUS experts.

It seems DL might help us identify structures in the future. How the benefits hold up in day to day emergency medicine remains to be seen.

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 74, July 3th, 2020

Welcome to the 74th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick


Question 1

Your patient presents with a hemopneumothorax and 4 rib fractures after a motor vehicle collision. Your usual analgesics (including opioids and analgesic dose ketamine) are ineffective and you didn’t even perform the thoracocentesis yet. You consider a serratus anterior plane block.

Which of the following statements is true regarding this block?

A: It affects dermatomes C6-T3

B: Anticoagulation is not a contraindication

C: It is equally effective in providing analgesia to the posterior part and anterior part of the ribs

D: The anesthetic should always be injected just superficial the serratus anterior muscle, never deep to the muscle

The correct answer is B

CountyEM covered the serratus anterior plane block this week. 

This block is fairly easy to perform and can be beneficial in these painful patients with thoracic trauma. Anticoagulation is not a contraindication. The block affects dermatomes T2 to T9. The block may not be effective for posterior chest wall trauma as the block only covers lateral cutaneous branches of the long thoracic nerve. The block can be performed superficial to and deep to the serratus anterior muscle. 

Source image: Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 13211

Question 2

The PESIT trial caused some consternation a couple of years ago, stating one in every 6 patients with syncope in the ED has pulmonary embolism. Fortunately this was proven wrong by numerous studies. However, what does it mean when a patient with pulmonary embolism suffers syncope?

This recent meta-analysis evaluated the prognostic value of syncope on mortality in patients with pulmonary embolism (PE).

What did the authors find?

A: Patients with PE and syncope have an increased risk of short term mortality compared to patients with PE without syncope

B: Patients with PE and syncope have an equal risk of short term mortality compared to patients with PE without syncope

C: Patients with PE and syncope have a decreased risk of short term mortality compared to patients with PE without syncope

The correct answer is A.

Clay Smith covered this meta-analysis on Journal Feed this week.

This meta-analysis of 20 studies showed an increase of short-term mortality in patients with PE and syncope compared to patients with PE without syncope (OR 1.82, 95%CI 1.14 tot 2.90). 

Source image: www.pixabay.com

Question 3

The recently published LOCO2 trial (Liberal Oxygenation vs Conservative Oxygenation) recently compared liberal and conservative oxygen targets in patients with acute respiratory distress syndrome (ARDS) which had been intubated and mechanically ventilated for less than 12 hours.

Patients in the liberal oxygen (LO) group had a target PaO2 of 90-105 mmHg with a SpO2 of >96% while patients in the conservative oxygen (CO) group had a target PaO2 of 55-70 mmHg with a SpO2 of 88 to 92%.

The primary outcome was death from any cause at 28 days. Mortality in the ICU or at day 90 days was the most important secondary outcome.

What did the authors find?

A: Mortality from any cause at 28 days was significantly higher in the conservative oxygen group compared to the liberal oxygen group

B: Mortality from any cause at 28 days was significantly higher in the liberal oxygen group compared to the conservative oxygen group

C: Mortality at day 90 or in the ICU was significantly higher in the liberal oxygen group compared to the conservative oxygen group

D: Mortality at day 90 or in the ICU was significantly higher in the conservative oxygen group compared to the liberal oxygen group

The correct answer is D

The LOCO2 trial was covered by Leen Alblaihed on RebelEM this week.

This prospective multicenter study was conducted in 13 French ICU’s. A total of 205 patients were randomized. 

At day 28, no significant difference in mortality between the conservative oxygen and liberal oxygen group was found (34.3% vs 26.5%; 95% CI -4.8 to 20.6) while mortality in the ICU or at day 90 was significantly higher in the conservative oxygen group compared to the liberal oxygen group (44.4% vs 30.4%). 

The main take home point is that conservative oxygen therapy may worsen mortality in patients with ARDS compared to liberal therapy. According to the Oxygen-ICU, ICU-ROX and LOCO2 trials, both hyperoxia (SpO2 >97%) and hypoxemia (SpO2 <90%) should be avoided. 

The LOCO2 Trial: Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome

    

Source image: www.pixabay.com

Question 4

A 67 year old female presents to your emergency department with complaints of dysuria, right flank pain, fever and increased urinary frequency. She is febrile and shows tachycardia and tachypnoea. On physical examination she has right flank and suprapubic tenderness. Urinalysis shows positive nitrite and white blood cells. The patient is diagnosed with pyelonephritis.

Which of the following options is a correct management for this patient’s illness?

A: The patient can go home with oral antibiotics due to its mild presentation and acceptable vital signs for this diagnosis

B: The patient can go home with oral antibiotics despite fever and tachycardia

C: The patient needs to be admitted for intravenous antibiotics because she shows tachycardia and tachypnea

D: The patient needs to be admitted for intravenous antibiotics because all patients with acute pyelonephritis should be admitted for intravenous fluids and antibiotics

The correct answer is C.

EMDocs covered pyelonephritis this week.

The majority of the mild to moderately ill patients with acute pyelonephritis can be discharged home with oral antibiotics. Important for discharging will be the ability to tolerate oral intake and the absence of tachycardia, hypotension and tachypnea. The patients should have stable comorbidities, a reliable psychosocial situation and the ability to visit for outpatient follow-up. 

What if it’s not just cystitis? Disposition of pyelonephritis…

Source image: Case courtesy of Dr Haytham Bedier, Radiopaedia.org, rID: 56857

Question 5 

‘This radiographic abnormality on a knee x-ray represents an avulsion fracture of the proximal fibula and is associated with cruciate ligament injury (in about 90 percent of cases). It is caused by a direct blow with the tibia in external rotation or sudden hyperextension of the knee with the tibia internally rotated.’

What abnormality is described here?

A: The Segond fracture

B: Stieda fracture

C: The arcuate sign

D: The intercondylar eminence fracture

The correct answer is C

AliEM covered not to miss knee injuries this week. 

The arcuate sign is often a subtle finding on knee x-rays and represents an avulsion fracture of the proximal fibula at the site of insertion of the arcuate ligament complex. It is usually associated with cruciate ligament injury (~90% of cases). The Segond fracture is also strongly associated with ACL injury, but it is an avulsion fracture of the lateral tibial plateau. A Stieda fracture refers to a bony avulsion injury of the medial collateral ligament (MCL) at the medial femoral condyle.

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 73, June 26th, 2020

Welcome to the 73th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.rebelem.com

Question 1

This week the most widely discussed Randomized Controlled Trial (RCT) is about the use of dexamethasone in patients with COVID-19. 

Hospitalized patients with clinically suspected or laboratory confirmed COVID-19 received either usual care or usual care plus dexamethasone 6 mg daily (either orally or intravenously) for up to 10 days, or until discharge. The primary outcome was all cause mortality at 28 days.

What did the authors find?

A: All cause mortality at 28 days was higher in the dexamethasone group compared to the usual care group

B: All cause mortality at 28 days was not different between the groups

C: All cause mortality at 28 days was lower in the dexamethasone group compared to the usual care group

The correct answer is C

First10EM covered the pre-publication of The RECOVERY trial along with others like Emcrit,  REBEL EM, FOAMcast  and Broom Docs

This pragmatic, open-label, multi-centre RCT from 176 hospitals in the United Kingdom, randomized 2104 patients to the dexamethasone group and 4321 to the usual care group.

All cause mortality at 28-days was lower in the dexamethasone group compared to the usual care group (21.6% vs 24.6%; OR 0.83; 95% CI 0.74-0.92, P<0.01). The biggest benefit was among the sickest patients who needed oxygen and appeared to occur later in the disease course. Dexamethasone thereby reduced the duration of hospitalization.

These results seem very promising. Keep in mind that there is a possibility of selection bias and a lack of blinding. Furthermore this article hasn’t been peer reviewed yet.

Dexamethasone for COVID: The RECOVERY trial

Source image: www.pixabay.com

Question 2

The second widely discussed RCT this week is not about COVID-19. The HALT-IT trial is about Tranexamic Acid (TXA) versus Placebo in patients with acute gastrointestinal bleeding. The primary outcome was death due to bleeding at 5 days. Close to 6000 patients were randomised to both groups (12000 is total).

What did the authors find?

A: There was lower death due to bleeding at 5 days and lower all cause mortality at 28 days in the TXA group compared to the control group

B: There was no difference in death due to bleeding at 5 days and all cause mortality at 28 days between both groups

C: There was lower death due to bleeding at 5 days in the TXA group compared to the control group, but all cause mortality at 28 days was equal

D: There was lower all cause mortality at 28 days in the TXA group compared to the control group, but death due to bleeding at 5 days was equal

The correct answer is B

The HALT-IT trial was discussed on StEmlyns, First10EM  and the Resus Room podcast this week.

This is definitely a negative trial. There was no difference in death due to bleeding at 5 days and all cause mortality at 28 days between both groups. The authors did change the primary outcome from a patient centered outcome (all cause mortality at 28 days to death due to bleeding at 5 days) which does not make a lot of sense.

Keep in mind the subjects were not very sick on average and the time from symptom onset to inclusion was very long (22 hours on average). Both can impact the efficacy of TXA in gastrointestinal bleeds.

Image from the original open access paper on www.thelancet.com

JC: Halt! It’s not time for TXA! Or is it? HALT-IT results at St Emlyn’s

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 8935

Question 3

The Aortic Dissection Detection Risk Score (ADD-RS) is a useful tool for aortic dissection. Does adding a d-dimer with a cutoff of 500 ng/dL alter the diagnostic accuracy of this tool even further?

A: Adding a d-dimer to the ADD-RS increases sensitivity without decreasing specificity

B: Adding a d-dimer to the ADD-RS increases sensitivity, but decreases specificity

C: Adding a d-dimer to the ADD-RS does does alter its diagnostic accuracy

The correct answer is B

This recently published systematic review was covered on Journal Feed last week.

An ADD-RS with a cutoff of ≥ 1 was found to have a sensitivity of 94% on its own. Adding a d-dimer increases the sensitivity to 1 at the cost of lowering the specificity to 15%.

 

Source image: http://www.emdocs.net/

Question 4

Your 53 year old patient presents to your ED with a backache and fever. Even though there are no neurological deficits found on physical exam you suspect her of having an spinal epidural abscess. The patient reports having recovered from a skin infection recently.

Which of the following statements is true about spinal epidural abscesses (SEA)?

A: Neurological symptoms are found in most of the patients

B: CT with contrast is equally accurate in diagnosing SEA compared to MRI

C: Recent Soft Tissue Infection with bacteremia is an independent risk factor for SEA

D: The most common causative organism of SAE is E. coli

The correct answer is C

RebelEM covered spinal epidural abscesses this week.

Neurological symptoms are found in only 33 percent of patients with SEA. Gadolinium enhanced MRI is considered gold standard for diagnosis with a sensitivity of over 90 percent. The most common causative organism is Staphylococcus aureus.

Recent Soft Tissue Infection with bacteremia is associated with pyogenic spinal infection (OR 13.5).

Spinal Epidural Abscess (SEA)

Source image: www.pixabay.com

Question 5

A 30 year old female presents to the Emergency Department. She tells you that she took a substantial amount of aspirin about 5 hours ago because she wanted to end her life after a fight with her two best friends. Her complaints include a ringing sensation in her ears and mild nausea. She is tachycardic and tachypneic but appears well and non-toxic.

What will her arterial blood gas most likely look like?

A: A mixed respiratory alkalosis / metabolic acidosis with an elevated anion gap

B: A mixed respiratory acidosis / metabolic alkalosis with an elevated  anion gap

C: A mixed respiratory acidosis / metabolic alkalosis with a normal anion gap

D: A mixed respiratory alkalosis / metabolic acidosis with a normal  anion gap

The correct answer is A

Salicylate overdose was covered on emDocs this week.

Aspirin has a high overdose potential since it can be bought over the counter in different formulations. An overdose leads to activation of the medulla in the early stages, leading to hyperventilation causing a respiratory alkalosis.

In later stages, salicylates like aspirin cause inhibition of oxidative phosphorylation, increased renal bicarbonate excretion and lipolysis, leading to metabolic acidosis.

Finally, an increased anion gap can be found due to increased fatty acid metabolism leading to an increase in ketone bodies.

EM@3AM: Salicylate Overdose

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 71, June 12th, 2020

Welcome to the 71th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

This week’s COVID-19 Randomised Controlled Trial (RCT) is about Ruxolitinib. Ruxolitinib blocks a shared signal transduction pathway which is used by several cytokine receptors (many immunomodulatory therapies only block one specific interleukin). 43 Severely ill but not yet intubated patients were enrolled and randomised to either Ruxolitinib or placebo (in this case Vitamin C).

What did the authors find?

A: Ruxolitinib did improve cytokine levels and C-reactive protein

B: Immunomodulation was found to delay viral clearance

C: A statistically significant reduction in mortality was found at day 28 in the treatment group

D: A statistically significant reduction in duration of invasive ventilation was found in the treatment group

The correct answer is A

Josh Farkas discusses this RCT this week on PulmCrit.

Yet another study that was terminated early. This time due to the simple fact that there were no more patients with COVID-19 in the Chinese center to enroll. A not statistically significant reduction in mortality (7.3 vs 14.3 percent) was found in favor of the treatment group. No difference was found in time to clinical improvement. However, cytokine levels and CRP were reduced in the treatment group indicating its ability to function rapidly as an immunomodulator. Ruxolitinib was not found to delay viral clearance.

PulmCrit Wee – Multicenter RCT evaluating ruxolitinib (a JAK inhibitor) for COVID-19

 

 

Question 2

Your 75 year old patient comes in with sudden onset vertigo and vomiting. Her vertigo is provoked by specific types of head movements and the episodes last for about 20 seconds. She has no other neurologic complaints. The Dix-Hallpike test shows a rotational nystagmus which disappears after 10 seconds.

You suspect Benign Paroxysmal Positional Vertigo (BPPV). The patient does not believe the Epley maneuver will be helpful as it just sounds silly and wants to know what the literature says. What do you tell your patient?

A: Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (83% vs 5%) for a NNT of 1.2

B: Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (56% vs 21%) for a NNT of 3

C: Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (61% vs 55%) for a NNT of 17

D: Compared to sham groups, Epley maneuver does not increase likelihood of symptom resolution

The correct answer is B

Clay Smith covered this review on the Epley Manoeuvre last week.

The paper reviews a cochrane review and another recent randomized trial set in 6 EDs.

Compared to sham groups, Epley maneuver increases likelihood of symptom resolution (56% vs 21%).

Well, you can’t get around an NNT of 3.

Source image: www.aliem.com

Question 3

Your 75 year old patient tells you that he used some fresh herbs out of his garden to prepare dinner. Shortly after his meal he started to be dyspnoeic, the parsley out of his garden turned out to be Poison Hemlock.

Which of the following statements is true about Poison Hemlock?

A: It causes a cholinergic toxidrome

B: It causes a anticholinergic toxidrome

C: It causes a sympathomimetic toxidrome

D: It causes a sedative-hypnotic syndrome

The correct answer is C

This week Aliem posted about poison hemlock.

Poison hemlock is a plant that can be mistaken for parsley, wild carrots or sweet fennel.

Poison Hemlock contains multiple toxic agents of which the most important is coniine. Coniine causes primarily nicotinic effects (muscle fasciculations, weakness, paralysis, coma, seizures, tachycardia and hypertension) and secondary muscarinic symptoms (salivation, lacrimation, vomiting, diarrhea, wheezing, bradycardia, diaphoresis, and small pupils).

Treatment is usually supportive and intubation might be required. Muscarinic symptoms (bradycardia, bronchorrhea, or bronchospasm) can be treated with atropine.

ACMT Toxicology Visual Pearls: A Foraging Experience to Die For

Source image: www.pixabay.com

Question 4

Which of the following statements is true about pediatric ECGs?

A: The amplitude of the p-wave increases with age

B: The duration of the p-wave shortens with age

C: A right QRS axis is normal in children < 6 months

D: Inversion of T-waves a week after birth is concerning

 The correct answer is C

The very basics of pediatric ECG’s were covered at Don’t Forget the Bubbles last week.

The amplitude of the p-wave does not increase with age (should be < 3 mm). The duration of the p-wave lengthens a little with age. A right axis in young children is normal in the very young due to right ventricular dominance. After the first week of life T waves become inverted in V1-3.

Approaching the paediatric ECG

 

Source image: www.emottowablog.com

Question 5

Which of the following statements about the use of ultrasound in COVID-19 is true?

A: It is possible to differentiate a COVID-19 pneumonia from other viral pneumonia on ultrasound

B: B-lines are not typically seen in COVID-19 patients

C: Irregularity of the pleural line is typically seen in COVID-19 patients

D: Large pleural effusions are common in COVID-19

The correct answer is C

EMOttawa covered ultrasound in COVID-19 patients this week.

It is not possible to distinguish COVID-19 from other viral pneumonia on ultrasound (or any other imaging as far as I’m aware). B-lines, irregularity of the pleural line and subpleural consolidation are common findings. Lung sliding is typically present but can be absent in case of ARDS. Large pleural effusions are typically absent in COVID-19.

Protocol for lung ultrasound in COVID-19 patients

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 70, June 5th, 2020

Welcome to the 70th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

    Source image: www.radiopaedia.org. Case courtesy of Dr. Henry Knipe

Question 1

A healthy 45 year old patient presents to your ED with a displaced humeral shaft fracture after a fall on the football pitch. According to this recently published Randomised Controlled Trial, does surgery lead to better functional outcome (Disabilities of Arm, Shoulder and Hand (DASH) score) compared to functional bracing ?

A: The functional outcome (DASH) at 12 months after injury was statistically better in the surgical intervention group

B: The functional outcome (DASH) at 12 months after injury was statistically better in the functional bracing

C: There was no statistically significant difference between the two groups

The correct answer is C

Anand Swaminathan covered the FISH RCT on RebelEM last week.

This rather small RCT (n = 82) revealed no significant difference in DASH scores at 12 months (12.0 for bracing vs 8.9 for surgery). This is in line with the 2017 Masunga trial.

However, non-union occurred in 11 out of 44 patients in the functional bracing group leading to significant cross-over.

The FISH RCT: Surgical vs Non-Surgical Management of Displaced Humeral Shaft Fractures

Question 2

The use of tranexamic acid (TXA) in the emergency department has been increasing in the last decade after CRASH-2 showed a reduction in all cause mortality in severely injured patients. CRASH-2 also reported no difference in vascular occlusive events (2 percent in the TXA group). However, TXA is still considered to be quite thrombogenic.

This recently published paper looked at 273 patients in a level 1 trauma centre receiving TXA. What did the authors find?

A: The rate of thromboembolic events was lower (1 percent) compared to the rate in the CRASH-2 cohort (2 percent)

B: The rate of thromboembolic events was equal to the rate in the CRASH-2 cohort (2 percent)

C: The rate of thromboembolic events was higher (6 percent) compared to the rate in the CRASH-2 cohort (2 percent)

The correct answer is C

Clay Smith covered this paper on Journal Feed.

This paper found a higher rate of thromboembolic events compared to the CRASH-2 cohort (6,6 percent compared to 2 percent). The mortality was about equal to the CRASH-2 cohort. Some differences to the CRASH-2 cohort were noted. Patients in this study received blood transfusions and surgery more often, were older, and there was a higher percentage of female patients than the CRASH-2 cohort. Interestingly only 61% received both boluses of TXA.

 

Source image: www.pixabay.com

Question 3

Low dose non contrast CT are increasingly performed in case of suspected renal colic. However, the effect these CT’s on patient oriented outcomes are uncertain (Ultrasonography Versus Computed Tomography for Suspected Nephrolithiasis).

According to this paper combining a systematic review and multidisciplinary consensus, which of the following patients should receive a CT?

A: A 35-y-old man with no history of kidney stones presents with an acute onset of flank pain during the last 3 h. He reports nausea with vomiting and has hematuria on urine dip. He has no abdominal tenderness. His pain is relieved after intravenous analgesics.

B: A 35-y-old man with 2 previous kidney stones that passed spontaneously presents with an acute onset of flank pain during the last 3 h. He reports nausea with vomiting and has hematuria on urine dip. He has no abdominal tenderness. His pain is relieved after intravenous analgesics. Ultrasonography is performed; there is hydronephrosis on the side with the pain, and a stone is not visualized.

C: A 75-y-old man with no history of kidney stones presents with an acute onset of flank pain during the last 3 h. He reports nausea with vomiting and has hematuria on urine dip. He has no abdominal tenderness. His pain is relieved after intravenous analgesics.

D: A 35-y-old woman who is 10 weeks pregnant with no history of kidney stones presents with an acute onset of right flank pain during the last 3 h. She reports nausea with vomiting and has hematuria on urine dip. She has no abdominal tenderness. Her pain is relieved after intravenous analgesics.

The correct answer is C

This week Justin Morgenstern discussed this paper on Imaging in Renal Colic on First10EM

According to this systematic review an alternative diagnosis is found on CT in 0-33 percent of cases and a clinically important diagnosis is found on CT in less than 5% of patients. The sensitivity of a formal ultrasound is reported to be between 3 and 98 percent, so that does not help us a lot. For POCUS, the authors report a pooled sensitivity of 70% and specificity of 75%.

In general it seems ultrasound will do in younger patients if pain is not relieved by analgesics. Older patients may benefit from CT because alternative diagnoses are more likely to show up and radiation is less of a concern.

A panel of 9 clinicians (emergency physicians, urologists, and radiologists) was used to determine the recommended imaging strategy. There was perfect consensus about the 75 years old patient requiring CT (patients A, B and D do not).

Imaging for renal colic

Source image: www.emcrit.org

Question 4

Your 62-year old female presents with severe chest pain, elevated troponin and dyspnea. Your views on bedside ultrasound are far from perfect, but you suspect some apical ballooning. Furthermore, 2 weeks ago your patient lost a relative. Both acute myocardial infarction (AMI) and Takotsubo cardiomyopathy (TC) are on your differential diagnosis.

Which of the following statements about findings that could help you differentiate between AMI and TC is true?

A: Presence of anterior ST-elevation makes TC unlikely

B: Hyperacute T-waves exclude TC

C: An elevated troponin makes TC unlikely

D: An elevated BNP is seen in 80 percent of TC patients

The correct answer is D

Josh Farkas from Emcit covered Takotsubo cardiomyopathy this week as part of the IBCC series. 

Takotsubo cardiomyopathy is present in 1-2% of patients who present with chest pain and troponin elevation. 

Although EKG cannot reliably differentiate Takotsubo cardiomyopathy from occlusive MI, there are some characteristic EKG features which are worth being aware of. ST elevation is usually most notable in V3-V6 in TC, but it has lower magnitude than is typically seen with an anterior occlusive MI. Hyperacute T-waves may be seen in Takotsubo cardiomyopathy. Troponin is elevated in 90% and BNP is elevated in 80% of cases of Takotsubo cardiomyopathy (however very non-specific).

 

 

Source image: www.aliem.com

Question 5

The lab calls you to alert you on a sodium of 112 mmol/L. 3 minutes later your patient is seizing. You order 100 cc of 3% sodium chloride, but your nurse tells you this can take a while. You do have 8,4 percent sodium bicarbonate in the crashcart.

Can you use sodium bicarbonate 8,4% instead of sodium chloride 3% to treat symptomatic hyponatremia?

A: Yes, 50 ml of sodiumbicarbonate 8.4% equals 100 ml of sodium chloride 3%

B: Yes, 500 ml of sodiumbicarbonate 8.4 % equals 100 ml of sodium chloride 3%

C: Yes, 5 ml of sodiumbicarbonate 8.4 % equals 10 ml of sodium chloride 3%

C: No, this is not a safe thing to do

The correct answer is A

Dr. Jonathan Hootman explains how to use sodium bicarbonate in symptomatic hyponatremia on Aliem this week.

We usually treat symptomatic hyponatremia with boluses of 100 to 150 ml sodium chloride 3%. However, sodium bicarbonate is a reasonable alternative. One ampule of sodium bicarbonate 8.4 % contains about the same amount of sodium as 100 ml sodium chloride 3% (50 mEq vs 51.3 mEq).

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 69, May 29th, 2020

Welcome to the 69th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.thebottomline.org.uk

Question 1

The ACTT-1 trial was covered by almost every FOAMed blog and podcast this week. This preliminary report concerning an RCT comparing Remdesivir to placebo for in COVID-19 patients was published earlier this week. 


Which of the following statements is true about this trial?


A: A clear mortality benefit was found in favour of the Remdesivir group


B: Time to recovery was shorter in favour of the Remdesivir group


C: The sickest patients seem to benefit most from Remdesivir therapy

The correct answer is B

This trial was covered by:

Justin Morgenstern on First10EM 

Fraser Magee on the Bottom Line 

Salim Rezaie on RebelEM 

Josh Farkas on EMcrit 

Rory Spiegel on EMcrit 

They all come to the same conclusion. Yes, the trial shows faster recovery in the not very ill COVID-19 patients (11 vs. 15 days). However there are some methodological concerns. The trial was stopped early (full outcomes available of 69% of the patients). The primary outcome was changed after data collection commenced (but before data analysis). A lot of data is not reported (including laboratory results).

 

Question 2

Quite some research has been published recently on the Canadian Syncope Risk Score (CSRS). It seems to have excellent diagnostic diagnostic accuracy for serious adverse events (SAE) (sensitivity of 99% if cutoff is -2 and sensitivity of 98% if cutoff is -1 on serious adverse events at 30 days) in syncope patients. NT-proBNP is found to have an independent association with mortality and SAE in patients with syncope. 

Does adding NT-pro-BNP to the CSRS improve its diagnostic accuracy? 

A: Yes, it does

B: No, it does not

C: it might

The correct answer is B

Clay Smith covered this paper last week on JournalFeed.

Of 1452 patients enrolled, 152 had 30-day SAEs. Serum NT-proBNP concentrations were significantly higher among patients with SAEs than those without them, but adding this value did not significantly improve prognostication.

Source image: www.pixabay.com

Question 3

Malaria continues to cause 230 million clinical infections and almost half a million deaths each year. Therefore it continues to caused a lot more deaths than COVID-19 (so far at least).

Which of the following statements about malaria is true?

A: A single negative blood film, or negative antigen test, does not completely exclude the diagnosis of malaria

B: A thick blood film is used to determine the Plasmodium species

C: Severe malaria only occurs secondary to Plasmodium falciparum infection

D: Artemether can cause severe hemolysis in patients with G6PD deficiency

The correct answer is A

Malaria was covered on Don´t forget the bubbles this week.

A single negative blood film, or negative antigen test, does not completely exclude the diagnosis of malaria . Some guidelines recommend 3 negative tests to exclude malaria in patients with a high pre-test probability.

A thick blood film is used to detect the presence of the parasites and the percentage of parasitised erythrocytes.

Severe malaria was previously considered only to occur secondary to P. falciparum, although there are increasing case reports of patients with P. vivax or P. knowlesi malaria presenting severely ill.

When prescribing primaquine you should definitely be aware of G6PD deficiency, as it can cause severe hemolysis.

Malaria

Source image: www.pixabay.com

Question 4

A 36 year old man with a history of severe alcohol abuses comes in with diaphoresis, tachycardia, hypertension and a tremor. He is clearly anxious and agitated. You expect he might be suffering from alcohol withdrawal and you consider different treatment options.

Which of the following statements about phenobarbital versus lorazepam for alcohol withdrawal is true?

A: Phenobarbital and benzodiazepines both target NMDA receptors in order to decrease withdrawal symptoms

B: Phenobarbital has a shorter length of action (i.e. half life) compared to lorazepam

C: Phenobarbital has low bioavailability when administered PO so it has to be given IV, whereas lorazepam can be administered IV, IM and PO

D: Phenobarbital dosing is more standardised compared to lorazepam dosing and is therefore more predictable and easier to titrate

The correct answer is D

Nuem covered treatment of alcohol withdrawal this week.

Alcohol withdrawal can be treated in multiple ways. Benzodiazepines are the current treatment of choice whereas phenobarbital was used as a first line treatment in the past although it seems to be making a comeback.

Both lorazepam and phenobarbital target GABA receptors to decrease excitatory tone. Phenobarbital does this more effectively since it does not rely on the presence of endogenous GABA hormone alone.

Both lorazepam and phenobarbital can be given IV, IM or PO. One benefit of phenobarbital is its longer half life of 80-120 hours compared to 14-20 hours for lorazepam.

The efficiency of lorazepam varies between different patients and drug levels. Therefore its effect is very hard to predict. The linear relationship between cumulative weight based dose and resulting plasma concentration of phenobarbital make it easier to achieve the right target dose and also easier to avoid levels in which toxicity may occur.

This subject was previously also discussed on Emcrit. 

Source image: www.tamingthesru.com

Question 5

You see a 64 year old female with a history of hypertension and diabetes. Her chief complaints are shortness of breath and a productive cough. She has a fever and an SpO2 of 82% on ambient air. She looks ill and she has diminished breath sounds on the right. You place her on a non-rebreather mask at 15 liters per minute. As part of your further work-up, you perform point-of-care ultrasound (POCUS). You suspect she has pneumonia.

Which of the following ultrasonographic signs are not typically found in case of pneumonia?

A: Shred sign

B: Localized B-lines

C: Subpleural fluid / pleural effusion

D: Lung point

E: Air bronchograms

F: Hepatization of the lung

The correct answer is D

POCUS for the diagnosis of pneumonia was covered by Taming the SRU this week.

The shred sign refers to a shredded deep border of the tissular image, as in connection with the aerated lung.

Localised B-lines and air bronchograms are typically seen in pneumonia. 

Hepatization of the lung refers to tissue-like appearance of the lung in which lung tissue loses its traditional artificial appearance and takes on an echo texture which is similar to liver tissue. 

A lung point is seen in pneumothorax. 

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This quiz was written by Eefje Verschuuren, NIcole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 67, May 15th, 2020

Welcome to the 67th FOAMed Quiz. 

Enjoy!

 Eefje, Joep, Nicole and Rick

 

Question 1

While treating an eyelid laceration you accidentally glued the eyelids shut a couple of minutes ago. Which of the following compounds is recommended for removal of histoacryl tissue adhesive according to this recently published paper?

A: Acetone

B: Ciprofloxacin eye ointment

C: Polydexa ear/eye drops

The correct answer is C

Clay Smith covered this paper on Journal Feed last week.

Interestingly, Polydexa (neomycin, polymyxin B, and dexamethasone) eye drops were most effective in removal of tissue adhesive in a porcine model if the adhesive was not removed within 90 seconds. The authors soaked the adhesive in test compound, with removal attempted hourly by rubbing gently for 1 min before reapplication of test compound.

Acetone seems to be effective if the adhesive has just been applied, but at 90 seconds it is not effective anymore. Furthermore, it leads to skin lesions if prolonged use. 

Question 2

Source image: http://litfl.com

Which of the following statements is true about U-waves?

A: They can appear in the setting of hypomagnesemia

B: They are the usually the first electrophysiological sign of hypokalemia

C: They are not associated with significant electrolyte disturbances

D: Once visible they always signify serious underlying disease

The correct answer is A

Steve Smith covered hypokalemia this week on dr. Smit’s ECG blog.

U-waves also appear in case of hypomagnesemia. The first electrophysiological sign of hypokalemia is flattening of the T-wave. U-waves are associated with a number of significant underlying disease, but can also occasionally occur as normal variant.

 

Source image: www.pixabay.com

Question 3

A 30 year old female presents to your emergency department with a wide range of symptoms including numbness of the lips, tongue and hands, hot and cold temperature reversal, generalized weakness and red skin rash. She states she ate barracuda in a restaurant yesterday after which she had some mild nausea and loose stool. Which one of the following foodborne diseases fit the picture best?

A: Scombroid fish poisoning

B: Botulism

C: Tetraodon poisoning

D: Ciguatera fish poisoning

The correct answer is D.

CountyEM covered Ciguatera fish poisoning last week.

Scombroid occurs from eating fish high in histamine due to inappropriate storage or processing and does not cause neurological symptoms. Botulism could present in similar fashion, but typically causes no sensory deficits. Tetraodon poisoning causes these symptoms but the patient would have recalled eating puffer fish.

This syndrome is typical for ciguatera fish poisoning. Patients can present with dysesthesia, vomiting, diarrhea, and/or a red skin rash. Hot and cold temperature reversal, generalized weakness, blurred vision, photophobia and myalgias may also occur.

Source image: http://blog.clinicalmonster.com/2020/05/08/ciguatera-fish-poisoning-2/
Source image: www.pixabay.com

Question 4

A 10 year old girl presents to your emergency department with complaints of monocular loss of vision and light flashes on her left eye. Her visual acuity on her left eye is 20/70. Her history is unremarkable. You wonder if, however rare, this child could have retinal detachment.

What is NOT a risk factor for retinal detachment in children?

A: Trauma

B: Myopia

C: Hyperopia

D: Previous ocular surgery

The correct answer is C

Last week Pediatric EM Morsels covered retinal detachment in children.

Retinal detachment is rare in children, but can occur. It is more common in the age 9-13 years old. Known risk factors are trauma, surgery, myopia and congenital abnormalities. Most children will not present with the classic symptoms like floaters, light flashes or a dark curtain falling down and might have a more gradual evolution of the condition. Ocular and fundoscopic examination is important. Ultrasound has a high sensitivity and specificity for this diagnosis

Retinal Detachment

Source image: www.pixabay.com

Question 5

The use of steroids in COVID-19 remains highly controversial. This recent multi-center pre/post implementation study evaluated the effect of a protocol involving early steroid administration in confirmed COVID-19 patients with bilateral pulmonary infiltrates and hypoxemic respiratory failure.

Patients admitted between 3/12 – 3/19 (pre- implementation of steroids) were compared to patients admitted the following week 3/20 – 3/27 (post- inplementation of use of steroids).

What did the authors find?

A: Treatment with corticosteroids correlated with an increase in clinical deterioration (composite outcome including ICU admission if not already in the ICU, intubation, mortality)

B: Treatment with corticosteroids correlated with a reduction in clinical deterioration (composite outcome including ICU admission if not already in the ICU, intubation, mortality)

C: Treatment with corticosteroids did NOT correlate with a difference in clinical deterioration (composite outcome including ICU admission if not already in the ICU, intubation, mortality)

The correct answer is B

Josh Farkas covered this paper on PulmCrit this week.

Compared to patients in the pre-steroid protocol, a significantly lower percentage of patients in the post-steroid protocol died (13.6% vs 26.3%), was admitted to the ICU (27.3% vs 44.3%) or needed to be intubated (21.7% vs 36.6%). 

Up until now, corticosteroids are more widely accepted among intubated patients than among non-intubated patients. This study suggests that steroids might be useful if administered earlier in the disease course in order to avoid deterioration and intubation in COVID-19 patients.

Nevertheless, we need to be aware of the fact that this was a pre/post study and therefore causality cannot be proven. Subtle changes in management of COVID-19 patients could have occurred during the two weeks of the post-steroid protocol. A randomised controlled trial will therefore be needed.

PulmCrit – Before/after study of short-course steroid in COVID-19

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This quiz was written by Eefje Verschuuren, Joep Hermans and Nicole van Groningen

Reviewed and edited by Rick Thissen