Quiz 131, October 8th, 2021

Welcome to the 131th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

A 33 week pregnant patient comes in after a motor vehicle accident. Upon waiting for her arrival, you and your team prepare for the initial assessment.

Which of the following statements is true?

A: Due to higher arterial pO2 state in third trimester pregnancy, desaturation will appear late

B: A chest drain should be inserted at the 5th intercostal space in the anterior axillary line just like in non-pregnant patients

C: Foetal distress on CTG is an early sign of maternal hypovolemia and shock

D: You should add in the Kleihauer-Betke test  if you think the patient could be Rhesus positive (Rh+)

The correct answer is C.

This week St. Emlyn’s discussed trauma in pregnant patients.

A difficult airway should be anticipated due to relative airway oedema, reduced esophageal sphincter tone and delayed gastric emptying.

Because of reduced functional residual capacity, desaturation will be fast so pre-oxygenation is especially important.

Foetal distress on CTG (loss of beat to beat variability or any decelerations) are an early sign of maternal hypovolemia and shock.

Use the Kleihauer-Betke test if you think the patient could be Rhesus negative (Rh-).

Source image: www.pixabay.com

Question 2

A 37-year-old female is presented to the emergency department with headache, emesis and diplopia. There are no other signs of stroke. You remember that in rare cases an anterior communicating artery (ACOM) aneurysm may produce ophthalmologic symptoms in the form of 3rd nerve palsy.

Which clinical finding corresponds to 3rd nerve palsy?

A: Inability to move the eye down and inwards (look towards the nose)

B: Inability to move the eye outwards (look away from the nose)

C: Presence of ptosis and mydriasis

The correct answer is C.

This week First10EM discussed diplopia last week.

Cranial nerve 3 innervates all the ocular muscles except for the superior oblique (moving the eye down and inwards, CN4) and the lateral rectus muscle (abducting the eye, CN6). CN 3 lesions present with a pupil that is “down and out”, in combination with ptosis and mydriasis.

DON’T FORGET THE DOUBLE VISION (Diplopia rapid review)

Source image: www.pixabay.com

Question 3

This recently published paper is a secondary analysis of the National Emergency Airway Registry (NEAR) between 2016 and 2018. The authors evaluated first-pass success in about 19.000 trauma intubations.

What did the authors find?

A: Direct laryngoscopy had a higher first pass success rate compared to video laryngoscopy

B: Video laryngoscopy had a higher first pass success rate compared to direct laryngoscopy

C: Video laryngoscopy and direct laryngoscopy had similar first pass success rates

The correct answer is B.

The paper was covered on JournalFeed last week.

Video laryngoscopy had a 90% first-pass success rate compared to 79% for direct laryngoscopy.

Another piece of evidence supporting the use of video laryngoscopy in the ED.

Source image: https://twitter.com/srrezaie

Question 4

The 2020 LoDoCo2 and 2019 COLCOT studies suggest that daily low dose colchicine in patients with chronic coronary disease or a myocardial infarction reduces the risk of future acute myocardial infarction or death from cardiovascular causes.

The COVERT trial was published last August. It is about the benefits of colchicine in the acute phase of myocardial infarction. Theoretically the anti-inflammatory properties of colchicine may decrease size of myocardial infarction. 192 patients with occlusion myocardial infarction were randomised to receive either colchicine (2 mg loading and 0,5 mg per day) or placebo.

The primary outcome was infarct size (IS) in grams.

What did the authors find?

A: The myocardial infarct size was largest in the colchicine group

B: The myocardial infarct size was largest in the placebo group

C: There was no difference between the groups

The correct answer is C.

The Bottom Line covered the COVERT trial last week.

At 5 days post randomisation, the infarct size did not differ between the colchicine and placebo groups with a mean of 26 versus 28.4 grams.

At 3 months follow-up, there was no significant difference in left ventricular remodeling between the colchicine and placebo groups.

COVERT MI

Source image: www.pixabay.com

Question 5

Your patient presents with a methotrexate intoxication. A calculation error led to administration of a 10-fold dose of intravenous methotrexate.

Which of the following treatments should be initiated?

A: Folinic acid

B: Folic acid

C: Dexamethasone

D: Hydroxocobalamin

The correct answer is A.

Methotrexate intoxication was covered on EMDocs last week.

Folinic acid antagonizes the toxic effects of methotrexate on bone marrow. Folic acid will not suffice.

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 129, September 16th, 2021

Welcome to the 129th FOAMed Quiz.

Source image: www.pedemmorsels.com

Question 1

Your 4 year old patient comes in with a nail bed laceration.

Which of the following statements is true about the management of nail bed injuries?

A: Nail bed injuries with tuft fractures are considered open fractures and therefore antibiotics are indicated

B: Cyanoacrylates (glue) should not be used to repair the nail bed

C: Nail bed injuries occur in up to one quarter of fingertip injuries

D: Most nail bed lacerations do not need repair

The correct answer is C.

Pediatric EM Morsels covered nail bed injuries last week.

According to available literature, prophylactic antibiotics do not change the rate of infection or osteomyelitis.

Cyanoacrylates may be as effective as suturing for nail bed injury repairs in children.

Nail bed injuries occur in up to one quarter of fingertip injuries.

Significant nail bed lacerations should be repaired to avoid bad cosmesis.

Nail Bed Lacerations

Question 2

Your 64 year old patient is brought in by prehospital services. She was found unconscious at home and she was intubated. She had been complaining about dyspnoea for 2 days.

Her capnography waveform looks like this:

Which of the following mechanisms causes a waveform like this?

A: Circulatory arrest

B: Tube in the right main bronchus

C: Bronchospasm

D: Hypoventilation

The correct answer is C.

NuEM covered capnography waveforms last week.

A normal waveform looks like this:

Delayed exhalation causes the typical sawtooth slope often seen in airway obstruction and bronchospasms such as COPD or asthma exacerbation.

Source image: www.thebottomline.org.uk

Question 3

The recently published DOREMI trial is about Dobutamine versus Milrinone in cardiogenic shock.

192 patients with cardiogenic shock were randomised to receive either Dobutamine or Milrinone in this randomised controlled trial.

The primary outcome was a composite of in-hospital death, resuscitated cardiac arrest and other badness.

What did the authors find?

A: Dobutamine was superior to Milrinone in patients with cardiogenic shock

B: Milrinone was superior to Dobutamine in patients with cardiogenic shock

C: Milrinone and Dobutamine were equally effective in patients with cardiogenic shock

The correct answer is C

The Bottom Line covered the recently published paper last week.

There was no significant difference in the composite of in-hospital death, resuscitated cardiac arrest, receipt of cardiac transplant or mechanical support, non-fatal myocardial infarction, cerebrovascular event or renal replacement therapy (Milrinone: 49% vs Dobutamine: 54%).

Keep in mind the study was not powered to detect smaller differences in the composite outcome or individual components of the primary outcome.

DOREMI

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 35793

Question 4

Differentiating acute heart failure from other causes of dyspnoea is often challenging. This recently published paper is about POCUS in dyspneic patients.

81 patients aged 50 years and older with shortness of breath from suspected acute heart failure or COPD were evaluated in this cohort study.

The classification performance of lung POCUS to diagnose acute heart failure as well as that of chest x-ray study was calculated.

What did the authors find?

A: Lung POCUS has a higher sensitivity for heart failure than chest x-ray

B: Chest x-ray has a higher sensitivity for heart failure than lung POCUS

C: Lung POCUS and chest X-ray have equal sensitivity for heart failure

The correct answer is A

Last week Journalfeed covered this recently published paper.

This small study showed POCUS has a sensitivity of 92.5% for identification of acute heart failure. Chest X-ray has a sensitivity of 63.6%.

This is in line with previous data.

The study has been limited by a small sample size and high prevalence of heart failure but it highlights the importance of early use of ultrasound in the undifferentiated dyspneic patient.

Source image: www.emcrit.org

Question 5

Suppletion of Antidiuretic hormone (ADH) has a wide variety of indications. 

For which of the following patients is ADH certainly NOT part of the management?

A: Patient of the Neuro-ICU with diabetes insipidus

B: Patient on Aspirin who sustained traumatic head injury

C: Patient with hyponatremia due to primary polydipsia

D: Patient with septic shock

E: Patient with central hypernatremia

The correct answer is C.

This week, Josh Farkas EMCrit posted his Cooper Conference talk about ADH on EMCrit.

Roughly, ADH can be used to prevent water loss (and thereby influence blood sodium levels), cause vasoconstriction and promote platelet aggregation (due to increase of platelet activating factor).

NeuroEMCrit – The Many Aliases and Uses of ADH by Casey Albin

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 127, August 27th, 2021

Welcome to the 127th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

As part of the RECOVERY platform a randomised controlled trial was started about non-invasive ventilation for hospitalised patients with COVID-19. This trial is called the RECOVERY – Respiratory Support or RECOVERY-RS trial.

1272 adult hospitalised patients with COVID-19, deemed at risk for treatment escalation (invasive ventilation), were randomized to either High Flow Nasal Oxygen (HFNO), Continuous Positive Airway Pressure (CPAP) or conventional oxygen.

The primary outcome was a composite of tracheal intubation and mortality at 30 days post randomisation.

What did the authors find?

A: CPAP was significantly superior to conventional oxygen therapy

B: HFNO was significantly superior to conventional oxygen therapy

C: Both CPAP and HFNO were significantly superior to conventional oxygen therapy

D: Neither CPAP nor HFNO were significantly superior to conventional oxygen therapy

The correct answer is A.

The pre-print RECOVERY-RS trial was covered on criticalcarereviews.com, RebelEM, St. Emlyns and the Bottom line this week.

CPAP was significantly superior to conventional oxygen therapy. HFNO was not. The difference was mainly due to reduction in need for intubation, not due to a difference in mortality.

Keep in mind this trial was not blinded (obviously) and there was quite some crossover between the groups.

Source image: tamingthesru.com

Question 2

Your patient comes in with submandibular swelling. He has a fever and difficulty swallowing. You suspect he has Ludwig’s Angina. Which of the following is NOT part of the ED management of Ludwig’s Angina?

A: Broad Spectrum Antibiotics

B: Dexamethasone

C: Surgical debridement of any necrotic tissue and drainage of any abscess

D: Placing a Laryngeal Mask (LMA) when a compromised airway is suspected

The correct answer is D.

First10EM covered Ludwig’s Angina last week.

Whenever Ludwig’s Angina progresses to cause a compromised airway, a supraglottic airway is a poor choice as it can get displaced as swelling progresses. Due to swelling, cricothyroidotomy can be very challenging.

Ludwig’s Angina: A Rapid Review

Source image: www.huidziekten.nl

Question 3

Injuries caused by which of the following animals are most likely to cause necrotising fasciitis?

A: Cat

B: Caterpillar

C: Catfish

The correct answer is C.

Taming the SRU covered necrotising fasciitis last week.

Noodling is the art of catching a catfish with bare hands. Injuries sustained while practising this activity are known to progress to necrotising fasciitis. Most often, severe infections follow wounds caused by the fins of catfish.

Of course a bite from a cat can cause necrotising fasciitis as well, but it is less common.

Question 4

Source image: aliem.com

Your 32 year old patient presents with palpitations and dizzyness. He has a heartrate of over 200 per minute, blood pressure of 90/60 mmHg and is diaphoretic. His ECG is show above.

Which of the following is the most suitable intervention?

A: Adenosine

B: Amiodarone

C: Diltiazem

D: Electric Cardioversion

The correct answer is D.

Aliem covered atrial fibrillation in Wolff Parkinson White syndrome last week.

Atrial fibrillation in patients with WPW (fast, broad and irregular) is fortunately quite uncommon. 

Treatment with AV nodal blocking drugs (like adenosine, calcium-channel blockers and beta-blockers) can increase conduction via the accessory pathway, which can lead to degeneration into unstable ventricular arrhythmias and VF.

Diagnosis on Sight: “I have a rapid heart rate”

Question 5

Source image: www.safestroke.eu

 

The ABCD2 score is used to stratify the risk of stroke in patients presenting with TIA.

The Canadian TIA Score is a new tool for this purpose. In this paper published in february 2021, the Canadian TIA Score was compared to the ABCD2 score.

7607 patients were analysed in 13 hospitals in the country of risk scores, Canada.

What did the authors find?

A: The Canadian TIA Score stratified the risk of stroke within seven days as low more accurately than the ABCD2 score

B: The ABCD2 score stratified the risk of stroke within seven days as low more accurately than the Canadian TIA Score

C: The Canadian TIA Score and ABCD2 score stratified the risk of stroke as low within seven days equally accurate

The correct answer is A.

RebelEM covered the Canadian TIA Score this week.

The Canadian TIA Score stratified the risk of stroke within seven days as low more accurately than the ABCD2 score.

Rebellion21: Canadian TIA Risk Score vs ABCD2

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 126, August 20th, 2021

Welcome to the 126th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

COVID-19 patients are at high risk for the development of venous thromboembolic disease.

Recently two randomised controlled trials were published in which the authors investigated the effectiveness and safety of therapeutic dose anticoagulation in critically ill patients (trial 1, n= 1098) and non critically ill patients (trial 2, n=2219) with COVID-19.

Patients were randomized to one of two arms (unfractionated or low molecular weight heparin):
Therapeutic Anticoagulation (TA): Full dose anticoagulation
Prophylactic Anticoagulation (PA): Prophylactic or intermediate dose anticoagulation

The primary outcome was organ support-free days (cardiovascular and respiratory) after 21 days.

What did the authors find about the use of therapeutic dose anticoagulation in COVID-19 patients?

A: Non-critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm. In critically ill patients, there was no difference

B: Critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm. In non-critically ill patients, there was no difference

C: Both critically ill and non-critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm

D: Neither critically ill nor non-critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm

The correct answer is A.

This week RebelEM covered the two trials (trial 1 and trial 2) about Anticoagulation in COVID-19 patients.

In non critically ill COVID-19 patients the use of therapeutic dose anticoagulation increased organ support-free days and survival to hospital discharge. These results were not found in critically ill COVID-19 patients.

The reason therapeutic coagulation seems beneficial in non-critically ill patients and not in critically ill patients is up for debate. However, one can imagine the antithrombotic and anti-inflammatory properties of therapeutic anticoagulation is most effective in early stages of the disease.

COVID-19 and Anticoagulation: Full Dose or Prophylactic Dose?

Source image: www.pixabay.com

Question 2

A 4 year old patient presents to the ED after possible ingestion of a coin. He is completely asymptomatic. His mother only found him playing with her wallet without actually seeing him swallow something.

You wonder whether a handheld metal detector might be sufficient to rule out the presence of a coin.

Which of the following is true about the sensitivity of a handheld metal detector for detection of ingested coins?

A: The sensitivity is low and a handheld metal detector is not useful for this indication

B: The sensitivity is about 85 percent. Combined with a low pretest probability this test is pretty accurate

C: The sensitivity is 99-100 percent. You can safely exclude the presence of a coin with this test

The correct answer is C.

EMDocs covered ingestion of metal foreign bodies last week.

It seems a handheld metal detector can be safely and reliably used as a screening tool in the process of detecting ingested coins.

A 2005 systematic review and a 2018 observational study showed the sensitivity of a handheld metal detector for detection of coins to be almost 100%. Keep in mind the sensitivity for other metal objects (long and sharp objects, lid of a can) is lower.

The metal detector might even be used to localize the coin.

EM@3AM: Beverage Tab Ingestion

Source image: www.nuemblog.com

Question 3

When exposed to cold, unprotected tissues can sustain frostbite injury. If digits sustain severe frostbite, this can result in amputation.

Which of the following has a role in the management of severe frostbite?

A: Tissue plasminogen activators (tPA)

B: Beta Blockers

C: Phenylephrine

D: Tranexamic acid

The correct answer is A.

This week NUEM blog covered frostbite injury.

Treatment consists of warming the affected tissue. Rewarming leads to a second mechanism of injury, a reperfusion injury resulting in patchy microvascular thrombosis and tissue death. To prevent the latter tPA can be administered. Evidence is limited, but intravenous and intra-arterial tPA seem to be effective in preventing loss of limbs.

Source image: www.orthobullets.com

Question 4

In acute compartment syndrome of the lower leg, which of the following compartments is most commonly affected?

A: Lateral compartment

B: Deep posterior compartment

C: Superficial posterior compartment

D: Anterior compartment

The correct answer is D.

Taming the SRU covered compartment syndrome last week.

The anterior compartment of the lower extremities is most commonly affected in acute compartment syndrome.

Source image: www.pixabay.com

Question 5

Complaints about waiting time are common in the ED. This recently published paper is about patients’ perception of their waiting time.

Which of the following is true according to the paper.

A: Most ED patients overestimate their waiting time

B: Most ED patients underestimate their waiting time

C: Most ED patients are accurate about their waiting time

The correct answer is A.

The paper was covered on first10EM this week.

Most patients overestimate their waiting time.

Justin Morgenstern adds an important note: ´´For the most part, we just blame the patients and call them dumb. Patients will complain that they have been waiting for 2 hours, and will be met with the response, “no, dummy, the computer says you have only been waiting 1.5 hours.” The key point is that the patient feels like they have been waiting 2 hours, and that is largely our fault. There are lots of ways that we could influence the perception of wait times, but we routinely fail.´´ 

Research Roundup (August 2021)

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 125, August 13th, 2021

Welcome to the 125th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

A 28-year-old male felt a painful snap in his posterior left lower leg while playing basketball. Physical exam is suggestive of Achilles tendon rupture, but you are not certain.

You decide to perform a bedside ultrasound to confirm the diagnosis.

Which of the following statements is true about POCUS in Achilles tendon injury?

A: Minimal fluid surrounding the Achilles tendon is normal due to the synovial sheath

B: Most Achilles tendon ruptures occur at the calcaneal insertion

C: Anisotropy is a useful ultrasonographic artifact to confirm tendon tear

D: Plantaris tendon is usually found medial of the Achilles tendon

The correct answer is D.

This week ALiEM discussed Achilles tendon rupture.

The Achilles tendon is surrounded by paratenon, rather than a synovial sheath, therefore fluid is normally not seen on ultrasound. A tear rarely occurs at calcaneal insertion. Anisotropy can mimic a tendon rupture and can be used to identify the tendon (which shouldn’t be a problem in case of the Achilles tendon). The Plantaris tendon is found medial to the Achilles tendon. Keep in mind the Thompson test can be false negative if the Plantaris tendon is intact.

SplintER Series: My Foot Doesn’t Work Right

Source image: www.pixabay.com

Question 2

A patient is brought in unconcious after a suicide attempt. He was found hanging on a self made noose. He did not drop from height.

Which of the following is most likely the primary main pathologic mechanism?

A: Fracture of the upper cervical spine

B: Venous obstruction in the neck

C: Arterial damage in the neck

D: Airway compromise

The correct answer is B.

NUEM blog wrote about hanging injuries this week.

Loss of consciousness in hanging occurs most often due to obstruction of venous outflow from the brain and occurs in 15 seconds.

When the drop is greater than or equal to the height of the victim, there will almost always be cervical spine injury. Without a drop cervical injury is rare.

The rate of arterial damage is pretty uncommon as well.

Airway compromise plays less of a role in the immediate death of hanging.

Source image: www.nuemblog.com

Question 3

Which of the following findings on POCUS is suggestive of cardiac tamponade?

A: Right atrial diastolic collapse

B: A collapsed Inferior Vena Cava (IVC)

C: Right ventricular systolic collapse

D: Absence of a pericardial effusion

The correct answer is A.

Jacob Avila covered POCUS in cardiac tamponade on Core Ultrasound last week.

Right atrial or right ventricular diastolic collapse is highly suggestive for cardiac tamponade. Systolic collapse is normal. When in doubt whether the atrium or ventricle collapses during diastole or systole, slow down the clip and have a look at what the tricuspid and mitral valve are doing.

One would expect at least some amount of pericardial effusions and a wide IVC in case of tamponade.

 

Source image: rebelem.com

Question 4

Last week the BaSICS paper was published. This study was about normal saline (NS) versus balanced solution (Plasma-Lyte) in ICU patients. 10520 patients were randomised to receive either NS or balanced solution. The primary outcome was difference in all cause mortality at 90 days.

In 2018, the SMART  trial found a small but statistically significant difference in Major Kidney Events in favour of balanced solutions.

What did the BaSICS paper show?

A: Mortality was lower in the normal saline group compared to the balanced solution group

B: Mortality was lower in the balanced solution group compared to the normal saline group

C: Mortality was equal between the groups

The correct answer is C.

The Bottom Line and EMCrit covered the BaSICS trial last week.

In this extremely large, multi-centre trial 5290 ICU patients were randomised to the NS group and 5230 patients were randomised to the balanced solution group. Fluid that patients were randomised to was used for entire ICU stay. 26.4% in the balanced solution group died vs 27.2% in the NS group (p = 0.47).

The use of a balanced crystalloid compared to 0.9% sodium chloride did not reduce 90-day mortality.

There actually was another part of this study about fast fluid boluses versus slow infusion. No difference in mortality was found either.

BaSICS

Source image: www.pixabay.com

Question 5

You are evaluating your 9 year old patient for hearing loss. Weber test lateralizes to the right ear. Rinne’s test is positive on the left side and negative on the right side.

What is most likely the cause of this girls hearing loss?

A: Sensorineural hearing loss on the right side

B: Conductive hearing loss on the right side

C: Sensorineural hearing loss on the left side

D: Conductive hearing loss on the left side

The correct answer is B.

Don’t forget the Bubbles covered Weber’s and Rinne’s test last week.

Weber’s test lateralizes to the right ear, so there is either sensorineural hearing loss on the left side or conductive hearing loss on the right side.

Rinne’s test is positive (air conduction > bone conduction) on the left side and negative (air conduction < bone conduction) indicating there is a conductive problem on the right side or a sensorineural problem on the left side. However, a negative Rinne’s test is always abnormal, making conductive hearing loss on the right side most likely.

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 124, August 6th, 2021

Welcome to the 124th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Listening to educational podcasts is becoming increasingly popular amongst emergency medicine staff. A lot of us listen while commuting by car.

However, the question remains if any of the information sticks when you’re on the road. This paper compared initial and delayed recall of a podcast while driving versus undistracted seated listening.

What conclusion did the authors draw?

A: Recall is better when listening to a podcast undistracted compared to while driving

B: Recall is better when listening to a podcast while driving compared to undistracted

C: Initial recall is better while listening undistracted but there is no difference in delayed recall

D: There is no difference in recall between the driving and undistracted cohort

The correct answer is D.

The RCEM podcast covered the paper last week.

This multicenter, randomized trial looked at initial (within 30 minutes after listening) and delayed (one month after listening) recall of a podcast by 100 postgraduate emergency medicine residents. They were divided into a cohort of listeners while seated undistracted and a cohort of listeners while driving a car.

There was no statistically significant difference between the driving and undistracted cohorts. 

Source image: www.litfl.com

Question 2

Your 40 year old patient needs intubation due to respiratory failure. She has a wide QRS on the ECG, but potassium results have not come back yet. You are in doubt between using succinylcholine and rocuronium.

Which of the following predisposing conditions do not increase the risk of clinically significant hyperkalemia when using succinylcholine?

A: Denervating, crush or burn injuries

B: Chronic dialysis

C: Rhabdomyolysis

D: Prolonged total body immobilization

The correct answer is B

This week AliEM covered succinylcholine and the risk of hyperkalemia.

Succinylcholine is preferably avoided in selected patients. Hyperkalemia can be caused by activation of acetylcholine receptors which leads to an influx of sodium and calcium and an efflux of potassium to the extracellular space.

Patients with a normal renal function have an average increase of potassium of 0.5mEq/L. Patients on chronic dialysis do not have an increased risk of developing clinically significant hyperkalemia. Succinylcholine should be avoided when ECG changes are present prior to administration, rhabdomyolysis, prolonged total body immobilization, denervating disease, inherited myopathies and crush or burn injuries after 72 hours.

Source image: https://static.wixstatic.com

Question 3

A 35 year old male patient presents to the ED with a swollen finger. He tells you that the swelling started 4-5 days ago after minor trauma to the fingertip. The problem is located on the finger pad, anterior and very distal of the finger. A picture is shown above.

 Would you expect all Kanavel’s cardinal signs to be positive in this patient?

A: Yes

B: No

The correct answer is B.

AliEM covered the swollen finger in their SplintER series last week.

Kanavel’s signs are used to differentiate between a felon and flexor tenosynovitis. These 4 make up Kanavel’s signs:

1. Exquisite tenderness over the course of the sheath, limited to the sheath.
2. Flexion of the finger.
3. Exquisite pain on extending the finger, most marked at the proximal end.
4. Fusiform swelling of the finger.

This patient most likely has a felon which is a subcutaneous abscess in the finger pulp and usually presents on the pad of the finger.

Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 71639

Question 4

Flail chest is most often defined as a fracture of 3 or more contiguous ribs in 2 or more locations.

Flail chest is not mentioned in the latest ATLS guidelines as life threatening thoracis injury anymore.

This study included 407 patients with rib fractures, of which 79 (19.4%) had flail chest. Patients with a flail chest were compared to patients with the same number of ribs fractured, but without a flail segment.

According to this paper, what difference does the presence of a flail chest make in patients with three to five rib fractures?

A: Patients with a flail chest had higher mortality compared to patients without a flail chest

B: Patients with a flail chest had longer need for intensive care compared to patients without a flail chest

C: Patients with a flail chest had longer need for hospitalisation compared to patients without a flail chest

D: Patients with a flail chest had higher incidence of pneumothorax compared to patients without a flail chest

The correct answer is D

The Resus Room podcast covered the paper this week.

When comparing patients with three to five rib fractures, there was no difference in length of intensive care and length of hospitalisation or mortality; however, there was a higher incidence of pneumothorax (24.6% vs 50.0%, p<0.05). When comparing patients with six or more rib fractures, no difference was found between patients with and without flail chest.

Source image: www.nysora.com

Question 5

Your 65 year old patient presents with a dislocated shoulder. He has obesity, major chronic cardiac ischemic disease and he ate 3 quarter pounders at a well known fast food restaurant about 45 minutes ago. Shoulder reduction techniques with intra-articular and intravenous anesthesia are not successful. You are not very keen on sedating this patient and you decide to perform an interscalene brachial plexus block (ISB).

Which of the following actions can be used to reduce the chance of phrenic nerve blockade when performing an ISB (2 correct answers)?

A: Decreasing local anesthetic volume

B: Increasing local anesthetic volume

C: Performing the ISB more caudad in the neck

D: Performing the ISB more cephalad in the neck

The correct answers are A and C.

CoreEM covered the interscalene brachial plexus block last week.

The ISB effectively numbs C5-C7 nerve distribution unilaterally. It can affect C8-T1 as well but not as reliably.

Phrenic nerve blockade is a well known complication and can induce respiratory problems.

Reducing the anesthetic volume and using a more caudad location reduce the chance of phrenic nerve blockade.

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 120, June 25th, 2021

Welcome to the 120th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

The 2021 European Resuscitation Council guidelines about newborn resuscitation (European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth) and the UK guideline (Newborn resuscitation and support of transition of infants at birth Guidelines | Resuscitation Council UK) include some changes from the previous guidelines.

According to these guidelines, at what time should the umbilical cord be clamped after the first cry?

A: Immediately

B: Within 30 seconds

C: Between 30 and 60 seconds

D: After at least 60 seconds

The correct answer is D

Don’t forget the Bubbles covered the new UK guideline on neonatal resuscitation last week.

Ideally, we should delay clamping the cord for sixty seconds after the first cry.

However, we should delay cord clamping only if we are able to appropriately support the infant when the transition is incomplete or poor.

Where delayed cord clamping is not possible consider cord milking in infants >28 weeks gestation.

Source image: www.rebelem.com

Question 2

Headache is a known complication after Lumbar Punture (LP). Which of the following actions is proven to reduce the risk of post LP headache according to this recently published paper ?

A: Using a lower intervertebral space

B: Using an atraumatic needle instead of a cutting needle

C: Advising the patient to drink 3 cups of caffeinated coffee per day for three days

D: Placing the patient in upright position instead of lateral decubitus position

The correct answer is B

Journalfeed covered this systematic review about post LP headache last week.

Factors that are associated with post-LP headache are female sex, lower BMI, younger age, and history of headache.

Atraumatic needles are definitely effective to reduce this complication and are not more difficult to use compared to cutting needles.

Lateral decubitus position and using a higher intervertebral space may reduce the risk, whereas IV fluids and caffeine do not reduce the risk on post LP headache.

Question 3

Last month, this article  about the treatment of acute basilar occlusion was published in the New England Journal of Medicine.

The authors included 300 patients with proven basilar artery occlusion on CTA or MRA and an NIHSS score of ≥ 10. These patients were randomly assigned to either endovascular therapy (154 patients) or standard therapy (146 patients). Primary outcome was favorable functional outcome, which was defined as having a modified Rankin score of 0-3 at 90 days post randomisation.

What did the authors find?

A: Patients treated with endovascular therapy had a higher rate of favorable functional outcome compared to patients treated with standard therapy

B: Patients treated with endovascular therapy had an equal rate of favorable functional outcome compared to patients treated with standard therapy

C: Patients treated with endovascular therapy had a lower rate of favorable functional outcome compared to patients treated with standard therapy

The correct answer is B.

RebelEM covered the paper last week.

The paper did not show benefit of endovascular therapy in basilar artery occlusion. A favorable functional outcome occurred in 68 of 154 patients (44.2%) in the endovascular group and 55 of 146 patients (37.7%) in the medical care group (confidence interval, 0.92 to 1.50).

However, there are some limitations. The sample size was small and no perfusion imaging was used (no information about salvageable tissue in patients receiving artra arterial therapy).

Should we Consider Endovascular Therapy for Acute Basilar Artery Occlusion?

Source image: www.pixabay.com

Question 4

Your patient presents with altered mental status, visual disturbance and a headache. He also has marked hypertension and had a seizure on the way to your ED. You suspect this patient to have Posterior Reversible Encephalopathy Syndrome (PRES).

Which of the following diagnostic tools can help you to diagnose PRES?

A: MRI

B: CT

C: Lumbar Puncture

The correct answer is A.

Josh Farkas covered PRES in The internet Book of Critical Care last week.

PRES is characterised by vasogenic edema which occurs predominantly in the posterior brain. The pathogenesis is largely unknown, but is likely partly due to failure of autoregulation in hypertension.

No single diagnostic test proves PRES and it is mostly a clinical diagnosis, but MRI typically shows vasogenic edema.

Source image: www.pixabay.com

Question 5

Your 65 year old patient presents with decreased vision, headache, severe eye pain and vomiting. You do not have the equipment to measure ocular pressure, but the affected eye appears rock hard on gentle palpation. You suspect the patient to have angle-closure glaucoma.

Which of the following is part of the acute management of this patient?

A: Do not give any analgesics, for this may lead to an increased ocular pressure

B: Make the patient sit upright

C: Intraocular Acetazolamide (Diamox) will lower the intraocular pressure

D: Timolol eye drops will lower the intraocular pressure

The correct answer is D

The RCEM podcast covered ophthalmic emergencies last week.

Acute angle-closure glaucoma is an emergency diagnosis and should be treated promptly. It is advised to place the patient in supine position and give analgesics as soon as possible.

Acetazolamide can be given intravenously and orally, but not ocular.

Timolol eye drops or a combination drug containing timolol (like Cosopt) is effective in order to lower intraocular pressure.

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 119, June 18th, 2021

Welcome to the 119th FOAMed Quiz.

 

Question 1

A 25-year-old male has fallen from his bike on his left side. He complains of left-sided chest pain and dyspnea. On physical examination, you hear decreased breath sounds on the left side. X-ray shows rib fractures of ribs 6-8 and a pneumothorax. You insert a chest tube.

Chest tube placement is frequently performed in the ED. Usually the course is not remarkable, but occasionally these tubes cause problems.

Which of the following actions to chest tube complications is correct?

A: Your chest tube is placed intrafissural. You don’t have to reposition the tube as long as it is draining blood and air

B: You suspect a clot is obstructing your tube. You can try to extract the clot by squeezing the tube with your entire hand (milking)

C: Your patient develops miosis, ptosis, anhidrosis and enophthalmos. This is a neurosurgical emergency

D: 500 cc’s of blood is evacuated immediately after placement. It continues to produce 80cc/hour. This patient should undergo emergency thoracotomy as you suspect a laceration of an intercostal artery

The correct answer is A.

County EM covered complications of chest tube placement.

In suspected obstructing clot, milking a chest tube can be dangerous due to high negative intrathoracic pressure. You can irrigate the tube with saline or insert an embolectomy catheter through the tube to resolve the obstructing clot.

Horner’s syndrome (miosis, ptosis, anhidrosis and enophthalmos) after tube placement is caused by direct pressure of the tube or hematoma. The first action is to pull the chest tube back 2-3 cm, and confirm placement. Most patients will fully recover.

Iatrogenic hematothorax is not an uncommon complication. According to ATLS, emergent surgical intervention should be performed if the evacuated volume exceeds 1500 cc or if the ongoing blood loss is greater than 150 cc per hour.

Source image: www.pixabay.com

Question 2

It is a congenital abnormality of the small intestine that is present in 2% of the population. 2% of these people will become symptomatic. It is 2 inches long. There can be 2 types of ectopic tissue in it: gastric and pancreatic. There is a 2:1 male preponderance.

Which of the following congenital intestinal abnormalities fits this description?

A: Duodenal atresia

B: Intestinal malrotation

C: Duodenal web

D: Meckel’s diverticulum

The correct answer is D.

Don’t forget the Bubbles covered Meckel’s diverticulum last week.

The rule of 2s is about the features of Meckel diverticulum (although the ranges are quite wide):

It usually becomes symptomatic (if at all) before the age of 2
It occur in 2% of the population
Meckel’s diverticulum is about 2 inches (5 cm) long
You can find a Meckel’s diverticulum 2 feet (60 cm) from the ileocecal valve
2 types of ectopic tissue are commonly present (gastric and pancreatic)
2% become symptomatic

Source image: www.epmonthly.com

Question 3

Urine drug screens are occasionally used in the ED in patients with unexplained changes in mental status. The interpretation of these tests is challenging, because of frequent false positive and false negative results.

Which of the following statements is true about urine drug screens?

A: Bupropion can cause a false positive result for amphetamines

B: Sertraline can cause a false positive result for benzodiazepines

C: Synthetic opioids (fentanyl, methadone, tramadol) are typically missed on the standard urine drug screen and require a specific immunoassay

D: All of the above are true

The correct answer is D.

This week’s emDocs toxcard is about urine drug screens.

The big take-home-message of this toxcard is to interpret urine drug screens with great caution. Be aware of the many false positive results and also of the high percentage of false negative screens.

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 35793

Question 4

Recently, this systematic review about the value of POCUS for patients with acute dyspnea was published. Two RCT’s and a prospective cohort study reported on use of POCUS and the rate of correct diagnosis and correct treatment within 4 hours.

What did the authors find?

A: Adding POCUS to standard care did not improve the rate of correct diagnosis and did not improve the rate of the correct treatment within 4 hours

B: Adding POCUS to standard care did not improve the rate of correct diagnosis, but led to an improvement in the rate of the correct treatment within 4 hours

C: Adding POCUS to standard care did improve the rate of correct diagnosis and the rate of the correct treatment within 4 hours

The correct answer is C

This week Graham van Schaik covered POCUS for acute dyspnea on JournalFeed.

In case of diagnostic uncertainty POCUS should be used for patients in acute dyspnea in addition to the standard diagnostic pathway in the ED or inpatient settings.

According to this paper, adding POCUS improved the rate of correct diagnosis at the 4 hours mark (88% vs 64%) and, even more important, the rate of appropriate treatment (78% vs 57%).

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 4425

Question 5

A 39 year old female patient presents to your ED with thunderclap headache and vomiting. She has had these headaches five times before over the past two weeks. These episodes lasted about 1-3 hours but now she does not seem to recover. The headache started directly after sneezing. You suspect a Subarachnoid Hemorrhage (SAH) or Reversible Cerebral Vasoconstriction Syndrome (RCVS).

Which of the following statements is true about RCVS?

A: RCVS has a mortality rate of about 40 percent

B: About a third of patients recover spontaneously

C: RVCS can lead to subarachnoid hemorrhage

D: CT without contrast is the gold standard diagnostic test for RVCS

The correct answer is C

This week Josh Farkas covers the Reversible Cerebral Vasoconstriction Syndrome.

RCVS causes severe headaches due to diffuse, multifocal vasospasm of intracranial arteries.

About 90% of patients will improve spontaneously, so conservative therapy is appropriate for nearly all patients.

Small convexity subarachnoid hemorrhages occur in about a third of patients.

Invasive angiography is the gold standard diagnostic test however it is safer and easier to obtain an CTA or MRA, because of the risk of provoking ischemia (9%).

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 117, June 4th, 2021

Welcome to the 117th FOAMed Quiz.

 

Source image: www.emdocs.net

Question 1

A 48-year-old patient is brought in by the EMS after a motor vehicle collision. He complains of pain in his lower back. His vital signs are SpO2 97% on room air, RR 24/min, HR 124bpm, BP 97/72 mmHg and T 36.4 °C. On physical examination you notice bilateral normal breath sounds and his abdomen is non-tender without distention. FAST is negative. There are no bony deformities. No fractures are seen on the X-rays of his back.

You should have a high suspicion of bleeding in this patient, given his vital signs. You suspect a retroperitoneal bleeding source. Which of the following statements about retroperitoneal trauma is true?

A: Vascular injury in pelvic fractures is usually venous

B: The most common retroperitoneal source of bleeding is renal

C: Negative FAST combined with normal abdominal examination has a negative predictive value of 98% for retroperitoneal bleeding

D: Signs of retroperitoneal hemorrhage (Cullen’s, Turner’s, and Bryant’s sign) are usually present within one hour after trauma

The correct answer is A.

Retroperitoneal trauma was covered by emDocs this week. Retroperitoneal trauma is common; up to a third of polytrauma patients have retroperitoneal trauma. If your trauma patient is hemodynamically unstable, suspect retroperitoneal bleeding, especially if you can’t find another source.

The most common source of bleeding is due to pelvic fractures (use the pelvic binder!). Physical examination is usually normal. 

Source image: www.pixabay.com

Question 2

A 3 year old boy visits the emergency department (ED) with burns on both of his upper legs. He pulled a kettle of hot water from the kitchen table. The mother cooled the boy in the shower and rushed to the ED.

Which of the following statements is true about pediatric burns?

A: Children have a lower metabolic rate and their need for glucose and oxygen is lower compared to adult patients

B: Due to their smaller intravascular volume, children are more sensitive for fluid overload

C: Ice is an effective and safe cooling method

D: The threshold for starting fluid replacement in Total body surface area (TBSA) is higher for children than for adults

The correct answer is B

This week First10EM covered the Pediatric burns.

You should use cool running water for 20 minutes and never use ice This can lead to vasoconstriction and secondary tissue injury.

Fluid resuscitation should be considered for infants with a TBSA greater than 10%. In adults this threshold is generally 15%.

Keep in mind pediatric patients are vulnerable to fluid overload. This can be explained by the smaller intravascular volume per unit burned surface area.

Children have a higher metabolic rate and therefore have an increased fluid loss, oxygen and glucose demand.

Pediatric Burns: A Rapid Review

Source image: www.pixabay.com

Question 3

In patients defining themselves as either black or white, what can be said about the incidence of false normal pulse oximetry measurement (occult hypoxia) according to this paper?

A: The rate of occult hypoxia is equal in black and white patients

B: The rate of occult hypoxia is 3 times higher in black patients compared to white patients

D: The rate of occult hypoxia is 3 times higher in white patients compared to black patients

The correct answer is B.

JournalFeed discussed an article concerning racial bias in pulse oximetry this week.

The authors analyzed a total of 48,097 pairs of measures of oxygen saturation by pulse oximetry and arterial oxygen saturation in arterial blood gas. Black patients had nearly three times the frequency of occult hypoxemia compared to white patients.

Source image: www.pixabay.com

Question 4

Naloxon can be used in different ways in patients with suspected opioid intoxication. The most common route of administration is intravenous. It can also be nebulized.

Which of the following statements is true about nebulized naloxone?

A: This is especially useful in apneic patients

B: The correct dose is 0,2 mg in 3 ml of sodium chloride 0,9%

C: Patients do not get withdrawal symptoms when naloxone is nebulized

D: Patients can self-titrate and remove the nebulizer mask when responsive

The correct answer is D

This week ALIEM covered the utility of nebulized naloxone.

Most studies show a positive result using nebulized naloxone in patients with mildly decreased consciousness. Patients can experience withdrawal symptoms. They can remove the nebulizer mask and this can be seen as ‘self titrating’.

It should not be used as a therapy for apneic patients with suspected opioid intoxication.

Utility of Nebulized Naloxone

Source image: www.saem.org

Question 5

Your patient presents with ascending progressive symmetrical weakness. You want to distinguish Guillain Barré Syndrome (GBS) from tick paralysis and transverse myelitis. You perform a lumbar puncture.

Which of the following is typically elevated in cerebrospinal fluid (CSF) in GBS?

A: Leukocytes

B: Glucose

C: Protein

D: Erythrocytes

The correct answer is C.

EM Cases covered neuromuscular disease in their 2 part podcast series.

Elevated cerebrospinal fluid proteins are seen in GBS. However, during the initial phase of the disease course protein levels may be normal requiring a repeat lumbar puncture if GBS remains on the differential.

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 115, May 21th, 2021

Welcome to the 115th FOAMed Quiz.

 

Source image: www.cdc.gov

Question 1

Gonorrhea is one of the most common sexually transmitted diseases (STD). Hematogenous spread of Neisseria gonorrhoeae leads to systemic infection, called disseminated gonococcal infection (DGI).

What symptoms are part of the classic triad of DGI?

A: Tenosynovitis, arthritis and dermatitis

B: Perihepatitis, salpingitis and vaginal discharge

C: Arthritis, urethritis and conjunctivitis

D: Dermatitis, lymphadenopathy and fever

The correct answer is A.

This week, emDOCS discussed DGI.

It should be in your differential in patients (especially young adults) presenting with migratory polyarthralgia, arthritis, or tenosynovitis, in combination with skin lesions.
The other answers are all STD related; can you name the syndrome or disease?

Answer B is the triad of Fitz-Hugh-Curtis syndrome
Answer C is the triad of Reiter’s syndrome.
Answer D are symptoms of secondary syphilis.

Question 2

A 5 day old baby presents to your ED after vomiting bright red blood. This otherwise healthy baby had a normal birth. The past few days he was drinking normally and had a normal stool. You want to perform an Apt-Downey test.

Which of the following statements is true about the Apt-Downey test for neonatal hematemesis?

A: The Apt-Downey test is useful in children up 9 months of age

B: The Apt-Downey test is a test to distinguish neonatal from maternal blood

C: The Apt-Downey test relies on the fact that fetal hemoglobin is resistant to acid denaturation

The correct answer is B

Neonatal hematemesis can be terrifying for parents. Some benign causes can be easily detected with a simple test such as the Apt-Downey test.

Fetal hemoglobin is resistant to alkali denaturation and after centrifugation it should have a pink color due to free floating hemoglobin. If it turns yellow this means that it did denature and it is adult or maternal hemoglobin. The test should not be used in infants > 6 months. You need a ‘fresh’ bloody specimen and it should be tested within 30 minutes of collection. You can use stool or emesis but it has to contain bright red blood. 

Source image: www.brownemblog.com

Question 3

Your 65 year old patient presents after someone hit her in the right eye. Immediately afterwards, the patient complained about blurring and diplopia. You think she might have a traumatic lens dislocation. Unfortunately, in the meantime her eyelids are very swollen and you cannot visualize the eye anymore. You decide to use Point of Care Ultrasound (POCUS).

What is the sensitivity of POCUS for traumatic lens dislocation?

A: 65%

B: 75%

C: 85%

D: 95%

The correct answer is D.

BrownEM covered POCUS in traumatic eye injuries last week.

According to this prospective cohort study, POCUS has a sensitivity of 96.8% (95% CI 83.3% to 99.9%) in the diagnosis of lens dislocation, and a sensitivity of 95.7% (95% CI 78.1% to 99.9%) in the diagnosis of retrobulbar hematoma.

Source image: www.nysora.com

Question 4

Your patient presents with a pretty nasty wound on the lower leg. You want to perform an ultrasound guided popliteal sciatic nerve block.

The sciatic nerve bifurcates just above the popliteal fossa. Distal to the bifurcation two nerve trunks are visible on ultrasound.

These two trunks are called:

A: Tibial nerve and common peroneal nerve

B: Tibial nerve and sural nerve

C: Sural nerve and common peroneal nerve

D: Saphenous nerve and sural nerve

The correct answer is A

The sciatic nerve consists of two separate nerve trunks: the tibial and common peroneal nerves. A common paraneural sheath envelops these two nerves from their origin in the pelvis

A popliteal block results in anesthesia of the entire distal two thirds of the lower extremity, with the exception of the medial aspect of the leg.


Question 5

Source image: www.pixabay.com

A 70 day old infant presents to your ED with fever. The COVID test turns out positive. You wonder whether this means you can stop evaluating for serious bacterial infection (SBI).

This recently published retrospective study is about 53 COVID positive infants with fever and 53 matched COVID negative febrile infants. What did the authors conclude about the difference in rate of serious bacterial infection between the two groups?

A: The authors found the risk of SBI was much lower in COVID positive infants

B: The authors found the risk of SBI equal in COVID positive and COVID negative infants

C: The authors found the risk of SBI was much lower in COVID negative infants

The correct answer is A.

Clay Smith covered the paper last week on Journalfeed.

The authors found the risk of SBI (UTI, bacterial enteritis, bacteremia, or bacterial meningitis) was much lower in COVID positive infants versus COVID negative infants 8% vs 34%. The most common SBI was UTI.

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen