Joep Hermans – The FOAMed Quiz

February 11, 2022February 11, 2022

Quiz 144, February 11th

Welcome to the 144th FOAMed Quiz.

Question 1

Which of the following techniques is most effective for reduction of a nursemaid’s elbow?

A: Hyperpronation of the lower arm

B: Supination of the lower arm and flexion of the elbow

C: Traction

Reveal answer

The correct answer is A.

Radial head subluxation (RHS) was covered on NuEM last week.

Hyperpronation is associated with a higher rate of successful RHS reduction than supination and flexion. Traction is the injuries mechanism and is not considered a reduction technique.

Question 2

Patients on DOAC are at increased risk of major traumatic intracerebral bleeding compared to patients who don’t use anticoagulation. The risk of delayed bleeding after an initial negative CT of the brain may be a reason to admit patients and repeat a CT.

In our hospital, we generally dismiss asymptomatic patients on DOAC after mild traumatic brain injury (mTBI) and a negative CT, but in other places it seems to be practice to admit these patients and repeat a CT the following day.

In this Italian retrospective paper, 1426 patients on DOACs with mTBI were evaluated in the ED. 68.3% underwent a repeat CT after an initial negative CT and 24 hours of observation.

What was the rate of delayed intracerebral hemorrhage?

A: 35.4 percent of which 12.3 percent required neurosurgical intervention or died

B: 25.2 percent of which 8.4 percent required neurosurgical intervention or died

C: 8.6 percent of which 4.4 percent required neurosurgical intervention or died

D: 1.5 percent of which 0 percent required neurosurgical intervention or died

Reveal answer

The correct answer is D.

The paper was covered on JournalFeed last week.

A total of 1426 patients taking DOACs were evaluated for an mTBI. Of these, 68.3% (916/1426) underwent a repeat CT after an initial negative CT and 24 h of observation, with a rate of delayed intracranial hemorrhage of 1.5% (14/916). None of the patients with delayed ICH at 24-h repeat CT required neurosurgery or died within 30 days.

Question 3

Your 65 year old female patient comes in with altered mental status. She started using new medication from her psychiater yesterday.

She presents with abrupt altered mental status, hyperthermia (39.2 degrees Celsius), vomiting, myoclonus, tremor and mydriasis.

Which of the following diagnoses is most likely?

A: Neuroleptic Malignant Syndrome (NMS)

B: Serotonin Syndrome (SS)

C: Malignant Hyperthermia (MH)

Reveal answer

The correct answer is B

Hyperthermic conditions in the psychiatric patient were covered on CanadiEM this week.

SS presents abrupt, whereas NMS has a more gradual onset. SS typically causes myoclonus, tremor and mydriasis, whereas NMS causes rigidity.

Malignant hyperthermia is typically caused by volatile anesthetic gasses or depolarizing muscle relaxants (succinylcholine).

Hyperthermic Conditions in the Psychiatric Patient

Question 4

Your patient presents to your ED 30 minutes after a suicide attempt by ingestion of a large amount of tablets. She does not appear ill and is alert.

In what case will activated charcoal not work?

A: Lithium intoxication

B: Tricyclic antidepressant intoxication

C: Barbiturate intoxication

D: Benzodiazepine intoxication

Reveal answer

The correct answer is A.

SinaiEM covered activated charcoal last week.

Activated charcoal binds toxins preventing absorption, both initial or reabsorption via enterohepatic recirculation. It does not work well for electrolytes, alcohols and metals such as lithium.

Activated Charcoal in Brief

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

Reviewed and edited by Rick Thissen

January 21, 2022January 21, 2022

Quiz 142, January 21th, 2022

Welcome to the 142th FOAMed Quiz.

Question 1

The Pediatric Emergency Care Applied Research Network (PECARN) developed a clinical decision rule (CDR) in identifying pediatric patients with a low-risk of intra-abdominal injury. The patient was deemed low risk if there was:

No evidence of abdominal wall trauma
A GCS > 13
No abdominal tenderness
No thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds
No history of vomiting afte the injury

In 11919 cases, the performance of the rule to detect the need for acute intervention was compared to clinical gestalt.

What did the authors find?

A: The derived clinical prediction rule had a significantly higher sensitivity, but lower specificity compared to clinical gestalt

B: The derived clinical prediction rule had a significantly higher specificity, but lower sensitivity compared to clinical gestalt

C: The derived clinical prediction rule had both a significantly higher sensitivity and a higher specificity compared to clinical gestalt

D: The derived clinical prediction rule had both a significantly lower sensitivity and a lower specificity compared to clinical gestalt

Reveal answer

The correct answer is A.

This week RebelEM discussed the PECARN Blunt Abdominal Trauma rule.

The prediction rule had a higher sensitivity (97% vs 82.8%) but lower specificity (42.5% vs 78.7%) when compared to clinical gestalt. The negative predictive value of the prediction rule was 99.9%.

This clinical decision rule can be used to identify low-risk individuals and thereby decrease the use of CT. Keep in mind it is NOT a two-way tool. It does not determine individuals at high risk of intra-abdominal injury and who needs further imaging. It also needs external validation.

PECARN Blunt Abdominal Trauma: Is A Clinical Decision Instrument Better Than Clinician Gestalt?

Question 2

A 76-year-old female presents with a sudden onset of vision loss presents to your ED.

Can you match the case descriptions with the correct diagnosis?

Case descriptions:

A: Normal appearance of the eye, mild relative afferent pupillary defect, no associated headache, halo

B: Red eye, no relative afferent pupillary defect, associated headache, vomiting

C: Normal appearance of the eye, relative afferent pupillary defect, no associated headache, cherry red spot on fundoscopy

D: Normal appearance of the eye, a relative afferent pupillary defect, associated headache, elevated BSE

Diagnoses:

1: Giant cell arteritis

2: Central retinal artery occlusion

3: Retinal detachment

4: Acute angle closure glaucoma

Reveal answer

The correct answer is A-3, B-4, C-2, D-1.

This week emDOCS covered the differential diagnosis of central and peripheral causes of vision loss.

Question 3

Which of the following clinical findings is not caused by the Bezold-Jarisch reflex?

A: Post myocardial infarction bradycardia

B: Vaso-vagal syncope

C: Bradycardia in the trauma patient with ongoing hemorrhage

D: Syncope due to ventricular fibrillation

Reveal answer

The correct answer is D.

The cardiovascular effects of the Bezold-Jarisch reflex in trauma patients were recently discussed on Stemlyns.

The Bezold-Jarisch consists of bradycardia and hypotension due to vasodilation in response to stimuli detected in the cardiac ventricles through vagal afferent C fibers.

This seems counter-intuitive, especially in trauma patients. As hemorrhage continues, the volume of blood entering the ventricle diminishes. This is detected by the C-fibers and this triggers activation of the cardioinhibitory response and causes inhibition of sympathetic tone, hence the triad of signs.

So, if you see bradycardia in your trauma patient, assume the patient is very sick.

What is the Bezold-Jarisch Reflex and why do I care?! St Emlyn’s

Question 4

The effectiveness of intravenous lipid emulsion therapy in acute intoxications is widely debated.

Intoxication with which of the following drugs is least likely to respond to lipid emulsion therapy?

A: Metoprolol

B: Bupivacaine

C: Lamotrigine

D: Bleomycine

Reveal answer

The correct answer is D.

Lipid emulsion therapy was covered on EMOttawa this week.

The exact mechanism of action of lipid emulsion therapy is unknown. However, it is assumed lipophilic drugs (of lipophilic toxins) are scavenged by intravenous lipids.

Bleomycin has a very low lipophilicity and is therefore not likely to respond to intravenous lipid therapy.

Intravenous Lipid Emulsion: The New Fad Diet

Question 5

Your 55 year old patient presents with a beta blocker intoxication. He is in profound shock. You start iv fluids, vasopressors, calcium and insulin.

What would be the correct dose of insulin in this case?

A: 0.1 U/kg

B: 0.2 U/kg

C: 0.5 U/kg

D: 1.0 U/kg

Reveal answer

The correct answer is D.

Treatment of beta blocker and calcium antagonist intoxication was covered on Pediatric EM Morsels last week.

The correct dose of insulin in treatment of beta blocker intoxication is 1 U/kg.

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

Reviewed and edited by Rick Thissen

January 13, 2022January 14, 2022

Quiz 141, January 14th, 2022

Welcome to the 141th FOAMed Quiz.

Question 1

The 2015 REVERT trial showed the modified Valsalva technique was more effective than standard Valsalva technique (without lifting the legs) as an early treatment for hemodynamically stable patients presenting with supraventricular tachycardia.

This recently published meta-analysis includes 4 studies (including the REVERT trial) about modified Valsalva versus standard Valsalva for cardioversion of stable supraventricular tachycardia in adults.

What did the review show?

A: The modified Valsalva technique is more effective than the standard Valsalva technique

B: The standard Valsalva technique is more effective than the modified Valsalva technique

C: Both techniques are equally effective

Reveal answer

The correct answer is A.

The paper was covered on RebelEM last week.

The modified Valsalva technique was effective in 43.8% of cases, whereas the standard Valsalva technique was only effective in 16.0% of cases (NNT = 3.6).

To view a video about how to perform the modified Valsalva technique click here.

The Modified Valsalva Maneuver: Head Down, Legs Up

Question 2

What is the name of the set of criteria used to distinguish septic arthritis from transient synovitis in a child with an inflamed hip?

A: Sgarbossa criteria

B: Kocher criteria

C: Duke criteria

D: Hestia criteria

Reveal answer

The correct answer is B.

PEMblog covered the Kocher criteria last week.

Hestia criteria are used to identify low-risk PE patients safe for outpatient treatment.

Duke criteria are for diagnosis of endocarditis.

Sgarbossa criteria are used to diagnose acute MI in patients with prior LBBB.

Question 3

Your 20 year old patient presents after smoke inhalation. There was a fire in her living room and she couldn’t leave in time. She has no signs of inhalation injury, an oxygen saturation of 100% on a non rebreather mask but is severely tachypneic. Her heart rate is 130/min, blood pressure of 132/82 mmHg, cool extremities and a capillary refill time of 4 seconds. Her blood gas shows a pH of 7.14, bicarbonate of 14 mmol/L, lactate of 16 mmol/L and hypocarbia without hypoxia. Her carbon monoxide is 8%. Methemoglobin turns out to be 10%.

What is the most likely cause of these symptoms?

A: Carbon monoxide

B: Cyanide

C: Methemoglobinemia

D: Hydrazine

Reveal answer to question 3

The correct answer is B.

Cyanide inhibits aerobic metabolism by binding to the binuclear heme center of cytochrome c oxidase (CcOX) in mitochondria.

High Anion Gap Metabolic Acidosis (AGMA), lactic >10 and normal pulse oximetry point in the direction of cyanide toxicity. A carbon mono-oxide level of 8% and a MetHB level of 10% are not likely to cause severe symptoms. Hydrazine (eg. rocket fuel) intoxication is very unlikely in this case.

Question 4

Which of the following is not a treatment option in this case?

A: Methylene blue

B: Hydroxocobalamine

C: Amyl nitrite

D: Sodium thiosulfate

Reveal answer to question 4

The correct answer is A.

CoreEM and PedEM Morsels covered cyanide toxicity last week.

In case of cyanide poisoning, hydroxocobalamine scavenges cyanide present in blood and forms cyanocobalamin (vitamin B12).

Amyl nitrite (inhalation) and sodium nitrite (intravenous) antagonize cyanide toxicity in part by oxidizing hemoglobin to methemoglobin, which then scavenges cyanide. Keep in mind iatrogenic methemoglobinemia can be dangerous, especially in case of co-intoxication with carbon monoxide.

Sodium thiosulfate acts as a sulfur donor in the conversion of cyanide to thiocyanate through rhodanese.

Methylene blue is used in case of methemoglobinemia.

Toxic Gas Exposure

Cyanide Poisoning in Children

Question 5

Sotrovimab is a monoclonal antibody that binds to a conserved epitope on the spike protein of SARS-CoV-2.

In the COMET-ICE trial 583 not severely ill adults in early stages of COVID-19 (≤5 days) with risk factors for progression of the disease were randomised to receive either Sotrovimab (500 mg IV over 1 hour) or placebo.

The primary outcome was hospitalisation for >24 hours or death from any cause up to 29 days after randomization.

What did the authors find?

A: Patients in the Sotrovimab group had a lower rate of hospitalisation compared to patients in the placebo group

B: Patients in the placebo group had a lower rate of hospitalisation compared to patients in the Sotrovimab group

C: The rate of hospitalisation was equal in both groups

Reveal answer

The correct answer is A.

EMOttawa covered the COMET-ICE trial last week.

The primary outcome (hospitalisation for >24 hours or death from any cause) was met in 1 percent of cases in the Sotrovimab group and in 7 percent of cases in the placebo group. This was driven by the rate of hospitalisations, as only 1 patient in the entire study population died (placebo group).

It seems Sotrovimab is effective in preventing hospitalisation if administered early on to not (yet) severely ill COVID-19 patients with risk factors for disease progression.

Keep in mind this trial was funded by Vir Biotechnology and GlaxoSmithKline.

COMET-ICE Trial on Sotrovimab

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

December 23, 2021December 24, 2021

Quiz 139, December 24th, 2021

Welcome to the last FOAMed Quiz of the year..

Question 1

Your 25-year old patient comes in with high fever and mono-arthritis of the right knee. Aspiration of synovial fluid reveals pus. You suspect him of having bacterial arthritis.

He is known with sickle cell disease.

Which of the following pathogens is quite commonly a cause of bacterial arthritis in patients with sickle cell disease and is a rare cause of musculoskeletal infections in patients without sickle cell disease?

A: Staphylococcus aureus

B: Kingella species

C: Salmonella species

D: Klebsiella pneumoniae

Reveal answer

The correct answer is C.

Pediatric hip pain was covered on NUEM last week.

Staphylococcus aureus is the most common pathogen in bacterial arthritis overall. Due to functional asplenia, patients with sickle cell disease are more susceptible to encapsulated bacteria and gram-negative bacteria, especially Salmonella.

Question 2

Earlier this month, the HEP-COVID trial was published.

257 Hospitalized adult patients with COVID-19 with D-dimer levels more than 4 times the upper limit of normal or sepsis-induced coagulopathy score of 4 or greater were randomised to standard prophylactic or intermediate-dose LMWH or unfractionated heparin versus therapeutic-dose enoxaparin.

32.8% of these patients received ICU-level care.

The primary outcome was a composite of venous thromboembolism (VTE), arterial thromboembolism (ATE), or death from any cause within 30 days.

In which group did the authors find a benefit of therapeutic anticoagulation?

A: ICU patients

B: Non-ICU patients

C: Neither ICU nor non-ICU patients

Reveal answer

The correct answer is B.

The paper was covered on Rebel-EM last week.

Therapeutic-dose LMWH reduced the incidence of the primary outcome (48.0% vs 30.1%; P = .007). This benefit is seen only among the 170 patients who are sick enough to be hospitalized but not sick enough to be managed in the ICU.

There was no statistically significant difference in major bleeding.

There was a trend toward mortality benefit in the therapeutic dose anticoagulation group, but the study was not powered to find a mortality benefit.

The HEP-COVID Trial: Therapeutic Anticoagulation in Non-Critically Ill COVID-19 Patients

Question 3

A 20 year old patient presents to the ED with diffuse abdominal pain and vomiting for a couple of days. He has no prior medical history. His abdomen reveals mild distention and diffuse tenderness to palpation. His laboratory results show a lactate of 4.9 and no signs of infection. Ultrasound is non conclusive. CT scan reveals Superior Mesenteric Artery (SMA) Syndrome (or Wilke’s syndrome).

Which of the following causes Superior Mesenteric Artery Syndrome?

A: A thrombus in the SMA

B: Dissection of the SMA

C: An increase in mesenteric fat surrounding the SMA, leading to compression of the artery

D: A decrease in mesenteric fat surrounding the SMA, leading to compression of the artery

Reveal answer

The correct answer is D

ALiEM covered the Superior Mesenteric Artery Syndrome this week.

Superior Mesenteric Artery (SMA) syndrome is also called Wilke’s or Cast syndrome. A loss of mesenteric fat which normally surrounds the SMA, can lead to a steep angle between the aorta and SMA. Due to this angulation the duodenum can be compressed and can result in a partial or complete obstruction of the proximal duodenum.

The treatment includes gastric decompression and supportive care.

SAEM Clinical Image Series: I Have a Stomachache

Question 4

Your patient presents with a peritonsillar abscess. You treat your patient with drainage and antibiotics.

What does the evidence say about the addition of corticosteroids?

A: Evidence is clear, glucocorticoids are ineffective

B: Evidence is clear, glucocorticoids should be administered after drainage

C: Evidence is inconsistent, routine use of glucocorticoids can not yet be recommended

Reveal answer

The correct answer is C.

Taming the SRU covered peritonsillar abscess last week.

Evidence is inconsistent. A few very small trials suggest benefit (less pain at 24 hours, faster recovery), but a larger retrospective paper did not reproduce these results.

Question 5

Which of the following ultrasound images suggests tamponade?

Reveal answer

The correct answer is C.

CountyEM covered POCUS in cardiac tamponade last week.

It is often challenging to appreciate diastolic collapse in dynamic ultrasound images. M-mode can help. The anterior leaflet of the mitral valve is closest to the septum in diastole (at the point you measure e-point septal separation). If the anterior wall of the right ventricle moves further away from the probe during diastole, right ventricular collapse is very likely. This is visible on image C.

Ultrasonography of Cardiac Tamponade

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

December 17, 2021December 17, 2021

Quiz 138, December 17th, 2021

Welcome to the 138th FOAMed Quiz.

Question 1

The use of the bougie at the first intubation attempt is gaining popularity since the 2018 BEAM trial paper was published.

Recently, the multicentre BOUGIE trial was published about the same topic.

1102 critically ill patients undergoing tracheal intubation were randomised to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546). In 60% of patients, the intubation was performed by a resident. Video laryngoscopy was used in 75%.

The primary outcome was successful intubation on the first attempt.

What did the authors find?

A: The first attempt success rate was significantly higher in the bougie group

B: The first attempt success rate was significantly higher in the stylet group

C: There was no difference in first attempt success rate between the groups

Reveal answer

The correct answer is C.

This week First10EM covered the Bougie trial.

Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (P = .27).

In this trial, the stunning results of the BEAM trial could not be reproduced. However, this trial has its limitations. Notice the pretty low first pass success rates of about 80 %.

The BOUGIE trial: No difference between bougie and stylet?

Question 2

Cardiac arrest in pregnant patients is fortunately rare. A gestational age of > 20 weeks warrants resuscitative hysterotomy without delay.

Which of the following is associated with faster time to delivery in resuscitative hysterotomy?

A: Higher maternal survival

B: Higher neonatal survival

C: Neither higher maternal nor higher neonatal survival

D: Both higher maternal and higher neonatal survival

Reveal answer

The correct answer is D.

Resuscitative hysterotomy was covered on NUEM last week.

Faster time to delivery is associated with both higher maternal and higher neonatal survival.

Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 87136

Question 3

This recently published multicenter RCT is about the treatment of intra-articular distal radius fractures after acceptable reduction.

90 patients with reduced intra-articular distal radius fractures were randomised to nonoperative treatment (continued cast immobilization) or to operative treatment (ORIF with a volar plate).

The primary outcome was a Patient-Rated Wrist Evaluation (PRWE) score after one year.

What did the authors find?

A: When treated operatively, patients had clinically relevant better functional outcomes after 12 months

B: When treated nonoperatively, patients had clinically relevant better functional outcomes after 12 months

C: There was no difference in functional outcomes

Reveal answer

The correct answer is A.

This week JournalFeed discussed this article.

Patients operatively treated had significantly better functional outcomes measured with the PRWE at 6 weeks, 3 months, 6 months, and 1 year.

In the nonoperative group 28% received subsequent surgery.

Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 36509

Question 4

Whether or not to treat isolated subsegmental pulmonary embolism without proximal deep venous thrombosis is controversial. The CHEST, ACEP and ESC guidelines suggest or at least permit clinical surveillance instead of anti-coagulation.

This recently published paper is about the risk for recurrent venous thromboembolism in patients with isolated subsegmental pulmonary embolism without a proximal deep venous thrombosis who were not anticoagulated.

266 patients were analysed across Canada and Europe.

What was the rate of recurrent thromboembolic disease by 90 days in this cohort of patients with isolated subsegemental pulmonary embolism without proximal deep venous thrombosis who were not treated with anti-coagulation?

A: 1,1 %

B: 3,1 %

C: 10,1%

Reveal answer

The correct answer is B.

The paper was covered on FOAMcast last week.

8 patients had recurrent venous thromboembolic disease (4 of these had proximal deep venous thrombosis and 4 had pulmonary embolism). This rate was higher than expected. No patients had a fatal recurrent pulmonary embolism.

Question 5

Neutropenic fever is quite commonly encountered in the ED. Broad spectrum antibiotics are the mainstay of initial treatment and their administration shouldn’t be delayed.

What percentage of neutropenic fevers is caused by an infection?

A: 10-20%

B: 20-30%

C: 50-60%

D: 90-100%

Reveal answer

The correct answer is B.

Neutropenic fever was covered on EMDocs this week.

20-30 percent of neutropenic fevers are caused by infection. These infections are mostly bacterial.

emDOCs Podcast – Episode 43: Oncologic Emergencies Part 2

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

December 9, 2021December 11, 2021

Quiz 137, December 10th, 2021

Welcome to the 137th FOAMed Quiz.

Question 1

Calcium plays an important role in cardiac physiology.

The COCA trial is about empiric administration of calcium in patients with out of hospital cardiac arrest that received at least one dose of epinephrine.

383 patients were randomised to receive 5 mmol calcium chloride or placebo immediately after the first and second dose of epinephrine. The primary outcome was return of spontaneous circulation (ROSC).

What did the authors find?

A: The rate of ROSC was higher in the calcium group compared to the placebo group

B: The rate of ROSC was higher in the placebo group compared to the calcium group

C: There was no significant difference in ROSC between both groups

Reveal answer

The correct answer is B

This week First10EM covered the COCA trial.

The COCA trial was stopped early because after enrolling 383 patients it seemed that administering calcium was harmful. Return of spontaneous circulation occured in 19% of the calcium group and in 27% of the placebo group.

Calcium for of out hospital cardiac arrest: the COCA trial

Source image: www.dontforgetthebubbles.com

Question 2

An eight-year old child is presented to your ED after enduring chemical eye injury. His mother brought the glass polisher which has caused the injury.

Overall, alkali substances are responsible for the more severe chemical injuries compared to acides.

Which acid compound is an exception to this rule?

A: Sulphuric acid

B: Acetic acid

C: Hydrochloric acid

D: Hydrofluoric acid

Reveal answer

The correct answer is D.

This week Don’t Forget The Bubbles discussed chemical eye injuries.

Acid burns are often well-demarcated and superficial, whereas alkali substances cause extensive and penetrating eye injuries due to their ability to saponify fatty acids.

Hydrofluoric acid however, penetrates very quickly into the anterior chamber and causes vast injury

How to manage chemical eye injuries

Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 13087

Question 3

Standard care of ischemic stroke patients includes IV treatment (IVT) before endovascular treatment (EVT).

Recent evidence suggests EVT alone is non-inferior compared to the combination of treatments (DEVT trial).

This recently published paper is about endovascular treatment alone versus IV alteplase plus endovascular treatment (EVT) in a European population.

539 patients that were eligible for IVT and EVT were randomised to receive either both therapies or EVT alone.

The primary end point was functional outcome on the modified Rankin scale at 90 days.

What did the authors find?

A: EVT alone was superior to EVT plus IVT

B: EVT alone was non-inferior to EVT plus IVT

C: EVT alone was neither superior, nor non-inferior to EVT plus IVT

Reveal answer

The correct answer is C.

This week, JournalFeed discussed this paper .

The median score on the modified Rankin scale at 90 days was 3 with EVT alone and 2 with alteplase plus EVT.

EVT alone was neither superior, nor non-inferior to EVT plus IVT. Mortality and the incidence of symptomatic intracerebral bleeding was not significantly different.

It is still too soon to stop using IV-alteplase before EVT in ischemic stroke.

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

November 25, 2021November 26, 2021

Quiz 135, November 26th, 2021

Welcome to the 135th FOAMed Quiz.

Only 3 questions this week.. Enjoy!

Question 1

Diabetic Ketoacidosis (DKA) is a life threatening event in which fluid replacement is important. Current guidelines recommend normal saline. However, normal saline can cause hyperchloremic acidosis and might worsen the DKA. An alternative could be Plasmalyte, which as a side effect may increase ketone bodies. A true consensus has not been reached.

In this trial, 90 patients with DKA were randomised to either Plasmalyte or normal saline.

What did the authors find?

A: Patients in the Plasmalyte group had slower resolution of DKA and an increased ketosis

B: Patients in the Plasmalyte group had faster resolution of DKA, but an increased ketosis

C: Patients in the Plasmalyte group had slower resolution of DKA, but not an increased ketosis

D: Patients in the Plasmalyte group had faster resolution of DKA, and not an increased ketosis

Reveal answer

The correct answer is D

This week Mark Ramzy discussed this study on RebelEM.

The authors conclusion was that Plasmalyte-148, compared to Sodium chloride 0.9%, may lead to faster resolution of acidosis in patients with a DKA without an increase in ketosis. A larger Phase 3 trial is needed for further conclusions.

SCOPE-DKA: Normal Saline vs Plasmalyte in Severe DKA

Question 2

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a potentially fatal drug reaction. Fortunately it is very rare.

Which of the following drugs are most commonly associated with DRESS?

A: NSAIDS

B: Antidepressants

C: Antiepileptics

D: Antibiotics

Reveal answer

The correct answer is C.

DRESS was covered on PedEM Morsels this week.

Antiepileptics are the drugs commonly associated with DRESS.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

Case courtesy of Dr Eric F Greif, Radiopaedia.org, rID: 29674

Question 3

Atraumatic back pain is a pretty common complaint in ED. Cauda Equina Syndrome is one of the diagnoses requiring fast intervention. Unfortunately, classic symptoms are often not strong predictors.

The authors of this recently published retrospective review evaluated which symptoms and clinical findings in patients with atraumatic back pain correlate best with the diagnosis of cauda equina compression (CEC).

Which of the following symptoms appeared to be most suggestive for CEC?

A: Bilateral leg pain

B: Dermatomal sensory loss

C: Bilateral absent ankle or ankle and knee jerks

D: Lower anal sphincter tone

Reveal answer

The correct answer is C.

This week JournalFeed discussed this article about Cauda Equina Compression.

Bilateral absent ankle or ankle and knee reflexes was the strongest predictor of CEC (OR=2.9), followed by bilateral leg pain (OR=2.2) and dermatomal sensory loss (OR 1.8). The authors did not find a relationship between digital rectal examination findings and the diagnosis of CEC.

Keep in mind this was a single-centre study and that the individual diagnostic performance of all history or exam elements was poor.

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

November 19, 2021November 19, 2021

Quiz 134, November 19th, 2021

Welcome to the 134th FOAMed Quiz.

Question 1

A 25 year old male presents to your ED after being stung by a stingray in his right lower extremity.

Immersion in which liquid is part of the pain management?

A: Vinegar

B: Urine

C: Cold water

D: Warm water

Reveal answer

The correct answer is D.

This week NUEM Blog covered stingray stings.

Stingray venom is heat-labile, so the pain is best reduced by immersion of the affected limb in water heated to the warmest temperature tolerated.

Case courtesy of Dr Goran Mitrovic, Radiopaedia.org, rID: 37422

Question 2

Prior studies have shown that patients admitted with a COPD exacerbation, have a high prevalence of pulmonary embolism (PE).

In this randomized clinical trial, usual care (n=367) was compared to usual care plus active strategy for diagnosing PE (D-dimer testing and, if positive, CTa) (n=370) in COPD exacerbations requiring hospitalization. The primary outcome was a composite including readmission for COPD, or death within 90 days after randomization.

What did the authors find?

A: The addition of an active strategy to exclude PE in patients admitted with a COPD exacerbation did not significantly improve a composite health outcome

B: The addition of an active strategy to exclude PE in patients admitted with a COPD exacerbation did significantly improve a composite health outcome

Reveal answer

The correct answer is A.

This week JournalFeed discussed this paper about active exclusion of PE in hospitalized COPD patients.

The primary composite outcome occurred in about 29% of both the control group and the intervention group.

In patients hospitalized for a COPD exacerbation, addition of an active strategy for the diagnosis of PE plus usual care compared to usual care alone did not significantly improve outcome of nonfatal new or recurrent venous thromboembolism (VTE), readmission for COPD, or death at 90 days.

Keep in mind patients were excluded if PE was initially suspected. Furthermore, the trial was underpowered to detect individual outcomes (like non-fatal PE).

Question 3

In the Netherlands we are used to pre-charging of the defibrillator before each rhythm check in cardiac arrest.

Last month, this Danish pre- post implementation (of pre-charging the defibrillator) trial was published. 178 patients (523 defibrillation procedures) with cardiac arrest who had at least one shock were included.

What did the authors find?

A: The total hands-off fraction per cardiac arrest was reduced after implementation of the pre-charge method

B: An increase in unindicated shocks (non-shockable rhythms or personnel) was registered

C: Patients who received only post-charge defibrillations had an increased odds ratio for return of spontaneous circulation

Reveal answer

The correct answer is A.

The paper was covered on Rebel-EM last week.

The total hands-off fraction per cardiac arrest was reduced after implementation of the pre-charge method (16.5% vs. 20.4%).

No increase in shocks to non-shockable rhythms or personnel was registered.

Patients who received only pre-charge defibrillations had am increased odds ratio for return of spontaneous circulation (aOR 2.91).

Pre-Charging the Defibrillator Before Rhythm Checks in Cardiac Arrest

Question 4

Your patient presents 30 minutes after ingesting hydrochloric acid.

Which of the following is a good idea in the management of this patient?

A: Provide anti-emetics as needed

B: Induce emesis

C: Attempt neutralization of the ingested agent by drinking sodium bicarbonate

D: Administer activated charcoal

Reveal answer

The correct answer is A.

Ingestion of caustic agents was covered on EMDocs last week.

Supportive care is the mainstay of treatment. You can provide symptomatic treatment with pain medications and anti-emetics as needed. Do not induce emesis.

Question 5

Which of the following arrhythmias is likely to respond to adenosine?

A: Atrial fibrillation

B: Atrial flutter

C: Ventricular tachycardia (VT) originating from the left ventricular outflow tract (LVOT)

D: Ventricular tachycardia originating from the right ventricular outflow tract (RVOT)

Reveal answer

The correct answer is D.

VT versus AVRT was covered on dr. Smith’s ECG blog last week.

Yes, some VT’s are adenosine sensitive. They typically originate from the RVOT and occur in patients with apparently normal hearts.

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

November 12, 2021November 14, 2021

Quiz 133, November 12th, 2021

Welcome to the 133th FOAMed Quiz.

Case courtesy of Dr Joachim Feger, Radiopaedia.org, rID: 72001

Question 1

In case of traumatic haemothorax, large bore chest tubes are often used. Chest tubes with a smaller diameter are often believed to be less effective for drainage and easier obstructed.

This recently published paper is about small (14 Fr) percutaneous catheter versus large (28-32 Fr) open chest tube for traumatic hemothorax. 119 not critically ill patients with hemothorax were randomised. The primary outcome was failure rate, defined as a retained haemothorax requiring a second intervention.

What did the authors find?

A: Failure rate was higher in the small percutaneous catheter group

B: Failure rate was higher in the large bore chest tube group

C: Failure rate was equal between the two groups

Reveal answer

The correct answer is C.

The paper was covered on St. Emlyns this week.

The failure rate was similar between the two groups (11% in small catheter group vs. 13% in chest tubes). Patients in the percutaneous catheter group reported lower IPE (insertion perception experience) scores, meaning that percutaneous catheters are better tolerated.

They kept all drains on -20mmHg suction

JC: Can we use smaller pigtail drains in traumatic haemothorax?

Question 2

Your patient presents with thunderclap headache (TCH). She also has ophthalmoplegia, decreased visual acuity, and change in mental status. She also has profound hypotension and her laboratory results show hyperkalemia and hyponatremia.

Which of the following causes of TCH explain the combination of these findings?

A: Pituitary apoplexy

B: Subarachnoid Hemorrhage

C: Posterior Reversible Encephalopathy Syndrome

D: Cervical artery dissection

Reveal answer

The correct answer is A.

EMDocs covered thunderclap headache this week.

Pituitary apoplexy is caused by hemorrhage or infarction of the pituitary gland. It can manifest as acute headache, ophthalmoplegia, change in mental status and adrenal crisis. Diagnosis is often made by MRI.

emDOCs Podcast – Episode 40: Thunderclap Headache

Question 3

In the recently published ADVANCE trial, patients with skin and soft tissue infections (SSTIs), who are normally often hospitalized to receive IV antibiotics, were directly discharged after being treated with a single dose of IV Dalbavancin (a novel second-generation lipoglycopeptide antibiotic belonging to the same class as vancomycin). This was a pre-intervention (usual care) versus postintervention (Dalvancin pathway) trial.

What did the ADVANCE trial show comparing Dalbavancin outpatient treatment to usual care in SSTIs?

A: Dalbavancin use led to lower hospitalisation, but higher overall healthcare utilization

B: No difference was found in patient hospitalization rates or overall healthcare utilization

C: Dalbavancin was associated with significant reduction of initial hospitalization and decreased healthcare utilization

Reveal answer

The correct answer is C.

This week Journalfeed.org discussed the ADVANCE trial.

This study suggests that a single dose of Dalbavacin in the ED, is an option for treating uncomplicated SSTIs that otherwise would have been admitted for IV antibiotics. Because Dalbavacin reaches steady state after 3 days and has a half-life of 8.5 days, it is ideal for outpatient management.

Keep in mind it is expensive, so cost efficiency should first be investigated. Furthermore, the local antimicrobial resistance might make these results less generalisable.

Question 4

We all remember the face helmets for CPAP during the beginning of the COVID pandemic in Italy. The helmets seem to be better tolerated than facemasks.

This recently published paper is about helmet continuous positive airway pressure (hCPAP) and facemask continuous positive airway pressure (fCPAP). 224 patients with respiratory insufficiency ( 80% cardiogenic pulm oedema vs 20% COPD. No COVID) were included and randomized in this Malaysian, noninferiority study. The primary outcome was change in respiratory rate.

What did the authors find?

A: hCPAP was non-inferior to fCPAP and resulted in greater comfort levels

B: hCPAP was inferior to fCPAP but resulted in greater comfort levels

C: hCPAP was inferior to fCPAP and did not result in greater comfort levels

Reveal answer

The correct answer is A.

The paper was covered on the RCEM podcast last week.

Both techniques reduced respiratory rate equally.

However, change inrespiratory rate is a weird and not patient centered primary outcome.

Question 5

Your patient presents with profound hyperglycemia. Which of the following is consistent with hyperosmolar hyperglycemic state (HHS) and not with diabetic keto-acidosis (DKA)?

A: pH < 7.30

B: Serum osmolarity of 305 mOsm/L

C: Develops over days to weeks

D: Anion Gap > 12z

Reveal answer

The correct answer is C

Taming the SRU covered HHS and DKA last week.

In general, DKA develops quite rapidly (hours to days), whereas HHS develops more slowly (days to weeks).

A pH of < 7.3, serum osmolarity of < 320 and a high anion gap are typically seen in DKA.

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

November 3, 2021November 5, 2021

Quiz 132, November 5th, 2021

Welcome to the 132th FOAMed Quiz.

Question 1

Another paper about therapeutic hypothermia was published just a few weeks ago.

In the CAPITAL CHILL trial, 389 comatose survivors of out-of-hospital cardiac arrest were randomised to either a target body temperature of 31 °C (moderate hypothermia) or 34 °C (mild hypothermia) for a period of 24 hours. The primary outcome was all-cause mortality or poor neurologic outcome at 180 days.

What did the authors find?

A: Patients in the moderate hypothermia group had lower all-cause mortality or poor neurologic outcome at 180 days compared to patients in the mild hypothermia group

B: Patients in the mild hypothermia group had lower all-cause mortality or poor neurologic outcome at 180 days compared to patients in the moderate hypothermia group

C: The rate or all-cause mortality or poor neurologic outcome at 180 days did not differ between the two groups

Reveal answer

The correct answer is C

EM cases covered the trial last week.

The primary outcome occurred in 48.4% in the 31 °C group and in 45.4% in the 34 °C group.

Keep in mind there was no normothermia group.

Question 2

Concussion symptoms can last for quite a while.

This recently published paper is about the role of digital screen time (TV, computer, phone) in the recovery of concussion.

125 patients aged 12 to 25 years were randomised to either be permitted to engage in screen time or were asked to abstain from screen time (screen time abstinent group) for 48 hours after injury.

The primary outcome was days to resolution of symptoms, defined as a total Post-Concussive Symptom Scale (PCSS) score of 3 points or lower.

What did the authors find?

A: Abstainers recovered quicker compared to screen users

B: Screen users recovered quicker compared to abstainers

C: Speed of recovery was not different between the two group

Reveal answer

The correct answer is A.

The paper was covered on JournalFeed last week.

The screen time permitted group had a significantly longer median recovery time of 8.0 days compared with 3.5 days in the screen time abstinent group.

The screen time permitted group reported a median screen time of a whopping 630 minutes, compared with (only) 130 minutes in the screen time abstinent group.

Question 3

The recently published CAP-IT trial is about dose of amoxicillin and duration of treatment of community acquired pneumonia (CAP) in children.

814 children requiring amoxicillin for CAP were randomized into four groups.
3 day course of amoxicillin 35 to 50 mg/kg per day
3 day course of amoxicillin 70 to 90 mg/kg per day
7 day course of amoxicillin 35 to 50 mg/kg per day
7 day course of amoxicillin 70 to 90 mg/kg per day

The primary outcome was clinically indicated antibiotic re-treatment for respiratory infection within 28 days after randomization. The non-inferiority margin was 8%.

What did the authors find?

A: 3 day course of amoxicillin was inferior compared to a 7 day course

B: The lower dose of amoxicillin was inferior compared to the higher dose of amoxicillin

C: Both a shorter duration of treatment and a lower dose of amoxicillin were non-inferior

Reveal answer

The correct answer is C

The trial was covered on Don’t forget the Bubbles last week.

The primary outcome occurred in 12.6% with lower dose and 12.4% with higher dose and in 12.5% with 3-day treatment vs 12.5% with 7-day treatment. Both groups demonstrated noninferiority.

How long should we treat children with pneumonia for? – the results of CAP-IT

Question 4

Which of the following is not a treatment option for cannabis hyperemesis syndrome (CHS)?

A: Hot shower

B: Haloperidol

C: Capsaicin cream

D: Morphine

Reveal answer

The correct answer is D

PEM Cincinnati covered cannabis hyperemesis syndrome last week.

Morphine is not effective in CHS.

Source image: www.blog.clinicalmonster.com

Question 5

The syndrome we are looking for is a complication after pacemaker implantation. It is caused by manipulation of the pacemaker box at the implantation site with the result of device malfunction.

What is the name of this syndrome?

A: Stiffler’s syndrome

B: Swiffer’s syndrome

C: Twiddler’s syndrome

D: Swimmer syndrome

Reveal answer

The correct answer is C.

Twiddler’s syndrome was covered on County EM last week. It is caused by external manipulation of the pacemaker box, leading to lead displacement.

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