Quiz 84, September 11th, 2020

Welcome to the 84th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Source image: https://rebelem.com/

 The CoDEX trial is another trial about dexamethasone as treatment of Covid.

Patients with moderate to severe ARDS (receiving mechanical ventilation within 48hrs of meeting criteria for moderate to severe ARDS (P/F ratio ≤200)) were randomised to either dexamethasone plus standard care (n=151) or standard care (n=148).

The primary outcome was ventilator free days during the first 28 days.

What was the effect of dexamethasone treatment on ventilator free days in this patient population?

A: Patients in the dexamethasone group had more ventilator free days during the first 28 days after enrollment

B: Patients in the standard care group had more ventilator free days during the first 28 days after enrollment

C: There was no difference in ventilator free days between patients in both groups

The correct answer is A

Salim Rezaie covered three recently published trials about corticosteroids and Covid last week.

This RCT showed a difference of ventilator free days of 2.6 in favor of the dexamethasone group (6.6 vs 4.0, p=0.04). The study was underpowered for secondary outcomes (mortality).

It’s Raining Steroids in COVID-19: REMAP-CAP, CoDEX, & CAPE COVID

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 7132

Question 2

You see a 25 year old patient with suspected first time anterior shoulder dislocation. You wonder if POCUS is reliable to confirm your suspicion to speed up reduction of the shoulder.

Which of the following is true about POCUS in shoulder dislocations according to this paper?

A: Sensitivity of POCUS for shoulder dislocations is 100 percent

B: Time to diagnosis using POCUS is equal compared to x-ray

C: Sensitivity of POCUS for non Hill Sachs fractures is 100 percent

The correct answer is A

This week’s ultrasound gel podcast is about this recently published paper about POCUS in shoulder dislocation.

A novel technique of posterior shoulder ultrasound showed perfect accuracy for diagnosing shoulder dislocation and reduction. For non Hill Sachs fractures the sensitivity of POCUS was 92 percent (including Hill Sachs and Bankart lesion the sensitivity dropped significantly). Time to diagnosis was almost twice as fast in the pocus group.

Source image: https://www.ultrasoundgel.org/

 

Question 3

In the ACTT-1 trial Remdesivir was not effective in the really sick (HFNC, NIV, IMV, and ECMO) and completely useless in patients that didn’t need O2. It seems the moderately ill might benefit from Remdesivir.

This paper, published last week, is about the effect of Remdesivir in just this patient group.

Patients with pulmonary infiltrates on X-ray and with room air oxygen saturation >94% were randomised to either a 10-day course of remdesivir, a 5-day course or remdesivir and standard care (no remdesivir). The primary outcome was clinical status on day 11 on a 7-point ordinal scale (ranging from death to discharged from hospital).

What did the result show?

A: Patients receiving 10 days Remdesivir had significantly better clinical status on day 11 compared to patients receiving standard care alone

B: Patients receiving 5 days Remdesivir had significantly better clinical status on day 11 compared to patients receiving standard care alone

C: Patients receiving 10 days Remdesivir had significantly better clinical status on day 11 compared to patients receiving 5 days Remdesivir

D: Patients receiving standard care alone had significantly better clinical status on day 11 compared to patients receiving standard care 10 days Remdesivir or 5 days Remdesivir

The correct answer is B

Salim Rezaie covered this paper on RebelEM last week.

596 patients were randomized to either a 10-day course of remdesivir, a 5-day course of remdesivir and standard care (no remdesivir).

Only the 5 day remdesivir group did significantly better than the standard care alone group (OR 1.65; 95% CI 1.09 – 2.48; p = 0.02). Interestingly, the 10 day remdesivir group did not statistically better (by far).

This is even more remarkable when considered the patient in the 10 day remdesivir group only used remdesivir for 6 days on average. This leaves the question whether the effect seen in the 5-day arm is just random chance.

Only 76% of patients completed therapy in the 5 days group and 38% in the 10 days group.

So, yet another paper with some major methodological issues leaving the question whether or not to embrace Remdesivir as an effective drug for Covid unanswered.

Remdesivir in Moderate COVID-19

Question 4

Your 34 year old patient presents with a pelvic fracture after a motor vehicle collision. Opioid and NSAIDs are inefficient for pain control. Your next step is low dose ketamine and you consider slow continuous infusion (SI) instead of iv push (IVP) to prevent the patient freaking out (like your last patient did).

This paper is about iv push versus slow continuous infusion of ketamine for analgesia. 48 patients were randomised to either IV push ketamine (0.3 mg/kg) or mixed in a 100cc NS bag and infused over 15 minutes.

What does the evidence say about iv push versus slow continuous infusion of ketamine for analgesia?

A: Patients were more likely to experience a feeling of unreality at any time in the IV push group compared to the slow infusion group

B: Patients in the slow infusion group had a higher degree of sedation compared to the slow infusion group at 5 minutes

C: Patients in the slow infusion group had larger a decrease in mean pain scores from baseline to 15 minutes compared to the slow infusion group at 5 minutes

The correct answer is A

Taming the SRU covered 3 quite important papers on ketamine last week. Among them this paper on ketamine iv push versus slow continuous infusion for analgesia.

Patients were more likely to experience a feeling of unreality at any time in the IV push group compared to the slow infusion group (91.7% vs 54.2%, p=0.008).

Patients in the IV push group had a higher degree of sedation compared to the slow infusion group (RASS -2 versus RASS 0, p=0.01).

Decrease in mean pain scores from baseline to 15 min was similar across groups: 5.2 ± 3.53 (95% CI 3.7–6.7) for IVP; 5.75 ± 3.48 (95% CI 4.3–7.2) for SI.

Question 5

Source image: https://pixabay.com/

Your 38 year old female patient comes in with a severe headache which is rapidly increasing over the past few days. She is overweight and her past medical history includes migraine and a pulmonary embolism. She tells you that this headache is different from previous episodes of migraine. Your differential diagnosis includes a cerebral venous sinus thrombosis.

Which of the following statements about diagnostic tools for cerebral venous sinus thrombosis is true?

A: A negative D-dimer excludes cerebral venous sinus thrombosis as a diagnosis

B: Lumbar puncture is part of the standard work-up in patients with suspected cerebral venous sinus thrombosis

C: CT-venogram and MRI-venography are both equally accurate in diagnosing a cerebral venous sinus thrombosis

The correct answer is C

Josh Farkas covered cerebral venous sinus thrombosis on the Internet Book of Critical Care this week.

Symptoms and chief complaints in patients with cerebral venous thrombosis are variable and non specific. They include headache, focal neurologic findings, seizure and encephalopathy.

The diagnosis is difficult and the sensitivity of D-dimer varies between 82-94%. The diagnosis can therefore not be excluded solely based on a D-dimer. Lumbar puncture is not indicated for this condition but may be performed as part of a broader evaluation to exclude infection. Imaging findings can be divided between direct (visualising the clot itself) and indirect signs (hemorrhage or edema as a consequence of the clot).

IBCC chapter & cast – Cerebral Venous Thrombosis

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

Reviewed and edited by Rick Thissen

Quiz 83, September 4th, 2020

Welcome to the 83th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

The recently published THALES trial is about Ticagrelor and Aspirin versus Aspirin alone in patients with acute ischemic stroke (NIHSS score of 5 or less who were not undergoing intravenous or endovascular thrombolysis) or TIA. Ticagrelor is not dependent on metabolic activation (as opposed to clopidogrel) and its efficacy might be more reliable compared to clopidogrel.

What did the authors find?

A: Patients in the ticagrelor + aspirin group had a higher incidence of subsequent ischemic stroke compared to patients on aspirin alone

B: Patients in the ticagrelor + aspirin group had a equal rate of severe hemorrhage and cerebral hemorrhage compared to patients on aspirin alone

C: Patients in the ticagrelor + aspirin group had a equal incidence of overall disability compared to patients on aspirin alone

The correct answer is C.

Benjamin Gerritsen covered the THALES trial on REBELem this week.

The authors randomized 11016 patients.

Patients in the ticagrelor + aspirin group had a lower incidence of subsequent ischemic stroke at 30 days compared to patients on aspirin alone. However, no benefit of ticagrelor + aspirin over aspirin alone was found on overall disability and mortality. A higher incidence of severe bleeding was noted in the ticagrelor + aspirin group compared to the aspirin alone group.

The THALES Trial: Ticagrelor and Aspirin vs Aspirin Alone in Acute Ischemic Stroke or TIA

Source image: www.pixabay.com

Question 2

You find yourself working in a ski-resort at 2700 meters. A 45 year old man comes in with profound respiratory distress. He normally lives at sea level and came for holidays to the mountains. You give supplemental oxygen and plan for descent.

Which of the following drugs can be considered in treatment of acute high altitude pulmonary edema (HAPE)?

A: Acetazolamide

B: Nifedipine

C: Dexamethasone

D: Sildenafil

The correct answer is B

NuEM covered Acute Mountain Sickness (AMS), High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE).

The mainstay of treatment of severe HAPE is supplemental oxygen and descent.

Acetazolamide is used as prophylaxis for AMS and HACE and might be beneficial as prophylactic medication for HAPE as well. It has no role in acute HAPE.

Dexamethasone is used for treatment of HACE or severe AMS. It might be beneficial in HAPE prophylaxis, but this is controversial.

Sildenafil has been shown to be effective as prophylaxis for HAPE, but has not been studied as treatment for acute HAPE.

Nifedipine is the preferred agent for prophylaxis and treatment of HAPE, although not a large body of evidence is available so for. The dosage is 60 mg extended-release orally divided daily (30 mg orally every 12 hours; or 20 mg orally every 8 hours).

 

Question 3

Source image: www.pixabay.com

Appendicitis can be a challenging diagnosis in the ED.

How accurate is physician gestalt in appendicitis according to this recently published paper?

A: Physician gestalt for acute appendicitis diagnosis performed poorly

B: Physician gestalt for acute appendicitis diagnosis performed well, especially in high-risk patients

C: Physician gestalt for acute appendicitis diagnosis performed well, especially when employed by experienced physician

The correct answer is C

BrownEM covered this paper last week.  

This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain. 

Physician gestalt for acute appendicitis diagnosis performed well, especially in low‐risk patients and when employed by experienced physicians.

Question 4

High sensitive troponin rule-out and rule-in strategies are not really uniform around the world. There are huge differences in used protocols between continents, countries and even between hospitals in the same region.

We slowly seem to move towards shorter time interval troponin testing (0 and 1 hour / 0 and 3 hour).

This recently published paper evaluated a 0 and 1 hour rule-out and rule-in strategies (among others), using a new high-sensitivity cardiac troponin I (hscTnI) assays from Siemens Healthineers. The primary outcome was meeting STEMI test criteria according to the 3rd Universal Definition of Acute Myocardial Infarction.

Which of the following statements is true?

A: The 0 and 1 hour rule out strategy had a sensitivity of 79.7 percent for Acute Myocardial Infarction (NSTEMI)

B: The 0 and 1 hour rule out strategy had a sensitivity of 98.7 percent for Acute Myocardial Infarction (NSTEMI)

C: The 0 and 1 hour rule in strategy had a sensitivity of 79.7 percent for Acute Myocardial Infarction (NSTEMI)

D: The 0 and 1 hour rule in strategy had a sensitivity of 98.7 percent for Acute Myocardial Infarction (NSTEMI)

The correct answer is B 

CoreEM covered this paper last week. 

It turns out a 0 and 1 hours rule-out strategy actually has a very high sensitivity in this US population using this TnI assay.

Source image: coreem.net

Performance of Novel High-Sensitivity Cardiac Troponin I Assays for 0/1-Hour and 0/2- to 3-Hour Evaluations for Acute Myocardial Infarction: Results From the HIGH-US Study

Question 5

A 64-year old female patient is brought in by EMS after she was found unconscious and cyanotic. She has a known history of dermatitis herpetiformis for which she is treated with dapsone. The first thing you notice when you look at her is the blue color of her skin. Your differential diagnosis includes methemoglobinemia.

Which of the following clinical findings are typically found in profound methemoglobinemia?

A: The presence of a peripheral oxygen saturation in the 80’s, improving with oxygen administration

B: Cherry red colour of blood

C: An arterial blood gas with a high PaO2 combined in combination with a low peripheral oxygen saturation

The correct answer is C.

Methemoglobinemia was covered by Justin Morgenstern on First10EM this week.

Methemoglobinemia can be congenital or acquired (exposure to certain medicines, chemicals or foods). Typical symptoms include headache, shortness of breath, nausea, tachycardia, confusion and loss of consciousness.

Patients with profound methemoglobinemia appear cyanotic with saturations below 80%. Saturation levels do not improve with oxygen administration.

The diagnosis is confirmed by an arterial blood gas (typical chocolate brown blood) with elevated methemoglobin levels. The treatment consists of methylene blue 1-2 mg/kg infused over 5 minutes. Methylene blue is contra-indicated in patients with a known G6PD deficiency.

Methemoglobinemia

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

Reviewed and edited by Rick Thissen

Quiz 82, August 28th, 2020

Welcome to the 82th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Critically ill patients admitted to the intensive care unit (ICU) with acute kidney injury have a higher morbidity and mortality.

The authors of the STARRT-AKI study compared accelerated initiation of Renal Replacement Therapy (RRT) and standard strategy of RRT initiation to investigate if this would result in lower risk of death from any cause at 90 days.

What did the authors find?

A: In the accelerated strategy group a smaller percentage of the patients were dependent on RRT at 90 days

B: There is no significant difference in mortality between early RRT initiation and standard initiation

C: In the accelerated strategy group more serious adverse events were seen compared to the standard RRT initiation. 

The correct answer is B

This week Mark Ramzey covered the STARRT AKI trail on RebelEM.

A larger percentage of the patients in the accelerated strategy group were dependent on RRT at 90 days. The authors suggest longer exposure to RRT can compromise kidney recovery.

There was no difference in serious adverse events between the two strategies.

This is not the first study that shows no significant difference in mortality between early RRT and standard or delayed RRT.

STARRT-AKI Trial: Timing of Renal Replacement Therapy Initiation in Acute Kidney Injury

Source image: www.pixabay.com

Question 2

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (or PFAPA) is a pretty rare syndrome, yet it is still the most common periodic fever syndrome in children.

Which of the following statements is true about the management and prognosis of PFAPA?

A: A single dose of corticosteroids will rapidly resolve the PFAPA symptoms in about 90% of patients

B: Colchicine is the most effective treatment for active PFAPA

C: The prognosis is poor. This syndrome leads to long term sequelae very often

D: Episodes of PFAPA generally seize spontaneously 3-5 years after symptoms onset

The correct answer is A

First10EM covered PFAPA this week.

It is a disease of unknown etiology that is characterized by clock-work regular episodes of fever, aphthous stomatitis, pharyngitis, and cervical adenitis.

A single dose of corticosteroids will rapidly resolve the PFAPA symptoms in about 90% of patients.

Colchicine has been used prophylactically to reduce the number of attacks.

The prognosis is excellent. The syndrome does not induce any long term sequelae and is not associated with comorbidities. It generally resolves spontaneously 3-5 years after symptoms onset.

PFAPA: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome

Source image: www.nuemblog.com

Question 3

Lightning injuries are not often seen in the Emergency Department. The majority of subjects struck by lightning survive. However, 10% of injuries are fatal. Lightning (as any electrical current) follows the path of least resistance. 

What is the right order of conductivity of tissues, starting with the tissue with the best conductive properties? 

A: fat – muscle – nerve – skin – bone

B: bone – nerve – muscle – skin – fat

C: fat – muscle – skin – fat – nerve – bone

D: nerve – muscle – skin – fat – bone

The correct answer is D

NuEM covered lightning injuries last week. 

´´Lightning strikes can cause primarily neurologic injury, but the most common fatal complications are cardiac and respiratory arrest. This is due to the relative nature of conductivity of the various organs in the body, with lightning following the path of least resistance. The order of conductivity is: nerve > blood > muscle > skin > fat > bone ´´

Question 4

In infants with traumatic brain injury the challenge lies in finding those with clinically important brain injury (ciTBI) while limiting the use of radiation exposure from CT imaging.

The Infant Scalp Score (ISS) is a risk stratification tool for infants under 1 year of age with isolated scalp hematoma who are otherwise asymptomatic, well-appearing, but may still be getting head CTs when guided by existing clinical decision aids.

source image: journalfeed.org

This recently published paper is about the validation of the Infant Scalp Score (ISS) to stratify risk for traumatic brain injury in infants with isolated scalp hematoma.

What did the authors find?

A: Using a scalp score cutoff of ≥7 to obtain a cranial CT, no TBI and no ciTBI would be missed

B: Using a scalp score cutoff of ≥6 to obtain a cranial CT, no TBI and no ciTBI would be missed

C: Using a scalp score cutoff of ≥4 to obtain a cranial CT, no TBI and no ciTBI would be missed

The correct answer is C

This week JournalFeed covered the Infant Scalp Hematoma Score.

This easy to use risk stratification tool seems to be helpful in avoiding CT’s in the very young.

No infant with an ISH and an infant scalp score < 4 had TBI found on CT.

No infant with an ISH and an infant scalp score <5 had a ciTBI defined as death, need for neurosurgical intervention, intubation for at least 24 hours or hospitalization for two or more nights for TBI.

Source image: www.coreem.net

Question 5

Which of the following statements about a Maisonneuve fracture is true?

A: A Maisonneuve fracture should be suspected in all patients with fractures of the medial and / or posterior malleolus

B: Maisonneuve fractures are seen in 15% of all ankle fractures

C: A distal positive ‘’Squeeze test’’ suggests more severe injury to the tibiofibular syndesmosis than a more proximal positive ‘’Squeeze test’’

D: Weakness of ankle dorsiflexion, subtalar foot eversion and/or numbness along the lateral lower leg and dorsum of the foot should raise clinical suspicion for a Maisonneuve injury due to a damaged sural nerve

The correct answer is A

Maisonneuve fractures were covered by Jessica Tsao from CORE EM this week.

A Maisonneuve fracture is defined by the combination of a proximal fibula fracture and an unstable ankle joint injury. It involves an injury of the distal tibiofibular syndesmosis and/or fracture of the medial or posterior malleolus and it is seen in 5% of all ankle fractures.

The ‘’Squeeze test’’ is performed by giving compression on the tibia and fibula simultaneously and is considered positive when ankle or distal lower leg pain is felt. The more proximal the test is positive, the more severe the injury to the syndesmosis is and therefore the more likely a Maisonneuve fracture is.

The common peroneal nerve can be damaged in a Maisonneuve fracture since it courses over the fibular head.

Maisonneuve Fractures

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

Reviewed and edited by Rick Thissen

Quiz 79, August 7th, 2020

Welcome to the 79th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

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

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

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

What did the authors find?

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

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

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

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

The correct answer is C

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

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

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

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

GRECCO-19

Question 2

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

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

A: Ketamine

B: Etomidate

C: There was no difference in post procedure hypotension

The correct answer is A

This recently published paper was discussed at JournalFeed this week.

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

Source image: www.pixabay.com

Question 3

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

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

– Urinalysis is negative

– Absolute Neutrophil Count <4,090/μL 

– Procalcitonin <1.71 ng/mL

What is the sensitivity of these criteria for SBI?

A: 76 %

B: 82 %

C: 91 %

D: 98 %

The correct answer is D

Justin Morgenstern covered this paper on First10EM.

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

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

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

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

Source image: www.emdocs.net

Question 4

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

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

Which statement is true about CRITOE?

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

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

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

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

The correct answer is C.

This week EMDocs covered pediatric elbow injuries.

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

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

Source image: www.pixabay.com

Question 5

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

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

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

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

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

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

The correct answer is D.

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

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

IBCC chapter & cast – Hyperosmolar Hyperglycemic State

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

Reviewed and edited by Rick Thissen

Quiz 78, July 31th, 2020

Welcome to the 78th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

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

Which of the following statements is true about TAPSE?

A: TAPSE is a multiple-plane measurement

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

C: Abnormal TAPSE measurement is only seen in pulmonary embolism

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

The correct answer is D

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

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

Right ventricle dysfunction may still be present with normal TAPSE.

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

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

A TAPSE of less than 2 cm is considered abnormal.

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

 Question 2

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

A: Change in pain between day one and two

B: FEV1 on day one

C: Grip strength on day one

The correct answer is B

Sam Parnell covered this paper on JournalFeed.

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

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

 

Source image: www.pixabay.com

Question 3

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

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

A: Faster pain relief

B: Better pain relief

C: Less adverse events

D: There is no benefit

The correct answer is D

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

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

Don’t use lidocaine for epigastric pain

Question 4

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

Which of the following features is inconsistent with GBS?

A: Relatively symmetric symptoms

B: Fever at onset of symptoms

C: Cranial nerve involvement

D: Autonomic dysfunction

The correct answer is B

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

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

Guillain Barre Syndrome (GBS)

Question 5

Source image: Pixabay.com

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

A: Bystander CPR

B: Prehospital intubation

C: Penetrating mechanism of injury

D: Use of prehospital or in-hospital epinephrine 

The correct answer is A

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

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

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

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

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

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

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

Reviewed and edited by Rick Thissen

Quiz 76, June 17th, 2020

Welcome to the 76th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

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

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

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

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

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

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

The correct answer is A

EMottawa covered the management of status epilepticus this week. 

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

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

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

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

The Status on Status: Management of Status Epilepticus

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

Question 2

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

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

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

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

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

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

The correct answer is B

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

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

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

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

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

Question 3

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

You suspect Bell’s palsy.

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

A: Artificial tears

B: Steroids

C: Antivirals

The correct answer is C

CountyEM covered Bell’s palsy last week.

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

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

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

 

Question 4

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

A: Valproic acid

B: Lithium

C: Carbamazepine

D: Haloperidol

The correct answer is B

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

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

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

 

Question 5

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

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

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

What did the authors find?

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

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

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

D: All of the above

The correct answer is D

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

96 Patients were enrolled in the study.

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

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

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

Thromboelastography for Hypocoagulable Patients with Non-Traumatic Bleeding

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

Reviewed and edited by Rick Thissen

Quiz 75, July 10th, 2020

Welcome to the 75th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

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

Question 1

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

What did the authors find?

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

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

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

The correct answer is A

Clay Smith covered this paper on Journal Feed this week.

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

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

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

 

Question 2

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

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

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

What did the authors find?

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

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

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

The correct answer is C

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

396 Subjects were enrolled.

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

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

Question 3

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

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

A: The recommended oxygen saturation target is >88%

B: A state of hypervolemia should be obtained

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

D: NSAIDs can safely be used

The correct answer is C

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

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

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

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

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

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

IBCC chapter & cast – Sickle Cell Acute Chest Syndrome

Question 4

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

A: Inflammatory bowel disease

B: Migraine

C: Hyperemesis gravidarum

D: Psoriasis

The correct answer is B

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

Cyclic Vomiting Syndrome

Source image: www.ultrasoundgel.org

Question 5

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

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

What did the investigators find?

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

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

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

The correct answer is A

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

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

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

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

Reviewed and edited by Rick Thissen

Quiz 74, July 3th, 2020

Welcome to the 74th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick


Question 1

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

Which of the following statements is true regarding this block?

A: It affects dermatomes C6-T3

B: Anticoagulation is not a contraindication

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

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

The correct answer is B

CountyEM covered the serratus anterior plane block this week. 

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

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

Question 2

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

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

What did the authors find?

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

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

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

The correct answer is A.

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

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

Source image: www.pixabay.com

Question 3

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

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

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

What did the authors find?

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

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

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

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

The correct answer is D

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

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

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

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

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

    

Source image: www.pixabay.com

Question 4

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

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

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

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

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

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

The correct answer is C.

EMDocs covered pyelonephritis this week.

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

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

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

Question 5 

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

What abnormality is described here?

A: The Segond fracture

B: Stieda fracture

C: The arcuate sign

D: The intercondylar eminence fracture

The correct answer is C

AliEM covered not to miss knee injuries this week. 

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

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

Reviewed and edited by Rick Thissen

Quiz 73, June 26th, 2020

Welcome to the 73th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.rebelem.com

Question 1

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

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

What did the authors find?

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

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

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

The correct answer is C

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

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

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

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

Dexamethasone for COVID: The RECOVERY trial

Source image: www.pixabay.com

Question 2

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

What did the authors find?

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

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

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

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

The correct answer is B

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

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

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

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

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

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

Question 3

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

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

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

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

The correct answer is B

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

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

 

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

Question 4

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

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

A: Neurological symptoms are found in most of the patients

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

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

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

The correct answer is C

RebelEM covered spinal epidural abscesses this week.

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

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

Spinal Epidural Abscess (SEA)

Source image: www.pixabay.com

Question 5

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

What will her arterial blood gas most likely look like?

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

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

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

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

The correct answer is A

Salicylate overdose was covered on emDocs this week.

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

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

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

EM@3AM: Salicylate Overdose

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

Reviewed and edited by Rick Thissen

Quiz 71, June 12th, 2020

Welcome to the 71th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

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

What did the authors find?

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

B: Immunomodulation was found to delay viral clearance

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

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

The correct answer is A

Josh Farkas discusses this RCT this week on PulmCrit.

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

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

 

 

Question 2

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

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

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

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

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

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

The correct answer is B

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

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

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

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

Source image: www.aliem.com

Question 3

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

Which of the following statements is true about Poison Hemlock?

A: It causes a cholinergic toxidrome

B: It causes a anticholinergic toxidrome

C: It causes a sympathomimetic toxidrome

D: It causes a sedative-hypnotic syndrome

The correct answer is C

This week Aliem posted about poison hemlock.

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

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

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

ACMT Toxicology Visual Pearls: A Foraging Experience to Die For

Source image: www.pixabay.com

Question 4

Which of the following statements is true about pediatric ECGs?

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

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

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

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

 The correct answer is C

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

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

Approaching the paediatric ECG

 

Source image: www.emottowablog.com

Question 5

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

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

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

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

D: Large pleural effusions are common in COVID-19

The correct answer is C

EMOttawa covered ultrasound in COVID-19 patients this week.

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

Protocol for lung ultrasound in COVID-19 patients

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

Reviewed and edited by Rick Thissen