Quiz 99, January 22th, 2021

Welcome to the 99th FOAMed Quiz. 

Sophie, Nicole, Joep, Denise, Gijs and Rick

Source image: www.pixabay.com

Question 1

Your 27 year old patient comes in after a motor vehicle accident. She has respiratory failure (saturation 88 percent on non rebreather, breathing 48 times per minute) and has extensive rib fractures. She appears to be hemodynamically stable (for now). After bilateral finger thoracostomy you will have to intubatie her. By the way, she is pregnant (AD 26 weeks and 2 days).

Which of the following statements is true about emergency intubation of a pregnant patient?

A: Rocuronium should not be used because it easily passes the placenta

B: Succinylcholine should not be used because it easily passes the placenta

C: Etomidate is a good induction agent in this case

D: Thiopental is the only induction agent that can be used safely in this case

The correct answer is C

NUEM covered intubation of the pregnant patient this week.

Moral of the story: Use the medications you would typically use for the patient. All induction agents cross the placenta, but hypoxia, hypercarbia and acidosis are far more harmful to the fetus.

Paralytic agents are highly ionized and do not cross the placenta in significant amounts. Etomidate can be used in these cases.

 

Question 2

Soft tissue injuries due to retained foreign bodies are regularly seen in the Emergency Department. These sometimes radiolucent foreign bodies can not always be identified on conventional X-rays or computed tomography.

Ultrasonography has a high accuracy for detecting radiopaque foreign bodies. Each material has his own common sonographic signature.

The picture shown below shows a foreign body in a patient’s finger:

Source image: rebelem.com

This foreign body is most likely made of:

A: Glass

B: Wood

The correct answer is A

POCUS and Soft Tissue Foreign Bodies were covered on REBELEM this week.

The linear series of bright echogenic structures (reverberation artifacts) along the path of this foreign body are often seen in foreign bodies made out of glass.

Wooden foreign bodies have a more discrete acoustic shadow without artifacts.

POCUS and Soft Tissue Foreign Bodies

Source image: www.pixabay.com

Question 3

In Disseminated Intravascular Coagulation (DIC) there is widespread, uncontrolled clot formation in the microvascular as well as macrovascular system. Due to depletion of procoagulant proteins it can also cause hemorrhage.

DIC is a clinical diagnosis based on the presence of a constellation of laboratory abnormalities, the presence of an underlying disorder known to cause DIC and absence of a different explanation for the laboratory abnormalities.

Laboratory tests which can help diagnosing DIC include a complete blood count, PT/INR, APTT, fibrinogen and D-dimer.

Which of the following statements about laboratory tests in DIC is NOT true?

A. Thrombocytopenia is often the first laboratory abnormality to appear

B. Normal PT/INR and APTT occur in half of the patients with DIC

C. The majority of patients with DIC show low fibrinogen

D. A normal D-dimer essentially excludes DIC

The correct answer is C.

Disseminated intravascular coagulation (DIC) was covered by EMCRIT’s IBCC this week.

Low fibrinogen is seen in only 25% of patients with DIC. It supports the diagnosis of DIC, but usually isn’t seen. Remember fibrinogen is an acute phase protein, so sepsis-induced DIC may have normal or elevated levels of fibrinogen.

Source image: www.ntvt.nl

Question 4

The management of ACE-inhibitor induced angioedema can be challenging. No drugs are proven effective and it is not always obvious which patients need a secure airway.

In this retrospective study, investigators wanted to determine which patients have a higher risk and need for intubation.

What did the investigators find?

A: Isolated lip swelling was associated with an increase in risk for intubation

B: Intubation should only be performed within the first 6 hours of onset of angioedema symptoms

C: Anterior tongue swelling and vocal changes are associated with a high risk for intubation

D: Over 30 percent of patients presenting with ACE-inhibitor induced angioedema required intubation

The correct answer is C

This week Sam Parnell covered ACEi angioedema on Spoon Feed.

Isolated lip swelling was present in 54% of all patients and more common in patients that did not require intubation. These patients are usually at low risk for intubation but be aware of rapid symptom progression. Patients that required intubation were more likely to present within 6 hours of onset of angioedema symptoms. Rapid progression within the first 6 hours of onset and anterior tongue swelling, vocal changes, drooling and dyspnea are associated with intubation for ACEi associated angioedema.

 

Source image: www.pixabay.com

Question 5

Which of the following can potentially cause pancreatitis?

A: Soy beans

B: Lentils

C: Fava beans

D: Kidney beans

The correct answer is A

CountyEM covered soy bean induced pancreatitis this week.

Soy beans contain a component that is a known trypsin inhibitor. Trypsin inhibitors cause hypertrophy and hyperplasia of acinar cells (at least in rats) and are believed to cause pancreatitis in humans.

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This quiz was written by Sophie Nieuwendijk, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 98, January 15th, 2021

Welcome to the 98th FOAMed Quiz! 

 

Question 1

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


Your 37 year old patient presents with palpitations. He denies any chest pain and dyspnea. His ECG is shown above. He has a capillary refill of 3 seconds, his blood pressure is 80/40 and he feels generally really unwell.

Which of the following treatment options is correct in this case?

A: Adenosine

B: Electric cardioversion

C: Amiodarone

D: Metoprolol

The correct answer is B.

Pendell Meyers covered atrial fibrillation (AF) with Wolff Parkinson White (WPW).

This ECG shows an irregular, wide complex tachycardia. AF with WPW is pretty likely and therefore all nodal blockers should be avoided. The best way to treat this patient is with electric cardioversion.

Source image: www.pixabay.com


Question 2

The following drug is a natural alkaloid originally derived from Autumn Crocus. It is approximately 50% protein bound and highly lipophilic, which make it non-dialyzable in case of toxicity. One of the typical symptoms of severe poisoning is profound leukopenia.

What drug matches this description?

A: Aspirin

B: Digoxine

C: Quinine

D: Colchicine

The correct answer is D

EMDocs covered colchicine toxicity last week.

Of these plant derived drugs, colchicine is derived from the autumn crocus. Colchicine poisoning can lead to severe disease and death. After an initial phase of gastro-intestinal symptoms, multi-organ failure can develop. Profound leukopenia is very often present in severe intoxications.

ToxCard: Colchicine Toxicity

Source image: www.pixabay.com

Question 3

A fall from height is a pretty common presentation in the ED. This 2020 paper is about a model for the fatality likelihood associated with falls from heights. 285 cases were analyzed.

From how many floors (and over) did the authors find a mortality rate of 100 percent?

A: 3 floors

B: 5 floors

C: 6 floors

D: 8 floors

The correct answer is D, 8 floors.

CanadiEM covered falls from height last week.

However the mortality ratio is very high in falls from 5 floors and over, no survivors were seen in a fall from 8 floors and more.

Case Report: Parkour aftermath – Andy’s fall from height in The Office

Source image: www.theempulse.org

Question 4

Your 47 year old patient presents to your ED with suspected cellulitis of her upper left leg. She is in severe pain and has a fever. She is hemodynamically stable. Blood results are pending.

POCUS reveals the image shown above.

What is the most likely diagnosis?

A: Uncomplicated cellulitis

B: Abscess

C: Necrotizing fasciitis

The correct answer is C

Coreultrasound covered soft tissue ultrasonography this week.

The image shows cobblestones, typical for cellulitis. However, deep in the subcutis a large amount of air is present, making necrotizing fasciitis very likely.

Source image: www.emcrit.org

Question 5

Hemodynamically unstable patients often need inotropic agents to maintain a sufficient mean arterial pressure (MAP). Phenylephrine can be used as a push dose pressor.

This retrospective multicenter study is about patients with septic shock. Patients who received push-dose phenylephrine were matched to patients who did not receive push-dose phenylephrine before continuous administration of vasopressors.

The primary outcome was hemodynamic stability at 3 hours. Patients were considered stable if MAP was ≥65 for 6 hours without increase in continuous vasoactive infusions.

What did they authors find?

A: At 3 hours, significantly more patients who received push-dose phenylephrine were stable compared to those who did not

B: Hemodynamic stability at 3 hours was not significantly different between patients who received push-dose phenylephrine compared to those who did not

C: At 3 hours, significantly more patients who did not receive push-dose phenylephrine were stable compared to those who did

The correct answer is A

This retrospective multicenter study was covered by Clay Smith from JournalFeed this week.

Out of 1.317 patients, 181 received push dose phenylephrine. Hemodynamic stability at 3 hours was significantly more often achieved in the phenylephrine group compared to the non phenylephrine group (28.4% vs 18.8%).

This effect was not seen at later stages. Furthermore, the use of push-dose phenylephrine was associated with increased ICU mortality with an adjusted OR of 1.88 (95% CI 1.1-3.21).

Keep in mind that patients who received push-dose phenylephrine might have been sicker than those who did not.  

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This quiz was written by Sophie Nieuwendijk, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 97, January 8th, 2021

Welcome to the 97th FOAMed Quiz. 

Sophie, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

While the vaccinating campaign against COVID-19 finally started, research on treatment options is not slowing down. The previous BLAZE-1 trial on bamlanivimab showed no differences in patient centered outcomes as well as serious methodological flaws.

This recently published paper is about casirivimab/imdevimab (REGN-COV2) monoclonal antibody cocktail. The researchers compared a high (8.0 g) and low dose (2.5 g) of this cocktail to placebo in non-hospitalized patients over 18 years of age with a confirmed SARS-COV2 infection within 72 hours of randomization and symptom onset.

Viral load was one of the most important outcomes although no primary endpoint was selected a priori.

What did the authors find?

A: Viral load was significantly lower in the low-dose and high-dose REGN-COV2 groups compared to the placebo group at day 7

B: Viral load was not significantly different between both REGN-COV2 groups compared to the placebo group at day 7

C: Viral load was significantly higher in the low-dose and high-dose REGN-COV2 groups compared to the placebo group at day 7

The correct answer is A

Anand Swaminathan covered the paper last week on RebelEM.

A total of 275 patients (REGN-COV2 low dose: n=92, REGBN-COV2 high dose: n=90, placebo: n=93) underwent randomization from which 228 were analyzed. Antibody status prior to treatment was measured (45% with antibodies, 41 without antibodies and 14% with unknown antibody status).

The viral load was significantly lower in both REGN-COV2 groups in comparison to placebo at day 7 while clinical efficacy (change in medically attended visits) was not significantly different (3% vs 6%, -3% CI -16 to 9).

Even though these results might seem promising, we have to inperpret these results with a lot of caution due to numerous limitations such as the fact that no formal hypothesis testing was performed and the fact that the authors randomly mentioned positive outcomes while they downplayed a large number of negative findings. They thereby combined all medically attended visits ignoring the very obvious difference between for example a Telehealth visit and an admission to the hospital. Finally, this study was sponsored by Regeneron, a large pharmaceutical company.

No Evidence that REGN-COV2 (Regeneron) Antibody Cocktail Has Clinical Benefits

Source image: www.pixabay.com

Question 2

After an uncomplicated home delivery (39+1 weeks), the paramedics present to your ED a 1 hour old girl with hypoxia. There were no problems during the pregnancy. In the ED you see mask ventilation is difficult and oxygen is dropping again. You have to intubate the neonate.

Which of the following statements is true about Rapid Sequence Induction/Intubation (RSI) in neonates?

A: The use of both sedative and paralytic medication shows reduction of adverse events compared to sedation only

B: The use of sedative only shows a reduction in adverse events compared to using both sedative and paralytic medication

C: The use of paralytic medication only is good practice

D: No medication need to be given because neonates are to small, young and immature to perceive pain

The correct answer is A

This week Pediatric EM Morsels covered Neonatal Intubation and RSI.

Neonates have all the characteristics of a difficult airway. They have a challenging physiology with a low functional residual capacity and a high metabolic rate and oxygen consumption. First attempt success rate in the NICU is about 49%. Significantly fewer adverse events occur when both paralytics and sedative medication is used compared to either sedative alone or no medication. Despite the fact that they are small and young, neonates do feel pain. Not using any medication or paralytic only is just inhumane.

Neonatal Intubation and RSI

Source image: www.litfl.com

Question 3

Your 59 year old female patient has ongoing pain in her chest since yesterday. She denies dyspnoea. Her ECG is shown above. She was treated with aspirin, ticagrelor, and heparin. Troponin came back markedly elevated. Catheterization showed normal coronary arteries and POCUS revealed the following:

Source image: coreultrasound.com

What is the most likely diagnosis?


A: Occlusion Myocardial Infarction (OMI)


B: Myocarditis

C: Takotsubo cardiomyopathy

The correct answer is C

Brown EM covered takotsubo cardiomyopathy last week.

Takotsubo cardiomyopathy is an acute, transient stress-induced cardiomyopathy. The diagnosis of takotsubo can be quite challenging as it cannot be distinguished from OMI without coronary angiography. ST elevation and apical ballooning are typical for takotsubo. There is no consensus on diagnostic criteria for Takotsubo so far. Although most patients will have a complete recovery within a month, this disease is certainly not purely benign.

Question 4

A 23 year old male comes in with pain in his right foot after a jump from the second floor. He landed on both feet. The X-ray shows the following:

Source image: www.aliem.com

Which of the following injuries is associated with this fracture?

A: Vertebral fracture of the cervical spine

B: Vertebral fracture of the thoracic or lumbar spine

C: Fracture of the skull base

D: Dislocated shoulder

The correct answer is B

ALIEM covered fractures of the calcaneus last week.

‘’7-10% of calcaneal fractures are associated with a concomitant vertebral fracture, including compression or burst fractures, especially with high energy mechanisms such as a fall from height’’ 

SplintER Series: We’ve Got A Jumper

Source image: www.tamingthersu.com

Question 5

Your 54 year old patient presents to your emergency department with a painful right hand. He has been cleaning his car about 6 hours ago with ‘’some chemical stuff’’ and he thinks his glove might have been perforated. Initially he did not notice a burn, but since 2 hours ago the pain was increasing.

What chemical compound is most likely the cause of this injury?

A: Chloric acid

B: Sodium hydroxide

C: Hydrofluoric Acid

D: Ammonia

The correct answer is C

Taming the SRU covered hydrofluoric acid burns last week.

The chronology of this story is typical for hydrofluoric (HF) acid burns. High concentration (>60 percent) solutions will cause immediate symptoms, as lower concentrations tend to cause symptoms later on. This latent period causes delay in treatment.

Hydrofluoric acid is a calcium and magnesium scavenger, leading to local (and if the burn is large enough systemic) hypocalcemia and hypomagnesemia and therefore to extensive and deep necrosis. Treatment consists of decontamination, irrigation and calcium, calcium and calcium. Calcium should be applied topically and can be injected locally (subcutaneous), intravenously and even intra-arterial.

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This quiz was written by Sophie Nieuwendijk, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 94, December 11th, 2020

Welcome to the 94th FOAMed Quiz. 

Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Corneal abrasions are common in the ED and usually heal spontaneously within 24 to 72 hours. Patients can experience a fierce pain. Tetracaine and other topical anesthetics have been avoided due to the concerns for poor wound healing and subsequent corneal ulceration, scarring or blindness. However evidence is limited.

This paper compared the home use of topical tetracaine 0.5% vs placebo for uncomplicated corneal abrasions. The primary outcome was the overall pain score measured at the 24-48 hour ED follow up examination.

What did the authors find?

A: The topical tetracaine group showed a lower median pain score and decreased use of hydrocodone compared to placebo

B: There is no difference in median pain score between topical tetracaine and placebo

C: The topical tetracaine group showed an increase in adverse events compared to the placebo group

The correct answer is A

This week Sam Parnell covered the treatment of uncomplicated corneal abrasions on SpoonFeed.

Topical tetracaine use was associated with lower median pain score (1/10 vs 8/10) and decreased use of hydrocodone tablets for breakthrough pain (median 1 vs 7) compared to placebo for the first 24-48 hours. No serious adverse events were reported, however this was a small group with numerous exclusion criteria. Therefore the overall safety is still unknown but topical tetracaine might be used safely with strict counselling and instructions.

Source image: www.pixabay.com

Question 2

Your 30 year old male patient was involved in a motor vehicle accident. He is in profound hemorrhagic shock. FAST shows free abdominal fluid. You initiate Massive Transfusion Protocol (MTP).

Which of the following statements is true about Massive Transfusion Protocols (MTP’s)?

A: A triple lumen central venous catheter is ideal for transfusing large amounts of packed red blood cells

B: Whenever possible, crystalloids should be avoided In hemorrhagic shock with ongoing bleeding

C: There is no place for fibrinogen supplementation in trauma-induced bleeding

D: A mild hypocalcemia due to the citrate in blood products can be accepted and suppletion is not necessary

The correct answer is B

This week Josh Farkas discusses the Massive Transfusion Protocols in EMCrit

In hemorrhagic shock with ongoing bleeding, crystalloid administration may dilute coagulation factors and erythrocyte concentration. Crystalloids should be avoided whenever possible.

Due to the length of the catheter and its relatively small diameter, central venous catheters can not handle rapid fluid administration.

Administration of fibrinogen should be initiated rather early. Recent guidelines for trauma-induced bleeding suggest targeting a fibrinogen level > 150-200mg/dL

If blood products are given rapidly, the citrate in blood products chelates calcium and will lead to hypocalcemia. Hypocalcemia can cause coagulopathy and therefore after each round of MTP you should also give 1 gram of IV calcium chloride or 3 grams of IV calcium gluconate.

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 12560

Question 3

Your 19-year old male patient comes in with a painful lateral clavicle on the left side.

The X-ray is shown above.

Which of the following statements about acromioclavicular joint (ACJ) injuries is true?

A: The first ligament to rupture in ACJ injuries is typically the coracoclavicular (CC) ligament, followed by the acromioclavicular (AC) ligament and coracoacromial (CA) ligament

B: A positive scarf test suggests an ACJ injury

C: The normal space between the clavicle and acromion on X-ray is <8mm

D: Management of Rockwood grades I-IV ACJ injuries is conservative whereas Rockwood grades V-VI require operative management

The correct answer is B

ACJ injuries were covered on Don’t Forget The Bubbles this week.

Injury to the ACJ means disruption of the AC ligaments with or without disruption of the CC ligament. ACJ injuries most often occur due to a direct blow or fall onto the superior or lateral part of the shoulder with the arm adducted.

The Scarf test is performed by compression on the affected shoulder while the patient’s hand on the affected side holds the contra-lateral side of the patient’s neck. If painful, it suggests an ACJ injury.

The normal space between the clavicle and the acromion is <5mm (or <2mm difference compared to the other side). Management of Rockwood Grades I-III is conservative while Rockwood Grades IV-VI need surgical management. Grade III ACJ injuries also need surgical intervention when non-operative management fails.

Question 4

The use of convalescent plasma therapy (CPT) in the treatment of COVID-19 increases despite a lack of supporting evidence from randomised studies.

This recently published paper comparesd CPT to placebo in hospitalized adult patients with severe COVID-19 pneumonia. It is a double-blind, placebo-controlled, multicenter, randomized controlled trial from Argentina and the first randomised study on this topic.

The primary outcome was clinical status 30 days after intervention, measured on a 6-point ordinal scale ranging from total recovery to death.

What did the authors find?

A: There was no difference in the distribution of clinical status at 30d after intervention

B: CPT was superior to placebo in the distribution of clinical status at 30d after intervention

C: Placebo was superior to CPT in the distribution of clinical status at 30d after intervention

The correct answer is A

RebelEM covered the paper  last week.

334 patients with severe COVID-19 pneumonia (SaO2 <93% on room air, P/F ratio <300mmHg or SOFA or mSOFA score ≥2 above baseline status) were randomised to either CPT (228 patients) or placebo (105 patients). The median time from onset of symptoms to enrollment was 8 days.

There was no difference in the distribution of clinical status at 30d after intervention. Furthermore, overall mortality was equal (11.0 vs 11.4 percent), ICU admissions (53.9 vs 60.0 percent or progression to invasive ventilatory support (26.8 vs 22.9 percent).

Keep in mind transfusion-associated cardiac overload (TACO) and transfusion-related acute lung injury (TRALI) could not be differentiated from COVID-19 progression in this trial.

COVID-19 Update: The PlasmAr Trial – Convalescent Plasma vs Placebo

Question 5

Source image: www.tamingthesru.com

Your 40 year old patient presents with urticaria, wheezing, hypotension and shock after injection of antibiotics.

The use of which of the following drugs is supported by evidence in this case?

A: Diphenhydramine or another antihistamine

B: Prednisolone or another glucocorticoid

C: Adrenalin (epinephrine)

D: Methylene blue

The correct answer is C

Taming the SRU covered the treatment of anaphylaxis this week.

There is no data so far that supports the use of glucocorticoids in anaphylaxis. The dreaded biphasic reaction sure seems quite rare and often not clinically significant.

Antihistamines may reduce cutaneous manifestations of anaphylaxis, but their benefit in systemic anaphylactic reactions is not supported by evidence.

Animal studies and case reports have indicated a possible role for IV methylene blue in anaphylactic shock refractory to epinephrine.

And well, adrenalin is the mainstay of management of anaphylaxis. It agonizes α1, β1, and β2 receptors and so increases peripheral vascular resistance and aids significantly in bronchodilation. Agonism of β2 receptors leads to decreased release of mast cells contents.

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This quiz was written by Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thisse

Quiz 93, December 4th, 2020

Welcome to the 93th FOAMed Quiz. 

Enjoy!

Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Morphine and low dose ketamine (0.25 to 0.5 mg/kg) are commonly used analgesics in the ED. A 2018 meta-analysis did not show any difference in effectiveness between the two.

Recently a new and larger meta-analysis was published. What did the authors find?

A: Morphine is superior to low dose Ketamine in pain control up to 60 minutes after administration

B: Low dose Ketamine is superior to Morphine in pain control up to 60 minutes after administration

C: No difference was found between Morphine and low dose Ketamine in pain control up to 60 minutes after administration

The correct answer is C

The paper was covered on JournalFeed this week.

A total of 1191 patients (morphine = 593, LDK = 598) were included.

The recently published, larger, meta-analysis did not show any difference in effectiveness between the two drugs in the first hour after administration. Beyond 60 minutes however, morphine may be more effective.

Furthermore, the rate of adverse effects (nausea, vomiting) were equal.

Source image: www.aliem.com

Question 2

Your 25 year old patient presents to the ED, three months after a punch to the left side of the head. He complains of intermittent blurry vision. His aching left eye gets worse with ocular movements and is associated with conjunctival injection. 

Due to the story, a high intraocular pressure and a mild proptosis in the left eye you decide for further imaging (CT-angiography). You see a dilatation of the left ophthalmic vein.

What is the most likely diagnosis?

A: Rupture of the opthalmic nerve

B: Carotid cavernous fistula

C: Frontal subdural hematoma

D: Orbital fracture

The correct answer is B

This week Aliem covered carotid cavernous fistula this week.

Carotid-cavernous fistulas present shortly after trauma and can become symptomatic until weeks after trauma.

Conventional angiography is the gold standard for this diagnosis and neurosurgery should be consulted. Treatment will be coil embolization of the carotid-cavernous fistula by interventional radiology.

Question 3

The Head Impulse test is part of the HINTS exam (along with Nystagmus and Test of Skew) used in patients with continuous vertigo to distinguish peripheral from central causes.

In this test, the patient is asked to maintain focus on your nose while gently moving the patient’s head to one side and then rapidly move the head back to the neutral position. The Head Impulse test can be abnormal or normal. In an abnormal test, a corrective saccade can be seen.

What does an abnormal Head Impulse test tell you?

A: It makes a central cause of vertigo more likely

B: It makes a peripheral cause of vertigo more likely

The correct answer is B

The HINTS exam was covered on JournalFeed this week.

An abnormal Head Impulse test makes a peripheral cause of vertigo more likely and is good news for your patient. Patients with a central cause of vertigo typically have a normal Head Impulse test. This test can only be used in continuous vertigo, so it is not to be used in patients with BPPV.

 

Source image: www.rebelem.com

Question 4

Magnesium Sulfate may have analgesic effects. Most likely this is due to its antagonism of NMDA receptors. Perioperative Magnesium decreases opioid use post-operatively (source).

This recently published paper is about Magnesium Sulfate (50 mg/kg iv with a maximum of 2 g) versus Morphine (0.1 mg/kg iv with a maximum of 5 mg) as monotherapy for renal colic. 80 Patients were randomised.

What did the authors find?

A: Magnesium Sulfate resulted in better pain scores at 20 minutes post administration compared to Morphine

B: Morphine resulted in better pain scores at 20 minutes post administration compared to Magnesium Sulfate

C: There was no difference in pain score at 20 minutes post administration between Morphine and Magnesium Sulfate

The correct answer is C

Salim Rezaie covered the paper last week on RebelEM.

In this small, single centre study, Magnesium Sulfate showed to be possible non-inferior to Morphine in renal colic at 20 minutes past administration. However, morphine showed to give faster pain relief. Magnesium Sulfate may help in reducing opioid use in renal colic.

Pain reduction was equal between both groups Magnesium (3.20: decrease by 4.68 from baseline) and Morphine (3.65: Decrease by 4.28 from baseline).

The effectiveness of these agents in conjunction with an NSAID was not evaluated.

Adjunctive Pain Management of Renal Colic and Migraines

Source image: www.dontforgetthebubbles.com

Question 5

What is the correct eponym for this fracture?

 A: Galeazzi

B: Monteggia

C: Essex-Lopresti

The correct answer is A

Galeazzi fracture-dislocation was covered on Don’t Forget The Bubbles this week.

I have seen countless mnemonics for Monteggia versus Galeazzi in the past years. Personally the best one that works for me is: just remember it.

An Essex-Lopresti fracture occurs due to the compressive force of trauma transmitted down the forearm leading to a radial head fracture, interruption of the interosseous membrane and dislocation of the distal radio-ulnar joint (DRU).

 

Source image: www.pixabay.com

Question 6

Your 40 year old male patient is admitted to a nearby psychiatric clinic. He comes in with diarrhoea and vomiting. The psychiatrist suspects lithium intoxication. He has been using lithium for some months now.

Which of the following is true about lithium intoxication?

A: Lithium plasma levels correlate quite well to severity of intoxication

B: Cardiac toxicity is the most pronounced feature of lithium intoxication

C: Renal replacement therapy is the mainstay of treatment for lithium toxicity

D: Activated charcoal is the mainstay of treatment for lithium toxicity

The correct answer is C

CountyEM covered multiple toxicology cases this week.

A lithium level can help confirm the diagnosis, but plasma levels can’t tell you how much is in the tissue compartments, particularly the central nervous system.

Cardiac toxicity of lithium might very well be a significant consequence of intoxication, but the evidence behind cardiac toxicity is very limited so far.

Activated charcoal does not bind well to lithium and has no role when lithium is the sole agent in the overdose.

And yes, renal replacement therapy is the mainstay of treatment for lithium toxicity (if severe enough).

 

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This quiz was written by Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 92, November 27th, 2020

Welcome to the 92th FOAMed Quiz. 

Enjoy!

Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

The recently published PLACID-trial is about the use of convalescent plasma in the treatment of admitted patients with COVID-19.

The researchers compared the use of convalescent plasma (2 doses of 200ml convalescent plasma 24 hours apart) plus standard care (intervention group) to standard care alone (control group) in patients with confirmed moderate COVID-19 (PaO2/FiO2 ratio between 200-300 mmHg OR a respiratory rate of >24/min with oxygen saturation 93% or less on room air).

Their primary outcome was progression to serious disease (PaO2/FiO2 ratio <100 mmHg) or death within 28 days.

What did the authors find?

A: Progression to serious disease or death within 28 days was significantly decreased in the intervention group compared to the control group

B: Progression to serious disease or death within 28 days was not significantly different between both groups

C: Progression to serious disease or death within 28 days was significantly increased in the intervention group compared to the control group

The correct answer is B

The PLACID-trial was covered by Simon Carley on St.Emlyn’s this week.

464 adult patients underwent randomization. Convalescent plasma was not associated with a reduction in progression to severe COVID-19 or death (intervention group 19% vs control group 18%). These results are consistent with the previous ConCOVID-trial.

The validity of these results might be affected by large differences in standard of care between hospitals which participated in this study.

Larger ongoing trials, such as the RECOVERY-trial, will help to further address the role of convalescent plasma in patients with COVID-19.

JC: Convalescent plasma in COVID 19 patients.

Source image: www.rebelem.com

Question 2

The subclavian vein is a preferred central venous access site given its fixed puncture location, ease for nursing access and low incidence of infections. However, access can be a bit more challenging compared to the internal jugular vein and there may be a higher chance of complications like arterial puncture and pneumothorax.

This recently published paper is about static ultrasound-guided (needle not directly visualised) puncture versus traditional anatomic landmark guided subclavian vein puncture in the ICU.

What did the authors find?

A: The rate of successful vein puncture was higher in the ultrasound group

B: The rate of pneumothoraces was higher in the ultrasound group

C: The rate of arterial puncture was higher in the ultrasound group

The correct answer is A

RebelEM covered the paper last week on their podcast.

The authors of this study sought to compare the efficacy and safety of static ultrasound-guided puncture with traditional anatomic landmark guided subclavian vein puncture. 95 patients were randomised to the ultrasound group and 98 patients to the landmark group.

The rate of successful vein puncture was higher in the ultrasound group (91 vs 77 percent). The rate of pneumothoraces was higher in the landmark group (0 vs 2 patients) and the rate of arterial puncture was also higher in the landmark group (2 vs 14 percent).

It seems static ultrasound clearly has advantages over the landmark technique. But then again, who doesn’t use ultrasound guidance in central line placement nowadays?

REBEL Cast Ep91: Static Ultrasound vs Landmark Placement of Subclavian Central Lines

Source image: www.LITFL.com

Question 3

This patient has a normal QRS axis. Which of the following leads are most likely reversed?

A: Left arm and left leg

B: Right arm and left leg

C: Left arm and right arm

The correct answer is C

This weeks dr. Smith’s ECG blog is about left ventricular hypertrophy and limb lead misplacement.

Source image: www.LITFL.com

The following happens when right and left are replaced:
– Lead I becomes inverted.
– Leads II and III switch places.
– Leads aVL and aVR switch places.
– Lead aVF remains unchanged.

Source image: www.wikem.org

Question 4

Your patient comes in feeling generally unwell after using amyl nitrite. He is profoundly tachypnoeic and cyanotic, saturation levels reach 88 percent with a non rebreather mask. His blood appears brown. You suspect methemoglobinemia. The pharmacy is already preparing methylene blue.

Which of the following is a contra-indication for methylene blue?

A: COPD exacerbation

B: Sickle cell disease

C: G6PD deficiency

D: Gilbert’s syndrome

The correct answer is C

EMdocs covered methemoglobinemia this week.

Methylene blue is the mainstay of methemoglobinemia treatment. However, by itself methylene blue can cause hemolysis, but the combination of G6PD and methylene blue makes severe hemolysis very likely to occur. Furthermore, it seems methylene blue is not as effective in patients with G6PD deficiency.

EM@3AM: Methemoglobinemia

Source image: www.emottowablog.com

Question 5

Diagnosis of pulmonary embolism (PE) is often challenging. Classic Wells score and D-dimer stretegy probably leads to too many CT-scans. Quite a few risk based diagnostic strategies for diagnosis of PE have been suggested and validated so far, leading to less scanning with acceptable sensitivity.

Which of the following diagnostic strategies lead to the lowest imaging rate while maintaining high sensitivity for PE according to available evidence?

A: Classic Wells score strategy

B: YEARS algorithm strategy (link)

C: Adjusted d-dimer based on Wells score (threshold of 1000 vs 500 vs direct CT, the 2019 PEGed paper) strategy

D: Age adjusted d-dimer strategy (link)

The correct answer is C

EMOttawa covered diagnostic strategies in suspected pulmonary embolism.

In the 2019 PEGeD paper, about 2000 patients with suspected PE were divided into three groups based on the Wells score. Patients were deemed low risk (d-dimer cutoff 1000) if the Wells score was 4 or lower, moderate risk (d-dimer cutoff 500) if the Wells score was higher than 4 and lower than 6,5, or high risk (direct imaging) if the Wells score was 6,5 or higher. The vast majority of patients were low risk and no venous thrombo-embolisms were missed.

The standard Wells strategy leads to a 51.9% imaging rate, the Age-adjusted strategy to 42.9%, the YEARS strategy to 36.3% and the PEDeg strategy to 34.3%.

The D-Dimer Dilemma: It’s Use In Low-Risk PE

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This quiz was written by Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 91, November 20th, 2020

Welcome to the 91th FOAMed Quiz. 

Nicole, Joep and Rick

Source image: www.first10em.com

Question 1

Idiopathic Intracranial Hypertension (IIH) is reguraly missed diagnosis with potentially devastating consequences.

Headache is the main symptom and papilledema is common. Patients can present with abducens nerve palsy, pulsatile tinnitus, dizziness, neck or back pain and confusion.

Which of the following patients is most at risk for IIH?

A: A 22 year old female with a body mass index (BMI) of 36

B: A 63 year old female with a BMI of 31

C: A 22 year old female with a BMI of 22

D: A 45 year old male with a BMI of 40

The correct answer is A

First10EM covered IHH this week.

The diagnosis of IIH is a tricky one. The headache is often nonspecific and can be confused with migraine.

Always keep this diagnosis in your mind when treating a female of childbearing age who is overweight.

Idiopathic Intracranial Hypertension: a rapid review

Source image: www.emottowablog.com

Question 2

The role of viscoelastic hemostatic assays (VHA) like TEG and ROTEM in trauma patients is not supported by a lot of evidence so far.

In this recently published study, trauma patients with activated major haemorrhage protocols were randomised to either VHA or Conventional Coagulation Tests (CCT) guided therapy.

The primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of ongoing massive transfusion.

What did the authors find?

A: VHA guided therapy resulted in a increase in patients alive and free of massive transfusion at 24 hours after injury compared to CCT guided therapy

B: CCT guided therapy resulted in a decrease in patients alive and free of massive transfusion at 24 hours after injury compared to VHA guided therapy

C: There was no difference between the two groups in number of patients alive and free of massive transfusion at 24 hours after injury

The correct answer is C

EMOttawa covered this paper last week.

There was no difference in patients alive and free of massive transfusion at 24 hours after injury between VHA- and CCT-augmented-major haemorrhage protocols (64 versus 67 percent). This may be due to the lower than expected rate of coagulopathy and therefore the study may have been underpowered.

There was a reduction in 28-day mortality in the VHA group in patients who also had severe TBI. However, this is probably a chance finding.

Source image: www.atsu.edu

Question 3

Which of the following bacteria is the most likely causative organism of menstrual toxic shock syndrome due to colonisation of tampons?

A: Streptococcus pyogenus

B: Staphylococcus aureus

C: Enterococcus faecium

D: Pseudomonas aeruginosa

The correct answer is B

Toxic Shock Syndrome (TSS) is covered on the Internet Book of Critical Care this week.

Toxic shock syndrome can either be caused by Streptococci of Staphylococci. The bacteria found to be the causative organism in menstrual related TTS is Staphylococcus aureus.

Question 4

In which of the following situations is administration of sodium bicarbonate most likely to be beneficial to the patient?

A: A patient with diabetic ketoacidosis (DKA) and a pH of 7.05

B: A patient with renal failure and a pH of 7.15

C: A patient with lactic acidosis and a pH of 7.10

D: A patient with Hyperchloremic Metabolic Acidosis and a pH of 7.31

The correct answer is B

NUEM covered sodium bicarbonate and the recently published BICAR-ICU trial last week.

In patients with DKA, please do not administer sodium bicarbonate unless the pH is well under 7.00. In lactic acidosis it seems sodium bicarbonate is not beneficial.

Patients with uremic acidosis are likely to benefit from sodium bicarbonate to cope with the inability of the kidney to excrete anions.

Patients with hyperchloremic acidosis might benefit from sodium bicarbonate, but not if the acidosis is very mild like in this case.

Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9644

Question 5

The discussion about antibiotics versus surgical management of appendicitis has been around for some years now.

Recently the CODA trial was published. The CODA trial is an RCT comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis. The primary outcome was 30-day health status (by questionnaire). Patients with signs of severe disease were excluded.

What did the authors find?

A: Antibiotics were inferior to appendectomy on the basis of results of a standard health-status measure

B: Antibiotics were superior to appendectomy on the basis of results of a standard health-status measure

C: Antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure

The correct answer is C

RebelEM covered this paper last week.

1552 adults underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy. Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores.

However, in the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Only 30% of eligible patients agreed to undergo randomization.This data was only from the first 90 days after randomisation, so long term adverse effects may be missed.

Interestingly, perforation was more common in the antibiotics group compared to the appendectomy group (32% vs 16%) when the analysis was limited to participants in either group who had undergone appendectomy. This difference was only seen in patients with an appendicolith (61% vs 24%).

REBEL Cast Ep 89: The CODA Trial – Antibiotics vs Appendectomy for Appendicitis

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This quiz was written by Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 90, November 12th, 2020

Welcome to the 90th FOAMed Quiz. 

Nicole, Joep and Rick

Source image: www.rebelem.com

Question 1

The effectiveness of sodium bicarbonate (SB) on mortality in patients with cardiac arrest is widely debated. The ACLS and ALS guidelines state that routine use of SB is not recommended.

This recently published systematic review compared intravenous SB administration in cardiac arrest to no intravenous SB administration in cardiac resuscitation. Their primary outcomes were return of spontaneous circulation (ROSC) and survival to discharge.

What did the authors find?

A: Use of Sodium Bicarbonate in cardiac arrest was associated with increased ROSC and survival to discharge compared to no use of Sodium Bicarbonate

B: Use of Sodium Bicarbonate in cardiac arrest was not associated with increased or decreased ROSC and survival to discharge compared to no use of Sodium Bicarbonate

C: Use of Sodium Bicarbonate in cardiac arrest was associated with decreased ROSC and survival to discharge compared to no use of Sodium Bicarbonate

The correct answer is B

Muhammad Durrani covered this systematic review on the effectiveness of Sodium Bicarbonate administration on mortality in cardiac arrest patients this week on REBEL EM.

Six observational studies were included. Administration of Sodium Bicarbonate was not associated with increase or decrease in ROSC or survival to discharge in cardiac resuscitation, in line with current ACLS guidelines.

These findings need to be interpreted cautiously due to the small amount of included studies, poor statistical quality with high heterogeneity and risk of bias and confounders.

Effectiveness of Sodium Bicarbonate Administration on Mortality in Cardiac Arrest Patients: A Systematic Review and Meta-Analysis

Source image: www.pixabay.com

Question 2

Lung-protective ventilation proved to be beneficial in the ICU, especially in acute respiratory distress syndrome (ARDS). Invasive mechanical ventilation will often be started in the ED. This recently published paper is about the association between the use of lung-protective ventilation in the ED and outcomes among invasively patients. Lung-protective ventilation was defined by use of tidal volumes ≤ 8 mL/kg predicted body weight.

What did the investigators find about lung-protective ventilation in the ED?

A: Lung-protective ventilation in the ED is associated with lower hospital mortality and better overall outcomes

B: Lung-protective ventilation in the ED is associated with lower hospital mortality but overall outcomes did not improve

C: Lung-protective ventilation in the ED is associated with better overall outcomes but did not improve mortality rates

D: Lung-protective ventilation in the ED did not improve mortality and overall outcomes are the same for invasive ventilation

The correct answer is A

Clay Smith covered Low Tidal Volume in the ED in this weeks Spoon Feed

The authors of this retrospective study included 4.174 patients of which 58.4% received lung-protective ventilation in the ED. The use of lung-protective ventilation was associated with decreased odds of hospital death (adjusted odds ratio: 0.91 [95% CI] 0.84-0.96) compared to patients who received higher tidal volumes. There was a decreased incidence of ARDS, lower hospital length of stay, and decreased total costs.

Source image: www.ultrasoundgel.org

Question 3

Your
 75 year old patient presents with left lower quadrant abdominal pain for 2 days. Vital signs are normal. The labs show leukocytosis and elevated CRP. You suspect diverticulitis and you wonder whether Point Of Care UltraSound (POCUS) could help you in your workup.

This recently published paper is about POCUS in diverticulitis. What was the sensitivity of POCUS for diverticulitis according to this paper?

A: 62%

B: 72%

C: 82%

D: 92%

The correct answer is D

This recently published paper was covered on the Ultrasound Podcast last week.

The researchers included 452 patients. 36% had a diagnosis of diverticulitis based on CT scan. Of the 452 patients, there were 13 false-positive (3%) and 10 false-negative (2%) point-of-care ultrasonographic examinations leading to a stunning sensitivity of 92% and specificity of 97%.

Keep in mind these ultrasound exams were performed by experienced ultrasonographers and this was a single centre study.

It almost sounds too good to be true and I wonder whether these results will be reproducible.

Source image: radiopaedia.org/

Question 4

What is the name of the fracture shown above?

A: Bennett’s fracture

B: Rolando’s fracture

C: Epibasal fracture of the thumb

The correct answer is A

BrownEM covered minor hand injury last week.

Bennett’s fracture is an intra-articular fracture of the base of the thumb generally and consists of two parts.

Rolando’s fracture is a comminuted version of Bennett’s and usually consists of 3 parts.

An epibasal fracture is, like a Bennett’s fracture, a two parts fracture of the base of metacarpal 1, but runs extra-articular.

Question 5

Source image: emergencymedicinecases.com/


You review an ECG without knowing the clinical context. The tall R-wave in V1 puzzles you and you decide to look into it.

Which of the following entities is NOT a cause of a tall R-wave in V1?

A: Posterior MI

B: Arrhythmogenic right ventricular dysplasia (ARVD)

C: Pulmonary Embolism

D: Dextrocardin

The correct answer is B

EM cases covered the causes of a tall R-wave in V1 this week.

The differential for tall R-wave in V1 can be remembered by the mnemonic R-WAVED.
RBBB
WPW left sided pathway
Acute MI – posterior
Ventricular hypertrophy or HCM
Embolism, pulmonary
Dextrocardia

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This quiz was written by Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 89, November 6th, 2020

Welcome to the 89th FOAMed Quiz. 

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Your 34 year old patient comes in with agitation with an unknown cause. He shows profound tachypnoea and tachycardia with a capillary refill time of <2 seconds. His blood pressure cannot be measured because of severe agitation. His GCS is E4V3M5 and his glucose is normal. He has hyperthermia (38,8 degrees Celsius) and is diaphoretic.

It is impossible to get an IV in and you decide to sedate your patient using IM medication.

Which of the following drugs is most effective for acute undifferentiated agitation in the emergency department according to this recently published paper?

A: Droperidol

B: Ziprasidone

C: Lorazepam

The correct answer is A

This recently published paper was covered on JournalFeed last week.

115 patients were enrolled. Adequate sedation at 15 minutes was the primary outcome. Droperidol 5 mg was effective in 64% of patients, compared to 25% for ziprasidone 10 mg, 35% for ziprasidone 20 mg and 29% for lorazepam 2 mg. Numerically, respiratory depression was lower with droperidol compared to ziprasidone and lorazepam. QTc durations were similar in all groups.

It looks like another win for droperidol, although I would like to see how it holds up against IM ketamine.

Source image: www.pixabay.com

Question 2

I am aerobic and facultatively anaerobic and I am a gram-positive rod. I am naturally occurring in soil, water, and flora. I live in unpasteurized milk, soft cheeses, deli meats, and smoked seafood. I generally only cause gastro-intestinal symptoms in healthy adults, but if I find a way to get neuro-invasive I cause a nasty meningitis and occasionally a focal encephalitis involving the brainstem and/or cerebellum called rhombo-encephalitis.

Which of the following causative organisms of meningitis am I?

A: Streptococcus pneumoniae

B: Haemophilus influenzae type b (Hib)

C: Neisseria meningitidis

D: Listeria monocytogenes

The correct answer is D

Taming the SRU covered neurolisteriosis this week.

Well, the only gram negative rod in this list is Listeria monocytogenes.

While L. monocytogenes accounts for only four percent of bacterial meningitis cases in patients aged two to 60, it is responsible for 25% of cases in patients younger than two and older than sixty years.

Question 3

Your patient comes in after an intoxication with unknown prescription drugs. She has hypotension and an altered mental status.

Which of the following intoxications is most likely to cause the abnormalities on the ECG shown above?

A: Amitriptyline intoxication

B: Gabapentin intoxication

C: Metoprolol intoxication

D: Diltiazem intoxication

The correct answer is A

Tricyclic antidepressant (TCA) intoxication was covered last week in the Annals of B-pod, the Fall issue.

This issue contains case-reports about paracetamol intoxication, mandibular dislocation, lightning injuries and subclavian steal syndrome as well.

The ECG shows signs of sodium channel blockade as seen in TCA intoxication. These include a wide QRS, right axis deviation of the terminal QRS and a terminal R wave > 3 mm in aVR.

Gabapentin does not cause specific ECG abnormalities.

Metoprolol and diltiazem will cause bradycardia and AV-block, which are not present in ths case.

Source image: https://emergencymedicinecases.com/

Question 4

Your 38 year old female patient is brought in by prehospital services with a seizure. First line medication was not effective and the seizure persists beyond 10 minutes.

Which of the following is true about the treatment of status epilepticus?

A: Administration of benzodiazepines within the first 5 minutes of the seizure is clearly harmful because most seizures terminate by themselves within a short timeframe

B: Seizures caused by tricyclic antidepressants (TCA’s) should be treated with phenytoin

C: Phenytoin causes less cardiovascular side effects compared to fosphenytoin

D: The use of ketamine in addition to propofol as third line agent may have synergistic effect through modulating GABA and NMDA receptors

The correct answer is D

This week EM Docs covered the Management of Status Epilepticus.

Most guidelines still advocate waiting 5 minutes to administer the first dose of benzodiazepines. Although it is true seizures are generally self-terminating, 5 minutes is quite a long time to wait and although benzodiazepines are not harmless, the effects of ongoing seizures are not benign either. It seems logical not to wait 5 minutes to administer the first dose of benzodiazepines, but this is not supported by evidence so far.

TCA’s cause sodium blockade and so does phenytoin, so administration of phenytoin in a TCA intoxication bound to cause cardiovascular problems.

Fosphenytoin causes less cardiovascular side effects compared to phenytoin.

Use of ketamine in addition to propofol as a third line agent may have synergistic effect through modulating GABA and NMDA receptors. Although not supported by evidence so far.

Question 5

Your 43 year old patient presents with ‘’the worst headache ever”. You suspect her of having a subarachnoid hemorrhage (SAH). She denies loss of consciousness and vomiting. The physical  exam does not reveal neck stiffness. Since her headache started less than 6 hours ago, you urgently order a CT of the brain. In the meantime you wonder which symptom is most commonly present in patients with SAH.

Put the following symptoms of SAH in order of occurrence in patients with SAH starting with the least common and finishing with the most common:

A: Vomiting, loss of consciousness, thunderclap headache, worst headache of life, neck stiffness

B: Loss of consciousness, vomiting, neck stiffness, thunderclap headache, worst headache of life

C: Neck stiffness, vomiting, thunderclap headache, loss of consciousness, worst headache of life

D: Thunderclap headache, loss of consciousness, neck stiffness, worst headache of life, vomiting

The correct answer is B

EMOttawa covered subarachnoid hemorrhage last week.

The correct order of symptoms of SAH in order of occurrence is:

Loss of consciousness – 13%
Vomiting – 62%
Neck stiffness – 74%
Thunderclap headache – 83%
Worst headache of life – 95%

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

Reviewed and edited by Rick Thissen

Quiz 87, October 23th, 2020

Welcome to the 87th FOAMed Quiz. 

We’re back after a small break, enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Source image: coreem.net

A healthy 15 month old boy presents to your ED after suspicion of swallowing a button battery. The parents saw the boy playing with the remote control which he opened. The battery was nowhere to be found and parents think he may have swallowed the battery.

Which of the following statements is true about battery-related injuries?

A: Damage occurs hours after ingestion and not directly

B: For damage control until removal, no therapies are indicated

C: Complications after removal can present late (even after more than 9 days)

D: After removal of the battery no following therapy is necessary

The correct answer is C

This week Sean Fox covered Button Batteries in the Esophagus on PedEM Morsels.

Tissue damage is due to isothermal hydrolysis reaction and alkaline caustic exposure. When placed in a moist environment an electrical charge is generated. This electrical charge hydrolyses water generating hydroxide ions, which are leading to alkaline injury.

Tissue damage starts even within 2 hours. Damage continues after removing the battery and complications can present after 9 days up to even weeks later.

Removing the battery is imperative. Honey (children > 1 year) or sucralfate may reduce the severity of esophageal burns and improve patient outcomes. After removal a weak acid can reduce continued liquefaction necrosis.

Neutralize Button Battery in the Esophagus

Souce image: www.pixabay.com

Question 2

As the COVID pandemic reaches a second peak in our country, more data emerges on treatment options. Lopinavir – Ritonavir (Kaletra) has been regarded as a potentially useful drug, although evidence available so far does not show any benefit.

The RECOVERY trial is an overarching trial design that looks at different treatment options simultaneously. This paper is about the Lopinavir-Ritonavir (Kaletra) arm of the RECOVERY trial.

What does the trial show about the efficacy of Lopinavir-Ritonavir?

A: Lopinavir-Ritonavir reduced mortality at day 28

B: Lopinavir-Ritonavir reduced time to hospital discharge at day 28

C: Lopinavir-Ritonavir reduced progression to receipt of mechanical ventilation

D: Lopinavir-Ritonavir did not show any benefit 

The correct answer is D

The Lopinavir – Ritonavir arm of the RECOVERY trial was discussed at The Bottom Line last week.

1616 COVID patients admitted to hospital received Lopinavir-Ritonavir and 3424 patients were allocated usual care. Only 4% of the patients included were invasively mechanically ventilated.

Time to hospital discharge (median 11 days vs. 11 days), progression to receipt of mechanical ventilation (10% vs. 9%) and mortality at day 28 (22% vs. 22%) did not show any difference. 

RECOVERY: COVID-19 Kaletra

Source image: ww.pixabay.com

Question 3

A 16-year old male presents to your ED after ´twisting his right ankle’ on the football pitch. He cannot bear weight, but the ankle does not appear swollen. An X-ray is made (lateral view not shown here).

Source image: dontforgetthebubbles.com

Which of the following is the most likely diagnosis?

A: Tillaux fracture

B: Triplane fracture

Don’t Forget The Bubbles covered Tillaux fractures last week.

Both Tillaux fractures and Triplane fractures are considered transitional fractures, which occur in patients with partially closed growth plates.

In case of a Tillaux fracture, an avulsion of the distal tibia epiphysis by the tibiofibular ligament.

In case of a Triplane fracture, in addition to a epiphyseal fracture similar to the Tillaux fracture, the physis is separated in the axial plane and the metaphysis is fractured on the posterior aspect in the coronal plane.

Both fractures are caused by supination and external rotation of the foot. Patient with a Tillaux (average age is fracture tend to be a little older than patients with a triplane fracture (average age is 13 years).

The lack of a fracture through the coronal plane distinguishes this injury from that of a triplane fracture.

https://dontforgetthebubbles.com/tillaux-fractures/ 

Question 4

Source image: litfl.com

A 46-year old female patient presents to your emergency department with severe chest pain. She does not have a medical history, does not smoke and also never experienced this pain before.

Her ECG shows an anterior OMI while her troponines are not (yet) elevated. The cardiologist takes her to the cath lab and performs a coronary angiography which shows a spontaneous coronary arterial dissection (SCAD) of the left anterior descending (LAD) coronary artery.

Which of the following statements about SCAD is true?

A: Male gender is a known risk factor

B: Cardiac enzymes are rarely elevated

C: The left coronary artery (LAD) is most commonly affected

D: Treatment always includes PCI or CABG

The correct answer is C

Muhammad Durrani covered SCAD on REBELEM this week.

SCAD is defined as a non-traumatic and non-iatrogenic tear in the coronary arterial wall. It accounts for approximately 1-4% of ACS cases overall.

Women, especially <50 years old, are at highest risk. The diagnosis is difficult to make and patients may mistakenly be discharged due to their relatively young age and lack of cardiovascular risk factors. Cardiac enzymes are frequently elevated and the most commonly affected vessel is the LAD, followed by the left circumflex artery and RCA.

A conservative approach is recommended unless there is ongoing ischemia, hemodynamic instability, or left main dissection might need PCI or CABG.

Spontaneous Coronary Artery Dissection (SCAD)

Source image: www.emdocs.net

Question 5

Puncture wounds can be associated with complications such as soft tissue infections and deep abscesses.

Which of the following statements is true about puncture wounds?

A: Puncture wounds through a rubber sole have increased risk of pseudomonas infection and therefore osteomyelitis

B: The risk of an infection in puncture wounds is about 50% and 20% of these patients will develop osteomyelitis

C: Ultrasound has a low specificity and sensitivity for the detection of foreign bodies

The correct answer is A

EMDocs covered puncture wounds this week.

Pseudomonas infections are commonly seen when puncture injury occurs through rubber soles. Infection with Pseudomonas is the most common cause of osteomyelitis. In approximately 10% of the puncture wounds an infection is seen and 1-2% of patients will develop osteomyelitis.

Ultrasound can be used for the detection of foreign bodies and has a sensitivity of 87% and specificity of 97%. A benign course is seen in the majority of the puncture wounds if a foreign body is not retained. 

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

Reviewed and edited by Rick Thissen