Quiz 185, March 31, 2023

Welcome to the 185th FOAMed Quiz.

Question 1

The timing of cardiac catheterisation in patients with return of spontaneous circulation (ROSC) after out of hospital cardiac arrest (OHCA) in the absence of ischemic changes on the ECG remains subject of debate.

In the EMERGE trial, 279 patients with ROSC after OHCA without clear evidence of cardiac ischemia on ECG and without any obvious cause of their cardiac arrest were randomized to either delayed (performed after 48-96 hour) (n=138) or emergent CAG (n=141).

The primary outcome was 180-day survival rate with Cerebral Performance Category (CPC) < 2 (independent activities of daily life).

What did the authors find?

A: Patients in the early CAG group had higher 180-day survival with good neurologic outcome compared to patients in the emergent CAG group

B: Patients in the delayed CAG group had higher 180-day survival with good neurologic outcome compared to patients in the emergent CAG group

C: There was no difference between the groups

Reveal answer

The correct answer is C.

The EMERGE trial was covered on RebelEM last week.

The mean time delay between randomization and CAG was 0.6 hours in the emergent CAG group and 55.1 hours in the delayed CAG group. The 180-day survival rates among patients with a CPC of 2 or less were 34.1% (47 of 141) in the emergency CAG group and 30.7% (42 of 138) in the delayed CAG group (P = .32).

Keep in mind that the study was stopped early due to insufficient enrollment. Investigators enrolled approximately 280 patients out of 970 planned.

The EMERGE Trial: Emergency vs Delayed Catheterization in Survivors of Out-of-Hospital Cardiac Arrest

Question 2

Combine the incomplete spinal cord injury types with the correct set of symptoms.

1: Brown-Sequard syndrome

2: Central cord syndrome

3: Anterior cord syndrome

A: Disproportionately greater motor impairment in upper compared with lower extremities, bladder dysfunction, and a variable degree of sensory loss below the level of injury

B: Motor paralysis below the level of the lesion as well as the loss of pain and temperature at and below the level of the lesion

C: Loss of motor function, loss of vibration sense and fine touch, loss of proprioception and signs of weakness on the ipsilateral side and loss of pain and temperature sensation and crude touch 1 or 2 segments below the level of the lesion on the contralateral side

Reveal answer

The correct answer is 1C, 2A, 3B

Spinal fractures were covered on Geekymedics last week.

The dorsal columns travel in the posterior section of the spinal cord and carry information about fine touch. The fibers remain ipsilateral and do not decussate until they reach the medulla of the brainstem.

The spinothalamic tracts travel in the anterior part of the spinal cord and carry information regarding pain and temperature. The fibers decussate as soon as they enter the spinal cord and ascend contralaterally.

The corticospinal tract carries motor information from the motor centers of the frontal lobe down to the skeletal muscles. The fibers descend contralaterally.

Spinal Fractures

Question 3

What is not a name for the fracture in the picture below?

A: The tripod fracture

B: Zygomaticomaxillary complex fracture

C: Malar fracture

D: Lateral triangular fracture

Reveal answer

The correct answer is D.

The trauma pro covered the tripod fracture this week; also known as zygomaticomaxillary complex fracture or malar fracture. Fundamentally, the zygoma is separated from the rest of the face. There are, as the name suggests, three components of this fracture. The zygomatic arch, the floor of the orbit (and includes the maxillary sinus) and the lateral orbital rim and wall.

What Is: The Tripod Fracture?

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

March 2, 2023March 3, 2023

Quiz 182, March 3rd, 2023

Welcome to the 182th FOAMed Quiz.

Question 1

Major joint dislocations are a common problem in the emergency room and shoulder dislocations account for 50 percent of them. Most often we use analgesia before reduction, varying from procedural sedation and analgesia (PSA), intra-articular injection to nerve blocks.

In this systematic review and meta-analysis (based on 12 RCT’s, n = 630) the authors compared intravenous sedation (IV sedation, n total = 303) with intra-articular lidocaine (IAL, n total = 327) for dislocation reduction.

What did the authors find concerning the rate of successful reduction?

A: There was no significant difference in rate of successful reduction.

B: The rate of successful reduction was significantly higher in the IAL group compared to the IV sedation group.

C: The rate of successful reduction was significantly higher in the IV sedation group compared to the IAL group.

Reveal answer

The correct answer is A.

The paper was covered by CanadiEM last week.

The successful reduction rate was 83.8% in the IAL group and 91.4% in the IV sedation group (RR 0.93, CI 0.86-1.01). There was also no difference in pain scores or ease of reduction.

However, patient satisfaction was significantly greater in the IV sedation group with decreased procedural time, suggesting the benefit of this approach in resource-appropriate settings.

Also, most of the included studies used a combination of opioids and a benzodiazepine as ‘’IV sedation’’ which is definitely not my go to choice of drugs.

CJEM Visual Abstract: Intra-articular lidocaine versus intravenous sedation for closed reduction of acute shoulder dislocation

Question 2

The use of sodium bicarbonate in cardiac arrest remains controversial and routine use is not advised in current guidelines.

In this recently published cohort study, 1100 children with in hospital cardiac arrest (IHCA) were analyzed. 528 (48.0%) received sodium bicarbonate during CPR.

The primary outcome was survival to hospital discharge.

What did the authors find?

A: Sodium bicarbonate use was associated with lower rates of survival to hospital discharge

B: Sodium bicarbonate use was associated with higher rates of survival to hospital discharge

C: Sodium bicarbonate use was not associated with lower or higher rates of survival to hospital discharge

Reveal answer

The correct answer is A.

The SGEM covered the paper last week.

Survival to hospital discharge was 42.2% in patients who received sodium bicarbonate and 73.3% in patients who did not receive sodium bicarbonate (aOR 0.7, 95% CI; 0.54-0.92).

Sodium bicarbonate use was also associated with lower survival to hospital discharge with favorable neurologic outcome rate .

SGEM#394: Say Bye Bye Bicarb for Pediatric In-Hospital Cardiac Arrest

Question 3

Source image: www.ucsfbenioffchildrens.org

Your patient has a two lead pacemaker which is set to DDD mode. What does the third D stand for?

A: Paces both atrium and ventricle

B: Senses both atrium and ventricle

C: Dual trigger of both atria and ventricular pacing in response to absence of intrinsic ventricular depolarization

D: Dual inhibition of both atria and ventricular pacing in response to intrinsic ventricular depolarization

Reveal answer

The correct answer is D.

The first letter reveals which chamber gets paced. The second letter means which chamber is sensed and the third letter gives away the sensing response. That is, what the pacemaker does in response to a sensed intrinsic electrical activity. This can be triggered, inhibited, dual or none.

Question 4

Methylene blue is widely prescribed as treatment for methemoglobinemia.

For which purpose is methylene blue also used?

A: CO intoxication

B: Refractory vasoplegic shock

C: Haemochromatosis

Reveal answer

The correct answer is B

Methylene blue as an off-label treatment in refractory vasoplegic shock was covered by ALiEM.

By inhibiting the NO/cGMP pathway, the systemic vascular resistance increases. It can function as a vasopressor in patients with shock.

ACMT Toxicology Visual Pearl: Is the Silver Bullet for Refractory Vasoplegia Really Blue?

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

February 23, 2023February 24, 2023

Quiz 181, February 24th, 2023

Welcome to the 181th FOAMed Quiz.

Question 1

What is the most common risk factor for malignant otitis externa?

A: Immunosuppression

B: Age

C: Diabetes mellitus

D: Smoking

E: HIV

Reveal answer

The correct answer is C.

EmDOCs Podcast covered this week malignant otitis externa (MOE).

MOE is a severe and progressive infection of the external auditory canal. The most common risk factor is DM, with an estimated 90% of patients with MOE having DM. It is thought to predispose due to microangiopathy, impaired wound healing and increased pH in diabetic cerumen.

Immunosuppression, including HIV, is another risk factor.

The disease is rare in children and mostly seen at age >65 years.

Question 2

In glaucoma, several different types of eye drops are used for lowering intraocular pressure (IOP). Link the correct medicine and mechanism of action:

A: Timolol

B: Latanoprost

C: Pilocarpine

D: Acetazolamide

1: Reduces production of aqueous humor via decreasing cAMP concentration in the ciliary body

2: Reduces production of aqueous humor via decreasing bicarbonate concentration

3: Causes the iris to contract

4: Increases drainage of aqueous humor

Reveal answer

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

This week’s REBEL Core Cast was about acute vision loss (including acute glaucoma and giant cell arteritis).

Acute glaucoma causes vision loss by damaging the optic nerve via high IOP. Open angle glaucoma is the most common form of glaucoma and is usually unnoticed until late in disease vision loss occurs. Closed angle glaucoma gives a painful vision loss, halos, nausea and vomiting. First-line therapy is beta-blockade (timolol).

REBEL Core Cast 96.0 – Acute Vision Loss I

Question 3

The effect of specialist consultation in the ED remains subject of debate.

In this recently published Canadian paper 829 patients in 11 ED sites with recent-onset uncomplicated atrial fibrillation or flutter were analyzed. Uncomplicated atrial fibrillation was defined as asymptomatic after rate or rhythm control. 364 (44%) of patients had specialist consultation.

What effect did specialist consultation in the ED have?

A: The ED length of stay was longer but patients had less ED revisits within 30 days

B: The ED length of stay was longer and patients had equal ED revisits within 30 days

C: The ED length of stay was shorter and patients had less ED revisits within 30 days

D: The ED length of stay was shorter but patients had more ED revisits within 30 days

Reveal answer

The correct answer is B.

The paper was covered on CanadiEM last week.

After propensity-matching, specialist-consulted patients had a 0.6% lower risk of 30-day revisits than non-consulted patients. Median length of stay was 591 minutes for consulted patients and 300 minutes for patients without consultation. This means ED length of stay was almost double in specialist-consulted patients.

CJEM Visual Abstract: Effect of specialist consultation on emergency department revisits with uncomplicated recent-onset atrial fibrillation or flutter

Question 4

Oral anticoagulation, particularly warfarin, is associated with an increased risk of intracranial hemorrhage after head trauma. However, available data on delayed bleeds in anticoagulated patients are limited.

In this recently published observational study 69.321 patients with an emergency visit because of minor head injury (so without intracranial hemorrhage) were included. 58.233 (84.0%) patients were not on oral anticoagulation, 3081 (4.4%) had a warfarin prescription, and 8007 (11.6%) had a direct oral anticoagulant (DOAC) prescription.

The primary outcome was delayed intracranial hemorrhage, defined as a new intracranial hemorrhage within 90 days of the initial ED visit for a head injury where no intracranial hemorrhage was diagnosed.

What did the authors find?

A: Both patients on DOAC and patients on warfarin had a higher chance of delayed intracranial hemorrhage compared to patients that were not on anticoagulation

B: Only patients on DOAC had a higher chance of delayed intracranial hemorrhage compared to patients that were not on anticoagulation

C: Only patients on warfarin had a higher chance of delayed intracranial hemorrhage compared to patients that were not on anticoagulation

D: Neither patients on DOAC nor patients on warfarin had a higher chance of delayed intracranial hemorrhage compared to patients that were not on anticoagulation

Reveal answer

The correct answer is C.

The paper was covered in UMEM last week.

Overall, 718 (1.0%) patients had a delayed intracranial hemorrhage within 90 days of ED visit for head injury. Among patients that did not receive anticoagulation, 586 (1.0%) had delayed intracranial hemorrhage, 54 (1.8%) of the patients on warfarin had delayed intracranial hemorrhage, and 78 (1.0%) patients on a direct oral anticoagulant had delayed intracranial hemorrhage.

Question 5

Which of the following antibiotics should be administered in patients with (suspected) Toxic Shock Syndrome (TSS) in order to suppress toxin production.

A: A third generation cephalosporin

B: Gentamicin

C: Penicillin G (Benzylpenicillin)

D: Clindamycin

Reveal answer

The correct answer is D.

Toxic Shock Syndrome was covered in DFTB last week.

TSS is caused by either toxin production by Staphylococcus aureus or Group A Streptococci (GAS).

Clindamycin is added based on the ability of this drug to suppress synthesis of bacterial toxins. Since it is merely bacteriostatic and not bactericidal it should never be used as monotherapy for TSS, but always as an adjunct to a bactericidal antibiotic.

Toxic shock syndrome

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

February 17, 2023February 17, 2023

Quiz 180, February 17th, 2023

Welcome to the 180th FOAMed Quiz.

Question 1

A patient presents with anisocoria to your ED. She has a “down and out” appearance of the eye, ptosis and mydriasis of her right eye. When turning the light off, her right pupil fails to constrict. There are no other neurological abnormalities found in physical examination.

What is the most likely cause of this patient’s anisocoria?

A: Cranial nerve III palsy

B: Horner syndrome

C: Adie pupil

D: Anticholinergic drugs

Reveal answer

The correct answer is A.

Anisocoria was discussed by EMdocs this week.

Horner syndrome is caused by compression of the oculomotor sympathetic pathway somewhere along its course. It causes ptosis and miosis instead of mydriasis and it will not cause extraocular movement disorders.

An Adie pupil arises from the parasympathetic denervation of the constrictor muscle, causing mydriasis, but no ptosis or extraocular movement disorders.

An anticholinergic toxidrome will cause bilateral mydriasis.

Anisocoria in the ED: Pathophysiology, Evaluation, and Management

Question 2

To what stage of syphilis belong nephrotic syndrome and isolated cranial nerve dysfunction?

A: First stage

B: Second stage

C: Third stage

Reveal answer

The correct answer is B.

Syphilis was covered on DFTB last week.

The first stage includes a chancre also known as ulcus durum.

The second stage includes skin and mucosa lesions such as condylomata lata, hepatitis, nephrotic syndrome and cranial nerve damage.

The third stage includes neurosyphilis (tabes dorsalis, dementia paralytica) or heart problems, such as aneurysms or coronary arteritis.

Syphilis

Question 3

Which of the following microorganisms is a known common trigger of Stephens-Johnson syndrome?

A: Legionella pneumoniae

B: Chlamydia pneumoniae

C: Mycoplasma pneumoniae

Reveal answer

The correct answer is C.

Stephens-Johnson syndrome was covered in EMDocs last week.

A wide variation of Infections can cause Stephens-Johnson syndrome. Mycoplasma pneumoniae infections are the next most common infectious trigger.

EM@3AM: Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Question 4

De Winter T-waves are characterized by upsloping ST segment depression > 1mm at the J point in the precordial leads with tall T waves in the same leads and reciprocal ST segment elevation in aVR. It is a sign of occlusion myocardial infarction.

Which of the following coronary arteries is most likely occluded in case of de Winter’s T-waves?

A: RCA

B: LAD

C: Cx

Reveal answer

The correct answer is B.

A case of de Winter T-wave was covered on Dr. Smith’s ECG blog last week.

The de Winter pattern is seen in about 2% of acute LAD occlusions.

Question 5

Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) is a method of testing the efficiency of blood coagulation. It is used in emergency medicine with increasing frequency. The result of TEG is a reaction curve which shows the elasticity over time when the clot forms and dissolves.

The main parameters of the curve are:
R time: Time to initial clot formation
K time: Time from initial clot formation until reaching 20 mm in amplitude
Alpha angle (α): Angle between the baseline at initial clot formation
Maximum amplitude (MA): Maximum deviation of tracing to baseline
LY30: Amplitude 30 minutes after reaching maximum amplitude

The curve looks as follows:

Whenever the R-time (time to initiation of cot formation) in a bleeding patient is prolonged, what should you do to promote clot formation?

A: Administer platelets

B: Administer cryoprecipitate (or fibrinogen)

C: Administer Fresh Frozen Plasma (FFP) or anticoagulation reversal agents

D: Administer tranexamic acid

Reveal answer

The correct answer is C.

Taming the SRU covered TEG last week.

In case of a prolonged initiation of clot formation (R-time), we should administer FFP of reversal agents if the patient is on anticoagulation.

A prolonged K-time and a decreased alpha angle warrants cryoprecipitate administration.

A reduced maximum amplitude points you in the direction of platelet inactivity.

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

February 10, 2023February 10, 2023

Quiz 179, February 10th, 2023

Welcome to the 179th FOAMed Quiz.

Question 1

A five year old girl who recently started with chemotherapy for acute lymphoblastic leukemia presents at the emergency department with acute kidney injury. Based on laboratory findings you suspect a tumor lysis syndrome.

Which of the following laboratory findings fits this diagnosis?

A: High potassium, high calcium

B: Low potassium, high LDH

C: High calcium, low creatinine

D: High potassium, low calcium

Reveal answer

The correct answer is D.

Tumor lysis syndrome was covered on DFTB last week.

It is defined by massive tumor cell lysis with the release of intracellular molecules, such as potassium, phosphate and uric acid. The phosphate binds to the calcium already in the blood, forming complexes and thus causing hypocalcemia. Tumor lysis syndrome often occurs after initiation of chemotherapy and mostly in patients with high-grade lymphomas, but it can also occur spontaneously and with other fast proliferating tumor types.

Ten oncology emergencies in kids

Question 2

What type of drug use is referred to when your patient talks about “nanging”?

A: Sipping GHB (gamma-hydroxybutyric acid)

B: Smoking crack (cocaine)

C: Inhalation of laughing gas (nitrous oxide)

D: Snorting speed

Reveal answer

The correct answer is C.

Don’t forget the bubbles covered the use and abuse of nitrous oxide.

The use of nitrous oxide to obtain a so-called “safe high” has increased over the past decade. The exact mechanism is poorly understood. Long term use of N2O can cause permanent damage to the nervous system.

Recreational nitrous oxide

Question 3

Can we swap neuromuscular blockers (NMB) for remifentanil in rapid sequence intubation (RSI)?

In this recently published paper, 1150 ED patients undergoing PSI were randomised to receive (next to a sedation) either a neuromuscular blocker (succinylcholine or rocuronium) or remifentanil (3-4mcg/kg). The aim of the study was to prove remifentanil non-inferior to neuromuscular blockers for rapid sequence induction.

The primary outcome was successful tracheal intubation on the first attempt without major complications.

What did the authors find?

A: Remifentanil was indeed non-inferior to neuromuscular blockers in rapid sequence induction

B: Remifentanil was not non-inferior to neuromuscular blockers in rapid sequence induction

C: Remifentanil was superior to neuromuscular blockers in rapid sequence induction

Reveal answer

The correct answer is B.

The paper was covered on St. Emlyns last week.

Tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (95% CI, –11.6% to –0.5%). Remifentanil was not non-inferior to neuromuscular blockers in rapid sequence induction.

This paper was covered by St. Emlyn’s this week. Keep in mind that a non-inferiority paper can never prove the intervention to be superior to a control. That takes a different kind of study approach.

JC: Keep on blocking in the free world. Remi vs. NMB for RSI. St Emlyn’s

Question 4

Abdominal compartment syndrome is defined by an intra abdominal pressure > 20 mm Hg with organ dysfunction.

The standard method for diagnosis is:

A: Intravesical pressure measurement, typically through a Foley catheter

B: CT abdomen

C: Intra and extra abdominal pressure measurement, typically by surgery

D: Point of care ultrasound (POCUS)

Reveal answer

The correct answer is A.

Abdominal compartment syndrome was discussed this week at emDOCs last week.

Measurement of intravesical pressure is the standard method for diagnosis of intra-abdominal hypertension. However, intragastric, intracolonic or inferior vena cava catheters can also be used.

Normal abdominal compartment pressure is 2-5 mmHg. This pressure is higher in critically ill patients, obese patients and pregnancy. Above 5 mm Hg we call it intra abdominal hypertension, at this point there is no organ dysfunction.

emDOCs Podcast – Episode 71: Abdominal Compartment Syndrome

Question 5

Which of the following is most likely the causative microorganism of this patient’s eye problem?

A: Varicella zoster virus

B: Herpes simplex virus 2 (HSV 2)

C: Herpes simplex virus 1 (HSV 1)

Reveal answer

The correct answer is C.

RebelEM covered herpes keratitis last week.

Herpes simplex virus 1 (HSV 1) is almost always the causative agent. HSV 2 is sexually transmitted and rarely causes symptoms of the upper body.

REBEL Core Cast 95.0 – Herpetic Keratitis

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

February 3, 2023February 10, 2023

Quiz 178, February 3, 2023

Welcome to the 178th FOAMed Quiz.

Question 1
Evidence suggests steroids are beneficial for Bell’s Palsy in adults, but in children data is lacking.

In this paper, published august 2022, 187 children with Bells palsy were randomised to treatment with prednisolone (n=93) and to placebo (n=93).

The primary outcome was complete recovery of facial function at 1 month defined by a House-Brackmann score of 1.

What did the authors find?

A: The percentage of children with complete recovery was significantly higher in the group of children receiving prednisolone compared to the placebo group

B: There was no significant difference in percentage of children with complete recovery.

C: The percentage of children with a complete recovery was significantly lower in the group of children receiving prednisolone compared to the placebo group

Reveal answer

The correct answer is B.

The SGEM covered the paper last week.

At 1 month, the proportions of patients who had recovered facial function were 49% (n=43/87) in the prednisolone group compared with 57% (n=50/87) in the placebo group (95% CI -22.8 to 6.7). At 6 months recovery was 99% (n=77/78) in the prednisolone groups and 93% (n=76/82) in the placebo group (CI -0.1 to 12.2).

SGEM#390: I Can’t Feel My Face when I Have Bell Palsy, but will Steroids Help?

Question 2

Which of the following drugs may be added to N-acetylcysteine in the treatment of acetaminophen overdose?

A: Flumazenil

B: Pyridoxine

C: Ethanol

D: Fomepizole

Reveal answer

The correct answer is D.

Fomepizole for Acetaminophen Toxicity was covered on EMDocs last week.

Fomepizole is known for treatment of toxic alcohol poisoning. However, it seems to reduce conversion of acetaminophen to NAPQI and some other things that may help in acetaminophen poisoning.

ToxCard: Fomepizole for Acetaminophen Toxicity

Question 3

A healthy woman is pregnant for the first time. She is known to have an abnormal dystrophin gene which makes her a Duchenne Muscular Dystrophy (DMD) carrier. The sex of the unborn child is not known yet. The father is a healthy man.

What is the chance the child will have DMD?

A: 25%

B: 50%

C: 75%

D: 100%

Reveal answer

The correct answer is A.

DMD was covered on DFTB last week.

DMD is inherited as an X-linked recessive disorder from a mother who carries a mutation. However one-third of cases are due to de novo mutations.

A mother who is a carrier of an X-linked recessive disorder will have a 50 percent chance of passing it on. This means she has a 25% chance of having an affected son and a 25% chance of having a carrier daughter.

Duchenne Muscular Dystrophy

Question 4

Are we still administering too much oxygen to patients after cardiac arrest?

The EXACT trial was published in November 2022. 425 unconscious adults with return of spontaneous circulation after out of hospital cardiac arrest (OHCA) were included in the primary analysis. These patients were randomised by paramedics to receive oxygen titration to achieve an oxygen saturation of either 90% to 94% (intervention; n = 216) or 98% to 100% (standard care; n = 212) until arrival at the intensive care unit.

The primary outcome was survival to hospital discharge.

What did the authors find?

A: Survival to hospital discharge was higher in the low oxygen group compared to the high oxygen group

B: Survival to hospital discharge was lower in the low oxygen group compared to the high oxygen group

C: Survival to hospital discharge was equal between the two groups

Reveal answer

The correct answer is B.

The paper was covered in EMDocs last week.

38.3% of patients in the intervention group survived to hospital discharge compared to 47.9% of patients in the standard care group ([95% CI, -18.9% to -0.2%]; unadjusted odds ratio, 0.68 [95% CI, 0.46-1.00]; P = .05)

Keep in mind the trial was stopped early because of the COVID pandemic. Furthermore, the trial suggests harm of the intervention (less patients survived to hospital discharge and more patients had an hypoxic event). However, the trial was not designed to detect harm, so this is actually a negative trial and this conclusion cannot be drawn with certainty.

52 in 52 – #26: The EXACT Trial

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

January 26, 2023January 28, 2023

Quiz 177, January 26th, 2023

Welcome to the 177th FOAMed Quiz.

Question 1

Your patient comes in with vomiting and a distended, painful abdomen. 3 years ago he had an hemicolectomy because of Crohn’s disease, which has been stable ever since.

You suspect bowel obstruction.

Which of the following findings on POCUS is most sensitive for small bowel obstruction?

A: Fluid filled bowel with extra-luminal free air

B: Bowel wall thickening (> 3 mm)

C: Decreased peristalsis and retrograde peristalsis

D: Dilated loops of small bowel (diameter > 2.5 cm)

Reveal answer

The correct answer is D.

Small bowel obstruction was covered on RebelEM last week.

Dilated loops of small bowel is the most sensitive and specific finding for small bowel obstruction. The other signs mentioned above can be found as well.

A normal lactate or plain X-ray does not rule out the diagnosis. POCUS has a high positive (9.5 (2.1 – 42.2)) and a low negative (0.04 (0.01 – 0.13)) likelyhood ratio.

REBEL Core Cast 94.0 – SBO

Question 2

Your resident mentions your patient has a Insall-Salvati ratio of 1.4 on the X-ray.

What is she talking about?

A: A patient with suspected patellar tendon rupture

B: A patient with suspected achilles tendon rupture

C: A patient with suspected biceps tendon rupture

D: A patient with suspected supraspinatus muscle rupture

Reveal answer

The correct answer is A.

AliEM covered the patellar tendon rupture last week.

The Insall-Salvati ratio or index is the ratio of the patella tendon length to the length of the patella on a 30° flexed lateral knee x-ray and is used to determine patellar height.

SplintER Series: Patellar Tendon Rupture

Question 3

Your patient presents in profound cardiogenic shock and respiratory insufficiency. He does not tolerate non-invasive ventilation and you put him on High Flow Nasal Cannula (HFNC) therapy.

Which of the following statements is true about HFNC in this patient?

A: HFNC will likely decrease his hypercarbia

B: HFNC is less well tolerated than non invasive ventilation

C: HFNC will provide some PEEP

D: HFNC can be administered to a maximum of 100 L/min

Reveal answer

The correct answer is C

Cardiogenic shock was covered on EMDocs last week.

HFNC is a very useful tool in patients with respiratory insufficiency. Although its main goal is to optimize oxygenation by matching inspiratory flow rates and deliver humidified and warm oxygen with an adjustable FiO2, it also decreases hypercarbia slightly by providing a washout effect of the upper airway dead space.

It can deliver some PEEP (some say up to 7 cm H2O) and can provide up to 60 L/min flow.

http://www.emdocs.net/cardiogenic-shock-emergency-department-focused-management/

Question 4

Which of the following medication delivery devices is worst for the environment?

Reveal answer

The correct answer is A. Don’t forget the Bubbles covered inhalers and sustainability last week. The hydrofluorocarbons (HFCs) used in metered dose inhaler (MDIs) are potent greenhouse gasses. ‘’Their effect on climate change is up to 3800 times more potent than carbon dioxide’’.

Inhalers and sustainability

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

January 13, 2023January 13, 2023

Quiz 175, January 13th, 2022

Welcome to the 175th FOAMed Quiz.

Question 1

Which of the following radiographic views is most appropriate for assessment of symmetry in the ankle joint?

A: AP view

B: Mortise view

C: Lateral view

Reveal answer

The correct answer is B.

SinaiEM covered radiography of the ankle last week.

The standard ankle radiographic series consists of the AP, mortise and lateral views. The image is obtained in internal rotation at 15-20 degrees with the foot in slight dorsiflexion. The joint space width should be uniform and should measure about 4 mm.

The Ankle Radiograph

Question 2

Source image: www.medicosisperfectionalis.com

In acid base disturbances, most of us are taught to use the Henderson–Hasselbalch equation (pH = pKₐ + log([A⁻]/[HA])). Although this simplistic approach is sufficient for use in the ED most of the time, it is notoriously imperfect and incomplete.

Another method of analyzing acid-base disturbances uses electroneutrality as a main principle. Anions and cations have to be balanced to maintain electroneutrality. Addition of anions (like chloride) means less other anions (like bicarbonate) are present. Addition of cations (like sodium) means more anions can be present. So, a higher concentration of anions causes acidosis and a higher concentration of cations causes alkalosis.

What is the name of this approach to acid-base disturbances?

A: Liebermeister’s rule

B: Naegele’s rule

C: Coons method

D: Stewart method

Reveal answer

The correct answer is D.

DFTB covered acid-base disturbances and fluid therapy last week.

The approach described above is known as the Stewart method.

Coons fluorescent antibody method is about detection of antibodies by fluorescence microscopy using fluorescein-labeled antibodies.

Liebermeister’s rule says for each fever degree Celsius the cardiac frequency increases 8 beats per minute.

Naegele’s rule is a method of estimating the due date.

Time for a fluid shift?

Question 3

Source image: https://en.rotterdam.info/

Your 40 year old patient who works in a fireworks factory presents with yellowish, necrotic, full‐thickness burns on his hands. You suspect white phosphorus exposure and you start copious irrigation and removal of visible particles.

What is the safest method to make the white phosphorus particles more visible?

A: Add copper sulfate tot the wound

B: Use a Woods lamp

C: Nothing, the particles are so small, you can’t visualize them anyway

Reveal answer

The correct answer is B.

Taming the SRU covered caustic skin injuries last week.

White phosphorus burns can be very severe and even life threatening. It auto-combusts at about 30 degrees Celsius, leading to thermal burns and it causes extensive chemical burns due to it’s lipophilic properties. The wound should be irrigated extensively and visible particles should be removed. Copper sulfate turns white phosphorus black, making it more visible. However, copper sulfate can lead to systemic toxicity (hemolysis) and is no longer used for this purpose. A Woods lamp can be used instead to visualize the particles.

Question 4

The photo shown above belongs to your 54 year old patient in the Emergency Department. He has a medical past of atrial flutter and alcohol abuse. This wound is already six months present and there is no history of prior infection, trauma or surgery. The wound is intermittent and mildly painful. He has no other complaints.

Which of the following diagnoses is most likely?

A: Sister Mary Joseph (SMJ) nodule

B: Brother Mary Joseph (BMJ) nodule

C: Umbilical Joseph Infection (UJI) nodule

D: Umbilical Mid Laceration (UML) nodule

Reveal answer

The correct answer is A.

This case was covered on ALiEM this week.

A Sister Mary Joseph nodule is a rare cutaneous metastasis of gastrointestinal or genitourinary primary malignancies to the umbilicus. Sister Mary Joseph nodules arise late in disease and portend a poor prognosis. The mean survival of patients with SMJ nodules is less than 12 months.

SAEM Clinical Images Series: An Ominous Umbilical Lesion

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

January 6, 2023January 6, 2023

Quiz 174, January 6, 2023

Welcome to the 174th FOAMed Quiz.

Question 1

The X-ray shown above belongs to your 13 year old patient in the Emergency Department after twisting the left knee while playing soccer. He is unable to bear weight.

Which of the following diagnoses is most likely?

A: Patella fracture with anterior cruciate ligament injury

B: Anterior tibial spine avulsion fracture with anterior cruciate ligament injury

C: Quadriceps tendon rupture

D: Displaced tibial plateau fracture with posterior cruciate ligament injury

E: Patellar tendon rupture with posterior cruciate ligament injury

Reveal answer

The correct answer is B.

This case was covered on ALiEM this week.

The anterior tibial spine is the insertion point of the ACL. The injury is most common in pediatric patients. It can be caused by a twisting or pivoting knee injury, hyperextension or direct trauma.

SplintER Series: Don’t forget about the (tibial) spine!

Question 2

Your 23 year old patient presents with new onset anemia without clinical signs of blood loss. She is hemodynamically stable and did not receive any transfusions lately. Her MCV is 85 fL. Her liver and kidney function are normal. Thrombocytes and leukocytes are within normal range. Reticulocytes are 92/1000 cells (increased). LDH and bilirubin are elevated. Haptoglobin is decreased. Iron and ferritin are normal. The direct antiglobulin test (Coombs) is negative and the blood smear shows ‘’bite cells’’, but no other atypical cells. When asked she states her skin to have been ‘’a little bit yellow’’ once in a while for as long as she can remember.

Which of the following is the most likely cause of this patient’s anemia?

A: Hereditary spherocytosis

B: Vitamin B12 deficiency

C: Glucose-6-phostphate dehydrogenase deficiency (G6PD)

D: Auto-immune hemolysis

E: Sickle cell disease

Reveal answer

The correct answer is C.

Acute hemolytic anemia was covered on EM@3AM last week.

The patient has new onset anemia, so sickle cell disease is very unlikely. High reticulocytes make a hemoglobin production problem such as vitamin B12 deficiency less likely. A normal MCV also does not fot vitamin B12 deficiency. A low haptoglobin points in the direction of hemolysis. The negative Coombs test makes auto-immune hemolysis unlikely and the absence of spherocytes on blood smear exclude hereditary spherocytosis. Bite cells are commonly identified in glucose-6-phosphate dehydrogenase deficiency. Her history of episodes of a yellow skin supports this diagnosis.

EM@3AM: Acute Hemolytic Anemia

Question 3

What is the proper location to apply a pelvic binder?

A: Over the iliac crest

B: Over the femur shaft

C: Over the greater trochanters

Reveal answer

The correct answer is C.

Last week UMem covered pelvic binders.

This paper suggests that it takes about 8 attempts to properly apply a pelvic binder.

Question 4

Source image: https://www.semanticscholar.org/figure/1

The ECG above belongs to a patient with chest pain.

Which of the following waves is present?

A: N-wave

B: J-wave

C: U-wave

D: Epsilon-wave

Reveal answer

The correct answer is A.

Dr. Smith’s ECG blog covered a case of N-wave NSTEMI last week.

N waves are transient appearing notches at the end of the QRS complex and are associated with myocardial ischemia. N-waves are usually ≥2 mm in size with respect to the PR segment which results in slight widening of the QRS complex. N-waves are usually seen in one or more of the inferior leads, and/or in leads I, aVL. An N-wave is also called a delayed activation wave of the left ventricular basal region. They indicate the LCx is likely to be the “culprit” artery.

Question 5

We universally advise patients to reduce screen time after a concussion, but so far evidence to support this habit lacks.

In this recently published paper, 663 children and adolescents with acute concussion and 334 children and adolescents with orthopedic injury were followed.

Postconcussion symptoms were measured (Health and Behavior Inventory) up to 6 months post injury. Screen time was measured by using the Healthy Lifestyle Behavior Questionnaire.

What did the authors find? Two answers are correct.

A: Low screen time was associated with relatively more severe symptoms in the concussion group compared to the orthopedic injury group during the first 30 days post injury

B: Intermediate screen time was associated with relatively more severe symptoms in the concussion group compared to the orthopedic injury group during the first 30 days post injury

C: High screen time was associated with relatively more severe symptoms in the concussion group compared to the orthopedic injury group during the first 30 days post injury

Reveal answer

The correct answers are A and C.

The paper was covered on DFTB last week.

Interestingly, low and high screen time were both associated with relatively more severe symptoms in the concussion group compared to the orthopedic injury group during the first 30 days post injury but not after 30 days.

The 67th Bubble Wrap

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

December 30, 2022December 30, 2022

Quiz 173, December 30th, 2022

Welcome to the 173th FOAMed Quiz.

A short one this time!

Happy new year!

Question 1

A 37-year old male presents with pain in his left foot after stepping into a pothole. You obtain radiographs and find a small bony fragment between the base of the 1st and 2nd metatarsal, which is associated with Lisfranc injury.

This small bony fragment between the base of the 1st and 2nd metatarsal has a name. How is it called?

A: Cupid’s bow sign

B: Inverted Napoleon Hat Sign

C: Sail Sign

D: Fleck sign

Reveal answer

The correct answer is D.

Lisfranc injury was covered on SinaiEM last week.

Cupid’s bow sign is seen as a normal variant in the endplate of the vertebral body.

Inverted Napoleon Hat Sign is a radiologic sign seen on the frontal pelvic or lumbar radiograph at the level of the 5th lumbar vertebra and the sacrum.

Sail sign is also known as the anterior fat pad sign, describing the elevation of the anterior fat pad to create a silhouette similar to a billowing spinnaker sail from a boat.

Fleck sign is an avulsion fracture of the second metatarsal or medial cuneiform and associated with a Lisfranc injury.

Lisfranc Injury

Question 2

You are treating your patient for severe methemoglobinemia.

Which of the following is first line treatment?

A: Ascorbic acid

B: Methylene blue

C: Exchange transfusion

D: Hyperbaric oxygen

Reveal answer

The correct answer is B.

Methemoglobinemia was discussed in this week’s emDOCS ToxCard.

Methylene blue is a carrier for electrons which aids in reducing Fe3+ back to Fe2+ and thus resolving methemoglobinemia. Ascorbic acid is also an option, but it acts a lot slower.

Treatment with exchange transfusion and hyperbaric oxygen have been described in case reports.

ToxCard: Methylene Blue

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen