Quiz 161, July 8th, 2022

Welcome to the 161st FOAMed Quiz.

 

Source image: www.uampa.com

Question 1
A seventeen year old male presents to the emergency department with severe pain in his scrotum for several hours. During physical examination you see a swollen and red scrotum. Elevation of the scrotum increased the pain and did not give a relief of symptoms. We call this a negative Prehn’s sign.

Which of the following diagnoses is most likely in patients with negative Prehn’s sign?

A: Acute epididymitis

B: Testicular Torsion

The corrects answer is B.

Life in The Fast Lane covered the eponym Prehn’s sign this week in their blog.

Prehn’s sign (1934) is named after the American urologist Dougles Theodore Prehn. It is most commonly described as elevation of the scrotum not decreasing the pain in the scrotum. This clinical sign may help to differentiate between testicular torsion and acute epididymitis. It should always be followed by imaging to confirm the diagnosis.

Douglas Prehn

Source image: www.dontforgetthebubbles.com

Question 2

Management of children with torus fractures still often includes application of a cast. The evidence behind treatment without immobilization is of low quality. At least so far.

In the recently published FORCE trial, 965 children (aged 4–15 years) with a distal radius torus fracture were randomly allocated to the ”offer of bandage” group or rigid immobilization group. 94% of the participants in the “offer of a bandage” group choose for bandage instead of rigid immobilization.

The primary outcome was pain on day three. Secondary outcomes included pain or function during the 6 weeks of follow-up.

What did the authors find?

A: Pain at day three was equal in both groups and there was no difference in pain and function during 6 weeks follow-up

B: Pain at day three was higher in the bandage group, but there was no difference in pain and function during 6 weeks follow-up

C: Pain at day three was equal in both groups, but patients in the bandage group reported reduced function during 6 weeks follow-up compared to the immobilization group

D: Pain at day three was higher in the bandage group and patients in the bandage group reported reduced function during 6 weeks follow-up compared to the immobilization group

The correct answer is A.

Don’t forget the Bubbles covered the paper last week.

‘’This trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilization group, with no between-group differences in pain or function during the 6 weeks of follow-up.’’

The FORCE trial

Question 3

Source image: EMDocs.com

The dose of intravenous insulin in hyperkalemia is often adjusted for renal dysfunction. Patients with renal dysfunction typically receive 5 IU instead of 10 IU to avoid hypoglycemia.

In this recently published retrospective study, 377 patients with Chronic Kidney Disease (CKD) stages 3a, 3b, and 4 and hyperkalemia were analysed. 186 patients received 5 units and 191 patients received 10 units of insulin.

What did the authors find?

A: More patients receiving 10 units of i.v. insulin had hypoglycemic events, but there was no difference in decrease of serum potassium between the groups

B: There was no difference in hypoglycemic events and there was no difference in decrease of serum potassium between the groups

C: More patients receiving 10 units of i.v. insulin had hypoglycemic events and 10 units of i.v. insulin lowered serum potassium significantly more than 5 units of i.v. insulin

D: There was no difference in hypoglycemic events among patients receiving 5 vs. 10 units of i.v. insulin. However, 10 units of i.v. insulin lowered serum potassium significantly more than 5 units of i.v. insulin

The correct answer is D.

The paper was covered on UMEM last week.

Hypoglycemia occurred in 6.5% of patients who received 5 units of i.v. insulin and in 8.4% of patients who received 10 units of i.v. insulin (p = 0.476).

There was no difference in hypoglycemic events among patients with moderate renal dysfunction receiving 5 vs. 10 units of i.v. insulin for hyperkalemia. However, 10 units of i.v. insulin lowered serum potassium significantly more than 5 units of i.v. insulin.

Keep in mind this is a retrospective paper. In the 5 unit group, significantly more patients had CKD stage 4 (60% v 30%).

Question 4

Source image: anatomytool.org/

Which of the following cardiac abnormalities are present in classic tetralogy of Fallot?

A: Atrial Septal Defect

B: Ventricular Septal Defect

C: Pulmonary Artery Stenosis

D: Coarctation of the Aorta

E: Ebstein Anomaly

F: Tricuspid Atresia

G: Overriding Aorta

H: Hypoplastic Left Heart

I: Right Ventricular Hypertrophy

The correct answers are B, C, G and I.

Geeky Medics covered tetralogy of Fallot last week.

It consists of:
Ventricular Septal Defect
Pulmonary Artery Stenosis
Overriding Aorta
Right Ventricular Hypertrophy

Tetralogy of Fallot

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

Reviewed and edited by Rick Thissen

Quiz 159, June 24th, 2022

Welcome to the 159th FOAMed Quiz.

 

Source image: www.alodokter.com

Question 1

For some reason, Ramsay Hunt syndrome is all over the news these days.

As we all know by now, this is a peripheral facial paralysis. But how does it compare to the (formerly) more famous Bell’s Palsy?

Which of the following statements is NOT true?

A: Ramsay Hunt syndrome has a worse prognosis than Bell’s Palsy

B: Dizziness is a more common complaint in Ramsay Hunt syndrome than in Bell’s Palsy

C: Both in Ramsay Hunt syndrome and Bell’s Palsy, an erythematous vesicular auricular skin rash is often seen preceding paralysis

D: Antiviral therapy is a cornerstone in treating Ramsay Hunt syndrome, but has no evidence based benefit in Bell’s Palsy

The correct answer is C.

This week, Ramsay Hunt syndrome was discussed by Pediatric EM Morsels.

Ramsay Hunt syndrome is caused by reactivation of Varicella Zoster Virus. This leads to an auricular skin rash, which is not typically seen in Bell’s Palsy. Ramsay Hunt syndrome is described as more painful. Both Ramsay Hunt syndrome and Bell’s Palsy affect CN VII, but the first can also affect CN VIII, leading to vestibular symptoms, not typically seen in Bell’s Palsy.

Pediatric Ramsay Hunt Syndrome

Source image: www.rebelem.com

Question 2

While COVID-19 causes yet another surge in Europe, we hope to avoid the next overload of our critical care system.

The benefit of awake proning of our ill COVID patients has been uncertain and it was surely not general practice in our hospital.

Last month the COVI-PRONE trial was published. 400 patients (of which 97% had confirmed COVID-19) were randomised to either awake prone positioning (targeted for 8 hours daily) and usual care without prone positioning. These patients were not intubated and required oxygen (≥40%) or noninvasive ventilation.

The primary outcome was endotracheal intubation within 30 days of randomisation.

What did the authors find?

A: Patients in the awake proning group had statistically significant lower rates of intubation

B: Patients in the standard group had statistically significant lower rates of intubation

C: There was no difference in intubation rate between the two groups

The correct answer is C.

RebelEM covered the paper last week.

The achieved medial duration of prone positioning of the patient was 4.8 hours per day.

There was no statistically significant difference in intubation rate between the two groups. However, the rate of intubation was 34.1% in the awake proning group compared to 40.5% in the usual care group. This is a rather big difference, and the study just might be underpowered to detect a statistically significant difference.

REBEL Cast Ep110: The COVI-PRONE Trial – Awake Prone Positioning and COVID-19

Source image: www.pixabay.com

Question 3

Which of the following bacteria causes about 1/3th of cases of Lemierre’s syndrome?

A: Staphylococcus aureus

B: Fusobacterium necrophorum

C: Streptococcus pyogenes

D: Pseudomonas aeruginosa

The correct answer is B.

EMDocs covered Lemierre’s syndrome last week.

Lemierre’s syndrome is one of the ENT emergencies we should always consider in a patient with severe pharyngitis.

Lemierre’s syndrome is a suppurative thrombophlebitis of the internal jugular vein

Fusobacterium necrophorum accounts for about 33 percent of cases of Lemierre’s syndrome.

 

Source image: www.lompocvmc.com

Question 4

The foramen of Monro connects which two cerebrospinal fluid (CSF) containing structures?

A: The two lateral ventricles only

B: The lateral ventricles and the third ventricle

C: The third ventricle and the fourth ventricle

D: The fourth ventricle and the cisterna magna

The correct answer is B.

Geeky Medics covered anatomy of the cerebrospinal fluid filled structures last week.

The interventricular foramina (or foramina of Monro) connect the lateral ventricles to the third ventricle.

CSF exits the fourth ventricle via three foramina (Magendie and Luschka) into the cisterna magna.

The Ventricular System

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

Reviewed and edited by Rick Thissen

Quiz 158, June 17th, 2022

Welcome to the 158th FOAMed Quiz.

 

Source image: www.venousforum.org

Question 1

Which of the following ECG abnormalities is NOT caused by pulmonary embolism?

A: Atrial fibrillation

B: New tall R-wave in V1

C: ST elevation in lead aVR

D: Peaked and pointed P waves in lead I and aVL

The correct answer is D.

Ken Grauer covered ECG abnormalities in pulmonary embolism last week.

Possible EC changes due to pulmonary embolism include:
– Sinus tachycardia
– Signs of RV strain
– S1Q3T3 pattern
– Right atrial enlargement (peaked and pointed p waves in II, III, aVF, V1 and V2
– Right axis
– RBBB
– New tall R-wave in V1
– ST elevation in lead aVR
– Atrial fibrillation

Source image: www.nursing.nl

Question 2

Which of the following clinical features is NOT typical for monkeypox?

A: Lymphadenopathy

B: Acute onset of rash

C: Dermatomal distribution

D: Back pain

The correct answer is C.

Geeky Medics covered monkeypox last week.

Typical clinical features of monkeypox include: acute rash accompanying either headache, acute onset fever, lymphadenopathy, myalgia, back pain and asthenia.

If the rash follows a dermatomal distribution, consider shingles.

Monkeypox

Source image: https://radiopaedia.org

Question 3

Your patient was dropped and left outside of your emergency department. He is hemodynamically unstable, diaphoretic and has an altered level of consciousness. He states he is a body stuffer and he is transporting an unknown substance.

What is the difference between a body packer and a body stuffer?

A: A body packer usually ingests about 1 kilogram of drugs, whereas a body stuffer ingests as much as possible

B: A body packer ingests drug packets and a body stuffer hides drug packets in various orifices

C: In a body packer, ingestion of drug packets is well coordinated, whereas a body stuffer swallows drugs in a hurry

The correct answer is C.

EMDocs covered body packers, stuffers and pushers last week.

In a body packer, ingestion of drug packets is well coordinated, whereas a body stuffer swallows drugs in a hurried fashion (often to avoid immediate arrest). The packets are often more prone to break. The amount of drugs is usually smaller in body stuffers.

A person who hides drug packets in various orifices is called a body pusher.

Body Packers, Stuffers, and Pushers: Time Bombs in Our EDs

Question 4

In the images above. The blue area is supplied by which artery?

A: LAD

B: Cx

C: RCA

The correct answers is C.

 Jacob Avila covered advanced cardiac ultrasound last week on Core Ultrasound.

The blue area is supplied by the RCA, the yellow area by the LAD, the red area by the LAD or Cx and the green area by the RCA or Cx. 

5 Top Tips for Advanced Echo

Source image: https://my360pt.com

Question 5

Unilateral pain that radiates along the path of the sciatic nerve, from the lower back through the hip and buttock towards the leg is typical for sciatica. Ultrasound guided sciatic nerve block may be beneficial for patients with sciatica. A long-acting anesthetic such as bupivacaine, in combination with a corticosteroid may provide pain relief.

Which of the following statements about the anatomy of the sciatic nerve is true?

A: It runs between the ischial tuberosity and greater trochanter

B: It runs above the gluteus maximus and below the quadratus femoris muscles

C: It runs within a fascial plane through the obturator foramen

D: Distally it branches in the saphenous nerve

The correct answer is A.

This week AcepNow discussed The ultrasound-guided transgluteal sciatic nerve block (TGSNB).

The sciatic nerve is identified by ultrasound located inferior to the gluteus maximus muscle, superior to the quadratus femoris muscle as it courses adjacent to the ischial tuberosity (medially) and greater trochanter (laterally).

TransGluteal Sciatic Nerve Block

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

Reviewed and edited by Rick Thissen

Quiz 157, June 10th, 2022

Welcome to the 157th FOAMed Quiz.

 

Source image: www.litfl.com

Question 1

A patient is brought to your ED with nausea and palpitations after drinking tea from self picked garden plants. The ECG, as displayed, shows “sagging” ST segments and T waves taking on a typical appearance.

Which of the following plants was likely to be inside the tea?

A: Oleander

B: Monkshood

C: Yew

D: Foxglove

The correct answer is D.

AliEM discussed Foxglove intoxication this week.

The botanical name for foxglove is Digitalis purpurea. ECG changes are in line with digoxin intoxication.

Oleander is a poisonous plant with a non-digitalis cardiac glycoside effect. The Na+/K+ ATPase pump of the heart is affected, resulting in hyperkalaemia which might lead to matching ECG changes.

Both Monkshood and Yew contain alkaloids that disrupt impulse conduction in the heart by blocking sodium channels in the cell membrane, slowing depolarization, leading to bradycardia and cardiac arrest.

ACMT Toxicology Visual Pearl: Pretty (and Deadly) in Purple

Source image: https://thesgem.com

Question 2

There used to be a time every patient with pneumothorax, traumatic or not, received a large bore chest tube. Fortunately, nearly all patients with pneumothorax get a smaller percutaneous catheter nowadays.

Patients with hemothorax still routinely get a 28-32 Fr chest tube, for smaller tubes are thought to increase the risk of complications and retained hemothorax.

In this 2021 paper, patients with traumatic hemothorax or hemopneumothorax requiring drainage were randomized to receive a 14 Fr pigtail catheter or a 28–32 Fr large-bore chest tube.

The primary outcome was failure rate of the drainage catheter, defined as retained hemothorax requiring additional intervention including a second catheter, thrombolysis and video-assisted thoracoscopy surgery.

What did the authors find?

A: The failure rate of the drainage catheter was higher in the 28-32 Fr group

B: The failure rate of the drainage catheter was higher in the 14 Fr pigtail group

C: The failure rate of the drainage catheter did not differ between the two groups

The correct answer is C.

The paper was covered on RebelEM last week.

The failure rate was 11 percent in the pigtail group versus 13 percent in the 28-32 Fr chest tube group. This difference was not statistically significant.

Keep in mind this is a rather small RCT with some methodological flaws. Larger RCT’s are needed for change of practice.

Traumatic Hemothorax: Pigtail vs Chest Tube

Source image: www.litfl.com

Question 3

The patient behind this ECG presents with a certain type of hypertrophic cardiomyopathy (HCM).

In patients with what nationality is this type of HCM most frequently seen?

A: Mongolian

B: Japanese

C: Philippine

D: South Korean

The correct answer is B.

This ECG is typical for apical HCM. Apical HCM was covered on LITFL last week.

‘’This relatively uncommon form of HCM is seen most frequently in Japanese patients (13-25% of all HCM cases in Japan) and it is also known as Yamaguchi syndrome’’.

https://litfl.com/apical-hypertrophic-cardiomyopathy-ahc/

Source image: www.henw.org

Question 4

Your patient presents with acute hearing loss.

The Weber test lateralizes to the right ear and the Rinne test is positive (normal) on both sides.

What does this patient most likely have?

A: Conductive hearing loss of the right ear

B: Conductive hearing loss of the left ear

C: Sensorineural hearing loss of the right ear

D: Sensorineural hearing loss of the left ear

The correct answer is D.

Taming the SRU covered tinnitus and auditory disturbances last week.

Weber test lateralizes to the right ear, so this patient either has conductive hearing loss on the right side or sensorineural hearing loss on the left side.

A positive Rinne on both sides means there is no conductive hearing loss, leaving sensorineural hearing loss on the left side as the most likely cause.

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

Reviewed and edited by Rick Thissen

Quiz 155, May 20, 2022

Welcome to the 155th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Your 65 year old patient comes in with tachypnea, profound tachycardia, diaphoresis, fever and confusion. She has been losing weight and is feeling restless for the last few months and last week she had influenza.

You suspect her of having thyrotoxic crisis.

Which of the following agents is not part of ED treatment of thyrotoxic crisis?

A: A beta blocker (propranolol)

B: A glucocorticosteroids (hydrocortisone)

C: A thioamides (propylthiouracil)

D: Acetylsalicylic acid (Aspirin)

The correct answer is D.

Thyrotoxic crisis was covered on EM Pills last week (in Italian).

Aspirin interacts with protein binding and might increase free T4 and T3 serum levels. It should be avoided in case of thyrotoxic crisis.

Source image: www.gezondheid.be

Question 2

Renal colic is a clinical diagnosis and imaging is often unnecessary. However, when in doubt, imaging can be helpful. The preferred initial imaging modality (CT, POCUS or formal ultrasound) is debatable.

In this 2014 paper, 2759 patients with suspected nephrolithiasis were randomized to undergo diagnostic ultrasonography performed by an emergency physician (POCUS), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT as initial imaging. The patients were only included if the treating physician decided imaging was necessary.

The primary outcomes included high-risk diagnoses with complications that could be related to missed or delayed diagnoses.

What did the authors find?

A: Patients in the POCUS group had a higher rate of complications that could be related to missed or delayed diagnoses compared to patients in the CT group. Patients in the radiology ultrasound group did not

B: Patients in both the POCUS group and the radiology ultrasound group had a higher rate of complications that could be related to missed or delayed diagnoses compared to patients in the CT group

C: The incidence of high-risk diagnoses with complications in the first 30 days did not vary according to imaging method

The correct answer is C.

The paper was covered on NUEM last week.

High-risk diagnoses with complications during the first 30 days after randomization occurred in only 11 patients with no significant difference according to study group.

However, 40.7% of the patients in the point-of-care ultrasonography group and 27.0% of the patients in the radiology ultrasonography group underwent subsequent CT in the emergency department. This did not result in a higher mean ED length of stay.

The sensitivity was 54% for point-of-care ultrasonography, 57% for radiology ultrasonography, and 88% for CT.

Source image: www.pixabay.com

Question 3

Alcohol consumption appears to be increasing and alcohol withdrawal syndrome (AWS) is quite frequently encountered in our ED.

Which of the following statements about the management of AWS is true?

A: IV midazolam is superior to IV lorazepam in treatment of AWS

B: IV benzodiazepine have higher effectiveness in treatment of AWS compared to IV phenobarbital

C: IV benzodiazepines have a favorable safety profile for treating alcohol withdrawal compared to IV phenobarbital

D: IV phenobarbital can cause persistent coma in patients with liver failure or hepatic encephalopathy

The correct answer is D.

Both EMDocs and Downeast EM covered alcohol withdrawal syndrome last week.

There is no clear evidence suggesting superiority of one benzodiazepine over another for AWS treatment and phenobarbital is most likely at least as effective as benzodiazepines. The safety profile of phenobarbital appears similar to that of benzodiazepines, but beware of patients with liver failure.

Source image: first10EM.com

Question 4

The prevalence of monkeypox is increasing. This viral zoonosis is endemic to central and western Africa, but is increasingly encountered throughout Europe and the US. 

Which of the following statements about monkeypox is true?

A: The first clinical features of the illness are skin lesions. There are no prodromes.

B: Monkeypox may look very similar to chickenpox

C: Monkeypox has a higher rate of transmission from human to human compared to smallpox

D: Smallpox vaccination does not provide protection against monkeypox

The correct answer is B.

Monkeypox was covered on first10EM last week.

Monkeypox may mimic chickenpox.

Prodromes include fever, malaise and headaches and typically last for 2 days.

Monkeypox has a lower transmission rate compared to smallpox and the smallpox vaccine actually provides some protection against monkeypox.

Smallpox vaccination appears to provide reasonable (approximately 85%) protection against monkeypox.

Monkeypox

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

Reviewed and edited by Rick Thissen

Quiz 153, May 6, 2022

Welcome to the 153th FOAMed Quiz.

 

Question 1

Source image: www.emra.org

Patients often report that a peripheral intravenous catheter (IV) should not be placed on the same side of the body as prior breast surgery.

In this 2021 retrospective paper a chart review was performed on 3724 patients with prior surgery for breast cancer. These patients underwent 7896 IV placements. The IVs were being placed a median of 1.5 years after the original breast cancer surgery. 5153 were placed in the ipsilateral arm and 2743 were placed in the contralateral arm.

What did the authors find?

A: More complications were found in patients with an IV in the ipsilateral arm

B: More complications were found in patients with an IV in the contralateral arm

C: There were only 2 complications in both groups

The correct answer is C.

The paper was covered on First10EM last week.

Indeed, there were only 2 complications in both groups. Prior breast surgery is not a contra-indication for IV placement on the ipsilateral side. However, it may take some gentle discussion with the patient due to the misinformation they have received.

Research Roundup (May 2022)

Question 2

Source image: www.pixabay.com

Your 35 year old patient is brought in after a fire in his living room. He inhaled a lot of smoke. He is profoundly tachypneic, confused and has a lactate of 16 mmol/L. You want to treat him for cyanide intoxication.

Which of the following agents is first line treatment in cyanide intoxication?

A: Amyl nitrite

B: Sodium nitrite

C: Sodium thiosulfate

D: Hydroxocobalamin

The correct answer is D.

Carbon mono-oxide and Cyanide poisoning were covered on NuEM last week.

Historically, amyl nitrite or sodium nitrite in combination of sodium thiosulfate was used for cyanide intoxication. These days the first line treatment is high dose Hydroxocobalamin (5 grams). Hydroxocobalamin scavenges cyanide by binding it to form cyanocobalamin.

Question 3

Source image: lermagazine.com

Your patient presents with a lower leg fracture and is in extreme pain. You wonder whether he has compartment syndrome and decide to measure compartment pressure.

What is the generally accepted compartment pressure above which the diagnosis becomes very likely?

A: > 10 mmHg

B: > 20 mmHg

C: > 30 mmHg

The correct answer is C

RebelEM covered compartment syndrome last week.

The diagnostic threshold for compartment syndrome is 30 mmHg.

REBEL Core Cast 80.0 – Compartment Syndrome

Question 4

Source image: www.pixabay.com

To anesthetize the sole of the foot (for example in removal of foreign objects), ultrasound guided nerve blocks are very useful.

A block of which of the following nerves results in anesthesia of the largest part of the sole of the foot?

A: Posterior tibial nerve

B: Saphenous nerve

C: Sural nerve

The correct answer is A. 

Ultrasound guided posterior tibial nerve block was covered on Core Ultrasound last week.

A posterior tibial nerve block will anesthetize most of the sole of the foot.

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

Reviewed and edited by Rick Thissen

Quiz 151, April 22nd, 2022

Welcome to the 151th FOAMed Quiz.

 

Source image: www.theanesthesiaconsultant.com

Question 1

In our emergency department, succinylcholine is very rarely used because nondepolarizing agents are thought to have a better safety profile.

Which of the following patients does NOT have an increased risk of developing succinylcholine induced hyperkalemia?

A: A patient with Guillain Barré syndrome

B: A patient with extensive trauma

C: A patient with liver disease

D: A patient with septic shock

The correct answer is C.

Succinylcholine was covered on EMDocs last week.

Succinylcholine causes prolonged depolarisation. Sodium channels are activated and cause an influx of sodium which depolarizes the cell. When this happens potassium channels also open that cause efflux of potassium, leading to hyperkalemia. This process gets significant whenever upregulation and expression of ACh receptors occurs (like in trauma of denervation).


Source image: www.researchgate.net

Question 2

Your 2 year old patient presents with an inguinal bulge and you are in doubt whether this is hydrocele or an inguinal hernia. You palpate the cord structures against the pubic tubercle and it feels like 2 silk sheets rubbing over one another (positive silk glove sign).

What diagnosis is supported by a positive silk glove sign?

A: Hydrocele

B: Inguinal hernia

The correct answer is B.

Hernias were covered on DFTB last week.

A positive silk glove sign can be found in case of a patent processus vaginalis. What you actually feel is the smooth edges of the peritoneal sac. This rules out hydrocele and has a pretty decent accuracy for detection of an inguinal hernia.

Hernias

Question 3

Where can a Bezold abscess be found?

A: Groin

B: Neck

C: Armpit

D: Foot

The correct answer is B.

Bezold abscess was covered on pedEM morsels last week.

It is a complication of acute mastoiditis. An eroded mastoid cortex leads to pus spreading between the digastric and sternocleidomastoid muscles.

Bezold’s Abscess in Children

Source image: www.healio.com

Question 4

Your 78 year old patient presents with diarrhea and vomiting. Her vital signs are normal. She had an episode of syncope with swift full recovery. The ED nurse performed orthostatic vital sign measurements and found a decrease in systolic blood pressure of 30 mmHg.

Which of the following statements about orthostatic vital signs is true?

A: In the healthy population, orthostatic hypotension is common and its frequency increases with age

B: Positional systolic blood pressure changes occur in 2-5% of patients of over 65 years of age

C: In order to obtain orthostatic vital signs, they should be measured 30 seconds after standing from a supine position

The correct answer is A.

Orthostatic vitals signs were covered on RebelEM last week.

In the healthy population, orthostatic hypotension is common and its frequency increases with age. Positional systolic blood pressure changes occur in 11 – 50% of patients > 65 years of age. In order to obtain orthostatic vital signs, they should be measured 3 minutes after standing from a supine position.

 

REBEL Core Cast 79.0 – Orthostatics in Volume Loss

Source image: www.pixabay.com

Question 5


What is the correct dose of intravenous insulin in case of calcium channel blocker intoxication?

A: 0.01 U/kg

B: 0.1 U/kg

C: 1 U/kg

D: 10 U/kg

The correct answer is C.

Calcium channel blocker intoxication was covered on SinaiEM last week.

Yes, the correct insulin dose in calcium channel blocker and beta blocker intoxication is 1 U/kg, followed by a continuous infusion of 0.5 – 1 U/kg.

Calcium Channel Overdose

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

Reviewed and edited by Rick Thissen

Quiz 150, April 1st, 2022

Welcome to the 150th FOAMed Quiz.

 

Source image: media.npr.org

Question 1

In stroke patients that undergo successful intra-arterial thrombectomy of a large vessel occlusion, it is thought that microthrombi cause suboptimal neurological recovery.

In the recently published CHOICE trial, 121 patients undergoing successful intra-arterial thrombectomy of a large vessel occlusion were randomized to receive either additional intra-arterial alteplase (0.225 mg/kg) or intra-arterial placebo.

The primary outcome was proportion of patients achieving a modified Rankin Scale (mRS) of 0-1 at 90 days.

What did the authors find?

A: The proportion of patients achieving a mRS of 0-1 was higher in the intra-arterial alteplase group compared to the intra-arterial placebo group

B: The proportion of patients achieving a mRS of 0-1 was higher in the intra-arterial placebo group compared to the intra-arterial alteplase group

C: The proportion of patients achieving a mRS of 0-1 was equal in both groups

The correct answer is A.

Mechanical thrombectomy was covered on EMCrit last week.

The results of this trial are promising. Treatment with intra-arterial alteplase was associated with a score of 0 or 1 on the mRS at 90 days in 59.0% in the alteplase group and in 40.4% in the placebo group (P = .047).

There was no increase in intracranial hemorrhage in the intra-arterial alteplase group.

NeuroEMCrit – Time is Brain – Acute Ischemic Stroke Part 2: Mechanical Thrombectomy

Source image: www.changesggz.nl

Question 2

A known alcoholic is brought to your ER. Bystanders saw him drinking from a bottle, which did not appear to contain normal potable liquor. His level of consciousness is decreased. Lab results come back. You expected to find a high anion gap metabolic acidosis, but this is not the case.

Which toxic alcohol does not typically lead to high anion gap metabolic acidosis?

A: Methanol

B: Ethylene glycol

C: Propylene glycol

D: Isopropanol

The correct answer is D.

This week NUEMBlog discussed toxic alcohols.

Isopropanol, found in hand sanitizers, mouthwashes and disinfectants, is hepatically metabolized by alcohol dehydrogenase to acetone. There is no further metabolism, and because no acid byproducts are formed, isopropanol is the only toxic alcohol that does not cause an elevated anion gap acidosis.It does cause an osmol gap though.

Source image: www.pixabay.com

Question 3

Pre-endoscopy administration of intravenous proton pump inhibitors (PPI) in patients with upper gastro-intestinal tract bleeding is common practice.

According to the Cochrane review on this topic, what is the rationale behind this practice?

A: It is associated with a benefit in mortality

B: It is associated with lower chance of rebleeding

C: It is associated with lower need for transfusion

D: It is associated with lower need for surgery

E: There is no evidence for any patient related benefit

The correct answer is E.

First10EM covered the evidence behind pre-endoscopy PPI administration quite extensively.

To put it shortly, there is no evidence for any patient related benefit of pre-endoscopy PPI administration.

There is moderate-certainty evidence that pre-endoscopy PPI treatment likely reduces the requirement for endoscopic haemostatic treatment at index endoscopy. However, this is not a patient centered outcome.

Source image: www.radiopeadia.org

Question 4

Your patient presents with Sympathetic Crashing Acute Pulmonary Edema (SCAPE). She has profound tachypnea, hypoxia, a heart rate of 120 bpm, blood pressure of 210/110 mmHg and a capillary refill time of 4 seconds.

Which of the following treatment options is least likely to be beneficial in the acute phase?

A: Nitroglycerin (NTG)

B: Continuous Positive Airway Pressure (PEEP)

C: Loop diuretics

The correct answer is C.

Heart failure was covered on EMDocs last week.

The mainstay of SCAPE treatment is NTG and CPAP. There is insufficient evidence for diuretics like furosemide in acute SCAPE.

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

Reviewed and edited by Rick Thissen

Quiz 148, March 11, 2022

Welcome to the 148th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1
Your 35 year old patient presents with bilateral facial palsy, diplopia and descending muscle weakness. He states he had a barbeque yesterday. His vital signs are normal, he has no fever and he denies any gastro-intestinal complaints or headache.

Which of the following foodborne illnesses fits the picture best?

A: Ciguatera

B: Botulism

C: Salmonellosis

D: Scombroid

The correct answer is B.

Botulism was covered on EMDocs last week.

Cranial nerve dysfunction and descending muscle weakness are typical for botulism. Respiratory difficulties often require intubation and mechanical ventilation. Nonspecific gastrointestinal (GI) symptoms may be present.

Source image: www.ahajournals.org

Question 2

Electrical cardioversion of atrial fibrillation is often performed in the ED. The defi pads can be placed either anterior-posteriorly and anterior-laterally.

In this recently published RCT468 patients undergoing elective cardioversion for atrial fibrillation were randomized to either anterior-posterior or anterior-lateral pads placement.

What placement was associated with a higher rate of conversion to sinus rhythm at the first attempt?

A: Anterior-lateral pads placement

B: Anterior-posterior pads placement

C: The rate was equal between the two groups

The correct answer is A.

JournalFeed covered the paper last week.

The authors found that after the first shock, 54% of patients in the anterior-lateral group vs 33% of patients in the anterior-posterior group converted to sinus rhythm (95% CI, 13-30; P<0.001).

Source image: www.morancore.utah.edu

Question 3

Your 22 year old patient comes in after a blow to the right eye. He has grade III hyphema.

Which of the following symptoms should certainly warrant emergent ophthalmic referral (2 correct answers)?

A: Blurred vision

B: Elevated intraocular pressure (IOP)

C: Corneal abrasion

D: Associated globe rupture

The correct answers are B and D.

AlieEM covered hyphema last week.

Emergency consultation of an ophthalmologist is certainly warranted in case of elevated IOP and globe rupture. Blurred vision is always present in high grade hyphema. 

SAEM Clinical Image Series: Snowball Effects

Source image: www.pixabay.com

Question 4

Your patient presents after being stung in the ocean by ‘some sort of animal’. He is in severe pain.

In what case might an X-ray help you in the management of this patient?

A: Stingray attack

B: Coral wound

C: Stonefish sting

D: Sea urchin injury

The correct answer is D.

NuEM covered marine envenomations last week.

The spines of sea urchins are often visible in X-rays, giving you an indication about the job ahead.

In general marine venoms are heat labile and hot water submersion should be commenced as soon as possible, although evidence for hot water submersion is not as clear as it is for jellyfish injury.

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

Reviewed and edited by Rick Thissen

Quiz 146, February 25th

Welcome to the 146th FOAMed Quiz.

Question 1

Source: www.consumersafety.org

This recently published retrospective study is a head to head comparison of apixaban versus rivaroxaban in venous thromboembolism (VTE).

The primary effectiveness outcome was recurrent VTE, a composite of deep venous thrombosis and pulmonary embolism. The primary safety outcome was a composite of gastrointestinal and intracranial bleeding.

18.618 patients with VTE were included in both groups and median follow-up duration was a little over 100 days in both groups.

What did the authors find?

A: Apixaban was associated with a lower rate for recurrent VTE and a lower rate of gastro-intestional or intracranial bleeding compared to rivaroxaban

B: Apixaban was associated with a higher rate for recurrent VTE and a lower rate of gastro-intestional or intracranial bleeding compared to rivaroxaban

C: Apixaban was associated with a lower rate for recurrent VTE and a higher rate of gastro-intestional or intracranial bleeding compared to rivaroxaban

D: Apixaban was associated with a higher rate for recurrent VTE and a lower higher of gastro-intestional or intracranial bleeding compared to rivaroxaban

The correct answer is A.

This recently published paper was covered on JournalFeed last week.

An absolute reduction in probability of recurrent VTE and gastro-intestinal and intracranial bleeding was seen in favor of apixaban (recurrent VTE: 8.9 vs 11.4 events per 100 person-years. ICH and GI bleeds (7.2 vs 11.0 per 100 person-years).

Question 2

Source: www.highlandultrasound.com

You are attempting reduction of a distal metacarpal 5 fracture and you decide to perform an ultrasound guided ulnar nerve block.

Which of the following statements is true about performing an ulnar nerve block.

A: The ulnar nerve always runs radially to the ulnar artery

B: You need at least 10 cc’s of local anesthetic

C: The nerve should only be surrounded by local anesthetic on its superficial side

D: The ulnar nerve is most easily anesthetized proximal of the lower arm as it runs alongside the ulnar artery more distally

The correct answer is D.

SinaiEM covered hand blocks last week.

The ulnar nerve runs on the ulnar (medial) side of the ulnar artery and at the proximal lower arm it is separated from the artery. 3-5 cc’s of local anesthetic should be sufficient and the goal is to surround the nerve entirely by local anesthetic (however it should still work a bit if not the entire nerve is surrounded).

Question 3

Source: www.litfl.com

What is the most common ECG abnormality in patients with digoxin intoxication?

A: Atrial fibrillation

B: Any type of AV block

C: Ventricular tachycardia

D: Frequent Premature Ventricular Complex (PVC) including ventricular bigeminy and trigeminy

The correct answer is D.

Digoxin toxicity was covered on RebelEM this week.

Digoxin can cause a large variety of ECG abnormalities. The most common ECG abnormality is frequent PVCs.

Question 4

Source: www.dreamstime.com

The dose of IV insulin for hyperkalemia is often adjusted in patients with renal disease.

This recently published single center retrospective study is about 5 vs 10 units of IV insulin in patients with moderate renal dysfunction (eGFR 15-59 mL/min/m2) and symptomatic hyperkalemia.

A total of 377 hyperkalemic patients with moderate renal dysfunction were included.

The primary outcome was the rate of hypoglycemia in each group. Secondary outcomes included rate of potassium-lowering effect and incidence of severe hypoglycemia.

What did the authors find?

A: There were less hypoglycemic events in the 5 units group. Serum potassium was equally lowered in both groups

B: There were less hypoglycemic events in the 5 units group and serum potassium was lowered more in the 10 units group

C: There was no difference in hypoglycemic events between both groups and serum potassium was equally lowered in both groups

D: There was no difference in hypoglycemic events between both groups and serum potassium was lowered more in the 10 units group

The correct answer is D.

This week, JournalFeed discussed Insulin dose for hyperkalemia treatment in patients with moderate renal dysfunction.

In this study hypoglycemia occurred in 6.5% of patients in the 5 units iv insulin group and 8.4% of patients in the 10 units group (p = 0.476). Serum potassium lowered significantly more in the 10 units group compared to the 5 units group (-0.9 mmol/L vs. -0.63 mmol/L, p = 0.001).

Question 5

Source: www.safetylabintl.com

Your patient comes in comatose with a carbon monoxide (CO) level of 50 percent.

Which of the following results in the shortest CO half life?

A: Non rebreather mask

B: Hyperbaric oxygen

C: High Flow Nasal Cannula (HFNC)

D: Intubation and ventilation with an FiO2 of 1.0

The correct answer is B.

Carbon monoxide intoxication (and ECG changes) was covered on dr. Smith’s ECG blog last week.

Although evidence is not clear about it’s exact benefits, hyperbaric oxygen therapy is indicated for patients with carbon monoxide poisoning at high risk of persistent neurological sequelae. Carbon monoxide half life is 90 minutes in an intubated patient with 100% FiO2 and only 23 minutes in at 3 atmospheres (and 100% oxygen).

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

Reviewed and edited by Rick Thissen