Nicole van Groningen – Page 2

December 8, 2022December 9, 2022

Quiz 171, December 9, 2022

Welcome to the 171th FOAMed Quiz.

Question 1

Your 10 year old male patient presents with unilateral scrotal pain for 26 hours. He denies trauma and fever, but he vomited a couple of times.

You suspect testicular torsion.

Which of the following statements is true regarding diagnosis and management of this patient?

A: Emergent surgical exploration is not indicated, for the testicle will not survive after 24 hours anyway

B: Presence of flow on doppler ultrasound excludes testicular torsion

C: If manual detorsion is successful, your patient can be discharged and required outpatient follow up in 1 week

D: When treated promptly by surgical exploration, the chance of survival of the testicle is still about 7 percent

Reveal answer

The correct answer is D.

Testicular torsion was covered on RebelEM last week.

A systematic review demonstrates a 7.4 percent survival rate between 24 and 48 hours.
Presence of flow on doppler ultrasound does not reliably exclude testicular torsion.
Regardless of the success of manual detorsion, all patients will require surgical evaluation.

REBEL Core Cast 91.0 – Testicular Torsion

Question 2

Your 87 year old patient presents with a femoral neck fracture. She is in severe pain and you decide to perform an ultrasound guided nerve block.

In which of the following blocks, the local anesthetic should be injected deep to the psoas tendon?

A: Fascia Iliaca Compartment Block (FICB)

B: Femoral nerve block (FNB)

C: Pericapsular Nerve Group (PENG) block

Reveal answer

The correct answer is C.

EMDOcs covered nerve blocks in hip fractures last week.

There are 3 nerves that innervate the proximal femur. These are the femoral nerve, the obturator nerve and the accessory obturator nerve. The PENG block is thought to target these three nerves best. When performing a PENG block, the local anesthetic should be injected deep to the psoas tendon.

Ultrasound-Guided Regional Anesthesia for Hip Fractures

Question 3

Your patient presents with severe vulvar pain and she notices a swelling near her vagina.

In what location would you expect to find a Bartholin’s abscess in regard to the vaginal opening?

A: At 12 o’clock

B: At 2 o’clock

C: At 4 o’clock

D: At 6 o’clock

Reveal answer

The correct answer is C.

Bartholin’s abscess was covered on EM@3AM last week.

Bartholin’s glands are pea-sized and located bilaterally at the 4 o’clock and 8 o’clock positions of the introitus.

EM@3AM: Bartholin’s Abscess

Question 4

A woman with suspected ovarian torsion presents to your ED.

Which of the following statements is true about ovarian torsion?

A: Ovarian torsion affects women below 50 years of age only

B: Most patients have a cyst or mass >5 cm

C: The majority of patients present with fever

D: Nausea and vomiting is rare in patients wth ovarian torsion

Reveal answer

The correct answer is B.

Ovarian torsion was covered on emDOCs last week.

Women of all ages can have ovarian torsion. 15% of cases occur during infancy or childhood.

Most patients have a cyst or mass >5 cm.

Nausea and vomiting is present in 70% of patients.

Up to 20% of patients presents with fever.

emDOCs Podcast – Episode 67: Ovarian Torsion

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 1, 2022December 8, 2022

Quiz 170, December 2nd, 2022

Welcome to the 170th FOAMed Quiz.

Question 1

Pyridoxine is commonly found in food and dietary supplements. Pyridoxine is also used in the medical field as a treatment for pyridoxine deficiency, certain types of mushroom poisoning and treatment of a certain type of intoxication with tuberculosis antibiotics.

For which of the following intoxications is pyridoxine used?

A: Ethambutol

B: Rifampicin

C: Isoniazid

D: Pyrazinamide

Reveal answer

The correct answer is C, isoniazid.

The use of pyridoxine in the medical field was covered by emDOCS last week.

One of its active forms, pyridoxal phosphate plays an important role in the synthesis of GABA. Isoniazid causes pyridoxine deficiency which leads to GABA deficiency and seizures.

ToxCard: Pyridoxine Uses in Clinical Toxicology

Question 2

Source image: http://hqmeded-ecg.blogspot.com/

The ECG shown above belongs to your patient with acute shortness of breath and hemodynamic instability.

Which of the following is the most likely reason for her illness?

A: Pulmonary embolism

B: Cardiac tamponade

C: Myocardial infarction

D: Tension pneumothorax

Reveal answer

The correct answer is B.

This ECG was covered in dr. Smith’s ECG blog last week.

The ECG shows sinus tachycardia and a low voltage QRS with alternating amplitudes. This beat-to-beat variation in QRS amplitude and morphology is called electrical alternans and is seen in cardiac tamponade. On ultrasound you will find pericardial fluid and a ‘’swinging heart’’.

Question 3

Your patient presents with unilateral angio-edema. He is not in acute distress and shows no signs of acute airway compromise. He is known to have hypertension.

Which of the following antihypertensives is most likely the cause of his angio-edema?

A: Metoprolol

B: Nifedipine

C: Hydrochlorothiazide

D: Lisinopril

Reveal answer

The correct answer is D.

EMOttawa covered ACE-inhibitor induced angioedema last week.

ACE inhibitor-induced angioedema accounts for 30% of all angioedema presentations.

Question 4

Which of the following statements about ACE-inhibitor induced angioedema is true?

A: It is bradykinin-mediated

B: It is histamine-mediated

C: It is eosinophil-mediated

Reveal answer

ACE-induced angioedema, although not fully understood, is a bradykinin-mediated process.
Episodic angioedema with eosinophilia (EAE) is called Gleich’s syndrome.

Question 5

Which of the following is most likely effective in treatment of ACE-inhibitor induced angioedema according to the available evidence?

A: Adrenalin

B: Fresh Frozen Plasma (FFP)

C: Icatibant

D: Dexamethasone

E: None of the above.

Reveal answer

The correct answer is E.

So far, the available evidence shows no medications to be beneficial in ACE-inhibitor induced angio-edema.

Avoidance of airway compromise is the main goal of the therapy.

Question 6

Source image: www.multimedi.com and www.medbis.nl

What does the available evidence say about skin adhesives (glue) versus sutures for simple and non-infected wound?

A: Sutures lead to better cosmesis and lower pain scores but a slightly lower rate of wound dehiscence compared to skin adhesives

B: Sutures lead to equal cosmesis and equal pain scores and an equal rate of wound dehiscence compared to skin adhesives

C: Sutures lead to equal cosmesis, higher pain scores and a slightly lower rate of wound dehiscence

D: Sutures lead to worse cosmesis, equal pain scores but a slightly lower rate of wound dehiscence compared to skin adhesives

Reveal answer

The correct answer is C.

Wound closure techniques were covered on first10EM last week.

Using skin glue has benefits over sutures. It is faster and it leads to lower pain scores. Cosmesis is equal. Wound dehiscence is almost certainly more common, although this doesn’t seem to have any impact on long term outcomes.

Lacerations: Does closure technique matter?

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

November 25, 2022November 25, 2022

Quiz 169, November 25th, 2022

Welcome to the 169th FOAMed Quiz.

Question 1

In ophthalmology there are only a few, but serious emergency diagnoses. One of these is orbital compartment syndrome (OCS). Signs of an OCS include diminished visual acuity, relative afferent pupillary defect (RAPD) and reduced colour vision.

Which of the following statements is true?

A: Before treatment is initiated, it is essential to perform a CT-scan

B: In case of signs of OCS, one should not wait for imaging before treatment

C: OCS generally does not require treatment

Reveal answer

The correct answer is B.

Geeky Medics covered eye trauma last week.

In case of an OCS, direct intervention is required in the form of lateral canthotomy and cantholysis. Any delay in treatment due to waiting for imaging may cause irreversible sight loss. If there are no problems with the patient’s vision yet, frequent monitoring of visual acuity, pupils and intraocular pressure during the first 6 to 8 hours is vital to detect a deterioration early.

Eye Trauma

Question 2

Methemoglobinemia (MetHb) can cause a variety of symptoms depending on the level of MetHb. Methemoglobinemia can be caused by a variety of drugs.

Which of the following does not cause methemoglobinemia?

A: Isobutyl Nitrite (also called “poppers”)

B: Benzocaine

C: Ondansetron

D: Nitrofurantoin

Reveal answer

The correct answer is C

The diagnosis and treatment of methemoglobinemia was discussed on RebelEM last week.

Dapsone and topical anaesthetic agents (i.e. benzocaine) are the most common medications that cause methemoglobinemia. Isobutyl nitrite is probably the most common cause of methemoglobinemia in the Emergency Department. The pathophysiology is based on oxidation of the iron in the haemoglobin molecule.

REBEL Core Cast 90.0 – Methemoglobinemia

Question 3

POCUS is a valuable diagnostic tool for suspected right heart failure.

Which of the following signs supports the diagnosis of right heart failure:

A: Right ventricle (RV) free-wall thickness of 4 mm

B: Inferior vena cava (IVC) diameter of 9 mm

C: Tricuspid annular plane systolic excursion (TAPSE) of 14 mm

D: Right ventricle to left ventricle ratio of 0.6

Reveal answer

The correct answer is C.

This week emDocs covered diagnosis of right heart failure in the Emergency Department.

A right ventricle free wall of less than 5 mm is considered normal, as well as a right ventricle to left ventricle ratio of 0.6. A IVC diameter of only 9 mm suggests no elevated right ventricular pressure. A TAPSE of less than 20 mm is consistent with reduced right ventricular function.

Right Heart Failure in the ED: Approach to Diagnosis and Management

Question 4

In laceration repair, we are taught that eversion of wound edges leads to improved cosmesis.

What does the available evidence say?

A: Plenty of evidence concludes wound edge eversion indeed leads to improved cosmesis

B: No evidence is available on this subject

C: There is very little evidence available, but the evidence suggests wound edge eversion does not lead to improved cosmesis

Reveal answer

The correct answer is C.

Justin Morgenstern covered wound edge eversion on First10EM last week.

He concludes: ´There is very little evidence to guide us, but the necessity of eversion in wound repair seems to fall into the medical dogma camp.’

Laceration repair: Does eversion matter?

Question 5

Which of the following statements is true regarding necrotising enterocolitis (NEC)?

A: It is most likely to occure in neonates born postterm (after 42 weeks)

B: All neonates with NEC require surgical intervention

C: NEC has an 80 percent mortality rate

D: Severity of the disease is scored by the modified Bell’s staging criteria

Reveal answer

The correct answer is D.

Don’t forget the Bubbles covered the distended abdomen in neonates last week.

NEC occurs when sections of bowel tissue undergo inflammation leading to bacterial invasion and necrosis.

About 90 percent of NEC patients are born preterm. The mortality rate is 20 – 40 percent. Approximately 1 in 4 infants with NEC require surgery.

The modified Bell’s staging criteria can be used to determine the severity of the disease.

An approach to distended abdomens in neonates

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

November 17, 2022November 18, 2022

Quiz 168, November 18th, 2022

Welcome to the 168th FOAMed Quiz.

Question 1

What kind of device is this?

A: Implantable cardioverter defibrillator (ICD)

B: Regular pacemaker

C: Biventricular pacemaker

Reveal answer

The correct answer is A.

The thick coils are found in ICD’s, not in pacemakers.

The Pacemaker

Question 2

This ECG belongs to a patient with a pacemaker (obviously).

What is going on?

A: Failure to pace

B: Failure to capture

C: Failure to sense

Reveal answer

The correct answer is C.

There is a pacemaker spike present just before the p-wave and a spike after the start of the QRS. The QRS simply cannot be narrow when the pacemaker is conducted, so this is the patient’s native conduction at work.

The Pacemaker

Question 3

What happens (most likely) if you put a magnet on a pacemaker?

A: It shuts down and will not pace anymore

B: It will pace in a fixed rate (VOO)

C: It will go into DDD mode

Reveal answer

The correct answer is B.

The pacemaker should go into VOO mode when a magnet is placed on top of it. This means it will stop ‘’thinking’’ and just paces at a fixed rate.

The Pacemaker

Question 4

And the last one on pacemakers. Which of the following is a real pacemaker problem?

A: Faraway pacemaker

B: Takeaway pacemaker

C: Fadeaway pacemaker

D: Runaway pacemaker

Reveal answer

The correct answer is D. SinaiEM covered pacemaker problems last week. Runaway pacemaker is something you never hope to see: a total pulse generator malfunction in which the pacemaker creates rapid and unsustainable pulses. If conducted, this generates a potentially lethal ventricular arrhythmia. Cutting the pacemaker wires will save the life of your patient.

The Pacemaker

Question 5

Acute aortic dissection (AAD) requires rapid diagnosis and treatment.

On POCUS, which view can be used for the identification of an intimal flap in the aortic arch?

A: Parasternal long axis view

B: Suprasternal notch view

C: Abdominal aorta view

D: Subxyphoidal view

Reveal answer

The correct answer is B

EMDocs covered POCUS for aortic dissection in the clinical presentation of ischemic stroke last week.

A suprasternal notch view is acquired by placing the (phased array) transducer in the suprasternal notch and rotating the length of the probe between the left sternocleidomastoid muscle and the right clavicular head. The aortic arch and its branches can be visualised.

POCUS for aortic dissection in the clinical presentation of ischemic stroke

Question 6

Ultrasound assistance for lumbar punctures is used more and more regularly. It provides an opportunity to visualise and mark the spinous processes and the midline (and visualise the ligamentum flavum).

The most recent meta-analysis on this topic dates from 2019 and includes a total of 957 patients.

What did this meta-analysis show?

A: There was a statistically significant higher success rate when using ultrasound assistance versus a ‘blind’ procedure

B: There was no difference in success rate between ultrasound assistance and ‘blind’ procedure

C: There was a statistically significant higher success rate when using a ‘blind’ procedure versus ultrasound assistance

Reveal answer

The correct answer is A

SinaiEM covered ultrasound assisted lumbar puncture last week.

In this meta-analysis, there was a statistically significant increase in success rate as well as decrease in procedure time, fewer passes with the needle, and decrease in pain score when comparing ultrasound assisted lumbar puncture versus a blind procedure.

POCUS guided LP

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

November 10, 2022November 11, 2022

Quiz 167, November 11, 2022

Welcome to the 167th FOAMed Quiz.

Question 1

Acute decompensated heart failure is the cause of dyspnea in up to 40% of the older adults in the ED. Accurate and timely diagnosis is important.

When comparing POCUS to plain radiography, which has the highest sensitivity for acute decompensated heart failure?

A: Plain radiography

B: POCUS

C: The sensitivity of plain radiography and ultrasound is equal

Reveal answer

The correct answer is B

POCUS versus plain radiography for acute decompensated heart failure was covered on CanadiEM last week.

The sensitivity of POCUS for acute decompensated heart failure is about 90 percent, compared to a sensitivity of about 70 percent of plain radiography. The specificity of both modalities is more or less equal.

Clinical Question: How does the sensitivity/specificity of lung ultrasound compare to plain films in diagnosing acute decompensated heart failure?

Question 2

Manual pulse checks during CPR tend to be quite inaccurate.

In this recently published paper, 54 patients and 213 pulse checks were analysed during CPR. All patients had an arterial line in place. During a pulse check, manual pulse detection, femoral artery doppler ultrasound clips, and systolic blood pressure were recorded simultaneously.

The primary outcome was detection of any pulse which correlated with an arterial line signal.

What did the authors find?

A: Manual pulse check was more accurate than doppler ultrasound

B: Doppler ultrasound was more accurate than manual pulse check

C: Manual pulse check and doppler ultrasound were equally accurate

Reveal answer

The correct answer is B

Taming the SRU covered the paper last week.

The accuracy of doppler ultrasound of the femoral artery was higher than manual palpation (95.3% vs. 54.0%; p < 0.001) for detection of any pulse during the pulse checks.

Question 3

Which of the following recommendations concerning irrigation in laceration wound care is supported by evidence?

A: Irrigation leads to fewer wound infections

B: High pressure irrigation leads to fewer wound infections

C: 50 to 100 mL of irrigation for every centimetre of the laceration leads to fewer wound infections

D: Irrigation with povidone-iodine leads to delayed wound healing

E: Irrigation with normal saline leads to fewer wound infections compared to tap water

F: None of the recommendations above are supported by evidence

Reveal answer

The correct answer is F

Justin Morgenstern covered the literature behind irrigation of lacerations on First10EM last week.

Apparently there is not a lot of data on this subject and the available data isn’t very conclusive.However, that doesn’t mean you should change your practice.

How should we irrigate lacerations? Does it even matter?

Question 4

Your patient’s ECG shows bizarre T-waves and you suspect a ‘’pulse tapping artefact’’.

What causes a pulse tapping artefact?

A: The patient taps his of her finger on an electrode, synchronous to the heartbeat

B: An electrode is placed on top of an artery

C: The ECG lead junction box is connected in a wrong way

D: The patient has a Parkinsonian tremor

Reveal answer

The correct answer is B

A case of pulse tapping artefact was covered on dr. Smiths ECG blog.

A pulse tapping artefact or arterial pulse tapping artefact can be found when an electrode is placed on top of an artery. It is generated by the movement of the electrode with each pulsatile motion of blood flow.

Question 5

The role of dual sequential defibrillation (using 2 defibrillators more or less simultaneously) in refractory shockable rhythms remains uncertain.

In the recently published DOSE VF study, 450 adult patients with out-of-hospital cardiac arrest and refractory ventricular fibrillation (at least 3 attempts at defibrillation had been unsuccessful) were randomised to either:

– Standard defibrillation

– Vector Change defibrillation: pads were changed to an anterior-posterior position

– Double Sequential defibrillation

The primary outcome was survival to hospital discharge.

What did the authors find?

A: Patients in the Double Sequential defibrillation group and patients in the Vector Change defibrillation group had a statistically significant higher survival to hospital discharge rate compared to standard defibrillation

B: Patients in the Double Sequential defibrillation group had a statistically significant higher survival to hospital discharge rate compared to standard defibrillation. Patients in the Vector Change defibrillation group did not

C: Survival to hospital discharge was not statistically significantly different between the 3 groups

Reveal answer

The correct answer is A

The paper was covered on First10EM and UMEM last week.

Both treatment groups were statistically superior to standard defibrillation. Survival was 30.4% with Double Sequential defibrillation, 21.7% with Vector Change defibrillation, and 13.3% with standard care.

However, keep in mind this trial is unblinded and stopped early without a pre-specified endpoint. Justin Morgenstern sums up the methodological issues nicely on First10EM.

One other issue to consider is the possibility of damaging a defibrillator by using Dual Sequential defibrillation.

Dose VF: A double sequential defibrillation game changer?

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

November 4, 2022November 5, 2022

Quiz 166, November 4th, 2022

Welcome to the 166th FOAMed Quiz.

Question 1

Which of the following risk scores is developed for necrotizing soft tissue infections?

A: EDACS

B: LRINEC

C: ADD-RS

D: ABCD2

Reveal answer

The correct answer is B

Necrotizing soft tissue infections were covered on EMDocs last week.

EDACS stands for Emergency Department Assessment of Chest Pain Score.

ADD-RS is the Aortic Dissection Detection Risk Score.

The ABCD2 score is used to estimate risk of stroke (CVA) after a transient ischemic attack (TIA).

The LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) score was developed to distinguish necrotizing fasciitis from severe cellulitis. However, its sensitivity and specificity are pretty low so it is pretty much useless.

Question 2

Source image: www.banyantreatmentcenter.com

Your 50 year old patient with alcoholic liver disease presents with altered mental status and a fever. On POCUS you find extensive free intraperitoneal fluid and you suspect Spontaneous Bacterial Peritonitis (SBP).

Which of the following findings makes the diagnosis less likely?

A: Serum CRP of 5 mg/L

B: Ascites pH of 7.40

C: Ascites neutrophil count of 350 cells/mm3

D: Negative ascites gram stain

Reveal answer

The correct answer is B

Spontaneous bacterial peritonitis was covered on RebelEM last week.

Serum CRP is not beneficial in the diagnosis of SBP.

An ascites neutrophil count of > 250 cells/mm3 makes the diagnosis more likely.

The gram stain of ascites is generally negative in SBP.

A normal pH (or pH gradient of < 0.10) correlates with a low likelyhood ratio (LR = 0.12). Source

REBEL Core Cast 89.0 – Spontaneous Bacterial Peritonitis

Question 3

Your 89 year old patient has fallen in her home and presents to you with pelvic pain. Conventional X-ray of the pelvis was negative but she remains unable to walk. You wonder what the chance is of an occult fracture.

This recently published retrospective study is about the diagnostic value of conventional imaging in suspected pelvic injury in patients of 65 years and older. 177 patients were included, with a total of 555 fractures. All patients had an X-ray and CT scan of the pelvis.

What was the sensitivity of plain radiographs?

A: 28%

B: 48%

C: 68%

D: 88%

Reveal answer

The correct answer is B.

UMEM mentioned the paper in their pearls section last week.

Global pooled sensitivity for pelvic radiographs in detecting pelvic fractures compared to CT was 48%, with a specificity of 93%. Sensitivity was lowest in Sacrum and Ilium fractures.

18 patients were treated with surgical fixation of which in only half the cases the fractures were appreciated on plain radiographs by both examiners.

Question 4

Patients with acute pancreatitis generally receive large amounts of iv fluid.

This recently published multicentre randomised controlled trial (the WATERFALL study) is about aggressive versus moderate fluid administration in patients with acute pancreatitis.

Aggressive fluid resuscitation consisted of a bolus of 20 ml per kilogram of body weight, followed by 3 ml per kilogram per hour. Moderate fluid resuscitation consisted of a bolus of 10 ml per kilogram in patients with hypovolemia or no bolus in patients with normovolemia, followed by 1.5 ml per kilogram per hour.

A total of 249 patients were included in the interim analysis. The primary outcome was development of moderately severe or severe pancreatitis during hospitalisation. The main safety outcome was fluid overload.

What did the authors find?

A: Development of moderately severe or severe pancreatitis was more common in the aggressive fluid resuscitation group. Fluid overload was also more common in the agressive fluid resuscitation group.

B: Development of moderately severe or severe pancreatitis was more common in the aggressive fluid resuscitation group but there was no difference in rate of fluid overload between the groups

C: Development of moderately severe or severe pancreatitis was equal between the groups but fluid overload was more common in the aggressive in fluid group

D: Development of moderately severe or severe pancreatitis was equal between the groups and there was no difference in rate of fluid overload

Reveal answer

The correct answer is C.

The paper was covered on First10EM last week.

The incidence of moderately severe or severe pancreatitis was 22.1% in the aggressive-resuscitation group and 17.3% in the moderate-resuscitation group (p = 0.32). Fluid overload developed in 20.5% of patients in the aggressive resuscitation and in 6.3% of those who received moderate resuscitation (P = 0.004).

The trial was halted due to this difference in the safety outcome without a significant difference in the incidence of moderately severe or severe pancreatitis.

Research Roundup October 2022

Question 5

Adverse reactions of immunotherapy in treatment of cancer are quite common. They include colitis, pneumonitis and endocrine dysfunction among many others.

Until what time after immunotherapy treatment is seized can these complications occur?

A: 2 days

B: 2 weeks

C: 2 months

D: 2 years

Reveal answer

The correct answer is D

Taming the SRU covered complications of immunotherapy last week.

Adverse reactions can occur up to 2 years after immunotherapy.

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

October 14, 2022October 24, 2022

Quiz 164, October 21st, 2022

Welcome to the 164th FOAMed Quiz.

Question 1

Source image: www.infectioncontroltoday.com

Early recognition of necrotizing soft tissue infections is very important.

Point of care ultrasound (POCUS) can be a valuable tool for rapid identification of necrotizing soft tissue infections.

What are possible signs of a necrotizing soft tissue infection with POCUS?

A: Subcutaneous thickening, air / emphysema in the subcutaneous tissue, fascial fluid layer greater than or equal to 2mm, cobblestoning

B: Subcutaneous atrophy, air / emphysema in the subcutaneous tissue, fascial fluid layer greater than or equal to 2mm

C: Subcutaneous atrophy, fascial fluid layer smaller than or equal to 0.5mm, cobblestoning

D: Air / emphysema in the subcutaneous tissue, fascial fluid layer greater than or equal to 2mm, squish sign

Reveal answer

The correct answer is A.

This week CoreEM covered POCUS in necrotizing soft tissue infections.

Ultrasound findings include:
– Subcutaneous thickening
– Air or emphysema in the subcutaneous tissue, which will appear as dirty shadowing – reverberation artifact from the interface where the air meets the tissue
– A fascial fluid layer greater than or equal than 2 mm

Squish sign is a movement of echogenic particles in response to compression, it is a sign of abscess.

Ultrasound Diagnosis of Necrotizing Soft Tissue Infections

Question 2

Idarucizumab (average costs 1.373,40 euro per ampule.. and you need 2) can be administered in life threatening hemorrhage in case the patient uses which of the following Direct Oral AntiCoagulants?

A: Edoxaban

B: Dabigatran

C: Rivaroxaban

D: Apixaban

Reveal answer

The correct answer is B.

EMOttawa covered reversal of anticoagulants last week.

Idarucizumab is a monoclonal antibody which binds serum dabigatran with 350 times the affinity than dabigatran has for thrombin. Although expensive, the costs are similar to the costs of reversal by using four-factor prothrombin complex concentrate.

Question 3

Your 63 year old patient comes in with profound hypertension. Her blood pressure is 230 / 120. You perform fundoscopy and you find the following:

To which grade hypertensive retinopathy according to the The Keith-Wagener-Barker classification does this image correspond?

A: Grade 1

B: Grade 2

C: Grade 3

D: Grade 4

Reveal answer

The correct answer is B.

Geekymedics covered hypertensive retinopathy last week.

The image above shows AV nicking and focal vasoconstriction, but no hemorrhages or cotton wool spots. Therefore is should be scored as a grade 2 hypertensive retinopathy.

Source image: myneurologytips.blogspot.com

Hypertensive Retinopathy

Question 4

Which of the following capnography waveforms suggests bronchospasm?

Reveal answer

The correct answer is B.

The basics of capnography were covered on Don’t Forget the Bubbles last week.

Image A is considered a normal capno wave.

In B, the plateau has not been reached during expiration before inspiration occurs. This is consistent with bronchospasm.

In C, a small depression during expiration suggests spontaneous respiratory effort.

A Beginner’s Guide to Capnography

Question 5

What is a typical presentation of ‘acute flaccid myelitis’?

A: Upper respiratory and/or gastro-intestinal symptoms 1-2 weeks preceding a rapidly progressive weakness of one or more extremities

B: Upper respiratory and/or gastro-intestinal symptoms 1-2 weeks preceding a gradual progressive weakness of one or more extremities

C: Upper respiratory and/or gastro-intestinal symptoms 3-4 weeks preceding a rapidly progressive weakness of one or more extremities

D: Upper respiratory and/or gastro-intestinal symptoms 3-4 weeks preceding a gradual progressive weakness of one or more extremities

Reveal answer

The correct answer is A.

Pediatric EM Morsels discussed acute flaccid myelitis last week.

Acute flaccid myelitis is used for presentations similar to poliomyelitis, but without poliovirus being found. There is a rapidly progressive weakness (most often proximal) with a viral prodrome 1-2 weeks preceding the weakness. It is associated with infections with enteroviruses, coxsackieviruses, flaviviruses, herpesviruses and adenoviruses. Because of its rapid progression, patients need to be hospitalized to observe and treat respiratory distress.

Acute Flaccid Myelitis

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

August 12, 2022October 21, 2022

Quiz 163, October 14th, 2022

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Welcome to the 163th FOAMed Quiz

Question 1

A 6-year-old boy fell with his right side on the curb while cycling and presents with abdominal pain. You decide to perform a FAST exam (Focussed Assessment with Sonography for Trauma).

Which statement about pediatric FAST is true?

A: Pediatric FAST is as sensitive as adult FAST in detection of traumatic solid organ injuries

B: The most sensitive view for detection of free intra-abdominal fluid is the suprapubic view

C: A limited amount of pelvic free fluid is never physiologic in pediatric patients

Reveal answer

The correct answer is B

ALiEM discussed pediatric FAST in their PEM POCUS series this week.

Pediatric FAST is less sensitive than adult FAST in detection of traumatic solid organ injuries, because intra-abdominal injury in children is less likely to result in hemoperitoneum. The suprapubic view is the most sensitive, whereas in adults the RUQ view is the most sensitive for detection of free intra-abdominal fluid. A limited amount of pelvic free fluid can be physiologic in children (both boys and girls).

PEM POCUS Series: Pediatric Focused Assessment with Sonography for Trauma (FAST)

Question 2

Early seizures are common after spontaneous intracerebral hemorrhage (SIH). The clinical value of these seizures is unknown, but it is thought they might be associated with haematoma expansion and worse neurological outcomes. At of this moment, routine prophylactic anti-epileptic treatment is not recommended.

In the recently published PEACH trial, 50 adult patients (42 included in analysis) who presented with spontaneous intracerebral hemorrhage within 24 hours after onset were randomly assigned to levetiracetam (intravenous 500 mg every 12 hours) or placebo.

The primary outcome was the occurrence of at least one clinical seizure within 72 hours of inclusion or at least one electrographic seizure recorded on continuous EEG.

What did the authors find?

A: The incidence of seizures was statistically significant higher in the placebo group

B: The incidence of seizures was statistically significant higher in the levetiracetam group

C: The incidence of seizures did not differ between the groups

Reveal answer

The correct answer is A.

The PEACH trial was covered on First10EM and EMCrit last week.

Clinical or electrographic seizure was observed in three (16%) of 19 patients in the levetiracetam group versus ten (43%) of 23 patients in the placebo group (p=0.043).

However, there were no clinical seizures observed and the difference is entirely based on non-clinical seizures detected on EEG.

Furthermore, the authors were planning on including 102 patients and ended up with only 42.

The PEACH trial of seizure prophylaxis for head bleeds: Not such a peach

Question 3

‘’The armor phenomenon’’ refers to the theoretical protective factor of obesity for abdominal injury in trauma.

This recently published systematic review and meta-analysis looked at whether obesity was indeed a protective factor in penetrating abdominal trauma.

9 studies were included for quantitative analysis, including 5,013 patients sustaining penetrating thoracoabdominal injuries, of which 29.6% were obese.

What did the authors find?

A: Obese patients had a lower morbidity and mortality following penetrating thoracoabdominal injuries

B: Obese patients had a higher morbidity and mortality following penetrating thoracoabdominal injuries

C: The morbidity and mortality did not differ between obese and non-obese patients

Reveal answer

The correct answer is B.

UMEM covered the paper briefly last week.

Obese patients suffered more respiratory complications and were at an increased risk of death during their admission.

Question 4

Source image: youtube.com/rhesus medicine

Which of the following ECG abnormalities is caused by hypercalcemia?

A: Long QTc interval

B: Short PR interval

C: Widened QRS complex

Reveal answer

The correct answer is C.

RebelEM covered hypercalcemia on their podcast last week.

Hypercalcemia causes shortening of the QTc interval, prolonging of the PR interval and can cause widening of the QRS complex.

REBEL Core Cast 87.0 – Hypercalcemia

Question 5

During CPR, pulse checks should be as short as possible. Cardiac POCUS has been used but there have been concerns about longer duration of interruption of compressions.

Another way of using POCUS for pulse checks is to check for carotid pulse using doppler.

In this recently published paper 25 cardiac arrest patients and 155 pulse checks were analyzed.

The average time for carotid pulse identification using POCUS was compared to the manual carotid identification time.

What did the authors find?

A: The time for carotid pulse identification using POCUS was shorter than the time for manual carotid pulse identification

B: The time for carotid pulse identification using POCUS was longer than the time for manual carotid pulse identification

C: There was no difference

Reveal answer

The correct answer is A

The average time to carotid pulse identification per patient using POCUS was 1.62 (1.14-2.14) seconds compared to 3.50 (2.99-4.99) seconds in manual carotid identification.

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

July 7, 2022July 9, 2022

Quiz 161, July 8th, 2022

Welcome to the 161st FOAMed Quiz.

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

Reveal answer

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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

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

June 24, 2022June 24, 2022

Quiz 159, June 24th, 2022

Welcome to the 159th FOAMed Quiz.

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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.

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

Reveal answer

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

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