Nicole van Groningen – Page 3

June 16, 2022June 17, 2022

Quiz 158, June 17th, 2022

Welcome to the 158th FOAMed Quiz.

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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

Reveal answer

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

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

Reveal answer

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

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 9, 2022June 10, 2022

Quiz 157, June 10th, 2022

Welcome to the 157th FOAMed Quiz.

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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/

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

Reveal answer

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.

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

May 20, 2022May 20, 2022

Quiz 155, May 20, 2022

Welcome to the 155th FOAMed Quiz.

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)

Reveal answer

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.

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

Reveal answer

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.

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

Reveal answer

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.

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

Reveal answer

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

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

May 5, 2022May 6, 2022

Quiz 153, May 6, 2022

Welcome to the 153th FOAMed Quiz.

Question 1

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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.

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

April 22, 2022April 22, 2022

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

Reveal answer

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).

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

Reveal answer

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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

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

March 31, 2022April 1, 2022

Quiz 150, April 1st, 2022

Welcome to the 150th FOAMed Quiz.

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

Reveal answer

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

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

Reveal answer

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.

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

Reveal answer

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.

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

Reveal answer

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.

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

March 9, 2022March 18, 2022

Quiz 148, March 11, 2022

Welcome to the 148th FOAMed Quiz.

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

Reveal answer

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.

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 RCT, 468 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

Reveal answer

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).

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

Reveal answer

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

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

Reveal answer

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.

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

February 24, 2022February 25, 2022

Quiz 146, February 25th

Welcome to the 146th FOAMed Quiz.

Question 1

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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).

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

February 18, 2022February 18, 2022

Quiz 145, February 18th

Welcome to the 145th FOAMed Quiz.

Question 1

A routine urinalysis comes back clearly positive for a urinary tract infection. Among the results is the urine pH. You intend to treat it with nitrofurantoin.

What does an urine pH ≥8 say about possible nitrofurantoin resistance?

A: Nothing

B: More likely to be resistant

C: Less likely to be resistant

Reveal answer

The correct answer is B.

This week JournalFeed discussed Alkaline Urine and Nitrofurantoin resistance.

Proteae group bacteria, more often resistant to nitrofurantoin, are urease producing, which often makes the urine pH alkaline. This recently paper found that for a urine pH 5-7, 80% of cultures were sensitive to nitrofurantoin, but for a urine pH >9 just 54.6% were sensitive.

Question 2

The efficacy of topical tranexamic acid (TXA) in epistaxis remains controversial. The NoPac RCT, published last year, failed to demonstrate superiority of topical TXA compared to placebo at controlling bleeding and reducing the need for anterior nasal packing.

Recently a systematic review and meta-analysis about this topic was published. A total of eight studies were included in the analysis, including seven randomized trials and one retrospective study. A total of 1299 patients were included, of which 46% received TXA while 54% received control treatment.

What did the authors of this systematic review and meta-analysis find?

A: Placebo was more effective in controlling bleeding compared to topical TXA

B: Placebo and topical TXA were equally effective in controlling bleeding

C: Topical TXA was more effective in controlling bleeding compared to placebo

Reveal answer

The correct answer is C.

The paper was covered on JournalFeed last week.

Patients who were treated with TXA were 3.5 times more likely to achieve bleeding cessation at the first assessment and had a 63% less likelihood of returning due to rebleeding at 24-72 hours.

Question 3

Which of the following statements about febrile seizures is true?

A: Keeping the temperature down will stop the child having a febrile convulsion

B: Children who have had a simple febrile convulsion have a slightly higher risk than the general population of developing epilepsy

C: Simple febrile convulsions can cause brain damage or long-term problems

D: Febrile convulsions often need medication to stop them

Reveal answer

The correct answer is B.

Febrile seizures was covered on Don’t Forget the Bubbles last week.

Children who have had a simple febrile convulsion have a slightly higher risk than the general population of developing epilepsy

5 febrile convulsion myths

Question 4

You are performing procedural sedation on a 4 year old child for abscess drainage. 10 minutes after Ketamine administration she develops a stridor and becomes hypoxic.

Which of the following options is not indicated as treatment for larygospasm?

A: Positive Pressure Ventilation

B: Deeper sedation using propofol

C: Administration of paralytic agent

D: Try to wake the child up

Reveal answer

The correct answer is D.

PedEM Morsels covered laryngospasm last week.

Trying to wake the child up (or proceeding with a painful procedure) will most likely make laryngospasm worse.

You can try pressing the laryngospasm notch behind the earlobe and the mandible’s ramus, but most of all you have to stop all stimuli and if needed deepen sedation (I would you propofol in this case). Further down the road of troubles you can intubate after administration of a paralytic agent.

Ketamine and Laryngospasm

Question 5

Which of the following pathogens is most common in cellulitis?

A: Group A Streptococcus

B: Staphylococcus aureus

C: Haemophilus influenzae type B

D: Neisseria meningitidis

Reveal answer

The correct answer is A.

Cellulitis was covered on EMDocs last week.

The most common cause of cellulitis are beta-hemolytic streptococci (groups A, B, C, G, and F) and most commonly group A Streptococcus.

EM@3AM: Cellulitis

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

Reviewed and edited by Rick Thissen

February 3, 2022February 4, 2022

Quiz 143, February 4th, 2022

Welcome to the 143th FOAMed Quiz.

Question 1

The discussion about normal saline versus balanced fluids in critically ill patients is ever ongoing. The 2018 SMART trial suggested a reduction of renal dysfunction in favor of balanced fluids. The 2021 BASICS trial did not find any difference in mortality between normal saline and balanced fluids.

The PLUS trial was recently published. 5037 critically ill (ICU) patients were randomized to either normal saline or Plasma-Lyte. The primary outcome was death from any cause within 90 days of randomization.

What did the authors find?

A: Mortality was significantly higher in the normal saline group

B: Mortality was significantly higher in the Plasma-Lyte group

C: Mortality was equal in both groups

Reveal answer

The correct answer is C.

First10EM covered the PLUS trial last week.

There was no difference in the primary outcome of all cause mortality (21.8% vs 22.0%).

The ongoing saga of normal saline versus balanced fluids

Question 2

Much can be said about the best induction agent for emergency endotracheal intubation.

The recently published EvK trial is about ketamine versus etomidate in emergency tracheal intubation.

801 critically ill inpatients requiring emergency intubation were randomly assigned to receive etomidate or ketamine for sedation prior to intubation.

The primary outcome was 7 day survival. Secondary endpoints included 28 day survival.

What did the authors find?

A: 7 day survival was significantly lower in the etomidate arm than in the ketamine arm

B: 21 day survival was significantly lower in the etomidate arm than in the ketamine arm

C: 7 day survival was significantly lower in the ketamine arm than in the etomidate arm

D: 21 day survival was significantly lower in the ketamine arm than in the etomidate arm

Reveal answer

The correct answer is A.

The EvK trial was covered on JournalFeed this week.

The 7 day survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%). 28 day survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%).

Question 3

A 49 year old, otherwise healthy, man visits your ED. He complains of a local red swollen left elbow. His vital signs are normal. You suspect septic olecranon bursitis.

According to this recently published retrospective cohort study, would it be appropriate to treat the patient with antibiotics only (without aspiration of incision and drainage)?

A: Yes, antibiotics alone is an appropriate approach

B: No, antibiotics alone only resolves the symptoms in 20 percent of patients

Reveal answer

The correct answer is A.

This week Skeptic Guide to EM covered treatment of septic bursitis.

This retrospective study included 190 cases of septic olecranon bursitis over eight years time. 147 patients were discharged on empiric antibiotics (no aspiration or drainage), of which 134 had follow up data available. 88% of them had no need for further intervention and healed.

Question 4

Vomiting and nausea are among the most frequently encountered and difficult to treat complaints in the emergency department.

Match the correct drug and mechanism of action.

A: Metoclopramide

B: Ondansetron

C: Erytromycin

D: Domperidon

1: D2-dopamine antagonist

2: Motilin receptor agonist

3: Central and peripheral dopamine receptor antagonist, 5-HT4 agonist, and a weak 5-HT3 antagonist

4: 5-HT3 antagonist

Reveal answer

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

This week’s Taming the SRU blog was about gastroparesis, cyclic vomiting syndrome and cannabinoid hyperemesis syndrome.

Drugs that act as antagonists of D2-dopamine receptors have antiemetic properties, drugs that act as motilin receptor agonist or 5-HT4 agonist have prokinetic properties and drugs that act as 5-HT3 antagonist suppress the vomiting reflex.

Question 5

What is the name of the lead placement used to increase accuracy for detection of epsilon waves in arrhythmogenic right ventricular dysplasia (ARVD)?

A: Lewis lead placement

B: Fontaine lead placement

C: V4R lead placement

Reveal answer

The correct answer is B.

LITFL covered Fontaine lead placement this week.

Fontaine bipolar precordial leads (F-ECG) can be used to increase the sensitivity of epsilon wave detection in ARVD.

Fontaine lead

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

Reviewed and edited by Rick Thissen