Quiz 46, October 11th, 2019

Question 1

Which of the following statements is true about Wernicke’s Encephalopathy?

A: Administration of 100 mg IV thiamine prophylactically protects against deficiency for approximately one week

B: The 3 classic clinical features of Wernicke’s Encephalopathy are: ophthalmoplegia, paresis, and altered mental status/confusion

C: Only alcoholics get Wernicke’s Encephalopathy

The correct answer is A

Wernicke’s Encephalopathy was discussed on the ever great Tox and Hound blog this week.

Administration of 100 mg IV thiamine prophylactically protects against deficiency for approximately one week.

The 3 classic clinical features include: ophthalmoplegia, ataxia, and altered mental status/confusion. And well, everybody can get Wernicke’s Encephalopathy, as long as you are thiamine deficient.

Tox and Hound – Don’t Wernicke’s, B(1) Happy

Question 2

Source image: litfl.com

According to this 2019 paper, can Emergency Physician Gestalt “Rule In” or “Rule Out” Acute Coronary Syndrome (ACS)?

A: Clinician gestalt is not safe to ‘’rule out’’ ACS

B: Clinician gestalt is sufficiently accurate to ‘’rule in’’ ACS

C: The ECG does not improve the Positive Predictive Value (PPV) when added to clinical gestalt to ‘’rule in’’ ACS

The correct answer is A

REBELem covered this really interesting paper.

Clinician gestalt was not safe to ‘’rule out’’ ACS (NPV 95.0%) and not sufficiently accurate to ‘’rule in’’ ACS (PPV: 71.2%). The ECG did improve the Positive Predictive Value (PPV) when added to clinical gestalt to ‘’rule in’’ ACS (PPV 95%).

Can Emergency Physicians Use Clinical Gestalt to Predict Acute Coronary Syndrome?

Question 3

A 28-year-old male presents to the ED with hyperthermia, tachycardia and a yellow discoloration of the skin, eyes and body fluids. He states he just started a new weight loss supplement and his symptoms started about 5 hours after ingestion.

Which bodybuilding supplement is associated with these symptoms?

A: Creatine

B: Arginine

C: DNP (2,4-dinitrophenol)

D: Ginseng

The correct answer is C

ALiem covered DNP intoxication last week.

DNP is a yellow organic compound which causes mitochondrial uncoupling, loss of ATP production and unregulated hyperthermia. It can affect all organ systems and can cause yellow discoloration of the skin. Symptoms will present within 4-8 hours. DNP is currently on the market as a weight loss agent.

The treatment exists of supportive care and management of hyperthermia.

ACMT Toxicology Visual Pearls: Getting Caught Yellow-handed

Question 4

A 37-year-old patient is brought to your Emergency Department after being shocked with a conductive energy device (CEW) (for example a TASER) for about 5 seconds. He is awake, alert and does not have any physical complaints.

Which of the following has to be part of your initial work-up?

A: Electrocardiogram

B: Serum CK

C: Electrolytes

D: None of the above

The correct answer is D

This recently published paper was discussed on JournalFeed.

CEW’s give a jolt of 50.000 volts, which seems like a lot. If the duration of the shock was below 15 seconds (which should normally be enough for a defense mechanism) and your patient is awake and alert, there is no indication for ECG, prolonged cardiac monitoring or measurement of troponin. Also, no studies found electrolyte abnormalities. Marginal elevations of lactate and CK are occasionally encountered. A careful physical examination should be enough to rule out injury from the device.

Question 5

Source image: https://first10em.com/heparin/

Which of the following statements about Heparin in management of Acute Coronary Syndrome is true?

A: The practice of giving STEMI patients anticoagulation is based on strong evidence

B: There are no trials of Heparin in STEMI patients undergoing percutaneous coronary intervention (PCI)

C: Heparin is absolutely necessary for PCI

The correct answer is B

Justin Morgenstern covered Heparin in STEMI and PCI on his latest post on First10EM.

‘’ The practice of giving STEMI patients anticoagulation has never been based on strong evidence. There are no trials of heparin in STEMI patients undergoing PCI, and the trials of heparin in thrombolysed patients are mixed and have significant flaws.’’

Heparin does not seem to be absolutely necessary for elective PCI neither, for the only strong evidence available (the CIAO trial) demonstrated harm from heparin in the setting of PCI for stable coronary artery disease.

Heparin in STEMI and PCI – does it help?

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This quiz was written by Eefje Verschuuren, Nathalie Dollee Kirsten van der Zwet and Hüsna Sahin

Reviewed and edited by Rick Thissen

Quiz 45, September 27th, 2019

Question 1

Source: emdocs.net

Which of the following statements is true about Point Of Care UltraSound (POCUS) assessment of free intraperitoneal air?

A: POCUS has a higher specificity for intraperitoneal air compared to an upright plain X-ray

B: Movement of reverberation artifacts with peristalsis indicates free intraperitoneal air

C: POCUS has a similar sensitivity for intraperitoneal air compared to CT abdomen

D: An enhanced peritoneal stripe sign (EPSS) is caused by a highlighted interface between gas and soft tissue

The correct answer is D

EMdocs covered POCUS for diagnosis of free intraperitoneal air recently.

The sensitivity and specificity for pneumoperitoneum by POCUS are 92% and 53% respectively. The sensitivity is more or less equal to plain radiography. Movement of reverberation artifacts with peristalsis indicates intraluminal air. An enhanced peritoneal stripe sign (EPSS) is caused by a highlighted interface between gas and soft tissue. Normally (with fluid underneath) the peritoneum will only appear as a thin line.

Question 2

Source: emdocs.net

Which of the following statements is true about achilles tendon ruptures?

A: Ultrasound is useful to diagnose an achilles tendon rupture

B: The Thompson Test has a sensitivity of only 75%

C: Ultrasound can help differentiate between complete and partial ruptures

D: Operative management leads to better outcomes compared to conservative management

The correct answer is C

BrownEM covered achilles tendon ruptures last week.

Imaging is not necessary for diagnosis of achilles tendon ruptures. The Thompson Test has a sensitivity of 96%. Nonoperative vs. operative management management remains controversial. And indeed, ultrasound can help differentiate between complete and partial ruptures.

Question 3

Source: litfl.com

Your patient presents with an episode of AV Nodal Reentry Tachycardia (AVNRT) and you want to start with vagal manoeuvers. You wonder weather lifting her legs in the air after blowing the syringe is helpful at all. Is lifting the legs after blowing the syringe (Modified Valsalva) beneficial compared to just blowing a syringe (standard Valsalva) or does it just look silly according to recent evidence?

A: No, modified Valsalva is less effective compared to standard Valsalva

B: Modified Valsalva is equally effective compared to standard Valsalva

C: Modified Valsalva is more effective compared to standard Valsalva

The correct answer is C

REBELem covered this paper last week.

Yes lifting the legs after Valsalva is definitely beneficial. Conversion to sinus rhythm within 60 seconds after manoeuvre was found to be 16% in the standard Valsalva group versus 46% in the modified Valsalva group.

Standard Valsalva vs Modified Valsalva for Cardioversion of SVT?

Question 4

Your pregnant patient is in her 3th trimester (29 weeks) and she presents to your department feeling generally unwell. Her blood pressure is measured twice at 160/100, 4 hours apart and her urine protein to creatinine ratio is 0.45. Does your patient have preeclampsia?

A: Yes, the diagnostic criteria have been met

B: No she does not have preeclampsia

C: Maybe, but it depends on thrombocyte count and transaminase levels

The correct answer is A

NUEM published a great infographic about preeclampsia.

Diagnostic criteria are:
Blood pressure of ≥ 150 / 90 measured twice at least 4 hours apart or a blood pressure or ≥ 160/110 measured twice at least 15 minutes apart AND and-organ dysfunction. Just have a look at the infographic.

Question 5

Source: pixabay.com

The Mallampati score has become a routine part of airway screening in patients undergoing procedural sedation in the Emergency Department.

What is true about the accuracy and reliability of the Mallampati score?

A: The Mallampati score has a high sensitivity to predict a difficult bag-valve-mask ventilation, but lacks an adequate sensitivity to predict difficult intubation

B: The Mallampati score has a low sensitivity for predicting both a difficult bag-valve-mask ventilation and a difficult intubation. Furthermore, it has a poor inter-rater reliability

C: The Mallampati score has a high accuracy and reliability, but only in trained clinicians

The correct answer is B.

This 2019 paper was covered on journal feed last week.

A recent literature review of the Mallampati score in ED airway management and procedural sedation showed a poor sensitivity in predicting difficult laryngoscopy (53%), difficult intubation (51%), and difficult bag-valve-mask ventilation (17%). The inter-rater reliability is also poor. Furthermore, the Mallampati score is designed to evaluate the patient in sitting position, with a wide opened mouth, a protruding tongue and remaining quiet. This can be challenging in critically ill patients (and children).

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This quiz was written by Eefje Verschuuren, Nathalie Dollee Kirsten van der Zwet and Hüsna Sahin

Reviewed and edited by Rick Thissen

Quiz 44, September 12th 2019

Question 1

Source: https://www.aliem.com/

Your 7 year old patient has been in a motor vehicle accident. On physical examination he has normal vital signs, but you notice an area of bruising on the lower abdomen.

Which of the following statements is true about seat belt injury in children?

A: The risk on intra abdominal injury is higher than the risk of spinal injury

B: The most common site of intestinal injury is the duodenum

C: Seat belt sign without abdominal tenderness is not associated with an increased need for surgical intervention

D: Small mesenteric tears and perforation are the most common hollow viscus injury

The correct answer is D

Last weeks post on DFTB is about seat belt injuries. 

The seat belt sign is associated with an increased risk of intra abdominal and even higher risk of spinal injury. The most common intestinal injury are small mesenteric tears or perforation of the jejunum, followed by injury to the duodenum. A seat belt sign is associated with a higher requirement for surgical intervention, even in the absence of abdominal tenderness.

Seat Belt Injuries

Question 2

Source: https://www.aliem.com/

You see a 16 year old patient who has been complaining about abdominal pain, nausea and vomiting for the past 24 hours. He has been smoking marihuana regularly for the past year, and you think his symptoms might be caused by cannabinoid hyperemesis syndrome.

Which of the following is not effective in this condition?

A: Ondansetron

B: Capsaicin topical cream

C: Hot shower

The correct answer is A

Last week’s post on Pediatric EM Morsels covers Cannabinoid Hyperemesis Syndrome.

Cannabis consumption is very common. Cannabinoid Hyperemesis Syndrome causes cyclic nausea and vomiting. Symptom relief can be achieved by hot showers, topical capsaicin cream, and there have been some positive results with the use of haloperidol. Sadly, most anti-emetics (like ondansetron) are not effective.

Cannabinoid Hyperemesis Syndrome

Question 3

Source: https://www.aliem.com/

An 8-year-old female presents with pain on the lateral ankle. She is a dancer and she had no trauma in the past. The pain exists for 4 months and is worse while exercising. On X-ray you see a vertically oriented bone fragment of the base of MT 5. Your supervisor says it’s a MT5 apophysis. What is your diagnosis?

A: Osgood- Schlatter disease

B: Iselin disease

C: Kohler disease

The correct answer is B

Iselin disease is also called traction apophysitis at the base of the 5th metatarsal. The pain typically begins after activity. It is a stress reaction at the insertion apophysis from overpull of the peroneus tendon. Do not confuse this on imaging with a base of the 5th MT fracture, these are typically horizontally oriented.

Osgood-Schlatter disease is a common cause of knee pain caused by overuse in growing adults.

Kohler disease is childhood osteonecrosis of the navicular bone.

SplintER Series: Ankle and Foot Pain in a Child

Question 4

Which of the following is NOT part of the HINTS exam in order to differentiate between peripheral and central vertigo?

A: Test of Skew

B: Nystagmus observation

C: Dix-Hallpike Manoevre

D: Head Impulse Test

The correct answer is C

Taming the SRU covered the HINTS exam last week.

In the original study, a HINTS exam indicating peripheral etiology had a 100% sensitivity for ischemic stroke. However, a negative HINTS exam on its own should never prevent you from further examination. Furthermore, the HINTS exam hasn’t been validated for use by emergency physicians. Always keep pre-test probability in mind and be sure there is no additional focal neurological sign.

The HINTS test consists of: Head Impuls test, Nystagus and Test of Skew. Although Dix-Hallpike is not officially not part of this exam, it can be used to provoke nystagmus.

http://www.tamingthesru.com/blog/diagnostics/hints-exam

Question 5

In chemical sedation of the agitated patient, which of the following drugs has the fastest time of onset when given intramuscular?

A: Midazolam

B: Ketamine

C: Haloperidol

D: Droperidol

The correct answer is B

NUEM covered chemical sedation of the agitated patient this week.

This post contains an excellent infographic about the various drugs used to sedate agitated patients in the ED. It seems ketamine (5 mg/kg im) has the fastest time of onset.

https://www.nuemblog.com/blog/chemical-sedation

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This quiz was written by Eefje Verschuuren, Nathalie Dollee, Kirsten van der Zwet and Hüsna Sahin.

Reviewed and edited by Rick Thissen

Quiz 43, August 28th, 2019

Question 1

Which of the following statements is true about the use of epinephrine in anaphylaxis?

A: Intramuscular (IM) epinephrine takes 30 seconds to reach peak blood levels

B: A bolus of 50 micrograms epinephrine intravenous (IV) should be given to patients with mild anaphylaxis

C: For severe hypotension, start epinephrine (IV) infusion at 20 micrograms per minute until the mean arterial pressure increases over 65 mm

D: Maintenance epinephrine infusion (IV) rate should be titrated within a range of 20-50 micrograms per minute

The correct answer is C

Josh Farkas covered the benefits of IV epinephrine in the management of anaphylaxis this week.

His post is about patients who have pre-existing IV access and are being managed by a resuscitationist who is comfortable with the use of IV epinephrine. IV epinephrine has several potential advantages over IM epinephrine, including faster onset and greater titratability. An infusion of IV epinephrine provides greater control.

Patients in peri-arrest should get a bolus of 20-50 micrograms IV epinephrine. Patients with mild to moderate anaphylaxis should start on a loading epinephrine infusion at a rate of 20 micrograms per minute for 2 minutes. In case of severe hypotension, continue epinephrine at 20 micrograms per minute until the mean arterial pressure increases over 65 mm. Then the infusion rate should be dropped to 10 micrograms per minute and titrated to effect with a range of roughly 5-15 micrograms per minute. Begin weaning off epinephrine after 20-30 minutes of clinical improvement.

PulmCrit- How to use IV epinephrine for anaphylaxis

Question 2

 

 

Which of the following statements is true about SCUBA diving injuries?

A: The first symptoms of nitrogen narcosis can occur once descending past 10 meters (33ft)

B: Oxygen toxicity can occur without the use of enriched gas mixtures (O2 > 21%) or closed circuit rebreathers

C: A Non Rebreathing Mask is just as effective as hyperbaric therapy in treatment of barotrauma

D: Tooth fractures do occur due to barotrauma

The correct answer is D

Diving injuries were covered on NUEM this week.

The first symptoms of nitrogen narcosis occur once descending past 30 meters (99ft).

Oxygen toxicity occurs due to the use of enriched gas mixtures (O2 > 21%) or closed circuit rebreathers.

All cases of barotrauma should be treated with hyperbaric therapy (hyperbaric chamber) if available. If not, use 100% oxygen and place the patient in horizontal position.

An yes, tooth fractures do occur due to barotrauma.

Click logo for link to post

Question 3

Which of the following is NOT a side-effect of intravascular contrast used in CT-scanning?

A: Vasodilatation

B: Functional hypocalcemia

C: Osmotic diuresis

D: Change of urine color

The correct answer is D

Justin Morgenstern discusses why patients are more likely to die during a CT-scan (if so) and why iv contrast might cause this.

It turns out contrast has a lot more side effects than anaphylactoid reactions and the feeling of peeing in the pants (vasodilation). The contrast binds calcium, resulting in functional hypocalcemia and it causes osmotic diuresis (which might harm the sick patient later on).

Click on logo for link to post

Question 4

Diagnosing Necrotising Fasciitis (NF) can be quite challenging. Fortunately The Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) was developed to make our lives a bit easier. Which statement is correct about this risk score?

A: This score has excellent diagnostic utility

B: Use it, but with caution. Sensitivity is likely around 80 percent

C: It is absolutely rubbish. Please do not use this score

The correct answer is C

CountyEM covered necrotising fasciitis this week.

The original derivation study was retrospective observational. Validation studies showed poor sensitivity (around 50%) and specificity for the LRINEC score. It is not uncommon for fatal NF cases to have scores ≤ 2 (low risk).

Everything you ever wanted to know about Necrotizing Fasciitis

Question 5

Which of the following statements is true about colchicine poisoning?

A: Activated charcoal will not be effective in colchicine overdose

B: Most life threatening effects will occur within the first 12 hours after ingestion

C: There is no specific antidote

The correct answer is C

Life in the Fast Lane covered colchicine poisoning this week.

Clinical symptoms of colchicine poisoning include: Gastrointestinal symptoms, cardiovascular collapse, coagulopathy and acute renal failure. The most dangerous phase is 2 to 7 days after ingestion. Administer activated charcoal as soon as possible as any reduction in absorption may be lifesaving and no, there is no specific antidote.

Colchicine toxicity

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This quiz was written by Eefje Verschuuren, Nathalie Dollee, Kirsten van der Zwet and Hüsna Sahin.

Reviewed and edited by Rick Thissen

Quiz 42, 16th of August, 2019

Question 1



This trial published earlier this year
compared oral Ibuprofen at three single-dose regimens for treating acute pain in the emergency department. Which dose of ibuprofen was found to be most effective?

A: Doses of 400 mg, 600 mg and 800 mg were found to be equally effective

B: Doses 600 mg and 800 mg were found to be more effective than 400 mg

C: A dose of 800 mg was found to be more effective than 400 mg and 600 mg

The correct answer is A

The authors conclude: Ibuprofen has similar analgesic efficacy profiles at single oral dosing regimens of 400 mg, 600 mg and 800 mg for short-term treatment of moderate to severe acute pain in the ED.

REBEL EM covered this paper last week. Keep in mind the follow-up time was only 60 minutes and patients who already received opioids were excluded.

A Randomized Control Trial Comparing Oral Ibuprofen at Three Single-Dose Regimens for Treating Acute Pain in the ED

Question 2

Source image: https://www.aliem.com/

Which of the following signs is NOT commonly seen on ultrasound in the case of an occult supracondylar humerus fracture in children?

A: Bulging or the posterior fat pad

B: Lipohemarthrosis

C: Cortical disruption

The correct answer is C

AliEM covered the diagnostic value of ultrasound in radiographically occult supracondylar humerus fractures in children.

Signs of potential occult fracture include a bulging posterior fat pad and lipohemarthrosis. It seems elbow ultrasound can assist in ruling out a supracondylar fracture because of it’s excellent sensitivity.

PEM Pearls: Ultrasound for Diagnosing Occult Supracondylar Fractures

Question 3

Source image: http://blog.clinicalmonster.com/2019/08/09/high-pressure-injection-injury/

Which of the following statements is true about the management of high pressure injection injuries in the Emergency Department?

A: Patients are often discharged home due to the benign initial appearance of the injury

B: Digital nerve blocks can be given safely

C: The most important prognostic factor is the result of microbiological culture

The correct answer is A

County EM covered this topic last week.

Diagnosis is often delayed and patients are often discharged home due to the benign initial appearance of the injury which later results in amputation of the affected digit or hand. Do NOT perform digital nerve blocks given the risk of increased compartment pressure at the fingers. The most important prognostic factor is aggressive debridement by a hand surgeon within the first six hours following injury.

ED Management of High-Pressure Injection Injury

Question 4

A 42 year old patient with a history of alcohol abuse presents to your emergency department after he ingested half a bottle of antifreeze. What is correct about this intoxication?

A: Antifreeze contains propylene glycol

B: Acetonemia is typically seen in this intoxication

C: Hypocalcemia is typically seen in this intoxication

D: Optic Nerve Toxicity is typically seen in this intoxication

The correct answer is C

This weeks blog on Taming the SRU is about toxic alcohols and covers the clinical presentation, diagnosis and management of this intoxication.

Antifreeze contains ethylene glycol and forms calcium oxalate crystals that can be seen with microscopic urine analysis. It can cause hypocalcemia, a wide QRS and prolonged QT.
Ingestion of methanol can cause blurred vision caused by optic nerve toxicity. Methanol is found in wiper fluid and paint. Isopropanolol is found in hand sanitizer and rubbing alcohol, and is broken down to acetone. Propylene glycol is used as a diluent for parenteral medications and can cause lactic acidosis. All of these toxic alcohols can cause CNS depression, GI symptoms and an increased osmol gap. For more about this topic you can read the following post.

Question 5

Source image: https://www.nuemblog.com/blog/pleural-effusions-101

What would probably be the best strategy to drain large pleural effusions keeping the risk of re-expansion pulmonary edema (REPE) in mind?

A: Limit initial fluid removal to 1,5 liters

B: Do not limit fluid removal, but stop the procedure when the patient is experiencing central chest discomfort

C: There are no limitations with regard to the drainage of large pleural effusions

The correct answer is B

Josh Farkas wrote about large volume pleural drainage in his latest blog. Although there is no data to support it, traditional guidelines recommend a maximal volume of fluid removal of 1,5L during thoracentesis to prevent re-expansion pulmonary edema (REPE). Josh explains why this is arbitrary, and why the risk of REPE is probably due to the baseline size of the effusion rather than the volume of fluid removed.

In a large cohort study with 9320 inpatients who underwent thoracentesis, the rate of REPE after removal of >1,5L fluid was very low (0,75%). Josh concluded that large pleural effusions can generally be drained entirely, although the procedure should be stopped if the patient experience vague central chest discomfort.

Using multiple small-volume thoracenteses is a misguided strategy, since this causes an overall increase in procedural complications (bleeding, infection, lung laceration).

PulmCrit- Large volume thora: Can we drain ‘em dry?

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This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet.

Reviewed and edited by Rick Thissen

Quiz 41, August 2nd, 2019

After a short break (Holidays!) we are back. Thanks for joining us again!

The FOAMed Quiz Crew

Question 1

You admit a patient with Diabetic KetoAcidosis (DKA). Which of the following insulin strategies would be appropriate?

A: Start long acting insulin treatment after you stop the insulin drip

B: Stop the insulin drip when the anion gap is normal, even if the patient is still acidotic

C: Administer the home dose basal insulin at least two hours before you stop the drip

The correct answer is C

Josh Farkas covered the management of patients with DKA on the latest EMCRIT blog.

The blog includes a literature review on early administration of basal insulin and some pointers about the management of patients with DKA.

If you stop the insulin drip before you administer long acting insulin or when the patient is still acidotic, there is a risk on widening of the anion gap and cause rebound hyperglycemia. However, if you administer basal insulin at least two hours before you discontinue the drip, there is lower risk on sub-therapeutic insulin levels. When basal insulin is administered early in the course of the disease this time gap could be eliminated and the insulin drip can stop when the patient meets the criteria for discontinuation.

PulmCrit – Early basal insulin in DKA

Question 2

Source image: https://litfl.com/

Which of the following statements is true about the Pediatric ECG?

A: A Right Axis on ECG is abnormal in the first 6 months of life

B: The first months of life a short QTc can be found

C: A negative QRS complex in AVF is abnormal and can be seen with some cardiac malformations

D: T-wave inversion in anterior precordial leads is abnormal in a 3 year old child

The correct answer is C

Dr. Sean Fox covered the Pediatric ECG on emDocs this week.

Pediatric ECGs may make us less comfortable because of the infrequent encounters.

The initial right axis is because of a thicker RV and is caused by the high pulmonary pressure in utero. QTc is longer in the young. A negative QRS vector in AVF can be seen with some cardiac malformations like AtrioVentricular septal defect or single ventricle. T-wave inversions in anterior precordial leads are normal. They will usually turn upright in adolescence.

Pediatric ECG

Question 3

https://www.flexicare.com/

The management of bronchiolitis is quite simple, nothing really works except for oxygen, right? Which of the following statements is true about oxygen administration in bronchiolitis?

A: Infants with bronchiolitis and hypoxia should be started on 5L oxygen via nasal cannula

B: High Flow Nasal Cannula (HFNC) should only be started if there is deterioration after low flow (2L) oxygen via nasal cannula has been administered

C: There is plenty of evidence supporting the use of HFNC in order to reduce work of breathing in infants without hypoxia

D: There is plenty of evidence supporting the use of HFNC as an early treatment for bronchiolitis in Emergency Department

The correct answer is B

Don’t Forget The Bubbles covered HFNC and bronchiolitis this week.

Infants with bronchiolitis and hypoxia should be started on 2L oxygen via nasal cannula. HFNC should indeed only be started if there is deterioration after this has been administered. There is no evidence for using HFNC for work of breathing in infants with no hypoxia. There is no evidence for using HFNC as an early treatment for bronchiolitis in the emergency department.

https://dontforgetthebubbles.com/evidence-high-flow-bronchiolitis/

Question 4

This recently published paper is about budding taping versus plaster immobilization for uncomplicated neck of fifth metacarpal fractures (boxers fracture).

What did the authors find?

A: Buddy taping is equally effective compared to plaster immobilization in patients with an uncomplicated boxer’s fracture

B: Buddy taping is inferior to plaster immobilization in patients with an uncomplicated boxer’s fracture

C: Buddy taping is superior to plaster immobilization in patients with an uncomplicated boxer’s fracture

The correct answer is A

EMOttawa covered this paper last week.

It looks like buddy taping may be a reasonable treatment option for selected ED patients with an uncomplicated boxer’s fracture. Well, somewhere in the future…

Is Buddy Taping as Effective as Plaster Immobilization for Adults With an Uncomplicated Neck of Fifth Metacarpal Fracture? A Randomized Controlled Trial

Question 5

Source image: https://litfl.com/

Which of the following statements is correct about ECG abnormalities?

A: A Flipped T-wave in AVL might be an early sign of inferior STEMI

B: Wellens syndrome type B includes biphasic T waves in V1-V4

C: Isolated T wave inversion in III is usually an early sign of inferior STEMI

D: De Winters T waves are symmetric inverted T waves in V1-V4

The correct answer is A

This week’s Emergency Medicine Cases podcast is all about chest pain.

Some key ECG patterns and their significance are covered in this podcast. In Wellens syndrome type A, biphasic T waves in V1-V4 are seen and type B is characterized by deeply inverted T-waves in V1-V4.

This pattern is a sign of high grade LAD or Left main artery lesion. De Winter T-waves are an equivalent of anterior STEMI, and are tall, symmetric T-Wave in leads V1 – V4 with upsloping ST-Depression at J Point in leads V1 – V4 without ST elevation. Although an inverted T wave in lead III is nonspecific, it increases the risk of major cardiac events in patients with chest pain.

Ep 128 Low Risk Chest Pain and High Sensitivity Troponin – A Paradigm Shift

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This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet.

Edited by Rick Thissen

Quiz 40, June 21th, 2019

Question 1

Source image: https://litfl.com/ultrasound-case-097/

Which of the following syndromes is best described by: episodes of vessel inflammation due to blood clot (thrombophlebitis) which are recurrent or appearing in different locations over time (thrombophlebitis migrans)?

A: Lemierre’ s Syndrome

B: Trousseau’s Syndrome

C: Antiphospholipid Antibody Syndrome

The correct answer is B

LIFTL published this great ultrasound case  last week.

Lemierre’s Syndrome refers to infectious thrombophlebitis of the internal jugular vein.

Antiphospholipid Antibody Syndrome (ASP) can cause widely spread thrombosis, but in general causes no thrombophlebitis. Very rarely, some people who have APS develop many blood clots within weeks or months.

Trousseau’s Syndrome is characterised by thrombophlebitis migrans secondary to several types of cancer.

Ultrasound Case 097

Question 2

Which of the following statements is true about Serotinin Syndrome?

A: Compared to Malignant Neuroleptic Syndrome, the onset of symptoms is slow

B: Hypothermia is often present

C: Lack of clonus argues strongly against the diagnosis of serotonin syndrome

D: If a sedative is needed, benzodiazepines are superior to dexmedetomidine

The correct answer is C

The Internet Book of Critical Care covers Serotonin Syndrome this week.

Compared to Malignant Neuroleptic Syndrome, the onset of symptoms in Serotonin Syndrome is rather rapid. Hyperthermia is often seen. Lack of clonus argues strongly against the diagnosis of serotonin syndrome. However, serotonin syndrome can occur in the absence of clonus under certain circumstances. If a sedative is needed, dexmedetomidine is a good choice because it seems to treat the underlying pathophysiology (serotonin excess) as well (and benzodiazepines do not).

IBCC chapter & cast: Serotonin syndrome

Question 3

Source image: https://litfl.com

What is the sensitivity of ECG abnormalities for detecting severe hyperkalemia (K > 6,5)?

A: About 10 percent

B: About 30 percent

C: About 50 percent

D: About 70 percent

The correct answer is B

This recently published paper
was discussed on journal feed last week.

The authors let 8 attending physicians read 528 ECGs from end stage renal disease patients. 30% of these ECG’s belonged to patients with a potassium of > 6,5. The sensitivity for detecting severe hyperkalemia was only 29%. The specificity was 95%.

Keep in mind you cannot rule out severe hyperkalemia by just an ECG reading.

Question 4

Source image: https://litfl.com

A 40 year old patient presents with a regular, monomorphic, narrow complex tachycardia. Previous ECG’s show a Delta Wave and a short PR interval. She shows no signs of shock or ischemic discomfort. You tried Valsalva maneuver, but it failed. What is true about the management of this case?

A: Adenosine is contraindicated in this case

B: You treat her as any other patient with a small complex, regular tachycardia

C: If adenosine is given, there is no chance of inducing Ventricular Tachycardia

D: Adenosine never triggers atrial tachyarrhythmias

The correct answer is B

The treatment of tachycardia in Adult with WPW recommended by the American Heart Association is discussed by Paula Sneath on CanadiEM.

The first step in the treatment of AVRT in Wolff Parkinson White is vagal maneuvers. The second step they recommend is adenosine, but even in the abcence of Atrial Fibrillation induction of Atrial and Ventricular Tachy-arrhytmias is a concern so electrical cardioversion should be available. Synchronized cardioversion is recommended for acute treatment in hemodynamically unstable patients or when pharmacological therapy is ineffective or contraindicated. IV diltiazem and verapamil are good choices for hemodynamically stable AVRT if adenosine fails (or if the patient refuses adenosine because of the sensation of dying).

https://canadiem.org/sirens-to-scrubs-wolff-parkinson-white-syndrome/

Question 5

Source image: http://www.emdocs.net/

Thromboelastography (TEG) is a laboratory test to assess coagulation. It has been around for decades, but so far has not been widely available. It has some real benefits over our standard clotting test (aPTT, PT/INR, thrombocytes) as a guide for transfusion of FFP, thrombocytes and cryoprecipitate. Which of the following is NOT one of these benefits?

A: TEG examines both clot formation and fibrinolysis. Our standard tests only examine clot formation

B: TEG examines clot strength, our standard tests do not

C: TEG guided transfusion leads to fewer blood product transfusion in bleeding cirrhotic patients

D: Validated algorithms on TEG-guided transfusion are available

The correct answer is D

Josh Farkas covered new literature on TEG this week on Pulmcrit.

I can’t say I fully understand TEG, but the potential benefits make a lot of sense. One disadvantage of TEG is the number of transfusion algorithms that come with it and the absence of validation of these algorithms. I do recommend reading the post on Pulmcrit, for understanding this concept will at least help you understand the flaws of our current blood product transfusion strategies.

PulmCrit- TEG for cirrhotic coagulopathy: Time for clinical implementation?

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This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet.

Edited by Rick Thissen

Quiz 39, June 13th, 2019

Question 1

Source image: http://sinaiem.org/tis-the-season-summer-edition/

Which of the following statements is true about Hand Foot Mouth Disease (HFMD)?

A: The majority of HFMD cases last 3-4 days

B: Most cases of HFMD result in encephalitis, acute flaccid paralysis or aseptic meningitis

C: HFMD is caused by several species of the flavivirus genus

D: Herpangina is the mouth-only cousin of HFMD

The correct answer is D

SinaiEM covered Hand Foot Mouth Disease this week.

The majority of HFMD cases last 7-10 days. Most cases of HFMD are benign, self-limiting and treated with supportive care. HFMD and its mouth-only cousin, herpangina, are caused by several species of the Enterovirus genus.

 

Question 2

Source image: https://litfl.com/an-unusual-wrist-injury/

Your patient presents to your emergency department with a distal radio-ulnar joint (DRUJ) dislocation. Which of the following statements is true about DRUJ dislocations?

A: The mechanism of injury for isolated volar DRUJ dislocation is most commonly due to hyper- pronation of the forearm

B: Postero-anterior (PA) view will not show any abnormalities

C: Isolated DRUJ dislocation is pretty common

D: DRUJ dislocation is often associated with injury to surrounding structures

The correct answer is D

Dan Stevens and Mike Cadogan covered DRUJ dislocation on LITFL.

The mechanism for isolated volar DRUJ dislocation is most commonly due to hyper-supination of the forearm. Postero-anterior (PA) view will show increased overlap of radius and ulna. Isolated (i.e. with no associated fracture) DRUJ dislocation is very rare with dorsal dislocation thought to be more common than ulnar.

An unusual wrist injury

Question 3

Recently this Randomised Controlled Trial was published about Phenobarbital as a second line agent in status epilepticus in children. Phenobarbital was compared to Phenytoin after 2 doses of benzodiazepines. The primary outcome was termination of seizure activity. What did the authors found?

A: Phenobarbital was superior to Phenytoin in terminating the seizure

B: Phenobarbital equally effective compared to Phenytoin in terminating the seizure

C: Phenytoin was superior to Phenobarbital in terminating the seizure

The correct answer is A

Justin Morgenstern discusses this very interesting paper on first 10 EM. He suggests anaesthetics (Phenobarbital, Propofol) might be a better second line agent for status epilepticus because of high failure rates of current second line agents (Phenytoin, Levetiracetam) and therefore delay in termination seizure activity (and I agree).

In the Phenobarbital group 86% of children responded with seizure termination. In contrast, seizures where terminated in only 46% of children who received a single parenteral dose of Phenytoin (p = 0.0003). Also, Phenobarbital terminated status epilepticus significantly faster compared to Phenytoin (10 vs 28 minutes).

Keep in mind this is a non-blinded study and it was designed to look at seizure management in a resource limited setting.

Question 4

Source image: https://www.rcemlearning.co.uk/references/angioedema/

Your patient presents with swelling of the face and tongue as well as profound urticaria. You wonder if this reaction is bradykinin or histamine mediated. Which of the following statements is true?

A: Medication always causes a histamine mediated reaction

B: Presence of urticaria is suggestive of a histamine mediated reaction

C: Hereditary Angio Edema (HAE) causes a histamine mediated reaction

D: Acquired C1-INH deficiency causes a histamine mediated reaction

The correct answer is B

Brit Long covered angio-edema on EMdocs this week.

Medication can cause both a histamine and bradykinin (like ACE-inhibitors) mediated reaction. Presence of urticaria is indeed suggestive of a histamine mediated reaction. HAE and Acquired C1-INH deficiency cause a bradykinin mediated reaction. Bradykinin-mediated forms are usually longer-lasting, more severe, and tend to affect the upper airway.

emDocs Cases: Angioedema Evaluation and Management

Question 5

 

You see another two year old child in your emergency department with fever and a rash. She is not vaccinated and your differential diagnosis includes measles.

Which of the following statements is true about measles?

A: The mortality rate is 0.02 %

B: Transmission occurs only via direct contact

C: The vaccine is 87% effective after 2 shots

D: There is no animal reservoir

The correct Answer is: D

This weeks REBEL corecast is about measles.

Since vaccination rates are dropping, it is vital to know more about contagious infectious diseases like measles ( which was almost eliminated in the year 2000).
The vaccine is highly effective, (97 % after 2 shots). Because humans are the only host, (there is no animal reservoir) we keep this virus in circulation because of failure to vaccinate. Transmission occurs by airborne droplets, and the transmission rates are extremely high. The mortality rate is 0.2 %

REBEL Core Cast 13.0 – Measles

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This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet.

Edited by Rick Thissen

Quiz 38, June 7th 2019

Question 1

Which cardiac arrhythmia is seen most often in patients with electrical injury?

A: Bundle branch blocks

B: QT prolongation

C: Atrial fibrillation

D: AV-blocks

The correct answer is C

Lorraine Lau and Anton Helman covered Electrical Injuries on EM cases this week.

Fortunately, cardiac complications from electrical injury are relatively uncommon with an overall incidence of 4-17%. Atrial fibrillation is the most common arrhythmia. Other ECG findings are bundle branch blocks, AV-blocks, QT prolongation, ST-changes, ventricular fibrillation and asystole. The fatal arrhythmias normally appear directly after the electrical trauma, with a VF more common after a trauma with alternating current and an asystole more common after injury with direct current. Cardiac monitoring is required in the first few hours for all high voltage (>1000V) injured patients, and for low voltage injured patients with symptoms (chest pain or syncope). Troponines are only indicated in patients with clinical presentation of cardiac ischemia and should not be obtained routinely.

Ep 125 Electrical Injuries – The Tip of the Iceberg

Question 2

How many days after tracheostomy can the trach be replaced safely without fiberoptic guidance?

A: > 3 days

B: > 4 days

C: > 7 days

D: > 10 days

The correct answer is C

REBELem covered tracheostomy emergencies this week.

It takes 7-10 days for the tract to become mature. It is not recommended to blindly replace the trach if 7 days old or less, because of the risk of creating a false tract.

REBEL Core Cast 12.0 – Tracheostomy Emergencies

Question 3

In a patient with superficial venous thrombosis, which of the following is NOT a risk factor for development of deep venous thrombosis or pulmonary embolism?

A: The clot is less than 3 cm from SaphenoFemoral junction

B: The clot is more than 5 cm in length

C: The clot is in a varicose vein

D: Male gender

The correct answer is C

Jacob Avila covered superficial venous thrombosis on emDOCs.

Risk factors for extension of Superficial Venous Thrombosis include: a clot > 5 cm; < 3 cm from the SaphenoFemoral Junction; male gender; clot in a non-varicose vein; severe symptoms (whatever they may be); involvement above the knee; history of thrombo-embolic disease; active cancer and recent surgery.

CORE EM: Superficial Venous Thrombosis (SVT)

Question 4

Source image: https://www.stemlynsblog.org/

Which of the following statements is true about fluid boluses?

A: The majority of fluid boluses lead to sustained clinical benefit in patient with septic shock

B: Fluid boluses always provide reliable information about the patient’s hemodynamics

C: The transient improvement in hemodynamics sometimes seen after crystalloid fluid bolus is probably caused by its low temperature

D: Increase in cardiac output always translate into an increase in oxygen delivery

The correct answer is C

Josh Faskas published ‘’Myth-busting the fluid bolus’’ on EMcrit this week.

Fluid boluses usually cause only a transient hemodynamic improvement and don’t necessarily provide reliable information about the patient’s hemodynamics. It appears it is hypothermia that triggers an endogenous sympathetic nervous system response leading to transient improvement of hemodynamics. An increase in cardiac output duo to a fluid bolus does not necessarily lead to an increase in oxygen delivery, because a fluid bolus leads to decrease of hemoglobin (and oxygen transport).

PulmCrit: Myth-busting the fluid bolus

Question 5

Source image: https://litfl.com/

What is the optimal puncture site for needle decompression in tension pneumothorax in children?

A: 2nd intercostal space midclavicular

B: 4th intercostal space anterior axillary line

The correct answer is B

The Resus Room discusses this paper in it’s papers of the month podcast of June. Although there is plenty of evidence in the adult literature, evidence regarding needle decompression in children is scarce.
This paper evaluates chest wall thickness and relation to vital structures on CT in children in three different age groups. The authors recommend the 4th intercostal space in the anterior axillary line as the primary site for needle decompression. Especially in children 0-5 year old the authors found vital structures like thymus and heart close to the 2nd intercostal space puncture site.

Papers of June 2019

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This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet.

Edited by Rick Thissen

Quiz 37, May 31th 2019

Question 1

Source image: http://www.emdocs.net/

Which of the following diseases is described by: ‘’Suppurative thrombophlebitis of the internal jugular vein and subsequent disseminated infection, often with septic pulmonary emboli. It usually presents as a prolonged pharyngitis in a patient who is febrile.’’?

A: Ludwigs Angina

B: Lemierre’s Syndrome

C: Retropharygeal abcess

The correct answer is B

Clay Smith mentioned this case report in the NEJM this week.

Always keep Lemierre’s Syndrome in your Dx in patients with a sore throat as you cannot miss this one. The causative organism is most commonly Fusobacterium necrophorum.

Question 2

Which of the following characteristics of bruising in children does not immediately raise concern for non-accidental trauma?

A: Bruising in an under 4 month old

B: Bruising to the frenulum, auricular area, cheek, eyes and sclera

C: Bruises with Patterns: Linear or appearance similar to a known object

D: Bruises to upper arms and upper legs

The correct answer is D

Pediatric EM morsels covered bruises in abuse this week.

Of course, always stay vigilant for non-accidental trauma when a child comes in after trauma.

Remember TEN 4 FACES P:
– TEN (Trunk, Ears, Neck)
– 4 (under 4 months)
– FACES (Frenulum, Auricular area, Cheek, Eyes, Sclera
– P Patterned bruising

Sentinel Bruising & Abusive Injury

Question 3

Source image: https://litfl.com

The past years the Neutrofil / Leucocyte Ratio (NLR) gained a lot of attention. Which of the following statements is true about the NLR?

A: A raised NLR is always caused by en inflammatory process

B: Exogenous steroids do not increase the NLR

C: When a cutoff of 10 is used, the NLR has really good diagnostic performance to detect bacteriemia

D: In every study directly comparing NLR with white blood cell count, the NLR has proven to be far more accurate

The correct answer is D

Josh Farkas covered the NLR in a pretty extensive post this week.

It seems the NLR is far from perfect, but it is cheap, fast and a decent sign of overall badness. It outperforms white blood cell count in diagnosis, prognosis and trajectory. The NLR is raised as a cause of physiologic stress, which can be caused by numerous disease entities (not only inflammatory). Exogenous steroid do increase the NLR. The NLR has pretty poor diagnostic performance for bacteremia (but better than white blood cell count).

PulmCrit: Neutrophil-Lymphocyte Ratio (NLR): Free upgrade to your WBC

Question 4

Source image: https://litfl.com

Which of the following statements is true about Left Ventricular Assist Devices (LVADs)?

A: Patients with LVADs are preload dependent

B: In case the pump stops, you have to change both batteries simultaneously

C: Most LVADs produce a pulsatile flow

D: The most common complication of an LVAD is hemolysis

The correct answer is A

Adam Gottula covered the LVAD in the latest post on Taming the SRU

Patients with LVADs are very preload dependent. If there is no inflow, the pump will stop working. This is also true in the case of a suction event (in which the septum can collapse which results in flow obstruction). Never change both batteries simultaneously, plug in the LVAD power to wall power. Modern LVADs produce a continuous flow (in contrast to early LVADs, which produced a pulsatile flow). The most common complication is GI bleeding.

Question 5

Source image: https://www.aliem.com

The false morel mushroom is considered a delicatesse in some countries and sometimes eaten by mistake in others. Unfortunately, the mushroom contains the toxic gyromitrin, which can cause seizures, nausea and vomiting, abdominal pain, myalgias and rhabdomyolysis.

What agent should be used to treat seizures due to gyromitrin toxicity?

A: Pyridoxine (vitamin B6)

B: Midazolam or any other benzodiazepine

C: Glucose 50%

D: Thiamine (vitamin B1)

The correct answer is A

ALIEM covered gyromitrin poisoning this week.

The false morel mushroom contains the toxic gyromitrin, which can cause gastro-intestinal symptoms, hepatic failure, seizures, rhabdomyolysis, methemoglobinemia and hemolysis.

Gyromitrin’s metabolite (a hydrazine) prevents the formation of the active form of vitamin B6, which leads to GABA depletion. Seizures due to GABA depletion can be refractory to benzodiazepine therapy. Therefore, pyridoxine in a dose of 50-70mg/kg i.v. should be given in addition to phenobarbital. Further treatment is mainly supportive.

Although the fungus is widely recognized as potentially deadly and prohibited in many countries, it is still highly regarded and consumed in some countries including Finland and Bulgaria. Drying them for ten days and parboiling for at least 2 times can decrease the toxicity of the mushroom.

ACMT Toxicology Visual Pearls: Eating Foraged Wild Mushrooms

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This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet.

Edited by Rick Thissen