Christmas edition, December 26th 2019

Welcome to the Christmas Special

Merry Christmas and a Happy New Year!

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Which eponyms are we looking for???

Question 1

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

M

The Monteggia fracture is a fracture of the proximal third of the ulna with dislocation of the proximal head of the radius. It is named after Giovanni Battista Monteggia.

EM Cases – Elbow Injuries – Ten Pitfalls in Diagnosis and Management

Question 2

Source Image: http://www.surgeryassistant.nl/

E

An Essex-Lopresti injury consists of a radial head fracture with dislocation of the distal radioulnar joint (DRUJ) and disruption of the interosseous membrane (IOM).

Essex-Lopresti fracture

Question 3

”Aspirin has been linked with this syndrome, so use caution when giving aspirin to children or teenagers for fever or pain. Though aspirin is approved for use in children older than age 3, children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin.’ (Mayoclinic)

R

Reye’s Syndrome was first describe in 1963. It may occur at any age in childhood, although higher rates in children < 2 years of age. Death occurs in ~30-40% of cases due to brainstem dysfunction. The etiology is not clearly known. An association (although not clear causality) is described between recent viral illness and aspirin therapy.

Reye’s Syndrome

Question 4

Fundoscopy revealed these ‘spots´ in a patient with suspected endocarditis:

Source image: https://litfl.com/

R

Roth spots are retinal haemorrhages with white or pale centres, commonly associated with subacute bacterial endocarditis and immune complex mediated vasculitis.”

Roth spots

Question 5

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

Y

Yankauer suction tip. Doesn’t need a lot of explanation, but I couldn’t think of anything else starting with a Y.

Sidney Yankauer

Question 6

”This disease is also known as American trypanosomiasis, is a tropical parasitic disease caused by the protist Trypanosoma cruzi. It is spread mostly by insects known as Triatominae.”’ 

C

”’ Chagas disease is an inflammatory, infectious disease caused by the parasite Trypanosoma cruzi, which is found in the feces of the triatomine (reduviid) bug. Chagas disease is common in South America, Central America and Mexico, the primary home of the triatomine bug. ”

https://www.cdc.gov/parasites/chagas/index.html

Question 7

A 9 year old male presents to your emergency department with a chief complaint of abdominal pain. 

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

H

Henoch–Schonlein Purpura (HSP) is an immune-mediated small vessel vasculitis. Compared to purpura commonly caused by thrombocytopenia, the etiology of the purpuric lesions in HSP are secondary to IgA-mediated immune complex deposition in the skin.

PEM Pointers: Henoch-Schonlein Purpura

Question 8

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

R

Rolando Fracture is a complete and comminuted intraarticular fracture, usually in a T or Y shape

SplintER Series: Case of a First Metacarpal Fracture

Question 9

This is a system of categorizing scapula fractures involving the glenoid fossa.

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

I

The Ideberg classification is a system of categorizing scapula fractures involving the glenoid fossa.

https://www.orthobullets.com/trauma/1013/scapula-fractures

Question 10

A 55 years old patient comes in with a rash after starting with ibuprofen for a backache 5 days ago. 

Source image: https://my.clevelandclinic.org/

S

Stevens-Johnson Syndrome (SJS) is a rare type IV hypersensitivity reaction with sheet-like skin loss and mucosal ulceration.

https://em3.org.uk/foamed/3/6/2019/lightning-learning-stevens-johnson-syndrome

Question 11

A 12-year old boy comes in with an ankle sprain.

Source image: https://litfl.com

T

A Tillaux Fracture is a fracture of the anterolateral tibial epiphysis commonly seen in adolescents. (Salter-Harris III tibial fracture)

Tillaux fracture

Question 12

A 60 years old patient comes in with fever and upper belly pain. You find this on POCUS and pressing the probe hurts. What is this sign called?

Source image: https://westjem.com

M

(Sonographic) Murphy’s Sign is positive when the maximal intensity of patient’s pain is when the gallbladder is in view directly beneath the probe.

https://www.nuemblog.com/biliary

Question 13

”If a patient’s hand flushes fully and rapidly after an artery is released, that artery, the palmar arch, and the digital arteries are patent. If pallor persists throughout the hand, the artery that was released is occluded. Pallor in patches indicates insufficiency of the smaller vessels.”

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

Question 14

Source image: https://litfl.com

S

A Segond Fracture is an avulsion fracture (small) of the lateral surface of the lateral tibial condyle. Usually results from excessive internal rotation and varus stress resulting in increased tension on the lateral capsular ligament of the knee joint.

Segond fracture

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 53, December 6th, 2019

Welcome to the 53th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://litfl.com/

Your 53-year-old female patient presents with an AV-nodal reentry tachycardia (AVNRT). She is hemodynamically stable with a pulse rate of 175/min and blood pressure of 118/90 mmHg. You want to give her adenosine.

Which of the following statements is true about the administration of adenosine?

A: Adenosine diluted with saline in a single syringe push seems to be at least non-inferior to the usual adenosine push followed by a rapid saline flush

B: Adenosine diluted with saline in a single syringe push seems to be inferior to the usual adenosine push followed by a rapid saline flush

C: Adenosine diluted with saline as a single syringe push seems to induce more adverse events in comparison to the usual adenosine push followed by a rapid saline flush

The correct answer is A

Clay Smith covered this trial about the single syringe method for the administration of adenosine on JournalFeed.

One of the challenges of giving adenosine is the very quick saline push needed after the adenosine push. A few seconds between the two administrations might make a difference for successful cardioversion. Diluted adenosine in one syringe (a sort of push and flush together) can make it a lot easier!

The results of this trial are promising: successful conversion to normal sinus rhythm (NSR) with the first dose of adenosine was higher in the single syringe group: 73.1% compared to 40.7% in the controlgroup. There were no adverse events reported in the single syringe group. Keep in mind that this was a small, unblinded pilot study.

Source image: https://journalfeed.org/

Question 2

We prescribe a lot of antiemetics in the Emergency Department (ED). After all, nausea and vomiting are pretty common complaints.

But how about the evidence? Justin Morgenstern covered this paper earlier this week on First10EM. Which of the following statements is correct regarding the efficacy of droperidol and ondansetron as an antiemetic in the ED?

A: This paper shows ondansetron is more effective than placebo in reducing nausea

B: This paper shows droperidol is more effective than placebo in reducing nausea

C: This paper shows droperidol and ondansetron are more effective than placebo in reducing nausea

D: This paper shows ondansetron, droperidol and placebo are equally effective in reducing nausea

The correct answer is D

This paper compared ondansetron, droperidol and placebo. Their primary outcome was an improvement of 8 mm of a visual analogue scale and was met in 75 (droperidol), 80 (ondansetron) and 76 percent (placebo). These differences were not statistically significant. However patients reported significantly higher rates of achieving desired effect when using droperidol (this was elicited from direct questioning—”The drug I received had the desired effect for me: Yes or No”). Furthermore, the authors enrolled 215 patients (unfortunately, this was only about half way to the calculated sample size of 378 patients). So, although this paper shows no clear benefit of droperidol and ondansetron, it is not a done deal.

Nausea and vomiting in the ED: Does nothing work?

Question 3

Source image: www.pixabay.com

Auwch, that hurts! Penile injuries are men’s worst nightmare. Examples include penile fracture, zipper injuries and penile strangulation.

Which of the following statements is true?

A: ‘’A zucchini deformity’’ is an often notable clinical sign in penile fractures

B: Urethral injuries are seen in 60-70% of penile fractures

C: The best way to separate an entrapped penis from a zipper is by using a wire cutter to cut the middle portion of the zipper that connects the two halves

D: In case of penile strangulation blood can be drained from the corpora cavernosa in a manner similar to draining a priapism to get underneath the constricting band

The correct answer is D

Jacob Stelter covered penile injuries this week on NUEM.

A penile fracture is a medical emergency in which the‘’eggplant deformity’’ refers to the clinical presentation of a fractured penis with swelling and detumescence of the penis, often with notable ecchymosis and deformity.

Penile fracture could lead to urethral injuries which occur in up to 38%. If suspected, a retrograde urethrogram or cystoscopy should be performed before a Foley catheter is inserted.

In case you see a patient with his penis trapped in a zipper, use a lubricant, this almost always works. If not, try using a wire cutter to cut the piece connecting the two halves of the zipper.

Finally, injuries resulting from penile strangulation are divided into five grades ranging from isolated penile edema in stage I all the way up to penile necrosis or amputation of the distal segment in grade 5.

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

Question 4

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

A 4 years old patient presents to your department with colicky abdominal pain. The ultrasound image looks like the one above.

Which of the following statements is true regarding this diagnosis?

A: Surgery is indicated for all pediatric patients

B: Pneumatic or hydrostatic enema is preferred modality in pediatric patients

C: The male to female ratio is 1:5

D: Currant jelly stools are very common in these patients

The correct answer is B

AliEM covered intussusception this week in their ´´Ultrasound for the Win´´ series.

The male to female ratio is 3-8:1. While pneumatic or hydrostatic enema is preferred modality in pediatric patients, surgery is indicated in adults patients. Currant jelly stools are pretty rare.

Ultrasound for the Win! 3-year-old with abdominal pain #US4TW

Question 5

Which of the following statements is true about acute torsion of the appendix epididymis?

A: Torsion of the testicular appendages is dangerous

B: Diagnosis is made via color doppler ultrasound

C: Treatment includes surgical detorsion

D: Late torsion of the appendix testis or epididymis may present with a “blue dot sign”

The correct answer is B

BrownEM covered acute torsion of the appendix epididymis this week.

Torsion of the testicular appendages is not dangerous. Diagnosis is made via color doppler ultrasound. Treatment includes NSAIDs, scrotal support, and reassurance and early torsion of the appendix testis or epididymis may present with a “blue dot sign”.

Source image: http://brownemblog.com/

 

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

the CanadiEM special

Source image: https://canadiem.org/

Welcome to the first dedicated Quiz

The development of this website relies completely on high quality content on FOAMed Blogs and Podcasts all over the world. Website like CanadiEM make our existence possible. 

This Quiz contains 5 questions about content appearing on CanadiEM in the past 6 months. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://canadiem.org/
 

A 31 year old woman presents to the emergency department (ED) with a regular narrow-complex tachycardia at a rate of 180 bpm. Previous ECGs show a short PR-interval and delta wave.

Which of the following statements is true about Wolff Parkinson White (WPW) syndrome?

A: The most common tachydysrhythmia seen in WPW is AV-nodal reentrant tachycardia (AVNRT)

B: In atrioventricular reentrant tachycardia (AVRT) and WPW, the impulses mostly travel up through AV node and down through the accessory pathway (antidromic)

C: Classic ECG findings in WPW syndrome include: long PR-interval (>120 ms) a delta wave and QRS prolongation

D: Adenosine might cause ventricular tachydysrhythmias, even in patients with regular AVRT

The correct answer is D

Paula Sneathon covered WPW earlier this year.

WPW syndrome is a combination of the presence of a congenital accessory pathway, often called ‘’the Bundle of Kent’’, and episodes of tachyarrhythmia.

Atrioventricular Reentrant Tachycardia (AVRT) is the most common tachydysrhythmia in WPW (80%).

Orthodromic AVRT (down the AV node and up the accessory pathway) is way more common than antidromic AVRT (up the AV node and down the accessory pathway).

Classic features of WPW on the ECG include a short PR-interval, delta waves and a prolonged QRS duration.

Despite being really rare, adenosine administration once in a while causes nasty ventricular tachydysrhythmias, even in patients without underlying Atrial Fibrillation (AF). This might be caused by another accessory bundle or development of AF during AV-nodal blockade.

Sirens to Scrubs: Wolff-Parkinson-White Syndrome

Question 2

Source image: https://pixabay.com/

A 32 year old female presents to your ED with nausea and headache. She tells you she is ten weeks pregnant and is known with migraine. After considering other (more dangerous) causes of headache in pregnancy (like pre eclampsia, cerebral venous thrombosis and pituitary apoplexy) you conclude that she is experiencing an episode of migraine. You want to prescribe her analgesia and anti emetics.

Which of the following combinations is the safest option for this patient and her child?

A: Acetaminophen and haloperidol

B: Acetaminophen and ondansetron

C: Acetaminophen and metoclopramide

D: Ibuprofen and metoclopramide

The correct answer is C

Vivian Tam discussed the management of headache in pregnant patients recently.

Acetaminophen can be given safely in all pregnant patients.

Haloperidol use during pregnancy has been linked to severe limb reduction defects.

Ondansetron might cause doubling in risk of cleft palate and heart defects in newborns.

There is no evidence for an increased risk of congenital malformations with the use of metoclopramide.

NSAIDs might increase the risk of early pregnancy loss in the first trimester. There is some weak evidence for diphenhydramine causing cleft palate in the first trimester.

Managing headaches in pregnancy

Question 3

Source image: https://pixabay.com/

A 75-year-old man presents with 2 days of abdominal pain due to an acute cholecystitis. He will require a laparoscopic cholecystectomy. The patient is on dabigatran 110mg twice daily because of atrial fibrillation and took his last dose 6 hours before presentation. His glomerular filtration rate is 40 ml/min.

Which of the following is true about the anticoagulant effect of dabigatran in this patient?

A: The anticoagulant effect of dabigatran will be insignificant after 3 half-lives

B: A normal thrombin time (TT) can safely be used to rule out a clinically significant dabigatran effect

C: The half-life of dabigatran can be estimated at 12 hours in this patient

D: An anti-Xa assay is needed to estimate the current anticoagulation effect of dabigatran

The correct answer is B

Matthew Nicholson covered the determination of anticoagulant effect of DOACs earlier this year.

Since DOACs have predictable pharmacokinetics, testing for DOAC levels is in general not required if the time of last ingestion is known. However, in some cases laboratory testing can be useful, for example in patients with renal failure. The anticoagulant effect is considered to be insignificant after 4-5 half lives. The half-life of dabigatran is estimated at 12-14 hours, but will be longer in patients with renal dysfunction.

The standard thrombin time (TT) is highly sensitive for dabigatran and can be used to rule out a clinically significant dabigatran effect. If the TT is abnormal, you will need a dilute thrombin time (dTT) essay to quantify the dabigatran effect (if you would like to know).

Blood & Clots Series: How do I determine if my patient on a DOAC is still at increased risk of bleeding?

Question 4

Source image: https://pixabay.com/

Your patients presents with acute onset radicular back pain after lifting weights. There are no red flags, but acetaminophen and a non steroidal anti inflammatory drug (NSAID) do not provide adequate pain relief. Your savvy nurse suggests a single dose of intravenous corticosteroids. Which of the following statements is true regarding the evidence behind a single intravenous bolus of corticosteroid in reducing pain in patients with radicular back pain?

A: A single intravenous bolus of 8 mg dexamethasone or 500 mg methylprednisolone significantly improves VAS pain scores at 6 weeks after onset of symptoms

B: A single intravenous bolus of 8 mg dexamethasone or 500 mg methylprednisolone might improve VAS pain scores at 24 hours after onset of symptoms

C: A single intravenous bolus of 500 mg methylprednisolone for treatment of radicular back pain is clearly safe

The correct answer is B

Jessie Grewal covered single intravenous bolus of corticosteroid in reducing pain in Emergency Department patients with radicular back pain last week.

Only two small RCTs are published on this topic (one on dexamethasone 8 mg and one on methylprednisolone 500 mg). It seems that corticosteroids might have a transient beneficial effect on pain scores. However, both RCTs are ‘’too small to detect rare and dangerous adverse effects.’’

Is there a role for a single intravenous bolus dose of corticosteroid in reducing pain in Emergency Department patients with radicular back pain?

Question 5

Source image: https://canadiem.org/

Patients with fever, we see them every day in the Emergency Department. Most fevers are benign, some are not. For a symptom so common, do we know enough about it? Which of the following statements is true about fever?

A: Fevers under 42 degrees Celsius (107.6 °F) are harmless

B: Fever can cause seizures in adults without pre-existing seizure disorders

C: External cooling methods should be first line treatment to lower fever

D: Nearly every aspect of our immune system has been shown to function better in higher temperatures

The correct answer is D

Paula Sneath covered the pathogenesis of fever last August.

It seems fever below 41 degrees Celsius is harmless and fever between 41 and 42 degrees Celsius is only harmful if sustained for a longer period of time. Fever by itself does not cause seizures in adults without pre-existing seizure disorders (but it can provoke seizures in adults with pre-existing seizure disorders). External cooling methods are not recommended because of the secondary increase in metabolism and discomfort as the body tries to achieve the target temperature. And yes, it seems our immune system is more effective in higher temperatures.

Sirens to Scrubs: Fever-Phobia

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 52, november 29th, 2019

Welcome to the 52nd FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://first10em.com/

Drug reaction with eosinophilia and systemic symptoms, also known as DRESS syndrome, is a rare but severe condition which should be in the differential diagnosis of every sick patient presenting to the Emergency Department with a rash.

Which of the following is true about DRESS syndrome?

A: Symptoms generally occur within 72-hours after exposure to the drug

B: Carbamazepine is the drug most commonly associated with this condition

C: Diseases like Stevens-Johnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis and erythroderma are easy to discriminate from DRESS syndrome

D: As the name suggests, eosinophilia is present in at least 75% of patients with DRESS syndrome

The correct answer is B

Justin Morgenstern covered DRESS syndrome on First10EM.

Symptoms of DRESS syndrome generally appear within 2-6 weeks after starting the drug.

Carbamazepine is the drug most commonly associated with this condition and although leukocytosis is very common, eosinophilia is only present in 30% of patients.

There is no golden standard for diagnosis, it is based on a combination of diagnostic criteria. The most important takeaway from this post is to think about DRESS syndrome in patients with a rash with at least one systemic and one hematologic symptom.

DRESS syndrome – a rapid review

Question 2

You see a five year old patient with a dislocated distal radius fracture, and you want to provide analgesia. You wonder if you should give fentanyl or ketamine intranasal (IN). Recently the PRIME trial was published addressing this topic.

What did the results of this paper tell us?

A: IN fentanyl was superior to IN ketamine in providing analgesia

B: IN fentanyl was inferior to IN ketamine in providing analgesia

C: IN ketamine was non inferior to IN fentanyl in providing analgesia

D: IN ketamine leads to less adverse events compared to IN fentanyl

The correct answer is C

Simon Carley covered this paper on St. Emlyns last week.

This relatively small study ( 90 patients) is a randomized controlled trial designed to show non inferiority between IN fentanyl and IN ketamine for analgesia. The two treatments were similar in reducing pain score at 15, 30 en 60 minutes post administration. There were more adverse effect in the ketamine group, although they were minor.

JC: IN Fentanyl vs Ketamine for analgesia in PED. St Emlyn’s

Source image: pixabay.com

Question 3

Massive Transfusion Protocols (MTPs) differ between hospitals. The ratio PRBC to FFP to Platelets- ratio generally differs between 1:1:1 and 2:1:1. Which statement is true about the evidence behind this in trauma patients?

A: Evidence suggests a 2:1:1 ratio is superior to 1:1:1 ratio in reducing mortality at 30 days

B: Evidence suggests a 1:1:1 ratio is superior to 2:1:1 ratio in reducing mortality at 30 days

C: Evidence suggests a 2:1:1 ratio is superior to 1:1:1 ratio in decreasing death from exsanguination at 24 hours

D: Evidence suggests a 1:1:1 ratio is superior to 2:1:1 ratio in decreasing death from exsanguination at 24 hours

The correct answer is D

Last week this systematic review was discussed at The Trauma Professional’s Blog.

Most of the evidence comes from the PROPPR trial (2015)  which was broadly covered by lots of FOAMed blogs like RebelEM and EMNerd.

Massive Transfusion: What’s The Right Ratio?

Question 4

Source image: pixabay.com

A known cirrhotic patient comes in with hematemesis. He is hemodynamically unstable, you start with Packed Red Blood Cells (PRBCs) and prepare to intubate. Which of the following three additional treatment options has shown benefit in reducing mortality?

A: Octreotide

B: A Proton Pump Inhibitor (PPI)

C: Antibiotics (3rd generation cephalosporin)

The correct answer is C

RebelEM covered Decompensated Liver Disease last week in their latest Rebel Core Cast.

There is no proven benefit of octreotide or PPIs in these patients. However, administration of antibiotics (ceftriaxone) has shown benefit with an NNT for preventing one death of 22! Keep in mind this evidence comes from 12 trials of which only one was placebo controlled (the others were antibiotics vs no treatment).

REBEL Core Cast 22.0 – Decompensated Liver Disease

Question 5

In which type of hyponatremia is treatment with oral Urea indicated?

A: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

B: Cerebral Salt wasting

C: Primary polydipsia or malnutrition

D: Cortisol deficiency

The correct answer is A

Josh Farkas covered treatment of hyponatremia in SIADH with oral Urea this week. 

‘’Oral urea functions as an osmotic diuretic (an “aquaretic”).  Ingested urea will be completely excreted by the kidneys.  It is excreted along with water, so the ultimate effect is removal of water.’’’

PulmCrit- Controlled aquaresis: Management of hypervolemic or euvolemic hyponatremia with oral urea

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 51, November 21th, 2019

Welcome to the 51th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: www.nuemblog.com

Your patient presents to the Emergency Care because of worsening binocular diplopia since yesterday. She does not complain of a headache and no fever is present. On physical examination you find bilateral ataxia and areflexia without hemiparesis. No additional abnormal findings are found. Which of the following diagnosis is the likely ?

A: Myasthenia Gravis

B: Claude Syndrome

C: Botulism

D: Miller Fisher variant of Guillain Barré Syndrome

The correct answer is D

NUEM covered diplopia this week.

Myasthenia Gravis can present with isolated diplopia, but one would not expect areflexia and ataxia. Often ptosis is present as well.
Claude syndrome is caused by a midbrain infarct and typically includes unilateral oculomotor or trochlear palsy with contralateral ataxia. One would not expect worsening of symptoms over time and bilateral ataxia.
Botulism should be considered, but does not cause areflexia until a muscle group is paralyzed.
This set of symptoms (diplopia, areflexia and ataxia) is typical for Miller Fisher variant of Guillain Barré syndrome.

Click Image for link to source
Source image: pixabay.com


Question 2

You see a 27 year old G4P2 female at 25 weeks of gestation at the emergency department (ED) with right upper quadrant abdominal pain and vomiting. While abdominal pain during pregnancy is an extremely common complaint, medical emergencies should be considered.

Which of the following statements is true about medical emergencies in pregnant women:

A: Risk factors for uterine rupture include blunt abdominal trauma, grand multiparity and prior cesarean sections or myomectomies

B: Diagnostic criteria of HELLP syndrome include: proteinuria, leukocytes >12, AST and ALT ≥ 2x the upper limit of normal and platelet counts <100,000 x 10⁹/L

C: The ‘’discriminatory zone’’ describes that there is a certain ß -hCG level above which the gestational sac associated with a normal intrauterine pregnancy should reliably be visible on ultrasound. In case of transvaginal ultrasound (TVUS) this has been set at >500 mlU/ml

D: Physical examination in women with Pelvic Inflammatory Disease (PID) typically reveals lower abdominal pain and cervical motion tenderness. Treatment of PID in pregnant and non-pregnant woman is the same

The correct answer is A.

EMdocs covered pathologic obstetric abdominal pain this week and provided some useful summaries of notable signs in these conditions.

Uterine rupture most commonly occurs at the site of prior uterine surgical manipulation such as scar sites of prior cesarean sections or myomectomies. It most commonly occurs during labour but it should also be considered in blunt abdominal trauma in pregnant woman.

HELLP syndrome is a severe form of preeclampsia and is associated with hemolysis, transaminitis and thrombocytopenia. It is often associated with hypertension and proteinuria but these elements are not necessary for the diagnosis.

The ß -hCG level in the ‘’discriminatory zone’’ has traditionally been set at >1500 mlU/ml for TVUS but recently the American College of Obstetrics and Gynecology set this value conservatively high at >3500 mlU/ml. If no intrauterine gestational sac is visible on TVUS, an ectopic pregnancy should be considered.

PID is an infection of the upper genital tract (uterus, endometrium, fallopian tubes and ovaries) in women and is mostly caused by sexually-transmitted infections such as Neisseria gonorrhea and Chlamydia trachomatis. Pregnant women are treated with a second generation, cephalosporin and azithromycin, since regimens using doxycycline should be avoided during pregnancy due to adverse fetal effects.

Click Image for link to source

Question 3

You treat a patient with septic shock. After fluid resuscitation, antibiotics and the start of norepinephrine at 5 microgram per minute your patient is not improving. According to this recently published study about the non-catecholaminergic vasopressor Selepressin you should:

A: Start selepressin at 3.5 ng/kg/min in addition to norepinephrine

B: Stop norepinephrine and start selepressin at 3.5 ng/kg/min

C: Start selepressin at 1.7 ng/kg/min in addition to norepinephrine

D: Not start selepressin

The correct answer is D

RebelEM covered this recently published paper last week.

This study addresses an important question about whether adding a second vasopressor with a different action mechanism has an effect on the outcome in refractory septic shock. The authors did not find any significant difference in primary outcomes as vasopressor and ventilator free days. However, the study did show some differences in secondary outcomes (norepinephrine requirement and urine output).

SEPSIS-ACT: Selepressin in Septic Shock

Question 4

Source image: https://emergencymedicinecases.com/

Your patient presents with suspected hook of Hamate fracture. Which of the following statements is true about this condition?

A: Patients may have decreased grip strength and can endorse numbness in the 2th and 3th fingers as the deep branch of the ulnar nerve lies under the hook of the hamate

B: Hook of hamate fractures almost always require open reduction internal fixation (ORIF)

C: Hook of hamate fractures can be managed conservatively with a short arm cast

D: Excision of the fractured portion of the hamate is never indicated

The correct answer is C

AliEM covered Hook of Hamate fractures this week.

Patients may have decreased grip strength and can endorse numbness in the 4th and 5th fingers as the deep branch of the ulnar nerve lies under the hook of the hamate. ORIF is possible but has little benefit. Excision of the fractured portion of the hamate is sometimes indicated. And yes, hook of Hamate fractures can be managed conservatively with a short arm cast.

SplintER Series: Pain in the Palm

Question 5

Source image: www.pixabay.com

A number of methods are used to estimate the weight of pediatric patients. Which of the following methods was most accurate according to this recently published paper?

A: Parent estimation

B: Broselow tape

C: The Mercy Method

D: The APLS formula

The correct answer is A

JournalFeed covered this paper last week.

Parent estimation was within 10% of actual weight 89% of the time and within 20% of actual weight 97% of the time. The Broselow tape came second and the APLS formula and the Mercy Method were less accurate. Bear in mind this study was conducted in Thailand.

Click Image for link to source
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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 50, November 14th, 2019

Welcome to the th FOAMed Quiz. 

This weeks Quiz is about Cardiogenic Shock, PSA and Testicles. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Which of the following statements is correct regarding diagnosis and management of cardiogenic shock?

A: Dobutamine should almost always be first line treatment in cardiogenic shock

B: Patients in cardiogenic shock are not always hypotensive

C: Milrinone is easy titratable in the Emergency Department

D: Intra Aortic Balloon Pumps (IABPs) increase cardiac contractility

The correct answer is B

In the latest very interesting EMcrit podcast, Scott Weingard discusses cardiogenic shock with Jenelle Badulak.

Starting dobutamine without a vasopressor can cause vasodilatation and hypotension. Patients in cardiogenic shock are quite often normotensive. Milrinone is not easy to titrate, especially in patients with suspected kidney failure. And finally, AIBPs do not increase cardiac contractility directly.

EMCrit 259 – Cardiogenic Shock — The Next Level & Mechanical Circulatory Support with Jenelle Badulak

Question 2

Source image: www.nuemblog.com

NUEM covered the basics of Procedural Sedation and Analgesia (PSA) this week. Which of the following statements is true?

A: Third trimester pregnant patients do not have an increased chance of vomiting

B: Midazolam can safely be used  in pregnant patients

C: End tidal (Et) CO2 provides earlier detection of hypoventilation

D: Ketofol is clearly superior to Ketamine and Propofol alone

The correct answer is C

Yes, pregnant patients do have an increased risk of vomiting. This is one of the reasons PSA is rarely performed in the Emergency Department in pregnant patients (at least in our shop). Some benzodiazepines have been shown to be teratogenic, so midazolam should not be used. EtCO2 does provide earlier recognition of hypoventilation, although false positives occur (apnea on etCO2, but still breathing). Evidence is mixed on Ketofol. Although in theory lower doses of ketamine and propofol are necessary and chance of side effects smaller, you will have to deal with the side effects of 2 drugs instead of 1.

Click Image for link to source

Question 3

Which of the following statements is true about patellar sleeve fractures?

A: Injury to the proximal pole typically leads to avascular necrosis of the proximal portions

B: Patellar Sleeve Fractures are the most common type of patellar fractures in pediatric patients

C: Patellar sleeve fractures occur most often due to powerful contraction of the hamstrings while knee is extended

D: Patellar sleeve fractures are easily seen on conventional X-ray

The correct answer is B

Pediatric EM Morsels covered patellar sleeve fractures this week.

Blood supply to the immature patella comes from the distal pole and the anterior surface. Therefore, injury to the anterior or distal pole can lead to avascular necrosis of the proximal portions. Patellar sleeve fractures are quite often due to powerful contraction of the quadriceps while the knee is flexed. Patellar sleeve fractures are easily missed on conventional X-ray. MRI might be necessary for diagnosis. And indeed, a Patellar Sleeve Fracture is the most common type of patellar fracture in pediatric patients. Most fractures require open reduction and internal fixation.

Patellar Sleeve Fracture

Question 4

Source image: pixabay.com

An 18-year old male is seen in the emergency department with sudden onset severe pain in his right testicle. His pain increased over time and is now 9/10.

Which of the following is true about testicular torsion?

A: Testicular torsion is equally common in all age groups

B: At 4 hours after onset of symptoms, damage to the testicle is irreversible.

C: Absence of cremasteric reflex is the most sensitive and specific clinical finding in diagnosing testicular torsion

D: Isolated tenderness at the superior pole of the affected testicle is not a very specific sign for torsion

The correct answer is C

Testicular torsion was covered by CanadiEM this week.

Testicular torsion should be considered in every patient presenting with testicular pain although it is most prevalent in the pediatric population. Irreversible damage is more likely to be present if torsion consists for 8 hours or more. An absent cremasteric reflex is very sensitive and specific and can help to distinguish between testicular torsion and other conditions like epididymitis. Isolated tenderness at the superior pole of the affected testical is very specific for testicular torsion.

Testicular Torsion

Question 5

Source image: pixabay.com

In critically ill patients admitted to the hospital and receiving at least 48 hours of oxygen therapy, what would be the range of oxygen saturation associated with the lowest adjusted mortality according to this recently published paper?

A: 90-94%

B: 92-96%

C: 94-98%

D: 96-100%

The correct answer is C

JournalFeed  discussed this Singaporean paper last week.  

No big surprise in this recently published paper. Retrospective analyses were conducted of two electronic medical record databases: the eICU Collaborative Research Database (eICU-CRD) and the Medical Information Mart for Intensive Care III database (MIMIC). Nonlinear regression was used to analyze the association between median pulse oximetry-derived oxygen saturation (Spo2) and hospital mortality. The optimal range of Spo2 was 94% to 98% in both databases (total of > 35.000 patients).

Click image for link to source
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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 49, November 8th, 2019

Welcome to the 49th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Winter is coming! This means people start warming their houses. Unfortunately this is not always been done in a safe way.

Which of the following statements is true about carbon monoxide (CO) poisoning?

A: Carbon monoxide poisoning is always caused by inhaling gas

B: There is a validated relationship between carboxyhemoglobin levels and specific symptoms

C: Half-life of carbon monoxide at 100% FiO2 is ~1 hour

D: Arterial Blood Gas (ABG) is preferred to Venous Blood Gas (VBG) for diagnosis of CO poisoning

The correct answer is C

The internet book of critical care covered carbon monoxide poisoning this week.

Exposure to methylene chloride (paint remover) can cause CO poisoning (after being metabolized). This can occur several hours after exposure. There is no validated relationship between carboxyhemoglobin levels and specific symptoms. VBG is accurate for diagnosing CO poisoning. And the half-life of carbon monoxide at 100% FiO2 is ~1 hour (at 21% FiO2 ~5 hours, at 250% (hyperbaric oxygen)~20 minutes)

IBCC chapter & cast – Carbon monoxide poisoning

Question 2

Justin Morgenstern covered the coronary CT angiography (CCTA) on First10EM this week. Which of the following is true about the use of CCTA in patients with suspected Acute Coronary Syndrome (ACS) seen in the Emergency Department?

A: CCTA improves 30-day mortality

B: CCTA leads to a decrease in length of stay, but only if you have incredibly long lengths of stay to begin with

C: CCTA causes a huge increase in radiation

The correct answer is B

All relevant papers about this topic were briefly reviewed. It seems CCTA does not provide any clinical benefits over standard care. However, ‘’the patients enrolled in these studies were so low risk that they could not have possibly benefited from further testing.’’ So a role for CCTA is not fully excluded.

Question 3

You intubate a critically ill patient and you struggle with correct placement confirmation since capnography malfunctions. You decide to use ultrasound. Which of the following statements is true?

A: A bullet sign suggests oesophageal intubation

Bullet Sign. Source: https://www.nuemblog.com/

B: A double tract sign suggests endotracheal intubation

Double tract sign. Source: http://www.emdocs.net/

C: Ultrasound assessment has about 98% sensitivity for tracheal intubation

D: In ultrasound assessment of tracheal intubation the probe should be placed superior to the suprasternal notch in a longitudinal orientation

The correct answer is C

NUEM covered Ultrasound Confirmation of Endotracheal Tube Placement this week.

A bullet sign suggests endotracheal intubation. A double tract sign suggests oesophageal intubation. In ultrasound assessment of tracheal intubation the probe should be placed superior to the suprasternal notch in a transverse orientation. Ultrasound assessment has about 98% sensitivity for tracheal intubation.

Click image for link

Question 4

Which statement is true about dizziness and vertigo?

A: Associated neurological complaints, such as imbalance, dysarthria, or numbness raise the likelihood of TIA or stroke

B: When performing the Hallpike test, the head should be turned to the side 90 degrees prior to laying the patient back into the head-hanging position

C: The presence of auditory symptoms suggest a central cause of the vertigo

D: Vertigo after neck injury and is usually benign

The correct answer is A

CanadiEM covered dizzyness and vertigo in Crackcast episode 207

When performing the Hallpike test, the head should be turned to the side 45 degrees prior to laying the patient back into the head-hanging position. The presence of auditory symptoms suggest a peripheral cause of the vertigo. Neck injury can cause vertigo from vertebral artery dissection, resulting in posterior circulation ischemia.

CRACKCast E207 – Dizziness and Vertigo

Question 5

Which statement about urolithiasis is true?

A: Prevalence of kidney stones is higher in a cold and wet climate

B: A restrictive calcium diet decreases the risk of stone formation

C: Microscopic hematuria is present in only 50% of the patients

D: Intravenous (IV) hydration has no impact on stone passage

The correct answer is D

Daniel Tauber covered urolithiasis last week on emDOCs.

He clarifies why a calcium restrictive diet will not help to prevent urolithiasis, but paradoxically increases the risk of stone formation. He also emphasizes that the lack of microscopic hematuria can not be used to rule out kidney stones, since the sensitivity is only 85%. Prevalence is higher in hot, dry, arid climates such as mountain, desert, or tropical regions. IV hydration has no impact on stone passage.

EM@3AM: Urolithiasis

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 48, November 1th, 2019

Welcome to the th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

 

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Question 1

As emergency physicians we see a lot of septic patients coming into our emergency departments (ED’s). As early as possible administration of antibiotics sometimes conflicts with obtaining blood cultures before administration of these antibiotics. A recently published study, discussed in JournalFeed this week, compared positive blood cultures taken before and after administration of antibiotics.

What did this study find?

A: Administration of antibiotics before drawing blood cultures makes it harder to culture causative bacteria

B: The rate of positive blood cultures is the same as long as blood cultures are taken within 2 hours after administration of antibiotics in the ‘after’ group

C: It is reasonable to delay admission of antibiotics so blood cultures can be taken before the antibiotics will be administered, even if the patient is very ill

D: Timing does not matter at all, just make sure blood cultures are taken before the patient leaves the ED

​The correct answer is A

This recently published paper in Annals of Internal Medicine by Cheng et al. (september 2019) was discussed on JournalFeed this week and also reviewed by Rory Spiegel.

Cheng et al. included a total of 325 patients (aged 18 years and older) with severe sepsis (defined as having two SIRS criteria with a suspected or confirmed infectious source and either hypotension or a serum lactate > 4 mmol?L) from seven emergency departments. The data add proof to the long held belief that blood cultures should be taken before antibiotics are administered. However, sometimes antibiotics just need to be administered as soon as possible without any delay caused by taken blood cultures first.

EM Nerd-The Case of the Microscopic Imperative

Question 2

Last year 1182 people were diagnosed with measles in the United States. This was the highest number since 27 years. Emergency Physicians should be aware of this disease, especially in children with fever seen at the Emergency Department. Which of the following is true about Measles?

A: The ‘’classic’’ prodromes consist of: fever, conjunctivitis, and upper respiratory tract infection symptoms

B: Patients are only infectious in the first 48 hours after the onset of the maculopapular rash

C: The most common complication of measles is encephalomyelitis

D: If vaccinated, a child is 100% protected against the virus.

The correct answer is A

Last week ALiEM discussed measles.

The classic prodrome of symptoms consist of fever, conjunctivitis and upper respiratory tract symptoms. Children are infectious for 4 days before and 4 days after the onset of the rash. Measles are mostly if not always seen in children who are not vaccinated. Only 3% of vaccinated children get measles if regularly exposed. Only 1 in 1000 patients get encephalomyelitis. The complication of the measles leading to most deaths is pneumonia which occurs in 30% of hospitalized patients and is responsible for 60% of the deaths.

Measles 2019 Updates: The Comeback Kid

Question 3

Source: https://dontforgetthebubbles.com/

Last weeks post on Don’t Forget the Bubbles is about two kinds of palsy that can occur in the pediatric population; phrenic nerve palsy and Erb’s palsy. Which of the following statements is true ?

A: Phrenic nerve palsy’s most common cause is birth trauma

B: Erb’s palsy’s most common cause is birth trauma

C: Half of the patients with Erb’s palsy have associated phrenic nerve palsy

The correct answer is B

Phrenic nerve palsy causes hemidiaphragmatic paralysis, which compromises respiratory function. The most common cause is thoracic surgery, but can also occur with birth trauma. Mortality is reported up to 19 percent, and is even higher with delayed treatment. Treatment includes supportive respiratory care and most of the time surgical intervention. Erb’s palsy is a complex brachial plexus injury that causes paralysis of the arm. Most common cause is birth trauma, and most babies recover fully. There are similar risk factors for both palsies and in 2.4 percent of the patients with Erb’s palsy there is associated phrenic nerve palsy.

Question 4

Splenic abscesses are a rare condition, with an annual incidence rate of 0.05 – 0.7%. Despite this low incidence rate, it is important to have a high clinical suspicion of the condition in a subset of patients.

What is an important risk factor for the development of splenic abscesses, and which clinical findings can be expected?

A: Risk factor: endocarditis. Symptoms: generalized abdominal pain, diarrhea, leukopenia

B: Risk factor: deep skin infections. Symptoms: generalized abdominal pain, diarrhea, leukopenia

C: Risk factor: endocarditis. Symptoms: left upper quadrant pain, hiccups, leukocytosis

D: Risk factor: deep skin infections. Symptoms: left upper quadrant pain, hiccups, leukocytosis

The correct answer is C

EMdocs covered splenic abscesses last week. Early recognition of the condition is important for mortality rates are significant in missed or delayed diagnosis.

Splenic abscesses are quite frequently secondary to endocarditis. Risk factors include immunosuppression, prior splenic infarction, splenic trauma or hemoglobinopathies. Patients commonly present with fever, left upper quadrant pain and vomiting. In case of diaphragmatic irritation, patients usually have left shoulder pain and hiccups as well.

Splenic Abscess: ED Presentation, Evaluation, and Management

Question 5

Source: https://emsimcases.com

 Your 55 year old patient presents with diaphoresis, confusion and hypotension. During primary survey you notice a battery pack on his side and you realize he has a Left Ventricular Assist Device (LVAD). As the first sweat drops start to appear on your forehead, you try to remember everything you know about LVAD’s. Which of the following statements is true?

A: The LVAD patient will have a palpable pulse

B: The mean arterial pressure (MAP) should be measured with a doppler and a sphygmomanometer

C: On auscultation you shouldn’t be able to hear the device

D: The MAP goal for the majority of LVAD patients is between 40-60 mmHg

The correct answer is B

BrownEM covered LVAD issues this week.

The LVAD patient will most likely not have a palpable pulse, nor a measurable blood pressure. The mean arterial pressure (MAP) should be measured with a doppler and a sphygmomanometer. On auscultation, the physician should be able to hear the hum of the device. The MAP goal for the majority of LVAD patients is between 70-90mmHg.

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This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 47, October 25th 2019

Welcome to the 47h FOAMed Quiz. 

Please feel free to comment and (if you like it) share.

Enjoy!

Kirsten, Eefje, Hüsna, Nathalie and Rick

Question 1

Last week the CRASH-3 trial was published in the Lancet. It is about the effect of tranexamic acid (TXA) in patients with acute traumatic brain injury with a Glasgow Coma Scale of ≤ 12 or intracranial hemorrhage without significant extracranial bleeding.

What did the authors find?

A: Treatment with tranexamic acid is safe and reduces head injury related death in patients with an initial GCS of 9 and higher

B: Treatment with tranexamic acid reduces head injury related death in patients with an initial GCS of 3 to 8

C: Treatment with tranexamic acid does not reduce head injury related death

The correct answer is A

The CRASH-3 trial is a massive double-blind RCT involving 175 hospitals in 29 countries.

About every Emergency Medicine blog and podcast covered this paper last week and rightfully so.

The Resus Room, St Emlyn’s, EMlitofnote, JournalFeed, RebelEM and EMCrit are among those.

In short:
It is a massive and well conducted trial.
Only secondary analysis of an underpowered subgroup was found to be statistically significant (head injury related death in patients presenting with a GCS of 9 and above).
TXA seems to be safe, but Pulmonary Embolism and Deep Venous Thrombosis were only diagnosed when found positive by accident on imaging or post-mortem examination.

Question 2

Do we need to give a fluid bolus before intubation? The PrePARE Trial investigated the effect of a fluid bolus (500 cc) versus no bolus in critically ill adults undergoing tracheal intubation. The primary endpoint was a composite of post-intubation complications including new-onset hypotension (systolic Bp <65 mm), new or increased vasopressor administration, or cardiac arrest.

What is true according to the PrePARE trial?

A: A fluid bolus prevents hypotension caused by intubation

B: A fluid bolus increases the risk of a cardiac arrest

C: A fluid bolus leads to increased administration of vasopressors

D: There was no difference in primary outcome between giving a fluid bolus or not

The correct answer is D

The PrePARE trial is a multicenter RCT that investigated patients undergoing endotracheal intubation. Prior to intubation patients were randomized to receive 500 cc fluid bolus versus no bolus. The study was stopped early for futility after including 337 patients. The outcome in both groups were exactly the same.

PulmCrit Wee: Do fluid boluses before intubation help? (PREPARE trial)

Question 3

Which of the following statements is true about hydrocarbon poisoning?

A: Cardiovascular complications are the most commonly reported adverse effect

B: Hydrocarbons are believed to produce a decrease in myocardial sensitization to endogenous and exogenous catecholamines

C: Beta-blockers like esmolol may provide benefit in the treatment of hydrocarbon poisoning

D: Topical exposure to hydrocarbons does not cause harm

The correct answer is C

emDocs covered hydrocarbon poisoning this week.

Pulmonary complications are the most commonly reported adverse effect. Hydrocarbons are believed to produce an increase in myocardial sensitization to endogenous and exogenous catecholamines. Topical exposure to certain hydrocarbons can cause cell membrane injury leading to burns and skin necrosis from prolonged contact. And indeed, esmolol may provide benefit in the treatment of hydrocarbon poisoning by decreasing the myocardial sensitization to catecholamines.

TOXCard: Hydrocarbon Toxicity

Question 4

Source: https://litfl.com/

The management of uncomplicated atrial fibrillation in the emergency department (ED) is an ongoing topic of discussion. Recent literature suggests we shouldn’t try to achieve sinus rhythm in stable atrial fibrillation. But if you still wanted to cardiovert a patient with stable atrial fibrillation, what would be the best method?

This study compared initial electrical (and secondary chemical cardioversion in not successful) versus initial chemical cardioversion (and secondary electrical cardioversion in not successful).

What difference did the authors find?

A: The length of stay (LoS) in the emergency department was longer in the chemical cardioversion first group

B: Patients undergoing chemical cardioversion first were more likely to be discharged home

C: ED revisits were fewer in the electrical cardioversion group

The correct answer is A

This RCT compares procainamide-first versus electrical cardioversion-first approach for patients presenting in the emergency department with uncomplicated atrial fibrillation. 84 patients were included. The authors conclude that both strategies are successful and well tolerated. The length of stay in the ED was shorter in the cardioversion-first group (no surprise there). They found no difference in QOL, ED revisits and all patients were discharged home after the initial visit (no surprise there either).

Comparison of Chemical vs Electrical Cardioversion of Acute Uncomplicated Atrial Fibrillation

Question 5

Your 24 year old female patient presents with right lower quadrant abdominal pain for 3 days, you consider appendicitis. There is no fever, but blood works show mild leukocytosis. The abdominal ultrasound is inconclusive (appendix is not seen) and by hospital policy you order an MRI. Given the pretest probability of your patient having appendicitis is 20% and MRI has a 80% specificity (and close to 100% sensitivity) in diagnosis of appendicitis, what is the chance this MRI will turn out to be false positive?

A: 24,5%

B: 34,5%

C: 44,5%

D: 54,5%

Okay, your next patient is also 24 years old and presents with right lower quadrant abdominal pain since 5 days. Blood works do not show abnormalities but you still order an ultrasound, which turns out to be inconclusive. Again, by hospital policy you proceed to MRI (specificity 80%). In this case the pretest probability has fallen to 5%. What is the chance this MRI will turn out to be false positive?

A: 40%

B: 60%

C: 80%

D: 90%

The correct answer to the first part is C, 44,5%

The correct answer to the second part is C, 80%

Justin Morgenstern points out once more You can’t interpret the results of a test without knowing the pretest probability.

The first part: In every 1000 patients, 200 will have appendicitis. Given the sensitivity is 100% these 200 patients will have a positive scan. Furthermore, of the 800 patients without appendicitis, 160 patients will have a positive scan (.2 x 800). So, eventually there is a 160 / (200+160) = 44,4% chance on a false positive result (and most likely negative laparoscopy).

The second part: In 1000 patients, 50 will have appendicitis. Given the sensitivity is 100% these 50 patients will have a positive scan. Furthermore, of the 950 patients without appendicitis, 190 patients will have a positive scan (.2 x 950). So, eventually there is a 190/ (50+190) = 79,1% chance on a false positive result (and most likely negative laparoscopy).

Why pretest probability is absolutely essential

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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 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