Quiz 130, September 24th, 2021

Welcome to the 130th FOAMed Quiz.

 

Question 1

Source image: wolverem.com

Which of the following is not a sign of orbital compartment syndrome?

A: Positive Seidel test

B: Proptosis

C: Marcus-Gunn pupil

D: Decreased visual acuity

The correct answer is A.

Orbital compartment syndrome was covered on AliEM this week.

Signs of orbital compartment syndrome include:
– Proptosis
– Increased intraocular pressure
– Marcus-Gunn pupil
– Decreased visual acuity
– Restricted ocular movements

A Marcus-Gunn pupil is caused by a relative afferent pupillary defect (RAPD).

A positive Seidel test is seen in case of globe rupture

SAEM Clinical Image Series: Traumatic Swollen Eye

Question 2

Your 19 year old patient presents to your ED after recurrent episodes of syncope. His father died suddenly at the age of 32 without a known cause. On your patients ECG to see inverted T-waves in V1-5.

Sourrce image: litfl.com

Which of the following waves are visible on his ECG?

A: Delta wave

B: Osborn wave

C: Epsilon wave

The correct answer is C.

A case of Arrhythmogenic right ventricular cardiomyopathy (ARVC) was covered on dr. Smith’s ECG blog this week.

This patient most likely suffers from ARVC. Epsilon waves (Small positive deflection at the end of the QRS) are seen in about a quarter of patients with ARVC.

Question 3

Source image: www.proceduresconsult.jp

Your patient comes in with a plantar sole laceration.

Which of the following ultrasound guided nerve blocks is best used in this case?

A: Femoral nerve block

B: Ischiadic nerve block

C: Posterior tibial nerve block

D: Saphenous nerve block

The correct answer is C.

Jacob Avila and Arun Nagdev covered various ultrasound guided procedures this week on core-ultrasound.

For this indication, a posterior tibial nerve block is indicated. It will provide anesthesia to almost the entire sole of the foot.

Nerve Block Talks Episode 3!

Question 4

Source image: www.acc.org

Which of the following statements is true about using ultrasound for detection of regional wall motion abnormalities (RWMA) in suspected occlusion myocardial infarction (OMI)?

A: RWMA is a relatively late finding in OMI

B: Besides OMI, myocarditis can cause RWMA as well

C: Data clearly shows emergency care physician performed assessment for RWMA has a high sensitivity for OMI

D: On the parasternal short axis view, the cardiac wall nearest to the top of the screen is supplied by the right coronary artery

The correct answer is B.

The performance of ultrasound assessment of RWMA in myocardial infarction was covered on CountyEM this week.

RWMA occurs very quickly after occlusion of a coronary artery, even before ECG changes and pain.

Focal myocarditis causes RWMA.

The sensitivity of emergency care physician performed assessment for RWMA for detection of OMI is yet unknown.

On the parasternal short axis view, the cardiac wall nearest to the top of the screen is the anterior wall which is supplied by the LAD.

Can Ultrasound Diagnose Myocardial Infarction?

Question 5

Source image: caperadiology.co.za


CT coronary angiography (CTCA) is an anatomic study that tells us about the presence and extent of coronary artery disease (CAD).

In theory, CTCA might help us risk stratify patients with chest pain in the ED.

According to available literature, what does CTCA lead to if used in patients with chest pain in the ED?

A: CTCA leads to more accurate identification of CAD

B: CTCA leads to less coronary angiography

C: CTCA leads to a reduction in mortality at 6 months

D: CTCA leads to shorter duration of stay in the ED

The correct answer is A.

A review of available literature on CTCA in the ED was posted on RebelEM this week.

‘’CTCA can help optimize medical management but doesn’t change long term patient-oriented outcomes compared to optimal medical treatment alone.’’

Rebellion21: Approach to Angina in 2021 via Tarlan Hedayati, MD

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

Reviewed and edited by Rick Thissen

Quiz 128, September 3th, 2021

Welcome to the 128th FOAMed Quiz.

 

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

Question 1

Intoxication with which of the following drugs will not cause the ECG shown above?

A: Flecainide

B: Procainamide

C: Lidocaine

D: Propranolol

The correct answer is D.

Sodium channel blockade was covered on dr. Smith’s ECG blog last week.

This ECG is characteristic for sodium channel blockade (wide QRS, tall R in aVR). Flecainide, Procainamide and Lidocaine are all class I (sodium blocking) antiarrhythmics.

Source image: www.pixabay,com

Question 2

Oral ondansetron is frequently prescribed to children presenting with gastro-enteritis in the emergency department (ED). This recently published observational study is about the effectiveness of ondansetron in children 3 to 48 months old with gastroenteritis and ≥3 episodes of vomiting in the 24 hours preceding ED presentation.

What do you think the authors found?

Children who received oral ondansetron:

A: Were less likely to receive intravenous fluids at the index visit

B: Were less likely to be hospitalization at the index visit

C: Had reduced episodes of vomiting

D: Had reduced frequency of intravenous fluid resuscitation

The correct answer is A.

The paper was covered on JournalFeed last week.

This study was a planned secondary analysis of 2 trials conducted in 10 US and 6 Canadian institutions. 794 children were included. Children administered oral ondansetron were less likely to receive intravenous fluids at the index visit. There were no differences in the frequencies of intravenous fluid administration within the first 72 hour, hospitalization at the index visit or episodes of vomiting and diarrhea.

Source image: www.emra.org

Question 3

What distinguishes phlegmasia cerulea dolens from uncomplicated deep venous thrombosis?

A: The presence of arterial occlusion

B: The presence of total or near total venous occlusion

C: The presence of compartment syndrome

D: The presence of bacterial infection

The correct answer is B

Phlegmasia cerulea dolens was covered on AliEM last week.

In phlegmasia cerulea dolens there is near-total or total occlusion of the deep venous system, causing severe venous congestion. This leads to limb ischemia and eventually loss of the limb. It can be complicated by compartment syndrome and gangrene.

Management includes elevation of the limb, anticoagulation and often catheter-directed thrombolysis or thrombectomy.

SAEM Clinical Image Series: Pulseless and Painful Blue Leg

Source image: www.pixabay.com

 Question 4

This recently published RCT is about Ketamine (5 mg/kg) versus a combination of Midazolam (5 mg) and Haloperidol (5 mg) for intramuscular treatment of patients with severe psychomotor agitation.

80 patients were randomized equally to the 2 study arms.

The primary outcome was time from medication administration to adequate sedation (RASS ≤ -1).

What did the authors find?

A: Patients in the Ketamine group had a shorter time to adequate sedation

B: Patients in the Midazolam and Haloperidol group had a shorter time to adequate sedation

C: There was no difference between the two groups

The correct answer is A.

The paper was covered on RebelEM last week.

Time to adequate sedation was 5.8 minutes in the Ketamine group versus 14.7 minutes in the Midazolam and Haloperidol group.

The proportion of patients requiring rescue medications was similar in both arms.

This is consistent with the results of previous trial. I would like to see how Ketamine holds up to Droperidol.

Rapid Agitation Control With Ketamine in the Emergency Department

Source image: www.aliem.com

Question 5

Your 76 year old patient comes in after a fall. You suspect her of having an acetabulum fracture, but plain pelvis radiography is inconclusive. Which of the following views might help visualising the acetabulum?

A: Frog view

B: Judet view

C: Pelvic inlet / outlet view

The correct answer is B

AliEM covered imaging in pelvic trauma last week.

The frog view can be helpful in suspected Legg-Calvé-Perthes or slipped femoral epiphysis. A pelvic inlet / outlet view is helpful in visualization of the pelvic brim and the SI joints.

The Judet view (also oblique pelvis view) is an additional projection to the pelvic series when there is suspicion of an acetabular fracture.

EMRad: Radiologic Approach to the Traumatic Hip/Pelvis

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

Reviewed and edited by Rick Thissen

Quiz 123, July 30th, 2021

Welcome to the 123th FOAMed Quiz.

 

Question 1

Source image: www.acc.org

A 35-year-old male presents with symptoms of dyspnea on exertion and palpitations, which have been present for the last two weeks. His ECG shows sinus tachycardia of 125 bpm. X-ray shows evidence of pulmonary edema and cardiomegaly. POCUS reveals poor left ventricular function. He has no cardiovascular risk factors, no past medical history and no relevant family history. You suspect him of having myocarditis.

What statement about myocarditis is true?

A: Absence of ECG changes has a high negative predictive value

B: The extent of troponin elevation can be used as a prognostic factor

C: Regional wall motion abnormalities on echocardiography can distinguish between acute coronary syndrome and myocarditis: myocarditis causes diffuse systolic dysfunction

D: One of the most common viral causes of myocarditis in developed countries are enteroviruses like coxsackie B

The correct answer is D.

JournalFeed highlighted this recently published paper in the Journal of Emergency Medicine about myocarditis this week. The review presents a nice overview of the diagnosis and management of myocarditis.

Myocarditis has viral, toxic, or autoimmune etiologies. Viral infections compromise the majority of cases in Western countries. The most common viral causes are coxsackie B viruses and adenoviruses.

The ECG may be normal in myocarditis. ECG changes include non-specific ST-changes, dysrhythmias, findings consistent with pericarditis and heart blocks.

Troponin levels are commonly elevated, but normal values can’t be used to exclude myocarditis. They cannot be used as a prognostic factor either.

Echocardiography can reveal regional wall abnormalities, dilated heart chambers, reduced left ventricular ejection fraction or right ventricular dysfunction.

Question 2

Source image: emergencymedicinecases.com

Your 74 year old patient presents with chest discomfort. His ECG shows mild (0,5 mV) St elevation in leads III and AVF. You are trying to distinguish inferior occlusion myocardial infarction (OMI) from pericarditis. You also notice a negative T and subtle ST depression in lead AVL.

What does the subtle ST depression in lead aVL tell you in this case?

A: This is most likely pericarditis

B: This is most likely inferior OMI

C: ST depression in aVL will not help you distinguish between the two

The correct answer is B.

Dr. Smith’s ECG blog was about subtle inferior OMI last week. This paper is about the value of ST depression in aVL in the setting of ST elevation in the inferior leads.

In case of inferior ST-segment elevation, the presence of any ST depression in lead aVL is highly sensitive for coronary occlusion in inferior myocardial infarction and very specific for differentiating inferior myocardial infarction from pericarditis.

Question 3

Source image: www.chromagar.com/

A 65 year old patient presents to your emergency department with urosepsis. She has a known penicillin allergy. The previous urine culture showed Pseudomonas aeruginosa and you want to start piperacillin – tazobactam.

Which of the following statements is true regarding the safety of administering piperacillin – tazobactam in patients with penicillin allergy?

A: Never give piperacillin – tazobactam to patients with a penicillin allergy, for the rate of cross-reactivity is high due to a similar side chain

B: Patients with known penicillin allergy should never receive beta lactam antibiotics, because the allergy is caused by reactivity to the core beta-lactam ring which is equal in all beta lactams

C: As penicillin allergy is caused by reactivity to a side chain, the rate of cross reactivity between penicillin and piperacillin – tazobactam is very low

The correct answer is C.

Josh Farkas covered beta lactam allergies on EMCrit last week.

Allergy to beta-lactam antibiotics is mediated by the R side chain, rather than the core structure.

There doesn’t seem to be consistent allergic cross-reaction between piperacillin-tazobactam and penicillin, because the side chain of piperacillin is structurally distinct from penicillin.

There are occasional patients with piperacillin-tazobactam allergy who are also allergic to penicillin or amoxicillin, but this probably doesn’t represent a true cross-allergic reaction.

PulmCrit – Is piperacillin-tazobactam safe in patients with penicillin allergy?

Question 4

Source image: www.aliem.com

When a patient needs rapid fluid resuscitation, the choice of IV catheter type makes a huge difference.

Which of the following options gives the potentially highest fluid flow?

A: Saline through a 18 Gauge, 16cm long, central triple lumen cath

B: Saline through a 18 Gauge, 32 mm long, peripheral IV

C: Packed cells through a 22 Gauge, 32 mm long, peripheral IV

D: Saline through a 22 Gauge, 32 mm long, peripheral IV

The correct answer is B.

This week the Trauma Pro discussed the physics behind rapid fluid infusion.

In short: a larger internal diameter (lower Gauge size), shorter line length and lower viscosity of the liquid, lead to a higher flow.

So with a multilumen line, the flow is often lower as these are generally long.

Rapid Infusers: How Fast Can They Go?

Question 5

Source image: www.theguardian.com

Your 50 year old patient presents to the ED with a prolonged erection. You want to differentiate between ischemic and non-ischemic priapism. This can be done based on history and laboratory results.

Which of the following is NOT typical for ischemic priapism?

A: Severe pain

B: Often caused by trauma

C: Often medication induced or related to sickle cell disease

D: Acidotic penile blood gas

The correct answer is B

This week EmDocs covered Priapism last week.

Low flow (ischemic) priapism is more common than high flow (non-ischemic) priapism (only 2%).

Drugs such as intracavernosal injections, PDE5 inhibitors (sildenafil and tadalafil), anti-hypertensives, neuroleptics and cocaine and marijuana can cause ischemic priapism. A baseline penile blood gas can be performed dan in case of low flow priapism it will turn out dark, hypoxemic and acidotic.

EM Cases: Priapism and Urinary Retention: Nuances in Management

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

Reviewed and edited by Rick Thissen

Quiz 122, July 23th, 2021

Welcome to the 122th FOAMed Quiz.

 

Question 1

Source image: rebelem.com

Both conventional X-ray and point of care ultrasound (POCUS) can be used to diagnose pneumothorax.

This recently published meta-analysis is about X-ray versus POCUS for diagnosis of pneumothorax in trauma patients.

9 studies were included with a total of 1271 patients.

Which imaging modality had the highest sensitivity for pneumothorax in trauma patients?

A: POCUS

B: X-ray

C: POCUS and X-ray were equally sensitive

The correct answer is A.

The paper was covered on JournalFeed last week.

The overall sensitivity of chest ultrasonography was 0.91 (95% confidence interval [CI] 0.85 to 0.94) and the specificity was 0.99 (95% CI 0.97 to 1.00). The sensitivity of chest radiography was only 0.47 (95% CI 0.31 to 0.63) and the specificity was 1.00 (95% CI 0.97 to 1.00).

In 8 of 9 studies, POCUS was performed by Emergency Physicians.

Question 2

Source image: sinaiem.org/

The recently published TTM2 trial is about hypothermia versus normothermia in post cardiac arrest. 1861 patients that were unconscious after out of hospital cardiac arrest (OHCA) were included. They were randomised to cooling to target 33 degrees celsius (targeted hypothermia) or cooling if the temperature reached 37,8 degrees celsius (targeted normothermia).

The primary outcome was death from any cause at 6 months.The main secondary outcome was a poor functional outcome at 6 months, defined as a score of 4 to 6 on the modified Rankin scale.

What did the authors find?

A: Targeted hypothermia did not lead to a lower incidence of death by 6 months than targeted normothermia, but it did lead to a lower incidence of poor functional outcome by 6 months compared to targeted normothermia

B: Targeted hypothermia did lead to a lower incidence of death by 6 months and it did lead to a lower incidence of poor functional outcome by 6 months compared to targeted normothermia

C: Targeted hypothermia did not lead to a lower incidence of death by 6 months and it did not lead to a lower incidence of poor functional outcome by 6 months than targeted normothermia

The correct answer is C

RCEM and RebelEM (among others) covered the recently published TTM2 trial.

465 of 925 patients (50%) in the hypothermia group had died by 6 months, compared with 446 of 925 (48%) in the normothermia group (P = 0.37). 55% in the hypothermia group had moderately severe disability or worse, compared with 479 of 866 (55%) in the normothermia group.

Hypothermia seems to be not beneficial for unconscious patients after OHCA compared to normothermia according to this well done paper.

TTM2: Hypothermia vs Normothermia for Out-of-Hospital Cardiac Arrest

Question 3

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

Aortic dissection can present with a wide variety of symptoms.

In type A aortic dissection (TAAD), which symptom is most commonly present?

A: Cerebral Malperfusion Syndrome

B: Myocardial Malperfusion Syndrome (RCA or LCA)

C: Cardiac tamponade

D: Aortic regurgitation

The correct answer is D.

County EM covered aortic dissection this week.

The incidence of aortic regurgitation in TAAD is 50-66%.
The incidence of cardiac tamponade in TAAD is 20-36%.
The incidence of myocardial malperfusion in TAAD is 10-15%.
The incidence of cerebral malperfusion in TAAD is 6-14%.

Malperfusion Syndromes of Aortic Dissection

Question 4

Source image: unicef.org

Although evidence does not support the use of antibiotics in uncomplicated upper respiratory tract infections (URTI), they are still quite widely prescribed.

This recently published paper is about the concept of delayed antibiotic prescription (DAP) in children with uncomplicated URTI. This means the parents received a prescription for antibiotics, which they could start if their child was not improving after some days or if the child got sicker. The most commonly prescribed antibiotic was amoxicillin.

436 children were randomised to receive either immediate antibiotic prescription (IAP), DAP or no antibiotic prescription (NAP). Primary outcomes were symptom duration and severity.

What did the authors find?

A: Patients receiving NAP showed shorter symptom duration and decreased severity in children with uncomplicated respiratory infections compared to patients receiving IAP or DAP

B: Patients receiving IAP showed shorter symptom duration and decreased severity in children with uncomplicated respiratory infections compared to patients receiving NAP or DAP

C: Patients receiving DAP showed shorter symptom duration and decreased severity in children with uncomplicated respiratory infections compared to patients receiving NAP or IAP

D: There was no statistically significant difference in symptom duration or severity in children with uncomplicated respiratory infections who received DAP compared to NAP or IAP

The correct answer is D

First10EM, EMOttawa and others covered the paper last week.

Delayed antibiotic prescription reduced the (inappropriate) use of antibiotics in children with uncomplicated URTI compared to immediate antibiotic use. Less antibiotics was not associated with a worse clinical course. This makes sense, for antibiotics simply do not work in this patient category. This is another piece of evidence to support the practice of not prescribing antibiotics for uncomplicated URTI.

Interestingly, the authors found that 80 percent of parents in the immediate antibiotic group believed that antibiotics were very or extremely effective, compared to 40 percent in the delayed antibiotic group and 30 percent in the no antibiotic group.

Delayed Antibiotic Prescription for Children With Respiratory Infections: A Randomized Trial

Question 5

Source image: emdocs.net/

Myocarditis can cause a wide variety of ECG changes. One of these changes is a fragmented QRS (fQRS or sometimes called Ferrero’s sign).

What is the clinical significance of a fragmented QRS?

A: None, a fragmented QRS is a random finding

B: A fragmented QRS cannot be caused by myocarditis. Underlying ischemia is very likely

C: A fragmented QRS in myocarditis represents structural tissue changes. Beware of arrhythmias

The correct answer is C.

EMdocs covered the significance of a fragmented QRS in myocarditis last week.

A fragmented QRS represents structural tissue changes (fibrosis). These structural changes in the myocardium lead to an increased chance of arrhythmias. It is certainly not a benign finding and it is not only caused by ischemia.

ECG Pointers: Myocarditis and QRS fragmentation

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

Reviewed and edited by Rick Thissen

Quiz 121, July 2nd , 2021

Welcome to the 121th FOAMed Quiz.

 

Question 1

Source image: www.stemlynsblog.org

In addition to Toculizumab and Dexamethasone, the REGN monoclonal antibodies combination (Casirivimab and Imdevimab) have shown to be beneficial in patients with COVID-19 according to this part of the RECOVERY trial.

However, the Casirivimab and Imdevimab combination was only associated with reduced mortality, increased speed of discharge and reduced progression to invasive mechanical ventilation or death in a subset of patients.

Which group of COVID-19 patients benefit from the Casirivimab and Imdevimab combination?

A: Patients on mechanical ventilation

B: Patients beyond the 10th day of their illness

C: Patients on oxygen therapy

D: Patients that were seronegative on randomisation

The correct answer is D

St Emlyns covered the RECOVERY trial about the Casirivimab and Imdevimab combination last week.

9785 patients were randomly allocated to receive usual care plus REGN antibody combination or usual care alone.

3153 (32%) of these patients were seronegative. In the primary efficacy population of seronegative patients, 396 (24%) of 1633 patients allocated to REGN antibody combination and 451 (30%) of 1520 patients allocated to usual care died within 28 days (p=0.0010). When combining the seropositive group with the seronegative patients, there was no longer a significant effect on 28-day mortality.

REGN monoclonal antibodies work in selected hospitalised COVID-19 patients. St Emlyn’s

Question 2

Source image: journals.lww.com

Your 65 year old patient presents to your ED with acute respiratory distress. She is tachypneic and her oxygen saturation is 92 percent without oxygen suppletion. She has tachycardia, capillary refill of 4 seconds, is diaphoretic and she has a blood pressure of 90/50 mmHg.

POCUS does not reveal any B-lines and lung sliding is present in all areas. You suspect this patient to have massive Pulmonary Embolism (PE). You get a parasternal short axis view of the base of the heart and you retrieve a pulse wave doppler image of the right ventricular outflow tract (RVOT). This image is shown above.

This POCUS finding makes a massive PE more likely.

How is this finding called?

A: McConnell’s sign

B: RVOT acceleration time

C: 60/60 sign

D: Early Systolic Notching

The correct answer is D.

The Ultrasound Gel podcast covered this paper about POCUS findings in PE.

277 patients of which 100 had massive or submassive PE were included. Early Systolic Notching was present in 92 percent of these patients (compared to only 2 percent in patients with subsegmental PE). This was superior to any other POCUS finding in suspected PE.

Source image: www.ultrasoundgel.org/

Question 3

Source image: radiopaedia.org/

 

Your 36-year-old patient is brought in by the EMS with head trauma after falling down the stairs. On arrival, his Glasgow Coma Scale was E1M3V2.

What statement about different types of traumatic brain injury is true?

A: Epidural hematoma is typically due to laceration of the anterior meningeal artery

B: An intraparenchymal hematoma with a volume of ≥20 ml is an indication for surgical drainage, regardless of location of the hematoma and midline shift

C: Traumatic subarachnoid hemorrhage (SAH) is typically located over the peripheral cerebral convexities, rather than the sylvian fissures and basal cisterns

D: Diffuse Axonal Injury (DAI) is usually associated with elevated intracranial pressure

The correct answer is C.

Traumatic brain injury was covered in this week’s Internet Book of Critical Care by EMcrit.

Epidural hematomas are typically due to laceration of the middle meningeal artery.

An intraparenchymal hematoma with a volume of ≥50 ml is a potential indication for surgical drainage; as well as a volume of ≥20 ml and located frontal or temporal with a midline shift of ≥ 5 mm and/or cisternal compression with GCS 6-8.

For traumatic subarachnoid hemorrhage, be careful not to miss primary aneurysmal hemorrhage which can lead to syncope and a fall.

DAI is usually not associated with elevated ICP.

Traumatic Brain Injury (TBI)

Question 4

Source image: https://saskblood.ca/

Postpartum hemorrhage (PPH) is an obstetric emergency. It is one of the most common causes of maternal mortality.

The causes of postpartum hemorrhage can be summarized by the four “T’s”.

Which of the following is not a part of the four T’s?

A: Trauma (rupture or lacerations)

B: Tension (hypertension)

C: Tone (uterine atony)

D: Tissue (retained placenta)

E: Thrombine (coagulopathies)

The correct answer is B.

JournalFeed covered this recently published paper about preparation, risk factors, identification and management of postpartum hemorrhage last week.

Postpartum hemorrhage can be defined by blood loss >500ml after vaginal delivery and > 1000ml after cesarean delivery.

The causes of postpartum hemorrhage can be summarized by the four “T’s”: tone (uterine atony), trauma (lacerations or uterine rupture), tissue (retained placenta or clots), and thrombin (clotting-factor deficiency). The most common cause is uterine atony (accounting for approximately 70% of cases).

Question 5

 

Source image: www.elmhurstfootdoc.com

Your patient presents with profound fever and severe pain with cramping in his calf for two days. The calf looks swollen and red and it feels warm. You suspect pyomyositis and you start empiric antibiotics.

Which of the following bacteria is most often the cause of pyomyositis?

A: Staphylococcus aureus

B: Mycobacterium tuberculosis

C: Fusobacterium necrophorum

D: Capnocytophaga canimorsus

The correct answer is A.

RebelEM covered pyomyositis last week.

Pyomyositis is a purulent infection of the skeletal muscles that arise from hematogenous spread.

The most common causative organism of pyomyositis is Staphylococcus aureus. Less common are Streptococci.

REBEL Core Cast 60.0 – Pyomyositis

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

Reviewed and edited by Rick Thissen

Quiz 118, June 11th, 2021

Welcome to the 111th FOAMed Quiz.

 

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


Question 1

Your 63 year old patient is in profound shock. His capillary refill is 4 seconds, his heart rate is 120 / minute, blood pressure 86/40 mmHg and his hands and feet are cold. He states he took a handful of his antiarrhythmic drugs to end his life. His ECG is shown above.

Which of the following antiarrhythmics is most likely the cause?

A: Flecainide

B: Metoprolol

C: Verapamil

D: Digoxine

The correct answer is A.

EMDocs covered flecainide poisoning this week.

The ECG shows prolonged QRS interval and a large terminal R wave in aVR. These findings are suggestive of sodium channel blockade.

Class I antiarrhythmics rely on sodium channel blockade. Flecainide is the only class I antiarrhythmic in this list.

Question 2

Your 65 year old patient presents with right hemiparesis. His medical history reveals an increased risk of cardiovascular disease and hypertension. He uses acetylsalicylic acid and metoprolol. He shows no abnormal findings in A and B, but he has mild hypertension (170/90).

His CT-scan reveals the following:

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

Which of the following statements about the management of this patient is true?

A: Platelet transfusion is required because the patient uses antiplatelet therapy

B: Lowering the systolic blood pressure to below 140 mmHg is safe

C: The blood pressure should not be lowered

D: Seizure prophylaxis is recommended in this patient

The correct answer is B

County EM covered Spontaneous Intracranial Hemorrhage (SIH) this week.

To this date there is no evidence to support the use of seizure prophylaxis in patients with Spontaneous Intracranial Hemorrhage.

The PATCH trial showed that patients with ICH who are on antiplatelet agents have worse neurological outcomes at 3 months if they are treated with a platelet transfusion compared to standard care alone.

INTERACT2 and ATACH II trial showed at least no harm of lowering systolic blood pressure in patients with SIH to < 140 mmHg. Whether lowering the blood pressure to < 140 mmHg is beneficial to < 180 mmHg remains uncertain to this point.

Question 3

Which of the following odontoid fractures is considered the least stable?

A:

Source image: https://radiologykey.com/spine-12/

B:

Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 20305

C:

Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org, rID: 12233

The correct answer is B.

AliEM covered odontoid fractures last week.

Answer A shows a type I odontoid fracture. This fracture is considered stable.

Answer B shows a type II odontoid fracture. This fracture is the most likely to require surgery. It has a high nonunion rate due to interruption of blood supply.

Answer C shows a type III odontoid fracture. It is a mechanically unstable injury, but has good prognosis for healing.

SplintER Series: The Tooth of the Cervical Spine

Source image: www.pixabay.com

Question 4

Your patient presents to the ED with tachycardia, hypertension, tachypnea and dystonia. He recovered completely during observation in the ED. His symptoms occurred for the fifth time this week and lasted about 30 minutes. He is admitted because of the suspicion of Paroxysmal Sympathetic Hyperactivity (PSH).

Which of the following pathologies is NOT a cause of Paroxysmal Sympathetic Hyperactivity?

A: Lithium intoxication

B: Traumatic Brain injury

C: Stroke

D: Cerebral Fat Embolism Syndrome

The correct answer is A

EMCrit covered Paroxysmal sympathetic Hyperactivity on their The Internet Book of Critical Care.

Paroxysmal Sympathetic Hyperactivity (PSH) causes recurrent episodes of dysregulated sympathetic activity, resulting from severe brain injury.

PSH typically occurs in the first two weeks after severe and diffuse brain injury. It usually resolves within a year.

Symptoms include tachycardia, hypertension, tachypnea, fever, diaphoresis and dystonia. They can last up to 30 minutes with a near complete resolution.

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8161

Question 5

Your 29 year old female patient presents to the ED with left sided abdominal pain, syncope and hypotension. She tells you she missed a couple of menses and all of a sudden she started vaginal bleeding this afternoon. You suspect ectopic pregnancy.

Which of the following statements is true about ectopic pregnancy?

A: Low serum B-HCG rules out an ectopic pregnancy

B: The absence of visible pregnancy on ultrasound rules out an ectopic pregnancy

C: Risk factors such as prior tubal surgery, ectopic pregnancy or previous PID are present in almost every patient with ectopic pregnancy

D: The triad, consisting of abdominal pain, missed menses and vaginal bleeding is not seen in a quarter of the patients

The correct answer is D

This week’s EMDocs covered Ectopic Pregnancy.

No hCG level or series of hCG levels can rule out ectopic pregnancy completely.

If no pregnancy is visible on ultrasound, an ectopic pregnancy can still be present. It may just be too early to visualize it.

Half of patients with ectopic pregnancy have no risk factors such as prior tubal surgery, ectopic pregnancy, previous PID, assisted fertility and smoking.

Abdominal pain (80-90%), missed menses 4-12 weeks after last menstrual period (75-90%) and vaginal bleeding (50-80%) is the classic triad and seen in 75% of the patients.

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

Reviewed and edited by Rick Thissen

Quiz 116, May 28th, 2021

Welcome to the 116th FOAMed Quiz.

 

Question 1

Source image: dontforgetthebubbles.com

Your 12 year old patient presents to your ED after his gastrostomy tube has fallen out 30 minutes ago. He and his parents do not have a spare one. You decide to place a foley catheter through the tract to keep it open as soon as possible.

Which of the following is a contra-indication for placement of the foley catheter?

A: This is a primary tube, placed 3 weeks ago

B: There is minor bleeding from the tract

C: It concerns a gastro-jejunostomy tube

D: Never place a foley in the tract of a gastrostomy tube

The correct answer is A

Don’t forget the Bubbles covered feeding tube troubles last week.

If the tract is left empty it will close up in hours. Replace the tube if you can. Otherwise put a foley catheter in the tract and tape it to the skin.

In patients that had the gastrostomy placed less than 4 weeks ago, the tract has not matured yet and placing a catheter should be avoided. Between 4 and 6 weeks, placement of a catheter can be tried very carefully.

Question 2

Source image: ctscanmachines.blogspot.com

Your 67 year old patient presents to the emergency department with an altered level of consciousness. Her Glasgow Coma Scale is E1M4V1. Her husband tells you she has been complaining of progressive headaches, diplopia and vomiting for a couple of weeks. You suspect her of having elevated intracranial pressure due to a cerebral mass.

Elevated intracranial pressure (ICP) can occur due to mass lesions, cerebral edema (stroke, traumatic brain injury, metabolic disturbances) or obstruction of venous or cerebrospinal fluid outflow.

Which of the following statements about elevated intracranial pressure is true?

A: Lumbar puncture is safe when elevated ICP exists due to a mass lesion

B: Patients with elevated ICP should be hyperventilated to sustain a normal ICP (target PaCO2 20-25 mmHg)

C: Mannitol seems to be less effective in improving cerebral perfusion pressure compared to hypertonic saline

D: Hypothermia improves clinical outcomes

The correct answer is C.

Elevated intracranial pressure was discussed in EMcrit’s Internet Book of Critical Care this week.

Mannitol is frequently used to decrease ICP, but is increasingly replaced by hypertonic saline as a first line agent. Mannitol is nephrotoxic, causes volume depletion (and brain hypoperfusion) and can cause a rebound elevation in ICP. Hypertonic saline (3%) is a safer treatment option. Furthermore, Mannitol seems to be less effective in improving cerebral perfusion pressure compared to hypertonic saline

When performing a lumbar puncture you risk downward herniation of the brain if there is a mass lesion.

Hyperventilation causes cerebral vasoconstriction and thus lowers ICP, but also lowers cerebral perfusion pressure. Low-normal PaCO2 (35-40 mmHg) is a reasonable target.

Hypothermia lowers ICP, but also causes bradycardia and hypotension. There is no high-quality evidence to support its use.

Elevated intracranial pressure (ICP)

Question 3

Source image: www.endoskopiebilder.de/

What is the cause of a stercoral ulcer?

A: Ingestion of a button battery

B: Recent abdominal surgery

C: Fecal mass

D: Malignancies

The correct answer is C

EMdocs covered a case in which a patient died from a perforated stercoral ulcer in their medical malpractice series

As you know, constipation is not always benign. Hard stool can cause colonic wall ulceration (stercoral ulcer) which leads to stercoral perforation.

Medical Malpractice Insights: Bowel perforation due to stercoral ulcer

source image: pixabay.com

Question 4

Intravenous calcium is increasingly used in the bleeding trauma patient. However, it is not yet included in all major guidelines.

This recently published systematic review covered 3 cohort studies including 1213 trauma patients.

What did the authors find?

A: Higher mortality rates were observed in patients with hypocalcemia in all three studies compared to patients with normal serum calcium

B: Patients with hypocalcemia required less blood transfusion compared to patients with normal serum calcium

C: Patients with normal serum calcium had increased coagulopathy (defined as initial INR ⪖ 1,5) compared to patients with hypocalcemia

The correct answer is A

Calcium in the trauma patient was covered on St. Emlyns last week.

In general, hypocalcemia in the bleeding patient is a bad thing. It is associated with higher mortality. Furthermore, patients with hypocalcemia require more blood transfusion and hypocalcemia is associated with increased coagulopathy and clot strength.

Hypocalcaemia, Trauma and Major Transfusion. St Emlyn’s

Question 5

Source image: www.first-nature.com

 

Your 45 year old patient presents to your ED after eating mushrooms. He ate several different types and does not remember what they looked like exactly.

Which of the following symptoms points in the direction of a life threatening intoxication?

A: Gastrointestinal symptoms starting 20 minutes after ingestion

B: Gastrointestinal symptoms starting 8 hours after ingestion

The correct answer is B

Mushroom poisoning was covered on CountyEM last week.

Mushrooms that cause symptoms more than six hours after consumption are associated with serious and potentially lethal toxicity.

The Poisoned Mushroom Hunter

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

Reviewed and edited by Rick Thissen

Quiz 107, March 19th

Welcome to the 107th FOAMed Quiz.

 

Question 1

Source image: pixabay.com

Your 37 year old patient presents with hypertension, flushing and a tremor. During physical exam she makes a confused impression and you notice a tremor. She has a bipolar disease and uses fluoxetine. You suspect serotonin syndrome in this patient.

Which of the following statements about serotonin syndrome is true?

A: The clinical triad of serotonin syndrome includes mental state changes, autonomic dysfunction and neuromuscular abnormalities

B: The clinical triad of serotonin syndrome includes ophthalmoplegia, ataxia and confusion

C: The clinical triad of serotonin syndrome includes retinopathy, encephalopathy and deafness

The correct answer is A.

This week EMDocs covered the Serotonin Syndrome.

The clinical triad of the Serotonin Syndrome consists of mental state changes (anxiety, agitation, delirium, seizure or coma), autonomic dysfunction (hypertension, hyperthermia, tachycardia, diaphoresis, flushing and mydriasis) and neuromuscular abnormalities (such as hyperreflexia, clonus, myoclonus, tremor, hypertonia/rigidity).

Wernicke encephalopathy is classically characterised by ophthalmoplegia, ataxia and confusion. If a patient presents with retinopathy, encephalopathy and deafness, Susac Syndrome is a possibility.

EM@3AM: Serotonin Syndrome

Question 2

Source image: www.ultrasoundcases.info/

 

A 42-year-old woman who recently had a few teeth extracted visits the emergency room. She has a fever and a sore neck. Ultrasound shows a non compressible internal jugular vein. After a CT you determine that she has septic thrombophlebitis of the internal jugular vein (Lemierre’s syndrome). You start antibiotics.

Which bacteria is the most common cause of Lemierre’s syndrome and should therefore definitely be covered?

A: Streptococcus pyogenes

B: Fusobacterium necrophorum

C: Staphylococcus aureus

D: Eikenella corrodens

The correct answer is B.

This week Lemierre’s syndrome was discussed by Taming the SRU.

The disease pathway typically begins with oropharyngeal infection leading to inflammation within the wall of the jugular vein, leading to infected thrombus within the lumen, leading to soft tissue inflammation, leading to persistent bacteremia and eventually septic emboli.

The most common (but not the only) causative pathogen is the anaerobe Fusobacterium necrophorum.

Question 3

Source image: pemcincinnati.com

An 8-year-old child has been hit in the face with a football. His nose is painful, but doesn’t look deviated. On inspection you see a swelling of the right nasal septum that occludes almost the entire nostril.

Which of the following is the correct management?

A: Ice packs for several hours and start xylometazoline

B: Emergent drainage of the hematoma

C: Consultation with ENT doctor within a week

D: X-rays of the nasal bones

The correct answer is B.

This week, PedEMmorsels discussed nasal septal hematomas in children.

About 15% of children with a nasal fracture will have a septal hematoma. Despite being an uncommon condition, it can have far-reaching consequences. A septal hematoma can lead to necrosis, which in the long term can lead to saddle nose deformity. It is therefore a clinical diagnosis requiring urgent surgical intervention.

Nasal Septal Hematoma in Children

Question 4

Source image: pixabay.com

In your emergency room, a middle-aged man with no relevant medical history presents with seizures. Family tells you that after swimming in a lake last week (on holiday in Florida), he became increasingly ill. He has a high fever and a headache. This morning he also started vomiting.

Which of the following exotic-sounding pathogens really exist?

A: Brain-eating amoeba

B: Liquor drinking bacteria

C: Nerve devouring parasite

D: Seizure worm

The correct answer is A.

NuEM covered various pathogens that can be acquired in, around or through water this week.

One of these is Naegleria fowleri. This is a protozoa, also known as the Brain-eating Amoeba. It occurs in warm fresh water. It reaches the brain through the olfactory nerve and causes acute hemorrhagic meningoencephalitis. It is rare but has a high fatality rate of almost 98%. Treatment includes miltefosine, an anti-leishmania drug.

 

Question 5

Source image: www.neurologyadvisor.com

With the emergence of endovascular treatment of acute ischemic stroke, the question arises which role systemic thrombolysis still has. Previous research shows the role of systemic thrombolysis in patients eligible for endovascular treatment is limited.

Last month, the DEVT trial was published.

In this trial, patients > 18 years of age presenting within 4.5 hours of ischemic stroke symptom onset, eligible for IV alteplase treatment and with cerebral vascular occlusion on CT angiography (CTA) or magnetic resonance angiography (MRA) of the intracranial internal carotid artery or middle cerebral artery (first segment) were randomised to either systemic thrombolysis and endovascular treatment (control) or endovascular treatment alone.

The primary outcome was the proportion of patients achieving a modified Rankin Scale (mRS) 0-2 assessed at 90 days after randomization.

What did the trial show?

A: The trial showed endovascular treatment alone to be superior to systemic thrombolysis and endovascular treatment in achieving a mRS of 0-2 at 90 days

B: The trial showed endovascular treatment alone to be inferior to systemic thrombolysis and endovascular treatment in achieving a mRS of 0-2 at 90 days

C: The trial showed endovascular treatment alone to be non-inferior to systemic thrombolysis and endovascular treatment in achieving a mRS of 0-2 at 90 days

The correct answer is C

RebelEM covered the DEVT trial last week.

235 patients were randomised to either standard care (systemic + endovascular treatment) or intervention (endovascular treatment only).

An mRS of 0-2 was achieved in 54.3% (endovascular alone) versus 46.6% (combination). The non-inferiority margin (-10%) was met. The study was stopped early due to pre-planned interim analysis that demonstrated non-inferiority.

Unfortunately, only 25% of the planned enrollment was completed.

There are additional ongoing trials that will add to the available evidence on this topic.

The DEVT + SKIP Trials: Does Systemic Thrombolysis Prior to Endovascular Treatment Improve Outcomes in Large Vessel Occlusion Strokes?

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

Reviewed and edited by Rick Thissen

Quiz 103, February 19th, 2021

Welcome to the 103th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Your 68-year old patient comes in with septic shock. He is hypotensive, tachycardic, tachypnoeic and has a fever. His blood pressure normalises after initial resuscitation with iv fluids but he continues to be tachycardic with a heart rate of 140 bpm.

You wonder if it might be beneficial for this patient to add a beta blocker to his current treatment in order to moderate his hypersympathetic state.

This recently published systematic review and meta-analysis is about 7 trials in which patients in septic shock with persistent tachycardia, after adequate initial resuscitation, were randomised to either a short acting beta blocker (esmolol or landiolol) or placebo. The primary outcome was 28-day mortality.

What did the authors find?

A: 28-day mortality was significantly lower in patients who received a beta blocker compared to patients who received placebo

B: 28-day mortality was not statistically different in patients who received a beta blocker compared to patients who received placebo

C: 28-day mortality was significantly higher in patients who received a beta blocker compared to patients who received placebo

The correct answer is A

This recently published systematic review and meta-analysis was covered by Clay Smith on SpoonFeed this week.

A total of 7 RCT’s (613 patients) were included in this systematic review and 6 of these trials (572 patients) were eventually analysed. Mortality risk was reduced by 32% in patients who received a beta blocker vs placebo. The overall mortality rates were 36.7% and 54.9% in the esmolol/landiolol cohort and placebo group respectively (absolute risk reduction 18%, NNT 5.5). 

Heart rate was significantly lower in patients who received a beta blocker compared to patients who received placebo while the mean arterial pressure (MAP) was not statistically different between these two groups.

Although these results look encouraging, we have to take in mind that the studies were rather small and that there was a wide range of mortality across these centers (12-62% in the beta blocker group; 20-80% in the placebo group).

Source image: Case contributed by Dr Alexandra Stanislavsky, Radiopaedia.org

Question 2

The “empty cup” sign is a radiological image of a perilunate dislocation. The distal radius is the saucer and the tilted lunate is the cup.

In a normal situation, which bone would project above the lunate and be the “fill” of the cup?

A: Trapezium

B: Trapezoid

C: Capitate

D: Hamate

The correct answer is C.

This week, DFTB discussed carpal injuries in children.

In this case the apple, cup, saucer analogy, the capitate, lunate and radius, respectively, should be aligned.

Source image: www.pixabay.com

Question 3

Benign Paroxysmal Positional Vertigo (BPPV) is common in the ED. Displaced otoliths are located in the semicircular canals, causing brief episodes of dizziness.

Which of the following is most commonly affected?

A: Unilateral posterior canal

B: Unilateral horizontal canal

C: Bilateral posterior canals

D: Bilateral horizontal canals

The correct answer is A

AliEM covered BPPD and its treatment last week.

The affected canals are:
83%: Unilateral posterior canal
7% : Unilateral horizontal canal
6% Bilateral posterior canals
Rare: Anterior canal

The same maneuvers can be used to treat both posterior and anterior BPPV (Epley, Semont).

Tricks of Trade: Benign paroxysmal positional vertigo | Beyond the Basics

Source image: www.pixabay.com

Question 4

Diabetic ketoacidosis (DKA) is often encountered in the ED. Despite improved treatment in the last decades, mortality is still about 2 percent.

Euglycemic ketoacidosis is quite often missed leading to delayed treatment.

Which of the following drugs can cause euglycemic ketoacidosis?

A: Metformin

B: Liraglutide

C: Sitagliptine

D: Canagliflozine

The correct answer is D

The resus room covered DKA extensively in their podcast last week.

SGLT2 inhibitors are known to (although very rare) cause euglycemic ketoacidosis.

Liraglutide is a GLP1 agonist. Sitagliptin is a DPP4 inhibitor.

Diabetic Ketoacidosis

Source image: www.rebelem.com

Question 5

Although alteplase is registered as the first line agent of choice for iv thrombolysis in ischemic stroke, tenecteplase may have some benefits over alteplase. It is about half the price, it has greater fibrin specificity and has a longer half-life than alteplase.

Recent data has emerged regarding tenecteplase as an alternative to alteplase in ischemic stroke. This recently published systematic review and meta-analysis covers these papers.

What did the authors find?

A: Alteplase was associated with an increase in good or excellent functional outcome (modified Rankin Scale 0-2) compared to tenecteplase

B: There was no difference in good or excellent functional outcome (modified Rankin Scale 0-2) between the two drugs

C: Tenecteplase was associated with an increase in good or excellent functional outcome (modified Rankin Scale 0-2) compared to alteplase

The correct answer is B

RebelEM covered the paper last week.

8 trials were included (of which 6 randomised and 2 observational), covering data of 2031 patients. There was no difference in good or excellent functional outcome. However, tenecteplase showed higher rates of recanalization.

There are several studies using tenecteplase in ischemic stroke patients underway to be on the lookout for.

Tenecteplase may well be equally effective or even more effective as iv thrombolytic agent compared to alteplase.

Tenecteplase for Thrombolysis of AIS?

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

Reviewed and edited by Rick Thissen

Christmas Quiz 2020

Wishing you a Merry Christmas!

 

Nicole, Joep, Sophie and Rick

 

This is the FOAMed podcast jingle quiz.

 

Do you know which jingle belongs to which podcast?

Jingle No. 1

This podcast originated in Toronto and was founded by Anton Helman. Justin Morgenstern and Rory Spiegel are contributers to this podcast.

Podcast: Emergency Medicine Cases

Jingle No. 2

On this podcast, Simon, Rob and James highlight the papers that have caught their eyes in their paper round ups each month.

Pocast: The Resus Room

Jingle No. 3

The organisation behind this podcast was founded in 1968 and gained the title ”Royal” in 2015.

Podcast: RCEM

Jingle No. 4

This podcast was founded by Anand Swaminathan in 2015.

Podcast: Core EM

Jingle No. 5

Well, this dude doesn’t do jingles. Pay atention, the sample is pretty short.

Podcast: The EMCrit podcast by Scott Weingard

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen