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

Quiz 95, December 18th, 2020

Welcome to the 95th FOAMed Quiz

Nicole, Joep, Sophie and Rick
Source image: www.thebottomline.org.uk

Question 1

Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly used in patients with out of hospital cardiac arrest (OHCA). Nevertheless, evidence regarding ECMO is fairly limited and mainly consists of three observational studies (Wang 2017, Dennis 2016  and Dennis 2020).

The ARREST trial is the first randomized controlled trial of ECMO CPR in OHCA.

The authors included adult patients with OHCA with an initial shockable rhythm without return of spontaneous circulation (ROSC) after three defibrillation defibrillation attempts and an estimated transfer time to the ED of <30 minutes.

The authors compared ECMO CPR to standard ALS. Their primary outcome was survival to hospital discharge.

What did they find?

A: Survival to hospital discharge was better in the ECMO group compared to the standard ALS group

B: Survival to hospital discharge was not significantly different between the ECMO group compared and the standard ALS group

C: Survival to hospital discharge was worse in the ECMO group compared to the standard ALS group

The correct answer is A

The ARREST trial was covered by Justin Morgenstern on First10EM this week.

A total of 30 patients (83% male, 17% female) with a mean age of 59 years were included. Survival to hospital discharge was more frequent in the ECMO group compared to the standard ALS group (43% vs 7%). Survival to 3 and 6 months was also significantly better in the ECMO CPR group ( 43% vs 0%, p=0.006%). Cumulative 6-month survival was also significantly better in the early ECMO group than in the standard ACLS group.

Although these results are impressive, some limitations have to be taken into account. 83% of patients were male while previous research shows that females tend to have worse outcomes. Furthermore, ECMO was performed in the cath lab so every patient in the ECMO group received an immediate angiogram while the standard ALS group only underwent angiography if ROSC was obtained and the cath was warranted by clinical protocol (13 patients in the ECMO group vs 2 patients in the standard ALS group).

The ARREST trial – ECMO CPR

Source image: www.pixabay.com

Question 2

While in the Netherlands we are awaiting the verdict of the European Medicines Agency (EMA), the UK and USA are already deploying the Pfizer vaccine. Last week the results of Pfizer’s phase 3 trial were published.

21,669 patients received the vaccine (of which 98.4 percent received both doses) and 21,728 received placebo.

How many patients contracted COVID-19 ≽7 days after the second dose?

A: 153 in the vaccine group and 159 in the placebo group

B: 72 in the vaccine group and 323 in the placebo group

C: 14 in the vaccine group and 28 in the placebo group

D: 9 in the vaccine group and 172 in the placebo group

The correct answer is D

RebelEM covered the Pfizer paper last week.

Yes, it is a manufacturer sponsored trial and no one knows how long its effects will last. But these results are very promising.

The incidence of minor systemic adverse events was quite frequent, the incidence of serious adverse events was similar between groups (vaccine 0.6% vs placebo 0.5%).

COVID-19 Update: The COVID-19 Pfizer Vaccine

Source image: www.emdocs.net

Question 3

This ECG shows diffuse ST depression and ST elevation in aVR (and perhaps a little bit in III).

Which of the following statements about ECG’s this pattern (diffuse ST depression with ST elevation in aVR) is true?

A: 50 percent of patients with a similar ECG have left main ACS

B: This pattern is associated with very high mortality

C: 65 percent of patients with a similar ECG have ACS (not just left main)

The correct answer is B

ST elevation in aVR with diffuse ST depression is covered on dr. Smith’s ECG blog this week.

While this pattern is frequently thought to represent either left main occlusion or 3 vessel disease, the rate of ACS in patients with these ECG’s turns out to be quite low (24 percent). The pattern represents subendothelial ischemia, which can have numerous causes (like valvular disease, severe anemia and everything that can cause decreased oxygen supply to the myocardium).

However, it is clear that patients with an ECG-pattern like this have a very high mortality.

Source image: www.coreultrasound.com

Question 4

In ultrasound guided peripheral nerve blocks, a nerve and a tendon can 
appear very similar.

Which of the following ultrasound artifacts can be used to distinguish the two?

A: Reverberation

B: Blooming artifact

C: Acoustic shadowing

D: Anisotropy

The correct answer is D

Jacob Avila covered nerve block basics on Core Ultrasound this week.

Anisotropy is the property of a material which allows it to change or assume different properties in different directions. Tendons will appear less echogenic (will be less bright) if you increase or decrease the angle (less perpendicular). Nerves keep their echogenecity.

 

Source image: www.emottowablog.com

Question 5

Which of the following findings on Point of Care UltraSound (PoCUS) makes a pneumothorax very likely?

A: Lung pulse

B: Lung sliding

C: Lung point

D: Presence of comet tails

The correct answer is C.

EMOttawa covered the diagnosis of pneumothorax last week.

A lung pulse, lung sliding and comet tails can only be present if there is no air between the pleural membranes, so they make a pneumothorax very unlikely. On the other hand, a lung point (visualisation of the location at which the anterior pleural membranes make contact, so showing lung sliding on one side and no lung sliding on the other) makes a pneumothorax very likely.

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This quiz was written by Nicole van Groningen and Joep Hermans

Edited by Rick Thissen

Quiz 88, October 30th

Welcome to the 88th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

This recently published paper is about the efficacy of tranexamic acid (TXA) in the prehospital setting.

Injured patients, between 18 and 90 years old, transferred from scene or referring hospital to one of four level 1 trauma centers within 2 hours of injury and with at least one episode of hypotension (systolic blood pressure <90 mmHg) or one episode of tachycardia (heart rate >110 bpm), were included.

Patients were pre-hospitally randomized to either the placebo group (100cc of sterile water) or the TXA group (1g of TXA in 100cc of sterile water).

The primary outcome was 30-day mortality.

What did the authors find?

A: 30-day mortality was significantly higher in the placebo group

B: 30-day mortality was not significantly different between both groups

C: 30-day mortality was significantly higher in the TXA group

The correct answer is B

The STAAMP trial (Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport) was covered on St. Emlyns and RebelEM this week.

The STAAMP trial is a multicenter, double-blind, placebo controlled randomized trial. A total of 447 patients were randomized to the TXA group and 456 to the placebo group. No statistically significant difference in 30-day mortality was found between the placebo group and TXA group (9.9 vs 8.1%; 95% CI 5.6-1.9%; p=0.17).

Some limitations have to be taken into account. The trial was stopped early, was underpowered  and enrolled patients had an overall low injury severity (median ISS of 12).

Should we Rubber STAAMP Prehospital TXA?

Question 2

Source image: first10em.com/

 

You see a 30 year old male after a blow to the right eye. You suspect an orbital compartment syndrome (OCS) which warrants immediate treatment to present vision loss.
To prevent ischemia to the retinal and optic nerve you need to perform lateral canthotomy and inferior cantholysis (LCIC).

Which of the following statements is true about LCIC?

A: Globe rupture is the most common complication of LCIC

B: A Morgan Lens cannot be used as a shield to protect the globe

C: An intraocular pressure (IOP) greater than 30mmHg should be treated immediately

D: Delayed presentation is a contraindication for LCIC

The correct answer is C

This week, RebelEM covered Orbital Compartment Syndrome.

Globe rupture is indeed the most devastating complication of LCIC. The list of complications includes infection, damage to the lacrimal gland or artery, excessive bleeding, damage to the lateral rectus muscle and ptosis from levator aponeurosis injury.

A Morgan lens can be used to protect the globe but insertion can be challenging in patients with significant edema and ecchymosis.

An intraocular pressure (IOP) greater than 30mmHg should be treated immediately, but even without measurement of ocular pressure, clinical signs of orbital compartment syndrome warrant immediate treatment.

In 73% of the OCS cases patients returned to baseline vision after LCIC even after a delayed presentation beyond one hour after arrival.

Orbital Compartment Syndrome: Pearls and Pitfalls for the ED Physician

Question 3

This recently published paper is about the accuracy of diagnostics in septic arthritis in the ED.

Septic arthritis can be difficult to differentiate from other causes of monoarticular arthritis. In this study the investigators aimed to assess the diagnostic accuracy of synovial lactate, white blood cell count (WBC), gram stain, PCR, and clinical evaluation.

What did the investigators find?

A: Synovial L-lactate is a good predictor for septic arthritis

B: PCR of the synovial fluid showed to be accurate for the diagnosis of septic arthritis

C: Synovial WBC and gram stain are the best predictors for septic arthritis

D: Combination of history and physical exam showed to be a good predictor for septic arthritis

The correct answer is C.

This week Clay Smith covered this paper about diagnosis of septic arthritis.

In this study the prevalence of septic arthritis was 7% (out of 71 patients, so only 5 patients had septic arthritis). No findings on history or physical examination accurately ruled in or ruled out septic arthritis. Synovial L-lactate and PCR showed to be inaccurate for the diagnosis of septic arthritis.

Synovial WBC (in this study sens. 80% en spec 96%) and gram stain (in this study sens. 100% and spec 97%) were the best tests for septic arthritis.

Keep in mind this is a very small single centre study.

Question 4

Manual pulse checks by healthcare providers during cardiac arrest are pretty unreliable at best.

This recently published paper is about the validity of two-dimensional carotid ultrasound to detect the presence and absence of a pulse.

What did the authors find?

A: 2D ultrasound of the common carotid artery is both sensitive and specific for detection of the presence or absence of a pulse

B: 2D ultrasound of the common carotid artery is sensitive but not specific for detection of the presence or absence of a pulse

C: 2D ultrasound of the common carotid artery is specific but not sensitive for detection of the presence or absence of a pulse

D: 2D ultrasound of the common carotid artery is neither sensitive nor specific for detection of the presence or absence of a pulse

The correct answer is A

StEmlyns covered this recently published paper last week.

The concept of carotid ultrasonography instead of a manual pulse check sure is interesting. In theory, it should be a lot more sensitive compared to manual pulse checks, especially in low output states. This paper showed a sensitivity of detection of a pulse was 91%.

However, given the methodology of the paper this does not mean we can apply this technique in the ED yet as the patients included were undergoing routine bypass surgery, so this study was not performed in the ED. Furthermore, the ultrasound images were obtained without CPR in progress, by two experienced sonographers.

JC: Finger on the Pulse?

Question 5

 

Intoxications with calcium channel blockers (CCB), such as verapamil and diltiazem, are potentially very dangerous. Even a single pill can cause severe toxicity in children and pills with sustained release products can have delayed onset and prolonged toxicity.

Which of the following statements about the treatment of CCB overdose in children is true?

A: Asymptomatic patients need observation for a minimum of 6 hours

B: Activated charcoal is only indicated if ingestion was within an hour of presentation

C: Treatment of CCB intoxication with calcium is supported by plenty of evidence

D: High-dose insulin is considered first line therapy for patients with signs of myocardial dysfunction

The correct answer is D

Sean M. Fox from pediatric EM Morsels covered CCB overdose in children this week.

Although development of symptoms in asymptomatic patients later than 6 hours after ingestion is rare, consensus is to monitor for at least 24 hours.

Activated charcoal (0.5-1 g/kg) is typically used if ingestion was within the last 60 minutes but benefits may still be seen if ingestion is of large quantities of sustained-release products even after 1 hour.

It seems intuitive to give calcium in case of a CCB overdose. However, as with almost every treatment in toxicology, supporting evidence is scarce. 10% calcium calciumgluconate (60 mg/kg) is prefered over 10% calciumchloride (20 mg/kg) since this is better tolerated in peripheral veins.

Finally, CCB overdose causes a hypoinsulinemic state which could cause hyperglycemia and decreased glucose uptake by myocardial and end organ tissues. High-dose insuline (1IE/kg) followed by infusion of 1IE/kg/hr) is considered first-line therapy in patients with signs of myocardial dysfunction in order increase inotropy and overcome hypoinsulinemia and insulin resistance.

Calcium Channel Blocker Overdose in Children

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

Reviewed and edited by Rick Thissen

Quiz 86, September 25th, 2020

Welcome to the 86th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

This multicentre randomized trial, published this month is about the effect of vitamin D and calcium in patients with Benign Paroxysmal Peripheral Vertigo (BPPV) in addition to standard canalith repositioning manoeuvres.

What did the authors find?

A: Vitamin D and calcium reduced the number of episodes per year

B: Vitamin D and calcium increased the number of episodes per year

C: Vitamin D and calcium had no effect on the number of episodes per year

The correct answer is A

This week, Clay Smith covered treatment of Benign Paroxysmal Peripheral Vertigo.

Otoconia, causing the otolithic membrane to be heavier than the surrounding fluid, are made of calcium crystals. Low calcium may lead to higher turnover and release of crystalline debris and therefore causing BPPV. Despite its limitations this study showed a benefit with treatment compared to the group without treatment resulting in a reduction of number of episodes.

Source image: www.pixabay.com

Question 2

Your 43 year old patient presents with rapidly progressive aphasia and right hemiparesis. Vital signs are unremarkable except for a fever (39.0 ℃ = 102.2 ℉). Cerebrospinal fluid PCR is positive for Herpes Simplex Virus (HSV).

Which of the following statements about HSV encephalitis is true?

A: HSV-2 constitutes 90% of encephalitis in adults and children

B: Almost all patients with HSV encephalitis ultimately have seizures

C: The in hospital mortality is as high as 15 percent despite adequate treatment

D: All patients with HSV encephalitis should receive dexamethasone in addition to acyclovir

The correct answer is C

HSV encephalitis was covered on BrownEM this week.

HSV-1 accounts for 90% of encephalitis in adults and children.

Classically, we are taught to think of HSV encephalitis whenever a patient presents with altered mental status and seizures; however, only about half of patients ultimately have seizures

Nearly 20% of patients require mechanical ventilation with around 11-15% in-hospital mortality.

There is no role for dexamethasone in HSV encephalitis. Early IV acyclovir continues to be the treatment of choice.

Source image: coreultrasound.com

Question 3

A 56 year old patient comes in with acute and progressive vision loss on his right eye. He also complains about floaters for a few days. You decide to perform ocular ultrasound and you see the following:

You doubt whether this is a retinal detachment or a posterior vitreous detachment.

Which of the following signs make retinal detachment more likely than vitreous detachments?

A: The detachment crossing the midline (surpassing the optic disc)

B: Retinal detachment is visible in low gain (the retina is less echogenic compared to the abnormality seen in vitreous detachment)

C: Presence of vitreous hemorrhage

D: “swaying seaweed” or aftermovements (after the eye stops moving)

The correct answer is B

Core Ultrasound covered ocular ultrasound last week. 

When in doubt whether you are looking at retinal detachment of posterior vitreous detachment, keep in mind that:

In retinal detachment the flap will be attached firmly to the optic nerve sheath, not crossing the midline

A retinal detachment appears ´thicker´ compared to posterior vitreous detachment.

Vitreous hemorrhage does not make retinal detachment more likely, but it can occur secondary to posterior vitreous detachment (so secondary to retinal detachment as well).

Swaying seaweed appearance (the visible membrane keep moving slowly after the eye stopped moving) makes posterior vitreous detachment more likely.

Case courtesy of Dr David Cuete, Radiopaedia.org, rID: 23768

Question 4

Which of the following can cause a false negative cranial CT in patients with suspected subarachnoid hematoma?

A: Severe anemia

B: Scanning less that 1 hour after start of symptoms

C: Polycythemia 

The correct answer is A

Justin Morgenstern covered the diagnosis of subarachnoid hemorrhage on First10EM this week.

Sensitivity of non contrast cranial CT for subarachnoid hemorrhage is very high (although not 100%) when performed within 6 hours after start of symptoms.

One of the known causes of false negative cranial CT when evaluating for hemorrhage is severe anemia.

Subarachnoid Hemorrhage: What is the role of LP?

Source image: www.aliem.com

Question 5

Your 76 year old patient presents with progressive abdominal pain. He looks ill. CT shows portal venous gas.

Which of the following is the most common cause of venous portal gas?

A: Trauma

B: Decompression syndrome

C: Life-threatening gastrointestinal problem

D: Tension pneumothorax

The correct answer is C

Portal venous gas was covered by AliEM last week.

Hepatic portal venous gas (HPVG) is the accumulation of gas in the portal vein and its branches. It usually indicates a life-threatening gastrointestinal problem.

When HPVG is associated with bowel ischemia, there is usually transmural necrosis and a high mortality rate.

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

Reviewed and edited by Rick Thissen

Quiz 85, September 18th, 2020

Welcome to the 85th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Pediatric Inflammatory Multisystem Syndrome (PIMS) is a recently described clinical syndrome associated with COVID-19 infection. Children present with persistent fever and other nonspecific symptoms. It can present with mucocutaneous, gastrointestinal, dermatologic, neurologic or cardiac manifestations.

Which of the following statements about PIMS is true?

A: Most patients with PIMS only have mild symptoms

B: It affects mostly children with pre existing comorbidity

C: About 2 percent of the patients require inotropic support

D: Myocarditis prevalence increases with age

The correct answer is D

First10EM covered PIMS this week. This syndrome is also known as multisystem inflammatory syndrome in children.

It is a febrile inflammatory syndrome associated with covid-19 infections and can present with a wide variation of symptoms. It affects mostly previously healthy children.

It presents 3 to 6 weeks following exposure to covid-19 virus and can progress rapidly to multiorgan dysfunction.

80 percent of the children have cardiac involvement, and prevalence of myocarditis increases with age.

80 percent of the children are admitted to the intensive care unit, and 50 percent need inotropic support.

Pediatric Inflammatory Multisystem Syndrome (PIMS)

Source image: www.pixabay.com

Question 2

Your 61 year old male patient with a history of diabetes and myocardial infarction presents with diffuse abdominal pain which began after eating dinner. This is the first time he experiences these symptoms. Physical exam reveals a mild diffuse tenderness of the abdomen. CTA reveals bowel ischemia.

Which of the following etiologies is most likely to be the cause of the bowel ischemia in this patient?

A: An arterial embolic occlusion

B: An arterial thrombotic occlusion

C: Arterial non-occlusive ischemia

D: A venous occlusion

The correct answer is A

Mesenteric ischemia was covered on emDOCs this week.

Mesenteric ischemia is known to have several distinct etiologies.

The majority of cases (60%) of mesenteric ischemia are caused by an arterial embolism. Most commonly the superior mesenteric artery (SMA) and less frequently in the celiac artery or inferior mesenteric artery (IMA) are occluded. These patients commonly have atrial fibrillation and often present with a severe sudden abdominal pain which is out of proportion to abdominal tenderness during physical examination.

Thrombotic occlusion of the mesenteric arteries may present with similar acuity or a more progressive onset depending on the preexisting vessel disease and collateral flow.

Mesenteric vein thrombosis presents more insidiously with vague abdominal pain and risk factors include hypercoagulability which can be seen in sepsis, malignancy, liver disease, portal hypertension and thrombophilias.

Nonocclusive arterial mesenteric ischemia results from inadequate supply of blood due to an underlying critical illness or treatment with eg. vasopressors.

Source image: www.pixabay.com

Question 3

Patients with Sickle Cell disease develop symptoms when polymerisation of hemoglobin occurs leading to ‘sickling’ of red blood cells. This process is often triggered by hypoxia or other underlying illness of stress.

Different types of Sickle Cell disease exist, depending on the genetic combination coding for hemoglobin.

Which of the following genetic combinations results in the most severe form of Sickle Cell disease?

A: HbAS: HbA (normal Hb) and HbS (Sickle cell Hb)

B: HbSS: Homozygous for HbS

C: HbSβ: HbS and Hbβ (Beta Thalassemia)

D: HbSC: HbS and HbC (abnormal hemoglobin forming crystals)

The correct answer is B

Don’t forget the Bubbles covered Sickle Cell disease last week.

In sickle cell anaemia, individuals are homozygous for HbS (HbSS). This is the most frequent and severe form of the disease.

Patients with Sickle Cell trait (HbAS) usually do not develop symptoms and are not considered to have Sickle Cell disease.

In patients with Sickle Cell beta Thalassemia the frequency and severity of symptoms vary based on the mount normal Hb (HbA) still formed (not all beta Thalassemia result in the absence of formation of normal Hb).

In HbSC disease, HbC does not participate in polymerization leading to less frequent and severe symptoms compared to HbS disease.

Question 4

Which of the following is not part of the classic triad in Wernicke Encephalopathy (WE)?

A: Cachexia

B: Ataxia

C: Altered mental status

D: Ophthalmoplegia

The correct answer is A

Anand Swaminathan recorded a podcast on RebelEM about Wernicke Encephalopathy.

The classic triad consists of ataxia, altered mental status and ophthalmoplegia. However, the full triad is present in only 10 percent of patients with WE. Therefore, suspect Wernicke encephalopathy in any patient that is at risk of malnutrition or malabsorption and has any one of the classic symptoms.

REBEL Core Cast 40.0 – Wernicke Encephalopathy

Source image: www.pixabay.com

Question 5

In patients pulmonary embolism (PE), the majority of patients has a low 30-day mortality risk. These patients can be identified by clinical decision tools such as PESI, sPESI and Hestia Criteria and can be managed as an outpatient.These patients are most often treated with either a DOAC or a vitamin K antagonist (VKA). Outpatient treatment of low risk PE with VKA seems to be safe, but data are sparse regarding outcomes for patients with low-risk PE treated with DOACs as outpatients.

This systematic review is about the outcome of patients discharged from the ED with low risk PE and the association with anticoagulation class (DOAC vs vitamin K antagonist).

The authors investigated major adverse outcomes (all-cause mortality, PE-related mortality, recurrent VTE, and major bleeding) within 90 days from discharge from the ED.

What did the authors find?

A: Major adverse outcomes were very low in both patients treated with VKA and patients treated with DOAC

B: Major adverse outcomes were more common in patients treated with VKA compared to patients treated with DOAC

C: Major adverse outcomes were more common in patients treated with DOAC compared to patients treated with VKA

D: Major adverse outcomes were unacceptably high in both patients treated with VKA and patients treated with DOAC

The correct answer is A.

Bo Stubblefield covered this systematic review on journalfeed this week.

There were very low rates of major adverse outcomes in both patients treated with VKA and patients treated with DOA. The 90 day all cause mortality was 0.7%. No episodes of recurrent VTE of major bleeding were reported in the majority of included studies. 

No significant association has been found between class of anticoagulant and rates of major adverse events.

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

Reviewed and edited by Rick Thissen

Quiz 81, August 21th, 2020

Welcome to the 81th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Source image: http://brownemblog.com/

A 28 year old female comes in with suspected first trimester bleed. Her last menstrual period was about 5 weeks ago. Her B-hCG comes back 4000 mIU/mL.

Should an intrauterine pregnancy be visible on ultrasound?

A: Intrauterine pregnancy should be visible on both transvaginal and transabdominal ultrasound in this case

B: Intrauterine pregnancy should not yet visible on both transvaginal and transabdominal ultrasound in this case

C: Intrauterine pregnancy should be visible on transvaginal ultrasound but is unlikely to be visible on transabdominal ultrasound

The correct answer is C

BrownEM covered first trimester ultrasound and hydatidiform mole this week.
Intrauterine pregnancy can usually be seen at B-hCG levels > 1500 via trans-vaginal ultrasound and > 6500 via trans-abdominal ultrasound.

Question 2

Source image: emcrit.org

Catecholamine-resistant vasodilatory shock (CRVS), in which hypotension persists despite the use of high-dose vasopressors, carries a 50% to 80% mortality.

The 2019 ATHOS-3 trial showed that in patients with severe vasodilatory shock, administration of angiotensin II (ATII) is associated with a 45% absolute increase in MAP response compared to placebo.

This suggests in most people with CRVS, there is significant disturbance in the RAAS likely resulting from impairment of ACE function. However, identification of patients with RAAS disturbance is challenging because ATII levels cannot be measured in most labs.

This recently published paper assesses renin levels as an easy to assess surrogate for ATII levels and so to predict which patients with CRVS would benefit from ATII therapy.

What does this paper show?

A: Patients with RAAS disturbance cannot be identified through simple laboratory assessment of serum renin levels

B: Renin assessment could be used to identify patients without RAAS disturbance, in whom treatment with angiotensin II would likely be beneficial

C: Renin has the potential to be used to identify CRVS patients at high risk for poor outcome and who may benefit from treatment with synthetic angiotensin II

D: Patients with serum renin levels above the study population median had a significantly reduced risk of mortality.

The correct answer is C

Scott Weingard discussed this paper with the author on the EMCrit podcast. 

Patients with RAAS disturbance can be readily identified through simple laboratory assessment of serum renin levels. 

Renin assessment could be used to identify patients without RAAS disturbance, in whom treatment with angiotensin II would likely be futile.

Patients with serum renin levels above the study population median had a significantly increased risk of mortality. 

And indeed: Renin has the potential to be used to identify CRVS patients at high risk for poor outcome and who may benefit from treatment with synthetic angiotensin II.

Question 3

Source image: Pixabay.org

A 58 year old male with a medical history of gastroesophageal reflux disease and hypertension presents to your emergency department with abdominal pain. This morning he had one episode of coffee ground emesis. He reports frequent cocaine use with his last use three days ago.

Conventional X-ray reveals a pneumoperitoneum. You suspect bowel perforation caused by cocaine use.

Which of the following statements is true about cocaine use and bowel perforations?

A: Cocaine causes bowel perforation in previously affected bowels only

B: Cocaine stimulates norepinephrine reuptake in the presynaptic nerve endings leading to arterial vasoconstriction

C: The onset of symptoms typically occurs within one hour to sixty hours after cocaine use

The correct answer is C.

This week Eric Beyer covered the cocaine gut on ALiEM.

Bowel ischemia due to cocaine use is caused by blocking norepinephrine reuptake in presynaptic nerve endings. This leads to arterial vasospasm or constriction which can lead to complete bowel wall ischemia and perforation. Cocaine use can also exacerbate underlying peptic ulcer disease. Symptoms of a cocaine-induced bowel perforation typically occur between one and sixty hours after cocaine use.

SAEM Clinical Image Series: The Cocaine Gut

Question 4

Source image: emdocs.net

A 25-year old man presents to your Emergency Department with a painful and swollen thumb after he fell on it during a soccer game with his friends. The X-ray shows a fracture of the first metacarpal base.

Which of the following statements is true about 1st metacarpal base fractures?

A: Bennett fractures are multi-fragmented

B: Bennett fractures are considered stable fractures

C: Rolando fractures require operative management due to the intrinsic instability of the fracture

D: Fracture lines in Bennett fractures typically form a Y or a T shape

The correct answer is C.

This week Rachel Bridwell covered metacarpal base fractures on EmDocs.

Bennett fractures occur on the ulnar side. The base of the 1st MCP can subluxate due to an intact Abductor Pollicis Longus and Brevis and Extensor Pollicis Longus and Brevis.

Both Bennett and Rolando fractures are considered unstable.

Rolando fractures are complex fractures. Operative fixation is necessary.

Fracture lines in Rolando fractures typically form a Y or a T shape

Question 5

Your 4 year old patient presents with a hemolytic anemia, abdominal pain, thrombocytopenia and acute renal failure. You suspect Haemolytic-Uremic Syndrome (HUS).

About 90% of HUS cases follow an infection. Which is the most commonly encountered causative pathogen?

A: Entero-Haemorrhagic E. Coli (EHEC)

B: Streptococcus pneumoniae

C: Staphylococcus aureus

D: Klebsiella pneumoniae

The correct answer is A

Don’t forget the Bubbles covered HUS last week.

´´About 90% of cases follow an infection, most commonly with entero-haemorrhagic E. Coli (EHEC). Other infective causes to be considered include Shigella and Streptococcus pneumoniae.´´

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

Reviewed and edited by Rick Thissen

Quiz 80, August 14th, 2020

Welcome to the 80th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

A 28 year old patient is brought in by prehospital services for ‘medical clearance’ before he will be evaluated by psychiatry for acute psychosis. His history and physical are unremarkable.

You wonder if doing labs and a urine tox screen would be beneficial.

What does the current literature say about routine laboratory investigations and drugs screen for ‘medical clearance’ of this patient?

A: Routine labs and tox screen are indicated, because in more than 10 percent of patients an acute medical condition is found

B: Routine labs are not indicated, but routine tox screening is, because it often changes disposition

C: Routine labs and tox screening are not indicated, because an acute medical problem is very rare in patients with normal history and physical

The correct answer is C

Justin Morgenstern covered routine testing in psychiatric patients this week. 

The current body of literature says routine laboratory testing does not lead to identification of more acute medical problems compared to history and physical exam alone. 

Tox screen will be positive quite frequently, but does not change management or disposition.

 

Question 2

Source image: pixabay.com

Your 52 year old patient presents with a stroke. His NIHSS score is 13. CT shows no bleed and you decide to start Intravenous tissue plasminogen activator (tPA) and evaluate the patient for intra arterial treatment. 

Suddenly your patient develops unilateral swelling of the tongue. Which of the following statements is true about this condition?

A: Angioedema is very rare in patients receiving tPA

B: This type of angioedema is most likely bradykinin mediated

C: The chance of this patient needing intubation or a surgical airway is high

D: Fresh frozen plasma (FFP), C1-inhibitor concentrate, icatibant and ecallintide are proven beneficial in tPA mediated angioedema

The correct answer is B

EMdocs covered adverse effects of tPA this week. 

Angioedema is estimated to occur in 1.3 – 5.1% of stroke patients receiving tPA.

Although the pathophysiology of tPA induced angioedema is poorly understood, it is thought to involve complement and plasmin mediated bradykinin release.

The majority of cases are mild and self-limiting. Few will progress to life threatening levels of edema and airway compromise 

Fresh frozen plasma (FFP), C1-inhibitor concentrate, icatibant, ecallintide, and even TXA are potential medical therapies, but no direct evidence for their use in tPA induced angioedema so far.

Question 3

Source image: pixabay.com

A 49 year old patient presents to you ED feeling generally unwell. He has been drinking a bottle of vodka every day for the last month and has been admitted for alcohol intoxication a couple of times. He wants to quit. 

Which of the following risk scores can help you predict the alcohol withdrawal severity?

A: PAWWS score

B: DSM5 criteria

C: CIWA-Ar score

D: SHOT scale 

The correct answer is A

EMOttawa covered alcohol withdrawal in the ED last week. 

Perhaps deserving more attention than it does (at least in Dutch ED’s), alcohol withdrawal is quite common. 

The PAWWS (Prediction of Alcohol Withdrawal Severity Scale) score helps you predict the alcohol withdrawal severity. 

Alcohol withdrawal is diagnosed by the DSM5 criteria. 

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol scale) score objectifies alcohol withdrawal severity to help guide therapy.

The Sweating Hallucinations Orientation and Tremor (SHOT) score is a simple 4 item score which focuses on the objective signs of withdrawal and can help you guide therapy and disposition as well. 

Question 4

In most cases, there is little or no benefit of arterial blood gas over venous blood gas. But does the patient care?

The recently published VEINART Trial compared maximal experienced pain levels during venous and arterial blood gas sampling in non-hypoxemic patients by using a visual analog scale (VAS) on a 0 to 100 scale.

What did the author find?

A: Mean maximal experienced pain was significantly higher in the VBG group compared to the ABG group 

B: Mean maximal experienced pain was similar in both groups

C: Mean maximal experienced pain was significantly lower in the VBG group compared to the ABG group 

The correct answer is C

Salim Rezaie from REBEL EM covered The VEINART Trial this week.

This relatively small (n= 113) multicenter, open-label, randomized, prospective clinical trial in 4 French EDs found a total difference in mean maximal pain of 17.9 points (95% CI; 9.6 -26.3; p<0.0001) between VBG (mean 22.6; +/- 24.9) and ABG sampling (40.5; +/- 20.2).

In (by far) most cases a venous blood gas will be all you need. 

Question 5

Your 60 year old patient tells you that he went for a run and fell on an outstretched hand. The elbow was painful and had a deviating position. You diagnose the patient with a posterior elbow dislocation.

Which of the following is true about elbow dislocations?

A: About 80% of elbow dislocations are posteriorly

B: Brachial artery disruption occurs in a quarter of the patients that present with a elbow dislocation

C: After reduction a splint is only indicated in case of concomitant fractures

D: Elbow dislocations with fractures always need surgical stabilisation

The correct answer is A

ALiEM covered elbow injuries this week.

Posterior dislocations are the most common type of elbow dislocation (80%). Simple elbow dislocations are characterised by the absence of a major associated fracture, aside from small periarticular avulsion fractures.

Neurovascular examination should be performed to assess for brachial artery, median nerve and ulnar nerve injuries. Brachial artery disruption is the most serious complication and it occurs in 5-13% of the cases.

Stable reductions should be immobilised in a posterior splint with 90 degrees of elbow flexion for 3-5 days.

The terrible triad is an elbow dislocation with associated fractures of the radial head and coronoid process and in these cases surgical intervention is recommended. 

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

Reviewed and edited by Rick Thissen

Quiz 77, July 24th, 2020

Welcome to the 24th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 18269

Question 1

Scaphoid fractures are commonly seen in the Emergency Department but are also often missed. This can lead to non-union. Non-union often leads to post-traumatic osteoarthritis with chronic pain and stiffness.

Which of the following statements about diagnosis of scaphoid fractures is true?

A: Tenderness of the “anatomic snuffbox” has a low sensitivity and specificity

B: Combining anatomic snuffbox tenderness, scaphoid tubercle tenderness, and positive thumb longitudinal compression test (all three positive) has a high sensitivity and fair specificity

C: In the first week after injury scaphoid radiographs have a sensitivity of 95%

D: CT is the most accurate diagnostic test

The correct answer is B

Vivian Lei covered scaphoid fractures on Journal Feed this week.

Tenderness of the “anatomic snuffbox” alone has a sensitivity of 87-100% and a very low specificity. When you combine this with scaphoid tubercle tenderness and a positive thumb longitudinal compression test the sensitivity will still be very high and its specificity will rise to 74%.

A negative x-ray of the wrist does not exclude a scaphoid fracture as it has a sensitivity of only 80% in the first week after injury. MRI is most accurate for diagnosing scaphoid fractures (sensitivity of 94.2% and a specificity of 97.7%).

Case courtesy of Dr David Carroll, Radiopaedia.org, rID: 62774

Question 2

This systematic review from 2020, is about the prognostic value of ultrasonographic absence of cardiac motion during cardiopulmonary resuscitation (CPR). The outcome the authors were looking for was Return of Spontaneous Circulation (ROSC) or survival to hospital admission or 24-h survival (depending on the outcomes in the original articles).

What percentage of patients with Pulseless Electrical Activity (PEA) arrest without cardiac motion on ultrasound during CPR did meet the outcome criteria (ROSC or survival to hospital admission or 24-h survival)?

A: 0,5 percent

B: 4 percent

C: 7 percent

D: 13 percent

The correct answer is D

The Resus Room covered this systematic review last week

Results about prognostication using ultrasound in PEA-arrest were included from 10 papers. Half of which (5) reported ROSC as the primary outcome. A combined 188 patients had no cardiac motion on ultrasound of which 26 (13,8 percent) still achieved ROSC or survival to hospital admission or 24-h survival.

Indeed it seems quite a lot of patients (13,8 percent) still achieved ROSC or better. However, the vast majority of these cases (20 out of 26) came from one paper.

This brings up the issue of definition of cardiac motion (if only the valves are moving, is that a moving heart?) and even ROSC which may vary between physicians (and papers). Furthermore, this paper does not give us any numbers on survival to discharge with good neurologic outcome. 

Anyway these numbers tell us the absence of cardiac motion on its own does not mean you are dealing with a hopeless case as some of these patients may still achieve ROSC or better. On the other hand, combined with duration of CRP, underlying disease and age it can certainly help make the call to stop resuscitation efforts.

Ultrasound in Cardiac Arrest

Source image: www.pixabay.com

Question 3

Systemic toxicity of local anesthetics (LAST) is a feared complication of local anesthetic use. It is a very rare condition but one that is potentially lethal.

Early recognition of the signs and symptoms is therefore essential in order to start treatment as quickly as possible.

Which of the following statements about LAST is true?

A: Symptoms always start within 5 minutes of administration of local anaesthetic

B: Plenty of data supports the efficacy of Lipid Emulsion Therapy (LET) in LAST

C: Hypoxia and acidosis inhibit the effect of LET

D: Angioedema is often a first sign of LAST

The correct answer is C

Dana Loke from NUEM blog covered Lipid Emulsion Therapy for LAST this week. 

Onset of LAST is typically 30 seconds to 60 minutes after administration of the anesthetic but more often than not occurs within 1-5 minutes.

Not a lot of data exists about the efficacy of LET in LAST (in humans at least). But this is almost universal in the area of toxicology. 

Hypoxia and acidosis may inhibit lipid emulsion therapy and should therefore be treated in order to optimize the effect of the lipid emulsion therapy.

Angioedema is not typically seen in LAST.

Source image: www.aliem.com

Question 4

A healthy 7 year old boy presents to your ED with forearm fracture after a fall in the playground. For pain and efficient splint placement you use intranasal medication.

Which of the following statements is true about intranasal analgetic administration?

A: Repeated dosing is more often required with intranasal fentanyl compared to intravenous morphine

B: Intranasal fentanyl produces more nasal discomfort compared to intranasal midazolam

C: Intranasal ketamine is less effective for pain control compared to intranasal fentanyl

D: Intranasal fentanyl is equally effective compared to intravenous morphine in children with long-bone fractures

The correct answer is D

This week Aliem posted about intranasal medication in the Paediatric Emergency Department.

The use of intranasal fentanyl shows a more rapid pain-control, shorter length of stay and decrease in repeated dosing compared to intravenous morphine. It is equally effective compared to intravenous morphine in children with long-bone fracture.

Midazolam causes nasal burning and mucosal irritation, so also consider pre-treatment with intranasal lidocaine. Fentanyl does not have this effect.

Intranasal ketamine has been shown to be as effective compared to intranasal fentanyl. 

Question 5

Catastrophic antiphospholipid syndrome (CAPS) is a severe manifestation of antiphospholipid syndrome that involves widespread thrombosis.

Which of the following is most commonly seen with clinical presentation?

A: Respiratory involvement

B: Cardiac involvement

C: Renal failure

D: Skin manifestations

The correct answer is C

EMCrit covered Catastrophic Antiphospholipid Syndrome (CAPS) last week. 

CAPS is an often severe syndrome in which a range of antiphospholipid antibodies bind to cell walls and activate the classical complement system leading to widespread thrombosis and overall badness. 

Renal failure is most often present (75 percent of cases). 

One can speak of definite CAPS when these criteria are present:

  • Involvement of three or more organs, systems, or tissues
  • Development of manifestations simultaneously or in less than a week
  • Confirmation by histopathology of small vessel occlusion in at least one organ or tissue
  • Laboratory confirmation of the presence of anti-phospholipid antibodies (i.e., lupus anticoagulant and/or anti-cardiolipin antibodies)

Treatment options include steroids, heparin, and either plasmapheresis or IVIG.

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

Reviewed and edited by Rick Thissen

Quiz 72, June 19th, 2020

Welcome to the 72th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

A 50 year old male presents to your emergency department with the complaint of dizziness and nausea. You want to distinguish a peripheral from a central cause.

Which of the following findings make a central cause more likely?

A: A negative test of skew

B: Positive head impulse test (eyes make corrective saccade to fix on target)

C: A predominantly vertical nystagmus

D: A unidirectional nystagmus

The correct answer is C

This week’s post on EMdocs by Ava Pierce is about posterior circulation strokes and how to approach the patient with vertigo.

Almost half of the patients with a posterior circulation stroke present with dizziness. The HINTS (consisting of: 1. head impulse test, 2. nystagmus 3. test of skew) examination is helpful to distinguish central from peripheral causes. A positive head impulse test suggests peripheral pathology. Although most strokes present with a horizontal nystagmus, this is also often seen in peripheral vestibular disease. Vertical and bidirectional nystagmus suggest a central cause of vertigo.

Source image: www.radiopaedia.org

Question 2

This multicenter retrospective observational cohort study is about the safety and efficacy of prothrombin complex concentrates (PCCs) in adult patients with spontaneous or traumatic intracranial hemorrhage (ICH) using apixaban or rivaroxaban.

The primary outcome was the percentage of patients with excellent or good hemostasis defined as 0-20% and 20-35.0% increase of hematoma size respectively on follow-up CT of MRI within the first 24 hours. The primary safety outcome was the occurrence of thrombotic events (DVT, PE).

What did the authors find?

A: Excellent or good hemostasis was found in about 40% of patients

B: Excellent or good hemostasis was found in about 80% of patients

C: Thrombotic events were seen in 20% of patients

D: Thrombotic events were seen in only 1% of patients

The correct answer is B

Salim Rezaie from REBEL EM covered factor Xa inhibitor related ICH and PCCs this week.

Excellent or good hemostasis was found in 81.8% (95% CI 77.9 – 85.2) of patients whereas thrombotic events were only seen in 3.8% of patients.

Although this study is the largest multicenter, observational study to date to evaluate hemostatic efficacy and safety of PCC’s in patients on apixaban or rivaroxaban with ICH, it still has quite some limitations. Of course, the absence of a comparison group make any useful conclusion about the efficacy of PCC’s in these cases impossible.

In the future, randomised controlled trials are needed in order to evaluate the clinical efficacy of PCCs in patients on Xa inhibitors with ICH.

Factor Xa Inhibitor Related ICH & PCCs

Source image: www.emottowablog.com

 Question 3

Your otherwise healthy 19 year old patient presents with an AV-nodal Reentrant Tachycardia. The modified Valsalva manoeuvre is not effective. In your hospital the usual path is to try Adenosine first, but as you read up on your literature, you choose Diltiazem.

Which of the following is an advantage of diltiazem over adenosine?

A: Diltiazem has a shorter duration of action compared to adenosine

B: Diltiazem does not make patients feel like they are dying, like adenosine does

C: Diltiazem is not as likely to cause hypotension compared to adenosine

D: Diltiazem can be safely administered in patients in cardiogenic shock, while adenosine is not safe in these cases

The correct answer is B

EMOttawa covered a couple of treatment controversies on their blog this week. The first part is about adenosine vs diltiazem in terminating supraventricular tachycardia.

Diltiazem has a range of benefits over adenosine. The most important one is probably not causing the patient to feel like he or she is dying (like adenosine frequently does). It is a safe drug and at least equally effective for this indication compared to adenosine.

However, diltiazem is not harmless as it can cause hypotension. In cardiogenic shock, please use electrical cardioversion. 

Diltiazem for intravenous use is not globally available. Verapamil is a proper alternernative.

Source image: www.pixabay.com

Question 4

Headache is one of the most common complaints of patients in the Emergency Department (ED). This, randomized double blind, placebo controlled trial compared the administration of 2.5 mg IV haloperidol with placebo (0.9% NaCl) in patients with benign headaches. Their primary outcome was pain reduction at 60 minutes.

What did they authors find?

A: >50% pain reduction at 60 minutes was significantly more often seen in the haloperidol group compared to the control group

B: No differences were found in >50% pain reduction at 60 minutes after administration of haloperidol or placebo

C: >50% pain reduction at 60 minutes was significantly more often seen in the placebo group compared to the haloperidol group

The correct answer is A

Meghan Breed from Journal Feed covered this RCT this week.

58 patientes, aged 18-55 years, received haloperidol while 60 patients received placebo. Pain reduction of >50% at 60 minutes was seen in 63.8% of patients treated with haloperidol. Patients in the haloperidol group thereby reported an average reduction in visual analogue scale score (VAS) of 4.77 units compared to 1.87 units in the placebo group, 60 minutes after administration of either haloperidol or placebo.

This study suggests that the administration of haloperidol 2.5 mg IV could be useful in the treatment of benign headaches. Further research with larger studies are needed to confirm these results.

Question 5

Your 26 year old patient presents with some mild weakness of the lower limbs since 1 day. She also complaints about diplopia and an ‘unsteady walk’ starting about a week ago and getting worse. She does not feel ill and does not appear to be confused. Physical examination reveals symmetric areflexia without any sensory deficits. Her Cerebrospinal Fluid (CSF) shows elevated CSF protein and normal CSF White Blood Cell count.

Which of the following Guillain Barré Syndrome (GBS) types is most likely?

A: Miller Fisher Syndrome (MSF)

B: Acute inflammatory demyelinating polyneuropathy (AIDP)

C: Acute motor-sensory axonal neuropathy (AMSAN)

D: Bickerstaff encephalitis

The correct answer is A

BrownEM covered the variants of GBS this week. 

AMSAN would cause sensory deficits so is not very likely. AIDP is the most common form in the United States and Europe, representing approximately 85 to 90 percent of cases. However ophtalmoplegia and ataxia point us in the direction of either Miller Fisher Syndrome (MSF) or Brickerstaff encephalitis. Since this patient has no signs of encephalopathy, Brickerstaff encephalitis is unlikely, which leaves MSF as the most likely GBS type in this case. 

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

Reviewed and edited by Rick Thissen

Quiz 68, May 22th, 2020

Welcome to the 68th FOAMed Quiz. 

Enjoy!

Eefje, Joep, Nicole and Rick

Source image: www.pixabay.com

Question 1

Your 45 year old patient is presented in cardiac arrest after an electrical injury on a construction site. Co-workers stated he passed out after a spark came from the fuse box of a residential building he was working on. This patient therefore most likely suffered an Alternating Current (AC) injury. A Direct Current (DC) injury is unlikely.

Which of the following statements about this case is true?

A: This type of electrical injury causes rhythmic muscle contractions and can induce tetany

B: The electrical injury most likely caused asystole immediately, ventricular fibrillation is unlikely

C: This electrical injury is most likely considered high voltage

D: This type of electrical injury tends to throw a victim with significant force

The correct answer is A

BrownEM covered electrical injury this week.

This patient suffered Alternating Current (AC) injury and the direction of flow of electrons alternates on a cyclical basis, like a metronome. The electricity we use in our houses is AC. Direct Current (DC) is found in circuits using batteries, railway tracts and lightning.

AC causes muscle contractions and is far more likely to cause ventricular arrhythmias than DC does. DC is more likely to ‘’throw’’ a patient. High voltage injury is considering electrical injury > 1000 Volts. These voltages are not typically found in our house.

Source image: www.pixabay.com

Question 2

A 3-year old boy is brought into the emergency department by EMS after being found unconscious during a house fire. Besides carbon monoxide poisoning, you guess the risk of cyanide poisoning is high.

Which of the following statements about the treatment of cyanide poisoning is true?

A: Sodium Thiosulfate helps to convert cyanide to thiocyanate, which is another harmful compound but readily metabolized in the liver

B: The preferred administration route of amyl nitrite is intravenously

C: Sodium nitrite is used to treat methemoglobinemia

D: Hydroxocobalamin complexes cyanide to form the not very toxic cyanocobalamin

The correct answer is D

Cyanide poisoning was covered by Elise Alves Graber from emDocs this week as part of the ToxCards series.

Toxicity is mainly due to inhibition of cytochrome oxidase in the electron transport which halts ATP production leading to acidosis and anaerobic metabolism despite an often oxygen rich environment.

Sodium Thiosulfate helps to convert cyanide to thiocyanate, which is a harmless compound eliminated in the urine.

Amyl nitrite is no longer used due to unpredictable effectiveness. It is highly volatile and used to be administered by inhalation.

Sodium nitrite causes methemoglobinemia. This helps because cyanide has a higher affinity for the ferric iron in methemoglobin than for cytochrome oxidase.

Indeed, hydroxocobalamin complexes cyanide to form the not very toxic cyanocobalamin.

ToxCard: Cyanide Toxicity and Treatment

Source image: www.first10em.com

Question 3

A 30 year old woman presents to your emergency department with ongoing seizures.

Which of the following non-intravenous options has the shortest duration from administration to seizure cessation according to this recently published paper?

A: Intranasal midazolam

B: Buccal midazolam

C: Intramuscular midazolam

D: Rectal diazepam

E: Sublingual lorazepam

The correct answer is C

Justin Morgenstern discussed this paper on First 10 EM this week.

The authors of this systematic review analysed data about different routes and medications for terminating status epilepticus. 20 RCT’s were included, of which most were unblinded and of low methodological quality.

Intramuscular midazolam was the fastest to terminate seizures (2.1 minutes), followed by intranasal midazolam (2.4 minutes). Rectal diazepam and buccal midazolam both needed around 4 minutes.

Is there any reason to use intranasal midazolam for seizures?

Question 4

A 40 year old man comes in with altered mental status, agitation, tachypnoea, tachycardia, hypertension, diffuse (lead-pipe) tremors and hyperthermia. His neighbor found him confused and states the patient uses drugs from his psychiatrist. Which of the following clinical findings may point you in the direction of Serotonin Syndrome (SS) and does not so much fit Malignant Neuroleptic Syndrome?

A: Hypertension

B: Hyperthermia

C: Tachypnoea

D: Tremor

The correct answer is D

SinaiEM covered Serotonin Syndrome this week.

The difference between SS and NMS is quite tricky sometimes. Especially when the causative agent is not known. Differences in clinical findings are often very subtle. Hypertension, Hyperthermia, Tachypnoea, Tachycardia and Altered mental status can fit both etiologies. However, tremor and increased muscle tone are more typically seen in SS, while diffuse rigidity is more typical for NMS. Furthermore, the onset of SS is a lot faster compared to the more gradual onset of NMS.

 

 

Question 5

A 13 year old boy presents to your emergency department with severe pain in his right ankle caused by an uncomfortable landing during a basketball game. The X-ray of his ankle shows a triplane ankle fracture.

Which of the following statements is true about triplane ankle fractures?

A: They mostly occur shortly after closure of the distal tibial physis

B: Since triplane ankle fractures are caused by rotational forces, proximal spiral fibula fractures and base of the 5th metatarsal fractures are relatively common concomitant fractures

C: Triplane ankle fractures always consist of three parts as the name suggests

D: The Arcuate sign on CT is typical for this type of fracture

The correct answer is B

Anna O’Leary covered triplane ankle fractures this week in Don’t Forget the Bubbles.

Triplane fractures are classically seen in 10-17 year olds and occur before complete closure of the distal tibial physis. Tillaux fractures are seen in a bit older patients within 1 year after complete distal tibia physeal closure.

Triplane fractures may be classified as 2 part, 3 part or 4 part fractures and additional CT imaging is often necessary to evaluate the amount of dislocation of the different fracture parts. The typical sign which can be seen on CT is the Mercedes sign (see picture above).

The Arcuate sign refers to an avulsion fracture of the head of the fibula at the insertion site of the arcuate ligament complex.

Triplane ankle fractures

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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen