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

Quiz 66, May 8th, 2020

Welcome to the 66th FOAMed Quiz. 

Slowly the Corona-crisis seems te be under control in our region (for now). Time for some good old FOAMed trivia. Did you read up on the latest?

Enjoy!

Eefje, Joep and Rick

Question 1

The next trial in the Vitamin C story has arrived. This trial (the HYVCTTSSS trial) is a single-center RCT evaluating the combination of hydrocortisone, vitamin C, and thiamine versus placebo for patients with sepsis or septic shock. What did the authors find?

A: There was statistically significant lower mortality in the intervention (hydrocortisone, vitamin C, and thiamine) group compared to the control group

B: There was statistically significant lower mortality in the control group compared to the intervention (hydrocortisone, vitamin C, and thiamine) group

C: The trial was stopped early because of safety (adverse events in the intervention group)

D: The trial was stopped early because of benefit (the study hypothesis is unexpectedly proven early)

The correct answer is C

Josh Farkas covered this trial on PulmCrit and Clay Smith devoted a journal feed post to this trial. 

Severe hypernatremia (>160meq/L) was more common in the treatment group, 13 vs. 3 in the control (p=0.005), leading to early termination of the study.  Whether this is justified remains debatable, as Josh Farkas explains in his post. The result is this trial was profoundly underpowered and it provides no meaningful information about the intervention (hydrocortisone, ascorbate, and thiamine.)

Question 2

Your patient presents after following a high speed motor vehicle collision. You suspect a posterior sternoclavicular dislocation. Which of the following X-ray views is the most likely to help you?

A: Clavicle series

B: Velpeau view

C: Modified Axillary view

D: ‘’Serendipity’’ view

The correct answer is D

AliEM posted on a radiologic approach to the traumatic shoulder this week.

A ‘’Serendipity view’’ can be obtained when there is suspicion for sternoclavicular dislocations. It is obtained at an angle where the displacement of the clavicle is better appreciated

A Velpeau view is useful if the patient has too much pain to obtain a true axillary view or if the patient re-dislocates the shoulder upon taking post-reduction films.

Serendipity View

Source image: radiopaedia.org

Velpeau View

Source image: www.orthobullets.com

Question 3

Source image: www.litfl.com

Your 45 year old patient presents with a wide complex tachycardia (WCT) of about 190/minute. The patient is hemodynamically stable. You are not sure if this is ventricular tachycardia or supraventricular tachycardia with aberrancy or pre-existing bundle branch block. Which of the following findings makes a ventricular tachycardia more likely?

A: Normal QRS-axis

B: Resemblance to any known form of conduction block

C: Relative “delay” in the initial QRS deflection

D: Dominant terminal R wave in aVR

The correct answer is C

Ken Grauer covered VT vs SVT on dr. Smith’s ECG blog this week.

A normal QRS does not make VT more likely, an extreme axis does. Resemblance to any known conduction block makes pre-existent bundle branch block more likely. A dominant initial R in aVR makes VT more likely (Vereckei Algorithm). A relative slow initial deflection makes a VT more likely.

When in doubt, just assume it as VT.

Source image: http://hqmeded-ecg.blogspot.com/ Click image for link to original post

Question 4

Source: radiopaedia.org

A 78 year old patient with diabetes, COPD and stage 2 chronic kidney disease presents to your ED with significant abdominal distension, as well as abdominal pain, nausea, and vomiting. There is no fever and she does not feel unwell. The patient is stable and does not have peritoneal signs on exam. Contrast abdominal CT shows colonic dilation involving the right and transverse colon with no evidence of mechanical obstructive cause. There are no signs of (impending) perforation. What would be your diagnosis?

A: Ischaemic colitis

B: Wilkie’s syndrome

C: Sigmoid volvulus

D: Ogilvie’s syndrome

The correct answer is D

Justin Morgenstern covered Ogilvie’s syndrome this week. 

Ogilvie’s syndrome or acute colonic pseudo-obstruction is a cause of abdominal pain typically seen in elderly patients with multiple chronic illnesses. The underlying pathophysiology is uncertain. Management is conservative unless there are signs of (impending) hollow viscus perforation.

Ischemic colitis and sigmoid volvulus would show on the CT. Wilkie’s syndrome is a rare cause of duodenal obstruction, caused by a low aortomesenteric angle resulting in vascular compression of the duodenum. 

Acute colonic pseudo-obstruction (Ogilvie’s syndrome)

Question 5

Source image: @matslumholdt on pixabay.com

Slightly longer IV-cannulas are increasingly used when ultrasound guidance is necessary for peripheral vascular access. This recently published paper is about standard 4.78-cm, 20-gauge ultrasonographically guided intravenous peripheral catheters versus 6.35-cm, 20-gauge ultrasonographically guided intravenous peripheral catheters in patients in the emergency department with self stated  difficult vascular access. The primary endpoint was duration of catheter survival. What did the authors find?

A: Catheter survival was increased with use of 6,35 cm catheters

B: Catheter survival was increased with use of 4,78 cm catheters

C: There was no difference in catheter survival between 6,35 and 4,78 cm catheters

The correct answer is A

The RCEM learning podcast of May 2020 covered this paper.

It seems, as expected, catheter survival is increased when longer catheters are used.  Especially when cannulating deeper veins a longer than standard catheter should be used. A minimum of 2,5 to 3 cm of the cannula should be located in the vein. Even with the 6,35 cm catheters (which are still not very long) the chance of dislodgement after placement is high if deeper veins are cannulated. Midlines are likely to be more useful in this case.

https://www.rcemlearning.co.uk/foamed/may-2020/#1588607334956-2c93064d-8474

rcemlearning.co.uk
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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen

SARS-CoV-2 literature review April 2 – April 10, 2020

Dear colleague,

Our weekly FOAMed Quiz is suspended until further notice. 

However, quite a large body of evidence is published weekly on COVID-19. Evidence that might help us and our patients get through the upcoming weeks to months.

These are the best FOAMed resources and most useful papers of the last 7 days.

The following papers deserve some additional attention or are not yet covered in the FOAM society.

Paper 1

Title: The use of high-flow nasal oxygen in COVID-19

Author: Lyons, C.

Publication date: April 4, 2020

Journal: Anaesthesia

 

Aim: Explaining why High-Flow Nasal Oxygen could well be an appropriate therapy for COVID-19. 

Conclusion: ‘’The COVID-19 pandemic has evoked an understandable sense of vulnerability in healthcare workers. Clinicians should remain open-minded that HFNO may be an appropriate therapy for many patients for whom tracheal intubation has not yet become a necessity but for whom low-flow nasal oxygen or facemask oxygen is not providing adequate respiratory support.’’


Link to paper: The use of high‐flow nasal oxygen in COVID‐19

Paper 2

Title: Prediction of Number of Cases of 2019 Novel Coronavirus (COVID-19) Using Social Media Search Index

Author: Qin, L.

Publication date: Apr 5, 2020

Journal: International Journal of Environmental Research and Public Health,

 

Aim: This study investigated the correlation between the number of new cases of COVID-19 and the search index for a popular social network in China

Methods: Social media search indexes (SMSI) for dry cough, fever, chest distress, coronavirus, and pneumonia to predict new suspected COVID-19 case numbers from 20 January 2020 to 9 February 2020. 

Results:  The new suspected COVID-19 case numbers correlated significantly with the lagged series of SMSI. SMSI could be detected 6–9 days earlier than new suspected cases of COVID-19.

Conclusion: SMSI could be an effective early predictor for the number of COVID-19 infections.

Link to paper: Prediction of Number of Cases of 2019 Novel Coronavirus (COVID-19) Using Social Media Search Index

Paper 3

Title: Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy

Author: Grasselli, G.

Publication date: April 6, 2020

Journal: JAMA

 

Aim: What are the baseline characteristics and outcomes of patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection admitted to intensive care units (ICUs) in Lombardy, Italy?

Methods / Results: Retrospective case series that involved 1591 critically ill patients 

The majority were older men, a large proportion required mechanical ventilation and high levels of PEEP, and ICU mortality was 26%.

Link to paper: Characteristics and Outcomes of Patients Infected With SARS-CoV-2 Admitted to ICUs in Italy 

Paper 4

Title: Pre-proof: A first Case of Meningitis/Encephalitis associated with SARS-Coronavirus-2

Author: Moriguchi, T.

Publication date: April 3, 2020

Journal: International Journal of Infectious Diseases

 

Aim: This is the first case of meningitis associated with SARS-CoV-2 who was brought in by ambulance.

Highlight: This patient had transient generalized seizures and obvious neck stiffness The specific SARS-CoV-2 RNA was not detected in the nasopharyngeal swab but was detected in a CSF.

Link to paper: A first Case of Meningitis/Encephalitis associated with SARS-Coronavirus-2

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SARS-CoV-2 literature review March 25 – April 1, 2020

Dear colleague,

Our weekly FOAMed Quiz is suspended until further notice. 

However, quite a large body of evidence is published weekly on COVID-19. Evidence that might help us and our patients get through the upcoming weeks to months.

These are the best FOAMed resources and most useful papers of the last 7 days.

Last weeks most useful FOAMed resources:

Clay Smith provides an overview on the evidence so far on Journal Feed (COVID-19 | Spoon-Feed Version). 

Justin Morgenstern covered some really useful papers on First10EMs COVID Research Roundup and published his take on the evidence behind antivirals (Antivirals for COVID19 – Not ready for clinical use)

EmDocs covered anti-inflammatory agents (Anti-Inflammatory Agents and Corticosteroids in COVID-19: What’s the Controversy?) and antivirals  (Antiviral Agents: What is their use in COVID-19?)

Salim Rezaie discussed NIV, awake proning and more on RebelEM  (COVID-19 Hypoxemia: A Better and Still Safe Way.)

EM cases provided another on the latest literature as well  (COVID-19 Updates)

Scott Weingard uploads a new podcast almost every other day about a range of critical care topics (EMCrit RACC Blog & Podcast)

Josh Farkas discusses how a risk stratification tool for COVID might look like (PulmCrit Theoretical Post – The COVID Severity Index (CSI 1.0)).

EM Ottawa covered the airway (Guidelines for Emergency Airway Management of COVID-19)

And taming the SRU is thinking of ways to make intubation safer (The Mother of Invention Meets the Little Red Hen – The “Nat Mat”).

The following papers deserve some additional attention or are not yet covered in the FOAM society.

Paper 1

Title: Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)
Author: Alhazzani, W.
Publication date: March 28, 2020
Journal: Intensive Care Medicine

A panel of 36 experts from 12 countries was formed. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU.

Results: Follow this link for a Table containing all Recommendations and statements

Link to paper: https://link.springer.com/article/10.1007/s00134-020-06022-5

FOAMed sources covering the guideline: 
First10EM: Surviving Sepsis Campaign COVID Guidelines
CanadiEM: Surviving Sepsis Campaign: COVID-19 Recommendations
RebelEML Surviving Sepsis Campaign Guidelines on the Management of Critically Ill Adults with COVID-19

Paper 2

Title: Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study
Author: To, K. K.
Publication date: March 25, 2020
Journal: The Lancet INfectious Diseases

Aim: To ascertain the serial respiratory viral load of SARS-CoV-2 in posterior oropharyngeal (deep throat) saliva samples from patients with COVID-19, and serum antibody responses.

Methods: This is a cohort study at two hospitals in Hong Kong. Serial viral load was ascertained by reverse transcriptase quantitative PCR (RT-qPCR). 

Results: 23 patients were included. Salivary viral load was highest during the first week after symptom onset and subsequently declined with time. In one patient, viral RNA was detected 25 days after symptom onset. Older age was correlated with higher viral load.

Conclusion: The high viral load on presentation suggests that SARS-CoV-2 can be transmitted easily, even when symptoms are relatively mild. 

Link to paper: https://www.thelancet.com/journals/laninf/article/PIIS1473-3099(20)30196-1/fulltext

Paper 3

Title: Quantitative Detection and Viral Load Analysis of SARS-CoV-2 in Infected Patients
Author: Yu, F.
Publication date: March 28, 2020
Journal: Clinical Infectious Diseases

Aim: To explore the changes in viral load in different tissue samples and during disease progression with SARS-CoV-2- infected patients.

Methods:  127 patients were tested simultaneously by RT-PCR and ddPCR. 

Results: 76 COVID19 confirmed cases were included in the final analysis (77.6% mild). The average viral load in sputum was significantly higher than in throat swabs and nasal swabs. The viral load in the early and progressive stages were significantly higher than that in the recovery stage.

Conclusion: Sputum is a better indicator of viral replication in the body than throat and nasal swabs. The viral load of sputum samples tends to increase and then decrease during the course of the disease.

Link to paper: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciaa345/5812997

Paper 4

 

Title: Performance of VivaDiagTM COVID-19 IgM/IgG Rapid Test is inadequate for diagnosis of COVID-19 in acute patients referring to emergency room department
Author: Cassaniti, I.
Publication date: March 30, 2020
Journal: Journal of Medical Virology

Aim: To investigate the diagnostic Performance of VivaDiagTM COVID-19 IgM/IgG Rapid Test 

Methods: Pre-proof. The performance of VivaDiagTM COVID-19 IgM/IgG Rapid Test LFIA was tested in 50 patients at their first access at emergency room department with fever and respiratory syndrome (34 M/16 F; median age 61.50 range 33-97 years) in comparison with results of nasal swab molecular screening.

Results:  All 30 COVID-19 negative volunteers were negative for both IgG and IgM. No cross-reactivity was detected in the 10 subjects with previous coronaviruses infection. 38 patients were positive for COVID-19 by real time RT-PCR. Of these, only seven (18.4%) showed a positive or weak positive serology for IgM and/or IgG while the other 31/38 (81.6%) tested negative for the rapid serology assay.

Conclusion: VivaDiagTM COVID-19 IgM/IgG Rapid Test LFIA is not recommended for triage of patients with suspected COVID-19.

Link to paper: https://onlinelibrary.wiley.com/doi/abs/10.1002/jmv.25800

Paper 5

Title: Proposal for international standardization of the use of lung ultrasound for COVID-19 patients; a simple, quantitative, reproducible method.
Author:  Soldatini, G.
Publication date: March 30, 2020
Journal: Journal of Ultrasound in Medicine

Aim:  The authors share their experience and propose a standardized approach in order to optimize the use of lung ultrasound in covid‐19 patients.

Link to paper: https://onlinelibrary.wiley.com/doi/epdf/10.1002/jum.15285

Paper 6

Title: Life-threatening cardiac tamponade complicating myo-pericarditis in COVID-19
Author: Hua, A.
Publication date: March 30, 2020
Journal: European Heart Journal

Aim: This is the first reported case of COVID-19-associated cardiac tamponade.

Conclusion: Cardiac tamponade is an important differential to consider in a deteriorating patient with COVID-19.

Link to paper: https://academic.oup.com/eurheartj/advance-article/doi/10.1093/eurheartj/ehaa253/5813280

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SARS-CoV-2 literature review March 17-24 2020

Dear colleague,

Our weekly FOAMed Quiz is postponed until further notice.

However, quite a large body of evidence is published weekly on COVID-19. Evidence that might help us to help more patients in the upcoming weeks to months.

This is a selection of useful papers on SARS-CoV-2 published in the last 7 days.

Wishing you all the courage and strength to push forward…

Paper 1

Source: First10EM

Title: Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial.
Author: Gautret P,
Publication date: March 20, 2020
Journal: International Journal of Antimicrobial Agents.

Goal: This is an observational study of patients 12 years and older with documented COVID-19 admitted to a single hospital in France, with a control group from other hospitals around France.

Methods: Patients in the primary centre with rather mild disease were treated with hydroxychloroquine. Patients in the control centres did not. The authors originally enrolled 42 patients. However, 6 were excluded from the main site, mostly because of death or transfer to the ICU, while no patients were excluded from the controls.

Results: Viral clearance on day 6 occured in 70% of the treatment group and 13% of the controls (p=0.001)

Conclusion: Due to profound methodological flaws this paper does not provide any evidence for treatment of COVID-19 with hydroxychloroquine

Chloroquine for COVID: No good evidence yet

Paper 2

Title: The characteristics and clinical value of chest CT images of novel coronavirus pneumonia
Author: Zhao, X.
Publication date: March 19th, 2020
Journal: Clinical Radiology

Goal: This study was undertaken to retrospectively analyse the chest CT images of 80 PCR-confirmed COVID-19 patients at various hospitals in Anhui Province, China.

Conclusion: The chest CT of these patientis is typically characterised by bilateral groundglass lesions located in the subpleural area of the lung. Pleural effusions and mediastinal lymphadenopathy are rare.


Click image for link

Paper 3

Title: Case-Fatality Rate and Characteristics of Patients Dying in Relation to COVID-19 in Italy
Author: Onder, G.
Publication date: March 23, 2020
Journal: JAMA

Goal: To explain the relatively high case fatality (CFR) rate in Italy compared to China and other countries

Conclusion: The relatively high CFR in Italy may be due to an older population, a difference in definition of SARS-CoV-2 related death compared to other coutries and a difference in testing strategies (less testing in Italy compared to China).


Click image for link

Paper 4

Title:  COVID-19 outbreak: less stethoscope, more ultrasound
Author: Buonsenso, D.
Publication date: March 20, 2020
Journal: The Lancet

Goal: A view on the use of portable ultrasound in these challenging times

Conclusion: The use of ultrasound is now essential in the safe management of the COVID-19 outbreaks, since it can allow the concomitant execution of clinical examination and lung imaging at the bedside by the same doctor.


Paper 5

Title:  Time Kinetics of Viral Clearance and Resolution of Symptoms in Novel Coronavirus Infection
Author: Chang, D.
Publication date: March 20, 2020
Journal: American Journal of Respiratory and Critical Care Medicine

Goal: To determine the time kinetics of viral clearance in reference to the resolution of symptoms in 16 patients treated in Beijing, China

Conclusion: Half (8/16) of the patient remained viral positive (a surrogate marker of shedding) even after the resolution of symptoms (median 2.5 days, range 1 to 8 days).


Click image for link

Paper 6

Title: Platelet‐to‐lymphocyte ratio is associated with prognosis in patients with Corona Virus Disease‐19
Author: Qu, R.
Publication date: March 17, 2020
Journal: Journal of Medical Virology

Goal: The platelet‐to‐lymphocyte ratio (PLR) is considered quite a good marker for overall badness (and mortality). If this holds true for SARS-CoV-2 patients is the main question in this paper.

Conclusion: The PLR, when measured at the peak of thrombocytosis, was significantly higher in patients with severe disease (from oxygen sat <94% and a respirtory rate of > 30 to respiratory failure) compared to patients with non-severe disease.
Only 30 patient were enrolled in this study.

Click image for link

Paper 7

Title:  Transmission potential and severity of COVID-19 in South Korea
Author: Shim, E.
Publication date: March 17, 2020
Journal International Journal of Infectious Diseases

Goal: To examine the growth rate of the outbreak, the authors aimed to present the first study to report the reproduction number of COVID-19 in South Korea.

Conclusion: The mean reproduction number of COVID-19 in Korea was estimated at 1.5. Futhermore, the crude case fatality rate is higher among males and increases with age.

Click image for link

Paper 8

Title: Covid-19: European drugs agency to review safety of ibuprofen
Author: Michael Day (journalist)
Publication date: March 23, 2020
Journal: BMJ

Goal: This newsflash is about the use of ibuprofen for symptoms relief in SARS-CoV-2 patients? The authors interviewed several specialists on this topic.

Conclusion: 1. There is no evidence relating specifically to people with covid-19. 2. Pending further research, a pragmatic and cautionary approach would be for the public to avoid these plausible harms.

Click image for link

Paper 9

Title:  Systematic review of COVID‐19 in children show milder cases and a better prognosis than adults
Author: Ludvigsson, J.
Publication date: March 23, 2020
Journal:Acta Pedeatrica

Goal: A systematic literature review was carried out to identify papers on COVID‐19, which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), using the Medline and EMBASE databases between 1 January and 18 March 2020.

Summary: This review identified 45 relevant studies on COVID-19 in children. The disease course in paediatric COVID-19 was milder than in adults, children had a better prognosis and deaths were extremely rare. Diagnostic findings have been similar to adults.

Click image for link
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Quiz 64, February 28th, 2020

Welcome to the 64th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Question 1

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

Ankle injuries are common in the Emergency Department. Which of the following statements is true about ankle x-rays?

A: A tibiofibular space >2 mm indicates a syndesmotic injury

B: The AP view should be used to asses the medial clear space

C: A Bohler’s angle <20 degrees suggest a calcaneus fracture

D: A gravity stress view should be considered in Weber A fractures to assess for syndesmotic involvement

The correct answer is C

This week’s post on ALIEM is about the approach to the traumatic ankle x-ray. 

The tibiofibular space is widened in syndesmotic injury, when > 6 mm suspect a syndesmotic injury. 

The medial clear space is assessed on the mortise view. This is the medial border of talus and lateral border of medial malleolus. When > 4 mm there might be syndesmotic injury. 

Another approach to assess for syndesmotic injury is the gravity stress view. To be considered in Weber B fractures. 

Bohler’s angle is measured on the lateral view. If < 20 degrees, a calcaneus fracture might be present. You could then consider ordering a calcaneus view, although CT has higher sensitivity and specificity for this fracture.

https://www.aliem.com/emrad-ankle/

Question 2

Source image: https://litfl.com/

You see a 70 year old patient with in the past medical history diabetes mellitus, hypertension and epilepsy. He presents with fever-like symptoms and an erythematous macular rash. There is mucosal and ocular involvement and the Nickolsky sign is positive. He has been taking penicillin recently.

Which of the following critical rashes do not have mucosal involvement?

A: Toxic Epidermal necrolysis (TEN )

B: Stevens-Johnson syndrome (SJS)

C: Staphylococcal scalded skin syndrome (SSSS)

D: Acute generalised exanthematous pustulosis (AGEP)

E: Pemphigus Vulgaris ( PV)

The correct answer is C

This week critical rashes were covered on emDocs.

Nickolsky sign is positive when lateral pressure on intact skin causes shedding of the epidermis. This sign can be seen in all of the above critical rashes. Mucosal involvement is common in TEN and SJS, and is less common, but can be seen in AGEP and PV. SSSS presents as erythematous painful skin with flaccid bullae and desquamation, but without mucosal involvement.

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis Mimics – Differential Diagnosis and Initial Management

Question 3

Which combination of vasopressor and mechanisms of action is correct?

A: Vasopressin – increase in systemic vascular resistance and increase in pulmonary vascular resistance

B: Milrinone – positive effect on inotropy and decrease in pulmonary vascular resistance

C: Dopamine, low dose – decrease in systemic vascular resistance and increase in pulmonary vascular resistance

D: Phenylephrine – decrease in systemic vascular resistance and increase in pulmonary vascular resistance

The correct answer is B

This week’s chapter of the internet book of critical care on emcrit is about vasopressors. The table below gives a summary of the most commonly used vasopressors and their mechanisms of action.

Vasopressors

Source image: https://emcrit.org/ibcc/pressors/
Source image: https://emergencymedicinecases.com

Question 4

Your 40 year old patient presents with acute chest pain. You find some ST-elevation (STE) in the precordial leads and you doubt whether you are looking at Benign Early Repolarization (BER) or an acute myocardial infarction (MI).

Which of the following findings may point you in the direction of MI?

A: Convex STE morphology

B: Concave STE morphology

C: Notching at the J point

D: Normal R wave progression

The correct answer is A

County EM covered Benign Early Repolarization Pattern vs. Anterior STEMI this week.

Convex STE morphology is highly specific for AMI, while STE at the J point with upward concavity is more typical for BER (but LAD occlusions can be seen with concave morphology).

Notching at the J point is typical for BER, as well as normal R wave progression (of course).

Benign Early Repolarization Pattern vs. Anterior STEMI

Question 5

Source image: https://first10em.com/

Your 34 year old patient presents with a linearly arranged itching rash over his trunk and arms 2 days after eating mushrooms. This presentation is typical for:

A: Type 1 (IgE mediated) hypersensitivity

B: Type 4 (T-cell mediated) hypersensitivity

C: Tinea corporis

D: Shiitake dermatitis

The correct answer is D First10EM covered shiitake dermatitis this week. ´Shiitake dermatitis is an intensely pruritic rash caused by a toxic reaction to lentinan, a component of shiitake mushrooms. It usually develops 1-3 days after eating raw or undercooked shiitake mushrooms.´ Type 1 hypersensitivity reactions occur earlier after exposure. Type 4 hypersensitivity can present 2 days after exposure, but as contact dermatitis. Tinea corporis has nothing to do with eating mushrooms.
Shiitake Dermatitis
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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 62, February 14th 2020

Welcome to the 62th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Question 1

Source image: litfl.com
 

Last week this paper was published in NEJM. 316 patients between 18 and 50 years old with moderate to large (> 32%) one-sided pneumothoraces were randomized to either conservative treatment or treatment with a 12 Fr pleural catheter. What did this paper show?

A: Conservative treatment was inferior compared to insertion of a pleural catheter for re-expansion at 8 weeks

B: Conservative treatment was superior compared to insertion of a pleural catheter for re-expansion at 8 weeks

C: Conservative treatment was non-inferior compared to insertion of a pleural catheter for re-expansion at 8 weeks

The correct answer is C

St. Emlyn’s covered this recently published paper. In our ED, patients with these large pneumothoraces always get a pleural catheter. This paper certainly opens up possibilities to study conservative management of pneumothoraces.

The primary outcome (reexpansion at 8 weeks) was met in 94.4 percent of patients in the conservative management group and 98.5 percent of patients in the non-conservative group. This was non-inferior according to the authors, who set the non-inferiority margin at 9 percentage points. As expected the conservative managed patients spend less time in the hospital (1.6 to 6.1 days), had less adverse events and a lower 1-year recurrence rate.

There are some methodological issues to mention. The non-inferiority margin of 9 percent seems a bit high. Furthermore there was a significant loss to follow up in both groups (23 in the non-consevative group and 37 in the conservative group). 15 percent of patients in the conservative group ended up getting an intervention after all and it seems 316 patients out of 2600 screened patients might suggest selection bias.

JC: Conservative management of pneumothoraces.

Question 2

For what kind of pediatric fracture should the Ogden classification be used?

A: Tillaux fractures

B: Greenstick fractures

C: Tibial Tubercle Fractures

D: Supracondylar fractures

The correct answer is C

AliEM covered tibial tubercle fractures last week.

The Ogen classification schema is similar to the Salter-Harris classification, but is used preferentially in the proximal tibia because of the presence of two ossification centers.

I: Fracture of the secondary ossification center
II: Fracture propagates proximal between primary and secondary ossification center
IV: Fracture crosses the primary ossification center
V: Fracture through the entire proximal primary ossification center
VI: Avulsion fracture of the patellar tendon from the secondary ossification center

Source image: https://musculoskeletalkey.com/

SplintER: Knee pain after the jump

Question 3

Which of the following is not part of the classic triad of Serotonin Syndrome?

A: Agitation, Confusion (Altered mental status)

B: Tachycardia, Fever and Flushing (Autonomic hyperactivity)

C: Lead pipe rigidity, hyporeflexia (Neuromuscular abnormality)

The correct answer is C

em3 covered serotonin syndrome this week.

Yes, the triad consists of Altered mental status, Autonomic hyperactivity and Neuromuscular abnormality. However, the neuromuscular abnormality you will find in serotonin syndrome is hyperreflexia and myoclonus.

Lead-pipe’ rigidity is found in Malignant Neuroleptic Syndrome.

Question 4

A 39-year old male presents with severe epigastric pain, nausea and several episodes of non-bloody, non bilious emesis. He describes the pain as sharp and it radiates to her back. On examination, he is tachycardic and tachypneic with abdominal tenderness. Lipase comes back markedly elevated.

Which of the following statements about acute pancreatitis is true?

A: The most common etiology is alcohol (up to 50%), followed by gallstones (20%), hypertriglyceridemia (5-10%), idiopathic (up to 20%), medications and some more rare causes

B: Diagnosis requires the following: characteristic abdominal pain AND a lipase or amylase >3 times the upper limit of normal AND characteristic findings on ultrasound (US) or computed tomography (CT)

C: Conditions, other than pancreatitis, like bowel obstruction, bowel ischemia, perforation, biliary disease and renal failure can not elevate lipase and amylase >3 times the normal limit

D: A triglyceride level of at least 500 mg/dL (typically >1000 mg/dL or 11.2 mM) suggests hypertriglyceridemia as the underlying etiology

The correct answer is D

Britt Long covered pancreatitis this week on EMdocs.

Pancreatitis is a common diagnosis in the Emergency Department. It is caused by numerous things but mostly by gallstones (up to 40%), alcohol (30%) or hypertriglyceridemia (5-10%).

Diagnosis requires 2 of the following: characteristic abdominal pain, lipase >3x the upper limit of normal, characteristic findings on US or CT. Besides pancreatitis, other conditions like bowel obstruction, bowel ischemia etc can also cause elevated levels of lipase, but normally won’t exceed levels 3 times the upper limit.

Treatment is mostly supportive. In case of hypovolemia, flu. Antibiotics are controversial and only warranted in patients with signs/sources of infection, necrosis, abscess and infected pseudocysts.

EM@3AM: Pancreatitis

Question 5

Your patient presents with fever of unknown origin. POCUS reveals a mitral valve vegetation. Which of the following statements about endocarditis is true?

A: Fever is present in about half of patients with endocarditis

B: Roth spots are an example of extracardiac manifestations of endocarditis and present as tender lesions which can be found on finger pulps and thenar/hypothenar eminences

C: Flank pain in a patient with endocarditis could be due to splenic or renal emboli and therefore abdominal imaging should be considered in these patients

D: Workup should include two proper sets of blood cultures

The correct answer is C.

Endocarditis was covered by Anand Swaminathan this week as part of the REBEL Core Cast.

Endocarditis is an infection of the endocardial surface of the heart, heart valves or both. Fever is present in 90% of patients whereas a new murmur is present in 50-80% of patients. Examples of extracardiac symptoms are: Osler nodes, Janeway lesions, splinter hemorrhages and Roth Spots which are emboli in the eye causing boat-shaped hemorrhages with pale centers.

Emboli can cause all sorts of complications in the lungs, spleen and kidneys. Splenic and renal emboli can cause flank pain.

Workup should include three sets of blood cultures.

REBEL Core Cast 27.0 – Endocarditis

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

Reviewed and edited by Rick Thissen