Quiz 42, 16th of August, 2019

Question 1



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

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

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

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

The correct answer is A

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

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

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

Question 2

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

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

A: Bulging or the posterior fat pad

B: Lipohemarthrosis

C: Cortical disruption

The correct answer is C

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

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

PEM Pearls: Ultrasound for Diagnosing Occult Supracondylar Fractures

Question 3

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

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

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

B: Digital nerve blocks can be given safely

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

The correct answer is A

County EM covered this topic last week.

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

ED Management of High-Pressure Injection Injury

Question 4

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

A: Antifreeze contains propylene glycol

B: Acetonemia is typically seen in this intoxication

C: Hypocalcemia is typically seen in this intoxication

D: Optic Nerve Toxicity is typically seen in this intoxication

The correct answer is C

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

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

Question 5

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

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

A: Limit initial fluid removal to 1,5 liters

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

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

The correct answer is B

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

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

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

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

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

Reviewed and edited by Rick Thissen

Quiz 41, August 2nd, 2019

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

The FOAMed Quiz Crew

Question 1

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

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

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

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

The correct answer is C

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

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

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

PulmCrit – Early basal insulin in DKA

Question 2

Source image: https://litfl.com/

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

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

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

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

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

The correct answer is C

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

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

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

Pediatric ECG

Question 3

https://www.flexicare.com/

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

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

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

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

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

The correct answer is B

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

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

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

Question 4

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

What did the authors find?

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

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

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

The correct answer is A

EMOttawa covered this paper last week.

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

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

Question 5

Source image: https://litfl.com/

Which of the following statements is correct about ECG abnormalities?

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

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

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

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

The correct answer is A

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

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

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

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

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

Edited by Rick Thissen

Quiz 40, June 21th, 2019

Question 1

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

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

A: Lemierre’ s Syndrome

B: Trousseau’s Syndrome

C: Antiphospholipid Antibody Syndrome

The correct answer is B

LIFTL published this great ultrasound case  last week.

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

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

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

Ultrasound Case 097

Question 2

Which of the following statements is true about Serotinin Syndrome?

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

B: Hypothermia is often present

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

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

The correct answer is C

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

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

IBCC chapter & cast: Serotonin syndrome

Question 3

Source image: https://litfl.com

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

A: About 10 percent

B: About 30 percent

C: About 50 percent

D: About 70 percent

The correct answer is B

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

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

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

Question 4

Source image: https://litfl.com

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

A: Adenosine is contraindicated in this case

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

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

D: Adenosine never triggers atrial tachyarrhythmias

The correct answer is B

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

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

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

Question 5

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

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

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

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

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

D: Validated algorithms on TEG-guided transfusion are available

The correct answer is D

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

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

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

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

Edited by Rick Thissen

Quiz 39, June 13th, 2019

Question 1

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

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

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

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

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

D: Herpangina is the mouth-only cousin of HFMD

The correct answer is D

SinaiEM covered Hand Foot Mouth Disease this week.

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

 

Question 2

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

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

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

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

C: Isolated DRUJ dislocation is pretty common

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

The correct answer is D

Dan Stevens and Mike Cadogan covered DRUJ dislocation on LITFL.

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

An unusual wrist injury

Question 3

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

A: Phenobarbital was superior to Phenytoin in terminating the seizure

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

C: Phenytoin was superior to Phenobarbital in terminating the seizure

The correct answer is A

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

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

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

Question 4

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

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

A: Medication always causes a histamine mediated reaction

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

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

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

The correct answer is B

Brit Long covered angio-edema on EMdocs this week.

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

emDocs Cases: Angioedema Evaluation and Management

Question 5

 

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

Which of the following statements is true about measles?

A: The mortality rate is 0.02 %

B: Transmission occurs only via direct contact

C: The vaccine is 87% effective after 2 shots

D: There is no animal reservoir

The correct Answer is: D

This weeks REBEL corecast is about measles.

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

REBEL Core Cast 13.0 – Measles

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

Edited by Rick Thissen

Quiz 38, June 7th 2019

Question 1

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

A: Bundle branch blocks

B: QT prolongation

C: Atrial fibrillation

D: AV-blocks

The correct answer is C

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

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

Ep 125 Electrical Injuries – The Tip of the Iceberg

Question 2

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

A: > 3 days

B: > 4 days

C: > 7 days

D: > 10 days

The correct answer is C

REBELem covered tracheostomy emergencies this week.

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

REBEL Core Cast 12.0 – Tracheostomy Emergencies

Question 3

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

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

B: The clot is more than 5 cm in length

C: The clot is in a varicose vein

D: Male gender

The correct answer is C

Jacob Avila covered superficial venous thrombosis on emDOCs.

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

CORE EM: Superficial Venous Thrombosis (SVT)

Question 4

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

Which of the following statements is true about fluid boluses?

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

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

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

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

The correct answer is C

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

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

PulmCrit: Myth-busting the fluid bolus

Question 5

Source image: https://litfl.com/

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

A: 2nd intercostal space midclavicular

B: 4th intercostal space anterior axillary line

The correct answer is B

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

Papers of June 2019

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

Edited by Rick Thissen

Quiz 37, May 31th 2019

Question 1

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

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

A: Ludwigs Angina

B: Lemierre’s Syndrome

C: Retropharygeal abcess

The correct answer is B

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

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

Question 2

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

A: Bruising in an under 4 month old

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

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

D: Bruises to upper arms and upper legs

The correct answer is D

Pediatric EM morsels covered bruises in abuse this week.

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

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

Sentinel Bruising & Abusive Injury

Question 3

Source image: https://litfl.com

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

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

B: Exogenous steroids do not increase the NLR

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

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

The correct answer is D

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

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

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

Question 4

Source image: https://litfl.com

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

A: Patients with LVADs are preload dependent

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

C: Most LVADs produce a pulsatile flow

D: The most common complication of an LVAD is hemolysis

The correct answer is A

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

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

Question 5

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

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

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

A: Pyridoxine (vitamin B6)

B: Midazolam or any other benzodiazepine

C: Glucose 50%

D: Thiamine (vitamin B1)

The correct answer is A

ALIEM covered gyromitrin poisoning this week.

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

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

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

ACMT Toxicology Visual Pearls: Eating Foraged Wild Mushrooms

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

Edited by Rick Thissen

Quiz 36, May 24th 2019

Question 1

Are you using chest compressions in hemorrhage induced traumatic cardiac arrest? It doesn’t make a lot of sense to start compressions if the patient has no intravascular volume. Last week a paper was published comparing closed chest compression with and without fluid therapy (normal saline or whole blood). Importantly, it was an animal study using exsanguinating large pigs. What did the authors find?

A: Closed chest compressions alone may lead to Return of Spontaneous Circulation (ROSC)

B: Closed chest compressions and whole blood therapy led to increased rates of ROSC compared to whole blood therapy without chest compressions

C: Closed chest compressions and normal saline therapy led to increased rates of ROSC compared to normal saline therapy without chest compressions

D: Closed chest compressions and whole blood therapy led to reduced rates of ROSC compared to whole blood therapy without chest compressions

The correct answer is D

Simon Carley covered this paper on St.Emlyn’s last week.

It sure is an interesting paper. Pigs were divided in 5 groups, anaesthetised and exsanguinated. The pigs in group 1 received closed chest compressions only, in group 2 whole blood only, in group 3 normal saline only, in group 4 whole blood + closed chest compressions and in group 5 normal saline + closed chest compressions. Pigs only receiving chest compressions did not achieve ROSC. The only pigs achieving ROSC where the pigs treated with whole blood while chest compressions seem to reduce the rate of ROSC in the ‘’whole blood’’ group.

Of course this does not mean you should never initiate chest compression in trauma patients. These are small numbers and well, the subjects were pigs. However, if the cause of the cardiac arrest is definitely hemorrhage, it makes sense to withhold chest compressions and focus on restoring intravascular volume first.

JC: Should we use chest compressions in traumatic cardiac arrest? St Emlyn’s

Question 2

Which of the following is the most common complication of endoscopic retrograde cholangiopancreatography (ERCP)?

A: Viscous perforation

B: Gastrointestinal bleeding

C: Post-ERCP pancreatitis (PEP)

D: Biliary infections (acute cholangitis and cholecystitis)

The correct answer is C

Tim Montrief covered post ERCP complications pretty extensively on emDOCs.

Acute pancreatitis is the most common complication of ERCP, with an estimated incidence between 3.5-9.7% and a mortality rate of 0.7%.

Complications of ERCP: ED presentations, evaluation, and management

Question 3

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

Which of the following statements about epiglottitis is NOT true?

A: Epiglottitis is most common in the adult population

B: A lateral neck X-ray might support the diagnosis of epiglottitis

C: Epiglottitis presents most commonly with the 3D’s: drooling, dysphagia and distress

D: Do not use supraglottic devices; they can aggravate the situation

The correct answer is C.

Anand Swaminathan covers epiglottitis in his latest podcast on RebelEM.

Despite of what we all learned in medical school, epiglottitis seldom presents with the classical triad of drooling, dysphagia and distress. Most commonly the patient presents with a painful throat, dysphagia and hoarseness without any obvious findings in the oropharynx on physical examination. Epiglottitis can, of course, lead to airway occlusion over a very short period of time, so be ready for a difficult airway. You should not use any supraglottic devices, or perform any oropharyngeal manipulations since they can aggravate the situation due to compression of the epiglottis.

Since the introduction of the Haemophilus influenza type B vaccin the child versus adult ratio changed from 2,6 to 1 to 0,3 to 1, with a mean age of 55 years. Risk factors include the immunocompromised patient, smoking and diabetes.

With a lateral (soft tissue) neck x-ray a typical ‘thumbprint’ sign can be seen in 90% of the cases.

REBEL Core Cast 11.0 – Epiglottitis

Question 4

Which of the following statements is true about Rhabdomyolysis?

A: Early on, Creatine Kinase (CK) levels might be normal or moderately elevated

B: CK levels correlate very well with the risk of acute kidney injury and dialysis

C: If treatment is indicated, starting with 300 ml per hours of crystalloid seems to be a reasonable approach, even if the patient has no urine output

D: A McMahon score of six or greater indicates risk of acute kidney injury or dialysis, suggesting a possible benefit from treatment

The correct answer is D

Josh Farkas covered rhabdomyolysis in his latest IBCC podcast.

CK levels often rise quite late in the course of the illness, while kidney injury might develop early on. Kidney injury is due to hypermyoglobinemia, not due to CK levels directly and CK levels correlate poorly with the risk of acute kidney injury and dialysis. The McMahon score is useful in patient with a CK between 1000 and 5000 U/L, as a McMahon score of 6 or greater means treatment is indicated.

Be careful with iv fluids, for patients can get volume overloaded quite easily. Start with 150 to 200 cc’s of crystalloids per hour and monitor urine output closely. If the patient is (or gets) anuric or not matching urine output to fluids given, stop administration of iv fluids.

IBCC chapter & cast: Rhabdomyolysis

Question 5

Defibrillation often causes delay in compressions during cardiopulmonary resuscitation, for everyone has to be clear from patient and bed before a shock is delivered. According to this recently published paper  do polyethylene drapes provide sufficient protection from defibrillator currents during hands-on defibrillation?

A: Yes, current leaks were well below accepted IEC safety standards

B: No, current leaks did not meet IEC safety standards

C: No, the shocks were perceptible

The correct answer is A

This interesting paper was discussed on Journal Feed last week.

Both mean and peak current leaks were well below accepted IEC safety standards. None of the shocks were perceptible.

This might be the future. Using these drapes (of same material gloves) sure would reduce compression pause during defibrillation.

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

Edited by Rick Thissen

Quiz 35, May 17th 2019

Question 1

Which of the following statements about myxedema coma is true?

A: Patients van Myxedema coma typically present with bradypnea, bradycardia, hypertension and hypernatremia

B: If untreated, mortality is 60%

C: Most of the time it is caused by a primary thyroid problem and the lab will show a low TSH

D: You need to give thyroid hormones IV and also a stress dose (hydrocortisone) prior to the thyroid hormones to prevent adrenal crisis

The correct answer is D

Rachel Bridwell wrote about Myxedema Coma on emDOCs. The incidence is very low, but mortality is between 20-60% and if untreated 100%.

The typical patient is a middle aged or elderly woman with a history of hypothyroidism. Most common symptoms are: Bradycardia, hypothermia, bradypnea, hypotension, constipation, fatigue and hypoactive delirium. Two types can be distinguished. Primary: thyroid problem and secondary: failure of hypothalamus. The lab will show a elevated or normal TSH. Hyponatremia and hypoglycemia are common. Always be aware of other causes like infection metabolic abnormality or intoxication.

EM@3AM: Myxedema Coma

Question 2

A 4 year old boy comes in with with vomiting and change in mental status. He has been ill for a couple of days and his mother states she gave him some Aspirin. You feel somewhat excited for this might be a case of Reye’s syndrome. Which of the following statements is true about Reye’s syndrome?

A: Causality is described between aspirin therapy and this syndrome

B: Reye’s Syndrome rates did not decline after warnings to avoid aspirin therapy in children

C: Analysis of Cerebrospinal Fluid (CSF) typically shows a high white blood cell count

D: Gastroenteritis, Varicella, and Influenza are classically described as being associated with Reye’s Syndrome

The correct answer is D

Sean Fox published an overview of Reye’s syndrome on Pediatric EM Morsels.

An association (although no clear causality) is described between aspirin therapy and Reye’s syndrome. Reye’s Syndrome rates declined after warnings to avoid aspirin therapy in children. Reye’s syndrome is characterised by an acute non-inflammatory encephalopathy, so there should be no or few white blood cells in the CSF. Gastroenteritis, Varicella, and Influenza are indeed classically described as being associated with Reye’s Syndrome

Reye’s Syndrome

Question 3

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

Which of the following statements is true about proximal first metacarpal fractures?

A: A Rolando Fracture is a partial intra-articular fracture at the base of the 1st metacarpal with a single fracture fragment displaced to the medial and palmar aspect of the bone

B: A Bennett Fracture is a complete and comminuted intraarticular fracture, usually in a T or Y shape

C: Intra-articular fractures should get urgent (≤3 days) follow-up with hand surgery clinic for likely operative fixation

D: Extra-articular fractures with up to 50 degrees of angulation may be managed conservatively

Tabitha Ford covered first metacarpal fractures on ALIEM this week.

A Bennett Fracture is a partial intra-articular fracture at the base of the 1st metacarpal with a single fracture fragment displaced to the medial and palmar aspect of the bone. A Rolando Fracture is a complete and comminuted intra-articular fracture, usually in a T or Y shape. Extra-articular fractures with up to 20-30 degrees of angulation may be managed conservatively.

SplintER Series: Case of a First Metacarpal Fracture

Question 4

I personally haven’t prescribed Tramadol for years now. Why did it get bad publicity the past few years?

A: A significant portion of the population has no activity at the necessary enzyme (CYP2D6) to metabolize tramadol in its active metabolite

B: Some people are ultra-metabolizers that get much higher concentrations of the active metabolite

C: Tramadol acts as a serotonin and norepinephrine reuptake inhibitor (SNRI) as well

D: All of the above

The correct answer is D

Justin Morgenstern covered Tramadol problems on first 10 EM this week.

Tramadols opioid action is the result of a metabolite, so it requires metabolism through the P450 enzymes before it starts working. The rate of this metabolism varies significantly among the population. This means some patients may have no benefit at all and others me develop toxicity with normal doses.

Question 5

The window for the use of intravenous alteplase in patients with ischemic stroke is still 4.5 hours. This recent paper is a multicenter, randomized placebo-controlled trial, involving patients who had hypoperfused, but salvageable regions of brain on the perfusion scan. They received intravenous alteplase or placebo between 4.5 and 9 hours from symptoms onset or upon awakening (if within 9 hours of the midpoint of sleep).

What is the conclusion of this trial?

A: There was no difference in neurological outcome between the alteplase and the placebo group. There were more deaths at 90 days in the alteplase group compared to the placebo group

B: There was a higher percentage of patients with excellent neurological outcome in the alteplase group compared to the placebo group. There was no difference in symptomatic intracranial hemorrhages (ICH)

C: In the alteplase group there was a higher percentage of patients with excellent neurological outcome compared to the placebo group. There were more symptomatic ICH in the alteplase group compared to placebo

The correct answer is C

Clay Smith wrote about the EXTEND trial in his latest blog.

The use of alteplase in patients with ischemic stroke with salvageable brain on perfusion imaging was superior to placebo, NNT = 17. Symptomatic hemorrhage was more common in the alteplase group NNH = 19. There was no difference in death at 7 and 90 days between groups. Late alteplase may help slightly more people than it hurts, but this is risky business.

Since this study began in 2010, thrombectomy is the treatment of choice for large vessel occlusion. In this study 70% had large vessel occlusion, which would make the use of alteplase alone obsolete. The EXTEND trial was terminated early because loss of equipoise after the publication of positive results from a previous trial (WAKE-UP). Furthermore, seven of the authors had received some form of support or compensation from the producer of alteplase in Europe.

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

Edited by Rick Thissen

Quiz 34, 10th of May 2019

Question 1

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

A 30 year old pregnant lady is referred to you by her General Practitioner because of suspected pulmonary embolism (she has had mild dyspnoea for 2 days). We have been scanning a lot of pregnant patients because d-dimers are often (falsely) positive and so far no single rule out strategy turned out to be reliable enough. Until now maybe. Last week this paper was published in the New England about the YEARS algorithm for ruling out pulmonary embolism in pregnant patient. What did the authors find?

A: Pulmonary embolism was safely ruled out by the pregnancy-adapted YEARS diagnostic algorithm across all trimesters of pregnancy

B: Of a total of 498 included patients, CT pulmonary angiography was avoided in 195 patients

C: During follow-up of the patients not receiving imaging, no patient had pulmonary embolism

D: All of the above

The correct answer is D

This algorithm uses the YEARS criteria to elevate the d-dimer cutoff to 1000 ng/ml if negative. This seems to be a viable clinical decision tool to rule out PE in pregnant patients and safely reduce CT use. Take note PE was only diagnosed in 4% of the study population (20 patients).

 

Question 2

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

Which of the following statements is true about push dose vasopressors?

A: Phenylephrine may cause reflex bradycardia

B: Ephedrine has a short duration of action (< 15 minutes)

C: There is plenty of evidence to support the use of push dose noradrenaline in the Emergency Department

D: Adrenaline has a longer duration of action compared to Phenylephrine

The correct answer is A

emDOCS published about push dose vasopressors this week.

Phenylephrine is a pure alpha agonist that causes arterial vasoconstriction and an in increase systemic vascular resistance. It has no chronotropic effect and may lead to baroreceptor-mediated, reflex bradycardia. Ephedrine is an indirect alpha and beta-1 receptor agonist, it has extended duration of action (60 minutes). Evidence to support norepinephrine as a push dose pressor in the ED is lacking. Push-dose phenylephrine has a slightly longer duration of action compared to epinephrine (10 to 20 minutes vs. 5 to 10 minutes).

Push-Dose Vasopressors: An Update for 2019

Question 3

Source image: https://pixabay.com

Which of the following statements about Acetaminophen is true?

A: Dialysis is never indicated in Acetaminophen overdose

B: Patients with Acetaminophen overdose can present with altered mental status and a high anion gap metabolic lactic acidosis

C: Acetaminophen can cause a decreased INR in patients on Warfarin

The correct answer is B

Emergency Medicine Cases’ EM Quick Hits is about Acetaminophen (and more) this week.

Patients with a massive acetaminophen overdose (for example, > 500 mg/kg) may benefit from hemodialysis. These patients can present with altered mental status and a high anion gap metabolic lactic acidosis. Even normal dose acetaminophen can cause a rise of INR in patients on Warfarin.

EM Quick Hits 4 Acetaminophen Overdose & Warfarin Interaction, Dental Infections, MTP RABT Score, Statins for STEMI, Cricothyrotomy Tips

Question 4

Source image: https://litfl.com/

Which of the following statements is true about Ludwig’s Angina?

A: Ludwig’s angina is more common in females than in males at a 2:1 ratio

B: The diagnosis of Ludwig’s angina is typically made clinically and CT or MRI imaging is not beneficial

C: Oral intubation is not more difficult than usual in patients with Ludwig’s Angina

D: The biggest predictor for complications (like necrotizing fasciitis, carotid artery rupture, pericarditis, jugular vein thrombosis) is anterior visceral space involvement

The correct answer is D

Taming the SRU is all about Ludwig’s Angina this week. Although pretty uncommon in the ED, you HAVE to recognise this entity.

Ludwig’s angina presents in males more often than females at a 2:1 ratio. The diagnosis of Ludwig’s angina is typically made clinically, however obtaining CT or MRI scans of the neck can help determine the location and extent of the infection. Oral intubation is often difficult due to displacement of the tongue and swelling of the posterior pharynx. Anterior visceral space involvement is the biggest predictor for complications.

 

Question 5

Source image: https://emottawablog.com/

A 25 year old patient with sickle cell disease (SCD) presents with severe pain. He reports a pain score of 8, but is texting while waiting for the laboratory results. Which of the following is true about pain management in vaso-occlusive pain crisis?

A: Opioid addiction is more common in patients with SCD compared to opioid addiction in the general population

B: Always administer oxygen in patient with vaso-occlusive crisis

C: Patients with SCD often express their pain in an unusual way, leading to suspicion of drug seeking behaviour

D: Always give iv fluids in patient with vaso-occlusive crisis

The correct answer is C

The latest podcast on FOAMcast is about sickle cell disease.

Patients with Sickle Cell Disease often visit the emergency Department with pain crises or complications of the disease like infections. Patients live with pain at baseline every day and have acute pain episode as well. Therefore these patients may express their pain in an abnormal way. These patients may be in severe pain and look comfortable at the same time. Do not assume this is drug seeking behavior. You can prescribe NSAIDs, but 40 percent of patients have renal insufficiency due to renal infarction. Ketamine or a nerve block are a good options when the pain is refractory to opioids. Patients often need high doses of opioids, for many have some degree of opioid tolerance.

Routinely administering oxygen and iv fluids in vaso-occlusive crisis is no longer recommended. Acute Chest Syndrome is a whole different story though.

Emergent Issues in Sickle Cell Disease

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

Edited by Rick Thissen

Quiz 33, 2nd of May 2019

Question 1

Source: https://resusreview.com

A 78-year-old woman with a body weight of 63kg is brought into your ED with a massive pulmonary embolism (PE). She has a respiratory rate of 30/min, pulse oximetry of 86% on room air, a heart rate of 132/min and a blood pressure of 70/55. You consider alteplase because she is in shock.

What is true about low dose alteplase?

A: It is a safe treatment with a comparable efficacy as full dose alteplase, but it does not seem to lower the bleeding risk

B: It seems to have a similar efficacy and a significant lower bleeding risk than standard dose alteplase

C: It has a lower efficacy than full dose alteplase and it should not be used in clinical practice

The correct answer is B.

Although low dose alteplase seems to have a similar efficacy and a significant lower bleeding risk when compared to standard dose alteplase, it’s use is still controversial. The lower bleeding risk is especially seen in patients with a body weight <65kg. (Wang et al., Chest 2010)

Dr. Amit Shah talks about the controversy around the use of half dose alteplase in his latest podcast. He recommends to evaluate the effect of a standard dose of alteplase after 1 hour and skip the other half of alteplase if your patient is doing well.

Question 2

There is a growing body of literature supporting the use of Thiamine in patients with septic shock. According to this recently published paper, Thiamine intravenously in the first 24 hours of hospital admission:

A: Might reduce 28 day mortality, especially in female patients

B: Is only beneficial in patients that are actually thiamine deficient

C: Has no effect on lactate levels

D: Reduces 28 day mortality, especially in male patients

The correct answer is A

The bottom line discussed this paper recently. Patients who received thiamine in the first 24 hours in septic shock were retrospectively matched to patients who did not. Thiamine seems to have an effect on lactate clearance and reduces the 28 day mortality, especially in female patients. There was no difference in vasopressor use, ICU admission and ventilator free days. Thiamine levels were not measured, so it is not clear if the benefit is related to thiamine deficiency.

Keep in mind this is a retrospective observational study based on data derived from electronic medical records.

Woolum

Question 3

 

In CPR for Out of Hospital Cardiac Arrest (OHCA), the use of telephone guidance from trained dispatchers leads to:

A: Better compression depth

B: Better compression rate

C: Shorter no flow time

D: No difference

The correct answer is B

In OHCA, quality of CPR is important. Telephone guidance from dispatchers leads to an increased bystander participation. In this recently published paper in Resuscitation the authors found that compression rate is improved with the telephone guidance from dispatchers too. No difference was found in compression depth, no flow time or complete releases during CPR.

Dispatcher-Assisted Cardiopulmonary Resuscitation (DA-CPR)

Question 4

Source: https://litfl.com

Ocular ultrasound is a fast and simple technique that helps to differentiate between various ophthalmologic emergencies.

For which diagnoses in ocular trauma is ultrasound a suitable diagnostic approach?

A: Globe rupture, retrobulbar hematoma, ocular foreign bodies

B: Lens detachment, globe rupture, retrobulbar hematoma

C: Lens detachment, retrobulbar hematoma, ocular foreign bodies

D: Lens detachment, globe rupture, ocular foreign bodies

The correct answer is C.

Lee Johnson (Core EM) wrote about ocular ultrasound in his latest blog.

Lens detachment, retrobulbar hematoma and ocular foreign bodies can be detected with ultrasound with a sensitivity of >80%. The sensitivity for retinal detachment and vitreous detachment are slightly lower. Do NOT perform ocular ultrasound in cases with a known or suspected globe rupture, since even mild ocular pressure can be potentially exacerbate damage. If you are concerned about a globe rupture in your patient, obtain a CT.

Ocular Ultrasound

Question 5

Source: https://valk4.jouwweb.nl

The prehospital services rush in with a 29 year old pregnant lady (estimated 34 weeks). The was involved in a motor vehicle collision and seems to be in profound shock. As the first sweat pearls appear on your forehead you place the patient in 30 degrees left lateral tilt. A recently published paper about pregnant patients (3th trimester) looked at the ideal lilt. What did the authors find?

A: A 30° left-lateral tilt position most consistently reduced inferior vena cava compression

B: A 15° left-lateral tilt position most consistently reduced inferior vena cava compression

C: A 30° right-lateral tilt position most consistently reduced inferior vena cava compression

D: A 15° right-lateral tilt position most consistently reduced inferior vena cava compression

The correct answer is A

Clay Smith discussed this article on Journal Feed.

In quite simple but rather brilliant paper, 13 3th trimester females were tilted in 15 and 30 degrees, left and right. Inferior Vena Cava volumes where measured by MRI. 70% (9/13) had the greatest IVC volume in the 30° left tilt position, however 23% (3/13) had the greatest IVC volume in the 30° right lateral tilt position.

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