Quiz 156, May 27, 2022

Welcome to the 156th FOAMed Quiz.

 

Question 1

Source image: pixabay.com

Your 3 year old patient comes in with a cough. There is no respiratory distress. Her mom is pretty sure she aspirated a peanut.

Which of the following statements about aspiration of a peanut is true?

A: In case of mild symptoms, there is no need to retrieve the peanut. It will dissolve by itself

B: In case of mild symptoms, the peanut should be retrieved within 48 hours

C: Even in case of mild symptoms, the peanut should be retrieved as soon as possible

The correct answer is C.

Don’t forget the Bubbles covered foreign object aspiration last week.

Peanuts should be retrieved as soon as possible. ‘’ lipophilic objects (like peanuts) can cause massive cytokine release and inflammation due to their fat content.’’

The hidden dangers of inhaled plastic toys

Question 2

Source image: http://brownemblog.com/

Diagnosing pyogenic flexor tenosynovitis can be challenging when the clinical picture is not obvious. The diagnostic value of laboratory testing is uncertain and plain X-ray and CT are not helpful. MRI can aid in diagnosing tenosynovitis but is not always available. In comes ultrasound…

In this 2018 paper 57 patients with suspected pyogenic flexor tenosynovitis (but not obvious, those were excluded) underwent ultrasound in addition to clinical examination (fluid within the tendon sheath). The gold standard was inter-operative findings or (whenever the patient did not get surgical intervention) the clinical course when treated with antibiotics only.

What did the authors find?

A: Ultrasound had both a high sensitivity and a high specificity

B: Ultrasound had a high sensitivity, but a low specificity

C: Ultrasound had a low sensitivity, but a high specificity

D: Ultrasound had both a low sensitivity and a low specificity

The correct answer is B.

AlieEM covered pyogenic flexor tenosynovitis last week.

In the 2018 paper, of 57 patients, 29 patients had a negative ultrasound and were treated with antibiotics only with good outcome. There was only 1 patient that turned out to have flexor tenosynovitis after all. Of the 27 patients that had a positive ultrasound, 10 patients did not have flexor tenosynovitis intra-operatively.

The sensitivity was 94% and the specificity only 65%.

SplintER Series: Point Tender

Question 3

Your 55 year old patient comes in with hypovolemic shock due to esophageal varices bleeding. You intubate and ask for a minnesota tube.

Which of the following is a Minnesota tube?

A
C
B

The correct answer is C (tough one)

This very helpful EMRap video was shared on UMEM last week.

A is a Linton tube and B is a Blakemore tube. The Missesota tube is the one with the many ports. It has a port for both balloons and for suction of gastric content as well as for esophageal content. For an explanation of the differences, watch the video.

Question 4

Source image: pixabay.com

Which of the following clinical signs fit the picture of heparin induced thrombocytopenia?

A: A fall in platelet of 20 percent

B: The platelet fall starts 1 days after start of heparin

C: New venous thrombosis

D: The patient 1 one day post surgery

The correct answer is C.

Critical Care Now covered heparin induced thrombocytopenia (HIT) last week.

A platelet fall of > 50 percent, platelet fall within 5-10 days of starting heparin, new thrombosis and no other cause of thrombocytopenia eg. no surgery) are typical for HIT.

4Ts versus 3Ls: heparin induced thrombocytopenia probability scoring

Question 5

Source image: pixabay.com

There are two generations of anticoagulant rodenticides: first generation include warfarin. Second generation rodenticides are also called superwarfarins and very long acting and potent.

Which of the following statements is true about management of superwarfarin intoxication in the emergency department?

A: Asymptomatic patients with a normal INR 12 hours post ingestion can be safely discharged and don’t need follow-up

B: Charcoal may be useful if administered in the first 1-2 hours after ingestion

C: Vitamin K should definitely be administered at presentation in the emergency department

D: If INR is normal at 48-72h after ingestion, toxicity still can’t be ruled out

The correct answer is B.

Anticoagulant rodenticide intoxication was covered on EMDocs last week.

Charcoal may be useful if administered to prevent absorption in the first 1-2 hours after ingestion.

Administration of vitamin K prior to detecting an elevated INR is debatable, as vitamin K1 may delay INR elevation and underestimate severity of exposure.

If INR is normal at 48-72 hrs, clinical toxicity can be safely ruled out with very rare exceptions.

emDOCs.net – Emergency Medicine EducationToxCard: Superwarfarins – emDOCs.net – Emergency Medicine Education

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

Reviewed and edited by Rick Thissen

Quiz 154, May 13

Welcome to the 154th FOAMed Quiz.

 

Question 1

Source image: first10EM.com

What is the maximum dose of lidocaine without adrenaline for peripheral nerve blocks?

A: 2 mg/kg

B: 3 mg/kg

C: 4.5 mg/kg

D: 6.5 mg/kg

The correct answer is C.

BrownEM Local Anesthetic Systemic Toxicity (LAST) last week.

The maximum dose of lidocaine is 4.5 mg/kg.

LAST the most feared complication of ‘’amide’’ local anesthetics like lidocaine. To minimize the risk of LAST, the smallest effective dose of local anesthetic should be used.

Question 2

Source image: dontforgetthebubbles.com/toddler-fracture/

On this X-ray, a spiral fracture of the tibia can be found.

How is his fracture often called?

A: Toddler’s fracture

B: Neonate fracture

C: Infant fracture

D: Preschool fracture

The correct answer is A.

Pediatric EM Morsels covered tibial shaft fractures last week.

Tibial shaft fractures are the 3rd most common long bone injuries in children.

A toddler fracture is a minimally or undisplaced spiral fracture of the tibia, typically encountered in toddlers. It is the result of low impact trauma and these fractures can be really hard to detect on an X-ray.

Tibial Shaft Fractures in Children

Question 3

Source image: pixabay.com

Your patient presents with progressive weakness and difficulty breathing. He has myasthenia gravis and you suspect a myasthenic crisis with so far an unknown cause.

Which of the following statements is true about the treatment of myasthenic crisis?

A: In rapid sequence intubation, succinylcholine should be used instead of nondepolarizing agents

B: Patients with difficulty breathing should be in supine position as long as possible

C: Plasma exchange is the first-line agent for severe exacerbations

The correct answer is is C.

SinaiEM covered myasthenic crisis last week.

The effect of succinylcholine is unreliable due to reduced acetylcholine receptor density in patients with myasthenia gravis.

Patients with myasthenic crisis have weak diaphragm and will have a higher forced vital capacity when sitting upright, compared to lying down.

Plasma exchange is the first-line agent for severe exacerbation, as it causes improvement in a few days. Intravenous Immunoglobulin (IVIG) needs a couple of weeks to be effective.

Myasthenic Crisis

Question 4

Source image: pixabay.com

Your 2 year old patient presents with a painful elbow after her father lifted her by her arms. You suspect a radial head subluxation (nursemaid’s elbow).

Which of the following reduction techniques is considered to be the most effective?

A: Hyperpronation

B: Supination and flexion

C: Traction

The correct answer is A.

EM Pills blog (in Italian) covered the nursemaid’s elbow last week.

Hyperpronation is considered to have greater effectiveness compared to the supination-flexion maneuver. Furthermore, this maneuver would seem to be less painful for the child.

IL GOMITO DELLA BAMBINAIA

Question 5

 

Source image: semanticscholar.org

Point of care ultrasound (POCUS) can be helpful whenever the diagnosis of a radial head subluxation is not clear. Which of the following POCUS signs are found in a nursemaid’s elbow?

A: Twinkle sign

B: Hook sign

C: Donut Sign

The correct answer is B.

The twinkle sign (or twinkling artifact) consists of rapid alternation of color immediately behind an echogenic object, causing false appearance of movement.

The donut sign is seen in intussusception.

The hook sign is caused by ‘’pulling’’ the annular ligament between the radial head and the capitellum. It is seen in longitudinal view

IL GOMITO DELLA BAMBINAIA

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

Reviewed and edited by Rick Thissen

Quiz 152, April 29th, 2022

Welcome to the 152th FOAMed Quiz.

 

Source image: theultrasoundsite.co.uk

Question 1

Your 75 year old patient presents with arthritis of his knee. Which of the following sonographic signs is typically found in gout?

A: Banana sign

B: Whirlpool sign

C: Falling snow sign

D: Double contour sign

The correct answer is D.

The role of ultrasonography in the diagnosis of gout was discussed on BrownEM last week.

The double contour sign is a hyperechoic irregular or linear enhancement parallel to the subchondral bone. However, this can also be present in calcium pyrophosphate deposition disease (pseudogout).

The banana sign is seen in Chiari II malformation in the fetus.

The whirlpool sign is seen in midgut volvulus (or ovarian or testicular torsion).

The falling snow sign is seen in spermatocele.

Source image: www.healthline.com

Question 2

Which of the following drugs generally does not cause a positive standard opioid urine drug screen test?

A: Oxycodone

B: Heroin

C: Morphine

D: Codeine

The correct answer is A.

Opioid drug screening was covered on AliEM last week.

Heroin and codeine are metabolized to morphine and generally cause a positive drug screen test. (semi) Synthetic opioids like oxycodone might not cross react and frequently do not cause a positive test. However, oxycodone can be tested in another essay.

Interpretation and Limitations of Opiate Urine Drug Tests

Source image: avssuk.co.uk

Question 3

In which of the following injuries can the saline load test be useful?

A: Pneumothorax

B: Liver injury

C: Shoulder dislocation

D: Traumatic arthrotomy

The correct answer is D.

Traumatic arthrotomy was covered on NUEM last week.

The saline load test is done by performing an arthrocentesis of the affected joint away from laceration. Once confirmed in the correct space, sterile saline is injected into the joint and the laceration site is observed for extravasation.

Source image: emottawablog.com

Question 4

Which of the following treatment options is NOT considered first line in pericarditis?

A: NSAID

B: Corticosteroids

C: Colchicine

The correct answer is B.

Pericarditis and myocarditis were covered on EMOttawa last week.

NSAIDs (ibuprofen or acetylsalicylic acid) and colchicine are first line treatment options for acute pericarditis. Corticosteroids are not.

Pericarditis and Myocarditis in the ED

Source image: anatomytool.org

Question 5

Aortic dissection is a life threatening condition that is often hard to diagnose. POCUS has been reported to have low sensitivity, but it can make this diagnosis more likely whenever abnormalities are found.

Choose between the following options to form a correct statement about the aortic root on POCUS.

The aortic root is best measured in the (A) ….. at the level of (B)….. at the end of (C)….. and should not be larger than (D)…. in diameter.

A: Parasternal long axis view / Parasternal short axis view

B: Aortic annulus / sinus of valsalva

C: Systole / Diastole

D: 3.5cm / 4.5cm

The correct answer is:
The aortic root is best measured in the parasternal long axis view at the level of the sinus of valsalva at the end of the diastole and should not be larger than 4.5 cm in diameter.

This week Taming the SRU discussed aortic dissection.

POCUS can be useful for rapid assessment of aortic dissection complications: aortic root dilatation, aortic regurgitation, pericardial effusion and hemothorax. Remember that the negative predictive value is (very) low.

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

Reviewed and edited by Rick Thissen

Quiz 149, March 18, 2022

Welcome to the 149th FOAMed Quiz.

 

Question 1

Source image: thesgem.com

Chest tubes for a small traumatic pneumothorax has been subject of discussion the last couple of years.

In this recently published paper, a single center implemented a guideline in which traumatic pneumothoraces of ≤35 mm in stable patients were treated conservatively. The outcomes were observation failure (patient needing a chest tube after all), length of hospital stay, complications and mortality.

A pre-guideline implementation (n=99) group was compared to a post-guideline implementation group (n=167).

After implementation of the guideline, there was a decrease in number of patients receiving chest tubes from 28.3% to 18% (p=0.04).

What else did the authors find?

A: Observation failure was higher after conservative guideline implementation

B: Observation failure was higher before conservative guideline implementation

C: No significant differences were found in observation failure

The correct answer is C.

The paper was covered on JournalFeed last week.

There was a significant increase in observation rates, while tube thoracostomies decreased. No statistically significant changes in observation failure rates, hospital or ICU length-of stay, complications, or mortality were found.

Question 2

Source image: rcemlearning.co.uk

Your 64 year old presents to the Emergency Department with acute dyspnea and chest pain. After questioning and examining the patient you suspect him to have acute heart failure (AHF).

Which statement about diagnosis of AHF is true?

A: Obese patients typically demonstrate higher BNP and NT-proBNP

B: Chest x-ray is very sensitive for the diagnosis of AHF

C: Point of care ultrasound is a reliable tool for assessing pulmonary edema in AHF

The correct answer is C

This week EMDocs covered the misconceptions and pearls about Acute Heart Failure

Natriuretic peptides include BNP and NT-proBNP which are cardiac neurohormones produced in cardiac muscle when there is myocyte stretch.

Due to less myocardial stress, obese patients may demonstrate lower BNP and NT-proBNP.

Chest X-ray has a pretty low sensitivity for AHF.

POCUS has a high sensitivity for pulmonary edema.

emDOCs Podcast – Episode 49: Acute Heart Failure Evaluation Misconceptions

Question 3

Source image: litfl.com

An ECG is essential to differentiate between acute myocardial infarction (MI) and pericarditis.

Which of the following features is more indicative for pericarditis than for MI?

Two answers are correct.

A: ST elevation II > ST elevation III

B: ST elevation III > ST elevation II

C: ST elevation > 5mm

D: Convex shaped ST elevations

E: Spodick’s sign

The correct answers are A and E.

This week Emergency Medicine Cases covered pericarditis.

In pericarditis there is widespread/diffuse PR depression and/or ST elevation. The ST elevations are more commonly concave shaped than convex.

ST elevation is rarely > 5mm in pericarditis.

Furthermore, ST elevation II > ST elevation III favors pericarditis and ST elevation III > ST elevation II is highly indicative for inferior STEMI.

Spodick’s sign is seen in approximately 80% of patients with acute pericarditis and in only 5% of STEMIs. It is characterized by down-sloping from the T wave to the QRS segments with the terminal PR segment depressed.

Ep 166 Pericarditis and Cardiac Tamponade

Question 4

Source image: dailymail.co.uk

High dose hydroxocobalamin administration (in case of cyanide intoxication) leads to a typical discoloration of urine.

What color is it?

A: Blue

B: Red

C: Green

D: Brown

The correct answer is B, red.

LITFL covered cyanide intoxication last week.

Hydroxocobalamin leads to a harmless and transient reddish colour to the skin and urine. The urine can have this colour for about a month after administration.

Raspberry urine?

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

Reviewed and edited by Rick Thissen

Quiz 147, March 4, 2022

Welcome to the 147th FOAMed Quiz.

 

Question 1

Source image: www.genome.gov/

Pain control in patients with sickle cell disease (SCD) and vaso-occlusive crisis (VOC) is often challenging. High doses of opioids are often needed to achieve acceptable analgesia.

In this paper 278 adults with acute sickle VOC were randomized to receive a single dose of either ketamine or morphine, infused over 30 min.

The primary outcome was the mean difference in the numerical pain rating scale (NPRS) score over 2 hours.

What did the authors find?

A: Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2-h period and reduced the cumulative morphine dose in the ED compared to morphine alone

B: Early use of ketamine in adults with VOC did not result in a meaningful reduction in pain scores over a 2-h period and did not reduce the cumulative morphine dose in the ED compared to morphine alone

C: Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2-h period and did not reduce the cumulative morphine dose in the ED compared to morphine alone

The correct answer is A.

The paper was covered on BrownEM last week.

Early use of ketamine in adults with VOC resulted in a meaningful reduction in pain scores over a 2-h period and reduced the cumulative morphine dose in the ED with no significant drug-related side effects in the ketamine-treated group.

 

Question 2

Source image: www.nextgenerationvillage.com/

Your patient comes in with altered mental status, bradypnoeic and with miosis after ingesting quite a large amount of pills he uses ´for his stomach’.

Which of the following drugs is most likely the cause.

A: Metoclopramide

B: Ondansetron

C: Loperamide

The correct answer is C.

PEMCincinnati covered loperamide intoxication last week.

Loperamide is an over-the-counter μ-opioid receptor agonist which can be abused to get an opioid high. The required dosages are quite significant.

Metoclopramide can cause lethargy, bradypnoea and extrapyramidal symptoms, but no miosis.

Ondansetron can cause serotonin syndrome.

Loperamide abuse and misuse

Question 3

Source image: litfl.com/

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in the Emergency Department. Rate control is one of the treatment goals in permanent AF.

This recently published meta analysis is about IV Diltiazem versus IV Metoprolol for rate control in patients with AF and rapid ventricular rate (RVR).

Seventeen studies involving 1214 patients in nine RCTs were included.

What did the authors find?

A: Intravenous diltiazem has higher efficacy but an increase in adverse events compared to intravenous metoprolol

B: Intravenous diltiazem has higher efficacy and with no increase in adverse events compared to intravenous metoprolol

C: Intravenous diltiazem has lower efficacy and an increase in adverse events compared to intravenous metoprolol

The correct answer is B.

The paper was covered in JournalFeed last week.

Intravenous diltiazem was found to have higher efficacy, shorter onset time and no increase in adverse events compared to intravenous metoprolol.

Question 4

Source image: www.mdedge.com/

The effectiveness of andexanet alfa (AA) for reversal of oral factor Xa inhibitors (FXi) therapy remains uncertain.

In this retrospective cohort study, 44 adult patients with life-threatening traumatic or spontaneous intracranial bleeds in the setting of apixaban or rivaroxaban use were analysed. 28 of these patients received AA and 16 patients received 4F-PCC.

The primary outcome was ´stable´ head CT (no large increase in hematoma size) at 6 and 24 hours post-administration of AA or 4F-PCC.

What did the authors find?

A: Patients receiving AA had significantly more stable neuroimaging assessment at 24 hours compared to patients receiving 4F-PCC

B: Patients receiving 4F-PCC had significantly more stable neuroimaging assessment at 24 hours compared to patients receiving AA

C: There was no significant difference in the proportion of patients with stable neuroimaging at 24 hours assessment between the two groups

The correct answer is C.

This retrospective observational paper was covered on Rebel EM last week.

There was no statistically significant difference rate of stable neuroimaging at 24 hours between the two groups.

Keep in mind this paper has several methodological issues. The sample size is very small and the primary outcome is not patient centered. Furthermore there is major concern for selection bias and unbalanced baseline characteristics.

Andexanet Alfa Vs. Four-Factor PCC: Is Andexanet Alfa Worth The Hype?

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

Reviewed and edited by Rick Thissen

Quiz 140, January 7th, 2022

Welcome to the 140th FOAMed Quiz.

 

Question 1

The MR CLEAN-NO IV trial was published last november. It is another trial about the benefit of treatment with alteplase in patients who qualify for endovascular therapy.

539 adult ischemic stroke patients with an NIHSS of ≥2 that were eligible for endovascular treatment (EVT) and IV alteplase, within 4.5 hours after symptom onset, were included. They were randomised to usual care (alteplase plus EVT) or EVT alone. The primary outcome was functional outcome (modified Rankin scale at 90 days). The outcome was analyzed for superiority and then for noninferiority.

What did the authors find (two correct answers)?

A: EVT alone was superior to alteplase followed by EVT

B: EVT alone was not superior to alteplase followed by EVT

C: EVT alone was non-inferior to alteplase followed by EVT

D: EVT alone was not non-inferior to alteplase followed by EVT

The correct answers are B and D.

RebelEM covered the MR CLEAN-NO IV trial last week.

Patients in the EVT-alone group had a median mRS of 3. Patients in the Alteplase + EVT group had a median mRS of 2.

EVT alone was both not superior and non-inferior compared to EVT plus alteplase.

MR CLEAN-NO IV: Endovascular Treatment for Stroke Compared to Alteplase Followed by Endovascular Treatment: No Difference, But Also Not Not Worse

Question 2

Source image: healio.com

You see a 6-year-old boy in your emergency department who complains of a funny feeling in his chest. This started during his soccer training an hour ago. On 12-lead ECG, you see a narrow-complex tachycardia of 205bpm. His BP is 110/70 mmHg. He appears comfortable and is neither tachypneic nor diaphoretic. He has no history of structural heart disease.

Of the following options, which is the most appropriate?

A: You carefully examine the 12-lead ECG for signs that indicate the presence of a bypass tract as this is a contra-indication for giving adenosine

B: You give adenosine (with pads for electrical cardioversion standby) 0.1 mg/kg whether you have reasons to think about a bypass tract or not

C: You treat him with electrical cardioversion (0.5-2J/kg) because adenosine is contra-indicated in children under 8

D: You search for an underlying etiology as sepsis or a toxidrome, as a narrow-complex tachycardia in children is nearly always a secondary phenomenon and responds poorly to cardioversion (high recurrence rate) if the primary condition remains untreated

The correct answer is B.

EMDocs’ pediatric small talk was about narrow complex tachyarrhythmia this week.

Nearly all children under 1 and most children under 8 have a bypass tract which can cause AVRT. Presence of a bypass tract is not a contra-indication to use adenosine if resuscitative equipment is readily available (low risk of conversion into ventricular fibrillation). Electrical cardioversion with 0.5-2J/kg is indicated when the patient is unstable. When cardioversion (chemical or electrical) fails due to immediate recurrence of the SVT, search for an underlying etiology.

Pediatric Small Talk – The Rhythm Is Gonna Get Ya’: Age Based Approach to Pediatric Narrow Complex Tachydysrhythmia

Question 3

Source image: tamingthesru.com

What type of fracture is shown in this image?

A: Le Fort 1

B: Le Fort 2

C: Le Fort 3

D: Le Fort 4

The correct answer is B.

Taming the SRU covered facial trauma last week.

‘’Le Fort I fractures are transverse fractures that separate the maxilla from the pterygoid plate and nasal septum.

Le Fort II fractures are pyramidal fractures that extend into the orbital floor and inferior orbital rim separating the central maxilla and hard palate from the rest of the face.

Le Fort III fractures, also known as craniofacial disjunction, cause mobility of the entire face.’’

Question 4

Source image: www.mdpi.com

You suspect a high intracranial pressure in your patient. He is too unstable for CT-scanning right now and you perform ocular ultrasound.

To assess for elevated intracranial pressure, the optic nerve sheath diameter (ONSD) should be measured at a fixed distance from the rim of the globe.

How many millimeters behind the rim should the ONSD be measured?

A: 0 mm (at the rim)

B: 1 mm

C: 3 mm

D: 7 mm

 

The correct answer is C.

BrownEM covered ocular ultrasound this week.

The ONSD can be measured 3 mm behind the rim of the globe and its diameter should measure approximately 5 mm or less in healthy adults (although this cutoff is arbitrary).

 

Question 5

Source image: radiopaedia.org

You’ve ordered an AP chest x-ray for a 5 year old patient who you suspect of pneumonia. His parents are worried about radiation.

Everyone is exposed to a normal amount of background radiation during their life. For example the activity in Australia is 1.5mSv per year.

How many days of background radiation is equivalent to one AP chest x-ray for this patient living in Australia?

A: 3

B: 15

C: 89

D: 294

The correct answer is A.

This week Don’t Forget The Bubbles discussed ionizing imaging in children.

It is difficult to provide parents with clear information, because of the wide variety of contributing factors to the risk of ionizing radiation imaging. For chest x-rays the lifetime risk of radiation-induced cancers is considered to range from negligible to low.

However for CT scans in pediatric patients studies have shown a statistically significantly increased risk for malignant and non-malignant brain tumors.

Best to keep in mind: Is this test really needed and will it change the patient’s diagnosis or management?

How safe are CT scans in children?

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

Reviewed and edited by Rick Thissen

Quiz 136, december 3th, 2021

Welcome to the 136th FOAMed Quiz.

 

Question 1

Source image: emedz.net

The addition of vasopressin and methylprednisolone to standard care in cardiac arrest has shown promising in this 2009 and this 2013 papers.

Last month, the VAM-IHCA trial was published. 501 patients with in hospital cardiac arrest (IHCA) were randomised after the first dose of adrenaline to either standard care and standard care plus vasopressin and methylprednisolone (VAM: a combination of vasopressin 20IU and methylprednisolone 40mg or placebo). Additional doses of vasopressin (20 IU) or placebo were administered after each additional dose of epinephrine for a maximum of 4 doses.

The primary outcome was return of spontaneous circulation (ROSC).

What did the authors find?

A: Patients in the VAM group had more ROSC and higher favorable neurological outcome at 30 days

B: Patients in the VAM group had more ROSC but equal neurological outcome at 30 days

C: Patients in the VAM group had less ROSC but higher favorable neurological outcome at 30 days

D: Patients in the VAM group had less ROSC and lower favorable neurological outcome at 30 days

The correct answer is B.

RebelEM covered the trial last week.

Patients in the VAM group had more ROSC (42% vs. 32%), but lower survival at 30 days (8,7% vs. 12%) and equal neurological outcome at 30 days (Cerebral Performance Category scale (CPC) of 1 or 2).

REBEL Cast Ep104: VAM-IHCA – Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest

Question 2

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

What electrolyte abnormality results in a very flat and long QT segment with an otherwise normal T-wave?

A: Hyperkalemia

B: Hypokalemia

C: Hypocalcemia

D: Hypercalcemia

E: Hypernatremia

F: Hyponatremia

The correct answer is C.

Hypocalcemia was covered on dr. Smith’s ECG blog this week.

Hypocalcemia causes a long QT without evident abnormalities in T-wave morphology.

Question 3

Source image: pixabay.com

Your 18 month old patient presents after a simple febrile seizure. What do you tell her terrified parents?

A: Febrile seizures are very common. About half of children will have a febrile seizure.

B: The risk of recurrence is not higher than the risk of a first febrile seizure

C: Evidence suggests antipyretic medication prevents febrile seizures

D: Unfortunately, children with a febrile seizure are at increased risk for epilepsy compared to the general population, but the absolute risk is still small

The correct answer is D.

Simple febrile seizures were covered on EMdocs this week.

Children with a febrile seizure are at increased risk for epilepsy compared to the general population.

Febrile seizures affect 2-5% of children in the United States.

Children have an approximately 30% risk of recurrence.

Prophylactic antipyretics do not prevent the occurrence of febrile seizures during illness.

Pediatric Small Talk – The FAQ Approach to Simple Febrile Seizures

Question 4

Source image: www.medicinenet.com

In nephritic syndrome, inflammation of the glomerular basement membranes leads to passage of both red blood cells and protein into urine. Hematuria is specific to nephritis.

In nephrotic syndrome, damage to the glomerulus leads to increased passage of large molecules such as albumin into urine.

Which of the following disorders causes nephrotic syndrome?

A: Focal Segmental glomerulosclerosis

B: Hemolytic Uremic Syndrome

C: Henoch-Schonlein purpura

D: Post-streptococcal glomerulonephritis

The correct answer is A.

Taming the SRU covered nephrotic and nephritic syndromes last week.

Focal Segmental glomerulosclerosis leads to nephrotic syndrome.

Hemolytic Uremic Syndrome, Henoch-Schonlein purpura and Post-streptococcal glomerulonephritis lead to nephritic syndrome.

Question 5

C-spine tenderness is part of the NEXUS criteria and warrants imaging in trauma patients. This finding however, has very low specificity.

In this recently published study, 478 non-trauma patients were enrolled. Two examiners individually examined for midline c-spine tenderness on palpation.

What percentage of these patients had midline c-spine tenderness on palpation according to both examiners?

A: 16.4%

B: 37.8%

C: 59.8%

D: 74.1%

The correct answer is C.

This week JournalFeed discussed this article about the prevalence of midline cervical spine tenderness in non-trauma patients.

59.8% had midline c-spine tenderness on palpation according to both examiners. Most of them were female (70.6%).

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

Reviewed and edited by Rick Thissen

Quiz 130, September 24th, 2021

Welcome to the 130th FOAMed Quiz.

 

Question 1

Source image: wolverem.com

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

A: Positive Seidel test

B: Proptosis

C: Marcus-Gunn pupil

D: Decreased visual acuity

The correct answer is A.

Orbital compartment syndrome was covered on AliEM this week.

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

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

A positive Seidel test is seen in case of globe rupture

SAEM Clinical Image Series: Traumatic Swollen Eye

Question 2

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

Sourrce image: litfl.com

Which of the following waves are visible on his ECG?

A: Delta wave

B: Osborn wave

C: Epsilon wave

The correct answer is C.

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

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

Question 3

Source image: www.proceduresconsult.jp

Your patient comes in with a plantar sole laceration.

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

A: Femoral nerve block

B: Ischiadic nerve block

C: Posterior tibial nerve block

D: Saphenous nerve block

The correct answer is C.

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

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

Nerve Block Talks Episode 3!

Question 4

Source image: www.acc.org

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

A: RWMA is a relatively late finding in OMI

B: Besides OMI, myocarditis can cause RWMA as well

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

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

The correct answer is B.

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

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

Focal myocarditis causes RWMA.

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

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

Can Ultrasound Diagnose Myocardial Infarction?

Question 5

Source image: caperadiology.co.za


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

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

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

A: CTCA leads to more accurate identification of CAD

B: CTCA leads to less coronary angiography

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

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

The correct answer is A.

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

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

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

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

Reviewed and edited by Rick Thissen

Quiz 128, September 3th, 2021

Welcome to the 128th FOAMed Quiz.

 

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

Question 1

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

A: Flecainide

B: Procainamide

C: Lidocaine

D: Propranolol

The correct answer is D.

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

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

Source image: www.pixabay,com

Question 2

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

What do you think the authors found?

Children who received oral ondansetron:

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

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

C: Had reduced episodes of vomiting

D: Had reduced frequency of intravenous fluid resuscitation

The correct answer is A.

The paper was covered on JournalFeed last week.

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

Source image: www.emra.org

Question 3

What distinguishes phlegmasia cerulea dolens from uncomplicated deep venous thrombosis?

A: The presence of arterial occlusion

B: The presence of total or near total venous occlusion

C: The presence of compartment syndrome

D: The presence of bacterial infection

The correct answer is B

Phlegmasia cerulea dolens was covered on AliEM last week.

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

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

SAEM Clinical Image Series: Pulseless and Painful Blue Leg

Source image: www.pixabay.com

 Question 4

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

80 patients were randomized equally to the 2 study arms.

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

What did the authors find?

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

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

C: There was no difference between the two groups

The correct answer is A.

The paper was covered on RebelEM last week.

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

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

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

Rapid Agitation Control With Ketamine in the Emergency Department

Source image: www.aliem.com

Question 5

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

A: Frog view

B: Judet view

C: Pelvic inlet / outlet view

The correct answer is B

AliEM covered imaging in pelvic trauma last week.

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

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

EMRad: Radiologic Approach to the Traumatic Hip/Pelvis

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

Reviewed and edited by Rick Thissen

Quiz 123, July 30th, 2021

Welcome to the 123th FOAMed Quiz.

 

Question 1

Source image: www.acc.org

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

What statement about myocarditis is true?

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

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

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

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

The correct answer is D.

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

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

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

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

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

Question 2

Source image: emergencymedicinecases.com

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

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

A: This is most likely pericarditis

B: This is most likely inferior OMI

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

The correct answer is B.

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

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

Question 3

Source image: www.chromagar.com/

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

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

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

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

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

The correct answer is C.

Josh Farkas covered beta lactam allergies on EMCrit last week.

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

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

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

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

Question 4

Source image: www.aliem.com

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

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

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

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

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

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

The correct answer is B.

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

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

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

Rapid Infusers: How Fast Can They Go?

Question 5

Source image: www.theguardian.com

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

Which of the following is NOT typical for ischemic priapism?

A: Severe pain

B: Often caused by trauma

C: Often medication induced or related to sickle cell disease

D: Acidotic penile blood gas

The correct answer is B

This week EmDocs covered Priapism last week.

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

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

EM Cases: Priapism and Urinary Retention: Nuances in Management

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

Reviewed and edited by Rick Thissen