Rick Thissen – The FOAMed Quiz

April 7, 2023April 7, 2023

Quiz 186, April 7, 2023

Welcome to the 186th FOAMed Quiz.

Question 1

Your 65 year old patient with Myasthenia Gravis presents with Myasthenic crisis and you decide to intubate the patient using RSI.

Which of the following statements is true regarding neuromuscular blockers?

A: A higher dose of non-depolarising agents and depolarising agents is generally required in patients with MG

B: A lower dose of non-depolarising agents and depolarising agents is generally required in patients with MG

C: A higher dose of non-depolarising agents and a lower dose of depolarising agents is generally required in patients with MG

D: A lower dose of non-depolarising agents and a higher dose of depolarising agents is generally required in patients with MG

Reveal answer

The correct answer is D.

Neuromuscular blockers in Myasthenia Gravis were covered on UMEM last week.

Myasthenia Gravis patients have increased sensitivity to non-depolarizing agents and require lower doses than typically used. They have decreased expression of normal acetylcholine receptors which are required for depolarizing agents to work effectively and require higher doses than typically used.

Question 2

Warfarin should not be used together with naproxen due to the chance of increased levels of warfarin.

What is the major mechanism for this drug interaction?

A: Naproxen increases absorption of warfarin

B: Naproxen can displace warfarin from the plasma protein binding sites, leading to more unbound warfarin available

C: Naproxen interacts with cytochrome P2C9 and decreases warfarin metabolism

D: Naproxen decreases active tubular secretion of warfarin

Reveal answer

The correct answer is B

Geekymedics covered mechanisms of drug interaction last week.

Naproxen can displace warfarin from the plasma protein binding sites, leading to more unbound warfarin available, increasing its pharmacological effect (as well as toxic effects).

Drug Interactions

Question 3

Which of the following is useful advice for ultrasound guided peripheral cannula placement?

A: Look for flash in the cannula hub, as soon as you see it, advance the cannula

B: Insert the needle at an angle of about 60 degrees. The steeper you go, the more visible the needle will be on the screen

C: Don’t use a tourniquet, for it will increase the chance of bleeding

D: Aim for a vein less than 1 cm deep

Reveal answer

The correct answer is D.

DFTB covered ultrasound guided peripheral IV placement last week.

Never look for the flash of blood in the hub, look at your screen.

Insert the needle at 30-45 degrees. If you go steeper, the needle will be hard to visualize.

Always apply a tourniquet.

And indeed, aim for superficial veins. The deeper the vein, the more chance of dislocation.

5 top tips to gain confidence in ultrasound-guided peripheral IVs

Question 4

The performance of D-dimer in exclusion of pulmonary embolism in COVID positive patients remains somewhat subject of debate.

In this recently published retrospective trial, 10837 patients who received a D-dimer and COVID test in the ED were analyzed. 4311 patients turned out to have COVID. Follow up to detect pulmonary embolism was 30 days.

What did the authors find?

A: A d-dimer cutoff of 500 ng/mL was found to perform a little bit better in COVID positive patients compared to COVID negative patients

B: A d-dimer cutoff of 500 ng/mL was found to perform a little bit better in COVID negative patients compared to COVID positive patients

C: A d-dimer cutoff of 500 ng/mL was found to perform equal in both groups

Reveal answer

The correct answer is B.

The paper was covered on JournalFeed last week.

The prevalence of pulmonary embolism in the cohort was 3.7 percent.

A D-dimer cutoff value of 500 ng/mL had a sensitivity of 96.2 percent in COVID positive patients, compared to 98.5 percent in COVID negative patients. The NPV was 99.6 percent in COVID positive patients and 99.9 percent in COVID negative patients.

The sensitivity of age adjusted D-dimer cutoff (age times 10 with a lower limit of 500 ng/mL) had a sensitivity of 93.9 percent in COVID positive patients, compared to 97.1 percent in COVID negative patients.

The authors conclude that while the sensitivity of D-dimer with a cutoff of 500 ng/mL for pulmonary embolism was a little lower in COVID positive patients, it is still a useful marker.

Keep in mind the authors did not include any probability scores (like YEARS) in this paper, which would have been interesting. Furthermore, quite some d-dimer levels were not drawn because of suspected embolism, but purely for routine use in COVID patients.

Journal Feed Weekly Wrap-Up

Question 5

The X-ray shown above belongs to your 46-year-old patient in the Emergency Department. It is a female with a history of diabetes mellitus and obesity. She fell onto her right knee and has difficulty with walking right now.

Which of the following diagnoses is most likely?

A: Quadriceps tendon rupture

B: Displaced tibial plateau fracture with posterior cruciate ligament injury

C: Patellar tendon rupture

D: Contusion of the knee

Reveal answer

The correct answer is C.

This case was covered on SplintER Series this week.

Patellar tendon ruptures are most frequently seen in men under 40 years old. This is opposed to quadriceps tendon ruptures, which are typically seen in older patients. Risk factors of a patellar tendon rupture are; diabetes mellitus, chronic renal failure and gout.
The elevated patella is a sign of a patellar tendon rupture.

SplintER Series: Patellar Tendon Rupture

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

March 24, 2023March 24, 2023

Quiz 184, March 24, 2023

Welcome to the 184th FOAMed Quiz.

Question 1

Thyroid storm has a mortality rate of 100% if untreated and if treated it is 30-40%. It is a clinical syndrome that is important to be recognised.

Which of the following drugs should be given first in the management of thyroid storm?

A: Iodine

B: Dexamethasone

C: Propranolol

D: Propylthiouracil (PTU)

Reveal answer

The correct answer is D.

Thyroid storm was covered at EMOttawa this week.

Thyroid storm is ultimately a clinical diagnosis based on the triad of symptoms pyrexia, altered mental status and tachycardia. Keep in mind this triad of symptoms is non-specific for thyroid storm.

The first drug to administer is PTU. Iodine should be delayed at least one hour after the administration of PTU, for iodine could stimulate thyroid hormone synthesis.

Question 2

Which of the following trauma patients should receive Rhesus D immunoglobulines?

A: A 30 weeks pregnant patient who is rhesus D positive with profound hemorrhagic shock after a motor vehicle accident

B: A 30 weeks pregnant patient who is rhesus D positive with a traumatic head injury after a seizure

C: A 30 weeks pregnant patient who is rhesus D negative with a complicated tibia and fibula fracture after twisting the ankle on the sidewalk

D: A 30 weeks pregnant patient who is rhesus D negative and who was punched in the abdomen and has a negative Kleihauer-Betke-test

E: None of the above

Reveal answer

The correct answer is D.

SinaiEM covered trauma in pragnancy last week.

All pregnant Rh-negative trauma patients should receive Rh immunoglobulin therapy unless the injury is remote from the uterus.

A negative Kleihauer-Betke-test does not exclude minor degrees of fetomaternal hemorrhage that are capable of immunizing the mother.

Trauma in Pregnancy

Question 3

Your 34 year old patient was bitten by a snake that escaped the terrarium at his friend’s home. He didn’t bring the snake, but shows you a picture.

Which of the following snakes is venomous?

Reveal answer

The correct answer is B.

PedEM morsels covered snake bites last week.

A is a nonvenomous milk snake. To be distinguished from B, which is a venomous coral snake. The following rhyme is sometimes used to remember them: “Red on yellow, kill a fellow. Red on black, venom lack.”

C is a green tree python (a constrictor, also nonvenomous) and D is a rat snake, which might have a little bit of venom but poses no threat to humans.

Snake Bites and Children

Question 4

Your 23 year old patient with Sickle Cell Disease presents with fatigue, shortness of breath and profound anemia. You suspect aplastic crisis. Which of the following viruses does most likely cause aplastic crisis in Sickle Cell Disease:

A: CMV

B: EBV

C: Parvovirus

D: Herpes zoster

Reveal answer

The correct answer is C.

SinaiEM covered complications of Sickle Cell Disease this week.

Aplastic crisis is commonly due to Parvovirus B19, so the patient may report a viral prodrome.

Sickle Cell Disease Emergencies

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

March 17, 2023March 17, 2023

Quiz 183, March 17

Welcome to the 183th FOAMed Quiz.

Question 1

Not a lot is known about the effectiveness of addition of corticosteroid to an NSAID in renal colic.

In this paper from August 2022, 120 patients with renal colic were randomized to receive just ketorolac or ketorolac + dexamethasone (60 patients in either group).

The primary outcome was pain intensity based on the visual analog scale (VAS), which was assessed at baseline and after 30 and 60 min of treatment.

What did the authors find?

A: Patients in the ketorolac and dexamethasone group had significantly lower pain score at 30 and 60 minutes

B: Patients in the ketorolac and dexamethasone group had significantly lower pain score at 30 minutes, but not at 60 minutes

C: Patients in the ketorolac and dexamethasone group had significantly lower pain score at 60 minutes, but not at 30 minutes

D: Patients in the ketorolac and dexamethasone group did not have significantly lower pain score at 30 and 60 minutes

Reveal answer

The correct answer is B.

The paper was mentioned on EMOttawa last week.

There were no differences in baseline pain scores between the groups. Differences in VAS scores were significantly lower in the intervention group after 30 min of drug administration (VAS 3,5 vs VAS 5. P = 0.009). There was no difference at 60 minutes. Furthermore, decreased opioid requirements and decreased an antiemetic need were noted in the intervention group.

Question 2

!hich of the following statements is true about the management of patient with acetaminophen overdose?

A: A normal ALT and AST, 8 hours after ingestion of acetaminophen practically rules out severe intoxication

B: The Rumack-Matthew nomogram can be used in single dose and chronic acetaminophen intoxication

C: An mildly elevated INR within 24 hours of acetaminophen ingestion does not reflect severe liver toxicity

D: The typical threshold for toxicity is ingestion of 400 mg/kg acetaminophen for the acute one time dose

Reveal answer

The correct answer is C.

Acetaminophen intoxication was covered on EM cases last week.

Liver enzymes are usually normal in the first 12 hours after an overdose.

The Rumack-Matthew nomogram should be used in single dose intoxications only.

While elevated INR on day 3 or later is a reliable sign of severe liver toxicity, mild elevations of INR on day 1 do not reflect severe liver toxicity.

The typical threshold for toxicity is 200 mg/kg acetaminophen for the acute one time dose

Ep 180 Acetaminophen Poisoning – Pitfalls in Assessment and Management

Question 3

The gradient between the arterial CO2 pressure (PaCO2) and the end tidal CO2 (ETCO2) is approximately 0.5 kPa (3.8 mmHg) under normal physiological conditions.

Which of the following can produce an elevated PaCO2 – ETCO2 gradient?

A: Pulmonary embolism

B: Hyperthermia

C: Hypothermia

D: Hyperventilation

Reveal answer

The correct answer is A

The PaCO2 – ETCO2 gradient was covered on DFTB last week.

Normally, the PaCO2 – ETCO2 gradient is fairly stable and under 0.5 kPa. However, if something happens to ventilation (COPD) of perfusion (PE, shock, pulmonary hypertension) this will cause an V/Q imbalance and will cause the PaCO2 – ETCO2 gradient to rise.

The PaCO2-ETCO2 Gradient

Question 4

Traumatic injury of the spinal cord can result in shock. At or above which level of injury is the patient at risk for neurogenic shock?

At or above C5

At or above T4

At or above T6

At or above T8

Reveal answer

The correct answer is C.

Neurogenic shock was covered by emDOCs this week.

Trauma is the most common cause of neurogenic shock. It occurs in 19.3% of cervical spine injuries and 7% of thoracic spine injuries. When the injury occurs at or above T6, the patient is at risk due the disruption of sympathetic innervation to the heart and peripheral vessels.

Neurogenic Shock: Definition, Identification, and Management in the ED

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

January 19, 2023January 20, 2023

Quiz 176, January 20, 2023

Welcome to the 176th FOAMed Quiz.

Not a lot of FOAMed content this week, so we’re going to do it a little bit different.

Name the eponyms of the following fractures and te nationality of the namegiver for extra points 🙂

Question 1

Reveal answer

An osseous Bankart lesion is commonly seen in patients with an anterior shoulder dislocation.

Arthur Sidney Blundell Bankart (1879- 1951) was a British Orthopaedic surgeon.

Question 2

Reveal answer

A Segond fracture is considered pathognomonic for ACL disruption

Paul Ferdinand Segond (1851-1912) was a French surgeon.

Question 3

Reveal answer

A Bennett fracture is an intra-articular two-part fracture of the base of the first metacarpal with carpometacarpal joint involvement.

Edward Hallaran Bennett (1837-1907) was an Irish Surgeon.

Question 4

Reveal answer

A Smith fracture is an extra-articular fracture of the distal radius with volar angulation.

Robert William Smith (1807 – 1873) was an Irish surgeon and pathologist.

Question 5

Reveal answer

A Tillaux fracture is a fracture of the anterolateral tibial epiphysis. It commonly seen in adolescents.

I could be a triplane fracture as well, but there is no surgeon called triplane as far as I know.

Paul Jules Tillaux (1834-1904) was a French surgeon.

Question 6

Reveal answer

A Chance fracture is a transverse fracture through a vertebral body and neural arch.

George Quentin Chance was an Irish radiologist

Question 7

Reveal answer

A Jefferson fracture is a burst fracture of the atlas (C1).

Geoffrey Jefferson (1886 – 1961) was a British neurosurgeon.

Question 8

Reveal answer

A Jones fracture is a fracture of the proximal diaphysis of the 5th metatarsal, distal to the tuberosity.

Sir Robert Jones (1857-1933) was a Welsh general and orthopaedic surgeon.

Question 9

Reveal answer

A Lisfranc injury is a tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal.

Jacques Lisfranc de Saint-Martin (1787 – 1847) was a French surgeon.

Question 10

Reveal answer

The Malgaigne fracture is an unstable fracture of the pelvis. The Malgaigne fracture usually results from a vertical shear force causing two ipsilateral pelvic ring fractures.

Joseph François Malgaigne (1806 – 1865) was a French surgeon.

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

October 28, 2022October 28, 2022

Quiz 165, October 28, 2022

Welcome to the 165th FOAMed Quiz.

Question 1

Your patient presents with a triad of ophthalmoplegia, ataxia, and areflexia.

Which variant of Guillain-Barré syndrome fits best?

A: Acute inflammatory demyelinating polyneuropathy (AIDP)

B: Acute motor axonal neuropathy (AMAN)

C: Acute motor sensory axonal neuropathy (AMSAN)

D: Miller-Fisher syndrome

Reveal answer

The correct answer is D.

Geeky Medics covered Guillain-Barré syndrome last week.

Miller-Fisher syndrome is typically associated with a triad of ophthalmoplegia, ataxia, and areflexia

Guillain-Barré Syndrome

Question 2

Winter is coming.

This retrospective, observational paper published earlier this year is about prostaglandin (iloprost) in frostbite. 90 patients with grade 2-4 frostbite injuries were included. 26 were treated with 5-day intravenous prostaglandin, compared to 64 patients who received usual care.

The primary outcome was the rate of affected digits amputated.

What did the authors find?

A: Significantly lower digital amputation rates were observed for patients with severe (grade 3 and 4) frostbite injuries treated with iloprost versus usual care

B: Significantly lower digital amputation rates were observed for patients with severe (grade 3 and 4) frostbite injuries treated with usual care versus iloprost

C: There was no difference between the groups

Reveal answer

The correct answer is A

CanadiEM covered the paper last week.

Significantly lower digital amputation rates were observed in patients with more severe frostbite injuries treated with iloprost versus usual care: Grade 3 (18% vs 44%, p < 0.001), Grade 4 (46% vs 95%, p < 0.001).

CJEM Visual Abstract: IV Prostaglandin to Reduce Digital Amputations in Frostbite

Question 3

Which of the following structures is most likely damaged in a patient with this X-ray?

A: Anterior Cruciate Ligament (ACL)

B: Posterior Cruciate Ligament (PCL)

C: Medial collateral ligament (MCL)

D: Lateral collateral ligament (LCL)

Reveal answer

The correct answer is A

EM cases covered frequently missed diagnoses last week.

The depression on the lateral femoral condyle is called a deep sulcus terminalis sign or simply lateral femoral notch sign. It suggests an ACL tear.

Ep 175 Emergency Orthopedics Differential: SCARED OF Mnemonic – When X-rays Lie

Question 4

Your patient presents with a small complex tachycardia of 160 bpm. He is hemodynamically stable. 6 mg Adenosine converted the rhythm to sinus for about 10 seconds, but it relapsed into an AVNRT.

Which of the following treatment options is not a reasonable next step?

A: Adenosine 12 mg

B: A Beta Blocker

C: A Calcium Antagonist

Reveal answer

The correct answer is A

A case just like this one has been covered on dr. Smith’s ECG blog last week.

Adenosine converted the rhythm, but this only lasted for some seconds. A higher dose will most likely do just the same. You need something that converts the rhythm and acts longer. Both an intravenous calcium antagonist or intravenous beta blocker will likely do the job.

Question 5

We are all taught that you should not give nitroglycerin in acute right ventricular infarction (RVMI) due to risk of compromised right ventricular ejection fraction.

This recently published meta-analysis included 5 papers (1113 patients). The outcome consists of all forms of adverse events reported in literature.

What did the authors find?

A: No, there is no statistically significant difference in the rate of adverse events when nitrates are administered to RVMI compared with other cardiac regions. However, the adverse events were major.

B: No, there is no statistically significant difference in the rate of adverse events when nitrates are administered to RVMI compared with other cardiac regions. Furthermore, the adverse events were only minor.

C: Yes, there is a statistically significant difference in the rate of adverse events when nitrates are administered to RVMI compared with other cardiac regions and the adverse events were major.

D: Yes, there is a statistically significant difference in the rate of adverse events when nitrates are administered to RVMI compared with other cardiac regions but the adverse events were only minor.

Reveal answer

The correct answer is B.

EMCrit covered the meta-analysis last week.

This meta-analysis did find a non-statistically significant difference in adverse event rates
from nitrates based on the cardiac region of the infarction. These adverse events were noted to be minor and transient.

EMCrit Wee – Is there Evidence of Harm for Nitroglycerin in Right Ventricular MI? #Dogmalysis

This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

July 15, 2022July 15, 2022

Quiz 162, July 15, 2022

Welcome to the 162th FOAMed Quiz.

Question 1

The recently published SALSA trial was about the risk of overcorrection of symptomatic hyponatremia using hypertonic saline (3%) bolus versus slow continuous infusion. 178 patients with moderately severe to severe symptomatic hyponatremia were randomised to receive either a rapid intermittent bolus (RIB, 2 cc per kilogram, repeated if necessary) versus slow continuous infusion (SCI, 0,5 to 1 cc per kilogram per hour, adjusted if necessary).

Overcorrection was defined as an increase in serum sodium of 12 mmol/L in 24 hours or 18 mmol/L in 48 hours.

What did the authors find?

A: Overcorrection occurred significantly more in the RIB group compared to the SCI group

B: Overcorrection occurred significantly more in the SCI group compared to the RIB group

C: There was no significant difference in occurrence of overcorrection between the RIB group and SCI group

Reveal answer

The correct answer is C.

emDOCs covered the SALSA trial last week.

In this randomized clinical trial, overcorrection occurred in 17.2% of patients in the RIB group and 24.2% in the SCI group (absolute risk difference, -6.9% [95% CI, -18.8% to 4.9%]; P = .26). Both RIB and SCI therapy strategies for treating symptomatic hyponatremia seem effective and safe.

The groups did not differ in terms of efficacy in increasing serum sodium concentrations nor improving symptoms. However, RIB, when compared with SCI, showed better efficacy in achieving target correction rate within 1 hour (intention-to-treat analysis: 32.2% vs 17.6% P = .02). Because of this RIB seems to be preferable in treating hyponatremia in the emergency department

52 in 52 – #2: The SALSA Trial

Question 2

Source image: emergencymedicinecases.com

We are most likely overdiagnosing pulmonary embolism and harming our patient with unnecessary anticoagulation. Whether to treat isolated subsegmental pulmonary embolism or not remains controversial.

In this recently published observational trial, 292 patients with isolated subsegmental pulmonary embolism who did not receive anticoagulation were included. Patients with active cancer or history of venous thromboembolism (VTE) were excluded.

The primary outcome was recurrent venous thromboembolism during the 90 day follow-up period.

What did the authors find?

A: The risk of recurrent VTE was 0%

B: The risk of recurrent VTE was 1%

C: The risk of recurrent VTE was 3%

Reveal answer

The correct answer is C.

The paper was covered on first10EM last week.

In this cohort, the risk of recurrent VTE was 3%. There were a total of 8 patients with recurrent VTE. 4 were proximal PE’s and 4 were proximal DVT’s. This number seems a bit high to deny patients from anticoagulation.

What to do about subsegmental pulmonary embolism?

Question 3

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

The ECG above shows de Winter’s T- waves. There are hyperacute T waves with depressed ST takeoff or ST depression in leads V2-V4.

What are de Winter’s T-waves indicative of?

A: Occlusion on the RCA

B: Occlusion of the LAD

C: Occlusion of the Cx

D: Pericarditis

Reveal answer

The correct answer is B.

This ECG was covered on dr. Smiths ECG blog last week.

The de Winter pattern is seen in about 2% of acute LAD occlusions and is often under recognized.

Question 4

The PEricapsular Nerve Group block (PENG-block) is used as an alternative (and likely more effective block) to nerve blocks like the femoral nerve block and the Fascia Iliaca Compartment Block in patients with proximal femur pathology.

In performing the PENG block, in what location should the local anesthetic be injected?

A: Deep to the psoas tendon

B: Just superficial to the anterior inferior iliac spine

C: Just superficial to the iliopubic eminence

D: Superficial to the iliopsoas muscle

Reveal answer

The correct answer is A.

EM Pills covered the PENG block last week.

The local anesthetic should be injected in the iliopsoas recess deep to the psoas tendon.

PENG Block

Question 5

Which of the following statements about B-lines in ultrasonography is true?

A: B-lines are only seen in pulmonary ultrasound

B: B-lines in pulmonary ultrasound are typically seen in case of pneumothorax

C: B-lines are caused by adjacent fluid filled and air filled structures

D: B-lines typically fade with increasing depth

Reveal answer

The correct answer is C.

Ultrasound artifacts are covered by Jacob Avila on Core ultrasound last week.

B-lines are often seen in pulmonary ultrasound, but can be present around the body as long as reverberation artifacts can be caused by adjacent fluid filled and air filled structures. These artifacts are not seen in pneumothorax and they typically don’t fade with increasing depth.

Ultrasound Artifacts, Part 2

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

July 1, 2022July 1, 2022

Quiz 160, July 1, 2022

Welcome to the 160th FOAMed Quiz.

Question 1

The electrocardiogram shown above belongs to a 7 year old boy who suddenly collapsed during exercise. It is an example of a Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT).

Which of the following statements about CPVT is NOT true?

A: Children between the ages of 7 – 9 years are mostly affected by CPVT, but it also occurs in children under 2 years old. It is uncommon in children older than12 years

B: CPVT is induced by physical or emotional stress

C: If CPVT is not timely diagnosed and treated, it has a mortality rate of up to 35%

D: CPTV occurs in an anatomically and structurally normal heart

E: Patients with CPVT typically have a normal baseline ECG

Reveal answer

The correct answer is A

Critical Care Now covered CPVT last week.

Children between the ages of 7 and 9 years are most commonly affected, but it also occurs in children up to 12 years old. It is rare in children less than 2 years old.

Obtaining a family history in these patients is extremely important because thirty percent of patients have family history positive for exercise-induced syncope, seizure or sudden death.

Many patients are initially misdiagnosed as having vasovagal syncope or epilepsy. The most common presentation is syncope during exercise.

Patients with CPVT typically have an anatomically and structurally normal heart and a normal baseline ECG.

Catecholaminergic Polymorphic Ventricular Tachycardia: Recognize And Treat It Early

Question 2

Your patient presents with a swan neck deformity of his right index finger.

Rupture of which of the following structures typically causes a swan neck deformity?

A: Terminal extensor tendon

B: Central band of the extensor tendon

C: Flexor digitorum profundus (FDP)

D: Flexor digitorum superficialis (FDS)

Reveal answer

The correct answer is D

AliEM covered finger injuries last week.

A swan neck deformity is caused by rupture of the FDS.

Rupture of the FPD causes inability to flex in the distal interphalangeal joint.

Central band rupture causes Boutonniere’s deformity.

Rupture of the terminal extensor tendon causes a mallet finger.

SplintER Series: Stop! Hammer Time

Question 3

Which of the following mushrooms would you choose to eat (assuming you are not suicidal)?

Reveal answer

The correct answer is B.

Morel mushrooms and their imposters were covered on Taming the SRU last week.

A morel mushroom (B) exhibits a spongy, porous labyrinth of deeply-ridged craters and pits. It is completely hollow on the inside.

Its imposter, Gyromitra (A), appears rufous, mahogany, or crimson – colored and are not hollow on the inside. It contains gyromitrin, which is hydrolyzed into monomethylhydrazine (MMH), which reacts with pyridoxal phosphate. A lack of pyridoxal phosphate (active form of vitamin B6) results in cessation of production of GABA and as you can image, this causes seizures and overall badness.

Number C is called Autumn Skullcap (cute name) and contains amatoxins, causing gastrointestinal and hepatotoxic problems, coma, and death.

Question 4

Source image: ecg-interpretation.blogspot.com

An eldery male patient presents to the ED with new-onset chest pain since a couple of hours. The patient had a long history of smoking, but no prior history of heart disease. His ECG is shown above.

Which of the following coronary arteries was most likely to be occluded?

A. Right coronary artery (RCA)

B. Left Main (LCA)

C. Left anterior descending artery (LAD)

D. Left circumflex artery (LCX)

Reveal answer

Correct answer is C

This ECG and case was covered by Ken Grauer on ECG interpretations last week.

The ECG shows a huge ongoing STEMI. There are ST elevations in 9 out of 12 leads, most dominant in leads V2-V6. This suggests either acute proximal LAD occlusion or Left main occlusion (LCA). Unfortunately, in this case the patient died before cardiac catheterization could be performed. The culprit lesion is most likely to be found in the proximal LAD, since the patient survived another 1-2 hours after presentation which is not very common in a complete Left Main obstruction.

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

May 27, 2022May 27, 2022

Quiz 156, May 27, 2022

Welcome to the 156th FOAMed Quiz.

Question 1

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

Reveal answer

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

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

Reveal answer

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?

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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

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

May 13, 2022May 13, 2022

Quiz 154, May 13

Welcome to the 154th FOAMed Quiz.

Question 1

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

Reveal answer

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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

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

Reveal answer

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

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

April 29, 2022April 29, 2022

Quiz 152, April 29th, 2022

Welcome to the 152th FOAMed Quiz.

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

Reveal answer

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.

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

Reveal answer

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

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

Reveal answer

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.

Question 4

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

A: NSAID

B: Corticosteroids

C: Colchicine

Reveal answer

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

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

Reveal answer

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.

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