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

Dear colleague,

Our weekly FOAMed Quiz is suspended until further notice. 

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

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

Last weeks most useful FOAMed resources:

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

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

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

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

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

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

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

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

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

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

Paper 1

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

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

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

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

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

Paper 2

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

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

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

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

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

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

Paper 3

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

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

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

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

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

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

Paper 4

 

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

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

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

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

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

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

Paper 5

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

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

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

Paper 6

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

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

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

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

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

Dear colleague,

Our weekly FOAMed Quiz is postponed until further notice.

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

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

Wishing you all the courage and strength to push forward…

Paper 1

Source: First10EM

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

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

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

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

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

Chloroquine for COVID: No good evidence yet

Paper 2

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

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

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


Click image for link

Paper 3

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

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

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


Click image for link

Paper 4

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

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

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


Paper 5

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

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

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


Click image for link

Paper 6

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

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

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

Click image for link

Paper 7

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

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

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

Click image for link

Paper 8

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

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

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

Click image for link

Paper 9

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

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

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

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

Welcome to the 64th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Question 1

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

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

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

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

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

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

The correct answer is C

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

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

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

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

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

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

Question 2

Source image: https://litfl.com/

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

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

A: Toxic Epidermal necrolysis (TEN )

B: Stevens-Johnson syndrome (SJS)

C: Staphylococcal scalded skin syndrome (SSSS)

D: Acute generalised exanthematous pustulosis (AGEP)

E: Pemphigus Vulgaris ( PV)

The correct answer is C

This week critical rashes were covered on emDocs.

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

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

Question 3

Which combination of vasopressor and mechanisms of action is correct?

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

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

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

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

The correct answer is B

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

Vasopressors

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

Question 4

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

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

A: Convex STE morphology

B: Concave STE morphology

C: Notching at the J point

D: Normal R wave progression

The correct answer is A

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

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

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

Benign Early Repolarization Pattern vs. Anterior STEMI

Question 5

Source image: https://first10em.com/

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

A: Type 1 (IgE mediated) hypersensitivity

B: Type 4 (T-cell mediated) hypersensitivity

C: Tinea corporis

D: Shiitake dermatitis

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

Reviewed and edited by Rick Thissen

Quiz 62, February 14th 2020

Welcome to the 62th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Question 1

Source image: litfl.com
 

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

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

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

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

The correct answer is C

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

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

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

JC: Conservative management of pneumothoraces.

Question 2

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

A: Tillaux fractures

B: Greenstick fractures

C: Tibial Tubercle Fractures

D: Supracondylar fractures

The correct answer is C

AliEM covered tibial tubercle fractures last week.

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

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

Source image: https://musculoskeletalkey.com/

SplintER: Knee pain after the jump

Question 3

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

A: Agitation, Confusion (Altered mental status)

B: Tachycardia, Fever and Flushing (Autonomic hyperactivity)

C: Lead pipe rigidity, hyporeflexia (Neuromuscular abnormality)

The correct answer is C

em3 covered serotonin syndrome this week.

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

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

Question 4

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

Which of the following statements about acute pancreatitis is true?

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

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

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

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

The correct answer is D

Britt Long covered pancreatitis this week on EMdocs.

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

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

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

EM@3AM: Pancreatitis

Question 5

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

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

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

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

D: Workup should include two proper sets of blood cultures

The correct answer is C.

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

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

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

Workup should include three sets of blood cultures.

REBEL Core Cast 27.0 – Endocarditis

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

Reviewed and edited by Rick Thissen

Christmas edition, December 26th 2019

Welcome to the Christmas Special

Merry Christmas and a Happy New Year!

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Which eponyms are we looking for???

Question 1

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

M

The Monteggia fracture is a fracture of the proximal third of the ulna with dislocation of the proximal head of the radius. It is named after Giovanni Battista Monteggia.

EM Cases – Elbow Injuries – Ten Pitfalls in Diagnosis and Management

Question 2

Source Image: http://www.surgeryassistant.nl/

E

An Essex-Lopresti injury consists of a radial head fracture with dislocation of the distal radioulnar joint (DRUJ) and disruption of the interosseous membrane (IOM).

Essex-Lopresti fracture

Question 3

”Aspirin has been linked with this syndrome, so use caution when giving aspirin to children or teenagers for fever or pain. Though aspirin is approved for use in children older than age 3, children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin.’ (Mayoclinic)

R

Reye’s Syndrome was first describe in 1963. It may occur at any age in childhood, although higher rates in children < 2 years of age. Death occurs in ~30-40% of cases due to brainstem dysfunction. The etiology is not clearly known. An association (although not clear causality) is described between recent viral illness and aspirin therapy.

Reye’s Syndrome

Question 4

Fundoscopy revealed these ‘spots´ in a patient with suspected endocarditis:

Source image: https://litfl.com/

R

Roth spots are retinal haemorrhages with white or pale centres, commonly associated with subacute bacterial endocarditis and immune complex mediated vasculitis.”

Roth spots

Question 5

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

Y

Yankauer suction tip. Doesn’t need a lot of explanation, but I couldn’t think of anything else starting with a Y.

Sidney Yankauer

Question 6

”This disease is also known as American trypanosomiasis, is a tropical parasitic disease caused by the protist Trypanosoma cruzi. It is spread mostly by insects known as Triatominae.”’ 

C

”’ Chagas disease is an inflammatory, infectious disease caused by the parasite Trypanosoma cruzi, which is found in the feces of the triatomine (reduviid) bug. Chagas disease is common in South America, Central America and Mexico, the primary home of the triatomine bug. ”

https://www.cdc.gov/parasites/chagas/index.html

Question 7

A 9 year old male presents to your emergency department with a chief complaint of abdominal pain. 

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

H

Henoch–Schonlein Purpura (HSP) is an immune-mediated small vessel vasculitis. Compared to purpura commonly caused by thrombocytopenia, the etiology of the purpuric lesions in HSP are secondary to IgA-mediated immune complex deposition in the skin.

PEM Pointers: Henoch-Schonlein Purpura

Question 8

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

R

Rolando Fracture is a complete and comminuted intraarticular fracture, usually in a T or Y shape

SplintER Series: Case of a First Metacarpal Fracture

Question 9

This is a system of categorizing scapula fractures involving the glenoid fossa.

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

I

The Ideberg classification is a system of categorizing scapula fractures involving the glenoid fossa.

https://www.orthobullets.com/trauma/1013/scapula-fractures

Question 10

A 55 years old patient comes in with a rash after starting with ibuprofen for a backache 5 days ago. 

Source image: https://my.clevelandclinic.org/

S

Stevens-Johnson Syndrome (SJS) is a rare type IV hypersensitivity reaction with sheet-like skin loss and mucosal ulceration.

https://em3.org.uk/foamed/3/6/2019/lightning-learning-stevens-johnson-syndrome

Question 11

A 12-year old boy comes in with an ankle sprain.

Source image: https://litfl.com

T

A Tillaux Fracture is a fracture of the anterolateral tibial epiphysis commonly seen in adolescents. (Salter-Harris III tibial fracture)

Tillaux fracture

Question 12

A 60 years old patient comes in with fever and upper belly pain. You find this on POCUS and pressing the probe hurts. What is this sign called?

Source image: https://westjem.com

M

(Sonographic) Murphy’s Sign is positive when the maximal intensity of patient’s pain is when the gallbladder is in view directly beneath the probe.

https://www.nuemblog.com/biliary

Question 13

”If a patient’s hand flushes fully and rapidly after an artery is released, that artery, the palmar arch, and the digital arteries are patent. If pallor persists throughout the hand, the artery that was released is occluded. Pallor in patches indicates insufficiency of the smaller vessels.”

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

Question 14

Source image: https://litfl.com

S

A Segond Fracture is an avulsion fracture (small) of the lateral surface of the lateral tibial condyle. Usually results from excessive internal rotation and varus stress resulting in increased tension on the lateral capsular ligament of the knee joint.

Segond fracture

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

Reviewed and edited by Rick Thissen

Quiz 53, December 6th, 2019

Welcome to the 53th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://litfl.com/

Your 53-year-old female patient presents with an AV-nodal reentry tachycardia (AVNRT). She is hemodynamically stable with a pulse rate of 175/min and blood pressure of 118/90 mmHg. You want to give her adenosine.

Which of the following statements is true about the administration of adenosine?

A: Adenosine diluted with saline in a single syringe push seems to be at least non-inferior to the usual adenosine push followed by a rapid saline flush

B: Adenosine diluted with saline in a single syringe push seems to be inferior to the usual adenosine push followed by a rapid saline flush

C: Adenosine diluted with saline as a single syringe push seems to induce more adverse events in comparison to the usual adenosine push followed by a rapid saline flush

The correct answer is A

Clay Smith covered this trial about the single syringe method for the administration of adenosine on JournalFeed.

One of the challenges of giving adenosine is the very quick saline push needed after the adenosine push. A few seconds between the two administrations might make a difference for successful cardioversion. Diluted adenosine in one syringe (a sort of push and flush together) can make it a lot easier!

The results of this trial are promising: successful conversion to normal sinus rhythm (NSR) with the first dose of adenosine was higher in the single syringe group: 73.1% compared to 40.7% in the controlgroup. There were no adverse events reported in the single syringe group. Keep in mind that this was a small, unblinded pilot study.

Source image: https://journalfeed.org/

Question 2

We prescribe a lot of antiemetics in the Emergency Department (ED). After all, nausea and vomiting are pretty common complaints.

But how about the evidence? Justin Morgenstern covered this paper earlier this week on First10EM. Which of the following statements is correct regarding the efficacy of droperidol and ondansetron as an antiemetic in the ED?

A: This paper shows ondansetron is more effective than placebo in reducing nausea

B: This paper shows droperidol is more effective than placebo in reducing nausea

C: This paper shows droperidol and ondansetron are more effective than placebo in reducing nausea

D: This paper shows ondansetron, droperidol and placebo are equally effective in reducing nausea

The correct answer is D

This paper compared ondansetron, droperidol and placebo. Their primary outcome was an improvement of 8 mm of a visual analogue scale and was met in 75 (droperidol), 80 (ondansetron) and 76 percent (placebo). These differences were not statistically significant. However patients reported significantly higher rates of achieving desired effect when using droperidol (this was elicited from direct questioning—”The drug I received had the desired effect for me: Yes or No”). Furthermore, the authors enrolled 215 patients (unfortunately, this was only about half way to the calculated sample size of 378 patients). So, although this paper shows no clear benefit of droperidol and ondansetron, it is not a done deal.

Nausea and vomiting in the ED: Does nothing work?

Question 3

Source image: www.pixabay.com

Auwch, that hurts! Penile injuries are men’s worst nightmare. Examples include penile fracture, zipper injuries and penile strangulation.

Which of the following statements is true?

A: ‘’A zucchini deformity’’ is an often notable clinical sign in penile fractures

B: Urethral injuries are seen in 60-70% of penile fractures

C: The best way to separate an entrapped penis from a zipper is by using a wire cutter to cut the middle portion of the zipper that connects the two halves

D: In case of penile strangulation blood can be drained from the corpora cavernosa in a manner similar to draining a priapism to get underneath the constricting band

The correct answer is D

Jacob Stelter covered penile injuries this week on NUEM.

A penile fracture is a medical emergency in which the‘’eggplant deformity’’ refers to the clinical presentation of a fractured penis with swelling and detumescence of the penis, often with notable ecchymosis and deformity.

Penile fracture could lead to urethral injuries which occur in up to 38%. If suspected, a retrograde urethrogram or cystoscopy should be performed before a Foley catheter is inserted.

In case you see a patient with his penis trapped in a zipper, use a lubricant, this almost always works. If not, try using a wire cutter to cut the piece connecting the two halves of the zipper.

Finally, injuries resulting from penile strangulation are divided into five grades ranging from isolated penile edema in stage I all the way up to penile necrosis or amputation of the distal segment in grade 5.

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

Question 4

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

A 4 years old patient presents to your department with colicky abdominal pain. The ultrasound image looks like the one above.

Which of the following statements is true regarding this diagnosis?

A: Surgery is indicated for all pediatric patients

B: Pneumatic or hydrostatic enema is preferred modality in pediatric patients

C: The male to female ratio is 1:5

D: Currant jelly stools are very common in these patients

The correct answer is B

AliEM covered intussusception this week in their ´´Ultrasound for the Win´´ series.

The male to female ratio is 3-8:1. While pneumatic or hydrostatic enema is preferred modality in pediatric patients, surgery is indicated in adults patients. Currant jelly stools are pretty rare.

Ultrasound for the Win! 3-year-old with abdominal pain #US4TW

Question 5

Which of the following statements is true about acute torsion of the appendix epididymis?

A: Torsion of the testicular appendages is dangerous

B: Diagnosis is made via color doppler ultrasound

C: Treatment includes surgical detorsion

D: Late torsion of the appendix testis or epididymis may present with a “blue dot sign”

The correct answer is B

BrownEM covered acute torsion of the appendix epididymis this week.

Torsion of the testicular appendages is not dangerous. Diagnosis is made via color doppler ultrasound. Treatment includes NSAIDs, scrotal support, and reassurance and early torsion of the appendix testis or epididymis may present with a “blue dot sign”.

Source image: http://brownemblog.com/

 

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

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the CanadiEM special

Source image: https://canadiem.org/

Welcome to the first dedicated Quiz

The development of this website relies completely on high quality content on FOAMed Blogs and Podcasts all over the world. Website like CanadiEM make our existence possible. 

This Quiz contains 5 questions about content appearing on CanadiEM in the past 6 months. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://canadiem.org/
 

A 31 year old woman presents to the emergency department (ED) with a regular narrow-complex tachycardia at a rate of 180 bpm. Previous ECGs show a short PR-interval and delta wave.

Which of the following statements is true about Wolff Parkinson White (WPW) syndrome?

A: The most common tachydysrhythmia seen in WPW is AV-nodal reentrant tachycardia (AVNRT)

B: In atrioventricular reentrant tachycardia (AVRT) and WPW, the impulses mostly travel up through AV node and down through the accessory pathway (antidromic)

C: Classic ECG findings in WPW syndrome include: long PR-interval (>120 ms) a delta wave and QRS prolongation

D: Adenosine might cause ventricular tachydysrhythmias, even in patients with regular AVRT

The correct answer is D

Paula Sneathon covered WPW earlier this year.

WPW syndrome is a combination of the presence of a congenital accessory pathway, often called ‘’the Bundle of Kent’’, and episodes of tachyarrhythmia.

Atrioventricular Reentrant Tachycardia (AVRT) is the most common tachydysrhythmia in WPW (80%).

Orthodromic AVRT (down the AV node and up the accessory pathway) is way more common than antidromic AVRT (up the AV node and down the accessory pathway).

Classic features of WPW on the ECG include a short PR-interval, delta waves and a prolonged QRS duration.

Despite being really rare, adenosine administration once in a while causes nasty ventricular tachydysrhythmias, even in patients without underlying Atrial Fibrillation (AF). This might be caused by another accessory bundle or development of AF during AV-nodal blockade.

Sirens to Scrubs: Wolff-Parkinson-White Syndrome

Question 2

Source image: https://pixabay.com/

A 32 year old female presents to your ED with nausea and headache. She tells you she is ten weeks pregnant and is known with migraine. After considering other (more dangerous) causes of headache in pregnancy (like pre eclampsia, cerebral venous thrombosis and pituitary apoplexy) you conclude that she is experiencing an episode of migraine. You want to prescribe her analgesia and anti emetics.

Which of the following combinations is the safest option for this patient and her child?

A: Acetaminophen and haloperidol

B: Acetaminophen and ondansetron

C: Acetaminophen and metoclopramide

D: Ibuprofen and metoclopramide

The correct answer is C

Vivian Tam discussed the management of headache in pregnant patients recently.

Acetaminophen can be given safely in all pregnant patients.

Haloperidol use during pregnancy has been linked to severe limb reduction defects.

Ondansetron might cause doubling in risk of cleft palate and heart defects in newborns.

There is no evidence for an increased risk of congenital malformations with the use of metoclopramide.

NSAIDs might increase the risk of early pregnancy loss in the first trimester. There is some weak evidence for diphenhydramine causing cleft palate in the first trimester.

Managing headaches in pregnancy

Question 3

Source image: https://pixabay.com/

A 75-year-old man presents with 2 days of abdominal pain due to an acute cholecystitis. He will require a laparoscopic cholecystectomy. The patient is on dabigatran 110mg twice daily because of atrial fibrillation and took his last dose 6 hours before presentation. His glomerular filtration rate is 40 ml/min.

Which of the following is true about the anticoagulant effect of dabigatran in this patient?

A: The anticoagulant effect of dabigatran will be insignificant after 3 half-lives

B: A normal thrombin time (TT) can safely be used to rule out a clinically significant dabigatran effect

C: The half-life of dabigatran can be estimated at 12 hours in this patient

D: An anti-Xa assay is needed to estimate the current anticoagulation effect of dabigatran

The correct answer is B

Matthew Nicholson covered the determination of anticoagulant effect of DOACs earlier this year.

Since DOACs have predictable pharmacokinetics, testing for DOAC levels is in general not required if the time of last ingestion is known. However, in some cases laboratory testing can be useful, for example in patients with renal failure. The anticoagulant effect is considered to be insignificant after 4-5 half lives. The half-life of dabigatran is estimated at 12-14 hours, but will be longer in patients with renal dysfunction.

The standard thrombin time (TT) is highly sensitive for dabigatran and can be used to rule out a clinically significant dabigatran effect. If the TT is abnormal, you will need a dilute thrombin time (dTT) essay to quantify the dabigatran effect (if you would like to know).

Blood & Clots Series: How do I determine if my patient on a DOAC is still at increased risk of bleeding?

Question 4

Source image: https://pixabay.com/

Your patients presents with acute onset radicular back pain after lifting weights. There are no red flags, but acetaminophen and a non steroidal anti inflammatory drug (NSAID) do not provide adequate pain relief. Your savvy nurse suggests a single dose of intravenous corticosteroids. Which of the following statements is true regarding the evidence behind a single intravenous bolus of corticosteroid in reducing pain in patients with radicular back pain?

A: A single intravenous bolus of 8 mg dexamethasone or 500 mg methylprednisolone significantly improves VAS pain scores at 6 weeks after onset of symptoms

B: A single intravenous bolus of 8 mg dexamethasone or 500 mg methylprednisolone might improve VAS pain scores at 24 hours after onset of symptoms

C: A single intravenous bolus of 500 mg methylprednisolone for treatment of radicular back pain is clearly safe

The correct answer is B

Jessie Grewal covered single intravenous bolus of corticosteroid in reducing pain in Emergency Department patients with radicular back pain last week.

Only two small RCTs are published on this topic (one on dexamethasone 8 mg and one on methylprednisolone 500 mg). It seems that corticosteroids might have a transient beneficial effect on pain scores. However, both RCTs are ‘’too small to detect rare and dangerous adverse effects.’’

Is there a role for a single intravenous bolus dose of corticosteroid in reducing pain in Emergency Department patients with radicular back pain?

Question 5

Source image: https://canadiem.org/

Patients with fever, we see them every day in the Emergency Department. Most fevers are benign, some are not. For a symptom so common, do we know enough about it? Which of the following statements is true about fever?

A: Fevers under 42 degrees Celsius (107.6 °F) are harmless

B: Fever can cause seizures in adults without pre-existing seizure disorders

C: External cooling methods should be first line treatment to lower fever

D: Nearly every aspect of our immune system has been shown to function better in higher temperatures

The correct answer is D

Paula Sneath covered the pathogenesis of fever last August.

It seems fever below 41 degrees Celsius is harmless and fever between 41 and 42 degrees Celsius is only harmful if sustained for a longer period of time. Fever by itself does not cause seizures in adults without pre-existing seizure disorders (but it can provoke seizures in adults with pre-existing seizure disorders). External cooling methods are not recommended because of the secondary increase in metabolism and discomfort as the body tries to achieve the target temperature. And yes, it seems our immune system is more effective in higher temperatures.

Sirens to Scrubs: Fever-Phobia

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

Reviewed and edited by Rick Thissen

Quiz 52, november 29th, 2019

Welcome to the 52nd FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://first10em.com/

Drug reaction with eosinophilia and systemic symptoms, also known as DRESS syndrome, is a rare but severe condition which should be in the differential diagnosis of every sick patient presenting to the Emergency Department with a rash.

Which of the following is true about DRESS syndrome?

A: Symptoms generally occur within 72-hours after exposure to the drug

B: Carbamazepine is the drug most commonly associated with this condition

C: Diseases like Stevens-Johnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis and erythroderma are easy to discriminate from DRESS syndrome

D: As the name suggests, eosinophilia is present in at least 75% of patients with DRESS syndrome

The correct answer is B

Justin Morgenstern covered DRESS syndrome on First10EM.

Symptoms of DRESS syndrome generally appear within 2-6 weeks after starting the drug.

Carbamazepine is the drug most commonly associated with this condition and although leukocytosis is very common, eosinophilia is only present in 30% of patients.

There is no golden standard for diagnosis, it is based on a combination of diagnostic criteria. The most important takeaway from this post is to think about DRESS syndrome in patients with a rash with at least one systemic and one hematologic symptom.

DRESS syndrome – a rapid review

Question 2

You see a five year old patient with a dislocated distal radius fracture, and you want to provide analgesia. You wonder if you should give fentanyl or ketamine intranasal (IN). Recently the PRIME trial was published addressing this topic.

What did the results of this paper tell us?

A: IN fentanyl was superior to IN ketamine in providing analgesia

B: IN fentanyl was inferior to IN ketamine in providing analgesia

C: IN ketamine was non inferior to IN fentanyl in providing analgesia

D: IN ketamine leads to less adverse events compared to IN fentanyl

The correct answer is C

Simon Carley covered this paper on St. Emlyns last week.

This relatively small study ( 90 patients) is a randomized controlled trial designed to show non inferiority between IN fentanyl and IN ketamine for analgesia. The two treatments were similar in reducing pain score at 15, 30 en 60 minutes post administration. There were more adverse effect in the ketamine group, although they were minor.

JC: IN Fentanyl vs Ketamine for analgesia in PED. St Emlyn’s

Source image: pixabay.com

Question 3

Massive Transfusion Protocols (MTPs) differ between hospitals. The ratio PRBC to FFP to Platelets- ratio generally differs between 1:1:1 and 2:1:1. Which statement is true about the evidence behind this in trauma patients?

A: Evidence suggests a 2:1:1 ratio is superior to 1:1:1 ratio in reducing mortality at 30 days

B: Evidence suggests a 1:1:1 ratio is superior to 2:1:1 ratio in reducing mortality at 30 days

C: Evidence suggests a 2:1:1 ratio is superior to 1:1:1 ratio in decreasing death from exsanguination at 24 hours

D: Evidence suggests a 1:1:1 ratio is superior to 2:1:1 ratio in decreasing death from exsanguination at 24 hours

The correct answer is D

Last week this systematic review was discussed at The Trauma Professional’s Blog.

Most of the evidence comes from the PROPPR trial (2015)  which was broadly covered by lots of FOAMed blogs like RebelEM and EMNerd.

Massive Transfusion: What’s The Right Ratio?

Question 4

Source image: pixabay.com

A known cirrhotic patient comes in with hematemesis. He is hemodynamically unstable, you start with Packed Red Blood Cells (PRBCs) and prepare to intubate. Which of the following three additional treatment options has shown benefit in reducing mortality?

A: Octreotide

B: A Proton Pump Inhibitor (PPI)

C: Antibiotics (3rd generation cephalosporin)

The correct answer is C

RebelEM covered Decompensated Liver Disease last week in their latest Rebel Core Cast.

There is no proven benefit of octreotide or PPIs in these patients. However, administration of antibiotics (ceftriaxone) has shown benefit with an NNT for preventing one death of 22! Keep in mind this evidence comes from 12 trials of which only one was placebo controlled (the others were antibiotics vs no treatment).

REBEL Core Cast 22.0 – Decompensated Liver Disease

Question 5

In which type of hyponatremia is treatment with oral Urea indicated?

A: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

B: Cerebral Salt wasting

C: Primary polydipsia or malnutrition

D: Cortisol deficiency

The correct answer is A

Josh Farkas covered treatment of hyponatremia in SIADH with oral Urea this week. 

‘’Oral urea functions as an osmotic diuretic (an “aquaretic”).  Ingested urea will be completely excreted by the kidneys.  It is excreted along with water, so the ultimate effect is removal of water.’’’

PulmCrit- Controlled aquaresis: Management of hypervolemic or euvolemic hyponatremia with oral urea

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

Reviewed and edited by Rick Thissen

Quiz 51, November 21th, 2019

Welcome to the 51th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: www.nuemblog.com

Your patient presents to the Emergency Care because of worsening binocular diplopia since yesterday. She does not complain of a headache and no fever is present. On physical examination you find bilateral ataxia and areflexia without hemiparesis. No additional abnormal findings are found. Which of the following diagnosis is the likely ?

A: Myasthenia Gravis

B: Claude Syndrome

C: Botulism

D: Miller Fisher variant of Guillain Barré Syndrome

The correct answer is D

NUEM covered diplopia this week.

Myasthenia Gravis can present with isolated diplopia, but one would not expect areflexia and ataxia. Often ptosis is present as well.
Claude syndrome is caused by a midbrain infarct and typically includes unilateral oculomotor or trochlear palsy with contralateral ataxia. One would not expect worsening of symptoms over time and bilateral ataxia.
Botulism should be considered, but does not cause areflexia until a muscle group is paralyzed.
This set of symptoms (diplopia, areflexia and ataxia) is typical for Miller Fisher variant of Guillain Barré syndrome.

Click Image for link to source
Source image: pixabay.com


Question 2

You see a 27 year old G4P2 female at 25 weeks of gestation at the emergency department (ED) with right upper quadrant abdominal pain and vomiting. While abdominal pain during pregnancy is an extremely common complaint, medical emergencies should be considered.

Which of the following statements is true about medical emergencies in pregnant women:

A: Risk factors for uterine rupture include blunt abdominal trauma, grand multiparity and prior cesarean sections or myomectomies

B: Diagnostic criteria of HELLP syndrome include: proteinuria, leukocytes >12, AST and ALT ≥ 2x the upper limit of normal and platelet counts <100,000 x 10⁹/L

C: The ‘’discriminatory zone’’ describes that there is a certain ß -hCG level above which the gestational sac associated with a normal intrauterine pregnancy should reliably be visible on ultrasound. In case of transvaginal ultrasound (TVUS) this has been set at >500 mlU/ml

D: Physical examination in women with Pelvic Inflammatory Disease (PID) typically reveals lower abdominal pain and cervical motion tenderness. Treatment of PID in pregnant and non-pregnant woman is the same

The correct answer is A.

EMdocs covered pathologic obstetric abdominal pain this week and provided some useful summaries of notable signs in these conditions.

Uterine rupture most commonly occurs at the site of prior uterine surgical manipulation such as scar sites of prior cesarean sections or myomectomies. It most commonly occurs during labour but it should also be considered in blunt abdominal trauma in pregnant woman.

HELLP syndrome is a severe form of preeclampsia and is associated with hemolysis, transaminitis and thrombocytopenia. It is often associated with hypertension and proteinuria but these elements are not necessary for the diagnosis.

The ß -hCG level in the ‘’discriminatory zone’’ has traditionally been set at >1500 mlU/ml for TVUS but recently the American College of Obstetrics and Gynecology set this value conservatively high at >3500 mlU/ml. If no intrauterine gestational sac is visible on TVUS, an ectopic pregnancy should be considered.

PID is an infection of the upper genital tract (uterus, endometrium, fallopian tubes and ovaries) in women and is mostly caused by sexually-transmitted infections such as Neisseria gonorrhea and Chlamydia trachomatis. Pregnant women are treated with a second generation, cephalosporin and azithromycin, since regimens using doxycycline should be avoided during pregnancy due to adverse fetal effects.

Click Image for link to source

Question 3

You treat a patient with septic shock. After fluid resuscitation, antibiotics and the start of norepinephrine at 5 microgram per minute your patient is not improving. According to this recently published study about the non-catecholaminergic vasopressor Selepressin you should:

A: Start selepressin at 3.5 ng/kg/min in addition to norepinephrine

B: Stop norepinephrine and start selepressin at 3.5 ng/kg/min

C: Start selepressin at 1.7 ng/kg/min in addition to norepinephrine

D: Not start selepressin

The correct answer is D

RebelEM covered this recently published paper last week.

This study addresses an important question about whether adding a second vasopressor with a different action mechanism has an effect on the outcome in refractory septic shock. The authors did not find any significant difference in primary outcomes as vasopressor and ventilator free days. However, the study did show some differences in secondary outcomes (norepinephrine requirement and urine output).

SEPSIS-ACT: Selepressin in Septic Shock

Question 4

Source image: https://emergencymedicinecases.com/

Your patient presents with suspected hook of Hamate fracture. Which of the following statements is true about this condition?

A: Patients may have decreased grip strength and can endorse numbness in the 2th and 3th fingers as the deep branch of the ulnar nerve lies under the hook of the hamate

B: Hook of hamate fractures almost always require open reduction internal fixation (ORIF)

C: Hook of hamate fractures can be managed conservatively with a short arm cast

D: Excision of the fractured portion of the hamate is never indicated

The correct answer is C

AliEM covered Hook of Hamate fractures this week.

Patients may have decreased grip strength and can endorse numbness in the 4th and 5th fingers as the deep branch of the ulnar nerve lies under the hook of the hamate. ORIF is possible but has little benefit. Excision of the fractured portion of the hamate is sometimes indicated. And yes, hook of Hamate fractures can be managed conservatively with a short arm cast.

SplintER Series: Pain in the Palm

Question 5

Source image: www.pixabay.com

A number of methods are used to estimate the weight of pediatric patients. Which of the following methods was most accurate according to this recently published paper?

A: Parent estimation

B: Broselow tape

C: The Mercy Method

D: The APLS formula

The correct answer is A

JournalFeed covered this paper last week.

Parent estimation was within 10% of actual weight 89% of the time and within 20% of actual weight 97% of the time. The Broselow tape came second and the APLS formula and the Mercy Method were less accurate. Bear in mind this study was conducted in Thailand.

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

Reviewed and edited by Rick Thissen

Quiz 50, November 14th, 2019

Welcome to the th FOAMed Quiz. 

This weeks Quiz is about Cardiogenic Shock, PSA and Testicles. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Which of the following statements is correct regarding diagnosis and management of cardiogenic shock?

A: Dobutamine should almost always be first line treatment in cardiogenic shock

B: Patients in cardiogenic shock are not always hypotensive

C: Milrinone is easy titratable in the Emergency Department

D: Intra Aortic Balloon Pumps (IABPs) increase cardiac contractility

The correct answer is B

In the latest very interesting EMcrit podcast, Scott Weingard discusses cardiogenic shock with Jenelle Badulak.

Starting dobutamine without a vasopressor can cause vasodilatation and hypotension. Patients in cardiogenic shock are quite often normotensive. Milrinone is not easy to titrate, especially in patients with suspected kidney failure. And finally, AIBPs do not increase cardiac contractility directly.

EMCrit 259 – Cardiogenic Shock — The Next Level & Mechanical Circulatory Support with Jenelle Badulak

Question 2

Source image: www.nuemblog.com

NUEM covered the basics of Procedural Sedation and Analgesia (PSA) this week. Which of the following statements is true?

A: Third trimester pregnant patients do not have an increased chance of vomiting

B: Midazolam can safely be used  in pregnant patients

C: End tidal (Et) CO2 provides earlier detection of hypoventilation

D: Ketofol is clearly superior to Ketamine and Propofol alone

The correct answer is C

Yes, pregnant patients do have an increased risk of vomiting. This is one of the reasons PSA is rarely performed in the Emergency Department in pregnant patients (at least in our shop). Some benzodiazepines have been shown to be teratogenic, so midazolam should not be used. EtCO2 does provide earlier recognition of hypoventilation, although false positives occur (apnea on etCO2, but still breathing). Evidence is mixed on Ketofol. Although in theory lower doses of ketamine and propofol are necessary and chance of side effects smaller, you will have to deal with the side effects of 2 drugs instead of 1.

Click Image for link to source

Question 3

Which of the following statements is true about patellar sleeve fractures?

A: Injury to the proximal pole typically leads to avascular necrosis of the proximal portions

B: Patellar Sleeve Fractures are the most common type of patellar fractures in pediatric patients

C: Patellar sleeve fractures occur most often due to powerful contraction of the hamstrings while knee is extended

D: Patellar sleeve fractures are easily seen on conventional X-ray

The correct answer is B

Pediatric EM Morsels covered patellar sleeve fractures this week.

Blood supply to the immature patella comes from the distal pole and the anterior surface. Therefore, injury to the anterior or distal pole can lead to avascular necrosis of the proximal portions. Patellar sleeve fractures are quite often due to powerful contraction of the quadriceps while the knee is flexed. Patellar sleeve fractures are easily missed on conventional X-ray. MRI might be necessary for diagnosis. And indeed, a Patellar Sleeve Fracture is the most common type of patellar fracture in pediatric patients. Most fractures require open reduction and internal fixation.

Patellar Sleeve Fracture

Question 4

Source image: pixabay.com

An 18-year old male is seen in the emergency department with sudden onset severe pain in his right testicle. His pain increased over time and is now 9/10.

Which of the following is true about testicular torsion?

A: Testicular torsion is equally common in all age groups

B: At 4 hours after onset of symptoms, damage to the testicle is irreversible.

C: Absence of cremasteric reflex is the most sensitive and specific clinical finding in diagnosing testicular torsion

D: Isolated tenderness at the superior pole of the affected testicle is not a very specific sign for torsion

The correct answer is C

Testicular torsion was covered by CanadiEM this week.

Testicular torsion should be considered in every patient presenting with testicular pain although it is most prevalent in the pediatric population. Irreversible damage is more likely to be present if torsion consists for 8 hours or more. An absent cremasteric reflex is very sensitive and specific and can help to distinguish between testicular torsion and other conditions like epididymitis. Isolated tenderness at the superior pole of the affected testical is very specific for testicular torsion.

Testicular Torsion

Question 5

Source image: pixabay.com

In critically ill patients admitted to the hospital and receiving at least 48 hours of oxygen therapy, what would be the range of oxygen saturation associated with the lowest adjusted mortality according to this recently published paper?

A: 90-94%

B: 92-96%

C: 94-98%

D: 96-100%

The correct answer is C

JournalFeed  discussed this Singaporean paper last week.  

No big surprise in this recently published paper. Retrospective analyses were conducted of two electronic medical record databases: the eICU Collaborative Research Database (eICU-CRD) and the Medical Information Mart for Intensive Care III database (MIMIC). Nonlinear regression was used to analyze the association between median pulse oximetry-derived oxygen saturation (Spo2) and hospital mortality. The optimal range of Spo2 was 94% to 98% in both databases (total of > 35.000 patients).

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

Reviewed and edited by Rick Thissen