Quiz 34, 10th of May 2019

Question 1

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

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

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

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

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

D: All of the above

The correct answer is D

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

 

Question 2

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

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

A: Phenylephrine may cause reflex bradycardia

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

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

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

The correct answer is A

emDOCS published about push dose vasopressors this week.

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

Push-Dose Vasopressors: An Update for 2019

Question 3

Source image: https://pixabay.com

Which of the following statements about Acetaminophen is true?

A: Dialysis is never indicated in Acetaminophen overdose

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

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

The correct answer is B

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

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

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

Question 4

Source image: https://litfl.com/

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

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

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

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

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

The correct answer is D

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

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

 

Question 5

Source image: https://emottawablog.com/

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

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

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

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

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

The correct answer is C

The latest podcast on FOAMcast is about sickle cell disease.

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

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

Emergent Issues in Sickle Cell Disease

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

Edited by Rick Thissen

Quiz 33, 2nd of May 2019

Question 1

Source: https://resusreview.com

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

What is true about low dose alteplase?

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

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

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

The correct answer is B.

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

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

Question 2

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

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

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

C: Has no effect on lactate levels

D: Reduces 28 day mortality, especially in male patients

The correct answer is A

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

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

Woolum

Question 3

 

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

A: Better compression depth

B: Better compression rate

C: Shorter no flow time

D: No difference

The correct answer is B

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

Dispatcher-Assisted Cardiopulmonary Resuscitation (DA-CPR)

Question 4

Source: https://litfl.com

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

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

A: Globe rupture, retrobulbar hematoma, ocular foreign bodies

B: Lens detachment, globe rupture, retrobulbar hematoma

C: Lens detachment, retrobulbar hematoma, ocular foreign bodies

D: Lens detachment, globe rupture, ocular foreign bodies

The correct answer is C.

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

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

Ocular Ultrasound

Question 5

Source: https://valk4.jouwweb.nl

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

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

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

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

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

The correct answer is A

Clay Smith discussed this article on Journal Feed.

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

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