Quiz 119, June 18th, 2021

Welcome to the 119th FOAMed Quiz.

 

Question 1

A 25-year-old male has fallen from his bike on his left side. He complains of left-sided chest pain and dyspnea. On physical examination, you hear decreased breath sounds on the left side. X-ray shows rib fractures of ribs 6-8 and a pneumothorax. You insert a chest tube.

Chest tube placement is frequently performed in the ED. Usually the course is not remarkable, but occasionally these tubes cause problems.

Which of the following actions to chest tube complications is correct?

A: Your chest tube is placed intrafissural. You don’t have to reposition the tube as long as it is draining blood and air

B: You suspect a clot is obstructing your tube. You can try to extract the clot by squeezing the tube with your entire hand (milking)

C: Your patient develops miosis, ptosis, anhidrosis and enophthalmos. This is a neurosurgical emergency

D: 500 cc’s of blood is evacuated immediately after placement. It continues to produce 80cc/hour. This patient should undergo emergency thoracotomy as you suspect a laceration of an intercostal artery

The correct answer is A.

County EM covered complications of chest tube placement.

In suspected obstructing clot, milking a chest tube can be dangerous due to high negative intrathoracic pressure. You can irrigate the tube with saline or insert an embolectomy catheter through the tube to resolve the obstructing clot.

Horner’s syndrome (miosis, ptosis, anhidrosis and enophthalmos) after tube placement is caused by direct pressure of the tube or hematoma. The first action is to pull the chest tube back 2-3 cm, and confirm placement. Most patients will fully recover.

Iatrogenic hematothorax is not an uncommon complication. According to ATLS, emergent surgical intervention should be performed if the evacuated volume exceeds 1500 cc or if the ongoing blood loss is greater than 150 cc per hour.

Source image: www.pixabay.com

Question 2

It is a congenital abnormality of the small intestine that is present in 2% of the population. 2% of these people will become symptomatic. It is 2 inches long. There can be 2 types of ectopic tissue in it: gastric and pancreatic. There is a 2:1 male preponderance.

Which of the following congenital intestinal abnormalities fits this description?

A: Duodenal atresia

B: Intestinal malrotation

C: Duodenal web

D: Meckel’s diverticulum

The correct answer is D.

Don’t forget the Bubbles covered Meckel’s diverticulum last week.

The rule of 2s is about the features of Meckel diverticulum (although the ranges are quite wide):

It usually becomes symptomatic (if at all) before the age of 2
It occur in 2% of the population
Meckel’s diverticulum is about 2 inches (5 cm) long
You can find a Meckel’s diverticulum 2 feet (60 cm) from the ileocecal valve
2 types of ectopic tissue are commonly present (gastric and pancreatic)
2% become symptomatic

Source image: www.epmonthly.com

Question 3

Urine drug screens are occasionally used in the ED in patients with unexplained changes in mental status. The interpretation of these tests is challenging, because of frequent false positive and false negative results.

Which of the following statements is true about urine drug screens?

A: Bupropion can cause a false positive result for amphetamines

B: Sertraline can cause a false positive result for benzodiazepines

C: Synthetic opioids (fentanyl, methadone, tramadol) are typically missed on the standard urine drug screen and require a specific immunoassay

D: All of the above are true

The correct answer is D.

This week’s emDocs toxcard is about urine drug screens.

The big take-home-message of this toxcard is to interpret urine drug screens with great caution. Be aware of the many false positive results and also of the high percentage of false negative screens.

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 35793

Question 4

Recently, this systematic review about the value of POCUS for patients with acute dyspnea was published. Two RCT’s and a prospective cohort study reported on use of POCUS and the rate of correct diagnosis and correct treatment within 4 hours.

What did the authors find?

A: Adding POCUS to standard care did not improve the rate of correct diagnosis and did not improve the rate of the correct treatment within 4 hours

B: Adding POCUS to standard care did not improve the rate of correct diagnosis, but led to an improvement in the rate of the correct treatment within 4 hours

C: Adding POCUS to standard care did improve the rate of correct diagnosis and the rate of the correct treatment within 4 hours

The correct answer is C

This week Graham van Schaik covered POCUS for acute dyspnea on JournalFeed.

In case of diagnostic uncertainty POCUS should be used for patients in acute dyspnea in addition to the standard diagnostic pathway in the ED or inpatient settings.

According to this paper, adding POCUS improved the rate of correct diagnosis at the 4 hours mark (88% vs 64%) and, even more important, the rate of appropriate treatment (78% vs 57%).

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 4425

Question 5

A 39 year old female patient presents to your ED with thunderclap headache and vomiting. She has had these headaches five times before over the past two weeks. These episodes lasted about 1-3 hours but now she does not seem to recover. The headache started directly after sneezing. You suspect a Subarachnoid Hemorrhage (SAH) or Reversible Cerebral Vasoconstriction Syndrome (RCVS).

Which of the following statements is true about RCVS?

A: RCVS has a mortality rate of about 40 percent

B: About a third of patients recover spontaneously

C: RVCS can lead to subarachnoid hemorrhage

D: CT without contrast is the gold standard diagnostic test for RVCS

The correct answer is C

This week Josh Farkas covers the Reversible Cerebral Vasoconstriction Syndrome.

RCVS causes severe headaches due to diffuse, multifocal vasospasm of intracranial arteries.

About 90% of patients will improve spontaneously, so conservative therapy is appropriate for nearly all patients.

Small convexity subarachnoid hemorrhages occur in about a third of patients.

Invasive angiography is the gold standard diagnostic test however it is safer and easier to obtain an CTA or MRA, because of the risk of provoking ischemia (9%).

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

Reviewed and edited by Rick Thissen

Quiz 118, June 11th, 2021

Welcome to the 111th FOAMed Quiz.

 

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


Question 1

Your 63 year old patient is in profound shock. His capillary refill is 4 seconds, his heart rate is 120 / minute, blood pressure 86/40 mmHg and his hands and feet are cold. He states he took a handful of his antiarrhythmic drugs to end his life. His ECG is shown above.

Which of the following antiarrhythmics is most likely the cause?

A: Flecainide

B: Metoprolol

C: Verapamil

D: Digoxine

The correct answer is A.

EMDocs covered flecainide poisoning this week.

The ECG shows prolonged QRS interval and a large terminal R wave in aVR. These findings are suggestive of sodium channel blockade.

Class I antiarrhythmics rely on sodium channel blockade. Flecainide is the only class I antiarrhythmic in this list.

Question 2

Your 65 year old patient presents with right hemiparesis. His medical history reveals an increased risk of cardiovascular disease and hypertension. He uses acetylsalicylic acid and metoprolol. He shows no abnormal findings in A and B, but he has mild hypertension (170/90).

His CT-scan reveals the following:

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

Which of the following statements about the management of this patient is true?

A: Platelet transfusion is required because the patient uses antiplatelet therapy

B: Lowering the systolic blood pressure to below 140 mmHg is safe

C: The blood pressure should not be lowered

D: Seizure prophylaxis is recommended in this patient

The correct answer is B

County EM covered Spontaneous Intracranial Hemorrhage (SIH) this week.

To this date there is no evidence to support the use of seizure prophylaxis in patients with Spontaneous Intracranial Hemorrhage.

The PATCH trial showed that patients with ICH who are on antiplatelet agents have worse neurological outcomes at 3 months if they are treated with a platelet transfusion compared to standard care alone.

INTERACT2 and ATACH II trial showed at least no harm of lowering systolic blood pressure in patients with SIH to < 140 mmHg. Whether lowering the blood pressure to < 140 mmHg is beneficial to < 180 mmHg remains uncertain to this point.

Question 3

Which of the following odontoid fractures is considered the least stable?

A:

Source image: https://radiologykey.com/spine-12/

B:

Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 20305

C:

Case courtesy of Dr Alexandra Stanislavsky, Radiopaedia.org, rID: 12233

The correct answer is B.

AliEM covered odontoid fractures last week.

Answer A shows a type I odontoid fracture. This fracture is considered stable.

Answer B shows a type II odontoid fracture. This fracture is the most likely to require surgery. It has a high nonunion rate due to interruption of blood supply.

Answer C shows a type III odontoid fracture. It is a mechanically unstable injury, but has good prognosis for healing.

SplintER Series: The Tooth of the Cervical Spine

Source image: www.pixabay.com

Question 4

Your patient presents to the ED with tachycardia, hypertension, tachypnea and dystonia. He recovered completely during observation in the ED. His symptoms occurred for the fifth time this week and lasted about 30 minutes. He is admitted because of the suspicion of Paroxysmal Sympathetic Hyperactivity (PSH).

Which of the following pathologies is NOT a cause of Paroxysmal Sympathetic Hyperactivity?

A: Lithium intoxication

B: Traumatic Brain injury

C: Stroke

D: Cerebral Fat Embolism Syndrome

The correct answer is A

EMCrit covered Paroxysmal sympathetic Hyperactivity on their The Internet Book of Critical Care.

Paroxysmal Sympathetic Hyperactivity (PSH) causes recurrent episodes of dysregulated sympathetic activity, resulting from severe brain injury.

PSH typically occurs in the first two weeks after severe and diffuse brain injury. It usually resolves within a year.

Symptoms include tachycardia, hypertension, tachypnea, fever, diaphoresis and dystonia. They can last up to 30 minutes with a near complete resolution.

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 8161

Question 5

Your 29 year old female patient presents to the ED with left sided abdominal pain, syncope and hypotension. She tells you she missed a couple of menses and all of a sudden she started vaginal bleeding this afternoon. You suspect ectopic pregnancy.

Which of the following statements is true about ectopic pregnancy?

A: Low serum B-HCG rules out an ectopic pregnancy

B: The absence of visible pregnancy on ultrasound rules out an ectopic pregnancy

C: Risk factors such as prior tubal surgery, ectopic pregnancy or previous PID are present in almost every patient with ectopic pregnancy

D: The triad, consisting of abdominal pain, missed menses and vaginal bleeding is not seen in a quarter of the patients

The correct answer is D

This week’s EMDocs covered Ectopic Pregnancy.

No hCG level or series of hCG levels can rule out ectopic pregnancy completely.

If no pregnancy is visible on ultrasound, an ectopic pregnancy can still be present. It may just be too early to visualize it.

Half of patients with ectopic pregnancy have no risk factors such as prior tubal surgery, ectopic pregnancy, previous PID, assisted fertility and smoking.

Abdominal pain (80-90%), missed menses 4-12 weeks after last menstrual period (75-90%) and vaginal bleeding (50-80%) is the classic triad and seen in 75% of the patients.

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

Reviewed and edited by Rick Thissen

Quiz 117, June 4th, 2021

Welcome to the 117th FOAMed Quiz.

 

Source image: www.emdocs.net

Question 1

A 48-year-old patient is brought in by the EMS after a motor vehicle collision. He complains of pain in his lower back. His vital signs are SpO2 97% on room air, RR 24/min, HR 124bpm, BP 97/72 mmHg and T 36.4 °C. On physical examination you notice bilateral normal breath sounds and his abdomen is non-tender without distention. FAST is negative. There are no bony deformities. No fractures are seen on the X-rays of his back.

You should have a high suspicion of bleeding in this patient, given his vital signs. You suspect a retroperitoneal bleeding source. Which of the following statements about retroperitoneal trauma is true?

A: Vascular injury in pelvic fractures is usually venous

B: The most common retroperitoneal source of bleeding is renal

C: Negative FAST combined with normal abdominal examination has a negative predictive value of 98% for retroperitoneal bleeding

D: Signs of retroperitoneal hemorrhage (Cullen’s, Turner’s, and Bryant’s sign) are usually present within one hour after trauma

The correct answer is A.

Retroperitoneal trauma was covered by emDocs this week. Retroperitoneal trauma is common; up to a third of polytrauma patients have retroperitoneal trauma. If your trauma patient is hemodynamically unstable, suspect retroperitoneal bleeding, especially if you can’t find another source.

The most common source of bleeding is due to pelvic fractures (use the pelvic binder!). Physical examination is usually normal. 

Source image: www.pixabay.com

Question 2

A 3 year old boy visits the emergency department (ED) with burns on both of his upper legs. He pulled a kettle of hot water from the kitchen table. The mother cooled the boy in the shower and rushed to the ED.

Which of the following statements is true about pediatric burns?

A: Children have a lower metabolic rate and their need for glucose and oxygen is lower compared to adult patients

B: Due to their smaller intravascular volume, children are more sensitive for fluid overload

C: Ice is an effective and safe cooling method

D: The threshold for starting fluid replacement in Total body surface area (TBSA) is higher for children than for adults

The correct answer is B

This week First10EM covered the Pediatric burns.

You should use cool running water for 20 minutes and never use ice This can lead to vasoconstriction and secondary tissue injury.

Fluid resuscitation should be considered for infants with a TBSA greater than 10%. In adults this threshold is generally 15%.

Keep in mind pediatric patients are vulnerable to fluid overload. This can be explained by the smaller intravascular volume per unit burned surface area.

Children have a higher metabolic rate and therefore have an increased fluid loss, oxygen and glucose demand.

Pediatric Burns: A Rapid Review

Source image: www.pixabay.com

Question 3

In patients defining themselves as either black or white, what can be said about the incidence of false normal pulse oximetry measurement (occult hypoxia) according to this paper?

A: The rate of occult hypoxia is equal in black and white patients

B: The rate of occult hypoxia is 3 times higher in black patients compared to white patients

D: The rate of occult hypoxia is 3 times higher in white patients compared to black patients

The correct answer is B.

JournalFeed discussed an article concerning racial bias in pulse oximetry this week.

The authors analyzed a total of 48,097 pairs of measures of oxygen saturation by pulse oximetry and arterial oxygen saturation in arterial blood gas. Black patients had nearly three times the frequency of occult hypoxemia compared to white patients.

Source image: www.pixabay.com

Question 4

Naloxon can be used in different ways in patients with suspected opioid intoxication. The most common route of administration is intravenous. It can also be nebulized.

Which of the following statements is true about nebulized naloxone?

A: This is especially useful in apneic patients

B: The correct dose is 0,2 mg in 3 ml of sodium chloride 0,9%

C: Patients do not get withdrawal symptoms when naloxone is nebulized

D: Patients can self-titrate and remove the nebulizer mask when responsive

The correct answer is D

This week ALIEM covered the utility of nebulized naloxone.

Most studies show a positive result using nebulized naloxone in patients with mildly decreased consciousness. Patients can experience withdrawal symptoms. They can remove the nebulizer mask and this can be seen as ‘self titrating’.

It should not be used as a therapy for apneic patients with suspected opioid intoxication.

Utility of Nebulized Naloxone

Source image: www.saem.org

Question 5

Your patient presents with ascending progressive symmetrical weakness. You want to distinguish Guillain Barré Syndrome (GBS) from tick paralysis and transverse myelitis. You perform a lumbar puncture.

Which of the following is typically elevated in cerebrospinal fluid (CSF) in GBS?

A: Leukocytes

B: Glucose

C: Protein

D: Erythrocytes

The correct answer is C.

EM Cases covered neuromuscular disease in their 2 part podcast series.

Elevated cerebrospinal fluid proteins are seen in GBS. However, during the initial phase of the disease course protein levels may be normal requiring a repeat lumbar puncture if GBS remains on the differential.

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

Reviewed and edited by Rick Thissen

Quiz 116, May 28th, 2021

Welcome to the 116th FOAMed Quiz.

 

Question 1

Source image: dontforgetthebubbles.com

Your 12 year old patient presents to your ED after his gastrostomy tube has fallen out 30 minutes ago. He and his parents do not have a spare one. You decide to place a foley catheter through the tract to keep it open as soon as possible.

Which of the following is a contra-indication for placement of the foley catheter?

A: This is a primary tube, placed 3 weeks ago

B: There is minor bleeding from the tract

C: It concerns a gastro-jejunostomy tube

D: Never place a foley in the tract of a gastrostomy tube

The correct answer is A

Don’t forget the Bubbles covered feeding tube troubles last week.

If the tract is left empty it will close up in hours. Replace the tube if you can. Otherwise put a foley catheter in the tract and tape it to the skin.

In patients that had the gastrostomy placed less than 4 weeks ago, the tract has not matured yet and placing a catheter should be avoided. Between 4 and 6 weeks, placement of a catheter can be tried very carefully.

Question 2

Source image: ctscanmachines.blogspot.com

Your 67 year old patient presents to the emergency department with an altered level of consciousness. Her Glasgow Coma Scale is E1M4V1. Her husband tells you she has been complaining of progressive headaches, diplopia and vomiting for a couple of weeks. You suspect her of having elevated intracranial pressure due to a cerebral mass.

Elevated intracranial pressure (ICP) can occur due to mass lesions, cerebral edema (stroke, traumatic brain injury, metabolic disturbances) or obstruction of venous or cerebrospinal fluid outflow.

Which of the following statements about elevated intracranial pressure is true?

A: Lumbar puncture is safe when elevated ICP exists due to a mass lesion

B: Patients with elevated ICP should be hyperventilated to sustain a normal ICP (target PaCO2 20-25 mmHg)

C: Mannitol seems to be less effective in improving cerebral perfusion pressure compared to hypertonic saline

D: Hypothermia improves clinical outcomes

The correct answer is C.

Elevated intracranial pressure was discussed in EMcrit’s Internet Book of Critical Care this week.

Mannitol is frequently used to decrease ICP, but is increasingly replaced by hypertonic saline as a first line agent. Mannitol is nephrotoxic, causes volume depletion (and brain hypoperfusion) and can cause a rebound elevation in ICP. Hypertonic saline (3%) is a safer treatment option. Furthermore, Mannitol seems to be less effective in improving cerebral perfusion pressure compared to hypertonic saline

When performing a lumbar puncture you risk downward herniation of the brain if there is a mass lesion.

Hyperventilation causes cerebral vasoconstriction and thus lowers ICP, but also lowers cerebral perfusion pressure. Low-normal PaCO2 (35-40 mmHg) is a reasonable target.

Hypothermia lowers ICP, but also causes bradycardia and hypotension. There is no high-quality evidence to support its use.

Elevated intracranial pressure (ICP)

Question 3

Source image: www.endoskopiebilder.de/

What is the cause of a stercoral ulcer?

A: Ingestion of a button battery

B: Recent abdominal surgery

C: Fecal mass

D: Malignancies

The correct answer is C

EMdocs covered a case in which a patient died from a perforated stercoral ulcer in their medical malpractice series

As you know, constipation is not always benign. Hard stool can cause colonic wall ulceration (stercoral ulcer) which leads to stercoral perforation.

Medical Malpractice Insights: Bowel perforation due to stercoral ulcer

source image: pixabay.com

Question 4

Intravenous calcium is increasingly used in the bleeding trauma patient. However, it is not yet included in all major guidelines.

This recently published systematic review covered 3 cohort studies including 1213 trauma patients.

What did the authors find?

A: Higher mortality rates were observed in patients with hypocalcemia in all three studies compared to patients with normal serum calcium

B: Patients with hypocalcemia required less blood transfusion compared to patients with normal serum calcium

C: Patients with normal serum calcium had increased coagulopathy (defined as initial INR ⪖ 1,5) compared to patients with hypocalcemia

The correct answer is A

Calcium in the trauma patient was covered on St. Emlyns last week.

In general, hypocalcemia in the bleeding patient is a bad thing. It is associated with higher mortality. Furthermore, patients with hypocalcemia require more blood transfusion and hypocalcemia is associated with increased coagulopathy and clot strength.

Hypocalcaemia, Trauma and Major Transfusion. St Emlyn’s

Question 5

Source image: www.first-nature.com

 

Your 45 year old patient presents to your ED after eating mushrooms. He ate several different types and does not remember what they looked like exactly.

Which of the following symptoms points in the direction of a life threatening intoxication?

A: Gastrointestinal symptoms starting 20 minutes after ingestion

B: Gastrointestinal symptoms starting 8 hours after ingestion

The correct answer is B

Mushroom poisoning was covered on CountyEM last week.

Mushrooms that cause symptoms more than six hours after consumption are associated with serious and potentially lethal toxicity.

The Poisoned Mushroom Hunter

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

Reviewed and edited by Rick Thissen

Quiz 115, May 21th, 2021

Welcome to the 115th FOAMed Quiz.

 

Source image: www.cdc.gov

Question 1

Gonorrhea is one of the most common sexually transmitted diseases (STD). Hematogenous spread of Neisseria gonorrhoeae leads to systemic infection, called disseminated gonococcal infection (DGI).

What symptoms are part of the classic triad of DGI?

A: Tenosynovitis, arthritis and dermatitis

B: Perihepatitis, salpingitis and vaginal discharge

C: Arthritis, urethritis and conjunctivitis

D: Dermatitis, lymphadenopathy and fever

The correct answer is A.

This week, emDOCS discussed DGI.

It should be in your differential in patients (especially young adults) presenting with migratory polyarthralgia, arthritis, or tenosynovitis, in combination with skin lesions.
The other answers are all STD related; can you name the syndrome or disease?

Answer B is the triad of Fitz-Hugh-Curtis syndrome
Answer C is the triad of Reiter’s syndrome.
Answer D are symptoms of secondary syphilis.

Question 2

A 5 day old baby presents to your ED after vomiting bright red blood. This otherwise healthy baby had a normal birth. The past few days he was drinking normally and had a normal stool. You want to perform an Apt-Downey test.

Which of the following statements is true about the Apt-Downey test for neonatal hematemesis?

A: The Apt-Downey test is useful in children up 9 months of age

B: The Apt-Downey test is a test to distinguish neonatal from maternal blood

C: The Apt-Downey test relies on the fact that fetal hemoglobin is resistant to acid denaturation

The correct answer is B

Neonatal hematemesis can be terrifying for parents. Some benign causes can be easily detected with a simple test such as the Apt-Downey test.

Fetal hemoglobin is resistant to alkali denaturation and after centrifugation it should have a pink color due to free floating hemoglobin. If it turns yellow this means that it did denature and it is adult or maternal hemoglobin. The test should not be used in infants > 6 months. You need a ‘fresh’ bloody specimen and it should be tested within 30 minutes of collection. You can use stool or emesis but it has to contain bright red blood. 

Source image: www.brownemblog.com

Question 3

Your 65 year old patient presents after someone hit her in the right eye. Immediately afterwards, the patient complained about blurring and diplopia. You think she might have a traumatic lens dislocation. Unfortunately, in the meantime her eyelids are very swollen and you cannot visualize the eye anymore. You decide to use Point of Care Ultrasound (POCUS).

What is the sensitivity of POCUS for traumatic lens dislocation?

A: 65%

B: 75%

C: 85%

D: 95%

The correct answer is D.

BrownEM covered POCUS in traumatic eye injuries last week.

According to this prospective cohort study, POCUS has a sensitivity of 96.8% (95% CI 83.3% to 99.9%) in the diagnosis of lens dislocation, and a sensitivity of 95.7% (95% CI 78.1% to 99.9%) in the diagnosis of retrobulbar hematoma.

Source image: www.nysora.com

Question 4

Your patient presents with a pretty nasty wound on the lower leg. You want to perform an ultrasound guided popliteal sciatic nerve block.

The sciatic nerve bifurcates just above the popliteal fossa. Distal to the bifurcation two nerve trunks are visible on ultrasound.

These two trunks are called:

A: Tibial nerve and common peroneal nerve

B: Tibial nerve and sural nerve

C: Sural nerve and common peroneal nerve

D: Saphenous nerve and sural nerve

The correct answer is A

The sciatic nerve consists of two separate nerve trunks: the tibial and common peroneal nerves. A common paraneural sheath envelops these two nerves from their origin in the pelvis

A popliteal block results in anesthesia of the entire distal two thirds of the lower extremity, with the exception of the medial aspect of the leg.


Question 5

Source image: www.pixabay.com

A 70 day old infant presents to your ED with fever. The COVID test turns out positive. You wonder whether this means you can stop evaluating for serious bacterial infection (SBI).

This recently published retrospective study is about 53 COVID positive infants with fever and 53 matched COVID negative febrile infants. What did the authors conclude about the difference in rate of serious bacterial infection between the two groups?

A: The authors found the risk of SBI was much lower in COVID positive infants

B: The authors found the risk of SBI equal in COVID positive and COVID negative infants

C: The authors found the risk of SBI was much lower in COVID negative infants

The correct answer is A.

Clay Smith covered the paper last week on Journalfeed.

The authors found the risk of SBI (UTI, bacterial enteritis, bacteremia, or bacterial meningitis) was much lower in COVID positive infants versus COVID negative infants 8% vs 34%. The most common SBI was UTI.

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

Reviewed and edited by Rick Thissen

Quiz 114, May 14th, 2021

Welcome to the 114th FOAMed Quiz.

Case courtesy of Dr Behrang Amini, Radiopaedia.org, rID: 3456

Question 1

A 2-year old is brought to the ER with severe abdominal pain. The pain is intermittent and is accompanied by vomiting and a bloody stool. You decide to perform an intussusception POCUS examination. Transverse sonography shows an alternating concentric pattern of echogenic and hypoechoic bands. This is called a “target sign”.

Which two of the following structures are seen as echogenic bands in a target sign?

A: Mucosa

B: Submucosa

C: Muscularis

D: Lymph node

The correct answers are A & C.

This week ALiEM discussed intussusception POCUS examination.

POCUS findings consistent with intussusception are a sandwich sign (or pseudo-kidney sign) in the longitudinal view and target sign (or donut sign) in the transverse view. There are few studies that have looked at POCUS for intussusception, but the existing studies have shown favorable test characteristics and a decreased length of ER stay with using POCUS.

PEM POCUS Series: Intussusception | Learn about it and test your skills on ALiEMU

Source image: www.pixabay.com

Question 2

The RECOVERY trial  showed a clear mortality benefit of dexamethasone in COVID-19 patients requiring oxygen therapy or mechanical ventilation. In contrast, methylprednisolone is the preferred anti-inflammation agent in other pulmonary diseases because of its direct effect on cell membrane associated proteins.

This recently published single centre retrospective study compared methylprednisolone (1mg/kg/day for > 3 days) to dexamethasone (6mg/day for > 7 days) and usual care (no steroid treatment) in adult patients who were admitted to the ICU for respiratory failure due to COVID-19.

What did the authors find?

A: Methylprednisolone had a mortality benefit over dexamethasone in patients on mechanical ventilation but no benefit in patients not requiring mechanical ventilation

B: Methylprednisolone had a mortality benefit over dexamethasone in patients on mechanical ventilation and in patients not requiring mechanical ventilation

C: Methylprednisolone had no mortality benefit over dexamethasone in patients on mechanical ventilation and in patients not requiring mechanical ventilation

D: Methylprednisolone had no mortality benefit over dexamethasone in patients on mechanical ventilation but was superior in patients not requiring mechanical ventilation

The correct answer is A.

This recent study was covered by Mark Ramzy on RebelEM this week.

This study addressed a clinically relevant and important question. External validity is limited since this study was single center and causation can not be determined since this was a retrospective study.

Switching from dexamethasone to methylprednisolone in a subgroup of patients on mechanical ventilation could be beneficial and should therefore be investigated in future studies.

Dexamethasone vs Methylprednisolone in ICU Patients with COVID19

Source image: www.pixabay.com

Question 3

A 38-year-old man is brought in by the EMS with acute chest pain. He is pale and diaphoretic. In his medical file you find that he is a frequent flyer in your emergency department. His visits are usually drug related. He has been known to use cocaine for several years.

What statement is true about cocaine related chest pain?

A: Beta blockers are absolutely contra-indicated in cocaine induced myocardial infarction

B: Cocaine induces tachycardia and thus higher oxygen demands by inhibition of M2-receptors

C: Patients with cocaine intoxication and clear ST elevations should undergo PCI immediately

D: Cocaine can cause myocardial or pulmonary infarction due to pro-thrombotic properties

The correct answer is D.

This week’s NUEM blog was about cocaine related chest pain. Acute coronary syndrome is caused by coronary vasospasm, higher oxygen demands by inhibiting the reuptake of norepinephrine and enhancing platelet aggregation. Chronic effects of cocaine further contribute to a higher risk of cardiovascular disease (especially acute coronary syndrome and aortic dissection) by accelerating atherogenesis, weakening of the aortic vessel wall and inducing left ventricular hypertrophy.

The mainstay of treatment is benzodiazepines which decrease adrenergic response. Beta-blockers are avoided by some physicians because of fear for unopposed alpha-stimulation. However, this is most likely only a theroretical risk.

Source image: LITFL.com

Question 4

Your 65 year old patient comes in with ongoing chest pain. The ECG shows STE in III, ST depression in any of leads V4 to 6, ST in lead V1 higher than ST in V2.

How is this pattern called?

A: De Winter’s pattern

B: Wellen’s pattern

C: Aslanger’s pattern

D: Brugada’s pattern

The correct answer is C

Dr. Smith’s ECG blog this week was about Aslanger’s pattern.

It is caused by a combination of inferior OMI and diffuse subendocardial ischemia. The subendocardial ischemia produces an ST depression vector toward leads II and V5 (with reciprocal STE in aVR) and cancels most of the STE caused by the inferior OMI results (except for lead III).

Source image: www.pixabay.com

Question 5

Sepsis is a common condition with a high mortality and morbidity. The first (blood) cultures are often taken in the emergency room. Whenever no microbiological pathogens are found, this is referred to as culture negative sepsis.

This systematic review and meta-analysis, consisting of 7 studies with a total of 22,655 patients, compared the overall mortality and clinically relevant secondary outcomes between culture-negative and culture-positive sepsis.

What conclusion did the authors draw?

A: There was no association between culture negativity or positivity and overall mortality. But culture-positive septic patients had a longer hospital stay and mechanical ventilation duration

B: Culture negativity was associated with higher mortality. It also resulted in an extended ventilation duration and a higher need for renal replacement therapy

C: Culture positivity was associated with higher mortality, but there was no significant difference in secondary clinically relevant outcomes

D: Culture-positive septic patients had longer ICU length of stay, but no significantly higher overall mortality compared to culture-negative patients

The correct answer is A.

The proportion of culture negativity is reported between 28 and 49% of all patients with sepsis. Culture positivity or negativity was not associated with a difference in mortality.

Culture-positive septic patients had comparable ICU length of stay, mechanical ventilation requirements and renal replacement requirements compared to culture-negative patients. However, the length of hospital stay and mechanical ventilation time of culture-positive septic patients were both longer than those of culture-negative patients.

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

Reviewed and edited by Rick Thissen

Quiz 113, May 7th, 2021

Welcome to the 113th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Vaccine induced immune thrombotic thrombocytopenia (VITT) (or vaccine-induced prothrombotic immune thrombocytopenia (VIPIT), or Thrombosis with Thrombocytopenia Syndrome (TTS)), is a very very rare, but possibly fatal adverse effect of Astra-Zeneca and Johnson & Johnson COVID-19 vaccines.

Which of the following statements about VITT is true?

A: Platelet count is typically normal in VITT

B: Platelet Factor 4 ELISA is generally positive in VITT (like in Heparin Induced Thrombocytopenia)

C: Normal d-dimer levels are often seen in VITT

D: Heparin is the mainstay of treatment of VITT

The correct answer is B

EM Quick Hits covered VITT last week.

VITT is an evolving disorder and changes in practice come quickly when new data become available.

In VITT, there is typically thrombocytopenia, elevated d-dimer and a positive PF4 ELISA.

Treatment consists of intravenous immune immunoglobulin (IVIG) and nonheparin anticoagulation.

Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.org, rID: 14979

Question 2

Shortening the duration of antibiotic therapy should help reduce antibiotic consumption and thus bacterial resistance, adverse events, and related costs.

This recently published double blind, randomised, placebo-controlled trial  is about a 3 day course of B-lactam antibiotics versus a 8 day course of B-lactam antibiotics for Community Acquired Pneumonia (CAP) in admitted non-ICU patients.

The primary outcome was resolution of symptoms at 15 days post randomisation.

What did the authors find?

A: 3 days of B-lactam treatment in patients with moderate CAP was non-inferior to 8 days of treatment

B: 3 days of B-lactam treatment in patients with moderate CAP was inferior to 8 days of treatment

C: 3 days of B-lactam treatment in patients with moderate CAP was superior to 8 days of treatment

The correct answer is A

RebelEM covered The Pneumonia Short Treatment Trial

The authors found that discontinuing B-lactam treatment after 3 days in patients with moderate CAP who were clinically stable, was non-inferior to patients who continued treatment for an additional 5 days.

113 of 145 (78%) of patients in the 3 day β-lactam group and 100 of 146 (68%) of patients in the 8 day β-lactam group were cured.

Because the authors used a relatively small sample size and the study was conducted in one country (France) a large multinational trial should be performed in order to make major practical changes.

The Pneumonia Short Treatment Trial: Antibiotic Treatment for 3 days vs 8 days

Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 8720

Question 3

A 17 year old competitive athlete visits the emergency department with pain in her right ankle since a few days without a specific trauma. Besides this problem she tells you that she missed periods and states she cannot be pregnant.

On the X-ray of the ankle you see a stress fracture at the distal tibial metaphysis. You suspect the female athlete triad.

Which of the following symptoms are part of the female athlete triad?

A: Menstrual dysfunction, insufficient energy intake and alopecia

B: Menstrual dysfunction, low bone mineral density and insufficient energy intake

C: Cachexia, osteoporosis and alopecia

The correct answer is B

AliEM covered the Female Athlete Triad this week

Stress fractures can be multifactorial due to increased activity and poor nutrition which can lead to disordered eating with or without an eating disorder.

You should be aware of this triad in patients with risk factors such as participation in sports that emphasize leanness or a specific weight or appearance. These sports typically include gymnastics, ice skating, wrestling, boxing, dance, and track and field.

SplintER Series: What is Wrong With My Daughter?

Source image: www.rcemlearning.co.uk

Question 4

A 35 year old otherwise healthy man, visits your ED because of inflammation on his left leg. The leg is red and warm, but there is no outflow of pus, you doubt whether you feel fluctuation of an abscess.

Which of the following pathogens is most likely to cause cellulitis after penetrating trauma or in the presence of an abscess?

A: Streptococci

B: Pseudomonas

C: Staphylococcus aureus

D: Vibrio vulnificus

The correct answer is C.

This week, emDOCs discussed cellulitis.

Cellulitis without abscess is usually caused by streptococci. However, if an abscess is found, S. aureus is the most common cause.

EMdocs discussed indications for intravenous antibiotic therapy in cellulitis and hospitalization versus treatment at home.

Source image: www.coreultrasound.com

Question 5

The least common place to find free intraperitoneal fluid in the focused assessment with sonography in trauma (FAST) exam is the left upper quadrant.

However, in case you find free fluid in the left upper quadrant, what is the most likely place?

A: Paracolic gutter

B: Suprasplenic

C: Kohler’s pouch

The correct answer is B

Jacob Avila covered the RUSH exam last week on Core Ultrasound.

In contrast to the right upper quadrant (where the most caudal tip of the liver / inferior pole of the kidney is the most likely place to find free fluid), the suprasplenic space is the most common place to find free fluid in the left upper quadrant.

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

Reviewed and edited by Rick Thissen

Quiz 112, April 23th, 2021

Welcome to the 112th FOAMed Quiz.

 

Case courtesy of Dr Naqibullah Foladi, Radiopaedia.org, rID: 73139

Question 1

Direct needle decompression (ND) is known to be a possible lifesaving intervention in patients with tension pneumothorax. Current guidelines recommend different locations for this decompression. Preferred locations are the 2nd intercostal space midclavicular line (ICS2-MCL) and the 4th-5th intercostal space at the anterior axillary line (ICS4/5-AAL).

Chest wall thickness (CWT) of the patient and needle length both play a role in the success rate of ND.

The primary outcome in this study was the CWT at ICS2-MCL and ICS4/5-AAL in normal weight (BMI <25), overweight (BMI 25-30) and obese patients (BMI >30) using Point of Care Ultrasound (POCUS). Their secondary outcome was the hypothetical failure rates of ND for these locations, based on standard catheter lengths (45mm and 50mm).

What did the authors find concerning CWT for both locations in overweight and obese patients?

A: CWT in ICS2-MCL was significantly thinner than ICS4/5-AAL

B: CWT was not significantly different in ICS2-MCL compared to ICS4/5-AAL

C: CWT in ICS2-MCL was significantly thicker than ICS4/5-AAL

The correct answer is A.

This prospective, multicenter, observational study was covered by Benjamin Gerritsen on REBEL EM this week.

CWT in ICS2-MCL was significantly thinner than ICS4/5-AAL in both overweight (p<0.001) and obese patientes (p=0.016) but not in patients with a normal BMI.

Hypothetical failure rates for 45mm and 50mm catheters were 2.5% and 0.8% for ICS2-MCL and 6.2% and 2.5% for ICS4/5-AAL (p=0.016 and -=0.052 respectively).

The authors concluded that, in overweight and obese patients, ICS2-MCL is the preferred anatomical location for ND in tension pneumothorax compared to the ICS4/5-AAL when using standard large bore catheters (45mm and 50mm).

Optimal Needle Position for Decompression of Tension Pneumothorax

Source image: www.pixabay.com

Question 2

Your 62 year old patient comes in with gradually worsening mental status changes, lead-pipe rigidity, hyperthermia and tachycardia. She uses medication prescribed by her psychiater, but it remains unclear what medication exactly.

Your differential diagnosis includes neuroleptic malignant syndrome (NMS) and serotonin syndrome (SS).

Which of the following clinical features point in the direction of NMS instead of SS?

A: Mental status changes

B: Lead-pipe rigidity

C: Hyperthermia

D: Tachycardia

The correct answer is B.

NMS was covered on the Internet Book of Critical Care last week.

Both patients with NMS and patients with SS present typically with mental status changes, hyperthermia and tachycardia. However, NMS leads to lead-pipe rigidity, whereas SS typically causes clonus and hyperreflexia.

IBCC – Neuroleptic Malignant Syndrome (NMS)

Source image: www.emdocs.net

Question 3

The use of Droperidol was largely abandoned in 2001 due to concerns about QT-prolongation and Torsade de Pointes. However, recent data supports it’s safety and effectiveness in the treatment of acute agitation and nausea.

These two Australian papers (paper 1, paper 2) covered the safety of Droperidol. A total of 209 patients older than 65 years receiving 2.5, 5 or 10 mg intramuscularly for agitation control were followed. 9 adverse events were reported. What was the most common adverse event?

A: Hypoxia

B: Airway obstruction

C: QT-prolongation

D: Hypotension

The correct answer is D.

AliEM covered these papers (paper 1, paper 2) last week.

In these cohorts of elderly agitated patients, adverse events were rare. The most common adverse event was hypotension (6/9). No patients developed Torsades de Pointes. Droperidol appears to be both effective and safe in agitated adults ≥ 65 years of age for the treatment of agitation.

Droperidol for Agitation in Older Adults in the Emergency Department

Source image: www.intranasal.net

Question 4

The use of intranasal midazolam is pretty convenient in the convulsing patient. At least for emergency care providers. This recently published retrospective pre-hospital study assessed the effectiveness of intranasal midazolam (0,1 mg/kg) versus alternative routes of administration (IV, IM) in children ≤14 years with a seizure. The primary outcome was need for redosing.

What did the authors find?

A: Intranasal midazolam was associated with lower rates of redosing compared to intravenous or intramuscular midazolam

B: Intranasal midazolam was associated with equal rates of redosing compared to intravenous or intramuscular midazolam

C: Intranasal midazolam was associated with higher rates of redosing compared to intravenous or intramuscular midazolam

The correct answer is C.

JournalFeed covered the paper last week.

Redosing of midazolam occurred in 25% (116/461) of patients receiving intranasal midazolam initially compared to 14% (222/1573) of patients receiving alternative routes. It seems intranasal administration is (at least in this dosage) less effective compared to intravenous and intramuscular administration of midazolam in children with a seizure.

Case courtesy of David Puyó, Radiopaedia.org, rID: 22317

Question 5

Your 67 year old patient presents with a renal colic. CT shows a 0.7 cm stone in the right distal ureter. POCUS and CT show moderate hydronephrosis on the right side. In addition to analgesics, you decide to start tamsulosin (an alpha blocker).

Which of the following characteristics make tamsulosin more likely to be beneficial in this patient?

A: Hydronephrosis

B: Location of the stone in the proximal ureter

C: The size of the stone is > 5 mm

The correct answer is C.

Taming the SRU covered the treatment of renal colic this week.

The role of alpha blockers is up for debate in renal colic. Especially patients with a stone > 5 mm may benefit from an alpha blocker in terms of time to stone passage, episodes of pain, hospital admissions and surgical intervention. This effect is irrespective of stone location and the existence of hydronephrosis.

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

Reviewed and edited by Rick Thissen

Quiz 111, April 16th, 2021

Welcome to the 111th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Your 64-year old male patient was brought in by EMS with a decreased level of consciousness. He is hypotensive and EMS reports that they found an empty bottle of doxepin, a tricyclic antidepressant (TCA).

Which of the following ECG abnormalities is atypical for a TCA overdose?

A: Prominent R wave in aVR

B: Widened QRS segment

C: Diffuse T-top inversion

D: QTc prolongation

The correct answer is C

TCA overdose was covered on Canadiem this week.

Sinus tachycardia is likely to appear first due to the anticholinergic effects. Widening of the QRS segment is typical and often seen in TCA overdose. It is an important predictor of the clinical course, as opposed to drug levels. A QRS width of >100 ms carried a 33% risk of seizures in this previous study while a QRS width >160 ms carried a 50% risk of dysrhythmias. QTc prolongation >430 ms and a prominent R wave in aVR (R/S ratio >0.7) are also frequently seen.

Inverted T-waves are atypical for TCA overdose and can be seen in various conditions.

Vicious Cycles: Management of the Tricyclic Antidepressant Overdose

Case courtesy of Dr David Cuete, Radiopaedia.org, rID: 22770

Question 2

Your patient comes in with acute onset headache and vomiting since 2 hours. Which of the following comorbidities may decrease the accuracy of the CT-scan for sub arachnoid hemorrhage (SAH)?

A: Anemia

B: Hypertriglyceridemia

C: Diabetes mellitus

D: Hemochromatosis

The correct answer is A

EMOttawa covered SAH this week.

Anemia will make acute blood less hyperdense on CT of the brain and intracerebral hemorrhage more difficult to appreciate. In patients polycythemia, for example, CT imaging may demonstrate hyperdense cerebral vasculature.

EMOttawa Podcast Episode 3: Thunderclap Headache

Source image: www.dontforgetthebubbles.com

Question 3

A 13 year old boy visits the ED after twisting his right foot during football. The X-ray is shown above. You wonder whether you are looking at a zone 1 fracture of the fifth metatarsal (pseudo Jones) or a normal apophysis.

Which of the following statements is correct and may help you distinguish between the two?

A: The apophysis of the base of the fifth metatarsal will not appear before 14 years of age in boys, so this has to be a fracture

B: There is no apophysis at the base of the fifth metatarsal, so this has to be a fracture

C: A fracture line through the base of the fifth metatarsal will run transversely, while the apophysis will run longitudinally, so this is not a fracture

D: A fracture line through the base of the fifth metatarsal will run longitudinally, while the apophysis will run transversely, so this has to be a fracture

The correct answer is C

Don’t forget the bubbles covered foot and toe injuries last week.

The apophysis of the base of the fifth metatarsal is often mistaken for a zone 1 fracture. The apophysis appears at about 12 years in boys. A fracture line through the base of the fifth metatarsal will run transversely, while the apophysis will run longitudinally.

An irregular apophysis at the base of the fifth metatarsal is seen in apophysitis. This self limiting condition is called Iselin disease.

Source image: www.emdocs.net

Question 4

Your 52 year old patient comes in after accidentally ingesting a bone while eating a chicken wing. There is a mild stridor, but no respiratory distress and a saturation of 98%. You administer nebulized lidocaine and plan to retrieve the foreign body with Magill or sponge forceps during laryngoscopy. A GlideScope® and standard Macintosh laryngoscope (size 3 blade) are available. Which one is most effective in retrieving the foreign body according to available evidence?

A: GlideScope®

B: Macintosh

C: Both are equally effective

The correct answer is B

EMDocs covered upper airway foreign bodies last week.

A 2012 paper by Je et al. covered this topic. 28 first year emergency residents with little prior airway management experience extracted hypopharyngeal foreign bodies using a Macintosh laryngoscope and GlideScope®. The success rate in relation to time to extraction was significantly higher with the Macintosh laryngoscope than with the GlideScope® (p < 0.001).

I guess the difficulty in foreign body extraction using a GlideScope® may be the hyperangulated blade. I wonder how standard geometry blade video laryngoscopy holds up against direct laryngoscopy.

Source image: www.pixabay.com

Question 5

Back to basics: resuscitation fluids.

The most commonly used fluid is still 0.9% Sodium Chloride. But do you know what is being administered to the patient?

What is the pH of 0.9% Sodium Chloride?

A: 5.5

B: 6.4

C: 7.4

D: 8.2

The correct answer is A.

Resuscitation fluids were discussed by ALiEM this week.

The differences between them, mainly based on the different electrolyte amounts, were shown for the most commonly used; 0.9% Sodium Chloride, Lactated Ringer’s solution,
Plasma Lyte A and blood.

Is Lactated Ringer’s Solution Safe for Hyperkalemia Patients?

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

Reviewed and edited by Rick Thissen

Quiz 110, April 9th, 2021

Welcome to the 110th FOAMed Quiz.

Source image: www.tamingthersu.com

Question 1

Your 27 year old patient presents with an anterior shoulder dislocation. You are in doubt whether reduction was successful. You use POCUS to assess the position of the humeral head.

On POCUS (posterior view) the humeral head appears to be deep to the glenoid fossa. What does that mean?

A: Reduction was successful

B: Anterior dislocation persists

C: There is a posterior dislocation

The correct answer is B.

Taming The SRU discussed ultrasound in shoulder dislocation this week.

POCUS has a high sensitivity (99.1%) and specificity (99.9%) for shoulder dislocation. A major advantage is the possibility of real-time reduction confirmation during sedation.

Standard approach is to place the probe posterior and transverse. In case of anterior shoulder dislocation, the humeral head projects deep to the glenoid fossa. In posterior dislocation, the humeral head is superficial to the glenoid.

Source image: www.journalfeed.org

Question 2

This recently published case series is about the reverse valsalva manoeuvre in 11 patients. The reversed valsalva manoeuvre does not require assistance (like the modified valsalva manoeuvre) or IV access (adenosine, diltiazem).

The patient starts by exhaling without forcing in sitting position, followed by pinching the nose and closing the mouth, finished by inhaling against the self made resistance for ten seconds.

Which of the following statements is true?

A: SVT was terminated in 10% of patients

B: SVT was terminated in 50% of patients

C: SVT was terminated in 90% of patients

The correct answer is C

Journal feed covered this small observational trial about the reverse valsalva manoeuvre this week.

The reverse valsalva manoeuvre increases vagal tone, decreases sympathetic activity and seems to be a very simple, patient friendly and safe technique which can be performed autonomously by patients at home. SVT was terminated by this manoeuvre in 10/11 (91%) of patients, including 4 patients who already tried the modified valsalva manoeuvre.

Future studies like randomised controlled trials should be performed in order to see what the true efficacy of this method is.

Source image: www.aliem.com

Question 3

An otherwise healthy 55-year-old woman visits your emergency department with an increasingly painful swollen finger. You think she has flexor tenosynovitis (FTS). 

The Kanavel signs show a high sensitivity (91.4% – 97.1%) but a low specificity (51.3% – 69.2%) in detecting FTS.

Which 2 physical examination findings, combined with tenderness along the flexor tendon sheath and fusiform swelling, constitute the Kanavel signs?

A: Finger maintained in passive flexion

B: Finger maintained in passive extension

C: Pain elicited with passive flexion

D: Pain elicited with passive extension

The correct answers are A & D.

ALiEM covered FTS this week.

FTS is an acute inflammation of the synovial space of a flexor tendon most often caused by Staphylococcus aureus (40-75%). Typically, patients cannot fully extend the finger and it is usually red, warm and swollen. Passive extension is painful. Drainage is required because the tendon sheaths are connected to other deep spaces of the hand and thus inflammation can spread quickly.

SplintER Series: Kitty Nibble: A Case of the Sausage Finger

Source image: www.emdocs.net / www.LITFL.com

Question 4

Lewis lead placement of ECG electrodes is done by:
Placing the Right Arm (RA) electrode on the manubrium
Placing the Left Arm (LA) electrode over the 5th intercostal space on the right sternal border
Placing the Left Leg (LL) electrode over the right lower costal margin

In what case might Lewis lead placement help you?

A: Detecting an epsilon wave in Arrhythmogenic Right Ventricular Dysplasia (ARVD)

B: Detecting flutter waves in atrial flutter

C: Detecting PTa depression in pericarditis

D: Increase accuracy of QT-interval

The correct answer is B

EMDocs covered the Lewis ECG last week.

Lewis lead placement is used to detect atrial electrical activity better. It can be useful in observing flutter waves in atrial flutter and detecting P waves in wide complex tachyarrhythmia.

Question 5

Source image: https://hqmeded.com

Necrotizing fasciitis is a life-threatening and limb-threatening condition. Which of the following statements about the clinical presentation and diagnosis of necrotizing fasciitis is true?

A: About 80% of patients present with fever

B: Early skin findings include edema and purple discoloration

C: The sensitivity of ultrasonography for finding gas in the skin is only 30%

D: The Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) score is an accurate tool to differentiate necrotizing fasciitis from other soft tissue infections

The correct answer is C.

Necrotizing fasciitis was covered in EMCrit’s Internet Book of Critical Care (IBCC) this week.

In patients with necrotizing fasciitis, fever is present in only 25-40% of cases at admission.
Early findings of the skin include edema and erythema (cellulitis like), but severe pain that extends beyond the skin findings is probably the most useful clinical finding.

Imaging studies (POCUS, CT, MRI) can show subcutaneous gas and abnormal fascia (thickening, filled with fluid, fat stranding).

The LRINEC score should not be used. External validation studies showed poor sensitivity and specificity.

Probably the most important thing to remember is that surgical exploration should be performed if necrotizing fasciitis is suspected based on clinical findings. Lab results and imaging studies are not accurate enough to exclude necrotizing fasciitis.

Necrotizing fasciitis

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

Reviewed and edited by Rick Thissen