Quiz 129, September 16th, 2021

Welcome to the 129th FOAMed Quiz.

Source image: www.pedemmorsels.com

Question 1

Your 4 year old patient comes in with a nail bed laceration.

Which of the following statements is true about the management of nail bed injuries?

A: Nail bed injuries with tuft fractures are considered open fractures and therefore antibiotics are indicated

B: Cyanoacrylates (glue) should not be used to repair the nail bed

C: Nail bed injuries occur in up to one quarter of fingertip injuries

D: Most nail bed lacerations do not need repair

The correct answer is C.

Pediatric EM Morsels covered nail bed injuries last week.

According to available literature, prophylactic antibiotics do not change the rate of infection or osteomyelitis.

Cyanoacrylates may be as effective as suturing for nail bed injury repairs in children.

Nail bed injuries occur in up to one quarter of fingertip injuries.

Significant nail bed lacerations should be repaired to avoid bad cosmesis.

Nail Bed Lacerations

Question 2

Your 64 year old patient is brought in by prehospital services. She was found unconscious at home and she was intubated. She had been complaining about dyspnoea for 2 days.

Her capnography waveform looks like this:

Which of the following mechanisms causes a waveform like this?

A: Circulatory arrest

B: Tube in the right main bronchus

C: Bronchospasm

D: Hypoventilation

The correct answer is C.

NuEM covered capnography waveforms last week.

A normal waveform looks like this:

Delayed exhalation causes the typical sawtooth slope often seen in airway obstruction and bronchospasms such as COPD or asthma exacerbation.

Source image: www.thebottomline.org.uk

Question 3

The recently published DOREMI trial is about Dobutamine versus Milrinone in cardiogenic shock.

192 patients with cardiogenic shock were randomised to receive either Dobutamine or Milrinone in this randomised controlled trial.

The primary outcome was a composite of in-hospital death, resuscitated cardiac arrest and other badness.

What did the authors find?

A: Dobutamine was superior to Milrinone in patients with cardiogenic shock

B: Milrinone was superior to Dobutamine in patients with cardiogenic shock

C: Milrinone and Dobutamine were equally effective in patients with cardiogenic shock

The correct answer is C

The Bottom Line covered the recently published paper last week.

There was no significant difference in the composite of in-hospital death, resuscitated cardiac arrest, receipt of cardiac transplant or mechanical support, non-fatal myocardial infarction, cerebrovascular event or renal replacement therapy (Milrinone: 49% vs Dobutamine: 54%).

Keep in mind the study was not powered to detect smaller differences in the composite outcome or individual components of the primary outcome.

DOREMI

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

Question 4

Differentiating acute heart failure from other causes of dyspnoea is often challenging. This recently published paper is about POCUS in dyspneic patients.

81 patients aged 50 years and older with shortness of breath from suspected acute heart failure or COPD were evaluated in this cohort study.

The classification performance of lung POCUS to diagnose acute heart failure as well as that of chest x-ray study was calculated.

What did the authors find?

A: Lung POCUS has a higher sensitivity for heart failure than chest x-ray

B: Chest x-ray has a higher sensitivity for heart failure than lung POCUS

C: Lung POCUS and chest X-ray have equal sensitivity for heart failure

The correct answer is A

Last week Journalfeed covered this recently published paper.

This small study showed POCUS has a sensitivity of 92.5% for identification of acute heart failure. Chest X-ray has a sensitivity of 63.6%.

This is in line with previous data.

The study has been limited by a small sample size and high prevalence of heart failure but it highlights the importance of early use of ultrasound in the undifferentiated dyspneic patient.

Source image: www.emcrit.org

Question 5

Suppletion of Antidiuretic hormone (ADH) has a wide variety of indications. 

For which of the following patients is ADH certainly NOT part of the management?

A: Patient of the Neuro-ICU with diabetes insipidus

B: Patient on Aspirin who sustained traumatic head injury

C: Patient with hyponatremia due to primary polydipsia

D: Patient with septic shock

E: Patient with central hypernatremia

The correct answer is C.

This week, Josh Farkas EMCrit posted his Cooper Conference talk about ADH on EMCrit.

Roughly, ADH can be used to prevent water loss (and thereby influence blood sodium levels), cause vasoconstriction and promote platelet aggregation (due to increase of platelet activating factor).

NeuroEMCrit – The Many Aliases and Uses of ADH by Casey Albin

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

Reviewed and edited by Rick Thissen

Quiz 128, September 3th, 2021

Welcome to the 128th FOAMed Quiz.

 

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

Question 1

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

A: Flecainide

B: Procainamide

C: Lidocaine

D: Propranolol

The correct answer is D.

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

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

Source image: www.pixabay,com

Question 2

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

What do you think the authors found?

Children who received oral ondansetron:

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

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

C: Had reduced episodes of vomiting

D: Had reduced frequency of intravenous fluid resuscitation

The correct answer is A.

The paper was covered on JournalFeed last week.

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

Source image: www.emra.org

Question 3

What distinguishes phlegmasia cerulea dolens from uncomplicated deep venous thrombosis?

A: The presence of arterial occlusion

B: The presence of total or near total venous occlusion

C: The presence of compartment syndrome

D: The presence of bacterial infection

The correct answer is B

Phlegmasia cerulea dolens was covered on AliEM last week.

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

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

SAEM Clinical Image Series: Pulseless and Painful Blue Leg

Source image: www.pixabay.com

 Question 4

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

80 patients were randomized equally to the 2 study arms.

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

What did the authors find?

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

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

C: There was no difference between the two groups

The correct answer is A.

The paper was covered on RebelEM last week.

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

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

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

Rapid Agitation Control With Ketamine in the Emergency Department

Source image: www.aliem.com

Question 5

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

A: Frog view

B: Judet view

C: Pelvic inlet / outlet view

The correct answer is B

AliEM covered imaging in pelvic trauma last week.

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

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

EMRad: Radiologic Approach to the Traumatic Hip/Pelvis

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

Reviewed and edited by Rick Thissen

Quiz 127, August 27th, 2021

Welcome to the 127th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

As part of the RECOVERY platform a randomised controlled trial was started about non-invasive ventilation for hospitalised patients with COVID-19. This trial is called the RECOVERY – Respiratory Support or RECOVERY-RS trial.

1272 adult hospitalised patients with COVID-19, deemed at risk for treatment escalation (invasive ventilation), were randomized to either High Flow Nasal Oxygen (HFNO), Continuous Positive Airway Pressure (CPAP) or conventional oxygen.

The primary outcome was a composite of tracheal intubation and mortality at 30 days post randomisation.

What did the authors find?

A: CPAP was significantly superior to conventional oxygen therapy

B: HFNO was significantly superior to conventional oxygen therapy

C: Both CPAP and HFNO were significantly superior to conventional oxygen therapy

D: Neither CPAP nor HFNO were significantly superior to conventional oxygen therapy

The correct answer is A.

The pre-print RECOVERY-RS trial was covered on criticalcarereviews.com, RebelEM, St. Emlyns and the Bottom line this week.

CPAP was significantly superior to conventional oxygen therapy. HFNO was not. The difference was mainly due to reduction in need for intubation, not due to a difference in mortality.

Keep in mind this trial was not blinded (obviously) and there was quite some crossover between the groups.

Source image: tamingthesru.com

Question 2

Your patient comes in with submandibular swelling. He has a fever and difficulty swallowing. You suspect he has Ludwig’s Angina. Which of the following is NOT part of the ED management of Ludwig’s Angina?

A: Broad Spectrum Antibiotics

B: Dexamethasone

C: Surgical debridement of any necrotic tissue and drainage of any abscess

D: Placing a Laryngeal Mask (LMA) when a compromised airway is suspected

The correct answer is D.

First10EM covered Ludwig’s Angina last week.

Whenever Ludwig’s Angina progresses to cause a compromised airway, a supraglottic airway is a poor choice as it can get displaced as swelling progresses. Due to swelling, cricothyroidotomy can be very challenging.

Ludwig’s Angina: A Rapid Review

Source image: www.huidziekten.nl

Question 3

Injuries caused by which of the following animals are most likely to cause necrotising fasciitis?

A: Cat

B: Caterpillar

C: Catfish

The correct answer is C.

Taming the SRU covered necrotising fasciitis last week.

Noodling is the art of catching a catfish with bare hands. Injuries sustained while practising this activity are known to progress to necrotising fasciitis. Most often, severe infections follow wounds caused by the fins of catfish.

Of course a bite from a cat can cause necrotising fasciitis as well, but it is less common.

Question 4

Source image: aliem.com

Your 32 year old patient presents with palpitations and dizzyness. He has a heartrate of over 200 per minute, blood pressure of 90/60 mmHg and is diaphoretic. His ECG is show above.

Which of the following is the most suitable intervention?

A: Adenosine

B: Amiodarone

C: Diltiazem

D: Electric Cardioversion

The correct answer is D.

Aliem covered atrial fibrillation in Wolff Parkinson White syndrome last week.

Atrial fibrillation in patients with WPW (fast, broad and irregular) is fortunately quite uncommon. 

Treatment with AV nodal blocking drugs (like adenosine, calcium-channel blockers and beta-blockers) can increase conduction via the accessory pathway, which can lead to degeneration into unstable ventricular arrhythmias and VF.

Diagnosis on Sight: “I have a rapid heart rate”

Question 5

Source image: www.safestroke.eu

 

The ABCD2 score is used to stratify the risk of stroke in patients presenting with TIA.

The Canadian TIA Score is a new tool for this purpose. In this paper published in february 2021, the Canadian TIA Score was compared to the ABCD2 score.

7607 patients were analysed in 13 hospitals in the country of risk scores, Canada.

What did the authors find?

A: The Canadian TIA Score stratified the risk of stroke within seven days as low more accurately than the ABCD2 score

B: The ABCD2 score stratified the risk of stroke within seven days as low more accurately than the Canadian TIA Score

C: The Canadian TIA Score and ABCD2 score stratified the risk of stroke as low within seven days equally accurate

The correct answer is A.

RebelEM covered the Canadian TIA Score this week.

The Canadian TIA Score stratified the risk of stroke within seven days as low more accurately than the ABCD2 score.

Rebellion21: Canadian TIA Risk Score vs ABCD2

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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 126, August 20th, 2021

Welcome to the 126th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

COVID-19 patients are at high risk for the development of venous thromboembolic disease.

Recently two randomised controlled trials were published in which the authors investigated the effectiveness and safety of therapeutic dose anticoagulation in critically ill patients (trial 1, n= 1098) and non critically ill patients (trial 2, n=2219) with COVID-19.

Patients were randomized to one of two arms (unfractionated or low molecular weight heparin):
Therapeutic Anticoagulation (TA): Full dose anticoagulation
Prophylactic Anticoagulation (PA): Prophylactic or intermediate dose anticoagulation

The primary outcome was organ support-free days (cardiovascular and respiratory) after 21 days.

What did the authors find about the use of therapeutic dose anticoagulation in COVID-19 patients?

A: Non-critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm. In critically ill patients, there was no difference

B: Critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm. In non-critically ill patients, there was no difference

C: Both critically ill and non-critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm

D: Neither critically ill nor non-critically ill patients in the Therapeutic Anticoagulation (TA) arm had more organ support-free days compared to patients in the Prophylactic Anticoagulation (PA) arm

The correct answer is A.

This week RebelEM covered the two trials (trial 1 and trial 2) about Anticoagulation in COVID-19 patients.

In non critically ill COVID-19 patients the use of therapeutic dose anticoagulation increased organ support-free days and survival to hospital discharge. These results were not found in critically ill COVID-19 patients.

The reason therapeutic coagulation seems beneficial in non-critically ill patients and not in critically ill patients is up for debate. However, one can imagine the antithrombotic and anti-inflammatory properties of therapeutic anticoagulation is most effective in early stages of the disease.

COVID-19 and Anticoagulation: Full Dose or Prophylactic Dose?

Source image: www.pixabay.com

Question 2

A 4 year old patient presents to the ED after possible ingestion of a coin. He is completely asymptomatic. His mother only found him playing with her wallet without actually seeing him swallow something.

You wonder whether a handheld metal detector might be sufficient to rule out the presence of a coin.

Which of the following is true about the sensitivity of a handheld metal detector for detection of ingested coins?

A: The sensitivity is low and a handheld metal detector is not useful for this indication

B: The sensitivity is about 85 percent. Combined with a low pretest probability this test is pretty accurate

C: The sensitivity is 99-100 percent. You can safely exclude the presence of a coin with this test

The correct answer is C.

EMDocs covered ingestion of metal foreign bodies last week.

It seems a handheld metal detector can be safely and reliably used as a screening tool in the process of detecting ingested coins.

A 2005 systematic review and a 2018 observational study showed the sensitivity of a handheld metal detector for detection of coins to be almost 100%. Keep in mind the sensitivity for other metal objects (long and sharp objects, lid of a can) is lower.

The metal detector might even be used to localize the coin.

EM@3AM: Beverage Tab Ingestion

Source image: www.nuemblog.com

Question 3

When exposed to cold, unprotected tissues can sustain frostbite injury. If digits sustain severe frostbite, this can result in amputation.

Which of the following has a role in the management of severe frostbite?

A: Tissue plasminogen activators (tPA)

B: Beta Blockers

C: Phenylephrine

D: Tranexamic acid

The correct answer is A.

This week NUEM blog covered frostbite injury.

Treatment consists of warming the affected tissue. Rewarming leads to a second mechanism of injury, a reperfusion injury resulting in patchy microvascular thrombosis and tissue death. To prevent the latter tPA can be administered. Evidence is limited, but intravenous and intra-arterial tPA seem to be effective in preventing loss of limbs.

Source image: www.orthobullets.com

Question 4

In acute compartment syndrome of the lower leg, which of the following compartments is most commonly affected?

A: Lateral compartment

B: Deep posterior compartment

C: Superficial posterior compartment

D: Anterior compartment

The correct answer is D.

Taming the SRU covered compartment syndrome last week.

The anterior compartment of the lower extremities is most commonly affected in acute compartment syndrome.

Source image: www.pixabay.com

Question 5

Complaints about waiting time are common in the ED. This recently published paper is about patients’ perception of their waiting time.

Which of the following is true according to the paper.

A: Most ED patients overestimate their waiting time

B: Most ED patients underestimate their waiting time

C: Most ED patients are accurate about their waiting time

The correct answer is A.

The paper was covered on first10EM this week.

Most patients overestimate their waiting time.

Justin Morgenstern adds an important note: ´´For the most part, we just blame the patients and call them dumb. Patients will complain that they have been waiting for 2 hours, and will be met with the response, “no, dummy, the computer says you have only been waiting 1.5 hours.” The key point is that the patient feels like they have been waiting 2 hours, and that is largely our fault. There are lots of ways that we could influence the perception of wait times, but we routinely fail.´´ 

Research Roundup (August 2021)

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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 125, August 13th, 2021

Welcome to the 125th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

A 28-year-old male felt a painful snap in his posterior left lower leg while playing basketball. Physical exam is suggestive of Achilles tendon rupture, but you are not certain.

You decide to perform a bedside ultrasound to confirm the diagnosis.

Which of the following statements is true about POCUS in Achilles tendon injury?

A: Minimal fluid surrounding the Achilles tendon is normal due to the synovial sheath

B: Most Achilles tendon ruptures occur at the calcaneal insertion

C: Anisotropy is a useful ultrasonographic artifact to confirm tendon tear

D: Plantaris tendon is usually found medial of the Achilles tendon

The correct answer is D.

This week ALiEM discussed Achilles tendon rupture.

The Achilles tendon is surrounded by paratenon, rather than a synovial sheath, therefore fluid is normally not seen on ultrasound. A tear rarely occurs at calcaneal insertion. Anisotropy can mimic a tendon rupture and can be used to identify the tendon (which shouldn’t be a problem in case of the Achilles tendon). The Plantaris tendon is found medial to the Achilles tendon. Keep in mind the Thompson test can be false negative if the Plantaris tendon is intact.

SplintER Series: My Foot Doesn’t Work Right

Source image: www.pixabay.com

Question 2

A patient is brought in unconcious after a suicide attempt. He was found hanging on a self made noose. He did not drop from height.

Which of the following is most likely the primary main pathologic mechanism?

A: Fracture of the upper cervical spine

B: Venous obstruction in the neck

C: Arterial damage in the neck

D: Airway compromise

The correct answer is B.

NUEM blog wrote about hanging injuries this week.

Loss of consciousness in hanging occurs most often due to obstruction of venous outflow from the brain and occurs in 15 seconds.

When the drop is greater than or equal to the height of the victim, there will almost always be cervical spine injury. Without a drop cervical injury is rare.

The rate of arterial damage is pretty uncommon as well.

Airway compromise plays less of a role in the immediate death of hanging.

Source image: www.nuemblog.com

Question 3

Which of the following findings on POCUS is suggestive of cardiac tamponade?

A: Right atrial diastolic collapse

B: A collapsed Inferior Vena Cava (IVC)

C: Right ventricular systolic collapse

D: Absence of a pericardial effusion

The correct answer is A.

Jacob Avila covered POCUS in cardiac tamponade on Core Ultrasound last week.

Right atrial or right ventricular diastolic collapse is highly suggestive for cardiac tamponade. Systolic collapse is normal. When in doubt whether the atrium or ventricle collapses during diastole or systole, slow down the clip and have a look at what the tricuspid and mitral valve are doing.

One would expect at least some amount of pericardial effusions and a wide IVC in case of tamponade.

 

Source image: rebelem.com

Question 4

Last week the BaSICS paper was published. This study was about normal saline (NS) versus balanced solution (Plasma-Lyte) in ICU patients. 10520 patients were randomised to receive either NS or balanced solution. The primary outcome was difference in all cause mortality at 90 days.

In 2018, the SMART  trial found a small but statistically significant difference in Major Kidney Events in favour of balanced solutions.

What did the BaSICS paper show?

A: Mortality was lower in the normal saline group compared to the balanced solution group

B: Mortality was lower in the balanced solution group compared to the normal saline group

C: Mortality was equal between the groups

The correct answer is C.

The Bottom Line and EMCrit covered the BaSICS trial last week.

In this extremely large, multi-centre trial 5290 ICU patients were randomised to the NS group and 5230 patients were randomised to the balanced solution group. Fluid that patients were randomised to was used for entire ICU stay. 26.4% in the balanced solution group died vs 27.2% in the NS group (p = 0.47).

The use of a balanced crystalloid compared to 0.9% sodium chloride did not reduce 90-day mortality.

There actually was another part of this study about fast fluid boluses versus slow infusion. No difference in mortality was found either.

BaSICS

Source image: www.pixabay.com

Question 5

You are evaluating your 9 year old patient for hearing loss. Weber test lateralizes to the right ear. Rinne’s test is positive on the left side and negative on the right side.

What is most likely the cause of this girls hearing loss?

A: Sensorineural hearing loss on the right side

B: Conductive hearing loss on the right side

C: Sensorineural hearing loss on the left side

D: Conductive hearing loss on the left side

The correct answer is B.

Don’t forget the Bubbles covered Weber’s and Rinne’s test last week.

Weber’s test lateralizes to the right ear, so there is either sensorineural hearing loss on the left side or conductive hearing loss on the right side.

Rinne’s test is positive (air conduction > bone conduction) on the left side and negative (air conduction < bone conduction) indicating there is a conductive problem on the right side or a sensorineural problem on the left side. However, a negative Rinne’s test is always abnormal, making conductive hearing loss on the right side most likely.

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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 124, August 6th, 2021

Welcome to the 124th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Listening to educational podcasts is becoming increasingly popular amongst emergency medicine staff. A lot of us listen while commuting by car.

However, the question remains if any of the information sticks when you’re on the road. This paper compared initial and delayed recall of a podcast while driving versus undistracted seated listening.

What conclusion did the authors draw?

A: Recall is better when listening to a podcast undistracted compared to while driving

B: Recall is better when listening to a podcast while driving compared to undistracted

C: Initial recall is better while listening undistracted but there is no difference in delayed recall

D: There is no difference in recall between the driving and undistracted cohort

The correct answer is D.

The RCEM podcast covered the paper last week.

This multicenter, randomized trial looked at initial (within 30 minutes after listening) and delayed (one month after listening) recall of a podcast by 100 postgraduate emergency medicine residents. They were divided into a cohort of listeners while seated undistracted and a cohort of listeners while driving a car.

There was no statistically significant difference between the driving and undistracted cohorts. 

Source image: www.litfl.com

Question 2

Your 40 year old patient needs intubation due to respiratory failure. She has a wide QRS on the ECG, but potassium results have not come back yet. You are in doubt between using succinylcholine and rocuronium.

Which of the following predisposing conditions do not increase the risk of clinically significant hyperkalemia when using succinylcholine?

A: Denervating, crush or burn injuries

B: Chronic dialysis

C: Rhabdomyolysis

D: Prolonged total body immobilization

The correct answer is B

This week AliEM covered succinylcholine and the risk of hyperkalemia.

Succinylcholine is preferably avoided in selected patients. Hyperkalemia can be caused by activation of acetylcholine receptors which leads to an influx of sodium and calcium and an efflux of potassium to the extracellular space.

Patients with a normal renal function have an average increase of potassium of 0.5mEq/L. Patients on chronic dialysis do not have an increased risk of developing clinically significant hyperkalemia. Succinylcholine should be avoided when ECG changes are present prior to administration, rhabdomyolysis, prolonged total body immobilization, denervating disease, inherited myopathies and crush or burn injuries after 72 hours.

Source image: https://static.wixstatic.com

Question 3

A 35 year old male patient presents to the ED with a swollen finger. He tells you that the swelling started 4-5 days ago after minor trauma to the fingertip. The problem is located on the finger pad, anterior and very distal of the finger. A picture is shown above.

 Would you expect all Kanavel’s cardinal signs to be positive in this patient?

A: Yes

B: No

The correct answer is B.

AliEM covered the swollen finger in their SplintER series last week.

Kanavel’s signs are used to differentiate between a felon and flexor tenosynovitis. These 4 make up Kanavel’s signs:

1. Exquisite tenderness over the course of the sheath, limited to the sheath.
2. Flexion of the finger.
3. Exquisite pain on extending the finger, most marked at the proximal end.
4. Fusiform swelling of the finger.

This patient most likely has a felon which is a subcutaneous abscess in the finger pulp and usually presents on the pad of the finger.

Case courtesy of Dr Matt Skalski, Radiopaedia.org, rID: 71639

Question 4

Flail chest is most often defined as a fracture of 3 or more contiguous ribs in 2 or more locations.

Flail chest is not mentioned in the latest ATLS guidelines as life threatening thoracis injury anymore.

This study included 407 patients with rib fractures, of which 79 (19.4%) had flail chest. Patients with a flail chest were compared to patients with the same number of ribs fractured, but without a flail segment.

According to this paper, what difference does the presence of a flail chest make in patients with three to five rib fractures?

A: Patients with a flail chest had higher mortality compared to patients without a flail chest

B: Patients with a flail chest had longer need for intensive care compared to patients without a flail chest

C: Patients with a flail chest had longer need for hospitalisation compared to patients without a flail chest

D: Patients with a flail chest had higher incidence of pneumothorax compared to patients without a flail chest

The correct answer is D

The Resus Room podcast covered the paper this week.

When comparing patients with three to five rib fractures, there was no difference in length of intensive care and length of hospitalisation or mortality; however, there was a higher incidence of pneumothorax (24.6% vs 50.0%, p<0.05). When comparing patients with six or more rib fractures, no difference was found between patients with and without flail chest.

Source image: www.nysora.com

Question 5

Your 65 year old patient presents with a dislocated shoulder. He has obesity, major chronic cardiac ischemic disease and he ate 3 quarter pounders at a well known fast food restaurant about 45 minutes ago. Shoulder reduction techniques with intra-articular and intravenous anesthesia are not successful. You are not very keen on sedating this patient and you decide to perform an interscalene brachial plexus block (ISB).

Which of the following actions can be used to reduce the chance of phrenic nerve blockade when performing an ISB (2 correct answers)?

A: Decreasing local anesthetic volume

B: Increasing local anesthetic volume

C: Performing the ISB more caudad in the neck

D: Performing the ISB more cephalad in the neck

The correct answers are A and C.

CoreEM covered the interscalene brachial plexus block last week.

The ISB effectively numbs C5-C7 nerve distribution unilaterally. It can affect C8-T1 as well but not as reliably.

Phrenic nerve blockade is a well known complication and can induce respiratory problems.

Reducing the anesthetic volume and using a more caudad location reduce the chance of phrenic nerve blockade.

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

Reviewed and edited by Rick Thissen

Quiz 123, July 30th, 2021

Welcome to the 123th FOAMed Quiz.

 

Question 1

Source image: www.acc.org

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

What statement about myocarditis is true?

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

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

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

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

The correct answer is D.

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

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

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

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

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

Question 2

Source image: emergencymedicinecases.com

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

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

A: This is most likely pericarditis

B: This is most likely inferior OMI

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

The correct answer is B.

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

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

Question 3

Source image: www.chromagar.com/

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

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

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

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

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

The correct answer is C.

Josh Farkas covered beta lactam allergies on EMCrit last week.

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

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

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

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

Question 4

Source image: www.aliem.com

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

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

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

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

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

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

The correct answer is B.

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

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

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

Rapid Infusers: How Fast Can They Go?

Question 5

Source image: www.theguardian.com

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

Which of the following is NOT typical for ischemic priapism?

A: Severe pain

B: Often caused by trauma

C: Often medication induced or related to sickle cell disease

D: Acidotic penile blood gas

The correct answer is B

This week EmDocs covered Priapism last week.

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

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

EM Cases: Priapism and Urinary Retention: Nuances in Management

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

Reviewed and edited by Rick Thissen

Quiz 122, July 23th, 2021

Welcome to the 122th FOAMed Quiz.

 

Question 1

Source image: rebelem.com

Both conventional X-ray and point of care ultrasound (POCUS) can be used to diagnose pneumothorax.

This recently published meta-analysis is about X-ray versus POCUS for diagnosis of pneumothorax in trauma patients.

9 studies were included with a total of 1271 patients.

Which imaging modality had the highest sensitivity for pneumothorax in trauma patients?

A: POCUS

B: X-ray

C: POCUS and X-ray were equally sensitive

The correct answer is A.

The paper was covered on JournalFeed last week.

The overall sensitivity of chest ultrasonography was 0.91 (95% confidence interval [CI] 0.85 to 0.94) and the specificity was 0.99 (95% CI 0.97 to 1.00). The sensitivity of chest radiography was only 0.47 (95% CI 0.31 to 0.63) and the specificity was 1.00 (95% CI 0.97 to 1.00).

In 8 of 9 studies, POCUS was performed by Emergency Physicians.

Question 2

Source image: sinaiem.org/

The recently published TTM2 trial is about hypothermia versus normothermia in post cardiac arrest. 1861 patients that were unconscious after out of hospital cardiac arrest (OHCA) were included. They were randomised to cooling to target 33 degrees celsius (targeted hypothermia) or cooling if the temperature reached 37,8 degrees celsius (targeted normothermia).

The primary outcome was death from any cause at 6 months.The main secondary outcome was a poor functional outcome at 6 months, defined as a score of 4 to 6 on the modified Rankin scale.

What did the authors find?

A: Targeted hypothermia did not lead to a lower incidence of death by 6 months than targeted normothermia, but it did lead to a lower incidence of poor functional outcome by 6 months compared to targeted normothermia

B: Targeted hypothermia did lead to a lower incidence of death by 6 months and it did lead to a lower incidence of poor functional outcome by 6 months compared to targeted normothermia

C: Targeted hypothermia did not lead to a lower incidence of death by 6 months and it did not lead to a lower incidence of poor functional outcome by 6 months than targeted normothermia

The correct answer is C

RCEM and RebelEM (among others) covered the recently published TTM2 trial.

465 of 925 patients (50%) in the hypothermia group had died by 6 months, compared with 446 of 925 (48%) in the normothermia group (P = 0.37). 55% in the hypothermia group had moderately severe disability or worse, compared with 479 of 866 (55%) in the normothermia group.

Hypothermia seems to be not beneficial for unconscious patients after OHCA compared to normothermia according to this well done paper.

TTM2: Hypothermia vs Normothermia for Out-of-Hospital Cardiac Arrest

Question 3

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

Aortic dissection can present with a wide variety of symptoms.

In type A aortic dissection (TAAD), which symptom is most commonly present?

A: Cerebral Malperfusion Syndrome

B: Myocardial Malperfusion Syndrome (RCA or LCA)

C: Cardiac tamponade

D: Aortic regurgitation

The correct answer is D.

County EM covered aortic dissection this week.

The incidence of aortic regurgitation in TAAD is 50-66%.
The incidence of cardiac tamponade in TAAD is 20-36%.
The incidence of myocardial malperfusion in TAAD is 10-15%.
The incidence of cerebral malperfusion in TAAD is 6-14%.

Malperfusion Syndromes of Aortic Dissection

Question 4

Source image: unicef.org

Although evidence does not support the use of antibiotics in uncomplicated upper respiratory tract infections (URTI), they are still quite widely prescribed.

This recently published paper is about the concept of delayed antibiotic prescription (DAP) in children with uncomplicated URTI. This means the parents received a prescription for antibiotics, which they could start if their child was not improving after some days or if the child got sicker. The most commonly prescribed antibiotic was amoxicillin.

436 children were randomised to receive either immediate antibiotic prescription (IAP), DAP or no antibiotic prescription (NAP). Primary outcomes were symptom duration and severity.

What did the authors find?

A: Patients receiving NAP showed shorter symptom duration and decreased severity in children with uncomplicated respiratory infections compared to patients receiving IAP or DAP

B: Patients receiving IAP showed shorter symptom duration and decreased severity in children with uncomplicated respiratory infections compared to patients receiving NAP or DAP

C: Patients receiving DAP showed shorter symptom duration and decreased severity in children with uncomplicated respiratory infections compared to patients receiving NAP or IAP

D: There was no statistically significant difference in symptom duration or severity in children with uncomplicated respiratory infections who received DAP compared to NAP or IAP

The correct answer is D

First10EM, EMOttawa and others covered the paper last week.

Delayed antibiotic prescription reduced the (inappropriate) use of antibiotics in children with uncomplicated URTI compared to immediate antibiotic use. Less antibiotics was not associated with a worse clinical course. This makes sense, for antibiotics simply do not work in this patient category. This is another piece of evidence to support the practice of not prescribing antibiotics for uncomplicated URTI.

Interestingly, the authors found that 80 percent of parents in the immediate antibiotic group believed that antibiotics were very or extremely effective, compared to 40 percent in the delayed antibiotic group and 30 percent in the no antibiotic group.

Delayed Antibiotic Prescription for Children With Respiratory Infections: A Randomized Trial

Question 5

Source image: emdocs.net/

Myocarditis can cause a wide variety of ECG changes. One of these changes is a fragmented QRS (fQRS or sometimes called Ferrero’s sign).

What is the clinical significance of a fragmented QRS?

A: None, a fragmented QRS is a random finding

B: A fragmented QRS cannot be caused by myocarditis. Underlying ischemia is very likely

C: A fragmented QRS in myocarditis represents structural tissue changes. Beware of arrhythmias

The correct answer is C.

EMdocs covered the significance of a fragmented QRS in myocarditis last week.

A fragmented QRS represents structural tissue changes (fibrosis). These structural changes in the myocardium lead to an increased chance of arrhythmias. It is certainly not a benign finding and it is not only caused by ischemia.

ECG Pointers: Myocarditis and QRS fragmentation

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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 121, July 2nd , 2021

Welcome to the 121th FOAMed Quiz.

 

Question 1

Source image: www.stemlynsblog.org

In addition to Toculizumab and Dexamethasone, the REGN monoclonal antibodies combination (Casirivimab and Imdevimab) have shown to be beneficial in patients with COVID-19 according to this part of the RECOVERY trial.

However, the Casirivimab and Imdevimab combination was only associated with reduced mortality, increased speed of discharge and reduced progression to invasive mechanical ventilation or death in a subset of patients.

Which group of COVID-19 patients benefit from the Casirivimab and Imdevimab combination?

A: Patients on mechanical ventilation

B: Patients beyond the 10th day of their illness

C: Patients on oxygen therapy

D: Patients that were seronegative on randomisation

The correct answer is D

St Emlyns covered the RECOVERY trial about the Casirivimab and Imdevimab combination last week.

9785 patients were randomly allocated to receive usual care plus REGN antibody combination or usual care alone.

3153 (32%) of these patients were seronegative. In the primary efficacy population of seronegative patients, 396 (24%) of 1633 patients allocated to REGN antibody combination and 451 (30%) of 1520 patients allocated to usual care died within 28 days (p=0.0010). When combining the seropositive group with the seronegative patients, there was no longer a significant effect on 28-day mortality.

REGN monoclonal antibodies work in selected hospitalised COVID-19 patients. St Emlyn’s

Question 2

Source image: journals.lww.com

Your 65 year old patient presents to your ED with acute respiratory distress. She is tachypneic and her oxygen saturation is 92 percent without oxygen suppletion. She has tachycardia, capillary refill of 4 seconds, is diaphoretic and she has a blood pressure of 90/50 mmHg.

POCUS does not reveal any B-lines and lung sliding is present in all areas. You suspect this patient to have massive Pulmonary Embolism (PE). You get a parasternal short axis view of the base of the heart and you retrieve a pulse wave doppler image of the right ventricular outflow tract (RVOT). This image is shown above.

This POCUS finding makes a massive PE more likely.

How is this finding called?

A: McConnell’s sign

B: RVOT acceleration time

C: 60/60 sign

D: Early Systolic Notching

The correct answer is D.

The Ultrasound Gel podcast covered this paper about POCUS findings in PE.

277 patients of which 100 had massive or submassive PE were included. Early Systolic Notching was present in 92 percent of these patients (compared to only 2 percent in patients with subsegmental PE). This was superior to any other POCUS finding in suspected PE.

Source image: www.ultrasoundgel.org/

Question 3

Source image: radiopaedia.org/

 

Your 36-year-old patient is brought in by the EMS with head trauma after falling down the stairs. On arrival, his Glasgow Coma Scale was E1M3V2.

What statement about different types of traumatic brain injury is true?

A: Epidural hematoma is typically due to laceration of the anterior meningeal artery

B: An intraparenchymal hematoma with a volume of ≥20 ml is an indication for surgical drainage, regardless of location of the hematoma and midline shift

C: Traumatic subarachnoid hemorrhage (SAH) is typically located over the peripheral cerebral convexities, rather than the sylvian fissures and basal cisterns

D: Diffuse Axonal Injury (DAI) is usually associated with elevated intracranial pressure

The correct answer is C.

Traumatic brain injury was covered in this week’s Internet Book of Critical Care by EMcrit.

Epidural hematomas are typically due to laceration of the middle meningeal artery.

An intraparenchymal hematoma with a volume of ≥50 ml is a potential indication for surgical drainage; as well as a volume of ≥20 ml and located frontal or temporal with a midline shift of ≥ 5 mm and/or cisternal compression with GCS 6-8.

For traumatic subarachnoid hemorrhage, be careful not to miss primary aneurysmal hemorrhage which can lead to syncope and a fall.

DAI is usually not associated with elevated ICP.

Traumatic Brain Injury (TBI)

Question 4

Source image: https://saskblood.ca/

Postpartum hemorrhage (PPH) is an obstetric emergency. It is one of the most common causes of maternal mortality.

The causes of postpartum hemorrhage can be summarized by the four “T’s”.

Which of the following is not a part of the four T’s?

A: Trauma (rupture or lacerations)

B: Tension (hypertension)

C: Tone (uterine atony)

D: Tissue (retained placenta)

E: Thrombine (coagulopathies)

The correct answer is B.

JournalFeed covered this recently published paper about preparation, risk factors, identification and management of postpartum hemorrhage last week.

Postpartum hemorrhage can be defined by blood loss >500ml after vaginal delivery and > 1000ml after cesarean delivery.

The causes of postpartum hemorrhage can be summarized by the four “T’s”: tone (uterine atony), trauma (lacerations or uterine rupture), tissue (retained placenta or clots), and thrombin (clotting-factor deficiency). The most common cause is uterine atony (accounting for approximately 70% of cases).

Question 5

 

Source image: www.elmhurstfootdoc.com

Your patient presents with profound fever and severe pain with cramping in his calf for two days. The calf looks swollen and red and it feels warm. You suspect pyomyositis and you start empiric antibiotics.

Which of the following bacteria is most often the cause of pyomyositis?

A: Staphylococcus aureus

B: Mycobacterium tuberculosis

C: Fusobacterium necrophorum

D: Capnocytophaga canimorsus

The correct answer is A.

RebelEM covered pyomyositis last week.

Pyomyositis is a purulent infection of the skeletal muscles that arise from hematogenous spread.

The most common causative organism of pyomyositis is Staphylococcus aureus. Less common are Streptococci.

REBEL Core Cast 60.0 – Pyomyositis

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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 120, June 25th, 2021

Welcome to the 120th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

The 2021 European Resuscitation Council guidelines about newborn resuscitation (European Resuscitation Council Guidelines 2021: Newborn resuscitation and support of transition of infants at birth) and the UK guideline (Newborn resuscitation and support of transition of infants at birth Guidelines | Resuscitation Council UK) include some changes from the previous guidelines.

According to these guidelines, at what time should the umbilical cord be clamped after the first cry?

A: Immediately

B: Within 30 seconds

C: Between 30 and 60 seconds

D: After at least 60 seconds

The correct answer is D

Don’t forget the Bubbles covered the new UK guideline on neonatal resuscitation last week.

Ideally, we should delay clamping the cord for sixty seconds after the first cry.

However, we should delay cord clamping only if we are able to appropriately support the infant when the transition is incomplete or poor.

Where delayed cord clamping is not possible consider cord milking in infants >28 weeks gestation.

Source image: www.rebelem.com

Question 2

Headache is a known complication after Lumbar Punture (LP). Which of the following actions is proven to reduce the risk of post LP headache according to this recently published paper ?

A: Using a lower intervertebral space

B: Using an atraumatic needle instead of a cutting needle

C: Advising the patient to drink 3 cups of caffeinated coffee per day for three days

D: Placing the patient in upright position instead of lateral decubitus position

The correct answer is B

Journalfeed covered this systematic review about post LP headache last week.

Factors that are associated with post-LP headache are female sex, lower BMI, younger age, and history of headache.

Atraumatic needles are definitely effective to reduce this complication and are not more difficult to use compared to cutting needles.

Lateral decubitus position and using a higher intervertebral space may reduce the risk, whereas IV fluids and caffeine do not reduce the risk on post LP headache.

Question 3

Last month, this article  about the treatment of acute basilar occlusion was published in the New England Journal of Medicine.

The authors included 300 patients with proven basilar artery occlusion on CTA or MRA and an NIHSS score of ≥ 10. These patients were randomly assigned to either endovascular therapy (154 patients) or standard therapy (146 patients). Primary outcome was favorable functional outcome, which was defined as having a modified Rankin score of 0-3 at 90 days post randomisation.

What did the authors find?

A: Patients treated with endovascular therapy had a higher rate of favorable functional outcome compared to patients treated with standard therapy

B: Patients treated with endovascular therapy had an equal rate of favorable functional outcome compared to patients treated with standard therapy

C: Patients treated with endovascular therapy had a lower rate of favorable functional outcome compared to patients treated with standard therapy

The correct answer is B.

RebelEM covered the paper last week.

The paper did not show benefit of endovascular therapy in basilar artery occlusion. A favorable functional outcome occurred in 68 of 154 patients (44.2%) in the endovascular group and 55 of 146 patients (37.7%) in the medical care group (confidence interval, 0.92 to 1.50).

However, there are some limitations. The sample size was small and no perfusion imaging was used (no information about salvageable tissue in patients receiving artra arterial therapy).

Should we Consider Endovascular Therapy for Acute Basilar Artery Occlusion?

Source image: www.pixabay.com

Question 4

Your patient presents with altered mental status, visual disturbance and a headache. He also has marked hypertension and had a seizure on the way to your ED. You suspect this patient to have Posterior Reversible Encephalopathy Syndrome (PRES).

Which of the following diagnostic tools can help you to diagnose PRES?

A: MRI

B: CT

C: Lumbar Puncture

The correct answer is A.

Josh Farkas covered PRES in The internet Book of Critical Care last week.

PRES is characterised by vasogenic edema which occurs predominantly in the posterior brain. The pathogenesis is largely unknown, but is likely partly due to failure of autoregulation in hypertension.

No single diagnostic test proves PRES and it is mostly a clinical diagnosis, but MRI typically shows vasogenic edema.

Source image: www.pixabay.com

Question 5

Your 65 year old patient presents with decreased vision, headache, severe eye pain and vomiting. You do not have the equipment to measure ocular pressure, but the affected eye appears rock hard on gentle palpation. You suspect the patient to have angle-closure glaucoma.

Which of the following is part of the acute management of this patient?

A: Do not give any analgesics, for this may lead to an increased ocular pressure

B: Make the patient sit upright

C: Intraocular Acetazolamide (Diamox) will lower the intraocular pressure

D: Timolol eye drops will lower the intraocular pressure

The correct answer is D

The RCEM podcast covered ophthalmic emergencies last week.

Acute angle-closure glaucoma is an emergency diagnosis and should be treated promptly. It is advised to place the patient in supine position and give analgesics as soon as possible.

Acetazolamide can be given intravenously and orally, but not ocular.

Timolol eye drops or a combination drug containing timolol (like Cosopt) is effective in order to lower intraocular pressure.

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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