Quiz 91, November 20th, 2020

Welcome to the 91th FOAMed Quiz. 

Nicole, Joep and Rick

Source image: www.first10em.com

Question 1

Idiopathic Intracranial Hypertension (IIH) is reguraly missed diagnosis with potentially devastating consequences.

Headache is the main symptom and papilledema is common. Patients can present with abducens nerve palsy, pulsatile tinnitus, dizziness, neck or back pain and confusion.

Which of the following patients is most at risk for IIH?

A: A 22 year old female with a body mass index (BMI) of 36

B: A 63 year old female with a BMI of 31

C: A 22 year old female with a BMI of 22

D: A 45 year old male with a BMI of 40

The correct answer is A

First10EM covered IHH this week.

The diagnosis of IIH is a tricky one. The headache is often nonspecific and can be confused with migraine.

Always keep this diagnosis in your mind when treating a female of childbearing age who is overweight.

Idiopathic Intracranial Hypertension: a rapid review

Source image: www.emottowablog.com

Question 2

The role of viscoelastic hemostatic assays (VHA) like TEG and ROTEM in trauma patients is not supported by a lot of evidence so far.

In this recently published study, trauma patients with activated major haemorrhage protocols were randomised to either VHA or Conventional Coagulation Tests (CCT) guided therapy.

The primary outcome was the proportion of subjects who, at 24 h after injury, were alive and free of ongoing massive transfusion.

What did the authors find?

A: VHA guided therapy resulted in a increase in patients alive and free of massive transfusion at 24 hours after injury compared to CCT guided therapy

B: CCT guided therapy resulted in a decrease in patients alive and free of massive transfusion at 24 hours after injury compared to VHA guided therapy

C: There was no difference between the two groups in number of patients alive and free of massive transfusion at 24 hours after injury

The correct answer is C

EMOttawa covered this paper last week.

There was no difference in patients alive and free of massive transfusion at 24 hours after injury between VHA- and CCT-augmented-major haemorrhage protocols (64 versus 67 percent). This may be due to the lower than expected rate of coagulopathy and therefore the study may have been underpowered.

There was a reduction in 28-day mortality in the VHA group in patients who also had severe TBI. However, this is probably a chance finding.

Source image: www.atsu.edu

Question 3

Which of the following bacteria is the most likely causative organism of menstrual toxic shock syndrome due to colonisation of tampons?

A: Streptococcus pyogenus

B: Staphylococcus aureus

C: Enterococcus faecium

D: Pseudomonas aeruginosa

The correct answer is B

Toxic Shock Syndrome (TSS) is covered on the Internet Book of Critical Care this week.

Toxic shock syndrome can either be caused by Streptococci of Staphylococci. The bacteria found to be the causative organism in menstrual related TTS is Staphylococcus aureus.

Question 4

In which of the following situations is administration of sodium bicarbonate most likely to be beneficial to the patient?

A: A patient with diabetic ketoacidosis (DKA) and a pH of 7.05

B: A patient with renal failure and a pH of 7.15

C: A patient with lactic acidosis and a pH of 7.10

D: A patient with Hyperchloremic Metabolic Acidosis and a pH of 7.31

The correct answer is B

NUEM covered sodium bicarbonate and the recently published BICAR-ICU trial last week.

In patients with DKA, please do not administer sodium bicarbonate unless the pH is well under 7.00. In lactic acidosis it seems sodium bicarbonate is not beneficial.

Patients with uremic acidosis are likely to benefit from sodium bicarbonate to cope with the inability of the kidney to excrete anions.

Patients with hyperchloremic acidosis might benefit from sodium bicarbonate, but not if the acidosis is very mild like in this case.

Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 9644

Question 5

The discussion about antibiotics versus surgical management of appendicitis has been around for some years now.

Recently the CODA trial was published. The CODA trial is an RCT comparing antibiotic therapy (10-day course) with appendectomy in patients with appendicitis. The primary outcome was 30-day health status (by questionnaire). Patients with signs of severe disease were excluded.

What did the authors find?

A: Antibiotics were inferior to appendectomy on the basis of results of a standard health-status measure

B: Antibiotics were superior to appendectomy on the basis of results of a standard health-status measure

C: Antibiotics were noninferior to appendectomy on the basis of results of a standard health-status measure

The correct answer is C

RebelEM covered this paper last week.

1552 adults underwent randomization; 776 were assigned to receive antibiotics (47% of whom were not hospitalized for the index treatment) and 776 to undergo appendectomy. Antibiotics were noninferior to appendectomy on the basis of 30-day EQ-5D scores.

However, in the antibiotics group, nearly 3 in 10 participants had undergone appendectomy by 90 days. Only 30% of eligible patients agreed to undergo randomization.This data was only from the first 90 days after randomisation, so long term adverse effects may be missed.

Interestingly, perforation was more common in the antibiotics group compared to the appendectomy group (32% vs 16%) when the analysis was limited to participants in either group who had undergone appendectomy. This difference was only seen in patients with an appendicolith (61% vs 24%).

REBEL Cast Ep 89: The CODA Trial – Antibiotics vs Appendectomy for Appendicitis

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This quiz was written by Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 90, November 12th, 2020

Welcome to the 90th FOAMed Quiz. 

Nicole, Joep and Rick

Source image: www.rebelem.com

Question 1

The effectiveness of sodium bicarbonate (SB) on mortality in patients with cardiac arrest is widely debated. The ACLS and ALS guidelines state that routine use of SB is not recommended.

This recently published systematic review compared intravenous SB administration in cardiac arrest to no intravenous SB administration in cardiac resuscitation. Their primary outcomes were return of spontaneous circulation (ROSC) and survival to discharge.

What did the authors find?

A: Use of Sodium Bicarbonate in cardiac arrest was associated with increased ROSC and survival to discharge compared to no use of Sodium Bicarbonate

B: Use of Sodium Bicarbonate in cardiac arrest was not associated with increased or decreased ROSC and survival to discharge compared to no use of Sodium Bicarbonate

C: Use of Sodium Bicarbonate in cardiac arrest was associated with decreased ROSC and survival to discharge compared to no use of Sodium Bicarbonate

The correct answer is B

Muhammad Durrani covered this systematic review on the effectiveness of Sodium Bicarbonate administration on mortality in cardiac arrest patients this week on REBEL EM.

Six observational studies were included. Administration of Sodium Bicarbonate was not associated with increase or decrease in ROSC or survival to discharge in cardiac resuscitation, in line with current ACLS guidelines.

These findings need to be interpreted cautiously due to the small amount of included studies, poor statistical quality with high heterogeneity and risk of bias and confounders.

Effectiveness of Sodium Bicarbonate Administration on Mortality in Cardiac Arrest Patients: A Systematic Review and Meta-Analysis

Source image: www.pixabay.com

Question 2

Lung-protective ventilation proved to be beneficial in the ICU, especially in acute respiratory distress syndrome (ARDS). Invasive mechanical ventilation will often be started in the ED. This recently published paper is about the association between the use of lung-protective ventilation in the ED and outcomes among invasively patients. Lung-protective ventilation was defined by use of tidal volumes ≤ 8 mL/kg predicted body weight.

What did the investigators find about lung-protective ventilation in the ED?

A: Lung-protective ventilation in the ED is associated with lower hospital mortality and better overall outcomes

B: Lung-protective ventilation in the ED is associated with lower hospital mortality but overall outcomes did not improve

C: Lung-protective ventilation in the ED is associated with better overall outcomes but did not improve mortality rates

D: Lung-protective ventilation in the ED did not improve mortality and overall outcomes are the same for invasive ventilation

The correct answer is A

Clay Smith covered Low Tidal Volume in the ED in this weeks Spoon Feed

The authors of this retrospective study included 4.174 patients of which 58.4% received lung-protective ventilation in the ED. The use of lung-protective ventilation was associated with decreased odds of hospital death (adjusted odds ratio: 0.91 [95% CI] 0.84-0.96) compared to patients who received higher tidal volumes. There was a decreased incidence of ARDS, lower hospital length of stay, and decreased total costs.

Source image: www.ultrasoundgel.org

Question 3

Your
 75 year old patient presents with left lower quadrant abdominal pain for 2 days. Vital signs are normal. The labs show leukocytosis and elevated CRP. You suspect diverticulitis and you wonder whether Point Of Care UltraSound (POCUS) could help you in your workup.

This recently published paper is about POCUS in diverticulitis. What was the sensitivity of POCUS for diverticulitis according to this paper?

A: 62%

B: 72%

C: 82%

D: 92%

The correct answer is D

This recently published paper was covered on the Ultrasound Podcast last week.

The researchers included 452 patients. 36% had a diagnosis of diverticulitis based on CT scan. Of the 452 patients, there were 13 false-positive (3%) and 10 false-negative (2%) point-of-care ultrasonographic examinations leading to a stunning sensitivity of 92% and specificity of 97%.

Keep in mind these ultrasound exams were performed by experienced ultrasonographers and this was a single centre study.

It almost sounds too good to be true and I wonder whether these results will be reproducible.

Source image: radiopaedia.org/

Question 4

What is the name of the fracture shown above?

A: Bennett’s fracture

B: Rolando’s fracture

C: Epibasal fracture of the thumb

The correct answer is A

BrownEM covered minor hand injury last week.

Bennett’s fracture is an intra-articular fracture of the base of the thumb generally and consists of two parts.

Rolando’s fracture is a comminuted version of Bennett’s and usually consists of 3 parts.

An epibasal fracture is, like a Bennett’s fracture, a two parts fracture of the base of metacarpal 1, but runs extra-articular.

Question 5

Source image: emergencymedicinecases.com/


You review an ECG without knowing the clinical context. The tall R-wave in V1 puzzles you and you decide to look into it.

Which of the following entities is NOT a cause of a tall R-wave in V1?

A: Posterior MI

B: Arrhythmogenic right ventricular dysplasia (ARVD)

C: Pulmonary Embolism

D: Dextrocardin

The correct answer is B

EM cases covered the causes of a tall R-wave in V1 this week.

The differential for tall R-wave in V1 can be remembered by the mnemonic R-WAVED.
RBBB
WPW left sided pathway
Acute MI – posterior
Ventricular hypertrophy or HCM
Embolism, pulmonary
Dextrocardia

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This quiz was written by Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 89, November 6th, 2020

Welcome to the 89th FOAMed Quiz. 

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Your 34 year old patient comes in with agitation with an unknown cause. He shows profound tachypnoea and tachycardia with a capillary refill time of <2 seconds. His blood pressure cannot be measured because of severe agitation. His GCS is E4V3M5 and his glucose is normal. He has hyperthermia (38,8 degrees Celsius) and is diaphoretic.

It is impossible to get an IV in and you decide to sedate your patient using IM medication.

Which of the following drugs is most effective for acute undifferentiated agitation in the emergency department according to this recently published paper?

A: Droperidol

B: Ziprasidone

C: Lorazepam

The correct answer is A

This recently published paper was covered on JournalFeed last week.

115 patients were enrolled. Adequate sedation at 15 minutes was the primary outcome. Droperidol 5 mg was effective in 64% of patients, compared to 25% for ziprasidone 10 mg, 35% for ziprasidone 20 mg and 29% for lorazepam 2 mg. Numerically, respiratory depression was lower with droperidol compared to ziprasidone and lorazepam. QTc durations were similar in all groups.

It looks like another win for droperidol, although I would like to see how it holds up against IM ketamine.

Source image: www.pixabay.com

Question 2

I am aerobic and facultatively anaerobic and I am a gram-positive rod. I am naturally occurring in soil, water, and flora. I live in unpasteurized milk, soft cheeses, deli meats, and smoked seafood. I generally only cause gastro-intestinal symptoms in healthy adults, but if I find a way to get neuro-invasive I cause a nasty meningitis and occasionally a focal encephalitis involving the brainstem and/or cerebellum called rhombo-encephalitis.

Which of the following causative organisms of meningitis am I?

A: Streptococcus pneumoniae

B: Haemophilus influenzae type b (Hib)

C: Neisseria meningitidis

D: Listeria monocytogenes

The correct answer is D

Taming the SRU covered neurolisteriosis this week.

Well, the only gram negative rod in this list is Listeria monocytogenes.

While L. monocytogenes accounts for only four percent of bacterial meningitis cases in patients aged two to 60, it is responsible for 25% of cases in patients younger than two and older than sixty years.

Question 3

Your patient comes in after an intoxication with unknown prescription drugs. She has hypotension and an altered mental status.

Which of the following intoxications is most likely to cause the abnormalities on the ECG shown above?

A: Amitriptyline intoxication

B: Gabapentin intoxication

C: Metoprolol intoxication

D: Diltiazem intoxication

The correct answer is A

Tricyclic antidepressant (TCA) intoxication was covered last week in the Annals of B-pod, the Fall issue.

This issue contains case-reports about paracetamol intoxication, mandibular dislocation, lightning injuries and subclavian steal syndrome as well.

The ECG shows signs of sodium channel blockade as seen in TCA intoxication. These include a wide QRS, right axis deviation of the terminal QRS and a terminal R wave > 3 mm in aVR.

Gabapentin does not cause specific ECG abnormalities.

Metoprolol and diltiazem will cause bradycardia and AV-block, which are not present in ths case.

Source image: https://emergencymedicinecases.com/

Question 4

Your 38 year old female patient is brought in by prehospital services with a seizure. First line medication was not effective and the seizure persists beyond 10 minutes.

Which of the following is true about the treatment of status epilepticus?

A: Administration of benzodiazepines within the first 5 minutes of the seizure is clearly harmful because most seizures terminate by themselves within a short timeframe

B: Seizures caused by tricyclic antidepressants (TCA’s) should be treated with phenytoin

C: Phenytoin causes less cardiovascular side effects compared to fosphenytoin

D: The use of ketamine in addition to propofol as third line agent may have synergistic effect through modulating GABA and NMDA receptors

The correct answer is D

This week EM Docs covered the Management of Status Epilepticus.

Most guidelines still advocate waiting 5 minutes to administer the first dose of benzodiazepines. Although it is true seizures are generally self-terminating, 5 minutes is quite a long time to wait and although benzodiazepines are not harmless, the effects of ongoing seizures are not benign either. It seems logical not to wait 5 minutes to administer the first dose of benzodiazepines, but this is not supported by evidence so far.

TCA’s cause sodium blockade and so does phenytoin, so administration of phenytoin in a TCA intoxication bound to cause cardiovascular problems.

Fosphenytoin causes less cardiovascular side effects compared to phenytoin.

Use of ketamine in addition to propofol as a third line agent may have synergistic effect through modulating GABA and NMDA receptors. Although not supported by evidence so far.

Question 5

Your 43 year old patient presents with ‘’the worst headache ever”. You suspect her of having a subarachnoid hemorrhage (SAH). She denies loss of consciousness and vomiting. The physical  exam does not reveal neck stiffness. Since her headache started less than 6 hours ago, you urgently order a CT of the brain. In the meantime you wonder which symptom is most commonly present in patients with SAH.

Put the following symptoms of SAH in order of occurrence in patients with SAH starting with the least common and finishing with the most common:

A: Vomiting, loss of consciousness, thunderclap headache, worst headache of life, neck stiffness

B: Loss of consciousness, vomiting, neck stiffness, thunderclap headache, worst headache of life

C: Neck stiffness, vomiting, thunderclap headache, loss of consciousness, worst headache of life

D: Thunderclap headache, loss of consciousness, neck stiffness, worst headache of life, vomiting

The correct answer is B

EMOttawa covered subarachnoid hemorrhage last week.

The correct order of symptoms of SAH in order of occurrence is:

Loss of consciousness – 13%
Vomiting – 62%
Neck stiffness – 74%
Thunderclap headache – 83%
Worst headache of life – 95%

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 88, October 30th

Welcome to the 88th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

This recently published paper is about the efficacy of tranexamic acid (TXA) in the prehospital setting.

Injured patients, between 18 and 90 years old, transferred from scene or referring hospital to one of four level 1 trauma centers within 2 hours of injury and with at least one episode of hypotension (systolic blood pressure <90 mmHg) or one episode of tachycardia (heart rate >110 bpm), were included.

Patients were pre-hospitally randomized to either the placebo group (100cc of sterile water) or the TXA group (1g of TXA in 100cc of sterile water).

The primary outcome was 30-day mortality.

What did the authors find?

A: 30-day mortality was significantly higher in the placebo group

B: 30-day mortality was not significantly different between both groups

C: 30-day mortality was significantly higher in the TXA group

The correct answer is B

The STAAMP trial (Study of Tranexamic Acid During Air Medical and Ground Prehospital Transport) was covered on St. Emlyns and RebelEM this week.

The STAAMP trial is a multicenter, double-blind, placebo controlled randomized trial. A total of 447 patients were randomized to the TXA group and 456 to the placebo group. No statistically significant difference in 30-day mortality was found between the placebo group and TXA group (9.9 vs 8.1%; 95% CI 5.6-1.9%; p=0.17).

Some limitations have to be taken into account. The trial was stopped early, was underpowered  and enrolled patients had an overall low injury severity (median ISS of 12).

Should we Rubber STAAMP Prehospital TXA?

Question 2

Source image: first10em.com/

 

You see a 30 year old male after a blow to the right eye. You suspect an orbital compartment syndrome (OCS) which warrants immediate treatment to present vision loss.
To prevent ischemia to the retinal and optic nerve you need to perform lateral canthotomy and inferior cantholysis (LCIC).

Which of the following statements is true about LCIC?

A: Globe rupture is the most common complication of LCIC

B: A Morgan Lens cannot be used as a shield to protect the globe

C: An intraocular pressure (IOP) greater than 30mmHg should be treated immediately

D: Delayed presentation is a contraindication for LCIC

The correct answer is C

This week, RebelEM covered Orbital Compartment Syndrome.

Globe rupture is indeed the most devastating complication of LCIC. The list of complications includes infection, damage to the lacrimal gland or artery, excessive bleeding, damage to the lateral rectus muscle and ptosis from levator aponeurosis injury.

A Morgan lens can be used to protect the globe but insertion can be challenging in patients with significant edema and ecchymosis.

An intraocular pressure (IOP) greater than 30mmHg should be treated immediately, but even without measurement of ocular pressure, clinical signs of orbital compartment syndrome warrant immediate treatment.

In 73% of the OCS cases patients returned to baseline vision after LCIC even after a delayed presentation beyond one hour after arrival.

Orbital Compartment Syndrome: Pearls and Pitfalls for the ED Physician

Question 3

This recently published paper is about the accuracy of diagnostics in septic arthritis in the ED.

Septic arthritis can be difficult to differentiate from other causes of monoarticular arthritis. In this study the investigators aimed to assess the diagnostic accuracy of synovial lactate, white blood cell count (WBC), gram stain, PCR, and clinical evaluation.

What did the investigators find?

A: Synovial L-lactate is a good predictor for septic arthritis

B: PCR of the synovial fluid showed to be accurate for the diagnosis of septic arthritis

C: Synovial WBC and gram stain are the best predictors for septic arthritis

D: Combination of history and physical exam showed to be a good predictor for septic arthritis

The correct answer is C.

This week Clay Smith covered this paper about diagnosis of septic arthritis.

In this study the prevalence of septic arthritis was 7% (out of 71 patients, so only 5 patients had septic arthritis). No findings on history or physical examination accurately ruled in or ruled out septic arthritis. Synovial L-lactate and PCR showed to be inaccurate for the diagnosis of septic arthritis.

Synovial WBC (in this study sens. 80% en spec 96%) and gram stain (in this study sens. 100% and spec 97%) were the best tests for septic arthritis.

Keep in mind this is a very small single centre study.

Question 4

Manual pulse checks by healthcare providers during cardiac arrest are pretty unreliable at best.

This recently published paper is about the validity of two-dimensional carotid ultrasound to detect the presence and absence of a pulse.

What did the authors find?

A: 2D ultrasound of the common carotid artery is both sensitive and specific for detection of the presence or absence of a pulse

B: 2D ultrasound of the common carotid artery is sensitive but not specific for detection of the presence or absence of a pulse

C: 2D ultrasound of the common carotid artery is specific but not sensitive for detection of the presence or absence of a pulse

D: 2D ultrasound of the common carotid artery is neither sensitive nor specific for detection of the presence or absence of a pulse

The correct answer is A

StEmlyns covered this recently published paper last week.

The concept of carotid ultrasonography instead of a manual pulse check sure is interesting. In theory, it should be a lot more sensitive compared to manual pulse checks, especially in low output states. This paper showed a sensitivity of detection of a pulse was 91%.

However, given the methodology of the paper this does not mean we can apply this technique in the ED yet as the patients included were undergoing routine bypass surgery, so this study was not performed in the ED. Furthermore, the ultrasound images were obtained without CPR in progress, by two experienced sonographers.

JC: Finger on the Pulse?

Question 5

 

Intoxications with calcium channel blockers (CCB), such as verapamil and diltiazem, are potentially very dangerous. Even a single pill can cause severe toxicity in children and pills with sustained release products can have delayed onset and prolonged toxicity.

Which of the following statements about the treatment of CCB overdose in children is true?

A: Asymptomatic patients need observation for a minimum of 6 hours

B: Activated charcoal is only indicated if ingestion was within an hour of presentation

C: Treatment of CCB intoxication with calcium is supported by plenty of evidence

D: High-dose insulin is considered first line therapy for patients with signs of myocardial dysfunction

The correct answer is D

Sean M. Fox from pediatric EM Morsels covered CCB overdose in children this week.

Although development of symptoms in asymptomatic patients later than 6 hours after ingestion is rare, consensus is to monitor for at least 24 hours.

Activated charcoal (0.5-1 g/kg) is typically used if ingestion was within the last 60 minutes but benefits may still be seen if ingestion is of large quantities of sustained-release products even after 1 hour.

It seems intuitive to give calcium in case of a CCB overdose. However, as with almost every treatment in toxicology, supporting evidence is scarce. 10% calcium calciumgluconate (60 mg/kg) is prefered over 10% calciumchloride (20 mg/kg) since this is better tolerated in peripheral veins.

Finally, CCB overdose causes a hypoinsulinemic state which could cause hyperglycemia and decreased glucose uptake by myocardial and end organ tissues. High-dose insuline (1IE/kg) followed by infusion of 1IE/kg/hr) is considered first-line therapy in patients with signs of myocardial dysfunction in order increase inotropy and overcome hypoinsulinemia and insulin resistance.

Calcium Channel Blocker Overdose in Children

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 87, October 23th, 2020

Welcome to the 87th FOAMed Quiz. 

We’re back after a small break, enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Source image: coreem.net

A healthy 15 month old boy presents to your ED after suspicion of swallowing a button battery. The parents saw the boy playing with the remote control which he opened. The battery was nowhere to be found and parents think he may have swallowed the battery.

Which of the following statements is true about battery-related injuries?

A: Damage occurs hours after ingestion and not directly

B: For damage control until removal, no therapies are indicated

C: Complications after removal can present late (even after more than 9 days)

D: After removal of the battery no following therapy is necessary

The correct answer is C

This week Sean Fox covered Button Batteries in the Esophagus on PedEM Morsels.

Tissue damage is due to isothermal hydrolysis reaction and alkaline caustic exposure. When placed in a moist environment an electrical charge is generated. This electrical charge hydrolyses water generating hydroxide ions, which are leading to alkaline injury.

Tissue damage starts even within 2 hours. Damage continues after removing the battery and complications can present after 9 days up to even weeks later.

Removing the battery is imperative. Honey (children > 1 year) or sucralfate may reduce the severity of esophageal burns and improve patient outcomes. After removal a weak acid can reduce continued liquefaction necrosis.

Neutralize Button Battery in the Esophagus

Souce image: www.pixabay.com

Question 2

As the COVID pandemic reaches a second peak in our country, more data emerges on treatment options. Lopinavir – Ritonavir (Kaletra) has been regarded as a potentially useful drug, although evidence available so far does not show any benefit.

The RECOVERY trial is an overarching trial design that looks at different treatment options simultaneously. This paper is about the Lopinavir-Ritonavir (Kaletra) arm of the RECOVERY trial.

What does the trial show about the efficacy of Lopinavir-Ritonavir?

A: Lopinavir-Ritonavir reduced mortality at day 28

B: Lopinavir-Ritonavir reduced time to hospital discharge at day 28

C: Lopinavir-Ritonavir reduced progression to receipt of mechanical ventilation

D: Lopinavir-Ritonavir did not show any benefit 

The correct answer is D

The Lopinavir – Ritonavir arm of the RECOVERY trial was discussed at The Bottom Line last week.

1616 COVID patients admitted to hospital received Lopinavir-Ritonavir and 3424 patients were allocated usual care. Only 4% of the patients included were invasively mechanically ventilated.

Time to hospital discharge (median 11 days vs. 11 days), progression to receipt of mechanical ventilation (10% vs. 9%) and mortality at day 28 (22% vs. 22%) did not show any difference. 

RECOVERY: COVID-19 Kaletra

Source image: ww.pixabay.com

Question 3

A 16-year old male presents to your ED after ´twisting his right ankle’ on the football pitch. He cannot bear weight, but the ankle does not appear swollen. An X-ray is made (lateral view not shown here).

Source image: dontforgetthebubbles.com

Which of the following is the most likely diagnosis?

A: Tillaux fracture

B: Triplane fracture

Don’t Forget The Bubbles covered Tillaux fractures last week.

Both Tillaux fractures and Triplane fractures are considered transitional fractures, which occur in patients with partially closed growth plates.

In case of a Tillaux fracture, an avulsion of the distal tibia epiphysis by the tibiofibular ligament.

In case of a Triplane fracture, in addition to a epiphyseal fracture similar to the Tillaux fracture, the physis is separated in the axial plane and the metaphysis is fractured on the posterior aspect in the coronal plane.

Both fractures are caused by supination and external rotation of the foot. Patient with a Tillaux (average age is fracture tend to be a little older than patients with a triplane fracture (average age is 13 years).

The lack of a fracture through the coronal plane distinguishes this injury from that of a triplane fracture.

https://dontforgetthebubbles.com/tillaux-fractures/ 

Question 4

Source image: litfl.com

A 46-year old female patient presents to your emergency department with severe chest pain. She does not have a medical history, does not smoke and also never experienced this pain before.

Her ECG shows an anterior OMI while her troponines are not (yet) elevated. The cardiologist takes her to the cath lab and performs a coronary angiography which shows a spontaneous coronary arterial dissection (SCAD) of the left anterior descending (LAD) coronary artery.

Which of the following statements about SCAD is true?

A: Male gender is a known risk factor

B: Cardiac enzymes are rarely elevated

C: The left coronary artery (LAD) is most commonly affected

D: Treatment always includes PCI or CABG

The correct answer is C

Muhammad Durrani covered SCAD on REBELEM this week.

SCAD is defined as a non-traumatic and non-iatrogenic tear in the coronary arterial wall. It accounts for approximately 1-4% of ACS cases overall.

Women, especially <50 years old, are at highest risk. The diagnosis is difficult to make and patients may mistakenly be discharged due to their relatively young age and lack of cardiovascular risk factors. Cardiac enzymes are frequently elevated and the most commonly affected vessel is the LAD, followed by the left circumflex artery and RCA.

A conservative approach is recommended unless there is ongoing ischemia, hemodynamic instability, or left main dissection might need PCI or CABG.

Spontaneous Coronary Artery Dissection (SCAD)

Source image: www.emdocs.net

Question 5

Puncture wounds can be associated with complications such as soft tissue infections and deep abscesses.

Which of the following statements is true about puncture wounds?

A: Puncture wounds through a rubber sole have increased risk of pseudomonas infection and therefore osteomyelitis

B: The risk of an infection in puncture wounds is about 50% and 20% of these patients will develop osteomyelitis

C: Ultrasound has a low specificity and sensitivity for the detection of foreign bodies

The correct answer is A

EMDocs covered puncture wounds this week.

Pseudomonas infections are commonly seen when puncture injury occurs through rubber soles. Infection with Pseudomonas is the most common cause of osteomyelitis. In approximately 10% of the puncture wounds an infection is seen and 1-2% of patients will develop osteomyelitis.

Ultrasound can be used for the detection of foreign bodies and has a sensitivity of 87% and specificity of 97%. A benign course is seen in the majority of the puncture wounds if a foreign body is not retained. 

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 86, September 25th, 2020

Welcome to the 86th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

This multicentre randomized trial, published this month is about the effect of vitamin D and calcium in patients with Benign Paroxysmal Peripheral Vertigo (BPPV) in addition to standard canalith repositioning manoeuvres.

What did the authors find?

A: Vitamin D and calcium reduced the number of episodes per year

B: Vitamin D and calcium increased the number of episodes per year

C: Vitamin D and calcium had no effect on the number of episodes per year

The correct answer is A

This week, Clay Smith covered treatment of Benign Paroxysmal Peripheral Vertigo.

Otoconia, causing the otolithic membrane to be heavier than the surrounding fluid, are made of calcium crystals. Low calcium may lead to higher turnover and release of crystalline debris and therefore causing BPPV. Despite its limitations this study showed a benefit with treatment compared to the group without treatment resulting in a reduction of number of episodes.

Source image: www.pixabay.com

Question 2

Your 43 year old patient presents with rapidly progressive aphasia and right hemiparesis. Vital signs are unremarkable except for a fever (39.0 ℃ = 102.2 ℉). Cerebrospinal fluid PCR is positive for Herpes Simplex Virus (HSV).

Which of the following statements about HSV encephalitis is true?

A: HSV-2 constitutes 90% of encephalitis in adults and children

B: Almost all patients with HSV encephalitis ultimately have seizures

C: The in hospital mortality is as high as 15 percent despite adequate treatment

D: All patients with HSV encephalitis should receive dexamethasone in addition to acyclovir

The correct answer is C

HSV encephalitis was covered on BrownEM this week.

HSV-1 accounts for 90% of encephalitis in adults and children.

Classically, we are taught to think of HSV encephalitis whenever a patient presents with altered mental status and seizures; however, only about half of patients ultimately have seizures

Nearly 20% of patients require mechanical ventilation with around 11-15% in-hospital mortality.

There is no role for dexamethasone in HSV encephalitis. Early IV acyclovir continues to be the treatment of choice.

Source image: coreultrasound.com

Question 3

A 56 year old patient comes in with acute and progressive vision loss on his right eye. He also complains about floaters for a few days. You decide to perform ocular ultrasound and you see the following:

You doubt whether this is a retinal detachment or a posterior vitreous detachment.

Which of the following signs make retinal detachment more likely than vitreous detachments?

A: The detachment crossing the midline (surpassing the optic disc)

B: Retinal detachment is visible in low gain (the retina is less echogenic compared to the abnormality seen in vitreous detachment)

C: Presence of vitreous hemorrhage

D: “swaying seaweed” or aftermovements (after the eye stops moving)

The correct answer is B

Core Ultrasound covered ocular ultrasound last week. 

When in doubt whether you are looking at retinal detachment of posterior vitreous detachment, keep in mind that:

In retinal detachment the flap will be attached firmly to the optic nerve sheath, not crossing the midline

A retinal detachment appears ´thicker´ compared to posterior vitreous detachment.

Vitreous hemorrhage does not make retinal detachment more likely, but it can occur secondary to posterior vitreous detachment (so secondary to retinal detachment as well).

Swaying seaweed appearance (the visible membrane keep moving slowly after the eye stopped moving) makes posterior vitreous detachment more likely.

Case courtesy of Dr David Cuete, Radiopaedia.org, rID: 23768

Question 4

Which of the following can cause a false negative cranial CT in patients with suspected subarachnoid hematoma?

A: Severe anemia

B: Scanning less that 1 hour after start of symptoms

C: Polycythemia 

The correct answer is A

Justin Morgenstern covered the diagnosis of subarachnoid hemorrhage on First10EM this week.

Sensitivity of non contrast cranial CT for subarachnoid hemorrhage is very high (although not 100%) when performed within 6 hours after start of symptoms.

One of the known causes of false negative cranial CT when evaluating for hemorrhage is severe anemia.

Subarachnoid Hemorrhage: What is the role of LP?

Source image: www.aliem.com

Question 5

Your 76 year old patient presents with progressive abdominal pain. He looks ill. CT shows portal venous gas.

Which of the following is the most common cause of venous portal gas?

A: Trauma

B: Decompression syndrome

C: Life-threatening gastrointestinal problem

D: Tension pneumothorax

The correct answer is C

Portal venous gas was covered by AliEM last week.

Hepatic portal venous gas (HPVG) is the accumulation of gas in the portal vein and its branches. It usually indicates a life-threatening gastrointestinal problem.

When HPVG is associated with bowel ischemia, there is usually transmural necrosis and a high mortality rate.

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 85, September 18th, 2020

Welcome to the 85th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Pediatric Inflammatory Multisystem Syndrome (PIMS) is a recently described clinical syndrome associated with COVID-19 infection. Children present with persistent fever and other nonspecific symptoms. It can present with mucocutaneous, gastrointestinal, dermatologic, neurologic or cardiac manifestations.

Which of the following statements about PIMS is true?

A: Most patients with PIMS only have mild symptoms

B: It affects mostly children with pre existing comorbidity

C: About 2 percent of the patients require inotropic support

D: Myocarditis prevalence increases with age

The correct answer is D

First10EM covered PIMS this week. This syndrome is also known as multisystem inflammatory syndrome in children.

It is a febrile inflammatory syndrome associated with covid-19 infections and can present with a wide variation of symptoms. It affects mostly previously healthy children.

It presents 3 to 6 weeks following exposure to covid-19 virus and can progress rapidly to multiorgan dysfunction.

80 percent of the children have cardiac involvement, and prevalence of myocarditis increases with age.

80 percent of the children are admitted to the intensive care unit, and 50 percent need inotropic support.

Pediatric Inflammatory Multisystem Syndrome (PIMS)

Source image: www.pixabay.com

Question 2

Your 61 year old male patient with a history of diabetes and myocardial infarction presents with diffuse abdominal pain which began after eating dinner. This is the first time he experiences these symptoms. Physical exam reveals a mild diffuse tenderness of the abdomen. CTA reveals bowel ischemia.

Which of the following etiologies is most likely to be the cause of the bowel ischemia in this patient?

A: An arterial embolic occlusion

B: An arterial thrombotic occlusion

C: Arterial non-occlusive ischemia

D: A venous occlusion

The correct answer is A

Mesenteric ischemia was covered on emDOCs this week.

Mesenteric ischemia is known to have several distinct etiologies.

The majority of cases (60%) of mesenteric ischemia are caused by an arterial embolism. Most commonly the superior mesenteric artery (SMA) and less frequently in the celiac artery or inferior mesenteric artery (IMA) are occluded. These patients commonly have atrial fibrillation and often present with a severe sudden abdominal pain which is out of proportion to abdominal tenderness during physical examination.

Thrombotic occlusion of the mesenteric arteries may present with similar acuity or a more progressive onset depending on the preexisting vessel disease and collateral flow.

Mesenteric vein thrombosis presents more insidiously with vague abdominal pain and risk factors include hypercoagulability which can be seen in sepsis, malignancy, liver disease, portal hypertension and thrombophilias.

Nonocclusive arterial mesenteric ischemia results from inadequate supply of blood due to an underlying critical illness or treatment with eg. vasopressors.

Source image: www.pixabay.com

Question 3

Patients with Sickle Cell disease develop symptoms when polymerisation of hemoglobin occurs leading to ‘sickling’ of red blood cells. This process is often triggered by hypoxia or other underlying illness of stress.

Different types of Sickle Cell disease exist, depending on the genetic combination coding for hemoglobin.

Which of the following genetic combinations results in the most severe form of Sickle Cell disease?

A: HbAS: HbA (normal Hb) and HbS (Sickle cell Hb)

B: HbSS: Homozygous for HbS

C: HbSβ: HbS and Hbβ (Beta Thalassemia)

D: HbSC: HbS and HbC (abnormal hemoglobin forming crystals)

The correct answer is B

Don’t forget the Bubbles covered Sickle Cell disease last week.

In sickle cell anaemia, individuals are homozygous for HbS (HbSS). This is the most frequent and severe form of the disease.

Patients with Sickle Cell trait (HbAS) usually do not develop symptoms and are not considered to have Sickle Cell disease.

In patients with Sickle Cell beta Thalassemia the frequency and severity of symptoms vary based on the mount normal Hb (HbA) still formed (not all beta Thalassemia result in the absence of formation of normal Hb).

In HbSC disease, HbC does not participate in polymerization leading to less frequent and severe symptoms compared to HbS disease.

Question 4

Which of the following is not part of the classic triad in Wernicke Encephalopathy (WE)?

A: Cachexia

B: Ataxia

C: Altered mental status

D: Ophthalmoplegia

The correct answer is A

Anand Swaminathan recorded a podcast on RebelEM about Wernicke Encephalopathy.

The classic triad consists of ataxia, altered mental status and ophthalmoplegia. However, the full triad is present in only 10 percent of patients with WE. Therefore, suspect Wernicke encephalopathy in any patient that is at risk of malnutrition or malabsorption and has any one of the classic symptoms.

REBEL Core Cast 40.0 – Wernicke Encephalopathy

Source image: www.pixabay.com

Question 5

In patients pulmonary embolism (PE), the majority of patients has a low 30-day mortality risk. These patients can be identified by clinical decision tools such as PESI, sPESI and Hestia Criteria and can be managed as an outpatient.These patients are most often treated with either a DOAC or a vitamin K antagonist (VKA). Outpatient treatment of low risk PE with VKA seems to be safe, but data are sparse regarding outcomes for patients with low-risk PE treated with DOACs as outpatients.

This systematic review is about the outcome of patients discharged from the ED with low risk PE and the association with anticoagulation class (DOAC vs vitamin K antagonist).

The authors investigated major adverse outcomes (all-cause mortality, PE-related mortality, recurrent VTE, and major bleeding) within 90 days from discharge from the ED.

What did the authors find?

A: Major adverse outcomes were very low in both patients treated with VKA and patients treated with DOAC

B: Major adverse outcomes were more common in patients treated with VKA compared to patients treated with DOAC

C: Major adverse outcomes were more common in patients treated with DOAC compared to patients treated with VKA

D: Major adverse outcomes were unacceptably high in both patients treated with VKA and patients treated with DOAC

The correct answer is A.

Bo Stubblefield covered this systematic review on journalfeed this week.

There were very low rates of major adverse outcomes in both patients treated with VKA and patients treated with DOA. The 90 day all cause mortality was 0.7%. No episodes of recurrent VTE of major bleeding were reported in the majority of included studies. 

No significant association has been found between class of anticoagulant and rates of major adverse events.

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 84, September 11th, 2020

Welcome to the 84th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Source image: https://rebelem.com/

 The CoDEX trial is another trial about dexamethasone as treatment of Covid.

Patients with moderate to severe ARDS (receiving mechanical ventilation within 48hrs of meeting criteria for moderate to severe ARDS (P/F ratio ≤200)) were randomised to either dexamethasone plus standard care (n=151) or standard care (n=148).

The primary outcome was ventilator free days during the first 28 days.

What was the effect of dexamethasone treatment on ventilator free days in this patient population?

A: Patients in the dexamethasone group had more ventilator free days during the first 28 days after enrollment

B: Patients in the standard care group had more ventilator free days during the first 28 days after enrollment

C: There was no difference in ventilator free days between patients in both groups

The correct answer is A

Salim Rezaie covered three recently published trials about corticosteroids and Covid last week.

This RCT showed a difference of ventilator free days of 2.6 in favor of the dexamethasone group (6.6 vs 4.0, p=0.04). The study was underpowered for secondary outcomes (mortality).

It’s Raining Steroids in COVID-19: REMAP-CAP, CoDEX, & CAPE COVID

Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 7132

Question 2

You see a 25 year old patient with suspected first time anterior shoulder dislocation. You wonder if POCUS is reliable to confirm your suspicion to speed up reduction of the shoulder.

Which of the following is true about POCUS in shoulder dislocations according to this paper?

A: Sensitivity of POCUS for shoulder dislocations is 100 percent

B: Time to diagnosis using POCUS is equal compared to x-ray

C: Sensitivity of POCUS for non Hill Sachs fractures is 100 percent

The correct answer is A

This week’s ultrasound gel podcast is about this recently published paper about POCUS in shoulder dislocation.

A novel technique of posterior shoulder ultrasound showed perfect accuracy for diagnosing shoulder dislocation and reduction. For non Hill Sachs fractures the sensitivity of POCUS was 92 percent (including Hill Sachs and Bankart lesion the sensitivity dropped significantly). Time to diagnosis was almost twice as fast in the pocus group.

Source image: https://www.ultrasoundgel.org/

 

Question 3

In the ACTT-1 trial Remdesivir was not effective in the really sick (HFNC, NIV, IMV, and ECMO) and completely useless in patients that didn’t need O2. It seems the moderately ill might benefit from Remdesivir.

This paper, published last week, is about the effect of Remdesivir in just this patient group.

Patients with pulmonary infiltrates on X-ray and with room air oxygen saturation >94% were randomised to either a 10-day course of remdesivir, a 5-day course or remdesivir and standard care (no remdesivir). The primary outcome was clinical status on day 11 on a 7-point ordinal scale (ranging from death to discharged from hospital).

What did the result show?

A: Patients receiving 10 days Remdesivir had significantly better clinical status on day 11 compared to patients receiving standard care alone

B: Patients receiving 5 days Remdesivir had significantly better clinical status on day 11 compared to patients receiving standard care alone

C: Patients receiving 10 days Remdesivir had significantly better clinical status on day 11 compared to patients receiving 5 days Remdesivir

D: Patients receiving standard care alone had significantly better clinical status on day 11 compared to patients receiving standard care 10 days Remdesivir or 5 days Remdesivir

The correct answer is B

Salim Rezaie covered this paper on RebelEM last week.

596 patients were randomized to either a 10-day course of remdesivir, a 5-day course of remdesivir and standard care (no remdesivir).

Only the 5 day remdesivir group did significantly better than the standard care alone group (OR 1.65; 95% CI 1.09 – 2.48; p = 0.02). Interestingly, the 10 day remdesivir group did not statistically better (by far).

This is even more remarkable when considered the patient in the 10 day remdesivir group only used remdesivir for 6 days on average. This leaves the question whether the effect seen in the 5-day arm is just random chance.

Only 76% of patients completed therapy in the 5 days group and 38% in the 10 days group.

So, yet another paper with some major methodological issues leaving the question whether or not to embrace Remdesivir as an effective drug for Covid unanswered.

Remdesivir in Moderate COVID-19

Question 4

Your 34 year old patient presents with a pelvic fracture after a motor vehicle collision. Opioid and NSAIDs are inefficient for pain control. Your next step is low dose ketamine and you consider slow continuous infusion (SI) instead of iv push (IVP) to prevent the patient freaking out (like your last patient did).

This paper is about iv push versus slow continuous infusion of ketamine for analgesia. 48 patients were randomised to either IV push ketamine (0.3 mg/kg) or mixed in a 100cc NS bag and infused over 15 minutes.

What does the evidence say about iv push versus slow continuous infusion of ketamine for analgesia?

A: Patients were more likely to experience a feeling of unreality at any time in the IV push group compared to the slow infusion group

B: Patients in the slow infusion group had a higher degree of sedation compared to the slow infusion group at 5 minutes

C: Patients in the slow infusion group had larger a decrease in mean pain scores from baseline to 15 minutes compared to the slow infusion group at 5 minutes

The correct answer is A

Taming the SRU covered 3 quite important papers on ketamine last week. Among them this paper on ketamine iv push versus slow continuous infusion for analgesia.

Patients were more likely to experience a feeling of unreality at any time in the IV push group compared to the slow infusion group (91.7% vs 54.2%, p=0.008).

Patients in the IV push group had a higher degree of sedation compared to the slow infusion group (RASS -2 versus RASS 0, p=0.01).

Decrease in mean pain scores from baseline to 15 min was similar across groups: 5.2 ± 3.53 (95% CI 3.7–6.7) for IVP; 5.75 ± 3.48 (95% CI 4.3–7.2) for SI.

Question 5

Source image: https://pixabay.com/

Your 38 year old female patient comes in with a severe headache which is rapidly increasing over the past few days. She is overweight and her past medical history includes migraine and a pulmonary embolism. She tells you that this headache is different from previous episodes of migraine. Your differential diagnosis includes a cerebral venous sinus thrombosis.

Which of the following statements about diagnostic tools for cerebral venous sinus thrombosis is true?

A: A negative D-dimer excludes cerebral venous sinus thrombosis as a diagnosis

B: Lumbar puncture is part of the standard work-up in patients with suspected cerebral venous sinus thrombosis

C: CT-venogram and MRI-venography are both equally accurate in diagnosing a cerebral venous sinus thrombosis

The correct answer is C

Josh Farkas covered cerebral venous sinus thrombosis on the Internet Book of Critical Care this week.

Symptoms and chief complaints in patients with cerebral venous thrombosis are variable and non specific. They include headache, focal neurologic findings, seizure and encephalopathy.

The diagnosis is difficult and the sensitivity of D-dimer varies between 82-94%. The diagnosis can therefore not be excluded solely based on a D-dimer. Lumbar puncture is not indicated for this condition but may be performed as part of a broader evaluation to exclude infection. Imaging findings can be divided between direct (visualising the clot itself) and indirect signs (hemorrhage or edema as a consequence of the clot).

IBCC chapter & cast – Cerebral Venous Thrombosis

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 83, September 4th, 2020

Welcome to the 83th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

The recently published THALES trial is about Ticagrelor and Aspirin versus Aspirin alone in patients with acute ischemic stroke (NIHSS score of 5 or less who were not undergoing intravenous or endovascular thrombolysis) or TIA. Ticagrelor is not dependent on metabolic activation (as opposed to clopidogrel) and its efficacy might be more reliable compared to clopidogrel.

What did the authors find?

A: Patients in the ticagrelor + aspirin group had a higher incidence of subsequent ischemic stroke compared to patients on aspirin alone

B: Patients in the ticagrelor + aspirin group had a equal rate of severe hemorrhage and cerebral hemorrhage compared to patients on aspirin alone

C: Patients in the ticagrelor + aspirin group had a equal incidence of overall disability compared to patients on aspirin alone

The correct answer is C.

Benjamin Gerritsen covered the THALES trial on REBELem this week.

The authors randomized 11016 patients.

Patients in the ticagrelor + aspirin group had a lower incidence of subsequent ischemic stroke at 30 days compared to patients on aspirin alone. However, no benefit of ticagrelor + aspirin over aspirin alone was found on overall disability and mortality. A higher incidence of severe bleeding was noted in the ticagrelor + aspirin group compared to the aspirin alone group.

The THALES Trial: Ticagrelor and Aspirin vs Aspirin Alone in Acute Ischemic Stroke or TIA

Source image: www.pixabay.com

Question 2

You find yourself working in a ski-resort at 2700 meters. A 45 year old man comes in with profound respiratory distress. He normally lives at sea level and came for holidays to the mountains. You give supplemental oxygen and plan for descent.

Which of the following drugs can be considered in treatment of acute high altitude pulmonary edema (HAPE)?

A: Acetazolamide

B: Nifedipine

C: Dexamethasone

D: Sildenafil

The correct answer is B

NuEM covered Acute Mountain Sickness (AMS), High Altitude Cerebral Edema (HACE) and High Altitude Pulmonary Edema (HAPE).

The mainstay of treatment of severe HAPE is supplemental oxygen and descent.

Acetazolamide is used as prophylaxis for AMS and HACE and might be beneficial as prophylactic medication for HAPE as well. It has no role in acute HAPE.

Dexamethasone is used for treatment of HACE or severe AMS. It might be beneficial in HAPE prophylaxis, but this is controversial.

Sildenafil has been shown to be effective as prophylaxis for HAPE, but has not been studied as treatment for acute HAPE.

Nifedipine is the preferred agent for prophylaxis and treatment of HAPE, although not a large body of evidence is available so for. The dosage is 60 mg extended-release orally divided daily (30 mg orally every 12 hours; or 20 mg orally every 8 hours).

 

Question 3

Source image: www.pixabay.com

Appendicitis can be a challenging diagnosis in the ED.

How accurate is physician gestalt in appendicitis according to this recently published paper?

A: Physician gestalt for acute appendicitis diagnosis performed poorly

B: Physician gestalt for acute appendicitis diagnosis performed well, especially in high-risk patients

C: Physician gestalt for acute appendicitis diagnosis performed well, especially when employed by experienced physician

The correct answer is C

BrownEM covered this paper last week.  

This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9 years with a chief complaint of abdominal pain. 

Physician gestalt for acute appendicitis diagnosis performed well, especially in low‐risk patients and when employed by experienced physicians.

Question 4

High sensitive troponin rule-out and rule-in strategies are not really uniform around the world. There are huge differences in used protocols between continents, countries and even between hospitals in the same region.

We slowly seem to move towards shorter time interval troponin testing (0 and 1 hour / 0 and 3 hour).

This recently published paper evaluated a 0 and 1 hour rule-out and rule-in strategies (among others), using a new high-sensitivity cardiac troponin I (hscTnI) assays from Siemens Healthineers. The primary outcome was meeting STEMI test criteria according to the 3rd Universal Definition of Acute Myocardial Infarction.

Which of the following statements is true?

A: The 0 and 1 hour rule out strategy had a sensitivity of 79.7 percent for Acute Myocardial Infarction (NSTEMI)

B: The 0 and 1 hour rule out strategy had a sensitivity of 98.7 percent for Acute Myocardial Infarction (NSTEMI)

C: The 0 and 1 hour rule in strategy had a sensitivity of 79.7 percent for Acute Myocardial Infarction (NSTEMI)

D: The 0 and 1 hour rule in strategy had a sensitivity of 98.7 percent for Acute Myocardial Infarction (NSTEMI)

The correct answer is B 

CoreEM covered this paper last week. 

It turns out a 0 and 1 hours rule-out strategy actually has a very high sensitivity in this US population using this TnI assay.

Source image: coreem.net

Performance of Novel High-Sensitivity Cardiac Troponin I Assays for 0/1-Hour and 0/2- to 3-Hour Evaluations for Acute Myocardial Infarction: Results From the HIGH-US Study

Question 5

A 64-year old female patient is brought in by EMS after she was found unconscious and cyanotic. She has a known history of dermatitis herpetiformis for which she is treated with dapsone. The first thing you notice when you look at her is the blue color of her skin. Your differential diagnosis includes methemoglobinemia.

Which of the following clinical findings are typically found in profound methemoglobinemia?

A: The presence of a peripheral oxygen saturation in the 80’s, improving with oxygen administration

B: Cherry red colour of blood

C: An arterial blood gas with a high PaO2 combined in combination with a low peripheral oxygen saturation

The correct answer is C.

Methemoglobinemia was covered by Justin Morgenstern on First10EM this week.

Methemoglobinemia can be congenital or acquired (exposure to certain medicines, chemicals or foods). Typical symptoms include headache, shortness of breath, nausea, tachycardia, confusion and loss of consciousness.

Patients with profound methemoglobinemia appear cyanotic with saturations below 80%. Saturation levels do not improve with oxygen administration.

The diagnosis is confirmed by an arterial blood gas (typical chocolate brown blood) with elevated methemoglobin levels. The treatment consists of methylene blue 1-2 mg/kg infused over 5 minutes. Methylene blue is contra-indicated in patients with a known G6PD deficiency.

Methemoglobinemia

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 82, August 28th, 2020

Welcome to the 82th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Critically ill patients admitted to the intensive care unit (ICU) with acute kidney injury have a higher morbidity and mortality.

The authors of the STARRT-AKI study compared accelerated initiation of Renal Replacement Therapy (RRT) and standard strategy of RRT initiation to investigate if this would result in lower risk of death from any cause at 90 days.

What did the authors find?

A: In the accelerated strategy group a smaller percentage of the patients were dependent on RRT at 90 days

B: There is no significant difference in mortality between early RRT initiation and standard initiation

C: In the accelerated strategy group more serious adverse events were seen compared to the standard RRT initiation. 

The correct answer is B

This week Mark Ramzey covered the STARRT AKI trail on RebelEM.

A larger percentage of the patients in the accelerated strategy group were dependent on RRT at 90 days. The authors suggest longer exposure to RRT can compromise kidney recovery.

There was no difference in serious adverse events between the two strategies.

This is not the first study that shows no significant difference in mortality between early RRT and standard or delayed RRT.

STARRT-AKI Trial: Timing of Renal Replacement Therapy Initiation in Acute Kidney Injury

Source image: www.pixabay.com

Question 2

Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome (or PFAPA) is a pretty rare syndrome, yet it is still the most common periodic fever syndrome in children.

Which of the following statements is true about the management and prognosis of PFAPA?

A: A single dose of corticosteroids will rapidly resolve the PFAPA symptoms in about 90% of patients

B: Colchicine is the most effective treatment for active PFAPA

C: The prognosis is poor. This syndrome leads to long term sequelae very often

D: Episodes of PFAPA generally seize spontaneously 3-5 years after symptoms onset

The correct answer is A

First10EM covered PFAPA this week.

It is a disease of unknown etiology that is characterized by clock-work regular episodes of fever, aphthous stomatitis, pharyngitis, and cervical adenitis.

A single dose of corticosteroids will rapidly resolve the PFAPA symptoms in about 90% of patients.

Colchicine has been used prophylactically to reduce the number of attacks.

The prognosis is excellent. The syndrome does not induce any long term sequelae and is not associated with comorbidities. It generally resolves spontaneously 3-5 years after symptoms onset.

PFAPA: Periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome

Source image: www.nuemblog.com

Question 3

Lightning injuries are not often seen in the Emergency Department. The majority of subjects struck by lightning survive. However, 10% of injuries are fatal. Lightning (as any electrical current) follows the path of least resistance. 

What is the right order of conductivity of tissues, starting with the tissue with the best conductive properties? 

A: fat – muscle – nerve – skin – bone

B: bone – nerve – muscle – skin – fat

C: fat – muscle – skin – fat – nerve – bone

D: nerve – muscle – skin – fat – bone

The correct answer is D

NuEM covered lightning injuries last week. 

´´Lightning strikes can cause primarily neurologic injury, but the most common fatal complications are cardiac and respiratory arrest. This is due to the relative nature of conductivity of the various organs in the body, with lightning following the path of least resistance. The order of conductivity is: nerve > blood > muscle > skin > fat > bone ´´

Question 4

In infants with traumatic brain injury the challenge lies in finding those with clinically important brain injury (ciTBI) while limiting the use of radiation exposure from CT imaging.

The Infant Scalp Score (ISS) is a risk stratification tool for infants under 1 year of age with isolated scalp hematoma who are otherwise asymptomatic, well-appearing, but may still be getting head CTs when guided by existing clinical decision aids.

source image: journalfeed.org

This recently published paper is about the validation of the Infant Scalp Score (ISS) to stratify risk for traumatic brain injury in infants with isolated scalp hematoma.

What did the authors find?

A: Using a scalp score cutoff of ≥7 to obtain a cranial CT, no TBI and no ciTBI would be missed

B: Using a scalp score cutoff of ≥6 to obtain a cranial CT, no TBI and no ciTBI would be missed

C: Using a scalp score cutoff of ≥4 to obtain a cranial CT, no TBI and no ciTBI would be missed

The correct answer is C

This week JournalFeed covered the Infant Scalp Hematoma Score.

This easy to use risk stratification tool seems to be helpful in avoiding CT’s in the very young.

No infant with an ISH and an infant scalp score < 4 had TBI found on CT.

No infant with an ISH and an infant scalp score <5 had a ciTBI defined as death, need for neurosurgical intervention, intubation for at least 24 hours or hospitalization for two or more nights for TBI.

Source image: www.coreem.net

Question 5

Which of the following statements about a Maisonneuve fracture is true?

A: A Maisonneuve fracture should be suspected in all patients with fractures of the medial and / or posterior malleolus

B: Maisonneuve fractures are seen in 15% of all ankle fractures

C: A distal positive ‘’Squeeze test’’ suggests more severe injury to the tibiofibular syndesmosis than a more proximal positive ‘’Squeeze test’’

D: Weakness of ankle dorsiflexion, subtalar foot eversion and/or numbness along the lateral lower leg and dorsum of the foot should raise clinical suspicion for a Maisonneuve injury due to a damaged sural nerve

The correct answer is A

Maisonneuve fractures were covered by Jessica Tsao from CORE EM this week.

A Maisonneuve fracture is defined by the combination of a proximal fibula fracture and an unstable ankle joint injury. It involves an injury of the distal tibiofibular syndesmosis and/or fracture of the medial or posterior malleolus and it is seen in 5% of all ankle fractures.

The ‘’Squeeze test’’ is performed by giving compression on the tibia and fibula simultaneously and is considered positive when ankle or distal lower leg pain is felt. The more proximal the test is positive, the more severe the injury to the syndesmosis is and therefore the more likely a Maisonneuve fracture is.

The common peroneal nerve can be damaged in a Maisonneuve fracture since it courses over the fibular head.

Maisonneuve Fractures

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This quiz was written by Eefje Verschuuren, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen