Quiz 177, January 26th, 2023

Welcome to the 177th FOAMed Quiz.

 

Question 1

Source image: www.freepik.com

Your patient comes in with vomiting and a distended, painful abdomen. 3 years ago he had an hemicolectomy because of Crohn’s disease, which has been stable ever since.

You suspect bowel obstruction.

Which of the following findings on POCUS is most sensitive for small bowel obstruction?

A: Fluid filled bowel with extra-luminal free air

B: Bowel wall thickening (> 3 mm)

C: Decreased peristalsis and retrograde peristalsis

D: Dilated loops of small bowel (diameter > 2.5 cm)

The correct answer is D.

Small bowel obstruction was covered on RebelEM last week.

Dilated loops of small bowel is the most sensitive and specific finding for small bowel obstruction. The other signs mentioned above can be found as well.

A normal lactate or plain X-ray does not rule out the diagnosis. POCUS has a high positive (9.5 (2.1 – 42.2)) and a low negative (0.04 (0.01 – 0.13)) likelyhood ratio. 

REBEL Core Cast 94.0 – SBO

Question 2

Your resident mentions your patient has a Insall-Salvati ratio of 1.4 on the X-ray.

What is she talking about?

A: A patient with suspected patellar tendon rupture

B: A patient with suspected achilles tendon rupture

C: A patient with suspected biceps tendon rupture

D: A patient with suspected supraspinatus muscle rupture

The correct answer is A.

AliEM covered the patellar tendon rupture last week.

The Insall-Salvati ratio or index is the ratio of the patella tendon length to the length of the patella on a 30° flexed lateral knee x-ray and is used to determine patellar height.

Source image: www.radiopaedia.org

SplintER Series: Patellar Tendon Rupture

Question 3

Source image: www.technopower.com.bd

Your patient presents in profound cardiogenic shock and respiratory insufficiency. He does not tolerate non-invasive ventilation and you put him on High Flow Nasal Cannula (HFNC) therapy.

Which of the following statements is true about HFNC in this patient?

A: HFNC will likely decrease his hypercarbia

B: HFNC is less well tolerated than non invasive ventilation

C: HFNC will provide some PEEP

D: HFNC can be administered to a maximum of 100 L/min

The correct answer is C

Cardiogenic shock was covered on EMDocs last week.

HFNC is a very useful tool in patients with respiratory insufficiency. Although its main goal is to optimize oxygenation by matching inspiratory flow rates and deliver humidified and warm oxygen with an adjustable FiO2, it also decreases hypercarbia slightly by providing a washout effect of the upper airway dead space.

It can deliver some PEEP (some say up to 7 cm H2O) and can provide up to 60 L/min flow.

http://www.emdocs.net/cardiogenic-shock-emergency-department-focused-management/

Question 4

Which of the following medication delivery devices is worst for the environment?

A:

Source image: www.pharmtech.com

B: 

Source image: BBC.co.uk

C: 

Source image: www.thehealthy.com
The correct answer is A. Don’t forget the Bubbles covered inhalers and sustainability last week. The hydrofluorocarbons (HFCs) used in metered dose inhaler (MDIs) are potent greenhouse gasses. ‘’Their effect on climate change is up to 3800 times more potent than carbon dioxide’’.
Inhalers and sustainability
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This quiz was written by Sophie Nieuwendijk, Denise van Vossen,  Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

Quiz 176, January 20, 2023

Welcome to the 176th FOAMed Quiz.

Not a lot of FOAMed content this week, so we’re going to do it a little bit different.

Name the eponyms of the following fractures and te nationality of the namegiver for extra points 🙂

 

Question 1

An osseous Bankart lesion is commonly seen in patients with an anterior shoulder dislocation.

Arthur Sidney Blundell Bankart (1879- 1951) was a British Orthopaedic surgeon.

Question 2

A Segond fracture is considered pathognomonic for ACL disruption

Paul Ferdinand Segond (1851-1912) was a French surgeon.

Question 3

A Bennett fracture is an intra-articular two-part fracture of the base of the first metacarpal with carpometacarpal joint involvement.

Edward Hallaran Bennett (1837-1907) was an Irish Surgeon.

Question 4

A Smith fracture is an extra-articular fracture of the distal radius with volar angulation.

Robert William Smith (1807 – 1873) was an Irish surgeon and pathologist.

Question 5

A Tillaux fracture is a fracture of the anterolateral tibial epiphysis. It commonly seen in adolescents.

I could be a triplane fracture as well, but there is no surgeon called triplane as far as I know. 

Paul Jules Tillaux (1834-1904) was a French surgeon.

Question 6

A Chance fracture is a transverse fracture through a vertebral body and neural arch.

George Quentin Chance was an Irish radiologist

Question 7

A Jefferson fracture is a burst fracture of the atlas (C1).

Geoffrey Jefferson (1886 – 1961) was a British neurosurgeon.

Question 8

A Jones fracture is a fracture of the proximal diaphysis of the 5th metatarsal, distal to the tuberosity.

Sir Robert Jones (1857-1933) was a Welsh general and orthopaedic surgeon.

Question 9

A Lisfranc injury is a tarsometatarsal fracture dislocation characterized by traumatic disruption between the articulation of the medial cuneiform and base of the second metatarsal.

Jacques Lisfranc de Saint-Martin (1787 – 1847) was a French surgeon.

Question 10

The Malgaigne fracture is an unstable fracture of the pelvis. The Malgaigne fracture usually results from a vertical shear force causing two ipsilateral pelvic ring fractures.

Joseph François Malgaigne (1806 – 1865) was a French surgeon.

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

Quiz 175, January 13th, 2022

Welcome to the 175th FOAMed Quiz.

 

Question 1

Source image: www.sinaiem.org

Which of the following radiographic views is most appropriate for assessment of symmetry in the ankle joint?

A: AP view

B: Mortise view

C: Lateral view

The correct answer is B.

SinaiEM covered radiography of the ankle last week.

The standard ankle radiographic series consists of the AP, mortise and lateral views. The image is obtained in internal rotation at 15-20 degrees with the foot in slight dorsiflexion. The joint space width should be uniform and should measure about 4 mm.

The Ankle Radiograph

Question 2

Source image: www.medicosisperfectionalis.com

In acid base disturbances, most of us are taught to use the Henderson–Hasselbalch equation (pH = pKₐ + log([A⁻]/[HA])). Although this simplistic approach is sufficient for use in the ED most of the time, it is notoriously imperfect and incomplete.

Another method of analyzing acid-base disturbances uses electroneutrality as a main principle. Anions and cations have to be balanced to maintain electroneutrality. Addition of anions (like chloride) means less other anions (like bicarbonate) are present. Addition of cations (like sodium) means more anions can be present. So, a higher concentration of anions causes acidosis and a higher concentration of cations causes alkalosis.

What is the name of this approach to acid-base disturbances?

A: Liebermeister’s rule

B: Naegele’s rule

C: Coons method

D: Stewart method

The correct answer is D.

DFTB covered acid-base disturbances and fluid therapy last week.

The approach described above is known as the Stewart method.

Coons fluorescent antibody method is about detection of antibodies by fluorescence microscopy using fluorescein-labeled antibodies.

Liebermeister’s rule says for each fever degree Celsius the cardiac frequency increases 8 beats per minute.

Naegele’s rule is a method of estimating the due date.

Time for a fluid shift?

Question 3

Source image: https://en.rotterdam.info/

Your 40 year old patient who works in a fireworks factory presents with yellowish, necrotic, full‐thickness burns on his hands. You suspect white phosphorus exposure and you start copious irrigation and removal of visible particles.

What is the safest method to make the white phosphorus particles more visible?

A: Add copper sulfate tot the wound

B: Use a Woods lamp

C: Nothing, the particles are so small, you can’t visualize them anyway

The correct answer is B.

Taming the SRU covered caustic skin injuries last week.

White phosphorus burns can be very severe and even life threatening. It auto-combusts at about 30 degrees Celsius, leading to thermal burns and it causes extensive chemical burns due to it’s lipophilic properties. The wound should be irrigated extensively and visible particles should be removed. Copper sulfate turns white phosphorus black, making it more visible. However, copper sulfate can lead to systemic toxicity (hemolysis) and is no longer used for this purpose. A Woods lamp can be used instead to visualize the particles.

Question 4

Source image: www.aliem.com

The photo shown above belongs to your 54 year old patient in the Emergency Department. He has a medical past of atrial flutter and alcohol abuse. This wound is already six months present and there is no history of prior infection, trauma or surgery. The wound is intermittent and mildly painful. He has no other complaints.

Which of the following diagnoses is most likely?

A: Sister Mary Joseph (SMJ) nodule

B: Brother Mary Joseph (BMJ) nodule

C: Umbilical Joseph Infection (UJI) nodule

D: Umbilical Mid Laceration (UML) nodule

The correct answer is A.

This case was covered on ALiEM this week.

A Sister Mary Joseph nodule is a rare cutaneous metastasis of gastrointestinal or genitourinary primary malignancies to the umbilicus. Sister Mary Joseph nodules arise late in disease and portend a poor prognosis. The mean survival of patients with SMJ nodules is less than 12 months.

SAEM Clinical Images Series: An Ominous Umbilical Lesion

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

Quiz 174, January 6, 2023

Welcome to the 174th FOAMed Quiz.

 

Question 1

Source image: www.radiopeadia.org

The X-ray shown above belongs to your 13 year old patient in the Emergency Department after twisting the left knee while playing soccer. He is unable to bear weight.

Which of the following diagnoses is most likely?

A: Patella fracture with anterior cruciate ligament injury

B: Anterior tibial spine avulsion fracture with anterior cruciate ligament injury

C: Quadriceps tendon rupture

D: Displaced tibial plateau fracture with posterior cruciate ligament injury

E: Patellar tendon rupture with posterior cruciate ligament injury

The correct answer is B.

This case was covered on ALiEM this week.

The anterior tibial spine is the insertion point of the ACL. The injury is most common in pediatric patients. It can be caused by a twisting or pivoting knee injury, hyperextension or direct trauma.

SplintER Series: Don’t forget about the (tibial) spine!

Question 2

Source image: nl.dreamstime.com

Your 23 year old patient presents with new onset anemia without clinical signs of blood loss. She is hemodynamically stable and did not receive any transfusions lately. Her MCV is 85 fL. Her liver and kidney function are normal. Thrombocytes and leukocytes are within normal range. Reticulocytes are 92/1000 cells (increased). LDH and bilirubin are elevated. Haptoglobin is decreased. Iron and ferritin are normal. The direct antiglobulin test (Coombs) is negative and the blood smear shows ‘’bite cells’’, but no other atypical cells. When asked she states her skin to have been ‘’a little bit yellow’’ once in a while for as long as she can remember.

Which of the following is the most likely cause of this patient’s anemia?

A: Hereditary spherocytosis

B: Vitamin B12 deficiency

C: Glucose-6-phostphate dehydrogenase deficiency (G6PD)

D: Auto-immune hemolysis

E: Sickle cell disease

The correct answer is C.

Acute hemolytic anemia was covered on EM@3AM last week. 

The patient has new onset anemia, so sickle cell disease is very unlikely. High reticulocytes make a hemoglobin production problem such as vitamin B12 deficiency less likely. A normal MCV also does not fot vitamin B12 deficiency. A low haptoglobin points in the direction of hemolysis. The negative Coombs test makes auto-immune hemolysis unlikely and the absence of spherocytes on blood smear exclude hereditary spherocytosis. Bite cells are commonly identified in glucose-6-phosphate dehydrogenase deficiency. Her history of episodes of a yellow skin supports this diagnosis.

EM@3AM: Acute Hemolytic Anemia

Question 3

Source image: www.maplespub.com

What is the proper location to apply a pelvic binder?

A: Over the iliac crest

B: Over the femur shaft

C: Over the greater trochanters

The correct answer is C.

Last week UMem covered pelvic binders.

This paper suggests that it takes about 8 attempts to properly apply a pelvic binder.

 

Question 4

Source image: https://www.semanticscholar.org/figure/1

The ECG above belongs to a patient with chest pain.

Which of the following waves is present?

A: N-wave

B: J-wave

C: U-wave

D: Epsilon-wave

The correct answer is A.

Dr. Smith’s ECG blog covered a case of N-wave NSTEMI last week.

N waves are transient appearing notches at the end of the QRS complex and are associated with myocardial ischemia. N-waves are usually ≥2 mm in size with respect to the PR segment which results in slight widening of the QRS complex. N-waves are usually seen in one or more of the inferior leads, and/or in leads I, aVL. An N-wave is also called a delayed activation wave of the left ventricular basal region. They indicate the LCx is likely to be the “culprit” artery.

Question 5

Source image: www.kaspersky.com



We universally advise patients to reduce screen time after a concussion, but so far evidence to support this habit lacks.

In this recently published paper, 663 children and adolescents with acute concussion and 334 children and adolescents with orthopedic injury were followed.

Postconcussion symptoms were measured (Health and Behavior Inventory) up to 6 months post injury. Screen time was measured by using the Healthy Lifestyle Behavior Questionnaire.

What did the authors find? Two answers are correct.

A: Low screen time was associated with relatively more severe symptoms in the concussion group compared to the orthopedic injury group during the first 30 days post injury

B: Intermediate screen time was associated with relatively more severe symptoms in the concussion group compared to the orthopedic injury group during the first 30 days post injury

C: High screen time was associated with relatively more severe symptoms in the concussion group compared to the orthopedic injury group during the first 30 days post injury

The correct answers are A and C.

The paper was covered on DFTB last week.

Interestingly, low and high screen time were both associated with relatively more severe symptoms in the concussion group compared to the orthopedic injury group during the first 30 days post injury but not after 30 days.

The 67th Bubble Wrap

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

Quiz 173, December 30th, 2022

Welcome to the 173th FOAMed Quiz.

A short one this time!

Happy new year!

Question 1

Source image: www.radiopaedia.org

A 37-year old male presents with pain in his left foot after stepping into a pothole. You obtain radiographs and find a small bony fragment between the base of the 1st and 2nd metatarsal, which is associated with Lisfranc injury.

This small bony fragment between the base of the 1st and 2nd metatarsal has a name. How is it called?

A: Cupid’s bow sign

B: Inverted Napoleon Hat Sign

C: Sail Sign

D: Fleck sign

The correct answer is D.

Lisfranc injury was covered on SinaiEM last week.

Cupid’s bow sign is seen as a normal variant in the endplate of the vertebral body.

Inverted Napoleon Hat Sign is a radiologic sign seen on the frontal pelvic or lumbar radiograph at the level of the 5th lumbar vertebra and the sacrum.

Sail sign is also known as the anterior fat pad sign, describing the elevation of the anterior fat pad to create a silhouette similar to a billowing spinnaker sail from a boat.

Fleck sign is an avulsion fracture of the second metatarsal or medial cuneiform and associated with a Lisfranc injury.

Lisfranc Injury

Question 2

Source image: www.medindia.net

You are treating your patient for severe methemoglobinemia.

Which of the following is first line treatment?

A: Ascorbic acid

B: Methylene blue

C: Exchange transfusion

D: Hyperbaric oxygen

The correct answer is B.

Methemoglobinemia was discussed in this week’s emDOCS ToxCard.

Methylene blue is a carrier for electrons which aids in reducing Fe3+ back to Fe2+ and thus resolving methemoglobinemia. Ascorbic acid is also an option, but it acts a lot slower.

Treatment with exchange transfusion and hyperbaric oxygen have been described in case reports.

ToxCard: Methylene Blue

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

Quiz 172, December 23rd, 2022

Welcome to the 172th FOAMed Quiz!

 

Question 1

Source image: www.radiopaedia.org

In hip dislocations of native joints (no total hip arthroplasty), which of the following is the most common?

A: Postero superior dislocation

B: Postero inferior dislocation

C: Antero superior dislocation

D: Antero inferior dislocation

The correct answer is A.

Hip dislocation was covered on AliEM last week.

Posterosuperior hip dislocations are the most common type of dislocation in native joints as well as total hip arthroplasties.

SplintER Series: Hip, Hip, Hooray!

Question 2

Source image: www.wikipedia.org

You work in a remote, resource-poor location in Southeast Asia and your 24 year old patient comes in with fever, aggressive behavior and hydrophobia. You suspect rabies.

What are the chances of survival in this patient?

A: Negligible

B: 5 percent

C: 10 percent

D: 20 percent

The correct answer is A.

Rabies is caused by a neurotropic lyssavirus and is transmitted via saliva of infected animals.
The chance of survival once symptoms appear are negligible.

EM@3AM: Rabies

Question 3

Source image: www.mountnittany.org

A bite by which of the following animals is the most common cause of rabies in the previously (question 2) described patient?

A: Rabbit

B: Reindeer

C: Dog

D: Bat

The correct answer is C.

In resource-poor countries, rabid dogs account for 90 percent or more of reported cases of rabies transmitted to humans. Reindeer actually can carry rabies. It cannot be carried by reptiles, amphibians, rabbits, or insects.

EM@3AM: Rabies

Question 4

Source image: www.castoredc.com

Okay, bonus question on rabies. A very controversial and aggressive treatment protocol that includes therapeutic coma, ketamine infusion and amantadine was developed in 2004. Experts advise against the use of this treatment combination due to lack of supportive evidence.

What is the name of this protocol?

A: Madison protocol

B: Chicago protocol

C: Minneapolis protocol

D: Milwaukee protocol

The correct answer is D.

Rabies was covered on EM@3AM last week.

The Milwaukee protocol was used to treat a 15 year old girl in 2004. The girl survived. However, the effectiveness of this protocol remains very poor in subsequent studies.

EM@3AM: Rabies

Question 5

Source image: www.aliem.com

Your 15 year old patient presents with osteomyelitis of the frontal bone associated with a subperiosteal abscess.

What is this disease called?

A: Brodie abscess

B: Evans tumor

C: Kaposi sarcoma

D: Pott’s puffy tumor

The correct answer is D.

Pott’s puffy tumor was covered on AliEM last week.

A Brodie Abscess is a subacute or chronic pyogenic osteomyelitis.

An Evans Tumor is a low-grade fibromyxoid sarcoma.

Kaposi sarcoma is a low grade vascular tumor associated with human herpesvirus 8 infection.

Pott’s puffy tumor indeed is osteomyelitis of the frontal bone associated with a subperiosteal abscess.

SAEM Clinical Images Series: Facial Swelling

Question 6

Source image: captionsfunnynl.blogspot.com

Fitz-Hugh Curtis Syndrome (FHCS), also known as perihepatitis is characterized by inflammation of the liver capsule and surrounding peritoneum with “violin-string” adhesion formation.

Which of the following patients is most likely to contract FHCS?

A: A 20 year old male

B: A 60 year old male

C: A 20 year old female

D: A 60 year old female

The correct answer is C

FHCS was covered on ACEP Now last week.

FHCS is a rare complication of pelvic inflammatory disease (PID). It’s usually found in sexually active women, but there are also reports of FHCS occurring in men. The most common causative organisms are Chlamydia trachomatis and Neisseria gonorrhoeae.

Case Report: Fitz-Hugh Curtis Syndrome in a Male with HIV

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

Quiz 171, December 9, 2022

Welcome to the 171th FOAMed Quiz.

 

Question 1

Source image: saem.org/

Your 10 year old male patient presents with unilateral scrotal pain for 26 hours. He denies trauma and fever, but he vomited a couple of times.

You suspect testicular torsion.

Which of the following statements is true regarding diagnosis and management of this patient?

A: Emergent surgical exploration is not indicated, for the testicle will not survive after 24 hours anyway

B: Presence of flow on doppler ultrasound excludes testicular torsion

C: If manual detorsion is successful, your patient can be discharged and required outpatient follow up in 1 week

D: When treated promptly by surgical exploration, the chance of survival of the testicle is still about 7 percent

The correct answer is D.

Testicular torsion was covered on RebelEM last week.

A systematic review demonstrates a 7.4 percent survival rate between 24 and 48 hours.
Presence of flow on doppler ultrasound does not reliably exclude testicular torsion.
Regardless of the success of manual detorsion, all patients will require surgical evaluation.

REBEL Core Cast 91.0 – Testicular Torsion

Question 2

Source image: resources.wfsahq.org/

Your 87 year old patient presents with a femoral neck fracture. She is in severe pain and you decide to perform an ultrasound guided nerve block.

In which of the following blocks, the local anesthetic should be injected deep to the psoas tendon?

A: Fascia Iliaca Compartment Block (FICB)

B: Femoral nerve block (FNB)

C: Pericapsular Nerve Group (PENG) block

The correct answer is C. 

EMDOcs covered nerve blocks in hip fractures last week.

There are 3 nerves that innervate the proximal femur. These are the femoral nerve, the obturator nerve and the accessory obturator nerve. The PENG block is thought to target these three nerves best. When performing a PENG block, the local anesthetic should be injected deep to the psoas tendon.

Ultrasound-Guided Regional Anesthesia for Hip Fractures

Question 3

Source image: www.tamariaclinic.com

Your patient presents with severe vulvar pain and she notices a swelling near her vagina.

In what location would you expect to find a Bartholin’s abscess in regard to the vaginal opening?

A: At 12 o’clock

B: At 2 o’clock

C: At 4 o’clock

D: At 6 o’clock

The correct answer is C.

Bartholin’s abscess was covered on EM@3AM last week.

Bartholin’s glands are pea-sized and located bilaterally at the 4 o’clock and 8 o’clock positions of the introitus.

EM@3AM: Bartholin’s Abscess

Question 4

Source image: www.pfcla.com

 A woman with suspected ovarian torsion presents to your ED.

Which of the following statements is true about ovarian torsion?

A: Ovarian torsion affects women below 50 years of age only

B: Most patients have a cyst or mass >5 cm

C: The majority of patients present with fever

D: Nausea and vomiting is rare in patients wth ovarian torsion

The correct answer is B.

Ovarian torsion was covered on emDOCs last week.

Women of all ages can have ovarian torsion. 15% of cases occur during infancy or childhood.

Most patients have a cyst or mass >5 cm. 

Nausea and vomiting is present in 70% of patients. 

Up to 20% of patients presents with fever.

emDOCs Podcast – Episode 67: Ovarian Torsion

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

Quiz 170, December 2nd, 2022

Welcome to the 170th FOAMed Quiz.

 

Question 1

Source image: https://en.wikipedia.org/

Pyridoxine is commonly found in food and dietary supplements. Pyridoxine is also used in the medical field as a treatment for pyridoxine deficiency, certain types of mushroom poisoning and treatment of a certain type of intoxication with tuberculosis antibiotics.

For which of the following intoxications is pyridoxine used?

A: Ethambutol

B: Rifampicin

C: Isoniazid

D: Pyrazinamide

The correct answer is C, isoniazid.

The use of pyridoxine in the medical field was covered by emDOCS last week.

One of its active forms, pyridoxal phosphate plays an important role in the synthesis of GABA. Isoniazid causes pyridoxine deficiency which leads to GABA deficiency and seizures.

ToxCard: Pyridoxine Uses in Clinical Toxicology

Question 2

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

The ECG shown above belongs to your patient with acute shortness of breath and hemodynamic instability.

Which of the following is the most likely reason for her illness?

A: Pulmonary embolism

B: Cardiac tamponade

C: Myocardial infarction

D: Tension pneumothorax

The correct answer is B.

This ECG was covered in dr. Smith’s ECG blog last week.

The ECG shows sinus tachycardia and a low voltage QRS with alternating amplitudes. This beat-to-beat variation in QRS amplitude and morphology is called electrical alternans and is seen in cardiac tamponade. On ultrasound you will find pericardial fluid and a ‘’swinging heart’’.

Question 3

Source image: www.emottawablog.com

Your patient presents with unilateral angio-edema. He is not in acute distress and shows no signs of acute airway compromise. He is known to have hypertension.

Which of the following antihypertensives is most likely the cause of his angio-edema?

A: Metoprolol

B: Nifedipine

C: Hydrochlorothiazide

D: Lisinopril

The correct answer is D.

EMOttawa covered ACE-inhibitor induced angioedema last week.

ACE inhibitor-induced angioedema accounts for 30% of all angioedema presentations.

Question 4

Source image: www.pixabay.com

Which of the following statements about ACE-inhibitor induced angioedema is true?

A: It is bradykinin-mediated

B: It is histamine-mediated

C: It is eosinophil-mediated

ACE-induced angioedema, although not fully understood, is a bradykinin-mediated process.
Episodic angioedema with eosinophilia (EAE) is called Gleich’s syndrome.

Question 5

Source image: www.aha.ch

Which of the following is most likely effective in treatment of ACE-inhibitor induced angioedema according to the available evidence?

A: Adrenalin

B: Fresh Frozen Plasma (FFP)

C: Icatibant

D: Dexamethasone

E: None of the above.

The correct answer is E.

So far, the available evidence shows no medications to be beneficial in ACE-inhibitor induced angio-edema.

Avoidance of airway compromise is the main goal of the therapy.

Question 6

Source image: www.multimedi.com and www.medbis.nl

What does the available evidence say about skin adhesives (glue) versus sutures for simple and non-infected wound?

A: Sutures lead to better cosmesis and lower pain scores but a slightly lower rate of wound dehiscence compared to skin adhesives

B: Sutures lead to equal cosmesis and equal pain scores and an equal rate of wound dehiscence compared to skin adhesives

C: Sutures lead to equal cosmesis, higher pain scores and a slightly lower rate of wound dehiscence

D: Sutures lead to worse cosmesis, equal pain scores but a slightly lower rate of wound dehiscence compared to skin adhesives

The correct answer is C.

Wound closure techniques were covered on first10EM last week.

Using skin glue has benefits over sutures. It is faster and it leads to lower pain scores. Cosmesis is equal. Wound dehiscence is almost certainly more common, although this doesn’t seem to have any impact on long term outcomes.

Lacerations: Does closure technique matter?

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

Quiz 169, November 25th, 2022

Welcome to the 169th FOAMed Quiz.

 

Question 1

Source image: www.grepmed.com

In ophthalmology there are only a few, but serious emergency diagnoses. One of these is orbital compartment syndrome (OCS). Signs of an OCS include diminished visual acuity, relative afferent pupillary defect (RAPD) and reduced colour vision.

Which of the following statements is true?

A: Before treatment is initiated, it is essential to perform a CT-scan

B: In case of signs of OCS, one should not wait for imaging before treatment

C: OCS generally does not require treatment

The correct answer is B.

Geeky Medics covered eye trauma last week.

In case of an OCS, direct intervention is required in the form of lateral canthotomy and cantholysis. Any delay in treatment due to waiting for imaging may cause irreversible sight loss. If there are no problems with the patient’s vision yet, frequent monitoring of visual acuity, pupils and intraocular pressure during the first 6 to 8 hours is vital to detect a deterioration early.

Eye Trauma

Question 2

Source image: www.medindia.net

Methemoglobinemia (MetHb) can cause a variety of symptoms depending on the level of MetHb. Methemoglobinemia can be caused by a variety of drugs.

Which of the following does not cause methemoglobinemia?

A: Isobutyl Nitrite (also called “poppers”)

B: Benzocaine

C: Ondansetron

D: Nitrofurantoin

The correct answer is C

The diagnosis and treatment of methemoglobinemia was discussed on RebelEM last week.

Dapsone and topical anaesthetic agents (i.e. benzocaine) are the most common medications that cause methemoglobinemia. Isobutyl nitrite is probably the most common cause of methemoglobinemia in the Emergency Department. The pathophysiology is based on oxidation of the iron in the haemoglobin molecule.

REBEL Core Cast 90.0 – Methemoglobinemia

Question 3

Source image: www.renalfellow.org

POCUS is a valuable diagnostic tool for suspected right heart failure.

Which of the following signs supports the diagnosis of right heart failure:

A: Right ventricle (RV) free-wall thickness of 4 mm

B: Inferior vena cava (IVC) diameter of 9 mm

C: Tricuspid annular plane systolic excursion (TAPSE) of 14 mm

D: Right ventricle to left ventricle ratio of 0.6

The correct answer is C.

This week emDocs covered diagnosis of right heart failure in the Emergency Department.

A right ventricle free wall of less than 5 mm is considered normal, as well as a right ventricle to left ventricle ratio of 0.6. A IVC diameter of only 9 mm suggests no elevated right ventricular pressure. A TAPSE of less than 20 mm is consistent with reduced right ventricular function.

Right Heart Failure in the ED: Approach to Diagnosis and Management

Question 4

Source image: www.ppemedical.com

In laceration repair, we are taught that eversion of wound edges leads to improved cosmesis.

What does the available evidence say?

A: Plenty of evidence concludes wound edge eversion indeed leads to improved cosmesis

B: No evidence is available on this subject

C: There is very little evidence available, but the evidence suggests wound edge eversion does not lead to improved cosmesis

The correct answer is C.

Justin Morgenstern covered wound edge eversion on First10EM last week.

He concludes: ´There is very little evidence to guide us, but the necessity of eversion in wound repair seems to fall into the medical dogma camp.’

Laceration repair: Does eversion matter?

Question 5

Source image: www.cigna.com

Which of the following statements is true regarding necrotising enterocolitis (NEC)?

A: It is most likely to occure in neonates born postterm (after 42 weeks)

B: All neonates with NEC require surgical intervention

C: NEC has an 80 percent mortality rate

D: Severity of the disease is scored by the modified Bell’s staging criteria

The correct answer is D.

Don’t forget the Bubbles covered the distended abdomen in neonates last week.

NEC occurs when sections of bowel tissue undergo inflammation leading to bacterial invasion and necrosis.

About 90 percent of NEC patients are born preterm. The mortality rate is 20 – 40 percent. Approximately 1 in 4 infants with NEC require surgery.

The modified Bell’s staging criteria can be used to determine the severity of the disease.

An approach to distended abdomens in neonates

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen

Quiz 168, November 18th, 2022

Welcome to the 168th FOAMed Quiz.

 

Question 1

Source image: www.wikipedia.org

What kind of device is this?

A: Implantable cardioverter defibrillator (ICD)

B: Regular pacemaker

C: Biventricular pacemaker

The correct answer is A.

The thick coils are found in ICD’s, not in pacemakers.

The Pacemaker

Question 2

Source image: www.sinaiem.org

This ECG belongs to a patient with a pacemaker (obviously).

What is going on?

A: Failure to pace

B: Failure to capture

C: Failure to sense

The correct answer is C.

There is a pacemaker spike present just before the p-wave and a spike after the start of the QRS. The QRS simply cannot be narrow when the pacemaker is conducted, so this is the patient’s native conduction at work. 

The Pacemaker

Question 3

Source image: www.doczero.com

What happens (most likely) if you put a magnet on a pacemaker?

A: It shuts down and will not pace anymore

B: It will pace in a fixed rate (VOO)

C: It will go into DDD mode

The correct answer is B.

The pacemaker should go into VOO mode when a magnet is placed on top of it. This means it will stop ‘’thinking’’ and just paces at a fixed rate.

The Pacemaker

Question 4

Source image: www.medtronic.com

And the last one on pacemakers. Which of the following is a real pacemaker problem?

A: Faraway pacemaker

B: Takeaway pacemaker

C: Fadeaway pacemaker

D: Runaway pacemaker

The correct answer is D. SinaiEM covered pacemaker problems last week. Runaway pacemaker is something you never hope to see: a total pulse generator malfunction in which the pacemaker creates rapid and unsustainable pulses. If conducted, this generates a potentially lethal ventricular arrhythmia. Cutting the pacemaker wires will save the life of your patient.
The Pacemaker

Question 5

Source image: www.hartcentrumhasselt.be

Acute aortic dissection (AAD) requires rapid diagnosis and treatment.

On POCUS, which view can be used for the identification of an intimal flap in the aortic arch?

A: Parasternal long axis view

B: Suprasternal notch view

C: Abdominal aorta view

D: Subxyphoidal view

The correct answer is B

EMDocs covered POCUS for aortic dissection in the clinical presentation of ischemic stroke last week.

A suprasternal notch view is acquired by placing the (phased array) transducer in the suprasternal notch and rotating the length of the probe between the left sternocleidomastoid muscle and the right clavicular head. The aortic arch and its branches can be visualised.

POCUS for aortic dissection in the clinical presentation of ischemic stroke

Question 6

Source image: www.acepnow.com

Ultrasound assistance for lumbar punctures is used more and more regularly. It provides an opportunity to visualise and mark the spinous processes and the midline (and visualise the ligamentum flavum).

The most recent meta-analysis on this topic dates from 2019 and includes a total of 957 patients.

What did this meta-analysis show?

A: There was a statistically significant higher success rate when using ultrasound assistance versus a ‘blind’ procedure

B: There was no difference in success rate between ultrasound assistance and ‘blind’ procedure

C: There was a statistically significant higher success rate when using a ‘blind’ procedure versus ultrasound assistance

The correct answer is A

SinaiEM covered ultrasound assisted lumbar puncture last week.

In this meta-analysis, there was a statistically significant increase in success rate as well as decrease in procedure time, fewer passes with the needle, and decrease in pain score when comparing ultrasound assisted lumbar puncture versus a blind procedure.

POCUS guided LP

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This quiz was written by Sophie Nieuwendijk, Denise van Vossen, Gijs de Zeeuw, Nicole van Groningen, Jeroen van Brakel, Noortje Geerts and Renée Deckers

Reviewed and edited by Rick Thissen