Quiz 105, March 5th, 2021

Welcome to the 105th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

A 54-year-old man with a history of intravenous drug abuse is referred for persistent neck pain which radiates to his left arm. He also complains of progressive hand weakness and a mild fever. You suspect him of a spinal epidural abscess (SEA).

What is the most appropriate next step?

A: Cervical X-ray and Lumbar Puncture

B: Spinal CT scan and surgical consultation for laminectomy

C: Start empirical intravenous antibiotics and order MRI

D: Start antibiotics and CT guided drainage

The correct answer is C

EMdocs discussed SEA this week.

SEA is an uncommon condition with often non-specific complaints. Less than 15% of the patients present themselves with the classical triad of; fever, neck / back pain and focal neurologic deficits.

SEA most often occurs in immunocompromised patients. Intravenous drug use and diabetes mellitus are significant risk factors for SEA.

Most of the SEA is caused by Staphylococcus aureus. Empirical antibiotics should not be delayed by imaging. The imaging modality of choice is MRI.

Source image: www.pixabay.com

Question 2

A 13-month old baby found a tablet of suboxone (buprenorphine/naloxone) and most likely ate it. The baby looked fine. Her mother calls your emergency department if she needs to worry. 

What should be the answer?

A: It depends on the dosing of the pills; if low dose (buprenorphine 2mg and naloxone 0.5mg), she does not need to worry. If high dose (buprenorphine 8mg and naloxone 2mg), she needs to come in with the toddler

B: The naloxone will counteract the buprenorphine, so this is not harmful.

C: She needs to come in with the baby. One pill can cause symptoms in babies and toddlers

The correct answer is C

Opioid intoxication was covered in PEM Currents toxicology podcast this week.

Suboxone is used in adults with opioid use disorder. These are sublingual pills. The added naloxone does not prevent opioid effects when taken orally, but prevents iv abuse of the suboxone pills.

One pill can cause severe symptoms in babies and toddlers. The Tmax is about 90 minutes.

Of course, this child should be thoroughly evaluated for child abuse as well.

Source image: slideplayer.com, published by Timothy Beasley

Question 3

Your 35 year old patient fell off his racing bike. He presents with an open fracture of his left lower leg. There appears to be no visible contamination and mild soft tissue damage.

Which Gustilo type matches the photo and description?

A: Type 1

B: Type 2

C: Type 3b

D: Type 4

The correct answer is B

Taming the SRU covered open fractures last week.

Grade II fractures have wounds between >1 cm and 10 cm and have mild soft tissue damage. Type 1 fractures are < 1 cm in size and type 3 fractures are more severe. Gustilo type 4 fractures do not exist.

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

Question 4

It seems every other week a trial about tranexamic acid (TXA) is published. Last month, the ULTRA trial was published in the Lancet.

955 patients with CT confirmed subarachnoid hemorrhage (SAH) were randomised to receive either TXA (1 gram iv bolus and 1 gram every 8 hours) or usual care.

The primary outcome was a good neurologic outcome (modified Rankin Scale 3 or less) at 6 months.

What did the authors find?

A: More patients in the TXA group had a good neurologic outcome at 6 months compared to patients in the usual care group

B: Less patients in the TXA group had a good neurologic outcome at 6 months compared to patients in the usual care group

C: The rate of good neurologic outcome did not differ between the groups

The correct answer is C

First10EM covered the trial last week.

This is another negative trial on TXA.

A good neurologic outcome was found in 60% of the TXA group and 64% of the control group. All cause mortality was 27% in the TXA group and 24% in the usual care.

Keep in mind the researchers were not blinded and the mRS is a far from perfect tool to assess neurologic state. Nevertheless, TXA should not be used in SAH. 

TXA for SAH: Another swing and a miss for the wonder drug

Source image: www.pixabay.com

Question 5

Your 64 year old, otherwise healthy patient states he has hearing loss in his left ear since yesterday. He denies any other complaints.

Rinne’s test is positive on both sides.

Weber’s test lateralizes to the right.

Which of the following causes is most likely?

A: Otitis externa

B: Otitis media

C: Cholesteatoma

D: Sudden sensorineural hearing loss (SSNHL) (sudden deafness)

The correct answer is D

Don’t forget the bubbles covered Rinnes and Webers test last week.

Weber’s test lateralizes to the good side, indicating there is sensorineural hearing loss on the left side or conductive hearing loss in the right side.

Rinne’s test is positive (normal) on both sides, indicating there is no conductive hearing loss.

So, there is sensorineural (perceptive) hearing loss on the left side.

Otitis externa, otitis media and cholesteatoma cause conductive hearing loss. The only sensorineural hearing loss in this list is SSNHL (formerly sudden deafness).

Sudden sensorineural hearing loss (SSHL), commonly known as sudden deafness, occurs as an unexplained, rapid loss of hearing—usually in one ear—either at once or over several days. It should be considered a medical emergency.

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

Reviewed and edited by Rick Thissen

Quiz 104, February 26th, 2021

Welcome to the 104th FOAMed Quiz.

 

Source image: www.rebelem.com


Question 1

Epistaxis can often be treated with local therapy and anterior nasal packing. Topical tranexamic acid (TXA) is quite often used for this indication. Evidence available so far supports the use of topical tranexamic acid, but the evidence is weak.

Recently, the first blinded RCT on this topic was published. The authors compared topical intranasal TXA to placebo in patients with persistent epistaxis

What did the investigators find?

A: Topical tranexamic acid was more effective compared to placebo in stopping the bleeding

B: Topical tranexamic acid was equally effective compared to placebo in stopping the bleeding

C: Topical tranexamic acid was less effective compared to placebo in stopping the bleeding

The correct answer is B

This paper was covered by StEmlyns, First10EM and FoamCast.

496 patients with epistaxis were randomized. All patients received a topical vasoconstrictor on emergency department arrival. If bleeding continued, the patient was included.

TXA (2 ml = 200 mg) was placed on a dental roll and left in the nose for 10 minutes. If necessary, this was repeated.

The primary outcome was the use of anterior nasal packing during the emergency department visit.

In the TXA group, 111 of 254 (43.7%) received nasal packing compared to 100 of the 242 (41.3%) in the placebo group. There were no statistically significant differences for any of the secondary outcomes either.


Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 20287

Question 2

A 32 year old male patient attends your ED after twisting his right knee during a football game. The X-ray shows an avulsion fracture of the lateral tibial plateau. Also known as a Segond fracture.

A tear in which ligament is associated with this finding?

A: Lateral Collateral Ligament (LCL)

B: Medial Collateral Ligament (MCL)

C: Anterior Cruciate Ligament (ACL)

D: Posterior Cruciate Ligament (PCL)

The correct answer is C

NuEM discussed knee trauma this week.

Internal rotation and varus stress can lead occurrence of a Segond fracture. It is frequently associated with disruption of the ACL.

Source image: www.pixabay.com

Question 3

Your 35 year old patient presents to your ED in southern Florida with vomiting, hot and cold reversal (cold allodynia) and a headache. Performing a thorough medical history, you find she ate barracuda earlier tonight.

Which of the following is most likely the cause of your patient’s symptoms:

A: Scombroid poisoning

B: Tetrodotoxin poisoning

C: Ciguatera (ciguatoxin poisoning)

The correct answer is C

EMDocs covered seafood poisoning this week.

Scombroid is caused by the improper storage of dark-meat fish (and sometimes raw milk cheese), which results in the conversion of histidine to large quantities of histamine.

Tetrodotoxin is the neurotoxin of pufferfish.

Ciguatera fish poisoning is the most frequently reported seafood illness worldwide. The syndrome is caused by ingestion of reef finfish. It causes gastrointestinal symptoms, cold allodynia (hot-cold reversal), paresthesias (stocking-glove & peri-oral), headache, and dizziness. Some patients go on to develop cardiovascular complications including heart block, bradycardia, and hypotension.

Source image: www.rebelem.com

Question 4

The optimal dosage for ketamine to achieve adequate analgesia with as little side effect as possible is still up for debate.

This recently published paper is about 0.15 mg/kg intravenous (IV) versus 0.3 mg/kg intravenous ketamine in emergency department (ED) patients with acute pain. Patients were randomised to either dose. The primary endpoint was NRS pain score at 30 minutes.

What did the authors find?

A: 0.15 mg/kg IV ketamine was inferior to 0.3 mg/kg IV ketamine

B: 0.15 mg/kg IV ketamine was noninferior to 0.3 mg/kg IV ketamine

C: Both 0.15 mg/kg and 0.3 mg/kg IV ketamine were not effective at all

The correct answer is B

The paper was covered on JournalFeed last week.

49 patients were included in each group. The mean NRS score at 30 minutes was 4.7 (95% confidence interval [CI] = 3.8 to 5.5) in the low-dose group and 5.0 (95% CI = 4.2 to 5.8) in the high-dose group. Differences in the baseline NRS score were adjusted for.

0.15 mg/kg iv ketamine does not appear to be less effective compared to 0.30 mg/kg iv ketamine.

Source image: www.pixabay.com

Question 5

Patients with hypoxaemic respiratory failure are frequently encountered in the ED and ICU. Hypoxia is harmful of course, but hyperoxia is potentially harmful as well. The OXYGEN-ICU trial showed a mortality benefit in favour of conservative protocol for oxygen therapy versus conventional therapy. Subsequent RCT’s could not reproduce these results.

Another RCT on this topic was published recently. 2928 Patients with hypoxaemic respiratory failure were randomised to either a lower oxygen target group (PaO2 of 60mmHg) or a higher oxygen target group (PaO2 of 90mmHg). The primary outcome was 90-day all–cause mortality.

What did the authors find?

A: Patients in the low target oxygen group had a decreased mortality compared to patients in the high target oxygen group

B: Patients in the low target oxygen group had a increased mortality compared to patients in the high target oxygen group

C: There was no difference in mortality between the two groups

The correct answer is C

The Bottom Line covered the paper last week.

All–cause mortality was 42.9% and 42.4% in the low target oxygen group and the high target oxygen group respectively (p = 0.64). There were no differences in serious adverse events either.

A target PaO2 of 60mmHg for patients with hypoxaemic respiratory failure does not result in a mortality benefit compared to a target of 90 mmHg, but it does not lead to harm either.

HOT-ICU

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

Reviewed and edited by Rick Thissen

Quiz 103, February 19th, 2021

Welcome to the 103th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Your 68-year old patient comes in with septic shock. He is hypotensive, tachycardic, tachypnoeic and has a fever. His blood pressure normalises after initial resuscitation with iv fluids but he continues to be tachycardic with a heart rate of 140 bpm.

You wonder if it might be beneficial for this patient to add a beta blocker to his current treatment in order to moderate his hypersympathetic state.

This recently published systematic review and meta-analysis is about 7 trials in which patients in septic shock with persistent tachycardia, after adequate initial resuscitation, were randomised to either a short acting beta blocker (esmolol or landiolol) or placebo. The primary outcome was 28-day mortality.

What did the authors find?

A: 28-day mortality was significantly lower in patients who received a beta blocker compared to patients who received placebo

B: 28-day mortality was not statistically different in patients who received a beta blocker compared to patients who received placebo

C: 28-day mortality was significantly higher in patients who received a beta blocker compared to patients who received placebo

The correct answer is A

This recently published systematic review and meta-analysis was covered by Clay Smith on SpoonFeed this week.

A total of 7 RCT’s (613 patients) were included in this systematic review and 6 of these trials (572 patients) were eventually analysed. Mortality risk was reduced by 32% in patients who received a beta blocker vs placebo. The overall mortality rates were 36.7% and 54.9% in the esmolol/landiolol cohort and placebo group respectively (absolute risk reduction 18%, NNT 5.5). 

Heart rate was significantly lower in patients who received a beta blocker compared to patients who received placebo while the mean arterial pressure (MAP) was not statistically different between these two groups.

Although these results look encouraging, we have to take in mind that the studies were rather small and that there was a wide range of mortality across these centers (12-62% in the beta blocker group; 20-80% in the placebo group).

Source image: Case contributed by Dr Alexandra Stanislavsky, Radiopaedia.org

Question 2

The “empty cup” sign is a radiological image of a perilunate dislocation. The distal radius is the saucer and the tilted lunate is the cup.

In a normal situation, which bone would project above the lunate and be the “fill” of the cup?

A: Trapezium

B: Trapezoid

C: Capitate

D: Hamate

The correct answer is C.

This week, DFTB discussed carpal injuries in children.

In this case the apple, cup, saucer analogy, the capitate, lunate and radius, respectively, should be aligned.

Source image: www.pixabay.com

Question 3

Benign Paroxysmal Positional Vertigo (BPPV) is common in the ED. Displaced otoliths are located in the semicircular canals, causing brief episodes of dizziness.

Which of the following is most commonly affected?

A: Unilateral posterior canal

B: Unilateral horizontal canal

C: Bilateral posterior canals

D: Bilateral horizontal canals

The correct answer is A

AliEM covered BPPD and its treatment last week.

The affected canals are:
83%: Unilateral posterior canal
7% : Unilateral horizontal canal
6% Bilateral posterior canals
Rare: Anterior canal

The same maneuvers can be used to treat both posterior and anterior BPPV (Epley, Semont).

Tricks of Trade: Benign paroxysmal positional vertigo | Beyond the Basics

Source image: www.pixabay.com

Question 4

Diabetic ketoacidosis (DKA) is often encountered in the ED. Despite improved treatment in the last decades, mortality is still about 2 percent.

Euglycemic ketoacidosis is quite often missed leading to delayed treatment.

Which of the following drugs can cause euglycemic ketoacidosis?

A: Metformin

B: Liraglutide

C: Sitagliptine

D: Canagliflozine

The correct answer is D

The resus room covered DKA extensively in their podcast last week.

SGLT2 inhibitors are known to (although very rare) cause euglycemic ketoacidosis.

Liraglutide is a GLP1 agonist. Sitagliptin is a DPP4 inhibitor.

Diabetic Ketoacidosis

Source image: www.rebelem.com

Question 5

Although alteplase is registered as the first line agent of choice for iv thrombolysis in ischemic stroke, tenecteplase may have some benefits over alteplase. It is about half the price, it has greater fibrin specificity and has a longer half-life than alteplase.

Recent data has emerged regarding tenecteplase as an alternative to alteplase in ischemic stroke. This recently published systematic review and meta-analysis covers these papers.

What did the authors find?

A: Alteplase was associated with an increase in good or excellent functional outcome (modified Rankin Scale 0-2) compared to tenecteplase

B: There was no difference in good or excellent functional outcome (modified Rankin Scale 0-2) between the two drugs

C: Tenecteplase was associated with an increase in good or excellent functional outcome (modified Rankin Scale 0-2) compared to alteplase

The correct answer is B

RebelEM covered the paper last week.

8 trials were included (of which 6 randomised and 2 observational), covering data of 2031 patients. There was no difference in good or excellent functional outcome. However, tenecteplase showed higher rates of recanalization.

There are several studies using tenecteplase in ischemic stroke patients underway to be on the lookout for.

Tenecteplase may well be equally effective or even more effective as iv thrombolytic agent compared to alteplase.

Tenecteplase for Thrombolysis of AIS?

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

Reviewed and edited by Rick Thissen

Quiz 102, February 12th, 2021

Welcome to the 102th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

An eight year old child presents to your ED with an acute asthma attack. After treatment with intravenous steroids and nebulised ipratropium and salbutamol, she shows no signs of improvement.

Your colleague suggests 
nebulised magnesium.

Based on recent research, what is the best response?

A: This must be a mistake. Nebulising magnesium has many side effects

B: In refractory acute asthma, nebulised magnesium decreases hospitalisation rate

C: Interesting suggestion, but the child will not really benefit from it

The correct answer is C

This week Don’t Forget The Bubbles discussed the use of nebulised magnesium sulphate in the management of acute asthma in children.

There is some evidence supporting the use of magnesium sulphate intravenously in refractory asthma. But little was known about the effects of inhaled magnesium.

DFTB covered this recently published paper. The authors randomized 816 children 2 to 17 years to either nebulized magnesium with placebo after completing 1 hour of initial treatment (steroids, salbutamol and ipratropium) . There was no significant decrease in the rate of hospitalization. Also no differences were found in secondary outcomes such as hospital revisits, oxygen use or respiratory rate. It did not lead to any serious adverse effects though.

Source image: www.emdocs.net

Question 2

As obesity is more and more common, so is the need for bariatric surgery. Roux-en-Y gastric bypass (RYGB) is one of the most common bariatric procedures. However, these procedures are not without risk.

Link the complications of RYGB to the most likely postoperative interval after RYGB:

A: marginal ulceration
B: anastomotic leak
C: internal herniation
D: stenosis

1: up to several weeks after surgery
2: several months after surgery
3: one year post-operative
4: any time post-operatively

The correct combinations are: B-1, D-2, A-3, C-4

This week, emDOCs addressed the complications of bariatric procedures and how to differentiate them in the emergency room.

Early complications are most likely bleeds or leaks of the anastomosis or staple line. Anastomotic stenosis (narrowing of the stoma <1cm) typically occur several weeks to months after the procedure.

Internal herniation is a devastating complication of RYGB. This condition can occur any time after surgery.

Always keep a broad differential. Because of the former obesity, these patients are still at risk of any disease linked to obesity.

Source image: www.pixabay,com

Question 3

Syncope is a commonly encountered complaint in the Emergency Department (ED). Identification of low risk patients is often challenging, leading to frequent hospital admission for rhythm observation.

In this systematic review, the researchers evaluated nine different syncope rules and their accuracy to detect patient with a high risk of any adverse event (such as death, myocardial infarction, stroke, or cardiac surgery).

The authors evaluated the San Francisco Syncope Rule (SFSR), Canadian Syncope Risk Score (CSRS), OESIL Score for Syncope, Risk stratification Of Syncope in the ED (ROSE), FAINT Score, Boston syncope, Syncope Risk Score, Canadian Syncope Arrhythmia Score and the Ottawa ECG rule.

Which of the risk scores was the most accurate?

A: San Francisco Syncope Rule (SFSR)

B: Canadian Syncope Risk Score (CSRS)

C: FAINT Score

D: OESIL Score for Syncope

The correct answer is B.

This week Clay Smith covered the Syncope Score Systematic Review on SpoonFeed.

The investigators included 17 studies and evaluated nine risk stratification scores. For all the syncope rules that have been externally validated, except the CSRS, the LR+ ranged from 1 to 2.5. This means they are pretty useless.

A CSRS of 4 or more was associated with a high likelihood of an adverse event and a CSRS of 0 or less was associated with a low likelihood of an adverse event.

Source image: www.pixabay.com


Question 4

The results of the RECOVERY trial on Tocilizumab in COVID-19 patients are available in pre-print. 2022 patients receiving oxygen or respiratory support were allocated to receive tocilizumab by intravenous infusion and were compared with 2094 patients randomly allocated to usual care alone.

What did the authors find?

A: Treatment with tocilizumab significantly reduced mortality

B: Treatment with tocilizumab had no effect on mortality

C: Treatment with tocilizumab significantly increased mortality

The correct answer is A

Simon Carley was the first one to cover the paper on St. Emlyns.

Keep in mind this is a pre-print.

In the studied population, 562 (14%) patients received invasive mechanical ventilation, 1686 (41%) received non-invasive respiratory support, and 1868 (45%) received no respiratory support other than oxygen.

596 (29%) of the 2022 patients allocated tocilizumab and 694 (33%) of the 2094 patients allocated to usual care died within 28 days (p=0·007).

Among patients not on invasive mechanical ventilation when entered into the trial, tocilizumab significantly reduced the chance of progressing to invasive mechanical ventilation or death from 38% to 33%.

JC: RECOVERY trial shows Tocilizumab effective for COVID19. St Emlyn’s

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

Question 5

Which of the following drugs causes ECG-changes resembling Salvador Dali’s moustache?

A: Amitriptyline

B: Isoprenaline

C: Procainamide

D: Digoxin

The correct answer is D.

Pendell Meyers covered ECG changes caused by digoxin this week on dr. Smith’s ECG blog.

‘’Digoxin in therapeutic levels causes downsloping ST depression with a characteristic “Salvador Dali sagging” appearance. Flattened, inverted, or biphasic T waves. Shortened QT interval.’’ 

Source image: hqmeded.com

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

Reviewed and edited by Rick Thissen

Quiz 101, February 5th, 2021

Welcome to the 101th FOAMed Quiz.

Sophie, Nicole, Joep, Denise, Gijs and Rick

 

Source image: www.emottowablog.com

Question 1

Achilles tendon ruptures are common in the ED. Whenever a conservative approach is chosen, patients receive a plaster cast. A walking boot may be a good alternative to casting, as patients can mobilize a lot sooner.

This recently published paper is about plaster cast versus walking boot for non-surgical treatment of achilles tendon rupture.

540 participants were randomised to receive plaster cast (n=266) or a functional brace (n=274). The primary outcome was patient-reported achilles tendon total rupture score (ATRS) at 9 months. This score consists of 10 questions about the function of the injured leg.

What did the authors find?

A: Plaster cast was superior to a functional brace at 9 months after randomisation

B: A functional brace was superior to plaster cast at 9 months after randomisation

C: Traditional plaster casting was not superior to early weight-bearing in a functional brace

The correct answer is C

EM Ottawa discussed this well conducted trial last week.

There was no difference in ATRS at 9 months post injury. There was also no difference in the rate of re-rupture of the tendon (17 [6%] of 266 in the plaster cast group vs 13 [5%] of 274 in the functional brace group).

Keep in mind blinding was not possible in this trial.

This just might be very good news for future achilles tendon rupture patients. Treatment with a walking boot allows these patients to mobilise straight away, without a cast for 8 weeks.

Source image: www.pixabay.com

Question 2

Which of the following is NOT part of the terrible triad of the elbow?

A: Fracture of the olecranon

B: Fracture of the coronoid process

C: Fracture of the radial head

D: Elbow dislocation

The correct answer is A

EMdocs covered elbow dislocations last week.

The classic terrible triad of the elbow consists of:
– Elbow dislocation
– Fracture of the coronoid process
– Fracture of the radial head

These devastating injuries need ORIF or replacement of radial head, ORIF of the coronoid, Lateral Collateral Ligament (LCL) reconstruction, and possible MCL reconstruction.

Source image: www.nuemblog.com

Question 3

Your 4-year old male patient presents with an unexplained fever for 6 days. You want to distinguish benign causes of fever and Kawasaki disease.

Which of the following clinical manifestations is most often present in patients with Kawasaki disease?

A: Adenopathy

B: Conjunctivitis

C: Strawberry tongue

D: Erythema on hand and feet

The correct answer is C

NUEM covered Kawasaki disease this week.

Kawasaki disease is a vasculitis of medium and small vessels. It is most often seen in children between 6 months and 5 years old.

Oral mucous membrane laesions are the most common clinical finding in Kawasaki disease, They are seen in approximately 90 percent of cases.

Treatment with IVIG within the first 10 days of illness has been shown to reduce the prevalence of the most feared complication: coronary artery aneurysms.

Source image: Case courtesy of Dr Chris O’Donnell, Radiopaedia.org, rID: 50812

Question 4

 Your 76 year old patient has unilateral headache for a couple of days. His Erythrocyte sedimentation Rate turns out to be 90 mm/hr.

Ultrasound may help you diagnose the patient’s condition. Which of the following is the most typical for giant cell arteritis (GCA)?

A: Stenosis of the temporal artery

B: Wall thickening (halo sign)

C: Cobblestones (cellulitis) of the adjacent subcutaneous tissue

D: Temporal artery dissection

The correct answer is B

This week the role of ultrasound in giant cell arteritis was discussed on Journal Feed.

The inflammatory infiltrate and edema of the tunica media leads to a hypoechoic, thickened rim of the vascular wall. This is called a halo sign. The compression sign is a permanent visible vessel wall during compression with the ultrasound probe. Both stenosis and complete vessel occlusion can also be seen in GCA, but are non specific. Cellulitis is not typically seen in GCA. Temporal artery dissections in GCA are very rare.

The sensitivity of ultrasound for GCA is thought to be about 85%.

Source image: www.pixabay.com

Question 5

Traumatic head injury in children is a common emergency department presentation. Every hospital uses protocols to choose whether or not to make a CT scan. Often children with coagulation diseases, such as haemophilia or Von Willebrand disease, are excluded from these protocols. CT is routinely performed by many practitioners in children with bleeding disorders who sustain a minor head injury.

The Bubble Wrap discussed a paper from Australia and New Zealand that looked at 20,137 children (<18 years) who presented to an emergency department after a traumatic head injury. In this group, 103 children had a bleeding disease.

 What did the researchers find?

A: The rate of CT scans was not more frequent in the group of children with a bleeding disease compared to children without a bleeding disease

B: There was a high incidence of intracranial hematomas in the group of children with bleeding disease receiving CT imaging

C: In the patients who underwent a CT, the trauma mechanism was milder in the group with a coagulation disorder compared to children without a bleeding disease

The correct answer is C

Dont forget the Bubble covered this paper last week.

In this study, only 1 of 103 children with a bleeding disorder had an intracranial hematoma requiring neurosurgical intervention. The rate of CT scans in children with bleeding disorders was significantly higher compared with children without bleeding disorders.

A more selective approach to CT decision-making is suggested by the authors. This might combine the severity of injury mechanism, a period of clinical observation and the type of underlying bleeding disorder.

 

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

Reviewed and edited by Rick Thissen

Quiz 100, January 29th, 2021

Welcome to the 100th FOAMed Quiz!

 

Source image: www.emcrit.org

Question 1

Extracorporeal membrane oxygenation (ECMO) can improve survival after out of hospital cardiac arrest (OHCA). However, we can’t put them all on ECMO.

This recently published paper is about the use of ECMO in patients with refractory ventricular fibrillation (VF). 30 patients were randomised to either start of ECMO on the cath lab or standard ACLS with catheterisation after ROSC.

What did the authors find?

A: Survival to hospital discharge with a favourable neurologic outcome (modified Rankin score of  3 at 6 months) was higher in the ECMO group compared to the standard ACLS group

B: Survival to hospital discharge was higher in the ECMO group compared to the standard ACLS group, but a favourable neurologic outcome (modified Rankin score of  3 at 6 months) was equal in both groups

C: Survival to hospital discharge was equal in both groups

The correct answer is A

Micheal Wolf covered this paper on Journal Feed this week.

15 patients were randomised to each group. The mean age was just below 60 years in both groups. One patient in the ECMO group withdrew consent at day 3 after randomisation. In the ECMO group, 6 patients survived to hospital discharge. All had a modified Rankin score of  3 at 6 months after randomisation. 1 patient in the standard ACLS group survived to hospital discharge (however, with devastating neurology).

Source image: www.rebelem.com

Question 2

Awake proning may be beneficial in patients suffering from COVID-19. However, data to support this is scarce.

This recently published systematic review and meta-analysis of observational trials is about multiple small observational studies in which awake proning was compared to standard care in patients receiving oxygen therapy (conventional, NIV or HFNC). The outcomes included intubation rate and in-hospital mortality.

What did the authors find?

A: Both in-hospital intubation rate and in-hospital mortality were significantly higher in patients who underwent awake proning compared to patients who underwent standard care

B: The in hospital intubation rate and in hospital mortality rate were not statistically different between patients who underwent awake proning compared to patients who underwent standard care

C: Both in-hospital intubation rate and in-hospital mortality rate were significantly lower in patients who underwent awake proning compared to patients who underwent standard care

The correct answer is B

This systematic review and meta-analysis was covered on REBEL EM this week.

No significant differences were found for both primary endpoints. In-hospital intubation rates were 27% and 30% for patients who underwent awake proning and standard care respectively (p = 0.71). In-hospital mortality rates were not statistically different (11% in awake proning vs 22% in standard care, p = 0.10).

Keep in mind this systematic review and meta-analysis is a summation of small and methodologically flawed studies. However, this is all the evidence available so far.

COVID-19 Awake Proning – All Hype?

Source image: www.coreultrasound.com

Question 3

Your colleague pulled an emesis bag over a patient’s foot and filled it with water.

What is she doing?

A: Cooling the foot after a thermal burn

B: Trying to ultrasonographically determine the composition of her patient’s vomit (not sure why the patient put her foot in though)

C: Using the bag as an alternative to a water bath to ultrasonographically assess for effusion of the ankle joint

The correct answer is C

Jacob Avila mentioned this trick on his vodcast on core ultrasound.

This is actually pretty cool and something I will try soon. Quite often I cannot find a water bowl large enough to submerge the patient’s limb. This just might be the solution.

Source image: www.rebelem.com

Question 4

In wintertime a patient with severe hypothermia arrives at your emergency department. He was found in the snow and upon arriving has a core body temperature of 27,4°C. You immediately decide to rewarm the patient by using a Bair Hugger.

After how many hours do you reckon he reaches a core temperature of 37°C if you don’t use any other warming technique besides a Bair Hugger?

A: 2 h

B: 4 h

C: 6 h

D: 8 h

The correct answer is B

This week The Trauma Pro provided an updated compilation of the average rewarming rates of commonly used techniques.

Source image: Case courtesy of Dr Jeremy Jones, Radiopaedia.org, rID: 6136

Question 5

Glucocorticoids have been used in chronic subdural hematoma. However, there is limited evidence from multicenter, randomized trials to assess the effects of glucocorticoids on outcomes.
This recently published paper is about dexamethasone in patients with chronic subdural hematoma. 748 patients with chronic subdural hematoma were randomised to either 2 two week course of dexamethasone or placebo.

 What did the authors find?

A: A favourable neurologic outcome (modified Rankin scale score 0-3) at 6 months post randomisation was significantly more frequent in the dexamethasone group compared to the placebo group

B: A favourable neurologic outcome (modified Rankin scale score 0-3) at 6 months post randomisation was significantly more frequent in the placebo group compared to the dexamethasone group

C: The modified Rankin scale score at 6 months post randomisation did not differ significantly between the two groups

The correct answer is B

The Bottom Line covered this paper last week.

A favorable outcome was reported in 286 of 341 patients (83.9%) in the dexamethasone group and in 306 of 339 patients (90.3%) in the placebo group (P=0.01). However, recurrence of the subdural haematoma requiring repeat surgery was less likely in the dexamethasone group.

Anyway, it seems patients with chronic subdural hematoma should not be treated with dexamethasone.

Dex-CSDH

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

Reviewed and edited by Rick Thissen

Quiz 99, January 22th, 2021

Welcome to the 99th FOAMed Quiz. 

Sophie, Nicole, Joep, Denise, Gijs and Rick

Source image: www.pixabay.com

Question 1

Your 27 year old patient comes in after a motor vehicle accident. She has respiratory failure (saturation 88 percent on non rebreather, breathing 48 times per minute) and has extensive rib fractures. She appears to be hemodynamically stable (for now). After bilateral finger thoracostomy you will have to intubatie her. By the way, she is pregnant (AD 26 weeks and 2 days).

Which of the following statements is true about emergency intubation of a pregnant patient?

A: Rocuronium should not be used because it easily passes the placenta

B: Succinylcholine should not be used because it easily passes the placenta

C: Etomidate is a good induction agent in this case

D: Thiopental is the only induction agent that can be used safely in this case

The correct answer is C

NUEM covered intubation of the pregnant patient this week.

Moral of the story: Use the medications you would typically use for the patient. All induction agents cross the placenta, but hypoxia, hypercarbia and acidosis are far more harmful to the fetus.

Paralytic agents are highly ionized and do not cross the placenta in significant amounts. Etomidate can be used in these cases.

 

Question 2

Soft tissue injuries due to retained foreign bodies are regularly seen in the Emergency Department. These sometimes radiolucent foreign bodies can not always be identified on conventional X-rays or computed tomography.

Ultrasonography has a high accuracy for detecting radiopaque foreign bodies. Each material has his own common sonographic signature.

The picture shown below shows a foreign body in a patient’s finger:

Source image: rebelem.com

This foreign body is most likely made of:

A: Glass

B: Wood

The correct answer is A

POCUS and Soft Tissue Foreign Bodies were covered on REBELEM this week.

The linear series of bright echogenic structures (reverberation artifacts) along the path of this foreign body are often seen in foreign bodies made out of glass.

Wooden foreign bodies have a more discrete acoustic shadow without artifacts.

POCUS and Soft Tissue Foreign Bodies

Source image: www.pixabay.com

Question 3

In Disseminated Intravascular Coagulation (DIC) there is widespread, uncontrolled clot formation in the microvascular as well as macrovascular system. Due to depletion of procoagulant proteins it can also cause hemorrhage.

DIC is a clinical diagnosis based on the presence of a constellation of laboratory abnormalities, the presence of an underlying disorder known to cause DIC and absence of a different explanation for the laboratory abnormalities.

Laboratory tests which can help diagnosing DIC include a complete blood count, PT/INR, APTT, fibrinogen and D-dimer.

Which of the following statements about laboratory tests in DIC is NOT true?

A. Thrombocytopenia is often the first laboratory abnormality to appear

B. Normal PT/INR and APTT occur in half of the patients with DIC

C. The majority of patients with DIC show low fibrinogen

D. A normal D-dimer essentially excludes DIC

The correct answer is C.

Disseminated intravascular coagulation (DIC) was covered by EMCRIT’s IBCC this week.

Low fibrinogen is seen in only 25% of patients with DIC. It supports the diagnosis of DIC, but usually isn’t seen. Remember fibrinogen is an acute phase protein, so sepsis-induced DIC may have normal or elevated levels of fibrinogen.

Source image: www.ntvt.nl

Question 4

The management of ACE-inhibitor induced angioedema can be challenging. No drugs are proven effective and it is not always obvious which patients need a secure airway.

In this retrospective study, investigators wanted to determine which patients have a higher risk and need for intubation.

What did the investigators find?

A: Isolated lip swelling was associated with an increase in risk for intubation

B: Intubation should only be performed within the first 6 hours of onset of angioedema symptoms

C: Anterior tongue swelling and vocal changes are associated with a high risk for intubation

D: Over 30 percent of patients presenting with ACE-inhibitor induced angioedema required intubation

The correct answer is C

This week Sam Parnell covered ACEi angioedema on Spoon Feed.

Isolated lip swelling was present in 54% of all patients and more common in patients that did not require intubation. These patients are usually at low risk for intubation but be aware of rapid symptom progression. Patients that required intubation were more likely to present within 6 hours of onset of angioedema symptoms. Rapid progression within the first 6 hours of onset and anterior tongue swelling, vocal changes, drooling and dyspnea are associated with intubation for ACEi associated angioedema.

 

Source image: www.pixabay.com

Question 5

Which of the following can potentially cause pancreatitis?

A: Soy beans

B: Lentils

C: Fava beans

D: Kidney beans

The correct answer is A

CountyEM covered soy bean induced pancreatitis this week.

Soy beans contain a component that is a known trypsin inhibitor. Trypsin inhibitors cause hypertrophy and hyperplasia of acinar cells (at least in rats) and are believed to cause pancreatitis in humans.

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This quiz was written by Sophie Nieuwendijk, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 98, January 15th, 2021

Welcome to the 98th FOAMed Quiz! 

 

Question 1

Source image: http://blog.clinicalmonster.com/


Your 37 year old patient presents with palpitations. He denies any chest pain and dyspnea. His ECG is shown above. He has a capillary refill of 3 seconds, his blood pressure is 80/40 and he feels generally really unwell.

Which of the following treatment options is correct in this case?

A: Adenosine

B: Electric cardioversion

C: Amiodarone

D: Metoprolol

The correct answer is B.

Pendell Meyers covered atrial fibrillation (AF) with Wolff Parkinson White (WPW).

This ECG shows an irregular, wide complex tachycardia. AF with WPW is pretty likely and therefore all nodal blockers should be avoided. The best way to treat this patient is with electric cardioversion.

Source image: www.pixabay.com


Question 2

The following drug is a natural alkaloid originally derived from Autumn Crocus. It is approximately 50% protein bound and highly lipophilic, which make it non-dialyzable in case of toxicity. One of the typical symptoms of severe poisoning is profound leukopenia.

What drug matches this description?

A: Aspirin

B: Digoxine

C: Quinine

D: Colchicine

The correct answer is D

EMDocs covered colchicine toxicity last week.

Of these plant derived drugs, colchicine is derived from the autumn crocus. Colchicine poisoning can lead to severe disease and death. After an initial phase of gastro-intestinal symptoms, multi-organ failure can develop. Profound leukopenia is very often present in severe intoxications.

ToxCard: Colchicine Toxicity

Source image: www.pixabay.com

Question 3

A fall from height is a pretty common presentation in the ED. This 2020 paper is about a model for the fatality likelihood associated with falls from heights. 285 cases were analyzed.

From how many floors (and over) did the authors find a mortality rate of 100 percent?

A: 3 floors

B: 5 floors

C: 6 floors

D: 8 floors

The correct answer is D, 8 floors.

CanadiEM covered falls from height last week.

However the mortality ratio is very high in falls from 5 floors and over, no survivors were seen in a fall from 8 floors and more.

Case Report: Parkour aftermath – Andy’s fall from height in The Office

Source image: www.theempulse.org

Question 4

Your 47 year old patient presents to your ED with suspected cellulitis of her upper left leg. She is in severe pain and has a fever. She is hemodynamically stable. Blood results are pending.

POCUS reveals the image shown above.

What is the most likely diagnosis?

A: Uncomplicated cellulitis

B: Abscess

C: Necrotizing fasciitis

The correct answer is C

Coreultrasound covered soft tissue ultrasonography this week.

The image shows cobblestones, typical for cellulitis. However, deep in the subcutis a large amount of air is present, making necrotizing fasciitis very likely.

Source image: www.emcrit.org

Question 5

Hemodynamically unstable patients often need inotropic agents to maintain a sufficient mean arterial pressure (MAP). Phenylephrine can be used as a push dose pressor.

This retrospective multicenter study is about patients with septic shock. Patients who received push-dose phenylephrine were matched to patients who did not receive push-dose phenylephrine before continuous administration of vasopressors.

The primary outcome was hemodynamic stability at 3 hours. Patients were considered stable if MAP was ≥65 for 6 hours without increase in continuous vasoactive infusions.

What did they authors find?

A: At 3 hours, significantly more patients who received push-dose phenylephrine were stable compared to those who did not

B: Hemodynamic stability at 3 hours was not significantly different between patients who received push-dose phenylephrine compared to those who did not

C: At 3 hours, significantly more patients who did not receive push-dose phenylephrine were stable compared to those who did

The correct answer is A

This retrospective multicenter study was covered by Clay Smith from JournalFeed this week.

Out of 1.317 patients, 181 received push dose phenylephrine. Hemodynamic stability at 3 hours was significantly more often achieved in the phenylephrine group compared to the non phenylephrine group (28.4% vs 18.8%).

This effect was not seen at later stages. Furthermore, the use of push-dose phenylephrine was associated with increased ICU mortality with an adjusted OR of 1.88 (95% CI 1.1-3.21).

Keep in mind that patients who received push-dose phenylephrine might have been sicker than those who did not.  

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This quiz was written by Sophie Nieuwendijk, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 97, January 8th, 2021

Welcome to the 97th FOAMed Quiz. 

Sophie, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

While the vaccinating campaign against COVID-19 finally started, research on treatment options is not slowing down. The previous BLAZE-1 trial on bamlanivimab showed no differences in patient centered outcomes as well as serious methodological flaws.

This recently published paper is about casirivimab/imdevimab (REGN-COV2) monoclonal antibody cocktail. The researchers compared a high (8.0 g) and low dose (2.5 g) of this cocktail to placebo in non-hospitalized patients over 18 years of age with a confirmed SARS-COV2 infection within 72 hours of randomization and symptom onset.

Viral load was one of the most important outcomes although no primary endpoint was selected a priori.

What did the authors find?

A: Viral load was significantly lower in the low-dose and high-dose REGN-COV2 groups compared to the placebo group at day 7

B: Viral load was not significantly different between both REGN-COV2 groups compared to the placebo group at day 7

C: Viral load was significantly higher in the low-dose and high-dose REGN-COV2 groups compared to the placebo group at day 7

The correct answer is A

Anand Swaminathan covered the paper last week on RebelEM.

A total of 275 patients (REGN-COV2 low dose: n=92, REGBN-COV2 high dose: n=90, placebo: n=93) underwent randomization from which 228 were analyzed. Antibody status prior to treatment was measured (45% with antibodies, 41 without antibodies and 14% with unknown antibody status).

The viral load was significantly lower in both REGN-COV2 groups in comparison to placebo at day 7 while clinical efficacy (change in medically attended visits) was not significantly different (3% vs 6%, -3% CI -16 to 9).

Even though these results might seem promising, we have to inperpret these results with a lot of caution due to numerous limitations such as the fact that no formal hypothesis testing was performed and the fact that the authors randomly mentioned positive outcomes while they downplayed a large number of negative findings. They thereby combined all medically attended visits ignoring the very obvious difference between for example a Telehealth visit and an admission to the hospital. Finally, this study was sponsored by Regeneron, a large pharmaceutical company.

No Evidence that REGN-COV2 (Regeneron) Antibody Cocktail Has Clinical Benefits

Source image: www.pixabay.com

Question 2

After an uncomplicated home delivery (39+1 weeks), the paramedics present to your ED a 1 hour old girl with hypoxia. There were no problems during the pregnancy. In the ED you see mask ventilation is difficult and oxygen is dropping again. You have to intubate the neonate.

Which of the following statements is true about Rapid Sequence Induction/Intubation (RSI) in neonates?

A: The use of both sedative and paralytic medication shows reduction of adverse events compared to sedation only

B: The use of sedative only shows a reduction in adverse events compared to using both sedative and paralytic medication

C: The use of paralytic medication only is good practice

D: No medication need to be given because neonates are to small, young and immature to perceive pain

The correct answer is A

This week Pediatric EM Morsels covered Neonatal Intubation and RSI.

Neonates have all the characteristics of a difficult airway. They have a challenging physiology with a low functional residual capacity and a high metabolic rate and oxygen consumption. First attempt success rate in the NICU is about 49%. Significantly fewer adverse events occur when both paralytics and sedative medication is used compared to either sedative alone or no medication. Despite the fact that they are small and young, neonates do feel pain. Not using any medication or paralytic only is just inhumane.

Neonatal Intubation and RSI

Source image: www.litfl.com

Question 3

Your 59 year old female patient has ongoing pain in her chest since yesterday. She denies dyspnoea. Her ECG is shown above. She was treated with aspirin, ticagrelor, and heparin. Troponin came back markedly elevated. Catheterization showed normal coronary arteries and POCUS revealed the following:

Source image: coreultrasound.com

What is the most likely diagnosis?


A: Occlusion Myocardial Infarction (OMI)


B: Myocarditis

C: Takotsubo cardiomyopathy

The correct answer is C

Brown EM covered takotsubo cardiomyopathy last week.

Takotsubo cardiomyopathy is an acute, transient stress-induced cardiomyopathy. The diagnosis of takotsubo can be quite challenging as it cannot be distinguished from OMI without coronary angiography. ST elevation and apical ballooning are typical for takotsubo. There is no consensus on diagnostic criteria for Takotsubo so far. Although most patients will have a complete recovery within a month, this disease is certainly not purely benign.

Question 4

A 23 year old male comes in with pain in his right foot after a jump from the second floor. He landed on both feet. The X-ray shows the following:

Source image: www.aliem.com

Which of the following injuries is associated with this fracture?

A: Vertebral fracture of the cervical spine

B: Vertebral fracture of the thoracic or lumbar spine

C: Fracture of the skull base

D: Dislocated shoulder

The correct answer is B

ALIEM covered fractures of the calcaneus last week.

‘’7-10% of calcaneal fractures are associated with a concomitant vertebral fracture, including compression or burst fractures, especially with high energy mechanisms such as a fall from height’’ 

SplintER Series: We’ve Got A Jumper

Source image: www.tamingthersu.com

Question 5

Your 54 year old patient presents to your emergency department with a painful right hand. He has been cleaning his car about 6 hours ago with ‘’some chemical stuff’’ and he thinks his glove might have been perforated. Initially he did not notice a burn, but since 2 hours ago the pain was increasing.

What chemical compound is most likely the cause of this injury?

A: Chloric acid

B: Sodium hydroxide

C: Hydrofluoric Acid

D: Ammonia

The correct answer is C

Taming the SRU covered hydrofluoric acid burns last week.

The chronology of this story is typical for hydrofluoric (HF) acid burns. High concentration (>60 percent) solutions will cause immediate symptoms, as lower concentrations tend to cause symptoms later on. This latent period causes delay in treatment.

Hydrofluoric acid is a calcium and magnesium scavenger, leading to local (and if the burn is large enough systemic) hypocalcemia and hypomagnesemia and therefore to extensive and deep necrosis. Treatment consists of decontamination, irrigation and calcium, calcium and calcium. Calcium should be applied topically and can be injected locally (subcutaneous), intravenously and even intra-arterial.

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This quiz was written by Sophie Nieuwendijk, Nicole van Groningen and Joep Hermans

Reviewed and edited by Rick Thissen

Christmas Quiz 2020

Wishing you a Merry Christmas!

 

Nicole, Joep, Sophie and Rick

 

This is the FOAMed podcast jingle quiz.

 

Do you know which jingle belongs to which podcast?

Jingle No. 1

This podcast originated in Toronto and was founded by Anton Helman. Justin Morgenstern and Rory Spiegel are contributers to this podcast.

Podcast: Emergency Medicine Cases

Jingle No. 2

On this podcast, Simon, Rob and James highlight the papers that have caught their eyes in their paper round ups each month.

Pocast: The Resus Room

Jingle No. 3

The organisation behind this podcast was founded in 1968 and gained the title ”Royal” in 2015.

Podcast: RCEM

Jingle No. 4

This podcast was founded by Anand Swaminathan in 2015.

Podcast: Core EM

Jingle No. 5

Well, this dude doesn’t do jingles. Pay atention, the sample is pretty short.

Podcast: The EMCrit podcast by Scott Weingard

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

Reviewed and edited by Rick Thissen