Quiz 162, July 15, 2022

Welcome to the 162th FOAMed Quiz.

 

Question 1

source image: pixabay.com

The recently published SALSA trial was about the risk of overcorrection of symptomatic hyponatremia using hypertonic saline (3%) bolus versus slow continuous infusion. 178 patients with moderately severe to severe symptomatic hyponatremia were randomised to receive either a rapid intermittent bolus (RIB, 2 cc per kilogram, repeated if necessary) versus slow continuous infusion (SCI, 0,5 to 1 cc per kilogram per hour, adjusted if necessary).

Overcorrection was defined as an increase in serum sodium of 12 mmol/L in 24 hours or 18 mmol/L in 48 hours.

What did the authors find?

A: Overcorrection occurred significantly more in the RIB group compared to the SCI group

B: Overcorrection occurred significantly more in the SCI group compared to the RIB group

C: There was no significant difference in occurrence of overcorrection between the RIB group and SCI group

The correct answer is C.

emDOCs covered the SALSA trial last week.

In this randomized clinical trial, overcorrection occurred in 17.2% of patients in the RIB group and 24.2% in the SCI group (absolute risk difference, -6.9% [95% CI, -18.8% to 4.9%]; P = .26). Both RIB and SCI therapy strategies for treating symptomatic hyponatremia seem effective and safe.

The groups did not differ in terms of efficacy in increasing serum sodium concentrations nor improving symptoms. However, RIB, when compared with SCI, showed better efficacy in achieving target correction rate within 1 hour (intention-to-treat analysis: 32.2% vs 17.6% P = .02). Because of this RIB seems to be preferable in treating hyponatremia in the emergency department

52 in 52 – #2: The SALSA Trial

Question 2

Source image: emergencymedicinecases.com

We are most likely overdiagnosing pulmonary embolism and harming our patient with unnecessary anticoagulation. Whether to treat isolated subsegmental pulmonary embolism or not remains controversial.

In this recently published observational trial, 292 patients with isolated subsegmental pulmonary embolism who did not receive anticoagulation were included. Patients with active cancer or history of venous thromboembolism (VTE) were excluded.

The primary outcome was recurrent venous thromboembolism during the 90 day follow-up period.

What did the authors find?

A: The risk of recurrent VTE was 0%

B: The risk of recurrent VTE was 1%

C: The risk of recurrent VTE was 3%

The correct answer is C.

The paper was covered on first10EM last week.

In this cohort, the risk of recurrent VTE was 3%. There were a total of 8 patients with recurrent VTE. 4 were proximal PE’s and 4 were proximal DVT’s. This number seems a bit high to deny patients from anticoagulation.

What to do about subsegmental pulmonary embolism?

Question 3

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

The ECG above shows de Winter’s T- waves. There are hyperacute T waves with depressed ST takeoff or ST depression in leads V2-V4.

What are de Winter’s T-waves indicative of?

A: Occlusion on the RCA

B: Occlusion of the LAD

C: Occlusion of the Cx

D: Pericarditis

The correct answer is B.

This ECG was covered on dr. Smiths ECG blog last week.

The de Winter pattern is seen in about 2% of acute LAD occlusions and is often under recognized.

Question 4

Source image: EMDocs.com

The PEricapsular Nerve Group block (PENG-block) is used as an alternative (and likely more effective block) to nerve blocks like the femoral nerve block and the Fascia Iliaca Compartment Block in patients with proximal femur pathology.

In performing the PENG block, in what location should the local anesthetic be injected?

A: Deep to the psoas tendon

B: Just superficial to the anterior inferior iliac spine

C: Just superficial to the iliopubic eminence

D: Superficial to the iliopsoas muscle

The correct answer is A.

EM Pills covered the PENG block last week.

The local anesthetic should be injected in the iliopsoas recess deep to the psoas tendon.

PENG Block

Question 5

Source image: myblockbuddy.com

Which of the following statements about B-lines in ultrasonography is true?

A: B-lines are only seen in pulmonary ultrasound

B: B-lines in pulmonary ultrasound are typically seen in case of pneumothorax

C: B-lines are caused by adjacent fluid filled and air filled structures

D: B-lines typically fade with increasing depth

The correct answer is C.

Ultrasound artifacts are covered by Jacob Avila on Core ultrasound last week.

B-lines are often seen in pulmonary ultrasound, but can be present around the body as long as reverberation artifacts can be caused by adjacent fluid filled and air filled structures. These artifacts are not seen in pneumothorax and they typically don’t fade with increasing depth.

Ultrasound Artifacts, Part 2

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

Reviewed and edited by Rick Thissen

Quiz 161, July 8th, 2022

Welcome to the 161st FOAMed Quiz.

 

Source image: www.uampa.com

Question 1
A seventeen year old male presents to the emergency department with severe pain in his scrotum for several hours. During physical examination you see a swollen and red scrotum. Elevation of the scrotum increased the pain and did not give a relief of symptoms. We call this a negative Prehn’s sign.

Which of the following diagnoses is most likely in patients with negative Prehn’s sign?

A: Acute epididymitis

B: Testicular Torsion

The corrects answer is B.

Life in The Fast Lane covered the eponym Prehn’s sign this week in their blog.

Prehn’s sign (1934) is named after the American urologist Dougles Theodore Prehn. It is most commonly described as elevation of the scrotum not decreasing the pain in the scrotum. This clinical sign may help to differentiate between testicular torsion and acute epididymitis. It should always be followed by imaging to confirm the diagnosis.

Douglas Prehn

Source image: www.dontforgetthebubbles.com

Question 2

Management of children with torus fractures still often includes application of a cast. The evidence behind treatment without immobilization is of low quality. At least so far.

In the recently published FORCE trial, 965 children (aged 4–15 years) with a distal radius torus fracture were randomly allocated to the ”offer of bandage” group or rigid immobilization group. 94% of the participants in the “offer of a bandage” group choose for bandage instead of rigid immobilization.

The primary outcome was pain on day three. Secondary outcomes included pain or function during the 6 weeks of follow-up.

What did the authors find?

A: Pain at day three was equal in both groups and there was no difference in pain and function during 6 weeks follow-up

B: Pain at day three was higher in the bandage group, but there was no difference in pain and function during 6 weeks follow-up

C: Pain at day three was equal in both groups, but patients in the bandage group reported reduced function during 6 weeks follow-up compared to the immobilization group

D: Pain at day three was higher in the bandage group and patients in the bandage group reported reduced function during 6 weeks follow-up compared to the immobilization group

The correct answer is A.

Don’t forget the Bubbles covered the paper last week.

‘’This trial found equivalence in pain at 3 days in children with a torus fracture of the distal radius assigned to the offer of a bandage group or the rigid immobilization group, with no between-group differences in pain or function during the 6 weeks of follow-up.’’

The FORCE trial

Question 3

Source image: EMDocs.com

The dose of intravenous insulin in hyperkalemia is often adjusted for renal dysfunction. Patients with renal dysfunction typically receive 5 IU instead of 10 IU to avoid hypoglycemia.

In this recently published retrospective study, 377 patients with Chronic Kidney Disease (CKD) stages 3a, 3b, and 4 and hyperkalemia were analysed. 186 patients received 5 units and 191 patients received 10 units of insulin.

What did the authors find?

A: More patients receiving 10 units of i.v. insulin had hypoglycemic events, but there was no difference in decrease of serum potassium between the groups

B: There was no difference in hypoglycemic events and there was no difference in decrease of serum potassium between the groups

C: More patients receiving 10 units of i.v. insulin had hypoglycemic events and 10 units of i.v. insulin lowered serum potassium significantly more than 5 units of i.v. insulin

D: There was no difference in hypoglycemic events among patients receiving 5 vs. 10 units of i.v. insulin. However, 10 units of i.v. insulin lowered serum potassium significantly more than 5 units of i.v. insulin

The correct answer is D.

The paper was covered on UMEM last week.

Hypoglycemia occurred in 6.5% of patients who received 5 units of i.v. insulin and in 8.4% of patients who received 10 units of i.v. insulin (p = 0.476).

There was no difference in hypoglycemic events among patients with moderate renal dysfunction receiving 5 vs. 10 units of i.v. insulin for hyperkalemia. However, 10 units of i.v. insulin lowered serum potassium significantly more than 5 units of i.v. insulin.

Keep in mind this is a retrospective paper. In the 5 unit group, significantly more patients had CKD stage 4 (60% v 30%).

Question 4

Source image: anatomytool.org/

Which of the following cardiac abnormalities are present in classic tetralogy of Fallot?

A: Atrial Septal Defect

B: Ventricular Septal Defect

C: Pulmonary Artery Stenosis

D: Coarctation of the Aorta

E: Ebstein Anomaly

F: Tricuspid Atresia

G: Overriding Aorta

H: Hypoplastic Left Heart

I: Right Ventricular Hypertrophy

The correct answers are B, C, G and I.

Geeky Medics covered tetralogy of Fallot last week.

It consists of:
Ventricular Septal Defect
Pulmonary Artery Stenosis
Overriding Aorta
Right Ventricular Hypertrophy

Tetralogy of Fallot

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

Reviewed and edited by Rick Thissen

Quiz 160, July 1, 2022

Welcome to the 160th FOAMed Quiz.

 

Question 1

The electrocardiogram shown above belongs to a 7 year old boy who suddenly collapsed during exercise. It is an example of a Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT).

Which of the following statements about CPVT is NOT true?

A: Children between the ages of 7 – 9 years are mostly affected by CPVT, but it also occurs in children under 2 years old. It is uncommon in children older than12 years

B: CPVT is induced by physical or emotional stress

C: If CPVT is not timely diagnosed and treated, it has a mortality rate of up to 35%

D: CPTV occurs in an anatomically and structurally normal heart

E: Patients with CPVT typically have a normal baseline ECG

The correct answer is A

Critical Care Now covered CPVT last week.

Children between the ages of 7 and 9 years are most commonly affected, but it also occurs in children up to 12 years old. It is rare in children less than 2 years old.

Obtaining a family history in these patients is extremely important because thirty percent of patients have family history positive for exercise-induced syncope, seizure or sudden death.

Many patients are initially misdiagnosed as having vasovagal syncope or epilepsy. The most common presentation is syncope during exercise.

Patients with CPVT typically have an anatomically and structurally normal heart and a normal baseline ECG.

Catecholaminergic Polymorphic Ventricular Tachycardia: Recognize And Treat It Early

Question 2

Source image: pixabay.com

Your patient presents with a swan neck deformity of his right index finger.

Rupture of which of the following structures typically causes a swan neck deformity?

A: Terminal extensor tendon

B: Central band of the extensor tendon

C: Flexor digitorum profundus (FDP)

D: Flexor digitorum superficialis (FDS)

The correct answer is D

AliEM covered finger injuries last week.

A swan neck deformity is caused by rupture of the FDS.

Rupture of the FPD causes inability to flex in the distal interphalangeal joint.

Central band rupture causes Boutonniere’s deformity.

Rupture of the terminal extensor tendon causes a mallet finger.

SplintER Series: Stop! Hammer Time

Question 3

Which of the following mushrooms would you choose to eat (assuming you are not suicidal)?

A

B

C

The correct answer is B.

Morel mushrooms and their imposters were covered on Taming the SRU last week.

A morel mushroom (B) exhibits a spongy, porous labyrinth of deeply-ridged craters and pits. It is completely hollow on the inside.

Its imposter, Gyromitra (A), appears rufous, mahogany, or crimson – colored and are not hollow on the inside. It contains gyromitrin, which is hydrolyzed into monomethylhydrazine (MMH), which reacts with pyridoxal phosphate. A lack of pyridoxal phosphate (active form of vitamin B6) results in cessation of production of GABA and as you can image, this causes seizures and overall badness.

Number C is called Autumn Skullcap (cute name) and contains amatoxins, causing gastrointestinal and hepatotoxic problems, coma, and death.

Question 4

Source image: ecg-interpretation.blogspot.com

An eldery male patient presents to the ED with new-onset chest pain since a couple of hours. The patient had a long history of smoking, but no prior history of heart disease. His ECG is shown above.

Which of the following coronary arteries was most likely to be occluded?

A. Right coronary artery (RCA)

B. Left Main (LCA)

C. Left anterior descending artery (LAD)

D. Left circumflex artery (LCX)

Correct answer is C

This ECG and case was covered by Ken Grauer on ECG interpretations last week.

The ECG shows a huge ongoing STEMI. There are ST elevations in 9 out of 12 leads, most dominant in leads V2-V6. This suggests either acute proximal LAD occlusion or Left main occlusion (LCA). Unfortunately, in this case the patient died before cardiac catheterization could be performed. The culprit lesion is most likely to be found in the proximal LAD, since the patient survived another 1-2 hours after presentation which is not very common in a complete Left Main obstruction.

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

Reviewed and edited by Rick Thissen

Quiz 159, June 24th, 2022

Welcome to the 159th FOAMed Quiz.

 

Source image: www.alodokter.com

Question 1

For some reason, Ramsay Hunt syndrome is all over the news these days.

As we all know by now, this is a peripheral facial paralysis. But how does it compare to the (formerly) more famous Bell’s Palsy?

Which of the following statements is NOT true?

A: Ramsay Hunt syndrome has a worse prognosis than Bell’s Palsy

B: Dizziness is a more common complaint in Ramsay Hunt syndrome than in Bell’s Palsy

C: Both in Ramsay Hunt syndrome and Bell’s Palsy, an erythematous vesicular auricular skin rash is often seen preceding paralysis

D: Antiviral therapy is a cornerstone in treating Ramsay Hunt syndrome, but has no evidence based benefit in Bell’s Palsy

The correct answer is C.

This week, Ramsay Hunt syndrome was discussed by Pediatric EM Morsels.

Ramsay Hunt syndrome is caused by reactivation of Varicella Zoster Virus. This leads to an auricular skin rash, which is not typically seen in Bell’s Palsy. Ramsay Hunt syndrome is described as more painful. Both Ramsay Hunt syndrome and Bell’s Palsy affect CN VII, but the first can also affect CN VIII, leading to vestibular symptoms, not typically seen in Bell’s Palsy.

Pediatric Ramsay Hunt Syndrome

Source image: www.rebelem.com

Question 2

While COVID-19 causes yet another surge in Europe, we hope to avoid the next overload of our critical care system.

The benefit of awake proning of our ill COVID patients has been uncertain and it was surely not general practice in our hospital.

Last month the COVI-PRONE trial was published. 400 patients (of which 97% had confirmed COVID-19) were randomised to either awake prone positioning (targeted for 8 hours daily) and usual care without prone positioning. These patients were not intubated and required oxygen (≥40%) or noninvasive ventilation.

The primary outcome was endotracheal intubation within 30 days of randomisation.

What did the authors find?

A: Patients in the awake proning group had statistically significant lower rates of intubation

B: Patients in the standard group had statistically significant lower rates of intubation

C: There was no difference in intubation rate between the two groups

The correct answer is C.

RebelEM covered the paper last week.

The achieved medial duration of prone positioning of the patient was 4.8 hours per day.

There was no statistically significant difference in intubation rate between the two groups. However, the rate of intubation was 34.1% in the awake proning group compared to 40.5% in the usual care group. This is a rather big difference, and the study just might be underpowered to detect a statistically significant difference.

REBEL Cast Ep110: The COVI-PRONE Trial – Awake Prone Positioning and COVID-19

Source image: www.pixabay.com

Question 3

Which of the following bacteria causes about 1/3th of cases of Lemierre’s syndrome?

A: Staphylococcus aureus

B: Fusobacterium necrophorum

C: Streptococcus pyogenes

D: Pseudomonas aeruginosa

The correct answer is B.

EMDocs covered Lemierre’s syndrome last week.

Lemierre’s syndrome is one of the ENT emergencies we should always consider in a patient with severe pharyngitis.

Lemierre’s syndrome is a suppurative thrombophlebitis of the internal jugular vein

Fusobacterium necrophorum accounts for about 33 percent of cases of Lemierre’s syndrome.

 

Source image: www.lompocvmc.com

Question 4

The foramen of Monro connects which two cerebrospinal fluid (CSF) containing structures?

A: The two lateral ventricles only

B: The lateral ventricles and the third ventricle

C: The third ventricle and the fourth ventricle

D: The fourth ventricle and the cisterna magna

The correct answer is B.

Geeky Medics covered anatomy of the cerebrospinal fluid filled structures last week.

The interventricular foramina (or foramina of Monro) connect the lateral ventricles to the third ventricle.

CSF exits the fourth ventricle via three foramina (Magendie and Luschka) into the cisterna magna.

The Ventricular System

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

Reviewed and edited by Rick Thissen

Quiz 158, June 17th, 2022

Welcome to the 158th FOAMed Quiz.

 

Source image: www.venousforum.org

Question 1

Which of the following ECG abnormalities is NOT caused by pulmonary embolism?

A: Atrial fibrillation

B: New tall R-wave in V1

C: ST elevation in lead aVR

D: Peaked and pointed P waves in lead I and aVL

The correct answer is D.

Ken Grauer covered ECG abnormalities in pulmonary embolism last week.

Possible EC changes due to pulmonary embolism include:
– Sinus tachycardia
– Signs of RV strain
– S1Q3T3 pattern
– Right atrial enlargement (peaked and pointed p waves in II, III, aVF, V1 and V2
– Right axis
– RBBB
– New tall R-wave in V1
– ST elevation in lead aVR
– Atrial fibrillation

Source image: www.nursing.nl

Question 2

Which of the following clinical features is NOT typical for monkeypox?

A: Lymphadenopathy

B: Acute onset of rash

C: Dermatomal distribution

D: Back pain

The correct answer is C.

Geeky Medics covered monkeypox last week.

Typical clinical features of monkeypox include: acute rash accompanying either headache, acute onset fever, lymphadenopathy, myalgia, back pain and asthenia.

If the rash follows a dermatomal distribution, consider shingles.

Monkeypox

Source image: https://radiopaedia.org

Question 3

Your patient was dropped and left outside of your emergency department. He is hemodynamically unstable, diaphoretic and has an altered level of consciousness. He states he is a body stuffer and he is transporting an unknown substance.

What is the difference between a body packer and a body stuffer?

A: A body packer usually ingests about 1 kilogram of drugs, whereas a body stuffer ingests as much as possible

B: A body packer ingests drug packets and a body stuffer hides drug packets in various orifices

C: In a body packer, ingestion of drug packets is well coordinated, whereas a body stuffer swallows drugs in a hurry

The correct answer is C.

EMDocs covered body packers, stuffers and pushers last week.

In a body packer, ingestion of drug packets is well coordinated, whereas a body stuffer swallows drugs in a hurried fashion (often to avoid immediate arrest). The packets are often more prone to break. The amount of drugs is usually smaller in body stuffers.

A person who hides drug packets in various orifices is called a body pusher.

Body Packers, Stuffers, and Pushers: Time Bombs in Our EDs

Question 4

In the images above. The blue area is supplied by which artery?

A: LAD

B: Cx

C: RCA

The correct answers is C.

 Jacob Avila covered advanced cardiac ultrasound last week on Core Ultrasound.

The blue area is supplied by the RCA, the yellow area by the LAD, the red area by the LAD or Cx and the green area by the RCA or Cx. 

5 Top Tips for Advanced Echo

Source image: https://my360pt.com

Question 5

Unilateral pain that radiates along the path of the sciatic nerve, from the lower back through the hip and buttock towards the leg is typical for sciatica. Ultrasound guided sciatic nerve block may be beneficial for patients with sciatica. A long-acting anesthetic such as bupivacaine, in combination with a corticosteroid may provide pain relief.

Which of the following statements about the anatomy of the sciatic nerve is true?

A: It runs between the ischial tuberosity and greater trochanter

B: It runs above the gluteus maximus and below the quadratus femoris muscles

C: It runs within a fascial plane through the obturator foramen

D: Distally it branches in the saphenous nerve

The correct answer is A.

This week AcepNow discussed The ultrasound-guided transgluteal sciatic nerve block (TGSNB).

The sciatic nerve is identified by ultrasound located inferior to the gluteus maximus muscle, superior to the quadratus femoris muscle as it courses adjacent to the ischial tuberosity (medially) and greater trochanter (laterally).

TransGluteal Sciatic Nerve Block

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

Reviewed and edited by Rick Thissen

Quiz 157, June 10th, 2022

Welcome to the 157th FOAMed Quiz.

 

Source image: www.litfl.com

Question 1

A patient is brought to your ED with nausea and palpitations after drinking tea from self picked garden plants. The ECG, as displayed, shows “sagging” ST segments and T waves taking on a typical appearance.

Which of the following plants was likely to be inside the tea?

A: Oleander

B: Monkshood

C: Yew

D: Foxglove

The correct answer is D.

AliEM discussed Foxglove intoxication this week.

The botanical name for foxglove is Digitalis purpurea. ECG changes are in line with digoxin intoxication.

Oleander is a poisonous plant with a non-digitalis cardiac glycoside effect. The Na+/K+ ATPase pump of the heart is affected, resulting in hyperkalaemia which might lead to matching ECG changes.

Both Monkshood and Yew contain alkaloids that disrupt impulse conduction in the heart by blocking sodium channels in the cell membrane, slowing depolarization, leading to bradycardia and cardiac arrest.

ACMT Toxicology Visual Pearl: Pretty (and Deadly) in Purple

Source image: https://thesgem.com

Question 2

There used to be a time every patient with pneumothorax, traumatic or not, received a large bore chest tube. Fortunately, nearly all patients with pneumothorax get a smaller percutaneous catheter nowadays.

Patients with hemothorax still routinely get a 28-32 Fr chest tube, for smaller tubes are thought to increase the risk of complications and retained hemothorax.

In this 2021 paper, patients with traumatic hemothorax or hemopneumothorax requiring drainage were randomized to receive a 14 Fr pigtail catheter or a 28–32 Fr large-bore chest tube.

The primary outcome was failure rate of the drainage catheter, defined as retained hemothorax requiring additional intervention including a second catheter, thrombolysis and video-assisted thoracoscopy surgery.

What did the authors find?

A: The failure rate of the drainage catheter was higher in the 28-32 Fr group

B: The failure rate of the drainage catheter was higher in the 14 Fr pigtail group

C: The failure rate of the drainage catheter did not differ between the two groups

The correct answer is C.

The paper was covered on RebelEM last week.

The failure rate was 11 percent in the pigtail group versus 13 percent in the 28-32 Fr chest tube group. This difference was not statistically significant.

Keep in mind this is a rather small RCT with some methodological flaws. Larger RCT’s are needed for change of practice.

Traumatic Hemothorax: Pigtail vs Chest Tube

Source image: www.litfl.com

Question 3

The patient behind this ECG presents with a certain type of hypertrophic cardiomyopathy (HCM).

In patients with what nationality is this type of HCM most frequently seen?

A: Mongolian

B: Japanese

C: Philippine

D: South Korean

The correct answer is B.

This ECG is typical for apical HCM. Apical HCM was covered on LITFL last week.

‘’This relatively uncommon form of HCM is seen most frequently in Japanese patients (13-25% of all HCM cases in Japan) and it is also known as Yamaguchi syndrome’’.

https://litfl.com/apical-hypertrophic-cardiomyopathy-ahc/

Source image: www.henw.org

Question 4

Your patient presents with acute hearing loss.

The Weber test lateralizes to the right ear and the Rinne test is positive (normal) on both sides.

What does this patient most likely have?

A: Conductive hearing loss of the right ear

B: Conductive hearing loss of the left ear

C: Sensorineural hearing loss of the right ear

D: Sensorineural hearing loss of the left ear

The correct answer is D.

Taming the SRU covered tinnitus and auditory disturbances last week.

Weber test lateralizes to the right ear, so this patient either has conductive hearing loss on the right side or sensorineural hearing loss on the left side.

A positive Rinne on both sides means there is no conductive hearing loss, leaving sensorineural hearing loss on the left side as the most likely cause.

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

Reviewed and edited by Rick Thissen

Quiz 156, May 27, 2022

Welcome to the 156th FOAMed Quiz.

 

Question 1

Source image: pixabay.com

Your 3 year old patient comes in with a cough. There is no respiratory distress. Her mom is pretty sure she aspirated a peanut.

Which of the following statements about aspiration of a peanut is true?

A: In case of mild symptoms, there is no need to retrieve the peanut. It will dissolve by itself

B: In case of mild symptoms, the peanut should be retrieved within 48 hours

C: Even in case of mild symptoms, the peanut should be retrieved as soon as possible

The correct answer is C.

Don’t forget the Bubbles covered foreign object aspiration last week.

Peanuts should be retrieved as soon as possible. ‘’ lipophilic objects (like peanuts) can cause massive cytokine release and inflammation due to their fat content.’’

The hidden dangers of inhaled plastic toys

Question 2

Source image: http://brownemblog.com/

Diagnosing pyogenic flexor tenosynovitis can be challenging when the clinical picture is not obvious. The diagnostic value of laboratory testing is uncertain and plain X-ray and CT are not helpful. MRI can aid in diagnosing tenosynovitis but is not always available. In comes ultrasound…

In this 2018 paper 57 patients with suspected pyogenic flexor tenosynovitis (but not obvious, those were excluded) underwent ultrasound in addition to clinical examination (fluid within the tendon sheath). The gold standard was inter-operative findings or (whenever the patient did not get surgical intervention) the clinical course when treated with antibiotics only.

What did the authors find?

A: Ultrasound had both a high sensitivity and a high specificity

B: Ultrasound had a high sensitivity, but a low specificity

C: Ultrasound had a low sensitivity, but a high specificity

D: Ultrasound had both a low sensitivity and a low specificity

The correct answer is B.

AlieEM covered pyogenic flexor tenosynovitis last week.

In the 2018 paper, of 57 patients, 29 patients had a negative ultrasound and were treated with antibiotics only with good outcome. There was only 1 patient that turned out to have flexor tenosynovitis after all. Of the 27 patients that had a positive ultrasound, 10 patients did not have flexor tenosynovitis intra-operatively.

The sensitivity was 94% and the specificity only 65%.

SplintER Series: Point Tender

Question 3

Your 55 year old patient comes in with hypovolemic shock due to esophageal varices bleeding. You intubate and ask for a minnesota tube.

Which of the following is a Minnesota tube?

A
C
B

The correct answer is C (tough one)

This very helpful EMRap video was shared on UMEM last week.

A is a Linton tube and B is a Blakemore tube. The Missesota tube is the one with the many ports. It has a port for both balloons and for suction of gastric content as well as for esophageal content. For an explanation of the differences, watch the video.

Question 4

Source image: pixabay.com

Which of the following clinical signs fit the picture of heparin induced thrombocytopenia?

A: A fall in platelet of 20 percent

B: The platelet fall starts 1 days after start of heparin

C: New venous thrombosis

D: The patient 1 one day post surgery

The correct answer is C.

Critical Care Now covered heparin induced thrombocytopenia (HIT) last week.

A platelet fall of > 50 percent, platelet fall within 5-10 days of starting heparin, new thrombosis and no other cause of thrombocytopenia eg. no surgery) are typical for HIT.

4Ts versus 3Ls: heparin induced thrombocytopenia probability scoring

Question 5

Source image: pixabay.com

There are two generations of anticoagulant rodenticides: first generation include warfarin. Second generation rodenticides are also called superwarfarins and very long acting and potent.

Which of the following statements is true about management of superwarfarin intoxication in the emergency department?

A: Asymptomatic patients with a normal INR 12 hours post ingestion can be safely discharged and don’t need follow-up

B: Charcoal may be useful if administered in the first 1-2 hours after ingestion

C: Vitamin K should definitely be administered at presentation in the emergency department

D: If INR is normal at 48-72h after ingestion, toxicity still can’t be ruled out

The correct answer is B.

Anticoagulant rodenticide intoxication was covered on EMDocs last week.

Charcoal may be useful if administered to prevent absorption in the first 1-2 hours after ingestion.

Administration of vitamin K prior to detecting an elevated INR is debatable, as vitamin K1 may delay INR elevation and underestimate severity of exposure.

If INR is normal at 48-72 hrs, clinical toxicity can be safely ruled out with very rare exceptions.

emDOCs.net – Emergency Medicine EducationToxCard: Superwarfarins – emDOCs.net – Emergency Medicine Education

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

Reviewed and edited by Rick Thissen

Quiz 155, May 20, 2022

Welcome to the 155th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Your 65 year old patient comes in with tachypnea, profound tachycardia, diaphoresis, fever and confusion. She has been losing weight and is feeling restless for the last few months and last week she had influenza.

You suspect her of having thyrotoxic crisis.

Which of the following agents is not part of ED treatment of thyrotoxic crisis?

A: A beta blocker (propranolol)

B: A glucocorticosteroids (hydrocortisone)

C: A thioamides (propylthiouracil)

D: Acetylsalicylic acid (Aspirin)

The correct answer is D.

Thyrotoxic crisis was covered on EM Pills last week (in Italian).

Aspirin interacts with protein binding and might increase free T4 and T3 serum levels. It should be avoided in case of thyrotoxic crisis.

Source image: www.gezondheid.be

Question 2

Renal colic is a clinical diagnosis and imaging is often unnecessary. However, when in doubt, imaging can be helpful. The preferred initial imaging modality (CT, POCUS or formal ultrasound) is debatable.

In this 2014 paper, 2759 patients with suspected nephrolithiasis were randomized to undergo diagnostic ultrasonography performed by an emergency physician (POCUS), ultrasonography performed by a radiologist (radiology ultrasonography), or abdominal CT as initial imaging. The patients were only included if the treating physician decided imaging was necessary.

The primary outcomes included high-risk diagnoses with complications that could be related to missed or delayed diagnoses.

What did the authors find?

A: Patients in the POCUS group had a higher rate of complications that could be related to missed or delayed diagnoses compared to patients in the CT group. Patients in the radiology ultrasound group did not

B: Patients in both the POCUS group and the radiology ultrasound group had a higher rate of complications that could be related to missed or delayed diagnoses compared to patients in the CT group

C: The incidence of high-risk diagnoses with complications in the first 30 days did not vary according to imaging method

The correct answer is C.

The paper was covered on NUEM last week.

High-risk diagnoses with complications during the first 30 days after randomization occurred in only 11 patients with no significant difference according to study group.

However, 40.7% of the patients in the point-of-care ultrasonography group and 27.0% of the patients in the radiology ultrasonography group underwent subsequent CT in the emergency department. This did not result in a higher mean ED length of stay.

The sensitivity was 54% for point-of-care ultrasonography, 57% for radiology ultrasonography, and 88% for CT.

Source image: www.pixabay.com

Question 3

Alcohol consumption appears to be increasing and alcohol withdrawal syndrome (AWS) is quite frequently encountered in our ED.

Which of the following statements about the management of AWS is true?

A: IV midazolam is superior to IV lorazepam in treatment of AWS

B: IV benzodiazepine have higher effectiveness in treatment of AWS compared to IV phenobarbital

C: IV benzodiazepines have a favorable safety profile for treating alcohol withdrawal compared to IV phenobarbital

D: IV phenobarbital can cause persistent coma in patients with liver failure or hepatic encephalopathy

The correct answer is D.

Both EMDocs and Downeast EM covered alcohol withdrawal syndrome last week.

There is no clear evidence suggesting superiority of one benzodiazepine over another for AWS treatment and phenobarbital is most likely at least as effective as benzodiazepines. The safety profile of phenobarbital appears similar to that of benzodiazepines, but beware of patients with liver failure.

Source image: first10EM.com

Question 4

The prevalence of monkeypox is increasing. This viral zoonosis is endemic to central and western Africa, but is increasingly encountered throughout Europe and the US. 

Which of the following statements about monkeypox is true?

A: The first clinical features of the illness are skin lesions. There are no prodromes.

B: Monkeypox may look very similar to chickenpox

C: Monkeypox has a higher rate of transmission from human to human compared to smallpox

D: Smallpox vaccination does not provide protection against monkeypox

The correct answer is B.

Monkeypox was covered on first10EM last week.

Monkeypox may mimic chickenpox.

Prodromes include fever, malaise and headaches and typically last for 2 days.

Monkeypox has a lower transmission rate compared to smallpox and the smallpox vaccine actually provides some protection against monkeypox.

Smallpox vaccination appears to provide reasonable (approximately 85%) protection against monkeypox.

Monkeypox

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

Reviewed and edited by Rick Thissen

Quiz 154, May 13

Welcome to the 154th FOAMed Quiz.

 

Question 1

Source image: first10EM.com

What is the maximum dose of lidocaine without adrenaline for peripheral nerve blocks?

A: 2 mg/kg

B: 3 mg/kg

C: 4.5 mg/kg

D: 6.5 mg/kg

The correct answer is C.

BrownEM Local Anesthetic Systemic Toxicity (LAST) last week.

The maximum dose of lidocaine is 4.5 mg/kg.

LAST the most feared complication of ‘’amide’’ local anesthetics like lidocaine. To minimize the risk of LAST, the smallest effective dose of local anesthetic should be used.

Question 2

Source image: dontforgetthebubbles.com/toddler-fracture/

On this X-ray, a spiral fracture of the tibia can be found.

How is his fracture often called?

A: Toddler’s fracture

B: Neonate fracture

C: Infant fracture

D: Preschool fracture

The correct answer is A.

Pediatric EM Morsels covered tibial shaft fractures last week.

Tibial shaft fractures are the 3rd most common long bone injuries in children.

A toddler fracture is a minimally or undisplaced spiral fracture of the tibia, typically encountered in toddlers. It is the result of low impact trauma and these fractures can be really hard to detect on an X-ray.

Tibial Shaft Fractures in Children

Question 3

Source image: pixabay.com

Your patient presents with progressive weakness and difficulty breathing. He has myasthenia gravis and you suspect a myasthenic crisis with so far an unknown cause.

Which of the following statements is true about the treatment of myasthenic crisis?

A: In rapid sequence intubation, succinylcholine should be used instead of nondepolarizing agents

B: Patients with difficulty breathing should be in supine position as long as possible

C: Plasma exchange is the first-line agent for severe exacerbations

The correct answer is is C.

SinaiEM covered myasthenic crisis last week.

The effect of succinylcholine is unreliable due to reduced acetylcholine receptor density in patients with myasthenia gravis.

Patients with myasthenic crisis have weak diaphragm and will have a higher forced vital capacity when sitting upright, compared to lying down.

Plasma exchange is the first-line agent for severe exacerbation, as it causes improvement in a few days. Intravenous Immunoglobulin (IVIG) needs a couple of weeks to be effective.

Myasthenic Crisis

Question 4

Source image: pixabay.com

Your 2 year old patient presents with a painful elbow after her father lifted her by her arms. You suspect a radial head subluxation (nursemaid’s elbow).

Which of the following reduction techniques is considered to be the most effective?

A: Hyperpronation

B: Supination and flexion

C: Traction

The correct answer is A.

EM Pills blog (in Italian) covered the nursemaid’s elbow last week.

Hyperpronation is considered to have greater effectiveness compared to the supination-flexion maneuver. Furthermore, this maneuver would seem to be less painful for the child.

IL GOMITO DELLA BAMBINAIA

Question 5

 

Source image: semanticscholar.org

Point of care ultrasound (POCUS) can be helpful whenever the diagnosis of a radial head subluxation is not clear. Which of the following POCUS signs are found in a nursemaid’s elbow?

A: Twinkle sign

B: Hook sign

C: Donut Sign

The correct answer is B.

The twinkle sign (or twinkling artifact) consists of rapid alternation of color immediately behind an echogenic object, causing false appearance of movement.

The donut sign is seen in intussusception.

The hook sign is caused by ‘’pulling’’ the annular ligament between the radial head and the capitellum. It is seen in longitudinal view

IL GOMITO DELLA BAMBINAIA

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

Reviewed and edited by Rick Thissen

Quiz 153, May 6, 2022

Welcome to the 153th FOAMed Quiz.

 

Question 1

Source image: www.emra.org

Patients often report that a peripheral intravenous catheter (IV) should not be placed on the same side of the body as prior breast surgery.

In this 2021 retrospective paper a chart review was performed on 3724 patients with prior surgery for breast cancer. These patients underwent 7896 IV placements. The IVs were being placed a median of 1.5 years after the original breast cancer surgery. 5153 were placed in the ipsilateral arm and 2743 were placed in the contralateral arm.

What did the authors find?

A: More complications were found in patients with an IV in the ipsilateral arm

B: More complications were found in patients with an IV in the contralateral arm

C: There were only 2 complications in both groups

The correct answer is C.

The paper was covered on First10EM last week.

Indeed, there were only 2 complications in both groups. Prior breast surgery is not a contra-indication for IV placement on the ipsilateral side. However, it may take some gentle discussion with the patient due to the misinformation they have received.

Research Roundup (May 2022)

Question 2

Source image: www.pixabay.com

Your 35 year old patient is brought in after a fire in his living room. He inhaled a lot of smoke. He is profoundly tachypneic, confused and has a lactate of 16 mmol/L. You want to treat him for cyanide intoxication.

Which of the following agents is first line treatment in cyanide intoxication?

A: Amyl nitrite

B: Sodium nitrite

C: Sodium thiosulfate

D: Hydroxocobalamin

The correct answer is D.

Carbon mono-oxide and Cyanide poisoning were covered on NuEM last week.

Historically, amyl nitrite or sodium nitrite in combination of sodium thiosulfate was used for cyanide intoxication. These days the first line treatment is high dose Hydroxocobalamin (5 grams). Hydroxocobalamin scavenges cyanide by binding it to form cyanocobalamin.

Question 3

Source image: lermagazine.com

Your patient presents with a lower leg fracture and is in extreme pain. You wonder whether he has compartment syndrome and decide to measure compartment pressure.

What is the generally accepted compartment pressure above which the diagnosis becomes very likely?

A: > 10 mmHg

B: > 20 mmHg

C: > 30 mmHg

The correct answer is C

RebelEM covered compartment syndrome last week.

The diagnostic threshold for compartment syndrome is 30 mmHg.

REBEL Core Cast 80.0 – Compartment Syndrome

Question 4

Source image: www.pixabay.com

To anesthetize the sole of the foot (for example in removal of foreign objects), ultrasound guided nerve blocks are very useful.

A block of which of the following nerves results in anesthesia of the largest part of the sole of the foot?

A: Posterior tibial nerve

B: Saphenous nerve

C: Sural nerve

The correct answer is A. 

Ultrasound guided posterior tibial nerve block was covered on Core Ultrasound last week.

A posterior tibial nerve block will anesthetize most of the sole of the foot.

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

Reviewed and edited by Rick Thissen