Quiz 85, September 18th, 2020

Welcome to the 85th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

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

Which of the following statements about PIMS is true?

A: Most patients with PIMS only have mild symptoms

B: It affects mostly children with pre existing comorbidity

C: About 2 percent of the patients require inotropic support

D: Myocarditis prevalence increases with age

The correct answer is D

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

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

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

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

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

Pediatric Inflammatory Multisystem Syndrome (PIMS)

Source image: www.pixabay.com

Question 2

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

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

A: An arterial embolic occlusion

B: An arterial thrombotic occlusion

C: Arterial non-occlusive ischemia

D: A venous occlusion

The correct answer is A

Mesenteric ischemia was covered on emDOCs this week.

Mesenteric ischemia is known to have several distinct etiologies.

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

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

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

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

Source image: www.pixabay.com

Question 3

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

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

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

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

B: HbSS: Homozygous for HbS

C: HbSβ: HbS and Hbβ (Beta Thalassemia)

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

The correct answer is B

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

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

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

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

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

Question 4

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

A: Cachexia

B: Ataxia

C: Altered mental status

D: Ophthalmoplegia

The correct answer is A

Anand Swaminathan recorded a podcast on RebelEM about Wernicke Encephalopathy.

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

REBEL Core Cast 40.0 – Wernicke Encephalopathy

Source image: www.pixabay.com

Question 5

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

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

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

What did the authors find?

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

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

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

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

The correct answer is A.

Bo Stubblefield covered this systematic review on journalfeed this week.

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

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

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:
Loading

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

Reviewed and edited by Rick Thissen

Quiz 84, September 11th, 2020

Welcome to the 84th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Source image: https://rebelem.com/

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

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

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

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

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

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

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

The correct answer is A

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

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

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

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

Question 2

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

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

A: Sensitivity of POCUS for shoulder dislocations is 100 percent

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

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

The correct answer is A

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

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

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

 

Question 3

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

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

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

What did the result show?

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

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

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

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

The correct answer is B

Salim Rezaie covered this paper on RebelEM last week.

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

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

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

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

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

Remdesivir in Moderate COVID-19

Question 4

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

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

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

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

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

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

The correct answer is A

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

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

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

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

Question 5

Source image: https://pixabay.com/

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

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

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

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

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

The correct answer is C

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

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

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

IBCC chapter & cast – Cerebral Venous Thrombosis

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:
Loading

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

Reviewed and edited by Rick Thissen

Quiz 83, September 4th, 2020

Welcome to the 83th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

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

What did the authors find?

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

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

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

The correct answer is C.

Benjamin Gerritsen covered the THALES trial on REBELem this week.

The authors randomized 11016 patients.

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

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

Source image: www.pixabay.com

Question 2

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

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

A: Acetazolamide

B: Nifedipine

C: Dexamethasone

D: Sildenafil

The correct answer is B

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

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

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

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

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

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

 

Question 3

Source image: www.pixabay.com

Appendicitis can be a challenging diagnosis in the ED.

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

A: Physician gestalt for acute appendicitis diagnosis performed poorly

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

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

The correct answer is C

BrownEM covered this paper last week.  

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

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

Question 4

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

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

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

Which of the following statements is true?

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

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

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

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

The correct answer is B 

CoreEM covered this paper last week. 

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

Source image: coreem.net

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

Question 5

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

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

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

B: Cherry red colour of blood

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

The correct answer is C.

Methemoglobinemia was covered by Justin Morgenstern on First10EM this week.

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

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

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

Methemoglobinemia

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:
Loading

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

Reviewed and edited by Rick Thissen

Quiz 82, August 28th, 2020

Welcome to the 82th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

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

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

What did the authors find?

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

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

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

The correct answer is B

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

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

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

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

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

Source image: www.pixabay.com

Question 2

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

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

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

B: Colchicine is the most effective treatment for active PFAPA

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

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

The correct answer is A

First10EM covered PFAPA this week.

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

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

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

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

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

Source image: www.nuemblog.com

Question 3

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

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

A: fat – muscle – nerve – skin – bone

B: bone – nerve – muscle – skin – fat

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

D: nerve – muscle – skin – fat – bone

The correct answer is D

NuEM covered lightning injuries last week. 

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

Question 4

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

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

source image: journalfeed.org

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

What did the authors find?

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

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

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

The correct answer is C

This week JournalFeed covered the Infant Scalp Hematoma Score.

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

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

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

Source image: www.coreem.net

Question 5

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

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

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

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

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

The correct answer is A

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

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

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

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

Maisonneuve Fractures

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:
Loading

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

Reviewed and edited by Rick Thissen

Quiz 81, August 21th, 2020

Welcome to the 81th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Source image: http://brownemblog.com/

A 28 year old female comes in with suspected first trimester bleed. Her last menstrual period was about 5 weeks ago. Her B-hCG comes back 4000 mIU/mL.

Should an intrauterine pregnancy be visible on ultrasound?

A: Intrauterine pregnancy should be visible on both transvaginal and transabdominal ultrasound in this case

B: Intrauterine pregnancy should not yet visible on both transvaginal and transabdominal ultrasound in this case

C: Intrauterine pregnancy should be visible on transvaginal ultrasound but is unlikely to be visible on transabdominal ultrasound

The correct answer is C

BrownEM covered first trimester ultrasound and hydatidiform mole this week.
Intrauterine pregnancy can usually be seen at B-hCG levels > 1500 via trans-vaginal ultrasound and > 6500 via trans-abdominal ultrasound.

Question 2

Source image: emcrit.org

Catecholamine-resistant vasodilatory shock (CRVS), in which hypotension persists despite the use of high-dose vasopressors, carries a 50% to 80% mortality.

The 2019 ATHOS-3 trial showed that in patients with severe vasodilatory shock, administration of angiotensin II (ATII) is associated with a 45% absolute increase in MAP response compared to placebo.

This suggests in most people with CRVS, there is significant disturbance in the RAAS likely resulting from impairment of ACE function. However, identification of patients with RAAS disturbance is challenging because ATII levels cannot be measured in most labs.

This recently published paper assesses renin levels as an easy to assess surrogate for ATII levels and so to predict which patients with CRVS would benefit from ATII therapy.

What does this paper show?

A: Patients with RAAS disturbance cannot be identified through simple laboratory assessment of serum renin levels

B: Renin assessment could be used to identify patients without RAAS disturbance, in whom treatment with angiotensin II would likely be beneficial

C: Renin has the potential to be used to identify CRVS patients at high risk for poor outcome and who may benefit from treatment with synthetic angiotensin II

D: Patients with serum renin levels above the study population median had a significantly reduced risk of mortality.

The correct answer is C

Scott Weingard discussed this paper with the author on the EMCrit podcast. 

Patients with RAAS disturbance can be readily identified through simple laboratory assessment of serum renin levels. 

Renin assessment could be used to identify patients without RAAS disturbance, in whom treatment with angiotensin II would likely be futile.

Patients with serum renin levels above the study population median had a significantly increased risk of mortality. 

And indeed: Renin has the potential to be used to identify CRVS patients at high risk for poor outcome and who may benefit from treatment with synthetic angiotensin II.

Question 3

Source image: Pixabay.org

A 58 year old male with a medical history of gastroesophageal reflux disease and hypertension presents to your emergency department with abdominal pain. This morning he had one episode of coffee ground emesis. He reports frequent cocaine use with his last use three days ago.

Conventional X-ray reveals a pneumoperitoneum. You suspect bowel perforation caused by cocaine use.

Which of the following statements is true about cocaine use and bowel perforations?

A: Cocaine causes bowel perforation in previously affected bowels only

B: Cocaine stimulates norepinephrine reuptake in the presynaptic nerve endings leading to arterial vasoconstriction

C: The onset of symptoms typically occurs within one hour to sixty hours after cocaine use

The correct answer is C.

This week Eric Beyer covered the cocaine gut on ALiEM.

Bowel ischemia due to cocaine use is caused by blocking norepinephrine reuptake in presynaptic nerve endings. This leads to arterial vasospasm or constriction which can lead to complete bowel wall ischemia and perforation. Cocaine use can also exacerbate underlying peptic ulcer disease. Symptoms of a cocaine-induced bowel perforation typically occur between one and sixty hours after cocaine use.

SAEM Clinical Image Series: The Cocaine Gut

Question 4

Source image: emdocs.net

A 25-year old man presents to your Emergency Department with a painful and swollen thumb after he fell on it during a soccer game with his friends. The X-ray shows a fracture of the first metacarpal base.

Which of the following statements is true about 1st metacarpal base fractures?

A: Bennett fractures are multi-fragmented

B: Bennett fractures are considered stable fractures

C: Rolando fractures require operative management due to the intrinsic instability of the fracture

D: Fracture lines in Bennett fractures typically form a Y or a T shape

The correct answer is C.

This week Rachel Bridwell covered metacarpal base fractures on EmDocs.

Bennett fractures occur on the ulnar side. The base of the 1st MCP can subluxate due to an intact Abductor Pollicis Longus and Brevis and Extensor Pollicis Longus and Brevis.

Both Bennett and Rolando fractures are considered unstable.

Rolando fractures are complex fractures. Operative fixation is necessary.

Fracture lines in Rolando fractures typically form a Y or a T shape

Question 5

Your 4 year old patient presents with a hemolytic anemia, abdominal pain, thrombocytopenia and acute renal failure. You suspect Haemolytic-Uremic Syndrome (HUS).

About 90% of HUS cases follow an infection. Which is the most commonly encountered causative pathogen?

A: Entero-Haemorrhagic E. Coli (EHEC)

B: Streptococcus pneumoniae

C: Staphylococcus aureus

D: Klebsiella pneumoniae

The correct answer is A

Don’t forget the Bubbles covered HUS last week.

´´About 90% of cases follow an infection, most commonly with entero-haemorrhagic E. Coli (EHEC). Other infective causes to be considered include Shigella and Streptococcus pneumoniae.´´

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:
Loading

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

Reviewed and edited by Rick Thissen

Quiz 80, August 14th, 2020

Welcome to the 80th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

A 28 year old patient is brought in by prehospital services for ‘medical clearance’ before he will be evaluated by psychiatry for acute psychosis. His history and physical are unremarkable.

You wonder if doing labs and a urine tox screen would be beneficial.

What does the current literature say about routine laboratory investigations and drugs screen for ‘medical clearance’ of this patient?

A: Routine labs and tox screen are indicated, because in more than 10 percent of patients an acute medical condition is found

B: Routine labs are not indicated, but routine tox screening is, because it often changes disposition

C: Routine labs and tox screening are not indicated, because an acute medical problem is very rare in patients with normal history and physical

The correct answer is C

Justin Morgenstern covered routine testing in psychiatric patients this week. 

The current body of literature says routine laboratory testing does not lead to identification of more acute medical problems compared to history and physical exam alone. 

Tox screen will be positive quite frequently, but does not change management or disposition.

 

Question 2

Source image: pixabay.com

Your 52 year old patient presents with a stroke. His NIHSS score is 13. CT shows no bleed and you decide to start Intravenous tissue plasminogen activator (tPA) and evaluate the patient for intra arterial treatment. 

Suddenly your patient develops unilateral swelling of the tongue. Which of the following statements is true about this condition?

A: Angioedema is very rare in patients receiving tPA

B: This type of angioedema is most likely bradykinin mediated

C: The chance of this patient needing intubation or a surgical airway is high

D: Fresh frozen plasma (FFP), C1-inhibitor concentrate, icatibant and ecallintide are proven beneficial in tPA mediated angioedema

The correct answer is B

EMdocs covered adverse effects of tPA this week. 

Angioedema is estimated to occur in 1.3 – 5.1% of stroke patients receiving tPA.

Although the pathophysiology of tPA induced angioedema is poorly understood, it is thought to involve complement and plasmin mediated bradykinin release.

The majority of cases are mild and self-limiting. Few will progress to life threatening levels of edema and airway compromise 

Fresh frozen plasma (FFP), C1-inhibitor concentrate, icatibant, ecallintide, and even TXA are potential medical therapies, but no direct evidence for their use in tPA induced angioedema so far.

Question 3

Source image: pixabay.com

A 49 year old patient presents to you ED feeling generally unwell. He has been drinking a bottle of vodka every day for the last month and has been admitted for alcohol intoxication a couple of times. He wants to quit. 

Which of the following risk scores can help you predict the alcohol withdrawal severity?

A: PAWWS score

B: DSM5 criteria

C: CIWA-Ar score

D: SHOT scale 

The correct answer is A

EMOttawa covered alcohol withdrawal in the ED last week. 

Perhaps deserving more attention than it does (at least in Dutch ED’s), alcohol withdrawal is quite common. 

The PAWWS (Prediction of Alcohol Withdrawal Severity Scale) score helps you predict the alcohol withdrawal severity. 

Alcohol withdrawal is diagnosed by the DSM5 criteria. 

The CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol scale) score objectifies alcohol withdrawal severity to help guide therapy.

The Sweating Hallucinations Orientation and Tremor (SHOT) score is a simple 4 item score which focuses on the objective signs of withdrawal and can help you guide therapy and disposition as well. 

Question 4

In most cases, there is little or no benefit of arterial blood gas over venous blood gas. But does the patient care?

The recently published VEINART Trial compared maximal experienced pain levels during venous and arterial blood gas sampling in non-hypoxemic patients by using a visual analog scale (VAS) on a 0 to 100 scale.

What did the author find?

A: Mean maximal experienced pain was significantly higher in the VBG group compared to the ABG group 

B: Mean maximal experienced pain was similar in both groups

C: Mean maximal experienced pain was significantly lower in the VBG group compared to the ABG group 

The correct answer is C

Salim Rezaie from REBEL EM covered The VEINART Trial this week.

This relatively small (n= 113) multicenter, open-label, randomized, prospective clinical trial in 4 French EDs found a total difference in mean maximal pain of 17.9 points (95% CI; 9.6 -26.3; p<0.0001) between VBG (mean 22.6; +/- 24.9) and ABG sampling (40.5; +/- 20.2).

In (by far) most cases a venous blood gas will be all you need. 

Question 5

Your 60 year old patient tells you that he went for a run and fell on an outstretched hand. The elbow was painful and had a deviating position. You diagnose the patient with a posterior elbow dislocation.

Which of the following is true about elbow dislocations?

A: About 80% of elbow dislocations are posteriorly

B: Brachial artery disruption occurs in a quarter of the patients that present with a elbow dislocation

C: After reduction a splint is only indicated in case of concomitant fractures

D: Elbow dislocations with fractures always need surgical stabilisation

The correct answer is A

ALiEM covered elbow injuries this week.

Posterior dislocations are the most common type of elbow dislocation (80%). Simple elbow dislocations are characterised by the absence of a major associated fracture, aside from small periarticular avulsion fractures.

Neurovascular examination should be performed to assess for brachial artery, median nerve and ulnar nerve injuries. Brachial artery disruption is the most serious complication and it occurs in 5-13% of the cases.

Stable reductions should be immobilised in a posterior splint with 90 degrees of elbow flexion for 3-5 days.

The terrible triad is an elbow dislocation with associated fractures of the radial head and coronoid process and in these cases surgical intervention is recommended. 

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:
Loading

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

Reviewed and edited by Rick Thissen

Quiz 79, August 7th, 2020

Welcome to the 79th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

The recently published GRECCO-19 trial is about the use of colchicine in hospitalized adult patients with SARS-CoV-2 infection, confirmed by PCR.

Patients in the intervention group received a loading dose of colchicine followed by a maintenance dose of 0.5 mg twice daily until hospital discharge or a maximum of 21 days. Patients in the control group received standard care.

The objective was to evaluate the effect of treatment with colchicine on cardiac and inflammatory biomarkers and clinical outcomes in patients hospitalized with coronavirus disease 2019 (COVID-19).

What did the authors find?

A: hsTnT and CRP levels were significantly lower and clinical deterioration occurred significantly less often in the intervention group compared to the control group

B: hsTnT and CRP levels were significantly higher and clinical deterioration occurred significantly more often in the intervention group compared to the control group

C: hsTnT and CRP levels were not statistically different while clinical deterioration occurred significantly less often in the intervention group compared to the control group

D: no differences were found between both groups for all the primary outcomes

The correct answer is C

The GRECCO-19 trial was covered by David Slessor from The Bottom Line this week. 

A total of 105 patients were included in this multicentre trial. 

This small study (n=105) demonstrates that colchicine may be effective in reducing the number of admitted patients with COVID-19 that deteriorate to the level of needing ICU admission. 

Although these results sound promising, we have to be aware of several limitations such as small number of subjects, even smaller absolute benefit numbers and wide confidence intervals. 

GRECCO-19

Question 2

Your 63-year old septic patient needs endotracheal intubation. Worried about hemodynamical deterioration you choose ketamine as the induction agent instead of etomidate.

According to this recently published paper, which intubation agent leads more often to post procedure hypotension?

A: Ketamine

B: Etomidate

C: There was no difference in post procedure hypotension

The correct answer is A

This recently published paper was discussed at JournalFeed this week.

It is a an observational cohort study of the prospective (US) National Emergency Airway Registry (NEAR) data set. 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Interestingly, postprocedure hypotension was higher is those intubated with ketamine compared to etomidate (74% vs. 50%).

Source image: www.pixabay.com

Question 3

Exclusion of Serious Bacterial Infections (SBI) in infants remains one of the biggest diagnostic challenges in the ED. Multiple risk stratification tools have been developed along the years, but none of them seem to be very accurate.

Quite recently the Pecarn Rule for Low Risk Febrile Infants (or Kuppermann criteria) was developed in order to exclude SBI. According to this rule, SBI can be excluded in infants between 29 and 60 days if:

– Urinalysis is negative

– Absolute Neutrophil Count <4,090/μL 

– Procalcitonin <1.71 ng/mL

What is the sensitivity of these criteria for SBI?

A: 76 %

B: 82 %

C: 91 %

D: 98 %

The correct answer is D

Justin Morgenstern covered this paper on First10EM.

The group included 1,821 febrile infants less than 60 days of age. The mean age was 36 days old and 42% were female. 9.3% were SBI positive with 7.7% from urinary tract infection alone.

The sensitivity was 97.7% and negative likelihood ratio of 0.04.

Keep in mind this risk score is not yet externally validated. While derived in infants aged 0-60 days, the authors recommend using this calculator only in infants aged 29-60 days.

To LP, or not to LP (the febrile infant): That is the question

Source image: www.emdocs.net

Question 4

 A healthy 5 year old boy presents to your ED after a fall on his right arm. The elbow is painful and slightly swollen. An X-ray is made to rule out a fracture.

For the assessment of the x-ray of the elbow you use the mnemonic CRITOE.

Which statement is true about CRITOE?

A: The C stands for capitellum and the R for the radial head and they appear simultaneously at the age of 3

B: The I stands for the internal epicondyle which starts to be visible at the age of 7

C: The T stands for the trochlea and is visible at the age of 7

 D: The O stands for the olecranon and the E for the external epicondyle and both appear at the age of 9

The correct answer is C.

This week EMDocs covered pediatric elbow injuries.

CRITOE stands for capitellum, radial head, internal epicondyle, trochlea, olecranon and external epicondyle. 

The first ossification is the Capitellum at the age of one. By the age of three the Radial head appears as a small balloon. The Internal epicondyle starts to ossify by the age of five and the Trochlea will be visible at the age of seven. By the age of nine the Olecranon of the ulna will appear. And finally at the age of eleven the external Epicondyle will appear.

Source image: www.pixabay.com

Question 5

Step one in the treatment of Hyperosmolar Hyperglymic State (HHS) will be volume resuscitation and insulin administration.

What changes in serum laboratory values can be seen after initial treatment?

A: Serum sodium, serum glucose and serum osmolality all decrease

B: Serum sodium decreases, serum glucose increases and serum osmolality decreases

C: Serum sodium increases, serum glucose decreases and serum osmolality increases

D: Serum sodium increases, serum glucose decreases and serum osmolality decreases

The correct answer is D.

Josh Farkas covered Hyperosmolar Hyperglycemic State in this week’s podcast on PULMCrit.

Due to the resuscitation with isotonic fluids serum sodium will increase. The tonicity will decrease despite the rising sodium. Serum glucose will fall due to the administration of insulin and fluids. Serum osmolality will decrease because it is affected by chloride and glucose.

IBCC chapter & cast – Hyperosmolar Hyperglycemic State

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:
Loading

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

Reviewed and edited by Rick Thissen

Quiz 78, July 31th, 2020

Welcome to the 78th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Question 1

Tricuspid Annular Plane Systolic Excursion (TAPSE) is a quantitative measurement of the movement of the tricuspid annulus during the cardiac cycle and is quite often measured as a surrogate of right ventricular function.

Which of the following statements is true about TAPSE?

A: TAPSE is a multiple-plane measurement

B: TAPSE is very sensitive for pulmonary embolism in normotensive patients

C: Abnormal TAPSE measurement is only seen in pulmonary embolism

D: A TAPSE of less than 2 cm is considered abnormal

The correct answer is D

County EM covered TAPSE as a diagnostic parameter for pulmonary embolism this week.

TAPSE is a pretty easy one plane measurement in apical view.

Right ventricle dysfunction may still be present with normal TAPSE.

TAPSE is not sensitive or specific enough in normotensive patients, however it is more sensitive in patients with tachycardia.

Abnormal TAPSE measurement may be seen in other disease processes that cause RV strain, such as pulmonary hypertension, RV ischaemia, and congestive heart failure.

A TAPSE of less than 2 cm is considered abnormal.

Case courtesy of Dr Henry Knipe, Radiopaedia.org, rID: 31240

 Question 2

Your 78 year old patient presents to the ED after a fall with her bicycle. She turns out to have 3 rib fractures. According to this paper  which of the following parameters is a useful predictor for length of stay (LOS) in the hospital?

A: Change in pain between day one and two

B: FEV1 on day one

C: Grip strength on day one

The correct answer is B

Sam Parnell covered this paper on JournalFeed.

It turns out FEV1 is a reliable predictor of LOS. The course of pain is not. Furthermore, pain did not correlate with spirometry values.

Spirometry as a adjunct test to decide which patients can be discharged sure sound interesting.

 

Source image: www.pixabay.com

Question 3

You see a forty year old male patient with gastritis. You consider prescribing a combination of an antacid and lidocaine.

What is the benefit of this cocktail compared to antacid monotherapy?

A: Faster pain relief

B: Better pain relief

C: Less adverse events

D: There is no benefit

The correct answer is D

This recently published randomised controlled trial compared antacid monotherapy versus antacid and lidocaine.

The authors included and randomised 89 patients. They found no statistical difference in pain scores between the groups. Patients did prefer the taste of the antacid monotherapy and there were more adverse events reported in the lidocaine group.

Don’t use lidocaine for epigastric pain

Question 4

Progressive weakness of extremities and diminished reflexes in the affected limbs are cornerstone features of Guillain-Barre Syndrome (GBS).

Which of the following features is inconsistent with GBS?

A: Relatively symmetric symptoms

B: Fever at onset of symptoms

C: Cranial nerve involvement

D: Autonomic dysfunction

The correct answer is B

Josh Farkas covered GBS on the internet book of critical care this week.

The usual presentation of this disease involves sensory disturbances, ascending flaccid paralysis and autonomic dysfunction. Cranial nerve involvement can be present, especially facial palsy. Although infection is involved as a trigger, fever is not typically present at onset of the disease.

Guillain Barre Syndrome (GBS)

Question 5

Source image: Pixabay.com

The prognosis of traumatic cardiac arrest is dismal. Which of the following parameters is associated with higher odds of survival according to this paper?

A: Bystander CPR

B: Prehospital intubation

C: Penetrating mechanism of injury

D: Use of prehospital or in-hospital epinephrine 

The correct answer is A

RebelEM covered this systematic review and meta-analysis on prognostic factors in traumatic cardiac arrest last week. 

A total of 53 studies involving 37,528 patients were included.

Male sex, penetrating mechanism of injury and head injury were not associated with a lower or higher survival rate. 

Presence of cardiac motion on ultrasound, shockable initial cardiac rhythm, witnessed arrest and bystander CPR had higher odds of survival. 

Use of prehospital or in-hospital epinephrine and prehospital intubation had lower odds of survival.

Traumatic Cardiac Arrest – Can we Find Prognostic Factors that Predict Survival?

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:
Loading

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

Reviewed and edited by Rick Thissen

Quiz 77, July 24th, 2020

Welcome to the 24th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 18269

Question 1

Scaphoid fractures are commonly seen in the Emergency Department but are also often missed. This can lead to non-union. Non-union often leads to post-traumatic osteoarthritis with chronic pain and stiffness.

Which of the following statements about diagnosis of scaphoid fractures is true?

A: Tenderness of the “anatomic snuffbox” has a low sensitivity and specificity

B: Combining anatomic snuffbox tenderness, scaphoid tubercle tenderness, and positive thumb longitudinal compression test (all three positive) has a high sensitivity and fair specificity

C: In the first week after injury scaphoid radiographs have a sensitivity of 95%

D: CT is the most accurate diagnostic test

The correct answer is B

Vivian Lei covered scaphoid fractures on Journal Feed this week.

Tenderness of the “anatomic snuffbox” alone has a sensitivity of 87-100% and a very low specificity. When you combine this with scaphoid tubercle tenderness and a positive thumb longitudinal compression test the sensitivity will still be very high and its specificity will rise to 74%.

A negative x-ray of the wrist does not exclude a scaphoid fracture as it has a sensitivity of only 80% in the first week after injury. MRI is most accurate for diagnosing scaphoid fractures (sensitivity of 94.2% and a specificity of 97.7%).

Case courtesy of Dr David Carroll, Radiopaedia.org, rID: 62774

Question 2

This systematic review from 2020, is about the prognostic value of ultrasonographic absence of cardiac motion during cardiopulmonary resuscitation (CPR). The outcome the authors were looking for was Return of Spontaneous Circulation (ROSC) or survival to hospital admission or 24-h survival (depending on the outcomes in the original articles).

What percentage of patients with Pulseless Electrical Activity (PEA) arrest without cardiac motion on ultrasound during CPR did meet the outcome criteria (ROSC or survival to hospital admission or 24-h survival)?

A: 0,5 percent

B: 4 percent

C: 7 percent

D: 13 percent

The correct answer is D

The Resus Room covered this systematic review last week

Results about prognostication using ultrasound in PEA-arrest were included from 10 papers. Half of which (5) reported ROSC as the primary outcome. A combined 188 patients had no cardiac motion on ultrasound of which 26 (13,8 percent) still achieved ROSC or survival to hospital admission or 24-h survival.

Indeed it seems quite a lot of patients (13,8 percent) still achieved ROSC or better. However, the vast majority of these cases (20 out of 26) came from one paper.

This brings up the issue of definition of cardiac motion (if only the valves are moving, is that a moving heart?) and even ROSC which may vary between physicians (and papers). Furthermore, this paper does not give us any numbers on survival to discharge with good neurologic outcome. 

Anyway these numbers tell us the absence of cardiac motion on its own does not mean you are dealing with a hopeless case as some of these patients may still achieve ROSC or better. On the other hand, combined with duration of CRP, underlying disease and age it can certainly help make the call to stop resuscitation efforts.

Ultrasound in Cardiac Arrest

Source image: www.pixabay.com

Question 3

Systemic toxicity of local anesthetics (LAST) is a feared complication of local anesthetic use. It is a very rare condition but one that is potentially lethal.

Early recognition of the signs and symptoms is therefore essential in order to start treatment as quickly as possible.

Which of the following statements about LAST is true?

A: Symptoms always start within 5 minutes of administration of local anaesthetic

B: Plenty of data supports the efficacy of Lipid Emulsion Therapy (LET) in LAST

C: Hypoxia and acidosis inhibit the effect of LET

D: Angioedema is often a first sign of LAST

The correct answer is C

Dana Loke from NUEM blog covered Lipid Emulsion Therapy for LAST this week. 

Onset of LAST is typically 30 seconds to 60 minutes after administration of the anesthetic but more often than not occurs within 1-5 minutes.

Not a lot of data exists about the efficacy of LET in LAST (in humans at least). But this is almost universal in the area of toxicology. 

Hypoxia and acidosis may inhibit lipid emulsion therapy and should therefore be treated in order to optimize the effect of the lipid emulsion therapy.

Angioedema is not typically seen in LAST.

Source image: www.aliem.com

Question 4

A healthy 7 year old boy presents to your ED with forearm fracture after a fall in the playground. For pain and efficient splint placement you use intranasal medication.

Which of the following statements is true about intranasal analgetic administration?

A: Repeated dosing is more often required with intranasal fentanyl compared to intravenous morphine

B: Intranasal fentanyl produces more nasal discomfort compared to intranasal midazolam

C: Intranasal ketamine is less effective for pain control compared to intranasal fentanyl

D: Intranasal fentanyl is equally effective compared to intravenous morphine in children with long-bone fractures

The correct answer is D

This week Aliem posted about intranasal medication in the Paediatric Emergency Department.

The use of intranasal fentanyl shows a more rapid pain-control, shorter length of stay and decrease in repeated dosing compared to intravenous morphine. It is equally effective compared to intravenous morphine in children with long-bone fracture.

Midazolam causes nasal burning and mucosal irritation, so also consider pre-treatment with intranasal lidocaine. Fentanyl does not have this effect.

Intranasal ketamine has been shown to be as effective compared to intranasal fentanyl. 

Question 5

Catastrophic antiphospholipid syndrome (CAPS) is a severe manifestation of antiphospholipid syndrome that involves widespread thrombosis.

Which of the following is most commonly seen with clinical presentation?

A: Respiratory involvement

B: Cardiac involvement

C: Renal failure

D: Skin manifestations

The correct answer is C

EMCrit covered Catastrophic Antiphospholipid Syndrome (CAPS) last week. 

CAPS is an often severe syndrome in which a range of antiphospholipid antibodies bind to cell walls and activate the classical complement system leading to widespread thrombosis and overall badness. 

Renal failure is most often present (75 percent of cases). 

One can speak of definite CAPS when these criteria are present:

  • Involvement of three or more organs, systems, or tissues
  • Development of manifestations simultaneously or in less than a week
  • Confirmation by histopathology of small vessel occlusion in at least one organ or tissue
  • Laboratory confirmation of the presence of anti-phospholipid antibodies (i.e., lupus anticoagulant and/or anti-cardiolipin antibodies)

Treatment options include steroids, heparin, and either plasmapheresis or IVIG.

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:
Loading

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

Reviewed and edited by Rick Thissen

Quiz 76, June 17th, 2020

Welcome to the 76th FOAMed Quiz. 

Enjoy!

Eefje, Nicole, Joep and Rick

Source image: www.pixabay.com

Question 1

Your 27 year old patient comes in with status epilepticus. She had a first seizure one month ago without a clear cause and she is currently not on anti epileptic medications. Now she is seizing for 5 minutes already.

Which of the following statements is true about the management of status epilepticus?

A: Ketamine might play a role once conventional therapies are not effective

B: Evidence shows levetiracetam is more effective as a second line drug compared to valproic acid and phenytoin

C: The first dose of benzodiazepines should not be administered in the first 5 minutes of the seizure

D: The time frame in which neurolytic intubation should be performed in status epilepticus is one hour

The correct answer is A

EMottawa covered the management of status epilepticus this week. 

Ketamine might well be beneficial in status epilepticus as a fourth line treatment as the first to 3th line treatments focus on GABA receptors, while ketamine is a strong NMDA antagonist. Evidence so far is limited (case reports). 

There still is no answer to which drug is most effective as second line treatment. Choose wisely depending on potential effects and ease of administration. 

The first dose of benzodiazepines should be given within 5 minutes, as longer lasting seizures are more difficult to treat. 

The timeframe in which neurolytic intubations should be performed is definitely not 1 hour, but 20 minutes. However, especially when administration of the second line drug is delayed, 20 minutes go by quickly. 

The Status on Status: Management of Status Epilepticus

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 6079

Question 2

You see a 29 months old girl with a history of spina bifida. She has a ventriculoperitoneal (VP) shunt which was implanted in the first month of her life. She is now more lethargic than usual and vomited twice during triage. Her shunt was revised when she was just 18 months old. You think that her symptoms could be explained by a raised intracranial pressure due to a problem with her VP shunt.

Which of the following statements about VP shunt failure is true?

A: Distal occlusion of the VP shunt is more common than proximal occlusion of the VP shunt

B: VP shunt infections are most common during the first 6 months after implantation

C: Symptoms occur rapidly in case of a VP shunt fracture or VP shunt disconnection

D: Over-drainage by the VP shunt is not possible

The correct answer is B

VP shunts were covered by Angharad Griffiths from Don’t Forget the Bubbles this week.

A VP shunt is a medical device used to drain fluid via a pressure gradient, away from the brain for conditions of excessive cerebrospinal fluid (CSF). They drain according to the difference in pressure gradient between the ventricle and the tip of the distal catheter which is tunneled down into the abdomen inside the peritoneal cavity.

The most common cause of shunt malfunction is proximal occlusion and infections are mostly seen during the first 6 months after implantation.
Since CSF can still drain when the VP shunt fractures or disconnects, symptoms take time to evolve. 

Over-drainage leading to the ‘’slit ventricle syndrome’’ is rare but can occur.

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

Question 3

Your 38 year old patient has a progressive asymmetrical face since this morning. He is unable to move the right side of his mouth and he can’t shut his right eye. Further physical examination reveals no additional focal deficits.

You suspect Bell’s palsy.

Which of the following is not routinely part of treatment of Bells palsy?

A: Artificial tears

B: Steroids

C: Antivirals

The correct answer is C

CountyEM covered Bell’s palsy last week.

Difficulty fully closing the eyelids puts patients at risk for corneal abrasions, foreign bodies, and other ocular trauma. The eye should be protected and artificial tears should be started.

The evidence on steroids (prednisolone 60 to 80 mg daily) is quite clear as they have been shown to increase the chance of full recovery, particularly if started within 3 days of onset of symptoms.

The evidence on antivirals is far less convincing as you can read on the blog.

 

Question 4

In which of the following mood stabilizers is activated charcoal NOT effective in case of toxicity?

A: Valproic acid

B: Lithium

C: Carbamazepine

D: Haloperidol

The correct answer is B

NuEM posted a really useful summary about Lithium and Valproic acid last week

4 drugs quite commonly encountered in intentional overdose are Valproic acid, Lithium, Carbamazepine and Haloperidol.

Activated charcoal does not bind Lithium, so it is not useful in Lithium overdose. It should be considered in cases of Valproic acid, Carbamazepine and Haloperidol overdose. 

 

Question 5

Thromboelastography (TEG) (or the quite similar ROTEM) is commonly used to guide treatment in acute traumatic bleeding.

Not a lot of evidence exists about its efficacy in non-traumatic bleeding.

This paper published in January 2020 is about the use of TEG versus standard of care (SOC) in the treatment of cirrhotic patients with non-traumatic, non-variceal upper GI bleeding.

What did the authors find?

A: Compared to the SOC group, the patient in the TEG group required half the total volume of Fresh Frozen Plasma (FFP) transfused

B: Compared to the SOC group, the patient in the TEG group were more likely to require no transfusions

C: Compared to the SOC group, less serious transfusion reactions occurred in the TEG group

D: All of the above

The correct answer is D

EMdocs covered this single-center, randomized controlled trial last week.

96 Patients were enrolled in the study.

In the TEG-group the subjects received TEG-guided FFP (long r-time), platelets (small amplitude) and cryoprecipitate (small alpha angle). In the control group the patients received FFP when the INR was greater than 1.8 and/or received platelets when the platelet count was below 50× 109/L.

Compared to the SOC group, the TEG group required half the total volume of FFP transfused, were less likely to require transfusion of all three blood components (27% vs. 87%), and were more likely to require no transfusions (14% vs. 0%; P<0.02 for all comparisons). Serious transfusion reactions occurred significantly less often in the TEG group (31% vs. 75%).

Interestingly, this paper does not mention packet red blood cell use. Keep in mind this study excluded patients who were on antiplatelet and anticoagulation therapy, which are common in bleeding patients in the emergency department.

Thromboelastography for Hypocoagulable Patients with Non-Traumatic Bleeding

Would you like to receive an e-mail every time a quiz is published? Please leave your e-mail address here:
Loading

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

Reviewed and edited by Rick Thissen