Uncategorized – The FOAMed Quiz

April 7, 2023April 7, 2023

Quiz 186, April 7, 2023

Welcome to the 186th FOAMed Quiz.

Question 1

Your 65 year old patient with Myasthenia Gravis presents with Myasthenic crisis and you decide to intubate the patient using RSI.

Which of the following statements is true regarding neuromuscular blockers?

A: A higher dose of non-depolarising agents and depolarising agents is generally required in patients with MG

B: A lower dose of non-depolarising agents and depolarising agents is generally required in patients with MG

C: A higher dose of non-depolarising agents and a lower dose of depolarising agents is generally required in patients with MG

D: A lower dose of non-depolarising agents and a higher dose of depolarising agents is generally required in patients with MG

Reveal answer

The correct answer is D.

Neuromuscular blockers in Myasthenia Gravis were covered on UMEM last week.

Myasthenia Gravis patients have increased sensitivity to non-depolarizing agents and require lower doses than typically used. They have decreased expression of normal acetylcholine receptors which are required for depolarizing agents to work effectively and require higher doses than typically used.

Question 2

Warfarin should not be used together with naproxen due to the chance of increased levels of warfarin.

What is the major mechanism for this drug interaction?

A: Naproxen increases absorption of warfarin

B: Naproxen can displace warfarin from the plasma protein binding sites, leading to more unbound warfarin available

C: Naproxen interacts with cytochrome P2C9 and decreases warfarin metabolism

D: Naproxen decreases active tubular secretion of warfarin

Reveal answer

The correct answer is B

Geekymedics covered mechanisms of drug interaction last week.

Naproxen can displace warfarin from the plasma protein binding sites, leading to more unbound warfarin available, increasing its pharmacological effect (as well as toxic effects).

Drug Interactions

Question 3

Which of the following is useful advice for ultrasound guided peripheral cannula placement?

A: Look for flash in the cannula hub, as soon as you see it, advance the cannula

B: Insert the needle at an angle of about 60 degrees. The steeper you go, the more visible the needle will be on the screen

C: Don’t use a tourniquet, for it will increase the chance of bleeding

D: Aim for a vein less than 1 cm deep

Reveal answer

The correct answer is D.

DFTB covered ultrasound guided peripheral IV placement last week.

Never look for the flash of blood in the hub, look at your screen.

Insert the needle at 30-45 degrees. If you go steeper, the needle will be hard to visualize.

Always apply a tourniquet.

And indeed, aim for superficial veins. The deeper the vein, the more chance of dislocation.

5 top tips to gain confidence in ultrasound-guided peripheral IVs

Question 4

The performance of D-dimer in exclusion of pulmonary embolism in COVID positive patients remains somewhat subject of debate.

In this recently published retrospective trial, 10837 patients who received a D-dimer and COVID test in the ED were analyzed. 4311 patients turned out to have COVID. Follow up to detect pulmonary embolism was 30 days.

What did the authors find?

A: A d-dimer cutoff of 500 ng/mL was found to perform a little bit better in COVID positive patients compared to COVID negative patients

B: A d-dimer cutoff of 500 ng/mL was found to perform a little bit better in COVID negative patients compared to COVID positive patients

C: A d-dimer cutoff of 500 ng/mL was found to perform equal in both groups

Reveal answer

The correct answer is B.

The paper was covered on JournalFeed last week.

The prevalence of pulmonary embolism in the cohort was 3.7 percent.

A D-dimer cutoff value of 500 ng/mL had a sensitivity of 96.2 percent in COVID positive patients, compared to 98.5 percent in COVID negative patients. The NPV was 99.6 percent in COVID positive patients and 99.9 percent in COVID negative patients.

The sensitivity of age adjusted D-dimer cutoff (age times 10 with a lower limit of 500 ng/mL) had a sensitivity of 93.9 percent in COVID positive patients, compared to 97.1 percent in COVID negative patients.

The authors conclude that while the sensitivity of D-dimer with a cutoff of 500 ng/mL for pulmonary embolism was a little lower in COVID positive patients, it is still a useful marker.

Keep in mind the authors did not include any probability scores (like YEARS) in this paper, which would have been interesting. Furthermore, quite some d-dimer levels were not drawn because of suspected embolism, but purely for routine use in COVID patients.

Journal Feed Weekly Wrap-Up

Question 5

The X-ray shown above belongs to your 46-year-old patient in the Emergency Department. It is a female with a history of diabetes mellitus and obesity. She fell onto her right knee and has difficulty with walking right now.

Which of the following diagnoses is most likely?

A: Quadriceps tendon rupture

B: Displaced tibial plateau fracture with posterior cruciate ligament injury

C: Patellar tendon rupture

D: Contusion of the knee

Reveal answer

The correct answer is C.

This case was covered on SplintER Series this week.

Patellar tendon ruptures are most frequently seen in men under 40 years old. This is opposed to quadriceps tendon ruptures, which are typically seen in older patients. Risk factors of a patellar tendon rupture are; diabetes mellitus, chronic renal failure and gout.
The elevated patella is a sign of a patellar tendon rupture.

SplintER Series: Patellar Tendon Rupture

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

Reviewed and edited by Rick Thissen

March 30, 2023March 31, 2023

Quiz 185, March 31, 2023

Welcome to the 185th FOAMed Quiz.

Question 1

The timing of cardiac catheterisation in patients with return of spontaneous circulation (ROSC) after out of hospital cardiac arrest (OHCA) in the absence of ischemic changes on the ECG remains subject of debate.

In the EMERGE trial, 279 patients with ROSC after OHCA without clear evidence of cardiac ischemia on ECG and without any obvious cause of their cardiac arrest were randomized to either delayed (performed after 48-96 hour) (n=138) or emergent CAG (n=141).

The primary outcome was 180-day survival rate with Cerebral Performance Category (CPC) < 2 (independent activities of daily life).

What did the authors find?

A: Patients in the early CAG group had higher 180-day survival with good neurologic outcome compared to patients in the emergent CAG group

B: Patients in the delayed CAG group had higher 180-day survival with good neurologic outcome compared to patients in the emergent CAG group

C: There was no difference between the groups

Reveal answer

The correct answer is C.

The EMERGE trial was covered on RebelEM last week.

The mean time delay between randomization and CAG was 0.6 hours in the emergent CAG group and 55.1 hours in the delayed CAG group. The 180-day survival rates among patients with a CPC of 2 or less were 34.1% (47 of 141) in the emergency CAG group and 30.7% (42 of 138) in the delayed CAG group (P = .32).

Keep in mind that the study was stopped early due to insufficient enrollment. Investigators enrolled approximately 280 patients out of 970 planned.

The EMERGE Trial: Emergency vs Delayed Catheterization in Survivors of Out-of-Hospital Cardiac Arrest

Question 2

Combine the incomplete spinal cord injury types with the correct set of symptoms.

1: Brown-Sequard syndrome

2: Central cord syndrome

3: Anterior cord syndrome

A: Disproportionately greater motor impairment in upper compared with lower extremities, bladder dysfunction, and a variable degree of sensory loss below the level of injury

B: Motor paralysis below the level of the lesion as well as the loss of pain and temperature at and below the level of the lesion

C: Loss of motor function, loss of vibration sense and fine touch, loss of proprioception and signs of weakness on the ipsilateral side and loss of pain and temperature sensation and crude touch 1 or 2 segments below the level of the lesion on the contralateral side

Reveal answer

The correct answer is 1C, 2A, 3B

Spinal fractures were covered on Geekymedics last week.

The dorsal columns travel in the posterior section of the spinal cord and carry information about fine touch. The fibers remain ipsilateral and do not decussate until they reach the medulla of the brainstem.

The spinothalamic tracts travel in the anterior part of the spinal cord and carry information regarding pain and temperature. The fibers decussate as soon as they enter the spinal cord and ascend contralaterally.

The corticospinal tract carries motor information from the motor centers of the frontal lobe down to the skeletal muscles. The fibers descend contralaterally.

Spinal Fractures

Question 3

What is not a name for the fracture in the picture below?

A: The tripod fracture

B: Zygomaticomaxillary complex fracture

C: Malar fracture

D: Lateral triangular fracture

Reveal answer

The correct answer is D.

The trauma pro covered the tripod fracture this week; also known as zygomaticomaxillary complex fracture or malar fracture. Fundamentally, the zygoma is separated from the rest of the face. There are, as the name suggests, three components of this fracture. The zygomatic arch, the floor of the orbit (and includes the maxillary sinus) and the lateral orbital rim and wall.

What Is: The Tripod Fracture?

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

Reviewed and edited by Rick Thissen

March 24, 2023March 24, 2023

Quiz 184, March 24, 2023

Welcome to the 184th FOAMed Quiz.

Question 1

Thyroid storm has a mortality rate of 100% if untreated and if treated it is 30-40%. It is a clinical syndrome that is important to be recognised.

Which of the following drugs should be given first in the management of thyroid storm?

A: Iodine

B: Dexamethasone

C: Propranolol

D: Propylthiouracil (PTU)

Reveal answer

The correct answer is D.

Thyroid storm was covered at EMOttawa this week.

Thyroid storm is ultimately a clinical diagnosis based on the triad of symptoms pyrexia, altered mental status and tachycardia. Keep in mind this triad of symptoms is non-specific for thyroid storm.

The first drug to administer is PTU. Iodine should be delayed at least one hour after the administration of PTU, for iodine could stimulate thyroid hormone synthesis.

Question 2

Which of the following trauma patients should receive Rhesus D immunoglobulines?

A: A 30 weeks pregnant patient who is rhesus D positive with profound hemorrhagic shock after a motor vehicle accident

B: A 30 weeks pregnant patient who is rhesus D positive with a traumatic head injury after a seizure

C: A 30 weeks pregnant patient who is rhesus D negative with a complicated tibia and fibula fracture after twisting the ankle on the sidewalk

D: A 30 weeks pregnant patient who is rhesus D negative and who was punched in the abdomen and has a negative Kleihauer-Betke-test

E: None of the above

Reveal answer

The correct answer is D.

SinaiEM covered trauma in pragnancy last week.

All pregnant Rh-negative trauma patients should receive Rh immunoglobulin therapy unless the injury is remote from the uterus.

A negative Kleihauer-Betke-test does not exclude minor degrees of fetomaternal hemorrhage that are capable of immunizing the mother.

Trauma in Pregnancy

Question 3

Your 34 year old patient was bitten by a snake that escaped the terrarium at his friend’s home. He didn’t bring the snake, but shows you a picture.

Which of the following snakes is venomous?

Reveal answer

The correct answer is B.

PedEM morsels covered snake bites last week.

A is a nonvenomous milk snake. To be distinguished from B, which is a venomous coral snake. The following rhyme is sometimes used to remember them: “Red on yellow, kill a fellow. Red on black, venom lack.”

C is a green tree python (a constrictor, also nonvenomous) and D is a rat snake, which might have a little bit of venom but poses no threat to humans.

Snake Bites and Children

Question 4

Your 23 year old patient with Sickle Cell Disease presents with fatigue, shortness of breath and profound anemia. You suspect aplastic crisis. Which of the following viruses does most likely cause aplastic crisis in Sickle Cell Disease:

A: CMV

B: EBV

C: Parvovirus

D: Herpes zoster

Reveal answer

The correct answer is C.

SinaiEM covered complications of Sickle Cell Disease this week.

Aplastic crisis is commonly due to Parvovirus B19, so the patient may report a viral prodrome.

Sickle Cell Disease Emergencies

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

Reviewed and edited by Rick Thissen

March 17, 2023March 17, 2023

Quiz 183, March 17

Welcome to the 183th FOAMed Quiz.

Question 1

Not a lot is known about the effectiveness of addition of corticosteroid to an NSAID in renal colic.

In this paper from August 2022, 120 patients with renal colic were randomized to receive just ketorolac or ketorolac + dexamethasone (60 patients in either group).

The primary outcome was pain intensity based on the visual analog scale (VAS), which was assessed at baseline and after 30 and 60 min of treatment.

What did the authors find?

A: Patients in the ketorolac and dexamethasone group had significantly lower pain score at 30 and 60 minutes

B: Patients in the ketorolac and dexamethasone group had significantly lower pain score at 30 minutes, but not at 60 minutes

C: Patients in the ketorolac and dexamethasone group had significantly lower pain score at 60 minutes, but not at 30 minutes

D: Patients in the ketorolac and dexamethasone group did not have significantly lower pain score at 30 and 60 minutes

Reveal answer

The correct answer is B.

The paper was mentioned on EMOttawa last week.

There were no differences in baseline pain scores between the groups. Differences in VAS scores were significantly lower in the intervention group after 30 min of drug administration (VAS 3,5 vs VAS 5. P = 0.009). There was no difference at 60 minutes. Furthermore, decreased opioid requirements and decreased an antiemetic need were noted in the intervention group.

Question 2

!hich of the following statements is true about the management of patient with acetaminophen overdose?

A: A normal ALT and AST, 8 hours after ingestion of acetaminophen practically rules out severe intoxication

B: The Rumack-Matthew nomogram can be used in single dose and chronic acetaminophen intoxication

C: An mildly elevated INR within 24 hours of acetaminophen ingestion does not reflect severe liver toxicity

D: The typical threshold for toxicity is ingestion of 400 mg/kg acetaminophen for the acute one time dose

Reveal answer

The correct answer is C.

Acetaminophen intoxication was covered on EM cases last week.

Liver enzymes are usually normal in the first 12 hours after an overdose.

The Rumack-Matthew nomogram should be used in single dose intoxications only.

While elevated INR on day 3 or later is a reliable sign of severe liver toxicity, mild elevations of INR on day 1 do not reflect severe liver toxicity.

The typical threshold for toxicity is 200 mg/kg acetaminophen for the acute one time dose

Ep 180 Acetaminophen Poisoning – Pitfalls in Assessment and Management

Question 3

The gradient between the arterial CO2 pressure (PaCO2) and the end tidal CO2 (ETCO2) is approximately 0.5 kPa (3.8 mmHg) under normal physiological conditions.

Which of the following can produce an elevated PaCO2 – ETCO2 gradient?

A: Pulmonary embolism

B: Hyperthermia

C: Hypothermia

D: Hyperventilation

Reveal answer

The correct answer is A

The PaCO2 – ETCO2 gradient was covered on DFTB last week.

Normally, the PaCO2 – ETCO2 gradient is fairly stable and under 0.5 kPa. However, if something happens to ventilation (COPD) of perfusion (PE, shock, pulmonary hypertension) this will cause an V/Q imbalance and will cause the PaCO2 – ETCO2 gradient to rise.

The PaCO2-ETCO2 Gradient

Question 4

Traumatic injury of the spinal cord can result in shock. At or above which level of injury is the patient at risk for neurogenic shock?

At or above C5

At or above T4

At or above T6

At or above T8

Reveal answer

The correct answer is C.

Neurogenic shock was covered by emDOCs this week.

Trauma is the most common cause of neurogenic shock. It occurs in 19.3% of cervical spine injuries and 7% of thoracic spine injuries. When the injury occurs at or above T6, the patient is at risk due the disruption of sympathetic innervation to the heart and peripheral vessels.

Neurogenic Shock: Definition, Identification, and Management in the ED

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

Reviewed and edited by Rick Thissen

March 2, 2023March 3, 2023

Quiz 182, March 3rd, 2023

Welcome to the 182th FOAMed Quiz.

Question 1

Major joint dislocations are a common problem in the emergency room and shoulder dislocations account for 50 percent of them. Most often we use analgesia before reduction, varying from procedural sedation and analgesia (PSA), intra-articular injection to nerve blocks.

In this systematic review and meta-analysis (based on 12 RCT’s, n = 630) the authors compared intravenous sedation (IV sedation, n total = 303) with intra-articular lidocaine (IAL, n total = 327) for dislocation reduction.

What did the authors find concerning the rate of successful reduction?

A: There was no significant difference in rate of successful reduction.

B: The rate of successful reduction was significantly higher in the IAL group compared to the IV sedation group.

C: The rate of successful reduction was significantly higher in the IV sedation group compared to the IAL group.

Reveal answer

The correct answer is A.

The paper was covered by CanadiEM last week.

The successful reduction rate was 83.8% in the IAL group and 91.4% in the IV sedation group (RR 0.93, CI 0.86-1.01). There was also no difference in pain scores or ease of reduction.

However, patient satisfaction was significantly greater in the IV sedation group with decreased procedural time, suggesting the benefit of this approach in resource-appropriate settings.

Also, most of the included studies used a combination of opioids and a benzodiazepine as ‘’IV sedation’’ which is definitely not my go to choice of drugs.

CJEM Visual Abstract: Intra-articular lidocaine versus intravenous sedation for closed reduction of acute shoulder dislocation

Question 2

The use of sodium bicarbonate in cardiac arrest remains controversial and routine use is not advised in current guidelines.

In this recently published cohort study, 1100 children with in hospital cardiac arrest (IHCA) were analyzed. 528 (48.0%) received sodium bicarbonate during CPR.

The primary outcome was survival to hospital discharge.

What did the authors find?

A: Sodium bicarbonate use was associated with lower rates of survival to hospital discharge

B: Sodium bicarbonate use was associated with higher rates of survival to hospital discharge

C: Sodium bicarbonate use was not associated with lower or higher rates of survival to hospital discharge

Reveal answer

The correct answer is A.

The SGEM covered the paper last week.

Survival to hospital discharge was 42.2% in patients who received sodium bicarbonate and 73.3% in patients who did not receive sodium bicarbonate (aOR 0.7, 95% CI; 0.54-0.92).

Sodium bicarbonate use was also associated with lower survival to hospital discharge with favorable neurologic outcome rate .

SGEM#394: Say Bye Bye Bicarb for Pediatric In-Hospital Cardiac Arrest

Question 3

Source image: www.ucsfbenioffchildrens.org

Your patient has a two lead pacemaker which is set to DDD mode. What does the third D stand for?

A: Paces both atrium and ventricle

B: Senses both atrium and ventricle

C: Dual trigger of both atria and ventricular pacing in response to absence of intrinsic ventricular depolarization

D: Dual inhibition of both atria and ventricular pacing in response to intrinsic ventricular depolarization

Reveal answer

The correct answer is D.

The first letter reveals which chamber gets paced. The second letter means which chamber is sensed and the third letter gives away the sensing response. That is, what the pacemaker does in response to a sensed intrinsic electrical activity. This can be triggered, inhibited, dual or none.

Question 4

Methylene blue is widely prescribed as treatment for methemoglobinemia.

For which purpose is methylene blue also used?

A: CO intoxication

B: Refractory vasoplegic shock

C: Haemochromatosis

Reveal answer

The correct answer is B

Methylene blue as an off-label treatment in refractory vasoplegic shock was covered by ALiEM.

By inhibiting the NO/cGMP pathway, the systemic vascular resistance increases. It can function as a vasopressor in patients with shock.

ACMT Toxicology Visual Pearl: Is the Silver Bullet for Refractory Vasoplegia Really Blue?

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

Reviewed and edited by Rick Thissen

February 23, 2023February 24, 2023

Quiz 181, February 24th, 2023

Welcome to the 181th FOAMed Quiz.

Question 1

What is the most common risk factor for malignant otitis externa?

A: Immunosuppression

B: Age

C: Diabetes mellitus

D: Smoking

E: HIV

Reveal answer

The correct answer is C.

EmDOCs Podcast covered this week malignant otitis externa (MOE).

MOE is a severe and progressive infection of the external auditory canal. The most common risk factor is DM, with an estimated 90% of patients with MOE having DM. It is thought to predispose due to microangiopathy, impaired wound healing and increased pH in diabetic cerumen.

Immunosuppression, including HIV, is another risk factor.

The disease is rare in children and mostly seen at age >65 years.

Question 2

In glaucoma, several different types of eye drops are used for lowering intraocular pressure (IOP). Link the correct medicine and mechanism of action:

A: Timolol

B: Latanoprost

C: Pilocarpine

D: Acetazolamide

1: Reduces production of aqueous humor via decreasing cAMP concentration in the ciliary body

2: Reduces production of aqueous humor via decreasing bicarbonate concentration

3: Causes the iris to contract

4: Increases drainage of aqueous humor

Reveal answer

The correct answer is A-1, B-4, C-3, D-2.

This week’s REBEL Core Cast was about acute vision loss (including acute glaucoma and giant cell arteritis).

Acute glaucoma causes vision loss by damaging the optic nerve via high IOP. Open angle glaucoma is the most common form of glaucoma and is usually unnoticed until late in disease vision loss occurs. Closed angle glaucoma gives a painful vision loss, halos, nausea and vomiting. First-line therapy is beta-blockade (timolol).

REBEL Core Cast 96.0 – Acute Vision Loss I

Question 3

The effect of specialist consultation in the ED remains subject of debate.

In this recently published Canadian paper 829 patients in 11 ED sites with recent-onset uncomplicated atrial fibrillation or flutter were analyzed. Uncomplicated atrial fibrillation was defined as asymptomatic after rate or rhythm control. 364 (44%) of patients had specialist consultation.

What effect did specialist consultation in the ED have?

A: The ED length of stay was longer but patients had less ED revisits within 30 days

B: The ED length of stay was longer and patients had equal ED revisits within 30 days

C: The ED length of stay was shorter and patients had less ED revisits within 30 days

D: The ED length of stay was shorter but patients had more ED revisits within 30 days

Reveal answer

The correct answer is B.

The paper was covered on CanadiEM last week.

After propensity-matching, specialist-consulted patients had a 0.6% lower risk of 30-day revisits than non-consulted patients. Median length of stay was 591 minutes for consulted patients and 300 minutes for patients without consultation. This means ED length of stay was almost double in specialist-consulted patients.

CJEM Visual Abstract: Effect of specialist consultation on emergency department revisits with uncomplicated recent-onset atrial fibrillation or flutter

Question 4

Oral anticoagulation, particularly warfarin, is associated with an increased risk of intracranial hemorrhage after head trauma. However, available data on delayed bleeds in anticoagulated patients are limited.

In this recently published observational study 69.321 patients with an emergency visit because of minor head injury (so without intracranial hemorrhage) were included. 58.233 (84.0%) patients were not on oral anticoagulation, 3081 (4.4%) had a warfarin prescription, and 8007 (11.6%) had a direct oral anticoagulant (DOAC) prescription.

The primary outcome was delayed intracranial hemorrhage, defined as a new intracranial hemorrhage within 90 days of the initial ED visit for a head injury where no intracranial hemorrhage was diagnosed.

What did the authors find?

A: Both patients on DOAC and patients on warfarin had a higher chance of delayed intracranial hemorrhage compared to patients that were not on anticoagulation

B: Only patients on DOAC had a higher chance of delayed intracranial hemorrhage compared to patients that were not on anticoagulation

C: Only patients on warfarin had a higher chance of delayed intracranial hemorrhage compared to patients that were not on anticoagulation

D: Neither patients on DOAC nor patients on warfarin had a higher chance of delayed intracranial hemorrhage compared to patients that were not on anticoagulation

Reveal answer

The correct answer is C.

The paper was covered in UMEM last week.

Overall, 718 (1.0%) patients had a delayed intracranial hemorrhage within 90 days of ED visit for head injury. Among patients that did not receive anticoagulation, 586 (1.0%) had delayed intracranial hemorrhage, 54 (1.8%) of the patients on warfarin had delayed intracranial hemorrhage, and 78 (1.0%) patients on a direct oral anticoagulant had delayed intracranial hemorrhage.

Question 5

Which of the following antibiotics should be administered in patients with (suspected) Toxic Shock Syndrome (TSS) in order to suppress toxin production.

A: A third generation cephalosporin

B: Gentamicin

C: Penicillin G (Benzylpenicillin)

D: Clindamycin

Reveal answer

The correct answer is D.

Toxic Shock Syndrome was covered in DFTB last week.

TSS is caused by either toxin production by Staphylococcus aureus or Group A Streptococci (GAS).

Clindamycin is added based on the ability of this drug to suppress synthesis of bacterial toxins. Since it is merely bacteriostatic and not bactericidal it should never be used as monotherapy for TSS, but always as an adjunct to a bactericidal antibiotic.

Toxic shock syndrome

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

Reviewed and edited by Rick Thissen

February 17, 2023February 17, 2023

Quiz 180, February 17th, 2023

Welcome to the 180th FOAMed Quiz.

Question 1

A patient presents with anisocoria to your ED. She has a “down and out” appearance of the eye, ptosis and mydriasis of her right eye. When turning the light off, her right pupil fails to constrict. There are no other neurological abnormalities found in physical examination.

What is the most likely cause of this patient’s anisocoria?

A: Cranial nerve III palsy

B: Horner syndrome

C: Adie pupil

D: Anticholinergic drugs

Reveal answer

The correct answer is A.

Anisocoria was discussed by EMdocs this week.

Horner syndrome is caused by compression of the oculomotor sympathetic pathway somewhere along its course. It causes ptosis and miosis instead of mydriasis and it will not cause extraocular movement disorders.

An Adie pupil arises from the parasympathetic denervation of the constrictor muscle, causing mydriasis, but no ptosis or extraocular movement disorders.

An anticholinergic toxidrome will cause bilateral mydriasis.

Anisocoria in the ED: Pathophysiology, Evaluation, and Management

Question 2

To what stage of syphilis belong nephrotic syndrome and isolated cranial nerve dysfunction?

A: First stage

B: Second stage

C: Third stage

Reveal answer

The correct answer is B.

Syphilis was covered on DFTB last week.

The first stage includes a chancre also known as ulcus durum.

The second stage includes skin and mucosa lesions such as condylomata lata, hepatitis, nephrotic syndrome and cranial nerve damage.

The third stage includes neurosyphilis (tabes dorsalis, dementia paralytica) or heart problems, such as aneurysms or coronary arteritis.

Syphilis

Question 3

Which of the following microorganisms is a known common trigger of Stephens-Johnson syndrome?

A: Legionella pneumoniae

B: Chlamydia pneumoniae

C: Mycoplasma pneumoniae

Reveal answer

The correct answer is C.

Stephens-Johnson syndrome was covered in EMDocs last week.

A wide variation of Infections can cause Stephens-Johnson syndrome. Mycoplasma pneumoniae infections are the next most common infectious trigger.

EM@3AM: Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

Question 4

De Winter T-waves are characterized by upsloping ST segment depression > 1mm at the J point in the precordial leads with tall T waves in the same leads and reciprocal ST segment elevation in aVR. It is a sign of occlusion myocardial infarction.

Which of the following coronary arteries is most likely occluded in case of de Winter’s T-waves?

A: RCA

B: LAD

C: Cx

Reveal answer

The correct answer is B.

A case of de Winter T-wave was covered on Dr. Smith’s ECG blog last week.

The de Winter pattern is seen in about 2% of acute LAD occlusions.

Question 5

Thromboelastography (TEG) or rotational thromboelastometry (ROTEM) is a method of testing the efficiency of blood coagulation. It is used in emergency medicine with increasing frequency. The result of TEG is a reaction curve which shows the elasticity over time when the clot forms and dissolves.

The main parameters of the curve are:
R time: Time to initial clot formation
K time: Time from initial clot formation until reaching 20 mm in amplitude
Alpha angle (α): Angle between the baseline at initial clot formation
Maximum amplitude (MA): Maximum deviation of tracing to baseline
LY30: Amplitude 30 minutes after reaching maximum amplitude

The curve looks as follows:

Whenever the R-time (time to initiation of cot formation) in a bleeding patient is prolonged, what should you do to promote clot formation?

A: Administer platelets

B: Administer cryoprecipitate (or fibrinogen)

C: Administer Fresh Frozen Plasma (FFP) or anticoagulation reversal agents

D: Administer tranexamic acid

Reveal answer

The correct answer is C.

Taming the SRU covered TEG last week.

In case of a prolonged initiation of clot formation (R-time), we should administer FFP of reversal agents if the patient is on anticoagulation.

A prolonged K-time and a decreased alpha angle warrants cryoprecipitate administration.

A reduced maximum amplitude points you in the direction of platelet inactivity.

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

Reviewed and edited by Rick Thissen

February 10, 2023February 10, 2023

Quiz 179, February 10th, 2023

Welcome to the 179th FOAMed Quiz.

Question 1

A five year old girl who recently started with chemotherapy for acute lymphoblastic leukemia presents at the emergency department with acute kidney injury. Based on laboratory findings you suspect a tumor lysis syndrome.

Which of the following laboratory findings fits this diagnosis?

A: High potassium, high calcium

B: Low potassium, high LDH

C: High calcium, low creatinine

D: High potassium, low calcium

Reveal answer

The correct answer is D.

Tumor lysis syndrome was covered on DFTB last week.

It is defined by massive tumor cell lysis with the release of intracellular molecules, such as potassium, phosphate and uric acid. The phosphate binds to the calcium already in the blood, forming complexes and thus causing hypocalcemia. Tumor lysis syndrome often occurs after initiation of chemotherapy and mostly in patients with high-grade lymphomas, but it can also occur spontaneously and with other fast proliferating tumor types.

Ten oncology emergencies in kids

Question 2

What type of drug use is referred to when your patient talks about “nanging”?

A: Sipping GHB (gamma-hydroxybutyric acid)

B: Smoking crack (cocaine)

C: Inhalation of laughing gas (nitrous oxide)

D: Snorting speed

Reveal answer

The correct answer is C.

Don’t forget the bubbles covered the use and abuse of nitrous oxide.

The use of nitrous oxide to obtain a so-called “safe high” has increased over the past decade. The exact mechanism is poorly understood. Long term use of N2O can cause permanent damage to the nervous system.

Recreational nitrous oxide

Question 3

Can we swap neuromuscular blockers (NMB) for remifentanil in rapid sequence intubation (RSI)?

In this recently published paper, 1150 ED patients undergoing PSI were randomised to receive (next to a sedation) either a neuromuscular blocker (succinylcholine or rocuronium) or remifentanil (3-4mcg/kg). The aim of the study was to prove remifentanil non-inferior to neuromuscular blockers for rapid sequence induction.

The primary outcome was successful tracheal intubation on the first attempt without major complications.

What did the authors find?

A: Remifentanil was indeed non-inferior to neuromuscular blockers in rapid sequence induction

B: Remifentanil was not non-inferior to neuromuscular blockers in rapid sequence induction

C: Remifentanil was superior to neuromuscular blockers in rapid sequence induction

Reveal answer

The correct answer is B.

The paper was covered on St. Emlyns last week.

Tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (95% CI, –11.6% to –0.5%). Remifentanil was not non-inferior to neuromuscular blockers in rapid sequence induction.

This paper was covered by St. Emlyn’s this week. Keep in mind that a non-inferiority paper can never prove the intervention to be superior to a control. That takes a different kind of study approach.

JC: Keep on blocking in the free world. Remi vs. NMB for RSI. St Emlyn’s

Question 4

Abdominal compartment syndrome is defined by an intra abdominal pressure > 20 mm Hg with organ dysfunction.

The standard method for diagnosis is:

A: Intravesical pressure measurement, typically through a Foley catheter

B: CT abdomen

C: Intra and extra abdominal pressure measurement, typically by surgery

D: Point of care ultrasound (POCUS)

Reveal answer

The correct answer is A.

Abdominal compartment syndrome was discussed this week at emDOCs last week.

Measurement of intravesical pressure is the standard method for diagnosis of intra-abdominal hypertension. However, intragastric, intracolonic or inferior vena cava catheters can also be used.

Normal abdominal compartment pressure is 2-5 mmHg. This pressure is higher in critically ill patients, obese patients and pregnancy. Above 5 mm Hg we call it intra abdominal hypertension, at this point there is no organ dysfunction.

emDOCs Podcast – Episode 71: Abdominal Compartment Syndrome

Question 5

Which of the following is most likely the causative microorganism of this patient’s eye problem?

A: Varicella zoster virus

B: Herpes simplex virus 2 (HSV 2)

C: Herpes simplex virus 1 (HSV 1)

Reveal answer

The correct answer is C.

RebelEM covered herpes keratitis last week.

Herpes simplex virus 1 (HSV 1) is almost always the causative agent. HSV 2 is sexually transmitted and rarely causes symptoms of the upper body.

REBEL Core Cast 95.0 – Herpetic Keratitis

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

Reviewed and edited by Rick Thissen

February 3, 2023February 10, 2023

Quiz 178, February 3, 2023

Welcome to the 178th FOAMed Quiz.

Question 1
Evidence suggests steroids are beneficial for Bell’s Palsy in adults, but in children data is lacking.

In this paper, published august 2022, 187 children with Bells palsy were randomised to treatment with prednisolone (n=93) and to placebo (n=93).

The primary outcome was complete recovery of facial function at 1 month defined by a House-Brackmann score of 1.

What did the authors find?

A: The percentage of children with complete recovery was significantly higher in the group of children receiving prednisolone compared to the placebo group

B: There was no significant difference in percentage of children with complete recovery.

C: The percentage of children with a complete recovery was significantly lower in the group of children receiving prednisolone compared to the placebo group

Reveal answer

The correct answer is B.

The SGEM covered the paper last week.

At 1 month, the proportions of patients who had recovered facial function were 49% (n=43/87) in the prednisolone group compared with 57% (n=50/87) in the placebo group (95% CI -22.8 to 6.7). At 6 months recovery was 99% (n=77/78) in the prednisolone groups and 93% (n=76/82) in the placebo group (CI -0.1 to 12.2).

SGEM#390: I Can’t Feel My Face when I Have Bell Palsy, but will Steroids Help?

Question 2

Which of the following drugs may be added to N-acetylcysteine in the treatment of acetaminophen overdose?

A: Flumazenil

B: Pyridoxine

C: Ethanol

D: Fomepizole

Reveal answer

The correct answer is D.

Fomepizole for Acetaminophen Toxicity was covered on EMDocs last week.

Fomepizole is known for treatment of toxic alcohol poisoning. However, it seems to reduce conversion of acetaminophen to NAPQI and some other things that may help in acetaminophen poisoning.

ToxCard: Fomepizole for Acetaminophen Toxicity

Question 3

A healthy woman is pregnant for the first time. She is known to have an abnormal dystrophin gene which makes her a Duchenne Muscular Dystrophy (DMD) carrier. The sex of the unborn child is not known yet. The father is a healthy man.

What is the chance the child will have DMD?

A: 25%

B: 50%

C: 75%

D: 100%

Reveal answer

The correct answer is A.

DMD was covered on DFTB last week.

DMD is inherited as an X-linked recessive disorder from a mother who carries a mutation. However one-third of cases are due to de novo mutations.

A mother who is a carrier of an X-linked recessive disorder will have a 50 percent chance of passing it on. This means she has a 25% chance of having an affected son and a 25% chance of having a carrier daughter.

Duchenne Muscular Dystrophy

Question 4

Are we still administering too much oxygen to patients after cardiac arrest?

The EXACT trial was published in November 2022. 425 unconscious adults with return of spontaneous circulation after out of hospital cardiac arrest (OHCA) were included in the primary analysis. These patients were randomised by paramedics to receive oxygen titration to achieve an oxygen saturation of either 90% to 94% (intervention; n = 216) or 98% to 100% (standard care; n = 212) until arrival at the intensive care unit.

The primary outcome was survival to hospital discharge.

What did the authors find?

A: Survival to hospital discharge was higher in the low oxygen group compared to the high oxygen group

B: Survival to hospital discharge was lower in the low oxygen group compared to the high oxygen group

C: Survival to hospital discharge was equal between the two groups

Reveal answer

The correct answer is B.

The paper was covered in EMDocs last week.

38.3% of patients in the intervention group survived to hospital discharge compared to 47.9% of patients in the standard care group ([95% CI, -18.9% to -0.2%]; unadjusted odds ratio, 0.68 [95% CI, 0.46-1.00]; P = .05)

Keep in mind the trial was stopped early because of the COVID pandemic. Furthermore, the trial suggests harm of the intervention (less patients survived to hospital discharge and more patients had an hypoxic event). However, the trial was not designed to detect harm, so this is actually a negative trial and this conclusion cannot be drawn with certainty.

52 in 52 – #26: The EXACT Trial

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

Reviewed and edited by Rick Thissen

January 26, 2023January 28, 2023

Quiz 177, January 26th, 2023

Welcome to the 177th FOAMed Quiz.

Question 1

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

You suspect bowel obstruction.

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

A: Fluid filled bowel with extra-luminal free air

B: Bowel wall thickening (> 3 mm)

C: Decreased peristalsis and retrograde peristalsis

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

Reveal answer

The correct answer is D.

Small bowel obstruction was covered on RebelEM last week.

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

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

REBEL Core Cast 94.0 – SBO

Question 2

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

What is she talking about?

A: A patient with suspected patellar tendon rupture

B: A patient with suspected achilles tendon rupture

C: A patient with suspected biceps tendon rupture

D: A patient with suspected supraspinatus muscle rupture

Reveal answer

The correct answer is A.

AliEM covered the patellar tendon rupture last week.

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

SplintER Series: Patellar Tendon Rupture

Question 3

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

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

A: HFNC will likely decrease his hypercarbia

B: HFNC is less well tolerated than non invasive ventilation

C: HFNC will provide some PEEP

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

Reveal answer

The correct answer is C

Cardiogenic shock was covered on EMDocs last week.

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

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

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

Question 4

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

Reveal answer

The correct answer is A. Don’t forget the Bubbles covered inhalers and sustainability last week. The hydrofluorocarbons (HFCs) used in metered dose inhaler (MDIs) are potent greenhouse gasses. ‘’Their effect on climate change is up to 3800 times more potent than carbon dioxide’’.

Inhalers and sustainability

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

Reviewed and edited by Rick Thissen