Quiz 59, January 24th, 2020

Welcome to the 59th FOAMed Quiz.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Most certainly the most widely discussed study last week was the VITAMINS paper. Some two and a half years after the Marik report, this randomized controlled trial provides some real evidence about the golden cocktail of Hydrocortisone, Vitamin C, and Thiamine in septic ICU patients. What did the VITAMINS paper show?

A: Treatment with Hydrocortisone, Vitamin C, and Thiamine resulted in significantly more septic ICU patients off the ventilator and alive on day 7 after randomization compared to hydrocortisone only

B: Treatment with Hydrocortisone, Vitamin C, and Thiamine resulted in significantly less septic ICU patients off the ventilator and alive on day 7 after randomization compared to hydrocortisone only

C: Treatment with Hydrocortisone, Vitamin C, and Thiamine resulted in equal numbers of septic ICU patients off the ventilator and alive on day 7 after randomization compared to hydrocortisone only

Reveal answer

The correct answer is C

The Bottom Line , St. Emlyn’s, Emergency Medicine Literature of Note and others covered the VITAMINS trial this week.

This is the first in a series of papers about Hydrocortisone, Vitamin C, and Thiamine (or HAT). This one shows no sign of benefit. However, it is a relatively small study (n = 216) and it has some weaknesses (eg. underpowered for mortality, thiamine levels not measured). More to come….

https://www.thebottomline.org.uk/summaries/icm/vitamins/

Question 2

A sixty year old patient with no past medical history presents to your emergency department with nonspecific chest pain. His physical exam is normal. The ADD-RS (aortic dissection detection risk score) shows a low pretest probability for aortic dissection. You decide to perform focused cardiac ultrasound (FoCUS) to feel more secure about sending this patient home later on.

What is the sensitivity of FoCUS for acute aortic syndromes with a low ADD-RS score?

A: Presence of direct symptoms (an intimal flap, intramural aortic haematoma or a penetrating aortic ulcer) on FoCUS has a sensitivity of 89 percent for acute aortic syndromes in patients with a low ADD-RS score

B: Presence of direct symptoms (an intimal flap, intramural aortic haematoma or a penetrating aortic ulcer) on FoCUS has a sensitivity of 70 percent for acute aortic syndromes in patients with a low ADD-RS score

C: Presence of direct symptoms or indirect symptoms (thoracic aorta dilatation, pericardial effusion and aortic valve regurgitation) has a sensitivity of 89 percent for acute aortic syndromes in patients with a low ADD-RS score

D: Presence of direct symptoms or indirect symptoms (thoracic aorta dilatation, pericardial effusion and aortic valve regurgitation) has a sensitivity of 70 percent for acute aortic syndromes in patients with a low ADD-RS score

Reveal answer

The correct answer is C

This weeks Ultrasound G.E.L podcast is about this paper published in 2019. This was a prespecified subanalysis of the ADvISED multicentre prospective study. It turns out sensitivity of PoCUS in a population with low pretest probability for acute aortic syndromes is quite fair if indirect signs like pericardial effusion and a dilated aortic root are considered to be a positive test. If only direct signs (visualize the intimal flap itself of detect an intramural hematoma) are considered to be positive, the sensitivity drops to about 45 percent.

Question 3

Your 34 year old patient is in convulsive status epilepticus. 2 Doses of 5 mg Midazolam intravenously were administered without any effect. Your patient turns out to use Isoniazid (INH), Pyrazinamide and Rifampin. Which of the following should be your next step?

A: Levetiracetam

B: Fosphenytoin

C: Valproate

D: Pyridoxine

Reveal answer

The correct answer is D

EmDOCs covered INH toxicity this week.

This seizure is most likely caused by INH (isonicotinylhydrazide). This is a hydrazide (like rocketfuel) and causes a functional pyridoxine deficiency. INH also inhibits the enzyme that converts the stimulatory neurotransmitter glutamate to GABA. Dosing of pyridoxine when an unknown amount of INH is ingested is 5 g IV and 70 mg/kg IV in pediatrics, repeated every 5-20 minutes.

Question 4

You see a 54-year old patient with cirrhosis now complaining about progressive abdominal pain.

Which of the following statements about spontaneous bacterial peritonitis (SBP) is true?

A: If a patient has fever or abdominal pain/tenderness, empiric antibiotics should be given even if ascitic neutrophil count < 250 cells/mm3

B: The most common causative organisms are Pseudomonas aeruginosa and Bacteroides fragilis

C: The classic triad includes fever, abdominal pain and increasing ascites. Presence of all three components is common.

D: Serum blood tests (i.e. WBC, CRP, ESR) are helpful in making this diagnosis

Reveal answer

The correct answer is A

RebelEM covered SBP this week.

If a patient has fever or abdominal pain/tenderness, empiric antibiotics should be given even if ascitic neutrophil count < 250 cells/mm3. The most common bacterial causes are E. Coli, S. Pneumoniae and Enterococci. The classic triad includes fever, abdominal pain and increasing ascites, but the presence of all three symptoms is rare.

https://rebelem.com/spontaneous-bacterial-peritonitis-sbp/

Question 5

What percentage of patients over 60 years old have rotator cuff tears after a shoulder dislocation?

A: 10 percent

B: 30 percent

C: 50 percent

D: 80 percent

Reveal answer

The correct answer is D

AliEM covered recurrent shoulder dislocations in their Splinter Series this week.

35 Percent of patients over 40 years of age have concomitant rotator cuff tears with their shoulder dislocations. This number jumps to over 80 percent when patients with shoulder dislocations are over 60.

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

January 16, 2020November 20, 2020

Quiz 58, January 17th, 2020

Welcome to the 58th FOAMed Quiz.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://www.aliem.com. Case courtesy of Andrew Murphy, Radiopaedia.org

Which of the following suspected injuries of the hand and wrist can be a reason to perform a ‘’clenched fist view’’?

A: A hook of hamate fracture

B: Scapholunate dissociation

C: A Scaphoid Fracture

D: Perilunate or lunate dislocation

Reveal answer

The correct answer is B

AliEM covered radiographic approach to the injured wrist this week.

A hook of hamate fracture can be seen most easily on a carpal tunnel view.

A perilunate or lunate dissociation should be visible on normal AP and Lateral views.

Scaphoid series might help you find a scaphoid fracture, which leaves a Scapholunate dissociation to be most easily found on a ‘’clenched fist view’’.

EMRad: Radiologic Approach to the Traumatic Wrist

Question 2

An otherwise healthy 24-year-old female is brought to the emergency department by her roommate because of an altered mental status. They went to a party together. After she got home this morning she was acting strange and progressively became more somnolent. The roommate admits she and the patient taking 3,4-Methylenedioxymethamphetamine (MDMA) last night. Her sodium comes back 103 mEq/l.

Which of the following statements is true regarding the hyponatremia in this patient?

A: MDMA causes hyponatremia due to adrenal insufficiency and polydipsia

B: MDMA causes hyponatremia due to heart failure and polydipsia

C: MDMA causes hyponatremia due to hypothyroidism and polydipsia

D: MDMA causes hyponatremia due to Syndrome of Inappropriate ADH secretion (SIADH) and polydipsia

Reveal answer

The correct answer is D

EmDocs covered the pearls and pitfalls of hyponatremia this week.

This patient most likely suffered acute hyponatremia after using MDMA at the party. Drugs like MDMA can be a trigger for SIADH.

Patients with acute onset hyponatremia are at risk for cerebral edema because intracellular osmolality suddenly exceeds extracellular osmolality. This causes water to move into the cells.

Current recommendations have defined correction should be no greater than 8 mEq/L in a 24-hour period and a total of 16 mE1/L in a 48-hour period.

Critical Hyponatremia: Pearls and Pitfalls

Question 3

Febrile illnesses are the most common cause of presentation to acute pediatric medical services. Which of the following statements is true about fever in children?

A: Bacteria are killed more easily by antibiotics at higher core temperatures

B: Higher temperature indicates a more serious infection

C: Rigors are associated with an increased risk of bacterial infection in children

D: Fever should always be treated with antipyretics

Reveal answer

The correct answer is A.

Don’t forget the bubbles covered fever last week.

Fever is a beneficial response to an infection, with higher temperatures promoting the immune response and inhibiting the growth of pathogens. Furthermore, bacteria are killed more easily by antibiotics at higher temperatures.

There is little to no evidence that higher temperatures, fever that don’t respond to antipyretics, or rigors indicate an increased risk of a serious infection.

Since fever doesn’t cause any harm (unless exceeding 41°C (105.8°F), treating a fever is only necessary if the child is uncomfortable.

https://dontforgetthebubbles.com/hot-garbage-mythbusting-fever-children/

Question 4

This French retrospective, observational, multicenter study is about efficiency of thrombolysis in out of hospital cardiac arrest (OHCA) caused by pulmonary embolism (PE). The primary endpoint was 30-day survival. 328 patients with confirmed or suspected PE were included. What did the authors find?

A: Thirty-day survival was higher in the thrombolysis group than in the control group but good neurologic outcome was not significantly different

B: Thirty-day survival was higher in the thrombolysis group than in the control group and good neurologic outcome was significantly higher in patients receiving thrombolysis

C: Thirty-day survival was similar in the thrombolysis group and the control group and good neurologic outcome was not significantly different

D: Thirty-day survival was similar in the thrombolysis group but good neurologic outcome was significantly higher in patients receiving thrombolysis

Reveal answer

The correct answer is A

Clay Smith covered this paper on JournalFeed last week.

The authors of the paper state: ‘‘Thirty-day survival was higher in the thrombolysis group than in the control group (16% vs 6%; P ¼ .005) but the good neurologic outcome was not significantly different (10% vs 5%; adjusted relative risk, 1.97; 95% CI, 0.70-5.56).’’

However, it is a bit unclear to me which patient were eventually considered having PE. ‘’PE was diagnosed on hospital admission by CT pulmonary angiography (CTPA) (definite PE) or echocardiogram (probable PE)’’. There is no mention of sonographic evaluation for deep venous thrombosis.

Question 5

Which of the following statements is true about the Greater Occipital Nerve Block (GONB)?

A: If palpation of the Greater Occipital Nerve (GON) reproduces headache pain or irritation, it should be avoided

B: The GONB can be used in the treatment of refractory migraine, cluster headache, occipital neuralgia, or cervicogenic headache

C: A GONB should not be performed bilaterally

D: The GON lies just lateral to the occipital artery

Reveal answer

The correct answer is B

NUEM covered the GONB this week.

GONB has been used in the treatment of cervicogenic headache, cluster headache, and occipital neuralgia, with demonstrated efficacy in improving pain and reducing headache frequency.

If palpation of the GON reproduces headache pain or irritation, it may be a good target for GONB

A GONB can be performed bilaterally if needed and the GON lies just medial to the occipital artery.

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

January 10, 2020November 20, 2020

Quiz 57, January 10th, 2020

Welcome to the 57th FOAMed Quiz.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: https://www.reviewofoptometry.com/

Diplopia is pretty common in the Emergency Department (ED) and proves often to be quite a diagnostic dilemma.

Which of the following statements is true about diplopia?

A: A patient with mononuclear diplopia should be evaluated by a neurologist first

B: Rotational diplopia that worsens when looking down and towards the nose is caused by a cranial nerve IV (trochlear nerve) palsy

C: The most common oculomotor nerve palsy is palsy of the nervus oculomotorius (n. III)

D: Multidirectional horizontal and vertical diplopia, except on lateral gaze to the affected side and eyelid droop are symptoms of cranial nerve VI (abducens nerve) palsy

Reveal answer

The correct answer is B.

Diplopia was covered by CanadiEM this week as part of their CRACKCast series.

Diplopia, the perception of double vision, is most often divided into monocular and binocular diplopia. Monocular diplopia is caused by a dysfunction in one eye whereas binocular diplopia is caused by misalignment of the visual axis and causes diplopia in both eyes. Patients with monocular diplopia should be evaluated by an ophthalmologist instead of a neurologist.

One important group causing binocular diplopia are cranial nerve palsies. Palsy of the nervus abducens is most common and causes diplopia when a patients looks to the side of the affected nerve.

Rotational diplopia that worsens when looking down and towards the nose is caused by a cranial nerve IV (trochlear nerve) palsy

Multidirectional horizontal and vertical diplopia, except on lateral gaze to the affected side and eyelid droop are symptoms of cranial nerve III palsy.

Question 2

This recently published paper compares elective intubation using direct laryngoscopy (DL) in supine position, DL in Bed Up Head Elevated (BUHE) position and video laryngoscopy (VL) in supine position. What did the authors find?

A: VL in supine position was superior to DL in BUHE position regarding obtained view of the glottis (POGO score)

B: DL in BUHE position was superior to VL in supine position regarding obtained view of the glottis (POGO score)

C: DL in BUHE position was non inferior to VL in supine position regarding obtained view of the glottis (POGO score)

D: DL in supine position was non inferior compared to VL in supine position and DL in BUHE position

Reveal answer

The correct answer is C

RebelEM covered this paper last week.

It is a non-inferiority trial comparing VL in supine position and BUHE DL to DL in supine position. Because it was a non inferiority trial, we can not make a statement about superiority. DL in BUHE was non inferior to videolaryngoscopy. Intubation with video took 8 seconds longer than DL in BUHE. The authors did find both BUHE and videolaryngoscopy to give better views of the glottis compared to DL in supine position. This trial was conducted in a controlled and elective setting in the operating room though, so might not be applicable to our Emergency Department patients. Furthermore, the primary outcome is not patient centered. To me it is not clear why the authors chose not to include a group using VL in BUHE position.

Should Bed Up Head Elevated (BUHE) be the New Standard Position for RSI in the ED?

Question 3

It is a pretty busy shift and you have to intubate yet another patient. You position the patient bed up head elevated (BUHE). You visualise the glottis, but not completely and you want to use a Gum Elastic Bougie (GEB).

Which of the following is true about the effect of using a GEB on the first pass success (FPS) rate of intubation?

A: A GEB is most effective in Cormack-Lehane grade 1 views

B: A GEB is only effective in Cormack-Lehane grade 2 views

C: A GEB is most effective in Cormack-Lehane grade 3 views

D: A GEB is only effective using videolaryngoscopy

E: A GEB is only effective using direct laryngoscopy

Reveal answer

The correct answer is C

George Kovacs shared an overview of the literature and his take on the bougie this week on EMcrit.

Use of a GEB does not lead to an increased first pass success rate in case of Cormack-Lehane grade 1 views, but it does result in better FPS when a Cormack-Lehane grade 2 or 3 view is found.

A GEB can improve FPS in both video and direct laryngoscopy. Keep in mind that not all blades used in videolaryngoscopy are suitable for using a bougie.

Of course the first pass success rate is a combination of many parameters other than the hardware used, including experience and skills of the physician.

https://emcrit.org/emcrit/bougie-lessons-from-the-literature/

Question 4

Your patient presents with hyperkalemia (potassium of 6,9 mmol/l) and ECG abnormalities. There are some caveats in treatment of hyperkalemia. Which of the following statements is true?

A: Treating hyperkalaemia with insulin will not cause blood glucose levels to fall if you co-administer dextrose

B: The effects of IV dextrose will wear off before those of insulin, so check blood glucose after 1-2 hours

C: Use 10% calcium gluconate unless you have a central line. Give 1 dose of 10ml

D: The duration of action of iv calcium is 3-4 hours

Reveal answer

The correct answer is B

The BREACH covered two important caveats in the treatment of hyperkalemia this weeks.

Treating hyperkalemia with insulin will cause blood glucose levels to fall, even if you co-administer dextrose. The effects of IV dextrose will ideed wear off before those of insulin, so check blood glucose after 1-2 hours.

Use 10% calcium gluconate unless you have a central line. Give 3 sequential doses of 10ml until the ECG normalises (advice from the UK Renal Association). The duration of action is 30-60min, so be ready to repeat the dose if ECG changes reappear.

Hyperkalaemia: two problems with our current management

Question 5

Pacemaker complications are quite common and most of these complications can occur at any time after placement.

Which of the following statements is true about pacemaker complications?

A: The incidence of phlebitis or thrombophlebitis is 20-30%

B: ‘Pacemaker Syndrome’ involves tricuspid regurgitation due to damage to this valve during pacemaker insertion

C: Patients with pacemaker syndrome usually present with vague symptoms including fatigue and exercise intolerance

D: Pocket infection of the pacemaker site can be managed with oral antibiotics most of the time

Reveal answer

The correct answer is C

Lorne Costello covered pacemaker complications in the last part of his Pacemaker Essentials trilogie on CanadiEM.

Phlebitis and thrombophlebitis have a very high incidence of 30-50% in pacemaker patients. However, symptomatic presentations are rare because patients develop collateral blood flow.

Pacemaker syndrome arises from the contraction of the atria against closed tricuspid and mitral valves, resulting in high pulmonary pressures. Patients usually present with vague symptoms like fatigue, weakness and dizziness, but they can also present with syncope or congestive heart failure.

A pocket infection requires most often intravenous antibiotics and removal of the pacemaker. Keep in mind that a pocket infection equals endocarditis until proven otherwise.

https://canadiem.org/pacemaker-essentials-complications/

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

January 3, 2020November 20, 2020

Quiz 56, January 3th, 2020

Welcome to the 56th FOAMed Quiz.

Enjoy the first quiz of 2020!

Kirsten, Eefje, Hüsna, Joep and Rick

Written by Joep Hermans. Post edited by Rick Thissen.

Question 1

Nowadays peripheral vasopressor use is quite common in the Emergency Department. It seems to be pretty safe, but still includes some risks.

Which of the following statements is true about the safety of peripheral vasopressors according to 2 recently published observational studies?

A: The rate of extravasation is about 5 percent

B: Tissue necrosis or limb ischemia was present in over half of extravasation cases

C: All reported extravasation events in both papers were managed conservatively or with vasodilatory medications

Reveal answer

The correct answer is C

REBELem covered this and this paper this week.

The extravasation rate was found to be below 2,6 percent and all 43 cases between these papers were managed conservatively without tissue necrosis or limb ischemia.

Peripheral vasopressor use seems to be really safe according to these papers, but keep in mind there are no randomized studies on this topic. All data comes from observational studies.

REBEL Cast Ep73: Are Peripheral Vasopressors Safe?

Question 2

A 52-year-old male was hit by a car and suffered a tibia fracture. He has no other injuries but keeps complaining about severe pain, despite repeated doses of morphine.

Which statement about compartment syndrome (CS) is true?

A: Female patients above 50 years of age have the highest risk for developing CS

B: The anterior compartment of the lower leg is the most common location for CS to occur

C: Clinical findings such as excessive pain, pain which increases with passive stretching, paresthesia and paresis have a very high sensitivity for CS

D: Removal of external compressive devices, elevation of the extremity at risk and relocation of a displaced fracture may possible decrease pain sensation but will not reduce pressure inside the compartment at risk

Reveal answer

The correct answer is B.

EMdocs covered the pearls and pitfalls of compartment syndrome this week as part of their EM Educator Series.

Compartment syndrome is most common in males <35 years of age since these patients have increased risk of high-energy injuries, stronger fascia and greater muscle bulk. It mostly occurs in the anterior compartment in the lower leg but it is also seen in the deep posterior compartment and in other limbs like the upper legs, underarms and hands/feet.

It is true that most seen clinical signs include excessive pain, pain which increases with passive stretching, paresthesia and paresis. These signs have a high specificity but a low sensitivity on their own, when all four are compared, sensitivity is much better (93%).

Finally, pressures inside compartments can certainly be lowered by removal of external compressive devices, elevation of the extremity and relocation of a displaced fracture. Each centimeter of elevation decreases pressure with 0.8 mmHg. However, treatment is fasciotomy.

Question 3

Your patient presents with an acute first CarpoMetaCarpal (CMC) dislocation. Which of the following statements is true about this topic?

A: Isolated dislocations are uncommon and are usually associated with Bennett, Roland and carpal fractures

B: Thumb CMC dislocations are often caused by direct force into the webspace between the first and second digits

C: Closed reduction performed with traction in the Emergency Department is absolutely futile

D: Operative treatment is always indicated

Reveal answer

The correct answer is A

AliEM covered CMC dislocations this week.

Indeed, isolated dislocations are uncommon.

´Thumb CMC dislocations are often caused by axial loading of the thumb in a flexed position, and less commonly, direct force into the webspace between the first and second digits.’

During initial treatment in the ED, CMC dislocations should be anesthetized with an intra-articular injection, and then closed reduction should be performed with traction. The joint is likely unstable after reduction.

There is debate over the optimal treatment strategy, and several studies have compared nonoperative and operative treatment.

SplintER Series: A Rare Cause of Traumatic Thumb Pain

Question 4

Ah, the ever continuing discussion about the best anti-epileptic drug when benzodiazepines fail.

Recently the ESETT trial was published. This is a multicenter, randomized, blinded, trial of second line agents for the treatment of status epilepticus in the emergency department. What did the authors find?

A: Levetiracetam was superior in terminating seizure activity compared to Valproate and Fosphenytoin at 60 minutes after administration

B: Fosphenytoin was superior in terminating seizure activity compared to Valproate and Levetiracetam at 60 minutes after administration

C: No difference in effectiveness and safety was seen between the three drugs

D: Levetiracetam is safer compared to Valproate and Fosphenytoin

Reveal answer

The correct answer is C

First10EM covered this trial last week (REBELem and EMcrit covered this trial as well).

It is the best evidence we have so far on second line agents for status epilepticus and it tells us: no agent is more effective compared to the others and no agent is clearly less safe compared to the others.

The effectiveness (termination of seizure activity at 60 minutes after administration without the need of additional medication) isn’t really that good to put it lightly.

Furthermore, letting patients seize for up to 1 hour after administration of second line agent without proceeding to the next step (sedation and intubation) is not acceptable.

The ESETT Trial: 2nd Line Medications in Status Epilepticus

Question 5

Non-traumatic cardiac arrest (CA) is often associated with multiple pathologies. This retrospective study reviewed 100 whole body CT (WBCT) performed within 6 hours after Return Of Spontaneous Circulation (ROSC). What did the authors find?

A: Pneumothorax was present in about 5 percent of patients

B: Rib fractures were found in nearly 50 percent of patients

C: Pulmonary embolism was found in 10 percent of patients

D: No abdominal acute pathologies were found on these scans

Reveal answer

The correct answer is C

The ever fantastic Resus Room paper of the month podcast covered this pretty interesting paper (January 2020).

The authors found a staggering amount of pathologies in 100 consecutive patients. These include pneumothorax in 26%, rib fractures in nearly 90%, pulmonary embolism in 10 percent of patients, acute pathology of the brain in 15 percent and acute pathology in the abdomen in 6% of cases (including splenic hematoma in 2 percent and bowel rupture in 1 percent) and so on… It is not clear how many of these findings led to a different treatment.

Well. We normally don’t perform WBCT after ROSC and we are not likely to start doing so, but these numbers are quite impressive.

https://theresusroom.co.uk/papers-of-january-2020/

December 26, 2019November 20, 2020

Christmas edition, December 26th 2019

Welcome to the Christmas Special

Merry Christmas and a Happy New Year!

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Which eponyms are we looking for???

Question 1

Reveal answer

M

The Monteggia fracture is a fracture of the proximal third of the ulna with dislocation of the proximal head of the radius. It is named after Giovanni Battista Monteggia.

EM Cases – Elbow Injuries – Ten Pitfalls in Diagnosis and Management

Question 2

Source Image: http://www.surgeryassistant.nl/

Reveal answer

E

An Essex-Lopresti injury consists of a radial head fracture with dislocation of the distal radioulnar joint (DRUJ) and disruption of the interosseous membrane (IOM).

Essex-Lopresti fracture

Question 3

”Aspirin has been linked with this syndrome, so use caution when giving aspirin to children or teenagers for fever or pain. Though aspirin is approved for use in children older than age 3, children and teenagers recovering from chickenpox or flu-like symptoms should never take aspirin.’ (Mayoclinic)

Reveal answer

R

Reye’s Syndrome was first describe in 1963. It may occur at any age in childhood, although higher rates in children < 2 years of age. Death occurs in ~30-40% of cases due to brainstem dysfunction. The etiology is not clearly known. An association (although not clear causality) is described between recent viral illness and aspirin therapy.

Reye’s Syndrome

Question 4

Fundoscopy revealed these ‘spots´ in a patient with suspected endocarditis:

Reveal answer

R

”Roth spots are retinal haemorrhages with white or pale centres, commonly associated with subacute bacterial endocarditis and immune complex mediated vasculitis.”

Roth spots

Question 5

Reveal answer

Y

Yankauer suction tip. Doesn’t need a lot of explanation, but I couldn’t think of anything else starting with a Y.

Sidney Yankauer

Question 6

”This disease is also known as American trypanosomiasis, is a tropical parasitic disease caused by the protist Trypanosoma cruzi. It is spread mostly by insects known as Triatominae.”’

Reveal answer

C

”’ Chagas disease is an inflammatory, infectious disease caused by the parasite Trypanosoma cruzi, which is found in the feces of the triatomine (reduviid) bug. Chagas disease is common in South America, Central America and Mexico, the primary home of the triatomine bug. ”

https://www.cdc.gov/parasites/chagas/index.html

Question 7

A 9 year old male presents to your emergency department with a chief complaint of abdominal pain.

Reveal answer

H

Henoch–Schonlein Purpura (HSP) is an immune-mediated small vessel vasculitis. Compared to purpura commonly caused by thrombocytopenia, the etiology of the purpuric lesions in HSP are secondary to IgA-mediated immune complex deposition in the skin.

PEM Pointers: Henoch-Schonlein Purpura

Question 8

Reveal answer

R

Rolando Fracture is a complete and comminuted intraarticular fracture, usually in a T or Y shape

SplintER Series: Case of a First Metacarpal Fracture

Question 9

This is a system of categorizing scapula fractures involving the glenoid fossa.

Source image: https://www.orthobullets.com/

Reveal answer

I

The Ideberg classification is a system of categorizing scapula fractures involving the glenoid fossa.

https://www.orthobullets.com/trauma/1013/scapula-fractures

Question 10

A 55 years old patient comes in with a rash after starting with ibuprofen for a backache 5 days ago.

Source image: https://my.clevelandclinic.org/

Reveal answer

S

Stevens-Johnson Syndrome (SJS) is a rare type IV hypersensitivity reaction with sheet-like skin loss and mucosal ulceration.

https://em3.org.uk/foamed/3/6/2019/lightning-learning-stevens-johnson-syndrome

Question 11

A 12-year old boy comes in with an ankle sprain.

Reveal answer

T

A Tillaux Fracture is a fracture of the anterolateral tibial epiphysis commonly seen in adolescents. (Salter-Harris III tibial fracture)

Tillaux fracture

Question 12

A 60 years old patient comes in with fever and upper belly pain. You find this on POCUS and pressing the probe hurts. What is this sign called?

Reveal answer

M

(Sonographic) Murphy’s Sign is positive when the maximal intensity of patient’s pain is when the gallbladder is in view directly beneath the probe.

https://www.nuemblog.com/biliary

Question 13

”If a patient’s hand flushes fully and rapidly after an artery is released, that artery, the palmar arch, and the digital arteries are patent. If pallor persists throughout the hand, the artery that was released is occluded. Pallor in patches indicates insufficiency of the smaller vessels.”

Source image: https://www.handsurgeryresource.com/

Reveal answer

A

Allen test

The Hand: An Expedited Examination and Key Points Regarding ED Diagnoses

Question 14

Reveal answer

S

A Segond Fracture is an avulsion fracture (small) of the lateral surface of the lateral tibial condyle. Usually results from excessive internal rotation and varus stress resulting in increased tension on the lateral capsular ligament of the knee joint.

Segond fracture

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

December 20, 2019November 20, 2020

Quiz 55, December 20th, 2019

Welcome to the 55th FOAMed Quiz.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

A 38-year old male presents to your emergency department (ED) with a red left eye. The symptoms started yesterday and are getting worse. He describes the feeling as something stuck in his eye. His past medical history contains allergies, asthma and genital herpes.

Which of the following statements is true about corneal disorders?

A: This patient could be suffering of Herpes simplex keratitis, a condition which is most often bilateral

B: Contact lens users are at increased risk for bacterial keratitis, but only if the lenses are worn overnight

C: If a patient has a painful eye with pain which is out of proportion, corneal abrasion is more likely than corneal laceration

D: A positive Seidel’s test indicates corneal laceration

Reveal answer

The correct answer is D

Corneal disorders were covered by Hubert Yu from CanadiEM this week.

The differential diagnosis for corneal disorders in the Emergency Department contains corneal abrasion, foreign bodies, corneal laceration, superficial punctate keratitis, herpes simplex keratitis, herpes zoster ophthalmicus and bacterial keratitis.

Herpes simplex keratitis is almost always unilateral and is most likely a reactivation of latent HSV infection.

Lens users are at increased risk of bacterial keratitis, particularly when the keep them in overnight.

If you see a patient with pain out of proportion, think about corneal laceration.

The Seidel test is intended to detect the leak of aqueous fluid following globe penetration (and it looks pretty).

Approach to Corneal Disorders in the ED

Question 2

A 61-year-old woman presents to your Emergency Department with severe hypertension (RR 240/130 mmHg) and grade 4 hypertensive retinopathy.

Which of the following statements about hypertensive emergency is true?

A: Headache is almost always indicates end-organ damage

B: In this patient you should target a systolic blood pressure (SBP) of 120mmHg in 2 hours

C: Hypertensive Urgencies should be managed in the Emergency Department

D: Stopping previously prescribed medication is the most common reason for hypertensive urgency

Reveal answer

The correct answer is D

Clay Smith discussed the management of acute severe hypertension this week at JournalFeed.

Headache by itself is not diagnostic for end organ damage. Be sure no underlying disorder like Spontaneous Intracranial Hemorrhage, Stroke or Posterior reversible encephalopathy syndrome (PRES) is present.

Acute severe hypertension without acute target-organ damage is not associated with adverse short-term outcomes and can be safely managed in the ambulatory setting.

The target SBP depends on the type of end-organ damage. In case of grade 3 or 4 hypertensive retinopathy you should strive to decrease the SPB with 20-25% in a couple of hours. In case of more serious pathology the reduction in SBP should be faster and more rigorous (like 120 mmHg immediately in case of an Aortic Dissection).

Question 3

Which of the following statements is true about Vaping Associated Lung Injury (VALI) according to this recently published descriptive paper?

A: The causative agent of VALI is Tetrahydrocannabinol (THC)

B: It seems most patients with VALI have unilateral infiltrates on chest imaging

C: Glucocorticoids does not seem to improve respiratory symptoms

D: Vaping THC containing substance leads to a higher chance of developing VALI compared to vaping a non-THC containing substance.

Reveal answer

The correct answer is D

RebelEM covered this paper about VALI this week.

The authors of this paper analyzed 53 case patients. The causative agent is still unknown, but vaping THC containing substance leads to a higher chance of developing VALI compared to vaping a non-THC containing substance. All case patients had bilateral infiltrates on chest imaging (which was part of the case definition) and 65% of patients who received systemic glucocorticoids had “documentation by the clinical team that respiratory improvement was due to the use of glucocorticoids.”

Vaping Associated Lung Injury (VALI)

Question 4

Source image: https://www.grayscalecourses.com/

Which of the following statements is true about Nontraumatic Atlantoaxial Subluxation (Grisel Syndrome)?

A: It is most frequently associated with recent head, eyes, ears, nose, and throat (HEENT) infection or recent HEENT surgery

B: Adolescents are more predisposed to Grisel syndrome compared to young children

C: Cervical plain films with odontoid views are not helpful

D: Most cases require surgical management

Reveal answer

The correct answer is A

Pediatric EM Morsels covered Nontraumatic Atlantoaxial Subluxation this week.

Nontraumatic Atlantoaxial Subluxation is most frequently associated with recent HEENT infection or recent HEENT surgery. Children are more predisposed to Grisel syndrome, likely due to greater ligamentous laxity in the cervical region. Cervical plain films with odontoid views can be a helpful screening tool and most cases are able to be managed without surgery.

Nontraumatic AtlantoAxial Subluxation in Children

Question 5

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

Which of the following statements is true about Monteggia fracture – dislocations in children?

A: The fracture is most often located at the distal to middle third of the ulna

B: Monteggia fracture-dislocations can occur with other more subtle ulna fractures such as greensticks and even plastic deformation fractures

C: Monteggia fracture-dislocations do not require reduction most of the time

D: Isolated midshaft ulna fractures are pretty common in children

Reveal answer

The correct answer is B

Don’t Forget the Bubbles covered Monteggia fracture – dislocation this week.

The ulna fracture is most often at the proximal to middle third of the ulna. Monteggia fracture-dislocations can occur with other more subtle ulna fractures such as greensticks and even plastic deformation fractures. All Monteggia fracture-dislocations will require an urgent reduction of the radial head dislocation. Isolated midshaft ulna fractures are very rare in children, so when an ulna fracture is identified you must also get an x-ray of the wrist and elbow joints.

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

December 13, 2019November 20, 2020

Quiz 54, December 13th, 2019

Welcome to the 54th FOAMed Quiz.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Early use of vasopressors is considered harmful in trauma patients and is not recommended by ATLS or other trauma courses.

This year the AVERT trial was published. This randomized controlled trial is about the efficacy of low dose Arginine Vasopressin (AVP) versus placebo in patients with major trauma. What did the authors find?

A: AVP reduced mortality in this cohort

B: AVP reduced transfusion of blood products in this cohort

C: AVP reduced use of crystalloids in this cohort

D: AVP did not have any significant effect

Reveal answer

The correct answer is B

This paper was covered on REBELem this week.

In august 2019 the AVERT trial was published. As stated above, this is an RCT comparing low dose AVP versus placebo in 999 sick trauma patients (receiving at least 6 U of any blood product within 12 hours of injury). Participants received either placebo or AVP bolus (4 U) followed by an infusion to achieve a mean arterial pressure of 65 mmHg.

Patient receiving AVP required significantly less blood products, but requirement of crystalloids and mortality were similar between groups.

Keep in mind that 80 percent of the studied population sustained penetration injury, which is not very comparable to our shop.

https://rebelem.com/avert-shock-vasopressin-for-acute-hemorrhage/

Question 2

A 75 year old female with a history of diabetes mellitus presents with one day of abdominal pain with numerous loose, bloody bowel movements. She is hemodynamically and respiratory stable.
The abdominal exam shows significant left lower quadrant tenderness without guarding or rebound tenderness.

A diagnosis you don’t want to miss is Ischemic Colitis (IC).

Which of the following statements is true about this condition?

A: Symptoms usually include abdominal pain, severe rectal bleeding and vomiting

B: Patients are most often male, at least 40 years old and have a history of hypertension, vascular disease, chronic kidney disease and or diabetes mellitus

C: Bowel wall thickening, edema and thumbprinting on CT suggest IC. Colonic pneumatosis and portomesenteric venous gas indicate more severe disease

D: IC and mesenteric ischemia are two different names for the same condition.

Reveal answer

The correct answer is C.

EMDocs covered the presentation, evaluation and management of IC this week.

Patients with IC most often present with abdominal pain (87%), subtile rectal bleeding (84%) and diarrhea (57%). Since these are non specific symptoms, up to 80% of cases are missed in the emergency department.

Patients are most often at least 50 years old, female and have a history of hypertension, vascular disease, chronic kidney disease and diabetes mellitus.

Although IC and mesenteric ischemia both occur in the setting of poor perfusion, acute mesenteric ischemia results in ischemia of the small bowel, most often due to occlusion of the superior mesenteric artery whereas ischemic colitis affects the colon in the distribution of the inferior mesenteric artery. Mesenteric ischemia also has a much higher mortality rate (60-80%) compared to ischemic colitis (10-15%).

Ischemic Colitis: ED Presentations, Evaluation, and Management

Question 3

Although advanced cardiac life support (ACLS) protocols do not currently mandate the use of echocardiography, cardiac point-of-care ultrasound (POCUS) has become standard practice in many emergency departments during cardiopulmonary resuscitation (CPR).

Recently, the SHoC-ED2 trial has been published, which is about POCUS and ECG findings as predictors of cardiac arrest outcomes.

Which of the following is true about POCUS in the prediction of return of spontaneous circulation (ROSC) during CPR in non-shockable cardiac arrest?

A: Absence of cardiac activity on POCUS by itself has both high sensitivity and a high specificity for futility of CPR

B: In patients with asystole on ECG, the sensitivity of POCUS for futility of CPR is higher than in patients with electrical activity on ECG

C: ECG in combinations with POCUS performs well as reliable tests to identify patients likely to survive

Reveal answer

The correct answer is B.

Simon Huang discussed the results of this trial on his blog at CanadiEM.

Absence of cardiac activity on POCUS alone has a high sensitivity (96%) but a low specificity (34%) for futility of CPR.

The combination of no cardiac activity on POCUS and an asystole on the ECG has a sensitivity of 98.2% for failure of ROSC, compared to 87% with no cardiac activity on POCUS and a PEA on the ECG.

Unfortunately, neither ECG nor POCUS alone or in combination performed well as reliable tests to identify patients likely to survive, with specificities maximizing at just over 50%.

SHoC-ED2: Ultrasound and ECG findings as predictors of cardiac arrest outcomes in the emergency department

Question 4

A 66-year-old otherwise healthy female presents at your emergency department after being found unconscious on the floor. On arrival she is back to her baseline normal mental status, without complaints and with normal vital signs.

Which of the following statements is true about syncope?

A: Unilateral tongue biting is more common in seizures compared to vasovagal syncope, whereas bilateral tongue biting is more characteristic for vasovagal syncope

B: Several Clinical Decision Rules for syncope are reliable and externally validated

C: The rate of pulmonary embolism in syncope patients is most likely about 17 percent

D: Routine use of laboratory tests in syncope are not recommended in ACEP guidelines

Reveal answer

The correct answer is D.

Andrew Grock covered the work-up of syncope this week on AliEM.

He introduced a 3-step, evidence-based framework for the evaluation and work-up of syncope. Step 1: make sure it’s syncope, step 2: consider true syncope versus symptom syncope and step 3: assess the patient’s dysrhythmia risk.

Lateral tongue biting, especially bilateral, or postictal confusion is more characteristic for a seizure than for syncope.

Not a single Clinical Decision Rule for syncope is externally validated so far, although the Canadian Syncope Rule looks promising.

17 Percent pulmonary embolism… well enough said about the PESIT trial. The rate of pulmonary embolism in patients presenting to the ED is most likely < 1 percent.

And indeed, routine use of laboratory tests in syncope is not recommended in ACEP guidelines.

Question 5

In this recently published secondary analysis of patients from the Isotonic Solutions and Major Adverse Renal Events Trial (SMART), the authors compared balanced crystalloids (>90 % Lactated Ringer’s) and normal saline in sepsis patients admitted to the intensive care.

What did this paper show?

A: In this cohort of very ill patients, the 30 day mortality was significantly lower in patients treated with balanced crystalloids

B: In this cohort of very ill patients, the 30 day mortality was significantly lower in patients treated with normal saline

C: There was no difference between the two groups

Reveal answer

The correct answer is A.

RebelEM covered this secondary analysis of the SMART trial last week.

1,641 Out of >15,000 patients were analyzed. A total of 217 patients (26.3%) in the balanced crystalloids group and 255 patients (31.2%) in the saline group experienced 30-day in-hospital mortality.

Probably one more piece of evidence toward the use of balanced crystalloid… to be continued.

SMART Trial Part 2: Secondary Analysis of Balanced Crystalloids vs Saline in Sepsis

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

December 6, 2019November 20, 2020

Quiz 53, December 6th, 2019

Welcome to the 53th FOAMed Quiz.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Your 53-year-old female patient presents with an AV-nodal reentry tachycardia (AVNRT). She is hemodynamically stable with a pulse rate of 175/min and blood pressure of 118/90 mmHg. You want to give her adenosine.

Which of the following statements is true about the administration of adenosine?

A: Adenosine diluted with saline in a single syringe push seems to be at least non-inferior to the usual adenosine push followed by a rapid saline flush

B: Adenosine diluted with saline in a single syringe push seems to be inferior to the usual adenosine push followed by a rapid saline flush

C: Adenosine diluted with saline as a single syringe push seems to induce more adverse events in comparison to the usual adenosine push followed by a rapid saline flush

Reveal answer

The correct answer is A

Clay Smith covered this trial about the single syringe method for the administration of adenosine on JournalFeed.

One of the challenges of giving adenosine is the very quick saline push needed after the adenosine push. A few seconds between the two administrations might make a difference for successful cardioversion. Diluted adenosine in one syringe (a sort of push and flush together) can make it a lot easier!

The results of this trial are promising: successful conversion to normal sinus rhythm (NSR) with the first dose of adenosine was higher in the single syringe group: 73.1% compared to 40.7% in the controlgroup. There were no adverse events reported in the single syringe group. Keep in mind that this was a small, unblinded pilot study.

Question 2

We prescribe a lot of antiemetics in the Emergency Department (ED). After all, nausea and vomiting are pretty common complaints.

But how about the evidence? Justin Morgenstern covered this paper earlier this week on First10EM. Which of the following statements is correct regarding the efficacy of droperidol and ondansetron as an antiemetic in the ED?

A: This paper shows ondansetron is more effective than placebo in reducing nausea

B: This paper shows droperidol is more effective than placebo in reducing nausea

C: This paper shows droperidol and ondansetron are more effective than placebo in reducing nausea

D: This paper shows ondansetron, droperidol and placebo are equally effective in reducing nausea

Reveal answer

The correct answer is D

This paper compared ondansetron, droperidol and placebo. Their primary outcome was an improvement of 8 mm of a visual analogue scale and was met in 75 (droperidol), 80 (ondansetron) and 76 percent (placebo). These differences were not statistically significant. However patients reported significantly higher rates of achieving desired effect when using droperidol (this was elicited from direct questioning—”The drug I received had the desired effect for me: Yes or No”). Furthermore, the authors enrolled 215 patients (unfortunately, this was only about half way to the calculated sample size of 378 patients). So, although this paper shows no clear benefit of droperidol and ondansetron, it is not a done deal.

Nausea and vomiting in the ED: Does nothing work?

Question 3

Auwch, that hurts! Penile injuries are men’s worst nightmare. Examples include penile fracture, zipper injuries and penile strangulation.

Which of the following statements is true?

A: ‘’A zucchini deformity’’ is an often notable clinical sign in penile fractures

B: Urethral injuries are seen in 60-70% of penile fractures

C: The best way to separate an entrapped penis from a zipper is by using a wire cutter to cut the middle portion of the zipper that connects the two halves

D: In case of penile strangulation blood can be drained from the corpora cavernosa in a manner similar to draining a priapism to get underneath the constricting band

Reveal answer

The correct answer is D

Jacob Stelter covered penile injuries this week on NUEM.

A penile fracture is a medical emergency in which the‘’eggplant deformity’’ refers to the clinical presentation of a fractured penis with swelling and detumescence of the penis, often with notable ecchymosis and deformity.

Penile fracture could lead to urethral injuries which occur in up to 38%. If suspected, a retrograde urethrogram or cystoscopy should be performed before a Foley catheter is inserted.

In case you see a patient with his penis trapped in a zipper, use a lubricant, this almost always works. If not, try using a wire cutter to cut the piece connecting the two halves of the zipper.

Finally, injuries resulting from penile strangulation are divided into five grades ranging from isolated penile edema in stage I all the way up to penile necrosis or amputation of the distal segment in grade 5.

Question 4

A 4 years old patient presents to your department with colicky abdominal pain. The ultrasound image looks like the one above.

Which of the following statements is true regarding this diagnosis?

A: Surgery is indicated for all pediatric patients

B: Pneumatic or hydrostatic enema is preferred modality in pediatric patients

C: The male to female ratio is 1:5

D: Currant jelly stools are very common in these patients

Reveal answer

The correct answer is B

AliEM covered intussusception this week in their ´´Ultrasound for the Win´´ series.

The male to female ratio is 3-8:1. While pneumatic or hydrostatic enema is preferred modality in pediatric patients, surgery is indicated in adults patients. Currant jelly stools are pretty rare.

Ultrasound for the Win! 3-year-old with abdominal pain #US4TW

Question 5

Which of the following statements is true about acute torsion of the appendix epididymis?

A: Torsion of the testicular appendages is dangerous

B: Diagnosis is made via color doppler ultrasound

C: Treatment includes surgical detorsion

D: Late torsion of the appendix testis or epididymis may present with a “blue dot sign”

Reveal answer

The correct answer is B

BrownEM covered acute torsion of the appendix epididymis this week.

Torsion of the testicular appendages is not dangerous. Diagnosis is made via color doppler ultrasound. Treatment includes NSAIDs, scrotal support, and reassurance and early torsion of the appendix testis or epididymis may present with a “blue dot sign”.

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

November 29, 2019November 20, 2020

the CanadiEM special

Welcome to the first dedicated Quiz

The development of this website relies completely on high quality content on FOAMed Blogs and Podcasts all over the world. Website like CanadiEM make our existence possible.

This Quiz contains 5 questions about content appearing on CanadiEM in the past 6 months.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

A 31 year old woman presents to the emergency department (ED) with a regular narrow-complex tachycardia at a rate of 180 bpm. Previous ECGs show a short PR-interval and delta wave.

Which of the following statements is true about Wolff Parkinson White (WPW) syndrome?

A: The most common tachydysrhythmia seen in WPW is AV-nodal reentrant tachycardia (AVNRT)

B: In atrioventricular reentrant tachycardia (AVRT) and WPW, the impulses mostly travel up through AV node and down through the accessory pathway (antidromic)

C: Classic ECG findings in WPW syndrome include: long PR-interval (>120 ms) a delta wave and QRS prolongation

D: Adenosine might cause ventricular tachydysrhythmias, even in patients with regular AVRT

Reveal answer

The correct answer is D

Paula Sneathon covered WPW earlier this year.

WPW syndrome is a combination of the presence of a congenital accessory pathway, often called ‘’the Bundle of Kent’’, and episodes of tachyarrhythmia.

Atrioventricular Reentrant Tachycardia (AVRT) is the most common tachydysrhythmia in WPW (80%).

Orthodromic AVRT (down the AV node and up the accessory pathway) is way more common than antidromic AVRT (up the AV node and down the accessory pathway).

Classic features of WPW on the ECG include a short PR-interval, delta waves and a prolonged QRS duration.

Despite being really rare, adenosine administration once in a while causes nasty ventricular tachydysrhythmias, even in patients without underlying Atrial Fibrillation (AF). This might be caused by another accessory bundle or development of AF during AV-nodal blockade.

Sirens to Scrubs: Wolff-Parkinson-White Syndrome

Question 2

A 32 year old female presents to your ED with nausea and headache. She tells you she is ten weeks pregnant and is known with migraine. After considering other (more dangerous) causes of headache in pregnancy (like pre eclampsia, cerebral venous thrombosis and pituitary apoplexy) you conclude that she is experiencing an episode of migraine. You want to prescribe her analgesia and anti emetics.

Which of the following combinations is the safest option for this patient and her child?

A: Acetaminophen and haloperidol

B: Acetaminophen and ondansetron

C: Acetaminophen and metoclopramide

D: Ibuprofen and metoclopramide

Reveal answer

The correct answer is C

Vivian Tam discussed the management of headache in pregnant patients recently.

Acetaminophen can be given safely in all pregnant patients.

Haloperidol use during pregnancy has been linked to severe limb reduction defects.

Ondansetron might cause doubling in risk of cleft palate and heart defects in newborns.

There is no evidence for an increased risk of congenital malformations with the use of metoclopramide.

NSAIDs might increase the risk of early pregnancy loss in the first trimester. There is some weak evidence for diphenhydramine causing cleft palate in the first trimester.

Managing headaches in pregnancy

Question 3

A 75-year-old man presents with 2 days of abdominal pain due to an acute cholecystitis. He will require a laparoscopic cholecystectomy. The patient is on dabigatran 110mg twice daily because of atrial fibrillation and took his last dose 6 hours before presentation. His glomerular filtration rate is 40 ml/min.

Which of the following is true about the anticoagulant effect of dabigatran in this patient?

A: The anticoagulant effect of dabigatran will be insignificant after 3 half-lives

B: A normal thrombin time (TT) can safely be used to rule out a clinically significant dabigatran effect

C: The half-life of dabigatran can be estimated at 12 hours in this patient

D: An anti-Xa assay is needed to estimate the current anticoagulation effect of dabigatran

Reveal answer

The correct answer is B

Matthew Nicholson covered the determination of anticoagulant effect of DOACs earlier this year.

Since DOACs have predictable pharmacokinetics, testing for DOAC levels is in general not required if the time of last ingestion is known. However, in some cases laboratory testing can be useful, for example in patients with renal failure. The anticoagulant effect is considered to be insignificant after 4-5 half lives. The half-life of dabigatran is estimated at 12-14 hours, but will be longer in patients with renal dysfunction.

The standard thrombin time (TT) is highly sensitive for dabigatran and can be used to rule out a clinically significant dabigatran effect. If the TT is abnormal, you will need a dilute thrombin time (dTT) essay to quantify the dabigatran effect (if you would like to know).

Blood & Clots Series: How do I determine if my patient on a DOAC is still at increased risk of bleeding?

Question 4

Your patients presents with acute onset radicular back pain after lifting weights. There are no red flags, but acetaminophen and a non steroidal anti inflammatory drug (NSAID) do not provide adequate pain relief. Your savvy nurse suggests a single dose of intravenous corticosteroids. Which of the following statements is true regarding the evidence behind a single intravenous bolus of corticosteroid in reducing pain in patients with radicular back pain?

A: A single intravenous bolus of 8 mg dexamethasone or 500 mg methylprednisolone significantly improves VAS pain scores at 6 weeks after onset of symptoms

B: A single intravenous bolus of 8 mg dexamethasone or 500 mg methylprednisolone might improve VAS pain scores at 24 hours after onset of symptoms

C: A single intravenous bolus of 500 mg methylprednisolone for treatment of radicular back pain is clearly safe

Reveal answer

The correct answer is B

Jessie Grewal covered single intravenous bolus of corticosteroid in reducing pain in Emergency Department patients with radicular back pain last week.

Only two small RCTs are published on this topic (one on dexamethasone 8 mg and one on methylprednisolone 500 mg). It seems that corticosteroids might have a transient beneficial effect on pain scores. However, both RCTs are ‘’too small to detect rare and dangerous adverse effects.’’

Is there a role for a single intravenous bolus dose of corticosteroid in reducing pain in Emergency Department patients with radicular back pain?

Question 5

Patients with fever, we see them every day in the Emergency Department. Most fevers are benign, some are not. For a symptom so common, do we know enough about it? Which of the following statements is true about fever?

A: Fevers under 42 degrees Celsius (107.6 °F) are harmless

B: Fever can cause seizures in adults without pre-existing seizure disorders

C: External cooling methods should be first line treatment to lower fever

D: Nearly every aspect of our immune system has been shown to function better in higher temperatures

Reveal answer

The correct answer is D

Paula Sneath covered the pathogenesis of fever last August.

It seems fever below 41 degrees Celsius is harmless and fever between 41 and 42 degrees Celsius is only harmful if sustained for a longer period of time. Fever by itself does not cause seizures in adults without pre-existing seizure disorders (but it can provoke seizures in adults with pre-existing seizure disorders). External cooling methods are not recommended because of the secondary increase in metabolism and discomfort as the body tries to achieve the target temperature. And yes, it seems our immune system is more effective in higher temperatures.

Sirens to Scrubs: Fever-Phobia

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

November 29, 2019November 20, 2020

Quiz 52, november 29th, 2019

Welcome to the 52nd FOAMed Quiz.

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Drug reaction with eosinophilia and systemic symptoms, also known as DRESS syndrome, is a rare but severe condition which should be in the differential diagnosis of every sick patient presenting to the Emergency Department with a rash.

Which of the following is true about DRESS syndrome?

A: Symptoms generally occur within 72-hours after exposure to the drug

B: Carbamazepine is the drug most commonly associated with this condition

C: Diseases like Stevens-Johnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis and erythroderma are easy to discriminate from DRESS syndrome

D: As the name suggests, eosinophilia is present in at least 75% of patients with DRESS syndrome

Reveal answer

The correct answer is B

Justin Morgenstern covered DRESS syndrome on First10EM.

Symptoms of DRESS syndrome generally appear within 2-6 weeks after starting the drug.

Carbamazepine is the drug most commonly associated with this condition and although leukocytosis is very common, eosinophilia is only present in 30% of patients.

There is no golden standard for diagnosis, it is based on a combination of diagnostic criteria. The most important takeaway from this post is to think about DRESS syndrome in patients with a rash with at least one systemic and one hematologic symptom.

DRESS syndrome – a rapid review

Question 2

You see a five year old patient with a dislocated distal radius fracture, and you want to provide analgesia. You wonder if you should give fentanyl or ketamine intranasal (IN). Recently the PRIME trial was published addressing this topic.

What did the results of this paper tell us?

A: IN fentanyl was superior to IN ketamine in providing analgesia

B: IN fentanyl was inferior to IN ketamine in providing analgesia

C: IN ketamine was non inferior to IN fentanyl in providing analgesia

D: IN ketamine leads to less adverse events compared to IN fentanyl

Reveal answer

The correct answer is C

Simon Carley covered this paper on St. Emlyns last week.

This relatively small study ( 90 patients) is a randomized controlled trial designed to show non inferiority between IN fentanyl and IN ketamine for analgesia. The two treatments were similar in reducing pain score at 15, 30 en 60 minutes post administration. There were more adverse effect in the ketamine group, although they were minor.

JC: IN Fentanyl vs Ketamine for analgesia in PED. St Emlyn’s

Question 3

Massive Transfusion Protocols (MTPs) differ between hospitals. The ratio PRBC to FFP to Platelets- ratio generally differs between 1:1:1 and 2:1:1. Which statement is true about the evidence behind this in trauma patients?

A: Evidence suggests a 2:1:1 ratio is superior to 1:1:1 ratio in reducing mortality at 30 days

B: Evidence suggests a 1:1:1 ratio is superior to 2:1:1 ratio in reducing mortality at 30 days

C: Evidence suggests a 2:1:1 ratio is superior to 1:1:1 ratio in decreasing death from exsanguination at 24 hours

D: Evidence suggests a 1:1:1 ratio is superior to 2:1:1 ratio in decreasing death from exsanguination at 24 hours

Reveal answer

The correct answer is D

Last week this systematic review was discussed at The Trauma Professional’s Blog.

Most of the evidence comes from the PROPPR trial (2015) which was broadly covered by lots of FOAMed blogs like RebelEM and EMNerd.

Massive Transfusion: What’s The Right Ratio?

Question 4

A known cirrhotic patient comes in with hematemesis. He is hemodynamically unstable, you start with Packed Red Blood Cells (PRBCs) and prepare to intubate. Which of the following three additional treatment options has shown benefit in reducing mortality?

A: Octreotide

B: A Proton Pump Inhibitor (PPI)

C: Antibiotics (3rd generation cephalosporin)

Reveal answer

The correct answer is C

RebelEM covered Decompensated Liver Disease last week in their latest Rebel Core Cast.

There is no proven benefit of octreotide or PPIs in these patients. However, administration of antibiotics (ceftriaxone) has shown benefit with an NNT for preventing one death of 22! Keep in mind this evidence comes from 12 trials of which only one was placebo controlled (the others were antibiotics vs no treatment).

REBEL Core Cast 22.0 – Decompensated Liver Disease

Question 5

In which type of hyponatremia is treatment with oral Urea indicated?

A: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

B: Cerebral Salt wasting

C: Primary polydipsia or malnutrition

D: Cortisol deficiency

Reveal answer

The correct answer is A

Josh Farkas covered treatment of hyponatremia in SIADH with oral Urea this week.

‘’Oral urea functions as an osmotic diuretic (an “aquaretic”). Ingested urea will be completely excreted by the kidneys. It is excreted along with water, so the ultimate effect is removal of water.’’’

PulmCrit- Controlled aquaresis: Management of hypervolemic or euvolemic hyponatremia with oral urea

This quiz was written by Eefje Verschuuren, Kirsten van der Zwet, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen