Quiz 112, April 23th, 2021

Welcome to the 112th FOAMed Quiz.

 

Case courtesy of Dr Naqibullah Foladi, Radiopaedia.org, rID: 73139

Question 1

Direct needle decompression (ND) is known to be a possible lifesaving intervention in patients with tension pneumothorax. Current guidelines recommend different locations for this decompression. Preferred locations are the 2nd intercostal space midclavicular line (ICS2-MCL) and the 4th-5th intercostal space at the anterior axillary line (ICS4/5-AAL).

Chest wall thickness (CWT) of the patient and needle length both play a role in the success rate of ND.

The primary outcome in this study was the CWT at ICS2-MCL and ICS4/5-AAL in normal weight (BMI <25), overweight (BMI 25-30) and obese patients (BMI >30) using Point of Care Ultrasound (POCUS). Their secondary outcome was the hypothetical failure rates of ND for these locations, based on standard catheter lengths (45mm and 50mm).

What did the authors find concerning CWT for both locations in overweight and obese patients?

A: CWT in ICS2-MCL was significantly thinner than ICS4/5-AAL

B: CWT was not significantly different in ICS2-MCL compared to ICS4/5-AAL

C: CWT in ICS2-MCL was significantly thicker than ICS4/5-AAL

The correct answer is A.

This prospective, multicenter, observational study was covered by Benjamin Gerritsen on REBEL EM this week.

CWT in ICS2-MCL was significantly thinner than ICS4/5-AAL in both overweight (p<0.001) and obese patientes (p=0.016) but not in patients with a normal BMI.

Hypothetical failure rates for 45mm and 50mm catheters were 2.5% and 0.8% for ICS2-MCL and 6.2% and 2.5% for ICS4/5-AAL (p=0.016 and -=0.052 respectively).

The authors concluded that, in overweight and obese patients, ICS2-MCL is the preferred anatomical location for ND in tension pneumothorax compared to the ICS4/5-AAL when using standard large bore catheters (45mm and 50mm).

Optimal Needle Position for Decompression of Tension Pneumothorax

Source image: www.pixabay.com

Question 2

Your 62 year old patient comes in with gradually worsening mental status changes, lead-pipe rigidity, hyperthermia and tachycardia. She uses medication prescribed by her psychiater, but it remains unclear what medication exactly.

Your differential diagnosis includes neuroleptic malignant syndrome (NMS) and serotonin syndrome (SS).

Which of the following clinical features point in the direction of NMS instead of SS?

A: Mental status changes

B: Lead-pipe rigidity

C: Hyperthermia

D: Tachycardia

The correct answer is B.

NMS was covered on the Internet Book of Critical Care last week.

Both patients with NMS and patients with SS present typically with mental status changes, hyperthermia and tachycardia. However, NMS leads to lead-pipe rigidity, whereas SS typically causes clonus and hyperreflexia.

IBCC – Neuroleptic Malignant Syndrome (NMS)

Source image: www.emdocs.net

Question 3

The use of Droperidol was largely abandoned in 2001 due to concerns about QT-prolongation and Torsade de Pointes. However, recent data supports it’s safety and effectiveness in the treatment of acute agitation and nausea.

These two Australian papers (paper 1, paper 2) covered the safety of Droperidol. A total of 209 patients older than 65 years receiving 2.5, 5 or 10 mg intramuscularly for agitation control were followed. 9 adverse events were reported. What was the most common adverse event?

A: Hypoxia

B: Airway obstruction

C: QT-prolongation

D: Hypotension

The correct answer is D.

AliEM covered these papers (paper 1, paper 2) last week.

In these cohorts of elderly agitated patients, adverse events were rare. The most common adverse event was hypotension (6/9). No patients developed Torsades de Pointes. Droperidol appears to be both effective and safe in agitated adults ≥ 65 years of age for the treatment of agitation.

Droperidol for Agitation in Older Adults in the Emergency Department

Source image: www.intranasal.net

Question 4

The use of intranasal midazolam is pretty convenient in the convulsing patient. At least for emergency care providers. This recently published retrospective pre-hospital study assessed the effectiveness of intranasal midazolam (0,1 mg/kg) versus alternative routes of administration (IV, IM) in children ≤14 years with a seizure. The primary outcome was need for redosing.

What did the authors find?

A: Intranasal midazolam was associated with lower rates of redosing compared to intravenous or intramuscular midazolam

B: Intranasal midazolam was associated with equal rates of redosing compared to intravenous or intramuscular midazolam

C: Intranasal midazolam was associated with higher rates of redosing compared to intravenous or intramuscular midazolam

The correct answer is C.

JournalFeed covered the paper last week.

Redosing of midazolam occurred in 25% (116/461) of patients receiving intranasal midazolam initially compared to 14% (222/1573) of patients receiving alternative routes. It seems intranasal administration is (at least in this dosage) less effective compared to intravenous and intramuscular administration of midazolam in children with a seizure.

Case courtesy of David Puyó, Radiopaedia.org, rID: 22317

Question 5

Your 67 year old patient presents with a renal colic. CT shows a 0.7 cm stone in the right distal ureter. POCUS and CT show moderate hydronephrosis on the right side. In addition to analgesics, you decide to start tamsulosin (an alpha blocker).

Which of the following characteristics make tamsulosin more likely to be beneficial in this patient?

A: Hydronephrosis

B: Location of the stone in the proximal ureter

C: The size of the stone is > 5 mm

The correct answer is C.

Taming the SRU covered the treatment of renal colic this week.

The role of alpha blockers is up for debate in renal colic. Especially patients with a stone > 5 mm may benefit from an alpha blocker in terms of time to stone passage, episodes of pain, hospital admissions and surgical intervention. This effect is irrespective of stone location and the existence of hydronephrosis.

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

Reviewed and edited by Rick Thissen

Quiz 111, April 16th, 2021

Welcome to the 111th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Your 64-year old male patient was brought in by EMS with a decreased level of consciousness. He is hypotensive and EMS reports that they found an empty bottle of doxepin, a tricyclic antidepressant (TCA).

Which of the following ECG abnormalities is atypical for a TCA overdose?

A: Prominent R wave in aVR

B: Widened QRS segment

C: Diffuse T-top inversion

D: QTc prolongation

The correct answer is C

TCA overdose was covered on Canadiem this week.

Sinus tachycardia is likely to appear first due to the anticholinergic effects. Widening of the QRS segment is typical and often seen in TCA overdose. It is an important predictor of the clinical course, as opposed to drug levels. A QRS width of >100 ms carried a 33% risk of seizures in this previous study while a QRS width >160 ms carried a 50% risk of dysrhythmias. QTc prolongation >430 ms and a prominent R wave in aVR (R/S ratio >0.7) are also frequently seen.

Inverted T-waves are atypical for TCA overdose and can be seen in various conditions.

Vicious Cycles: Management of the Tricyclic Antidepressant Overdose

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

Question 2

Your patient comes in with acute onset headache and vomiting since 2 hours. Which of the following comorbidities may decrease the accuracy of the CT-scan for sub arachnoid hemorrhage (SAH)?

A: Anemia

B: Hypertriglyceridemia

C: Diabetes mellitus

D: Hemochromatosis

The correct answer is A

EMOttawa covered SAH this week.

Anemia will make acute blood less hyperdense on CT of the brain and intracerebral hemorrhage more difficult to appreciate. In patients polycythemia, for example, CT imaging may demonstrate hyperdense cerebral vasculature.

EMOttawa Podcast Episode 3: Thunderclap Headache

Source image: www.dontforgetthebubbles.com

Question 3

A 13 year old boy visits the ED after twisting his right foot during football. The X-ray is shown above. You wonder whether you are looking at a zone 1 fracture of the fifth metatarsal (pseudo Jones) or a normal apophysis.

Which of the following statements is correct and may help you distinguish between the two?

A: The apophysis of the base of the fifth metatarsal will not appear before 14 years of age in boys, so this has to be a fracture

B: There is no apophysis at the base of the fifth metatarsal, so this has to be a fracture

C: A fracture line through the base of the fifth metatarsal will run transversely, while the apophysis will run longitudinally, so this is not a fracture

D: A fracture line through the base of the fifth metatarsal will run longitudinally, while the apophysis will run transversely, so this has to be a fracture

The correct answer is C

Don’t forget the bubbles covered foot and toe injuries last week.

The apophysis of the base of the fifth metatarsal is often mistaken for a zone 1 fracture. The apophysis appears at about 12 years in boys. A fracture line through the base of the fifth metatarsal will run transversely, while the apophysis will run longitudinally.

An irregular apophysis at the base of the fifth metatarsal is seen in apophysitis. This self limiting condition is called Iselin disease.

Source image: www.emdocs.net

Question 4

Your 52 year old patient comes in after accidentally ingesting a bone while eating a chicken wing. There is a mild stridor, but no respiratory distress and a saturation of 98%. You administer nebulized lidocaine and plan to retrieve the foreign body with Magill or sponge forceps during laryngoscopy. A GlideScope® and standard Macintosh laryngoscope (size 3 blade) are available. Which one is most effective in retrieving the foreign body according to available evidence?

A: GlideScope®

B: Macintosh

C: Both are equally effective

The correct answer is B

EMDocs covered upper airway foreign bodies last week.

A 2012 paper by Je et al. covered this topic. 28 first year emergency residents with little prior airway management experience extracted hypopharyngeal foreign bodies using a Macintosh laryngoscope and GlideScope®. The success rate in relation to time to extraction was significantly higher with the Macintosh laryngoscope than with the GlideScope® (p < 0.001).

I guess the difficulty in foreign body extraction using a GlideScope® may be the hyperangulated blade. I wonder how standard geometry blade video laryngoscopy holds up against direct laryngoscopy.

Source image: www.pixabay.com

Question 5

Back to basics: resuscitation fluids.

The most commonly used fluid is still 0.9% Sodium Chloride. But do you know what is being administered to the patient?

What is the pH of 0.9% Sodium Chloride?

A: 5.5

B: 6.4

C: 7.4

D: 8.2

The correct answer is A.

Resuscitation fluids were discussed by ALiEM this week.

The differences between them, mainly based on the different electrolyte amounts, were shown for the most commonly used; 0.9% Sodium Chloride, Lactated Ringer’s solution,
Plasma Lyte A and blood.

Is Lactated Ringer’s Solution Safe for Hyperkalemia Patients?

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

Reviewed and edited by Rick Thissen

Quiz 110, April 9th, 2021

Welcome to the 110th FOAMed Quiz.

Source image: www.tamingthersu.com

Question 1

Your 27 year old patient presents with an anterior shoulder dislocation. You are in doubt whether reduction was successful. You use POCUS to assess the position of the humeral head.

On POCUS (posterior view) the humeral head appears to be deep to the glenoid fossa. What does that mean?

A: Reduction was successful

B: Anterior dislocation persists

C: There is a posterior dislocation

The correct answer is B.

Taming The SRU discussed ultrasound in shoulder dislocation this week.

POCUS has a high sensitivity (99.1%) and specificity (99.9%) for shoulder dislocation. A major advantage is the possibility of real-time reduction confirmation during sedation.

Standard approach is to place the probe posterior and transverse. In case of anterior shoulder dislocation, the humeral head projects deep to the glenoid fossa. In posterior dislocation, the humeral head is superficial to the glenoid.

Source image: www.journalfeed.org

Question 2

This recently published case series is about the reverse valsalva manoeuvre in 11 patients. The reversed valsalva manoeuvre does not require assistance (like the modified valsalva manoeuvre) or IV access (adenosine, diltiazem).

The patient starts by exhaling without forcing in sitting position, followed by pinching the nose and closing the mouth, finished by inhaling against the self made resistance for ten seconds.

Which of the following statements is true?

A: SVT was terminated in 10% of patients

B: SVT was terminated in 50% of patients

C: SVT was terminated in 90% of patients

The correct answer is C

Journal feed covered this small observational trial about the reverse valsalva manoeuvre this week.

The reverse valsalva manoeuvre increases vagal tone, decreases sympathetic activity and seems to be a very simple, patient friendly and safe technique which can be performed autonomously by patients at home. SVT was terminated by this manoeuvre in 10/11 (91%) of patients, including 4 patients who already tried the modified valsalva manoeuvre.

Future studies like randomised controlled trials should be performed in order to see what the true efficacy of this method is.

Source image: www.aliem.com

Question 3

An otherwise healthy 55-year-old woman visits your emergency department with an increasingly painful swollen finger. You think she has flexor tenosynovitis (FTS). 

The Kanavel signs show a high sensitivity (91.4% – 97.1%) but a low specificity (51.3% – 69.2%) in detecting FTS.

Which 2 physical examination findings, combined with tenderness along the flexor tendon sheath and fusiform swelling, constitute the Kanavel signs?

A: Finger maintained in passive flexion

B: Finger maintained in passive extension

C: Pain elicited with passive flexion

D: Pain elicited with passive extension

The correct answers are A & D.

ALiEM covered FTS this week.

FTS is an acute inflammation of the synovial space of a flexor tendon most often caused by Staphylococcus aureus (40-75%). Typically, patients cannot fully extend the finger and it is usually red, warm and swollen. Passive extension is painful. Drainage is required because the tendon sheaths are connected to other deep spaces of the hand and thus inflammation can spread quickly.

SplintER Series: Kitty Nibble: A Case of the Sausage Finger

Source image: www.emdocs.net / www.LITFL.com

Question 4

Lewis lead placement of ECG electrodes is done by:
Placing the Right Arm (RA) electrode on the manubrium
Placing the Left Arm (LA) electrode over the 5th intercostal space on the right sternal border
Placing the Left Leg (LL) electrode over the right lower costal margin

In what case might Lewis lead placement help you?

A: Detecting an epsilon wave in Arrhythmogenic Right Ventricular Dysplasia (ARVD)

B: Detecting flutter waves in atrial flutter

C: Detecting PTa depression in pericarditis

D: Increase accuracy of QT-interval

The correct answer is B

EMDocs covered the Lewis ECG last week.

Lewis lead placement is used to detect atrial electrical activity better. It can be useful in observing flutter waves in atrial flutter and detecting P waves in wide complex tachyarrhythmia.

Question 5

Source image: https://hqmeded.com

Necrotizing fasciitis is a life-threatening and limb-threatening condition. Which of the following statements about the clinical presentation and diagnosis of necrotizing fasciitis is true?

A: About 80% of patients present with fever

B: Early skin findings include edema and purple discoloration

C: The sensitivity of ultrasonography for finding gas in the skin is only 30%

D: The Laboratory Risk Indicator for Necrotizing fasciitis (LRINEC) score is an accurate tool to differentiate necrotizing fasciitis from other soft tissue infections

The correct answer is C.

Necrotizing fasciitis was covered in EMCrit’s Internet Book of Critical Care (IBCC) this week.

In patients with necrotizing fasciitis, fever is present in only 25-40% of cases at admission.
Early findings of the skin include edema and erythema (cellulitis like), but severe pain that extends beyond the skin findings is probably the most useful clinical finding.

Imaging studies (POCUS, CT, MRI) can show subcutaneous gas and abnormal fascia (thickening, filled with fluid, fat stranding).

The LRINEC score should not be used. External validation studies showed poor sensitivity and specificity.

Probably the most important thing to remember is that surgical exploration should be performed if necrotizing fasciitis is suspected based on clinical findings. Lab results and imaging studies are not accurate enough to exclude necrotizing fasciitis.

Necrotizing fasciitis

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

Reviewed and edited by Rick Thissen

Quiz 109, April 2nd, 2021

Welcome to the 109th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

An 11 year old boy presents to the ED after he fell off his bike. He complains about abdominal pain. He is hemodynamically stable. You wonder what the chance is this boy has intra-abdominal injury (IAI) despite a negative Focused Assessment with Sonography for Trauma (FAST).

What is the posttest (post FAST) probability of IAI according to this recently published systematic review?

A: 1%, IAI is very unlikely

B: 3%, IAI is unlikely, but can be missed

C: 9%, IAI is still a possibility, clinical suspicion warrants further testing

D: 20%, FAST is not useful

The correct answer is C.

This systematic review included a total of 2135 patients, which found FAST had pooled sensitivity of 35%, specificity 96% for IAI.

The results from FAST examinations for IAI showed a pooled sensitivity of 35%, specificity of 96%, LR+ of 10.84, and LR- of 0.64. A positive FAST posttest probability for IAI (63%) and a negative FAST posttest probability for IAI (9%). A positive FAST warrants imaging. A negative FAST does not exclude IAI.

Case courtesy of Dr Matthew Lukies, Radiopaedia.org, rID: 51249

Question 2

Your 75 year old female patient presents after a fall on the right hip. The X-ray shows no signs of fractures, but your patient is not able to mobilise. You know a fracture of the femoral neck can be missed on conventional imaging, but what about other imaging modalities?

Which of the following imaging modalities does not have a sensitivity of 100% (or close to a 100%) according to this paper?

A: CT

B: MRI

C: Ultrasound

The correct answer is A

Both ultrasound and MRI have a sensitivity of 100% for hip fractures . Ultrasound findings include joint effusion, hematoma and fracture line. The sensitivity of CT is about 87 percent.

SplintER Series: A Case of Hip Pain

Source image: www.rebelem.com

Question 3

Ketamine is frequently used in the ED. The standard analgesic dose is 0.1 to 0.3 mg/kg (that is of ketamine, not esketamine). Of course, we occasionally witness neuropsychiatric side effects (like hallucination, agitation).

Which of the following can reduce the rate of these neuropsychiatric side effects?

A: Rapid administration (< 2 minutes)

B: Administration over a short infusion (15-30 minutes)

C: Increasing the dose to 0.6 mg/kg

D: Let the patient listen to heavy metal

The correct answer is B

The NuEM blog covered this paper about Ketamine this week.

A rapid administration (push dose) and higher subdissociative dose increase the chance of neuropsychiatric side effects. I guess listening to heavy metal will have the same effect.

To reduce the rate of neuropsychiatric side effects of analgesic dose ketamine you can slow down the administration. One way to do that is to put the ketamine in a bag of 100 cc NS and administer over 20 minutes.

Source image: www.emdocs.net

Question 4

Which of the following underlying conditions lead to a direct (conjugated) hyperbilirubinemia?

A: Crigler Najjar syndrome

B: Dubin Johnson syndrome

C: Gilbert syndrome

D: G6PD-deficiency

The correct answer is B

EMDocs covered adult jaundice this week.

In Crigler-Najjar syndrome, there is a defect in conjugation of bilirubin and glucuronic acid within hepatocytes, leading to indirect hyperbilirubinemia. Gilbert syndrome is caused by a mutation in the same gene, but unlike Crigler-Najjar syndrome, is benign. G6PD deficiency leads to hemolysis, thus leading to indirect hyperbilirubinemia as well.

Dubin-Johnson syndrome is caused by a defect in the ability to secrete conjugated bilirubin into the bile, leading to direct hyperbilirubinemia. It is usually asymptomatic.

Source image: www.orthobullets.com

Question 5

Your 76 year old patient is admitted after a fall and a fracture of the left femoral neck. About 24 hours after the fall he develops severe respiratory distress and a right hemiparesis. He did not have surgery yet. An X-ray of the chest and CT of the lungs, chest and brain show no obvious cause. The diagnosis fat embolism syndrome is made.

Which of the following treatment options is most widely accepted?

A: Corticosteroids

B: Correction of the fracture

C: Heparin

The correct answer is B

BrownEM covered fat embolism syndrome last week.

The mainstay of treatment of fat embolism syndrome is supportive care. However, early correction of the fracture is considered wise since it is likely to stop formation of new fat emboli.

Although inflammation is thought to have a roll in the development of fat embolism syndrome, there is not enough evidence to support its use. Heparin does not seem to be beneficial either, although it may increase intravascular lipid breakdown.

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

Reviewed and edited by Rick Thissen

Quiz 108, March 26th, 2021

Welcome to the 108th FOAMed Quiz.

 

Source image: https://pemplaybook.org/

Question 1

Your 7-year-old patient fell backwards on her outstretched left hand and is now complaining of pain in her elbow. You order an X-ray of her left elbow.

Which of the following statements about pediatric elbow X-ray is true?

A: The anterior humeral line should pass through the posterior third of the capitellum

B: A sail sign can indicate an occult supracondylar fracture

C: The capitellum is the last ossification centre to appear

D: An oblique view is useful when suspicion for a supracondylar fracture is high

The correct answer is B.

ALiEM covered the pediatric traumatic elbow X-ray in their EMRad series.

The anterior humeral line should pass through the middle third of the capitellum. An anterior humeral line passing through the anterior third of the capitellum can be normal, however, in children < 4 years of age.

A sail sign is an excessively prominent anterior fat pad and is (like a posterior fat pad) considered pathologic.

There are six ossification centers in the elbow. If one is missing or prematurely present you should consider a fracture. The mnemonic CRITOE is used for the order in which these ossification centers appear: capitellum – radial head – internal (medial) epicondyle – trochlea – olecranon – external (lateral) epicondyle.

Oblique views allow for better visualization of the radiocapitellar joint, medial epicondyle, radioulnar joint, and coronoid process.

EMRad: Radiologic Approach to the Pediatric Traumatic Elbow X-ray

Case courtesy of Dr Maulik S Patel, Radiopaedia.org, rID: 20542

Question 2

A 44-year-old woman presents to the emergency department with persistent abdominal pain. The pain is located in the upper right quadrant. She states to have had similar symptoms before, but then they were self-limiting. POCUS reveals pericholecystic fluid and gallstones. The wall looks thickened.

Which of the following statements is true?

A: Wall thickness up to 5 mm is considered normal

B: Wall thickening and pericholecystic fluid are the most sensitive US findings in acute cholecystitis

C: The posterior wall may appear falsely thickened because of posterior acoustic enhancement

The correct answer is C.

This week ultrasound for suspected acute cholecystitis was discussed on NUEM blog.

POCUS by EM physicians has been shown to be very sensitive (82-91%) and specific (66-95%) for diagnosing biliary pathology.

The most sensitive US finding in acute cholecystitis is the presence of cholelithiasis in combination with the sonographic Murphy sign. Both gallbladder wall thickening (> 3 mm) and pericholecystic fluid are secondary findings.

Wall thickness is best measured on the anterior wall. Posterior gallbladder wall thickness is frequently more unreliable due to gallstones, intestinal loops or posterior acoustic enhancement.

 

Source image: www.pixabay.com

Question 3

The HEART Pathway consists of History, ECG, Age, Risk factors (HEAR) and serial troponins to identify those who most likely do not have ACS. So, to follow the pathway correctly, you need a troponin.

This recently published paper is about identification of very low-risk acute chest pain patients without troponin testing. The main goal was to measure the major adverse cardiac event (MACE) rate among patients with ≼1 HEAR scores and determine whether serial troponin testing is needed to achieve a miss rate <1%.

What do you think the authors found?

A: The HEAR score without troponin testing had a sensitivity of 81,8 percent for MACE at 30 days

B: The HEAR score without troponin testing had a sensitivity of 87,4 percent for MACE at 30 days

C: The HEAR score without troponin testing had a sensitivity of 97,8 percent for MACE at 30 days

D: The HEAR score without troponin testing had a sensitivity of 99,4 percent for MACE at 30 days

The correct answer is C

RebelEM covered the trial last week.

This was a preplanned secondary analysis of the HEART Pathway Implementation Trial.

447 patients had a HEAR score of ≤1.

The sensitivity was 97.8% for a HEAR score ≤1 without troponin and 99.4% for HEAR score ≤1 with troponin.

Risk stratifying algorithms without the need for biochemical tests sure are interesting. However, in this paper the sensitivity seems a tad low.

The HEAR Score: Does Very Low-Risk Acute Chest Pain Not Require Troponin Testing?

Source image: www.rcemlearning.co.uk

Question 4

Your 45 year old patient presents with abdominal pain which radiates to his back. His prior history of alcohol abuse and the high lipase in his blood make the diagnosis of pancreatitis.

This recently published review is about acute pancreatitis. The evidence of disease severity, fluid and nutrition management and risk reduction methods are summarised.

Which of the following statements is true about acute pancreatitis?

A: Gallstone disease and triglyceridemia are the two most common causes of acute pancreatitis

B: Cross sectional imaging (CT/MRI) are necessary for the definite diagnosis of acute pancreatitis

C: Enteral nutrition should be delayed at least 24 hours in pancreatitis

D: The BISAP score is the best and easiest score used for risk stratification in pancreatitis

The correct answer is D.

This week’s Spoon feed covered Acute Pancreatitis. 

The two most common causes of acute pancreatitis are gallstones (21-33%) and alcohol (16-27%). 

To diagnose acute pancreatitis 2 of the following criteria must be present: (1) Abdominal pain suggestive of pancreatitis, (2) serum amylase and/or lipase greater than 3 times the upper limit of normal, (3) cross sectional imaging (CT/MRI) findings consistent with acute pancreatitis. 

The APACHE II and Ranson score are cumbersome to calculate. The Bedside Index for Severity in Acute Pancreatitis (BISAP) score is based on 5 variables: BUN, impaired mental status, SIRS, age >60 years or radiographic evidence of pleural effusion within the first 24 hours of admission. This easy score gives an indication about mortality and the association of developing organ failure. 

Starting enteral nutrition within 24 hours of admission is favored because it decreases mortality and multi-organ failure. Use a low fat, soft diet.

Source image: www.rebelem.com

Question 5

The role of Point of Care Ultrasound in patients with Pulmonary Embolism (PE) remains controversial, especially in hemodynamically stable patients.

This paper is about cardiac ultrasound in suspected PE.

Which of the following findings on cardiac ultrasound was the most sensitive for PE according to the paper?

A: Tricuspid Annular Plane Systolic Excursion (TAPSE)

B: McConnell’s sign

C: Septal flattening

D: Right ventricular enlargement

The correct answer is A

BrownEM covered the paper last week.

In this study the sensitivity of focused cardiac ultrasound for pulmonary embolism in emergency department patients with abnormal vital signs was quite high. In patients with a heart rate of >110/min, the sensitivity was even 100%. However, the sensitivity quickly falls when the patient’s vitals signs are close to normal.

Of the cardiac ultrasonographic findings, TAPSE was the most accurate.

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

Reviewed and edited by Rick Thissen

Quiz 107, March 19th

Welcome to the 107th FOAMed Quiz.

 

Question 1

Source image: pixabay.com

Your 37 year old patient presents with hypertension, flushing and a tremor. During physical exam she makes a confused impression and you notice a tremor. She has a bipolar disease and uses fluoxetine. You suspect serotonin syndrome in this patient.

Which of the following statements about serotonin syndrome is true?

A: The clinical triad of serotonin syndrome includes mental state changes, autonomic dysfunction and neuromuscular abnormalities

B: The clinical triad of serotonin syndrome includes ophthalmoplegia, ataxia and confusion

C: The clinical triad of serotonin syndrome includes retinopathy, encephalopathy and deafness

The correct answer is A.

This week EMDocs covered the Serotonin Syndrome.

The clinical triad of the Serotonin Syndrome consists of mental state changes (anxiety, agitation, delirium, seizure or coma), autonomic dysfunction (hypertension, hyperthermia, tachycardia, diaphoresis, flushing and mydriasis) and neuromuscular abnormalities (such as hyperreflexia, clonus, myoclonus, tremor, hypertonia/rigidity).

Wernicke encephalopathy is classically characterised by ophthalmoplegia, ataxia and confusion. If a patient presents with retinopathy, encephalopathy and deafness, Susac Syndrome is a possibility.

EM@3AM: Serotonin Syndrome

Question 2

Source image: www.ultrasoundcases.info/

 

A 42-year-old woman who recently had a few teeth extracted visits the emergency room. She has a fever and a sore neck. Ultrasound shows a non compressible internal jugular vein. After a CT you determine that she has septic thrombophlebitis of the internal jugular vein (Lemierre’s syndrome). You start antibiotics.

Which bacteria is the most common cause of Lemierre’s syndrome and should therefore definitely be covered?

A: Streptococcus pyogenes

B: Fusobacterium necrophorum

C: Staphylococcus aureus

D: Eikenella corrodens

The correct answer is B.

This week Lemierre’s syndrome was discussed by Taming the SRU.

The disease pathway typically begins with oropharyngeal infection leading to inflammation within the wall of the jugular vein, leading to infected thrombus within the lumen, leading to soft tissue inflammation, leading to persistent bacteremia and eventually septic emboli.

The most common (but not the only) causative pathogen is the anaerobe Fusobacterium necrophorum.

Question 3

Source image: pemcincinnati.com

An 8-year-old child has been hit in the face with a football. His nose is painful, but doesn’t look deviated. On inspection you see a swelling of the right nasal septum that occludes almost the entire nostril.

Which of the following is the correct management?

A: Ice packs for several hours and start xylometazoline

B: Emergent drainage of the hematoma

C: Consultation with ENT doctor within a week

D: X-rays of the nasal bones

The correct answer is B.

This week, PedEMmorsels discussed nasal septal hematomas in children.

About 15% of children with a nasal fracture will have a septal hematoma. Despite being an uncommon condition, it can have far-reaching consequences. A septal hematoma can lead to necrosis, which in the long term can lead to saddle nose deformity. It is therefore a clinical diagnosis requiring urgent surgical intervention.

Nasal Septal Hematoma in Children

Question 4

Source image: pixabay.com

In your emergency room, a middle-aged man with no relevant medical history presents with seizures. Family tells you that after swimming in a lake last week (on holiday in Florida), he became increasingly ill. He has a high fever and a headache. This morning he also started vomiting.

Which of the following exotic-sounding pathogens really exist?

A: Brain-eating amoeba

B: Liquor drinking bacteria

C: Nerve devouring parasite

D: Seizure worm

The correct answer is A.

NuEM covered various pathogens that can be acquired in, around or through water this week.

One of these is Naegleria fowleri. This is a protozoa, also known as the Brain-eating Amoeba. It occurs in warm fresh water. It reaches the brain through the olfactory nerve and causes acute hemorrhagic meningoencephalitis. It is rare but has a high fatality rate of almost 98%. Treatment includes miltefosine, an anti-leishmania drug.

 

Question 5

Source image: www.neurologyadvisor.com

With the emergence of endovascular treatment of acute ischemic stroke, the question arises which role systemic thrombolysis still has. Previous research shows the role of systemic thrombolysis in patients eligible for endovascular treatment is limited.

Last month, the DEVT trial was published.

In this trial, patients > 18 years of age presenting within 4.5 hours of ischemic stroke symptom onset, eligible for IV alteplase treatment and with cerebral vascular occlusion on CT angiography (CTA) or magnetic resonance angiography (MRA) of the intracranial internal carotid artery or middle cerebral artery (first segment) were randomised to either systemic thrombolysis and endovascular treatment (control) or endovascular treatment alone.

The primary outcome was the proportion of patients achieving a modified Rankin Scale (mRS) 0-2 assessed at 90 days after randomization.

What did the trial show?

A: The trial showed endovascular treatment alone to be superior to systemic thrombolysis and endovascular treatment in achieving a mRS of 0-2 at 90 days

B: The trial showed endovascular treatment alone to be inferior to systemic thrombolysis and endovascular treatment in achieving a mRS of 0-2 at 90 days

C: The trial showed endovascular treatment alone to be non-inferior to systemic thrombolysis and endovascular treatment in achieving a mRS of 0-2 at 90 days

The correct answer is C

RebelEM covered the DEVT trial last week.

235 patients were randomised to either standard care (systemic + endovascular treatment) or intervention (endovascular treatment only).

An mRS of 0-2 was achieved in 54.3% (endovascular alone) versus 46.6% (combination). The non-inferiority margin (-10%) was met. The study was stopped early due to pre-planned interim analysis that demonstrated non-inferiority.

Unfortunately, only 25% of the planned enrollment was completed.

There are additional ongoing trials that will add to the available evidence on this topic.

The DEVT + SKIP Trials: Does Systemic Thrombolysis Prior to Endovascular Treatment Improve Outcomes in Large Vessel Occlusion Strokes?

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

Reviewed and edited by Rick Thissen

Quiz 106, March 12th, 2021

Welcome to the 106th FOAMed Quiz.

 

Case courtesy of Dr Piotr Gołofit, Radiopaedia.org, rID: 46128

Question 1

A 74-year-old man presents to the ED with a painful left arm after a fall. The X-ray shows a comminuted humeral shaft fracture.

What is the most frequently damaged nerve in this injury and which clinical finding corresponds?

Nerve:

A: Radial Nerve

B: Ulnar Nerve

C: Median Nerve

Finding:

1: Claw hand

2: Ape hand

3: Wrist drop

The correct answer is A – 3.

This week ALiEM discussed the humeral shaft fracture.

The most commonly injured nerve, in about 12% of humeral shaft fractures, is the radial nerve. Most of these nerve injuries will recover spontaneously.

The radial nerve runs along the spiral groove of the humerus. It provides motor innervation to the extrinsic extensors of the wrists and hands; therefore radial nerve palsy can lead to a wrist drop.

SplintER Series: A Case of Arm Pain

Source image: www.pixabay.com

Question 2

West Nile Virus (WNV) is a mosquito-borne flavivirus and neuropathogen.

Which of the following statements is true about this virus?

A: 80% of cases are asymptomatic

B: The virus is indigenous to Africa only

C: Most human infections with WNV are due to human to human transmission

D: Available evidence supports aciclovir as an effective therapeutic agent

The correct answer is A

80% of cases are asymptomatic while 20% develop symptoms. The virus is indigenous to Africa, Asia, Europe, and Australia. Most human infections with WNV are due to mosquito bites and not due to interhuman transmission. Therapeutic agents that have been considered include IVIG, monoclonal antibodies, corticosteroids, and aciclovir. Data to support the use of these agents is lacking.

West Nile Virus

Source image: www.pixabay.com

Question 3

Previous trials such as the TRISS-trial, TRICC and TRICS-III-trial  demonstrated that a restrictive blood transfusion strategy was non-inferior to a liberal transfusion strategy in patients with septic shock, patients admitted to the ICU and patients undergoing cardiac surgery respectively.

The presence of anaemia in patients with acute coronary syndromes is associated with worse outcomes. For that reason, blood transfusions in patients with anemia and acute coronary syndromes are often performed.

The recently published randomized controlled REALITY-trial is about patients with acute myocardial infarction and a haemoglobin (Hb) between 7 and 10 g/dL during admission. The authors compared liberal (transfusion if Hb <10g/dL with target Hb >11g/dL) vs restrictive transfusion (transfusion if Hb <8 g/dL with target Hb >11g/dL) strategies in patients with acute myocardial infarction and anaemia.

Their primary outcome was 30 day MACE (composite of all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization prompted by ischemia).

What did the authors find?

A: MACE at day 30 occurred significantly less often in the liberal transfusion group compared to the restrictive transfusion group

B: MACE at day 30 was not significantly different between the liberal transfusion group compared and the restrictive transfusion group

C: MACE at day 30 occurred significantly more often in the liberal transfusion group compared to the restrictive transfusion group

The correct answer is B

The REALITY trial was covered by Celia Bradford on The Bottom Line this week.

A total of 668 patients were randomised (mean age 77 years, 57.8% male, 70% NSTEMI, 30% STEMI).

MACE at day 30 was not significantly different in the liberal transfusion group compared to the restrictive transfusion group.

REALITY

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

Question 4

Your 65-year-old patient presents with ongoing chest pain for 2 hours. Nitroglycerin did not bring any relief. His ECG is shown above.

Which of the following coronary arteries is likely to be occluded?

A: Right coronary artery (RCA)

B: Left circumflex artery (Cx)

C: Left anterior descending (LAD)

D: Left main coronary

The correct answer is C

De Winter’s T-waves were covered on dr. Smith’s ECG blog last week.

De Winter’s T-waves typically present as ST depression and peaked T waves in the precordial leads.

This pattern is seen in about 2% of acute LAD occlusions.

Source image: www.cdc.gov

Question 5

Most people know anthrax as a biological weapon (powdered letters).

Which of the following statements about anthrax is correct?

A: Overall mortality of anthrax is about 80%

B: Human-to-human transmission of anthrax is responsible for about 5% of inhalational anthrax cases

C: Gastrointestinal anthrax is a result from eating undercooked meat from an infected animal

D: Cutaneous anthrax presents as a disproportionately painful ulcerating vesicle

The correct answer is statement C.

This week’s EMdocs’ toxcard was about Bacillus anthracis.

Animals (usually cattle) are infected through spores which are found in soil and which are very resistant to environmental changes. Humans can be infected by four different routes of exposure. Human-to-human transmission is non-existent.

Cutaneous exposure is the most common (95%) by entering of spores through a superficial laceration. Other routes of exposure are injectional (associated with intravenous drug use), inhalational and gastrointestinal.

Inhalational and gastrointestinal anthrax have the highest mortality rates of up to 50-80%, cutaneous and injectional anthrax have lower mortality rates (5-30%).

Cutaneous anthrax presents as papules that become ulcerating vesicles. These lesions are usually painless.

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

Reviewed and edited by Rick Thissen

Quiz 105, March 5th, 2021

Welcome to the 105th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

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

What is the most appropriate next step?

A: Cervical X-ray and Lumbar Puncture

B: Spinal CT scan and surgical consultation for laminectomy

C: Start empirical intravenous antibiotics and order MRI

D: Start antibiotics and CT guided drainage

The correct answer is C

EMdocs discussed SEA this week.

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

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

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

Source image: www.pixabay.com

Question 2

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

What should be the answer?

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

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

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

The correct answer is C

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

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

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

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

Source image: slideplayer.com, published by Timothy Beasley

Question 3

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

Which Gustilo type matches the photo and description?

A: Type 1

B: Type 2

C: Type 3b

D: Type 4

The correct answer is B

Taming the SRU covered open fractures last week.

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

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

Question 4

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

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

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

What did the authors find?

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

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

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

The correct answer is C

First10EM covered the trial last week.

This is another negative trial on TXA.

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

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

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

Source image: www.pixabay.com

Question 5

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

Rinne’s test is positive on both sides.

Weber’s test lateralizes to the right.

Which of the following causes is most likely?

A: Otitis externa

B: Otitis media

C: Cholesteatoma

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

The correct answer is D

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

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

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

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

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

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

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

Reviewed and edited by Rick Thissen

Quiz 104, February 26th, 2021

Welcome to the 104th FOAMed Quiz.

 

Source image: www.rebelem.com


Question 1

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

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

What did the investigators find?

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

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

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

The correct answer is B

This paper was covered by StEmlyns, First10EM and FoamCast.

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

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

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

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


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

Question 2

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

A tear in which ligament is associated with this finding?

A: Lateral Collateral Ligament (LCL)

B: Medial Collateral Ligament (MCL)

C: Anterior Cruciate Ligament (ACL)

D: Posterior Cruciate Ligament (PCL)

The correct answer is C

NuEM discussed knee trauma this week.

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

Source image: www.pixabay.com

Question 3

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

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

A: Scombroid poisoning

B: Tetrodotoxin poisoning

C: Ciguatera (ciguatoxin poisoning)

The correct answer is C

EMDocs covered seafood poisoning this week.

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

Tetrodotoxin is the neurotoxin of pufferfish.

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

Source image: www.rebelem.com

Question 4

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

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

What did the authors find?

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

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

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

The correct answer is B

The paper was covered on JournalFeed last week.

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

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

Source image: www.pixabay.com

Question 5

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

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

What did the authors find?

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

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

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

The correct answer is C

The Bottom Line covered the paper last week.

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

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

HOT-ICU

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

Reviewed and edited by Rick Thissen

Quiz 103, February 19th, 2021

Welcome to the 103th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

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

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

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

What did the authors find?

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

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

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

The correct answer is A

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

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

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

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

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

Question 2

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

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

A: Trapezium

B: Trapezoid

C: Capitate

D: Hamate

The correct answer is C.

This week, DFTB discussed carpal injuries in children.

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

Source image: www.pixabay.com

Question 3

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

Which of the following is most commonly affected?

A: Unilateral posterior canal

B: Unilateral horizontal canal

C: Bilateral posterior canals

D: Bilateral horizontal canals

The correct answer is A

AliEM covered BPPD and its treatment last week.

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

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

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

Source image: www.pixabay.com

Question 4

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

Euglycemic ketoacidosis is quite often missed leading to delayed treatment.

Which of the following drugs can cause euglycemic ketoacidosis?

A: Metformin

B: Liraglutide

C: Sitagliptine

D: Canagliflozine

The correct answer is D

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

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

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

Diabetic Ketoacidosis

Source image: www.rebelem.com

Question 5

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

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

What did the authors find?

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

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

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

The correct answer is B

RebelEM covered the paper last week.

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

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

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

Tenecteplase for Thrombolysis of AIS?

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

Reviewed and edited by Rick Thissen