Quiz 144, February 11th

Welcome to the 144th FOAMed Quiz.

 

Question 1

Source image: http://brownemblog.com/

Which of the following techniques is most effective for reduction of a nursemaid’s elbow?

A: Hyperpronation of the lower arm

B: Supination of the lower arm and flexion of the elbow

C: Traction

The correct answer is A.

Radial head subluxation (RHS) was covered on NuEM last week.

Hyperpronation is associated with a higher rate of successful RHS reduction than supination and flexion. Traction is the injuries mechanism and is not considered a reduction technique.

Question 2

Patients on DOAC are at increased risk of major traumatic intracerebral bleeding compared to patients who don’t use anticoagulation. The risk of delayed bleeding after an initial negative CT of the brain may be a reason to admit patients and repeat a CT.

In our hospital, we generally dismiss asymptomatic patients on DOAC after mild traumatic brain injury (mTBI) and a negative CT, but in other places it seems to be practice to admit these patients and repeat a CT the following day.

In this Italian retrospective paper, 1426 patients on DOACs with mTBI were evaluated in the ED. 68.3% underwent a repeat CT after an initial negative CT and 24 hours of observation.

What was the rate of delayed intracerebral hemorrhage?

A: 35.4 percent of which 12.3 percent required neurosurgical intervention or died

B: 25.2 percent of which 8.4 percent required neurosurgical intervention or died

C: 8.6 percent of which 4.4 percent required neurosurgical intervention or died

D: 1.5 percent of which 0 percent required neurosurgical intervention or died

The correct answer is D.

The paper was covered on JournalFeed last week.

A total of 1426 patients taking DOACs were evaluated for an mTBI. Of these, 68.3% (916/1426) underwent a repeat CT after an initial negative CT and 24 h of observation, with a rate of delayed intracranial hemorrhage of 1.5% (14/916). None of the patients with delayed ICH at 24-h repeat CT required neurosurgery or died within 30 days.

Question 3

Source image: www.pixabay.com

Your 65 year old female patient comes in with altered mental status. She started using new medication from her psychiater yesterday.

She presents with abrupt altered mental status, hyperthermia (39.2 degrees Celsius), vomiting, myoclonus, tremor and mydriasis.

Which of the following diagnoses is most likely?

A: Neuroleptic Malignant Syndrome (NMS)

B: Serotonin Syndrome (SS)

C: Malignant Hyperthermia (MH)

The correct answer is B

Hyperthermic conditions in the psychiatric patient were covered on CanadiEM this week.

SS presents abrupt, whereas NMS has a more gradual onset. SS typically causes myoclonus, tremor and mydriasis, whereas NMS causes rigidity.

Malignant hyperthermia is typically caused by volatile anesthetic gasses or depolarizing muscle relaxants (succinylcholine).

Hyperthermic Conditions in the Psychiatric Patient

Question 4

Your patient presents to your ED 30 minutes after a suicide attempt by ingestion of a large amount of tablets. She does not appear ill and is alert.

In what case will activated charcoal not work?

A: Lithium intoxication

B: Tricyclic antidepressant intoxication

C: Barbiturate intoxication

D: Benzodiazepine intoxication

The correct answer is A.

SinaiEM covered activated charcoal last week.

Activated charcoal binds toxins preventing absorption, both initial or reabsorption via enterohepatic recirculation. It does not work well for electrolytes, alcohols and metals such as lithium.

Activated Charcoal in Brief

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

Reviewed and edited by Rick Thissen

Quiz 143, February 4th, 2022

Welcome to the 143th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

The discussion about normal saline versus balanced fluids in critically ill patients is ever ongoing. The 2018 SMART trial suggested a reduction of renal dysfunction in favor of balanced fluids. The 2021 BASICS trial did not find any difference in mortality between normal saline and balanced fluids.

The PLUS trial was recently published. 5037 critically ill (ICU) patients were randomized to either normal saline or Plasma-Lyte. The primary outcome was death from any cause within 90 days of randomization.

What did the authors find?

A: Mortality was significantly higher in the normal saline group

B: Mortality was significantly higher in the Plasma-Lyte group

C: Mortality was equal in both groups

The correct answer is C.

First10EM covered the PLUS trial last week.

There was no difference in the primary outcome of all cause mortality (21.8% vs 22.0%).

The ongoing saga of normal saline versus balanced fluids

Question 2

Source image: druglijn.be

Much can be said about the best induction agent for emergency endotracheal intubation.

The recently published EvK trial is about ketamine versus etomidate in emergency tracheal intubation.

801 critically ill inpatients requiring emergency intubation were randomly assigned to receive etomidate or ketamine for sedation prior to intubation.

The primary outcome was 7 day survival. Secondary endpoints included 28 day survival.

What did the authors find?

A: 7 day survival was significantly lower in the etomidate arm than in the ketamine arm

B: 21 day survival was significantly lower in the etomidate arm than in the ketamine arm

C: 7 day survival was significantly lower in the ketamine arm than in the etomidate arm

D: 21 day survival was significantly lower in the ketamine arm than in the etomidate arm

The correct answer is A.

The EvK trial was covered on JournalFeed this week.

The 7 day survival was significantly lower in the etomidate arm than in the ketamine arm (77.3% versus 85.1%). 28 day survival rates for the two groups were not significantly different (etomidate 64.1%, ketamine 66.8%).


Source image: www.thesgem.com

Question 3

A 49 year old, otherwise healthy, man visits your ED. He complains of a local red swollen left elbow. His vital signs are normal. You suspect septic olecranon bursitis.

According to this recently published retrospective cohort study, would it be appropriate to treat the patient with antibiotics only (without aspiration of incision and drainage)?

A: Yes, antibiotics alone is an appropriate approach

B: No, antibiotics alone only resolves the symptoms in 20 percent of patients

The correct answer is A.

This week Skeptic Guide to EM covered treatment of septic bursitis.

This retrospective study included 190 cases of septic olecranon bursitis over eight years time. 147 patients were discharged on empiric antibiotics (no aspiration or drainage), of which 134 had follow up data available. 88% of them had no need for further intervention and healed.

Source image: www.pixabay.com

Question 4

Vomiting and nausea are among the most frequently encountered and difficult to treat complaints in the emergency department.

Match the correct drug and mechanism of action.

A: Metoclopramide

B: Ondansetron

C: Erytromycin

D: Domperidon

 

1: D2-dopamine antagonist

2: Motilin receptor agonist

3: Central and peripheral dopamine receptor antagonist, 5-HT4 agonist, and a weak 5-HT3 antagonist

4: 5-HT3 antagonist

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

This week’s Taming the SRU blog was about gastroparesis, cyclic vomiting syndrome and cannabinoid hyperemesis syndrome.

Drugs that act as antagonists of D2-dopamine receptors have antiemetic properties, drugs that act as motilin receptor agonist or 5-HT4 agonist have prokinetic properties and drugs that act as 5-HT3 antagonist suppress the vomiting reflex.

Source image: www.litfl.com

Question 5

What is the name of the lead placement used to increase accuracy for detection of epsilon waves in arrhythmogenic right ventricular dysplasia (ARVD)?

A: Lewis lead placement

B: Fontaine lead placement

C: V4R lead placement

The correct answer is B.

LITFL covered Fontaine lead placement this week.

Fontaine bipolar precordial leads (F-ECG) can be used to increase the sensitivity of epsilon wave detection in ARVD.

Fontaine lead

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

Reviewed and edited by Rick Thissen

Quiz 142, January 21th, 2022

Welcome to the 142th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1
 
The Pediatric Emergency Care Applied Research Network (PECARN) developed a clinical decision rule (CDR) in identifying pediatric patients with a low-risk of intra-abdominal injury. The patient was deemed low risk if there was:

No evidence of abdominal wall trauma
A GCS > 13
No abdominal tenderness
No thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds
No history of vomiting afte the injury

In 11919 cases, the performance of the rule to detect the need for acute intervention was compared to clinical gestalt.

What did the authors find?

A: The derived clinical prediction rule had a significantly higher sensitivity, but lower specificity compared to clinical gestalt

B: The derived clinical prediction rule had a significantly higher specificity, but lower sensitivity compared to clinical gestalt

C: The derived clinical prediction rule had both a significantly higher sensitivity and a higher specificity compared to clinical gestalt

D: The derived clinical prediction rule had both a significantly lower sensitivity and a lower specificity compared to clinical gestalt

The correct answer is A.

This week RebelEM discussed the PECARN Blunt Abdominal Trauma rule.

The prediction rule had a higher sensitivity (97% vs 82.8%) but lower specificity (42.5% vs 78.7%) when compared to clinical gestalt. The negative predictive value of the prediction rule was 99.9%.

This clinical decision rule can be used to identify low-risk individuals and thereby decrease the use of CT. Keep in mind it is NOT a two-way tool. It does not determine individuals at high risk of intra-abdominal injury and who needs further imaging. It also needs external validation.

PECARN Blunt Abdominal Trauma: Is A Clinical Decision Instrument Better Than Clinician Gestalt?

Source image: www.pixabay.com

Question 2

A 76-year-old female presents with a sudden onset of vision loss presents to your ED. 

Can you match the case descriptions with the correct diagnosis?

Case descriptions:

A: Normal appearance of the eye, mild relative afferent pupillary defect, no associated headache, halo

B: Red eye, no relative afferent pupillary defect, associated headache, vomiting

C: Normal appearance of the eye, relative afferent pupillary defect, no associated headache, cherry red spot on fundoscopy

D: Normal appearance of the eye, a relative afferent pupillary defect, associated headache, elevated BSE

Diagnoses:

1: Giant cell arteritis

2: Central retinal artery occlusion

3: Retinal detachment

4: Acute angle closure glaucoma

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

This week emDOCS covered the differential diagnosis of central and peripheral causes of vision loss.

Source image: www.pixabay.com

Question 3

Which of the following clinical findings is not caused by the Bezold-Jarisch reflex?

A: Post myocardial infarction bradycardia

B: Vaso-vagal syncope

C: Bradycardia in the trauma patient with ongoing hemorrhage

D: Syncope due to ventricular fibrillation

The correct answer is D.

The cardiovascular effects of the Bezold-Jarisch reflex in trauma patients were recently discussed on Stemlyns.

The Bezold-Jarisch consists of bradycardia and hypotension due to vasodilation in response to stimuli detected in the cardiac ventricles through vagal afferent C fibers.

This seems counter-intuitive, especially in trauma patients. As hemorrhage continues, the volume of blood entering the ventricle diminishes. This is detected by the C-fibers and this triggers activation of the cardioinhibitory response and causes inhibition of sympathetic tone, hence the triad of signs.

So, if you see bradycardia in your trauma patient, assume the patient is very sick.

What is the Bezold-Jarisch Reflex and why do I care?! St Emlyn’s

Source image: www.first10em.com

Question 4

The effectiveness of intravenous lipid emulsion therapy in acute intoxications is widely debated.

Intoxication with which of the following drugs is least likely to respond to lipid emulsion therapy?

A: Metoprolol

B: Bupivacaine

C: Lamotrigine

D: Bleomycine

The correct answer is D.

Lipid emulsion therapy was covered on EMOttawa this week.

The exact mechanism of action of lipid emulsion therapy is unknown. However, it is assumed lipophilic drugs (of lipophilic toxins) are scavenged by intravenous lipids.

Bleomycin has a very low lipophilicity and is therefore not likely to respond to intravenous lipid therapy.

Intravenous Lipid Emulsion: The New Fad Diet

Source image: www.pixabay.com

Question 5

Your 55 year old patient presents with a beta blocker intoxication. He is in profound shock. You start iv fluids, vasopressors, calcium and insulin. 

What would be the correct dose of insulin in this case?

A: 0.1 U/kg

B: 0.2 U/kg

C: 0.5 U/kg

D: 1.0 U/kg

The correct answer is D.

Treatment of beta blocker and calcium antagonist intoxication was covered on Pediatric EM Morsels last week.

The correct dose of insulin in treatment of beta blocker intoxication is 1 U/kg.

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

Reviewed and edited by Rick Thissen

Quiz 141, January 14th, 2022

Welcome to the 141th FOAMed Quiz.

 

Source image: www.litfl.com

Question 1

The 2015 REVERT trial showed the modified Valsalva technique was more effective than standard Valsalva technique (without lifting the legs) as an early treatment for hemodynamically stable patients presenting with supraventricular tachycardia.

This recently published meta-analysis includes 4 studies (including the REVERT trial) about modified Valsalva versus standard Valsalva for cardioversion of stable supraventricular tachycardia in adults.

What did the review show?

A: The modified Valsalva technique is more effective than the standard Valsalva technique

B: The standard Valsalva technique is more effective than the modified Valsalva technique

C: Both techniques are equally effective

The correct answer is A.

The paper was covered on RebelEM last week.

The modified Valsalva technique was effective in 43.8% of cases, whereas the standard Valsalva technique was only effective in 16.0% of cases (NNT = 3.6).

To view a video about how to perform the modified Valsalva technique click here.

The Modified Valsalva Maneuver: Head Down, Legs Up

Source image: www.aliem.com

Question 2

What is the name of the set of criteria used to distinguish septic arthritis from transient synovitis in a child with an inflamed hip?

A: Sgarbossa criteria

B: Kocher criteria

C: Duke criteria

D: Hestia criteria

The correct answer is B.

PEMblog covered the Kocher criteria last week.

Hestia criteria are used to identify low-risk PE patients safe for outpatient treatment.

Duke criteria are for diagnosis of endocarditis.

Sgarbossa criteria are used to diagnose acute MI in patients with prior LBBB.

Question 3

Source image: pixabay.com

Your 20 year old patient presents after smoke inhalation. There was a fire in her living room and she couldn’t leave in time. She has no signs of inhalation injury, an oxygen saturation of 100% on a non rebreather mask but is severely tachypneic. Her heart rate is 130/min, blood pressure of 132/82 mmHg, cool extremities and a capillary refill time of 4 seconds. Her blood gas shows a pH of 7.14, bicarbonate of 14 mmol/L, lactate of 16 mmol/L and hypocarbia without hypoxia. Her carbon monoxide is 8%. Methemoglobin turns out to be 10%.

What is the most likely cause of these symptoms?

A: Carbon monoxide

B: Cyanide

C: Methemoglobinemia

D: Hydrazine

The correct answer is B.

Cyanide inhibits aerobic metabolism by binding to the binuclear heme center of cytochrome c oxidase (CcOX) in mitochondria.

High Anion Gap Metabolic Acidosis (AGMA), lactic >10 and normal pulse oximetry point in the direction of cyanide toxicity. A carbon mono-oxide level of 8% and a MetHB level of 10% are not likely to cause severe symptoms. Hydrazine (eg. rocket fuel) intoxication is very unlikely in this case.

Which of the following is not a treatment option in this case?

A: Methylene blue

B: Hydroxocobalamine

C: Amyl nitrite

D: Sodium thiosulfate

The correct answer is A.

CoreEM and PedEM Morsels covered cyanide toxicity last week.

In case of cyanide poisoning, hydroxocobalamine scavenges cyanide present in blood and forms cyanocobalamin (vitamin B12).

Amyl nitrite (inhalation) and sodium nitrite (intravenous) antagonize cyanide toxicity in part by oxidizing hemoglobin to methemoglobin, which then scavenges cyanide. Keep in mind iatrogenic methemoglobinemia can be dangerous, especially in case of co-intoxication with carbon monoxide.

Sodium thiosulfate acts as a sulfur donor in the conversion of cyanide to thiocyanate through rhodanese.

Methylene blue is used in case of methemoglobinemia.

Toxic Gas Exposure

Cyanide Poisoning in Children

Question 5

Sotrovimab is a monoclonal antibody that binds to a conserved epitope on the spike protein of SARS-CoV-2.

In the COMET-ICE trial 583 not severely ill adults in early stages of COVID-19 (≤5 days) with risk factors for progression of the disease were randomised to receive either Sotrovimab (500 mg IV over 1 hour) or placebo.

The primary outcome was hospitalisation for >24 hours or death from any cause up to 29 days after randomization.

What did the authors find?

A: Patients in the Sotrovimab group had a lower rate of hospitalisation compared to patients in the placebo group

B: Patients in the placebo group had a lower rate of hospitalisation compared to patients in the Sotrovimab group

C: The rate of hospitalisation was equal in both groups

The correct answer is A.

EMOttawa covered the COMET-ICE trial last week.

The primary outcome (hospitalisation for >24 hours or death from any cause) was met in 1 percent of cases in the Sotrovimab group and in 7 percent of cases in the placebo group. This was driven by the rate of hospitalisations, as only 1 patient in the entire study population died (placebo group).

It seems Sotrovimab is effective in preventing hospitalisation if administered early on to not (yet) severely ill COVID-19 patients with risk factors for disease progression.

Keep in mind this trial was funded by Vir Biotechnology and GlaxoSmithKline.

COMET-ICE Trial on Sotrovimab

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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 140, January 7th, 2022

Welcome to the 140th FOAMed Quiz.

 

Question 1

The MR CLEAN-NO IV trial was published last november. It is another trial about the benefit of treatment with alteplase in patients who qualify for endovascular therapy.

539 adult ischemic stroke patients with an NIHSS of ≥2 that were eligible for endovascular treatment (EVT) and IV alteplase, within 4.5 hours after symptom onset, were included. They were randomised to usual care (alteplase plus EVT) or EVT alone. The primary outcome was functional outcome (modified Rankin scale at 90 days). The outcome was analyzed for superiority and then for noninferiority.

What did the authors find (two correct answers)?

A: EVT alone was superior to alteplase followed by EVT

B: EVT alone was not superior to alteplase followed by EVT

C: EVT alone was non-inferior to alteplase followed by EVT

D: EVT alone was not non-inferior to alteplase followed by EVT

The correct answers are B and D.

RebelEM covered the MR CLEAN-NO IV trial last week.

Patients in the EVT-alone group had a median mRS of 3. Patients in the Alteplase + EVT group had a median mRS of 2.

EVT alone was both not superior and non-inferior compared to EVT plus alteplase.

MR CLEAN-NO IV: Endovascular Treatment for Stroke Compared to Alteplase Followed by Endovascular Treatment: No Difference, But Also Not Not Worse

Question 2

Source image: healio.com

You see a 6-year-old boy in your emergency department who complains of a funny feeling in his chest. This started during his soccer training an hour ago. On 12-lead ECG, you see a narrow-complex tachycardia of 205bpm. His BP is 110/70 mmHg. He appears comfortable and is neither tachypneic nor diaphoretic. He has no history of structural heart disease.

Of the following options, which is the most appropriate?

A: You carefully examine the 12-lead ECG for signs that indicate the presence of a bypass tract as this is a contra-indication for giving adenosine

B: You give adenosine (with pads for electrical cardioversion standby) 0.1 mg/kg whether you have reasons to think about a bypass tract or not

C: You treat him with electrical cardioversion (0.5-2J/kg) because adenosine is contra-indicated in children under 8

D: You search for an underlying etiology as sepsis or a toxidrome, as a narrow-complex tachycardia in children is nearly always a secondary phenomenon and responds poorly to cardioversion (high recurrence rate) if the primary condition remains untreated

The correct answer is B.

EMDocs’ pediatric small talk was about narrow complex tachyarrhythmia this week.

Nearly all children under 1 and most children under 8 have a bypass tract which can cause AVRT. Presence of a bypass tract is not a contra-indication to use adenosine if resuscitative equipment is readily available (low risk of conversion into ventricular fibrillation). Electrical cardioversion with 0.5-2J/kg is indicated when the patient is unstable. When cardioversion (chemical or electrical) fails due to immediate recurrence of the SVT, search for an underlying etiology.

Pediatric Small Talk – The Rhythm Is Gonna Get Ya’: Age Based Approach to Pediatric Narrow Complex Tachydysrhythmia

Question 3

Source image: tamingthesru.com

What type of fracture is shown in this image?

A: Le Fort 1

B: Le Fort 2

C: Le Fort 3

D: Le Fort 4

The correct answer is B.

Taming the SRU covered facial trauma last week.

‘’Le Fort I fractures are transverse fractures that separate the maxilla from the pterygoid plate and nasal septum.

Le Fort II fractures are pyramidal fractures that extend into the orbital floor and inferior orbital rim separating the central maxilla and hard palate from the rest of the face.

Le Fort III fractures, also known as craniofacial disjunction, cause mobility of the entire face.’’

Question 4

Source image: www.mdpi.com

You suspect a high intracranial pressure in your patient. He is too unstable for CT-scanning right now and you perform ocular ultrasound.

To assess for elevated intracranial pressure, the optic nerve sheath diameter (ONSD) should be measured at a fixed distance from the rim of the globe.

How many millimeters behind the rim should the ONSD be measured?

A: 0 mm (at the rim)

B: 1 mm

C: 3 mm

D: 7 mm

 

The correct answer is C.

BrownEM covered ocular ultrasound this week.

The ONSD can be measured 3 mm behind the rim of the globe and its diameter should measure approximately 5 mm or less in healthy adults (although this cutoff is arbitrary).

 

Question 5

Source image: radiopaedia.org

You’ve ordered an AP chest x-ray for a 5 year old patient who you suspect of pneumonia. His parents are worried about radiation.

Everyone is exposed to a normal amount of background radiation during their life. For example the activity in Australia is 1.5mSv per year.

How many days of background radiation is equivalent to one AP chest x-ray for this patient living in Australia?

A: 3

B: 15

C: 89

D: 294

The correct answer is A.

This week Don’t Forget The Bubbles discussed ionizing imaging in children.

It is difficult to provide parents with clear information, because of the wide variety of contributing factors to the risk of ionizing radiation imaging. For chest x-rays the lifetime risk of radiation-induced cancers is considered to range from negligible to low.

However for CT scans in pediatric patients studies have shown a statistically significantly increased risk for malignant and non-malignant brain tumors.

Best to keep in mind: Is this test really needed and will it change the patient’s diagnosis or management?

How safe are CT scans in children?

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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 139, December 24th, 2021

Welcome to the last FOAMed Quiz of the year..

 

 

Source image: www.pixabay.com

Question 1

Your 25-year old patient comes in with high fever and mono-arthritis of the right knee. Aspiration of synovial fluid reveals pus. You suspect him of having bacterial arthritis.

He is known with sickle cell disease.

Which of the following pathogens is quite commonly a cause of bacterial arthritis in patients with sickle cell disease and is a rare cause of musculoskeletal infections in patients without sickle cell disease?

A: Staphylococcus aureus

B: Kingella species

C: Salmonella species

D: Klebsiella pneumoniae

The correct answer is C.

Pediatric hip pain was covered on NUEM last week.

Staphylococcus aureus is the most common pathogen in bacterial arthritis overall. Due to functional asplenia, patients with sickle cell disease are more susceptible to encapsulated bacteria and gram-negative bacteria, especially Salmonella.

Source image: www.pixabay.com

Question 2

Earlier this month, the HEP-COVID trial was published.

257 Hospitalized adult patients with COVID-19 with D-dimer levels more than 4 times the upper limit of normal or sepsis-induced coagulopathy score of 4 or greater were randomised to standard prophylactic or intermediate-dose LMWH or unfractionated heparin versus therapeutic-dose enoxaparin.

32.8% of these patients received ICU-level care.

The primary outcome was a composite of venous thromboembolism (VTE), arterial thromboembolism (ATE), or death from any cause within 30 days.

In which group did the authors find a benefit of therapeutic anticoagulation?

A: ICU patients

B: Non-ICU patients

C: Neither ICU nor non-ICU patients

The correct answer is B.

The paper was covered on Rebel-EM last week.

 

Therapeutic-dose LMWH reduced the incidence of the primary outcome (48.0% vs 30.1%; P = .007). This benefit is seen only among the 170 patients who are sick enough to be hospitalized but not sick enough to be managed in the ICU.

There was no statistically significant difference in major bleeding.

There was a trend toward mortality benefit in the therapeutic dose anticoagulation group, but the study was not powered to find a mortality benefit.

The HEP-COVID Trial: Therapeutic Anticoagulation in Non-Critically Ill COVID-19 Patients

 

Source image: www.aliem.com

Question 3

A 20 year old patient presents to the ED with diffuse abdominal pain and vomiting for a couple of days. He has no prior medical history. His abdomen reveals mild distention and diffuse tenderness to palpation. His laboratory results show a lactate of 4.9 and no signs of infection. Ultrasound is non conclusive. CT scan reveals Superior Mesenteric Artery (SMA) Syndrome (or Wilke’s syndrome).

Which of the following causes Superior Mesenteric Artery Syndrome?

A: A thrombus in the SMA

B: Dissection of the SMA

C: An increase in mesenteric fat surrounding the SMA, leading to compression of the artery

D: A decrease in mesenteric fat surrounding the SMA, leading to compression of the artery

The correct answer is D

ALiEM covered the Superior Mesenteric Artery Syndrome this week.

Superior Mesenteric Artery (SMA) syndrome is also called Wilke’s or Cast syndrome. A loss of mesenteric fat which normally surrounds the SMA, can lead to a steep angle between the aorta and SMA. Due to this angulation the duodenum can be compressed and can result in a partial or complete obstruction of the proximal duodenum.

The treatment includes gastric decompression and supportive care.

SAEM Clinical Image Series: I Have a Stomachache

Source image: www.tamingthersu.com

Question 4

 Your patient presents with a peritonsillar abscess. You treat your patient with drainage and antibiotics.

What does the evidence say about the addition of corticosteroids?

A: Evidence is clear, glucocorticoids are ineffective

B: Evidence is clear, glucocorticoids should be administered after drainage

C: Evidence is inconsistent, routine use of glucocorticoids can not yet be recommended

The correct answer is C.

Taming the SRU covered peritonsillar abscess last week.

Evidence is inconsistent. A few very small trials suggest benefit (less pain at 24 hours, faster recovery), but a larger retrospective paper did not reproduce these results.

Question 5

Which of the following ultrasound images suggests tamponade?

A:

:

B:

C:

D

:

The correct answer is C.

CountyEM covered POCUS in cardiac tamponade last week.

It is often challenging to appreciate diastolic collapse in dynamic ultrasound images. M-mode can help. The anterior leaflet of the mitral valve is closest to the septum in diastole (at the point you measure e-point septal separation). If the anterior wall of the right ventricle moves further away from the probe during diastole, right ventricular collapse is very likely. This is visible on image C.

Ultrasonography of Cardiac Tamponade

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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 138, December 17th, 2021

Welcome to the 138th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

The use of the bougie at the first intubation attempt is gaining popularity since the 2018 BEAM trial paper was published.

Recently, the multicentre BOUGIE trial was published about the same topic.

1102 critically ill patients undergoing tracheal intubation were randomised to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546). In 60% of patients, the intubation was performed by a resident. Video laryngoscopy was used in 75%.

The primary outcome was successful intubation on the first attempt.

What did the authors find?

A: The first attempt success rate was significantly higher in the bougie group

B: The first attempt success rate was significantly higher in the stylet group

C: There was no difference in first attempt success rate between the groups

The correct answer is C.

This week First10EM covered the Bougie trial. 

Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (P = .27). 

In this trial, the stunning results of the BEAM trial could not be reproduced. However, this trial has its limitations. Notice the pretty low first pass success rates of about 80 %.

The BOUGIE trial: No difference between bougie and stylet?

Source image: www.nuemblog.com

Question 2

Cardiac arrest in pregnant patients is fortunately rare. A gestational age of > 20 weeks warrants resuscitative hysterotomy without delay.

Which of the following is associated with faster time to delivery in resuscitative hysterotomy?

A: Higher maternal survival

B: Higher neonatal survival

C: Neither higher maternal nor higher neonatal survival

D: Both higher maternal and higher neonatal survival

The correct answer is D.

Resuscitative hysterotomy was covered on NUEM last week.

Faster time to delivery is associated with both higher maternal and higher neonatal survival.

Case courtesy of Dr Mohammad Taghi Niknejad, Radiopaedia.org, rID: 87136

Question 3

This recently published multicenter RCT is about the treatment of intra-articular distal radius fractures after acceptable reduction.

90 patients with reduced intra-articular distal radius fractures were randomised to nonoperative treatment (continued cast immobilization) or to operative treatment (ORIF with a volar plate).

The primary outcome was a Patient-Rated Wrist Evaluation (PRWE) score after one year.

What did the authors find?

A: When treated operatively, patients had clinically relevant better functional outcomes after 12 months

B: When treated nonoperatively, patients had clinically relevant better functional outcomes after 12 months

C: There was no difference in functional outcomes

The correct answer is A.

This week JournalFeed discussed this article.

Patients operatively treated had significantly better functional outcomes measured with the PRWE at 6 weeks, 3 months, 6 months, and 1 year.

In the nonoperative group 28% received subsequent surgery.

Case courtesy of Dr Andrew Dixon, Radiopaedia.org, rID: 36509

Question 4

Whether or not to treat isolated subsegmental pulmonary embolism without proximal deep venous thrombosis is controversial. The CHEST, ACEP and ESC guidelines suggest or at least permit clinical surveillance instead of anti-coagulation.

This recently published paper is about the risk for recurrent venous thromboembolism in patients with isolated subsegmental pulmonary embolism without a proximal deep venous thrombosis who were not anticoagulated.

266 patients were analysed across Canada and Europe.

What was the rate of recurrent thromboembolic disease by 90 days in this cohort of patients with isolated subsegemental pulmonary embolism without proximal deep venous thrombosis who were not treated with anti-coagulation?

A: 1,1 %

B: 3,1 %

C: 10,1%

The correct answer is B.

The paper was covered on FOAMcast last week.

8 patients had recurrent venous thromboembolic disease (4 of these had proximal deep venous thrombosis and 4 had pulmonary embolism). This rate was higher than expected. No patients had a fatal recurrent pulmonary embolism.

Source image: www.pixabay.com

Question 5

Neutropenic fever is quite commonly encountered in the ED. Broad spectrum antibiotics are the mainstay of initial treatment and their administration shouldn’t be delayed.

What percentage of neutropenic fevers is caused by an infection?

A: 10-20%

B: 20-30%

C: 50-60%

D: 90-100%

The correct answer is B.

Neutropenic fever was covered on EMDocs this week.

20-30 percent of neutropenic fevers are caused by infection. These infections are mostly bacterial.

emDOCs Podcast – Episode 43: Oncologic Emergencies Part 2

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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 137, December 10th, 2021

Welcome to the 137th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Calcium plays an important role in cardiac physiology.

The COCA trial is about empiric administration of calcium in patients with out of hospital cardiac arrest that received at least one dose of epinephrine.

383 patients were randomised to receive 5 mmol calcium chloride or placebo immediately after the first and second dose of epinephrine. The primary outcome was return of spontaneous circulation (ROSC).

What did the authors find?

A: The rate of ROSC was higher in the calcium group compared to the placebo group

B: The rate of ROSC was higher in the placebo group compared to the calcium group

C: There was no significant difference in ROSC between both groups

The correct answer is B

This week First10EM covered the COCA trial.

The COCA trial was stopped early because after enrolling 383 patients it seemed that administering calcium was harmful. Return of spontaneous circulation occured in 19% of the calcium group and in 27% of the placebo group.

Calcium for of out hospital cardiac arrest: the COCA trial

Source image: www.dontforgetthebubbles.com

Question 2

An eight-year old child is presented to your ED after enduring chemical eye injury. His mother brought the glass polisher which has caused the injury.

Overall, alkali substances are responsible for the more severe chemical injuries compared to acides.

Which acid compound is an exception to this rule?

A: Sulphuric acid

B: Acetic acid

C: Hydrochloric acid

D: Hydrofluoric acid

The correct answer is D.

This week Don’t Forget The Bubbles discussed chemical eye injuries.

Acid burns are often well-demarcated and superficial, whereas alkali substances cause extensive and penetrating eye injuries due to their ability to saponify fatty acids.

Hydrofluoric acid however, penetrates very quickly into the anterior chamber and causes vast injury

 

How to manage chemical eye injuries

Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 13087

Question 3

Standard care of ischemic stroke patients includes IV treatment (IVT) before endovascular treatment (EVT).

Recent evidence suggests EVT alone is non-inferior compared to the combination of treatments (DEVT trial).

This recently published paper is about endovascular treatment alone versus IV alteplase plus endovascular treatment (EVT) in a European population.

539 patients that were eligible for IVT and EVT were randomised to receive either both therapies or EVT alone.

The primary end point was functional outcome on the modified Rankin scale at 90 days.

What did the authors find?

A: EVT alone was superior to EVT plus IVT

B: EVT alone was non-inferior to EVT plus IVT

C: EVT alone was neither superior, nor non-inferior to EVT plus IVT

The correct answer is C.

This week, JournalFeed discussed this paper .

The median score on the modified Rankin scale at 90 days was 3 with EVT alone and 2 with alteplase plus EVT.

EVT alone was neither superior, nor non-inferior to EVT plus IVT. Mortality and the incidence of symptomatic intracerebral bleeding was not significantly different.

It is still too soon to stop using IV-alteplase before EVT in ischemic stroke.

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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 136, december 3th, 2021

Welcome to the 136th FOAMed Quiz.

 

Question 1

Source image: emedz.net

The addition of vasopressin and methylprednisolone to standard care in cardiac arrest has shown promising in this 2009 and this 2013 papers.

Last month, the VAM-IHCA trial was published. 501 patients with in hospital cardiac arrest (IHCA) were randomised after the first dose of adrenaline to either standard care and standard care plus vasopressin and methylprednisolone (VAM: a combination of vasopressin 20IU and methylprednisolone 40mg or placebo). Additional doses of vasopressin (20 IU) or placebo were administered after each additional dose of epinephrine for a maximum of 4 doses.

The primary outcome was return of spontaneous circulation (ROSC).

What did the authors find?

A: Patients in the VAM group had more ROSC and higher favorable neurological outcome at 30 days

B: Patients in the VAM group had more ROSC but equal neurological outcome at 30 days

C: Patients in the VAM group had less ROSC but higher favorable neurological outcome at 30 days

D: Patients in the VAM group had less ROSC and lower favorable neurological outcome at 30 days

The correct answer is B.

RebelEM covered the trial last week.

Patients in the VAM group had more ROSC (42% vs. 32%), but lower survival at 30 days (8,7% vs. 12%) and equal neurological outcome at 30 days (Cerebral Performance Category scale (CPC) of 1 or 2).

REBEL Cast Ep104: VAM-IHCA – Vasopressin and Methylprednisolone for In-Hospital Cardiac Arrest

Question 2

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

What electrolyte abnormality results in a very flat and long QT segment with an otherwise normal T-wave?

A: Hyperkalemia

B: Hypokalemia

C: Hypocalcemia

D: Hypercalcemia

E: Hypernatremia

F: Hyponatremia

The correct answer is C.

Hypocalcemia was covered on dr. Smith’s ECG blog this week.

Hypocalcemia causes a long QT without evident abnormalities in T-wave morphology.

Question 3

Source image: pixabay.com

Your 18 month old patient presents after a simple febrile seizure. What do you tell her terrified parents?

A: Febrile seizures are very common. About half of children will have a febrile seizure.

B: The risk of recurrence is not higher than the risk of a first febrile seizure

C: Evidence suggests antipyretic medication prevents febrile seizures

D: Unfortunately, children with a febrile seizure are at increased risk for epilepsy compared to the general population, but the absolute risk is still small

The correct answer is D.

Simple febrile seizures were covered on EMdocs this week.

Children with a febrile seizure are at increased risk for epilepsy compared to the general population.

Febrile seizures affect 2-5% of children in the United States.

Children have an approximately 30% risk of recurrence.

Prophylactic antipyretics do not prevent the occurrence of febrile seizures during illness.

Pediatric Small Talk – The FAQ Approach to Simple Febrile Seizures

Question 4

Source image: www.medicinenet.com

In nephritic syndrome, inflammation of the glomerular basement membranes leads to passage of both red blood cells and protein into urine. Hematuria is specific to nephritis.

In nephrotic syndrome, damage to the glomerulus leads to increased passage of large molecules such as albumin into urine.

Which of the following disorders causes nephrotic syndrome?

A: Focal Segmental glomerulosclerosis

B: Hemolytic Uremic Syndrome

C: Henoch-Schonlein purpura

D: Post-streptococcal glomerulonephritis

The correct answer is A.

Taming the SRU covered nephrotic and nephritic syndromes last week.

Focal Segmental glomerulosclerosis leads to nephrotic syndrome.

Hemolytic Uremic Syndrome, Henoch-Schonlein purpura and Post-streptococcal glomerulonephritis lead to nephritic syndrome.

Question 5

C-spine tenderness is part of the NEXUS criteria and warrants imaging in trauma patients. This finding however, has very low specificity.

In this recently published study, 478 non-trauma patients were enrolled. Two examiners individually examined for midline c-spine tenderness on palpation.

What percentage of these patients had midline c-spine tenderness on palpation according to both examiners?

A: 16.4%

B: 37.8%

C: 59.8%

D: 74.1%

The correct answer is C.

This week JournalFeed discussed this article about the prevalence of midline cervical spine tenderness in non-trauma patients.

59.8% had midline c-spine tenderness on palpation according to both examiners. Most of them were female (70.6%).

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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 135, November 26th, 2021

Welcome to the 135th FOAMed Quiz.

 

Only 3 questions this week.. Enjoy!

 

Source image: www.pixabay.com

Question 1

Diabetic Ketoacidosis (DKA) is a life threatening event in which fluid replacement is important. Current guidelines recommend normal saline. However, normal saline can cause hyperchloremic acidosis and might worsen the DKA. An alternative could be Plasmalyte, which as a side effect may increase ketone bodies. A true consensus has not been reached.

In this trial, 90 patients with DKA were randomised to either Plasmalyte or normal saline.

What did the authors find?

A: Patients in the Plasmalyte group had slower resolution of DKA and an increased ketosis

B: Patients in the Plasmalyte group had faster resolution of DKA, but an increased ketosis

C: Patients in the Plasmalyte group had slower resolution of DKA, but not an increased ketosis

D: Patients in the Plasmalyte group had faster resolution of DKA, and not an increased ketosis

The correct answer is D

This week Mark Ramzy discussed this study on RebelEM.

The authors conclusion was that Plasmalyte-148, compared to Sodium chloride 0.9%, may lead to faster resolution of acidosis in patients with a DKA without an increase in ketosis. A larger Phase 3 trial is needed for further conclusions.

SCOPE-DKA: Normal Saline vs Plasmalyte in Severe DKA

Source image: www.pixabay.com

Question 2

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a potentially fatal drug reaction. Fortunately it is very rare.

Which of the following drugs are most commonly associated with DRESS?

A: NSAIDS

B: Antidepressants

C: Antiepileptics

D: Antibiotics

The correct answer is C.

DRESS was covered on PedEM Morsels this week.

Antiepileptics are the drugs commonly associated with DRESS.

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS)

 

Case courtesy of Dr Eric F Greif, Radiopaedia.org, rID: 29674

Question 3

Atraumatic back pain is a pretty common complaint in ED. Cauda Equina Syndrome is one of the diagnoses requiring fast intervention. Unfortunately, classic symptoms are often not strong predictors.

The authors of this recently published retrospective review evaluated which symptoms and clinical findings in patients with atraumatic back pain correlate best with the diagnosis of cauda equina compression (CEC).

Which of the following symptoms appeared to be most suggestive for CEC?

A: Bilateral leg pain

B: Dermatomal sensory loss

C: Bilateral absent ankle or ankle and knee jerks

D: Lower anal sphincter tone

The correct answer is C.

This week JournalFeed discussed this article about Cauda Equina Compression.

Bilateral absent ankle or ankle and knee reflexes was the strongest predictor of CEC (OR=2.9), followed by bilateral leg pain (OR=2.2) and dermatomal sensory loss (OR 1.8). The authors did not find a relationship between digital rectal examination findings and the diagnosis of CEC.

Keep in mind this was a single-centre study and that the individual diagnostic performance of all history or exam elements was poor.

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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