Quiz 116, May 28th, 2021

Welcome to the 116th FOAMed Quiz.

 

Question 1

Source image: dontforgetthebubbles.com

Your 12 year old patient presents to your ED after his gastrostomy tube has fallen out 30 minutes ago. He and his parents do not have a spare one. You decide to place a foley catheter through the tract to keep it open as soon as possible.

Which of the following is a contra-indication for placement of the foley catheter?

A: This is a primary tube, placed 3 weeks ago

B: There is minor bleeding from the tract

C: It concerns a gastro-jejunostomy tube

D: Never place a foley in the tract of a gastrostomy tube

The correct answer is A

Don’t forget the Bubbles covered feeding tube troubles last week.

If the tract is left empty it will close up in hours. Replace the tube if you can. Otherwise put a foley catheter in the tract and tape it to the skin.

In patients that had the gastrostomy placed less than 4 weeks ago, the tract has not matured yet and placing a catheter should be avoided. Between 4 and 6 weeks, placement of a catheter can be tried very carefully.

Question 2

Source image: ctscanmachines.blogspot.com

Your 67 year old patient presents to the emergency department with an altered level of consciousness. Her Glasgow Coma Scale is E1M4V1. Her husband tells you she has been complaining of progressive headaches, diplopia and vomiting for a couple of weeks. You suspect her of having elevated intracranial pressure due to a cerebral mass.

Elevated intracranial pressure (ICP) can occur due to mass lesions, cerebral edema (stroke, traumatic brain injury, metabolic disturbances) or obstruction of venous or cerebrospinal fluid outflow.

Which of the following statements about elevated intracranial pressure is true?

A: Lumbar puncture is safe when elevated ICP exists due to a mass lesion

B: Patients with elevated ICP should be hyperventilated to sustain a normal ICP (target PaCO2 20-25 mmHg)

C: Mannitol seems to be less effective in improving cerebral perfusion pressure compared to hypertonic saline

D: Hypothermia improves clinical outcomes

The correct answer is C.

Elevated intracranial pressure was discussed in EMcrit’s Internet Book of Critical Care this week.

Mannitol is frequently used to decrease ICP, but is increasingly replaced by hypertonic saline as a first line agent. Mannitol is nephrotoxic, causes volume depletion (and brain hypoperfusion) and can cause a rebound elevation in ICP. Hypertonic saline (3%) is a safer treatment option. Furthermore, Mannitol seems to be less effective in improving cerebral perfusion pressure compared to hypertonic saline

When performing a lumbar puncture you risk downward herniation of the brain if there is a mass lesion.

Hyperventilation causes cerebral vasoconstriction and thus lowers ICP, but also lowers cerebral perfusion pressure. Low-normal PaCO2 (35-40 mmHg) is a reasonable target.

Hypothermia lowers ICP, but also causes bradycardia and hypotension. There is no high-quality evidence to support its use.

Elevated intracranial pressure (ICP)

Question 3

Source image: www.endoskopiebilder.de/

What is the cause of a stercoral ulcer?

A: Ingestion of a button battery

B: Recent abdominal surgery

C: Fecal mass

D: Malignancies

The correct answer is C

EMdocs covered a case in which a patient died from a perforated stercoral ulcer in their medical malpractice series

As you know, constipation is not always benign. Hard stool can cause colonic wall ulceration (stercoral ulcer) which leads to stercoral perforation.

Medical Malpractice Insights: Bowel perforation due to stercoral ulcer

source image: pixabay.com

Question 4

Intravenous calcium is increasingly used in the bleeding trauma patient. However, it is not yet included in all major guidelines.

This recently published systematic review covered 3 cohort studies including 1213 trauma patients.

What did the authors find?

A: Higher mortality rates were observed in patients with hypocalcemia in all three studies compared to patients with normal serum calcium

B: Patients with hypocalcemia required less blood transfusion compared to patients with normal serum calcium

C: Patients with normal serum calcium had increased coagulopathy (defined as initial INR ⪖ 1,5) compared to patients with hypocalcemia

The correct answer is A

Calcium in the trauma patient was covered on St. Emlyns last week.

In general, hypocalcemia in the bleeding patient is a bad thing. It is associated with higher mortality. Furthermore, patients with hypocalcemia require more blood transfusion and hypocalcemia is associated with increased coagulopathy and clot strength.

Hypocalcaemia, Trauma and Major Transfusion. St Emlyn’s

Question 5

Source image: www.first-nature.com

 

Your 45 year old patient presents to your ED after eating mushrooms. He ate several different types and does not remember what they looked like exactly.

Which of the following symptoms points in the direction of a life threatening intoxication?

A: Gastrointestinal symptoms starting 20 minutes after ingestion

B: Gastrointestinal symptoms starting 8 hours after ingestion

The correct answer is B

Mushroom poisoning was covered on CountyEM last week.

Mushrooms that cause symptoms more than six hours after consumption are associated with serious and potentially lethal toxicity.

The Poisoned Mushroom Hunter

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

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 115, May 21th, 2021

Welcome to the 115th FOAMed Quiz.

 

Source image: www.cdc.gov

Question 1

Gonorrhea is one of the most common sexually transmitted diseases (STD). Hematogenous spread of Neisseria gonorrhoeae leads to systemic infection, called disseminated gonococcal infection (DGI).

What symptoms are part of the classic triad of DGI?

A: Tenosynovitis, arthritis and dermatitis

B: Perihepatitis, salpingitis and vaginal discharge

C: Arthritis, urethritis and conjunctivitis

D: Dermatitis, lymphadenopathy and fever

The correct answer is A.

This week, emDOCS discussed DGI.

It should be in your differential in patients (especially young adults) presenting with migratory polyarthralgia, arthritis, or tenosynovitis, in combination with skin lesions.
The other answers are all STD related; can you name the syndrome or disease?

Answer B is the triad of Fitz-Hugh-Curtis syndrome
Answer C is the triad of Reiter’s syndrome.
Answer D are symptoms of secondary syphilis.

Question 2

A 5 day old baby presents to your ED after vomiting bright red blood. This otherwise healthy baby had a normal birth. The past few days he was drinking normally and had a normal stool. You want to perform an Apt-Downey test.

Which of the following statements is true about the Apt-Downey test for neonatal hematemesis?

A: The Apt-Downey test is useful in children up 9 months of age

B: The Apt-Downey test is a test to distinguish neonatal from maternal blood

C: The Apt-Downey test relies on the fact that fetal hemoglobin is resistant to acid denaturation

The correct answer is B

Neonatal hematemesis can be terrifying for parents. Some benign causes can be easily detected with a simple test such as the Apt-Downey test.

Fetal hemoglobin is resistant to alkali denaturation and after centrifugation it should have a pink color due to free floating hemoglobin. If it turns yellow this means that it did denature and it is adult or maternal hemoglobin. The test should not be used in infants > 6 months. You need a ‘fresh’ bloody specimen and it should be tested within 30 minutes of collection. You can use stool or emesis but it has to contain bright red blood. 

Source image: www.brownemblog.com

Question 3

Your 65 year old patient presents after someone hit her in the right eye. Immediately afterwards, the patient complained about blurring and diplopia. You think she might have a traumatic lens dislocation. Unfortunately, in the meantime her eyelids are very swollen and you cannot visualize the eye anymore. You decide to use Point of Care Ultrasound (POCUS).

What is the sensitivity of POCUS for traumatic lens dislocation?

A: 65%

B: 75%

C: 85%

D: 95%

The correct answer is D.

BrownEM covered POCUS in traumatic eye injuries last week.

According to this prospective cohort study, POCUS has a sensitivity of 96.8% (95% CI 83.3% to 99.9%) in the diagnosis of lens dislocation, and a sensitivity of 95.7% (95% CI 78.1% to 99.9%) in the diagnosis of retrobulbar hematoma.

Source image: www.nysora.com

Question 4

Your patient presents with a pretty nasty wound on the lower leg. You want to perform an ultrasound guided popliteal sciatic nerve block.

The sciatic nerve bifurcates just above the popliteal fossa. Distal to the bifurcation two nerve trunks are visible on ultrasound.

These two trunks are called:

A: Tibial nerve and common peroneal nerve

B: Tibial nerve and sural nerve

C: Sural nerve and common peroneal nerve

D: Saphenous nerve and sural nerve

The correct answer is A

The sciatic nerve consists of two separate nerve trunks: the tibial and common peroneal nerves. A common paraneural sheath envelops these two nerves from their origin in the pelvis

A popliteal block results in anesthesia of the entire distal two thirds of the lower extremity, with the exception of the medial aspect of the leg.


Question 5

Source image: www.pixabay.com

A 70 day old infant presents to your ED with fever. The COVID test turns out positive. You wonder whether this means you can stop evaluating for serious bacterial infection (SBI).

This recently published retrospective study is about 53 COVID positive infants with fever and 53 matched COVID negative febrile infants. What did the authors conclude about the difference in rate of serious bacterial infection between the two groups?

A: The authors found the risk of SBI was much lower in COVID positive infants

B: The authors found the risk of SBI equal in COVID positive and COVID negative infants

C: The authors found the risk of SBI was much lower in COVID negative infants

The correct answer is A.

Clay Smith covered the paper last week on Journalfeed.

The authors found the risk of SBI (UTI, bacterial enteritis, bacteremia, or bacterial meningitis) was much lower in COVID positive infants versus COVID negative infants 8% vs 34%. The most common SBI was UTI.

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

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 114, May 14th, 2021

Welcome to the 114th FOAMed Quiz.

Case courtesy of Dr Behrang Amini, Radiopaedia.org, rID: 3456

Question 1

A 2-year old is brought to the ER with severe abdominal pain. The pain is intermittent and is accompanied by vomiting and a bloody stool. You decide to perform an intussusception POCUS examination. Transverse sonography shows an alternating concentric pattern of echogenic and hypoechoic bands. This is called a “target sign”.

Which two of the following structures are seen as echogenic bands in a target sign?

A: Mucosa

B: Submucosa

C: Muscularis

D: Lymph node

The correct answers are A & C.

This week ALiEM discussed intussusception POCUS examination.

POCUS findings consistent with intussusception are a sandwich sign (or pseudo-kidney sign) in the longitudinal view and target sign (or donut sign) in the transverse view. There are few studies that have looked at POCUS for intussusception, but the existing studies have shown favorable test characteristics and a decreased length of ER stay with using POCUS.

PEM POCUS Series: Intussusception | Learn about it and test your skills on ALiEMU

Source image: www.pixabay.com

Question 2

The RECOVERY trial  showed a clear mortality benefit of dexamethasone in COVID-19 patients requiring oxygen therapy or mechanical ventilation. In contrast, methylprednisolone is the preferred anti-inflammation agent in other pulmonary diseases because of its direct effect on cell membrane associated proteins.

This recently published single centre retrospective study compared methylprednisolone (1mg/kg/day for > 3 days) to dexamethasone (6mg/day for > 7 days) and usual care (no steroid treatment) in adult patients who were admitted to the ICU for respiratory failure due to COVID-19.

What did the authors find?

A: Methylprednisolone had a mortality benefit over dexamethasone in patients on mechanical ventilation but no benefit in patients not requiring mechanical ventilation

B: Methylprednisolone had a mortality benefit over dexamethasone in patients on mechanical ventilation and in patients not requiring mechanical ventilation

C: Methylprednisolone had no mortality benefit over dexamethasone in patients on mechanical ventilation and in patients not requiring mechanical ventilation

D: Methylprednisolone had no mortality benefit over dexamethasone in patients on mechanical ventilation but was superior in patients not requiring mechanical ventilation

The correct answer is A.

This recent study was covered by Mark Ramzy on RebelEM this week.

This study addressed a clinically relevant and important question. External validity is limited since this study was single center and causation can not be determined since this was a retrospective study.

Switching from dexamethasone to methylprednisolone in a subgroup of patients on mechanical ventilation could be beneficial and should therefore be investigated in future studies.

Dexamethasone vs Methylprednisolone in ICU Patients with COVID19

Source image: www.pixabay.com

Question 3

A 38-year-old man is brought in by the EMS with acute chest pain. He is pale and diaphoretic. In his medical file you find that he is a frequent flyer in your emergency department. His visits are usually drug related. He has been known to use cocaine for several years.

What statement is true about cocaine related chest pain?

A: Beta blockers are absolutely contra-indicated in cocaine induced myocardial infarction

B: Cocaine induces tachycardia and thus higher oxygen demands by inhibition of M2-receptors

C: Patients with cocaine intoxication and clear ST elevations should undergo PCI immediately

D: Cocaine can cause myocardial or pulmonary infarction due to pro-thrombotic properties

The correct answer is D.

This week’s NUEM blog was about cocaine related chest pain. Acute coronary syndrome is caused by coronary vasospasm, higher oxygen demands by inhibiting the reuptake of norepinephrine and enhancing platelet aggregation. Chronic effects of cocaine further contribute to a higher risk of cardiovascular disease (especially acute coronary syndrome and aortic dissection) by accelerating atherogenesis, weakening of the aortic vessel wall and inducing left ventricular hypertrophy.

The mainstay of treatment is benzodiazepines which decrease adrenergic response. Beta-blockers are avoided by some physicians because of fear for unopposed alpha-stimulation. However, this is most likely only a theroretical risk.

Source image: LITFL.com

Question 4

Your 65 year old patient comes in with ongoing chest pain. The ECG shows STE in III, ST depression in any of leads V4 to 6, ST in lead V1 higher than ST in V2.

How is this pattern called?

A: De Winter’s pattern

B: Wellen’s pattern

C: Aslanger’s pattern

D: Brugada’s pattern

The correct answer is C

Dr. Smith’s ECG blog this week was about Aslanger’s pattern.

It is caused by a combination of inferior OMI and diffuse subendocardial ischemia. The subendocardial ischemia produces an ST depression vector toward leads II and V5 (with reciprocal STE in aVR) and cancels most of the STE caused by the inferior OMI results (except for lead III).

Source image: www.pixabay.com

Question 5

Sepsis is a common condition with a high mortality and morbidity. The first (blood) cultures are often taken in the emergency room. Whenever no microbiological pathogens are found, this is referred to as culture negative sepsis.

This systematic review and meta-analysis, consisting of 7 studies with a total of 22,655 patients, compared the overall mortality and clinically relevant secondary outcomes between culture-negative and culture-positive sepsis.

What conclusion did the authors draw?

A: There was no association between culture negativity or positivity and overall mortality. But culture-positive septic patients had a longer hospital stay and mechanical ventilation duration

B: Culture negativity was associated with higher mortality. It also resulted in an extended ventilation duration and a higher need for renal replacement therapy

C: Culture positivity was associated with higher mortality, but there was no significant difference in secondary clinically relevant outcomes

D: Culture-positive septic patients had longer ICU length of stay, but no significantly higher overall mortality compared to culture-negative patients

The correct answer is A.

The proportion of culture negativity is reported between 28 and 49% of all patients with sepsis. Culture positivity or negativity was not associated with a difference in mortality.

Culture-positive septic patients had comparable ICU length of stay, mechanical ventilation requirements and renal replacement requirements compared to culture-negative patients. However, the length of hospital stay and mechanical ventilation time of culture-positive septic patients were both longer than those of culture-negative patients.

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

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 113, May 7th, 2021

Welcome to the 113th FOAMed Quiz.

 

Source image: www.pixabay.com

Question 1

Vaccine induced immune thrombotic thrombocytopenia (VITT) (or vaccine-induced prothrombotic immune thrombocytopenia (VIPIT), or Thrombosis with Thrombocytopenia Syndrome (TTS)), is a very very rare, but possibly fatal adverse effect of Astra-Zeneca and Johnson & Johnson COVID-19 vaccines.

Which of the following statements about VITT is true?

A: Platelet count is typically normal in VITT

B: Platelet Factor 4 ELISA is generally positive in VITT (like in Heparin Induced Thrombocytopenia)

C: Normal d-dimer levels are often seen in VITT

D: Heparin is the mainstay of treatment of VITT

The correct answer is B

EM Quick Hits covered VITT last week.

VITT is an evolving disorder and changes in practice come quickly when new data become available.

In VITT, there is typically thrombocytopenia, elevated d-dimer and a positive PF4 ELISA.

Treatment consists of intravenous immune immunoglobulin (IVIG) and nonheparin anticoagulation.

Case courtesy of Dr Sajoscha Sorrentino, Radiopaedia.org, rID: 14979

Question 2

Shortening the duration of antibiotic therapy should help reduce antibiotic consumption and thus bacterial resistance, adverse events, and related costs.

This recently published double blind, randomised, placebo-controlled trial  is about a 3 day course of B-lactam antibiotics versus a 8 day course of B-lactam antibiotics for Community Acquired Pneumonia (CAP) in admitted non-ICU patients.

The primary outcome was resolution of symptoms at 15 days post randomisation.

What did the authors find?

A: 3 days of B-lactam treatment in patients with moderate CAP was non-inferior to 8 days of treatment

B: 3 days of B-lactam treatment in patients with moderate CAP was inferior to 8 days of treatment

C: 3 days of B-lactam treatment in patients with moderate CAP was superior to 8 days of treatment

The correct answer is A

RebelEM covered The Pneumonia Short Treatment Trial

The authors found that discontinuing B-lactam treatment after 3 days in patients with moderate CAP who were clinically stable, was non-inferior to patients who continued treatment for an additional 5 days.

113 of 145 (78%) of patients in the 3 day β-lactam group and 100 of 146 (68%) of patients in the 8 day β-lactam group were cured.

Because the authors used a relatively small sample size and the study was conducted in one country (France) a large multinational trial should be performed in order to make major practical changes.

The Pneumonia Short Treatment Trial: Antibiotic Treatment for 3 days vs 8 days

Case courtesy of Dr Hani Makky Al Salam, Radiopaedia.org, rID: 8720

Question 3

A 17 year old competitive athlete visits the emergency department with pain in her right ankle since a few days without a specific trauma. Besides this problem she tells you that she missed periods and states she cannot be pregnant.

On the X-ray of the ankle you see a stress fracture at the distal tibial metaphysis. You suspect the female athlete triad.

Which of the following symptoms are part of the female athlete triad?

A: Menstrual dysfunction, insufficient energy intake and alopecia

B: Menstrual dysfunction, low bone mineral density and insufficient energy intake

C: Cachexia, osteoporosis and alopecia

The correct answer is B

AliEM covered the Female Athlete Triad this week

Stress fractures can be multifactorial due to increased activity and poor nutrition which can lead to disordered eating with or without an eating disorder.

You should be aware of this triad in patients with risk factors such as participation in sports that emphasize leanness or a specific weight or appearance. These sports typically include gymnastics, ice skating, wrestling, boxing, dance, and track and field.

SplintER Series: What is Wrong With My Daughter?

Source image: www.rcemlearning.co.uk

Question 4

A 35 year old otherwise healthy man, visits your ED because of inflammation on his left leg. The leg is red and warm, but there is no outflow of pus, you doubt whether you feel fluctuation of an abscess.

Which of the following pathogens is most likely to cause cellulitis after penetrating trauma or in the presence of an abscess?

A: Streptococci

B: Pseudomonas

C: Staphylococcus aureus

D: Vibrio vulnificus

The correct answer is C.

This week, emDOCs discussed cellulitis.

Cellulitis without abscess is usually caused by streptococci. However, if an abscess is found, S. aureus is the most common cause.

EMdocs discussed indications for intravenous antibiotic therapy in cellulitis and hospitalization versus treatment at home.

Source image: www.coreultrasound.com

Question 5

The least common place to find free intraperitoneal fluid in the focused assessment with sonography in trauma (FAST) exam is the left upper quadrant.

However, in case you find free fluid in the left upper quadrant, what is the most likely place?

A: Paracolic gutter

B: Suprasplenic

C: Kohler’s pouch

The correct answer is B

Jacob Avila covered the RUSH exam last week on Core Ultrasound.

In contrast to the right upper quadrant (where the most caudal tip of the liver / inferior pole of the kidney is the most likely place to find free fluid), the suprasplenic space is the most common place to find free fluid in the left upper quadrant.

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

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 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.

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

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?

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

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

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

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.

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

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.

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

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?

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

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