Quiz 63, February 21th, 2020

Welcome to the 51th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Source image: www.emcrit.org

Question 1

Recently, the 65 Trial, was published in JAMA. 2463 critically ill patients with vasodilatory hypotension, aged 65 years and older, were randomized between usual care (MAP targets at the discretion of the treating ICU team, usually a MAP >65 mmHg) and permissive hypotension (MAP of 60-65 mmHg). The primary outcome was mortality at day 90.

What did the authors find?

A: Mortality at day 90 was significantly higher in the permissive hypotension group

B: Mortality at day 90 was not significantly different between both groups

C: Mortality at day 90 was significantly lower in the permissive hypotension group

The correct answer is B

Celia Bradford from The Bottom Line and Josh Farkas from PulmCrit covered this recently published paper this week.

The 65 Trial is a multi-center, unblinded RCT (in of course… 65 ICU’s, in the United Kingdom).

1221 patients were assigned to the intervention group (target op MAP between 60 and 65 mmHg) and 1242 patients were assigned to the control group (MAP targets were at the discretion of the treating ICU team).

The mean MAP was 66.7 mmHg in the intervention group and 72.6 mmHg in the control group.

Targeting a MAP of 60-65 mmHg resulted in the use of lower doses of vasopressors and allowed for faster weaning off these vasopressors (33 hours with permissive hypotension vs 38 hours with conventional therapy).

The primary endpoint, mortality at day 90, was 2.9% lower in the permissive hypotension group (41.0 vs 43.8 percent) but this small benefit was not statistically significant. Secondary endpoints showed no differences in renal function, ICU length of stay, ventilation and 90-day cognitive outcomes.

Keep in mind the mean MAP in the permissive hypotension group was higher than targeted. Furthermore, this was an unblinded trial.

It appears safe to target a MAP of 60-65mmHg in elderly patients with vasodilatory shock.

 

65 Trial

Source image: http://blog.clinicalmonster.com/

Question 2

Your 53-year old patient presents with shock. POCUS reveals this image.

You remember seeing your colleague struggle with pericardiocentesis and you really want to releaf this tamponade under ultrasound guidance. Which of the following approaches is best suited for ultrasound guided tamponade drainage?

A: Subxiphoid approach

B: Parasternal approach

C: Apical approach

The correct answer is B

CountyEM covered pericardiocentesis last week.

Of course there are more variables to take into account when choosing an approach for tamponade drainage than just the best way to visualise the needle. However, if you find a large quantity of effusion on every view, the parasternal approach might be the easiest. The pericardium is located most superficially and the angle of your needle accounts for better visualisation compared to an apical or subxiphoid approach. Keep in mind there is a risk of injury to the left internal mammary artery and pleura of your site of puncture is too lateral.

Question 3

Quite a lot of evidence has recently emerged regarding clinical pretest probability (CPTP) guided d-dimer cutoff in the diagnosis of pulmonary embolism. But how does CPTP guided d-dimer cutoff compare to age-adjusted d-dimer cutoff in the diagnosis of deep venous thrombosis according to this recently published paper 

A: CPTP guided d-dimer cutoff has superior diagnostic utility compared to age-adjusted d-dimer

B: CPTP guided d-dimer cutoff has similar diagnostic utility compared to age-adjusted d-dimer

C: CPTP guided d-dimer cutoff has inferior diagnostic utility compared to age-adjusted d-dimer

The correct answer is B

Clay Smith covered this paper last week.

It seems that both D-dimer interpretation strategies were associated with a high and similar NPV, and similar utility.

Sensitivity was 98.7% for CPTP guided cutoff and 98.0% for age-adjusted cutoff.

 

Source image: www.pixabay.com

Question 4

You commence high dose insulin (HDI) in a patient with combined calcium channel blocker (CCB) and beta blocker (BB) intoxication. Which of the following is true about the mechanism of action of HDI?

A: HDI acts as a strong vasoconstrictor

B: HDI is a specific antidote to CCB

C: HDI acts as a strong inotrope

The correct answer is C

The latest Tox and Hound post on EMcrit is about cardiotoxic overdoses.

It seems HDI has a couple of mechanisms of action. The most important one is inotropy by augmenting calcium mediated contractility in cardiovascular tissue and by increasing the availability of intracellular glucose to maximize ATP production in stressed myocardium. Insuline is a vasodilator, not a vasoconstrictor. There is no specific antidote voor CCBs.

 

 

https://emcrit.org/toxhound/hdi-vs-pressor/ 

Source image: www.pixabay.com

Question 5

You are at 35.000 feet, sitting in your airplane seat on your way to a well deserved holiday when suddenly: ‘’ Is there a medical professional on board?’’ You, as a well trained emergency physician, decide to volunteer.

Which of the following statements about In-Flight Medical Emergencies (IMEs) is true?

A: The most common reason for an IME is cardiac arrest

B: Every airplane should be equipped with an IV start kit, AED, oral airways, oxygen tank and a stethoscope

C: Physicians from the United States, Canada and Europa have a legal obligation to help when medical assistance is needed due to a IME

D: Airlines do not have medical ground support available

The correct answer is B

IMEs happen roughly once in every 604 flights and about 4% of IMEs require diversion to a nearby airport. The most common reason is syncope or pre-syncope (33-37%), followed by all kinds of complaints like GI symptoms, respiratory symptoms, seizures, allergic reactions and obstetric emergencies. Only 0.2-0.3% of IMEs are due to cardiac arrest.

There are minimal requirements for on board medical equipment and medications which includes basic supplies for assessment, airway/breathing, and intravenous access. Additional equipment and medications differ between airliners.

Physicians from the United States, Canada and England have no legal obligation to assist in an IME. But when they do, they are protected from liability by the Good Samaritan provision of the Aviation Medical Assistance Act. However, physicians from Australia and some European countries like ours (the Netherlands), do have a legal obligation to assist in an IME.

Every airline should be able to assist you with medical ground support during a significant IME.

 

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This quiz was written by Eefje Verschuuren and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 62, February 14th 2020

Welcome to the 62th FOAMed Quiz. 

Enjoy!

Eefje, Joep and Rick

Question 1

Source image: litfl.com
 

Last week this paper was published in NEJM. 316 patients between 18 and 50 years old with moderate to large (> 32%) one-sided pneumothoraces were randomized to either conservative treatment or treatment with a 12 Fr pleural catheter. What did this paper show?

A: Conservative treatment was inferior compared to insertion of a pleural catheter for re-expansion at 8 weeks

B: Conservative treatment was superior compared to insertion of a pleural catheter for re-expansion at 8 weeks

C: Conservative treatment was non-inferior compared to insertion of a pleural catheter for re-expansion at 8 weeks

The correct answer is C

St. Emlyn’s covered this recently published paper. In our ED, patients with these large pneumothoraces always get a pleural catheter. This paper certainly opens up possibilities to study conservative management of pneumothoraces.

The primary outcome (reexpansion at 8 weeks) was met in 94.4 percent of patients in the conservative management group and 98.5 percent of patients in the non-conservative group. This was non-inferior according to the authors, who set the non-inferiority margin at 9 percentage points. As expected the conservative managed patients spend less time in the hospital (1.6 to 6.1 days), had less adverse events and a lower 1-year recurrence rate.

There are some methodological issues to mention. The non-inferiority margin of 9 percent seems a bit high. Furthermore there was a significant loss to follow up in both groups (23 in the non-consevative group and 37 in the conservative group). 15 percent of patients in the conservative group ended up getting an intervention after all and it seems 316 patients out of 2600 screened patients might suggest selection bias.

JC: Conservative management of pneumothoraces.

Question 2

For what kind of pediatric fracture should the Ogden classification be used?

A: Tillaux fractures

B: Greenstick fractures

C: Tibial Tubercle Fractures

D: Supracondylar fractures

The correct answer is C

AliEM covered tibial tubercle fractures last week.

The Ogen classification schema is similar to the Salter-Harris classification, but is used preferentially in the proximal tibia because of the presence of two ossification centers.

I: Fracture of the secondary ossification center
II: Fracture propagates proximal between primary and secondary ossification center
IV: Fracture crosses the primary ossification center
V: Fracture through the entire proximal primary ossification center
VI: Avulsion fracture of the patellar tendon from the secondary ossification center

Source image: https://musculoskeletalkey.com/

SplintER: Knee pain after the jump

Question 3

Which of the following is not part of the classic triad of Serotonin Syndrome?

A: Agitation, Confusion (Altered mental status)

B: Tachycardia, Fever and Flushing (Autonomic hyperactivity)

C: Lead pipe rigidity, hyporeflexia (Neuromuscular abnormality)

The correct answer is C

em3 covered serotonin syndrome this week.

Yes, the triad consists of Altered mental status, Autonomic hyperactivity and Neuromuscular abnormality. However, the neuromuscular abnormality you will find in serotonin syndrome is hyperreflexia and myoclonus.

Lead-pipe’ rigidity is found in Malignant Neuroleptic Syndrome.

Question 4

A 39-year old male presents with severe epigastric pain, nausea and several episodes of non-bloody, non bilious emesis. He describes the pain as sharp and it radiates to her back. On examination, he is tachycardic and tachypneic with abdominal tenderness. Lipase comes back markedly elevated.

Which of the following statements about acute pancreatitis is true?

A: The most common etiology is alcohol (up to 50%), followed by gallstones (20%), hypertriglyceridemia (5-10%), idiopathic (up to 20%), medications and some more rare causes

B: Diagnosis requires the following: characteristic abdominal pain AND a lipase or amylase >3 times the upper limit of normal AND characteristic findings on ultrasound (US) or computed tomography (CT)

C: Conditions, other than pancreatitis, like bowel obstruction, bowel ischemia, perforation, biliary disease and renal failure can not elevate lipase and amylase >3 times the normal limit

D: A triglyceride level of at least 500 mg/dL (typically >1000 mg/dL or 11.2 mM) suggests hypertriglyceridemia as the underlying etiology

The correct answer is D

Britt Long covered pancreatitis this week on EMdocs.

Pancreatitis is a common diagnosis in the Emergency Department. It is caused by numerous things but mostly by gallstones (up to 40%), alcohol (30%) or hypertriglyceridemia (5-10%).

Diagnosis requires 2 of the following: characteristic abdominal pain, lipase >3x the upper limit of normal, characteristic findings on US or CT. Besides pancreatitis, other conditions like bowel obstruction, bowel ischemia etc can also cause elevated levels of lipase, but normally won’t exceed levels 3 times the upper limit.

Treatment is mostly supportive. In case of hypovolemia, flu. Antibiotics are controversial and only warranted in patients with signs/sources of infection, necrosis, abscess and infected pseudocysts.

EM@3AM: Pancreatitis

Question 5

Your patient presents with fever of unknown origin. POCUS reveals a mitral valve vegetation. Which of the following statements about endocarditis is true?

A: Fever is present in about half of patients with endocarditis

B: Roth spots are an example of extracardiac manifestations of endocarditis and present as tender lesions which can be found on finger pulps and thenar/hypothenar eminences

C: Flank pain in a patient with endocarditis could be due to splenic or renal emboli and therefore abdominal imaging should be considered in these patients

D: Workup should include two proper sets of blood cultures

The correct answer is C.

Endocarditis was covered by Anand Swaminathan this week as part of the REBEL Core Cast.

Endocarditis is an infection of the endocardial surface of the heart, heart valves or both. Fever is present in 90% of patients whereas a new murmur is present in 50-80% of patients. Examples of extracardiac symptoms are: Osler nodes, Janeway lesions, splinter hemorrhages and Roth Spots which are emboli in the eye causing boat-shaped hemorrhages with pale centers.

Emboli can cause all sorts of complications in the lungs, spleen and kidneys. Splenic and renal emboli can cause flank pain.

Workup should include three sets of blood cultures.

REBEL Core Cast 27.0 – Endocarditis

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

Reviewed and edited by Rick Thissen

Quiz 61, February 7th, 2020

Welcome to the 61th FOAMed Quiz. 

Enjoy!

Eefje, Hüsna, Joep and Rick

Source image: www.pixabay.com


Question 1

A 50-year old male presents to your Emergency Department after incidental ingestion of windshield washer fluid he had stored in a Gatorade bottle, although you doubt this is really what happened. 30 Minutes after ingestion he felt dizzy, nauseated and sleepy. Physical examination shows a vomiting patient with normal vital signs as well as ataxia and dysarthria.

Which of the following statements about ingestion of this is true?

A: Windshield washer fluid typically contains hydrocarbons

B: An arterial blood gas will most likely show a normal osmolar gap and a metabolic acidosis

C: This patient should be treated with activated charcoal

D: This patient has an indication for treatment with fomepizole or ethanol

The correct answer is: D

Richard Byrne of EM Daily presented a case of windshield washer ingestion and recently toxic alcohol toxicity was covered on the Internet Book of Critital Care.

Windshield washer fluid often contains ethylene glycol and or methanol. An arterial blood gas will show a metabolic acidosis with an elevated anion gap and osmolar gap indicating the presence of unmeasured osmotically active solute.

Activated charcoal is not effective in treatment of toxic alcohol toxicity.

The enzyme alcohol dehydrogenase is responsible for metabolism of (on themselves not very toxic) alcohols into their toxic metabolites. Fomepizole and ethanol are inhibitors of alcohol dehydrogenase therefore reduce formation of toxic metabolites. Consider hemodialysis early on.

IBCC chapter & cast – Toxic Alcohols

 

Question 2

A 14-year old boy just arrived by ambulance after playing a rugby match. A sudden course correction was followed by a surge of severe pain in his knee. You see a hugely swollen knee with an obvious deformity on the lateral side.

The triage nurse thinks his patella is dislocated.

Which of the following statements about patella dislocation is true?

A: Most patella dislocations are due to direct contact like knee to knee strike in basketball or a helmet/head to knee in rugby

B: Lateral tenderness is common as the lateral patellofemoral ligament (LPFL) is ruptured in 94% of dislocations

C: Reduction of the dislocation should be done by flexing the hip, applying pressure to the lateral border of the patella in a medial direction while extending the knee

D: The older the patient the higher the rate of re-dislocation

The correct answer is C

Tadgh Moriarty covered acute patella dislocation this week in Don’t Forget the Bubbles.

Patella dislocations are caused by non-contact twisting injuries most of the time (66-82%) and cause medial tenderness of the knee due to rupture of the medial patellafemoral ligament (MPFL) in over 94% of dislocations.

Reduction of the dislocated patella should be done by flexing the hip while applying pressure to the lateral border of the patella in a medial direction while extending the knee. Post reduction management consists of immobilisation with a knee immobilizer and follow up with a orthopedic or trauma surgeon.

The younger the patient, the higher the change of re-dislocation: 60% for those 11-14 years old and 33% for those 15-18 years old.

Source image: www.pixabay.com

Question 3

A lot of controversies exist regarding the use of Oseltamivir in influenza (read the BMJ campaign here). It seems Oseltamivir does not have any effect on preventing secondary complications and mortality, but it might shorten symptom duration.

Luckily this paper was recently published in the Lancet. What does this paper show according to the authors?

A: Oseltamivir shortens duration of symptoms in patients with suspected influenza

B: Oseltamivir reduces X-ray confirmed pneumonia in patients with suspected influenza

C: Oseltamivir reduces use of acetaminophen or ibuprofen containing medicine in patients with suspected influenza

The correct answer is A, I think

Justin Morgenstern covered this paper last week in First10EM.

Conclusion of the authors: Oseltamivir shortens duration of symptoms in patients with suspected influenza.

However: there are evident methodological issues with this paper. The authors randomized some 3000 patients with suspected influenza to either ´usual care’ or ´usual care´ plus Oseltamivir, no placebo in the comparison group. This combined with the subjective primary outcome (patient-reported time to recovery, defined as having returned to usual daily activity and fever, headache, and muscle ache rated as minor or no problem in key subgroups) make a very high risk on bias.

Furthermore, it seems Oseltamivir had the same effect regardless of the subject having influenza or not (only half of the population tested influenza PCR positive). This suggests even more the entire reported difference is due to placebo effect.

Tamiflu doesn’t work

Source image: www.pixabay.com

Question 4

Your patient presents to the Emergency Department after an unknown substance was sprayed into her eyes.

Which of the following statements is true about caustic eye injuries?

A: Pain is a good indicator of degree of injury

B: Acids erode through the corneal epithelium and penetrate into the anterior chamber more easily than alkali do

C: Acidic injuries may initially look worse than an alkali burn but are often less severe

D: Hydrofluoric acid injury should be treated just like any acidic eye injury

The correct answer is C

Pain is not a good indicator of degree of injury, as alkali substances cause nerve damage. Alkali erode through the corneal epithelium and penetrate into the anterior chamber more easily than acids. Acidic injuries may initially look worse than an alkali burn but are often less severe. Hydrofluoric acid is an exception as it chelates calcium (and magnesium) ions and causes serious and deep injury with possible systemic toxicity. Treatment consists of irrigations and calcium, calcium and calcium (more on this another time). 

Source image: NTSP Manuel 2013 from www.tracheostomy.org.uk

Question 5

Your 45 year old patient comes in with dyspnoea and difficulty breathing through his permanent tracheostomy tube he had for years. He has increased work of breathing and you wonder if the tube is patent.

Which of the following would be adequate in this situation?

A: Do not remove the inner tube when obstruction is suspected

B: Passing a suction catheter via the tracheostomy is a safe way to assess whether or not the tube is patent

C: Passing a Gum Elastic Bougie (GEB) via the tracheostomy is a safe way to assess whether or not the tube is patent

D: Most laryngectomy stomas will have a tube in situ

The correct answer is B

The RCEM learning podcast covered tracheostomy issues this month.

Passing a suction catheter via the tracheostomy will establish whether or not the tube is patent and also allow therapeutic suction to be performed. Gum elastic bougies or similar introducers should be avoided at this stage because these stiffer devices are more likely to create a false passage if the tracheal tube tip is partially displaced.

Most laryngectomy stomas will NOT have a tube in situ. Try to find out early whether your patient still has a patent orotracheal route or not.

Have a read here and here. 

 

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This quiz was written by Eefje Verschuuren, Hüsna Sahin and Joep Hermans

Reviewed and edited by Rick Thissen

Quiz 60, January 31th, 2020

Welcome to the 60th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: http://www.ultrasoundpodcast.com
 

Ultrasound guided intravenous access is a procedure commonly performed in our ED. Success rates are pretty high, but dislodgement in case of cannulation of a deeper vein is a concern. Does the use of ultralong (6.35 cm) catheters for ultrasound guided peripheral intravenous access have benefit over the use of standard catheter (4.78 cm) in patients with difficult IV access?

A: No, use of ultralong catheters does not have any benefit over use of a standard catheter

B: Yes, use of ultralong catheters leads to a higher success rate on first attempt compared to use of a standard catheter

C: Yes, use of ultralong catheters leads to a decrease in minutes to completion compared to use of a standard catheter

D: Yes, use of ultralong catheters leads to an increase in survival time of the catheter compared to use of a standard catheter

The correct answer is D

This weeks journal club of St. Emlynsblog covered the following paper.

I guess it depends a bit on if you consider 6.35 cm (2.5 inch) ultralong (I wouldn’t). 

This is a randomised controlled trial comparing standard catheters for ultrasound guided intravenous access to ultralong catheters. The ultralong catheters survived on average 44 hours longer than the standard catheters. There was no difference in first attempt success, number of attempts and time to completion.

JC: Long lines for USS guided peripheral IVs. St Emlyn's

Question 2

 

Source image: https://litfl.com/

A 7-year-old child is seen at your emergency department with a temperature of 38.2℃, a little tachypnoe, oxygen saturation around the high 80s and some crackles on auscultation. The X-ray shows bilateral peribronchial shadowing. You piece her age and clinical picture together and consider Mycoplasma pneumonia.

Which of the following statements about acute Mycoplasma pneumoniae infection is true?

A: β-lactams should be the first-line antibiotic prescribed when a clinical diagnosis of M. pneumoniae pneumonia is made

B: Antibiotic therapy is always indicated for extra-pulmonary manifestations

C: 1/3 of children hospitalized with M. pneumoniae infection have a concurrent viral infection

D: M. pneumoniae has an incubation period of 3 days

The correct answer is C

Phoebe Williams covered acute M. pneumoniae infection this week in Don’t Forget the Bubbles.

M. pneumoniae infection can occur in children of all ages, with a median age of hospitalization with community-acquired pneumonia (CAP) due to M. pneumoniae of 7 years.
Codetection of viral pathogens (in 1/3 of children hospitalized with M. pneumoniae infection) is common.

M. pneumoniae is transmitted via infected respiratory droplets during close contact, with a long incubation period of up to 23 days.

Mycoplasma spp. lack a cell wall, so are intrinsically resistant to a number of our most common antibiotic classes (including β-lactams). Azithromycin should be the first-line antibiotic prescribed when a clinical diagnosis of M. pneumoniae pneumonia is made. Antibiotic therapy is generally only indicated for pulmonary disease, as extra-pulmonary manifestations tend to be immune-mediated.

The mire of mycoplasma

Question 3

Source image: pixabay.com

 

Which of the following therapies is not indicated in a hemodynamically unstable patient with calcium channel blocker (CCB) toxicity?

A: High‐dose insulin euglycaemic therapy (HIET)

B: Calcium intravenously

C: Catecholamine adrenergic receptor agonists

D: hemodialysis or hemofiltration

The correct answer is D

Scott Weingard recorded a podcast about a very interesting case of beta blocker (BB) and calcium channel blocker (CCB) poisoning.

Treatment of BB and CCB poisoning is more or less the same. Both can be lethal and both should be managed very carefully, even if the patient does not look ill to start with. Treatment generally consists of:

•Calcium
•HIET
•Inotropy and if needed vasoactive medication
•Methylene Blue (to be considered)
•Lipid emulsion therapy (to be considered)
•Glucagon (to be considered)

Because of their affinity to plasma proteins, high hepatic first pass, and a large volume of distribution, hemodialysis or hemofiltration are not effective.

EMCrit 264 – Case Discussion of Combined CCB and BB Overdose

Question 4

Your 65 year old patient presents to the ED with diarrhea since 4 days with some bloody stools. You wonder whether antibiotics might benefit recovery of your patient. Diarrhea caused by which of the following causative organisms does not respond to antibiotics?

A: Shiga Toxin producing E. Coli

B: Shigella

C: Campylobacter

The correct answer is A

EMdocs covered infectious diarrhea this week.

Shigella and Campylobacter may benefit from antimicrobials, whereas Shiga Toxin producing E. Coli (STEC) and most likely salmonella do not. When concern for Shiga Toxin producing organisms, distinguishing between Shiga toxin 1 and Shiga toxin 2 (which is more potent) is useful. Considering HUS in these cases is important

Infectious Diarrhea

Question 5

A 12-year old child, with a history of moderate Hemophilia, is seen at your emergency department with hemarthrosis of his/her right knee after falling down from a skateboard.

The three most common bleeding disorders in children are Hemophilia A, Hemophilia B and Von Willebrands.

Which of the following statements is true about this child and Hemophilia?

A: This child is most likely female

B: Patiënts with Hemophilia A have a deficiency of coagulation factor IV while patients with Hemophilia B have a deficiency of coagulation factor VIII

C: This child’s site of bleeding is the most common site of bleeding in Hemophilia patients

D: Patients with Hemophilia A need higher doses of replacement coagulation factors compared to patients with Hemophilia B

The correct answer is C

Brad Sobolewski from PEMblog covered the most common bleeding disorders in children this week.

This child is most likely male since Hemophilia is a X-linked recessive disease. Patients with Hemophilia A have a deficiency of coagulation factor VIII while patients with Hemophilia B have a deficiency of coagulation factor IV.

Hemophilia can be mild, moderate or severe. The most common type of bleeding is hemarthrosis of a joint like the knee but it can cause all kinds of bleeding complications ranging from minor bruises to heavy menorrhagia, muscle bleeds and even intracranial bleeds.

The first line of treatment in the ED is replacement of coagulation factors. Patients with Hemophilia B need higher doses than patients with Hemophilia A and depending on the kind of injury site and bleed type, further treatment and admission to the hospital could be necessary.

Factor First! Hemophilia management in the Emergency Department

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

Reviewed and edited by Rick Thissen

Quiz 59, January 24th, 2020

Welcome to the 59th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

Source image: www.thebottomline.org

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

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

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

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

The correct answer is C

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

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

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

Question 2

Source image: https://litfl.com/

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

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

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

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

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

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

The correct answer is C

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

Question 3

Source image: www.pixabay.com

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

 A: Levetiracetam

 B: Fosphenytoin 

 C: Valproate 

 D: Pyridoxine

The correct answer is D

EmDOCs covered INH toxicity this week.

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

Question 4

Source image: www.rebelem.com

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

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

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

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

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

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

The correct answer is A

RebelEM covered SBP this week.

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

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

Question 5

www.aliem.com

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

 A: 10 percent

 B: 30 percent

 C: 50 percent

 D: 80 percent

The correct answer is D

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

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

 

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

Reviewed and edited by Rick Thissen

Quiz 58, January 17th, 2020

Welcome to the 58th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

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

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

A: A hook of hamate fracture

B: Scapholunate dissociation

C: A Scaphoid Fracture

D: Perilunate or lunate dislocation

The correct answer is B

AliEM covered radiographic approach to the injured wrist this week.

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

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

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

EMRad: Radiologic Approach to the Traumatic Wrist

Question 2

Source image: www.pixabay.com

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

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

A: MDMA causes hyponatremia due to adrenal insufficiency and polydipsia

B: MDMA causes hyponatremia due to heart failure and polydipsia

C: MDMA causes hyponatremia due to hypothyroidism and polydipsia

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

The correct answer is D

EmDocs covered the pearls and pitfalls of hyponatremia this week.

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

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

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

 

Critical Hyponatremia: Pearls and Pitfalls

Question 3

Source image: www.pixabay.com

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

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

B: Higher temperature indicates a more serious infection

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

D: Fever should always be treated with antipyretics

The correct answer is A.

Don’t forget the bubbles covered fever last week. 

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

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

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

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

Question 4

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

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

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

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

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

The correct answer is A

Clay Smith covered this paper on JournalFeed last week.

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

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

Question 5

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

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

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

C: A GONB should not be performed bilaterally

D: The GON lies just lateral to the occipital artery

The correct answer is B

NUEM covered the GONB this week.

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

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

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

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

Reviewed and edited by Rick Thissen

Quiz 57, January 10th, 2020

Welcome to the 57th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Question 1

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

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

Which of the following statements is true about diplopia?

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

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

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

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

The correct answer is B.

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

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

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

Source image: https://entokey.com/

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

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

Link to crackcast chapter

Question 2

Source image: www.pixabay.com

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

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

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

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

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

The correct answer is C

RebelEM covered this paper last week.

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

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

Question 3

Source image: www.emcrit.org

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

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

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

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

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

D: A GEB is only effective using videolaryngoscopy

E: A GEB is only effective using direct laryngoscopy

The correct answer is C

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

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

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

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

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

Question 4

Source image: https://litfl.com/

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

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

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

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

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

The correct answer is B

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

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

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

Hyperkalaemia: two problems with our current management

Question 5

www.canadiem.org

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

Which of the following statements is true about pacemaker complications?

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

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

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

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

The correct answer is C

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

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

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

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

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

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

Reviewed and edited by Rick Thissen

Quiz 56, January 3th, 2020

Welcome to the 56th FOAMed Quiz. 

Source image: www.pixabay.com

Enjoy the first quiz of 2020!

Kirsten, Eefje, Hüsna, Joep and Rick

Written by Joep Hermans. Post edited by Rick Thissen.

Question 1

Source image: www.pixabay.com

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

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

A: The rate of extravasation is about 5 percent

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

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

The correct answer is C

REBELem covered this and this paper this week.

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

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

REBEL Cast Ep73: Are Peripheral Vasopressors Safe?

Question 2

Source image: www.pixabay.com

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

Which statement about compartment syndrome (CS) is true?

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

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

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

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

The correct answer is B.

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

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

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

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

Question 3

Source image: www.aliem.com

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

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

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

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

D: Operative treatment is always indicated

The correct answer is A

AliEM covered CMC dislocations this week.

Indeed, isolated dislocations are uncommon.

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

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

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

SplintER Series: A Rare Cause of Traumatic Thumb Pain

Question 4

Source image: www.pixabay.com

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

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

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

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

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

D: Levetiracetam is safer compared to Valproate and Fosphenytoin

The correct answer is C

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

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

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

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

The ESETT Trial: 2nd Line Medications in Status Epilepticus

Question 5

Source image: www.pixabay.com

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

A: Pneumothorax was present in about 5 percent of patients

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

C: Pulmonary embolism was found in 10 percent of patients

D: No abdominal acute pathologies were found on these scans

The correct answer is C

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

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

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

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

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Christmas edition, December 26th 2019

Welcome to the Christmas Special

Merry Christmas and a Happy New Year!

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Which eponyms are we looking for???

Question 1

 
Source image: http://www.emdocs.net/

M

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

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

Question 2

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

E

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

Essex-Lopresti fracture

Question 3

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

R

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

Reye’s Syndrome

Question 4

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

Source image: https://litfl.com/

R

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

Roth spots

Question 5

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

Y

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

Sidney Yankauer

Question 6

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

C

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

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

Question 7

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

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

H

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

PEM Pointers: Henoch-Schonlein Purpura

Question 8

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

R

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

SplintER Series: Case of a First Metacarpal Fracture

Question 9

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

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

I

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

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

Question 10

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

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

S

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

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

Question 11

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

Source image: https://litfl.com

T

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

Tillaux fracture

Question 12

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

Source image: https://westjem.com

M

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

https://www.nuemblog.com/biliary

Question 13

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

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

Question 14

Source image: https://litfl.com

S

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

Segond fracture

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

Reviewed and edited by Rick Thissen

Quiz 55, December 20th, 2019

Welcome to the 55th FOAMed Quiz. 

Enjoy!

Kirsten, Eefje, Hüsna, Joep and Rick

Source image: www.canadiem.org

Question 1

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

Which of the following statements is true about corneal disorders?

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

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

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

D: A positive Seidel’s test indicates corneal laceration

The correct answer is D

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

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

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

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

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

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

Approach to Corneal Disorders in the ED

Source image: www.pixabay.com

Question 2

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

Which of the following statements about hypertensive emergency is true?

A: Headache is almost always indicates end-organ damage

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

C: Hypertensive Urgencies should be managed in the Emergency Department

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

The correct answer is D

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

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

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

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

Question 3

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

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

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

C: Glucocorticoids does not seem to improve respiratory symptoms

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

The correct answer is D

RebelEM covered this paper about VALI this week.

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

Vaping Associated Lung Injury (VALI)

Question 4

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

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

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

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

C: Cervical plain films with odontoid views are not helpful

D: Most cases require surgical management

The correct answer is A

Pediatric EM Morsels covered Nontraumatic Atlantoaxial Subluxation this week.

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

Nontraumatic AtlantoAxial Subluxation in Children

Question 5

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

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

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

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

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

D: Isolated midshaft ulna fractures are pretty common in children

The correct answer is B

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

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

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

Reviewed and edited by Rick Thissen