Quiz 23. week 8. 2019

Question 1

The use of lidocaine intravenously as an analgesic for renal colic is increasing the last couple of years. Results of papers regarding the use of iv lidocaine are quite conflicting so far. Recently this study (Motov, Sergey et al. 2019) aimed on settling the score. According to this paper, is a combination of ketorolac (an NSAID) and iv lidocaine beneficial in providing pain relief in patients with suspected renal colic?

A: Lidocaine/ketorolac provided better pain relief than ketorolac alone

B: Lidocaine/ketorolac provided better pain relief than lidocaine alone

C: Lidocaine alone provided better pain relief than ketorolac alone

The correct answer is B

RebelEM discussed this paper in more detail.

This study provides some additional proof there is no benefit in giving iv lidocaine in addition to an NSAID in patients with suspected renal colic. The combination of lidocaine and ketorolac was not more effective than ketorolac alone. Furthermore, ketorolac alone was superior to lidocaine alone, by far.

REBELCast Ep63: LIDOKET – IV Lidocaine for Renal Colic?

Question 2

Two ‘’ancient’’ techniques for gastric decontamination in the intoxicated patient are gastric lavage and drug-induced emesis (Ipecac). Is there an indication for one of the two methods after ingestion of lethal dose of tablets?

A: No, never

B: Yes, gastric lavage can be performed when a poison is ingested less than 1 hour ago

C: Yes, Ipecac-induced emesis can be used when a poison is ingested less than 1 hour ago

The correct answer is B

Ravi Katari posted on gastric emptying in acute poisonings on SinaiEM.

Yes, you can use gastric lavage on limited occasions. To be honest, there is room for debate here. Personally I use gastric lavage very rarely (maybe once a year) and only in patients who have a known recent (< 1 hour) ingestion of a lethal dose of tablets and who have no contraindication. Drug induced emesis (Ipecac) is never recommended.

(Ipacac (sounds dirty) is a drug prepared from the roots and rhizomes of the Carapichea ipecacuanha plant.)

http://sinaiem.org/gastric-emptying-for-acute-poisonings/

Question 3

Which statement is is NOT true about cocaine induced cardiomyopathy?

A: It is a reversible process

B: Cocaine directly evokes a negative inotropic effect on cardiac myocytes

C: Coronary artery vasoconstriction is an alpha 1 adrenergic effect caused by cocaine

D: One way cocaine leads to myocardial cell death is by increasing calcium entry into the myocytes

The correct answer is D

ALiEM posted about cocaine induced cardiomyopathy this week

Cocaine induced cardiomyopathy can be reversible, but it cocaine also induces permanent myocardial dysfunction. Besides coronary artery vasoconstriction due to adrenergic stimulation it also directly evokes a negative inotropic effect. ‘’Cocaine itself has been demonstrated to increase calcium entry into cells, leading to calcium overload and augmenting myocyte dysfunction and death.’’

ACMT Toxicology Visual Pearls: Don’t Go Breaking My Heart

Question 4

Which of the following electrolyte disturbances does not cause chronic organic constipation?

A: Hypokalemia

B: Hypomagnesemia

C: Hyperphosphatemia

D: Hypercalcemia

The correct answer is C

Roger Farney wrote a pretty extensive post on emDOCs about constipation mimics.

While hypokalemia, hypomagnesemia and hypercalcemia lead to constipation, hyperphosphatemia does not. Keep this in mind before sending your patient home with some laxatives. Do not forget to make an ECG in these patients, as these electrolyte disturbances can cause arrhythmia as well, of course.

Constipation Mimics: Differential Diagnosis and Approach to Management

Question 5

The best strategy for intubating the critically ill patient is reason for debate. At this point the way to go in our department is ‘’real’’ Rapid Sequence Induction/Intubation (RSI), meaning we pre-oxygenate as best we can, push sedative and paralytic, wait until the patient is ready to intubate and intubate. This is the way we were thought, because if the critically ill patient was ventilated after pushing drugs the risk on aspiration was assumed to be very high. However, bag mask ventilation between pushing medication and intubation can be beneficial in oxygenation and might give you more time to drop the tube. This recently published paper examined the pro’s and con’s of bag mask ventilation before intubation and ‘real’ RSI. What did the authors find?

A: Bag Mask ventilation during induction led to less severe hypoxemia, but more aspiration

B: Bag Mask ventilation during induction led to less severe hypoxemia and similar numbers of aspiration

C: Bag Mask ventilation during induction led to similar numbers of severe hypoxemia and more aspiration

D: Bag Mask ventilation during induction led to similar numbers of severe hypoxemia and similar numbers of aspiration

The correct answer is B

Josh Farkas wrote a must-read post on EMCrit.

This is a really interesting and well performed study, but of course there is plenty of room for debate here. One thing to keep in mind is the study was not designed to detect a difference in aspiration. However, once more some proof to help us remember there are a lot of nuances to intubating a critically ill patient and ‘pure’ RSI might not always be the best strategy.

PulmCrit: Is pure RSI a failed paradigm in critical illness? The primacy of pressure

This quiz was written by Eefje Verschuuren

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