Question 1
What is true about operative treatment of an olecranon fracture?
A: Patients require operative treatment if the total extension/flexion range of motion is less than 70 degrees (<50% of normal)
B: Patients who are unable to extend their elbow against mild resistance require operative treatment, even if there’s no significant radiological dislocation of the fracture
C: Only radiological features are important to distinguish between conservative vs operative treatment
The correct answer is B
Emergency Medicine cases is all about elbow injuries this week
A major pitfall in the examination of patients with an olecranon fracture is the failure to adequately test the extensor mechanism and the integrity of the triceps. It is important to check extension against mild resistance, because only this test indicates complete loss of extensor mechanism. Just like the importance of assessing the integrity of the extensor mechanism of the knee for patella or quadriceps tendon injuries, this test is important to predict the likelihood of operative intervention.
The only two absolute indications for operative treatment of the olecranon are fractures with >5mm displacement and/or complete loss of extensor mechanism.
Ep 121 Elbow Injuries – Ten Pitfalls in Diagnosis and Management
Question 2
A patient is rushed into your Emergency Department with recurrent episodes of pulseless Ventricular Tachycardia (VT). His Implantable Cardioverter Defibrillator (ICD) delivers appropriate shocks, but the VT reappears quickly. Which statement is true about the management of this patient?
A: Amiodarone is more effective than procainamide in the treatment of ventricular tachycardia
B: Sedation has no role in the management of electrical storm
C: Esmolol should be considered if first line treatment fails
D: Double Sequential Defibrillation should be attempted as soon as possible
The correct answer is C
Justin Morgenstern wrote a really good post on the management of electrical storm on first10EM
Procainamide seems to be more effective than amiodarone in the treatment of ventricular tachycardias. However, the evidence comes from a paper (PROCAMIO trial) about well tolerated Ventricular Tachycardia. Sedation can absolutely be beneficial in this case. The evidence on double sequential defibrillation (DSD) is very limited and in this case (effective shock from the ICD) there is no reason to believe DSD will be of any use. Sympathetic blockade (esmolol of propranolol) should definitely be considered if first line treatment fails.
https://first10em.com/electrical-storm/
Question 3
The recently published CENSER trial is about early initiation of fixed dose noradrenalin in patients presenting with septic shock. What did the authors find?
A: Early administration of noradrenaline in addition to volume resuscitation led to increased shock control at six hours
B: Early administration of noradrenaline in addition to volume resuscitation had no effect on shock control at six hours
C: Early administration of noradrenaline led to lower median volumes of resuscitative fluids needed
D: Early administration of noradrenaline in addition to volume resuscitation led to a statistically significant lower mortality at day 28
The correct answer is A
Celia Bradford discusses this paper on The Bottom Line and Scott Weingard does so on EMCrit.
This study was conducted in a single centre in Thailand. It is a randomised trial with one group receiving early fixed dose noradrenaline and the other group receiving conventional treatment. A lot of patients were treated (yes, with noradrenalin) on the ward, which is not common practice in our shop (and most likely is not in yours). The primary outcome was not patient centered (shock control) and the study was not designed to detect a difference in secondary outcomes (like mortality). However, the authors did find a statistically significant difference in ‘’shock control’’ at six hours after inclusion. Patients received about the same amount of fluids in both groups.
CENSER
Question 4
Your patient presents with hyperthermia and rigidity. She says she is being treated by a psychiatrist, but she is unable to recall the medication she takes. Which symptom can help you distinguish between Serotonin Syndrome (SS) and Neuroleptic Malignant Syndrome (NMS)?
A: Hyperthermia is almost always present in NMS, but almost never in SS
B: Hypertension is almost always present in SS, but almost never in NMS
C: Myoclonus is typical for NMS, but rarely seen in SS
D: NMS develops in days to weeks, while SS develops suddenly
The correct answer is D
Sarah Brubaker wrote a pretty extensive post about non infectious causes of fever on emDOCs.
I find these syndromes very hard to distinguish as hyperthermia, hypertension, rigidity and altered mental status is common in both. However, there are a couple of differences between the two. Myoclonus is typical for SS, but not for NMS. Mydriasis is another symptom commonly seen in SS, but not in NMS. And finally the timing is different. As NMS develops in days, SS does so acutely.
Nuances to the Management of Febrile Patients: Non-Infectious Causes of Fever
Question 5
Your patient presents to your Emergency Department after an attempted suicide. She took ‘’a lot’’ of acetaminophen. The serum concentration 8 hours after ingestion is 150 µg/ml and you are starting acetylcysteine treatment. Which statement is true about managing acetaminophen poisoning with acetylcysteine?
A: Allergic reactions to acetylcysteine are very common
B: Acetylcysteine is contraindicated in pregnancy
C: The use of oral acetylcysteine is tolerated better than iv acetylcysteine
D: Acetylcysteine still provides benefit if delayed until after hepatic failure has occurred
The correct answer is D
Josh Farkas published a new podcast about acetaminophen poisoning on the Internet Book of Critical Care.
Reactions to acetylcysteine are generally anaphylactoid reactions, not allergic reaction. This involves histamine release due to a direct action of the medication. Acetylcysteine is not contraindicated in pregnancy. The use of oral acetylcysteine is logistically difficult and apparently it smells like rotten eggs (never smelled it). And yes, acetylcysteine still provides benefit if delayed until after hepatic failure has occurred.
IBCC chapter & cast: Acetaminophen toxicity
This quiz was written by Nathalie Dollee and Kirsten van der Zwet
