Quiz 25. week 10. 2019

Question 1


You want to perform a diagnostic paracentesis in a known cirrhotic patient to exclude spontaneous bacterial peritonitis. Which of the following is an absolute contraindication?

A: The presence on an acute abdomen which would require immediate surgery

B: Thrombocytopenia of 40.000 per ml

C: An INR of 5.0

D: Presence of large bowel obstruction

The correct answer is A

Anthony Devivo wrote a useful overview about paracentesis in the Emergency Department

The presence of large bowel obstruction is a relative contraindication, if you can find a large fluid collection with ultrasound, go for it. Both thrombocytopenia and a high INR are frequently believed to lead to more hemorrhagic complication, however evidence suggests that diagnostic paracentesis can be safely performed if the INR is below 7 and the platelet count is above 20.000 per ml.

Unlocking Common ED Procedures – Pocket Full of Sunshine: Paracentesis in the ED

Question 2

Which of the following is a rare side effect of propofol?

A: Green discoloration of the tongue

B: Green discoloration of the nails

C: Green discoloration of the hair

The correct answer is C

(Green) discoloration of the urine is a known side-effect of propofol, but green discoloration of the hair is rarely seen. A recently published case report described green discoloration of the hair <1 hour after administration. It is benign and self-limiting, it will resolve 1-2 months.

Click here to view the case report

Question 3

At last there is an antidote (Andexanet Alfa) for factor Xa inhibitors (apixaban, rivaroxaban, edoxaban)…. Or not. A recently published paper in the New England Journal of Medicine (the ANNEXA-4 study) should have given us the evidence needed to spend more than 20.000 US dollars on patients with hemorrhage and on a Xa inhibitor. Unfortunately, the study doesn’t. Which of the following make the paper entirely useless (more than one answer possible)

A: There is no randomisation

B: The sickest patients were excluded

C: There are no patient centered outcomes measured

D: The study was funded by Portola Pharmaceuticals the maker of Andexanet Alpha

The correct answers are A, B, C and D

REBELem, First 10 EM and EM lit of Note published about this trial.. Not in a very positive way.

Is seems this paper is a way to get a very expensive drugs without any proven benefit on the market. Beware.


Question 4

Your patient with medium risk of Acute Coronary Syndrome (ACS) presents after an episode of chest pain. She is now asymptomatic. Her troponin is mildly elevated and the ECG shows no signs of ACS. She gets admitted for serial ECG and troponin testing. The ECG is not dynamic and the troponin levels are stable (no rise and fall). The cardiologist sends her home for outpatient follow up. What does the initial (mild) elevation of troponin say about her prognosis?

A: In patients admitted to the hospital with concern for ACS and discharged without a specific diagnosis, elevated troponin levels have no effect on the risk of major adverse events (MAEs).

B: In patients admitted to the hospital with concern for ACS and discharged without a specific diagnosis, the higher the troponin elevation, the greater their risk for major adverse events (MAEs).

C: In patients admitted to the hospital with concern for ACS and discharged without a specific diagnosis, elevated troponin levels mean greater risk for major adverse events (MAEs). However, elevated is elevated and the height of the elevation is not important.

The correct answer is B

Clay Smith discussed a recently published paper about the meaning of elevated troponin in the absence of acute coronary syndrome.

The study is a retrospective registry-based cohort study investigating 48,872 patients. The authors included patients with chest pain without acute coronary syndrome but with a cardiac troponin elevation. The primary outcome was a composite of all-cause mortality, MI, cardiovascular mortality, non- CV mortality, hospitalization for heart failure, ischemic stroke and MAEs. Troponin elevation was associated with cardiovascular and non cardiovascular comorbidities and it predicts major adverse events in acutely admitted patients in the absence of ACS.

Question 5

You see 35 years old female patient in the emergency department with sudden onset headache behind the left eye. She has no past medical history, and she denies a family history of migraine. She only uses oral anti contraceptives. Her vital signs are: heart rate 80/min, blood pressure of 150/75 mmhg, saturation 98 % and respiratory rate of 14/min. The physical exam shows proptosis and chemosis of the left eye. You think she might have a cerebral venous thrombosis. If this is true, what is the most likely location of the sinus thrombosis?

A: Cavernous sinus

B: Cortical vein

C: Sagittal sinus

D: Lateral sinus

The correct answer is A

Taming the SRU wrote about dural venous sinus thrombosis in their latest blog.
Cerebral venous thrombosis is a rare cause of headache. It is more often seen in women under the age of 50 with a higher hypercoagulability ( ie pregnancy/ oral contraceptives ). Isolated thrombosis of a specific dural sinus causes specific symptomatology. But the location of the headache has no spatial relation to the location of the thrombosis. Cavernous sinus thrombosis is associated with ocular pain, chemosis , proptosis and ocular palsy.

This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet


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