Question 1
Your patient is known with Myasthenia Gravis. He has been using ciprofloxacin for 3 days now for a suspected urinary tract infection (because his wife had some left). He complaints of generalised weakness. His vitals are normal and he has no fever. He denies dyspnea. You are concerned your patient is developing Myasthenic Crisis. Which of the following tests is most useful to confirm this diagnosis?
A: Arterial blood gas (ABG)
B: Chest X-ray
C: Electromyography (EMG)
D: Forced Vital Capacity measurement
The correct answer is D
The Internet Book of Critical Care published a podcast about Myasthenic Crisis this week.
Admission Forced Vital Capacity (FRC) is the most useful measurement. The chest X-ray and EMG will not help to confirm this diagnosis. An ABG is only indicated in patients with chronic hypercapnia (eg. with co-existing COPD), for hypercapnia is a very late finding in Myasthenic Crisis.
IBCC chapter & cast: Myasthenic Crisis
Question 2
Your patient has therapy resistant migraine. She still vomits and the headache persists after acetaminophen, an NSAID and metoclopramide. Even a triptan does not relieve pain. You consider a Greater Occipital Nerve (GON) Block, because you read about it a couple of months ago. Which of the following statements is true?
A: The GON block should be performed bilaterally
B: The GON block should always be done under ultrasound guidance
C: Complications of a GON block are pretty common
D: The injection site is located between the mastoid process and occipital protuberance at 1/3th distance from the mastoid process
The correct answer is A
The always useful RCEM podcast has a part about management of migraine this month. A paper (from Friedman) about GON blocks is discussed. The results of this paper sound promising, but unfortunately the target sample size in this study has not been met because of slow enrollment.
Seems to me this is definitely something I would use. However, I do not encounter that many therapy resistant migraines in practice.
March 2019
Question 3
Do you remember the TICH-2 trial?
It was published in 2018 and it is about the use of tranexamic acid in spontaneous intracerebral hemorrhage (ICH). Does the administration of tranexamic acid (TXA) compared to a placebo improve functional status at 90 days according to this trial?
A: Yes, TXA does affect functional status at day 90 positively, but it results in a higher risk of venous thromboembolic events
B: No, TXA does not affect functional status at day 90 and it results in a higher risk of venous thromboembolic events
C: Yes, TXA does affect functional status at day 90 positively and it does not lead to a higher risk of venous thromboembolic events
D: No, TXA does not affect functional status at day 90, but it does not lead to a higher risk of venous thromboembolic events
The correct answer is D
The Bottom Line discussed this trial once again this week.
It seems tranexamic acid has no proven benefit on outcome in patients with spontaneous ICH. It has no effect on the risk of thromboembolic events either. Some may argue TXA can still be given for this indication because of its excellent safety profile. I personally will wait until any evidence rises this has any benefit.
TICH-2
Question 4
What can be said about the diagnostic accuracy of serum ammonia levels in patients with hepatic encephalopathy (HE)?
A: An elevated ammonia level is very sensitive for diagnosing HE
B: An elevated ammonia level is very specific for diagnosing HE
C: A single ammonia level has little utility in diagnosing HE
The correct answer is D
Setareh Mohammadie writes about hepatic encephalopathy on emDOCs.
She states it is a common misconception that an elevated ammonia level is necessary to diagnose HE. In fact, the diagnosis remains largely clinical (history, exam, clinical suspicion) after alternative explanations for altered mental status are ruled out.
Multiple studies could not demonstrate a correlation between plasma ammonia levels (PAL) and the severity of HE in patient with chronic liver disease (CLD). Elevated ammonia values cannot confirm nor exclude the diagnosis of HE. The clinical utility of determining plasma ammonia levels for diagnosis of HE in CLD patients is likely to be very limited.
Hepatic Encephalopathy: Common Precipitants, Sneaky Precipitants, and Clinical Pearls
Question 5
Which of the following is not a typical symptom of Kawasaki disease?
A: Fever > 5 days
B: A rash (polymorphous exanthema)
C: Conjunctivitis
D: Vomiting and diarrhea
The correct answer is D
The always interesting EM quick hits on EM cases is about Kawasaki Disease (and suturing dog bites, the PREVENT trial and more).
The diagnostic criteria for Kawasaki disease can be found in an easy calculator on MDcalc.
If the diagnosis is made in the acute phase, treatment with immunoglobulins should be initiated to prevent coronary artery abnormalities.
EM Quick Hits 3 – Kawasaki Disease, Suturing Dog Bites, BVM in RSI, Anticraving Meds for Alcohol Misuse, ED Violence
This quiz was written by Eefje Verschuuren, Nathalie Dollee and Kirsten van der Zwet
